Predictive Factors for Subjective Vertigo Following Cochlear Implantation: A Regional Multicenter Cohort Study of 395 Patients

INTRODUCTION

Cochlear implantation (CI) is generally accepted as having a low rate of postoperative complications, but between 9.3% and 13% of cases experience vertigo postoperatively. This study aimed to examine patient, surgical, and device factors contributing toward the risk of postoperative vertigo.

METHODOLOGY

A retrospective review was conducted of adult patients who underwent cochlear implant in a regional area of New South Wales from 2007 to 2018. A total of 395 cochlear implant cases were included in the final study.

RESULTS

The overall incidence of vertigo at 3 months of follow-up was 7.1% (n = 28/395). No difference was identified in this study between rates of postoperative vertigo between device factors, including implant make (Cochlear vs. Med-El), electrode shape (perimodiolar vs. straight), and electrode model. No significant difference was found also for surgical factors such as the number of electrode rings inserted, side of implantation, or surgical approach of tympanic ramp (round window insertion vs. cochleostomy).A higher percentage of patients with preoperative vertigo experienced vertigo postoperatively (18.4%, n = 7/38), compared with the population without preoperative vertigo (6.0%, n = 21/352) ( p = 0.005). Patients with previous mastoid surgery also reported a higher rate of postoperative vertigo (20%, n = 9/45) compared with those who had not had mastoid surgery (5.43%, n = 19/350) ( p = 0.006). The mean age of patients experiencing postoperative vertigo was higher than the population without postoperative symptoms (67 vs. 63).

CONCLUSION

This study of a large multicenter population outlines that patient factors are more critical than surgical or device factors when considering risk factors for vertigo post-cochlear implant.

Arterial Spin Labeling in Migraine: A Review of Migraine Categories and Mimics

Migraine is a complex headache characterized by changes in functional connectivity and cerebral perfusion. The perfusion changes represent a valuable domain for targeted drug therapy. Arterial spin labeling is a noncontrast imaging technique of quantifying cerebral perfusion changes in the migraine setting. In this narrative review, we will discuss the pathophysiology of the different categories of migraine, as defined by the International Classification of Headache Disorders-3 and describe a category-based approach to delineating perfusion changes in migraine on arterial spin labeling images. We will also discuss the use of arterial spin labeling to differentiate migraine from stroke and/or seizures in the adult and pediatric populations. Our systematic approach will help improve the understanding of the complicated vascular changes that occur during migraines and identify potential areas of future research.

Functional MRI and Diffusion Tensor Imaging in Migraine: A Review of Migraine Functional and White Matter Microstructural Changes

Migraine is a complex and heterogenous disorder whose disease mechanisms remain disputed. This narrative review summarizes functional MRI (fMRI) and diffusion tensor imaging (DTI) findings and interprets their association with migraine symptoms and subtype to support and expand our current understanding of migraine pathophysiology. Our PubMed search evaluated and included fMRI and DTI studies involving comparisons between migraineurs vs healthy controls, migraineurs with vs without aura, and episodic vs chronic migraineurs. Migraineurs demonstrate changes in functional connectivity (FC) and regional activation in numerous pain-related networks depending on migraine phase, presence of aura, and chronicity. Changes to diffusion indices are observed in major cortical white matter tracts extending to the brainstem and cerebellum, more prominent in chronic migraine and associated with FC changes. Reported changes in FC and regional activation likely relate to pain processing and sensory hypersensitivities. Diffuse white matter microstructural changes in dysfunctional cortical pain and sensory pathways complement these functional differences. Interpretations of reported fMRI and DTI measure trends have not achieved a clear consensus due to inconsistencies in the migraine neuroimaging literature. Future fMRI and DTI studies should establish and implement a uniform methodology that reproduces existing results and directly compares migraineurs with different subtypes. Combined fMRI and DTI imaging may provide better pathophysiological explanations for nonspecific FC and white matter microstructural differences.

Persisting facial nerve palsy or trigeminal neuralgia - red flags for perineural spread of head and neck cutaneous squamous cell carcinoma (HNcSCC)

BACKGROUND

Perineural spread (PNS) of head and neck cutaneous squamous cell carcinoma (HNcSCC) is a unique diagnostic challenge, presenting with insidious trigeminal (CN V) or facial nerve (CN VII) neuropathies without clinically discernible primary masses. These patients are often sub-optimally investigated and misdiagnosed as Bell's palsy or trigeminal neuralgia. This case series highlights the red flags in history and pitfalls that lead to delays to diagnosis and treatment.

METHODS

A retrospective case series of 19 consecutive patients with complete clinical histories with HNcSCC PNS without an obvious cutaneous primary lesion at time of presentation to a quaternary head and neck centre in Australia were identified and included for analysis.

RESULTS

Fifteen had CN VII PNS, 17 had CN V PNS, and 13 had both. The overall median symptom-to-diagnosis time was 12-months (IQR-15 months). Eight patients had CN VII PNS and described progressive segmental facial nerve palsy with a median symptom-to-diagnosis time of 9-months (IQR-11.75 months). Eleven patients had primary CN V PNS and described well localized parathesia, formication or neuralgia with a median symptom-to-diagnosis time of 19-months (IQR 27.5 months).

