Systematic Implementation of Effective Quality Assurance Processes for the Assessment of Radiation Target Volumes in Head and Neck Cancer

PURPOSE

Significant heterogeneity exists in clinical quality assurance (QA) practices within radiation oncology departments, with most chart rounds lacking prospective peer-reviewed contour evaluation. This has the potential to significantly affect patient outcomes, particularly for head and neck cancers (HNC) given the large variance in target volume delineation. With this understanding, we incorporated a prospective systematic peer contour-review process into our workflow for all patients with HNC. This study aims to assess the effectiveness of implementing prospective peer review into practice for our National Cancer Institute Designated Cancer Center and to report factors associated with contour modifications.

METHODS AND MATERIALS

Starting in November 2020, our department adopted a systematic QA process with real-time metrics, in which contours for all patients with HNC treated with radiation therapy were prospectively peer reviewed and graded. Contours were graded with green (unnecessary), yellow (minor), or red (major) colors based on the degree of peer-recommended modifications. Contours from November 2020 through September 2021 were included for analysis.

RESULTS

Three hundred sixty contours were included. Contour grades were made up of 89.7% green, 8.9% yellow, and 1.4% red grades. Physicians with >12 months of clinical experience were less likely to have contour changes requested than those with <12 months (8.3% vs 40.9%; P < .001). Contour grades were significantly associated with physician case load, with physicians presenting more than the median number of 50 cases having significantly less modifications requested than those presenting <50 (6.7% vs 13.3%; P = .013). Physicians working with a resident or fellow were less likely to have contour changes requested than those without a trainee (5.2% vs 12.6%; P = .039). Frequency of major modification requests significantly decreased over time after adoption of prospective peer contour review, with no red grades occurring >6 months after adoption.

CONCLUSIONS

This study highlights the importance of prospective peer contour-review implementation into systematic clinical QA processes for HNC. Physician experience proved to be the highest predictor of approved contours. A growth curve was demonstrated, with major modifications declining after prospective contour review implementation. Even within a high-volume academic practice with subspecialist attendings, >10% of patients had contour changes made as a direct result of prospective peer review.

Phase I Study of Bortezomib, Fludarabine, and Melphalan, with or without Total Marrow Irradiation as Conditioning for Allogeneic Hematopoietic Stem Cell Transplantation in Patients with High-Risk or Relapsed/Refractory Multiple Myeloma

PURPOSE/OBJECTIVE(S)

Though outcomes of patients with multiple myeloma (MM) have improved, cure remains elusive. Allogeneic hematopoietic stem cell transplantation (allo-sCT) is associated with a lower relapse rate, but its role is hindered due to toxicities. We hypothesized that targeted total body irradiation in the form of total marrow irradiation (TMI) could safely facilitate allo-SCT via an improved toxicity profile. Therefore, we conducted a phase I study to investigate the safety and feasibility of a bortezomib (BTZ), fludarabine (FLU), and melphalan (MEL), with or without TMI, prior to allo-SCT for patients with high-risk (HR) or relapsed/refractory (R/R) MM.

MATERIALS/METHODS

Between 2012 and 2018 this study enrolled patients with HR or R/R MM on one of two strata, each comprising BTZ dose-escalation cohorts. Patients aged 18-60 with no prior radiation (RT) received TMI at 900 cGy (in 6 fractions delivered twice-daily), FLU, and MEL conditioning, with BTZ added in the second cohort (stratum I). Patients aged 18-70 with prior RT received FLU, MEL, and BTZ, without TMI (stratum II). The primary endpoint was feasibility of escalating doses of BTZ, with or without TMI, defined using a 3+3 design. Dose-limiting toxicity (DLT) was defined as any Grade 3+ Bearman toxicity or prolonged CTCAE v4.0 Grade 4+ neutropenia. Secondary endpoints included treatment response, time to neutrophil and platelet engraftment, incidence of acute (a) and chronic (c) graft-versus-host disease (GVHD), progression-free-survival (PFS), and overall survival (OS).

