Endoscopic Resections in Inflammatory Bowel Disease: A Multicentre European Outcomes Study

BACKGROUND AND AIMS

Inflammatory bowel disease is associated with an increased risk of colorectal cancer, with estimates ranging 2-18%, depending on the duration of colitis. The management of neoplasia in colitis remains controversial. Current guidelines recommend endoscopic resection if the lesion is clearly visible with distinct margins. Colectomy is recommended if complete endoscopic resection is not guaranteed. We aimed to assess the outcomes of all neoplastic endoscopic resections in inflammatory bowel disease.

METHODS

This was a multicentre retrospective cohort study of 119 lesions of visible dysplasia in 93 patients, resected endoscopically in inflammatory bowel disease.

RESULTS

A total of 6/65 [9.2%] lesions <20 mm in size were treated by ESD [endoscopic submucosal dissection] compared with 59/65 [90.8%] lesions <20 mm treated by EMR [endoscopic mucosal resection]; 16/51 [31.4%] lesions >20 mm in size were treated by EMR vs 35/51 [68.6%] by ESD. Almost all patients [97%] without fibrosis were treated by EMR, and patients with fibrosis were treated by ESD [87%], p < 0.001. In all, 49/78 [63%] lesions treated by EMR were resected en-bloc and 27/41 [65.9%] of the ESD/KAR [knife-assisted resection] cases were resected en-bloc, compared with 15/41 [36.6%] resected piecemeal. Seven recurrences occurred in the cohort. Seven complications occurred in the cohort; six were managed endoscopically and one patient with a delayed perforation underwent surgery.

CONCLUSIONS

Larger lesions with fibrosis are best treated by ESD, whereas smaller lesions without fibrosis are best managed by EMR. Both EMR and ESD are feasible in the management of endoscopic resections in colitis.

4300Strain parameters at rest and after exercise in symptomatically stable patients with improved heart failure - STRESS-HF

Background

Optimal medical therapy (OMT) results in improvement in left ventricular (LV) ejection fraction (EF) and reduction in LV size in approximately 40% of patients of heart failure with reduced ejection fraction (HFrEF). Recent studies have proposed to continue treatment in all patients of this subgroup as improvement in LVEF does not indicate actual myocardial recovery. Global Longitudinal strain (GLS) is more sensitive marker of LV systolic function and better predictor of mortality than LVEF. GLS may identify probable patients in whom the therapy can be minimized or stopped.

Aim

To determine global longitudinal strain at rest and after exercise in patients with idiopathic dilated cardiomyopathy (DCM) who have improved LVEF ≥50% on guideline directed medical therapy (GDMT) and compare with resting & exercising LVEF on 3-dimesional (3D).

Material and methods

This Observational study was conducted in a tertiary care referral hospital, from February 2018 to October 2018. All patients with idiopathic DCM who had a documented LVEF of ≤40% in the past and improved LVEF (LVEF ≥50%) on GDMT were included in the study. Patients with secondary causes of HFrEF, poor echocardiographic window and inability to exercise were excluded from the study. Strain parameters were calculated at rest and after atleast 5 METS of exercise. GLS value of ≥ minus 12.6% was considered as mildly reduced strain, ≤ minus 8% as severely reduced strain and the values in between as moderately reduced strain. Post exercise, drop of >5% in absolute LVEF value or decrease in GLS >15% from baseline was considered as poor myocardial recovery.

Results

A total of 44 patients [mean age of 46.8±13.1 years and 24 males (54.5%)] constituted the study group. At the time of diagnosis, 31 (70.5%) patients were in NYHA class II and the remaining were in class III. Duration of GDMT ranged from 4 to 38 (median 12) months. Following improvement on GDMT, 25 (56.8%) were in class I and rest were in class II. Mean LVEF at diagnosis and after recovery was 33.6±4.9% and 55.1±4.5%, respectively with a mean absolute change in LVEF of 21.3±6.1%. At rest, mean 3D LVEF was 53±3.5% and GLS was −12.3±3.1. Mild, moderate and severely reduced strain was seen in 24 (54.5%), 13 (29.6%) and 7 (15.9%), respectively. After exercise, mean 3D LVEF was 51.5.±4.5% (mean decrease 1.5±2.1%) and mean GLS was −7±4.2% (mean decrease −5.3±4.6%). After exercise, none had a fall of LVEF >5% however 32 (72.7%) had a decrease of >15% in GLS. Seven (15.9%) patients had improvement in GLS, 4 (9.1%) had <15% decrease and 1 (2.3%) showed no change in GLS on exercise. The change in GLS on exercise was significant (p=0.001), but change in 3D LVEF was not significant (p=0.956).

Conclusion

Global longitudinal strain is a better marker for assessing myocardial recovery than LVEF in patients of heart failure with improved ejection fraction.

