Sentinel Lymph Node Evaluation in Early-Stage Vulvar Cancer

OPINION STATEMENT

Sentinel lymph node mapping (SLNM) and dissection (SLND) should be used as an alternative to full inguinofemoral lymph node dissection (IFLND) in select patients with early-stage vulvar cancer. IFLND is associated with high postoperative complications such as wound breakdown, lymphedema, lymphocyst formation, and infection. SLND in select patients offers a safe, effective, and less morbid alternative. Candidates for SLND include patients with a unifocal vulvar tumor less than four centimeters, clinically negative lymph nodes, and no prior inguinofemoral surgeries. SLND should ideally be performed by a high-volume SLN surgeon. Most commonly, SLND is performed using both radiocolloid lymphoscintigraphy (e.g., Technetium-99) and a visual tracer such as blue dye; however, near infrared imaging with indocyanine green injection is becoming more widely adopted. Further prospective studies are needed to examine the safety and efficacy of various techniques for SLND. SLND has been demonstrated to be cost-effective, especially when including perioperative complications. Further studies are needed to demonstrate quality of life differences between IFLND and SLND.

Understanding the spectrum of malignant bowel obstructions in gynecologic cancers and the application of the Henry score

OBJECTIVE

Malignancy-associated bowel obstruction (MBO) is a potential sequela of advanced gynecologic cancers, adversely impacting both quality of life and prognosis. The Henry score (HS) was developed in a gastrointestinal cancer-predominant population to predict 30-day mortality. We aim to characterize MBO in gynecologic cancers and assess the utility of the HS in this population.

METHODS

This is a retrospective review of patients with gynecologic cancer and MBO admitted to a single academic institution from 2016 to 2021. The primary outcome is to characterize malignant small and large bowel obstructions in primary and recurrent gynecologic cancer using readmission and mortality rates. Secondary outcomes are to assess the Henry score and inpatient MBO management.

RESULTS

179 patients totaling 269 were admissions identified, most commonly affecting patients with ovarian cancer. The majority (89.4%) were managed non-operatively while 10.6% were managed surgically. No significant differences were observed in survival for medical versus surgical management. Thirty-day mortality increased with increasing HS (0%, 0-1; 14.3%, 2-3; 40.9%, 4-5). Over 1/3 (34.1%) of patients were readmitted for recurrent or persistent MBO. Goals of care conversations were documented for 56.8% of patients with HS 4-5. Mortality rates across the entire cohort were high-20.1% and 60.9% had died by 1 and 6 months, respectively.

CONCLUSIONS

Survival rates following an initial MBO admission are poor. The HS has utility in gynecologic cancers for assessing 30-day mortality and may be a useful tool to aid in the management and counseling of patients with gynecologic cancer and MBO.

A Pilot Study of a Screening Program for Human Papillomavirus-Related Squamous Intraepithelial Lesion and Malignancy in Gynecologic Oncology Patients

OBJECTIVE

Human papillomavirus (HPV)-related squamous intraepithelial lesion (SIL) or malignancy is associated with a significantly increased risk of second-site SIL or malignancy. The primary objective of this study was to determine the feasibility and acceptability of concurrent anal, cervical, and vulvovaginal screening in patients with a history of HPV-related gynecologic high-grade SIL or malignancy. The secondary objective was to assess subjects' knowledge regarding HPV screening and risks.

METHODS

Women with high-grade cervical, vulvar, or vaginal SIL or malignancy were enrolled during a 1-year pilot period. Subjects with cervical SIL or malignancy underwent vulvar examination and anoscopy. Subjects with vulvovaginal SIL or malignancy underwent Pap test if indicated and anoscopy. Appropriate referrals were made for abnormal findings. Feasibility was assessed by compliance using study acceptance rate, screening procedure adherence, and referral adherence. Acceptability was assessed using a Likert-scaled question after completion of screening procedures.

RESULTS

One hundred three women with a diagnosis of high-grade vulvovaginal or cervical SIL or carcinoma were approached regarding study enrollment; of these, 74 (71.8%) enrolled. The median score on the HPV knowledge assessment was 8.1 ± 1.6 (max score 10). Seventy-three (98.6%) of 74 patients rated the screening procedures as acceptable (score of 5/5). On examination, 14 (18.9%) subjects had abnormalities noted; 7 (9.5%) were referred for colorectal surgical evaluation, and 6/7 (85.7%) were compliant with their referral appointments.

CONCLUSIONS

Screening examinations for other HPV-related SILs and malignancies, including Pap tests, vulvovaginal inspection, and anoscopy, are acceptable to patients, with abnormal findings in almost 1 in 5 women.

Concordance Between Genomic Alterations Detected by Tumor and Germline Sequencing: Results from a Tertiary Care Academic Center Molecular Tumor Board

OBJECTIVE

The majority of tumor sequencing currently performed on cancer patients does not include a matched normal control, and in cases where germline testing is performed, it is usually run independently of tumor testing. The rates of concordance between variants identified via germline and tumor testing in this context are poorly understood. We compared tumor and germline sequencing results in patients with breast, ovarian, pancreatic, and prostate cancer who were found to harbor alterations in genes associated with homologous recombination deficiency (HRD) and increased hereditary cancer risk. We then evaluated the potential for a computational somatic-germline-zygosity (SGZ) modeling algorithm to predict germline status based on tumor-only comprehensive genomic profiling (CGP) results.

METHODS

A retrospective chart review was performed using an academic cancer center's databases of somatic and germline sequencing tests, and concordance between tumor and germline results was assessed. SGZ modeling from tumor-only CGP was compared to germline results to assess this method's accuracy in determining germline mutation status.

