The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

BRD3 Regulates the Inflammatory and Stress Response in Rheumatoid Arthritis Synovial Fibroblasts

BACKGROUND

Individual functions of members of the bromodomain (BRD) and extra-terminal (BET) protein family underlying the anti-inflammatory effects of BET inhibitors in rheumatoid arthritis (RA) are incompletely understood. Here, we aimed to analyze the regulatory functions of BRD3, an understudied member of the BET protein family, in RA synovial fibroblasts (FLS).

METHODS

BRD3 was silenced in FLS prior to stimulation with TNF. Alternatively, FLS were treated with I-BET. Transcriptomes were analyzed by RNA sequencing (RNAseq), followed by pathway enrichment analysis. We confirmed results for selective target genes by real-time PCR, ELISA, and Western blotting.

RESULTS

BRD3 regulates the expression of several cytokines and chemokines in FLS, and positively correlates with inflammatory scores in the RA synovium. In addition, RNAseq pointed to a profound role of BRD3 in regulating FLS proliferation, metabolic adaption, and response to stress, including oxidative stress, and autophagy.

CONCLUSIONS

BRD3 acts as an upstream regulatory factor that integrates the response to inflammatory stimuli and stress conditions in FLS and executes many functions of BET proteins that have previously been identified using pan-BET inhibitors.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Transferability of radiomic signatures from experimental to human interstitial lung disease

Background

Interstitial lung disease (ILD) defines a group of parenchymal lung disorders, characterized by fibrosis as their common final pathophysiological stage. To improve diagnosis and treatment of ILD, there is a need for repetitive non-invasive characterization of lung tissue by quantitative parameters. In this study, we investigated whether CT image patterns found in mice with bleomycin induced lung fibrosis can be translated as prognostic factors to human patients diagnosed with ILD.

Methods

Bleomycin was used to induce lung fibrosis in mice (n_control = 36, n_experimental = 55). The patient cohort consisted of 98 systemic sclerosis (SSc) patients (n_ILD = 65). Radiomic features (n_histogram = 17, n_texture = 137) were extracted from microCT (mice) and HRCT (patients) images. Predictive performance of the models was evaluated with the area under the receiver-operating characteristic curve (AUC). First, predictive performance of individual features was examined and compared between murine and patient data sets. Second, multivariate models predicting ILD were trained on murine data and tested on patient data. Additionally, the models were reoptimized on patient data to reduce the influence of the domain shift on the performance scores.

Results

Predictive power of individual features in terms of AUC was highly correlated between mice and patients (r = 0.86). A model based only on mean image intensity in the lung scored AUC = 0.921 ± 0.048 in mice and AUC = 0.774 (CI95% 0.677-0.859) in patients. The best radiomic model based on three radiomic features scored AUC = 0.994 ± 0.013 in mice and validated with AUC = 0.832 (CI95% 0.745-0.907) in patients. However, reoptimization of the model weights in the patient cohort allowed to increase the model’s performance to AUC = 0.912 ± 0.058.

Conclusion

Radiomic signatures of experimental ILD derived from microCT scans translated to HRCT of humans with SSc-ILD. We showed that the experimental model of BLM-induced ILD is a promising system to test radiomic models for later application and validation in human cohorts.

P13.05.A Image annotation guideline for invivo confocal laser endomicroscopy, interrater reliability and how to learn from medical consensus for machine learning algorithms

Background

Intraoperative confocal laser endomicroscopy (CLE) is an in vivo imaging technique increasingly studied in neurosurgery and neuropathology. It can be affected by artifacts introduced by the CLE device or related to the intraoperative setting. We developed and evaluated an image annotation guideline (AGL) to detect and eliminate images bearing no valuable information as a result of such artifacts. Images ware classified into good and bad quality, based on defined technical criteria, which are also considered relevant by clinical experts.

Material and Methods

Datasets were created from intraoperative CLE in vivo specimens of patients resected for brain tumors. The process from data collection to development of the ML algorithm followed 7 steps: data quality specification, image and metadata collection, AGL development, annotation, data allocation for clinical validation, clinical validation, and, optionally, algorithm development. Final diagnoses were obtained by pathological analysis. Artifacts were grouped into three categories: diminished signal-to-noise-ratio (dSNR), optical distortions (movement/perturbations), and contrast/brightness artifacts. Images were annotated by 4 medical data annotators (T4). For clinical validation, 500 images were excluded from the training data and additionally annotated by 3 board certified neuropathologists (NPs 1-3) with experience in CLE imaging, to determine the medical consensus on good and bad images. All raters (NPs) were compared against each other and against T4; T4 was also compared against the medical consensus. Cohen’s Kappa and overall percentage agreement (OPA) were used to evaluate inter-rater reliability. Positive percent agreement (PPA) and negative percentage agreement (NPA) were also used to evaluate agreement between medical consensus and T4.

Results

21,616 CLE images and corresponding clinical metadata were collected from 94 patients and annotated. For each case between 27 and 815 CLE images were acquired over the course of the surgery (mean=175 images per case, SD=170.6). 11% and 13% of images were labeled as dSNR and distortion, respectively, and 34% as class contrast. 42% of the images represented the good quality images. Interrater agreement between the 3 NPs ranged between 0.30 and 0.59. Agreement between T4 and the medical consensus was substantial (Cohen’s Kappa >=0.61). OPA between T4 and the medical consensus was 80.60%, PPA 72.34% and NPA 87.92%.

Conclusion

Annotations according to a well-structured and expertly curated AGL show higher values for Cohen’s Kappa and Overall Percent Agreement (OPA) with the medical consensus, than that of individual experts among one another. Such an AGL can be considered appropriate and produces on par results with annotations by a group of experts in the field and can be further employed for training machine learning (ML) algorithms.

OP0199 RADIOMIC SIGNATURES REFLECT TREATMENT RESPONSE TO NINTEDANIB IN PRECLINICAL LUNG FIBROSIS MODEL

Background

Responses to anti-fibrotic drugs in preclinical disease models are difficult to quantify by histological analysis of single tissue sections. Quantitative in-depth analysis of imaging data, termed “radiomics”, may represent a more reliable and accurate measure of treatment response since the pathology of the whole organ is captured.

Objectives

To study the potential of µCT-derived radiomic features to reflect response to Nintedanib in the bleomycin (BLM)-induced murine model of fibrosing interstitial lung disease.

Methods

All C57BL/6J mice from both study groups were intratracheally instilled with 2 U/kg BLM on day 0 to induce lung fibrosis. Nintedanib was administered daily by gavage at 60 mg/kg for two weeks starting from day 7 (n=15). Controls received equivalent treatment with vehicle-only (n=19). Whole lung µCT scans (SkyScan 1176, Bruker) of each animal were acquired at baseline (day 0), pre-treatment (day 7), and post-treatment (day 21). The Ashcroft score was assessed on Sirius Red stained lung sections post-treatment. Lung volumes in µCTs were defined semi-automatically in MIM Software (6.9.2), followed by extraction of radiomic features with our in-house developed software Z-Rad (7.3.1). Each data set contained 1’386 features, describing image characteristics with histogram, texture, and wavelet functions. Data pre-processing involved removal of features sensitive to intra- and interobserver delineation variability (ICC<0.75), highly correlated features (Pearson’s r>0.95), and features not significantly changing between days 0 and 7 (p>0.05). Agglomerative clustering of radiomic temporal trajectories was performed on the Nintedanib group to identify distinct feature clusters. The identified feature sets were then used to plot average feature value trajectories for both study groups in each cluster. To identify features significantly different between a) Nintedanib vs. control, and b) pre- vs. post-treatment, Mann-Whitney U and Wilcoxon signed-rank tests were used, respectively. Samples were pooled from two independent experiments.

Results

Evaluation of tissue sections did not show a significant treatment-induced reduction of fibrosis with average Ashcroft scores of 3.7 (±1.2 s.d.) and 3.4 (±1.6 s.d.) in Nintedanib and control samples, respectively (p>0.05). Radiomics data analysis revealed two feature clusters in Nintedanib samples, composed of 52 features (cluster 1) and 96 features (cluster 2), the trajectories of which were then plotted for both study groups. In cluster 1, feature value trajectories significantly decreased in both Nintedanib and control group between pre-and post-treatment (p<0.001), whereas feature values in cluster 2 remained flat (p>0.05). Importantly, Nintedanib-treated mice displayed a much more pronounced feature value decrease post-treatment in cluster 1 compared to the control group (p<0.05). Here, feature values post-treatment resembled pre-disease baseline conditions in the Nintedanib group (p>0.05), whereas the control group remained significantly different from baseline (p<0.01). Cluster 1 was composed of 6 histogram, 11 texture, and 35 wavelet features, emphasizing the role of high-dimensional metrics for the detection of differences.

