Breast cancer: Online education’s effect on clinician ability to assess risk of recurrence and understanding the latest data

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Background: Hormone receptor positive breast cancer (HR+ BC) is often diagnosed in the early, curable, stage. Emerging treatment options make it important to educate clinicians on how to identify patients eligible for these options and increase their understanding of the clinical data associated with therapies in HR+/HER2- early breast cancer (EBC). The study objective was to assess the impact of 2 educational activities on HR+/HER2- EBC on oncologists’ knowledge, competence, and confidence related to risk of recurrence and clinical data. Methods: Two online continuing medical education activities were launched in 2021 covering a range of topics focused on identification of patients at high risk of recurrence and the latest clinical trial data for CDK4/6 inhibitors (CDK4/6i) in HR+/HER2- EBC. Educational impact was assessed using a repeated pair design, with knowledge/competence and confidence questions pre- and post-education. Confidence was assessed on a Likert-type scale ranging from not confident to very confident. Questions were designed to assess if certain learning objectives (LOs), covering identified educational gaps, were met. Data was collected from 06/14/2021 to 01/31/2022. Statistical significance was assessed using McNemar’s test ( P < .05 level). Results: 5,544 learners participated in these 2 activities, including 727 oncologists. The LOs were grouped in 3 themes that assessed oncologists’ knowledge/competence and confidence related to identifying patients with HR+/HER2- EBC at high risk of recurrence and understanding the clinical trial data investigating CDK4/6i in this setting. Two themes showed a significant improvement. The number of oncologist learners assessed per theme differed from 228 to 260. Conclusions: Participation in text- and video-based activities resulted in a significant improvement of oncologists’ knowledge, competence, and confidence related to CDK4/6i clinical data and treatment eligibility for patients with HR+/HER2- EBC. Baseline knowledge regarding the identification of high risk of recurrence in HR+/HER2-EBC was high (89% correct responses pre-education) in comparison that of clinical trial data and confidence in identification of patients eligible for adjuvant therapy (54% and 21% respectively). This finding could be reflective of clinicians having a high-level knowledge and competence related to risk stratification prior to the developments that occurred secondary to the approval of CDK4/6i in the adjuvant setting. With these new developments additional education around this topic will be required.[Table: see text]

The effect of a series of online CME activities on the multidisciplinary management of patients with GEP-NETs

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Background: Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are rare, heterogenous neoplasms characterized by a wide spectrum of clinical manifestations. Management strategies are varied and include surgery, radiological intervention, cytotoxic chemotherapies, somatostatin analogs, TKIs, and novel peptide receptor radionuclide therapy (PRRT). Due to their clinical complexity, the diagnosis and treatment of GEP-NETS should involve collaboration between specialists in multiple disciplines. The objective of this study was to assess the educational impact of a series of continuing medical education (CME) activities on the knowledge, competence, and confidence of oncologists, gastroenterologists, and pathologists with respect to the use of novel systemic therapies for the multidisciplinary management of patients with GEP-NETs. Methods: The educational series consisted of 3 online, CME-certified activities. Educational impact was assessed with repeated pre-/post-education including multiple choice knowledge/competence questions and 5-point Likert scale confidence questions. Data from all oncologists, gastroenterologists, and pathologists who completed pre- and/or post-education assessments were aggregated across activities and stratified by learning theme. Relative changes in percentage of correct responses and clinicians who were confident (value of 4 or 5) were used to measure improvement in knowledge, competence, and confidence. A McNemar’s test assessed significant levels of changes reported with P values < .05 considered statistically significant. The first activity in the series launched December 2020 and the last launched February 2021; data were collected until February 2022. Results: The educational series resulted in overall statistically significant improvements in oncologists’, gastroenterologists’, and pathologists’ knowledge, competence, and confidence after education (N = 125 to 455, P < .05). Conclusions: This analysis demonstrates that oncologists’, gastroenterologists’, and pathologists’ knowledge, competence, and confidence regarding the use of novel systemic therapies in the multidisciplinary management of patients with GEP-NETs improved after education. Despite these improvements, additional educational activities are needed to address residual gaps and further increase clinicians’ ability in this clinical setting.[Table: see text]

