The implementation of a hepatitis C testing service in community pharmacies: I-COPTIC consensus statement

OBJECTIVES

This aimed to develop a blueprint for an effective community pharmacy Hepatitis C virus (HCV) testing service by producing a consensus statement.

STUDY DESIGN

This was a modified Delphi process.

METHODS

We recruited a heterogenous panel of experts (who had been involved in the setup or delivery of a community pharmacy HCV testing service) by purposive and chain referral methods. We had three rounds of a modified Delphi process. The first was a series of questions with free text responses and was analysed using thematic analysis, and the second and third were statements for the respondents to rate using a 7-point Likert scale. Consensus was predefined in a published protocol, and the results were reviewed by a public and patient involvement panel before the statement was finalised.

RESULTS

We had 24 participants, including community and hospital-based pharmacists, local pharmaceutical committee members, charity representatives (Hepatitis C Trust), local clinical service lead, nurse specialists and doctors. The response rate of the first, second and third rounds were 100%, 96% and 88%, respectively. After the third round, we had 60 statements that reached consensus. We discussed the accepted statements with a patient and public involvement group. We used these statements to produce the I-COPTIC statement and a graphical summary.

CONCLUSIONS

We developed a blueprint for the design of a gold standard community pharmacy HCV testing service. We believe this will support the successful implementation of community pharmacy testing for HCV. Community pharmacy testing is an important service to help achieve and maintain HCV elimination.

POS1234 DMARD DISRUPTION, INCREASED DISEASE ACTIVITY, AND PROLONGED SYMPTOM DURATION AFTER ACUTE COVID-19 AMONG PATIENTS WITH RHEUMATIC DISEASE: A PROSPECTIVE STUDY

Background

Systemic autoimmune rheumatic disease (SARD) patients may be at risk for disease flare and prolonged symptom duration after COVID-19, perhaps related to DMARD disruption and immune activation.

Objectives

To describe DMARD disruption and identify differences in SARD activity among patients with and without prolonged COVID-19 symptom duration.

Methods

We identified all SARD patients with confirmed COVID-19 at the Mass General Brigham healthcare system in Boston, USA; prospective recruitment is ongoing. Surveys were used to collect demographics, clinical characteristics, DMARD disruption, COVID-19 course, and SARD disease activity before and after COVID-19. The survey included validated instruments measuring disease activity, pain, fatigue, functional status, and respiratory quality of life. Prolonged symptom duration was defined as COVID-19 symptoms lasting ≥28 days. We compared differences in patient-reported measures between those with and without prolonged symptoms.

Results

We analyzed survey responses from 174 COVID-19 survivors with SARDs (mean age 52±16 years, 81% female, 80% White). The most common SARDs were RA (40%) and SLE (14%). Fifty-one percent of the 127 respondents on any DMARD reported a disruption to their regimen at COVID-19 onset (Figure 1). Among individual DMARDs, 56-77% were reported to have any change, except for hydroxychloroquine (23%) and rituximab (46%). SARD flare after COVID-19 was reported by 41% of respondents (Table 1). Patient global assessment of SARD activity was worse after COVID-19 (mean 7.6±2.3 before vs. 6.6±2.9 after COVID-19, p<0.001). Prolonged symptom duration was reported by 45% of participants. Those with prolonged symptoms had a higher initial COVID-19 symptom count (median 7 vs. 4, p<0.001) and were more likely to be hospitalized for COVID-19 (28% vs. 17%, p=0.001). Respondents experiencing prolonged symptom duration had higher disease activity on RAPID3 (p=0.007) as well as more pain (p<0.001) and fatigue (p=0.03) compared to those without prolonged symptoms.

Table 1.

Acute COVID-19 course, SARD flare/activity, and patient-reported outcomes among COVID-19 survivors with SARDs.

All COVID-19 survivors with SARDs (n=174)Prolonged symptom duration ≥28 days (n=78)No prolonged symptom duration/(n=96)p-value (prolonged vs. not)Acute COVID-19 courseCOVID-19 symptom duration, days, median [IQR]14 [9, 29]46 [30, 65]11 [7, 14]<0.0001Initial symptom count, median [IQR]6 [3, 8]7 [6, 9]4 [2, 7]<0.001Hospitalized, n (%)38 (22)22 (28)16 (17)0.001SARD flare/activitySelf-reported SARD flare after COVID-19, n (%)71 (41)38 (49)33 (34)0.15Disease activity by RAPID3, median [IQR]9 [4, 14]11.2 [6, 16]7 [3, 13]0.0067RAPID3 categorical score, n (%)0.13Remission (0)11 (7)4 (5)7 (7)Near remission (0.3-1.0)23 (14)5 (7)18 (19)Low severity (1.3-2.0)26 (15)10 (14)16 (17)Moderate severity (2.3-4.0)55 (33)27 (36)28 (29)High severity (4.3-10.0)54 (32)28 (38)26 (27)Patient-reported outcomesPain by SF-MPQ, median [IQR]2 [1, 2]2 [1, 2]1 [0, 2]0.0008Fatigue by FSI, median [IQR]53 [27, 84]66 [31, 91.5]43 [26, 76]0.031mHAQ, median [IQR]0.125 [0, 0.38]0.25 [0, 0.75]0.125 [0, 0.38]0.11Respiratory quality of life by SGRQ, global [IQR]15 [4, 29]16 [4, 36]10 [4, 26]0.49

RAPID3, Routine Assessment of Patient Index Data 3; SF-MPQ, Short-form McGill Pain Questionnaire; FSI, Fatigue Symptom Inventory; mHAQ, modified Health Assessment Questionnaire; SGRQ, Saint George’s Respiratory Questionnaire.

Figure 1.

Frequency of baseline DMARD use and proportion with any disruption at COVID-19 onset.

Conclusion

DMARD disruption, SARD flare, and prolonged symptoms were common in this prospective study of COVID-19 survivors with SARDs. Those with prolonged COVID-19 symptom duration, defined as ≥28 days, had higher SARD activity, more pain, and more fatigue compared to those without prolonged symptoms. These findings suggest that post-acute sequelae of COVID-19 may have a large impact on underlying SARD activity and quality of life.

Disclosure of Interests

Michael Di Iorio: None declared, Claire Cook: None declared, Kathleen Vanni: None declared, Naomi Patel Consultant of: Receives consulting fees from FVC Health unrelated to this work., Kristin D’Silva: None declared, Xiaoqing Fu: None declared, Jiaqi Wang: None declared, Lauren Prisco: None declared, Emily Kowalski: None declared, Alessandra Zaccardelli: None declared, Lily Martin: None declared, Grace Qian: None declared, Tiffany Hsu: None declared, Zachary Wallace Consultant of: Receives consulting fees from Viela Bio, Zenas BioPharma, and MedPace unrelated to this work., Grant/research support from: Receives research support from Bristol-Myers Squibb and Principia/Sanofi., Jeffrey Sparks Consultant of: Receives consultant fees from AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Gilead, Inova Diagnostics, Janssen, Optum, and Pfizer unrelated to this work., Grant/research support from: Receives research support from Bristol Myers Squibb.

