Shock Index as a Predictor of Mortality and Hospital Admission in Prehospital Gastrointestinal Bleeding: A Retrospective Cohort Study

OBJECTIVE

To evaluate the Shock Index (SI) as a predictive tool for triage of gastrointestinal bleeding (GI) in the prehospital setting, assessing its correlation with mortality, admission rates, and hospital length of stay.

METHODS

In this retrospective cohort study, we analyzed data from the ESO Data Collaborative encompassing EMS records from the year 2022, focusing on 1525 patients with a primary GI bleeding diagnosis. The primary measure was the SI, calculated at initial contact and highest recorded prior to ED arrival. Statistical analysis included t-tests, linear regression, and ROC curves, performed using SPSS v29.

RESULTS

A significantly higher mean SI was observed in patients who died (mean SI 0.997) compared to survivors (mean SI 0.795), p < 0.001. Admission rates also correlated with higher SI values, p < 0.001. However, SI was not predictive of the hospital length of stay. ROC analysis for mortality prediction yielded an AUC of 0.656 for the initial SI and 0.739 for the highest SI. The standard SI cutoff of 0.9 predicted mortality with a sensitivity of 74.14% and specificity of 55.35% for the highest SI.

CONCLUSION

The SI is a valuable predictive tool for mortality among prehospital patients with GI bleeding. Its application may improve the triage process, potentially influencing transport decisions and initial hospital care. Despite its predictive capability for mortality, the SI should be supplemented with other clinical assessments to make comprehensive prehospital care decisions. Further research into SI as part of a comprehensive assessment which includes end-title CO2, mentation, and heaviness of bleeding.

The development and acceptability of an educational and training intervention for recruiters to neonatal trials: the TRAIN project

BACKGROUND

Suboptimal or slow recruitment affects 30-50% of trials. Education and training of trial recruiters has been identified as one strategy for potentially boosting recruitment to randomised controlled trials (hereafter referred to as trials). The Training tRial recruiters, An educational INtervention (TRAIN) project was established to develop and assess the acceptability of an education and training intervention for recruiters to neonatal trials. In this paper, we report the development and acceptability of TRAIN.

METHODS

TRAIN involved three sequential phases, with each phase contributing information to the subsequent phase(s). These phases were 1) evidence synthesis (systematic review of the effectiveness of training interventions and a content analysis of the format, content, and delivery of identified interventions), 2) intervention development using a Partnership (co-design/co-creation) approach, and 3) intervention acceptability assessments with recruiters to neonatal trials.

RESULTS

TRAIN, accompanied by a comprehensive intervention manual, has been designed for online or in-person delivery. TRAIN can be offered to recruiters before trial recruitment begins or as refresher sessions during a trial. The intervention consists of five core learning outcomes which are addressed across three core training units. These units are the trial protocol (Unit 1, 50 min, trial-specific), understanding randomisation (Unit 2, 5 min, trial-generic) and approaching and engaging with parents (Unit 3, 70 min, trial-generic). Eleven recruiters to neonatal trials registered to attend the acceptability assessment training workshops, although only four took part. All four positively valued the training Units and resources for increasing recruiter preparedness, knowledge, and confidence. More flexibility in how the training is facilitated, however, was noted (e.g., training divided across two workshops of shorter duration). Units 2 and 3 were considered beneficial to incorporate into Good Clinical Practice Training or as part of induction training for new staff joining neonatal units.

CONCLUSION

TRAIN offers a comprehensive co-produced training and education intervention for recruiters to neonatal trials. TRAIN was deemed acceptable, with minor modification, to neonatal trial recruiters. The small number of recruiters taking part in the acceptability assessment is a limitation. Scale-up of TRAIN with formal piloting and testing for effectiveness in a large cluster randomised trial is required.

Low-density lipoprotein cholesterol in adolescents and young adults with type 1 diabetes: Data from the Australasian Diabetes Data Network registry

AIM

To determine low-density lipoprotein cholesterol (LDL-C) screening frequency and levels, and factors associated with elevated LDL-C, in Australasian youth with type 1 diabetes (T1D).

METHODS

Data were extracted from the Australasian Diabetes Data Network (ADDN), a prospective clinical quality registry, on all T1D healthcare visits attended by young people aged 16-25 years (with T1D duration of >1 year) between January 2011 and December 2020. The primary outcomes were elevated LDL-C > 2.6 mmol/L (100 mg/dL) and threshold for treatment: >3.4 mmol/L (130 mg/dL), according to consensus guidelines. Multivariable Generalised Estimated Equations (GEE) were used to examine factors associated with elevated LDL-C across all visits.

RESULTS

A cohort of 6338 young people (52.6% men) were identified, of whom 1603 (25.3%) had ≥1 LDL-C measurement documented. At last measurement, mean age, age at T1D diagnosis and T1D duration were 18.3 ± 2.4, 8.8 ± 4.5 and 8.9 ± 4.8 years, respectively. LDL-C was elevated in 737 (46.0%) and at the treatment threshold in 250 (15.6%). In multivariable GEE elevated LDL-C continuously was associated with older age (OR = 0.07; 0.01-0.13, p = 0.02), female sex (OR = 0.31; 0.18-0.43; p < 0.001), higher HbA1c (OR = 0.04; 0.01-0.08; p = 0.01) and having an elevated BMI (OR = 0.17, 0.06-0.39, p < 0.001).

CONCLUSIONS

LDL-C screening and levels are suboptimal in this cohort, increasing future cardiovascular complication risk. There is an urgent need to understand how healthcare services can support improved screening and management of dyslipidaemia in this population.

