[The effect of the ratio of aneurysm sac diameter to patient age on the long-term efficacy of different surgical methods for infrarenal abdominal aortic aneurysm]

Objective: To investigate the effect of the ratio of the maximum diameter of aneurysm sac to age (R) on the long-term efficacy of endovascular aneurysm repair (EVAR) and open surgical repair (OSR) in patients with infrarenal abdominal aortic aneurysm (IAAA). Methods: This is a retrospective cohort study.The clinical data of 317 patients with IAAA who underwent surgical repair in the Department of Vascular Surgery,the Third Affiliated Hospital of Sun Yat-Sen University from January 2016 to October 2022 were retrospectively collected.There were 266 males and 51 females,aged (69.7±8.3) years (range:37 to 87 years).The R value of the patient was calculated and the receiver operating characteristic(ROC) curve was used to establish a model to calculate the optimal cut-off value.The propensity score matching method was used to match the baseline data of patients in the EVAR and OSR group by 3∶1 (the caliper value was 0.05),and the patients were stratified according to the cutoff value of R,and the postoperative efficacy and survival of the patients were analyzed.The primary endpoint was the total mortality rate,and the secondary endpoints included the occurrence of postoperative complications and reintervention.Pearson χ2 or Fisher 's exact test was used for categorical variables,and t test was used for continuous variables to compare differences between groups.The survival curves of the two groups were described by Kaplan-Meier method. Results: After propensity score matching,198 cases were in the EVAR group and 66 cases were in the OSR group.The ROC model showed that the best cut-off value of R value was 0.90,and the two groups were divided into two layers:R<0.90 and R≥0.90.Among them,112 patients with R<0.90 (84 cases of EVAR,28 cases of OSR);there were 152 patients with R≥0.90 (114 cases of EVAR and 38 cases of OSR).The follow-up time was (23.6±1.6) months (range:1 to 70 months).In the R≥0.90 stratification,the total mortality (26.3% vs.5.3%,P<0.05),complication rate (44.7% vs.26.3%,P<0.05), and secondary intervention rate (31.6% vs.13.2%,P<0.05) in the EVAR group were higher than those in the OSR group.In the R<0.90 stratification,there was no significant difference in the total mortality rate (13.1% vs.10.7%,P<0.05),complication rate (28.6% vs.35.7%,P>0.05) and secondary intervention rate (14.3% vs.21.4%, P>0.05) between the two groups. Conclusions: When R≥0.90 in IAAA patients,OSR maybe more beneficial to patients in terms of survival rate,postoperative complication rate and secondary intervention rate than EVAR.When R<0.90,there are no significant differences in survival rate,complication rate and secondary intervention rate between the two surgical methods.

Effect of contact precautions on preventing meticillin-resistant Staphylococcus aureus transmission in intensive care units: a review and modelling study of field trials

BACKGROUND

Contact precautions (CPs) have been widely implemented in hospitals, particularly in intensive care units (ICUs), as the standard approach for managing meticillin-resistant Staphylococcus aureus (MRSA). However, the effectiveness of CPs in preventing MRSA transmission remains a subject of debate.

AIM

To assess the effectiveness of CPs in reducing MRSA transmission within ICUs.

METHODS

A comprehensive analysis was conducted using data from 16 sets of parameters collected from 13 field studies investigating the effectiveness of CPs in ICUs, and an epidemiologic model was developed to simulate the dynamics of MRSA incidence in the hospital setting.

FINDINGS

The analysis demonstrated a mean reduction of 20.52% (95% confidence interval -30.52 to 71.60%) in the MRSA transmission rate associated with the implementation of CPs. Furthermore, reducing the time-delay of screening tests and increasing the percentage of patients identified with MRSA through screening at admission were found to contribute to the effectiveness of CPs.

CONCLUSION

Proper implementation of CPs, with a particular emphasis on early identification of MRSA-colonized/infected patients, demonstrated a strong association with reduced MRSA transmission within the hospital setting. However, further research is necessary to investigate the effectiveness and safety of decolonization and other interventions used in conjunction with CPs to mitigate the risk of infection among colonized patients.

[Metagenomic next-generation sequencing for the diagnosis of Pneumocystis jirovecii pneumonia after allogeneic hematopoietic stem cell transplantation]

Objectives: To investigate the value of metagenomic next-generation sequencing (mNGS) in the diagnosis of Pneumocystis jirovecii pneumonia (PJP) in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) . Methods: The data of 98 patients with suspected pulmonary infection after allo-HSCT who underwent pathogen detection from bronchoalveolar lavage fluid between June 2016 and August 2023 at Nanfang Hospital were analyzed. The diagnostic performance of mNGS, conventional methods, and real-time quantitative polymerase chain reaction (qPCR) for PJP were compared. Results: A total of 12 patients were diagnosed with PJP, including 11 with a proven diagnosis and 1 with a probable diagnosis. Among the patients with a proven diagnosis, 1 was positive by both conventional methods and qPCR, and 10 were positive by qPCR only. Pneumocystis jirovecii was detected by mNGS in all 12 patients. The diagnostic sensitivity of mNGS for PJP was 100%, which was greater than that of conventional methods (8.3%, P=0.001) and similar to that of qPCR (91.6%, P=1.000) . A total of 75% of the patients developed mixed pulmonary infections, and cytomegalovirus and Epstein-Barr virus were the most common pathogens. Mixed infection was detected in eight patients by mNGS and in five patients by qPCR, but not by conventional methods (P=0.008) . Conclusions: mNGS had good sensitivity for diagnosing PJP after allo-HSCT and was advantageous for detecting mixed infectious pathogens; therefore, mNGS might be an effective supplement to regular detection methods and qPCR.

