The emerging role of lipid nanosystems and nanomicelles in liver diseases

Nanoparticles (NPs) exhibit remarkable potential in the diagnosis and treatment of various liver ailments, including primary liver cancer or hepatocellular carcinoma (HCC), liver cirrhosis, viral hepatitis, and alcoholic and non-alcoholic liver diseases. High surface area-to-volume ratio with distinct physicochemical and bio-pharmaceutical properties have contributed numerous benefits to NPs, such as high intracellular uptake and efficient drug delivery capabilities stemming from their ability to encapsulate a diverse range of drugs. Lipid-based nanosystems have demonstrated significant potential as reliable and efficient transport vehicles for a variety of actives, including small interfering RNA, targeting the liver, owing to their excellent in vivo compatibility, biodegradable nature, and non-toxic properties. Multiple aspects of various lipid-based materials, lipid nanosystems like solid lipid NPs, nanovesicles such as nanoemulsions, liposomes, and nanomicelles for liver-specific active targeting have been comprehensively reviewed. Ongoing and completed clinical trials of lipid nanosystems developed for HCC, hepatic fibrosis, and hepatitis are tabulated. Types of receptors and ligands typically used for active liver targeting in HCC are extensively discussed. The US FDA's recent approval for the use of Onpattro (Patisiran) injection to treat polyneuropathy in adult patients is indicative of the rapid development of lipid nanosystems employed for hepatic targeting. Nanoemulsions loaded with diagnostic imaging agents for multi-modal liver imaging were briefly discussed. Emerging technologies are being developed to integrate desirable properties of nanoparticles (NPs), including high stability, efficient drug loading, opsonization avoidance, active liver targeting, and facilitation of endosomal escape. Clinical translations of many lipid NPs for drug and gene therapy applications targeting different liver diseases are expected in the near future.

Global application of National Comprehensive Cancer Network resource-stratified guidelines for systemic treatment of colon cancer: a population-based, customisable model for cost, demand, and procurement

BACKGROUND

Resource-stratified guidelines (RSGs) can inform systemic treatment decisions in the face of limited resources. The objective of this study was to develop a customisable modelling tool to predict the demand, cost, and drug procurement needs of delivering National Comprehensive Cancer Network (NCCN) RSG-based systemic treatment for colon cancer.

METHODS

We developed decision trees for first-course systemic therapy for colon cancer based on the NCCN RSGs. Decision trees were merged with data from the Surveillance, Epidemiology, and End Results programme, the International Agency for Research on Cancer's GLOBOCAN 2020 national estimates for colon cancer incidence, country-level income data, and data on drug costs from Redbook (USA), the Pharmaceutical Benefits Scheme (Australia), and the Management Sciences for Health 2015 International Medical Products price guide to estimate global treatment needs and costs, and forecast drug procurement. Simulations and sensitivity analyses were used to explore the effect of scaling up services globally and the effect of alternative stage distributions on treatment demand and cost. We generated a customisable model, in which estimates can be tailored to local incidence, epidemiological, and costing data.

FINDINGS

First-course systemic therapy is indicated in 608 314 (53·6%) of 1 135 864 colon cancer diagnoses in 2020. Indications for first-course systemic therapy are projected to rise to 926 653 in 2040; the indications in 2020 might be as high as 826 123 (72·7%), depending on stage distribution assumptions. Adhering to NCCN RSGs, patients with colon cancer in low-income and middle income countries (LMICs) would constitute 329 098 (54·1%) of 608 314 global systemic therapy demands, but only 10% of global expenditure on systemic therapies. The total cost of NCCN RSG-based first-course systemic therapy for colon cancer in 2020 would be between about US$4·2 and about $4·6 billion, depending on stage distribution. If all patients with colon cancer in 2020 were treated according to maximal resources, global expenditure on systemic therapy for colon cancer would rise to around $8·3 billion.

INTERPRETATION

We have developed a customisable model that can be applied at global, national, and subnational levels to estimate systemic treatment needs, forecast drug procurement, and calculate expected drug costs on the basis of local data. This tool can be used to plan resource allocation for colon cancer globally.

FUNDING

None.

The onset of puberty in colony-housed male and female titi monkeys (Plecturocebus cupreus): Possible effects of oxytocin treatment during peri-adolescent development

Oxytocin has been used to treat neurodevelopmental conditions in adolescent patients but possible effects on reproductive development have not been well investigated. The effects of daily intra-nasal oxytocin treatment (12-18 months of age) on puberty and fertility were studied in colony-housed, male and female titi monkeys (Plecturocebus cupreus). Body weight, urinary conjugated pregnanes and estrogens (defining cyclicity) in females, and androgens and sperm in urine of in males, were measured from 1 to 3 years of age to detect puberty. Serum testosterone was also measured in males at 13, 23 and 33 months of age and hemi-castration at 3 years of age enabled assessment of testicular morphometry and oxytocin receptor expression. An oxytocin treatment*time interaction suggested a minor, transient suppression in weight gain after treatment ended. Note that females weighed 10% less across all ages. Oxytocin-treated females exhibited early, spurious ovulations but neither regular cyclicity (≈30 months) nor pregnancies were affected by treatment. Oxytocin did not affect the pubertal increase in urinary androgen or the first appearance of sperm, which occurred as early as 15 months of age. Treatment did delay the puberty-associated rise in serum testosterone in males. All males were pubertal by 22 months and all females by 32 months of age. Although no major male or female fertility outcome was observed, oxytocin demonstrated some physiological effects through a delay of testosterone secretion in males, induction of precocious ovulation in females, and a suppression of general weight gain for the months following treatment.

