CAnceR IN PreGnancy (CARING) - a retrospective study of cancer diagnosed during pregnancy in the United Kingdom

BACKGROUND

The incidence of cancer diagnosed during pregnancy is increasing. Data relating to investigation and management, as well as maternal and foetal outcomes is lacking in a United Kingdom (UK) population.

METHODS

In this retrospective study we report data from 119 patients diagnosed with cancer during pregnancy from 14 cancer centres in the UK across a five-year period (2016-2020).

RESULTS

Median age at diagnosis was 33 years, with breast, skin and haematological the most common primary sites. The majority of cases were new diagnoses (109 patients, 91.6%). Most patients were treated with radical intent (96 patients, 80.7%), however, gastrointestinal cancers were associated with a high rate of palliative intent treatment (63.6%). Intervention was commenced during pregnancy in 68 (57.1%) patients; 44 (37%) had surgery and 31 (26.1%) received chemotherapy. Live births occurred in 98 (81.7%) of the cases, with 54 (55.1%) of these delivered by caesarean section. Maternal mortality during the study period was 20.2%.

CONCLUSIONS

This is the first pan-tumour report of diagnosis, management and outcomes of cancer diagnosed during pregnancy in the UK. Our findings demonstrate proof of concept that data collection is feasible and highlight the need for further research in this cohort of patients.

Registry-derived stage (RD-Stage) for capturing cancer stage at diagnosis for endometrial cancer

BACKGROUND

Capture of cancer stage at diagnosis is important yet poorly reported by health services to population-based cancer registries. In this paper we describe current completeness of stage information for endometrial cancer available in Australian cancer registries; and develop and validate a set of rules to enable cancer registry medical coders to calculate stage using data available to them (registry-derived stage or 'RD-Stage').

METHODOLOGY

Rules for deriving RD-stage (Endometrial carcinoma) were developed using the American Joint Commission on Cancer (AJCC) TNM (tumour, nodes, metastasis) Staging System (8th Edition). An expert working group comprising cancer specialists responsible for delivering cancer care, epidemiologists and medical coders reviewed and endorsed the rules. Baseline completeness of data fields required to calculate RD-Stage, and calculation of the proportion of cases for whom an RD stage could be assigned, was assessed across each Australian jurisdiction. RD-Stage (Endometrial cancer) was calculated by Victorian Cancer Registry (VCR) medical coders and compared with clinical stage recorded by the patient's treating clinician and captured in the National Gynae-Oncology Registry (NGOR).

RESULTS

The necessary data completeness level for calculating RD-Stage (Endometrial carcinoma) across various Australian jurisdictions varied from 0 to 89%. Three jurisdictions captured degree of spread of cancer, rendering RD-Stage unable to be calculated. RD-Stage (Endometrial carcinoma) could not be derived for 64/485 (13%) cases and was not captured for 44/485 (9%) cases in NGOR. At stage category level (I, II, III, IV), there was concordance between RD-Stage and NGOR captured stage in 393/410 (96%) of cases (95.8%, Kendall's coefficient = 0.95).

CONCLUSION

A lack of consistency in data captured by, and data sources reporting to, population-based cancer registries meant that it was not possible to provide national endometrial carcinoma stage data at diagnosis. In a sample of Victorian cases, where surgical pathology was available, there was very good concordance between RD-Stage (Endometrial carcinoma) and clinician-recorded stage data available from NGOR. RD-Stage offers promise in capturing endometrial cancer stage at diagnosis for population epidemiological purposes when it is not provided by health services, but requires more extensive validation.

Abstract 2949: Enabling single cell analysis of copy number variation in breast cancer

Breast cancer is arguably one of the solid tumors most comprehensively analyzed by massively parallel sequencing. Although the repertoire of clonal somatic genetic alterations in primary and metastatic breast cancers has been characterized, a complete characterization of the subclonal genetic alterations present in these cancers, as well as their clonal composition and clonal dynamics remain to be fully defined. Addressing these knowledge gaps is germane to the successful personalization of treatments for breast cancer patients. Single cell sequencing is uncovering many insights into the clonal evolution and heterogeneity of breast cancers and how this can be leveraged for clinical and therapeutic benefit. Bulk next generation sequencing has primarily focused on mutation profiling; however, there are several lines of evidence to demonstrate the biological and clinical importance of accurately detecting copy number alterations. Previous single cell sequencing studies focusing on copy number alterations were based on whole-genome amplification methods or could not concurrently define the repertoire of somatic mutations and copy number alterations in single cells. Here we report on a novel single cell DNA sequencing approach leveraging the Tapestri device and Insights bioinformatic pipeline to detect both copy number alterations and somatic mutations in individual cells derived from breast cancer specimens. The identification of targeted somatic genetic alterations at single cell resolution provides novel insights about the development, progression and therapeutic resistance of breast cancers, and enables the development of novel diagnostic tools and predictive biomarkers.

Citation Format: Saurabh Parikh, Arnaud Da Cruz Paula, Shirin Issa Bhaloo, Alex Li, Britta Weigelt, Khushali Patel, Ania Wronski, Anup Parikh, Khushali Patel, Jorge Reis-Filho. Enabling single cell analysis of copy number variation in breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2949.

Abstract 833: Linking phenotype and genotype: Multimodal analysis of surface proteins, intracellular proteins, and SNV in single cells

Cancers evolve via processes of clonal expansion, selection, and somatic variation, which contribute to tumor heterogeneity. While bulk analysis has improved our understanding of cancer, the heterogeneity of a tumor is masked with the average readout provided by a bulk measurement. This problem could be overcome by employing single-cell technologies. One of the most common single-cell technologies is single-cell RNA sequencing (scRNA-seq). Transcriptomic data collected by scRNA-seq are used to imply activity of gene products based on RNA levels. Signaling pathways related to cancer initiation and progression have been mapped solely based on scRNA-seq results. This approach, however, is not an accurate measurement of proteins that are the functional molecules responsible for key events in cancer. Recent breakthroughs of multimodal approaches such as CITE-seq and REAP-seq partially addressed this problem by allowing simultaneous analysis of transcriptomes and surface protein expression levels. These methods still lack a couple components that are required to fully dissect the biology of cancer. First, the methods are limited to the measurements of cell surface proteins, whereas proteins involved in cancer-related signal transduction and transcriptional pathways are mostly localized in the intracellular compartments. Second, the methods do not allow direct analysis of DNA sequences, hence unable to provide an accurate readout of genotypic information such as single-nucleotide variants and copy number variations. Here we describe a technology that could overcome these hurdles. To achieve this, cells are first treated with oligonucleotide-barcoded antibodies targeting surface proteins. Cells are then fixed and permeabilized, followed by incubation with barcoded antibodies for intracellular proteins. The resulting cells are processed on the Mission Bio TapestriⓇ platform, a device that enables encapsulation of single cells in droplets. Targeted DNA sequencing libraries are generated from the single cells using a multiplex panel of primers targeting regions of interest. Protein sequencing libraries are separately generated from the oligonucleotides off the antibodies. The inclusion of intracellular protein detection enables measurement of pivotal proteins in cancer mechanisms, including apoptosis (BCL2 family proteins), transcription factors (GATA3), tumor suppressors (TP53), as well as phosphorylated proteins involved in cell growth signaling pathways (phosphorylated ERK and STAT proteins). This is the first ever method that provides a solution to effectively link surface and intracellular protein measurement with targeted DNA analysis. With this approach, single-cell readout of genotypic and phenotypic information can be collected together, allowing concurrent complex analyses of cancer clonal evolution and driver protein expression.

Citation Format: Prithvi Singh, Saurabh Parikh, Tim Lai, Dalia Dhingra, Aik Ooi. Linking phenotype and genotype: Multimodal analysis of surface proteins, intracellular proteins, and SNV in single cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 833.

