Multifocal MRI-Directed Simultaneous Integrated Boost (SIB) in the Treatment of Prostate Cancer with Stereotactic Body Radiation Therapy (SBRT)

PURPOSE/OBJECTIVE(S)

Conventionally fractionated MRI-directed radiation boosts in the treatment of prostate cancer have been shown to improve oncologic outcomes in the FLAME trial. Moreover, recent data has demonstrated local recurrences following SBRT predominately occur at the site of the dominant intraprostatic lesion. Modern protocols including HYPO-Flame have demonstrated early safety profiles of a 5-fraction intraprostatic SBRT boost. This study aims to determine if multifocal SIB treatment is associated with additional acute toxicity relative to unifocal boosts.

MATERIALS/METHODS

In this single-center retrospective analysis, we identified all patients who underwent SBRT with a SIB using a robotic radiosurgical platform. Fiducial markers and hydrogel rectal spacers were placed prior to simulation. All patients underwent treatment planning MRI with documented PI-RADS 3-5 lesions targeted for SIB delineation. Patients were treated to a prescription dose of 3500 to 3625 cGy in 5 fractions, or 1800 to 2100 cGy in 3 fractions in concert with pelvic nodal irradiation. The SIB prescription dose ranged from 4000 to 4200 cGy and 2100 to 2300 cGy for the 5- and 3-fraction regimens, respectively. Acute toxicity was defined as that occurring within 60 days of treatment completion using the CTCAE v. 5.0.

RESULTS

A total of 35 patients with a median age of 70 underwent SBRT SIB from 5/2022 to 1/2023 with the following risk distribution: low (3%), intermediate (66%), high (28%), and regional (3%). Most patients received rectal spacers (77%) and neoadjuvant ADT (71%) prior to treatment. The majority of patients underwent 5-fraction SBRT (74%) with the remainder receiving SBRT as a boost. Approximately half (51%) of the cohort was treated with a multifocal SIB to multiple PI-RADS lesions. Mean SIB dose was 4105 and 2377 cGy in 5- and 3-fractions, respectively. With a median follow up of 33 days, we identified no grade 3+ acute toxicities. Crude rate of grade 2 GU and GI toxicity was 51% and 6%, respectively, on par with prior unifocal publications. There was no difference in median SIB volume between uni- and multifocal boosts (1.47 vs. 1.72 cc, p = 0.57), nor was SIB volume associated with an increased risk of grade 2 GU toxicity (p = 0.28). Dominant lesion location was not associated with increased grade 2 GU toxicity (p = 0.29). No grade 2 GI toxicities occurred in the multifocal group. Finally, univariate analysis did not identify multifocal boost as a risk of grade 2 GU toxicity (35%) relative to unifocal (67%) boost (p = 0.09).

CONCLUSION

In the first analysis of its kind in the literature, we demonstrate that multifocal MRI-directed intraprostatic SBRT SIB yields no acute high-grade toxicity and is not associated with a higher risk of low-grade GU and GI toxicity relative to unifocal boost. Longer follow is necessary to determine risk of late toxicity and oncologic efficacy.

Robotic SBRT in Prostate Cancer Patients Younger Than 50 Years Old-Updated Results

PURPOSE/OBJECTIVE(S)

Stereotactic Body Radiation Therapy (SBRT) is a standard therapeutic option for men with prostate adenocarcinoma. The median age of prostate cancer in the US is 66 but patients as young as 35 have been reported. Many younger patients will have surgery rather than SBRT for localized prostate cancer but some will be treated with SBRT. There is a paucity of data on the outcomes of this younger subset. This study reports updated outcomes on patients younger than 50 treated with SBRT at a single institution and compares outcomes to older patients.

MATERIALS/METHODS

Between April 2006 and December 2022, 6,130 patients with prostate cancer were treated with inhomogeneous-dosed SBRT using a robotic linear accelerator. Information was available for 4,143 patients. 3568 (86.12%) of patients were treated with a median dose of 3500cGY (3500-3625) delivered over 5 consecutive fractions prescribed to the 83-85% isodose line, and the remaining 575 (13.88%) other patients receiving a median dose of 4500cGY (4500-5400) to the pelvis in conventional fractionation followed by a 3 fraction SBRT boost of 2100 cGY (1950-2100) over 3 consecutive fractions. Androgen deprivation Therapy (ADT) was prescribed in 1,035 (24.98%) of these cases. The mean age was 67.4 years old. 48 patients were younger than 50 years old (mean age 46.6). 4,095 patients were 50 or older. Patients were divided into prognostic D'Amico risk groups with 43.75%, 50.00%, 6.25% of patients falling in the low, intermediate, and high-risk stratifications in the younger cohort and 23.88%, 57.05%, 19.07% in the older cohort respectively. Pretreatment PSA was 1.72 - 43.2 (median: 5.4) in the younger group and 0.3 - 661 (median: 6.5) in the older group. In the younger group, Gleason scores were 6 in 47.92%, 7 in 47.92%, and 8-10 in 4.16%. 44 younger patients were treated with SBRT alone. 4 patients also received supplemental external beam radiation (median dose 4500cGY) and 5 patients (10.42%) received Androgen Deprivation Therapy (ADT) as part of their treatment regimen. In the older group, Gleason scores were 6 in 29.84%, 7 in 54.14%, and 8-10 in 16.02%. 3522 were treated with SBRT alone. 573 patients also received supplemental external beam radiation (median dose 4500cGY) and 1030 patients (25.15%) received Androgen Deprivation Therapy (ADT) as part of their treatment.

