A Phase II Trial of Intravesical Gemcitabine and Docetaxel in the Treatment of Bacillus Calmette-Guérin‒Naïve Nonmuscle-Invasive Urothelial Carcinoma of the Bladder

PURPOSE

Combination intravesical gemcitabine and docetaxel (GemDoce) has demonstrated efficacy as second-line therapy for patients with bacillus Calmette-Guérin (BCG)‒unresponsive nonmuscle-invasive urothelial carcinoma of the bladder (NMIBC). In the context of widespread BCG shortages, we performed a phase 2 prospective trial to assess GemDoce for BCG-naïve NMIBC.

MATERIALS AND METHODS

This study is a prospective, single-arm, open-label phase 2 trial for patients with BCG-naïve high-risk NMIBC. Intravesical GemDoce was given weekly for 6 weeks as induction followed by monthly maintenance therapy for 2 years among responders. The primary end point was 3-month complete response, and key secondary end points included adverse events (AEs) and 12-month recurrence-free survival.

RESULTS

Twenty-five patients were enrolled between August 2020 and August 2022 with median follow-up of 19.6 months. The pretrial pathologic stages were high-grade (HG) T1 with carcinoma in situ (CIS; n = 7), HGT1 without CIS (n = 6), HGTa (n = 9), and CIS alone (n = 3). The 3-month complete response rate was 100% and recurrence-free survival at 12 months was 92%. Two patients with pretrial HGT1 had HGT1 recurrences at 9 and 12 months. No patients progressed to T2 disease, underwent radical cystectomy, or had any radiographic evidence of progressive disease. Grade 1 AEs were common (23/25 patients) including hematuria, urinary frequency, urgency, and fatigue. Five patients (20%) experienced a grade 3 AE including hematuria and UTI.

CONCLUSIONS

In this single-arm phase 2 trial, GemDoce was well tolerated with promising efficacy for patients with BCG-naïve high-risk NMIBC.

Clinical Risk Factors Associated With Small Renal Mass Malignant Histology in a Multi-Ethnic Population Undergoing Partial Nephrectomy

INTRODUCTION

Small renal masses (SRMs) are often incidentally diagnosed, and a large proportion are malignant. However, there is a paucity of data describing predictors of malignancy in minority patients with SRMs. Thus, our goal was to examine clinical risk factors associated with SRM malignant histology in patients undergoing partial nephrectomy (PN) a diverse, urban academic center.

MATERIALS AND METHODS

Patients with a SRM undergoing PN at a single institution between 2010 to 2018 were reviewed. Demographic, clinical, and imaging characteristics were compared to pathology results. Logistic regression was used to examine associations between demographic/clinical variables for malignant and high-grade histology.

RESULTS

In total, 331 patients who underwent PN for SRM were included. Of those, 264 (79.8%) had malignant histology while 67 (20.2%) had benign histology. The proportions of men and of current smokers were significantly higher among patients with malignant histology. In multivariate models, non-Hispanic Black (NHB) patients had increased odds of having malignant histology (OR 2.46, 95% CI: 1.01-5.99, P = .048) and current smokers (OR = 4.02; 95% CI 1.14-14.18, P = .031). Hispanic patients had a 3-fold increased risk of high-grade RCC (OR 3.06, 95% CI: 1.19-7.87, P = 0.02) compared to Non-Hispanic White patients.

CONCLUSION

In our population, male sex, smoking, and NHB race/ethnicity was associated with an increased risk of malignancy in patients undergoing partial nephrectomy for SRM. Older age and Hispanic race/ethnicity were associated with high grade RCC. Our results suggest that urologists should exercise a higher level of vigilance in managing and treating SRM among NHB and Hispanic patients.

A Non-Resolving "Hematoma" Diagnosed as an Arteriovenous Malformation by POCUS

Point-of-care ultrasound (POCUS) is a useful tool for the evaluation of soft tissue masses. We present the case of a patient with a mass on his forehead initially thought to be a slowly resolving hematoma. POCUS examination of the mass revealed a vascular structure more consistent with a post-traumatic arteriovenous malformation (AVM). This case illustrates how POCUS can be utilized to rapidly assess soft tissue masses and even identify unexpected vascularity.

Individual and organizational perceptions of hospital workers during COVID-19: the link with burnout

Background

The COVID-19 crisis poses challenges to healthcare systems and their employees. Medical staff are at the front of the battle against COVID-19. They must cope with a crisis accompanied by personal health and occupational ramifications and ongoing job stressors, which may lead to adverse mental health symptoms and may affect the quality of medical care provided to patients. This study evaluated health workers' perceptions and concerns about the COVID-19 crisis and its management in an Israeli hospital.

Methods

At the end of the pandemic's first wave in Israel, 547 healthcare workers responded to an online survey, which inquired about COVID-19 concerns at the individual and family level, perceptions at the national and organizational level, perceptions of the way the crisis was managed, self-assessment of coping with the crisis and burnout, and demographics.

Results

Findings showed that healthcare workers expressed deep concerns for family members and apprehension at a national level. Respondents noted that they were coping well with the crisis while expressing negative perceptions of how the crisis was managed. The regression model showed that concerns for family members, perceptions at the system level, working directly with COVID-19 patients, and having negative perceptions towards the crisis management at the national level, were associated with burnout.

Conclusions

The findings of this study deepen our understanding of issues that require systemic attention to strengthen mental resilience among hospital staff. Several actions are recommended to improve healthcare systems' ability to continue fighting the virus and confront future health crises:

Further examination and monitoring of healthcare workers' concerns and job stressors. Providing psychosocial support plans for frontline workers to ensure their safety and health and prevent burnout. Strengthening supportive organizational culture.

Key messages

Healthcare workers express deep concerns and perceptions associated with burnout. Health services management needs a good understanding of workers' concerns and develop strategies to address them.

Increased Malignancy Rate in Children With IgE Deficiency: A Single-center Experience

BACKGROUND

Immunoglobulin (Ig) E-deficient adults (IgE<2.5 kU/L) have increased susceptibility for developing malignancy. We evaluated the association between IgE deficiency and cancer diagnosis in children (age younger than 18 y), compared with those non-IgE-deficient (IgE≥2.5 kU/L).

