240 STANDARDISING POST-FALL MEDICAL REVIEWS FOR HOSPITAL INPATIENTS

Background

Falls are the most common adverse incident of inpatients in Irish hospitals. 6% of inpatient falls cause serious injury. Older inpatients have the highest risk of falling and the highest risk of injury. The post-fall medical review is critical to assess why a patient fell, did the fall cause injury and for the introduction of measures to prevent future falls. We assessed the quality of the post fall reviews in a large hospital. We then introduced a standardised post-fall medical review pro forma and reassessed the quality of the reviews.

Methods

We reviewed 18 charts of patients that fell in hospital and assessed the documentation of the post fall review in terms of the inclusion of key elements such as patient identifiers, history, examination, injury management and future falls prevention. We then introduced a post-fall standardised pro-forma on five wards in the hospital and following this assessed 19 charts of patients who had fallen looking at the same key elements of the post fall review. We compared the quality of the post-fall review before and after the introduction of the pro forma.

Results

The post-falls medical review pro forma improved the quality of the post fall medical review. Hip Trauma: 11.1% of doctors asked about hip strike prior to proforma versus 100% who asked with the proforma. Joint examination: 50% assessed this prior to the proforma versus 100% with the pro-forma. Other aspects of the review that improved included head-strike assessment (89% versus 100%), loss of consciousness history (61% versus 95%), medication reviewed (22% versus 68%) and vital signs assessed (67% versus 95%).

Conclusion

The introduction of a standardised post fall review pro forma improves the quality of this important medical review. It is a useful aid for doctors and provides a framework to follow when reviewing the patient.

60 EVALUATING THE TIME THAT PATIENT’S WITH DEMENTIA/DELIRIUM SPEND IN THE EMERGENCY DEPARTMENT PRIOR TO TRANSFER TO A WARD

Background

Patients with dementia and delirium are often waiting long times in the emergency department (ED) prior to being transferred to a ward bed during an acute hospital admission. This may be associated with increased morbidity and mortality. Best practice is for rapid triage to an appropriate bed via a delirium/dementia pathway.

Our aim was to document the patient experience time (PET) for older patients with a diagnosis of dementia or delirium in ED in an urban tertiary-referral hospital.

Methods

Over a two-week period 07/12/20–21/12/20, we identified all patients admitted under a general medical specialty through ED, aged ≥65 years, with a diagnosis of dementia or delirium on the admission sheet. Patients admitted with a stroke or hip fracture were excluded. ED PET was recorded, as well as final ward destination.

Results

We included 29 patients in the study—median age was 82 years (range 71–92); 19 (66%) were female. Delirium was the presenting complaint in 79.31% (n = 23) of cases.

Sixteen (55%) patients presented between 8 am-5 pm. The average time spent from triage to ED doctor review was 1 hour 48 minutes; from ED doctor review to medical referral −1 hour 27 minutes; from medical referral to decision for medical admission—2 hours 28 minutes; from decision for medical admission to ward admission- 5 hours. Overall, the average ED PET for these patients was 10 hours 42 minutes.

Five patients (17%) were admitted directly to a Specialist Geriatric Ward (SGW). Twenty patients (69%) did not reach a SGW during the study period.

Conclusion

Patients with dementia and delirium may spend prolonged periods of time in the ED putting them at risk for multiple complications. We hope that by introduction of a dementia/delirium combined pathway and care bundle that we can reduce PET for these vulnerable patients.

61 AUDIT: MEDICATION REVIEW POST INPATIENT FALLS

Background

Falls are the most commonly reported incident in the Health Service Executive (HSE). Inappropriate medications and polypharmacy in the elderly can contribute to increased falls risk.

Our aim was to assess whether a medication review was being completed at the time of the post-fall clinician review.

Methods

We completed a retrospective chart review using an audit tool of consecutive inpatient falls, resulting in serious injury, from March–December 2019.

