The effects of cognitive rehabilitation combined with aerobic exercise or stretching-and-toning on new learning and memory in persons with moderate-to-severe TBI: Protocol for a randomized controlled trial

This paper describes the protocol for a Phase I/II, parallel-group, blinded randomized controlled trial that compares the effects of 12-weeks of combined learning and memory rehabilitation with either aerobic cycling exercise or stretching on cognitive, neuroimaging, and everyday life outcomes in 60 persons with moderate-to-severe traumatic brain injury (TBI) who demonstrate impairments in new learning. Briefly, participants will undergo baseline testing consisting of neuropsychological testing, neuroimaging, daily life measures, and cardiorespiratory fitness. Following baseline testing, participants will be randomized to one of 2 conditions (30 participants per condition) using concealed allocation. Participants will be masked as to the intent of the conditions. The conditions will both involve supervised administration of an enhanced, 8-week version of the Kessler Foundation modified Story Memory Technique, embedded within either 12-weeks of supervised and progressive aerobic cycling exercise training (experimental condition) or 12-weeks of supervised stretching-and-toning (active control condition). Following the 12-week intervention period, participants will complete the same measures as at baseline that will be administered by treatment-blinded assessors. The primary study outcome is new learning and memory impairment based on California Verbal Learning Test (CVLT)-III slope, the secondary outcomes include neuroimaging measures of hippocampal volume, activation, and connectivity, and the tertiary outcomes involve measures of daily living along with other cognitive outcomes. We further will collect baseline sociodemographic data for examining predictors of response heterogeneity. If successful, this trial will provide the first Class I evidence supporting combined memory rehabilitation and aerobic cycling exercise training for treating TBI-related new learning and memory impairment.

Quantifying the Impact of Research Productivity on Salary in Academic Radiation Oncology

PURPOSE/OBJECTIVE(S)

Academic physicians typically do not receive a salary based on individual publications; however, publications are necessary for promotion, and the impact of publication productivity among ranks on salary is unknown. The objective of this was to evaluate salary changes associated with publication productivity among academic radiation oncologists.

MATERIALS/METHODS

Radiation oncologist faculty-level academic productivity data were obtained, including the h-index, m-index, number of papers, and number of citations, based on prior work (Holliday et al, 2014). The AAMC and MGMA Provider Compensation Data from 2017 provided percentile-level salaries. The delta in salary was calculated for each delta in rank the publication metrics among ranks. The primary outcome was delta in salary per delta in h-index; additional calculations were performed for delta in m-index and delta in publications.

RESULTS

A total of 986 radiation oncologists were included. For assistant professor, median salary was $367,000, average h-index 6.8, m-index 0.68, 15.7 publications. For associate professor, median salary was $452,000, average h-index 14, m-index 0.87, 41.8 publications. For full professor, median salary was $520,000, average h-index 31.3, m-index 1.33, 118.7 publications. For chair (not mutually exclusive from full professor), median salary was $720,000, average h-index 34.8, m-index 1.36, 146.8 publications. The delta in salary per delta in rank and the associated changes in h-index, m-index, and publications are shown in Table 1. The average change in salary from assistant to associate professor is $11,805.56 / h-index, $447,368.42 / m-index, and $3,256.70 / publication; for associate to full it is $3,930.64 / h-index, $147,826.09 / m-index, and $884.27 / publication; and for full to chair it is $57,142.86 / h-index, and $7,117.44 / publication.

CONCLUSION

This work provides the average change in salary among academic ranks based on changes in research publication productivity. Our present analysis is unable to assess causality of this association, and many unaccounted confounders may affect this relationship. Further work in this area may include evaluation of demographic factors that have demonstrated rank and salary disparities in radiation oncology, such as gender.

Atezolizumab for Advanced Alveolar Soft Part Sarcoma

BACKGROUND

Alveolar soft part sarcoma (ASPS) is a rare soft-tissue sarcoma with a poor prognosis and no established therapy. Recently, encouraging responses to immune checkpoint inhibitors have been reported.

METHODS

We conducted an investigator-initiated, multicenter, single-group, phase 2 study of the anti-programmed death ligand 1 (PD-L1) agent atezolizumab in adult and pediatric patients with advanced ASPS. Atezolizumab was administered intravenously at a dose of 1200 mg (in patients ≥18 years of age) or 15 mg per kilogram of body weight with a 1200-mg cap (in patients <18 years of age) once every 21 days. Study end points included objective response, duration of response, and progression-free survival according to Response Evaluation Criteria in Solid Tumors (RECIST), version 1.1, as well as pharmacodynamic biomarkers of multistep drug action.

RESULTS

A total of 52 patients were evaluated. An objective response was observed in 19 of 52 patients (37%), with 1 complete response and 18 partial responses. The median time to response was 3.6 months (range, 2.1 to 19.1), the median duration of response was 24.7 months (range, 4.1 to 55.8), and the median progression-free survival was 20.8 months. Seven patients took a treatment break after 2 years of treatment, and their responses were maintained through the data-cutoff date. No treatment-related grade 4 or 5 adverse events were recorded. Responses were noted despite variable baseline expression of programmed death 1 and PD-L1.

CONCLUSIONS

Atezolizumab was effective at inducing sustained responses in approximately one third of patients with advanced ASPS. (Funded by the National Cancer Institute and others; ClinicalTrials.gov number, NCT03141684.).

CT in the detection of latent tuberculosis: a systematic review

AIM

To evaluate the use of computed tomography (CT) and low-dose CT in the detection of latent tuberculosis (TB).

MATERIALS AND METHODS

A systematic search of literature in adherence with the PRISMA guidelines was carried out. Quality assessment of the included studies was conducted.

RESULTS

The search strategy identified a total of 4,621 studies. Sixteen studies were considered eligible and included in the review. There was high heterogeneity among all studies. CT was identified as much more sensitive for the detection of latent TB in all studies despite chest radiography often being recommended in guidelines to assess patients for latent TB. Low-dose CT showed promising results in four of the studies; however, these results were limited due to small sample sizes.

CONCLUSION

CT is much superior to chest radiography consistently identifying additional cases of latent TB. There are limited high-quality publications available using low-dose CT but findings thus far suggest low-dose CT could be used as an alternative to standard-dose CT for the detection of latent TB. It is recommended that a randomised controlled trial investigating low-dose CT should be carried out.

Establishing weight-based diagnostic reference levels for neonatal chest X-rays

INTRODUCTION

As weights among neonates can vary from <900 g to >2.5 kg, weight-based Diagnostic Reference Levels (DRLs) specific to the neonatal intensive care unit (NICU) are essential. Repeated radiation exposure to this sensitive patient group raises concerns regarding high cumulative radiation doses and the potential for long-term health detriment. This study aimed to establish weight-based DRLs for neonates undergoing mobile chest radiography (CXR) in the NICU.

METHODS

Neonates were classified into three discrete groups; <1000, 1000-2500 and >2500 g. Data were collected prospectively over three months; 95 DAP values were collected, and five were excluded due to poor technique, leaving 90 patients that met the inclusion criteria for mobile CXR in the NICU. Dose-area-product (DAP) in mGycm², the peak kilovoltage (kVp) and the product of tube current and exposure time (mAs) were retrieved from the Picture Archiving and Communication System (PACS). Images and radiological reports were also analysed to confirm diagnostic image quality (IQ). Local DRLs (LDRLs) were derived using the median DAP, and national DRLs were suggested using the 3rd quartile value.

RESULTS

The proposed LDRLs for neonates weighing <1000 g was 2.7 mGycm², for neonates weighing between 1000 g and 2500 g, it was 3.7 mGycm², and for neonates weighing >2500 g it was 6.6 mGycm². The radiation dose received by the 90 (100%) neonates included in the study fell below 11.4 mGycm²; of these, 82% of the DAP values fell below the study institution's existing LDRL of 7.25 mGycm².

CONCLUSION

Weight-based DRLs provide crucial information on doses to this specific radiation-sensitive group. This work recommends using weight-based categories for DRLs and serves as a benchmark for neonatal CXR standardisation and optimisation.

IMPLICATIONS FOR PRACTICE

The proposed weight-based DRLs can be adopted for neonates' locally, nationally and internationally.

