Place, Race, and Lapses in Diabetic Retinopathy Care

This cohort study investigates the association of neighborhood-level social determinants of health with lapses in diabetic retinopathy care by race and ethnicity.

Benzodiazepines for pediatric epilepsies and their risks in a cohort within the French health care data

OBJECTIVE

The management of antiseizure treatment in patients with epilepsy relies on the benefit-risk ratio. Data on antiseizure medication (ASM) use in children are limited. We described antiseizure medication use in children with epilepsy (CwE) in France, with a focus on the chronic use of benzodiazepines and related implications.

METHODS

We conducted a 5-year cohort study from January 2012, using data from the French national health care data system (Système National des Données de Santé). We included CwE identified through International Classification of Diseases, 10th Revision codes and medications from January 2012 to December 2015 and followed them until December 2016. We described ASMs and assessed whether the risk of initiating a polytherapy after a bitherapy depends on whether benzodiazepine was included in the bitherapy.

RESULTS

We identified 62 885 CwE. Valproate was the most reimbursed ASM (40%), followed by lamotrigine (17.6%), levetiracetam (9.3%), clobazam (6.1%), and carbamazepine (5.8%). Prescriptions were initiated at the hospital in 74.5% of CwE. We observed a decrease in the number of CwE with at least one benzodiazepine reimbursement from 15.3% in 2013 to 10.1% in 2016 (p < .0001). The prevalence of CwE with levetiracetam reimbursements increased, whereas that of CwE with valproate decreased. A switch from a bitherapy to a polytherapy was more likely when the bitherapy included a benzodiazepine (subdistribution hazard ratio [sHR] = 1.20 [1.03-1.39]).

SIGNIFICANCE

The prevalence of CwE with at least one benzodiazepine reimbursement decreased during the study period. Benzodiazepines were associated with an increased use of subsequent ASM polytherapy.

Similar Risk of Kidney Failure among Patients with Blinding Diseases Who Receive Ranibizumab, Aflibercept, and Bevacizumab: An Observational Health Data Sciences and Informatics Network Study

PURPOSE

To characterize the incidence of kidney failure associated with intravitreal anti-VEGF exposure; and compare the risk of kidney failure in patients treated with ranibizumab, aflibercept, or bevacizumab.

DESIGN

Retrospective cohort study across 12 databases in the Observational Health Data Sciences and Informatics (OHDSI) network.

SUBJECTS

Subjects aged ≥ 18 years with ≥ 3 monthly intravitreal anti-VEGF medications for a blinding disease (diabetic retinopathy, diabetic macular edema, exudative age-related macular degeneration, or retinal vein occlusion).

METHODS

The standardized incidence proportions and rates of kidney failure while on treatment with anti-VEGF were calculated. For each comparison (e.g., aflibercept versus ranibizumab), patients from each group were matched 1:1 using propensity scores. Cox proportional hazards models were used to estimate the risk of kidney failure while on treatment. A random effects meta-analysis was performed to combine each database's hazard ratio (HR) estimate into a single network-wide estimate.

MAIN OUTCOME MEASURES

Incidence of kidney failure while on anti-VEGF treatment, and time from cohort entry to kidney failure.

RESULTS

Of the 6.1 million patients with blinding diseases, 37 189 who received ranibizumab, 39 447 aflibercept, and 163 611 bevacizumab were included; the total treatment exposure time was 161 724 person-years. The average standardized incidence proportion of kidney failure was 678 per 100 000 persons (range, 0-2389), and incidence rate 742 per 100 000 person-years (range, 0-2661). The meta-analysis HR of kidney failure comparing aflibercept with ranibizumab was 1.01 (95% confidence interval [CI], 0.70-1.47; P = 0.45), ranibizumab with bevacizumab 0.95 (95% CI, 0.68-1.32; P = 0.62), and aflibercept with bevacizumab 0.95 (95% CI, 0.65-1.39; P = 0.60).

CONCLUSIONS

There was no substantially different relative risk of kidney failure between those who received ranibizumab, bevacizumab, or aflibercept. Practicing ophthalmologists and nephrologists should be aware of the risk of kidney failure among patients receiving intravitreal anti-VEGF medications and that there is little empirical evidence to preferentially choose among the specific intravitreal anti-VEGF agents.

FINANCIAL DISCLOSURES

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Social Risk Groups in Patients With Diabetes With Differing Eye Care Utilization and Vision Outcomes

Purpose

To evaluate whether latent class analysis on social determinants of health (SDoH) data can identify social risk groups that differ by adverse SDoH and vision outcomes in patients with diabetes.

Methods

This was a prospective cohort study of adults ≥18 years with diabetes who completed a SDoH survey. Latent class analysis was used to cluster patients into social risk groups. The association of social risk group and severity of diabetic retinopathy, history of lapses in diabetic retinopathy care, and visual acuity was evaluated.

