Effect of Hepatic Impairment on the Pharmacokinetics of Nirmatrelvir/Ritonavir, the First Oral Protease Inhibitor for the Treatment of COVID-19

Nirmatrelvir, a novel, potent, orally bioavailable severe acute respiratory syndrome coronavirus 2 main protease inhibitor, coadministered with ritonavir for pharmacokinetic (PK) enhancement is licensed for the treatment of mild to moderate COVID-19 in individuals at increased risk of progression to severe disease. Cytochrome P450 3A4 is the primary metabolic enzyme responsible for nirmatrelvir metabolism; however, when cytochrome P450 3A4 is inhibited by ritonavir, nirmatrelvir is primarily excreted, unchanged, in urine. Because of intended use of nirmatrelvir among individuals with hepatic impairment, this Phase 1 study (NCT05005312) evaluated the effects of hepatic impairment on nirmatrelvir PK parameters to assess the potential need for any dose adjustments in this population. Participants with normal hepatic function or moderate hepatic impairment (n = 8 each) were administered a single 100-mg nirmatrelvir dose, with 100 mg of ritonavir administered 12 hours before, together with, and 12 and 24 hours after nirmatrelvir. Nirmatrelvir median plasma concentrations and systemic exposure measured by area under the plasma concentration-time curve from time zero extrapolated to infinite time and maximum observed plasma concentration values were comparable in both groups. Nirmatrelvir/ritonavir had an acceptable safety profile in both groups, and no clinically significant changes in laboratory measurements, vital signs, or electrocardiogram assessments were observed. Based on these results, no dose adjustment is deemed necessary in patients with moderate hepatic impairment and, by extension, in patients with mild hepatic impairment.

Safety, Tolerability, and Pharmacokinetics of Single and Multiple Ascending Intravenous Infusions of PF-07304814 (Lufotrelvir) in Participants Hospitalized With COVID-19

BACKGROUND

An urgent need remains for antiviral therapies to treat patients hospitalized with COVID-19. PF-07304814-the prodrug (lufotrelvir) and its active moiety (PF-00835231)-is a potent inhibitor of the SARS-CoV-2 3CL protease.

METHOD

Eligible participants were 18 to 79 years old and hospitalized with confirmed COVID-19. This first-in-human phase 1b study was designed with 2 groups: single ascending dose (SAD) and multiple ascending dose (MAD). Participants could receive local standard-of-care therapy. In SAD, participants were randomized to receive a 24-hour infusion of lufotrelvir/placebo. In MAD, participants were randomized to receive a 120-hour infusion of lufotrelvir/placebo. The primary endpoint was to assess the safety and tolerability of lufotrelvir. The secondary endpoint was to evaluate the pharmacokinetics of lufotrelvir and PF-00835231.

RESULTS

In SAD, participants were randomized to receive 250 mg lufotrelvir (n = 2), 500 mg lufotrelvir (n = 2), or placebo (n = 4) by continuous 24-hour infusion. In MAD, participants were randomized to receive 250 mg lufotrelvir (n = 7), 500 mg lufotrelvir (n = 6), or placebo (n = 4) by continuous 120-hour infusion. No adverse events or serious adverse events were considered related to lufotrelvir. At doses of 250 and 500 mg, concentrations for the prodrug lufotrelvir and active moiety PF-00835231 increased in a dose-related manner. Unbound concentrations of the lufotrelvir active metabolite reached steady state approximately 2- and 4-fold that of in vitro EC90 following 250- and 500-mg doses, respectively.

CONCLUSIONS

These safety and pharmacokinetic findings support the continued evaluation of lufotrelvir in clinical studies. Clinical Trials Registration. ClinicalTrials.gov NCT04535167.

Efficacy and safety of topical brepocitinib cream for mild-to-moderate chronic plaque psoriasis: a phase IIb randomized double-blind vehicle-controlled parallel-group study

BACKGROUND

Plaque psoriasis (PsO) is an inflammatory skin disease driven, in part, by the activation of Janus kinase (JAK) signalling pathways.

OBJECTIVES

To assess the efficacy and safety of multiple doses of topical brepocitinib, a tyrosine kinase 2/JAK1 inhibitor, in participants with mild-to-moderate PsO.

METHODS

This phase IIb multicentre randomized double-blind study was conducted in two stages. In stage 1, participants received one of eight treatments for 12 weeks: brepocitinib 0.1% once daily, 0.3% once or twice daily, 1.0% once or twice daily, 3.0% once daily, or vehicle once or twice daily. In stage 2, participants received brepocitinib 3.0% twice daily or vehicle twice daily. The primary endpoint was the change from baseline in Psoriasis Area and Severity Index (PASI) score at week 12, analysed using analysis of covariance. The key secondary endpoint was the proportion of participants who achieved a Physician Global Assessment response [score of clear (0) or almost clear (1) and an improvement of ≥ 2 points from baseline] at week 12. Additional secondary endpoints included the difference vs. vehicle in change from baseline in PASI, using mixed-model repeated measures, and the change from baseline in Peak Pruritus Numerical Rating Scale at week 12. Safety was monitored.