OP0251 IMPACT OF INTERSTITIAL LUNG DISEASE ON SEVERE COVID-19 OUTCOMES FOR PATIENTS WITH RHEUMATOID ARTHRITIS: A MULTICENTER STUDY

Background

RA has been associated with poor COVID-19 outcomes, but few studies have investigated outcomes in RA features such as interstitial lung disease.

Objectives

To assess COVID-19 outcomes in patients with RA overall, and those with and without ILD, compared to general population comparators.

Methods

A multicenter, retrospective cohort study was conducted at Mayo Clinic (19 hospitals and affiliated outpatient centers in 4 states) and Mass General Brigham (14 hospitals and affiliated outpatient centers in New England). Consecutive patients with RA meeting ACR/EULAR criteria and a positive COVID-19 test from March 1, 2020 through June 6, 2021 were matched 1:5 on age, sex, race, and COVID-19 test date with general population comparators without RA. RA features assessed included: RA-ILD per Bongartz criteria [1], duration, rheumatoid factor (RF), cyclic citrullinated peptide antibody (CCP), bone erosions, and treatments. The primary outcome was a composite of hospitalization or death following COVID-19 diagnosis. We used multivariable Cox regression to investigate the association of RA, and features such as ILD, with COVID-19 outcomes compared to matched comparators.

Results

We analyzed 582 patients with RA and 2892 comparators without RA, all with COVID-19. Mean age was 62 years, 51% were female, and 79% were White. Mean RA duration was 11 years, 67% were seropositive (52% RF+ and 54% CCP+), 27% had bone erosions, 28% were on steroids, and 79% were on DMARDs. 50/582 (9%) patients with RA had ILD.

The COVID-19 hospitalization or death rate for RA patients was higher than comparators (3.0 per 1,000 days [95% CI 2.5-3.6] vs. 1.9 per 1,000 days [95% CI 1.7-2.1], respectively). Overall, RA patients had a 53% higher risk of hospitalization or death than comparators after adjustment (95% CI 1.20-1.94).

Among those with RA-ILD, the hospitalization or death rate was significantly higher than comparators (10.9 [95% CI 6.7-15.2] vs. 2.5 per 1,000 days [1.8-3.2], respectively). RA-ILD was associated with nearly 3-fold higher risk for hospitalization or death than comparators (multivariable HR 2.84 [95% CI 1.64-4.91], Table 1). There was a significant interaction between RA/comparator status and presence/absence of ILD for risk of severe COVID-19 (p<0.001, Figure 1). The elevated risk for severe COVID-19 was similar for RA subgroups defined by serostatus or bone erosions.

Table 1.

Frequencies, proportions, and hazard ratios for COVID-19 outcomes, comparing all RA patients, and subgroups with or without RA-ILD, to matched comparators.

COVID-19 OutcomesAll RA Patients (n=582)RA-ILD (n=50)RA Patients without ILD (n=532)Comparators (n=2,892)Hospitalization, n (%)121 (21)24 (48)97 (18)402 (14)Unadjusted HR (95% CI)1.58 (1.27, 1.96)2.65 (1.71, 4.09)1.43 (1.12, 1.82)Ref.Adjusted* HR (95% CI)1.45 (1.14, 1.83)2.35 (1.38, 4.00)1.31 (1.00, 1.70)Ref.Death, n (%)26 (4)9 (18)17 (3)63 (2)Unadjusted HR (95% CI)1.72 (0.98, 3.01)5.88 (2.07, 16.71)1.13 (0.56, 2.29)Ref.Adjusted* HR (95% CI)1.24 (0.66, 2.32)13.94 (4.30, 45.18)0.75 (0.35, 1.63)Ref.Hospitalization or death, n (%)126 (22)25 (50)101 (19)419 (14)Unadjusted HR (95% CI)1.66 (1.33, 2.07)3.01 (1.93, 4.70)1.47 (1.14, 1.89)Ref.Adjusted* HR (95% CI)1.53 (1.20, 1.94)2.84 (1.64, 4.91)1.34 (1.02, 1.77)Ref.

*Adjusted for age, sex, race, and smoking

Figure 1.

Multivariable hazard ratios for the composite outcome of hospitalization or death from COVID-19, comparing all RA and subgroups by serostatus, bone erosions, and ILD to matched comparators without RA.

Conclusion

We confirmed that RA was associated with severe COVID-19 outcomes compared to the general population. We found evidence that ILD may be an effect modifier for the relationship between RA and severe COVID-19 outcomes, but RA subgroups defined by serostatus and bone erosions had similarly elevated risk. These findings suggest that ILD or its treatment may be a major contributor to severe COVID-19 outcomes in RA.

References

[1]Bongartz, T, et al, Arthritis Rheum. 2010 Jun;62(6):1583-91.

Disclosure of Interests

None declared

AB0624 Patients with vasculitis have a high prevalence of coronary microvascular dysfunction

Background

Vasculitides are a heterogenous group of diseases characterized by intense vessel wall inflammation, endothelial injury, and systemic inflammation. Several vasculitides are associated with high risk of cardiovascular (CV) disease, an important source of morbidity and mortality in this population. This excess CV risk is attributed both to a high burden of traditional risk factors and to inflammation, but this remains poorly studied. Indeed, inflammation is a known risk factor for CV disease and implicated in coronary microvascular dysfunction (CMD) which may precede obstructive coronary artery disease (CAD).

Objectives

We sought to assess whether vasculitis is associated with CMD in the absence of obstructive CAD.

Methods

We retrospectively identified subjects with systemic vasculitis who underwent symptom prompted rest/stress myocardial perfusion PET. Patients with an abnormal myocardial perfusion study (summed stress score ≥3) or LVEF<40% were excluded. Controls were identified from the same population and matched on age, gender and cardiovascular risk factors (CAD, hypertension, dyslipidemia, diabetes mellitus, and obesity). Coronary flow reserve (CFR), was calculated as the ratio of myocardial blood flow (ml/min/g) at peak stress compared to rest. CMD was defined as CFR <2.

Results

We studied 26 vasculitis cases and 66 matched controls. The most common vasculitides were giant cell arteritis (38%), ANCA-associated vasculitis (31%), and Takayasu’s arteritis (12%). Median (IQR) time between diagnosis and PET was 6.5 (2.9, 14.2) years. Seven (27%) cases had active vascultis at the time of PET. Cases and controls were well-matched on age, sex, and CV risk factors (Table 1). Despite a similar prevalence of CV risk factors, coronary flow reserve (reflected by CMD) was abnormal in 38% of vasculitis cases compared to 15% of controls (p=0.004). The mean [SD] CFR was 19% lower in vasculitis cases vs controls (2.11 [0.5] versus 2.6 [0.7], p=0.003).

