Invariant NKT cells promote expansion of novel CXCR3+CCR4+CD8+ T cells in the liver following allogeneic hepatocyte transplant

Hepatocyte transplant (HcTx) is a treatment for metabolic diseases and a bridge to liver transplant but is limited by immunogenicity. Our prior work identified the critical role of CD4-dependent and CD4-independent CD8+ T cells in HcTx rejection. Herein, we evaluated the influence of invariant natural killer T cells (iNKTs), abundant in the liver, upon CD8+ T cell responses in the presence and absence of CD4+ T cells. To investigate this, C57BL/6 (wild-type; WT) or iNKT deficient Jα18 KO (H-2b) received FVB/N (H-2q) HcTx. Cohorts were depleted of CD4+ T cells and/or reconstituted with iNKTs. Recipients were evaluated for cytotoxicity, CD8+ T cell phenotype, and HcTx rejection. By comparing CD4-sufficient WT and Jα18 KO recipients, we found that the presence of iNKTs significantly enhanced in vivo CD8-mediated cytotoxicity (83±3% vs 23±3%; p<0.001) but did not affect survival (10 days vs 14 days; p=ns). However, in CD4-deficient recipients, iNKTs were critical, since without CD4+ T cells and iNKTs, CD8-mediated in vivo cytotoxicity was completely abrogated (31±3% vs 2±1%; p<0.001) and HcTx survival was significantly prolonged (14 days vs 56 days; p<0.001). iNKTs enhanced the quantity of a novel CD8+ T cell subset, CD44+IFN-γ+CXCR3+CCR4+CD8+ T cells, in the liver (2-fold) in all HcTx recipients (p<0.03 for all comparisons). CXCR3+CCR4+CD8+ T cells, when compared to CXCR3+CCR4−CD8+ T cells, express higher IFN-γ (32±3% vs 9±1%; p<0.001) and TNF-α (37±3% vs 6±1%; p<0.001). They also exhibit greater in vivo cytotoxicity (13±1% vs 5±1%; p<0.001) and mediate rapid HcTx rejection in RAG1 KO recipients (5 days vs 16 days; p=0.02). We show that iNKTs enhance the expansion of highly cytotoxic CXCR3+CCR4+CD8+ T cells that mediate rapid rejection of HcTx.

Family-centered communication: A pilot educational intervention using deliberate practice and patient feedback

OBJECTIVE

There are few opportunities in medical education dedicated to learning skills for effective communication in life altering patient scenarios. We therefore aimed to develop and assess a longitudinal advanced communication curriculum for pediatric residents using patient feedback and deliberate practice.

METHODS

Pediatric residents at a large academic center were randomized into 2 groups. The intervention group received 6 educational sessions from 2019 to 2020, parent feedback of performance via the Communication Assessment Tool (CAT), and monthly communication tips. Communication skills of both groups were assessed at the end of the intervention.

RESULTS

We collected 937 CAT assessments on 36 first-year residents. The intervention group demonstrated statistically significant improvement in communication skills from pre to post assessment (p = 0.0063, (odds ratio (OR) 1.76, 95 % confidence interval (CI) [1.17, 2.63]) compared to the control group (p = 0.080, OR 1.41, 95 % CI [0.96, 2.05]).

CONCLUSIONS

There are patient and self-identified performance gaps in communication skills for pediatric residents, underscoring the need for formalized curricula dedicated to these skills.

PRACTICE IMPLICATIONS

Our study highlights the value of deliberate practice and the integration of family feedback as an educational tool in communication skills development.

Evaluation of the Efficacy of Enoxaparin in the Neonatal Intensive Care Unit

OBJECTIVE

This article evaluates the efficacy of enoxaparin when targeting anti-factor Xa levels of 0.5 to 1 units per milliliter in the neonatal intensive care unit.

STUDY DESIGN

This is a retrospective chart review of 45 neonates receiving enoxaparin for the treatment of venous thromboembolism. Enoxaparin dosing and corresponding anti-factor Xa levels were collected. Time to resolution of clot was confirmed by imaging and compared between clots in various locations.

RESULTS

The median time to clot resolution was 76 days (interquartile range 40-91 days). Clot location, postnatal age, and sex at the clot onset were significantly associated with time to clot resolution in a multivariable Cox model (p-value: 0.03, 0.03, and < 0.01, respectively). Of the 54 patients analyzed for safety, 5 patients (9.3%) experienced bleeding events resulting in the discontinuation of enoxaparin.

CONCLUSION

Based on our findings, 50% of all patients evaluated, regardless of thrombus location, achieved resolution within the first 76 days of therapy. Clots located in the extremities tended to resolve sooner, hence earlier reimaging should be considered.

Implementation of a Pharmacist-Led Antimicrobial Time-Out for Medical-Surgery Services in an Academic Pediatric Hospital

OBJECTIVE

This report describes a quality improvement initiative to implement a pharmacist-led antimicrobial time-out (ATO) in a large, freestanding pediatric hospital. Our goal was to reach 90% ATO completion and documentation for eligible patients hospitalized on general pediatric medicine or surgery services.

