Influence of lamina propria invasion extension on T1 high-grade non-muscle-invasive bladder cancer in patients undergoing BCG or radical cystectomy

OBJECTIVE

To evaluate the prognostic value of T1 substaging in patients treated with bacillus Calmette-Guérin (BCG) or immediate radical cystectomy (iRC).

MATERIALS AND METHODS

We performed an institutional review board-approved retrospective study analysing non-muscle-invasive bladder cancer (NMIBC) patients with pT1 disease treated with either BCG or iRC between 2000 and 2020. Lamina propria (LP) invasion characteristics were extracted from the pathology report. The Kaplan-Meier method was used to calculate overall survival (OS), cancer-specific survival (CSS) and metastasis-free survival (MFS). Multivariable Cox models were used to determine the association between progression-free survival (PFS) and characteristics in the BCG cohort. A logistic regression model explored the relationship between T1 substaging and upstaging to >pT2 at iRC.

RESULTS

A total of 411 T1 high-grade patients were identified. LP invasion characteristics were as follows: not specified: 115 (28%); focal/superficial (F/S): 147 (35.8%); and extensive/multifocal (E/M): 149 (36.2%). Overall, 303 patients (73.7%) received BCG, and 108 patients (26.3%) underwent iRC. The median (interquartile range) follow-up was 53 (32-96) months. Patients with E/M LP invasion were significantly more likely to undergo iRC (34% vs. 19%; P = 0.003). Patients with E/M LP invasion showed poorer MFS and CSS compared to those with F/S LP invasion when treated with BCG but not when treated with iRC. Among BCG-treated patients, progression occurred in 41 patients and E/M LP invasion was independently associated with progression after BCG (hazard ratio 5.3, 95% confidence interval [CI] 2.2-13.1; P < 0.001). T1 substaging was not associated with upstaging at RC (odds ratio 3.15, 95% CI 0.82-12.12; P = 0.095).

CONCLUSIONS

Extensive/multifocal LP invasion was associated with poor PFS, MFS and CSS in patients treated with BCG. T1 substaging provides valuable prognostic information and should be reported in pathology reports.

Role of the Atypical MAPK ERK3 in Cancer Growth and Progression

Extracellular signal-regulated kinase 3 (ERK3) is an atypical mitogen-activated protein kinase (MAPK) whose structural and regulatory features are distinct from those of conventional MAPKs, such as ERK1/2. Since its identification in 1991, the regulation, substrates and functions of ERK3 have remained largely unknown. However, recent years have witnessed a wealth of new findings about ERK3 signaling. Several important biological functions for ERK3 have been revealed, including its role in neuronal morphogenesis, inflammation, metabolism, endothelial cell tube formation and epithelial architecture. In addition, ERK3 has been recently shown to play important roles in cancer cell proliferation, migration, invasion and chemoresistance in multiple types of cancers. Furthermore, accumulating studies have uncovered various molecular mechanisms by which the expression level, protein stability and activity of ERK3 are regulated. In particular, several post-translational modifications (PTMs), including ubiquitination, hydroxylation and phosphorylation, have been shown to regulate the stability and activity of ERK3 protein. In this review, we discuss recent findings regarding biochemical and cellular functions of ERK3, with a main focus on its roles in cancers, as well as the molecular mechanisms of regulating its expression and activity.

Patient reported treatment burden and attitudes towards in-home intravesical therapy among patients with bladder cancer

PURPOSE

To quantify patient reported treatment burden while receiving intravesical therapy for bladder cancer and to survey patient perspectives on in-home intravesical therapy.

MATERIALS AND METHODS

We conducted a cross-sectional survey of the Bladder Cancer Advocacy Network Patient Survey Network. Survey questions were developed by investigators, then iteratively revised by clinician and patient advocates. Eligible participants had to have received at least 1 dose of intravesical therapy delivered in an ambulatory setting.

RESULTS

Two hundred thirty-three patients responded to the survey with median age of 70 years (range 33-88 years). Two-thirds of respondents (66%, 151/232) had received greater than 12 bladder instillations. A travel time of >30 minutes to an intravesical treatment facility was reported by 55% (126/231) of respondents. Fifty-six percent (128/232) brought caregivers to their appointments, and 36% (82/230) missed work to receive treatment. Sixty-one respondents (26%) felt the process of receiving bladder instillations adversely affected their ability to perform regular daily activities. Among those surveyed, 72% (168/232) reported openness to receiving in-home intravesical instillations and 54% (122/228) answered that in-home instillations would make the treatment process less disruptive to their lives.

