Development of a shared decision-making intervention to improve drug safety and to reduce polypharmacy in frail elderly patients living at home

Objectives

For patients with geriatric frailty, reducing inappropriate medication is an important goal to improve patient safety in primary care. GP-side barriers include knowledge gaps, legal concerns, and lack of communication between the actors involved. The aim was to develop a multi-faceted intervention to facilitate deprescribing and shared prioritisation among frail elderlies with polypharmacy living at home.

Methods

Mixed methods study including: 1) scoping review on family conferences, expert panels; 2) group discussions with GPs, mapping of needs and challenges in Primary Care; 3) workshops and expert interviews with GPs, patient advocates, researchers as a basis for a theoretical intervention model; 4) piloting.

Results

A major challenge for GPs is to conduct a productive discussion with patients and family cares on deprescribing and drug safety. A guideline for a structured family conference with a medication check and geriatric assessment was developed and proved to be feasible in the pilot study.

Conclusion

The intervention developed to facilitate deprescribing and shared prioritisation of drug therapy based on family conferences seems suitable to be tested in a subsequent cRCT.

Innovation

Adapting family conferences to primary care for frail patients with polypharmacy.

Effects of Renal Denervation vs Sham in Resistant Hypertension After Medication Escalation: Prespecified Analysis at 6 Months of the RADIANCE-HTN TRIO Randomized Clinical Trial

Importance

Although early trials of endovascular renal denervation (RDN) for patients with resistant hypertension (RHTN) reported inconsistent results, ultrasound RDN (uRDN) was found to decrease blood pressure (BP) vs sham at 2 months in patients with RHTN taking stable background medications in the Study of the ReCor Medical Paradise System in Clinical Hypertension (RADIANCE-HTN TRIO) trial.

Objectives

To report the prespecified analysis of the persistence of the BP effects and safety of uRDN vs sham at 6 months in conjunction with escalating antihypertensive medications.

Design, Setting, and Participants

This randomized, sham-controlled, clinical trial with outcome assessors and patients blinded to treatment assignment, enrolled patients from March 11, 2016, to March 13, 2020. This was an international, multicenter study conducted in the US and Europe. Participants with daytime ambulatory BP of 135/85 mm Hg or higher after 4 weeks of single-pill triple-combination treatment (angiotensin-receptor blocker, calcium channel blocker, and thiazide diuretic) with estimated glomerular filtration rate (eGFR) of 40 mL/min/1.73 m2 or greater were randomly assigned to uRDN or sham with medications unchanged through 2 months. From 2 to 5 months, if monthly home BP was 135/85 mm Hg or higher, standardized stepped-care antihypertensive treatment starting with aldosterone antagonists was initiated under blinding to treatment assignment.

Interventions

uRDN vs sham procedure in conjunction with added medications to target BP control.

Main Outcomes and Measures

Six-month change in medications, change in daytime ambulatory systolic BP, change in home systolic BP adjusted for baseline BP and medications, and safety.

Results

A total of 65 of 69 participants in the uRDN group and 64 of 67 participants in the sham group (mean [SD] age, 52.4 [8.3] years; 104 male [80.6%]) with a mean (SD) eGFR of 81.5 (22.8) mL/min/1.73 m2 had 6-month daytime ambulatory BP measurements. Fewer medications were added in the uRDN group (mean [SD], 0.7 [1.0] medications) vs sham (mean [SD], 1.1 [1.1] medications; P = .045) and fewer patients in the uRDN group received aldosterone antagonists at 6 months (26 of 65 [40.0%] vs 39 of 64 [60.9%]; P = .02). Despite less intensive standardized stepped-care antihypertensive treatment, mean (SD) daytime ambulatory BP at 6 months was 138.3 (15.1) mm Hg with uRDN vs 139.0 (14.3) mm Hg with sham (additional decreases of -2.4 [16.6] vs -7.0 [16.7] mm Hg from month 2, respectively), whereas home SBP was lowered to a greater extent with uRDN by 4.3 mm Hg (95% CI, 0.5-8.1 mm Hg; P = .03) in a mixed model adjusting for baseline and number of medications. Adverse events were infrequent and similar between groups.

Conclusions and Relevance

In this study, in patients with RHTN initially randomly assigned to uRDN or a sham procedure and who had persistent elevation of BP at 2 months after the procedure, standardized stepped-care antihypertensive treatment escalation resulted in similar BP reduction in both groups at 6 months, with fewer additional medications required in the uRDN group.

Trial Registration

ClinicalTrials.gov Identifier: NCT02649426.

Increased Drug Intoxications Seen in Heart Transplant Donors During COVID-19 Pandemic

Purpose

The majority of heart transplant centers decline heart donors with known or suspected COVID-19. In addition to impacting donor utilization, we hypothesize that the COVID pandemic is associated with increased number of drug intoxication in heart donors.

Methods

The COVID pandemic was declared on March 11^th, 2020. The Scientific Registry of Transplant Recipient was analyzed during two 15-month eras: era 1 was defined as January 1^st2019 - March 30^th, 2020 and era 2 was defined as March 31^th, 2020 - June 30th 2021. Donor populations are described by era and UNOS region. T-test was used for trend analysis.

Results

Era 1 identified 7,649 donor hearts and era 2 identified 8,475 donor hearts. There was a significant increase of 577 (45.2%) heart donors with drug intoxication identified as the cause of death from era 1 to era 2 (p<0.0001, Figure 1). There was an increase in heart donors from drug intoxication cross all UNOS regions, but the greatest increase was seen in UNOS region 5 (120.3%) followed by region 7 (69.1%) and region 4 (61.4%) (Figure 2).

Conclusion

More donor hearts were recovered for transplantation during the COVID-19 pandemic, with a notable increase in those who died from drug intoxication. This finding may reflect a psychosocial effect of the pandemic on the general population that has impacted the field of heart transplantation.