Abstract 6171: A single-cell solution for solid tumors to detect mutations and quantify copy number variations

Cancer is a highly heterogeneous disease characterized by the presence of chromosomal structural copy number variation (CNV) and driver gene mutation events, which appear somatically at the early stages of oncogenesis and can drive tumor progression. Previously, we have developed a high throughput single cell DNA analysis platform that leverages droplet microfluidics and a multiplex-PCR based targeted DNA sequencing approach. It demonstrates high sensitivity detection of SNVs and indels in the same cells and generation of high resolution maps of clonal architecture based on mutational profiling. Here we expand upon the same approach and create an algorithm to accurately quantify CNVs along with genetic mutations from the same single cells. To estimate the CNV the amplicon read counts were corrected for artefacts related to cell to cell variability due sequencing efficiencies along with amplicon to amplicon variability that occur due to amplification efficiency differences. We used a spiked in diploid cell line as a reference to normalize all the cells. The spiked cell line was identified using its mutational profile. We validated the system using cell lines with known CNVs and found that we could at least accurately estimate copy numbers ranging from 0 through 5. Some of the regions were also validated orthogonally using droplet digital PCR. Another set of validation was performed using well characterized cell lines from NIST. We enable multiple visualizations of the copy number estimates in karyotype plots and line plots projected on SNV clones. With improved biochemistry, panel design and novel data analysis algorithms we develop a complete solution to detect amplification or loss of function in oncogenes and tumor suppressors reliably. Integration of CNVs and SNVs facilitates more accurate reconstruction of tumor evolution to better understand cancer progression mechanisms as well for quality control of gene edited cells, to further advance cancer research and therapy.

Citation Format: Saurabh Parikh, Khushali Patel, Alex Li, Anup Parikh. A single-cell solution for solid tumors to detect mutations and quantify copy number variations [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6171.

Safety of emergency, elective and day case operating during the winter period at East Suffolk and North Essex NHS Foundation Trust: lessons from the outcomes of 4,254 surgical patients from the first COVID-19 wave

BACKGROUND

There is limited evidence on perioperative outcomes of surgical patients during the COVID-19 pandemic to inform continued operating into the winter period.

METHODS

We retrospectively analysed the rate of 30-day COVID-19 transmission and mortality of all surgical patients in the three hospitals in our trust in the East of England during the first lockdown in March 2020. All patients who underwent a swab were swabbed on or 24 hours prior to admission.

RESULTS

There were 4,254 patients and an overall 30-day mortality of 0.99%. The excess surgical mortality in our region was 0.29%. There were 39 patients who were COVID-19 positive within 30 days of admission, 12 of whom died. All 12 were emergency admissions with a length of stay longer than 24 hours. There were three deaths among those who underwent day case surgery, one of whom was COVID-19 negative, and the other two were not swabbed but not suspected to have COVID-19. There were two COVID-19 positive elective cases and none in day case elective or emergency surgery. There were no COVID-19 positive deaths in elective or day case surgery.

CONCLUSIONS

There was a low rate of COVID-19 transmission and mortality in elective and day case operations. Our data have allowed us to guide patients in the consent process and provided the evidence base to restart elective and day case operating with precautions and regular review. A number of regions will be similarly affected and should perform a review of their data for the winter period and beyond.

Abstract 246: Method to analyze mutational and phenotypic profiles from single cell for clonal evolution

Single cell multiomics assays targeting RNA and Protein from the same cell provide a high-resolution view of the heterogeneity of the sample. However both analytes target the phenotype of the cells and unambiguous inference that a cellular phenotype is caused by a genotype can only be achieved by their measurement from the same single cell. To address this gap, we have developed the Tapestri multi-omics workflow to analyze the DNA and Protein information from the same cell.

After pre-processing the reads, cell calling is performed using DNA reads. Variant calling and filtering is carried out using DNA reads to identify the high quality genetic variants within each cell and the variant-cell matrix is then analyzed to identify clones.

The Protein reads for the valid cells are log normalized. A systemic artefact resulting in random uniform amplification of antibodies is corrected for by learning the scaling factor from the read count distribution. This reduces the number of false positives. Furthermore read depth dependence of expression is corrected by identifying the correlation of the mean expression and background counts with the total reads in the cell. The mean signal and background for each cell is learned using a 2 component gaussian mixture model. Then, z-score normalization is applied to prevent high expressors from skewing further analysis. The scaled values are dimensionally reduced using PCA. A graph structure is created using KNN with weights calculated using Jaccard similarity following which community detection is employed to identify the cell types.

We test this method on a model system with two donor PBMC, 2 cell lines mixture titrated at a 47:47:5:1 ratio with a 312 amplicon DNA panel and 45 plex antibody panel. We filter cells using isotype controls from the antibody panel and mixed cell signatures using the DNA panel. We can identify 4 clones using the genetic variants. We can identify multiple cell types including the major populations such as T-cells, B-cells, Monocytes and NK-cells using the phenotypic expression in the PBMC donors. Moreover, we are able to correlate the proportions of each PBMC cell type for the identified clones with that of the individual donors.

Due to the corrections applied during the normalization of protein counts we are also able to accurately identify various expected expression profiles in PBMCs such as CD45RA-CD45RO and CD8-CD4 mutual exclusion, and the trimodal expression of CD4.

Citation Format: Saurabh Parikh, Manimozhi Manivannan, Jacqueline Marin, Kate Thompson, Daniel Mendoza, Benjamin Schroeder, Saurabh Gulati, Shu Wang, Aik Ooi. Method to analyze mutational and phenotypic profiles from single cell for clonal evolution [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 246.

Abstract 2259: Single-cell multi-omics analysis of SNV, CNV, and protein expression

Recent advancements in precision medicine, while highly promising, presents a major technical challenge to researchers due to disease heterogeneity. The emergence of single-cell technologies has greatly refined the resolution in which sample diversity can be investigated, enhancing the efficiency of selecting appropriate molecular targets. Additionally, applying multi-omics analysis on single cells would further improve the understanding of cell-to-cell heterogeneity by providing unique insights on cellular and genetic composition. Using a two-step droplet microfluidic technology, the Mission Bio Tapestri Platform enables multiplex-PCR based high-throughput targeted DNA sequencing in single cells to obtain single-nucleotide variation (SNV) and copy number variation (CNV) information. By leveraging this technology, a new workflow is developed to detect protein expression in addition to DNA genotype in the same single cells. In this approach, cells are labeled with a pool of oligonucleotide-conjugated antibodies prior to loading the cells into the Tapestri Instrument. Sequencing libraries are then prepared from both antibody oligonucleotides and the amplified DNA sequences, followed by identification of single-cell DNA genotypes and protein signatures from the sequencing readout. The number of protein targets can be in the range from 6 to over 40, which is beyond the limit for a single flow cytometry run. This method has been successfully performed on cell lines, fresh and frozen PBMCs, as well as clinical samples. In an acute myeloid leukemia (AML) sample, combined single-cell SNV, CNV, and protein expression data illustrated the heterogeneity within the sample. The data clearly identified CD3+ T cells and CD19+ B cells without pathogenic SNVs and CNVs. CD34hiCD11blo and CD34loCD11bhi subpopulations were also identified within the cells carrying the same pathogenic SNVs and CNVs. We believe that this novel multi-omics technology will facilitate new discoveries in the complex relationship between genotype and phenotype, enable a better understanding of disease biology, and subsequently improve the design of diagnostics and therapies.

Citation Format: Aik Ooi, Dalia Dhingra, Adam Sciambi, Kate Thompson, Jacqueline Marin, Saurabh Parikh, Mani Manivannan, David Ruff. Single-cell multi-omics analysis of SNV, CNV, and protein expression [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2259.

POS0695 KZR-616, A SELECTIVE IMMUNOPROTEASOME INHIBITOR FOR THE TREATMENT OF SYSTEMIC LUPUS ERYTHEMATOSUS: RESULTS FROM THE COMPLETED DOSE ESCALATION PHASE 1B PORTION OF THE MISSION STUDY

Background:

KZR-616 is a first-in-class selective inhibitor of the immunoproteasome, which is active in >15 autoimmune disease models, including murine models of systemic lupus erythematosus (SLE)/lupus nephritis (LN).1,2,3 Selective inhibition of the immunoproteasome modulates both innate and adaptive immune effector cells, resulting in reduced inflammatory T helper cell subsets (Th1 and Th17), increased regulatory T cells, and decreased plasma cells and autoantibodies. KZR-616 was well tolerated in two healthy volunteer studies of 100 subjects receiving up to 75 mg subcutaneously (SC). Target levels of immunoproteasome inhibition were observed at doses ≥30 mg.3,4 KZR-616 is currently in Phase 2 studies for several autoimmune indications, including the ongoing Phase 2 portion of the MISSION Study (KZR-616-002; NCT0339013) in patients with LN.