RESULTS

Overall, 344 participants were randomized. Topical brepocitinib did not result in statistically significant changes compared with respective vehicle controls in the primary or key secondary efficacy endpoints for any dose group. At week 12, least squares mean change from baseline in PASI score ranged from -1.4 to -2.4 for the brepocitinib once-daily groups vs. -1.6 for vehicle once daily, and from -2.5 to -3.0 for the brepocitinib twice-daily groups vs. -2.2 for vehicle twice daily. From week 8, change from baseline in PASI score separated from vehicle in all brepocitinib twice daily groups. Brepocitinib was well tolerated, with adverse events (AEs) occurring at similar rates across groups. One participant in the brepocitinib 1.0% once-daily group developed a treatment-related AE of herpes zoster in the neck area.

CONCLUSIONS

Topical brepocitinib was well tolerated but did not result in statistically significant changes compared with vehicle when administered at the doses evaluated to treat signs and symptoms of mild-to-moderate PsO.

Efficacy and safety of topical brepocitinib for the treatment of mild-to-moderate atopic dermatitis: a phase IIb, randomized, double-blind, vehicle-controlled, dose-ranging and parallel-group study

BACKGROUND

Atopic dermatitis (AD) is a prevalent inflammatory, pruritic skin disease. The Janus kinase (JAK) pathway is a treatment target.

OBJECTIVES

To assess the efficacy, safety and pharmacokinetics of topical cream brepocitinib, a small-molecule tyrosine kinase 2 (TYK2)/JAK1 inhibitor, in participants with mild-to-moderate AD.

METHODS

In this phase IIb, double-blind, dose-ranging study, participants were randomized to receive one of eight treatments for 6 weeks: brepocitinib 0·1% once daily (QD), 0·3% QD or twice daily (BID), 1·0% QD or BID, 3·0% QD, or vehicle QD or BID. The primary endpoint was the percentage change from baseline in the Eczema Area and Severity Index (EASI) total score at week 6. Adverse events (AEs) were monitored.

RESULTS

Overall, 292 participants were enrolled and randomized. The brepocitinib 1% QD and 1% BID groups achieved statistically significantly greater (with multiplicity-adjusted P < 0·05 due to Hochberg's step-up method) percentage reductions from baseline in EASI total score at week 6 [least squares mean (90% confidence interval, CI): QD: -70·1 (-82·1 to -58·0); BID: -75·0 (-83·8 to -66·2)] compared with respective vehicle [QD: -44·4 (-57·3 to -31·6); BID: -47·6 (-57·5 to -37·7)]. There was not a dose-dependent trend in AE frequency, and there were no serious AEs or deaths.

CONCLUSIONS

Topical brepocitinib is effective and well tolerated in participants with mild-to-moderate AD. What is already known about this topic? Janus kinase (JAK) inhibitors are in development for treatment of atopic dermatitis (AD). The tyrosine kinase 2 and JAK 1 inhibition by brepocitinib may bring a new profile for topical JAK inhibitors for treatment of mild-to-moderate AD. What does this study add? Topical brepocitinib can provide rapid, effective symptom reduction, and could offer a novel alternative to current topical treatments for mild-to-moderate AD.

P-070 Comparison of Microfluidic Sperm Sorting (MFSS) versus Physiological Intracytoplasmic Sperm Injection (PICSI) versus Density Gradient versus Swim Up in high DNA fragmentation index sperm samples

Study question

To evaluate the effectiveness of using Microfluidic Sperm Sorting (MFSS) over other technique in patient with high DNA fragmentation index (DFI) sperm samples?

Summary answer

Microfluidic is not only correlated with better DNA integrity but also with the better reproductive outcome.

What is known already

DNA damage is unrecognisable in living sperm prior to insemination and an increased sperm DNA fragmentation index has been associated with lower fertilization rates, impaired embryo development and reduced pregnancy rates. Standard semen processing techniques are associated with centrifugation, which may induce reactive oxygen species and DNA damage.

In strategies to minimize sperm DNA fragmentation, Physiological ICSI can relatively reduce sperm DNA fragmentation by 67.9% (Parmegiani et al., 2010) while new technique Microfluidic sperm sorter technique also demonstrate sperm selection with significantly reduced DNA damage

Study design, size, duration

A prospective randomised study was conducted from 1st January 2019 to 1st December 2021. Four hundred patients were randomised by computer generated list and divided into 4 groups. Group A (n = 100) , in which sperm were processed by microfluidic sperm sorter (MFSS) while in group B (n = 100), sperm were selected by Physiological Intracytoplasmic Sperm Injection (PICSI), Group C (n = 100), sperm were processed by density gradient and Group D (n = 100), sperm were processed by swim-up technique.

