Canakinumab as Adjuvant Therapy in Patients With Completely Resected Non-Small-Cell Lung Cancer: Results From the CANOPY-A Double-Blind, Randomized Clinical Trial

PURPOSE

Effective treatments for resectable non-small-cell lung cancer (NSCLC) are limited and relapse rates are high. The interleukin (IL)-1β pathway has been linked with tumor development and progression, including in the Canakinumab Anti-Inflammatory Thrombosis Outcomes cardiovascular study in which IL-1β pathway inhibition with canakinumab reduced lung cancer incidence and mortality in an exploratory analysis.

METHODS

CANOPY-A (ClinicalTrials.gov identifier: NCT03447769) is a phase III, randomized, double-blind, multicenter study of canakinumab versus placebo for adult patients with stage II-IIIA or IIIB (T >5 cm, N2-positives II-IIIB; American Joint Committee on Cancer/Union for International Cancer Control version 8), completely resected NSCLC who had received adjuvant cisplatin-based chemotherapy. The primary end point was disease-free survival (DFS) and the key secondary end point was overall survival (OS).

RESULTS

In total, 1,382 patients were randomized to 200 mg canakinumab (n = 693) or placebo (n = 689) once every 3 weeks for 18 cycles. Grade ≥3 adverse events (AEs) were reported in 20.8% and 19.6% of patients receiving canakinumab and placebo, respectively; AEs led to discontinuation in 4.3% and 4.1% of patients in these groups, respectively. This study did not meet its primary end point. Median DFS was 35.0 months (canakinumab arm) and 29.7 months (placebo arm; hazard ratio, 0.94; 95% CI, 0.78 to 1.14; one-sided P = .258). DFS subgroup analyses did not show any meaningful differences between arms. As expected, because of canakinumab-driven IL-1β pathway inhibition, C-reactive protein and IL-6 levels decreased in the canakinumab arm versus placebo arm, but had no correlation with differential clinical outcomes. OS was not formally tested as DFS was not statistically significant.

CONCLUSION

CANOPY-A did not show a DFS benefit of adding canakinumab after surgery and adjuvant cisplatin-based chemotherapy in patients with resected, stage II-III NSCLC. No new safety signals were identified with canakinumab.

A randomized double-blind, placebo-controlled trial to evaluate the safety and efficacy of live Bifidobacterium longum CECT 7347 (ES1) and heat-treated Bifidobacterium longum CECT 7347 (HT-ES1) in participants with diarrhea-predominant irritable bowel syndrome

To determine the efficacy of the probiotic Bifidobacterium longum CECT 7347 (ES1) and postbiotic heat-treated Bifidobacterium longum CECT 7347 (HT-ES1) in improving symptom severity in adults with diarrhea-predominant irritable bowel syndrome (IBS-D), a randomised, double-blind, placebo-controlled trial with 200 participants split into three groups was carried out. Two capsules of either ES1, HT-ES1 or placebo were administered orally, once daily, for 84 days (12 weeks). The primary outcome was change in total IBS-Symptom Severity Scale (IBS-SSS) score from baseline, compared to placebo. Secondary outcome measures were stool consistency, quality of life, abdominal pain severity and anxiety scores. Safety parameters and adverse events were also monitored. The change in IBS-SSS scores from baseline compared to placebo, reached significance in the ES1 and HT-ES1 group, on Days 28, 56 and 84. The decrease in mean IBS-SSS score from baseline to Day 84 was: ES1 (-173.70 [±75.60]) vs placebo (-60.44 [±65.5]) (p < .0001) and HT-ES1 (-177.60 [±79.32]) vs placebo (-60.44 [±65.5]) (p < .0001). Secondary outcomes included changes in IBS-QoL, APS-NRS, stool consistency and STAI-S and STAI-T scores, with changes from baseline to Day 84 being significant in ES1 and HT-ES1 groups, compared to the placebo group. Both ES1 and HT-ES1 were effective in reducing IBS-D symptom severity, as evaluated by measures such as IBS-SSS, IBS-QoL, APS-NRS, stool consistency, and STAI, in comparison to the placebo. These results are both statistically significant and clinically meaningful, representing, to the best of the authors' knowledge, the first positive results observed for either a probiotic or postbiotic from the same strain, in this particular population.

A268 RESOLUTION RATES IN OPEN-LABEL VERSUS RANDOMIZED CONTROLLED TRIALS FOR MICROBIOTA RESTORATION FOR RECURRENT CLOSTRIDIOIDES DIFFICILE INFECTION: AN UPDATED META-ANALYSIS

Background

Microbiota restoration is highly effective to treat recurrent Clostridioides difficile infection (CDI) in observational studies (cure rates >90%) but efficacy in controlled clinical trials appears lower.

Purpose

We performed an updated meta-analysis to assess the efficacy of microbiota restoration for recurrent CDI in open-label registered prospective clinical trials compared to randomized controlled trials (RCTs).

Method

A systematic search of Embase, Web of Science and Scopus was performed up to June 2022 to identify studies of interest. Clinical trials of microbiota restoration for recurrent CDI with clinical resolution with one dose as the primary outcome were included. We calculated both unweighted and weighted pooled resolution rates (UPR and WPR) with 95% confidence intervals (CI).

