Venous Thromboembolism in Children and Teenagers Admitted for Trauma: A 5-Year Nationwide Perspective

Venous thromboembolism (VTE) in pediatric trauma patients is under-investigated. The purpose of this study was to perform an evaluation of the risk factors for VTE after pediatric trauma, including readmissions across the United States. The Nationwide Readmissions Database for 2016-2020 was queried for all patients under the age of 18 years admitted for trauma. 276 670 patients were identified; 2063 (.8%) were diagnosed with VTE. Among those with VTE, 300 (15%) were identified during a readmission. Higher rates of VTE were seen in ages 15-17 years (n = 1,294, 1.3%, P < .001), penetrating injuries (n = 478, .9%, P < .001), and assault (n = 271, 2.7%, P < .001). The strongest risk factor for VTE was prolonged mechanical ventilation (OR 5.5 [4.9-6.3] P < .001). Our study found that a significant portion of post-traumatic VTE in children and teenagers occur during readmissions. A deeper understanding of the risk factors outlined here can guide enhanced clinical protocols, ensuring early detection and prevention of this complication.

EEG rhythmic and arrhythmic spectral components and functional connectivity at resting state may predict the development of synucleinopathies in idiopathic REM sleep behavior disorder

STUDY OBJECTIVES

Idiopathic/isolated REM-sleep behavior disorder (iRBD) often precedes the onset of synucleinopathies. Here, we investigated whether baseline resting-state EEG advanced spectral power and functional connectivity differ between iRBD patients who converted towards a synucleinopathy at follow-up and those who did not.

METHODS

Eighty-one participants with iRBD (66.89±6.91 years) underwent a baseline resting-state EEG recording, a neuropsychological assessment and a neurological examination. We estimated EEG power spectral density using standard analyses and derived spectral estimates of rhythmic and arrhythmic components. Global and pairwise EEG functional connectivity analyses were computed using the weighted phase-lag index (wPLI). Pixel-based permutation tests were used to compare groups.

RESULTS

After a mean follow-up of 5.01±2.76 years, 34 patients were diagnosed with a synucleinopathy (67.81±7.34 years) and 47 remained disease-free (65.53±7.09 years). Among patients who converted, 22 were diagnosed with Parkinson's disease and 12 with dementia with Lewy bodies. As compared to patients who did not convert, patients who converted exhibited at baseline higher relative theta standard power, steeper slopes of the arrhythmic component and higher theta rhythmic power mostly in occipital regions. Furthermore, patients who converted showed higher beta global wPLI but lower alpha wPLI between left temporal and occipital regions.

CONCLUSION

Analyses of resting-state EEG rhythmic and arrhythmic components and functional connectivity suggest an imbalanced excitatory-to-inhibitory activity within large-scale networks, which is associated with later development of a synucleinopathy in iRBD patients.

The Role of Pharmaceutical Innovation in Clinical Practice Guidelines for Chronic Diseases

Background

Over the last 25 years, clinical practice guidelines have emerged as a means to standardize and improve care. As pharmaceutical innovations develop, guidelines are updated to incorporate new interventions. However, the extent to which pharmacotherapies are represented as treatment options in guideline recommendations has not been well elucidated. This study aimed to quantify the role pharmacotherapy has played in clinical practice guidelines across a range of chronic diseases over the past 20 years.

Methods

Clinical practice guidelines published from 2000 to 2021 were identified for five chronic diseases: ischemic heart disease (IHD), non-small cell lung cancer (NSCLC), chronic obstructive pulmonary disease (COPD), Alzheimer's disease (AD), and type 2 diabetes (T2D). Guidelines were reviewed and data on treatment recommendations were collected, including the type of intervention, line of therapy, and, for pharmacotherapies, year of regulatory approval and year of inclusion in guidelines.

Results

In total, 92 clinical practice guidelines were reviewed. Among the 184 discrete recommended interventions across the five disease areas, 146 (79.3%) were pharmacotherapies, 21 (11.4%) were behavioral modifications, 6 (3.3%) were surgical interventions, and 11 (6%) were other interventions. Across guidelines, when a line of therapy was specified, behavioral modifications and pharmacotherapies were most frequently recommended as first-line interventions, whereas surgical interventions were more often recommended for subsequent lines of treatment. The time from regulatory approval of novel pharmacotherapies to inclusion in guideline recommendations varied considerably by disease area and geography.

Conclusions

Across the reviewed disease areas, behavioral interventions and pharmacotherapies are shown to be critical components of clinical practice. Over the last 20 years, novel pharmaceutical innovations have been incorporated into clinical practice guideline recommendations; however, with varying speeds of adoption. Given the increasing pace of pharmacologic innovation, timely updates of clinical practice guidelines are critical to evolving the standard of care and practicing evidence-based medicine.

Hospitalizations and Mortality From Myasthenia Gravis: Trends From 2 US National Datasets

BACKGROUND AND OBJECTIVES

Myasthenia gravis (MG) is a rare neuromuscular disorder where IgG antibodies damage the communication between nerves and muscles, leading to muscle weakness that can be severe and have a significant impact on patients' lives. MG exacerbations include myasthenic crisis with respiratory failure, the most serious manifestation of MG. Recent studies have found MG prevalence increasing, especially in older patients. This study examined trends in hospital admissions and in-hospital mortality for adult patients with MG and readmissions and postdischarge mortality in older (65 years or older) adults with MG.

METHODS

Data from the Nationwide Inpatient Sample (NIS), an all-payer national database of hospital discharges, were used to characterize trends in hospitalizations and in-hospital mortality related to MG exacerbations and MG crisis among adult patients aged 18 years or older. The Medicare Limited Data Set, a deidentified, longitudinal research database with demographic, enrollment, and claims data was used to assess hospitalizations, length of stay (LOS), readmissions, and 30-day postdischarge mortality among fee-for-service Medicare beneficiaries aged 65 years or older. The study period was 2010-2019. Multinomial logit models and Poisson regression were used to test for significance of trends.

RESULTS

Hospitalization rates for 19,715 unique adult patients and 56,822 admissions increased from 2010 to 2019 at an average annualized rate of 4.9% (MG noncrisis: 4.4%; MG crisis: 6.8%; all p < 0.001). Readmission rates were approximately 20% in each study year for both crisis and noncrisis hospitalizations; the in-hospital mortality rate averaged 1.8%. Among patients aged 65 years or older, annualized increases in hospitalizations were estimated at 5.2%, 4.2%, and 7.7% for all, noncrisis, and crisis hospitalizations, respectively (all p < 0.001). The average LOS was stable over the study period, ranging from 11.3 to 13.1 days, but was consistently longer for MG crisis admissions. Mortality among patients aged 65 years or older was higher compared with that in all patients, averaging 5.0% across each of the study years.

DISCUSSION

Increasing hospitalization rates suggest a growing burden associated with MG, especially among older adults. While readmission and mortality rates have remained stable, the increasing hospitalization rates indicate that the raw numbers of readmissions-and deaths-are also increasing. Mortality rates are considerably higher in older patients hospitalized with MG.

Dynamic, sex- and diet-specific pleiotropism in the PAC1 receptor-mediated regulation of arcuate proopiomelanocortin and Neuropeptide Y/Agouti related peptide neuronal excitability by anorexigenic ventromedial nucleus PACAP neurons

This study furthers the investigation of how pituitary adenylate cyclase activating polypeptide (PACAP) and the PAC1 receptor (PAC1R) regulate the homeostatic energy balance circuitry. We hypothesized that apoptotic ablation of PACAP neurones in the hypothalamic ventromedial nucleus (VMN) would affect both energy intake and energy expenditure. We also hypothesized that selective PAC1R knockdown would impair the PACAP-induced excitation in anorexigenic proopiomelanocortin (POMC) neurones and inhibition of orexigenic neuropeptide Y (NPY)/agouti-related peptide (AgRP) neurones in the hypothalamic arcuate nucleus (ARC). The results show CASPASE-3-induced ablation of VMN PACAP neurones leads to increased energy intake and meal frequency as well as decreased energy expenditure in lean animals. The effects were more robust in obese males, whereas we saw the opposite effects in obese females. We then utilized visualized whole-cell patch clamp recordings in hypothalamic slices. PAC1R knockdown in POMC neurones diminishes the PACAP-induced depolarization, increase in firing, decreases in energy intake and meal size, as well as increases in CO2 production and O2 consumption. Similarly, the lack of expression of the PAC1R in NPY/AgRP neurones greatly attenuates the PACAP-induced hyperpolarization, suppression of firing, decreases in energy intake and meal frequency, as well as increases in energy expenditure. The PACAP response in NPY/AgRP neurones switched from predominantly inhibitory to excitatory in fasted animals. Finally, the anorexigenic effect of PACAP was potentiated when oestradiol was injected into the ARC in ovariectomized females. This study demonstrates the critical role of anorexigenic VMN PACAP neurones and the PAC1R in exciting POMC and inhibiting NPY/AgRP neurons to control homeostatic feeding.

Improving Vaccine Equity: How Community Engagement and Informatics Facilitate Health System Outreach to Underrepresented Groups

BACKGROUND

Given the inequities in access to health care resources like COVID-19 vaccination, health systems should carefully consider how to reach underrepresented groups. Reflecting on vaccine rollout efforts holds insight on the role of community engagement and informatics support in promoting health equity.

OBJECTIVES

This study aimed to assess the effectiveness of four outreach strategies deployed by University of Washington (UW) Medicine in improving vaccine equity over traditional vaccine scheduling online or by phone, we report on appointment scheduling and completion of appointments (i.e., vaccine administration) through (1) automated outreach to individuals from underrepresented groups, (2) temporary "pop-up" clinics in neighborhoods highly impacted by COVID-19, (3) vulnerable population clinics, and (4) mobile vaccine vans.