RESULTS

Eight patients were enrolled on stratum I. One of three patients in the first cohort of stratum I experienced DLT, which led to expansion to three more patients with no DLT. Cohort 2 enrolled only 2 patients due to low accrual, with BTZ added at 0.5 mg/m2; neither experienced DLT. Nine patients were enrolled on stratum II. Three patients were enrolled on cohort 1 (BTZ 0.5 mg/m2) and none experienced DLT. Three were enrolled on cohort 2 (bortezomib 0.7 mg/m2), and one experienced DLT. Therefore, the cohort expanded to three more patients. One more patient experienced DLT and 0.5 mg/m2 was considered the maximum tolerated dose. There were no primary or secondary graft failures. Complete response was achieved in 7 and 4 patients in strata I and II, respectively. Median follow-up for all patients was 30.7 months (mos) and was 99.8 mos for surviving patients. Median overall survival (OS) on strata I and II were 44.5 mos and 21.6 mos, respectively. Median PFS on strata I and II were 18.1 mos and 8.9 mos, respectively. In strata I, 5 patients developed Grade 2+ aGVHD and 8 developed extensive cGVHD. In strata II, 4 patients developed Grade 2+ aGVHD and 6 developed extensive cGVHD.

CONCLUSION

The TMI 900 cGy, FLU, and MEL conditioning regimen is considered safe as conditioning for allo-SCT and may warrant further investigation due to favorable response rates and survival; the conditioning regimen of FLU, MEL, and BTZ (0.7 mg/m2) is associated with unacceptable toxicities.

First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

Persistent Orofacial Pain Attendances at General Medical Practitioners

Patients with persistent orofacial pain (POFP) can go through complex care pathways to receive a diagnosis and management, which can negatively affect their pain. This study aimed to describe 44-y trends in attendances at Welsh medical practices for POFP and establish the number of attendances per patient and referrals associated with orofacial pain and factors that may predict whether a patient is referred. A retrospective observational study was completed using the nationwide Secure Anonymised Information Linkage Databank of visits to general medical practices in Wales (UK). Data were extracted using diagnostic codes ("Read codes"). Orofacial and migraine Read codes were extracted between 1974 and 2017. Data were analyzed using descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 468,827 POFP and migraine diagnostic codes, accounting for 468,137 patient attendances, or 301,832 patients. The overall attendance rate was 4.22 attendances per 1,000 patient-years (95% confidence interval [CI], 4.21-4.23). The attendance rate increased over the study period. Almost one-third of patients (n = 92,192, 30.54%) attended more than once over the study period, and 15.83% attended more than once within a 12-mo period. There were 20,103 referral codes that were associated with 8,183 patients, with over half these patients being referred more than once. Odds of receiving a referral were highest in females (odds ratio [OR], 1.23; 95% CI, 1.17-1.29), in those living in rural locations (OR, 1.17; 95% CI, 1.12-1.22), and in the least deprived quintile (OR, 1.39; 95% CI, 1.29-1.48). Odds also increased with increasing age (OR, 1.03; 95% CI, 1.03-1.03). The increasing attendance may be explained by the increasing incidence of POFP within the population. These patients can attend on a repeated basis, and very few are referred, but when they are, this may occur multiple times; therefore, current care pathways could be improved.

1023 An Audit of The Prevalence of Frailty and The Impact on Surgical Management and Resource Use, For Vascular Inpatients Using the National Vascular Registry (NVR) Frailty Classifications

Aim

To determine if the NVR frailty score was being routinely collected on all relevant vascular patients on admission, identify the prevalence of frailty in vascular inpatients and determine if frailty was associated with a higher mortality and morbidity.

Method

A prospective audit of consecutive patients admitted onto the vascular ward who were eligible for inclusion on the NVR. Data was collected from electronic patient records and paper case notes between November 2019 and February 2020. The primary outcome was completeness of frailty assessment. Secondary outcomes were prevalence of frailty and mortality and morbidity associated with frailty score.