Objectives:

Results of the completed MISSION Phase 1b dose escalation portion of the study are reported.

Methods:

In the open-label, multicenter, dose escalation Phase 1b portion, SLE patients (per SLICC Classification Criteria) with SLEDAI ≥4 despite stable background immunosuppressant, anti-malarial, and/or corticosteroid therapy were administered weekly KZR-616 subcutaneously at doses of 45 mg (cohort 1), 60 mg (cohort 2), 60 mg following step-up doses of 30 mg and 45 mg (cohort 2a), 60 mg following a step-up dose of 30 mg (cohorts 2b, 2c) or 75 mg following a step-up dose of 30 mg (cohort 3) for 13 weeks with follow-up through Week 25 (W25); a lyophilized formulation was used for cohorts 2b, 2c and 3. The disease activity measures assessed were: SLEDAI-2K, Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI), 28 tender and swollen joint counts, Physician and Patient Global Assessments, and Patient Assessment of Pain. Safety and tolerability were assessed in the safety population (patients receiving at least one dose of KZR-616).

Results:

The Phase 1b portion of MISSION enrolled 47 SLE patients, including 2 patients with active proliferative LN. The most common treatment-emergent adverse events (TEAE) were injection site reactions, which were mostly mild. Infections occurred at a low rate, and there were no reports of peripheral neuropathy, prolonged hematologic AEs, or clinically significant laboratory abnormalities. No discontinuations were observed in cohorts 2b and 2c; no serious AEs were reported in cohort 3 and TEAEs were consistent with those reported in earlier cohorts. Mean values of all measures of disease activity improved in evaluable patients who completed the 13-week treatment period, and improvements were generally maintained at W25. All patients with elevated anti-double-stranded DNA antibody (anti-dsDNA) levels at baseline (n=7) had a reduction in levels with 3 of 7 experiencing a >50% reduction in their levels. Two of two patients with active proliferative LN had a >50% reduction in UPCR and experienced reductions in SLEDAI-2K scores as well as anti-dsDNA levels. Exposure to KZR-616, similar to that reported in healthy volunteers, was dose-proportional across doses, and no accumulation was observed.

Conclusion:

KZR-616 SC, once weekly for 13 weeks up to 75 mg, appears to be safe and well-tolerated in patients with active SLE on stable background therapy in the MISSION Phase 1b. At doses ≥45mg, efficacy was noted, including improvements in proteinuria in two of two patients with LN and serologic improvement in all 7 patients with quantifiable levels of anti-dsDNA antibodies at baseline. KZR-616 60 mg SC weekly for 24 weeks is currently being evaluated in the MISSION Phase 2 in patients with LN. Based on the results of MISSION, inhibition of the immunoproteasome with KZR-616 represents a novel strategy to treat autoimmune diseases.

References:

[1]Basler M et al. Clin Exp Rheumatol 2015 (suppl 92);S74.

[2]Muchamuel T et al. Ann Rheumatol Dis 2018;77(suppl 2);685.

[3]Muchamuel T et al. ASN 2020 Virtual Conference.

[4]Snyder B et al. ACR/ARP 2019 Annual Meeting.

[5]Fan RA et al. ACR/ARP 2019 Annual Meeting.

Acknowledgements:

Kezar Life Sciences acknowledges the support of site investigators and patient participants in the MISSION study

Disclosure of Interests:

Richard Furie Consultant of: Genentech;Kezar Life Sciences, Grant/research support from: Kezar Life Sciences, SV Parikh Consultant of: Aurinia Pharmaceuticals, BMS, GlaxoSmithKline, and Kezar Life Sciences, Grant/research support from: Aurinia Pharmaceuticals;EMD-Serono, Jinhai Wang Shareholder of: Kezar Life Sciences, Employee of: Kezar Life Sciences, Darrin Bomba Shareholder of: Kezar Life Sciences, Employee of: Kezar Life Sciences, Richard Leff Employee of: Kezar Life Sciences [part-time], Christopher Kirk Shareholder of: Kezar Life Sciences, Employee of: Kezar Life Sciences -- full-time employee, Noreen Henig Shareholder of: Kezar Life Sciences, Employee of: Kezar Life Sciences

481 Improving the Quality of Pelvic Radiographs - Making A Difference One Picture at A Time

Inadequate pelvic radiographs can lead to missed pathology, necessitate repeat imaging, and subsequently compromise patient safety. The audit conducted aimed to assess and improve the quality of pelvic radiographs at our Trust against local and international guidelines.

Retrospective analysis of pelvic radiographs over a one-month period using PACS at Colchester General Hospital was conducted. All pelvic radiographs were assessed according to International Guidelines (EUR 16250EN). Postoperative radiographs were measured against local guidelines. The results were then presented in the departmental meeting and a re-audit was performed in June 2020.

A total of 190 pelvic radiographs were collected in September 2019. From the 23 postoperative radiographs, 9 did not include distal end of prosthesis. During the re-audit in June 2020 the same number of pelvic images were collected. Data showed that only 2 out of 29 postoperative images did not include the distal end of the prosthesis.

The audit demonstrated need for improvement at our Trust. This was carried out through a presentation in the departmental meeting, highlighting areas that needed improvement. The re-audited results from June 2020 have shown an improvement in the quality of pelvic radiographs and have had direct implications in clinical outcomes.

480 Preoperative Templating in Hip Hemiarthroplasty Improves Femoral Offset and Function

The use of preoperative templating for hip hemiarthroplasty increases the likelihood of successfully restoring offset. This study sought to identify whether templating improves radiographic and clinical outcomes in this group.

Data belonging to all patients that underwent hip hemiarthroplasty between March 2018 and March 2019 were collected. The patients were grouped based on whether or not their preoperative images were templated. Radiographs were studied retrospectively to calculate preoperative and postoperative offset and LLD for each patient. The clinical outcomes that were measured included the rate of periprosthetic fracture, dislocation and contra-lateral neck of femur fracture for each group. Data was analysed by SPSS.

There were 208 patients of which 72 were templated and 136 not templated. The percentage difference between the preoperative and postoperative offset was lower in the templated group (p < 0.05). There was no significant difference in radiographic LLD between the two groups. There was no significant difference in the clinical outcomes between the two groups.

A significantly closer restoration to the original offset was achieved with preoperative templating, which is likely to improve function in this group. There were no significant differences in the other clinical outcomes between the two groups.

Lasmiditan for acute treatment of migraine

Lasmiditan, a selective 5-HT1F receptor agonist, is a harbinger for the novel ditan class of medications for acute migraine treatment. Lasmiditan activates 5-HT1F receptors on presynaptic trigeminal nerve terminals, which impedes the release of calcitonin gene-related peptide (CGRP) from trigeminal nerve endings and thereby suppresses activation of the trigeminovascular system. Notably, lasmiditan does not result in vasoconstriction, making lasmiditan a migraine-specific acute treatment option for those with cardiovascular risk factors. However, lasmiditan does have centrally mediated side effects. This review will discuss the background of lasmiditan development, its preclinical pharmacology, safety, drug interactions and indications for use.

Abstract 861: Improvements in variant calling sensitivity and specificity in single-cell DNA sequencing using deep learning

Background: It is now possible to interrogate thousands of cells in a single experiment for studying genetic variability with the advancements in single-cell sequencing technologies. Single-cell DNA platforms like Tapestri is still susceptible to errors from polymerase incorporations, structure induced template switching, PCR mediated recombination in Tapestri workflow or DNA-damage. Errors from sequencing could propagate from cluster amplification, cycle sequencing or image analysis. All together these errors can be divided into substitutions, insertions and deletion errors and can range from 0.5% to 2% depending on the sequencer. This makes rare variant and minimal residual disease detection challenging. To address these challenges, we developed deep learning models for correcting the errors, reduce false-positive rates and predict true variants.