Conclusion

Histological quantification of lung fibrosis accounts only for a small fraction of the whole pathology in a spatially heterogeneous disease. We demonstrated that µCT-derived radiomic features identified significant differences on imaging level following Nintedanib treatment, which we could not reliably detect on tissue level using Ashcroft scoring. These findings hold great potential for the development of novel readouts for improved stratification of anti-fibrotic treatment effects in preclinical models.

Acknowledgements

This study received funding support from the Swiss Lung Association.

Disclosure of Interests

David Lauer Shareholder of: Roche (no relation to project), Employee of: Former employee of Roche (no relation to project), Janine Schniering: None declared, Hubert Gabrys: None declared, Malgorzata Maciukiewicz: None declared, Matthias Brunner: None declared, Oliver Distler Speakers bureau: Speaker fees in the area of systemic sclerosis and related complications from Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Consultancies in the area of systemic sclerosis and its complications with Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Grant/research support from Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Thomas Frauenfelder: None declared, Stephanie Tanadini-Lang: None declared, Britta Maurer Speakers bureau: Received speaker fees from Boehringer-Ingelheim as well as congress support from Medtalk, Pfizer, Roche, Actelion, Mepha, and MSD, Consultant of: Consultancies with Novartis, Boehringer Ingelheim, Janssen-Cilag. Has a patent mir-29 for the treatment of systemic sclerosis issued (US8247389, EP2331143), Grant/research support from: Had grant/research support from AbbVie, Protagen, Novartis Biomedical Research.

Computed tomography-based radiomics decodes prognostic and molecular differences in interstitial lung disease related to systemic sclerosis

Background

Radiomic features calculated from routine medical images show great potential for personalised medicine in cancer. Patients with systemic sclerosis (SSc), a rare, multiorgan autoimmune disorder, have a similarly poor prognosis due to interstitial lung disease (ILD). Here, our objectives were to explore computed tomography (CT)-based high-dimensional image analysis (“radiomics”) for disease characterisation, risk stratification and relaying information on lung pathophysiology in SSc-ILD.

Methods

We investigated two independent, prospectively followed SSc-ILD cohorts (Zurich, derivation cohort, n=90; Oslo, validation cohort, n=66). For every subject, we defined 1355 robust radiomic features from standard-of-care CT images. We performed unsupervised clustering to identify and characterise imaging-based patient clusters. A clinically applicable prognostic quantitative radiomic risk score (qRISSc) for progression-free survival (PFS) was derived from radiomic profiles using supervised analysis. The biological basis of qRISSc was assessed in a cross-species approach by correlation with lung proteomic, histological and gene expression data derived from mice with bleomycin-induced lung fibrosis.

Results

Radiomic profiling identified two clinically and prognostically distinct SSc-ILD patient clusters. To evaluate the clinical applicability, we derived and externally validated a binary, quantitative radiomic risk score (qRISSc) composed of 26 features that accurately predicted PFS and significantly improved upon clinical risk stratification parameters in multivariable Cox regression analyses in the pooled cohorts. A high qRISSc score, which identifies patients at risk for progression, was reverse translatable from human to experimental ILD and correlated with fibrotic pathway activation.

Conclusions

Radiomics-based risk stratification using routine CT images provides complementary phenotypic, clinical and prognostic information significantly impacting clinical decision making in SSc-ILD.

CT-based radiomics decodes phenotypic, prognostic and molecular differences in SSc-ILD, and predicts progression-free survival with a significant impact on future clinical decision making in SSc-ILDhttps://bit.ly/3zPaMOn

Metabolic treatment of an electrical disease? Beneficial APD/QT prolongation by L-Carnitine in transgenic SQT1 rabbit models

Background

Short-QT syndrome 1 (SQT1) is a genetic cardiac channelopathy caused by gain-of-function mutations (KCNH2-N588K) in HERG/IKr, that leads to shortened QT-interval, increased risk for arrhythmias and sudden cardiac death (SCD). An acquired form of SQTS has been described in patients with primary (genetic) carnitine-deficiency, indicating that carnitine might affect cardiac repolarization.

Purpose

We aimed to investigate potential beneficial (APD/QT-prolonging) effect of L-Carnitine in (genetic) SQTS using transgenic SQT1 rabbits that mimic the human disease phenotype.

Methods

Effects of L-carnitine on cardiac repolarisation were assessed in adult wildtype (WT) and transgenic SQT1 rabbits (KCNH2-N588K) using in vivo ECG and ex vivo Langendorff-perfused whole-heart or isolated ventricular cardiomyocyte action potential (AP) recordings. Effects on ion currents were assessed by whole-cell patch-clamping.

Results

In vivo, the heart-rate corrected QT index (QTi) was prolonged significantly by L-carnitine both in WT (QTi, baseline 102.7%±4.9 vs. L-carnitine 106.9%±6.2, p&lt;0.05, n=12) and SQT1 (QTi, baseline 94.8%±7.4 vs. L-carnitine 99.5%±8.2, p&lt;0.05, n=13), leading to normalisation of QTi in SQT1. Ex vivo, whole-heart monophasic and cellular APs were also significantly prolonged by L-carnitine in WT and SQT1 (change in monophasic APD75, ms, WT +13.9±4.4, SQT1 +9.9±7.0; change in cellular APD90, %, WT +10.4%, SQT1 +10.4%, all p&lt;0.05). As underlying mechanisms, we identified acute effects on the main repolarizing ion currents IKr and IKs: IKr-steady, which is significantly increased in SQT1 contributing to accelerated repolarization, was reduced by L-carnitine (WT: −23%, SQT1: −16%). Moreover, L-carnitine accelerated the deactivation kinetics of IKr - while no change was observed in IKr-tail. In addition, IKs-steady was decreased by L-carnitine in SQT1 and WT cardiomyocytes.

Conclusion

L-carnitine prolongs/normalizes QT and APD in transgenic SQT1 rabbits by decreasing the pathologically increased IKr-steady and also IKs-steady and may therefore serve as potential future anti-arrhythmic therapy in SQTS.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Research Foundation (DFG)

Differences in extent of mechano-induced QT-changes in SQTS, WT and LQTS rabbit models

Background

Electro-mechanical (EMC) and mechano-electrical coupling (MEC) are essential for normal cardiac function. Alterations in these can result in increased arrhythmia formation. In “electrical” cardiac diseases, long-QT and short-QT syndrome, regional mechanical function is altered via EMC.

Purpose

In this study, we aimed to investigate how acute changes in mechanics may impact on electrical function (MEC) in these diseases.

Methods

To determine how acute changes in preload impact on QT duration, adult rabbits of both sexes were given a 6ml/kg BW bolus of 0.9% NaCl IV and 12-lead-ECGs were assessed first in wildtype (WT) and acquired drug-induced (E4031 to block IKr) LQT2 (“aLQT2”) rabbits, and in a second step in transgenic short-QT type 1 (“SQT1”, KCNH2-N588K) and WT littermate control rabbits (“WT-LMC”).

Results

At baseline, aLQT2 rabbits demonstrated a markedly prolonged heart-rate corrected QTc duration compared to WT (p&lt;0.0001; n=13), with increased QT-dispersion (QTMax-Min [ms], WT 21.4±5.7 vs. aLQT2 25.8±5.8; p=0.003; n=13) and increased short-term variability of QT (STVQT [ms], WT 3.5±1.0 vs. aLQT2 5.3±1.7; p=0.02; n=13), markers for regional and temporal heterogeneity of repolarization, respectively. SQT1 rabbits (n=8) demonstrated a shorter QTc duration compared to WT-LMC (n=10; p=0.04), with no differences in QT-dispersion and STVQT between the two groups.

