Ketoacidosis in a Patient with Type 2 Diabetes Requiring Alpelisib: Learnings and Observations Regarding Alpelisib Initiation and Rechallenge

Background

Diabetic ketoacidosis (DKA) is a rare complication of alpelisib, but cases of DKA are reported. Alpelisib's safety in patients with long-standing, suboptimally controlled diabetes is unclear since clinical trials of alpelisib did not include them.

Case

A case is presented on a patient with metastatic breast cancer and type 2 diabetes admitted for DKA eleven days after starting alpelisib. Since DKA is implicated in antihyperglycemics that inhibit sodium-glucose cotransporter-2 (SGLT2) inhibitors, her empagliflozin was discontinued. Alpelisib was also held since it was recently initiated. After the DKA resolved, she was discharged and restarted alpelisib. Within 4 hours of taking the first dose, the patient developed a second episode of DKA, and alpelisib treatment was stopped permanently.

Conclusion

Patients with long-standing type 2 diabetes are at high risk of alpelisib-induced Grade 3 and 4 hyperglycemia, including DKA. It is essential to communicate with non-oncology stakeholders about the risk of DKA with alpelisib as it can be overlooked for more common causes. Restarting alpelisib can result in severe hyperglycemia or DKA within 24 hours of the first dose. In this population, the risks associated with rechallenging alpelisib must be heavily weighed against its benefits. Before restarting alpelisib, a thorough evaluation of the appropriateness of the patient's antihyperglycemics and diet must occur to anticipate and mitigate a second event. Antihyperglycemics independent of the PI3K/AKT/mTOR pathway may be preferred agents. A plan should be in place to quickly respond to rising glycemia and early referral to a diabetologist or endocrinologist is recommended. Continuous glucose monitoring and hospital admission are recommended during rechallenge. A better understanding of alpelisib-induced hyperglycemia, especially in patients with diabetes, is required to navigate alpelisib treatment safely. Emphasis should be placed on patient education of symptoms and monitoring parameters.

Findings from the first public COVID-19 temporary test centre in Hong Kong

INTRODUCTION

The Hospital Authority of Hong Kong Special Administrative Region established a coronavirus disease 2019 (COVID-19) temporary test centre at the AsiaWorld-Expo from March 2020 to April 2020, which allowed high-risk individuals to undergo early assessment of potential severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. This study reviewed the characteristics and outcomes of individuals who attended the centre for COVID-19 testing.

METHODS

This retrospective cross-sectional study collected epidemiological and clinical data. The primary outcome was a positive or negative SARS-CoV-2 test result, according to reverse transcription polymerase chain reaction analyses of pooled nasopharyngeal and throat swabs collected at the centre. The relationships of clinical characteristics with SARS-CoV-2 positive test results were assessed by multivariable binary logistic regression.

RESULTS

Of 1258 attendees included in the analysis, 86 individuals tested positive for SARS-CoV-2 infection (positivity rate=6.84%; 95% confidence interval [CI]=5.57%-8.37%). Of these 86 individuals, 40 (46.5%) were aged 15 to 24 years and 81 (94.2%) had a history of recent travel. Symptoms were reported by 86.0% and 96.3% of individuals with positive and negative test results, respectively. The clinical characteristics most strongly associated with a positive test result were anosmia (adjusted odds ratio [OR_adj]=8.30; 95% CI=1.12-127.09) and fever OR_adj=1.32; 95% CI=1.02-3.28).

CONCLUSION

The temporary test centre successfully helped identify individuals with COVID-19 who exhibited mild disease symptoms. Healthcare providers should carefully consider the epidemiological and clinical characteristics of COVID-19 to arrange early testing to reduce community spread.

P6443Late outcomes in patients undergoing PCI for ST elevation myocardial infarction with respect to diabetic status and completeness of revascularisation

Objectives

This paper examines the degree to which the poor prognosis of ST elevation myocardial infarction (STEMI) patients with diabetes mellitus (DM) can be attributed to incomplete revascularization (ICR).

Background

Cardiovascular disease is the most common cause of death for patients with DM; patients with DM often have complex coronary disease and ICR. In STEMI the relative impact of DM and ICR is uncertain as these two factors frequently co-exist, the potential for confounding is high.

