The burden of Finke Desert race-related trauma: A 10-year retrospective descriptive analysis

INTRODUCTION

The Finke Desert Race is an annual motorsport race (motorbikes, cars and buggies) held in Alice Springs resulting in a significant major trauma burden. This imposes unique challenges in one of the world's most remote healthcare settings.

OBJECTIVES

To quantify the volume and characteristics of Finke Desert Race-related trauma presenting to the Alice Springs Hospital.

DESIGN

A retrospective descriptive study was undertaken to review all patients presenting to the Alice Springs Hospital with Finke Desert Race-related trauma over a 10-year period. Information collected included demographic data, injury characteristics, patient disposition and required management.

FINDINGS

Over the 9 years the event was held, 325 patients were admitted to the Alice Springs Hospital. Patients were almost exclusively male (98.8%), with a mean age of 34.75 and residing outside of Alice Springs (82.2%). There were a total of 460 distinct injuries with the clavicle, spine and ribs the three most commonly injured sites. A total of 129 operations were required, of which 19 required retrieval to an interstate centre.

DISCUSSION

Alice Springs is one of the most remote and geographically isolated centres on Earth. This rurality poses unique challenges when trying to coordinate medical and retrieval services, exacerbated for a concentrated, yet highly resource intensive event such as Finke. It has far reaching impacts, placing additional stresses on all aspects of healthcare provision.

CONCLUSION

This review has quantified the trauma burden of the event for the first time, enabling local and interstate stakeholders' ability to plan an adequate and sustainable response while also enabling the future effectiveness evaluation of recent safety reforms.

Extended Safety and Tolerability of Darolutamide for Nonmetastatic Castration-Resistant Prostate Cancer and Adverse Event Time Course in ARAMIS

BACKGROUND

Patients with nonmetastatic castration-resistant prostate cancer (nmCRPC) are usually asymptomatic and seek treatments that improve survival but have a low risk of adverse events. Darolutamide, a structurally distinct androgen receptor inhibitor (ARi), significantly reduced the risk of metastasis and death versus placebo in ARAMIS. We assessed the extended safety and tolerability of darolutamide and the time-course profile of treatment-emergent adverse events (TEAEs) related to ARis and androgen-suppressive treatment.

PATIENTS AND METHODS

Patients with nmCRPC were randomized 2:1 to darolutamide (n = 955) or placebo (n = 554). After trial unblinding, patients could receive open-label darolutamide. Tolerability and TEAEs were assessed every 16 weeks. Time interval-specific new and cumulative event rates were determined during the first 24 months of the double-blind period.

RESULTS

Darolutamide remained well tolerated during the double-blind and open-label periods, with 98.8% of patients receiving the full planned dose. The incidence of TEAEs of interest in the darolutamide group was low and ≤2% different from that in the placebo group, except for fatigue. When incidences were adjusted for exposure time, there were minimal differences between the darolutamide double-blind and double-blind plus open-label periods. The rate of initial onset and cumulative incidence of grade 3/4 TEAEs and serious TEAEs were similar for darolutamide and placebo groups over 24 months.

CONCLUSION

Extended treatment with darolutamide was well tolerated and no new safety signals were observed. Most ARi-associated and androgen-suppressive treatment-related TEAEs occurred at low incidences with darolutamide, were similar to placebo, and showed minimal increase over time with continued treatment.

TRIAL NUMBER

ClinicalTrials.gov identifier NCT02200614.

Challenges and Opportunities for Commercializing Technologies in the Pulmonary Arena: An Official American Thoracic Society Report

"Translational medicine" has been a buzzword for over two decades. The concept was intended to be lofty, to reflect a new "bench-to-bedside" approach to basic and clinical research that would bridge fields, close gaps, accelerate innovation, and shorten the time and effort it takes to bring novel technologies from basic discovery to clinical application. Has this approach been successful and lived up to its promise? Despite incredible scientific advances and innovations developed within academia, successful clinical translation into real-world solutions has been difficult. This has been particularly challenging within the pulmonary field, because there have been fewer U.S. Food and Drug Administration-approved drugs and higher failure rates for pulmonary therapies than with other common disease areas. The American Thoracic Society convened a working group with the goal of identifying major challenges related to the commercialization of technologies within the pulmonary space and opportunities to enhance this process. A survey was developed and administered to 164 participants within the pulmonary arena. This report provides a summary of these survey results. Importantly, this report identifies a number of poorly recognized challenges that exist in pulmonary academic settings, which likely contribute to diminished efficiency of commercialization efforts, ultimately hindering the rate of successful clinical translation. Because many innovations are initially developed in academic settings, this is a global public health issue that impacts the entire American Thoracic Society community. This report also summarizes key resources and opportunities and provides recommendations to enhance successful commercialization of pulmonary technologies.

Surface Passivation by Quantum Exclusion: On the Quantum Efficiency and Stability of Delta-Doped CCDs and CMOS Image Sensors in Space

Radiation-induced damage and instabilities in back-illuminated silicon detectors have proved to be challenging in multiple NASA and commercial applications. In this paper, we develop a model of detector quantum efficiency (QE) as a function of Si-SiO2 interface and oxide trap densities to analyze the performance of silicon detectors and explore the requirements for stable, radiation-hardened surface passivation. By analyzing QE data acquired before, during, and after, exposure to damaging UV radiation, we explore the physical and chemical mechanisms underlying UV-induced surface damage, variable surface charge, QE, and stability in ion-implanted and delta-doped detectors. Delta-doped CCD and CMOS image sensors are shown to be uniquely hardened against surface damage caused by ionizing radiation, enabling the stability and photometric accuracy required by NASA for exoplanet science and time domain astronomy.

Knowledge, attitude, and practices regarding cervical collars in adult trauma patients amongst practitioners at three hospitals in KwaZulu-Natal, South Africa

Background

The use of cervical collars in adult patients with possible injuries to the cervical spine has been an accepted standard of care for many years, despite the absence of evidence for the efficacy of these devices in preventing unwanted movement and harm. Changes to the terminology and recommendations of major trauma guidelines have been made but are limited by low quality evidence. In this context, little is known about what practitioners know, believe, and do, when managing the cervical spine of trauma patients.

Methods

In this quantitative, observational, descriptive, cross-sectional survey a specifically designed questionnaire was used to collect data on the knowledge, attitude, and practices of practitioners managing adult trauma patients regarding cervical collars at three hospitals in KwaZulu-Natal, South Africa.

Results

A total of 128 completed questionnaires were collected, captured, and analysed. Participants with the additional qualification of ATLS and DipPEC had a mean knowledge score of 8.1 (SD=1.70), compared to those with no additional qualification of 4.5 (SD=1.9) (p<0.001). Participants in the Emergency Department (ED) attained a mean knowledge score of 7.1 (SD=2.2) followed by Surgery (Mean=6, SD=2.0), Orthopaedics (Mean=5.5, SD=1.7) and ICU/Anaesthetics (Mean=4.4, SD=1.8), p<0.001. Head blocks only were most frequently used by 97.4 % of ED, 55.6 % of Surgery, 3.8 % Orthopaedic and 22.2 % ICU/Anaesthetics participants (p<0.001).

Conclusion

The knowledge of management principles of cervical spine injuries was influenced by the department in which practitioners worked, the frequency that they managed patients with suspected injuries and additional courses. Head blocks were the most frequently used spinal protection device in all three hospitals. Most participants would be open to a change in practice if new guidelines were recommended. Further research is needed to determine the optimal management of patients with suspected cervical spine injuries and the role of motion restriction devices in limiting movement of the injured spine.