Acknowledgement/Funding

None

Abstract CT065: A Phase I clinical trial: Use of 4-demethyl-4-cholesteryl- oxycarbonyl-penclomedine (DM-CHOC-PEN) plus radiation as treatments for cancers involving the CNS

Purpose: 4-Demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) is a poly-chlorinated pyridine cholesteryl carbonate with a MOA via bis-alkylation of DNA @ N7-guanine and N4-cytosine that has completed Phase II studies [AACR, #CT129, 2017] in subjects with cancers involving the CNS. Four (4) subjects in the Phase I/II trials required surgery for persistent CNS lesions following DM-CHOC-PEN therapy with 39-98.8 mg/m2 of drug. DM-CHOC-PEN was identified in samples from all 4-subjects - 90-212 ng/g tumor. Thus, the drug penetrates the CNS and tumors and is available to act as a radiosensitizer; the latter has been supported with in vitro studies [AACR, #4746, 2017]. The current presentation reviews Phase I clinical data that supports the safety, dose-tolerance and use for DM-CHOC-PEN plus radiation in subjects with cancers involving the CNS - IND 68,876.

Patients & Methods: DM-CHOC-PEN was administered as a 3-hr IV infusion once to subjects with advanced cancer involving the CNS. A single dose (39 mg/m2 to 98.7 mg/m2 in escalating Phase I scheme) was administered once 3-weeks prior to receiving stereotaxic radio-surgery (SRS), gamma knife or whole brain irradiation (WBRT) therapy. Radiation was administered in doses of 15-30 Gy depending on the size and number of lesions.

Results: Thirteen (13) subjects with cancer involving the CNS have been treated to date with DM-CHOC-PEN (6-NSCLC, 1-breast, 1-melanoma, 2-GBM & 3-sarcomas). Subjects received 39, 50, 70, 86.8 or 98.7 mg/m2 and 15-30 Gy of radiation. The drug/radiation combination was well tolerated. One (1) subject with NSCLC did develop vasogenic edema and tumor necrosis which resolved and the subject is in complete remission 42+ mos. A second subject with a recurrent GBM with confusion progressed - Gr-3. Ten (10) of the thirteen (13) subjects have had objective results (OS 8-54+ mos.) Bioavailability for DM-CHOC-PEN revealed a rebound phenomenon @ ~ 50 hours post-infusion with a T-release of 26.7 h. The same phenomenon was observed with RBCs (estimation using Monolix 3.2). DM-CHOC-PEN was detected bound to RBCs for 3-days (after 70 mg/m2) and was also detected in the urine (Cmax=17.5 µg/mL) until day 15. The AUC was linear for all doses. Pre-clinical radiosensitization in vitro studies [AACR #1917, 2017] support the present trial study result. Photon induced charge transfer reactions with DM-CHOC-PEN will be discussed as a MOA.

Conclusion: Data is presented that documents effectiveness and safety of DM-CHOC-PEN plus radiation as therapy for subjects with cancers involving the CNS. Observations during Phase I/II clinical trials with DM-CHOC-PEN alone supported the drug’s persistent presence in human tumors after systemic administration and possible positive effects on response to subsequent radiation. Complete data on subject responses and observed toxicities will be presented. Supported by - NCI/SBIR grants - R43 CA213545-02 and NIH NIGMS 1 U54 GM104940 - the latter funds the Louisiana Clinical and Translational Science Center.

Citation Format: RS Weiner, T Mahmood, Lee Roy Morgan, K. Harris, A. Baghian, SJ DiBiase, P. Friedlander, ML Ware, R. Kawauchi, J. Herman, M. Bhandari. A Phase I clinical trial: Use of 4-demethyl-4-cholesteryl- oxycarbonyl-penclomedine (DM-CHOC-PEN) plus radiation as treatments for cancers involving the CNS [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT065.

Abstract P2-13-01: Efficacy of neratinib in hormone receptor-positive patients who initiated treatment within 1 year of completing trastuzumab-based adjuvant therapy in HER2+ early-stage breast cancer: Subgroup analyses from the phase III ExteNET trial

Background: The international, randomized, placebo-controlled phase III ExteNET trial showed that 1 year (yr) of neratinib 240 mg/day after trastuzumab-based adjuvant therapy significantly improved invasive disease-free survival (iDFS) in 2840 patients with early-stage HER2+ breast cancer at 2 yr (hazard ratio 0.67; 95% CI 0.50–0.91; p=0.009) [Chan 2016] and 5 yr (hazard ratio 0.73; 95% CI 0.57-0.92; p=0.008) [Martin 2017]. A prespecified subgroup analysis by hormone receptor (HR) status suggested enhanced efficacy with neratinib in patients with HR+ (2-yr hazard ratio 0.51; 95% CI 0.33–0.77) vs. HR– tumors (2-yr hazard ratio 0.93; 95% CI 0.60–1.43). The efficacy of neratinib was also greater in patients who initiated treatment within 1 yr of prior trastuzumab compared with those who started neratinib later. The European Medicines Agency's Committee for Medicinal Products for Human Use recently recommended neratinib for use in patients with HR+ tumors who initiate treatment within 1 yr of completing trastuzumab-based adjuvant therapy. Subgroup analyses from ExteNET examining iDFS benefits in this patient population are presented here.

