Ventral hernia repair using bioresorbable poly-4-hydroxybutyrate mesh in clean and contaminated surgical fields: a systematic review and meta-analysis

PURPOSE

Use of biologic or synthetic mesh in hernia repair shifts is based on evolving evidence. Poly-4-hydroxybutyrate (P4HB) biosynthetic mesh is a potential alternative to biologic and synthetic mesh in ventral hernia repair (VHR). This meta-analysis assesses the efficacy of P4HB mesh in clean and contaminated surgical settings.

METHODS

Two authors searched literature on PubMed, reviewing titles and abstracts of all articles to determine inclusion eligibility. Post-operative data were compared via transformation method to convert the proportion of patients with the outcome of interest into a suitable quantity for random-effects synthesis using STATA software.

RESULTS

Initial search yielded 287 citations. Six studies were included and categorized on whether hernia repairs were conducted in clean (CDC class I) or contaminated cases (CDC class II-IV). The pooled proportion of surgical site infection (SSI), surgical site occurrence (SSO), hernia recurrence, total surgical complications, and reoperation were calculated in 391 clean and 81 contaminated cases. For clean vs. contaminated cases, the following pooled proportions were noted: SSI (2% (CI 0-7%) vs 9% (CI 0-025) (p = 0.03), SSO: 14% (CI 5-25%) vs 35% (CI 22-50%) (p = 0.006), hernia recurrence (8% (CI 1-19%) vs 4% (CI 0-12%) (p = 0.769); surgical complications (17% (CI 6-32%) vs 50% (CI 27-72%) (p = 0.009). Reoperation data were available in 298 clean cases across four studies: 5% (CI 0-15%).

CONCLUSIONS

P4HB biosynthetic mesh may be more effective than previously thought, particularly in clean wounds. P4HB may also be superior to biologic mesh when compared to clinical trial data. Further research is necessary for more direct comparison.

Pneumonitis After Concurrent Chemoradiation and Immune Checkpoint Inhibition in Patients with Locally Advanced Non-small Cell Lung Cancer

AIMS

Pneumonitis is a common and potentially deadly complication of combined chemoradiation and immune checkpoint inhibition (CRT-ICI) in patients with locally advanced non-small cell lung cancer (LA-NSCLC). In this study we sought to identify the risk factors for pneumonitis with CRT-ICI therapy in LA-NSCLC cases and determine its impact on survival.

MATERIALS AND METHODS

We conducted a retrospective chart review of 140 patients with LA-NSCLC who underwent curative-intent CRT-ICI with durvalumab between 2018 and 2021. Pneumonitis was diagnosed by a multidisciplinary team of clinical experts. We used multivariable cause-specific hazard models to identify risk factors associated with grade ≥2 pneumonitis. We constructed multivariable Cox proportional hazard models to investigate the impact of pneumonitis on all-cause mortality.

RESULTS

The median age of the cohort was 67 years; most patients were current or former smokers (86%). The cumulative incidence of grade ≥2 pneumonitis was 23%. Among survivors, 25/28 patients had persistent parenchymal scarring. In multivariable analyses, the mean lung dose (hazard ratio 1.14 per Gy, 95% confidence interval 1.03-1.25) and interstitial lung disease (hazard ratio 3.8, 95% confidence interval 1.3-11.0) increased the risk for pneumonitis. In adjusted models, grade ≥2 pneumonitis (hazard ratio 2.5, 95% confidence interval 1.0-6.2, P = 0.049) and high-grade (≥3) pneumonitis (hazard ratio 8.3, 95% confidence interval 3.0-23.0, P < 0.001) were associated with higher all-cause mortality.

CONCLUSIONS

Risk factors for pneumonitis in LA-NSCLC patients undergoing CRT-ICI include the mean radiation dose to the lung and pre-treatment interstitial lung disease. Although most cases are not fatal, pneumonitis in this setting is associated with markedly increased mortality.