What is 'successful rehabilitation'? A multi-stakeholder nominal group technique study to inform rehabilitation outcome measurement

OBJECTIVE

To explore how stakeholders in rehabilitation conceptualise 'successful rehabilitation', to inform the development of a minimum dataset and core outcomes for sub-acute rehabilitation.

DESIGN

Qualitative consensus study using the nominal group technique.

SETTING

Online focus groups.

PARTICIPANTS

Consumer representatives (n = 7), clinicians (n = 15), and health service managers (n = 9) from Australia.

INTERVENTION

Participants responded to the question, 'What does successful rehabilitation look like?'. Following item generation, they prioritised their top five responses, allocating 100 points across items to denote relative importance.

MAIN MEASURES

Prioritised responses were analysed across stakeholder groups using qualitative content analysis.

RESULTS

Ten themes were identified. 'Successful rehabilitation' is: (1) person and family centred; (2) effective; (3) inter-professional; (4) accessible; (5) goal oriented with meaningful outcomes; (6) connected to the continuum of care; (7) evidence-based and supportive of innovation and research; (8) appropriately funded and skilled; (9) satisfying and engaging; and (10) safe.

CONCLUSIONS

Stakeholder-defined 'successful rehabilitation' aligned with principles of value-based care and evidence-based rehabilitation. Provision and receipt of person and family centred care was the most important indicator of successful rehabilitation. Measures of success should include indicators of structure, process, outcome, and experience, and be conducted at multiple time-points.

EPIC: an evaluation of the psychological impact of early-phase clinical trials in cancer patients

Background

Anxiety and depression in patients with cancer is associated with decreased quality of life and increased morbidity and mortality. However, these are often overlooked and untreated. Early-phase clinical trials (EPCTs) recruit patients with advanced cancers who frequently lack future treatment options, which may lead to increased anxiety and depression. Despite this, EPCTs do not routinely consider psychological screening for patients.

Patients and methods

This prospective observational study explored levels of anxiety and depression alongside impact of trial participation in the context of EPCTs. The Hospital Anxiety and Depression Scale and the Brief Illness Perceptions Questionnaire were completed at the point of EPCT consent, the end of screening and at pre-specified time points thereafter.

Results

Sixty-four patients (median age 56 years; median Eastern Cooperative Oncology Group performance status 1) were recruited. At consent, 57 patients returned questionnaires; 39% reported clinically relevant levels of anxiety whilst 18% reported clinically relevant levels of depression. Sixty-three percent of patients experiencing psychological distress had never previously reported this. Males were more likely to be depressed (P = 0.037) and females were more likely to be anxious (P = 0.011). Changes in anxiety or depression were observed after trial enrolment on an individual level, but not significant on a population level.

Conclusions

Patients on EPCTs are at an increased risk of anxiety and depression but may not seek relevant support. Sites offering EPCTs should consider including psychological screening to encourage a more holistic approach to cancer care and consider the sex of individuals when tailoring psychological support to meet specific needs.

•

Early-phase cancer trial patients have an increased risk of anxiety and depression.

•

Patients at risk were not seeking support for anxiety and depression.

•

Male patients were more likely to be depressed; female patients were more likely to be anxious.

•

This work highlights the need to screen for psychological symptoms in patients entering early-phase trials.

Biological and clinical manifestations of Huntington’s disease in gene carriers very far from predicted onset

Introduction

Crucial to the future success of treatments in Huntington’s disease is identifying a timepoint where there is a measurable biomarker of early neurodegeneration without detectable changes in clinical function. By performing deep phenotyping in premanifest gene carriers (preHD) further from predicted onset than previously studied, we aimed to identify this timepoint and the best measures for efficacy endpoints in future therapeutic trials.

Methods

We recruited 64 young adult preHD, approximately 24 years from predicted clinical onset, and 67 matched controls. All participants underwent detailed cognitive and neuropsychiatric assessments, multi-modal imaging and collection of blood and cerebrospinal fluid (CSF).

Results

We found no significant evidence of cognitive or psychiatric impairment in preHD (minimum q>0.22). The PreHD cohort had smaller putamen volumes (q=0.03), but this was not related to predicted years to onset. There were no group differences in other brain imaging measures (q>0.16). CSF and plasma neurofilament light (NfL) (q<0.0001 and q=0.01) and YKL-40 (q=0.03) were elevated in preHD.

Conclusion

With normal brain function but with sensitive measures of neurodegeneration starting to rise, this stage of preHD may represent an optimal time to initiate future disease-modifying prevention treatments. CSF NfL appears more sensitive at this time than plasma NfL to monitor treatment response.

p.d.zeun@gmail.com

OP0275-PARE THE UNACCEPTABLE DELAY TO DIAGNOSIS IN AXIAL SPONDYLOARTHRITIS; DEVELOPING A CALL TO ACTION FOR A GLOBAL HEALTHCARE CHALLENGE

Background:

The current delay to diagnosis from symptom onset represents one of the greatest challenges in axial spondyloarthritis (axSpA). Research shows an average global delay of almost 7 years1 – and as long as 15 years in some cases2 – during which time the condition can progress considerably and lead to irreversible damage. Data indicates that women wait longer than men for a diagnosis3, and there has been very limited progress in reducing the time to axSpA diagnosis. The axSpA diagnosis delay has a hugely detrimental impact on an individual’s quality of life. Because the disease frequently has early onset1, individuals are left with untreated or incorrectly-treated symptoms at a formative period in their life course, whilst they await their diagnosis.

Objectives:

The Axial Spondyloarthritis International Federation (ASIF) set out to coordinate a comprehensive evidence-based global review of the factors influencing the current axSpA diagnosis delay and to produce a definitive report that shines a light on these barriers, as well as providing a resource that can ultimately empower a range of international stakeholders to reduce this delay.