METHODS

A multidisciplinary quality improvement team developed an ATO process and electronic documentation tool. Clinical pharmacists were responsible to initiate and document an ATO for pediatric medicine or surgery patients on or before the fifth calendar day of therapy. The quality improvement team educated pharmacists and physicians and provided ATO audit and feedback to the pharmacists. We used statistical process control methods to track monthly rates of ATO completion retrospectively from October 2017 through March 2018 and prospectively from April 2018 through April 2019. Additionally, we retrospectively evaluated the completion of 6 data elements in the ATO note over the final 12-month period of the study.

RESULTS

Among 647 eligible antimicrobial courses over the 19-month study period, the mean monthly documentation rate increased from 54.6% to 83.5% (p < 0.001). The mean ATO documentation rate increased from 32.8% to 74.2% (p < 0.001) for the pediatric medicine service and from 65.0% to 88.1% for the pediatric surgery service (p = 0.006). Among 302 notes assessed for completeness, 35.8% had all the required data fields completed. A tentative antimicrobial stop date was the data element completed least often (49.3%).

CONCLUSIONS

We implemented a pharmacist-led ATO, highlighting the role pharmacists play in antimicrobial stewardship. Additional efforts are needed to further increase ATO completion rates and to define treatment duration.

Evaluation of an Enteral Clonidine Taper following Prolonged Dexmedetomidine Exposure in Critically Ill Children

The aim of the current study is to evaluate the use of an enteral clonidine transition for the prevention or management of dexmedetomidine withdrawal symptoms in critically ill children not exposed to other continuous infusion sedative agents. A retrospective, single-center study was conducted in patients ≤ 18 years of age admitted to the pediatric intensive care unit who received a continuous infusion of dexmedetomidine for ≥ 24 hours and who were prescribed enteral clonidine within 72 hours of dexmedetomidine discontinuation. Predefined withdrawal terminology was established to assess for hypertension, tachycardia, agitation, tremors, and decreased sleep. A total of 105 patients were included and received enteral clonidine for prevention or management of dexmedetomidine withdrawal symptoms, with 13 patients (12.4%) requiring a taper modification to manage withdrawal symptoms. The median duration of dexmedetomidine infusion was 120.5 hours (95.5, 143.5) and median peak infusion rate was 1 µg/kg/h (1, 1.2). A higher cumulative dexmedetomidine dose of 119.2 µg/kg (96.6, 154.9) and duration of 142.9 hours (122.6, 158.3) were noted in patients who required a taper modification. Risk factors for dexmedetomidine withdrawal such as dexmedetomidine duration and cumulative dose may help predict patients at the highest risk of withdrawal that would benefit from an enteral clonidine taper to prevent dexmedetomidine withdrawal symptoms. An enteral clonidine taper can be effective in the prevention and management of dexmedetomidine withdrawal symptoms.

Pulmonary artery size on computed tomography is associated with major morbidity after pulmonary lobectomy

OBJECTIVE

To investigate the relationship of pulmonary artery diameter (PAD) measured by computed tomography (CT) with outcomes following lobectomy.

METHODS

Records of patients undergoing pulmonary lobectomy for lung cancer between 2011 and 2018 were reviewed. Baseline characteristics and postoperative outcome data were derived from the institutional Society of Thoracic Surgeons database. Luminal diameter of the central pulmonary arteries and ascending aorta were measured on preoperative CTs. Logistic regression analyses were performed to test the association of PAD with complications.

RESULTS

A total of 736 lobectomy patients were included, who had a preoperative CT scan (25% with contrast, 75% noncontrast) available for review. A total of 141 (19.2%) patients had an enlarged main PAD ≥30 mm, and 58 (7.9%) patients had a main PAD that was larger than the ascending aorta (PA/ascending aorta ratio > 1). The right or left PAD on the surgical side was associated with major complication (odds ratio per mm, 1.12; 95% confidence interval, 1.05-1.18; P < .001), unexpected intensive care unit admission (odds ratio per millimeter, 1.11; 95% confidence interval, 1.04-1.19; P = .002), and 30-day mortality (odds ratio per millimeter, 1.25; 95% confidence interval, 1.06-1.46; P = .007). On multivariable analysis, adjusted for cardiovascular comorbidities, pulmonary function, and the operative approach, surgical side PAD remained an independent factor associated with major complication.

CONCLUSIONS

CT-based measurements of the PAD on the operative side may inform of the about the risk of major complications after lobectomy. Review of PA size on preoperative CT scans may help identify patients who would benefit from formal evaluation of PA pressures to improve the operative risk assessment.

Effect of Cognitive Prehabilitation on the Incidence of Postoperative Delirium Among Older Adults Undergoing Major Noncardiac Surgery: The Neurobics Randomized Clinical Trial

Importance

Postoperative delirium in older adults is a common and costly complication after surgery. Cognitive reserve affects the risk of postoperative delirium, and thus preoperative augmentation of reserve as a preventive technique is of vital interest.

Objective

To determine whether cognitive prehabilitation reduces the incidence of postoperative delirium among older adults.