Results

Frailty status was documented in 65% of patients. 43% (28/65) were assessed to be frail. The 30-day mortality rate was 1.53% (1/65). 26.15% (17/65) had one or more complication. The commonest complications were graft occlusions, acute kidney injury, hospital acquired pneumonia and groin infections. 93.84% (61/65) were discharged home. There was no correlation between frailty and number of post-operative complications (p = 0.394), length of stay (p = 0.171) or mortality (p = 0.371).

Conclusions

This audit found frailty assessment is poorly assessed and the current NVR frailty classification did not correlate to increase mortality or morbidity in this patient cohort.

Pilot scale demonstration of a two-stage pretreatment and bioethanol fermentation process for cotton gin trash

A two-stage dilute acid and steam explosion (SE) pretreatment process was developed and evaluated at pilot scale for ethanol production from cotton gin trash (CGT). Optimal conditions for CGT processing were defined as 1:6 solids to liquids ratio with 9% H₂SO₄ wt. on solids at 180 °C for 15 min. during stage 1 with ensuing pressed fibres successively exposed to SE at 200 °C for 5 min during stage 2. SE fibres were highly acquiescent to enzyme hydrolysis (76%) in the presence of PEG 6000, yielding 381 g glucose kg^-1 fibre. Simultaneous saccharification and fermentation (SSF) trials validated the selected process option and additional fed-batch SSFs confirmed titres above the minimum 4% ww^-1 benchmark for economically viable distillation. The practicality of converting CGT to ethanol was demonstrated at pilot scale with titres above 4% ww^-1 and a conversion efficiency of 60% t^-1 dry GCT.

548 FRAILTY ANALYSIS ACROSS POPULATIONS: THE USE OF THE HOSPITAL FRAILTY RISK SCORE IN SPECIALISED SERVICES USING NHS NATIONAL DATA

Introduction

Frailty is increasingly used to risk stratify older people, but across specialised services there is no standardised approach. The aim of this study was to answer the question posed by NHS England to assess frailty could be measured and related to outcomes across Specialsed Services. The Hospital Frailty Risk Score (HFRS) was used and the data published in Age and Ageing in 2020.

Method

A retrospective cohort study was performed using the Secondary Uses Service (SUS) electronic database for people aged 75 or older admitted between April 2017 and March 2018. Based on HFRS, the populations were risk stratified into mild, moderate and severe frailty risk. The relationships with length of stay, readmission rate, mortality and some selected condition specific treatment complications were quantified using descriptive statistics.

Results

Frailty was differentially distributed across the specialties; around one-third had mild frailty; another third had moderate frailty and one-quarter severe frailty. Increasing frailty risk was associated with increased length of stay for the index admission, more days in hospital in the year following intervention and increased risk of dying in hospital. Severe frailty was a powerful discriminator of the risk of death; between 25 and 40% of those with severe frailty risk died at 30 months across all specialties.

Conclusions

This study demonstrates the first application of the HFRS to a national dataset to describe service outcomes and mortality for older people undergoing a range of specialised interventions. This information was used to identify those that might benefit from holistic assessment, aid prognostication, commissioning and service planning. It informed the promotion of quality improvement work in this area via the Specialised Clinical Frailty Network. By implementing the HFRS, changes in outcomes can be plotted across years to assess improvements, performance and benchmarking.

Inactivation of the gene encoding the cationic antimicrobial peptide resistance factor MprF increases biofilm formation but reduces invasiveness of Listeria monocytogenes

AIMS

To understand the genetics involved in surface attachment and biofilm formation of Listeria monocytogenes.

METHODS AND RESULTS

An in vitro screen of a Himar1 transposon library of L. monocytogenes strain 15G01 identified three transposants that produced significantly different biofilm levels when compared to the wild-type strain; two mutants exhibited enhanced biofilm formation and one produced less biofilm biomass than the wild-type. The mutant 15G01 mprF::Himar1, which had a transposon insertion in the mprF gene, was selected for further analysis. The mutant produced a more densely populated biofilm on solid surfaces such as stainless steel and polystyrene, as determined using scanning electron and light microscopy. The 15G01 mprF::Himar1 mutant remained viable in biofilms, but showed an increase in sensitivity to the cationic antimicrobial gallidermin. The mutant also displayed reduced invasiveness in CaCo-2 intestinal cells, suggesting virulence properties are compromised by the inactivation of mprF.

