Predictors of major bleeding following an acute coronary event: insights from a national study of 5,116 consecutive patients in clinical practice

Background

Major bleeding after acute coronary syndrome (ACS) predicts a poor outcome. Although predictors of major bleeding following ACS have been validated, these have been mostly in clinical trial populations and few contemporary analyses have been undertaken in clinical practise

Methods

Major bleeding was assessed in a national study of ACS and antiplatelet choice. A total of 5116 consecutive patients [Clopidogrel (n 2,491, 2011–13) and Ticagrelor (n 2,625, 2013–16)] were enrolled in 5 UK hospitals. Clinical outcomes were identified from a national coding database (n=59.5 million) with bleeding events tracked to 11 health care facilities. Bleed severity was independently adjudicated by 2 consultant cardiologists, blinded to antiplatelet, sequence and year. Bleeding events were categorised using BARC 3–5 and PLATO criteria. A logistic regression analysis was used to define independent predictors of bleeding.

Results

The median age was 68 (IQR57–78, 30.5%>75), 34% were female. 39% underwent PCI and 13% coronary artery bypass surgery. Clinical outcome data was 100% complete. 1-year mortality was 12.9%. Of 1193 icd10 codes for bleeding or anaemia 165 (3.2%) and 193 (3.8%) patients were adjudicated to have suffered a BARC 3–5 and PLATO major bleeding respectively. Independent predictors common between PLATO major and BARC 3–5 bleeding, in the year following ACS, were CRUSADE score >40 (OR 1.63, CI 1.1–2.4, p=0.008) moderate left ventricular systolic dysfunction (OR, 1.65, CI: 1.2–2.4, p=0.006), age (OR per year increase in age 1.03, CI 1.02–1.05, p<0.001) and subsequent coronary artery bypass surgery (OR 2.6, CI 1.8–3.8, p<0.001)

Conclusion

In a broad real-world population of ACS, CRUSADE score >40, incorporating simple clinical and laboratory criteria, remained an independent predictor of major bleeding using 2 internationally recognised bleed criteria

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Liverpool university hospitals; North-West Educational Cardiac Group

In vitro targeted screening and molecular docking of stilbene, quinones, and flavonoid on 3T3-L1 pre-adipocytes for anti-adipogenic actions

In metabolic disorders like obesity, NAFLD and T2DM, adipocytes are dysfunctional. Hence, pharmacological interventions have importance in preventing differentiation of adipocytes and stimulating lipid uptake. We, therefore, investigated the effects of arbutin (ARB), purpurin (PUR), quercetin (QR), and pterostilbene (PTS) on adipocyte differentiation and lipid uptake using 3T3-L1 adipocytes. Further, in silico docking studies were achieved to investigate interactions of ARB, PUR, QR, and PTS with beta-ketoacyl reductase (KR) and thioesterase (TE) domains of fatty acid synthase (FAS) enzyme. Mature 3T3-L1 adipocytes were used to investigate the anti-adipogenic effect of selected pharmacological agents by Oil Red O staining and in vitro fatty acid uptake analysis. Molecular docking studies were performed to predict the binding interactions of selected compounds with KR and TE domains of FAS enzyme. All these agents significantly decrease the adipocyte differentiation and showed the stimulatory effect on fatty acid uptake in 3T3-L1 adipocytes. However, PTS and PUR proved to be anti-adipogenic, whereas ARB and QR showed significant effect on fatty acid uptake, compared to others. Similarly, all the compounds displayed significant binding interactions with KR and TE domains of FAS enzyme, supporting the results of in vitro studies. Graphical abstract.

Medical education focus in published articles related to COVID-19

OBJECTIVE

The ongoing pandemic of Coronavirus Disease 2019 (COVID-19) has affected >2 million patients with approximately 900,000 cases in the United States alone. Medical education has possibly suffered during this time, due to disease mitigation strategies and stress on both students and teachers. We aimed to quantify the publications describing the impact of COVID-19 on medical education in the early stage of the pandemic.