Design, Setting, and Participants

This was a prospective, single-blinded randomized clinical trial conducted from March 2015 to August 2019 at the Ohio State University Wexner Medical Center in Columbus. Patients 60 years and older undergoing major, noncardiac, nonneurological surgery under general anesthesia, with an expected hospital stay of at least 72 hours, were eligible for trial inclusion. Patients were excluded for preoperative cognitive dysfunction and active depression.

Interventions

Participation in electronic, tablet-based preoperative cognitive exercise targeting memory, speed, attention, flexibility, and problem-solving functions.

Main Outcomes and Measures

The primary outcome was incidence of delirium between postoperative day 0 to day 7 or discharge, as measured by a brief Confusion Assessment Method, Memorial Delirium Assessment Scale, or a structured medical record review. Secondary outcomes compared delirium characteristics between patients in the intervention and control groups.

Results

Of the 699 patients approached for trial participation, 322 completed consent and 268 were randomized. Subsequently, 17 patients were excluded, leaving 251 patients in the primary outcome analysis. A total of 125 patients in the intervention group and 126 control patients were included in the final analysis (median [interquartile range] age, 67 [63-71] years; 163 women [64.9%]). Ninety-seven percent of the patients in the intervention group completed some brain exercise (median, 4.6 [interquartile range, 1.31-7.4] hours). The delirium rate among control participants was 23.0% (29 of 126). With intention-to-treat analysis, the delirium rate in the intervention group was 14.4% (18 of 125; P = .08). Post hoc analysis removed 4 patients who did not attempt any cognitive exercise from the intervention group, yielding a delirium rate of 13.2% (16 of 121; P = .04). Secondary analyses among patients with delirium showed no differences in postoperative delirium onset day or duration or total delirium-positive days across study groups.

Conclusions and Relevance

The intervention lowered delirium risk in patients who were at least minimally compliant. The ideal activities, timing, and effective dosage for cognitive exercise-based interventions to decrease postoperative delirium risk and burden need further study.

Trial Registration

ClinicalTrials.gov Identifier: NCT02230605.

Estimating the risk of conversion from video-assisted thoracoscopic lung surgery to thoracotomy-a systematic review and meta-analysis

Background

Understanding the risk of conversion from video-assisted thoracic surgery (VATS) to thoracotomy is important when considering patient selection and preoperative surgical risk assessment. This review aims to estimate the rate of intraoperative conversions to thoracotomy, predictive factors, and associated outcomes for VATS anatomic lung resections.

Methods

PubMed/MEDLINE and EMBASE were searched systematically in May of 2020. Observational studies examining conversions of VATS anatomic resections to thoracotomy were included. Conversion rates, causes, risk factors, and post-operative outcomes were reviewed and analyzed in aggregate.

Results

Twenty retrospective studies were reviewed, with a total of 72,932 patients undergoing VATS anatomic lung resection. The median conversion rate was 9.6% (95% CI: 6.6–13.9%). Nine studies reported a total of 114 emergency conversions, with a median incidence rate of 1.3% (95% CI: 0.6–2.8%). The most common reasons for thoracotomy were vascular injury/bleeding, difficulty lymph node dissection, and adhesions, accounting for 27.9%, 26.2% and 19% of conversions, respectively. Risk factors for conversion varied, but frequently included nodal disease, large tumors, and induction therapy. The risk of complications (OR 2.06; 95% CI: 1.77–2.40) and mortality (OR 4.11; 95% CI: 1.59–10.61) were significantly increased following conversions. There was also a significant increase in chest tube duration and length of stay following conversion.

Conclusions

The risk of conversion to thoracotomy may be as high as one in ten patients undergoing VATS anatomic lung resections, but may vary significantly based on patient selection. Although emergent conversions are rare, the need for thoracotomy may significantly increase postoperative morbidity and mortality.

Racial Disparities in Overall Survival and Surgical Treatment for Early Stage Lung Cancer by Facility Type

BACKGROUND

Early stage Non-small cell lung cancer (NSCLC) is potentially curable with surgical resection. There are persistent racial disparities for the receipt of surgery and overall survival rate for early stage NSCLC. The facility type where patients receive NSCLC treatment may directly impact racial disparities.

METHODS

A total of 111,009 patients with the American Joint Committee on Cancer TNM clinical stage I and II NSCLC that were reported to the National Cancer Data Base were analyzed. Healthcare facilities were dichotomized into the community and academic facility types. A multivariate adjusted multinomial logistic regression was used to evaluate differences in the probability of undergoing surgery based on race and facility type. Kaplan Meier 3 and 5-year overall survival estimates were calculated for black and white patients based on treatment and the facility type where patients received care.

RESULTS

We identified 99,767 white (89.87%) and 11,242 (10.12%) black patients with early stage NSCLC. Black patients were more likely to undergo surgery at academic facilities (OR: 1.12; 95% CI: 1.01-1.24; P-value = .04) compared to community facilities. Black patients treated at academic facility types demonstrated significantly better 3 and 5-year overall survival compared to black patients treated at community facilities (Log Rank P-value < .0001).

CONCLUSION

Black patients with early stage NSCLC who were treated at academic facility types had a significantly higher overall survival compared black patients treated at community facility types. The odds of black patients undergoing surgery were higher at academic facilities compared to community facilities.

