Consensus goals and standards for specialist cough clinics: the NEUROCOUGH international Delphi study

Background

Current guidelines on the management of chronic cough do not provide recommendations for the operation of specialist cough clinics. The objective of the present study was to develop expert consensus on goals and standard procedures for specialist cough clinics.

Methods

We undertook a modified Delphi process, whereby initial statements proposed by experts were categorised and presented back to panellists over two ranking rounds using an 11-point Likert scale to identify consensus.

Results

An international panel of 57 experts from 19 countries participated, with consensus reached on 15 out of 16 statements, covering the aims, roles and standard procedures of specialist cough clinics. Panellists agreed that specialist cough clinics offer optimal care for patients with chronic cough. They also agreed that history taking should enquire as to cough triggers, cough severity rating scales should be routinely used, and a minimum of chest radiography, spirometry and measurements of type 2 inflammatory markers should be undertaken in newly referred patients. The importance of specialist cough clinics in promoting clinical research and cough specialty training was acknowledged. Variability in healthcare resources and clinical needs between geographical regions was noted.

Conclusions

The Delphi exercise provides a platform and guidance for both established cough clinics and those in planning stages.

Oral Cavity Squamous Cell Carcinomas in Patients with a History of Oral Lichen Planus: Frequency and Outcomes

PURPOSE/OBJECTIVE(S)

Oral lichen planus (OLP) is an inflammatory condition which affects the mucous membranes of the oral cavity. While previous studies have described the association between OLP and development of oral cavity cancer, there is currently a paucity of literature examining the impact of this disease on treatment response and prognosis. As such, we present a retrospective cohort study of Oral cavity squamous cell carcinoma (OCSCC) patients with a history of OLP to explore the course of their disease.

MATERIALS/METHODS

Using an IRB approved tertiary care registry of head and neck cancer patients, we identified patients with OCSCC who had a prior diagnosis of OLP. The number of new primary tumors, rates of local (LF), regional (RF) and distant failure (DF), as well as overall survival (OS) were assessed using Cox proportional hazards and Kaplan Meier analysis for actuarial survival estimates.

RESULTS

Fifty-four patients with OCSCC and OLP were identified with 109 individual OCSCC diagnoses. Patients had a median age of 67 years, were predominantly female (n = 42, 77.8%) and never smokers (n = 29, 53.7%) with a median follow up after diagnosis of OCSCC of 46.5 months. Nine patients (16.7%) had a history of immunosuppression of whom 6 (11.1%) had chronic steroid use for treatment of OLP. Within the cohort, 33 (61.1%) of OLP patients had a single OCSCC, 11 (20.4%) had 2, and 10 (18.5%) had >3 separate tumors develop. The most common oral cavity subsites were oral tongue (n = 42, 38.5%), followed by alveolar ridge (n = 14, 12.8%) and gingiva (n = 13, 11.9%). Papillary SCC subtype was identified in 10.1%. 92.7% of tumors (n = 101) were treated with primary surgery, with 23 (21.1%) receiving adjuvant RT and 10 of those patients receiving concurrent chemotherapy. Among resected patients, pathologic stages were predominantly T1-2 (84.1%) and N0 (50% vs N1 15.6% and N2a-3 34.4%). The mean RT dose was 62 Gy in 32 fractions. Locoregional failure occurred in 24.8% of cancers (n = 27), with local and regional failure occurring in 13.8% (n = 15) and 11% (n = 12) of lesions, respectively. Recurrence free survival at 3 and 5 years was 75% and 70.3%, respectively, with overall survival at 3 and 5 years of 71.1% and 67%, respectively.

CONCLUSION

Patients with OCSCC and a history of OLP are predominantly female and never smokers. The tumors that develop in such patients are often early stage but a proportion of patients appear to be at higher risk of developing multiple malignancies and surveillance of this patient population to identify new tumors is crucial.

Dosimetric Analysis of Major Wound Complications Following Preoperative Ultra-Hypofractionated Radiation Therapy for Soft Tissue Sarcoma

PURPOSE/OBJECTIVE(S)

Preoperative radiation therapy (RT) for soft tissue sarcomas (STS), delivered with conventional fractionation, has been shown to reduce long-term toxicity at the expense of increased postoperative major wound complications (MWC). Ultra-hypofractionated RT has emerged as a potential alternative preoperative modality with early but comparable outcomes to conventional regimens. However, limited data are available evaluating dosimetric, patient, and treatment specific factors associated with development of MWC in this setting.

MATERIALS/METHODS

This IRB approved review included STS patients treated with preoperative 5 fraction daily RT followed by surgical resection within 7 days. Patients were evaluated for MWCs in association with patient and tumor characteristics, dosimetric parameters, and treatment techniques. MWCs were defined as a return to operating room, readmission for wound care or IV antibiotics, and persistent deep packing for >120 days. Prescription isodose line, PTV mean dose and the PTV volume exposed to 105% and 110% of prescribed dose were recorded. Dose to tissue likely to be involved in wound healing was assessed by creating a 1 cm thick superficial skin strip within 2 cm of the PTV which was then evaluated for volume, mean dose, V15, V21, V27, and V30. Secondary endpoints were locoregional control (LRC), metastasis free survival (MFS), and overall survival (OS).

RESULTS

A total of 31 patients with a median age of 66 years (range 28-87) and a median follow up of 21 months (IQR 8-43) were included. All patients received 30 Gy in 5 fractions using IMRT/VMAT. There were 11 upper limb (36%) and 20 lower limb (65%) tumors included. Median time to resection following RT was 1 day (IQR 0-3). Median tumor size was 8 cm (IQR 5-13). MWC occurred in 13 patients (42%) with 10 patients (32%) requiring additional surgery. Dehiscence and infection requiring IV antibiotics occurred in 12 (39%) and 6 patients (19%), respectively. RT plans were predominately prescribed to the PTV mean (87%) with a median prescription isodose of 97% (IQR 96-97) and PTV mean dose of 3110 cGy (IQR 3089-3142). Median PTV volume, mean dose, and volume of PTV receiving 105% and 110% of the prescribed dose were higher in the MWC cohort although none reached significance. Similarly, for the 1 cm skin strip the median volume, mean dose, V30, V27, V21, and V15 were all higher in the MWC cohort without significant difference. Among patient, treatment, and tumor factors: tumor size, location, grade, margin status, type of wound closure, and prior non-oncologic resection were not associated with MWC. LRC, MFS, and OS at 3-years were 96%, 67%, and 76%, respectively.