CONCLUSIONS

Bladder cancer patients reported considerable travel distances, time requirements, and need for caregiver support when receiving intravesical therapy. Nearly three-quarters of survey respondents reported openness to receiving intravesical instillations in their home, with many identifying potential benefits for home over clinic-based therapy.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Effectiveness of a Digital Peer Support Training Program Designed for Rapid Uptake Among Peer Support Specialists Pilot Study

Peer telemental health recently became Medicaid reimbursable during the COVID-19 crisis, increasing the need for standardized training on digital peer support (DPS) services. DPS has the potential to reduce barriers to services and expand the reach of peer support specialists. The 4-h Digital Peer Support Training program was developed to train peer support specialists for rapid uptake in providing digital peer support during the COVID-19 crisis. The purpose of this study was to examine the impact of the 4-h DPS course for peer support specialists. Surveys were administered to examine pre-post changes in DPS course for participants (N = 75) related to attitudes/ beliefs towards DPS, ability to use/ engage in DPS, and organizational readiness to implement DPS. Data were analyzed by conducting paired samples t-tests. Linear mixed models were used to explore significant results further. Statistically significant (< .05) changes were observed related to readiness to use DPS, attitudes/ beliefs towards DPS, and ability to use/ engage in DPS. The 4-h DPS course may be beneficial in providing diverse groups of peer support specialists with a standardized training framework. Widespread dissemination of the DPS short course may be beneficial in rapidly equipping peer support specialists with the skills and resources needed to expand the reach of peer support services during the COVID-19 crisis and beyond.

The Association Between Mood and Anxiety Disorders with Perioperative Outcomes Following Radical Cystectomy

OBJECTIVE

To identify associations between preoperative psychiatric diagnoses and perioperative outcomes after RC.

METHODS

The Florida Inpatient Data File was used to identify patients who underwent RC from 2013-2019. ICD-10 codes for a mood or anxiety disorder were identified and analyzed as a 3-level variable: neither, one of these, or both. Outcomes included inpatient mortality, non-home discharge, in-hospital complications, and length of stay. Mixed-effects logistic regression (accounting for clustering within hospitals) and negative binomial regression models were utilized.

RESULTS

We identified 4396 RC patients, including 306 (7.0%) with a mood disorder and 389 (8.8%) with an anxiety disorder. After multivariable adjustment, there was no significant association between mood and/or anxiety disorders with mortality or the presence or number of in-hospital complications. However, a mood or anxiety disorder was significantly associated with increased odds of non-home discharge (OR 1.60, 95% CI 1.20-2.14) and longer length of stay (IRR 1.13, 95% CI 1.07-1.19); these associations were also increased among patients with both mood and anxiety disorder diagnoses (non-home discharge OR 2.66, 95% CI 1.61-4.38; length of stay IRR 1.12, 95% CI 1.01-1.24).

CONCLUSION

Patients with mood and/or anxiety disorders undergoing RC had longer length of stay and increased odds of discharge to a non-home facility despite similar risks of perioperative complications. These data suggest an opportunity for perioperative intervention to address these disparities in postoperative outcomes. However, further work is needed to determine the underlying causes of these differences and to develop effective interventions.

Core Competencies to Promote Consistency and Standardization of Best Practices for Digital Peer Support: Focus Group Study

BACKGROUND

As digital peer support is quickly expanding across the globe in the wake of the COVID-19 pandemic, standardization in the training and delivery of digital peer support can advance the professionalism of this field. While telehealth competencies exist for other fields of mental health practice, such as social work, psychiatry, and psychology, limited research has been done to develop and promote digital peer support competencies.

OBJECTIVE

The goal of this study is to introduce the coproduction of core competencies that can guide digital peer support.

METHODS

Peer support specialists were recruited through an international listserv and participated in a 1-hour virtual focus group. A total of four focus groups were conducted with 59 peer support specialists from 11 US states and three countries.