CONCLUSION

PNS is often mistaken for benign cranial nerve dysfunction with delays in diagnosis worsening prognosis. Red flags such as progressive CN VII palsy or persistent CN V paraesthesia, numbness, formication or pain, particularly in the presence of immuno-compromise and/or a history of facial actinopathy should raise suspicion for PNS. Gadolinium-enhanced MR Neurography should be obtained expediently in patients with persistent/progressive CN V/CN VII palsies in patients with red flags, with low threshold for referral to a Head and Neck Surgeon.

Evaluation of S201086/GLPG1972, an ADAMTS-5 inhibitor, for the treatment of knee osteoarthritis in ROCCELLA: a phase 2 randomized clinical trial

OBJECTIVE

To evaluate the efficacy and safety of the anti-catabolic ADAMTS-5 inhibitor S201086/GLPG1972 for the treatment of symptomatic knee osteoarthritis.

DESIGN

ROCCELLA (NCT03595618) was a randomized, double-blind, placebo-controlled, dose-ranging, phase 2 trial in adults (aged 40-75 years) with knee osteoarthritis. Participants had moderate-to-severe pain in the target knee, Kellgren-Lawrence grade 2 or 3 and Osteoarthritis Research Society International joint space narrowing (grade 1 or 2). Participants were randomized 1:1:1:1 to once-daily oral S201086/GLPG1972 75, 150 or 300 mg, or placebo for 52 weeks. The primary endpoint was change from baseline to week 52 in central medial femorotibial compartment cartilage thickness (cMFTC) assessed quantitatively by magnetic resonance imaging. Secondary endpoints included change from baseline to week 52 in radiographic joint space width, Western Ontario and McMaster Universities Osteoarthritis Index total and subscores, and pain (visual analogue scale). Treatment-emergent adverse events (TEAEs) were also recorded.

RESULTS

Overall, 932 participants were enrolled. No significant differences in cMFTC cartilage loss were observed between placebo and S201086/GLPG1972 therapeutic groups: placebo vs 75 mg, P = 0.165; vs 150 mg, P = 0.939; vs 300 mg, P = 0.682. No significant differences in any of the secondary endpoints were observed between placebo and treatment groups. Similar proportions of participants across treatment groups experienced TEAEs.

CONCLUSIONS

Despite enrolment of participants who experienced substantial cartilage loss over 52 weeks, during the same time period, S201086/GLPG1972 did not significantly reduce rates of cartilage loss or modify symptoms in adults with symptomatic knee osteoarthritis.

The Utility of Near-Infrared Autofluorescence for Parathyroid Gland Identification During Thyroid Surgery: A Single-Center Experience

Parathyroid gland injury during thyroid surgery is common and can lead to postoperative hypocalcemia. This study aims to determine the utility of near-infrared autofluorescence (NIRAF) technology for parathyroid gland identification in thyroid surgery. A prospective case series of patients who underwent thyroid surgery between March and June 2021 were examined. Following intra-operative visualisation, parathyroid glands and surrounding tissues were exposed to near-infrared light with a wavelength of approximately 800 nm using the Storz® Near-Infrared Range/Indocyanine Green (NIR/ICG) endoscopic system. Parathyroid glands were expected to show autofluorescence following exposure. Twenty patients who underwent thyroid surgery were included. Eighteen patients (90%) were female, with a median age of 50.0 (IQR 41.0 - 62.5). Surgeries performed include hemithyroidectomy (9 patients; 45.0%), total thyroidectomy (8 patients; 40.0%), completion thyroidectomy (2 patients; 10.0%) and right inferior parathyroidectomy (1 patient; 5.0%). Attempts were made to identify 56 parathyroid glands in this case series. There were 46/56 (82.1%) surgeon-identified parathyroid glands through direct visualisation. Using NIRAF technology, 39/46 (84.8%) were identified as parathyroid glands. There was no inadvertent resection of parathyroid glands or post-operative hypocalcaemia. NIRAF technology has the potential to be a useful tool in confirming the presence of parathyroid glands following direct visualisation intra-operatively.

Structural MRI in Migraine: A Review of Migraine Vascular and Structural Changes in Brain Parenchyma

Migraine is a complex and common disorder that affects patients around the world. Despite recent advances in this field, the exact pathophysiology of migraine is still not completely understood. Structural MRI sequences have revealed a variety of changes to brain parenchyma associated with migraine, including white matter lesions, volume changes, and iron deposition. This Review highlights different structural imaging findings in various types of migraine and their relationship to migraine characteristics and subtypes in order to improve our understanding of migraine, its pathophysiologic mechanisms, and how to better diagnose and treat it.