RESULTS

A total of 115 patients with 146 total alterations were identified. Concordance rates between somatic and germline alterations ranged from 0% to 85.7% depending on the gene and variant classification. After correcting for differences in variant classification and filtering practices, SGZ modeling was found to have 97.2% sensitivity and 90.3% specificity for the prediction of somatic versus germline origin.

CONCLUSIONS

Mutations in HRD genes identified by tumor-only sequencing are frequently germline. Providers should be aware that technical differences related to assay design, variant filtering, and variant classification can contribute to discordance between tumor-only and germline sequencing test results. In addition, SGZ modeling had high predictive power to distinguish between mutations of somatic and germline origin without the need for a matched normal control, and could potentially be considered to inform clinical decision-making.

Shotgun metagenome sequencing of a Sudanese toombak snuff tobacco: genetic attributes of a high tobacco-specific nitrosamine containing smokeless tobacco product

The most alarming aspect of the Sudanese toombak smokeless tobacco is that it contains high levels of highly toxic tobacco-specific nitrosamines (TSNAs). Understanding the microbiology of toombak is of relevance because TSNAs are an indirect result of microbial-mediated nitrate reductions. We conducted shotgun metagenomic sequencing on a toombak product for which relevant features are presented here. The microbiota was composed of over 99% Bacteria. The most abundant taxa included Actinobacteria, specifically the genera Enteractinococcus and Corynebacterium, while Firmicutes were represented by the family Bacillaceae and the genus Staphylococcus. Selected gene targets were nitrate reduction and transport, antimicrobial resistance, and other genetic transference mechanisms. Canonical nitrate reduction and transport genes (i.e. nar) were found for Enteractinococcus and Corynebacterium while various species of Staphylococcus exhibited a notable number of antimicrobial resistance and genetic transference genes. The nitrate reduction activity of the microbiota in toombak is suspected to be a contributing factor to its high levels of TSNAs. Additionally, the presence of antimicrobial resistance and transference genes could contribute to deleterious effects on oral and gastrointestinal health of the end user. Overall, the high toxicity and increased incidences of cancer and oral disease of toombak users warrants further investigation into the microbiology of toombak.

Performance of seven consumer sleep-tracking devices compared with polysomnography

STUDY OBJECTIVES

Consumer sleep-tracking devices are widely used and becoming more technologically advanced, creating strong interest from researchers and clinicians for their possible use as alternatives to standard actigraphy. We, therefore, tested the performance of many of the latest consumer sleep-tracking devices, alongside actigraphy, versus the gold-standard sleep assessment technique, polysomnography (PSG).

METHODS

In total, 34 healthy young adults (22 women; 28.1 ± 3.9 years, mean ± SD) were tested on three consecutive nights (including a disrupted sleep condition) in a sleep laboratory with PSG, along with actigraphy (Philips Respironics Actiwatch 2) and a subset of consumer sleep-tracking devices. Altogether, four wearable (Fatigue Science Readiband, Fitbit Alta HR, Garmin Fenix 5S, Garmin Vivosmart 3) and three nonwearable (EarlySense Live, ResMed S+, SleepScore Max) devices were tested. Sleep/wake summary and epoch-by-epoch agreement measures were compared with PSG.

RESULTS

Most devices (Fatigue Science Readiband, Fitbit Alta HR, EarlySense Live, ResMed S+, SleepScore Max) performed as well as or better than actigraphy on sleep/wake performance measures, while the Garmin devices performed worse. Overall, epoch-by-epoch sensitivity was high (all ≥0.93), specificity was low-to-medium (0.18-0.54), sleep stage comparisons were mixed, and devices tended to perform worse on nights with poorer/disrupted sleep.

CONCLUSIONS

Consumer sleep-tracking devices exhibited high performance in detecting sleep, and most performed equivalent to (or better than) actigraphy in detecting wake. Device sleep stage assessments were inconsistent. Findings indicate that many newer sleep-tracking devices demonstrate promising performance for tracking sleep and wake. Devices should be tested in different populations and settings to further examine their wider validity and utility.

Facilitated cascade testing (FaCT): a randomized controlled trial

BACKGROUND

Identifying mutation-carrying relatives of patients with hereditary cancer syndromes via cascade testing is an underused first step in primary cancer prevention. A feasibility study of facilitated genetic testing of at-risk relatives of patients with a known pathogenic mutation demonstrated encouraging uptake of cascade testing.

PRIMARY OBJECTIVE

Our primary objective is to compare the proportion of genetic testing of identified first-degree relatives of probands with a confirmed BRCA1/2 mutation randomized to a facilitated cascade testing strategy versus standard of care, proband-mediated, information sharing.

STUDY HYPOTHESIS

We hypothesize that facilitated cascade testing will drive significantly higher uptake of genetic testing than the standard of care.

TRIAL DESIGN

The FaCT (Facilitated Cascade Testing) trial is a prospective multi-institutional randomized study comparing the efficacy of a multicomponent facilitated cascade testing intervention with the standard of care. Patients with a known BRCA1/2 mutation (probands) cared for at participating sites will be randomized. Probands randomized to the standard of care group will be instructed to share a family letter with their first-degree relatives and encourage them to complete genetic testing. First-degree relatives of probands randomized to the intervention arm will receive engagement strategies with a patient navigator, an educational video, and accessible genetic testing services.

MAJOR INCLUSION/EXCLUSION CRITERIA

Adult participants who are first-degree relatives of a patient with a BRCA1/2 mutation and have not had prior genetic testing will be included.

PRIMARY ENDPOINT

Analyses will assess the proportion of first-degree relatives identified by the proband who complete genetic testing by 6 months in the intervention arm versus the control arm.

SAMPLE SIZE

One hundred and fifty probands with a BRCA1/2 mutation will be randomized. Each proband is expected to provide an average of 3 relatives, for an expected 450 participants.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

January 2024.