RESULTS

Analysis was conducted using the rigorous and accelerated data reduction (RADaR) technique, and 10 themes were identified: (1) protecting the rights of service users, (2) technical knowledge and skills in the practice of digital peer support, (3) available technologies, (4) equity of access, (5) digital communication skills, (6) performance-based training, (7) self-care, (8) monitoring digital peer support and addressing digital crisis, (9) peer support competencies, and (10) health literacy (emerging). The authors present recommendations based on these themes.

CONCLUSIONS

The introduction of digital peer support core competencies is an initial first step to promote the standardization of best practices in digital peer support. The established competencies can potentially act as a guide for training and skill development to be integrated into US state peer support specialist competencies and to enhance competencies endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA).

Stakeholders' Perspectives on Partnering to Inform the Software Development Lifecycle of Smartphone Applications for People with Serious Mental Illness: Enhancing the Software Development Lifecycle Through Stakeholder Engagement

Serious mental illness (SMI) is a leading disability worldwide. Partnering with people with SMI to co-produce smartphone apps to support mental health outcomes throughout the software development lifecycle may support patient engagement with smartphone health app interventions. Partnering with this community is often challenging and requires a highly specialized community engagement training and skillset. The purpose of this study was to identify stakeholders' perspectives on partnering to inform the software development lifecycle of a smartphone health app intervention for people with SMI. We conducted thirty-five semi-structured qualitative interviews with 20 mental health patients and 15 peer support specialists. We identified six themes: (1) co-produce health app intervention content; (2) selection of app technology features; (3) integration of human factors in digital health apps; (4) consideration of personalized patient preferences in digital health apps; (5) identify unrecognized concerns early in the software development lifecycle; and (6) inclusion of real-world social, cognitive, and environmental contexts. Integration of these considerations may elucidate the partnering process to facilitate engagement among vulnerable populations that commonly disengage from mental health smartphone apps use such as people with SMI.

Peer and Non-Peer Academic Scientists and Peer Support Specialist Community of Practice: Stakeholder Engagement to Advance the Science of Peer Support

Community of Practice, a community-engagement method that encourages a group of people to interact regularly towards a common goal, may promote satisfying experiences in patient-outcomes research among marginalized populations. Peer support specialists are increasingly being involved in peer-informed mental health research due to their lived experiences of mental illness and are an asset in co-designing healthcare programs along with researchers. In 2015, ten scientists and ten mental health service users joined as a Community of Practice that trained to engage in patient-centered outcomes research. The group has so far has presented at 20 conferences, published three book chapters and 30 peer-reviewed publications, and developed two smartphone applications. Of note are the co-production of a smartphone application, a digital peer support certification program, an app decision support tool, and an instrument to assess the value of patient-research partnerships. Future research will assess the feasibility of incorporating more stakeholders to enhance research outcomes.

Probing Strong-Field QED with Doppler-Boosted Petawatt-Class Lasers

We propose a scheme to explore regimes of strong-field quantum electrodynamics (SF QED) otherwise unattainable with the currently available laser technology. The scheme relies on relativistic plasma mirrors curved by radiation pressure to boost the intensity of petawatt-class laser pulses by Doppler effect and focus them to extreme field intensities. We show that very clear SF QED signatures could be observed by placing a secondary target where the boosted beam is focused.

Co-production development of a decision support tool for peers and service users to choose technologies to support recovery

Peer support specialists (i.e., lay interventionists representing one of the fastest-growing mental health workforce) are increasingly using technologies to support individuals with mental health challenges between clinical encounters. The use of technology by peers has been significantly increased During COVID-19. Despite the wide array of technologies available, there is no framework designed specifically for peer support specialists and service users to select technologies to support their personal recovery. The objective of the study was to develop a Decision-Support Tool for Peer Support Specialists and Service Users to facilitate shared decision-making when choosing technologies to support personal recovery. The study used an iterative co-production process, including item formulation and a series of group cognitive interviews with peer support specialists and service users (n=9; n=9, n=4). The total sample included 22 participants: peer support specialists (n=18, 81.8%) and service users (n=4, 18.2%). The final version of the Decision-Support Tool for Peer Support Specialists and Service Users (D-SPSS), includes 8 domains: (1) privacy and security; (2) cost; (3) usability; (4) accessibility; (5) inclusion and equity; (6) recovery principles; (7) personalized for service users' needs; and (8) device set-up. Our study found that involving peer support specialists and service users in the design and co-production phase of a decisionsupport tool is feasible and has the potential to empower both peer support specialists and service users, and potentially increase engagement in the use of technologies that support individuals' recovery from traditional clinical encounters.