Standards measured against were: HSE Guideline—Service User Falls: A Practical Guide for Review, Medicines and Falls in Hospital: British Society Guidelines, STOPP & START criteria and NICE Guidelines: Falls in Older People 2013.

Results

We identified 33 charts for review (n = 33)—54.55% (18) female and 45.45% (15) male. Average age was 81 ± 11.2 years. The immediate post-fall review was mainly completed by interns (48.49% (16)) and SHO’s (39.39% (13)). A medication review was carried out 9.09% (3) of the time.

A total of n = 28 (84.85%) had poly pharmacy. When analysed for medications known to increase risk of falling, 51.52% (n = 17) were on anti-hypertensives, 45.45% (n = 15) on laxatives, 24.24% (n = 8) on sedative medications, 18.18% (n = 6) on hypnotics/anxiolytics, 15.15% (n = 5) on opioids and 15.15% (n = 5) on diuretics at the time of fall. The majority of these medications (77.42% (n = 24)) were commenced prior to admission. None of these medications were discontinued or the dose changed on review post fall.

Conclusion

Our audit demonstrates that in a cohort of patients who had an inpatient fall medication discontinuation and dose reductions were not performed. Yet, a high burden of polypharmacy and high-risk falls medication were found. This may result in missing a pertinent opportunity to prevent future falls. We advise a structured medication review is carried out for each patient who suffers an in-patient fall to efficiently modify such an easily identifiable risk factor.

Abstract P6-06-50: Obesity and the influence on tumor biology as determined by the intermediate risk 21-gene recurrence scores (RS) and the 70-gene breast cancer recurrence signature (70-GS) assay

BACKGROUND

Obesity is an apparent risk factor for postmenopausal breast cancer (BC), estrogen receptor (ER) positive BC, larger tumors, lymph node (LN) involvement, as well as recurrence of BC and BC death despite treatment. However, the specific mechanism of these increased risks remains unclear. Our prior work described the negative influence of metabolic syndrome on BC recurrence in patients assessed by a 21 gene recurrence score (RS) in the low risk and intermediate risk tertiles (Lakhani et al PSABCS 2012). The objective of this study was to analyze the interaction of obesity and BC biology in patients assessed by the 70 gene signature (70-GS) for BC recurrence and the 80 gene molecular subtyping.

METHODS

We studied consecutive patients with newly diagnosed ER positive, LN negative BC treated at Loyola University Medical Center between 2005 -2012 who had an intermediate RS. The 70-GS was done on these same paraffin-embedded tumor blocks for risk level and molecular subtype. Standard descriptive statistics are reported. Wilcoxon rank sum tests were performed for the comparison of BMI by groups defined by RS scores (≤24 vs ≥25) and the 70 gene signature assay (high risk vs low risk). In addition, Chi-squared test, or Fisher's exact test as appropriate, was used to examine the association between BMI tertiles and the 70GS or molecular subtype.

RESULTS

From 102 patients with intermediate RS, the 70-GS was successful in 89 samples. The average age was 61 years (range 41-79). The median body mass index (BMI) was 29 (range 18-53). There was a significant association between BMI and RS (p = 0.0110): median BMI = 28 in patients with RS ≤24; median BMI 33 in patients with RS ≥25. There was a significant association between BMI and the 70-GS (p = 0.0116). Median BMI 27 in low risk group; median BMI 32 in high risk group. There was a significant association between the 70-GS and BMI (p = 0.0190).

Association between the 70-GS and BMI70-GS RiskHealthy (18-25)Overweight (26-30)Obese (>30)TotalHigh (n pts)1292950Low (n pts)15131139

There was a significant association between molecular subtype and BMI tertiles (p = 0.0803).

Association between molecular subtype and BMI tertiles HealthyOverweightObeseTotalLuminal A (n pts)14131239Luminal B (n pts)1392648

CONCLUSION

There is a striking interaction of obesity and BC biology as defined by the RS and 70-GS assays. Our data suggest that BC in obese women may have more aggressive tumor biology and higher risk of recurrence than BC in those with a low BMI. Further molecular characterization of the BC from obese patients may elucidate the role obesity plays in BC development and progression, as well as provide rationale for targeted therapeutic trials. Clinical trials targeting known carcinogenic pathways related to obesity (such as metformin and statins) are ongoing. Several genes in the 70-GS are the same genes expressed in obese patients. Additional studies examining the prognostic and predictive value of the 70-GS need to be conducted for this patient population.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-50.

