Effect of antibiotic prophylaxis for preventing infectious complications following impacted mandibular third molar surgery. A randomized controlled trial

Background

The objective of this study was to determine the effect of antibiotic prophylaxis in preventing postoperative infections after extraction of impacted mandibular third molars.

Material and Methods

A Parallel-group, randomized, blind, placebo-controlled trial was performed. 154 patients were randomly allocated to 2 groups; experimental (n=77) receiving 2g amoxicillin 1 hour prior to surgery and control (n=77) receiving placebo. Primary outcome was postoperative infections and secondary outcome was the need for rescue analgesia.

Results

4.5% of patients developed postoperative infections, five patients of the control group (4 alveolar osteitis, 1 surgical site infection) and two of the experimental group (1 alveolar osteitis, 1 surgical site infection). Difference between groups was not statistically significant, RR=0.4 (95%CI 0.08-1.99, 𝘱=0.41) NNTB=26. Rescue analgesia intake was significantly higher in the control group (41 vs 18 patients of experimental group) RR=0.49 (95%CI 0.32-0.75, 𝘱<0.05) NNTB=3.

Conclusions

The use of 2g amoxicillin 1 hour before surgery was not effective in significantly reducing the risk of postoperative infections from impacted mandibular third molars extraction, when compared to placebo. Nevertheless, antibiotic prophylaxis was associated with a reduced need for rescue analgesia.

Key words:Antibiotic prophylaxis, third molar, tooth extraction, impacted tooth, dry socket, surgical wound infection, oral surgery.

First-line nivolumab plus ipilimumab with two cycles of chemotherapy versus chemotherapy alone (four cycles) in advanced non-small-cell lung cancer: CheckMate 9LA 2-year update

BACKGROUND

To further characterize survival benefit with first-line nivolumab plus ipilimumab with two cycles of chemotherapy versus chemotherapy alone, we report updated data from the phase III CheckMate 9LA trial with a 2-year minimum follow-up.

PATIENTS AND METHODS

Adult patients were treatment naïve, with stage IV/recurrent non-small-cell lung cancer, no known sensitizing EGFR/ALK alterations, and an Eastern Cooperative Oncology Group performance status ≤1. Patients were randomized 1 : 1 to nivolumab 360 mg every 3 weeks plus ipilimumab 1 mg/kg every 6 weeks with two cycles of chemotherapy, or four cycles of chemotherapy. Updated efficacy and safety outcomes are reported, along with progression-free survival (PFS) after next line of treatment (PFS2), treatment-related adverse events (TRAEs) by treatment cycle, and efficacy outcomes in patients who discontinued all treatment components in the experimental arm due to TRAEs.

RESULTS

With a median follow-up of 30.7 months, nivolumab plus ipilimumab with chemotherapy continued to prolong overall survival (OS) versus chemotherapy. Median OS was 15.8 versus 11.0 months [hazard ratio 0.72 (95% confidence interval 0.61-0.86)]; 2-year OS rate was 38% versus 26%. Two-year PFS rate was 20% versus 8%. ORR was 38% versus 25%, respectively; 34% versus 12% of all responses were ongoing at 2 years. Median PFS2 was 13.9 versus 8.7 months. Improved efficacy outcomes in the experimental versus control arm were observed across most subgroups, including by programmed death-ligand 1 and histology. No new safety signals were observed; onset of grade 3/4 TRAEs was mostly observed during the first two treatment cycles in the experimental arm. In patients who discontinued all components of nivolumab plus ipilimumab with chemotherapy treatment due to TRAEs (n = 61) median OS was 27.5 months; 56% of responders had an ongoing response ≥1 year after discontinuation.

CONCLUSIONS

With a 2-year minimum follow-up, nivolumab plus ipilimumab with two cycles of chemotherapy provided durable efficacy benefits over chemotherapy with a manageable safety profile and remains an efficacious first-line treatment of advanced non-small-cell lung cancer.

Adcitmer® , a new CD56-targeting monomethyl auristatin E-conjugated antibody, is a potential therapeutic approach in Merkel cell carcinoma

BACKGROUND

Merkel cell carcinoma (MCC) is an aggressive skin cancer, whose tumour cells often express CD56. While immune checkpoint inhibitors constitute a major advance for treating patients with MCC with advanced disease, new therapeutic options are still urgently required.

