Clinical outcomes with utilization of high-potency topical steroids in patients with lichen sclerosus-associated vulvar cancer

OBJECTIVES

To evaluate the impact of high-potency topical steroid use on risk of recurrence of lichen sclerosus-associated vulvar cancer.

METHODS

This is a retrospective cohort study evaluating patients with lichen sclerosus (LS)- associated vulvar squamous cell cancer (VSCC). Demographic and clinical outcome data were compared between two comparison groups: patients who received steroids, mainly clobetasol, and patients who did not receive steroids following treatment of LS-related vulvar cancer. Categorical variables were compared using Fisher's exact test or chi-square test. Continuous variables were compared using a two-sided student's t-test. Time to recurrence (TTR) and overall survival (OS) were analyzed using Kaplan-Meier survival plot and compared using Mantel-Cox log rank test. Cox proportional hazard regression models were conducted to generate hazard ratios for both TTR and OS. A p value of <0.05 was considered statistically significant.

RESULTS

A total of 49 patients were included, with 36 patients receiving steroid treatment and 13 patients in the expectant management group. The median age of diagnosis was 68. The average BMI was 31.7 +/- 7.0. The median length of follow up was 41 months. The majority of patients were diagnosed with stage I VSCC. There was no difference in demographics or oncologic management of vulvar cancer between the two cohorts. Overall recurrence was decreased among patients who received steroid treatment when compared to patients who did not, 12 patients (33.3%) versus 9 patients (69.2%) respectively (p = 0.048).

CONCLUSIONS

High-potency topical steroid use following treatment of lichen sclerosus-associated vulvar squamous cell carcinoma is associated with decreased risk of recurrence and prolonged median time to recurrence.

Microsecond Isomer at the N=20 Island of Shape Inversion Observed at FRIB

Excited-state spectroscopy from the first experiment at the Facility for Rare Isotope Beams (FRIB) is reported. A 24(2)-μs isomer was observed with the FRIB Decay Station initiator (FDSi) through a cascade of 224- and 401-keV γ rays in coincidence with ^{32}Na nuclei. This is the only known microsecond isomer (1  μs≤T_{1/2}<1  ms) in the region. This nucleus is at the heart of the N=20 island of shape inversion and is at the crossroads of the spherical shell-model, deformed shell-model, and ab initio theories. It can be represented as the coupling of a proton hole and neutron particle to ^{32}Mg, ^{32}Mg+π^{-1}+ν^{+1}. This odd-odd coupling and isomer formation provides a sensitive measure of the underlying shape degrees of freedom of ^{32}Mg, where the onset of spherical-to-deformed shape inversion begins with a low-lying deformed 2^{+} state at 885 keV and a low-lying shape-coexisting 0_{2}^{+} state at 1058 keV. We suggest two possible explanations for the 625-keV isomer in ^{32}Na: a 6^{-} spherical shape isomer that decays by E2 or a 0^{+} deformed spin isomer that decays by M2. The present results and calculations are most consistent with the latter, indicating that the low-lying states are dominated by deformation.

Effects of the menstrual cycle phase on anterior cruciate ligament neuromuscular and biomechanical injury risk surrogates in eumenorrheic and naturally menstruating women: A systematic review

BACKGROUND

Eumenorrheic women experience cyclic variations in sex hormones attributed to the menstrual cycle (MC) which can impact anterior cruciate ligament (ACL) properties, knee laxity, and neuromuscular function. This systematic review aimed to examine the effects of the MC on ACL neuromuscular and biomechanical injury risk surrogates during dynamic tasks, to establish whether a particular MC phase predisposes women to greater ACL injury risk.

METHODS

PubMed, Medline, SPORTDiscus, and Web of Science were searched (May-July 2021) for studies that investigated the effects of the MC on ACL neuromuscular and biomechanical injury risk surrogates. Inclusion criteria were: 1) injury-free women (18-40 years); 2) verified MC phases via biochemical analysis and/or ovulation kits; 3) examined neuromuscular and/or biomechanical injury risk surrogates during dynamic tasks; 4) compared ≥1 outcome measure across ≥2 defined MC phases.

RESULTS

Seven of 418 articles were included. Four studies reported no significant differences in ACL injury risk surrogates between MC phases. Two studies showed evidence the mid-luteal phase may predispose women to greater risk of non-contact ACL injury. Three studies reported knee laxity fluctuated across the MC; two of which demonstrated MC attributed changes in knee laxity were associated with changes in knee joint loading (KJL). Study quality (Modified Downs and Black Checklist score: 7-9) and quality of evidence were low to very low (Grading of Recommendations Assessment Development and Evaluation: very low).

CONCLUSION

It is inconclusive whether a particular MC phase predisposes women to greater non-contact ACL injury risk based on neuromuscular and biomechanical surrogates. Practitioners should be cautious manipulating their physical preparation, injury mitigation, and screening practises based on current evidence. Although variable (i.e., magnitude and direction), MC attributed changes in knee laxity were associated with changes in potentially hazardous KJLs. Monitoring knee laxity could therefore be a viable strategy to infer possible ACL injury risk.

