Short Course Radiotherapy (SCRT) with Simultaneous Integrated Boost (SIB) in the Treatment of Rectal Cancer: Feasibility and Early Toxicities

PURPOSE/OBJECTIVE(S)

To report the feasibility and early toxicities of dose-escalated SCRT in rectal cancer patients receiving total neoadjuvant therapy (TNT).

MATERIALS/METHODS

This retrospective cohort study included 13 patients treated via a TNT approach (guided by RAPIDO trial) for locally advanced rectal cancer. The planned radiation was a standard dose of 25 Gy in 5 fractions to the primary tumor and at-risk lymphatics (PTV_Low). The dose-escalation was achieved via SIB delivering 30 Gy to the primary tumor (PTV_Mid) and 40 Gy (PTV_High) to inoperable lateral pelvic lymph nodes (LN), when present, over 5 fractions. A 5 mm margin was added to the rectal tumor and lateral pelvic LN to create the SIB targets. All patients were planned for intensity modulated radiation therapy via Varian EclipseTM (Palo Alto, CA) treatment planning system. Prior to treatment patients underwent kV and cone beam CT (CBCT) imaging for image guidance. Shifts were not performed solely to accommodate the boost target volume if it was felt to compromise the coverage of at-risk lymphatics. Normal tissue constraints were prioritized over boost coverage. Early toxicities were assessed for 30 days following treatment and graded using the Common Terminology Criteria for Adverse Events version 5.0. Offline image review was performed to determine the frequency at which the gross tumor volume (GTV) was captured within the 5 mm planning target volume (PTV_Mid) margin on daily CBCT scans. If a misalignment (tumor crossing outside of PTV_High) was discovered, the direction of misalignment (lateral/anterior/posterior) and location (superior/inferior) in relation to the superior border of the pubic symphysis was documented. An additional 5 mm margin from the PTV_Mid was created to determine if this would have captured the target.

RESULTS

Twelve of the 13 patients were ≥ 30 days from treatment completion and were included in the toxicity analysis. The most common grade 1-2 toxicities were proctitis and diarrhea, which occurred in 42% and 25% of patients, respectively. Other toxicities were new onset rectal bleeding (17%), rectal pain (17%) and radiation dermatitis (8%). No grade 3+ toxicities were observed. Given five fractions for each of the 13 patients, a total of 65 CBCTs were reviewed and compared to the planning CT obtained at simulation. A total of 14/65 (22%) misalignments were discovered across six patients. All occurred above the superior edge of the pubic symphysis. Four misalignments were multi-directional. Nine were anterior, 6 were lateral, and 1 was posterior. Twelve of the 14 (86%) would have been covered within the additional 5 mm expansion volume.

CONCLUSION

In this cohort of patients who received dose-escalated SCRT, the composite rate of acute toxicity was expectedly low. Feasibility of treatment delivery was established but could be improved upon with an addition 5 mm expansion, specifically in locations cranial to the superior edge of the pubic symphysis.

The Design of Making Pre-K count and High Fives: Two-Stage, Multiyear Random Assignment at Different Levels

The Making Pre-K Count and High 5s studies represent a recent application of a phased two-stage, multi-level design, which was used to examine the effects of two aligned math programs implemented in early childhood settings. The purpose of this paper is to describe the challenges encountered in implementing this two-stage design and to describe approaches to resolving them. We then present a set of sensitivity analyses the study team used to examine the robustness of the findings. During the pre-K year, pre-K centers were randomly assigned either to receive an evidence-based early math curriculum and associated professional development (Making Pre-K Count) or to a pre-K-as-usual control condition. In the kindergarten year, students who had been in Making Pre-K Count program classrooms in pre-K were then individually randomly assigned within schools to small-group supplemental math clubs that were designed to sustain the gains from the pre-K program, or to a business-as-usual kindergarten experience. Making Pre-K Count took place in 69 pre-K sites, comprising 173 classrooms across New York City. High 5s took place in the 24 sites that were part of the public school treatment arm of the Making Pre-K Count study and included 613 students. The study focuses on the effect of the Making Pre-K Count and High 5s programs on children's math skills at the end of kindergarten as measured by two instruments, the Research-Based Early Math Assessment-Kindergarten (REMA-K) and the Woodcock-Johnson Applied Problems test. The multi-armed design, while logistically and analytically challenging, balanced multiple considerations of power, the number of research questions that could be answered, and efficiency of resources. Robustness checks suggest that the design created groups that were both meaningfully and statistically equivalent. Decisions to use a phased multi-armed design should consider both its strengths and weaknesses. While the design allows for a more flexible, expansive research study, it also introduces complexities that need to be addressed both logistically and analytically.

Videos using different message strategies to promote the interruption of sedentary behavior in university students during online lectures - A pilot study

Background

Sedentary behavior (SB) is highly prevalent among university students and has increased during COVID-19 pandemic. As SB is associated with negative health outcomes, appropriate prevention measures in the university setting are needed.

Objective

This pilot study aimed at investigating the effects of videos using different message strategies to interrupt SB in the collective of university students during online lectures.

Methods

During online lectures, university students (N = 96) were shown one of three videos on the interruption of SB. The videos differed in their message strategies with regard to evidence type (statistical vs. narrative) and vividness (static vs. animated images). Demographics, health variables (SB intentions, SB attitudes) and selected media reception variables (identification, homophily, counterarguing) were examined as possible influence factors on the interruption of SB evoked by watching the video.

Results

Approximately half of the students interrupted sedentary behavior during watching the videos and students of the older age group (cut-off: median = 22 years) interrupted SB significantly more often (p = 0.046). The interruption of SB was predicted by SB intentions (p < 0.05). Identification with characters significantly predicted the intentions to reduce SB (p < 0.001), with a large effect of the overall regression model (R2corr = 0.47).

Conclusion

Considering the increased digitalization in general and restrictions due to COVID-19 pandemic, videos seem to be a useful tool to interrupt SB among university students during online lectures. Narrative formats could facilitate the intention to reduce SB, which in turn could have a positive impact on the interruption of SB. However, further research on effective communication and message strategies is needed.

Outcomes of additional substrate modification in de novo atrial fibrillation ablation

Background

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Data regarding additional substrate modification has been conflicting, both in paroxysmal and persistent atrial fibrillation.

Purpose

To assess the effect of additional linear substrate modification during de novo AF ablation on AF recurrence.

Methods

We reviewed 1575 AF ablations in 1254 patients from January 2013 to June 2021 at a single academic medical center. There were 1096 de novo ablations. We defined substrate modification as linear ablations including cavotricuspid isthmus (CTI), superior vena cava isolation, intercaval line, mitral isthmus, and left atrial roof and floor lines. We evaluated clinical and procedural characteristics to identify risk factors for AF recurrence and complications. Patients were followed for a minimum of 6 months.