METHODS

We conducted a 6-month retrospective analysis of electronic health records (EHR) to describe the sociodemographic characteristics of individuals who scheduled appointments using the outreach strategies and characteristics associated with a greater likelihood of vaccine administration based on appointment completion. To help explain trends in the EHR data, we engaged 10 health system leaders and staff who spearheaded the outreach strategies in follow-up conversations to identify qualitative insights into what worked and why.

RESULTS

Compared with traditional scheduling, all outreach strategies except vulnerable population clinics had higher vaccine appointment completion rates, including automated outreach (N = 3,734 [94.7%], p < 0.001), pop-up clinics (N = 4,391 [96.0%], p < 0.001), and mobile vans (N = 4,198 [99.1%], p < 0.001); and lower cancellation rates, including automated outreach (N = 166 [1.1%], p < 0.001), pop-up clinics (N = 155 [0.6%], p < 0.001), and mobile vans (N = 0 [0%], p < 0.001). Qualitative insights emphasized ongoing community partnerships and information resources in successful outreach.

CONCLUSION

Vaccine equity outreach strategies improved the proportion of patients who scheduled and completed vaccination appointments among populations disproportionately impacted by COVID-19. Engaging community partners and equity-focused informatics tools can facilitate outreach. Lessons from these outreach strategies carry practical implications for health systems to amplify their health equity efforts.

Feasibility of Acquiring Radiotherapy Linac Commissioning Data with a Three-Dimensional Cubic Electronic Detector Array

PURPOSE/OBJECTIVE(S)

Linac commissioning data acquisition consists of measurements of PDDs/TMRs, profiles, and dosimetric factors done in water and lasting several weeks to complete. Data collected with an early prototype 3D cubic electronic detector suggests faster, reliable, accurate, and a cost-effective option for commissioning data collection in the future.

MATERIALS/METHODS

A 10 × 10 × 15 cm3 3D cubic electronic detector array prototype of acrylic, silicon rubber, and five 10 × 10 × 0.2 cm3 planar active matrices at 2.0, 4.0, 6.0, 8.0, and 10 cm depths, was constructed. Each active matrix has 25 pixels (diode, capacitor, MOSFET) of 2.0 cm separation in a 10 × 10 cm2 active area resulting in 125 pixels in the array. Data readout consists of a multiplex connectivity configuration where one channel provides data input/output to multiple pixels rather than one channel per pixel. Simultaneous absolute depth-dose (ADD) and profile measurements were performed using a 6 MV photon beam, 100 cm SSD, 10 × 10 cm2 open field, 100 MU, and 400 MU/min, without scanning. Also, ADDs and profiles were measured with 15-, 30- and 45-deg wedges. Data processing for these measurements, and 2D and 3D DD and profile displays, were done in a programming environment, and results were compared to calculated data in acrylic.

RESULTS

Table with ADD and profile results for the 10 × 10 cm2 open field. ADD and profiles with wedges showed similar results.

CONCLUSION

Absolute depth-dose and profile data acquired with an early prototype agreed within ±4 % of calculated values. This suggests that an improved 3D cubic electronic detector array could be used for commissioning data collection. If realized, it could reduce commissioning time from weeks to hours saving cost, staff time, and leveraging a new Linac into clinical operations sooner.

A Real World Perspective of PARP Inhibitor Use in Gynecological Cancer Patients

Introduction: Over the last few years, targeted therapy has become the mainstay maintenance treatment of patients with ovarian cancer including patients with BRCA1/BRCA2 mutations. Poly ADP ribose polymerase inhibitors (PARPi) are effective in the treatment of patients who are in complete or partial remission. PARPi are known to cause hematological adverse events (AEs), but have not been compared directly to each other. Objective: Primary objective was to compare the incidence of hematological and non-hematological AEs associated with the use of PARPi. Methods: This was a single institution, retrospective study evaluating patients who were treated with PARPi for ovarian cancer from January 2017 to October 2020. Patients were stratified according to which PARP inhibitor they received. Results: Ninety-two patients were included in final analysis. Thirty-one (33.7%) patients received niraparib and 61 (66.3%) patients received olaparib. Median age of patients were 64.3 (range, 33.8 to 92.3) years, 66 (71.7%) were white, and 84 (91.3%) had an ECOG PS of 0/1. Patients in the niraparib group experienced a higher rate of hematologic AEs, with 11 (35.5%), 20 (64.5%), and 18 (58.1%) experiencing neutropenia, anemia, and thrombocytopenia, respectively. Eight (13.1%), 24 (39.3%), and 16 (26.2%) patients in the olaparib group experienced neutropenia, anemia, and thrombocytopenia, respectively. Conclusion: This single institution retrospective study outlines the hematological toxicities observed between two PARPi. Our results suggested that niraparib tended to be associated with a higher risk for hematologic toxicities than olaparib. Anemia was the most common hematologic toxicity which was consistent with what has been widely documented in the literature.

Fulminant Overwhelming Necrotizing Vibrio vulnificus Sepsis Secondary to Oyster Consumption

Vibrio vulnificus is an opportunistic gram-negative rod-shaped bacteria found in warm, low salinity waters. Transmission through open wounds or consumption of contaminated seafood can lead to wound infections, sepsis, and potentially death. A 44-year-old man with a history of poly-substance abuse, cirrhosis, and recent oyster consumption presented to the emergency department in June with acute onset bilateral leg pain associated with rash and fever. Within 6 hours of his arrival, the rash rapidly progressed to large bullae with extensive necrosis ascending to the level of the abdomen, and he developed septic shock. Despite prompt surgical intervention and appropriate antibiotic and resuscitative therapies, the patient had progressive multi-system organ failure and died 7 days after admission. Concurrent necrotizing fasciitis with sepsis secondary to V. vulnificus infection is rare and potentially fatal, as demonstrated in this case.

Expert consensus established around flexible, individualized migraine treatment utilizing a modified Delphi panel

OBJECTIVE

To characterize treatment decision-making processes and formalize consensus regarding key factors headache specialists consider in treatment decisions for patients with migraine, considering novel therapies.

BACKGROUND

Migraine therapies have long been subject to binary classification, acute versus preventive, due to limitations of available drugs. The emergence of novel therapies that can be used more flexibly creates an opportunity to rethink this binary classification. To determine the role of these novel therapies in treatment, it is critical to understand whether existing guidelines reflect clinical practice and to establish consensus around factors driving management.

METHODS

A three-round modified Delphi process was conducted with migraine clinical experts. Round 1 consisted of an online questionnaire; Round 2 involved an online discussion of aggregated Round 1 results; and Round 3 allowed participants to revise Round 1 responses, incorporating Round 2 insights. Questions elicited likelihood ratings (0 = highly unlikely to 100 = highly likely), rankings, and estimates on treatment decision-making.

RESULTS

Nineteen experts completed three Delphi rounds. Experts strongly agreed on definitions for "acute" (median = 100, inter-quartile range [IQR] = 5) and "preventive" treatment (median = 90, IQR = 15), but noted a need for treatment customization for patients (median = 100, IQR = 6). Experts noted certain aspects of guidelines may no longer apply based on established tolerability and efficacy of newer acute and preventive agents (median = 91, IQR = 17). Further, experts agreed on a treatment category referred to as "situational prevention" (or "short-term prevention") for patients with reliable and predictable migraine triggers (median = 100, IQR = 10) or time-limited periods when headache avoidance is important (median = 100, IQR = 12).

CONCLUSIONS

Using the modified Delphi method, a panel of migraine experts identified the importance of customizing treatment for people with migraine and the utility of "situational prevention," given the ability of new treatment options to meet this need and the potential to clinically identify patients and time periods when this approach would add value.

Comparing Severely Injured Trauma Patients Admitted to Investor-Owned versus Public and Not-For-Profit Hospitals Reveals Opportunities for Improvement in the US

BACKGROUND

Non-elderly trauma patients represent the largest portion of preventable years of life loss in the US. The purpose of this study was to compare outcomes in patients admitted to investor-owned vs public and not-for-profit hospitals across the US.

MATERIAL AND METHODS

The Nationwide Readmissions Database 2018 was queried for trauma patients with an Injury Severity Score greater than 15 and age 18-65 years. The primary outcome was mortality; secondary outcomes were prolonged length of stay (LOS) greater than 30 days, readmission within 30 days, and readmission to a different hospital. Patients admitted to investor-owned hospitals were compared to public and not-for-profit hospitals. Univariable analysis was performed using chi-squared tests. Multivariable logistic regression was performed for each outcome.

RESULTS

157 945 patients were included with 11.0% (n = 17 346) admitted to investor-owned hospitals. The overall mortality rate and prolonged LOS were similar for both groups. The overall readmission rate was 9.2% (n = 13 895), with the rate in investor-owned hospitals at 10.5% (n = 1,739, P < .001). Multivariable logistic regression revealed investor-owned hospitals had an increased risk of readmission (OR 1.2 [1.1-1.3] P < .001) and readmission to a different hospital (OR 1.3 [1.2-1.5] P < .001).

DISCUSSION

Severely injured trauma patients have similar rates of mortality and prolonged length of stay in investor-owned vs public and not-for-profit hospitals. However, patients admitted to investor-owned hospitals have an increased risk of readmission and readmission to different hospitals. Efforts to improve outcomes after trauma must consider hospital ownership and readmission to different hospitals.

Peripheral T-cell receptor repertoire dynamics in small cell lung cancer

Background

Identifying a circulating biomarker predictive of immune checkpoint inhibitor (ICI) benefit in patients with small cell lung cancer (SCLC) remains an unmet need. Characteristics of peripheral and intratumoral T-cell receptor (TCR) repertoires have been shown to predict clinical outcomes in non-small cell lung cancer (NSCLC). Recognizing a knowledge gap, we sought to characterize circulating TCR repertoires and their relationship with clinical outcomes in SCLC.

