Safety and efficacy of oral anticoagulants in extreme weights

BACKGROUND

The 2021 International Society on Thrombosis and Haemostasis' (ISTH) recommends standard doses of apixaban and rivaroxaban regardless of high body mass index (BMI) and weight, but had not compare DOACs head-to-head in obesity or address underweight patients.

METHODS

Our aim is to evaluate the safety and efficacy of DOACs in underweight and obese patients compared to warfarin. The primary endpoints include incidence of thromboembolic and bleeding events. Descriptive statistics was used for continuous variables. The Kruskal-Wallis test was used to compare the four-groups for continuous measures and the chi-square test or Fisher's exact test was used to analyze categorical data. The chi-square test or Fisher's exact test, was used for categorical variables, and the Mann-Whitney test (the non-parametric counterpart to the two-sample t-test) for continuous data.

RESULTS

Of 2940 patients receiving anticoagulation for venous thromboembolism (VTE) treatment or atrial fibrillation (AF), 492 met eligibility criteria. Within each group, 248 patients received warfarin, 101 received apixaban, 100 received rivaroxaban and 43 received dabigatran. Patients were characterized in 4 body mass index (BMI) categories, in which 80 were underweight and 412 were obese.

CONCLUSIONS

When each DOAC was compared to warfarin in rates of VTE, apixaban showed statistically significant lower rate of VTE (p = 0.0149). However, no statistical significance was identified in the rate of VTE between DOACs combined vs. warfarin (p = 0.1529). When each DOAC was compared to warfarin, apixaban showed the lowest rate of overall bleeding (p = 0.0194). However, no statistical difference in the rate of bleeding was observed between DOACs combined vs. warfarin (p = 0.3284). Patients with extreme body weights requiring anticoagulation for VTE and AF may safety benefit from DOAC therapy. This evaluation showed apixaban with the lowest rate of VTE and bleeding compared to warfarin, rivaroxaban, and dabigatran. These results provide experience for the clinician to use DOACs, particularly apixaban, in underweight and obese populations.

Global Incidence, Mortality, Risk Factors and Trends of Melanoma: A Systematic Analysis of Registries

BACKGROUND

Melanoma of the skin is the most dangerous skin cancer in the world, though the numbers of reported new cases and melanoma-related deaths are low.

OBJECTIVE

This study evaluated the global incidence, mortality, risk factors and temporal trends by age, sex and locations of melanoma skin cancer.

PATIENTS AND METHODS

Cancer Incidence in Five Continents (CI5) volumes I-XI; the Nordic Cancer Registries (NORDCAN); the Surveillance, Epidemiology and End Results (SEER) Program; and the World Health Organization (WHO) International Agency for Research on Cancer (IARC) mortality database were accessed for worldwide incidence and mortality rates. Average Annual Percentage Change (AAPC) was calculated using a Joinpoint regression to examine trends.

RESULTS

Age-standardized rates of cancer incidence and mortality were 3.4 and 0.55 per 100,000 worldwide in 2020. Australia and New Zealand reported the highest incidence and mortality rates. Associated risk factors included higher prevalence of smoking, alcohol consumption, unhealthy diet, obesity and metabolic diseases. Increasing incidence trends were observed mostly in European countries, whilst mortality displayed an overall decreasing trend. For both sexes in the age group 50 years and above, a significant increase in incidence trend was observed.

CONCLUSIONS

Although mortality rates and trends were found to decrease, global incidence has increased, especially in older age groups and males. Whilst incidence increase may be attributed to improved healthcare infrastructure and cancer detection methods, the growing prevalence of lifestyle and metabolic risk factors in developed countries should not be discounted. Future research should explore underlying variables behind epidemiological trends.

Prediction algorithm for gastric cancer in a general population: A validation study

BACKGROUND

Worldwide, gastric cancer is a leading cause of cancer incidence and mortality. This study aims to devise and validate a scoring system based on readily available clinical data to predict the risk of gastric cancer in a large Chinese population.

METHODS

We included a total of 6,209,697 subjects aged between 18 and 70 years who have received upper digestive endoscopy in Hong Kong from 1997 to 2018. A binary logistic regression model was constructed to examine the predictors of gastric cancer in a derivation cohort (n = 4,347,224), followed by model evaluation in a validation cohort (n = 1,862,473). The algorithm's discriminatory ability was evaluated as the area under the curve (AUC) of the mathematically constructed receiver operating characteristic (ROC) curve.

RESULTS

Age, male gender, history of Helicobacter pylori infection, use of proton pump inhibitors, non-use of aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), and statins were significantly associated with gastric cancer. A scoring of ≤8 was designated as "average risk (AR)". Scores at 9 or above were assigned as "high risk (HR)". The prevalence of gastric cancer was 1.81% and 0.096%, respectively, for the HR and LR groups. The AUC for the risk score in the validation cohort was 0.834, implying an excellent fit of the model.

CONCLUSIONS

This study has validated a simple, accurate, and easy-to-use scoring algorithm which has a high discriminatory capability to predict gastric cancer. The score could be adopted to risk stratify subjects suspected as having gastric cancer, thus allowing prioritized upper digestive tract investigation.

Adoption of colonoscopy surveillance intervals in subjects who received polypectomy in southern China: A cost-effectiveness analysis

BACKGROUND AND AIM

We aimed to evaluate the cost-effectiveness of different colonoscopy intervals among average-risk (5 vs 10 years) and high-risk (1 vs 3 years) southern Chinese populations.