Method: First we build a consensus sequence from several reads to predict the correct sequence. The initial layers learn the motifs and local sequence contexts in classifying the patterns. The output of this network is a probability distribution over possible bases and the prediction is the base with highest probability. The bases in the reads are subsequently corrected to the predicted base from the first step model. After error correcting the reads, we used the variants called by Genome Analysis Toolkit to feed into a multi-class classifier network. Our features consists of percent of cells mutated, and the different genotype features including depth, AF and quality of each variant in these cells. The truth labels are generated using tapestri instrument from multiple experiments with known bulk truth. We trained the network on over 200k cells from 13 samples and tested on a larger set of samples. Class imbalance was handled using upsampling the truth data. Our training samples include diverse samples from cell mixtures at various dilution uptill 0.1% and clinical samples processed through tapestri instrument and sequenced on a diverse set of sequencers including miseq and novaseq.

Conclusion: To validate this method, we used two different targeted panels on a Latin square model system with known truth mutations. With our 2-step workflow using error correction and variant prediction model, we significantly improved our median PPV 2-3 fold at 0.5% LOD while maintaining the sensitivity. We are further optimizing the model by adding more training samples and feature optimization.

Citation Format: Manimozhi Manivannan, Sombeet Sahu, Kim Dong, Shu Wang, Saurabh Gulati, Saurabh Parikh, Nigel Beard, Anup Parikh. Improvements in variant calling sensitivity and specificity in single-cell DNA sequencing using deep learning [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 861.

Abstract 2109: Amplicon design algorithm for single cell targeted DNA sequencing using machine learning

Background: To realize the promise of precision medicine for cancer, assessing genetic variation present in rare cells and understanding the role that these cells play in the evolution of tumor progression is essential. High throughput single cell DNA targeted sequencing enables detection of rare mutations in cells and identification of subclones defined by co-occurrence of mutations. The big challenge with multiplex sequencing at single cell level is the non-uniform amplification of the targeted regions during PCR. This results in inadequate coverage of mutations of interest in the panel and hence makes genotyping challenging. To address this challenge, we developed a machine learning engine to optimize amplicon design for uniform amplification by making reliable performance prediction.

Methods: Multiple panels with various sizes were designed with amplicons spanning a wide range of design properties such as amplicon GC, length, secondary structure prediction, primer specificity. These panels were synthesized and processed through Tapestri single cell DNA platform. The tested amplicons are classified into low-performer, OK-performer and high flyer based on their normalized reads-per-cell value. Design properties and property distribution of the amplicons and the panel are the features. We used random forest classifier to calculate feature importance and analyzed the range of the top features for each class and their significance of variance between classes. These ranges were then used as parameters in the assay design pipeline. Next, we train machine learning models with performance data to develop a performance prediction engine.

Results: To test the performance of the design pipeline with new parameters, we designed a small (31), medium (128) and large (287) amplicon panel. Multiple runs were conducted for each panel with different cell types. We were able to achieve high panel performance of 97%, 92% and 88% across the three panels. The new parameters resulted in ~10-20% improvement in panel uniformity. We are working on further optimizing the performance prediction engine by using different ML classification models with K-fold cross validation, training using larger group of amplicons and optimizing features using combinations of properties.

Citation Format: Shu Wang, Saurabh Gulati, Dong Kim, Sombeet Sahu, Saurabh Parikh, Nianzhen Li, Manimozhi Manivannan, Nigel Beard. Amplicon design algorithm for single cell targeted DNA sequencing using machine learning [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2109.

Abstract 865: Using machine learning to detect heterogeneity in single cell multi-omics datasets

Background: While scRNA-seq helps in obtaining high-resolution views of single-cell heterogeneity through characterization of the functional state of cells, our understanding of the cellular properties and population architectures of heterogeneous tissues will be greatly advanced by the multi-omics investigation of single cells. Recently, several computational methods have been developed to integrate data from multiple different single cell experiments measuring individual analytes. But unambiguous inference that a cellular phenotype is caused by a genotype can only be achieved by their measurement from the same single cell. To address this gap, we have developed the Tapestri multi-omics workflow to analyze the RNA and DNA information from the same cell.

Methods: After pre-processing of the reads, cell calling is done by identifying the good barcodes using both DNA and RNA reads. DNA reads are processed to identify genetic variants in each cell. The variant cell matrix is then filtered for data completeness to ensure only high-quality data is used in downstream processing. Ploidy is estimated using by normalizing DNA reads, genetic variants and ploidy information together is used to identify subclones. The RNA reads are log normalized and scaled within each cell. Next we set the mean expression of each transcript to 0 and scale the variance to 1. This avoids downstream analysis being skewed by high expressors. We then trained a random forest classifier to identify significantly differentially expressed transcripts across subclones which were identified using genetic variants and ploidy information.

Results: Using the top differentially expressed transcripts we performed dimensionality reduction followed by clustering of cell types. The resulting visualization showed how well the genotypic and transcriptomic datasets integrated with one another. We tested this method on a model system with Raji and KG1 cell lines titrated at 50:50 ratio and were clearly able to associate the transcriptional variation with the genotypic variation of the 2 different cell lines. The method was also validated on a PBMC sample to ensure robustness of methods. We were able to identify the different cell types present the sample and were able to overlay that information with genetic variants to identify sub-clones in the identified cell types.

Citation Format: Saurabh Gulati, Shu Wang, Saurabh Parikh, Ben Liu, Kaustubh Gokhale, Manimozhi Manivannan, Sombeet Sahu, Dong Kim, Anup Parikh. Using machine learning to detect heterogeneity in single cell multi-omics datasets [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 865.

AB0373 TREATMENT OF SLE WITH THE IMMUNOPROTEASOME INHIBITOR KZR-616: RESULTS FROM THE FIRST 4 COHORTS OF THE MISSION STUDY, AN OPEN-LABEL PHASE 1B DOSE ESCALATION TRIAL

Background:

Non-specific proteasome inhibitors, such as bortezomib (BTZ), target the constitutive proteasome and immunoproteasome and are approved treatments for multiple myeloma1. BTZ has also been used to treat systemic lupus erythematosus (SLE) and lupus nephritis (LN); however, treatment emergent adverse events (TEAEs), such as gastrointestinal (GI) effects, hematologic abnormalities, asthenia and peripheral neuropathy, limit its use as a long-term treatment option for chronic autoimmune disease2. KZR-616 is a first-in-class selective immunoproteasome inhibitor and is highly active in murine SLE3. Subcutaneous (SC) administration of KZR-616 (30 and 45 mg weekly [QW]) was demonstrated as safe and well-tolerated, and successfully achieved target levels of immunoproteasome inhibition in healthy volunteers4, 5.

Objectives:

We report the preliminary safety and efficacy of KZR-616 in the first 4 cohorts of the Phase 1b portion of Study KZR-616-002 in patients with active SLE (NCT03393013).

Methods:

SLE patients (per SLICC Classification Criteria) with SLEDAI ≥4 despite stable background immunosuppressant, anti-malarial, and/or corticosteroid (≤20 mg prednisone equivalent) therapy in this open-label multicentric dose-escalation trial received KZR-616 at doses of 45mg (Cohort 1), 60mg (Cohort 2), or 30mg with escalation to 60mg (Cohorts 2a and 2b) SC weekly through Week 13 (W13) with 12 weeks of follow-up. Efficacy measures included SLEDAI, Cutaneous Lupus Erythematous Disease Area and Severity Index, 28 tender and swollen joint counts, Physicians Global Assessment, Patient Global Assessment, and Patient Assessment of Pain, in evaluable patients (those who received ≥1 month of KZR-616).

Results:

As of 16 January 2020, 33 patients had enrolled and received at least 1 dose of KZR-616. The majority of TEAEs have been mild or moderate with no reported peripheral neuropathy, prolonged GI-related AEs, and no clinically significant laboratory AEs. There were 3 treatment emergent SAEs, one each of thrombotic microangiopathy (Cohort 2), localized herpes zoster (Cohort 2a), and systemic inflammatory response syndrome (Cohort 2a) with the latter 2 patients completing the full 13 weeks of treatment after resolution. When compared to baseline, improvement in all measures of disease activity were seen at W13 and maintained or improved during the follow-up period, and 94% of evaluable patients had improvements on at least 2 measures/assessments of disease activity. A single patient with active class IV/V nephritis was enrolled on prednisone 10 mg, leflunomide 10 mg, and hydroxychloroquine 200mg/day; nephrotic-range proteinuria at baseline (3.85 g/day) decreased to 0.6 g/day 4 weeks after the last dose of KZR-616.

