Management of human epidermal growth factor receptor inhibitors-related acneiform rash: A position paper based on the first Europe/USA Delphi consensus process

BACKGROUND

There is a need for unified guidance in the management of acneiform rash induced by epidermal growth factor receptor inhibitors (EGFRi) among dermatologists.

OBJECTIVE

To establish unified international guidelines for the management of acneiform rash caused by EGFR inhibitors, based on an experts' Delphi consensus.

METHODS

The initiative was led by five members of the European Academy of Dermatology and Venereology Task Force 'Dermatology for Cancer Patients' who developed a questionnaire that was circulated to a group of 32 supportive oncodermatology experts in Europe, Canada, Argentina, the US States and Asia. The questionnaire consisted of 84 statements in total, regarding diagnosis and treatment of EGFRi-induced acneiform rash. Experts responded to an anonymous 5-point Likert scale survey. The coordinators collected the first-round responses that were checked for consensus (≥75% agreement in positive [agree or strongly agree] or in negative [disagree or strongly disagree] vote). The statements that did not reach strong consensus in the first round were revised, according to experts' feedback, for a second-round survey.

RESULTS

Strong consensus was reached in 75/84 (89.3%) of the statements, whilst moderate consensus was achieved in 6/84 elements. Key points include consideration of low-dose isotretinoin for refractory grade II/III acneiform rash, use of topical steroid-sparing agents like topical pimecrolimus in the maintenance phase and use of doxycycline in either 100 or 200 mg per day as prophylactic treatment. Interestingly, experts did not recommend topical antibiotics, neither for prevention, nor for treatment. Consensus failure in 3/84 objects is mostly related to the lack of robust data on these topics.

CONCLUSION

This consensus offers crucial insights often overlooked by radiotherapists, general practitioners, dermatologists and oncologists, and it is expected to improve the management of oncologic patients treated with EGFRi in different settings and continents.

Decoding oxygen prescriptions: electronic health record documentation versus patient-reported use

BACKGROUND

Long term oxygen therapy (LTOT) is prescribed for hypoxemia in pulmonary disease. Like other medical therapies, LTOT requires a prescription documenting the dosage (flow rate) and directions (at rest, with activity) which goes to a supplier. Communication with patients regarding oxygen prescription (flow rate, frequency, directions), monitoring (pulse oximetry) and dosage adjustment (oxygen titration) differs in comparison with medication prescriptions. We examined the communication of oxygen management plans in the electronic health record (EHR), and their consistency with patient-reported LTOT use.

STUDY DESIGN AND METHODS

A cross-sectional study was conducted in 71 adults with chronic lung disease on LTOT. Physician communication regarding oxygen management was obtained from the EHR. Participants were interviewed on their LTOT management plan. The information from each source was compared.

RESULTS

The study population was, on average, 64 years, two-thirds women, and most used oxygen for over 3 years. Only 45% of both at-rest and with-activity oxygen prescriptions were documented in the Electronic Health Record (EHR). Less than 20% of prescriptions were relayed to the patient in the after-visit summary. Of those with EHR-documented oxygen prescriptions, 44% of patients adhered to prescribed oxygen flow rates. Nearly all patients used a pulse oximeter (96%).

INTERPRETATION

We identified significant gaps in communication of oxygen management plans from provider to patient. Even when the oxygen prescription was clearly documented, there were differences in patient-reported oxygen management. Critical gaps in oxygen therapy result from the lack of consistent documentation of oxygen prescriptions in the EHR and patient-facing documents. Addressing these issues systematically may improve home oxygen management.

Mimics of primary ovarian cancer and primary peritoneal carcinomatosis - A pictorial review

Numerous conditions can mimic ovarian malignancy. Identifying the origin of a pelvic mass or disseminated peritoneal abnormality on imaging is important to ensure that the patient receives optimal management by the appropriate clinical team. Ovarian cancer mimics include infections and other neoplastic processes, for example, actinomycosis, lymphoma, and sarcoma. We will illustrate intraperitoneal and extraperitoneal ovarian and non-ovarian mimics. Primary peritoneal carcinomatosis mimics include processes such as deep infiltrating endometriosis and rare causes such as gliomatosis peritonei and diffuse peritoneal leiomyomatosis. We aim to illustrate the multimodality key imaging appearances of common and rarer types of mimics.