TRIAL REGISTRATION

NCT04613440.

Chemotherapy discontinuation processes in a gynecologic oncology population

OBJECTIVE

We sought to categorize the processes by which gynecologic oncology patients stop chemotherapy and to evaluate associations between these processes and end-of-life outcome metrics.

METHODS

A cohort of patients with metastatic or recurrent gynecologic cancer in an outpatient setting from January 2016 to May 2018 was identified. All deceased patients in this cohort were included for analysis. Processes of discontinuing chemotherapy were categorized as: 1) definitive decision inpatient; 2) definitive decision outpatient; 3) delayed decision (eg: treatment break and never resumed chemotherapy); 4) no decision. Associations between patient characteristics and clinical outcomes of those who made a definitive outpatient decision versus those who made any other type of decision were assessed.

RESULTS

220 patients were identified; 205 patients were deceased at time of analysis. Of these, 36.6% made a definitive decision to stop chemotherapy as an outpatient, while 41.5% never made a decision to discontinue chemotherapy. Making a definitive decision as an outpatient, when compared to all other decision types, was associated with significantly lower incidence of death in the hospital (5.6% vs 21.1%, p < 0.004) and hospitalization within 30 days of death (20.8% vs 56.6%, p < 0.001), and significantly increased median time from last chemotherapy to death (135.5 vs 62 days, p < 0.001).

CONCLUSION

Only one in three women in this cohort of patients deceased from gynecologic cancer made a definitive decision to discontinue chemotherapy in an outpatient setting, and this process was associated with improved end-of-life outcomes. Future efforts should examine the impact of interventions designed to increase the proportion of patients who transition away from chemotherapy via shared decision making in the outpatient setting.

Survey of trends in authorship assignment in gynecologic oncology: Keeping score and playing fair

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30.6% of responding gynecologic oncologists reported assignment of authorship that did not meet ICMJE criteria.

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The majority reported that ICMJE criteria were generalizable, helpful and considered non-adherence as scientific misconduct.

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Fellows and faculty in their first five year of practice were more likely not adhere to ICMJE authorship criteria.

Authorship confers credit to those responsible for a publication. In 1985, the International Committee of Medical Journal Editors criteria were founded to standardize authorship assignment. We sought to investigate practices and values in authorship assignment in Society of Gynecologic Oncology (SGO) members. An anonymous online survey was distributed to SGO members from 09/2018–10/2018. Three multivariable logistic regression models were fit to predict ICJME authorship acceptance, assignment and denial. Of 1111 members surveyed, 266 responses were received (23.9%); 30.6% reported prior authorship assignment that did not meet ICMJE criteria, and 18.8% (n = 50) reported a history of accepting authorship not meeting ICJME criteria. Reasons for non-adherence included: inclusion of the author’s patients in the study (59.3%), resumé building (45.7%), and networking for career advancement (22.2%). The majority responded that ICJME criteria were generalizable (91.3%), helpful (83.8%), and considered non-adherence as scientific misconduct (66.0%). On multivariable analysis, practice duration of 5–20 years (HR 0.40, 95% CI 0.16, 0.99, p < 0.05) or > 20 years (HR 0.22, 95% CI 0.08, 0.59, p < 0.05) were significant predictors for adherence with ICMJE authorship assignment compared to fellows and those in practice < 5 years. Similarly, practice duration of 5–20 years (HR 10.0, 95% CI 2.0, 49.2, p < 0.05) or > 20 years (HR 25.9, 95% CI 1.06, 3.9, p < 0.05) were significant predictors for denial of authorship assignment compared to fellows and those in practice < 5 years. While the majority of respondents report that ICJME criteria are helpful, adherence to these criteria is a concern, especially in fellows and early-career faculty.

Microbial communities and gene contributions in smokeless tobacco products

Smokeless tobacco products (STP) contain bacteria, mold, and fungi due to exposure from surrounding environments and tobacco processing. This has been a cause for concern since the presence of microorganisms has been linked to the formation of highly carcinogenic tobacco-specific nitrosamines. These communities have also been reported to produce toxins and other pro-inflammatory molecules that can cause mouth lesions and elicit inflammatory responses in STP users. Moreover, microbial species in these products could transfer to the mouth and gastrointestinal tract, potentially altering the established respective microbiotas of the consumer. Here, we present the first metagenomic analysis of select smokeless tobacco products, specifically US domestic moist and dry snuff. Bacterial, eukaryotic, and viral species were found in all tobacco products where 68% of the total species was comprised of Bacteria with 3 dominant phyla but also included 32% Eukarya and 1% share abundance for Archaea and Viruses. Furthermore, 693,318 genes were found to be present and included nitrate and nitrite reduction and transport enzymes, antibiotic resistance genes associated with resistance to vancomycin, β-lactamases, their derivatives, and other antibiotics, as well as genes encoding multi-drug transporters and efflux pumps. Additional analyses showed the presence of endo- and exotoxin genes in addition to other molecules associated with inflammatory responses. Our results present a novel aspect of the smokeless tobacco microbiome and provide a better understanding of these products' microbiology. KEY POINTS: • The findings presented will help understand microbial contributions to overall STP chemistries. • Gene function categorization reveals harmful constituents outside canonical forms. • Pathway genes for TSNA precursor activity may occur at early stages of production. • Bacteria in STPs carry antibiotic resistance genes and gene transfer mechanisms.

Management of high, moderate, and low penetrance ovarian cancer susceptibility mutations: an assessment of current risk reduction practices

OBJECTIVE

Limited information exists regarding risk reduction strategies for women with moderate and low penetrance ovarian cancer susceptibility mutations. We sought to assess current risk reduction practice patterns for carriers of these mutations through a survey of members of the Society of Gynecologic Oncology.

