Nocturnal agitation: From sleep state dissociation to sleep-related dissociative state

Nocturnal agitation refers to a broad spectrum of symptoms from simple movements to aggressive behaviors with partial or complete loss of awareness. An accurate identification of its etiology is critical for appropriate therapeutic intervention. In children and young adults, distinguishing between non-rapid eye movement (NREM) sleep parasomnias and psychogenic non-parasomniac manifestations, a condition known as sleep-related dissociative disorder (SRDD), can be challenging. This review aims to summarize current clinical, neurophysiological, and epidemiological knowledge on NREM parasomnia and SRDD, and to present the pathophysiological hypotheses underlying these nocturnal manifestations. Sleepwalking, sleep terror and confusional arousals are the three main presentations of NREM parasomnias and share common clinical characteristics. Parasomniac episodes generally occur 30minutes to three hours after sleep-onset, they are usually short, lasting no more than few minutes and involve non-stereotyped, clumsy behaviors with frequent amnesia. The prevalence of NREM parasomnia decreases from 15-30% in children to 2-4% in adults. Parasomniac episodes are incomplete awakening from the deepest NREM sleep and are characterized by a dissociated brain activity, with a wake-like activation in motor and limbic structures and a preserved sleep in the fronto-parietal regions. SRDD is a less known condition characterized by dramatic, often very long episodes with frequent aggressive and potentially dangerous behaviors. SRDD episodes frequently occur in quiet wakefulness before falling asleep. These dissociative manifestations are frequently observed in the context of psychological trauma. The pathophysiology of SRDD is poorly understood but could involve transient changes in brain connectivity due to labile sleep-wake boundaries in predisposed individuals. We hypothesize that SRDD and NREM parasomnia are forms of sleep-related dissociative states favored by a sleep-wake state dissociation during sleep-onset and awakening process, respectively.

Evaluation of hypersomnolence: From symptoms to diagnosis, a multidimensional approach

Hypersomnolence is a major public health issue given its high frequency, its impact on academic/occupational functioning and on accidentology, as well as its heavy socio-economic burden. The positive and aetiological diagnosis is crucial, as it determines the therapeutic strategy. It must consider the following aspects: i) hypersomnolence is a complex concept referring to symptoms as varied as excessive daytime sleepiness, excessive need for sleep, sleep inertia, or drowsiness, all of which warrant specific dedicated investigations; ii) the boundary between physiological and abnormal hypersomnolence is blurred, since most symptoms can be encountered in the general population to varying degrees without being considered as pathological, meaning that their severity, frequency, context of occurrence and related impairment need to be carefully assessed; iii) investigation of hypersomnolence relies on scales/questionnaires as well as behavioural and neurophysiological tests, which measure one or more dimensions, keeping in mind the possible discrepancy between objective and subjective assessment; iv) aetiological reasoning is driven by knowledge of the main sleep regulation mechanisms, epidemiology, and associated symptoms. The need to assess hypersomnolence is growing, both for its management, and for assessing the efficacy of treatments. The landscape of tools available for investigating hypersomnolence is constantly evolving, in parallel with research into sleep physiology and technical advances. These investigations face the challenges of reconciling subjective perception and objective data, making tools accessible to as many people as possible and predicting the risk of accidents.

Detecting and characterizing special nuclear material for nuclear nonproliferation applications

There is an urgent need for new, better instrumentation and techniques for detecting and characterizing special nuclear material (SNM), i.e., highly enriched uranium and plutonium. The development of improved instruments and techniques requires experiments performed with the SNM itself, which is of limited availability. This paper describes the findings of experiments performed at the National Criticality Experiments Research Center conducted using new instruments and techniques on unclassified, kg-quantity SNM objects. These experiments, performed in the framework of the Department of Energy, National Nuclear Security Administration Consortium for Monitoring, Technology, and Verification, focused on detecting, characterizing, and localizing SNM samples with masses ranging from 3.3 to 13.8 kg, including plutonium and highly enriched uranium using prototype detectors and techniques. The work demonstrates SNM detection and characterization using recently-developed prototype detection systems. Specifically, we present new results in passive detection and imaging of plutonium and uranium objects using gamma-ray and dual particle (fast neutron and gamma-ray) imaging. We also present a new analysis of the delayed neutron emissions during active interrogation of uranium using a neutron generator.

Mechano-electrical interactions and heterogeneities in wild-type and drug-induced long QT syndrome rabbits

BACKGROUND

Electromechanical reciprocity - comprising electro-mechanical (EMC) and mechano-electric coupling (MEC) - provides cardiac adaptation to changing physiological demands. Understanding electromechanical reciprocity and its impact on function and heterogeneity in pathological conditions - such as (drug-induced) acquired long QT syndrome (aLQTS) - might lead to novel insights in arrhythmogenesis. Our aim is to investigate how electrical changes impact on mechanical function (EMC) and vice versa (MEC) under physiological conditions and in aLQTS.

METHODS

To measure regional differences in EMC and MEC in vivo, we used tissue phase mapping cardiac MRI and 24-lead ECG vest in healthy (control) and I_Kr -blocker E-4031-induced aLQTS rabbit hearts. MEC was studied in vivo by acutely increasing cardiac preload, and ex vivo by using voltage optical mapping in beating hearts at different preloads.

RESULTS

In aLQTS, electrical repolarization (heart rate corrected RT-interval, RTn370) was prolonged compared to control (p<0.0001) with increased spatial and temporal RT heterogeneity (p<0.01). Changing electrical function (in aLQTS) resulted in significantly reduced diastolic mechanical function and prolonged contraction duration (EMC), causing increased apico-basal mechanical heterogeneity. Increased preload acutely prolonged RTn370 in both control and aLQTS hearts (MEC). This effect was more pronounced in aLQTS (p<0.0001). Additionally, regional RT-dispersion increased in aLQTS. Motion-correction allowed to determine APD-prolongation in beating aLQTS hearts, but limited motion correction accuracy upon preload-changes prevented a clear analysis of MEC ex vivo.

CONCLUSION

Mechano-induced RT-prolongation and increased heterogeneity were more pronounced in aLQTS than in healthy hearts. Acute MEC effects may play an additional role in LQT-related arrhythmogenesis, warranting further mechanistic investigations.

KEY POINT SUMMARY

Electromechanical reciprocity - comprising excitation-contraction coupling (EMC) and mechano-electric feedback loops (MEC) - is essential for physiological cardiac function. Alterations in electrical and/or mechanical heterogeneity are known to have potentially pro-arrhythmic effects. In this study, we aimed to investigate how electrical changes impact on the mechanical function (EMC) and vice versa (MEC) - both under physiological conditions (control) and in acquired long QT syndrome (aLQTS). We show that changing the electrical function (in aLQTS) results in significantly altered mechanical heterogeneity via EMC and - vice versa - that increasing the preload acutely prolongs repolarization duration and increases electrical heterogeneity, particularly in aLQTS as compared to control. Our results substantiate the hypothesis that LQTS is an 'electro-mechanical' - rather than a 'purely electrical' - disease and suggest that acute MEC effects may play an additional role in LQT-related arrhythmogenesis. Abstract figure legend Electromechanical reciprocity in healthy (control) and acquired long QT syndrome (aLQTS) rabbit hearts. A.-B. Electrical alteration in aLQTS. A. Exemplary ECG traces demonstrating I_Kr -blocker E-4031-induced RT prolongation in aLQTS. B. Visualization of heart rate corrected RTn370 (each color-coded scale includes 20ms) on rabbits' torso in aLQTS compared to control (n = 6 each). C. Electro-mechanical coupling (EMC). Exemplary myocardial longitudinal velocity curve in base (cm/s) during cardiac cycle in control (blue) and aLQTS (red). Indicated are peak amplitudes (AMPsys, AMPdia) and time-to-diastolic peak (TTPdia). D. Mechano-electrical coupling (MEC). Box plots of preload induced changes in repolarization. Comparison between the timepoints baseline (15 sec before increase in preload) and time of the maximal RTn370 increase peak-preload (around 20 sec after NaCl bolus injection). Heart rate corrected RTn370 demonstrates more pronounced RT-changes in aLQTS compared to control (n = 13 each). This article is protected by copyright. All rights reserved.