UV-chlorine advanced oxidation for potable water reuse: A review of the current state of the art and research needs

This paper reports conclusions from a recent study completed for the Water Research Foundation and the State of California to offer guidance on UV-chlorine advanced oxidation for potable water reuse. The fundamentals of UV-chlorine advanced oxidation are discussed, and lessons learned from some of the early adopters of this technology are presented. Important highlights include the significant impact of ammonia and chloramines on UV-chlorine treatment, challenges associated with predicting UV-chlorine performance due to complex photochemistry, and an ongoing need to monitor potential byproducts and transformation products when employing any form of advanced oxidation for potable reuse.

Evaluating the indotecan-neutropenia relationship in patients with solid tumors by population pharmacokinetic modeling and sigmoidal Emax regressions

PURPOSE

This study aimed at characterizing indotecan population pharmacokinetics and explore the indotecan-neutropenia relationship in patients with solid tumors.

METHODS

Population pharmacokinetics were assessed using nonlinear mixed-effects modeling of concentration data from two first-in-human phase 1 trials evaluating different dosing schedules of indotecan. Covariates were assessed in a stepwise manner. Final model qualification included bootstrap simulation, visual and quantitative predictive checks, and goodness-of-fit. A sigmoidal Emax model was developed to describe the relationship between average concentration and maximum percent neutrophil reduction. Simulations at fixed doses were conducted to determine the mean predicted decrease in neutrophil count for each schedule.

RESULTS

518 concentrations from 41 patients supported a three-compartment pharmacokinetic model. Body weight and body surface area accounted for inter-individual variability of central/peripheral distribution volume and intercompartmental clearance, respectively. Estimated typical population values were CL 2.75 L/h, Q3 46.0 L/h, and V3 37.9 L. The estimated value of Q2 for a typical patient (BSA = 1.96 m2) was 17.3 L/h, while V1 and V2 for a typical patient (WT = 80 kg) was 33.9 L and 132 L. The final sigmoidal Emax model estimated that half-maximal ANC reduction occurs at an average concentration of 1416 µg/L and 1041 µg/L for the daily and weekly regimens, respectively. Simulations of the weekly regimen demonstrated lower percent reduction in ANC compared to the daily regimen at equivalent cumulative fixed doses.

CONCLUSION

The final PK model adequately describes indotecan population pharmacokinetics. Fixed dosing may be justified based on covariate analysis and the weekly dosing regimen may have a reduced neutropenic effect.

Radiographers' knowledge and attitudes toward dementia

INTRODUCTION

Dementia is a syndrome associated with a decline in brain function, impacting how we speak, think, feel, and behave. Misunderstanding of dementia and how it affects patients and their carers is common. There is limited research on how radiographers provide adequate care to those with dementia. Radiographers with knowledge and positive attitudes can reduce stigma and fear, improving the quality of care. This study aimed to assess radiographers' knowledge and attitudes towards dementia.

METHODS

A cohort of registered radiographers in Ireland participated in an online survey. Two pre-existing validated questionnaires: The Alzheimer's Disease Knowledge Scale (ADKS) and the Dementia Attitudes Scale (DAS), assessed radiographers' knowledge and attitudes towards dementia and people with dementia. Scores were compared across variables such as gender, age, grade, qualification, work setting, and the number of years qualified.

RESULTS

A total of 123 radiographers responded. Knowledge scores did not significantly differ across demographic groups (p > 0.05). Total knowledge scores ranged from 60% to 100%. Total attitude scores ranged from 50% to 100%. Participants with a BSc, MSc, and other post-graduate degrees scored higher on the attitude scale than those with a diploma qualification (p = 0.027). Those with less than 20 years' experience scored higher than those with more. Knowledge had little correlation with attitude (r = 0.0522; p = 0.5667).

CONCLUSION

Findings indicate variations in attitudes linked to age and experience, and some misconceptions can be observed across varying groups. Interventions to improve attitudes and raise awareness are needed.

IMPLICATIONS FOR PRACTICE

There is a need for further research and education on dementia care in the imaging department. We have identified areas requiring further education.

Digital Pathology, A Cognitively Efficient Teaching Strategy: Current Application and a Glimpse into Future

Introduction/Objective

If pathology education is to be efficacious, it must embrace the ramifications of cognitive load of the learners, to optimize the capacity of the working memory. When undergraduate students commence their learning of pathology, they encounter a heap of new data and classifications. Simplifying these intricate systems into assimilable subschemas and items is key for effective transfer of knowledge. The minimization of the profundity of intrinsic cognitive load is essential, considering that its impact on pathology beginners is often left unaccounted, both in active learning as well as in traditional methods of instruction. In today’s digital generation, digital pathology plays a key role by intertwining disease morphology with clinical presentation and fortifying its pathophysiologic basis. We designed a teaching methodology utilizing digital pathology to evaluate its effect on cognitive load.

Methods/Case Report

Active learning was implemented online using digital pathology, molecular pathology, and laboratory data in case-based setting with question-answer sessions. In small groups, students were encouraged to analyze digital pathology slides with the help of annotations and identify areas of histopathological significance. They utilized this information further to make an accurate diagnosis and answer corresponding questions, with access to answers available later, complemented with algorithms and concept maps. A 14-item structured questionnaire was delivered afterwards to evaluate the efficacy and popularity of the exercise.

Results (if a Case Study enter NA)

End-of-term examination results showed that learners developed higher-order comprehension skills along with a greater potential in interpreting histopathological data towards solving case studies. Feedback revealed a higher degree of overall satisfaction and increased ability to retain information.

Conclusion

Digital transformation of pathology education provides the kind of framework where learning happens naturally - developing in small boosts of progress until expertise is achieved, and students appreciate the value of the ‘learned thing’ along with the real utility of that knowledge. The innovative approach utilizing digitization and integration offers the opportunity of decrement in intrinsic cognitive load by invoking students to build better, reliable, long-lasting, supportable and inclusive schemata while correlating the relevant incoming information with previously stabilized knowledge and consolidating the entirety of understanding.

Should dual antiplatelet therapy be maintained beyond one year after a myocardial infarction? A cohort study within the French SNDS nationwide claims database

Background

Dual antiplatelet therapy (DAPT), aspirin plus a P2Y12-i (clopidorel, prasugrel or ticagrelor), is recommended for one year after myocardial infarction (MI) for secondary prevention of cardiovascular disease (SP-CVD). Beyond one year maintaining DAPT is controversial.

Purpose

To compare the 3-year risk of a composite of MI, ischemic stroke (IS), major bleeding (MB) and death between DAPT and single antiplatelet therapy with aspirin (SAPT) beyond one year after MI.

Methods

All adults hospitalized in 2013 or 2014 for acute MI (trigger event) with intensive care unit stay were identified in the French SDNS nationwide claims database. Patients who survived at least one year without MI or MB, and with a DAPT medication possession ratio (MPR) ≥80% were included in a cohort study. All patients were followed for 3 years after the index date (defined 365 days after the MI trigger event), except right-censored observations for those who died or discontinued aspirin with a 60-day grace period. The 3-year hazard ratios (HR [95% CI]) were estimated using Cox proportional hazards risk model for outcomes including death, and Fine and Gray competing risks model for non-fatal outcomes, with a time-dependent variable for DAPT-SAPT exposure, and adjusted on a high-dimensional disease risk score (hdDRS) plus time dependent variables for SP-CVD drugs, oral antidiabetics, insulin, anticoagulants, NSAIDs, corticoids and proton pump inhibitors. HdDRS were estimated for the composite outcome, a composite of ischemic outcomes, and MB alone, and variables were selected using a combination of Principal Component Analysis and Lasso regression.

