Safety and Efficacy of IPX203 in Parkinson's Disease: The RISE-PD Open-Label Extension Study

BACKGROUND

IPX203 is a novel oral extended-release formulation of carbidopa/levodopa (CD/LD) developed to address the short half-life of immediate-release CD/LD. In the phase 3 RISE-PD trial, IPX203 significantly improved "Good On" time in patients with Parkinson's disease compared with immediate-release CD/LD.

OBJECTIVES

To evaluate the safety and efficacy of IPX203 in an open-label extension of the pivotal phase 3 study.

METHODS

This 9-month extension enrolled patients who completed the randomized, double-blind trial. Key efficacy endpoints included Movement Disorder Society-Unified Parkinson's Disease Rating Scale and Patient and Clinical Global Impression scores. Adverse events (AEs) were recorded.

RESULTS

Improvements in efficacy were maintained and dosing frequency and total daily dose remained stable through the trial. A total of 52.7% of patients experienced ≥1 treatment-emergent AE, mostly mild or moderate and occurred within the first 90 days of treatment.

CONCLUSIONS

In this phase 3 open-label extension, IPX203 exhibited a favorable safety and tolerability profile and sustained efficacy of comparable magnitude to the end of the double-blind study. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

A nationwide analysis of cardiac sarcoidosis and related in-hospital outcomes

Introduction

Sarcoidosis is a multisystem disorder characterized by an autoimmune response to an unidentified antigen in genetically susceptible persons. Despite clinically detectable cardiac manifestations of sarcoidosis occurring in approximately 5% of patients, recent studies have revealed cardiac involvement to be at 25% in patients with the disease, highlighting the fact that cardiac involvement in sarcoidosis is much more common than was once thought to be.

Purpose

With cardiac involvement in sarcoidosis being increasingly recognized due to the availability of advanced cardiac imaging, large scale data regarding in-hospital mortality and clinical outcomes of patients admitted with cardiac sarcoidosis (CS) is lacking. Our study aimed to fill this knowledge gap by analyzing demographics and in-hospital outcomes of a large cohort of patients admitted with CS across the United States (US).

Methods

We analyzed data from the national inpatient sample (NIS) database between October 2015 to December 2018 to identify patients who had been admitted with primary and secondary diagnoses of CS. The NIS is an administrative database sponsored by the Agency for Healthcare Research and Quality consisting of data from 46 participating states, representing more than 95% of the US population and providing nationwide estimates of over 35 million hospitalizations annually. The NIS uses de-identified hospital discharges as samples and hence no additional ethical committee approval was required. International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code D86.85 was used to identify hospitalizations with CS in patients aged 18 years or older. SAS 9.4 (SAS Institute, Inc, Cary, NC) was used for statistical analyses.

Results

A total of 4275 patients were included in the analysis. A higher proportion of patients with CS were females (62.43% vs. 37.57%). Hypertension was the most common comorbidity (43.99%), followed by hyperlipidemia (39.21%) and chronic kidney disease (26.95%). All-cause in-hospital mortality was 2.57%. Atrial fibrillation (AF) was the most common arrhythmia (28.12%), followed by ventricular tachycardia (VT) (22.52%). About 16% of CS patients underwent implantable cardioverter-defibrillator (ICD) implantation during hospital stay. About 42% of patients had concurrent heart failure, out of whom 33.84% had heart failure with reduced ejection fraction (HFrEF). Mean length of hospital stay was 5 days (3–8 days), and the mean cost of hospitalization was $14,177 ($7,121–35,993).

Conclusion

Given the low prevalence of CS, most of the available studies have been retrospective in nature, based on small sample sizes. Despite being retrospective and cross-sectional, our study has the advantage of being based on a nationally representative sample population, providing key formation on the demographics and in-hospital outcomes of patients with CS.

Funding Acknowledgement

Type of funding sources: None.

Effects of Levodopa-Carbidopa Intestinal Gel on Dyskinesia and Non-Motor Symptoms Including Sleep: Results from a Meta-Analysis with 24-Month Follow-Up

BACKGROUND

In advanced Parkinson's disease (PD), dyskinesias and non-motor symptoms such as sleep dysfunction can significantly impair quality of life, and high-quality management is an unmet need.