Methods

SCLC patients with limited (n=4) and extensive (n=10) stage disease were prospectively enrolled for blood collection and chart review. Targeted next-generation sequencing of TCR beta and alpha chains of peripheral blood samples was performed. Unique TCR clonotypes were defined by identical CDR3, V gene, and J gene nucleotide sequences of the beta chain and subsequently used to calculate TCR diversity indices.

Results

Patients with stable versus progressive and limited versus extensive stage disease did not demonstrate significant differences in V gene usage. Kaplan-Meier curve and log-rank analysis did not identify a statistical difference in progression-free survival (PFS) (P=0.900) or overall survival (OS) (P=0.200) between high and low on-treatment TCR diversity groups, although the high diversity group exhibited a trend toward increased OS.

Conclusions

We report the second study investigating peripheral TCR repertoire diversity in SCLC. With a limited sample size, no statistically significant associations between peripheral TCR diversity and clinical outcomes were observed, though further study is warranted.

Comparing Payments to Surgeons From Drug and Medical Device Corporations Reveals Inequalities Between Genders and Specialties

INTRODUCTION

Maintaining trust in the patient-doctor relationship requires transparency in the details of the financial relationships between physicians and drug and medical device corporations. These details are publicly available through the Open Payments database, and patients are encouraged to ask surgeons to interpret their implications. The purpose of this study was to better equip surgeons in responding to these inquiries and to compare the distribution of these payments by gender and specialty.

METHODS

The 2021 Open Payments dataset was searched for all payments to surgeons from the 14 different specialties recognized by the American College of Surgeons. The total payments per surgeon were compared by calculating the mean and median payments. The Gini index, a measure of income inequality, was also calculated for each specialty.

RESULTS

There were 96 724 surgeons who received over $755 million in payments from drug and medical device companies. There were 72 245 (74.7%) men and 24 479 (25.3%) women. The total amount of payments to men was $712 million (94.2%) and for women it was $44 million (5.8%). The overall Gini index was .9508. The specialty with the highest Gini index was pediatric surgery (.9844) and the lowest was cardiothoracic surgery (.8656).

DISCUSSION

Male surgeons received disproportionately higher payments from drug and device corporations than female surgeons. Surgeons should be aware of their own standing within the Open Payments database in order to respond appropriately to patient inquiries.

An Unusual Combination of Arthrogryposis, Gastroschisis, Cecal Volvulus, and Malignant Hyperthermia in a Young Woman: A Case Report

BACKGROUND The purpose of this study is to discuss a patient with a history of conditions, including arthrogryposis, gastroschisis, and malignant hyperthermia, who presented with cecal volvulus requiring urgent surgical intervention. CASE REPORT A 29-year-old woman with a history of arthrogryposis, gastroschisis, malignant hyperthermia, and multiple childhood abdominal surgeries presents to the Emergency Department (ED) with 2 days of abdominal pain and bloody diarrhea. A CT abdomen/pelvis revealed findings concerning for a cecal volvulus. The patient was premedicated and monitored closely by the anesthesia team due to her history of malignant hyperthermia. She underwent an exploratory laparotomy, where a dilated cecum and proximal ascending colon were found to be completely volvulized around the mesentery. Manual bowel detorsion was performed, which resulted in reperfusion of the ischemic-appearing bowel, which then appeared viable. She recovered well after the procedure and was discharged on postoperative day 5. CONCLUSIONS This case highlights a patient who presented with a combination of 4 findings: arthrogryposis, gastroschisis, malignant hyperthermia, and cecal volvulus. With arthrogryposis reported to be associated with gastroschisis and malignant hyperthermia, this report not only corroborates this association, but also aims to draw attention to the fact that these conditions have potential to occur jointly with cecal volvulus. Given the patient's history of gastroschisis requiring extensive abdominal surgeries that contribute as risk factors for cecal volvulus, it is possible there may be other arthrogryposis patients who present with cecal volvulus similar to that seen in this patient.

Perioperative Outcomes in Patients With Failing Single-Ventricle Physiology Undergoing Ventricular Assist Device Placement: A Single Institutional Experience

OBJECTIVE

To address the current lack of specified data existing regarding the perioperative characteristics and outcomes in a novel patient population, which may bridge the current understanding of how patient characteristics and perioperative management may influence the postoperative hospital course before cardiac transplantation.

DESIGN

A retrospective electronic chart review included all patients with failing single- ventricle (SV) physiology receiving ventricular assist device (VAD) support at a high-volume pediatric VAD center between April 5, 2010, and December 1, 2020, using institution-based electronic medical records for retrospective analysis.

SETTING

At a single pediatric hospital.

PARTICIPANTS

Fourteen pediatric patients with failing SV physiology receiving ventricular assist device therapy (SVAD).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Preoperative, intraoperative, and postoperative patient demographic and medical data were obtained from prior inpatient progress notes, laboratory values, anesthetic records, cardiac catheterization reports, echocardiography reports, and postoperative surgical notes entered during inpatient encounters at the time of SVAD placement. Between April 5, 2010, and December 1, 2020, 16 VAD device implants supported 14 pediatric patients with failing SV physiology. Most patients presented with a preoperative diagnosis of hypoplastic left heart syndrome (N = 9, 64.3%). A total of 6 patients expired on VAD therapy (43%), 7 (50%) survived to receive a cardiac transplant, and 1 patient currently remains on device therapy.

CONCLUSION

Although our institutional approach represents a single perspective, we anticipate that our experience institutional experience may prove helpful to others caring for peditric patients with single ventricle physiology undergoing ventricular assist device placement and promote collaborative efforts to improve their care.

The vital role of arcuate nociceptin/orphanin FQ neurones in mounting an oestradiol-dependent adaptive response to negative energy balance via inhibition of nearby proopiomelanocortin neurones

We tested the hypothesis that N/OFQ neurones in the arcuate nucleus (N/OFQ^ARC ) inhibit proopiomelanocortin (POMC^ARC ) neurones in a diet- and hormone-dependent manner to promote a more extensive rebound hyperphagia upon re-feeding following an 18 h fast. We utilized intact male or ovariectomized (OVX) female mice subjected to ad libitum-feeding or fasting conditions. N/OFQ^ARC neurones under negative energy balance conditions displayed heightened sensitivity as evidenced by a decreased rheobase threshold, increased firing frequency, and increased burst duration and frequency compared to ad libitum-feeding conditions. Stimulation of N/OFQ^ARC neurones more robustly inhibited POMC^ARC neurones under fasting conditions compared to ad libitum-feeding conditions. N/OFQ^ARC inhibition of POMC^ARC neurones is hormone dependent as chemostimulation of N/OFQ^ARC neurones from fasted males and OVX females produced a sizable outward current in POMC^ARC neurones. Oestradiol (E₂ ) markedly attenuated the N/OFQ-induced POMC^ARC outward current. Additionally, N/OFQ tonically inhibits POMC^ARC neurones to a greater degree under fasting conditions than in ad libitum-feeding conditions as evidenced by the abrogation of N/OFQ-nociceptin opioid peptide (NOP) receptor signalling and inhibition of N/OFQ release via chemoinhibition of N/OFQ^ARC neurones. Intra-arcuate nucleus application of N/OFQ further elevated the hyperphagic response and increased meal size during the 6 h re-feed period, and these effects were mimicked by chemostimulation of N/OFQ^ARC neurones in vivo. E₂ attenuated the robust N/OFQ-induced rebound hyperphagia seen in vehicle-treated OVX females. These data demonstrate that N/OFQ^ARC neurones play a vital role in mitigating the impact of negative energy balance by inhibiting the excitability of anorexigenic neural substrates, an effect that is diminished by E₂ in females. KEY POINTS: Nociceptin/orphanin FQ (N/OFQ) promotes increased energy intake and decreased energy expenditure under conditions of positive energy balance in a sex- and hormone-dependent manner. Here it is shown that under conditions of negative energy balance, i.e. fasting, N/OFQ inhibits anorexigenic proopiomelanocortin (POMC) neurones to a greater degree compared to homeostatic conditions due to fasting-induced hyperexcitability of N/OFQ neurones. Additionally, N/OFQ promotes a sustained increase in rebound hyperphagia and increase in meal size during the re-feed period following a fast. These results promote greater understanding of how energy balance influences the anorexigenic circuitry of the hypothalamus, and aid in understanding the neurophysiological pathways implicated in eating disorders promoting cachexia.

Real-world outcomes in patients with first-line and second-line therapy for advanced esophageal squamous cell carcinoma

Background: Little is known about real-world outcomes for first-line and anti-PD-1 second-line treatment for advanced/metastatic esophageal squamous cell carcinoma (ESCC). Patients & methods: Retrospective data of advanced/metastatic ESCC patients treated between 2011 and 2021 were collected from Flatiron Health. Median duration of therapy (mDoT) and median overall survival (mOS) were evaluated for patients initiating first-line and anti-PD-1 second-line therapy. Results: Among patients receiving first-line therapy (n = 948), mDoT was 1.4 months and mOS was 16.0 months, with mOS of 16.0 and 18.0 months for the non-immunotherapy and immunotherapy cohorts, respectively. Among patients receiving anti-PD-1 second-line therapy (n = 60), mDoT was 5.7 months and mOS was 10.1 months. Conclusion: Patients with advanced/metastatic ESCC have short duration of therapy, and overall survival remains limited. This real-world study underscores the need for efficacious treatments for advanced/metastatic ESCC in the first- and second-line setting. Direct comparisons of emerging therapies in the real world are urgently needed.

