Complication rates associated with nasoesophageal versus nasogastric feeding tube placement in dogs and cats: a randomised controlled trial

OBJECTIVES

To determine the rate of accidental placement of nasoenteric tubes into the respiratory tract. To compare the methods of checking correct tube placement. To compare the complication rates between nasoesophageal and nasogastric tubes.

MATERIALS AND METHODS

Animals requiring nasoenteric feeding tubes were prospectively randomised to have either nasoesophageal or nasogastric tube placement. Various techniques for assessing tube position were compared with thoracic radiographic findings. Complications during placement and use were recorded.

RESULTS

Ninety-seven animals (82 dogs and 15 cats) were studied. The tube was misplaced into the respiratory tract in three (3.1%) cases. No technique for checking placement was completely concordant with radiography but the presence of negative pressure at the thoracic inlet during placement was consistent with the presence of the tube in the oesophagus in 86.2% cases, while capnography can be considered to confirm tracheal placement. The overall rate of complications during tube placement was 25.8%, with mostly minor clinical complications reported. There was no significant difference in the new-onset regurgitation/vomiting rate, or complications while the tube was in situ between the nasoesophageal and nasogastric groups.

CLINICAL SIGNIFICANCE

Misplacement of nasoenteric tubes is uncommon but a consistent alternative test to radiography for checking correct nasoenteric tube placement was not demonstrated. The choice of placement of either a nasoesophageal or nasogastric tube should be guided by clinician preference, and clients should be warned about possible complications during placement and while the nasoenteric tube is in situ.

VegAnn, Vegetation Annotation of multi-crop RGB images acquired under diverse conditions for segmentation

Applying deep learning to images of cropping systems provides new knowledge and insights in research and commercial applications. Semantic segmentation or pixel-wise classification, of RGB images acquired at the ground level, into vegetation and background is a critical step in the estimation of several canopy traits. Current state of the art methodologies based on convolutional neural networks (CNNs) are trained on datasets acquired under controlled or indoor environments. These models are unable to generalize to real-world images and hence need to be fine-tuned using new labelled datasets. This motivated the creation of the VegAnn - Vegetation Annotation - dataset, a collection of 3775 multi-crop RGB images acquired for different phenological stages using different systems and platforms in diverse illumination conditions. We anticipate that VegAnn will help improving segmentation algorithm performances, facilitate benchmarking and promote large-scale crop vegetation segmentation research.

A Phase II, Open-Label Study of an Accelerated Infusion Rate of Daratumumab in Patients With Relapsed and Refractory Multiple Myeloma

INTRODUCTION/BACKGROUND

Daratumumab is an anti-CD38 monoclonal antibody initially approved as a single agent for the treatment of relapsed and refractory multiple myeloma. The infusion-related reactions (IRRs) commonly seen with intravenous daratumumab have been managed by prolonging the first infusion, temporarily stopping/slowing the rate if reactions occur and using adequate pre- and post-infusion medications. Several retrospective studies have evaluated shorter infusions after ≥ 2 prior doses administered at the standard rates. Although the shorter infusions were well-tolerated, patients in these reports were given heterogeneous daratumumab regimens and had often already received multiple doses at the longer standard rates.

PATIENTS AND METHODS

CMRG-009 is a prospective study designed to demonstrate the safety of accelerated daratumumab infusions commencing with the second dose. After an initial dose on Cycle 1 Day consisting of 8 mg/kg over 4 hours, all subsequent doses were given over 90 minutes.

RESULTS

No grade 3 IRRs were observed with the 90-minutes infusions. Both the safety profile and anti-myeloma effects were otherwise similar to those observed with other single agent daratumumab studies using longer infusion times.

CONCLUSION

This is the first formal prospective trial using infusion times shorter than the standard schedule directly after an initial 4-hours dose. This rapid infusion protocol has resulted in more efficient resource utilization and has become the standard protocol for the use in all intravenous daratumumab regimens in Canada. This approach has been particularly helpful in shortening chair time during the COVID-19 pandemic and providing a useful alternative in jurisdictions without access to subcutaneous daratumumab.

The relationship between early weight loss and weight loss maintenance with naltrexone-bupropion therapy

BACKGROUND

Extended-release (ER) naltrexone/bupropion (NB) was associated with greater weight loss than placebo in four randomized, 56-week trials. The association of NB with longer-term maintenance of weight loss remains unknown.

METHODS

We conducted a post-hoc analysis of four phase III, randomized, double-blind, placebo-controlled, 56-week studies (COR-I, COR-II, COR-BMOD, and COR-DM), the placebo-controlled cardiovascular outcomes trial LIGHT (208 weeks), and the randomized, open-label trial IGNITE (78 weeks). Included subjects were treated with NB 32 mg/360 mg or placebo, with baseline, week 16, and final time point data. The primary outcome was Kaplan-Meier-estimated weight loss maintenance in each study for up to 204 weeks.

FINDINGS

Our analysis included data from 10,198 particpants (NB=5412; placebo=4786). Proportions of patients with ≥5% or ≥10% weight loss maintenance were numerically higher for NB vs. placebo in all studies and time points. Differences were statistically significant for ≥5% weight loss maintenance in COR-BMOD and COR-I/-II at weeks 52 and 56 and the LIGHT study at weeks 52, 104, and 208. For ≥10% weight loss maintenance, differences were statistically significant in COR-I/COR-II at weeks 52 and 56.

INTERPRETATION

These data suggest that NB could be used as part of long-term, comprehensive weight loss and weight loss maintenance strategies.

FUNDING

Orexigen Therapeutics, Inc. and Bausch Health Canada.

Extended-release naltrexone/bupropion is safe and effective among subjects with type 2 diabetes already taking incretin agents: a post-hoc analysis of the LIGHT trial

Background

Extended-release naltrexone/bupropion (NB) is indicated for chronic weight management. Incretin agents are recommended for patients with type 2 diabetes. This analysis looked at the add-on of NB to incretins to see if weight loss could occur in patients already stabilized on incretin agents.