Treatment of anastomotic leak after esophagectomy: insights of an international case vignette survey and expert discussions

Anastomotic leak (AL) is a severe complication after esophagectomy. Clinical presentation of AL is diverse and there is large practice variation regarding treatment of AL. This study aimed to explore different AL treatment strategies and their underlying rationale. This mixed-methods study consisted of an international survey among upper gastro-intestinal (GI) surgeons and focus groups with expert upper GI surgeons. The survey included 10 case vignettes and data sources were integrated after separate analysis. The survey was completed by 188 respondents (completion rate 69%) and 6 focus groups were conducted with 20 international experts. Prevention of mortality was the most important goal of primary treatment. Goals of secondary treatment were to promote tissue healing, return to oral feeding and safe hospital discharge. There was substantial variation in the preferred treatment principles (e.g. drainage or defect closure) and modalities (e.g. stent or endoVAC) within different presentations of AL. Patients with local symptoms were treated by supportive means only or by non-surgical drainage and/or defect closure. Drainage was routinely performed in patients with intrathoracic collections and often combined with defect closure. Patients with conduit necrosis were predominantly treated by resection and reconstruction of the anastomosis or by esophageal diversion. This mixed-methods study shows that overall treatment strategies for AL are determined by vitality of the conduit and presence of intrathoracic collections. There is large variation in preferred treatment principles and modalities. Future research may investigate optimal treatment for specific AL presentations and aim to develop consensus-based treatment guidelines for AL after esophagectomy.

Crossing N=28 Toward the Neutron Drip Line: First Measurement of Half-Lives at FRIB

New half-lives for exotic isotopes approaching the neutron drip-line in the vicinity of N∼28 for Z=12-15 were measured at the Facility for Rare Isotope Beams (FRIB) with the FRIB decay station initiator. The first experimental results are compared to the latest quasiparticle random phase approximation and shell-model calculations. Overall, the measured half-lives are consistent with the available theoretical descriptions and suggest a well-developed region of deformation below ^{48}Ca in the N=28 isotones. The erosion of the Z=14 subshell closure in Si is experimentally confirmed at N=28, and a reduction in the ^{38}Mg half-life is observed as compared with its isotopic neighbors, which does not seem to be predicted well based on the decay energy and deformation trends. This highlights the need for both additional data in this very exotic region, and for more advanced theoretical efforts.

Identification of the New Isotope ^{244}Md

In an experiment performed at Lawrence Berkeley National Laboratory's 88-inch cyclotron, the isotope ^{244}Md was produced in the ^{209}Bi(^{40}Ar,5n) reaction. Decay properties of ^{244}Md were measured at the focal plane of the Berkeley Gas-filled Separator, and the mass number assignment of A=244 was confirmed with the apparatus for the identification of nuclide A. The isotope ^{244}Md is reported to have one, possibly two, α-decaying states with α energies of 8.66(2) and 8.31(2) MeV and half-lives of 0.4_{-0.1}^{+0.4} and ∼6  s, respectively. Additionally, first evidence of the α decay of ^{236}Bk was observed and is reported.

Publisher's Note: Direct Lifetime Measurements of the Excited States in ^{72}Ni [Phys. Rev. Lett. 116, 122502 (2016)]

This corrects the article DOI: 10.1103/PhysRevLett.116.122502.

Mirror-symmetry violation in bound nuclear ground states

Conservation laws are deeply related to any symmetry present in a physical system^1,2. Analogously to electrons in atoms exhibiting spin symmetries³, it is possible to consider neutrons and protons in the atomic nucleus as projections of a single fermion with an isobaric spin (isospin) of t = 1/2 (ref. ⁴). Every nuclear state is thus characterized by a total isobaric spin T and a projection T_z-two quantities that are largely conserved in nuclear reactions and decays^5,6. A mirror symmetry emerges from this isobaric-spin formalism: nuclei with exchanged numbers of neutrons and protons, known as mirror nuclei, should have an identical set of states⁷, including their ground state, labelled by their total angular momentum J and parity π. Here we report evidence of mirror-symmetry violation in bound nuclear ground states within the mirror partners strontium-73 and bromine-73. We find that a J^π = 5/2^- spin assignment is needed to explain the proton-emission pattern observed from the T = 3/2 isobaric-analogue state in rubidium-73, which is identical to the ground state of strontium-73. Therefore the ground state of strontium-73 must differ from its J ^π = 1/2^- mirror bromine-73. This observation offers insights into charge-symmetry-breaking forces acting in atomic nuclei.

Preliminary analysis of total neoadjuvant therapy for patients with locally advanced gastric (G) and gastroesophageal (GE) adenocarcinoma

393

Background: Nearly half of patients with G/GE cancer do not receive or complete post-operative chemotherapy and/or chemoradiation (CRT). Total neoadjuvant therapy (TNT) is as an emerging alternate treatment strategy. We have previously reported a 28% pCR with FOLFIRINOX followed by CRT. However, TNT outcomes with FLOT or FOLFOX followed by CRT are lacking. Methods: We retrospectively analyzed patients after resection of locally advanced G/GE after receiving TNT. Patient received neoadjuvant FOLFOX or FLOT x 8 cycles, CRT (G 45 Gy, GE 50.4 Gy) with concurrent chemotherapy (5FU, carboplatin/paclitaxel). The primary aim was to explore TNT completion rates. Secondary aims included pCR and toxicity. We performed descriptive statistics, t-test, chi-squared, and Fisher’s exact tests as appropriate. Results: From 12/2015 to 8/2019, 57.1% (40/70) completed TNT and resection (15.7% active treatment, 15.7% progressive disease, 11% treated elsewhere). Median age was 66.0 (range:27-79) and 73% male. Tumor locations included 57.5% G, 30.0% GE, and 12.5% overlapping. Neoadjuvant chemotherapy included FLOT 22.5% (n = 9) or FOLFOX 77.5% (n = 31). Overall we found a 25% pCR without significant differences between type of neoadjuvant chemotherapy. Conclusions: TNT followed by resection is feasible with acceptable rates of treatment completion and toxicity. Notable limitations include the retrospective analysis, small sample size, and heterogenous treatment. The pCR rate is promising and warrants further prospective study to optimize TNT approaches. [Table: see text]

