Real-world treatment patterns and clinical outcomes from a retrospective chart review study of patients with recurrent or advanced endometrial cancer who progressed following prior systemic therapy in Europe

OBJECTIVE

To evaluate real-world treatment patterns and clinical outcomes in recurrent/advanced endometrial cancer patients who progressed following prior systemic therapy in clinical practice in Europe.

DESIGN

Endometrial Cancer Health Outcomes-Europe (ECHO-EU) is a retrospective patient chart review study.

SETTING

ECHO-EU is a multicentre study conducted in the UK, Germany, Italy, France and Spain.

PARTICIPANTS

Patients with recurrent/advanced endometrial cancer who progressed between 1 July 2016 and 30 June 2019 following prior first-line systemic therapy were eligible and data were collected until last available follow-up through November 2021.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data collected included patient demographics, clinical and treatment characteristics, and clinical outcomes. Kaplan-Meier analyses were performed since initiation of second-line therapy to estimate time to treatment discontinuation, real-world progression-free survival (rwPFS) and overall survival (OS).

RESULTS

A total of 475 patients were included from EU5 countries. Median age was 69 years at advanced endometrial cancer diagnosis, 78.7% had stage IIIB-IV disease, 45.9% had Eastern Cooperative Oncology Group status ≥2 at second-line therapy initiation. In second line, a majority of patients initiated either non-platinum-based chemotherapy (55.6%) or endocrine therapy (16.2%). Physician-reported real-world overall response rate (classified as complete or partial response) to second-line therapy was 34.5%, median rwPFS was 7.4 months (95% CI 6.2 to 8.0) and median OS was 11.0 months (95% CI 9.9 to 12.3).

CONCLUSIONS

Patients had poor clinical outcomes with a median OS of <1 year and rwPFS of approximately 7 months, highlighting the significant unmet medical need in pretreated recurrent/advanced endometrial cancer patients. Novel therapies with potential to improve PFS and OS over conventional therapies could provide significant clinical benefit.

Durvalumab After Chemoradiotherapy in Patients With Unresectable Stage III Non-Small Cell Lung Cancer

Importance

The PACIFIC trial established consolidation durvalumab as the standard of care following chemoradiotherapy (CRT) for patients with unresectable stage III non-small cell lung cancer (NSCLC). Understanding its benefit in routine US clinical practice is critical.

Objective

To report characteristics, treatment patterns, and outcomes of patients who did or did not receive durvalumab.

Design, Setting, and Participants

Two prespecified cohorts were curated in this retrospective cohort study (SPOTLIGHT). Deidentified patient-level data from a US database (Flatiron Health) were analyzed. Patients had unresectable stage III NSCLC, were diagnosed on or after January 1, 2011, had 2 or more visits on or afterward, and received CRT. Data were analyzed from May 2021 to October 2023.

Exposures

Patients started durvalumab after CRT (durvalumab cohort) or ended CRT without durvalumab (nondurvalumab cohort) by June 30, 2019, to allow 15 or more months of follow-up from CRT end.

Main Outcomes and Measures

End points included progression-free survival (PFS), overall survival (OS), time to first subsequent therapy or death (TFST), and time to distant metastasis or death (TTDM).

Results

The durvalumab cohort included 332 patients (median [IQR] age, 67.5 [60.8-74.0] years; 187 were male [56.3%], 27 were Black [8.7%], 33 were other races [10.7%], and 249 were White [80.6%]) and the nondurvalumab cohort included 137 patients (median (IQR) age, 70.0 [64.0-75.0] years; 89 [65.0%] were male, 11 [8.9%] were Black, 19 [15.4%] were other races, and 93 [75.6%] were White). Most patients had a smoking history (durvalumab, 316 patients [95.2%] and nondurvalumab, 132 patients [96.4%]) and Eastern Cooperative Oncology Group performance status 0 through 1 (durvalumab, 251 patients [90.9%] and nondurvalumab, 88 patients [81.5%]). Median (IQR) CRT duration was 1.6 (1.4-1.8) months for the durvalumab cohort and 1.5 (1.4-1.8) months for the nondurvalumab cohort. Median time to durvalumab discontinuation was 9.5 months (95% CI, 7.8-10.6 months). Median TFST and TTDM were not reached (NR) in the durvalumab cohort and 8.3 months (95% CI, 4.8-11.8 months) and 11.3 months (95% CI, 6.4-14.5 months), respectively, in the nondurvalumab cohort. Median PFS and OS were 17.5 months (95% CI, 13.6-24.8 months) and NR in the durvalumab cohort and 7.6 months (95% CI, 5.2-9.8 months) and 19.4 months (95% CI, 11.7-24.0 months) in the nondurvalumab cohort. In Cox regression analyses of patients who completed concurrent CRT without progression, durvalumab was associated with a lower risk of progression or death (hazard ratio [HR], 0.36; 95% CI, 0.26-0.51) and lower risk of death (HR, 0.27; 95% CI, 0.16-0.43), adjusted for prior platinum agent and patient characteristics.

Conclusions and Relevance

In this cohort study, findings were consistent with PACIFIC, and durvalumab was associated with a lower risk of progression and/or death. Further investigation is warranted to explain why patients did not receive durvalumab after its approval.

Building Block Metal Nanocluster-Based Growth in 1D Direction

Metal nanoclusters with precisely modulated structures at the nanoscale give us the opportunity to synthesize and investigate 1D nanomaterials at the atomic level. Herein, it realizes selective 1D growth of building block nanocluster "Au13 Cd2 " into three structurally different nanoclusters: "hand-in-hand" (Au13 Cd2 )2 O, "head-to-head" Au25 , and "shoulder-to-shoulder" Au33 . Detailed studies further reveals the growth mechanism and the growth-related tunable properties. This work provides new hints for the predictable structural transformation of nanoclusters and atomically precise construction of 1D nanomaterials.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Prevalence and influencing factors of depressive and anxiety symptoms among hospital-based healthcare workers during the surge period of the COVID-19 pandemic in the Chinese mainland: a multicenter cross-sectional study

BACKGROUND

From November 2022 to February 2023, the Chinese mainland experienced a surge in COVID-19 infection and hospitalization, and the hospital-based healthcare workers (HCWs) might suffer serious psychological crisis during this period. This study aims to assess the depressive and anxiety symptoms among HCWs during the surge of COVID-19 pandemic and to provide possible reference on protecting mental health of HCWs in future infectious disease outbreaks.

METHODS

A multicenter cross-sectional study was carried out among hospital-based HCWs in the Chinese mainland from 5 January to 9 February 2023. The PHQ-9 (nine-item Patient Health Questionnaire) and GAD-7 (seven-item Generalized Anxiety Disorder Questionnaire) were used to measure depressive and anxiety symptoms. Ordinal logistic regression analysis was performed to identify influencing factors.

RESULTS

A total of 6522 hospital-based HCWs in the Chinse mainland were included in this survey. The prevalence of depressive symptoms among the HCWs was 70.75%, and anxiety symptoms was 47.87%. The HCWs who perceived higher risk of COVID-19 infection and those who had higher work intensity were more likely to experience depressive and anxiety symptoms. Additionally, higher levels of mindfulness, resilience and perceived social support were negatively associated with depressive and anxiety symptoms.

CONCLUSION

This study revealed that a high proportion of HCWs in the Chinese mainland suffered from mental health disturbances during the surge of the COVID-19 pandemic. Resilience, mindfulness and perceived social support are important protective factors of HCWs' mental health. Tailored interventions, such as mindfulness practice, should be implemented to alleviate psychological symptoms of HCWs during the COVID-19 pandemic or other similar events in the future.