MATERIALS AND METHODS

Abstract and titles related to COVID-19 listed in PubMed were reviewed for an educational focus. Articles with an educational focus were further evaluated for characteristics of content.

RESULTS

Out of a total of 3641 articles related to COVID-19, only 26 (0.7%) articles had an educational theme. Thirteen articles were pertaining to residency and fellowship education and twelve articles were focused on medical student education. Only one article referred to nursing education.

CONCLUSIONS

Publications pertaining to medical education during the ongoing COVID-19 pandemic are few. There is an urgent need for scholarship to understand the best processes and develop innovative methods that can help improve the educational experience of students and trainees during this extraordinary time.

Apoptosis-inducing factor deficient mice fail to develop hepatic steatosis under high fat high fructose diet or bile duct ligation

Apoptosis-inducing factor (AIF) is a mitochondrial flavoprotein involved in redox signalling and programmed cell death. The role of AIF has been well recognized in diabetes and obesity. However, the aspect of AIF deficiency in the development of hepatic steatosis and liver injury is unknown. Therefore, in the current study, Harlequin (Hq mutant) mouse with markedly reduced content of AIF was investigated to explore the role of AIF on the initiation of liver injury. The wild type (WT) developed physiological and pathological features of non-alcoholic fatty liver disease (NAFLD) that were not seen in the Hq mice with AIF deficiency, when fed on high fat high fructose (HFHF) diet. Following bile duct ligation (BDL), the liver associated pathological changes were less conspicuous in Hq mice as compared to WT mice. The expression of AIF protein and apoptosis was markedly lesser as compared to their respective control in Hq mice on HFHF diet. Furthermore, the genes involved in fatty acid metabolism were also altered in the group of treated Hq mice. In conclusion, Hq mice failed to develop diet induced hepatic steatosis, suggestive of a role of AIF mediated pathway in the initiation and progression of liver inflammation. Thus, partial loss of AIF appears to be hepatoprotective. SIGNIFICANCE OF THE STUDY: AIF deficiency has multiple roles in altered pathology processes and cellular metabolism, thereby compromising the cellular homeostasis. Considering the molecular functions of AIF in other organ pathology little is known about its role in diet induced liver injury. Hence, the aim of the current study was to investigate the role of AIF deficiency in liver injury and diseases with focus on NAFLD. The study will help to deliniate the mechanisms of NAFLD using Harliquin Mice.

Representation of specialties in Coronavirus Disease 2019 (COVID-19) research: analysis of published literature in the first 3 months

OBJECTIVE

Coronavirus disease 2019 (COVID-19) has infected more than 1.5 million patients worldwide and is associated with high morbidity and mortality. The volume of research published in a specialty, which may shed light on the perceived impact that a topic plays within that discipline, is unknown for the present pandemic.

MATERIALS AND METHODS

We analyzed all articles published in the first 3 months on COVID-19 and categorized them by journal type and article content.

RESULTS

There was a ~100-fold difference in articles published on COVID when categorized by journal type and ~65-fold difference when grouped by article content.

CONCLUSIONS

There is a wide variation in research published withing various specialties regarding COVID-19. Researchers across specialties need to urgently realize the impact of COVID-19 and publish articles that can help improve understanding of this ongoing pandemic.

Ketogenic diet in endocrine disorders: Current perspectives

Ketogenic diet (KD) is a high-fat, adequate-protein, and low-carbohydrate diet that leads to nutritional ketosis, long known for antiepileptic effects and has been used therapeutically to treat refractory epilepsy. This review attempts to summarize the evidence and clinical application of KD in diabetes, obesity, and other endocrine disorders. KD is usually animal protein based. An empiric vegetarian Indian variant of KD has been provided keeping in mind the Indian food habits. KD has beneficial effects on cardiac ischemic preconditioning, improves oxygenation in patients with respiratory failure, improves glycemic control in diabetics, is associated with significant weight loss, and has a beneficial impact on polycystic ovarian syndrome. Multivitamin supplementations are recommended with KD. Recently, ketones are being proposed as super-metabolic fuel; and KD is currently regarded as apt dietary therapy for "diabesity."