Results

The 1096 de novo ablations included 65.5% males with mean age 61.1 years, mean BMI 31.3, 81.8% paroxysmal AF and 18.2% persistent AF. There were four AF ablation subgroups: PVI alone (41.6%), PVI and CTI ablation (37.1%), PVI with CTI and additional substrate modification (15.6%), and PVI with substrate modification without CTI ablation (5.7%). Overall, AF recurred in 36.9% cases. AF recurrence with PVI only ablation was 41% compared to 32.7% in patients with PVI and CTI ablation (p=0.02). When looking at patients with paroxysmal and persistent AF, results were similar, with decreased AF recurrence with the addition of CTI ablation in both paroxysmal (37.3% v. 29.2%, p=0.03) and persistent AF (58.1% v. 40.0%, p=0.02). Additional substrate modification did not result in significant difference in outcome in either paroxysmal or persistent AF (Figure 1).

Conclusions

In de novo AF ablations, addition of CTI ablation to de novo PVI ablation is associated with lower AF recurrence in both paroxysmal and persistent AF. Additional linear substrate modification did not impact outcomes.

Funding Acknowledgement

Type of funding sources: None.

Safety of same day discharge after atrial fibrillation ablation

Background

Atrial fibrillation (AF) ablation is an outpatient procedure with traditionally an overnight hospital observation (OHO). Recently, there has been a trend towards same day discharge (SDD).

Purpose

Compare AF ablation procedure safety outcomes with SDD vs. OHO.

Methods

We reviewed consecutive AF procedures performed from January 2013 to June 2021 at a single academic center. Patients underwent OHO until June 2020, after which patients had SDD whenever feasible. Adverse events were assessed at three months, which included pericardial effusion, pericarditis, post-procedure hypotension, embolic events, and vascular complications. We also assessed emergency department (ED) visits and procedure-related hospital admissions.

Results

There were 1254 patients who underwent 1575 AF ablations. 1440 patients underwent OHO and 135 had SDD. Mean age was 62.2 years, BMI 33 kg/m2, 65% were male, and 27.6% had persistent AF, without significant differences in baseline characteristics between OHO and SDD. We found that SDD was not associated with increased complications (OHO 0.20% v. SDD 0.49%; p&gt;0.05), ED visits, or hospital admissions (2% v. 5%; p&gt;0.05) (Figure 1, 2). There were no gender or age-related disparities in all outcomes (p&gt;0.05).

Conclusion

SDD protocol after AF ablation is feasible and not associated with higher incidence of complications, ED visits, and procedure-related hospitalizations.

Funding Acknowledgement

Type of funding sources: None.

Does body mass index affect atrial fibrillation ablation outcomes

Background

There are conflicting reports in the literature regarding whether body-mass index (BMI) influences the success and procedural complication rates of atrial fibrillation (AF) ablation.

Purpose

To determine if differences in BMI affect AF ablation outcomes

Methods

At a single academic center, AF ablation procedures were reviewed from 2013 to 2021. Primary outcomes were AF recurrence (after a 90 day blanking period), procedure-related complications, emergency department visits or hospital admission (ED/HOSP). Patients had a minimum of 6 months follow-up

Results

We analyzed 1569 AF ablation consecutive procedures (1093 de novo, 476 repeat ablation) using either radiofrequency or cryoablation. The study population was 65% male with a mean age 62 years, with 28% persistent AF. BMI was separated into three cohorts: &lt;25 kg/m2 (N=218), 25–30 kg/m2 (N=547), and &gt;30 kg/m2 (N=804). There were no significant differences in the type of AF, left atrial diameter, or left ventricular ejection fraction in the BMI subgroups. There was a direct relationship between the prevalence of co-morbid conditions and increasing BMI: hypertension (49.1%, 59.9%, 60.2%; p 0.04), diabetes (6.4%, 13.5%, 21.3%; p 0.01), and obstructive sleep apnea (5.5%, 10.8%, 26.7%; p&lt;0.01). There were no significant differences in AF recurrence, procedural complications or ED/HOSP among the BMI cohorts (p&gt;0.05) (Figure 1). No gender related disparities were noted in outcomes (p&gt;0.05).

Conclusion

Higher BMI was not associated with AF recurrence, complications, or ED/HOSP after AF ablation despite a higher prevalence of comorbid medical conditions

Funding Acknowledgement

Type of funding sources: None.

Mental health needs in a large urban school district: Findings from a web-based survey

OBJECTIVE

To explore the mental health needs of students, and the professional development and support needs of teachers and school health professionals, as a way to foster community engagement and help set priorities for a comprehensive school mental health system in the Detroit Public Schools Community District (DPSCD).

SETTING

The study team surveyed all DPSCD staff in June 2019 and all students in grades 8-12 between October and December 2019.

STUDY DESIGN

A descriptive study based on anonymous, web-based surveys focused on student trauma exposure and mental health symptoms, student mental health resource utilization, staff burnout, and professional development needs.

DATA COLLECTION

All students (grades 8-12) and district staff were eligible to participate; the student survey was made available in six languages. Parents/guardians could opt children out; schools could exclude children unable to complete the survey independently. Student surveys were administered in school; staff surveys were sent via email.

PRINCIPAL FINDINGS

Thirty-four percent of DPSCD students reported moderate/severe depression symptoms; 22% had seriously considered suicide in the past year. Rates exceed national averages; 37% of students with severe depression and 34% of those with suicidal ideation had not accessed mental health supports. Staff indicated high levels of burnout and substantial interest in learning about self-care strategies or coping with vicarious trauma. Over 75% of teachers and school mental health professionals expressed interest in learning about best practices for supporting students impacted by trauma or mental illness.

CONCLUSIONS

A large number of DPSCD students are experiencing symptoms of depression and anxiety, and many students who need care are not accessing it. Addressing the mental health needs of students is a high priority for staff, but they need more training and support, as well as support for their own vicarious trauma and high levels of burnout.

[Cross-sectional diagnostic imaging in the InEK benchmark : An opportunity for radiology]

Hintergrund

Anhand der vom Institut für das Entgeltsystem im Krankenhaus (InEK) kalkulierten Fallpauschalen ist ein Vergleich der eigenen Leistungsdaten gegenüber allen nach der DRG („diagnosis-related groups“, diagnosebezogene Gruppen) abrechnenden Kliniken in Deutschland möglich. Ziel der vorliegenden Arbeit ist es, Über- oder Unterschreitungen von CT- oder MRT-Untersuchungen im Vergleich mit den InEK-Daten zu ermitteln und mögliche Verbesserungspotenziale zu erschließen.

Methodik

Die InEK-Kalkulationsdaten für 2021 wurden zur Bildung von Vergleichskennzahlen der CT- und MRT-Diagnostik auf DRG-Ebene herangezogen. Auf Fallebene wurden Daten eines universitären Maximalversorgers auf Gesamthaus‑, Klinik‑, DRG- und Hauptdiagnosen-Ebene gegenübergestellt.