A novel anti-FGFR1 monoclonal antibody OM-RCA-01 exhibits potent antitumor activity and enhances the efficacy of immune checkpoint inhibitors in lung cancer models

Background

Fibroblast growth factor receptor 1 (FGFR1) plays a crucial role in carcinogenesis. Exploring the combination of the novel humanized monoclonal anti-FGFR1 antibody OM-RCA-01 and immunotherapy was intriguing due to involvement of FGFR1 in mechanisms of resistance to checkpoint inhibitors.

Materials and methods

Lung cancer A549, exhibiting distinct levels of FGFR1 expression, were cultured in basic FGF medium with OM-RCA-01 supplementation. The efficacy of antibody monotherapy was validated in a lung cancer xenograft study. To investigate whether OM-RCA-01 could enhance the efficacy of immunotherapy in vitro and in vivo, mixed lymphocyte reaction/Staphylococcal enterotoxin B assays and FGFR1/programmed death-ligand 1-positive patient-derived xenograft model were established.

Results

The antibody effectively suppressed receptor phosphorylation, resulting in inhibited cell proliferation. OM-RCA-01 led to a substantial delay in tumor growth compared to non-specific immunoglobulin G in a xenograft study. The median tumor volume was 1048.5 mm3 and 2174 mm3 in the study and vehicle groups, respectively, representing a twofold difference in favor of the anti-FGFR1 antibody. In vitro, the combination of nivolumab and OM-RCA-01 resulted in higher levels of interferon gamma and interleukin-2 release compared with nivolumab alone. In vivo, pembrolizumab in combination with OM-RCA-01 produced a greater inhibitory effect on tumor growth compared with vehicle and pembrolizumab alone. The curve plateaued, indicating minimal tumor growth from day 16 onwards in the combination group. The OM-RCA-01 demonstrated no toxicity, even at therapeutic doses or higher doses.

Conclusions

Our preclinical studies demonstrate that OM-RCA-01 exhibits robust activity with minimal toxicity. Combining an anti-FGFR1 antibody with a checkpoint inhibitor may enhance the efficacy of both drugs. However, further studies are needed to elucidate the mechanism of this interaction.

Fine mapping of stem rust resistance derived from soft red winter wheat cultivar AGS2000 to an NLR gene cluster on chromosome 6D

The Puccinia graminis f. sp. tritici (Pgt) Ug99-emerging virulent races present a major challenge to global wheat production. To meet present and future needs, new sources of resistance must be found. Identification of markers that allow tracking of resistance genes is needed for deployment strategies to combat highly virulent pathogen races. Field evaluation of a DH population located a QTL for stem rust (Sr) resistance, QSr.nc-6D from the breeding line MD01W28-08-11 to the distal region of chromosome arm 6DS where Sr resistance genes Sr42, SrCad, and SrTmp have been identified. A locus for seedling resistance to Pgt race TTKSK was identified in a DH population and an RIL population derived from the cross AGS2000 × LA95135. The resistant cultivar AGS2000 is in the pedigree of MD01W28-08-11 and our results suggest that it is the source of Sr resistance in this breeding line. We exploited published markers and exome capture data to enrich marker density in a 10 Mb region flanking QSr.nc-6D. Our fine mapping in heterozygous inbred families identified three markers co-segregating with resistance and delimited QSr.nc-6D to a 1.3 Mb region. We further exploited information from other genome assemblies and identified collinear regions of 6DS harboring clusters of NLR genes. Evaluation of KASP assays corresponding to our co-segregating SNP suggests that they can be used to track this Sr resistance in breeding programs. However, our results also underscore the challenges posed in identifying genes underlying resistance in such complex regions in the absence of genome sequence from the resistant genotypes.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Does performing manipulation of nasal bones under local anaesthetic beyond two weeks after injury affect outcomes? A prospective study during the SARS-CoV-2 pandemic

Introduction

ENTUK guidelines recommend that manipulation of nasal bones (MNB) should be performed within 14 days of injury. However, evidence suggests treatment under general anaesthetic remains effective up to 5 weeks after injury. With the SARS-CoV-2 pandemic leading to delays in referral and limited access to theatre, local practice changed to offer delayed MNB under local anaesthetic. This prospective study assesses the effectiveness of MNB delayed until 3 weeks or later from time of injury when performed mostly under local anaesthetic.

