A fully integrated wearable ultrasound system to monitor deep tissues in moving subjects

Recent advances in wearable ultrasound technologies have demonstrated the potential for hands-free data acquisition, but technical barriers remain as these probes require wire connections, can lose track of moving targets and create data-interpretation challenges. Here we report a fully integrated autonomous wearable ultrasonic-system-on-patch (USoP). A miniaturized flexible control circuit is designed to interface with an ultrasound transducer array for signal pre-conditioning and wireless data communication. Machine learning is used to track moving tissue targets and assist the data interpretation. We demonstrate that the USoP allows continuous tracking of physiological signals from tissues as deep as 164 mm. On mobile subjects, the USoP can continuously monitor physiological signals, including central blood pressure, heart rate and cardiac output, for as long as 12 h. This result enables continuous autonomous surveillance of deep tissue signals toward the internet-of-medical-things.

Causality Network of Infectious Disease Revealed with Causal Decomposition

Causal inference in the field of infectious disease attempts to gain insight into the potential causal nature of an association between risk factors and diseases. Simulated causality inference experiments have shown preliminary promise in improving understanding of the transmission of infectious diseases but still lack sufficient quantitative causal inference studies based on real-world data. Here, we investigate the causal interactions between three different infectious diseases and related factors, us-ing causal decomposition analysis, to characterize the na-ture of infectious disease transmission. We show that the complex interactions between infectious disease and hu-man behavior have a quantifiable impact on transmission efficiency of infectious diseases. Our findings, by shedding light on the underlying transmission mechanism of infec-tious diseases, suggest that causal inference analysis is a promising approach to determine epidemiological interventions.

Patients not taking a previously prescribed bone active medication now prescribed medication through Ontario FLS

In an Ontario fracture liaison service (FLS), we compared medication prescription rates among patients not taking a previously prescribed bone active medication to those with no previous prescription. Prescription rates were similar between these two groups of patients. The FLS provided a secondary opportunity for patients to initiate bone active medication.

PURPOSE

We compared bone active medication prescription rates among patients presenting to an Ontario fracture liaison service (FLS) who reported not taking a previously prescribed bone active medication to those with no history of prescription.

METHODS

Eligible patients were those screened in 39 fracture clinics between July 1, 2017, and September 15, 2019, who were not taking bone active medication at the time of screening and classified as high risk for future fracture based on CAROC or FRAX. Sociodemographic and clinical risk factor variables were assessed at screening. Bone active medication prescription rate was assessed within 6 months of screening and defined as having received a prescription for the medication from either a specialist or primary care provider. In cases where a specialist report was not available, patient self-reported data were collected. The chi-square test of independence was used to assess differences in prescription rates.

RESULTS

Of 17,575 patients screened, eligible patients were 350 with a previous prescription and 2644 without a previous prescription. Compared with patients who reported no previous prescription, those who had a previous prescription were older, more likely to be female and to report a previous fracture, and less likely to smoke. There was no statistically significant difference between the medication prescription rate of patients with a previous prescription (73.7%) compared to patients with no previous prescription (70.7%) (p = 0.157).

CONCLUSION

A large jurisdiction-wide FLS approach provided a secondary opportunity to patients who were not taking a previously prescribed bone active medication to initiate that medication.

Fragility fracture patients with a history of prior fractures more likely to present with multiple risk factors: findings from a province-wide fracture liaison service

We examined the demographic characteristics and risk factors of FLS fragility fracture patients who had sustained prior fragility fracture(s) and found that this is an important high-risk subgroup that warrants further attention within FLS priority pathways in order to disrupt their fragility fracture cycle.

PURPOSE

Our primary objective was to examine whether fragility fracture patients presenting to a provincial fracture liaison service (FLS) having a history of prior fractures, versus those without, differ in demographic characteristics and risk factors for future fracture. A secondary objective was to understand if those who report two or more prior fractures differ from those reporting one prior fracture.

METHODS

This cohort study included fragility fracture patients aged 50 + enrolled in the Ontario FLS between July 2017 and September 2019. Patients with versus those without prior fractures were compared on age, sex, index fracture site, biological parents' history of hip fracture, current fracture due to a fall, history of feeling unsteady when walking, history of falls in the past year, smoking, oral steroid use, and comorbid chronic conditions. Pearson's chi-square, Fischer's exact, and analysis of variance tests were used to assess differences.

RESULTS

Among 14,454 patients, 16.8% (n = 2428) reported a history of one or more prior fractures after the age of 40. They were significantly more likely to be older, female, with a higher number of comorbidities, with greater incidence of falls, and feel unsteady when walking. Compared to those with one prior fracture, patients with greater than one prior fracture were more likely to report falls in the past year and feel unsteady when walking.

CONCLUSION

Findings suggest that FLS fragility fracture patients who had sustained prior fragility fracture are an important high-risk subgroup that warrants further attention within FLS priority pathways in order to disrupt their fragility fracture cycle.

Can immediate reconstruction with submandibular gland transposition broaden indications for transoral surgery for tonsillar cancer?

e18054

Background: Stratification based on pathologic parameters allows for reduced adjuvant radiotherapy in intermediate risk and observation alone for low risk oropharyngeal p16+ cancer (E3311 ECOG-ACRIN trial). Selection for transoral surgery (TOS), usually robotically assisted, for tonsillar cancers depends on the size and invasiveness of the primary tumor, involvement of adjacent parts such as the soft palate, proximity to external carotid artery branches, medial ipsilateral carotid artery that might be exposed with radical resection, and the likelihood of substantial communication between the oropharynx and internal neck structures. Postoperative recovery can be associated with substantial pain and dysphagia and a length of stay of > 5 days. There is a paucity of simple options for sealing the neck from the pharynx to prevent neck infection, exposure of larger vessels and salivary fistula, so large and deep tonsillar cancers are usually given chemoradiation. Larger surgical defects healing secondarily tend to require longer recoveries due to dysphagia and odynophagia. Methods: A prospective study of vascularized ipsilateral submandibular gland transposition flaps to primarily repair the surgical defect after TOS to resect previously untreated tonsillar cancers was performed from 2019 to 2022. A total of 19 patients underwent resection and repair. These included those with cancers extending to the soft palate (4) and medial position of internal carotid artery adjacent to the tumor (1). All had obvious communication between the neck and the pharynx after TOS, and had branches of the facial and external carotid arteries to the deep resection site ligated with neck dissection, prior to TOS. The submandibular gland flaps were sewn in place using robot assistance and hand. One patient had an extended flap with accompanying submental skin to repair the soft palate. Results: Partial dehiscence superiorly at the palate was the most common complication at 11%. None developed salivary fistulas or deep neck infections. Iatrogenic facial artery pedicle injury that was repaired occurred in one case. Oral intake was started at 1-3 days and length of stay averaged 5 days. There were no bleeding episodes at the TOS sites of cancer resection. All resections had clear margins. All submandibular gland flaps survived, with one patient having attached adipose tissue debrided in the office, healing uneventfully thereafter. Conclusions: The ability to primarily repair after resection of more extensive tonsillar cancers, that leave large communications between the pharynx and the neck, with a readily accessible and easy to harvest submandibular gland flap may change those previously selected for chemoradiation to be able to have TOS instead as initial treatment. This would allow for more pathological risk assessment of tonsil cancers and decreased adjuvant treatment when appropriate.