METHODS

We constructed a Markov model with a hypothetical population of 100 000 individuals aged 50-85 years. Average risk was defined as 1-2 non-advanced adenomas (tubular adenoma sized < 10 mm without high-grade dysplasia). High risk was defined as ≥ 3 non-advanced adenomas or any advanced adenoma (adenoma sized ≥ 10 mm, with high-grade dysplasia, or with villous/tubulovillous histology). Three strategies were compared: a 5/1 strategy (average-risk subjects: 5-year interval; high-risk subjects: 1-year interval), a 10/3 strategy, and a control strategy (a 10/10 strategy). Costs (US dollar), quality-adjusted-life-years, incremental cost-effectiveness ratio, and net health benefit were calculated. If the incremental cost-effectiveness ratio of one strategy against another was less than willingness-to-pay ($24 302 US/quality-adjusted-life-years), the strategy was more cost-effective than another.

RESULTS

Compared with the 10/3 strategy, the 5/1 strategy involved more costs and effects (incremental cost-effectiveness ratio = $40 044 US/quality-adjusted life-years). When the 10/10 strategy was regarded as the control, the 5/1 strategy had a higher incremental cost-effectiveness ratio than the 10/3 strategy ($26 056 vs $10 344 US/quality-adjusted life-years). Furthermore, the 10/3 strategy had the highest net health benefit.

CONCLUSIONS

A 10/3 interval was more cost-effective than a 5/1 interval. From an economic perspective, our findings supported a 10-year interval for average-risk individuals and a 3-year interval for high-risk subjects. The findings could help form the optimal colonoscopy interval for average-risk and high-risk patients.

The economic burden of coronary heart disease in mainland China

OBJECTIVES

The aim of this study was to systematically evaluate the current economic burden of coronary heart disease (CHD) in mainland China and provide a reference for the formulation of policies to reduce the economic burden of CHD.

STUDY DESIGN

A systematic literature review was conducted of empirical studies on the economic burden of CHD over the past 20 years.

METHODS

PubMed, Web of Science, Embase, China Knowledge Resource Integrated Database and the WANFANG database were comprehensively searched for relevant articles published between 1 January 2000 and 22 December 2021. Content analysis was used to extract the data, and Stata 17.0 software was used for analysis. The median values were used to describe trends.

RESULTS

A total of 35 studies were included in this review. The annual median per-capita hospitalisation expense and the average expense per hospitalisation were $3544.40 ($891.64-$18,371.46) and $5407.34 ($1139.93-$8277.55), respectively. The median ratio on medical consumables expenses, drug expenses, medical examination expenses and treatment expenses were 41.59% (12.40%-63.73%), 26.90% (7.30%-60.00%), 9.45% (1.65%-33.40%) and 10.10% (2.36%-66.00%), respectively. The median per-capita hospitalisation expense in the eastern, central and western regions were $9374.45 ($2056.13-$18,371.46), $4751.5 ($2951.95-$8768.93) and $3251.25 ($891.64-$13,986.38), respectively. The median average expense per hospitalisation in the eastern and central regions were $6177.15 ($1679.15-$8277.55) and $1285.49 ($1239.93-$2197.36), respectively. The median average length of stay in the eastern, central and western regions were 9.3 days, 15.2 days and 16.1 days, respectively.

CONCLUSIONS

The economic burden of CHD is more severe in mainland China than in developed countries, especially in terms of the direct economic burden. In terms of the types of direct medical expenses, a proportion of medical examination expenses, treatment expenses and drug expenses were lowest in the eastern region, but medical consumables expenses were the highest in this region. This study provides guidance for the formulation of policies to reduce the economic burden of CHD in mainland China.

Design of Power Amplifiers for BDS-3 Terminal Based on InGaP/GaAs HBT MMIC and LGA Technology

With the development and popularization of the Beidou-3 navigation satellite system (BDS-3), to ensure its unique short message function, it is necessary to integrate a radio frequency (RF) transmitting circuit with high performance in the BDS-3 terminal. As the key device in an RF transmitting circuit, the RF power amplifier (PA) largely determines the comprehensive performance of the circuit with its transmission power, efficiency, linearity, and integration. Therefore, in this paper, an L-band highly integrated PA chip compatible with 3 W and 5 W output power is designed in InGaP/GaAs heterojunction bipolar transistor (HBT) technology combined with temperature-insensitive adaptive bias technology, class-F harmonic suppression technology, analog pre-distortion technology, temperature-insensitive adaptive power detection technology, and land grid array (LGA) packaging technology. Additionally, three auxiliary platforms are proposed, dedicated to the simulation and optimization of the same type of PA designs. The simulation results show that at the supply voltage of 5 V and 3.5 V, the linear gain of the PA chip reaches 39.4 dB and 38.7 dB, respectively; the output power at 1 dB compression point (P1dB) reaches 37.5 dBm and 35.1 dBm, respectively; the saturated output power (Psat) reaches 38.2 dBm and 36.2 dBm, respectively; the power added efficiency (PAE) reaches 51.7% and 48.2%, respectively; and the higher harmonic suppression ratios are less than -62 dBc and -65 dBc, respectively. The size of the PA chip is only 6 × 4 × 1 mm3. The results also show that the PA chip has high gain, high efficiency, and high linearity under both output power conditions, which has obvious advantages over similar PA chip designs and can meet the short message function of the BDS-3 terminal in various application scenarios.