Methods and results

Of 589 consecutive STEMI patients, 22% had DM, who compared to patients without DM were of similar age (59 years), were more often female, had more hypertension and dyslipidaemia, but less often were smokers. A residual SYNTAX Score (rSS) >8, which defined ICR, occurred in 33%. Late cardiac death [median 3.5 years] was 4% among those without DM and 12% in those with DM (p=0.002) (p<0.001), and was 3% among 396 with rSS≤8 and 12% in 193 patients with rSS>8 (p<0.001). Patients with both ICR and DM accounted for only 8% of the STEMI population but 30% of all cardiac deaths. At final follow up (3.5 years) cardiac death rates (see Figure) were 22% in patients with both DM and ICR; these were significantly higher than rates in patients with ICR but no-DM (9%, p=0.034), and those with DM and rSS≤8 (6%, p<0.019). Multivariable analysis for cardiac death found a HR for ICR of 2.89 (95% CI 1.31–6.37; p=0.009) and a HR for DM of 5.18 (95% CI 2.45–10.97, p<0.001).

Diabetes, cardiac death & rSS

Conclusions

While ICR in DM patients with STEMI predicts a significantly poorer outcome, the poor prognosis seen in patients with DM is not explained by the degree of ICR alone. Both ICR and DM contribute independently to the risk of cardiac death in STEMI patients.

New Service Model for Common Mental Disorders in Hong Kong: a Retrospective Outcome Study

OBJECTIVE

To review the first 8-month outcome of the Common Mental Disorder Clinic model in Hong Kong in terms of patient exit status and improvement in depressive and anxiety symptoms.

METHODS

During the first appointment, patients were interviewed by a multidisciplinary team comprising a psychiatrist, a psychiatric nurse, and an occupational therapist. A multidisciplinary case conference was conducted to discuss clinical observations, diagnosis, issues of concern, and the optimal individualised treatment plan. Low-intensity interventions by nurses and/or occupational therapists were provided, as were optional, time-limited, protocol-based interventions by clinical psychologists for those with mild to moderate depressive and anxiety symptoms. Pharmacological intervention may be used when indicated. Upon completion of the treatment plan, patients were reassessed by the treating psychiatrist. Discharge options included discharge without psychiatric follow-up, step-up to psychiatric outpatient clinics, and step-down services. The self-administered Patient Health Questionnaire-9 (PHQ-9) and Generalised Anxiety Disorder 7-item scale (GAD-7) were used to assess the past 2 weeks' depressive and anxiety symptoms, respectively, at baseline and at each session.

RESULTS

From July 2015 to February 2016, 1325 Chinese patients received the new service. Of them, 170 men and 363 women (mean age, 52.6 years) completed the treatment plan. After treatment, their mean PHQ-9 score decreased from 11.06 to 7.55 (p < 0.001), and the mean GAD-7 score decreased from 9.94 to 6.54 (p < 0.001). After treatment, 42.4% and 48.2% of the patients were within the normal range of PHQ-9 and GAD-7 scores, respectively, compared with 16.9% and 20.8% before treatment. The mean time to implementation of the individualised treatment plan was 82.33 days. Of the patients, 54.4% were discharged without any need for medical or psychiatric follow-up; 28% were stepped up to psychiatric outpatient clinics; and 17.3% were stepped down. The predictors of exit status were whether psychiatric medication was prescribed during initial intake (p = 0.011), whether psychiatric medication was prescribed at last follow-up (p < 0.001), the service period (p = 0.010), and the GAD-7 final score (p = 0.005).

CONCLUSIONS

The first 8-month outcome of the new service model was encouraging, with shortened waiting time, reduced severity of symptoms, and better exit status (high recovery and step-down rates).