Results

From the 105,080 adults admitted in intensive care units for acute MI in 2013 or 2014, 53,399 were included in the cohort. The most common reasons for non-inclusion were death (n=12,012) and a DAPT MPR &lt;80% (n=25,000). At index date, mean age was 65 years, with 74.6% men, 21.8% diabetes, 9.4% heart failure, 5.6% peripheral arterial disease, 72.2% with DAPT score ≤2, 61.9% Charlson index ≤1; 79.2% had a STEMI trigger event and 82.6% had cardiac revascularization (PCI 98.6%). P2Y12-i used at least once from the trigger event to the index date were clopidogrel (41.5%), ticagrelor (41.1%) and prasugrel (26.2%). Follow-up was 111,770 person-years and 4,268 composite outcomes were recorded. The 3-year HR of DAPT compared to SAPT was 1.21 [1.13–1.30] for the composite of MI, IS, MB and death, 1.22 [1.07–1.38] for MI, 0.98 [0.80–1.20] for IS, 1.89 [1.55–2.30] for MB and 1.16 [1.06–1.27] for death.

Conclusions

In this nationwide real-life population-based study in France, DAPT maintained beyond one year after MI is significantly associated with increased harm compared to SAPT with increased risks of 21% (IC95% [13–30]) for the composite of MI, IS, MB and death (net clinical benefit), 22% [7–38] for MI, 89% [55–130] for MB, 16% [6–27] for death, and no difference for IS.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): French Ministry of Health (PHRCN-18-0745)

Cardiovascular or renal disease (CVRD) complication and mortality incidence for type 2 diabetics with a single or without CVRD comorbidity: a 5-year SNDS nationwide claims database cohort study

Background

Myocardial infarction (MI), stroke, peripheral arterial disease (PAD), heart failure (HF) and chronic kidney disease (CKD) are common cardiovascular renal disease (CVRD) complications for type 2 diabetes (T2D). However, for those with a single CVRD comorbidity, the incidence of a new CVRD complication and death is not well known.

Purpose

To assess the 5-year CVRD complication and mortality incidence for T2D patients with a single CVRD comorbidity or without CVRD at baseline.

Methods

A cohort study of all T2D patients with a single CVRD or without CVRD (disease-free) at baseline (January 1st, 2014) identified and followed-up for 5 years within the French SNDS nationwide claims database. Incidence rates were estimated for 5 years and the risk of all-cause death was compared to the disease-free population using Cox proportional hazards risk model: hazard ratio (HR) with [95% confidence interval].

Results

From about 2 million T2D patients without cancer or transplantation at baseline, 76.5% were disease-free, 7.9% with a single CVRD and the others having several CVRD comorbidities history. Five-year CVRD complication and mortality incidence rates for 1,000 patient-years are presented in the table. CKD and HF were the most frequent CVRD complications for the disease-free and all CVRD comorbid populations, far ahead of MI, stroke and PAD, except PAD complication for PAD population and to a lesser degree stroke complication for stroke population. The incidence rate of all-cause death was the highest for HF+CKD patients, followed by HF patients, then PAD, stroke and CKD patients. Compared to disease-free patients with same sex and age, the HR of death was 4.3 [4.2–4.5] higher for HF+CKD patients, 2.7 [2.7–2.8], 2.1 [2.0–2.1], 2.1 [2.0–2.1], 1.9 [1.9–1.9] and 1.4 [1.3–1.4] for HF, CKD, PAD, stroke and MI patients, respectively.

Conclusions

While MI, stroke and PAD comorbidities remain major risks of complications for T2D patients, HF and CKD nowadays represent a clearly higher risk of CVRD complications and death, that needs improved preventive strategies.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Study performed with unconditional funding from AstraZeneca

Radiographers' knowledge, attitudes and expectations of artificial intelligence in medical imaging

INTRODUCTION

Artificial intelligence (AI) is increasingly utilised in medical imaging systems and processes, and radiographers must embrace this advancement. This study aimed to investigate perceptions, knowledge, and expectations towards integrating AI into medical imaging amongst a sample of radiographers and determine the current state of AI education within the community.

METHODS

A cross-sectional online quantitative study targeting radiographers based in Europe was conducted over ten weeks. Captured data included demographical information, participants' perceptions and understanding of AI, expectations of AI and AI-related educational backgrounds. Both descriptive and inferential statistical techniques were used to analyse the obtained data.

RESULTS

A total of 96 valid responses were collected. Of these, 64% correctly identified the true definition of AI from a range of options, but fewer (37%) fully understood the difference between AI, machine learning and deep learning. The majority of participants (83%) agreed they were excited about the advancement of AI, though a level of apprehensiveness remained amongst 29%. A severe lack of education on AI was noted, with only 8% of participants having received AI teachings in their pre-registration qualification.

CONCLUSION

Overall positive attitudes towards AI implementation were observed. The slight apprehension may stem from the lack of technical understanding of AI technologies and AI training within the community. Greater educational programs focusing on AI principles are required to help increase European radiography workforce engagement and involvement in AI technologies.

IMPLICATIONS FOR PRACTICE

This study offers insight into the current perspectives of European based radiographers on AI in radiography to help facilitate the embracement of AI technology and convey the need for AI-focused education within the profession.

A phase 2 study of anti-PD-L1 antibody (atezolizumab) in grade 2 and 3 chondrosarcoma

11528

Background: Chondrosarcoma is one of the most common bone malignancies in adults, and the third most common in pediatric patients (pts). The most prevalent subtype, conventional chondrosarcoma, is a slow growing tumor that is historically known to be refractory to chemotherapy. Anecdotal reports indicated a role for anti-PD-(L)1 in the treatment of this disease. This is the first prospective report on the efficacy of the PD-L1-targeting agent, atezolizumab, in this rare disease. Methods: Patients (pts) ages 2 and older with unresectable grade 2 or 3 conventional chondrosarcoma were eligible. No prior anti-PD-(L)1 treatment was allowed, otherwise pts were eligible irrespective of prior therapies as long as protocol-specified washout period requirements were met. Pts received atezolizumab 1200 mg (15 mg/kg with 1200 mg cap in pediatric pts) once every 21 days. Imaging was carried out at end of cycle 3, and then every two cycles. Research biopsies were collected from adult pts prior to C1D1, prior to C3D1, and at progression. Immuno-pharmacodynamic (IO-PD) studies were performed on paired tumor samples and circulating immune cells to help elucidate signaling pathways mediating the immune response, with focus on subsets of effector cells in the tumor microenvironment. Results: A total of 9 pts (7 males, 2 females) were enrolled in 6 centers across the US and Canada. Six pts were Caucasian/White, 1 Asian, 1 Hispanic, and 1 unknown. Median age was 49 years (42-72). No objective responses were seen. Three pts (33%) experienced disease stability (SD) per RECIST 1.1, for a median duration of 21 weeks as of data cutoff (January 2022). A patient with SD remains on active treatment (tx) for 35 weeks. Three patients had no tx-related adverse events (AEs). Six pts (67%) experienced at least one tx-related AE. Two patients experienced > G2 AEs, but only one was considered tx-related (lymphopenia). Immune-related AEs were all G1/2 and included hepatitis (2), hypothyroidism (1), hyperthyroidism (1), and maculopapular rash (1). IO-PD studies are ongoing and will be reported at the conference if available. Conclusions: Atezolizumab was well-tolerated but demonstrated limited activity in this cohort of pts with few treatment options. Ongoing IO-PD studies will provide insight into atezolizumab’s effect upon immune cell content and activation in the tumor microenvironment that will help design future immunotherapy trials in this disease and other sarcoma types. The study was funded by NCI Contract HHSN261201500003I. Clinical trial information: NCT04458922.

Use of Surpass Streamline Flow Diverter for the Endovascular Treatment of Craniocervical Aneurysms: a Single-Institution Experience

INTRODUCTION

Flow diversion has revolutionized endovascular treatment for cerebral aneurysms. Surpass Streamline flow-diverter (SSFD) has shown promise for expanding flow diversion device options for aneurysm treatment. The SSFD differs from earlier stents by maintaining high porosity with increased pore density to ensure appropriate flow disruption. Given the delivery system's increased dimension options, and potential greater flow diverting properties, the SSFD is poised to extend the anatomic/pathologic reaches of flow diversion therapy.

METHODS

Data pertaining to SSFD-treated aneurysms were gathered retrospectively from 2019 to 2020. Collected information included aneurysm location, size, symptoms, complications, and occlusions rates at follow-up. Size was categorized as small (<10 mm), large (10-25 mm), and giant (>25 mm) according to SCENT trial criteria. Aneurysm occlusion on follow-up imaging was characterized by SMART grading with adequate occlusion defined as grades 3 and 4. Imaging was performed at time of treatment, six-month, and one-year follow-up.