Optimal and actual rates of Stereotactic Ablative Body Radiotherapy (SABR) utilisation for primary lung cancer in Australia

•

Stereotactic Ablative Body Radiotherapy (SABR) plays a major role in the management of early-stage non-small cell lung cancer (NSCLC).

•

An evidence-based model is developed to estimate optimal rates of lung SABR utilisation within the Australian population.

•

Optimal utilisation rates are compared against actual utilisation rates to evaluate service provision.

Background and purpose

Radiotherapy utilisation rates considerably vary across different countries and service providers, highlighting the need to establish reliable benchmarks against which utilisation rates can be assessed. Here, optimal utilisation rates of Stereotactic Ablative Body Radiotherapy (SABR) for lung cancer are estimated and compared against actual utilisation rates to identify potential shortfalls in service provision.

Materials and Methods

An evidence-based optimal utilisation model was constructed after reviewing practice guidelines and identifying indications for lung SABR based on the best available evidence. The proportions of patients likely to develop each indication were obtained, whenever possible, from Australian population-based studies. Sensitivity analysis was performed to account for variations in epidemiological data. Practice pattern studies were reviewed to obtain actual utilisation rates.

Results

A total of 6% of all lung cancer patients were estimated to optimally require SABR at least once during the course of their illness (95% CI: 4–6%). Optimal utilisation rates were estimated to be 32% for stage I and 10% for stage II NSCLC. Actual utilisation rates for stage I NSCLC varied between 6 and 20%. For patients with inoperable stage I, 27–74% received SABR compared to the estimated optimal rate of 82%.

Conclusion

The estimated optimal SABR utilisation rates for lung cancer can serve as useful benchmarks to highlight gaps in service delivery and help plan for more adequate and efficient provision of care. The model can be easily modified to determine optimal utilisation rates in other populations or updated to reflect any changes in practice guidelines or epidemiological data.

Risk of pacemaker implantation after radiotherapy for breast cancer: A study based on French nationwide health care database sample

Background

Among cardiac complications of breast cancer radiotherapy (BC RT), there are very limited data on arrhythmia and conduction disorders, in particular severe cases requiring permanent pacemaker implantation (PPMI). Therefore, this exploratory study aimed to evaluate the risk of PPMI for BC patients treated with RT, compared with the general population and with BC patients not treated with RT.

Methods

The study was performed on a 1/97 representative sample of the French health care database (EGB database). Adult women with a first BC treated with or without RT between 2008 and 2016 were included, followed until 2018, and de novo PPMI were identified. We compared the PPMI incidence in BC cohort relative to the general population with standardized incidence ratio (SIR) and evaluated the risk of PPMI in RT patients compared to patients without RT with a competing risk survival analysis.

Results

A total of 3853 BCE patients were included. Among BC patients treated with RT, 28 PPMI cases were observed compared with 13 expected cases, corresponding to a SIR of 2.18 [95% CI: 1.45-3.06]. For BC patients not treated with RT, the SIR was 1.01 [95% CI: 0.40-1.90]. Patients treated with RT showed a borderline significant higher risk of PPMI compared with those not treated with RT (subdistribution Hazard Ratio = 2.08, 95% CI 0.87-4.97, p = 0.09).

Conclusions

Our exploratory findings indicate that, over the last decade in France, BC patients treated with RT appeared to be at higher risk of PPMI than general population. Further studies are needed to expand on this topic.

Breast cancer radiotherapy and risk of pacemaker implantation: an epidemiologic analysis using the French nationwide claims database

Background

Radiotherapy (RT) is a major treatment for breast cancer (BC), but it is also associated with an increased long-term (>5–10 years) risk of cardiac complications. Specific data on cardiac arrhythmias and conduction disorders are warranted.

Purpose

To evaluate whether pacemaker (PM) implantation risk is higher in BC patients treated with RT compared to the general population or population of BC patients treated without RT.

Methods

Our study was based on the Echantillon Généraliste de Bénéficiaires (EGB), the 1/97 random sample of the French nationwide health insurance claims database. The population of patients treated for BC consisted of adult women with a first BC identified by the ICD-10 diagnosis codes between 2008 and 2016, and followed through 2018. PM implantations and RT were identified with medical procedures codes in the french Common Classification of Medical Procedures (CCAM). For each year from 2008 to 2018, the reference population included all adult women of the EGB database. History of PM or BC was an exclusion criteria. Annual incidence rates of PM implantations were evaluated between 2008 and 2018 in the reference populations. The number of PM cases observed in BC patients at least one year after BC diagnosis was compared with the expected number of PM cases calculated by using reference incidence rates with age standardization. We then computed the standardized incidence ratio (SIR) as the ratio of the observed number of PM to the expected number of PM, with 95% confidence intervals (CIs). Thereafter, a survival analysis was performed in BC patients using a Cox regression model (Hazard Ratio – HR) in order to evaluate the risk of PM associated with treatment including RT (RT) compared with treatment not including RT (no RT).