Training for a new environment: Using military operational concepts in counseling veterans

Since September 11, 2001, the United States has engaged in an extended period of military conflict, resulting in 4.1 million men and women serving in support of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. Whereas not all servicemembers experience mental health issues, many have experienced difficulties with readjusting to the civilian world, often requiring mental health services both inside and outside of the Department of Veterans Affairs. Issues related to stigma and military culture contribute to barriers not only for veterans seeking treatment but for clinicians providing services who may lack experience with military culture. This article provides a framework to use military concepts in clinical sessions to further therapeutic engagement with the military/veteran client.

Prospective, multicenter, international phase 2 trial evaluating ultrasonic energy for pulmonary artery branch sealing in video-assisted thoracoscopic surgery lobectomy

OBJECTIVES

The study objectives were to evaluate the immediate, short-, and medium-term efficacy and safety of pulmonary artery branch sealing using an ultrasonic vessel-sealing device in minimally invasive anatomic lung resection.

METHODS

This study consists of a prospective, phase 2, multicenter, international clinical trial (clinicaltrials.gov: NCT02719717) that enrolled patients planned for video-assisted thoracoscopic surgery/robotic anatomic lung resection in 7 centers (United States, Canada, United Kingdom). Pulmonary artery branches of 7 mm or less were sealed and divided with an ultrasonic energy vessel-sealing device. The remainder of the lobectomy was performed according to surgeon preference. Intraoperative, in-hospital, and 30-day postoperative bleeding and complications were prospectively recorded.

RESULTS

A total of 150 patients with a minimum of 1 pulmonary artery branch sealed with an ultrasonic vessel-sealing device were prospectively enrolled in the trial. Resections included 139 lobectomies and 11 segmentectomies. A total of 424 pulmonary artery branches were divided: 239 with the ultrasonic vessel-sealing device, 181 with endostaplers, and 4 with endoscopic clips. The mean and median pulmonary artery diameters were 4.7 mm/5.0 mm, 10.3 mm/10.0 mm, and 6.5 mm/6.5 mm for each method, respectively. Three of the pulmonary artery branches divided with the ultrasonic vessel-sealing device (1.3%) and 4 pulmonary artery branches divided with endostaplers (2.2%) bled intraoperatively. Among the patients with seal failures, 1 patient required conversion to thoracotomy. There was no postoperative bleeding from divided pulmonary artery branches with either sealing method. There was no mortality at 30 days.

CONCLUSIONS

Pulmonary artery branch sealing with ultrasonic energy during video-assisted thoracoscopic surgery lobectomy is safe for vessels 7 mm or less. The use of an ultrasonic device is a reasonable sealing method for pulmonary artery branches 7 mm or less.

A pilot study of neoadjuvant FOLFIRINOX followed by chemoradiation for gastric and gastroesophageal cancer: Preliminary results

4057

Background: We performed a single-arm pilot study of total neoadjuvant approach including FOLFIRINOX and chemoradiation (CRT) with concurrent carboplatin/taxol (C/T) followed by surgery in patients with locally advanced gastric or gastroesophageal junction (GEJ) cancer. Methods: Patients were enrolled on a NCI sponsored, prospective, single arm study (NCT03279237). Key eligibility criteria included: histologically confirmed T3/4 or lymph node (LN) positive gastric or GEJ cancer, ECOG PS ≤1, age 18+, life expectancy > 3 months. Exclusion criteria included: visceral metastases, prior chemotherapy or RT, or prior targeted therapy. Extensive LN disease beyond the surgical field (supraclavicular or para-aortic) was permitted if deemed feasible to be encompassed within a RT field. Laparoscopy was not required. Pts were treated with neoadjuvant FOLFIRINOX x 8, restaging, CRT (45 Gy for gastric, 50.4 Gy for GEJ) with concurrent C/T, restaging, followed by surgical resection. Dose reductions were at discretion of the treating physician. The primary objective was to determine the rate of completion of FOLFIRINOX x 8 followed by CRT delivered in the preoperative setting. Secondary endpoints included: 1) acute toxicity and 2) pathologic complete response (pCR). Results: From Oct 2017 to June 2018, 25 pts were enrolled. Median age was 60 (range:30-76), 17 pts were male (68%). All pts started FOLFIRINOX; 23 (92%) pts completed all 8 planned cycles. Two pts did not complete the planned 8 cycles due to metastatic progression. Rates of grade 3+ overall, gastrointestinal, and hematologic toxicities were 28%, 12%, and 28% respectively. Of the entire cohort, 23 (92%) pts started chemoRT and 22 (88%) pts completed chemoRT (1 pt died during CRT due to pulseless electrical activity arrest). All 22 pts (88%) who completed CRT went for surgical exploration, of whom 2 pts were found with intraoperative metastases. Therefore, 20 (80%) pts underwent surgical resection. At time of abstract, 1 pt’s pathology is in process; 7 pts had a pCR (37% in resected cohort, 28% in ITT cohort), all with R0 resection. Conclusions: Total neoadjuvant FOLFIRINOX followed by CRT is feasible with acceptable rates of treatment completion and grade 3+ toxicity. In our small series, the rate of pCR is promising and a follow-up study is currently planned. Clinical trial information: NCT03279237.

