Management of the Septic Wrist: A Systematic Review of Etiology and Therapeutic Strategies

Septic arthritis of the wrist can have severe deleterious effects on cartilage and bone if not promptly addressed. Expedient diagnosis and early medical intervention are important. The most effective strategy involves immediate arthrocentesis of the infected joint, enabling precise antibiotic selection based on joint fluid analysis. Diagnostic imaging is important in excluding fractures and identifying abscesses. This review explores the etiologic factors underlying septic wrist joint, identifying risk factors, and delineating optimal diagnosis and treatment approaches. The overarching goal is to impart valuable insights and guidance in the management of septic wrist joint, ensuring the highest quality patient care and optimal clinical outcomes.

The Septic Elbow Joint: Treatment Approaches for Improved Patient Outcomes

Septic arthritis of the elbow is a serious problem requiring prompt, accurate diagnosis and urgent surgical intervention. Achieving successful patient outcomes depends heavily on early diagnosis and efficient streamlined surgical treatment. Essential tactics for treating the septic elbow joint include immediate joint irrigation and debridement in addition to administration of appropriate antibiotics. This comprehensive review delves into the cause of the septic elbow joint, identifies associated risk factors, and provides a comprehensive approach encompassing the diagnosis and treatment of the septic elbow. The aim of this review is to optimize patient care and outcomes.

Combination ATR (ceralasertib) and PARP (olaparib) Inhibitor (CAPRI) Trial in Acquired PARP Inhibitor-Resistant Homologous Recombination-Deficient Ovarian Cancer

PURPOSE

Addition of ataxia telangiectasia and Rad3-related kinase inhibitors (ATRi) to PARP inhibitors (PARPi) overcomes PARPi resistance in high-grade serous ovarian cancer (HGSOC) cell and mouse models. We present the results of an investigator-initiated study of combination PARPi (olaparib) and ATRi (ceralasertib) in patients with acquired PARPi-resistant HGSOC.

PATIENTS AND METHODS

Eligible patients had recurrent, platinum-sensitive BRCA1/2 mutated or homologous recombination (HR)-deficient (HRD) HGSOC and clinically benefited from PARPi (response by imaging/CA-125 or duration of maintenance therapy; > 12 months first-line or > 6 months ≥ second-line) before progression. No intervening chemotherapy was permitted. Patients received olaparib 300 mg twice daily and ceralasertib 160 mg daily on days 1 to 7 of a 28-day cycle. Primary objectives were safety and objective response rate (ORR).

RESULTS

Thirteen patients enrolled were evaluable for safety and 12 for efficacy; 62% (n = 8) had germline BRCA1/2 mutations, 23% (n = 3) somatic BRCA1/2 mutations, and 15% (n = 2) tumors with positive HRD assay. Prior PARPi indication was treatment for recurrence (54%, n = 7), second-line maintenance (38%, n = 5) and first-line treatment with carboplatin/paclitaxel (8%, n = 1). There were 6 partial responses yielding an ORR of 50% (95% confidence interval, 0.15-0.72). Median treatment duration was 8 cycles (range 4-23+). Grade (G) 3/4 toxicities were 38% (n = 5); 15% (n = 2) G3 anemia, 23% (n = 3) G3 thrombocytopenia, 8% (n = 1) G4 neutropenia. Four patients required dose reductions. No patient discontinued treatment due to toxicity.

CONCLUSIONS

Combination olaparib and ceralasertib is tolerable and shows activity in HR-deficient platinum-sensitive recurrent HGSOC that benefited and then progressed with PARPi as the penultimate regimen. These data suggest that ceralasertib resensitizes PARPi-resistant HGSOCs to olaparib, warranting further investigation.

Medullary Tegmental Cap Dysplasia: Fetal and Postnatal Presentations of a Unique Brainstem Malformation

BACKGROUND AND PURPOSE

Medullary tegmental cap dysplasia is a rare brainstem malformation, first described and defined by James Barkovich in his book Pediatric Neuroimaging from 2005 as an anomalous mass protruding from the posterior medullary surface. We describe the neuroimaging, clinical, postmortem, and genetic findings defining this unique malformation.

MATERIALS AND METHODS

This is a multicenter, international, retrospective study. We assessed the patients' medical records, prenatal ultrasounds, MR images, genetic findings, and postmortem results. We reviewed the medical literature for all studies depicting medullary malformations and evaluated cases in which a dorsal medullary protuberance was described.

RESULTS

We collected 13 patients: 3 fetuses and 10 children. The medullary caps had multiple characteristics. Associated brain findings were a rotated position of the medulla, a small and flat pons, cerebellar anomalies, a molar tooth sign, and agenesis of the corpus callosum. Systemic findings included the following: polydactyly, hallux valgus, large ears, and coarse facies. Postmortem analysis in 3 patients revealed that the cap contained either neurons or white matter tracts. We found 8 publications describing a dorsal medullary protuberance in 27 patients. The syndromic diagnosis was Joubert-Boltshauser syndrome in 11 and fibrodysplasia ossificans progressiva in 14 patients.

CONCLUSIONS

This is the first study to describe a series of 13 patients with medullary tegmental cap dysplasia. The cap has different shapes: distinct in Joubert-Boltshauser syndrome and fibrodysplasia ossificans progressive. Due to the variations in the clinical, imaging, and postmortem findings, we conclude that there are multiple etiologies and pathophysiology. We suggest that in some patients, the pathophysiology might be abnormal axonal guidance.