Abstract P4-01-28: PALBOSPAIN: OBSERVATIONAL ANALYSIS OF FIRST-LINE THERAPY WITH PALBOCICLIB IN PATIENTS WITH HR+/HER2- METASTATIC BREAST CANCER (MBC) IN REAL-LIFE CONDITIONS

INTRODUCTION AND OBJECTIVES Palbociclib associated with hormone therapy (HT) has shown significant benefit in progression-free survival (PFS) and response rate versus HT alone in patients with HR+, HER2- MBC. The PALBOSPAIN study evaluates the efficacy and safety of palbociclib treatment under real-life conditions. The main objective of the study was to assess PFS, and secondary objectives were overall survival (OS), response rate, time to next line of treatment, percentage of dose reduction and safety.

MATERIAL AND METHODS This is an observational, ambispective, multicenter, nation-wide study. Patients diagnosed with HR+/HER2- MBC who had started first-line treatment with palbociclib between November 2017 and November 2019 were included. Patients treated within a clinical trial were excluded, as were those who had received any previous systemic treatment for advanced disease.

RESULTS 762 patients from 35 centers were included. 79% (n=600) were postmenopausal, 54.9% (n=418) had visceral disease, and 30.6% (n=233) had de-novo metastatic disease. Palbocliclib was combined with an aromatase inhibitor in 69.6% of patients and fulvestrant in 30.2% Four groups were established to assess efficacy (table 1): overall population; patients with de-novo metastatic disease (cohort A); patients relapsing &gt;12 months after the end of adjuvant hormonal therapy (cohort B); and patients relapsing within 12 months after the end of adjuvant hormonal therapy (cohort C). Median PFS was 24 months (CI 95%; 25-27) overall and 28 (IC 95%; 23-39), 29 (IC 95%;25-35) and 14 months (IC 95%;11-17) for cohorts a, B and C, respectively. Median overall survival was 42 months (40-NA). The most common side effects were neutropenia (71.3%, grade 3-4 in 52.5%, no episodes of febrile neutropenia), fatigue (38.6%), leucopenia (29.8%), anemia (28.9%), articular pain (19%), and thrombocytopenia (2,2%). 49% (n=385) of patients required dose reduction of palbociclib (one level in 27.6% and two levels in 21.4%).

CONCLUSION In the first two years after its approval in Spain, palbociclib in first line of HR+/HER2- MBC in real-life conditions yielded PFS and safety results comparable to those of PALOMA 2 and PALOMA 3 clinical trials. OS results were poorer, although the population included in this retrospective study is heterogeneous and median survival values have not been reached in some subgroups.

Table 1. Efficay results of palbociclib in real world

Citation Format: Noelia Martínez-Jáñez, Meritxell Bellet Ezquerra, Fernando Henao, Luis Manso, Antonio Antón, Pilar Zamora, Serafin Morales Murillo, Pablo Tolosa, Raquel Andrés, Lourdes Calvo, Elena Galve, Rafael Lopez, Francisco Ayala de la Peña, Sara López-Tarruella, Laia Boronat, Tamara Martos, J. Ignacio Chacón, Isabel Álvarez, Juan de la Haba-Rodríguez, Fernando Moreno Antón. PALBOSPAIN: OBSERVATIONAL ANALYSIS OF FIRST-LINE THERAPY WITH PALBOCICLIB IN PATIENTS WITH HR+/HER2- METASTATIC BREAST CANCER (MBC) IN REAL-LIFE CONDITIONS [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-01-28.

OC-011 PREOPERATIVE BOTULINUM TOXIN A INJECTION CAN ACHIEVE SIMILAR OUTCOMES AS COMPONENT SEPARATION TECHNIQUES IN COMPLEX ABDOMINAL WALL RECONSTRUCTION WITH DECREASED MORBIDITY– A PROPENSITY-SCORED MATCHED STUDY

Aims

CST have been effective in closing large defects but at the sacrifice of fascia and muscle and often increasing complication rates. Preoperative BTA has emerged as an adjunct to aid in fascial closure. Little data exist comparing pre-operative BTA versus CST, and our aim was to do so in a matched study.

Materials & Methods

A 3:1 propensity matched study of patients from a single institution hernia database undergoing AWR from 2016 to 2021 with BTA versus CST was performed based on BMI, defect width, hernia volume, and CDC wound classification. Demographics, operative characteristics, and outcomes were evaluated.

Results

35 BTA vs 105 CST matched patients were analyzed. Hernia defects and volume were large for both the CST and BTA groups (mean size:286.2+179.9cm2vs289.7+162.4cm2;p=0.73) (mean volume:1498.3+2043.4cm3vs2914.7+6539.4cm3;p=0.35). CDC wound classifications were equivalent (CDC3 and 4–39.1%vs40.0%;p=0.97). CST was more frequently performed in European Hernia Society M1 hernias (21% vs 2.9%;p=0.01). The BTA group had fewer surgical site occurrences (SSO) (32.4%vs11.4%;p=0.02) and surgical site infections (SSI) (11.7%vs0%;p=0.04). There was no difference in fascial closure (90.5%vs100%;p=0.11)) or recurrence (12.4%vs2.9%;p=0.10) with similar median follow-up (22.8+29.7vs 9.8+12.7months;p=0.13). In multivariate analysis, BTA was associated with lower rates of SSO (OR=5.3; 95% CI [1.4–34.4]).

Conclusion

There was no difference in fascial closure rates or in hernia recurrence between the two groups. Pre-operative BTA can thereby achieve similar outcomes as CST while concurrently decreasing the frequency of SSO. This similarity in outcomes is upheld when comparing BTA to both ACST and PCST separately.

Assessment of Spanish hospitals involved in the Quality Oncology Practice Initiative program

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Background: Measuring and tracking quality of care is highly relevant in today’s healthcare. The Quality Oncology Practice Initiative (QOPI) program is a referral for evaluating oncology practices worldwide. The ECO Foundation (Excellence and Quality in Oncology), a collaboration of oncology experts from the major Spanish hospitals involved in cancer treatment, reached an agreement with ASCO (American Society of Clinical Oncology) to include Spanish hospitals in its QOPI program. Methods: We analyzed the scores of the QOPI rounds from 14 Spanish hospitals, which submitted their charts from 2016 to 2021, and the measures obtained from 2018 to 2021, regarding the core/symptom, breast, colorectal (CRC) and NSCLC modules, in comparison with the QOPI aggregate measures. Results: Since 2016, 14 Spanish hospitals have participated in the QOPI program, achieving the certification 12 of them, and 3 are in process. Along the years, they have obtained a score over 85%, being 87,41% the worse in 2021, and 92,80% the best in 2020. We also analyzed the outstanding measures from 2018 onwards. The highest scores in Spanish hospitals were for information of infertility risks and chemotherapy intent prior to prescription, and documented plan for oral chemotherapy. However, measures regarding pain addressed, appropriate antiemetic therapy for high- and moderate-emetic-risk antineoplastic agents and action taken to address problems with emotional well-being by the second office visit, were among the lowest scored measures. When we focused in breast and NSCLC modules, Spanish hospitals didn´t show negative values, highlighting in the administration of Tamoxifen or AI within 1 year of diagnosis by patients with AJCC Stage IA (T1c) and IB - III ER or PR positive and in the status documentation for patients with initial AJCC Stage IV or distant metastatic NSCLC. In CRC module, Spanish hospitals showed lower scores in colonoscopy before or within 6 months of curative colorectal resection or completion of primary adjuvant chemotherapy. Conclusions: This study evaluates QOPI scores in Spain, showing that repeated participation enhances quality of care, although there is room for improvement. ECO Foundation will continue supporting Spanish practices to increase their participation aiming of improve oncology care in Spain.