Economic impact of pharmacist interventions in pediatric ambulatory care clinics

OBJECTIVES

Ambulatory care pharmacists have a unique opportunity to identify and prevent adverse drug events (ADEs) throughout a patient's treatment course. These interventions can reduce unexpected clinic visits or hospitalizations, which may lead to decreased health care costs. However, research on this topic has not been conducted in the pediatric population. This study explored the economic impact of pharmacist interventions related to ADEs in pediatric ambulatory care clinics. The primary objective was to determine the total cost avoidance of pharmacist interventions associated with the prevention or management of ADEs in pediatric ambulatory care clinics. The secondary objectives were to describe and quantify pharmacist interventions related to the prevention and management of ADEs in pediatric ambulatory care clinics.

METHODS

Pharmacist interventions from pediatric ambulatory care clinics were collected from an electronic health record. These interventions were categorized into 1 of 4 categories: Drug interaction, drug not indicated, prevent or manage ADE, or prevent or manage drug allergy. A review panel consisting of ambulatory care pharmacists reviewed the interventions. The expected probability of the event occurring was classified according to the Nesbit method (0-0.6), and the level of care necessary to treat the potential ADE was determined. The levels of care included hospitalization, ambulatory care, and self-care. The cost avoidance associated with each prevented ADE was calculated by multiplying the probability of the ADE occurring by the average charge of the expected level of care.

RESULTS

Of the 8755 interventions documented, 212 were included, leading to a total cost avoidance of $307,210 (range $76,802-$1,071,053). The estimated cost avoidance from each ADE subtype was $128,283 from drug interaction, $20,727 from drug not indicated, $157,993 from prevent or manage ADE, and $207 from prevent or manage drug allergy.

CONCLUSION

Pediatric ambulatory care pharmacists optimize health care cost savings through the prevention and management of ADEs as integrated members of the health care team.

Nomograms for predicting overall and recurrence-free survival after trimodality therapy for esophageal adenocarcinoma

BACKGROUND

Locally advanced esophageal carcinoma is treated with neoadjuvant chemoradiation and esophagectomy. Patients may still experience recurrence and death despite undergoing potentially curative trimodality therapy. This study describes predictive nomograms for recurrence-free (RFS) and overall survival (OS) after the completion of trimodality therapy.

METHODS

A total of 215 patients with esophageal adenocarcinoma underwent trimodality therapy from September 2010 to April 2018. Multivariate Cox proportional hazards regression models were used to create nomograms for OS and RFS. Kaplan-Meier survival curves were calculated for OS and RFS comparing high-risk and low-risk cohorts.

RESULTS

On multivariate analysis, clinical N-stage, tumor differentiation, tumor regression grade, anastomotic leak, body mass index, age, and number of lymph nodes removed were predictive variables for overall survival. Clinical N-stage, tumor differentiation, tumor regression grade, anastomotic leak, age, and positive lymph nodes were significant predictors of RFS in a multivariate model. The nomogram for OS had good predictive ability (Harrell's Concordance index [C-index]: 0.71 [95% confidence interval {CI}: 0.66-0.76]). The nomogram for RFS also performed well (C-index: 0.70 [95% CI: 0.65-0.74]).

CONCLUSION

Our nomograms can accurately predict OS and RFS after trimodality therapy and may provide guidance regarding adjuvant therapy and surveillance.

Efficacy of Intravenous Tranexamic Acid in Reducing Perioperative Blood Loss and Blood Product Transfusion Requirements in Patients Undergoing Multilevel Thoracic and Lumbar Spinal Surgeries: A Retrospective Study

Introduction: Acute perioperative blood loss is a common and potentially major complication of multilevel spinal surgery, usually worsened by the number of levels fused and of osteotomies performed. Pharmacological approaches to blood conservation during spinal surgery include the use of intravenous tranexamic acid (TXA), an anti-fibrinolytic that has been widely used to reduce blood loss in cardiac and orthopedic surgery. The primary objective of this study was to assess the efficacy of intraoperative TXA in reducing estimated blood loss (EBL) and red blood cell (RBC) transfusion requirements in patients undergoing multilevel spinal fusion.

Materials and Methods: This a single-center, retrospective study of subjects who underwent multilevel (≥7) spinal fusion surgery who received (TXA group) or did not receive (control group) IV TXA at The Ohio State University Wexner Medical Center between January 1st, 2016 and November 30th, 2018. Patient demographics, EBL, TXA doses, blood product requirements and postoperative complications were recorded.

Results: A total of 76 adult subjects were included, of whom 34 received TXA during surgery (TXA group). The mean fusion length was 12 levels. The mean total loading, maintenance surgery and total dose of IV TXA was 1.5, 2.1 mg per kilo (mg/kg) per hour and 33.8 mg/kg, respectively. The mean EBL in the control was higher than the TXA group, 3,594.1 [2,689.7, 4,298.5] vs. 2,184.2 [1,290.2, 3,078.3] ml. Among all subjects, the mean number of intraoperative RBC and FFP units transfused was significantly higher in the control than in the TXA group. The total mean number of RBC and FFP units transfused in the control group was 8.1 [6.6, 9.7] and 7.7 [6.1, 9.4] compared with 5.1 [3.4, 6.8] and 4.6 [2.8, 6.4], respectively. There were no statistically significant differences in postoperative blood product transfusion rates between both groups. Additionally, there were no significant differences in the incidence of 30-days postoperative complications between both groups.