OBJECTIVE

To analyze changes in dyskinesia and non-motor symptoms (including sleep) among studies with levodopa-carbidopa intestinal gel (LCIG) in patients with advanced PD.

METHODS

A comprehensive literature review identified relevant studies examining LCIG efficacy. Outcomes of interest were dyskinesia (UDysRS, UPDRS IV item 32), overall non-motor symptoms (NMSS), mentation/behavior/mood (UPDRS I), and sleep/daytime sleepiness (PDSS-2, ESS). The pooled mean (95% confidence interval) change from baseline per outcome was estimated for each 3-month interval with sufficient data (i.e., reported by≥3 studies) up to 24 months using a random-effects model.

RESULTS

Seventeen open-label studies evaluating 1243 patients with advanced PD were included. All outcomes of interest with sufficient data for meta-analysis showed statistically significant improvement within 6 months of starting LCIG. There were statistically significant improvements in dyskinesia duration as measured by UPDRS IV item 32 at 6 months (-1.10 [-1.69, -0.51] h/day) and 12 months (-1.35 [-2.07, -0.62] h/day). There were statistically and clinically significant improvements in non-motor symptoms as measured by NMSS scores at 3 months (-28.71 [-40.26, -17.15] points). Significant reduction of NMSS burden was maintained through 24 months (-17.61 [-21.52, -13.70] points). UPDRS I scores significantly improved at 3 months (-0.39 [-0.55, -0.22] points). Clinically significant improvements in PDSS-2 and ESS scores were observed at 6 and 12 months in individual studies.

CONCLUSION

Patients with advanced PD receiving LCIG showed significant sustained improvements in the burden of dyskinesia and non-motor symptoms up to 24 months after initiation.

POS0283 TREATMENT PATTERNS AND CLINICAL CHARACTERISTICS OF PATIENTS WITH OSTEOARTHRITIS OF THE HIP AND/OR KNEE TREATED WITH TRADITIONAL NSAIDS VS COX-2S: A REAL-WORLD STUDY OF COMMERCIALLY-INSURED PATIENTS

Background:

The 2019 American College of Rheumatology (ACR) guidelines strongly recommend oral nonsteroidal anti-inflammatory drugs (NSAIDs) for management of hip and knee osteoarthritis (OA) and strongly recommend topical NSAIDs for knee OA. There are, however, important safety considerations with NSAIDs in terms of increased rates of gastrointestinal, cardiovascular, and renal events. Given these risks, it is important to understand the characteristics and drug utilization of the patients who start treatment on these different treatments (i.e., traditional NSAIDs [tNSAIDs] and cyclooxygenase-2 inhibitors [COX-2s]).

Objectives:

The goal of this research was to describe and compare baseline characteristics of commercially-insured patients diagnosed with OA of the hip and/or knee who started treatment on different types of NSAIDs (i.e., oral tNSAIDs, topical tNSAIDs, and COX-2s).

Methods:

The Optum Healthcare Solutions, Inc. claims database (1/2012-3/2017) was used to identify patients ≥18 years old, with ≥2 diagnoses of hip and/or knee OA, and ≥90 days supply of oral tNSAIDs, topical tNSAIDs, or COX-2s during the one-year follow up period. The index date was defined as the first prescription after the first OA diagnosis. Patients were assigned to cohorts based on the type of NSAID prescribed on index date. Patients were required to be continuously-enrolled six months before (baseline period) and 36 months after (follow-up period) the index date. Demographic and clinical characteristics including age, sex, comorbidities, and healthcare resource use (HRU) were summarized during baseline. Drug utilization characteristics including days supply and number of prescriptions for the different NSAIDs types were summarized during follow-up period.