Definitive Radiotherapy for Oligometastatic and Oligoprogressive Thyroid Cancer

PURPOSE/OBJECTIVE(S)

Local consolidative radiotherapy (LCT) for oligometastatic disease is a promising paradigm improving outcomes for various malignancies but has been underexplored for metastatic thyroid cancer. We hypothesize that LCT to distant sites with definitive RT doses can yield favorable outcomes and defer systemic therapy escalation for these patients.

MATERIALS/METHODS

We reviewed 96 thyroid cancer patients who received 175 LCT courses from 2010-2022 to 228 metastatic sites, including: thorax (45%), bone (40%), brain (6%), head/neck (5%), and abdomen (3%). Common prescriptions were 50-55Gy/4-5fxs or 56-70Gy/8-10fxs for lung; 52.5-60Gy/15fxs for mediastinum; and 18-24Gy/1fx or 27-30Gy/3fxs for bone. RECIST v1.1 and CTCAE v5.0 were used to define progression and toxicities, respectively. Outcomes were evaluated via Kaplan-Meier and associations examined via Cox proportional hazards modeling.

RESULTS

Median age was 63 years (range: 26-92), with 62 oligometastatic cases (total 1-5 sites) and 34 oligoprogressive (with 1-5 growing sites). Primary disease was controlled in all patients, with 39% receiving post-op RT and 66% prior RAI. Histologies included papillary (40%), anaplastic (25%), follicular (12%), medullary (9%), Hurthle (7%), and poorly-differentiated (7%). Median time from initial diagnosis to LCT was 3 yrs (IQR 1-8), and median follow-up from 1st LCT was 21 mos (IQR 9-51). Patients received an average 2 LCT courses (range 1-8) treating 1-4 sites. Median survival (OS) from 1st LCT was 9 yrs (95% CI = 5-14). On multivariable analysis (MVA), worse OS was associated with anaplastic histology (HR 4.6, p<.01), but longer OS was associated with prior RAI (HR 0.33, p = .02) and oligometastatic disease (HR 0.3, p = .01). For anaplastic histology, median OS was 1.2 years vs. 9.3 years for non-anaplastic; 3-yr OS was 36% vs. 88% (log-rank, p<.01). Five-year OS for oligometastatic cases was 75% vs 53% for oligoprogressive (log-rank, p = .04). Median progression free survival (PFS) from 1st LCT was 15.5 mos (95% C I = 11-20). On MVA for all LCT courses, time to any progression (TTP) was negatively associated with anaplastic histology (HR 1.7, p = .02) and 2nd or higher LCT course (HR 1.45, p = .05), but favorably associated with thoracic site (HR 0.49, p<.01). Following later LCT courses, median TTP was 11 mos vs 17 mos for initial LCT course (log-rank, p = .03). After LCT to lung/chest, TTP was 18.6 mos vs 9.5 mos for non-thoracic sites (log-rank, p<.01). Only 6% of failures occurred at previously treated lesions. Most LCT courses (67%) were without ongoing chemotherapy, while 25% entailed continuing the same regimen and 9% had planned treatment post-RT. There were 2 Grade 3 toxicities (pneumonitis and esophagitis) and no Grade 4-5 events.

CONCLUSION

With high local control rates and minimal toxicity, LCT can be a feasible strategy to defer systemic therapy escalation for oligometastatic and oligoprogressive thyroid cancer.

Comorbidities and Their Impact on Treatment Tolerance and Outcome in Elderly NSCLC Patients Treated with Concurrent Chemoradiation Using Proton or Photon Followed by Immunotherapy

PURPOSE/OBJECTIVE(S)

To investigate comorbidities and their impact on treatment tolerance and survival for elderly NSCLC patients treated with concurrent chemoradiation using proton beam therapy (PBT) or intensity modulated radiation therapy (IMRT) followed by immunotherapy (IO).