Results

A total of 1006 participants were included. The three social risk groups differed by sociodemographic characteristics. The average age was 65, 60, and 54 in Groups 1, 2, and 3 respectively. Most (51%) patients in group 1 were non-Hispanic White, 66% in group 2 were non-Hispanic Black, and 80% in group 3 were Hispanic. Group 1 had the lowest burden of adverse SDoH per person (average 3.6), group 2 had 8.2, and group 3 had 10.5. In general, group 1 lacked diabetic retinopathy knowledge, group 2 had financial insecurity and difficulties with transportation, and group 3 had financial insecurity and did not have health insurance. Social risk group was associated with a history of lapses in diabetic retinopathy care, and presenting with worse vision.

Conclusions and Translational Relevance

We identified distinct social risk groups among patients seeking care for diabetic retinopathy that differed by social needs, eye care utilization, and vision. Identifying these groups and their specific needs can help guide interventions to effectively address adverse SDoH and improve eye care utilization and vision outcomes among patients with diabetes.

The Impact of Social Determinants of Health on Eye Care Utilization in a National Sample of People with Diabetes

PURPOSE

To evaluate the association of social determinants of health (SDoH) with eye care utilization among people with diabetes mellitus using the 2013-2017 National Health Interview Survey (NHIS).

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Participants ≥ 18 years of age with self-reported diabetes.

METHODS

The SDoH in the following domains were used: (1) economic stability; (2) neighborhood, physical environment, and social cohesion; (3) community and social context; (4) food environment; (5) education; and (6) health care system. An aggregate SDoH score was calculated and divided into quartiles, with Q4 representing those with the highest adverse SDoH burden. Survey-weighted multivariable logistic regression models evaluated the association of SDoH quartile with eye care utilization in the preceding 12 months. A linear trend test was conducted. Domain-specific mean SDoH scores were calculated, and the performance of domain-specific models was compared using area under the curve (AUC).

MAIN OUTCOME MEASURE

Eye care utilization in the preceding 12 months.

RESULTS

Of 20 807 adults with diabetes, 43% had not used eye care. Greater adverse SDoH burden was associated with decrements in odds of eye care utilization (P < 0.001 for trend). Participants in the highest quartile of adverse SDoH burden (Q4) had a 58% lower odds (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.37-0.47) of eye care utilization than those in Q1. The domain-specific model using economic stability had the highest performing AUC (0.63; 95% CI, 0.62-0.64).

CONCLUSIONS

Among a national sample of people with diabetes, adverse SDoH were associated with decreased eye care utilization. Evaluating and intervening upon the effects of adverse SDoH may be a means by which to improve eye care utilization and prevent vision loss.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Ensuring privacy protection in the era of big laparoscopic video data: development and validation of an inside outside discrimination algorithm (IODA)

BACKGROUND

Laparoscopic videos are increasingly being used for surgical artificial intelligence (AI) and big data analysis. The purpose of this study was to ensure data privacy in video recordings of laparoscopic surgery by censoring extraabdominal parts. An inside-outside-discrimination algorithm (IODA) was developed to ensure privacy protection while maximizing the remaining video data.

METHODS

IODAs neural network architecture was based on a pretrained AlexNet augmented with a long-short-term-memory. The data set for algorithm training and testing contained a total of 100 laparoscopic surgery videos of 23 different operations with a total video length of 207 h (124 min ± 100 min per video) resulting in 18,507,217 frames (185,965 ± 149,718 frames per video). Each video frame was tagged either as abdominal cavity, trocar, operation site, outside for cleaning, or translucent trocar. For algorithm testing, a stratified fivefold cross-validation was used.

RESULTS

The distribution of annotated classes were abdominal cavity 81.39%, trocar 1.39%, outside operation site 16.07%, outside for cleaning 1.08%, and translucent trocar 0.07%. Algorithm training on binary or all five classes showed similar excellent results for classifying outside frames with a mean F1-score of 0.96 ± 0.01 and 0.97 ± 0.01, sensitivity of 0.97 ± 0.02 and 0.0.97 ± 0.01, and a false positive rate of 0.99 ± 0.01 and 0.99 ± 0.01, respectively.

CONCLUSION

IODA is able to discriminate between inside and outside with a high certainty. In particular, only a few outside frames are misclassified as inside and therefore at risk for privacy breach. The anonymized videos can be used for multi-centric development of surgical AI, quality management or educational purposes. In contrast to expensive commercial solutions, IODA is made open source and can be improved by the scientific community.

Health Disparities in Lapses in Diabetic Retinopathy Care

Objective

To develop a novel methodology to identify lapses in diabetic retinopathy care in electronic health records (EHRs) and evaluate health disparities by race and ethnicity.

Design

Retrospective cohort study.

Subjects

Adult patients with diabetes mellitus who were evaluated at the Wilmer Eye Institute from January 1, 2013 to April 2, 2022.

Methods

The methodology to identify lapses in care first identified diabetic retinopathy screening or treatment visits and then compared the providers' recommended follow-up timeframe with the patient's actual time to next encounter. The association of race and ethnicity with odds of lapses in care was evaluated using a mixed-effects logistic regression model controlling for age, sex, insurance, severity of diabetic retinopathy, presence of other retinal disorders, and glaucoma.