The FLARE score, circulating neutrophils, and association with COVID-19 outcomes in patients with solid tumors

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Background: Inflammation and neutrophils play a central role in severe Covid-19 disease. In previous data, we showed that the FLARE score, combining both tumor and Covid-19-induced proinflammatory status (proinflam-status), predicts early mortality in cancer patients (pts) with Covid-19 infection. We aimed to assess the impact of this score in a larger cohort and characterize the immunophenotype (IF) of circulating neutrophils. Methods: Multicenter retrospective cohort (RC) of pts with cancer and Covid-19 infection across 14 international centers. Circulating inflammatory markers were collected at two timepoints: baseline (-15 to -45d before Covid-19 diagnosis) and Covid-19 diagnosis. Tumor-induced proinflam-status was defined by high dNLR (neutrophils/(leucocytes-neutrophils)>3) at baseline. Covid-19-induced proinflam-status was defined by +100% increase of dNLR between both timepoints. We built the FLARE score combining both Tumor and Infection-induced inflammation: T+/I+ (poor), if both proinflam-status; T+/I- (T-only), if inflammation only due to tumor; T-/I+ (I-only), if inflammation only due to Covid; T-/I- (favorable), if no proinflam-status. The IF of circulating neutrophils by flow cytometry was determined in a unicenter prospective cohort (PC) of pts with cancer during Covid-19 infection and in healthy volunteers (HV). Primary endpoint was 30-day mortality. Results: 524 pts were enrolled in the RC with a median follow-up of 84d (95%CI 78-90). Median age was 69 (range 35-98), 52% were male and 78% had baseline PS <1.Thoracic cancers were the most common (26%). 70% had active disease, 51% advanced stage and 57% were under systemic therapy. dNLR was high in 25% at baseline vs 55% at Covid-19 diagnosis. The median dNLR increase between both timepoints was +70% (IQR: 0-349%); 42% had +100% increase of dNLR. Pts distribution and mortality across FLARE groups is resumed in the Table. Overall mortality rate was 26%. In multivariate analysis, including gender, stage and PS, the FLARE poor group was independently associated with 30-day mortality [OR 5.27; 1.37-20.3]. 44 pts were enrolled in the PC. Median circulating neutrophils were higher in pts with cancer (n=10, 56.7% [IQR: 39-78.4%]) vs HV (n=6, 35.8% [IQR: 25.6-21%]), and particularly higher in pts with cancer and severe Covid-19 infection (n=7, 88.6% [IQR: 80.9-94%] (p=0.003). A more comprehensive characterization of the IF of circulating neutrophils, including Lox1/CD62/CD64, will be presented at ASCO. Conclusions: The FLARE score, combining tumor and Covid-19-induced proinflam-status, can identify the population at higher risk for mortality. A better characterization of circulating neutrophils may help improve the prediction of Covid-19 outcomes in pts with cancer. [Table: see text]

Updated analysis from the ATEZO-BRAIN trial: Atezolizumab plus carboplatin and pemetrexed in patients with advanced nonsquamous non–small cell lung cancer with untreated brain metastases

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Background: Atezolizumab plus chemotherapy was safe and yielded promising clinical outcome as frontline therapy for patients (pts) with advanced NSCLC with untreated brain metastases (BM) in the ATEZO-BRAIN study (NCT03526900). Methods: A multicenter single-arm phase II trial with a Bayesian design for evaluating the safety and efficacy of atezolizumab plus carboplatin with pemetrexed every 3 weeks for 4-6 cycles, followed by maintenance with pemetrexed plus atezolizumab in pts with stage IV non-squamous NSCLC without EGFR or ALK genetic alterations and untreated BM. Pts not presented neurologic symptoms at baseline; but anticonvulsants and dexamethasone (DXM) ≤ 4mg qd were allowed. Co-primary endpoints were safety and investigator-assessed progression-free survival (PFS) at 12 weeks according to RANO-BM and RECIST v1.1 for brain and systemic disease, respectively. Here we present the final data and an exploratory analysis based on PD-L1 expression and corticosteroid treatment at baseline. Results: Out of 40 pts included in the study, 22 (55%) were receiving DXM at baseline and 20 (50%) had positive expression of PD-L1. Sixteen (40%) pts had confirmed intracranial response based on RANO-BM (12 PR, 4 CR) and 19 (47.5%) pts achieved systemic response (all PR). Only 4 pts had discordant responses between the body and the brain. No differences were observed in the overall systemic and intracranial response rate according to the PD-L1 expression or the use of corticosteroids at baseline. As of December 31, 2021 (median follow-up, 20 months), the updated median (95% CI) systemic PFS was 8.9 (6.7 to 13.8) and intracranial PFS was 6.9 (4.7 to 11.9). Median (95% CI) OS was 13.6 (9.72 to not reached) and estimated 2-year OS rate (95% CI) was 30.5% (18.4 to 50.4). Median (95%CI) OS was longer for PD-L1 positive pts (16.2; 10.3 to not reached) compared to PD-L1 negative pts (10.7; 7.6 to not reached) but differences were not statistically significant due to the limited statistical power (HR = 0.99; 95% CI 0.35 to 2.12). No significant differences in OS were observed between pts receiving or not baseline DXM treatment. Treatment was well tolerated and no grade 5 toxicities were observed. Conclusions: In this updated analysis, treatment with atezolizumab plus carboplatin and pemetrexed yields a promising 2-year OS rate and intracranial response rate in patients with untreated BM from NSCLC, regardless of treatment with corticosteroids at baseline and PD-L1 expression. Clinical trial information: NCT03526900.

Beyond tobacco - the secondary impact of substance misuse in chronic obstructive lung disease

BackgroundChronic obstructive lung disease, specifically chronic asthma and COPD, impacts more than 500 million adults worldwide, and is associated with high healthcare spending and significant disease-related morbidity. While the direct impact of substance use disorder is well documented, little is known about the indirect impact of substance misuse within this patient population. The healthcare cost and indirect morbidity secondary to substance misuse in obstructive lung disease has yet to be quantified.ObjectiveTo determine the indirect impact of substance misuse on disease severity, healthcare utilization and healthcare costs in patients with chronic obstructive lung disease across the United States.MethodsUtilizing data from the 2012-2015 National Readmissions Database (NRD) patients with a diagnosis of COPD or asthma were identified. Documented substance misuse, rates of hospitalization, frequency of hospital readmission, markers of admission severity and cost were assessed utilizing weighted regression analysis.ResultsA total of 1,087,226 patients with an index admission for asthma or COPD were identified. Substance misuse was documented in 4.0% of patients. Substance misuse was associated with a 30% increase in odds of readmission and a higher cost per index admission. The additional index admission costs totaled $24 million for our cohort.Conclusion Substance misuse is associated with an increase in healthcare utilization and healthcare cost in patients with chronic obstructive lung disease. Targeting substance misuse in this patient population has the potential for significant cost savings to the healthcare system.