Abstract P1-12-04: Carboplatin, nab-paclitaxel and bevacizumab as first-line treatment for metastatic breast cancer

Background: Bevacizumab added to weekly paclitaxel resulted in improved progression free survival (PFS) and objective response rates (ORR) compared to weekly paclitaxel alone. Nab-paclitaxel and the platins are active in MBC. We conducted an efficacy and safety study of carboplatin, nab-paclitaxel and bevacizumab.

Methods: A phase II open label prospective multi-site study enrolled patients (pts) who had measurable MBC according to RECIST 1.1 criteria and no prior chemotherapy for advanced disease. The primary endpoint was PFS with secondary endpoints of overall survival (OS), ORR, and safety. Pts initially received carboplatin AUC 6 day 1, 22,43, plus weekly nab-paclitaxel 100mg/m2 and bevacizumab 15mg/m2 day 1,22,43 of a 56 day cycle. This was later changed to carboplatin AUC 6 day 1, nab-paclitaxel 100mg/m2 day 1,8,15, and bevacizumab 10mg/m2 day 1,15 of a 28 day cycle. Thirty-two pts were required to detect an increase in median PFS from 6.7 to 10.5 mo with 80% power based on a one-sided p = 0.05. Kaplan–Meier analyses estimated PFS and OS. The log rank test was used for the comparison of survival curves between pts with triple negative MBC (TNBC) and pts with non-TNBC.

Results: Thirty-two pts were enrolled between 2/2008 and 11/2011 by 1 academic and 5 community oncology practices. Two pts were ineligible due to non-measurable disease and not included in the response analyses. The median age was 58 years (range 35–81), 22 pts (69%) had an ECOG PS 0, 9 (28%) had a PS 1, 1 (3%) PS 2. Twenty-four (75%) pts had ER+ disease, 7 (22%) had TNBC, 1 (3%) had ER-HER2+ disease not eligible for trastuzumab-based therapy. Metastatic sites were bone (26%), liver (18%), loco-regional (16%), and lung (12%). One pt (3%) had bone and loco-regional disease only, 19 (59%) had visceral dominant disease. The median number of weeks on treatment was 28.9 (range 5–131). The median PFS in all pts was 13.6 months (mo) (95% CI 11.2–21.9), with a median OS of 26.8 mo (95% CI 13.3–41.2). The ORR (2 CR and 18 PR) was 66.7% (CI 47.2–82.7). There also were 6 (20%) unconfirmed PR and 3 (10%) stable disease, resulting in a clinical benefit rate of 96.7% (CI 82.78–99.92). There was no significant difference in PFS (median 13.6 vs 16.1mo, p = 0.37) or OS (median 13.6 vs 26.8mo, p = 0.32) in pts with TNBC versus non-TNBC disease. The most common toxicities of any grade (gr) include neutropenia and thrombocytopenia in 24 pts (75%) each, leukopenia and fatigue in 17 pts (53%) each, anemia in 15 (47%), and neuropathy in 10 (31%). Gr 4 neutropenia was seen in 7 pts (22%) without febrile neutropenia, and gr 4 thrombocytopenia occurred in 6 (19%). There were no pts with gr 4 sensory neuropathy. All pts required chemotherapy dose delays, 15 (47%) had chemotherapy dose reductions.

Conclusions: The carboplatin, nab-paclitaxel and bevacizumab combination is highly effective with good tolerance in first line MBC. As the role of anti-angiogenic therapy in first line metastatic breast cancer is being clarified, this would be an attractive regimen to test in the (neo)adjuvant setting and together with novel molecular targeted agents.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-12-04.