Methods

Data was prospectively collected between April and November 2020. All patients referred to ENT with a new nasal bone deformity presenting more than 21 days after injury were included. Demographic information, injury details and patient satisfaction was recorded for each patient.

Results

11 patients were included. Average age was 32.6 years (Range 8-65 years). 10 procedures (91%) were performed under local anaesthetic, with 1 (9%) performed under general anaesthetic. 9 patients (82%) gained complete reduction of the deformity, and 1 patient (9%) gaining partial reduction. 10 patients (91%) patients were satisfied with the cosmetic outcome.

Conclusion

This study supports the small volume of recent literature showing that delayed manipulation of nasal bones is effective and additionally demonstrates that efficacy is maintained when performed under local anaesthetic.

Infant and Parent Outcomes Related to NICU-Based Co-occupational Engagement

Neonatal intensive care unit (NICU) co-occupations may impact parent-infant outcomes. The main objective of this study was to explore relationships between parent and infant outcomes based on whether sensory-based interventions (co-occupations) occurred most often between parent-infant dyads or provider/volunteer-infant dyads. Thirty-five families received the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, which includes education defining specific amounts of sensory exposures for infants to receive each day of NICU hospitalization (with a preference for parent delivery). Infant sensory experiences in the NICU were logged, and dyads were grouped based on who conducted most of the sensory interventions with the infant in the NICU into a Parent-Infant Co-occupation group or Other Administered group. The Parent-Infant Co-occupation group had infants with less lethargy on the NICU Network Neurobehavioral Scale (p = .04), and parents with lower scores on the Parental Stress Scale (p = .003) and State-Trait Anxiety Inventory-state (p = .047). Parent-infant engagement in co-occupations was related to parental mental health and infant neurobehavior.

At-Home Administration of Gantenerumab by Care Partners to People with Early Alzheimer's Disease: Feasibility, Safety and Pharmacodynamic Impact

BACKGROUND

Monoclonal antibodies that target amyloid-beta and remove amyloid plaques can slow cognitive and functional decline in early Alzheimer's disease. Gantenerumab is a subcutaneously administered fully-human anti-amyloid-beta monoclonal antibody with highest affinity for aggregated amyloid-beta. Since the phase 3 GRADUATE trials did not meet the primary endpoint (change from baseline to Week 116 in Clinical Dementia Rating scale - Sum of Boxes), development of gantenerumab in sporadic Alzheimer's disease was stopped and all ongoing trials were terminated early due to sponsor decision. Subcutaneous administration at the clinic or at home by care partner would be an important option for other therapies in this class in order to increase flexibility and reduce overall burden. The insights obtained from the experience with gantenerumab home administration by care partner in the phase 2 GRADUATION trial will serve to guide the ongoing efforts with other anti-amyloid-beta antibodies.

OBJECTIVES

To evaluate the pharmacodynamic effects on brain amyloid load of once weekly subcutaneous administration of gantenerumab and the safety and feasibility of home administration by care partners.

DESIGN

Phase 2, open-label, single arm study.

SETTING

Multicenter trial conducted in 33 sites in 8 countries from November 2020 to March 2023.

PARTICIPANTS

Participants aged 50 to 90 with early symptomatic Alzheimer's disease (mild cognitive impairment/mild dementia due to Alzheimer's disease), and evidence of amyloid positron emission tomography positivity.

INTERVENTION

Participants could receive up to 255 mg gantenerumab once-weekly, administered subcutaneously at site or at home by healthcare professionals or non-healthcare-professional care partners.

