Beyond the symptoms: Personalizing giant cell arteritis care through multidimensional patient reported outcome measure

BACKGROUND

Giant Cell Arteritis (GCA) is the commonest form of systemic vasculitis in people over the age of 50. Published research highlighted the lack of a disease-specific patient reported outcomes (PROMs) for GCA.

OBJECTIVES

To assess the validity, reliability and responsiveness to change of a devised disease specific patient self-reported outcome measures questionnaire for Giant Cell Arteritis (GCA).

METHODS

The GCA-PROMs was conceptualized based on frameworks outlined in the OMERACT developed core set of Outcome Measures for Large-Vessel Vasculitis and the guiding principles of the FDA guidance. Initially, cognitive interviews were conducted to identify item pool of questions. Item selection and reduction was achieved based on patients as well as an interdisciplinary group of specialists. Rasch and internal consistency reliability analyses were implemented.

RESULTS

A total of 54 GCA patients completed the questionnaire. The GCA-PROMs questionnaire was reliable as demonstrated by a high standardized alpha (0.878-0.983). Content construct assessment of the GCA-PROMs functional disability and QoL revealed significant correlation (p< 0.01) with both HAQ and EQ-5D. Changes in functional disability, QoL showed significant (p< 0.01) variation with diseases activity status in response to therapy.

CONCLUSIONS

The developed GCA-PROMs questionnaire is a reliable and valid instrument for assessment of GCA patients. A stratified treatment regimen depending on the individual patient's risk factors as well as preferences and associated comorbidities is the best approach to tailored patient management.

HPB P10 Evaluation of the prognostic role of aspirin and metformin in the ESPAC 4 randomised trial of adjuvant gemcitabine versus gemcitabine plus capecitabine in patients with resected pancreatic cancer

Background

Pancreatic cancer is currently the world's seventh most common cancer with it's incidence being equivalent to it's mortality. It is the fourth most common cause of cancer-related mortality and is set to be the second most common by 2030. 5-year overall survival of pancreatic cancer is set at just below 10%, with only approximately 15% - 20% of diagnosed patients being eligible for resection. Patients eligible for resection have a 5-year overall survival improvement of up to 30% over recent years following the combination of resection and adjuvant therapy. The prognostic effects of chemo-preventive agents such as metformin and aspirin have been investigated previously in pancreatic cancer (PC) with variable results. ESPAC-4 was a phase-3 randomised controlled trial which recruited patients with resectable pancreatic cancer and examined the survival benefit between adjuvant monotherapy gemcitabine therapy and adjuvant gemcitabine-capecitabine (GEMCAP) combination therapy. This study aims to evaluate the prognostic impact of aspirin and metformin on survival among PC patients in the ESPAC 4 randomised trial.

Methods

Concomitant medication data was identified from ESPAC-4 trial database. Primary and secondaryoutcome measures were overall survival (OS) and disease-free survival (DFS) respectively for users and non-users of aspirin and metformin. Survival data was analysed using multivariate and univariate Cox-proportional hazard models and log-rank testing.The primary and secondary outcome was to investigate overall survival (OS) and Relapse-Free Survival (RFS) time respectively, between users and non- users of aspirin and metformin in either treatment arm.

Results

We identified 86 patients using aspirin and 55 patients using metformin out of 730 randomised trial patients at baseline . Aspirin usage led to a median OS of 30 months versus 26 months with non-users and a hazard ratio of 0.91 (95% CI:0.68–1.2; p=0.499). Median DFS with and without aspirin usage was 17.9 months versus 13.1 months respectively with a hazard ratio of 0.76 (95% CI: 0.58–0.99, p=0.044). Gemcitabine treatment amongst aspirin users demonstrated a median OS of 42.4 months compared to 24.7 months in non-aspirin users and a hazard ratio of 1.69 with non-users (95% CI:1.06–2.67; p=0.026). Aspirin users randomised to gemcitabine had a median DFS of 37.2 months, compared to non-aspirin users with 11.9 months and a hazard ratio of 2.01 (95% CI:1.31–3.08; p=0.001). Metformin usage resulted in a median OS of 23.8 months versus 27.7 months in non-users with a hazard ratio of 0.95 (95% CI:0.65–1.4; p=0.819). Median DFS with and without metformin usage was 14.7 months versus 12.5 months respectively, with a hazard ratio of 0.88 (95% CI:0.61–1.27; p=0.498). Metformin usage in either treatment arm did not demonstrate a significant survival difference