MATERIALS AND METHODS

Information about malignancy diagnosis were compared between 4 cohorts of children who had IgE levels measured at our institution: IgE-deficient (IgE<2.5 kU/L), normal IgE (2.5

RESULTS

Overall, 94/4586 (2%) children had IgE deficiency. A significantly higher malignancy rate was found in IgE-deficient children (3/94, 3.2%) compared with non-IgE-deficient cohort (13/4492, 0.3%, P<0.0001). Analysis of the groups with different IgE levels revealed a significantly higher rate of cancer in IgE-deficient children (3.2%) compared with those with normal (0.5%; odds ratio [OR]=7.84; 95% confidence interval [CI]: 1.94-31.61, P=0.004), high (0.2%; OR=25.80; 95% CI: 4.94-134.54, P=0.002), and very high IgE levels (0.2%; OR=42.17; 95% CI: 3.84-463.02, P<0.0001). All 3 IgE-deficient children had lymphoma. Malignancies in the other groups included lymphoma, leukemia, brain, liver, ovarian cancers.

CONCLUSIONS

Malignancy rate was higher in IgE-deficient children compared with those with normal, high, or very high IgE levels, supporting the hypothesis that IgE deficiency may be a marker for malignancy susceptibility in children. Larger, prospective studies are necessary to further evaluate this association.

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Key Words Collapse

MESH Headings

• Child
• Child, Preschool
• Female
• Humans
• Immunoglobulin E/blood
• Immunoglobulin E/deficiency
• Male
• Neoplasms/blood
• Neoplasms/diagnosis
• Neoplasms/etiology
• Odds Ratio
• Prospective Studies
• Risk Factors

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Grants Collapse

Affiliation(s)

Denisa Ferastraoaru Department of Internal Medicine/Allergy-Immunology, Albert Einstein College of Medicine/Montefiore Medical Center
Deborah Schwartz Albert Einstein College of Medicine, Bronx, NY
David Rosenstreich Department of Internal Medicine/Allergy-Immunology, Albert Einstein College of Medicine/Montefiore Medical Center

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Donor-Specific Transcriptomic Analysis of Alzheimer's Disease-Associated Hypometabolism Highlights a Unique Donor, Ribosomal Proteins and Microglia

Alzheimer's disease (AD) starts decades before clinical symptoms appear. Low-glucose utilization in regions of the cerebral cortex marks early AD. To identify these regions, we conducted a voxel-wise meta-analysis of previous studies conducted with positron emission tomography that compared AD patients with healthy controls. The resulting map marks hypometabolism in the posterior cingulate, middle frontal, angular gyrus, and middle and inferior temporal regions. Using the Allen Human Brain Atlas, we identified genes that show spatial correlation across the cerebral cortex between their expression and this hypometabolism. Of the six brains in the Atlas, one demonstrated a strong spatial correlation between gene expression and hypometabolism. Previous neuropathological assessment of this brain from a 39-year-old male noted a neurofibrillary tangle in the entorhinal cortex. Using the transcriptomic data, we estimate lower proportions of neurons and more microglia in the hypometabolic regions when comparing this donor's brain with the other five donors. Within this single brain, signal recognition particle (SRP)-dependent cotranslational protein targeting genes, which encode primarily cytosolic ribosome proteins, are highly expressed in the hypometabolic regions. Analyses of human and mouse data show that expression of these genes increases progressively across AD-associated states of microglial activation. In addition, genes involved in cell killing, chronic inflammation, ubiquitination, tRNA aminoacylation, and vacuole sorting are associated with the hypometabolism map. These genes suggest disruption of the protein life cycle and neuroimmune activation. Taken together, our molecular characterization reveals a link to AD-associated hypometabolism that may be relevant to preclinical stages of AD.

Distinguishing Extravascular from Intravascular Ferumoxytol Pools within the Brain: Proof of Concept in Patients with Treated Glioblastoma

BACKGROUND AND PURPOSE

Glioblastoma-associated macrophages are a major constituent of the immune response to therapy and are known to engulf the iron-based MR imaging contrast agent, ferumoxytol. Current ferumoxytol MR imaging techniques for localizing macrophages are confounded by contaminating intravascular signal. The aim of this study was to assess the utility of a newly developed MR imaging technique, segregation and extravascular localization of ferumoxytol imaging, for differentiating extravascular-from-intravascular ferumoxytol contrast signal at a delayed 24-hour imaging time point.

MATERIALS AND METHODS

Twenty-three patients with suspected post-chemoradiotherapy glioblastoma progression underwent ferumoxytol-enhanced SWI. Segregation and extravascular localization of ferumoxytol imaging maps were generated as the voxelwise difference of the delayed (24 hours) from the early (immediately after administration) time point SWI maps. Continuous segregation and extravascular localization of ferumoxytol imaging map values were separated into positive and negative components. Image-guided biologic correlation was performed.

RESULTS

Negative segregation and extravascular localization of ferumoxytol imaging values correlated with early and delayed time point SWI values, demonstrating that intravascular signal detected in the early time point persists into the delayed time point. Positive segregation and extravascular localization of ferumoxytol imaging values correlated only with delayed time point SWI values, suggesting successful detection of the newly developed extravascular signal.

CONCLUSIONS

Segregation and extravascular localization of ferumoxytol MR imaging improves on current techniques by eliminating intrinsic tissue and intravascular ferumoxytol signal and may inform glioblastoma outcomes by serving as a more specific metric of macrophage content compared with uncorrected T1 and SWI techniques.

FRI0164 BANFF INFLAMMATORY INDICES MAY BE SUPERIOR TO THE NIH SCORING IN PREDICTING CKD PROGRESSION IN LUPUS NEPHRITIS

Background:

Chronic kidney disease/end stage renal disease (CKD/ESRD) from lupus nephritis (LN) is a major cause of morbidity and mortality. Advanced tubulointerstitial disease (TID) in LN is a better predicor of renal outcome than glomerular lesions. The current NIH classification is heavily weighted towards glomerular lesions and only provides a semiqualitative assessment of TID. In contrast, Banff classification of renal allograft pathology provides 6 reproducible scores for TID (inflammation, fibrosis, atrophy). Banff scoring may better predict CKD/ESRD in LN than NIH scores

Objectives:

We compared Banff grading vs. NIH scoring as predictors of CKD progression at 5 years, defined as a decline in estimated glomerular filtration rate (eGFR) ≥30%, a strong risk factor for ESRD and mortality

Methods:

We included patients with LN class III, IV, V on the index biopsy Jan 2005 and Dec 2018. H&E/PAS stained slides were reviewed and scored by an experienced pathologist. Six TID Banff scores (0/1 vs. 2/3), NIH activity/chronicity (AI/CI) and NIH interstitial fibrosis/tubular atrophy (IF/TA), tubulointerstitial inflammation (TII) scores (none/mild vs. moderate/severe) were evaluated as predictors of CKD progression using survival analyses

Results:

Of the 125 patients, 46 had CKD progression and 20 subsequently developed ESRD. There were no differences between progressors and non-progressors in terms of baseline demographic, clinical data, LN class (Tab 1). Banff ti score (total inflammation) was associated with CKD progression in bivariate and time-dependent analyses. However, NIH TII score and corresponding Banff i score were not predictive (Tab 2, Fig 1). Overall NIH AI and CI were not predictive of CKD progression. Moderate/severe NIH IF/TA was associated with CKD progression as was Banff ci (interstitial fibrosis) score (Tab 2, Fig 2). Banff score for atrophy was not predictive. In a subset of 92 patients with baseline eGFR≥60ml/min/1.73m2only Banff ti score (but not i score or NIH TII, IF/TA) was predictive of CKD progression (Fig 1)

Table 1.