Molecular and Pathological Events Involved in the Pathogenesis of Diabetes-Associated Nonalcoholic Fatty Liver Disease

Diabetes mellitus is a rising epidemic in most part of the world and is often associated with multiple organ disorders such as kidney, liver, and cardiovascular diseases. Liver is a major metabolic hub, and the metabolic disorders associated with diabetes result in liver dysfunctions culminating in spectrum of liver diseases such as fatty liver disorders, cirrhosis, and hepatocellular carcinoma. The intervention strategies to prevent diabetes-associated liver injury require an overall understanding of the key factors and molecular pathways which can be strategically targeted. The present review focuses on some of the key aspects of fatty acid metabolism, fetuin-A regulation, inflammatory pathways, and genetic factors associated with insulin resistance, dyslipidemia, hyperglycemia, oxidative stress, and so on involved in the nexus between diabetes and liver injury. Further recent interventions, pharmacological target, and newer therapeutic agents are discussed briefly for the better clinical management of diabetes-associated hepatic disorders.

Abstract P3-16-02: Voice of cancer patient: Analysis of breast cancer patients' experience with PARP inhibitors

Background:

Many breast and ovarian cancer patients have germline or somatic mutations in BRCA 1&2 genes. These proteins are important for repairing double-strand DNA breaks by homologous recombinational repair. In patients who have mutations in these genes, PARP is the major alternative for repairing single-strand DNA breaks. PARP inhibitors (PARPi) inhibit PARP, thereby causing cell death by accumulation of damaged DNA in cells. Many PARPi, including Olaparib, have been approved and used in treatment of metastatic ovarian cancer patients with BRCA 1&2 mutation.

Recently, Olaparib was also approved by the FDA for treatment of metastatic breast cancer patients with germline BRCA 1&2 mutation, and many other PARPi are in clinical trial. In this study we analyzed breast cancer patients' awareness, use and experience with PARPi s.

Many patients share their experiences on online forums which contain millions of freely shared messages. These can be used to analyze patient concerns and experiences. However, this data is unstructured and difficult to analyze. We used our automated system VoCP, that uses techniques from Big Data Science and Artificial Intelligence (deep learning, topic modeling, information retrieval, and natural language processing) to analyze these messages.

Methods:

We collected 15.13 million unique messages by 987,189 users from 37 unrestricted cancer forums that provide clinically relevant information. We built custom ontologies for breast cancer, various PARPi, chemotherapy and side effects, and then used our automated system VoCP to extract relevant information from these messages.

Results:

We found 1,536 breast cancer patients discussing PARPi. 459 patients mentioned use of PARPi whereas 706 patients shared the information about PARPi and 196 inquired about them. 176 patients mentioned that they were planning to use PARPi.

76 patients using PARPi mentioned having BRCA 1 or 2 mutation and 1 patient mentioned CHEK 2 mutation. 91 patients mentioned having triple negative cancer.

212 patients mentioned being treated on clinical trial and 10 mentioned being off trial. 162 patients mentioned use of chemotherapy with PARPi and 40 mentioned use of PARPi as single agent.

Specific PARPi: 47 mentioned Olaparib, 104 mentioned Valiparib, & Talazoparib, 6 rucaparib and 4 Niraparib. Most patient just mentioned “PARP inhibitor.” Some patients mentioned iniparib on clinical trial.

Side effects were reported by 60 patients. These include:

· Nausea: 14

· Fatigue: 15

· GI side effect: 7

· Thrombocytopenia: 5

· Anemia: 2

· Neutropenia: 2

· Neuropathy: 5

· Insomnia:2

99 patients mentioned PARPi were “effective,” 21 mentioned they were “somewhat effective” and 36 mentioned they were “ineffective.”

144 patient expressed positive sentiments, 30 patients expressed negative sentiments and 16 patients expressed neutral sentiment for PARPi.

Conclusion:

· There is increasing awareness and curiosity for PARPi in breast cancer patients as more patients are being tested for BRCA and other mutations.