METHODS

Society of Gynecologic Oncology members were emailed a survey consisting of two vignettes: (1) a 35-year-old premenopausal woman; (2) a 55-year-old postmenopausal woman with comorbidities. Each vignette contained sub-scenarios in which the patient had either a BRCA1 (relative risk (RR)=30-60), RAD51C (RR=5.0), or ATM (RR=1.5-2.0) mutation. Respondents were queried about their preferred management approach. Summary statistics were performed to describe results of the survey. We used χ² testing for statistical analyses, comparing results according to mutation type and demographic information.

RESULTS

A total of 193 (15%) of 1284 Society of Gynecologic Oncology members responded. For the premenopausal woman, 99%, 80%, and 40% would perform a risk reducing salpingo-oophorectomy prior to menopause in the setting of a BRCA1, RAD51C, and ATM mutation, respectively. For the postmenopausal woman, 98%, 85%, and 42% would proceed with risk reducing salpingo-oophorectomy in the setting of a BRCA1, RAD51C, and ATM mutation, respectively. Response distribution for carriers of RAD51C and ATM mutations were different from BRCA1 in both vignettes (p<0.001).

CONCLUSIONS

Respondents were more likely to perform risk reducing salpingo-oophorectomy, in the setting of a BRCA1, RAD51C, and ATM mutation, earlier and more frequently in the setting of a BRCA1 mutation. However, there was a lack of consensus about management of the moderate and low penetrance mutations, suggesting that more data regarding age specific risks and appropriate risk reduction strategies for these alterations are needed.

Durable response to hormonal therapy in a patient with rapidly progressive low-grade serous ovarian cancer: A case report

This case report describes a 46-year-old patient with rapidly progressive stage IIIA1 estrogen receptor positive low grade serous ovarian cancer (LGSC). She was optimally debulked with no residual disease and received three cycles of adjuvant liposomal doxorubicin and carboplatin intravenous chemotherapy. CT scan and pelvic exam after her third cycle revealed a 5.7 cm nodular fixed left vaginal cuff mass involving the rectosigmoid consistent with rapidly progressive disease on chemotherapy. The decision was made to initiate letrozole, and she demonstrated a prolonged partial response for 34 months on hormonal therapy. The optimal management of newly diagnosed LGSC has yet to be determined. This unique case suggests that patients with newly diagnosed disease will not be compromised if treated with adjuvant hormonal monotherapy.

A39 Reconstruction of Ebola chains of transmission using sequence and epidemiological data

Transmission trees can be established through detailed contact histories, statistical inference, phylogenetic inference, or a combination of methods. Each method has its limitations, and the extent to which they succeed in revealing a ‘true’ transmission history remains unclear. Moreover, the net value of pathogen sequencing in transmission tree reconstruction is yet to be assessed. We explored the accuracy and sensitivity to biases of a range of methods for transmission chain inference. We studied eight transmission chains determined by contact tracing, each one having more than a third of its cases sequenced (87 samples over 199 cases in total). We compared three inference methods on the selected transmission chains: (i) phylogenetic inference: the Ebola virus (EBOV) sequences derived from patients were mapped onto a dated EBOV phylogeny tree including 398 EBOV sequences sampled in Guinea between March 2014 and October 2015; (ii) statistical inference: we used the maximum likelihood framework developed by Wallinga and Teunis to infer the most likely transmitter-recipient relationships from the onset dates; (iii) combined method: we inferred probabilistic transmission events using both pathogen sequences and collection dates with the R package Outbreaker2. The cases coming from each transmission chain were mostly clustered together in the phylogenetic tree. The few misclassified cases were most likely allocated to the wrong chains of transmission because of the timing of their symptom onsets. Probabilistic transmission tree using only onset dates broadly matched the contact tracing data, but multiple potential infectors were identified for each case. The combined method showed that an a priori knowledge of the number of independent imports had an important impact on the outcome. Although cases were allocated to the correct transmission chains, discrepancies were found in identifying direct case linkage and transmission generations within a chain. Phylogenetic, epidemiological, and combined approaches for transmission chain reconstructions globally concurred in their output. Sequence data proved useful (if not necessary) to place the sampled cases in a wider context, identify transmission clusters, and misclassified cases when epidemiological chains are inferred from date of symptom onset only, and to identify links between supposedly independent chains of transmission.

Therapy discontinuation processes in a gynecologic oncology population

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Background: The decision to discontinue anti-cancer therapies in oncology patients is a complex one and may occur in several unique ways. We sought to understand the processes of therapy discontinuation in a gynecologic oncology population and to discern possible changes in the distribution of these processes after implementation of a palliative care (PC) quality improvement project. Methods: Women with incurable gynecologic malignancies seen in the outpatient setting at an academic center were identified with the recommendation for ‘goals of care’ discussion within 3 visits following identification. Processes of discontinuing chemotherapy for this population were assessed and categorized into 1 of 4 categories: definitive outpatient decision, definitive inpatient decision, interruption by hospitalization, treatment holiday, and “no decision.” Retrospective chart review identified a similar cohort of women prior to the implementation of our PC intervention. Univariate analyses were conducted to determine associations between characteristics and binary outcome of definitive outpatient decision versus all other decision processes. Results: 90/102 (88%) pre-intervention subjects and 83/157 (53%) post-intervention subjects had died at time of analysis. Of the total deceased cohort, 59/173 (34%) made a definitive decision to stop therapy in the outpatient setting. After implementation of the PC initiative, there was a trend towards fewer women identified as having made “no decision” (18.1% vs 30%). Those who made a definitive outpatient decision were less likely to die within 30 days of hospitalization than those who did not (OR 0.16 [95% CI 0.07,0.390], p < 0.0001). Conclusions: Discontinuation of therapy is a nuanced concept in gynecologic oncology patients that can be stratified into several processes. While our data demonstrates a possible increase in active decision-making with the PC initiative, a majority of patients near the end of life still did not make definitive therapy cessation decisions. This reveals an urgent need for the development of initiatives to enhance patient engagement and shared decision making for women near the end of life.