Sex-based differences in timely emergency department evaluations for patients with drug poisoning

OBJECTIVES

Unintentional poisoning was the leading cause of injury-related death in the United States in 2017. Prescribed and illicit drugs are the most common cause of poisoning, and timely management in the emergency department (ED) is important. Our aim was to identify any disparities in wait times associated with sex for drug poisoning-related ED visits.

STUDY DESIGN

We examined ED visits using data from the 2009-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS).

METHODS

Drug poisoning-related visits were identified using the International Classification of Diseases, Ninth or Tenth Revision, Clinical Modification codes. Delayed assessment was defined as wait times exceeding the recommended triage time. Weighted logistic regression was used.

RESULTS

The average age was 36 years (standard error = 1.1), 54% female, 87% White and 29% had delayed assessment. Most common drugs were psychotropics (45%) and opioids (32%). Adjusting for race, payment source, urgency, multiple drug types and NSAIDs, females who had poisoning by substances other than opioids had 2.1 times higher likelihood of having a delayed assessment compared with males (odds ratio [95% confidence interval]: 2.1 [1.03-4.2]), although there was no difference between sexes among visits with opioid poisoning (P = 0.27). Neither race (P = 0.23) nor payment source (P = 0.22) were associated with delayed assessment, and the sex association was consistent across these groups.

CONCLUSIONS

Females with non-opioid drug poisoning were more likely to have delayed assessment than men. None of the other demographic factors demonstrated a correlation. Identifying more populations vulnerable to delays in the ED can help guide the development of interventions and policies to expedite care and attenuate existing disparities.

CCR2 Signaling Promotes Brain Infiltration of Inflammatory Monocytes and Contributes to Neuropathology during Cryptococcal Meningoencephalitis

Cryptococcal meningoencephalitis (CM) is a leading cause of central nervous system (CNS) infection-related mortality worldwide, with surviving patients often developing neurological deficiencies. While CNS inflammation has been implicated in the pathogenesis of CM, little is known about the relative contribution of the specific inflammatory/immune pathways to CNS pathology versus fungal clearance. Increased cerebrospinal fluid level of C-C chemokine receptor 2 (CCR2) ligand CCL2 is associated with disease deterioration in patients with CM. Using a murine model, we investigated the role of the CCR2 pathway in the development of CNS inflammation and pathology during CM. We found that CCR2-deficient mice exhibited improved 28-day survival and alleviated neurological disease scores despite a brain fungal burden higher than that of the WT mice. Reduced CM pathology in CCR2-deficient mice was accompanied by markedly decreased neuronal cell death around cryptococcal microcysts and restored expression of genes involved in neurotransmission, connectivity, and neuronal cell structure in the brains. Results show that CCR2 axis is the major pathway recruiting CD45hiCD11b+Ly6C+ inflammatory monocyte to the brain and indirectly modulates the accumulation of CD4+ T cells and CD8+ T cells. In particular, CCR2 axis promotes recruitment of interferon gamma (IFN-γ)-producing CD4+ T cells and classical activation of myeloid cells. In this context, CCR2 deletion limits the immune network dysregulation we see in CM and attenuates neuropathology. Thus, the CCR2 axis is a potential target for interventions aimed to limit inflammatory CNS pathology in CM patients. IMPORTANCE Cryptococcal meningoencephalitis (CM) causes nearly 200,000 deaths worldwide each year, and survivors frequently develop long-lasting neurological sequelae. The high rate of mortality and neurologic sequelae in CM patients indicate that antifungal therapies alone are often insufficient to control disease progression. Here, we reveal that CM disease progression in mice is accompanied by inflammatory monocytes infiltration at the periphery of the infected foci that overlap locally perturbed neuronal function and death. Importantly, we identified that CCR2 signaling is a critical pathway driving neuroinflammation, especially inflammatory monocyte recruitment, as well as CNS pathology and mortality in CM mice. Our results imply that targeting the CCR2 pathway may be beneficial as a therapy complementary to antifungal drug treatment, helping to reduce CNS damage and mortality in CM patients.

The external jugular vein axis: a new anatomical landmark for pre-operative prediction of the location of parotid gland tumours

The relationships between parotid tumours and the facial nerve determine duration of surgical procedure and risks involved. As the division of the facial nerve is not visible using standard imaging techniques, other anatomical landmarks are used to determine the pre-operative location of tumours. This retrospective study aimed to evaluate reliability of the 'external jugular vein axis' compared with other landmarks generally used in imaging, such as the retromandibular vein, Conn's arc, the facial nerve line and the Utrecht line. Forty-eight pre-operative imaging exams of patients who underwent parotid benign tumour surgery between 2010 and 2016 were examined. We determined the location of tumour using the five markers. A pre-operative simulation was compared with the description given by the surgeon intraoperatively, in terms of sensitivity and specificity for each marker. External jugular vein axis and retromandibular vein are the most sensitive markers for locating suprafacial tumours (Se = 1). External jugular vein axis and Conn's arc are the most specific markers for locating suprafacial tumours (Spe = 0.92). External jugular vein axis is reproducible and present on all radiological sections, thereby overcoming any anatomical and nomenclature variations. This landmark appears to be the most representative marker of the dividing branches of the facial nerve.

Scoping health literacy in Latin America

Studies evaluating the influence of health literacy on patient behavior and outcomes suggest a positive relationship between health literacy and health knowledge, health behaviors, and health status. In Latin American countries, studies assessing health literacy are few, regional, and demonstrate considerable variation, with reported rates of adequate health literacy ranging from 5.0% to 73.3%. In this paper, we examine and explore the state of health literacy and efforts to promote it in Latin America. Key challenges to those efforts include socioeconomic inequality, social/geographic isolation, and cultural-, language-, and policy-related barriers, many of which disproportionately affect indigenous populations and others living in rural areas. Greater use of infographics, videos, and mobile apps may enhance health literacy and patient empowerment, especially when language barriers exist. This paper provides strategies and tools for tailored programming, examples of successful health literacy interventions, and policy recommendations to improve health literacy in Latin America, intending to spur additional discussion and action. Centrally organized collaboration across multiple sectors of society, with community involvement, will enhance health literacy and improve health and well-being across Latin America.

Introduction and scaling up of new drugs for drug-resistant TB: experiences from the Americas

The number of multidrug-resistant tuberculosis (MDR-TB) cases reported in the Americas has increased by 21.2%, from 3737 in 2016 to 4791 in 2018. The WHO has been recommending changes on the treatment of DR-TB, moving from long-duration treatment with injectables to a short oral regimen with new drugs such as bedaquiline (BDQ) and delamanid (DLM), in selected cases and only under programmatic conditions. Injectables are no longer recommended by the WHO due to lower efficacy and the increasing seriousness of adverse events. The introduction of new oral drugs for DR-TB received a boost with a global donation of BDQ to some eligible countries, which continues with the countries purchasing drugs through the Pan American Health Organization Strategic Fund. The main challenges in the scaling up of new drugs for DR-TB include low DR-TB detection rate, the slow pace in transitioning to molecular testing and delays in the introduction of new oral short regimens for MDR-TB. The Americas need to accelerate the scale up of new oral treatments, improve detection rates, increase molecular diagnosis of resistance, and ensure the registration and introduction of the shorter treatment regimen in national MDR-TB guidelines.