Result(s)

Eighteen studies (9 RCTs and 9 open-label trials) with 1149 CDI patients were included. Of the patients treated with microbiota restoration, 881 experienced symptom resolution (UPR 77%%; WPR 79%, 95% CI, 72%-85%). There was significant heterogeneity among studies with an I²of 86%. Analysis of trials with a control arm (non-microbiota restoration) revealed CDI resolution in 357 of 496 patients (UPR 72%; WPR 73%, 95% CI 63%-82%) with microbiota restoration. Among the 9 open-label clinical trials, CDI resolution was seen in 524 of 653 patients after initial microbiota restoration (UPR 80%; WPR 84%, 95% CI 74%-92%). Comparison of resolution rates between RCTs and open-label trials revealed a lower cure rate in RCTs compared to open-label trials (WPR 73% vs 84%, p<0.0001).

Analysis of the 10 trials with non-microbiota restoration revealed CDI resolution in 201 of 397 patients with antibiotics (WPR 52%, 95% CI 43%-60%). There was significant heterogeneity among the included studies with an I²of 61%. Comparison of cure rates with microbiota restoration vs antibiotics showed higher cure rate with microbiota restoration (WPR 73%, [95% CI 63%-82%] vs 52% [95% CI, 43%-60%]; p<0.0001). There were no serious adverse events reported.

Conclusion(s)

Microbiota restoration in a randomized controlled setting leads to lower resolution rates compared to open label and observational settings, likely due to stricter definitions and inclusion criteria. Resolution rates in open label studies were similar to observational studies.

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A233 OUTCOMES OF CLOSTRIDIOIDES DIFFICILE INFECTION IN SURGICAL PATIENTS: RESULTS FROM NATIONAL INPATIENT SAMPLE 2016-2019

Background

Clostridioides difficile infection (CDI) is the most common nosocomial infection and is associated with significant morbidity and mortality.

Purpose

We aimed to identify the burden of CDI in patients undergoing common gastrointestinal (GI) surgical procedures in a national inpatient cohort, as GI surgeries have been thought to be a risk factor for CDI.

Method

We used the National Inpatient Sample (NIS) database from Unites States for the years 2016-2019 for this study. We included adult patients (age ≥ 18), who underwent common GI surgeries (identified using ICD-10 procedure codes), and among them identified patients with diagnosis of CDI. Outcomes assessed included risk of CDI among different surgeries, inpatient mortality, length of stay (LOS) and cost of hospitalization using regression analyses

Result(s)

From 2016 to 2019, an estimated total of 4,438,778 patients were hospitalized and underwent any of the studied GI surgeries. CDI was reported in 32,180 admissions (0.72%). Median age for CDI was higher than non-CDI patients (66 vs 56, p<0.001). Incidence of CDI was 2.5 times higher in patients admitted emergently compared to elective admissions (1.00% vs 0.40%, p<0.0001). Among all surgeries, the incidence of CDI was the highest for small bowel resection at 2.1% followed by partial esophagectomy at 1.6% and partial colectomy at 1.4%. Logistic regression analysis showed the patients undergoing esophagectomy had the highest risk with adjusted Odds Ratio (aOR) of 2.48, (95% CI 2.01 – 3.07, p<0.0001), followed by pancreatectomy with aOR 2.03 (95% CI 1.91 – 2.16, p<0.0001). Overall, surgical patients with CDI had a significantly higher in-patient mortality compared to non-CDI patients (8.2% vs 1.4%, p<0.0001). Logistic regression analysis showed an increased risk of inpatient mortality with CDI, with aOR 1.36, 95% CI 1.30 – 1.42, p<0.0001. Median LOS for surgical patients with CDI was higher than non-CDI patients (14 days vs 3 days, p<0.0001). The linear regression analysis for length of stay showed that among patients undergoing surgical procedures, CDI was associated with an increased LOS with beta of 8.39 days ± SE 0.04 (95% CI 8.31 – 8.46, p<0.0001). The mean cost of hospitalization for surgical patients with CDI was higher than non-CDI patients ($90,590 vs $31,702, p<0.0001) after adjusting for inflation over the four-year period. The linear regression analysis showed that CDI was associated with an increased cost of hospitalization with a beta of $25,343 ± SE 166 (95% CI 25,017 – 25,670, p<0.0001).

Conclusion(s)

CDI among GI surgeries leads to increase in inpatient mortality, length of stay and cost of hospitalization. Although the rate of CDI is showing a downwards trend, its impact on these outcome measures makes it an important complication to prevent and promptly treat in these surgical patients.

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Abstract CT559: Capmatinib plus osimertinib vs platinum-pemetrexed doublet chemotherapy as second-line therapy in patients with stage IIIB/IIIC or IV EGFR-mutant, T790M-negative NSCLC harboring MET amplification

Background: MET amplification can arise as a bypass resistance mechanism to EGFR tyrosine kinase inhibitors (TKIs) and occurs in ~5-26% of EGFR TKI resistant EGFR-mutant non-small cell lung cancer (NSCLC). These patients (pts) have limited treatment options, particularly in the EGFR T790M negative (T790M−) setting. Capmatinib, a MET inhibitor, is approved in more than 10 countries for the treatment of metastatic MET exon 14 skipping NSCLC. In preliminary studies, capmatinib plus EGFR TKIs showed antitumor activity in the post-EGFR TKI, EGFR-mutant NSCLC setting. GEOMETRY-E (NCT04816214) is a randomized, controlled, open-label, multicenter, phase 3 study evaluating the efficacy and safety of capmatinib + osimertinib vs platinum-pemetrexed doublet chemotherapy as second line treatment in the advanced NSCLC setting.