Table 1.

The presence of coronary microvasculature dysfunction in patients with systemic vasculitis without obstructive coronary artery disease

Cohort characteristicsVasculitis (n=26)Control (n=66)P-valueAge at PET, years62 (18)61 (17)0.24Time from Vasculitis Diagnosis to PET, years (median, IQR)6.5 (2.9, 14.2)n/aFemale, n (%)18 (72%)43 (65%)0.99Vasculitis CharacteristicsLarge Vessel (e.g., giant cell arteritis, Takayasu’s), n(%)13 (50%)n/an/aMedium Vessel (e.g., polyarteritis nodosa, Kawasaki’s arteritis), n(%)2 (8%)n/an/aSmall Vessel (e.g., ANCA-associated vasculitis, Henoch-Schonlein Purpura), n(%)11 (42%)n/an/aCardiovascular Risk FactorsAt DiagnosisAt PETAt PETHypertension, n (%)12 (46%)20 (71%)47 (80%)0.47Obesity, n (%)3 (12%)2 (32%)2 (32%)0.84Diabetes, n (%)3 (12%)5 (20%)13 (20%)0.99Dyslipidemia, n (%)4 (15%)15 (58%)40 (61%)0.99Known CAD, n (%)0 (0%)1 (4%)1 (2%)0.48Imaging FindingsRest myocardial blood flow, ml/min/g1.0 (0.3)1.0 (0.3)0.8Stress myocardial blood flow, ml/min/g2.1 (0.6)2.6 (1.0)0.008Coronary Flow Reserve, ml/min/g*2.1 (0.5)2.6 (0.7)0.003Coronary Microvasculature Dysfunction** (CMD), n (%)10 (38%)11 (15%)0.004

Conclusion

Patients with systemic vasculitis, even in the absence of obstructive CAD, have a high prevalence of CMD compared with non-vasculitis patients. These differences were observed despite matching cases and controls on traditional CV risk factors, highlighting the importance of other factors, such as inflammation and vasculitis treatments on CMD and CV disease in this population. CMD is a known independent risk factor for CV mortality. Future prospective studies are needed to understand the relationship between vasculitis, systemic inflammation, and CMD.

Disclosure of Interests

None declared

Thank you for biting: dispersal of beneficial microbiota through 'antagonistic' interactions

Multicellular organisms harbor populations of microbial symbionts; some of these symbionts can be dispersed through the feeding activities of consumers. Studies of consumer-mediated microbiota dispersal generally focus on pathogenic microorganisms; the dispersal of beneficial microorganisms has received less attention, especially in the context of 'antagonistic' trophic interactions (e.g., herbivory, parasitism, predation). Yet, this 'trophic transmission' of beneficial symbionts has significant implications for microbiota assembly and resource species (e.g., prey) health. For example, trophic transmission of microorganisms could assist with environmental acclimatization and help resource species to suppress other consumers or competitors. Here, we highlight model systems and approaches that have revealed these potential 'silver-linings' of antagonism as well as opportunities and challenges for future research.

Abstract P02-04: BDTX-1535, a CNS penetrant MasterKey inhibitor of common, uncommon and resistant EGFR mutations, demonstrates in vivo efficacy and has potential to treat osimertinib-resistant NSCLC with or without brain metastases

NSCLC accounts for approximately 85% of lung cancer cases worldwide. NSCLC harboring EGFR mutations constitutes 10-20% of all lung cancer cases in Europe and North America, and up to 50% of those in Asia. The majority (80-90%) of these mutations are either Exon19del or L858R. Uncommon EGFR mutations, of which G719X, S768I and L861Q are amongst the most frequent, account for 10-20% of EGFR mutations in NSCLC. Additionally, secondary EGFR mutations such as C797S that emerge during treatment with osimertinib occur in ~10% of patients. Current generation EGFR inhibitors with efficacy against common, uncommon and/or resistance mutations are either poorly brain penetrant or do not have broad spectrum activity against multiple mutations. BDTX-1535 is an irreversible, spectrum selective MasterKey inhibitor of common, uncommon and resistance EGFR mutations such as G719X and C797S that occur in NSCLC (IC50&lt;10nM). BDTX-1535 is differentiated from many EGFR inhibitors by its CNS-penetrating properties. BDTX-1535 has a Kpuu, defined as the ratio of the unbound brain tissue concentration over the unbound plasma concentration, of 0.8 in rat. In studies of EGFR Exon19del+C797S, BDTX-1535 achieved pEGFR suppression exceeding 24 hours in vitro and following a single dose in vivo. BDTX-1535 has demonstrated robust tumor growth inhibition and regressions in multiple pre-clinical models, including PDX intracranial models. Thus, BDTX-1535 has potential to treat patients with NSCLC harboring a broad range of mutations, both common and uncommon, as well as those associated with resistance to the current standard of care TKIs. The CNS penetrating properties may help to treat CNS metastases or to prevent them from occurring. BDTX-1535 is currently being evaluated in IND-enabling studies.

Citation Format: Matthew C. Lucas, Melinda S. Merchant, Matthew O'Connor, Carl Cook, Sherri Smith, Anthony Trombino, Wu-Yan Zhang, Irache Visiers, Kate Tith, Reza Foroughi, Nigel Waters, Iwona Wrona, Michael Pickard, Sudharshan Eathiraj, Karsten Witt, Christopher Roberts, Rachel Humphrey, Elizabeth Buck. BDTX-1535, a CNS penetrant MasterKey inhibitor of common, uncommon and resistant EGFR mutations, demonstrates in vivo efficacy and has potential to treat osimertinib-resistant NSCLC with or without brain metastases [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2021 Oct 7-10. Philadelphia (PA): AACR; Mol Cancer Ther 2021;20(12 Suppl):Abstract nr P02-04.

POS1428 VALIDATION OF ANCA-ASSOCIATED VASCULITIS AS THE CAUSE OF END-STAGE RENAL DISEASE IN THE UNITED STATES RENAL DATA SYSTEM

Background:

Glomerulonephritis and other renal manifestations are common in ANCA-associated vasculitis (AAV). Renal involvement in AAV is associated with adverse outcomes, including end-stage renal disease (ESRD) in up to 25% of patients (1). The United States Renal Data System (USRDS), a national registry of ESRD patients, represents a unique nationwide data source for studying AAV patients with ESRD. Prior research has assessed how often patients with ESRD attributed to AAV have biopsy-proven glomerulonephritis in USRDS (2), but the validity of the diagnosis of AAV as the cause of ESRD in the USRDS remains unknown.

Objectives:

We aim to validate the diagnosis of AAV as the primary cause of ESRD listed in USRDS.