A frequentist approach to dynamic borrowing

There has been growing interest in leveraging external control data to augment a randomized control group data in clinical trials and enable more informative decision making. In recent years, the quality and availability of real-world data have improved steadily as external controls. However, information borrowing by directly pooling such external controls with randomized controls may lead to biased estimates of the treatment effect. Dynamic borrowing methods under the Bayesian framework have been proposed to better control the false positive error. However, the numerical computation and, especially, parameter tuning, of those Bayesian dynamic borrowing methods remain a challenge in practice. In this paper, we present a frequentist interpretation of a Bayesian commensurate prior borrowing approach and describe intrinsic challenges associated with this method from the perspective of optimization. Motivated by this observation, we propose a new dynamic borrowing approach using adaptive lasso. The treatment effect estimate derived from this method follows a known asymptotic distribution, which can be used to construct confidence intervals and conduct hypothesis tests. The finite sample performance of the method is evaluated through extensive Monte Carlo simulations under different settings. We observed highly competitive performance of adaptive lasso compared to Bayesian approaches. Methods for selecting tuning parameters are also thoroughly discussed based on results from numerical studies and an illustration example.

A Ferroptosis Microneedle Integrated Wireless Implanted Photodynamic Therapy Pellet for Cancer Treatment

PURPOSE/OBJECTIVE(S)

Effective, non-toxic, and targeted induction of lung cancer cell death is urgently needed. The goal of this research is to create a new implantable battery-free therapeutic pellet with integrated drug microneedles that allows for wireless photodynamic therapy (PDT) and targeted release of a ferroptosis inducer (Imidazole ketone erastin, IKE) into tumor tissue.

MATERIALS/METHODS

A wireless power unit, μ-LED illuminant, a flexible control circuit, and an IKE-stored biodegradable microneedle enclosed in polydimethylsiloxane (PDMS) were all built into an integrated therapeutic pellet. Lung cancer cells were used to illustrate the in vitro viability and molecular biological processes of this system. Therapeutic pellet implanted into the LLC xenograft C57BL/6 model. PDT was conducted by 660 nm laser irradiation after injecting a photosensitizer (Chlorin e6, Ce6) and targeted IKE released into the tumor. Systematically analyzing the therapeutic effects on lung cancer and toxic side-effects.

RESULTS

The PDT-IKE group reduced cellular viability by 90% compared to the control group at the cellular level. In mouse model studies, the PDT-IKE group suppressed tumors at 78.8%, three or four times greater than the PDT (26.6%) or IKE (19.2%) group alone. The PDT-IKE group also controlled IKE release more precisely with heated electrodes, reducing nephrotoxicity and improving safety. Moreover, the combination of PDT and IKE can effectively cause ferroptosis in tumor cells, both in vivo and in vitro.

CONCLUSION

A new implantable battery-free therapeutic pellet was designed for wireless PDT with integrated IKE microneedles to induce obvious ferroptosis in lung cancer. The proposed pellet would provide a promising strategy for cancer treatment.

Nurse-led dexmedetomidine sedation for magnetic resonance imaging in children: a 6-year quality improvement project

We aimed to safely introduce dexmedetomidine into a nurse-led sedation service for magnetic resonance imaging in children. Secondary aims were to increase the number of children eligible for sedation and to increase the actual number of children having sedation performed by our nurse sedation team. We analysed 1768 consecutive intravenous and 219 intranasal dexmedetomidine sedation episodes in infants, children and adolescents having magnetic resonance imaging scans between March 2016 and March 2022. The overall sedation success rate was 98.4%, with a 98.9% success rate for intravenous dexmedetomidine and a 95.0% success rate for intranasal dexmedetomidine. The incidence of scan interruption during intravenous and intranasal dexmedetomidine sedation was 8.8% and 21.9%, respectively. We conclude that paediatric sedation with dexmedetomidine for magnetic resonance scanning is safe and successful.

Deep learning for predicting the risk of immune checkpoint inhibitor-related pneumonitis in lung cancer

AIM

To develop and validate a nomogram model that combines computed tomography (CT)-based radiological factors extracted from deep-learning and clinical factors for the early predictions of immune checkpoint inhibitor-related pneumonitis (ICI-P).