Disseminated Sporotrichosis in a Bilby (Macrotis lagotis)

A male bilby (Macrotis lagotis) was presented to the Murdoch University Veterinary Anatomical Pathology Service following humane destruction due to severe lethargy. The bilby was emaciated with a focal ulcerated skin lesion on the dorsal tail base. Multifocal to coalescing foci of pyogranulomatous and often necrotizing inflammation was present within multiple organs, including the tail wound, adrenal glands, kidneys, lungs, brain, testes, lymph nodes, heart, liver, spleen and salivary glands. Admixed were abundant intrahistiocytic and extracellular pleomorphic yeast (round, oval and cigar-shaped) up to 6 μm diameter, often with a thin clear halo and occasional narrow-based budding. The diagnosis of disseminated sporotrichosis was confirmed via culture and sequencing of the internal transcribed spacer region of the causative agent, Sporothrix schenckii sensu lato. The route of entry of infection was considered most likely to have been via cutaneous inoculation of the tail base wound. To the authors' knowledge, this report describes the first known case of sporotrichosis in a native Australian animal.

Developing recommendations for the safe handling of oral anti-cancer drugs in community pharmacies: A pan-Canadian consensus approach

Purpose

To create a set of consensus-based and evidence-informed recommendations to provide guidance around the safe dispensing and handling of oral anti-cancer drugs in low-volume settings unique to the community pharmacy setting.

Methods

A review of published and grey literature (published in non-commercial domains such as national organizations and associations) documents and nine key informant interviews were conducted and a modified Delphi approach was taken to achieve consensus. The final list of 47 candidate recommendations was reviewed by a task force and validated by multi-disciplinary stakeholders. A draft of the statements was circulated broadly within the community pharmacy community in an effort to assess relevance and implementation feasibility.

Results

The final report included 44 recommendations that addressed 11 key areas germane to the safe handling of oral anti-cancer drugs in community pharmacies. Mean agreement increased from 70% to 95%. Early feedback from community pharmacy leaders during the external review suggests that many of the proposed recommendations can be feasibly implemented within a reasonable timeframe when released with appropriate education and resource materials.

Conclusions

A modified-Delphi approach supplemented by key informant interviews and a comprehensive external review resulted in a set of evidence-informed, community-driven recommendations for community pharmacies. The recommendations address a gap in existing literature to improve understanding of the risks associated with handling and dispensing oral anti-cancer drugs for both community pharmacy staff and management and offer mitigating strategies to reduce those risks. Incorporating feasibility assessment actions early (through the key informant interviews) and late (through the external review) ensures recommendations are grounded in practicality and support broad and early knowledge translation strategies.

A One-Year Hospital-Based Analysis of Sports Injuries

Objectives

(1) To survey and analyse the pattern of sports injuries; (2) to make implication from the results.

Methodology

Subjects with sports injuries attending the emergency department of Princess Margaret Hospital in 2006 were retrieved via the Injury Surveillance System. The characteristics of the subjects and their injuries were evaluated.

Results

In 2006, 709 subjects had sports injuries, from which 83% were male. The median age was 19. Age below 20 accounted for 53% of the attendance. Football (35%), basketball (25%) and cycling (9%) were the three commonest sport-injury activities. All sports injuries had the maximum AIS ≤3 and 83% had MAIS of 1 only. Overall, 39% had contusion and scrape, 36% with sprain and strain, and 18% had fracture. Nearly half (47%) had lower limb injury; 30% and 24% had upper limb injury and head injury respectively. Contusion and scrape of the head, and sprain and strain of the lower limb were the two commonest injuries in football and basketball. In cycling, two-thirds suffered from contusion and scrape of any body region and 57% of those involved the head.

Conclusion

Sports injury surveillance with characterised patterns of injuries helped to devise prevention measures.

A Retrospective Epidemiological Study of the Traffic-Related Injuries Cases Admitted to a Local Hospital

Road traffic injuries (RTI) are important public health problem globally. Accurate data about RTIs and its subsequent health consequences are essential to monitor the effectiveness of current RTI prevention measures and to readdress policies.

Objective

We presented the surveillance of RTI in Kwai Tsing by integrating data from traffic accident data system (TRADS) and injury surveillance system (ISS) from Princess Margaret Hospital.

Method

Retrospective observational study to examine traffic-related injuries by integrating data from TRADS and ISS databases. A multivariate analysis was performed to identify risk factors associated with hospital admissions in RTI.