Conclusions

Though numbers are small, gemcitabine therapy and aspirin usage demonstrated a prognostic benefit in OS and DFS in this study. Further in vivo studies exploring the mechanism of this interaction would be beneficial. There was no survival benefit observed with metformin usage. Standardisation of dosages in chemopreventive agents such as metformin and aspirin in future trials could yield further standardised results.

Major variation in hepatocellular carcinoma treatment and outcomes in England: a retrospective cohort study

OBJECTIVE

Hepatocellular carcinoma (HCC) is increasingly incident in England, while survival remains poor with regional disparities. We aimed to explore the differences in HCC treatment across different geographical regions and to examine the impact on cancer survival.

METHODS

Incident HCC cases and treatment were identified from the English Hospital Episode Statistics (2016-2017) and then a subset by National Health Service (NHS) regions. Treatment was grouped into curative, palliative and untreated. Median survival was estimated to date of death in the national statistics.

RESULTS

The median observed survival was 8.6 months (95% CI 7.5 to 9.9) across all 2160 HCC cases, 52.1 months (CI 50.5, not reached) in 449 (20.8%) treated with curative intent, 21.0 months (CI 18.5 to 24.5) after other cancer-specific treatment in 449 (20.8%), and 2.3 months (CI 2.1 to 2.6) in 1262 (58.4%) untreated. Across NHS regions, <50% of cases received treatment (30.4%-49.6%), while between 14.2% and 27.7% had curative treatment. The 3-year survival was similar (23.5%-29.7%), except in the London region (40.0%).

CONCLUSION

Majority of HCC cases in England are untreated and survival remains low, with variation in outcomes in regions with similar incident rates. A deeper exploration of regional treatments and screening practice is required to improve early detection and survival.

OUP accepted manuscript

Background

Photochemical internalization (PCI) is a novel technology for light-induced enhancement of the local therapeutic effect of cancer drugs, utilizing a specially designed photosensitizing molecule (fimaporfin). The photosensitizing molecules are trapped in endosomes along with macromolecules or drugs. Photoactivation of fimaporfin disrupts the endosomal membranes so that drug molecules are released from endosomes inside cells and can reach their therapeutic target in the cell cytosol or nucleus. Compared with photodynamic therapy, the main cytotoxic effect with PCI is disruption of the endosomal membrane resulting in delivery of chemotherapy drug, and not to the photochemical reactions per se. In this study we investigated the effect of PCI with gemcitabine in patients with inoperable perihilar cholangiocarcinoma (CCA).

Methods

The in vitro cytotoxic effect of PCI with gemcitabine was studied on two CCA-derived cell lines. In a fimaporfin dose-escalation phase I clinical study, we administered PCI with gemcitabine in patients with perihilar CCA (n = 16) to establish a safe and tolerable fimaporfin dose and to get early signals of efficacy. The patients enrolled in the study had tumors in which the whole length of the tumor could be illuminated from the inside of the bile duct, using an optical fiber inserted via an endoscope (Fig. 1). Fimaporfin was administered intravenously at day 0; gemcitabine (i.v.) and intraluminal biliary endoscopic laser light application on day 4; followed by standard gemcitabine/cisplatin chemotherapy.

Results

Preclinical experiments showed that PCI enhanced the effect of gemcitabine. In patients with CCA, PCI with gemcitabine was well tolerated with no dose-limiting toxicities, and no unexpected safety signals. Disease control was achieved in 10 of 11 evaluable patients, with a clearly superior effect in the two highest dose groups. The objective response rate (ORR) was 42%, including two complete responses, while ORR at the highest dose was 60%. Progression-free survival at 6 months was 75%, and median overall survival (mOS) was 15.4 months, with 22.8 months at the highest fimaporfin dose.