Baseline data in patients with/without CKD progression

Progressors1n=46Non-progressorsn=79pn (%) or median (IQR)Female36 (78)69 (87)0.18Age (years)26 (20-41)29 (21-43)0.53<18 years7 (15)13 (16)0.86Race0.82 White4 (9)4 (5) Black18 (39)35 (44) Asian1 (2)1 (1) Unknown23 (50)39 (50)Diabetes5 (11)3 (4)0.12Hypertension33 (72)55 (70)0.8eGFR ml/min/1.73m296.1 (56.6-117.8)88.9 (47-117)0.51C3 mg/dL71 (52-88)67.5 (43-94)0.58C4 mg/dL12.65 (9-23)12 (7-20)0.48Anti-ds DNA titer IU108.7(36.6-194.9)151.3(39.2-200)0.57Total SLEDAI11 (8-16)12 (8-16)0.47Renal SLEDAI8 (4-12)8 (4-12)0.9LNProliferative GN2: III, IV18 (39)30 (38)0.15Nonproliferative GN: V9 (20)27 (34)Mixed GN: V and III/IV19 (41)22 (28)

1Progressors: LN patients with eGFR decline ≥30% within 5 years.2GN: glomerulonephritis

Table 2.

NIH and Banff scores with/without progressors

Progressorsn=46Non-progressorsn=79pn (%) or median (IQR)NIHOverall AI1 (0-4)1 (0-3)0.61AI ≥ 111 (2)3 (3.8)0.62Overall CI3 (0-5)2 (0-3)0.33CI ≥ 324 (52)28 (35.4)0.07Moderate/severe TII7 (15.2)4 (5)0.05Moderate/severe IF/TA16 (35)15 (19)0.049BanffTubulitis: t00Interstitial inflammation: i 2/33 (6.5)5 (6.3)0.9Total inflammation: ti 2/316 (34.8)12 (15.2)0.01Tubular atrophy: ct 2/316 (34.8)16 (20.3)0.07Interstitial fibrosis: ci 2/317 (37)15 (19)0.03Inflammation in area of interstitial fibrosis and/or tubular atrophy: i-IFTA 2/3n=26*18 (69)n=51*25 (49)0.09

* Biopsy number is smaller due to inability to apply score to biopsies without areas of fibrosis/tubular atrophy

Conclusion:

Banff inflammation scores may be superior predictors of CKD/ESRD progression at 5 years, compared to the currently used NIH classification. Detection of inflammation by Banff scores may allow earlier interventions to prevent ESRD

Disclosure of Interests:

None declared

1177 Cost Effectiveness Of Diagnostic Approaches To Sleep Apnea Evaluation During Inpatient Rehabilitation For Moderate To Severe TBI

Introduction

Recent work has highlighted prevalent obstructive sleep apnea (OSA) after traumatic brain injury (TBI) when patients are vulnerable to disruption of neural repair. The recently completed clinical trial comparing screening and diagnostic tools for OSA during inpatient rehabilitation provided the opportunity to conduct economic modeling of phased approaches using actual trial findings to address one perspective (the payor) on the value of phased testing.

Methods

A cost-effectiveness analysis of four phased approaches to OSA diagnosis including initial utilization of portable sleep monitoring [HSAT] regardless of pre-test probability, determination of pre-test probability using two prediction models [STOPBANG, MAPI], and initial assessment using Level 1 polysomnography was conducted. The analyses were modeled assuming all participants were considered high risk thus a negative screen or portable diagnostic test would result in a participant being referred for Level 1 polysomnography. The cost aversion used in analyses were derived from a recent white paper on the economic modeling of untreated OSA. Trial data from 214 participants were used in analyses (mean age 44 [SD 18], 82% male, 75% white, with primarily motor-vehicle related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8 (SD 5).

Results

At AHI ≥15 (33.6%), the prediction models (STOPBANG [-$5,291], MAPI [-$5,262]) resulted in greater cost savings and effectiveness relative to the HSAT approach (-$5,210) and initial use of Level 1 PSG (-$5,011). Sensitivity analyses at AHI ≥5 (70.1%) revealed the initial use of HSAT (-$6,322.85) relative to the prediction models (MAPI [-$6,249.71], STOPBANG [-$6,237) and initial assessment with Level 1 PSG (-$5,977) resulted in greater savings and cost effectiveness.

Conclusion

The high rates of sleep apnea after TBI highlight the importance of accurate diagnosis and treatment of this comorbid disorder. However, financial and practical barriers exist to obtaining an earlier diagnosis during inpatient rehabilitation hospitalization. Diagnostic cost savings are demonstrated across all phased approaches and OSA severity levels with the most cost-effective approach varying by incidence of OSA.

Support

PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

1136 Polysomnography Is Feasible During Inpatient TBI Rehabilitation

Introduction

A recent meta-analytic report highlighted that obstructive sleep apnea was 12 times more prevalent in TBI (mixed severity) than in community-based samples. Recent studies highlight prevalent obstructive sleep apnea during acute inpatient rehabilitation which is a time of critical neural repair. Acute sleep disturbances are associated with therapy cooperation due to effects on daytime sleepiness and are associated with key rehabilitation outcomes. Given the high rates of OSA and risk for negative morbidity, this analysis sought to examine the feasibility of administering polysomnography (PSG) with EEG to diagnose sleep apnea during inpatient rehabilitation in persons with moderate to severe TBI.

Methods

This is a secondary analysis from a prospective diagnostic comparative effectiveness clinical trial (NCT03033901) that took place at six NIDILRR and one VA TBI Model System Centers. Participants were included if they met the TBI Model System case definition and slept at least 2 hours per night prior to PSG. PSG was conducted following AASM procedures in the participant’s hospital bed on the inpatient rehabilitation unit. Studies were scored by RPSGT staff and interpreted by a board certified sleep medicine physician at a centralized sleep scoring center in Tampa, FL.

