Prospects for online adaptive radiation therapy (ART) for head and neck cancer

BACKGROUND

The aim of the present study is to examine the impact of kV-CBCT-based online adaptive radiation therapy (ART) on dosimetric parameters in comparison to image-guided-radiotherapy (IGRT) in consecutive patients with tumors in the head and neck region from a prospective registry.

METHODS

The study comprises all consecutive patients with tumors in the head and neck area who were treated with kV-CBCT-based online ART or IGRT-modus at the linear-accelerator ETHOS™. As a measure of effectiveness, the equivalent-uniform-dose was calculated for the CTV (EUDCTV) and organs-at-risk (EUDOAR) and normalized to the prescribed dose. As an important determinant for the need of ART the interfractional shifts of anatomic landmarks related to the tongue were analyzed and compared to the intrafractional shifts. The latter determine the performance of the adapted dose distribution on the verification CBCT2 postadaptation.

RESULTS

Altogether 59 consecutive patients with tumors in the head-and-neck-area were treated from 01.12.2021 to 31.01.2023. Ten of all 59 patients (10/59; 16.9%) received at least one phase within a treatment course with ART. Of 46 fractions in the adaptive mode, irradiation was conducted in 65.2% of fractions with the adaptive-plan, the scheduled-plan in the remaining. The dispersion of the distributions of EUDCTV-values from the 46 dose fractions differed significantly between the scheduled and adaptive plans (Ansari-Bradley-Test, p = 0.0158). Thus, the 2.5th percentile of the EUDCTV-values by the adaptive plans amounted 97.1% (95% CI 96.6-99.5%) and by the scheduled plans 78.1% (95% CI 61.8-88.7%). While the EUDCTV for the accumulated dose distributions stayed above 95% at PTV-margins of ≥ 3 mm for all 8 analyzed treatment phases the scheduled plans did for margins ≥ 5 mm. The intrafractional anatomic shifts of all 8 measured anatomic landmarks were smaller than the interfractional with overall median values of 8.5 mm and 5.5 mm (p < 0.0001 for five and p < 0.05 for all parameters, pairwise comparisons, signed-rank-test). The EUDOAR-values for the larynx and the parotid gland were significantly lower for the adaptive compared with the scheduled plans (Wilcoxon-test, p < 0.001).

CONCLUSIONS

The mobile tongue and tongue base showed considerable interfractional variations. While PTV-margins of 5 mm were sufficient for IGRT, ART showed the potential of decreasing PTV-margins and spare dose to the organs-at-risk.

Respiration-controlled radiotherapy in lung cancer: Systematic evaluation of the optimal application practice

Background and purpose

Definitive radiochemotherapy (RCT) for non-small cell lung cancer (NSCLC) in UICC/TNM I-IVA (singular, oligometastatic) is one of the treatment methods with a potentially curative concept. However, tumour respiratory motion during RT requires exact pre-planning. There are various techniques of motion management like creating internal target volume (ITV), gating, inspiration breath-hold and tracking. The primary goal is to cover the PTV with the prescribed dose while at the same time maximizing dose reduction of surrounding normal tissues (organs at risk, OAR). In this study, two standardized online breath-controlled application techniques used alternately in our department are compared with respect to lung and heart dose.

Materials and methods

Twenty-four patients who were indicated for thoracic RT received planning CTs in voluntary deep inspiration breath-hold (DIBH) and in free shallow breathing, prospectively gated in expiration (FB-EH). A respiratory gating system by Varian (Real-time Position Management, RPM) was used for monitoring. OAR, GTV, CTV and PTV were contoured on both planning CTs. The PTV margin to the CTV was 5 mm in the axial and 6-8 mm in the cranio-caudal direction. The consistency of the contours was checked by elastic deformation (Varian Eclipse Version 15.5). RT plans were generated and compared in both breathing positions using the same technique, IMRT over fixed irradiation directions or VMAT. The patients were treated in a prospective registry study with the approval of the local ethics committee.

Results

The PTV in expiration (FB-EH) was on average significantly smaller than the PTV in inspiration (DIBH): for tumours in the lower lobe (LL) 431.5 vs. 477.6 ml (Wilcoxon test for connected samples; p = 0.004), in the upper lobe (UL) 659.5 vs. 686.8 ml (p = 0.005). The intra-patient comparison of plans in DIBH and FB-EH showed superiority of DIBH for UL-tumours and equality of DIBH and FB-EH for LL-tumours. The dose for OAR in UL-tumours was lower in DIBH than in FB-EH (mean lung dose p = 0.011; lungV20, p = 0.002; mean heart dose p = 0.016). The plans for LL-tumours in FB-EH showed no difference in OAR compared to DIBH (mean lung dose p = 0.683; V20Gy p = 0.33; mean heart dose p = 0.929). The RT setting was controlled online for each fraction and was robustly reproducible in FB-EH.

Conclusion

RT plans for treating lung tumours implemented depend on the reproducibility of the DIBH and advantages of the respiratory situation with respect to OAR. The primary tumour localization in UL correlates with advantages of RT in DIBH, compared to FB-EH. For LL-tumours there is no difference between RT in FB-EH and RT in DIBH with respect to heart or lung exposure and therefore, reproducibility is the dominant criterion. FB-EH is recommended as a very robust and efficient technique for LL-tumours.

Main results of the first Brazilian Registry of Heart Failure (BREATHE)

Background

Heart failure represents a common cause of hospitalization associated with poor short-term clinical outcomes. Little is known about the long-term prognosis of these patients in Latin America.

Methods

The rationale and design of the study were previously published (1). Briefly, BREATHE was the first nation-wide prospective observational study that included patients hospitalized due to acute heart failure in Brazil. In-hospital management as well as 12-month clinical outcomes were assessed. Patients were included during two time periods: from February 2011 to December 2012 (BREATHE I) and from June 2016 to July 2018 (BREATHE Extension). Adherence to evidence-based therapies was also evaluated.