MEASUREMENTS

The primary endpoint was the change from baseline to Week 52 and to Week 104 in brain amyloid load as measured by PET centiloid levels. The secondary endpoints were responses to the home administration questionnaire, plasma concentrations and safety.

RESULTS

The overall number of participants enrolled was 192, with a mean (standard deviation) amyloid PET load at baseline of 101.80 (29.80) centiloids. At the time of early study termination by sponsor, 149 participants had valid Week 52 amyloid PET data (primary endpoint), and 12 participants had an early termination PET within the pre-defined time range of Week 104. The mean change in amyloid PET from baseline to Week 52 and Week 104 was -26.19 centiloids (range: -75.6-15.8; n=149) and -35.48 centiloids (range: -63.2--7.0; n=12), respectively. Responses to the home administration questionnaire at Week 52 (n=148) indicated that the majority of care partners (88-97%) considered administration of study drug at home easy (30.4%) or very easy (57.4%), and convenient (25.7%) or very convenient (70.9%). Care partners felt confident (31.1%) or very confident (62.2%) and satisfied (29.7%) or very satisfied (64.9%) with giving the injection at home. Responses by care partners at Week 36 (n=72), Week 76 (n=126) and Week 104 (n=29) and participant (patient) assessment of convenience and satisfaction at these time points were similar. There were no new safety findings associated with gantenerumab administered subcutaneously once weekly at 255 mg or safety issues associated with at-home injections by non-healthcare professional care partners.

CONCLUSIONS

Once-weekly subcutaneous home administration of the anti-amyloid-beta antibody gantenerumab by non-healthcare-professional care partners to participants with early Alzheimer's disease was feasible, safe, well tolerated, and considered as a convenient option by both the care partners and participants with Alzheimer's disease. Although gantenerumab's development has been stopped due to lack of efficacy, this approach has the potential to reduce the frequency of hospital/outpatient clinic visits required for treatment with other anti-amyloid-β antibodies and can increase flexibility of drug administration for people living with Alzheimer's disease and their families.

Commentary on the published position statement regarding the pathogenesis of fetal basal ganglia- thalamic hypoxic-ischaemic injury

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Mediator Kinase Inhibition Impedes Transcriptional Plasticity and Prevents Resistance to ERK/MAPK-Targeted Therapy in KRAS-Mutant Cancers

Acquired resistance remains a major challenge for therapies targeting oncogene activated pathways. KRAS is the most frequently mutated oncogene in human cancers, yet strategies targeting its downstream signaling kinases have failed to produce durable treatment responses. Here, we developed multiple models of acquired resistance to dual-mechanism ERK/MAPK inhibitors across KRAS-mutant pancreatic, colorectal, and lung cancers, and then probed the long-term events enabling survival against this class of drugs. These studies revealed that resistance emerges secondary to large-scale transcriptional adaptations that are diverse and cell line-specific. Transcriptional reprogramming extends beyond the well-established early response, and instead represents a dynamic, evolved process that is refined to attain a stably resistant phenotype. Mechanistic and translational studies reveal that resistance to dual-mechanism ERK/MAPK inhibition is broadly susceptible to manipulation of the epigenetic machinery, and that Mediator kinase, in particular, can be co-targeted at a bottleneck point to prevent diverse, cell line-specific resistance programs.

Use of high-flow nasal oxygen for pregnant women with COVID-19 in the labour ward setting

The presentation and management of SARS-CoV-2 (COVID-19) infection in the obstetric population is affected by the hormonal and mechanical changes of pregnancy. The increased oxygen demands in pregnancy in the face of conventional oxygen therapy, risks of tracheal intubation and discomfort from non-invasive positive pressure ventilation all support the use of high-flow nasal oxygen (HFNO) as an alternative therapy. The lack of published guidance for the use of HFNO has led to the development of local-level guidance based on expert consensus. More evidence exploring the use of HFNO therapy in the pregnant population is required to assist in developing clinical guidelines.