CONCLUSION

Although not reaching significance, increased plan homogeneity and reduced dose/volume relationships in proximity to the skin trended to reduced MWC in this limited cohort. Multi-institutional collaboration may be warranted to better identify factors associated with MWC in patients treated with preoperative ultra-hypofractionated RT.

Liver Stereotactic Body Radiation Therapy (SBRT) to Downstage Patients with Hepatocellular Carcinoma prior to Liver Transplant

PURPOSE/OBJECTIVE(S)

Orthotopic liver transplantation (OLT) marks the most successful treatment for hepatocellular carcinoma (HCC) patients meeting Milan criteria. The process of reducing the disease burden of HCC patients not currently meeting criteria for OLT with local therapy is referred to as "downstaging" and has proven to be a feasible approach. RTOG 1112 recently demonstrated the efficacy and acceptable toxicity of liver SBRT for treating HCC. However, limited data currently exists describing the efficacy of SBRT for downstaging HCC patients and facilitating OLT.

MATERIALS/METHODS

A single institution IRB approved prospective liver SBRT registry was surveyed for all patients outside of Milan criteria (1 lesion >5 cm; 2-3 lesions >3 cm) without vascular invasion or extrahepatic disease. Patients felt least likely to become OLT candidates with downstaging (age >80, >4 lesions, lesion >12 cm) were excluded. The primary endpoints were downstaging and OLT. Secondary endpoints were time to transplant, local control (LC), recurrence free survival (RFS) and overall survival (OS).

RESULTS

A total of 38 HCC patients with a median age of 65 years (range 28 - 80) met inclusion criteria. Median follow up was 14 months (IQR 3 - 35). At baseline, median KPS was 80 (range 60 - 100) with 16 Child-Pugh (CP) A (42%), 13 CP B (34%), and 9 CP C patients (24%). All patients were outside of Milan criteria and 25 patients (66%) were outside of UCSF criteria at time of SBRT. No patients had extrahepatic disease or vascular invasion. Median number of lesions, largest tumor size, and total sum of lesions were 2 (range 1 - 4), 5.0 cm (IQR, 4.0 - 6.5), and 6.6 cm (IQR 5.9 - 9.2), respectively. Prior to SBRT, 22 patients (58%) had received non-SBRT local therapy. At time of SBRT a variety of dose fractionation schedules were selected with a median BED10 of 78 (IQR 62 - 100). Concurrent sorafenib was used in 2 patients (8%). Following completion of SBRT, 21 patients (55%) were successfully downstaged at a median 3.0 months (IQR 1.9 - 6.1) after treatment, most frequently secondary to decrease in size of the largest lesion (86%). Twelve patients (32%) proceeded to undergo OLT at a median 7 months (IQR 3 - 14) after SBRT and 105 days (IQR 18 - 344) following successful downstaging. Of the 25 patients initially exceeding UCSF criteria, 7 (28%) underwent OLT. Among those receiving OLT, 5 patients (42%) remain alive without evidence of disease, 3 patients (25%) have recurred, 3 patients (33%) died within 2 years from transplant complications, and 1 patient (8%) died from an unrelated cause. LC at 2 years was 83%. Median RFS and OS for the overall cohort were 7 months (95% CI 0 - 21) and 24 months (95% CI 11 - 36), respectively. Among the transplant recipients, the median OS was 37 months (95% CI 30 - 44) compared to 15 months (95% CI 6 - 23) among those not receiving transplant.

CONCLUSION

With careful patient selection, liver SBRT serves as a feasible downstaging method to facilitate OLT in HCC patients.

Outcomes with Five Fraction Image-Guided Partial Breast Irradiation to Reduced Target Volumes

PURPOSE/OBJECTIVE(S)

The use of 5-fraction partial breast irradiation has been shown in a randomized trial to provide comparable rates of local control and reduced toxicities as compared to standard fractionation whole breast irradiation. The initial technique utilized a 2 cm expansion on the lumpectomy cavity (1 cm for clinical target volume [CTV], and 1 cm planning target volume [PTV]) without consistent image guidance (ex. cone beam computed tomography [CBCT]) or motion management recommendations. We present clinical outcomes using a 5-fraction image guided PBI technique (IG-PBI) to reduced target volumes for patients with early-stage breast cancer.

MATERIALS/METHODS

A retrospective review of an IRB approved institutional registry was performed to identify patients treated with IG-PBI. A total of 258 patients with early-stage breast cancer (Stage 0-IIA) receiving IG-PBI were identified. Patients received a dose of 30 Gy in 5 fractions delivered daily or every other day. An expansion of 1 cm on the lumpectomy cavity was used for those patients using deep inspiration breath hold (DIBH) while an expansion of 1.5 cm was utilized for those not using DIBH. All patients received daily CBCT. Plans were delivered using intensity-modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT) technique; while the prescription isodose line covered the PTV, the 26 Gy line was allowed to expand beyond the PTV. Kaplan-Meier analyses were used to assess rates of local control and survival. Patient demographics, stage, hormone therapy use, recurrence, mortality, and toxicity data were collected. Survival was analyzed with Kaplan-Meier curve.

RESULTS

Median age at diagnosis was 67 years (range 40-87) with a median follow-up of 29 months (IQR 22-40). Forty-six (18%) patients had in situ disease, 200 (78%) patients T1 tumors, and 12 (5%) patients had T2 tumors. Two hundred thirty-four (91%) patients were White, 15 (6%) were Black, and 9 (4%) were other races. One hundred ninety-six (76%) patients received endocrine therapy, and 16 (6%) patients received chemotherapy. Thirty-two (12%) patients developed grade 1 dermatitis and no grade 2 events were observed. One (0.4%) patient had a cardiac event (aortic stenosis) 19 months after breast radiotherapy. At last follow-up, one (0.4%) patient had a local recurrence and one (0.4%) developed a distant metastasis, with no regional nodal failures. Overall, 4 (1.5%) patients had died, all due to other causes. At 3 years, locoregional control was 99.4%.