Three-dimensional transistor arrays for intra- and inter-cellular recording

Electrical impulse generation and its conduction within cells or cellular networks are the cornerstone of electrophysiology. However, the advancement of the field is limited by sensing accuracy and the scalability of current recording technologies. Here we describe a scalable platform that enables accurate recording of transmembrane potentials in electrogenic cells. The platform employs a three-dimensional high-performance field-effect transistor array for minimally invasive cellular interfacing that produces faithful recordings, as validated by the gold standard patch clamp. Leveraging the high spatial and temporal resolutions of the field-effect transistors, we measured the intracellular signal conduction velocity of a cardiomyocyte to be 0.182 m s^-1, which is about five times the intercellular velocity. We also demonstrate intracellular recordings in cardiac muscle tissue constructs and reveal the signal conduction paths. This platform could provide new capabilities in probing the electrical behaviours of single cells and cellular networks, which carries broad implications for understanding cellular physiology, pathology and cell-cell interactions.

An Evaluation of Docusate Monotherapy and the Prevention of Opioid-Induced Constipation after Surgery

Our purpose was to determine if docusate monotherapy is effective in preventing opioid-induced constipation in patients receiving opioids following orthopedic surgery. Our single-center, retrospective, cohort study evaluated 212 orthopedic patients who received opioids between May 1, 2018, and December 31, 2018. All patients were aged 18 years and older, hospitalized for more than 48 hours, and received docusate for primary prevention of constipation post-operatively. The primary outcome was the proportion of patients taking opioid medications who experienced docusate failure, defined as patients who did not have a bowel movement within 5 days of starting docusate after surgery or those patients who required the use of additional laxative agents to produce a bowel movement. After excluding patients which did not meet the inclusion criteria, 79.9% (n = 159/199) experienced docusate treatment failure. Of these patients, 42.8% (68/159) failed to have a bowel movement or had a bowel movement greater than 5 days post-surgery. The remaining 57.2% (91/159) of patients required an additional laxative to produce a bowel movement. Docusate monotherapy was not effective in preventing constipation in patients receiving opioids following elective orthopedic surgery. Based on these findings, we propose utilization of stimulant bowel products with proven efficacy as primary therapy after surgery to prevent constipation. Future multi-centered, randomized controlled trials are necessary to evaluate the differences in efficacy and safety between common bowel regimens in treating opioid-induced constipation in patients who undergo elective orthopedic surgery.

54. The Effect of Targeting High-Risk Patients for Antimicrobial Stewardship Intervention on Hospital-Onset Clostridioides Difficile Infection Rates

Background

Clostridioides difficile infection contributes to significant burden on patients and the healthcare system, costing billions in excess costs every year for hospital care. Continued use of antibiotics after C. difficile infection diagnosis is a risk factor for recurrent infection. Also, individuals who have had a recurrence of C. difficile infection are at a higher risk of subsequent episodes.

Methods

This prospective, observational, pre-post study evaluated the effect of implementing a targeted antimicrobial stewardship initiative towards a high-risk target population on the rate of in-hospital C. difficile infection rates. High-risk targets were identified through an electronic health system report of admitted patients at a large academic medical center who were toxin assay positive or had a documented history of C. difficile infection. Subjects who met the criteria were assessed for interventions by the pharmacy-driven antimicrobial stewardship service. The primary outcome compared the hospital-onset C. difficile rates and standardized infection ratio (SIR) before and after implementation of the initiative. The SIR is reported to the National Healthcare Safety Network (NHSN) and is calculated as a ratio between the number of observed and predicted infections, which is adjusted for facility-specific factors that contribute C. difficile risk. Negative binomial regression was used to calculate the predicted C. difficile infections in the SIR. Poisson regression was used to generate a 95% prediction interval for the predicted C. difficile infection rate.

Results

The mean age of subjects was 63 years old and 85% had no history of prior C. difficile infection. The most common intervention was de-escalation of antibiotics (46%). The post-implementation SIR was 0.55 and hospital-onset C. difficile rate was 13, both of which were significantly lower than predicted.

Conclusion

Targeting patients who have a history of or are newly diagnosed with C. difficile infection may decrease hospital-onset C. difficile rates.

Disclosures

All Authors: No reported disclosures

Patients 80 + have similar medication initiation rates to those aged 50-79 in Ontario FLS

Among individuals presenting to an Ontario FLS, we compared bone active medication initiation rates of patients 80 years and older with those 50-79 years old. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates between the two age groups INTRODUCTION: A Fracture Liaison Service (FLS) offers post-fracture services to individuals over the age of 50 years and could potentially address age inequities in pharmacotherapy often observed for older adults. Among individuals presenting to an Ontario FLS and classified as being at high risk for future fracture, our objective was to compare bone active medication initiation rates of patients 80 years and older with those 50-79 years old.

METHODS

In 39 FLS fracture clinics across Ontario, Canada, fracture prevention coordinators identified, assessed, and facilitated the referral of eligible patients for bone densitometry, fracture risk assessment, and implementation of pharmacotherapy in patients classified as high risk for future fracture. Variables assessed at baseline included age, sex, marital status, living location, fracture location, history of previous fracture, parent's history of hip fracture, history of falls, and fracture risk status. At 6 months, bone active medication initiation was assessed in patients classified as high risk for future fracture. The Chi-square test of independence was used to compare medication initiation rates between patients 80 + and those 50-79 years old.