Results:

Data for 23,796 patients were analyzed: 18,100 patients received oral tNSAIDs, 4,825 received COX-2s, and 871 topical tNSAIDs. Patients who initiated treatment on oral tNSAIDs were the youngest (mean age of 60.6 vs. 64.6 for COX-2s and 65.0 for topical tNSAIDs) and topical tNSAIDs had the highest proportion of female patients (71% vs. 62% for oral tNSAIDs and 63% for COX-2s). The topical tNSAIDs cohort had the highest presence of chronic kidney disease (2.6% vs. 1.0% and 1.5% for oral tNSAIDs and COX-2s, respectively) and congestive heart failure (2.5% vs. 0.8% and 1.7% for oral tNSAIDs and COX-2s, respectively) at baseline. In terms of HRU during baseline, topical tNSAIDs had the most patients with emergency department visits (20.8% vs. 16.7% in both COX-2s and oral tNSAIDs), and COX-2 had the most patients with inpatient visits (18.1% vs. 15.4% for topical tNSAIDs and 11.8% for oral tNSAIDs). Oral tNSAIDs had the lowest total all-cause cost ($6,504), and the topical tNSAIDs cohort had the highest costs ($8,455), but fairly comparable with COX-2s ($8,289). During follow-up, oral tNSAIDs patients stayed mostly on oral tNSAIDs as less than 15% of oral tNSAIDs patients later had a prescription for COX-2s or topical tNSAIDs. 37% of COX-2 patients and 56% of topical tNSAIDs patients later took oral tNSAIDs. Topical tNSAIDs patients had an average of 184.4 days of supply for topical tNSAIDs yet also extensively used oral NSAIDs during follow-up (average days of supply for oral tNSAIDs was 315.5 days and for COX-2s was 383.5 days).

Conclusion:

This study suggests that patients with more complex comorbidity profiles, including higher rates of adverse effects, often start pharmacological treatment with topical tNSAIDs. However, patients who start treatment with topical tNSAIDs switch to other types of NSAIDs; oral tNSAIDs were the most frequently prescribed treatment across the cohorts. Thus, despite the safety concerns with oral tNSAIDs and COX-2s, patients are still placed on these treatments to manage their OA pain. There is a need for new innovative treatments as there is currently a lack of other options.

Disclosure of Interests:

Stuart Silverman Consultant of: Stuart Silverman is a paid consultant to Pfizer and Eli Lilly and Company in connection with this study, Patricia Schepman Shareholder of: Patricia Schepman is an employee of Pfizer with stock and/or stock options, Employee of: Pfizer, James B Rice Consultant of: Brad Rice is an employee of Analysis Group, who were paid consultants to Pfizer and Eli Lilly and Company for this study, Craig Beck Shareholder of: Craig Beck is an employee of Pfizer with stock and/or stock options, Employee of: Pfizer, Alan White Consultant of: Alan White is an employee of Analysis Group, who were paid consultants to Pfizer and Eli Lilly and Company for this study, Sheena Thakkar Shareholder of: Sheena Thakkar is an employee of Pfizer with stock and/or stock options, Employee of: Pfizer, Michaela Johnson Consultant of: Michaela Johnson is an employee of Analysis Group, who were paid consultants to Pfizer and Eli Lilly and Company for this study, Rebecca Robinson Shareholder of: Rebecca Robinson is an employee and minor stockholder of Eli Lilly and Company, Employee of: Eli Lilly and Company, Birol Emir Shareholder of: Birol Emir is an employee of Pfizer with stock and/or stock options, Employee of: Pfizer

AB0035 A REVIEW OF THE CLINICAL AND ECONOMIC BURDEN OF OSTEOARTHRITIS PAIN BY SEVERITY IN THE UNITED STATES

Background:

The development of new therapies to treat symptomatic osteoarthritis (OA) often requires targeting patient subgroups such as mild and/or moderate and/or severe. Multiple assessments for pain are used in clinical and research settings, yet to quantify patient burden with increasing pain severity it is important to understand the potential variability in outcomes based on definitions of severity used1.

Objectives:

The objective of this study was to examine studies in the published literature that report the burden of OA pain by severity to assess similarities and/or differences across study methodologies and outcomes.

Methods:

A targeted literature review of PubMed and Google Scholar was conducted January 2021 and included search terms: osteoarthritis, severity, United States (US), burden, quality of life, medication/treatment, and healthcare resource utilization. The search was limited to the English language, full-text articles, and no restriction on publication date. Results included a recent study of the burden of symptomatic OA pain respondents by severity level in the US2,3. Over 100 publication titles were reviewed. Comparison of findings was descriptive in nature.