Increased preload acutely prolonged QT and heart-rate corrected QTc in all groups (despite a slight increase in heart-rate by an average of 25 beats/min): in WT [ms] 171.6±11.6 to 213.3±20.3 (p&lt;0.0001) vs. aLQT2 208.9±19.6 to 271.0±37.5 (p&lt;0.0001; n=13 each), and in WT-LMC 171.3±4.8 to 199.2±5.4 (p&lt;0.0001; n=10) vs. SQT1 156.0±4.7 to 177.3±3.5 (p=0.0004; n=8). Importantly, the extent of mechano-induced electrical changes differed among genotypes, with less pronounced QTc prolongation in SQT1 compared to WT-LMC (delta QTc [ms], SQT1 21.2±3.4 (n=8) vs. WT-LMC 27.9±2.8 (n=10; p=0.15)), and a more pronounced QTc prolongation in aLQT2 compared to WT (delta QTc [ms], WT 41.6±14.9 vs. aLQT2 62.1±32.1; p=0.006; n=13 each). Moreover, QT-dispersion was increased significantly upon global mechanical change only in aLQTS (QTMax-Min [ms], 25.8±5.5 to 32.7±12.3; p=0.03; n=13).

Conclusion

Acute changes in mechanical function result in electrical changes via MEC in SQT1, WT and aLQT2 rabbits. The extent of these changes, however, depends on the underlying QTc duration, with the least pronounced QTc prolongation in SQT1 rabbits, with the shortest QTc, and the most pronounced QTc prolongation in aLQT2 rabbits, with the longest QTc. The most pronounced MEC effects on global QT duration as well as on regional QT dispersion in aLQT2 indicate that acute MEC effects may play an additional role in LQTS-related arrhythmogenesis.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): German Research Foundation (DFG) andSwiss National Science Foundation (SNF)

Staphylococcus aureus impairs dermal fibroblast functions with deleterious effects on wound healing

Chronic wounds are a major disease burden worldwide. The breach of the epithelial barrier facilitates transition of skin commensals to invasive facultative pathogens. Therefore, we investigated the potential effects of Staphylococcus aureus (SA) on dermal fibroblasts as key cells for tissue repair. In co-culture systems combining live or heat-killed SA with dermal fibroblasts derived from the BJ-5ta cell line, healthy individuals, and patients with systemic sclerosis, we assessed tissue repair including pro-inflammatory cytokines, matrix metalloproteases (MMPs), myofibroblast functions, and host defense responses. Only live SA induced the upregulation of IL-1β/-6/-8 and MMP1/3 as co-factors of tissue degradation. Additionally, the increased cell death reduced collagen production, proliferation, migration, and contractility, prerequisite mechanisms for wound closure. Intracellular SA triggered inflammatory and type I IFN responses via intracellular dsDNA sensor molecules and MyD88 and STING signaling pathways. In conclusion, live SA affected various key tissue repair functions of dermal fibroblasts from different sources to a similar extent. Thus, SA infection of dermal fibroblasts should be taken into account for future wound management strategies.

OP0150 MACHINE LEARNING APPROACHES FOR RISK MODELLING IN INTERSTITIAL LUNG DISEASE ASSOCIATED WITH SYSTEMIC SCLEROSIS USING HIGH DIMENSIONAL IMAGE ANALYSIS

Background:

The interstitial lung disease (ILD) associated with connective tissue diseases including systemic sclerosis (SSc) is heterogenous disease characterized by reduced survival of approximately 3 years (1). “Radiomics’’ is a field of research which describes the in-depth analysis of tissues by computational retrieval of high-dimensional quantitative features from medical images (2). Our previous study suggested capacity of radiomics features to differentiate between “high” and “low” risk groups for lung function decline in two independent cohorts (3).

Objectives:

  •bTo develop robust, machine learning (ML) workflow for “radiomics” data in SSc-ILD to select optimal methods for prediction.

  •oTo predict the time to individual lung function decline defined as defined by the time to a relative decline of ≥ 15% in Forced Vital Capacity (FVC)% as previously (3), using workflow.

Methods:

We investigated two cohorts of SSc-ILD: 90 patients (76.7% female, median age 57.5 years) from the University Hospital Zurich and 66 patients (75.8% female, median age 61.0 years) from Oslo University Hospital’s. Patients were retrospectively selected if (3): a) diagnosed with early/mild SSc according to the Very Early Diagnosis of Systemic Sclerosis (VEDOSS) criteria, b) presence of ILD on HRCT as determined by a senior radiologist. For every subject, we defined 1,355 robust radiomic features from HRCT images. The follow-up period was defined as the time interval between baseline visit and the last available follow-up visit.

We have developed a systematic computational workflow to build predictive ML models. To reduce the number of redundant radiomic features, we applied correlation thresholds. We applied distinct methods including 1) Lasso Penalized Regression for feature selection, and 2) Random Forest (RF) for modeling using the R package ‘caret’. To select the optimal ML model, we randomly divided derivation cohort into Training (70%) and Holdout (30%) sets and applied fivefold cross-validation (5kCV) for feature and classifier selection on Training set only.

Results:

We have investigated various methods to select the optimal set of predictive radiomic features. Since the ML model performance is affected by both, feature, and classifier selection, we assessed these factors first.

Results from feature filtering and selection, suggested that the combination of correlation threshold of 0.9 with Lasso regression proved best. As we perform feature selection in 5k CV workflow, features present in at least 2 sets entered model optimization step.

During model selection, we selected RF classifier. We detected positive correlation between actual and predicted values with Spearman’s rho = 0.313, p = 0.167 and Spearman’s rho = 0.341, p = 0.015 in Oslo and Holdout sets respectively, as shown on Figure 1. The percentage of variance remained modest for both Holdout (Rsq = 0.104) and Oslo (Rsq = 0.126) datasets.

Figure 1.

Performance of the best, RF classifier shown as scatterplot between actual and predicted values of individual time to lung decline.

Conclusion:

In summary, we: (1) developed ML workflow that allowed to select o optimal methodology for modeling (i.e., feature and classifier selection), and (2) provide models that predicted time to individual lung function decline, characterized by significant correlation between predicted and actual values.

References:

[1]Hansell DM, Goldin JG, King TE, Jr., Lynch DA, Richeldi L, Wells AU. CT staging and monitoring of fibrotic interstitial lung diseases in clinical practice and treatment trials: a position paper from the Fleischner Society. Lancet Respir Med. 2015;3(6):483-96.

[2]Lambin, P. et al. Radiomics: extracting more information from medical images using advanced feature analysis. Eur. J. Cancer 48, 441–446 (2012).

[3]Schniering J. et al. Resolving phenotypic and prognostic differences in interstitial lung disease related to systemic sclerosis by computed tomography-based radiomics. https://www.medrxiv.org/content/10.1101/2020.06.09.20124800v1

Disclosure of Interests:

None declared

POS0866 TWO-DIMENSIONAL HRCT-BASED RADIOMIC FEATURES IN SSC-ILD DISTINGUISH DRUG RESPONDERS FROM NON-RESPONDERS

Background:

Management of patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD) is complicated by high inter-patient variability. To date, no validated predictors of treatment response are available for routine use. High resolution computed tomography (HRCT)-based radiomics, i.e. the high-dimensional, quantitative analysis of imaging metadata, have previously been shown to be successful in discriminating (SSc-)ILD phenotypes in preclinical and clinical studies1. Since HRCT is an integral part of the routine work-up in SSc, HRCT-based radiomic features may hold potential as non-invasive biomarkers.

Objectives:

To predict treatment response using two-dimensional (2D) HRCT-based radiomics in SSc-ILD patients from a prospectively followed cohort.

Methods:

Inclusion criteria were diagnosis of SSc-ILD in HRCT, availability of a suitable chest HRCT scan within 12 months prior to initiation of a new treatment, and availability of clinical baseline and follow-up information. Treatment response was defined as the absence of all of the following over a follow-up period of 12-24 months: relative decrease in forced vital capacity (FVC) ≥5%, increase of ILD in HRCT as assessed by a radiologist, change in treatment regimen due to insufficient response, ILD-related death or lung transplantation. Of each pre-treatment HRCT, 6 slices (15±5 mm apart, starting from the basal lung margin) were manually segmented and 1513 2D radiomic features were extracted using the in-house software Z-Rad (Python 2.7). Features were Z-score transformed and pre-filtered for inter- and intra-reader robustness (intraclass correlation coefficient >0.85) and inter-feature correlation (Spearman’s rho <0.9). A categorical linear regression model was created using 3-fold cross-validated elastic nets for feature selection. Features were then summarized and divided by their number. For generation of a score cut-off, Youden’s score was used. For two-group analyses of continuous variables, Wilcoxon’s test was performed, whereas categorical data was assessed using Fisher’s exact test.