Determining degradation kinetics, byproducts and toxicity for the reductive treatment of Nitroguanidine (NQ) by magnesium-based bimetal Mg/Cu

Energetic-laden process water from industrial munition facilities can be treated by zero-valent metals (ZVMs) or zero-valent iron (ZVI) to remove residual energetics. This reduction-based treatment is significantly enhanced with the addition of a secondary catalytic metal (i.e. forming a bimetal reagent). The reagent is further enhanced by using a more reductive base metal, such as Mg. In this work, the reductive degradation of nitroguanidine (NQ) in aqueous solutions by Mg/Cu bimetal is investigated. Two initial pH conditions (unadjusted and pH 2.7) were studied. Under unadjusted initial pH conditions, 90% of NQ degraded within 30 min reaction time. After 150 min, NQ degradation generated a suite of products including guanidine (44%), cyanamide (31%), formamide (15%), aminoguanidine (AQ) (6%), urea (2%) and cyanoguanidine (0.03%), leading to 100.0% carbon closure when accounting for residual NQ. The experimentally-derived degradation reaction pathway consisted of two parallel reactions: nitroreduction led to formation of AQ with further degradation to urea, cyanamide and formamide, or reductive cleavage of the N-N bond led to guanidine formation. Toxicological assessments indicated only cyanamide and AQ were toxic to S. obliquus at certain concentrations. A lowered initial pH promoted AQ transformation to benign formamide, thus reducing toxicity and complexity of products.

Plasma renin and aldosterone concentrations related to endovascular ultrasound renal denervation in the RADIANCE-HTN SOLO trial

OBJECTIVE

The RADIANCE-HTN SOLO trial demonstrated a greater reduction in daytime ambulatory SBP at 2 months by endovascular ultrasound renal denervation than sham procedure. We hypothesized that plasma renin and aldosterone concentrations would be associated with the SBP response to renal denervation.

METHODS

Hypertensive patients were randomized to renal denervation (n = 74) or sham (n = 72) after a 4-week washout of antihypertensive medications. In a 53-patient subset, 2-month and 6-month plasma renin and aldosterone concentration were measured. Dietary sodium was not controlled.

RESULTS

Mean age of the 29 treatment and 24 sham patients was 54 years; 62% were men; 17% black. Daytime ambulatory SBP fell in the denervation but not the sham group at 2 months (-7.8 ± 10.7 vs. -0.1 ± 10.1 mmHg; P = 0.048). Baseline plasma renin and aldosterone concentrations were in the low-normal range, did not change significantly at 2 months in either group and did not predict response to renal denervation. At 6 months, after the addition of antihypertensive medications, there was a significant rise in renin in the sham but not the denervation group.

CONCLUSION

Although renal denervation but not sham resulted in a decrease in daytime ambulatory SBP at 2 months, renin and aldosterone concentrations did neither predict the BP response to renal denervation; nor did they fall after denervation. A rise in renin at 6 months in the sham group likely represents confounding from antihypertensive medications. Whether the BP-lowering effect of renal denervation depends on reducing local intrarenal renin release requires further study.

12-Month Results From the Unblinded Phase of the RADIANCE-HTN SOLO Trial of Ultrasound Renal Denervation

OBJECTIVES

This study reports the 12-month results of the RADIANCE-HTN (A Study of the ReCor Medical Paradise System in Clinical Hypertension) SOLO trial following unblinding of patients at 6 months.

BACKGROUND

The blood pressure (BP)-lowering efficacy and safety of endovascular ultrasound renal denervation (RDN) in the absence (2 months) and presence (6 months) of antihypertensive medications were previously reported.

METHODS

Patients with daytime ambulatory BP ≥135/85 mm Hg after 4 weeks off medication were randomized to RDN (n = 74) or sham (n = 72) and maintained off medication for 2 months. A standardized medication escalation protocol was instituted between 2 and 5 months (blinded phase). Between 6 and 12 months (unblinded phase), patients received antihypertensive medications at physicians' discretion. Outcomes at 12 months included medication burden, change in daytime ambulatory systolic BP (dASBP) and office or home systolic BP (SBP), visit-to-visit variability in SBP, and safety.

RESULTS

Sixty-five of 74 RDN patients and 67 of 72 sham patients had 12-month dASBP measurements. The proportion of patients on ≥2 medications (27.7% vs. 44.8%; p = 0.041), the number of medications (0 vs. 1.4; p = 0.015), and defined daily dose (1.4 vs. 2.2; p = 0.007) were less with RDN versus sham. The decrease in dASBP from baseline in the RDN group (-16.5 ± 12.9 mm Hg) remained stable at 12 months. The RDN versus sham adjusted difference at 12 months was -2.3 mm Hg (95% confidence interval [CI]: -5.9 to 1.3 mm Hg; p = 0.201) for dASBP, -6.3 mm Hg (95% CI: -11.1 to -1.5 mm Hg; p = 0.010) for office SBP, and -3.4 mm Hg (95% CI: -6.9 to 0.1 mm Hg; p = 0.062) for home SBP. Visit-to-visit variability in SBP was smaller in the RDN group. No renal artery injury was detected on computed tomographic or magnetic resonance angiography.

CONCLUSIONS

Despite unblinding, the BP-lowering effect of RDN was maintained at 12 months with fewer prescribed medications compared with sham.

Ambulatory Blood Pressure Monitoring to Predict Response to Renal Denervation: A Post Hoc Analysis of the RADIANCE-HTN SOLO Study

Renal denervation (RDN) is effective in lowering blood pressure (BP) in patients with hypertension. The issue remains how to best identify potential responders. Ambulatory BP monitoring may be useful. Baseline nighttime systolic BP (SBP) ≥136 mm Hg and its variability (SD) ≥12 mm Hg in DENER-HTN trial or 24-hour heart rate ≥73.5 bpm in SPYRAL HTN-OFF MED Trial were shown to predict the BP response to RDN. We applied these criteria to the patients with hypertension in the sham-controlled RADIANCE-HTN SOLO trial to predict the BP response to ultrasound RDN at 2 months while patients were maintained off medications. BP responders were defined as: clinical with 24-hour SBP <130 mm Hg (RDN: 22/64 versus sham: 7/58); meaningful with 24-hour SBP reduction ≥10 mm Hg (RDN: 24/64, sham: 7/58); and extreme with 24-hour SBP reduction above mean+2 SD of the SBP decrease in the sham group, that is, ≥16.5 mm Hg (RDN: 10/64 versus sham: 2/58). The predictive criteria reported above were tested for sensitivity, specificity, and positive and negative predictive values. The predictive value varied according to the definition of response, with the clinical definition being strongly influenced by regression to the mean. Baseline nighttime SBP and its variability, especially when combined, offered good specificity (>90% irrespective of definition) but low sensitivity (from 9.1% to 30% depending on the definition) to predict responders; the heart rate criterion had insufficient predictive value. This analysis suggests the potential role of nighttime SBP and its variability to predict BP response to RDN in patients with hypertension. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02649426.