Results:

Nine publications were identified representing 7 unique studies, 6 being patient and/or healthcare provider surveys. Two studies focused on OA severity: the remaining 5 stratified patients by pain severity, and all but 2 of the 5 identified and confirmed pain as OA-related. Pain measures included numeric rating scales (generic 0-10, Western Ontario and McMaster Universities Arthritis Index [WOMAC] NRS 3.1), visual analog scales (generic 0-100, Short-Form McGill Pain Questionnaire Visual Analog Scale [SF-MPQ-VAS]) or Pain Interference with Activities (PIA) scale derived from the 12-Item Short Form Health Survey [SF-12v2] developed for the Medical Outcomes Study, with recall periods varying from 48 hours to 7 days to 4 weeks. Only one study exclusively assessed symptomatic patients only i.e., patients with pain scores of 0 were excluded; the remainder compared cohorts of no/mild pain with increasing severity cohorts. Four of the 7 studies examined pairwise differences among mild, moderate, and severe patients (1 study vs. a non-OA cohort); 2 compared no/mild vs. moderate-to-severe OA pain and 1 study compared mild to moderate-to-severe OA pain. For most outcomes examined like clinical comorbidities, quality of life, and healthcare resource utilization, increasing burden was observed with increasing OA and/or pain severity despite study variability.

Conclusion:

Pain severity levels represent an important and distinguishing factor that contributes to health outcomes in OA patients in the US. Considerable heterogeneity across studies may impact how OA pain is defined, perceived by patients, and treated. Selecting appropriate OA pain severity assessments, including cut-points, may contribute to the successful monitoring of outcomes or comparisons of therapies to manage symptomatic OA pain, especially those that target specific pain severity subgroups.

References:

[1]Hawker GA, Mian S, Kendzerska T et al. Arthritis Care and Research. 2011; 63(11):S240-S252.

[2]Schepman P, Robinson RL, Thakkar S, et al. International Society of Pharmacoeconomics and Outcomes Research (ISPOR) Virtual Annual Meeting; May 2020.

[3]Schepman P, Thakkar S, Robinson RL, et al. PAINWeek 2020 Virtual Meeting; September 2020.

Disclosure of Interests:

Alesia Sadosky Shareholder of: Own stock in Pfizer Inc, Consultant of: I am an employee with the consulting firm Apperture Health, Employee of: I am retired from Pfizer Inc, Patricia Schepman Shareholder of: Owns shares in Pfizer Inc, Employee of: Employee of Pfizer Inc, Sheena Thakkar Shareholder of: Owns shares of Pfizer Inc, Employee of: Employee of Pfizer Inc, Rebecca Robinson Shareholder of: Owns shares of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Craig Beck Shareholder of: Owns shares of Pfizer Inc, Employee of: Employee of Pfizer Inc

Impact of carbidopa-levodopa enteral suspension on quality of life and activities of daily living in patients with advanced Parkinson's disease: Results from a pooled meta-analysis

INTRODUCTION

To estimate the impact of carbidopa/levodopa enteral suspension (CLES) on key patient-centered outcomes in patients with advanced Parkinson's disease (PD).

METHODS

A comprehensive literature review identified relevant studies, from which data were meta-analyzed over 3-month intervals up to 24 months. Patient-centered outcomes of interest included mean (95% CI) changes from baseline (Δ) in quality of life (QoL), measured using PD-specific (PDQ-8, PDQ-39) and generic (EQ-5D) instruments; activities of daily living (ADL), measured in On and Off states using UPDRS Part II; and motor symptoms (i.e., Off time/day and motor examination [measured in On and Off states using UPDRS Part III]).

RESULTS

The pooled meta-analysis included data from 26 studies evaluating 1556 patients on CLES. At 3 months, all outcomes showed significant improvement: QoL (ΔPDQ-39 = -10.26 [-11.54, -8.97], ΔEQ-5D_VAS = 15.42 [12.58, 18.26]); ADL (ΔUPDRS II_ON = -4.32 [-5.63, -3.01]); motor symptoms (ΔOff time hours/day = -3.48 [-4.15, -2.82], ΔUPDRS III_ON = -6.20 [-9.88, -2.51]). At 24 months, there were statistically significant mean improvements in QoL (ΔPDQ-39 = -7.74 [-12.40, -3.07], ΔEQ-5D_VAS = 11.18 [6.90, 15.45]) and ADL (ΔUPDRS II_OFF = -3.88 [-5.34, -2.42]), and Off time (-4.21 [-5.16, -3.26] hours/day).