Associations between GoSmart Channel, health literacy and health behaviours in adolescents: A population-based study

BACKGROUND

Health literacy is essential in the promotion of healthy lifestyle habits and chronic disease prevention.

OBJECTIVE

To assess the health literacy level among Hong Kong adolescents; to evaluate the association between access of an online health information platform (GoSmart Channel) and health literacy level; and to examine the association between health literacy level and various unhealthy behaviours.

DESIGN

This study recruited students from 10 local secondary schools in Hong Kong to assess the health literacy level among adolescents.

SETTINGS AND PARTICIPANTS

Participants were required to complete a self-administered questionnaire on health behaviours and health literacy using the Health Literacy Measure for Adolescents (HELMA). MAIN OUTCOME MEASURE: Data were analysed using descriptive statistics and multivariate regression modelling.

RESULTS

A total of 777 responses were collected. Overall, most (74.4%) of the adolescents in Hong Kong have limited health literacy (HELMA score <66). The majority (63.7%) of adolescents relied on their parents for health information, while 11.4% of the respondents sought information from the GoSmart Channel. The intervention of GoSmart Channel was significantly associated with better health literacy in almost all aspects among adolescents. Desired levels of health literacy were significantly associated with better perceived health (adjusted odds ratio: 2.04, p = .001) and negatively associated with a range of unhealthy and risky behaviours including unhealthy dietary habits, poor hygienic measures and physical inactivity.

DISCUSSION AND CONCLUSION

This study highlights the importance of improving health literacy among Hong Kong adolescents and the potential of technology-based interventions. The findings suggest the need for continued efforts to promote health literacy and healthy behaviours among adolescents, especially given the limited health literacy levels observed in the study.

PATIENT OR PUBLIC CONTRIBUTION

Members of the GoSmart.Net Built-on Project patient and public involvement and engagement group advised about survey development.

Characteristics of Metabolites in the Development of Atherosclerosis in Tibetan Minipigs Determined Using Untargeted Metabolomics

BACKGROUND

Atherosclerosis (AS) is a chronic progressive disease caused by lipometabolic disorder. However, the pathological characteristics and mechanism of AS have not been fully clarified. Through high-fat and high-cholesterol diet induction, Tibetan minipigs can be used as the AS model animals, as they have a very similar AS pathogenesis to humans.

METHODS

In this study, we built an AS model of Tibetan minipigs and identified the differential abundance metabolites in the development of AS based on untargeted metabolomics.

RESULTS

We found that sphingolipid metabolism and glucose oxidation were obviously higher in the AS group and phenylalanine metabolism was reduced in the AS group. Moreover, in the development of AS, gluconolactone was enriched in the late stage of AS whereas biopterin was enriched in the early stage of AS.

CONCLUSIONS

Our research provides novel clues to investigate the metabolic mechanism of AS from the perspective of metabolomics.

Successional action of Bacteroidota and Firmicutes in decomposing straw polymers in a paddy soil

BACKGROUND

Decomposition of plant biomass is vital for carbon cycling in terrestrial ecosystems. In waterlogged soils including paddy fields and natural wetlands, plant biomass degradation generates the largest natural source of global methane emission. However, the intricate process of plant biomass degradation by diverse soil microorganisms remains poorly characterized. Here we report a chemical and metagenomic investigation into the mechanism of straw decomposition in a paddy soil.

RESULTS

The chemical analysis of 16-day soil microcosm incubation revealed that straw decomposition could be divided into two stages based on the dynamics of methane, short chain fatty acids, dissolved organic carbon and monosaccharides. Metagenomic analysis revealed that the relative abundance of glucoside hydrolase (GH) encoding genes for cellulose decomposition increased rapidly during the initial stage (3-7 days), while genes involved in hemicellulose decomposition increased in the later stage (7-16 days). The increase of cellulose GH genes in initial stage was derived mainly from Firmicutes while Bacteroidota contributed mostly to the later stage increase of hemicellulose GH genes. Flagella assembly genes were prevalent in Firmicutes but scarce in Bacteroidota. Wood-Ljungdahl pathway (WLP) was present in Firmicutes but not detected in Bacteroidota. Overall, Bacteroidota contained the largest proportion of total GHs and the highest number of carbohydrate active enzymes gene clusters in our paddy soil metagenomes. The strong capacity of the Bacteroidota phylum to degrade straw polymers was specifically attributed to Bacteroidales and Chitinophagales orders, the latter has not been previously recognized.

CONCLUSIONS

This study revealed a collaborating sequential contribution of microbial taxa and functional genes in the decomposition of straw residues in a paddy soil. Firmicutes with the property of mobility, WLP and cellulose decomposition could be mostly involved in the initial breakdown of straw polymers, while Bacteroidota became abundant and possibly responsible for the decomposition of hemicellulosic polymers during the later stage.