MATERIALS AND METHODS

Forty ICI-P patients and 101 patients without ICI-P were divided randomly into the training (n=113) and test (n=28) sets. The convolution neural network (CNN) algorithm was used to extract the CT-based radiological features of predictable ICI-P and calculated the CT score of each patient. A nomogram model to predict the risk of ICI-P was developed by logistic regression.

RESULTS

CT score was calculated from five radiological features extracted by the residual neural network-50-V2 with feature pyramid networks. Four predictors of ICI-P in the nomogram model included a clinical feature (pre-existing lung diseases), two serum markers (absolute lymphocyte count and lactate dehydrogenase), and a CT score. The area under curve of the nomogram model in the training (0.910 versus 0.871 versus 0.778) and test (0.900 versus 0.856 versus 0.869) sets was better than the radiological and clinical models. The nomogram model showed good consistency and better clinical practicability.

CONCLUSION

The nomogram model that combined CT-based radiological factors and clinical factors can be used as a new non-invasive tool for the early prediction of ICI-P in lung cancer patients after immunotherapy with low cost and low manual input.

A meta-analytic framework to adjust for bias in external control studies

While randomized controlled trials (RCTs) are the gold standard for estimating treatment effects in medical research, there is increasing use of and interest in using real-world data for drug development. One such use case is the construction of external control arms for evaluation of efficacy in single-arm trials, particularly in cases where randomization is either infeasible or unethical. However, it is well known that treated patients in non-randomized studies may not be comparable to control patients-on either measured or unmeasured variables-and that the underlying population differences between the two groups may result in biased treatment effect estimates as well as increased variability in estimation. To address these challenges for analyses of time-to-event outcomes, we developed a meta-analytic framework that uses historical reference studies to adjust a log hazard ratio estimate in a new external control study for its additional bias and variability. The set of historical studies is formed by constructing external control arms for historical RCTs, and a meta-analysis compares the trial controls to the external control arms. Importantly, a prospective external control study can be performed independently of the meta-analysis using standard causal inference techniques for observational data. We illustrate our approach with a simulation study and an empirical example based on reference studies for advanced non-small cell lung cancer. In our empirical analysis, external control patients had lower survival than trial controls (hazard ratio: 0.907), but our methodology is able to correct for this bias. An implementation of our approach is available in the R package ecmeta.

Neoadjuvant chemotherapy and radiotherapy outcomes in borderline-resectable and locally-advanced pancreatic cancer patients

BACKGROUND

There is no agreed upon standard of care for borderline-resectable pancreatic cancer (BRPC) or locally-advanced pancreatic cancer (LAPC) patients regarding the benefit of chemotherapy or radiation alone or in combination.

PATIENTS AND METHODS

We completed a retrospective cohort analysis of BRPC and LAPC patients at a cancer center with expertise in multi-disciplinary pancreatic ductal adenocarcinoma (PDAC) treatment over a 5-year period from 03/01/2014 to 03/01/2019 (cut-off date). The total evaluable newly diagnosed, treatment naïve, BRPC, and LAPC patients with adequate organ function and ability to obtain treatment after multidisciplinary review was 52 patients. After analysis, patients were evaluated for rates of resection, extent of resection (R0 or R1), median progression-free survival (mPFS), and median overall survival (mOS).

RESULTS

Patients were treated with chemotherapy alone (gemcitabine and nab-paclitaxel = 77% (20/26); FOLFIRINOX = 19% (5/26); single agent gemcitabine 3.8% (1/26)), or chemotherapy followed by chemoradiation (gemcitabine +5 Gy × 5 weeks), or chemoradiation alone prior to re-staging and potential resection. Of the 29% (15/52) of patients who went on to surgical resection, 73% (11/15) achieved R0 resection. An R0 resection was achieved in 35% (9/26) of patients treated with chemotherapy alone, 7.6% (1/13) in a patient treated with chemotherapy followed by radiation, and 7.6% (1/13) with concurrent chemoradiotherapy alone. Chemotherapy alone achieved a mPFS of 16.4 months (p  < 0.0025) and mOS of 26.2 months (p  < 0.0001), chemotherapy followed by chemoradiation was 13.0 months and 14.9 months respectively, while concurrent chemoradiotherapy was 6.9 months and 7.3 months.

CONCLUSIONS AND RELEVANCE

BRPC and LAPC patients capable of surgery after only receiving neoadjuvant treatment with chemotherapy had higher rates of R0 resection with prolonged median PFS and OS compared with any patient needing combination chemotherapy with radiotherapy.

Sustaining Antimicrobial Stewardship in a High-Antibiotic Resistance Setting

IMPORTANCE

There is a lack of studies comparing the intended and unintended consequences of prospective review and feedback (PRF) with computerized decision support systems (CDSS), especially in the longer term in antimicrobial stewardship.

OBJECTIVE

To examine the outcomes associated with the sequential implementation of PRF and CDSS and changes to these interventions with long-term use of antibiotics for and incidence of multidrug resistant organisms (MDROs) and other unintended outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used an interrupted time series with segmented regression analysis of data from January 2007 to December 2018. Data were extracted from the electronic medical records of patients admitted at a large university teaching hospital with high rates of antibiotic resistance in Singapore. Data were analyzed from June 2019 to June 2020.