Understanding the impact of long-chain fatty acid oxidation disorders for patients and caregivers

Long-chain fatty acid oxidation disorders (LC-FAOD) are a group of rare, autosomal recessive genetic disorders that impair conversion of long-chain fatty acids into energy. Here we describe the impact of LC-FAOD in terms of effects on work and school, absenteeism and presenteeism at work, importance of symptoms, physical activity, participation in social activities, and quality of life (QoL). A convenience sample of adults (≥18 years) and caregivers of patients with LC-FAOD was invited to take the online survey (Confirmit). To be included, patients must have been receiving medical care from a healthcare provider for their LC-FAOD, and caregivers must not have been compensated for their care. Degree of physical activity, represented by metabolic equivalents (METs), was calculated using the NHANES Physical Activity Questionnaire. Absenteeism and presenteeism at work were calculated using the WHO Health Productivity Questionnaire. QoL was assessed using the 12-Item Short Form of the Medical Outcomes Survey. Significance was assessed using two tailed independent sample t-tests and z-tests at α = 0.1. Fourteen adults and 30 caregivers of LC-FAOD patients (answering for 37 patients) answered the survey (51 unique respondents). 59.2% of LC-FAOD patients experienced effects on their schooling due to LC-FAOD. 84.2% of working patients experienced effects on their work due to LC-FAOD. 70% of caregivers experienced effects on their work due to their child's LC-FAOD. Unique respondents report that muscle weakness (69%), physical fatigue (49%), and rhabdomyolysis (39%) are the most impactful symptoms of LC-FAOD. Adults (n = 14) scored significantly below the normalized average (50) on both physical (34.51, p < 0.001) and mental (45.27, p = 0.04) component scores of the SF-12 health-related quality of life measure. LC-FAOD impart a high disease impact on patients and their caregivers. In particular, symptoms relating to energy production were rated as highly impactful and limiting. Activities that may be considered normal for many people can prove to be very difficult or impossible for respondents with LC-FAOD, with respondents reporting lower physical and mental health-related quality of life measures than the average American.

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LC-FAOD has a measurable impact on patient and caregiver education and employment (83/85).

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Muscle weakness was the most impactful symptom of LC-FAOD on individuals' lives (82/85).

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Physical and mental health were significantly lower in individuals with LC-FAOD (82/85).

Characterizing Determinants of Near-Road Ambient Air Quality for an Urban Intersection and a Freeway Site

INTRODUCTION

Near-road ambient air pollution concentrations that are affected by vehicle emissions are typically characterized by substantial spatial variability with respect to distance from the roadway and temporal variability based on the time of day, day of week, and season. The goal of this work is to identify variables that explain either temporal or spatial variability based on case studies for a freeway site and an urban intersection site. The key hypothesis is that dispersion modeling of near-road pollutant concentrations could be improved by adding estimates or indices for site-specific explanatory variables, particularly related to traffic. Based on case studies for a freeway site and an urban intersection site, the specific aims of this project are to (1) develop and test regression models that explain variability in traffic-related air pollutant (TRAP) ambient concentration at two near-roadway locations; (2) develop and test refined proxies for land use, traffic, emissions and dispersion; and (3) prioritize inputs according to their ability to explain variability in ambient concentrations to help focus efforts for future data collection and model development.

The key pollutants that are the key focus of this work include nitrogen oxides (NOx), carbon monoxide (CO), black carbon (BC), fine particulate matter (PM2.5; PM ≤ 2.5 μm in aerodynamic diameter), ultrafine particles (UFPs; PM ≤ 0.1 μm in aerodynamic diameter), and ozone (O3). NOx, CO, and BC are tracers of vehicle emissions and dispersion. PM2.5 is influenced by vehicle table emissions and regional sources. UFPs are sensitive to primary vehicle emissions. Secondary particles can form near roadways and on regional scales, influencing both PM2.5 and UFP concentrations. O3 concentrations are influenced by interaction with NOx near the roadway. Nitrogen dioxide (NO2), CO, PM2.5, and O3 are regulated under the National Ambient Air Quality Standards (NAAQS) because of demonstrated health effects. BC and UFPs are of concern for their potential health effects. Therefore, these pollutants are the focus of this work.

METHODS

The methodological approach includes case studies for which variables are identified and assesses their ability to explain either temporal or spatial variability in pollutant ambient concentrations. The case studies include one freeway location and one urban intersection. The case studies address (1) temporal variability at a fixed monitor 10 meters from a freeway; (2) downwind concentrations perpendicular to the same location; (3) variability in 24-hour average pollutant concentrations at five sites near an urban intersection; and (4) spatiotemporal variability along a walking path near that same intersection.

The study boundary encompasses key factors in the continuum from vehicle emissions to near-road exposure concentrations. These factors include land use, transportation infrastructure and traffic control, vehicle mix, vehicle (traffic) flow, on-road emissions, meteorology, transport and evolution (transformation) of primary emissions, and production of secondary pollutants, and their resulting impact on measured concentrations in the near-road environment. We conducted field measurements of land use, traffic, vehicle emissions, and near-road ambient concentrations in the vicinity of two newly installed fixed-site monitors. One is a monitoring station jointly operated by the U.S. Environmental Protection Agency (U.S. EPA) and the North Carolina Department of Environmental Quality (NC DEQ) on I-40 between Airport Boulevard and I-540 in Wake County, North Carolina. The other is a fixed-site monitor for measuring PM2.5 at the North Carolina Central University (NCCU) campus on E. Lawson Street in Durham, North Carolina. We refer to these two locations as the freeway site and the urban site, respectively. We developed statistical models for the freeway and urban sites.

RESULTS

We quantified land use metrics at each site, such as distances to the nearest bus stop. For the freeway site, we quantified lane-by-lane total vehicle count, heavy vehicle (HV) count, and several vehicle-activity indices that account for distance from each lane to the roadside monitor. For the urban site, we quantified vehicle counts for all 12 turning movements through the intersection. At each site, we measured microscale vehicle tailpipe emissions using a portable emission measurement system.

At the freeway site, we measured the spatial gradient of NOx, BC, UFPs, and PM, quantified particle size distributions at selected distances from the roadway and assessed partitioning of particles as a function of evolving volatility. We also quantified fleet-average emission factors for several pollutants.