OBJECTIVES

To produce and evaluate the therapeutic performance of a new antibody-drug conjugate (Adcitmer^® ) targeting CD56 in preclinical models of MCC.

METHODS

CD56 expression was evaluated in a MCC cohort (immunohistochemistry on a tissue microarray of 90 tumour samples) and MCC cell lines. Interaction of an unconjugated CD56-targeting antibody with CD56⁺ MCC cell lines was investigated by immunohistochemistry and imaging flow cytometry. Adcitmer^® product was generated by the bioconjugation of CD56-targeting antibody to a cytotoxic drug (monomethyl auristatin E) using the McSAF Inside^® bioconjugation process. The chemical properties and homogeneity of Adcitmer^® were characterized by hydrophobic interaction chromatography. Adcitmer^® cytotoxicity was evaluated in vitro and in an MCC xenograft mice model.

RESULTS

Similar to previous reports, CD56 was expressed by 66% of MCC tumours in our cohort, confirming its relevance as a therapeutic target. Specific binding and internalization of the unconjugated CD56-targeting antibody was validated in MCC cell lines. The high homogeneity of the newly generated Adcitmer^® was confirmed by hydrophobic interaction chromatography. The CD56-mediated cytotoxicity of Adcitmer^® was demonstrated in vitro in MCC cell lines. Moreover, Adcitmer^® significantly reduced tumour growth in a MCC mouse model.

CONCLUSIONS

Our study suggests that Adcitmer^® should be further assessed as a therapeutic option in patients with MCC, as an alternative therapy or combined with immune checkpoint inhibitors.

Bidirectional reflectance measurement of tungsten samples to assess reflection model in WEST tokamak

This paper presents the measurement of the bidirectional reflectance distribution function of tungsten (W) samples and the resulting reflection models in the nuclear fusion device WEST (tokamak). For this, an experimental gonio-spectrophotometer was developed to fully characterize the material's optical and thermal-radiative properties of metallic samples with different roughnesses. Ray-tracing photonic simulation was then carried out to predict the photon behavior in a fully metallic environment as a function of reflectance measurement. Low emissivity (0.1 at 4 μm) and highly specular reflectance (fitting with a Gaussian distribution around the specular direction with a small width lower than 10°) are found for W samples. These measurements have been used as input for the photonic simulation, and the resulting synthetic image reproduced the reflection features well on the upper divertor, detected in WEST infrared experimental images.

Bridging the age gap in breast cancer: impact of omission of breast cancer surgery in older women with oestrogen receptor-positive early breast cancer on quality-of-life outcomes

BACKGROUND

Primary endocrine therapy may be an alternative treatment for less fit women with oestrogen receptor (ER)-positive breast cancer. This study compared quality-of-life (QoL) outcomes in older women treated with surgery or primary endocrine therapy.

METHODS

This was a multicentre, prospective, observational cohort study of surgery or primary endocrine therapy in women aged over 70 years with operable breast cancer. QoL was assessed using European Organisation for Research and Treatment of cancer QoL questionnaires QLQ-C30, -BR23, and -ELD14, and the EuroQol Five Dimensions 5L score at baseline, 6 weeks, and 6, 12, 18, and 24 months. Propensity score matching was used to adjust for baseline variation in health, fitness, and tumour stage.

RESULTS

The study recruited 3416 women (median age 77 (range 69-102) years) from 56 breast units. Of these, 2979 (87.2 per cent) had ER-positive breast cancer; 2354 women had surgery and 500 received primary endocrine therapy (125 were excluded from analysis due to inadequate data or non-standard therapy). Median follow-up was 52 months. The primary endocrine therapy group was older and less fit. Baseline QoL differed between the groups; the mean(s.d.) QLQ-C30 global health status score was 66.2(21.1) in patients who received primary endocrine therapy versus 77.1(17.8) among those who had surgery plus endocrine therapy. In the unmatched analysis, changes in QoL between 6 weeks and baseline were noted in several domains, but by 24 months most scores had returned to baseline levels. In the matched analysis, major surgery (mastectomy or axillary clearance) had a more pronounced adverse impact than primary endocrine therapy in several domains.