Ergebnis

Auf Gesamthausebene zeigt sich eine Überschreitung der MRTs um 1025 und der CTs um 371 gegenüber InEK. Die Analyse nach Fachabteilungen ergab am Beispiel der Neurologie eine Überschreibung der MRTs gegenüber InEK um 489 sowie eine Unterschreitung der CTs um \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$-$$\end{document}-620. Der Benchmark der DRGs zeigte in beiden Untersuchungsmodalitäten insbesondere die DRG B70B als Treiber der Abweichungen (MRT + 42,7; CT − 273). Die identifizierten Abweichungen lassen sich auf Hauptdiagnosen-Ebene weiter herunterbrechen.

Diskussion

Das Bewusstsein über eine überdurchschnittliche Schnittbilddiagnostik kann einen wichtigen Anstoß zur Weiterentwicklung der Behandlungspfade einer Klinik bilden. Die Methodik des InEK-Benchmarks ist für jedes Krankenhaus anwendbar und identifiziert valide bereits erbrachte Leistungen und Prozesse mit einem Verbesserungspotenzial. Die Prüfung beeinflussender Faktoren sowie die Bewertung durch Mediziner und Kaufleute bildet die Voraussetzung für Akzeptanz und Erfolg der daraus generierten Maßnahmen.

Admission NT-proBNP and outcomes in patients without history of heart failure hospitalized with COVID-19

Aims

We examined the value of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) in patients admitted for coronavirus disease 2019 (COVID‐19) without prior history of heart failure (HF) or cardiomyopathy.

Methods and results

Retrospective cohort of consecutive adults (N = 679; median age 59 years; 38.7% women; 87.5% White; 7.1% Black; 5.4% Asian; 34.3% Hispanic) admitted with documented COVID‐19 in an academic centre in Long Island, NY. Admission NT‐proBNP was categorized using the European Society of Cardiology Heart Failure Association age‐specific criteria for acute presentations. We examined (i) mortality and the composite of death or mechanical ventilation and (ii) out‐of‐hospital, intensive care unit (ICU)‐free, and ventilator‐free days at 28 days. Estimates were adjusted for confounders using a lasso selection process. Using age‐specific criteria, 417 patients (61.4%) had low, 141 (20.8%) borderline, and 121 (17.8%) high NT‐proBNP. Mortality was 5.8%, 20.6%, and 36.4% for patients with low, borderline, and high NT‐proBNP, respectively. In lasso‐adjusted models, high NT‐proBNP was associated with higher mortality [hazard ratio (HR) 2.15; 95% confidence interval (CI) 1.06–4.39; P = 0.034] and composite endpoint rates (HR 1.66; 95%CI 1.04–2.66; P = 0.035). Patients with high NT‐proBNP had 32%, 33%, and 33% fewer out‐of‐hospital, ICU‐free, and ventilator‐free days compared with low NT‐proBNP counterparts. Results were consistent across age, sex, and race, and regardless of coronary artery disease or hypertension, except for stronger mortality signal with high NT‐proBNP in women.

Conclusions

In patients with COVID‐19 and no HF history, high admission NT‐proBNP is associated with higher mortality and healthcare resources utilization. Preventive strategies may be required for these patients.

Abstract 1951: SMAC mimetic and BET inhibitor - a promising combination for solid cancer treatment

SMAC mimetics (SMACm), drugs that mimic natural antagonists of Inhibitor of Apoptosis (IAP) are in clinical trials for hematological malignancies and solid cancers. The clinical benefit for patients in monotherapy was so far dismal. Hence, current clinical evaluation of SMACm focuses on combinations, in particular with checkpoint inhibitors and/or radiation therapy. The BET family protein BRD4 is a “reader” of epigenetic information and binds to acetylated chromatin to act as a key regulator of transcription. BET inhibitors (BETi) were tested in numerous clinical trials as novel treatment option for hematological and solid cancers. Like SMACm, monotherapy with BETi showed only moderate clinical activity stressing the importance of combination trials. BI 891065 a monovalent, oral SMACm, with a favorable safety profile allowing continuous dosing, is in Clinical Phase I (NCT03166631, NCT04138823). BI 894999 is a very potent and selective oral BETi, administered by intermittent dosing in Clinical Phase I (NCT02516553). We studied the combinatorial effect of both compounds in vitro across a large number of human tumor cell lines (lung, colorectal, pancreatic, and gastric cancer) in proliferation assays using Bliss synergy analysis and IncuCyte ZOOM® live cell imaging, and in vivo in three independent models. Of the 60+ cancer cell lines, around 30% showed synergy when treated with the BI 891065 + BI 894999 combination, irrespective of indication. Efficacy correlated with downmodulation of the key apoptosis regulator XIAP by BI 894999. In most of the cell lines tested, the synergistic effect was blocked by addition of the TNFα scavenger Enbrel and/or the apoptotic pathway inhibitor zVAD. In vivo efficacy was tested in two PDAC xenograft models (one immunocompetent and one immunodeficient) and one CRC model at clinically relevant doses. Daily oral application of both compounds was well tolerated and did not lead to drug-drug interactions. Target engagement markers were modulated as expected (cIAP1 degradation for SMACm and Hexim1 induction for BETi) and not compromised by the combination. Tumor growth inhibition in the BxPC3 pancreas model achieved 22% TGI for 50 mg/kg BI 891065, 70% TGI for 2 mg/kg BI 894999, and 96% TGI for the combination. In the Pan02 pancreas model 9% TGI for 50 mg/kg BI 891065, 30% TGI for 4 mg/kg BI 894999 and 92% TGI for the combination were recorded. Evaluation of the cellular composition of the tumor microenvironment in this immunocompetent model showed distinct changes evident of a reduced immuno-suppressive milieu upon combination treatment. Combination effects on tumor growth in the CRC model LoVo were far less pronounced. These preclinical in vitro and in vivo data are highlighting the potential of a SMACm/BETi combination for the treatment of solid cancers. The identification of patient selection markers for this combination will be necessary for advancing this concept into pivotal clinical trials.

Citation Format: Paula-Elena Traexler, Dominik Arnold, Florian Ebner, Ksenija Slavic-Obradovic, Robin Jacob, Ha Pham Thi Thanh, Martin Aichinger, Anke Baum, Andreas Wernitznig, Daniel Gerlach, Maria-Antonietta Impagnatiello, Valeria Santoro, Sabine Olt, Dirk Scharn, Regina Ruzicka, Reniqua P. House, Mary Y. Murphy, Ulrich Reiser, Harald Engelhardt, Vittoria Zinzalla, Thorsten Laux, Flavio Solca, Ulrike Tontsch-Grunt. SMAC mimetic and BET inhibitor - a promising combination for solid cancer treatment [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 1951.

High-dose methylprednisolone in nonintubated patients with severe COVID-19 pneumonia

BACKGROUND

Recent trials with dexamethasone and hydrocortisone have demonstrated benefit in patients with coronavirus disease 2019 (COVID-19). Data on methylprednisolone are limited.