Methods

This was a post-hoc analysis of NB vs. placebo (PL) among subjects with type 2 diabetes stable on an incretin agent prior to randomization in a double-blind, PL-controlled cardiovascular outcome trial (N = 1317).

Results

Over 1 year, mean weight loss was significantly greater among NB patients vs. PL among those taking DPP-4i (mean absolute difference 4.6% [p < 0.0001]) and those taking GLP-1RAs (mean absolute difference 5.2%, p < 0.0001). Proportions of subjects achieving 5% weight loss were significantly greater for NB vs. PL at weeks 26 and 52 among those taking DPP-4is or GLP-1RAs. There were no significant differences in effectiveness observed between NB + DPP-4i and NB + GLP-1RA or between PL + DPP-4i and PL + GLP-1RA in any of the analyses. Serious adverse events were reported by 9.1% and 11.1% for PL + DPP-4i and PL + GLP-1RA, respectively, and 13.3% and 12.4% of NB + DPP-4i and NB + GLP-1RA, respectively.

Conclusion

NB appears to be effective in reducing weight in patients with T2DM and obesity/overweight who are taking DPP-4ihibitors or GLP-1RA. The SAE rates in all arms of this analysis were lower than have been reported in other cardiovascular outcome trials in type 2 diabetes.

Early Acute Kidney Injury Following Major Burns

Acute kidney injury (AKI) early after a major burn has not been widely studied. Our purpose was to evaluate the prevalence of and risk factors for early AKI and the effect of early AKI on outcome. Retrospective cohort study of adults with burns ≥20% TBSA admitted between November 24, 2015 and July 1, 2019. "Early AKI" occurring within 7 days of injury was identified using urine output and serum creatinine Kidney Disease International Global Outcome criteria. Multivariate regression models were developed for development of early AKI, development of AKI on day 0 or 1 postburn ("very early AKI"), and for in-hospital death. Among 85 patients, 62.4% developed early AKI, of which 26% had stage 3 AKI. Renal replacement therapy was required in 64% of stage 3 patients by day 7. Patients with early AKI were significantly older [50 (40.5-61) vs 37.5 (27.2-46.8) years, P < .001], and a significantly greater proportion was intubated in the first 24 hours postburn (90.6 vs 59.4%, P = .001). Resuscitation with high-dose vitamin C (HDVC) was independently associated with more frequent early AKI. Older age was significantly associated and HDVC was closely associated with increased very early AKI. In-hospital mortality was 37.7% for patients with early AKI. Older age, larger burn size, and development of early stage 3 AKI were independently associated with increased in-hospital death. Early AKI is common and carries a poor prognosis for survival. Resuscitation involving HDVC appears to be related to a higher likelihood of early and possibly very early AKI.

Extended-release naltrexone/bupropion and liver health: Pooled, post hoc analysis from four randomized controlled trials

Sustained weight loss improves liver histology in non-alcoholic fatty liver disease. This post hoc analysis of four phase III, 56-week, randomized controlled trials investigated if extended-release naltrexone and bupropion (NB) affects alanine aminotransferase (ALT) and Fibrosis-4 (FIB-4) index in adults with overweight or obesity. Two thousand and seventy-three subjects (NB = 1310; placebo = 763; 79.0% female; 81.6% Caucasian) had baseline mean weight 101 kg, body mass index 36.2 kg/m² , ALT 26.9 IU/L and FIB-4 0.79. At 56 weeks, NB-treated subjects experienced more weight loss than placebo (8.7 vs. 3.2 kg, respectively, P < .0001). Weight loss, independent of treatment, was associated with improved ALT and FIB-4 (P < .0001). There was a significant independent effect of NB on change from baseline for FIB-4 (P < .0001), but not for ALT (P = .54). Categorical ALT response (from above to within normal ranges: 10-40 IU/L for men; 7-35 IU/L for women) and achievement of 25% and 50% reduction in ALT were greater for NB versus placebo, and independently affected by weight loss (P < .0001), but not treatment. NB-associated weight loss may improve liver health by normalizing ALT values for those with high baseline levels.

Peer navigation-delivered loving kindness meditation: A pilot project

Peer navigators (PNs), including trained cancer survivor volunteers, can be an important resource to the cancer care team in reducing barriers to screening, treatment, and psychosocial care among underserved communities through their roles in outreach, education, advocacy, and peer support. As cancer centers face growing patient demand and evidence for integrating complementary therapies into conventional care, opportunities to envision new roles for PN arise. Based on psychosocial assessments conducted at an academic cancer center serving the low-income population of Bronx, NY, we found strong interest in both providing (44 %) and receiving (76 %) peer support, as well as in (76 %) mind-body practices (e.g., meditation). In research, these mind-body modalities and peer support have both been found to improve many aspects of physical and emotional outcomes in cancer patients, but none has looked at PNs as a potential resource for delivering such mind-body interventions. Towards this end, we conducted two pilot studies to train PN from an onsite peer navigation program called the BOLD Buddy Program, to deliver a well-defined, easy to learn, and culturally-aligned mind-body practice, i.e., Loving Kindness (LK) Meditation, to each other and to patients. Incorporating comparison to professional meditation instructors, our pilot work demonstrated that peer-lead LKM was associated with benefits to emotional well-being, relaxation, satisfaction, and perceived usability and that PNs were equally well-received in delivering LK as their professional counterparts. Evaluating 8 domains of feasibility using standardized measures, we were able to demonstrate that peer-lead LK was: in demand, acceptable, implementable, practical, adaptable, adoptable, expandable, and promising in efficacy.

