Cedirogant in adults with psoriasis: a phase 2, randomized, placebo-controlled clinical trial

BACKGROUND

Dysregulated interleukin (IL)-17/IL-23 signaling contributes to psoriasis pathogenesis. Cedirogant is an inverse agonist of retinoic acid-related orphan receptor gamma thymus (RORγt), a key transcription factor responsible for IL-17 synthesis and a regulator of the T helper 17 cell lineage program.

OBJECTIVE

To evaluate the efficacy and safety of cedirogant to treat moderate-to-severe psoriasis.

METHODS

In this phase 2b, multicenter, double-blind, 16-week study (NCT05044234), adults aged 18-65 years were randomized 1:1:1:1 to once-daily oral cedirogant 75 mg, 150 mg, 375 mg, or placebo. Assessments included ≥50%/75%/90%/100% improvement from baseline in Psoriasis Area and Severity Index (PASI 50/75/90/100), static Physician Global Assessment 0/1, Psoriasis Symptoms Scale 0, and improvements in itch, adverse events (AEs), pharmacokinetics, and IL-17A/F levels. Efficacy results based on observed cases were summarized descriptively.

RESULTS

Of 156 enrolled patients, most were male (70.5%); 39 patients were randomized to each treatment. Only 47 patients completed the study; the study was terminated early due to preclinical findings. At week 16, PASI 75 achievement rates (primary endpoint) were 28.6%, 7.7%, and 41.7% in the cedirogant 75 mg, 150 mg, and 375 mg groups, respectively, and 0% in the placebo group. AE rates were similar in the cedirogant 75 mg, 150 mg, and placebo groups and higher in the cedirogant 375-mg group; most AEs were mild or moderate.

CONCLUSIONS

Patients with psoriasis who received cedirogant showed PASI improvement and cedirogant was generally well tolerated. Results should be interpreted in the context of early study termination. Cedirogant development has been discontinued.

Erector spinae plane block did not improve postoperative pain-related outcomes and recovery after video-assisted thoracoscopic surgery : a randomised controlled double-blinded multi-center trial

INTRODUCTION

There is a sizable niche for a minimally invasive analgesic technique that could facilitate ambulatory video-assisted thoracoscopic surgery (VATS). Our study aimed to determine the analgesic potential of a single-shot erector spinae plane (ESP) block for VATS. The primary objective was the total hydromorphone consumption with patient-controlled analgesia (PCA) 24 h after surgery.

METHODS

We conducted a randomized, controlled, double-blind study with patients scheduled for VATS in two major university-affiliated hospital centres. We randomized 52 patients into two groups: a single-shot ESP block using bupivacaine or an ESP block with normal saline (control). We administered a preoperative and postoperative (24 h) quality of recovery (QoR-15) questionnaire and assessed postoperative pain using a verbal numerical rating scale (VNRS) score. We evaluated the total standardized intraoperative fentanyl administration, total postoperative hydromorphone consumption (PCA; primary endpoint), and the incidence of adverse effects.

RESULTS

There was no difference in the primary objective, hydromorphone consumption at 24 h (7.6 (4.4) mg for the Bupivacaine group versus 8.1 (4.2) mg for the Control group). Secondary objectives and incidence of adverse events were not different between the two groups at any time during the first 24 h following surgery.

CONCLUSION

Our multi-centre randomized, controlled, double-blinded study found no advantage of an ESP block over placebo for VATS for opioid consumption, pain, or QoR-15 scores. Further studies are ongoing to establish the benefits of using a denser block (single-shot paravertebral with a continuous ESP block), which may provide a better quality of analgesia.

Transitioning through the vapour-liquid equilibrium for low energy thermal stripping of ammonia from wastewater: Enabling transformation of NH3 into a zero-carbon fuel

Vacuum thermal stripping permits the recovery of ammonia from wastewater in a concentrated form, which is key to its exploitation in the circular economy, but the latent heat demand for thermal separation remains a critical barrier to exploitation. In this study, we investigate the vapor-liquid equilibrium (VLE) for ammonia-water as a mechanism to enhance recovered ammonia quality and minimise the thermal energy required for ammonia separation. Below the dew point (65 °C at 0.25 bar) a two-phase region of the VLE exists where 48 %wt gas-phase ammonia could be produced (61 °C) compared to only 2 %wt within the stripping region adopted widely in the literature. This was complemented by a 98 % reduction in thermal separation energy, since limited water vaporization can occur when the feed is maintained below the activation energy threshold for bulk evaporation. Operation within this practically unexplored region of the ammonia-water VLE fosters a gas-phase product suitable for energy generation in gas turbines or solid oxide fuel cells. Comparable product quality was achieved using concentrated wastewater, which validated the VLE for design in the presence of a broad range of dissolved gases and volatile inorganic compounds. Rapid desorption of CO2 occurred during vacuum stripping, subsequently increasing pH >9 without the requirement for alkali addition to shift the ammonia-ammonium equilibrium in favor of gaseous ammonia. Consequently, the two-phase region of the VLE defined for vacuum thermal stripping provides a synergistic strategy to mitigate chemical demand, minimise separation energy and recover gas-phase ammonia for zero carbon energy generation, constituting a significant advancement toward the net zero ambitions of the water sector.