Results

Of 896 potential TBI participants, 449 met initial eligibility and 345 consented for further screening; a final sample of 263 (76%) completed PSG during hospitalization. Primary reasons for not completing PSG included early discharge or medical instability (n=59) and last-minute withdrawal of consent for PSG (n=23). Of the 263 participants who completed PSG, 3 were excluded from analysis due to technical issues and 12 were excluded as the total sleep time (TST) was less than 120 minutes. Of the 248, 85.5% of the PSGs were rated as interpretable/scoreable by RPSGT and sleep physicians.

Conclusion

For a majority of participants, polysomnography is feasible during inpatient rehabilitation. Participants with shorter lengths of stay, medical instability, prolonged agitation may require polysomnography follow-up after discharge.

Support

Supported by PCORI (CER-1511-33005), VA TBIMS, DVBIC with subcontract from GDIT/GDHS (W91YTZ-13-C-0015, HT0014-19-C-0004), and NIDILRR (90DPTB00070, 90DPTB00130100, 90DPTB0008, 90DPT8000402, 90DPTB0001).

0606 Comparative Effectiveness of Sleep Apnea Screening Tools During Inpatient Rehabilitation for Moderate to Severe TBI

Introduction

Recent studies highlight prevalent obstructive sleep apnea after moderate to severe TBI during a time of critical neural repair. The purpose of this study is to determine the diagnostic sensitivity, specificity and comparative effectiveness of traditional sleep apnea screening tools in TBI neurorehabilitation admissions.

Methods

This is a prospective diagnostic comparative effectiveness trial of sleep apnea screening tools (STOPBANG, Berlin, MAPI [Multi-Apnea Prediction Index]) relative Level 1 polysomnography at six TBI Model System Inpatient Rehabilitation Centers. Between 05/2017 and 02/2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248. The primary outcome was the Area Under the Curve (AUC) of screening tools relative to total apnea hypopnea index ≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (IQR 29-47).

Results

Participants were primarily young to middle age (AGE IQR 28,40,59), male (81%), white (74%), and had primarily severe TBI (IQR GCS 3,6,14). A subset (26%) had a history of military service. Results revealed that the Berlin high risk score (ROC-AUC=0.63) was inferior to the MAPI (ROC-AUC = 0.7802) (p=.0211, CI: 0.0181, 0.2233) and STOPBANG (ROCAUC = 0.7852) (p=.0006, CI: 0.0629, 0.2302); both of which had comparable AUC (p=.7245, CI: -0.0472, 0.0678). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI&gt;5. The pattern was similar across TBI severity subgroups except for delirium or post-traumatic amnesia status wherein the MAPI outperformed the Berlin and STOPBANG. Youden’s Index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples.

Conclusion

This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for moderate to severe TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome.

Support

PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

1272 Control of Sleep-Associated Respiratory Distress with a Mandibular Advancement Oral Appliance in an Unusual Case of a Patient with a Mild Rather Persistent Nocturnal Baseline Hypoventilation/Hypoxia

Introduction

Normal respiratory function is crucial for adequate sleep. Sleep Related Breathing Disorders, namely Obstructive Sleep Apnea (OSA) are frequent conditions among a large spectrum of obstructive events in the upper airway which are often linked to significant sleep related oxyhemoglobin dessaturation levels compared to those observed in baseline PSG-oximetry recorded. On the other hand, low baseline oxygen saturation (LBOS) is commonly linked to symptomatic cardiorespiratory disturbances which may adversely impact respiratory outcomes either awake or during sleep. Therefore it is relevant to be aware of the baseline ventilatory status in order to optimize the therapeutic care.

Report of Case

We present an unusual case of a patient with moderate OSA which was successfully controlled with a Mandibular Advancement Oral Appliance (OAm). Despite the control with the OAm, the patient still maintained a nocturnal pattern of hypoventilation/hypoxia. The 53 yo female patient with normal weight/height ratio (BMI=25,2) complaining of non restorative sleep, tiredness, impaired memory, excessive diurnal sleepiness (Epworth Sleepiness Scale - ESS=10 and bruxism with a PSG diagnosis of moderate OSA (BaselineO2Sat=94%; IAH=17,4 ev/h; ODI=32,9 ev/h; T90=34,7% of TST) was referred for treatment with a OAm. A PM Type 1 positioner was inserted and titrated until 12 mm of advancement (80% of maximal measured protrusion). Within 6 months follow up and after clinical titration, there was a clear symptomatic and objective improvement with resolution of all major complaints including sleepiness (ESS=5). Titration PSG showed a normalization in all parameters (IAH=1,4 ev/h;ODI=4 ev/h;T90=0,1% of TST). Baseline O2 Sat however remained low (93%) in the titration PSG even though no symptoms or signs of a disorder existed even after discounting for Ph related metabolic changes (normal levels of HCO3)

Conclusion

This is an interesting case of an unusual patient who presented with a LBOS level in the diagnostic PSG. Despite the therapeutic success of the OAm in controlling the sleep related respiratory condition, measured by all otherwise normalized PSG based sleep and respiratory parameters, maintained a LBOS in the titration PSG without any signs or symptoms of disease.

P476 Efficacy and safety of 2 vedolizumab IV regimens in patients with perianal fistulising Crohn’s disease: results of the ENTERPRISE study

Background

Perianal fistulae occurring with Crohn’s disease (CD) are a challenge to treat. Vedolizumab (VDZ) is a gut-selective, monoclonal α 4β7 integrin antibody approved to treat patients (patients) with moderately to severely active CD. Here we report results from ENTERPRISE (NCT02630966; EudraCT 2015-000852-12), a randomised, double-blind, phase 4 trial to evaluate 2 VDZ IV dosing regimens in patients with fistulising CD.

Methods

Patients with moderately to severely active CD and 1–3 draining perianal fistulae received either VDZ 300 mg IV at Weeks (Week) 0, 2, 6, 14, and 22 (VDZ), or the same regimen plus an additional VDZ dose at Wk10 (VDZ+Wk10). The primary endpoint was the proportion of patients with a ≥50% reduction from baseline (BL) in the number of draining fistulae (absence of draining despite gentle finger compression) at Wk30. Secondary endpoints were the proportion of patients with a ≥50% reduction from BL in the number of draining fistulae at Wk22 and Wk30, and the proportion of patients with 100% fistulae closure at Wk30. Patients with missing data at study visits were counted as non-responders. Perianal disease activity index (PDAI), perianal pain score, Van Assche score, gadolinium contrast enhancement by pelvic MRI, and safety were assessed. Study enrolment closed early due to slow recruitment; thus, all analyses are descriptive.