MATERIALS/METHODS

This is a retrospective study in senior patients (≥ 65 years) with inoperable locally advanced- NSCLC (LA-NSCLC) who received concurrent chemoradiation (CRT) therapy followed by adjuvant IO. Comorbidities are listed in table 1 and scored according to hazard ratios (HRs) of death. Treatment tolerance and comorbidities were compared between modalities using Fisher's exact test. Association between comorbidities and treatment tolerance was analyzed using logistic regression; association between comorbidities and survival was analyzed by Cox proportional hazards regression.

RESULTS

Total 218 patients were included with median age of 72 (range 65-86) years. Fifty-three (24.3%) were PBT and 165 (75.7%) were IMRT. Majority patients were white ethnics, had stage III adenocarcinoma disease and good performance score, and received RT dose 60-66 Gy. The median follow-up time for the whole group was 23 months. A 97% of patients had ≥1, and 62% had ≥4 comorbidities. The combined comorbidity scores ranged from 0 to 25. No significant difference in comorbidities between modalities except IMRT had more patients with COPD (36% vs. 51%, p = 0.047). Rates of hospitalization and ER visit during CRT+IO were 28% and 5%, respectively. Rates of IO discontinuation and interruption were 55% and 8%, respectively. Patients received >6 months IO had significantly lower risk of death (HR: 0.25, p<0.001). No significant difference in treatment tolerance between modalities. In multivariable analysis, atrial fibrillation, pulmonary disease, and depression were the comorbidities associated with hospitalization during CRT+IO (p<0.05); dementia was the comorbidity associated with IO interruption (p = 0.042); heart failure, COPD, asthma, osteoporosis and HIV were the comorbidities associated with poor OS (p<0.05). Combined comorbidity score was associated with OS with HR of 1.13 (p<0.001) with adjustment of race, GTV and induction chemotherapy.

CONCLUSION

Comorbidities were associated with hospitalization and IO interruption during the whole course of CRT and IO therapy, with increased IO discontinuation which negatively impacted survival. Evaluating and scoring comorbidities at diagnosis could be a useful method to predict risk of death before treatment start.

Prospective Trial of Using Imaging to Predict Pathologic Response and Clinical Outcomes in Locally Advanced Esophageal Cancer

PURPOSE/OBJECTIVE(S)

Trimodality therapy with chemoradiation (CRT) followed by esophagectomy is the standard of care for locally advanced esophageal cancer. An unresolved question is whether pathologic complete response (pCR) can be assessed non-invasively for patients post-CRT. In this study, we assessed whether diffusion-weighted imaging (DWI) with MRI or PET can be used as predictors of pCR and other clinical outcomes after CRT.

MATERIALS/METHODS

Patients were enrolled on a single-arm institutional trial (PA13-0380) assessing the role of imaging in predicting outcomes in potentially resectable esophageal patients undergoing trimodality therapy. All patients received neoadjuvant CRT, and 29 patients had subsequent surgery. DWI MRI and PET scans were obtained at baseline, 2 weeks after the start of CRT (interim) and 4 to 6 weeks after completion of CRT (follow up). Apparent diffusion coefficients (ADCs) were calculated based on DWI images. Circulating tumor DNA was obtained for 27 patients post-radiation using CAPP-Seq. Mann-Whitney tests compared imaging changes associated with pCR. Discrimination of pCR by imaging changes was quantified by received operating characteristics. Youden's index was applied to select optimal thresholds. Kaplan-Meier analysis was performed to assess differences in overall survival (OS) and progression-free survival (PFS) by changes in DWI, PET, and ctDNA parameters.