CONCLUSION

Adverse effects on QoL are seen in the first few months after surgery, but by 24 months these have largely resolved. Women considering surgery should be informed of these effects.

POS0373 LIRAGLUTIDE HAS POTENT ANTI-INFLAMMATORY AND ANTI-CATABOLIC IN VITRO ACTIVITIES IN OSTEOARTHRITIS

Background:

Osteoarthritis (OA) is an age-related joint disease which provokes chronic pain and limits mobility. The disease progression is associated with inflammatory responses and cartilage degradation. Both chondrocytes, the only cell type present in cartilage, and macrophages from the synovium, play a major role in OA pathophysiology. Liraglutide is a Glucagon-Like Peptide-1 Receptor (GLP-1R) agonist widely prescribed for the treatment of type 2 diabetes. Interestingly, anti-inflammatory properties of the GLP-1 pathway have been reported in various diseases outside diabetes.

Objectives:

We evaluated the anti-inflammatory and anti-catabolic effects of Liraglutide in two in vitro models relevant to OA by evaluating surrogate markers of inflammation, cartilage matrix proteolysis and differentiation.

Methods:

Lipopolysaccharide (LPS)-stimulated murine Raw 264.7 macrophages were treated with 10 concentrations (6.6nM-3.4µM) of Liraglutide for 24h. Anti-inflammatory activity was evaluated by the production of nitric oxide (NO) and prostaglandin E2 (PGE2) using Griess reaction and ELISA, respectively. Interleukin 1β (IL-1β)-stimulated mouse articular chondrocytes were treated with Liraglutide (6.6nM-3.4µM) for 24h. Production of IL-6, matrix metalloproteinase-3 (MMP-3) and glycosaminoglycans (GAG) was measured by ELISA and GAG assay, respectively. RTqPCR analyses were performed with three selected concentrations of Liraglutide (13.3nM, 53.1nM and 1.7µM) on both cell types to assess the expression of a panel of genes related to inflammation (IL-6, TNF, iNOS), M1/M2 macrophage phenotype (MCP-1, CD38, ERG-2), catabolism (MMP-13, ADAMTS-5) and differentiation (Sox9, Col2a1, Acan).

Results:

Liraglutide induced a dose-dependent inhibition of the LPS-induced production of NO (IC50=45nM) and PGE2 (IC50=54nM) in macrophages. Moreover, IL-6 and TNF gene expressions were significantly and dose-dependently decreased in Raw 264.7 cells treated with Liraglutide compared to LPS alone. Interestingly, there was a significant dose-dependent reduction of MCP-1 and CD38 (M1 marker) gene expression in cells treated with the 3 doses of Liraglutide compared to LPS alone while we observed a dose-dependent increase of ERG-2 (M2 marker) gene expression induced by Liraglutide. Liraglutide significantly dose-dependently reduced the IL-1β-induced release of IL-6 (IC50=38nM), MMP-3 (IC50=56nM) and GAG (IC50=47nM) in chondrocytes. Additionally, Liraglutide treatment dose-dependently decreased the IL-1β-induced gene expression of iNOS, MMP-13 and ADAMTS-5. Finally, IL-1β decreased gene expression of Sox9, Col2a1 and Acan differentiation markers, which was rescued in a dose-dependent manner by Liraglutide (Table 1).

Table 1.

Gene expression results (fold change) in Raw 264.7 murine macrophages or mouse primary articular chondrocytes

Cell typeMarkersVehicleVehicleLiraglutide (nM)13.353.11700Macrophages- LPS+ LPSIL61.0±0.2*63.6±7.158.8±6.536.3±8.4*30.8±2.6*TNFα1.0±0.2*26.8±4.917.5±2.6*9.5±1.8*4.1±2.1*MCP11.1±0.6*91.7±11.267.8±4.3*47.3±6.1*25.1±5.5*CD381.1±0.6*103.5±22.373.2±12.3*44.6±8.9*17.4±3.3*ERG21.0±0.3*0.3±0.11.1±0.5*2.1±0.6*3.1±0.2*Chondrocytes- IL1β+ IL1βiNOS1.0±0.2*47.8±17.634.2±15.518.9±8.2*11.8±2.9*MMP131.0±0.2*9.8±2.07.6±1.04.6±0.7*2.5±0.4*ADAMTS51.2±0.82.7±0.62.0±0.61.6±0.31.1±0.2Sox91.0±0.1*0.4±0.20.4±0.20.6±0.00.7±0.2Col2a11.0±0.2*0.3±0.10.3±0.10.5±0.30.8±0.3*Acan1.2±0.8*0.2±0.10.1±0.00.5±0.1*0.7±0.2*