Conclusion

Photochemical internalization with gemcitabine was found to be safe and resulted in encouraging response and survival rates in patients with unresectable perihilar CCA.

Locoregional therapies in patients with intrahepatic cholangiocarcinoma: A systematic review and pooled analysis

BACKGROUND

Locoregional treatments (LRT) including radioembolisation (SIRT), transarterial chemo-embolisation (TACE), hepatic arterial infusion (HAI) of chemotherapy, external beam radiotherapy (EBRT) and ablation have been studied for the management of intrahepatic cholangiocarcinoma (iCC). The aim of this systematic review was to provide outcome benchmarks for clinical trial design.

METHODS

Identification of studies reporting outcomes of patients treated with LRT for iCC was performed using PubMed and Embase. Pooled weighted means were calculated for progression-free survival (PFS) and overall survival (OS); meta-analysis of proportions was used for estimation of pooled response rate.

RESULTS

6325 entries were reviewed; 93 studies were eligible, representing 101 cohorts and 3990 patients: 15 cohorts (645 patients) for ablation, 18 cohorts (541 patients) for EBRT, 27 cohorts (1232 patients) for SIRT, 22 cohorts (1145 patients) for TACE, 16 cohorts (331 patients) for HAI and 3 cohorts (96 patients) not pooled. 74% of the studies were retrospective, 99% non-randomised. The pooled mean weighted OS was 30.2 months (95% confidence interval (CI): 21.8-38.6) for ablation, 18.9 (14.2-23.5) for EBRT, 14.1 (12.1-16.0) for SIRT, 15.9 (12.9-19.0) for TACE and 21.3 (15.4-27.1) for HAI. The pooled complete response rate was 93.9% for ablation. When analysed together, SIRT, TACE and HAI had a pooled mean weighted OS of 15.7 months, and 25.2 months for patients treated in first-line with concomitant systemic chemotherapy.

CONCLUSIONS

Available literature on LRT for iCC was heterogeneous and of insufficient quality to make strong recommendations. Ablation achieved satisfactory outcomes, and may be recommended when surgery is not feasible.

Kinetics of the formation and destruction of PCDD/Fs in a laboratory tubular furnace

A kinetic model has been developed for the formation of selected congeners of PCDD/Fs during the thermal decomposition of different wastes in a horizontal reactor. Previously published data on the decomposition of wastes have been correlated using a kinetic model that only considers process parameters, such as the presence of different amounts of oxygen in the atmosphere of reaction, chlorine and metals in the waste. The effect of both chlorine and metals is modelled through an equation assuming a "saturation effect", i.e., that a certain amount of each substance produces the maximum rate, and that higher amounts do not increase the rate. The presence of oxygen is modelled by a destruction reaction over part of the PCDD/Fs produced. The model, which uses data from more than 64 experiments, correlated the emissions of three selected congeners: 1,2,3,6,7,8-HxCDD, OCDF and 2,3,7,8-TCDF, which are enough to estimate the total amount and toxicity of an emission.

OP0304-PARE DEVELOPMENT OF INTERACTIVE DECISION AID TOOL FOR MOTHERHOOD AND PARENTHOOD AMONG PATIENTS LIVING WITH AUTOIMMUNE RHEUMATIC DISEASES

Background:

There are clear educational pregnancy-related needs for both women and men living with Autoimmune Rheumatic Diseases (ARDs) who seek specific advice from their health care providers. Most of the time those subjects would seek specific information regarding their chances of pregnancy, impact of the disease, as well as safety of their medications during pregnancy and breast feeding. They also require emotional and physical support as well as advice towards practical coping strategies to manage pain and disease flares particularly during the postnatal period.

Objectives:

To evaluate the effectiveness of a new interactive pregnancy decision aid (DA) developed for both men and women living with inflammatory arthritis.