Management of high, moderate, and low penetrance ovarian cancer susceptibility gene mutations: An assessment of current practice patterns

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Background: Limited information exists regarding appropriate risk-reduction strategies for women with moderate and low penetrance ovarian cancer (OVCA) susceptibility mutations. We sought to assess current practice patterns for women with these genetic changes through a survey of members of the Society of Gynecologic Oncology (SGO). Methods: All full SGO members were e-mailed a survey consisting of two vignettes: 1) a 35-year-old premenopausal woman who desires pregnancy; 2) a 55-year-old postmenopausal woman with multiple comorbidities. Each vignette contained sub-scenarios in which the patient had either a BRCA1 (RR = 30-60), RAD51C (RR = 5.0) or ATM (RR 1.5-2.0) OVCA susceptibility mutation. Respondents were queried about their preferred management approach. Chi-square test was used for statistical analysis. Results: 193 (15%) of 1284 SGO members responded. 58% were in academic practice. For the premenopausal woman, 52%, 13% and 6% would perform an RRSO prior to age 40 in the setting of a BRCA1, RAD51C and ATM mutation respectively. 47%, 68% and 9% would perform RRSO at 40-50; and 0%, 9% and 23% would perform RRSO at menopause, depending on the gene mutated. For the postmenopausal woman with comorbidities, 98%, 85% and 42% would proceed with RRSO in the setting of a BRCA1, RAD51C and ATM mutation respectively; 2%, 8% and 39% would observe (with/without screening); and 0%, 7% and 19% would do further research prior to proceeding. Distribution of responses for carriers of RAD51C and ATM mutations were different from BRCA1 in both vignettes [p < 0.001]. Conclusions: Respondents were more likely to perform RRSO earlier and more frequently in the setting of a BRCA1 mutation compared to either a RAD51C or ATM mutation. However, there was lack of consensus in management of the moderate and low penetrance OVCA susceptibility mutations. These patterns likely reflect the limited information available regarding the timing and magnitude of risk associated with these genes. Given the immediate and long-term morbidity of oophorectomy, more data regarding age-specific risks and appropriate risk-reduction strategies for moderate and low penetrance OVCA susceptibility mutations is needed.

Real-time dynamic modelling for the design of a cluster-randomized phase 3 Ebola vaccine trial in Sierra Leone

BACKGROUND

Declining incidence and spatial heterogeneity complicated the design of phase 3 Ebola vaccine trials during the tail of the 2013-16 Ebola virus disease (EVD) epidemic in West Africa. Mathematical models can provide forecasts of expected incidence through time and can account for both vaccine efficacy in participants and effectiveness in populations. Determining expected disease incidence was critical to calculating power and determining trial sample size.

METHODS

In real-time, we fitted, forecasted, and simulated a proposed phase 3 cluster-randomized vaccine trial for a prime-boost EVD vaccine in three candidate regions in Sierra Leone. The aim was to forecast trial feasibility in these areas through time and guide study design planning.

RESULTS

EVD incidence was highly variable during the epidemic, especially in the declining phase. Delays in trial start date were expected to greatly reduce the ability to discern an effect, particularly as a trial with an effective vaccine would cause the epidemic to go extinct more quickly in the vaccine arm. Real-time updates of the model allowed decision-makers to determine how trial feasibility changed with time.

CONCLUSIONS

This analysis was useful for vaccine trial planning because we simulated effectiveness as well as efficacy, which is possible with a dynamic transmission model. It contributed to decisions on choice of trial location and feasibility of the trial. Transmission models should be utilised as early as possible in the design process to provide mechanistic estimates of expected incidence, with which decisions about sample size, location, timing, and feasibility can be determined.

Video-assisted genetic counseling in patients with ovarian, fallopian and peritoneal carcinoma

OBJECTIVES

To compare the proportion of patients with ovarian, fallopian or peritoneal carcinoma who receive genetic testing after observing a genetic counseling video versus after traditional referral for genetic counseling and testing at physician discretion.

METHODS

A retrospective chart review was performed of all patients seen at the West Cancer Center for evaluation of ovarian, fallopian or peritoneal carcinoma from 7/2014 to 8/2015. Patients seen between 7/2014 and 12/2014 were offered standard genetic counseling. We adopted a new standard of care from 3/2015 to 8/2015 involving the use of a genetic counseling video on a digital tablet. The video was shown to patients with ovarian, fallopian or peritoneal cancer, who were then given the option to undergo genetic testing at the end of the viewing. We compared the number and proportion of patients who received genetic testing in both groups.

RESULTS

The initial group of 267 patients received referral and te\sting at the physician's discretion between 8/2014 and 12/2014. 77/267 (29%) of these patients underwent genetic testing. 295 patients viewed the condensed genetic counseling video with the option to receive testing the same day between 3/2015 and 8/2015. 162/295 (55%) of these patients received testing. The transition from a referral method to the video counseling method resulted in a significant increase of patients tested (p<0.001).

CONCLUSION

Using a genetic counseling video and providing an immediate option for testing significantly increased the proportion of patients with ovarian, fallopian or peritoneal carcinoma who received genetic testing.