Conclusion: Our results suggest that the prophylactic use of TXA may reduce intraoperative EBL and RBC unit transfusion requirements in patients undergoing multilevel spinal fusion procedures ≥7 levels.

Nomograms for Predicting Overall and Recurrence-free Survival From Pathologic Stage IA and IB Lung Cancer After Lobectomy

BACKGROUND

Stage I non-small-cell lung cancer (NSCLC) is potentially curable with surgical resection. Significant proportions of patients may still experience recurrence and death despite undergoing curative surgery. This study describes predictive nomograms for recurrence-free (RFS) and overall survival (OS) after lobectomy.

PATIENTS AND METHODS

A total of 301 patients with the American Joint Committee on Cancer pathologic stage IA and IB NSCLC who underwent open, thoracoscopic, or robotic lobectomy from January 2011 to April 2017 were analyzed. Multivariate Cox proportional hazards regression models were used to create nomograms for OS and RFS. Kaplan-Meier survival curves were calculated for OS and RFS comparing high-risk and low-risk cohorts based on nomogram scores.

RESULTS

Histology (hazard ratio [HR], 0.24; 95% confidence interval [CI], 0.10-0.56; P = .002), lymphovascular invasion (HR, 0.46; 95% CI, 0.29-0.74; P = .001), smoking status (HR, 3.46; 95% CI, 1.25-9.55: P = .02), and total lymph nodes removed (HR, 1.05; 95% CI, 1.01-1.10; P = .021) were significant predictors for OS in a multivariate model. Lymphovascular invasion (HR, 0.55; 95% CI, 0.36-0.83; P = .0040), smoking status (HR, 2.56; 95% CI, 1.16-5.62; P = .02), total lymph nodes removed (HR, 1.04; 95% CI, 1.00-1.08; P = .029), and tumor size (HR, 1.30; 95% CI, 1.30-1.68; P = .047) were significant predictors of RFS in a multivariate model.

CONCLUSION

Nomograms can predict OS and RFS for pathologic stage IA and IB NSCLC after lobectomy regardless of operative approach. The risk for death and recurrence after stratification by the nomogram scores may provide guidance regarding adjuvant therapy and surveillance.

Safety, feasibility, and acceptability of patient-controlled anxiolysis with dexmedetomidine for burn-care dressing changes: an open-label, single-arm, pilot study

Anxiety is common among patients with burn injury, occurring frequently surrounding wound care. Few pharmacologic interventions targeting anxiety in burn injury have been evaluated. This study aimed to evaluate patient-controlled anxiolysis using dexmedetomidine (PCA-DEX) in patients undergoing burn dressing changes. This was a prospective, open-label, single-arm pilot study to determine the feasibility, safety, and acceptability of PCA-DEX. PCA-DEX included a loading dose, continuous infusion, and patient-administered boluses during dressing changes for up to 5 days. Vital signs were monitored throughout PCA-DEX. Procedural pain and anxiety were evaluated before and after each dressing change. Nursing and patient satisfaction were evaluated after each dressing change. Twenty patients were included; 9 (45%) males and 11 females (55%) with a mean age of 45.1 ± 16.9 years and median total body surface area burn injury of 7 [IQR 4-9.5]%. Median heart rate and systolic blood pressure prior to PCA-DEX on day 1 were 82 [75-97] bpm and 147 [128-170] mmHg. Overall PCA-DEX was tolerated well with a median heart rate of 72 [66-82] bpm and systolic blood pressure 115 [99-141] mmHg after PCA-DEX. One patient was withdrawn due to severe bradycardia (heart rate < 45 bpm) not attributed to PCA-DEX; 4 patients experienced mild hypotension (systolic blood pressure 85-89/diastolic blood pressure 45-49 mmHg), all of which resolved without intervention. The majority of both nurses and patients were either satisfied or highly satisfied with PCA-DEX overall (78.1% for nursing, 86.5% for patients). PCA-DEX is a novel, safe and feasible method of anxiolysis during burn dressing changes with high patient and nurse satisfaction rates. A randomized, controlled trial is warranted to confirm the efficacy of PCA-DEX.

Comparative Effectiveness of Best Practice Alerts with Active and Passive Presentations: A Retrospective Study

We assess the relationship of active or passive presentation of Best Practice Advisories (BPAs) for hospital clinicians with compliance rates of recommended actions. We identify the design characteristics of alerts that can be used to assess the effectiveness of design choices with superior usability. Alerts in Electronic Health Records (EHRs) are frequently overridden by healthcare providers. Identifying characteristics of effective alerts can increase the frequency that actions recommended in evidence-based care guidelines are done, reduce user frustration, and improve interface usability along with the willingness to use alerts. We conducted a retrospective analysis of data for 11 BPAs between June 2014 and May 2015. The outcome measure was the percent correspondence with recommended actions. A repeated measures regression model was used for the correlation of the BPA presentation type with the outcome measure. The BPA presentation type was significant such that the odds are 7.7 times greater that a recommended action would be taken by a provider with an active BPA presentation type after adjusting for whether an action was required. Active presentation alerts achieve higher compliance rates. CDS alerts that actively interrupted the provider’s workflow were associated with a higher compliance rate with recommended actions.