Results:

A total of 64 pre-treatment HRCTs from 54 patients were analyzed. In 9 patients, >1 asynchronous treatments were assessed, while 45 patients had only 1 eligible treatment approach. The response rate within the assessed follow-up period was 45.3% (n=29). For score generation, 13 radiomic features were selected and an optimal cut-off value of -0.1589 was determined. Univariate linear regression showed significant association between our categorical radiomics-based score and treatment response (p=0.007, area under the curve = 0.65 (0.51-0.79), sensitivity=0.90, specificity=0.43), whereby a high score was predictive for treatment response.

No differences between patients with high (n=46) or low (n=18) scores were detected for baseline age (mean±SD=55.5±12.0 and 55.5±13.6 years, p=0.84), duration of SSc (mean±SD=6.2±8.4 and 4.7±4.4 years, p=0.79), time since ILD diagnosis (2.7±2.9 and 2.4±3.1 years, p=0.59), FVC (77.6±20.6 and 80.1±17.9, p=0.41) or DLco (54.4±21.0 and 57.6±18.9, p=0.40). Distribution of anti-Scl-70 positivity (45.7% vs. 55.6%, p=0.58) and diffuse cutaneous disease (47.7% vs. 61.1%, p=0.41) was not significantly different between patients with high and low scores, respectively, although a trend towards higher percentages in the high score group was observed.

Conclusion:

Our results indicate that, following validation in external cohorts, radiomics may be a promising tool for future pre-treatment patient stratification. Moreover, our radiomics-based score seems not to be associated with commonly studied clinical predictors such as anti-Scl-70 positivity or lung function, underlining a possible additive value to ‘traditional’ clinical parameters.

References:

[1]Schniering, J., et al. Resolving phenotypic and prognostic differences in interstitial lung disease related to systemic sclerosis by computed tomography-based radiomics. medRxiv [Preprint] doi:10.1101/2020.06.09.20124800 (2020).

Disclosure of Interests:

Chantal Meier: None declared, Malgorzata Maciukiewicz: None declared, Matthias Brunner: None declared, Janine Schniering: None declared, Hubert Gabrys: None declared, Anja Kühnis: None declared, Oliver Distler Speakers bureau: Speaker fee on Scleroderma and related complications: Bayer, Boehringer Ingelheim, Medscape, Novartis, Roche. Speaker fee on rheumatology topic other than Scleroderma: MSD, iQone, Novartis, Pfizer, Roche, Consultant of: Consultancy fee for Scleroderma and its complications: Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Bayer, Baecon Discovery, Boehringer, CSL Behring, ChemomAb, Corbus Pharmaceuticals, Horizon Pharmaceuticals, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, Kymera, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Roivant Sciences, Sanofi, UCB. Consultancy fee for rheumatology topic other than Scleroderma: Abbvie, Amgen, Lilly, Pfizer, Grant/research support from: Research Grants to investigate the pathophysiology and potential treatment of Scleroderma and its complications: Kymera Therapeutics, Mitsubishi Tanabe, Thomas Frauenfelder: None declared, Stephanie Tanadini-Lang: None declared, Britta Maurer Speakers bureau: Speaker fees from Boehringer-Ingelheim, Grant/research support from: Grant/research support from AbbVie, Protagen, Novartis Biomedical Research, congress support from Pfizer, Roche, Actelion, mepha, and MSD

Application of metabolic modeling for targeted optimization of high seeding density processes

Process intensification by application of perfusion mode in pre‐stage bioreactors and subsequent inoculation of cell cultures at high seeding densities (HSD) has the potential to meet the increasing requirements of future manufacturing demands. However, process development is currently restrained by a limited understanding of the cell's requirements under these process conditions. The goal of this study was to use extended metabolite analysis and metabolic modeling for targeted optimization of HSD cultivations. The metabolite analysis of HSD N‐stage cultures revealed accumulation of inhibiting metabolites early in the process and flux balance analysis led to the assumption that reactive oxygen species (ROS) were contributing to the fast decrease in cell viability. Based on the metabolic analysis an optimized feeding strategy with lactate and cysteine supplementation was applied, resulting in an increase in antibody titer of up to 47%. Flux balance analysis was further used to elucidate the surprisingly strong synergistic effect of lactate and cysteine, indicating that increased lactate uptake led to reduced ROS formation under these conditions whilst additional cysteine actively reduced ROS via the glutathione pathway. The presented results finally demonstrate the benefit of modeling approaches for process intensification as well as the potential of HSD cultivations for biopharmaceutical manufacturing.

Changing paradigm of sacral neuromodulation and external anal sphincter repair for faecal incontinence in specialist centres

AIM

The aim of this study was to determine whether the paradigm of surgical intervention for faecal incontinence (FI) has changed between 2000 and 2013.

METHOD

This was a multi-centre retrospective study of patients who had undergone either sacral neuromodulation (SNM) or delayed sphincter repair or sphincteroplasty (SR) as a primary surgical intervention for FI in five centres in Europe and one in the United States. The flow of patients according to the intervention, sustainability of the treatment at a minimum follow-up of 5 years, complications and requirement for further interventions were recorded.

RESULTS

A total of 461 patients (median age 56 years, range 24-90 years, 41 men) had either SNM or SR as an index operation during the study period [SNM 284 (61.6%), SR 177 (38.4%)]. Among SNM patients, there were 169 revisional operations (change of battery and/or lead, re-siting or removal). At the time of last follow-up 203 patients (71.4%) continued to use SNM. Among SR patients, 30 (16.9%) had complications, most notably wound infection (22, 12.4%). During follow-up 32 patients (18.1%) crossed over to SNM. Comparing two 4-year periods (2000-2003 and 2007-2010), the proportion of patients operated on who had a circumferential sphincter defect of less than 90° was 48 (68%) and 45 (46%), respectively (P = 0.03), while those who had SNM as the primary intervention increased from 29% to 89% (P < 0.05).

CONCLUSION

The paradigm of surgical intervention for FI has changed with increasing use of SNM.

Societal costs of primary progressive multiple sclerosis in Australia and the economic impact of a hypothetical disease-modifying treatment that could delay disease progression

AIMS

Primary progressive multiple sclerosis (PPMS) has a progressive course of disability with continuous neurological worsening. We investigated societal costs of PPMS in Australia and the economic impact of increasing the independence of people with PPMS through delaying disease progression.

METHODS

This prevalence-based retrospective cost-of-illness analysis used observational data from publicly available secondary data sources and literature findings. Direct and indirect costs of PPMS were considered. A replica estimated population was created using the National Centre for Social and Economic Modelling (NATSEM) microsimulation model of the Australian tax and transfer system (STINMOD+). Using a budget impact analysis approach, we modelled the effect on PPMS costs of an effective hypothetical disease-modifying treatment (DMT) that delays disease progression by a year from mild to moderate and a further year from moderate to severe PPMS.

RESULTS

An estimated 31,650 Australians have multiple sclerosis (MS) including 4,430 with PPMS. The proportion with PPMS was estimated to increase with age and disease severity. Overall 25% of males with MS, and 10% of females, were estimated to have PPMS. Societal cost of PPMS in Australia in 2018 was estimated at AU$418.1 million. Indirect costs contributed 67.5% of total costs, attributable to reduced workforce participation and need for informal care. The modelled DMT was estimated to create savings of AU$14.9 million (3.6%). Fewer people had moderate and severe PPMS resulting in major cost savings, partially offset by increased costs of treatment, care and support for a relative increase in the number of people with mild PPMS and their increased productivity losses.

LIMITATIONS

Publicly available data may be incomplete. The potential cost of the DMT was not considered.

CONCLUSIONS

The economic burden of PPMS was estimated at AU$418 million in 2018. An effective DMT that delayed progression from disease severity states by one year could provide significant cost savings.

Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative

AIM

At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.

METHOD

Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.

RESULTS

Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006).

CONCLUSION

Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.