CONCLUSIONS

Biofilm formation and gallidermin resistance of L. monocytogenes is influenced by mprF, but this trait is associated with a compromise in invasiveness.

SIGNIFICANCE AND IMPACT OF THE STUDY

The presence of pathogenic microorganisms in the food processing environment can cause a significant problem, especially when these microorganisms are established as biofilms. This study shows that the inactivation of the mprF gene results in enhanced biofilm formation and abiotic surface attachment of L. monocytogenes.

The effect of phosphate on the heat resistance of spores of dairy isolates of Geobacillus stearothermophilus

In this study, we show that phosphate decreases the spore heat resistance by accelerating the rate of loss of cations from spores. Heat resistance of spores of Geobacillus stearothermophilus A1, D1, P3 and ATCC 12980 were determined in distilled water containing varying concentrations (0.1, 1 and 2% w/v) of di‑sodium phosphate. The average decimal reduction times (D value) for strains A1, D1, P3 and ATCC 12980 in distilled water were 5.8, 6.8, 5.7 and 9 min at 110 °C respectively. On the addition of 0.1, 1 and 2% w/v of di‑sodium phosphate, the average D₁₁₀ values of all the strains in distilled water were lowered by 50, 61 and 70% respectively. Addition of 0.05% w/v of Na-EDTA to distilled water resulted in lowering of the average D₁₁₀ value of all the strains by 55%. Heat resistance of spores of A1, D1, P3 and ATCC 12980 was found to be associated with the Dipicolinic Acid (DPA) content whose concentrations were 0.25, 0.30, 0.27 and 1.6 pg per spore respectively. Analysis by atomic absorption spectroscopy revealed that the phosphate present in the heating medium causes excess release of calcium from spores with 2% w/v phosphate being highly effective, thus confirming the chelating effect of phosphate. This study provides insight into the heat resistance and the increased heat sensitivity of spores of G. stearothermophilus A1, D1 and P3 in the presence of phosphate, which can be used in the design of Cleaning in Place (CIP) systems involving phosphate based cleaning agents to combat biofilms and spores in the dairy industry.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Low-Dose Anti-Thymocyte Globulin (ATG) Preserves β-Cell Function and Improves HbA1c in New-Onset Type 1 Diabetes

OBJECTIVE

A pilot study suggested that combination therapy with low-dose anti-thymocyte globulin (ATG) and pegylated granulocyte colony-stimulating factor (GCSF) preserves C-peptide in established type 1 diabetes (T1D) (duration 4 months to 2 years). We hypothesized that 1) low-dose ATG/GCSF or 2) low-dose ATG alone would slow the decline of β-cell function in patients with new-onset T1D (duration <100 days).

RESEARCH DESIGN AND METHODS

A three-arm, randomized, double-masked, placebo-controlled trial was performed by the Type 1 Diabetes TrialNet Study Group in 89 subjects: 29 subjects randomized to ATG (2.5 mg/kg intravenously) followed by pegylated GCSF (6 mg subcutaneously every 2 weeks for 6 doses), 29 to ATG alone (2.5 mg/kg), and 31 to placebo. The primary end point was mean area under the curve (AUC) C-peptide during a 2-h mixed-meal tolerance test 1 year after initiation of therapy. Significance was defined as one-sided P value < 0.025.

RESULTS

The 1-year mean AUC C-peptide was significantly higher in subjects treated with ATG (0.646 nmol/L) versus placebo (0.406 nmol/L) (P = 0.0003) but not in those treated with ATG/GCSF (0.528 nmol/L) versus placebo (P = 0.031). HbA_1c was significantly reduced at 1 year in subjects treated with ATG and ATG/GCSF, P = 0.002 and 0.011, respectively.