Final Results of GERDA on the Two-Neutrino Double-β Decay Half-Life of ^{76}Ge

We present the measurement of the two-neutrino double-β decay rate of ^{76}Ge performed with the GERDA Phase II experiment. With a subset of the entire GERDA exposure, 11.8 kg yr, the half-life of the process has been determined: T_{1/2}^{2ν}=(2.022±0.018_{stat}±0.038_{syst})×10^{21}  yr. This is the most precise determination of the ^{76}Ge two-neutrino double-β decay half-life and one of the most precise measurements of a double-β decay process. The relevant nuclear matrix element can be extracted: M_{eff}^{2ν}=(0.101±0.001).

Experimental Validation of a Kinetic Ballooning Mode in High-Performance High-Bootstrap Current Fraction Fusion Plasmas

We report the observation of a set of coherent high frequency electromagnetic fluctuations that leads to a turbulence induced self-regulating phenomenon in the DIII-D high bootstrap current fraction plasma. The fluctuations have frequency of 130-220  kHz, the poloidal wavelength and phase velocity are 16-30  m^{-1} and ∼30  km/s, respectively, in the outboard midplane with the estimated toroidal mode number n∼5-9. The fluctuations are located in the internal transport barrier (ITB) region at large radius and are experimentally validated to be kinetic ballooning modes (KBM). Quasilinear estimation predicts the KBM to be able to drive experimental particle flux and non-negligible thermal flux, suggesting its significant role in regulating the ITB saturation.

Synthesis and exceptional operational durability of polyaniline-inspired conductive ladder polymers

Ladder-type structures can impart exceptional stability to polymeric electronic materials. This article introduces a new class of conductive polymers featuring a fully ladder-type backbone. A judicious molecular design strategy enables the synthesis of a low-defect ladder polymer, which can be efficiently oxidized and acid-doped to achieve its conductive state. The structural elucidation of this polymer and the characterization of its open-shell nature are facilitated with the assistance of studies on small molecular models. An autonomous robotic system is used to optimize the conductivity of the polymer thin film, achieving over 7 mS cm-1. Impressively, this polymer demonstrates unparalleled stability in strong acid and under harsh UV-irradiation, significantly surpassing commercial benchmarks like PEDOT:PSS and polyaniline. Moreover, it displays superior durability across numerous redox cycles as the active material in an electrochromic device and as the pseudocapacitive material in a supercapacitor device. This work provides structural design guidance for durable conductive polymers for long-term device operation.

A Pilot Study of Simulation-Free Hippocampal-Avoidance Whole Brain Radiotherapy Using Diagnostic MR-Based and Online Adaptive Planning

PURPOSE/OBJECTIVE(S)

We aimed to demonstrate the clinical feasibility and safety of a simulation-free hippocampal avoidance whole brain radiotherapy (HA-WBRT) workflow in a Phase I clinical trial (NCT05096286). Feasibility was defined as successful completion of the simulation-free HA-WBRT workflow through treatment delivery in at last 70% of treated patients.

MATERIALS/METHODS

Ten candidates for HA-WBRT were enrolled for treatment on a ring gantry CT-guided Linac with online adaptive capabilities. Structures were contoured on the diagnostic brain MRI, which was then registered to a separate head computed tomography (CT) of similar head shape, obtained from an atlas-based database. A HA-WBRT "pre-plan" was generated using the atlas-based CT (AB-CT) and the NRG-CC001 constraints. At first fraction, the AB-CT was used as the primary dataset and deformed to the patient's cone-beam CT (CBCT) for dose calculation. The brain, ventricles, and brainstem contours were matched through rigid translation and rotation to the corresponding anatomy on the CBCT to aid in alignment, given the differences in rotational head positioning from diagnostic MRI to CBCT setup. Lastly, the lens, optic nerves, and brain contours were manually edited based on CBCT visualization. Plans were then optimized, and the adaptive plan was chosen for treatment if the plan met all objectives. Workflow tasks were timed. In addition, conventional plans using patients' sim CTs were created for each patient for the purpose of prospective dosimetric comparison. The dosimetric parameters were compared for each patient between the delivered sim-free plan and the conventional sim CT plan using the sign test via statistical software, with p<.05 indicating significance.

RESULTS

Median time from approved sim order to first fraction was 4 days (range: 2-7); median time in room (door-to-door) was 49 minutes (range: 35-70). All patients successfully completed all ten fractions and 90% of the simulation-free radiation plans met all NRG-CC001 constraints. For one patient, the sim-free plan at fraction one failed the planning target volume (PTV) coverage objective (coverage of 89%); this was deemed acceptable for delivery by the treating radiation oncologist. An offline replan was then performed to meet NRG-CC001 constraints and used for the subsequent nine fractions. There was no clinically meaningful difference in dosimetric constraints between the sim-free plan (calculated on AB-CT) and conventional CT sim plan. Statistically, the sim-free plans provided improved PTV coverage to higher doses compared to the conventional plans (Table). At a median follow-up of 43 days (range: 9 -280), the intracranial progression-free survival rate was 90%.

CONCLUSION

Simulation-free HA-WBRT is feasible, results in plans that are dosimetrically comparable to conventional CT sim workflows and succeeds in decreasing time to initiation of HA-WBRT by at least 50%. Further studies with a larger cohort are warranted to optimize the workflow.