Main Outcome Measures

Lapses in diabetic retinopathy care.

Results

The methodology to identify diabetic retinopathy-related visits had a 95.0% (95% confidence interval, 93.0-96.6) sensitivity and 98.8% (98.1-99.3) specificity as compared with a gold standard grader. The methodology resulted in a 97.3% (96.2-98.4) sensitivity and 98.1% (97.3-98.9) specificity for detecting a follow-up recommendation, with an average error of -0.05 (-0.31 to 0.21) weeks in extracting the precise timeframe. A total of 39 561 patients with 91 104 office visits were included in the analysis. The average age was 61.4 years. More than 3 (77.6%) in 4 patients had a lapse in care. In multivariable analysis, non-Hispanic Black patients had 1.24 (1.19-1.30) odds and Hispanic patients had 1.26 (1.13-1.40) odds of ever having a lapse in care compared with non-Hispanic White patients (P < 0.001, respectively).

Conclusions

We have developed a reliable methodology for identifying lapses in diabetic retinopathy care that is tailored to a provider's recommended follow-up. Using this approach, we find that 3 in 4 patients experience a lapse in diabetic retinopathy care and that these rates are higher among non-Hispanic Black and Hispanic patients. Deploying this methodology in the EHR is one potential means by which to identify and mitigate lapses in critical ophthalmic care in patients with diabetes.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Diagnostic performance of MRI perfusion and spectroscopy for brainstem glioma grading

OBJECTIVE

This study investigated the roles of dynamic susceptibility contrast (DSC) perfusion and multivoxel magnetic resonance spectroscopy (MRS) in grading brainstem glioma (BSG).

PATIENTS AND METHODS

Our retrospective study comprised 12 patients, including 6 with pathology verified low-grade BSGs and 6 with high-grade BSGs. We examined differences in age, relative cerebral blood volume (rCBV), regional cerebral blood flow (rCBF), and the metabolite ratios of choline (Cho)/N-acetyl aspartate (NAA) and Cho/creatine (Cr) between these two groups using the Mann-Whitney U test and Chi-square test. Receiver operating characteristic (ROC) curve analysis was used to establish cutoff values and assess their usefulness in grading BSG.

RESULTS

The Cho/NAA metabolite ratio had the strongest preoperative predictive performance for identifying the correct histological grade among BSGs, with an area under the ROC curve (AUC) value of 0.944 (cutoff: 3.88, sensitivity [Se]: 83.3%; specificity [Sp]: 100%), followed by the Cho/Cr ratio (cutoff: 3.08; AUC: 0.917; Se: 83.3%; Sp: 100%), rCBF (cutoff: 3.56, AUC: 0.917; Se: 83.3%; Sp: 100%), rCBV (cutoff: 3.16, AUC: 0.889; Se: 100%; Sp: 66.7%), and age (cutoff: 9.5 years, AUC: 0.889; Se: 100%; Sp: 83.3%).

CONCLUSIONS

rCBF and rCBV values comparing solid tumors with the normal brain parenchyma and the metabolite ratios for Cho/NAA and Cho/Cre may serve as useful indices for establishing BSG grading and provide important information when determining treatment planning and prognosis in patients with BSG.

Processed electroencephalography: impact of patient age and surgical position on intraoperative processed electroencephalogram monitoring of burst-suppression

We previously reported that processed EEG underestimated the amount of burst suppression compared to off-line visual analysis. We performed a follow-up study to evaluate the reasons for the discordance. Forty-five patients were monitored intraoperatively with processed EEG. A computer algorithm was used to convert the SedLine® (machine)-generated burst suppression ratio into a raw duration of burst suppression. The reference standard was a precise off-line measurement by two neurologists. We measured other potential variables that may affect machine accuracy such as age, surgery position, and EEG artifacts. Overall, the median duration of bust suppression for all study subjects was 15.4 min (Inter-quartile Range [IQR] = 1.0-20.1) for the machine vs. 16.1 min (IQR = 0.3-19.7) for the neurologists' assessment; the 95% limits of agreement fall within - 4.86 to 5.04 s for individual 30-s epochs. EEG artifacts did not affect the concordance between the two methods. For patients in prone surgical position, the machine estimates had significantly lower overall sensitivity (0.86 vs. 0.97; p = 0.038) and significantly wider limits of agreement ([- 4.24, 3.82] seconds vs. [- 1.36, 1.13] seconds, p = 0.001) than patients in supine position. Machine readings for younger patients (age < 65 years) had higher sensitivity (0.96 vs 0.92; p = 0.021) and specificity (0.99 vs 0.88; p = 0.007) for older patients. The duration of burst suppression estimated by the machine generally had good agreement compared with neurologists' estimation using a more precise off-line measurement. Factors that affected the concordance included patient age and position during surgery, but not EEG artifacts.