CONCLUSIONS

Impact of CLES on significantly reducing Off time/day was observed to be rapid and durable (i.e., remained consistent across 24 months). Most QoL and ADL measures showed a consistent pattern of improvement with initiation of treatment and remained significantly improved from baseline at 24 months.

“Clots and Failures” A Case of COVID-19 Causing STEMI and Persistent Cardiogenic Shock Ultimately Requiring LVAD

Introduction

We present a case of COVID-19 causing hypercoagulability and inflammatory stress leading to STEMI in a patient who went on to develop persistent cardiogenic shock requiring LVA) implantation.

Case Report

57-year-old lady developed COVID-19 infection in May 2020. In June 2020, she presented with chest pain, was noted to have STEMI on EKG, complicated by cardiac arrest with ROSC in 14 minutes. She was in cardiogenic shock as well and was started on veno-arterial ECMO. She underwent left anterior descending artery stent placement. Further hospitalization was complicated by persistent cardiogenic shock and complete heart block and underwent pacemaker and cardiac-defibrillator implantation. She developed pulmonary edema, acute kidney injury requiring hemodialysis, shock liver, and persistent cardiogenic shock. She was weaned off VA-ECMO after 4 days but continued to have severely reduced cardiac function. RHC revealed severe volume overload, pulmonary venous hypertension, low cardiac output, and right heart dysfunction. Echo showed severe LV dysfunction with an EF of 15%. A femoral intra-aortic balloon pump(IABP) was placed on July 7, 2020. An attempt was made to wean her off of IABP on July 10^th,however, it was unsuccessful and she was transitioned to axillary intra-aortic balloon pump. She remained IABP dependent thereafter and on July 15th, given persistent cardiogenic shock, decision was made to pursue advanced heart failure therapies. After multi-disciplinary discussion, the decision to pursue LVAD implantation was made. She underwent a successful LVAD implantation on July 20^th . She failed an extubation trial and underwent tracheostomy on July 23^rd . Post LVAD, she developed atrial fibrillation and was started on digoxin and amiodarone. Her symptoms improved and she was subsequently discharged to rehabilitation in late August on amiodarone, digoxin, metoprolol, prasugrel, warfarin, spironolactone and lisinopril. The detailed timeline is shown in figure 1.

Summary

Hypercoagulability and severe inflammatory stress leading to life-threatening illness is a significant complication of COVID-19 infection. A low threshold for suspecting and treating hypercoagulability and inflammatory induced myocardial ischemia and injury and cardiogenic shock is a reasonable strategy to decrease acute as well as chronic morbidity and mortality.

ECMO for Critically Ill COVID-19 with ARDS: A Case Series

Introduction

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) as bridge to recovery in critically ill COVID-19 continues to be commonly utilized strategy in cases with persistent respiratory failure refractory to traditional ventilation support

Case Report

We report 5 cases of severe acute respiratory syndrome coronavirus-2 infection (SARS-CoV-2) who were treated with ECMO (Table 1). All 5 cases presented with fever, cough and shortness of breath and a positive nasopharyngeal swab for SARS-CoV-2 on admission. Case 1, 2, 3 and 5 patients were hypoxemic with saturation less than 90% on admission and decompensated rapidly, whereas Case 4 decompensated after day 14. Mechanical ventilation failed to provide adequate oxygenation in all 5 cases; case 2,3 and 5 were started on recruitment measures with proning while it was not possible for case 1 owing to morbid obesity. Proning was not possible in the case 4 as patient became severely hypoxemic while patient was undergoing mechanical thrombectomy. The case 1-4 remained on ECMO for 19, 17, 17 and 2 days respectively. All except case 2 had improvement in APACHEII and SOFA score after ECMO initiation. All 5 patients had elevated inflammatory markers of serum ferritin, D-dimer, Lactate dehydrogenase (LDH), C-reactive protein (CRP) which trended down after a few days of ECMO initiation All 5 patients received high dose steroids during their stay in the ICU. Case 4 and 5 passed away after compassionate extubation. Case 1-3 had prolonged hospital course with complication of hospital acquired pneumonia requiring multiple courses of broad-spectrum antibiotics.