Low Dose Fractionated Radiation Therapy as a Chemo-Potentiator of Salvage Temozolomide (TMZ) for Recurrent Anaplastic Astrocytoma (AA) and Glioblastoma Multiforme (GBM): A Single-Arm Phase I/II Trial

PURPOSE/OBJECTIVE(S)

Cell survival curves demonstrate low-dose radiation hypersensitivity, with steepest cell kill at 0.3-0.5 Gy/fx. This phase 1/2 study assessed the safety and efficacy of low-dose fractionated radiation therapy (LDFRT) as a chemopotentiator of concurrent TMZ for patients with recurrent GBM or AA.

MATERIALS/METHODS

Patients with recurrent GBM or AA s/p standard of care therapy and ≥12 months from prior RT and ≥2 months from prior TMZ were eligible to receive 0.5 Gy of RT twice daily for 10 fx with concurrent TMZ (150-200 mg/m2), both delivered in 5 consecutive days of a 28-day cycle for up to 6 cycles, followed by 6 more cycles of adjuvant TMZ. In phase 1, hematologic toxicity was assessed 1 month after starting therapy. Brain MRIs were obtained every 2 months, or every 1 month in cases of potential progression. Progression was defined by RANO criteria. Pseudoprogression consisted of MRI changes independent of clinical deterioration or steroid use that stabilize/reverse without oncologic intervention. The primary endpoint was 1-year overall survival (OS), with a lower bound of an 80% CI >28% deemed promising for further study based on historical data. Secondary endpoints were rates of pseudoprogression and hematologic toxicity.

RESULTS

Thirty-one patients were enrolled/analyzed. Grade 3-4 acute hematologic toxicity was seen in 8 (27%) patients. Median follow-up was 9.5 (range: 0.1-66.3) months (mos). Median and 1-yr OS were 9.6 (95% CI = 7.0-15.4) mos and 34.5% (95% CI = 20.9%-57.0%). The lower bound of the 80% CI for 1-yr OS was 24.8%. 77% of patients experienced pseudoprogression, with a median time to pseudoprogression from start of LDFRT of 1.9 (95% CI = 1.7-4.4) mos and median duration of 3.6 (95% CI = 1.6-Not estimable) mos. Patients with pseudoprogression had improved OS vs. those without (N = 6; median 10.6 vs 3.9 mos, HR = 0.12 [95% CI = 0.03-0.40]; P < 0.01).

CONCLUSION

LDFRT in the re-irradiation setting for GBM or AA was safe. High rates of pseudoprogression were observed at strikingly low RT doses, with improved OS amongst patients with vs. without pseudoprogression. While pseudoprogression is common at definitive doses of brain RT, it is rare at palliative doses (e.g., 30 Gy/10 fx). Thus, low-dose RT hypersensitivity may be elicited by LDFRT with TMZ for patients with GBM/AA. Further study is needed to optimally apply this radiobiological property to improve patient outcomes.

Phase II Study of Hemithoracic Intensity-Modulated Pleural Radiation Therapy (IMPRINT) for Patients with Pleural Metastases from Thymic Malignancies

PURPOSE/OBJECTIVE(S)

Pleural metastases are common sites for recurrence and progression in patients with thymic malignancies. The management of pleural metastases typically involves surgical resection with or without neoadjuvant or adjuvant systemic therapy. After surgical resection of pleural metastases, the 5-year progression-free survival (PFS) rate is about 29-45%. While radiation therapy (RT) is standardly used in the management of locally-advanced thymic malignancies, the role of RT in patients with pleural metastases in unclear. Intensity-modulated pleural radiation therapy (IMPRINT) is a RT technique currently being used to treat malignant pleural mesothelioma (MPM) patients with 2 intact lungs at centers that specialize in MPM treatment. This IMPRINT technique can potentially be extrapolated to thymic patients with pleural metastases. Because the risk of toxicity is of greater concern for thymic patients given their overall relatively favorable prognosis, the rate of toxicity, particularly radiation pneumonitis, needs to be established in the thymic patient population.

MATERIALS/METHODS

This is a single-arm, single institution Phase II study of hemithoracic IMPRINT for patients with pleural metastases from thymic malignancies. The primary endpoint of this study is grade 3 or higher radiation pneumonitis within 4 months of completing RT. Secondary endpoints include any toxicity, progression-free survival, patterns of failure and overall survival. Patients must have a pathologically confirmed diagnosis of a thymic malignancy with radiologic or pathologic evidence of pleural metastases. Thymoma or thymic carcinoma are allowed. Patients may have de novo stage IVA disease or recurrent disease in the pleura. There must be no evidence of extrathoracic metastatic disease or contralateral pleural/pericardial disease. Surgical resection of the pleural nodules (ex: pleurectomy/decortication, debulking/metastasectomy) are allowed. Extrapleural pneumonectomy is not allowed. Patients are excluded if they have undergone prior thoracic radiation therapy preventing hemithoracic pleural IMRT, whereas prior thymic bed radiation and/or prior pleural SBRT are allowed. RT will be administered to the ipsilateral pleura to 50.4 Gy in 28 fractions. An optional dose-painting boost to gross disease up to 60 Gy while respecting normal tissue constraints is allowed. Patients can be treated with photon or proton therapy. Simulation, contouring and RT planning guidelines have been developed. Patients will be followed per protocol at regular intervals for at least 12 months following RT. The expected accrual is 36 patients over 4 years. Further information can be found on clinicaltrials.gov (NCT05354570).

RESULTS

To be determined.

CONCLUSION

To be determined.