Six-Month Results of Treatment-Blinded Medication Titration for Hypertension Control After Randomization to Endovascular Ultrasound Renal Denervation or a Sham Procedure in the RADIANCE-HTN SOLO Trial

BACKGROUND

The multicenter, international, randomized, blinded, sham-controlled RADIANCE-HTN SOLO trial (A Study of the ReCor Medical Paradise System in Clinical Hypertension) demonstrated a 6.3 mm Hg greater reduction in daytime ambulatory systolic blood pressure (BP) at 2 months by endovascular ultrasound renal denervation (RDN) compared with a sham procedure among patients not treated with antihypertensive medications. We report 6-month results after the addition of a recommended standardized stepped-care antihypertensive treatment to the randomized endovascular procedure under continued blinding to initial treatment.

METHODS

Patients with a daytime ambulatory BP ≥135/85 mm Hg and <170/105 mm Hg after a 4-week discontinuation of up to 2 antihypertensive medications, and a suitable renal artery anatomy, were randomized to RDN (n=74) or sham (n=72). Patients were to remain off antihypertensive medications throughout the first 2 months of follow-up unless safety BP criteria were exceeded. Between 2 and 5 months, if monthly measured home BP was ≥135/85 mm Hg, a standardized stepped-care antihypertensive treatment was recommended consisting of the sequential addition of amlodipine (5 mg/d), a standard dose of an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and hydrochlorothiazide (12.5 mg/d), followed by the sequential uptitration of hydrochlorothiazide (25 mg/d) and amlodipine (10 mg/d). Outcomes included the 6-month (1) change in daytime ambulatory systolic BP adjusted for medications and baseline systolic BP, (2) medication burden, and (3) safety.

RESULTS

A total of 69/74 RDN patients and 71/72 sham patients completed the 6-month ambulatory BP measurement. At 6 months, 65.2% of patients in the RDN group were treated with the standardized stepped-care antihypertensive treatment versus 84.5% in the sham group (P=0.008), and the average number of antihypertensive medications and defined daily dose were less in the RDN group than in the sham group (0.9±0.9 versus 1.3±0.9, P=0.010 and 1.4±1.5 versus 2.0±1.8, P=0.018; respectively). Despite less intensive standardized stepped-care antihypertensive treatment, RDN reduced daytime ambulatory systolic BP to a greater extent than sham (-18.1±12.2 versus -15.6±13.2 mm Hg, respectively; difference adjusted for baseline BP and number of medications: -4.3 mm Hg, 95% confidence interval, -7.9 to -0.6, P=0.024). There were no major adverse events in either group through 6 months.

CONCLUSIONS

The BP-lowering effect of endovascular ultrasound RDN was maintained at 6 months with less prescribed antihypertensive medications compared with a sham control.

CLINICAL TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov. Unique identifier: NCT02649426.

Abstract OT3-03-03: PARTNER: Randomised, phase II/III trial to evaluate the safety and efficacy of the addition of olaparib to platinum-based neoadjuvant chemotherapy in triple negative and/or germline BRCA mutated breast cancer patients

Background: No specific targeted therapies are available for Triple Negative Breast Cancers (TNBC), an aggressive and diverse subgroup. The basal TNBC sub-group share some phenotypic and molecular similarities with germline BRCA (gBRCA) tumours. In gBRCA patients, and potentially other homologous recombination deficiencies, these already compromised pathways may allow drugs called PARP inhibitors (Olaparib) to work more effectively. Aims: To establish if the addition of olaparib to neoadjuvant platinum based chemotherapy for basal TNBC and/or gBRCA breast cancer is safe and improves efficacy (pathological complete response (pCR)).

Methods: Trial design: 3-stage open label randomised phase II/III trial of neoadjuvant paclitaxel and carboplatin +/- olaparib, followed by clinicians' choice of anthracycline regimen. Stage 1 and 2: Randomisation (1:1:1) to either control (3 weekly carboplatin AUC5/weekly paclitaxel 80mg/m2 for 4 cycles) or one of two research arms with the same chemotherapy regimen but with two different schedules of olaparib 150mg BD for 12 days. Stage 3: Patients are randomised (1:1) to either control arm or to the research arm selected in stage 2. End-points: Stage 1: Safety; Stage 2: Schedule selection using pCR rate and completion rate of olaparib using a “pick-the-winner” design. Stage 3: pCR rate. Enrichment design is applied with an overall significance level 0.05(α) and 80% power. A total of 527 patients will be included to detect an absolute improvement of 15% (all patients) and 20% (gBRCA patients) by adding olaparib to platinum based chemotherapy.

Trial Progress: PARTNER has been recruiting in UK since 27th May 2016. IDSMC recommended to continue the trial without change after reviewing the Stage 1 safety data. The recruitment of stage 2 was completed in April 2018 and results to be reviewed by the IDSMC in early 2019. The trial is open and enrolling patients to national and international sites.

Citation Format: Abraham J, Vallier A-L, Qian W, Machin A, Grybowicz L, Thomas S, Weiss M, Harvey C, McAdam K, Hughes-Davies L, Roberts A, Roylance R, Copson E, Pinilla K, Armstrong A, Provenzano E, Tischkowitz M, McMurty E, Earl H. PARTNER: Randomised, phase II/III trial to evaluate the safety and efficacy of the addition of olaparib to platinum-based neoadjuvant chemotherapy in triple negative and/or germline BRCA mutated breast cancer patients [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 OT3-03-03.

Abstract PD3-04: Analysis of ERBB2 (HER2) amplification by ctDNA in a phase Ib dose-escalation trial evaluating trastuzumab emtansine (T-DM1) with neratinib in women with metastatic disease with initially diagnosed HER2+ breast cancer: NSABP FB-10

Background:

In this phase Ib study, the activity of T-DM1 plus N was assessed in patients (pt) previously treated with trastuzumab, pertuzumab, and a taxane (H+P+T). Several mechanisms of resistance have been hypothesized in pts progressing following H+P+T, including acquired alterations in the ERBB (HER) family proteins, reactivation of bypass or parallel pathways, or selective elimination of HER2-overexpressing clones. Loss of HER2 amp has been shown to occur in 25-35% of pts with residual tumor after neoadjuvant therapy or in metastatic disease after initial therapy with chemotherapy and HER2-targeted agents. Data on concordance of HER2 status between tissue and blood is limited. In 7 pts with cfDNA HER2 amp, concomitant tissue was concordant in all 7 pairs and response to anti-HER2 therapy occurred in 6. In our study we have retrospectively analyzed cfDNA in blood samples obtained at study entry.