CONCLUSION

Outcomes with IG-PBI demonstrate low rates of local recurrence and limited toxicity. The use of reduced target volumes is not associated with increased rates of local recurrence.

Meta-Analysis of Five Fraction Preoperative Radiotherapy for Soft Tissue Sarcoma

PURPOSE/OBJECTIVE(S)

There is increasing interest in shorter courses of radiation therapy (RT) in the management of soft tissue sarcoma (STS). Studies investigating preoperative ultra-hypofractionated 5-fraction RT for STS are few and often limited to single institution experiences with less than 50 patients. We therefore performed a meta-analysis to determine the efficacy and safety of preoperative 5-fraction RT for STS based on currently published literature, with an analysis evaluating effects of dose delivered.

MATERIALS/METHODS

This study level meta-analysis was conducted using Bayesian methods. Statistical estimation for risk of outcome rates were conducted by posterior mean and 95% highest posterior density (HPD) intervals. Studies with two-year local control (LC) and description of major wound complications (MWC) per the CAN-NCIC-SR2 study were included in this meta-analysis, and these served as the primary endpoints. Secondary endpoints included rates of acute and late toxicity. A total of ten studies were identified; seven met inclusion criteria (Kalbasi 2020, Kubicek 2021, Leite 2021, Spalek 2021, Gobo Silva 2021, Bedi 2022, Mayo 2022). Three studies (Kosela-Paterczyk 2014, Kosela-Paterczyk 2021, Potkrajcic 2021) did not include adequate information to accurately determine 2-year LC or MWC. Subgroup analyses were performed for ≥30 Gy vs <30 Gy as the EQD2 of 30 Gy in 5 fractions for an α/β of 3-4 is 50-54 Gy, equivalent to standard preoperative RT fractionation.

RESULTS

A total of 208 patients were included from seven studies. Five studies used ≥30 Gy (n = 144) and 2 studies <30 Gy (n = 64). The median follow-up was 29 months (range: 21-57). Primary tumor location was lower extremity in 68%, upper extremity in 22%, and trunk in 10%. In studies with available information, most tumors were intermediate (27%, 46/169) or high grade (67%, 114/169) and 50% (79/158) were >10 cm. Two-year LC for the entire cohort was 96.9% (95% HPD: 0.9374-0.9889) and the rate of MWC was 30.6% (95% HPD: 0.2106-0.4149). Acute grade 2 and 3 dermatitis was seen in 12.7% and 2.2%, respectively. Late grade 2 toxicities included fibrosis (11.1%), stiffness (6.0%), and lymphedema (4.0%) and late grade 3 toxicities included fibrosis (1.8%) and stiffness (0.4%). Grade 4 toxicity was rare and included fibrosis (0.6%) and stiffness (0.6%). There was a trend toward improved LC with ≥ 30 Gy (95% HPD: 0.949-0.997 vs 0.838-0.986). There was no difference in MWC (95% HPD: 0.185-0.420 vs 0.172-0.553) or late toxicity between the two groups. Acute grade 3 dermatitis was seen less frequently with regimens <30 Gy (95% HPD: 0-0 vs 0.009-0.072), however rare overall.

CONCLUSION

Preoperative 5-fraction RT for STS demonstrates excellent 2-year LC with MWC and toxicity similar to standard fractionation preoperative RT. Multi-institutional trials with a universal RT protocol and larger sample size are warranted to assess this novel treatment paradigm.

Five Fraction Accelerated Partial Breast Irradiation vs. Intraoperative Radiation Therapy for Early-Stage Breast Cancer

PURPOSE/OBJECTIVE(S)

Accelerated partial breast irradiation (APBI) represents an alternative to whole breast irradiation (WBI), reducing the target volume and potentially treatment duration. APBI delivered in 5 fractions with intensity modulated radiation therapy (IMRT) has been shown to have comparable outcomes to WBI with reduced toxicity profiles. In contrast, intraoperative radiation therapy (IORT) offers patients the potential to complete adjuvant radiation therapy in a single treatment. While early data were initially promising, concerns regarding long-term rates of local recurrence exist. We present a comparison of 5 fraction APBI versus IORT.

MATERIALS/METHODS

We performed a retrospective review of 473 patients with early-stage breast cancer (Stage 0-IIA) treated at a single institution with 258 receiving APBI and 215 IORT from October 2011 to May 2021. APBI patients received 30 Gy in 5 fractions delivered with IMRT daily or every other day. IORT patients received 20 Gy in 1 fraction prescribed to the applicator surface delivered at the time of surgery. Kaplan-Meier analysis was used to estimate locoregional control rates and overall survival among the 2 groups.

RESULTS

Mean age was 70.7 years old (IQR:67-74) for the IORT patients and 66.6 years old (IQR:62-72) for the APBI patients (p<0.001). Median follow up was 5.7 years for IORT patients and 2.4 years for APBI patients (p<0.001). For IORT patients, 11%/83.5%/5.5% of patients and for APBI 17.8%/77.5%/4.7% of patients had Tis/T1/T2 disease (p = 0.005). With regards to adjuvant therapies, 79%/76% of IORT/APBI patients were offered endocrine therapy (p = 0.50) and 1.4%/6.2% chemotherapy (p = 0.008). Recurrence at any time was seen in 7.9% (n = 17) of patients receiving IORT as compared to 0.8% (n = 2) of patients receiving APBI. APBI was however no differences in recurrence free survival (92.6% vs. 98.5%, p = .079) or overall survival were noted (92.8% vs. 95.1%, p = 0.99).

CONCLUSION

In a series of almost 500 patients with stage 0-IIA breast cancer, IORT was associated with higher rates of locoregional recurrence compared to APBI with no survival difference at 5 years. These outcomes, consistent with other series and current guidelines, suggest a limited role for IORT as monotherapy following breast conserving surgery.

