International variation in managing locally advanced or recurrent rectal cancer: prospective benchmark analysis

BACKGROUND

Tumour extension beyond the mesorectal plane (ymrT4) occurs in 5-10 per cent of patients with rectal cancer and 10 per cent of patients develop locally recurrent rectal cancer (LRRC) after primary surgery. There is global variation in healthcare delivery for these conditions.

METHODS

An international benchmark trial of the management of ymrT4 tumours and LRRC was undertaken in France and Australia between 2015 and 2017. Heterogeneity in management and operative decision-making were analysed by comparison of surgical resection rates, blinded intercountry reading of pelvic MRI, quality-of-life assessment and qualitative evaluations.

RESULTS

Among 154 patients (97 in France and 57 in Australia), 31·8 per cent had ymrT4 disease and 68·2 per cent LRRC. The surgical resection rates were 88 and 79 per cent in France and Australia respectively (P = 0·112). The concordance in operative planning was low (κ = 0·314); the rate of pelvic exenteration was lower in France than Australia both in clinical practice (36 of 78 versus 34 of 40; P < 0·001) and in theoretical conditions (10 of 25 versus 50 of 57; P = 0·002). The R0 resection rate was lower in France than Australia for LRRC (25 of 49 versus 18 of 21; P = 0·007) but not for ymrT4 tumours (21 of 26 versus 15 of 15; P = 0·139). Morbidity rates were similar. Patients who underwent non-exenterative procedures had higher scores on the mental functioning subscale at 12 months (P = 0·047), and a lower level of distress at 6 months (P = 0·049). Qualitative analysis highlighted five categories of psychosocial factors influencing treatment decisions: patient, strategy, specialist, organization and culture.

CONCLUSION

This international benchmark trial has highlighted the differences in worldwide treatment of locally advanced and LRRC. Standardized care should improve outcomes for these patients.

Is neoadjuvant chemoradiotherapy sufficient in patients with advanced rectal malignancy and positive extra-mesorectal lateral lymph nodes?

AIM

There is current debate about the optimal management of lateral pelvic lymph nodes (LPLNs) in rectal cancer between Western and Eastern centres. This paper aims to report the rate of histologically proven positive LPLNs in a group of patients undergoing the conventional Western approach to primary and recurrent rectal cancer.

METHOD

A retrospective cohort review of all patients who underwent LPLN dissection at Royal Prince Alfred Hospital in Sydney, Australia. This included patients who underwent pelvic exenteration who had LPLNs excised either en bloc for laterally invasive or recurrent tumours or as part of selective node dissection for suspicious lymph nodes on preoperative imaging. Histopathological results for these patients were compared with node status at preoperative imaging.

RESULTS

Seventy-one patients satisfied the inclusion criteria. Of those patients with positive nodes on histology, 27% (9/33) with radiologically positive LPLNs were treated with preoperative radiotherapy and 75% (9/12) with radiologically positive LPLNs were not treated with preoperative radiotherapy (P = 0.004). None of the 12 patients with radiologically negative nodes treated with radiotherapy had positive nodes; 25% (3/12) of the patients with radiologically negative nodes who were not treated with radiotherapy had positive nodes. Fifty-three per cent of patients developed postoperative complications.

CONCLUSION

Our study suggests that in patients with radiologically positive LPLNs chemoradiotherapy may not be enough to sterilize these extra-mesorectal lymph nodes as a large proportion (27%) will have residual viable adenocarcinoma cells. In patients with radiologically negative LPLNs, however, the addition of chemoradiotherapy may serve to adequately sterilize these lymph nodes without the need for prophylactic LPLN dissection.

0819 Objective Sleep Efficiency is Associated with Longitudinal Risk of High Depressive Symptoms in Pregnant Women

Introduction

Sleep disturbances are one of the most frequent complaints identified during routine prenatal care visits. Sleep and mood disturbances are often intertwined, and depression in particular is a leading cause of disability and disease burden worldwide. The purpose of this study was to examine the predictive association of objective actigraphic and subjective sleep disturbances with depressive symptoms in pregnant women.