RESULTS

Our sample size consisted of 808 patients aged 50-79 years and 346 aged 80 + years. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates of patients 50-79 and 80 + years old (76.9% versus 73.7%, p = 0.251).

CONCLUSION

A systematic approach to identifying patients at high risk for future fracture and tailoring treatment recommendations to these patients appeared to eliminate differences in treatment initiation rates based on older age.

Vibrio harveyi isolated from marine aquaculture species in eastern China and virulence to the large yellow croaker (Larimichthys crocea)

AIMS

Diseases of maricultured species caused by Vibrio harveyi are increasing in China and other regions. This study examined the genetic diversity, antimicrobial susceptibility, plasmid profiles and virulence potential of the V. harveyi isolated from marine organisms farmed in two provinces in eastern China between 2014 and 2019.

METHODS AND RESULTS

A total of 54 V. harveyi were obtained from seven marine species. Enterobacterial repetitive intergenic consensus (ERIC)-PCR fingerprinting revealed substantial genetic heterogeneity among the V. harveyi isolates. There was no significant correlation between ERIC-PCR genotypes and host origins or fish farms. All the isolates were resistant to amoxicillin and ampicillin, and 79·6% to kanamycin. We found that 61·1% of the V. harveyi isolates had plasmid(s) and there were 14 different plasmid profiles. Most isolates from fish hosts (76·5%) contained plasmids; however, 75% of isolates from nonfish hosts lacked plasmids. Experimental infection results showed that isolates with plasmid(s) were more virulent to large yellow croaker than isolates lacking plasmids (P < 0·05).

CONCLUSIONS

This study confirmed that V. harveyi isolates obtained from animals farmed in the coastal region of east China were genetically diverse. Our results suggest that the virulence of various V. harveyi strains to fish is associated with the plasmids they carry.

SIGNIFICANCE AND IMPACT OF THE STUDY

More than 50% of the V. harveyi isolates carried one to 11 plasmids. The plasmid-borne traits of V. harveyi strains might be important for host adaptation and virulence, but they were not associated with susceptibility to the tested antibiotics.

A graphical method for breaking logical loops based on multi-tree structure

Logical loops or circular logics, interpreted as circular supporting relations among systems, remain a longstanding challenge in the probabilistic safety assessment (PSA). Logical loops are commonly found in complex industrial systems. Due to the existence of the logical loops, the minimal cut sets cannot be directly obtained. In order to solve this problem, the logical loops should be broken properly. This paper proposes a graphical method based on multi-tree structure. By constructing the simplified multi-tree, logical loops both in linearly and non-linearly interrelated systems are solved. To illustrate this method, examples of linearly interrelated systems and non-linearly interrelated systems are given in this paper. As a supplement, this method is applied to the well-known complex logical loops in the nuclear power plant. It shows that this method is highly intuitive and efficient by means of graphs.

A graphical method for breaking logical loops based on multi-tree structure

Logical loops or circular logics, interpreted as circular supporting relations among systems, remain a longstanding challenge in the probabilistic safety assessment (PSA). Logical loops are commonly found in complex industrial systems. Due to the existence of the logical loops, the minimal cut sets cannot be directly obtained. In order to solve this problem, the logical loops should be broken properly. This paper proposes a graphical method based on multi-tree structure. By constructing the simplified multi-tree, logical loops both in linearly and non-linearly interrelated systems are solved. To illustrate this method, examples of linearly interrelated systems and non-linearly interrelated systems are given in this paper. As a supplement, this method is applied to the well-known complex logical loops in the nuclear power plant. It shows that this method is highly intuitive and efficient by means of graphs.

Transoral robotic submandibular gland transposition to reconstruct radical tonsillar resection defects

Significant dysphagia, pain, and risk of bleeding occur after transoral robotic surgery (TORS) radical tonsillectomy. We present a novel surgical technique utilizing robotically assisted submandibular gland transposition (SMGT) to reconstruct the radical tonsillar defect. A 48-year-old male with p16+ tonsillar squamous cell carcinoma underwent deep TORS radical tonsillectomy, contralateral tonsillectomy, ipsilateral neck dissection, and TORS-assisted reconstruction of the radical defect with ipsilateral SMGT. Postoperatively, the patient experienced minimal pain and was discharged on postoperative day (POD) 3 tolerating a soft diet. There were no episodes of postoperative bleeding. This procedure was performed in five other cases as well. Transoral robotic SMGT can be used successfully to repair deep TORS radical tonsillectomy defects and may theoretically reduce dysphagia, pain, and the risk of hemorrhage.

Pilot validation of blood-based biomarkers during pregnancy and postpartum in women with prior or current depression

Major depressive disorder (MDD) is more common in women than in men, and evidence of gender-related subtypes of depression is emerging. Previously identified blood-based transcriptomic biomarkers distinguished male and female subjects with MDD from those without the disorder. In the present pilot study, we investigated the performance of these biomarkers in pregnant and postpartum women with prior major depressive episodes, some of whom had current symptomatology. The symptom scores of 13 pregnant and 15 postpartum women were identified by the Inventory of Depressive Symptoms (IDS-SR-30) at the time of blood sampling. Blood levels of the 20 transcriptomic biomarkers and that of estrogen receptor 2 (ESR2), membrane progesterone receptor alpha and beta (mPRα, mPRβ) were measured. In pregnant women, transcript levels of ADCY3, ASAH1, ATP11C, CDR2, ESR2, FAM46A, mPRβ, NAGA, RAPH1, TLR7, and ZNF291/SCAPER showed significant association with IDS-SR-30 scores, of which ADCY3, FAM46A, RAPH1, and TLR7 were identified in previous studies for their diagnostic potential for major depression. ASAH1 and ATP11C were previously also identified as potential markers of treatment efficacy. In postpartum women, transcript levels of CAT, CD59, and RAPH1 demonstrated a trend of association with IDS-SR-30 scores. Transcript levels of ADCY3, ATP11C, FAM46A, RAPH1, and ZNF291/SCAPER correlated with ESR2 and mPRβ expressions in pregnant women, whereas these associations only existed for mPRβ in postpartum women. These results suggest that a blood biomarker panel can identify depression symptomatology in pregnant women and that expression of these biomarker genes are affected by estrogen and/or progesterone binding differently during pregnancy and postpartum.