Results

A total of 3,013 patients were included in 71 centers in Brazil. The median follow-up was 346 days. The BREATHE population included 39.3% of women, had a mean age of 65.2 (± 15.6) with a mean ejection fraction of 39.7% (± 17.5). Among the comorbidities, systemic arterial hypertension was the most common, present in almost 75% of the sample. At hospital admission, 83.8% of patients had clear signs of pulmonary congestion and the main cause of decompensation was poor adherence to heart failure medications, representing 27.8% of cases. Among patients with reduced ejection fraction, the concomitant use of renin-angiotensin-aldosterone inhibitors, beta-blocker and spironolactone at hospital discharge was 44.5% and decreased to 35.2% after 3 months (p&lt;0.01). Mortality rate at 12 months was 28.9 for every 100 patient years with 26.2% readmission at 90 days and 46.4% at 365 days. The most common etiology of heart failure was ischemic disease (Figure 1) but the worst prognosis was associated with Chagas disease (Figure 2) including an analysis of a composite outcome encompassing death, myocardial infarction, stroke or cardiac arrest after discharge.

Conclusions

In this large national prospective registry of patients hospitalized with acute heart failure, mortality and readmission were higher than what have been reported globally. Poor adherence to evidence-based therapies was a common both at hospital discharge and 1-year of follow-up.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Brazilian Society of Cardiology

MR Imaging Characteristics and ADC Histogram Metrics for Differentiating Molecular Subgroups of Pediatric Low-Grade Gliomas

BACKGROUND AND PURPOSE

BRAF and type 1 neurofibromatosis status are distinctive features in pediatric low-grade gliomas with prognostic and therapeutic implications. We hypothesized that DWI metrics obtained through volumetric ADC histogram analyses of pediatric low-grade gliomas at baseline would enable early detection of BRAF and type 1 neurofibromatosis status.

MATERIALS AND METHODS

We retrospectively evaluated 40 pediatric patients with histologically proved pilocytic astrocytoma (n = 33), ganglioglioma (n = 4), pleomorphic xanthoastrocytoma (n = 2), and diffuse astrocytoma grade 2 (n = 1). Apart from 1 patient with type 1 neurofibromatosis who had a biopsy, 11 patients with type 1 neurofibromatosis underwent conventional MR imaging to diagnose a low-grade tumor without a biopsy. BRAF molecular analysis was performed for patients without type 1 neurofibromatosis. Eleven patients presented with BRAF V600E-mutant, 20 had BRAF-KIAA rearrangement, and 8 had BRAF wild-type tumors. Imaging studies were reviewed for location, margins, hemorrhage or calcifications, cystic components, and contrast enhancement. Histogram analysis of tumoral diffusivity was performed.

RESULTS

Diffusion histogram metrics (mean, median, and 10th and 90th percentiles) but not kurtosis or skewness were different among pediatric low-grade glioma subgroups (P < .05). Diffusivity was lowest in BRAF V600E-mutant tumors (the 10th percentile reached an area under the curve of 0.9 on receiver operating characteristic analysis). There were significant differences between evaluated pediatric low-grade glioma margins and cystic components (P = .03 and P = .001, respectively). Well-defined margins were characteristic of BRAF-KIAA or wild-type BRAF rather than BRAF V600E-mutant or type 1 neurofibromatosis tumors. None of the type 1 neurofibromatosis tumors showed a cystic component.

CONCLUSIONS

Imaging features of pediatric low-grade gliomas, including quantitative diffusion metrics, may assist in predicting BRAF and type 1 neurofibromatosis status, suggesting a radiologic-genetic correlation, and might enable early genetic signature characterization.

Tuberculosis (TB) Aftermath: study protocol for a hybrid type I effectiveness-implementation non-inferiority randomized trial in India comparing two active case finding (ACF) strategies among individuals treated for TB and their household contacts

BACKGROUND

Approximately 7% of all reported tuberculosis (TB) cases each year are recurrent, occurring among people who have had TB in the recent or distant past. TB recurrence is particularly common in India, which has the largest TB burden worldwide. Although patients recently treated for TB are at high risk of developing TB again, evidence around effective active case finding (ACF) strategies in this population is scarce. We will conduct a hybrid type I effectiveness-implementation non-inferiority randomized trial to compare the effectiveness, cost-effectiveness, and feasibility of two ACF strategies among individuals who have completed TB treatment and their household contacts (HHCs).

METHODS

We will enroll 1076 adults (≥ 18 years) who have completed TB treatment at a public TB unit (TU) in Pune, India, along with their HHCs (averaging two per patient, n = 2152). Participants will undergo symptom-based ACF by existing healthcare workers (HCWs) at 6-month intervals and will be randomized to either home-based ACF (HACF) or telephonic ACF (TACF). Symptomatic participants will undergo microbiologic testing through the program. Asymptomatic HHCs will be referred for TB preventive treatment (TPT) per national guidelines. The primary outcome is rate per 100 person-years of people diagnosed with new or recurrent TB by study arm, within 12 months following treatment completion. The secondary outcome is proportion of HHCs < 6 years, by study arm, initiated on TPT after ruling out TB disease. Study staff will collect socio-demographic and clinical data to identify risk factors for TB recurrence and will measure post-TB lung impairment. In both arms, an 18-month "mop-up" visit will be conducted to ascertain outcomes. We will use the RE-AIM framework to characterize implementation processes and explore acceptability through in-depth interviews with index patients, HHCs and HCWs (n = 100). Cost-effectiveness will be assessed by calculating the incremental cost per TB case detected within 12 months and projected for disability-adjusted life years averted based on modeled estimates of morbidity, mortality, and time with infectious TB.

DISCUSSION

This novel trial will guide India's scale-up of post-treatment ACF and provide an evidence base for designing strategies to detect recurrent and new TB in other high burden settings.