The use of vasopressors during acute burn resuscitation

BACKGROUND

Vasopressors may be required during acute burn resuscitation to support mean arterial blood pressure, but their use is not well-described in the burn literature. The purpose of this study was to examine vasopressor use during acute fluid resuscitation.

METHODS

Retrospective review of adults with burns ≥ 20% TBSA admitted to an ABA-verified regional burn center. Patients administered an infusion of a vasopressor for at least 30 min during the 1 st 48 h post-burn formed the PRESSOR group while patients who did not receive vasopressors formed the NoPRESSOR group.

RESULTS

We studied 52 burned adults, 85% of which had flame burns. Vasopressors were administered during resuscitation to 31% of patients. Vasopressor infusions began at 20.9 ± 10.9 h post burn and were continued for 16.8 ± 10.8 h. PRESSOR patients (N = 16) had significantly greater total (p = 0.001) and full thickness burn size (p < 0.001), and need for mechanical ventilation (p = 0.005) than NoPRESSOR patients (N = 36). PRESSOR and NoPRESSOR patients did not differ significantly in per cent predicted fluid volume received in the first 24 h (143 ± 58 Vs. 125 ± 46 respectively). PRESSOR patients compared to NoPRESSOR patients tended to have been administered 5% albumin (Alb) less often (38% Vs 47%) and high dose vitamin C (HDVC) more often during resuscitation (69% vs 17%). Multivariate regression analysis found that patient age (OR 1.189, 95% CI: 1.047, 1.351) and HDVC (OR 24.701, 95% CI: 1.558, 391.551) were independently associated with greater use of vasopressors. An inverse probability weighted propensity analysis also identified a significant association between HDVC and increased use of vasopressors (OR 6.902, 95 % CI: 2.503, 19.026), and significantly decreased vasopressor administration following Alb administration (OR 0.310, 95% CI: 0.130, 0.739).

CONCLUSION

Advanced age appears to be the most important determinant of vasopressor use during resuscitation. While vasopressor requirements appear to have been increased by HDVC and decreased by Alb, this needs to be formally evaluated in a large randomized study.

CANadian CAnagliflozin REgistry: Effectiveness and safety of canagliflozin in the treatment of type 2 diabetes mellitus in Canadian clinical practice

AIM

There is limited information concerning the effects of canagliflozin (CANA), a sodium-glucose co-transporter 2 inhibitor (SGLT2i) in a real-world clinical setting in Canada. CanCARE is a 12-month, prospective, observational analysis to demonstrate the effectiveness and safety of CANA in usual clinical practice in Canada.

MATERIALS AND METHODS

SGLT2i-naïve adult patients with type 2 diabetes mellitus (T2DM) (n = 527) on a stable antihyperglycemic agent (AHA) regimen with glycated hemoglobin (A1C) ≥ 7%, an estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73m2 , were initiated on CANA as part of their usual treatment approach, and were followed for a period of 12 months. The primary effectiveness objective was the mean change in HbA1c from baseline to 6 and 12 months.

RESULTS

Significant improvement from baseline in mean HbA1c levels were observed at 6 months (-0.90%; 95% CI, -1.02, -0.78) and at 12 months (-1.04%; 95% CI, -1.15, -0.92), regardless of duration of diabetes or background AHA treatment regimen. Similarly, significant decreases in systolic blood pressure (-4.65 mm Hg); body weight (-3.24 kg), waist circumference (-2.91 cm) and body mass index (-1.15 kg/m2 ) were observed at 12 months. Additionally, 40.5% of patients achieved the double endpoint (≥0.5% HbA1c reduction and ≥ 3% weight loss), while 24.3% of patients achieved the triple composite endpoint (≥0.5% HbA1c reduction, ≥3% weight loss and ≥ 4 mm Hg systolic blood pressure reduction). No unexpected adverse events were reported.

CONCLUSION

CANA provided sustained clinically meaningful improvements in cardiometabolic parameters in this study in a real-world setting, confirming findings from randomized controlled trials.

Real World Effectiveness of Golimumab Therapy in Ulcerative Colitis Regardless of Prior TNF Exposure

Background

The efficacy of golimumab to induce and maintain remission in biologic-naïve patients with ulcerative colitis (UC) is established from placebo-controlled trials. However, golimumab's real-world effectiveness, important to physicians and payers, remains unexplored.

Aim

The goal of this study was to describe real-world use and rate of persistence among UC patients with golimumab therapy and to assess factors that predict discontinuation during golimumab maintenance treatment.

Methods

A retrospective study of UC patients receiving golimumab maintenance therapy (August 2012-August 2015) was conducted on dosing data from a national case management program. Treatment persistence, defined as time from index prescription to the last dose (gap in dose >60 days), was assessed using Kaplan-Meier survival analysis. Predictors of treatment persistence were explored with Cox proportional hazards regression.

Results

One hundred thirty-six patients (50.7% male) with a mean (SD) age of 44.4 (15.6) years were included. At golimumab initiation, 72.1% were naïve to anti-TNFs; 77.2% received 200 mg, while 4.4% and 18.4% received 50 mg and 100 mg, respectively, every 4 weeks (induction therapy). The median time to discontinuation was 530 days, with a cumulative probability of 63% to remain on therapy at one year. Age, gender, golimumab induction, golimumab maintenance dose and prior anti-TNF exposure were not significantly associated with treatment persistence. Dose adjustment occurred in 7.4% of patients during maintenance treatment.

Conclusions

Overall, the persistence rate of golimumab observed in the current real-world study is similar to that described in previous single-centre UC cohorts and consistent with that seen in controlled clinical trials.