Linoleic Acid-Rich Oil Supplementation Increases Total and High-Molecular-Weight Adiponectin and Alters Plasma Oxylipins in Postmenopausal Women with Metabolic Syndrome

BACKGROUND

The onset of menopause increases the risk of metabolic syndrome (MetS). Adiponectin is an adipokine associated with insulin sensitivity that is lower in people with MetS. Supplementing diets with linoleic acid (LA)-rich oil increased adiponectin concentrations and improved glucose control in women with type 2 diabetes. The effect of LA on adipokines, especially total and the bioactive form of adiponectin, high-molecular-weight (HMW) adiponectin, in women with MetS is unknown.

OBJECTIVES

The aim of this study was to explore the effect of supplementation of the diet with an oil rich in LA on adipokines in women with MetS. The effect of the LA-rich oil (LA-oil) on oxylipins, key metabolites that may influence inflammation and metabolism, was also explored.

METHODS

In this open-label single-arm pilot study, 18 postmenopausal nondiabetic women with MetS enrolled in a 2-phase study were instructed to consume LA-rich vegetable oil (10 mL/d) as part of their habitual diets. Women consumed an oleic acid-rich oil (OA-oil) for 4 wk followed by an LA-oil for 16 wk. Fasting concentrations of adipokines, fatty acids, oxylipins, and markers of glycemia and inflammation were measured.

RESULTS

After 4 wk of OA-oil consumption, fasting glucose and total adiponectin concentrations decreased whereas fasting C-reactive protein increased. After 16 wk of LA-oil supplementation total and HMW adiponectin and plasma oxylipins increased. Markers of inflammation and glycemia were unchanged after LA-oil consumption.

CONCLUSIONS

Supplementation with LA-oil increased total and HMW adiponectin concentrations and altered plasma oxylipin profiles. Larger studies are needed to elucidate the links between these changes and MetS.This trial was registered at clinicaltrials.gov as NCT02063165.

The Academic Facility Type Is Associated With Improved Overall Survival for Early-Stage Lung Cancer

BACKGROUND

Early-stage non-small cell lung cancer (NSCLC) is potentially curable with surgical resection. The overall survival rate for early-stage NSCLC may be determined by the healthcare facility type where patients receive their lung cancer treatment.

METHODS

A total of 103,748 cases with the American Joint Committee on Cancer clinical stage I and II NSCLC that were reported to the National Cancer Database at over 1150 facilities were analyzed in this study. Healthcare facilities were dichotomized into the community and academic facility types. Marginal multivariable Cox proportional hazards models were used to evaluate differences in overall survival. Propensity score methodology with inverse probability of treatment weighting was used to adjust for facility volume and patient-related baseline differences between facility types.

RESULTS

Patients with early-stage NSCLC who were treated at academic facility types had a significantly better median overall survival (63.2 months) compared with patients who received care at community healthcare facilities (54.2 months) (hazard ratio, 0.86; 95% confidence interval, 0.82-0.91; P < .0001). The surgical quality outcomes for NSCLC surgery, including 30-day mortality, 90-day mortality, and the median number of lymph nodes removed were significantly better for patients treated at the academic facility types.

CONCLUSIONS

Patients with early-stage NSCLC who were treated at academic facility types had a significantly higher overall median survival compared with patients treated at community facility types. The short-term surgical quality outcomes were significantly better for patients who underwent surgery for early-stage NSCLC at academic facility types.

Metastatic breast cancer patient perceptions of somatic tumor genomic testing

BACKGROUND

To assess metastatic breast cancer (MBC) patient psychological factors, perceptions, and comprehension of tumor genomic testing.

METHODS

In a prospective, single institution, single-arm trial, patients with MBC underwent next-generation sequencing at study entry with sequencing results released at progression. Patients who completed surveys before undergoing sequencing were included in the present secondary analysis (n = 58). We administered four validated psychosocial measures: Center for Epidemiologic Studies Depression Scale, Beck Anxiety Inventory, Trust in Physician Scale, and Communication and Attitudinal Self-Efficacy scale for Cancer. Genetic comprehension was assessed using 7-question objective and 6-question subjective measures. Longitudinal data were assessed (n = 40) using paired Wilcoxon signed rank and McNemar's test of agreement.

RESULTS

There were no significant differences between the beginning and end of study in depression, anxiety, physician trust, or self-efficacy (median time on study: 7.6 months). Depression and anxiety were positively associated with each other and both negatively associated with self-efficacy. Self-efficacy decreased from pre- to post-genomic testing (p = 0.05). Objective genetics comprehension did not significantly change from pre- to post-genomic testing, but patients expressed increased confidence in their ability to teach others about genetics (p = 0.04). Objective comprehension was significantly lower in non-white patients (p = 0.02) and patients with lower income (p = 0.04).