Health-related quality of life of X-linked hypophosphatemia in Spain

BACKGROUND

Health-related quality of life (HRQoL) of patients with X-linked hypophosphatemia (XLH) is lower than that of both the general population and the patients with other chronic diseases, mainly due to diagnostic delay, treatment difficulties, poor psychosocial support, and problems with social integration. Early diagnosis and optimal treatment are paramount to control the disease in patients with XLH, avoid complications, and maintain or improve their HRQoL. We, therefore, analyzed the HRQoL of pediatric and adult patients with XLH treated with conventional therapy in Spain.

RESULTS

We used several versions of the EuroQol-5 dimensions (EQ-5D) instrument according to the age of patients with XLH. Then we compared the HRQoL of patients to that of the general Spanish population. Children with XLH (n = 21) had moderate problems in walking about (61.9%), washing or dressing themselves (9.52%), and performing their usual activities (33.33%). They also felt moderate pain or discomfort (61.9%) and were moderately anxious or depressed (23.81%). Adults with XLH (n = 29) had lower HRQoL, with problems in walking (93%, with 3.45% unable to walk independently), some level of pain (86%, with 3.45% experiencing extreme pain), problems with their usual activities (80%) and self-care (> 50%), and reported symptoms of anxiety and/or depression (65%). There were important differences with the general Spanish population.

CONCLUSIONS

XLH impacts negatively on physical functioning and HRQoL of patients. In Spanish patients with XLH, the HRQoL was reduced despite conventional treatment, clearly indicating the need to improve the therapeutic approach to this disorder.

Real-world treatment patterns and survival of U.S. patients receiving second-line anti-programmed cell death protein-1 therapy for advanced/metastatic esophageal squamous cell carcinoma

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Background: Current second-line (2L) therapies for patients (pts) with advanced/metastatic esophageal squamous cell carcinoma (adv/met ESCC), including docetaxel, paclitaxel and irinotecan, have demonstrated modest survival gains. The National Comprehensive Cancer Network added the use of anti-programmed cell death protein-1 (PD-1) therapies (e.g., pembrolizumab, nivolumab) in the 2L to their guidelines in 2020. A real-world evidence study of 2L therapy for adv/met ESCC patients reported a median (95% CI) overall survival (OS) of 201 (153-249) days but did not include recently approved anti-PD-1 agents. Other studies of 2L anti-PD-1 therapy relied on claims data without the ability to report survival. Limited studies exist for 2L ESCC real-world treatment patterns. Herein, we characterize the real-world treatment patterns and OS for a recent cohort of US pts initiating an anti-PD-1 2L therapy. Methods: Pts (≥ 18 years of age) from the United States diagnosed with adv/met ESCC and initiating an anti-PD-1 2L therapy between January 1, 2011 and February 28, 2021 were selected using the electronic health record (EHR)-derived de-identified Flatiron Health database. Pt characteristics and descriptive treatment patterns were reported. Duration of therapy (DoT; start of therapy until last administration) was computed and OS (start of therapy until death or last recorded medical activity) was estimated by the Kaplan Meier method. Results: 60 pts were included who initiated an anti-PD-1 2L therapy. At 2L initiation, the median age was 66 years, 65% were male, 53% were white, 82% had a history of smoking, and 53% had stage IV disease. The median DoT was 92 days and median OS was 303 days with variability across agents (Table) . Of the 60 pts, a total of 21 (35%) initiated 3L therapy (8 initiated an anti-PD-1; 13 initiated a non-anti-PD-1). Of the 39 (65%) pts who did not initiate a 3L therapy, 16 (41%) died within 60 days of the final 2L administration, 12 (31%) lacked 60 days of follow-up observation, and the remaining 11 (28%) patients had no further 2L treatment. Conclusions: Compared to prior real-world analyses, use of anti-PD-1 therapy in the 2L for patients with advanced/metastatic ESCC may be associated with survival gains over other approved non-anti-PD-1 therapies. However, future real-world studies are needed to directly compare PD-1 inhibitors with other 2L therapies.[Table: see text]

Repeat cryoablation as a redo procedure for atrial fibrillation ablation: Is it a good choice?

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Medtronic Inc.

Introduction

Catheter ablation of atrial fibrillation, both cryoablation and radiofrequency pulmonary vein isolation, have demonstrated to be safe and effective techniques for treating symptomatic atrial fibrillation as a first procedure. However, about one in three patients may face a redo procedure due to AF recurrence. The most suitable technique for redo is unknown.

Purpose

The aim of this study is to assess the efficacy of cryoballoon AF ablation as a redo technique in patients with prior cryoballoon or radiofrequency AF ablation.

Methods

We analyzed a nation-wide real-world cryoablation registry (RECABA) and compared patients who were referred for a first cryoballoon AF ablation procedure with those who had previously undergone cryoballoon or radiofrequency pulmonary vein isolation. The primary endpoint was AF recurrence during the first year after a 3-month blanking period. We performed survival analysis and built univariate and multivariate cox regression models.

Results

From 1742 patients, 1625 had a 12-month follow-up visit. 1551 (95.45%) underwent a first cryoballoon ablation, whereas 33 (2.03%) had a previous CB ablation performed and 41 (2.52%) a previous RF ablation.

Mean age was 58.6 ±10.4 years and 511 (31.5%) were women. 463 (28.5%) had persistent atrial fibrillation and there were no major clinical differences between groups.

Prior-CB group had a higher share of veins without electrogram visualization, with a median of 100% (IQR 75%-100%), compared to prior-RF group (median 67%, IQR 25%-75%) and first procedure group (median 25%, IQR 0%-50%). Kruskal-Wallis test Chi2=54.35, p&lt;0.0001.

12-month Kaplan–Meier estimate of freedom from AF recurrence after the blanking period was 78.5% (95% CI 76.2% - 80.7%) in the first procedure group, 61.0% (95% CI 41.4% - 75.8%) in the prior-CB and 89.2% (95% CI 73.6% - 95.9%) in the prior-RF group. Log-rank test Chi2=17.49, p&lt;0.0001.

Multivariate cox regression analysis pointed female sex, persistent AF, and prior-CB ablation as independent predictors of AF recurrence. The adjusted HR for AF recurrence of prior-CB ablation vs first-CB ablation was 3.13 (95% CI 1.82 -5.40) and for prior-RF vs first CB-ablation was 1.01 (95% CI 0.51 – 1.97).

Conclusion

Repeat cryoballoon AF ablation shows higher rates of AF recurrences compared to first CB procedures or after prior RF ablation. These data suggest that patients with AF recurrence after CB-ablation have worse arrhythmic outcomes and may benefit from other ablation techniques after a recurrence.

Hemipelvectomy as a Salvage Procedure in Massive Pelvic Trauma

“Pedestrian struck by train” represents one of the highest magnitude blunt force traumas. Despite the severity of injuries, these patients can have good outcomes. A 25-year-old male presented after being struck by a train. He had several injuries, including extensive complex pelvic fractures, right external iliac artery and vein laceration, and right femur and tibia fracture. He was taken to the operating room for damage control surgery and attempted revascularization of the right lower extremity. The extremity became ischemic and required above knee amputation followed by hip disarticulation and hemipelvectomy. His pelvic wounds were treated with negative pressure wound therapy and gradually closed. He was eventually discharged to a rehab facility for continued recovery. This case highlights the interventions that allowed a young man who was struck by a train to survive. He improved significantly since undergoing hemipelvectomy, indicating that severe pelvic injuries from high energy trauma may necessitate hemipelvectomy.

Assessing the Availability of Foreign and American Sign Language Interpreting Services in Community Pharmacies

Objective To determine community pharmacists' experience with foreign language and American Sign Language (ASL) interpretation services. Design A survey was drafted to gather information about pharmacists' familiarity with ASL and foreign language interpreting services as well as the frequency with which pharmacists encountered patients who needed these services. Setting Independent and chain community pharmacies in Spokane County, Washington, USA. Participants Fifty-two community pharmacies were identified using a provider-credential search. Fifty-one pharmacists (98%) agreed to participate and completed the survey. Interventions Surveys were initially conducted in person, but after the COVID-19 pandemic began data collection was halted and restarted via phone in accordance with the Washington State University Office of Research Support and Operations. Results Four out of 51 pharmacists surveyed (7.84%) indicated that they were fluent in a language besides English. Pharmacists reported encountering patients who spoke Spanish (31%), Russian (31%), ASL (8%), Arabic (5%), Mandarin Chinese (5%), Vietnamese (5%), Marshallese (5%), and Ukrainian (2%). Some pharmacists (8%) reported not encountering patients who spoke other languages besides English. Most pharmacists (72.5%) indicated their company offered interpreting services for foreign languages, but less than half of pharmacists surveyed (43.1%) had experience using these services. Forty-five percent of pharmacists surveyed did not know whether their company offered an interpreting service for ASL, and only 23.5% indicated that they had experience using ASL interpreting services. Conclusion Pharmacists are less familiar with services for patients who speak ASL and are less likely to have experience with ASL interpretation services than they are to have assisted foreign-language-speaking patients.

Brine residues and organics in the Urvara basin on Ceres

Ceres is a partially differentiated dwarf planet, as confirmed by NASA's Dawn mission. The Urvara basin (diameter ~170 km) is its third-largest impact feature, enabling insights into the cerean crust. Urvara's geology and mineralogy suggest a potential brine layer at the crust-mantle transition. Here we report new findings that help in understanding the structure and composition of the cerean crust. These results were derived by using the highest-resolution Framing Camera images acquired by Dawn at Ceres. Unexpectedly, we found meter-scale concentrated exposures of bright material (salts) along the crater's upper central ridge, which originate from an enormous depth, possibly from a deep-seated brine or salt reservoir. An extended resurfacing modified the southern floor ~100 Myr after crater formation (~250 Myr), long after the dissipation of the impact-generated heat. In this resurfaced area, one floor scarp shows a granular flow pattern of bright material, showing spectra consistent with the presence of organic material, the first such finding on Ceres beyond the vast Ernutet area. Our results strengthen the hypothesis that Ceres is and has been a geologically active world even in recent epochs, with salts and organic-rich material playing a major role in its evolution.