Results

Of the 32 patients with post-BL assessment of fistulae healing (full analysis set, FAS), 28 had ≥1 draining fistula at BL (modified FAS). Median CD duration was 8.5 years (VDZ [n = 14]: 11.2 years; VDZ+ Week 10 [n = 14]: 6.1 years). In each arm, 11 patients (78.6%) had prior anti-tumour necrosis factor therapy at BL; concomitant corticosteroid use was 21.4% (VDZ) and 14.3% (VDZ+ Week 10), and concomitant immunosuppressant use was 28.6% (VDZ) and 21.4% (VDZ+ Week 10). At Wk30, 53.6% of all patients achieved ≥50% decrease in the number of draining fistulae (VDZ: 64.3%; VDZ+ Week 10: 42.9%; Figure 1). The proportion of patients with fistulae response increased rapidly and remained high through Week 30 (Figure 2); 46.4% of patients (VDZ: 57.1%; VDZ+Week 10: 35.7%) achieved ≥50% decrease in the number of draining fistulae at both Weeks 22 and 30. Closure of all fistulae draining at BL was observed at Week 30 in 42.9% of patients (VDZ: 50.0%; VDZ+ Week 10: 35.7%). In the FAS, mean (SD) PDAI scores changed from BL to Weeks 30–4.1 (3.3) and perianal pain scores changed –2.2 (2.7) (table). At Wk30, mean (SD) Van Assche scores and contrast enhancement scores changed –1.1 (3.1) and –9.5 (69.4) from screening, respectively. No new safety signals were observed.

Conclusion

Over half of CD patients treated with VDZ had reductions of ≥50% in the number of draining perianal fistulae. Clinically relevant reductions in draining fistulae were seen as early as Wk2 and maintained through Wk30.

Assessing the efficacy-effectiveness gap for cancer therapies: A comparison of overall survival and toxicity between clinical trial and population-based, real-world data for contemporary parenteral cancer therapeutics

BACKGROUND

Although increasing evidence has suggested that an efficacy-effectiveness gap exists between clinical trial (CT) and real-world evidence (RWE), to the authors' knowledge, the magnitude of this difference remains undercharacterized. The objective of the current study was to quantify the magnitude of survival and toxicity differences between CT and RWE for contemporary cancer systemic therapies.

METHODS

Patients receiving cancer therapies funded under Cancer Care Ontario's New Drug Funding Program (NDFP) were identified. Landmark CTs with data regarding survival and adverse events (AEs) for each drug indication were identified. RWE for survival and hospitalization rates during treatment were ascertained through Canadian population-based databases. The efficacy-effectiveness gap for each drug indication was calculated as the difference between RWE and CT data for median overall survival (OS), 1-year OS, and generated hazard ratios (HRs) with 95% CIs from Kaplan-Meier OS curves. Toxicity differences were calculated as the difference between RWE of hospitalization rates and CT serious AE rates.

RESULTS

Twenty-nine indications from 20 systemic therapies were included. Twenty-eight of 29 indications (97%) demonstrated worse survival in RWE, with a median OS difference of 5.2 months (interquartile range, 3.0-12.1 months). Lower effectiveness in RWE also was demonstrated through a meta-analysis of an OS hazard ratio of 1.58 (95% CI, 1.39-1.80). The median difference between RWE for hospitalization rates and CT serious AEs was 14% (95% CI, 9%-22%).

CONCLUSIONS

An efficacy-effectiveness gap exists for contemporary cancer systemic therapies, with a 5.2-month lower median OS observed in RWE compared with CT data. These data supports the use of RWE to better inform real-world decision making regarding the use of cancer systemic therapies.

Are population-based patient-reported outcomes associated with overall survival in patients with advanced pancreatic cancer?

BACKGROUND

Advanced pancreatic cancer (APC) patients often have substantial symptom burden. In Ontario, patients routinely complete the Edmonton Symptom Assessment Scale (ESAS), which screens for nine symptoms (scale: 0-10), in cancer clinics. We explored the association between baseline patient-reported outcomes, via ESAS, and overall survival (OS).

METHODS

Advanced pancreatic cancer patients with ESAS records prior to receiving publicly funded drugs from November 2008 to March 2016 were retrospectively identified from Cancer Care Ontario's administrative databases. We examined three composite ESAS scores: total symptom distress score (TSDS: 9 symptoms), physical symptom score (PHS: 6/9 symptoms), and psychological symptom score (PSS: 2/9 symptoms); Composite scores greater than defined thresholds (TSDS ≥36, PHS ≥24, PSS ≥8) were considered as high symptom burden. Crude OS was assessed using Kaplan-Meier method. Hazard ratios (HRs) were assessed using multivariable Cox models. Analysis was repeated in a sub-cohort with Eastern Cooperative Oncology Group (ECOG) status and metastasis.

RESULTS

We identified 2199 APC patients (mean age 64 years, 55% male) with ESAS records prior to receiving chemotherapy. Crude median survival was 4.5 and 7.3 months for high and low TSDS, respectively. High TSDS was associated with lower OS (HR = 1.47, 95% CI: 1.33, 1.63). In the sub-cohort (n = 393) with ECOG status and metastasis, high TSDS was also associated with lower OS (HR = 1.34, 95% CI: 1.04, 1.73). Similar trends were observed for PHS and PSS.

CONCLUSIONS

Higher burden of patient-reported outcome was associated with reduced OS among APC patients. The effect was prominent after adjusting for ECOG status.

Real-world outcomes of FOLFIRINOX vs gemcitabine and nab-paclitaxel in advanced pancreatic cancer: A population-based propensity score-weighted analysis

BACKGROUND

In Ontario, FOLFIRINOX (FFX) and gemcitabine + nab-paclitaxel (GnP) have been publicly funded for first-line unresectable locally advanced pancreatic cancer (uLAPC) or metastatic pancreatic cancer (mPC) since April 2015. We examined the real-world effectiveness and safety of FFX vs GnP for advanced pancreatic cancer, and in uLAPC and mPC.

METHODS

Patients receiving first-line FFX or GnP from April 2015 to March 2017 were identified in the New Drug Funding Program database. Baseline characteristics and outcomes were obtained through the Ontario Cancer Registry and other population-based databases. Overall survival (OS) was assessed using Kaplan-Meier and weighted Cox proportional hazard models, weighted by the inverse propensity score adjusting for baseline characteristics. Weighted odds ratio (OR) for hospitalization and emergency department visits (EDV) were estimated from weighted logistic regression models.