Disparities in prostate cancer diagnoses in persons experiencing homelessness

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Background: We previously reported that persons experiencing homelessness (PEH) are significantly less likely to undergo prostate specific antigen (PSA) testing compared to persons not experiencing homelessness (non-PEH). The purpose of this study was to determine if reduced PSA testing in PEH results in more advanced prostate cancer diagnoses. Methods: We identified PSA screening eligible PEH (men ages 50-69) from an institutional registry of all patients that presented to our healthcare system as homeless from 2014 to 2021. A matched cohort of non-PEH was generated for comparison. Institutional CPT and HCPCS billing codes for PSA testing were available beginning 01/01/2017 and cross-referenced to identify PEH and non-PEH who underwent PSA testing at least once between 01/01/2017 and 12/31/2021. In patients with ≥ 1 PSA test, we recorded screening, oncologic and treatment related variables. Patients with a history of prostate cancer diagnosed outside the study timeframe were excluded. Results: A total of 9,249 PEH were identified, with 1,597 meeting PSA screening criteria during the study timeframe; 3,370 screening eligible non-PEH were available for comparison. The median age was 59.0 for PEH and 60.0 for non-PEH. PEH were significantly less likely to have a primary care provider (58% vs 81%, p<0.001) or to have a PSA test (12% vs 33%, p<0.001). Among patients with a PSA test, PEH were significantly less likely to have multiple PSA tests compared to non-PEH (28% vs 61%, p<0.001) and significantly more likely to have a PSA ≥ 4.0 (18% vs 12%, p=0.028). In patients with a PSA ≥ 4.0, PEH were less likely to receive a prostate biopsy (37% vs 61%, p =0.009) and there was a trend towards decreased prostate MRI (11% vs 25%, p=0.085). A total of 6 PEH (0.4%) and 46 non-PEH (1.4%) were diagnosed with prostate cancer. The median PSA at diagnosis was 12.6 in PEH vs 7.0 in non-PEH (p=0.052). PEH were significantly more likely to present with high/very high risk disease (4/6 [66%] vs 9/46 [20%], p=0.019); no PEH had very low/low risk disease compared with 20 (43.5%) non-PEH. PEH were more likely to present with lymph node positive or metastatic disease (3/6 [50%] vs 3/46 [7%], p=0.016). The median time from biopsy to treatment was 119 days in PEH and 76 days in non-PEH (p=0.391). Conclusions: PEH are less likely to receive prostate cancer testing following an elevated PSA and more likely to present with high risk advanced prostate cancer. Interventions to increase prostate cancer awareness in PEH are needed to reduce disparities.

Prostate Cancer Screening Disparities in Persons Experiencing Homelessness

PURPOSE

The purpose of this study was to assess prostate-specific antigen (PSA) testing rates in persons experiencing homelessness (PEH), identify factors associated with screening, and compare PSA screening rates in PEH with a matched cohort of persons not experiencing homelessness (non-PEH).

MATERIALS AND METHODS

We identified 9,249 potentially eligible PEH cared for at a large metropolitan hospital system from an institutional registry of all patients who presented to the health care system as homeless from 2014 to 2021. Homelessness was defined by the presence of the Z-code for homelessness (Z59), the listed address matching to the address of a homeless shelter or other transitional housing or a positive screen for homelessness. A matched cohort of 10,000 non-PEH was generated for comparison. Univariate chi-square analysis and multivariate logistic regression were performed to evaluate variables associated with PSA testing.

RESULTS

A total of 1,605 PEH and 3,413 non-PEH were eligible for PSA screening within the study timeframe. Half of PEH were Black (50%). Medicaid was the most common insurance (51%), followed by Medicare (18%). PEH were less likely to have a PCP (58% v 81%, P < .001) and had a significantly lower PSA testing rate (13% v 34%, P < .001) compared with non-PEH. Univariate analysis revealed that PSA testing was more common in PEH who were employed (P < .001), had private insurance or Medicare (P < .001), or had an established primary care provider (PCP; P < .001). Multivariate analysis confirmed that having a PCP (OR, 2.54; 95% CI, 1.62 to 4.00; P < .001) significantly increased the likelihood of PSA testing in PEH.

CONCLUSION

PEH experience low rates of prostate cancer screening. Interventions to increase screening in this population, including increased PCP access, are needed.

Eliapixant (BAY 1817080), a P2X3 receptor antagonist, in refractory chronic cough: a randomised, placebo-controlled, crossover phase 2a study

BACKGROUND

ATP acting via P2X3 receptors is an important mediator of refractory chronic cough (RCC). This phase 2a double-blinded crossover study assessed the safety, tolerability and efficacy of eliapixant (BAY 1817080), a selective P2X3 receptor antagonist, in adults with RCC attending specialist centres.

METHODS

In period A, patients received placebo for 2 weeks then eliapixant 10 mg for 1 week. In period B, patients received eliapixant 50, 200 and 750 mg twice daily for 1 week per dose level. Patients were randomised 1:1 to period A-B (n=20) or B-A (n=20). The primary efficacy end-point was change in cough frequency assessed over 24 h. The primary safety end-point was frequency and severity of adverse events (AEs).

RESULTS

37 patients completed randomised therapy. Mean cough frequency fell by 17.4% versus baseline with placebo. Eliapixant reduced cough frequency at doses ≥50 mg (reduction versus placebo at 750 mg: 25% (90% CI 11.5-36.5%); p=0.002). Doses ≥50 mg also significantly reduced cough severity. AEs, mostly mild or moderate, were reported in 65% of patients with placebo and 41-49% receiving eliapixant. Cumulative rates of taste-related AEs were 3% with placebo and 5-21% with eliapixant; all were mild.

CONCLUSIONS

Selective P2X3 antagonism with eliapixant significantly reduced cough frequency and severity, confirming this as a viable therapeutic pathway for RCC. Taste-related side-effects were lower at therapeutic doses than with the less selective P2X3 antagonist gefapixant. Selective P2X3 antagonism appears to be a novel therapeutic approach for RCC.

Factors Predictive of Publication Among Medical Students Participating in School-Sponsored Research Programs

Introduction: Publishing research is an important component of medical students’ career development and becoming a more competitive residency applicant. Many medical schools offer structured programs to enable students to participate in research during their preclinical and clinical years, but the majority of student-mentor partnerships do not culminate in publication across a variety of institutions and medical specialties. The primary objective of this study is to determine if any factors associated with mentee-mentor partnerships are predictive of publication from two school-sponsored research programs at a single US medical school.