TRIAL REGISTRATION

NCT04333485 , registered April 3, 2020. CTRI/2020/05/025059 [Clinical Trials Registry of India], registered May 6 2020.

[Cochlear nerve continuity preservation during retrosigmoid ablative osteotomy of the internal auditory canal for advanced vestibular schwannomas]

The data of 86 patients with retrosigmoid microsurgical resection of vestibular schwannoma in tumor stage Koos II-IV were evaluated. In more than two thirds of the cases it was shown that the cochlear nerve followed the facial nerve, which is easily identified by electroneurography, in recurrent similar patterns in the region of the internal auditory canal. Starting from the fundus, this facilitated early identification and thus preservation of continuity of the cochlear nerve in the course of the internal auditory canal. This was of particular importance when safe functional preservation could not be guaranteed due to tumor size or formation despite intraoperative derivation of somatosenoric potentials, but when the possibility of subsequent hearing rehabilitation with a cochlear implant should be granted. Preoperative MRI sequences gave an indication of the possible nerve courses in some cases, but intraoperative imaging in the internal auditory canal was superior to MRI.

Changing HCW attitudes: a case study of normalizing HIV service delivery in emergency departments

Background

Delays in the implementation of evidence-based practices are significant and ubiquitous, compromising health outcomes. Resistance to change is a key factor in hindering adoption and integration of new evidence-based interventions. This study seeks to understand the impact of exposure to HIV testing within a research context on provider attitudes towards HIV counselling and testing (HCT) in emergency departments (ED).

Methods

This is a pre-and-post study design measuring the effect of a new ED-based HCT intervention, conducted by lay counsellors, on provider attitudes in Eastern Cape, South Africa. A validated, anonymized, 7-item survey was self-completed by routine care providers (physicians, nurses, and case managers). Questions were scored on a 5-point Likert scale with 5 consistently reflecting a positive attitude. Mean scores were calculated for each question and compared using a two-sample t-test to assess change in sample means for attitudes among providers surveyed before and after the intervention.

Results

A total of 132 surveys were completed across three EDs. Majority of respondents were female (70.5%), 20–29 years old (37.9%), of African race (81.1%), nurses (39.4%), and practicing medicine for 0–4 years (37.9%). Pre-intervention, providers displayed a positive attitude towards ‘the benefit of offering ED-based HCT to patients’ (4.33), ‘the ED offering HCT’ (3.53), ‘all ED patients receiving HCT’ (3.42), ‘concern about patient reaction to HCT’ (3.26), and ‘comfort with disclosing HCT results’ (3.21); and a mildly negative attitude towards ‘only high-risk ED patients receiving HCT’ (2.68), and ‘the burden of offering HCT in a clinical environment’ (2.80). Post-intervention, provider attitudes improved significantly towards ‘all ED patients receiving HCT’ (3.86, p < 0.05), ‘only high-risk ED patients receiving HCT’ (2.30, p < 0.05), ‘the burden of offering HCT in a clinical environment’ (3.21, p < 0.05), and ‘comfort with disclosing HCT results’ (3.81, p < 0.05).

Conclusions

Controlled exposure to new practices with a structured implementation period can shift attitudes beginning a process of practice normalization. In our study, we observed improvements in provider attitudes regarding the benefits of HCT and the burden of offering HCT to all patients in the ED. Research activities may have a role in mitigating resistance to change and supporting intervention adoption.

Third Trimester Structural and Diffusion Brain Imaging after Single Intrauterine Fetal Death in Monochorionic Twins: MRI-Based Cohort Study

BACKGROUND AND PURPOSE

Single intrauterine fetal death increases the risk of antenatal brain lesions in the surviving twin. We evaluated the prevalence of structural brain lesions, biometry, and diffusivity on routine third trimester MR imaging performed following single intrauterine fetal death.

MATERIALS AND METHODS

In a retrospective MR imaging-based cohort study, we compared 29 monochorionic twins complicated with single intrauterine fetal death (14 following laser ablation treatment for twin-to-twin transfusion syndrome, 8 following selective fetal reduction, and 7 spontaneous) with 2 control cohorts (49 singleton fetuses and 28 uncomplicated twin fetuses). All fetuses in the single intrauterine fetal death group underwent fetal brain MR imaging as a routine third trimester evaluation. Structural brain lesions were analyzed. Cerebral biometry and diffusivity were measured and compared.

RESULTS

Brain lesions consistent with the evolution of prior ischemic injury were found in 1 of 29 fetuses, not detected by ultrasound. No acute brain infarction, hemorrhage, or cortical abnormalities were found. Supratentorial biometric measurements in the single intrauterine fetal death group were significantly smaller than those in the singleton group, but not significantly different from those in the uncomplicated twin group. There were no significant differences in ADC values of the cerebral hemispheres, basal ganglia, and pons between the single intrauterine fetal death group and either control group.

CONCLUSIONS

Although smaller brain biometry was found, normal diffusivity in surviving twins suggests normal parenchymal microstructure. The rate of cerebral structural injury was relatively low in our cohort, arguing against the routine use of fetal brain MR imaging in twin pregnancies complicated with single intrauterine fetal death. Larger prospective studies are necessary to guide appropriate surveillance protocol and parental counseling in twin pregnancies complicated by single intrauterine fetal death.