Methods:

Eligible pts had prior H+P+T as neoadjuvant therapy, or 1st-line metastatic disease, measurable disease, ECOG PS ≤2, and adequate hematologic, renal, and liver function. Pts with stable brain metastases were eligible. Treatment consisted of T-DM1 3.6 mg/kg iv q3wk and N 120, 160, 200, or 240 mg/d using a 3+3 dose-escalation design. HER2+ was determined at initial diagnosis; tissue confirmation at study entry (after H+P+T progression) was not required. Blood was collected in for pharmacokinetic analyses of N peak and trough, and for cfDNA using the Guardant360 assay, which is a 73-gene next-generation cfDNA-sequencing panel that detects SNVs, indels, CNAs, and fusions, utilizing Digital Sequencing and custom bioinformatics methods for error correction. The cut-off for HER2 amp was a copy number of ≥2.0 established by Guardant based on training-set data.

Results:

There were 27 H+P+T-resistant pts enrolled and all pts had a blood sample analyzed for HER2 amp. Eighteen pts were evaluable for efficacy at 6 wks and 11 pts at 12 wks. Dose-limiting toxicity occurred in 6 pts during cycle 1, 1 pt was withdrawn for non-compliance, and 2 pts were withdrawn for disease complications. The recommended phase II dose of N was determined to be 160 mg/d. Responses were seen at all dose-levels of N. Pharmacokinetic analyses did not show a clear relationship with either peak or trough and dose-level. Ten pts showed HER2 amp in blood and 17 were non-amp. Of 18 pts evaluable after 2 cycles (6 wks), 12 pts had an objective response (7 amp; 5 non-amp) and 5 had progressive disease (1 amp; 4 non-amp). At 12 wks, there were 3 CRs and 8 PRs (7 amp; 4 non-amp). All CRs were in amp pts and lasted 364, 510, and 859+ days.

Conclusions:

HER2 amp as determined by cfDNA was found in 10 of 27 pts. The deeper and more prolonged (&gt;12 wk) responses occurred in 7 of 10 amp HER2 pts v 4 of 17 non-amp HER2 pts (p=0.04). In our ongoing phase II study of this regimen concomitant tissue and blood will be analyzed to better understand potential benefit or lack of benefit, with continued use of anti-HER2 therapy after progression on anti-HER2 therapies.

Support: Puma Biotechnology, Inc.

Citation Format: Abraham J, Puhalla SL, Sikov WM, Montero AJ, Salkeni MA, Razaq WA, Beumer JH, Kiesel BF, Buyse ME, Adamson LM, Srinivasan A, Pogue-Geile KL, Allegra CJ, Nagy RJ, Jacobs SA. Analysis of ERBB2 (HER2) amplification by ctDNA in a phase Ib dose-escalation trial evaluating trastuzumab emtansine (T-DM1) with neratinib in women with metastatic disease with initially diagnosed HER2+ breast cancer: NSABP FB-10 [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 PD3-04.

Endovascular ultrasound renal denervation to treat hypertension (RADIANCE-HTN SOLO): a multicentre, international, single-blind, randomised, sham-controlled trial

BACKGROUND

Early studies suggest that radiofrequency-based renal denervation reduces blood pressure in patients with moderate hypertension. We investigated whether an alternative technology using endovascular ultrasound renal denervation reduces ambulatory blood pressure in patients with hypertension in the absence of antihypertensive medications.

METHODS

RADIANCE-HTN SOLO was a multicentre, international, single-blind, randomised, sham-controlled trial done at 21 centres in the USA and 18 in Europe. Patients with combined systolic-diastolic hypertension aged 18-75 years were eligible if they had ambulatory blood pressure greater than or equal to 135/85 mm Hg and less than 170/105 mm Hg after a 4-week discontinuation of up to two antihypertensive medications and had suitable renal artery anatomy. Patients were randomised (1:1) to undergo renal denervation with the Paradise system (ReCor Medical, Palo Alto, CA, USA) or a sham procedure consisting of renal angiography only. The randomisation sequence was computer generated and stratified by centres with randomised blocks of four or six and permutation of treatments within each block. Patients and outcome assessors were blinded to randomisation. The primary effectiveness endpoint was the change in daytime ambulatory systolic blood pressure at 2 months in the intention-to-treat population. Patients were to remain off antihypertensive medications throughout the 2 months of follow-up unless specified blood pressure criteria were exceeded. Major adverse events included all-cause mortality, renal failure, an embolic event with end-organ damage, renal artery or other major vascular complications requiring intervention, or admission to hospital for hypertensive crisis within 30 days and new renal artery stenosis within 6 months. This study is registered with ClinicalTrials.gov, number NCT02649426.

FINDINGS

Between March 28, 2016, and Dec 28, 2017, 803 patients were screened for eligibility and 146 were randomised to undergo renal denervation (n=74) or a sham procedure (n=72). The reduction in daytime ambulatory systolic blood pressure was greater with renal denervation (-8·5 mm Hg, SD 9·3) than with the sham procedure (-2·2 mm Hg, SD 10·0; baseline-adjusted difference between groups: -6·3 mm Hg, 95% CI -9·4 to -3·1, p=0·0001). No major adverse events were reported in either group.

INTERPRETATION

Compared with a sham procedure, endovascular ultrasound renal denervation reduced ambulatory blood pressure at 2 months in patients with combined systolic-diastolic hypertension in the absence of medications.

FUNDING

ReCor Medical.

Abstract P1-06-09: Correlation of breast cancer index (BCI) results to lymphovascular invasion in early stage HR+ breast cancer

Background: Positive lymphovascular invasion (LVI) is a negative prognostic factor for women with early-stage ER+ breast cancer. LVI, along with other clinicopathologic factors such as larger tumor size, higher grade and positive nodal status, increase a patient's risk of late (post-5y) recurrence. Breast Cancer Index (BCI) is a validated gene expression-based assay for patients with early-stage HR+ breast cancer that reports an individualized risk of late distant recurrence based on a combination of the HOXB13/I17BR ratio and the molecular grade index (MGI). The correlation of LVI and individualized risk stratification by genomic analysis is not well characterized. Therefore, this study evaluated risk stratification by BCI based on the presence or absence of LVI.

Methods: A population of 2,613 patients with known LVI status were identified in the Breast Cancer Index Clinical Database for Correlative Studies, an IRB-approved de-identified database which contains clinicopathologic and molecular variables of more than 19,000 clinical cases submitted for BCI testing. LVI was recorded as either positive or negative based on pathology report review. BCI results based on LVI status from LN- (n=2035) and LN+ patients (n=578) were evaluated separately. Chi-squared tests were used to compare BCI results between LVI groups.