Methods: The PubMed-indexed publications of all student-mentor pairings from a summer internship (after year 1 of medical school) or research elective (during year 4 of medical school) at a single institution from 2008 to 2018 were retrospectively reviewed. Student/mentor demographic information was associated with the probability of publication.

Results: A total of 124 students participated in the summer internship with 32 (26%) achieving publication. The publication was significantly more likely for students that were from highly ranked undergraduate institutions (p = 0.04; likelihood ratio (LR) = 5.788), were future Alpha Omega Alpha (AOA) members (p = 0.03; LR = 4.597), or worked with a mentor focused on clinical rather than basic science research (p = 0.02; LR = 5.662). Forty-four students participated in the fourth-year elective with 11 (25%) achieving publication. The publication was more likely if the student worked with a mentor without a Doctor of Medicine (MD)/Doctor of Osteopathic Medicine (DO) degree (p = 0.001; LR = 7.051), with a PhD degree (p = 0.002; LR = 7.820), or a mentor with prior publication(s) with prior mentee(s) (p = 0.03; LR = 5.368).

Conclusion: Only one-quarter of mentor-mentee research pairings resulted in publication, with student-related factors more predictive for publication from the internship and mentor-related factors more predictive of publication from the elective. Approaches to promote successful completion of medical student research projects should be considered to yield the greatest value from students’ work and strengthen the development of future physician-scientists.

Adaptive study design to assess effect of TRPV4 inhibition in patients with chronic cough

Objective

Airway sensory nerves involved in the cough reflex are activated by adenosine triphosphate (ATP) agonism of P2X purinoceptor 3 (P2X3) receptors. Transient receptor potential vanilloid 4 (TRPV4) channel activation causes ATP release from airway cells, and it is hypothesised that a TRPV4-ATP-P2X3 axis contributes to chronic cough. An adaptive study was run to determine if TRPV4 inhibition, using the selective TRPV4 channel blocker GSK2798745, was effective in reducing cough.

Methods

A two-period randomised, double blinded, placebo-controlled crossover study was designed with interim analyses for futility and sample size adjustment. Refractory chronic cough patients received either GSK2798745 or placebo once daily for 7 days with a washout between treatments. Pharmacokinetic samples were collected for analysis of GSK2798745 at end of study. The primary end-point was total cough counts assessed objectively during day-time hours (10 h) following 7 days of dosing.

Results

Interim analysis was performed after 12 participants completed both treatment periods. This showed a 32% increase in cough counts on Day 7 for GSK2798745 compared to placebo; the pre-defined negative criteria for the study were met and the study was stopped. At this point 17 participants had been enrolled (mean 61 years; 88% female), and 15 had completed the study. Final study results for posterior median cough counts showed a 34% (90% credible interval: -3%, +85%) numerical increase for GSK2798745 compared to placebo.

Conclusion

There was no evidence of an anti-tussive effect of GSK2798745. The study design allowed the decision on lack of efficacy to be made with minimal participant exposure to the investigational drug.

Nonpharmacological cough control therapy for chronic refractory cough and cough associated with underlying lung disease

Nonpharmacological cough control therapy (CCT) is effective for refractory chronic cough but there is a significant subgroup of nonresponders. CCT appears to be effective in cough associated with underlying disease such as asthma. http://bit.ly/2uCCwu3.

A targeted needs assessment to improve referral patterns for palliative radiation therapy

Radiation therapy (RT) can effectively palliate a variety of symptoms in patients with metastatic cancer, using relatively low doses that infrequently cause major side effects. However, palliative radiation is often underutilized and sub-optimally implemented. In this study, we surveyed the Society of Palliative Radiation Oncology (SPRO) membership to identify barriers to appropriate referral for palliative RT that they encounter in their practice, and identify specific groups of physicians who radiation oncologists believed would benefit most from further education on when to refer patients. A total of 28 radiation oncologists responded to the survey with a response rate of 20.5%. On average, participants felt that referrals for palliative RT were inappropriately delayed 46.5% [standard deviation (STD) 20.2%] of the time. The most common barrier to referral for medical oncologists was thought to be potential interference with systemic therapy (33%); for primary care physicians and surgeons it was a lack of knowledge about the benefit (42%), and for palliative care physicians it was concern for patient convenience (25%). For brain metastases and spinal cord compression radiation oncology was felt to be part of the initial referral sequence more than 50% of the time, but less so for thoracic airway obstruction/bleeding (38%), esophageal obstruction (16%), or urinary obstruction/bleeding (8%), where another subspecialist was more often consulted first. Primary care, geriatric medicine, and emergency medicine were considered among the least knowledgeable specialties about palliative radiation. These hypothesis-generating findings can guide approaches to improve referral patterns for this important aspect of supportive care.

Multi-institutional report on toxicities of concurrent nivolumab and radiation therapy

PURPOSE

Radiation therapy (RT) and nivolumab are standard therapies for a wide range of advanced and metastatic cancers, yet little is known about the toxicity profile of their combined treatment. The rate of grade ≥3 toxicities from nivolumab monotherapy and radiation-only palliative treatments has been reported at 10% to 18% and 0% to 26%, respectively. We reviewed our experience to assess the acute toxicity profile of concurrent RT-nivolumab.

METHODS AND MATERIALS

A retrospective review of all consecutive patients from January 2015 to May 2017 who received concurrent RT-nivolumab was conducted at 4 separate centers. Concurrent RT-nivolumab was defined as RT completed between 3 days prior to initial nivolumab infusion and 28 days after the last nivolumab infusion.