Conclusion:

Weekly subcutaneous administration of KZR-616 at 45 and 60 mg was safe and well-tolerated. Evidence of disease suppression at W13 in active SLE patients on stable background therapy was observed. In addition, one study participant with active proliferative nephritis was enrolled with significant reduction in proteinuria. The Phase 2 portion of this study in active proliferative LN is open for enrollment.

References:

[1]Scott K.et al.Cochrane Database Syst Rev 2016;4:CD010816

[2]Alexander Tet al.Ann Rheum Dis 2015;74: 1474–8

[3]Muchamuel T.et al.Ann Rheum Dis 2018;77: A685

[4]Lickliter J.et al.Ann Rheum Dis 2018;77: A1413

[5]Furie Ret al.Ann Rheum Dis 2019;78: A776

Disclosure of Interests:

Richard Furie Grant/research support from: AstraZeneca, Biogen, Consultant of: AstraZeneca, Biogen, SV Parikh Grant/research support from: Aurinia Pharmaceuticals, EMD-Serono, Consultant of: Aurinia, BMS, GSK, Adonis Maiquez: None declared, Amber Khan: None declared, Orlando Moreno: None declared, Miguel Soneira: None declared, Christopher Kirk Shareholder of: Kezar Life Sciences, LLC, Employee of: Kezar Life Sciences, LLC, Darrin Bomba Shareholder of: Kezar Life Sciences, LLC, Employee of: Kezar Life Sciences, LLC, Ken Harvey Shareholder of: Kezar Life Sciences, LLC, Employee of: Kezar Life Sciences, LLC, Mary Katherine Farmer Shareholder of: Kezar Life Sciences, Employee of: Kezar Life Sciences

Outcome of Weekly Carboplatin-Paclitaxel-based Definitive Chemoradiation in Oesophageal Cancer in Patients Not Considered to be Suitable for Platinum-Fluoropyrimidine-based Treatment: A Multicentre, Retrospective Review

AIMS

Although cisplatin-fluoropyrimidine-based definitive chemoradiotherapy (dCRT) is a standard of care for oesophageal cancer, toxicity is significant and limits its use in elderly and frail patients. Weekly carboplatin-paclitaxel-based dCRT provides a viable alternative, although prospective data are lacking in the dCRT setting. Here we report the results of a national, multicentre retrospective review of outcome in patients treated with weekly carboplatin-paclitaxel-based dCRT.

MATERIALS AND METHODS

In this multicentre retrospective study of nine radiotherapy centres across the UK we evaluated the outcome of patients who had non-metastatic, histologically confirmed carcinoma of the oesophagus (adenocarcinoma, squamous cell or undifferentiated; World Health Organization performance status 0-2; stage I-III disease) and had been selected to receive weekly carboplatin-paclitaxel-based dCRT as they were considered not suitable for cisplatin-fluoropyrimidine-based dCRT. dCRT consisted of carboplatin AUC 2 and paclitaxel 50 mg/m2 (days 1, 8, 15, 22, 29) and the recommended radiation dose was 50 Gy in 25 daily fractions. We assessed overall survival, progression-free survival (PFS; overall, local and distant), proportion of patients who were failure free at the response assessment (12 weeks after dCRT), treatment compliance and toxicity.

RESULTS

In total, 214 patients from nine UK centres were treated between 15 February 2013 and 19 March 2019: 39.7% of patients were ≥75 years; 18.7% ≥ 80 years. Indications for weekly carboplatin-paclitaxel-based dCRT were comorbidities (47.2%), clinician choice (36.4%) and poor tolerance/progression on cisplatin-fluoropyrimidine induction chemotherapy (15.8%). The median overall survival was 24.28 months (95% confidence interval 20.07-30.09) and the median PFS was 16.33 months (95% confidence interval 14.29-20.96). Following treatment, 69.1% (96/139) had a combined complete response on endoscopy with non-progression (complete response/partial response/stable disease) on imaging. The 1- and 2-year overall survival rates for this patient group were 81.9% (95% confidence interval 75.6-86.8%) and 50.6% (95% confidence interval 40.5-60.0%), respectively. Thirty-three per cent (n = 70) of patients experienced at least one grade 3 + acute toxicity (grade 3/4 haematological: 10%; grade 3/4 non-haematological: 32%) and there were no treatment-related deaths. 86.9% of patients completed at least four cycles of concomitant weekly carboplatin-paclitaxel-based chemotherapy and planned radiotherapy was completed in 97.7% (209/214).

CONCLUSION

Weekly carboplatin-paclitaxel-based CRT seems to be well tolerated in elderly patients and in those with comorbidities, where cisplatin-fluoropyrimidine-based dCRT is contraindicated. Survival outcomes are comparable with cisplatin-fluoropyrimidine-based dCRT.

Screening for cognitive impairment in SLE using the Self-Administered Gerocognitive Exam

Objective Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that can affect the central nervous system in multiple ways, including causing cognitive dysfunction. Cognitive dysfunction is a common complaint of SLE patients yet diagnosis is challenging, time consuming, and costly. This study evaluated the Self-Administered Gerocognitive Exam (SAGE) as a screening test for cognitive impairment in a cohort of SLE patients. Methods A total of 118 SLE patients completed the SAGE. Providers completed the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and the Systemic Lupus International Collaborative Clinics Damage Index (SLICC-DI). SAGE scores were grouped into normal (>16) and abnormal (≤16) categories. Univariate and multivariate analyses were performed. Results Of the 118 participants, 21(18%) scored ≤16 on the SAGE instrument. In univariate analysis, race, ethnicity, household income, and SLICC-DI scores were associated with the SAGE ( p < 0.05). In multivariable analysis, abnormal SAGE score was independently associated with higher SLICC-DI score (odds ratio (OR) = 1.44, 95% confidence intervals 1.04-1.99, p = 0.03)), Hispanic ethnicity (OR = 43.4, 95% CI 3.1-601, p = 0.005), and lower household income (OR = 11.9 for ≤$15,000 vs >$50,000, 95% CI 2.45-57, p = 0.002). Conclusions In SLE patients, this study demonstrates an independent relationship between neurocognitive impairment (as measured by the SAGE) and higher lupus-related damage, as measured by the SLICC-DI, and lower household income. Abnormal SAGE scores were also associated with Hispanic ethnicity. A language barrier could explain this because the SAGE instrument was conducted in English only. The SAGE was feasible to measure in the clinic setting.

Australian multicentre study of current real-world prophylaxis practice in severe and moderate haemophilia A and B

INTRODUCTION

With the emergence of novel treatment products for haemophilia and an increasing focus on the benefits of pharmacokinetic driven individualized prophylaxis, robust national data with regard to current patterns of factor consumption and adherence are required.

AIM

To characterize current Australian practice with regard to use of prophylactic clotting factor infusions in patients with moderate or severe haemophilia A (HA) and haemophilia B (HB).

METHODS

This was a retrospective, non-interventional study utilizing Australian Bleeding Disorder Registry (ABDR) data collected over a 12 month period. Registered and consented patients with moderate or severe HA or HB without inhibitors were included.

RESULTS

A total of 718 HA (551 severe, 167 moderate) and 166 HB (87 severe, 79 moderate) patients were included. Regular prophylaxis was prescribed in 453 patients (82%) with severe HA, 42 patients (25%) with moderate HA, 66 patients (75%) with severe HB and 11 patients (14%) with moderate HB. Near universal prophylaxis was achieved in the paediatric subgroup. The mean weekly dose of factor VIII in severe HA was 84 international units/kg/wk (IU/kg/wk) vs 71 IU/kg/wk of factor IX in severe HB. Most patients on prophylaxis were treated ≥3 times/wk (HA) or 2 times/wk (HB). Non-adherence peaked in the 20-29 year age group. Older individuals on regular prophylaxis used more factor than was expected for their prescribed regimen.

CONCLUSION

Prophylaxis rates in severe haemophilia are comparable with other developed nations. The benefit of a national registry is demonstrable. Furthermore research into the underlying reasons for non-compliance in young adults with haemophilia is required.