Results

A total of 3,853 patients were included in the population of patients treated for BC between 2008 and 2016 with a mean age of 60 years old and a mean follow-up of 5.6 years. In this population, 35 cases of PM were observed, compared with 19.9 expected cases of PM, corresponding to a significant SIR=1.76 (95% CI: 1.22 - 2.39). This excess risk was carried by the RT group of 2973 patients (77% of BC population): 28 observed PM vs 12.9 expected, SIR=2.18 (95% CI: 1.45–3.06). In Cox regression analysis, after adjustment on age, RT was associated with an increased risk of PM compared with no RT, but this result did not reach statistical significance (HR=1.73; p-value=0.21).

Conclusion

Based on our study, BC patients receiving RT appeared to be at higher risk of PM implantation than general female population and BC patients without RT, illustrating a potential association between cardiac exposure during BC RT and conduction disorders.

Funding Acknowledgement

Type of funding sources: None.

Impact of transcatheter aortic valve implantations on temporal trends of pacemaker implantations among French octogenarians: a nation-wide cohort study over the period 2008–2018

Background

The indications for permanent pacemaker implantation (PPMI) are strongly associated with age, with the highest rates for octogenarians (>80 years old). Over the last decade, impact of aging on temporal trends in PPMI rates among octogenarians is questionable. In the 2010's, transcatheter aortic valve implantation (TAVI) has emerged for inoperable or high-risk patients, mainly octogenarians, with an exponential increase over years. PPMI is a common short-term complication after TAVI procedure. Many studies have explored these post-TAVI PPMI in terms of incidence, timing and outcomes of PPMI following TAVI, but there are no data on the impact of TAVI on PPMI temporal trend at a nationwide scale.

Purpose

To evaluate whether PPMI in octogenarians have increased during the last decade, independently from age and sex, on a nationwide scale. Eventually, to estimate the potential contribution of TAVI in PPMI increase in this setting.

Methods

Our study was based on octogenarians from the Echantillon Généraliste de Bénéficiaires, the 1/97 random sample of the French nationwide health insurance claims database. Between 2008 and 2018, we identified de novo PPMI and TAVI with medical procedures codes in the French Common Classification of Medical Procedures (CCAM). Annual incidence rates of PPMI were evaluated between 2008 and 2012 (preTAVI-period). The number of observed PPMI cases, O, in the period 2013–2018 (TAVI-period) was compared with the expected number of PPMI cases, E, calculated by using 2008–2012 incidence rates with age and sex standardization. We then computed the standardized incidence ratio (SIR) of the observed number of PPMI to the expected number of PPMI (O/E), with 95% confidence intervals (CIs). Thereafter, we evaluated the contribution of post-TAVI PPMI in the number of excess cases of PPMI (O-E) for the period 2013–2018.

Results

The population of octogenarians increased from 23,822 in 2008 to 33,752 in 2018. In 2008, 130 PPMI were observed (546/100,000 inhabitants) reaching 228 PPMI (676/100,000) in 2018 with a marked increase in rates from the year 2012. During the period 2013–2018, for all octogenarians, 1242 cases of PPMI were observed, compared with 1171.3 expected cases of PPMI, corresponding to a significant SIR=1.06 (95% CI: 1.01–1.12). For the subpopulation of octogenarians without TAVI, no excess risk was observed with a SIR=1.01 (95% CI: 0.95–1.06). Among the excess cases of PPMI observed in 2013–2018 in all octogenarians, 72% were post-TAVI PPMI.

Conclusion

Based on our study, the number of observed PPMI in octogenarians in period 2013–2018 is 6% higher than the number we would expect. Nearly three-quarter of these excess cases are attributable to TAVI complication.

Funding Acknowledgement

Type of funding sources: None.

Are NCCN Resource-Stratified Guidelines for Breast Cancer Systemic Therapy Achievable? A Population-Based Study of Global Need and Economic Impact

PURPOSE

Resource-stratified guidelines (RSG) for cancer provide a hierarchy of interventions, based on resource availability. We quantify treatment need and cost if National Comprehensive Cancer Network (NCCN) RSGs for breast cancer (BC) are adopted globally.

METHODS

We developed decision trees for first-course systemic therapy, merged with SEER and Global Cancer Observatory 2018 incidence data to estimate treatment need and cost if NCCN RSG are implemented globally based on country-level income. Simulations were used to quantify need and cost of globally scaling up services to Maximal.