RESULTS

Our cohort of 60 patients had a median follow up of 42.7 months, age of 65.4 yrs, and ECOG of 1 at completion of CRT. 90% were male, 58% had a history of smoking, and 85% were white. 83% had adenocarcinoma with the rest squamous cell carcinoma. Stages of the patients ranged from IIA to IIIB. All had moderately (47%) or poorly (53%) differentiated disease. All received 41.4-50.4 Gy in 1.8 Gy fractions with the majority receiving 50.4 Gy (95%). 29 patients underwent surgery after CRT of which 8 (27.6%) had pCR. Mean ΔADC from baseline to mid-treatment was most associated with pCR (AUC = 0.98, p<0.001) for patients undergoing surgery. Max ΔADC from baseline to first follow-up was most associated with OS (p = 0.002) and PFS (p<0.001) for the whole cohort. 27 patients had ctDNA analyzed after RT with the presence of ctDNA significantly associated with worse OS (HR = 0.12, p = 0.05) and PFS (HR = 0.10, p = 0.002). Combining ctDNA and max ΔADC generated a model that was more predictive of OS and PFS than either alone. We found that neither the PET parameters of TLG or SUV max at baseline or changes in these parameters from baseline to mid-treatment or first follow-up were as predictive as DWI.

CONCLUSION

We show that changes in DWI is associated with pCR, OS, and PFS in resectable esophageal cancer patients undergoing CRT. DWI was more predictive than PET and a model combining DWI and ctDNA was the most predictive of clinical outcomes. This study shows the significant promise of using DWI in potentially guiding treatment decisions in esophageal cancer patients and will require validation in a larger cohort.

Parieto-Occipital Injury on Diffusion MRI Correlates with Poor Neurologic Outcome following Cardiac Arrest

BACKGROUND AND PURPOSE

MR imaging of the brain provides unbiased neuroanatomic evaluation of brain injury and is useful for neurologic prognostication following cardiac arrest. Regional analysis of diffusion imaging may provide additional prognostic value and help reveal the neuroanatomic underpinnings of coma recovery. The purpose of this study was to evaluate global, regional, and voxelwise differences in diffusion-weighted MR imaging signal in patients in a coma after cardiac arrest.

MATERIALS AND METHODS

We retrospectively analyzed diffusion MR imaging data from 81 subjects who were comatose for >48 hours following cardiac arrest. Poor outcome was defined as the inability to follow simple commands at any point during hospitalization. ADC differences between groups were evaluated across the whole brain, locally by using voxelwise analysis and regionally by using ROI-based principal component analysis.

RESULTS

Subjects with poor outcome had more severe brain injury as measured by lower average whole-brain ADC (740 [SD, 102] × 10-6 mm2/s versus 833 [SD, 23] × 10-6 mm2/s, P < .001) and larger average volumes of tissue with ADC below 650 × 10-6 mms/s (464 [SD, 469] mL versus 62 [SD, 51] mL, P < .001). Voxelwise analysis showed lower ADC in the bilateral parieto-occipital areas and perirolandic cortices for the poor outcome group. ROI-based principal component analysis showed an association between lower ADC in parieto-occipital regions and poor outcome.

CONCLUSIONS

Brain injury affecting the parieto-occipital region measured with quantitative ADC analysis was associated with poor outcomes after cardiac arrest. These results suggest that injury to specific brain regions may influence coma recovery.

Patients not taking a previously prescribed bone active medication now prescribed medication through Ontario FLS

In an Ontario fracture liaison service (FLS), we compared medication prescription rates among patients not taking a previously prescribed bone active medication to those with no previous prescription. Prescription rates were similar between these two groups of patients. The FLS provided a secondary opportunity for patients to initiate bone active medication.

PURPOSE

We compared bone active medication prescription rates among patients presenting to an Ontario fracture liaison service (FLS) who reported not taking a previously prescribed bone active medication to those with no history of prescription.

METHODS

Eligible patients were those screened in 39 fracture clinics between July 1, 2017, and September 15, 2019, who were not taking bone active medication at the time of screening and classified as high risk for future fracture based on CAROC or FRAX. Sociodemographic and clinical risk factor variables were assessed at screening. Bone active medication prescription rate was assessed within 6 months of screening and defined as having received a prescription for the medication from either a specialist or primary care provider. In cases where a specialist report was not available, patient self-reported data were collected. The chi-square test of independence was used to assess differences in prescription rates.