Investigation on the Alteration of Brain Functional Network and Its Role in the Identification of Mild Cognitive Impairment

Mild cognitive impairment (MCI) is generally regarded as a prodromal stage of Alzheimer’s disease (AD). In coping with the challenges caused by AD, we analyzed resting-state functional magnetic resonance imaging data of 82 MCI subjects and 93 normal controls (NCs). The alteration of brain functional network in MCI was investigated on three scales, including global metrics, nodal characteristics, and modular properties. The results supported the existence of small worldness, hubs, and community structure in the brain functional networks of both groups. Compared with NCs, the network altered in MCI over all the three scales. In scale I, we found significantly decreased characteristic path length and increased global efficiency in MCI. Moreover, altered global network metrics were associated with cognitive level evaluated by neuropsychological assessments. In scale II, the nodal betweenness centrality of some global hubs, such as the right Crus II of cerebellar hemisphere (CERCRU2.R) and fusiform gyrus (FFG.R), changed significantly and associated with the severity and cognitive impairment in MCI. In scale III, although anatomically adjacent regions tended to be clustered into the same module regardless of group, discrepancies existed in the composition of modules in both groups, with a prominent separation of the cerebellum and a less localized organization of community structure in MCI compared with NC. Taking advantages of random forest approach, we achieved an accuracy of 91.4% to discriminate MCI patients from NCs by integrating cognitive assessments and network analysis. The importance of the used features fed into the classifier further validated the nodal characteristics of CERCRU2.R and FFG.R could be potential biomarkers in the identification of MCI. In conclusion, the present study demonstrated that the brain functional connectome data altered at the stage of MCI and could assist the automatic diagnosis of MCI patients.

Sound levels with aural suctioning: Effects of suction size, canal moisture, and distance from the eardrum

OBJECTIVE

To determine sound levels resulting from aural suctioning of the external auditory canal.

METHODS

Unweighted decibels (dB) and A-weighted decibels (dBA) sound pressure level measurements were recorded using a retrotympanic microphone in cadaveric human temporal bones. Sound measurements were made with common otologic suctions, size 3, 5, and 7 French, within the external ear canal at the tympanic membrane, 5, and 10 mm from the tympanic membrane in the dry condition. In the wet condition, the ear canal was filled with fluid and completely suctioned clear to determine sound effects of suctioning liquid from the ear canal.

RESULTS

Sound levels generated from ear canal suctioning ranged from 68.3 to 97 dB and 62.6 to 95.1 dBA. Otologic suctions positioned closer to the tympanic membrane resulted in louder sound levels, but was not statistically significant (P > .05). Using larger diameter suctions generated louder dB and dBA sound levels (P < .001) and the addition of liquid in the ear canal during the suction process generated louder dB and dBA sound levels (P < .001).

CONCLUSIONS

Smaller caliber suction sizes and nonsuctioning techniques should be utilized for in-office aural toilet to reduce noise trauma and patient discomfort.

LEVEL OF EVIDENCE

5.

Transcervical dissection of metastatic suprahyoid retropharyngeal lymph nodes from papillary thyroid carcinoma through three anatomical barriers

Papillary thyroid carcinoma (PTC) rarely metastasizes to the suprahyoid retropharyngeal lymph nodes (SRPLNs). Studies on SRPLN metastasis from PTC and a description of the dissection of the SRPLNs via the transcervical approach are rare in the literature. In this study, the cases of six patients diagnosed with PTC with SRPLN metastasis, who underwent dissection of the SRPLNs between 2001 and 2017, were reviewed retrospectively. A transcervical approach was applied for exposure and dissection of the SRPLNs in all patients. All patients were successfully treated by transcervical resection of the metastatic SRPLNs. No patient needed a mandibulotomy or presented severe complications. The median duration of follow-up after dissection of the SRPLNs was 83 months. No recurrence of SRPLN metastasis was identified during follow-up, and none of the patients died of the disease. Surgery might be the best treatment for SRPLN metastasis from PTC. The transcervical route to the retropharyngeal space is through three anatomical barriers, including the submandibular gland, the posterior belly of the digastric muscle, and the blood vessels branching from the external carotid artery and internal jugular vein. Surgical removal of metastatic SRPLNs through the transcervical approach was safe and effective.

Impact of the extent of axillary surgery in patients with N2-3 disease in the de-escalation era: a propensity score-matched study

BACKGROUND

Reduction of surgeries in axillary has been proved feasible in breast cancer with negative and limited involved axillary lymph nodes. However, for women with a heavy axillary burden, the extent of dissection is still arguable.

PATIENTS AND METHODS

From a total of 7042 patients with breast cancer who underwent surgical treatments between 2008 and 2014, 692 (9.85%) patients with the axillary staging of N2-3M0 were classified into Level I-II dissection group and Level I-III dissection group. 203 pairs of patients were matched by the propensity score.

RESULTS

The positive rate of level-III lymph nodes is 62.4% in patients who underwent Level I-III dissection. There are 67 (22.1%) patients who experienced rise in staging from N2 to N3 due to level-III dissection. With a median follow-up of 62.4 months, no significant difference was observed in RFS (P = 0.897), MFS (P = 0.610) and OS (P = 0.755) between level I-II group and level I-III group. The same results were observed in the independent analysis of neoadjuvant and non-neoadjuvant subgroups. The binary regression model showed the positivity of level-III is only associated with involved lymph nodes in level-II.

CONCLUSION

Additional level-III dissection has a limited impact on survival but still valuable in an accurate stage. The reduction of surgeries in axillary should be treated with discretion in breast cancer patients with a heavy axillary burden.

0532 Cognitive Behavioral Therapy Delivered Via Telemedicine vs. Face-to-Face: Results from a Randomized Controlled Non-Inferiority Trial

Introduction

Telemedicine is increasingly an option for delivery of healthcare services, but its efficacy and acceptability for delivering CBT for insomnia has not been adequately tested. In a randomized controlled non-inferiority trial, we compared face-to-face and telemedicine delivery (via the AASM SleepTM platform) of CBT for insomnia for improving sleep and daytime functioning at post-treatment and 12-week follow-up.

Methods

Sixty-five adults with chronic insomnia (46 women, mean age 47.2 ± 16.3 years) were recruited primarily from insomnia clinics and screened for disqualifying sleep, medical, and mental health disorders. Eligible participants were randomized to 6 sessions of CBT for insomnia delivered face-to-face (n=32) or via AASM SleepTM (n=33). Participants completed self-report measures of insomnia (Insomnia Severity Index, ISI) and daytime functioning (fatigue, depression, anxiety, and overall functioning) at pre-treatment, post-treatment, and 12-week follow-up. The ISI was the primary non-inferiority outcome.