Summary

Our observational report of 5 patients reports the use of ECMO in critically ill SARS-CoV-2 with ARDS and difficult to maintain saturation despite mechanical ventilation and proning with recovery for 3 patients. However, given the lack of ECMO centers; this is not a readily available option. Further studies are warranted to investigate the role of ECMO in SARRS-CoV-2 and careful identification of appropriate candidates.

24-Hour Levodopa-Carbidopa Intestinal Gel: Clinical Experience and Practical Recommendations

Infusion of levodopa-carbidopa intestinal gel (LCIG; also designated carbidopa-levodopa enteral suspension) for 16 hours is a standard treatment for patients with advanced Parkinson's disease, and clinical observations suggest that 24-hour LCIG infusion may further reduce symptoms. This review provides practical advice on the management of patients transitioning to 24-hour LCIG infusion. We review available clinical data for 24-hour infusion and discuss adjustments to dosing, recommendations for monitoring, and management of patient concerns, based on our clinical experience. Data from multiple studies suggest that LCIG may improve non-motor symptoms. Although few studies have examined 24-hour LCIG infusion, available data indicate that certain patients may benefit from around-the-clock treatment. Studies of 24-hour LCIG infusion are limited by small sample sizes and open-label study designs, which may hamper translation to clinical practice. In our experience, we have found that patients may benefit from 24-hour infusion when reductions in nocturnal symptoms and improvements to quality of sleep are needed. Levodopa-unresponsive freezing of gait or poorly controlled troublesome dyskinesias may also indicate a patient may benefit from 24-hour infusion. Dose adjustments, especially of the nocturnal rate, are typically necessary and, as with 16-hour infusion, patients should be monitored for autonomic dysfunction; overnight wearing off symptoms; weight changes; fluctuations in plasma levels of vitamins B₆/B₁₂, folate, and homocysteine; changes in sleep patterns; or worsening of hallucinations, delusions, and/or nightmares. Available data and our clinical experience suggest that 24-hour LCIG may be warranted among selected patients who have poorly controlled nocturnal fluctuations or early morning "off" symptoms.

Oral anticoagulant monotherapy compared to oral anticoagulant plus single anti-platelet therapy in stable ischemic heart disease with atrial fibrillation: a meta-analysis

Introduction

Evidence for antithrombotic therapy regimen in patients with concurrent stable ischemic heart disease (SIHD) and atrial fibrillation (AF) is not well established. The ideal regimen needs to been balanced to prevent thrombotic and embolic events, without increasing the risk of bleeding tendencies. Two randomized control trials have been published studying oral anticoagulant monotherapy (OAC) as compared to oral anticoagulant plus single antiplatelet therapy (OAC+SAPT), of which one trial was terminated prematurely and was underpowered.

Purpose

We performed a meta-analysis of RCTs and observational studies comparing OAC monotherapy to OAC+ SAPT in SIDH patients with AF.

Methods

We performed a systematic search of the PubMed, EMBASE and Cochrane databases to identify relevant articles. The database search was performed from the inception of the databases to January 2020. Inclusion criteria were RCTs and observation studies comparing OAC to OAC+SAPT in SIDH patients with AF and reporting time to event outcomes of major bleeding or cardiovascular mortality. The definition of major bleeding as per the definition provided by individual studies. Two authors independently performed data extraction to check for reproducibility. We used inverse variance method with random effect model to calculate hazard ratio (HR) with 95% confidence interval (CI). Statistical heterogeneity was calculated using Higgins I2 statistics. All statistical analysis was performed using RevMan Version 5.3 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014).

Results

Seven studies (2 RCTs and 5 observational studies) were included in the final analysis. OAC+ SAPT as compared to OAC monotherapy in patients with SIHD and AF was associated with a higher incidence of major bleeding [HR: 1.59, 95% CI: 1.36–1.85, P value<0.05, I2: 0%] [Figure 1, Panel A]. OAC+SPT as compared to OAC monotherapy was associated with similar incidence of cardiovascular mortality [HR: 1.07, 95% CI: 0.86–1.33, P value= 0.55, I2: 32%] [Figure 1, Panel B]. There was no statistical heterogeneity associated with either pooled estimates.