RESULTS

Of the 261 patients who received nivolumab, 46 (17.6%) had concurrent RT to 67 treatment sites. The median follow-up was 3.3 months (interquartile range, 1.7-6.1 months) and the 1-year overall survival rate was 22%. For the 11 of 46 patients (24%) who were alive at last analysis, the median follow-up was 12.8 months (interquartile range, 8.3-14.9 months). The most common histology, RT prescription, and treatment site were non-small cell lung cancer (23 of 46 patients; 50%), 30 Gy in 10 fractions (24 of 67 patients; 35.8%), and abdomen/pelvis (16 of 67 patients; 24%), respectively. Four patients with melanoma had concurrent ipilimumab and were removed from the final toxicity analysis of RT-nivolumab. Within 3 months of treatment with RT-nivolumab, 4 of 42 patients (9.5%) experienced grade 3 toxicity and 2 of these patients' toxicities were attributed specifically to the addition of RT: grade 3 hearing loss after whole brain RT and grade 3 pancreatitis after stereotactic body RT to the left adrenal gland. One death from transaminitis was attributed to nivolumab alone because the RT field did not encompass the liver.

CONCLUSIONS

Concurrent RT-nivolumab did not appear to increase the toxicity profile from the previously reported toxicity rates from nivolumab or radiation alone.

Psychological profile of individuals presenting with chronic cough

Chronic refractory cough (CRC) is a common problem in respiratory clinics. Adverse effects on quality of life are documented in the literature, but relatively little is known about the underlying psychological factors in this patient population. We aimed to investigate the association of psychological factors with chronic cough, comparing CRC to explained cough and non-cough groups. 67 patients attending a specialist cough clinic (CRC, n=25; explained cough, n=42) and 22 non-cough individuals participated. All participants completed the Hospital Anxiety & Depression Scale, Big Five Inventory (Personality), Chalder Fatigue Scale and Patient Health Questionnaire-15. Cough patients also completed the Illness Perception Questionnaire-Revised. Appropriate statistical analyses were used to compare participant groups. Chronic refractory coughers displayed significantly higher levels of anxiety, depression, fatigue and somatic physical symptoms than non-cough participants. Compared to explained coughers, there were higher depression and fatigue scores and significantly more negative illness representations (specifically, strong beliefs regarding negative consequences, lower illness coherence and higher emotional representations). "Explained" coughers reported significantly increased fatigue and somatic symptoms in comparison to non-coughers. The prevalence of fatigue, low mood, negative illness beliefs and increased physical symptom reporting should be considered in consultations and in developing novel interventions for CRC patients.

Physiotherapy, and speech and language therapy intervention for patients with refractory chronic cough: a multicentre randomised control trial

BACKGROUND

Physiotherapy, and speech and language therapy are emerging non-pharmacological treatments for refractory chronic cough. We aimed to investigate the efficacy of a physiotherapy, and speech and language therapy intervention (PSALTI) to improve health-related quality of life (HRQoL) and to reduce cough frequency in patients with refractory chronic cough.

METHODS

In this multicentre randomised controlled trial, patients with refractory chronic cough were randomised to four weekly 1:1 sessions of either PSALTI consisting of education, laryngeal hygiene and hydration, cough suppression techniques, breathing exercises and psychoeducational counselling or control intervention consisting of healthy lifestyle advice. We assessed the change in HRQoL at week 4 with the Leicester Cough Questionnaire (LCQ). Secondary efficacy outcomes included 24-hour objective cough frequency (Leicester Cough Monitor) and cough reflex sensitivity. The primary analysis used an analysis of covariance adjusted for baseline measurements with the intention-to-treat population. This study was registered at UK Clinical Research Network (UKCRN ID 10678).

FINDINGS

Between December 2011 and April 2014, we randomly assigned 75 participants who underwent baseline assessment (34 PSALTI and 41 controls). In the observed case analysis, HRQoL (LCQ) improved on average by 1.53 (95% CI 0.21 to 2.85) points more in PSALTI group than with control (p=0.024). Cough frequency decreased by 41% (95% CI 36% to 95%) in PSALTI group relative to control (p=0.030). The improvements within the PSALTI group were sustained up to 3 months. There was no significant difference between groups in the concentration of capsaicin causing five or more coughs.

INTERPRETATION

Greater improvements in HRQoL and cough frequency were observed with PSALTI intervention. Our findings support the use of PSALTI for patients with refractory chronic cough.

TRIAL REGISTRATION NUMBER

UKCRN ID 10678 and ISRCTN 73039760; Results.

'Chronic cough, cause unknown': A qualitative study of patient perspectives of chronic refractory cough

Chronic refractory cough patients have persistent, unexplained, treatment-resistant symptoms. Very little is known about non-physiological processes underlying chronic refractory cough or patients' experience of the condition. In all, 14 patients participated in semi-structured interviews. Interviews were based on the comprehensive cognitive behavioural model and analysed thematically. Eight key themes emerged illustrating that the experience of the onset and persistence of chronic refractory cough is complex, often involving multiple interlinking factors. Themes highlighted the involvement of biological and psychological factors, and the prominent role of the social dimension in how the cough is experienced, perceived and managed. Implications for intervention development are discussed.

A worldwide survey of chronic cough: a manifestation of enhanced somatosensory response

Reports from individual centres suggest a preponderance of females with chronic cough. Females also have heightened cough reflex sensitivity. Here we have reviewed the age and sex of unselected referrals to 11 cough clinics. To investigate the cause of any observed sex dimorphism, functional magnetic resonance imaging of putative cough centres was analysed in normal volunteers. The demographic profile of consecutive patients presenting with chronic cough was evaluated. Cough challenge with capsaicin was undertaken in normal volunteers to construct a concentration-response curve. Subsequent functional magnetic resonance imaging during repeated inhalation of sub-tussive concentrations of capsaicin observed areas of activation within the brain and differences in the sexes identified. Of the 10,032 patients presenting with chronic cough, two-thirds (6591) were female (mean age 55 years). The patient profile was largely uniform across centres. The most common age for presentation was 60-69 years. The maximum tolerable dose of inhaled capsaicin was lower in females; however, a significantly greater activation of the somatosensory cortex was observed. Patients presenting with chronic cough from diverse racial and geographic backgrounds have a strikingly homogeneous demographic profile, suggesting a distinct clinical entity. The preponderance of females may be explained by sex-related differences in the central processing of cough sensation.