Methods

We recruited 204 first-trimester pregnant women from a large university-affiliated hospital. They provided baseline socio-demographic and health information, wore a wrist actigraph for 7 days, and completed the Pittsburgh Sleep Quality Index and Center for Epidemiologic Studies - Depression Scale and repeated this again in the second and third trimesters. Each data collection was scheduled at least 8 weeks apart. Unadjusted and multivariable adjusted odds ratios with 95% confidence intervals were used to evaluate sleep disturbances at 1st trimester and risk of high depressive symptoms at follow-up.

Results

A total of 121 (59.3%) women had actigraphic sleep efficiency of &lt; 85% and 92 (45.1%) had Pittsburgh Sleep Quality Index global scores &gt; 5 indicative of poor sleep quality. In multivariable adjusted models, 1st trimester objectively measured sleep efficiency &lt; 85% was associated with 2.65-, 3.86-, and 5.27-fold increased odds having risk of high depressive symptoms at 2nd trimester, 3rd trimester, and both 2nd and 3rd trimesters, respectively. No subjective sleep disturbance variables were significantly associated with risk of high depressive symptoms in multivariate adjusted models.

Conclusion

Objectively assessed poor sleep efficiency in the 1st trimester plays a crucial role in the development of both elevated and persistent high depressive symptoms in pregnancy. Future studies using objective sleep measurements and clinical diagnostic interviews are warranted to examine whether early interventions to improve sleep may help reduce high depressive symptom risk and lower depression rates in women during pregnancy.

Support

This study was funded by the Ministry of Science and Technology, Taiwan (MOST-101-2314-B-002-049-MY3).

0580 Habitual Sleep Pattern, Anxiety and Depression are Predictive of Excessive Daytime Sleepiness in a Large-Scale Clinical Samples of Obstructive Sleep Apnea

Introduction

Excessive daytime sleepiness (EDS) is a common symptom that patients with obstructive sleep apnea (OSA) seek medical attention for. Prevalence ranged from 20% to 60%. Previous studies reported factors associated with EDS included age, body mass index (BMI), depression, and OSA severity. In most studies, the sample size was small, participants having specific co-morbidities, and the definitions of EDS was heterogeneous. Moreover, the association between anxiety, depression, habitual sleep pattern, and EDS has not been widely studied. Therefore, the present study aims to investigate the prevalence of EDS and associated factors, especially anxiety, depression, and habitual sleep pattern, in a large-scale clinical sample.

Methods

Data was prospectively collected from 8,081 adult patients who underwent initial overnight polysomnography (PSG) for the first time were referred from 2009 to 2016. Patients with total recording time less than 240 minutes and missing data were excluded. Data collected include demographics, anthropometrics, co-morbidities, and self-reported habitual sleep patterns. Subjective sleepiness was assessed by the Epworth Sleepiness Scale (ESS) with EDS defined as ESS ≥10. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS). The stepwise forward Logistic regression was used to identified predictors for EDS.

Results

In 5,780 (82.6%) patients with OSA (apnea-hypopnea index, AHI≥5/h), mean age was 63.9±0.2 yr, BMI was 27.7±0.1, and ESS was 10.4±0.1 and 80.5% were male. Prevalence of EDS in all OSA patients was 55.1% where the patients with severe OSA had higher prevalence (59.8%) than that in mild (49.5%) and moderate OSA (51.8%). Anxiety (OR: 2.036, 95% CI:1.153-1.502), depression (OR: 1.159, 95% CI:1.01-1.33), and short sleep (&lt;6hr/night) (OR:1.316, 95% CI:1.32,1.70) were top three risk factors for EDS. Other risk factors for EDS included AHI, arousal index, % total sleep time with SpO2&lt;90%, %REM, smoking while hypnotic use and long sleep (≥ 8hr/night) were associated with lower risk.

Conclusion

Anxiety, depression, short sleep are predictive and OSA severity are predictive of EDS while long sleep was associated with lower risk.