RESULTS

At 75 months the 6-year biochemical relapse free survival was 95.83% in younger patients compared to 98.41% in older patients using the Phoenix definition of biochemical failure. The 6-year median post treatment PSA was 0.3 in younger patients and 0.2 in the older patients. There were no significant differences in the risk stratification between the 2 groups.

CONCLUSION

This represents the largest series evaluating outcomes in very young patients treated with definitive SBRT for prostate cancer. With updated 6-year follow up, SBRT remains an effective treatment for this younger subset of patients. Continued follow up will be required to see if these results remain durable.

The effect of distinct dietary interventions on proximal aortic stiffness; the DIRECT-PLUS randomized controlled trial

Background

Proximal aortic stiffness (PAS) reflects arterial aging and is strongly associated with increased cardiovascular risk. Plant-rich, specifically Mediterranean-style, diets are associated with reduced cardiovascular risk. The effect of dietary interventions on PAS remains unclear.

Methods

We randomized participants with abdominal-obesity/dyslipidemia to healthy-dietary-guidelines (HDG), Mediterranean, or green-Mediterranean diets combined with physical activity (PA). Both Mediterranean diets were similarly hypocaloric and included 28g/day walnuts. The green-Mediterranean group also consumed green tea (3–4 cups/day) and a Wolffia-globosa (Mankai) plant green-shake. PAS was estimated based on aortic-arch pulse-wave-velocity using magnetic resonance imaging (MRI) at baseline and after 18-months.

Results

Among 294 participants [age=51±10.6 years, body-mass-index 31.3±4.0 kg/m2, PAS = 6.1±2.7 m/sec, retention rate = 89.8%], 281 had valid PAS measurements. Higher PAS was mostly associated with aging, hypertension, dyslipidemia, diabetes, and increased visceral adiposity (p<0.05 for all). After 18-months of intervention, all diet groups significantly reduced their PAS ([HDG: −4.8% (interquartile-range [IQR]: −22.3 to 8.7); Mediterranean: −7.3%, IQR (−20.8 to 11.9); green-Mediterranean: −14.0%, IQR (−27.0 to 2.4); p<0.05 for within-groups changes).

Green-Mediterranean dieters had significantly greater PAS reduction than HDG dieters (p=0.007), also after controlling for age, sex, baseline-PAS, and Δweight. Further adjustment to baseline dyslipidemia, diabetes, and hypertension also revealed significant differences in PAS reduction between green-Mediterranean and Mediterranean groups (p=0.027). Specifically, greater green tea consumption was associated with greater PAS regression (p=0.04). ΔPAS was significantly associated with improvements in Δlow-density-lipoprotein cholesterol and Δtotal-cholesterol (p<0.05, multivariable models). All lifestyle intervention showed aortic age regression as compared to the expected (1.8±0.14 years vs.: HDG: −2.9±7.5 years; MED: −4.1±7.4 years; green-MED:-4.9±8.0 years; p<0.001).

Conclusions

Higher PAS is strongly related to aging and is associated with traditional cardiovascular risk factors. Lifestyle intervention promotes PAS reduction. Green-Mediterranean diet may be associated with more remarkable aortic rejuvenation.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Deutsche Forschungsgemeinschaft (DFG, German Research Foundation); the Israel Ministry of Health

Communicating about Sexual Problems

Sexual side effects of cancer treatment are common and, unfortunately, often not discussed with patients and their partner. This may be due to personal factors of the health care provider, fear of offending the patient or lack of knowledge, time constraints, and perception of the importance to the patient based on age and severity of the cancer. Despite the barriers to communication about a sensitive topic, oncology care providers are well situated to initiate the conversation. This article will identify key issues related to communication about sexuality by oncology care providers with individuals with the most common kinds of cancer. Models for assessing sexuality in these patients are presented to facilitate communication about this important aspect of quality of life that is impacted by cancer treatment.

OP0229 THE GROUP FOR RESEARCH AND ASSESSMENT OF PSORIASIS AND PSORIATIC ARTHRITIS (GRAPPA) TREATMENT RECOMMENDATIONS 2021

Background:

Since the 2015 GRAPPA treatment recommendations were published, therapeutic options and management strategies for psoriatic arthritis (PsA) have advanced considerably.

Objectives:

The goal of the GRAPPA recommendations update is to develop high quality, evidence-based recommendations for the treatment of PsA, including related conditions and comorbidities.