NIMG-12. DSC-MRI PERFUSION IMAGING IN UNTREATED BRAIN METASTASES USING THE CONSENSUS ACQUISITION PROTOCOL: A MULTI-SITE BENCHMARK STUDY

INTRODUCTION

DSC-MRI perfusion methods are commonly used to evaluate both primary and metastatic brain cancer with the creation of maps of relative cerebral blood volume (rCBV). Recently, guidelines were established to ensure a standard DSC-MRI acquisition protocol that reduces inter-site variability. The purpose of this study was to initiate the determination of rCBV benchmark values using the DSC-MRI consensus protocol in treatment-naïve brain metastases.

METHODS

Patients from three sites with treatment-naïve, contrast-enhancing brain metastases on MRI were considered for inclusion in this retrospective study. The MRIs included pre- and post-contrast T1w(T1+C) images obtained after administration of gadolinium-based contrast agent (GBCA) (0.1 mmol/kg), which serves as the recommended preload for the DSC-MRI data collection. A 2nd GBCA dose (0.1 mmol/kg) was administered 40-60sec after the collection of baseline GRE-EPI images using recommended settings (FA=60o, TE/TR=30ms/1100-1250ms) for 120s. Calibrated pre/post T1w difference maps (dT1) were used for delineation of enhancing lesion, and standardized (calibrated) rCBV (sRCBV) created. Mean sRCBV for metastases were compared to normal appearing white matter (NAWM) and treatment-naive glioblastoma (GBM) from a previous study. Pairwise comparisons were performed using the Mann-Whitney nonparametric test.

RESULTS

N=52 patients with primary histology of lung (n=27); breast (n=6); skin (n=7); gastrointestinal (GI: n=3) and genitourinary (GU: n=9) cancers were included in comparison to GBM (n=31). The mean sRCBV for all metastases (1.77+/-1.05) is significantly lower (p=0.0003) than for GBM (2.67+/-1.34) but with both statistically greater (p< 0.0001) than NAWM (0.706+/-0.163). Individually, lung (1.47+/- 0.61), breast (2.275+/-0.87), skin (2.10+/-1.22), GI (1.91+/- 0.64) and GU (2.01+/-0.63) mean sRCBV are statistically greater than for NAWM.

CONCLUSION

Using the consensus DSC-MRI acquisition protocol confirms use of sRCBV to identify biologically active, treatment-naive brain metastases setting benchmark values for future applications.

Survival outcomes of perineural spread in head and neck cutaneous squamous cell carcinoma

AIM

To present an institution's experience and survival outcomes for patients with head and neck cutaneous squamous cell carcinoma (HNcSCC) and perineural spread (PNS).

METHOD

Retrospective study of patients with HNcSCC and PNS treated between January 2010 and August 2020 from the Sydney Head and Neck Cancer Institute database, Sydney, Australia; a high-volume, tertiary, academic head and neck centre. Patient demographics, primary site, involved cranial nerves, treatment modality, loco-regional failure and survival data were obtained.

RESULTS

Forty-five patients were identified, of which 32 patients were male (71%). Mean age at diagnosis was 68.7 years (range 43-90). Median follow-up was 16.1 months (range 1-107). The trigeminal nerve was most frequently involved (n = 30, 66.6%) followed by facial nerve (n = 13, 28.9%). Most patients underwent surgery followed by radiotherapy (n = 33, 73%) and eight received definitive radiotherapy. The median overall survival (OS) was 4.5 years (95% CI 3.71-5.38), median disease-specific survival 5.1 years (95% CI 4.21-5.97) and median disease-free survival (DFS) was 1.7 years (95% CI 1.11-2.22). The estimated 5-year OS and DFS were 45% and 25%, respectively. Patients treated with surgery and adjuvant radiotherapy with a clear proximal nerve margin had favourable DFS (P = 0.035) and trended towards better OS (P = 0.134) compared with patients with an involved nerve margin. Patients treated surgically with involved proximal nerve margins had similar outcomes compared with patients with treated definitive radiotherapy (HR 0.80, 95% CI 0.29-2.22, P = 0.664).

CONCLUSION

The likelihood of achieving a clear proximal nerve margin should be a strong consideration in the selection of appropriate patients for primary surgery.

Translaryngeal ultrasound in thyroid surgery: state of the art review

BACKGROUND

Clinical voice assessment prior to thyroid and parathyroid surgery is essential, but the paradigm of indirect laryngoscopy (IDL), when indicated, has been challenged by the risk of aerosolised SARS-Cov-2 during endoscopy of the aerodigestive tract. Translaryngeal ultrasound (TLUS) to assess the vocal cords has been proposed as a safe, non-invasive and sensitive alternative. The aim of this review was to verify TLUS as a viable tool for perioperative laryngeal assessment.

METHOD

A literature review was performed using Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials and Scopus with the following search strategy: (vocal cord OR vocal fold OR glottic OR glottis OR vocal ligaments OR rima glottidis) AND (ultras* OR sonograph* OR echography OR echotomography).

RESULTS

Fifteen studies were included in this review. All studies compared TLUS to IDL in visualizing the vocal cords in adults. Ten studies compared pre-operative TLUS to IDL where 50.6-100% of vocal cords were successfully visualized. Nine studies compared post-operative TLUS to IDL and reported visualization between 39.6% and 100%. Pre- and post-operative negative predictive values ranged from 60% to 100%.