Barriers and Facilitators for Older Adults with Serious Mental Illness to Utilizing Medicaid Smartphone Services

As increasingly more older adults in the general population utilize smartphones to access health services, the digital divide between older adults with serious mental illness (SMI) and the general older adult population continues to widen. The purpose of this study was to examine older adult peer support specialists’ and older people with SMI’s perspectives of barriers and facilitators to utilizing Medicaid Safelink smartphone services. Data from two focus groups and five semi-structured interviews from older adult peer support specialists (N=10) and older adults with SMI (N=15) were analyzed using the Consolidated Framework for Implementation Science Research. A mixed methods convergent design integrated quantitative with qualitative data. Older adults with SMI (N= 15) had a mean age of 55 years and were mainly women (70%) and White (100%). Certified peer specialists (N= 10) had a mean age of 52 years (age range 45-67) and were mainly female (75%), 66% identified as White, and 33% identified as African American. Four themes that were identified across different aspects of barriers included technology knowledge, technology adoption, design features (i.e., smartphone size, option to increase font sizes, multi-modal capacity, navigational architecture, 508 compliance), and Safelink policies and procedures. Facilitators included free and continuous services, access to technical support, and smartphone capabilities to enable healthcare communications and facilitate the delivery of services. Improving upon the themes identified as barriers to utilizing Safelink may promote a continuum of care for older adults with SMI, closing the gap of services that occurs between in-person therapy and other interventions.

Older Adult Peer Specialists’ Role in Reducing Loneliness Among People With Mental Health Conditions

PeerTECH is a peer-delivered and technology-support integrated medical and psychiatric self-management intervention developed by peers. A pre/post trial by our group has shown PeerTECH is associated with statistically significant improvements in self-efficacy for managing chronic disease and psychiatric self-management skills. This presentation will discuss the feasibility and potential effectiveness of using ecological momentary assessments (EMA) with older adults with mental health conditions to allow us to recognize early signs of loneliness and intervene as early as possible in real-world settings. EMA involves repeated sampling of an individual’s behaviors and experiences in real time, real-world environments on the smartphone application. Then, we will discuss the main and interactive effects of loneliness and factors linked to mortality. In conclusion, we will discuss potential effectiveness of PeerTECH with older adults with SMI.

Spontaneous extrusion of renal calculi presenting as a retroperitoneal abscess

Spontaneous extrusion of a kidney stone is an extremely rare event with few reported cases. We present the unusual case of a 62-year-old female who presented with worsening of fever and flank pain over a 5 day period. Imaging revealed retroperitoneal and abdominal wall abscesses that upon evaluation of prior imaging were attributed to spontaneously extruded kidney stones. Prior reports suggest surgical exploration and extraction is the preferred treatment option for extruded renal calculi. Based on the experience presented here, conservative management may be an attractive first-line treatment option for patients with extruded renal stones and associated retroperitoneal abscesses.

Polygenic Risk Score Analysis of Alzheimer's Disease in Cases without APOE4 or APOE2 Alleles

The We and others have previously shown that polygenic risk score analysis (PRS) has considerable predictive utility for identifying those at high risk of developing Alzheimer’s disease (AD) with an area under the curve (AUC) of >0.8. However, by far the greatest determinant of this risk is the apolipoprotein E locus with the E4 allele alone giving an AUC of ∼0.68 and the inclusion of the protective E2 allele increasing this to ∼0.69 in a clinical cohort. An important question is to determine how good PRS is at predicting risk in those who do not carry the E4 allele (E3 homozygotes, E3E2 and E2E2) and in those who carry neither the E4 or E2 allele (i.e. E3 homozygotes). Previous studies have shown that PRS remains a significant predictor of AD risk in clinical cohorts after controlling for APOE ε4 carrier status. In this study we assess the accuracy of PRS prediction in a cohort of pathologically confirmed AD cases and controls. The exclusion of APOE4 carriers has surprisingly little effect on the PRS prediction accuracy (AUC ∼0.83 [95% CI: 0.80-0.86]), and the accuracy remained higher than that in clinical cohorts with APOE included as a predictor. From a practical perspective this suggests that PRS analysis will have predictive utility even in E4 negative individuals and may be useful in clinical trial design.