METHODS

Retrospective cohort of consecutive adults with severe COVID-19 pneumonia on high-flow oxygen (FiO₂  ≥ 50%) admitted to an academic centre in New York, from 1 March to 15 April 2020. We used inverse probability of treatment weights to estimate the effect of methylprednisolone on clinical outcomes and intensive care resource utilization.

RESULTS

Of 447 patients, 153 (34.2%) received methylprednisolone and 294 (65.8%) received no corticosteroids. At 28 days, 102 patients (22.8%) had died and 115 (25.7%) received mechanical ventilation. In weighted analyses, risk for death or mechanical ventilation was 37% lower with methylprednisolone (hazard ratio 0.63; 95% CI 0.47-0.86; P = .003), driven by less frequent mechanical ventilation (subhazard ratio 0.56; 95% CI 0.40-0.79; P = .001); mortality did not differ between groups. The methylprednisolone group had 2.8 more ventilator-free days (95% CI 0.5-5.1; P = .017) and 2.6 more intensive care-free days (95% CI 0.2-4.9; P = .033) during the first 28 days. Complication rates were not higher with methylprednisolone.

CONCLUSIONS

In nonintubated patients with severe COVID-19 pneumonia, methylprednisolone was associated with reduced need for mechanical ventilation and less-intensive care resource utilization without excess complications.

Product Design to Enhance Consumer Liking of Cull Ewe Meat

The global sheepmeat industry aspires to increase consumer liking for cull ewe meat and thereby increase its value; dry ageing application can increase the consumer appeal of this meat. In order to develop novel consumer-liked dry aged sheepmeat products, an innovation process aligned with design thinking principles was initiated. The objective was to understand optimal dry aged sheepmeat product formats from chef, butcher, producer and consumer perspectives, and use these findings to develop “highly liked” and “premium” dry aged cull ewe meat dishes. The methodology used and the results of stakeholder engagement, perceptual mapping, and quantitative consumer assessments are reported. Stakeholder engagement showed the importance of how novel products are introduced to the consumer and to the chef. Perceptual mapping highlighted that chef-perceived product “premiumness” was driven by eating quality and complexity of the dish. Consumer assessment validated these findings with increases in dish liking associated with increased premiumness and complexity in dish presentation. Overall, the described approach was successful; eight highly liked dry aged cull ewe meat dishes were developed (all scored > 7.69 on a 9-point hedonic scale for liking), and four of the eight dishes were rated “at the level of a very premium food”.

Cone-beam CT versus Multidetector CT in Postoperative Cochlear Implant Imaging: Evaluation of Image Quality and Radiation Dose

BACKGROUND AND PURPOSE

Cone-beam CT is being increasingly used in head and neck imaging. We compared cone-beam CT with multidetector CT to assess postoperative implant placement and delineate finer anatomic structures, image quality, and radiation dose used.

MATERIALS AND METHODS

This retrospective multicenter study included 51 patients with cochlear implants and postoperative imaging via temporal bone cone-beam CT (n = 32 ears) or multidetector CT (n = 19 ears) between 2012 and 2017. We evaluated the visualization quality of single electrode contacts, the scalar position of the electrodes, cochlear walls, mastoid facial canal, metallic artifacts (using a 4-level visual score), and the ability to measure the insertion angle of the electrodes. The signal-to-noise ratio and radiation dose were also evaluated.

RESULTS

Cone-beam CT was more sensitive for visualizing the scalar position of the electrodes (P = .046), cochlear outer wall (P = .001), single electrode contacts (P < .001), and osseous spiral lamina (P = .004) and had fewer metallic artifacts (P < .001). However, there were no significant differences between both methods in visualization of the modiolus (P = .37), cochlear inner wall (P > .99), and mastoid facial canal wall (P = .07) and the ability to measure the insertion angle of the electrodes (P > .99). The conebeam CT group had significantly lower dose-length product (P < .001), but multidetector CT showed a higher signal-to-noise ratio in both bone and air (P = .22 and P = .001).

CONCLUSIONS

Cone-beam CT in patients with cochlear implants provides images with higher spatial resolution and fewer metallic artifacts than multidetector CT at a relatively lower radiation dose.

Comprehensive Review of Complete Versus Culprit-only Revascularization for Multivessel Disease in ST-segment Elevation Myocardial Infarction

Collapse

76. Effect of Early Administration of Systemic Corticosteroids on Outcomes in Patients with COVID-19 Pneumonia

Background

Systemic corticosteroids (steroids) have been empirically used in acute respiratory distress syndrome, an entity also present in coronavirus disease 19 (COVID-19). Early steroids administration could accelerate resolution of symptoms and reduce intensive care unit (ICU) stay in these patients, but practice varies widely as evidence is scant.

Methods

We reviewed the records of 498 adults admitted to Stony Brook University Hospital, NY, from 3/1 to 4/15, 2020 with COVID-19 requiring high-flow O2 (non-rebreather mask, Venturi mask with FiO2 >50%, or high-flow nasal cannula). We excluded those (N=29) who received mechanical ventilation (MV) or died within 24h of admission. We followed patients until death or discharge. We compared outcomes between patients who received early steroids (i.e. prior to MV) and those who did not. We used adjusted Cox models to evaluate the composite of death or need for MV. We also evaluated healthcare resources utilization.

Results

Of 469 patients, 175 (37.3%) received steroids while on high flow O2. Table 1 summarizes the baseline characteristics. Patients who received steroids were more likely to have asthma, had slightly longer duration of symptoms, lower O2 saturation, higher NT-proBNP and lower IL-6 levels at baseline. In total, 228 patients (48.6%) reached the composite endpoint (123 died and 105 received MV). By 7 days, 32.5% of patients who received steroids died or were intubated vs. 44.8% of those who did not (log-rank P=0.008), Figure 1. In models adjusted for race, age, sex, comorbidities, baseline O2 saturation and procalcitonin, steroids reduced risk for death or MV by 44% (hazard ratio [HR] 0.56; 95%CI 0.42–0.76; P< 0.001). The effect was time-dependent with initial HR 0.34 (95%CI 0.21–0.56; P< 0.001) and daily attenuation by 10.2% (95%CI 1.7%–19.4%; P=0.017). Mortality at 7 and 14 days did not differ between groups (8.1% vs. 8.3% and 19.1% vs. 21.0%, respectively, log-rank P=0.75). Among discharged patients, length of hospital stay was longer, but ICU stay was shorter with steroids, Table 2.

Patient Characteristics According to Use of Early Steroids

Healthcare Resources Utilization According to Use of Early Steroids Among Discharged Patients

Conclusion

Early administration of steroids reduced primarily the need for MV in our high-risk COVID-19 patients, with shorter ICU utilization, at the expense of longer hospital stay. Further studies are needed to optimize the use of steroids in these patients.