CONCLUSION

Whilst promising, successful visualization of the cords is limited by inter-user variability, older age and male gender. Thus, we see the role of TLUS as an alternative to IDL in the post-operative setting in the young patient following uncomplicated surgery with a normal voice on clinical examination, to confirm recurrent laryngeal nerve integrity while minimizing the risk of aerosolization.

Methods of identification of parathyroid glands in thyroid surgery: A literature review

Intra-operative identification and preservation of parathyroid glands is an important but challenging aspect of thyroid surgery. Failure to do so may lead to transient or permanent hypocalcaemia, where the latter represents a serious complication causing life-long morbidity. It would be beneficial, therefore, if a simple and reliable modality can be developed to assist in the identification of parathyroid glands intra-operatively. The aim of this literature review is to provide an overview of intra-operative modalities used to identify parathyroid glands with a particular focus on near-infrared autofluorescence (NIRAF). Twenty-seven studies were considered relevant in this literature review. Several modalities have been used to aid parathyroid gland identification, including Raman spectroscopy, indocyanine green angiography, and NIRAF. NIRAF technology allows parathyroid glands to spontaneously give off light (autofluorescence) when exposed to near-infrared light at a wavelength of 785 nm, creating a contrast between tissues to allow intra-operative differentiation. Studies utilising NIRAF technology were able to identify 76.3%-100% of parathyroid glands intra-operatively. Furthermore, two randomised controlled trials comparing NIRAF and white light showed that the use of NIRAF was able to significantly increase the mean number of parathyroid glands detected and reduce the incidence of post-operative hypocalcaemia. NIRAF is an emerging tool that has been shown to increase the number of intra-operative parathyroid gland identification and reduce the rate of post-operative hypocalcaemia in a safe and reproducible manner. Future trials are needed to evaluate the real-life impact of NIRAF technology in outcomes of patients following thyroid surgery.

Using the health beliefs model to explore children's attitudes and beliefs on air pollution

OBJECTIVES

Traffic-related air pollution (TRAP) negatively impacts children's health. Self-protective measures are available, but population uptake is variable. It is essential to understand human beliefs and behaviours related to air pollution in order to understand the lack of self-protection in communities. As a prelude to undertaking a comprehensive assessment of children's attitudes and beliefs on the health effects of TRAP exposure, we sought to develop and validate an appropriate instrument.

STUDY DESIGN

This study used exploratory sequential mixed methods.

METHODS

This instrument, based on the constructs of the health belief model (HBM), aimed to determine factors predicting wearing a mask to protect against TRAP exposure. An initial literature-based questionnaire was modified using in-depth interviews, focus group discussions, and a quantitative survey pilot. This study included 121 school students and nine professional experts in Vietnam. The questionnaire was tested for content validity, agreement, test-retest reliability, and internal consistency.

RESULTS

The concordance of questionnaire items between two repeated assessments ranged from 47.2% to 78.3%, intraclass correlation coefficients ranged from 0.16 to 0.87 and Cronbach's internal reliability coefficient for the instrument was 0.60.

CONCLUSION

The self-administered instrument, based on the HBM, is suitable to understand health attitudes and beliefs related to self-protective behaviours to reduce TRAP exposure.

Tracheostomy in free-flap reconstruction of the oral cavity: can it be avoided? A cohort study of 187 patients

BACKGROUND

Head and neck surgeons are moving away from routine tracheostomy in free-flap reconstruction. We reviewed prophylactic tracheostomy use in patients undergoing oral cavity or oropharynx free-flap reconstruction to identify patient groups who avoided tracheostomy. Secondary aims were to describe complications associated with and without tracheostomy.

METHODS

A retrospective cohort study was undertaken, using a prospectively maintained database. Inclusion criteria was free-flap reconstruction for an oral cavity or oropharyngeal defect, excluding partial or total laryngectomy. Variables collected included demographics, comorbidity, American Society of Anesthesiologists grade, Charlson Comorbidity Index, tumour site and subsite, extent of resection, surgery duration, tracheostomy, complications, return to theatre and re-intubation.

RESULTS

A total of 344 head and neck free-flap reconstructions were performed between January 2017 and July 2019. A total of 164 (87.7%) oral cavity and 23 (12.3%) oropharyngeal reconstructions were included totalling 187 free flaps. A total of 107 (57.2%) were males and 80 (42.8%) females, mean age 62.4 years (range 21-89). Of 187 patients, 100 (53.5%) underwent prophylactic tracheostomy at time of reconstruction. Longer operative time (P < 0.001), resection site (P < 0.001), number of subsites resected (P = 0.007), segmental mandibulectomy (P = 0.04), lip-split (P = 0.05), floor of mouth resection (P < 0.001), lingual release (P = 0.007), glossectomy (P < 0.001), extent of tongue resection (P < 0.001), extent of hard palate resection (P = 0.04), soft palate resection (P < 0.001) and double free-flap reconstruction (P = 0.04) were associated with tracheostomy use.