CONCLUSIONS

This is the only study, to our knowledge, to longitudinally evaluate multiple psychological metrics in MBC as patients undergo tumor genomic testing. Overall, psychological dimensions remained stable over the duration of tumor genomic testing. Among patients with MBC, depression and anxiety metrics were negatively correlated with patient self-efficacy. Patients undergoing somatic genomic testing had limited genomic knowledge, which varied by demographic groups and may warrant additional educational intervention.

CLINICAL TRIAL INFORMATION

NCT01987726, registered November 13, 2013.

Antibody-suppressor CD8+ T cells ameliorate antibody-mediated rejection following kidney transplant in mice

Purpose

CCR5 KO kidney transplant (KT) mice produce high titer alloantibody (alloAb) associated with severe antibody-mediated rejection (AMR) that reproduces AMR histology observed in human KT recipients. We previously reported the novel alloAb suppressor activity of alloprimed CXCR5+IFNγ+CD8+ T (Tab-supp) cells following hepatocellular transplant in mice. Here, we investigated the biologic impact of alloprimed CD8+ Tab-supp cells and their capacity to suppress alloAb following adoptive cell transfer (ACT) into CCR5 KO KT mice.

Methods

CCR5 KO (H-2b) mice were transplanted with allogeneic A/J (H-2a) kidneys, and on postoperative day (POD) 5 underwent ACT of alloprimed CD8+ Tab-supp cells (retrieved from C57BL/6 mice alloprimed with A/J alloantigen). A second cohort received concomitant bilateral native nephrectomy, and allograft survival was monitored with serial serum creatinine (&gt;100 μmol/L defines KT graft loss). Untreated CCR5 KO KT mice served as controls.

Results

CCR5 KO KT mice developed high alloAb titer compared to wild-type (WT) recipients (5,800±700 vs 1,200±100; p=0.0003). ACT significantly inhibited alloAb production by 5-fold (1,200±200; p&lt;0.0001) and POD14 AMR pathology (peritubular capillary margination and C4d deposition, arteritis) in CCR5 KO KT mice (composite histologic score 3.6±1.5 vs 8.4±0.2 in untreated controls; p=0.006). Following ACT, alloAb remained suppressed beyond POD 30, correlating with enhanced allograft survival (MST 52 vs 14 days; p=0.006).

Conclusion

ACT of CD8+ Tab-supp cells effectively inhibits alloAb production and AMR not only after allogeneic hepatocellular transplant, but also after vascularized solid organ transplant such as in CCR5 KO KT recipients.

Novel insights into high alloantibody production in CCR5 KO recipient mice

Purpose

Conventional immunosuppressants do not effectively control development of humoral alloimmunity in a substantial proportion of kidney allograft recipients. CCR5 KO (H-2b) mice are a useful model to study antibody-mediated rejection: A/J (H-2a) kidney transplant (KT) recipients produce 10x more alloantibody (alloAb) versus wild-type (WT, H-2b) mice. CXCR5+IFNγ+CD8+ T (Tab-supp) cells are a novel regulatory CD8+ T cell subset that can kill alloprimed IgG+ B cells and mediate suppression of in vivo alloAb in an allogeneic hepatocellular transplant (HcT) model. We hypothesize that high alloAb-producing CCR5 KO KT mice have reduced CD8+ Tab-supp cells.

Methods

Investigate CD8+ Tab-supp cells in peripheral blood and splenocytes of CCR5 KO compared to WT HcT and KT recipients using flow cytometry.

Results

CCR5 KO compared to WT HcT recipients had fewer splenic Tab-supp cells (8.75±2.73×103 vs 19.1±3.07×103; p=0.03). CCR5 KO compared to WT KT mice produce higher alloAb by postoperative day (POD) 14 (5,800±700 vs 1,200±100; p=.0003) and have reduced peripheral CD8+ Tab-supp cells (650±400 vs 11,500±450 per 106 PBMC; p=0.002). Alloprimed CD8+ Tab-supp cells injected into CCR5 KO KT mice are detected in the peripheral blood, spleen, and lymph nodes, but not in the allograft. CCR5 KO KT mice that receive adoptive transfer of CD8+ Tab-supp cells on POD5 produce significantly less alloAb than WT KT mice (1,200±200 vs 5,800±700; titer assayed on POD 14; p&lt;0.0001).

Conclusion

Deficiency of CD8+ Tab-supp cells is likely an important mechanism driving high alloAb production in CCR5 KO KT recipients. This subset exerts antibody suppressor function in lymphoid depots rather than in the kidney allograft.

Recurrence After Stereotactic Body Radiation Therapy Versus Lobectomy for Non-Small Cell Lung Cancer

BACKGROUND

Although lobectomy remains the standard of care for early-stage non-small cell lung cancer, several studies suggest equipoise between lobectomy and stereotactic body radiation therapy (SBRT). However randomized evidence is lacking. We compared outcomes of early-stage non-small cell lung cancer patients treated with lobectomy or SBRT.