* p<0.05 vs LPS or IL1β alone, n=4

Conclusion:

A shift in M1/M2 macrophage phenotype and the inhibition of chondrocyte expression of several mediators involved in inflammation and cartilage degradation explain, at least in part, our previous results from rodent osteoarthritis models that showed an analgesic, anti-inflammatory and anti-degradative effect of Liraglutide. The fact that Liraglutide is already safely prescribed in another indication allows us to foresee a first trial in humans in the short term.

Acknowledgements:

All the people who contributed to the InOsteo project: the members of 4P-Pharma, INSERM UMRS_938 research team, SATT Lutech and Sorbonne University

Disclosure of Interests:

Francis Berenbaum Consultant of: Boehringer, Bone Therapeutics, CellProthera, Expanscience, Galapagos, Gilead, GSK, Merck Sereno, MSD, Nordic, Novartis, Pfizer, Regulaxis, Roche, Sandoz, Sanofi, Servier, UCB, Peptinov, 4P Pharma, 4Moving Biotech, Grant/research support from: TRB Chemedica, Coralie Meurot Employee of: 4P-Pharma, Laure Sudre Employee of: 4P-Pharma, Keren Bismuth Employee of: 4P-Pharma, Revital Rattenbach Shareholder of: 4P-Pharma, Employee of: 4P-Pharma, Patrice Denefle Speakers bureau: 4P-Pharma, Consultant of: 4P-Pharma, Pierre Fabre, Mimetas, Employee of: 4P-Pharma, Celine Martin Employee of: 4P-Pharma, Claire Jacques: None declared

Safety and acute clinical outcomes of atrial fibrillation catheter ablation in octogenarians: a multicentre evaluation with a matched younger cohort

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Sven Knecht and the International Octogenarian AF ablation group

Background

Octogenarians are a fast-growing demographic with a high burden of atrial fibrillation (AF). There are limited data on procedural safety and acute outcomes of catheter ablation (CA) for AF in this group.

Purpose

Investigation of complications & outcomes in octogenarians undergoing CA for AF.

Methods

Data on all octogenarian patients who underwent AF ablation at nine European cardiology centres between 2013 and 2019 were retrospectively analysed and matched with control patients aged &lt;80 years.  The characteristics used for matching were type of AF, type of procedure (de novo or redo), & the year of procedure.

Results

216 octogenarians (81.9 ± 1.9 years; 52.8% females) underwent an AF ablation procedure, and were matched with 216 patients aged &lt;80 years (62.4 ± 9.5 years, 34.7% females), p &lt;0.001 for both. The proportion of paroxysmal and persistent AF was 43.5% & 56.5% respectively in both groups, and 79.3% of the procedures were de novo. RF ablation made up 75.4% & 75.9% (p = 0.90) procedures in octogenarians and controls respectively.  17 complications occurred in 14 (7.9%) octogenarian patients and 11 in 11 (5.1%) patients in the younger matched cohort (p = 0.07). There were 4.2% & 1.9% major complications (p= 0.17) and 3.7% & 3.2% minor complications (p= 0.77) in the octogenarian & younger cohorts respectively. Complications in octogenarians consisted of groin complications (n = 6), pneumonia (n = 3), pericardial effusion (n = 2), phrenic nerve injury (n = 2), pulmonary oedema (n = 1), gastroparesis (n = 1), stroke (n = 1). Acute procedural success rates were 99.1% & 99.5% (p = 0.62) The complication rates were similar for RF; 6.0% vs 5.4% (p = 0.79) and Cryoballoon; 14.0% vs 4.1% (p = 0.09) in both octogenarians and younger cohort respectively.