Methods:

A full literature review was carried out to identify relevant available global evidence exploring the axSpA diagnosis delay. In autumn 2020 ASIF held two virtual global forum events, involving patients and patient group representatives, researchers, rheumatologists and other healthcare professionals, to methodically explore key diagnosis challenges across different healthcare systems and the opportunities for addressing these. Break-out discussions were held and participants were asked to identify the personal and societal effects of the diagnostic delay; the reasons it occurs; and initiatives to tackle the challenge. Alongside key stakeholder testimonies, best practices from around the world were also identified. 92 stakeholders participated in the events; they represented patients and healthcare professionals from 23 countries across five continents.

Results:

The findings from these activities were incorporated within a new ‘Delay to Diagnosis’ report, which for the first time definitively sets out the lived realities from a global perspective of the axSpA diagnosis delay. The report identified important commonalities across different countries and healthcare systems contributing to the current average global 7-year diagnosis delay, including:

 •Poor awareness of axSpA, particularly in primary care services

 •Complexities in diagnosing the disease

 •Poorly defined referral pathways

 •Insufficient patient access to rheumatologists and appropriate diagnostics

The report also highlights the significant impact this delay has on individuals and wider society, providing a foundation for future advocacy work. A series of recommendations have also been identified, the implementation of which will help to instigate tangible progress in reducing the current delay.

Conclusion:

Despite longstanding challenges, there are now clear opportunities for transforming how axSpA is diagnosed around the world. This message needs to be heard and acted upon urgently by all those involved in the management and delivery of axSpA care. The future programme of work for ASIF’s Delay to Diagnosis project will respond to these findings and be centred around supporting axSpA patient associations globally to take this call to action forward throughout 2021 and beyond.

References:

[1]Zhao et al; Diagnostic delay in axial spondyloarthritis: a systematic review and meta-analysis; Rheumatology, 2021

[2]Garrido-Cumbrera, M., Poddubnyy, D., Gossec, L. et al. The European Map of Axial Spondyloarthritis: Capturing the Patient Perspective—an Analysis of 2846 Patients Across 13 Countries. Curr Rheumatol Rep 21, 19 (2019)

[3]Jovani et al; Understanding How the Diagnostic Delay of Spondyloarthritis Differs Between Women and Men: A Systematic Review and Metaanalysis; The Journal of Rheumatology December 2016

Disclosure of Interests:

Wendy Gerhart Employee of: I was employed by Janssen Canada from 1992 - 2017, Mehmet Tuncay Duruöz: None declared, Jo Lowe Grant/research support from: No financial grants received individually. However, my role as Project Manager at ASIF is currently funded partially by UCB Global and partially by Novartis Global, Dale Webb Speakers bureau: Janssen and Novartis, Grant/research support from: Individually, no. But NASS receives grants from AbbVie, Biogen, Eli Lilly, Janssen, Novartis and UCB, Lillann Wermskog Grant/research support from: Individually, no. But Spafo Norge receives a small amount of funding for ongoing projects from Novartis., Jo Davies Grant/research support from: Individually, no. However, ASIF are currently funded by UCB, Lilly, Boehringer Ingelheim, Janssen and Novartis; this funding partially covers staff salaries as well as a range of projects, the content and outputs of which are not influenced by the funders., Richard Howard Shareholder of: AbbVie, Amgen, Bristol-Myers Squibb, GSK, Johnson & Johnson, Eli Lilly, Merck, Novartis, Pfizer, and Teva. I own <20 shares of any one stock and these stocks represent <4% of personal investments, Consultant of: Yes, GSK, Novartis - but then donated to Spondylitis Association of America, Grant/research support from: I have not personally received financial grants. SAA has received financial support from AbbVie, Amgen, BI, J&J, Lilly, Novartis, Pfizer, UCB., Michael Mallinson Consultant of: No. But, for full disclosure: I have received honoraria in the past, for participating in patient advisory board activities, from Abbvie, Novartis, Pfizer and UCB., Cheryl L Koehn Grant/research support from: OUR ORGANIZATION, ARTHRITIS CONSUMER EXPERTS, HAS. I HAVE NOT AS AN INDIVIDUAL. HERE IS OUR PUBLICLY AVAILABLE DISCLOSURE ON ALL ONLINE AND PRINT MATERIALS, PRESENTATIONS, MEETINGS, GOVERNMENT CONSULTATIONS:

https://jointhealth.org/about-principles.cfm?locale=en-CA

Over the past 12 months, ACE received grants-in-aid from: Arthritis Research Canada, Amgen Canada, Canadian Institutes of Health Research, Canadian Rheumatology Association, Eli Lilly Canada, Hoffman-La Roche Canada Ltd., Knowledge Translation Canada, Merck Canada, Novartis Canada, Pfizer Canada, Sandoz Canada, Sanofi Canada, St. Paul’s Hospital (Vancouver), UCB Canada, and the University of British Columbia.

Cylindrospermopsin impairs tubular transport function in kidney cells LLC-PK1

Cylindrospermopsin (CYN) has been involved in cases of poisoning in humans following ingestion. Studies have demonstrated that the kidney is the most affected organ. CYN exposure leads to low-molecular-weight proteinuria and increased excretions of the tubular enzymes in mice, suggesting the damage caused by CYN is mainly tubular. However, the mechanism involved in CYN nephrotoxicity remains unknown. Thus, in order to evaluate the effects of CYN exposure (0.1, 0.5 and 1.0 μg/mL) on tubular renal cells LLC-PK1 distinct mechanisms were analyzed by assessing cell death using flow cytometry, albumin uptake by fluorescence analysis, Na⁺/K⁺-ATPase activity by a colorimetric method, RT-qPCR of genes related to tubular transport and function as well as internalization of CYN by ELISA. In this study, CYN was found to induce necrosis in all concentrations. CYN also decreased albumin uptake as well as downregulated megalin and dab2 expression, both proteins involved in albumin endocytosis process. Moreover, CYN appears to be internalized by renal tubular cells through a receptor-mediated endocytosis. Finally, the present study demonstrates that CYN is responsible for disrupting tubular cell transport and function in LLC-PK1 cells.