Influence of Habitual Physical Behavior - Sleeping, Sedentarism, Physical Activity - On Bone Health in Community-Dwelling Older People

Sedentary behavior (SB) has emerged as an independent public-health risk and may contribute to the lower bone mineral density (BMD) in old (>60 years of age) than young adults. The purpose of this study was to quantify SB and habitual physical behavior (PB) in community-dwelling older adults and how this correlates with BMD. In 112 relatively healthy and independent-living individuals aged 72.5 ± 6.4 years, BMD, PB and SB were determined using dual energy X-ray absorptiometry and 7-day three-dimensional accelerometry, respectively. In men, only healthy and osteopenic BMDs were found, whereas in women, osteoporotic BMD classifications also occurred. Our sample spent ∼61%, 7%, 12% and 19% of daily waking hours in SB, standing, LIPA [light intensity physical activity (PA)] and MVPA (medium-to-vigorous intensity PA), respectively. In men, after accounting for covariates (BMI, total fat, android:gynoid ratio), sleeping (hours/day), number of breaks in SB, number of SB ≥ 5 min, number of PA bouts, total duration of PA bouts (min), mean PA bouts duration (min), LIPA (%PA bout time) and MVPA (%PA bout time) were all predictors of BMD. In women, after accounting for covariates (age, BMI, total fat, android:gynoid ratio), SB (hours/day), SB (% waking hours), LIPA (hours/day), LIPA (% waking hours), MVPA (% waking hours) and number of short SB (i.e., <5 min), total time spent in PA (min) significantly correlated with BMD. In conclusion, the PB predictors of bone health in older persons include: night time sleeping duration, number of short bouts of SB, number and duration of bouts of PA relative to total waking hours. While radar graphs of PB patterns for healthy, osteopenic, osteoporotic individuals highlighted significant differences in PB between them, they were not consistent with the expectations from the Mechanostat Theory: i.e., more loading leads to better bone. Rather, our results suggest that a balance of activities must be maintained across the PB spectrum, where certain PB parameters are especially impactful in each sex, supporting the recently coined multifactorial-based variations in the Mechanostat threshold.

Heterotopic atypical trophoblasts mimicking ectopic choriocarcinoma coexistent with a viable intrauterine pregnancy: A diagnostic dilemma

•

Ectopic choriocarcinoma coexistent with viable IUP is rare but has been reported.

•

Atypical and proliferative trophoblasts are normal in an early conceptus.

•

Evaluation including MRI and CXR did not reveal metastatic choriocarcinoma.

•

IHC analysis for p57, molecular genotyping of DNA microsatellites was performed.

•

β-hCGs appropriately rose then plateaued; remainder of pregnancy was unremarkable.

Nonglycemic Outcomes of Antidiabetic Medications

IN BRIEF The number of medications used to treat diabetes has increased dramatically in the past 15 years. With so many options that have shown significant A1C improvement, it is important to consider side effects, precautions, and additional benefits these agents may offer. This article is a review of some of the most compelling literature available on the nonglycemic benefits of sulfonylureas, thiazolidinediones, biguanides, glucagon-like peptide 1 receptor agonists, dipeptidyl peptidase 4 inhibitors, and sodium-glucose cotransporter 2 inhibitors. Other classes of antihyperglycemic agents, such as dopamine agonists, meglitinides, and amylin agonists, are not discussed in this article.

Whole-body and segmental analysis of body composition in adult males with achondroplasia using dual X-ray absorptiometry

Achondroplasia is a condition characterized by a genetic mutation affecting long bone endplate development. Current data suggests that the bone mineral content (BMC) and bone mineral density (BMD) of achondroplasic populations are below age matched individuals of average stature (controls). Due to the disproportionate limb-to-torso length compared to controls however, the lower BMC and BMD may be nullified when appropriately presented. The aim of this study was to measure whole-body and segmental body composition in adult males with achondroplasia (N = 10, 22 ±3 yrs), present data relative to whole-body and whole-limb values and compare all values to age matched controls (N = 17, 22 ±2 yrs). Dual X-ray absorptiometry (DEXA) was used to measure the in vivo mass of the whole-body and 15 segments, from which BMD, BMC, fat free mass (FFM) and body fat mass were measured. BMC of lumbar vertebrae (L1-4) was also measured and presented as a volumetric BMD (BMD_VOL). The achondroplasic group had less BMC, BMD and FFM, and more body fat mass than controls as a whole-body measure. The lower achondroplasic BMC and BMD was somewhat nullified when presented relative to whole-body and whole-limb values respectively. There was no difference in lumbar BMD_VOL between groups. Whole-body BMD measures presented the achondroplasic group as ‘osteopenic’. When relative to whole-limb measures however, achondroplasic BMD descriptions were normal. Further work is needed to create a body composition database for achondroplasic population’s, or for clinicians to present achondroplasic body composition values relative to the whole-limb.