RESULTS

42 SSFD-treated aneurysms were treated throughout the cerebrovascular system; 3 cervical, 4 posterior, and 35 intracranial anterior circulation. Complete occlusion rates at six months and one year were 48% and 57% with adequate occlusion achieved in 89.6% and 85.7% respectively. Rates of complete occlusion were higher for small aneurysms (69%) compared to large aneurysms (38%).

CONCLUSIONS

Our data suggests comparable complete occlusion rates compared to the SCENT trial (66.1% vs 57% in our center) and adequate occlusion rates. Similar occlusion rates to prior studies despite broadened inclusion criteria/diversity of aneurysms treated demonstrates favorable generalizability of flow-diverting technology to a wide array of aneurysmal pathology.

Identifying barriers to Irish traveller women attending breast screening

INTRODUCTION

Breast cancer is one of the most prevalent cancers in women, however Irish Traveller women have lower breast screening rates than that of the general population. This work aims to address the gap in knowledge of Irish Traveller womens' perceptions of breast screening and the perceived barriers and enablers to attendance.

METHODS

This phenomenological qualitative study involves interviews with Irish Traveller women and Health Care Professionals and discusses the incentives and barriers to attending breast screening mammography in Ireland. The work investigated attitudes and decision making amongst the Irish Traveller women across breast screening and breast health. The research investigated the participants knowledge, experience and opinions about the topic of Irish Traveller womens' attendance at BreastCheck and breast health RESULTS: Influences that create barriers to breast screening for Irish Traveller women include inequality and family/community support, fear, literacy and education, embarrassment and the health care professional, stress and appointment suitability. Findings also demonstrate inadequate data and information is available in Ireland regarding Irish Traveller women attending breast screening.

CONCLUSION

Irish Traveller women face several influences when it comes to attending breast screening. The existing Irish national breast screening programme provides a health promotion service however, it is impossible to assess poor attendance at screening without the presence of an ethnic identifier. It would be very beneficial for screening promotion to record the ethnicity of attendees for statistical progress. This would benefit Irish Traveller women by recording the progress of attendance in the breast screening programme and creating a need for awareness and education within the annual reports.

IMPLICATIONS FOR PRACTICE

Creating awareness and educating Irish Traveller women about the breast screening programme may remove barriers and lead to improved attendance rates.

Revue exhaustive de la littérature sur le bon usage des AINS, dont l’ibuprofène, en période de Covid-19

Introduction

Le GRAINS, groupe de réflexion sur les AINS, est composé d’experts pluridisciplinaire hospitalier et de ville qui regroupe plusieurs médecins spécialistes. Il s’est constitué en vue de réfléchir sur le bon usage des anti-inflammatoires non-stéroïdiens (AINS) dans le contexte de la pandémie de COVID-19, et est soutenu par GlaxoSmithKline Santé Grand Public. Les travaux effectués par le GRAINS ont été publiés dans une revue de littérature exhaustive. L’objectif du GRAINS est d’avoir une discussion ouverte sur l’utilisation des AINS dans la gestion de la douleur dans le contexte de la COVID-19 et des infections en général, considérant les progrès réalisés dans la production de connaissances et les preuves de la littérature scientifique.

Matériels et méthodes

Ce groupe pluridisciplinaire d’experts constitué de rhumatologues, infectiologues, pédiatre, médecin généraliste, pharmacologue et pharmaciens, a pointé l’inquiétude et le manque d’informations énoncés par les patients à leur pharmacien. Les experts du GRAINS se sont réunis au travers de différentes assemblées et se sont accordés sur la nécessité de mettre à disposition des professionnels de santé une information synthétique de la littérature scientifique et des outils pour vulgariser cette information pour le grand public. La revue de littérature réalisée par les experts du GRAINS porte sur plus de 40 études internationales récentes concernant l’utilisation des AINS dans un contexte de la COVID-19.

Résultats

Le recours aux anti-inflammatoires non stéroïdiens (AINS) en général, et à l’ibuprofène en particulier, n’expose pas à un risque accru de la Covid-19 ni à des formes grave de cette infection.

Discussion

Encourager la discussion sur le bon usage des AINS en automédication. Les experts pointent l’inquiétude et le manque d’information énoncés par les patients à leur pharmacien. Par leur action ils souhaitent alerter sur les risques liés au surdosage d’alternatives aux AINS en particulier dans le traitement de la fièvre et de la douleur. Ils encouragent à ne pas se priver davantage de l’arsenal thérapeutique des AINS et militent pour une utilisation raisonnée de ces traitements.

Conclusion

Il n’existe actuellement aucune preuve scientifique établissant un lien entre l’ibuprofène et l’aggravation de l’infection due au SARS-CoV-2.

Adherence to Direct Oral Anticoagulants in Patients With Non-Valvular Atrial Fibrillation: A Cross-National Comparison in Six European Countries (2008-2015)

Aims: To describe and compare the adherence to different direct oral anticoagulants (DOACs) in eight European databases representing six countries. Methods: Longitudinal drug utilization study of new users (≥18 years) of DOACs (dabigatran, rivaroxaban, apixaban) with a diagnosis of non-valvular atrial fibrillation (2008-2015). Adherence was examined by estimating persistence, switching, and discontinuation rates at 12 months. Primary non-adherence was estimated in BIFAP and SIDIAP databases. Results: The highest persistence rate was seen for apixaban in the CPRD database (81%) and the lowest for dabigatran in the Mondriaan database (22%). The switching rate for all DOACs ranged from 2.4 to 13.1% (Mondriaan and EGB databases, respectively). Dabigatran had the highest switching rate from 5.0 to 20.0% (Mondriaan and EGB databases, respectively). The discontinuation rate for all DOACs ranged from 16.0 to 63.9% (CPRD and Bavarian CD databases, respectively). Dabigatran had the highest rate of discontinuers, except in the Bavarian CD and AOK NORDWEST databases, ranging from 23.2 to 64.6% (CPRD and Mondriaan databases, respectively). Combined primary non-adherence for examined DOACs was 11.1% in BIFAP and 14.0% in SIDIAP. There were differences in population coverage and in the type of drug data source among the databases. Conclusion: Despite the differences in the characteristics of the databases and in demographic and baseline characteristics of the included population that could explain some of the observed discrepancies, we can observe a similar pattern throughout the databases. Apixaban was the DOAC with the highest persistence. Dabigatran had the highest proportion of discontinuers and switchers at 12 months in most databases (EMA/2015/27/PH).

Use of a Novel Silicone-Acrylic Drape with Negative Pressure Wound Therapy in Four Patients with Periwound Skin Breakdown

INTRODUCTION

Negative pressure wound therapy (NPWT) is applied using a foam dressing and an adhesive acrylic drape to create a seal. Removal of this drape can be painful and may play a role in periwound skin breakdown during dressing changes. A novel silicone-acrylic hybrid drape (HA-drape) has been developed for use with NPWT to allow for repositioning after initial placement and easier removal.

OBJECTIVE

This retrospective case series reports on the use of HA-drape in 4 patients who experienced periwound skin breakdown. The goal was to minimize skin breakdown while maintaining a seal on the dressing.

MATERIALS AND METHODS

 Four patients with mild to moderate periwound skin breakdown were selected to receive NPWT with HA-drape. Negative pressure wound therapy was applied using a reticulated open cell foam dressing followed by placement of HA-drape to create a seal. Negative pressure wound therapy was initiated at -125 mm Hg with dressing changes occurring every 2 days. Wound healing, periwound healing, and patient-reported pain were assessed at dressing changes.

RESULTS

All 4 patients showed significant periwound skin improvement after the first dressing change. All patients reported a decrease in pain with dressing removal.

CONCLUSIONS

In these 4 patients' wounds, use of NPWT with HA-drape resulted in intact periwound with improved periwound skin healing and reduction in patient-reported pain associated with dressing changes.