Free radical generation induces epithelial-to-mesenchymal transition in lung epithelium via a TGF-β1-dependent mechanism

Fibrotic remodelling of lung parenchymal and airway compartments is the major contributor to life-threatening organ dysfunction in chronic lung diseases such as idiopathic pulmonary fibrosis (IPF) and Chronic Obstructive Pulmonary Disease (COPD). Since transforming growth factor-β1 (TGF-β1) is believed to play a key role in disease pathogenesis and markers of oxidative stress are also commonly detected in bronchoalveolar lavage (BAL) from such patients we sought to investigate whether both factors might be interrelated. Here we investigated the hypothesis that oxidative stress to the lung epithelium promotes fibrotic repair by driving epithelial-to-mesenchymal transition (EMT) via the augmentation of TGF-β1. We show that in response to 400μM hydrogen peroxide (H(2)O(2)) A549 cells, used a model for alveolar epithelium, and human primary bronchial epithelial cells (PBECs) undergo EMT displaying morphology changes, decreased expression of epithelial markers (E-cadherin and ZO-1), increased expression of mesenchymal markers (vimentin and α-smooth muscle actin) as well as increased secretion of extracelluar matrix components. The same oxidative stress also promotes expression of TGF-β1. Inhibition of TGF-β1 signalling as well as treatment with antioxidants such as phenyl tert-butylnitrone (PBN) and superoxide dismutase 3 (SOD3) prevent the oxidative stress driven EMT-like changes described above. Interventions also inhibited EMT-like changes. This study identifies a link between oxidative stress, TGF-β1 and EMT in lung epithelium and highlights the potential for antioxidant therapies to limit EMT and its potential contribution to chronic lung disease.

Epithelial to mesenchymal transition (EMT) and airway remodelling after human lung transplantation

BACKGROUND

Aberrant epithelial repair is a key event in the airway remodelling which characterises obliterative bronchiolitis (OB) in the transplanted lung. The potential for airway epithelium from lung transplant recipients to undergo epithelial to mesenchymal cell transition (EMT) was assessed in culture and in vivo in lung allograft tissue.

METHODS

Change in epithelial and mesenchymal marker expression was assessed after stimulation with transforming growth factor beta(1) (TGF-beta(1)) alone or in combination with tumour necrosis factor alpha (TNFalpha) and compared with untreated controls. The ability of cells to deposit extracellular matrix, secrete matrix metalloproteinases (MMPs) and invade collagen was investigated. Immunolocalisation of epithelial and mesenchymal markers was compared in airway tissue from stable recipients and those with OB.

RESULTS

Untreated cells maintained epithelial morphology and phenotype. TGF-beta(1) reduced expression of epithelial markers, increased expression of vimentin and fibronectin, promoted collagen I and fibronectin deposition and increased MMP-9 production. Co-treatment with TNFalpha dramatically accentuated phenotypic and some functional features of EMT. Airway epithelial biopsies from recipients with OB demonstrated significantly increased staining for mesenchymal markers and significantly reduced E-cadherin staining compared with stable recipients.

CONCLUSIONS

These observations demonstrate the ability of human airway epithelium to undergo EMT and suggest this phenomenon may be a potential link between inflammatory injury and TGF-beta(1)-driven airway remodelling in the development of OB.

Airway epithelial cell senescence in the lung allograft

Chronic lung allograft dysfunction, manifesting as bronchiolitis obliterans syndrome (BOS), is characterized by airway epithelial injury, impaired epithelial regeneration and subsequent airway remodeling. Increased cellular senescence has been reported in renal and liver allografts affected by chronic allograft dysfunction but the significance of cellular senescence in the airway epithelium of the transplanted lung is unknown. Thirty-four lung transplant recipients, 20 with stable graft function and 14 with BOS, underwent transbronchial lung biopsy and histochemical studies for senescence markers in small airways. Compared to nontransplant control lung tissue (n = 9), lung allografts demonstrate significantly increased airway epithelial staining for senescence-associated beta galactosidase (SA beta-gal) (p = 0.0215), p16(ink4a) (p = 0.0002) and p21(waf1/cip) (p = 0.0138) but there was no difference in expression of these markers between stable and BOS affected recipients (p > 0.05). This preliminary cross-sectional study demonstrates that cellular senescence occurs with increased frequency in the airway epithelium of the lung allograft but does not establish any association between airway epithelial senescence and BOS. A prospective longitudinal study is required to better address any potential causal association between airway epithelial senescence in stable allograft recipients and the subsequent development of BOS.

Evaluation of a transcutaneous carbon dioxide monitor (“TOSCA”) in adult patients in routine respiratory practice

BACKGROUND

Non-invasive measurement of oxygenation is routine in adult clinical practice but transcutaneous monitoring of PCO(2) (PtcCO(2)) is used much less due to technical difficulties with earlier transcutaneous electrodes.

OBJECTIVE

Our aim was to determine the reliability of estimating arterial PCO(2) (PaCO(2)) using a recently introduced combined SaO(2)/PtcCO(2) monitor ("TOSCA", Linde Medical Systems) in adult patients in routine clinical respiratory practice.

METHODS

PtcCO(2) was measured in patients requiring arterial blood gases for clinical reasons. Ten minutes after the probe had been attached to an earlobe PtcCO(2) was recorded, immediately before arterial blood sampling. The PCO(2) values obtained were compared by Bland-Altman analysis.

RESULTS

Samples were taken from 48 unselected patients with varied pathology. There were no technical problems. Median age was 56 years (range 20-86 years). The mean difference between PaCO(2) and PtcCO(2) was -0.04kPa, sd of the difference 0.67kPa. Bland-Altman analysis showed generally good agreement between the two measurements across the range of PaCO(2) values (4-10.9kPa). Four of 48 measurements showed a PCO(2) difference >1kPa with no technical or clinical explanations apparent.

CONCLUSIONS

The accuracy of estimation of PaCO(2) by the TOSCA transcutaneous electrode was generally good and the device appears promising for use in routine clinical respiratory practice.