Standard Therapy vs. Individualized Therapy in Elderly Locally Advanced Nasopharyngeal Carcinoma: A Real-World Study

PURPOSE/OBJECTIVE(S)

Concurrent chemoradiotherapy (CRT) with/without induction chemotherapy has been the standard therapy (ST) for locally advanced nasopharyngeal carcinoma (LA-NPC). However, most patients supporting these clinical trials were younger than 65 years of age. For the toxicity of CRT and the poor tolerance of elderly patients, it is still controversial whether ST could bring the most promising survival benefits for elderly NPC compared with individualized therapy (IT). Thus, in this real-world study we compared the survival and safety of ST with IT in elderly LA-NPC to explore an effective and tolerable treatment strategy for elderly LA-NPC.

MATERIALS/METHODS

A total of 109 newly diagnosed elderly LA-NPC (>65 years old) from Jan. 2013-Jul. 2020 were retrospectively enrolled and divided into the ST group and IT group according to the original treatment tendency. ST refers to CRT with/without induction chemotherapy. IT group included patients not suitable for CRT and were given individualized treatment fully discussed by at least two oncologists from our head and neck team. A 1:1 propensity score matching (PSM) generated a matched cohort of ST and IT. The survivals and treatment related toxicities were compared between the two groups.

RESULTS

There were 46 cases in the ST group and 63 cases in the IT group. The 5-year overall survival (OS) rate, cancer-specific survival (CSS) rate, progression- free survival (PFS) rate, local recurrence-free survival (LRFS) rate and distant metastasis-free survival (DMFS) rate were 68.64%, 76.42%, 73.69%, 85.67% and 86.82%, respectively. By 1:1PSM, 35 cases in each group were matched. No significant differences of OS, CSS, PFS, LRFS and DMFS were found between ST and IT groups in the PSM-matched cohorts (P = 0.87, P = 0.79, P = 0.51, P = 0.81 and P = 0.24, respectively). Compared with patients in the ST group, cases received IT were associated with less severe acute toxicities including anemia, leucopenia, neutropenia, and thrombocytopenia.

CONCLUSION

For elderly LA-NPC, IT had similar survivals while less severe toxicities compared with ST, which revolutionarily challenged the role of ST for elderly LA-NPC. In the future, more studies are need to explore a less toxic treatment modality with noninferior efficacy for elderly LA-NPC.

Factors associated with physical inactivity among the pre-school children: A cohort of 1681 participants

AIM

To investigate the risk factors associated with physical inactivity of young children in Hong Kong.

METHODS

This follow-up study was part of a prospective cohort study named Studying Impact of Nutrition on Growth (SING) initiated in 2015. Subjects were recruited from randomly selected local nurseries and kindergartens in Hong Kong. Self-administrated questionnaires were distributed to parents in 2016-2017 to collect information on: (i) socio-economic background; (ii) health-related factors, including gestation at time of birth, and hospitalisation of the child since birth; (iii) types of leisure activities, including time spent on electronic games and physical activity.

RESULTS

A total of 1681 responses were collected. A higher likelihood of physical inactivity on weekdays was associated with being female, not being the firstborn, having been hospitalised three or more times since birth, and having physically inactive care givers. Meanwhile, children whose mother was unemployed/retired, and who spent more than 1 h on electronic games per day were significantly less likely to be physically inactive. Similarly, being female, being the secondborn or the thirdborn, and having a care giver with low physical activity level were associated with a higher chance of physical inactivity on weekends.

CONCLUSIONS

Parental support could play a pivotal role in determining a child's physical activity level. Public health policies should be implemented to promote family-based physical activities.

Facial expression of patients with Graves' orbitopathy

PURPOSE

Patients with Graves' orbitopathy (GO) have characteristic facial expressions that are different from those of healthy individuals due to the combination of somatic and psychiatric symptoms. However, the facial expressions of GO patients have not yet been described and analyzed systematically. Thus, the present study aimed to present the facial expressions of GO patients and explore their applications in clinical practice.

METHODS

Facial image and clinical data of 943 GO patients were included, and 126 patients answered quality of life (GO-QOL) questionnaires. Each patient was labeled for one facial expression. Then, a portrait was drawn for every facial expression. Logistic and linear regression was performed to analyze the correlation between facial expression and clinical indicators, including QOL, disease activity and severity. The VGG-19 network model was utilized to discriminate facial expressions automatically.

RESULTS

Two groups, i.e., the non-negative emotion (neutral, happy) and the negative emotion (disgust, angry, fear, sadness, surprise), and seven expressions of GO patients were systematically analyzed. Facial expression was statistically associated with GO activity (P = 0.002), severity (P < 0.001), QOL visual functioning subscale scores (P = 0.001), and QOL appearance subscale score (P = 0.012). The deep learning model achieved satisfactory results (accuracy 0.851, sensitivity 0.899, precision 0.899, specificity 0.720, F1 score 0.899, and AUC 0.847).

CONCLUSIONS

As a novel clinical sign, facial expression holds the potential to be incorporated into GO assessment system in the future. The discrimination model may assist clinicians in real-life patient care.

Dose-Effect of Proton and Photon Craniospinal Irradiation on Vertebral Growth in Pediatric Patients with Medulloblastoma

PURPOSE/OBJECTIVE(S)

Craniospinal irradiation (CSI) directly damages vertebral growth plates causing skeletal dysplasia leading to reduced height in pediatric long-term survivors. The objective of this study is to quantify the adjusted effect of CSI on standing and sitting height by radiation dose and modality in children.