Methods: This ongoing study began enrollment in September 2021 and is recruiting adult pts with stage IIIB/IIIC or IV EGFR-mutant, T790M−, MET-amplified NSCLC who had progressed on either 1st/2nd generation EGFR TKIs, osimertinib or other 3rd generation EGFR TKIs. Pts with neurologically unstable, symptomatic CNS metastases or those requiring increasing doses of steroids ≤2 weeks prior to study entry to manage CNS symptoms are ineligible. This is a 2-part study where Part 1 (initial run-in, ~10 pts) will confirm the recommended dose for the randomized Part 2 and evaluate the safety and tolerability of capmatinib + osimertinib. In Part 1, pts will receive oral capmatinib 400 mg twice daily + osimertinib 80 mg once daily in 21-day cycles. Part 2 will evaluate the efficacy and safety of capmatinib + osimertinib vs platinum (cisplatin/carboplatin)-pemetrexed. Part 2 will enroll ~225 pts, in 2:1 randomization, stratified by the presence of brain metastases (yes/no) and prior treatment with 3rd generation EGFR TKIs (yes/no). In Part 1, the primary endpoint is the incidence of dose limiting toxicities during the first 21 days of treatment. Secondary endpoints include safety; tolerability; pharmacokinetics (PK); investigator-assessed overall response rate (ORR), duration of response (DOR), time to response (TTR), disease control rate (DCR) and progression-free survival (PFS) per the Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1). In Part 2, the primary endpoint is blinded independent review committee (BIRC)-assessed PFS per RECIST 1.1. The key secondary endpoints are ORR by BIRC per RECIST 1.1 and overall intracranial response rate (OiRR) by BIRC per Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM). Other secondary endpoints include DOR, TTR and DCR by BIRC; investigator-assessed PFS after next line of treatment; PK; safety; overall survival; patient-reported outcomes; intracranial DCR, duration of and time to intracranial response by BIRC per RANO-BM.

Citation Format: Yi-Long Wu, Ji-Youn Han, Terufumi Kato, Fabrice Barlesi, Edward B. Garon, Federico Cappuzzo, Yuji Shibata, Nathalie Smith, Sadhvi Khanna, Riccardo Belli, Alejandro Yovine, Daniel Tan. Capmatinib plus osimertinib vs platinum-pemetrexed doublet chemotherapy as second-line therapy in patients with stage IIIB/IIIC or IV EGFR-mutant, T790M-negative NSCLC harboring MET amplification [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 CT559.

Capmatinib plus osimertinib versus platinum-pemetrexed doublet chemotherapy as second-line therapy in patients with stage IIIb/IIIc or IV EGFR-mutant, T790M-negative NSCLC harboring MET amplification

TPS9153

Background: MET amplification can arise as a bypass resistance mechanism to EGFR tyrosine kinase inhibitors (TKIs) and occurs in ̃5-26% of EGFR TKI resistant EGFR-mutant non-small cell lung cancer (NSCLC). These patients (pts) have limited treatment options, particularly in the EGFR T790M negative (T790M−) setting. Capmatinib, a MET inhibitor, is approved in about ten countries for the treatment of metastatic MET exon 14 skipping NSCLC. In preliminary studies, capmatinib plus EGFR TKIs showed antitumor activity in the post-EGFR TKI, EGFR-mutant NSCLC setting. GEOMETRY-E (NCT04816214) is a randomized, controlled, open-label, multicenter, phase 3 study evaluating the efficacy and safety of capmatinib + osimertinib vs platinum-pemetrexed doublet chemotherapy as second line treatment for advanced NSCLC. Methods: This ongoing study began enrollment in September 2021 and is recruiting adult pts with stage IIIB/IIIC or IV EGFR-mutant, T790M−, MET-amplified NSCLC who had progressed on either 1st/2nd generation EGFR TKIs, osimertinib or other 3rd generation EGFR TKIs. Pts with neurologically unstable, symptomatic CNS metastases or those requiring increasing doses of steroids ≤2 weeks prior to study entry to manage CNS symptoms are ineligible. This is a 2-part study where Part 1 (initial run-in,̃10 pts) will confirm the recommended dose for the randomized Part 2 and evaluate the safety and tolerability of capmatinib + osimertinib. In Part 1, pts will receive oral capmatinib 400 mg twice daily + osimertinib 80 mg once daily in 21-day cycles. Part 2 will evaluate the efficacy and safety of capmatinib + osimertinib vs platinum (cisplatin/carboplatin)-pemetrexed. Part 2 will enroll ̃225 pts, in 2:1 randomization, stratified by the presence of brain metastases (yes/no) and prior treatment with 3rd generation EGFR TKIs (yes/no). In Part 1, the primary endpoint is the incidence of dose limiting toxicities during the first 21 days of treatment. Secondary endpoints include safety; tolerability; pharmacokinetics (PK); investigator-assessed overall response rate (ORR), duration of response (DOR), time to response (TTR), disease control rate (DCR) and progression-free survival (PFS) per the Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1). In Part 2, the primary endpoint is blinded independent review committee (BIRC)-assessed PFS per RECIST 1.1. The key secondary endpoints are ORR by BIRC per RECIST 1.1 and overall intracranial response rate (OiRR) by BIRC per Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM). Other secondary endpoints include DOR, TTR and DCR by BIRC; investigator-assessed PFS after next line of treatment; PK; safety; overall survival; patient-reported outcomes; intracranial DCR, duration of and time to intracranial response by BIRC per RANO-BM. Clinical trial information: NCT04816214.