Real-world evidence in patient-related outcomes (PROs) of metastatic castrate-resistant prostate cancer (mCRPC) patients treated with abiraterone acetate plus prednisone (AA+P)

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Background: Oral androgen biosynthesis inhibitor, abiraterone acetate plus prednisone (AA+P), has shown to improve survival and patient-related outcomes (PROs) in clinical trials. The COSMiC study (Canadian Observational Study in Metastatic Cancer of the Prostate; ClinicalTrials.gov: NCT02364531) set out to prospectively amass real-world data on mCRPC patients (pts) managed with AA+P in communities within Canada. Here, we report the interim analysis of their PROs. Methods: At planned data cutoff in Sept 2017 after a median follow-up of 33.8 months, 264 pts were enrolled in 39 sites across Canada. Their FACT-P (Functional Assessment of Cancer Therapy – Prostate) and MoCA (Montreal Cognitive Assessment) were evaluated at baseline as well as at weeks 12, 24, 48 and 72 after AA+P initiation. A 10-point decrease denotes clinically significant degradation in FACT-P and a total MoCA score of > = 26 is considered normal. Descriptive analysis was utilized with continuous variables. Changes from baseline were summarized using mean (SD). Results: At a median age of 77 among 264 pts, 230, 185, 110 and 63 pts were available for analysis at their week 12, 24, 48, and 72 assessments respectively. The mean baseline FACT-P total score was 111.2 (19.44) with a < 3-point absolute change from baseline at subsequent assessments, denoting no clinically significant change in functional status over time. The mean baseline MoCA score was 25.2 (4.50), yet all subsequent assessments scored above 26 and a mean absolute change from baseline of < 1, showing an absence of cognitive decline over time. PSA value was available for 221 pts, 64.3% (142/221) and 34.4% (76/221) achieved a PSA decline of > 50% and 90% respectively. All-grade treatment-related adverse events were reported in 63 pts, with 11% who have had AA+P discontinuation or interruption. Conclusions: COSMiC represents the largest Canadian mCRPC cohort treated with AA+P with real world prospective evaluation of PROs. This data demonstrated the maintenance in quality of life and cognitive status over the course of the study, and underscores the importance of PRO utilization in this complex patient population. Clinical trial information: NCT02364531.

Cost-effectiveness of golimumab for the treatment of patients with moderate-to-severe ulcerative colitis in Quebec using a patient level state transition microsimulation

OBJECTIVE

To conduct cost-effectiveness analyses comparing the addition of golimumab to the standard of care (SoC) for treatment of patients with moderate-to-severe ulcerative colitis (UC) who are refractory to conventional therapies in Quebec (Canada).

METHODS

An individual patient state transition microsimulation model was developed to project health outcomes and costs over 10 years, using a payer perspective. The incremental benefit estimates for golimumab were driven by induction response and risk of a flare. Flare risks post-induction were derived for golimumab from the PURSUIT maintenance trial and extension study, while those for SoC were derived from the placebo arms of the Active Ulcerative Colitis Trials (ACT) 1 and 2. Other inputs were derived from multiple sources, including retrospective claims analyses and literature. Costs are reported in 2014 Canadian dollars. A 5% annual discount rate was applied to costs and quality-adjusted life-years (QALYs).

RESULTS

Compared with SoC, golimumab was projected to increase the time spent in mild disease or remission states, decrease flare rates, and increase QALYs. These gains were achieved with higher direct medical costs. The incremental cost-effectiveness ratio for golimumab vs SoC was $63,487 per QALY.

LIMITATIONS

The long-term flare projections for SoC were based on the data available from the ACT 1 and 2 placebo arms, as data were not available from the PURSUIT maintenance or extension trial. Additionally, the study was limited to only SoC and golimumab, due to the availability of individual patient data to analyze.

CONCLUSION

This economic analysis concluded that treatment with golimumab is likely more cost-effective vs SoC when considering cost-effectiveness acceptability thresholds from $50,000-$100,000 per QALY.

Fibroblast Growth Factor 23 Predicts Mortality and End-Stage Renal Disease in a Canadian Asian Population with Chronic Kidney Disease

BACKGROUND

Chronic kidney disease (CKD) is a leading cause of morbidity and mortality. Biomarkers that predict end-stage renal disease (ESRD) and/or mortality could usher in new therapeutics to halt this onslaught. While fibroblast growth factor (FGF)23 can predict both ESRD and mortality, it has not been studied in North American CKD patients of Asian ethnicity.

METHOD

This is a prospective investigation about the role of FGF23 in 998 Canadian patients of Asian descent with CKD defined by an estimated glomerular filtration rate (eGFR) <60 mL/min/m2 and followed up for 3 years.

RESULTS

The mean age of patients was 68.9 years and 68.3% were males. The mean (range) eGFR, and median FGF23 were 40.2 (11.0-59.0) mL/min and 154.1 (7.0-7,823.0) RU/mL, respectively. Over the 3 years, higher values of FGF23 levels at baseline were associated with higher risk of ESRD (hazard ratio [HR] for log[Fgf23] = 2.16 [95% CI 1.20-3.89]). Despite the short follow-up, 42 patients died due to cardiovascular diseases (38.8%), cancer (14.9%), and infections (12.7%). Log-FGF23 levels were independently associated with death, HR 1.94, 95% CI 1.24-3.03. Mortality risk increased in FGF23 subgroups from <100 to >400 RU/mL. In a time-changing covariate analysis, serial log-FGF23 levels over the 3 years predicted mortality with a HR of 2.66 (95% CI 1. 79-3.95).

CONCLUSION

In a Canadian Asian population with CKD, FGF23 levels obtained at 6-monthly intervals for 3 years predicted ESRD and mortality suggesting that it is also a risk marker in Asians.