Results: In analyses of 2,613 patients with LVI data available (median age 59.1 y; range 28-89y; 74% ≥50y), 18.3% of patients showed evidence of LVI (LVI-pos). In comparison to the LVI-neg tumors submitted for BCI testing, the LVI-pos tumors had a higher proportion of grade 3 tumors (33% vs 16%, p&lt;0.0001), more LVI-pos tumors were 2.0 cm or greater (45% vs 23%, p&lt;0.0001), a higher percentage LVI-pos patients had node-positive disease (51% vs 16%, p&lt;0.0001), and a higher proportion of LVI-pos tumors showed high Ki67 (Ki67 ≥14%; 64% vs 51%, p=0.004). A correlation between LVI positivity and high BCI prognostic risk was observed, with a higher proportion of LVI-pos patients classified as high risk of late distant recurrence in both the LN- (68% vs 49%, p&lt;0.0001) and LN+ subsets (84% vs 70%, p&lt;0.0001) compared to LVI-neg patients. LVI-pos patients had a higher median molecular proliferative status (MGI) compared to LVI-neg patients regardless of nodal status (p&lt;0.0001 for both). In contrast to the categorical LVI prognostic factor, the wide distribution of BCI individual risk scores provides additional resolution that identifies a substantial subset of LVI positive tumors (32%) that that have a low risk of late recurrence by genomic analysis.

Conclusion: While BCI Prognostic stratification correlated with LVI status, BCI identified a subset of patients with LVI positivity as having a low risk of late distant recurrence that otherwise would have an unfavorable prognosis based on LVI and/or LN positivity. These findings help to characterize differential patient stratification based on an individualized assessment of tumor biology versus LVI for patients considering EET.

Citation Format: Vulchi M, Sagalnik M, Schnabel CA, Abraham J. Correlation of breast cancer index (BCI) results to lymphovascular invasion in early stage HR+ breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-06-09.

Abstract P5-21-26: T-DM1 activity in metastatic HER2-positive breast cancer patients who have received prior trastuzumab and pertuzumab: NSABP B-005

Background :

The pivotal phase III EMILIA trial reported a progression free survival (PFS) rate of 9.6 months and an objective response rate of 43% with T-DM1 in patients with HER2-positive metastatic breast cancer previously treated with trastuzumab and a taxane. However, there is very limited data on the efficacy of T-DM1 in patients who have received prior pertuzumab either neoadjuvantly or as first line therapy in the metastatic setting. The primary goal of this study was to assess the clinical efficacy (tumor response rates and median duration on therapy) of T-DM1 in patients previously treated with pertuzumab and trastuzumab.

Methods:

After IRB approval, a cancer data registry and electronic pharmacy database were utilized to identify breast cancer patients receiving treatment with T-DM1 at Cleveland Clinic and University of Pittsburgh. Patients that received trastuzumab and pertuzumab, in either the neoadjuvant or metastatic setting, with baseline and follow up imaging available for review were identified. Patient charts were reviewed to collect accurate information about the treatment sequencing and outcomes. RECIST version 1.1 was utilized for tumor assessment and patients with measurable disease and non measurable disease were included in the study.

Results:

We identified a total of 23 patients with a median age of 55 years that met the inclusion criteria. 69% percent of patients received T-DM1 as first line or second line therapy and 31% received it as third line or later. All patients had at least 1 measurable lesion. Best overall response showed rates of complete response, partial response and stable disease of 17%, 26% and 22% respectively. 35% patients progressed on first assessment after start of treatment. The median duration on therapy was 5.3 months (range 3 weeks to 33 months) with 43% of patients receiving T-DM1 for greater than 6 months.

Conclusion:

Our results were comparable to those reported by EMILIA trial. T-DM1 has reasonable clinical efficacy in patients who have received prior treatment with pertuzumab and trastuzumab with an overall response rate of 43% and median duration on therapy of 5.3 months.

Citation Format: Tiwari SR, Sussman T, Kota K, Moore HC, Montero AJ, Budd GT, Puhalha S, Abraham J. T-DM1 activity in metastatic HER2-positive breast cancer patients who have received prior trastuzumab and pertuzumab: NSABP B-005 [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-26.

Abstract OT3-04-03: PARTNER randomised, phase II/III trial to evaluate the safety and efficacy of the addition of olaparib to platinum based neoadjuvant chemotherapy in triple negative and/or germline BRCA mutated breast cancer patients

Background: No specific targeted therapies are available for Triple Negative Breast Cancers (TNBC), an aggressive and diverse subgroup. The basal TNBC subgroup show some phenotypic and molecular similarities with germline BRCA (gBRCA). In gBRCA patients, and potentially other homologous recombination deficiencies, these already compromised pathways may allow drugs called PARP inhibitors (olaparib) to work more effectively.

Aims: To establish if the addition of olaparib to neoadjuvant platinum based chemotherapy for basal TNBC and/or gBRCA breast cancer is safe and improves efficacy (pathological complete response (pCR)).

Trial design: 3 stage open label randomised phase II/III trial of neoadjuvant paclitaxel and carboplatin +/olaparib, followed by clinicians' choice of anthracycline regimen.

Stage 1 and 2: Patients are randomised (1:1:1) to either control (3 weekly carboplatin AUC5/weekly paclitaxel 80mg/m2 for 4 cycles) or one of two research arms with the same chemotherapy regimen but with two different schedules of olaparib 150mg BD for 12 days.

Stage 3: Patients are randomised (1:1) to either control arm or to the research arm selected in stage 2.

Methods:

Stage 1 Safety: both research arms combined.

Stage 2 Schedule selection criteria: pCR rate and completion rate of olaparib protocol treatment. It is a “pickthewinner” design with 53 patients in each research arm. This allows a 90% power, 5% onesided significance level to test null hypothesis of pCR ≤35% versus an alternative hypothesis of pCR ≥55% in each of the research arms.

Stage 3 Efficacy:anticipated pCR ˜55-60% for all trial patients and ˜60-65% for gBRCA patients. The trial is powered to detect an absolute improvement of 15% (all patients) and 20% (gBRCA patients) by adding olaparib to chemotherapy (enriched design). TNBC patient recruitment will be capped, to ensure required gBRCA patients are enrolled. Enrichment design is applied with overall significance level 0.05(α) = 0.025(αall)+ 0.025(αgBRCA) and 80% power.

Target accrual: 527 [gBRCA 220] Current accrual: 56 Sites activated: 15 [expected number of sites 30-50].

