A narrative synthesis of the effectiveness and acceptability of musculoskeletal first contact physiotherapy practitioner roles in primary care

BACKGROUND

Musculoskeletal (MSK) First Contact Practitioners (FCP), diagnostic clinicians with expertise in the assessment and management of undifferentiated MSK conditions in primary care have been widely employed in the United Kingdom since 2020. The role aims to bring specialist clinical knowledge to patients at the first point of contact and reduce the burden on existing primary care services. Since the national adoption of the role, little has been published to support the effectiveness or acceptability of the role. This narrative synthesis review aims to highlight and summarise the current body of evidence.

METHODOLOGY

An adapted systematic review was carried out to inform thematic reporting and narrative synthesis, under the sub-themes of clinical outcomes, patient satisfaction, acceptability and cost analysis.

RESULTS

Eight publications were included in the review, reporting improvements in clinical outcomes in patients seen by MSK FCP, patient satisfaction and general acceptability of the role. However, all data were collected from observational studies and qualitative sources, some of which were found to be of low methodological quality.

CONCLUSION

Although the review identified consistent positivity relating to effectiveness, satisfaction and acceptability across the reviewed publications, conclusions are limited due to the relatively recent introduction of the FCP role leading to limited availability of relevant publications.

Setup Uncertainty of Pediatric Brain Tumor Patients Receiving Proton Therapy: A Prospective Study

This study quantifies setup uncertainty in brain tumor patients who received image-guided proton therapy. Patients analyzed include 165 children, adolescents, and young adults (median age at radiotherapy: 9 years (range: 10 months to 24 years); 80 anesthetized and 85 awake) enrolled in a single-institution prospective study from 2020 to 2023. Cone-beam computed tomography (CBCT) was performed daily to calculate and correct manual setup errors, once per course after setup correction to measure residual errors, and weekly after treatments to assess intrafractional motion. Orthogonal radiographs were acquired consecutively with CBCT for paired comparisons of 40 patients. Translational and rotational errors were converted from 6 degrees of freedom to a scalar by a statistical approach that considers the distance from the target to the isocenter. The 95th percentile of setup uncertainty was reduced by daily CBCT from 10 mm (manual positioning) to 1-1.5 mm (after correction) and increased to 2 mm by the end of fractional treatment. A larger variation existed between the roll corrections reported by radiographs vs. CBCT than for pitch and yaw, while there was no statistically significant difference in translational variation. A quantile mixed regression model showed that the 95th percentile of intrafractional motion was 0.40 mm lower for anesthetized patients (p=0.0016). Considering additional uncertainty in radiation-imaging isocentricity, the commonly used total plan robustness of 3 mm against positional uncertainty would be appropriate for our study cohort.

Tipifarnib Potentiates the Antitumor Effects of PI3Kα Inhibition in PIK3CA- and HRAS-Dysregulated HNSCC via Convergent Inhibition of mTOR Activity

Outcomes for patients with recurrent/metastatic (R/M) head and neck squamous cell carcinoma (HNSCC) are poor, with median overall survival (OS) ranging from 6 to 18 months. For those who progress on standard-of-care (chemo)immunotherapy, treatment options are limited, necessitating the development of rational therapeutic strategies. Toward this end, we targeted the key HNSCC drivers PI3K-mTOR and HRAS via the combination of tipifarnib, a farnesyltransferase (FTase) inhibitor, and alpelisib, a PI3Kα inhibitor, in multiple molecularly defined subsets of HNSCC. Tipifarnib synergized with alpelisib at the level of mTOR in PI3Kα- or HRAS-dependent HNSCCs, leading to marked cytotoxicity in vitro and tumor regression in vivo. On the basis of these findings, the KURRENT-HN trial was launched to evaluate the effectiveness of this combination in PIK3CA-mutant/amplified and/or HRAS-overexpressing R/M HNSCC. Preliminary evidence supports the clinical activity of this molecular biomarker-driven combination therapy. Combined alpelisib and tipifarnib has potential to benefit >45% of patients with R/M HNSCC. By blocking feedback reactivation of mTORC1, tipifarnib may prevent adaptive resistance to additional targeted therapies, enhancing their clinical utility.

SIGNIFICANCE

The mechanistically designed, biomarker-matched strategy of combining alpelisib and tipifarnib is efficacious in PIK3CA- and HRAS-dysregulated head and neck squamous carcinoma and could improve outcomes for many patients with recurrent, metastatic disease. See related commentary by Lee et al., p. 3162.

Abstract 1815: AVA6000, a novel Precision medicine, targeted to the tumor microenvironment via Fibroblast Activation Protein (FAP) mediated cleavage

