Efficacy of Inclisiran in patients having familial hypercholesterolemia: heterozygous compared to homozygous trait, a systematic review and meta analysis

OBJECTIVE

To find out whether Inclisiran sodium has different efficacy in heterozygous familial hypercholesterolemia (HeFH) and homozygous familial hypercholesterolemia (HoFH) patient groups.

METHODS

We conducted the systematic review and meta analysis of ORION Clinical Trials Pubmed, Embase and Clinicaltrials.gov databases were searched for the relevant studies.Atheroscalerotic parameters considered for our objective were LDL-C,Total cholesterol,PCSK9, Apolipoportien-B, and Non HDL-C. Primary outcomes were the percentage difference in atheroscalerotic parameters at followup relative to baseline values. Our study examined these primary outcomes in order to determine whether there is a statistically significant difference between the HeFH and HoFH groups. Risk of bias was assessed by Cochrane risk of bias tool. Meta-analysis was performed when at least two studies reported on the same variable.

RESULTS

Four ORION Clinical Trials provided the data related to the mean difference in the atheroscalerotic parameters at followup relative to baseline, of HeFH and HoFH patient populations, after administration of 300mg inclisiran subcutaneously. We pooled together these mean difference for each group and applied a statistical test to analyse if the values were significantly different between the groups. The results of our study unveiled the significant difference in pooled mean differences in LDL-C (HeFH:-48.62% HoFH:-9.12% p<0.05) Total cholesterol (HeFH:-30.31% HoFH:-11.50% p<0.05),Apolipoprotein(HeFH:-39.97% HoFH:-14.68% p<0.05), non HDL(HeFH:-44.51% HoFH:-12.22% p<0.05) between HeFH and HoFH groups. However the difference in pooled mean difference in PCSK9 values (HeFH:-68.41% HoFH:-56.25% p=0.2)between HeFH and HoFH groups, was statistically insignificant. Studies were of high quality.

CONCLUSION

There was significant difference in the reductions in atherosclerotic lipid parameters in heterozygous and homozygous populations after the administration of Inclisiran except for PCSK9 parameter. Further studies are needed to support this conclusion.

Phase 3 RCT comparing docetaxel-platinum with docetaxel-platinum-5FU as neoadjuvant chemotherapy in borderline resectable oral cancer

BACKGROUND

Neoadjuvant chemotherapy (NACT) with TPF (docetaxel, cisplatin, and 5FU) is one of the treatment options in very locally advanced oral cancer with a survival advantage over PF (cisplatin and 5FU). TP (docetaxel and cisplatin) has shown promising results with a lower rate of adverse events but has never been compared to TPF.

METHODS

In this phase 3 randomized superiority study, adult patients with borderline resectable locally advanced oral cancers were randomized in a 1:1 fashion to either TP or TPF. After the administration of 2 cycles, patients were evaluated in a multidisciplinary clinic and further treatment was planned. The primary endpoint was overall survival (OS) and secondary endpoints were progression-free survival (PFS) and adverse events.

RESULTS

495 patients were randomized in this study, 248 patients in TP arm and 247 in TPF arm. The 5-year OS was 18.5% (95% CI 13.8-23.7) and 23.9% (95% CI 18.1-30.1) in TP and TPF arms, respectively (Hazard ratio 0.778; 95% CI 0.637-0.952; P = 0.015). Following NACT, 43.8% were deemed resectable, but 34.5% underwent surgery. The 5-year OS was 50.7% (95% CI 41.5-59.1) and 5% (95%CI 2.9-8.1), respectively, in the surgically resected versus unresected cohort post NACT (P < 0.0001). Grade 3 or above adverse events were seen in 97 (39.1%) and 179 (72.5%) patients in the TP and TPF arms, respectively (P < 0.0001).

CONCLUSION

NACT with TPF has a survival benefit over TP in borderline resectable oral cancers, with an increase in toxicity which is manageable. Patients who undergo surgery achieve a relatively good, sustained survival.

MEDITERRANEAN DIET AND ITS IMPACT ON THE ILLNESS CHARACTERISTIC OF YOUTH WITH IRRITABLE BOWEL CONDITION

Irritable Bowel Disorder (IBD) is a prevalent digestive illness that frequently affects young people and drastically decreases the Quality of Life (QoL). Adults with IBD indications may find relief from their symptoms through nutritional changes like the Mediterranean-style diet. Concerning the seriousness of symptoms, QoL, and additional pertinent results in young people with IBD, this investigation seeks to determine the impact of the Mediterranean-style diet. 200 individuals with IBD who met the Rome-IV criterion and were between the ages of 13 and 19 were enrolled in the present research. A Mediterranean-style diet was provided to the Study Group (SG), which consisted of 100 individuals, while the Control Group (CG), which consisted of 100 patients, followed the usual diet. Various laboratory and clinical characteristics were also assessed at the beginning and end of the study, in addition to IBD values. The Mediterranean-style diet has been demonstrated to be effective and tolerated well in kids and teenagers with IBD. The IBD -SSS (from 148±42.3 to 224±71) IBD -QoL (from 76.7±8.1 to 61.3±9.8), and cumulative IBD rating (from 29.3±11.7 to 32.6±12.1) all showed notable increases in individuals who followed well to this diet. The CG, in comparison, did not show any significant enhancements in these factors. This indicates that a Mediterranean-style diet might provide therapeutic advantages for IBD individuals, especially those who keep adherent to it, concerning symptom severity and QoL. The Mediterranean-style diet proved to be both secure and associated with notable improvements in IBD rates in young and adolescents with IBD.

Incurable advanced salivary gland tumours: a retrospective analysis and peek into the perplexing clinical and molecular intricacies from a tertiary care centre in India

Background

Salivary gland tumours are rare cancers with variable course and prognosis. There is a paucity of data, especially for the advanced stages.

Materials and methods

This is a retrospective analysis carried out in our institute. All patients seeking treatment for incurable advanced salivary gland tumours from October 2018 to September 2022 were included. Relevant clinical data were collected and appropriate statistical analysis was applied.