Citation Format: Abraham J, Vallier A-L, Qian W, Grybowicz L, Thomas S, Machin A, Harvey C, Chiu E, McAdam K, Hughes-Davies L, Roylance R, Copson E, Armstrong A, Provenzano E, Tischkowitz M, McMurtry E, Earl H. PARTNER randomised, phase II/III trial to evaluate the safety and efficacy of the addition of olaparib to platinum based neoadjuvant chemotherapy in triple negative and/or germline BRCA mutated breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT3-04-03.

Individualized Survival and Treatment Response Predictions for Breast Cancers Using Phospho-EGFR, Phospho-ER, Phospho-HER2/neu, Phospho-IGF-IR/In, Phospho-MAPK, and Phospho-p70S6K Proteins

The development and progression of breast cancer involves the activation of numerous protein kinases, and the change in phosphorylation is a hallmark of protein kinase activation. In this study, we identified a comprehensive profile to predict individual breast cancer patients’ survival and treatment responses using the Random Committee algorithm. The profile incorporated a subset of phosphorylated signal protein expressions and several selected clinical factors of breast cancer. The parameters of our profile were identified by supervised feature selection algorithms, Gain Ratio Attribute Evaluation and Relief. The results showed that the overall accuracy of survival prediction reached 92.3% for individual breast cancer patients with the use of the expression profiles of phospho-EGFR, phospho-ER, phospho-HER2/neu, phospho-IGF-IR/In, phospho-MAPK, and phospho-p70S6K plus the selected clinical factors. The results also indicated that the overall accuracy of treatment response prediction was 92.6% with the use of the level of phospho-EGFR, phospho-ER, phospho-HER2/neu, phospho-MAPK, and phospho-p70S6K plus the selected clinical information. The prediction system combines multiple signal protein activation profiles and relevant clinical information, and provides a unique guideline to aid individualized decision-making in the clinical management of breast cancer.

Neurotensin receptor type 2 protects B-cell chronic lymphocytic leukemia cells from apoptosis

B-cell chronic lymphocytic leukemia (B-CLL) cells are resistant to apoptosis, and consequently accumulate to the detriment of normal B cells and patient immunity. Because current therapies fail to eradicate these apoptosis-resistant cells, it is essential to identify alternative survival pathways as novel targets for anticancer therapies. Overexpression of cell-surface G protein-coupled receptors drives cell transformation, and thus plays a critical role in malignancies. In this study, we identified neurotensin receptor 2 (NTSR2) as an essential driver of apoptosis resistance in B-CLL. NTSR2 was highly expressed in B-CLL cells, whereas expression of its natural ligand, neurotensin (NTS), was minimal in both B-CLL cells and patient plasma. Surprisingly, NTSR2 remained in a constitutively active phosphorylated state, caused not by a mutation-induced gain-of-function but rather by an interaction with the oncogenic tyrosine kinase receptor TrkB. Functional and biochemical characterization revealed that the NTSR2-TrkB interaction acts as a conditional oncogenic driver requiring the TrkB ligand brain-derived neurotrophic factor (BDNF), which unlike NTS is highly expressed in B-CLL cells. Together, NTSR2, TrkB and BDNF induce autocrine and/or paracrine survival pathways that are independent of mutation status and indolent or progressive disease course. The NTSR2-TrkB interaction activates survival signaling pathways, including the Src and AKT kinase pathways, as well as expression of the anti-apoptotic proteins Bcl-2 and Bcl-xL. When NTSR2 was downregulated, TrkB failed to protect B-CLL cells from a drastic decrease in viability via typical apoptotic cell death, reflected by DNA fragmentation and Annexin V presentation. Together, our findings demonstrate that the NTSR2-TrkB interaction plays a crucial role in B-CLL cell survival, suggesting that inhibition of NTSR2 represents a promising targeted strategy for treating B-CLL malignancy.

Lymphocyte density determined by computational pathology validated as a predictor of response to neoadjuvant chemotherapy in breast cancer: secondary analysis of the ARTemis trial

BACKGROUND

We have previously shown lymphocyte density, measured using computational pathology, is associated with pathological complete response (pCR) in breast cancer. The clinical validity of this finding in independent studies, among patients receiving different chemotherapy, is unknown.

PATIENTS AND METHODS

The ARTemis trial randomly assigned 800 women with early stage breast cancer between May 2009 and January 2013 to three cycles of docetaxel, followed by three cycles of fluorouracil, epirubicin and cyclophosphamide once every 21 days with or without four cycles of bevacizumab. The primary endpoint was pCR (absence of invasive cancer in the breast and lymph nodes). We quantified lymphocyte density within haematoxylin and eosin (H&E) whole slide images using our previously described computational pathology approach: for every detected lymphocyte the average distance to the nearest 50 lymphocytes was calculated and the density derived from this statistic. We analyzed both pre-treatment biopsies and post-treatment surgical samples of the tumour bed.

RESULTS

Of the 781 patients originally included in the primary endpoint analysis of the trial, 609 (78%) were included for baseline lymphocyte density analyses and a subset of 383 (49% of 781) for analyses of change in lymphocyte density. The main reason for loss of patients was the availability of digitized whole slide images. Pre-treatment lymphocyte density modelled as a continuous variable was associated with pCR on univariate analysis (odds ratio [OR], 2.92; 95% CI, 1.78-4.85; P < 0.001) and after adjustment for clinical covariates (OR, 2.13; 95% CI, 1.24-3.67; P = 0.006). Increased pre- to post-treatment lymphocyte density showed an independent inverse association with pCR (adjusted OR, 0.1; 95% CI, 0.033-0.31; P < 0.001).

CONCLUSIONS

Lymphocyte density in pre-treatment biopsies was validated as an independent predictor of pCR in breast cancer. Computational pathology is emerging as a viable and objective means of identifying predictive biomarkers for cancer patients.

CLINICALTRIALS.GOV

NCT01093235.

Abstract P6-09-22: Detecting high mutational load ER+ breast cancer patients through Foundation One cancer gene panel mutations

Background:

Cancer gene panels such as Foundation One are widely used clinically for aiding with cancer treatment decision-making since single point mutations in important genes and gene pathways in the tumor can point to tumor susceptibility that can be targeted with specific drugs. Tumor mutational load has more recently been proposed as a useful prognostic factor and indicator of clinical benefit in treatment with PD-1 and CTLA-4 blockade therapy. Breast cancer estrogen receptor positive patients (ER+) in particular appear to have a subset of high mutational load patients that could benefit if identified. However whole exome sequencing needed to directly measure mutational load is not yet widely available as a clinical tool. In this study we evaluate the predictive value of Foundation One cancer gene panel mutations for estimating tumor genome-wide mutational load and its use in identifying a clinically meaningful subset of breast cancer patients.