Conclusion

OAC monotherapy as compared to OAC+SAPT in patients with SIHD and AF was associated with a lower incidence of major bleeding and similar incidence of cardiovascular mortality.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of catheter ablation for atrial flutter on mortality and hospital readmission rates in patients with heart failure and reduced ejection fraction

Background

The effectiveness of catheter ablation as a management modality amongst patients with coexisting atrial flutter (AFL) and heart failure with reduced ejection fraction (HFrEF) is scarcely studied.

Methods

Appropriate ICD 10 codes were applied to the 2016 and 2017 National Readmission Database (NRD) to isolate patients having coexistent AFL and HFrEF including who had undergone an ablation. All-cause mortality at the end of 1 year was used as a primary outcome. Readmission due to AFL, heart failure (HF) and other causes were secondary outcomes. The hazard ratios were generated using Cox regression analysis while the time to event analysis was demonstrated with the Kaplan Meier curves.

Results

Out of a total of 9966 patients with AFL and HFrEF, 1980 (24.79%) patients underwent catheter ablation. The primary outcome, all-cause mortality (2.8% vs. 4.6%, HR: 0.610, 95% CI: 0.460–0.808, p=0.001) at the end of 1 year was significantly lower. Significant difference was also noted amongst two groups when it came to secondary outcomes such as readmissions due to AFL (1.6% vs. 6.3%, HR: 0.247, 95% CI: 0.173–0.354, p<0.001), HF (8.2% vs. 11.4%, HR: 0.693, 95% CI: 0.587–0.819, p<0.001) and other causes (29.4% vs. 37.1%, HR: 0.735, 95% CI: 0.673–0.804, p<0.001)

Conclusion

Ablative intervention amongst AFL patients with concomitant HFrEF showed a significant reduction in all-cause mortality. It also leads to significant reductions in readmissions due to AFL, HF and other causes at the end of one year.

Outcomes of AFL and HFrEF

Funding Acknowledgement

Type of funding source: None

Impact of catheter ablation for atrial flutter on mortality and hospital readmission rates in patients with heart failure and preserved ejection fraction

Background

The availability of real-world data regarding the impact of the catheter ablation in patients with concomitant atrial flutter (AFL) and heart failure with preserved ejection fraction (HFpEF) is limited.

Methods

2016 and 2017 National Readmission Database (NRD) was subjected to appropriate ICD-10 codes to identify and extract patients having coexistent atrial flutter and heart failure with preserved ejection fraction including who had undergone ablation. At 1 year, all-cause mortality was utilized as the primary outcome while readmissions due to AFL, heart failure (HF) and any other causes were designated as secondary outcomes. Kaplan Meier curves were used for a time to event analysis. Cox proportional hazard regression was used to generate hazard ratios.

Results

Out of a total 6099 patients with AFL and HFpEF, 906 (14.85%) underwent catheter ablation. At 1 year all cause mortality (3%, vs. 4.4%, HR: 0.661, 95% CI: 0.444–0.985, p=0.042) and readmissions due to AFL (2.3% vs. 5.3%, HR: 0.424, 95% CI: 0.272–0.661, p<0.001) were significantly less among ablation group. Readmission due to HF (9.3% vs. 9.7%, HR: 0.938, 95% CI: 0.745–1.182, p=0.587) and other causes (37% vs.40.3%, HR: 0.926, 95% CI: 0.825–1.040, p=0.193) did not show any significant difference in outcomes at the end of 1 year.

Conclusion

The utilization of catheter ablation amongst AFL patients with concomitant HFpEF showed a significant reduction in all-cause mortality and readmission due to AFL. However, it did not show any significant changes in readmissions due to HF or other causes at the end of one year.