Randomized comparison between perineural dexamethasone and combined perineural dexamethasone-dexmedetomidine for ultrasound-guided infraclavicular block

BACKGROUND

This randomized trial compared perineural dexamethasone with combined perineural dexamethasone-dexmedetomidine for ultrasound-guided infraclavicular block. We hypothesized that the combination of perineural adjuvants would result in a longer motor block.

METHODS

Fifty patients undergoing upper limb surgery with ultrasound-guided infraclavicular block (using 35 mL of lidocaine 1%-bupivacaine 0.25% with epinephrine 5 µg/mL) were randomly allocated to receive perineural dexamethasone (2 mg) or combined perineural dexamethasone (2 mg)-dexmedetomidine (50 µg). After the performance of the block, a blinded observer assessed the success rate (defined as a minimal sensorimotor composite score of 14 out of 16 points at 30 min), the onset time (defined as the time required to reach a minimal composite score of 14 points) as well as the incidence of surgical anesthesia (defined as the ability to complete surgery without local infiltration, supplemental blocks, intravenous opioids or general anesthesia).Postoperatively, the blinded observer contacted patients with successful blocks to inquire about the duration of motor block, sensory block and postoperative analgesia.

RESULTS

No intergroup differences were observed in terms of success rate, onset time and surgical anesthesia. Compared with dexamethasone alone, combined dexamethasone-dexmedetomidine provided longer durations of motor block (21.5 (2.7) vs 17.0 (3.9) hours; p<0.001; 95% CI 2.6 to 6.4), sensory block (21.6 (3.6) vs 17.2 (3.6) hours; p<0.001; 95% CI 2.2 to 6.5), and postoperative analgesia (25.5 (9.4) vs 23.5 (5.6) hours; p=0.038; 95% CI 1.0 to 7.7).

CONCLUSION

Compared with perineural dexamethasone (2 mg) alone, combined perineural dexamethasone (2 mg)-dexmedetomidine (50 µg) results in longer durations of sensorimotor block and analgesia. Further studies are required to determine the optimal dosing combination for dexamethasone-dexmedetomidine.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT04875039.

Impact of Childhood Onset Psoriasis on Addictive Behaviours, Socioeconomic and Educational Data in Adulthood

Paediatric psoriasis has been associated with school absenteeism, limitation of physical activities, psychiatric disorders and, in the longer term, with sexual dysfunction and addictions. This raises the hypothesis that childhood onset psoriasis may affect patients’ educational development, and further social and professional outcomes. This study evaluated the relationship between childhood onset psoriasis and patients’ educational and socioeconomic characteristics, and the development of addictions in adulthood. This cross-sectional ancillary study captured patients’ characteristics at baseline in the French PSOBIOTEQ registry. Data in adulthood included: educational (baccalaureate) and socioeconomic (working activity) groups, smoking status (self-reporting of being a current smoker vs past smoker or non-smoker), alcohol consumption (defined as at least 1 glass of alcoholic beverage per day), and living conditions (alone/family/social institutions; child at home). A total of 1,960 patients were included, of whom 26.2% had childhood onset psoriasis. In multivariate analyses, childhood onset psoriasis was associated with smoker status (p = 0.02). No association was observed with educational level, working activity, living conditions, or alcohol consumption. This study provides reassuring data overall with regard to the impact of childhood onset psoriasis on major social outcomes. Evidence for some association with addictive behaviours paves the way for larger prospective studies assessing in depth the social and educational impact of this disease.

POS1405 LESS THAN 50% FEMALES WITH CHRONIC RHEUMATIC INFLAMMATORY DISEASES CONTINUE A DMARD DURING PREGNANCY: A DESCRIPTIVE ANALYSIS OF THE NATIONAL FRENCH SOCIAL SECURITY DATABASE

Background

Treatment of patients with chronic rheumatic inflammatory diseases (CRID) during pregnancy has changed in the last decade, namely due to the availability of new DMARDs labelled to be used during pregnancy.

Objectives

To describe the anti-rheumatic drug use during pregnancy in women with CRID (i.e. rheumatoid arthritis (RA) or spondyloarthritis (SpA)) in France over the past decade.

Methods

This is a retrospective cohort study within the French Healthcare database (SNDS), which covers 98% of the French population. Adult women were included if they had RA or SpA according to CIM-10 codes, had started a singleton pregnancy between 2008 and 2017 (index date), and were continuously covered by this health insurance from 1-year before pregnancy onset to 1-year after end of the pregnancy or death (whichever comes first). The treatment exposures of interest were: NSAIDs, oral corticosteroids, csDMARD (methotrexate, leflunomide, sulfasalazine, azathioprine, hydroxychloroquine), biologics (anti-TNF, rituximab, abatacept, tocilizumab, ustekinumab, anakinra). Exposure during pregnancy was defined as at least one drug reimbursement from the 6 months before the last menstrual period (LMP) to the end of pregnancy period.

