Development and validation of a risk score (Delay-7) to predict the occurrence of a treatment delay following cycle 1 chemotherapy

BACKGROUND

The risk of toxicity-related dose delays, with cancer treatment, should be included as part of pretreatment education and be considered by clinicians upon prescribing chemotherapy. An objective measure of individual risk could influence clinical decisions, such as escalation of standard supportive care and stratification of some patients, to receive proactive toxicity monitoring.

PATIENTS AND METHODS

We developed a logistic regression prediction model (Delay-7) to assess the overall risk of a chemotherapy dose delay of 7 days for patients receiving first-line treatments for breast, colorectal and diffuse large B-cell lymphoma. Delay-7 included hospital treated, age at the start of chemotherapy, gender, ethnicity, body mass index, cancer diagnosis, chemotherapy regimen, colony stimulating factor use, first cycle dose modifications and baseline blood values. Baseline blood values included neutrophils, platelets, haemoglobin, creatinine and bilirubin. Shrinkage was used to adjust for overoptimism of predictor effects. For internal validation (of the full models in the development data) we computed the ability of the models to discriminate between those with and without poor outcomes (c-statistic), and the agreement between predicted and observed risk (calibration slope). Net benefit was used to understand the risk thresholds where the model would perform better than the 'treat all' or 'treat none' strategies.

RESULTS

A total of 4604 patients were included in our study of whom 628 (13.6%) incurred a 7-day delay to the second cycle of chemotherapy. Delay-7 showed good discrimination and calibration, with c-statistic of 0.68 (95% confidence interval 0.66-0.7), following internal validation and calibration-in-the-large of -0.006.

CONCLUSIONS

Delay-7 predicts a patient's individualised risk of a treatment-related delay at cycle two of treatment. The score can be used to stratify interventions to reduce the occurrence of treatment-related toxicity.

1362 ANTICHOLINERGIC PRESCRIBING HABITS AND ITS ASSOCIATIONS IN A COMMUNITY POPULATION OF PEOPLE LIVING WITH DEMENTIA

Introduction

Many commonly prescribed medications have inadvertent anticholinergic effects. People with Dementia (PwD) are more vulnerable to these effects and at risk of adverse outcomes, the risk being higher with a greater degree of anticholinergic exposure. We investigated prescribing patterns and Anticholinergic burden (ACB) in a cohort of community-dwelling older adults with dementia and aimed to explore the effect of ACB on cognition, mood, and quality of life(QoL).

Method

The medication and demographic information for 87 (39 female) community-dwelling PwD were obtained from Electronic Care Summaries. We used the German Anticholinergic Burden Scale (GABS) to measure ACB. Additionally, we investigated associations between ACB and cognitive (ADAS-Cog), functional (BADL) and QoL (DemQoL) assessments.

Results

28.7% of participants had a clinically significant score (ACB> 2). The most commonly prescribed medications with ACB were Lansoprazole(18.3%), Mirtazapine(12.6%) and Codeine(12.6%). ACB was higher in males and negatively correlated with age, r(87)=-.21,p=.03. There was no association between ACB and cognition, QoL, functional independence, and neuropsychiatric symptoms. Over six months, PLWD with no ACB had a greater negative change in neuropsychiatric symptoms[t(18)=2.27,p=.04] and functional independence[t(23)=-3.8,p=.001], indicating greater dependence and worsening neuropsychiatric symptoms.

Conclusion

A third of PLWD in the community had clinically significant ACB. No ACB was associated with worsening neuropsychiatric symptoms and functional dependence over a six-month period. Community prescribers should consider regular medication reviews with PLWD and carers to ensure medications are prescribed safely and appropriately.

Validating low-fidelity arthroscopic simulation in medical students: a feasibility trial

INTRODUCTION

With surgical opportunities becoming increasingly restricted for orthopaedic trainees, simulation training is a valuable alternative at providing sufficient practice. This pilot study aims to assess the potential effectiveness of low-fidelity simulation in teaching medical students basic arthroscopic skills and the feasibility of its incorporation into formal student training programmes.