AVA6000 is a therapeutic product based on proprietary pre|CISION™ technology which incorporates a substrate that is sensitive to cleavage by FAP. The pre|CISION™ substrate can be utilized in a drug conjugate linker or to generate chemotherapy prodrugs that are only activated in the tumor microenvironment. AVA6000 consists of a doxorubicin molecule covalently bonded to a dipeptide (pyridine-4-carbonyl)-D-Ala-L-Pro), which is designed to be susceptible to hydrolysis by Fibroblast Activation Protein α (FAP) but is resistant to hydrolysis by both closely related and wider mammalian peptidases. FAP, a post-prolyl endopeptidase, is overexpressed on the surface of activated fibroblastic cells which are abundant in the supporting stroma of over 90% of malignant epithelial cancers, as well as in bone and soft tissue sarcoma. While FAP is also present both in normal tissues and as a soluble enzyme in plasma, levels are significantly lower than those present in malignant epithelial cancers. Consequently, AVA6000 has the potential to deliver doxorubicin directly to the tumor microenvironment, while exposing the patient to a lesser degree of doxorubicin-associated toxicities. The primary mechanism of action of doxorubicin is thought to involve stabilisation of a topoisomerase-II-DNA cleavable complex through non-specific DNA-intercalation. The non-specific DNA-intercalation causes a number of downstream effects, which may ultimately result in apoptotic cell death. Although doxorubicin has been one of the most effective and widely used chemotherapeutic agents for the treatment of various solid malignancies for over 40 years, its clinical utility is limited by dose-limiting toxicities, including myelosuppression and cardiotoxicity. The unique FAP specificity of the N-(pyridine-4-carbonyl)-D-Ala-L-Pro leaving group conjugated to doxorubicin in AVA6000 is supported by the absence of cleavage of the fluorogenic analogue, 3114-AMC, in FAP gene-knockout mice (Fap-/-). In vitro cytotoxicity assessments involving human tumor cell lines showed that AVA6000 was between 80-fold to 4,000-fold less cytotoxic compared to doxorubicin. In several in vivo efficacy studies in tumours with high FAP levels, AVA6000 significantly decreased tumor volume and increased survival in a dose-dependent manner. In a PDX model of osteosarcoma, AVA6000 significantly decreased tumor volume while doxorubicin had no significant effect. The efficacy and tolerability profile of AVA6000 strongly support its clinical development, and a Phase I trial in patients with locally advanced or metastatic selected solid tumours in underway.

Citation Format: Fiona McLaughlin, Sarah E. Poplawski, David G. Sanford, Andrew Saunders, Jack H. Lai, Matthew Vincent, William W. Bachovchin, Neil Bell. AVA6000, a novel Precision medicine, targeted to the tumor microenvironment via Fibroblast Activation Protein (FAP) mediated cleavage [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1815.

A phase 1/2 trial to evaluate the safety and antitumor activity of tipifarnib and alpelisib for patients with PIK3CA-mutated/amplified and/or HRAS-overexpressing recurrent/metastatic head and neck squamous cell carcinoma

TPS6104

Background: Understanding connections between key cellular pathways is particularly important when selecting combinatorial cancer therapies. HRAS preferentially activates PI3K 5-fold more efficiently than KRAS, while KRAS is a more efficient activator of RAF (Yan et al. 1998). Further, mutant HRAS is insufficient for oncogenic transformation if it is unable to recruit PI3K in preclinical models (Gupta et al. 2007). Conversely, mutant PI3K requires RAS to drive tumor growth (Zhao and Vogt 2008). HRAS mutation/overexpression and PIK3CA mutations/amplifications account for up to 50% of head and neck squamous cell carcinoma (HNSCC). Recognition of these interdependencies was the basis for the evaluation of HNSCC PDX models which demonstrated additive or synergistic anti-tumor effects that confirmed the codependency of these pathways, thus providing robust rationale for investigating combined pathway inhibition in the clinic. The KURRENT trial is enrolling patients with HRAS and/or PIK3CA-dependent tumors who will receive combination treatment with tipifarnib (a potent and selective inhibitor of farnesyltransferase, a critical enzyme for HRAS activity) and alpelisib, a PI3K inhibitor. Methods: The KURRENT trial (KO-TIP-013, NCT04809233) is an ongoing multicenter, open-label, 2-cohort, phase 1/2 trial designed to evaluate the safety of the combination of tipifarnib and alpelisib, determine the recommended combination dose(s) regimen, and evaluate preliminary anti-tumor activity in patients with recurrent/metastatic (R/M) HNSCC whose tumors are dependent upon HRAS and/or PIK3CA signaling. The trial will enroll 40 HNSCC patients; 20 each into two biomarker defined cohorts (Cohort 1; PIK3CA; Cohort 2; HRAS). Participants must have documented treatment failure from at least one prior therapy in the R/M setting and have measurable disease by RECIST v1.1. At the starting dose level, participants will receive tipifarnib at 300 mg twice daily on days 1-7 and 15-21 and alpelisib 200 mg each morning continuously during a 28-day cycle. The trial will use an adaptive dose escalation design (based on a Bayesian logistic regression model) to characterize safety, tolerability, and clinical activity of the combination to identify the Optimal Biologically Active Dose (OBAD) while maintaining a dose limiting toxicity (DLT) rate < 33%. No formal interim analysis is planned as the model-based dose escalation process requires decisions based on real-time evaluation of aggregate toxicity and efficacy data. All observed/available data among each cohort will be evaluated before choosing the combination dose for a subsequent cohort. Enrollment into the PIK3CA cohort began in October 2021. Clinical trial information: NCT04809233.

The First Examination of Diagnostic Performance of Automated Measurement of the Callosal Angle in 1856 Elderly Patients and Volunteers Indicates That 12.4% of Exams Met the Criteria for Possible Normal Pressure Hydrocephalus

BACKGROUND AND PURPOSE

Many patients with dementia may have comorbid or misdiagnosed normal pressure hydrocephalus, a treatable neurologic disorder. The callosal angle is a validated biomarker for normal pressure hydrocephalus with 93% diagnostic accuracy. Our purpose was to develop and evaluate an algorithm for automatically computing callosal angles from MR images of the brain.

MATERIALS AND METHODS

This article reports the results of analyzing callosal angles from 1856 subjects with 5264 MR images from the Open Access Series of Imaging Studies and the Alzheimer's Disease Neuroimaging Initiative databases. Measurement variability was examined between 2 neuroradiologists (n = 50) and between manual and automatic measurements (n = 281); from differences in simulated head orientation; and from real-world changes in patients with multiple examinations (n = 906). We evaluated the effectiveness of the automatic callosal angle to differentiate normal pressure hydrocephalus from Alzheimer disease in a simulated cohort.