Trifarotene Reduces Risk for Atrophic Acne Scars: Results from A Phase 4 Controlled Study

BACKGROUND

Atrophic acne scarring often accompanies acne vulgaris. The efficacy of topical retinoids for treatment of acne is well documented; however, evidence for use in atrophic acne scars is limited.

METHODS

In this randomized, split-face, double-blind study, subjects (age: 17-34 years, N = 121) with moderate-to-severe facial acne, with acne scars present, were treated with either trifarotene 50 μg/g or vehicle once daily for 24 weeks. Efficacy was assessed by absolute and percent change from baseline in atrophic acne scar counts, Scar Global assessment (SGA), and IGA success rates as well as acne lesion counts.

RESULTS

At week 24, a statistically significantly greater reduction in the mean absolute change from baseline in the total atrophic scar count was noted in the trifarotene- vs vehicle-treated area (- 5.9 vs - 2.7; p < 0.0001) with differences between sides noted as early as week 2 (- 1.5 vs - 0.7; p = 0.0072). The SGA success rate was higher in the trifarotene side at week 12 (14.9% vs 5.0%, P < 0.05) and improved through week 24 (31.3% vs 8.1%, P < 0.001). Similarly, at week 24, the IGA success rate was higher with trifarotene (63.6% vs 31.3%, P < 0.0001) along with reductions in total (70% vs 45%) and inflammatory (76% vs 48%) lesion counts. The incidence of treatment-emergent adverse events was 5.8% (trifarotene) and 2.5% (vehicle); most common (> 1%) was skin tightness (1.7% vs 0.8%), and all events were mild to moderate in severity.

CONCLUSIONS

Trifarotene was effective and well tolerated in treating moderate-to-severe facial acne and reducing atrophic acne scars, with reduction of total atrophic scar count as early as week 2.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04856904.

Diagnosing the origin and impact of low-mode asymmetries in ignition experiments at the National Ignition Facility

Inertial confinement fusion ignition requires high inflight shell velocity, good energy coupling between the hotspot and shell, and high areal density at peak compression. Three-dimensional asymmetries caused by imperfections in the drive symmetry or target can grow and damage the coupling and confinement. Recent high-yield experiments have shown that low-mode asymmetries are a key degradation mechanism and contribute to variability. We show the experimental signatures and impacts of asymmetry change with increasing implosion yield given the same initial cause. This letter has implications for improving robustness to a key degradation in ignition experiments.

Pre-Brachytherapy Diffusion-Weighted Magnetic Resonance Imaging (DW-MRI) Response as Predictor of Local Control in the Definitive Treatment of Cervical Cancer

PURPOSE/OBJECTIVE(S)

Chemoradiation consisting of external beam radiotherapy (EBRT) followed by brachytherapy (BT) is the standard of care for Stage IB2-IVA cervical cancer (CC). Multi-parametric MRI (mpMRI) is a valuable tool for initial staging, treatment planning and response assessment. In this study, we aim to explore the potential of mpMRI, in particular DW-MRI, to predict overall tumor control following chemoradiation in CC.

MATERIALS/METHODS

We identified 78 consecutive patients treated with chemoradiation for FIGO IB2-IVA CC between 2012-2020, who had an MRI at baseline (MRb) and post-EBRT prior to brachytherapy boost (MRpb) that included DW-MRI (b-value = 0 and 800 s/mm2). Median age was 53 years, most patients had squamous cell carcinoma (76.9%) and advanced-stage disease (56.4% stage IIIA-IVA). Median time from completion of EBRT to MRpb was 3 days. Regions of interest (ROI) in primary tumor were delineated on DW image (b = 0 s/mm2) using ITK-SNAP software. DW-MRI data were fitted to a monoexponential model to calculate apparent diffusion coefficient (ADC) values using in-house software platform (MRI-QAMPER). MRpb mean ADC values (n = 78) and relative changes (%) in mean ADC values between MRb and MRpb (n = 64) were correlated with outcomes, including local failure (LF), regional or distant failure (RDF), and failure at any site (FAS), with death without failure as a competing risk. Median follow-up time was 45 months (95% CI 38, 53).