GPCR kinase knockout cells reveal the impact of individual GRKs on arrestin binding and GPCR regulation

G protein-coupled receptors (GPCRs) activate G proteins and undergo a complex regulation by interaction with GPCR kinases (GRKs) and the formation of receptor-arrestin complexes. However, the impact of individual GRKs on arrestin binding is not clear. We report the creation of eleven combinatorial HEK293 knockout cell clones lacking GRK2/3/5/6, including single, double, triple and the quadruple GRK knockout. Analysis of β-arrestin1/2 interactions for twelve GPCRs in our GRK knockout cells enables the differentiation of two main receptor subsets: GRK2/3-regulated and GRK2/3/5/6-regulated receptors. Furthermore, we identify GPCRs that interact with β-arrestins via the overexpression of specific GRKs even in the absence of agonists. Finally, using GRK knockout cells, PKC inhibitors and β-arrestin mutants, we present evidence for differential receptor-β-arrestin1/2 complex configurations mediated by selective engagement of kinases. We anticipate our GRK knockout platform to facilitate the elucidation of previously unappreciated details of GRK-specific GPCR regulation and β-arrestin complex formation.

Real-world implementation of video-observed therapy in an urban TB program in the United States

BACKGROUND:

Video directly observed therapy (vDOT) was introduced to increase flexibility and meet patient-specific needs for TB treatment. This study aimed to assess the reach and effectiveness of vDOT for TB treatment under routine conditions in Alameda County, CA, USA, a busy, urban setting, from 2018 to 2020.

METHODS:

We prospectively evaluated routinely collected data to estimate 1) reach (proportion of patients initiated on vDOT vs. in-person DOT); and 2) effectiveness (proportion of prescribed doses with verified administration by vDOT vs. in-person DOT).

RESULTS:

Among 163 TB patients, 94 (58%) utilized vDOT during treatment, of whom 54 (57%) received exclusively vDOT. Individuals receiving vDOT were on average younger than those receiving in-person therapy (46 vs. 61 years; P < 0.001). The median time to vDOT initiation was 2.2 weeks (IQR 1.1–10.0); patients were monitored for a median of 27.0 weeks (IQR 24.6–31.9). vDOT led to higher proportions of verified prescribed doses than in-person DOT (68% vs. 54%; P < 0.001). Unobserved self-administration occurred for all patients on weekends based on clinic instructions, but a larger proportion of doses were self-administered during periods of in-person DOT than of vDOT (45% vs. 24%; P < 0.001).

CONCLUSION:

A TB program successfully maintained vDOT, reaching the majority of patients and achieving greater medication verification than in-person DOT.

Real-world efficacy of docetaxel plus nintedanib after chemo-immunotherapy failure in advanced pulmonary adenocarcinoma

Aim: This real-world analysis evaluated docetaxel plus nintedanib in patients with advanced pulmonary adenocarcinoma after chemotherapy and immune checkpoint inhibitor failure, for whom treatment options are limited. Methods: Data were sourced retrospectively from seven German centers. Results: Of 93 patients, overall response rate was 41.4% (disease control rate: 75.9%). Of 57 patients given third-line docetaxel plus nintedanib, overall response rate was 50.0% (disease control rate: 82.7%). Median overall survival following third-line docetaxel plus nintedanib was 8.4 months. Adverse events were consistent with the known safety profile of docetaxel plus nintedanib. Conclusion: To date, this was the largest retrospective, real-world analysis of docetaxel plus nintedanib after chemotherapy-immunotherapy failure, indicating that docetaxel plus nintedanib offers meaningful clinical benefits in this setting.

Prognostic value of tumor mutational burden in patients with oral cavity squamous cell carcinoma treated with upfront surgery

Background

Oral cavity is the most prevalent site of head and neck squamous cell carcinomas (HNSCCs). Most often diagnosed at a locally advanced stage, treatment is multimodal with surgery as the cornerstone. The aim of this study was to explore the molecular landscape of a homogenous cohort of oral cavity squamous cell carcinomas (OCSCCs), and to assess the prognostic value of tumor mutational burden (TMB), along with classical molecular and clinical parameters.

Patients and methods

One hundred and fifty-one consecutive patients with OCSCC treated with upfront surgery at the Institut Curie were analyzed. Sequencing of tumor DNA from frozen specimens was carried out using an in-house targeted next-generation sequencing panel (571 genes). The impact of molecular alterations and TMB on disease-free survival (DFS) and overall survival (OS) was evaluated in univariate and multivariate analyses.

Results

Pathological tumor stage, extranodal spread, vascular emboli, and perineural invasion were associated with both DFS and OS. TP53 was the most mutated gene (71%). Other frequent molecular alterations included the TERT promoter (50%), CDKN2A (25%), FAT1 (17%), PIK3CA (14%), and NOTCH1 (15%) genes. Transforming growth factor-β pathway alterations (4%) were associated with poor OS (P = 0.01) and DFS (P = 0.02) in univariate and multivariate analyses. High TMB was associated with prolonged OS (P = 0.01 and P = 0.02, in the highest 10% and 20% TMB values, respectively), but not with DFS. Correlation of TMB with OS remained significant in multivariate analysis (P = 0.01 and P = 0.005 in the highest 10% and 20% TMB values, respectively). Pathological tumor stage combined with high TMB was associated with good prognosis.

Conclusion

Our results suggest that a high TMB is associated with a favorable prognosis in patients with OCSCC treated with upfront surgery.

•

High TMB is associated with a favorable prognosis in patients with OCSCC treated with upfront surgery

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Pathological tumor stage combined with high TMB is associated with good prognosis

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TP53 was the most mutated gene (71%). Other frequent molecular alterations included the TERT promoter (50%)

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TGFβ pathway alterations were associated with poor outcomes, although it was only observed in 4% of the patients

Afatinib as first-line treatment in patients with EGFR-mutated non-small cell lung cancer in routine clinical practice

Background:

Lung cancer is a leading cause of cancer-related death in Germany and worldwide. Non-small cell lung cancer (NSCLC) comprises ~80% of lung cancer diagnoses; in White patients, around 10% of NSCLC cases are epidermal growth factor receptor mutation-positive (EGFRm+). Head-to-head clinical trials have demonstrated superior efficacy with second-/third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) versus first-generation EGFR TKIs in EGFRm+ NSCLC. Data from routine clinical practice are necessary to confirm that clinical trial findings are transferable to real-world populations.