Methods:

We identified all patients in the Mass General Brigham (MGB) healthcare system with a billing code for advanced chronic kidney disease or end-stage renal disease or procedure code for dialysis or renal transplantation. We identified all MGB patients fulfilling these criteria to records in the USRDS by name, sex, date of birth, and social security number. From this cohort of patients, we identified those with AAV or related diagnoses listed as the primary disease causing ESRD (ICD9: 446.0, 446.4 or ICD10: M31.3X, M31.7). Two authors reviewed medical records to collect information on whether or not a physician had diagnosed AAV, details of AAV history, renal and non-renal biopsies, and antineutrophil cytoplasmic antibody (ANCA) tests. Discrepancies were resolved through consensus. Details regarding initial ESRD onset date were obtained from the USRDS. To calculate the positive predictive value (PPV) for AAV as the primary cause of ESRD a definite physician diagnosis of AAV (a diagnosis confirmed by two physicians based on available data) in the MGB medical record was used as the gold standard. To calculate sensitivity, we linked the Partners (MGB) AAV Cohort to USRDS records using the same methods. A diagnosis code of AAV as the cause of ESRD was considered a true positive and a diagnosis code for other types of nephritis was considered a false negative.

Results:

We identified 89 USRDS records linked to MGB medical records in which the primary cause of ESRD was attributed to AAV. Of these, 85 were confirmed to be true cases of AAV after medical record review (PPV=96%) (Table 1). Among the cases classified as AAV, 84 (99%) had a positive ANCA test, which was predominantly MPO/P-ANCA (47, 55%); 36 (42%) had a renal biopsy, all of which were supportive of the diagnosis. The majority of cases were identified as AAV by ICD9 or 10 codes for Wegener’s granulomatosis (446.4 or M313.1). Within the Partners (MGB) AAV cohort linked to USRDS records, 33 (55%) of 60 identified cases had AAV listed as the cause of ESRD; in the remainder, ESRD was attributed to non-specific nephritis codes.

Table 1.

AAV and non-AAV patients in the USRDS with ESRD due to AAV (N=89)

Physician-Diagnosed AAV(N=85)ANCA type n (%)84 (98.8)MPO/P-ANCA+47 (55.3)PR3/C-ANCA+33 (38.8)Renal biopsy n (%)36 (42.4)Pauci-Immune Glomerulonephritis n (%)16 (44%)Non-renal biopsy n (%) Yes10 (11.8) No74 (87.1)Years from AAV diagnosis to ESRD median [IQR]1 [0, 6]Principal diagnosis code (ICD9/ICD10) n (%) Wegener’s granulomatosis (446.4, 446.4B, or M313.1)81 (95.3)

Conclusion:

We found that the diagnosis of AAV as the primary cause of ESRD in the USRD had a high PPV, suggesting accurate classification of ESRD due to AAV in the USRDS, but that sensitivity was moderate. These findings support the past and future use of the USRDS for research with ESRD attributed to AAV.

References:

[1]Moiseev S, Novikov P, Jayne D, Mukhin N. End-stage renal disease in ANCA-associated vasculitis. Nephrol Dial Transplant. 2017;32(2):248-53.

[2]Layton JB, Hogan SL, Jennette CE, Kenderes B, Krisher J, Jennette JC, et al. Discrepancy between Medical Evidence Form 2728 and renal biopsy for glomerular diseases. Clin J Am Soc Nephrol. 2010;5(11):2046-52.

Disclosure of Interests:

None declared

POS1174 HYPERINFLAMMATION AND CLINICAL OUTCOMES FOR PATIENTS WITH SYSTEMIC RHEUMATIC DISEASES HOSPITALIZED FOR COVID-19: A COMPARATIVE COHORT STUDY

Background:

COVID-19 can induce a hyperinflammatory state resulting in cytokine storm, which can lead to poor outcomes. Patients with systemic rheumatic diseases may be at increased risk for respiratory failure with COVID-19. Therefore, we investigated the relationship between rheumatic disease, hyperinflammation, and clinical outcomes among hospitalized COVID-19 patients.

Objectives:

To compare laboratory values, hyperinflammation, and clinical outcomes of hospitalized COVID-19 rheumatic patients and matched comparators.

Methods:

We performed a comparative cohort study of patients with polymerase chain reaction (PCR)-confirmed COVID-19 requiring hospitalization between 3/1/20-7/7/20 at a large health care system. We compared each systemic rheumatic disease case to up to 5 matched (by age, sex, and date of +SARS-CoV-2 PCR) comparators without systemic rheumatic disease. We extracted laboratory values from their hospitalization to compare peaks/troughs of individual laboratory results by case status and derived the COVID-19-associated hyperinflammation score (cHIS), a composite of 6 laboratory domains (0-6, ≥2 indicating hyperinflammation), as previously developed1. We used multivariable logistic regression to estimate ORs for COVID-19 outcomes by hyperinflammation and case status.

Results:

We identified 57 hospitalized rheumatic disease cases (mean age 67 years, 67% female) and 232 matched comparators hospitalized with PCR-confirmed COVID-19. Among cases, 26 (46%) had rheumatoid arthritis and 14 (25%) had systemic lupus erythematosus. Most cases (34, 60%) had active rheumatic disease. At baseline, 15 (27%) of cases were treated with biologic DMARDs, and 32 (56%) were using glucocorticoids. We analyzed 39,900 total laboratory results (median 85 per patient). Cases had higher peak neutrophil-to-lymphocyte ratio (9.6 vs 7.8, p=0.02), LDH (421 vs 345 U/L, p=0.04), creatinine (1.2 vs 1.0 mg/dL, p=0.01), and BUN (31 vs 23 mg/dL, p=0.03) than comparators but similar peak CRP (149 vs 116 mg/L, p=0.11, Figure 1). Cases had higher peak median cHIS (3 vs 2, p=0.01). Peak cHIS ≥2 had higher odds of intensive care unit (ICU) admission (OR 3.45, 95%CI 1.98-5.99), mechanical ventilation (OR 66.0, 95%CI 9.0-487.8), and mortality (OR 16.4, 95%CI 4.8-56.4) compared to cHIS <2 (Table 1). Cases had increased risk of ICU admission (OR 2.0, 95%CI 1.1-3.7) and mechanical ventilation (OR 2.7, 95%CI 1.4-5.2) than comparators.

Table 1.