Safety and Efficacy of Hizentra® Following Pediatric Hematopoietic Cell Transplant for Treatment of Primary Immunodeficiencies

Primary immunodeficiency disease (PIDD) comprises a group of disorders of immune function. Some of the most severe PIDD can be treated with hematopoietic cell transplant (HCT). Hizentra® is a 20% liquid IgG product approved for subcutaneous administration in adults and children greater than 2 years of age with PIDD-associated antibody deficiency. Limited information is available on the use of Hizentra® in children following HCT for PIDD. A multicenter retrospective chart review demonstrated 37 infants and children (median age 70.1 [range 12.0 to 176.4] months) with PIDD treated by HCT who received Hizentra® infusions over a median duration of 31 (range 4-96) months post-transplant. The most common indication for HCT was IL2RG SCID (n = 16). Thirty-two patients switched from IVIG to SCIG administration, due to one or more of the following reasons: patient/caregiver (n = 17) or physician (n = 12) preference, discontinuation of central venous catheter (n = 16), desire for home infusion (n = 12), improved IgG serum levels following lower levels on IVIG (n = 10), and loss of venous access (n = 8). Serious bacterial infections occurred at a rate of 0.041 per patient-year while on therapy. Weight percentile increased by a mean of 16% during the observation period, with females demonstrating the largest gains. Mild local reactions were observed in 24%; 76% had no local reactions. One serious adverse event (death from sepsis) was reported. Hizentra® was discontinued in 15 (41%) patients, most commonly due to recovery of B cell function (n = 11). These data demonstrate that Hizentra® is a safe and effective option in children who have received HCT for PIDD.

Efficacy of National Comprehensive Cancer Network Guidelines in Identifying Pathogenic Germline Variants Among Unselected Patients with Prostate Cancer: The PROCLAIM Trial

BACKGROUND

Prostate cancer (PCa) patients with pathogenic/likely pathogenic germline variants (PGVs) in cancer predisposition genes may be eligible for U.S. Food and Drug Administration-approved targeted therapies, clinical trials, or enhanced screening. Studies suggest that eligible patients are missing genetics-informed care due to restrictive testing criteria.

OBJECTIVE

To establish the prevalence of actionable PGVs among prospectively accrued, unselected PCa patients, stratified by their guideline eligibility.

DESIGN, SETTING, AND PARTICIPANTS

Consecutive, unselected PCa patients were enrolled at 15 sites in the USA from October 2019 to August 2021, and had multigene cancer panel testing.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Correlates between the prevalence of PGVs and clinician-reported demographic and clinical characteristics were examined.

RESULTS AND LIMITATIONS

Among 958 patients (median [quartiles] age at diagnosis 65 [60, 71] yr), 627 (65%) had low- or intermediate-risk disease (grade group 1, 2, or 3). A total of 77 PGVs in 17 genes were identified in 74 patients (7.7%, 95% confidence interval [CI] 6.2-9.6%). No significant difference was found in the prevalence of PGVs among patients who met the 2019 National Comprehensive Cancer Network Prostate criteria (8.8%, 43/486, 95% CI 6.6-12%) versus those who did not (6.6%, 31/472, 95% CI 4.6-9.2%; odds ratio 1.38, 95% CI 0.85-2.23), indicating that these criteria would miss 42% of patients (31/74, 95% CI 31-53%) with PGVs. The criteria were less effective at predicting PGVs in patients from under-represented populations. Most PGVs (81%, 60/74) were potentially clinically actionable. Limitations include the inability to stratify analyses based on individual ethnicity due to low numbers of non-White patients with PGVs.

CONCLUSIONS

Our results indicate that almost half of PCa patients with PGVs are missed by current testing guidelines. Comprehensive germline genetic testing should be offered to all patients with PCa.

PATIENT SUMMARY

One in 13 patients with prostate cancer carries an inherited variant that may be actionable for the patient's current care or prevention of future cancer, and could benefit from expanded testing criteria.

Outcomes for Colorectal Cancer Cases With Peritoneal Metastases Treated With Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy: A Comparative Analysis of Survival Between Peritoneal Carcinomatosis Scores - PCI in a Single Centre

BACKGROUND/AIM

Peritoneal cancer index (PCI) has been a strong indicator of prognosis for patients receiving cytoreductive surgery. The aim of this single institution study was to compare the survival of peritoneal carcinoma cases treated with cytoreduction surgery arising from colorectal cancer grouped by PCI scores.

PATIENTS AND METHODS

A retrospective study of a prospective dataset maintained from 2000 till September 2022, for peritoneal metastases from colorectal cancers was carried out. Of the total of 1,625 peritoneal metastases cases, 415 were identified with colorectal cancer and considered for analysis. Survival was followed for 60 months since the index-peritonectomy for cases in this study.

RESULTS

Hazard ratio for 5-year survival using the Cox regression analysis over time (t) with a Log-rank (Mantel-Cox) test for significance between the groups indicated, <15 vs. 15 (HR=2.121, p=0.0338), <15 vs. 16-20 (HR=2.748, p<0.0001), <15 vs. >20 (HR=3.158, p<0.0001), 15 vs. 16-20 (HR=1.262, p=0.5658), 15 vs. >20 (HR=1.566, p=0.2771) and for PCI category 16-20 vs. >20 (HR=1.204, p=0.5355) for survival. Median survival for the categories of PCI <15, PCI-15, PCI-16-20, and PCI >15 was 43.967 (95%CI=28.31-59.63), 20.67 (95%CI=5.01-36.33), 19.50 (95%CI=3.84-35.16), and 14.30 (95%CI=1.36-29.96), respectively.

CONCLUSION

A correlation of PCI with survival was confirmed in this study reinforcing the need for assessment of PCI at surgery to help prognostication. Detecting synchronous peritoneal metastases early and prompt treatment can help prevent recurrence and increase survival.

Peritoneal metastasis of advanced epithelial ovarian carcinoma treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: A retrospective international multicentric data analysis

INTRODUCTION

The purpose of our study was to evaluate outcome data after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with peritoneal metastasis originating from advanced epithelial ovarian carcinoma (PMOC).

PATIENTS AND METHODS

A retrospective international multi-institutional registry was established through collaborative efforts of participating units affiliated with the Peritoneal Surface Oncology Group.

RESULTS

One thousand four hundred and ninety-one patients from 11 specialized units underwent CRS and HIPEC that of those 326 (21.9%) upfront surgeries, 504 (33.8%) interval surgery, and 661(44.3%) recurrent cases. Complete Cytoreduction(CC0/1) was achieved in 1213 patients (81.3%). Treatment -related mortality was 0.8%, major operative complications (Grades 3-5) was 25.1%. Factors associated with major operative complications include prior surgical score (PSS for recurrent cases; RC) PSS>2,p = 0.000), PCI(≤15, >15 cut-off level; p ≤ 0.000), completeness of cytoreduction (CC, p=0.000), high CA125 levels (>25 mg/dl), presence of ascites, high CRP (>5 mg/dl) levels and low albumin levels (below to 2.5 mg/dl) (p ≤ 0.05). The median survival was 58 months in upfront surgery(UFS), 60 months in interval surgery(IS), and 42 months in RC. The overall survival for five years was 45% for UFS, 37% for IS, 28% for RC cases. CCscore (p = 0.000), CA125, CRP and albumin levels (p ≤ 0.05) were predictors for progression free survival. PCI(p ≤ 0.000), major postoperative complications (p = 0.004), incomplete CRS(CC2/3)(p < 0.001), prior chemotherapy (hazard ratio [HR], 3-8; p < 0.001) and PSS>2 for RC were independent predictors of poor overall survival.

CONCLUSION

The combined treatment strategy for PMOC may be performed safely with acceptable morbidity and mortality in the specialized units.

The changing vaccine landscape: rates of COVID-19 vaccine acceptance and hesitancy in young adults during vaccine rollout

AIMS

Development and rollout of vaccines offers the best opportunity for population protection against the SARS-CoV-2 (COVID-19) virus. However, hesitancy towards the vaccines might impede successful uptake in the United Kingdom, particularly in young adults who demonstrate the highest rates of hesitancy. This prospective study explored COVID-19 vaccine hesitancy in young adults and whether the reasons behind these attitudes changed during the initial stages of the United Kingdom's vaccine rollout.

METHOD

Data on vaccination intention were collected from a British university student cohort at three time points: October 2020, February 2021, and March 2021. This online survey included items on intention to receive a vaccine and a free-text response for the reasons behind this intention. Cochran's Q tests examined changes in rates of hesitancy and acceptance over time and free-text responses were analysed thematically.

RESULTS

At baseline, 893 students provided data, with 476 participants completing all three time points. Hesitancy declined over time, with 29.4% of participants expressing hesitancy at baseline, reducing to 9.1% at wave 2 and 5.9% at wave 3. The most commonly endorsed themes for those willing to accept a vaccine were self-protection against COVID-19 and pro-social reasons, including protecting the population or unspecific others, and ending the pandemic/returning to normal life. The most commonly endorsed hesitancy themes related to 'confidence' in the vaccines and potential personal risk, including insufficient testing/scientific evidence, concern about side effects, and long-term effects. These reasons remained the most commonly endorsed at both waves 2 and 3.