SAT0193 A PHASE 3, OPEN-LABEL, CONTINUATION STUDY EVALUATING LONG-TERM SAFETY AND EFFICACY OF BELIMUMAB IN PATIENTS FROM JAPAN AND KOREA WITH SYSTEMIC LUPUS ERYTHEMATOSUS, FOR UP TO 7 YEARS

Background:

Systemic lupus erythematosus (SLE) is an autoimmune disorder more prevalent in the Asian population vs Caucasians. Belimumab (BEL), a monoclonal antibody targeting B-lymphocyte stimulator, is approved in patients (pts) ≥5 years with active, autoantibody-positive SLE.

Objectives:

Evaluate long-term safety and efficacy of intravenous (IV) BEL + standard SLE therapy (SST) in pts with SLE in Japan/Korea.

Methods:

In this Phase 3, multicentre, open-label (OL) study (BEL114333;NCT01597622), eligible (≥18 years of age) completers of the double-blind phase of GSK study BEL113750 in Japan and South Korea or the subcutaneous OL phase of GSK Study BEL112341 in Japan, received monthly BEL 10 mg/kg IV plus SST. Primary endpoints: safety assessments. Key secondary endpoints: SRI4 response rate at each scheduled visit (observed data), defined as a ≥4-point reduction from baseline in SELENA-SLEDAI score, no worsening in PGA (<0.3-point increase from baseline) and no new BILAG 1A/2B organ domain scores; time to first severe SFI flare over time. Endpoints were analysed relative to first BEL dose (parent or current study). No follow-up data were collected after study withdrawal.

Results:

Overall, 142 pts were enrolled (Japan n=72; Korea n=70), 104 (73.2%) completed the study, 1 (0.7%) died and 37 (26.1%) withdrew.

Overall, 139 (97.9%) pts had ≥1 adverse event (AE) (Table). Most frequent AEs included: nasopharyngitis (60.6%); headache (28.2%); cough, herpes zoster and viral upper respiratory tract infection (18.3% each). Serious AEs (SAEs) occurred in 48 (33.8%) pts. Most common SAEs were infections and infestations, reported in 24 (16.9%) pts (Table). During this study, the annual incidence of AEs, including SAEs and AESI, remained stable or declined, with no trends of clinical concerns regarding the incidence of Grade 3 or 4 values for laboratory parameters. There was 1 transient positive immunogenicity result of no clinical concern.

Table.

The proportion of SRI4 responders was 47.8% at Year 1 (Week 24) and tended to increase numerically up to 84.6% at Year 7 (Week 48). The proportion of pts with a ≥4-point decrease from baseline in SELENA-SLEDAI score numerically increased from 51.5% at Year 1 (Week 24) to 84.6% at Year 7 (Week 48). Proportion of pts with no PGA worsening was 91.3-100% and the proportion with no new BILAG 1A/2B organ domain scores was 93.3-100% up to Year 7 (Week 48). A total of 21 (14.8%) pts had 24 severe SFI flares.

Conclusion:

BEL was well tolerated as add-on therapy to SST for ≤7 years in pts with SLE from Japan/Korea. Safety results were consistent with the known BEL safety profile.

Study funding: GSK.

Disclosure of Interests:

Yoshiya Tanaka Grant/research support from: Received research grants from Asahi-Kasei, Mitsubishi-Tanabe, Chugai, Takeda, Sanofi, Bristol-Myers, UCB, Daiichi-Sankyo, Eisai, Ono, Speakers bureau: Received speaking fees and/or honoraria from Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Teijin, Sang-Cheol Bae: None declared, Damon Bass Shareholder of: GSK, Employee of: GSK, Myron Chu Shareholder of: GSK, Employee of: GSK, Paula Curtis Shareholder of: GSK, Employee of: GSK, Kathleen DeRose Shareholder of: GSK, Employee of: GSK, Beulah Ji Shareholder of: GSK, Employee of: GSK, Regina Kurrasch Shareholder of: GSK, Employee of: GSK, Jenny Lowe Shareholder of: GSK, Employee of: GSK, Paige Meizlik Shareholder of: GSK, Employee of: GSK, David Roth Shareholder of: GSK, Employee of: GSK

The Ultimate Poker Face: A Case Report of Facial Diplegia, a Guillain-Barré Variant

Introduction

Facial diplegia, a rare variant of Guillain-Barré syndrome (GBS), is a challenging diagnosis to make in the emergency department due to its resemblance to neurologic Lyme disease.

Case report

We present a case of a 27-year-old previously healthy man who presented with bilateral facial paralysis.

Discussion

Despite the variance in presentation, the recommended standard of practice for diagnostics (cerebrospinal fluid albumin-cytological dissociation) and disposition (admission for observation, intravenous immunoglobulin, and serial negative inspiratory force) of facial diplegia are the same as for other presentations of GBS.

Conclusion

When presented with bilateral facial palsy emergency providers should consider autoimmune, infectious, idiopathic, metabolic, neoplastic, neurologic, and traumatic etiologies in addition to the much more common neurologic Lyme disease.