CONCLUSION

A personalized approach to postoperative airway management allowed almost half of our cohort to avoid tracheostomy. In high-volume institutions with the necessary expertise and support, appropriately selected patients may be safely managed without routine tracheostomy.

Thyroid gland metastasis from renal cell carcinoma: a case series and literature review

BACKGROUND

Renal cell carcinoma (RCC) is the most common malignancy that metastasises to the thyroid. This study aims to better understand the clinical characteristics of patients with thyroid metastasis from RCC.

METHODS

A retrospective case series of patients with thyroid metastasis from RCC between 2008 and 2020 from two tertiary centres were examined. MEDLINE and PubMed database searches were performed to retrieve the relevant literature.

RESULTS

Fifteen patients (eight males) were identified, with a median age of 57.0 (interquartile range (IQR) 51.0-63.0) at time of RCC diagnosis. Median time to thyroid metastasis was 92.0 months (IQR 40.0-156.0), with 12 (80.0%) patients undergoing thyroidectomy within 2 months of diagnosis. No patients developed post-operative complications or local thyroid recurrence. The two most common non-thyroid metastatic sites in this case series are lungs and bone (five patients, respectively; 33.3%) and pancreas (four patients; 26.7%). Ten (66.6%) patients underwent systemic chemotherapy, and five (33.4%) patients underwent radiotherapy for other sites of metastasis. Median survival following thyroid metastasis was 54.0 months (IQR 15.0-100.0). The literature review was conducted through MEDLINE and PubMed database searches, and 30 papers were considered relevant to this review. Results from our study are comparable to those reported in the literature.

CONCLUSION

Thyroid metastases can occur long after nephrectomy and portends a better prognosis. To prevent development of central neck disease, thyroidectomy should be considered.

FRI0393 BASELINE CHARACTERISTICS OF THE STUDY POPULATION IN ROCCELLA, A PHASE 2 CLINICAL TRIAL EVALUATING THE EFFICACY AND THE SAFETY OF S201086/GLPG1972 IN PATIENTS WITH KNEE OSTEOARTHRITIS

Background:

Osteoarthritis (OA) is a degenerative joint disease involving structural pathology of all joint tissues, and most commonly affecting the knee, hip and hand. Degradation of the cartilage extracellular matrix represents a central feature of OA and is widely thought to be mediated by proteinases that degrade primarily aggrecan and collagen. ADAMTS-5, a Disintegrin And Metalloproteinase with ThromboSpondin-motif-5, is a key aggrecan-cleaving enzyme involved in cartilage degradation. S201086/GLPG1972, a potent and highly selective inhibitor of ADAMTS-5, is an oral Disease-Modifying OsteoArthritis Drug (DMOAD) candidate.

Objectives:

The primary objective of the ROCCELLA phase 2 clinical trial (NCT03595618) is to evaluate the effect of S201086/GLPG1972 over 52 weeks of treatment (3 dose groups compared to placebo) in reducing cartilage loss. Cartilage thickness of the knee is being measured quantitatively by Magnetic Resonance Imaging. Here, we describe the baseline characteristics of patients included in the ROCCELLA clinical trial.

Methods:

The main inclusion criteria were: male or female, aged 40 to 75, with a diagnosis of knee OA according to the clinical and radiological criteria of the American College of Rheumatology. The target knee had to meet a pain score between 40 and 90 mm on a 100 mm Visual Analog Scale (VAS), and the following radiographic feature upon central radiographic readings: Kellgren/Lawrence (KL) 2 or 3 and OARSI medial joint space narrowing (JSN) 1 or 2 (for more details see Deckxet al. OARSI 2020). The rationale for these specific radiographic inclusion criteria was to ensure sufficient cartilage loss over 12 months to assess the efficacy of S201086/GLPG1972.

Results:

Across 12 countries, 3319 patients were screened and 932 were finally included in the study. The screen failure of 72% is mainly due to the radiological criteria. The age of the patients was 62.9 ± 7.3 years (mean ± SD) with a majority of women (69.3%). The BMI was 30.5 ± 4.7 kg/m2. The duration of knee OA was 7.2 ± 6.9 years. Five hundred and one (53.8%) patients reported a medical history of musculoskeletal and connective tissue disorders, mainly osteoarthritis in other sites (20.2%), back pain (13.6%), and arthralgia (9.8%). At inclusion, 97.2% of the patients were taking different types of drug treatments, mainly anti-inflammatory and anti-rheumatic products (69.4%) and analgesics (42%). At baseline, 11% of the target knees were KL2 and 89% were KL3; 32% were OARSI medial JSN grade 1 and 68% grade 2. Target knees at inclusion had a pain score on the VAS of 63.5 ± 11.4 mm (range 0-100, with 0 for no and 100 for extreme pain) and a total WOMAC (Likert 3.1) score of 48.0 ± 15.0 (range 0-96). The WOMAC subscores for pain, stiffness and physical function were 10.0 ± 3.2 (range 0-20), 4.2 ± 1.6 (range 0-8) and 33.8 ± 11.2 (range 0-68, indicating functional limitation), respectively.