METHODS

Twenty-two medical students completed pre- and post-training tests on the Probing (Task 1) and Maze (Task 2) exercises from the Sawbones 'Fundamentals of Arthroscopy Surgery Training' (FAST) programme. Training consisted of practising horizon control, deliberate linear motion and probing within 25min over a period of days. Completion time and error frequency were measured. The difference in performance was assessed using a paired two-tailed t-test. Qualitative data were collected.

RESULTS

Test completion time decreased significantly by a mean of 83s (±46s, 95% confidence intervals [CI] 37 to 129) for Task 1 (p=0.001) and 105s (±55s, 95% CI 50 to 160) for Task 2 (p=0.0007). Frequency of direct visualisation errors decreased significantly by a mean of 1.0 errors (±1.0 errors, 95% CI 0.1 to 2.0) for Task 1 (p = 0.04) and 0.8 errors (±0.8 errors, 95% CI 0.1 to 1.6) for Task 2 (p = 0.04). At post-training, 82% of participants were willing to incorporate FAST into formal training.

CONCLUSIONS

Low-fidelity simulators such as FAST can potentially teach basic arthroscopic skills to medical students and are feasible for incorporation into formal training. They also give students a cost-effective and safe basic surgical training experience.

Metal nanoparticles produced by plants with antibacterial properties against Staphylococcus aureus

Staphylococcus aureus (S. aureus) is a pathogenic bacteria that causes a variety of potentially fatal infections. The emergence of antibiotic-resistant strains of S. aureus has made treatment even more difficult. In recent years, nanoparticles have been used as an alternative therapeutic agent for S. aureus infections. Among various methods for the synthesis of nanoparticles, the method utilizing plant extracts from different parts of a plant, such as root, stem, leaf, flower, seeds, etc. is gaining widespread usage. Phytochemicals present in plant extract are an inexpensive, eco-friendly, natural material that act as reducing and stabilization agent for the nanoparticle synthesis. The utilization of plant-fabricated nanoparticles against S. aureus is currently in trend. The current review discusses recent findings in the therapeutic application of phytofabricated metal-based nanoparticles against Staphylococcus aureus.

Cytosolic aldose metabolism contributes to progression from cirrhosis to hepatocarcinogenesis

Oxidative stress modulates carcinogenesis in the liver; however, direct evidence for metabolic control of oxidative stress during pathogenesis, particularly, of progression from cirrhosis to hepatocellular carcinoma (HCC), has been lacking. Deficiency of transaldolase (TAL), a rate-limiting enzyme of the non-oxidative branch of the pentose phosphate pathway (PPP), restricts growth and predisposes to cirrhosis and HCC in mice and humans. Here, we show that mitochondrial oxidative stress and progression from cirrhosis to HCC and acetaminophen-induced liver necrosis are critically dependent on NADPH depletion and polyol buildup by aldose reductase (AR), while this enzyme protects from carbon trapping in the PPP and growth restriction in TAL deficiency. Both TAL and AR are confined to the cytosol; however, their inactivation distorts mitochondrial redox homeostasis in opposite directions. The results suggest that AR acts as a rheostat of carbon recycling and NADPH output of the PPP with broad implications for disease progression from cirrhosis to HCC.

Utility of sirolimus coated balloons in the peripheral vasculature – a review of the current literature

Sirolimus-coated balloons (SCB) have demonstrated much promise as an alternative drug eluting device to the existing paclitaxel coated balloon platforms for the treatment of peripheral arterial disease (PAD). They have been well tested pre-clinically and have demonstrated anti-restenotic effects as well as clinical safety in its use for treatment of coronary artery disease. The existing approved SCBs have thus far demonstrated good short-term patency (12-months) and did not exhibit any major adverse events or device related shortcomings in its use for treatment of PAD. There are several studies ongoing which aim to further investigate the efficacy of existing SCBs and establish a direct comparison of its outcomes compared with plain balloon angioplasty. Also, SCB utility to salvage failing arteriovenous fistulas for haemodialysis patients has also been explored. We review the current progress made in the establishment of SCB in the treatment of PAD as well as highlight ongoing studies investigating the role of SCB in various settings.