Palmitate potentiation of glucose-induced insulin release: a study using 2-bromopalmitate

The mechanisms whereby fatty acids (FA) potentiate glucose-induced insulin secretion from the pancreatic beta cell are incompletely understood. In this study, the effects of palmitate on insulin secretion were investigated in isolated rat islets. Palmitate did not initiate insulin secretion at nonstimulatory glucose concentrations, but markedly stimulated insulin release at concentrations of glucose > or = 5.6 mmol/L. At concentrations of palmitate > or =0.5 mmol/L, the important determinant of the potency of the FA was its unbound concentration. At total concentrations < or = 0.5 mmol/L, both the total and unbound concentrations appeared important. Surprisingly, 2-bromopalmitate did not affect palmitate oxidation, but significantly diminished palmitate esterification into cellular lipids. Neither methyl palmitate, which is not activated into a long-chain acyl-CoA ester, nor 2-bromopalmitate affected glucose-stimulated insulin release. Further, 2-bromopalmitate partly inhibited the potentiating effect of palmitate. These results support the concept that FA potentiation of insulin release is mediated by FA-derived signals generated in the esterification pathway.

Extramammary Paget's disease with diffuse involvement of the lower female genito-urinary system

Extramammary Paget's disease of the lower female genito-urinary system is an uncommon neoplasm with a high rate of recurrence. A 52-year-old white female with a history of extramammary Paget's disease, originally excised in 1985 by skinning vulvectomy and who had multiple recurrences, including two in a vaginal graft and with extension to the urethra and the uterine cervix, in 1992 underwent an anterior pelvic exenteration for control of the disease process. Standard surgical management for extramammary Paget's disease without invasion or without an underlying adenocarcinoma is simple or skinning vulvectomy. However, because the disease commonly recurs, diffuse involvement may require more extensive surgery including pelvic exenteration in extraordinary cases.

Successful transplantation of a kidney with early membranous nephropathy

This report describes a patient with end-stage renal disease secondary to long-standing type II diabetes mellitus who received a cadaveric renal transplant from a 37-year-old woman who died of massive cerebral infarction. An autopsy performed on the donor following organ procurement revealed no obvious contraindications to transplantation. A renal biopsy of the donor kidney performed at the time of transplantation, however, subsequently showed early membranous nephropathy by electron microscopy. There was immediate graft function and the recipient continues to have good renal function 3 years post-transplantation.

CRAHCA (Center for Research in Ambulatory Health Care Administration): member involvement leads to practical applications

The research undertaken by CRAHCA results in many new techniques and ideas being adopted by medical practice managers. However, it is not merely a one-way street. In this article, six group practice managers respond to questions about how they have used and been involved with research activities the Center has developed.

Making room in the marketplace: a special initiative for the poor

Faced with increased concern over the role of the voluntary healthcare sector, specifically Catholic providers, in the care of the poor, Mercy Health Services (MHS), a healthcare system, established a two-year, three-phase planning and development effort known as the Special Initiative for the Poor (SIP). Established in March 1986, SIP was designed to find out: Who are the poor? What are their needs? What is MHS's responsibility in meeting these needs? Among its objectives, SIP was charged with: 1. Educating and raising awareness of governance and management staffs. 2. Developing a way to assess human needs. 3. Determining the financial implications of the organization's commitment to the poor. 4. Recommending ways to enhance the understanding, energy, and commitment to the poor throughout the system. During the first six months, SIP staffers traveled to hospitals and subsidiaries throughout the system, meeting with management and staff, explaining the project, laying the groundwork, and gaining support. In the development phase, SIP created the Community Assessment of Human Needs, a systematic approach to identify and understand the unmet human needs of the poor. It also developed a simple inventory formula to help hospitals determine which of their programs were specifically for the poor and determine what these programs cost. Finally, in the implementation stage, several of SIP's recommendations are challenging the organization to move beyond its current commitments.

Forward locomotion elicited by electrical stimulation in the diencephalon and mesencephalon of the awake rat

Stimulation electrodes were implanted in 63 rats at a total of 208 sites in the diencephalon and midbrain. The sites were tested for elicited forward locomotion, i.e., alternate stepping of the forelimbs and/or hindlimbs, while the rats stood on a treadmill belt in a 27 X 9 X 24-cm chamber. Current levels of 50-300 microA and pulse frequencies of 50, 100 and 154 Hz were presented as single 5-sec trains and as 20 repetitive trains of 1-sec duration with a 3-sec intertrain interval. Locomotion was elicited with low current (50 or 100 microA) single trains at 28% of the sites. Of the regions sufficiently well sampled to warrent comparisons, two showed high densities of locomotion-positive sites with single low current trains. They were the medial hypothalamus (the dorsomedial and the posterior nuclei) and the ventral tegmental area. The medial forebrain bundle and the zona incerta were generally positive but many sites in these regions required repetitive trains. Among the regions with few locomotion-positive sites were the subthalamic nucleus, the fields of Forel and the habenular complex. In the dorsal midbrain, in and around the central gray, low current single trains elicited leaping. The results are discussed in terms of the existence of a delimited subthalamic locomotor region and a ventral midbrain locomotor system independent of a dorsal midbrain system.

Unilateral lesions of the anteromedial cortex in the rat impair approach to contralateral visual cues

This experiment determined the effects of large unilateral lesions of the anteromedial cortex (AMC) on visually guided performance of rats in a cross maze. Deficits were found in the approach to only visual cues that were located in the arm contralateral to the lesion. The deficit appeared in three testing conditions: when the cue was continuously visible throughout the trial; when it was visible only at the choice point; and when it was seen only at the start of the trial but not at the choice point. The failure to approach a contralateral cue was not due to a simple ipsilateral turning bias; rats with lesions could approach cues in the anterior arm as efficiently as controls. The deficit was most apparent on the initial sessions and recovery occurred for all conditions. The findings indicate that the AMC participates in the visual guidance of approach behavior.

Protrusio acetabuli in rheumatoid arthritis

Protrusio acetabuli is common is rheumatoid arthritis. Progression of this deformity can be measured by serial roentgenograms. The inward progression of the femoral head is the result of upward migration of the acetabular roof and collapse of the femoral head which appears to occur in a ratio of approximately two to one. Adrenal cortical steroids may play a significant role in the etiology of this condition in rheumatoid arthritis. This complication of intrapelvic protrusion of the prosthetic acetabulum following total hip replacement has been presented and suggestions made to overcome this problem. Early operation on those patients showing rapid development of protrusio may prevent complications.