[Application effects of 3D visualization reconstruction technique in pheochromocytoma/ paraganglioma surgery]

To investigate the value of 3D visualization reconstruction technology in pheochromocytoma/paraganglioma surgery.The clinical data of 87 patients with pheochromocytoma/paraganglioma admitted to the Department of Urology of Peking Union Medical College Hospital between January 2019 and December 2022 were retrospectively analyzed, and 3D visualization model reconstruction was performed preoperatively in 47 patients [Group A:males was 24 cases,the age M(Q1, Q3)42.00(30.00, 54.00)]. while the remaining 40 patients [Group B: males was 23 cases,the age M(Q1, Q3) 44.00(30.25, 53.75)] was not. The maximum tumor diameter, operation time, intraoperative bleeding, drain retention time and postoperative hospital stay were compared between the two groups. Surgery was successfully completed in both groups. 37 (78.7%) patients in group A underwent laparoscopic surgery, 7 (14.9%) patients underwent open surgery, and 3 (6.4%) patients underwent laparoscopic-to-open surgery. Thirty-one (77.5%) patients in group B underwent laparoscopic surgery, 5 (12.5%) patients underwent open surgery, and 4 (10.0%) patients underwent laparoscopic to open surgery. There was a difference in the maximum diameter of the tumor between the two groups [(6.09±3.02) cm vs (5.32±1.76) cm, P<0.05], the retention time of the drainage tube was significantly shorter in group A compared with group B [(3.20±1.38) d vs (4.02±1.98) d, P<0.05], and the length of the hospital stay after surgery was significantly shorter [(5.75±2.12) d vs (6.49±3.37) d, P<0.05]. Comparison of operation time and intraoperative bleeding between the two groups showed no statistically significant difference (P>0.05).Two cases of postoperative anemia and one case of pulmonary atelectasis in group B patients improved before discharge. Conclusion when the tumor diameter is>6 cm or has a close relationship with the surrounding organs and blood vessels, the use of 3D visual reconstruction technology can formulate and implement a more accurate and safe surgical plan, shorten the retention time of the drainage tube and postoperative hospitalization time, which is conducive to the patient's postoperative recovery and reduce postoperative complications.

Clinical efficacy of modified percutaneous kyphoplasty (PKP) vs. conventional PKP for osteoporotic vertebral compression fractures: a single-center retrospective study

OBJECTIVE

To investigate the clinical efficacy of using a standardized modified percutaneous kyphoplasty (transverse process‑pedicle approach to percutaneous kyphoplasty, TPKP) approach for the treatment of osteoporotic vertebral compression fractures (OVCFs) and to explore the possibility that it may become the preferred option in the future.

PATIENTS AND METHODS

A retrospective analysis was conducted on a total of 81 patients (TPKP group, 43 cases; PKP group, 38 cases) with OVCFs who underwent TPKP and PKP at the Department of Spine Surgery, Wuhan Fourth Hospital, from May 2021 to October 2021. We evaluated the patients' demographic information, intraoperative data (volume of cement injection and, duration of surgery), clinical outcomes at different time points (Visual Analog Scale, Oswestry Dysfunction Index), and radiographic data (Cobb angle, anterior vertebral body height). Statistical analysis was performed to assess the efficacy of the procedure, both within and between the two groups before and after surgery.

RESULTS

The difference in preoperative general information between the two groups of patients was non-statistically significant (p>0.05), and they were comparable. Additionally, no statistically significant difference (p>0.05) was found between the TPKP and PKP groups in terms of operative time, length of hospital stay, recovery of injured spine height, Cobb angle, and cement leakage rate. However, significant statistical differences (p<0.05) were noted between the two groups regarding cement volume, distribution pattern, 1-day postoperative VAS scores, 1-day postoperative ODI scores, and loss of height of the injured spine. TPKP demonstrated superior performance compared to PKP in these specific areas.

CONCLUSIONS

TPKP offers the same surgical safety as the conventional approach, with better cement distribution and better pain relief, as well as the advantage of maintaining the height of the operated vertebral body. The technique is easy to master and use when guided by standard puncture procedures.

[Current use of oral anticoagulation therapy and influencing factors among coronary artery disease patients with nonvalvular atrial fibrillation in China]

Objective: To investigate current use of oral anticoagulant (OAC) therapy and influencing factors among coronary artery disease (CAD) patients with nonvalvular atrial fibrillation (NVAF) in China. Methods: Results of this study derived from "China Atrial Fibrillation Registry Study", the study prospectively enrolled atrial fibrillation (AF) patients from 31 hospitals, and patients with valvular AF or treated with catheter ablation were excluded. Baseline data such as age, sex and type of atrial fibrillation were collected, and drug history, history of concomitant diseases, laboratory results and echocardiography results were recorded. CHA₂DS₂-VASc score and HAS-BLED score were calculated. The patients were followed up at the 3rd and 6th months after enrollment and every 6 months thereafter. Patients were divided according to whether they had coronary artery disease and whether they took OAC. Results: 11 067 NVAF patients fulfilling guideline criteria for OAC treatment were included in this study, including 1 837 patients with CAD. 95.4% of NVAF patients with CAD had CHA₂DS₂-VASc score≥2, and 59.7% of patients had HAS-BLED≥3, which was significantly higher than NVAF patients without CAD (P<0.001). Only 34.6% of NVAF patients with CAD were treated with OAC at enrollment. The proportion of HAS-BLED≥3 in the OAC group was significantly lower than in the no-OAC group (36.7% vs. 71.8%, P<0.001). After adjustment with multivariable logistic regression analysis, thromboembolism(OR=2.48,95%CI 1.50-4.10,P<0.001), left atrial diameter≥40 mm(OR=1.89,95%CI 1.23-2.91,P=0.004), stain use (OR=1.83,95%CI 1.01-3.03, P=0.020) and β blocker use (OR=1.74,95%CI 1.13-2.68,P=0.012)were influence factors of OAC treatment. However, the influence factors of no-OAC use were female(OR=0.54,95%CI 0.34-0.86,P=0.001), HAS-BLED≥3 (OR=0.33,95%CI 0.19-0.57,P<0.001), and antiplatelet drug(OR=0.04,95%CI 0.03-0.07,P<0.001). Conclusion: The rate of OAC treatment in NVAF patients with CAD is still low and needs to be further improved. The training and assessment of medical personnel should be strengthened to improve the utilization rate of OAC in these patients.

Quality-adjusted time without symptoms or toxicity analysis of nivolumab plus chemotherapy versus chemotherapy alone for the management of previously untreated patients with advanced gastric cancer, gastroesophageal junction cancer, or esophageal adenocarcinoma

BACKGROUND

The phase 3 CheckMate 649 established superior overall survival of nivolumab in combination with chemotherapy (NIVO + chemo) compared with chemotherapy (chemo) alone as a first-line treatment for patients with Her2-negative advanced gastric cancer, gastroesophageal junction cancer, and esophageal adenocarcinoma (GC/GEJC/EAC). This post hoc trial analysis aimed to evaluate the benefit of NIVO + chemo using quality-adjusted time without symptoms or toxicity (Q-TWiST) to further account for quality of life (QoL) in different health states depending on disease progression and treatment toxicity.

METHODS

Using data from CheckMate 649, we evaluated the quality-adjusted survival gain associated with NIVO + chemo compared with chemo alone among all randomized patients and repeated similar analyses among those with programmed cell death-ligand 1 (PD-L1) combined positive score (CPS) ≥ 5. Relative Q-TWiST gains of ≥ 10% were predefined as clinically important.

RESULTS

In all randomized patients, those receiving NIVO + chemo had a mean Q-TWiST gain of 1.8 (95% CI 0.9, 2.7) months compared with those receiving chemo alone. The relative Q-TWiST gain was estimated to be 12.8%. Patients with PD-L1 CPS ≥ 5 had greater quality-adjusted survival gain from NIVO + chemo with an estimated Q-TWiST gain of 2.8 (95% CI 1.5, 4.1) months, representing a relative gain of 20.6%. Subgroup analyses and sensitivity analyses with various QoL utility values yielded consistent findings in favor of NIVO + chemo compared with chemo alone. Q-TWiST gain from NIVO + chemo increased with longer duration of follow-up.

CONCLUSIONS

NIVO + chemo was associated with a statistically significant and clinically important gain in quality-adjusted survival compared with chemo alone among previously untreated patients with advanced GC/GEJC/EAC.