RESULTS

At first post treatment assessment, 72 patients (92.3%) had a complete response (CR) in the cervix and 68 patients (87.2%) had CR in all disease sites. Of patients who had CR in the cervix (n = 72), only 1 patient had local recurrence. Of patients who had CR in all disease sites, 10 later recurred (1 LF only, 1 LF&RDF, 8 RDF only). Overall, 7 patients (9%) had LF, and 19 patients (24.4%) had FAS. A higher mean ADC value in MRpb was associated with LF (HR 4.3, 95% CI 1.32, 14.6; P = 0.016), but not with RDF (P = 0.4) or FAS (P = 0.5). A higher relative change in the mean ADC value between MRb and MRpb was associated with a lower risk of LF (HR 0.94, 95% CI 0.90, 0.98; P = 0.002), but not with RDF (P = 0.8) or FAS (P = 0.4).

CONCLUSION

Treatment response as measured on prebrachytherapy DW-MRI is a significant predictor of local control in patients undergoing chemoradiation for stage IB2-IVA CC. ADC values, a quantitative imaging biomarker on MRpb may be instrumental in dose intensification/de-escalation efforts in CC.

Once-daily roflumilast foam 0.3% for scalp and body psoriasis: a randomized, double-blind, vehicle-controlled phase IIb study

BACKGROUND

Scalp psoriasis affects most patients with psoriasis, but it can be difficult to treat.

OBJECTIVES

To evaluate the efficacy and safety of once-daily roflumilast foam 0.3% on scalp and body psoriasis.

METHODS

In a phase IIb randomized controlled trial, adults and adolescents aged ≥ 12 years with scalp and body psoriasis were randomized (2 : 1) to roflumilast foam 0.3% or vehicle for 8 weeks. The primary efficacy endpoint was scalp Investigator Global Assessment (S-IGA) success (score of 'clear' or 'almost clear' plus ≥ 2-grade improvement from baseline) at week 8. Safety and tolerability were also evaluated.

RESULTS

Significantly more roflumilast-treated patients (59.1%) than vehicle-treated patients (11.4%) achieved S-IGA success at week 8 (P < 0.001); differences favoured roflumilast as early as the first postbaseline visit at week 2 (P < 0.001). Significant improvements were also seen for secondary endpoints, including body IGA success, Scalp Itch Numeric Rating Scale and the Psoriasis Scalp Severity Index. The safety of roflumilast was generally similar to vehicle. Patients treated with roflumilast experienced low rates of treatment-emergent adverse events (AEs), with few discontinuations due to an AE. Few patients with skin of colour (11%) and few adolescents (0.7%) were included.

CONCLUSIONS

The results support the further development of roflumilast foam for treating scalp and body psoriasis.

Safety of Lebrikizumab in Adults and Adolescents with Moderate-to-Severe Atopic Dermatitis: An Integrated Analysis of Eight Clinical Trials

BACKGROUND

Lebrikizumab is a monoclonal antibody that binds with high affinity to interleukin (IL)-13, thereby blocking the downstream effects of IL-13 with high potency.

OBJECTIVES

To report integrated safety of lebrikizumab in adults and adolescents with moderate-to-severe atopic dermatitis from phase 2 and 3 studies.

METHODS

Five double-blind, randomized placebo-controlled studies; one randomized open-label study; one adolescent open-label, single-arm study; and one long-term safety study were summarized in two datasets: (1) placebo-controlled week 0-16 (All-PC Week 0-16) in patients who received lebrikizumab 250 mg every 2 weeks (LEBQ2W) versus placebo and (2) patients who received any dose of lebrikizumab at any time during the studies (All-LEB). Exposure-adjusted incidence rates (IR)/100 patient-years (PY) are provided.

RESULTS

A total of 1720 patients received lebrikizumab (1637.0 PY exposure). In All-PC Week 0-16, the frequency of treatment-emergent adverse events (TEAEs) was similar between treatment groups; most events were nonserious and mild or moderate in severity. The most frequently reported TEAEs were atopic dermatitis (placebo) and conjunctivitis (LEBQ2W). Frequencies of conjunctivitis cluster were 2.5% (placebo) and 8.5% (LEBQ2W), and all events were mild or moderate (All-LEB 10.6%, IR, 12.2). Frequencies of injection site reactions were 1.5% (placebo) and 2.6% (LEBQ2W; All-LEB 3.1%, IR, 3.3). Frequencies of adverse events leading to treatment discontinuation were 1.4% (placebo) and 2.3% (LEBQ2W; All-LEB 4.2%, IR, 4.5).