RESULTS

The algorithm identified that 12.4% of subjects from these carefully screened cohorts had callosal angles of <90°, a published threshold for possible normal pressure hydrocephalus. The intraclass correlation coefficient was 0.97 for agreement between neuroradiologists and 0.90 for agreement between manual and automatic measurement. The method was robust to different head orientations. The median coefficient of variation for repeat examinations was 4.2% (Q1 = 3.1%, Q3 = 5.8%). The simulated classification of normal pressure hydrocephalus versus Alzheimer using the automatic callosal angle had an accuracy, sensitivity, and specificity of 0.87 each.

CONCLUSIONS

In even the most pristine research databases, analyses of the callosal angle indicate that some patients may have normal pressure hydrocephalus. The automatic callosal angle measurement can rapidly and objectively screen for normal pressure hydrocephalus in patients who would otherwise be misdiagnosed.

Improved Neutron Lifetime Measurement with UCNτ

We report an improved measurement of the free neutron lifetime τ_{n} using the UCNτ apparatus at the Los Alamos Neutron Science Center. We count a total of approximately 38×10^{6} surviving ultracold neutrons (UCNs) after storing in UCNτ's magnetogravitational trap over two data acquisition campaigns in 2017 and 2018. We extract τ_{n} from three blinded, independent analyses by both pairing long and short storage time runs to find a set of replicate τ_{n} measurements and by performing a global likelihood fit to all data while self-consistently incorporating the β-decay lifetime. Both techniques achieve consistent results and find a value τ_{n}=877.75±0.28_{stat}+0.22/-0.16_{syst}  s. With this sensitivity, neutron lifetime experiments now directly address the impact of recent refinements in our understanding of the standard model for neutron decay.

Safety, Antitumor Activity, and T-cell Responses in a Dose-Ranging Phase I Trial of the Oncolytic Peptide LTX-315 in Patients with Solid Tumors

PURPOSE

LTX-315 is a first-in-class, 9-mer membranolytic peptide that has shown potent immunomodulatory properties in preclinical models. We conducted a phase I dose-escalating study of intratumoral LTX-315 administration in patients with advanced solid tumors.

PATIENTS AND METHODS

Thirty-nine patients were enrolled, receiving LTX-315 injections into accessible tumors. The primary objective was to assess the safety and tolerability of this approach, with antitumor and immunomodulatory activity as secondary objectives. Tumor biopsies were collected at baseline and posttreatment for analysis of immunologic parameters.

RESULTS

The most common treatment-related grade 1-2 adverse events were vascular disorders including transient hypotension (18 patients, 46%), flushing (11 patients, 28%), and injection site reactions in 38% of patients. The most common grade 3 LTX-315-related toxicities were hypersensitivity or anaphylaxis (4 patients, 10%). Analysis of immune endpoints in serial biopsies indicated that LTX-315 induces necrosis and CD8⁺ T-cell infiltration into the tumor microenvironment. Sequencing of the T-cell receptor repertoire in peripheral blood identified significant expansion of T-cell clones after treatment, of which 49% were present in available tumor biopsies after treatment, suggesting that they were tumor associated. Substantial volume reduction (≥30%) of injected tumors occurred in 29% of the patients, and 86% (12/14 biopsies) had an increase in intralesional CD8⁺ T cells posttreatment. No partial responses by immune-related response criteria were seen, but evidence of abscopal effect was demonstrated following treatment with LTX-315.

CONCLUSIONS

LTX-315 has an acceptable safety profile, is clinically active, induces changes in the tumor microenvironment and contributes to immune-mediated anticancer activity.

Abstract OT-09-05: A randomized, pre-surgical study to investigate the biological effects of AZD9833 doses in women with ER-positive HER2-negative primary breast cancer (SERENA-3)

Background AZD9833 is an orally bioavailable selective estrogen receptor (ER) antagonist and degrader (SERD) that has shown anti-tumor efficacy in a range of preclinical breast cancer models. SERENA-1, an ongoing first-in-human study assessing AZD9833 as a monotherapy and in combination with palbociclib, established dose-dependent tolerability in pre- and post-menopausal women at doses of 25-450 mg once daily (QD), with clinical benefit and target engagement at all dose levels. Two randomized, open-label Phase 2 trials are also ongoing in women with ER+ HER2- breast cancer. SERENA-2 compares the efficacy of AZD9833 with fulvestrant in post-menopausal women with advanced breast cancer following treatment with ≤1 endocrine therapy. SERENA-3 will examine the biological effects of different doses of AZD9833 in treatment-naïve women with primary breast cancer. Methods SERENA-3 is a randomized, open-label, parallel-group, pre-surgical study to investigate the biological effects of different doses of AZD9833 in ER+, HER2- primary breast cancer. Eligible patients will be post-menopausal (and potentially pre-menopausal) women awaiting curative-intent surgery for newly diagnosed, ER+ HER2- primary breast cancer. The study is designed in two stages. In Stage 1, 24 post-menopausal women will be randomized 1:1 to receive either 75 mg or 150 mg oral AZD9833 QD for 5-7 days, followed by a minimum 5-day pre-surgery washout period; Stage 2 gives provision for additional groups depending on emerging data from Stage 1. The primary objective of this study is to explore the effect of AZD9833 on ER expression in pre- and on-treatment tumor samples from women with primary breast cancer, as assessed by immunohistochemistry and H-score. Safety and tolerability will be assessed as secondary endpoints, along with the pharmacokinetic and pharmacodynamic effects of AZD9833 on other biomarkers. Blood will be collected at screening, on the day of biopsy and the day of surgery to assess circulating tumor DNA and exploratory biomarkers. Primary endpoint analysis will be performed on the pharmacodynamic analysis set. The study will be conducted in 20 centers across 3 countries. For more information please contact Professor John Robertson at: john.robertson@nottingham.ac.uk.