Quality-Adjusted Time without Symptoms or Toxicity: Analysis of Axicabtagene Ciloleucel versus Standard of Care in Patients with Relapsed/Refractory Large B Cell Lymphoma

The quality-adjusted time without symptoms or toxicity (Q-TWiST) methodology provides a comprehensive framework for treatment comparison that partitions survival time into distinct health states reflecting both treatment toxicity and disease progression. ZUMA-7 (ClinicalTrials.gov identifier NCT03391466), a phase 3 randomized open-label multicenter study, was conducted to evaluate the efficacy of axicabtagene ciloleucel (axi-cel), a chimeric antigen receptor T cell therapy, compared with standard of care (SOC) involving platinum-based salvage chemotherapy with autologous stem cell transplantation (ASCT) consolidation as a second-line treatment for relapsed/refractory (R/R) large B cell lymphoma (LBCL), and met its primary endpoint of improved event-free survival (EFS). We aimed to use the Q-TWiST method to compare the quality-adjusted survival of R/R LBCL patients treated with axi-cel and those treated with SOC who were enrolled in ZUMA-7. The preplanned analysis of overall survival (OS) was partitioned into 3 mutually exclusive health states: time with grade ≥3 adverse events before the event as defined in the EFS analysis (TOX), time without severe toxicity before the event (TWiST), and time after the event (REL). Q-TWiST was computed as a weighted sum of mean TOX, TWiST, and REL values multiplied by state-specific quality of life (QoL) utility scores. Q-TWiST was evaluated in the intention-to-treat cohort at median follow-up. A relative Q-TWiST gain of 10% was deemed "clinically important" and a gain of ≥15% was deemed "clearly clinically important" based on established categorization. Sensitivity analyses with follow-up ranging from 3 months to the maximum follow-up and subgroup analyses by age and R/R status were explored. At a median follow-up of 23.5 months, the axi-cel cohort showed a significantly longer time without severe toxicity compared with the SOC cohort, with a mean TWiST duration of 11.18 months versus 5.39 months, respectively. The mean TOX was 1.16 months versus .74 months, and mean REL was 6.02 months versus 10.66 months. Quality-adjusted survival was significantly longer with axi-cel by 3.7 months (95% CI, 2.3 to 5.2 months), representing a relative gain of 21.9%. This was reflected across all subgroups, with estimated Q-TWiST gains of 3.1 months (95% CI, 1.5 to 4.9 months) for patients age <65 years, 5.2 months (95% CI, 2.4 to 7.9 months) for those age ≥65 years, 3.2 months (95% CI, 1.4 to 4.9 months) for those with primary refractory disease, 9.1 months (95% CI, 3.9 to months 13.5) for those who relapsed within 6 months, and 4.1 months (95% CI, 1.1 to 7.1 months) for those who relapsed between 6 and 12 months. The Q-TWiST gain for axi-cel also was statistically significant across follow-up durations, increasing from .2 month (95% CI, .1 to .3 month) at a 3-month follow-up to 4.9 months (95% CI, 2.4 to 7.8 months) at the maximum follow-up of 37.7 months. Axi-cel was associated with a statistically significant and "clearly clinically important" gain in quality-adjusted survival, regardless of the relative decline in QoL associated with treatment toxicity, disease progression, or additional cancer treatment. This finding adds to the existing evidence supporting a benefit for axi-cel as a second-line treatment for patients with R/R LBCL.

[Changes in percentage of GATA3+ regulatory T cells and their pathogenic roles in allergic rhinitis]

OBJECTIVE

To investigate the changes in percentage of GATA3⁺ regulatory T (Treg) cells in patients with allergic rhinitis (AR) and mouse models.

METHODS

The nasal mucosa specimens were obtained from 6 AR patients and 6 control patients for detection of nasal mucosal inflammation. Peripheral blood mononuclear cells (PBMC) were collected from 12 AP patients and 12 control patients to determine the percentages of Treg cells and GATA3⁺ Treg cells. In a C57BL/6 mouse model of AR, the AR symptom score, peripheral blood OVA-sIgE level, and nasal mucosal inflammation were assessed, and the spleen of mice was collected for detecting the percentages of Treg cells and GATA3⁺ Treg cells and the expressions of Th2 cytokines.

RESULTS

Compared with the control patients, AR patients showed significantly increased eosinophil infiltration and goblet cell proliferation in the nasal mucosa (P < 0.01) and decreased percentages of Treg cells and GATA3⁺ Treg cells (P < 0.05). The mouse models of AR also had more obvious allergic symptoms, significantly increased OVA-sIgE level in peripheral blood, eosinophil infiltration and goblet cell hyperplasia (P < 0.01), markedly lowered percentages of Treg cells and GATA3⁺ Treg cells in the spleen (P < 0.01), and increased expressions of IL-4, IL-6 and IL-10 (P < 0.05).

CONCLUSION

The percentage of GATA3⁺ Treg cells is decreased in AR patients and mouse models. GATA3⁺ Treg cells possibly participate in Th2 cell immune response, both of which are involved in the occurrence and progression of AR, suggesting the potential of GATA3⁺ Treg cells as a new therapeutic target for AR.

Survey of the American Society of Neuroradiology Membership on the Use and Value of Extracranial Carotid Vessel Wall MRI

BACKGROUND AND PURPOSE

Extracranial vessel wall MRI (EC-VWI) contributes to vasculopathy characterization. This survey study investigated EC-VWI adoption by American Society of Neuroradiology (ASNR) members and indications and barriers to implementation.

MATERIALS AND METHODS

The ASNR Vessel Wall Imaging Study Group survey on EC-VWI use, frequency, applications, MR imaging systems and field strength used, protocol development approaches, vendor engagement, reasons for not using EC-VWI, ordering provider interest, and impact on clinical care was distributed to the ASNR membership between April 2, 2019, to August 30, 2019.

RESULTS

There were 532 responses; 79 were excluded due to minimal, incomplete response and 42 due to redundant institutional responses, leaving 411 responses. Twenty-six percent indicated that their institution performed EC-VWI, with 66.3% performing it ≤1-2 times per month, most frequently on 3T MR imaging, with most using combined 3D and 2D protocols. Protocols most commonly included pre- and postcontrast T1-weighted imaging, TOF-MRA, and contrast-enhanced MRA. Inflammatory vasculopathy (63.3%), plaque vulnerability assessments (61.1%), intraplaque hemorrhage (61.1%), and dissection-detection/characterization (51.1%) were the most frequent applications. For those not performing EC-VWI, the reasons were a lack of ordering provider interest (63.9%), lack of radiologist time/interest (47.5%) or technical support (41.4%) for protocol development, and limited interpretation experience (44.9%) and knowledge of clinical applications (43.7%). Reasons given by 46.9% were that no providers approached radiology with interest in EC-VWI. If barriers were overcome, 51.1% of those not performing EC-VWI indicated they would perform it, and 40.6% were unsure; 48.6% did not think that EC-VWI had impacted patient management at their institution.

CONCLUSIONS

Only 26% of neuroradiology groups performed EC-VWI, most commonly due to limited clinician interest. Improved provider and radiologist education, protocols, processing techniques, technical support, and validation trials could increase adoption.

Survey of the American Society of Neuroradiology Membership on the Use and Value of Intracranial Vessel Wall MRI

BACKGROUND AND PURPOSE

Intracranial vessel wall MR imaging is an emerging technique for intracranial vasculopathy assessment. Our aim was to investigate intracranial vessel wall MR imaging use by the American Society of Neuroradiology (ASNR) members at their home institutions, including indications and barriers to implementation.

MATERIALS AND METHODS

The ASNR Vessel Wall Imaging Study Group survey on vessel wall MR imaging use, frequency, applications, MR imaging systems and field strength used, protocol development approaches, vendor engagement, reasons for not using vessel wall MR imaging, ordering-provider interest, and impact on clinical care, was distributed to the ASNR membership between April 2 and August 30, 2019.