EXPOSURES

PRF of piperacillin-tazobactam and carbapenems (intervention 1, April 2009), with the addition of hospital-wide CDSS (intervention 2, April 2011), and lifting of CDSS for half of the hospital wards for 6 months (intervention 3, March 2017).

MAIN OUTCOMES AND MEASURES

Monthly antimicrobial use was measured in defined daily doses (DDDs) per 1000 patient-days. The monthly incidence of MDROs was calculated as number of clinical isolates detected per 1000 inpatient-days over a 6-month period. Unintended outcomes examined included in-hospital mortality and age-adjusted length of stay (LOS).

RESULTS

The number of inpatients increased from 56 263 in 2007 to 63 572 in 2018. During the same period, the mean monthly patient days increased from 33 929 in 2007 to 45 603 in 2018, and the proportion of patients older than 65 years increased from 45.5% in 2007 to 56.6% in 2018. After intervention 1, there were 0.33 (95% CI, 0.18 to 0.48) more DDDs per 1000 patient-days per month of piperacillin-tazobactam and carbapenems and -11.05 (95% CI, -15.55 to -6.55) fewer DDDs per 1000 patient-days per month for other broad-spectrum antibiotics. After intervention 2, there were -0.22 (95% CI, -0.33 to -0.10) fewer DDDs per 1000 patient-days per month of piperacillin-tazobactam and carbapenems and -2.10 (95% CI, -3.13 to -1.07) fewer DDDs per 1000 patient-days per month for other broad-spectrum antibiotics. After intervention 3, use of piperacillin-tazobactam and carbapenem increased by 0.28 (95% CI, 0.02 to 0.55) DDDs per 1000 patient-days per month. After intervention 2, incidence of Clostridioides difficile decreased (estimate, -0.02 [95% CI, -0.03 to -0.01] cases per 1000 patient-days per month).

CONCLUSIONS AND RELEVANCE

In this cohort study, concurrent PRF and CDSS were associated with limiting the use of piperacillin-tazobactam and carbapenems while reducing use of other antibiotics.

[Effect of enhanced recovery after surgery on surgical stress response in patients with gastric cancer complicated with type 2 diabetes mellitus]

Objective: To investigate the effect of enhanced recovery after surgery on the stress response of gastric cancer patients complicated with type 2 diabetes mellitus. Methods: We retrospectively analyzed the data of 49 patients with type 2 diabetes who underwent radical gastrectomy for gastric cancer in the Department of gastroenterology of the Affiliated Hospital of Jiangsu University from Jan to Dec 2020. They were randomly divided into experimental group and control group according to different perioperative management measures. The perioperative C-reactive protein (CRP), white blood cell (WBC), interleukin-6(IL-6), insulin resistance (HOMA-IR), blood glucose fluctuation and postoperative recovery were compared between the two groups. Results: A total of 49 patients were enrolled in the study (23 in the experimental group and 26 in the control group). The degree of stress reaction of the experimental group was lighter than that of the control group. The levels of CRP were significantly different on the 5th and 7th day after operation, IL-6 was significantly different on the 1st, 3rd, 5th and 7th day after operation, WBC and HOMA-IR were significantly different on the 1st day postoperatively. And the changes of HOMA-IR and blood glucose in experimental group were more gentle than those in control group. All the differences were statistically significant(P<0.05). In the experimental group, the time of first anal exhaust, indwelling time of drainage tube or nasointestinal tube and the total hospitalization time were significantly shorter than those of the control group(P<0.05). Conclusion: ERAS can reduce the degree of inflammatory stress and the postoperative IR level promote the early recovery of patients with gastric cancer complicated with type 2 diabetes mellitus.

[Association between metabolically healthy obesity and incident risk of stroke in adult aged over 40 from rural Henan province]

Objective: To investigate the association between metabolically healthy obesity and the incident risk of stroke in people aged ≥40 years from rural areas of Henan Province. Methods: During 2007 to 2008, 20 194 residents aged ≥18 years were selected for baseline examination by random cluster sampling and 17 265 participants were followed up during 2013 to 2014. According to the aim of current study, a total of 11 864 eligible subjects were included in this post-hoc analysis. Depending on body mass index and metabolic status, subjects were divided into four groups: metabolically healthy normal weight, metabolically healthy obesity, metabolically abnormal normal weight and metabolically abnormal obesity. Multivariate logistic regression model was used to analyze the relationship between metabolically healthy obesity and the risk of stroke. Results: The median (Q₁, Q₃) age of study participants was 54(46, 61) years, and 4 526 participants were men. During the mean follow-up of 6 years, the cumulative incidence of stroke was 7.16%. The incidence of stroke in metabolically healthy normal weight, metabolically healthy obesity, metabolically abnormal normal weight, and metabolically abnormal obesity were 3.73%, 4.61%, 8.99% and 9.38%, respectively (χ²=117.458, P<0.001). After adjusting possible confounding factors, compared with metabolically healthy normal weight, the risk of stroke was significantly increased in the metabolically healthy obesity group, metabolically abnormal normal weight group and metabolically abnormal obesity group with the odds ratio (OR) and 95% confidence interval (CI) of 1.52(1.10-2.12), 2.11(1.61-2.77) and 2.78(2.18-3.55), respectively. Stratified analysis showed that the risk of stroke was significantly higher in metabolically healthy obesity people aged 40-59 years compared with metabolically healthy normal weight group (OR=2.12, 95%CI: 1.36-3.30). Conclusion: Metabolically healthy obesity, metabolically abnormal normal weight and metabolically abnormal obesity are positively associated with the risk of stroke.