Associations of peak cHIS and systemic rheumatic disease with COVID-19 hospitalization outcomes

Intensive care unit admissionMechanical ventilationDeath%Adjusted OR (95%CI)%Adjusted OR (95%CI)%Adjusted OR (95%CI)Hospitalization outcomes by hyperinflammation on cHIS1cHIS <2 (n=112)21%1.0 (Ref)1%1.0 (Ref)3%1.0 (Ref)cHIS ≥2 (n=177)48%3.5 (2.0-6.0)37%66.2 (9.0-487.8)27%16.4 (4.8-56.4)Hospitalization outcomes by rheumatic disease statusComparators (n=232)30%1.0 (Ref)19%1.0 (Ref)16%1.0 (Ref)Rheumatic cases (n=57)51%1.87 (1.03-3.40)39%2.46 (1.30-4.67)21%1.32 (0.61-2.88)

Matching factors: age, sex, and date of +PCR.

1Adjusted for age, sex, and case status.

2Adjusted for race, smoking, comorbidities, and body mass index.

cHIS, COVID-19-associated hyperinflammation score; CI, confidence interval; OR, odds ratio; PCR, polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

Conclusion:

Patients with systemic rheumatic disease hospitalized for COVID-19 had higher risk for hyperinflammation, kidney injury, and mechanical ventilation than non-rheumatic comparators. We validated the cHIS in our cohort, which was strongly associated with poor COVID-19 outcomes. These findings highlight that hospitalized patients with rheumatic diseases may be vulnerable to poor COVID-19 outcomes.

References:

[1]Webb BJ et al. Clinical criteria for COVID-19-associated hyperinflammatory syndrome. Lancet Rheumatol. 2020 Dec;2(12):e754-e763.

Disclosure of Interests:

Tiffany Hsu: None declared, Kristin D’Silva: None declared, Naomi Serling-Boyd: None declared, Jiaqi Wang: None declared, Alisa Mueller: None declared, Xiaoqing Fu: None declared, Lauren Prisco: None declared, Lily Martin: None declared, Kathleen Vanni: None declared, Alessandra Zaccardelli: None declared, Claire Cook: None declared, Hyon Choi Consultant of: Dr. Choi reports consultancy fees from Takeda, Selecta, GlaxoSmithKline, and Horizon, Grant/research support from: Dr. Choi reports research support from AstraZeneca., Yuqing Zhang: None declared, Ellen Gravallese: None declared, Zachary Wallace Consultant of: Dr. Wallace reports consulting fees from Viela Bio and MedPace., Grant/research support from: Dr. Wallace reports research support from Bristol-Myers Squibb and Principia., Jeffrey Sparks Consultant of: Dr. Sparks reports consultancy fees from Bristol-Myers Squibb, Gilead, Inova, Janssen, Optum, and Pfizer., Grant/research support from: Dr. Sparks reports research support from Amgen and Bristol-Myers Squibb.

Safety and preliminary efficacy from the phase 1 portion of MasterKey-01: A First-in-human dose-escalation study to determine the recommended phase 2 dose (RP2D), pharmacokinetics (PK) and preliminary antitumor activity of BDTX-189, an inhibitor of allosteric ErbB mutations, in patients (pts) with advanced solid malignancies

3086

Background: BDTX-189 is an orally available, ATP-competitive and irreversible inhibitor directed against families of allosteric HER2 and EGFR oncogenic mutations. In preclinical studies BDTX-189 achieved potent inhibition of 48 allosteric HER2 and EGFR/HER2 exon 20 insertion mutant variants with selectivity versus EGFR wild-type (WT) and demonstrated tumor growth inhibition and regression in vivo. The primary objective of the Ph 1 portion of this trial (NCT04209465) is to determine the RP2D and schedule of monotherapy BDTX-189 in pts with advanced solid tumors. Methods: Eligibility includes pts with relapsed or refractory locally advanced or metastatic solid tumors with no standard therapy available whose tumor harbors an allosteric HER2 or HER3 mutation; EGFR or HER2 exon 20 insertion mutation; HER2 amplification or overexpression; or EGFR exon 19 deletion or L858R mutation. BDTX-189 is dosed continuously orally in 3-wk cycles QD and BID in separate dose escalation cohorts. A separate cohort is also evaluating the high- and low-fat food-effect (FE) on BDTX-189 PK. Results: As of 1/11/21, 46 pts have been dosed, with 36 in the QD (fasting) schedule (25-1200 mg), including pts from the FE cohort who received 800 mg QD fasting after FE evaluation: 58% female; 67% white; median age 63.5 yrs; 53% received ≥ 3 prior tx lines. Cancer types: 12 NSCLC, 5 breast, 4 ovary, 3 biliary, and 12 other. Genomic alterations: 23 HER2 amplification and the following mutations: 11 allosteric HER2, 5 EGFR exon 20 insertion, 5 HER2 exon 20 insertion, 3 EGFR exon 19 del./L858R, and 2 HER3. At ≥ 800 mg QD, 3 and 2 pts had EGFR or HER2 exon 20 mutations, respectively. The maximum tolerated dose (MTD) for QD (fasting) was 800 mg, with 2/6 pts with DLTs at 1200 mg. DLTs: gastrointestinal (G3 diarrhea; G1/2 nausea/vomiting). The most frequent (≥20%) related adverse events were diarrhea (36%, 8% G3), nausea (28%, 0% G3), and vomiting (25%, 3% G3). The rate of skin disorders was 11% with the highest severity of G2 in 1 pt. Dose-dependent exposure increases were observed, with the exposure at 800 mg QD fasting within the projected efficacious range. Pilot FE data suggest possible increased exposure with food. 27 pts were evaluable for efficacy, 15 at ≥ 800 mg QD, with 2 partial responses observed: 1 PR confirmed and ongoing (800 mg QD, CUP, HER2 amp, 3 prior lines of chemo) and 1 PR unconfirmed (NSCLC with brain mets, 1200 mg QD, HER2 amp + exon 19 del., 2 prior EGFR TKIs). 3 pts had a best response of SD and 10 with progressive disease. Conclusions: BDTX-189 has a generally manageable safety profile with early evidence of anti-tumor activity. Enrollment is ongoing in non-fasting QD and BID cohorts, and the FE cohort, prior to RP2D identification. Clinical trial information: NCT04209465.