Conclusion:

For this clinical trial, patients were selected to present radiological criteria (i.e.OARSI JSN 1 and 2) to ensure sufficient structural progression (cartilage loss) over 12 months, as well as clinical symptoms. These stringent selection criteria were the main cause for the high screen failure rate. These baseline characteristics should warrant the ability to evaluate the efficacy of S201086/GLPG1972 as a DMOAD candidate. The search for an effective pharmacological treatment that can prevent or cure OA remains a major challenge and unmet medical need.

Disclosure of Interests:

Katy Bernard Employee of: Institut de Recherches Internationales Servier, Sergey GRANKOV Employee of: Institut de Recherches Internationales Servier, Marjolijne van der Stoep Employee of: Galapagos, Agnès Lalande Employee of: Institut de Recherches Internationales Servier, Olivier Imbert Employee of: Institut de Recherches Internationales Servier, De Phung Employee of: Galapagos, Damien Chimits Employee of: Institut de Recherches Internationales Servier, Karine Muller Employee of: Galapagos, Ellen van der Aar Employee of: Galapagos, Henri Deckx Employee of: Galapagos, Maria Pueyo Employee of: Institut de Recherches Internationales Servier, Felix Eckstein Grant/research support from: Merck, Orthotrphix, Servier, Galapagos, Kolon Tissuegene, Samumed, Novartis, Consultant of: Merck, Bioclinica, Servier, Samumed, Roche, Kolon Tissuegene, Galapagos and Novartis, Employee of: co-owner and employment with Chondrometrics

Development and validation of a prognostic model for overall survival in chemotherapy-naïve men with metastatic castration-resistant prostate cancer

Background

Prognostic models are needed that reflect contemporary practice for men with metastatic castration-resistant prostate cancer (mCRPC). We sought to identify predictive and prognostic variables for overall survival (OS) in chemotherapy-naïve men with mCRPC treated with enzalutamide.

Patients and methods

Patients from the PREVAIL trial database (enzalutamide versus placebo) were randomly split 2 : 1 into training (n = 1159) and testing (n = 550) sets. Using the training set, 23 predefined variables were analyzed and a multivariable model predicting OS was developed and validated in an independent testing set.

Results

Patient characteristics and outcomes were well balanced between training and testing sets; median OS was 32.7 months in each. The final validated multivariable model included 11 independent prognostic variables. Median OS for low-, intermediate-, and high-risk groups (testing set) defined by prognostic risk tertiles were not yet reached (NYR) (95% CI NYR-NYR), 34.2 months (31.5-NYR), and 21.1 months (17.5-25.0), respectively. Hazard ratios (95% CI) for OS in the low- and intermediate-risk groups versus high-risk group were 0.20 (0.14-0.29) and 0.40 (0.30-0.53), respectively. Secondary outcomes of response and progression differed widely in model-defined risk groups. Enzalutamide improved outcomes in all prognostic risk groups.

Conclusions

Our validated prognostic model incorporates variables routinely collected in chemotherapy-naïve men with mCRPC treated with enzalutamide, identifying subsets of patients with widely differing survival outcomes that provide useful information for external validation, patient care, and clinical trial design.

Trial registration

ClinicalTrials.gov: NCT01212991.

297Seeing is believing: the feasibility and acceptability of using wearable cameras to enhance self-management of heart failure

Introduction

For people with heart failure (HF), self-management (e.g., adhering to prescribed medication, management of fluid restrictions and daily weighing) and dietary management is critical for disease management. The rise of technologies (mobile phones, wearable cameras) for healthcare use offers potential support for people to better manage their disease. We aimed to test the feasibility and utility of wearable cameras for identifying self-management practices and to determine if these images can be used to enhance self-management in people with HF.

Methods

Participants wore the “narrative clip”, a small wearable camera for one month during waking hours; still images were taken every 30 seconds. Using state-of-the-art artificial intelligence techniques, we investigated automated image analysis of daily life activities to determine the potential of these systems to identify four categories of human activities: medication management, dietary intake, meal preparation and physical activity. Participants also completed a semi-structured questionnaire about acceptability and feasibility.

Results

30 participants (mean age 73.6 years, 60% male) with HF NYHA Class II-III were recruited. A total of 629,603 images were available for analysis. Higher order analyses were conducted to determine precision of identifying correct images for the pre-defined self-management categories. Precision of identifying the correct images was highest in dietary intake (average 49%, range 13–94%) followed by meal preparation (average 40%, range 1–99%) and physical activity (average 31%, range 0–95%). Medication management had the lowest precision (average 6%, range 6–22%). Manual review of images revealed substantial periods of sedentary time, typically paired with screen time (watching television, playing cards on a computer). All participants agreed the camera was easy to use and felt they had privacy when using the camera. The majority of participants felt comfortable wearing the camera (93%) and thought this technique will help people with HF in the future (93%).

Conclusions

Images from wearable cameras provided rich contextual data to better understand the lived experiences of people with HF and the device was acceptable to participants. Automated machine learning tools require more annotated data for training to enhance precision, which will be achieved via further annotation, fine-tuning and retraining the data analysis model. Despite these challenges, the data collected can be used as an adjunct to traditional data collection methods such as self-report. Once data analysis techniques are refined, objective data from wearable cameras may also prove useful for nurses to provide tailored education for self-management.