0340 Regional Changes in Sleep Electroencephalography Power in Youth with Sleep-Disordered Breathing: A High-Density EEG Study

Introduction

Daytime neurobehavioral impairments are commonly associated with sleep disordered breathing (SDB) in children. However, a large number of studies have shown only minimal differences in sleep between children with SDB relative to control children, suggesting that sleep dysfunction is not responsible for daytime impairment. Importantly, however, previous studies have measured sleep EEG using only frontal scalp electrodes, failing to capture the regional features of sleep that are prominent during development. Here we measure sleep using hdEEG in SDB and healthy children to determine if regional sleep impairment is related to daytime neurobehavioral performance.

Methods

Overnight high-density electroencephalography (hdEEG, 256 channels) was recorded in 17 children with sleep disordered breathing (SDB) (age: M = 8.46, SD = 1.82, AHI: M = 11.3, SD = 8.6, 53% female) and 17 age and sex matched controls (age: M = 8.47, SD = 1.66, AHI: M = 1.5, SD = .64). Attentional capacity was assessed using the Test of Variables of Attention (TOVA) before and after sleep. Group differences in sleep macrostructure variables were assessed using unpaired t-tests. All-night spectral analysis was performed for NREM sleep and averaged across groups. Topographic differences between groups were assessed using statistical non-parametric mapping. Pearson correlations were used to determine associations between sleep and TOVA variables.

Results

Sleep macrostructure did not differ between groups. All-night spectral density analysis revealed a global increase in high-frequency activity in N2N3 and N3, in the alpha band (8-12 Hz, p&lt;0.05). Global alpha power was higher in SDB youth, although this effect reached significance during N3 in a large cluster of posterior channels (N=55, p=.02).

Conclusion

Elevated alpha during NREM is frequently considered a correlate of nonrestorative sleep. In this sample of youth with SDB, posterior alpha is robustly increased during the deepest stage of NREM sleep. In this small sample, however, alpha power did not predict performance on an attentional task sensitive to the effects of impaired sleep.

Support

R21 HD092986-02 to SJ

Abstract 4308: Phosphatidic acid binds to ERK3 and stimulates phosphorylation of the ERK3 activation loop

Protein kinases modulate the activity of other proteins through phosphorylation and themselves are often regulated by phosphorylation of their activation loop. Extracellular signal-Regulated Kinase 3 (ERK3) is an atypical member of the ERK family of Mitogen-Activated Protein Kinases (MAPK), with a SerGlu-Gly (SEG) motif in its activation loop rather than the canonical Thr-Xaa-Tyr (TXY) motif of ERK1/2. Activation loop phosphorylation of ERK3 is not regulated by the signals known to activate ERK1/2, such as mitogenic growth factors. The cellular stimuli activating ERK3 kinase are virtually unknown. Some kinases, including mTOR and p21 activated kinase 1 and 2 (PAK1/2), are stimulated by binding to certain phospho-lipid signaling molecules, such as phosphatidic acids. Here, we show ERK3 binds to specific phospholipids in vitro, and the C-terminal domain may be important for this interaction. In addition, ERK3 can localize to the cell membrane. Further, phosphatidic acid stimulated phosphorylation of the activation loop in ERK3. Together, these results suggest that ERK3 kinase activity might be upregulated by specific phosphatidic acid species in cells.

Citation Format: Amanda Myers, Hitham Aldharee, Shimpi Bedi, Weiwen Long. Phosphatidic acid binds to ERK3 and stimulates phosphorylation of the ERK3 activation loop [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4308.

Drugs that target aging: how do we discover them?