Disclosures

All Authors: No reported disclosures

382. Incidence of Hospital-Acquired and Ventilator-Associated Pneumonia in Patients with Severe COVID 19 on High Flow Oxygen

Background

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) can be serious complications of coronavirus disease 19 (COVID-19). Co-infections may worsen outcomes and prolong hospitalization. This risk may be exacerbated by systemic corticosteroids (steroids) and other adjunctive therapies.

Methods

We reviewed the records of all adults admitted to Stony Brook University Hospital, NY, from 3/1 to 4/15, 2020 with severe COVID-19 pneumonia, requiring high-flow O2 (non-rebreather mask, Venturi mask with FiO2 &gt;50%, or high-flow nasal cannula). We excluded patients who received mechanical ventilation (MV) or died within 24h. Patients were followed until death or hospital discharge. We reviewed positive sputum cultures (PSC) for pathogenic microorganisms and calculated the incidence of HAP and VAP (nosocomial pneumonia, [NP]), rates of MV and impact on mortality. Fungi isolated from sputum, were considered colonization unless associated with fungemia. We also examined the impact of adjunctive therapies with immunosuppressive potential (steroids and tocilizumab), on HAP or VAP.

Results

A total of 469 patients were included (Table 1). Of these, 199 (42.4%) required intensive care and 172 (36.7%) MV. Median length of stay was 13 days (8–22) and 105 (22.4%) had PSC. Of these, 59 were considered true pathogens (HAP: 11, VAP: 48), with predominance of S. aureus (MSSA) 38.9%, Enterobacteriaceae 33.8% and Pseudomonas species 18.6%. 39 isolates were considered colonization (Table 2); Patients with PSC &lt; 48h (N=7) from admission, were not considered NP. The incidence of NP was 7.0 per 1000 patient-days (95%CI 5.5–8.5). Of 11 patients with HAP, 9 needed MV. NP was more frequent among patients receiving steroids (9.0 vs 5.7 per 1000 patient-days; P=0.023). Use of tocilizumab was not associated with NP (6.2 vs 8.4 per 1000 patient-days; P=0.11). Mortality was nonsignificantly higher in patients with (20/59, 33.9%) vs. without (103/410, 25.1%) NP (P=0.16). Intubation and length of stay were the strongest predictors of NP in multivariable models.

Cohort Characteristics of Patients with Severe COVID -19 Pneumonia on High Flow Oxygen (N= 469)

Conclusion

Among high risk COVID-19 patients, NP is a common complication. MSSA and Enterobacteriaceae were the most frequent isolates. The risk increases with intubation, longer hospital stay and use of steroids but not tocilizumab.

Disclosures

All Authors: No reported disclosures

53. Incidence of Bloodstream Infections and Outcomes in Patients with Severe COVID-19 Pneumonia

Background

Coronavirus disease 19 (COVID-19) leading to acute respiratory distress syndrome is associated with need for intensive care (IC), mechanical ventilation (MV), and prolonged recovery. These patients are thus predisposed to blood stream infections which can worsen outcomes. This risk may be aggravated by adjunctive therapies.

Methods

We reviewed the medical records of all adults admitted to Stony Brook University Hospital, NY, from March 1 to April 15, 2020 with severe COVID-19 pneumonia (requiring high-flow O2). Patients who received MV or died within 24h were excluded. Patients were followed until death or hospital discharge. We reviewed positive blood cultures (PBC) for pathogenic microorganisms, and calculated the incidence of bacteremia, rates of infective endocarditis (IE), and impact on mortality. Microbes isolated only once and belonging to groups defined as commensal skin microbiota were labelled as contaminants. We also examined the impact of adjunctive therapies with immunosuppressive potential (steroids and tocilizumab), on bacteremia.

Results

A total of 469 patients with severe COVID-19 pneumonia were included (Table 1). Of these, 199 (42.4%) required IC and 172 (36.7%) MV. Median length of stay was 13 days (8–22) and 94 (20.0%) had PBC. Of these, 43 were considered true pathogens (bacteremia), with predominance of E. faecalis and S. epidermidis, and 51 were considered contaminants (Table 2). The incidence of bacteremia (43/469, 9.2%) was 5.1 per 1000 patient-days (95%CI 3.8–6.4). An echocardiogram was performed in 21 patients, 1 had an aortic valve vegetation (IE) by methicillin sensitive S. aureus. Bacteremia rates were nonsignificantly higher with steroids (5.9 vs 3.7 per 1000 patient-days; P=0.057). Use of tocilizumab was not associated with bacteremia (5.8 vs 4.8 per 1000 patient-days; P=0.28). Mortality was nonsignificantly higher in patients with (15/43, 34.9%) vs. without (108/426, 25.4%) bacteremia (P=0.20). Length of stay was the strongest predictor of bacteremia, with risk increasing by 7% (95%CI 6%-9%, P&lt; 0.001) per additional day.

Cohort Characteristics of Patients with Severe COVID-19 Pneumonia on High-Flow O2 (N= 469)

Conclusion

The incidence of bacteremia was relatively low and IE was uncommon in this study of severe COVID-19 patients. Risk of bacteremia increased with longer hospital stay and with steroids use, but not with tocilizumab.

Disclosures

All Authors: No reported disclosures

Energy Drink Effects on Hemodynamics and Endothelial Function in Young Adults

INTRODUCTION

Cardiovascular side effects associated with energy drink consumption may be related to effects on vascular endothelial function, heart rate, blood pressure, and electrocardiogram parameters. We sought to measure them following energy drink consumption.

METHODS

Forty-four healthy non-smoking young volunteer medical students, at an average age of 24.7 years (range 23-27 years, 34 males), with an average BMI of 23.4, received electrocardiograms and had their heart rates and blood pressures taken. Subjects then underwent baseline testing of endothelial function using the technique of endothelium-dependent flow-mediated dilatation (FMD) with high-resolution ultrasound. The subjects then drank an energy drink (24 oz Monster Energy Drink®). Hemodynamic measurements were repeated 15 and 90 min later. FMD and the electrocardiogram were repeated 90 min later. The FMD was calculated as the ratio of the post-cuff release and the baseline diameter.

RESULTS

Energy drink consumption resulted in a significantly attenuated peak FMD response (mean ± SD): baseline 5.1 ± 4.1% versus post-energy drink (2.8 ± 3.8%; p = 0.004). In addition, systolic and diastolic blood pressures and heart rate increased after 15 min. Diastolic blood pressure and heart rate remained increased 90 min following energy drink consumption. There were no significant changes in electrocardiogram parameters.

CONCLUSION

Energy drink consumption was associated with an acute significant impairment in endothelial function in young healthy adults as well as with significant hemodynamic changes. As energy drinks are becoming more popular, it is important to study their effects to better determine safe consumption patterns.