Phase II study of atezolizumab in advanced alveolar soft part sarcoma (ASPS)

11519

Background: ASPS constitutes < 1% of soft tissue sarcomas and frequently presents in adolescents and young adults. There are no approved therapies for ASPS. We are currently evaluating the clinical activity of atezolizumab (atezo), an anti-PD-L1 antibody, in patients (pts) with advanced ASPS. Methods: This is a multicenter, open-label, single-arm phase II study where atezo is administered at a fixed dose of 1200 mg in adults or 15 mg/kg (1200 mg max) in pediatric pts age ≥2 once Q21 days. The primary objective is to determine the objective response rate (ORR) of atezo using RECIST 1.1. Secondary objectives include duration of response and correlating response with the immune effects of atezo in blood and paired tumor biopsies (pre- and post-treatment). Tumor specimens were analyzed with multiplex immunofluorescence immuno-oncology panels to quantify CD8+, PD-1+, and PD-L1+ cells/mm2 in the tumor microenvironment. CD8+ density was calculated as the total number of CD8+ cells divided by the entire area (mm2) of the tumor and invasive margins of the biopsy. Results: As of February 4, 2021, 44 pts have been enrolled. The median age in the study was 31 years (range, 12–70) with equal male: female distribution. 54.5% of pts were Caucasian. Baseline ECOG ≤1 was present in 97.7%. The median time on study was 11.5 months (range, 0.8–40.3 months). At data cutoff, response evaluation was available for 43 pts with an ORR of 37.2% (16/43). One pt experienced a complete response and 15 pts experienced a partial response (PR), of which 14 were confirmed. The median time to confirmed response was 3.5 months (range, 2.1–14.9 months). The median duration of confirmed response was 16.5 months (range, 4.9–38.1 months). Stable disease (SD) was present in 58.1% (25/43). One or more grade 3 adverse events potentially related to atezo were identified in 16.3% (7/43) pts. These include diarrhea, hypothyroidism, transaminitis, anemia, vertigo, extremity pain, myalgia, pneumonitis, rash, and stroke (n = 1 each). No grade 4 or 5 events have been reported. Among 8 cases with evaluable biopsy pairs, both baseline and C3D1 specimens in all cases demonstrated CD8+ T cell infiltration and PD-L1 expression. PD-1 expression was detected at baseline in 5 cases and at C3D1 in 7 cases. In 6 cases (3 SDs and 3 PRs), treatment did not change CD8+ cell density. In the other 2 cases (both PRs), CD8+ density increased > 3x above baseline by C3D1. Analysis of T cell activation using pharmacodynamic response biomarkers, along with whole exome and RNA-seq to evaluate the genomic and transcriptomic landscape of ASPS, are ongoing. Conclusions: Atezo is well tolerated and demonstrates promising single agent activity with durable responses in advanced ASPS. Preliminary tumor biomarker analysis confirms the presence of multiple PD-1/PD-L1 immune checkpoint (IC) components, indicating that advanced ASPS is an ideal candidate for therapeutic IC inhibition. Funded by NCI Contract No HHSN261200800001E. Clinical trial information: NCT03141684.

Phase 1 study of Z-endoxifen in patients with advanced gynecologic, desmoid, and hormone receptor-positive solid tumors

Background: Differential responses to tamoxifen may be due to inter-patient variability in tamoxifen metabolism into pharmacologically active Z-endoxifen. Z-endoxifen administration was anticipated to bypass these variations, increasing active drug levels, and potentially benefitting patients responding sub-optimally to tamoxifen.

Materials and Methods: Patients with treatment-refractory gynecologic malignancies, desmoid tumors, or hormone receptor-positive solid tumors took oral Z-endoxifen daily with a 3+3 phase 1 dose escalation format over 8 dose levels (DLs). Safety, pharmacokinetics/pharmacodynamics, and clinical outcomes were evaluated.

Results: Thirty-four of 40 patients were evaluable. No maximum tolerated dose was established. DL8, 360 mg/day, was used for the expansion phase and is higher than doses administered in any previous study; it also yielded higher plasma Z-endoxifen concentrations. Three patients had partial responses and 8 had prolonged stable disease (≥ 6 cycles); 44.4% (8/18) of patients at dose levels 6–8 achieved one of these outcomes. Six patients who progressed after tamoxifen therapy experienced partial response or stable disease for ≥ 6 cycles with Z-endoxifen; one with desmoid tumor remains on study after 62 cycles (nearly 5 years).

Conclusions: Evidence of antitumor activity and prolonged stable disease are achieved with Z-endoxifen despite prior tamoxifen therapy, supporting further study of Z-endoxifen, particularly in patients with desmoid tumors.

Ultra-low-dose thoracic CT with model-based iterative reconstruction (MBIR) in cystic fibrosis patients undergoing treatment with cystic fibrosis transmembrane conductance regulators (CFTR)

AIM

To assess the utility of a volumetric low-dose computed tomography (CT) thorax (LDCTT) protocol at a dose equivalent to a posteroanterior (PA) and lateral chest radiograph for surveillance of cystic fibrosis (CF) patients.

MATERIALS AND METHODS

A prospective study was undertaken of 19 adult patients with CF that proceeded to LDCTT at 12 and 24 months following initiation of ivacaftor. A previously validated seven-section, low-dose axial CT protocol was used for the 12-month study. A volumetric LDCTT protocol was developed for the 24-month study and reconstructed with hybrid iterative reconstruction (LD-ASIR) and pure iterative reconstruction (model-based IR [LD-MBIR]). Radiation dose was recorded for each scan. Image quality was assessed quantitatively and qualitatively, and disease severity was assessed using a modified Bhalla score. Statistical analysis was performed and p-values of <0.05 were considered statistically significant.

RESULTS

Volumetric LD-MBIR studies were acquired at a lower radiation dose than the seven-section studies (0.08 ± 0.01 versus 0.10 ± 0.02 mSv; p=0.02). LD-MBIR and seven-section ASIR images had significantly lower levels of image noise compared with LD-ASIR images (p<0.0001). Diagnostic acceptability scores and depiction of bronchovascular structures were found to be acceptable for axial and coronal LD-MBIR images. LD-MBIR images were superior to LD-ASIR images for all qualitative parameters assessed (p<0.0001). No significant change was observed in mean Bhalla score between 1-year and 2-year studies (p=0.84).

CONCLUSIONS

The use of a volumetric LDCTT protocol (reconstructed with pure IR) enabled acquisition of diagnostic quality CT images, which were considered extremely useful for surveillance of CF patients, at a dose equivalent to a PA and lateral chest radiograph.

Molecular Profiling-Based Assignment of Cancer Therapy (NCI-MPACT): A Randomized Multicenter Phase II Trial

This trial assessed the utility of applying tumor DNA sequencing to treatment selection for patients with advanced, refractory cancer and somatic mutations in one of four signaling pathways by comparing the efficacy of four study regimens that were either matched to the patient's aberrant pathway (experimental arm) or not matched to that pathway (control arm).

MATERIALS AND METHODS

Adult patients with an actionable mutation of interest were randomly assigned 2:1 to receive either (1) a study regimen identified to target the aberrant pathway found in their tumor (veliparib with temozolomide or adavosertib with carboplatin [DNA repair pathway], everolimus [PI3K pathway], or trametinib [RAS/RAF/MEK pathway]), or (2) one of the same four regimens, but chosen from among those not targeting that pathway.

RESULTS

Among 49 patients treated in the experimental arm, the objective response rate was 2% (95% CI, 0% to 10.9%). One of 20 patients (5%) in the experimental trametinib cohort had a partial response. There were no responses in the other cohorts. Although patients and physicians were blinded to the sequencing and random assignment results, a higher pretreatment dropout rate was observed in the control arm (22%) compared with the experimental arm (6%; P = .038), suggesting that some patients may have had prior tumor mutation profiling performed that led to a lack of participation in the control arm.

CONCLUSION

Further investigation, better annotation of predictive biomarkers, and the development of more effective agents are necessary to inform treatment decisions in an era of precision cancer medicine. Increasing prevalence of tumor mutation profiling and preference for targeted therapy make it difficult to use a randomized phase II design to evaluate targeted therapy efficacy in an advanced disease setting.