At the urban site, we measured daily average concentrations of nitric oxide (NO), NOx, O3, and PM2.5 at five sites surrounding the intersection of interest; we also measured high resolution (1-second to 10-second averages) concentrations of O3, PM2.5, and UFPs along a pedestrian transect. At both sites, the Research LINE-source (R-LINE) dispersion model was applied to predict concentration gradients based on the physical dispersion of pollution.

Statistical models were developed for each site for selected pollutants. With variables for local wind direction, heavy-vehicle index, temperature, and day type, the multiple coefficient of determination (R2) was 0.61 for hourly NOx concentrations at the freeway site. An interaction effect of the dispersion model and a real-time traffic index contributed only 24% of the response variance for NOx at the freeway site. Local wind direction, measured near the road, was typically more important than wind direction measured some distance away, and vehicle-activity metrics directly related to actual real-time traffic were important. At the urban site, variability in pollutant concentrations measured for a pedestrian walk-along route was explained primarily by real-time traffic metrics, meteorology, time of day, season, and real-world vehicle tailpipe emissions, depending on the pollutant. The regression models explained most of the variance in measured concentrations for BC, PM, UFPs, NO, and NOx at the freeway site and for UFPs and O3 at the urban site pedestrian transect.

CONCLUSIONS

Among the set of candidate explanatory variables, typically only a few were needed to explain most of the variability in observed ambient concentrations. At the freeway site, the concentration gradients perpendicular to the road were influenced by dilution, season, time of day, and whether the pollutant underwent chemical or physical transformations. The explanatory variables that were useful in explaining temporal variability in measured ambient concentrations, as well as spatial variability at the urban site, were typically localized real-time traffic-volume indices and local wind direction. However, the specific set of useful explanatory variables was site, context (e.g., next to road, quadrants around an intersection, pedestrian transects), and pollutant specific. Among the most novel of the indicators, variability in real-time measured tailpipe exhaust emissions was found to help explain variability in pedestrian transect UFP concentrations. UFP particle counts were very sensitive to real-time traffic indicators at both the freeway and urban sites. Localized site-specific data on traffic and meteorology contributed to explaining variability in ambient concentrations. HV traffic influenced near-road air quality at the freeway site more so than at the urban site. The statistical models typically explained most of the observed variability but were relatively simple. The results here are site-specific and not generalizable, but they are illustrative that near-road air quality can be highly sensitive to localized real-time indicators of traffic and meteorology.

Diversity and Agronomic Performance of Lupinus mutabilis Germplasm in European and Andean Environments

The introduction of Lupinus mutabilis (Andean lupin) in Europe will provide a new source of protein and oil for plant-based diets and biomass for bio-based products, while contributing to the improvement of marginal soils. This study evaluates for the first time the phenotypic variability of a large panel of L. mutabilis accessions both in their native environment and over two cropping conditions in Europe (winter crop in the Mediterranean region and summer crop in North-Central Europe), paving the way for the selection of accessions adapted to specific environments. The panel of 225 accessions included both germplasm pools from the Andean region and breeding lines from Europe. Notably, we reported higher grain yield in Mediterranean winter-cropping conditions (18 g/plant) than in the native region (9 g/plant). Instead, North European summer-cropping conditions appear more suitable for biomass production (up to 2 kg/plant). The phenotypic evaluation of 16 agronomical traits revealed significant variation in the panel. Principal component analyses pointed out flowering time, yield, and architecture-related traits as the main factors explaining variation between accessions. The Peruvian material stands out among the top-yielding accessions in Europe, characterized by early lines with high grain yield (e.g., LIB065, LIB072, and LIB155). Bolivian and Ecuadorian materials appear more valuable for the selection of genotypes for Andean conditions and for biomass production in Europe. We also observed that flowering time in the different environments is influenced by temperature accumulation. Within the panel, it is possible to identify both early and late genotypes, characterized by different thermal thresholds (600°C-700°C and 1,000-1,200°C GDD, respectively). Indications on top-yielding and early/late accessions, heritability of morpho-physiological traits, and their associations with grain yield are reported and remain largely environmental specific, underlining the importance of selecting useful genetic resources for specific environments. Altogether, these results suggest that the studied panel holds the genetic potential for the adaptation of L. mutabilis to Europe and provide the basis for initiating a breeding program based on exploiting the variation described herein.

Controlling the parameters of focused ion beam for ultra-precise fabrication of nanostructures

At present, the focused ion beam method is an effective technique for nanoscale profiling of a solid surface and prototyping of micro- and nanoscale structures. The article reveals the results of experimental studies on improving the accuracy and resolution of nanoscale profiling of the surface of solids with a focused ion beam. Investigations of the regularities of the influence of the focused ion beam current, beam dwell time and overlap on the parameters of nanoscale structures and the surface profile have been carried out. The influence of the FIB parameters on the deviation of the structure profile from the specified by the template was estimated. Experimental studies have been carried out to determine the influence of the direction of scanning of the ion beam by the template on the magnitude of the error that occurs when the structure of the graphic template is transferred to the substrate. The optimal relationships between the FIB current and the dimensions of the structures being formed have been determined, thus making it possible to ensure the highest accuracy and rate of formation of nanoscale structures. The results can be used to optimize the choice of the ion-beam milling parameters to achieve the maximum accuracy of reproduction of the given sizes of structures.

Combination ATR and PARP Inhibitor (CAPRI): A phase 2 study of ceralasertib plus olaparib in patients with recurrent, platinum-resistant epithelial ovarian cancer

OBJECTIVE

Platinum-resistant, high-grade serous ovarian cancer (HGSOC) has limited treatment options. Preclinical data suggest that poly(ADP-ribose) polymerase inhibitors (PARPi) and ataxia telangiectasia and Rad3-related kinase inhibitors (ATRi) are synergistic. CAPRI (NCT03462342) is an investigator-initiated study of olaparib plus ceralasertib in recurrent HGSOC. Herein, we present results from the platinum-resistant cohort.