Methods: Patients with early-stage HER2+ breast cancer who completed trastuzumab-based (neo)adjuvant therapy were assigned to oral neratinib 240 mg/day or placebo for 1 yr. Randomization was stratified by HR status (determined locally before trial entry), nodal status, and trastuzumab regimen. Endocrine therapy was allowed in patients with HR+ disease. The primary endpoint, iDFS, was tested by 2-sided log-rank test and hazard ratios (95% CI) were estimated using Cox proportional hazards models. Kaplan-Meier methods were used to estimate iDFS rates. Secondary endpoints were DFS-DCIS, time to distant recurrence, distant DFS, and CNS recurrences. The primary analysis was conducted at 2 yr, and a sensitivity analysis conducted at 5 yr. Clinicaltrials.gov:NCT00878709.

Results: Of the 2840 patients (neratinib, n=1420; placebo, n=1420), 1631 (57%) had HR+ disease (neratinib, n=816; placebo, n=815). Most (93%) HR+ patients were receiving endocrine therapy at baseline. 1334 of 1631 (82%) patients with HR+ tumors were randomized to start neratinib within 1 yr of last trastuzumab dose (neratinib, n=670; placebo, n=664). iDFS benefits from neratinib in this population are shown in the table. Secondary endpoints were also improved with neratinib vs. placebo in this population. Safety data in this subset will be presented at the meeting.

Table. iDFS in patients with an interval between last trastuzumab dose and randomization of ≤1 yr

 HR+ population (N=1334)ITT population (N=2297)  Hazard ratiob  Hazard ratiob  Δ, %a(95% CI)P-valueΔ, %a(95% CI)P-value2-yr analysisc+4.50.490.002+2.90.630.006  (0.30–0.78)  (0.45–0.88) 5-yr analysisd+5.10.580.002+3.20.700.006  (0.41–0.82)  (0.54–0.90) aDifference in iDFS rates between neratinib vs. placebo; bNeratinib vs. placebo; cData cut-off: July 2014; dData cut-off: March 2017

Conclusions: Neratinib may have enhanced and sustained efficacy in patients with HR+ disease who initiate treatment within 1 yr of trastuzumab-based adjuvant therapy.

Citation Format: Gnant M, Martin M, Holmes F-A, Jackisch C, Chia SK, Iwata H, Moy B, Martinez N, Mansi J, Morales S, Ruiz-Borrego M, von Minckwitz G, Buyse M, Delaloge S, Bhandari M, Murias Rosales A, Galeano T, Fujita T, Luczak A, Barrios CH, Saura C, Rugo HS, Chien J, Johnston SR, Spencer M, Xu F, Barnett B, Chan A, Ejlertsen B. Efficacy of neratinib in hormone receptor-positive patients who initiated treatment within 1 year of completing trastuzumab-based adjuvant therapy in HER2+ early-stage breast cancer: Subgroup analyses from the phase III ExteNET trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-13-01.

Does the chromagen blue filter lens affect the reading speed, accuracy and contrast sensitivity

PURPOSE

To determine the effects of ChromaGen blue filter lens in reading speed, accuracy and contrast sensitivity.

METHODS

A cross-over, randomised study was carried out on 40 individuals (11 males and 29 females) aged 21 to 30 years. The rate of reading and reading accuracy was calculated with and without ChromaGen blue filter lens in all subjects. Wilkins Rate of Reading Test was used to measure the rate of reading and reading accuracy. Contrast sensitivity was also evaluated by using with and without the ChromaGen blue filter lens.

RESULTS

The mean rate of reading with and without ChromaGen blue filter lens was 160.58±16.03 words per minute and 150.52±15.66 words per minute respectively, with significant difference of p<0.001. The mean of reading accuracy (words correctly read per minute) in subjects, with ChromaGen blue filter was 149.30±0.79 words and without using filter lens was 148.53±1.11 words and found to be significant (p<0.001). There was no significant difference in the contrast sensitivity between subjects with and without the ChromaGen blue filter lens (p=0.083). No significant correlation was noted between the reading speed with age, spherical equivalent, contrast sensitivity, and reading accuracy.

CONCLUSION

This study concludes that there was an increase of 6.68% in the rate of reading and improvement of 0.52% in accuracy among subjects with ChromaGen blue filter lens.

A systematic review of meta-analyses in orthopaedic surgery between 2000 and 2016

AIMS

The aims of this systematic review were to describe the quantity and methodological quality of meta-analyses in orthopaedic surgery published during the last 17 years.

MATERIALS AND METHODS

MEDLINE, EMBASE, and PubMed, between 1 January 2000 and 31 December 2016, were searched for meta-analyses in orthopaedic surgery dealing with at least one surgical intervention. Meta-analyses were included if the interventions involved a human muscle, ligament, bone or joint.