Methods:

GRAPPA rheumatologists, dermatologists and patient research partners (PRPs) updated overarching principles for the management of adults with PsA by consensus. Principles considering use of biosimilars and tapering/discontinuing of therapy were added to this update. Systematic literature searches based on data publicly available from three databases (MEDLINE, EMBASE, and Cochrane CENTRAL) were conducted from the end of the previous recommendations’ searches through August 2020. Additional abstract searches were performed for conference presentations in 2017-2020. Searches covered PsA treatments (peripheral arthritis, axial arthritis, enthesitis, dactylitis, skin, and nail disease). Additional searches were performed for related conditions (uveitis and IBD) and comorbidities evaluating their impact on safety and treatment outcomes. Individual groups assessed the risk of bias and applied the GRADE system to generate strong or conditional recommendations for therapies within the domain groups and for the management of comorbidities and related conditions. These recommendations were then incorporated into an overall treatment schema.

Results:

Updated, evidence-based treatment recommendations are shown (Table 1). Since 2015, many new medications have been incorporated. Additional results for older medications, such as methotrexate, have been published across PsA domains. Based on the evidence, the treatment recommendations developed by individual groups were incorporated into the overall schema including principles for management of arthritis, spondylitis, enthesitis, dactylitis, skin, and nail disease in PsA, and associated conditions (Figure 1). Choice of therapy for an individual should ideally address all of the domains that impact on that patient, supporting shared decision making with the patient involved. Additional consideration in the recommendations was given to key associated conditions and comorbidities as these often impact on therapy choice.

Conclusion:

These GRAPPA treatment recommendations provide up to date, evidence-based guidance to providers who manage and treat adult patients with PsA. These recommendations are based on domain-based strategy for PsA and supplemented by overarching principles developed by consensus of GRAPPA members.

IndicationStrongForConditional ForConditionalAgainstStrongAgainstInsufficient evidencePeripheral Arthritis DMARD NaïvecsDMARDs, TNFi, PDE4i, IL-12/23i, IL-17i, IL-23i, JAKiNSAIDs, oral CS, IA CS,IL-6i,Peripheral Arthritis DMARD IRTNFi, IL-12/23i, IL-17i, IL-23i, JAKiPDE4i, other csDMARD, NSAIDs, oral CS, IA CS,IL-6i,Peripheral ArthritisbDMARD IRTNFi, IL-17i, IL-23i, JAKi,NSAIDs, oral CS, IA CS, IL-12/23i, PDE4i, CTLA-4-IgIL-6i,Axial arthritis, Biologic NaïveNSAIDs, Physiotherapy, simple analgesia, TNFi, IL-17i, JAKiCS SIJ injections, bisphosphonatescsDMARDs, IL-6i,IL-12/23i, IL-23iAxial PsA, Biologic IRNSAIDs, Physiotherapy, simple analgesia, TNFi, IL-17i, JAKi csDMARDs, IL-6i,IL-12/23i, IL-23iEnthesitisTNFi, IL-12/23i, IL-17i, PDE4i, IL-23i, JAKiNSAIDs, physiotherapy, CS injections, MTXIL-6i,Other csDMARDsDactylitisTNFi IL-12/23i, IL-17i, IL-23i, JAKi, PDE4iNSAIDs, CS injections, MTXOther csDMARDsPsoriasisTopicals, phototherapy, csDMARDs, TNFi, IL-12/23i, IL-17i, IL-23i, PDE4i, JAKi AcitretinNail psoriasisTNFi, IL12/23i, IL17i, IL23i, PDE4iTopical CS, tacrolimus and calcipotriol combination or individual therapies, Pulsed dye laser, csDMARDs, acitretin, JAKiTopical Cyclosporine / Tazarotene, Fumarate, Fumaric Acid Esters, UVA and UVB Phototherapy, AlitretinoinIBDTNFi (not ETN), IL-12/23i, JAKiIL-17iUveitisTNFi (not ETN)

Disclosure of Interests:

Laura C Coates Speakers bureau: AbbVie, Amgen, Biogen, Celgene, Gilead, Eli Lilly, Janssen, Medac, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Pfizer, and Novartis, Enrique Soriano Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb,GSK, Genzyme, Janssen, Lilly, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb,GSK, Genzyme, Janssen, Lilly, Novartis, Pfizer, Roche, Sandoz, Sanofi, UCB, Grant/research support from: AbbVie, Janssen, Novartis Pharma, Pfizer, Roche, and UCB, Nadia Corp: None declared, Heidi Bertheussen Consultant of: Pfizer, Kristina Callis-Duffin Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Lilly, Janssen, Novartis, Pfizer, Sienna Biopharmaceuticals, Stiefel Laboratories, UCB, Ortho Dermatologics, Inc, Regeneron Pharmaceuticals, Inc., Anaptys Bio, Boehringer Ingelheim., Cristiano Barbosa Campanholo Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Jeffrey Chau: None declared, Lihi Eder Consultant of: Abbvie, UCB, Janssen, Eli Lily, Pfizer, Novartis, Grant/research support from: Abbvie, UCB, Janssen, Eli Lily, Pfizer, Novartis, Daniel Fernandez Consultant of: Abbvie, UCB, Roche, Janssen, Pfizer, Amgen and Brystol, Grant/research support from: Abbvie, UCB, Roche, Janssen, Pfizer, Amgen and Brystol, Oliver FitzGerald Speakers bureau: AbbVie, Janssen and Pfizer Inc, Consultant of: BMS, Celgene, Eli Lilly, Janssen and Pfizer Inc, Grant/research support from: AbbVie, BMS, Eli Lilly, Novartis and Pfizer Inc, Amit Garg Consultant of: Abbvie, Amgen, Asana Biosciences, Bristol Myers Squibb, Boehringer Ingelheim, Incyte, InflaRx, Janssen, Pfizer, UCB, Viela Biosciences, Grant/research support from: Abbvie, Dafna D Gladman Consultant of: Abbvie, Amgen, BMS, Eli Lilly, Galapagos, Gilead, Jansen, Novartis, Pfizer and UCB, Grant/research support from: Abbvie, Amgen, Eli Lilly, Jansen, Novartis, Pfizer and UCB, Niti Goel: None declared, Suzanne Grieb: None declared, Philip Helliwell Speakers bureau: Janssen, Novartis, Pfizer, Consultant of: Eli Lilly, M Elaine Husni Consultant of: Abbvie, Amgen, Janssen, Novartis, Lilly, UCB, Regeneron, and Pfizer, Deepak Jadon Speakers bureau: AbbVie, Amgen, Celgene, Eli Lilly, Gilead, Healthcare Celltrion, Janssen, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Gilead, Healthcare Celltrion, Janssen, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Gilead, Healthcare Celltrion, Janssen, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Arnon Katz: None declared, Dhruvkumar Laheru: None declared, John Latella: None declared, Ying Ying Leung Speakers bureau: Novartis, AbbVie, Eli Lilly, Janssen, Consultant of: Pfizer and Boehringer Ingelheim, Grant/research support from: Pfizer and conference support from AbbVie, Christine Lindsay Shareholder of: Amgen, Employee of: Aurinia pharmaceuticals, Ennio Lubrano Speakers bureau: Alfa-Sigma, Abbvie, Galapagos, Janssen Cilag, Lilly., Consultant of: Alfa-Sigma, Abbvie, Galapagos, Janssen Cilag, Lilly., Luis Mazzuoccolo Speakers bureau: Abbvie, Amgen, Novartis, Elli Lilly, Jansen, Consultant of: Abbvie, Amgen, Novartis, Elli Lilly, Jansen, Roland McDonald: None declared, Philip J Mease Speakers bureau: AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Galapagos, Gilead Sciences, GlaxoSmithKline, Janssen, Novartis, Pfizer, SUN and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Galapagos, Gilead Sciences, Janssen, Novartis, Pfizer, SUN and UCB, Denis O’Sullivan: None declared, Alexis Ogdie Consultant of: AbbVie, Amgen, BMS, Celgene, Corrona, Gilead, Janssen, Lilly, Novartis, and Pfizer, Grant/research support from: Novartis and Pfizer and Amgen, Wendy Olsder: None declared, Lori Schick: None declared, Ingrid Steinkoenig: None declared, Maarten de Wit Consultant of: AbbVie, BMS, Celgene, Janssen, Lilly, Novartis, Pfizer, Roche, Danielle van der Windt: None declared, Arthur Kavanaugh Speakers bureau: AbbVie, Amgen, BMS, Eli Lilly, Gilead Janssen, Novartis, Pfizer, UCB, Consultant of: AbbVie, Amgen, BMS, Eli Lilly, Gilead Janssen, Novartis, Pfizer, UCB

Metabolic determinants of proximal aortic stiffness among healthy people with abdominal obesity

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): (1) the Deutsche Forschungsgemeinschaft; (2) Israel Ministry of Health

Background

Increased proximal aortic stiffness (PAS) is directly associated with cardiovascular risk. Likewise, metabolic syndrome (MS) and abdominal obesity are associated with cardiovascular risk. The direct association between MS determinants and PAS among a healthy population with abdominal obesity remains to be examined.

Purpose

To examine the association between MS determinants and PAS among healthy participants with abdominal obesity.

Methods

We utilized the cross-sectional baseline data of the DIRECT-PLUS study (clinicaltrials.gov NCT03020186), where we recruited healthy participants with abdominal obesity/dyslipidemia. Along with anthropometric measurements and blood tests, all participants underwent magnetic-resonance-imaging from which PAS we assessed by calculating the aortic arch pulse-wave-velocity (from the ascending to the descending aorta). We defined MS according to the NCEP-ATP-III criteria.

Results

Of 282 participants who had a valid PAS estimation [mean-age: 51.0, 88.3% male, mean-body-mass-index: 31.2kg/m2, mean-waist circumference (WC): 109.5cm] 171 (60.9%) had MS. PAS was mainly associated with age (r = 0.735, p < 0.001). PAS was associated with an increased 10-year Framingham Risk Score (β=0.165,p = 0.008 after adjustment for age and gender). Participants with MS had higher PAS than non-MS participants (6.6m/sec vs. 5.4m/sec, p = 0.002 after adjusting for age and gender). PAS increased along with cumulative number of MS criteria (p-of-trend < 0.001). In multivariate models, adjusted for gender, age, and dichotomous-components of the MS, worse PAS remained significantly associated with high-density lipoprotein cholesterol (HDL-c; β=0.-116,p = 0.007) and increased blood-pressure (β=0.165,p < 0.001), but not with fasting-glucose, waist-circumference or plasma-triglycerides (p > 0.05 for all). In models adjusted for age, gender, and continuous determinants of MS, worse PAS remained associated with mean-arterial pressure (β=0.218,p < 0.001) and HDL-c (β=0.-126,p = 0.004).