Masterkey-01: Phase I/II, open-label multicenter study to assess safety, tolerability, pharmacokinetics, and antitumor activity of BDTX-189, an inhibitor of allosteric ErbB mutations, in patients with advanced solid malignancies

TPS3665

Background: A significant unmet need exists for drugs targeting allosteric ErbB mutations (non-canonical mutations outside the ATP binding site). Current EGFR and HER2 tyrosine kinase inhibitors or mAbs have limited antitumor activity against allosteric mutations, resulting in toxicity before adequate drug exposure (Connell and Doherty, 2017). BDTX-189 is a potent and selective orally available irreversible inhibitor targeting unique oncogenic driver mutations of ErbB kinases in EGFR and HER2, while sparing WT EGFR. Preclinical studies demonstrated antitumor activity across a range of allosteric ErbB mutants, including extracellular domain allosteric mutations of HER2 as well as EGFR and HER2 kinase domain exon 20 insertions (Buck, 2019). This first-in-human trial (NCT04209465) is aimed to determine the recommended phase 2 dose (RP2) and schedule (Phase 1, P1), and evaluate the efficacy (Phase 2, P2) of BDTX-189. P1 primary objective is to determine the RP2 dose and schedule of monotherapy BDTX-189. Secondary objectives include assessment of safety, tolerability, pharmacokinetics (PK), pharmacodynamic (PD) effects in tumor, and preliminary efficacy. The P2 primary objective is to assess antitumor activity of monotherapy BDTX-189. Methods: The study will enroll patients (pts) ≥18 yrs with histologically or cytologically confirmed locally advanced or metastatic solid tumors with no standard therapy available or for whom standard therapy is unsuitable or intolerable. P1 dose-escalation will use a BOIN design (Yuan, 2016) and will enroll ≤ 88 pts with allosteric HER2 or HER3 mutation; EGFR or HER2 exon 20 insertion mutation; HER2 amplified or overexpressing tumor; or EGFR exon 19 deletion or L858R mutation. BDTX-189 will be dosed orally (PO) initially QD in 3 wk cycles. Regimen optimization will use PK, PD and safety data and may explore a BID schedule. An expansion cohort of ≤12 pts will further evaluate safety and preliminary efficacy of BDTX-189 prior to P2. P2, utilizing a Simon 2-stage design, will enroll ≤100 pts with NSCLC with EGFR or HER2 exon 20 insertion mutations (cohort 1); breast cancer with an allosteric ErbB mutation (cohort 2); tumors (except breast) with S310F/Y mutation (cohort 3); and other allosteric ErbB mutations not defined in cohorts 1-3 (cohort 4). Assessments include safety, tolerability, DLTs, evaluation of MTD, PK, PD, and preliminary antitumor activity. Enrollment began 1/2020. Clinical trial information: NCT04209465 .

Determination of Glyphosate and Aminomethylphosphonic Acid in Crops by Capillary Gas Chromatography with Mass-Selective Detection: Collaborative Study

A collaborative study was conducted to validate a method for the determination of glyphosate and aminomethylphosphonic acid (AMPA) in crops. The analytes are extracted from crops with water, and the crude extracts are then subjected to a cation exchange cleanup. The analytes are derivatized by the direct addition of the aqueous extract into a mixture of heptafluorobutanol and trifluoroacetic anhydride. The derivatized analytes are quantitated by capillary gas chromatography with mass-selective detection (MSD). The collaborative study involved 13 laboratories located in 5 countries 12 laboratories returned valid data sets. The crops tested were field corn grain, soya forage, and walnut nutmeat at concentrations of 0.050, 0.40, and 2.0 mg/kg. The study used a split-level pair replication scheme with blindly coded laboratory samples. Twelve materials were analyzed, including 1 control and 3 split-level pairs for each matrix, 1 pair at each nominal concentration. For glyphosate, the mean recovery was 91%, the average intralaboratory variance, the repeatability relative standard deviation (RSDr), was 11%, and the interlaboratory variance, the reproducibility relative standard deviation (RSDR), was 16%. For AMPA, the mean recovery was 87%, the RSDr was 16%, and the RSDR was 25% at mg/kg levels.

Gut microbiome alteration in MORDOR I: a community-randomized trial of mass azithromycin distribution

The MORDOR I trial1, conducted in Niger, Malawi and Tanzania, demonstrated that mass azithromycin distribution to preschool children reduced childhood mortality1. However, the large but simple trial design precluded determination of the mechanisms involved. Here we examined the gut microbiome of preschool children from 30 Nigerien communities randomized to either biannual azithromycin or placebo. Gut microbiome γ-diversity was not significantly altered (P = 0.08), but the relative abundances of two Campylobacter species, along with another 33 gut bacteria, were significantly reduced in children treated with azithromycin at the 24-month follow-up. Metagenomic analysis revealed functional differences in gut bacteria between treatment groups. Resistome analysis showed an increase in macrolide resistance gene expression in gut microbiota in communities treated with azithromycin (P = 0.004). These results suggest that prolonged mass azithromycin distribution to reduce childhood mortality reduces certain gut bacteria, including known pathogens, while selecting for antibiotic resistance.

Distribution, habitats, phenology and conservation of New Caledonian Odonata

Compared to other archipelagos of the Pacific, the New Caledonian Odonata fauna is rich and diverse with 56 valid species or subspecies (23 endemics, 41%) from eight families (four Zygoptera: Argiolestidae, Coenagrionidae, Isostictidae, Lestidae, and four Anisoptera: Aeshnidae, Corduliidae, Synthemistidae, Libellulidae) and 31 genera (including four endemics, 13%). In Zygoptera, we record 19 species including 12 endemics (63%), and among Anisoptera, we record 37 species or subspecies, including 11 endemics (30%). We removed five species from the list that had been erroneously recorded as occurring in New Caledonia: Tramea carolina (Linnaeus, 1763), Austroargiolestes icteromelas (Selys-Longchamps, 1862), Ischnura torresiana Tillyard, 1913, Xiphiagrion cyanomelas Selys-Longchamps, 1876 and Hemicordulia oceanica Selys-Longchamps, 1871. The occurrence of Tramea limbata (Desjardins, 1835) appears also doubtful, but we were unable to clarify to which taxon this record referred hence we excluded it from our update. From a biogeographic perspective, the New Caledonian fauna has mostly Australian affinities with some connections with southeast Asia and the Pacific region. We provide for each species, whenever information was available, a distribution map with a brief review of its known ecology, behaviour and phenology. We also evaluated each species' conservation status, in light of known threats (range restriction, scarcity and human activity including altered water flow). We consider seventeen species (30%) endangered. The most immediate threats concern water pollution including alteration to the flow of water courses caused by mining, deforestation and fires. Invasive species, such as alien fish, may be predators of concern for odonata larva, although this has not yet been proven in New Caledonia.

Performance measurement of a Canadian provincial tuberculosis programme: Manitoba, 2008-2012

BACKGROUND

Performance measurement assists tuberculosis (TB) programmes in understanding areas of strength and weakness, and planning for improvements. Canada currently does not have a national comprehensive system for the measurement and analysis of TB programme performance.

OBJECTIVE

To analyse the performance of a Canadian provincial TB programme using measures and targets based on those published by the US Centers for Disease Prevention and Control for 2015.

DESIGN

Using provincial surveillance data from the Canadian province of Manitoba, we analysed key programme performance outcome measures (treatment completion, early detection, human immunodeficiency virus [HIV] testing, paediatric TB, retreatment, and contact elicitation and assessment) for people diagnosed with TB between 2008 and 2010.