The societal burden of haemophilia A. III - The potential impact of emicizumab on costs of haemophilia A in Australia

INTRODUCTION

Emicizumab is a humanized monoclonal modified IgG4 antibody with bispecific antibody structure bridging Factor IXa and Factor X. Emicizumab has demonstrated efficacy and safety in adults, adolescents and paediatrics with HA, with or without inhibitors to Factor VIII (FVIII). There is currently no evidence that reports on the potential impact of the introduction of emicizumab on the societal costs of haemophilia A (HA). The purpose of this study was to explore the cost impact associated with the introduction of emicizumab on the current societal costs of people with HA (PwHA) in Australia.

METHODS

We conducted an analysis of the impact of emicizumab on societal costs, based on changes in the direct and indirect costs incurred by PwHA. Potential impacts of emicizumab on outcomes in PwHA were modelled based on HAVEN 1, HAVEN 2 and HAVEN 3 studies. We assumed that eligible PwHA commenced use of emicizumab on 1 January 2018. The impact of emicizumab on costs of HA in Australia males was then estimated for the 12-month period to 31 December 2018.

RESULTS

Overall, uptake of emicizumab in its first year of use reduces annual costs associated with moderate/severe HA by AUD$69.197M (62.3%). This reflects 64.2% reduction in the cost of FVIII blood products and 92% reduction in cost of bypassing agents.

CONCLUSION

The cost of emicizumab is likely to offset some or all of the projected reductions in treatment costs. However, we also found 30.7% reduction in non-treatment direct costs (AUD$3.771M) and 19.1% reduction in indirect costs (AUD$2.732M).

The societal burden of haemophilia A. I - A snapshot of haemophilia A in Australia and beyond

INTRODUCTION

Few studies, both in Australia and overseas, have examined the social impacts of living with haemophilia A (HA) or the economic costs associated with the disorder. The purpose of this paper is to examine the epidemiology and societal burden of people with HA (PwHA) in Australia, with a particular focus on men with this disorder.

METHODS

The epidemiology and societal burden of HA in Australia, with a particular focus on men with this disorder, were assessed, using data available in the Australian and international literature and publicly available data.

RESULTS

The mean annual prevalence of HA is approximately 1-2 per 10 000 males. Prophylactic treatment is used in one-quarter (25.1%) of people with moderate HA, and 82.2% of people with severe HA. Within the latter group, 16.1% have inhibitors for Factor VIII, predisposing them to worse morbidity, mortality and quality of life when compared to the non-inhibitor population. Joint pain and joint disease occur commonly in PwHA, with up to 70% of adults with HA experiencing joint problems. HA is associated with poor physical health, and PwHA miss school and work due to bleeding-related events.

CONCLUSION

HA is associated with substantial economic burden; with large differences in costs reported between countries. Overall, HA imposes a significant burden of disease on PwHA, their families and the community at large.

Oncological outcome after hyperthermic isolated limb perfusion for primarily unresectable versus locally recurrent soft tissue sarcoma of extremities

INTRODUCTION

The management of locally advanced extremity soft tissue sarcomas, particularly in terms of a limb salvage strategy, represents a challenge, especially in recurrent tumors. In the context of a patient-tailored multimodal therapy, hyperthermic isolated limb perfusion (ILP) is a promising limb-saving treatment option. We report the outcome of patients with primarily irresectable and locally recurrent soft tissue sarcoma (STS) treated by ILP.

PATIENTS AND METHODS

Data about patient demographics, clinical und histopathological characteristics, tumor response, morbidity and oncological outcome of all patients with STS, who underwent an ILP at our institution in a 10-year period, were retrospectively detected and analyzed.

RESULTS

The cohort comprised 30 patients. Two patients were treated with ILP for palliative tumor control, 13 patients because of a local recurrent soft tissue sarcoma (rSTS) and 15 patients because of primarily unresectable soft tissue sarcoma (puSTS). 25 of the 28 patients with curative intention received surgery after ILP (11 pts with rSTS and 14 pts with puSTS). Histopathologically we observed complete response in 6 patients (24%) and partial responses in 19 patients (76%) with a significant better remission in patients with puSTS (p = 0,043). Limb salvage rate was 75%. Mean follow-up was 69 months [range 13-142 months]. Seven (7/11; 64%) patients with rSTS and one (1/14; 7%) patient with puSTS developed local recurrence after ILP and surgery, whereas eight (8/13; 62%) rSTS patients and seven (7/15; 47%) puSTS patients developed distant metastasis. During follow-up, eight patients (28.5%) died of disease (5/13; 38%) rSTS and 3/15 (20%) puSTS. ILP in the group of previously irradiated sarcoma patients (n = 13) resulted in a limb salvage rate of 69% and was not associated in an increased risk for adverse events.

DISCUSSION

ILP for advanced extremity STS is a treatment option for both puSTS and rSTS resulting in good local control and should be considered in multimodal management. ILP is also a good option for patients after radiation history.

Towards robust cell culture processes - Unraveling the impact of media preparation by spectroscopic online monitoring

Biopharmaceutical manufacturing processes can be affected by variability in cell culture media, e.g. caused by raw material impurities. Although efforts have been made in industry and academia to characterize cell culture media and raw materials with advanced analytics, the process of industrial cell culture media preparation itself has not been reported so far. Within this publication, we first compare mid-infrared and two-dimensional fluorescence spectroscopy with respect to their suitability as online monitoring tools during cell culture media preparation, followed by a thorough assessment of the impact of preparation parameters on media quality. Through the application of spectroscopic methods, we can show that media variability and its corresponding root cause can be detected online during the preparation process. This methodology is a powerful tool to avoid batch failure and is a valuable technology for media troubleshooting activities. Moreover, in a design of experiments approach, including additional liquid chromatography-mass spectrometry analytics, it is shown that variable preparation parameters such as temperature, power input and preparation time can have a strong impact on the physico-chemical composition of the media. The effect on cell culture process performance and product quality in subsequent fed-batch processes was also investigated. The presented results reveal the need for online spectroscopic methods during the preparation process and show that media variability can already be introduced by variation in media preparation parameters, with a potential impact on scale-up to a commercial manufacturing process.

SAT0569 “IMAGES ARE MORE THAN PICTURES, THEY ARE DATA” [1] – EXPLORATION OF RADIOMICS ANALYSIS FOR SYSTEMIC SCLEROSIS-ASSOCIATED INTERSTITIAL LUNG DISEASE

Background:

Interstitial lung disease (ILD) affects 60% of patients with systemic sclerosis (SSc) and is the primary cause of death. Medical imaging is an integral part of the routine work-up for diagnosis and monitoring of SSc-ILD and includes high-resolution computed tomography (HRCT). Radiomics is a novel research area that describes the in-depth analysis of tissue phenotypes in medical images with computational retrieval of quantitative, mineable metadata appropriate for statistical analyses.

Objectives:

To explore the performance of HRCT-derived radiomic features for the assessment of SSc-associated ILD (i.e. diagnosis, staging, and lung function).

Methods:

Radiomics analysis was performed on HRCT scans from 98 SSc patients, including n=33 SSc patients without ILD, n=33 with limited and n=32 with extensive ILD as defined by 0%, <20% and ≥20% visual extent of fibrosis on HRCT, respectively. Following semi-automated segmentation of lung tissue on 3D reconstructed HRCT scans, 1386 radiomic features, including 17 intensity, 137 texture, and 1232 wavelet features were extracted using the in-house developed software Z-Rad (Python 2.7). In order to identify robust features, we conducted intra- and inter-reader correlation analysis (ICC) in a subgroup of patients. Only features with good reproducibility (ICC ≥ 0.75) entered subsequent analyses. We applied the Wilcoxon test, followed by Receiver Operating Characteristic ROC) curve analyses, to identify features significantly different between a) ILD and non-ILD and b) limited vs. extensive ILD patients. Spearman rank correlation was performed to reveal significant associations of radiomic features from a) and b) with lung function as measured by percentage of predicted forced vital capacity (FVC% predicted).

Results:

In total, 1355/1386 radiomic features passed the test of robustness and were eligible for further, exploratory analyses. Radiomic features with good performance (area under the ROC curve (AUC) ≥ 0.7 and p-value ≤ 0.05) were considered as potential candidate discriminators. Under this criterion, we identified 288/1355 (21.3%) radiomic features that were significantly different between ILD and non-ILD patients and 409/1355 (30.2%) features that significantly discriminated between limited and extensive ILD (Fig. 1). For diagnosis, the texture featuredependence count entropywas the top parameter to distinguish ILD patients from healthy controls (AUC = 0.89, p = 1.83x10-10), whereas for staging the wavelet featureHHH long run high grey level emphasisproved to be best suited to separate limited from extensive ILD (AUC = 0.88, p = 7.76x10-9).