RESULTS

For 1130 patients (632 FFX, 498 GnP), crude median OS was 9.6 and 6.1 months for FFX and GnP, respectively. Weighted OS was improved for FFX vs GnP (HR = 0.77, 0.70-0.85). Less frequent EDV and hospitalization were observed in FFX (EDV: 67.8%; Hospitalization: 49.2%) than GnP (EDV: 77.7%; Hospitalization: 59.3%). More frequent febrile neutropenia-related hospitalization was observed in FFX (5.8%) than GnP (3.3%). Risk of EDV and hospitalization were significantly lower for FFX vs GnP (EDV: OR = 0.68, P = .0001; Hospitalization: OR = 0.76, P = .002), whereas the risk of febrile neutropenia-related hospitalization was significantly higher (OR = 2.12, P = .001). Outcomes for uLAPC and mPC were similar.

CONCLUSION

In the real world, FFX had longer OS, less frequent all-cause EDV and all-cause hospitalization, but more febrile neutropenia-related hospitalization compared to GnP.

Improved survival in overweight and obese patients with aggressive B-cell lymphoma treated with rituximab-containing chemotherapy for curative intent

The association between obesity and survival in non-Hodgkin lymphoma is unclear. Using the Ontario Cancer Registry we conducted a retrospective analysis of incident cases of aggressive-histology B-cell lymphoma treated with a rituximab-containing regimen with curative intent between 2008-2016. 6246 patients were included. On multivariable analysis the rate of all-cause mortality was lower for the overweight body mass index (BMI 25-29.9 kg/m²) (HR 0.85; 95%CI 0.77-0.95) and obese BMI (≥30 kg/m²) (HR 0.75; 95%CI 0.67-0.85) groups compared to the normal weight group (18.5-24.9 kg/m²). Binomial logistic regression analysis revealed a lower odds ratio (OR) of admission to hospital during treatment in the overweight (OR 0.84; 95%CI 0.75-0.95) compared to normal weight BMI group. In the largest cohort to date of aggressive-histology B-cell lymphoma patients treated with rituximab, increased BMI is associated with a survival advantage, and the magnitude of this effect increases from overweight to obese BMI.

Are real-world patient-reported outcomes associated with survival in patients with advanced pancreatic cancer?

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Background: Advanced pancreatic cancer (APC) patients often have a substantial symptom burden. In Ontario, patients visiting cancer clinics routinely complete the Edmonton Symptom Assessment Scale (ESAS), which screens for 9 symptoms (scale: 0-10). Using ESAS, we explored the association between baseline patient-reported outcomes and overall survival (OS). Methods: APC Patients with ESAS records prior to receiving publicly-funded drugs from November 2008 to March 2016 were identified from Cancer Care Ontario’s New Drug Funding Program and Symptom Management databases. We examined 3 baseline composite ESAS scores: Total Symptom Distress Score (TSDS: all 9 symptoms), Physical Symptom Score (PHS: 6/9 symptoms), and Psychological Symptom Score (PSS: 2/9 symptoms); Composite scores greater than a threshold (defined as number of symptoms in composite score multiplied by clinically relevant score (≥4)) were categorized as High Symptom Burden (TSDS ≥ 36, PHS ≥ 24, PSS ≥ 8). The primary endpoint, OS, was assessed using Kaplan-Meier. Multivariable Cox models were used to adjust for age, gender, income, prior therapies (surgery, adjuvant gemcitabine, radiation), and Charlson's comorbidity. Analysis was repeated in a sub-cohort with identifiable ECOG status and stage. Results: We identified 2,199 APC patients (mean age 64 years, 55% male) with ESAS records prior to receiving gemcitabine (54%), FOLFIRINOX (40%) or gemcitabine/nab-paclitaxel (6%). Crude median survival was 4.5 and 7.3 months for patients with high and low TSDS burden, respectively (HR = 1.50, 95% CI: 1.36, 1.66). After adjustment with multivariable Cox model, high TSDS burden was associated with lower OS (HR = 1.47, 95% CI: 1.33, 1.63). Similar trends were observed for PHS and PSS. When adjusting for both PHS and PSS in a Cox model, only the effect of PHS remained significant. In the sub-cohort (n = 393), high TSDS burden (HR = 1.34, 95% CI: 1.04, 1.73) was associated with lower OS, after adjusting for ECOG and stage. Conclusions: Among APC patients, a higher burden of patient-reported symptoms, via ESAS, at baseline was associated with reduced OS. The effect was prominent for physical symptoms, even after adjusting for treatment, stage and ECOG.

Combining VITEK® 2 with colistin agar dilution screening assist timely reporting of colistin susceptibility

OBJECTIVES

The rise in carbapenem resistance among Gram-negative bacteria has renewed interest in colistin. Recently, the EUCAST-CLSI Polymyxin Breakpoints Working Group declared that broth microdilution (BMD) is the only valid method for colistin susceptibility testing. BMD is not easily incorporated into the routine work of clinical laboratories, and usually this test is incorporated serially, resulting in delayed susceptibility reporting. We tested a strategy of combining VITEK^® 2 with a 2 μg/mL colistin agar dilution (VITEK^® 2/AD) screening plate to improve performance and time to reporting of colistin susceptibility.

METHODS

Colistin susceptibility for 364 clinical isolates was determined by VITEK^® 2/AD and compared with the reference standard BMD according to the ISO 20776-1:2007 and CLSI guidelines. The EUCAST colistin susceptibility breakpoint of ≤2 μg/mL was used. Escherichia coli NCTC 13846 served as quality control strain. Agreement, very major error (VME) and major error rates were determined using ISO 20776-2:2007.

RESULTS

The VME rate for VITEK^® 2 alone was 30.6% (15/49, 95% CI 18.3-45.4%), and was reduced to 10.2% (5/49, 95% CI 3.4-22.2%) using the VITEK^® 2/AD combined testing. The combined testing had categorical agreement with BMD of 97% (354/364, 95% CI 95.0-98.7%), and a major error (ME) rate of 1.6% (5/315, 95% CI 0.5-3.7%). Using the combined testing, even against challenging strains, 349 (95.8%, 95% CI 93.3-97.7%) colistin susceptibility results could be reported, and only 15 isolates required further analysis by BMD.

DISCUSSION

Our method is simple to apply and allows rapid reporting of colistin susceptibility.