CONCLUSION

The safety profile for lebrikizumab consisted of TEAEs that were mostly nonserious, mild or moderate in severity, and did not lead to treatment discontinuation. The safety profile was similar in both adults and adolescents.

CLINICALTRIALS

GOV: NCT02465606, NCT02340234, NCT03443024, NCT04146363, NCT04178967, NCT04250337, NCT04250350, NCT04392154 Safety of lebrikizumab in adults and adolescents with moderate-to-severe atopic dermatitis: an integrated analysis of eight clinical trials (MP4 34165 KB).

Determining spectral response of the National Ignition Facility particle time of flight diagnostic to x rays

The Particle Time of Flight (PTOF) diagnostic is a chemical vapor deposition diamond detector used for measuring multiple nuclear bang times at the National Ignition Facility. Due to the non-trivial, polycrystalline structure of these detectors, individual characterization and measurement are required to interrogate the sensitivity and behavior of charge carriers. In this paper, a process is developed for determining the x-ray sensitivity of PTOF detectors and relating it to the intrinsic properties of the detector. We demonstrate that the diamond sample measured has a significant non-homogeneity in its properties, with the charge collection well described by a linear model ax + b, where a = 0.63 ± 0.16 V^-1 mm^-1 and b = 0.00 ± 0.04 V^-1. We also use this method to confirm an electron to hole mobility ratio of 1.5 ± 1.0 and an effective bandgap of 1.8 eV rather than the theoretical 5.5 eV, leading to a large sensitivity increase.

Remote EPID-based dosimetric auditing using DVH patient dose analysis

Objective.The aim of this work was to develop and validate a method for remote dosimetric auditing that enables dose-volume histogram parameter comparisons of measured and planned dose in the patient CT volume.Approach. The method is derived by adapting and combining a remote electronic portal imaging (EPID) based auditing method (Virtual Epid based Standard Phantom Audit-VESPA) and a method to estimate 3D in-patient dose distributions from planar dosimetric measurements. The method was tested with a series of error-induced plans including monitor unit and multileaf collimator (MLC) positioning errors. A pilot audit study was conducted with eleven radiotherapy centres. IMRT plans from two clinical trials, a post-prostatectomy (RAVES trial) plan and a head and neck (HPV trial) plan were utilized. Clinically relevant DVH parameters for the planned dose and estimated measured dose were compared.Main results. The method was found to reproduce the induced dose errors within 0.5% and was sensitive to MLC positioning errors as small as 0.5 mm. For the RAVES plan audit all DVH results except one were within 3% and for the HPV plan audit all DVH results were within 3% except three with a maximum difference of 3.2%.Significance. The results from the audit method produce clinically meaningful DVH metrics for the audited plan and could enable an improved understanding of a centre's radiotherapy quality.

1367 RECOGNITION AND MANAGEMENT OF ACUTE FUNCTIONAL DECLINE: A QUALITATIVE INTERVIEW STUDY WITH UK CARE HOME STAFF

Introduction

Older people living in care homes sometimes experience episodes of acute functional decline. These represent a diagnostic challenge to healthcare professionals and can result in antibiotic prescriptions or hospital admissions, though this may not always the most appropriate management strategy. We aimed to understand how episodes of acute functional decline are recognised, managed and escalated by care home staff in the UK.

Method

This was a qualitative interview study with UK care home staff, including managers, nurses and carers. Participants were recruited through advertisements circulated via email, social media and word of mouth. Semi-structured interviews were conducted over the phone between January 2021 and April 2022. Thematic analysis was facilitated by NVivo software.

Results

25 care home staff were interviewed. Participants described feeling confident in recognising when residents were less well than usual, especially if they knew them well. However, they sometimes felt it was difficult to differentiate between an ‘off day’ and something more significant. Most participants talked about clear early communication amongst the team to flag a resident of concern. Initial management steps in the care home included checking clinical observations and doing a urine dipstick. Many participants talked about considering the underlying cause for deterioration. Some participants felt comfortable monitoring residents for a few days themselves or trying a simple intervention. Others preferred escalating directly to outside clinical support. Triggers for escalation included perceived severity of illness, gut feeling or failure to respond to initial supportive management.

Conclusions

These results highlight the skill base of care home staff. However, it has also helped to identify areas for additional support and training including the use and interpretation of the urine dipstick. The findings of this study are being used to inform the design of a feasibility prospective cohort study of UK care home residents.