Analysis of toxic metals in commercial moist snuff and Alaskan iqmik

The extent to which smokeless tobacco endangers human health is an ongoing subject of debate. Studies have shown that smokeless tobacco products contain high levels of biologically available nicotine and tobacco-specific nitrosamines. Toxic metals in smokeless tobacco products have been less extensively studied. In this study, concentrations of arsenic, barium, beryllium, cadmium, chromium, cobalt, lead, and nickel were measured in snuff products and iqmik tobacco, a product popular among some Alaska Natives. The average arsenic, cadmium, lead, and nickel concentrations in 17 commercially available brands were 0.23 +/- 0.06 microg/g, 1.40 +/- 0.31 microg/g, 0.45 +/- 0.13 microg/g and 2.28 +/- 0.36 microg/g, respectively. In 17 iqmik tobacco samples, the average arsenic, cadmium, lead, and nickel concentrations were 0.19 +/- 0.06 microg/g, 1.41 +/- 0.56 microg/g, 0.55 +/- 0.19 microg/g, and 2.32 +/- 1.63 microg/g, respectively. Using artificial saliva, the extractable levels of beryllium and lead were relatively low and consistent, whereas barium extracted from tobacco samples ranged from 2 to 21%. The group 1 and 2B carcinogens cadmium, cobalt, and nickel were more efficiently extracted by artificial saliva (30-65% of the cobalt, 20-46% of the nickel, and 21-47% of the cadmium).

Effect of charcoal-containing cigarette filters on gas phase volatile organic compounds in mainstream cigarette smoke

Of the chemicals identified to date in mainstream cigarette smoke with known toxicological properties, the volatile organic compounds (VOCs) are considered the most hazardous group owing to their high abundance and toxicity. In this research we evaluate a recently introduced line of cigarettes that contain charcoal in their filters. The amount of charcoal in these filters ranged from 45 mg to 180 mg and were either dispersed among the filter material or contained in a small cavity in the filter segment. Charcoal has long been used for removing VOCs from both water and air. Our findings indicate that these cigarettes reduce machine generated mainstream smoke deliveries of a wide range of VOCs compared to a similar, non-charcoal filtered, cigarette. However, this reduction is dependent not only on the amount of charcoal present but also on the volume of smoke being drawn through the filter. While a brand with 45 mg charcoal reduces VOC delivery under ISO smoking conditions, charcoal saturation and breakthrough occur under more intense smoking conditions. Breakthrough is minimised for brands with the most charcoal. Overall, the brands with the most charcoal are effective at reducing VOC deliveries under even intense smoking conditions.

Cadmium, lead, and thallium in smoke particulate from counterfeit cigarettes compared to authentic US brands

Smoking remains the leading cause of preventable disease in the United States. Exposure to tobacco smoke leads to cancer, heart and lung disease, and addiction. The origin of the tobacco and cigarette manufacturing practices of counterfeit cigarettes are unknown. Because toxic metals are incorporated into the tobacco lamina during cultivation, the ambient metal content of the soil could produce significant differences in metal levels in both the tobacco and smoke of counterfeit cigarettes. We compared mainstream smoke cadmium, thallium, and lead deliveries from counterfeit and authentic brands. Mainstream smoke levels of all three metals were far greater for counterfeit than the authentic brands, in some cases by an order of magnitude. Significant differences still existed even after normalizing mainstream smoke metal levels with nicotine delivery; the counterfeits typically delivered much higher levels of all three analytes. Our findings, based on 21 different counterfeit samples, suggest that counterfeit cigarettes potentially result in a markedly greater exposure to toxic heavy metals than authentic brands, even after correcting for differences in nicotine intake. In view of the unknown health risks associated with inhaling higher levels of toxic metals, it is prudent to minimize exposure to toxic substances whenever possible.

Cadmium, lead, and thallium in mainstream tobacco smoke particulate

The deliveries of cadmium, thallium, and lead in mainstream smoke particulate from cigarettes with different smoke delivery designs were determined by inductively coupled plasma-mass spectrometry in order to investigate their impact on the delivery of these known toxic compounds. Analyses showed that the levels of all three metals in smoke particulate were associated with their tar delivery category. After normalizing the metal concentrations to tar, there were no longer any statistically significant delivery differences between full-flavor, light or ultra-light cigarettes. When the concentrations were normalized to nicotine, the mean levels from the three delivery groups were much smaller than before normalization. But unlike the case using tar to normalize, in some of the cases, there were still some statistically significant differences in the nicotine-normalized results. These findings suggest that if smokers compensate for differences in nicotine intake, they receive exposures to toxic heavy metals from ultra-light, light and full-flavor cigarettes that are more similar than results would suggest from using the Federal Trade Commission method alone.

The development of a quantitative flexibility test for body armour and comparison with wearer trials

In this paper a mechanical flexibility test is developed which can be used to assess multi layer body armour systems. This is compared with a subjective manual test, and then with the results of wearer trials conducted using the recently approved ISO body armour standard ISO 14876-1 (2002). A series of trials was conducted on six different ballistic and/or stab resistant body armour types with a variety of protection levels and constructions. These were tested using the mechanical test system in which the armour was forced through a 200 mm hole by a 100 mm hemispherical plunger. The results of this test were then compared to a second set of trials in which flexibility of the same armour was assessed by manual handling and flexing of the armour. Finally an ergonomic wearer trial was conducted with four armours according to ISO 14876-1 (2002) each armour being assessed by four volunteers and the results compared to flexibility data collected in the first two trials. It was shown that the mechanical flexibility test produced results which were in good agreement with a purely subjective flexibility assessment. These results in turn showed reasonable but not exact correlation with the wearer trials. The ISO wearer trials addressed other factors such as overall comfort and fit of the systems and so the results were not purely a function of flexibility.

Determination of tar, nicotine, and carbon monoxide yields in the mainstream smoke of selected international cigarettes

OBJECTIVE

Survey of nicotine, tar, and carbon monoxide (CO) smoke deliveries from 77 cigarette brands purchased in 35 countries was conducted using a standardised machine smoking method. The goal of this study was to determine regional variations and differences in the tar, nicotine, and CO smoke yields of a cigarette brand manufactured by a leading transnational corporation and of non-US locally popular cigarette brands.