Results

Among the 35,737 adult women with a CIRD (40.7% with RA and 59.3% with SpA) who had a past history of DMARD reimbursement, 11,274 (41.7%) started a singleton pregnancy during the study period. In total, during preconception and pregnancy, 4,773 (42.3%) women were not delivered any DMARD nor corticosteroids, 769 (6.8%) were delivered corticosteroids alone, 3,639 (32.2%) a csDMARD alone and 2,862 (25.4%) a biologic (among whom 33.1% associated a csDMARD). Biologics delivered during pregnancy were mainly anti-TNFs (92.1%).

Exposure to NSAIDs was more frequent during the first trimester (30% patients) of pregnancy but occurred all along the pregnancy (6% and 2% in the second and third trimesters, respectively). Conversely, exposure to oral corticosteroids was stable during the pregnancy (33% to 27%); however, more than half of the prescriptions corresponded to doses higher than 10mg. Exposure to DMARDs including bDMARDs during pregnancy was more frequent during the first trimester, compared to the rest of the pregnancy (see graph).

Conclusion

Overall, less than 50% of women with a CRID who received a DMARD prior to the pregnancy continued to retrieve such treatment during pregnancy, and overall less than 20% were delivered biologics during pregnancy. Whether the withdrawal of DMARDs led to unfavorable maternal and pregnancy outcomes needs to be evaluated.

Acknowledgements

This study was conducted thanks to a grant from the French Ministry of Health - Programme Hospitalier de Recherche Clinique

Disclosure of Interests

Anna Moltó Consultant of: UCB, Abbvie, Lilly, Pfizer, BMS, MSD, Novartis, Biogen, Janssen, Grant/research support from: UCB, Aya Ajrouche: None declared, Diep Tran: None declared, Barbara Roux: None declared, Nathalie Costedoat-Chalumeau Grant/research support from: UCB, Elisabeth Elefant: None declared, Vassilis Tsatsaris: None declared, Jeanne Fresson: None declared, Brigitte Bader-Meunier: None declared, Bruno Fautrel: None declared, Florence Tubach: None declared

AB1391 19% PATIENTS WITH CHRONIC RHEUMATIC INFLAMMATORY DISEASES PRESENT AN UNFAVORABLE PREGNANCY OUTCOME: A DESCRIPTIVE ANALYSIS OF THE NATIONAL FRENCH SOCIAL SECURITY DATABASE

Background

patients with chronic rheumatic inflammatory diseases (CRID, i.e. rheumatoid arthritis (RA) or spondyloarthritis (SpA)) have been reported to have poorer pregnancy outcomes than the general population.

Objectives

to describe the pregnancy outcomes of singleton in patients with CRID in France in the past decade.

Methods

this is an analysis of the French Health Insurance claims database (SNDS), which represents 87% of the French population) from 2008 to 2016. To be included in the analysis patients had to be identified as RA or SpA according to existing diagnostic algorithms, to have at least one pregnancy declaration in the database, and to have continuous health insurance from 1-year before pregnancy onset to 1-year after end of the pregnancy or until death (if death occured before the 1-year-period after the end of pregnancy) to be included. Only the first singleton pregnancy occurring during the study period was included in this analysis. Both maternal and pregnancy outcomes were considered. Outcomes were identified either by ICM-10 codes or hospital discharge summaries discharge between 2008-2016.

Results

Among the 35 737 identified adult females with a CRID diagnosis (40.7% with RA and 59.3% with SpA), 27 722 (78%) had a pregnancy during the study period. 11 274 (42%) had received at least one DMARD prior to the pregnancy and were included in the analysis. Among them, only 4025 (36%) were exposed to DMARDs during pregnancy.

Mean (SD) age of females at the start of the pregnancy was 32 (5) years, and mean (SD) disease duration was 4 (4) years. Pregnancy ended before 13 WG in 21% and after 37 WG in 70% cases. Live-birth represented the most frequent pregnancy outcome (76.9%), and overall 34.7% patients presented at least one unfavorable outcome (see Table 1).

Table 1.Unfavourable outcomeN(%)Pregnancy outcomesMiscarriage (<22WG)579 (5.3%)Abortion91 (0.8%)Stillbirth48 (0.4%)Preterm delivery (>= 22WG and <37 WG)779 (7.1%)Low weight at birth (<3th percentile)287 (2.6%)Perinatal mortality (22WG to 6 days of life)2 (0%)Maternal outcomesSevere maternal infection*211 (1.9%)Newborn outcomesHospitalisation in neonatal intensive care > 48h in full-term newborns (after 37 WG)95 (0.8%)Neonatal mortality (27 first days of life)2 (0%)Severe infection * during first year603 (5.3%)

Conclusion

More than 75% pregnancies in patients with CRID resulted in a live-birth. Prevalence of miscarriage was surprisingly low, probably related to under-coding. Maternal and infant outcomes seemed comparable to general population. Whether medications had an impact on such outcomes is currently under evaluation.