Tri-modal management of primary small cell carcinoma of the pancreas (SCCP): a rare neuroendocrine carcinoma (NEC)

Background

Primary small cell carcinoma of the pancreas (SCCP) is a rare malignant neuroendocrine carcinoma (NEC). Typically, it presents with lymphovascular invasion as well as metastasis at the time of diagnosis which portends a dismal prognosis. Treatment is typically based on therapy used for other aggressive NECs such as small cell lung cancer. Although multimodal surgery, radiation and chemotherapy may improve prognosis, the outcome generally remains poor.

Case presentation

Here we present a primary SCCP managed with neoadjuvant multi-agent chemotherapy combined with radiotherapy and surgery

Conclusions

Multi-disciplinary therapy resulted in an ongoing 28 + month radiographic complete response and overall survival.

Abstract 1869: Novel TNFR2 antibodies to overcome T cell exhaustion and suppressive tumor microenvironment

TNFR2 is highly expressed on the surface of activated T effector cells, T regulatory cells and myeloid cells, and it plays essential roles in modulating the tumor microenvironment. In most cancer types, higher TNFR2 expression correlates with increased immune cell infiltration. Furthermore, the TNFR2 gene is differentially expressed in various cancer types, including breast, lung, renal, liver and skin cancers. In cancers such as head and neck cancer and cutaneous melanoma, high TNFR2 expression correlates with better overall survival. The therapeutic potential of antibodies targeting TNFR2 has been demonstrated by agonist antibodies for the T effector cells, and antibodies that antagonize or deplete the T regulatory cells and suppressive myeloid cells. We discovered novel TNFR2 antibodies that demonstrate unique mechanisms to overcome T cell exhaustion and the suppressive tumor microenvironment for more effective immunotherapy. In vitro studies have shown that our antibodies block TNFα ligand binding and potently inhibit TNFR2 signaling in the monocytic cells. Moreover, these antibodies enhance CD8 T cell function to overcome the suppressive effect from the T regulatory cells and can invigorate exhausted CD8 T cells in an FcγR-dependent manner. In a humanized mouse model, our antibodies demonstrate strong anti-tumor efficacy as single agents or in combination with a PD-L1 inhibitor. Therefore, these antibodies offer potential advantages when the tumor microenvironment is enriched in the exhausted T cells, the suppressive myeloid cells, or the regulatory T cells, as found in anti-PD-1/PD-L1 resistant and PD-1 refractory patients. In conclusion, the data obtained indicate that our TNFR2 antibodies are a novel and promising class of drug candidates for cancer immunotherapeutics. Our lead antibody is currently at the IND-enabling stage with the target of entering clinical studies in early 2022.

Citation Format: Chi Shing Sum, Makenzie Danton, Qii hu, Alla Pritsker, Ray Lin, Raymond Yu, Kevin Chen, Fangqiang Tang, Thomas Pohl, Samantha Wallner, Ahmed Hassan, Huarui Lu, Haichun Huang, James Pei, Zhong Liu, Han Li, Ming Lei. Novel TNFR2 antibodies to overcome T cell exhaustion and suppressive tumor microenvironment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1869.

Checkpoint Inhibition in the Treatment of Unresectable, Advanced Lymphoepithelioma-like Hepatocellular Carcinoma

Lymphoepithelioma-like hepatocellular carcinoma (LEL-HCC) is a very rare neoplasm, with distinct epidemiologic, morphologic and clinical characteristics. Molecular mechanistic insight into the pathogenesis of this carcinoma suggests a pivotal role for the host immune system in the proliferation and progression of this tumor. However, while detailed genomic profiling of these hepatic tumors have revealed an intra-tumoral inflammatory mutational signature that may predispose to immune checkpoint inhibitor efficacy, no published report has described their use in this tumor type. Unfortunately, with near 100 cases of LEL-HCC reported in the literature to date and the majority of cases confined to localized and resectable disease, current evidence-based practices in the unresectable setting are lacking, with unknown benefit of chemotherapy or immunotherapy. We report on the case of a 68 year-old man with unresectable, advanced LEL-HCC who had evidence of disease stability after starting on the immune checkpoint inhibitor nivolumab. His disease response persisted off therapy for over a year and was potentially augmented by radiotherapy at the site of local progression. For this extremely rare tumor subtype, this case highlights the potential efficacy and safety of immune checkpoint blockade in LEL-HCC and reinforces the need for more robust, large-scale analysis of patients with these rare tumors to better evaluate treatment strategies and outcomes.