Strong Evidence for ^{9}N and the Limits of Existence of Atomic Nuclei

The boundaries of the chart of nuclides contain exotic isotopes that possess extreme proton-to-neutron asymmetries. Here we report on strong evidence of ^{9}N, one of the most exotic proton-rich isotopes where more than one half of its constitute nucleons are unbound. With seven protons and two neutrons, this extremely proton-rich system would represent the first-known example of a ground-state five-proton emitter. The invariant-mass spectrum of its decay products can be fit with two peaks whose energies are consistent with the theoretical predictions of an open-quantum-system approach; however, we cannot rule out the possibility that only a single resonancelike peak is present in the spectrum.

Assessment of autonomic symptom scales in patients with neurodevelopmental diagnoses using electronic health record data

Background

Sleep disturbances, gastrointestinal problems, and atypical heart rate are commonly observed in patients with autism spectrum disorder (ASD) and may relate to underlying function of the autonomic nervous system (ANS). The overall objective of the current study was to quantitatively characterize features of ANS function using symptom scales and available electronic health record (EHR) data in a clinically and genetically characterized pediatric cohort.

Methods

We assessed features of ANS function via chart review of patient records adapted from items drawn from a clinical research questionnaire of autonomic symptoms. This procedure coded for the presence and/or absence of targeted symptoms and was completed in 3 groups of patients, including patients with a clinical neurodevelopmental diagnosis and identified genetic etiology (NPD, n=244), those with an ASD diagnosis with no known genetic cause (ASD, n=159), and age and sex matched controls (MC, n=213). Symptoms were assessed across four main categories: (1) Mood, Behavior, and Emotion; (2) Secretomotor, Sensory Integration; (3) Urinary, Gastrointestinal, and Digestion; and (4) Circulation, Thermoregulation, Circadian function, and Sleep/Wake cycles.

Results

Chart review scores indicate an increased rate of autonomic symptoms across all four sections in our NPD group as compared to scores with ASD and/or MC. Additionally, we note several significant relationships between individual differences in autonomic symptoms and quantitative ASD traits.

Conclusion

These results highlight EHR review as a potentially useful method for quantifying variance in symptoms adapted from a questionnaire or survey. Further, using this method indicates that autonomic features are more prevalent in children with genetic disorders conferring risk for ASD and other neurodevelopmental diagnoses.

Financial Toxicity and Out-of-Pocket Costs for Patients with Head and Neck Cancer: An Australian Perspective

PURPOSE/OBJECTIVE(S)

Financial toxicity is under-investigated for patients with head and neck cancer (HNC). The aim of this study was to quantify and describe the financial toxicity and out-of-pocket costs for patients with HNC in regional Australia and to consider its relationship with quality of life.

MATERIALS/METHODS

A cross-sectional survey was administered to patients with mucosal HNC who were disease free and 1-3 years after completion of radiotherapy at a regional tertiary hospital in Australia. The survey included questions on socio-demographics, out-of-pocket expenses, and health-related quality of life (HRQoL) measured with the FACT-H&N. Financial toxicity was evaluated using the Financial Index of Toxicity (FIT) survey, which scores financial toxicity on a scale of 0-100 (higher score indicating higher financial toxicity). The relationship between high financial toxicity scores (top quartile) and HRQoL was explored.

RESULTS

Of 57 total patients, 41 (72%) reported out-of-pocket expenses at a median of AU$1,796 (interquartile range AU$2,700) and a maximum of AU$25,050. The overall median FIT score was 13.9 (interquartile range 19.5) and patients with high financial toxicity (n = 14) reported poorer HRQoL (76.5 vs 114.5, p < 0.001). Patients who were not married had a higher financial toxicity score (23.1 vs 11.1, p = 0.01). Similarly, those participants with lower levels of education had higher financial toxicity (19.3 vs 11.1, p = 0.06). Participants with private health insurance were found to have lower rates of financial toxicity (8.3 vs 17.6, p = 0.01). Medications (41%, median AU$400), dietary supplements (41%, median AU$600), travel (36%, median AU$525) and dental (29%, AU$388) were the most common out-of-pocket expenses. Only nineteen patients (33%) reported that a member of their treating team had asked if they have any financial concerns. Participants living in rural locations (> 100km from the hospital) had higher out-of-pocket expenses (AU$2655 vs AU$730, p = 0.01).