RESULTS

There were 532 responses; 79 were excluded due to nonresponse and 42 due to redundant institutional responses, leaving 411 responses. Fifty-two percent indicated that their institution performs vessel wall MR imaging, with 71.5% performed at least 1-2 times/month, most frequently on 3T MR imaging, and 87.7% using 3D sequences. Protocols most commonly included were T1-weighted pre- and postcontrast and TOF-MRA; 60.6% had limited contributions from vendors or were still in protocol development. Vasculopathy differentiation (94.4%), cryptogenic stroke (41.3%), aneurysm (38.0%), and atherosclerosis (37.6%) evaluation were the most common indications. For those not performing vessel wall MR imaging, interpretation (53.1%) or technical (46.4%) expertise, knowledge of applications (50.5%), or limitations of clinician (56.7%) or radiologist (49.0%) interest were the most common reasons. If technical/expertise obstacles were overcome, 56.4% of those not performing vessel wall MR imaging indicated that they would perform it. Ordering providers most frequently inquiring about vessel wall MR imaging were from stroke neurology (56.5%) and neurosurgery (25.1%), while 34.3% indicated that no providers had inquired.

CONCLUSIONS

More than 50% of neuroradiology groups use vessel wall MR imaging for intracranial vasculopathy characterization and differentiation, emphasizing the need for additional technical and educational support, especially as clinical vessel wall MR imaging implementation continues to grow.

Quality-adjusted time without symptoms or toxicities (Q-TWiST) analysis of ZUMA-7, a randomized controlled trial of axicabtagene ciloleucel versus standard of care for second-line large B-cell lymphoma

7555

Background: Quality of life (QoL) post cancer therapy is increasingly important. We conducted a Q-TWiST analysis to compare the quality-adjusted survival of axicabtagene ciloleucel (axi-cel, a chimeric antigen receptor T-cell therapy) versus standard of care (SOC) among relapsed/refractory (R/R) large B-cell lymphoma (LBCL) patients enrolled in ZUMA-7 (NCT03391466), a Phase 3, randomized, open-label, multicenter study. ZUMA-7 met its primary endpoint of event-free survival; events were defined as death, progression, or new lymphoma therapy. Methods: Overall survival (OS) in the intention-to-treat (ITT) cohort was partitioned into 3 mutually exclusive health states as measured through a median follow-up duration of 23.5 months (m): time with grade 3/4 adverse events (AE) before an event (TOX); time without symptoms from events or toxicity (TWiST); and time after event (REL). Q-TWiST was calculated as the average time spent in each state, weighted by state-specific QoL utility (u, ranging from 0 to 1), assuming a base case u(TOX)=0.5, u(REL)=0.5, u(TWiST)=1. Threshold analyses assessed the mean Q-TWiST differences between axi-cel and SOC by varying u(TOX) and u(REL) from 0 to 1. Relative gains for axi-cel (axi-cel Q-TWIST gain divided by mean SOC OS) ≥15% were considered “clearly clinically important” using published norms. Nonparametric bootstrap 95% confidence intervals (CI) were computed. Subgroup analyses were performed for relapse status and age. Sensitivity analyses varying the follow-up duration from 3 to 37.7m were explored. Results: For the ITT cohort (n=359), mean time spent in TOX and TWiST was significantly longer for the axi-cel cohort compared to SOC, and mean time spent in REL was significantly shorter for axi-cel (Table). Using the base case, quality-adjusted survival was significantly longer for axi-cel by 3.7m, representing a 21.9% relative gain. In threshold analyses, the difference in Q-TWiST ranged from 1.2m (u(TOX)=0, u(REL)=1) to 6.2m (u(TOX)=1, u(REL)=0) in favor of axi-cel. Q-TWiST gains favored axi-cel across all subgroup analyses. Q-TWiST gains from axi-cel increased with longer follow-up. Conclusions: Axi-cel was associated with statistically significant and “clearly clinically important” gains in quality-adjusted OS vs. SOC in R/R LBCL, regardless of the relative decline in QoL associated with treatment toxicity, disease progression, or additional cancer treatment.[Table: see text]

Treatment patterns and outcomes among patients with recurrent or advanced endometrial cancer in Europe: Endometrial Cancer Health Outcomes Europe (ECHO EU) Study

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Background: Until recently, recurrent or advanced endometrial cancer (aEC) patients in Europe had limited treatment options, with no consensus on standard of care in such settings. Approval of novel targeted therapies in 2021 are changing the treatment landscape. However, there is little real-world evidence among aEC patients in Europe. The objective of our study was to evaluate real-world treatment patterns and clinical outcomes in aEC patients who progressed following prior systemic therapy (FPST) in clinical practice in Europe. Methods: The ECHO-EU is a multicenter, retrospective chart review study in United Kingdom (UK), Germany (GE), Italy (IT) and Spain (SP). Adult women diagnosed with aEC who received at least one prior systemic therapy and progressed between July 1, 2016 – June 30, 2019, were included. De-identified patient data extracted by treating oncologists from patients’ medical records included patient demographics, clinical and treatment characteristics, and clinical outcomes. Kaplan-Meier analyses were performed to estimate real-world overall survival (OS). Results: A total of 379 (UK=101, GE=88, IT=100, SP=90) eligible aEC patients were included in the analysis. At aEC diagnosis, patients’ median age was 69 years, 97% were White/Caucasian and most prevalent histology was endometrioid carcinoma (58%). Molecular characterization of tumors including microsatellite instability/mismatch repair (MSI/MMR) status was performed in only 37% of patients. Metastases were observed in 56% of the patients at diagnosis. Median duration of follow up from aEC diagnosis was 24 months. The majority (95%) of patients initiated 1st line with chemotherapy (most commonly with platinum chemotherapy and paclitaxel). As 2nd line therapy, 81% received mono or combination chemotherapy, and 19% received hormonal therapy. Doxorubicin was the most frequently used agent (45%) in 2nd line, and 16% of patients were re-treated with platinum therapy. At last follow-up, the majority (90%) of patients discontinued 2nd line treatment, mostly due to disease progression (54%). Median duration of 2nd line therapy was 5 months (95% Confidence Interval [CI]: 4-5). Median OS from initiation of 2nd line therapy was 11 months (95% CI: 10-13). Estimated probability of OS from initiation of 2nd line therapy at 6, 12, and 24 months were 70%, 45%, and 30%, respectively. Conclusions: Our study finds thatin Europe prior to mid-2019, available treatment options were sub-optimal for aEC patients FPST, leading to poor prognosis. The utilization of MSI/MMR testing for molecular characterization of tumors was low and needs to increase. There was a significant unmet need for novel therapies that improve clinical outcomes in this patient population. Future studies evaluating treatment patterns and clinical outcomes with more recently approved treatments are warranted.

Clinical and Economic Burden of Out-of-Hospital Cardiac Arrest in US Commercial Insurance Population (2014 to 2019)

Little is known about the economic burden incurred by out-of-hospital cardiac arrest (OHCA) in the US commercial insurance setting. We used IBM MarketScan Commercial Claims and Encounters Database (January 2014 to March 2019) to identify patients hospitalized with OHCA based on the International Classification of Diseases codes. Patients who survived the initial OHCA episode were stratified by prognosis based on discharge setting and classified into mild (discharged home), moderate (skilled nursing facility), severe (inpatient rehabilitation or long-term hospital), and very severe (hospice) prognosis groups, respectively. Patients were followed up for 12 months after discharge for health care resource utilization and medical costs, which were inflated to year 2020. Overall, 23,512 patients with OHCA hospitalization were identified, of whom 14,667 were <65 years and 60.5% were men. The incidence of OHCA per 100,000 was steady in patients <65 years over the years (17.9 in 2014; 17.5 in 2018) but among those ≥65 years, decreased from 139.7 in 2014 to 111.1 in 2018. Total medical costs 12 months after discharge generally increased with severity of prognosis, with an average for the mild, moderate, and severe prognosis group, respectively, estimated to be $52,746, $100,394, and $130,530 among patients <65 years, and $63,194, $65,794, and $70,973 among those ≥65 years. Costs were lower for those with very severe prognosis ($7,102 for <65 years; $2,553 for ≥65 years), possibly due to high mortality. In conclusion, OHCA continues to pose a substantial clinical and economic burden on patients and the US health care system, which increases with the severity of disease prognosis.