Methods:

In NCT02047903, a prospective non-interventional study in Germany, patients with EGFRm+ NSCLC received first-line afatinib until disease progression or intolerable adverse events. Key objectives were progression-free survival (PFS) rate at 12 months, objective response rate (ORR) and overall survival (OS). Safety/tolerability was also assessed.

Results:

Of 152 patients, 106 (69.7%) were female, 20 (13.1%) patients had an uncommon EGFR mutation and 51 patients (33.6%) had brain metastases. A starting dose of <40 mg was received by 39 (25.7%) patients. Overall, the 12-month PFS rate was 50.2% while the median PFS was 12.2 months. The ORR was 74.6% and the median OS was 30.4 months. In patients with brain metastases and uncommon mutations, the median PFS was 10.5 and 10.7 months, and the ORR was 77.3% and 83.3%, respectively. Treatment effectiveness was similar in patients with a starting dose of <40 mg (median PFS: 16.4 months; ORR, 81.3%) and a starting dose of 40 mg (median PFS: 10.8 months; ORR, 72.1%). Adverse drug reactions were manageable and consistent with the known afatinib safety profile.

Conclusion:

The results support clinical trial data for afatinib in routine clinical practice, including in patients generally excluded from clinical trials. Outcomes were positive in patients with uncommon EGFR mutations and in those with brain metastases. Treatment benefit was also seen in patients receiving a <40 mg afatinib starting dose, supporting patient-tailored dosing.

Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Human leukocyte antigen associations with protection against tuberculosis infection and disease in human immunodeficiency virus-1 infected individuals, despite household tuberculosis exposure and immune suppression

BACKGROUND

To determine the association of human leukocyte antigen (HLA) alleles as correlates of risk for and protection against tuberculin skin test (TST) positivity and active TB disease amongst HIV-infected adults.

METHODS

Genomic DNA was extracted from 754 HIV-infected adults whole-blood. HLA-A, -B, -C and -DRB1 loci were genotyped by next generation sequencing methods. HLA alleles were analysed by the presence/absence of TST immune conversion and active TB disease and further stratified by exposure to a household TB contact, CD4⁺ T-cell count and, for active TB disease, TST-positivity.

RESULTS

HLA-A*29:11 and - B*45:01/07 were associated with TST-positivity, while HLA-A*24:02, -A*29:02 and -B*15:16 with TST-negativity. In participants with a household TB contact, HLA-A*66:01, -A*68:02 and -B*49:01 were associated with TST-negativity. For TB disease, HLA-B*41:01, -C*06:02, -DRB1*04:01 and -DRB1*15:01 were associated with susceptibility, while HLA-B*07:02 and -DRB1*11:01 were protective, even for CD4⁺ T-cell count <350 cells/mm³. For initial TST-positivity and subsequent TB disease, HLA-A*01:01 and -DRB1*11:01 conveyed protection including for those with CD4⁺ T-cell count <350 cells/mm³.

CONCLUSION

Several HLA alleles are noted as correlates of TB infection, risk and natural protection in HIV-infected individuals. HLA associations may enable risk stratification of those with HIV infection. Protective alleles may assist in future TB vaccine development.

A systematic review and in-depth analysis of outcome reporting in early phase studies of colorectal cancer surgical innovation

AIM

Early phase studies are essential to evaluate new technologies prior to randomized evaluation. Evaluation is limited, however, by inconsistent measurement and reporting of outcomes. This study examines outcome reporting in studies of innovative colorectal cancer surgery.

METHODS

Systematic searches identified studies of invasive procedures treating primary colorectal adenocarcinoma. Included were a random sample of studies which authors reported as 'new' or 'modified'. Outcomes were extracted verbatim and categorized using an existing framework of 32 domains relevant to early phase studies. Outcomes were classified as 'measured' (where there was an explicit statement to that effect or evidence that data collection had occurred) or 'mentioned but not measured' (where outcomes were discussed but data collection was not evident). Patterns of identified outcomes are described.

RESULTS

Of 8373 records, 816 were potentially eligible. Full-text review of a random sample of 218 studies identified 51 for inclusion of which 34 (66%) were 'new' and 17 (33%) were 'modified'. Some 2073 outcomes were identified, and all mapped to domains. 'Anticipated disadvantages' were most frequently identified [660 (32%) outcomes identified across 50 (98%) studies]. No domain was represented in all studies. Under half (944, 46%) of outcomes were 'measured'. 'Surgeon's/operator's experience of the innovation' was more frequently 'mentioned but not measured' [207 (18%) outcomes across 46 (90%) studies] than 'measured' [17 (2%) outcomes, 11 (22%) studies].

CONCLUSION

There is outcome reporting heterogeneity in studies of early phase colorectal cancer surgery. The adoption of core outcome sets may help to resolve these inconsistencies and enable efficient evaluation of surgical innovations.

Comparison between transthoracic echocardiography and transcranial Doppler for detection of PFO in patients in the acute phase of a pulmonary embolism. A Post-hoc analysis of EPIC-FOP

Introduction

Patent foramen ovale is a fairly common defect found in a quarter of the population. PFO has always been associated with an increased risk of stroke, the mechanism of which has been attributed to the paradoxical embolism of venous thrombi passing through the PFO directly into the left atrium, however this mechanism remains debated to date.

For the detection of PFO, several modalities exist including transcranial doppler (TCD), transthoracic echocardiography (TTE) and transoesophageal echocardiography. This raises the question of the examination with the best diagnostic performance for its detection.

Purpose

The majority of studies comparing the different modalities of patient PFO diagnosis have been conducted in the context of stroke assessment. Very few studies have focused on the acute PE patient population. The interest of our study is therefore to evaluate the diagnostic performance of two modalities (TTE versus TCD) for the detection of shunts, especially since this population is at risk of stroke by paradoxical embolism due to the phenomenon of hyperpressure in the right heart chambers increasing the chances of having a paradoxical embolism.