Participants/materials, setting, methods

The study period included all normozoospermic patients with high DNA fragmentation index (&gt;25%) while oligospermic, asthenozoospermic samples, patients with poor ovarian reserve and advanced age were excluded from the study. All A grade embryos were vitrified and transferred in frozen embryo replacement cycle. All the 3 groups were compared on the basis of fertilisation rate, day 3 grade A embryo development rate, clinical pregnancy rate and miscarriage rate.

Main results and the role of chance

Cycle characteristics (female age, length of stimulation, gonadotrophin dose, number of oocytes and number of transferred embryos) were similar among all 4 groups.

Among 4 groups, There was a statistically significant increase observed in Group A (Microfluidic Sperm Sorting), day 3 grade A embryo development rate (60% vs. 42% vs. 38% vs. 40%, p-0.016) and clinical pregnancy rate (62% vs. 46% vs. 41% vs 43%, p-0.049), while no statistical significant difference observed in fertilisation rate (82% vs. 78% vs. 76% vs. 78%, p-0.80) comparing group B, group C and group D. But significantly higher miscarriage rate (12% vs. 11% vs. 25%, 12%) observed in density gradient (Group C) technique.

Limitations, reasons for caution

Larger randomised control studies are needed to strengthen these results.

Wider implications of the findings

We have demonstrated that sperm sorted by microfluidic helps in selection of sperm with better DNA integrity over Physiological ICSI, Density Gradient and Swim-up techniues. Using it in routine practice can help in reducing the negative effect of reactive oxygen species and thus improve pregnancy rate and live birth rate.

Trial registration number

MCDH/2019/35

Sex-based differences in program completion and clinical outcomes in patients following outpatient cardiac rehabilitation

Funding Acknowledgements

Type of funding sources: None.

Background

Females have greater reduction in mortality compared to males, following completion of a cardiac rehabilitation (CR) program, yet they continue to have lower referral rates and program completion. Since 1996, a local rehabilitation program has been the main provider of CR in our health zone. A standardized rapid referral program was implemented in 2008 to improve referral rates of hospitalized patients. Since then, the relationship between sex and CR completion is unknown.

Purpose

To evaluate the relationship between sex and CR completion and to evaluate the association between CR completion and clinical outcomes, stratified by sex.

Methods: We included consecutive patients who were referred to CR and who

1) were hospitalized for an acute coronary syndrome (ACS) or stable angina between 2008 and 2016; 2) had angiographic evidence of at least one-vessel coronary disease; and 3) had revascularization with percutaneous intervention, coronary artery bypass or medical management. The outcomes of interest were CR completion, anxiety and depression categories, exercise capacity, death, and need for revascularization. Logistics regression models were used to determine the association between sex and CR completion. The association between sex, CR completion, and the outcomes of interest were assessed using multivariable cox proportional hazards models.

Results

A total of 726 females and 2645 males were included in this study. The rate of CR completion was lower in females compared to males (64.6% vs 69.98%, p = 0.006). Following adjustment for baseline characteristics, female sex independently predicted lower rates of CR completion, OR 0.81 (95%CI 0.67-0.97).

Both sexes displayed improvements in peak metabolic equivalents (METs) achieved during exercise testing (W: initial 5.99 ± 1.93; 12-week 7.22 ± 1.92; M: initial 7.62 ± 2.04; 12-week 8.81 ± 1.93, p = 0.001). Amongst CR completers, one-year mortality was similar between sex (W: 1.84% vs M: 3.27%, p = 0.118), as was revascularization (W: 14.29% vs M: 11.97%, p = 0.193), however both sexes had higher one-year mortality in CR non-completers.

Conclusion

Despite a standardized CR referral protocol, a sex-difference in CR completion remains. In CR completers, one-year mortality and revascularization was similar in both sexes, however mortality was higher in CR non-completers. Our study suggests that addressing the causes of female CR non-completion following ACS or stable angina may improve outcomes.