Fig 1.

Correlation analysis of the most significant (best performing) discriminative radiomic features with lung function revealed a significant negative correlation ofdependence count entropy(rho = -0.51, p = 9.89x10-8) andHHH long run high grey level emphasis(rho = -0.51, p = 1.73x10-5) with FVC% predicted.

Conclusion:

Our study adds novelty to the field of SSc-ILD showing that radiomic features have great potential as quantitative imaging biomarkers for diagnosis and staging of SSc-ILD and that they may reflect lung function. As the next step, we are planning to build predictive models, using machine learning, for diagnosis, staging, and lung function and validate them in external patient cohorts. If validated such models will pave the way for computer-aided management in SSc-ILD and thus improve patients’ outcome.

References:

[1]Gillies, R. J., Kinahan, P. E. & Hricak, H. Radiomics: Images Are More than Pictures, They Are Data. Radiology 278, 563-577, doi:10.1148/radiol.2015151169 (2016).

Disclosure of Interests:

Janine Schniering: None declared, Malgorzata Maciukiewicz: None declared, Hubert Gabrys: None declared, Matthias Brunner: None declared, Christian Blüthgen: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Matthias Guckenberger: None declared, Thomas Frauenfelder: None declared, Stephanie Tanadini-Lang: None declared, Britta Maurer Grant/research support from: AbbVie, Protagen, Novartis, congress support from Pfizer, Roche, Actelion, and MSD, Speakers bureau: Novartis

18F-AzaFol for Detection of Folate Receptor-β Positive Macrophages in Experimental Interstitial Lung Disease-A Proof-of-Concept Study

Background: Interstitial lung disease (ILD) is a common and severe complication in rheumatic diseases. Folate receptor-β is expressed on activated, but not resting macrophages which play a key role in dysregulated tissue repair including ILD. We therefore aimed to pre-clinically evaluate the potential of 18F-AzaFol-based PET/CT (positron emission computed tomography/computed tomography) for the specific detection of macrophage-driven pathophysiologic processes in experimental ILD. Methods: The pulmonary expression of folate receptor-β was analyzed in patients with different subtypes of ILD as well as in bleomycin (BLM)-treated mice and respective controls using immunohistochemistry. PET/CT was performed at days 3, 7, and 14 after BLM instillation using the 18F-based folate radiotracer 18F-AzaFol. The specific pulmonary accumulation of the radiotracer was assessed by ex vivo PET/CT scans and quantified by ex vivo biodistribution studies. Results: Folate receptor-β expression was 3- to 4-fold increased in patients with fibrotic ILD, including idiopathic pulmonary fibrosis and connective tissue disease-related ILD, and significantly correlated with the degree of lung remodeling. A similar increase in the expression of folate receptor-β was observed in experimental lung fibrosis, where it also correlated with disease extent. In the mouse model of BLM-induced ILD, pulmonary accumulation of 18F-AzaFol reflected macrophage-related disease development with good correlation of folate receptor-β positivity with radiotracer uptake. In the ex vivo imaging and biodistribution studies, the maximum lung accumulation was observed at day 7 with a mean accumulation of 1.01 ± 0.30% injected activity/lung in BLM-treated vs. control animals (0.31 ± 0.06% % injected activity/lung; p < 0.01). Conclusion: Our preclinical proof-of-concept study demonstrated the potential of 18F-AzaFol as a novel imaging tool for the visualization of macrophage-driven fibrotic lung diseases.

Ventral rectopexy with biological mesh for recurrent disorders of the posterior pelvic organ compartment

PURPOSE

Recurrent prolapse of the posterior pelvic organ compartment presents a management challenge, with the best surgical procedure remaining unclear. We present functional outcome and patient satisfaction after laparoscopic and robotic ventral mesh rectopexy (VMR) with biological mesh in patients with recurrence.

METHODS

We analyzed data from 30 patients with recurrent posterior pelvic organ prolapse who underwent VMR with biological mesh from August 2012 to January 2018. Data included patient demographics and intra- and postoperative findings; functional outcome as assessed by Cleveland Clinic Constipation Score (CCCS), Obstructed Defecation Score Longo (ODS), and Cleveland Clinic Incontinence Score (CCIS); and patient satisfaction.

RESULTS

CCCS, CCIS, and ODS were significantly improved at 6-12 months postoperatively and at last follow-up. Patient satisfaction (visual analog scale [VAS] 6.7 [0 to 10]), subjective symptoms (+ 3.4 [scale - 5 to + 5]), and quality of life improvement (+ 3.0 [scale from - 5 to + 5]) were high at last follow-up. The rates of morbidity and major complications were 13% and 3%, respectively. There were no mesh-related complications or deaths. Difference in type of previous surgery (abdominal or transanal/perineal) had no significant effect on results.

CONCLUSIONS

VMR with biological mesh is a safe and effective option for patients with recurrent posterior pelvic organ prolapse. It reduces functional symptoms, has a low complication rate, and promotes patient satisfaction.

Use of a corneal impression membrane and PCR for the detection of herpes simplex virus type-1

Purpose. To investigate the use of a corneal impression membrane (CIM) for the detection of herpes simplex virus type 1 (HSV-1) in suspected herpes simplex keratitis (HSK).Methodology. In the laboratory study, swabs and CIMs made from polytetrafluoroethylene were spiked with different concentrations of HSV-1. DNA was extracted and real-time PCR undertaken using two sets of primers. In the clinical study, consecutive patients presenting with suspected HSK were included. For each patient, samples were collected from corneal lesions with a swab and a CIM in random order. Clinical details were collected using a standardized clinical form and patients were categorized into probable, presumed and possible HSK.Results. There was no difference in the performance of both primer sets for all HSV-1 dilutions (P=0.83) using a CIM or between a CIM and a swab (P=0.18). In total, 110 patients were included. Overall, 73 patients (66.4 %) had probable, 20 patients (18.2 %) presumed and 17 patients (15.5 %) possible HSV-1 keratitis. The HSV-1 detection rate was significantly higher using a CIM (40/110, 36.4 %) than a swab (28/110, 25.5 %) (P=0.004). In the probable HSV keratitis group, the detection rate using a CIM was 43.8 % compared to 27.4 % for a swab (P=0.004). The cycle threshold values obtained for the conjunctival swabs were higher than those obtained for the CIMs (P<0.001).Conclusions. In suspected HSK, a CIM is a useful alternative to a swab and more likely to detect the presence of HSV-1.

Visualisation of interstitial lung disease by molecular imaging of integrin αvβ3 and somatostatin receptor 2

OBJECTIVE

To evaluate integrin αvβ3 (alpha-v-beta-3)-targeted and somatostatin receptor 2 (SSTR2)-targeted nuclear imaging for the visualisation of interstitial lung disease (ILD).

METHODS

The pulmonary expression of integrin αvβ3 and SSTR2 was analysed in patients with different forms of ILD as well as in bleomycin (BLM)-treated mice and respective controls using immunohistochemistry. Single photon emission CT/CT (SPECT/CT) was performed on days 3, 7 and 14 after BLM instillation using the integrin αvβ3-targeting ¹⁷⁷Lu-DOTA-RGD and the SSTR2-targeting ¹⁷⁷Lu-DOTA-NOC radiotracer. The specific pulmonary accumulation of the radiotracers over time was assessed by in vivo and ex vivo SPECT/CT scans and by biodistribution studies.

RESULTS

Expression of integrin αvβ3 and SSTR2 was substantially increased in human ILD regardless of the subtype. Similarly, in lungs of BLM-challenged mice, but not of controls, both imaging targets were stage-specifically overexpressed. While integrin αvβ3 was most abundantly upregulated on day 7, the inflammatory stage of BLM-induced lung fibrosis, SSTR2 expression peaked on day 14, the established fibrotic stage. In agreement with the findings on tissue level, targeted nuclear imaging using SPECT/CT specifically detected both imaging targets ex vivo and in vivo, and thus visualised different stages of experimental ILD.

CONCLUSION

Our preclinical proof-of-concept study suggests that specific visualisation of molecular processes in ILD by targeted nuclear imaging is feasible. If transferred into clinics, where imaging is considered an integral part of patients' management, the additional information derived from specific imaging tools could represent a first step towards precision medicine in ILD.