Abstract 220: Plasma Extracellular RNAs In Lv Remodeling Post MI

Despite significant declines in early mortality after acute myocardial infarction (MI), heart failure (HF) remains a significant chronic complication following MI. Small non-coding RNAs are short (<200 nt) RNA transcripts that regulate networks of gene expression in cardiovascular disease (CVD), including fibrosis, atherosclerosis and arrhythmia. We hypothesized that plasma circulating extracellular RNAs (ex-RNAs) would be associated with cardiac remodeling by cardiac magnetic resonance in humans post-MI and dysregulated in animal models of ischemia. First, we found that plasma circulating ex-RNA profiles by RNA-seq are distinct in individuals with prior MI relative to healthy individuals without cardiovascular disease with several novel ex-RNAs detected (e.g., y-RNAs; Figure 1 ). Principal components of candidate RNAs selected from differential expression n RNA-seq were associated with LV phenotypes post-MI, specifically LV mass and fibrosis at 4-6 weeks post-MI and change in LV mass at 6 months. In animal and cellular models of ischemia, we found that (1) candidate miRNAs found in humans were expressed in a temporally and cell-specific fashion in the myocardium and (2) candidate miRNA expression increased in cardiomyocyte culture after hypoxia/reoxygenation. Collectively, these data add to a burgeoning literature implicating plasma circulating ex-RNAs as functional markers of acute cardiovascular disease involved in cardiac remodeling en route to HF.

Gedunin inhibits pancreatic cancer by altering sonic hedgehog signaling pathway

INTRODUCTION

The lack of efficient treatment options for pancreatic cancer highlights the critical need for the development of novel and effective chemotherapeutic agents. The medicinal properties found in plants have been used to treat many different illnesses including cancers. This study focuses on the anticancer effects of gedunin, a natural compound isolated from Azadirachta indica.

METHODS

Anti–proliferative effect of gedunin on pancreatic cancer cells was assessed using MTS assay. We used matrigel invasion assay, scratch assay, and soft agar colony formation assay to measure the anti–metastatic potential of gedunin. Immunoblotting was performed to analyze the effect of gedunin on the expression of key proteins involved in pancreatic cancer growth and metastasis. Gedunin induced apoptosis was measured using flow cytometric analysis. To further validate, xenograft studies with HPAC cells were performed.

RESULTS

Gedunin treatment is highly effective in inducing death of pancreatic cancer cells via intrinsic and extrinsic mediated apoptosis. Our data further indicates that gedunin inhibited metastasis of pancreatic cancer cells by decreasing their EMT, invasive, migratory and colony formation capabilities. Gedunin treatment also inhibited sonic hedgehog signaling pathways. Further, experiments with recombinant sonic hedgehog protein and Gli inhibitor (Gant-61) demonstrated that gedunin induces its anti–metastatic effect through inhibition of sonic hedgehog signaling. The anti–cancer effect of gedunin was further validated using xenograft mouse model.

CONCLUSION

Overall, our data suggests that gedunin could serve as a potent anticancer agent against pancreatic cancers.

Assessment of urologists experience with abiraterone acetate and with a real-world trial: Results obtained from a Canadian Observational Study in Metastatic Cancer of the Prostate (COSMiC)

238

Background: Abiraterone Acetate (AA) is a selective inhibitor of the androgen biosynthesis and has significantly improved OS for mCRPC patients. Canadian Observational Study in Metastatic Cancer of the Prostate (COSMiC) is a Non-Interventional Observational Study pPhase IV clinical trial; NCT02364531) specifically designed to (1) collect real-world drug-specific outcomes (clinical and patient reported outcomes) and (2) assess urologists experience with incorporation of AA in their practice. Here we report data collected from COSMiC trial on the success of AA integration into the urology practice and physicians experience in participating in the trial. Methods: (1) A comprehensive questionnaire was developed to assess urologists experience with (a) integration and usage of AA in their practice and (b) COSMiC trial. (2) Questionnaire was sent to the active trial sites (47 sites) and collected data from 30 sites is summarized here. Results: 93.3% of participants in COSMiC trial were urologists (63.3% community vs. 30% academic). The ease of use and success in integration of AA in urology practice was rated easy by 50% of the participants, easy once they overcame few barriers by 46.7% and challenging by 3.3%. Drug-related barriers identified included time involvement (50%), resource issues such as nursing support (23.3%), and lack of appropriate infrastructure (33.3%). 90% of the active sites indicated that treating mCRPC patients with AA will be part of their practice post-trial. As part of this report we also assessed and identified physicians barriers in participating in COSMiC trial. 86.7% of the sites reported that trials such as COSMiC will add value to the therapeutic area and 93.3% of the sites reported interest in participating in trials of this nature in future. Conclusions: This report indicates that integration of AA in urology practices is considered easy and manageable for most urologists, in some cases after overcoming few initial barriers. There is high interest in participating in future real-world trials of this nature among urologists and such studies add value to the therapeutic area. Clinical trial information: NCT02364531.

Influence of enzymes, pH and temperature on the kinetics of whey protein hydrolysis / Influencia de los enzimas, pH y temperatura en la cinética de la hidrólisis de las proteínas del lactosuero

The influence of pH, temperature and the mixture of enzymes (MKC Protease 660 L and PEM 2500 S) on the enzymatic hydrolysis of whey proteins was studied. The experiments show that all results were reproducible via a kinetic model that supposes the rapid and irreversible binding of part of the proteases to an inhibitor in the substrate, followed by a zero-order hydrolysis with respect to the substrate which occurs simultaneously with a second order enzymatic denatural ization produced by an attack of the free proteases upon those bound to the substrate-enzyme complex. Use of the optimum operating temperature of 60 °C and pH 8-10 led to a greater degree of hydrolysis. However, increasing the pH to these levels means that the salt content, on neutral izing the hydrolysate, is somewhat high and this is often unsuitable for the preparation of special diets. In the experiments performed with mixtures of enzymes, two contrasting phenomena occurred; there appears to be synergism between the proteases, which is preceded by a loss in enzymatic activity greater than that which can be accounted for by the presence of the inhibitor in the whey proteins.