Results

Telemedicine was non-inferior to face-to-face delivery of CBT for insomnia, based on a non-inferiority margin of 4 points on the ISI (β = -0.07, 95% CI -2.28 to 2.14). Compared to pre-treatment, ISI scores improved significantly at post-treatment (β = -9.02, 95% CI -10.56 to -7.47) and at 12-week follow-up (β = -9.34, 95% CI -10.89 to -7.79). Similarly, daytime functioning measures improved from pre- to post-treatment, with sustained improvements at 12-week follow-up. Scores on the fatigue scale were lower in the telemedicine group at both post-treatment (F=4.64, df=1,119, p&lt;.03) and follow-up (F=5.79, df=1,119, p&lt;.02).

Conclusion

Insomnia and daytime functioning improve similarly whether CBT for insomnia is delivered via telemedicine or face-to-face. Telemedicine delivery of CBT for insomnia should be implemented more systematically to improve access to this evidence-based treatment.

Support

American Sleep Medicine Foundation Grant # 168-SR-17 (JT Arnedt, PhD)

0513 Comparison of Patient Satisfaction and Therapeutic Alliance for Telemedicine vs. Face-to-Face Delivered Cognitive Behavioral Therapy for Insomnia

Introduction

CBT for insomnia (CBTI) is effective but a barrier to its widespread use is the lack of evidence-based delivery modalities other than face-to-face. The perception and acceptability of telemedicine for the delivery of CBTI is unknown. We conducted a randomized controlled non-inferiority trial comparing face-to-face (F2F) and telemedicine (via AASM SleepTM) delivery of CBTI. We compared measures of patient satisfaction with treatment and the perception of the therapist’s warmth and skills between F2F and SleepTM.

Methods

Adults with insomnia were recruited from insomnia clinics and the community and screened for sleep, medical, and mental health disorders. Eligible participants were randomized to receive CBTI either via AASM SleepTM or F2F in 6 weekly sessions of 45-60 minutes each. Participants completed the Client Satisfaction Questionnaire (CSQ-8) and The Therapy Evaluation Questionnaire (TEQ) after completing treatment. The CSQ-8 score ranges from 8-32 with high scores indicating greater satisfaction. We also analyzed the two items on the TEQ that assess participants’ perception of therapist’s warmth and skills. Item scores ranged from 1-7, with higher scores indicating greater warmth and skills.

Results

Sixty-five adults with chronic insomnia were recruited primarily from insomnia clinics. Sixty-two participants (41 women, mean age 48.9 ± 15.4 years) completed all 6 sessions of CBTI via F2F (n=32) or via AASM SleepTM (n=30). Independent samples t-tests revealed no significant differences between conditions on patient satisfaction (SleepTM, 28.5 +/-4.2 vs F2F 29.9 +/-2.4, t(-1.5), p=.14), therapist warmth (SleepTM, 6.0 ±1.1 vs F2F, 6.4±0.95, t(-1.4), p=.16), or therapist skills (Sleep TM 6.4 ±1.0 vs F2F, 6.7±0.59, t(-1.5), p=.15).

Conclusion

Our findings suggest no differences in patient satisfaction, perception of therapist’s warmth, or confidence in therapist’s skills between telemedicine (via the AASM SleepTM) and F2F delivery of CBTI. Telemedicine-delivered CBTI should be implemented more widely.

Support

Research supported by American Sleep Medicine Foundation Grant # 168-SR-17 (JT Arnedt)

Singlet Pathway to the Ground State of Ultracold Polar Molecules

Starting from weakly bound Feshbach molecules, we demonstrate a two-photon pathway to the dipolar ground state of bi-alkali molecules that involves only singlet-to-singlet optical transitions. This pathway eliminates the search for a suitable intermediate state with sufficient singlet-triplet mixing and the exploration of its hyperfine structure, as is typical for pathways starting from triplet dominated Feshbach molecules. By selecting a Feshbach state with a stretched singlet hyperfine component and controlling the laser polarizations, we assure coupling to only single hyperfine components of the A^{1}Σ^{+} excited potential and the X^{1}Σ^{+} rovibrational ground state. In this way an ideal three level system is established, even if the hyperfine structure is not resolved. We demonstrate this pathway with ^{6}Li^{40}K molecules, and discuss its application to other important molecular species.

Abnormal topology of brain functional networks in unipolar depression and bipolar disorder using optimal graph thresholding

Two popular debilitating illness, unipolar depression (UD) and bipolar disorder (BD), have the similar symptoms and tight association on the psychopathological level, leading to a clinical challenge to distinguish them. In order to figure out the underlying common and different mechanism of both mood disorders, resting-state functional magnetic resonance imaging (rs-fMRI) data derived from 36 UD patients, 42 BD patients (specially type I, BD-I) and 45 healthy controls (HC) were analyzed retrospectively in this study. Functional brain networks were firstly constructed on both group and individual levels with a density 0.2, which was determined by a network thresholding approach based on modular similarity. Then we investigated the alterations of modular structure and other topological properties of the functional brain network, including global network characteristics and nodal network measures. The results demonstrated that the functional brain networks of UD and BD-I groups preserved the modularity and small-worldness property. However, compared with HC, reduced number of modules was observed in both patients' groups with shared alterations occurring in hippocampus, para hippocampal gyrus, amygdala and superior parietal gyrus and distinct changes of modular composition mainly in the caudate regions of basal ganglia. Additionally, for the network characteristics, compared to HC, significantly decreased global efficiency and small-worldness were observed in BD-I. For the nodal metrics, significant decrease of local efficiency was found in several regions in both UD and BD-I, while a UD-specified increase of participant coefficient was found in the right paracentral lobule and the right thalamus. These findings may contribute to throw light on the neuropathological mechanisms underlying the two disorders and further help to explore objective biomarkers for the correct diagnosis of UD and BD.

Validation of the BIOCHIP test for the diagnosis of bullous pemphigoid, pemphigus vulgaris and pemphigus foliaceus

BACKGROUND

The BIOCHIP is a novel multiplex indirect immunofluorescence technique used in the serological diagnosis of bullous pemphigoid and pemphigus. The BIOCHIP method combines the screening of autoantibodies and target antigen-specific substrates in a single miniature incubation field.