RESULTS

A total of 392 meta-analyses met eligibility criteria, for which the mean AMSTAR quality score was 7.1/11. There was a positive correlation between the year of publication and the quality of the meta-analysis (r = 0.238, p < 0.001). Between 2000 and 2011, the mean AMSTAR score corresponded to that of a medium quality review. However, between 2012 and 2016, the mean scores have been consistently equivalent to those of a high-quality review. The number of meta-analyses published increased 10-fold between 2005 and 2014.

CONCLUSION

The quantity and quality of meta-analyses in orthopaedic surgery which have been published has increased, reaching a plateau in 2012. Methodological flaws remain to be addressed in future meta-analyses in order to continue increasing the quality of the orthopaedic literature. Cite this article: Bone Joint J 2018;100-B:1270-4.

Deficits in preference-based health-related quality of life after complications associated with tibial fracture

Aims

The aims of this study were to quantify health state utility values (HSUVs) after a tibial fracture, investigate the effect of complications, to determine the trajectory in HSUVs that result in these differences and to quantify the quality-adjusted life years (QALYs) experienced by patients.

Patients and Methods

This is an analysis of 2138 tibial fractures enrolled in the Fluid Lavage of Open Wounds (FLOW) and Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trials. Patients returned for follow-up at two and six weeks and three, six, nine and 12 months. Short-Form Six-Dimension (SF-6D) values were calculated and used to calculate QALYs.

Results

Compared with those who did not have a complication, those with a complication treated either nonoperatively or operatively had lower HSUVs at all times after two weeks. The HSUVs improved in all patients with the passage of time. However, they did not return to the remembered baseline preinjury values nor to US age-adjusted normal values by 12 months after the injury.

Conclusion

While the acute fracture and complications may have resolved clinically, the detrimental effect on a patient’s quality of life persists up to 12 months after the injury. Cite this article: Bone Joint J 2018;100-B:1227–33.

Abstract CT119: Early phase I clinical trial results for 4-demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) plus radiation in cancers involving the CNS

Purpose:4-Demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) is a poly-chlorinated pyridine cholesteryl carbonate with a mechanism of action (MOA) via bis-alkylation of DNA @ N7-guanine and N4-cytosine that has completed Phase I/II studies [AACR, 58, #CT129, 2017] in subjects with cancers involving the CNS. Four (4) subjects in the Phase I/II trials required surgery for persistent CNS lesions following DM-CHOC-PEN therapy and DM-CHOC-PEN was identified in samples from all 4-subjects - 90-212 ng/g tumor [subjects had been treated with 39-98.8 mg/m2 of drug]. Thus, the drug penetrates the CNS and concentrates in tumors. It is available, therefore, to act as a radiosensitizer as demonstrated in in vitro studies [AACR, 58, #4746, 2017]. The current presentation reviews Phase I clinical data that supports the safety, dose-tolerance, and use of DM-CHOC-PEN with radiation in subjects with cancers involving the CNS - IND 68,876.

Patients & Methods: DM-CHOC-PEN was administered as a 3-hr IV infusion once every 21 days to subjects with advanced cancer involving the CNS. A single dose was administered prior to standard radiation therapy. The dose was escalated from 39 mg/m2 to 98.7 mg/m2 I.X1, then 3-weeks later the subject received stereotaxic radio-surgery (SRS) or whole brain irradiation (WBRT). Total radiation administered was 15-30 Gy depending on the size and number of lesions.

Results: Nine (9) subjects with cancer involving the CNS have been treated to date - (6-NSCLC, 1-breast, 1-melanoma & 1-sarcoma). Subjects received 39, 55, 70, 86.8 or 98.7 mg/m2 followed by 15-30 Gy of radiation. The drug/radiation combination was well tolerated. One (1) subject with NSCLC developed vasogenic edema and tumor necrosis which resolved; that subject is in complete remission 31+ mos. Six out of nine subjects have had objective responses (OS 4 - 42+ mos.) Bioavailability for DM-CHOC-PEN revealed a rebound phenomenon @ ~ 50 hours post-infusion with a T-release of 26.7 h. The same phenomenon was observed with RBCs (estimation using Monolix 3.2). DM-CHOC-PEN was detected bound to RBCs for 3-days (after 70 mg/m2); DM-CHOC-PEN was also detected in the urine (Cmax=17.5 µg/mL) until day 15. The AUC was linear for all doses. Pre-clinical in vitro studies supported the clinical data: NSCLC cells treated with DM-CHOC-PEN (0.1 -1.0 µg/mL) demonstrated 50 & 100% cytotoxicity @ 0.4 & 1.0 µg/mL. For radiation alone (6, 9 &12 Gy) - cell kill was 20 & 65% @ 6 & 12 Gy [100% kill was not observed at this dose range]; for DM-CHOC-PEN (0.25 µg/mL) plus radiation (6-12 Gy) - cell kill was 80 & 100% @ 6 & 12 Gy. Photon induced charge transfer reactions with DM-CHOC-PEN will be discussed.