Conclusions

Among a healthy population with abdominal obesity, reduced HDL-c levels and increased blood pressure might be the more dominant predictors of poor PAS state, out of the MS components.

SHARP Joint Action – Strengthening International Health Regulations and preparedness in the EU

Although the preparedness to health emergencies of biological, chemical, environmental and unknown origin across the Europe is at high level, gaps do exist across the EU Member States and European countries. The previous coronavirus epidemic, SARS in 2002, showed that countries responded largely individually to this emerging threat. EU wide, joint responses were not taken. SARS epidemic showed that strengthening of the common EU efforts was needed.

Many actions were taken, and since 2013 the European Commission Decision 1082/2013/EU on serious cross-border threats to health has provided a framework to improve preparedness and to strengthen the response capacities in Europe to health threats.

SHARP Joint Action is a 3-year collaborative action of 26 countries and 61 partners, co-funded by the EC and coordinated by the Finnish Institute for Health and Welfare, Finland, and co-coordinated by Robert Koch Institute, Germany and National Institute of Infectious Diseases Lazzaro Spallanzani, Italy. SHARP started it's actions in June 2019, and it aims to strengthen implementation of the International Health Regulations (IHR) and the Decision 1082/2013/EU.

SHARP consists of ten work packages covering core public health capacities, including: IHR core capacity strengthening and assessment, preparedness and response planning, training, laboratory preparedness and responsiveness, chemical safety and threats, and case management, infection prevention and control preparedness.

Through this cross-sectoral approach, SHARP supports the Member States and partner countries in strengthening their capacities. In response to the COVID-19 outbreak, SHARP has also supported the EC and the Member States, and especially work packages for laboratory preparedness and responsiveness (WP7) and for case management and infection prevention and control preparedness (WP10) were activated. The activities regarding laboratory preparedness and response have been coordinated with the ECDC.

Can Linked Electronic Medical Record and Administrative Data Help Us Identify Those Living with Frailty?

Introduction

Frailty is a complex condition that affects many aspects of patients’ wellbeing and health outcomes.

Objectives

We used available Electronic Medical Record (EMR) and administrative data to determine definitions of frailty. We also examined whether there were differences in demographics or health conditions among those identified as frail in either the EMR or administrative data.

Methods

EMR and administrative data were linked in British Columbia (BC) and Manitoba (MB) to identify those aged 65 years and older who were frail. The EMR data were obtained from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and the administrative data (e.g. billing, hospitalizations) was obtained from Population Data BC and the Manitoba Population Research Data Repository. Sociodemographic characteristics, risk factors, prescribed medications, use and costs of healthcare are described for those identified as frail.

Results

Sociodemographic and utilization differences were found among those identified as frail from the EMR compared to those in the administrative data. Among those who were >65 years, who had a record in both EMR and administrative data, 5%-8% (n=191 of 3,553, BC; n=2,396 of 29,382, MB) were identified as frail. There was a higher likelihood of being frail with increasing age and being a woman. In BC and MB, those identified as frail in both data sources have approximately twice the number of contacts with primary care (n=20 vs. n=10) and more days in hospital (n=7.2 vs. n=1.9 in BC; n=9.8 vs. n=2.8 in MB) compared to those who are not frail; 27% (BC) and 14% (MB) of those identified as frail in 2014 died in 2015.

Conclusions

Identifying frailty using EMR data is particularly challenging because many functional deficits are not routinely recorded in structured data fields. Our results suggest frailty can be captured along a continuum using both EMR and administrative data.

Population Data Centre Profile: The Manitoba Centre for Health Policy

Objective

To profile the Manitoba Centre for Health Policy (MCHP), a population health data centre located at the University of Manitoba in Winnipeg, Canada.

Approach

We describe how MCHP was established and funded, and how it continues to operate based on a foundation of trust and respect between researchers at the University of Manitoba and stakeholders in the Manitoba Government’s Department of Health. MCHP’s research priorities are jointly determined by its scientists’ own research interests and by questions put forward from Manitoba government ministries. Data governance, data privacy, data linkage processes and data access are discussed in detail. We also provide three illustrative examples of the MCHP Data Repository in action, demonstrating how studies using a variety of Repository datasets have had an impact on health and social policies and programs in Manitoba.

Discussion

MCHP has experienced tremendous growth over the last three decades. We discuss emerging research directions as the capacity for innovation at MCHP continues to expand, including a focus on natural language processing and other applications of artificial intelligence techniques, a leadership role in the new SPOR Canadian Data Platform, and a foray into social policy evaluation and analysis. With these and other exciting opportunities on the horizon, the future at MCHP looks exceptionally bright.