Support

National Taiwan University (NTU-EPR-104R8951-1; 105R8951-1; 106R880301), Center of electronics technology integration (NTU-107L900502, 108L900502) by the Ministry of Education in Taiwan and MediaTek Inc (201802034RIND).

1206 Automated Sleep Apnea Assessment Based On Machine Learning And Wearable Technology

Introduction

Obstructive sleep apnea (OSA) is a condition characterized by repeated episodes of partial or complete obstruction of the respiratory passages during the sleep. Traditional polysomnography (PSG) for OSA estimation is bulky and time-consuming for daily use. Therefore, this study aims to develop a novel photoplethysmography (PPG) and accelerometer based smart watch for OSA detection, in which a high-performance and low-complexity automated OSA detection was embedded for long-term in-home measurement.

Methods

The developed watch measured PPG signals from wrist radial artery and body motion from accelerometer as well. 121 patients (92 males, 29 females) were recruited from the normal community and Center of Sleep, National Taiwan University Hospital, Taiwan in this study. All OSA scoring were analyzed by three registered PSG technologists. The AHI of the cohort was 10.1±18.3 (0 to 82.7). An automated OSA detection algorithm was designed based on machine-learning (ML) technique, in which was iteratively updated according to each 30-second epoch of the collected data. Subsequently, obstructive and hypopnea events were detected according to the OSA detection algorithm.

Results

To better valid the effectiveness, this study focused on the estimation performance of the subjects with AHI&gt;15. Based on hold-out validation, the average sensitivity and precision in the AHI&gt;15 cohort were 77.2% and 58.6%, respectively, with a Cohen’s kappa of 0.46. The interclass correlation between the watch and technologists was 0.81 (95%CI: 0.61-0.91). The result showed that the proposed automated OSA detection could achieve consistent result with technologist during standard sleep testing.

Conclusion

This study developed a wrist-based watch based on ML technique to assess OSA severity. We compared the performance with clinical technologists for the OSA detection. Further, the sensitivity and precision were generally acceptable while subjects were with AHI&gt;15. The proposed wrist-based watch could provide reliable performance for OSA estimation, and may be of a light for future in-home sleep studies.

Support

This study was supported by Mediatek Inc.

Phase-contrast 3D tomography of HeLa cells grown in PLLA polymer electrospun scaffolds using synchrotron X-rays

Advanced imaging is useful for understanding the three-dimensional (3D) growth of cells. X-ray tomography serves as a powerful noninvasive, nondestructive technique that can fulfill these purposes by providing information about cell growth within 3D platforms. There are a limited number of studies taking advantage of synchrotron X-rays, which provides a large field of view and suitable resolution to image cells within specific biomaterials. In this study, X-ray synchrotron radiation microtomography at Diamond Light Source and advanced image processing were used to investigate cellular infiltration of HeLa cells within poly L-lactide (PLLA) scaffolds. This study demonstrates that synchrotron X-rays using phase contrast is a useful method to understand the 3D growth of cells in PLLA electrospun scaffolds. Two different fiber diameter (2 and 4 µm) scaffolds with different pore sizes, grown over 2, 5 and 8 days in vitro, were examined for infiltration and cell connectivity. After performing visualization by segmentation of the cells from the fibers, the results clearly show deeper cell growth and higher cellular interconnectivity in the 4 µm fiber diameter scaffold. This indicates the potential for using such 3D technology to study cell-scaffold interactions for future medical use.

Immunological and biochemical evidence for identity of tartrate-resistant isoenzymes of acid phosphatases from human serum and tissues

We purified acid phosphatase isoenzyme 5b from a human spleen affected by leukemic reticuloendotheliosis and used it to produce a specific antiserum. The antiserum was used to show complete immunological identity among isoenzymes 5a and 5b in human serum, and 5b isolated from a giant-cell bone tumor and from the spleen of a case of Hodgkin's disease. Acid phosphatase 5b in a giant-cell bone tumor was isolated for biochemical characterization. Its pH optimum and substrate specificity were very similar to those of isoenzyme 5b from human spleen.