Outcomes by CR Completion and Sex All NC (n = 1051) W-NC (n = 257) M-NC (n = 794) p-value All C (n = 2320) W-C (n = 469) M-C (n = 1851) p-value Revascularization-1 year (%) 146 (14.94) 28 (11.72) 118 (15.59) 0.107 267 (12.44) 62 (14.29) 205 (11.97) 0.193 Death-1 year (%) 67 (6.86) 19 (7.95) 48 (6.50) 0.442 64 (2.98) 8 (1.84) 56 (3.27) 0.118 W = Women;M = Men;NC = Non-Completers;C = Completers

Supercritical carbon dioxide drying of municipal sewage sludge - Novel waste-to-energy valorization pathway

Eighty percent of the world's wastewater is discharged back into nature without reuse and further treatment and solid byproduct of wastewater is either spread on land or landfilled. The valorization of municipal sewage sludge for energy use is a major opportunity for sustainable energy applications. This includes effective dewatering and drying of the sludge in addition to producing biogas during the anaerobic digestion. Supercritical CO 2 extraction process was investigated for the purpose of drying municipal sewage sludge. Remarkably our results showed that after sCO2 processing the higher heating value (HHV) of sludge at wet basis moisture content of 52% was 14 MJ/kg and thus higher than the HHV of brown coal with similar moisture level (12 MJ/kg). Our research also shows that under specific conditions sCO2 extraction reduces the moisture content of the municipal sludge from 89% to 53% in 15 min. Although, more research is needed this dewatering process could be considerably less energy intensive than conventional thermal and other drying processes. Another benefit is extraction of micro pollutants by sCO₂ treatment and thus making the dried sludge more useable in energy applications as per regulations. Our results show an alternative and novel pathway for highly effective dewatering and drying of municipal and other types of sludge.

Practical consensus recommendations on Her2 +ve breast cancer with solitary brain mets

Breast cancer is a common cause of brain metastases, with metastases occurring in at least 10-16% of patients. Longer survival of patients with metastatic breast cancer and the use of better imaging techniques are associated with an increased incidence of brain metastases. Current therapies include surgery, whole-brain radiation therapy, stereotactic radiosurgery, chemotherapy and targeted therapies. However, the timing and appropriate use of these therapies is controversial and careful patient selection by using available prognostic tools is extremely important. Expert oncologist discussed on the mode of treatment to extend the OS and improve the quality of life ofHER2-positivebreast cancer patients with Solitary brain metastases. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations for tumor margins and breast conservative surgery

My suggestion: There is no difference in survival of breast cancer patients treated with either mastectomy or with breast conservation therapy combined with external beam radiotherapy. A positive margin (s) is an important factor contributing to the increased risk of local recurrence. However, in published literature, there is a lack of consensus on the definition of acceptable margin (s). As a result decision process about need for re-excision after positive margins remains uncrear.

Practical consensus recommendations regarding the management of HER2 neu positive metastatic breast cancer

Metastatic breast cancer (MBC) is cancer that has spread from the breast to another part of the body or has come back in another distant location. Treatment options for MBC depend on several factors, including where the cancer has spread, the patient's overall health, and the levels of hormone receptors and HER2 in the tumour. Over-expression of HER2 is generally considered to be a negative prognostic feature because it accompanies an increase in breast cancer mortality. However, the development of agents that specifically target HER2 has improved the management of patients with these tumours.^{[7],[8],[9],[10]} This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of these agents and the management of HER2 positive MBC for the benefit of community oncologists.

Practical consensus recommendations on fertility preservation in patients with breast cancer

Young women diagnosed with cancer today have a greater chance of long-term survival than ever before. Successful survivorship for this group of patients includes maintaining a high quality of life after a cancer diagnosis and treatment; however, lifesaving treatments such as chemotherapy, radiation, and surgery can impact survivors by impairing reproductive and endocrine health. Expert oncologists along with reproductive medicine specialists discuss fertility preservation options in this chapter since fertility preservation is becoming a priority for young women with breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations regarding the management of sentinel lymph node issues in early breast cancer

Axillary lymph node involvement is a very important poor prognostic factor in the clinical staging and management of breast cancer patients. Traditionally, axillary lymph node dissection (ALND) has been used for determining the status of the axillary lymph nodes. More recently the sentinel lymph node biopsy (SLNB) procedure has gained wider acceptance as the standard of care, having the advantage of being less invasivewhile providing good accuracy. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of the two different procedures and other issues in patients with early breast cancer for the benefit of community oncologists.

Practical consensus recommendations regarding role of mastectomy in metastatic breast cancer

Whether to recommend mastectomy in metastatic disease or not has been a matter of debate. Is local therapy, such as mastectomy, of any benefit in advanced breast cancer is the main question. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations regarding role of postmastectomy radiation therapy

The use of radiation therapy after mastectomy (PMRT) has been limited to those patients who are at significant risk of cancer recurring in the chest wall or in the nodal basins. The use of PMRT has been widely accepted for patients with four or more positive lymph nodes,^[1],[2] but there is still controversy regarding the value of PMRT for those with one to three positive nodes. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations for neo-adjuvant chemotherapy in triple negative breast cancer

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to use neoadjuvant chemotherapy in triple negative breast cancer patients.

Practical consensus recommendations for gestational breast cancer

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to manage gestational breast cancer.