Stool microbiome, pH and short/branched chain fatty acids in infants receiving extensively hydrolyzed formula, amino acid formula, or human milk through two months of age

BACKGROUND

Early infant feeding with intact or extensively hydrolyzed (EH) proteins or free amino acids (AA) may differentially affect intestinal microbiota composition and immune reactivity. This multicenter, double-blind, controlled, parallel-group, pilot study compared stool microbiota from Baseline (1-7 days of age) up to 60 days of age in healthy term infants who received mother's own milk (assigned to human milk [HM] reference group) (n = 25) or were randomized to receive one of two infant formulas: AA-based (AAF; n = 25) or EH cow's milk protein (EHF; n = 28). Stool samples were collected (Baseline, Day 30, Day 60) and 16S rRNA genes were sequenced. Alpha (Shannon, Simpson, Chao1) and beta diversity (Bray Curtis) were analyzed. Relative taxonomic enrichment and fold changes were analyzed (Wilcoxon, DESEq2). Short/branched chain fatty acids (S/BCFA) were quantified by gas chromatography. Mean S/BCFA and pH were analyzed (repeated measures ANOVA).

RESULTS

At baseline, alpha diversity measures were similar among all groups; however, both study formula groups were significantly higher versus the HM group by Day 60. Significant group differences in beta diversity at Day 60 were also detected, and study formula groups were compositionally more similar compared to HM. The relative abundance of Bifidobacterium increased over time and was significantly enriched at Day 60 in the HM group. In contrast, a significant increase in members of Firmicutes for study formula groups were detected at Day 60 along with butyrate-producing species in the EHF group. Stool pH was significantly higher in the AAF group at Days 30 and 60. Butyrate increased significantly from Baseline to Day 60 in the EHF group and was significantly higher in study formula groups vs HM at Day 60. Propionate was also significantly higher for EHF and AAF at Day 30 and AAF at Day 60 vs HM. Total and individual BCFA were higher for AAF and EHF groups vs HM through Day 60.

CONCLUSIONS

Distinct patterns of early neonatal microbiome, pH, and microbial metabolites were demonstrated for infants receiving mother's own milk compared to AA-based or extensively hydrolyzed protein formula. Providing different sources of dietary protein early in life may influence gut microbiota and metabolites.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02500563 . Registered July 28, 2015.

Prevalence of type 2 diabetes with stable coronary artery disease but without prior myocardial infarction or stroke and THEMIS-like patients from the SNDS French nationwide claims database

Background

The THEMIS randomized controlled trial showed that patients with stable coronary artery disease and type 2 diabetes mellitus (CAD-T2DM), without prior myocardial infarction (MI) or stroke, and who received ticagrelor plus aspirin, had a lower incidence of ischemic cardiovascular events but a higher incidence of major bleeding than those who received placebo plus aspirin. The number of patients concerned and their characteristics in current practice are not well known.

Purpose

To assess the characteristics of CAD-T2DM adults (≥18 years) without prior MI-stroke, and more specifically, of THEMIS-like patients in a real world setting.

Methods

Cohort within the main scheme of the SNDS (Système National des Données de Santé), the French nationwide claims database, representing about 86% of 66 million people. All CAD-T2DM prevalent patients without prior MI-stroke were identified on January 1st, 2014 (index date) based on a 5-year database history, and followed for two years. The THEMIS-like population included CAD-T2DM patients without prior MI-stroke ≥50 years at index date without renal failure with dialysis, cirrhosis or liver cancer history, as well as no intracranial and gastro-intestinal bleeding for the last 6 months, or anticoagulant or antiplatelet agent 2 months before and after index date. Study prevalence was standardized for the European population for 1,000 adults (‰) using sex and 5-year age classes from Eurostat statistics.

Results

From the 359,595 CAD-T2DM patients identified in the database, 71.8% had no prior MI-stroke (n=258,260), including 24.9% of THEMIS-like patients (n=64,334). CAD-T2DM without prior MI-stroke and THEMIS-like patients had the same mean age of 72 years, with 68% and 66% men, 26% and 25% with more than 4-year CAD and T2DM history, 79% and 76% of hypertension, 28% and 19% of revascularisation procedure, 19% and 11% of peripheral arterial disease, 16% and 9% of heart failure, and 39% and 32% of diabetes complications, respectively. The table below presents prevalence estimation per 1,000 European adults with differences according to both populations, as well as sex and age-classes.

Conclusions

The two populations had similar characteristics, although noting some differences in comorbidities. The THEMIS-like prevalence was estimated to 1.50‰ European adults, representing about a quarter of CAD-T2DM patients without prior MI-stroke.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Study performed with unconditional funding from AstraZeneca

Real world risk of major outcomes for type 2 diabetes with stable coronary artery disease without prior MI or stroke and THEMIS-like patients using the SNDS French nationwide claims database

Background

The THEMIS randomized controlled trial showed that patients with stable coronary artery disease and type 2 diabetes mellitus (CAD-T2DM), without a history of myocardial infarction (MI) or stroke, and who received ticagrelor plus aspirin, had a lower incidence of ischemic cardiovascular events but a higher incidence of major bleeding than those who received placebo plus aspirin. After 3 years of follow-up, the incidence of major outcomes in the placebo arm was 1.8% for ischemic stroke, 3.3% for MI, 4.9% for all-cause death, 9.2% for a composite of all-cause-death, MI or stroke, and 0.38 per 100 patients-years for TIMI major bleedings. The risk of these outcomes is not well known in current practice.

Purpose

To estimate the incidence of major outcomes for CAD-T2DM patients without prior MI-stroke and more specifically for THEMIS-like patients in a real world setting.

Methods

Cohort within the main scheme of the SNDS (Système National des Données de Santé), the French nationwide claims database, representing about 86% of 66 million people. All CAD-T2DM prevalent patients without prior MI-stroke were identified on January 1st, 2014 (inclusion date), based on a 5-year database history, and followed for two years. The THEMIS-like population included CAD-T2DM patients without prior MI-stroke ≥50 years at inclusion date without renal failure with dialysis, cirrhosis or liver cancer history, as well as no intracranial and gastro-intestinal bleeding for the last 6 months, or anticoagulant or antiplatelet agent 2 months before and after inclusion date. The Kaplan-Meier method was used to estimate the 2-year cumulative incidence of all-cause death and a composite of all-cause death, MI and stroke, and the cumulative incidence function, taking into account death as competing risk for other clinical outcomes.

Results

From 258,260 CAD-T2DM patients without prior MI-stroke, 64,334 were included in the THEMIS-like population (24.9%) with the same median age of 72 years, with 68.3% and 65.7% men, respectively. The 2-year cumulative incidence for the CAD-T2DM without prior MI-stroke and THEMIS-like populations was 1.7% and 1.5% for ischemic stroke, 1.7% and 1.3% for MI, 9.5% and 5.3% for heart failure, 4.9% and 3.2% for major bleeding, 13.6% and 9.7% for all-cause death, and 16.2% and 12.0% for the composite outcome, respectively.

Conclusions

In current practice, the median age of the THEMIS-like population was 6 years older than in the THEMIS trial (i.e. 66 years), with an observed risk after 2 years of follow-up, about double for the composite outcome, triple for deaths and quadruple for major bleedings than those of the placebo arm of the trial (estimation after 2 years of follow-up in the THEMIS trial placebo arm assuming constant risk across time according to Kaplan-Meier graph).

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Study performed with unconditional funding from AstraZeneca

Innovating With the Times: Pathology Education in Context of Physician Burnout

Introduction/Objective

Learning a boundless volume of information, preparing for multiple exams, and getting involved in several other academic activities are just a few things that the current medical students need to tackle in a finite duration. While these challenges encourage learners to be their best, and prepare them for their careers as future physicians, they can also result in a largely unnoticed issue — burnout. Curricular reform targeted at developing skills to mitigate burnout is the need of the hour. To combat this issue in the pathology classroom, we used our tried and tested strategy of algorithms in combination with fun activities, particularly keyword mnemonics, to evaluate the impact on reducing burnout in medical students.