Expression and purification of the surface proteins from Andes virus

Andes virus is the main causative agent of Hantavirus cardiopulmonary syndrome in South America. There are currently no vaccines or treatments against Andes virus. However, there are several evidences suggesting that antibodies against Andes virus envelope glycoproteins may be enough to confer full protection against Hantavirus cardiopulmonary syndrome. The goal of the present work was to express, purify and characterize the extracellular domains of Andes virus glycoproteins Gn and Gc. We generated two adenoviral vectors encoding the extracellular domains of Andes virus glycoproteins Gn and Gc. Both molecules were expressed by adenoviral transduction in SiHa cells. We found that sGc ectodomain was mainly secreted into the culture medium, whereas sGn was predominantly retained inside the cells. Both molecules were expressed at very low concentrations (below 1 μg/mL). Treatment with the proteasome inhibitor ALLN raised sGc concentration in the cell culture medium, but did not affect expression levels of sGn. Both ectodomains were purified by immobilized metal ion affinity chromatography, and were recognized by sera from persons previously exposed to Andes virus. To our knowledge, this is the first work that addresses the expression and purification of Andes virus glycoproteins Gn and Gc. Our results demonstrate that sGn and sGc maintain epitopes that are exposed on the surface of the viral envelope. However, our work also highlights the need to explore new strategies to achieve high-level expression of these proteins for development of a vaccine candidate against Andes virus.

Abstract P1-09-10: Disparities in presentation of breast cancer in a geriatric population

Background: Although there are known to be disparities by socioeconomic status (SES) in breast cancer presentation, this has not been as well studied in the elderly. We examined older women in North Carolina (NC) using insurance status as an indicator of SES. Dual Medicaid/Medicare (dMM) status was used as a surrogate for low SES and Medicare only (M) as a surrogate for higher SES.

Methods: From the 1999-2002 NC Central Cancer Registry, we identified women age ≥65 years presenting with nonmetastatic breast cancer, having surgery within 60 days of diagnosis, no neoadjuvant therapy, and insured by Medicare only or dual Medicaid/Medicare. We used Chi-square tests to compare demographic and tumor characteristics, including: age, race, ACE comorbidity index, tumor size, lymph node status (LN), ER/PR status and HER2 status.

Results: We identified n = 3088 women with mean age 75 (SD 6.69) years, including 560 dMM and 2528 M insured women. We found that the dMM patients were older than M patients, with 57.7% ≥75 years, vs. 42.6% (p&lt;0.001) and mean age 76.9 vs. 74.5 years (p&lt;0.001), as well as composed of more African Americans, 34.6% vs. 6.6% (p&lt;0.001). The dMM group also had significantly more comorbidity, with ACE comorbidity index: none 21.4% vs. 40.0%, minimal 45.2% vs. 43.2%, moderate 15.5% vs. 9.8% and severe 17.9% vs. 6.9% (p&lt;0.001). The dMM patients were diagnosed more often with regional as compared to local disease, 26.3% vs. 19.7% (p&lt;0.001) and had larger tumors at diagnosis, mean 23.46mm vs. 18.50mm (p&lt;0.001). Additionally, the dMM patients were found to have more LN involvement: 0 LN in 73.4% vs. 80.0%, 1-3 LN in 19.6% vs. 15.5%, 4-9 LN in 5.7% vs. 3.5% and ≥ 10 LN in 1.3% vs. 1.1% (p = 0.004). We did not find significant differences in tumor histology, grade, ER/PR subtype or HER2 status.

Conclusions: We found that in a population of elderly breast cancer patients, lower SES as defined by Medicaid insurance status was associated with older age, African American race and more advanced comorbidity. These same patients presented with move advanced disease, characterized by larger tumors and more LN involvement.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-09-10.

Kinetic Study of the Absorption of Carbon Dioxide by Aqueous Triethanolamine Solutions

In this work, the absorption of pure carbon dioxide by aqueous triethanolamine solutions (TEA) was studied in terms of the kinetic process. The process was made in a stirred tank reactor with a flat and known interfacial area, the operating variables being temperature (288 to 313 K) and concentration in the range 0.1-2.0 M. From the results, it was deduced that the absorption of pure carbon dioxide by aqueous triethanolamine takes place under isothermal conditions in which there is an instantaneous reaction regime at low concentrations, while at higher concentrations it takes place in a moderately fast reaction regime, following a first-order kinetic with respect to alkanolamine. In these conditions of concentrations and temperatures essayed, an expression for the constant kinetic was deduced.

Similar survival with single-agent capecitabine or taxane in first-line therapy for metastatic breast cancer

Capecitabine is often offered as a first-line chemotherapy option for metastatic breast cancer (MBC). In this study, we compare characteristics of and survival among women prescribed first-line capecitabine or taxane monotherapy for MBC. Women receiving first-line chemotherapy for MBC from 1998 to 2005 were identified from the North Carolina tumor registry linked with Medicaid and Medicare claims records, and were followed through the end of 2005 with survival data from the National Death Index. T Tests and Chi-square tests were used to compare baseline characteristics. Overall survival and cancer-specific survival were examined using Cox proportional hazard modeling. There were 257 patients with MBC starting first-line chemotherapy with capecitabine (n=71) or a taxane (n=186). No differences in age, race, or Charlson comorbidity status were observed between groups. Hormone receptor negative tumors (31.0 vs. 17.7%, p=0.02) and patients insured by Medicaid (28 vs. 12%, p=0.002) were more prevalent in the capecitabine group. Time from metastasis to first-line chemotherapy was longer in the capecitabine group (52 vs. 26% began after 3 months, p<0.001). In multivariate analysis, treatment received was not associated with overall or cancer-specific survival. Among standard demographics, age was the only factor significantly associated with overall survival (HR 1.02, p=04). In this population-based study, women who received capecitabine as first-line treatment for MBC were more often hormone receptor negative and insured by Medicaid. In multivariate analysis, first-line capecitabine and taxane for MBC yielded similar overall and cancer-specific survival outcomes.