Participant Outcomes of a Student-Run, Intensive, Short-Term, Task-Specific Rehabilitation Program for Individuals Post-Stroke

Stroke survivors continue to face chronic disability and limited access to early, continuous, and long-term rehabilitation. This pilot study examined the impact of a 6-day, intensive, short-term, task-specific rehabilitation program (ISTRP) on outcomes post-stroke as part of a service-learning experience (SLE) for Doctor of Physical Therapy (DPT) students. Participants (n=19) post-stroke completed a 6-day, student-led ISTRP. Outcome measures were used to assess balance, functional gait, upper extremity motor impairment, and self-reported recovery. Significant differences from pre- to post-intervention were found for all outcome measures (p<0.05) except for the Stroke-Impact Scale-16. This pilot study addresses a gap in literature and suggests an ISTRP should be further explored while integrating other allied health disciplines.

Monte Carlo simulations and phantom validation of low-dose radiotherapy to the lungs using an interventional radiology C-arm fluoroscope

PURPOSE

To use MC simulations and phantom measurements to investigate the dosimetry of a kilovoltage x-ray beam from an IR fluoroscope to deliver low-dose (0.3-1.0 Gy) radiotherapy to the lungs.

MATERIALS AND METHODS

PENELOPE was used to model a 125 kV, 5.94 mm Al HVL x-ray beam produced by a fluoroscope. The model was validated through depth-dose, in-plane/cross-plane profiles and absorbed dose at 2.5-, 5.1-, 10.2- and 15.2-cm depths against the measured beam in an acrylic phantom. CT images of an anthropomorphic phantom thorax/lungs were used to simulate 0.5 Gy dose distributions for PA, AP/PA, 3-field and 4-field treatments. DVHs were generated to assess the dose to the lungs and nearby organs. Gafchromic film was used to measure doses in the phantom exposed to PA and 4-field treatments, and compared to the MC simulations.

RESULTS

Depth-dose and profile results were within 3.2% and 7.8% of the MC data uncertainty, respectively, while dose gamma analysis ranged from 0.7 to 1.0. Mean dose to the lungs were 1.1-, 0.8-, 0.9-, and 0.8- Gy for the PA, AP/PA, 3-field, and 4-field after isodose normalization to cover ∼ 95% of each lung volume. Skin dose toxicity was highest for the PA and lowest for the 4-field, and both arrangements successfully delivered the treatment on the phantom. However, the dose distribution for the PA was highly non-uniform and produced skin doses up to 4 Gy. The dose distribution for the 4-field produced a uniform 0.6 Gy dose throughout the lungs, with a maximum dose of 0.73 Gy. The average percent difference between experimental and Monte Carlo values were -0.1% (range -3% to +4%) for the PA treatment and 0.3% (range -10.3% to +15.2%) for the 4-field treatment.

CONCLUSION

A 125 kV x-ray beam from an IR fluoroscope delivered through two or more fields can deliver an effective low-dose radiotherapy treatment to the lungs. The 4-field arrangement not only provides an effective treatment, but also significant dose sparing to healthy organs, including skin, compared to the PA treatment. Use of fluoroscopy appears to be a viable alternative to megavoltage radiation therapy equipment for delivering low-dose radiotherapy to the lungs.

Pituitary Adenylate Cyclase Activating Polypeptide Inhibits A10 Dopamine Neurons and Suppresses the Binge-like Consumption of Palatable Food

Pituitary adenylate cyclase-activating polypeptide (PACAP) binds to PACAP-specific (PAC1) receptors in multiple hypothalamic areas, especially those regulating energy balance. PACAP neurons in the ventromedial nucleus (VMN) exert anorexigenic effects within the homeostatic energy balance circuitry. Since PACAP can also reduce the consumption of palatable food, we tested the hypothesis that VMN PACAP neurons project to the ventral tegmental area (VTA) to inhibit A₁₀ dopamine neurons via PAC1 receptors and K_ATP channels, and thereby suppress binge-like consumption. We performed electrophysiological recordings in mesencephalic slices from male PACAP-Cre and tyrosine hydroxylase (TH)-Cre mice. Initially, we injected PACAP (30 pmol) into the VTA, where it suppressed binge intake in wildtype male but not female mice. Subsequent tract tracing studies uncovered projections of VMN PACAP neurons to the VTA. Optogenetic stimulation of VMN PACAP neurons in voltage clamp induced an outward current and increase in conductance in VTA neurons, and a hyperpolarization and decrease in firing in current clamp. These effects were markedly attenuated by the K_ATP channel blocker tolbutamide (100 μM) and PAC1 receptor antagonist PACAP_6-38 (200 nM). In recordings from A₁₀ dopamine neurons in TH-Cre mice, we replicated the outward current by perfusing PACAP_1-38 (100 nM). This response was again completely blocked by tolbutamide and PACAP_6-38, and associated with a hyperpolarization and decrease in firing. These findings demonstrate that PACAP activates PAC1 receptors and K_ATP channels to inhibit A₁₀ dopamine neurons and sex-dependently suppress binge-like consumption. Accordingly, they advance our understanding of how PACAP regulates energy homeostasis via the hedonic energy balance circuitry.

Fick versus flow: a real-time invasive cardiovascular magnetic resonance (iCMR) reproducibility study

BACKGROUND

Cardiac catheterization and cardiovascular magnetic resonance (CMR) imaging have distinct diagnostic roles in the congenital heart disease (CHD) population. Invasive CMR (iCMR) allows for a more thorough assessment of cardiac hemodynamics at the same time under the same conditions. It is assumed but not proven that iCMR gives an incremental value by providing more accurate flow quantification.

METHODS

Subjects with CHD underwent real-time 1.5 T iCMR using a passive catheter tracking technique with partial saturation pulse of 40° to visualize the gadolinium-filled balloon, CMR-conditional guidewire, and cardiac structures simultaneously to aid in completion of right (RHC) and left heart catheterization (LHC). Repeat iCMR and catheterization measurements were performed to compare reliability by the Pearson (PCC) and concordance correlation coefficients (CCC).

RESULTS

Thirty CHD (20 single ventricle and 10 bi-ventricular) subjects with a median age and weight of 8.3 years (2-33) and 27.7 kg (9.2-80), respectively,  successfully underwent iCMR RHC and LHC. No catheter related complications were encountered. Time taken for first pass RHC and LHC/aortic pull back was 5.1, and 2.9 min, respectively. Total success rate to obtain required data points to complete Fick principle calculations for all patients was 321/328 (98%). One patient with multiple shunts was an outlier and excluded from further analysis. The PCC for catheter-derived pulmonary blood flow (Qp) (0.89, p < 0.001) is slightly lower than iCMR-derived Qp (0.96, p < 0.001), whereas catheter-derived systemic blood flow (Qs) (0.62, p = < 0.001) was considerably lower than iCMR-derived Qs (0.94, p < 0.001). CCC agreement for Qp at baseline (C1-CCC = 0.65, 95% CI 0.41-0.81) and retested conditions (C2-CCC = 0.78, 95% CI 0.58-0.89) were better than for Qs at baseline (C1-CCC = 0.22, 95% CI - 0.15-0.53) and retested conditions (C2-CCC = 0.52, 95% CI 0.17-0.76).

CONCLUSION

This study further validates hemodynamic measurements obtained via iCMR. iCMR-derived flows have considerably higher test-retest reliability for Qs. iCMR evaluations allow for more reproducible hemodynamic assessments in the CHD population.

Characteristics of early-stage endometrial cancer and factors that influence disease recurrence

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Background: Early-stage endometrial cancer (EEC) with FIGO stage I-II generally has a favorable prognosis and overall survival (OS). However, up to 10% of EEC patients (pts) relapse and risk factors for recurrence remain unclear. We evaluated clinical and histopathologic characteristics of EEC and correlated them with OS and recurrence free survival (RFS) through a single-center retrospective analysis. Methods: We conducted a retrospective chart review on 511 pts with EEC identified by our cancer registry from 1/1/2009 to 12/31/2019. The two main histologic groups were endometrioid adenocarcinomas (E) and other subtypes (O) including carcinosarcoma, undifferentiated, and clear cell carcinomas. Papillary serous histology was excluded. Histopathologic and clinical findings recorded included age, FIGO stage and grade, tumor size, presence of recurrence, adjuvant therapies received, percent of myometrial invasion (MI), and lymphovascular invasion (LVI). OS and RFS were estimated, and each predictor was compared using the log-rank test. The association between OS and each continuous characteristic was examined using the Cox proportional hazards model. Factors significantly associated with OS and RFS in the univariable analysis (p < 0.05) were included in a multivariable analysis to examine the joint effects of those factors on survival. Results: A total of 511 cases were reviewed. The analysis included 501 pts (E = 485, O = 16), of which 47 had recurrent disease (E = 45, O = 2) and 17 had died without recurring (E = 15, O = 2) as of their last follow-up. Overall median age was 63 years. Factors significantly associated with recurrence in the multivariable analysis were FIGO grade, (Hazard Ratios (HR): Grade 2 vs 1: 1.95, 95% CI: 1.06-3.58, p = 0.0320, Grade 3 vs 1: 2.88, 95% CI: 1.50-5.52, p = 0.0015), LVI (HR: 2.03, 95% CI: 1.10-3.75, p = 0.0244), and greater than 50% of MI (HR: 3.15, 95% CI: 1.35-7.36, p = 0.0080). The overall RFS was 92% and 86% at three and five years, respectively. On univariate analysis, among pts with a measurable tumor size (n = 446), larger tumors were not significantly associated with OS (p = 0.65) but was associated with increased recurrence (HR 1.22, 95% CI: 1.10-1.37, for a unit increase, p = 0.0003). On univariate analysis, pts who received adjuvant therapy were more likely to recur (p = 0.0002) with RFS of 86% and 76% at three and five years respectively, versus RFS of 94% and 90%, for those who did not. Conclusions: We confirmed the clinical and histopathologic characteristics that are currently considered to increase risk of recurrence in EEC. On multivariate analysis, risk of recurrence was associated with FIGO grades 2 and 3, presence of LVI, and > 50% MI. A limitation of this study is the lack of molecular analysis. Further molecular stratification may help us identify the subset of pts who are at high risk of recurrence, enabling customized adjuvant therapy in EEC.