Duplicate Prescription Rates of Long-Acting Bronchodilator Inhalers

Background: Long-acting bronchodilator inhalers are widely used with or without inhaled corticosteroids (ICs) by patients with lung diseases. In Israel alone, there are 21 inhalers containing long-acting β2 agonists (LABAs) and/or long-acting muscarinic antagonists (LAMAs). Some patients are treated incorrectly with several inhalers of the same pharmacologic group. Methods: Electronic data of LABA and/or LAMA inhalers purchased during a period of 1 year were extracted in one district of Clalit Health Services in Israel. Patients who were treated with two or more inhalers from the same pharmacologic group were compared with patients without duplicate treatment. Inhaler purchases during the 12 months before and after the first duplicate purchase were compared with the purchases by patients without duplication of treatment. New diagnoses were compared to identify possible side effects. Results: Of the 13,528 patients who were treated with LABA and/or LAMA inhalers, 244 (1.8%) purchased at least two different inhalers from the same pharmacologic group. Inhaler purchases were 3.8 times higher in the duplication group during the 12 months before the first duplication. Inhaler purchase increased by 28% in the duplication group compared with a 4.5% increase in the nonduplication group (p < 0.001) during the following year. The risk for duplicated consumption was significantly higher in patients with a chronic obstructive pulmonary disease (COPD) diagnosis, males, and persons aged between 61 and 80 years. Conclusions: Nearly 2% of the patients treated with long-acting bronchodilators consumed different medications of the same pharmacologic group even when adherence was satisfactory. COPD patients are at higher risk for inhaler duplication. Clinical Trial Registration Number: 0151-20-COM1.

Oocyte ERM and EWI Proteins Are Involved in Mouse Fertilization

In mammalian fertilization, the link between the oocyte plasma membrane and underneath cytoskeleton has often been associated to key elements of successful gamete fusion, like microvilli shaping or CD9 function, but its effective role has poorly been studied. EWI-2 and EWI-F as cis partners of CD9, and ERM proteins (Ezrin, Radixin and Moesin) that both attach to the actin cytoskeleton and to the EWI are part of the molecules that make the link between the oocyte membrane and its cytoskeleton. This study aims to assay through siRNA inhibition, the involvement of these ERM and EWI molecules in mouse fertilization, their role in the microvilli morphology of the egg but also their possible contribution to the cortical tension, a parameter that reflects the mechanical behavior of the oocyte cortex. Whereas inhibiting separately the expression of each protein had no effect on fertilization, the combined inhibition of either EWI-2/EWI-F or the three ERM triggered a significant decrease of the fertilization index. This inhibition seems to correlate with an increase in the radius of curvature of the oocyte microvilli. It also causes a decrease of the oocyte cortical tension. These results show the importance of EWI-2 and EWI–F and ERM proteins in the smooth running of a fertilization event and support their involvement in the microvilli architecture of the oocyte and in its mechanical properties.

The role of premorbid transthoracic echocardiogram in identifying adverse clinical outcomes in patients admitted with COVID-19

Background/Introduction

The novel coronavirus disease (COVID-19) inpatient mortality rate is approximately 20% in the United States. Reports have described a wide pattern of abnormalities in echocardiograms performed in patients admitted with COVID-19. The role of premorbid transthoracic echocardiogram (TTE) in the prediction of COVID-19 severity and mortality is yet to be fully assessed.

Purpose

To assess whether a pre-COVID TTE can identify patients at high risk of adverse outcomes who are admitted with COVID-19.

Methods

All patients who underwent a TTE from one year to one month prior to an index inpatient admission for COVID-19 were retrospectively enrolled across five clinical sites. Demographic information, medical history, and laboratory data were included for analysis. Echocardiograms were analyzed by an observer blinded to clinical data. Linear and logistic regressions were performed to detect the association of variables with death, invasive mechanical ventilation, initiation of dialysis, and a composite of these endpoints during the COVID-19 admission. Outcomes were then adjusted for a risk score using inverse propensity weighting incorporating age, sex, diabetes, hypertension, obstructive sleep apnea, history of atherosclerotic cardiovascular disease, atrial fibrillation, diuretic use, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use.

Results

There were 104 patients (68±15 years old, 49% male, BMI 31.4±9.1kg/m2) who met inclusion criteria (baseline characteristics in Table 1). Mean time from TTE to positive SARS-CoV-2 PCR test was 139±91 days. Twenty-nine (28%) participants died during the index COVID-19 admission. There was no association of pre-COVID echocardiographic measures of systolic ventricular function with any endpoint. Diastolic function, as assessed by LV e', was associated with mortality (Table 2). There were 25 patients (24%) with a normal lateral e' (≥10cm/s); none died. There were 35 (34%) patients with LV e' lateral velocity &lt;8 cm/s, of whom 15 (43%) died. LV e' lateral velocity &lt;8 cm/s was associated with an unadjusted odds ratio of 7.69 (95% confidence interval [CI] 2.26–26.19) for death and 3.25 (95% CI 1.11–9.54) for the composite outcome. The odds ratio for death was 4.76 (95% CI 1.10–20.61) and 3.78 (95% CI 0.98–14.6) for the composite outcome after adjustment for clinical risk factors (Table 2).