Measurement of Dark Ice-Ablator Mix in Inertial Confinement Fusion

We present measurements of ice-ablator mix at stagnation of inertially confined, cryogenically layered capsule implosions. An ice layer thickness scan with layers significantly thinner than used in ignition experiments enables us to investigate mix near the inner ablator interface. Our experiments reveal for the first time that the majority of atomically mixed ablator material is "dark" mix. It is seeded by the ice-ablator interface instability and located in the relatively cooler, denser region of the fuel assembly surrounding the fusion hot spot. The amount of dark mix is an important quantity as it is thought to affect both fusion fuel compression and burn propagation when it turns into hot mix as the burn wave propagates through the initially colder fuel region surrounding an igniting hot spot. We demonstrate a significant reduction in ice-ablator mix in the hot-spot boundary region when we increase the initial ice layer thickness.

53 A REVIEW OF THE RAPID ACCESS FRAILTY TEAM (RAFT) IN THE EMERGENCY DEPARTMENT OF A MODEL THREE HOSPITAL

Background

The Rapid Access Frailty Team (RAFT) in the Emergency Department (ED) has evolved since 2016. The team comprises of 1 senior occupational therapist and 1 senior physiotherapist. The focus of the team is recognition and management of frailty in ED. Patients discharged by RAFT in ED are often followed up in our Rapid Access Frailty Hub. This audit examined the incidence and outcomes of frail older persons presenting to our ED and the impact of intervention from the Rapid Access Frailty team.

Methods

A Variable Indicative of Placement Risk (VIP) positive patient triggers an assessment by RAFTT in ED post triage. Analysis of intervention and discharge destination were used to assess the effectiveness and role of the team.

Results

We compared data over two distinct 6 month periods, between September – February 2019-2020 and 2021-2022.  2723 patients &gt;75 presented to ED in 2019 - 2020. Of these, 1620 were VIP positive patients. 628/1620 patients were seen by RAFFT. 443/628 (70.5%) assessed by RAFT were discharged. In comparison to 2021-2022, we saw an increase with 2818 patients &gt;75, 1657 of which were triaged as frail. 559 patients were assessed by RAFTT and 286/559 (51%) were discharged. We observed 20% reduction in our discharge rate. Most patients received on average five interventions each. 60% of patients received a mobility assessment, 45% received falls prevention intervention and 37% were provided with equipment to facilitate discharge.

Conclusion

Over a two year period we observed an increase in frail patients presenting to our ED. Comprehensive assessment by RAFT in ED is promoting discharge. The follow up through the frailty hub has enhanced our ability to follow up in a timely manner. We hypothesize that the reduction in discharge rates in 2021- 2022 may be due to deconditioning experienced by older adults post pandemic and the increased demand for medical intervention and admission.

Twitter data from the 2019-20 Australian bushfires reveals participatory and temporal variations in social media use for disaster recovery

Social media platforms have proved to be vital sources of information to support disaster response and recovery. A key issue, though, is that social media conversation about disasters tends to tail off after the immediate disaster response phase, potentially limiting the extent to which social media can be relied on to support recovery. This situation motivates the present study of social media usage patterns, including who contributes to social media around disaster recovery, which recovery activities they contribute to, and how well that participation is sustained over time. Utilising Twitter data from the 2019-20 Australian bushfires, we statistically examined the participation of different groups (citizens, emergency agencies, politicians and others) across categories of disaster recovery activity such as donations & financial support or mental health & emotional support, and observed variations over time. The results showed that user groups differed in how much they contributed on Twitter around different recovery activities, and their levels of participation varied with time. Recovery-related topics also varied significantly with time. These findings are valuable because they increase our understanding of which aspects of disaster recovery currently benefit most from social media and which are relatively neglected, indicating where to focus resources and recovery effort.

High-yield magnetic recoil neutron spectrometer on the National Ignition Facility for operation up to 60 MJ

Recent progress at the National Ignition Facility (NIF), with neutron yields of order 1 × 10¹⁷, places new constraints on diagnostics used to characterize implosion performance. The Magnetic Recoil neutron Spectrometer (MRS), which is routinely used to measure yield, ion temperature (T_ion), and down-scatter ratio (dsr), has been adapted to allow measurements of dsr up to 5 × 10¹⁷, and yield and T_ion up to 2 × 10¹⁸ in the near term with new data processing techniques and conversion foil solutions. This paper presents a solution for extending MRS operation up to a yield of 2 × 10¹⁹ (60 MJ) by moving the spectrometer outside of the NIF shield wall. This will not only enhance the upper yield limit by 10× but also improve signal-to-background by 5×.