RESULTS

Based on NCCN RSG, first-course chemotherapy is indicated in 0% (Basic), 87% (Core), and 86% (Enhanced) but declined to 50% (Maximal) because of incorporation of genomic profiling. First-course endocrine therapy (ET) is indicated in 80% in all settings. In 2018, treatment need was 1.4 million people for chemotherapy, 183,943 for human epidermal growth factor receptor 2 (HER2) therapies and 1.6 million for ET. The cost per person for chemotherapy or HER2 or immunotherapy increased by 17-fold from Core to Maximal ($1,278-$22,313 Australian dollars [AUD]). The cost of ET per person rose eight-fold from Basic to Maximal ($1,236-$9,809 AUD). If all patients with BC globally were treated with Maximal resources, the need for chemotherapy would decline by 28%, whereas cost of first-course treatment would rise by 1.8-fold ($21-$37 billion AUD) because of more costly therapies.

CONCLUSION

NCCN RSGs for BC could result in chemotherapy overtreatment in Core and Enhanced settings. The absence of chemotherapy in Basic settings should be reconsidered, and future iterations of RSG should perform cross-tumor comparisons to ensure equitable resource distribution and maximize population-level outcomes. Our model is flexible and can be tailored to the costs, population attributes, and resource availability of any institution or country for health-services planning.

Assessing the probability of having attained 16 years of age in juveniles using third molar development in a sample of South Indian population

Juvenile crime or delinquency has been increasing at an alarming rate in recent times. In many countries, including India, the minimum age for criminal responsibility is 16 years. The present study aimed to estimate the probability of a south Indian adolescent either being or being older than the legally relevant age of 16 years using Demirjian's tooth formation stages. Orthopantomograms (OPG) of 640 south Indian adolescents (320 boys and 320 girls) aged between 12 and 20 years were retrospectively analyzed. In each OPG, Demirjian's formation stage of the mandibular left third molar was recorded and the data was subjected to statistical analysis. Descriptive and Pearsons correlation statistics were performed. The empirical probabilities were provided relative to the medico-legal question of predicting 16 years of age. The distribution of age throughout the 10th, 25th, 50th, 75th and 90th percentile follows a logical distribution pattern horizontally and vertically. Pearson's correlation statistics showed a strong positive correlation between the Demirjian's stages and age for both sexes. Therefore, it can be concluded that stage "F" can be used to predict the attainment of age equal to or older than 16 years with a probability of 93.9% for boys and 96.6% for girls.

Covid-19 presentation among symptomatic healthcare workers in Ireland

BACKGROUND

It is recognized that healthcare workers (HCWs) are at high risk of contracting Covid-19. It is incumbent on occupational health staff to recognize potential symptoms of Covid-19 among HCWs.

AIMS

The aims of the study were to describe the presenting symptoms of HCWs who developed Covid-19 in Ireland, and to estimate the odds of specific symptoms being associated with a positive Covid-19 polymerase chain reaction (PCR) result.

METHODS

A retrospective chart review of all symptomatic HCWs who self-presented for Covid-19 testing in Cork from March to May 2020 was conducted. A sex-matched case-control study was carried out to compare presenting features among those who tested positive compared to those who tested negative. Univariate and multivariable-adjusted conditional logistic regression models were run using Stata 15.0 to identify the symptoms associated with positive Covid-19 swab results.

RESULTS

Three hundred and six HCWs were included in the study; 102 cases and 204 controls. Common presenting features among cases were fever/chills (55%), cough (44%) and headache (35%). The symptoms which were significantly associated with a positive Covid-19 swab result were loss of taste/smell (adjusted odds ratio [aOR] 12.15, 95% confidence interval [CI] 1.36-108.79), myalgia (aOR 2.36, 95% 1.27-4.38), fatigue (aOR 2.31, 95% CI 1.12-4.74), headache (aOR 2.11, 95% CI 1.19-3.74) and fever/chills (aOR 1.88, 95% CI 1.12-3.15).

CONCLUSIONS

Fever, fatigue, myalgia, loss of taste/smell and headache were associated with increased odds of a Covid-19 diagnosis among symptomatic self-referred HCWs compared with those had negative swab results. Testing criteria for HCWs should reflect the broad range of possible symptoms of Covid-19.

Global demand for cancer surgery and an estimate of the optimal surgical and anaesthesia workforce between 2018 and 2040: a population-based modelling study

BACKGROUND

The growing demand for cancer surgery has placed a global strain on health systems. In-depth analyses of the global demand for cancer surgery and optimal workforce requirements are needed to plan service provision. We estimated the global demand for cancer surgery and the requirements for an optimal surgical and anaesthesia workforce, using benchmarks based on clinical guidelines.

METHODS

Using models of benchmark surgical use based on clinical guidelines, we estimated the proportion of cancer cases with an indication for surgery across 183 countries, stratified by income group. These proportions were multiplied by age-adjusted national estimates of new cancer cases using GLOBOCAN 2018 data and then aggregated to obtain the estimated number of surgical procedures required globally. The numbers of cancer surgical procedures in 44 high-income countries were divided by the actual number of surgeons and anaesthetists in the respective countries to calculate cancer procedures per surgeon and anaesthetist ratios. Using the median (IQR) of these ratios as benchmarks, we developed a three-tiered optimal surgical and anaesthesia workforce matrix, and the predictions were extrapolated up to 2040.