RESULTS

Of 17,575 patients screened, eligible patients were 350 with a previous prescription and 2644 without a previous prescription. Compared with patients who reported no previous prescription, those who had a previous prescription were older, more likely to be female and to report a previous fracture, and less likely to smoke. There was no statistically significant difference between the medication prescription rate of patients with a previous prescription (73.7%) compared to patients with no previous prescription (70.7%) (p = 0.157).

CONCLUSION

A large jurisdiction-wide FLS approach provided a secondary opportunity to patients who were not taking a previously prescribed bone active medication to initiate that medication.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Prospective Hybrid Molecules with Dual Anti-Viral and Anti-Thrombotic Activity Against the SARS- CoV-2 Infection and Its Associated Complications Employing in Silico Studies

Covid-19, a SARS-CoV virus-based disease, was identified in Wuhan, China, in December 2019. Initially, it was considered just an infection of the respiratory system, but due to its transmittable nature, it was declared a pandemic. A variety of treatment options were implemented, including antivirals like remdesvir, favipiravir along with vitamins and antioxidants. Further investigations revealed that the Covid-19 infection results in thrombotic cardiovascular complications, which are the major concern for the increased mortality associated with this disease. This study investigates the in Silico design of hybrid molecules with antiviral and an-tithrombotic properties. A docking study was performed using Autodock Vina software, and binding energies of the designed compounds were determined for papain-like protease (PDB: 3E9S) and 3-chymotrypsin-like cysteine protease (PDB: 6LU7). The docked poses and amino acids interactions were verified using Biovia Discovery studio 4.5. The binding energies of all designed compounds were compared with the standards, Compound RL1 (2-(5-(3-carbamoyl-1H-1,2,4-triazol-1-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methoxy)-carbonyl)amino)(hydroxy)methyl)carbamoyl)phenyl acetate) and Compound FL2 (8-hydroxy-2-(3-hydroxy-4-methoxyphenyl)-4-oxochroman-6-yl(2-(6-flouro-3-oxo-3,4-dihydropyrazine-2-carboxamido)-1-hydroxy-3-phenylpropyl)carbamate) proved to be promising agents with strong binding interactions. Hybrid molecules that inhibit viral replication, possibly as transition state inhibitors, may be investigated further for use in the treatment of SARS-Co-V infection and its associated complications.

476 The Role of Medical Students in an International, Collaborative, Multi-Centre Global Surgery Study

Introduction

The gaps in formal education caused by the pandemic have provided medical students with opportunities to redefine their role in settings across clinical medicine, education and research. This task shifting could provide avenues for students to engage with global surgery, where the cultivation of research skills, networking, and global collaboration amongst students is imperative for sustainable progress.

COVIDPaedsCancer is an international collaborative cohort study assessing the impact of the pandemic on paediatric cancer services. We aimed to trial a student and junior doctor-lead team to perform the day-to-day running of this research.

Method

An operations team of 47 students and junior doctors across 11 countries was assembled. Sub-teams were created for social media, network management, email communications, REDCap, research support and graphics. Together, they ran the study under guidance from the steering committee.

Results

To date, the operations team has coordinated study collaborators in collecting data for 1252 patients from 78 centres across 39 countries. Cooperation between sub-teams enabled the recruitment of collaborators from 558 hospitals in total. They also identified 2 errors in the protocol and resolved them with steering committee input, and continuously managed hospital leadership issues and general queries throughout the course of the study. The team was able to adapt in response to the evolving needs of collaborators and the steering committee.

Conclusions

Medical students were able to aid the delivery of an international, multicentre, collaborative, global surgery research study while benefiting from learning opportunities, networking opportunities, and developing interest and understanding of global surgery.

Family Caregivers' Perspective on Factors Affecting Recovery from Schizophrenia

OBJECTIVE

To explore caregivers' perspective on factors affecting the recovery of their family members diagnosed with schizophrenia.