Characterization of Restenosis following Carotid Endarterectomy Using Contrast-Enhanced Vessel Wall MR Imaging

BACKGROUND AND PURPOSE

Restenosis is an important determinant of the long-term efficacy of carotid endarterectomy. Our aim was to assess the role of high-resolution vessel wall MR imaging for characterizing restenosis after carotid endarterectomy.

MATERIALS AND METHODS

Patients who underwent vessel wall MR imaging after carotid endarterectomy were included in this study. Restenotic lesions were classified as myointimal hyperplasia or recurrent atherosclerotic plaques based on MR imaging features of lesion compositions. Imaging characteristics of myointimal hyperplasia were compared with those of normal post-carotid endarterectomy and recurrent plaque groups. Recurrent plaques were matched with primary plaques by categories of stenosis, and differences in plaque features were compared between the 2 groups.

RESULTS

Twenty-two recurrent lesions from 18 patients (14 unilateral and 4 bilateral) were classified as myointimal hyperplasia or recurrent plaque. Myointimal hyperplasia showed no difference in enhancement compared with normal post-carotid endarterectomy vessels (5 unilateral) but showed stronger enhancement than recurrent plaques (80.10% [SD, 42.42%] versus 56.74% [SD, 46.54%], P = .042). A multivariate logistic regression model of plaque-feature detection in recurrent plaques compared with primary plaques adjusted for maximum wall thickness revealed that recurrent plaques were longer (OR, 4.27; 95% CI, 1.32-13.85; P = .015) and more likely to involve a flow divider and side walls (OR, 6.96; 95% CI, 1.37-35.28; P = .019). Recurrent plaques had a higher prevalence of intraplaque hemorrhage (61.5% versus 30.8%, P = .048) by a χ² test, but compositional differences were not significant in the multivariate model.

CONCLUSIONS

Vessel wall MR imaging can distinguish recurrent plaques from myointimal hyperplasia and reveal features that may differ between primary and recurrent plaques, highlighting its value for evaluating patients with carotid restenosis.

Oral Microbiota Changes Contribute to Autism Spectrum Disorder in Mice

The oral microbiota has been implicated in various neurologic conditions, including autism spectrum disorder (ASD), a category of neurodevelopmental disorders defined by core behavioral impairments. Recent data propose the etiopathogenetic role of intestinal microbiota in ASD. The aim of the present study was to elucidate whether the oral microbiota contributes to the pathogenesis of ASD. On the basis of microbial changes detected in the oral cavity of children with ASD, we transferred oral microbiota from donors with ASD and typical development (TD) into an antibiotic-mediated microbiota-depleted mouse model and found that the ASD microbiota is sufficient to induce ASD-like behaviors, such as impaired social behavior. Mice receiving oral microbiota from the ASD donor showed significantly different microbiota structures in their oral cavity and intestinal tract as compared with those receiving TD microbiota and those not receiving any bacterium. The prefrontal cortex of ASD microbiota recipient mice displayed an alternative transcriptional profile with significant upregulation of serotonin-related gene expression, neuroactive ligand-receptor interaction, and TGF-β signaling pathway relative to that in TD microbiota recipient mice. The expression of serotonin-related genes was significantly increased in ASD microbiota recipient mice and was associated with selective autistic behaviors and changes in abundance of specific oral microbiota, including species of Bacteroidetes [G-7], Porphyromonas, and Tannerella. Machine learning based on the causal inference method confirmed a contributing role of Porphyromonas sp. HMT 930 in ASD. Taken together, the oral microbiota of children with ASD can lead to ASD-like behaviors, differences in microbial community structures, and altered neurosignaling activities in recipient mice; this highlights the mouth-microbial-brain connections in the development of neuropathology and provides a novel strategy to fully understand the etiologic mechanism of ASD.

[The impact of digoxin on the long-term outcomes in patients with coronary artery disease and atrial fibrillation]

Objective: To investigate the long-term safety of digoxin in patients with coronary artery disease (CAD) and atrial fibrillation (AF). Methods: This was a prospective study, in which 25 512 AF patients were enrolled from China Atrial Fibrillation Registry Study. After exclusion of patients receiving ablation therapy at the enrollment, 1 810 CAD patients [age: (71.5±9.3)years] with AF were included. The subjects were grouped into the digoxin group and non-digoxin group, and were followed up for a period of 80 months. Long-term outcomes were compared between the groups and an adjusted Cox regression analysis was applied to evaluate the risk of digoxin on the long-term outcomes. The primary endpoint was all-cause mortality. Results: The patients were followed up for a median period of 3.05 years. After multivariable adjustment, the Cox regression analysis showed that digoxin significantly increased the risk of all-cause mortality (HR=1.28, 95%CI 1.01-1.61, P=0.038), cardiovascular mortality (HR=1.48,95%CI 1.10-2.00,P=0.010), cardiovascular hospitalization (HR=1.67,95%CI 1.35-2.07,P=0.008) and the composite endpoints (HR=2.02,95%CI 1.71-2.38,P<0.001). In the subgroup of patients with heart failure (HF), digoxin was not associated with the risk of all-cause mortality, but was still associated with the increased risk of cardiovascular mortality (HR=1.44,95%CI 1.05-1.98,P=0.025), cardiovascular hospitalization (HR=1.44,95%CI 1.09-1.90,P=0.010) and the composite endpoints (HR=1.37, 95%CI 1.01-1.70, P=0.004). However, in the subgroup of patients without HF, digoxin was only associated with all-cause mortality (HR=2.56,95%CI 1.44-4.54,P=0.001). Conclusion: Digoxin significantly increased the risk of all-cause mortality in CAD patients with AF, especially in patients without HF.

P–389 The relationship between serum hormone profiles and missed abortion in humans

Study question

Are circulating profiles of metabolic-related hormones also associated with the missed abortion (MA) in humans?

Summary answer

Serum levels of fatty acid-binding protein–4 (FABP4) and fibroblast growth factor 21 (FGF21) are positively associated with MA.

What is known already

A cluster of endocrine hormones, including FABP4, FGF21, adiponectin, lipocalin–2 (LCN2), exhibit pleiotropic effects on regulating systematic metabolism. Serum levels of them are associated with gestational obesity and diabetes and affect pregnancy outcomes, however, the relationship between their circulating profiles and MA is under-investigated.

Study design, size, duration

78 patients with MA and 86 healthy pregnant subjects matching on maternal age and body mass index (BMI) were nested from a prospective cohort in the Chinese population.

Participants/materials, setting, methods

Fasting serum samples from all participants were collected to test their serum levels of FGF21, FABP4, adiponectin, and LCN2 by enzyme-linked immunosorbent assay method (ELISA).

Main results and the role of chance

There were no significant differences in circulating profiles of adiponectin and LCN2 between MA patients and healthy pregnant subjects. By contrast, circulating levels of FGF21 and FABP4 were significantly and independently elevated in patients with MA relative to control cases even after adjusting confounding factors (for FGF21: MA: 28.96 ± 2.17 ng/ml; HP: 19.18 ± 1.12 ng/ml, P &lt; 0.001, for FABP4: MA: 152.50 ± 9.31 pg/ml; HP: 90.86 ± 4.14 pg/ml, P &lt; 0.001). Linear regression analysis showed, FGF21 raised every 10 pg/ml contributed to a 24% (95% CI: 15% - 34%) increase in the risk of MA, whereas the OR of FABP4 for the risk of MA was 1.052 (95% CI: 1.022 –1.088). Furthermore, using serum FGF21 level or FABP4 levels discriminated MA from healthy controls with an area under the operating characteristic’s curve (AUROC) of 0.81 (95% CI 0.76–0.92) and 0.70 (95% CI 0.62 - 0.78), respectively.