CONCLUSIONS

Low-dose ATG slowed decline of C-peptide and reduced HbA_1c in new-onset T1D. Addition of GCSF did not enhance C-peptide preservation afforded by low-dose ATG. Future studies should be considered to determine whether low-dose ATG alone or in combination with other agents may prevent or delay the onset of the disease.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

For debate: health service support planning for large-scale defensive land operations (part 2)

This is the second of two articles that considers the medical planning implications of large-scale defensive military operations. This paper describes a unified approach to theatre level health services support planning based on four phases: collection, hospitalisation, evacuation and reception. It highlights the need for a modular and agile system of medical capability building blocks that can be grouped together for specific military medical challenges. It also reintroduces the concepts of mass casualty and the medical reserve. These two papers are designed to encourage debate around how we should be organised to face the new challenges of health services support in potential peer-on-peer military operations.

For debate: health service support planning for large-scale defensive land operations (part 1)

This is the first of two articles that considers the medical planning implications of large-scale defensive military operations. This paper considers the military context and planning factors that may require a medical plan that is different from that seen in recent counterinsurgency operations. The scale and complexity of the challenge is likely to require a greater level of decentralisation and a more sophisticated approach to medical planning at the strategic and operational levels.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Autologous stem-cell transplantation after second-line brentuximab vedotin in relapsed or refractory Hodgkin lymphoma

Background

We previously demonstrated that brentuximab vedotin (BV) used as second-line therapy in patients with Hodgkin lymphoma is a tolerable and effective bridge to autologous hematopoietic cell transplantation (AHCT). Here, we report the post-AHCT outcomes of patients treated with second-line standard/fixed-dose BV and an additional cohort of patients where positron-emission tomography adapted dose-escalation of second-line BV was utilized.

Patients and methods

Patients on the dose-escalation cohort received 1.8 mg/kg of BV intravenously every 3 weeks for two cycles. Patients in complete remission (CR) after two cycles received two additional cycles of BV at 1.8 mg/kg, while patients with stable disease or partial response were escalated to 2.4 mg/kg for two cycles. All patients, regardless of treatment cohort, proceeded directly to AHCT or received additional pre-AHCT therapy at the discretion of the treating physician based on remission status after second-line BV.

Results

Of the 20 patients enrolled to the BV dose-escalation cohort, 8 patients underwent BV dose-escalation. BV escalation was well-tolerated, but no patients who were escalated converted to CR. Of 56 evaluable patients treated across cohorts, the overall response rate (ORR) to second-line BV was 75% with 43% CR. Twenty-eight (50%) patients proceeded directly to AHCT without post-BV chemotherapy, and a total of 50 patients proceeded to AHCT. Thirteen patients received consolidative post-AHCT therapy with either radiation, BV, or a PD-1 inhibitor. After AHCT, the 2-year progression-free survival (PFS) and overall survival were 67% and 93%, respectively. The 2-year PFS among patients in CR at the time of AHCT (n = 37) was 71% compared with 54% in patients not in CR (p = 0.12). The 2-year PFS in patients who proceeded to AHCT directly after receiving BV alone was 77%.

Conclusions

Second-line BV is an effective bridge to AHCT that produces responses of sufficient depth to provide durable remission in conjunction with AHCT (clinicaltrials.gov: NCT01393717).

EEG Source Imaging Indices of Cognitive Control Show Associations with Dopamine System Genes