Practical consensus recommendaton for adjuvant bone-modifying agents in breast cancer

Bone-modifying therapy is a primary research interest in breast cancer. Several features contribute to the importance of the bone environment in the management of breast cancer. Firstly, bone metastases represent the most common site of breast cancer metastases and secondly, the emergence of cancer treatment-induced bone loss (CTIBL) among breast cancer survivors and patients is of increasing concern. In the adjuvant setting, bisphosphonates can be given to prevent and treat tumor therapy-induced bone loss in premenopausal and postmenopausal women and, owing to their beneficial effect on bone turnover, have also been evaluated for prevention of bone metastases occurrence. Expert oncologists discusses on the update on the approaches of Bone-modifying Agents and its treatment options. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations on ovarian suppression in early breast cancer (adjuvant)

Substantial survival benefits exist for patients with early-stage breast cancer who undergo treatment with single-modality ovarian suppression, but its value is uncertain. Expert oncologist discussed to determine whether additional benefits exist with ovarian suppression plus multiple adjuvant therapy which provides a new treatment option that reduces the risk of recurrence in early breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations on management of HR + ve early breast cancer with specific reference to genomic profiling

Breast cancer is a heterogeneous disease and patients are managed clinically based on ER, PR, HER2 expression, and key risk factors. The use of gene expression assays for early stage disease is already common practice. These tests have found a place in risk stratifying the heterogeneous group of stage I–II breast cancers for recurrence, for predicting chemotherapy response, and for predicting breast cancer-related mortality. Most guidelines for hormone receptor (HR)–positive early breast cancer recommend addition of adjuvant chemotherapy for most women, leading to overtreatment, which causes considerable morbidity and cost. Expert oncologist discussed about strategies of gene expression assays and aid in chemotherapy recommendations for treatment of HR + ve EBC and the expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations regarding the management of hormone receptor positive early breast cancer in elderly women

Breast cancer is a leading cause of death among women, and its incidence increases with age. Currently the treatment of breast cancer in older patients is almost identical to their younger counterparts. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists regarding the management of early breast cancer specifically in elderly women.

Practical consensus recommendations regarding the use of hormonal therapy in metastatic breast cancer

Metastatic breast cancer (MBC) is cancer that has spread from the breast to another part of the body or has come back in another distant location. Treatment options for MBC depend on several factors. One of these factors is the levels of hormone receptors (HRs) in the tumor. Cancers with high levels of HRs, called HR-positive, use the hormones estrogen and progesterone to grow and spread. Hormonal therapy is a type of treatment specifically for HR-positive breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of hormonal therapy and the management of HR-positive MBC for the benefit of community oncologists.

Practical consensus recommendations on duration of adjuvant hormonal therapy in breast cancer

Optimization of adjuvant systemic therapy in women with early-stage hormone receptor-positive breast cancer includes the consideration of chemotherapy and duration of hormone therapy. Adjuvant hormonal therapy significantly improves long-term survival of breast cancer patients with hormone receptor-positive disease. Despite the proven clinical efficacy of tamoxifen and aromatase inhibitors, many breast cancer survivors either fail to take the correct dosage at the prescribed frequency (adherence) or discontinue therapy (persistence). Expert oncologist discussed on the duration of adjuvant hormonal therapy for improvement of OS and quality of life of breast cancer patients by providing reduction in recurrence and mortality. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Predictors of major bleeding following an acute coronary event: insights from a national study of 5,116 consecutive patients in clinical practice

Background

Major bleeding after acute coronary syndrome (ACS) predicts a poor outcome. Although predictors of major bleeding following ACS have been validated, these have been mostly in clinical trial populations and few contemporary analyses have been undertaken in clinical practise

Methods

Major bleeding was assessed in a national study of ACS and antiplatelet choice. A total of 5116 consecutive patients [Clopidogrel (n 2,491, 2011–13) and Ticagrelor (n 2,625, 2013–16)] were enrolled in 5 UK hospitals. Clinical outcomes were identified from a national coding database (n=59.5 million) with bleeding events tracked to 11 health care facilities. Bleed severity was independently adjudicated by 2 consultant cardiologists, blinded to antiplatelet, sequence and year. Bleeding events were categorised using BARC 3–5 and PLATO criteria. A logistic regression analysis was used to define independent predictors of bleeding.