A cadaveric study showing the anatomical variations in the branches of the dorsalis pedis artery at the level of the ankle joint and its clinical implication in ankle arthroscopy

Introduction Pseudoaneurysm formation following ankle arthroscopy is a rare but potentially catastrophic complication. The placement of anterior ankle portals carries inherent risk to the superficial and deep peroneal nerves, as well as to the dorsalis pedis artery. Anatomical variations in the dorsalis pedis and the presence of branches at the joint line may increase the risk of vascular injury and pseudoaneurysm formation during arthroscopy. There is limited anatomical evidence available regarding the branches of the dorsalis pedis artery, which occur at the point at which they cross the ankle joint. Objectives The objective of the study was to describe the frequency and direction of branches of the dorsalis pedis crossing the ankle joint. Materials and Methods Nineteen cadaveric feet were carefully dissected to explore the course of the dorsalis pedis artery, noting in particular the branching pattern at the joint line. Results Eleven of the nineteen feet had a branch of the dorsalis pedis artery that crossed the level of the ankle joint. Out of these, six were lateral, four medial and one bilateral. Eight of the eleven specimens had one branch at, or just before, the level of the joint. Two specimens had two branches and one had three branches crossing the ankle, which were all in the same direction, crossing laterally to the main trunk of the dorsalis pedis. Conclusions Our study demonstrated high rates of branching of the dorsalis pedis artery at the level of the ankle joint. The role of these branches in pseudoaneurysm formation during anterior hindfoot surgery remains unclear.

Long-term maintenance of efficacy of dapagliflozin in patients with type 2 diabetes mellitus and cardiovascular disease

AIM

To evaluate the long-term efficacy, safety and tolerability of dapagliflozin versus placebo added to usual care in patients with type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD).

METHODS

Data were pooled from two phase III studies (NCT01031680 and NCT01042977) in high-risk patients (N = 1887) with T2DM and CVD treated with dapagliflozin (10 mg/day) or placebo. Patients completing the double-blind treatment studies (24 weeks) entered one or two sequential double-blind, long-term (LT) extensions of 28 (LT1; n = 1649) and 52 (LT2; n = 568) weeks.

RESULTS

Baseline and CVD characteristics were similar in the two groups. Patients entering LT1 and LT2 on dapagliflozin maintained a greater mean reduction in glycated haemoglobin (HbA1c) versus placebo at 52 weeks [LT1, -0.58% (95% confidence interval -0.68, -0.49)] and 104 weeks [LT2, -0.35% (95% confidence interval -0.59, -0.12)]. Mean body weight and systolic blood pressure (SBP) reductions versus placebo were maintained in patients entering LT1 (52 weeks; -2.23 kg and -3.25 mmHg, respectively) and LT2 (104 weeks; -3.16 kg and -2.03 mmHg, respectively). Patients on dapagliflozin had a better three-item composite endpoint of clinical benefit (glycaemia, weight and SBP) compared with placebo at week 24 (LT1, 10.1% vs. 1.1%) and week 104 (LT2, 6.7% vs. 1.4%). Genital and urinary tract infections were more frequent with dapagliflozin than with placebo. Events of hypoglycaemia, renal impairment/failure and volume depletion were similar between groups.

CONCLUSIONS

The long-term efficacy of dapagliflozin to maintain reductions in HbA1c, SBP and body weight over 2 years, together with its tolerability profile, make dapagliflozin an appropriate option in high-risk patients with T2DM and CVD.

Clinical Characteristics and prognostic analysis of Triple-negative Breast Cancer: Single institute experience

BACKGROUND

Triple-negative breast cancer (TNBC) is a poor prognostic subset of breast cancer that lacks the benefit of specific targeted therapy.

MATERIALS AND METHODS

A prospective study of the clinical profile of triple negative breast cancer cases at a tertiary referral centre. The duration of the study period was 26 months and the median follow up period was ten months. A total of 111 invasive breast cancer patients were evaluated from 1st August 2009 to 31st October 2011. We examined TNBC patients with respect to clinicopathological parameters, adjuvant chemotherapy regimens and relapse free survival.

RESULTS

In our study, patients were young (median age at presentation, 47yrs), premenopausal (54%), tumour size was discordant with lymph node positivity, the histology was predominantly intraductal carcinoma (90%), histological grade higher than two (90%). Relapses were early and preferential visceral (32%) and CNS metastasises (11.7%). 91% of patients were eligible for adjuvant therapy but only 80% of the patients could complete full course of adjuvant chemotherapy. Anthracycline-based regimens (43%), sequential anthracycline and taxane-based regimen (24%) and other regimes like CMF (13%) were used as adjuvant chemotherapy in eligible TNBC patients. Median relapse free survival in patients following adjuvant chemotherapy was around 10 months at last follow-up.

CONCLUSIONS

Patients with TNBC have aggressive clinicopathological characteristics with early and higher rate of disease relapse and therefore derive inadequate benefit from current adjuvant chemotherapy. So, new treatment strategies in adjuvant chemotherapy for TNBC are needed.

Durability and tolerability of dapagliflozin over 52 weeks as add-on to metformin and sulphonylurea in type 2 diabetes

AIMS

To evaluate the safety and efficacy of dapagliflozin as add-on therapy to metformin plus sulphonylurea over 52 weeks.

METHODS

Patients with type 2 diabetes mellitus (T2DM) using sulphonylurea and metformin received dapagliflozin 10 mg/day or placebo added to therapy for 52 weeks (24-week randomized, double-blind period plus 28-week double-blind extension).

RESULTS

A total of 219 patients were randomized 1 : 1 to dapagliflozin or placebo. Over 52 weeks, glycated haemoglobin (HbA1c) and fasting plasma glucose levels showed greater improvement from baseline with dapagliflozin (-0.8% and -1.5 mmol/l) than with placebo (-0.1% and 0.6 mmol/l). More patients achieved HbA1c <7.0% with dapagliflozin (27.3%) than with placebo (11.3%) at 52 weeks. Dapagliflozin was associated with greater reductions in body weight and systolic blood pressure (-2.9 kg and -1.0 mmHg) compared with placebo (-1.0 kg and 1.1 mmHg). Greater increases in total, LDL and HDL cholesterol and decreases in triglycerides were observed with dapagliflozin (3.4, 4.8, 6.9 and -8.0%, respectively) versus placebo (1.4, 0.9, 0.6 and 2.9%, respectively). Fewer patients were rescued for failing to reach glycaemic targets with dapagliflozin (9.3%) than with placebo (44.4%). Adverse events and serious adverse events were similar between groups (dapagliflozin: 69.7 and 6.4%; placebo: 73.4 and 7.3%). More hypoglycaemic events were observed with dapagliflozin (15.6%) than with placebo (8.3%). Genital infections were reported in more patients in the dapagliflozin (10.1%) than in the placebo group (0.9%) and urinary tract infection frequency was similar in the two groups (10.1 and 11.0%).

CONCLUSION

Dapagliflozin as add-on to metformin plus a sulphonylurea was well tolerated and improvement in glycaemic control was maintained over 52 weeks.

Effects of hospital-acquired conditions on length of stay for patients with diabetes

BACKGROUND

Inpatients with diabetes have longer length of stays (LOS). Understanding patterns of in-hospital complications between patients with diabetes and others may reveal measures to improve patient welfare and minimise LOS.

AIM

This study evaluates the rates and types of hospital-acquired conditions among patients with and without diabetes and assesses any effects on LOS.

METHODS

A total of 47 615 admission episodes from The Northern Hospital over 12 months was reviewed. Episodes were divided into four groups: (i) patients without diabetes; (ii) patients with diabetes without end-organ sequelae (EOS); (iii) patients with diabetes with EOS; and (iv) a subset of non-diabetic patients with a Charlson Co-morbidity score ≥1 (comparison group). The Classification of Hospital Acquired Diagnoses (CHADx) was applied to the groups to compare rates and types of inpatient complications. Linear regression was used to analyse the impact of the number of CHADx on LOS.