Outcomes of AFL and HFpEF

Funding Acknowledgement

Type of funding source: None

Volumetric laser endomicroscopy and its application to Barrett's esophagus: results from a 1,000 patient registry

Volumetric laser endomicroscopy (VLE) uses optical coherence tomography (OCT) for real-time, microscopic cross-sectional imaging. A US-based multi-center registry was constructed to prospectively collect data on patients undergoing upper endoscopy during which a VLE scan was performed. The objective of this registry was to determine usage patterns of VLE in clinical practice and to estimate quantitative and qualitative performance metrics as they are applied to Barrett's esophagus (BE) management. All procedures utilized the NvisionVLE Imaging System (NinePoint Medical, Bedford, MA) which was used by investigators to identify the tissue types present, along with focal areas of concern. Following the VLE procedure, investigators were asked to answer six key questions regarding how VLE impacted each case. Statistical analyses including neoplasia diagnostic yield improvement using VLE was performed. One thousand patients were enrolled across 18 US trial sites from August 2014 through April 2016. In patients with previously diagnosed or suspected BE (894/1000), investigators used VLE and identified areas of concern not seen on white light endoscopy (WLE) in 59% of the procedures. VLE imaging also guided tissue acquisition and treatment in 71% and 54% of procedures, respectively. VLE as an adjunct modality improved the neoplasia diagnostic yield by 55% beyond the standard of care practice. In patients with no prior history of therapy, and without visual findings from other technologies, VLE-guided tissue acquisition increased neoplasia detection over random biopsies by 700%. Registry investigators reported that VLE improved the BE management process when used as an adjunct tissue acquisition and treatment guidance tool. The ability of VLE to image large segments of the esophagus with microscopic cross-sectional detail may provide additional benefits including higher yield biopsies and more efficient tissue acquisition. Clinicaltrials.gov NCT02215291.

Deep brain stimulation for the treatment of Parkinson's disease: efficacy and safety

Deep brain stimulation (DBS) surgery has become increasingly utilized in the treatment of advanced Parkinson's disease. Over the past decade, a number of studies have demonstrated that DBS is superior to best medical management in appropriately selected patients. The primary targets for DBS in Parkinson's disease include the subthalamic nucleus and the internal segment of the globus pallidus, both of which improve the cardinal motor features in Parkinson's disease. Recent randomized studies have revealed that both targets are similarly effective in treating the motor symptoms of Parkinson's disease, but emerging evidence suggests that the globus pallidus may be the preferred target in many patients, based on differences in nonmotor outcomes. Here, we review appropriate patient selection, and the efficacy and safety of DBS therapy in Parkinson's disease. Best outcomes are achieved if the problems of the individual patient are considered when evaluating surgical candidates and considering whether the subthalamic nucleus or the globus pallidus internus should be targeted.

A phase II trial of gemcitabine and docetaxel in hormone-refractory metastatic prostate cancer

14501

Background: Docetaxel is a microtubule stabilizing agent with demonstrated ability to improve survival in patients (pts) with hormone refractory metastatic prostate cancer (HRMPC). Gemcitabine is a nucleoside analogue that exhibits broad antitumor activity, although as a single agent has modest activity in advanced prostate cancer. The combination of docetaxel and gemcitabine has demonstrated significant activity in a variety of chemotherapy resistant neoplasms. We performed a phase II study of this combination to assess its safety and antitumor activity in chemotherapy naïve patients with HRMPC. Methods: Eligible pts had HRMPC with radiologic and/or biochemical evidence of progression following antiandrogen withdrawal with castrate testosterone levels, ECOG PS 0–2 and adequate organ function; no prior chemotherapy was permitted. Gemcitabine (800 mg/m2) was administered on days 1 and 8 and docetaxel (75mg/m2) on day 8 every 21 days for a maximum of 6 cycles. Results: Twenty-nine pts have been enrolled to date with 22 currently evaluable for response, all are evaluable for toxicity. The median age was 68. The average number of cycles completed was 4.9. Nine pts have experienced grade 4 neutropenia (1 neutropenic fever admission). Twelve of 29 pts have required dose delays secondary to wbc or platelets, two pts have required dose modification. Non-hematologic grade 3/4 toxicities include 1 pt with a PE, 1 grade 4 dyspnea, 1 grade 4 GI bleed. Four pts (18%) achieved measurable disease + PSA, partial response (PR), 7 (32%) additional pts had >50% decline in PSA, for a composite overall response rate of 50%. Conclusions: The combination of gemcitabine and docetaxel is moderately toxic primarily impacting bone marrow reserve. Although there is evidence of significant antitumor activity, the ulitmiate utility of this doublet remains undefined. Accrual to this study is ongoing.

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