Result

A total of 725 patients were included. About 19% of the visits led to hospitalisation and six deaths (0.83%) were reported. Pedestrian elders were significantly more at risk to traffic injury mortality and hospitalisation.

Conclusion

This study demonstrates the feasibility of an integrated surveillance system for RTI based on existing local databases. Special preventive measures should be tailored for pedestrian and elderly to improve their safety by improving the quality of their walking environment.

Clinical Outcomes of Trauma Patients after Implementation of a Standardised Diversion Protocol for Trauma Patients in Two Regional Hospitals in Hong Kong

Introduction

Despite recent advance in prehospital trauma diversion, patients are triaged to the nearest medical facility before transferred to designated trauma centre. A new standardised diversion protocol for trauma patients was implemented on 1st April 2011 to facilitate trauma care. Severely-injured patients were transferred to designated trauma centre directly from emergency department of the regional hospital after initial resuscitation.

Objective

This study was undertaken to examine clinical outcomes of trauma patients after implementation of the new standardised diversion protocol for trauma patients in the emergency department.

Method

This was a before-and-after interventional study on trauma patients presenting to the emergency department in critical or emergency conditions during the study period from 1st April 2011 to 31st March 2012. Patients presented in the two-year period before implementation of the trauma protocol were used as historical control. Medical records of eligible cases were reviewed. Main outcome measures were 30-day mortality, length of hospital stay and time to definitive care. Mortality data was compared with oversea standard by TRISS methodology.

Results

There were 153 eligible patients in the study group and 355 in the historical control group. After new arrangement of trauma diversion, W-statistics improves from -1.26 to 0.09. Z-statistics was -2.03 before and 0.09 after implementation. M-statistics were 0.91 before and 0.88 after the new protocol. Mean time to definitive care was shortened by 33.4 minutes in the subgroup who were transferred to trauma centre after trauma team activation (p=0.005).

Conclusion

A trend of improved outcomes and shorter time to definitive care are observed after implementation of the new trauma diversion protocol. (Hong Kong j.emerg.med. 2015;22:201-209)

How Accurate are Emergency Department Medical Staff in the Interpretation of Head Injury Related Computed Tomography?

Introduction

Computed tomography (CT) brain has become a popular modality to detect head injury related problems for patients seen at the Emergency Departments (ED) in Hong Kong. This study aims to assess the diagnostic accuracy of local ED medical staff in interpretation of head injury related CT and to assess the association between years of working experience of ED medical staff and the diagnostic accuracy of CT brain interpretation.

Methods

This is a retrospective cohort study reviewing all patients attending the ED of Princess Margaret Hospital in three years (from 2008 to 2010) with head injuries requiring CT brain during ED stay. The findings of CT brain by ED medical staff were compared with those by radiologists, the reference standard.

Results

A total of 1716 cases were assessed. The overall sensitivity and specificity for detecting an abnormal CT were 0.66 (95% confidence interval [CI] 0.60-0.71) and 0.96 (95% CI 0.95-0.97), respectively. The sensitivity showed an increasing trend from 0.63 (95% CI 0.54-0.72) in ED staff with 0-3 years of working experience, to 0.71 (95% CI 0.59-0.84) with 4-6 years of experience and 0.75 (95% CI 0.63-0.86) with 7-10 years of experience. It dropped to 0.59 (95% CI 0.47-0.71) with more than 10 years of experience.

Conclusions

The head injury related CT interpretation skill by ED medical staff is suboptimal. More training is necessary. (Hong Kong j.emerg.med. 2015;22:241-247)

Targeting the Epidemic: Interventions and Follow-up Are Necessary in the Pediatric Traumatic Brain Injury Clinic

Traumatic brain injury is a major public health problem in the pediatric population. Previously, management was acute emergency department/primary care evaluation with follow-up by primary care. However, persistent symptoms after traumatic brain injury are common, and many do not have access to a specialized traumatic brain injury clinic to manage chronic issues. The goal of this study was to determine the factors related to outcomes, and identify the interventions provided in this subspecialty clinic. Data were extracted from medical records of 151 retrospective and 403 prospective patients. Relationships between sequelae, injury characteristics, and clinical interventions were analyzed. Most patients returning to clinic were not fully recovered from their injury. Headaches were more common after milder injuries, and seizures were more common after severe. The majority of patients received clinical intervention. The presence of persistent sequelae for traumatic brain injury patients can be evaluated and managed by a specialty concussion/traumatic brain injury clinic ensuring that medical needs are met.