The role of echocardiography in the diagnosis of adult patients with myocarditis: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Transthoracic echocardiography (TTE) plays a key diagnostic role in the initial work-up of patients presenting with myocarditis. Its utility in myocarditis is for identification of structural and functional changes, which may assist with diagnosis, surveillance and prognostication.

Purpose

The purpose of this systematic review and meta-analysis was to appraise the evidence associated with the use of echocardiography for the diagnosis of myocarditis in adults.

Methods

A systematic literature search of medical databases including Pubmed, Ovid Online, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, Scopus, ProQuest, Science Direct and grey literature was performed using PRISMA principles to identify all relevant TTE studies on myocarditis in adult patients (1995-2020; English only; PROSPERO registration CRD42021243598). Data for a range of TTE parameters were individually extracted and then meta-analysed using a random-effects model for overall effect size through standard mean difference (SMD).

Results

Of the 13 relevant studies, 6 were included and revealed that myocarditis can be reliably differentiated from healthy controls, both in the acute and sub-acute phase by left ventricular (LV) global longitudinal strain, and less so by LV ejection fraction and LV end-diastolic volume (p &lt; 0.05 for all). See Table. LV-GLS demonstrated the strongest ability to discriminate myocarditis patients from healthy controls when compared to standard two-dimensional measures of LV size and function (p &lt; 0.05).

Conclusions

LV-GLS demonstrated the best discriminatory ability for differentiation of myocarditis from adult healthy controls. Further research is required to characterize the utility of these quantitative parameters in the diagnostic work-up of these patients. Abstract Figure.

LV-GLS is a predictor of all-cause death and cardiovascular MACE events in patients with neuro-immunological disorders

Background

Neuro-immunological disorders encompass several disease states, including multiple sclerosis (MS), autoimmune encephalitis (AE) and myasthenia gravis (MG). These autoimmune conditions are mediated via pro-inflammatory cytokines, and there is growing evidence to suggest cardiovascular involvement within these inflammatory states. Left ventricular global longitudinal strain (LV-GLS) is proposed to be a more sensitive measure of LV systolic function when compared to standard two-dimensional measures such as LV ejection fraction (LVEF).

Purpose

The purpose of this study was to assess for subclinical cardiac dysfunction in a cohort of patients with neuro-immunological disorders and correlate this with the development of outcomes on follow-up.

Methods

Consecutive patients with MS, AE and MG admitted to our institution during 2013–2020 were assessed (n=102). Patients without pre-existing cardiovascular disease, LVEF &lt;50% or lack of comprehensive transthoracic echocardiography during their index admission were included (n=55). This group was compared to age- and gender-matched controls (n=55) LV-GLS was measured offline using vendor-independent software (TomTec Arena, Germany v4.6) by two cardiologists blinded to the patient group or outcomes. These patients were followed for up for the composite outcome of all-cause death and major adverse cardiovascular events (MACE).

Results

A total of 55 patients (31 MS, 14 AE and 10 MG) were age- and gender- matched to 55 controls. There was no significant difference in baseline demographic characteristics or cardiovascular risk factors between groups. Patients with neuro-immunological disorders demonstrated impaired LV-GLS (−17.6±3.5 vs −20.8±1.9; p&lt;0.01) when compared to healthy controls, despite an LVEF within the normal range (60.9±7.7 vs 64.1±5.7; p=0.02) in both groups. There were a total of 9 (16.4%) outcomes during a mean follow-up of 41.0±33.0 months. LV-GLS was the only significant echocardiographic predictor of all-cause death and MACE events (p=0.013) on multi-variate analysis.

Conclusions

Our results suggest that patients with neuro-immunological disorders have subclinical LV dysfunction as assessed by LV-GLS which has prognostic capacity in this population. Further larger studies are required to further characterize this phenomenon.

Funding Acknowledgement

Type of funding sources: None.

Patients with rare autoimmune inflammatory disorders demonstrate sub-clinical left ventricular dysfunction

Background

ANCA-associated Vasculitis (AAV) and inflammatory myositis (IM) are rare inflammatory autoimmune disorders mediated via pro-inflammatory cytokines and result in a systemic inflammatory state with multi-organ involvement. There is growing evidence to suggest cardiovascular involvement within these inflammatory states. Left ventricular global longitudinal strain (LV-GLS) is proposed to be a more sensitive measure of LV systolic function when compared to standard two-dimensional measures such as LV ejection fraction (LVEF).

Purpose

The purpose of this study was to assess for subclinical cardiac dysfunction in these cohorts when compared to controls.