LBODP073 Non-functioning Pituitary Macroadenoma Presenting As Osteopenia In A Male

Non-functioning pituitary macroadenomas (NFPAs) account for 14-54% of all pituitary adenomas. NFPAs are benign, but mass effects may lead to significant symptoms, including visual impairment and pituitary insufficiency, of which secondary hypogonadism is present in 75% of reported cases. Patients with hypogonadism may experience decreased bone density, libido, muscle mass/strength, and fatigue. We describe a patient who presented with osteopenia, in addition to atypical symptoms of secondary hypogonadism, associated with low testosterone levels. Further workup disclosed a large pituitary macroadenoma. A 56-year-old male presented to the clinic for a two-year history of diffuse joint pain. X-rays were significant for bone loss. This led to a bone density scan that showed osteopenia with a T score of -2.3 in the lumbar spine and left femoral neck. He had no prior history of fractures or loss in height. Risk factors for bone disease were only pertinent for history of osteoporosis in his mother. He was referred to endocrinology for further evaluation. Work up included normal vitamin D levels, 24-hour urine calcium excretion, morning cortisol, and TSH. Given the patient's osteopenia and additional complaints of decreased appetite, weight loss, fatigue, and muscle weakness, testosterone levels were checked and found to be low. Free testosterone level was 14.3 pg/ml with inappropriately low FSH and LH. Prolactin was normal at 12.5 ng/ml. He subsequently had an MRI brain which revealed a pituitary macroadenoma measuring 2. 0×2.4×2.4 cm with mass effect on the optic chiasm. However, the patient did not complain of headaches or visual disturbances and visual field testing was normal. He underwent transsphenoidal resection of the pituitary tumor which led to normalization of testosterone levels and resolution of all his symptoms. This case exemplifies how non-specific symptoms of hypogonadism and absence of mass effect symptoms can lead to a delay in diagnosis of NFPA. Typically, NFPAs are detected when they are large enough to cause symptoms of mass effect which, interestingly, were absent in this patient despite compression of the optic chiasm. Male hypogonadism increases the risk for bone disease. Thus, it is important to pursue work up for secondary hypogonadism in males presenting with osteopenia/osteoporosis despite lack of overt symptoms. A thorough history and workup are essential in diagnosing NFPA. Prompt detection of NFPA can facilitate timely management leading to clinical improvement. The first line of treatment for NFPAs causing neurological symptoms is transsphenoidal surgical resection. Surgery is also recommended for NFPAs that are at high risk for causing visual deficits due to involvement of optic chiasm, as was seen in this patient. Post-surgical follow up includes long-term routine monitoring of hormone levels and neuroimaging.

Presentation: No date and time listed

ODP471 Concomitant Metastatic Papillary Thyroid Cancer and Graves’ Disease Presenting as Thyroid Storm

Papillary thyroid cancer (PTC) is the most prevalent form of thyroid cancer with a reported incidence of 4.7-5.3 per 100,000 people over the past 10 years. PTC is more commonly seen in females during the fourth and fifth decades of life. Radiation exposure during childhood and family history are known risk factors for thyroid cancer. Thyroid cancer typically presents as a thyroid nodule detected on physical exam or incidental finding on imaging. Patients may feel swollen glands or a lump in the neck that can cause dysphagia. It is uncommon for PTC to present as hyperthyroidism. However, patients with Graves’ disease have an increased risk of thyroid cancer. We share a rare case of PTC detected following newly diagnosed Grave's disease presenting as thyroid storm. A 27-year-old male with history of polysubstance abuse and bipolar disorder presented to the hospital for altered mentation. He appeared anxious, tremulous, and was persistently tachycardic and febrile. There was an initial concern for drug intoxication or overdose. However, the patient's mother stated that he had not used drugs for the past six months and that his prescription bottles were appropriately filled. Blood alcohol level was elevated however urine toxicology screen was unrevealing. Due to worsening mentation and inability to protect his airway, the patient was intubated and transferred to the ICU. Thyroid levels were checked and TSH was less than 0. 01 with free T4 of 3.6 and free T3 of 13.80. The patient's Burch-Warsofsky score was 40. With endocrinology input, the patient was started on thyroid storm protocol with propylthiouracil, iodine solution, hydrocortisone, and beta blocker. He had significant improvement and was able to be extubated. Propylthiouracil was transitioned to methimazole. Thyroid stimulatingimmunoglobulin was found to be elevated, consistent with Grave's disease. Patient did have a known enlarged thyroid with heterogeneity from a recent ultrasound that had not yet been investigated. A CT scan of the neck was ordered, and this showed cervical lymphadenopathy, diffuse thyroid enlargement without nodule, and anterior mediastinum density. An ultrasound guided cervical lymph node biopsy was consistent with metastatic papillary thyroid cancer. A PET CT showed metastatic adenopathy in the upper neck and chest. Patient is planned to undergo thyroidectomy with lymphadenectomy. He is being followed by oncology and endocrinology for further management outpatient. Concurrent hyperthyroidism from Grave's disease with thyroid cancer is rare, though with increasing reports, particularly with PTC. Thyroid stimulatingimmunoglobulins are thought to accelerate thyroid cancer cell turnover and promote angiogenesis through up-regulation of vascular endothelial growth factors, facilitating invasive and metastatic potential. Thyroid cancer with coexisting hyperthyroidism has a poorer prognosis. Having a high clinical suspicion of thyroid cancer in patients with hyperthyroidism can result in prompter diagnosis and treatment which is imperative.