CONCLUSIONS

While a decline in hesitancy was observed over time, the key reasons behind both vaccine acceptance and hesitancy remained consistent. Reasons behind hesitancy aligned with those of the general public, providing support for the use of generalist interventions. Pro-social reasons frequently underpinned vaccine acceptance, so cohort-specific interventions targeting those factors may be of benefit.

Shoulder complex and trunk coordination of individuals with severe hemiparesis following a constraint-induced movement therapy protocol: A case series

INTRODUCTION

Constraint Induced Movement Therapy (CIMT) has been shown to be an effective rehabilitation technique in individuals with mild and moderate upper limb (UL) hemiparesis. The aim was to evaluate the effect the CIMT for improving paretic UL use and interjoint coordination with individuals in severe hemiparesis.

METHODS

Six individuals with severe chronic hemiparesis (mean age = 55 ± 16 years) received a UL CIMT intervention for 2 weeks. UL clinical assessments were conducted five times: two assessments at pre-intervention and then, one assessment at post-intervention and 1- and 3-month follow-up using the Graded Motor Activity Log GMAL) and the Graded Wolf Motor Function Test (GWMFT). Scapula, humerus and trunk coordination variability were assessed using the 3-D kinematics during arm elevation, combing hair, turning on the switch and grasp a washcloth. A paired t-test was used to check differences between coordination variability and a one-way ANOVA repeated measures was used to check differences between GMAL and GWMFT scores.

RESULTS

There were no differences in GMAL and GWMFT between the patient screening and the baseline data collection (p > 0.05). GMAL scores increased at post-intervention and at follow-ups (p < 0.02). GWMFT performance time score decreased at post-intervention and at 1-month follow-up (p < 0.04). Improvements in kinematic variability of the paretic UL at pre and post-intervention were observed in all tasks, except in the activity of turn on the light switch.

CONCLUSION

Following the CIMT protocol, improvements in GMAL and GWMFT scores may reflect improvements in paretic UL performance, in real-life environment. Improvements in kinematic variability may reflect an improving of UL interjoint coordination for individuals with chronic severe hemiparesis.

Controversy Over Liver Transplantation or Resection for Neuroendocrine Liver Metastasis: Tumor Biology Cuts the Deal

BACKGROUND

In patients with neuroendocrine liver metastasis (NELM), liver transplantation (LT) is an alternative to liver resection (LR), although the choice of therapy remains controversial. In this multicenter study, we aim to provide novel insight in this dispute.

METHODS

Following a systematic literature search, 15 large international centers were contacted to provide comprehensive data on their patients after LR or LT for NELM. Survival analyses were performed with the Kaplan-Meier method, while multivariable Cox regression served to identify factors influencing survival after either transplantation or resection. Inverse probability weighting and propensity score matching was used for analyses with balanced and equalized baseline characteristics.

RESULTS

Overall, 455 patients were analyzed, including 230 after LR and 225 after LT, with a median follow-up of 97 months [95% confidence interval (CI): 85-110 months]. Multivariable analysis revealed G3 grading as a negative prognostic factor for LR [hazard ratio (HR)=2.22, 95% CI: 1.04-4.77, P =0.040], while G2 grading (HR=2.52, 95% CI: 1.15-5.52, P =0.021) and LT outside Milan criteria (HR=2.40, 95% CI: 1.16-4.92, P =0.018) were negative prognostic factors in transplanted patients. Inverse probability-weighted multivariate analyses revealed a distinct survival benefit after LT. Matched patients presented a median overall survival (OS) of 197 months (95% CI: 143-not reached) and a 73% 5-year OS after LT, and 119 months (95% CI: 74-133 months) and a 52.8% 5-year OS after LR (HR=0.59, 95% CI: 0.3-0.9, P =0.022). However, the survival benefit after LT was lost if patients were transplanted outside Milan criteria.

CONCLUSIONS

This multicentric study in patients with NELM demonstrates a survival benefit of LT over LR. This benefit depends on adherence to selection criteria, in particular low-grade tumor biology and Milan criteria, and must be balanced against potential risks of LT.

Safety, Tolerability, and Preliminary Efficacy of TAR-200 in Patients With Muscle-invasive Bladder Cancer Who Refused or Were Unfit for Curative-intent Therapy: A Phase 1 Study

PURPOSE

Half of patients with muscle-invasive bladder cancer worldwide may not receive curative-intent therapy. Elderly or frail patients are most affected by this unmet need. TAR-200 is a novel, intravesical drug delivery system that provides sustained, local release of gemcitabine into the bladder over a 21-day dosing cycle. The phase 1 TAR-200-103 study evaluated the safety, tolerability, and preliminary efficacy of TAR-200 in patients with muscle-invasive bladder cancer who either refused or were unfit for curative-intent therapy.

MATERIALS AND METHODS

Eligible patients had cT2-cT3bN0M0 urothelial carcinoma of the bladder. TAR-200 was inserted for 4 consecutive 21-day cycles over 84 days. The primary end points were safety and tolerability at 84 days. Secondary end points included rates of clinical complete response and partial response as determined by cystoscopy, biopsy, and imaging; duration of response; and overall survival.

RESULTS

Median age of the 35 enrolled patients was 84 years, and most were male (24/35, 68.6%). Treatment-emergent adverse events related to TAR-200 occurred in 15 patients. Two patients experienced treatment-emergent adverse events leading to removal of TAR-200. At 3 months, complete response and partial response rates were 31.4% (11/35) and 8.6% (3/35), respectively, yielding an overall response rate of 40.0% (14/35; 95% CI 23.9-57.9). Median overall survival and duration of response were 27.3 months (95% CI 10.1-not estimable) and 14 months (95% CI 10.6-22.7), respectively. Progression-free rate at 12 months was 70.5%.

CONCLUSIONS

TAR-200 was generally safe, well tolerated, and had beneficial preliminary efficacy in this elderly and frail cohort with limited treatment options.

Detection and impact of short-range order in medium/high-entropy alloys

Medium/High-entropy alloys (MEAs/HEAs) have attracted much attention during the past two decades and have been studied extensively owing to their excellent physical and mechanical properties. These materials form simple lattice structures and thermodynamically favored single-phase solutions. Despite having a single-phase, the local structure of MEAs/HEAs still contain some degree of order. Recently, short-range order (SRO) has been studied to better understand the local structure of MEAs/HEAs and how this order impacts their properties. Efforts to characterize SRO in high-entropy alloys have included non-imaging methods such as X-ray diffraction and X-ray absorption spectroscopy, as well as imaging methods such as transmission electron microscopy-based techniques. In this perspective, structural studies using non-imaging and imaging techniques to investigate SRO in MEAs/HEAs are discussed. Moreover, the impact of SRO on the physical and mechanical properties of MEAs/HEAs is also covered.

Survival benefits with EPIC in addition to HIPEC for low grade appendiceal neoplasms with pseudomyxoma peritonei: a propensity score matched study

Objectives

Appendiceal cancer is a rare malignancy, occurring in roughly 1.2 per 100,000 per year. Low grade appendiceal neoplasams (LAMN) in particular can lead to pseudomyxoma peritonei (PMP), and respond poorly to systemic chemotherapy. Standard treatment includes cytoreduction surgery (CRS) with addition of heated intraoperative peritoneal chemotherapy (HIPEC). Several centres include early postoperative intraperitoneal chemotherapy (EPIC) however; the literature is mixed on the benefits. We aim to examine the benefits of additional EPIC through a propensity-matched analysis.

Methods

Patients with LAMN with PMP who underwent cytoreductive surgery at St George hospital between 1996 and 2020 were included in this retrospective analysis. Propensity score matching was performed with the following used to identify matched controls; sex, age, American Society of Anesthesiologists (ASA) grade, peritoneal cancer index (PCI) and morbidity grade. Outcomes measured included length of stay and survival.

Results

A total of 224 patients were identified of which 52 received HIPEC alone. Propensity matching was performed to identify 52 matched patients who received HIPEC + EPIC. Those receiving HIPEC + EPIC were younger at 54.3 vs. 58.4 years (p=0.044). There was a median survival benefit of 34.3 months for HIPEC + EPIC (127.3 vs. 93.0 months, p=0.02). Median length of stay was higher in those who received EPIC (25.0 vs. 23.5 days, p=0.028).