INTRODUCTION

Biology of aging is focused on elucidating the biochemical and genetic pathways that contribute to cellular damage accumulation over time. Thirty years of research are beginning to bear fruit as the first pharmacological interventions based on biology of aging go through clinical trials. Evolutionary theories of aging suggest that naturally selected traits believed to impart fitness in young organisms may be damaging in later life. Three major areas of focus in biology of aging are lifespan, healthspan, and rejuvenation. Areas covered: Aging research has produced several validated pharmacological interventions currently in clinical trials. Herein, the authors consider two representative case studies: 1) rapamycin analogs and their effect on the mTORC1 pathway, and 2) small molecules that target and kill senescent cells. The authors also provide their expert current and future perspectives on aging targeting drug discovery. Expert opinion: Aging-related therapeutic interventions will continue to emerge at an accelerating pace, both from research in biology of aging, as well as from coordinated biomedical research in aging-related chronic conditions.

The role of inheritance in the development of adolescent varicoceles

Background

The prevalence of varicoceles is estimated to be 15% in the general population but is nearly 35% among men with primary infertility and increases by 10% with each decade of life. Studies among adults infer a higher rate of varicoceles among first-degree relatives of patients with varicoceles. However, these studies do not consider the presence of varicoceles, or other venous abnormalities, at the time of desired paternity in first-degree relatives of adolescent patients. Our aim was to document the prevalence of varicoceles and varicose veins among first-degree relatives of pediatric patients diagnosed with varicoceles.

Methods

A series of 884 patients between the ages of 17 and 22 diagnosed with a varicocele were contacted and of the responders, permission was asked to discuss family history. Each patient underwent a telephone survey regarding the presence of a varicocele in the father prior to achieving paternity, the presence of a varicocele in brothers in childhood, or varicose veins in the father and mother prior to achieving pregnancy. If a varicocele or varicose vein was present, a history of intervention was surveyed. Descriptive statistics were performed to assess overall prevalence of varicocele and varicose veins in first-degree relatives. Chi-squared and logistic regression analyses were performed.

Results

In total, 152 patients (17.2%) responded and 139 (91.4%) consented to the telephone survey (mean age 19.5±1.84 years old). Overall, 12.9% of fathers had varicoceles and 8.6% of fathers underwent surgical intervention. Among siblings, 18 individuals had a varicocele and 5.6% of siblings with varicocele required intervention. Varicose veins were diagnosed in 7.9% of fathers and 25.2% of mothers; 8.6% of mothers underwent intervention. Surveillance was employed in 76.3% of patients, and surgery undertaken 21.6%. Patients with grade 2 or 3 varicoceles were more likely to have a father with a varicocele than those with grade 1 varicocele (P=0.037). Patients with grade 2 varicocele were more likely to have a father who required varicocele surgery than grade 1 (P=0.019). There was no statistical association of adolescent varicocele and varicose veins in first degree relatives (P=0.306).

Conclusions

This series shows that while a father’s prevalence is similar to that of the general population, higher grade varicoceles were associated with a higher prevalence of varicoceles and surgical ligation. This suggests the existence of a hereditary predisposition to high grade varicoceles. Furthermore, varicocele is not associated with varicose veins in first degree relatives.

CT-stereotaktische Fibrinolyse bei spontanen intrazerebralen Massenblutungen

Die Prognose der spontanen intrazerebralen Massenblutungen gleich welcher Ätiologie ist nach wie vor ungünstig. Weder die konservative Therapie noch das konventionelle neurochirurgische Vorgehen konnten die hohen Mortalitäts-und Morbiditätsraten wesentlich senken.

Die CT-stereotaktische Hämatomteilentleerung mit anschließender Fibrinolyse des Resthämatoms stellt hierzu eine effektive therapeutische Alternative dar.

Von Oktober 1985 bis August 1988 wurden in der Abt. Stereotaxie und Neuronuklearmedizin der Neurochirurgischen Universitätsklinik Freiburg insgesamt 60 Patienten mit dieser Methode behandelt. Während des Beobachtungszeitraums von durchschnittlich 27 Monaten verstarben insgesamt 15 Patienten, 10 davon innerhalb der ersten 60 Tage unmittelbar an den Blutungsfolgen. Die aktuelle Lebensqualität der 45 überlebenden Patienten wurde nach der Karnofsky-Skala beurteilt. Sie war zum Nachuntersuchungszeitpunkt in 64,4% der Fälle sehr gut bis gut und in 28,9% mäßig. Nur 6,7% der Patienten waren schwer krank und benötigten spezielle Betreuung.