Results

30 patients were included in the analysis. The parotid gland was the most common site of origin (73%). Adenoid cystic carcinoma (ACC) and salivary duct carcinoma (SDC) were equally (37%) the most common pathological subtypes. The majority of patients were males (73%) and lungs (57%) were the most common site of metastases. On molecular analysis, SDC had high rates of androgen receptor (AR) (90%) and human epidermal growth factor receptor 2 (HER2) (55%) positivity. Mucoepidermoid carcinoma (MEC) had AR and HER2 positivity rates of 17% and 20%, respectively, while for ACC it was even lower. A variety of treatment regimens including hormonal therapy, anti-HER2 targeted therapy and chemotherapy were used in first-line treatment. With an overall response rate (ORR) of 10/21 (48%), only 9/21 (43%) went on to receive second-line treatment with an ORR of 4/9 (44%). The progression-free survival (PFS) with first-line treatment (PFS1) was a median of 5 months. The median PFS1 was worst for MEC. The median overall survival (OS) was 10 months. Median OS for ACC, SDC and MEC were 11, 10 and 7 months, respectively. At 24 months, ACC had much higher survival (50%) than others (10%) indicating a proportion of ACC with an indolent course.

Conclusion

Our analysis highlights the variable disease biology of advanced salivary gland tumours and throws light on the various possible treatment targets and strategies. Molecular profiling and advancement in targeted therapies are expected to increase survival in this group of rare cancers.

Predicting Corrosion Damage in the Human Body Using Artificial Intelligence: In Vitro Progress and Future Applications

Artificial intelligence (AI) is used in the clinic to improve patient care. While the successes illustrate AI's impact, few studies have led to improved clinical outcomes. In this review, we focus on how AI models implemented in nonorthopedic fields of corrosion science may apply to the study of orthopedic alloys. We first define and introduce fundamental AI concepts and models, as well as physiologically relevant corrosion damage modes. We then systematically review the corrosion/AI literature. Finally, we identify several AI models that may be implemented to study fretting, crevice, and pitting corrosion of titanium and cobalt chrome alloys.

Surface Acoustic Wave Propagation of GaN/Sapphire Integrated with a Gold Guiding Layer

Gallium nitride (GaN), widely known as a wide bandgap semiconductor material, has been mostly employed in high power devices, light emitting diodes (LED), and optoelectronic applications. However, it could be exploited differently due to its piezoelectric properties, such as its higher SAW velocity and strong electromechanical coupling. In this study, we investigated the affect of the presence of a guiding layer made from titanium/gold on the surface acoustic wave propagation of the GaN/sapphire substrate. By fixing the minimum thickness of the guiding layer at 200 nm, we could observe a slight frequency shift compared to the sample without a guiding layer, with the presence of different types of surface mode waves (Rayleigh and Sezawa). This thin guiding layer could be efficient in transforming the propagation modes, acting as a sensing layer for the binding of biomolecules to the gold layer, and influencing the output signal in terms of frequency or velocity. The proposed GaN/sapphire device integrated with a guiding layer could possibly be used as a biosensor and in wireless telecommunication applications.

Results of Phase III Randomized Trial for Use of Docetaxel as a Radiosensitizer in Patients With Head and Neck Cancer, Unsuitable for Cisplatin-Based Chemoradiation

PURPOSE

There is a lack of published literature on systemic therapeutic options in cisplatin-ineligible patients with locally advanced head and neck squamous cell carcinoma (LAHNSCC) undergoing chemoradiation. Docetaxel was assessed as a radiosensitizer in this situation.

METHODS

This was a randomized phase II/III study. Adult patients (age ≥ 18 years) with LAHNSCC planned for chemoradiation and an Eastern Cooperative Oncology Group performance status of 0-2 and who were cisplatin-ineligible were randomly assigned in 1:1 to either radiation alone or radiation with concurrent docetaxel 15 mg/m² once weekly for a maximum of seven cycles. The primary end point was 2-year disease-free survival (DFS).

RESULTS

The study recruited 356 patients between July 2017 and May 2021. The 2-year DFS was 30.3% (95% CI, 23.6 to 37.4) versus 42% (95% CI, 34.6 to 49.2) in the RT and Docetaxel-RT arms, respectively (hazard ratio, 0.673; 95% CI, 0.521 to 0.868; P value = .002). The corresponding median overall survival (OS) was 15.3 months (95% CI, 13.1 to 22.0) and 25.5 months (95% CI, 17.6 to 32.5), respectively (log-rank P value = .035). The 2-year OS was 41.7% (95% CI, 34.1 to 49.1) versus 50.8% (95% CI, 43.1 to 58.1) in the RT and Docetaxel-RT arms, respectively (hazard ratio, 0.747; 95% CI, 0.569 to 0.980; P value = .035). There was a higher incidence of grade 3 or above mucositis (22.2% v 49.7%; P < .001), odynophagia (33.5% v 52.5%; P < .001), and dysphagia (33% v 49.7%; P = .002) with the addition of docetaxel.

CONCLUSION

The addition of docetaxel to radiation improved DFS and OS in cisplatin-ineligible patients with LAHNSCC.[Media: see text].

Low-Dose Immunotherapy in Head and Neck Cancer: A Randomized Study

PURPOSE

The regimens approved for the treatment of advanced head and neck squamous cell carcinoma are accessible to only 1%-3% of patients in low- and middle-income countries because of their cost. In our previous study, metronomic chemotherapy improved survival in this setting. Retrospective data suggest that a low dose of nivolumab may be efficacious. Hence, we aimed to assess whether the addition of low-dose nivolumab to triple metronomic chemotherapy (TMC) improved overall survival (OS).

METHODS

This was a randomized phase III superiority study. Adult patients with recurrent or newly diagnosed advanced head and neck squamous cell carcinoma being treated with palliative intent with an Eastern Cooperative Oncology Group performance status of 0-1 were eligible. Patients were randomly assigned 1:1 to TMC consisting of oral methotrexate 9 mg/m² once a week, celecoxib 200 mg twice daily, and erlotinib 150 mg once daily, or TMC with intravenous nivolumab (TMC-I) 20 mg flat dose once every 3 weeks. The primary end point was 1-year OS.