Methods:

The Cancer Genome Atlas breast cancer sequencing data on 569 ER+ patients was used to establish mutational load distribution. ER+ patients were divided into low mutational load and high mutational load groups according to 3 criteria: mean mutational load, the point of inflection in the mutational load distribution and the mutational load that optimally separates groups in terms of survival. Foundation One (FO) mutational load was then calculated as the number of mutations present within the 314 genes queried by the panel. FO mutational load was used to predict whether patients fell into the low or high mutational load groups found through analysis of the full exome data. Receiver Operating Characteristic (ROC) curves were constructed and optimal values for specificity and sensitivity of the FO mutational load classification were found.

Results:

Mean mutational load for ER+ patients was found to be 57 mutations, the point of inflection of the mutational load distribution was established at 100 mutations, and the number of mutations that best separated groups in terms of survival was 160, (HR = 6.6, p-value=0.004). FO mutational load was found to be a good predictor for the low and high classifications established by all three criteria, with areas under the curve of 0.74, 0.91 and 0.945 respectively. The optimal predictive value of the FO mutational load classification was found at 5 mutations as the cut-off, with 94.2% specificity and 88% sensitivity for predicting groups defined by survival and 95% specificity and 71% sensitivity for those defined by the mean.

Conclusion:

The Foundation One cancer gene panel can be used to effectively identify a clinically meaningful subgroup of ER+ patients with high mutational load. These patients may benefit from targeted treatments such as PD-1 inhibitors being offered through clinical trials. The compromise in sensitivity that results from the reduction in number of genes queried by a panel means an important proportion of patients with high mutational load will be missed but this still translates to a large improvement in the identification of these patients given the wide availability of gene panels in the clinic. Basic and clinical follow-up studies need to take place to clinically validate the high mutational load ER+ patient subgroup.

Citation Format: Raska P, Abraham J, Budd T. Detecting high mutational load ER+ breast cancer patients through Foundation One cancer gene panel mutations [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-22.

Abstract P2-12-04: Impact of institution of young women's breast cancer clinic on time to treatment and utilization of fertility, genetics and social work consultations in women under age 50 with new diagnosis of early stage breast cancer

Background: Genetic counseling and fertility resources are often underutilized in young women with early stage breast cancer (ESBC) due, in part, to concerns about treatment delays. At our institution, women newly diagnosed with ESBC typically see a breast surgeon, medical oncologist and radiation oncologist in a multidisciplinary clinic with additional cancer related subspecialist referrals occurring at those providers' discretion. We hypothesized that time to treatment (TTT) and utilization of fertility, genetics and social work consultations would improve after implementing a Young Women's Breast Cancer Clinic. As of January 1, 2015, all patients under age 50 seen at Cleveland Clinic for new diagnosis of ESBC were automatically offered scheduling of appointments with medical genetics, reproductive endocrinology and social work in addition to the usual multidisciplinary team.

Methods: Women under age 50 diagnosed with ESBC seen at Cleveland Clinic from 1/2014-12/2015 were identified using our tumor registry. Demographics, tumor pathology, clinical and treatment histories were obtained through medical chart review as per IRB approved protocol. Time from initial visit in our system to date of treatment initiation was calculated for all patients and compared between the 2014 (pre-intervention) and 2015 (post-intervention) cohorts as was time from diagnosis (biopsy date) to treatment initiation. Completed reproductive endocrinology, genetic counseling and social work consultations were documented. Welch two sample t-test was used to compare time to treatment between groups. Chi squared test was used to compare frequency of subspecialty consultations between groups.

Results: 207 young women with ESBC were identified over the 2 year period, 99 in 2014 and 108 in 2015. Median age was 45 in 2014 and 44 in 2015. Most were diagnosed outside of our hospital system, 58% in 2014 and 76% in 2015. The most common initial treatment was surgery with reconstruction (S+R) (54% and 50% for 2014 and 2015 respectively) followed by chemotherapy (23% and 27%) then surgery without reconstruction (S) (20% and 24%). Median TTT from first encounter was 30 days in 2014 and 28 days in 2015 (p=0.33) and was 36 days versus 33.5 days (p=0.23) when calculated from biopsy date. TTT in the S and S+R groups was 37 vs 28 days (p=0.84) and 36.5 vs 32 days, (p=0.21), respectively. Genetics, reproductive endocrinology and social work consults in 2014 vs 2015 were documented as 89% vs 94%, 4% vs 9% and 58 vs% 55% (p=0.22, 0.32, 0.77). For patients under age 40, 27% in 2014 and 30% in 2015 completed reproductive endocrinology consultations.

Conclusions: Offering upfront scheduling of breast cancer related subspecialty appointments for young women with newly diagnosed ESBC did not significantly improve overall TTT. There was a trend towards improved TTT in those receiving surgery with or without reconstruction as first treatment and no suggestion of delay in TTT. A modest numeric increase in completed genetic counseling and reproductive endocrinology consultations was not statistically significant, but may have been clinically meaningful for affected individuals.

Citation Format: Kruse ML, Raska P, Abraham J, Budd GT, Montero A, Grobmyer S, Moore H. Impact of institution of young women's breast cancer clinic on time to treatment and utilization of fertility, genetics and social work consultations in women under age 50 with new diagnosis of early stage breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-12-04.

Abstract OT2-01-10: Pilot study of carboplatin, nab-paclitaxel and pembrolizumab for metastatic triple-negative breast cancer (ongoing clinical trial)

BACKGROUND. Triple-negative breast cancer (TNBC) is associated with an aggressive phenotype and decreased survival. TNBC is characterized by tumor-infiltrating lymphocytes (TIL) which predict for a better prognosis and likely reflect immune recognition of tumor-associated antigens by TIL. However, potent immune suppressive signals exist in the tumor microenvironment such as those mediated by PD-1 with its ligand, PD-L1. Therefore, to test the validity of decreasing PD-1/PD-L1-mediated immune suppression, a Phase Ib study of single-agent pembrolizumab in 32 patients with advanced TNBC showed a partial response of 16.1% and stable disease of 9.7%, thereby attesting to the effectiveness of single-agent pembrolizumab in these patients. Other studies have demonstrated that cytotoxic chemotherapy favorably modulates immunity against cancer and there is therefore a strong rationale to combine chemotherapy with an immune modulator such as pembrolizumab for the treatment of mTNBC.