METHODS

We included clinical T1-2N0 non-small cell lung cancer treated with lobectomy or SBRT to a biologically effective dose of ≥100 Gy₁₀. We used Cox proportional hazards and nearest-neighbor propensity score (2:1) matching to adjust for confounders. Kaplan-Meier curves were used to assess survival and recurrence.

RESULTS

We identified 554 patients treated with lobectomy (n = 389) or SBRT (n = 165) at our institution between 2008 and 2018. After propensity score matching, there were 132 SBRT patients and 85 lobectomy patients. SBRT was associated with increased local recurrence (hazard ratio [HR], 6.80; 95% confidence interval [CI], 1.92-24.10; P = .003) and regional nodal recurrence (HR, 2.58; 95% CI, 1.17-5.68; P = .018), and with worse overall survival (HR, 2.00; 95% CI, 1.21-3.32; P = .007) and progression-free survival (HR, 2.34; 95% CI, 1.50-3.67; P < .001). There was no difference in distant recurrence (HR, 1.19; 95% CI, 0.57-2.52; P = .64).

CONCLUSIONS

We found superior outcomes in patients with early-stage non-small cell lung cancer treated with lobectomy compared with SBRT, including locoregional control. These findings should be interpreted with caution because of selection bias but underscore the importance of robust randomized prospective data to clarify the relative efficacy of these modalities.

Abstract P5-10-03: Perceptions of somatic genomic testing in patients with metastatic breast cancer: Psychosocial factors, emotional well-being, and genetic comprehension

Background: Little is known regarding the effect of somatic tumor genomic testing on patient perceptions and psychological well-being. We previously demonstrated that patient perceptions of care can be negatively affected if their next cancer treatment is not supported by the genomic test. To further understand this, we investigated psychological effects of genomic testing, as well as sociodemographic and genomic comprehension factors that may attenuate these effects. Methods: In a prospective, single institution, single-arm trial, patients with metastatic breast cancer underwent next-generation sequencing (NGS) using Foundation Medicine at study entry, with sequencing results released to providers at time of next disease progression. We evaluated patient survey data before and after NGS, including questions about psychosocial characteristics, genetic comprehension, and perceived risks and expectations of the genomic testing. We evaluated psychosocial characteristics using 4 validated psychology measures: the Center for Epidemiologic Studies Depression Scale (CES-D), the Beck Anxiety Inventory (BAI), the Trust in Physician Scale (TPS), and the Communication and Attitudinal Self-Efficacy scale for Cancer (CASE-cancer). CASE-cancer measures self-efficacy, how confident patients are in their ability to navigate their cancer care. Genetic comprehension was assessed with a 7-question objective measure and a 6-question subjective measure. No formal genetic education was provided, but the informed consent process included an introduction to NGS. We included exploratory questions on perceived risks and expectations of NGS. Results: Among the 58 patients who completed the pre-NGS survey, we found high rates of depression (38%) and anxiety (47%) using validated metrics. Depression and anxiety were positively correlated (Pearson’s r=0.61; p&lt;0.0001) but both were negatively correlated with self-efficacy (Pearson’s r=-0.43 and -0.42 for depression and anxiety, respectively; p=0.001 for both). Baseline genetic knowledge was significantly lower for non-white and lower income status patients (p=0.04 and 0.001, respectively). Genetic knowledge was not associated with any of the 4 validated psychological measures. The validated psychological measures were not associated with demographic characteristics, treatment decisions, or number of treatment options offered by the NGS test. The average time between pre-test and post-test surveys was 7.6 months. Additionally, the validated psychology measures did not significantly change from pre- to post-study (n=40 patients). However, there was a strong trend of self-efficacy decreasing from pre- to post-NGS testing (p=0.05). Subjectively, patients gained confidence in their ability to teach others about genetics from the start (33% “confident”) to the end of study (46%). Yet, objective comprehension of genetics remained modest throughout the study, with an average score of 72% in both the pre- and post-NGS surveys. The exploratory patient perception questions revealed that 33% of patients felt learning their cancer had a high chance of progressing would be too much to cope with emotionally. Conclusions: This is the first study, to our knowledge, to longitudinally evaluate multiple validated psychological metrics in MBC. NGS did not have a significant effect on depression, anxiety, or trust, but there was a trend towards decreased self-efficacy. This may be influenced by the already high rates of depression, anxiety, and trust in this population. In this study, patient genetic knowledge was limited and associated with race and income. These findings raise important questions about how to support MBC patient emotional well-being and how to improve comprehension of somatic genomic testing in future studies.

Citation Format: Elizabeth J Adams, Sarah Asad, Mahmoud Abdel-Rasoul, Raquel E Reinbolt, Robert Wesolowski, Kaitlyn Tolliver, Susan Gillespie, Katherine A Collier, Anne Noonan, Sargar Sardesai, Jeffrey VanDeusen, Nicole Williams, Charles L Shapiro, Erin R Macre, Bhuvaneswari Ramaswamy, Clara N Lee, Maryam B Lustberg, Daniel G Stover. Perceptions of somatic genomic testing in patients with metastatic breast cancer: Psychosocial factors, emotional well-being, and genetic comprehension [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-10-03.