METHODS

A Simon 2-stage design was utilized. Platinum-resistant HGSOC patients received ceralasertib 160 mg orally daily, days 1-7 and olaparib 300 mg orally twice daily, days 1-28 of a 28-day cycle until toxicity or progression. Primary endpoints were toxicity and efficacy including objective response rate (ORR) by RECIST. Secondary endpoint was progression-free survival (PFS). The null hypothesis (≤5% ORR) would be rejected if there were ≥ 1 responses in 12 patients.

RESULTS

Fourteen PARPi-naïve patients were evaluable for toxicity; 12 were evaluable for response. Three had BRCA1 mutations (1 germline, 2 somatic). Adverse events possibly related to treatment were primarily grade (G) 1/2. G3 toxicities included nausea (14.3%), fatigue (7.1%), anorexia (7.1%), and anemia (7.1%). No objective responses occurred. Best response was stable disease in 9 patients and progressive disease in three. Five patients had a ≥ 20% to <30% reduction in disease burden, including 3 with BRCA1 mutations. Three of 11 patients (27%; 2 with BRCA1 mutations) evaluable by Gynecologic Cancer Intergroup criteria had >50% CA-125 decline, including 2 with CA-125 normalization. Median PFS was 4.2 months overall (90% CI:3.5-8.2) and 8.2 months (3.6 months-not determined) for patients with BRCA1 mutations.

CONCLUSIONS

Olaparib plus ceralasertib is well-tolerated. No objective responses occurred, though a signal of activity was seen particularly in disease associated with BRCA1. Further evaluation of this combination should include alternate dosing strategies in genomically-selected populations.

Psychometric validation and responder definition of the sleep disturbance numerical rating scale in moderate-to-severe atopic dermatitis

Background

Sleep disturbance (SD) is an important part of the burden of atopic dermatitis (AD), but patient‐reported outcomes that are easy to understand and interpret in the target population have been lacking. A daily, single‐item, self‐reported SD 11‐point numerical rating scale (NRS) was recently developed to assess SD for patients with moderate‐to‐severe AD, but its psychometric properties have not yet been described.

Objectives

To assess the psychometric properties of the SD NRS in patients with moderate‐to‐severe AD.

Methods

The psychometric properties of the SD NRS were assessed using data from a phase IIb clinical trial in 218 adults with moderate‐to‐severe AD.

Results

Test–retest reliability of the SD NRS was substantial to almost perfect (interclass correlation 0·66–1·00) in participants who had stable SD or stable pruritus scores over 1 week. Baseline correlations were moderate to large (r > 0·30) between SD NRS and pruritus or sleep loss scores, but were small (r = −0·11 to 0·17) between SD NRS and EQ‐5D‐3L index and visual analogue scores, Hospital Anxiety and Depression Scale, Scoring Atopic Dermatitis, and Investigator’s Global Assessment. The SD NRS could discriminate groups of participants in the expected direction according to different quality‐of‐life scores but not according to different clinician‐reported disease severity scores. SD NRS scores significantly decreased as sleep loss, itch and quality‐of‐life scores improved. Analysis of meaningful change suggested a 2–5‐point improvement as the initial range of responder definition in the SD NRS score.

Conclusions

The SD NRS is a reliable, valid and responsive measure of SD in adults with moderate‐to‐severe AD.

Whatis already known about this topic?

Sleep disturbance (SD) is a dynamic, multidimensional concept resulting in daytime fatigue and subsequent changes in physical and mental health that vary from day to day.

SD is an important part of the burden of atopic dermatitis, but ways of effectively and reliably measuring it from the patient perspective have been lacking.

A self‐reported, daily, 11‐point SD numerical rating scale (NRS) was recently developed for assessing SD in patients with moderate‐to‐severe atopic dermatitis, and its content validity was previously established.

Whatdoes this study add?

The study showed that the SD NRS is reliable, valid and responsive and can measure day‐to‐day fluctuations in SD related to atopic dermatitis.

The study also established an initial responder definition (i.e. meaningful interpatient change) for the SD NRS score.

Whatare the clinical implications of this work?

The SD NRS is a brief, simple, easy‐to‐interpret and validated patient‐reported global measure for the daily assessment of SD related to atopic dermatitis.

The SD NRS can be used in clinical trials and clinical practice to assess changes in sleep quality in patients with atopic dermatitis.

Plain language summary available online

Hypoxia Pathway Proteins and Their Impact on the Blood Vasculature

Every cell in the body requires oxygen for its functioning, in virtually every animal, and a tightly regulated system that balances oxygen supply and demand is therefore fundamental. The vascular network is one of the first systems to sense oxygen, and deprived oxygen (hypoxia) conditions automatically lead to a cascade of cellular signals that serve to circumvent the negative effects of hypoxia, such as angiogenesis associated with inflammation, tumor development, or vascular disorders. This vascular signaling is driven by central transcription factors, namely the hypoxia inducible factors (HIFs), which determine the expression of a growing number of genes in endothelial cells and pericytes. HIF functions are tightly regulated by oxygen sensors known as the HIF-prolyl hydroxylase domain proteins (PHDs), which are enzymes that hydroxylate HIFs for eventual proteasomal degradation. HIFs, as well as PHDs, represent attractive therapeutic targets under various pathological settings, including those involving vascular (dys)function. We focus on the characteristics and mechanisms by which vascular cells respond to hypoxia under a variety of conditions.

Left atrial appendage closure in the presence of thrombus: incidence, technique and outcomes

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with left atrial appendage (LAA) thrombus are excluded for LAA occlusion (LAAO) in clinical trials. However, some of them may require this therapy due to repeated thromboembolisms despite accurate anticoagulation. 