Long-Term Effects of Pregnancy on Renal Graft Function in Women After Kidney Transplantation Compared With Matched Controls

BACKGROUND

An important benefit associated with kidney transplantation in women of child-bearing age is increased fertility. We retrospectively evaluated the maternal and fetal complications and evolution of graft function associated with 22 pregnancies post-kidney and kidney-pancreas transplantation, compared with controls without pregnancy post-transplantation, who were matched for gender, year of transplantation, type of donor, age at transplantation, number of transplants, type of transplant (kidney vs kidney-pancreas), and cause of native kidney failure, as well as for renal parameters including serum creatinine and urine protein excretion 1 year before delivery.

RESULTS

The mean age at time of transplantation was 22.32 (range, 19.45-33.1) years. The mean interval between transplantation and delivery was 75.7 (range, 34-147.8) months. Main maternal complications were pre-eclampsia in 27.3%. The main fetal complications included delayed intrauterine growth (18.2%), preterm deliveries (89.4%), and one death at 3 days postdelivery. The mean serum creatinine level pre-pregnancy was 1.17 (range, 0.7-3.1) mg/dL. Graft failure was higher in the pregnancy group (6 vs 3) but did not differ statistically from the control group, and was associated with creatinine pre-pregnancy (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.15-3.45; P = .04), age at transplantation (1.13 [1.03-1.21]; P = .032), and time of follow-up (2.14 [1.27-2.98]; P = .026). Delta serum creatinine was not different in both groups: 1.05 ± 0.51 versus 0.99 ± 0.92 mg/dL, study versus control group, respectively (P = .17).

CONCLUSION

Pregnancy after kidney transplantation is associated with serious maternal and fetal complications. We did not observe a significantly increased risk of graft loss or reduced graft function in comparison with recipients with similar clinical characteristics.

Risk Factors for the Development of Cephalic Arch Stenosis

Purpose

The creation of a vascular access is necessary in hemodialysis patients, including those with marginal vessels. Upper arm fistulae are attractive due to the ease of creation and of achieving high access flow rates. Cephalic arch stenosis (CAS) can lead to failure of upper arm fistulae and is increasingly identified. We hypothesized that CAS is promoted by high blood flow rates, brachiocephalic fistulae, and an angle of cephalic vein insertion approaching 90 degrees.

Methods

All patients requiring a fistulogram between January 2004 and May 2006 had surveillance fluoroscopy of the central veins. Demographic, clinical and laboratory parameters were collected and the angle of the cephalic vein insertion measured by 3 blinded independent observers.

Results

Fifty-eight patients had fistulograms and CAS was detected in 18 subjects. Significant differences between the CAS and non-CAS groups were brachiocephalic fistula site (p=0.046), access flow (mL/min) (p=0.012), and absence of diabetes (p=0.03). Univariate predictors of CAS include access flow (per 100 mL/min) (p=0.042), platelet count (p=0.031) and calcium-phosphate product (p=0.026). The relationship of brachiocephalic site and CAS was confounded by access flow [(per 100 mL/min)*brachiocephalic fistula site (p=0.016)] and fistula age [brachiocephalic fistula site*fistula age (p=0.017)]. In multivariate analysis, renovascular disease, calcium-phosphate product, platelet count and access flow (per 100 mL/min)*brachiocephalic fistula predicted CAS (p<0.001, Negelkerke's R-Square= 0.55). The angle of insertion of the cephalic vein was not predictive for CAS.

Conclusions

CAS may be a long-term consequence of high blood flow rates. The interaction of access flow and brachiocephalic fistula supports the hypothesis that high flow through a brachiocephalic fistula promotes CAS. The multiple factors influencing cephalic arch remodeling require further research.

Analytical validation of a new point-of-care assay for serum amyloid A in horses

BACKGROUND

Serum amyloid A (SAA) is a major acute phase protein in horses. A new point-of-care (POC) test for SAA (Stablelab) is available, but studies evaluating its analytical accuracy are lacking.

OBJECTIVES

To evaluate the analytical performance of the SAA POC test by 1) determining linearity and precision, 2) comparing results in whole blood with those in serum or plasma, and 3) comparing POC results with those obtained using a previously validated turbidimetric immunoassay (TIA).

STUDY DESIGN

Assay validation.

METHODS

Analytical validation of the POC test was done in accordance with American Society of Veterinary Clinical Pathology guidelines using residual equine serum/plasma and whole blood samples from the Clinical Pathology Laboratory at the University of California-Davis. A TIA was used as the reference method. We also evaluated the effect of haematocrit (HCT).

RESULTS

The POC test was linear for SAA concentrations of up to at least 1000 μg/mL (r = 0.991). Intra-assay CVs were 13, 18 and 15% at high (782 μg/mL), intermediate (116 μg/mL) and low (64 μg/mL) concentrations. Inter-assay (inter-batch) CVs were 45, 14 and 15% at high (1372 μg/mL), intermediate (140 μg/mL) and low (56 μg/mL) concentrations. SAA results in whole blood were significantly lower than those in serum/plasma (P = 0.0002), but were positively correlated (r = 0.908) and not affected by HCT (P = 0.261); proportional negative bias was observed in samples with SAA>500 μg/mL. The difference between methods exceeded the 95% confidence interval of the combined imprecision of both methods (15%).

MAIN LIMITATIONS

Analytical validation could not be performed in whole blood, the sample most likely to be used stall side.

CONCLUSION

The POC test has acceptable accuracy and precision in equine serum/plasma with SAA concentrations of up to at least 1000 μg/mL. Low inter-batch precision at high concentrations may affect serial measurements, and the use of the same test batch and sample type (serum/plasma or whole blood) is recommended. Comparison of results between the POC test and the TIA is not recommended.