Methods:

Driven by the Cochrane review of patient decision aids (DA) and the International Patient Decision Aids framework (IPDAS), which identify shared decision making (SDM) instrument as evidence-based tools designed to help people engage in deliberative management-related decision making by providing information on the options and outcomes relevant to health status. This project involved an overall three-phase SDM aid development. It has been set up for both men and women and included information on pregnancy, contraception and breast feeding. The first phase included the development of the decision tool and review by expert faculty composed of: decision experts, patient representatives, policy makers, and patients living with RA, PsA, AS and SLE. The second phase was a pilot testing of the tool in both online and paper format styles. The third phase involved an evaluation of the decision support tool and its impact on the patients. The DA adopted an interactive style with embedded video recordings (this was converted into text in the paper format). All the patient completed these questionnaires: the ReproKnow, Decisional Conflict Scale (DCS), Hospital Anxiety and Depression Scale (HADS), and Arthritis Self-Efficacy Scale (ASES) pre- and post-intervention. A control group of 92 patients (19 men and 71 women) managed according to the standard protocols was also included. Comprehensibility of the video recordings were also assessed using VAS (0-10).

Results:

126 patients shared in this work (101 women and 25 men). The patients who received the DA had an 81% (women) and 83% (men) increase in ReproKnow scores and a 76 % decrease in scores on the decisional conflict (DCS), compared to the control group (10 % and 11 % respectively); p< 0.001. There were no changes in the scores of depression and anxiety symptoms (p= 0.873) indicating no adverse psychological impact detected. There was no significant difference in terms of self-efficacy assessment p=0.481. The patients rated the comprehensibility of the video recording as high (9.4/10)

Conclusion:

The DA which was developed to support pregnancy and breast feeding decision-making for patients with ARDs. The interactive SDM aid was found to be a simple, user-friendly tool which can be implemented in standard clinical practice. The interactive style made it more comprehensible to the patients. It is consistent with the IPDAS criteria. Results revealed its effectiveness in improving relevant knowledge and reducing decisional conflict without causing distress to the patients.

Disclosure of Interests:

None declared.

Longitudinal characterisation of haematological and biochemical parameters in cancer patients prior to and during COVID-19 reveals features associated with outcome

BACKGROUND

Cancer patients are at increased risk of death from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Cancer and its treatment affect many haematological and biochemical parameters, therefore we analysed these prior to and during coronavirus disease 2019 (COVID-19) and correlated them with outcome.

PATIENTS AND METHODS

Consecutive patients with cancer testing positive for SARS-CoV-2 in centres throughout the United Kingdom were identified and entered into a database following local governance approval. Clinical and longitudinal laboratory data were extracted from patient records. Data were analysed using Mann-Whitney U test, Fisher's exact test, Wilcoxon signed rank test, logistic regression, or linear regression for outcomes. Hierarchical clustering of heatmaps was performed using Ward's method.

RESULTS

In total, 302 patients were included in three cohorts: Manchester (n = 67), Liverpool (n = 62), and UK (n = 173). In the entire cohort (N = 302), median age was 69 (range 19-93 years), including 163 males and 139 females; of these, 216 were diagnosed with a solid tumour and 86 with a haematological cancer. Preinfection lymphopaenia, neutropaenia and lactate dehydrogenase (LDH) were not associated with oxygen requirement (O2) or death. Lymphocyte count (P < 0.001), platelet count (P = 0.03), LDH (P < 0.0001) and albumin (P < 0.0001) significantly changed from preinfection to during infection. High rather than low neutrophils at day 0 (P = 0.007), higher maximal neutrophils during COVID-19 (P = 0.026) and higher neutrophil-to-lymphocyte ratio (NLR; P = 0.01) were associated with death. In multivariable analysis, age (P = 0.002), haematological cancer (P = 0.034), C-reactive protein (P = 0.004), NLR (P = 0.036) and albumin (P = 0.02) at day 0 were significant predictors of death. In the Manchester/Liverpool cohort 30 patients have restarted therapy following COVID-19, with no additional complications requiring readmission.

CONCLUSION

Preinfection biochemical/haematological parameters were not associated with worse outcome in cancer patients. Restarting treatment following COVID-19 was not associated with additional complications. Neutropaenia due to cancer/treatment is not associated with COVID-19 mortality. Cancer therapy, particularly in patients with solid tumours, need not be delayed or omitted due to concerns that treatment itself increases COVID-19 severity.