Aim

The aim of the study is to describe the prevalence of LAA thrombosis in patients submitted for LAAO in a high-volume center of LAAO procedures, explaining the employed technique and results in this scenario.

Methods

Single-center retrospective analysis including all consecutive patients referred for LAAO.

Results

LAA thrombus was detected by TEE in 8/76 patients referred for LAAO (10.5%). Five of them underwent LAAO despite the presence of thrombus due to clinical conditions. All the procedures were successfully performed with  Amulet devices (Table). The following preventive measures were putting in place during the implants: avoidance of contrast injection into the LAA during the procedure (non-touch technique), TEE measure for device size election; and TEE device deployment guidance with special care to the the sheath orientation and depth enabling a slow and single implant of the device partially released in the LAA before complete implantation at the entrance of the LAA (Figure. A&B: Large LAA thrombus partially occupying the landing zone. C: Thrombus sealed by LAAO device. D&E: Non-touch technique: echo-guided progressive deployment of the LAAO device without thrombus shifting). No cerebral protection devices were used. TEE performed one month after the procedure ruled out the presence of residual thrombi or leaks in all cases. There were no events after a median follow-up of 17.1 months (range: 32.3-1.1)

Conclusion

LAAO in patient with LAA thrombus can be effectively and safely performed, in high-volume centers  and with an accurate technique, under accurate TEE guidance. Abstract Figure. LAA thrombus and occlusion technique

Combination of PARP and ATR inhibitors (olaparib and ceralasertib) shows clinical activity in acquired PARP inhibitor-resistant recurrent ovarian cancer

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Background: Following multiple blockbuster studies demonstrating long-term progression free and overall survival benefits with poly(ADP-ribose)polymerase inhibitors (PARPi), they have become an integral component of high grade serous ovarian cancer (HGSOC) treatment. Unfortunately, tumors ultimately acquire resistance and thus therapies that overcome PARPi-resistance are urgently needed. Preclinical studies show the addition of ataxia telangiectasia and Rad3-related kinase inhibitors (ATRi) to PARPi overcome PARPi-resistance. We present results of an investigator-initiated study of the combination PARPi (olaparib) and ATRi (ceralasertib) in patients who were on a PARPi and experienced disease progression. Methods: We conducted a non-randomized trial (NCT03462342) in platinum sensitive HGSOC immediately following prior PARPi treatment of a 28 day cycle of olaparib 300mg orally twice daily and ceralasertib 160mg orally once daily on days 1-7. Eligibility required a germline or somatic BRCA1/2 mutation, other homologous recombination deficient (HRD) mutation, or positive HRD score (>42 on Myriad My Choice). Clinical benefit from prior PARPi was required ( > 12 months on treatment for 1st line maintenance, > 6 months for ≥2nd line maintenance, or treatment of recurrence with response by CA-125 or imaging). No intervening treatment between the PARPi and enrollment was permitted. The primary objectives were safety and objective response rate (ORR). Results: Thirteen patients (pt) of median age 60 years (range 43-78) were enrolled. 9 pt (69%) had germline BRCA mutations, 3 (23%) somatic BRCA mutations and 1 (8%) a positive HRD score. Median time on prior PARPi was 13 months (range 4-60). Prior PARPi indication was 1st line maintenance in 8% (n = 1), 2nd line maintenance in 38% (n = 5) and recurrence in 54% (n = 7). Nine pt (69%) had received olaparib prior to enrollment. The time from prior PARPi to cycle 1, day 1 was 34 days (range 22-311). The ORR was 46% (n = 6); all 6 demonstrating a PR. Pt received a median of 8 (range 3-23) cycles of olaparib and ceralasertib. 4 pt remain on study (4-14 months). 4 pt (31%) experienced grade 3 toxicity: 23% (n = 3) thrombocytopenia, 16% (n = 2) anemia, and 16% (n = 2) neutropenia. There were no grade 4/5 toxicities. There were 4 dose reductions (3 olaparib, 1 ceralasertib). No pt discontinued treatment due to toxicity. Conclusions: The combination of olaparib and ceralasertib is well tolerated and shows clinical activity in in a cohort of patients with recurrent HRD HGSOC who have progressed on prior PARPi thus warranting further investigation. This study is the first to suggest the potential of ATR inhibitors to overcome PARPi resistance in an HRD patient population. Molecular profiling studies are underway to identify potential biomarkers associated with response to guide future clinical trial design. Clinical trial information: NCT03462342.

Interatrial septal tachycardias following atrial fibrillation ablation or cardiac surgery: Electrophysiological features and ablation outcomes

BACKGROUND

Interatrial septal tachycardias (IAS-ATs) following atrial fibrillation (AF) ablation or cardiac surgery are rare, and their management is challenging.

OBJECTIVE

The purpose of this study was to investigate the electrophysiological features and outcomes associated with catheter ablation of IAS-AT.

METHODS

We screened 338 patients undergoing catheter ablation of ATs following AF ablation or cardiac surgery. Diagnosis of IAS-AT was based on activation mapping and analysis of response to atrial overdrive pacing.

RESULTS

Twenty-nine patients (9%) had IAS-AT (cycle length [CL] 311 ± 104 ms); 16 (55%) had prior AF ablation procedures (median 3; range 1-5), 3 (10%) had prior surgical maze, and 12 (41%) had prior cardiac surgery (including atrial septal defect surgical repair in 5 and left atrial myxoma resection in 1). IAS substrate abnormalities were documented in all patients. Activation mapping always demonstrated a diffuse early IAS breakout with centrifugal biatrial activation, and atrial overdrive pacing showed a good postpacing interval (equal or within 25 ms of the AT CL) only at 1 or 2 anatomically opposite IAS sites in all cases. Ablation was acutely successful in 27 patients (93%) (from only the right IAS in 2, only the left IAS in 9, both IAS sides with sequential ablation in 13, and both IAS sides with bipolar ablation in 3). After median follow-up of 15 (6-52) months, 17 patients (59%) remained free from recurrent arrhythmias.