Citation Format: John FR Robertson, Iain Moppett, Juan Enrique Bargalló Rocha, Giorgi Dzagnidze, Joanna Harding, Teresa Klinowska, Richard Mather, Alastair Mathewson, Rhiannon Maudsley, Christopher J Morrow, Andrew Saunders, Andy Sykes, Li Zhang, Justin PO Lindemann. A randomized, pre-surgical study to investigate the biological effects of AZD9833 doses in women with ER-positive HER2-negative primary breast cancer (SERENA-3) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr OT-09-05.

Ultracold neutron properties of the Eljen-299-02D deuterated scintillator

In this paper, we report studies of the Fermi potential and loss per bounce of ultracold neutrons (UCNs) on a deuterated scintillator (Eljen-299-02D). These UCN properties of the scintillator enable its use in a wide variety of applications in fundamental neutron research.

Parent perceptions regarding literacy instruction for students with intellectual disability

BACKGROUND

Parents offer a unique perspective as they may view literacy instruction through the lens of its direct impact on their child's daily life. Further, they are likely to provide insight into the interactions between the perceived effectiveness of instruction and their expectations for their child's success. The purposes of the current investigation were to explore perceptions of parents of children with intellectual disability (ID) related to their child's literacy instruction in schools and understand parental expectations for their child's literacy performance.

METHODS

In the current investigation, we surveyed 211 parents of children with ID in one state within the USA to identify their perceptions related to their child's literacy outcomes and instruction. The survey instrument contained 25 items including 9 multiple-choice, 12 multiple-selection, 2 open-response and 2 rank order items.

RESULTS

Data indicated significant differences across grade bands related to the type of skills students engage in learning, the importance of specific literacy skills and the challenges or barriers for students to engage in literacy instruction. The overwhelming majority of parents reported their child learning to read as very important and believe there is a difference in life outcomes between children who can read written words and those who cannot. Parents of elementary school children report barriers of disruptive behaviour, the inability of children to remain seated and distractibility more so than parents of secondary students. Parents of high school students reported a lack of instructional time more often than parents of middle and elementary school.

CONCLUSIONS

While parents across grade bands reported the importance of literacy skills for students with ID and instruction in reading comprehension, listening comprehension and vocabulary, some differences were noted. Only half the parents reported an increased focus on literacy instruction, including on essential skills (e.g. decoding), in the earlier grades. Problem behaviour and motivation served as barriers to literacy for elementary students, and a lack of instructional time served as a barrier to writing for high school students.

Final results for the neutron -asymmetry parameter A0 from the UCNA experiment

The UCNA experiment was designed to measure the neutron β-asymmetry parameter A0 using polarized ultracold neutrons (UCN). UCN produced via downscattering in solid deuterium were polarized via transport through a 7 T magnetic field, and then directed to a 1 T solenoidal electron spectrometer, where the decay electrons were detected in electron detector packages located on the two ends of the spectrometer. A value for A0 was then extracted from the asymmetry in the numbers of counts in the two detector packages. We summarize all of the results from the UCNA experiment, obtained during run periods in 2007, 2008–2009, 2010, and 2011–2013, which ultimately culminated in a 0.67% precision result for A0.

Turning down the heat: An enhanced understanding of the relationship between urban vegetation and surface temperature at the city scale

Guiding urban planners on the cooling returns of different configurations of urban vegetation is important to protect urban dwellers from adverse heat impacts. To this end, we estimated statistical models that fused multi-temporal very fine spatial (20 cm) and vertical (1 mm) resolution imagery, that captures the complexity of urban vegetation, with remotely sensed temperature data to assess how urban vegetation configuration influences urban temperatures. Perth, Western Australia, was used as a case-study for this analysis. Panel regression models showed that within a location an increase in tree and shrub cover has a larger cooling effect than grass coverage. On average, holding all else equal, an approximate 1 km² increase in shrub (tree) cover within a location reduces surface temperatures by 12 °C (5 °C). We included a range of robustness checks for the observed relationships between urban vegetation type and temperature. Geographically weighted regression models showed spatial variation in the cooling effect of different vegetation types; this indicates that i) unobserved factors moderate temperature-vegetation relationships across urban landscapes, and ii) that urban vegetation type and temperature relationships are complex. Machine learning models (Random Forests) were used to further explore complex and non-linear relationships between different urban vegetation configurations and temperature. The Random Forests showed that vegetation type explained 31.84% of the out-of-bag variance in summer surface temperatures, that increased cover of large vegetation within a location increases cooling, and that different configurations of urban vegetation structure can lead to cooling gains. The models in this study were trained with vegetation data capturing local detail, multiple time-periods, and entire city coverage. Thus, these models illustrate the potential to develop locally-detailed and spatially explicit tools to guide planning of vegetation configuration to optimise cooling at local- and city-scales.

Status of the UCN experiment

The neutron is the simplest nuclear system that can be used to probe the structure of the weak interaction and search for physics beyond the standard model. Measurements of neutron lifetime and β-decay correlation coefficients with precisions of 0.02% and 0.1%, respectively, would allow for stringent constraints on new physics. The UCNτ experiment uses an asymmetric magneto-gravitational UCN trap with in situ counting of surviving neutrons to measure the neutron lifetime, τn = 877.7s (0.7s)stat (+0.4/−0.2s)sys. We discuss the recent result from UCNτ, the status of ongoing data collection and analysis, and the path toward a 0.25 s measurement of the neutron lifetime with UCNτ.