Presentation: No date and time listed

LBODP069 Parathyroid Crisis And Recalcitrant Hypercalcemia From Double Parathyroid Adenomas

Parathyroid crisis is a rare and life-threatening manifestation of hyperparathyroidism. Patients present with severe hypercalcemia and associated symptoms of bone disease, nephrolithiasis, abdominal pain, and fatigue. Multi-organ dysfunction in the form of encephalopathy, cardiac dysrhythmias, and renal failure is often present. There have also been reports of bleeding duodenal ulcers secondary to marked elevated parathyroid hormone. The most common etiology is a single parathyroid adenoma (85%) followed by hyperplasia (10%), double adenomas (4%), and carcinoma (1%). Parathyroid crisis requires immediate medical management of hypercalcemia and in recalcitrant cases, urgent parathyroidectomy. A 67-year-old female presented to the hospital with weakness and intermittent hematochezia. She was found to have acute renal failure, new onset anemia, and profound hypercalcemia of 17.1 mg/dl. On exam, she was slow to respond and exhibited diffuse muscle weakness. EKG showed sinus tachycardia, a right bundle branch block, and normal QTc. She received aggressive intravenous fluids and calcitonin. Bisphosphonate was not given due to renal failure. Due to refractory hypercalcemia, she was initiated on cinacalcet. She ultimately required hemodialysis due to failure of medical therapy. Further work-up showed a PTH of 2627 pg/ml. Vitamin D levels, TSH, and serum and urine protein electrophoresis were unremarkable. Renal ultrasound did not show nephrolithiasis. Given hematochezia and anemia in the setting of parathyroid crisis, endoscopy was done and was unrevealing of ulcers. A parathyroid ultrasound and nuclear medicine CT scan showed bilateral parathyroid adenomas. She underwent left superior and right inferior parathyroidectomy with biopsies revealing hypercellular parathyroid tissue with no features of malignancy. Following surgery, calcium levels gradually normalized. However, she remained dialysis dependent. This case exhibits a rare presentation of parathyroid crisis from double adenomas, requiring urgent double parathyroidectomy due to refractory hypercalcemia. This patient had an astoundingly elevated PTH level of 2627 pg/dl, one of the highest values documented in literature, which may attribute to the recalcitrant nature of hypercalcemia. Prompt diagnosis and treatment of parathyroid crisis is critical in preventing life-threatening complications.

Presentation: No date and time listed

OR03-3 Impact of Continuous Glucose Monitoring (CGM) on Lifestyle Modifications in Individuals with Prediabetes

Introduction

Adherence to lifestyle modifications can prevent diabetes; however, this poses a challenge for most individuals. CGM is an effective tool for glycemic control and lifestyle modifications in patients with diabetes on insulin therapy. We explored the impact of CGM use in individuals with prediabetes.

Hypothesis

Individuals using CGM in addition to diabetes education will show improved adherence to lifestyle modifications and greater reduction of HbA1c as compared to those receiving diabetes education alone.Design57 individuals with prediabetes were randomized to use CGM for 3 months along with diabetes education (CGM group) or receive diabetes education alone (EDU group). Food frequency (UKDDQ) and physical activity (IPAQ) questionnaires were completed by participants at the beginning and at the end of the study (6 months). Primary outcomes were lifestyle modifications and changes in HbA1c. Secondary outcomes were changes in weight and blood pressure.