Die Langzeitergebnisse der stereotaktischen Behandlungsmethode bei intrazerebralen Blutungen sind somit, verglichen mit den Angaben in der Literatur, deutlich günstiger und daher ermutigend. Durch frühzeitiges Einleiten einer intensiven neurologischen Rehabilitationsbehandlung mit optimaler Hilfsmittelversorgung lassen sich die Resultate wahrscheinlich noch verbessern.

Exploratory analysis of the association of depth of response and survival in patients with metastatic non-small-cell lung cancer treated with a targeted therapy or immunotherapy

BACKGROUND

Response Evaluation Criteria in Solid Tumors (RECIST) permits rapid evaluation of new therapeutic strategies in cancer. However, RECIST does not capture the heterogeneity of response in highly active therapies. Depth of tumor response may provide a more granular view of response. We explored the association between, depth of response (DepOR), with overall survival (OS) and progression-free survival (PFS) for patients with NSCLC being treated with an ALK inhibitor (ALKi) or an anti-PD-1 antibody (Ab).

METHODS

Experimental arms from two randomized controlled trials (RCTs) of an ALKi and two RCTs of an anti-PD-1 Ab were separately pooled. Patient responses were grouped into DepOR 'quartiles' by percentage of maximal tumor shrinkage (Q1 = 1%-25%, Q2 = 26%-50%, Q3 = 51%-75%, and Q4 = 76%-100%), Q0 had no shrinkage. We carried out a retrospective exploratory responder analysis to evaluate the association between DepOR and OS or PFS using hazard ratios (HR) generated by the Cox proportional hazards model.

RESULTS

In the pooled ALK analysis there were 12, 39, 70, 144, and 40 patients in quartiles 0-4, respectively. The DepOR versus PFS/OS analyses HR were: 0.19/0.94 for Q1 0.11/0.56 for Q2, 0.05/0.28 for Q3, and 0.03/0.05 for Q4. In the PD-1 trials within quartiles 0-4 there were 168, 70, 44, 45, and 28 patients, respectively. The DepOR versus PFS/OS analyses HR were 0.3/0.52 for Q1, 0.22/0.47 for Q2, 0.09/0.07 for Q3, and 0.07/0.14 for Q4.

CONCLUSIONS

Our analysis suggests a greater DepOR is associated with longer PFS and OS for patients receiving ALKi or anti-PD1 Ab. Overall, this suggests that DepOR may provide an additional outcome measure for clinical trials, and may allow better comparisons of treatment activity.

A Wearable Hydration Sensor with Conformal Nanowire Electrodes

A wearable skin hydration sensor in the form of a capacitor is demonstrated based on skin impedance measurement. The capacitor consists of two interdigitated or parallel electrodes that are made of silver nanowires (AgNWs) in a polydimethylsiloxane (PDMS) matrix. The flexible and stretchable nature of the AgNW/PDMS electrode allows conformal contact to the skin. The hydration sensor is insensitive to the external humidity change and is calibrated against a commercial skin hydration system on an artificial skin over a wide hydration range. The hydration sensor is packaged into a flexible wristband, together with a network analyzer chip, a button cell battery, and an ultralow power microprocessor with Bluetooth. In addition, a chest patch consisting of a strain sensor, three electrocardiography electrodes, and a skin hydration sensor is developed for multimodal sensing. The wearable wristband and chest patch may be used for low-cost, wireless, and continuous monitoring of skin hydration and other health parameters.

Fludarabine with pharmacokinetically guided IV busulfan is superior to fixed-dose delivery in pretransplant conditioning of AML/MDS patients

We hypothesized that IV Busulfan (Bu) dosing could be safely intensified through pharmacokinetic (PK-) dose guidance to minimize the inter-patient variability in systemic exposure (SE) associated with body-sized dosing, and this should improve outcome of AML/MDS patients undergoing allogeneic stem cell transplantation (allo-HSCT). To test this hypothesis, we treated 218 patients (median age 50.7 years, male/female 50/50%) with fludarabine (Flu) 40 mg/m² once daily ×4, each dose followed by IV Bu, randomized to 130 mg/m² (N=107) or PK-guided to average daily SE, AUC of 6,000 µM-min (N=111), stratified for remission-status, and allo-grafting from HLA-matched donors. Toxicity and graft vs. host disease (GvHD) rates in the groups were similar; the risk of relapse or treatment-related mortality remained higher in the fixed-dose group throughout the 80-month observation period. Further, PK-guidance yielded safer disease-control, leading to improved overall and progression-free survival, most prominently in MDS-patients and in AML-patients not in remission at allo-HSCT. We conclude that AML/MDS patients receiving pretransplant conditioning treatment with our 4-day regimen may benefit significantly from PK-guided Bu-dosing. This could be considered an alternative to fixed dose delivery since it provides the benefit of precise dose delivery to a predetermined SE without increasing risk(s) of serious toxicity and/or GvHD.