RESULTS

One hundred fifty-one patients were randomly assigned, 75 in TMC and 76 in the TMC-I arm. The addition of low-dose nivolumab led to an improvement in the 1-year OS from 16.3% (95% CI, 8.0 to 27.4) to 43.4% (95% CI, 30.8 to 55.3; hazard ratio, 0.545; 95% CI, 0.362 to 0.820; P = .0036). The median OS in TMC and TMC-I arms was 6.7 months (95% CI, 5.8 to 8.1) and 10.1 months (95% CI, 7.4 to 12.6), respectively (P = .0052). The rate of grade 3 and above adverse events was 50% and 46.1% in TMC and TMC-I arms, respectively (P = .744).

CONCLUSION

To our knowledge, this is the first-ever randomized study to demonstrate that the addition of low-dose nivolumab to metronomic chemotherapy improved OS and is an alternative standard of care for those who cannot access full-dose checkpoint inhibitors.

O-252 Next generation sequencing analysis of the seminal microbiome in male partners of women with idiopathic recurrent pregnancy loss: results of a prospective cohort study

Study question

Is there an association between the semen microbiome, seminal reactive oxygen species (ROS) and DNA fragmentation in men with recurrent pregnancy loss (RPL)?

Summary answer

This pilot study outlines the subtle role that microbiota play in influencing ROS and sperm DNA damage for male partners of women with RPL

What is known already

RPL is defined as the loss of two or more consecutive pregnancies. This devastating condition impacts approximately 1% of couples. Paternal causes are not routinely screened for and an underlying cause is not found in up to 50% of cases. Recent studies have reported an association between elevated seminal ROS and sperm DNA fragmentation in the male partner, and RPL. We hypothesised that seminal microbiota contribute to increased ROS and sperm DNA damage. To test this, we investigated the relationship between seminal bacterial composition and ROS levels in men with proven fertility versus men with a history of RPL.

Study design, size, duration

We conducted a prospective, case-control study and recruited participants between November 2018 and March 2020 at Imperial College Healthcare NHS Trust. A total of 109 men participated in the study; 46 men with RPL and 63 men with proven fertility and no history of RPL. Each participant attended for a single study visit which consisted of a full medical history, assessment of testicular volume, height, weight, blood samples and production of a semen sample.

Participants/materials, setting, methods

Routine semen analysis (WHO) and endocrine and lipid profiles were performed for all patients. Semen ROS and DNA fragmentation were performed (luminol and TUNEL methodologies, respectively). ROS were classified as high (&gt;3.77 RLU/s) or low (&lt;3.77 RLU/s). Metataxonomic profiling of samples was performed using Illumina Miseq-based sequencing of the V1-V2 hypervariable regions of bacterial 16S rRNA gene amplicons. Multivariate and univariate modelling was performed to explore associations between metataxonomic profiles, ROS levels and clinical metadata.

Main results and the role of chance

Men with RPL had higher mean semen volume (p = 0.02) and increased prevalence of high ROS (p = 0.02, Fisher's exact) compared with controls; but other clinical characteristics were similar between groups. A total of 3,700,136 high quality sequence reads were generated for the dataset with an average of 33,946 reads/sample. Hierarchical clustering of bacterial genera relative abundances identified 4 distinct microbial signatures characterised by high relative abundance of 1. Streptococcus, 2. Lactobacillus and Gardnerella, 3. polymicrobial (including Prevotella), and 4. Corynebacterium and Finegoldia. Prevalences of these groups were similar in control and RPL groups (p = 0.11). Additionally, no association between the bacterial genera groups and elevated ROS, DNA fragmentation, or clinical factors such as age, ethnicity, or semen volume were observed (chi-square tests). At species taxonomy level relative abundance of L. crispatus was higher in controls compared to RPL, but did not withstand false discovery rate correction for multiple testing (p = 0.006, q = 0.67). Higher relative abundance of Microbacterium was detected in semen samples with high DNA fragmentation (p = 8.7E-4, q = 0.08). This relationship was even stronger within the RPL cohort (p = 2.8E-5, q = 0.002). No significant enrichment of specific taxa was observed between high or low ROS samples however, low ROS was associated with Corynebacterium relative abundance &gt;20%.

Limitations, reasons for caution

More patients are required to enhance statistical power. Duplicate sample collection may establish the robustness of seminal compositions observed. Time since last sexual intercourse samples may affect the analysis. Concomitant analysis of the vaginal microbiome of female partners may improve our understanding of how partners may affect each other’s fertility.

Wider implications of the findings

Our data suggests interactions between microbiota composition, ROS and sperm DNA damage which may be implicated in the pathogenesis of recurrent miscarriage. Further studies are needed to determine if seminal microbiota play causal roles in RPL, and whether interventions modifying the seminal microbiome may modify pregnancy outcomes in affected couples

Trial registration number

not applicable

Study the Possibility of Creating Mucosal Valve Mechanism at Ureteric Orifice without Obstructing the Urine Outflow but Preventing the Urine Backflow into the Ureters

OBJECTIVE

To study the possibility of creating mucosal valve mechanism at ureteric orifice without obstructing the urine outflow but preventing the urine backflow into the ureters.

MATERIALS AND METHODS

Ethical waiver was obtained from the institutional ethical committee. Prospective experimental study was conducted on the post-mortem specimen of intact bladder with urethra and bilateral ureters retrieved from the already slaughtered lamb available in the meat market. Feeding tube inserted via urethral opening into the bladder lumen and bladder inflated with saline demonstrated no reflux of urine via transverse cut opening of ureters. Bladder lumen opened, ureteric orifices incised backwards to eliminate the obliquity. After closing the bladder opening, saline inflation test demonstrated bilateral reflux of saline via cut openings of bilateral ureters. Bladder was re-opened. The upper limb of horizontal U started 10 mm lateral and 8 mm above the refluxing ureteric orifice. Distal most curvature of horizontal U was kept 5 mm medial to ureteric orifice continuing along the lower limb of horizontal U terminating 10 mm lateral and 8 mm below the refluxing ureteric orifice, mucosal flaps from superior and inferior incision mobilized and edges joined to cover the ureteric orifice creating a flap valve mechanism. Influx of saline via cut end of ureters demonstrated no obstruction. Bladder was closed. Saline inflation test and contrast study demonstrated abolition of reflux on flap side and persistence of reflux on another side.

RESULTS

Five such experiments were conducted. On the side where the valve was created, Vesicoureteral reflux was abolished in four but in one minimal reflux still persisted.