Introduction of a national program for HbA1c testing in Guyana South America and initial results

Diabetes is an increasing challenge for low- and middle-income countries (LMIC) and access to HbA1c testing is limited. HbA1c, a measure of glycaemic control averaged over 3 months, provides both clinicians and policymakers with a tool to identify the risk of long-term diabetes comorbidity. We describe the steps used to implement standardised testing in Guyana South America and the initial results according to a locally developed protocol as part of a country-wide project to improve the care of people with all forms of diabetes The steps identified include: a standardised method traceable to a recognized international reference standard, participation in a quality control cycle with an international reference laboratory, a clinical pathway for testing to reduce inappropriate use and minimize resource wastage, training of technicians in operation and maintenance of equipment, identification of a suitable space with constant power supply, a reliable procurement system, education of healthcare professionals on interpretation and follow-up of results and feedback of programme results to improve clinical practice. Some steps for implementation of the national HbA1c testing program were initiated better than others. Initial unreliability of the service undermined confidence in the system. Failure to follow the testing protocol led to some patients being tested too soon and others too late. Cost of reagents was about 5.60 USD/test. We trained 340 people in diabetes care and knowledge was improved but were unable to assess whether it was appropriately applied. Over one third of people tested in the 30-70 age group had an HbA1c over 9% (75 mmol/mol) and this did not improve over the 5 years of testing. Despite the difficulties we think our unique experience of implementation of a nationwide HbA1c testing programme has important lessons for other LMICs.

Abstract P2-09-08: Imprime PGG, a novel innate immune modulator, combined with pembrolizumab in a phase 2 multicenter, open label study in chemotherapy-resistant metastatic triple negative breast cancer (TNBC)

Background: CPI monotherapy provides substantial clinical benefit to patients (pts) in multiple cancers, yet response rates are limited (˜15-30%) and fails to benefit the majority. In these pts there is limited or no ongoing T cell-based immune response. Imprime PGG (Imprime), a novel beta glucan derived from Saccharomyces, may expand the clinical benefit of CPI therapy by stimulating an anti-cancer immune response. Acting as a pathogen-associated molecularpattern (PAMP), Imprime enlists innate immune functions including cytotoxic effector mechanisms, reversal of immunosuppression and cross-talk with the adaptive immune system.Imprime-mediated innate immune activation requires formation of an immune complex with naturally-occurring anti-beta glucan antibodies (ABA); sufficient ABA levels is required for complex formation. Imprime is now being studied in combination with pembrolizumab (KEYTRUDA®,Pembro), a humanized mAb against PD-1 which has been previously studied in TNBC pts.

Methods: In this study of patients who previously failed chemotherapy for metastatic TNBC, Imprime is being used in combination with Pembro in a Simon 2 stage design. Asample size of 12 evaluable pts in Stage 1 was planned.Evaluable pts received at least one dose of study treatment (tx), had measurable disease at baseline per RECIST v1.1, had at least one post-baseline scan or discontinued tx as a result of progressive disease, death, or a tx-related adverse event before the first post-baseline scan.Pts received Imprime (4 mg/kg IV days 1, 8, 15 of each 3-week cycle) + Pembro 200 mg on D1 of each cycle. Criteria to advance to Stage 2 were ≤4 grade 3/4 AEs during the first tx cycle (other than infusion reactions) and ≥1 objective response. Study primary endpoints are ORR and safety; secondary endpoints are TTR, CRR, DoR, PFS, and OS. Exploratory endpoints include ORR and PFS per irRECIST. Biopsies and blood samples are being collected to assess tx impact on immune activating events at the tumor site and in the periphery.

Results: A review of efficacy and safety data was conducted at the end of Stage 1. Thirteen pts (12 evaluable) were enrolled into Stage 1. Safety review noted 2 grade 3 adverse events that met protocol definition of Stage 1 events (1 pt: cellulitis and 1 pt: pleural infusion; both unrelated to treatment). Two events lead to 2 pts discontinuing treatment (infusion reaction and pancreatitis) and only 1 autoimmune event was observed (pancreatitis). Observed efficacy responses in the evaluable pts included 1 complete response (CR; ongoing) and 2 partial responses (PR; ongoing). Secondary efficacy endpoints have not been assessed. Early translational results support proposed MOA and analysis of Stage 1 translational data is ongoing.

Conclusion: The use of Imprime with Pembro was well tolerated and met both safety and efficacy requirements to move forward with Stage 2 of the study. No significant safety concerns were identified in Stage 1. Further investigation is thus warranted and enrollment into Stage 2 is ongoing. Updated data will be presented.

Citation Format: O'Day S, Borges V, Chmielowski B, Rao R, Abu-Khalaf M, Stopeck A, Lowe J, Mattson P, Breuer K, Gargano M, Bose N, Uhlik M, Graff J, Chisamore M, Cox J, Osterwalder B. Imprime PGG, a novel innate immune modulator, combined with pembrolizumab in a phase 2 multicenter, open label study in chemotherapy-resistant metastatic triple negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-09-08.

5 The fluro project: a review of the approach and understanding of fluid resuscitation in a military tertiary centre from the perspective of care providers in the emergency setting

Introduction

The term fluid resuscitation (FR) is defined as the use of fluids to restore a state of normovolaemia, or to correct a hypovolaemic state. To establish normovolaeamia via FR, the term ‘fluid bolus’ is used to describe a prescribed fluid volume. As such, the authors looked to investigate the understanding of this term and to review approaches to fluid resuscitation by those healthcare workers closely associate with critically unwell patients.

Methods

A questionnaire was distributed to all clinical staff across Emergency Medicine (EM), Anaesthesia and Theatres (AT), Intensive Care Medicine (ICM) and Acute Medicine (AM). The questionnaire recorded role, area of responsibility, training grade, type, volume and administration time, time to reassessment and parameters to be assessed in relation to a clinical vignette. The results were then compared directly to the NICE Clinical Audit Standards (NCAS) for FR.