DESIGN

The majority of the cigarettes were purchased in each of the participating countries by delegate members of the World Health Organization and forwarded to the Centers for Disease Control and Prevention for analysis. Smoke deliveries were determined using a standardised smoking machine method and subsequent gravimetric and gas chromatography analysis.

RESULTS

The smoke deliveries varied widely. Mainstream smoke deliveries varied from 6.8 to 21.6 mg tar/cigarette, 0.5 to 1.6 mg nicotine/cigarette, and 5.9 to 17.4 mg CO/cigarette. In addition to the smoke deliveries, the cigarettes were examined to determine physical parameters such as filter composition, length, and ventilation levels.

CONCLUSION

Analysis of the smoke deliveries suggested that cigarettes from the Eastern Mediterranean, Southeast Asia, and Western Pacific WHO regions tended to have higher tar, nicotine, and CO smoke deliveries than did brands from the European, American, or African WHO regions surveyed.

Wounding patterns and human performance in knife attacks: optimising the protection provided by knife-resistant body armour

BACKGROUND

Stab attacks generate high loads, and to defeat them, armour needs to be of a certain thickness and stiffness. Slash attacks produce much lower loads and armour designed to defeat them can be far lighter and more flexible.

METHODS AND SUBJECTS

Phase 1: Human performance in slash attacks: 87 randomly selected students at the Royal Military College of Science were asked to make one slash attack with an instrumented blade on a vertically mounted target. No instructions on how to slash the target were given. The direction, contact forces and velocity of each attack were recorded. Phase 2: Clinical experience with edged weapon attacks: The location and severity of all penetrating injuries in patients attending the Glasgow Royal Infirmary between 1993 and 1996 were charted on anatomical figures.

RESULTS

Phase 1: Two types of human slash behaviour were evident: a 'chop and drag' blow and a 'sweep motion' type of attack. 'Chop and drag' attacks had higher peak forces and velocities than sweep attacks. Shoulder to waist blows (diagonal) accounted for 82% of attacks, 71% of attackers used a long diagonal slash with an average cut length of 34 cm and 11% used short diagonal attacks with an average cut length of 25 cm. Only 18% of attackers slashed across the body (short horizontal); the average measured cut length of this type was 28 cm. The maximum peak force for the total sample population was 212 N; the maximum velocity was 14.88 m s(-1). The 95 percentile force for the total sample population was 181 N and the velocity was 9.89 m s(-1). Phase 2: 431 of the 500 patients had been wounded with edged weapons. The average number of wounds sustained by victims in knife assaults was 2.4. The distribution of wounds by frequency and severity are presented.

CONCLUSIONS

Anti-slash protection is required for the arms, neck, shoulders, and thighs. The clinical experience of knife-attack victims provides information on the relative vulnerabilities of different regions of the body. It is anticipated that designing a tunic-type of Police uniform that is inherently stab and slash resistant will eventually replace the current obvious and often bulky extra protective vest. Attempts at making a combined garment will need to be guided by ergonomic considerations and field testing. A similar anatomical regional risk model might also be appropriate in the design of anti-ballistic armour and combined anti-ballistic and knife-resistant armour.

Concentrations of nine alkenylbenzenes, coumarin, piperonal and pulegone in Indian bidi cigarette tobacco

Indian-made bidi cigarettes sold in the United States are available in a variety of exotic (e.g. clove, mango) and candy-like (e.g. chocolate, raspberry) flavors. Because certain tobacco flavorings contain alkenylbenzenes and other toxic or carcinogenic chemicals, we measured the concentration of flavor-related compounds in bidi tobacco using a previously developed method. Twenty-three brands of bidis were sampled using automated headspace solid-phase microextraction and subsequently analyzed for 12 compounds by gas chromatography-mass spectrometry. Two alkenylbenzene compounds, trans-anethole and eugenol, were found in greater than 90% of the brands analyzed. Methyleugenol, pulegone and estragole were each detected in 30% or more of the brands, whereas safrole and elemicin were not detected in any of the brands. The flavor-related compounds with the highest tobacco concentrations were eugenol (12,000 microg/g tobacco) and trans-anethole (2200 microg/g tobacco). The highest eugenol and trans-anethole concentrations found in bidi tobacco were about 70,000 and 7500 times greater, respectively, than the highest levels previously found in US cigarette brands. Measurement of these compounds is crucial to evaluation of potential risks associated with inhaling highly concentrated flavor-related compounds from bidis or other tobacco products.

Reliability of individual differences in initial sensitivity and acute tolerance to nitrous oxide hypothermia

On average, the hypothermia exhibited by rats receiving 60% nitrous oxide (N2O) eventually abates despite the continued inhalation of the drug (i.e., acute tolerance develops). However, large individual differences occur in both the magnitude of hypothermia achieved and the degree of acute tolerance that develops. To determine whether the degree of temperature loss and subsequent recovery during N2O administration are reliable characteristics of an individual, we measured intraperitoneal temperature via telemetry in 77 Long-Evans rats that each received 60% N2O for 5 h during two sessions separated by 14 days. Good intersession reliability (Pearson's r) was observed for simple change and adjusted change scores for both initial N2O temperature sensitivity (.61 < or = r < or = .62), and acute tolerance development (.46 < or = r < or = .52). In a separate experiment, three groups of rats were selected based on their individual body temperature patterns during an initial N2O administration: (1) insensitive to N2O hypothermia (n = 8); (2) marked hypothermia followed by acute tolerance development (n = 6); and (3) marked hypothermia followed by little acute tolerance development (n = 6). When retested 10 days later, each group exhibited a body temperature profile similar to that observed during the initial N2O exposure. Thus, the temperature profile observed during a rat's initial exposure to 60% N2O reflects a reproducible response for that animal.