CONCLUSION

IAS-ATs are rare and typically occur in patients with evidence of IAS substrate abnormalities and prior cardiac surgery. Catheter ablation can be challenging and may require sequential unipolar ablation or bipolar ablation.

Healthcare professionals and patient information: a fresh look from the new italian law on consent

ABSTRACT

This article discusses the importance of providing patients with adequate information and creating the care relationship, particularly focusing on the role of healthcare professionals in this activity. It examines the main legislative references on this topic at a European level and the new law, No. 219/2017, in Italy on informed consent that serves as a starting point for recalling important legal and ethical principles regarding the information to be provided to patients in the therapeutic relationship.

One swallow does not make a summer: episodes and persistence in high growth

This paper analyzes firms' episodes (spells) of high growth (HG) using a sample of Spanish manufacturing firms observed over two decades. The use of duration models allows us to investigate the following: (i) the probability of experiencing HG episodes, (ii) persistence in HG, and (iii) the determinants of the transitions in and out of the HG state and whether their impact varies over the business cycle. We find that about half of the firms experience at least one HG episode, but they seldom experience more than one. Moreover, high-growth status is rarely repeated due to high first-year selection. Yet, in subsequent years beyond the first one, the hazard rate from HG status falls substantially. These results suggest an "episodic" nature of HG and further allow us to identify two groups of firms characterized by the following: (i) (relatively) long HG spells and short no high-growth (NHG) spells and (ii) short HG spells and long NHG spells. In addition, some firm and market (demand) characteristics increase the probability of becoming an HG firm and enhancing HG persistence. Finally, during the downturn, the role of younger age and smaller size in explaining HG decreases.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11187-020-00443-8.

Nimbro-OP2X: Affordable Adult-Sized 3D-Printed Open-Source Humanoid Robot for Research

For several years, high development and production costs of humanoid robots restricted researchers interested in working in the field. To overcome this problem, several research groups have opted to work with simulated or smaller robots, whose acquisition costs are significantly lower. However, due to scale differences and imperfect simulation replicability, results may not be directly reproducible on real, adult-sized robots. In this paper, we present the NimbRo-OP2X, a capable and affordable adult-sized humanoid platform aiming to significantly lower the entry barrier for humanoid robot research. With a height of 135[Formula: see text]cm and weight of only 19[Formula: see text]kg, the robot can interact in an unmodified, human environment without special safety equipment. Modularity in hardware and software allows this platform enough flexibility to operate in different scenarios and applications with minimal effort. The robot is equipped with an on-board computer with GPU, which enables the implementation of state-of-the-art approaches for object detection and human perception demanded by areas such as manipulation and human–robot interaction. Finally, the capabilities of the NimbRo-OP2X, especially in terms of locomotion stability and visual perception, are evaluated. This includes the performance at RoboCup 2018, where NimbRo-OP2X won all possible awards in the AdultSize class.

Intraoperative Fluoroscopy Reduces Complication and Reoperation Rate in Facial Fractures

Purpose: The purpose of this study is to evaluate surgical outcomes of facial fractures after the introduction of intraoperative radiology. Methods: An historic cohort of patients without intraoperative fluoroscopy (IOF) was compared with a prospective cohort of patients with IOF. Main outcomes were postoperative complications and reoperation rate. Results: There were 51 in the non-IOF group and 49 in the IOF group. In the group with IOF 10 patients required intraoperative revisions (20.46%). Overall postoperative complication rate was higher in the non-IOF group (25.49% vs. 6.12%) due to the significantly higher bone-related complication rate (15.69% vs. 2.04%). Reoperation rate was also higher in the non-IOF group (11.76% vs. 0%). Conclusion: This study demonstrates that IOF reduces bone-related complication and reoperation rate by allowing correction of surgical errors immediately during surgery.

Effect of reverse manual wheelchair propulsion on shoulder kinematics, kinetics and muscular activity in persons with paraplegia

Objective: Shoulder pain after spinal cord injury (SCI) is attributed to increased mobility demands on the arms and negatively impacts independence and quality of life. Repetitive superior and posterior shoulder joint forces produced during traditional wheelchair (WC) locomotion can result in subacromial impingement if unopposed, as with muscular fatigue or weakness. ROWHEELS^® (RW), geared rear wheels that produce forward WC movement with backward rim pulling, could alter these forces. Design: Cross sectional. Setting: Research laboratory at a rehabilitation hospital. Participants: Ten manual WC users with paraplegia. Outcome measures: Propulsion characteristics and right upper extremity/trunk kinematics and shoulder muscle activity were collected during ergometer propulsion: (1) self-selected free speed reverse propulsion with RW, (2) matched-speed reverse (rSW), and (3) forward propulsion (fSW) with instrumented Smartwheels (SW). Inverse dynamics using right-side SW rim kinetics and kinematics compared shoulder kinetics during rSW and fSW. Results: Free propulsion velocity, cycle distance and cadence were similar during RW, rSW and fSW. Overall shoulder motion was similar except that peak shoulder extension was significantly reduced in both RW and rSW versus fSW. Anteriorly and inferiorly directed SW rim forces were decreased during rSW versus fSW propulsion, but posteriorly and superiorly directed rim forces were significantly greater. Superior and posterior shoulder joint forces and flexor, adductor, and external rotation moments were significantly less during rSW, without a significant difference in net shoulder forces and moments. Traditional propulsive-phase muscle activity was significantly reduced and recovery-phase muscle activity was increased during reverse propulsion. Conclusion: These results suggest that reverse propulsion may redirect shoulder demands and prevent subacromial impingement, thereby preventing injury and preserving independent mobility for individuals with paraplegia.