Atraumatic Restorative Treatments in Australian Aboriginal Communities: A Cluster-randomized Trial

INTRODUCTION

The management of early childhood caries (ECC) is challenging.

OBJECTIVES

A model of care based on Atraumatic Restorative Treatment and the Hall Technique (ART-HT) to manage ECC was evaluated among remote Aboriginal communities in Australia.

METHODS

Aboriginal communities in the North-West of Western Australia were invited to participate and consenting communities were randomized into early or delayed intervention for the management of ECC. Children were examined at baseline and at the 11-mo follow-up. The early intervention group (test) was provided with the ART-based dental care at baseline while the delayed intervention group (control) was advised to seek care through the usual care options available within the community. At follow-up, both groups were examined by calibrated examiners, and were offered care using the ART-HT approach. Changes from baseline to follow-up in caries experience were tested using paired tests. Multivariate analysis after multiple imputation of missing data used generalised estimating equation (GEE) controlling for clustering within communities.

RESULTS

A total of 25 communities and 338 children (mean age = 3.6 y, SD 1.7) participated in the study (test = 177). At follow-up, 231 children were examined (68% retention, test = 125). At follow-up, children in the test group had more filled teeth (test filled teeth = 1.2, control filled teeth = 0.2, P < 0.001) and decreased levels of decayed teeth (mean test = 0.7 fewer teeth with decay, mean control = 1.0 more tooth with decay, P < 0.001). GEE analysis controlled for baseline caries experience, age, sex, and community water fluoride levels found increased rates of untreated decayed teeth (RR = 1.4, P = 0.02) and decreased rates of filled teeth (RR = 0.2, P < 0.001) at follow-up among the control group.

CONCLUSION

A model of care relying on the principles of minimally invasive atraumatic approaches enabled the delivery of effective dental services to young children (<6 y) in remote Aboriginal Australian communities resulting in increased levels of care and improved oral health.

KNOWLEDGE TRANSFER STATEMENT

This cluster-randomized trial tested a multi-component model of dental care to young children with ECC in remote Aboriginal communities in Australia. The intervention, based on the atraumatic approaches using minimally invasive techniques encompassing preventive care, Atraumatic Restorative Treatment and the Hall Technique (ART-HT), delivered more restorative care and reduced the incidence of caries. This model of care was more effective than available standard care and should be incorporated into mainstream service delivery programs.

Scheduling nab-paclitaxel combined with gemcitabine as first-line treatment for metastatic pancreatic adenocarcinoma

BACKGROUND

Nab-paclitaxel plus gemcitabine (nabP+gemcitabine) offers modest survival gains for patients with metastatic pancreatic ductal adenocarcinoma (PDAC). Sequential scheduling of nabP+gemcitabine in a PDAC mouse model improved efficacy; this hypothesis was tested in a clinical trial.

METHODS

Patients with previously untreated metastatic PDAC were randomised to receive nabP+gemcitabine administered either concomitantly on the same day, or sequentially, with gemcitabine administered 24 h after nabP. The primary outcome measure was progression-free survival (PFS). Secondary outcome measures were objective response rate (ORR), overall survival (OS), safety, quality of life (QoL) and predictive biomarkers.

RESULTS

In total, 71 patients received sequential (SEQ) and 75 concomitant (CON) treatment. Six-month PFS was 46% with SEQ and 32% with CON scheduling. Median PFS (5.6 versus 4.0 months, hazard ratio [HR] 0.67, 95% confidence interval [95% CI] 0.47-0.95, p = 0.022) and ORR (52% versus 31%, p = 0.023) favoured the SEQ arm; median OS was 10.2 versus 8.2 months (HR 0.93, 95% CI 0.65-1.33, p = 0.70). CTCAE Grade ≥3 neutropaenia incidence doubled with SEQ therapy but was not detrimental to QoL. Strongly positive tumour epithelial cytidine deaminase (CDA) expression favoured benefit from SEQ therapy (PFS HR 0.31, 95% CI 0.13-0.70).

CONCLUSIONS

SEQ delivery of nabP+gemcitabine improved PFS and ORR, with manageable toxicity, but did not significantly improve OS.