A clinical conundrum with a radiological answer

An 82-year-old woman with longstanding medial thigh pain presented with a 5-day history of constipation, vomiting, abdominal pain and distension. She was unable to pass flatus for the preceding 24 hours and had a past history of laparoscopic abdominal surgery. Computed tomography of the abdomen and pelvis revealed a right-sided obturator hernia containing a dilated loop of small bowel. She underwent emergency surgery for a right obturator hernia repair by limited laparotomy and was discharged after an extended stay complicated by postoperative atrial fibrillation.

Status of Competency-Based Medical Education in Endoscopy Training: A Nationwide Survey of US ACGME-Accredited Gastroenterology Training Programs

OBJECTIVES

The Accreditation Council for Graduate Medical Education (ACGME) emphasizes the importance of medical trainees meeting specific performance benchmarks and demonstrating readiness for unsupervised practice. The aim of this study was to examine the readiness of Gastroenterology (GI) fellowship programs for competency-based evaluation in endoscopic procedural training.

METHODS

ACGME-accredited GI program directors (PDs) and GI trainees nationwide completed an online survey of domains relevant to endoscopy training and competency assessment. Participants were queried about current methods and perceived quality of endoscopy training and assessment of competence. Participants were also queried about factors deemed important in endoscopy competence assessment. Five-point Likert items were analyzed as continuous variables by an independent t-test and χ(2)-test was used for comparison of proportions.

RESULTS

Survey response rate was 64% (94/148) for PDs and 47% (546/1,167) for trainees. Twenty-three percent of surveyed PDs reported that they do not have a formal endoscopy curriculum. PDs placed less importance (1—very important to 5—very unimportant) on endoscopy volume (1.57 vs. 1.18, P<0.001), adenoma detection rate (2.00 vs. 1.53, P<0.001), and withdrawal times (1.96 vs. 1.68, P=0.009) in determining endoscopy competence compared with trainees. A majority of PDs report that competence is assessed by procedure volume (85%) and teaching attending evaluations (96%). Only a minority of programs use skills assessment tools (30%) or specific quality metrics (28%). Specific competencies are mostly assessed by individual teaching attending feedback as opposed to official documentation or feedback from a PD. PDs rate the overall quality of their endoscopy training and assessment of competence as better than overall ratings by trainees.

CONCLUSIONS

Although the majority of PDs and trainees nationwide believe that measuring specific metrics is important in determining endoscopy competence, most programs still rely on procedure volume and subjective attending evaluations to determine overall competence. As medical training transitions from an apprenticeship model to competency-based education, there is a need for improved endoscopy curricula which are better suited to demonstrate readiness for unsupervised practice.

Novel wearable EMG sensors based on nanowire technology

Wearable electrodes made of silver nanowires (AgNWs) have demonstrated great potential for sensing a variety of physical and physiological signals. This paper aimed to study the feasibility of AgNWs electrodes for measuring surface electromyographic (sEMG) signals. One human subject was recruited and instructed to perform wrist extension repetitively or to produce no movement in the experiment. sEMG signals were collected from the right extensor digitorum communis of the human subject by an AgNWs electrode and a commercially available Ag/AgCl wet sEMG electrode, separately. The quality of recorded sEMG in time and frequency domains was compared between the two types of electrodes. The results showed that the sEMG signals recorded by the AgNW electrode were comparable with that by the Ag/AgCl electrode. Since the dry AgNWs electrodes are flexible, wearable, and potentially robust for daily use, novel AgNW-based EMG electrodes are promising for many biomedical applications, such as myoelectric control of artificial limbs.