Results

153 responses were received from across all working environments. Overall, 52% of respondents gave volumes aligned with NCAS (500 ml). 99% of respondents suggested crystalloid use with 88% giving an appropriate time for administration of less than 15 min. 55% of respondents suggested appropriate review times (0–5 min). 99% of respondents agreed heart rate and blood pressure should be reassessed, but other parameters for monitoring were poorly recognised.

Between specialties, EM suggested larger volumes while ICM were more likely to continuously review the patient during a bolus. AM were the only group to administer fluids over 60 min. EM and ICM were more likely to review lactate as a marker for effect. Higher specialist trainees were more likely to give a larger volume when compared to other grades.

Discussion

The overall perception of a fluid bolus varies between specialties and training grades. Most responses were aligned to NCAS with notable outliers. This suggests a discrepancy in the understanding of the term fluid bolus. This may also cause issues in fluid administration with multiple patients. It is therefore suggested that further work be undertaken on clarifying the term ‘fluid bolus’, aiming to minimise uncertainty and increase understanding to prevent adverse effects.

A randomized, open-label, multicenter, phase II study evaluating the efficacy and safety of BTH1677 (1,3-1,6 beta glucan; Imprime PGG) in combination with cetuximab and chemotherapy in patients with advanced non-small cell lung cancer

Introduction BTH1677, a 1,3–1,6 beta-glucan immunomodulator, stimulates a coordinated anti-cancer immune response in combination with anti-tumor antibody therapies. This phase II study explored the efficacy, pharmacokinetics (PK), and safety of BTH1677 combined with cetuximab/carboplatin/paclitaxel in untreated stage IIIB/IV non-small cell lung cancer (NSCLC) patients. Methods Patients were randomized 2:1 to the BTH1677 arm (N=60; BTH1677, 4 mg/kg, weekly; cetuximab, initial dose 400 mg/m² and subsequent doses 250 mg/m², weekly; carboplatin, 6 mg/mL/min AUC (area-under-the-curve) by Calvert formula, once each 3-week cycle [Q3W]); and paclitaxel, 200 mg/m², Q3W) or Control arm (N=30; cetuximab/carboplatin/paclitaxel as above). Carboplatin/paclitaxel was discontinued after 4–6 cycles; patients who responded or remained stable received maintenance therapy with BTH1677/cetuximab (BTH1677 arm) or cetuximab (Control arm). Investigator and blinded central radiology reviews were conducted. Efficacy assessments included objective response rate (ORR; primary endpoint), disease control rate, duration of objective response, time-to-progression and overall survival (OS); safety was assessed by adverse events (AEs). Potential biomarker analysis for BTH1677 response was also conducted. Results Compared to control treatment, the addition of BTH1677 numerically increased ORR by both investigator (47.8% vs 23.1%; p=0.0468) and central (36.6% vs 23.1%; p=0.2895) reviews. No other endpoints differed between arms. PK was consistent with previous studies. BTH1677 was well tolerated, with AEs expected of the backbone therapy predominating. Biomarker-positive patients displayed better ORR and OS than negative patients. Conclusions BTH1677 combined with cetuximab/carboplatin/paclitaxel was well tolerated and improved ORR as first-line treatment in patients with advanced NSCLC. Future patient selection by biomarker status may further improve efficacy

ClinicalTrials.gov Identifier: NCT00874848

Predictors of low diabetes risk perception in a multi-ethnic cohort of women with gestational diabetes mellitus

AIM

To determine what proportion of women with gestational diabetes underestimate their diabetes risk and identify factors associated with low diabetes risk perception.

METHODS

Participants included pregnant adult women with gestational diabetes between 2009 and 2012 across seven diabetes clinics in Ontario, Canada. Data were collected through chart review and a survey that included a diabetes risk perception question.

RESULTS

Of the 614 of 902 women (68% response rate) with gestational diabetes, 89% correctly responded that gestational diabetes increases the risk for developing diabetes. However, 47.1% of women perceived themselves to be at low risk for developing diabetes within 10 years. On multivariable analysis, BMI < 25 kg/m(2) , absent previous gestational diabetes history, absent diabetes family history and absent insulin use were appropriately associated with low diabetes risk perception. However, compared with Caucasian ethnicity, high-risk ethnicity (Aboriginal, Latin American, West Indian, South Asian, Middle Eastern, Filipino, Black, Pacific Islander) [odds ratio (OR) 2.07; 95% CI 1.30-3.31] and East and South East Asian ethnicity (OR 2.01; 1.10-3.67) were associated with low diabetes risk perception. After further adjustment for immigration, only high-risk ethnicity remained a predictor of low diabetes risk perception (OR 1.86; 1.09-3.19), whereas East and South East Asian ethnicity did not (OR 1.67; 0.86-3.22).

CONCLUSIONS

Although the majority of women recognized gestational diabetes as a risk factor for diabetes, almost half underestimated their personal high diabetes risk despite prenatal care. Furthermore, women from high-risk ethnic groups were more likely to underestimate their risk, even after adjusting for immigration. Interventions tailored to these groups are necessary to enhance perceived diabetes risk.

Short-term risk of cancer among women with previous gestational diabetes: a population-based study

AIMS

To evaluate the relationship between gestational diabetes (GDM) and incidence of cancer in women within the first decade postpartum.

METHODS

This population-based retrospective cohort study compared the risk of cancer in women with GDM with that of a matched control group comprising pregnant women without diabetes. We included women from Ontario, Canada aged 20-50 years with no history of cancer who had given birth between 1995 and 2008 (N = 149 049). Women with GDM (N = 49 684) were matched on age and year of giving birth, in a ratio of 1:2, to pregnant women without diabetes (N = 99 365).