Functional Staging of Corneal Neovascularization Using Fluorescein and Indocyanine Green Angiography

Purpose

Corneal neovascularization (CoNV) is a major risk factor for corneal graft rejection and other corneal conditions. The maturity of CoNV is important to guide treatment. This study investigated associations between clinical and angiographic characteristics of CoNV.

Methods

In a prospective cross-sectional study patients with CoNV of variable but known duration and etiology were included. All cases were clinically staged according to a simplified three-grade scale as active, inactive, and regressed and assessed using color photography, anterior-segment optical coherence tomography, and fluorescein and indocyanine green (ICG) angiography. Outcome parameters included age and depth of CoNV, perfusion times and time to leakage of fluorescein and ICG.

Results

Forty eyes of 39 patients with CoNV were included, active (14), inactive (22), and regressed CoNV (4). There were significant associations between the time to fluorescein or ICG leakage and clinical staging of CoNV (R² = 0.24; P = 0.0011, and R² = 0.3; P = 0.0001). In addition, there was a significant association between the time to fluorescein leakage and the age of CoNV (R² = 0.32; P = 0.0002). ICG leakage within 10 minutes was observed significantly more frequently in active than the inactive group and was not observed in regressed cases (P < 0.0001).

Conclusions

Simplification of the staging of CoNV to active, inactive, and regressed to is significantly associated with the time to extravascular leakage of fluorescein and indocyanine and may be useful to guide the selection of appropriate treatments.

Translational Relevance

The association between clinical and angiographic characteristics of CoNV may provide guidance to the treatment approaches.

[Palliative therapy concepts for pancreatic carcinoma]

The majority of patients with ductal pancreatic adenocarcinoma are already in a locally advanced or metastatic stage at the time of diagnosis and require palliative therapy. Interventional and operative measures are available for the restoration of biliary outflow in bile duct obstruction and the continuity of the upper intestinal lumen in duodenal or gastric outlet obstruction. In the presence of tumor-related pain, pain therapy according to the World Health Organization (WHO) scheme or a truncus coeliacus blockade, in cachexia a nutritional therapy and in thromboembolic events an anticoagulant therapy are used. An individualized palliative chemotherapy regimen should be selected for each patient, taking into account the patient's general condition and the side effects profile of the chemotherapeutic agents. Radiochemotherapy and local ablative therapies should currently only be used within the framework of studies. A palliative resection is not recommended according to current knowledge.

Imaging of Corneal Neovascularization: Optical Coherence Tomography Angiography and Fluorescence Angiography

Purpose

The purpose of this study was to compare optical coherence tomography angiography (OCTA) and indocyanine green angiography (ICGA) for the assessment of corneal neovascularization (CoNV).

Methods

Patients with CoNV extending at least 3 mm into the cornea were included. All patients underwent corneal imaging at the same visit. Images were recorded using the AngioVue OCTA system (Optovue, Inc.) with the long corneal adaptor module (CAM-L). ICGA images were recorded with fluorescent filters using the Heidelberg system (HRA2 Scanning Laser Ophthalmoscope; Heidelberg Engineering). Images were graded for quality by two independent observers. Vessel parameters: area, number, diameter, branch and end points, and tortuosity, were compared between devices. Bland-Altman plots were used to assess differences between parameters.

Results

Fifteen patients with CoNV predominantly associated with microbial keratitis were included. Mean subjective image quality score was better for ICGA (3.3 ± 0.9) than for OCTA (2.1 ± 1.2, P = 0.002), with almost perfect interobserver agreement for ICGA images (κ = 0.83) and substantial agreement for OCTA images (κ = 0.69). Agreement of grading of all investigated vessel parameters between ICGA and OCT images was slight to moderate, with significant differences found for vessel diameter (-8.98 μm, P = 0.01, 95% limits of agreement [LOA]: -15.89 to -2.07), number of branch (25.93, P = 0.09, 95% LOA: -4.31 to 56.17), and terminal points (49, P = 0.05, 95% LOA: 0.78 to 97.22).

Conclusion

Compared with ICGA, current OCTA systems are less precise in capturing small vessels in CoNV complexes, and validation studies are needed for OCTA segmentation software. OCTA, however, complements ICGA by providing evidence of red blood cell flow, which together with depth information, may be helpful when planning treatment of CoNV.

Evaluation of 99mTc-rhAnnexin V-128 SPECT/CT as a diagnostic tool for early stages of interstitial lung disease associated with systemic sclerosis

Background

Given the need for early detection of organ involvement in systemic sclerosis, we evaluated ^99mTc-rhAnnexin V-128 for the detection of early stages of interstitial lung disease (ILD) in respective animal models using single photon emission computed tomography (SPECT/CT).

Methods

In bleomycin (BLM)-challenged mice, fos-related antigen 2 (Fra-2) transgenic (tg) mice and respective controls, lung injury was evaluated by analysis of hematoxylin and eosin (HE) and Sirius red staining, with semi-quantification of fibrosis by the Ashcroft score. Apoptotic cells were identified by TUNEL assay, cleaved caspase 3 staining and double staining with specific cell markers. To detect early stages of lung remodeling by visualization of apoptosis, mice were injected intravenously with ^99mTc-rhAnnexin V-128 and imaged by small animal SPECT/CT. For confirmation, biodistribution and ex vivo autoradiography studies were performed.

Results

In BLM-induced lung fibrosis, inflammatory infiltrates occurred as early as day 3 with peak at day 7, whereas pulmonary fibrosis developed from day 7 and was most pronounced at day 21. In accordance, the number of apoptotic cells was highest at day 3 compared with saline controls and then decreased over time. Epithelial cells (E-cadherin+) and inflammatory cells (CD45+) were the primary cells undergoing apoptosis in the earliest remodeling stages of experimental ILD. This was also true in the pathophysiologically different Fra-2 tg mice, where apoptosis of CD45+ cells occurred in the inflammatory stage. In accordance with the findings on tissue level, at day 3 in the BLM and at week 16 in the Fra-2 tg model, biodistribution and/or ex vivo autoradiography showed increased pulmonary uptake of ^99mTc-rhAnnexin V-128 compared with controls. However, accumulation of the radiotracer and thus the signal intensity in lungs was too low to allow the differentiation of healthy and injured lungs in vivo.

Conclusion

At the tissue level, ^99mTc-rhAnnexin V-128 successfully demonstrated early stages of ILD in two animal models by detection of apoptotic epithelial and/or inflammatory cells. In vivo, however, we did not detect early lung injury. It remains to be investigated whether the same applies to human ILD.

Electronic supplementary material

The online version of this article (10.1186/s13075-018-1681-1) contains supplementary material, which is available to authorized users.

Media photo-degradation in pharmaceutical biotechnology - impact of ambient light on media quality, cell physiology, and IgG production in CHO cultures

BACKGROUND

Many vital components in bioprocess media are prone to photo-conversion or photo-degradation upon exposure to ambient light, with severe negative consequences for biomass yield and overall productivity. However, there is only limited awareness of light irradiation as a potential risk factor when working in transparent glass bioreactors, storage vessels or disposable bag systems. The chemical complexity of most media renders a root-cause analysis difficult. This study investigated in a novel, holistic approach how light-induced changes in media composition relate to alterations in radical burden, cell physiology, morphology, and product formation in industrial Chinese hamster ovary (CHO) bioprocesses.

RESULTS

Two media formulations from proprietary and commercial sources were tested in a pre-hoc light exposure scenario prior to cultivation. Using fluorescence excitation/emission (EEM) matrix spectroscopy, a photo-sensitization of riboflavin was identified as a likely cause for drastically decreased IgG titers (up to -80%) and specific growth rates (-50% to -90%). Up to three-fold higher radical levels were observed in photo-degraded medium. On the biological side, this resulted in significant changes in cell morphology and aberrations in the normal IgG biosynthesis/secretion pathway.

CONCLUSION

These findings clearly illustrate the underrated impact of room light after only short periods of exposure, occurring accidentally or knowingly during bioprocess development and scale- up. The detrimental effects, which may share a common mechanistic cause at the molecular level, correlate well with changes in spectroscopic properties. This offers new perspectives for online monitoring concepts, and improved detectability of such effects in future. © 2018 The Authors. Journal of Chemical Technology & Biotechnology published by JohnWiley & Sons Ltd on behalf of Society of Chemical Industry.