Methods

Lectures were delivered and recorded for students of semester 4 and 5, and sample algorithms and mnemonics were included. We also used pathophysiology case sessions comprising clinical vignettes and questions. Students were divided into small groups to solve questions and had to frame their own algorithms and mnemonics to help them. The method’s effectiveness was assessed using performance in past and current exams. Feedback was performed to gauge students’ perceptions

Results

Feedback evaluation showed that 86% of students indicated that algorithms and mnemonics not only strengthened the rote memory but also helped lessen the stress during exam preparation. 59% of students expressed that teamwork made it easier and fun to work. Almost 11% felt that mnemonics should be included as part of new lectures but they found it difficult and ineffective to make their own. Further assessment will be performed to analyze the strategy’s impact on burnout.

Conclusion

Classroom traditions that encourage shared problem-solving and decision-making leads to reduced burnout rates among medical students, with the added benefit of enhanced retention of complicated material and improved clinical correlation capabilities. The relationship between stress and memory is well-documented, and feedback revealed that this technique helped alleviate negative stress on the students. Our project underlines the essence of research studies to minimize burnout in medical students, for design and development of future interventions to prevent burnout at the outset in the training of future physicians.

Brush Licking Toxicity: Toxin & Microorganism Growth On Paint Brushes

Introduction/Objective

A common practice utilized by painters is licking their paint brush bristles to form a sharp point for fine lines and details. Literature details artists careless around their mediums have a higher incidence of becoming ill, yet if their brushes harbor any toxic substances or pathogenic bacteria it is currently unknown. Therefore, this study aims to determine if there is risk associated with brush licking, by determining if pathogenic bacteria and/or heavy metals are present on the brushes of volunteer artists.

Methods

We obtained 17 volunteer paint brushes and inoculated specialized collection and transport media (E- Swab, BD Biosciences, San Jose, CA) while the volunteer completed a qualitative de-identified survey indicating brush licking status. Brushes were swirled in the E-swab collection tube, then subbed to sheep blood agar plates and chocolate agar plates for bacteria growth analysis. Matrix-assisted laser desorption/ionization time-of-flight (MALDI- TOF) technology was used for identification. With the remaining E-Swab media, lead (3M, St. Paul, MN) and arsenic (HACH, Loveland, CO) testing using commercial kits was done. MALDI-TOF identification and heavy metal testing results were then compared to survey results.

Results

One of 17 specimens (6%) had pathogenic bacteria identified (Pseudomonas aeruginosa). This specimen’s survey also indicated routine brush licking. The sensitivity and specificity of MALDI-TOF for Pseudomonas aeruginosa is 96.67% and 97.87%, respectively. The remaining 16/17 (94%) had normal flora present. Importantly, the specimen containing Pseudomonas aeruginosa also had high levels of arsenic at 50 ppb. None of the specimen tested contained lead.

Conclusion

Our results indicated there is indeed some risk associated with brush licking. However, due to the small sample size, statistical significance could not be determined. Nonetheless, with the lack of knowledge surrounding this subject, it is beneficial to further explore and educate painters on the toxicities of brush licking.

Radiation dose tracking in computed tomography: Red alerts and feedback. Implementing a radiation dose alert system in CT

INTRODUCTION

This study investigates instances of elevated radiation dose on a radiation tracking system to determine their aetiologies. It aimed to investigate the impact of radiographer feedback on these alerts.

METHODS

Over two six-month periods 11,298 CT examinations were assessed using DoseWatch. Red alerts (dose length products twice the median) were identified and two independent reviewers established whether alerts were true (unjustifiable) or false (justifiable). During the second time period radiographers used a feedback tool to state the cause of the alert. A Chi-Square test was used to assess whether red alert incidence decreased following the implementation of radiographer feedback.

RESULTS

There were 206 and 357 alerts during the first and second time periods, respectively. These occurred commonly with CT pulmonary angiography, brain, and body examinations. Procedural documentation errors and patient size accounted for 57% and 43% of false alerts, respectively. Radiographer feedback was provided for 17% of studies; this was not associated with a significant change in the number of alerts, but the number of true alerts declined (from 7 to 3) (χ2 = 4.14; p = 0.04).

CONCLUSION

Procedural documentation errors as well as patient-related factors are associated with false alerts in DoseWatch. Implementation of a radiographer feedback tool reduced true alerts.

IMPLICATIONS FOR PRACTICE

The implementation of a radiographer feedback tool reduced the rate of true dose alerts. Low uptake with dose alert systems is an issue; the workflow needs to be considered to address this.

A phase I pharmacokinetic study of belinostat in patients with advanced cancers and varying degrees of liver dysfunction

AIMS

The histone deacetylase inhibitor belinostat has activity in various cancers. Because belinostat is metabolized by the liver, reduced hepatic clearance could lead to excessive drug accumulation and increased toxicity. Safety data in patients with liver dysfunction are needed for this drug to reach its full potential in the clinic.

METHODS

We performed a phase 1 trial to determine the safety, maximum tolerated dose (MTD) and pharmacokinetics of belinostat in patients with advanced cancer and varying degrees of liver dysfunction.

RESULTS

Seventy-two patients were enrolled and divided into cohorts based on liver function. In patients with mild dysfunction, the MTD was the same as the recommended phase 2 dose (1000 mg/m2 /day). Belinostat was well tolerated in patients with moderate and severe liver dysfunction, although the trial was closed before the MTD in these cohorts could be determined. The mean clearance of belinostat was 661 mL/min/m2 in patients with normal liver function, compared to 542, 505 and 444 mL/min/m2 in patients with mild, moderate and severe hepatic dysfunction. Although this trial was not designed to assess clinical activity, of the 47 patients evaluable for response, 13 patients (28%) experienced stable disease.

CONCLUSION

While a statistically significant difference in clearance indicates increased belinostat exposure with worsening liver function, no relationship was observed between belinostat exposure and toxicity. An assessment of belinostat metabolites revealed significant differences in metabolic pathway capability in patients with differing levels of liver dysfunction. Further studies are needed to establish formal dosing guidelines in this patient population.

A phantom study of the performance of model-based iterative reconstruction in low-dose chest and abdominal CT: When are benefits maximized?

INTRODUCTION

The aim of this study was to assess and compare the effects of CT image reconstruction techniques on low-dose CT image quality using phantoms.

METHODS

Anthropomorphic torso and spatial/contrast-resolution phantoms were scanned at decreasing tube currents between 400 and 10 mA. CT thorax and abdomen/pelvis series were reconstructed with filtered back projection (FBP) alone, combined 40% adaptive statistical iterative reconstruction & FBP (ASIR40), and model-based iterative reconstruction (MBIR) [(resolution-preference 05 (RP05) and RP20 in the thorax and RP05 and noise-reduction 05 (NR05) in the abdomen)]. Two readers rated image quality quantitatively and qualitatively.

RESULTS

In thoracic CT, objective image noise on MBIR RP05 data sets outperformed FBP at 200, 100, 50 and 10 mA and outperformed ASIR40 at 50 and 10 mA (p < 0.001). MBIR RP20 outperformed FBP at 50 and 10 mA and outperformed ASIR40 at 10 mA (p < 0.001). Compared with both FBP and ASIR40, MBIR RP05 demonstrated significantly better signal-to-noise ratio (SNR) at 10 mA. In abdomino-pelvic CT, MBIR RP05 and NR05 outperformed FBP and ASIR at all tube current levels for objective image noise. NR05 demonstrated greater SNR at 200, 100, 50 and 10 mA and RP05 demonstrated greater SNR at 50 and 10 mA compared with both FBP and ASIR. MBIR images demonstrated better subjective image quality scores. Spatial resolution, low-contrast detectability and contrast-to-noise ratio (CNR) were comparable between image reconstruction techniques.

CONCLUSION

CTs reconstructed with MBIR have lower image noise and improved image quality compared with FBP and ASIR. These effects increase with reduced radiation exposure confirming optimal use for low-dose CT imaging.

P1664Pharmacological treatment patterns in heart failure: a real world cohort study

Background

Although the efficacy and safety of existing therapies of heart failure (HF) have been demonstrated in clinical trials in the last 35 years, little is known about the treatment patterns of HF in clinical practice, especially in France.

Objectives

To describe the treatment initiation patterns and the subsequent treatment changes among HF patients, in the first year following an incident hospitalisation for HF, in a French real-world setting.