CLINICAL TRIAL REGISTRATION

ISRCTN71070888; ClinialTrials.gov (NCT03529175).

Temporal changes in circulatory blood cell parameters of sheep genetically different for faecal worm egg count and diarrhoea from late summer to spring in a Mediterranean environment

Differences in haematology traits were investigated in worm-resistant and worm-susceptible Merino sheep that were genetically prone or less prone to developing diarrhoea in a winter rainfall region. The experiment was a 2 × 2 × 2 × 5 design. Male and female sheep aged 8–9 months old identified as having high (H) or low (L) breeding values for dags (breech soiling) and for worm egg counts (WEC) were allocated to one of four genetic groups: HH, HL, LH and LL (the first letter refers to dags and the second to WEC). The animals were sampled five times from autumn through winter to spring, in March, May, June (ewes only), July (rams only), August and in September after exposure to a natural paddock infection dominated by Trichostrongylus, Teladorsagia, Chabertia and Oesophagostomum. Measurements were packed cell volume, haemoglobin, red blood cell count, differential white cell counts, WEC and faecal consistency score. At all sampling times, there were large (P &lt; 0.01) differences between groups within sex for both the faecal consistency score and WEC. The genetic effect for WEC was large (P &lt; 0.01), as worm-susceptible sheep shed 10- (ewes) and 6-fold (rams) as many worm eggs at their WEC peak as the worm-resistant sheep at the end of the experiment. In the high-dag groups, the faecal consistency score was ~0.5 units higher for rams and 0.4 units higher for ewes, throughout the experiment. The optimum time to measure dags and WEC in this environment appears to be 6–8 weeks after the start of the winter rain. No differences were found among any of the treatment groups for any haematology trait. The haematogram changed significantly throughout the experiment, but genetic selection for low-dag score (reduced diarrhoea) or low WEC did not provide an acceptable discriminator in circulatory haematology traits between these genetically distinct groups of Merino sheep. It was concluded that circulatory haematology traits do not offer opportunities to select against diarrhoea or increased worm resistance in sheep.

Multiple linear regression based congener profile correlation to estimate the toxicity (TEQ) and dioxin concentration in atmospheric emissions

The formation of polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/F) is governed by complex chemical reactions with complex kinetic models. The simulation of Municipal Solid Waste incinerators, or other industrial thermal processes, is a powerful tool that can be used to optimize and control them, and reducing the number of components to simulate is mandatory for a proper use. In this study it has been determined that only the formation of 3 of the 17 main PCDD/F congeners can be considered as linearly independent. This fact has been used to establish linear regression models that are able to estimate properly the total amount and toxicity of a sample considering only the amount of 1,2,3,6,7,8-HxCDD, OCDF and 2,3,7,8-TCDF. All models have been validated using new samples performing a close approach to the real values provided by complete analytical studies. The average relative error is 3.5% and the maximum relative error is below 9% for these new testing samples. The main goal of our investigation is to build a dynamic simulation process of a MSW facility and include the dioxins formation on it using these models.

Assistant radiographer practitioners: Creating capacity or challenging professional boundaries?

INTRODUCTION

Over the last 2 decades the assistant radiographer practitioner (ARP) role has been introduced into NHS diagnostic imaging departments as a strategy to expand the workforce and create capacity. This skill mix initiative has not been implemented in a standardised way and there is limited knowledge of the current role scope within general radiography (X-Ray).

METHOD

An electronic survey of ARPs working within UK diagnostic imaging departments was conducted. Both open and closed questions sought information regarding basic demographic data (age category; gender; geographic region), scope of practice (patient groups; anatomical regions; imaging outside of the diagnostic imaging department), limitations placed on practice, supervision and additional roles.

RESULTS

A total of 108 responses, including 13 trainees, were received. Most sites employ three or less ARPs in general radiography (n = 43/66; 65.2%), although 11 sites have five (range 1-15). The majority undertake imaging of both adults and children (n = 85/108; 78.7%), although limitations on age were described. Their scope of practice covers a broad anatomical range and included some non-ambulant patients. The level of supervision varied with some sites empowering ARPs to check the referral prior to examination (n = 25) or images post acquisition (n = 32) (both n = 20/66; χ² = 16.003; 1df; p = 0.000).