Limitations, reasons for caution

The study is limited by the sample size. In addition, our results were based-on Chinese population, whether it could be observed in other ethics group remain to be investigated. Meanwhile, the cause-effect relationship between increased serum FGF21 level and MA remains to be explored.

Wider implications of the findings: Our data would suggest that serum levels of FGF21 and FABP4 are associated with MA. Moreover, circulating FGF21 levels may serve as a potential diagnostic biomarker for the recognition of M.

Trial registration number

IRB Ref. No.: KY201913

Mutations in chronic myelomonocytic leukemia and their prognostic relevance

Chronic myelomonocytic leukemia (CMML) is a hematologic malignancy that overlaps with myeloproliferative neoplasms (MPN) and myelodysplastic syndromes (MDS) and tends to transform into acute myeloid leukemia (AML). Among cases of CMML, > 90% have gene mutations, primarily involving TET2 (~ 60%), ASXL1 (~ 40%), SRSF2 (~ 50%), and the RAS pathways (~ 30%). These gene mutations are associated with both the clinical phenotypes and the prognosis of CMML, special CMML variants and pre-phases of CMML. Cytogenetic abnormalities and the size of genome are also associated with prognosis. Meanwhile, cases with ASXL1, DNMT3A, NRAS, SETBP1, CBL and RUNX1 mutations may have inferior prognoses, but only ASXL1 mutations were confirmed to be independent predictors of the patient outcome and were included in three prognostic models. Novel treatment targets related to the various gene mutations are emerging. Therefore, this review provides new insights to explore the correlations among gene mutations, clinical phenotypes, prognosis, and novel drugs in CMML.

Improving the productivity of Candida glycerinogenes in the fermentation of ethanol from non-detoxified sugarcane bagasse hydrolysate by a hexose transporter mutant

AIMS

In this study, we attempted to increase the productivity of Candida glycerinogenes yeast for ethanol production from non-detoxified sugarcane bagasse hydrolysates (NDSBH) by identifying the hexose transporter in this yeast that makes a high contribution to glucose consumption, and by adding additional copies of this transporter and enhancing its membrane localisation stability (MLS).

METHODS AND RESULTS

Based on the knockout and overexpression of key hexose transporter genes and the characterisation of their promoter properties, we found that Cghxt4 and Cghxt6 play major roles in the early and late stages of fermentation, respectively, with Cghxt4 contributing most to glucose consumption. Next, subcellular localisation analysis revealed that a common mutation of two ubiquitination sites (K9 and K538) in Cghxt4 improved its MLS. Finally, we overexpressed this Cghxt4 mutant (Cghxt4.2A) using a strong promoter, P_CgGAP , which resulted in a significant increase in the ethanol productivity of C. glycerinogenes in the NDSBH medium. Specifically, the recombinant strain showed 18 and 25% higher ethanol productivity than the control in two kinds of YP-NDSBH medium (YP-NDSBH1_G160 and YP-NDSBH2_G160 ), respectively.

CONCLUSIONS

The hexose transporter mutant Cghxt4.2A (Cghxt4^K9A,K538A ) with multiple copies and high MLS was able to significantly increase the ethanol productivity of C. glycerinogenes in NDSBH.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our results provide a promising strategy for constructing efficient strains for ethanol production.

Preterm disparities between foreign and Swedish born mothers depend on the method used to estimate gestational age. A Swedish population-based register study

This study aims to examine whether disparities in gestational age outcomes between foreign and Swedish-born mothers are contingent on the measure used to estimate gestational age and, if so, to identify which maternal factors are associated with the discrepancy. Using population register data, we studied all singleton live births in Sweden from 1992–2012 (n = 1,317,265). Multinomial logistic regression was performed to compare gestational age outcomes classified into very (<32 weeks) and late preterm (32–36 weeks), term and post-term derived from the last menstrual period (LMP) and ultrasound estimates in foreign- and Swedish-born women. Compared to Swedish-born women, foreign-born women had similar odds of very preterm birth (OR: 0.98 [95% CI: 0.98, 1.01]) and lower odds of moderately preterm birth (OR: 0.95 [95% CI: 0.92, 0.98]) based on ultrasound, while higher risks based on LMP (respectively, OR: 1.10 [95% CI: 1.07, 1.14] and 1.09 [95% CI: 1.06, 1.13]). Conclusions on disparities in gestational age-related outcomes by mother’s country of origin depend on the method used to estimate gestational age. Except for very preterm, foreign-born women had a health advantage when gestational age is based on ultrasound, but a health disadvantage when based on LMP. Studies assessing disparities in very preterm birth by migration status are not affected by the estimation method but caution should be taken when interpreting disparities in moderately preterm and preterm birth rates.

Incidence and associated predictors of adverse pregnancy outcomes of maternal syphilis in China, 2016-19: a Cox regression analysis

OBJECTIVE

This study aimed to investigate the incidence and associated predictors of adverse pregnancy outcomes (APOs) among pregnant women infected with syphilis.

DESIGN

Cox regression analysis.

SETTING

China.

POPULATION OR SAMPLE

Pregnant women who were tested for and diagnosed with syphilis during the index pregnancy and delivered at a gestational age ≥28 weeks between 2016 and 2019.

METHODS

Data were extracted from China's Information System of Prevention of Mother-to-Child Transmission of Syphilis Management. Descriptive analysis provided profiles and pregnancy outcomes of maternal syphilis, as well as the incidence of APOs. Log-rank tests and Cox proportional hazard models were used to investigate factors influencing APOs in infected mothers with singleton births.

MAIN OUTCOME MEASURES

The incidence of APOs and the hazard ratios of associated predictors using Cox proportional hazard model.

RESULTS

Syphilis treatment data were available from 83.86% of diagnosed women. Including deliveries from the total study population, 13.33% experienced APOs. Cox regression indicated that APOs were more likely in women tested and diagnosed in the late trimester, at delivery or postpartum. Women who accepted non-standardised treatment and who received standardised treatment had less risk of APOs.

CONCLUSIONS

China has made huge progress over the last decades in the prevention of mother-to-child transmission of syphilis, but the incidence of APOs among pregnant women infected with syphilis remains high. It is essential to further strengthen access to early detection and standardised treatment of infected women to reduce the risk of APOs.

TWEETABLE ABSTRACT

Access to early detection and standardised treatment reduces the risk of APOs due to maternal syphilis.

Association of Albuminuria Levels With the Prescription of Renin-Angiotensin System Blockade

Multiple clinical guidelines recommend an ACE (angiotensin-converting enzyme) inhibitor or angiotensin II receptor blocker (ARB) in patients with elevated albuminuria, which can be measured through urine albumin-to-creatinine ratio (ACR), protein-to-creatinine ratio, or dipstick. However, how albuminuria test results relate to the prescription of ACE inhibitor/ARB is uncertain. We identified individuals with an ACR measurement between January 1, 2004, and June 30, 2018, and no contraindications or allergy to ACE inhibitor/ARB. We performed multivariable logistic regression analyses to evaluate the association between ACR level and prescription of ACE inhibitor/ARB within 6 months after the test. We applied similar methods to investigate the association of protein-to-creatinine ratio and dipstick measurement results with the prescription of ACE inhibitor/ARB. Among 67 237 individuals with an ACR measurement, 47.7% were already taking an ACE inhibitor or ARB at the time of first ACR measurement. Among the 35 138 individuals who were not on ACE inhibitor/ARB, those with higher ACR levels were more likely to be prescribed ACE inhibitor/ARB in the following 6 months, with steep increases in prescriptions until ACR 300 mg/g, after which the association plateaued. The majority (80.9%) of ACE inhibitor/ARB prescriptions were made by family medicine and internal medicine. A similar pattern held in the cohorts tested by protein-to-creatinine ratio and dipstick measurement. Our study provides evidence that albuminuria test results change patient care, suggesting that adherence to albuminuria testing is a key step in optimal medical management.

Hyperkalemia and Acute Kidney Injury with Spironolactone Use Among Patients with Heart Failure

OBJECTIVE

To quantify the risk of hyperkalemia and acute kidney injury (AKI) when spironolactone use is added on to loop diuretic use among patients with heart failure, and to evaluate whether the risk is modified by level of kidney function.