Comparative effectiveness and safety of the implementation of universal public funding of FOLFIRINOX (FFX) and gemcitabine (G) + nab-paclitaxel (GnP) in advanced pancreatic cancer (APC): A population-based study

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Background: FFX has been universally publicly funded in Ontario, Canada, for metastatic pancreatic cancer (mPC) and unresectable locally advanced pancreatic cancer (uLAPC) since 11/2011 and 04/2015, respectively. GnP has been publicly funded for uLAPC and mPC (APC) since 04/2015. We examined the real world comparative effectiveness and safety of implementing funding of FFX and GnP for patients with APC. Methods: Patients with APC who received first-line FFX, GnP, or G from 01/2008-03/2016 were identified in CCO’s New Drug Funding Program database and divided into 3 periods: 01/2008-10/2011 (P1), 11/2011-03/2015 (P2), and 04/2015-03/2016 (P3). Data were linked with the Ontario Cancer Registry and others to ascertain demographics, comorbidities, and outcomes. Matching weights of propensity score to simultaneously compare three periods were generated using multinomial logistic regression. Crude and adjusted survival analyses were conducted to assess overall survival (OS) using Kaplan-Meier and weighted Cox regression methods.Weighted negative binomial models were used to estimate rate ratios (RR) for all-cause hospitalization (H) and ED visits. Results: We identified 3696 patients (1250 in P1, 1891 in P2, 555 in P3) (overall mean age 65, female 46%). In P2, 49% received FFX. In P3, 53% received FFX and 35% received GnP. Median OS was 5.7, 7.0, and 7.5 months for P1, P2, and P3, respectively. Median OS for FFX and GnP in mPC were 8.8 and 5.5 months, respectively. OS was improved in P2 vs. P1 (HR = 0.84, 0.78-0.90) and in P3 vs. P2 (HR = 0.82, 0.73-0.92). ED visits were similar compared P2 vs. P1 (RR=1.02, p = 0.75) and P3 vs. P2 (RR=1.04, p = 0.48), and H was reduced in P2 vs. P1 (RR = 0.86, p = 0.01), but similar in P3 vs. P2 (RR = 0.98, p = 0.78). H for febrile neutropenia (FN) was increased in P2 vs. P1 (RR = 2.18, p = 0.04) but not in P3 vs. P2 (RR = 1.32, p = 0.45). Conclusions: Implementation of universal public funding of FFX for mPC improved OS and reduced the rates H overall, but increased FN-related H. Funding of FFX for uLAPC and GnP for APC improved OS without increased in ER and H.

Chemotherapy choice in advanced pancreatic cancer: What patient and disease factors influence prescription patterns?

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Background: FOLFIRINOX (FFX), gemcitabine+nab-paclitaxel (GnP) and gemcitabine monotherapy (Gem)) are universally funded as first-line chemotherapy regimens for advanced pancreatic cancer (APC) in Ontario, Canada. However, there is scarce real-world data on factors that may influence choice of chemotherapy regimens in APC. Methods: Patients who received first-line chemotherapy for APC between April 2015-March 2016 in Ontario were identified from CCO’s New Drug Funding Program database and linked to the Ontario Cancer Registry and other provincial databases to ascertain baseline factors. Multinomial logistic regressions were used to examine the associations between the prescribed chemotherapy regimen and baseline factors. Results: 546 patients were identified, with a mean age of 65 and 43.6% female. 9.9% and 9.7% had received adjuvant gemcitabine and radiation treatment respectively. 17.6% had previous pancreatic resection. 68.3% had zero Charlson score and 30.6% had ECOG performance status (PS) of 0. 72.7% had metastatic disease. The majority of the patients received FFX (52.4%) compared to GnP (35.7%) and Gem (11.9%). Age and ECOG PS were strongly associated with choice of chemotherapy regimens. (See Table) Conclusions: In Ontario, increased patient age and worse ECOG PS are strongly associated with choice of Gem compared to GnP and FFX. Previous treatments and stage of disease also impact chemotherapy choice. Understanding how providers choose chemotherapy in APC aids in comprehending our practices. Odds ratio (OR) and p value from multinomial logistic regressions. [Table: see text]

Loss of brain inter-frequency hubs in Alzheimer's disease

Alzheimer's disease (AD) causes alterations of brain network structure and function. The latter consists of connectivity changes between oscillatory processes at different frequency channels. We proposed a multi-layer network approach to analyze multiple-frequency brain networks inferred from magnetoencephalographic recordings during resting-states in AD subjects and age-matched controls. Main results showed that brain networks tend to facilitate information propagation across different frequencies, as measured by the multi-participation coefficient (MPC). However, regional connectivity in AD subjects was abnormally distributed across frequency bands as compared to controls, causing significant decreases of MPC. This effect was mainly localized in association areas and in the cingulate cortex, which acted, in the healthy group, as a true inter-frequency hub. MPC values significantly correlated with memory impairment of AD subjects, as measured by the total recall score. Most predictive regions belonged to components of the default-mode network that are typically affected by atrophy, metabolism disruption and amyloid-β deposition. We evaluated the diagnostic power of the MPC and we showed that it led to increased classification accuracy (78.39%) and sensitivity (91.11%). These findings shed new light on the brain functional alterations underlying AD and provide analytical tools for identifying multi-frequency neural mechanisms of brain diseases.

A randomized, controlled clinical trial to evaluate the immunogenicity of a PreS/S hepatitis B vaccine Sci-B-Vac™, as compared to Engerix B®, among vaccine naïve and vaccine non-responder dialysis patients

BACKGROUND

Dialysis patients have a suboptimal response to hepatitis B (HBV) vaccination. This study aimed to compare the immunogenicity of two vaccines: the third-generation Sci-B-Vac™ vs. the second-generation Engerix B^®. The cohort included two groups of dialysis patients: naïve and previously vaccinated non-responders. Primary endpoints were antibody titers ≥10 IU/L at 3 and 7 month post-vaccination. Secondary objectives were seroprotection rates in vaccine-naïve patients and in previously vaccinated non-responders.

METHODS

Eighty-six patients were assigned to vaccine (Sci-B-Vac™ or Engerix B^®) using computer-generated randomization, stratified by age, gender, diabetes, and previous HBV vaccination. Sci-B-Vac™ was administered in three doses, 10 μg, at 0, 1, and 6 months in naïve patients; or 20 μg in previously vaccinated non-responders. Engerix B^® included four doses, 40 μg at 0, 1, 2, and 6 months.

RESULTS

Each group had 43 patients. Seroconversion was 69.8% with Engerix B^® vs. 73.2% with Sci-B-Vac™. Antibody titers at 7 months were higher with Sci-B-Vac™ (266.4 ± 383.9, median 53.4) than with Engerix^® (193.2 ± 328.9, median 19). However, these differences were not significant, perhaps due to a suboptimal sample size.

CONCLUSIONS

This study suggests comparable immunogenicity for both vaccines. Thus, we cannot reject the null hypothesis that there is no difference in seroconversion by vaccine type. It is noteworthy that naïve patients were vaccinated with a standard dose of Sci-B-Vac™, while Engerix B^® was administered at a double dose. Similarly, although mean antibody titer levels in the Sci-B-Vac™ group were higher than in the Engerix^® group, this difference did not reach significance. Consequently, a future clinical trial should recruit a larger cohort of patients, using a standard double-dose protocol in both groups.