RNA sequencing of intestinal mucosa reveals novel pathways functionally linked to celiac disease pathogenesis

BACKGROUND & AIMS

The early steps in the pathophysiology of celiac disease (CD) leading to loss of tolerance to gluten are poorly described. Our aim was to use RNA sequencing of duodenal biopsies in patients with active CD, CD in remission, and non-CD controls to gain insight into CD pathophysiology, identify additional genetic signatures linked to CD, and possibly uncover targets for future therapeutic agents.

METHODS

We performed whole transcriptome shotgun sequencing of intestinal biopsies in subjects with active and remission CD and non-CD controls. We also performed functional pathway analysis of differentially expressed genes to identify statistically significant pathways that are up or down regulated in subjects with active CD compared to remission CD.

RESULTS

We identified the upregulation of novel genes including IL12R, ITGAM and IGSF4 involved in the immune response machinery and cell adhesion process in the mucosa of subjects with active CD compared to those in remission. We identified a unique signature of genes, related to innate immunity, perturbed exclusively in CD irrespective of disease status. Finally, we highlight novel pathways of interest that may contribute to the early steps of CD pathogenesis and its comorbidities such as the spliceosome, pathways related to the innate immune response, and pathways related to autoimmunity.

CONCLUSIONS

Our study confirmed previous findings based on GWAS and immunological studies pertinent to CD pathogenesis and describes novel genes and pathways that with further validation may be found to contribute to the early steps in the pathogenesis of CD, ongoing inflammation, and comorbidities associated with CD.

Patient-derived xenografts effectively capture responses to oncology therapy in a heterogeneous cohort of patients with solid tumors

Background

While patient-derived xenografts (PDXs) offer a powerful modality for translational cancer research, a precise evaluation of how accurately patient responses correlate with matching PDXs in a large, heterogeneous population is needed for assessing the utility of this platform for preclinical drug-testing and personalized patient cancer treatment.

Patients and methods

Tumors obtained from surgical or biopsy procedures from 237 cancer patients with a variety of solid tumors were implanted into immunodeficient mice and whole-exome sequencing was carried out. For 92 patients, responses to anticancer therapies were compared with that of their corresponding PDX models.

Results

We compared whole-exome sequencing of 237 PDX models with equivalent information in The Cancer Genome Atlas database, demonstrating that tumorgrafts faithfully conserve genetic patterns of the primary tumors. We next screened PDXs established for 92 patients with various solid cancers against the same 129 treatments that were administered clinically and correlated patient outcomes with the responses in corresponding models. Our analysis demonstrates that PDXs accurately replicate patients' clinical outcomes, even as patients undergo several additional cycles of therapy over time, indicating the capacity of these models to correctly guide an oncologist to treatments that are most likely to be of clinical benefit.

Conclusions

Integration of PDX models as a preclinical platform for assessment of drug efficacy may allow a higher success-rate in critical end points of clinical benefit.

Increased temperature accelerates glycogen synthesis and delays fatigue in isolated mouse muscle during repeated contractions

AIM

Elevated glycogen content in muscle delays fatigue during exercise. We examined if increasing muscle temperature during recovery from exercise affects glycogen synthesis and muscle performance during a subsequent bout of exercise.

METHODS

Isolated mouse extensor digitorum longus muscles were stimulated electrically to perform repeated tetanic contractions until force decreased to 40% of initial at 25°C. Thereafter, muscles recovered for 120 minutes at 25°C (control), 120 minutes at 35°C or 60 minutes at 35°C followed by 60 minutes at 25°C. After recovery, muscles were again stimulated to fatigue at 25°C.

RESULTS

In the control group, the number of contractions in the second run was slightly less than during the first run (92 ± 5%). Following recovery for 120 minutes at 35°C, the number of contractions was similar to the first run (98 ± 6%). Allowing recovery for 120 minutes at 35°C in the presence of the antioxidant N-acetylcysteine also did not alter the number of contractions in the second run (98 ± 3%). However, recovery for 60 minutes at 35°C followed by 60 minutes at 25°C resulted in an increase in the number of contractions during the second run (110 ± 2%, P < .001). Incorporation of [¹⁴ C]glucose into glycogen (glycogen synthesis) during recovery was 1.7-fold higher at 35°C vs 25°C (1.44 ± 0.08 μmol (30 min)^-1  (g wet muscle)^-1 vs 0.84 ± 0.04; P < .001).

CONCLUSION

These data demonstrate that, under the conditions studied, elevating muscle temperature for 60 minutes following a bout of repeated contractions delays muscle fatigue during a subsequent bout of repeated contractions and this is associated with enhanced glycogen synthesis in isolated muscle.

Resonantly pumped eye-safe Er3+:YAG SPS-HIP ceramic laser

We report for the first time laser action in resonantly-pumped transparent polycrystalline Er³⁺:YAG ceramic developed through a 2-step approach combining spark plasma sintering and HIP post treatment. Microstructural and spectroscopic properties, as well as the laser performance of large scale 0.5at.% Er:YAG transparent polycrystalline ceramic are discussed. A maximum slope efficiency of ∼31% and optical-optical efficiency of 20% was measured.