Abstract A72: Combination ATR and PARP inhibitor (CAPRI) for recurrent, platinum-resistant ovarian cancer

Background: Platinum-resistant (PR) ovarian cancer (OC) is a lethal disease for which effective therapies are limited. Preclinical data suggest that inhibitors of poly(ADP-ribose) polymerase (PARP) and ataxia telangiectasia and Rad3-related kinase (ATR) have synergistic antitumor activity in these tumors. We hypothesize that targeting two unique DNA repair pathways with combination therapy may increase response rates, durability of response, and lower off-target toxicities compared to standard treatments. This clinical trial examines PARP and ATR inhibition (PARPi-ATRi) in patients (pts) with recurrent OC (NCT03462342). Data from the PR arm of this trial are presented.

Methods: Twelve patients were enrolled with PROC in the first stage of a Simon optimal two-stage design with alpha=0.10 and beta=0.10. Eligible pts had recurrent, PR high-grade serous OC, measurable disease, and no prior treatment with a targeted inhibitor of DNA repair. Pts may or may not have a somatic or germline mutation of BRCA1 or BRCA2. Pts received olaparib (O) 300mg orally twice daily on days 1-28 and AZD6738 (A) 160mg orally daily on days 1-7 of a 28-day cycle. Endpoints were safety (toxicity based on CTCAE v5.0), objective response rate (RECIST v1.1), and PFS (RECIST v1.1). If ≥1 patient of 12 treated has a partial or complete response, then 25 additional patients will be treated; if no responses are seen, the PR arm of this trial will be terminated.

Results: Nine patients have been treated and 8 pts have had on-study imaging thus far. Median (M) age is 63 years (53-73); M ECOG, 0 (0-1); M prior lines of chemotherapy, 2.5 (1-4); M prior therapies after acquiring platinum resistance, 0.5 (0-2). BRCA1/2m status (positive/negative/unknown) is: gBRCA1 (1/5/4); gBRCA2 (0/6/4); sBRCA1 (1/7/2); sBRCA2 (0/8/2). No complete or partial responses were seen. Six of 8 patients achieved SD with a mean duration on study of 6.7 cycles (range 4-10 cycles), including 1 pt with gBRCA1m. Three of these 6 pts demonstrated 20-27% tumor regression of target lesions. Two patients had disease progression. Toxicities occurring in ≥50% of pts that were at least possibly related to combination therapy were nausea (grade (G) 1/2: 6, G3: 1); anorexia (G1/2: 5, G3: 1); fatigue (G1/2: 4, G3: 1), anemia (G1/2: 4, G3: 1). No G4 toxicities were observed and no pts discontinued therapy due to toxicity.

Conclusions: Combination O and A is tolerable with mostly low-grade toxicity similar to that of olaparib single-agent. 75% of response-evaluable pts had stable disease, half of whom had substantial tumor regression. Duration of disease stability was clinically meaningful in this PR, largely g/sBRCA1/2 wild-type OC population. Biopsy samples will be evaluated by genomics and proteomics. Updated response data will be presented.

Citation Format: Payal D. Shah, Haley Zarrin, Stephanie Wethington, Nawar Latif, Lainie Martin, Diego Rodriguez, Katie Elkins, Robert Giuntoli, Robert Burger, Janos Tanyi, Mark Morgan, Susan M. Domchek, Stephanie Gailliard, Deborah K. Armstrong, Fiona Simpkins. Combination ATR and PARP inhibitor (CAPRI) for recurrent, platinum-resistant ovarian cancer [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research; 2019 Sep 13-16, 2019; Atlanta, GA. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(13_Suppl):Abstract nr A72.

Telerehabilitation Programme as a Maintenance Strategy for COPD Patients: A 12-Month Randomized Clinical Trial

BACKGROUND

There is uncertainty regarding efficacy of telehealth-based approaches in COPD patients for sustaining benefits achieved with intensive pulmonary rehabilitation (PR).

RESEARCH QUESTION

To determine whether a maintenance pulmonary telerehabilitation (TelePR) programme, after intensive initial PR, is superior to usual care in sustaining over time benefits achieved by intensive PR.

STUDY DESIGN AND METHODS

A multicentre open-label pragmatic parallel-group randomized clinical trial was conducted. Two groups were created at completion of an 8-week intensive outpatient hospital PR programme. Intervention group (IG) patients were given appropriate training equipment and instructed to perform three weekly training sessions and send performance data through an app to a web-based platform. Patients in the control group (CG) were advised to exercise regularly (usual care).

RESULTS

Ninety-four patients (46 IG, 48 CG) were randomized. The analysis of covariance showed non-significant improvements in 6-min walk distance [19.9m (95% CI -4.1/+43.8)] and Chronic Respiratory Disease Questionnaire - Emotion score [0.4 points (0-0.8)] in the IG. Secondary linear mixed models showed improvements in the IG in Short Form-36 mental component summary [9.7, (4.0-15.4)] and Chronic Respiratory Disease Questionnaire - Emotion [0.5, (0.2-0.9)] scores, but there was no association between compliance and outcomes. Acute exacerbations were associated with a marginally significant decrease in 6-minute walk distance of 15.8m (-32.3/0.8) in linear models.

CONCLUSIONS

The TelePR maintenance strategy was both feasible and safe but failed to show superiority over usual care, despite improvements in some HRQoL domains. Acute exacerbations may have an important negative influence on long-term physical function. CLINICALTRIALS.

GOV IDENTIFIER

NCT03247933.