Search for neutron dark decay: n → χ + e+e−

In January, 2018, Fornal and Grinstein proposed that a previously unobserved neutron decay branch to a dark matter particle (χ) could account for the discrepancy in the neutron lifetime observed in two different types of experiments. One of the possible final states discussed includes a single χ along with an e+e− pair. We use data from the UCNA (Ultracold Neutron Asymmetry) experiment to set limits on this decay channel. Coincident electron-like events are detected with ∼ 4π acceptance using a pair of detectors that observe a volume of stored Ultracold Neutrons (UCNs). We use the timing information of coincidence events to select candidate dark sector particle decays by applying a timing calibration and selecting events within a physically-forbidden timing region for conventional n → p + e- + ν̅e decays. The summed kinetic energy (Ee+e−) from such events is reconstructed and used to set limits, as a function of the χ mass, on the branching fraction for this decay channel.

Search for the Neutron Decay n→X+γ, Where X is a Dark Matter Particle

Fornal and Grinstein recently proposed that the discrepancy between two different methods of neutron lifetime measurements, the beam and bottle methods, can be explained by a previously unobserved dark matter decay mode, n→X+γ. We perform a search for this decay mode over the allowed range of energies of the monoenergetic γ ray for X to be dark matter. A Compton-suppressed high-purity germanium detector is used to identify γ rays from neutron decay in a nickel-phosphorous-coated stainless-steel bottle. A combination of Monte Carlo and radioactive source calibrations is used to determine the absolute efficiency for detecting γ rays arising from the dark matter decay mode. We exclude the possibility of a sufficiently strong branch to explain the lifetime discrepancy with 97% confidence.

Measurement of the neutron lifetime using a magneto-gravitational trap and in situ detection

The precise value of the mean neutron lifetime, τ_n, plays an important role in nuclear and particle physics and cosmology. It is used to predict the ratio of protons to helium atoms in the primordial universe and to search for physics beyond the Standard Model of particle physics. We eliminated loss mechanisms present in previous trap experiments by levitating polarized ultracold neutrons above the surface of an asymmetric storage trap using a repulsive magnetic field gradient so that the stored neutrons do not interact with material trap walls. As a result of this approach and the use of an in situ neutron detector, the lifetime reported here [877.7 ± 0.7 (stat) +0.4/-0.2 (sys) seconds] does not require corrections larger than the quoted uncertainties.

Measurement of the neutron lifetime using a magneto-gravitational trap and in situ detection

The precise value of the mean neutron lifetime, τ_n, plays an important role in nuclear and particle physics and cosmology. It is used to predict the ratio of protons to helium atoms in the primordial universe and to search for physics beyond the Standard Model of particle physics. We eliminated loss mechanisms present in previous trap experiments by levitating polarized ultracold neutrons above the surface of an asymmetric storage trap using a repulsive magnetic field gradient so that the stored neutrons do not interact with material trap walls. As a result of this approach and the use of an in situ neutron detector, the lifetime reported here [877.7 ± 0.7 (stat) +0.4/-0.2 (sys) seconds] does not require corrections larger than the quoted uncertainties.

Abstract CT108: A phase I dose escalation study of intra-tumoral LTX-315 as monotherapy or in combination with either ipilimumab or pembrolizumab in patients with transdermally accessible tumors (NCT01986426)

This Phase I clinical study is evaluating the safety and tolerability of intra-tumoral doses of LTX-315 in patients with advanced/metastatic solid tumors. Intratumoral administration results in growth inhibition, complete regression and long lasting tumor specific immune responses in multiple pre-clinical tumor models. LTX-315 treatment results in increased CD8+ T cell infiltration, increased CD8+ T cell/Treg ratio and enhanced T cell clonality.

The oncolytic effect of LTX-315 involves immunogenic cell death as shown by disintegration of cytosolic organelles with subsequent release of DAMPs (Damage-Associated Molecular Pattern molecules) such as ATP, cytochrome C and HMGB1. Multi-domain proteins from the BCL-2 family seem to be partially involved in LTX-315 mediated killing. The membranolytic effect of LTX-315 also facilitates effective release of tumor antigens. In preclinical tumor models, combination of LTX-315 and immune checkpoint inhibitors demonstrates significant synergy.

In this phase I study a recommended Phase II dose as monotherapy and in combination with immune checkpoint inhibitors will be determined. Post-treatment biopsies are also being collected to assess changes in the tumor microenvironment resulting from LTX-315 treatment.

Patients are being recruited to one of 4 arms. Arm A: LTX-315 monotherapy single tumor lesion treatment; Arm B: LTX-315 monotherapy single or multiple lesion treatment; Arm C: LTX-315 and ipilimumab in patients with unresectable/metastatic malignant melanoma previously treated with an anti-PD-1 antibody; Arm D: LTX-315 and pembrolizumab in patients with triple negative breast cancer. Patients are receiving LTX-315 in transdermally accessible lesions on days 1, 2, 8, 9, 15 and 16. Ipilimumab and pembrolizumab are administered at standard dose and schedule. As of January 2017, 28 of 60 planned patients have been recruited. Immune responses are assessed by analysis of T lymphocyte subsets in (peripheral blood) and in tumor tissue. In Arm B PD-L1 expression is assessed in bystander (non-injected) tumor biopsies. Anti-tumor activity is assessed by the immune-related response criteria (irRC) for measureable lesions (irCR, irPR, overall response duration, progression free survival (PFS), time to response and disease control rate (irPR, irCR and stable disease (irSD)).