MATERIALS/METHODS

Two hundred sixty-five patients (M/F 169/96) were treated at a single institution on a clinical and molecular risk-directed trial for medulloblastoma (NCT01878617) using proton or photon therapy. Three CSI dose regimens were evaluated: 15 Gy (n = 31), 23.4 Gy (n = 103), ≥36 Gy (n = 131). Vertebral body dose was limited to 18-20 CGE for 23.4 Gy or 36 Gy proton therapy. All patients received post-CSI protocol-specified chemotherapy. Non-parametric tests were applied for baseline patient comparison. Changes in growth over time were calculated using random coefficients models using patient-specific intercepts and slopes. Dose-effects were modeled for ages 5, 10, and 18 years.

RESULTS

Age at CSI and race were similar between the three dose levels. Females most often received 23.4 Gy and males ≥36 Gy (p = 0.001). Higher CSI doses were associated with photon therapy (p<0.001). Median follow-up was 3 years (range 0.1-7.1). Annual growth rate was significantly different between 15 Gy (3.66 cm/year) and the higher dose levels of 23.4 Gy (2.81 cm/year, p = 0.0389) and ≥36 Gy (2.46 cm/year, p = 0.0032). Lower annual growth rate in females (vs. males, p = 0.0331) was observed in models for those aged 5 (-0.17 cm/year), 10 (-0.35 cm/year), and 18 years (-0.62 cm/year). In multivariate analysis, modelled annual growth rate was dose-dependent at ages 5 and 10 years. The differences were, respectively, 1.68 cm/year between 15 and 23.4 Gy (p = 0.0005) and 0.98 cm/year between 23.4 and ≥36 Gy (p = 0.0002), and 1.13 cm/year between 15 and 23.4 Gy (p = 0.0002) and 0.68 cm/year between 23.4 and ≥36 Gy (p = 0.0003). Radiation modality did not impact standing height over time significantly. Annual sitting height growth was 2.34, 1.67 and 1.1 cm/year for the three dose levels (p<0.0001-0.001). In the multivariate model, a 5-year-old receiving 15 or 23.4 Gy had similar annual sitting height growth, but not when 23.4 Gy was compared to ≥36 Gy (0.83 cm/year, p<0.0001). In a separate model for a patient aged 10 years, there was a difference comparing all CSI regimens (0.81 cm/year, p<0.0001, 15 vs 23.4 Gy; 0.54 cm/year, p = 0.0002, 23.4 vs ≥36 Gy). Sitting height growth was affected by CSI dose at age 18 years, with a difference of 2.2 cm/year between 15 vs 23.4 Gy (p = 0.0013), and no difference between 23.4 and ≥36 Gy.

CONCLUSION

Annual growth rates show a dose-response relationship, independent of treatment modality. A dose-response in sitting height growth rate is seen at any age, while the annual standing height growth rate was only affected by CSI dose in 5- and 10-year-olds. While all CSI doses had a significant impact on the annual standing height, sitting height growth rates approximated normal values for those treated with a low CSI dose.

Multi-Institutional Report of Re-Irradiation for Recurrent High-Grade Glioma

PURPOSE/OBJECTIVE(S)

Significant heterogeneity exists with regards to prior published reports of re-irradiation (re-RT) in patients with recurrent high grade glioma (HGG). A multi-institutional database of 10 academic centers across the United States was created to analyze prognostic outcomes for re-RT for recurrent HGG, which included WHO Grade III and Grade IV tumors.

MATERIALS/METHODS

Patients with HGG who had initially received standard radiotherapy (RT) and were subsequently treated with a course of re-RT at recurrence were included in the study. Factors assessed to delineate a significant association with overall survival (OS) and toxicity included age, KPS, number of relapses, dose, use of bevacizumab (BEV) or temozolomide (TMZ), time from prior RT, histology, RT target, re-RT target> 5cm and extent of resection, and MGMT methylation status. The Kaplan-Meier Method was used to estimate OS. Cox proportional hazards regression models were used to identify factors associated with OS. Toxicity outcomes were assessed using logistic regression. Significance was assumed if p<0.05. Data management and decision management software were used for all analyses.

RESULTS

Between 2001 and 2022, 280 patients from 10 academic institutions were treated with re-RT for diagnosis of recurrent HGG. 133 patients (71.1%) had a histologic glioblastoma (GBM) at the time of re-RT, with the remainder having Grade 3 gliomas. Median dose delivered at re-RT was 47 Gy BED10 (IQR 47 - 53 Gy BED10), with the most common regimen being 35 Gy in 10 fractions. 83 patients (56%) had GTV greater than 5 cm treated with re-RT. 183 patients (79%) received concurrent systemic therapy, including 95 (41%) who received concurrent TMZ and 86 (45%) who received concurrent BEV. Median OS for the entire cohort was 10 months. Increasing dose at re-RT was associated with improved OS (OR 0.80 95% CI 0.67-0.95, p = 0.10 per 10 Gy BED10), as was dose greater than 47 Gy BED10, which is equivalent to 35 Gy in 10 fractions (OR 0.70, 95% CI 0.54-0.91). Concurrent TMZ was also associated with improved OS (OR 0.68, 95% CI 0.46-0.83, p < 0.01). 32/143 (22%) patients evaluable for toxicity experienced Grade 2 or greater adverse radiation effect (ARE). Use of BEV was associated with decreased toxicity (OR 0.45, 95% CI 0.21-0.98, p = 0.05). Dose at re-RT (OR 1.07 per 10 Gy BED10, p = 0.78), a GTV > 5cm (OR 1.39, p = 0.44), and the use of concurrent TMZ (OR 1.90, p = 0.10) were not associated with Grade 2 or greater ARE.