Conclusion

In patients with an echocardiogram prior to COVID-19, impaired diastolic function as represented by an abnormal LV e' lateral velocity was associated with both inpatient COVID-19 mortality and a composite outcome of death, mechanical ventilation, and initiation of dialysis, even after adjustment for multiple co-morbidities and medication use. Knowledge of the pre-COVID TTE results may help clinicians identify patients at higher risk of adverse outcomes during an admission for COVID-19.

Funding Acknowledgement

Type of funding sources: None.

P–243 Improving ERICA’s (Embryo Ranking Intelligent Classification Assistant) performance. Should we train an AI to remain static or dynamic, adapting to specific conditions?

Study question

Can ERICA’s deep-learning capabilities allow it to learn specifics from individual clinics, and improve its performance through a quality assurance and fine-tuning process?

Summary answer

Quality assurance and fine-tuning allowed ERICA to adapt to unique specifications of individual clinics, resulting in an improved performance at each clinic.

What is known already

Machine learning (ML) solutions to real-life problems have shown that generalizability (applicability of a model to different scenarios) of a single model is fundamentally a suboptimal approach, due to the risk of underspecification. Under-specification becomes relevant in environments where there is a myriad of protocols and approaches, like during IVF treatments. It is naïve to assume that different features extracted from embryos to predict treatment success weigh the same along the overall heterogeneity of protocols. This underspecification problem takes special relevance when deploying an ML-based product, like ERICA, in a clinical setting.

Study design, size, duration

Retrospective analysis of results from the quality assurance (QA) and fine-tuning (adaptation) process performed for a deep learning algorithm named ERICA (Embryo Ranking Intelligent Classification Assistant) at five clinics (1879 embryos) between August and September 2020.

Participants/materials, setting, methods

QA and fine-tuning consist of a transfer-learning approach (of the ERICA Core model) and re-training using embryos of each clinic exclusively. Results are assessed by a 10-fold cross validation approach, which splits the database in 10 and iteratively validates on each by training on the rest. Performance of ERICA is assessed both before and after the fine-tuning process and results are presented as averages per clinic. Embryos considered for QA and fine-tuning had known outcome.

Main results and the role of chance

After the fine-tuning, ERICA showed an average improvement of 13% in accuracy (from 50.2% to 63.2%); 36.6% in specificity (from 22.4% to 59%); 11% for Positive Predictive Value (from 51% to 62); 19.6% for Negative Predictive Value (from 44.6% to 64.2%), and 3.4% for F1 score (from 60% to 63.4%). Sensitivity decreased from 78% to 65.4%.

Our results suggest ERICA’s Core is robust lending itself to be fine-tuned. It learns from individual laboratory specifics, and in this way adapts to new clinics. The results demonstrate that the Core model tends to classify embryos from new clinics as having a good prognosis, since it showed a high sensitivity and low specificity, both showing an improved balance following the fine-tune process. Additionally, the probability of finding a good prognosis embryo in the different labels, behaved as expected, decreasing its probability from Optimal (65.8%) to Poor prognosis (37.4%).

Limitations, reasons for caution

underspecification is a challenge to Artificial Intelligence (AI) based solutions pursuing a general model. For this study, our approach of QA followed by a fine-tuning process to overcome underspecification, was successful. However, it was only applied to 5 clinics, and the findings remain to be proven on a larger scale.

Wider implications of the findings: Performance of QA should be considered standard before clinical implementation of any AI based solution. Our results should be interpreted as the theoretical/expected future performance of ERICA for each clinic. Regular assessments on performance for all models generated after fine-tuning are encouraged.

Trial registration number

Not applicable

O-235 ERICA (Embryo Ranking Intelligent Classification Assistant) AI predicts miscarriage in poorly ranked embryos from one static, non-invasive embryo image assessment

Study question

Does ERICA’s prognosis ranking based on ploidy, predict early miscarriage following positive biochemical pregnancy test?

Summary answer

The lower ERICA grades embryos, the higher the likelihood of early miscarriage, irrespective of age group.

What is known already

The vast majority of early miscarriages are due to aneuploidy, but preimplantation genetic testing for aneuploidy (PGTA) is potentially invasive, expensive, time-consuming and usually necessitates cryopreservation. Current methods for embryo selection based on morphology and morphokinetics are poorly correlated with ploidy. ERICA is a deep-learning non-invasive tool for embryo ranking, trained to identify ploidy, and has previously been shown to be similar or better than experienced embryologists in assessing implantation potential. AI-based tools capable of embryo ranking and assessment could help save laboratory time and costs, avoiding risk to embryos from invasive techniques.