· Among the users, PARPi are generally associated with low toxicity and positive sentiments.

· VoCP reliably provides meaningful insights from the patient's point of view; it also gives insight into unmet needs where more resources and research should be focused.

Citation Format: Aggarwal S, Sharma R, Singh M, Aggarwal A. Voice of cancer patient: Analysis of breast cancer patients' experience with PARP inhibitors [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 P3-16-02.

Abstract P1-10-05: Analysis of genetic mutation in ethnically diverse population with Breast and ovarian cancer: Single institution experience

Only 5-10% of all breast and ovarian cancers have been attributed to inherited mutation. In unselected breast cancer patients, prevalence of germline BRCA 1 & 2 is about 2%. In Ashkenazi Jewish population the prevalence is estimated to be 11.7%. The rate of mutations in other populations has not been well characterized. The purpose of this study is to identify and characterize the risk of genetic mutations in an ethnically diverse population referred for genetic testing according to NCCN guidelines.

Method:

In this single institution retrospective study, we analyzed 782 patients referred for genetic testing between 2009-2018. Information regarding reason for referral, ethnicity, cancer history and results of genetic mutation using multigene panels were collected.

Results:

Reasons for referral were:

· Family History of cancer (142; 18.6%),

· Breast cancer diagnosed at early age (207; 26.4%),

· Triple negative breast cancer (12 ;53%

· Ovarian cancer (61; 7.8%)

· Multiple cancer (32; 4.09%)

· Known BRCA 1 or 2 mutation (51;6.5%)

· Known other mutation (9;1.15%)

· Family h/o cancer but not diagnosed with cancer (268)

Ethnic distribution:

· 328 Hispanic (41.94%)

· 177 Caucasian (22.6%),

· 27 Chinese, (3.4%)

· 52 Vietnamese (6.6%)

· 86 other- Asian (11%)

· 32 Middle eastern (4.1%),

· 14 South Asian (1.8%)

· 35 African American (4.5%)

· 8 Ashkenazi Jewish (1%)

· 19 Mixed Hispanic (2.1%)

Genetic testing was done in 545 /782 patients.

Deleterious Mutation detected: 88 patients (16.5% of tested)

· BRCA 1: 32(5.8%)

· BRCA 2:28 (5.14%)

· MSH2:5(0.9%)

· p53:39 (0.5%)

· PLB2:3 (0.38%)

· MUTYH:3 (0.38%)

· CDH1 :2 (0.26%)

· PMS2: 2 ( 0.26%)

· ATM: 1(0.13%)

· CCKn2A: 1(0.13%)

· CHEK 2: 1(0.13)

· MET:1(0.13%)

· MSH6:1 (0.13%)

· RAD50 :1(0.13%)

· RET1;1(0.13%)

BRCA1/BRCA2 mutation: 60

Mutation in BRCA 1/ 2 distribution by ethnicity:

· Hispanic (28; 8.54 %),

· Chinese (4;14.8%)

· Vietnamese (4; 7.7%)

· other Asian (12;13.9%)

· African American (3, 8.5, %)

· South Asian (0 %)

· Caucasian (8; 4.5 %)

· All Asian (20/165: 12.1%)

Mutation in other gene by Ethnicity: total 26

Hispanic (16, 4.5%), Caucasian: (3, 1.7%) Asian other than Chinese and Vietnamese (4, 4.65%)

Mutation in Breast cancer: 333 Breast cancer patients tested, 39 patients (11.17%) were found to have mutations.

10/32 triple negative (31%) 4/49 her2neu positive patients (8.1%) and 15/252 (5.9%) ER+ patients found to have mutations.

17/39 breast cancer patients with mutation had prophylactic BSO.

Mutation in BRCA 1& 2 by reason for referral:

Known family h/o of BRCA1 or 2 mutations (18; 39.5%)

Early age of cancer (10, 7.4%)

Cancer with positive family history (17, 8.2%)

Triple negative (2, 16%).

Variant of Unknown significance (VUS): 140 patients (25 %)

VUS in BRCA 2 were most common. VUS were found in 17% of Hispanic and African American patients.