Outcomes of Patients Undergoing Transcatheter Aortic Valve Implantation With Incidentally Discovered Masses on Computed Tomography

Routine preprocedural chest and abdomen computed tomography is done prior to transcatheter aortic valve implantation (TAVI), which, in turn, have led to the discovery of radiographic potentially malignant incidental masses (pMIM). It is largely unknown whether pMIM impact the outcomes of patients undergoing TAVI. In this retrospective cohort study from a single center, 1,081 patients underwent TAVI from 2012 to 2016, who had available computed tomographies, survived the index hospitalization, and also had 1 year follow-up data for review. Machine learning (backward propagation neural network)-augmented multivariable regression for mortality by pMIM was conducted. In this cohort of 1,081 patients, the mean age was 79.1 (± 9.0), 48.8% were females, 16.8% had a history of prior malignancy, and 21.1% had pMIM. One-year mortality for the entire cohort was 12.6%. The most common prior malignancies were prostate, breast, and lymphoma and the most common pMIM were present in the lung, kidneys, and thyroid. In a fully adjusted regression analysis, neither prior malignancy nor pMIM increased mortality odds. However, having both was associated with a higher 1-year mortality (odds ratio 4.02, 95% confidence interval 1.50 to 10.73, p = 0.006). In conclusion, presence of pMIM alone was not associated with an increased 1-year mortality among patients undergoing TAVI. However, the presence of pMIM and a history of prior malignancy was associated with a significant increase in 1-year mortality.

Abstract 3055: Xentuzumab, a humanized IGF-1 and IGF-2 ligand co-neutralizing monoclonal antibody, shows efficacy in a human breast cancer model of bone metastasis

Bone metastases are a frequent complication of cancer and are associated with considerable morbidity. Bones provide a permissive environment for metastatic colonization due to their dynamic turnover and an abundance of secreted factors that are required for bone maintenance. Insulin-like growth factors (IGF) are the most abundant growth factors in bone and are required for normal skeletal development and function. IGFs also promote cancer progression, aggressiveness, and treatment resistance via activation of the IGF-1 receptor (IGF-1R) and insulin receptor variant A (IR-A). Of specific relevance to bone metastases, excessive bone destruction in osteolytic metastatic lesions leads to a release of IGF-1 from the bone matrix, thus promoting proliferation of metastatic tumor cells, stimulating tumor cell homing to bones, and contributing to further enhancement of bone destruction. Therapeutic targeting of the IGF axis may therefore provide an effective method for treating bone metastases. The aim of this study was to explore the efficacy of the IGF-1/-2 ligand blocking antibody, xentuzumab (BI 836845[1]), alone and in combination with the mTOR inhibitor everolimus, in a breast cancer bone metastasis xenograft model. MDA-231-BoM cells[2], a subline of MDA-MB-231 selected in vivo for enhanced metastatic ability to bone, were injected intra-cardiacly to form bone metastases, and via tail vein to form lung/visceral metastases and treated with xentuzumab, everolimus, and the combination thereof. Tumor burden was monitored by bioluminescence imaging, and metastasis-associated osteolysis was measured by quantitative bone micro-computed tomography. Tumor-associated morbidity was evaluated by a multi-parameter health scoring scheme. Metastatic tumor burden in the bone was significantly reduced upon treatment with xentuzumab in monotherapy and in combination with everolimus vs. placebo. Xentuzumab (±everolimus) reduced the number and size of osteolytic lesions, delayed and diminished bone metastasis-associated morbidity, and prolonged survival. In contrast, the growth of lung/visceral metastases developing upon intravenous injection of tumor cells was not inhibited by xentuzumab. In summary, the IGF-1/-2 neutralizing antibody xentuzumab showed efficacy in a breast cancer bone metastasis model (with and without everolimus) but did not affect metastatic tumor growth in lung/visceral organs. A phase II trial evaluating the xentuzumab/ everolimus/ exemestane triple combination in HR+BC patients with non-visceral disease is currently ongoing (NCT03659136). [1] Friedbichler et al, 2014. Mol Cancer Ther 13(2):399 [2] Kang et al, 2003. Cancer Cell 3:537

Citation Format: Ulrike Weyer-Czernilofsky, Izabela Krecioch, Stephan Handschuh, Martin Glösmann, Mario Kuttke, Robin Jacob, Anna C. Obenauf. Xentuzumab, a humanized IGF-1 and IGF-2 ligand co-neutralizing monoclonal antibody, shows efficacy in a human breast cancer model of bone metastasis [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3055.

Proliferative potential and response to nivolumab in clear cell renal cell carcinoma patients

Background

Biomarkers predicting immunotherapy response in metastatic renal cell cancer (mRCC) are lacking. PD-L1 immunohistochemistry is a complementary diagnostic for immune checkpoint inhibitors (ICIs) in mRCC, but has shown minimal clinical utility and is not used in routine clinical practice.

Methods

Tumor specimens from 56 patients with mRCC who received nivolumab were evaluated for PD-L1, cell proliferation (targeted RNA-seq), and outcome.

Results

For 56 patients treated with nivolumab as a standard of care, there were 2 complete responses and 8 partial responses for a response rate of 17.9%. Dividing cell proliferation into tertiles, derived from the mean expression of 10 proliferation-associated genes in a reference set of tumors, poorly proliferative tumors (62.5%) were more common than moderately (30.4%) or highly proliferative (8.9%) counterparts. Moderately proliferative tumors were enriched for PD-L1 positive (41.2%), compared to poorly proliferative counterparts (11.4%). Objective response for moderately proliferative (29.4%) tumors was higher than that of poorly (11.4%) proliferative counterparts, but not statistically significant (p = .11). When cell proliferation and negative PD-L1 tumor proportion scores were combined statistically significant results were achieved (p = .048), showing that patients with poorly proliferative and PD-L1 negative tumors have a very low response rate (6.5%) compared to moderately proliferative PD-L1 negative tumors (30%).

Conclusions

Cell proliferation has value in predicting response to nivolumab in clear cell mRCC patients, especially when combined with PD-L1 expression. Further studies which include the addition of progression-free survival (PFS) along with sufficiently powered subgroups are required to further support these findings.

Implications of the variation in bloom properties of red meat: A review

This review aimed to examine the literature about blooming to determine any practical implications for meat colour and colour stability. Blooming is critical to surface colour in addition to pigment and achromatic factors and causes meat to become lighter (higher L*) and redder (higher a*) due to the formation of oxymyoglobin (OMb). Bloom depth of red meat varies in the range of about 1-12 mm due to a range of extrinsic factors notably oxygen partial pressure, temperature and time post slicing. A range of intrinsic factors also affect bloom acting via the oxygen consumption rate of mitochondria and metmyoglobin (MMb) reductase activity post mortem, such as post mortem age, muscle type, rigor temperature, ultimate pH (pHu), genotype and vitamin E status. These sources of variation have implications for measurement protocols and commercial applications for colour and colour stability. Development of a rapid method to measure bloom depth would enable assessment of bloom independently of surface colour.

Influence of single-sided deafness on the auditory capacity of the better ear

BACKGROUND

Patients with single-sided deafness (SSD) are limited by their asymmetric hearing in various areas of everyday life.