Conclusion: Preliminary data is presented that supports enhanced cytotoxicity and safety of DM-CHOC-PEN plus radiation as therapy for subjects with cancers involving the CNS. Observations during Phase I/II clinical trials with DM-CHOC-PEN alone support the drug's persistent presence in human tumors after systemic administration and possible positive effects on response to subsequent radiation. Complete data on subject responses and observed toxicities will be presented. Supported by - NCI/SBIR grants - R43 CA213545-01 and NIH NIGMS 1 U54 GM104940 - the latter funds the Louisiana Clinical and Translational Science Center.

Citation Format: LR Morgan, T Mahmood, R S. Weiner, R Kawauchi, M Bhandari, K Devisitty, J Herman, R Summe, ML Ware, P Friedlander, AH Rodgers. Early phase I clinical trial results for 4-demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) plus radiation in cancers involving the CNS [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT119.

Factors associated with health-related quality of life, hip function, and health utility after operative management of femoral neck fractures

Aims

The primary aim of this prognostic study was to identify baseline factors associated with physical health-related quality of life (HRQL) in patients after a femoral neck fracture. The secondary aims were to identify baseline factors associated with mental HRQL, hip function, and health utility.

Patients and Methods

Patients who were enrolled in the Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH) trial completed the 12-item Short Form Health Survey (SF-12), Western Ontario and McMaster Universities Arthritis Index, and EuroQol 5-Dimension at regular intervals for 24 months. We conducted multilevel mixed models to identify factors potentially associated with HRQL.

Results

The following were associated with lower physical HRQL: older age (-1.42 for every ten-year increase, 95% confidence interval (CI) -2.17 to -0.67, p < 0.001); female gender (-1.52, 95% CI -3.00 to -0.05, p = 0.04); higher body mass index (-0.69 for every five-point increase, 95% CI -1.36 to -0.02, p = 0.04); American Society of Anesthesiologists class III ( versus class I) (-3.19, 95% CI -5.73 to -0.66, p = 0.01); and sustaining a displaced fracture (-2.18, 95% CI -3.88 to -0.49, p = 0.01). Additional factors were associated with mental HRQL, hip function, and health utility.

Conclusion

We identified several baseline factors associated with lower HRQL, hip function, and utility after a femoral neck fracture. These findings may be used by clinicians to inform treatment and outcomes. Cite this article: Bone Joint J 2018;100-B:361-9.

Utilization of pelvic lymph node dissection in patients undergoing robot-assisted radical prostatectomy in India versus the United States - A Vattikuti Collective Quality Initiative database analysis

BACKGROUND

The utilization and extent of pelvic lymph node dissection (PLND) varies depending on the disease and practice patterns.

AIMS

This study compares practice patterns in utilization of PLND between Indian and United States (US) practices.

SETTINGS AND DESIGN

We focused on 415 patients (204 India; 211 US) prostate cancer patients treated with robot-assisted radical prostatectomy, between 2015 and 2016, within the Vattikuti Collective Quality Initiative database.

SUBJECTS AND METHODS

Utilization of PLND and number of nodes removed were evaluated for the entire cohort, and after stratifying for Country of treatment and D'Amico risk groups. Logistic regression tested the relationship between PLND and country of treatment, after adjusting for disease risk.

RESULTS

Indian patients had a higher risk distribution (D'Amico high-risk 53.4% in India vs. 27% in the US; P< 0.001) compared to their US counterparts. Overall, 193/204 (94.6%) Indian patients underwent PLND versus 181/211 (85.8%) US patients (P = 0.003). When stratified based on disease risk, PLND was performed more frequently in Indian patients with low-risk disease (81.0% vs. 41.4%,P= 0.008), but not in those with intermediate and high-risk disease. On multivariable analysis, Indian patients had a 2.57-fold higher probability of undergoing PLND than their US counterparts (P = 0.02). The analysis of the number of lymph nodes removed showed similar trends.

CONCLUSIONS

Indian patients are more likely to undergo PLND than US patients. This is, especially true for patients with low-risk disease, who are unlikely to benefit from this procedure. Efforts should focus on optimizing the utilization of PLND, and deliver it only when there is clinical indication.

Wound irrigation does not affect health-related quality of life after open fractures: results of a randomized controlled trial

AIMS

The Fluid Lavage in Open Fracture Wounds (FLOW) trial was a multicentre, blinded, randomized controlled trial that used a 2 × 3 factorial design to evaluate the effect of irrigation solution (soap versus normal saline) and irrigation pressure (very low versus low versus high) on health-related quality of life (HRQL) in patients with open fractures. In this study, we used this dataset to ascertain whether these factors affect whether HRQL returns to pre-injury levels at 12-months post-injury.

PATIENTS AND METHODS

Participants completed the Short Form-12 (SF-12) and the EuroQol-5 Dimensions (EQ-5D) at baseline (pre-injury recall), at two and six weeks, and at three, six, nine and 12-months post-fracture. We calculated the Physical Component Score (PCS) and the Mental Component Score (MCS) of the SF-12 and the EQ-5D utility score, conducted an analysis using a multi-level generalized linear model, and compared differences between the baseline and 12-month scores.