Retrospective analysis of ovarian cancer patients treated with PARP inhibitors

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Background: Over the last few years, targeted therapy has become the mainstay maintenance treatment of patients with ovarian cancer including patients with BRCA1 or BRCA2 mutations. Poly ADP ribose polymerase (PARP) inhibitors are effective in the treatment of patients who are in complete or partial remission. PARP inhibitors are known to cause hematological adverse events (AEs), but have not been compared directly to each other. Methods: We conducted a single institution, IRB approved, retrospective study on patients who were treated with PARP inhibitors from December 2016 to October 2020. Patients were stratified according to which PARP inhibitor they received. Our primary objective was to assess the incidence of hematological and non-hematological adverse events associated with the use of PARP inhibitor therapy used in patients with ovarian cancer. Data from absolute neutrophil count, hemoglobin and platelet count during the first 2 cycles were graded for hematologic toxicity according to CTCAE v 5.0. Results: A total of 126 patients received a PARP inhibitor during the study time frame. 34 were excluded and 92 patients were included for analysis. Median age of patients were 64.3 (range, 33.8 to 92.3) years, 66 (71.7%) white, and 84 (91.3%) had an ECOG PS of 0/1. Thirty-one (33.7%) of patients received niraparib and 61 (66.3%) of patients received olaparib. Patients in the niraparib group experienced more hematologic AEs, with 11 (35.5%) (95% CI 19.2-54.6), 20 (64.5%) (95% CI 45.4-80.8), and 18 (58.1%) (95% CI 39.1-75.5) experiencing neutropenia, anemia, thrombocytopenia, respectively. Eight (13.1%) (95% CI 5.8-24.2), 24 (39.3%) (95% CI 27.1-52.7), 16 (26.2%) (95% CI 15.8-39.1) patients in the olaparib group experienced neutropenia, anemia, thrombocytopenia, respectively. Conclusions: This single institution retrospective study outlines the hematological toxicities observed between two PARP inhibitors. Although there are four PARP inhibitors approved by FDA, our data compared only two of the four (as they were the most commonly prescribed PARP inhibitors in our institution). Our results suggested that niraparib tended to be associated with a higher risk for hematologic toxicities than olaparib. Our data showed anemia as the most common hematologic toxicity which was consistent with what has been widely documented in the literature.

Adaptive Changes in the Central Control of Energy Homeostasis Occur in Response to Variations in Energy Status

Energy homeostasis is regulated in coordinate fashion by the brain-gut axis, the homeostatic energy balance circuitry in the hypothalamus and the hedonic energy balance circuitry comprising the mesolimbcortical A10 dopamine pathway. Collectively, these systems convey and integrate information regarding nutrient status and the rewarding properties of ingested food, and formulate it into a behavioral response that attempts to balance fluctuations in consumption and food-seeking behavior. In this review we start with a functional overview of the homeostatic and hedonic energy balance circuitries; identifying the salient neural, hormonal and humoral components involved. We then delve into how the function of these circuits differs in males and females. Finally, we turn our attention to the ever-emerging roles of nociceptin/orphanin FQ (N/OFQ) and pituitary adenylate cyclase-activating polypeptide (PACAP)-two neuropeptides that have garnered increased recognition for their regulatory impact in energy homeostasis-to further probe how the imposed regulation of energy balance circuitry by these peptides is affected by sex and altered under positive (e.g., obesity) and negative (e.g., fasting) energy balance states. It is hoped that this work will impart a newfound appreciation for the intricate regulatory processes that govern energy homeostasis, as well as how recent insights into the N/OFQ and PACAP systems can be leveraged in the treatment of conditions ranging from obesity to anorexia.

Mutant Huntingtin stalls ribosomes and represses protein synthesis in a cellular model of Huntington disease

The polyglutamine expansion of huntingtin (mHTT) causes Huntington disease (HD) and neurodegeneration, but the mechanisms remain unclear. Here, we found that mHtt promotes ribosome stalling and suppresses protein synthesis in mouse HD striatal neuronal cells. Depletion of mHtt enhances protein synthesis and increases the speed of ribosomal translocation, while mHtt directly inhibits protein synthesis in vitro. Fmrp, a known regulator of ribosome stalling, is upregulated in HD, but its depletion has no discernible effect on protein synthesis or ribosome stalling in HD cells. We found interactions of ribosomal proteins and translating ribosomes with mHtt. High-resolution global ribosome footprint profiling (Ribo-Seq) and mRNA-Seq indicates a widespread shift in ribosome occupancy toward the 5' and 3' end and unique single-codon pauses on selected mRNA targets in HD cells, compared to controls. Thus, mHtt impedes ribosomal translocation during translation elongation, a mechanistic defect that can be exploited for HD therapeutics.

Nociceptin/orphanin FQ neurons in the Arcuate Nucleus and Ventral Tegmental Area Act via Nociceptin Opioid Peptide Receptor Signaling to Inhibit Proopiomelanocortin and A10 Dopamine Neurons and Thereby Modulate Ingestion of Palatable Food

The neuropeptide nociceptin/orphanin FQ (N/OFQ) inhibits neuronal activity via its cognate nociceptin opioid peptide (NOP) receptor throughout the peripheral and central nervous systems, including those areas involved in the homeostatic and hedonic regulation of energy homeostasis. We thus tested the hypothesis that N/OFQ neurons in the hypothalamic arcuate nucleus (ARC) and ventral tegmental area (VTA) act via NOP receptor signaling to inhibit nearby anorexigenic proopiomelanocortin (POMC) and A10 dopamine neuronal excitability, respectively, and thereby modulate ingestion of palatable food. Electrophysiologic recordings were performed in slices prepared from transgenic male and ovariectomized (OVX) female N/OFQ-cre/enhanced green fluorescent protein-POMC, N/OFQ-cre and tyrosine hydroxylase-cre animals to see if optogenetically-stimulated peptide release from N/OFQ neurons could directly inhibit these neuronal populations. Binge-feeding behavioral experiments were also conducted where animals were exposed to a high-fat-diet (HFD) for one hour each day for five days and monitored for energy intake. Photostimulation of ARC and VTA N/OFQ neurons produces an outward current in POMC and A10 dopamine neurons receiving input from these cells. This is associated with a hyperpolarization and decreased firing. These features are also sex hormone- and diet-dependent; with estradiol-treated slices from OVX females being less sensitive, and obese males being more sensitive, to N/OFQ. Limited access to HFD causes a dramatic escalation in consumption, such that animals eat 25-45% of their daily intake during that one-hour exposure. Moreover, the NOP receptor-mediated regulation of these energy balance circuits are engaged, as N/OFQ injected directly into the VTA or ARC respectively diminishes or potentiates this binge-like increase in a manner heightened by diet-induced obesity or dampened by estradiol in females. Collectively, these findings provide key support for the idea that N/OFQ regulates appetitive behavior in sex-, site- and diet-specific ways, along with important insights into aberrant patterns of feeding behavior pertinent to the pathogenesis of food addiction.

Pituitary Adenylate Cyclase-Activating Polypeptide Excites Proopiomelanocortin Neurons: Implications for the Regulation of Energy Homeostasis

OBJECTIVE

We examined whether pituitary adenylate cyclase-activating polypeptide (PACAP) excites proopiomelanocortin (POMC) neurons via PAC1 receptor mediation and transient receptor potential cation (TRPC) channel activation.

METHODS

Electrophysiological recordings were done in slices from both intact male and ovariectomized (OVX) female PACAP-Cre mice and eGFP-POMC mice.

RESULTS

In recordings from POMC neurons in eGFP-POMC mice, PACAP induced a robust inward current and increase in conductance in voltage clamp, and a depolarization and increase in firing in current clamp. These postsynaptic actions were abolished by inhibitors of the PAC1 receptor, TRPC channels, phospholipase C, phosphatidylinositol-3-kinase, and protein kinase C. Estradiol augmented the PACAP-induced inward current, depolarization, and increased firing, which was abrogated by estrogen receptor (ER) antagonists. In optogenetic recordings from POMC neurons in PACAP-Cre mice, high-frequency photostimulation induced inward currents, depolarizations, and increased firing that were significantly enhanced by Gq-coupled membrane ER signaling in an ER antagonist-sensitive manner. Importantly, the PACAP-induced excitation of POMC neurons was notably reduced in obese, high-fat (HFD)-fed males. In vivo experiments revealed that intra-arcuate nucleus (ARC) PACAP as well as chemogenetic and optogenetic stimulation of ventromedial nucleus (VMN) PACAP neurons produced a significant decrease in energy intake accompanied by an increase in energy expenditure, effects blunted by HFD in males and partially potentiated by estradiol in OVX females.