TRIAL DESIGN. This is an investigator-initiated, industry-sponsored (Merck) pilot study of carboplatin (C), nab-paclitaxel (N) and pembrolizumab (P) in 30 patients with metastatic (m) TNBC. Eligible patients will receive 3 cycles of CNP, with each cycle consisting of C (AUC 6 on days 1 of a 21-day cycle), N (100 mg/m2 IV on days 1, 8 and 15 of a 21-day cycle), and P (200 mg IV on day 15 of each cycle). After completion of 3 cycles CNP, patients with responding or stable disease by RECIST 1.1 criteria will be eligible for additional cycle(s) of CNP.

ELIGIBILITY CRITERIA. Patients must have radiologically measurable mTNBC, an ECOG performance status of 0-1, must not have received more than 2 prior therapies for this disease, and must be willing to undergo a preliminary biopsy of a metastatic focus for research purposes. A second post-treatment biopsy will be encouraged but will not be mandated.

SPECIFIC AIMS. The primary objective is to determine overall response rate (ORR) in patients treated with CNP. The secondary objectives are to determine progression-free survival (PFS) and safety/tolerability of CNP. Correlative objectives include the identification of pathologic and genomic correlates of response to CNP.

STATISTICAL METHODS. Clinical response will be scored using RECIST 1.1 criteria. Under the proposed treatment, the expected clinical response is about 35%. With the precision of the 2-sided 95% confidence interval for the response rate set to 0.17 (the distance to the expected response rate of 35%), the sample size required for the study is 30 patients. The true response rate of therapy will be estimated based on the number of responses using a binomial distribution and its confidence intervals will be estimated using Wilson's method. The Kaplan-Meier method will be used to estimate PFS. Factors including pathologic and genomic correlates that predict survival outcomes will be identified by Cox model or extensions of the Cox model.

TARGET ACCRUAL. We plan to enroll 30 patients over 2 years, with the first patient expected to be enrolled in September 2016.

CONTACT INFORMATION. Joseph Baar, MD, PhD. Seidman Cancer Center of University Hospitals Case Medical Center. E-mail: joseph.baar@uhhospitals.org.

Citation Format: Baar J, Abraham J, Silverman P, Budd GT, Vinayak S, Varadan V, Moore H, Montero A, Fu P. Pilot study of carboplatin, nab-paclitaxel and pembrolizumab for metastatic triple-negative breast cancer (ongoing clinical trial) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-01-10.

Aetiology of Preoperative Anaemia in Patients Undergoing Elective Cardiac Surgery—the Challenge of Pillar One of Patient Blood Management

Preoperative anaemia is common in patients undergoing cardiac surgery. Whilst there is a strong association with increased morbidity and mortality, it is currently unclear whether treatment of anaemia leads to patient benefit. This retrospective study aimed to determine the aetiology of preoperative anaemia in a cohort of patients undergoing elective cardiac surgery over two years at a tertiary hospital. Laboratory data obtained at the preoperative assessment clinic visit were assessed to stratify patients into four groups—iron deficiency anaemia (IDA), possible IDA, anaemia of chronic disease (ACD) and non-anaemic patients with low ferritin according to the ‘Preoperative haemoglobin assessment and optimisation template’ of the Australian Patient Blood Management (PBM) Guidelines. Of patients with preoperative anaemia, 23.1% had IDA, 6.6% had possible IDA and 70.3% had possible ACD. Of the patients with possible ACD, 30% had a ferritin <100 μg/l, representing limited iron stores or coexisting absolute iron deficiency in the setting of chronic disease. In addition, 46.2% of those with possible ACD had iron studies indicative of functional iron deficiency. Time between assessment and surgery was as little as one day in a third of patients and in only 7% was it more than seven days. Our findings indicate that about one-third of our patients with preoperative anaemia had evidence of iron deficiency, a potentially reversible cause of anaemia. In addition, a significant number had either limited iron stores that may render them iron deficient by surgery, or a functional iron deficiency.

A Survey of the Literature on Unintended Consequences Associated with Health Information Technology: 2014-2015

OBJECTIVE

To summarize recent research on unintended consequences associated with implementation and use of health information technology (health IT). Included in the review are original empirical investigations published in English between 2014 and 2015 that reported unintended effects introduced by adoption of digital interventions. Our analysis focuses on the trends of this steam of research, areas in which unintended consequences have continued to be reported, and common themes that emerge from the findings of these studies.

METHOD

Most of the papers reviewed were retrieved by searching three literature databases: MEDLINE, Embase, and CINAHL. Two rounds of searches were performed: the first round used more restrictive search terms specific to unintended consequences; the second round lifted the restrictions to include more generic health IT evaluation studies. Each paper was independently screened by at least two authors; differences were resolved through consensus development.

RESULTS

The literature search identified 1,538 papers that were potentially relevant; 34 were deemed meeting our inclusion criteria after screening. Studies described in these 34 papers took place in a wide variety of care areas from emergency departments to ophthalmology clinics. Some papers reflected several previously unreported unintended consequences, such as staff attrition and patients' withholding of information due to privacy and security concerns. A majority of these studies (71%) were quantitative investigations based on analysis of objectively recorded data. Several of them employed longitudinal or time series designs to distinguish between unintended consequences that had only transient impact, versus those that had persisting impact. Most of these unintended consequences resulted in adverse outcomes, even though instances of beneficial impact were also noted. While care areas covered were heterogeneous, over half of the studies were conducted at academic medical centers or teaching hospitals.

CONCLUSION

Recent studies published in the past two years represent significant advancement of unintended consequences research by seeking to include more types of health IT applications and to quantify the impact using objectively recorded data and longitudinal or time series designs. However, more mixed-methods studies are needed to develop deeper insights into the observed unintended adverse outcomes, including their root causes and remedies. We also encourage future research to go beyond the paradigm of simply describing unintended consequences, and to develop and test solutions that can prevent or minimize their impact.

Van der Waals pressure and its effect on trapped interlayer molecules

Van der Waals assembly of two-dimensional crystals continue attract intense interest due to the prospect of designing novel materials with on-demand properties. One of the unique features of this technology is the possibility of trapping molecules between two-dimensional crystals. The trapped molecules are predicted to experience pressures as high as 1 GPa. Here we report measurements of this interfacial pressure by capturing pressure-sensitive molecules and studying their structural and conformational changes. Pressures of 1.2±0.3 GPa are found using Raman spectrometry for molecular layers of 1-nm in thickness. We further show that this pressure can induce chemical reactions, and several trapped salts are found to react with water at room temperature, leading to two-dimensional crystals of the corresponding oxides. This pressure and its effect should be taken into account in studies of van der Waals heterostructures and can also be exploited to modify materials confined at the atomic interfaces.