First Direct Measurements of Superheavy-Element Mass Numbers

An experiment was performed at Lawrence Berkeley National Laboratory's 88-in. Cyclotron to determine the mass number of a superheavy element. The measurement resulted in the observation of two α-decay chains, produced via the ^{243}Am(^{48}Ca,xn)^{291-x}Mc reaction, that were separated by mass-to-charge ratio (A/q) and identified by the combined BGS+FIONA apparatus. One event occurred at A/q=284 and was assigned to ^{284}Nh (Z=113), the α-decay daughter of ^{288}Mc (Z=115), while the second occurred at A/q=288 and was assigned to ^{288}Mc. This experiment represents the first direct measurements of the mass numbers of superheavy elements, confirming previous (indirect) mass-number assignments.

Abstract 2555: Engineering adoptive T cell therapy to co-opt Fas ligand-mediated death signaling in solid tumors

Over 20,000 women are diagnosed with ovarian cancer annually, and over half will die within 5 years. This rate has changed little in the last 20 years, highlighting the need for therapy innovation. A promising new strategy with the potential to control tumor growth without toxicity to healthy tissues employs immune T cells engineered to target proteins uniquely overexpressed in tumors. Mesothelin (MSLN) contributes to the malignant and invasive phenotype in ovarian cancer, and has limited expression in healthy cells, making it a candidate immunotherapy target in these tumors. Using patient-derived cell lines and the ID8 mouse cell line, we found that T cells engineered to express a human or mouse MSLN-specific high-affinity T cell receptor (TCRMSLN) can kill respectively human or murine ovarian tumor cells in vitro. In a disseminated ID8 tumor model, adoptively transferred TCRMSLN T cells preferentially accumulated within established tumors, delayed ovarian tumor growth, and significantly prolonged mouse survival. However, our data also revealed that elements in the tumor microenvironment (TME) limit engineered T cell persistence and ability to kill cancer cells.

To identify immunosuppressive features active in the ovarian TME in both human and murine disease, we performed gene expression analyses on whole tumor tissue (Thermo Fisher) or sorted cell populations (Nanostring). Deep transcriptome profiling confirmed the expression of similar gene signatures in human cancers and the preclinical ID8 model, including immunosuppressive pathways. RNA sequencing revealed consistently high expression of Fas ligand (FasL), notable because FasL signaling can play a significant role in the generation and persistence of tumors. Fas/FasL signaling can mediate T cell death, including activation-induced cell death, an apoptotic mechanism responsible for regulating T cell expansion, suggesting tumor cells may upregulate FasL for protection from tumor-infiltrating lymphocytes. By flow cytometry and immunohistochemistry, we and others previously detected FasL in the tumor vasculature and TME of human ovarian cancer. To overcome this potential T cell evasion mechanism, we generated a panel of immunomodulatory fusion proteins (IFP) containing the Fas receptor (Fas) extracellular binding domain fused to a CD28 or 4-1BB co-stimulatory domain rather than the natural death domain. Relative to T cells modified with only TCRMSLN, T cells engineered to express both TCRMSLN and a Fas IFP better infiltrate tumors, preferentially expand/persist, and retain function in the TME when transferred into tumor-bearing mice. Moreover, adoptive immunotherapy with IFP+ T cells significantly prolonged survival in tumor-bearing mice, relative to TCRMSLN T cells lacking an IFP. As many solid tumors overexpress FasL, the use of IFPs may provide an opportunity to enhance engineered adoptive T cell therapy in many other malignancies.

Citation Format: Kristin Anderson, Shannon Oda, Breanna Bates, Edison Chiu, Christopher Morse, Nicolas Garcia, Philip Greenberg. Engineering adoptive T cell therapy to co-opt Fas ligand-mediated death signaling in solid tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2555.

Surgical vs Endoscopic Management of T1 Esophageal Adenocarcinoma: A Modeling Decision Analysis

BACKGROUND & AIMS

Although treatment of T1a esophageal adenocarcinoma (EAC) is shifting from esophagectomy to endoscopic therapy, T1b EACs are considered too high risk to be treated endoscopically. We investigated the effectiveness and cost effectiveness of esophagectomy vs endoscopic therapy for T1a and T1b EACs, and the effects of age and comorbidities, using a decision analytic Markov model.

METHODS

We developed a model to simulate a hypothetical cohort of men 75 years old with Charlson comorbidity index scores of 0 and either T1aN0M0 or T1bN0M0 EAC, as a base case. We used the model to compare the effects of esophagectomy vs serial endoscopic therapy. We performed sensitivity analyses based on age at diagnosis of 60-85 years, comorbidity indices of 0-2, and utilities. Post-procedure cancer-specific mortality was derived from the Surveillance, Epidemiology, and End Results Medicare database.

RESULTS

In the T1a base case, esophagectomy yielded more unadjusted life years than endoscopic therapy (6.97 vs 6.81), but fewer quality-adjusted life years (QALYs, 4.95 for esophagectomy vs 5.22 for endoscopic therapy). In the T1b base case, esophagectomy yielded more unadjusted life years than endoscopic therapy (5.73 vs 5.01) and QALYs (4.07 vs 3.85 for endoscopic therapy), but was not cost effective (incremental cost-effectiveness ratio $156,981). Sensitivity analyses showed endoscopic therapy optimized QALYs for patients more than 80 years old with a comorbidity index of 1 or 2, or if the ratio of post-esophagectomy to post-endoscopic therapy utilities was below 0.875.