FINDINGS

Our model estimates that the number of cancer cases globally with an indication for surgery will increase by 5 million procedures (52%) between 2018 (9 065 000) and 2040 (13 821 000). The greatest relative increase in surgical demand will occur in 34 low-income countries, where we also observed the largest gaps in workforce requirements. To match the median benchmark for high-income countries, the surgical workforce in these countries would need to increase by almost four times and the anaesthesia workforce by nearly 5·5 times. The greatest increase in optimal workforce requirements from 2018 to 2040 will occur in low-income countries (from 28 000 surgeons to 58 000 surgeons; 107% increase), followed by lower-middle-income countries (from 166 000 surgeons to 277 000 surgeons; 67% increase).

INTERPRETATION

The global demand for cancer surgery and the optimal workforce are predicted to increase over the next two decades and disproportionately affect low-income countries. These estimates provide an appropriate framework for planning the provision of surgical services for cancer worldwide.

FUNDING

University of New South Wales Scientia Scholarship and UK Research and Innovation Global Challenges Research Fund.

Evidence-based benchmarks for use of cancer surgery in high-income countries: a population-based analysis

BACKGROUND

Estimating a population-level benchmark rate for use of surgery in the management of cancer helps to identify treatment gaps, estimate the survival impact of such gaps, and benchmark the workforce and other resources, including budgets, required to meet service needs. A population-based benchmark for use of surgery in high-income settings to inform policy makers and service provision has not been developed but was recommended by the Lancet Oncology Commission on Global Cancer Surgery. We aimed to develop and validate a cancer surgery benchmarking model.

METHODS

We examined the latest clinical guidelines from high-income countries (Australia, the UK, the EU, the USA, and Canada) and mapped surgical treatment pathways for 30 malignant cancer sites (19 individual sites and 11 grouped as other cancers) that were notifiable in Australia in 2014, broadly reflecting contemporary high-income models of care. The optimal use of surgery was considered as an indication for surgery where surgery is the treatment of choice for a given clinical scenario. Population-based epidemiological data, such as cancer stage, tumour characteristics, and fitness for surgery, were derived from Australia and other similar high-income settings for 2017. The probabilities across the clinical pathways of each cancer were multiplied and added together to estimate the population-level benchmark rates of cancer surgery, and further validated with the comparisons of observed rates of cancer surgery in the South Western Sydney Local Health District in 2006-12. Univariable and multivariable sensitivity analyses were done to explore uncertainty around model inputs, with mean (95% CI) benchmark surgery rates estimated on the basis of 10 000 Monte Carlo simulations.

FINDINGS

Surgical treatment was indicated in 58% (95% CI 57-59) of newly diagnosed patients with cancer in Australia in 2014 at least once during the course of their treatment, but varied by site from 23% (17-27) for prostate cancer to 99% (96-99) for testicular cancer. Observed cancer surgery rates in South Western Sydney were comparable to the benchmarks for most cancers, but were higher for some cancers, such as prostate (absolute increase of 29%) and lower for others, such as lung (-14%).

INTERPRETATION

The model provides a new template for high-income and emerging economies to rationally plan and assess their cancer surgery provision. There are differences in modelled versus observed surgery rates for some cancers, requiring more in-depth analysis of the observed differences.

FUNDING

University of New South Wales Scientia Scholarship, UK Research and Innovation-Global Challenges Research Fund.

Characterization of cultural traits and fungicidal activity of strains belonging to the fungal genus Chaetomium

AIMS

Compare and characterize Chaetomium strains with special regard to their potentialities as biocontrol agents.

METHODS AND RESULTS

Twelve strains of the fungal genus Chaetomium from diverse ecological niches were identified as belonging to six different species. Large differences were observed between the strains with regard to temperature requirements for mycelial growth and pigmentation of culture filtrates. Culture filtrates and ethyl acetate extracts were assayed for fungicidal effects against important phytopathogens both on agar media and in multiwell plates. The samples from Chaetomium globosum were particularly active against Botrytis cinerea, Pyrenophora graminea and Bipolaris sorokiniana, while those from C. cochliodes and C. aureum were inhibitory towards Phytophthora infestans, and P. infestans and Fusarium culmorum respectively. To narrow down the active principle, the most promising extracts were separated by preparative HPLC and the resulting fractions tested in bioassays. Chaetoglobosins were identified as active compounds produced by C. globosum.

CONCLUSIONS

The bioassays revealed C. aureum and C. cochliodes as promising candidates for use in biocontrol. Both showed remarkably good activity against the prominent plant pathogen P. infestans.

SIGNIFICANCE AND IMPACT OF THE STUDY

We provide the first systematic study comparing six different Chaetomium species with regard to their use as biocontrol agents.