Phg1p is a nine-transmembrane protein superfamily member involved in dictyostelium adhesion and phagocytosis

To identify the molecular mechanisms involved in phagocytosis, we generated random insertion mutants of Dictyostelium discoideum and selected two mutants defective for phagocytosis. Both represented insertions in the same gene, named PHG1. This gene encodes a polytopic membrane protein with an N-terminal lumenal domain and nine potential transmembrane segments. Homologous genes can be identified in many species; however, their function is yet to be elucidated. Disruption of PHG1 caused a selective defect in phagocytosis of latex beads and Escherichia coli, but not Klebsiella aerogenes bacteria. This defect in phagocytosis was caused by a decrease in the adhesion of mutant cells to phagocytosed particles. These results indicate that the Phg1 protein is involved in the adhesion of Dictyostelium to various substrates, a crucial event of phagocytosis and demonstrate the usefulness of a genetic approach to dissect the molecular events involved in the phagocytic process.

Phase II trial of mitotane and cisplatin in patients with adrenal carcinoma: a Southwest Oncology Group study

PURPOSE

Previous reports of chemotherapy in patients with adrenal cancer have described responses to cisplatin (CDDP). Because of these reports of good results, a phase II trial that used CDDP with and without mitotane (o,p'DDD) was initiated.

PATIENTS AND METHODS

Patients with metastatic or residual adrenocortical carcinoma with objectively measurable disease or biochemical abnormalities were divided into good-risk and poor-risk categories. The latter received CDDP 100 mg/m2 intravenously, and the former received 75 mg/m2. o,p'DDD was administered at a 1,000-mg dose orally four times a day along with cortisone acetate and Florinef (fludrocortisone acetate; Bristol-Myers Squibb Co, Princeton, NJ).

RESULTS

Of a total of 42 patients entered onto the study, 37 were eligible. Twenty-nine patients received good-risk and eight received poor-risk doses of CDDP. Functioning tumors were present in 45% of patients. Objective responses were noted in 30% (11 of 37) patients (95% confidence interval, 16% to 50%). Response duration was 7.9 months, and the median time to response was 76 days. The median survival of the 37 eligible patients was 11.8 months, and a significant survival advantage was found for patients who underwent prior surgical removal of their primary tumor or bulky disease, who had a performance status of 0 or 1, or who had synchronous metastatic disease. Toxicity of the CDDP and o,p'DDD combination was moderate to severe, and the most common side effects were gastrointestinal, renal, and neurologic.

CONCLUSION

The regimen of CDDP and o,p'DDD has activity in patients with adrenocortical carcinoma; however, the toxicity of this treatment was moderate to severe.

Phase II trial of recombinant human interferon alpha in myelodysplastic syndromes

Twenty patients with myelodysplastic syndromes were treated with daily subcutaneous injections of interferon alpha 2a, at the initial dose of 3 x 10(6) U/m2. Hemogram, chemistry profile, natural killer (NK) cell activity and lymphokine-activated killer (LAK) cell cytotoxicity were monitored serially. Bone marrow with cytogenetic analysis was done before therapy and every three months afterwards. Normalization to the complete blood count, and wherever applicable, decrease in blast count of 5% or less were defined as a complete response. Improvement in hemoglobin level to 12 g/dl, neutrophil count to 1000/mm3 and platelets to 100,000/mm3 was considered a partial response. The median age was 71 (range 59-83) years and 16 of the patients were males. Two patients withdrew from the treatment in the first week and were considered ineligible. Among the other 18, two had refractory anemia, two refractory anemia with ringed sideroblasts, four chronic myelomonocytic leukemia, eight refractory anemia with excess blasts, and two refractory anemia with excess blasts in transformation to acute leukemia. Twelve patients were treated for six months, the other six were taken off the treatment after six to eight weeks because of disease progression. Only one patient with chronic myelomonocytic leukemia had a partial response for two months. NK cell activity remained unchanged before (18.3 +/- 4.6 lytic units) and during interferon therapy (19.6 +/- 5.3 lytic units). LAK cytotoxicity was not detected in any patient before therapy and was seen in only one patient (not the responder) during therapy (5.7 lytic units). The toxicity of the interferon therapy was substantial. Seventeen patients required a dose reduction and fifteen lost greater than 10% of body weight. Eleven patients (61%) developed infections requiring antibiotic therapy, and eight (44%) required hospitalization. Seven patients developed neurologic toxicity. Interferon alpha 2a is an ineffective but toxic therapy in these elderly patients with myelodysplastic syndromes.