Citation Format: Jean-Francois Baurain, Ahmad Awada, Paal F. Brunsvig, Rebecca Kristeleit, Delphine Loirat, Dag Eirik Jøssang, Laurence Zitvogel, Guido Kroemer, Aurilièn Marabelle, Øystein Rekdal, Baldur Sveinbjørnsson, Hedda Wold, Berit Nicolaisen, Andrew Saunders, James Spicer. A phase I dose escalation study of intra-tumoral LTX-315 as monotherapy or in combination with either ipilimumab or pembrolizumab in patients with transdermally accessible tumors (NCT01986426) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr CT108. doi:10.1158/1538-7445.AM2017-CT108

LTX-315, an oncolytic peptide, to convert immunogenically ‘cold' tumors to ‘hot' in patients with advanced or metastatic tumours: Results from an ongoing phase I study

3085

Background: Intratumoral LTX-315 disintegrates cytoplasmic organelles with release of tumor antigens in preclinical models accompanied by increase in tumor-infiltrating lymphocytes (TILs). LTX-315 induced complete regression in several rodent models, with systemic immune responses. LTX-315 is strongly synergistic preclinically with immune checkpoint inhibitors (ICI). We are conducting a phase 1 trial to evaluate LTX-315 in combination therapy. Methods: Patients with advanced metastatic solid tumours received injections of LTX-315 into a single accessible tumour over 6 weeks. Additional injections could be administered thereafter every 2 weeks. Biopsies of injected lesions were taken at baseline, and on treatment. Results: 28 have been enrolled to date, median age is 58 (range 32-80) and median prior treatments 2 (range 1-14). LTX-315 monotherapy was administered at doses of 2-7mg to a median of 1.8 tumour lesions (range 1-6) for a median of 9 weeks (range 1-33). In 24 patients all LTX-315-related adverse events were CTC grade 1 or 2, most commonly local erythema, flushing, pruritis and hypotension, most resolving within minutes of injection. Related grade 3 (3 patients) or 4 (1) allergic/anaphylaxis adverse event occurred and resolved without sequelae. Best response in 44 injected lesions in 20 evaluable patients included 2 complete responses, > 50% reduction in 5 tumours, and 20 stable (injected ). Significant increases in TILs occurred in 67% (14 of 21) patients with biopsies of injected tumours available. Regression of distant non-injected tumour has been observed clinically on biopsy (abscopal effect). No irRC response in non-injected tumours has been observed in 16 evaluable patients. Stable disease (median duration 14 weeks) occurred in 50% of patients as best response (melanoma (4), sarcoma (3), breast (1)). Conclusions: This phase 1 study demonstrates that intratumoural LTX-315 has a manageable safety profile and induces increases in TILs in pre-treated patients. Partial and complete regression was seen in some injected tumours. Evaluation of LTX-315 in combination with ICIs in breast and melanoma is ongoing. Clinical trial information: NCT01986426.

A new method for measuring the neutron lifetime using an in situ neutron detector

In this paper, we describe a new method for measuring surviving neutrons in neutron lifetime measurements using bottled ultracold neutrons (UCN), which provides better characterization of systematic uncertainties and enables higher precision than previous measurement techniques. An active detector that can be lowered into the trap has been used to measure the neutron distribution as a function of height and measure the influence of marginally trapped UCN on the neutron lifetime measurement. In addition, measurements have demonstrated phase-space evolution and its effect on the lifetime measurement.

A Comparison of Prenatal Exposures in Children with and Without A Diagnosis of Autism Spectrum Disorder in an Atlantic Canadian City

BACKGROUND: Autism spectrum disorder (ASD) is a multifactorial disorder characterized by varying deficits in social interactions, disordered communication and repetitive behaviour patterns. Signs that a child has autism are present in the early developmental stages and the symptoms cause significant impairment in many areas of functioning, including social, educational/occupational, and performance of everyday activities. There have been established genetic correlates and noticeable heredity with ASD diagnoses, but so far chromosomal genetic changes have only been found in approximately 25% of children with autism who were studied and there was no single variance that predominated. This signifies that there may be other external factors at play for autism to develop from preexisting genetic risk. Current studies suggest that prenatal exposures are more important to future autism diagnoses than those that happen after birth; there appears to be disruption of neuron gene networks in the cell cycle, protein folding, DNA damage repair and cell apoptosis. Potential prenatal triggers are the focus of this study, with interest to one geographical area in Atlantic Canada.

OBJECTIVES: The study focused on the presence of environmental exposures during pregnancy in children who developed autism spectrum disorder and those who did not, with a specific focus on a specific Atlantic Canadian city. Exposures inquired about included: acetaminophen/ paracetamol use, air pollution, fever, parental age, maternal diabetes, prenatal vitamin use, workplace exposures, recreational drug use, seafood consumption, obesity, and maternal thyroid issues.

DESIGN/METHODS: Mothers of children aged 0-10 years were asked to participate in a telephone interview regarding environmental exposures during their pregnancy. This was followed up by a prenatal chart review. There were two groups of participants: 107 from the autism group and 108 from the non-autism group. The data was analyzed with univariate tests and a logistic regression.

RESULTS: Univariate analysis revealed significant differences between groups for presence of siblings with ASD, presence of family members with ASD, presence of fever, use of medications, use of cigarettes, and gesta-tional age at the start of prenatal vitamins. Logistic regression analysis found significance with use of medications, use of cigarettes, and gesta-tional age at the start of prenatal vitamins.

CONCLUSION: The use of medications and cigarettes during pregnancy are associated with an increased rate of autism diagnosis. As well, a later starting date for use of prenatal vitamins was associated wth autism. Working towards an understanding of factors that come together to create a diagnosis of autism will be helpful for families, physicians, and allocating government resources.