Disclosure of Interests

None declared

Synergistic anti-tumor efficacy of mutant isocitrate dehydrogenase 1 inhibitor SYC-435 with standard therapy in patient-derived xenograft mouse models of glioma

•

A novel pair of orthotopic PDX models of glioma bearing IDH1-R132H/R132C mutations.

•

New mutant IDH1i (SY-435) with standard therapy led to strong therapeutic efficacy.

•

H3K4/K9 methylation/mtDNA-encoded molecules mediate anti-tumor activity of SYC-435.

•

Discovered MYO1F, CTC1 and BCL9 as novel genes that mediated SYC-435 resistance.

Clinical outcomes in patients with WHO grade II/III astrocytoma, oligodendroglioma or secondary glioblastoma remain poor. Isocitrate dehydrogenase 1 (IDH1) is mutated in > 70% of these tumors, making it an attractive therapeutic target. To determine the efficacy of our newly developed mutant IDH1 inhibitor, SYC-435 (1-hydroxypyridin-2-one), we treated orthotopic glioma xenograft model (IC-BT142AOA) carrying R132H mutation and our newly established orthotopic patient-derived xenograft (PDX) model of recurrent anaplastic oligoastrocytoma (IC-V0914AOA) bearing R132C mutation. In addition to suppressing IDH1 mutant cell proliferation in vitro, SYC-435 (15 mg/kg, daily x 28 days) synergistically prolonged animal survival times with standard therapies (Temozolomide + fractionated radiation) mediated by reduction of H3K4/H3K9 methylation and expression of mitochondrial DNA (mtDNA)-encoded molecules. Furthermore, RNA-seq of the remnant tumors identified genes (MYO1F, CTC1 and BCL9) and pathways (base excision repair, TCA cycle II, sirtuin signaling, protein kinase A, eukaryotic initiation factor 2 and α-adrenergic signaling) as mediators of therapy resistance. Our data demonstrated the efficacy SYC-435 in targeting IDH1 mutant gliomas when combined with standard therapy and identified a novel set of genes that should be prioritized for future studies to overcome SYC-435 resistance.

Real-world Safety of Bevacizumab with First-line Combination Chemotherapy in Patients with Metastatic Colorectal Cancer: Population-based Retrospective Cohort Studies in Three Canadian Provinces

AIMS

To examine the real-world safety of adding bevacizumab to first-line irinotecan-based chemotherapy for patients with metastatic colorectal cancer (mCRC).

MATERIALS AND METHODS

Patients diagnosed with CRC in three Canadian provinces (Ontario, Saskatchewan and British Columbia) who received publicly funded bevacizumab and/or irinotecan from 2000 to 2016 were identified from cancer registries. Propensity score 1:1 matching (PSM) and inverse probability of treatment weighting (IPTW) were performed to contemporaneous and historical controls, adjusting for baseline demographic and clinical characteristics. Safety end points evaluated during first-line treatment plus 30 days included mortality within 30 days and all-cause-, chemotherapy- and bevacizumab-related hospitalisations. Chemotherapy- and bevacizumab-related visits were defined as hospitalisations for specific conditions commonly associated with chemotherapy (e.g. infections) or bevacizumab (e.g. arteriovenous thromboembolism) using most responsible diagnosis codes. In PSM and IPTW-weighted cohorts, we assessed event frequencies using odds ratios from logistic regressions and event rate ratios using negative binomial regression models. The results from each province and comparison were pooled using random-effects meta-analysis.

RESULTS

We identified 16 250 mCRC patients who received first-line irinotecan-based treatment. In PSM cohorts, bevacizumab was associated with fewer deaths within 30 days of treatment compared with contemporaneous (pooled odds ratio = 0.62; 95% confidence interval 0.50-0.75) and historical controls (pooled odds ratio = 0.73; 95% confidence interval 0.58-0.93). Hospitalisations were more frequent among patients treated with bevacizumab compared with historical controls but similar to contemporaneous controls. As patients receiving bevacizumab were exposed to a longer average treatment duration, across their full treatment duration, patients receiving bevacizumab had significantly lower rates of hospitalisations (contemporaneous pooled rate ratio = 0.56; 95% confidence interval 0.47-0.67; historical pooled rate ratio = 0.73; 95% confidence interval 0.56-0.95). Similar trends were observed for chemotherapy- and bevacizumab-related hospitalisations and in IPTW-weighted cohorts.

DISCUSSION

We did not observe any increase in rates of hospitalisation or death within 30 days of treatment among mCRC patients treated with bevacizumab plus chemotherapy versus chemotherapy alone; these findings should be interpreted with caution due to the risk of residual confounding.

Successive Osteosarcoma Relapses after the First Line O2006/Sarcome-09 Trial: What Can We Learn for Further Phase-II Trials?