Acknowledgement/Funding

Heart Foundation Vanguard Grant, Australia (101348)

Radiographic progression with nonrising PSA in metastatic castration-resistant prostate cancer: post hoc analysis of PREVAIL

BACKGROUND

Advanced prostate cancer is a phenotypically diverse disease that evolves through multiple clinical courses. PSA level is the most widely used parameter for disease monitoring, but it has well-recognized limitations. Unlike in clinical trials, in practice, clinicians may rely on PSA monitoring alone to determine disease status on therapy. This approach has not been adequately tested.

METHODS

Chemotherapy-naive asymptomatic or mildly symptomatic men (n=872) with metastatic castration-resistant prostate cancer (mCRPC) who were treated with the androgen receptor inhibitor enzalutamide in the PREVAIL study were analyzed post hoc for rising versus nonrising PSA (empirically defined as >1.05 vs ⩽1.05 times the PSA level from 3 months earlier) at the time of radiographic progression. Clinical characteristics and disease outcomes were compared between the rising and nonrising PSA groups.

RESULTS

Of 265 PREVAIL patients with radiographic progression and evaluable PSA levels on the enzalutamide arm, nearly one-quarter had a nonrising PSA. Median progression-free survival in this cohort was 8.3 months versus 11.1 months in the rising PSA cohort (hazard ratio 1.68; 95% confidence interval 1.26-2.23); overall survival was similar between the two groups, although less than half of patients in either group were still at risk at 24 months. Baseline clinical characteristics of the two groups were similar.

CONCLUSIONS

Non-rising PSA at radiographic progression is a common phenomenon in mCRPC patients treated with enzalutamide. As restaging in advanced prostate cancer patients is often guided by increases in PSA levels, our results demonstrate that disease progression on enzalutamide can occur without rising PSA levels. Therefore, a disease monitoring strategy that includes imaging not entirely reliant on serial serum PSA measurement may more accurately identify disease progression.

A comparison of the pharmacokinetics and safety of enzalutamide in subjects with hepatic impairment and matched healthy subjects

WHAT IS KNOWN AND OBJECTIVE

Enzalutamide is an androgen receptor inhibitor approved for treatment of metastatic castration-resistant prostate cancer. Enzalutamide is highly protein bound and eliminated primarily by hepatic metabolism; therefore, it is important to understand whether enzalutamide pharmacokinetics is altered by hepatic impairment.

METHODS

Pharmacokinetic data were obtained from two non-randomized, open-label, single-dose, phase 1 studies conducted in patients with mild (Child-Pugh class A, n = 6) or moderate (Child-Pugh class B, n = 8) hepatic impairment (NCT01901133) or severe (Child-Pugh class C, n = 8) hepatic impairment (NCT02138162) and their corresponding matched healthy controls; data from both studies are presented here. Subjects with hepatic impairment had liver cirrhosis (n = 19) or chronic hepatitis (n = 3). All subjects received a single oral dose of 160 mg enzalutamide under fasting conditions, with blood samples collected predose and up to 49 days post-dose.

RESULTS AND DISCUSSION

Exposure to enzalutamide active moieties, based on the area under the curve of the sum of enzalutamide and N-desmethyl enzalutamide (an active metabolite with similar potency to enzalutamide), increased by 13%, 18% and 4% in subjects with mild, moderate and severe hepatic impairment, respectively, relative to matched controls. Compared with healthy controls, the mean maximum plasma concentration for enzalutamide active moieties was 24% higher in subjects with mild hepatic impairment and 11% and 41% lower in subjects with moderate and severe hepatic impairment, respectively. Enzalutamide was generally well tolerated, with no clinically significant trends in abnormal laboratory findings, vital signs or electrocardiograms.

WHAT IS NEW AND CONCLUSIONS

No major differences in single-dose pharmacokinetics were observed in subjects with hepatic impairment vs. matched healthy controls. Therefore, these studies indicate that no initial dose adjustment is necessary when administering enzalutamide to patients with hepatic impairment.

A phase II, open-label, single-arm, efficacy, and safety study of MDV3100 in patients with hormone-naïve prostate cancer

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Background: MDV3100 is a novel androgen receptor (AR) antagonist in clinical development for the treatment of prostate cancer (PCa). Compared to bicalutamide, MDV3100 has higher in vitro AR binding affinity and no evidence of partial agonism. Preliminary phase I-II data show antitumor activity with MDV3100 in men with advanced PCa who were concurrently using androgen deprivation therapy (ADT; Scher HI, et al. Lancet. 2010;375:1437-46). Phase II and III studies in men with progressive and earlier-stage PCa are ongoing. This abstract describes the design of a phase II study of MDV3100 in men with hormone-naïve PCa (HNPCa) who are candidates for ADT.