METHODS

A qualitative grounded theory approach was used. A convenience sample of seven male and eleven female family caregivers of patients with schizophrenia were invited from outpatient (n = 6), inpatient (n = 7), and psychiatric rehabilitation (n = 5) services in an Indian mental health institute to participate in semi-structured interviews. Interviews were recorded, transcribed, and analysed. Similar themes were grouped and the main themes identified.

RESULTS

Caregivers' perspectives on factors affecting recovery from schizophrenia were categorised to two themes: facilitators and barriers. The nine facilitators were (1) getting into a precise treatment regimen and sticking to it, (2) developing some personal attributes, (3) exercising family's role diametrically, (4) paying attention to basic needs, (5) sharing with the Almighty, (6) adapting to a supportive lifestyle, (7) not being idle… engage in something, (8) coming out, being and sharing with others, and (9) having adequate resources with a good support system. The ten barriers were (1) detrimental treatment practices, (2) hampering illness impacts, (3) off-putting personality elements, (4) unaccommodating family circumstances, (5) caregivers' limitation, (6) flaccid support system and scarce resources, (7) ambiguous treatment outcome or prognosis, (8) futile religious, health, and social belief systems, (9) situational factors, and (10) presence of troubling physical or psychological stressors.

CONCLUSION

The recovery process is facilitated through family involvement and support by mental health professionals. Thus, giving a pre-treatment counselling to the caregivers and repeating the same content to the patients after regaining insight can be helpful.

P1500Effects of empagliflozin on cardiac function in patients with type 2 diabetes mellitus: echocardiographic substudy of the EMPA-HEART cardiolink-6 trial

Background

The EMPA-HEART trial showed a reduction in left ventricular (LV) mass index by cardiac MRI at 6 months in patients treated with Empagliflozin vs placebo. A secondary analysis of key echocardiographic parameters was performed to provide further insight into the mechanism of LV remodeling.

Methods

All patients enrolled prospectively underwent transthoracic echocardiography (TTE) at baseline and at 6 months. Measurements were performed according to the American Society of Echocardiography guidelines. Key outcomes of interest included changes in diastolic function and right ventricle parameters at 6 months in patients treated with Empagliflozin vs placebo.

Results

A total of 97 patients were enrolled (49 treated with Empagliflozin and 48 in the placebo group). There was no significant difference in the change in average E/E' at 6-months in the Empagliflozin group vs placebo (−0.4 vs +0.2, adjusted difference −0.2, 95% CI [−1.3 to 0.82], p=0.7) Similarly, there was no difference between the groups in secondary TTE parameters (Table 1). Subgroup analyses showed no benefit among patients with baseline LVEF >50% vs. ≤50%, and baseline LV mass index ≥60 g/m2 vs <60 g/m2.