Engaging Consumer Voices in Health Care Policy: Lessons for Social Work Practice

Community health centers provide comprehensive public health care in some of the most disadvantaged communities in the United States. To ensure that health centers meet the needs of their consumers, they uniquely engage them in their organizational decision-making and policy-development processes by requiring that their boards of directors encompass a 51 percent consumer majority. To understand the quality of board members' experiences, a critical ethnography was conducted using Arnstein's ladder of citizen participation and the socioecological model as a framework. The analysis identified multiple influences on the quality of participation among consumer members. Findings also confirm other research that has found that knowledge of the economic, political, and cultural factors surrounding the context of the individual health center is important to understanding meaningful participation. The experience is important to understand given the shift driven by the Patient Protection and Affordable Care Act of 2010 in health care, which emphasizes a patient-entered model of care. Social work practitioners and others in the public health arena interested in empowering consumers to have a role in the provision of services need to understand the impact of each of these areas'and the experience of this unique sample of health center board members.

High order magnetic optics for high dynamic range proton radiography at a kinetic energy of 800 MeV

Flash radiography with 800 MeV kinetic energy protons at Los Alamos National Laboratory is an important experimental tool for investigations of dynamic material behavior driven by high explosives or pulsed power. The extraction of quantitative information about density fields in a dynamic experiment from proton generated images requires a high fidelity model of the proton imaging process. It is shown that accurate calculations of the transmission through the magnetic lens system require terms beyond second order for protons far from the tune energy. The approach used integrates the correlated multiple Coulomb scattering distribution simultaneously over the collimator and the image plane. Comparison with a series of static calibration images demonstrates the model's accurate reproduction of both the transmission and blur over a wide range of tune energies in an inverse identity lens that consists of four quadrupole electromagnets.

Benefits of an expanded use of plasma exchange for anti-neutrophil cytoplasmic antibody-associated vasculitis within a dedicated clinical service

Background

Current recommendations for ANCA-associated vasculitis (AAV) support its management within a dedicated clinical service. Therapies for AAV are imperfect with many patients failing to achieve disease control and others experiencing disease relapse. Plasma exchange (PEX) may be beneficial especially when the kidney is involved.

Methods

Within a new, dedicated service we retrospectively assessed, over a 6-year period, the benefits of PEX in two patient cohorts, discriminated by PEX treatment alone. Patients received PEX alongside standard of care if they fulfilled any of the following criteria: 1. serum creatinine >500 μmol/l or dialysis-requiring renal failure, 2. alveolar haemorrhage, 3. renal biopsy showing ≥30 % focal and necrotising lesions ± cellular crescents. Outcome measures included disease remission and relapse, cumulative immunosuppression, and morbidity and mortality.

Results

Of 104 new patients, 58 patients received PEX at presentation, 46 did not. Cyclophosphamide and/or rituximab dosing was similar for both groups. Although patients receiving PEX had poorer renal function, a higher C-reactive protein and disease activity score at presentation disease remission rate was similar in both groups (no PEX vs. PEX: 96 % vs. 98 %). The PEX group entered remission quicker (no PEX vs. PEX: 3.9 ± 4.0 vs. 2.8 ± 1.3 months, p < 0.05), with a lower 3-month cumulative glucocorticoid dose (no PEX vs. PEX: 2.5 ± 0.4 vs. 2.3 ± 0.2 g, p < 0.001). Relapse was similar between groups but adverse events lower in the PEX group.

Conclusions

PEX may be of benefit in AAV. Larger, longer randomised controlled trials are now needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0796-7) contains supplementary material, which is available to authorized users.

iCarer: AAL for the Informal Carers of the Elderly

In the context of the long-term care for older adults, informal carers play a key role. Daily competing priorities or a care-skills deficit may lead them to stress, anxiety and/or depression. The iCarer project (AAL-2012-5-239) proposes the design and implementation of a cloud-inspired personalised and adaptive platform which will offer support to informal carers of older adults with cognitive impairment. By means of a holistic approach comprising technologies and services addressing the intelligent and interactive monitoring of activities, knowledge management for personalised guidance and orientation, virtual interaction, e-learning, care coordination facilities and social network services, iCarer aims to reduce the informal carer stress and to enhance the quality of care they provide, thus improving their quality of life. The iCarer platform will be evaluated through a multi-centre non-controlled study (4 months; 48 homes located in England and in Slovenia). Currently the iCarer project is completing the development work. The evaluation trial is expected to start in August 2015.

Charged particle radiography

New applications of charged particle radiography have been developed over the past two decades that extend the range of radiographic techniques providing high-speed sequences of radiographs of thicker objects with higher effective dose than can be obtained with conventional radiographic techniques. In this paper, we review the motivation and the development of flash radiography and in particular, charged particle radiography.

Qualitative comparison of bremsstrahlung X-rays and 800 MeV protons for tomography of urania fuel pellets

We present an assessment of x-rays and proton tomography as tools for studying the time dependence of the development of damage in fuel rods. We also show data taken with existing facilities at Los Alamos National Laboratory that support this assessment. Data on surrogate fuel rods have been taken using the 800 MeV proton radiography (pRad) facility at the Los Alamos Neutron Science Center (LANSCE), and with a 450 keV bremsstrahlung X-ray tomography facility. The proton radiography pRad facility at LANSCE can provide good position resolution (<70 μm has been demonstrate, 20 μm seems feasible with minor changes) for tomography on activated fuel rods. Bremsstrahlung x-rays may be able to provide better than 100 μm resolution but further development of sources, collimation, and detectors is necessary for x-rays to deal with the background radiation for tomography of activated fuel rods.