Methods: This 25-week, open-label, single-arm, efficacy and safety study of MDV3100 (160 mg/d orally) will be initiated at ∼20 investigational sites in late 2010 (planned countries: Austria, Belgium, Czech Republic, Denmark, Germany). Inclusion criteria include histologically confirmed, locally advanced PCa (all stages), noncastrate testosterone (T; ≥230 ng/dL), prostate-specific antigen (PSA) ≥2 ng/mL (screening), Eastern Cooperative Oncology Group score of 0, and life expectancy ≥1 year. Exclusion criteria include, among others, previous/current hormonal therapy or chemotherapy for PCa. The primary endpoint is PSA response, defined as an ≥80% decrease from baseline to wk 25. A binary PSA response per patient (wk 25) will be determined, allowing for generation of a PSA response rate (95% CI) from all patients for the study. Secondary endpoints include: PSA dynamics; pharmacokinetics; change in gonadotropin, T, dihydrotestosterone, estradiol, sex-hormone binding globulin, and prolactin levels; and safety/tolerability. Exploratory endpoints include changes in bone mineral density, bone turnover markers, metabolic parameters, and quality of life.

Results: The planned enrollment is 60 patients. With a 20% dropout rate, the study will have 80% power to reject the unwanted PSA response rate of ≤50% (5% significance). Efficacy and safety data will be published later.

Conclusions: Previous data were in men with castrate levels of T (≤50 ng/dL). This trial will be the first to investigate the use of MDV3100 monotherapy in HNPCa.

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Postherpetic neuralgia: impact of famciclovir, age, rash severity, and acute pain in herpes zoster patients

New and previously reported analyses of the data from a placebo-controlled trial of famciclovir are reviewed in light of recently proposed recommendations for the analysis of pain in herpes zoster trials. The analyses examined the effect of famciclovir treatment on the duration of postherpetic neuralgia (PHN), which was defined as pain persisting after rash healing, pain persisting > 30 days after study enrollment, or pain persisting > 3 months after study enrollment; the baseline characteristics of patients in the famciclovir and placebo groups who developed PHN; the impact of famciclovir treatment on the duration of PHN, while controlling for significant covariates; and the prevalence of PHN at monthly intervals from 30 to 180 days after enrollment. The results of these analyses indicated that greater age, rash severity, and acute pain severity are risk factors for prolonged PHN. In addition, they demonstrated that treatment of acute herpes zoster patients with famciclovir significantly reduces both the duration and prevalence of PHN.

Influence of cutting edge configuration on surgical needle penetration forces

A standardized test for measuring the needle penetration forces has been developed that can be easily replicated in any laboratory. Using this test, conventional cutting edge needles utilized in the test produced lower penetration forces than reverse cutting edge needles. The lower penetration forces encountered by the conventional cutting edge needles imply that the physician should be able to handle these needles with more dexterity and precision than the reverse cutting edge needle.

Water treatment of hydrotherapy exercise pools

The major objectives of water treatment of hydrotherapy pools are to disinfect the water and to balance the water appropriately. A variety of disinfectant systems utilizing either halogens, ozone, or metals have been implemented in hydrotherapy pools. Regardless of the disinfectant system employed, continual and appropriate monitoring of the system is mandatory to prevent infection. Water balancing refers to the control of the water mineral concentration so that the water does not damage the pool. Five major factors that influence water balance are pH, total alkalinity, calcium hardness, total dissolved solids, and temperature. The extent to which these five factors affect water balance can be computed by the Langelier saturation index.

Evaluation of automatic disposable rotating cartridge skin staplers

Burn surgeons commonly employ skin staples for the application of skin grafts and to secure dressings on donor site dressings and over skin grafts. Disposable skin staplers with rotating cartridges are ideally suited for wound closure because the position of their cartridges can be manually adjusted to facilitate placement of their staples. In response to the burgeoning interest in disposable automatic skin staplers with rotating cartridges, three different models are now commercially available. This report describes the design configuration and mechanical performance of these disposable automatic staplers and their staples. Mechanical performance of these staplers and staples has been assessed by standardized tests that can be replicated in any research laboratory. On the basis of these objective design and performance parameters, the Premium stapler is recommended for wound closure. This stapler provides maximal visualization of the wound as well as the staple during its formation. It delivers the staple into the skin or wound in a manner that the cross member of the staple is above the skin or wound surface. In addition, the Premium stapler has a prepositioning mechanism that can be controlled by the surgeon with minimal force. This mechanism allows the stapler to hold its staple securely, even when its pointed legs extend beyond the delivery end of the stapler. Force required to form its staples is so low that the surgeon can staple repetitively without fatigue. Finally, the Premium stapler delivers a staple that has a uniform geometry and sharp points that can easily penetrate tissue.

Evaluation of flotation devices for deep-water exercise

Jogging and running in deep water (greater than or equal to 7 feet) appears to be a more efficient and safer means of aerobic exercise than jogging and running on land. Consequently, a variety of flotation devices have been developed to facilitate this deep-water exercise. A comprehensive evaluation of these devices revealed distinct performance limitations that interfered with this exercise. On the basis of the results of these studies, a new, improved flotation device has been conceptualized for individuals participating in deep-water exercise.