Assessing tumor centrality in lung stereotactic ablative body radiotherapy (SABR): the effects of variations in bronchial tree delineation and potential for automated methods

Accurate delineation of the proximal bronchial tree (PBT) is crucial for appropriate assessment of lung tumor centrality and choice of Stereotactic Ablative Body Radiotherapy (SABR) dose prescription. Here, we investigate variabilities in manual PBT delineation and their potential to influence assessing lesion centrality. A fully automatic, intensity-based tool for PBT contouring and measuring distance to the target is also described. This retrospective analysis included a total of 61 patients treated with lung SABR. A subset of 41 patients was used as a training dataset, containing clinical PBT contour and additional subsequently generated manual contours. The tool was optimized and compared against manual contours in terms of volume, distance to the target and various overlap/similarity metrics. The remaining 20 patients were used as a validation dataset to investigate the dosimetric effects of variations between manual and automatic PBT contours. Considerable interobserver variability was observed, particularly in identifying the superior and inferior borders of the PBT. Automatic PBT contours were comparable to manual contours with average Dice of 0.63 to 0.79 and mean distance to agreement of 1.78 to 3.34 mm. No significant differences in dosimetric parameters were found between automatically and manually generated contours. A moderate negative correlation was found between PBT maximum dose and distance to the lesion (p < 0.05). Variability in manual PBT delineation may result in inconsistent assessment of tumor centrality. Automatic contouring can help standardize clinical practice, support investigations into the link between SABR outcomes and lesion proximity to central airways and the development of predictive toxicity models that incorporate precise measurements of tumor location in relation to high-risk organs.

COVID-19-related intracranial imaging findings: a large single-centre experience

AIM

To describe the neuroradiological changes in patients with coronavirus disease 2019 (COVID-19).

MATERIALS AND METHODS

A retrospective review was undertaken of 3,403 patients who were confirmed positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and admitted to Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK between 1 March 2020 and 31 May 2020, and who underwent neuroimaging. Abnormal brain imaging was evaluated in detail and various imaging patterns on magnetic resonance imaging MRI were identified.

RESULTS

Of the 3,403 patients with COVID-19, 167 (4.9%) had neurological signs or symptoms warranting neuroimaging. The most common indications were delirium (44/167, 26%), focal neurology (37/167, 22%), and altered consciousness (34/167, 20%). Neuroimaging showed abnormalities in 23% of patients, with MRI being abnormal in 20 patients and computed tomography (CT) in 18 patients. The most consistent neuroradiological finding was microhaemorrhage with a predilection for the splenium of the corpus callosum (12/20, 60%) followed by acute or subacute infarct (5/20, 25%), watershed white matter hyperintensities (4/20, 20%), and susceptibility changes on susceptibility-weighted imaging (SWI) in the superficial veins (3/20, 15%), acute haemorrhagic necrotising encephalopathy (2/20, 10%), large parenchymal haemorrhage (2/20, 10%), subarachnoid haemorrhage (1/20, 5%), hypoxic–ischaemic changes (1/20, 5%), and acute disseminated encephalomyelitis (ADEM)-like changes (1/20, 5%).

CONCLUSION

Various imaging patterns on MRI were observed including acute haemorrhagic necrotising encephalopathy, white matter hyperintensities, hypoxic-ischaemic changes, ADEM-like changes, and stroke. Microhaemorrhages were the most common findings. Prolonged hypoxaemia, consumption coagulopathy, and endothelial disruption are the likely pathological drivers and reflect disease severity in this patient cohort.

Occupational low-dose irradiation and cancer risk among medical radiation workers

Background

Medical workers are the largest group of workers occupationally exposed to low doses of ionizing radiation (IR) worldwide.

Aims

This review presents all the cohorts of medical workers exposed in the world and summarizes cancer risks associated with radiation exposure in this population.

Methods

Epidemiological studies on health professionals exposed to IR published from 1975 to 2019 were reviewed. Strength of evidence was assessed according to the modified Royal College of General Practitioners three-star system.

Results

Among the 16 epidemiological studies focusing on cancers from 11 cohorts among medical staff exposed to radiation, higher risks of cancer were observed for pre-1950 exposure and for medical workers who performed fluoroscopically guided interventional procedures or radionuclides procedures compared to those who did not. However, strength of evidence supporting the associations remains moderate as several methodological limits including the lack of dosimetry data, lifestyle factors and recent updates may obscure the link between medical occupational exposure and cancer occurrence.

Conclusions

Excess risk of cancer is suspected for high and former exposures. The more highly exposed professions, i.e. interventional physicians and nuclear medicine workers, should be monitored carefully. Collaborative projects aiming to increase the quantity and quality of information of the studied populations would be a key point

Surgical management of oral submucous fibrosis with "Seagull-nasolabial flap" combined with short-term oral pentoxifylline for preventing relapse

The aim of the study was to evaluate the effectiveness of seagull-shaped nasolabial flap (NLF) along with adjunctive short-term oral pentoxifylline in the surgical reconstruction of oral sub mucous fibrosis (OSMF) following fibrotomy. We retrospectively evaluated 18 patients with grade IV oral sub mucous fibrosis treated by NLF. There were 3 females and 15 males. All patients were classified as stage IV OSMF with a mean preoperative mouth opening of 8.11±3.38mm. Postoperatively, patients were administered 400mg of pentoxifylline (PTX) thrice daily for 3 months. Patients were followed up at one month, six months and one year. Mouth opening, presence or absence of malignant transformation, relapse and complications were recorded at each follow-up. We found statistically significant increase in mouth opening from 8.11±3.3 to 37.67±3.74 in the postoperative period. The complications associated with NLF were very minimal. The PTX was well tolerated by all the patients. There was no incidence of relapse or rebound fibrosis seen in our series. To the best of our knowledge, this is the first time that oral pentoxifylline has been administered along with surgical treatment of oral submucous fibrosis to prevent relapse. The use of oral PTX as an adjunct along with surgical reconstruction in OSMF improves mouth opening, reduces burning sensation and relapse.