RESULTS

Over a median 8-year follow-up, there were a total of 2927 (1.5%) cancers. After adjustment for covariates, we found no significant difference in overall risk of cancer between women with GDM and matched control subjects; however, GDM was associated with a significantly greater risk of thyroid cancer (adjusted hazard ratio 1.24, 95% CI 1.05, 1.46) and a significantly lower risk of premenopausal breast cancer (hazard ratio 0.86, 95% CI 0.75, 0.98) compared with matched control subjects.

CONCLUSIONS

This large population-based study did not find a greater risk of cancers among women with GDM during the first decade postpartum; however, GDM was associated with a higher risk of thyroid cancer and a lower risk of premenopausal breast cancer. Further studies are needed to confirm these findings.

INDOMETHACIN TEST USAGE AT UNITED KINGDOM TERTIARY CENTRES OVER 20 YEARS-AN AUDIT

Background

Indomethacin-responsive trigeminal autonomic cephalalagias (TACS), paroxysmal hemicrania (PH) and hemicrania continua (HC), are unique, important syndromes to understand.

Aim

Evaluation of the role of the placebo-controlled indomethacin test (P-Indotest) in the diagnosis of primary headache disorders.

Method

Patients notes, clinic letters and headache diaries of patients under our care (PJG) over a 20 year period across various UK Neurology tertiary care centres were examined to obtain data against an audit collection tool. A pre-determined set of data were extracted, and the test procedure reviewed for compliance against a standard with minimum data set requirement by an unblinded observer. The original test score was noted, and prospectively re-scored by a blinded observer.

Results

Patients (n=7; 4 female) were aged from 24 to 51 years. The majority (85%) had side locked headache. P-Indotest was positive in 78% of the cases with patients having either HC or PH. Of all patients tested, 42% had unilateral photophobia and phonophobia and all these cases had a positive response. No serious adverse events were noted. Sleepiness was often reported on the active treatment as was transient worsening of headache in unilateral chronic migraine. Further data is being compiled.

Conclusion

The P-IndoTest is a reliable and safe test and should in the diagnosis of patients with possible indomethacin sensitive TACs. While far from ideal, a positive indomethacin test does identify a particular biology and should be retained as a diagnostic marker of PH and HC until its basis is understood.

Genome-wide association study of behavioural and psychiatric features in human prion disease

Prion diseases are rare neurodegenerative conditions causing highly variable clinical syndromes, which often include prominent neuropsychiatric symptoms. We have recently carried out a clinical study of behavioural and psychiatric symptoms in a large prospective cohort of patients with prion disease in the United Kingdom, allowing us to operationalise specific behavioural/psychiatric phenotypes as traits in human prion disease. Here, we report exploratory genome-wide association analysis on 170 of these patients and 5200 UK controls, looking for single-nucleotide polymorphisms (SNPs) associated with three behavioural/psychiatric phenotypes in the context of prion disease. We also specifically examined a selection of candidate SNPs that have shown genome-wide association with psychiatric conditions in previously published studies, and the codon 129 polymorphism of the prion protein gene, which is known to modify various aspects of the phenotype of prion disease. No SNPs reached genome-wide significance, and there was no evidence of altered burden of known psychiatric risk alleles in relevant prion cases. SNPs showing suggestive evidence of association (P<10(-5)) included several lying near genes previously implicated in association studies of other psychiatric and neurodegenerative diseases. These include ANK3, SORL1 and a region of chromosome 6p containing several genes implicated in schizophrenia and bipolar disorder. We would encourage others to acquire phenotype data in independent cohorts of patients with prion disease as well as other neurodegenerative and neuropsychiatric conditions, to allow meta-analysis that may shed clearer light on the biological basis of these complex disease manifestations, and the diseases themselves.

Characteristics of progressive supranuclear palsy presenting with corticobasal syndrome: a cortical variant

Aims

Since the first description of the classical presentation of progressive supranuclear palsy (PSP) in 1963, now known as Richardson's syndrome (PSP-RS), several distinct clinical syndromes have been associated with PSP-tau pathology. Like other neurodegenerative disorders, the severity and distribution of phosphorylated tau pathology are closely associated with the clinical heterogeneity of PSP variants. PSP with corticobasal syndrome presentation (PSP-CBS) was reported to have more tau load in the mid-frontal and inferior-parietal cortices than in PSP-RS. However, it is uncertain if differences exist in the distribution of tau pathology in other brain regions or if the overall tau load is increased in the brains of PSP-CBS.

Methods

We sought to compare the clinical and pathological features of PSP-CBS and PSP-RS including quantitative assessment of tau load in 15 cortical, basal ganglia and cerebellar regions.

Results

In addition to the similar age of onset and disease duration, we demonstrated that the overall severity of tau pathology was the same between PSP-CBS and PSP-RS. We identified that there was a shift of tau burden towards the cortical regions away from the basal ganglia; supporting the notion that PSP-CBS is a ‘cortical’ PSP variant. PSP-CBS also had less severe neuronal loss in the dorsolateral and ventrolateral subregions of the substantia nigra and more severe microglial response in the corticospinal tract than in PSP-RS; however, neuronal loss in subthalamic nucleus was equally severe in both groups.

Conclusions

A better understanding of the factors that influence the selective pathological vulnerability in different PSP variants will provide further insights into the neurodegenerative process underlying tauopathies.

MAGNEsium Trial In Children (MAGNETIC): a randomised, placebo-controlled trial and economic evaluation of nebulised magnesium sulphate in acute severe asthma in children

BACKGROUND

There are few data on the role of nebulised magnesium sulphate (MgSO4) in the management of acute asthma in children. Those studies that have been published are underpowered, and use different methods, interventions and comparisons. Thus, no firm conclusions can be drawn.

OBJECTIVES

Does the use of nebulised MgSO4, when given as an adjunct to standard therapy in acute severe asthma in children, result in a clinical improvement when compared with standard treatment alone?