Results

The median age was 68 (IQR57–78, 30.5%&gt;75), 34% were female. 39% underwent PCI and 13% coronary artery bypass surgery. Clinical outcome data was 100% complete. 1-year mortality was 12.9%. Of 1193 icd10 codes for bleeding or anaemia 165 (3.2%) and 193 (3.8%) patients were adjudicated to have suffered a BARC 3–5 and PLATO major bleeding respectively. Independent predictors common between PLATO major and BARC 3–5 bleeding, in the year following ACS, were CRUSADE score &gt;40 (OR 1.63, CI 1.1–2.4, p=0.008) moderate left ventricular systolic dysfunction (OR, 1.65, CI: 1.2–2.4, p=0.006), age (OR per year increase in age 1.03, CI 1.02–1.05, p&lt;0.001) and subsequent coronary artery bypass surgery (OR 2.6, CI 1.8–3.8, p&lt;0.001)

Conclusion

In a broad real-world population of ACS, CRUSADE score &gt;40, incorporating simple clinical and laboratory criteria, remained an independent predictor of major bleeding using 2 internationally recognised bleed criteria

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Liverpool university hospitals; North-West Educational Cardiac Group

Medical education focus in published articles related to COVID-19

OBJECTIVE

The ongoing pandemic of Coronavirus Disease 2019 (COVID-19) has affected >2 million patients with approximately 900,000 cases in the United States alone. Medical education has possibly suffered during this time, due to disease mitigation strategies and stress on both students and teachers. We aimed to quantify the publications describing the impact of COVID-19 on medical education in the early stage of the pandemic.

MATERIALS AND METHODS

Abstract and titles related to COVID-19 listed in PubMed were reviewed for an educational focus. Articles with an educational focus were further evaluated for characteristics of content.

RESULTS

Out of a total of 3641 articles related to COVID-19, only 26 (0.7%) articles had an educational theme. Thirteen articles were pertaining to residency and fellowship education and twelve articles were focused on medical student education. Only one article referred to nursing education.

CONCLUSIONS

Publications pertaining to medical education during the ongoing COVID-19 pandemic are few. There is an urgent need for scholarship to understand the best processes and develop innovative methods that can help improve the educational experience of students and trainees during this extraordinary time.

Representation of specialties in Coronavirus Disease 2019 (COVID-19) research: analysis of published literature in the first 3 months

OBJECTIVE

Coronavirus disease 2019 (COVID-19) has infected more than 1.5 million patients worldwide and is associated with high morbidity and mortality. The volume of research published in a specialty, which may shed light on the perceived impact that a topic plays within that discipline, is unknown for the present pandemic.

MATERIALS AND METHODS

We analyzed all articles published in the first 3 months on COVID-19 and categorized them by journal type and article content.

RESULTS

There was a ~100-fold difference in articles published on COVID when categorized by journal type and ~65-fold difference when grouped by article content.

CONCLUSIONS

There is a wide variation in research published withing various specialties regarding COVID-19. Researchers across specialties need to urgently realize the impact of COVID-19 and publish articles that can help improve understanding of this ongoing pandemic.

Ketogenic diet in endocrine disorders: Current perspectives

Ketogenic diet (KD) is a high-fat, adequate-protein, and low-carbohydrate diet that leads to nutritional ketosis, long known for antiepileptic effects and has been used therapeutically to treat refractory epilepsy. This review attempts to summarize the evidence and clinical application of KD in diabetes, obesity, and other endocrine disorders. KD is usually animal protein based. An empiric vegetarian Indian variant of KD has been provided keeping in mind the Indian food habits. KD has beneficial effects on cardiac ischemic preconditioning, improves oxygenation in patients with respiratory failure, improves glycemic control in diabetics, is associated with significant weight loss, and has a beneficial impact on polycystic ovarian syndrome. Multivitamin supplementations are recommended with KD. Recently, ketones are being proposed as super-metabolic fuel; and KD is currently regarded as apt dietary therapy for "diabesity."

Abstract P3-16-02: Voice of cancer patient: Analysis of breast cancer patients' experience with PARP inhibitors

Background:

Many breast and ovarian cancer patients have germline or somatic mutations in BRCA 1&2 genes. These proteins are important for repairing double-strand DNA breaks by homologous recombinational repair. In patients who have mutations in these genes, PARP is the major alternative for repairing single-strand DNA breaks. PARP inhibitors (PARPi) inhibit PARP, thereby causing cell death by accumulation of damaged DNA in cells. Many PARPi, including Olaparib, have been approved and used in treatment of metastatic ovarian cancer patients with BRCA 1&2 mutation.

Recently, Olaparib was also approved by the FDA for treatment of metastatic breast cancer patients with germline BRCA 1&2 mutation, and many other PARPi are in clinical trial. In this study we analyzed breast cancer patients' awareness, use and experience with PARPi s.

Many patients share their experiences on online forums which contain millions of freely shared messages. These can be used to analyze patient concerns and experiences. However, this data is unstructured and difficult to analyze. We used our automated system VoCP, that uses techniques from Big Data Science and Artificial Intelligence (deep learning, topic modeling, information retrieval, and natural language processing) to analyze these messages.

Methods:

We collected 15.13 million unique messages by 987,189 users from 37 unrestricted cancer forums that provide clinically relevant information. We built custom ontologies for breast cancer, various PARPi, chemotherapy and side effects, and then used our automated system VoCP to extract relevant information from these messages.