RESULTS

Significant outcome variation was found between Indigenous and non-Indigenous populations as well as within populations. The reporting rate of HIV testing was low. High rates of paediatric TB among Indigenous populations, particularly in rural areas, were found. Significantly better performance in HIV testing and reporting as well as in contact investigation was found for rural compared with urban Indigenous populations. Foreign-born persons had the lowest contact assessment rate.

CONCLUSION

This study of TB programme performance in Manitoba demonstrates the viability of the approach in the Canadian context, and could help to identify key areas for TB programme improvement.

First-in-human study of AZD5153, a small molecule inhibitor of bromodomain protein 4 (BRD4), in patients (pts) with relapsed/refractory (RR) malignant solid tumor and lymphoma: Preliminary data

3085

Background: BRD4 is a bromodomain and extraterminal (BET) protein that regulates oncogenic programs by modifying gene transcription and additional mechanisms. AZD5153 is a novel, reversible BRD4 inhibitor with bivalent mechanism of action and enhanced antitumor activity in preclinical models. This phase 1, multicenter, dose escalation study (NCT03205176) assesses AZD5153’s safety, pharmacokinetics (PK), and pharmacodynamics (PD). We report here preliminary, unvalidated data from AZD5153 monotherapy in pts with RR solid tumor, including lymphoma. Methods: Adult pts received oral AZD5153 QD/BID to determine the MTD. During dose escalation, a continual reassessment model was used to estimate toxicity and all final decisions were made by the Safety Review Committee. PK and PD were characterized using standard methods. Results: As of 1 Nov 2018, 28 pts (78.6% female, median age 66.5 y) were treated in 7 cohorts: 2 mg QD (3 pts), 5 mg QD (3 pts), 10 mg QD (3 pts), 10 mg BID (5 pts), 15 mg BID (4 pts), 20 mg BID (7 pts), and 30 mg QD (3 pts). Treatment was ongoing in 8 pts at data cut-off. Safety findings showed 50% of pts experienced treatment-related AEs. 25% of pts experienced treatment-related Grade ≥3 AEs, which were thrombocytopenia and fatigue (7.1% each), and anemia, diarrhea, and platelet count decreased (3.6% each). SAEs were observed in 25% of pts; none of the SAEs was attributable to AZD5153 alone. Dose-limiting toxicities of thrombocytopenia (1 pt) and diarrhea with herpetic rash leading to discontinuation (1 pt) occurred at 20 mg BID. 53.6% of pts discontinued due to disease progression. Total median treatment duration was 1.3 mo (range up to 8.9 mos). Dose proportional increase in Cmax and AUC were observed across the dose range tested. Tmax ranged from 0.5 to 3 h and t1/2 was 6 h. Dose-dependent changes in expression of target genes (eg, HEXIM1, HIST2H2BF, CD274, and CCR2) and platelet counts were observed in the peripheral blood. Conclusions: AZD5153 monotherapy is safe and tolerated at doses up to 30 mg QD and 15 mg BID. Linear increase in PK was observed. Additional safety and efficacy updates will be reported at the annual meeting. Clinical trial information: NCT03205176.

Population pharmacokinetic analysis of danvatirsen supporting flat dosing switch

Danvatirsen is a Generation 2.5 antisense oligonucleotide under clinical development. Population PK modelling was conducted using data from 3 available danvatirsen Phase I/II studies in oncology patients to investigate the impact of flat dosing on exposure compared to ideal body weight-based dosing. A total of 126 patients who received danvatirsen doses ranging from 1 to 4 mg/kg as monotherapy or in combination with durvalumab, most at 3 mg/kg (n = 70), was used in the danvatirsen population PK analysis. A 2-compartment model with linear elimination described the data well. Covariate analysis revealed ideal body weight was not a significant covariate on the PK of danvatirsen; nor was age, sex or race. The model-based simulation suggested that steady state weekly AUC and Cmax were very similar between 3 mg/kg and 200 mg flat dosing (geometric mean of AUC: 62.5 vs. 63.4 mg h/L and Cmax: 26.2 vs. 26.5 mg/L for two dose groups) with slightly less overall between-subject variability in the flat dosing regimen. The switch to flat dosing was approved by multiple regulatory agencies, including FDA, EMA, PMDA and ANSM. Several ongoing studies have been evaluating flat dosing. Interim analysis from an ongoing study (D5660C00016, NCT03421353) has shown the observed steady state concentration from 200 mg flat dose is in agreement with the model predictions. The population PK model could be further utilized in subsequent exposure-response efficacy and safety modelling.

STAT3 antisense oligonucleotide AZD9150 in a subset of patients with heavily pretreated lymphoma: results of a phase 1b trial

Background

The Janus kinase (JAK) and signal transduction and activation of transcription (STAT) signaling pathway is an attractive target in multiple cancers. Activation of the JAK-STAT pathway is important in both tumorigenesis and activation of immune responses. In diffuse large B-cell lymphoma (DLBCL), the transcription factor STAT3 has been associated with aggressive disease phenotype and worse overall survival. While multiple therapies inhibit upstream signaling, there has been limited success in selectively targeting STAT3 in patients. Antisense oligonucleotides (ASOs) represent a compelling therapeutic approach to target difficult to drug proteins such as STAT3 through of mRNA targeting. We report the evaluation of a next generation STAT3 ASO (AZD9150) in a non-Hodgkin’s lymphoma population, primarily consisting of patients with DLBCL.

Methods

Patients with relapsed or treatment refractory lymphoma were enrolled in this expansion cohort. AZD9150 was administered at 2 mg/kg and the 3 mg/kg (MTD determined by escalation cohort) dose levels with initial loading doses in the first week on days 1, 3, and 5 followed by weekly dosing. Patients were eligible to remain on therapy until unacceptable toxicity or progression. Blood was collected pre- and post-treatment for analysis of peripheral immune cells.

Results

Thirty patients were enrolled, 10 at 2 mg/kg and 20 at 3 mg/kg dose levels. Twenty-seven patients had DLBCL. AZD9150 was safe and well tolerated at both doses. Common drug-related adverse events included transaminitis, fatigue, and thrombocytopenia. The 3 mg/kg dose level is the recommended phase 2 dose. All responses were seen among DLBCL patients, including 2 complete responses with median duration of response 10.7 months and 2 partial responses. Peripheral blood cell analysis of three patients without a clinical response to therapy revealed a relative increase in proportion of macrophages, CD4+, and CD8+ T cells; this trend did not reach statistical significance.

Conclusions

AZD9150 was well tolerated and demonstrated efficacy in a subset of heavily pretreated patients with DLBCL. Studies in combination with checkpoint immunotherapies are ongoing.

Trial registration

Registered at ClinicalTrials.gov: NCT01563302. First submitted 2/13/2012.

Electronic supplementary material

The online version of this article (10.1186/s40425-018-0436-5) contains supplementary material, which is available to authorized users.