The Impact of Clinical Presentation on Survival in Patients Requiring Hemodialysis Catheters for Acute and Unplanned Dialysis: A Prospective Observational Study

BACKGROUND

Most studies addressing hemodialysis initiation with a dialysis catheter focus on patients entering maintenance dialysis programs and exclude other patients, such as those with acute kidney injury (AKI), making interpretation and application of the results difficult for clinicians managing patients at the time of dialysis commencement.

OBJECTIVE

To compare the survival of all patients requiring a catheter for hemodialysis access according to the nature of clinical presentation.

DESIGN

Prospective observational.

SETTING

An Australian tertiary renal unit.

PATIENTS

All patients requiring a central venous catheter (CVC) for hemodialysis access between 2005 and 2015.

MEASUREMENTS

Baseline comorbidities, demographics, and nature of clinical presentation. Data regarding each episode of dialysis access insufficiency and each CVC were collected. The primary outcome was all-cause mortality.

METHODS

Patients were classified into 1 of 3 groups based on physician assessment at the time of presentation: patients believed to have AKI with expected renal recovery (AKI), patients considered to be entering the maintenance dialysis program without a functioning dialysis access (Maintenance Dialysis), patients unable to perform peritoneal dialysis, or use their existing hemodialysis access (Access Failure). Time-split multivariable Cox regression analyses were used to compare survival between groups.

RESULTS

A total of 557 eligible patients had complete prospective data regarding CVC use and were included in the analyses. The majority of patients were in the AKI (246/557, 44%) and Maintenance Dialysis groups (182/557, 33%) compared with the Access Failure group (129/557, 23%). During a median follow-up of 3 years, 302 (54%) of the 557 patients died. Following adjustment, risk of all-cause mortality was higher in the AKI group (hazard ratio [HR]: 2.01, 95% confidence interval [CI]: 1.31-3.60, P = .001) during the first 2 years after catheter insertion and lower in years 2 to 4 (HR: 0.42, 95% CI: 0.20-0.88, P = .02) than in the reference Maintenance Dialysis group. No difference in mortality risk between the Access Failure and reference group was found.

LIMITATIONS

Single-center study. Possible residual confounding owing to the observational study design.

CONCLUSIONS

Patients requiring acute or unplanned hemodialysis experience high mortality, and the nature of clinical presentation does influence outcomes. Most notable is the greater early mortality experienced by patients with AKI compared to other patient groups. Prospective definition of the nature of unplanned dialysis initiation is important to accurately measure and improve outcomes in this high-risk patient population.

HUMAN RESEARCH ETHICS COMMITTEE APPROVAL NUMBER

CH62/6/2017-042.

Identification Of Strn-Ntrk2 Rearrangement In A High Grade Sarcoma, With Good Clinical Response To Firstline Larotrectinib Therapy

Casestudy

Gene fusions involving tropomyosin receptor kinase genes, NTRK (NTRK1-3), are important in tumorigenesis. Larotrectinib, a selective NTRK inhibitor, is recently approved to treat NTRK fusion positive solid tumors. We herein report a case of soft tissue sarcoma harboring two STRN-NTRK2 gene fusions, with good clinical response to firstline larotrectinib treatment.

Results

A 35 year-old female presented with pain in the right gluteal region, and a large solid mass without overlying erythema, edema and induration was identified. Initial MRI study showed a heterogenous, vascular and partially necrotic mass (16.5 x 12.9 x 10.4 cm) centered in the right gluteus medius and maximus muscles. A core biopsy of the mass showed a cellular mesenchymal neoplasm with round/ovoid cells, high mitosis (21 per 10 HPFs) and focal staghorn type vessels, reminiscent of solitary fibrous tumor. However, STAT6 immunostaining was negative.

Additional immunostains show no specific lineage. Our in-house NGS fusion panel showed two in-frame STRN- NTRK2 fusions, containing the same 5’ partner sequence (exon 1-3) of STRN, with the 3’ fusion partner starting from either the exon 15 or the exon 16 of NTRK2. Due to the large size and location of the tumor, larotrectinib was initiated as firstline therapy. The patient noticed a quick amelioration of tumor related pain, and a significant shrinkage of the size of tumor following the initial 7-day treatment. On post-treatment day 52, MRI showed the tumor significantly decreased in size to 7.7 x 7.4 x 6.6 cm with satisfactory symptomatic relief.

Conclusion

NTRK2 fusions are relatively rare when compared with NTRK1 and NTRK3, especially in sarcoma. Of note, the only other report in the literature of NRTK2 fusion- positive sarcoma also showed SFT-like morphology, and the patient responded well to larotrectinib as second line therapy.