[Management of emergency department inflows during the COVID-19 outbreak in the CHU of Liege : efficiency of an advanced triage center]

In March 2020, the COVID-19 pandemic started to spread among the Belgian territory. Our university hospital was confronted to the very need of specific reorganizations guided by the implementation of the Hospital Emergency Plan.This article aims to describe the experience of the University Hospital of Liège (CHU Liège) during the COVID-19 outbreak and demonstrates the efficiency of advanced triage centers to regulate hospital admissions from the emergency department (ED).

METHODS

since the beginning of March 2020, the CHU of Liège has implemented specific advanced triage centers to manage patients with SARS-CoV-2 suspected symptoms. The first center was organized inside the hospital but the need of outside structures led to the creation of two centers by the end of March. From March 2 to May 3, data from the different visits at the COVID-19 centers were collected (numbers of admissions, rationale for coming, work up and outcome).

RESULTS

during the study period, 3,094 patients were admitted to the specific COVID-19 centers of the CHU Liège. This represents 3,431 visits among which 337 were classified as readmission visits. The sensitivity and specificity of the triage centers to determine the need for hospitalization were, respectively, estimated at 87,9 % and 93,4 %.

CONCLUSION

our experience tends to demonstrate the role of specific COVID-19 triage centers located very close to the EDs aimed at managing COVID-19 suspected patients in order to actually determine their need for subsequent hospitalization.

Evaluation of Spanish hospitals participating in the Quality Oncology Practice Initiative program

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Background: Measuring and tracking quality of care is highly relevant in today’s healthcare. The Quality Oncology Practice Initiative (QOPI) program is a referral for evaluating oncology practices worldwide. The ECO Foundation (Excellence and Quality in Oncology), a collaboration of oncology experts from the major Spanish hospitals involved in cancer treatment, reached an agreement with ASCO (American Society of Clinical Oncology) to include Spanish hospitals in its QOPI program. Methods: We analyzed the results of the QOPI core module measures from 19 Spanish hospitals submitting their data in nine rounds (from Fall 2015 to Fall 2019). Results: Of the 19 hospitals, 15 participated more than once; none participated in all 9 rounds (2 hospitals participated in 8 rounds). The highest scores were for pathology report confirming malignancy, documenting plan of care for moderate/severe pain and chemotherapy dose, and chemotherapy administered to patients with metastatic solid tumor with performance status undocumented. Measures regarding a summary of chemotherapy treatment, tobacco use cessation counseling, and assessment of patient emotional well-being were among the lowest scored measures. Six of the 15 practices who participated repeatedly achieved a better score in their last round compared to their first. Overall, scores of Spanish hospitals improved from 67.79% in Fall 2015 to 68.91% in Fall 2019. Conclusions: This is the first study to evaluate QOPI scores in Spain; it showed that repeated participation enhances quality of care, although there is room for improvement. The ECO Foundation will continue supporting and engaging with practices to increase their participation in order to improve oncology care and implement strategies that address the areas for improvement.

Canopy position affects photosynthesis and anatomy in mature Eucalyptus trees in elevated CO2

Leaves are exposed to different light conditions according to their canopy position, resulting in structural and anatomical differences with consequences for carbon uptake. While these structure-function relationships have been thoroughly explored in dense forest canopies, such gradients may be diminished in open canopies, and they are often ignored in ecosystem models. We tested within-canopy differences in photosynthetic properties and structural traits in leaves in a mature Eucalyptus tereticornis canopy exposed to long-term elevated CO2 for up to three years. We explored these traits in relation to anatomical variation and diffusive processes for CO2 (i.e., stomatal conductance, gs and mesophyll conductance, gm) in both upper and lower portions of the canopy receiving ambient and elevated CO2. While shade resulted in 13% lower leaf mass per area ratio (MA) in lower versus upper canopy leaves, there was no relationship between leaf Nmass and canopy gap fraction. Both maximum carboxylation capacity (Vcmax) and maximum electron transport (Jmax) were ~ 18% lower in shaded leaves and were also reduced by ~ 22% with leaf aging. In mature leaves, we found no canopy differences for gm or gs, despite anatomical differences in MA, leaf thickness and mean mesophyll thickness between canopy positions. There was a positive relationship between net photosynthesis and gm or gs in mature leaves. Mesophyll conductance was negatively correlated with mean parenchyma length, suggesting that long palisade cells may contribute to a longer CO2 diffusional pathway and more resistance to CO2 transfer to chloroplasts. Few other relationships between gm and anatomical variables were found in mature leaves, which may be due to the open crown of Eucalyptus. Consideration of shade effects and leaf-age dependent responses to photosynthetic capacity and mesophyll conductance are critical to improve canopy photosynthesis models and will improve understanding of long-term responses to elevated CO2 in tree canopies.

Chemokine receptor CXCR3 is required for lethal brain pathology but not pathogen clearance during cryptococcal meningoencephalitis

Cryptococcal meningoencephalitis (CM) is the major cause of infection-related neurological death, typically seen in immunocompromised patients. However, T cell-driven inflammatory response has been increasingly implicated in lethal central nervous system (CNS) immunopathology in human patients and murine models. Here, we report marked up-regulation of the chemokine receptor CXCR3 axis in human patients and mice with CM. CXCR3 deletion in mice improves survival, diminishes neurological deficits, and limits neuronal damage without suppressing fungal clearance. CD4+ T cell accumulation and TH1 skewing are reduced in the CNS but not spleens of infected CXCR3-/- mice. Adoptive transfer of WT, but not CXCR3-/- CD4+ T cells, into CXCR3-/- mice phenocopies the pathology of infected WT mice. Collectively, we found that CXCR3+CD4+ T cells drive lethal CNS pathology but are not required for fungal clearance during CM. The CXCR3 pathway shows potential as a therapeutic target or for biomarker discovery to limit CNS inflammatory damages.

1166 Investigating Social Workers’ Sleep Health Knowledge: Opportunities to Promote Sleep Health Among Underserved Populations

Introduction

Social workers are often front-line psychosocial providers working with underserved populations, many of whom struggle with sleep. They are uniquely positioned to promote sleep health among individuals experiencing health inequities. However, U.S. accredited social work programs do not require sleep health training. We used both quantitative and qualitative methodologies to investigate social work students’: a) sleep health knowledge; b) self-reported sleep quality; c) prior sleep health education; and d) client discussions about sleep, in order to inform the development of a sleep health training for social work students.

Methods

Twenty-five social work students were recruited via a listserv email sent at a Florida university. Participants were asked to complete the Sleep Beliefs Scale (SBS) and the Pittsburgh Sleep Quality Index (PSQI) and then to participate in a one-hour long focus group (3 groups with 6-11 students/group) conducted by experienced qualitative researchers.

Results

Mean age was 27.0±11.5 yrs, 92.0% were female, and 48.0% were non-Hispanic white, 28.0% African American, 16.0% Hispanic, 8.0% other. Only 28.0% indicated that they had ever discussed sleep with clients. Knowledge of healthy sleep behaviors (assessed via the SBS) was moderate on a 0-20 scale (13.88, S.D.= 2.7). Participants had an average PSQI score of 8.8 (SD.=4.0), reported sleeping an average of 6.0 hours (SD=1.6), and mean sleep efficiency of 87.0% (SD=12.0). Themes from focus group data highlight students’ lack of exposure to sleep health training and a dearth of sleep discussions in clinical practice.

Conclusion

Though social work students acknowledged the importance of sleep health promotion, they reported feeling ill-equipped to promote healthy sleep practices due to lack of sleep education. Sleep health training could allow social workers to confidently promote healthy sleep practices among their clients, recognize when appropriate to refer clients for evaluation for sleep disorders, and improve social workers’ own sleep health. An online educational program was subsequently created by study investigators to meet these aims.