CONCLUSION

In a Markov model, we showed that endoscopic therapy of T1a EAC yields more QALYs and is more cost effective than esophagectomy for patients of all ages and comorbidity indices tested. In contrast, selection of therapy for T1b EAC depends on age and comorbidities, due to surgical mortality and the competing risk of non-cancer death.

Novel use of proton beam therapy for neoadjuvant treatment of radiation-associated squamous cell carcinoma of the esophagus

Secondary esophageal cancers from prior thoracic radiation therapy are rare but challenging cases to deliver standard combined modality therapy as part of a curative approach. In patients with prior exposure to cardiopulmonary-toxic chemotherapy or radiotherapy, management requires meticulous multidisciplinary evaluation given the morbidity associated with surgery in the previously irradiated thorax and re-irradiation of the spinal cord, heart, and lungs. Oftentimes, suboptimal treatment regimens, either with compromised radiation coverage, attenuated chemotherapy doses, or exclusion of surgery, are required to avoid significant toxicity. The physical properties inherent to protons allow for optimal coverage of tumor while achieving remarkably low dose to surrounding normal tissue compared to standard photon treatment. Proton therapy has been studied across various disease sites and may facilitate treatment intensification for radiation-associated esophageal tumors. While no comparative studies have evaluated the efficacy and safety of protons versus photons for esophageal cancer, three cases of radiation-associated esophageal cancer presented in this series are exemplary to highlight the benefit of protons in this unique clinical circumstance. The technical considerations in planning, including passively scattered versus pencil-beam scanning technique, as well as the clinical course and tolerance to treatment, are discussed, which may guide consideration of this advanced treatment modality in this disease site.

Observation of the Isovector Giant Monopole Resonance via the ^{28}Si(^{10}Be,^{10}B^{*}[1.74 MeV]) Reaction at 100 AMeV

The (^{10}Be,^{10}B^{*}[1.74  MeV]) charge-exchange reaction at 100  AMeV is presented as a new probe for isolating the isovector (ΔT=1) nonspin-transfer (ΔS=0) response of nuclei, with ^{28}Si being the first nucleus studied. By using a secondary ^{10}Be beam produced by fast fragmentation of ^{18}O nuclei at the NSCL Coupled Cyclotron Facility, applying the dispersion-matching technique with the S800 magnetic spectrometer to determine the excitation energy in ^{28}Al, and performing high-resolution γ-ray tracking with the Gamma-Ray Energy Tracking In-beam Nuclear Array (GRETINA) to identify the 1022-keV γ ray associated with the decay from the 1.74-MeV T=1 isobaric analog state in ^{10}B, a ΔS=0 excitation-energy spectrum in ^{28}Al was extracted. Monopole and dipole contributions were determined through a multipole-decomposition analysis, and the isovector giant dipole resonance and isovector giant monopole resonance (IVGMR) were identified. The results show that this probe is a powerful tool for studying the elusive IVGMR, which is of interest for performing stringent tests of modern density functional theories at high excitation energies and for constraining the bulk properties of nuclei and nuclear matter. The extracted distributions were compared with theoretical calculations based on the normal-modes formalism and the proton-neutron relativistic time-blocking approximation. Calculated cross sections based on these strengths underestimate the data by about a factor of 2, which likely indicates deficiencies in the reaction calculations based on the distorted wave Born approximation.

Isomeric Character of the Lowest Observed 4^{+} State in ^{44}S

Previous experiments observed a 4^{+} state in the N=28 nucleus ^{44}S and suggested that this state may exhibit a hindered E2-decay rate, inconsistent with being a member of the collective ground state band. We populate this state via two-proton knockout from a beam of exotic ^{46}Ar projectiles and measure its lifetime using the recoil distance method with the GRETINA γ-ray spectrometer. The result, 76(14)_{stat}(20)_{syst}  ps, implies a hindered transition of B(E2;4^{+}→2_{1}^{+})=0.61(19) single-particle or Weisskopf units strength and supports the interpretation of the 4^{+} state as a K=4 isomer, the first example of a high-K isomer in a nucleus of such low mass.

Impact of endometriosis on in vitro fertilization outcomes: an evaluation of the Society for Assisted Reproductive Technologies Database

OBJECTIVE

To assess the impact of endometriosis, alone or in combination with other infertility diagnoses, on IVF outcomes.

DESIGN

Population-based retrospective cohort study of cycles from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System database.

SETTING

Not applicable.

PATIENT(S)

A total of 347,185 autologous fresh and frozen assisted reproductive technology cycles from the period 2008-2010.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Oocyte yield, implantation rate, live birth rate.

RESULT(S)

Although cycles of patients with endometriosis constituted 11% of the study sample, the majority (64%) reported a concomitant diagnosis, with male factor (42%), tubal factor (29%), and diminished ovarian reserve (22%) being the most common. Endometriosis, when isolated or with concomitant diagnoses, was associated with lower oocyte yield compared with those with unexplained infertility, tubal factor, and all other infertility diagnoses combined. Women with isolated endometriosis had similar or higher live birth rates compared with those in other diagnostic groups. However, women with endometriosis with concomitant diagnoses had lower implantation rates and live birth rates compared with unexplained infertility, tubal factor, and all other diagnostic groups.

CONCLUSION(S)

Endometriosis is associated with lower oocyte yield, lower implantation rates, and lower pregnancy rates after IVF. However, the association of endometriosis and IVF outcomes is confounded by other infertility diagnoses. Endometriosis, when associated with other alterations in the reproductive tract, has the lowest chance of live birth. In contrast, for the minority of women who have endometriosis in isolation, the live birth rate is similar or slightly higher compared with other infertility diagnoses.