Identification Of Strn-Ntrk2 Rearrangement In A High Grade Sarcoma, With Good Clinical Response To Firstline Larotrectinib Therapy

Casestudy

Gene fusions involving tropomyosin receptor kinase genes, NTRK (NTRK1-3), are important in tumorigenesis. Larotrectinib, a selective NTRK inhibitor, is recently approved to treat NTRK fusion positive solid tumors. We herein report a case of soft tissue sarcoma harboring two STRN-NTRK2 gene fusions, with good clinical response to firstline larotrectinib treatment.

Results

A 35 year-old female presented with pain in the right gluteal region, and a large solid mass without overlying erythema, edema and induration was identified. Initial MRI study showed a heterogenous, vascular and partially necrotic mass (16.5 x 12.9 x 10.4 cm) centered in the right gluteus medius and maximus muscles. A core biopsy of the mass showed a cellular mesenchymal neoplasm with round/ovoid cells, high mitosis (21 per 10 HPFs) and focal staghorn type vessels, reminiscent of solitary fibrous tumor. However, STAT6 immunostaining was negative.

Additional immunostains show no specific lineage. Our in-house NGS fusion panel showed two in-frame STRNNTRK2 fusions, containing the same 5’ partner sequence (exon 1-3) of STRN, with the 3’ fusion partner starting from either the exon 15 or the exon 16 of NTRK2. Due to the large size and location of the tumor, larotrectinib was initiated as firstline therapy. The patient noticed a quick amelioration of tumor related pain, and a significant shrinkage of the size of tumor following the initial 7-day treatment. On post-treatment day 52, MRI showed the tumor significantly decreased in size to 7.7 x 7.4 x 6.6 cm with satisfactory symptomatic relief.

Conclusion

NTRK2 fusions are relatively rare when compared with NTRK1 and NTRK3, especially in sarcoma. Of note, the only other report in the literature of NRTK2 fusion- positive sarcoma also showed SFT-like morphology, and the patient responded well to larotrectinib as second line therapy.

Identification of differentially expressed genes and signalling pathways in the ovary of higher and lower laying ducks

1. Ovarian transcriptomic profiling between birds showing high egg number (HEN) and birds of low egg number (LEN) in Longyan Shan-ma ducks at 71 weeks of age was carried out using Illumina Hiseq 2500 technology. 2. A total of 343 differentially expressed genes (DEGs, 269 upregulated and 74 downregulated) were identified between HEN and LEN ovaries. These DEGs were enriched in 30 Gene Ontology terms. Pathway functional analysis found that the DEGs were enriched in 10 metabolic pathways (P < 0.05), one of which was regulation of the actin cytoskeleton pathway (Q < 0.05). 3. Three integrin family genes, ITGB2, ITGB5 and ITGA8 were differentially expressed in the RNA-seq and qPCR experiments. 4. The DEGs and signalling pathways identified in ovarian tissue in this study provide new insights into high egg production in Longyan Shan-ma duck.

Multiplexed drug testing of tumor slices using a microfluidic platform

Current methods to assess the drug response of individual human cancers are often inaccurate, costly, or slow. Functional approaches that rapidly and directly assess the response of patient cancer tissue to drugs or small molecules offer a promising way to improve drug testing, and have the potential to identify the best therapy for individual patients. We developed a digitally manufactured microfluidic platform for multiplexed drug testing of intact cancer slice cultures, and demonstrate the use of this platform to evaluate drug responses in slice cultures from human glioma xenografts and patient tumor biopsies. This approach retains much of the tissue microenvironment and can provide results rapidly enough, within days of surgery, to guide the choice of effective initial therapies. Our results establish a useful preclinical platform for cancer drug testing and development with the potential to improve cancer personalized medicine.

Transinguinal preperitoneal repair of giant inguinoscrotal hernias using Kugel mesh

INTRODUCTION

Giant inguinoscrotal hernias are rarely encountered in clinical settings, and their repair is technically challenging. The aim of this study is to evaluate the efficacy of transinguinal preperitoneal repair (TIPP) of giant inguinoscrotal hernias using Kugel mesh.

METHODS

A retrospective analysis was conducted on 9 patients with 11 giant inguinoscrotal hernias who underwent TIPP repair using Kugel mesh between December 2008 and January 2019. Demographics and perioperative and postoperative data were collected, and the operative experience was summarized.

RESULTS

The patients underwent a successful repair procedure with simultaneous omentectomy but without resection of the other abdominal organs. The median operation time was 120min, the median intraoperative blood loss was 75mL and the median defect area was 72 cm². The median duration for diet restoration was 4 days, and the median postoperative hospital stay was 6 days. The drainage tube placed in the preperitoneal space was removed after a median duration of 5 days, and the drainage tube placed in the distal hernia sac was removed after a median duration of 6 days. Three patients suffered from a postoperative increase in intra-abdominal pressure, while one patient deteriorated into abdominal compartment syndrome accompanied by respiratory dysfunction. No haematomas, seromas, incisional or mesh infections, recurrence or chronic pain occurred during the follow-up period.

CONCLUSIONS

TIPP repair using Kugel mesh is a feasible and effective method for giant inguinoscrotal hernias.