OBJECTIVE

To evaluate the diagnostic accuracy of the new immunofluorescence BIOCHIP multiplex tool in pemphigus and bullous pemphigoid.

METHODS

For the validation of the BIOCHIP, sera from patients with BP (n = 38), PF (n = 8) and pemphigus vulgaris (PV) (n = 23) were used. In addition, sera from disease control patients (n = 63) and healthy volunteers (n = 39) were used. The multiplex BIOCHIP and direct immunofluorescence (DIF) were performed for all BP, PF and PV patients. Additional indirect immunofluorescence (IIF) was performed on patients with BP, and ELISA was performed on patients with pemphigus.

RESULTS

The BIOCHIP mosaic showed a sensitivity of 86.8% and specificity of 85% for BP180 or BP230 being positive in BP. It demonstrated a sensitivity of 75% and specificity of 97.7% for Dsg1 in PF. The BIOCHIP was found to have a sensitivity of 60.9% and specificity of 73.6% for Dsg3 in PV.

CONCLUSION

The BIOCHIP mosaic-based immunofluorescence test is potentially a simple, time and effort saving test that can aid in the diagnosis and screening of BP, PV and PF. However, there is potential for interpretation bias and a learning curve that needs to be taken into consideration.

Etanercept reduces anxiety and depression in psoriasis patients, and sustained depression correlates with reduced therapeutic response to etanercept

BACKGROUND

The purpose of this study was to explore the correlation of anxiety and depression with therapeutic response to etanercept in psoriasis patients.

PATIENTS AND METHODS

One hundred and thirty-three patients with moderate-to-severe plaque psoriasis undergoing etanercept treatment were consecutively enrolled in this prospective cohort study, with all patients receiving etanercept treatment for 6 months. Psoriasis Area and Severity Index (PASI) score was evaluated at baseline (M0) and at month 1 (M1), M3 and M6 after treatment, and PASI 75/90 responses were calculated. The Hospital Anxiety and Depression Scale-Anxiety (HADS-A) score and the HADS-Depression (HADS-D) score were used to evaluate patients' anxiety and depression at M0, M1, M3 and M6. Sustained anxiety/depression were defined as HADS-A/D score≥8points both at M0 and M1.

RESULTS

Female gender and higher PASI score were associated with high risk of anxiety, while female gender, higher PASI score and longer disease duration were correlated with increased depression risk. After 6 months of etanercept treatment, 65.4% and 36.1% patients achieved PASI 75 and PASI 90 responses respectively, and both HADS-A and HADS-D scores were decreased. Most importantly, no correlation of baseline anxiety and depression with PASI 75 or PASI 90 response after 6 months of treatment was noted, while sustained depression, though not sustained anxiety, was observed to be correlated with decreased PASI 75 and PASI 90 responses.

CONCLUSIONS

Etanercept reduces anxiety and depression in psoriasis patients, and sustained depression correlates with reduced therapeutic response to etanercept.

Age-Related Alterations in Electroencephalography Connectivity and Network Topology During n-Back Working Memory Task

The study of the healthy brain in elders, especially age-associated alterations in cognition, is important to understand the deficits created by Alzheimer's disease (AD), which imposes a tremendous burden on individuals, families, and society. Although, the changes in synaptic connectivity and reorganization of brain networks that accompany aging are gradually becoming understood, little is known about how normal aging affects brain inter-regional synchronization and functional networks when items are held in working memory (WM). According to the classic Sternberg WM paradigm, we recorded multichannel electroencephalography (EEG) from healthy adults (young and senior) in three different conditions, i.e., the resting state, 0-back (control) task, and 2-back task. The phase lag index (PLI) between EEG channels was computed and then weighted and undirected network was constructed based on the PLI matrix. The effects of aging on network topology were examined using a brain connectivity toolbox. The results showed that age-related alteration was more prominent when the 2-back task was engaged, especially in the theta band. For the younger adults, the WM task evoked a significant increase in the clustering coefficient of the beta-band functional connectivity network, which was absent in the older adults. Furthermore, significant correlations were observed between the behavioral performance of WM and EEG metrics in the theta and gamma bands, suggesting the potential use of those measures as biomarkers for the evaluation of cognitive training, for instance. Taken together, our findings shed further light on the underlying mechanism of WM in physiological aging and suggest that different EEG frequencies appear to have distinct functional correlates in cognitive aging. Analysis of inter-regional synchronization and topological characteristics based on graph theory is thus an appropriate way to explore natural age-related changes in the human brain.

Human papillomavirus exposure and sexual behavior are significant risk factors for Barrett's dysplasia/esophageal adenocarcinoma

Given the comparable strains of high-risk human papillomavirus (HPV) present in a subset of Barrett's dysplasia and esophageal adenocarcinoma as in head and neck squamous cell carcinomas and the anatomical proximity of both lesions, we hypothesized that oral sex may increase the risk of Barrett's dysplasia/esophageal adenocarcinoma. Therefore, we compared the sexual behavior of patients with Barrett's dysplasia/esophageal adenocarcinoma and controls (hospital, reflux, and Barrett's metaplasia) to explore a plausible mechanism of viral transmission to the lower esophagus. A hospital-based case-control study involving 36 Barrett's dysplasia/esophageal adenocarcinoma subjects and 55 controls with known HPV DNA status and markers of transcriptional activity i.e p16INK4A and E6/E7 mRNA of the esophageal epithelium was conducted to evaluate differences in sexual history (if any). Barrett's dysplasia/esophageal adenocarcinoma patients were more likely than controls to be positive for HPV DNA (18 of 36, 50% vs. 6/55, 11%, p for trend <0.0001), be male (P = 0.001) and in a relationship (P = 0.02). Viral genotypes identified were HPV 16 (n = 14), 18 (n = 2), 11 (n = 1) and 6 (n = 1). HPV exposure conferred a significantly higher risk for Barrett's dysplasia/esophageal adenocarcinoma as compared with hospital/reflux/Barrett's metaplasia controls (OR = 6.8, 95% CI: 2.1-23.1, adjusted P = 0.002). On univariate analysis, ≥6 lifetime oral sex partners were significantly associated with dysplastic Barrett's esophagus and adenocarcinoma (OR, 4.0; 95% CI: 1.2-13.7, P = 0.046). After adjustment for confounders, HPV exposure and men with ≥2 lifetime sexual partners were at significant risk for Barrett's dysplasia/esophageal adenocarcinoma. If these initial findings can be confirmed in larger studies, it could lead to effective prevention strategies in combating some of the exponential increase in the incidence of esophageal adenocarcinoma in the West.