Direct Lifetime Measurements of the Excited States in (72)Ni

The lifetimes of the first excited 2^{+} and 4^{+} states in ^{72}Ni were measured at the National Superconducting Cyclotron Laboratory with the recoil-distance Doppler-shift method, a model-independent probe to obtain the reduced transition probability. Excited states in ^{72}Ni were populated by the one-proton knockout reaction of an intermediate energy ^{73}Cu beam. γ-ray-recoil coincidences were detected with the γ-ray tracking array GRETINA and the S800 spectrograph. Our results provide evidence of enhanced transition probability B(E2;2^{+}→0^{+}) as compared to ^{68}Ni, but do not confirm the trend of large B(E2) values reported in the neighboring isotope ^{70}Ni obtained from Coulomb excitation measurement. The results are compared to shell model calculations. The lifetime obtained for the excited 4_{1}^{+} state is consistent with models showing decay of a seniority ν=4, 4^{+} state, which is consistent with the disappearance of the 8^{+} isomer in ^{72}Ni.

College students' use of energy drinks, social problem-solving, and academic performance

Energy drink (ED) use among college students to improve academic performance (AP) has skyrocketed. A growing body of literature indicates that the risks associated with ED use may outweigh the perceived benefits. In this study, 486 undergraduates were surveyed on their general substance and ED usage, Social Problem-Solving (SPS) ability, and AP. It was hypothesized that: (1) ED use would be a negative predictor of AP; (2) SPS would be a positive predictor of AP; (3) SPS would be a negative predictor of ED use; and (4) SPS and ED use would account for a significant amount of the variance in AP. A linear multiple regression for AP was conducted, with predictor variables entered in the following order: total drug use, non-ED caffeine use, SPS, and ED use. The overall model was significant and accounted for approximately 7% of the variance in AP. The hypotheses of the study were supported, indicating that ED use may be related to decreased AP, SPS ability may be related to increased AP, or that students with poor AP and less effective SPS skills are more likely to use EDs. Implications of these findings are important for college students and other users of ED products.

Evolution of collectivity in 72Kr: evidence for rapid shape transition

The transition rates from the yrast 2+ and 4+ states in the self-conjugate 72Kr nucleus were studied via lifetime measurements employing the GRETINA array with a novel application of the recoil-distance method. The large collectivity observed for the 4+→2+ transition suggests a prolate character of the excited states. The reduced collectivity previously reported for the 2+→0+ transition was confirmed. The irregular behavior of collectivity points to the occurrence of a rapid oblate-prolate shape transition in 72Kr, providing stringent tests for advanced theories to describe the shape coexistence and its evolution.

The immunomodulatory effects of pegylated liposomal doxorubicin are amplified in BRCA1--deficient ovarian tumors and can be exploited to improve treatment response in a mouse model

OBJECTIVE

Women with BRCA-associated ovarian cancer demonstrate excellent responses to Pegylated Liposomal Doxorubicin (PLD). PLD has also been shown to enhance T cell recognition of tumor cells. Here we characterize immunophenotypic changes associated with BRCA1 dysfunction in ovarian cancer cells, and evaluate the T cell contribution to the therapeutic efficacy of PLD in a BRCA1- ovarian cancer model to determine whether enhanced anti-tumor immunity contributes to the improved response to PLD in BRCA1- ovarian cancers.

METHODS

The immunophenotype of BRCA1- and wild-type (WT) ovarian cancer cells and their response to PLD were compared in vitro using flow cytometry. T cell recruitment to BRCA1- tumors was evaluated with flow cytometry and immunohistochemistry. The contribution of T cell populations to the therapeutic effect of PLD in a BRCA1- model was evaluated using immunodepleting antibodies with PLD in vivo.

RESULTS

The cytotoxic response to PLD was similar in BRCA1- and WT cells in vitro. BRCA1- inactivation resulted in higher expression of Fas and MHC-I at baseline and after PLD exposure. PLD prolonged the survival of BRCA1- tumor bearing mice and increased intratumoral T cell recruitment. CD4+ depletion combined with PLD significantly prolonged overall survival (p=0.0204) in BRCA1- tumor-bearing mice.

CONCLUSION

Differences in the immunophenotype of BRCA1- and WT cells are amplified by PLD exposure. The enhanced immunomodulatory effects of PLD in BRCA1- tumors may be exploited therapeutically by eliminating suppressive CD4+ T cells. Our results support further study of combination therapy using PLD and immune agents, particularly in women with BRCA gene mutations.

Feasibility of endoscopic transesophageal thoracic sympathectomy (with video)

BACKGROUND

Thoracoscopic sympathectomy is the preferred surgical treatment for patients with disabling palmar hyperhidrosis. Current methods require a transthoracic approach to permit ablation of the thoracic sympathetic chain.

OBJECTIVE

To develop a minimally invasive, transesophageal endoscopic technique for a sympathectomy in a swine model.

DESIGN

Nonsurvival animal study.

SETTING

Animal trial at a tertiary care academic center.

SUBJECTS

This study involved 8 healthy Yorkshire swine.