CONCLUSIONS

These findings reveal that the PACAP-induced activation of PAC1 receptor and TRPC5 channels at VMN PACAP/ARC POMC synapses is potentiated by estradiol and attenuated under conditions of diet-induced obesity/insulin resistance. As such, they advance our understanding of how PACAP regulates the homeostatic energy balance circuitry under normal and pathophysiological circumstances.

Long-term follow-up of patients with Chagas cardiomyopathy living in a non-endemic area: moving towards identification of early markers of disease progression

Background

The number of patients with Chagas disease residing in Europe has increased significantly due to migration flows. Globally, Chagas cardiomyopathy has worse prognosis than other types of dilated cardiomyopathies and about 30% of patients develop cardiac involvement after a variable latency period (10–30 years). However, there is lack of data regarding the evolution of patients with Chagas disease living in a non-endemic area and potential early predictors of disease progression.

OBJETIVE

To describe the natural course of Chagas disease, the incidence rate of transformation into cardiac form and to assess if early predictors of myocardial involvement translate into a worse long-term prognosis in our non-endemic cohort.

Methods

Clinical and echocardiographic follow-up was performed in 202 individuals from endemic areas of Chagas disease. At baseline, electrocardiogram, BNP and a comprehensive echocardiography including diastolic function and longitudinal myocardial strain were performed. Four different groups were defined: healthy controls (N=77); Chagas indeterminate form (positive serology, normal ECG and left ventricle (LV) dimensions and LV ejection fraction (&gt;50%) and no segmental abnormalities, N=92); Chagas patients with abnormal ECG but normal LV dimensions and motility (N=15); and Chagas patients with LV diameter&gt;55 mm or LV ejection fraction&lt;50% or segmental abnormalities (N=18). The primary clinical outcome included advanced atrioventricular block, sustained ventricular tachycardia, heart failure, heart transplant, death or progression of cardiac disease defined as LV systolic dysfunction or new segmental abnormalities. Kaplan Meier with Long rank test and Cox regression analysis was used.

Results

Mean age was 37±9 and 34% were male. Median follow-up was 69 months (range 1 to 147). The primary endpoint occurred in a total of 17 (8.4%) individuals: 5 (5.4%) in the Indeterminate group; 3 (20%) in the abnormal ECG group; and 9 (50%) in the group with abnormal LV dimension or motility, with no events among controls (long-rank test&lt;0.01, Figure 2). Six patients evolved from the indeterminate phase to cardiac involvement (2 with isolated ECG changes and 4 with abnormal echocardiography without previous changes in ECG (Figure 1). On echocardiography, there were no differences regarding changes in LV dimensions or LV ejection fraction between Chagas patients with normal baseline echo and controls, but a significantly reduction of Em was observed (−1.6±3.0 vs. 0.2±1.0) in the former. Excluding patients with abnormal echo at baseline, BNP (HR=1.03, p=0.001), Em (HR=0.78, p=0.05) and left atrial diameter (1.23, p=0.01) were predictors of the combined event.

Conclusions

Conversion from the indeterminate to Chagas cardiomyopathy in our cohort was approximately 1.1%/year, but it may happen directly with contractility disturbances. BNP and comprehensive echocardiography may help to early detect disease progression.

Figure 1. Distribution of patients and KM curves

Funding Acknowledgement

Type of funding source: None

Relationship between episodes of unsustained VTs detected early after an ICD implant and subsequent monomorphic VTs causing appropriate therapy

Introduction

Non-sustained ventricular tachycardias (NSVT) are observed frequently among ICD patients with left ventricular dysfunction (LVD).

Purpose

To analyze the relationship between episodes of NSVTs and monomorphic VTs (MVTs) that subsequently cause appropriate therapies.

Methods

416 ICD patients with LVD (LVEF &lt;45%) followed for 41±27 months. ICD programming (detection and therapies) was standardized. NSVT was defined as any VT of ≥5 beats which did not met the detection criteria occurring within the first 6 months after ICD implant. We analyzed 2201 NSVTs (10+7 beats), which occurred in 250 of the 416 patients (Median=2; IQR=0–7). The mean cycle length (CL) of NSVT was 323±32 ms (adjusted per multiple episodes/patient, generalized estimating equation method (GEEM)).

Results

During the follow-up, 1441 MVT occurred in 183 patients. After showing a significant correlation between burden of NSVT and the occurrence of appropriate therapies due to MVT (C coefficient=0.68; p&lt;0.001), we observed that subjects with &gt;5 NSVT presented an excess of adjusted risk: HR=1.97 (95% CI=1.45–2.72); p&lt;0.001. However, the adjusted mean CL of NSVTs was similar in patients with (322±34) vs. without MVT (324±26 ms); p=0.3.

Among patients who presented NSVTs and MVTs (n=145 subjects), we analyzed the relationship between the adjusted mean CL of the NSVTs (n=1288 episodes) and the CL of the first appropriate therapy due to MVT occurring subsequently. We found a significant and positive correlation between the two (r=0.88; p&lt;0.001); the strongest correlation was observed in subjects with &gt;5 NSVTs (r=0.97, n=52)). The robustness of such correlation was similar in individuals with ischemic (r=0.86; n=91) versus non-ischemic cardiomyopathy (r=0.90; n=54), and in primary (r=0.86; n=75) versus secondary prevention (r=0.90; n=70). The agreement between the CL of first MVT and the adjusted mean CL of NSVT episodes (GEEM) was determined according to the Bland-Altman Method. The difference between the two values was 2±8.3 ms, with only 7.6% (11/145) of patients in whom the difference between the two CL was outside the concordance limits. The agreement was greater, again, in individuals with &gt;5 NSVTs. As shown in the Figure, in more than 95% of patients both values were within the interval of agreement (0.32±4 ms).

Conclusions

1-The burden of NSVTs occurring early after an ICD implant, but not their CL, is associated with a higher incidence of appropriate therapies due to MVT at follow-up.

2-The CL of the NSVTs and that of the first and subsequent MVTs is virtually the same in patients with higher NSVT burden. Therefore, it could be the same tachycardia, but with different duration.

Figure 1

Funding Acknowledgement

Type of funding source: None

Implication of heat shock proteins in rotavirus entry into Reh cells

The mechanisms of rotavirus entry into the target cell are described as a multi-step event in which the virions are bound to sialic acid (SA), followed by interaction with heat shock cognate protein 70 (Hsc70), some integrins and protein disulfide isomerase (PDI). However, the cell surface receptor molecules facilitating the entry of tumor cell-adapted rotavirus are not completely characterized. Using infection blocking assays with antibodies to some heat shock proteins (HSPs) and also some inhibitors of these cellular proteins, we were able to identify the cell surface Hsp90, Hsp70, Hsc70, Hsp60, Hsp40, PDI and integrin β3 as receptors of tumor cell-adapted rotavirus in Reh cells. Furthermore, the results also indicated that these rotavirus receptors are associated with lipid microdomains (rafts). Our findings provide evidence that rotavirus tropism for these human acute lymphocytic leukemia cells is explained by the relatively high expression of some HSPs in rafts. The results shown here encourage further research aim at evaluating the potential use of rotaviruses as an oncolytic agent for the treatment of some cancers. Keywords: heat shock proteins; rotavirus; cell receptor; cancer; oncolytic virus.

Design and microfabrication strategies for thin-film, flexible optical neural implant

Advanced polymer science and design technologies are constantly evolving to meet ever-growing expectations for flexible optical MEMS. In this work, we present design and microfabrication considerations for designed flexible Polymeric Opto-Electro-Mechanical Systems (POEMS). The presented methods integrate waveguide fabrication and laser diode (LD) chip assembly with Lawrence Livermore National Laboratory's (LLNL's) flexible thin-film technology to enable LLNL's first neural optoelectrode that can deliver guided light for neural activation. We support our findings with electrical and optical bench verification tests, present thermal simulation models to analyze heat dissipation of laser light sources on polymer substrates and discuss potential modifications for next generation prototypes. This fully integrated approach will allow spatial precision, scalability and more particularly, longer lifetime, needed to enable chronic studies of brain activities.

SAT0567 USE OF THERMOGRAPHY OF HANDS AND MACHINE LEARNING TO DIFFERENTIATE PATIENTS WITH ARTHRITIS FROM HEALTHY SUBJECTS

Background:

The early diagnosis of rheumatic diseases improves their prognosis. However, patients take several months to reach the rheumatologist from the beginning of the first symptoms. Thermography is a safe and fast technique that captures the heat of an object through infrared photography. The inflammation of the joints causes an increase in temperature and, therefore, can be measured by thermography. Machine learning methods have shown that they are capable of analyzing medical images with an accuracy similar or superior to that of a healthcare professional.

Objectives:

Develop an algorithm that, based on thermographic images of hands and machine learning, differentiates healthy subjects from patients with rheumatoid arthritis (RA), psoriatic arthritis (PA), undifferentiated arthritis (UA) and arthritis of hands secondary to other diseases (SA).

Methods:

Multicenter observational study conducted in the rheumatology and radiology service of two hospitals. Patients with RA, PA, UA and SA who attended the followup visit and healthy subjects (companions and healthcare proffesionals) were recruited. In all cases, a thermal image of the hands was taken using a Flir One Pro or Thermal Expert TE-Q1 camera connected to the mobile and an ultrasound of both hands. The degree of synovial hypertrophy (SH) and power doppler (PD) was assessed for each joint (score from 0 to 3). Inflammation was defined as the presence of SH> 1 or PD> 0. Machine learning was used to classify patients with RA, PA, UA and SA with inflammation evidenced by ultrasound and healthy subjects from thermographic images. The evaluation of the classifier was performed by leave-one-out cross-validation and the area under the ROC curve (AUCROC) in those subjects whose thermal image was performed with the Thermal Expert TE-Q1 camera. The study was approved by the Clinical Ethics and Research Committee of the centers.