Methods

We performed a post HOC analysis of the EPIC-FOP study which is a multicenter, prospective, French cohort study. Patients were recruited within 3 days of diagnosis of PE. Patients included were given a transthoracic echocardiography (TTE) with PFO screening by injection of saline contrast and magnetic resonance imaging (MRI) within 7 days of inclusion to look for signs of recent stroke. A proportion of the patients included in this study also received a transcranial doppler in search of PFO, the results of which were used in our study.

Results

The mean age of the patients was 62±14.66 years with a slight male predominance (55.6%). TCD was able to detect 97 right-left shunts while the TTE detected only 25 shunts. Concordance analysis by Cohen's Kappa Coefficient: 0.1767 [0.0427; 0.3107–p&lt;0.001] is considered poor.

Using TTE as the reference examination, transcranial Doppler has a very good sensitivity 96.00% (79.65% to 99.90%) and a poor specificity 42.06% (33.33% to 51.18%). A good negative likelihood ratio 0.10 (0.01 to 0.66).

Using TCD, incidence of stroke in the acute phase of PE was significantly higher in the PFO population. In the ten strokes detected 9 had occurred in patients with PFO, RR=1.43 IC95% (1.1169 to 1.8228) p=0. 0044. The difference in proportion is calculated to be 26.92%.

Conclusion

It is the first study that compared TCD vs TEE in the setting of acute phase of PE for detection of PFO. TCD showed a good sensitivity and negative likelihood ratio that can be used as a first means to rule out PFO or associated with TTE. Also, our analysis confirms the increased risk of stroke following a PE episode when a PFO is present.

Funding Acknowledgement

Type of funding source: None

Outcome selection, measurement and reporting for new surgical procedures and devices: a systematic review of IDEAL/IDEAL-D studies to inform development of a core outcome set

BACKGROUND

Outcome selection, measurement and reporting for the evaluation of new surgical procedures and devices is inconsistent and lacks standardization. A core outcome set may promote the safe and transparent evaluation of surgical innovations. This systematic review examined outcome selection, measurement and reporting in studies conducted within the IDEAL (Idea, Development, Exploration, Assessment and Long-term monitoring) framework to examine current practice and inform the development of a core outcome set for early-phase studies of surgical procedures/devices.

METHODS

Web of Science and Scopus citation searches were performed to identify author-reported IDEAL/IDEAL-D studies for any surgical procedure/device. Outcomes were extracted verbatim, including contextual information regarding outcome selection and measurement. Outcomes were categorized to inform a conceptual framework of outcome domains relevant to evaluating innovation.

RESULTS

Some 48 studies were identified. Outcome selection, measurement and reporting varied widely across studies in different IDEAL stages. From 1737 outcomes extracted, 22 domains specific to evaluating innovation were conceptualized under seven broad categories: procedure completion success/failure; modifications; unanticipated events; surgeons' experiences; patients' experiences; resource use specific to the innovative procedure/device; and other innovation-specific outcomes. Most innovation-specific outcomes were measured and reported in only a small number of studies.

CONCLUSION

This review highlighted the need for guidance and standardization in outcome selection and reporting in the evaluation of new surgical procedures/devices. Novel outcome domains specific to innovation have been identified to establish a core outcome set for future evaluations of surgical innovations.

Immunomodulatory activity of β-glucan-containing exopolysaccharides from Auricularia auricular in phagocytes and mice infected with Cryptococcus neoformans

Current antifungal drugs present poor effectiveness and there is no available vaccine for fungal infections. Thus, novel strategies to treat or prevent invasive mycosis, such as cryptococcosis, are highly desirable. One strategy is the use of immunomodulators of polysaccharide nature isolated from mushrooms. The purpose of the present work was to evaluate the immunostimulatory activity of β-(1,3)-glucan-containing exopolysaccharides (EPS) from the edible mushrooms Auricularia auricula in phagocytes and mice infected with Cryptococcus neoformans. EPS triggered macrophages and dendritic cell activation upon binding to Dectin-1, a pattern recognition receptor of the C-type lectin receptor family. Engagement of Dectin-1 culminated in pro-inflammatory cytokine production and cell maturation via its canonical Syk-dependent pathway signaling. Furthermore, upon EPS treatment, M2-like phenotype macrophages, known to support intracellular survival and replication of C. neoformans, repolarize to M1 macrophage pattern associated with enhanced production of the microbicidal molecule nitric oxide that results in efficient killing of C. neoformans. Treatment with EPS also upregulated transcript levels of genes encoding products associated with host protection against C. neoformans and Dectin-1 mediated signaling in macrophages. Finally, orally administrated β-glucan-containing EPS from A. auricular enhanced the survival of mice infected with C. neoformans. In conclusion, the results demonstrate that EPS from A. auricula exert immunostimulatory activity in phagocytes and induce host protection against C. neoformans, suggesting that polysaccharides from this mushroom may be promising as an adjuvant for vaccines or antifungal therapy.

Diagnostic accuracy of plasma kynurenine/tryptophan ratio, measured by enzyme-linked immunosorbent assay, for pulmonary tuberculosis

INTRODUCTION

The World Health Organization has identified the need for a non-sputum-based test capable of detecting active tuberculosis (TB) as a priority. The plasma kynurenine-to-tryptophan (K/T) ratio, largely mediated by activity of the enzyme indoleamine 2,3-dioxygenase, may have potential as a suitable biomarker for active TB.

METHOD

We evaluated a commercial enzyme-linked immunosorbent assay (ELISA) in comparison to mass spectrometry for measuring the K/T ratio. We also used ELISA to determine the K/T ratio in plasma from patients with active TB compared to latently infected controls, with and without HIV.