Methods

Consecutive patients with AAV (n=56) and IM (n=68) admitted to our institution during 2013–2021 were assessed. Patients with pre-existing cardiovascular disease, significant renal impairment (eGFR &lt;30mL/min/1.73m2), LVEF &lt;50% or lack of comprehensive transthoracic echocardiography during admission were excluded (n=72). LV-GLS was measured offline using vendor-independent software (TomTec Arena, Germany v4.6).

Results

A total of 52 patients (22 AAV and 30 IM) were age- and gender-matched to 52 controls. In comparison of the two study populations (AAV and IM), patients with AAV had higher rates of renal impairment (p=0.02) but lower rates of interstitial lung disease when compared to IM (p=0.02). There were no differences between the two groups in terms of cardiovascular risk factors, demographics or other laboratory investigations (p&gt;0.05 for all). In comparison to the control population, patients with AAV and IM had higher indexed LV mass and a lower TAPSE, respectively, when compared to controls. These cohorts also demonstrated impaired LV-GLS (−17.7±2.6 vs −20.6±2.4; p&lt;0.01) when compared to healthy controls, despite no differences in LVEF (62.6±7.8 vs 61.8±5.4; p=0.56) between both groups.

Conclusions

Our results suggest that patients with autoimmune inflammatory disorders demonstrate subclinical LV dysfunction which is likely secondary to a chronic inflammatory state.

Funding Acknowledgement

Type of funding sources: None.

A retrospective case-control cohort analysis of comorbidity and health expenditure in hospitalized adults diagnosed with obesity utilizing ICD-10 diagnostic coding

The cost and comorbidity of obesity in hospitalized inpatients, is less known. A retrospective study of patients presenting to a large district hospital in Western Sydney (April 2016-February 2017) using clinical, pathological as well as diagnostic coding data for obesity as per ICD-10. Of 43 212 consecutive hospital presentations, 390 had an obesity-coded diagnosis (Ob, 0.90%), of which 244 were gender and age-matched to a non-obesity coded cohort (NOb). Weight and BMI were higher in the Ob vs NOb group (126 ± 37 vs 82 ± 25 kg; BMI 46 ± 12 vs 29 ± 8 kg/m² , P < .001) with a medical record documentation rate of 62% for obesity among Ob. The Ob cohort had 2-5× higher rates of cardiopulmonary and metabolic complications (P < .001), greater pharmacologic burden, length of stay (LOS, 225 vs 89 hours, P < .001) and stay in intensive care but no differences in the prevalence of mental disorders. Compared with BMI <35 kg/m² , inpatients with BMI >35 kg/m² were 5× more likely to require intensive care (OR 5.08 [1.43-27.3, 95% CI], P = .0047). The initiation of obesity-specific interventions by clinical teams was very low. People with obesity who are admitted to hospital carry significant cost and complications, yet obesity is seldom recognized as a clinical entity or contributor.

Microbiota restoration for recurrent Clostridioides difficile: Getting one step closer every day!

Clostridioides difficile infection (CDI) is an urgent health threat being the most common healthcare-associated infection, and its management is a clinical conundrum. Over 450 000 infections are seen in the United States with similar incidence seen in the rest of the developed world. The majority of infections seen are mild-moderate with fulminant disease and mortality being rare complications seen in the elderly and in those with comorbidities. The most common complication of CDI is recurrent infection with rates as high as 60% after three or more infections. A dilemma in the management of primary and recurrent CDI is testing due to the high sensitivity of the nucleic acid amplification tests such as the polymerase chain reaction, which leads to clinical false positives if patients are not chosen carefully (with symptoms) before testing. A newer testing regimen involving a 2-step strategy is emerging using glutamate dehydrogenase as a screening strategy followed by enzyme immunoassay for the C. difficile toxin. Microbiota restoration therapies are the cornerstone of management of recurrent CDI to prevent future recurrences. The most common modality of microbiota restoration is faecal microbiota transplantation, which has been tainted with heterogeneity and adverse events such as serious infectious transmission. The success rates for recurrence prevention from microbiota restoration therapies are over 90% compared with less than 50% of recurrence prevention with courses of antibiotics. This has led to development and emergence of standardized microbiota restoration therapies in capsule and enema forms. Capsule-based therapies include CP101 (positive phase II results), RBX7455 (positive phase I results), SER-109 (positive phase III results) and VE303 (ongoing phase II trial). Enema-based therapy includes RBX2660 (positive phase III data). This review summarizes the principles of management and diagnosis of CDI and focuses on emerging and existing data on faecal microbiota transplantation and standardized microbiota restoration therapies.

POS0537 TRENDS AND PREDICTORS OF INPATIENT MORTALITY IN PATIENTS WITH CLOSTRIDIODES DIFFICILE INFECTION AMONG THOSE WITH AND WITHOUT RHEUMATOID ARTHRITIS: A NATIONWIDE ANALYSIS

Background:

People with rheumatoid arthritis (RA) have a higher risk of serious infections. The most common nosocomial infection in the United States (US) is Clostridioides difficile infection (CDI) and yet, little is known regarding the impact of comorbid RA on outcomes in persons hospitalized with CDI.

Objectives:

To evaluate the trends over time and predictors of inpatient mortality in hospitalized patients with CDI comparing those with and without RA.