Conclusions

In LAMN with PMP, the addition of EPIC to HIPEC with CRS improves overall survival in propensity score matched cases but results in prolonged hospitalisation. The use of EPIC should still be considered in selected patients.

Rucaparib or Physician's Choice in Metastatic Prostate Cancer

BACKGROUND

In a phase 2 study, rucaparib, an inhibitor of poly(ADP-ribose) polymerase (PARP), showed a high level of activity in patients who had metastatic, castration-resistant prostate cancer associated with a deleterious BRCA alteration. Data are needed to confirm and expand on the findings of the phase 2 study.

METHODS

In this randomized, controlled, phase 3 trial, we enrolled patients who had metastatic, castration-resistant prostate cancer with a BRCA1, BRCA2, or ATM alteration and who had disease progression after treatment with a second-generation androgen-receptor pathway inhibitor (ARPI). We randomly assigned the patients in a 2:1 ratio to receive oral rucaparib (600 mg twice daily) or a physician's choice control (docetaxel or a second-generation ARPI [abiraterone acetate or enzalutamide]). The primary outcome was the median duration of imaging-based progression-free survival according to independent review.

RESULTS

Of the 4855 patients who had undergone prescreening or screening, 270 were assigned to receive rucaparib and 135 to receive a control medication (intention-to-treat population); in the two groups, 201 patients and 101 patients, respectively, had a BRCA alteration. At 62 months, the duration of imaging-based progression-free survival was significantly longer in the rucaparib group than in the control group, both in the BRCA subgroup (median, 11.2 months and 6.4 months, respectively; hazard ratio, 0.50; 95% confidence interval [CI], 0.36 to 0.69) and in the intention-to-treat group (median, 10.2 months and 6.4 months, respectively; hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001 for both comparisons). In an exploratory analysis in the ATM subgroup, the median duration of imaging-based progression-free survival was 8.1 months in the rucaparib group and 6.8 months in the control group (hazard ratio, 0.95; 95% CI, 0.59 to 1.52). The most frequent adverse events with rucaparib were fatigue and nausea.

CONCLUSIONS

The duration of imaging-based progression-free survival was significantly longer with rucaparib than with a control medication among patients who had metastatic, castration-resistant prostate cancer with a BRCA alteration. (Funded by Clovis Oncology; TRITON3 ClinicalTrials.gov number, NCT02975934.).

Gene-Expression Profiling of Mucinous Ovarian Tumors and Comparison with Upper and Lower Gastrointestinal Tumors Identifies Markers Associated with Adverse Outcomes

PURPOSE

Advanced-stage mucinous ovarian carcinoma (MOC) has poor chemotherapy response and prognosis and lacks biomarkers to aid stage I adjuvant treatment. Differentiating primary MOC from gastrointestinal (GI) metastases to the ovary is also challenging due to phenotypic similarities. Clinicopathologic and gene-expression data were analyzed to identify prognostic and diagnostic features.

EXPERIMENTAL DESIGN

Discovery analyses selected 19 genes with prognostic/diagnostic potential. Validation was performed through the Ovarian Tumor Tissue Analysis consortium and GI cancer biobanks comprising 604 patients with MOC (n = 333), mucinous borderline ovarian tumors (MBOT, n = 151), and upper GI (n = 65) and lower GI tumors (n = 55).

RESULTS

Infiltrative pattern of invasion was associated with decreased overall survival (OS) within 2 years from diagnosis, compared with expansile pattern in stage I MOC [hazard ratio (HR), 2.77; 95% confidence interval (CI), 1.04-7.41, P = 0.042]. Increased expression of THBS2 and TAGLN was associated with shorter OS in MOC patients (HR, 1.25; 95% CI, 1.04-1.51, P = 0.016) and (HR, 1.21; 95% CI, 1.01-1.45, P = 0.043), respectively. ERBB2 (HER2) amplification or high mRNA expression was evident in 64 of 243 (26%) of MOCs, but only 8 of 243 (3%) were also infiltrative (4/39, 10%) or stage III/IV (4/31, 13%).

CONCLUSIONS

An infiltrative growth pattern infers poor prognosis within 2 years from diagnosis and may help select stage I patients for adjuvant therapy. High expression of THBS2 and TAGLN in MOC confers an adverse prognosis and is upregulated in the infiltrative subtype, which warrants further investigation. Anti-HER2 therapy should be investigated in a subset of patients. MOC samples clustered with upper GI, yet markers to differentiate these entities remain elusive, suggesting similar underlying biology and shared treatment strategies.

Investigating a psychological model of mental conditions and coping during the COVID-19 pandemic driven by participatory methods

BACKGROUND

There is evidence of increased mental health problems during the early stages of the COVID-19 pandemic. We aimed to identify the factors that put certain groups of people at greater risk of mental health problems.

METHODS

We took a participatory approach, involving people with lived experience of mental health problems and/or carers, to generate a set of risk factors and potential moderators of the effects of COVID on mental health. An online cross-sectional survey was completed by 1464 United Kingdom residents between 24th April and 27th June 2020. The survey had questions on whether respondents were existing mental health service users and or carers, level of depression (PHQ9) and anxiety (GAD7), demographics, threat and coping appraisals, perceived resilience (BRS), and specific coping behaviours (validated as part of this study). The relationship between responses and coping strategies was measured using tetrachoric correlations. Structural equation modelling was used to test the model.

RESULTS

A model significantly fit our data (rel χ² = 2.05, RMSEA = 0.029 95%, CI (0.016, 0.042), CFI = 0.99, TLI = 0.98, SRMR = 0.014). Age and coping appraisal predicted anxiety and depression. Whereas, threat appraisal and ethnicity only predicted anxiety, and resilience only predicted depression. Additionally, specific coping behaviours predicted anxiety and depression, with overlap on distraction.

CONCLUSIONS

Some, but not all, risk factors significantly predict anxiety and depression. While there is a relationship between anxiety and depression, different factors may put people at greater risk of one or the other during the pandemic.

Role of immunosuppression in patients with lymphocytic myocarditis and myocardial parvovirus B19 with or without human herpesvirus 6 co-presence

Background

Parvovirus B19 (B19V) and Human Herpesvirus 6 (HHV6) are commonly detected in endomyocardial biopsy (EMB) specimens of patients with myocarditis symptoms. Whether B19V- and HHV6-DNA belong to the cardiac bio-portfolio remains unclear [1,2]. Until today, the role of B19V-/HHV6-DNA presence in myocarditis is doubtful. Both viruses have been detected in the myocardium, even independent of cardiac inflammation. Yet, their contribution to myocarditis remains controversial. The European Society of Cardiology guidelines exclude the use of immunosuppression in patients with virus-associated myocarditis [3]. Whether myocarditis patients with the presence of B19V-DNA alone or with HHV6-DNA in EMB findings can be treated using immunosuppression, remains a delicate question for clinicians.

Methods

931 patients with unexplained heart failure symptoms underwent EMB investigation to determine the underlying cause. Patients with low-levels (&lt;1000 copies/μg DNA) of B19V-DNA and HHV6-DNA were identified. A sub-cohort of 28 patients who suffered from chronic-persistent lymphocytic myocarditis with ongoing symptoms was treated with azathioprine 100 mg once daily and prednisolone 1 mg/kg/day tapered down by 10 mg every two weeks followed by a second EMB. Twenty out of 28 patients had B19V-DNA only (mean LVEF=38%, age=47±15) and eight patients had B19V-/HHV6-DNA copresence (mean LVEF=39%, age=42±10). Patients with systemic infections were excluded. Both cohorts received standard heart failure medications. Continuous variables are expressed as mean±SD.

Results

B19V-DNA alone and in the presence of HHV6-DNA was detectable in the EMB of 377 and 63 patients, respectively. Following the immunosuppression course, the patients with B19V-DNA only and those with B19V-/HHV6-DNA showed complete resolution of inflammation in 12/20 and 5/8 patients, New York Heart Association (NYHA) functional class improvement in 9/20 and 4/8 patients, LVEF improvement by 8.0±13.8% (p&lt;0.05) and 8.4±9.6% (p&lt;0.05), and a reduction of LVEDD by 3.8±6.1mm (p&lt;0.05) and 1.0±7.7mm (p&gt;0.05), respectively. Importantly, following immunosuppression B19V and HHV6-DNA copy numbers went down from 186±266 to 130±186 copies/μg DNA and from 71±141 to 58±143 copies/μg DNA, respectively.