CONCLUSION

Higher dose of re-RT and use of concurrent TMZ led to improved OS in recurrent HGG patients without an associated increased rate of ARE. Use of BEV decreased the likelihood of Grade 2 or greater ARE in the re-RT setting for these recurrent HGG patients.

Clinical validation of an adapted Eleveld Model for high-dose propofol treatments for depression

Repeated administration of high doses of propofol to patients with treatment-resistant depression (TRD) has been shown to produce antidepressant effects in small clinical trials. These effects can be elicited when the patient's EEG burst-suppression ratio (BSR) is maintained at 70-90% for 15 min in repeated treatments. This deep anesthesia domain lies beyond the range of current propofol pharmacokinetic/pharmacodynamic (PK/PD) models. In this study, we adapt the Eleveld model for use at deep anesthesia levels with a BSR endpoint, with the goal of aiding the estimation of the dosage of propofol needed to achieve 70-90% BSR for 15 min. We test the ability of the adapted model to predict BSR for these treatments. Twenty participants underwent 6-9 treatments of high doses of propofol (5-9 of which were included in this analysis) for a total of 115 treatments. To adapt the Eleveld model for this endpoint, we optimized the model parameters Ke0, γ and Ce50. These parameters were then used in the adapted model to estimate second-by-second BSR for each treatment. Estimated BSR was compared with observed BSR for each treatment of each participant. Median absolute performance error (MdAPE) between the estimated and observed BSR (25th-75th percentile) was 6.63 (3.79-12.96) % points and 8.51 (4.32-16.74) % between the estimated and observed treatment duration. This predictive performance is statistically significantly better at predicting BSR compared with the standard Eleveld model at deep anesthesia levels. Our adapted Eleveld model provides a useful tool to aid dosing propofol for high-dose anesthetic treatments for depression.

CNS Control after First-Line Osimertinib in Patients with Metastatic EGFR-Mutant NSCLC

PURPOSE/OBJECTIVE(S)

Although osimertinib (osi) has excellent intracranial activity in EGFR-mutant metastatic non-small cell lung cancer (NSCLC), there is no consensus regarding whether to continue osi for central nervous system (CNS) control with second-line chemotherapy (chemo) at the time of systemic progression. We aimed to compare CNS outcomes after first-line osi in patients receiving second-line chemo with or without continuation of osi.

MATERIALS/METHODS

We retrospectively reviewed patients with EGFR-mutant NSCLC with brain metastases (BrM) at the time of initiating first-line osi who experienced progression and started second-line chemo. Cumulative incidence of local and distant CNS progression, and extracranial (EC) progression was calculated from time of second-line chemo initiation with death as a competing risk. Overall survival (OS) was analyzed using Kaplan-Meier.

RESULTS

We included 52 patients with a median follow up of 9.6 months (range 0.4-36.4). Median OS and CNS progression-free survival (PFS) from the time of starting second-line chemo was 12.5 months (95% CI 8.1-16.9), and 5.3 months (95% CI 3.35-7.26), respectively. The 1-year cumulative incidence of local, distant CNS progression, any CNS progression, and EC progression was 14.4% (95% CI 4.5-24.2), 42.8% (95% CI 22.8-56.8), 42.8% (95% CI 22.8-56.8) and 66.8% (95% CI 53.5-80.2), respectively. After progression on first-line osi, 25 (48.1%) and 27 patients (51.9%) continued and discontinued osi, respectively. Patients who continued osi had significantly higher BrM burden than those who did not, with 17 (68%), 3 (12%), and 5 (20%) versus 26 (96%), 0, and 1 (3.7%) patient having <10 or >11 parenchymal brain lesions, or leptomeningeal disease (LMD) at the time of second line therapy, respectively (p<0.01). In those who continued osi vs those who did not, median OS (10.8 vs 12.5 months; p = 0.37), median intracranial PFS (5.3 vs 4.8 months; p = 0.99), 1-year cumulative incidence of local (8.4% versus 20 % p = 0.26), and 1-year distant CNS progression (24.8% vs 60%; p = 0.08) was not significantly different. CNS complications such as symptomatic, hospitalizations, and steroid initiation for CNS disease, and progression of LMD were not significantly different between the two groups. Eventually, 10 patients underwent salvage RT post first-line osi and median time to salvage RT was 7.8 months (range 2-9.4). Of patients who underwent salvage RT, 2 patients (20%) had continued osi with second-line chemo. Twelve patients (44.4%) who did not continue osi eventually re-started osi for progressive disease.

CONCLUSION

Patients who continued osi had significantly higher BrM tumor burden. Despite these patients being at higher risk for CNS progression, time to CNS progression and incidence of CNS complications were not significantly different in the two cohorts. Patients who discontinued osi were more likely to undergo salvage RT. Continuation of osi may allow patients to defer salvage RT.