Abstract CT103: Rationale for flat dosing of AZD9150 by population pharmacokinetic analysis

Objective: AZD9150 (ISIS 481464) is a 16-nucleotide oligonucleotide antisense molecule designed to reduce expression of human STAT3 protein by targeted down-regulation of STAT3 messenger RNA and is currently in clinical development in advanced solid tumors. The recommended Phase 2 dose (RP2D) for AZD9150 is 3 mg/kg, dosed based on ideal body weight (IBW) with three loading doses on day 1, 3 and 5 in week 1 followed by weekly dosing thereafter. The objective of the current analysis was to assess the effect of body size on AZD9150 pharmacokinetics (PK) to determine the appropriate dosing approach using population PK modeling.

Methods: PK and demographics data from 3 phase I/II studies (481464-CS1 [NCT01563302], D5660C00001 [NCT01839604], D5660C00004 [NCT02499328]) in total of 126 patients with diffuse large B-cell lymphoma (DLBCL), hepatocellular carcinoma (HCC) and squamous-cell carcinoma in head and neck (SCCHN), receiving doses ranging from 1 to 4 mg/kg as monotherapy or in combination with durvalumab, were used in the population PK analysis. Both 2-compartment and 3-compartment structure PK models were tested in the analysis. Patient characteristics including age, ideal body weight (IBW), race and sex were explored as covariates on relevant AZD9150 PK parameters in an automated forward inclusion followed by backward elimination procedure through use of the stepwise covariate modelling. Once a final model was identified, simulations (n=1000, body weight distribution 30 to 100 kg) were conducted to compare AZD9150 exposures at the RP2D of 3 mg/kg versus a flat dose of 200 mg.

Results: A 2-compartment model with linear elimination well described the data. None of the covariates (inc. IBW) were found to significantly impact AZD9150 PK. The final PK model parameter estimate for clearance (CL), central volume of distribution (V1) and peripheral volume of distribution (V2) are 3.11 L/h, 5.56 L and 87.3 L, respectively. Model based simulations demonstrate that systemic exposure of AZD9150 was similar between 3 mg/kg versus 200 mg dose with slightly less overall between-patients variability with the flat dosing regimen.

Conclusion: Population PK modeling supports the potential switch of dosing approach from 3 mg/kg dose to a flat dose of 200 mg. The AZD9150 flat dosing rationale and schedule has been granted approval by FDA (for IND 137525) and also by MHRA (for BISCAY trial) as the first protocol / IMPD to be approved in the EU. Flat dose of 200 mg is currently being evaluated in ongoing clinical studies.

Citation Format: Xiao Tong, Ganesh Mugundu, Martin Scott, Carl Cook, Paul Lyne, Nidal Al-Huniti, Hongmei Xu. Rationale for flat dosing of AZD9150 by population pharmacokinetic analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT103.

A novel radiographic method to facilitate measurement of the tibial plateau angle in dogs

The tibial plateau levelling osteotomy (TPLO) is commonly performed for treatment of cranial cruciate ligament deficiency in dogs. In order to be performed as described, this procedure relies on consistent measurement of the tibial plateau angle (TPA) on radiographs. This prospective study compared two radiographic methods for subsequent TPA measurement with respect to measured angle and ease of determining landmarks for measurement as determined by four observers. One method was the accepted standard radiographic protocol outlined in the TPLO training seminars. The other method involved a novel split image radiographic protocol not yet described in the literature. Participants' subjective scores as to ease of identifying landmarks and determining TPA on radiographs for each method were evaluated. Inter-observer TPA measurement variability was also assessed for each method. The novel radiographic method was judged to be significantly better in terms of ease of measuring TPA. Inter-observer measurement variability was considered appropriate for recommending use of this novel method for radiographing patients for TPA measurements.

Randomised controlled trial of prophylactic antibiotic treatment for the prevention of endophthalmitis after open globe injury at Groote Schuur Hospital

BACKGROUND/AIMS

Most post-traumatic acute infectious endophthalmitis occur within a week of open globe trauma, necessitating early antibiotic prophylaxis. There are few randomised studies that demonstrate the benefits of prophylactic antibiotics. This randomised controlled non-inferiority trial was aimed at determining the incidence of post-traumatic endophthalmitis using established intravenous/oral prophylaxis and comparing this to the incidence using oral antibiotics only.

METHODS

All adult patients admitted with open globe injury were included. Those with proven endophthalmitis, high-risk features, who underwent primary evisceration and those allergic to the trial antibiotics were excluded. Patients were randomised to receive either intravenous cefazolin and oral ciprofloxacin or oral ciprofloxacin and oral cefuroxime for 3 days from admission. Acute endophthalmitis was the primary outcome. Patients completed the study if they were followed up for 6 weeks post injury.

RESULTS

Three hundred patients were enrolled, with 150 in each arm. There were 99 exclusions. Seven patients developed endophthalmitis despite prophylaxis-2.0% (three cases) in the intravenous and oral arm, compared with 2.7% (four cases) in the oral-only arm-this difference was not statistically significant (p=0.703).

CONCLUSIONS

The incidence of endophthalmitis with prophylaxis was 2-3%. Selected patients with open globe injuries (without high-risk features) may receive either intravenous cefazolin and oral ciprofloxacin, or oral cefuroxime and oral ciprofloxacin as prophylaxis against acute endophthalmitis-the latter regimen has the advantage of shortening patients' hospital stays and reducing costs. Non-inferiority study-design limitations should be taken into account, however.

Acute appendicitis in South Africa: a systematic review

BACKGROUND

Acute appendicitis is one of the most common surgical emergencies in the West. A large body of research is investigating the risk factors for disease and perforation. As South Africa has a social environment, health system structure, and population demography unique from developed nations, the findings may not be generalisable to this setting. A systematic review has not been performed for appendicitis research in South Africa. The objective of this review was to systematically examine the literature on appendicitis in South Africa.

METHOD

Published articles discussing appendicitis in South Africa up to March 2014 were identified using MEDLINE and EBMReviews. Research themes were analysed in the literature. Perforation rates, mortality, negative appendicectomy rates and gender differences were analysed from audits of patients undergoing appendicectomy for acute appendicitis.

RESULTS

Ten audits were included in the quantitative analysis. Some were excluded in the subgroup analyses. Negative appendicectomies occurred at a rate of 17% (580/3 354). Women were more likely to have a negative appendicectomy than men (28% vs. 9%, p < 0.01). The perforation rate for appendicectomy patients was 36% (970/2 688), and mortality rate was 1% (36/2 946). Research efforts focused on investigating differential incidence and outcomes between racial groups within the country.

CONCLUSION

Appendicitis trends in South Africa are consistent with those in developing regions. However, there is lack of research from the private sector. Further research is needed to investigate specific factors which delay care, outcomes and cost analyses for laparoscopic surgery, and the system strengthening of surgical services at district hospitals.