Conclusion

In spite of significantly higher overall risk profile of octogenarians undergoing AF ablation, there is no difference in acute procedural success and complication rates as compared to younger patients Catheter ablation of AF in octogenerians Octogenarians n = 216 Matched Controls (aged &lt; 80yrs) n = 216 P value Age (yrs), mean (SD)s 81.9 (1.9) 62.4(9.5) &lt; 0.0001 Females, (%) 52.8 34.7 0.0002 CHA2DS2-VASc, mean (SD) 3.6 (1.2) 1.4 (1.3) &lt; 0.0001 Mean LA size, mm 42.8 ± 8.3mm 45.8 ± 16.2 0.062 Impaired LV function, (%) 23.7 17.9 0.206 IHD, (%) 20.7 5.9 &lt; 0.0001 Procedural time (mins), mean (sd) 150.6 (69.7) 148.9 (64.4) 0.914 All complications, n (%) 17 (7.9) 11 (5.1) 0.073

‘I’m being forced to make decisions I have never had to make before’: Oncologists and the conundrums created by COVID-19

12001

Background: The COVID-19 pandemic has created conundrums for physicians. This study examines the experiences of oncologists who engage in complex decision-making regarding the use of chemotherapy in seriously ill persons in the context of the COVID-19 pandemic. Methods: Between January 2020 and August 2020, the authors conducted semi-structured, in-depth individual interviews with 22 purposefully sampled oncologists from practices enrolled in the Michigan Oncology Quality Consortium. Transcripts were double-coded and reconciled by consensus using qualitative data analysis software for thematic analysis. Results: Among the thematic clusters we identified, one was related to conundrums created by the COVID-19 pandemic. In this presentation, we report the results pertaining to three themes within this cluster: (1) the ethical dilemmas faced by oncologists due to the COVID-19 pandemic, (2) the need for both patients and oncologists to manage uncertainty and emotions, and (3) the importance and complexity of integrating technology and communication for seriously ill persons. Oncologists grappled with several conundrums including resource scarcity, resource allocation, delays in care, a duty to promote equity and non-abandonment, high levels of uncertainty and fear, and the importance of advanced care directives and end-of-life care planning. Non-abandonment featured as a coping mechanism for increased stress, and integration of communication with telemedicine was frequent and necessary. Conclusions: This study offers an in-depth exploration of the conundrums faced by oncologists due to the COVID-19 pandemic and how they navigated them. Optimal decision-making for seriously ill persons with cancer during the COVID-19 pandemic must include open acknowledgement of the ethical dilemmas faced, the heightened emotions experienced by both patients and their oncologists, and the urgent need for integrating technology with compassionate communication in determining patient preferences.

Patient perspectives following initiation of elexacaftor-tezacaftor-ivacaftor in people with cystic fibrosis and advanced lung disease

BACKGOUND

Elexacaftor-tezacaftor-ivacaftor partially restores cystic fibrosis transmembrane conductance regulator function, and has been shown to induce significant clinical improvement in patients with at least one Phe508del allele. Yet little data exist on patient perspectives following elexacaftor-tezacaftor-ivacaftor initiation.

METHODS

A mixed methods study was conducted using an online 13-item questionnaire (including 9 closed questions and 4 open questions), submitted from July 10^th to August 21^th 2020 to French patients aged 12 years and older with advanced CF who were treated with elexacaftor-tezacaftor-ivacaftor. Their responses were summarized as numbers (%), and free-text items were analysed using a grounded theory approach.

RESULTS

Of 245 patients who started elexacaftor-tezacaftor-ivacaftor in France, 101 (41%) participated. Median [IQR] age was 35 [28-41] years and duration of elexacaftor-tezacaftor-ivacaftor treatment was 4.3 [3.0-5.6] months. Patients generally reported a rapid impact on respiratory symptoms, sleep quality, general well-being and physical self-esteem, and a reduction in overall treatment burden. The majority of patients contrasted treatment burden, symptom severity, depression and a closed future marked by death or transplantation before elexacaftor-tezacaftor-ivacaftor, to renewed and unexpected physical strength, leading to greater self-confidence, autonomy and long-term planning, after treatment initiation. A small number of patients expressed concerns, mainly regarding changes in body representation and/or the fear of becoming dependent on the treatment.