CONCLUSION

Creating a mucosal flap valve around the ureteric orifice can prevent reflux in 80% of cases without obstruction and without the necessity of ureteric mobilization or creating submucosal tunnel.

Comment on: Multimodal analgesia with thoracic epidural after transthoracic oesophagectomy: Do we need more evidence?

This article is a response to the publication ‘Comparison of multimodal analgesia with thoracic epidural after transthoracic oesophagectomy’. It discuss the differing outcomes from using this technique in other publications.

P–635 Standard versus mild ovarian stimulation in women with polycystic ovaries (PCO): Impact on outcomes in subsequent frozen embryo treatment cycles (FET)

Study question

Does mild ovarian stimulation in women with PCO result in higher live birth rates during subsequent FET cycles?

Summary answer

Mild ovarian stimulation with FSH doses &lt;150IU did not result in higher clinical pregnancy or livebirth rates in subsequent FET.

What is known already

Ovarian stimulation during IVF in women with PCO is associated with an exaggerated response, ovarian hyperstimulation syndrome, poor egg to follicle ratio, low fertilisation rates and poor blastocyst conversion. Mild ovarian stimulation, often referred to as protocols with FSH doses under 150IU, is often employed to overcome these challenges. One of the perceived benefits of this approach is improved oocyte and embryo quality reflected in lower aneuploidy rates.

Study design, size, duration

This was a retrospective observational study looking at 99 FET between January 2011 and Jan 2021 that followed a fresh cycle in women with a pre-treatment antral follicle count of 12 + 12 or greater. Patients were identified through the antral follicle count at the pre-treatment investigation ultrasound scan. Ultrasound findings, treatment cycle details and clinical outcomes were entered prospectively into a dedicated clinic database. Data was retrieved and analysed using SPSS V25.

Participants/materials, setting, methods

The study was conducted in a large IVF centre. Data on women with an AFC of 12 + 12 or above, undergoing an autologous FET cycle following a fresh cycle were collected. Women were split into those receiving &lt;150IU of FSH (Group1, n = 51) and those receiving FSH ³150 IU (Group 2, n = 48). Binary logistic regression analysis was performed to control for confounders. Live birth was the primary outcome, with biochemical and clinical pregnancy being secondary outcomes.

Main results and the role of chance

Women in Group 1 were younger (30.8±3.6 v 33.8±3.65, p &lt; 0.005) but had a similar antral follicle count (38.2±11.7 v 34.2±9.1, p = 0.07). The total number of eggs collected (24.1±13.8 v 25.9±8.8, p = 0.45) and fertilisation rate (0.59±0.2 v 0.58±0.18, p = 0.77) during their fresh cycle were comparable. Women in Group 2 had a larger number of embryos suitable for cryopreservation (7.36±4.2 v 4.8±3.5, p = 0.001)

In the subsequent frozen embryo replacement cycle, there was no difference in the number or quality of embryos transferred with most women having a single embryo transfer (63% v 48%, p = 0.14) and at least one top quality embryo transferred (68.6% v 81%, p = 0.15). There was a higher biochemical pregnancy rate in Group 1 (84% v 66%, p = 0.035) but with no difference in clinical pregnancy rate (53% v 44%, p = 0.37) or live birth rate (49% v 42%, p = 0.76). Live birth rates remained comparable even after controlling for age, and number and quality of embryos transferred (OR: 1.21 (95% CI 0.50–2.94).

Limitations, reasons for caution

This was a retrospective analysis raising the risk of allocation bias. This study was also at risk of information bias as it relied on accurate documentation of the AFC at the pre-treatment scan.

Wider implications of the findings: Patients can be reassured that both stimulation protocols result in similar live birth rates in subsequent frozen embryo replacement cycles.

Prospective trials using PGT-A are required to assess whether aneuploidy could account for the discrepancy in biochemical pregnancy rates in the two groups considering the subsequent comparable clinical pregnancy rates.

Trial registration number

Not applicable

Pelvic organ motion and dosimetric implications during horizontal patient rotation for prostate radiation therapy

PURPOSE

Gantry-free radiation therapy systems utilizing patient rotation would be simpler and more cost effective than the conventional gantry-based systems. Such a system could enable the expansion of radiation therapy to meet global demand and reduce capital costs. Recent advances in adaptive radiation therapy could potentially be applied to correct for gravitational deformation during horizontal patient rotation. This study aims to quantify the pelvic organ motion and the dosimetric implications of horizontal rotation for prostate intensity-modulated radiation therapy (IMRT) treatments.

METHODS

Eight human participants who previously received prostate radiation therapy were imaged in a clinical magnetic resonance imaging (MRI) scanner using a bespoke patient rotation system (PRS). The patients were imaged every 45 degrees during a full roll rotation (0-360 degrees). Whole pelvic bone, prostate, rectum, and bladder motion were compared to the supine position using dice similarity coefficient (DSC) and mean absolute surface distance (MASD). Prostate centroid motion was compared in the left-right (LR), superior-inferior (SI), and anterior-posterior (AP) direction prior to and following pelvic bone-guided rigid registration. Seven-field prostate IMRT treatment plans were generated for each patient rotation angles under three adaption scenarios: No plan adaption, rigid planning target volume (PTV)-guided alignment to the prostate, and plan re-optimization. Prostate, rectum, and bladder doses were compared for each adaption scenario.

RESULTS

Pelvic bone motion within the PRS of up to 53 mm relative to the supine position was observed for some participants. Internal organ motion was greatest at the 180-degree PRS couch angle (prone), with prostate centroid motion range < 2 mm LR, 0 mm to 14 mm SI, and -11 mm to 4 mm AP. Rotation with no adaption of the treatment plan resulted in an underdose to the PTV -- in some instances up to 75% (D95%: 78 ± 0.3 Gy at supine to 20 ± 15.0 Gy at the 225-degree PRS couch angle). Bladder dose was reduced during the rotation by up to 98% (V60 Gy: 15.0 ± 9.4% supine to 0.3 ± 0.5% at the 225-degree PRS couch angle). In some instances, the rectum dose increased during rotation (V60Gy: 20.0 ± 4.5% supine to 25.0 ± 15.0% at the 135-degree PRS couch angle). Rigid PTV-guided alignment resulted in PTV coverage which, though statistically lower (P < 0.05 for all D95% values), was within 1 Gy of the supine plans. Plan re-optimization resulted in a statistically equivalent PTV coverage compared to the supine plans (P > 0.05 for all D95% metrics and all within ±0.4 Gy). For both rigid PTV-guided alignment and plan re-optimization, rectum dose volume metrics were reduced compared to the supine position between the 90- and 225-degree PRS couch angles (P < 0.05). Bladder dose volume metrics were not impacted by rotation.