Phase II trial of recombinant DNA gamma-interferon in advanced colorectal cancer: a Southwest Oncology Group study

Fifty evaluable patients with advanced colorectal cancer, but without prior chemotherapy or immunotherapy, were randomized to one of two schedules of recombinant gamma-interferon (rGIFN). Twenty-four evaluable patients received rGIFN as a 2-h intravenous infusion daily x 5 every other week at a starting dose of 4.0 x 10(6) IU/m2/day (arm I). Twenty-six evaluable patients received rGIFN as a 24-h continuous intravenous infusion daily x 5 every month at a starting dose of 2.6 x 10(6) IU/m2/day (arm II). Toxicities on both schedules included flu-like symptoms, fevers/rigors, nausea/vomiting, hypotension, leukopenia, hepatotoxicity, nephrotoxicity, diarrhea, anemia, confusion, and ileus. Toxicity appeared to be more severe on arm I. No antitumor responses were observed, with 95% confidence intervals of 0 to 14% for arm I and 0 to 13% for arm II.

Initial alkylating agent chemotherapy in a leukemic hairy cell patient

A patient with moderate splenomegaly and the leukemic phase of hairy cell leukemia presented with a white blood cell count (WBC) of 85,600/mm3 with 87% hairy cells and platelets of 125,000/mm3. Initial therapy consisted of chlorambucil alone at 4 mg each day. Within 6 months, the WBC decreased to 27,000/mm3 with 82% hairy cells, and the spleen was not palpable; platelets remained at 142,000/mm3. The patient has continued to do well for 2 years since the start of therapy, requiring no transfusions and having no problems secondary to organ infiltration. Selected hairy cell patients, those with a significant leukemic phase and with only mild thrombocytopenia, may benefit from initial chlorambucil therapy rather than immediate splenectomy.

Effect of sex hormones on rabbit arterial subendothelial connective tissue

The effect of sex hormones on subendothelial connective tissue in rabbit arteries was sought, and striking morphological alterations were noted after prolonged treatment. Depot preparations of testosterone cypionate, 100 mg/week, or estradiol cypionate, 200 mug/week, were injected intramuscularly into intact adult New Zealand male rabbits for 8-16 weeks. The iliac arteries were prepared for electron-microscopic examination from five rabbits in each treatment group and in four normal male rabbits. Thin sections were prepared from three randomly selected cross-sectional tissue blocks for each animal. A minimum of 7 mum of vessel circumference was studied in each block. Selection of an area for electron-microscopic examination was random, except that those sites in which the internal elastic lamina showed fragmentation were discarded. Electron micrographs at a single final magnification were evaluated 'blind' by several observers for qualitative difference in subendothelial constituents. In the control group, the subendothelium contained moderate numbers of elastin-associated microfibrils (MF); all the rabbits given testosterone consistently showed significantly fewer MF than the control. In contrast, rabbits given estradiol all had significantly greater numbers of MF. Statistical analysis of variance showed these difference to be significant at p less than 0.001.

Vascular lesions: possible pathogenetic basis of the generalized Shwartzman reaction

Evidence of vascular injury was found in rabbits after a single small dose of endotoxin from Escherichia coli. Eighty percent of the treated animals developed circulating endothelial cells, leukopenia, and thrombocytopenia, and 50 percent had aortic endothelial lesions as determined by electron microscopy. Prior anticoagulation with heparin did not prevent this response. No control animals showed these abnormalities.