Methods

A cohort of patients aged 40 years old and older, with an incident hospitalisation for HF between January 1, 2008 and December 31, 2013, was identified in the EGB, a 1/97 permanent random sample of the French nationwide claims database. All patients who died during the index hospitalization or with a period of at least 3 consecutive months with no healthcare dispensing recorded were excluded. All included patients were followed one year. HF drugs of interest were: beta blockers (BB), angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARBs), aldosterone antagonists (AA), diuretics, digoxin or ivabradine. Drug exposure was assessed quarterly using a Proportion of Days Covered >66% (>60 days out of the 90 days of the quarter covered by the treatment of interest), by considering HF drugs individually or in combination. Drug changes were assessed between each quarter over the first year of follow-up.

Results

Between 2008 and 2013, 7,387 from the EGB were included in the cohort study. The mean age at baseline was 77.7 years (±12.0 years) and 51.6% were women. During the follow-up, 24.4% of patients died and 20% did not receive any HF treatment. During the first quarter following initial hospitalisation, 42.7% of patients had diuretics, 26.0% had BB, 25.7% had ACEI, 7.4% had ARB, 7.6% had AA, 4.7% had digoxin and 1.3% had ivabradine. the most frequent combination was BB/ACE/ARB (23.4%). These proportions remained globally constant in each quarter of the follow-up. The main change occurred between thee first and the second quarter and concerned 53.1% of the initially untreated patients; by the second quarter, 22.2% of them initiated a BB/ACI/ARB combination, 13% a diuretic alone, 7.4% a BB and 4.9% a BB/ACI/ARB/AA combination.

Conclusion

This study provides precious information on treatment patterns after an initial hospital admission for HF at a time when new treatments for HF are emerging.

Acknowledgement/Funding

None

Interstitial lung disease in patients with common variable immunodeficiency disorders: several different pathologies?

Various reports of disease-related lung pathologies in common variable immunodeficiency disorder (CVID) patients have been published, with differing histological and high-resolution computed tomography (HRCT) findings. Data were extracted from the validated Oxford Primary Immune Deficiencies  Database (PID) database (1986-2016) on adult, sporadic CVID patients with suspected interstitial lung disease (ILD). Histology of lung biopsies was studied in relation to length of follow-up, clinical outcomes, HRCT findings and chest symptoms, to look for evidence for different pathological processes. Twenty-nine CVID patients with lung histology and/or radiological evidence of ILD were followed. After exclusions, lung biopsies from 16 patients were reanalysed for ILD. There were no well-formed granulomata, even though 10 patients had systemic, biopsy-proven granulomata in other organs. Lymphocytic infiltration without recognizable histological pattern was the most common finding, usually with another feature. On immunochemistry (n = 5), lymphocytic infiltration was due to T cells (CD4 or CD8). Only one patient showed B cell follicles with germinal centres. Interstitial inflammation was common; only four of 11 such biopsies also showed interstitial fibrosis. Outcomes were variable and not related to histology, suggesting possible different pathologies. The frequent nodules on HRCT were not correlated with histology, as there were no well-formed granulomata. Five patients were asymptomatic, so it is essential for all patients to undergo HRCT, and to biopsy if abnormal HRCT findings are seen. Internationally standardized pathology and immunochemical data are needed for longitudinal studies to determine the precise pathologies and prognoses in this severe complication of CVIDs, so that appropriate therapies may be found.

Stool Microbiota in Infants Receiving Extensively Hydrolyzed Formula, Amino Acid Formula, or Human Milk Through Two Months of Age (FS04-07-19)

Objectives

Infant feeding practices play a central role in development of gut microbiome and community structure. Our goal was to test the hypothesis that diets with intact or extensively hydrolyzed proteins or free amino acids may differentially affect the intestinal microbiota composition and immune reactivity.

Methods

This multicenter, double-blind, controlled, parallel-group, pilot study compared stool microbiota outcomes from Baseline (1-7 days of age) up to 60 days of age in healthy term infants. Infants received mother's own milk (assigned to human milk [HM] reference group) (n = 25) or were randomized to receive one of two infant formulas: amino-acid based (AAF; n = 25) or extensively hydrolyzed cow's milk protein (EHF; n = 28). Neither study formula included added Lactobacillus rhamnosus GG. DNA was extracted (Baseline, Day 30, Day 60), 16S rRNA genes were amplified and sequenced (Illumina MiSeq), and exact amplicon sequence variants (ASV) were assigned using the DADA2 model. Alpha (Shannon, Simpson, Chao1) and beta diversity (Bray Curtis distance) and differential abundance in taxa were analyzed. Relative ASV enrichment (Baseline vs Day 60) was visualized using heat maps and taxa abundance was analyzed by DESEq2 in R (ver 3.4.3).

Results

Complete stool data (all study time points) were available for 49 participants. Baseline alpha diversity measures were similar among groups. The HM group remained stable throughout the study. However, alpha diversity measures by Day 60 were significantly higher for AAF and EHF groups compared to HM. Significant group differences in beta diversity at Day 60 were detected (P < 0.001); AAF and EHF clustered more closely compared to the HM group. Relative Bifidobacterium abundance increased over time and was significantly enriched at Day 60 in the HM group (Figure, A). At Day 60, a significant increase in members of Firmicutes was detected for AAF and EHF groups; a decrease in Enterobacteriaceae (Escherichia) was observed for EHF (Figure, B).

Conclusions

Distinct patterns of early neonatal microbiome establishment were demonstrated for infants receiving mother's own milk compared to amino acid-based or extensively hydrolyzed protein infant formulas. Providing different sources of dietary protein early in life may impact gut microbiome development.

Funding Sources

Mead Johnson Pediatric Nutrition Institute.

Supporting Tables, Images and/or Graphs

Stool pH and Short/Branched Chain Fatty Acids in Infants Receiving Extensively Hydrolyzed Formula, Amino Acid Formula, or Human Milk Through Two Months of Age (P11-076-19)

Objectives

Infant feeding influences early development of the gut microbiome, colonization pattern, and community structure. Metabolites, including short- and branched-chain fatty acids (S/BCFA) (e.g., butyrate, propionate), produced by colonic bacteria serve as signaling molecules, influence immunity, and reduce luminal pH in the gastrointestinal environment. The objective of this study was to evaluate stool S/BCFA and pH in infants fed with different sources of dietary protein.

Methods

In this multicenter, double-blind, controlled, parallel-group, pilot study, healthy term infants were randomized to receive one of two infant formulas (IF): amino-acid based (AAF; n = 25) or extensively hydrolyzed cow's milk protein (EHF; n = 28) from Baseline (1-7 days of age) up to 60 days of age. A human milk reference group (HM; n = 25) received mother's own milk over the same period. Diethyl ether extractions of S/BCFA from stool samples (Baseline, Day 30, and Day 60) were quantified by gas chromatography (Clarus 580; PerkinElmer) using a fused silica capillary column (Nukol 30m × 0.25mm id × 0.25μm film). Mean stool S/BCFA (μmol/g) and pH were analyzed by repeated measures analysis of variance (ANOVA).

Results

Complete stool data (all study time points) were available for 49 participants. Stool pH (∼6) was similar among groups at Baseline with no significant changes for HM and EHF groups through Day 60. The AAF group was significantly higher at Days 30 and 60 (Figure 1). Total SCFA were similar for all groups through Day 60. Butyrate increased significantly from Baseline to Day 60 in the EHF group (P = 0.026) and was significantly higher vs HM at Days 30 and 60 (P = 0.0009 and 0.0004 respectively). Butyrate was significantly higher for AAF vs HM at Day 60 only (P = 0.038). Propionate was significantly higher for EHF and AAF at Day 30 (P = 0.0009 and < 0.0001 respectively) and AAF only at Day 60 (P = 0.005) vs HM. Total and individual BCFA increased for AAF and EHF groups vs HM through Day 60.

Conclusions

Distinct patterns of pH and microbial metabolites were demonstrated for infants receiving mother's own milk compared to amino acid-based or extensively hydrolyzed protein formula. Providing different sources of dietary protein early in life may influence gut microbiota and metabolites.

Funding Sources

Mead Johnson Pediatric Nutrition Institute.

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