CONCLUSION

Pelvic bone and internal organ motion are present during patient rotation. Rigid PTV-guided alignment to the prostate will be a requirement if prostate IMRT is to be safely delivered using patient rotation. Plan re-optimization for each PRS couch angle to account for anatomical deformations further improves the PTV coverage.

Detecting functional field units from satellite images in smallholder farming systems using a deep learning based computer vision approach: A case study from Bangladesh

Improving agricultural productivity of smallholder farms (which are typically less than 2 ha) is key to food security for millions of people in developing nations. Knowledge of the size and location of crop fields forms the basis for crop statistics, yield forecasting, resource allocation, economic planning, and for monitoring the effectiveness of development interventions and investments. We evaluated three different full convolutional neural network (F-CNN) models (U-Net, SegNet, and DenseNet) with deep neural architecture to detect functional field boundaries from the very high resolution (VHR) WorldView-3 satellite imagery from Southern Bangladesh. The precision of the three F-CNN was up to 0.8, and among the three F-CNN models, the highest precision, recalls, and F-1 score was obtained using a DenseNet model. This architecture provided the highest area under the receiver operating characteristic (ROC) curve (AUC) when tested with independent images. We also found that 4-channel images (blue, green, red, and near-infrared) provided small gains in performance when compared to 3-channel images (blue, green, and red). Our results indicate the potential of using CNN based computer vision techniques to detect field boundaries of small, irregularly shaped agricultural fields.

Degradation Mechanism Detection in Photovoltaic Backsheets by Fully Convolutional Neural Network

Materials and devices age with time. Material aging and degradation has important implications for lifetime performance of materials and systems. While consensus exists that materials should be studied and designed for degradation, materials inspection during operation is typically performed manually by technicians. The manual inspection makes studies prone to errors and uncertainties due to human subjectivity. In this work, we focus on automating the process of degradation mechanism detection through the use of a fully convolutional deep neural network architecture (F-CNN). We demonstrate that F-CNN architecture allows for automated inspection of cracks in polymer backsheets from photovoltaic (PV) modules. The developed F-CNN architecture enabled an end-to-end semantic inspection of the PV module backsheets by applying a contracting path of convolutional blocks (encoders) followed by an expansive path of decoding blocks (decoders). First, the hierarchy of contextual features is learned from the input images by encoders. Next, these features are reconstructed to the pixel-level prediction of the input by decoders. The structure of the encoder and the decoder networks are thoroughly investigated for the multi-class pixel-level degradation type prediction for PV module backsheets. The developed F-CNN framework is validated by reporting degradation type prediction accuracy for the pixel level prediction at the level of 92.8%.

Outcome prediction of intracranial aneurysm treatment by flow diverters using machine learning

OBJECTIVEFlow diverters (FDs) are designed to occlude intracranial aneurysms (IAs) while preserving flow to essential arteries. Incomplete occlusion exposes patients to risks of thromboembolic complications and rupture. A priori assessment of FD treatment outcome could enable treatment optimization leading to better outcomes. To that end, the authors applied image-based computational analysis to clinically FD-treated aneurysms to extract information regarding morphology, pre- and post-treatment hemodynamics, and FD-device characteristics and then used these parameters to train machine learning algorithms to predict 6-month clinical outcomes after FD treatment.METHODSData were retrospectively collected for 84 FD-treated sidewall aneurysms in 80 patients. Based on 6-month angiographic outcomes, IAs were classified as occluded (n = 63) or residual (incomplete occlusion, n = 21). For each case, the authors modeled FD deployment using a fast virtual stenting algorithm and hemodynamics using image-based computational fluid dynamics. Sixteen morphological, hemodynamic, and FD-based parameters were calculated for each aneurysm. Aneurysms were randomly assigned to a training or testing cohort in approximately a 3:1 ratio. The Student t-test and Mann-Whitney U-test were performed on data from the training cohort to identify significant parameters distinguishing the occluded from residual groups. Predictive models were trained using 4 types of supervised machine learning algorithms: logistic regression (LR), support vector machine (SVM; linear and Gaussian kernels), K-nearest neighbor, and neural network (NN). In the testing cohort, the authors compared outcome prediction by each model trained using all parameters versus only the significant parameters.RESULTSThe training cohort (n = 64) consisted of 48 occluded and 16 residual aneurysms and the testing cohort (n = 20) consisted of 15 occluded and 5 residual aneurysms. Significance tests yielded 2 morphological (ostium ratio and neck ratio) and 3 hemodynamic (pre-treatment inflow rate, post-treatment inflow rate, and post-treatment aneurysm averaged velocity) discriminants between the occluded (good-outcome) and the residual (bad-outcome) group. In both training and testing, all the models trained using all 16 parameters performed better than all the models trained using only the 5 significant parameters. Among the all-parameter models, NN (AUC = 0.967) performed the best during training, followed by LR and linear SVM (AUC = 0.941 and 0.914, respectively). During testing, NN and Gaussian-SVM models had the highest accuracy (90%) in predicting occlusion outcome.CONCLUSIONSNN and Gaussian-SVM models incorporating all 16 morphological, hemodynamic, and FD-related parameters predicted 6-month occlusion outcome of FD treatment with 90% accuracy. More robust models using the computational workflow and machine learning could be trained on larger patient databases toward clinical use in patient-specific treatment planning and optimization.

Availability and Quality of Online Information on Sub-Internships in U.S. Orthopaedic Residency Programs

Background:

The purpose of the present study was to assess the availability and quality of online information regarding sub-internships in orthopaedics among U.S. orthopaedic residency programs.

Methods:

Each U.S. orthopaedic surgery residency program web site was assessed for the following 4 criteria: any mention of a sub-internship offered by that program, contact information regarding the sub-internship, a list of learning objectives to be met by the rotating student during the sub-internship, and presence of a web page dedicated solely to the orthopaedic sub-internship. Each web site was given a sub-internship score (SI score) from 0 to 4 based on how many of the above criteria were met.