RESULTS

We found no clinically important differences between irrigating solutions or pressures for the SF-12 PCS, SF-12 MCS and EQ-5D. Irrespective of treatment, participants had not returned to their pre-injury function at 12-months for any of the three outcomes (p < 0.001).

CONCLUSION

Neither the composition of the irrigation solution nor irrigation pressure applied had an effect on HRQL. Irrespective of treatment, patients had not returned to their pre-injury HRQL at 12 months post-fracture. Cite this article: Bone Joint J 2018;100-B:88-94.

Are the patient-rated wrist evaluation (PRWE) and the disabilities of the arm, shoulder and hand (DASH) questionnaire used in distal radial fractures truly valid and reliable?

Objectives

The patient-rated wrist evaluation (PRWE) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire are patient-reported outcome measures (PROMs) used for clinical and research purposes. Methodological high-quality clinimetric studies that determine the measurement properties of these PROMs when used in patients with a distal radial fracture are lacking. This study aimed to validate the PRWE and DASH in Dutch patients with a displaced distal radial fracture (DRF).

Methods

The intraclass correlation coefficient (ICC) was used for test-retest reliability, between PROMs completed twice with a two-week interval at six to eight months after DRF. Internal consistency was determined using Cronbach’s α for the dimensions found in the factor analysis. The measurement error was expressed by the smallest detectable change (SDC). A semi-structured interview was conducted between eight and 12 weeks after DRF to assess the content validity.

Results

A total of 119 patients (mean age 58 years (sd 15)), 74% female, completed PROMs at a mean time of six months (sd 1) post-fracture. One overall meaningful dimension was found for the PRWE and the DASH. Internal consistency was excellent for both PROMs (Cronbach’s α 0.96 (PRWE) and 0.97 (DASH)). Test-retest reliability was good for the PRWE (ICC 0.87) and excellent for the DASH (ICC 0.91). The SDC was 20 for the PRWE and 14 for the DASH. No floor or ceiling effects were found. The content validity was good for both questionnaires.

Conclusion

The PRWE and DASH are valid and reliable PROMs in assessing function and disability in Dutch patients with a displaced DRF. However, due to the high SDC, the PRWE and DASH are less useful for individual patients with a distal radial fracture in clinical practice.

Cite this article: Y. V. Kleinlugtenbelt, R. G. Krol, M. Bhandari, J. C. Goslings, R. W. Poolman, V. A. B. Scholtes. Are the patient-rated wrist evaluation (PRWE) and the disabilities of the arm, shoulder and hand (DASH) questionnaire used in distal radial fractures truly valid and reliable? Bone Joint Res 2018;7:36–45. DOI: 10.1302/2046-3758.71.BJR-2017-0081.R1.

Low-intensity pulsed ultrasound for treatment of tibial fractures: an economic evaluation of the TRUST study

AIMS

This 501-patient, multi-centre, randomised controlled trial sought to establish the effect of low-intensity, pulsed, ultrasound (LIPUS) on tibial shaft fractures managed with intramedullary nailing. We conducted an economic evaluation as part of this trial.

PATIENTS AND METHODS

Data for patients' use of post-operative healthcare resources and time taken to return to work were collected and costed using publicly available sources. Health-related quality of life, assessed using the Health Utilities Index Mark-3 (HUI-3), was used to derive quality-adjusted life years (QALYs). Costs and QALYs were compared between LIPUS and control (a placebo device) from a payer and societal perspective using non-parametric bootstrapping. All costs are reported in 2015 Canadian dollars unless otherwise stated.

RESULTS

With a cost per device of $3,995, the mean cost was significantly higher for patients treated with LIPUS versus placebo from a payer (mean increase = $3647, 95% confidence interval (CI) $3244 to $4070; p < 0.001) or a societal perspective (mean increase = $3425, 95% CI $1568 to $5283; p < 0.001). LIPUS did not provide a significant benefit in terms of QALYs gained (mean difference = 0.023 QALYs, 95% CI -0.035 to 0.069; p = 0.474). Incremental cost-effectiveness ratios of LIPUS compared with placebo were $155 433/QALY from a payer perspective and $146 006/QALY from a societal perspective.

CONCLUSION

At the current price, LIPUS is not cost-effective for fresh tibial fractures managed with intramedullary nailing. Cite this article: Bone Joint J 2017;99-B:1526-32.

Abstract CT052: Clinical trial results for 4-demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) in cancers involving the CNS

Background: 4-Demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) is a poly-chlorinated pyridine cholesteryl carbonate with a MOA via bis-alkylation of DNA @ N7-guanine and N4-cytosine that has completed Phase I and II trials (the latter on subjects with CNS involvement) [AACR #1185, 2013; AACR #CT 129]. The primary aim was to assess clinical response and secondary aims to monitor toxicities/safety and verify the MTDs for IV administered DM-CHOC-PEN that derived in Phase I study (IND 68,876). We report here the responses and toxicities seen in all the subjects treated.