Conclusion

Chronic lymphocytic myocarditis patients with persistent B19V-DNA even in co-presence of HHV6-DNA may benefit from combined immunosuppression therapy. The therapy is clinically effective and safe to reduce cardiac inflammation independent of B19V- and HHV6-DNA copy numbers. In conclusion, we show for the first time that cases with chronic lymphocytic myocarditis can be principally treated with immunosuppression, despite B19V-/HHV6-DNA EMB presence.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Berlin Institute of Health-Center for Regenerative Therapies

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Incorporation of Hydrophilic Macrocycles Into Drug-Linker Reagents Produces Antibody-Drug Conjugates With Enhanced in vivo Performance

Antibody-drug conjugates (ADCs) have begun to fulfil their promise as targeted cancer therapeutics with ten clinical approvals to date. As the field matures, much attention has focused upon the key factors required to produce safe and efficacious ADCs. Recently the role that linker-payload reagent design has on the properties of ADCs has been highlighted as an important consideration for developers. We have investigated the effect of incorporating hydrophilic macrocycles into reagent structures on the in vitro and in vivo behavior of ADCs. Bis-sulfone based disulfide rebridging reagents bearing Val-Cit-PABC-MMAE linker-payloads were synthesized with a panel of cyclodextrins and crown ethers integrated into their structures via a glutamic acid branching point. Brentuximab was selected as a model antibody and ten ADCs with a drug-to-antibody ratio (DAR) of 4 were prepared for biological evaluation. In vitro, the ADCs prepared showed broadly similar potency (range: 16–34 pM) and were comparable to Adcetris® (16 pM). In vivo, the cyclodextrin containing ADCs showed greater efficacy than Adcetris® and the most efficacious variant (incorporating a 3′-amino-α-cyclodextrin component) matched a 24-unit poly(ethylene glycol) (PEG) containing comparator. The ADCs bearing crown ethers also displayed enhanced in vivo efficacy compared to Adcetris®, the most active variant (containing a 1-aza-42-crown-14 macrocycle) was superior to an analogous ADC with a larger 24-unit PEG chain. In summary, we have demonstrated that hydrophilic macrocycles can be effectively incorporated into ADC reagent design and offer the potential for enhanced alternatives to established drug-linker architectures.

Democratizing germline genetic testing and its impact on prostate cancer clinical decision-making

10500

Background: Approximately 10-15% of prostate cancer (PCa) patients (pts) have a pathogenic germline variant (PGV). Identification of a PGV has important implications affecting decisions regarding cancer screening, treatment selection, and family cascade testing. There exists limited data documenting real world recommendations post germline genetic testing (GGT). This study was designed to collect clinician reported outcomes from PCa pts who underwent GGT. Methods: An IRB-approved, nationwide, prospective registry recruited unselected PCa pts from 15 community and academic urology practices. Pts underwent an 84-gene panel test, with clinical outcomes collected via clinician-completed case report forms > 1-month post GGT. Statistical significance was determined by two-tailed Fisher’s exact test. Results: 982 predominantly white (75.9%), non-metastatic (80.7%) males with PCa were recruited; 56.9% met National Comprehensive Cancer Network (NCCN) GGT criteria. Average age was 65.3 years at PCa diagnosis. PGVs, most commonly CHEK2 (17) and BRCA2 (10), were identified in 100 (10.2%) pts; 34 (34%) of these did not meet NCCN GGT criteria. Among PGV positive pts, 241 recommendations were made (Table). They were more likely to have changes to treatment (p < 0.0001), follow up (p < 0.0001) and cascade testing recommendations (p < 0.0001) than those with negative/variant of uncertain significance (VUS) results. There were no significant differences in changes to treatment (p = 0.4471) or follow up (p = 0.861) for pts who met NCCN criteria versus those who did not. 7 pts with PGVs received targeted therapy or were referred to a clinical trial. 5 pts with VUS results were also referred to a clinical trial. Among these 12 pts, 6 (50%, 2 CHEK2 PGV, 1 ATM PGV, 1 VUS each ATM, BLM, CHEK2) did not meet NCCN GGT criteria. Referral to a genetic counselor was the most common follow up recommendation for those with PGV (38 patients, 38%) and VUS results (66, 13.7%). The most commonly reported impact to health outcomes for those with negative results was knowledge/reassurance (38, 7.88%). Conclusions: This study showed that GGT did influence PCa pts care. Appropriately, pts with PGVs received a greater number of recommendations for relatives, changes to follow up and treatment. [Table: see text]

OP0190 COMPREHENSIVE GENETIC AND FUNCTIONAL ANALYSES OF Fc GAMMA RECEPTORS EXPLAIN RESPONSE TO RITUXIMAB THERAPY FOR AUTOIMMUNE RHEUMATIC DISEASES

Background

Rituximab is widely used to treat rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) but clinical response varies. Efficacy is determined by the efficiency of depletion, which may depend on a variety of Fc gamma receptor (FcγR)-dependent mechanisms. Previous research was limited by complexity of the FCGR locus, not integrating copy number variation with functional SNP, and small sample size.

Objectives

The study objectives were to assess the effect of the full range of FcγRs variants on depletion, clinical response and functional effect on NK-cell-mediated killing in two rheumatic diseases with a view to personalised B-cell depleting therapies.

Methods

A prospective longitudinal cohort study was conducted in 873 patients [RA=611; SLE=262] from four cohorts (BSRBR-RA and BILAG-BR registries, Leeds RA and Leeds SLE Biologics). For RA, the outcome measures were 3C-DAS28CRP and 2C-DAS28CRP at 6 (+/-3) months post-rituximab (adjusted for baseline DAS28). For SLE, major clinical response (MCR) was defined as improvement of active BILAG-2004 domains to grade C/better at 6 months. B-cell depletion was evaluated by highly-sensitive flow cytometry. Qualitative and quantitative polymorphisms for five major FcγRs were measured using a commercial multiplex ligation-dependent probe amplification. Median NK cell FcγRIIIa expression (CD3-CD56+CD16+) and NK-cell degranulation (CD107a) in the presence of rituximab-coated Daudi/Raji B-cell lines were assessed using flow cytometry.

Results

In RA, for FCGR3A, carriage of V allele (coefficient -0.25 (SE 0.11); p=0.02) and increased copies of V allele (-0.20 (0.09); p=0.02) were associated with greater 2C-DAS28 response. Irrespective of FCGR3A genotype, increased gene copies were associated with a better response. In SLE, 177/262 (67.6%) achieved BILAG response [MCR=34.4%; Partial=33.2%]. MCR was associated with increased copies of FCGR3A-158V allele, OR 1.64 (95% CI 1.12-2.41) and FCGR2C-ORF allele 1.93 (1.09-3.40). Of patients with B-cells data in the combined cohort, 236/413 (57%) achieved complete depletion post-rituximab. Only homozygosity for FCGR3A-158V and increased FCGR3A-158V copy number were associated with increased odds of complete depletion. Patients with complete depletion had higher NK cell FcγRIIIa expression at rituximab initiation than those with incomplete depletion (p=0.04) and this higher expression was associated with improved EULAR response in RA. Moreover, for FCGR3A, degranulation activity was increased in V allele carriers vs FF genotype in the combined cohort; p=0.02.

Conclusion

FcγRIIIa is the major low affinity FcγR and increased copies of the FCGR3A-158V allele, encoding the allotype with a higher affinity for IgG1, was associated with clinical and biological responses to rituximab in two autoimmune diseases. This was supported by functional data on NK cell-mediated cytotoxicity. In SLE, increased copies of the FCGR2C-ORF allele was also associated with improved response. Our findings indicate that enhancing FcγR-effector functions could improve the next generation of CD20-depleting therapies and genotyping could stratify patients for optimal treatment protocols.