CONCLUSION

After initiation of elexacaftor-tezacaftor-ivacaftor, CF patients with advanced disease reported rapid and positive physical, psychological and social effects, which translated into improved quality of life and the formulation of new life goals.

Health-related quality of life in women after colposcopy: results from a longitudinal patient survey

BACKGROUND

Information concerning the health-related quality-of-life (HRQoL) consequences of colposcopy is limited, particularly over time. In a longitudinal study, we investigated women's HRQoL at 4, 8 and 12 months post colposcopy and the factors associated with this.

METHODS

Women attending colposcopy at two large hospitals affiliated with the national screening programme in Ireland were invited to complete questionnaires at 4, 8 and 12 months post colposcopy. HRQoL was measured using the EQ-5D-3L and compared across a range of socio-demographic, clinical and attitudinal variables. A mixed-effects logistic multivariable model was employed to investigate associations between these variables and low HRQoL.

RESULTS

Of 584 women initially recruited, 429, 343 and 303 completed questionnaires at 4, 8 and 12 months, respectively. The mean overall HRQoL score for the sample across all time points was 0.90 (SD 0.16). Approximately 18% of women experienced low HRQoL at each of the three time points. In multivariable testing, over the entire 12-month follow-up period, non-Irish nationals (OR 8.99, 95% CI 2.35-34.43) and women with high-grade referral cytology (OR 2.78, 95% CI 1.08-7.13) were at higher odds of low HRQoL. Women who were past (OR 0.20, 95% CI 0.07-0.58) or never (OR 0.42, 95% CI 0.16-1.12) smokers were at lower odds of low HRQoL than current smokers. As women's satisfaction with their healthcare increased their odds of experiencing low HRQoL fell (OR per unit increase 0.51, 95% CI 0.34-0.75).

CONCLUSIONS

Women's HRQoL did not change over the 12 months post colposcopy, but some subgroups of women were at higher risk of experiencing low HRQoL. These subgroups may benefit from additional support.

Bridging the age gap in breast cancer: cluster randomized trial of two decision support interventions for older women with operable breast cancer on quality of life, survival, decision quality, and treatment choices

BACKGROUND

Rates of surgery and adjuvant therapy for breast cancer vary widely between breast units. This may contribute to differences in survival. This cluster RCT evaluated the impact of decision support interventions (DESIs) for older women with breast cancer, to ascertain whether DESIs influenced quality of life, survival, decision quality, and treatment choice.

METHODS

A multicentre cluster RCT compared the use of two DESIs against usual care in treatment decision-making in older women (aged at least ≥70 years) with breast cancer. Each DESI comprised an online algorithm, booklet, and brief decision aid to inform choices between surgery plus adjuvant endocrine therapy versus primary endocrine therapy, and adjuvant chemotherapy versus no chemotherapy. The primary outcome was quality of life. Secondary outcomes included decision quality measures, survival, and treatment choice.

RESULTS

A total of 46 breast units were randomized (21 intervention, 25 usual care), recruiting 1339 women (670 intervention, 669 usual care). There was no significant difference in global quality of life at 6 months after the baseline assessment on intention-to-treat analysis (difference -0.20, 95 per cent confidence interval (C.I.) -2.69 to 2.29; P = 0.900). In women offered a choice of primary endocrine therapy versus surgery plus endocrine therapy, knowledge about treatments was greater in the intervention arm (94 versus 74 per cent; P = 0.003). Treatment choice was altered, with a primary endocrine therapy rate among women with oestrogen receptor-positive disease of 21.0 per cent in the intervention versus 15.4 per cent in usual-care sites (difference 5.5 (95 per cent C.I. 1.1 to 10.0) per cent; P = 0.029). The chemotherapy rate was 10.3 per cent at intervention versus 14.8 per cent at usual-care sites (difference -4.5 (C.I. -8.0 to 0) per cent; P = 0.013). Survival was similar in both arms.

CONCLUSION

The use of DESIs in older women increases knowledge of breast cancer treatment options, facilitates shared decision-making, and alters treatment selection. Trial registration numbers: EudraCT 2015-004220-61 (https://eudract.ema.europa.eu/), ISRCTN46099296 (http://www.controlled-trials.com).