CONCLUSION

Financial toxicity is a significant issue for a significant proportion of patients with head and neck cancer which was associated with a reduced HRQoL. All clinicians should consider asking patients with HNC about financial concerns and be aware of what financial support is available in their region. Interventions are required to reduce the burden of financial toxicity for patients with HNC.

The evolution of lung cancer and impact of subclonal selection in TRACERx

Lung cancer is the leading cause of cancer-associated mortality worldwide1. Here we analysed 1,644 tumour regions sampled at surgery or during follow-up from the first 421 patients with non-small cell lung cancer prospectively enrolled into the TRACERx study. This project aims to decipher lung cancer evolution and address the primary study endpoint: determining the relationship between intratumour heterogeneity and clinical outcome. In lung adenocarcinoma, mutations in 22 out of 40 common cancer genes were under significant subclonal selection, including classical tumour initiators such as TP53 and KRAS. We defined evolutionary dependencies between drivers, mutational processes and whole genome doubling (WGD) events. Despite patients having a history of smoking, 8% of lung adenocarcinomas lacked evidence of tobacco-induced mutagenesis. These tumours also had similar detection rates for EGFR mutations and for RET, ROS1, ALK and MET oncogenic isoforms compared with tumours in never-smokers, which suggests that they have a similar aetiology and pathogenesis. Large subclonal expansions were associated with positive subclonal selection. Patients with tumours harbouring recent subclonal expansions, on the terminus of a phylogenetic branch, had significantly shorter disease-free survival. Subclonal WGD was detected in 19% of tumours, and 10% of tumours harboured multiple subclonal WGDs in parallel. Subclonal, but not truncal, WGD was associated with shorter disease-free survival. Copy number heterogeneity was associated with extrathoracic relapse within 1 year after surgery. These data demonstrate the importance of clonal expansion, WGD and copy number instability in determining the timing and patterns of relapse in non-small cell lung cancer and provide a comprehensive clinical cancer evolutionary data resource.

Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa

BACKGROUND

Up to a quarter of inpatients in high-income countries (HICs) self-report beta-lactam allergy (BLA), which if incorrect,increases the use of alternative antibiotics, worsening individual health outcomes and driving bacterial resistance. In HICs, up to 95% ofself-reported BLAs are incorrect. The epidemiology of BLA in low- and middle-income African countries is unknown.

OBJECTIVES

To describe the epidemiology and de-labelling outcomes of self-reported BLA in hospitalised South African (SA) patients.

METHODS

Point-prevalence surveys were conducted at seven hospitals (adult, paediatric, government and privately funded, district andtertiary level) in Cape Town, SA, between April 2019 and June 2021. Ward prescription records and in-person interviews were conductedto identify and risk-stratify BLA patients using the validated PEN-FAST tool. De-labelling was attempted at the tertiary allergy clinic atGroote Schuur Hospital.

RESULTS

A total of 1 486 hospital inpatients were surveyed (1 166 adults and 320 children). Only 48 patients (3.2%) self-reported a BLA,with a higher rate in private than in government-funded hospitals (6.3% v. 2.8%; p=0.014). Using the PEN-FAST tool, only 10.4% (n=5/48)of self-reported BLA patients were classified as high risk for true penicillin hypersensitivity. Antibiotics were prescribed to 70.8% (n=34/48)of self-reported BLA patients, with 64.7% (n=22/34) receiving a beta-lactam. Despite three attempts to contact patients for de-labelling atthe allergy clinic, only 3/36 underwent in vivo testing, with no positive results, and 1 patient proceeded to a negative oral challenge.

CONCLUSION

Unlike HICs, self-reported BLA is low among inpatients in SA. The majority of those who self-reported BLA were low risk fortype 1 hypersensitivity, but outpatient de-labelling efforts were largely unsuccessful.