References

None

Acknowledgements

This research was funded/supported by the joint funding from the Medical Research Council (MRC) and Versus Arthritis of MATURA (grant codes 36661 and MR/K015346/1). MASTERPLANS was funded by the MRC (grant code MR/M01665X/1). The Leeds Biologics Cohort was part funded by programme grants from Versus Arthritis (grant codes 18475 and 18387), the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre (BRC) and Diagnostic Evaluation Co-operative and the Ann Wilks Charitable Foundation. The BILAG-BR has received funding support from Lupus UK, and unrestricted grants from Roche and GSK.

The functional studies were in part supported through a NIHR/HEFCE Clinical Senior Lectureship and a Versus Arthritis Foundation Fellowship (grant code 19764) to AWM, the Wellcome Trust Institutional Strategic Support Fund to JIR and MYMY (204825/Z/16/Z), NIHR Doctoral Research Fellowship to MYMY (DRF-2014-07-155) and NIHR Clinician Scientist to EMV (CS-2013-13-032). . AWM, INB, JDI and PE were supported by NIHR Senior Investigator awards. Work in JDI’s laboratory is supported by the NIHR Newcastle BRC, the Research Into Inflammatory Arthritis Centre Versus Arthritis, and Rheuma Tolerance for Cure (European Union Innovative Medicines Initiative 2, grant number 777357). INB is funded by the NIHR Manchester BRC.

This article/paper/report presents independent research funded/supported by the NIHR Leeds BRC and the NIHR Guy’s and St Thomas’ BRC. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Disclosure of Interests

Md Yuzaiful Md Yusof: None declared, James Robinson: None declared, Vinny Davies: None declared, Dawn Wild: None declared, Michael Morgan: None declared, John Taylor: None declared, Yasser El-Sherbiny: None declared, David Morris: None declared, Lu Liu: None declared, Andrew Rawstron: None declared, Maya H Buch: None declared, Darren Plant: None declared, Heather Cordell: None declared, John Isaacs: None declared, Ian N. Bruce: None declared, Paul Emery Speakers bureau: Roche, Consultant of: Roche, Grant/research support from: Roche, Anne Barton: None declared, Timothy Vyse: None declared, Jennifer Barrett: None declared, Edward Vital Consultant of: Roche, Grant/research support from: Roche, Ann Morgan Speakers bureau: Roche/Chugai, Consultant of: GSK, Roche, Chugai, AstraZeneka, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals

Multi-principal elemental intermetallic nanoparticles synthesized via a disorder-to-order transition

Nanoscale multi-principal element intermetallics (MPEIs) may provide a broad and tunable compositional space of active, high-surface area materials with potential applications such as catalysis and magnetics. However, MPEI nanoparticles are challenging to fabricate because of the tendency of the particles to grow/agglomerate or phase-separated during annealing. Here, we demonstrate a disorder-to-order phase transition approach that enables the synthesis of ultrasmall (4 to 5 nm) and stable MPEI nanoparticles (up to eight elements). We apply just 5 min of Joule heating to promote the phase transition of the nanoparticles into L1₀ intermetallic structure, which is then preserved by rapidly cooling. This disorder-to-order transition results in phase-stable nanoscale MPEIs with compositions (e.g., PtPdAuFeCoNiCuSn), which have not been previously attained by traditional synthetic methods. This synthesis strategy offers a new paradigm for developing previously unexplored MPEI nanoparticles by accessing a nanoscale-size regime and novel compositions with potentially broad applications.

Oral piercings and orthodontic treatment: A questionnaire-based national survey

OBJECTIVE

To obtain opinions from orthodontic colleagues nationally on how they currently manage orthodontic patients with oral piercings. The secondary objectives were to assimilate the national opinions from the survey and attempt to generate educational material as an advice sheet and a patient information leaflet for the professionals and the patients respectively for the British Orthodontic Society (BOS).

DESIGN

Cross-sectional survey.

SETTING

Primary and secondary care orthodontic providers.

PARTICIPANTS

Members of the BOS.

METHODS

An electronic questionnaire was developed and circulated to members of the BOS to obtain their opinions on the effects of oral piercings on their patients' orthodontic treatment 'journey'. In addition, the need for the development of informative material around the management of orthodontic treatment and appliances in patients with oral piercings was explored.

RESULTS

A total of 110 responses were received. However, only 88 respondents out of 110 attempted all the questions within the survey. There were 22 respondents who attempted it partially. We did include these partial responses well while analysing the results, since many of these offered personalised comments in the free-text boxes within the survey.

CONCLUSION

The most common general complications associated with oral piercings were inflammation of the surrounding tissue and enamel/dentine wear. Moreover, orthodontic complications, reported commonly, were inadequate oral hygiene maintenance, entanglement with the orthodontic appliance causing damage and interference with retainers. Most respondents expressed the need for the development of a web-based patient information leaflet and an advice sheet as educational tool, both of which have been proposed to and agreed by the BOS before submission of this publication.

A Phase 2 Trial of Response-Based Radiation Therapy for Localized Central Nervous System Germ Cell Tumors: Patterns of Failure and Radiation Dosimetry for Nongerminomatous Germ Cell Tumors

PURPOSE

Children's Oncology Group study ACNS1123 tested the efficacy of reduced dose and field of radiation therapy (RT) for patients with localized nongerminomatous germ cell tumors (NGGCT) who achieved a complete (CR) or partial response (PR) to chemotherapy. Here, we evaluate the quality of RT and patterns of failure for patients eligible for reduced RT in this phase 2 trial.

METHODS AND MATERIALS

Patients with localized NGGCT with CR/PR after induction chemotherapy received reduced RT to 30.6 Gy whole ventricular irradiation and 54 Gy tumor-bed total dose. An atlas was provided to assist with complex RT volumes. Early interventional review was performed for the initial RT plan. Complete RT plans for all patients and images of relapsed patients were centrally reviewed at completion of therapy.

RESULTS

Between May 2012 and September 2016, 107 eligible patients were enrolled and 66 achieved a CR/PR after induction chemotherapy (± second-look surgery) and were eligible for reduced RT. Median follow-up was 4.4 years. Median age was 11.0 years (3.7-21.6), and 75% were male. Progression-free survival and overall survival at 4 years were 87.9% ± 4.0% and 92.4% ± 3.3% for 66 evaluable patients, respectively. Eight patients relapsed: 6 with isolated spinal relapse and 2 with disease in the brain and spine. After central review, 62 (94%) patients had RT targets contoured and dose delivered per protocol. None of the patients with deviations (n = 4) have progressed.

CONCLUSIONS

Patterns of failure suggest the spine is at risk for recurrence for patients with localized NGGCT who receive reduced RT after a CR/PR to induction chemotherapy. Although survival data are encouraging, the pattern of failure has influenced the next prospective trial design. RT compliance was excellent despite complexity of radiation volumes, suggesting that providing visual guidance in the form of an online atlas contributes to higher quality RT plans.

Video game rehabilitation for outpatient stroke (VIGoROUS): A multi-site randomized controlled trial of in-home, self-managed, upper-extremity therapy

BACKGROUND

Integrating behavioral intervention into motor rehabilitation is essential for improving paretic arm use in daily life. Demands on therapist time limit adoption of behavioral programs like Constraint-Induced Movement (CI) therapy, however. Self-managed motor practice could free therapist time for behavioral intervention, but there remains insufficient evidence of efficacy for a self-management approach.

METHODS

This completed, parallel, five-site, pragmatic, single-blind trial established the comparative effectiveness of using in-home gaming self-management as a vehicle to redirect valuable therapist time towards behavioral intervention. Community-dwelling adults with post-stroke (>6 months) mild/moderate upper extremity hemiparesis were randomized to receive one of 4 different interventions over a 3-week period: 5 h of behaviorally-focused intervention plus gaming self-management (Self-Gaming), the same with additional behaviorally-focused telerehabilitation (Tele-Gaming), 5 h of Traditional motor-focused rehabilitation, or 35 h of CI therapy. Primary outcomes assessed everyday arm use (Motor Activity Log Quality of Movement, MAL) and motor speed/function (Wolf Motor Function Test, WMFT) immediately before treatment, immediately after treatment, and 6 months later. Intent-to-treat analyses were implemented with linear mixed-effects models on data gathered from March 15, 2016 to November 21, 2019. ClinicalTrials.gov, NCT02631850.