Subjects & Methods: In Phase I, DM-CHOC-PEN was administered as a 3-hr IV infusion once every 21 days to subjects with advanced cancer; cohorts received escalating doses from 39 - 111 mg/m2. The Phase II dose schedule was 2-tiered: 85.8 mg/m2 for subjects with liver involvement and 98.7 mg/m2 for subjects with normal livers.

Results: Fifty two (52) subjects have been treated to date - 25 in Phase I (cancer subjects with or without CNS involvement) and 27 in Phase II (with CNS involvement). The common tumor types treated were primary brain cancers and melanoma, breast, and lung cancers involving the CNS. The drug was well tolerated; the most common adverse effects were fatigue (17%), reversible liver dysfunction (9%) and nausea (11%). No neuro/psychological, hematological, cardiac or renal toxicities were observed. PK modeling revealed that AUCs were parallel for all dose levels (39-111 mg/m2). The Cmax for DM-CHOC-PEN and DM-PEN (4-demethylpenclomedine, a metabolite) were 3 and 24 hours, respectively. Both DM-CHOC-PEN and DM-PEN were detected 3 to 15 days after administration associated (up to 50%) with rbcs. Of interest, young adults (&lt;40 y/o) demonstrated significant increases in Cmax and AUC vs. older subjects, supporting the need for trials in adolescents and young adults. DM-CHOC-PEN was also detected in CNS tumor tissue obtained surgically from five (5) subjects - in concentrations of 75-210 ng/g, 22 days to 9 mos. post treatments at doses of 39 or 98.7 mg/m2 of drug. To date, 16 subjects with lung cancer (11 with NSCLC involving the CNS) have been treated. Seven of the 11 subjects with NSCLC involving the CNS (incl. 6 with cerebellar disease) have responded with CR/PR (RECIST 1.1) and improved OS/QOL/PFS (Kaplan-Meier) lasting 8+ - 32+ mos. Conclusion: DM-CHOC-PEN is safe at these dose levels and has produced objective responses with manageable toxicities in subjects with cancer involving the CNS. Complete data on subject responses and observed toxicities will be presented. We propose a 3-stage mechanism for drug entry into the CNS and into NSCLC cells via reversible binding with RBCs and then associated with L-glutamine transport into cells. Supported by NCI/SBIR grants - R43/44CA132257 and NIH NIGMS 1 U54 GM104940 - the latter funds the Louisiana Clinical and Translational Science Center.

Citation Format: Roy S. Weiner, Lee Roy Morgan, T Mahmood, R. Kawauchi, C. Gordon, ML Ware, M. Matrana, TM Cosgriff, AH Rodgers, G. Bastian, M. Bhandari, J-J Zou. Clinical trial results for 4-demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) in cancers involving the CNS [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr CT052. doi:10.1158/1538-7445.AM2017-CT052

Can experienced surgeons predict the additional value of a CT scan in patients with displaced intra-articular distal radius fractures?

There are no clear guidelines when an additional CT scan should be obtained for the treatment of displaced intra-articular distal radius fractures (DRF). This study aimed to investigate whether surgeons can predict the usefulness of CT scans to facilitate choice of treatment plan and/or pre-operative planning for DRF. Four surgeons evaluated 51 patients with displaced DRF. The choice of treatment (operative or nonoperative) was based on conventional radiographs. Subsequently, the surgeons were asked whether they would have requested an additional CT scan to determine this treatment choice, and also whether they required a CT scan for pre-operative planning. After 4 weeks, the additional CT scan was provided and the cases were assessed again. Based on these data, we calculated the number needed to scan (NNS) and number needed to harm (NNH) for two decision models. Model 1: Only provide a CT scan if the surgeon requested one based on their judgment of the X-rays. Model 2: CT scans for all displaced intra-articular DRF. For choice of treatment, the NNS was lower for model 1 than for model 2 (2.6 vs. 4.3) and the NNH is higher for model 1 (3.1 vs. 1.3). For pre-operative planning, the NNS (1.3 vs. 1.4) and NNH (3.7 vs. 3.4) were comparable for both models. Surgeons are able to predict the usefulness of an additional CT scan for intra-articular displaced DRF for OR indication. However, for pre-operative planning the usefulness of a CT scan is much harder to predict.

The inter-rater reliability of the diagnosis of surgical site infection in the context of a clinical trial

OBJECTIVES

The diagnosis of surgical site infection following endoprosthetic reconstruction for bone tumours is frequently a subjective diagnosis. Large clinical trials use blinded Central Adjudication Committees (CACs) to minimise the variability and bias associated with assessing a clinical outcome. The aim of this study was to determine the level of inter-rater and intra-rater agreement in the diagnosis of surgical site infection in the context of a clinical trial.

MATERIALS AND METHODS

The Prophylactic Antibiotic Regimens in Tumour Surgery (PARITY) trial CAC adjudicated 29 non-PARITY cases of lower extremity endoprosthetic reconstruction. The CAC members classified each case according to the Centers for Disease Control (CDC) criteria for surgical site infection (superficial, deep, or organ space). Combinatorial analysis was used to calculate the smallest CAC panel size required to maximise agreement. A final meeting was held to establish a consensus.