Methods:

We used the National Inpatient Sample (NIS) database, the largest available all-payer database of inpatient hospitalizations in the US. Patients aged ≥18 years admitted with CDI from 2006-2018 were included. Patients with RA were identified using the International Classification of Diseases (ICD) 9 and 10 codes. Categorical variables between CDI patients with and without RA were compared using Chi-squared test. Temporal trends of hospitalization charges, length of stay (LOS) and inpatient mortality were assessed using the Cochrane Armitage test. Predictors of inpatient mortality were assessed using multivariable logistic regression adjusting for: age ≥65, sex, race, presence of RA, and Elixhauser comorbidity index.

Results:

There were 4,396,945 hospitalizations with a discharge diagnosis of CDI in the study period, of which 111,336 (2.5%) had a coexisting diagnosis of RA. Over the study period, the proportion of CDI patients with a diagnosis of RA increased from 1.7% in 2006 to 3.3% in 2018 with a statistically significant trend of rise (p trend<0.001). There were significantly more females in the RA group (78.2%) than without RA (57.5%), p <0.001. RA group was significantly younger (68.0 vs 70.7, P<0.001). Races were similar between the groups.

The inflation-adjusted average charge for hospitalization for CDI without RA was significantly higher than for CDI with RA ($95,863 vs $73,025, p<0.001). There was an increasing trend in inflation-adjusted average charge for hospitalization for both CDI without RA ($76,966 in 2006 to $104,552 in 2018, p<0.001) and CDI with RA ($55,689 in 2006 to $77,295 in 2018, p<0.001). Patients with or without RA had the same median length of stay (LOS) of 7 days. But when trended over time, for patients without RA, the median LOS decreased from 8 days in 2006-08 to 6 days in 2016-18 whereas for patients with RA, the median LOS fluctuated between 6 and 7 days over the course of study period.

CDI patients without RA had a significantly higher mortality over the study period than those with RA (7.8% vs 6.1%, p<0.001). Among non-RA CDI patients, mortality decreased from 9.3% in 2006 to 6.3% in 2018 (p trend <0.001). Hospitalizations of people with CDI and comorbid RA showed an overall decreasing trend (p trend <0.001).

The multivariable analyses found age≥65 was associated with increased inpatient mortality (adjusted odds ratio [aOR], 1.77, 95% confidence interval [CI], 1.73-1.80), whereas a diagnosis of RA was associated with a decreased mortality (aOR 0.86, 95% CI, 0.81-0.91) (Table 1).

Table 1.

Predictors of inpatient mortality

aOR95% C.I. for aORP-valueLowerUpperAge ≥ 651.7651.7301.801<0.001Hospitalization years -Years 2006-2011Ref -Years 2011-20140.7070.6930.721<0.001 -Years 2015-20180.5820.5690.594<0.001Elixhauser Comorbidity Index1.0561.0551.056<0.001Rheumatoid Arthritis0.8590.8100.911<0.001Female0.8700.8550.885<0.001Race -WhiteRef -African American1.0711.0441.099<0.001 -Hispanic1.1441.1081.180<0.001 -Asian/Pacific Islander1.2671.2001.337<0.001 -Native American1.0220.9101.1470.716 -Other races1.2631.2011.329<0.001

aOR = Adjusted Odds Ratio; C.I.= confidence interval

Conclusion:

In this nationwide study, among hospitalized patients with CDI, those with comorbid RA had significantly decreased odds of inpatient mortality than those without RA. Further studies are needed to understand this association.

Figure 1.

Disclosure of Interests:

None declared

A five-year follow-up of untreated patients with chronic lymphocytic leukaemia treated with ofatumumab and chlorambucil: final analysis of the Complement 1 phase 3 trial

The Complement 1 trial investigated the efficacy and safety of ofatumumab + chlorambucil with chlorambucil monotherapy in patients with previously untreated chronic lymphocytic leukaemia (CLL). On long-term follow-up in the chemoimmunotherapy arm vs. the chemotherapy arm there was an estimated 12% (not significant) and 39% risk reduction in overall survival and progression-free survival, respectively. A high rate (61%) of treatment with next-line therapies in both the treatment arms may dilute any potential OS difference and confound the interpretation of the OS results. Addition of ofatumumab to chlorambucil demonstrated clinical benefit and tolerability as a frontline treatment option in patients unfit for fludarabine-containing therapy, with no new safety concerns.

P2468Clinical and cardiac structural differences between paroxysmal and persistent/permanent non-valvular atrial fibrillation

Background

Atrial Fibrillation (AF) is a heterogeneous condition and is traditionally classified by duration (paroxysmal, persistent and permanent). There is a relationship between AF and left atrial (LA) remodeling, with increased likelihood of AF recurrence and maintenance with increasing LA volumes.

Purpose

To assess clinical and cardiac structural differences between the subtypes of AF.

Methods

We examined 1247 (68±13.4y; 50% men) consecutive admissions presenting to our institution with the primary diagnosis of AF. Repeat admissions (n=263) were excluded. Of remaining 984 subjects, a majority had diagnosed paroxysmal (72.2%), with lower numbers of persistent (23.4%) and permanent (4.4%) AF. Echo parameters of cardiac chamber size and function were examined in a subset of subjects with complete echo (n=646) performed during incident hospital admission.