Results

Both groups reported an increase in healthy food choices; however, EDU group performed better (EDU: 12.4 vs 9.2, p<0.01, CGM: 10.6 vs 9.5, p 0.08). Unhealthy food choices were reduced in both groups. CGM group reported a greater increase in moderate physical activity levels (CGM: 230 vs 61 minutes/week, p 0.01, EDU: 78.5 vs 48 minutes/week, p 0.22). Vigorous physical activity was reported by more individuals in CGM group than EDU (35% vs 4%). Greater reduction in mean HbA1c was noted in CGM group (5.7 vs 5.9%, p 0.05) compared to EDU (5.8 vs 5.9%, p 0.01). 33% of participants in both groups had normalization of HbA1c at the end of study. CGM group had greater reduction in weight (3.5 vs 0.8 lb, p 0.1) and systolic BP (12 vs 2.4 mmHg, p 0.01) than EDU. Irrespective of group assignment, the study population had improvement in all outcomes despite the beginning of COVID-19 pandemic during 4th month of the study. Smaller number of participants in the CGM group reported negative impact of the pandemic on their lifestyle modifications than EDU (Diet: 68% vs 80%, Physical activity: 48% vs 64%). Majority of CGM group participants were able to maintain lifestyle changes after discontinuing CGM use (Diet: 72%, Physical activity: 84%). On comparing both interventions, 56% of CGM group participants felt CGM to be more helpful than education for lifestyle modifications, while 40% felt both interventions helped equally.

Conclusions

CGM use in addition to diabetes education resulted in improvement in physical activity, food choices, HbA1c, weight, and BP in individuals with prediabetes. The significance of diabetes education was noted by greater improvement in food choices in EDU group. CGM can be an effective tool for diabetes prevention with lifestyle modifications in prediabetes. The long-term impact of CGM use and cost-benefit analysis in high-risk patients needs to be explored further.

Presentation: Saturday, June 11, 2022 12:00 p.m. - 12:15 p.m.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

Physical activity, sedentary time and breast cancer risk: a Mendelian randomisation study

OBJECTIVES

Physical inactivity and sedentary behaviour are associated with higher breast cancer risk in observational studies, but ascribing causality is difficult. Mendelian randomisation (MR) assesses causality by simulating randomised trial groups using genotype. We assessed whether lifelong physical activity or sedentary time, assessed using genotype, may be causally associated with breast cancer risk overall, pre/post-menopause, and by case-groups defined by tumour characteristics.

METHODS

We performed two-sample inverse-variance-weighted MR using individual-level Breast Cancer Association Consortium case-control data from 130 957 European-ancestry women (69 838 invasive cases), and published UK Biobank data (n=91 105-377 234). Genetic instruments were single nucleotide polymorphisms (SNPs) associated in UK Biobank with wrist-worn accelerometer-measured overall physical activity (nsnps=5) or sedentary time (nsnps=6), or accelerometer-measured (nsnps=1) or self-reported (nsnps=5) vigorous physical activity.

RESULTS

Greater genetically-predicted overall activity was associated with lower breast cancer overall risk (OR=0.59; 95% confidence interval (CI) 0.42 to 0.83 per-standard deviation (SD;~8 milligravities acceleration)) and for most case-groups. Genetically-predicted vigorous activity was associated with lower risk of pre/perimenopausal breast cancer (OR=0.62; 95% CI 0.45 to 0.87,≥3 vs. 0 self-reported days/week), with consistent estimates for most case-groups. Greater genetically-predicted sedentary time was associated with higher hormone-receptor-negative tumour risk (OR=1.77; 95% CI 1.07 to 2.92 per-SD (~7% time spent sedentary)), with elevated estimates for most case-groups. Results were robust to sensitivity analyses examining pleiotropy (including weighted-median-MR, MR-Egger).

CONCLUSION

Our study provides strong evidence that greater overall physical activity, greater vigorous activity, and lower sedentary time are likely to reduce breast cancer risk. More widespread adoption of active lifestyles may reduce the burden from the most common cancer in women.