Amiloride-sensitive signals and NaCl preference and appetite: a lick-rate analysis

Rats prefer hypotonic and isotonic NaCl solutions to water in long-access drinking paradigms. To focus on the role of taste signals in NaCl preference, licking patterns of rats with 30-s exposure to NaCl solutions (0-0.5 M) were examined when they were either water deprived, sodium depleted, or not deprived (NaCl mixed in dilute sucrose). In all three conditions, rats displayed a preference for NaCl. The addition of 100 microM amiloride, a sodium channel blocker, to NaCl did not change rats' licking when they were sodium replete but dramatically reduced licking when they were deplete. Transection of the chorda tympani (CT) nerve, an afferent pathway for amiloride-sensitive Na(+) signals, had no effect on NaCl preference in nondeprived rats and only a modest effect on those that were Na(+) deplete. Amiloride was found to exert significant suppression of NaCl intake in Na(+)-depleted rats with transection of the CT, supporting the existence of other afferent pathways for transmission of amiloride-sensitive Na(+) signalling. Together, these studies argue for the involvement of different neural signalling mechanisms in NaCl preference in the presence and absence of explicit Na(+) need.

Quantitative analysis of acetates in cigarette tobacco using solid-phase microextraction and gas chromatography-mass spectrometry

A method incorporating solid-phase microextraction (SPME) and gas chromatography-mass spectrometry for the headspace analysis of selected volatile organic compounds present in cigarette tobacco is developed and evaluated. Quantitative information on methyl, ethyl, n-propyl, isopropyl, isopropenyl, vinyl, and butyl acetates present in 29 different flavor variants (full, light, and ultra-light) of the top ten selling brands in the United States is presented. The concentrations of the various acetate analytes range from the low nanaogram to microgram levels per cigarette. Clear differences are observed in the concentrations of various acetates when comparing the levels in brands from different manufacturers. The SPME technique provides a method that allows high sample throughput, requires little sample preparation, and yields useful analytical information. High precision is obtained on multiple measurements of cigarettes from an individual pack, but lower precision levels are observed in general when comparing results obtained on the analysis of cigarettes from different packs of the same brand. The higher pack-to-pack variations may be due in part to product aging with a proportionate amount of evaporative loss of the relatively volatile acetates.

An assessment of human performance in stabbing

Stab-resistant body armour is now becoming a standard item of equipment for police officers in the United Kingdom. In the UK these are usually required to have a stab resistance as specified by the Police Scientific Development Branch KR42 standard [G. Parker, PSDB Stab Resistant Body Armour Test Procedure, Police Scientific Development Branch, Publication No 10/93, 1993]. There are several other test standards, all of which specify that body armour must resist penetration by a specific blade type delivered at a specific energy level or range of levels. However, the actual range of energy levels specified varies over almost an order of magnitude and the basis for these levels is not clearly defined. This paper describes tests to determine the energy range and characteristics of stabbing actions that might be directed against stab resistant body armour by an assailant. The energy and velocity that can be achieved in stabbing actions has been determined for a number of sample populations. Volunteers were asked to stab a target using an instrumented knife that measured the axial force and acceleration during the stabbing. The maximum energy obtained in underarm stabbing actions was 64 J whilst overarm stabbing actions could produce 115 J. The loads produced on contact with the target often approached 1000 N.

Assessing enzyme substrate specificity using combinatorial libraries and electrospray ionization-Fourier transform ion cyclotron resonance mass spectrometry

A model experiment for the 'on-line' screening of substrate libraries by enzymes using combinatorial libraries in combination with electrospray ionization-Fourier transform ion cyclotron resonance (ESI-FTICR) mass spectrometry has been performed. The reaction between the electrophilic substrate 1-chloro-2,4-dinitrobenzene and component of a H-gamma-Glu-Cys-Xxx-OH library, catalyzed by glutathione-S-transferase, has been monitored. It shows the feasibility of 'two-dimensional' screening of substrate libraries by ESI-FTICR mass spectrometry.

Internal glow discharge-fourier transform ion cyclotron resonance mass spectrometry

A glow discharge (GD) ion source has been developed to work within the high magnetic field of a Fourier transform ion cyclotron resonance (FTICR) mass spectrometer. Characterization of this source revealed that the optimum operating voltage, pressure, and current are significantly lower than those for normal glow discharges. The sputter rate was lowered to 1/30th of that found with a normal glow discharge source operated external to the high magnetic field region. Operation of the GD source closer to the FTICR analyzer cell than with previous experimental designs resulted in improved ion transport efficiency. Preliminary results from this internal GD source have established detection limits in the low parts per million range for selected elemental species.

Analysis of combinatorial libraries using electrospray Fourier transform ion cyclotron resonance mass spectrometry

Electrospray ionization coupled with Fourier transform ion cyclotron resonance (FTICR) mass spectrometry has been used to provide information about complete combinatorial libraries of small peptides containing 10(3)-10(4) components. The fidelity of attempted synthesis steps can be ascertained rapidly, and, when the extremely high resolution FTICR mass spectra are combined with appropriate computer simulation, both diversity and degeneracy of the libraries as synthesized can be assessed.

Coconut and Salmonella infection

Raw, unprocessed coconut supports the growth of salmonellae as well as that of other enteric bacteria, salmonellae being particularly resistant to subsequent desiccation. Original contamination is not due to carriers or to polluted water supplies, but to contact with bacteria-containing soils followed by dispersion via infected coconut milk and shells. Pasteurization of raw coconut meat in a water bath at 80 C for 8 to 10 min effectively killed such bacteria, did not injure the product, and provided a prophylactic method now widely used by the coconut industry.