The STARRT trial: a cost comparison of optimal vs sub-optimal initiation of dialysis in Canada

BACKGROUND

Sub-optimal transitioning of patients from chronic kidney disease (CKD) to end stage renal disease (ESRD) may result in poor clinical outcomes and increased healthcare costs. The objectives of this study were to estimate the average total cost per patient who requires initiation of renal replacement therapy (RRT) stratified by status at initiation; optimal (RRT initiation as an outpatient with an arterio-venous [AV] Fistula, Graft or Peritoneal Dialysis [PD] catheter), and sub-optimal (RRT initiation as an inpatient and/or via central venous catheter [CVC]).

METHODS

Data from the Study To Assess Renal Replacement Therapy (STARRT), a Canadian, multi-centre, 6 month retrolective study (n = 339), were used for this analysis. Unit costs for resources were obtained from participating hospitals, the literature, and/or standard costing sources. The analysis was performed from the perspective of healthcare payors and reported in 2011 Canadian Dollars (CAD). A propensity score technique was applied to control for potential confounders between the two groups.

RESULTS

Two hundred of the eligible patients for analysis (61.9%) were sub-optimally and 123 (38.1%) were optimally prepared. For this analysis, 106 "matched" pairs were used. The average total cost per patient was estimated to be $63,225 (with a 95% CI ranging from $58,663-$67,958) for the sub-optimally initiated patients, and $39,260 (with a 95% CI ranging from $35,683-$43,007) for the optimally initiated patients (p < 0.001).

LIMITATIONS

Costs were calculated utilizing a conservative approach, using the cheapest available prices for medications and other resources. Assumptions had to be made for the costing of dialyses.

CONCLUSION

The results of this study indicate, after adjusting for potential confounders, that optimally initiated patients for RRT have significantly lower healthcare-associated costs compared to sub-optimally initiated patients.

Abstract P187: Assessing Gender Bias in the Treatment of Cardiovascular Disease in Canada

The objective of this study was to determine the presence of gender bias in the treatment of CVD in Canada. Gender bias has been explored extensively in the treatment of CVD, particularly AMI. Previous research is inconsistent in suggesting that women who suffer an AMI are treated less optimally than men. To date, gender bias has not been well addressed in other CVD's, specifically CVA, CABG, or RRT. In an attempt to get a clearer grasp of the problem, CAP was also studied and served as a control. Retrospective chart reviews for all AMI's, CVA's, CABG's, and CAP's in 1995/6, 1998/9, and 2000/1 in two locations of Newfoundland (St. John's and central) were reviewed. Outcomes were analyzed for differences between men and women. Adjusting for baseline differences, regression models were used to assess the following: AMI - time to thrombolytics, admission to CCU, death, discharge beta blockers, ACE/ARB, anti-lipids, ASA; CVA - LOS, transfer to and time to rehabilitation center, death; CABG - time to CABG; CAP - appropriateness of antibiotics (AB), death. RRT was analyzed from the results of the STARRT (Study To Assess Renal Replacement Therapy) study, a Canadian multicentre retrospective chart review of incident dialysis patients followed for six months. Outcomes were explored for differences in care between men and women. Optimal care was based on 1) length of pre-dialysis care; 2) modality choice; 3) access; 4) laboratory parameters at dialysis start; 5) clinical outcomes. Women who had suffered an AMI had a significantly longer time to thrombolytics and were less likely to be admitted to the CCU but did not differ significantly from men in other modes of treatment. Women who were RRT patients began dialysis at a lower eGFR level after receiving less pre-dialysis care than men. Women who received treatment for CAP were less likely than men to receive the appropriate AB's according to the 1993 guidelines for AB treatment of CAP. There were no significant treatment differences between men and women who had suffered a CVA or who had had a CABG. There were no gender differences in death for any of the diseases. There is little evidence of a significant gender bias in cardiovascular disease in Canada. A potential gender bias in the treatment of CVD patients needs to be explored further.

Suboptimal initiation of dialysis with and without early referral to a nephrologist

BACKGROUND

Our objective was to examine patients who initiate renal replacement therapy (RRT) at 10 representative Canadian centers, characterize their initiation as inpatient or outpatient and describe their initial type of dialysis access, duration of pre-dialysis care and clinical status at the time of dialysis initiation. We also examined the impact of an optimal dialysis start (i.e. initiated as an outpatient with an arteriovenous fistula, arteriovenous graft or peritoneal dialysis catheter) on subsequent health outcomes.

METHODS

Charts of consecutive incident RRT patients were identified from 1 July to 31 December 2006. Information was collected until 6 months after the initiation or until death, transplant or transfer.

RESULTS

Three hundred and thirty-nine incident RRT patients were studied: 39.6% initiated as an inpatient; 54% started hemodialysis (HD) with a central venous catheter; 15.3% had <1 month predialysis care, while 64.6% had >1 year. Optimal starts occurred in 39.5% of patients. For HD patients, optimal starts occurred in 19.8%. Suboptimal starts were noted in patients referred <12 months prior to end-stage renal disease (44%) and in patients referred earlier (56%). The composite end point of death, transfusion or subsequent hospitalization was significantly reduced with an optimal start [hazard ratio 0.47 (95% confidence interval 0.32-0.68), P = 0.0001].

CONCLUSIONS

Suboptimal initiation of dialysis is common in patients referred early or late. The benefits of early referral are lost if dialysis is initiated suboptimally. There is a need to identify factors that lead to suboptimal initiation despite early referral.