Design of multi neutron-to-gamma converter array for measuring time resolved ion temperature of inertial confinement fusion implosions

The ion temperature varying during inertial confinement fusion implosions changes the amount of Doppler broadening of the fusion products, creating subtle changes in the fusion neutron pulse as it moves away from the implosion. A diagnostic design to try to measure these subtle effects is introduced-leveraging the fast time resolution of gas Cherenkov detectors along with a multi-puck array that converts a small amount of the neutron pulse into gamma-rays, one can measure multiple snapshots of the neutron pulse at intermediate distances. Precise measurements of the propagating neutron pulse, specifically the variation in the peak location and the skew, could be used to infer time-evolved ion temperature evolved during peak compression.

Post-Covid-19 Syndrome: Improvements in Health-Related Quality of Life Following Psychology-Led Interdisciplinary Virtual Rehabilitation

Coronavirus disease 2019 (COVID-19) is increasingly recognized as having significant long-term impact on physical and mental health. The Primary Care Wellbeing Service (PCWBS) in Bradford District Care NHS Foundation Trust (BDCFT) is a psychology-led specialist interdisciplinary team of health professionals specializing in persistent physical symptoms (PPS) and Chronic Fatigue Syndrome (CFS)/Myalgic Encephalomyelitis (ME) with an emphasis on holistic integrated care. The PCWBS quickly recognized the risk of the long-term effects of COVID-19, particularly for social, health and care staff, and developed a 7-week virtual rehabilitation course which was piloted in October 2020. The “Recovering from COVID” course takes a whole system, biopsychosocial approach to understanding COVID-19 and post-viral fatigue (PVF) and is delivered by an interdisciplinary team consisting of a clinical psychologist, physiotherapist, occupational therapist, dietitian, speech and language therapist, assistant psychologist, and a personal support navigator with support from a team administrator. The course focuses on understanding PVF, sleep optimization, nutrition, swallowing, activity management, energy conservation, stress management, breathing optimization, managing setbacks, and signposting to appropriate resources and services. Since the pilot, PCWBS has delivered 7 courses to support over 200 people suffering from post-COVID-19 syndrome. One hundred and forty-nine individuals that enrolled on the “Recovering from COVID” course completed the EQ-5D-5L to assess Health-related quality of life (HRQoL) across 5 dimensions, including problems with mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Subsequently, 76 individuals completed these measures at the end of the rehabilitation course showing that patient ratings were significantly improved. In response to the NIHR recommendation for rapid evaluation of different service models for supporting people with post-COVID-19 syndrome, this data offers hope that rehabilitation is effective in reversing some of the problems faced by people living with the long-term effects of COVID-19.

Radiotherapy Quality Assurance in the PORTEC-3 (TROG 08.04) Trial

AIMS

Quality assurance in radiotherapy (QART) is essential to ensure the scientific integrity of a clinical trial. This paper reports the findings of the retrospective QART assessment for all centres that participated in PORTEC-3; a randomised controlled trial that compared pelvic radiotherapy with concurrent chemoradiotherapy to the pelvis followed by adjuvant chemotherapy. The trial showed an overall survival benefit for the addition of the chemotherapy in the management of women with high-risk endometrial cancer.

MATERIALS AND METHODS

Clinicians were invited to upload a randomly selected case/s treated at each of the participating sites. Panel reviewers analysed the contours to certify that the target volumes and organ at risk structures were contoured according to guidelines. The results were categorised into acceptable, minor variation, major variation or unevaluable. The radiotherapy plans were dosimetrically evaluated using the well-established Trans-Tasman Radiation Oncology Group (TROG) protocol.

RESULTS

Between August 2010 and January 2018, data from 146 patients of 686 consecutively treated patients were retrospectively reviewed. All 16 Australia and New Zealand and 71 of 77 international centres uploaded data for evaluation. In total, 3514 dosimetric and contour variables were reviewed. Of these, 3136 variables were deemed acceptable (89.2%), with 335 minor (9.6%) and 43 major variations (1.2%). Major contour variations included the clinical target volume vaginal vault, clinical target volume parametria and differential planning target volume vault expansion.

CONCLUSION

The results of the QART assessment confirmed high uniformity and low rates of both minor and major deviations in contouring and dosimetry in all sites. This supports the safe introduction of the PORTEC-3 treatment protocol into routine clinical practice.

Split Skin Grafting Precipitated Bullous Pemphigoid

Bullous pemphigoid (BP) is an autoimmune subepidermal blistering dermatological condition that can be triggered by several external factors. Here, we present a case of an immunocompetent patient with no prior dermatological history, who developed BP as a result of autologous skin graft surgery. It is an uncommon surgical complication and was most likely triggered by the trauma of the surgery itself.