Results:

From the 151 analyzed U.S. orthopaedic surgery residency program web sites, 69 (46%) did not have any mention of a sub-internship and thus received a score of 0, 4 (3%) received a score of 1, 18 (12%) received a score of 2, 20 (13%) received a score of 3, and 40 (26%) received a score of 4. The average SI score was 1.05 for the community-based orthopaedic residency programs, compared with 1.98 for the university-based orthopaedic programs (p = 0.003). Subgroup analysis based on SI scores (0 vs. 1 to 4) revealed that the higher-score group (1 to 4) had a higher percentage of university-based programs than the lower-score (0) group (80% vs. 62%; p = 0.003) and was associated with a greater number of residents per program than the lower-score group (mean, 26.4 vs. 21.0; p = 0.04). There was a weak association between the SI score and the number of residents in a given program (R² = 0.074, p = 0.0004).

Conclusions:

The availability and quality of online information regarding sub-internships offered at orthopaedic residency programs in the U.S. are variable. Nearly half of the programs did not have any available online information on their web sites regarding orthopaedic surgery sub-internships. Larger and university-based orthopaedic programs have more robust information regarding sub-internships than smaller and community-based programs.

Clinical Relevance:

There needs to be greater awareness and more uniformly accessible online information regarding orthopaedic surgery sub-internships for senior medical students seeking elective orthopaedic rotations prior to applying for residency training.

Acetyltransferase p300 inhibitor reverses hypertension-induced cardiac fibrosis

Epigenetic dysregulation plays a crucial role in cardiovascular diseases. Previously, we reported that acetyltransferase p300 (ATp300) inhibitor L002 prevents hypertension‐induced cardiac hypertrophy and fibrosis in a murine model. In this short communication, we show that treatment of hypertensive mice with ATp300‐specific small molecule inhibitor L002 or C646 reverses hypertension‐induced left ventricular hypertrophy, cardiac fibrosis and diastolic dysfunction, without reducing elevated blood pressures. Biochemically, treatment with L002 and C646 also reverse hypertension‐induced histone acetylation and myofibroblast differentiation in murine ventricles. Our results confirm and extend the role of ATp300, a major epigenetic regulator, in the pathobiology of cardiac hypertrophy and fibrosis. Most importantly, we identify the efficacies of ATp300 inhibitors C646 and L002 in reversing hypertension‐induced cardiac hypertrophy and fibrosis, and discover new anti‐hypertrophic and anti‐fibrotic candidates.

Risk Factors for Adverse Outcome in Pregnant Women with Obstructed Labor

Aims: The aim of the study was to assess the risk factors for adverse outcomes in pregnancy with obstructed labor.Methods: It was a prospective descriptive study conducted at BP Koirala Institute of Health sciences (BPKIHS).The patients with obstructed labour were managed and followed up until delivery and six weeks postpartum from Jan to Dec 2012.Results: There were 57 (0.6%) cases of obstructed labour out of 9500 deliveries. The main cause was cephalopelvic disproportion in 36 (63.2%). The majority of the cases were from rural areas, low socioeconomic status, non salaried and illiterate. Risk for maternal mortality, peripartum hysterectomy and perinatal mortality as adverse outcomes was significantly associated with low socioeconomic status (AOR 12.5, P=0.02) and literacy status (AOR 21.9, P=0.001). If only the risk of perinatal mortality is taken as an adverse outcome, it is significantly associated with booking status (AOR 7, P=0.001), low socioeconomic status (AOR 9.62, P=0.037) and literacy of the patient (AOR 15, P=0.001). Perinatal mortality rate was 100 per 1000 live births in women with obstructed labour. The case fatality rate was 1.2%.

Allosteric Site Inhibitor Disrupting Auto-Processing of Malarial Cysteine Proteases

Falcipains are major haemoglobinases of Plasmodium falciparum required for parasite growth and development. They consist of pro- and mature domains that interact via 'hot-spot' interactions and maintain the structural integrity of enzyme in zymogen state. Upon sensing the acidic environment, these interactions dissociate and active enzyme is released. For inhibiting falcipains, several active site inhibitors exist, however, compounds that target via allosteric mechanism remains uncharacterized. Therefore, we designed and synthesized six azapeptide compounds, among which, NA-01 & NA-03 arrested parasite growth by specifically blocking the auto-processing of falcipains. Inhibitors showed high affinity for enzymes in presence of the prodomain without affecting the secondary structure. Binding of NA-03 at the interface induced rigidity in the prodomain preventing structural reorganization. We further reported a histidine-dependent activation of falcipain. Collectively, for the first time we provide a framework for blocking the allosteric site of crucial haemoglobinases of the human malaria parasite. Targeting the allosteric site could provide high selectivity and less vulnerable to drug resistance.

Downregulation of the Apelinergic Axis Accelerates Aging, whereas Its Systemic Restoration Improves the Mammalian Healthspan

Aging drives the occurrence of numerous diseases, including cardiovascular disease (CVD). Recent studies indicate that blood from young mice reduces age-associated pathologies. However, the "anti-aging" factors in juvenile circulation remain poorly identified. Here, we characterize the role of the apelinergic axis in mammalian aging and identify apelin as an anti-aging factor. The expression of apelin (apln) and its receptor (aplnr) exhibits an age-dependent decline in multiple organs. Reduced apln signaling perturbs organismal homeostasis; mice harboring genetic deficiency of aplnr or apln exhibit enhanced cardiovascular, renal, and reproductive aging. Genetic or pharmacological abrogation of apln signaling also induces cellular senescence mediated, in part, by the activation of senescence-promoting transcription factors. Conversely, restoration of apln in 15-month-old wild-type mice reduces cardiac hypertrophy and exercise-induced hypertensive response. Additionally, apln-restored mice exhibit enhanced vigor and rejuvenated behavioral and circadian phenotypes. Hence, a declining apelinergic axis promotes aging, whereas its restoration extends the murine healthspan.