Interventions to address sexual problems in people with cancer

BACKGROUND

Sexual dysfunction in people with cancer is a significant problem. The present clinical practice guideline makes recommendations to improve sexual function in people with cancer.

METHODS

This guideline was undertaken by the Interventions to Address Sexual Problems in People with Cancer Expert Panel, a group organized by the Program in Evidence-Based Care (pebc). Consistent with the pebc standardized approach, a systematic search was conducted for existing guidelines, and the literature in medline and embase for the years 2003-2015 was systematically searched for both systematic reviews and primary literature. Evidence found for men and for women was evaluated separately, and no restrictions were placed on cancer type or study design. Content and methodology experts performed an internal review of the resulting draft recommendations, which was followed by an external review by targeted experts and intended users.

RESULTS

The search identified 4 existing guidelines, 13 systematic reviews, and 103 studies with relevance to the topic. The present guideline provides one overarching recommendation concerning the discussion of sexual health and dysfunction, which is aimed at all people with cancer. Eleven additional recommendations made separately for men and women deal with issues such as sexual response, body image, intimacy and relationships, overall sexual functioning and satisfaction, and vasomotor and genital symptoms.

CONCLUSIONS

To our knowledge this clinical practice guideline is the first to comprehensively evaluate interventions for the improvement of sexual problems in people with cancer. The guideline will be a valuable resource to support practitioners and clinics in addressing sexuality in cancer survivors.

Religiosity: Its Impact on Coping Styles Among Women Undergoing Fertility Treatment

The Israeli worldview places great significance on childbearing. This could create emotional and ethical difficulties for women coping with fertility issues in addition to their treatments. This study examined the relations between coping strategies and level of religiosity in 159 women undergoing infertility treatment. Statistically significant relations were found between the problem-solving coping style and religious observance (p < 0.01) and religious beliefs (p < 0.05). An inverse correlation was found between the emotional coping style and religious beliefs (p < 0.001). Health professionals should recognize the patient's coping styles and understand the patient's religious belief system as part of an ongoing fertility treatment.

Psychiatric and behavioral side effects of anti-epileptic drugs in adolescents and children with epilepsy

PURPOSE

The objective of the study was to compare the psychiatric and behavioral side effect (PBSE) profiles of both older and newer antiepileptic drugs (AEDs) in children and adolescent patients with epilepsy.

METHOD

We used logistic regression analysis to test the correlation between 83 non-AED/patient related potential predictor variables and the rate of PBSE. We then compared for each AED the rate of PBSEs and the rate of PBSEs that led to intolerability (IPBSE) while controlling for non-AED predictors of PBSEs.

RESULTS

922 patients (≤18 years old) were included in our study. PBSEs and IPBSEs occurred in 13.8% and 11.2% of patients, respectively. Overall, a history of psychiatric condition, absence seizures, intractable epilepsy, and frontal lobe epilepsy were significantly associated with increased PBSE rates. Levetiracetam (LEV) had the greatest PBSE rate (16.2%). This was significantly higher compared to other AEDs. LEV was also significantly associated with a high rate of IPBSEs (13.4%) and dose-decrease rates due to IPBSE (6.7%). Zonisamide (ZNS) was associated with significantly higher cessation rate due to IPBSE (9.1%) compared to other AEDs.

CONCLUSION

Patients with a history of psychiatric condition, absence seizures, intractable epilepsy, or frontal lobe epilepsy are more likely to develop PBSE. PBSEs appear to occur more frequently in adolescent and children patients taking LEV compared to other AEDs. LEV-attributed PBSEs are more likely to be associated with intolerability and subsequent decrease in dose. The rate of ZNS-attributed IPBSEs is more likely to be associated with complete cessation of AED.

Emergency Department Utilization Report to Decrease Visits by Pediatric Gastroenterology Patients

BACKGROUND AND OBJECTIVES

Emergency department (ED) utilization is a major driver of health care costs. Specialist physicians have an important role in addressing ED utilization, especially at highly specialized, academic medical centers. We sought to investigate whether reporting of ED utilization to specialist physicians can decrease ED visits.

METHODS

This study analyzed an intervention to reduce ED utilization among ED patients who were followed by pediatric gastroenterologists. In May 2013, each pediatric gastroenterologist began receiving reports with rates of ED use by their patients. The reports generated discussion that resulted in a cultural and process change in which patients with urgent gastrointestinal (GI)-related complaints were preferentially seen in the office. Using control charts, we examined GI-related and all-diagnoses ED use over a 2-year period.

RESULTS

The rate of GI-related ED visits decreased by 60% after the intervention, from 4.89 to 1.95 per 1000 office visits (P < .001). Similarly, rates of GI-related ED visits during office hours decreased by 59% from 2.19 to 0.89 per 1000 (P < .001). Rates of all-diagnoses ED visits did not change.