INTERVENTIONS

After insertion of a double-channel gastroscope, a Duette Band mucosectomy device was used to create a small esophageal mucosal defect. A short, 5-cm submucosal tunnel was created by using the tip of the endoscope and biopsy forceps. Within the submucosal space, a needle-knife was used to incise the muscular esophageal wall and permit entry into the mediastinum and chest. The sympathetic chain was identified at the desired thoracic level and was ablated or transected. The animals were killed at the completion of the procedure.

MAIN OUTCOME MEASUREMENTS

Feasibility of endoscopic transesophageal thoracic sympathectomy.

RESULTS

The sympathetic chain was successfully ablated in 7 of 8 swine, as confirmed by gross surgical pathology and histology. In 1 swine, muscle fibers were inadvertently transected. On average, the procedure took 61.4+/-24.5 minutes to gain access to the chest, whereas the sympathectomy was performed in less than 3 minutes in all cases. One animal was killed immediately after sympathectomy, before the completion of the observation period, because of hemodynamic instability.

LIMITATIONS

Nonsurvival series, animal study.

CONCLUSIONS

Endoscopic transesophageal thoracic sympathectomy is technically feasible, simple, and can be performed in a porcine model.

Manipulation of rest period length induces different causes of fatigue in vertical jumping

The aim of this study was to directly compare the causes of fatigue after a short- and a long-rest interval between consecutive stretch-shortening cycle exercises. Eleven healthy males jumped with different resting period lengths (short=6.1+/-1 s, long=8.6+/-0.9 s), performing countermovement jumps at 95% of their maximal jump height until they were unable to sustain the target height. After short- and long-rest, the maximal voluntary isometric contraction knee extension torque decreased (-7%; p=0.04), comparing to values obtained before exercise protocols. No change was seen from pre- to post-exercise, for either short- or long-rest, in biceps femoris coactivation (-1%; p=0.95), peak-to-peak amplitude (1%; p=0.95) and duration (-8%; p=0.92) of the compound muscle action potential of the vastus lateralis. Evoked peak twitch torque reduced after both exercise protocols (short=-26%, long=-32%; p=0.003) indicating peripheral fatigue. However, central fatigue occurred only after short-rest evidenced by a reduction in voluntary activation of the quadriceps muscle (-14%; p=0.013) measured using the interpolated twitch technique. In conclusion, after stretch-shortening cycle exercise using short rest period length, the cause of fatigue was central and peripheral, while after using long rest period length, the cause of fatigue was peripheral.

Pharmacodynamic resistance to warfarin is associated with nucleotide substitutions in VKORC1

BACKGROUND

Vitamin K epoxide reductase subunit 1 (VKORC1) is the molecular target of coumarin anticoagulants and mutations in VKORC1 have been identified previously in individuals who required high warfarin doses.

OBJECTIVE

Detailed characterization of the relationship between variation in VKORC1 and the warfarin resistance phenotype.

PATIENTS AND METHODS

Serum warfarin concentration and coagulation parameters were determined in 289 subjects who required warfarin doses >20 mg day(-1). The VKORC1 sequence was studied in selected study subjects.

RESULTS

Twenty-eight out of 289 (10%) subjects had serum warfarin >2.3 mg L(-1) during stable therapeutic anticoagulation indicating pharmacodynamic warfarin resistance. Detailed analysis of 15 subjects from this group showed that eight out of 15 (53%) had nucleotide substitutions in VKORC1 predictive of p.V66M, p.L128R, p.V54L or p.D36Y. VKORC1 was normal in the remaining seven out of 15 (47%) subjects and in nine out of nine (100%) subjects with high warfarin dose requirement not caused by pharmacodynamic resistance. At referral, subjects with VKORC1 mutations received a median warfarin dose of 32 mg day(-1) (range 22-55) and had a median serum warfarin concentration of 4.6 mg L(-1) (range 2.6-9.0). VKORC1 substitutions were associated with a requirement for high warfarin doses but not with adverse clinical events. Family members with VKORC1 nucleotide substitutions and not receiving warfarin had undetectable PIVKA-II and K(1) epoxide (K(1)O).

CONCLUSIONS

Nucleotide variations in VKORC1 are a common cause of pharmacodynamic warfarin resistance but are not associated with adverse outcome during anticoagulation. Mutations associated with warfarin resistance do not cause a discernible defect in VKORC1 reductase function.

What do parents think about enrolling their premature babies in several research studies?

OBJECTIVE

To investigate parents' opinions about enrolling their premature baby into several research studies in the few days after birth.

METHODOLOGY

A questionnaire was given to parents of premature babies in the neonatal intensive care unit who had been invited to join several studies (two to seven).

RESULTS

All 50 mothers and 42 of 48 fathers completed the questionnaire independently; 28% had been asked to join two studies, 32% three, 24% four, 14% five, and 2% six studies. There were 61 babies with mean (SD) gestational age 26.9 (1.6) weeks and birth weight 877 (249) g. Nearly three quarters (71%) of the parents thought it was very good for their baby to be in a hospital that was carrying out a lot of research. Most (93%) thought that their baby would get the same or better care in a study. Only 15% thought their baby was too small for research studies. Almost all (98%) wanted to be involved in the decision about their baby joining a study. Only 22% were worried about the number of studies; 10% would not enroll their baby in any studies, but 74% were willing for their baby to join two or more studies, and 10% would enroll in all the studies. Most (94%) believed that their baby's participation would improve care of future babies.

CONCLUSIONS

Most of these parents were willing to join several studies. The majority were not worried about their baby participating in the studies. The profession needs to be aware that parents are supportive of neonatal research and participation in multiple studies.