Methanol oxidation on stoichiometric and oxygen-rich RuO2(110)

We used temperature-programmed reaction spectroscopy (TPRS) to investigate the adsorption and oxidation of methanol on stoichiometric and O-rich RuO₂(110) surfaces. We find that the complete oxidation of CH₃OH is strongly preferred on stoichiometric RuO₂(110) during TPRS for initial CH₃OH coverages below ∼0.33 ML (monolayer), and that partial oxidation to mainly CH₂O becomes increasingly favored with increasing CH₃OH coverage from 0.33 to 1.0 ML. We present evidence that an adsorbed CH₂O₂ species serves as the key intermediate to complete oxidation and that CH₂O₂ formation is intrinsically facile but becomes limited by the availability of bridging O-atoms on stoichiometric RuO₂(110) at initial CH₃OH coverages above 0.33 ML. We show that methanol molecules adsorbed in excess of 0.33 ML dehydrogenate to mainly CH₂O and desorb during TPRS, with adsorbed CH₃O groups mediating the evolution of both CH₂O and CH₃OH. We find that O-rich RuO₂(110) surfaces are also highly active toward methanol oxidation and that selectivity toward the complete oxidation of methanol increases markedly with increasing coverage of on-top O-atoms (O_ot) on RuO₂(110). Our results demonstrate that CH₃OH species adsorbed within O_ot-rich domains react efficiently during TPRS, in parallel with reaction of CH₃OH adsorbed initially on cus-Ru sites. The data suggests that the facile hydrogenation of O_ot atoms and the resulting desorption of H₂O at low-temperature (<∼400 K) provides an efficient pathway for restoring reactive O-atoms and thereby promoting complete oxidation of methanol on the O-rich RuO₂(110) surface.

Adsorption of alkanes on stoichiometric and oxygen-rich RuO2(110)

We investigated the molecular adsorption of methane, ethane, propane and n-butane on stoichiometric and oxygen-rich RuO2(110) surfaces using temperature-programmed desorption (TPD) and dispersion-corrected density functional theory (DFT-D3) calculations. We find that each alkane adsorbs strongly on the coordinatively-unsaturated Ru (Rucus) atoms of s-RuO2(110), with desorption from this state producing a well-defined TPD peak at low alkane coverage. As the coverage increases, we find that alkanes first form a compressed layer on the Rucus atoms and subsequently adsorb on the bridging O atoms of the surface until the monolayer saturates. DFT-D3 calculations predict that methane preferentially adsorbs on top of a Rucus atom and that the C2 to C4 alkanes preferentially adopt bidentate configurations in which each molecule aligns parallel to the Rucus atom row and datively bonds to neighboring Rucus atoms. DFT-D3 predicts binding energies that agree quantitatively with our experimental estimates for alkane σ-complexes on RuO2(110). We find that oxygen atoms adsorbed on top of Rucus atoms (Oot atoms) stabilize the adsorbed alkane complexes that bind in a given configuration, while also blocking the sites needed for σ-complex formation. This site blocking causes the coverage of the most stable, bidentate alkane complexes to decrease sharply with increasing Oot coverage. Concurrently, we find that a new peak develops in the C2 to C4 alkane TPD spectra with increasing Oot coverage, and that the desorption yield in this TPD feature passes through a maximum at Oot coverages between ∼50% and 60%. We present evidence that the new TPD peak arises from C2 to C4 alkanes that adsorb in upright, monodentate configurations on stranded Rucus sites located within the Oot layer.

A novel acetyltransferase p300 inhibitor ameliorates hypertension-associated cardio-renal fibrosis

Hypertension-associated end-organ damage commonly leads to cardiac and renal fibrosis. As no effective anti-fibrotic therapy currently exists, the unchecked progression of fibrogenesis manifests as cardio-renal failure and early death. We have previously shown that FATp300-p300 with intrinsic factor acetyltransferase activity-is an essential epigenetic regulator of fibrogenesis, and is elevated in several fibrotic tissues. In this report, we investigate the therapeutic efficacy of a novel FATp300 inhibitor, L002, in a murine model of hypertensive cardio-renal fibrosis. Additionally, we examine the effects of L002 on cellular pro-fibrogenic processes and provide mechanistic insights into its antifibrogenic action. Utilizing cardiac fibroblasts, podocytes, and mesangial cells, we demonstrate that L002 blunts FATp300-mediated acetylation of specific histones. Further, incubating cells with L002 suppresses several pro-fibrogenic processes including cellular proliferation, migration, myofibroblast differentiation and collagen synthesis. Importantly, systemic administration of L002 in mice reduces hypertension-associated pathological hypertrophy, cardiac fibrosis and renal fibrosis. The anti-hypertrophic and anti-fibrotic effects of L002 were independent of blood pressure regulation. Our work solidifies the role of epigenetic regulator FATp300 in fibrogenesis and establishes it as a pharmacological target for reducing pathological matrix remodeling and associated pathologies. Additionally, we discover a new therapeutic role of L002, as it ameliorates hypertension-induced cardio-renal fibrosis and antagonizes pro-fibrogenic responses in fibroblasts, podocytes and mesangial cells.

Abstract 482: A Novel Small Molecule Inhibitor of Acetyltransferase p300 Ameliorates Hypertension-Induced Cardiac and Renal Fibrosis

Rationale: Fibrosis is a common pathophysiological manifestation of chronically injured or stress-affected organs. Additionally, cardiac and renal fibrosis remain leading causes of global morbidity and mortality. Meanwhile, no effective therapy is available to halt the onset and progression of cardiac and renal fibrogenesis. We have previously demonstrated that p300 with intrinsic factor acetyltransferase (FATp300) activity is an essential epigenetic regulator of profibrogenic signal-induced matrix protein synthesis.

Objective: Here, we attempted to delineate the therapeutic efficacy of a small molecule inhibitor of FATp300, L002, in blocking i) TGF-b-induced profibrogenic processes in cardiac and renal cells in vitro, and ii) Angiotensin II-induced cardiac and renal fibrogenesis in mice.

Methods and Results: Analysis of cardiac and renal cells demonstrates that L002 inhibits specific histone acetylation and blunts TGF-b induced profibrogenic processes, including cellular proliferation, migration, myofibroblast differentiation and extracellular matrix protein synthesis. The mRNA analysis further indicates that matrix protein, collagen, and myofibroblast marker, a-SMA are inhibited at the transcriptional level. L002 also prevents TGF-b-induced FATp300 upregulation suggesting that TGF-b-induced FATp300 expression is partly self-regulated. However, TGF-b-induced Smad activation is unaltered in the presence of L002, demonstrating its target specificity. Further, mice infused with Angiotensin II show increased blood pressure, cardiac hypertrophy and increased heart weight. Conversely, co-administration of L002 reduces Angiotensin II-induced cardiac hypertrophy and left ventricular wall thickness. Most importantly, L002 administration ameliorates Angiotensin II-induced cardiac and renal fibrosis in mice.