Results

There were significantly higher rates of diabetes mellitus (p=0.03), ischaemic heart disease (IHD; p=0.04) and peripheral vascular disease (PVD; p=0.02) in those with persistent/permanent AF compared to paroxysmal AF. No significant differences in age (p=0.19), BMI (p=0.42), OSA (p=0.05), or hypertension (p=0.76) was noted. There were significant differences in left ventricular (LV) mass and systolic function, LA size and function between the two groups (Table 1). Receiver operator curve analysis revealed that LAEF was a discriminator for persistent/permanent AF with an area under the curve of 0.689 (95% CI, 0.646 to 0.732; p<0.001).

Echo parameters in AF subtype Echocardiographic Parameters Paroxysmal AF (n=433) Persistent and Permanent AF (n=213) Significance (p value) LVEDD (cm) 4.8±3.0 5.0±0.9 0.29 LVESD (cm) 3.3±1.3 3.7±1.1 <0.01 IVS thickness (cm) 1.2±0.7 1.1±0.3 0.44 PW thickness (cm) 1.1±0.7 1.1±0.2 0.77 LV mass (g) 92.3±28.3 108.2±35.3 <0.01 LVEF (%) 56.1±14.1 47.4±16.8 <0.01 LA Expansion Index 89.4±69.1 53.4±40.3 <0.01 Min LA Volume indexed (ml/m2) 18.9±17.2 27.3±20.6 0.01 Max LA Volume indexed (ml/m2) 32.5±19.2 37.7±15.3 <0.01 LAEF (%) 41.8±16.4 31.5±13.6 <0.01

Conclusions

Our results suggest diabetes, IHD and PVD are associated with persistent/permanent AF. Additionally, greater LA remodeling and reduced atrial function was noted in this group, suggestive of an association between duration of AF electrical burden and LA remodeling and function.

P4353Global longitudinal strain is a measure of subclinical left ventricular dysfunction in chronic inflammatory autoimmune conditions

Background

Myocardial deformation indices are proposed to be a more sensitive marker of subclinical dysfunction compared to standard measures of left ventricular (LV) systolic function. We hypothesize that subclinical myocardial dysfunction is present in chronic inflammatory autoimmune diseases such as Systemic Lupus Erythematosus (SLE) and Rheumatoid Arthritis (RA), despite both conditions being mediated by different pro-inflammatory modulators.

Purpose

Identify subclinical myocardial dysfunction through assessment of global longitudinal strain in two different chronic autoimmune conditions, SLE and RA.

Methods

Consecutive patients admitted to our institution with known history of SLE or RA (>1 year disease activity) were examined. Patients with preexisting cardiac disease, LVEF <50% and those without comprehensive transthoracic echocardiograms (TTE) were excluded. Mean longitudinal LV strain was performed offline using vendor-independent software (TomTec v4.6) and compared to age- and gender-matched controls with normal LV function and no history of cardiac disease.

Results

Of the 86 patients examined (mean age 53.01±21.74, 85.4% female), 51 (59.3%) had SLE and 35 (40.7%) had RA. No significant difference in BMI, hypertension, hypercholesterolemia, diabetes, obesity, obstructive sleep apnea and stroke was observed between controls and patients with SLE or RA. While there was no significant difference in LVEF between RA patients and matched controls, there was a significantly lower GLS in the RA cohort. Conversely, patients with SLE had significantly lower LVEF and GLS when compared to matched controls, despite LVEF being in the normal range. See Table 1. Receiver operator curve analysis revealed that mean GLS is a better discriminator for autoimmune disease with an area under the curve of 0.829 (95% CI, 0.77 to 0.89; p<0.01) compared to LVEF with an area under the curve of 0.632 (95% CI, 0.55 to 0.72; p<0.01).

Echocardiographic Parameters SLE (n=51) Controls (n=51) Sig (p value) RA (n=35) Controls (n=35) Sig (p value) LVEDV (mls) 102±30 85±20 <0.01 84±28 89±30 0.43 LVESV (mls) 36±17 29±9 0.02 26±14 30±12 0.24 Biplane LVEF % 59±6 63±4 <0.01 62±6 62±5 0.81 LV Mass (grams/m2) 96±34 72±20 <0.01 79±26 82±23 0.67 LV Mean GLS % 16.7±2.8 21.3±2 <0.01 17.8±1.7 19.1±2.5 0.02

Conclusions

Our results suggest that chronic inflammatory conditions (SLE and RA) are associated with subclinical cardiac dysfunction. Impaired GLS may reflect early myocardial damage and be used as a tool for screening of patients with inflammatory conditions.