Study design, size, duration

Retrospective analysis of 599 blastocysts transferred over 12 months in which ERICA was used to assist embryologists during the embryo selection process. ERICA’s prognosis based on ploidy potential is presented as groups labelled as “optimal”, “good”, “fair”, or “poor”. Embryo transfers (ET) reaching biochemical pregnancy (beta-hCG ≥ 20iu) were considered for the study. Early pregnancy loss (EPL) was defined as a biochemical pregnancy failing to develop a gestational sac and/or failure to show heartbeat (FHR).

Participants/materials, setting, methods

ETs resulting in biochemical pregnancies at two IVF clinics were followed-up to FHR till 8 weeks gestation. EPLs were divided into groups according to the presence or absence of a pregnancy sac. ERICA’s suggested prognosis during the embryo selection process was tested against pregnancy outcomes. Further analysis of pregnancy outcomes and their relation to ERICA’s labels was also performed based on age groups. Z-test for two proportions was used to assess statistical significance.

Main results and the role of chance

506 ETs were performed for 599 embryos (mean 1.2 embryos), from which 285 resulted in positive pregnancy tests (56.3%). Thirty-one (10.9%) EPLs happened before the identification of a gestational sac (GS). Ten pregnancies failed to develop FHR after initial GS identification (3.9%), for an overall EPL of 14.4%. The average age in this group was 35.4 years. When evaluated using ERICA’s labels “optimal”, “good”, “fair, and “poor”, chances of miscarriage before GS were 8.9% (8/89); 14.1% (11/78); 18.5% (5/27); and 18.7% (9/48) respectively, where denominator represents total number within a label (i.e. EPL/n). When including all EPLs, chances of miscarriage according to the same labels were 11.2%; 17.9%; 22.2%; and 22.9% respectively.

ERICA’s performance to anticipate the risk of EPL showed statistical significance when the optimal label was compared against all other labels (Z -1.786, p &lt; 0.05), and against the poor prognosis label (Z=-1.653, p &lt; 0.05). After stratifying the dataset according to age groups, increasing miscarriage rates were maintained as ERICA’s prognosis for an embryo worsened, regardless of age groups. The most notable performance was for ≤35-year-olds, where embryos ranked as optimal had an EPL rate of 14.3% in contrast to lowest ranked embryos having a 33.3% EPL rate.

Limitations, reasons for caution

The retrospective nature of this study along with its sample-size might limit the reach of our conclusions, in particular for older patients. The results we present must still be confirmed prospectively, and on a larger dataset.

Wider implications of the findings

Most EPLs are attributed to genetic factors, hence ERICA’s training for embryo ranking was based on ploidy. We conclude that ERICA’s AI is able to identify embryos at a higher risk of EPL non-invasively. Cytogenetic studies from products of miscarriage would help to confirm the hypothesis.

Trial registration number

Not applicable

P–244 ERICA’s (Embryo Ranking Intelligent Classification Assistant) ranking, based on ploidy prediction, is strongly correlated with pregnancy outcomes

Study question

How does ERICA perform when ranking the most suitable embryos for transfer in terms of clinical pregnancy, and the presence of a fetal heartbeat (FHB)?

Summary answer

ERICA’s Artificial Intelligence ranking system was positively correlated with outcomes defined as implantation and presence of FHB. Best-ranking embryos outperformed lower-ranking embryos by statistical significance.

What is known already

ERICA, the Embryo Ranking Intelligent Classification Assistant, is a deep learning AI system trained to rank embryos based on their ploidy status, which is highly correlated with successful treatments.

ERICA ranks the embryos according to their prognosis predictions and labels them into four quality categories: optimal, good, fair, and poor. ERICA’s performance in the clinic remains to be tested.

Study design, size, duration

Retrospective analysis on ERICA’s performance over 4 consecutive months after quality assurance and fine-tuning processes. We compared both the ranking and prognosis of the AI algorithm against clinical outcomes in IVF cycles and subsequent embryo transfers. For this study, all cycles where ERICA was used to assist embryologists during the embryo selection process were included. Double embryo transfers with a single FHB where excluded.

Participants/materials, setting, methods

Total 77 cycles with 81 transfers of 98 embryos (17 cases underwent a double embryo transfer) from two IVF clinics. Evaluated clinical outcomes included biochemical pregnancy test (defined as beta human chorionic gonadotropin &gt;20 mUI/ml), and presence/absence of FHB. We compared the ERICA rankings and predictions against outcome and a sub-analysis was performed on transferred embryos with known ploidy status (14 embryos).