RESULTS

Full or near consensus was reached in 20 of the 29 cases. The Fleiss kappa value was calculated as 0.44 (95% confidence interval (CI) 0.35 to 0.53), or moderate agreement. The greatest statistical agreement was observed in the outcome of no infection, 0.61 (95% CI 0.49 to 0.72, substantial agreement). Panelists reached a full consensus in 12 of 29 cases and near consensus in five of 29 cases when CDC criteria were used (superficial, deep or organ space). A stable maximum Fleiss kappa of 0.46 (95% CI 0.50 to 0.35) at CAC sizes greater than three members was obtained.

CONCLUSIONS

There is substantial agreement among the members of the PARITY CAC regarding the presence or absence of surgical site infection. Agreement on the level of infection, however, is more challenging. Additional clinical information routinely collected by the prospective PARITY trial may improve the discriminatory capacity of the CAC in the parent study for the diagnosis of infection.Cite this article: J. Nuttall, N. Evaniew, P. Thornley, A. Griffin, B. Deheshi, T. O'Shea, J. Wunder, P. Ferguson, R. L. Randall, R. Turcotte, P. Schneider, P. McKay, M. Bhandari, M. Ghert. The inter-rater reliability of the diagnosis of surgical site infection in the context of a clinical trial. Bone Joint Res 2016;5:347-352. DOI: 10.1302/2046-3758.58.BJR-2016-0036.R1.

Retractions in orthopaedic research: A systematic review

Objectives

Despite the fact that research fraud and misconduct are under scrutiny in the field of orthopaedic research, little systematic work has been done to uncover and characterise the underlying reasons for academic retractions in this field. The purpose of this study was to determine the rate of retractions and identify the reasons for retracted publications in the orthopaedic literature.

Methods

Two reviewers independently searched MEDLINE, EMBASE, and the Cochrane Library (1995 to current) using MeSH keyword headings and the ‘retracted’ filter. We also searched an independent website that reports and archives retracted scientific publications (www.retractionwatch.com). Two reviewers independently extracted data including reason for retraction, study type, journal impact factor, and country of origin.

Results

One hundred and ten retracted studies were included for data extraction. The retracted studies were published in journals with impact factors ranging from 0.000 (discontinued journals) to 13.262. In the 20-year search window, only 25 papers were retracted in the first ten years, with the remaining 85 papers retracted in the most recent decade. The most common reasons for retraction were fraudulent data (29), plagiarism (25) and duplicate publication (20). Retracted articles have been cited up to 165 times (median 6; interquartile range 2 to 19).

Conclusion

The rate of retractions in the orthopaedic literature is increasing, with the majority of retractions attributed to academic misconduct and fraud. Orthopaedic retractions originate from numerous journals and countries, indicating that misconduct issues are widespread. The results of this study highlight the need to address academic integrity when training the next generation of orthopaedic investigators.

Cite this article: J. Yan, A. MacDonald, L-P. Baisi, N. Evaniew, M. Bhandari, M. Ghert. Retractions in orthopaedic research: A systematic review. Bone Joint Res 2016;5:263–268. DOI: 10.1302/2046-3758.56.BJR-2016-0047.

Total medical costs of treating femoral neck fracture patients with hemi- or total hip arthroplasty: a cost analysis of a multicenter prospective study

The aim of this study was to determine the total medical costs for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients. The mean total costs per patient at 2 years of follow-up were €26,399. These results contribute to cost awareness.

INTRODUCTION

The absolute number of hip fractures is rising and increases the already significant burden on society. The aim of this study was to determine the mean total medical costs per patient for treating displaced femoral neck fractures with hemi- or total hip arthroplasty in fit elderly patients.

METHODS

The population was the Dutch sample of an international randomized controlled trial consisting of femoral neck fracture patients treated with hemi- or total hip arthroplasty. Patient data and health care utilization were prospectively collected during a total follow-up period of 2 years. Costs were separated into costs for hospital care during primary stay, hospital costs for clinical follow-up, and costs generated outside the hospital during rehabilitation. Multiple imputations were used to account for missing data.

RESULTS

Data of 141 participants (mean age 81 years) were included in the analysis. The 2-year mortality rate was 19 %. The mean total cost per patient after 10 weeks of follow-up was €15,216. After 1 and 2 years of follow-up the mean total costs were €23,869 and €26,399, respectively. Rehabilitation was the main cost determinant, and accounted for 46 % of total costs. Primary hospital admission days accounted for 22 % of the total costs, index surgery for 11 %, and physical therapy for 7 %.

CONCLUSIONS

The main cost determinants for hemi- or total hip arthroplasty after treatment of displaced femoral neck fractures (€26,399 per patient until 2 years) were rehabilitation and nursing homes. Most of the costs were made in the first year. Reducing costs after hip fracture surgery should focus on improving the duration and efficiency of the rehabilitation phase.