Our patient's bullae first developed a month after his surgery at both surgical sites and subsequently became widespread. The diagnosis was confirmed histologically using punch biopsies of a bulla and the perilesional skin for direct immunofluorescence together with indirect immunofluorescence of the serum for anti-skin antibodies. Initial topical treatment and regular wound care were not improving the patient's condition at a satisfactory rate. Therefore, the patient was started on systemic steroids, which unfortunately resulted in a presumed split skin graft infection requiring admission. After histological diagnosis confirmation was achieved, the Dermatology team formulated a treatment plan, which combined both topical and systemic medication. The patient is currently making a good recovery and the graft loss resulting from the condition is only partial, requiring no further surgery.

We present this case as a reminder to all clinicians that, although rare, BP can be triggered by skin grafting, even in patients with no prior history of it or any predisposing conditions. This autoimmune condition needs to be recognised and treated promptly to ensure optimal clinical outcomes and minimise graft loss.

Improving retention of community-recruited participants in HIV prevention research through Saturday household visits; findings from the HPTN 071 (PopART) study in South Africa

BACKGROUND

Identifying successful strategies to improve participant retention in longitudinal studies remains a challenge. In this study we evaluated whether non-traditional fieldworker shifts (after hours during the week and weekends) enhanced participant retention when compared to retention during traditional weekday shifts in the HPTN 071 (PopART) population cohort (PC).

METHODS

HPTN 071 (PopART) PC participants were recruited and followed up in their homes on an annual basis by research fieldworkers over a 3-4 year period. The average number of successful follow-up visits, where a PC participant was found and retained in the study, was calculated for each of 3 visit schedules (early weekday shift, late weekday shift, and Saturday shift), and standardized to account for variation in fieldwork shift duration. We used one-way univariate analysis of variance (ANOVA) to describe differences in mean-successful visits and 95% confidence intervals between the shift types.

RESULTS

Data on 16 651 successful visits were included. Successful visit rates were higher when conducting Saturday visits (14.0; 95% CI: 11.3-16.6) compared to both regular (4.5; 95% CI: 3.7-5.3) and late weekday shifts (5.3; 95% CI: 4.7-5.8) overall and in all subgroup analyses (P<0.001). The successful visit rate was higher amongst women than men were during all shift types (3.2 vs. 1.3, p<0.001). Successful visit rates by shift type did not differ significantly by age, over time, by PC round or by community triplet.

CONCLUSION

The number of people living with HIV continues to increase annually. High quality evidence from longitudinal studies remains critical for evaluating HIV prevention and treatment strategies. This study showed a significant benefit on participant retention through introduction of Saturday shifts for home visits and these data can make an important contribution to the emerging body of evidence for improving retention in longitudinal research.

TRIAL REGISTRATION

PopART was approved by the Stellenbosch University Health Research Ethics Committees (N12/11/074), London School of Hygiene and Tropical Medicine (6326) ethics committee and the Division of AIDS (DAIDS) (Protocol ID 11865). PopART was registered with ClinicalTrials.gov (registration number NCT01900977 ).

Analytical and Clinical Performance Evaluation of ARK Fentanyl II Assay on Beckman Coulter AU System

Introduction/Objective

Drugs of abuse, specifically opioids, have been in recent years an important focus in both medicine and media due to the ‘opioid epidemic’ and large numbers of overdose deaths. Synthetic opioids such as fentanyl have contributed to this epidemic. The CDC reports that of roughly 50,000 opioid overdose deaths in 2019, nearly 73% were due to synthetic opioids. The objective of this study is to assess the analytical and clinical performance of the Fentanyl II Assay by ARK Diagnostics, Inc.

Methods/Case Report

Fentanyl was qualitatively determined by the ARK Fentanyl II Assay, a homogenous enzyme immunoassay based on competition between drug in the specimen and drug labeled with recombinant glucose-6- phosphate dehydrogenase (rG6PDH) for antibody binding sites. The presence of drug in urine increases enzyme activity, which converts nicotinamide adenine dinucleotide (NAD) to NADH in the presence of glucose-6-phosphate, resulting in an absorbance change measured by spectrophotometry. The evaluation was performed following CLSI guidelines. The analytical performance was evaluated for accuracy and precision.