Results:

500 subjects were recruited from March 2018 to January 2020, of these 73 were excluded due to poor quality in the thermal image (moved or absence of temperature contrast between hand and background). Of the 427 subjects analyzed, 129 corresponded to healthy subjects, 138 to patients without evidence of inflammation and 160 to patients with inflammation evidenced by ultrasound (116 RA and 44 PA, UA or SA). Of these, 42% were taken using the Thermal Expert TE-Q1 camera. An AUCROC of 0.73 (p-value <0.01) was obtained for the healthy classifier vs RA and 0.72 (p-value <0.01) for the healthy classifier vs PA, UA and SA.

Conclusion:

A classification model has been developed capable of differentiating patients with RA, PA, UA and SA with evidence of inflammation from healthy subjects. These results open an opportunity to develop tools that facilitate early diagnosis.

References:

[1]Barhamain AS, Magliah RF, Shaheen MH, Munassar SF, Falemban AM, Alshareef MM, Almoallim HM. The journey of rheumatoid arthritis patients: a review of reported lag times from the onset of symptoms. Open Access Rheumatol. 2017 Jul 28;9:139-150. doi: 10.2147/OARRR.S138830. eCollection 2017. Review.

[2]Lynch CJ, Liston C. New machine-learning technologies for computer-aided diagnosis. Nat Med. 2018 Sep;24(9):1304-1305. doi: 10.1038/s41591-018-0178-4.

[3]Brenner M, Braun C, Oster M, Gulko PS. Thermal signature analysis as a novel method for evaluating inflammatory arthritis activity. Ann Rheum Dis. 2006 Mar;65(3):306-11.

Disclosure of Interests:

None declared

A single-center analysis of adjuvant sequential versus ‘sandwich’ chemoradiotherapy for patients with stage III endometrial cancer

e18101

Background: To determine if the sequencing of chemotherapy with external beam radiotherapy (EBRT) in the adjuvant setting for FIGO stage III endometrial cancer impacts 2-year progression free survival (PFS). Methods: As part of our Gynecologic Oncology Multidisciplinary Group's initiative to establish an institutional guideline for the adjuvant treatment of Stage III endometrial cancer, we reviewed 144 cases identified by our cancer registry and departmental database. Treatment regimens were divided into three categories: sequential therapy with six cycles of carboplatin/taxane followed by EBRT, concurrent cisplatin for two cycles with EBRT followed by four cycles of carboplatin/taxane, or ‘sandwich’ therapy with three cycles of carboplatin/taxane followed by EBRT followed by three cycles of carboplatin/taxane. The published results of the phase III GOG-258 study called into question the efficacy of concurrent chemoradiation. Therefore, we only compared sequential versus ‘sandwich’ therapy using a Chi-Square analysis. We conducted a retrospective chart review to assess if patients were able to complete the prescribed six cycles and EBRT, and then measured their PFS at two years. We hypothesized that there would be no difference in PFS between the two groups. Results: There were no significant differences in clinical or pathologic factors between patients treated with either regimen. Ninety-four patients (65%) had stage IIIC disease. The majority of patients received six cycles of paclitaxel with carboplatin. Median EBRT dose was 45 Gy. There was no statistically significant difference in the estimated 2-year PFS between the sequential and ‘sandwich’ groups, which were 82% and 82.5%, respectively (p = 0.84). Conclusions: Adjuvant chemoradiation for FIGO stage III endometrial cancer given sequentially or in a ‘sandwich’ fashion appears to offer equally excellent early clinical patient outcomes.

Invasive cardiovascular magnetic resonance (iCMR) for diagnostic right and left heart catheterization using an MR-conditional guidewire and passive visualization in congenital heart disease

BACKGROUND

Today's standard of care, in the congenital heart disease (CHD) population, involves performing cardiac catheterization under x-ray fluoroscopy and cardiac magnetic resonance (CMR) imaging separately. The unique ability of CMR to provide real-time functional imaging in multiple views without ionizing radiation exposure has the potential to be a powerful tool for diagnostic and interventional procedures. Limiting fluoroscopic radiation exposure remains a challenge for pediatric interventional cardiologists. This pilot study's objective is to establish feasibility of right (RHC) and left heart catheterization (LHC) during invasive CMR (iCMR) procedures at our institution in the CHD population. Furthermore, we aim to improve simultaneous visualization of the catheter balloon tip, MR-conditional guidewire, and cardiac/vessel anatomy during iCMR procedures.

METHODS

Subjects with CHD were enrolled in a pilot study for iCMR procedures at 1.5 T with an MR-conditional guidewire. The CMR area is located adjacent to a standard catheterization laboratory. Using the interactive scanning mode for real-time control of the imaging location, a dilute gadolinium-filled balloon-tip catheter was used in combination with an MR-conditional guidewire to obtain cardiac saturations and hemodynamics. A recently developed catheter tracking technique using a real-time single-shot balanced steady-state free precession (bSSFP), flip angle (FA) 35-45°, echo time (TE) 1.3 ms, repetition time (TR) 2.7 ms, 40° partial saturation (pSAT) pre-pulse was used to visualize the gadolinium-filled balloon, MR-conditional guidewire, and cardiac structures simultaneously. MR-conditional guidewire visualization was enabled due to susceptibility artifact created by distal markers. Pre-clinical phantom testing was performed to determine the optimum imaging FA-pSAT combination.

RESULTS

The iCMR procedure was successfully performed to completion in 31/34 (91%) subjects between August 1st, 2017 to December 13th, 2018. Median age and weight were 7.7 years and 25.2 kg (range: 3 months - 33 years and 8 - 80 kg). Twenty-one subjects had single ventricle (SV) anatomy: one subject was referred for pre-Glenn evaluation, 11 were pre-Fontan evaluations and 9 post-Fontan evaluations for protein losing enteropathy (PLE) and/or cyanosis. Thirteen subjects had bi-ventricular (BiV) anatomy, 4 were referred for coarctation of the aorta (CoA) evaluations, 3 underwent vaso-reactivity testing with inhaled nitric oxide, 3 investigated RV volume dimensions, two underwent branch PA stenosis evaluation, and the remaining subject was status post heart transplant. No catheter related complications were encountered. Average time taken for first pass RHC, LHC/aortic pull back, and to cross the Fontan fenestration was 5.2, 3.0, and 6.5 min, respectively. Total success rate to obtain required data points to complete Fick principle calculations for all patients was 331/337 (98%). Subjects were transferred to the x-ray fluoroscopy lab if further intervention was required including Fontan fenestration device closure, balloon angioplasty of pulmonary arteries/conduits, CoA stenting, and/or coiling of aortopulmonary (AP) collaterals. Starting with subject #10, an MR-conditional guidewire was used in all subsequent subjects (15 SV and 10 BiV) with a success rate of 96% (24/25). Real-time CMR-guided RHC (25/25 subjects, 100%), retrograde and prograde LHC/aortic pull back (24/25 subjects, 96%), CoA crossing (3/4 subjects, 75%) and Fontan fenestration test occlusion (2/3 subjects, 67%) were successfully performed in the majority of subjects when an MR-conditional guidewire was utilized.

CONCLUSION

Feasibility for detailed diagnostic RHC, LHC, and Fontan fenestration test occlusion iCMR procedures in SV and BiV pediatric subjects with complex CHD is demonstrated with the aid of an MR-conditional guidewire. A novel real-time pSAT GRE sequence with optimized FA-pSAT angle has facilitated simultaneous visualization of the catheter balloon tip, MR-conditional guidewire, and cardiac/vessel anatomy during iCMR procedures.

A Prospective Study of Circulating Tumor DNA to Guide Matched Targeted Therapy in Lung Cancers

BACKGROUND

Liquid biopsy for plasma circulating tumor DNA (ctDNA) next-generation sequencing (NGS) is commercially available and increasingly adopted in clinical practice despite a paucity of prospective data to support its use.

METHODS

Patients with advanced lung cancers who had no known oncogenic driver or developed resistance to current targeted therapy (n = 210) underwent plasma NGS, targeting 21 genes. A subset of patients had concurrent tissue NGS testing using a 468-gene panel (n = 106). Oncogenic driver detection, test turnaround time (TAT), concordance, and treatment response guided by plasma NGS were measured. All statistical tests were two-sided.

RESULTS

Somatic mutations were detected in 64.3% (135/210) of patients. ctDNA detection was lower in patients who were on systemic therapy at the time of plasma collection compared with those who were not (30/70, 42.9% vs 105/140, 75.0%; OR = 0.26, 95% CI = 0.1 to 0.5, P < .001). The median TAT of plasma NGS was shorter than tissue NGS (9 vs 20 days; P < .001). Overall concordance, defined as the proportion of patients for whom at least one identical genomic alteration was identified in both tissue and plasma, was 56.6% (60/106, 95% CI = 46.6% to 66.2%). Among patients who tested plasma NGS positive, 89.6% (60/67; 95% CI = 79.7% to 95.7%) were also concordant on tissue NGS and 60.6% (60/99; 95% CI = 50.3% to 70.3%) vice versa. Patients who tested plasma NGS positive for oncogenic drivers had tissue NGS concordance of 96.1% (49/51, 95% CI = 86.5% to 99.5%), and directly led to matched targeted therapy in 21.9% (46/210) with clinical response.

CONCLUSIONS

Plasma ctDNA NGS detected a variety of oncogenic drivers with a shorter TAT compared with tissue NGS and matched patients to targeted therapy with clinical response. Positive findings on plasma NGS were highly concordant with tissue NGS and can guide immediate therapy; however, a negative finding in plasma requires further testing. Our findings support the potential incorporation of plasma NGS into practice guidelines.