RESULTS

The two methods showed good agreement, with a mean bias of 0.01 (limit of agreement from -0.06 to 0.10). Using ELISA, it was found that HIV-infected patients with active TB disease had higher K/T ratios than those without TB (median, 0.101 [interquartile range (IQR), 0.091-0.140] versus 0.061 [IQR, 0.034-0.077], P<0.0001). At a cutoff of 0.080, the K/T ratio produced a sensitivity of 90%, a specificity of 80%, a positive predictive value (PPV) of 82%, and a negative predictive value (NPV) of 90%. In a receiver operating characteristics analysis, the K/T ratio had an area under the curve of 0.93. HIV-uninfected patients with active TB also had higher K/T ratios than those with latent TB infections (median, 0.064 [IQR, 0.040-0.088] versus 0.022 [IQR, 0.016-0.027], P<0.0001). A cutoff of 0.040 gave a sensitivity of 85%, a specificity of 92%, a PPV of 91%, and an NPV of 84%.

CONCLUSION

The plasma K/T ratio is a sensitive biomarker for active TB. The K/T ratio can be measured from blood using ELISA. The K/T ratio should be evaluated as an initial test for TB.

[Direct oral anticoagulants: In which indications? Which one to prescribe? For or against their use in frail patients and in atypical cases? Which monitoring and management haemorrhage complications?]

Since their approval, the direct oral anticoagulants have been widely used in the management of venous thromboembolism, for stroke and systemic embolism prevention in non valvular atrial fibrillation, and in venous thromboembolism prophylaxis after surgical hip or knee replacement. Because they are easy to use, with oral fixed doses and no biological monitoring need, they are more and more prescribed. New indications are rising in cancer associated thrombosis in France beyond the 6 first months of treatment, and to prevent cardiovascular events after an acute coronary syndrome, or in stable coronary or peripheral arterial disease in Europe. The efficacity and safety of direct oral anticoagulants in frail patients or in unusual pathological contexts are not entirely known, but further data are coming and will probably bring new answers.

Efficacy of afatinib in the clinical practice: Final results of the GIDEON study in EGFR mutated non-small cell lung cancer (NSCLC) in Germany

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Background: Afatinib is an irreversible ErbB family blocker, which is approved for the treatment of advanced non-small cell lung cancer (NSCLC) patients with activating EGFR mutations. Here we report the final results of the prospective non-interventional study (NIS) GIDEON, which was initiated to investigate the efficacy and tolerability of afatinib in the daily clinical routine in Germany. Methods: EGFR-mutated NSCLC patients were treated with afatinib according to label until progression, death or discontinuation. Efficacy (progression-free survival (PFS) rate at 12 months, objective response rate, ORR; disease control rate, DCR; progression-free survival, PFS and overall survival, OS) was prospectively assessed by investigators. Data about tolerability were collected during routine treatment. Results: In total, 161 patients were enrolled at 41 sites in Germany, 152 patients received at least one dose of afatinib (treated set; TS) and 146 patients were treated according to the protocol (PPS). The majority of patients for the entire TS had exon 19 deletions (64.5%), followed by L858R point mut. (22.4%) and uncommon mut. (exon 18-21 point mut.; 13.1%). The primary objective was PFS-rate at 12 months, which was 50.2% in the PPS. Median PFS amounted to 12.2 months. ORR and DCR were 74.6% and 91.5% in the PPS, respectively. Median OS was 30.4 months with 1- and 2-year survival rates of 79.1% and 57.7%, respectively. Among pat. with uncommon EGFR-mut., the 12-months PFS rate was 40.2% with a mPFS of 10.7 months. ORR and DCR were 83.3% and 91.7%, respectively. The most frequent documented adverse drug reactions (ADRs) were diarrhea and rash/acne with 13.8% and 7.2% of grade 3 but no grade 4 or higher. Conclusions: Afatinib is a standard therapy for patients with activating EGFR mut. in Germany. The final results of this prospective NIS confirm the robust clinical data for afatinib in the clinical routine setting, including patients with uncommon exon 18-21 point mutations. Clinical trial information: NCT02047903.

Two-level ACDF with a zero-profile stand-alone spacer compared to conventional plating: a prospective randomized single-center study

PURPOSE

Stand-alone zero-profile devices have already proven safety, and a reduced dysphagia rate was assumed. So far, no level-one evidence is available to prove the proposed advantages of zero-profile implants in multilevel procedures. The aim of this RCT was to compare the clinical and radiological outcome of a zero-profile spacer versus cage + plate in two-level ACDF.

METHODS

Consecutive patients with contiguous two-level cDD were randomly assigned either to the interventional group (zero-profile device) or to the control group (cage + plate). Primary endpoint of the study was the prevalence of dysphagia at 24 months. Disability, progress of adjacent segment degeneration, fusion status and loss of correction were analyzed as secondary outcome measure. Primary outcome parameter was statistically analyzed by Chi-square test.

RESULTS

Forty-one patients met inclusion criteria and were randomly assigned to the interventional and the control group. Dysphagia was frequent in either group at 3 months FU favoring interventional group (p = 0.078). At final FU, less patients of the interventional group complained about dysphagia, but the difference was not significant. No relevant differences at final FU were recorded for NPDI, loss of correction and adjacent-level degeneration. Fusion rate was slightly lower in the interventional group.

DISCUSSION

Two-level ACDF either by a stand-alone zero-profile spacer or cage + plate is safe. Using a zero-profile cage dysphagia was infrequent at 24 months, but the value did not reach statistical significance in comparison with the cage + plate. Hence, this randomized trial was not able to prove the proposed clinical superiority for dysphagia rates for zero-profile anchored spacer in two-level cDD.

Neuroimaging Findings in Children with Constitutional Mismatch Repair Deficiency Syndrome

BACKGROUND AND PURPOSE

Constitutional mismatch repair deficiency is a hereditary childhood cancer predisposition syndrome characterized by brain tumors and colorectal and hematologic malignancies. Our objective was to describe the neuroimaging findings in patients with constitutional mismatch repair deficiency.