A Retrospective Study of Patients with Minor Head Injury to Compare the Canadian CT Head Rule and the New Orleans Criteria

Objective

To compare the performance of the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) in minor head injury patients.

Method

This retrospective cohort study collected data and CT head reports of all minor head injury patients from 1 January 2008 to 31 December 2010. We compared the sensitivity, specificity, positive and negative predictive values of both rules in predicting clinically important brain injury on CT and the need of neurosurgical intervention.

Results

We reviewed 474 patients with minor head injury. Seventy seven patients had clinically important brain injury and 11 underwent neurosurgical intervention. The sensitivity of the CCHR and NOC in predicting clinically important brain injury were 80% (95% confidence interval [CI] 70-88%) and 92% (95% CI 86-98%), respectively; and the specificity of the CCHR and NOC were 39% (95% CI 33-44%) and 17% (95% CI 13-21%), respectively. The sensitivity of the CCHR and NOC in predicting the need of neurosurgical intervention were 80% (95% CI 55-100%) and 100% (95% CI 100-100%), respectively; and the specificity of the CCHR and NOC were 36% (95% CI 31-41%) and 15% (95% CI 12-19%), respectively. The negative predictive values (NPV) of the CCHR and NOC for clinically important brain injury were 88% (95%CI 83-94%) and 91% (95%CI 84-98%); and for the need of neurosurgical intervention were 99% (95% CI 96-100%) and 100% (95% CI 100-100%). Amongst those missed cases, 88% in the CCHR group and 83% in the NOC group reported loss of consciousness.

Conclusions

The NOC is more sensitive but less specific than the CCHR in predicting both outcomes. Both rules have excellent NPV to rule out the need of neurosurgical intervention.

A modified filgrastim regimen does not reduce pain burden compared to pegfilgrastim in women receiving chemotherapy for non-metastatic breast cancer

PURPOSE

The short half-life of filgrastim allows for modification in the dose or duration of prophylaxis to limit inconvenience, adverse effects, and cost. The objectives of this study were to characterize and compare pain and neutropenic events between filgrastim and pegfilgrastim.

METHODS

A prospective, observational study was performed. Eligible patients had non-metastatic breast cancer and were to receive adjuvant or neo-adjuvant chemotherapy with prophylaxis for febrile neutropenia. The prophylaxis used was a fixed-dose regimen of filgrastim 300 μg subcutaneously once daily for 7 days or pegfilgrastim 6 mg subcutaneously for 1 day. Participants completed a pain diary once a day for 14 days commencing the evening of the patient's first chemotherapy. Telephone interviews occurred at two instances within 2 weeks after their first treatment. The primary endpoints of this study were the difference in pain and incidences of neutropenia. Muscle pain, pain burden, and potential risk factors for pain were also explored.

RESULTS

A total of 142 women were enrolled, 94 with pegfilgrastim and 48 with filgrastim. Filgrastim was associated with worse joint and muscle pain compared to pegfilgrastim. Joint pain was present in 38 and 26 % of diary entries for filgrastim and pegfilgrastim, respectively (p = 0.009). The mean AUC for joint pain score across 14 days, normalized to 100, were 6.0 for pegfilgrastim and 8.6 for filgrastim in patients receiving non-docetaxel chemotherapy and 14.6 for pegfilgrastim and 21.5 for filgrastim in patients receiving docetaxel-based chemotherapy (p = 0.037). Muscle pain patterns and frequencies were similar to joint pain. There were no statistical differences in febrile neutropenia and neutropenic events.

CONCLUSIONS

Both filgrastim and pegfilgrastim caused significant pain burden. A fixed-dose regimen of filgrastim may be effective, but offers no advantage to minimize muscle or joint pain and, in fact, appears to cause greater and more frequent pain.