DESIGN

Patients were randomised to receive three doses of MgSO4 or placebo, each combined with salbutamol and ipratropium bromide, for 1 hour. The Yung Asthma Severity Score (ASS) was measured at baseline, randomisation, and at 20, 40, 60 (T60), 120, 180 and 240 minutes after randomisation.

SETTING

Emergency departments and children's assessment units at 30 hospitals in the UK.

PARTICIPANTS

Children aged 2-15 years with acute severe asthma.

INTERVENTIONS

Patients were randomised to receive nebulised salbutamol 2.5 mg (ages 2-5 years) or 5 mg (ages ≥ 6 years) and ipratropium bromide 0.25 mg mixed with either 2.5 ml of isotonic MgSO4 (250 mmol/l, tonicity 289 mOsm; 151 mg per dose) or 2.5 ml of isotonic saline on three occasions at approximately 20-minute intervals.

MAIN OUTCOME MEASURES

The primary outcome measure was the ASS after 1 hour of treatment. Secondary measures included 'stepping down' of treatment at 1 hour, number and frequency of additional salbutamol administrations, length of stay in hospital, requirement for intravenous bronchodilator treatment, and intubation and/or admission to a paediatric intensive care unit. Data on paediatric quality of life, time off school/nursery, health-care resource usage and time off work were collected 1 month after randomisation.

RESULTS

A total of 508 children were recruited into the study; 252 received MgSO4 and 256 received placebo along with the standard treatment. There were no differences in baseline characteristics. There was a small, but statistically significant difference in ASS at T60 in those children who received nebulised MgSO4 {0.25 [95% confidence interval (CI) 0.02 to 0.48]; p = 0.034} and this difference was sustained for up to 240 minutes [0.20 (95% CI 0.01 to 0.40), p = 0.042]. The clinical significance of this gain is uncertain. Assessing treatment-covariate interactions, there is evidence of a larger effect in those children with more severe asthma exacerbations ( p = 0.034) and those with a shorter duration of symptoms ( p = 0.049). There were no significant differences in the secondary outcomes measured. Adverse events (AEs) were reported in 19% of children in the magnesium group and 20% in the placebo group. There were no clinically significant serious AEs in either group. The results of the base-case economic analyses are accompanied by considerable uncertainty, but suggest that, from an NHS and Personal Social Services perspective, the addition of magnesium to standard treatment may be cost-effective compared with standard treatment only. The results of economic evaluation show that the probability of magnesium being cost-effective is over 60% at cost-effectiveness thresholds of £1000 per unit decrement in ASS and £20,000 per quality-adjusted life-year (QALY) gained, respectively; it is noted that for some parameter variations this probability is much lower, reflecting the labile nature of the cost-effectiveness ratio in light of the small differences in benefits and costs shown in the trial and the relation between the main outcome measure (ASS) and preference based measures of quality of life used in cost-utility analysis (European Quality of Life-5 Dimensions; EQ-5D).

CONCLUSIONS

This study supports the use of nebulised isotonic MgSO4 at the dose of 151 mg given three times in the first hour of treatment as an adjuvant to standard treatment when a child presents with an acute episode of severe asthma. No harm is done by adding magnesium to salbutamol and ipratropium bromide, and in some individuals it may be clinically helpful. The response is likely to be more marked in those children with more severe attacks and with a shorter duration of exacerbation. Although the study was not powered to demonstrate this fully, the data certainly support the hypotheses that nebulised magnesium has a greater clinical effect in children who have more severe exacerbation with shorter duration of symptoms.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN81456894.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Regional cerebral blood flow in children from 3 to 5 months of age

BACKGROUND AND PURPOSE

Understanding the relationship between brain and behavior in early childhood requires a probe of functional brain development. We report the first large study of regional CBF by use of arterial spin-labeling in young children.

MATERIALS AND METHODS

Cerebral blood flow by use of arterial spin-labeling was measured in 61 healthy children between the ages of 3 and 5 months. Blood flow maps were parcellated into 8 broadly defined anatomic regions of each cerebral hemisphere.

RESULTS

There was no sex effect; however, group analysis demonstrated significantly greater CBF in the sensorimotor and occipital regions compared with dorsolateral prefrontal, subgenual, and orbitofrontal areas (P < .0001). A significant age effect was also identified, with the largest increase in blood flow between 3 and 5 months occurring in the following regions: orbitofrontal (P < .009), subgenual (P < .002), and inferior occipital lobe (P = .001).

CONCLUSIONS

These results are consistent with prior histologic studies demonstrating regional variation in brain maturation and suggest that arterial spin-labeling is sensitive to regional as well as age-related differences in CBF in young children.

Oestradiol differentially influences feeding behaviour depending on diet composition in female rhesus monkeys

In females, cyclical changes in the ovarian hormone oestradiol are known to modulate feeding behaviour. However, what is less clear is how these behavioural effects of oestradiol are modified by the macronutrient content of a diet. In the present study, we report data showing that oestradiol treatment results in both significantly smaller meals and a reduced total calorie intake in ovariectomised, socially-housed female rhesus macaques when only chow diet is available. Conversely, during a choice dietary condition where both palatable and chow options are available, oestradiol treatment had no observable, attenuating effect on calorie intake. During this choice dietary phase, all animals consumed more of the palatable diet than chow diet; however, oestradiol treatment appeared to further increase preference for the palatable diet. Finally, oestradiol treatment increased snacking behaviour (i.e. the consumption of calories outside of empirically defined meals), regardless of diet condition. These findings illustrate how oestradiol differentially influences feeding behaviour depending on the dietary environment and provides a framework in which we can begin to examine the mechanisms underlying these observed changes.