In Vivo Early Corneal Biomechanical Changes After Corneal Cross-linking in Patients With Progressive Keratoconus

PURPOSE

To report early corneal biomechanical changes after corneal cross-linking (CXL) in patients with keratoconus.

METHODS

Thirty-four eyes of 34 patients undergoing CXL for progressive keratoconus were included in this prospective clinical study. Dynamic corneal response (DCR) parameters obtained with the Corvis ST (OCULUS Optikgeräte GmbH; Wetzlar, Germany) were assessed at baseline (day of CXL) and after 1 month of follow-up; conversely, corneal tomography with the Pentacam (OCULUS Optikgeräte GmbH) was assessed at baseline and at 1, 3, and 6 months after CXL.

RESULTS

At the last follow-up visit (123.7 ± 69.6 days), all morphological parameters including steepest point (Kmax) and thinnest corneal thickness (ThCT) indicated stabilization of keratoconus (P > .05). Comparative analyses showed a rise of corneal stiffness demonstrated by a significant increase of Stiffness Parameter A1 (SP-A1) and Highest Concavity (SP-HC) and a significant decrease of Inverse Concave Radius (1/R) and Deformation Amplitude Ratio (DA Ratio) (P < .05). There was a significant correlation between the preoperative keratoconus characteristics (Kmax, Belin/Ambrósio final D value [BAD-D], and ThCT) and the DCR parameters (P < .05). Kmax and BAD-D showed a significant positive correlation with DA Ratio, Deflection Amplitude (DefA), and 1/R and a significant negative correlation with SPA1 and SP-HC. ThCT showed a significant positive correlation with SP-A1 and SP-HC and a significant negative correlation with DA Ratio, DefA, and 1/R.

CONCLUSIONS

This study suggests that the new DCR parameters of the Corvis ST are able to detect early changes in biomechanics following CXL and those that are measurable before corneal shape modifications take place. Based on these results, the authors suggest the use of these metrics to assess the early efficacy of cross-linking. [J Refract Surg. 2017;33(12):840-846.].

A splice site variant in the SUV39H2 gene in Greyhounds with nasal parakeratosis

Hereditary nasal parakeratosis (HNPK), described in the Labrador Retriever breed, is a monogenic autosomal recessive disorder that causes crusts and fissures on the nasal planum of otherwise healthy dogs. Our group previously showed that this genodermatosis may be caused by a missense variant located in the SUV39H2 gene encoding a histone 3 lysine 9 methyltransferase, a chromatin modifying enzyme with a potential role in keratinocyte differentiation. In the present study, we investigated a litter of Greyhounds in which six out of eight puppies were affected with parakeratotic lesions restricted to the nasal planum. Clinically and histologically, the lesions were comparable to HNPK in Labrador Retrievers. Whole genome sequencing of one affected Greyhound revealed a 4-bp deletion at the 5'-end of intron 4 of the SUV39H2 gene that was absent in 188 control dog and three wolf genomes. The variant was predicted to disrupt the 5'-splice site with subsequent loss of SUV39H2 function. The six affected puppies were homozygous for the variant, whereas the two non-affected littermates were heterozygous. Genotyping of a larger cohort of Greyhounds revealed that the variant is segregating in the breed and that this breed might benefit from genetic testing to avoid carrier × carrier matings.

Regressing conjunctival nevus in a child

Purpose:

Case Report:

Conclusion:

Elevated pCO2 affects the lactate metabolic shift in CHO cell culture processes

The shift from lactate production to consumption in CHO cell metabolism is a key event during cell culture cultivations and is connected to increased culture longevity and final product titers. However, the mechanisms controlling this metabolic shift are not yet fully understood. Variations in lactate metabolism have been mainly reported to be induced by process pH and availability of substrates like glucose and glutamine. The aim of this study was to investigate the effects of elevated pCO₂ concentrations on the lactate metabolic shift phenomena in CHO cell culture processes. In this publication, we show that at elevated pCO₂ in batch and fed-batch cultures, the lactate metabolic shift was absent in comparison to control cultures at lower pCO₂ values. Furthermore, through metabolic flux analysis we found a link between the lactate metabolic shift and the ratio of NADH producing and regenerating intracellular pathways. This ratio was mainly affected by a reduced oxidative capacity of cultures at elevated pCO₂. The presented results are especially interesting for large-scale and perfusion processes where increased pCO₂ concentrations are likely to occur. Our results suggest, that so far unexplained metabolic changes may be connected to increased pCO₂ accumulation in larger scale fermentations. Finally, we propose several mechanisms through which increased pCO₂ might affect the cell metabolism and briefly discuss methods to enable the lactate metabolic shift during cell cultivations.

Tribes and tribulations: interdisciplinary eHealth in providing services for people with a traumatic brain injury (TBI)

Background

eHealth has potential for supporting interdisciplinary care in contemporary traumatic brain injury (TBI) rehabilitation practice, yet little is known about whether this potential is being realised, or what needs to be done to further support its implementation. The purpose of this study was to explore health professionals’ experiences of, and attitudes towards eHealth technologies to support interdisciplinary practice within rehabilitation for people after TBI.

Methods

A qualitative study using narrative analysis was conducted. One individual interview and three focus groups were conducted with health professionals (n = 17) working in TBI rehabilitation in public and private healthcare settings across regional and metropolitan New South Wales, Australia.

Results

Narrative analysis revealed that participants held largely favourable views about eHealth and its potential to support interdisciplinary practice in TBI rehabilitation. However, participants encountered various issues related to (a) the design of, and access to electronic medical records, (b) technology, (c) eHealth implementation, and (d) information and communication technology processes that disconnected them from the work they needed to accomplish. In response, health professionals attempted to make the most of unsatisfactory eHealth systems and processes, but were still mostly unsuccessful in optimising the quality, efficiency, and client-centredness of their work.

Conclusions

Attention to sources of disconnection experienced by health professionals, specifically design of, and access to electronic health records, eHealth resourcing, and policies and procedures related to eHealth and interdisciplinary practice are required if the potential of eHealth for supporting interdisciplinary practice is to be realised.

The circumstellar envelope around the S-type AGB star W Aql. Effects of an eccentric binary orbit

CONTEXT

Recent observations at subarcsecond resolution, now possible also at submillimeter wavelengths, have shown intricate circumstellar structures around asymptotic giant branch (AGB) stars, mostly attributed to binary interaction. The results presented here are part of a larger project aimed at investigating the effects of a binary companion on the morphology of circumstellar envelopes (CSEs) of AGB stars.

AIMS

AGB stars are characterized by intense stellar winds that build CSEs around the stars. Here, the CO(J = 3→2) emission from the CSE of the binary S-type AGB star W Aql has been observed at subarcsecond resolution using ALMA. The aim of this paper is to investigate the wind properties of the AGB star and to analyse how the known companion has shaped the CSE.

METHODS

The average mass-loss rate during the creation of the detected CSE is estimated through modelling, using the ALMA brightness distribution and previously published single-dish measurements as observational constraints. The ALMA observations are presented and compared to the results from a 3D smoothed particle hydrodynamics (SPH) binary interaction model with the same properties as the W Aql system and with two different orbital eccentricities. Three-dimensional radiative transfer modelling is performed and the response of the interferometer is modelled and discussed.

RESULTS

The estimated average mass-loss rate of W Aql is Ṁ = 3.0×10-6 M⊙ yr-1 and agrees with previous results based on single-dish CO line emission observations. The size of the emitting region is consistent with photodissociation models. The inner 10″ of the CSE is asymmetric with arc-like structures at separations of 2-3″ scattered across the denser sections. Further out, weaker spiral structures at greater separations are found, but this is at the limit of the sensitivity and field of view of the ALMA observations.

CONCLUSIONS

The CO(J = 3→2) emission is dominated by a smooth component overlayed with two weak arc patterns with different separations. The larger pattern is predicted by the binary interaction model with separations of ~10″ and therefore likely due to the known companion. It is consistent with a binary orbit with low eccentricity. The smaller separation pattern is asymmetric and coincides with the dust distribution, but the separation timescale (200 yrs) is not consistent with any known process of the system. The separation of the known companions of the system is large enough to not have a very strong effect on the circumstellar morphology. The density contrast across the envelope of a binary with an even larger separation will not be easily detectable, even with ALMA, unless the orbit is strongly asymmetric or the AGB star has a much larger mass-loss rate.