METHODS

We identified 17,110 patients with heart failure treated with loop diuretics between January 1, 2004, and December 31, 2016 within the Geisinger Health System. We estimated the incidence of hyperkalemia and AKI associated with spironolactone initiation, and used target trial emulation methods to minimize confounding by indication.

RESULTS

During a mean follow-up of 134 mo, 3229 of 17,110 patients (18.9%) initiated spironolactone. Incidence rates of hyperkalemia and AKI in patients using spironolactone with a loop diuretic were 2.9 and 10.1 events per 1000 person-months, respectively. In propensity score-matched analyses, spironolactone initiation was associated with higher hyperkalemia and AKI risk compared with loop alone (hazard ratio, 1.69; 95% CI, 1.35 to 2.10; P<.001, and hazard ratio, 1.12; 95% CI, 1.00 to 1.26; P=.04, respectively). There were no differences in the relative risk of either outcome associated with spironolactone by level of kidney function.

CONCLUSION

The addition of spironolactone to loop diuretics in patients with heart failure was associated with higher risk of hyperkalemia and AKI; these risks must be weighed against the potential benefits of spironolactone.

[Establishment and primary clinical application of metabolic evaluation database of urolithiasis]

Objective: To establish the metabolic evaluation database of urolithiasis, perform metabolic evaluation, and provide instructions for treatment and prevention of urolithiasis. Methods: This metabolic evaluation database was developed by JAVA and was established by Oracle11g database and Browser/Server framework. We extracted the clinical data of all patients who had complete information, and analyzed their risk factors of stone formation, stone-related medical history, blood and urine tests results and 24-hour urine analysis. Results: A total of 360 patients diagnosed as urolithiasis were included in this research. Male to female ratio was 1.9∶1, and the urolithiasis was first diagnosed at (35.5±13.5) years old. Family history was positive in 39.7% of patients. Metabolic syndrome occurred in 35.0% of patients. Overweight or obesity occurred in 73.2% and 50.0% of male patients, respectively. Abdominal obesity in 62.3% and 56.1% of male and female patients, respectively. Among all patients, 67.5% had high urine sodium, 53.6% had hypercalciuria, 41.1% had hypocitraturia, 29.7% had hyperuricosuria, 22.5% had hypomagnesuria, 15.8% had hyperoxaluria, 11.7% had hyperphosphoraturia, and 36.4% had low urinary volume. Conclusions: The prevalence of overweight or obesity, abdominal obesity, hypertension, diabetes, and metabolic syndrome in stone patients were significantly higher than those in general population. The number of 24-hour urinary abnormalities was positively associated with body mass index. The interventions on high urinary sodium, low urinary volume, obesity and metabolic syndrome were important to the treatment of urolithiasis. This database would facilitate the metabolic evaluation, provide evidence for the treatment and prevention of urolithiasis, and lay foundation for finding important controllable risk factors of urinary stone.

Altered resting-state functional connectivity between subregions in the thalamus and cortex in migraine without aura

BACKGROUND AND PURPOSE

Migraine is a complex and disabling neurological disorder, the exact neurological mechanisms of which remain unclear. The thalamus is considered to be the hub of the central processing and integration of nociceptive information, as well as the modulation of these processes.

METHODS

A total of 48 migraineurs without aura (MWoAs) during the interictal phase and 48 age- and sex-matched healthy controls underwent resting-state functional magnetic resonance imaging scans. We utilized masked independent component analysis and seed-based functional connectivity (FC) to investigate whether MWoAs exhibited abnormal FC between subregions in the thalamus and the cortex regions.

RESULTS

The MWoAs showed significantly weaker FC between the anterior dorsal thalamic nucleus and left precuneus. Additionally, MWoAs exhibited significantly reduced FC between the ventral posterior nucleus (VPN) and left precuneus, right inferior parietal lobule (R-IPL) and right middle frontal gyrus. Furthermore, the FC Z-scores between the VPN and R-IPL were negatively correlated with pain intensity in MWoAs. The disease duration of patients was negatively correlated with the FC Z-scores between the VPN and R-IPL.

CONCLUSION

These altered thalamocortical connectivity patterns may contribute to multisensory integration abnormalities, deficits in pain attention, cognitive evaluation and pain modulation. Pain sensitivity and disease duration are closely tied to abnormal FC between the VPN and R-IPL. Remarkably, recurrent headache attacks might contribute to this maladaptive functional plasticity closely related to pain intensity.

P0771STOPPING MINERALOCORTICOID RECEPTOR ANTAGONISTS AFTER HYPERKALEMIA AND RISK OF ADVERSE OUTCOMES IN PATIENTS WITH HEART FAILURE

Background and Aims

Stopping mineralocorticoid receptor antagonists (MRAs) after an episode of hyperkalemia is common, particularly among patients with chronic kidney disease (CKD). This may involve therapeutic compromises, in that the cessation of MRAs deprives patients of their beneficial cardiovascular effects. The aim of this study is to determine the risks of adverse health outcomes in heart failure patients after an episode of hyperkalemia, comparing users of MRA who stop treatment to those who continue the drugs.

Method

Observational study from the Stockholm Creatinine Measurements (SCREAM) project. We identified patients with heart failure patients initiating MRAs and surviving a first-detected episode of hyperkalemia (plasma potassium &gt;5.0 mmol/L). We used Cox regression, adjusting for multiple confounders, to estimate hazard ratios (HR) for adverse events following hyperkalemia. The primary outcome was the composite of hospital admission with heart failure, stroke, myocardial infarction or death. The secondary outcome was a new hyperkalemia event. We compared risks between people who stopped MRA treatment and those who continued MRA within 4 months from the hyperkalemia event (landmark analysis at month 4 after event).

Results

We identified 1,330 patients with heart failure that developed hyperkalemia after initiating MRA therapy. Their median age was 80 years, 46% were women and their median eGFR was 43 ml/min/1.73m2. Of those, 595 (45%) had discontinued MRA by 4 months after hyperkalemia. Patients who stopped MRA were more likely to have eGFR &lt;60 ml/min/1.73m2 (81% vs 71%), had a more severe index hyperkalemia (potassium&gt;5.5 mmol/L, 35% vs 21%), and had hyperkalemia occur earlier in the course of MRA therapy (within 3 months from MRA initiation, 66% vs 51%).

During median 1.5 years of follow-up, a total of 846 patients (64%) experienced the primary composite outcome. Compared to patients who discontinued MRA, those who continued had a similar risk of the primary composite outcome (HR 0.95, 95% CI 0.82-1.10). A total of 569 patients (43%) developed a subsequent hyperkalemia event. Compared to patients who discontinued MRA, those who continued with the therapy were at higher risk of another hyperkalemia (HR 1.46, 95% CI 1.21-1.75). Results were consistent across age strata, sex and presence of CKD.

Conclusion

Continuing treatment with MRA after an episode of hyperkalemia was not associated with different medium-term cardiovascular risk compared to those who stopped the drugs.

Association Between Renin-Angiotensin System Blockade Discontinuation and All-Cause Mortality Among Persons With Low Estimated Glomerular Filtration Rate

IMPORTANCE

It is uncertain whether and when angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin II receptor blocker (ARB) treatment should be discontinued in individuals with low estimated glomerular filtration rate (eGFR).

OBJECTIVE

To investigate the association of ACE-I or ARB therapy discontinuation after eGFR decreases to below 30 mL/min/1.73 m2 with the risk of mortality, major adverse cardiovascular events (MACE), and end-stage kidney disease (ESKD).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, propensity score-matched cohort study included 3909 patients from an integrated health care system that served rural areas of central and northeastern Pennsylvania. Patients who initiated ACE-I or ARB therapy from January 1, 2004, to December 31, 2018, and had an eGFR decrease to below 30 mL/min/1.73 m2 during therapy were enrolled, with follow-up until January 25, 2019.