New scoring system in assessment of Hoffa’s fat pad synovitis: A comparative study with established scoring systems

AIM

To investigate the reliability of the established and new scoring methods for Hoffa’s fat pad synovitis using magnetic resonance imaging (MRI).

METHODS

A total of 139 knees of 115 patients who underwent MRI of the knee with and without gadolinium contrast were enrolled in this study. Proton density (PD)-weighted, PD-weighted fat-suppressed (PD-FS), and postcontrast T1-weighted fat-suppressed (T1CE) images were used for evaluation. Using contrast and non-contrast images, our grading method for synovitis was performed to measure synovial thickness and signal intensity changes of the fat pad [Synovial membrane (SM) score], which was compared with the established methods, including MRI Osteoarthritis Knee Score (MOAKS), parapatellar synovitis score, Whole-Organ Magnetic Resonance Imaging Score (WORMS), and suprapatellar effusion diameter. Intraclass correlation coefficients (ICC) for intra and interobserver reproducibility and Spearman correlation coefficients (r) were calculated for the parapatellar synovitis score and each scoring method.

RESULTS

All of the scores presented substantial to almost perfect intrareliability. Among three readers, effusion diameter had substantial to almost perfect interreliability (ICC = 0.68-0.81) and WORMS had substantial interreliability (ICC = 0.61-0.70). For two out of three readers, there was substantial interreliability for the thickness score in T1CE (ICC = 0.55-0.69), SM scores in T1CE (ICC = 0.56-0.78) and PD-FS (ICC = 0.51-0.79), and parapatellar synovitis score in T1CE (ICC = 0.53-0.72). The parapatellar synovitis score was significantly correlated with the thickness score in T1CE (r = 0.70) and the SM score in T1CE (r = 0.81) and PD-FS (r = 0.65).

CONCLUSION

The newly proposed quantitative thickness score on T1CE and the semi-quantitative SM score on T1CE and PD-FS can be useful for Hoffa’s fat pad synovitis.

Complexity of Wake Electroencephalography Correlates With Slow Wave Activity After Sleep Onset

Sleep electroencephalography (EEG) provides an opportunity to study sleep scientifically, whose chaotic, dynamic, complex, and dissipative nature implies that non-linear approaches could uncover some mechanism of sleep. Based on well-established complexity theories, one hypothesis in sleep medicine is that lower complexity of brain waves at pre-sleep state can facilitate sleep initiation and further improve sleep quality. However, this has never been studied with solid data. In this study, EEG collected from healthy subjects was used to investigate the association between pre-sleep EEG complexity and sleep quality. Multiscale entropy analysis (MSE) was applied to pre-sleep EEG signals recorded immediately after light-off (while subjects were awake) for measuring the complexities of brain dynamics by a proposed index, CI₁₋₃₀. Slow wave activity (SWA) in sleep, which is commonly used as an indicator of sleep depth or sleep intensity, was quantified based on two methods, traditional Fast Fourier transform (FFT) and ensemble empirical mode decomposition (EEMD). The associations between wake EEG complexity, sleep latency, and SWA in sleep were evaluated. Our results demonstrated that lower complexity before sleep onset is associated with decreased sleep latency, indicating a potential facilitating role of reduced pre-sleep complexity in the wake-sleep transition. In addition, the proposed EEMD-based method revealed an association between wake complexity and quantified SWA in the beginning of sleep (90 min after sleep onset). Complexity metric could thus be considered as a potential indicator for sleep interventions, and further studies are encouraged to examine the application of EEG complexity before sleep onset in populations with difficulty in sleep initiation. Further studies may also examine the mechanisms of the causal relationships between pre-sleep brain complexity and SWA, or conduct comparisons between normal and pathological conditions.

Clinical and echocardiographic predictors of embolism in infective endocarditis: systematic review and meta-analysis

OBJECTIVES

Prediction of embolic events (EEs) in infective endocarditis (IE) could inform clinical decisions, such as surgical timing. We conducted a systematic review to more precisely define associations between risk factors and EEs.

METHODS

We searched two bibliographic databases (1994-2018) for observational studies that reported EEs in IE patients and considered clinical, microbiological or echocardiographic risk factors. Studies that did not use Duke criteria or only investigated a subset of IE patients were excluded. Study quality was assessed using the Newcastle-Ottawa scale. A pooled risk ratio (RR) for each risk factor was estimated using random-effects models; statistical heterogeneity was estimated using I².

RESULTS

Of 3862 unique citations, 47 cohort studies (11 215 IE cases) were included; 54 risk factors were analysed in at least two studies, with nine studies reporting other individual factors. Most studies were of high methodological quality. Major predictors of EEs were intravenous drug use (RR 1.69, 95% CI 1.32-2.17; I² = 46%), Staphylococcus aureus infection (RR 1.64, 95% CI 1.45-1.86, I² = 32%), mitral valve vegetation (RR 1.24, 95% CI 1.11-1.37, I² = 30%), and vegetation size >10 mm (RR 1.87, 95% CI 1.57-2.21, I² = 48%). EE risk was also higher with human immunodeficiency virus, chronic liver disease, elevated C-reactive protein, Staphylococcus spp. infection, vegetation presence, and multiple, mobile or prosthetic mechanical valve vegetation, and lower with Streptococcus spp. infection. Most findings were unchanged in sensitivity analyses that removed studies with pulmonary EEs from the outcome.

CONCLUSIONS

Given the serious consequences of embolism, surgical evaluation may be considered in patients with these risk factors.

Utility of quantitative apparent diffusion coefficient measurements and normalized apparent diffusion coefficient ratios in the diagnosis of clinically significant peripheral zone prostate cancer

OBJECTIVE

The aim of this study is to evaluate the utility of quantitative apparent diffusion coefficient (ADC) measurements and normalized ADC ratios in multiparametric MRI for the diagnosis of clinically significant peripheral zone (PZ) prostate cancer particularly among equivocally suspicious prostate lesions.

METHODS

A retrospective analysis of 95 patients with PZ lesions by PI-RADSv2 criteria, and who underwent subsequent MRI-US fusion biopsy, was approved by an institutional review board. Two radiologists independently measured ADC values in regions of interest (ROIs) of PZ lesions and calculated normalized ADC ratio based on ROIs in the bladder lumen. Diagnostic performance was evaluated using ROC. Inter observer variability was assessed using intraclass correlation coefficient (ICC).