Acknowledgement/Funding

None

Long-term follow-up of previously untreated patients (pts) with chronic lymphocytic leukemia (CLL) treated with ofatumumab (OFA) and chlorambucil (CHL): Final analysis of the phase 3 COMPLEMENT 1 trial

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Background: Previously in the COMPLEMENT 1 study, treatment with OFA and CHL in pts with untreated CLL had shown a significant improvement in the progression-free survival (PFS) compared with CHL alone, and was well tolerated. Here, we report the final overall survival (OS) analysis of the 5-year (y) follow-up, updated investigator-assessed PFS and safety from the study. Methods: Untreated pts, not fit for fludarabine-based therapy (due to advanced age or co-morbidities) were randomized 1:1 to OFA+CHL or CHL alone. Pts in OFA+CHL arm received OFA (Cycle 1: 300 mg day (d) 1, 1000 mg d8; subsequent cycles: 1000 mg d1) in addition to CHL (10 mg/m2, d1-7) for 3 to 12 cycles of 28 d each. Pts in CHL arm received CHL only. Results: Overall, 447 pts were randomized to OFA+CHL (n = 221) or CHL (n = 226); 168 (76%) and 164 (73%) pts completed the scheduled treatments, respectively. Baseline characteristics were similar in both arms. The investigator-assessed median PFS was 23.4 months (mos) in the OFA+CHL arm and 14.7 mos in the CHL arm (HR: 0.61 [95% CI 0.49, 0.76], p < 0.001). Median OS could not be estimated for the OFA+CHL arm and was 84.7 mos for the CHL arm (HR: 0.88 [95% CI 0.65, 1.17], p = 0.363). Estimated OS rate (95% CI) at 5 y was 68.5% (61.5%, 74.5%) in the OFA+CHL arm, and 65.7% (58.6%, 71.9%) in the CHL arm. Post-treatment anti-cancer therapy after discontinuation was received by a greater proportion of pts in the CHL (66%) vs. OFA+CHL (56%), and started earlier in the CHL arm (486 d) vs. OFA+CHL (743 d) arm. Overall, 84 (39%) pts in the OFA+CHL, and 99 (44%) pts in the CHL arms died during the study with 5 on-treatment deaths in each group. Grade ≥3 adverse events were seen in 64% and 48% of pts in the OFA+CHL vs. CHL arms, respectively, most common being (≥5% in either arm) neutropenia (26% vs. 15%), thrombocytopenia (5% vs. 10%), pneumonia (9% vs. 5%), and anemia (5% vs. 5%). Conclusions: This 5-y survival follow-up analysis supported the results from primary analysis with an estimated 12% (not significant) and 39% risk reduction in OS and PFS, respectively, in the OFA+CHL arm compared with the CHL arm. No new safety concerns were observed in the OFA+CHL arm. Clinical trial information: NCT00748189.

Faecal microbiota transplantation for eradicating carriage of multidrug-resistant organisms: a systematic review

BACKGROUND

Multidrug-resistant (MDR) microorganism development in the gut is frequently the result of inappropriate antibiotic use. Faecal microbiota transplantation (FMT) restores normal gut microbiota in patients with Clostridium difficile infection. We hypothesized that it may help in decolonizing MDR organisms (MDROs) and in preventing recurrent MDR infections.

OBJECTIVES

To assess FMT efficacy (eradication rate) for decolonizing MDROs and preventing recurrent MDR infections.

DATA SOURCES

Medline, Embase and Web of Science (inception through 11 February 2019).

STUDY ELIGIBILITY CRITERIA

Clinical trials, retrospective studies, case reports and case series.

PARTICIPANTS

Patients with MDR infections or MDRO colonization treated with FMT.

INTERVENTIONS

FMT.

METHODS

Systematic review.

RESULTS

Twenty-one studies (one randomized clinical trial, seven uncontrolled clinical trials, two retrospective cohort studies, two case series, nine case reports) assessing 192 patients were included. Three studies assessed FMT efficacy in preventing MDR infections; 16 assessed its effect on MDRO colonization; two assessed both. Data from 151 patients were included in the final analyses. In studies with low to moderate risk of bias, the eradication rate was 37.5% to 87.5%. Efficacy was similar in studies looking at infection or colonization and did not differ by length of follow-up. No serious adverse events from FMT were reported. Seven patients died of other causes.

CONCLUSIONS

FMT could be used as a treatment for eradicating MDR colonization and possibly preventing recurrent MDR infections, once more supporting efficacy and safety data are available. Larger well-designed randomized controlled trials are needed to further explore this therapy.

Suppressed heat shock protein response in the kidney of exercise-trained diabetic rats

Impaired expression of heat shock proteins (HSPs) and increased oxidative stress may contribute to the pathophysiology of diabetes by disrupted tissue protection. Acute exercise induces oxidative stress, whereas exercise training up-regulates endogenous antioxidant defenses and HSP expression. Although diabetic nephropathy is a major contributor to diabetic morbidity, information regarding the effect of HSPs on kidney protection is limited. This study evaluated the effects of eight-week exercise training on kidney HSP expression and markers of oxidative stress at rest and after acute exercise in rats with or without streptozotocin-induced diabetes. Induction of diabetes increased DNA-binding activity of heat shock factor-1, but decreased the expression of HSP72, HSP60, and HSP90. The inflammatory markers IL-6 and TNF-alpha were increased in the kidney tissue of diabetic animals. Both exercise training and acute exercise increased HSP72 and HSP90 protein levels only in non-diabetic rats. On the other hand, exercise training appeared to reverse the diabetes-induced histological changes together with decreased expression of TGF-beta as a key inducer of glomerulosclerosis, and decreased levels of IL-6 and TNF-alpha. Notably, HSP72 and TGF-beta were negatively correlated. In conclusion, impaired HSP defense seems to contribute to kidney injury vulnerability in diabetes and exercise training does not up-regulate kidney HSP expression despite the improvements in histopathological and inflammatory markers.