Echocardiographic Parameter Placebo (n=48) Empagliflozin (n=49) Adjusted Difference Between Groups 95% CI P-Value Baseline 6 months Change Baseline 6 months Change LVEF (%)* 55.5 (8.7) 54.3 (8.9) −1.0 (6.5) 58.0 (7.5) 59.1 (8.57) 0.72 (5.1) 2.2 (−0.2, 4.7) 0.1 Diastolic Parameters:   Average E/e' 10.1 (3.1) 10.3 (2.5) 0.2 (3.0) 10.6 (3.0) 10.5 (3.6) −0.4 (2.5) −0.2 (−1.3, 0.8) 0.7   Medial E/e' 12.3 (3.9) 12.5 (3.6) 0.1 (3.7) 12.6 (4.2) 12.6 (5.2) −0.3 (3.3) −0.3 (−1.7, 1.1) 0.7   Lateral E/e' 8.0 (2.8) 8.2 (2.2) 0.2 (2.7) 8.7 (2.6) 8.4 (2.5) −0.4 (2.7) −0.1 (−1.0, 0.8) 0.8   E velocity (cm/sec) 68.6 (15.2) 70.6 (14.7) 1.8 (15.4) 74.4 (18.2) 71.2 (16.8) −3.2 (15.1) −2.3 (−7.9, 3.3) 0.4   A velocity (cm/sec) 74.7 (17.9) 77.9 (18.8) 2.9 (15.9) 76.2 (16.5) 75.8 (14.5) −1.4 (11.7) −3.5 (−8.9, 1.6) 0.2   LA volume index (mL/m2) 32.7 (7.9) 30.8 (8.1) −2.0 (6.7) 30.2 (6.7) 28.7 (5.5) −1.6 (6.5) −0.9 (−3.4, 1.6) 0.5 RV Parameters:   TAPSE (cm) 1.8 (0.5) 1.8 (0.4) 0.1 (0.4) 2.0 (1.2) 1.8 (0.4) −0.3 (1.4) −0.1 (−0.3, 0.1) 0.3   RV S' TDI (cm/sec) 10.9 (2.9) 10.6 (2.5) −0.1 (2.2) 10.4 (2.7) 10.2 (2.6) −0.4 (2.0) −0.3 (−1.2, 0.5) 0.4 *Measured by cardiac MRI. LA, left atrium; LVEF, left ventricular ejection fraction; RV, right ventricle; TAPSE, tricuspid annular plane systolic excursion; TDI, tissue Doppler imaging. Data expressed as mean (standard deviation).

Conclusion

This study showed no significant change in key echocardiographic parameters in patients treated with Empagliflozin, suggesting that changes in loading conditions induced by empagliflozin (i.e. preload) do not mediate the reduction in LV mass.

Intracranial Hemorrhage in a Young Woman: An Unusual Initial Presentation of Undiagnosed Choriocarcinoma

Choriocarcinoma is an uncommon tumor. Undiagnosed choriocarcinoma initially presenting with intracranial hemorrhage in an apparently healthy female is rare and presents a diagnostic difficulty. The authors report a case presenting as intracranial hemorrhage of unsuspected choriocarcinoma. As the measurement of beta-human chorionic gonadotropin (β-hCG) would have helped in the preoperative diagnosis, estimation of serum β-hCG levels is suggested in the diagnostic workup of a female of reproductive age group when radiological investigations are inconclusive. Craniotomy and excision of tumor followed by chemotherapy and radiotherapy may improve the outcome.

Abstract P2-06-17: A novel interaction of AURKA with MAPK pathway in breast cancer cells as a potential therapeutic target

Background: Aurora A (AURKA) is a mitotic kinase responsible for centrosome segregation and mitotic spindle formation. In normal cells, expression of AURKA is highly regulated and is predominantly restricted to G2/M phases of the cell cycle. Unlike healthy cells, cancer cells overexpress AURKA through all phases of the cell cycle resulting in the acquisition of alternate non-mitotic functions. Little is known about cellular functions regulated by AURKA and its interaction with other signaling molecules. Here, we report a novel interaction between AURKA and the mitogen-activated protein kinase (MAPK) pathway at the level of MEK1 in breast cancer cells. This interaction may serve as a novel target as well as demonstrate by an additive cytotoxic effect of AURKA- and MEK1/2-specific inhibitors against estrogen positive (ER+) and triple negative breast cancer (TNBC) cells.

Results: We show that treatment of ER+ HER2- MCF-7, ER- HER2+ SKBR3 and ER- HER2- BT549 cells with AURKA specific inhibitors alisertib, MK8745 and Aurora A Inhibitor I resulted in over 2-fold increase in relative levels of poMEK1/2 and poERK1/2 compared to untreated controls. The activation of the MAPK pathway was rapid with changes seen within 5 min after treatment with AURKA inhibitors and was sustained for at least 48 hours. Treatment with the pan RAF inhibitor TAK-632 did not diminish alisertib-induced poERK and poMEK1/2. Alternatively, treatment with the MEK1/2 specific inhibitor PD0325901 completely abrogated alisertib-induced phosphorylation of MEK1/2 and ERK1/2. In situ proximity ligation and pull down assays demonstrated AURKA and MEK1/2 direct interaction. In vitro kinase assay showed direct phosphorylation of MEK1 by AURKA. Combined treatment of alisertib and PD0325901 in vitro revealed significant additive cytotoxic effect in MCF-7 and BT549 cells when compared to either agent used alone (p&lt; 0.008 and p&lt;0.011; p &lt;0.04 and p&lt;0.028) with early trend toward significance in survival in a BT549 xenograft breast cancer in vivo model.