RESULTS

Of 193 enrolled participants, 167 began treatment and were analyzed, 150 (90%) completed treatment, and 115 (69%) completed follow-up. Tele-Gaming and Self-Gaming produced clinically meaningful MAL gains that were 1·0 points (95% CI 0·8 to 1·3) and 0·8 points (95% CI 0·5 to 1·0) larger than Traditional care, respectively. Self-Gaming was less effective than CI therapy (-0·4 points, 95% CI -0·6 to -0·2), whereas Tele-Gaming was not (-0·2 points, 95% CI -0·4 to 0·1). Six-month retention of MAL gains across all groups was 57%. All had similar clinically-meaningful WMFT gains; six-month retention of WMFT gains was 92%.

INTERPRETATION

Self-managed motor-gaming with behavioral telehealth visits has outcomes similar to in-clinic CI therapy. It addresses most access barriers, requiring just one-fifth as much therapist time that is redirected towards behavioral interventions that enhance the paretic arm's involvement in daily life.

FUNDING

PCORI, NIH.

Risk factors and clinical outcomes in patients undergoing cytoreductive surgery with concomitant ureteric reimplantation

Objectives

There are currently scarce data exploring ureteric reimplantation (UR) during cytoreductive surgery (CRS).

Methods

We identified patients undergoing CRS for peritoneal surface malignancies (PSM) of any origin at a single high-volume unit. UR was defined as ureteroureterostomy, transureterouretostomy, ureteroneocystostomy, ureterosigmoidostomy or ileal conduit performed during CRS. Peri-operative outcomes, long-term survival and risk factors for requiring UR were analysed.

Results

Seven hundred and sixty-seven CRSs were identified. Twenty-three (3.0%) procedures involved UR. Bladder resection and colorectal cancer (CRC) were associated with increased risk of UR (bladder resection: OR 12.90, 95% CI 4.91–33.90, p<0.001; CRC: OR 2.51, 95% CI 1.05–6.01, p=0.038). UR did not increase the risk of Grade III–IV morbidity or mortality. The rate of ureteric leak was 3/23 (13.0%) in the UR group. Mean survival was equivocal in patients with CRC (58.14 vs. 34.25 months, p=0.441) but significantly lower in those with high-grade appendiceal mucinous neoplasm (HAMN) undergoing UR (73.98 vs. 30.90 months, p=0.029).

Conclusions

UR during CRS does not increase major morbidity or mortality for carefully selected patients, and is associated with low rates of urologic complications. Whilst decreased survival was apparent in patients with HAMN undergoing UR, it is unclear whether this relationship is causal.

Acceptability of constraint induced movement therapy: influence of perceived difficulty and expected treatment outcome

BACKGROUND

Constraint-Induced Movement (CI) Therapy has evidence of efficaciously rehabilitating upper-extremity hemiparesis after stroke. Yet, it is not widely used in the United States. One barrier appears to be the perception of its difficulty among stroke care consumers, as reported by two published studies in which the participants had little or no apparent direct exposure to CI Therapy.

OBJECTIVES

Assess the perception of difficulty of CI Therapy by individuals with chronic stroke who have actually undergone CI Therapy.

METHODS

A secondary analysis was conducted of data from two randomized controlled trials of CI Therapy. Participants had chronic, mild-to-moderate upper-extremity hemiparesis after stroke. The Motor Activity Log and Wolf Motor Function Test were used to measure motor function of the more-affected arm. A Patient Opinion Survey assessed participants' perception of difficulty and satisfaction with treatment.

RESULTS

The participants (N = 40) showed large improvements in motor function of their more-affected arm after treatment, p's <001. CI Therapy was perceived to be of only moderate difficulty by participants before treatment (mean = 4.4 out of 7). Perception of its difficulty decreased afterward (mean = 3.7, p = .002). Moreover, participants were highly satisfied with their outcomes (mean = 6.3 out of 7). Satisfaction was positively related to the improvements in more-affected arm use in everyday life, ΔR² = .3, p < .001.

CONCLUSIONS

Chronic stroke survivors who have actually had CI Therapy perceive it to be of only moderate difficulty and are highly satisfied. Negative views about its acceptability warrant reconsideration.

Patterns of peritoneal dissemination and response to systemic chemotherapy in common and rare peritoneal tumours treated by cytoreductive surgery: study protocol of a prospective, multicentre, observational study

INTRODUCTION

Despite optimal patient selection and surgical effort, recurrence is seen in over 70% of patients undergoing cytoreductive surgery (CRS) for peritoneal metastases (PM). Apart from the Peritoneal Cancer Index (PCI), completeness of cytoreduction and tumour grade, there are other factors like disease distribution in the peritoneal cavity, pathological response to systemic chemotherapy (SC), lymph node metastases and morphology of PM which may have prognostic value. One reason for the underutilisation of these factors is that they are known only after surgery. Identifying clinical predictors, specifically radiological predictors, could lead to better utilisation of these factors in clinical decision making and the extent of peritoneal resection performed for different tumours. This study aims to study these factors, their impact on survival and identify clinical and radiological predictors.

METHODS AND ANALYSIS

There is no therapeutic intervention in the study. All patients with biopsy-proven PM from colorectal, appendiceal, gastric and ovarian cancer and peritoneal mesothelioma undergoing CRS will be included. The demographic, clinical, radiological, surgical and pathological details will be collected according to a prespecified format that includes details regarding distribution of disease, morphology of PM, regional node involvement and pathological response to SC. In addition to the absolute value of PCI, the structures bearing the largest tumour nodules and a description of the morphology in each region will be recorded. A correlation between the surgical, radiological and pathological findings will be performed and the impact of these potential prognostic factors on progression-free and overall survival determined. The practices pertaining to radiological and pathological reporting at different centres will be studied.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Zydus Hospital ethics committee (27 July, 2020) and Lyon-Sud ethics committee (A15-128).

TRIAL REGISTRATION NUMBER

CTRI/2020/09/027709; Pre-results.

Abstract 445: Genomic characteristics and response to rucaparib and enzalutamide in the phase 1b RAMP study of metastatic castration-resistant prostate cancer (mCRPC) patients

Background: Rucaparib, a poly(ADP-ribose) polymerase inhibitor (PARPi), is approved in the US as monotherapy for patients (pts) with BRCA1/2-mutated mCRPC after androgen receptor (AR)-directed therapy and a taxane. Synthetic lethality has been observed in studies combining AR-directed therapy (eg, enzalutamide) and a PARPi, independent of DNA-damage repair (DDR) gene defects. The RAMP study (NCT04179396) is investigating the safety and potential drug-drug interactions (DDIs) between rucaparib and enzalutamide in unselected mCRPC pts. In this exploratory analysis, we evaluated the association between treatment response and gene alterations of known clinical significance in mCRPC.

Methods: Enrolled pts were previously treated with 0-2 lines of AR-directed therapy and ≤2 lines of chemotherapy for mCRPC. A 1-week run-in of rucaparib monotherapy (600 mg BID) was followed by rucaparib (600 mg BID) + enzalutamide (160 mg QD). Primary endpoints were pharmacokinetics (PK) and safety, including dose-limiting toxicities (DLTs). Change in prostate-specific antigen (PSA) levels from baseline was a secondary endpoint. As an exploratory objective, plasma and/or tissue samples were profiled for genomic alterations using a Foundation Medicine, Inc., assay to evaluate the relationship between genomics and clinical outcome.

Results: As of Oct 1, 2020, 8 pts had received treatment; 7 were evaluable for PK and 6 for DLTs. The median age was 68.5 years and 7/8 (88%) pts had received 1 or 2 prior AR-directed therapies. The PK and overall safety profiles of rucaparib + enzalutamide were consistent with each as a single agent, and no DLTs were reported. Overall, 6/8 (75%) pts had a PSA decline, with 4/8 (50%) pts meeting criteria for a confirmed PSA response (≥50% decrease from baseline). Genomic data were available for 6/8 (75%) pts, all of whom had received prior AR-directed therapy. Of the 4/6 (66%) pts who had one or more somatic AR alterations, 3 had a PSA decline (best PSA change of -99%, -22%, and -17% from baseline) with the combination treatment. One pt had a DDR gene mutation, a subclonal (&lt;1% allele frequency) alteration of CHEK2 with no PSA decline observed; no BRCA1/2 or PALB2 alterations were identified. Mutations in TP53 and PTEN were observed in 4/6 (67%) and 2/6 (33%) pts, respectively.