RESULTS

Almost 30% of admissions of patients with diabetes and EOS had at least one CHADx, compared with 13% for non-diabetes patients and 17% for the comparison group. The types of CHADx experienced by diabetes patients with EOS were similar to the comparison group. However, rates were 10 times higher. Linear regression demonstrated diabetes patients with EOS have increased LOS and each CHADx per episode has a larger effect on LOS.

CONCLUSION

We demonstrate that diabetes patients have consistently higher rates of CHADx and longer LOS than similar patients with complex and chronic conditions. This provides a foundation for future studies to investigate preventative practices for this high-risk patient population.

Long-term glycaemic response and tolerability of dapagliflozin versus a sulphonylurea as add-on therapy to metformin in patients with type 2 diabetes: 4-year data

AIMS

To assess the long-term efficacy and tolerability of dapagliflozin versus glipizide as add-on to metformin in patients with inadequately controlled type 2 diabetes.

METHODS

The present study was an extension of an earlier randomized, double-blind, phase III study of dapagliflozin (n = 406) vs glipizide (n = 408) to 208 weeks (4 years). Patients continued to receive their assigned medication. No statistical treatment-group comparisons were calculated.

RESULTS

At 208 weeks, dapagliflozin compared with glipizide produced sustained reductions in glycated haemoglogin (HbA1c): -0.30% [95% confidence interval (CI), -0.51 to -0.09], in total body weight: -4.38 kg (95% CI -5.31 to -3.46) and in systolic blood pressure (SBP): -3.67 mmHg (95% CI -5.92 to -1.41). The HbA1c coefficient of failure was significantly lower for dapagliflozin than for glipizide: 0.19 (95% CI 0.12-0.25) versus 0.61 (95% CI 0.49-0.72, difference -0.42; p = 0.0001). Dapagliflozin was not associated with glomerular function deterioration, while this occurred more frequently in patients in the glipizide group. Fewer patients reported hypoglycaemia in the dapagliflozin compared with the glipizide group (5.4 vs 51.5%). Genital and urinary tract infections were more common with dapagliflozin than with glipizide, but their incidence decreased with time and all events responded well to antimicrobial treatment.

CONCLUSIONS

In patients completing 4 years of treatment, dapagliflozin was well tolerated and associated with sustained glycaemic efficacy and greater reductions in body weight and SBP versus glipizide.

Population Pharmacokinetics of Piperaquine in Young Ugandan Children Treated With Dihydroartemisinin-Piperaquine for Uncomplicated Malaria

This prospective trial investigated the population pharmacokinetics of piperaquine given with dihydroartemisinin to treat uncomplicated malaria in 107 Ugandan children 6 months to 2 years old, an age group previously unstudied. Current weight-based dosing does not adequately address physiological changes in early childhood. Patients were administered standard 3-day oral doses and provided 1,282 capillary plasma concentrations from 218 malaria episodes. Less than 30% of treatments achieved 57 ng/mL on day 7. A three-compartment model with first-order absorption described the data well. Age had a statistically significant effect (P < 0.005) on clearance/bioavailability in a model that accounts for allometric scaling. Simulations demonstrated that higher doses in all children, but especially in those with lower weight for age, are required for adequate piperaquine exposure, although safety and tolerance will need to be established. These findings support other evidence that both weight- and age-specific guidelines for piperaquine dosing in children are urgently needed.

A longitudinal cohort study evaluating the impact of a geriatrician-led residential care outreach service on acute healthcare utilisation

BACKGROUND

over the last decade, high demand for acute healthcare services by long-term residents of residential care facilities (RCFs) has stimulated interest in exploring alternative models of care. The Residential Care Intervention Program in the Elderly (RECIPE) service provides expert outreach services to RCFs residents, interventions include comprehensive care planning, management of inter-current illness and rapid access to acute care substitution services.

OBJECTIVE

to evaluate whether the RECIPE service decreased acute healthcare utilisation.

DESIGN

a retrospective cohort study using interrupted time series analysis to analyse change in acute healthcare utilisation before and after enrolment.

SETTING

a 300-bed metropolitan teaching hospital in Australia and 73 RCFs within its catchment.

SUBJECTS

there were 1,327 patients enrolled in the service with a median age of 84 years; 61% were female.

METHODS

data were collected prospectively on all enrolled patients from 2004 to 2011 and linked to the acute health service administrative data set. Primary outcomes change in admission rates, length of stay and bed days per quarter.

RESULTS

in the 2 years prior to enrolment, the mean number of acute care admissions per patient per year was 3.03 (SD 2.9) versus post 2.4 (SD 3.3), the service reducing admissions by 0.13 admissions per patient per quarter (P = 0.046). Prior to enrolment, the mean length of stay was 8.6 (SD 11.0) versus post 3.5 (SD 5.0), a reduction of 1.5 days per patient per quarter (P = 0.003).

CONCLUSIONS

this study suggests that an outreach service comprising a geriatrician-led multidisciplinary team can reduce acute hospital utilisation rates.

Dapagliflozin twice daily or once daily: effect on pharmacokinetics and urinary glucose excretion in healthy subjects

The primary objective of this single-centre, open-label crossover study (NCT01072578) was to assess the effect of dapagliflozin on the amount of glucose in the blood and urine in healthy volunteers when dapagliflozin was administered once a day (10 mg) versus twice a day (5 mg every 12 h) after 5 days of dosing. At steady state, the AUC(ss)₀₋₂₄ (area under the dapagliflozin curve (0-24 hours) at steady state), C(ss,av) (average concentration at steady state) between dapagliflozin 5 mg twice daily and 10 mg once daily were similar AUC(ss)₀₋₂₄ [5 mg bid, (458.0 (28.7)) and 10 mg qd, (470.0 (28.5))] and C(ss,av) [5 mg bid 18.8 (28.9)) and 10 mg qd, (19.6(28.5))], but minimum and maximum plasma levels of dapagliflozin differed significantly. Percent inhibition of renal glucose reabsorption (%IRGRA) and total urinary glucose excretion over 24 h were similar for both doses. The relationship between the mean dapagliflozin concentration and %IRGRA and the total urinary glucose excreted was well described by a maximum effect model. The results indicate that dapagliflozin may be used for either once daily or twice daily administration.

Dapagliflozin in type 2 diabetes: effectiveness across the spectrum of disease and over time

BACKGROUND

Despite many available therapies, patients with type 2 diabetes mellitus (T2DM) frequently do not achieve/maintain glycaemic control. Furthermore, side effects such as hypoglycaemia and weight gain may limit therapy choices. Dapagliflozin, a selective sodium-glucose cotransporter-2 inhibitor, reduces hyperglycaemia by increasing glucosuria independently of insulin, representing a novel approach in T2DM. Dapagliflozin efficacy, safety and tolerability were evaluated across a wide range of clinical trials.

METHODS

Dapagliflozin 10-mg efficacy data from (i) two short-term, active-comparator studies (vs. metformin-XR over 24 weeks and vs. glipizide over 52 weeks), (ii) pooled 24-week analyses of five placebo-controlled trials (as monotherapy or add-on therapy), and (iii) long-term studies over 2 years; dapagliflozin 5- and 10-mg pooled safety data from 12 placebo-controlled trials; and cardiovascular safety and malignancy data from 19 dapagliflozin studies were evaluated.

RESULTS

In treatment-naïve patients (baseline HbA1c 9%), dapagliflozin reduced HbA1c (-1.45%) similarly to metformin-XR (-1.44%). In metformin-treated patients (baseline HbA1c 7.7%), dapagliflozin achieved a clinically significant reduction (-0.52%) similar to glipizide (-0.52%). In pooled 24-week analyses, dapagliflozin vs. placebo differences in HbA1c, weight and systolic blood pressure (SBP) were -0.60%, -1.61 kg and -3.6 mmHg, respectively. At 2 years, dapagliflozin vs. placebo differences in HbA1c and weight were -0.44 to -0.80% and -2.41 to -3.19 kg, respectively, and vs. glipizide, differences in HbA1c, weight, and SBP were -0.18%, -5.06 kg, and -3.89 mmHg, respectively. Major hypoglycaemia with dapagliflozin was rare (< 0.1%). Urinary tract and genital infections were more common with dapagliflozin, but responded to standard care and rarely led to study discontinuation. Events of renal failure/impairment and malignancies were rare and balanced across treatment groups. Pooled analyses did not indicate that dapagliflozin increased cardiovascular event risk.