OBJECTIVE

The aim of this investigation was to perform an age-correlated comparison of the hearing threshold of the better ear of SSD patients with a normal-hearing (NH) reference cohort. In addition, the potential influence of etiology, duration of deafness, and cochlear implantation (CI) of the poorer ear on the peripheral hearing ability of the better ear was investigated.

MATERIALS AND METHODS

In a multicenter study, the mean bone conduction hearing threshold of the better ear of 413 adult SSD patients was compared with that of an NH cohort drawn from ISO 7029:2017 for the frequencies 0.5, 1, 2, and 4 kHz.

RESULTS

SSD patients showed significantly poorer hearing in the better ear compared to the age-correlated group of NH subjects. CI, duration of deafness, and etiology had no significant effect on the hearing ability of the better ear.

CONCLUSION

The origin of the poorer hearing of the better-hearing ear of SSD patients compared to an age-correlated NH cohort is still unclear. It is most likely a combination of different anatomical, immunological, etiological, and microcirculatory causes, which lead to poorer hearing of the better-hearing ear in SSD patients.

28Impact of non-invasive rapid cardiac magnetic resonance for the assessment of cardiomyopathies in developing countries

Background

Cardiovascular mortality is higher in developing countries. Part of that is suboptimal testing. Cardiac magnetic resonance (CMR) is the gold standard for measuring structure, function of the heart and adds incremental value by imaging scarring and to assess iron level. Despite the existence of MRI units, CMR is identified as a complex test, with poor training and availability in developing countries.

Purpose

To assess the potential impact of a faster CMR protocol at a multicentre level in developing countries; implementing it with an education program, for the assessment cardiomyopathies.

Methods

An international partnership. A rapid CMR protocol for the evaluation of cardiac volumes, function and tissue characterization (Cardiac Iron T2* and LGE for scar) Figure 1a. We deployed the protocol as a multicentre study: Argentina, Peru, India and South Africa accompanied by a program of education. Pre-scan clinical information, scanning data: complications, image quality and post-scan follow-up of participants for the assessment on impact, between 3 to 24 months.

Results

510 scans (4 countries, 6 cities, 12 centres) were performed with the rapid CMR protocol. Contrast studies in 378 (74%). There were no scan-related complications. Quality of the studies was maintained in a high level as an average of 89%. 97% of studies responded referral's question. All patients with contrast CMR scan have had at least one 2D echocardiogram before CMR. Average scan duration was 21±6 mins for contrast studies and 12±3 for non-contrast T2* protocol. The most common underlying diagnoses were non-ischaemic cardiomyopathy in 73% of participants (including cardiac iron level assessment in 26%, HCM in 17%, DCM in 15%), 27% for ischaemic cardiomyopathy and 15% for other pathologies. 4 of the 12 participant centres started to incorporate CMR for the first time. Findings impacted management in 60% of patients, including new diagnosis in 21% of participants. See table 1, figure 1b. For just cardiac iron assessment: 1/3 of participants had iron deposited in the heart with 14% of patients in severe levels.

Conclusions

CMR can be delivered faster and easier. When this abbreviated protocol is enabled with education, it can be implemented in developing countries with existing technology. This protocol shows high quality exam, with an important impact on patient's management.

Characteristics and impact on management Contrast studies Non-contrast studies All patients (%) 378 (74) 132 (36) Age, mean (range) years 54 (16–93) 24 (13–41) Male (%) 151 (39) 64 (48) Pre-echocardiography exam (%) 370 (98) 42 (32) Scanning duration mean (SD) 21 (6) 12 (3) Good quality exam (%) 329 (87) 120 (91) Impact on management Total All patients (%) 510 (100) Completely new diagnosis (%) 105 (21) Change/Addition of Medication (%) 128 (25) Intervention/ Surgery (%) 31 (6) Invasive angiography/biopsy (%) 25 (5) Hospital discharge/admission (%) 15 (3) TOTAL 306 (60%) SD: Standard Deviation.

Acknowledgement/Funding

Global Engagement UCL, UK Foreign & Commonwealth Office and The Peruvian Scientific, Technological Development and Technological Innovation (FONDECYT)

A Rare Case of Pancreatitis-Induced Thrombosis of the Aorta and Superior Mesenteric Artery

It is estimated that there are more than 210,000 hospital admissions for acute pancreatitis and more than 56,000 admissions for chronic pancreatitis each year in the United States. Pancreatitis comes with numerous complications that can increase morbidity, mortality, and length of hospital stay. Local and systemic complications include pseudocysts, necrosis, sepsis, multiorgan failure, and vascular complications. Thrombosis of the splanchnic venous system occurs in approximately 2% of patients with pancreatitis, but thrombosis is rarely seen in the arterial system. In this report, we describe a case of thrombosis of the abdominal aorta and superior mesenteric artery in a female patient who presented with acute pancreatitis.

Proliferative potential and resistance to immune checkpoint blockade in lung cancer patients

Background

Resistance to immune checkpoint inhibitors (ICIs) has been linked to local immunosuppression independent of major ICI targets (e.g., PD-1). Clinical experience with response prediction based on PD-L1 expression suggests that other factors influence sensitivity to ICIs in non-small cell lung cancer (NSCLC) patients.

Methods

Tumor specimens from 120 NSCLC patients from 10 institutions were evaluated for PD-L1 expression by immunohistochemistry, and global proliferative profile by targeted RNA-seq.

Results

Cell proliferation, derived from the mean expression of 10 proliferation-associated genes (namely BUB1, CCNB2, CDK1, CDKN3, FOXM1, KIAA0101, MAD2L1, MELK, MKI67, and TOP2A), was identified as a marker of response to ICIs in NSCLC. Poorly, moderately, and highly proliferative tumors were somewhat equally represented in NSCLC, with tumors with the highest PD-L1 expression being more frequently moderately proliferative as compared to lesser levels of PD-L1 expression. Proliferation status had an impact on survival in patients with both PD-L1 positive and negative tumors. There was a significant survival advantage for moderately proliferative tumors compared to their combined highly/poorly counterparts (p = 0.021). Moderately proliferative PD-L1 positive tumors had a median survival of 14.6 months that was almost twice that of PD-L1 negative highly/poorly proliferative at 7.6 months (p = 0.028). Median survival in moderately proliferative PD-L1 negative tumors at 12.6 months was comparable to that of highly/poorly proliferative PD-L1 positive tumors at 11.5 months, but in both instances less than that of moderately proliferative PD-L1 positive tumors. Similar to survival, proliferation status has impact on disease control (DC) in patients with both PD-L1 positive and negative tumors. Patients with moderately versus those with poorly or highly proliferative tumors have a superior DC rate when combined with any classification schema used to score PD-L1 as a positive result (i.e., TPS ≥ 50% or ≥ 1%), and best displayed by a DC rate for moderately proliferative tumors of no less than 40% for any classification of PD-L1 as a negative result. While there is an over representation of moderately proliferative tumors as PD-L1 expression increases this does not account for the improved survival or higher disease control rates seen in PD-L1 negative tumors.