Fungal microbiota from rain water and pathogenicity of Fusarium species isolated from atmospheric dust and rainfall dust

In order to determine the presence of Fusarium spp. in atmospheric dust and rainfall dust, samples were collected during September 2007, and July, August, and October 2008. The results reveal the prevalence of airborne Fusarium species coming from the atmosphere of the South East coast of Spain. Five different Fusarium species were isolated from the settling dust: Fusarium oxysporum, F. solani, F. equiseti, F. dimerum, and F. proliferatum. Moreover, rainwater samples were obtained during significant rainfall events in January and February 2009. Using the dilution-plate method, 12 fungal genera were identified from these rainwater samples. Specific analyses of the rainwater revealed the presence of three species of Fusarium: F. oxysporum, F. proliferatum and F. equiseti. A total of 57 isolates of Fusarium spp. obtained from both rainwater and atmospheric rainfall dust sampling were inoculated onto melon (Cucumis melo L.) cv. Piñonet and tomato (Lycopersicon esculentum Mill.) cv. San Pedro. These species were chosen because they are the main herbaceous crops in Almeria province. The results presented in this work indicate strongly that spores or propagules of Fusarium are able to cross the continental barrier carried by winds from the Sahara (Africa) to crop or coastal lands in Europe. Results show differences in the pathogenicity of the isolates tested. Both hosts showed root rot when inoculated with different species of Fusarium, although fresh weight measurements did not bring any information about the pathogenicity. The findings presented above are strong indications that long-distance transmission of Fusarium propagules may occur. Diseases caused by species of Fusarium are common in these areas. They were in the past, and are still today, a problem for greenhouses crops in Almería, and many species have been listed as pathogens on agricultural crops in this region. Saharan air masses dominate the Mediterranean regions. The evidence of long distance dispersal of Fusarium spp. by atmospheric dust and rainwater together with their proved pathogenicity must be taken into account in epidemiological studies.

Increased nitric oxide concentrations in the small airway of older normal subjects

BACKGROUND

There is a paucity of normal-age stratified data for fraction of exhaled nitric oxide (Feno). Our goal was to obtain normal data for large-airway nitric oxide flux (J'awno) and small-airway and/or alveolar nitric oxide concentration (Cano) in nonsmoking, healthy, adult subjects of various ages.

METHODS

In 106 normal volunteer subjects (60 women) aged 55 ± 20 years (mean ± SD), Feno (parts per billion [ppb]) was measured at 50, 100, 150, and 200 mL/s and J'awno (nL/s) and Cano (ppb) were calculated using a two-compartment model with correction for axial nitric oxide (NO) back diffusion. Fourteen older normal subjects were also treated with inhaled corticosteroid (540 μg budesonide bid) for 14 days.

RESULTS

We studied 34 younger normal subjects (17 women) aged 18 to 39 years (younger), 26 middle-aged normal subjects (22 women) aged 40 to 59 years (middle-aged), and 46 older normal subjects (21 women) aged 60 to 86 years (older). Feno at 50 mL/s in the younger group was 21 (14-28) ppb (median, 1-3 interquartile); in the middle-aged group it was 22 (18-30) ppb, and in the older group it was 27 (21-33) ppb, (analysis of variance [ANOVA]) P = .02. For Feno, the younger vs older groups was (Mann-Whitney) P = .03, and Feno in the combined younger and middle-aged groups was 21 (15-29) ppb vs 27 (21-33) ppb, P = .006 for the older group. Corrected J'awno in the younger group was 1.5 (1.0-2.1) nL/s; in the middle-aged group it was 1.4 (1.0-2.0) nL/s, and in the older group it was 1.8 (1.2-2.4) nL/s, (ANOVA) P = .3. Corrected Cano in the younger group was 1.9 (0.8-3.0) ppb; in the middle-aged group it was 2.8 (0.8-5.1) ppb, and in the older group it was 3.9 (1.4-6.6) ppb, (ANOVA) P = .02. Cano in the younger vs older groups was P = .003, and the combined younger and middle-aged group result was 2.0 (0.8-3.8) vs 3.9 (1.4-6.6), P = .01 in the older group. There was no change in NO gas exchange with inhaled corticosteroids.

CONCLUSIONS

In nonsmoking healthy subjects with normal spirometry, Feno at 50 mL/s and Cano increased significantly with age ≥ 60 years, whereas J'awno did not. We suspect the increase in Cano was due to a decrease in capillary blood volume with reduced NO diffusion, which is also reflected in increased Feno. Inhaled budesonide had no anti-NO-mediated inflammatory effect. Age-matched control subjects will be needed in NO comparative studies.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00576069 and NCT00568347; URL: www.clinicaltrials.gov.

Persistence with cholinesterase inhibitor therapy for dementia: an observational administrative health database study

OBJECTIVE

To determine if choice of drug and ease of administration affect persistence of therapy with cholinesterase inhibitors (ChEIs) for treatment of dementia.

METHODS

An observational administrative health database study was conducted in 5622 patients aged >or=65 years who received a new prescription for donepezil (DON), rivastigmine (RIV) or galantamine (GAL) from February to May 2006. Patients were followed for 1 year from initiation of therapy to determine percentage persistence and days of therapy. Once-daily galantamine extended release (GAL-ER) was compared with twice-daily galantamine immediate release (GAL-IR) to determine if ease of administration affected persistence. Previous treatment with ChEIs was also documented.

RESULTS

One-year persistence rates were significantly different among the ChEIs: GAL-ER 54% (95% CI 51, 57), DON 46% (95% CI 43, 49) and RIV 40% (95% CI 37, 43). Average days of therapy were greater for GAL-ER (293) than for RIV (272), but there were no differences between DON (287) and GAL-ER or DON and RIV. One-year persistence was significantly greater for GAL-ER 54% (95% CI 48, 59) than for GAL-IR 44% (95% CI 39, 50), although there was no significant difference in days of therapy (293 vs 286, respectively). More patients currently treated with RIV (40.5%) or GAL-ER (32.3%) had received previous treatment with a different ChEI than with DON (21.9%).

CONCLUSION

Among possible factors affecting persistence of ChEI therapy for dementia, choice of drug, ease of administration and previous treatment appear to be important.