Cerebral phaeohyphomycosis due to Cladophialophora bantiana in a French Guianese child

We report a case of cerebral phaeohyphomycosis, a fungal brain infection due to a dark (dematiaceous) fungi in a 6-year-old French Guyanese boy. The child presented fever and drowsiness due to several paraventricular brain abscesses. Neurological surgeries were performed to reduce intracranial hypertension and to obtain abscess biopsies. Mycological cultures of intraoperative samples led to the diagnosis of cerebral phaeohyphomycosis due to Cladophialophora bantiana. The patient neurological status deteriorated and remained critical after several weeks of combination antifungal therapy with voriconazole 8mg/kg/day, liposomal amphotericin B 10mg/kg/day and flucytosine 200mg/kg/day. A complete surgical resection was not possible because of multiple small abscesses. A multidisciplinary ethical staff decided on home medical care with palliative ventriculoperitoneal shunt, nasogastric feeding and analgesics. One year later, the patient's neurological condition had improved and cerebral lesions had regressed, while he had not received any antifungal treatment but only traditional medicines. Cerebral phaeohyphomycosis are rare diseases affecting immunocompromised but also apparently non-immunocompromised patients, as in this case. A complete surgical resection is not always possible and mortality rates are high in spite of treatments with a combination of antifungals. The diagnosis may be difficult because of these dematiaceous fungi's slowly growing and their potential pathogenicity for laboratory staff.

Personalised treatments for acute whiplash injuries: A pilot study of nested N-of-1 trials in a multiple baseline single-case experimental design

BACKGROUND

Whiplash associated disorder (WAD), a common and disabling condition, incurs huge burden and costs to Australia. Yet, current treatments for whiplash are not very effective; improved outcomes are urgently needed. Clinical guidelines recommend simple analgesia (paracetamol and non-steroidal anti-inflammatory drugs) but there have been no trials of guideline-recommended drugs. This study will investigate the effectiveness of evidence-based advice (EBA), paracetamol, naproxen, and both paracetamol and naproxen, in reducing daily neck pain and preventing chronic neck pain after whiplash injury.

METHODS

This study is a pilot series of multi-cycle, double-blinded, randomised N-of-1 trials, nested in a multiple baseline design. The design will comprise three baselines of 5, 8 or 11 days duration. Post enrolment, participants will be randomly assigned to one of the baselines. Fifteen participants with acute (<2 weeks) Grade II WAD, experiencing at least moderate pain (NRS: ≥ 5/10), and at risk of poor recovery will be recruited from hospitals in Queensland, Australia, and through local physiotherapists. Patients will receive EBA plus a randomised sequence of three cycles of ten day treatment triplets (paracetamol designated as a C phase, naproxen, designated as a D phase, and both paracetamol and naproxen, designated as an E phase).

DISCUSSION

We will test the effects of different treatments on the primary outcome of average neck pain intensity collected daily and at 4 and 7 months post-injury. Secondary outcomes, including disability, depression, post-traumatic stress symptoms, pain catastrophizing, and feasibility of study procedures, will also be evaluated. The results of this study will inform a larger trial aiming to strengthen the evidence on EBA and simple analgesics for WAD.

TRIAL REGISTRATION

Clinical Trials Primary Registry: Australian and New Zealand Clinical Trials Registry.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12618001291279.

DATE OF REGISTRATION

31/07/2018.

PRIMARY TRIAL SPONSOR

The University of Queensland, Brisbane QLD 4072 Australia.

FUNDING

The University of Queensland.

Factors influencing corneal predescemetic endothelial keratoplasty (PDEK) graft creation: It's all in a bubble

AIM

To assess the effect of pneumatic (air) and fluidic (transport medium) injection to the type of bubble (I, II or mixed III) and the resultant dissection of corneal endothelial grafts PDEK or DMEK.

MATERIALS AND METHODS

All grafts were obtained from Dr Agrawal Hospital's Eye Bank. Air injection was the initial preferred mode of graft harvest. If pneumatic dissection was unsuccessful after 10 tries, fluidic dissection with transport medium was tried. SPSS 23.0 was used to statistically analyse the data.

RESULTS

40 consecutive donor corneas with a mean age of 46.5 and a mean endothelial count of 2980 were analysed. Air dissection lead to the harvest of 27 endothelial grafts and fluid dissection led to the creation of 7 endothelial grafts. Statistically significant difference was found the different bubble types and the type of injection (χ² chi square=10.02, 0=0.008).

CONCLUSION

In young donors pneumatic (air) graft dissection leads to PDEK in a high proportion. This percentage is reduced when transport medium is tried after unsuccessful air injection. Injection of transport medium increases the percentage of grafts harvested but also increases the ratio of Type II and III DMEK grafts created.