Cognitive or executive control is a critical mental ability, an important marker of mental illness, and among the most heritable of neurocognitive traits. Two candidate genes, catechol-O-methyltransferase (COMT) and DRD4, which both have a roles in the regulation of cortical dopamine, have been consistently associated with cognitive control. Here, we predicted that individuals with the COMT Met/Met allele would show improved response execution and inhibition as indexed by event-related potentials in a Go/NoGo task, while individuals with the DRD4 7-repeat allele would show impaired brain activity. We used independent component analysis (ICA) to separate brain source processes contributing to high-density EEG scalp signals recorded during the task. As expected, individuals with the DRD4 7-repeat polymorphism had reduced parietal P3 source and scalp responses to response (Go) compared to those without the 7-repeat. Contrary to our expectation, the COMT homozygous Met allele was associated with a smaller frontal P3 source and scalp response to response-inhibition (NoGo) stimuli, suggesting that while more dopamine in frontal cortical areas has advantages in some tasks, it may also compromise response inhibition function. An interaction effect emerged for P3 source responses to Go stimuli. These were reduced in those with both the 7-repeat DRD4 allele and either the COMT Val/Val or the Met/Met homozygous polymorphisms but not in those with the heterozygous Val/Met polymorphism. This epistatic interaction between DRD4 and COMT replicates findings that too little or too much dopamine impairs cognitive control. The anatomic and functional separated maximally independent cortical EEG sources proved more informative than scalp channel measures for genetic studies of brain function and thus better elucidate the complex mechanisms in psychiatric illness.

Early colposcopic reassurance and discharge to routine recall does not increase subsequent high-grade referral or treatment rates

BACKGROUND

The Jessop Wing Colposcopy Unit identified that between 1st April 2014 and 31st March 2015 the number of women referred with high-grade dyskaryosis and the number of women undergoing treatment increased by 21% and 19%, respectively. There was concern that referral and treatment rates were increasing because we were now seeing women, previously discharged to routine recall with prior low-grade cytology hrHPV positive, re-enter the system for their second round of screening. The aim of this study was to assess the reasons for our significant increase in referral and treatment rates.

METHODS

A retrospective cohort study performed between 1st April 2012 and 30th June 2015 at the Jessop Wing Colposcopy Unit, Sheffield, UK.

RESULTS

During the study period, 1765 women underwent large loop excision of the transformation zone (LLETZ), of whom 1517 were referred with high-grade dyskaryosis. Fifty-six (4%) women undergoing treatment; and four untreated high-grade referrals were seen in the previous 3-5 years with low-grade cytology hrHPV positive and discharged to routine recall. There were no cases of invasive disease in the previously discharged groups. There was, however, a significantly higher likelihood of a negative LLETZ (P=.0066) in those women previously discharged to routine recall, and lower rates of CIN2 or worse identified.

CONCLUSION

Prior discharge to routine recall does not have any major influence on treatment rates or high-grade referrals. The finding of no invasive disease; lower rates of CIN2 or worse; and a significantly higher likelihood of a negative LLETZ in those women previously discharged to routine recall is reassuring and further reinforces the safety of HPV triage pathways.

Multicenter phase 2 study of combination therapy with ruxolitinib and danazol in patients with myelofibrosis

Myelofibrosis is a myeloproliferative neoplasm that is characterized by splenomegaly, profound symptom burden, and cytopenias. JAK inhibitor therapy offers improvements in splenomegaly, symptom burden, and potentially survival; however, cytopenias remain a significant challenge. Danazol has previously demonstrated improvements in myelofibrosis-associated anemia. We conducted a phase II clinical trial evaluating the efficacy and tolerability of combination therapy with ruxolitinib, an oral JAK inhibitor, and danazol. Fourteen intermediate or high-risk MF patients were enrolled at 2 institutions. Responses per IWG-MRT criteria were stable disease in 9 patients (64.2%) clinical improvement in 3 (21.4%) all of which were spleen responses, partial response in 1 (7.1%) and progressive disease in 1 (7.1%). Despite limited IWG-MRT response, stabilization of anemia and thrombocytopenia was demonstrated. In JAK inhibitor naïve patients, 4/5 (80%) had stable or increasing hemoglobin. Of the 9 patients on prior JAK inhibitor, 5 patients (55.5%) and 8 patients (88.9%) had stable or increasing hemoglobin or platelet levels, respectively. Adverse events possibly related included grade 3 or greater hematologic toxicity in ten patients (71.4%) and non-hematologic toxicity in two patients (14.3%). Although combination therapy did not lead to increased hematologic response per IWG-MRT criteria, hematologic stabilization was observed and may be clinically useful.