Conclusions

Cell proliferation is potentially a new biomarker of response to ICIs in NSCLC and is applicable to PD-L1 negative tumors.

Electronic supplementary material

The online version of this article (10.1186/s40425-019-0506-3) contains supplementary material, which is available to authorized users.

Next generation sequencing of PD-L1 for predicting response to immune checkpoint inhibitors

BACKGROUND

PD-L1 immunohistochemistry (IHC) has been traditionally used for predicting clinical responses to immune checkpoint inhibitors (ICIs). However, there are at least 4 different assays and antibodies used for PD-L1 IHC, each developed with a different ICI. We set to test if next generation RNA sequencing (RNA-seq) is a robust method to determine PD-L1 mRNA expression levels and furthermore, efficacy of predicting response to ICIs as compared to routinely used, standardized IHC procedures.

METHODS

A total of 209 cancer patients treated on-label by FDA-approved ICIs, with evaluable responses were assessed for PD-L1 expression by RNA-seq and IHC, based on tumor proportion score (TPS) and immune cell staining (ICS). A subset of serially diluted cases was evaluated for RNA-seq assay performance across a broad range of PD-L1 expression levels.

RESULTS

Assessment of PD-L1 mRNA levels by RNA-seq demonstrated robust linearity across high and low expression ranges. PD-L1 mRNA levels assessed by RNA-seq and IHC (TPS and ICS) were highly correlated (p < 2e-16). Sub-analyses showed sustained correlation when IHC results were classified as high or low by clinically accepted cut-offs (p < 0.01), and results did not differ by tumor type or anti-PD-L1 antibody used. Overall, a combined positive PD-L1 result (≥1% IHC TPS and high PD-L1 expression by RNA-Seq) was associated with a 2-to-5-fold higher overall response rate (ORR) compared to a double negative result. Standard assessments of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) showed that a PD-L1 positive assessment for melanoma samples by RNA-seq had the lowest sensitivity (25%) but the highest PPV (72.7%). Among the three tumor types analyzed in this study, the only non-overlapping confidence interval for predicting response was for "RNA-seq low vs high" in melanoma.

CONCLUSIONS

Measurement of PD-L1 mRNA expression by RNA-seq is comparable to PD-L1 expression by IHC both analytically and clinically in predicting ICI response. RNA-seq has the added advantages of being amenable to standardization and avoidance of interpretation bias. PD-L1 by RNA-seq needs to be validated in future prospective ICI clinical studies across multiple histologies.

Assessing Performance and Quality After Non-ST Segment Elevation Acute Coronary Syndromes

PURPOSE OF REVIEW

This review summarizes and discusses the evidence base supporting current performance and quality measures used in assessing institutions in their care of patients with non-ST segment elevation acute coronary syndromes (NSTE-ACS).

RECENT FINDINGS

Professional societies in the USA and Europe have developed performance and quality measures for NSTE-ACS. These measures are reviewed and updated periodically to reflect the most important evidence from the literature. In the USA, the ACC/AHA Task Force on Performance Measures published the updated 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction. In Europe, the ESC Acute Cardiac Care Association published the 2017 Quality Indicators for acute myocardial infarction. These documents build on guidelines previously developed and published by the two organizations. They include detailed reviews of current and past studies establishing that adherence with guidelines improves clinical outcomes. Both measure sets provide quantitative methodologies to assess program performance. Institutional programs that focus on these validated measures can increase guideline adherence, streamline and standardize care processes, and reduce morbidity and mortality. Performance and quality measures have become a critical part of healthcare today, allowing patients, providers, administrators, and payors to assess patient care objectively. They are also becoming an important component of value-based payment programs. To be fair, and useful, for internal institutional assessment, in comparing different institutions, and for value-based payments, only validated performance measures such as these should be employed.

Animal production, animal health and food safety: Gaps and challenges in the chilean industry

This paper summarizes the gaps and challenges related to animal production, health, and food safety as discussed by a panel at the 1st International Symposium of Food Safety (ISFS) in Santiago, Chile, in December 2016. Participating representatives of academia, industry, and government and statements from the audience confirmed that food safety is essential for increasing food security. First, panelists identified the need for a science-based regulatory framework to implement effective regulations. Second, they highlighted the importance of a risk analysis framework to quantify the risk of the potential for antimicrobial resistance associated with the use of antimicrobials, and the need of studies to evaluate foodborne prevention/control strategies. Third, the challenges of filling the gaps between industry and academia were addressed, including examples of successful collaboration, opportunities, and weakness identified by industry. Finally, challenges in animal food production included issues related to changing consumer preferences, animal welfare, the use of antimicrobials, and sustainable animal production. The symposium provided a regional platform to share experiences from the implementation of methods and approaches for food safety. The roundtable successfully explored the future science and technology challenges that are of strategic importance for Chile and the region in animal health and food safety.

Effect of patient and nurse ethnicity on emergency department analgesia for children with appendicitis in israeli government hospitals

BACKGROUND

Ethnicity is a risk factor for disparate Emergency Department (ED) analgesia. We aimed to explore ethnic variations in the administration of ED analgesia to children with acute appendicitis in Israeli government hospitals.

METHODS

Children discharged with an International Classification of Disease-Ninth Revision diagnosis of acute appendicitis between 2010 and 2015 were included. The association between patient ethnicity (Jewish, Arab) and analgesia administration (any, opioid) was assessed. Age, gender, triage category, pain score and time of arrival were tested as possible confounders. The effect of patient-nurse ethnic discordance (PNED) was examined.

RESULTS

Overall, 4714 children with acute appendicitis, 3520 Jewish and 1194 Arab, were cared for in the EDs; 1516 (32.2%) received any analgesia and 368 (7.8%) opioid analgesia. Stratified by pain score, no statistical differences were found in the administration of any or opioid analgesia between Jewish and Arab patients with either severe pain or moderate pain. In multivariate modelling adjusted for pain score and triage category, the rates of any analgesia for Arab and Jewish patients were 31.8% (95% CI, 30.9-32.6) and 36.5% (95% CI, 36.0-36.9), adjusted OR (aOR) = 1.16 (95% CI, 0.98-1.38), respectively. The rates of opioid analgesia for Arab and Jewish patients were 8.5% (95% CI, 8.2-8.9) and 7.9% (95% CI, 7.3-8.7), aOR = 0.77; (95% CI, 0.59-1.22), respectively. Jewish and Arab nurses treated proportionally fewer patients from the opposite ethnicity with any analgesia (p < 0.01).

CONCLUSION

Emergency Department analgesia was markedly low, and not associated with patient ethnicity. PNED was associated with decreased rates of analgesia.

SIGNIFICANCE

Emergency Department analgesia for children with acute appendicitis in Israeli government hospitals is markedly low. Patient-provider ethnic discordance may negatively influence the provision of analgesia. Significant efforts should be undertaken in order to increase analgesia provision rates and reduce social inequality.