EXPOSURES

Individuals were classified based on whether they discontinued ACE-I or ARB therapy within 6 months after an eGFR decrease to below 30 mL/min/1.73 m2.

MAIN OUTCOMES AND MEASURES

The association between ACE-I or ARB therapy discontinuation and mortality during the subsequent 5 years was assessed using multivariable Cox proportional hazards regression models, adjusting for patient characteristics at the time of the eGFR decrease in a propensity score-matched sample. Secondary outcomes included MACE and ESKD.

RESULTS

Of the 3909 individuals receiving ACE-I or ARB treatment who experienced an eGFR decrease to below 30 mL/min/1.73 m2 (2406 [61.6%] female; mean [SD] age, 73.7 [12.6] years), 1235 discontinued ACE-I or ARB therapy within 6 months after the eGFR decrease and 2674 did not discontinue therapy. A total of 434 patients (35.1%) who discontinued ACE-I or ARB therapy and 786 (29.4%) who did not discontinue therapy died during a median follow-up of 2.9 years (interquartile range, 1.3-5.0 years). In the propensity score-matched sample of 2410 individuals, ACE-I or ARB therapy discontinuation was associated with a higher risk of mortality (hazard ratio [HR], 1.39; 95% CI, 1.20-1.60]) and MACE (HR, 1.37; 95% CI, 1.20-1.56), but no statistically significant difference in the risk of ESKD was found (HR, 1.19; 95% CI, 0.86-1.65).

CONCLUSIONS AND RELEVANCE

The findings suggest that continuing ACE-I or ARB therapy in patients with declining kidney function may be associated with cardiovascular benefit without excessive harm of ESKD.

Long noncoding RNA ABHD11-AS1 predicts the prognosis of pancreatic cancer patients and serves as a promoter by activating the PI3K-AKT pathway

OBJECTIVE

Accumulating evidence showed aberrant expressions of long non-coding RNAs (lncRNAs) strongly correlated to the development of cancers, including pancreatic cancer (PC). Whether lncRNA ABHD11-AS1 (ABHD11-AS1) is involved in PC remains to be elucidated. Thus, we aimed to evaluate the effects of ABHD11-AS1 on PC and the underlying molecular mechanism.

PATIENTS AND METHODS

RT-PCR was used to detect the expression level of ABHD11-AS1 in both PC tissue and cell lines. Then, the correlation of ABHD11-AS1 expression with clinicopathological features and prognosis was studied. Cell proliferation, apoptosis, migration and invasion abilities were detected by MTT, flow cytometry, and transwell assays. We further investigated the effect of abnormal ABHD11-AS1 expression through the PI3K/AKT and EMT pathway by Western blot assays in treated PC cells.

RESULTS

We found that the expression of ABHD11-AS1 was significantly increased in both PC tissues and cell lines. The clinical analysis revealed that a high level of ABHD11-AS1 expression was correlated with distant metastasis, TNM stage, and tumor differentiation. The Kaplan-Meier analysis showed that high ABHD11-AS1 expression levels predicted poorer survival. Moreover, univariate and multivariate analyses confirmed that the expression of ABHD11-AS1 was an independent and significant factor associated with poor overall survival rates. Loss-of-function experiments showed that the knockdown of ABHD11-AS1 suppressed PC cell proliferation, migration, invasion, and EMT in vitro. Mechanistically, the knockdown of ABHD11-AS1 decreased phospho(p) AKT and phospho(p) PI3K expression, but did not affect the AKT and PI3K expression in PC cells CONCLUSIONS: This study suggested that ABHD11-AS1 may potentially function as a valuable prognostic biomarker and a therapeutic target for PC patients.

Are population-based patient-reported outcomes associated with overall survival in patients with advanced pancreatic cancer?

BACKGROUND

Advanced pancreatic cancer (APC) patients often have substantial symptom burden. In Ontario, patients routinely complete the Edmonton Symptom Assessment Scale (ESAS), which screens for nine symptoms (scale: 0-10), in cancer clinics. We explored the association between baseline patient-reported outcomes, via ESAS, and overall survival (OS).

METHODS

Advanced pancreatic cancer patients with ESAS records prior to receiving publicly funded drugs from November 2008 to March 2016 were retrospectively identified from Cancer Care Ontario's administrative databases. We examined three composite ESAS scores: total symptom distress score (TSDS: 9 symptoms), physical symptom score (PHS: 6/9 symptoms), and psychological symptom score (PSS: 2/9 symptoms); Composite scores greater than defined thresholds (TSDS ≥36, PHS ≥24, PSS ≥8) were considered as high symptom burden. Crude OS was assessed using Kaplan-Meier method. Hazard ratios (HRs) were assessed using multivariable Cox models. Analysis was repeated in a sub-cohort with Eastern Cooperative Oncology Group (ECOG) status and metastasis.

RESULTS

We identified 2199 APC patients (mean age 64 years, 55% male) with ESAS records prior to receiving chemotherapy. Crude median survival was 4.5 and 7.3 months for high and low TSDS, respectively. High TSDS was associated with lower OS (HR = 1.47, 95% CI: 1.33, 1.63). In the sub-cohort (n = 393) with ECOG status and metastasis, high TSDS was also associated with lower OS (HR = 1.34, 95% CI: 1.04, 1.73). Similar trends were observed for PHS and PSS.

CONCLUSIONS

Higher burden of patient-reported outcome was associated with reduced OS among APC patients. The effect was prominent after adjusting for ECOG status.

A genome-wide DNA methylation signature for SETD1B-related syndrome

SETD1B is a component of a histone methyltransferase complex that specifically methylates Lys-4 of histone H3 (H3K4) and is responsible for the epigenetic control of chromatin structure and gene expression. De novo microdeletions encompassing this gene as well as de novo missense mutations were previously linked to syndromic intellectual disability (ID). Here, we identify a specific hypermethylation signature associated with loss of function mutations in the SETD1B gene which may be used as an epigenetic marker supporting the diagnosis of syndromic SETD1B-related diseases. We demonstrate the clinical utility of this unique epi-signature by reclassifying previously identified SETD1B VUS (variant of uncertain significance) in two patients.

Discontinuation of Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Chronic Kidney Disease

OBJECTIVE

To assess the patterns of angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACE-I/ARB) discontinuation in the setting of chronic kidney disease (CKD) progression in real-world clinical practice.

PATIENTS AND METHODS

We identified incident ACE-I/ARB users with a baseline estimated glomerular filtration rate (eGFR) ≥15 mL/min/1.73 m2 and without end-stage renal disease in the Geisinger Health System between January 1, 2004, and December 31, 2015. We investigated the associations of CKD stage, hospitalizations with and without acute kidney injury (AKI), serum potassium, bicarbonate level, thiazide, and loop diuretic use with ACE-I/ARB discontinuation.

RESULTS

Among the 53,912 ACE-I/ARB users, the mean age was 59.9 years, and 50.6% were female. More than half of users discontinued ACE-I/ARB within 5 years of therapy initiation. The risk of ACE-I/ARB discontinuation increased with more advanced CKD stage. For example, patients who initiated ACE-I/ARB with CKD stage G4 (eGFR: 15-29 mL/min/1.73 m2) were 2.09-fold (95% CI, 1.87-2.34) more likely to discontinue therapy than those with eGFR ≥ 90 mL/min/1.73 m2. Potassium level greater than 5.3 mEq/L, systolic blood pressure ≤ 90 mm Hg, bicarbonate level < 22 mmol/L, and intervening hospitalization-particularly AKI-related-were also strong risk factors for ACE-I/ARB discontinuation. Thiazide diuretic use was associated with lower risk, whereas loop diuretic use was associated with higher risk of discontinuation.

CONCLUSION

In a real-world cohort, discontinuation of ACE-I/ARB was common, particularly in patients with lower eGFR. Hyperkalemia, hypotension, low bicarbonate level, and hospitalization (AKI-related, in particular) were associated with a higher risk of ACE-I/ARB discontinuation. Additional studies are needed to evaluate the risk-benefit balance of discontinuing ACE-I/ARB in the setting of CKD progression.