Support

American Academy of Sleep Medicine Foundation

1168 Preliminary Impact of a Sleep Health Educational Module for Social Work Students

Introduction

Social workers are well-positioned to promote healthy sleep behaviors among underserved populations; however sleep health training is rarely integrated into social work curriculums. To address this gap, our interdisciplinary team developed a 2-hour online sleep health educational module for social work students. The module was grounded in best e-learning pedagogical principles, and based on qualitative formative research. We tested the initial impact and acceptability of the module.

Methods

We recruited 32 social work students at a Florida University via a departmental listserve. Pre- to post-intervention changes in the Sleep Beliefs Scale (SBS) and the Sleep Practices and Attitudes Questionnaire (SPAQ) were assessed using Wilcoxon Signed-Rank tests. We conducted qualitative research to assess intervention acceptability,and to inform future iterations of the program.

Results

Mean age was 29.5±11.6 yrs, 100% were female, and primarily Non-Hispanic White (41.9%), followed by African American/Black (35.5%), and Hispanic/Latino (22.6%). Results showed pre/post intervention improvements in both the Sleep Beliefs Scale (14.7±2.2 vs.16.9±2.6 [p=.002]; higher score=higher knowledge) and SPAQ (2.1±0.6 to 1.5±0.6 [p=.001]; lower score=higher importance of sleep) indicating improvements in knowledge surrounding healthy sleep behaviors and the importance of sleep for overall health (respectively). Qualitative data supports the intervention’s acceptability and utility. When asked what participants liked best about the module, responses included: “I was educated and am better prepared to offer some insight to my clients and staff”; “..they offer resources we can use for ourselves and our clients;” and “easy to navigage, and full of useful information.” Suggestions for improvement included shortening the module’s length.

Conclusion

Assessment of an online sleep health educational module indicates a promising impact on sleep health knowledge. A larger study is planned to more definitively evaluate the module’s impact and acceptability among social work students.

Support

American Academy of Sleep Medicine Foundation

0750 Nocturnal Sleep Stability and Cerebrospinal Fluid Orexin-A Levels: Sleep and Wake Bouts

Introduction

The orexin (ORX)/hypocretin system stabilizes sleep-wake regulation by sustaining long periods of wakefulness in humans and animals. We aimed to evaluate the relationships between cerebrospinal fluid (CSF) ORX levels and markers of nocturnal sleep stability assessed by polysomnography (PSG) in humans.

Methods

Nocturnal PSG data and CSF ORX levels of 300 drug-free subjects (55% men, 29.9±15.5 years old, mean ORX levels 155.1±153.7 pg/mL) with a complaint of hypersomnolence were collected in the National Reference Center for Narcolepsy, France. Several markers of nocturnal sleep stability were analyzed: wake (WB), sleep bouts (SB), and sleep/wake transitions. Groups were categorized according to ORX levels: two categories (≤110, &gt;110 pg/mL, the current established threshold of ORX-deficiency), and tertiles (≤26,]26;254], &gt;254 pg/mL); and were compared using logistic regression models. Results were adjusted for age, gender and body mass index.

Results

ORX-deficient subjects had more WB, SB, and sleep-wake transitions than the others. The WB duration was longer and the SB duration shorter in ORX-deficient category. The proportion of the shortest WB (30 sec) was lower in the ORX-deficient category whereas the proportion of WB above 1 min 30 sec was higher. The proportion of SB ≤ 14min was higher among ORX-deficient patients, with opposite results for longer SB. Subsequent analyses performed in the population categorized according to tertiles of CSF ORX-A confirmed all these findings, with a strong dose-response effect of ORX levels in post-hoc comparisons. All results remained highly significant in adjusted statistical models.

Conclusion

This study provides a strong evidence of the direct effect of ORX on nocturnal sleep stabilization in humans. WB and SB are reliable markers of nighttime sleep stability, strongly correlated to CSF ORX-A levels in a dose dependent way. These PSG biomarkers are promising to be applied in clinical and research settings.

Support

none

Tuberculosis and HIV coinfection and related collaborative activities in Latin America and the Caribbean

Objective

To inform about the most recent epidemiological trends and integrated programmatic response to tuberculosis (TB) and HIV coinfection in Latin America and the Caribbean (LAC).

Methods

A descriptive review analyzed the most relevant indicators on TB/HIV coinfection in 33 countries in LAC with a cross-sectional and time-trend approach. Data were obtained from publicly available databases and analyzed through simple proportions, weighted means, and risk ratios.

Results

In LAC, during 2017, 80.8% of TB patients were actively screened for HIV, with a 25.6% increase between 2011 and 2017. In the same year, the proportion of TB patients with HIV-positive status was 11.2%, with a small but progressive reduction of 5% since 2011. The provision of antiretroviral therapy and anti-TB medication among TB/HIV coinfected patients for 2017 was at 60%. Only one-third of people living with HIV had access to isoniazid preventive therapy. Overall, the mortality in the TB/HIV cohort has not changed since 2012, hovering at around 20%.

Conclusions

TB/HIV collaborative activities, as the backbone to address TB/HIV coinfection, are being scaled up in LAC and some indicators show a tendency toward improvement; nevertheless, our review shed light on the need to keep strengthening integration of service delivery, joint monitoring and evaluation, and data quality.

Phase III APACT trial of adjuvant nab-paclitaxel plus gemcitabine (nab-P + Gem) versus gemcitabine (Gem) alone for patients with resected pancreatic cancer (PC): Outcomes by geographic region

4515

Background: The APACT trial was one of the largest and most geographically diverse trials of adjuvant chemotherapy for resected PC, allowing for comparison of outcomes by geographic region. In this analysis, we report updated overall survival (OS) results for the intent-to-treat (ITT) population and examine outcomes by geographic region. Methods: Treatment-naive patients with histologically confirmed PC, macroscopic complete resection, Eastern Cooperative Oncology Group performance status 0 or 1, and carbohydrate antigen 19-9 < 100 U/mL were eligible. Stratification factors were resection status (R0/R1) and lymph node status (positive/negative). Treatment was initiated ≤ 12 weeks postsurgery. Patients received nab-P 125 mg/m2 + Gem 1000 mg/m2 or Gem 1000 mg/m2 on days 1, 8, and 15 of six 28-day cycles. The primary endpoint was disease-free survival by independent review. Secondary endpoints were OS and safety. Results: The updated OS analysis (data cutoff date, January 2020) revealed a median OS of 41.8 months with nab-P + Gem compared with 37.7 months with Gem alone (hazard ratio [HR] 0.81; 95% CI, 0.68 - 0.97; nominal P = 0.047; Table). In each geographic region, the median OS with nab-P + Gem was numerically longer than with Gem alone. Conclusions: The updated OS analysis of the ITT population supports the previously reported trend favoring nab-P + Gem. The geographic regional analyses reveal numerically longer OS with nab-P + Gem vs Gem alone and variable outcomes by region; however, the differences do not support the trend observed in the ITT population, potentially due to limited sample sizes. Registration: EudraCT (2013-003398-91). Clinical trial information: NCT01964430 . [Table: see text]

The Function of Brain Th1-like regulatory T cells in Suppressing Lethal Immune Pathology and Neurological Deterioration during Cryptococcus neoformans Meningoencephalitis

Infection-induced inflammation in the brain frequently drives severe immunopathology, resulting in lasting neurological sequelae or high mortality. Cryptococcus neoformans meningoencephalitis (CM) is one of the leading causes of neurological death worldwide. The pathology of CM is increasingly recognized to be driven by brain inflammation, especially in immunocompetent or immune reconstituted patients. The function of FOXP3+ regulatory T (Treg) cells in maintaining immune balance under these conditions is still controversial.