Conclusions: A combination of enzalutamide and rucaparib had an acceptable safety profile and no clinically significant DDIs. In this small pt set, pts previously treated with AR-directed therapies showed responses to the combination even in the presence of AR alterations and in the absence of DDR gene alterations. These genomic and early efficacy data support further studies of rucaparib and enzalutamide at the recommended combination dose (rucaparib 600 mg BID + enzalutamide 160 mg QD), including in the phase 3 CASPAR study in biomarker-unselected mCRPC pts (NCT04455750).

Citation Format: Arpit Rao, Charles J. Ryan, David Morris, Vasileios Assikis, Gautam Jha, Adriel-John Ablaza, Jenn Habeck, Andrea Loehr, Jim Xiao, Esha A. Gangolli. Genomic characteristics and response to rucaparib and enzalutamide in the phase 1b RAMP study of metastatic castration-resistant prostate cancer (mCRPC) patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 445.

Darolutamide (DARO) tolerability from extended follow up and treatment response in the phase 3 ARAMIS trial

5079

Background: Patients (pts) with nonmetastatic castration-resistant prostate cancer (nmCRPC) need therapy that prolongs survival with little added toxicity, thus preserving quality of life. The second-generation androgen receptor inhibitors (ARIs) including DARO, apalutamide, and enzalutamide offer durable survival in nmCRPC but differences exist in AE profiles (eg, fatigue, falls, fractures, rash, mental impairment, and hypertension) that can limit daily activities. These AEs may require dose modifications and limit pts’ willingness to continue treatment, with an adverse impact on efficacy. DARO is a structurally distinct ARI that significantly extended metastasis-free survival and overall survival (OS) vs placebo (PBO) in ARAMIS (NCT02200614), with minimal AE risk. We report tolerability from extended follow-up and treatment response analyses from ARAMIS. Methods: Pts with nmCRPC (N=1509) were randomized 2:1 to DARO or PBO with androgen deprivation therapy. The ARAMIS trial was unblinded at the primary analysis, after which all pts could receive open-label (OL) DARO. Tolerability was assessed every 16 weeks. Pharmacodynamic modeling investigated the association between treatment response (maximum prostate-specific antigen [PSA] decline from baseline) and OS at 2 years using a Cox proportional hazards model. Results: As shown in the table, DARO remained well tolerated over the double-blind (DB) and OL periods: 98.8% of pts on DARO received the full planned dose and almost all pts with dose modifications were able to resume and re-establish the planned dose (DARO 89.6% vs PBO 89.7%). Discontinuation of DARO due to AEs increased slightly from the DB period (9.0%) to the DB+OL period (10.5%). Pharmacodynamic modeling showed that longer OS was positively associated with maximum PSA decline in DARO-treated pts. Conclusions: DARO remained well tolerated with extended treatment at the recommended dose of 600 mg twice daily. Almost all pts with nmCRPC were able to receive the full planned dose, increasing the likelihood of clinical benefit from effective disease control (PSA decline) and prolonged survival. Tolerability of different ARIs in the real world should be assessed. Clinical trial information: NCT02200614. [Table: see text]

Underdiagnosis of germline genetic prostate cancer: Are genetic testing guidelines an aid or an impediment?

10504

Background: Pathogenic/likely pathogenic (P/LP) germline genetic variants are estimated to occur in 10-15% of all prostate cancer (PCa) patients. However, genetic testing for PCa patients is underutilized, partially due to complicated and restrictive testing guidelines developed at a time when the cost of testing was high. We conducted a study based in community urology clinics to determine the incidence of P/LP variants in PCa patients who met and did not meet the NCCN 2019 PCa germline genetic testing criteria. Methods: An IRB-approved, multicenter, prospective registry was initiated with 15 community and academic urologists nationwide. Eligibility criteria included patients with a PCa diagnosis unselected for personal or family history, stage or histology who had not been previously tested. Consecutive patients ages 18-90 were consented and underwent an 84-gene germline panel test. HIPAA-compliant electronic case report forms distributed to clinician collected information on patient diagnoses, NCCN testing criteria, and results-based recommendations. Results: To date, 640 enrolled patients have genetic testing results available. Overall, 69 (10.8%) patients had 72 P/LP variants detected, 15% of which were in BRCA1/2. Of the 532 patients for whom we have clinician-reported data, 293 (55%) met NCCN criteria and 239 (45%) did not. Median age was 70 (range 44-90). Overall, 11.1% (59/532) of patients with clinician-reported data had a P/LP variant. 36 (12.3%) of patients who met NCCN criteria and 23 (9.6%) of patients who did not meet criteria had a P/LP variant. The difference in P/LP rate between the two groups was not statistically significant (p=0.33). If only a conservative 12-gene PCa panel was considered, P/LP yield was 5.5% (29/532), with 8 (28%) of these patients missed by guidelines. Stratification by self-reported ethnicity was: 76% White/Caucasian (52 patients w/ P/LP), 18% Black/African American (2 patients w/ P/LP), and <5% each of Hispanic or Asian. Conclusions: There was no statistically significant difference in the yield of P/LP variants between patients who met and those who did not meet NCCN PCa guidelines, reinforcing that a significant number of P/LP variants are missed if NCCN guidelines are required for genetic testing. Expanded panel testing yields more medically actionable P/LP variants than testing BRCA1/2 alone or PCa panels with 12 genes. While 18% of the cohort was Black/African American, there was a lower P/LP rate (2%) relative to other groups, indicating that more research is needed to understand genetic variation in underrepresented populations with PCa.

Nutrition in Physical Therapist Practice: Tools and Strategies to Act Now

It has been established that physical therapist practice includes screening for and providing information on diet and nutrition to patients, clients, and the community. Yet, an overwhelming amount of often contradictory diet and nutrition information poses a challenge for physical therapists to identify and maintain knowledge that they can rely on to screen for and discuss these topics with their patients, clients, and community members. The purposes of this perspective paper are to summarize the best known screening tools for general health, diet, and nutrition; provide intervention strategies that can be used to support behavior change related to diet and nutrition; and identify the most relevant resources and approaches from which physical therapist clinicians can build skill in addressing the nutritional needs of patients, clients, and the community.

Nutrition in Physical Therapist Practice: Setting the Stage for Taking Action

Diet and nutrition are critical components of health, recovery from disease and illness, performance, and normal growth across the lifespan. Thus, it is important for physical therapists to be knowledgeable about nutrition and to have competency in providing information and guidance to patients/clients. Yet, there is an overwhelming amount of diet and nutrition information available from numerous sources, which makes it difficult to reach conclusions and determine the importance and relevance to patient care. The purpose of this perspective paper is to increase the knowledge and skills of physical therapists by providing guidelines for healthy eating and outlining diet and nutrition information most relevant for physical therapist practice and to clarify professional scope of practice related to diet and nutrition, including boundaries created by law, and the connection between healthy eating and health outcomes, muscle strength, bone health, and wound healing.

State of the Art Care in Computer-Assisted Facial Prosthetic Rehabilitation

ABSTRACT

Autologous reconstruction for major facial defects is primarily considered for patient's lifetime care. There are situations, however, when autologous reconstruction is not ideal or feasible, and prosthetic reconstruction is necessary to reconstruct missing anatomy or to complement surgical reconstruction. The history of facial prosthetic reconstruction can be traced for millennia. At our craniofacial center, craniomaxillofacial prosthetic rehabilitation has been incorporated in the care provided to our patients since the center's inception, more than 70 years ago.The purpose of this review is to present the evolution of our current thinking based on our long experience since the implementation of computer-assistive technologies over 15 years ago, to further improve our patients' overall rehabilitation.These applications include all stages of prosthetic care from planning, design through device delivery, and for lifetime maintenance. The collaboration among surgeons and anaplastologists is fundamental to achieving optimal patient outcomes and in the success of our technology-based practice. Such collaboration starts with the patient's decision to proceed with prosthetic rehabilitation and continues with postoperative care and lifetime management of the patient's prosthetic device and prosthesis-bearing soft tissue.Although computer-assistive techniques often represent a substantial financial investment, the benefits of using them demonstrate clear advantages to both the clinician and patient. These benefits include: Improved predictability of outcomes, surgeon preparedness, reduction in operating room time, reduction in overall treatment times, improved precision and anatomical accuracy, improved treatment efficiencies, and overall treatment experience, particularly for those patients traveling great distances for access to care.Representative examples will be presented.