Chitinase-like protein YKL-40 regulates human bronchial epithelial cells proliferation, apoptosis, and migration through TGF-β1/Smads pathway

In order to study the effects of chitinase-like protein YKL-40 on proliferation, apoptosis, and migration of human bronchial epithelial cell line (BEAS-2B), and the underlying mechanisms, we cultured BEAS-2B alone or with different concentrations of YKL-40. thiazolyl blue tetrazolium bromide (MTT) assay was used to examine the cell proliferation. Annexin V-fluorescein isothiocyanate isomer (FITC)/propidium iodide staining and scratch assay were performed to test the cell apoptosis and migration. The concentrations of transforming growth factor-β1 (TGF-β1), Smad3, Smad7, alpha-smooth muscle actin (α-SMA), interleukin-4 (IL-4), IL-6, and IL-8 in the cell culture supernatant were detected by enzyme-linked immunosorbent assay. The messenger RNA and protein levels of YKL-40, TGF-β1, Smad3, Smad7, and α-SMA were detected by reverse transcription polymerase chain reaction and Western blot. BEAS-2B cells cultured with different concentrations of YKL-40 showed significantly higher cell proliferation and migration and inflammatory cytokines compared with that of control group, while the cell apoptosis was significantly lower than that of control group (p < 0.05). In addition, BEAS-2B cells cultured with YKL-40 had increased TGF-β1, Smad3, Smad7, and α-SMA levels in the supernatant, compared with that of BEAS-2B cells cultured alone (p < 0.05). Furthermore, LY364947, as TGF-β1/Smads signaling pathway inhibitor, decreased cell proliferation and migration ability and enhanced cell apoptosis of BEAS-2B cells compared with control group (p < 0.05). However, YKL-40 administration reversed the effect of LY364947 on the biological behavior of BEAS-2B cells. YKL-40 could affect the biological behaviors of BEAS-2B cells, which might be related to the TGF-β1/Smads pathway.

[Interfacility transport with extracorporeal membrane oxygenation in pediatric patients: a multicenter study in China]

Objective: To investigate application and safety of pediatric interfacility-transport with extracorporeal membrane oxygenation (ECMO) in China. Methods: The data of 48 patients transported inter-hospital from February 2016 to May 2018 were collected from the following 4 centers: pediatric intensive care unit (PICU) of Bayi Children's Hospital Affiliated to the 7th Medical Center of PLA General Hospital, Pediatric Hospital of Fudan University, Henan Provincial People's Hospital and Children's Hospital of Zhejiang University School of Medicine. The data of patients' characteristics, ECMO mode and wean rate, and mortality were reviewed, which was further compared with the data of 57 compatible inner-hospital ECMO cases with t test, Rank sum test or chi-square test. Results: All the 48 interfacility-transports were accomplished by ambulance on land, with an average transfer distance of (435±422) km. The incidence of ECMO complications was 13% (6 case), without death. There were no significant differences in lactic acid, PaO(2) or SaO(2) before and after transport (4.0 (2.0, 7.5) vs. 3.0 (1.5, 6.0) mmol/L, Z=-1.579, P>0.05; 112(47, 405) vs. 166(122, 240) mmHg (1 mmHg=0.133 kPa), Z=-0.104, P>0.05; 0.97±0.02 vs. 0.96±0.03, t=1.570, P>0.05). Instead, PaCO(2) and pH were significantly different ((47±8) vs. (42±5) mmHg, t=2.687, P<0.05; 7.3±0.2 vs. 7.5±0.2, t=3.379, P<0.05). The total ECMO weaned rate was 73% (35/48) and the survival rate was 67% (32/48). No significant differences in demographic characteristics, ECMO mode or duration, transport distance or duration, or complications existed between the survival group and the death group (7/25 vs. 2/14, χ(2)=0.615, P>0.05; 4/28 vs. 2/14, χ(2)=0, P>0.05; (405±404) vs. (493±465) km, t=0.525, P>0.05; (5±4) vs. (5±5) h, t=0.388, P>0.05; 166 (128, 239) vs. 187(52, 405) h, Z=-0.104, P>0.05; 3/32 vs. 3/16, χ(2)=0.734, P>0.05). The lowest lactate value in survival group before ECMO transport was significantly lower than that in the death group ((5±5) vs. (8±6) mmol/L, t=2.151, P<0.05). There were neither significant differences in age, ECMO mode or support pattern (9/39 vs. 15/42, χ(2)=0.845, P>0.05; 6/42 vs. 7/50, χ(2)=0.001, P>0.05; 29/19 vs. 38/19, χ(2)=0.441, P>0.05), nor in ECMO weaned rate, survival rate or complications between interfacility-transport group and inner-hospital group (35/48 vs. 37/57, χ(2)=0.775, P>0.05; 32/48 vs. 35/57, χ(2)=0.313, P>0.05; 20/48 vs. 22/57, χ(2)=0.102, P>0.05). Conclusion: With appropriate transport equipment and mature teams who handle problems timely during the transport, critically ill children could be safely transported to the destination with ECMO.