Main results and the role of chance

The distribution of embryos within the ERICA categories are 42% for optimal, 38% for good, 19% for fair, and 6% for poor. The observed biochemical pregnancy rate was 51%, 25%, 47% and 33% respectively, and 39%, 22%, 42%, 17% for FHB. We found statistical significance (Z = 1.78; p = 0.0378) for the proportion of biochemical pregnancy between transfers labelled by ERICA as optimal (51%) and all lower rankings (33%). The proportion of transfers with presence of FHB within the optimal group was 39%, compared with 29% for the rest of the embryos. This did not show statistical significance (Z = 1.141; p = 0.127). Additionally, we observed that the proportion of biochemical pregnancy and presence of FHB in the group of transfers with known ploidy (n = 14) was 50% and 36% respectively, and the transfers with unknown ploidy and labelled as optimal by ERICA (n = 35) was 54% and 43% respectively.

Limitations, reasons for caution

This is the first report on ERICA’s performance on real clinical data, and despite being a relatively small dataset, we observed statistical significance of the embryos labelled by ERICA as having optimal quality. Further studies should be conducted with larger datasets and more clinics included to strengthen the evidence.

Wider implications of the findings: This is the first report on ERICA’s performance on real clinical data, and despite being a relatively small dataset, we observed statistical significance of the embryos labelled by ERICA as having optimal quality. Further studies should be conducted with larger datasets and more clinics included to strengthen the evidence.

Trial registration number

Not applicable

P–096 Real-time ranking of single spermatozoa using artificial vision analysis of complex motility patterns during ICSI aimed at improving fertilization and blastocyst development

Study question

Can real-time artificial vision identify beneficial movement patterns of single spermatozoa in a cohort visualized in PVP during ICSI possibly enhancing fertilization and embryo development?

Summary answer

Artificial vision seems able to identify advantageous movement patterns of individual spermatozoa having a significant impact on both normal fertilization and blastocyst formation.

What is known already

Spermatozoa isolated from poor semen may reduce the quality of embryo development and blastocyst formation. Normal motility is dependent on general sperm morphology and characteristic movement of the flagellum enabling forward mobility. Spermatozoa roll as they swim. It is known that this rotational motion around their longitudinal axis promotes rheotaxis, which is a mechanism that allows the sperm to navigate to the site of fertilization. Therefore, it is possible that the characteristics of the rotational movement are related to sperm quality.

Study design, size, duration

Non-intervention study based on a cohort of 132 videos of in-vitro fertilization treatments with ICSI during which the sperm selection process was recorded up to sperm injection. The study was performed at one IVF center within a 6-month period. Injected spermatozoa and their corresponding oocytes were individually assessed from fertilization to blastocyst formation. Videos, where spermatozoa selected for injection could not be identified, were excluded. Relevant outcomes included normal fertilization (2PN), and blastocyst formation.

Participants/materials, setting, methods

Using a digitizer attached to an optical microscope (640 x 480 pixels), videos were recorded to include the sperm selection process, immobilization, and subsequent injection following standard ICSI protocols. Individual spermatozoa motility features were extracted using a proprietary computer-vision algorithm (SID, IVF 2.0 LTD). The rotational movements of spermatozoa were inferred by computing the variations of the mean intensity of the sperm in the video-sequence across time (MI).

Main results and the role of chance

Based on SID’s analysis, we found statistically significant differences between the median prominences of the MI of those injected spermatozoa that resulted in successful fertilization in comparison to those with failed fertilization (p-value=0.029, 28 negative fertilization, and 71 positive fertilization) using a one-tailed t-Student test with a significance level of 5%. We also found statistically significant differences between the median prominences of the MI of those spermatozoa that resulted in blastocysts in comparison with the spermatozoa-oocyte cohorts which didn’t reach the blastocyst stage (p-value 0.004, 51 with negative blastocyst formation and 48 with blastocyst formation).

Limitations, reasons for caution

The size of this database is modest, therefore a larger study with multiple clinics will be necessary to confirm the findings. Large prominence does not necessarily assurance successful fertilization or blastocyst formation since there may be other factors such as oocyte quality or the ICSI technique.

Wider implications of the findings: Objective assessment of sperm rotational movement is difficult to quantify and to be objectively assessed during standard sperm selection. Real-time artificial vision tools such as SID could assist embryologists during the sperm selection process for ICSI.