MATERIALS AND METHODS

This retrospective study included 14 children with genetically confirmed constitutional mismatch repair deficiency who were referred to 2 tertiary pediatric oncology centers.

RESULTS

Fourteen patients from 11 different families had diagnosed constitutional mismatch repair deficiency. The mean age at presentation was 9.3 years (range, 5-14 years). The most common clinical presentation was brain malignancy, diagnosed in 13 of the 14 patients. The most common brain tumors were glioblastoma (n = 7 patients), anaplastic astrocytoma (n = 3 patients), and diffuse astrocytoma (n = 3 patients). Nonspecific subcortical white matter T2 hyperintensities were noted in 10 patients (71%). Subcortical hyperintensities transformed into overt brain tumors on follow-up imaging in 3 patients. Additional non-neoplastic brain MR imaging findings included developmental venous anomalies in 12 patients (85%) and nontherapy-induced cavernous hemangiomas in 3 patients (21%).

CONCLUSIONS

On brain MR imaging, these patients have both highly characteristic intra-axial tumors (typically multifocal high-grade gliomas) and nonspecific findings, some of which might represent early stages of neoplastic transformation. The incidence of developmental venous anomalies is high in these patients for unclear reasons. Awareness of these imaging findings, especially in combination, is important to raise the suspicion of constitutional mismatch repair deficiency in routine diagnostic imaging evaluation or surveillance imaging studies of asymptomatic carriers because early identification of the phenotypic "gestalt" might improve outcomes.

Poor Obstetric and Infant Outcomes in Human Immunodeficiency Virus-Infected Pregnant Women With Tuberculosis in South Africa: The Tshepiso Study

Background

Before the wide availability of antiretroviral therapy (ART), tuberculosis and human immunodeficiency virus (HIV) disease among pregnant women resulted in poor maternal and neonatal outcomes, including high rates of mother-to-child transmission of both HIV and tuberculosis. We aimed to describe the impact of tuberculosis among HIV-infected mothers on obstetric and infant outcomes in a population with access to ART.

Methods

In this prospective cohort study, we followed up HIV-infected pregnant women with or without tuberculosis disease from January 2011 through January 2014 in Soweto, South Africa. Two controls were enrolled for each case patient, matched by enrollment time, maternal age, gestational age, and planned delivery clinic and followed up for 12 months after delivery.

Results

We recruited 80 case patients and 155 controls, resulting in 224 live-born infants. Infants of mothers with HIV infection and tuberculosis disease had a higher risk of low birth weight (20.8% vs 10.7%; P = .04), prolonged hospitalization at birth (51% vs 16%; P < .001), infant death (68 vs 7 deaths per 1000 births; P < .001), and tuberculosis disease (12% vs 0%; P < .001) despite appropriate maternal therapy and infant tuberculosis preventive therapy. HIV transmission was higher among these infants (4.1% vs 1.3%; P = .20), though this difference was not statistically significant. Obstetric outcomes in coinfected women were also poorer with higher risks of maternal hospitalization (25% vs 11%; P = .005) and preeclampsia (5.5% vs 0.7%; P = .03).

Conclusions

Tuberculosis in HIV coinfected pregnant women remains a significant threat to the health of both mothers and infants. Improving tuberculosis prevention and early diagnosis among pregnant women is critical.

HIV testing services in healthcare facilities in South Africa: a missed opportunity

INTRODUCTION

South Africa (SA) has the world's highest burden of HIV infection (approximately 7.2 million), yet it is estimated that 23.5% women and 31.5% of men are unaware that they are living with HIV. The 2015 national South African HIV testing guidelines mandate the universal offer of HIV testing services (HTS) in all healthcare facilities.

METHODS

A multi-prong approach was used from January 2017 to June 2017 to evaluate the current implementation of HTS in ten facilities in the Ekurhuleni District of SA. First, we conducted patient exit interviews to quantify engagement in HTS services. Second, we systematically mapped the flow of individual patients through the clinic.

RESULTS

We conducted a total of 2989 exit interviews and followed 568 patients for value stream mapping. Overall self-reported testing acceptance was high at 84.7% (244), but <10% of the patients (288) were offered testing. Female patients were more likely to be offered testing (233/2046, 11.4% vs. 55/943, 5.8% in males; chi-square p < 0.005), and also more likely to accept testing (203/233, 87.1% vs. 41/55, 74.6% in males; chi-square p = 0.02). Value stream mapping revealed that patients offered HIV testing had a total visit time of 51 minutes more (95% CI: 30-72) compared to those not offered testing.

CONCLUSIONS

The poor delivery of HTS appears to be due to a failure to recommend HTS and the added time burden placed on those accepting testing. There were significant differences in both the offer and acceptance of testing by gender. Health system issues need to be addressed to improve HTS delivery.

Association of Mycoplasma Hominis and head and neck cancer with unknown primary

INTRODUCTION

Beside HPV infection, there is currently no evidence of association between head and neck squamous cell carcinomas and microbial infections. We report the case of a cervical squamous cell carcinoma by Mycoplasma hominis.

CASE SUMMARY

A 20-year-old woman, consulted for a swelling on the left cervical side. Clinical examination found a large fixed mass. Biological tests found no evidence of infection. Biopsies of the cervical lesion diagnosed an HPV negative squamous cell carcinoma. Microbiological tests of 16sRNA identification showed the presence of Mycoplasma hominis in the 3 specimens. The patient was treated by induction chemotherapy associated to antibiotherapy, followed by chemo-radiotherapy.

DISCUSSION

The present case suggests that oropharyngeal infection by Mycoplasma hominis might be more frequent than expected, that 16sRNA is an efficient technique to isolate this pathogen and finally that further studies are required to document its potential oncogenic role in head and neck squamous cell carcinomas.