Results:

We found 1,536 breast cancer patients discussing PARPi. 459 patients mentioned use of PARPi whereas 706 patients shared the information about PARPi and 196 inquired about them. 176 patients mentioned that they were planning to use PARPi.

76 patients using PARPi mentioned having BRCA 1 or 2 mutation and 1 patient mentioned CHEK 2 mutation. 91 patients mentioned having triple negative cancer.

212 patients mentioned being treated on clinical trial and 10 mentioned being off trial. 162 patients mentioned use of chemotherapy with PARPi and 40 mentioned use of PARPi as single agent.

Specific PARPi: 47 mentioned Olaparib, 104 mentioned Valiparib, & Talazoparib, 6 rucaparib and 4 Niraparib. Most patient just mentioned “PARP inhibitor.” Some patients mentioned iniparib on clinical trial.

Side effects were reported by 60 patients. These include:

· Nausea: 14

· Fatigue: 15

· GI side effect: 7

· Thrombocytopenia: 5

· Anemia: 2

· Neutropenia: 2

· Neuropathy: 5

· Insomnia:2

99 patients mentioned PARPi were “effective,” 21 mentioned they were “somewhat effective” and 36 mentioned they were “ineffective.”

144 patient expressed positive sentiments, 30 patients expressed negative sentiments and 16 patients expressed neutral sentiment for PARPi.

Conclusion:

· There is increasing awareness and curiosity for PARPi in breast cancer patients as more patients are being tested for BRCA and other mutations.

· Among the users, PARPi are generally associated with low toxicity and positive sentiments.

· VoCP reliably provides meaningful insights from the patient's point of view; it also gives insight into unmet needs where more resources and research should be focused.

Citation Format: Aggarwal S, Sharma R, Singh M, Aggarwal A. Voice of cancer patient: Analysis of breast cancer patients' experience with PARP inhibitors [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-16-02.

Abstract P1-10-05: Analysis of genetic mutation in ethnically diverse population with Breast and ovarian cancer: Single institution experience

Only 5-10% of all breast and ovarian cancers have been attributed to inherited mutation. In unselected breast cancer patients, prevalence of germline BRCA 1 & 2 is about 2%. In Ashkenazi Jewish population the prevalence is estimated to be 11.7%. The rate of mutations in other populations has not been well characterized. The purpose of this study is to identify and characterize the risk of genetic mutations in an ethnically diverse population referred for genetic testing according to NCCN guidelines.

Method:

In this single institution retrospective study, we analyzed 782 patients referred for genetic testing between 2009-2018. Information regarding reason for referral, ethnicity, cancer history and results of genetic mutation using multigene panels were collected.

Results:

Reasons for referral were:

· Family History of cancer (142; 18.6%),

· Breast cancer diagnosed at early age (207; 26.4%),

· Triple negative breast cancer (12 ;53%

· Ovarian cancer (61; 7.8%)

· Multiple cancer (32; 4.09%)

· Known BRCA 1 or 2 mutation (51;6.5%)

· Known other mutation (9;1.15%)

· Family h/o cancer but not diagnosed with cancer (268)

Ethnic distribution:

· 328 Hispanic (41.94%)

· 177 Caucasian (22.6%),

· 27 Chinese, (3.4%)

· 52 Vietnamese (6.6%)

· 86 other- Asian (11%)

· 32 Middle eastern (4.1%),

· 14 South Asian (1.8%)

· 35 African American (4.5%)

· 8 Ashkenazi Jewish (1%)

· 19 Mixed Hispanic (2.1%)

Genetic testing was done in 545 /782 patients.

Deleterious Mutation detected: 88 patients (16.5% of tested)

· BRCA 1: 32(5.8%)

· BRCA 2:28 (5.14%)

· MSH2:5(0.9%)

· p53:39 (0.5%)

· PLB2:3 (0.38%)

· MUTYH:3 (0.38%)

· CDH1 :2 (0.26%)

· PMS2: 2 ( 0.26%)

· ATM: 1(0.13%)

· CCKn2A: 1(0.13%)

· CHEK 2: 1(0.13)

· MET:1(0.13%)

· MSH6:1 (0.13%)

· RAD50 :1(0.13%)

· RET1;1(0.13%)

BRCA1/BRCA2 mutation: 60

Mutation in BRCA 1/ 2 distribution by ethnicity:

· Hispanic (28; 8.54 %),

· Chinese (4;14.8%)

· Vietnamese (4; 7.7%)

· other Asian (12;13.9%)

· African American (3, 8.5, %)

· South Asian (0 %)

· Caucasian (8; 4.5 %)

· All Asian (20/165: 12.1%)

Mutation in other gene by Ethnicity: total 26

Hispanic (16, 4.5%), Caucasian: (3, 1.7%) Asian other than Chinese and Vietnamese (4, 4.65%)

Mutation in Breast cancer: 333 Breast cancer patients tested, 39 patients (11.17%) were found to have mutations.