CONCLUSIONS

Dapagliflozin improved glycaemic control, decreased body weight, and lowered blood pressure across the spectrum of T2DM disease, with maintenance of these benefits over time.

Changes in weight loss-related quality of life among type 2 diabetes mellitus patients treated with dapagliflozin

AIMS

This study evaluated change in health-related quality of life (HRQOL) associated with ongoing weight change among patients with type 2 diabetes mellitus (T2DM) treated with dapagliflozin, a highly selective sodium-glucose cotransporter 2 (SGLT2) inhibitor that lowers blood glucose by increasing urinary glucose excretion and is associated with body weight reductions.

METHODS

Patients with T2DM who had inadequate glycaemic control on metformin (MET) alone were enrolled in a 24-week, double-blind, randomized, placebo-controlled study with a 78-week extension to evaluate the effect of dapagliflozin + MET on body weight. Patients also completed the Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes Weight Questionnaire-9 (SHIELD-WQ-9), a weight change-related HRQOL survey. Difference in proportions of patients treated with dapagliflozin 10 mg + MET (n = 89) or placebo + MET (n = 91) who reported improvement in HRQOL was analysed with Fisher's exact test.

RESULTS

Dapagliflozin patients had significantly greater weight loss than placebo patients over 102 weeks (p < 0.05). This corresponded to a numerically greater proportion of dapagliflozin-treated patients reporting ongoing weight loss and associated improvements in most HRQOL domains at three different evaluation points (weeks 24, 50 and 102) than placebo-treated patients. In a post-hoc analysis among patients who reported ongoing weight loss regardless of treatment arm, a significantly greater proportion of patients reporting weight loss versus weight gain reported improvements in physical health, self-esteem and overall HRQOL at weeks 24, 50 and 102.

CONCLUSIONS

Dapagliflozin-induced weight loss was associated with improvement in overall HRQOL. Overall, ongoing weight loss was associated with improvements in several HRQOL domains compared with weight gain.

Health-related quality of life (EQ-5D) among type 2 diabetes mellitus patients treated with dapagliflozin over 2 years

AIMS

This study evaluated health status and health-related quality of life (HRQOL) among patients with type 2 diabetes mellitus (T2DM) treated with dapagliflozin, a highly selective sodium-glucose co-transporter 2 (SGLT2) inhibitor that lowers blood glucose by increasing glucose excretion, in a double-blind, randomised clinical trial.

METHODS

Subjects with T2DM who had inadequate glycaemic control on metformin alone were enrolled in a 24-week, double-blind, randomised, placebo-controlled study with a 78-week extension period to evaluate the effect of dapagliflozin in combination with metformin. Subjects treated with dapagliflozin 10 mg + metformin (n = 89) were compared with subjects treated with placebo + metformin (n = 91) at baseline and at weeks 24, 50 and 102. EQ-5D change from baseline was derived from a repeated-measures mixed model, adjusting for baseline EQ-5D, treatment group, time point and use of rescue medication.

RESULTS

Mean (SD) EQ-5D index was 0.85 (0.16) and 0.82 (0.15) at baseline and 0.85 (0.19) and 0.84 (0.19) at week 102 for dapagliflozin and placebo, respectively. The model indicated no change over 102 weeks in EQ-5D index scores in either treatment group. Mean (SD) EQ-5D visual analogue scale (VAS) was 72.5 (19.5) and 73.7 (15.6) at baseline and 79.8 (13.3) and 78.2 (12.1) at week 102 for dapagliflozin and placebo, respectively. The model indicated similar small improvements in EQ-5D VAS scores in both groups over 102 weeks.

CONCLUSION

Patients maintained high HRQOL scores from baseline through week 102 in both treatment groups. Dapagliflozin, a novel SGLT2 inhibitor, did not adversely affect HRQOL over 2 years of treatment.

Dapagliflozin maintains glycaemic control while reducing weight and body fat mass over 2 years in patients with type 2 diabetes mellitus inadequately controlled on metformin

AIMS

Dapagliflozin, a highly selective inhibitor of sodium-glucose cotransporter 2 (SGLT2), reduces hyperglycaemia and weight in patients with type 2 diabetes mellitus (T2DM) by increasing urinary glucose excretion. Long-term glycaemic control, body composition and bone safety were evaluated in patients with T2DM after 102 weeks of dapagliflozin treatment.

METHODS

This randomized, double-blind, placebo-controlled study (NCT00855166) enrolled patients with T2DM [mean: age 60.7 years; HbA1c 7.2%; body mass index (BMI) 31.9 kg/m(2) ; body weight 91.5 kg] inadequately controlled on metformin. Patients (N = 182) were randomly assigned 1 : 1 to receive dapagliflozin 10 mg/day or placebo added to open-label metformin for a 24-week double-blind treatment period followed by a 78-week site- and patient-blinded extension period. At week 102, changes from baseline in HbA1c, weight, waist circumference, total body fat mass as measured by dual-energy X-ray absorptiometry (DXA), serum markers of bone turnover, bone mineral density (BMD) as measured by DXA, and adverse events were evaluated.

RESULTS

A total of 140 patients (76.9%) completed the study. Over 102 weeks, dapagliflozin-treated patients showed reductions in HbA1c by -0.3%, weight by -4.54 kg, waist circumference by -5.0 cm and fat mass by -2.80 kg without increase in rate of hypoglycaemia. Compared with placebo, no meaningful changes from baseline in markers of bone turnover or BMD were identified over 102 weeks. One fracture occurred in each treatment group. The frequency of urinary tract infection (UTI) and genital infection was similar in both treatment groups.

CONCLUSIONS

Over 102 weeks, dapagliflozin improved glycaemic control, and reduced weight and fat mass, without affecting markers of bone turnover or BMD in patients with T2DM inadequately controlled on metformin.

Dapagliflozin in patients with type 2 diabetes receiving high doses of insulin: efficacy and safety over 2 years

AIMS

Dapagliflozin, a selective inhibitor of sodium-glucose cotransporter 2 (SGLT2), has been shown to improve glycaemic control, stabilize insulin dosing and mitigate insulin-associated weight gain over 48 weeks in patients whose type 2 diabetes mellitus (T2DM) was inadequately controlled despite high doses of insulin. Here the efficacy and safety of dapagliflozin therapy after a total of 104 weeks are evaluated in this population.

METHODS

This was a 24-week, randomized, placebo-controlled, double-blinded, multicentre trial followed by two site- and patient-blinded extension periods of 24 and 56 weeks (NCT00673231), respectively. A total of 808 patients, whose T2DM was inadequately controlled on insulin ≥30 IU/day, with or without up to two oral antidiabetic drugs, were randomly assigned to receive placebo or 2.5, 5 or 10 mg/day of dapagliflozin for 104 weeks. At 48 weeks, patients on dapagliflozin 5 mg were switched to 10 mg. Outcomes over 104 weeks included change from baseline in HbA1c, insulin dose and body weight; analyses used observed cases and included data after insulin up-titration. Adverse events (AEs) were evaluated throughout 104 weeks.

RESULTS

Five hundred and thirteen patients (63.6%) completed the study. Mean HbA1c changes from baseline at 104 weeks were -0.4% in the placebo group and -0.6 to -0.8% in the dapagliflozin groups. In the placebo group, mean insulin dose increased by 18.3 IU/day and weight increased by 1.8 kg at 104 weeks, whereas in the dapagliflozin groups, insulin dose was stable and weight decreased by 0.9-1.4 kg. AEs, including hypoglycaemia, were balanced across groups. Proportions of patients with events suggestive of genital infection and of urinary tract infection (UTI) were higher with dapagliflozin versus placebo (genital infection 7.4-14.3% vs. 3.0%; UTI 8.4-13.8% vs. 5.6%) but most occurred in the first 24 weeks and most were single episodes that responded to routine management.

CONCLUSIONS

Dapagliflozin improved glycaemic control, stabilized insulin dosing and reduced weight without increasing major hypoglycaemic episodes over 104 weeks in patients whose T2DM was inadequately controlled on insulin. However, rates of genital infection and of UTI were elevated with dapagliflozin therapy.