Simple Summary

Osteosarcoma is the most common primary malignant bone tumour in adolescents and young adults. The survival of osteosarcoma patients has not improved for four decades. The purpose was to describe first and subsequent relapses in patients from the OS2006/Sarcome-09 trial, to help future trial design. Among the 434 patients with a confirmed osteosarcoma who achieved CR1 during first line treatment, 157 patients experienced at least one relapse. The 3-year progression-free and overall survival rates were 21% and 37%, respectively. Only a quarter of the patients were included in clinical trials at first recurrence. We want to promote randomised phase-II trials in osteosarcoma relapses, with broad inclusion criteria at study entry in terms of age and disease status, and PFS as primary endpoint. Surgery/local treatment of all residual lesions should be allowed when feasible. Single-arm trial design could be used for subsequent relapses.

Abstract

The purpose was to describe first and subsequent relapses in patients from the OS2006/Sarcome-09 trial, to help future trial design. We prospectively collected and analysed relapse data of all French patients included in the OS2006/Sarcome-09 trial, who had achieved a first complete remission. 157 patients experienced a first relapse. The median interval from diagnosis to relapse was 1.7 year (range 0.5–7.6). The first relapse was metastatic in 83% of patients, and disease was not measurable according to RECIST 1.1 criteria in 23%. Treatment consisted in systemic therapy (74%) and surgical resection (68%). A quarter of the patients were accrued in a phase-II clinical trial. A second complete remission was obtained for 79 patients. Most of them had undergone surgery (76/79). The 3-year progression-free and overall survival rates were 21% and 37%, respectively. In patients who achieved CR2, the 3y-PFS and OS rates were 39% and 62% respectively. Individual correlation between subsequent PFS durations was poor. For osteosarcoma relapses, we recommend randomised phase-II trials, open to patients from all age categories (children, adolescents, adults), not limited to patients with measurable disease (but stratified according to disease status), with PFS as primary endpoint, response rate and surgical CR as secondary endpoints.

Deep learning as a predictive tool for fetal heart pregnancy following time-lapse incubation and blastocyst transfer

STUDY QUESTION

Can a deep learning model predict the probability of pregnancy with fetal heart (FH) from time-lapse videos?

SUMMARY ANSWER

We created a deep learning model named IVY, which was an objective and fully automated system that predicts the probability of FH pregnancy directly from raw time-lapse videos without the need for any manual morphokinetic annotation or blastocyst morphology assessment.

WHAT IS KNOWN ALREADY

The contribution of time-lapse imaging in effective embryo selection is promising. Existing algorithms for the analysis of time-lapse imaging are based on morphology and morphokinetic parameters that require subjective human annotation and thus have intrinsic inter-reader and intra-reader variability. Deep learning offers promise for the automation and standardization of embryo selection.

STUDY DESIGN, SIZE, DURATION

A retrospective analysis of time-lapse videos and clinical outcomes of 10 638 embryos from eight different IVF clinics, across four different countries, between January 2014 and December 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The deep learning model was trained using time-lapse videos with known FH pregnancy outcome to perform a binary classification task of predicting the probability of pregnancy with FH given time-lapse video sequence. The predictive power of the model was measured using the average area under the curve (AUC) of the receiver operating characteristic curve over 5-fold stratified cross-validation.

MAIN RESULTS AND THE ROLE OF CHANCE

The deep learning model was able to predict FH pregnancy from time-lapse videos with an AUC of 0.93 [95% CI 0.92-0.94] in 5-fold stratified cross-validation. A hold-out validation test across eight laboratories showed that the AUC was reproducible, ranging from 0.95 to 0.90 across different laboratories with different culture and laboratory processes.

LIMITATIONS, REASONS FOR CAUTION

This study is a retrospective analysis demonstrating that the deep learning model has a high level of predictability of the likelihood that an embryo will implant. The clinical impacts of these findings are still uncertain. Further studies, including prospective randomized controlled trials, are required to evaluate the clinical significance of this deep learning model. The time-lapse videos collected for training and validation are Day 5 embryos; hence, additional adjustment would need to be made for the model to be used in the context of Day 3 transfer.

WIDER IMPLICATIONS OF THE FINDINGS

The high predictive value for embryo implantation obtained by the deep learning model may improve the effectiveness of previous approaches used for time-lapse imaging in embryo selection. This may improve the prioritization of the most viable embryo for a single embryo transfer. The deep learning model may also prove to be useful in providing the optimal order for subsequent transfers of cryopreserved embryos.

STUDY FUNDING/COMPETING INTEREST(S)

D.T. is the co-owner of Harrison AI that has patented this methodology in association with Virtus Health. P.I. is a shareholder in Virtus Health. S.C., P.I. and D.G. are all either employees or contracted with Virtus Health. D.G. has received grant support from Vitrolife, the manufacturer of the Embryoscope time-lapse imaging used in this study. The equipment and time for this study have been jointly provided by Harrison AI and Virtus Health.