Results (if a Case Study enter NA)

To evaluate the accuracy, twelve positive and eight negative specimens were tested by the ARK immunoassay performed on two Beckman Coulter instruments (AU480 and AU680) and by LC- MS/MS. The results from both instruments showed 100% agreement with the results from LC-MS/MS. On instrument AU480, the within-run CVs were 18.0% at the level of 22.510 ng/mL and 0.8% at the level of 552.628 ng/mL. The between-run CVs were 8.8% at the level of 68.928 ng/mL and 3.7% at the level of 158.947 ng/mL. On instrument AU680, the within-run CVs were 273.4% at the level of 1.052 ng/mL and 0.8% at the level of 523.788 ng/mL. The between-run CVs were 7.8% at the level of 53.779 ng/mL and 3.1% at the level of 145.263 ng/mL. In May 2021, 2,075 fentanyl assays were run at UAB. Of those, 476 returned a positive result with a positive rate of 22.9%, and 1,599 were negative with a negative rate of 77.1%. One positive result was confirmed by LC-MS/MS as negative for fentanyl but positive for norfentanyl, a metabolite of fentanyl. The clinical specificity was 99.9% and sensitivity was 100%.

Conclusion

In Conclusion, the ARK fentanyl Assay II on Beckman Coulter AU system has good accuracy, sensitivity and specificity. The precision at medium and high levels are good. However, the precision at low level needs to be improved.

671 Fetus-In-Fetu Found at Excision of An Antenatally Diagnosed Abdominal Mass: Multi-Disciplinary Approach

We present a case of antenatally detected abdominal mass and an alternative diagnostic course for suspected neonatal neuroblastoma as a result of investigative findings. A female infant presented antenatally with a left upper quadrant mass initially managed as a suspected neonatal neuroblastoma; further cross-sectional imaging suggested a wider differential including teratoma and aided surgical planning. The multi-disciplinary team (MDT) decision was for an early excision at 31 days and post-operative histology identified a diagnosis of fetus-in-fetu (FIF). We describe this case as a compliment to the current literature and an example of a necessary variation to recognised diagnostic and treatment pathways as a result of investigative findings.

Applying a Hybrid Modeling Approach to Evaluate Potential Pesticide Effects and Mitigation Effectiveness for an Endangered Fish in Simulated Oxbow Habitats

The occurrence of some species listed under the United States' Endangered Species Act in agricultural landscapes suggests that their habitats could potentially be exposed to pesticides. However, the potential effects from such exposures on populations are difficult to estimate. Mechanistic models can provide an avenue to estimating the potential impacts on populations, considering realistic assumptions about the ecology of the species, the ecosystem it is part of, and the potential exposures within the habitat. In the present study, we applied a hybrid model of the Topeka shiner (Notropis topeka), a small endangered cyprinid fish endemic to the US Midwest, to assess the potential population-level effects of realistic exposures to a fungicide (benzovindiflupyr). The Topeka shiner populations were simulated in the context of the food web found in oxbow habitats that are the focus of ongoing habitat restoration efforts for the species. We applied realistic, time-variable exposure scenarios and represented lethal and sublethal effects to individual Topeka shiners using toxicokinetic-toxicodynamic models. With fish in general showing the highest sensitivity to the compound, direct effects on simulated Topeka shiner populations governed the population-level effects. We characterized the population-level effects of different exposure scenarios with exposure multiplication factors (EMFs) applied. The introduction of a vegetative filter strip (VFS; 15 ft; 4.6 m) between the treated area and the oxbow habitat was shown to be effective as mitigation because EMFs were 2 to 3 times higher than for the exposure scenario without VFS. Environ Toxicol Chem 2021;40:2615-2628. © 2021 SETAC.

Audit of waist measurement methods during statutory diving medical assessments

BACKGROUND

Measurement of waist circumference is used to assess abdominal fat and risk of heart disease, type 2 diabetes, cancer and stroke. It is performed in several clinical settings for health promotion and medical assessment purposes, including statutory medical assessments where results may influence decisions on fitness to work. Under the Diving at Work Regulations 1997, working divers must have an annual assessment of their fitness to dive performed by an approved medical examiner of divers (AMED), appointed by the Health and Safety Executive (HSE). The assessment includes measurement of height, weight and waist circumference, the latter used as an indicator of central adiposity and associated health risks.

AIMS

To establish the practice of AMEDs in measuring waist circumference of working divers undergoing medical assessment to determine their fitness to dive.

METHODS

Ninety-seven AMEDs were sent a questionnaire and asked to describe their current practice in measuring waist circumference. The response rate was 79%. The audit standard used was the consensus document published by the World Health Organization (WHO).

RESULTS

Of the 77 responses, 76 were completed sufficiently to allow analysis. When the waist was measured, there was consistency in the diver's level of clothing, stage of breathing and posture for the procedure but variability in the site of measurement. Only 7/76 (9%) respondents carried out waist measurement fully in line with WHO guidance.

CONCLUSIONS

The audit has identified that there is a need for guidance for AMEDs on measuring waist circumference in the statutory medical assessment of working divers.