Trial registration number

NA

Oncologist management of NTRK fusion-positive NSCLC improves after virtual patient simulation participation

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Background: Although relatively rare, neurotrophic receptor tyrosine kinase (NTRK) fusions, represent a clinically relevant subgroup of NSCLC that can derive benefit from targeted therapies. Relatively quick and durable responses have been achieved with these targeted therapies in advanced NSCLC and intracranial activity has also been observed. The objective of this study was to determine if an online, virtual patient simulation (VPS)-based continuing medical education (CME) intervention improved performance of oncologists in using appropriate strategies to diagnose and manage patients with NTRK fusion-positive advanced NSCLC. Methods: The CME intervention consisted of two patient cases presented in a VPS platform that allowed learners to order lab tests, diagnoses and treatments in a manner matching the scope and depth of actual practice. Clinical decisions made by the learners using open field entries within an EHR interface were analyzed and, after each decision, tailored clinical guidance (CG) was provided based on current evidence and expert recommendation. Learner decisions were collected post-CG and compared with each user’s baseline (pre-CG) data using a McNemar’s test to determine P values. Results were then aggregated for the two cases based on clinical decisions and stratified by practice setting. The activity posted July 31, 2020; data were collected through December 1, 2020. Results: Overall significant improvements were seen after CG in clinical decisions made by oncologists in both the community and academic settings [reported as % absolute improvement (% correct pre-CG vs % correct post-CG); P value]. Conclusions: This analysis demonstrated that VPS that immerses and engages oncologists in an authentic and practical learning experience can significantly improve evidence-based clinical decisions related to the diagnosis and management of patients with NTRK fusion-positive advanced NSCLC. Despite the improvements, additional educational activities are needed to address any residual gaps and further increase oncologists’ ability in this clinical setting.[Table: see text]

CME curriculum improves clinician knowledge, competence, and confidence in managing patients with NF1-related tumors

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Background: Neurofibromatosis type 1 (NF1) is an uncommon complex autosomal dominant disorder caused by germline mutations in the NF1 tumor suppressor gene. Therapeutic options have historically been limited with surgical debulking being the preferred treatment modality. However, recent clinical data have shown improved outcomes with the use of MEK inhibitors. The objective of this study was to assess the educational impact of a series of continuing medical education (CME) activities on the knowledge, competence, and confidence of physician learners with respect to the treatment of NF1-related tumors. Methods: The educational series consisted of four online, CME-certified activities. For each activity, educational effect was assessed with a repeated pairs pre-/post-assessment study including a 3-item, multiple choice, knowledge/competence questionnaire and one confidence assessment question, with each participant serving as his/her own control. To assess changes in knowledge, competence, and confidence data from all clinicians who completed both pre- and post-questions were aggregated across activities, stratified by learning theme, and evaluated by target specialty. A repeated pairs pre-/post-assessment study design was used and McNemar’s test or paired samples t-test (P < .05) assessed educational effect. The first activity in the series launched Dec. 2019 and the last launched June 2020; data were collected until Dec. 2020. Results: Overall significant improvements were seen after education for oncologists (N = 258, P < .001), neurologists (N = 474, P < .001), surgeons (N = 427, P < .001), neurosurgeons (N = 93, P < .05), and pediatricians (N = 56, P < .001), regardless of practice setting. A sub-analysis of community specialists also showed significant improvements after education: oncologists (N = 117, P < .01), neurologists (N = 188, P < .001), and surgeons (N = 206, P < .001). Outcomes assessed by learning themes and specialty showed relative percent increases, with the majority being statistically significant. Conclusions: This analysis demonstrates that oncologists’ and other specialists’ knowledge, competence, and confidence regarding the treatment of NF1-related tumors improved after education, as measured through a comprehensive analysis of CME outcomes data from a variety of activities designed to achieve these ends. These results have the ability to translate to improvements in clinical care. Despite the improvements, additional educational activities are needed to address residual gaps and further increase clinicians’ ability in this clinical setting.

Placenta-Expanded Stromal Cell Therapy in a Rodent Model of Simulated Weightlessness

Long duration spaceflight poses potential health risks to astronauts during flight and re-adaptation after return to Earth. There is an emerging need for NASA to provide successful and reliable therapeutics for long duration missions when capability for medical intervention will be limited. Clinically relevant, human placenta-derived therapeutic stromal cells (PLX-PAD) are a promising therapeutic alternative. We found that treatment of adult female mice with PLX-PAD near the onset of simulated weightlessness by hindlimb unloading (HU, 30 d) was well-tolerated and partially mitigated decrements caused by HU. Specifically, PLX-PAD treatment rescued HU-induced thymic atrophy, and mitigated HU-induced changes in percentages of circulating neutrophils, but did not rescue changes in the percentages of lymphocytes, monocytes, natural killer (NK) cells, T-cells and splenic atrophy. Further, PLX-PAD partially mitigated HU effects on the expression of select cytokines in the hippocampus. In contrast, PLX-PAD failed to protect bone and muscle from HU-induced effects, suggesting that the mechanisms which regulate the structure of these mechanosensitive tissues in response to disuse are discrete from those that regulate the immune- and central nervous system (CNS). These findings support the therapeutic potential of placenta-derived stromal cells for select physiological deficits during simulated spaceflight. Multiple countermeasures are likely needed for comprehensive protection from the deleterious effects of prolonged spaceflight.