The association between platelet dysfunction and adverse outcomes in cardiac surgical patients

Haemostatic activation during cardiopulmonary bypass is associated with prothrombotic complications. Although it is not possible to detect and quantify haemostatic activation directly, platelet dysfunction, as measured with point-of-care-assays, may be a useful surrogate. In this study, we assessed the association between cardiopulmonary bypass-associated platelet dysfunction and adverse outcomes in 3010 cardiac surgical patients. Platelet dysfunction, as measured near the end of the rewarming phase of cardiopulmonary bypass, was calculated as the proportion of non-functional platelets after activation with collagen. Logistic regression and multivariable analyses were applied to assess the relationship between platelet dysfunction and a composite of in-hospital death; myocardial infarction; stroke; deep vein thrombosis or pulmonary embolism; and acute kidney injury (greater than a two-fold increase in creatinine). The outcome occurred in 251 (8%) of 3010 patients. The median (IQR [range]) percentage platelet dysfunction was less for those without the outcome as compared with those with the outcome; 14% (8-28% [1-99%]) vs. 19% (11-45% [2-98%]), p < 0.001. After risk adjustment, platelet dysfunction was independently associated with the composite outcome (p < 0.001), such that for each 1% increase in platelet dysfunction there was an approximately 1% increase in the composite outcome (OR 1.012; 95%CI 1.006-1.018). This exploratory study suggests that cardiopulmonary bypass-associated platelet dysfunction has prognostic value and may be a useful clinical measure of haemostatic activation in cardiac surgery.

The FcRn inhibitor rozanolixizumab reduces human serum IgG concentration: A randomized phase 1 study

Pathogenic immunoglobulin G (IgG) autoantibodies characterize some human autoimmune diseases; their high concentration and long half-life are dependent on recycling by the neonatal Fc receptor (FcRn). Inhibition of FcRn is an attractive new treatment concept for IgG-mediated autoimmune diseases. Rozanolixizumab (UCB7665; CA170_01519.g57 IgG4P) is an anti-human FcRn monoclonal antibody. In cynomolgus monkeys, rozanolixizumab reduced IgG (maximum 75 to 90% by about day 10), was well tolerated, and did not increase risk of infection. We also report a first-in-human, randomized, double-blind, placebo-controlled, dose-escalating study of intravenous (IV) or subcutaneous (SC) rozanolixizumab in healthy subjects (NCT02220153). The primary objective was to evaluate safety and tolerability. Secondary objectives were assessment of rozanolixizumab pharmacokinetics and pharmacodynamics, including effects on circulating IgG concentrations. Forty-nine subjects were randomized to receive rozanolixizumab (n = 36) or placebo (n = 13) across six cohorts. The first three cohorts received IV doses, and the subsequent three cohorts received SC doses, of rozanolixizumab 1, 4, or 7 mg/kg (n = 6 for each cohort; plus n = 7 or 6 for placebo, respectively). The most frequent treatment-emergent adverse event [TEAE; headache, 14 of 36 (38.9%) subjects] was dose-dependent and more prominent after IV administration. Severe TEAEs occurred in four subjects, all in the highest-dose IV group [headache (n = 3) and back pain (n = 1)]. Rozanolixizumab pharmacokinetics demonstrated nonlinear increases with dose. There were sustained dose-dependent reductions in serum IgG concentrations (IV and SC rozanolixizumab). These data provide clinical evidence for the therapeutic potential of rozanolixizumab.

Bioactive extracellular compounds produced by the dinoflagellate Alexandrium minutum are highly detrimental for oysters

Blooms of the dinoflagellate Alexandrium spp., known as producers of paralytic shellfish toxins (PSTs), are regularly detected on the French coastline. PSTs accumulate into harvested shellfish species, such as the Pacific oyster Crassostrea gigas, and can cause strong disorders to consumers at high doses. The impacts of Alexandrium minutum on C. gigas have often been attributed to its production of PSTs without testing separately the effects of the bioactive extracellular compounds (BECs) with allelopathic, hemolytic, cytotoxic or ichthyotoxic properties, which can also be produced by these algae. The BECs, still uncharacterized, are excreted within the environment thereby impacting not only phytoplankton, zooplankton but also marine invertebrates and fishes, without implicating any PST. The aim of this work was to compare the effects of three strains of A. minutum producing either only PSTs, only BECs, or both PSTs and BECs, on the oyster C. gigas. Behavioral and physiological responses of oysters exposed during 4 days were monitored and showed contrasted behavioral and physiological responses in oysters supposedly depending on produced bioactive substances. The non-PST extracellular-compound-producing strain primarily strongly modified valve-activity behavior of C. gigas and induced hemocyte mobilization within the gills, whereas the PST-producing strain caused inflammatory responses within the digestive gland and disrupted the daily biological rhythm of valve activity behavior. BECs may therefore have a significant harmful effect on the gills, which is one of the first organ in contact with the extracellular substances released in the water by A. minutum. Conversely, the PSTs impact the digestive gland, where they are released and mainly accumulated, after degradation of algal cells during digestion process of bivalves. This study provides a better understanding of the toxicity of A. minutum on oyster and highlights the significant role of BECs in this toxicity calling for further chemical characterization of these substances.