Conclusions: Taken together this study demonstrates that specific pharmacological inhibition of elevated factor acetyltransferase activity of p300, a major epigenetic regulator, is an ideal approach to control hypertension- or other stress-induced cardiac and renal fibrogenesis as seen in a wide variety of cardiovascular and renal diseases.

A Profile of Patients with Molar Pregnancy

Aims: This study was done to determine the incidence, modes of presentation and prognosis of molar pregnancy at B. P. Koirala Institute of Health Sciences.Methods: This was a prospective study done among patients with molar pregnancy admitted at BPKIHS from January 2010 to January 2011. The study was conducted after ethical clearance from Institutional Ethical Review Board of BPKIHS. Written informed consent was taken for enrollment in the study. Baseline information like age, address, race  and patient’s  presenting complaints, period of gestation and serial serum beta human chorionic gonadotropin (βhCG) were collected and analyzed after entering in excel sheet.Results: Total 48 cases of molar pregnancy were diagnosed during the study period. The incidence of molar pregnancy was found to be 5.58 per 1000 deliveries. The most common mode of presentation was per vaginal bleeding i.e. in  64.58% of cases. Majority of the patients were in the age group of 20-34 years (62.5%). Mean time for normalization of βhCG after suction evacuation was 10.19 weeks.Conclusions: Molar pregnancy is a pregnancy related problem which most commonly presents with per vaginal bleeding during first and second trimester. Most of the patients are treated with suction and evacuation but some develop persistent gestational trophoblastic disease.

Plasminogen Activator Inhibitor-1 Is a Marker and a Mediator of Senescence

PAI-1 (plasminogen activator inhibitor-1) is a member of the evolutionarily conserved serine protease inhibitor family and a potent and rapid-acting inhibitor of both of the mammalian plasminogen activators. Organismal homeostasis requires physiological levels of endogenous PAI-1, and increased PAI-1 production guides the onset and progression of numerous human diseases and contributes to the multimorbidity of aging. Both chronological and stress-induced accelerated aging are associated with cellular senescence and accompanied by marked increases in PAI-1 expression in tissues. Recent studies suggest that PAI-1 is not only a marker but also a key mediator of cellular senescence and organismal aging. Here, we review the significance of PAI-1 as a bonafide marker, as well as a critical mediator, of cellular senescence associated with aging and aging-related pathologies.

Retracted Publications in Orthopaedics: Prevalence, Characteristics, and Trends

BACKGROUND

Retracted publications are a crucial, yet overlooked, issue in the scientific community. The purpose of our study was to assess the prevalence, characteristics, and trends of retracted publications in the field of orthopaedics.

METHODS

Five databases were utilized to identify retracted publications in orthopaedics. The cited articles were assessed for various characteristics, including reason for retraction, based on the Committee on Publication Ethics (COPE) guidelines and trends over time.

RESULTS

From 1984 to June 4, 2016, 59 of 229,502 orthopaedic publications were retracted (3 per 10,000 articles). There was a spike in the prevalence (22 of 59) of retracted articles in 2015. When compared with the total number of retracted publications identified through PubMed, the field of orthopaedics represented 1.4% of all retracted publications. The original version of 47 of these 59 retracted publications was still available on the respective journal's web site; 14 (30%) of these were not noted as having been retracted. The mean time from electronic publication to retraction was 19.4 ± 23.3 months. The mean number of citations of a retracted publication after the date of retraction was 9.3 ± 19.3. Reasons for retraction included plagiarism (32%), misconduct (27%), redundant publication (22%), miscalculation or experimental error (8%), and unethical research (0%); the reason for retraction was not stated for 10% of the publications. There was no correlation between a journal's impact factor and the mean number of months to retraction (p = 0.564).

CONCLUSIONS

While uncommon, the retraction of publications within the field of orthopaedics may be increasing. The most often cited reasons for retraction were plagiarism, misconduct, and redundant publication. Retracted articles continue to be cited in the literature after retraction.

CLINICAL RELEVANCE

Greater awareness of the COPE guidelines within the orthopaedic community and more efficient means to prevent the citation of retracted articles are needed.

Technical Note: Experimental results from a prototype high-field inline MRI-linac

PURPOSE

The pursuit of real-time image guided radiotherapy using optimal tissue contrast has seen the development of several hybrid magnetic resonance imaging (MRI)-treatment systems, high field and low field, and inline and perpendicular configurations. As part of a new MRI-linac program, an MRI scanner was integrated with a linear accelerator to enable investigations of a coupled inline MRI-linac system. This work describes results from a prototype experimental system to demonstrate the feasibility of a high field inline MR-linac.

METHODS

The magnet is a 1.5 T MRI system (Sonata, Siemens Healthcare) was located in a purpose built radiofrequency (RF) cage enabling shielding from and close proximity to a linear accelerator with inline (and future perpendicular) orientation. A portable linear accelerator (Linatron, Varian) was installed together with a multileaf collimator (Millennium, Varian) to provide dynamic field collimation and the whole assembly built onto a stainless-steel rail system. A series of MRI-linac experiments was performed to investigate (1) image quality with beam on measured using a macropodine (kangaroo) ex vivo phantom; (2) the noise as a function of beam state measured using a 6-channel surface coil array; and (3) electron contamination effects measured using Gafchromic film and an electronic portal imaging device (EPID).

RESULTS

(1) Image quality was unaffected by the radiation beam with the macropodine phantom image with the beam on being almost identical to the image with the beam off. (2) Noise measured with a surface RF coil produced a 25% elevation of background intensity when the radiation beam was on. (3) Film and EPID measurements demonstrated electron focusing occurring along the centerline of the magnet axis.

CONCLUSIONS

A proof-of-concept high-field MRI-linac has been built and experimentally characterized. This system has allowed us to establish the efficacy of a high field inline MRI-linac and study a number of the technical challenges and solutions.