No significant difference in PFS and OS was found in patient with mutation and without mutation

Conclusion:

We found much higher rates (16.5%) than previously reported mutation detection in this very highly diverse patient population.

Rate of BRCA 1&2 mutation was 8.55% in Hispanic and 12.1% in Asian patients compared with 4.5% in Caucasian patient when selected for high risk factors.

We Also noted very high rate of VUS especially in Hispanic and African American patients.

Citation Format: Aggarwal S, Chu C, Ngumi M. Analysis of genetic mutation in ethnically diverse population with Breast and ovarian cancer: Single institution experience [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-10-05.

Abstract P2-14-14: Voice of cancer patients (VoCP): Analysis of experiences of cancer patients undergoing breast cancer surgery

Surgery is an important part of breast cancer treatment. Most patients either go for mastectomy or lumpectomy + radiation (i.e., breast conserving surgery, BCS). It is well known that mastectomy and BCS have equal long-term outcomes, and more patients are choosing to get breast reconstruction.

In this study, we analyzed experiences, concerns, complications and side effects in patients who have undergone breast cancer surgery and who shared their views on various online forums. Such forums have millions of freely shared messages and are rich sources of such information. However, this data is unstructured. We used our automated system, VoCP, that used techniques from Big Data science and artificial intelligence (e.g., deep learning, topic modeling, information retrieval, natural language processing) to analyze concerns and experiences of patients undergoing breast cancer surgeries.

Methods: We collected 5.5 million messages from 174556 distinct users in 21 unrestricted breast cancer forums. We built specific ontology for different surgeries, reconstruction, side effects and sentiments and used our system, VoCP, to extract relevant information from these messages.

Results: 52172 users shared 307966 messages regarding surgery and their views are summarized below.

Lumpectomy (BCS):

· 25850 users provided 98499 messages

· 15771 users had lumpectomy and shared 50390 messages

· 3760 users shared 6322 messages with complications

· 2760 users mentioned need for additional surgery

· 1447 users mentioned satisfaction with the outcome whereas 117 were dissatisfied

Mastectomy:

· 37544 users shared 198494 messages

· 22716 users had mastectomy and shared 94595 messages

· 5065 users shared 8983 messages regarding complications

· 2730 patients expressed satisfaction with outcome whereas 286 patients were dissatisfied

Reconstruction:

· 23164 users provided 113568 messages regarding reconstruction

· 9850 users had reconstruction and shared 32472 messages

· 1904 users shared 2734 messages with complication

· 1982 users had immediate reconstruction; 353 users mentioned delayed reconstruction

· 2686 users had autologous tissue reconstruction and 3105 repot implant reconstruction

· Type of Autologous Reconstruction reported : 759 TRAM flap, 296 Diep flap, 820 fat grafting, 108 Latissimus Dorsi flap, 89 SGAP Flap/hip Flap

· 418 users expressed satisfaction whereas 40 were dissatisfied with outcome

Complications reportedComplicationsReconstruction #Lumpectomy #Mastectomy#Overall#Scars1071,5051,4163,028Pain7101,4104052,525Infection2823106521,244Necrosis22951167447Numbness35145369549Lymphedema80136334550Lumps60115196371Seroma56222462740Swelling83290385758Frozen Shoulder3783151271Bleeding 445599Hematoma 178139317Itching/Rash 130253383Anxiety 82145227Blood Clot  6464Bruising  6060Drainage  5454

Conclusions:

· Despite reports of equal long term outcomes between BCS and mastectomy, more patient had mastectomy.

· Scar issues and pain is the most common complication from any surgery.

· Most patients have expressed satisfaction from their chosen surgery.

· VoCP reliably provides meaningful insights from the patient's point of view; it also gives insight into unmet needs where more resources and research should be focused.

Citation Format: Aggarwal S, Sharma R, Bhoemick J, Singh M, Aggarwal A. Voice of cancer patients (VoCP): Analysis of experiences of cancer patients undergoing breast cancer surgery [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 P2-14-14.