10/32 triple negative (31%) 4/49 her2neu positive patients (8.1%) and 15/252 (5.9%) ER+ patients found to have mutations.

17/39 breast cancer patients with mutation had prophylactic BSO.

Mutation in BRCA 1& 2 by reason for referral:

Known family h/o of BRCA1 or 2 mutations (18; 39.5%)

Early age of cancer (10, 7.4%)

Cancer with positive family history (17, 8.2%)

Triple negative (2, 16%).

Variant of Unknown significance (VUS): 140 patients (25 %)

VUS in BRCA 2 were most common. VUS were found in 17% of Hispanic and African American patients.

No significant difference in PFS and OS was found in patient with mutation and without mutation

Conclusion:

We found much higher rates (16.5%) than previously reported mutation detection in this very highly diverse patient population.

Rate of BRCA 1&2 mutation was 8.55% in Hispanic and 12.1% in Asian patients compared with 4.5% in Caucasian patient when selected for high risk factors.

We Also noted very high rate of VUS especially in Hispanic and African American patients.

Citation Format: Aggarwal S, Chu C, Ngumi M. Analysis of genetic mutation in ethnically diverse population with Breast and ovarian cancer: Single institution experience [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-10-05.

Abstract P2-14-14: Voice of cancer patients (VoCP): Analysis of experiences of cancer patients undergoing breast cancer surgery

Surgery is an important part of breast cancer treatment. Most patients either go for mastectomy or lumpectomy + radiation (i.e., breast conserving surgery, BCS). It is well known that mastectomy and BCS have equal long-term outcomes, and more patients are choosing to get breast reconstruction.

In this study, we analyzed experiences, concerns, complications and side effects in patients who have undergone breast cancer surgery and who shared their views on various online forums. Such forums have millions of freely shared messages and are rich sources of such information. However, this data is unstructured. We used our automated system, VoCP, that used techniques from Big Data science and artificial intelligence (e.g., deep learning, topic modeling, information retrieval, natural language processing) to analyze concerns and experiences of patients undergoing breast cancer surgeries.

Methods: We collected 5.5 million messages from 174556 distinct users in 21 unrestricted breast cancer forums. We built specific ontology for different surgeries, reconstruction, side effects and sentiments and used our system, VoCP, to extract relevant information from these messages.

Results: 52172 users shared 307966 messages regarding surgery and their views are summarized below.

Lumpectomy (BCS):

· 25850 users provided 98499 messages

· 15771 users had lumpectomy and shared 50390 messages

· 3760 users shared 6322 messages with complications

· 2760 users mentioned need for additional surgery

· 1447 users mentioned satisfaction with the outcome whereas 117 were dissatisfied

Mastectomy:

· 37544 users shared 198494 messages

· 22716 users had mastectomy and shared 94595 messages

· 5065 users shared 8983 messages regarding complications

· 2730 patients expressed satisfaction with outcome whereas 286 patients were dissatisfied

Reconstruction:

· 23164 users provided 113568 messages regarding reconstruction

· 9850 users had reconstruction and shared 32472 messages

· 1904 users shared 2734 messages with complication

· 1982 users had immediate reconstruction; 353 users mentioned delayed reconstruction

· 2686 users had autologous tissue reconstruction and 3105 repot implant reconstruction

· Type of Autologous Reconstruction reported : 759 TRAM flap, 296 Diep flap, 820 fat grafting, 108 Latissimus Dorsi flap, 89 SGAP Flap/hip Flap

· 418 users expressed satisfaction whereas 40 were dissatisfied with outcome

Complications reportedComplicationsReconstruction #Lumpectomy #Mastectomy#Overall#Scars1071,5051,4163,028Pain7101,4104052,525Infection2823106521,244Necrosis22951167447Numbness35145369549Lymphedema80136334550Lumps60115196371Seroma56222462740Swelling83290385758Frozen Shoulder3783151271Bleeding 445599Hematoma 178139317Itching/Rash 130253383Anxiety 82145227Blood Clot  6464Bruising  6060Drainage  5454

Conclusions:

· Despite reports of equal long term outcomes between BCS and mastectomy, more patient had mastectomy.

· Scar issues and pain is the most common complication from any surgery.

· Most patients have expressed satisfaction from their chosen surgery.

· VoCP reliably provides meaningful insights from the patient's point of view; it also gives insight into unmet needs where more resources and research should be focused.

Citation Format: Aggarwal S, Sharma R, Bhoemick J, Singh M, Aggarwal A. Voice of cancer patients (VoCP): Analysis of experiences of cancer patients undergoing breast cancer surgery [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-14-14.