Patient-centric care in bladder cancer: Virtual simulation to benefit clinical decision-making of oncologists

492

Background: Immunotherapy (IO) utility in bladder cancer (UC) has expanded into multiple stages of disease. Employing IO optimally requires mastery of clinical trial data, patient eligibility criteria, and interpretation of biomarkers and determination of treatment sequencing. Given the nuanced therapeutic decision-making, education was developed in partnership between Medscape Oncology and Society for Immunotherapy of Cancer (SITC) to assist oncologists in improving their performance surrounding the management of patients with advanced UC. Methods: A virtual patient simulation (VPS) continuing medical education (CME)-certified activity depicting 2 advanced UC cases was made available to oncologist members of Medscape. The cases depicted 1) a patient with newly diagnosed metastatic UC with comorbidities and PDL1+ disease and 2) a patient with advanced UC progressing on platinum therapy with no actionable mutations. The VPS platform captures real-life decision making process of oncologists in an EHR-like format supported by an extensive database of diagnostic and treatment possibilities. Learners were able to interact with patients via video, order lab tests, assess patients, make diagnoses, and order treatments matching the scope and depth of actual practice. Tailored clinical guidance (CG) employing up-to-date evidence-based and faculty recommendations was provided after each decision point. Decisions were collected pre- and post-CG and analyzed using McNemar’s test to determine p-values. Data were collected from 4/28/20 to 7/13/20. Results: Analyses from oncologists (n = 51-66) found significant improvement in performance measured pre- to-post CG: Case 1: Ordering appropriate testing to determine patient eligibility for therapy (39% pre; 65% post; p < .001) Prescribing appropriate therapy based on patient- and disease-specific factors (38% pre; 77% post; p < .001) Providing appropriate counseling and follow-up for a patient receiving treatment (65% pre; 80% post; p < .01) Case 2: Ordering appropriate testing to determine patient eligibility for therapy (39% pre; 57% post; p < .01) Prescribing appropriate therapy based on patient- and disease-specific factors (25% pre; 41% post; p < .01) Providing appropriate counseling and follow-up for a patient receiving treatment (71% pre; 82% post; p < .05). Conclusions: This activity demonstrates the value of providing oncologists a simulation platform to practice and master clinical decision-making of the limitless possible diagnostic and therapeutic options in the management of advanced UC. Insights from rationales for each clinical decision point uncover continued gaps for oncologists on guideline recommendations, efficacy outcomes, or molecular implications. They also highlight barriers including limited experience or confidence with IO.

Factors of the human embryo culture system that may affect media evaporation and osmolality

STUDY QUESTION

Which lab-related factors impact the culture system's capacity to maintain a stable osmolality during human embryo culture?

SUMMARY ANSWER

Incubator humidity, the volume of mineral oil, the type of culture media and the design of time-lapse dishes have been identified as important parameters that can cause an impact on media evaporation and consequently osmolality during culture.

WHAT IS KNOWN ALREADY

Culture medium is a critical component in human embryo culture. Minimizing its evaporation during culture is an adequate strategy to stabilize osmolality and, as a result, improving culture conditions and clinical outcomes.

STUDY DESIGN, SIZE, DURATION

The studied variables included media composition and supplementation; volume of mineral oil; incubator humidification; and the type of dish and incubator used. Additionally, six time-lapse dish models were compared in their ability to prevent evaporation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Dishes were incubated in parallel to analyze osmolality during culture between groups: synthetic oviductal medium enriched with potassium versus human tubal fluid medium; protein versus no protein supplementation; dry versus humid atmosphere; high versus low volume of mineral oil. Additionally, media evaporation was compared between six models of time-lapse dishes with distinct designs, cultured in a joint incubator. Two of them were retested in their corresponding incubator to analyze the dish-incubator fit. Daily osmolality measurements were compared between groups. Linear regression was performed to analyze evaporation rates.

MAIN RESULTS AND THE ROLE OF CHANCE

Protein supplementation did not significantly affect evaporation. Contrarily, humidity levels inside the incubators, the volume of mineral oil and the type of culture media, played an important role in osmolality stabilization. The design of time-lapse dishes and their recommended preparation protocol heavily influenced their evaporation rates, which were further altered by each incubator's characteristics. Media with initially high osmolalities had a bigger risk of reaching hypertonic levels during culture.