Using a murine CM model, we found that Tregs massively accumulate in the mouse brain, suppressing lethal immune pathology and neurological deterioration during CM. Brain-infiltrating Tregs showed a CD44highCD62Llow activated status similar to effector T cells. Intriguingly, brain Tregs acquire a Th1-like phenotype, expressing transcription factor T-bet, IFN-γ, and chemokine receptor CXCR3. This Th1-like phenotype is critical for Treg accumulation in the brain during CM. Treg depletion using an anti-CD25 antibody intensifies CNS inflammation and results in deteriorated neurological symptoms and increased mortality. Mechanistically, we showed that CNS Tregs regulate activation of recruited monocyte-derived cells as well as cytokine production of T effector cells, both of which promote brain immunopathology during CM. Interestingly, Treg depletion only showed a minor effect on glia activation. Therapeutically, we showed that selectively enhancing Treg frequency through low-dose IL-2 treatment improves mice survival and neurological functions during CM. Our findings suggest that Tregs and their products may provide therapeutic opportunities for neuronal protection during CM.

Comparison Between Integrated Genomic DNA/RNA Profiling and Fluorescence In Situ Hybridization in the Detection of MYC, BCL-2, and BCL-6 Gene Rearrangements in Large B-Cell Lymphomas

OBJECTIVES

To compare fluorescence in situ hybridization (FISH) and a commercially available sequencing assay for comprehensive genomic profiling (CGP) to determine the best approach to identify gene rearrangements (GRs) in large B-cell lymphomas (LBCLs).

METHODS

Comparison of standard-of-care FISH assays (including a two-probe approach for MYC; break-apart and fusion probes) and an integrated genomic DNA/RNA sequencing CGP approach on a set of 69 consecutive LBCL cases.

RESULTS

CGP detected GRs, including those involving MYC (1), BCL-2 (3), and BCL-6 (3), not detected by FISH. FISH detected non-IgH-MYC (4) and BCL-6 (2) GRs that were not detected by CGP. In four instances, standalone CGP or FISH testing would have missed a double-hit lymphoma.

CONCLUSIONS

CGP was superior to FISH in the detection of IgH-MYC rearrangements but was inferior for the detection of non-IgH-MYC rearrangements. Our study demonstrates the rationale for development of a customized approach to identify GRs in LBCLs.

Concordance between blood- and tumor-based detection of RAS mutations to guide therapy in metastatic colorectal cancer

217

Background: The study of RAS using circulating tumor DNA (ctDNA) provides a good alternative for the detection and monitoring of RAS mutations during therapy course. Liquid biopsy has the advantage of being less invasive than conventional tissue biopsy. Therefore, it is necessary to determine the degree of concordance of RAS status between plasma and tissue samples from mCRC patients. Methods: We conducted a study to evaluate RAS concordance in several hospitals in Galicia, Northwest of Spain. We analyzed samples from 380 patients with mCRC in Galicia. RAS genotyping in plasma was performed using OncoBEAM RAS CRC kit, Sysmex and compared with the PyroMark Q24 System, Qiagen for FFPE-tissue analysis. Clinical data were collected from electronical reports from each patient. We analyzed the clinical features that can be related with discordant cases. Results: The overall percent of agreement was 83%, with a positive concordance of 79% (143/180 patients) and a negative concordance of 87% (116/132 patients). Taking into account the clinical features of the patients, those with only liver metastasis showed a higher level of concordance (88,8%) and the highest level was in the group of patients that presented liver metastasis and another location (91,3%). On the other hand, patients with only peritoneal disease showed the lowest level of agreement (68,2%), and the absence of liver metastasis was a significant factor of discordance of RAS (71% vs 28%, p<0.0001). Conclusions: The high overall concordance between plasma and tissue RAS mutation support the liquid biopsy technology as an alternative to tissue testing for RAS characterization in mCRC patients, especially in patients with liver metastasis and less in those with peritoneal disease. These results reinforce the use of liquid biopsy as a non-invasive tool for guiding targeted therapy in our patients.

[Table: see text]

Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults

Attention deficit with or without hyperactivity disorder (ADHD) is one of the most frequent neuropsychiatric disorders, and affects 2-4% of adults. In contrast with many European countries, the identification and management of adult ADHD remains underdeveloped in France, and a subject of controversy. This review provides a practical update on current knowledge about ADHD in adults for French-speaking professionals who have to detect or manage adult patients with ADHD. ADHD is classified as a neurodevelopmental disorder in the recent update of the international diagnostic classification. While symptoms and impairment due to ADHD are frequently severe during childhood, they often evolve as children grow older, with frequent persistent disabilities in adulthood. In adulthood, the clinical presentation, as in childhood, involves the symptom triad of inattention, hyperactivity and impulsivity. However, differences are noted: hyperactivity is more often internalized, symptoms of inattention may be masked by anxiety symptoms or obsessive-like compensation strategies. ADHD is often diagnosed during childhood, but it is not rare for the diagnosis to be made later. Failure to recognise symptoms resulting in misdiagnosis, or alternatively well-developed compensation factors could be two underlying reasons for the long delay until diagnosis. Other symptoms, such as emotional deregulation or executive function-related symptoms are also usually observed in adults. In addition, in adults, ADHD is often associated with other psychiatric disorders (in 80% of cases); this makes the diagnosis even more difficult. These disorders encompass a broad spectrum, from mood disorders (unipolar or bipolar), to anxiety disorders, and other neurodevelopmental disorders and personality disorders, especially borderline and antisocial personality disorder. Substance-use disorders are very common, either as a consequence of impulsivity and emotional dysregulation or as an attempt at self-treatment. Sleep disorders, especially restless leg syndrome and hypersomnolence, could share common pathophysiological mechanisms with ADHD. ADHD and comorbidity-related symptoms are responsible for serious functional impairment, in various domains, leading to academic, social, vocational, and familial consequences. The impact on other psychiatric disorders as an aggravating factor should also be considered. The considerable disability and the poorer quality of life among adults with ADHD warrant optimal evaluation and management. The diagnostic procedure for ADHD among adults should be systematic. Once the positive diagnosis is made, the evaluation enables characterisation of the levels of severity and impairment at individual level. A full examination should also assess medical conditions associated with ADHD, to provide personalized care. In recent years, a growing number of assessment tools have been translated and validated in French providing a wide range of structured interviews and standardized self-report questionnaires for the evaluation of core and associated ADHD symptoms, comorbidities and functional impairment. The treatment of ADHD in adults is multimodal, and aims to relieve the symptoms, limit the burden of the disease, and manage comorbidities. The most relevant and validated psychological approaches are psycho-education, cognitive-behavioural therapy and "third wave therapies" with a specific focus on emotional regulation. Cognitive remediation and neurofeedback are promising strategies still under evaluation. Medications, especially psychostimulants, are effective for alleviating ADHD symptoms with a large effect size. Their safety and tolerance are satisfactory, although their long-term clinical benefit is still under discussion. In France, methylphenidate is the only stimulant available for the treatment of ADHD. Unfortunately, there is no authorization for its use among adults except in continuation after adolescence. Hence the prescription, which is subject to the regulations on narcotics, is off-label in France. This article aims to provide practical considerations for the management of ADHD and associated disorders in adults, in this particular French context.