Estimates of global chemotherapy demands and corresponding physician workforce requirements for 2018 and 2040: a population-based study

BACKGROUND

The incidence of cancer (excluding non-melanomatous skin cancers) is projected to rise from 17·0 million to 26·0 million between 2018 and 2040. A large proportion of these patients would be likely to derive benefit from chemotherapy, but no studies so far have quantified current and projected global chemotherapy demands. We aimed to estimate changes in national, regional, and global demands for first-course chemotherapy and the cancer physician workforce between 2018 and 2040 if all patients were treated according to best-practice evidence-based guidelines.

METHODS

Data for the incidence of 29 types of cancer in 183 countries in 2018, and projections of incidence in 2040, were obtained from GLOBOCAN 2018. Optimal chemotherapy utilisation from evidence-based guidelines was applied to these incidence data to generate the number of new patients requiring first-course chemotherapy in 2018 and 2040. We then estimated the corresponding cancer physician workforce required to deliver this chemotherapy (on the basis of physicians seeing 150 new patients requiring chemotherapy per year). We did sensitivity analyses to investigate how cancer stage at presentation affected chemotherapy demands. We also did sensitivity analyses to explore changes to workforce requirements if each physician was seeing 100 new patients requiring chemotherapy per year or 300 new patients requiring chemotherapy per year.

FINDINGS

Between 2018 and 2040, the number of patients requiring first-course chemotherapy annually will increase from 9·8 million to 15·0 million, a relative increase of 53%. The estimated proportion of patients needing chemotherapy who reside in low-income or middle-income countries was 63% (6 162 240 of 9 782 783) in 2018, and will be 67% (10 071 049 of 14 984 560) in 2040. The most common indications for chemotherapy worldwide in 2040 will be lung cancer (accounting for 2 455 137 [16·4%] of 14 984 560 cases eligible for chemotherapy), breast cancer (1 898 740 [12·7%]), and colorectal cancer (1 678 153 [11·1%]). We estimated that, in 2018, 65 000 cancer physicians were required worldwide to deliver optimal chemotherapy-a figure that we estimate will rise to 100 000 by 2040 (with estimates ranging from from 50 000 to 150 000, depending on workload).

INTERPRETATION

Strategic investments in chemotherapy service provision and cancer physicians are needed to meet the projected increased demand for chemotherapy in 2040.

FUNDING

None.

Encephalitis on deployment in Kenya: think beyond the infections

A 34-year-old female soldier presented with fever and behavioural changes while deployed in Kenya and was diagnosed with encephalitis. The patient underwent urgent aeromedical evacuation to the Queen Elizabeth Hospital, Birmingham for further management. Microbiology tests excluded common infectious causes that are endemic in the East Africa region. However, an autoantibody screen was positive for antibodies against the N-methyl-D-aspartate receptor (NMDAR). Full body imaging confirmed the presence of limbic encephalitis and an ovarian mass suggestive of a teratoma. The patient was diagnosed with ovarian teratoma-associated anti-NMDAR encephalitis, a potentially fatal disease. The patient underwent surgery to remove the teratoma and commenced immunotherapy with steroids, plasma exchange and rituximab. This case highlights the diagnostic challenges of fever with behavioural changes in military personnel deployed in a tropical environment.

Relationship of Creatinine and Cystatin C-based Estimated Glomerular Filtration rates with Measured Glomerular Filtration Rate in Healthy Kidney Donors from South Asia

Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation is currently recommended for the estimation of glomerular filtration rate (GFR). This retrospective study aimed to evaluate the correlation between creatinine and cysC-based estimated GFRs and measured GFR in healthy adults. Consecutive healthy adults who were accepted as voluntary kidney donors at our center between January 2008 and December 2012 were included in the study. The 336 individuals who comprised the study population had a mean age of 41.6 ± 11.8 years, male:female ratio 1:1.7, mean creatinine 0.9 ± 0.1 mg/dl, and mean cysC 0.8 ± 0.1 mg/dl. Mean measured GFR by Tc-99m diethylenetriaminepentaacetic acid using Gates method was 98.4 ± 21.2 ml/min/1.73 m². The mean ± standard deviation of eGFRs by various formulae were as follows: Cockcroft–Gault (CG) = 88.1 ± 15.9 ml/min/1.73 m², Modification of Diet in Renal Disease (MDRD) = 78 ± 14.7 ml/min/1.73 m², CKD-EPI creatinine = 88.1 ± 15.5 ml/min/1.73 m², CKD-EPI cysC = 97 ± 19.9 ml/min/1.73 m², CKD-EPI creatinine-cysC (CKD-EPI cr-cysC) = 92.5 ± 14.1 ml/min/1.73 m². The CKD-EPI cr-cysC equation had the highest accuracy, with 43% and 72% of values lying within ±10% and ±20% of the measured GFR, respectively. Bland–Altman analyses for levels of agreement showed least bias with CKD-EPI cysC overall and among females, while among males, CKD-EPI creatinine equation had the least bias. The CKD-EPI equation showed a higher performance than the MDRD and CG equation in GFR estimation of a healthy population. Among CKD-EPI equations, CKD-EPI cr-cysC had the highest accuracy and CKD-EPI cysC the least bias.