Performance of the Los Alamos National Laboratory spallation-driven solid-deuterium ultra-cold neutron source

In this paper, we describe the performance of the Los Alamos spallation-driven solid-deuterium ultra-cold neutron (UCN) source. Measurements of the cold neutron flux, the very low energy neutron production rate, and the UCN rates and density at the exit from the biological shield are presented and compared to Monte Carlo predictions. The cold neutron rates compare well with predictions from the Monte Carlo code MCNPX and the UCN rates agree with our custom UCN Monte Carlo code. The source is shown to perform as modeled. The maximum delivered UCN density at the exit from the biological shield is 52(9) UCN/cc with a solid deuterium volume of ~1500 cm(3).

A high-field adiabatic fast passage ultracold neutron spin flipper for the UCNA experiment

The UCNA collaboration is making a precision measurement of the β asymmetry (A) in free neutron decay using polarized ultracold neutrons (UCN). A critical component of this experiment is an adiabatic fast passage neutron spin flipper capable of efficient operation in ambient magnetic fields on the order of 1 T. The requirement that it operate in a high field necessitated the construction of a free neutron spin flipper based, for the first time, on a birdcage resonator. The design, construction, and initial testing of this spin flipper prior to its use in the first measurement of A with UCN during the 2007 run cycle of the Los Alamos Neutron Science Center's 800 MeV proton accelerator is detailed. These studies determined the flipping efficiency of the device, averaged over the UCN spectrum present at the location of the spin flipper, to be ̅ε=0.9985(4).

Magnifying lens for 800 MeV proton radiography

This article describes the design and performance of a magnifying magnetic-lens system designed, built, and commissioned at the Los Alamos National Laboratory (LANL) for 800 MeV flash proton radiography. The technique of flash proton radiography has been developed at LANL to study material properties under dynamic loading conditions through the analysis of time sequences of proton radiographs. The requirements of this growing experimental program have resulted in the need for improvements in spatial radiographic resolution. To meet these needs, a new magnetic lens system, consisting of four permanent magnet quadrupoles, has been developed. This new lens system was designed to reduce the second order chromatic aberrations, the dominant source of image blur in 800 MeV proton radiography, as well as magnifying the image to reduce the blur contribution from the detector and camera systems. The recently commissioned lens system performed as designed, providing nearly a factor of three improvement in radiographic resolution.

Determination of the axial-vector weak coupling constant with ultracold neutrons

A precise measurement of the neutron decay β asymmetry A₀ has been carried out using polarized ultracold neutrons from the pulsed spallation ultracold neutron source at the Los Alamos Neutron Science Center. Combining data obtained in 2008 and 2009, we report A₀ = -0.119 66±0.000 89{-0.001 40}{+0.001 23}, from which we determine the ratio of the axial-vector to vector weak coupling of the nucleon g{A}/g{V}=-1.275 90{-0.004 45}{+0.004 09}.

First measurement of the neutron beta asymmetry with ultracold neutrons

We report the first measurement of an angular correlation parameter in neutron beta decay using polarized ultracold neutrons (UCN). We utilize UCN with energies below about 200 neV, which we guide and store for approximately 30 s in a Cu decay volume. The interaction of the neutron magnetic dipole moment with a static 7 T field external to the decay volume provides a 420 neV potential energy barrier to the spin state parallel to the field, polarizing the UCN before they pass through an adiabatic fast passage spin flipper and enter a decay volume, situated within a 1 T field in a 2x2pi solenoidal spectrometer. We determine a value for the beta-asymmetry parameter A_{0}=-0.1138+/-0.0046+/-0.0021.

Functionally relevant microorganisms to enhanced biological phosphorus removal performance at full-scale wastewater treatment plants in the United States

The abundance and relevance ofAccumulibacter phosphatis (presumed to be polyphosphate-accumulating organisms [PAOs]), Competibacter phosphatis (presumed to be glycogen-accumulating organisms [GAOs]), and tetrad-forming organisms (TFOs) to phosphorus removal performance at six full-scale enhanced biological phosphorus removal (EBPR) wastewater treatment plants were investigated. Coexistence of various levels of candidate PAOs and GAOs were found at these facilities. Accumulibacter were found to be 5 to 20% of the total bacterial population, and Competibacter were 0 to 20% of the total bacteria population. The TFO abundance varied from nondetectable to dominant. Anaerobic phosphorus (P) release to acetate uptake ratios (P(rel)/HAc(up)) obtained from bench tests were correlated positively with the abundance ratio of Accumulibacter/(Competibacter +TFOs) and negatively with the abundance of (Competibacter +TFOs) for all plants except one, suggesting the relevance of these candidate organisms to EBPR processes. However, effluent phosphorus concentration, amount of phosphorus removed, and process stability in an EBPR system were not directly related to high PAO abundance or mutually exclusive with a high GAO fraction. The plant that had the lowest average effluent phosphorus and highest stability rating had the lowest P(rel)/HAc(up) and the most TFOs. Evaluation of full-scale EBPR performance data indicated that low effluent phosphorus concentration and high process stability are positively correlated with the influent readily biodegradable chemical oxygen demand-to-phosphorus ratio. A system-level carbon-distribution-based conceptual model is proposed for capturing the dynamic competition between PAOs and GAOs and their effect on an EBPR process, and the results from this study seem to support the model hypothesis.

Direct observation of the phenomenology of a solid thermal explosion using time-resolved proton radiography

We present a new phenomenology for burn propagation inside a thermal explosion based on dynamic radiography. Radiographic images were obtained of an aluminum cased solid cylindrical sample of a plastic bonded formulation of octahydro-1,3,5,7-tetranitro-1,3,5,7-tetrazocine. The phenomenology observed is ignition followed by cracking in the solid accompanied by the propagation of a radially symmetric front of increasing proton transmission. This is followed by a further increase in transmission through the sample, ending after approximately 100 micros. We show that these processes are consistent with the propagation of a convective burn front followed by consumption of the remaining solid by conductive particle burning.