Development of an MCDA framework for evaluation and positioning of oncological treatments in clinical practice

95

Background: Ensuring that effective innovations are accessible in a timely and affordable manner to all cancer patients is a challenge that stakeholders face today. Several oncology frameworks (ASCO, ESMO, ICER, NCCN) have been developed to define and quantify the value of oncological therapies to support clinicians and patients at the time of selection and as a basis for decision-making. However, current frameworks only define treatment value in terms of clinical benefit, creating a need for one that allows holistic evaluation of treatments and supports decision-making in clinical practice. The ECO Foundation led this study to develop a reflective multi-criteria decision analysis (MCDA) based framework for evaluation and positioning of new oncological drugs from the clinical oncology perspective. Methods: The framework was developed following EVIDEM methodology. Systematic literature review was performed to identify most relevant criteria used for evaluation of innovative treatments to complement the EVIDEM V4.0 framework. The criteria compendium was presented to a group of clinical oncologists from ECO. The Expert Group assessed each criterion for its inclusion in the framework and suggested modifications in their definition and/or response scale. This framework was then tested with two case studies (Abemaciclib for metastatic HER-/HR+ breast cancer and TAS for metastatic colorectal cancer). The objective was to validate the criteria selected alongside their definitions and response scale with practical examples. A reflective discussion based on the score assigned to each criterion was also carried out. Results: Out of 15 criteria presented to the Expert Group, 8 were included in the final framework, and definition and/or response scale of 7 of these criteria were modified: Disease severity, Unmet needs, Efficacy comparison, Safety/tolerability comparison, Treatment intention, Treatment cost comparison, Comparison of other medical costs and Quality of evidence. Conclusions: A reflective MCDA framework has been developed and validated, based on the value of the treatment, for assessment and positioning of oncological therapies in the context of clinical practice in Spain.

Implementation of the quality training program in Spain

11

Background: The ECO Foundation is a collaboration of experts representing the major Spanish hospitals in the pursuit of excellence in cancer treatment. Since 2015, ECO has been collaborating with ASCO (American Society of Clinical Oncology) in quality initiatives in cancer care, like the QOPI (Quality Oncology Practice Initiative) program and the QOPI Certification Program (QCP). The Quality Training Program (QTP) is a 6-month course with 3 in-person learning sessions that prepares oncology teams to design, implement and lead successful quality improvement activities in their practices. In 2018, ECO reached a new agreement with ASCO to implement this program in Spain. Methods: The QTP was developed in Spain by ECO in collaboration with ASCO, following the same methodology and contents of ASCO’s program. The first session was carried out in October 2018, with 12 Spanish teams participating with diverse quality improvement projects. The program counted with ASCO and ECO faculty, constituted by experts in the quality and oncology field. Results: Each QTP Spanish team counted with 2-3 representatives from their hospitals and developed an improvement project, following the methodology of the course, including a problem statement, process map, cause and effect diagram, diagnostic data, aim statement, measures, baseline data, priority/pay-off matrix of possible changes/interventions, change data, next steps/plan for sustainability, among others. The projects were mainly focused on the waiting time reduction in the Emergency Area and from the patient’s visit to the oncologist until treatment administration, burnout reduction on oncology professionals, improvement of the identification and management of complications for cancer patients receiving immunotherapy, improvement of the uniformity in the medical records registry, among others. QTP participants presented their projects’ results on the third and last session of the program in April 2019 with positive outcomes. Conclusions: The QTP’s quality improvement approach allows Spanish teams and the ECO Foundation to enhance the goal of a quality-oriented health care system. ECO will continue pursuing excellence and quality with further initiatives like the QOPI program, the QCP and the QTP.

Interhospital Sepsis Code in Catalonia (Spain): Territorial model for initial care of patients with sepsis

Sepsis is a syndromic entity with high prevalence and mortality. The management of sepsis is standardized and exhibits time-dependent efficiency. However, the management of patients with sepsis is complex. The heterogeneity of the forms of presentation can make it difficult to detect and manage such cases, in the same way as differences in training, professional competences or the availability of health resources. The Advisory Commission for Patient Care with Sepsis (CAAPAS), comprising 7 scientific societies, the Emergency Medical System (SEM) and the Catalan Health Service (CatSalut), have developed the Interhospital Sepsis Code (CSI) in Catalonia (Spain). The general objective of the CSI is to increase awareness, promote early detection and facilitate initial care and interhospital coordination to attend septic patients in a homogeneous manner throughout Catalonia.

Efficacy and safety profile of lurbinectedin in second-line SCLC patients: Results from a phase II single-agent trial

8506

Background: Lurbinectedin (L) is a novel anticancer drug that inhibits activated transcription and induces DNA double-strand breaks, leading to apoptosis. Methods: A multicenter phase 2 basket trial assessed the efficacy and safety of L in several cancer types, including small cell lung cancer (SCLC). Primary endpoint was confirmed overall response rate (ORR) by RECIST v.1.1. In the SCLC cohort, a target ORR ≥30% was set. One-hundred and five patients (pts) with ECOG PS 0-2 who had received one prior chemotherapy line were treated with L 3.2 mg/m2 as a 1-hour i.v. infusion on Day 1 q3wk. Results: Median age was 60 years (range, 40-83), 60% were male, ECOG PS 0/1/2 (32%/62%/6%), liver metastasis 41%, history of CNS involvement 3.8%, prior platinum 100%, median chemotherapy-free interval (CTFI): 3.5 (0-16.1) months; prior immunotherapy (IO): 7.6%. Pts received a median of 4 cycles (range, 1-24). Conclusions: L monotherapy is active in second-line SCLC in both resistant and sensitive disease. The acceptable and manageable safety profile is also associated to a convenient treatment administration (Day 1 q3wk). L as second-line treatment in SCLC emerges as a new promising drug for this unmet clinical need. Clinical trial information: NCT02454972. [Table: see text]

Randomized phase II study on the influence of BRAF and PIK3CA mutations on the efficacy of FOLFIRI plus bevacizumab (Bev) or cetuximab (Cet), as first line therapy of patients (pts) with RAS wild-type metastatic colorectal carcinoma (mCRC) and <3 baseline circulating tumor cells (bCTCs)

3549

Background: The outcome for mCRC has changed since the introduction of new chemotherapy schedules and targeted therapies, however new predictive biomarkers are needed. bCTCs and BRAF / PIK3CA mutations have been studied as a potential predictive biomarkers. The primary endpoint was progression-free survival (PFS) in pts WT KRAS and <3 bCTCs, according to BRAF/ PIK3CA status. Methods: This is an open, multicentric, randomized phase II trial and included wildtype KRAS mCRC pts (RAS after approval of protocol amendment), younger than ≤70 with <3 bCTCs, ECOG 0-1 and available tissue for molecular analyses. Pts were stratified per number of metastatic organs involved (1 vs >1) and mutation status of BRAF and/or PIK3CA (WT vs MUT) and randomized to group A (FOLFIRI+Bev) or group B (FOLFIRI+Cet). Results: 240 pts (196 WT and 44 MUT: 6 BRAF, 12 PIK3CA and 6 BRAF + PIK3CA) were included. General characteristics per mutation status (WT vs MUT): Mean age (59 vs 61 years), gender (Male/Female 68/32 vs 70/30%), ECOG 0/1 (57/43 vs 66/34%), primary tumor unresected (48 vs 64%), RAS MUT in 12 pts (11 and 1 pts, respectively), previous chemotherapy (12 vs 9%). Overall response rate (ORR) was 52 and 41% in the WT and MUT groups, respectively. PFS and overall survival (OS) are presented in the table. Conclusions: In the low risk mCRC pts according to bCTCs, BRAF and/or PIK3CA MUT have a negative impact in OS and a trend to worse PFS in the ITT population. The impact of treatment is under evaluation and will be provided during the meeting. Clinical trial information: 2012-000840-90. [Table: see text]