CONCLUSIONS

Physician-level reporting of ED utilization to pediatric gastroenterologists was associated with physician engagement and a cultural and process change to preferentially treat patients with urgent issues in the office.

Issues Critical to the Successful Application of Cryosurgical Ablation of the Prostate

The techniques of present-day cryosurgery performed with multiprobe freezing apparatus and advanced imaging techniques yield predictable and encouraging results in the treatment of prostatic and renal cancers. Nevertheless, and not unique to cryosurgical treatment, the rates of persistent disease demonstrate the need for improvement in technique and emphasize the need for proper management of the therapeutic margin. The causes of persistent disease often relate to a range of factors including selection of patients, understanding of the extent of the tumor, limitations of the imaging techniques, and failure to freeze the tumor periphery in an efficacious manner. Of these diverse factors, the one most readily managed, but subject to therapeutic error, is the technique of freezing the tumor and appropriate margin to a lethal temperature [Baust, J. G., Gage, A. A. The Molecular Basis of Cryosurgery. BJU Int 95, 1187–1191 (2005)]. This article describes the recent experiments that examine the molecular basis of cryosurgery, clarifies the actions of the components of the freeze-thaw cycle, and defines the resultant effect on the cryogenic lesion from a clinical perspective. Further, this review addresses the important issue of management of the margin of the tumor through adjunctive therapy. Accordingly, a goal of this review is to identify the technical and future adjunctive therapeutic practices that should improve the efficacy of cryoablative techniques for the treatment of malignant lesions.

Screening for Celiac Disease in a Pediatric Primary Care Setting

Celiac disease (CD) is an autoimmune enteropathy in genetically predisposed individuals triggered by the ingestion of gluten. The prevalence in adults in the United States is increasing. Despite recognition of asymptomatic patients that benefit from screening and improved diagnostics, the majority of patients remain undiagnosed. The purpose of this study is to determine the prevalence of CD in at-risk and not-at-risk pediatric patients in a primary care practice routinely screening for CD. The records of 2325 pediatric patients who underwent serological testing with immunoglobulin A tissue transglutaminase (tTG) during a 5-year period were reviewed. Patients were categorized as at-risk or not-at-risk for CD. The prevalence of CD in at-risk patients was 1:26, the prevalence of CD in not-at-risk patients was 1:111. Our results suggest that the prevalence of CD in children approximates that of US adults and that the true prevalence in children without known risk factors may be increasing.

A randomized, double-blind, placebo-controlled study of the effects of pomegranate extract on rising PSA levels in men following primary therapy for prostate cancer

BACKGROUND

The primary objective of this study was to compare the effects of pomegranate juice on PSA doubling times (PSADT) in subjects with rising PSA levels after primary therapy for prostate cancer.

METHODS

Double-blind, placebo-controlled multi-institutional study, evaluated the effects of pomegranate liquid extract on serum PSA levels. The primary end point of this study was change in serum PSADT. Additional secondary and exploratory objectives were to evaluate the safety of pomegranate juice and to determine the interaction of manganese superoxide dismutase (MnSOD) AA genotype and pomegranate treatment on PSADT.

RESULTS

One-hundred eighty-three eligible subjects were randomly assigned to the active and placebo groups with a ratio of 2:1 (extract N=102; placebo N=64; juice N=17). The majority of adverse events were of moderate or mild grade. Median PSADT increased from 11.1 months at baseline to 15.6 months in the placebo group (P<0.001) compared with an increase from 12.9 months at baseline to 14.5 months in the extract group (P=0.13) and an increase from 12.7 at baseline to 20.3 in the juice group (P=0.004). However, none of these changes were statistically significant between the three groups (P>0.05). Placebo AA patients experienced a 1.8 month change in median PSADT from 10.9 months at baseline to 12.7 months (P=0.22), while extract patients experienced a 12 month change in median PSADT from 13.6 at baseline to 25.6 months (P=0.03).

CONCLUSIONS

Compared with placebo, pomegranate extract did not significantly prolong PSADT in prostate cancer patients with rising PSA after primary therapy. A significant prolongation in PSADT was observed in both the treatment and placebo arms. Men with the MnSOD AA genotype may represent a group that is more sensitive to the antiproliferative effects of pomegranate on PSADT; however, this finding requires prospective hypothesis testing and validation.

Long-term benefits of full-day kindergarten: a longitudinal population-based study

In the first longitudinal, population-based study of full-day kindergarten (FDK) outcomes beyond primary school in Canada, we used linked administrative data to follow 15 kindergarten cohorts (n ranging from 112 to 736) up to grade 9. Provincial assessments conducted in grades 3, 7, and 8 and course marks and credits earned in grade 9 were compared between FDK and half-day kindergarten (HDK) students in both targeted and universal FDK programmes. Propensity score matched cohort and stepped-wedge designs allowed for stronger causal inferences than previous research on FDK. We found limited long-term benefits of FDK, specific to the type of programme, outcomes examined, and subpopulations. FDK programmes targeted at low-income areas showed long-term improvements in numeracy for lower income girls. Our results suggest that expectations for wide-ranging long-term academic benefits of FDK are unwarranted.