LIMITATIONS, REASONS FOR CAUTION

While numerous, the studied variables are limited and therefore other factors could play a role in osmolality dynamics, as well. Incontrollable atmospheric factors could also result in some variation in the observed results between different centers and laboratories.

WIDER IMPLICATIONS OF THE FINDINGS

Published literature has extensively described how hypertonic media may impair embryo development and negatively affect clinical outcomes; therefore, maintaining a stable osmolality during culture should be considered essential. This work is of interest both for embryologists when analyzing their culture system and methodologies, as well as manufacturers in charge of designing IVF consumables.

STUDY FUNDING/COMPETING INTEREST(S)

This study was privately funded.

TRIAL REGISTRATION NUMBER

N/A.

Management of abdominal compartment syndrome in acute pancreatitis

Abdominal compartment syndrome (ACS), defined by the presence of increased intra-abdominal pressure>20mmHg in association with failure of at least one organ system, is a common and feared complication that may occur in the early phase of severe acute pancreatitis (AP). This complication can lead to patient death in the very short term. The goal of this review is to provide the surgeon and intensivist with objective information to help them in their decision-making. In the early phase of severe AP, it is essential to monitor intra-vesical pressure (iVP) to allow early diagnosis of intra-abdominal hypertension or ACS. The treatment of ACS is both medical and surgical requiring close collaboration between the surgical and resuscitation teams. Medical treatment includes vascular volume repletion, prokinetic agents, effective curarization and percutaneous drainage of large-volume ascites. If uncontrolled respiratory or cardiac failure develops or if maximum medical treatment fails, most teams favor performing an emergency xipho-pubic decompression laparotomy with laparostomy. This procedure follows the principles of abbreviated laparotomy as described for abdominal trauma.

Partisan pandemic: How partisanship and public health concerns affect individuals' social mobility during COVID-19

Rampant partisanship in the United States may be the largest obstacle to the reduced social mobility most experts see as critical to limiting the spread of the COVID-19 pandemic. Analyzing a total of just over 1.1 million responses collected daily between 4 April and 10 September reveals not only that partisanship is more important than public health concerns for explaining individuals' willingness to stay at home and reduce social mobility but also that the effect of partisanship has grown over time-especially among Republicans. All else equal, the relative importance of partisanship for the increasing (un)willingness of Republicans to stay at home highlights the challenge that politics poses for public health.

Virtual Patient Simulation in Continuing Education: Improving the Use of Guideline-Directed Care in Venous Thromboembolism Treatment

Results of a CME-certified activity completed by a total of 986 cardiologists and 783 haematologists-oncologists (haem-oncs) from around the world were examined to determine whether virtual patient simulation could improve decision-making and performance within the simulation related to patient evaluation, tailoring anticoagulant therapy, and patient management to improve adherence using patient-centred care strategies. Results showed a significant overall impact of education from pre- to post-clinical guidance (CG) on correct decisions made in both cases for cardiologists, with a relative improvement of 22% for Case 1 (45% pre- to 55% post-CG, n = 475, t(474) = 14.12, P<.001, Cohen’s d =.46) and 19% for Case 2 (62% pre- to 74% post-CG, n = 245, t(244) = 11.95, P<.001, Cohen’s d =.59). Impact also was seen for haem-oncs, with a relative improvement of 27% for Case 1 (45% pre- to 57% post-CG, n = 280, t(279) = 11.91, P <.001, Cohen’s d =.60) and 19% for Case 2 (63% pre- to 75% post-CG, n = 147, t(146) = 9.52, P <.001, Cohen’s d =.58). Virtual patient simulation improved cardiologists’ and haem-oncs management of patients with pulmonary embolism in a simulated environment.

Future mechanisms for funding research on unhealthy commodities – criteria for industry-supported research funding programs

Research funding is scarce and some argue that commercial enterprises not only can, but should, fund extramural research. Others are concerned by the evidence that commercial funding of research is used by these commercial interests to subvert the scientific process, to gain credibility and to advance their own financial interests, without regard to broader societal values and needs. A key question is whether there might be a funding model whereby industry-supported research funding programs are acceptable to the public health community and that support broader societal goals. We developed eight criteria for evaluating research funding programs that include support from the tobacco industry: (1) transparency and independence; (2) competitive funding process; (3) ownership of data and freedom to publish; (4) independent research agenda; (5) governance; (6) protection against conflict of interest; (7) industry public relations gains that counteract public health; and, (8) feasibility. We will discuss the applicability of similar programs for funding research on other unhealthy commodities, and on the practices of other harmful industries such as the fossil fuels industry.