RESULTS

Mean ADC and normalized ADC ratios for clinically significant and non-clinically significant lesions were 0.763 × 10-3 mm² s^-1, 29.8%; and 1.135 × 10-3 mm² s^-1, 47.2% (p < 0.001), respectively. Area under the ROC curve (AUC) was 0.880 [95% CI (0.816-0.944) and 0.885 (95% CI (0.814-0.955)] for ADC and ADC ratio, respectively. Optimal AUC threshold for ADC was 0.843 × 10-3 mm² s^-1 (Sn 70.5%, Sp 88.2%) and for normalized ADC was 33.1% (Sn 75.0%, Sp 95.7%). intraclass correlation coefficient was high at 0.889.

CONCLUSION

Quantitative ADC measurement in PZ prostate lesions demonstrates excellent diagnostic performance in differentiating clinically significant from non-clinically significant prostate cancer with high inter observer correlation. Advances In knowledge: Quantitative ADC is presented as an additional method to evaluate lesions in mpMRI of the prostate. This technique may be incorporated in new and existing methods to improve detection and discrimination of clinically significant prostate cancer.

Lymphopenia is associated with late onset Pneumocystis jirovecii pneumonia in solid organ transplantation

BACKGROUND

Pneumocystis jirovecii pneumonia (PJP) affected 5%-15% of solid organ transplant (SOT) recipients prior to universal prophylaxis, classically with trimethoprim-sulfamethoxazole (TMP-SMX). Guidelines generally recommend 6-12 months of prophylaxis post-SOT, yet optimal duration and robust PJP risk stratification have not been established.

METHODS

A retrospective, single-center, case-control study of PJP among SOT recipients from January 1998 to December 2013 was conducted. Cases had positive PJ direct fluorescent antibody assay of respiratory specimens. Controls were matched 4:1 by nearest date of SOT. Univariate testing and multivariate logistic regressions were performed.

RESULTS

Fifteen cases were identified among 5505 SOT recipients (0.27% rate) and analyzed vs 60 controls. PJP occurred on average 6.1 years (range 0.9-13.8) post-SOT; no case was receiving PJP prophylaxis at diagnosis. Most were treated with reduced immunosuppression and TMP-SMX plus steroids (80%). Six patients (40%) required critical care; 3 (20%) died. There were no significant demographic differences, though cases tended to be older at SOT (54 vs 48 years, P = .1). In univariate analysis, prior viral infection was more common among cases (67% vs 37%, P = .08). Lower absolute lymphocyte count (ALC) at diagnosis date was strongly associated with PJP (400 vs 1230 × 10⁶  cells/μL, P < .001); odds of infection were high with ALC ≤ 500 × 10⁶ cells (OR 18.7, P < .01).

CONCLUSION

Pneumocystis jirovecii pneumonia is a rare, late complication of SOT with significant morbidity and mortality. Severe lymphopenia may be useful in identifying SOT recipients who warrant continued or reinstated PJP prophylaxis.

Abstract P3-07-08: Temozolomide as a targeted therapy strategy for triple negative breast cancer

BACKGROUND:

Approximately 15% of newly diagnosed breast cancers are classified as triple negative (TNBC). TNBCs are considered more aggressive and have a worse prognosis as no targeted therapies are currently available. These tumors are routinely treated with chemotherapy agents with only modest proven efficacy.

Temozolomide (TMZ) is an oral chemotherapy agent commonly used for the treatment of brain tumors and melanoma. TMZ is an alkylating agent, and its therapeutic benefit depends on its ability to alkylate/methylate DNA, most commonly at the N-7 or O-6 positions of guanine residues. This process leads to DNA damage and subsequently triggers cell death. Cells that express the enzyme O6-Methylguanine-DNA Methyltransferase (MGMT) are able to repair damage caused by TMZ. Tumors that lack expression of MGMT, owing to methylation of the gene promoter, demonstrate a better response to TMZ treatment as a result of synthetic lethality.

It was first reported in 2012 that TNBCs were more likely to be MGMT methylated, which was confirmed by another group that reported up to 64% of wild-type BRCA1 TNBC exhibited MGMT gene methylation. In 2013 it was found that basal-like breast cancers were more likely to be MGMT methylated and linked to larger tumor size. Together these findings suggest that a sub-population of TNBCs lack MGMT expression, due to promoter methylation.

Currently, TMZ is not a treatment option for breast cancers given the modest efficacy of TMZ noted in breast cancer clinical trials; however, most of these trials have focused on using this agent to either treat or prevent brain metastases, due to TMZs ability to cross the blood-brain barrier. Importantly, none of these trials investigated MGMT expression or specifically TNBC populations.

We hypothesize that TMZ may be a viable and efficacious treatment option for TNBCs that lack MGMT expression, due to promoter methylation.

METHODS:

We analyzed 12 archival specimens and 4 TNBC cell lines (HTB132, HTB26, HTB126 and HCC1806) for MGMT expression using a qRT-PCR clinical assay available from Calgary Laboratory Services. Additionally, we also looked at MGMT protein expression in the cell lines using Western Blot analysis to confirm the qRT-PCR results. Finally, we performed an in vitro assay with TNBC cell lines to determine cytotoxicity of TMZ.

RESULTS:

Analysis of the archival specimens found that 33% of samples analyzed had MGMT promoter methylation by qRT-PCR. Additionally, we found that HTB26 and HTB126 cell lines showed MGMT promoter methylation by qRT-pCR analysis. Western Blot analysis confirmed lack of MGMT expression in these two cell lines, and also identified another cell line (HCC1806) lacking MGMT protein that was classified as unmethylated by the qRT-PCR clinical assay. Moreover, our in vitro assay found that two cell lines (HTB26 and HCC1806) showed a noticeable response to treatment with TMZ. Interestingly, HTB126 did not show response to TMZ, suggesting that there may be another putative resistance pathway.

CONCLUSIONS:

Preliminary findings suggest that TMZ may be a viable targeted treatment option for TNBCs. Currently, we are investigating drug response using in vivo mouse models, as well as investigating synergistic combination therapy options.

Citation Format: Kornaga EN, Gratton K, Shi Q, Yang A, Nixon NA, Roldan Urgoiti G, Morris DG. Temozolomide as a targeted therapy strategy for triple negative breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-07-08.