Conclusions: Our data shows a novel AURKA-MEK1 interaction in breast cancer cells. In depth in vivo analysis is ongoing. The results reveal a promising new strategy for the treatment TNBC patients using a combination of AURKA and MEK1/2 inhibitors.

Citation Format: Gandhi S, Gil M, Khoury T, Takabe K, Puzanov I, Gelman I, D'Assoro A, Opyrchal M. A novel interaction of AURKA with MAPK pathway in breast cancer cells as a potential therapeutic target [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-06-17.

Unusual array of neural communications in the infratemporal fossa: Useful for skull base surgery

Variations in the branching pattern of the mandibular nerve frequently accounts for failure to obtain adequate local anesthesia in routine oral and dental procedures, and also for unexpected injury to the nerves during surgery. The knowledge of the neurovascular relationships of the infratemporal region is relevant in odontostomatology practice. In this article we present a rare case of atypical communication between the inferior alveolar nerve and lingual nerve and the mylohyoid and lingual nerves. Further, the clinical implications of these communications on the development of the supplementary innervation and their possible role in anesthesia is discussed in detail. The communication between mylohyoid and lingual nerve was found in this case near the submandibular ganglion after the lingual nerve passes in close relation to third molar tooth, which makes it more susceptible to injury during third molar extractions. The communicating branch between the mylohyoid nerve and lingual nerve may also innervate the tongue, and surgeons should be aware of this variation to avoid post- operative complcations after oral surgeries. Thus the precise anatomy of structures of infratemporal region and its variations may prove beneficial to clinicians, especially to oral and maxillofacial surgeons.

Prebiotics for the prevention of allergies: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Prevalence of allergic diseases in infants is approximately 10% reaching 20 to 30% in those with an allergic first-degree relative. Prebiotics are selectively fermented food ingredients that allow specific changes in composition/activity of the gastrointestinal microflora. They modulate immune responses, and their supplementation has been proposed as an intervention to prevent allergies.

OBJECTIVE

To assess in pregnant women, breastfeeding mothers, and infants (populations) the effect of supplementing prebiotics (intervention) versus no prebiotics (comparison) on the development of allergic diseases and to inform the World Allergy Organization guidelines.

METHODS

We performed a systematic review of studies assessing the effects of prebiotic supplementation with an intention to prevent the development of allergies.

RESULTS

Of 446 unique records published until November 2016 in Cochrane, MEDLINE, and EMBASE, 22 studies fulfilled a priori specified criteria. We did not find any studies of prebiotics given to pregnant women or breastfeeding mothers. Prebiotic supplementation in infants, compared to placebo, had the following effects: risk of developing eczema (RR: 0.68, 95% CI: 0.40 to 1.15), wheezing/asthma (RR, 0.37; 95% CI: 0.17 to 0.80), and food allergy (RR: 0.28, 95% CI: 0.08 to 1.00). There was no evidence of an increased risk of any adverse effects (RR: 1.01, 95% CI: 0.92 to 1.10). Prebiotic supplementation had little influence growth rate (MD: 0.92 g per day faster with prebiotics, 95% CI: 0 to 1.84) and the final infant weight (MD: 0.10 kg higher with prebiotics, 95% CI: -0.09 to 0.29). The certainty of these estimates is very low due to risk of bias and imprecision of the results.

CONCLUSIONS

Currently available evidence on prebiotic supplementation to reduce the risk of developing allergies is very uncertain.