The complete mitochondrial and plastid genomes of the invasive marine red alga Caulacanthus okamurae (Caulacanthaceae, Rhodophyta) from Moss Landing, California, USA

Caulacanthus okamurae is an invasive red alga that forms extensive mats in sheltered marine habitats around the world. To determine its genomic structure and genetic relationship to native and other non-native populations of C. okamurae, high-throughput sequencing analysis was performed on an introduced specimen from Bennett Slough, Moss Landing, California, USA. Assembly of 23,146,595 filtered 150 bp paired-end Illumina sequencing reads yielded its complete mitogenome (GenBank accession MT193839) and plastid genome (GenBank accession MT193838). The mitogenome is 25,995 bp in length and contains 50 genes. The plastid genome is 173,516 bp and contains 234 genes. Comparison of the organellar chromosomes to other Gigartinales revealed a high-level of gene synteny. BLAST analysis of marker sequences (rbcL, cox1, cox2) of C. okamurae from Moss Landing identified four identical DNA sequences: one from a specimen from a native population of C. okamurae from South Korea and three from specimens representing invasive populations from France, Spain, and the USA. These genetic results confirm the presence of C. okamurae in central California, USA, and represent the first complete mitogenome and plastid genome from the Caulacanthaceae.

Two Linear Regimes in Optical Conductivity of a Type-I Weyl Semimetal: The Case of Elemental Tellurium

Employing high-pressure infrared spectroscopy we unveil the Weyl semimetal phase of elemental Te and its topological properties. The linear frequency dependence of the optical conductivity provides clear evidence for metallization of trigonal tellurium (Te-I) and the linear band dispersion above 3.0 GPa. This semimetallic Weyl phase can be tuned by increasing pressure further: a kink separates two linear regimes in the optical conductivity (at 3.7 GPa), a signature proposed for Type-II Weyl semimetals with tilted cones; this however reveals a different origin in trigonal tellurium. Our density-functional calculations do not reveal any significant tilting and suggest that Te-I remains in the Type-I Weyl phase, but with two valence bands in the vicinity of the Fermi level. Their interplay gives rise to the peculiar optical conductivity behavior with more than one linear regime. Pressure above 4.3 GPa stabilizes the more complex Te-II and Te-III polymorphs, which are robust metals.

A Five-Year Retrospective Cohort Study Analyzing Factors Influencing Complications after Nasal Trauma

The purpose of this study was to assess the outcomes of patients with nasal trauma during a long period of time and determine factors predisposing to complications after nasal trauma treatment. A retrospective cohort study was conducted that included all patients who were attended for a nasal trauma between January and December 2010. In 2015, the charts were retrospectively reviewed and the patients were prospectively followed up looking for outcomes after treatment of nasal trauma. A univariate analysis between complications and risk factors was performed and a logistic regression model was used to explore the prognostic role of the variables considered to have clinical relevance and to estimate the odds ratio for the occurrence of postoperative complications. A total of 220 consecutive patients with nasal trauma were included in the study. The mean follow-up was 44.3 ± 10.3 months (3-67) with 10% of lost patients. The most important factors determining complications after nasal trauma treatment were male gender, acute septal injury, chronic septal deviation, displaced or comminuted fractures in the radiologic study, and late nasal reduction surgery. A decision-making algorithm is proposed based on the fact that nasal bone fracture is not a minor problem and that closed nasal bone reduction is not the treatment of choice for all patients with nasal trauma.

A-21 Inhibition of Overlearned Verbal Responses and Quantity of Speech Among Age Cohorts

Objective

Off-topic speech (OTS) has been linked with deficits in executive functioning, and specifically inhibition. OTS research has focused primarily on tangentiality, whereas in this study we focused on quantity of speech. The purpose of this study was to investigate the relationship between inhibition of overlearned responses using a Stroop task and quantity of speech.

Method

A college sample of young adults (n = 63; age 18-28) and healthy, community-dwelling older adults (n = 76; age 60-99) completed the Delis-Kaplan Executive Function Systems (D-KEFS) Color-Word Interference Test and provided a verbal sample in which they recounted a procedural memory and an episodic memory. These samples were transcribed and rated for quantity of speech by three independent judges.

Results

Among all participants, longer time to complete color naming (r = -.21, p = .02) and inhibition (r = -.21, p = .01) was associated with lower quantity of speech on procedural memory. Among young adults, longer time to complete inhibition was associated with lower quantity of speech (r = -.26, p = .04). Among older adults, longer time to complete color naming (r = -.32, p = .005), word reading (r = -.27, p = .02), and inhibition (r = -.35, p = .002) was associated with lower quantity of speech. No relationships were found between performance on Stroop conditions and quantity of speech for episodic memory.

Conclusions

Results suggest that among both age cohorts, difficulty inhibiting overlearned verbal responses is associated with lower quantity of speech regarding a procedural memory but not an episodic memory.

A-13 Sustained Attention, Impulsivity, and Tangentiality of Speech Among Young Adults and Older Adults

Objective

Previous research has linked off-topic verbosity (OTV) among older adults with lower performance on neuropsychological tests tapping attention and executive functioning. However, most of this research has utilized relatively brief neurocognitive measures. Continuous performance tests (CPTs) measure sustained attention and impulsivity. The purpose of this study was to investigate relationships between sustained attention, impulsivity, and tangentiality of speech among young adults and older adults.

Method

Young adult college students (age 18-29; n= 61) and healthy, community-dwelling older adults (age 60-99; n = 81) were administered the Conners’ Continuous Performance Test – 3 and provided a sample of speech (one episodic memory and one procedural memory). These speech samples were transcribed and rated for tangentiality by three independent reviewers.

Results

Among all participants, greater tangentiality of speech was associated with omission errors (r = .22, p = .01) but not with commission errors. This same pattern was found among older adults: omission errors (r = .23, p = .04) were associated with greater tangentiality but commission errors were not. Among young adults, these relationships were not statistically significant.

Conclusions

Results suggest that tangentiality of speech is associated with inattentiveness but not impulsivity, and this relationship may be more marked among older adults than young adults. OTV among older adults may stem from difficulty sustaining attention over time rather than diminished capacity for inhibiting impulses.