CONCLUSION

ARPs are helping to maintain capacity in imaging departments but we suggest there is further scope for expansion. The practice described by the post holders suggests that many are working beyond the scope envisaged by the radiography professional body.

Does male preference play a role in maintaining female limited polymorphism in a Batesian mimetic butterfly?

Female-limited polymorphism occurs in multiple butterfly species with Batesian mimicry. While frequency-dependent selection is often argued as the driving force behind polymorphism in Batesian mimicry systems, male preference and alternative female mating strategies may also influence the maintenance of multiple female forms. Through a series of behavioural assays with the female-limited Batesian mimetic butterfly Papilio polytes, we show that males prefer stationary mimetic females over stationary non-mimetic females, but weigh female activity levels more heavily than female wing pattern when choosing between active mimetic and active non-mimetic females. Male preference for mimetic vs. non-mimetic females is independent of male genotype at the locus responsible for the female wing pattern, the autosomal gene doublesex. However male genotype does influence their response to active females. Male emphasis on female behaviour instead of appearance may reduce sexual selection pressures on female morphology, thereby facilitating frequency-dependent natural selection due to predation risk and toxic model abundance.

Self-bias modulates saccadic control

We present novel data on the role of attention in eliciting enhanced processing of stimuli associated with self. Participants were required to make pro- or anti-saccades according to whether learned shape–label pairings matched or mismatched. When stimuli matched participants were required to make an anti-saccade, and when the stimuli mismatched a pro-saccade was required. We found that anti-saccades were difficult to make to stimuli associated with self when compared to stimuli associated with a friend and a stranger. In contrast, anti-saccades to friend-stimuli were easier to make than anti-saccades to stranger-stimuli. In addition, a correct anti-saccade to a self-associated stimulus disrupted subsequent pro-saccade trials, relative to when the preceding anti-saccade was made to other stimuli. The data indicate that self-associated stimuli provide a strong cue for explicit shifts of attention to them, and that correct anti-saccades to such stimuli demand high levels of inhibition (which carries over to subsequent pro-saccade trials). The self exerts an automatic draw on attention.

Toward electronic health recording: evaluation of electronic patient reported outcome measures (e-PROMs) system for remote monitoring of early systemic lupus patients

The study aimed to assess the value of evaluation of electronic patient reported outcome measures (e-PROMs) in the assessment and management of SLE disease activity flares, its association with adherence to therapy as well as organ damage. A randomized, controlled crossover study was carried out over a 24-month duration. One hundred forty-seven SLE patients meeting the revised American College of Rheumatology (ACR) criteria were enrolled. Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was used to assess disease activity, whereas organ damage was scored using the Systemic Lupus International Collaborating Clinics (SLICC)/ACR Damage Index. In the first 12 months, the patients were assessed every 3 months. At 12 months, the patients were randomized into a cohort of 73 patients who continued their care in the same style and 74 patients who completed an online e-PROMs questionnaire on monthly basis for another 12-month period. The data captured were then retrospectively analyzed at the end of the 24-month study period. At the end of the first year of the study, the mean SLEDAI and SDI scores were 8.72 (6.1) and 1.9 (2.2). At the end of the second year, the mean SLEDAI and SDI scores in the e-PROMs cohort were 3.1 (2.6) and 1.2 (1.3), whereas in the control group, the scores were 7.63 (6.7) and 1.8 (2.3), respectively (p < 0.01). Adjusting for possible confounding variables, the number of flares, regardless of their severity, was associated with damage accrual (OR 2.03, 95% CI 1.34 to 2.83, p < 0.001). Adherence to therapy was significantly (p < 0.1) higher in the e-PROMs group. e-PROMs was equivalent to PROMs paper format and has a potential disease-modifying effect as it facilitated close monitoring of disease activity with an option of management escalation whenever indicated.

Immunohistochemical hENT1 expression as a prognostic biomarker in patients with resected pancreatic ductal adenocarcinoma undergoing adjuvant gemcitabine-based chemotherapy

BACKGROUND

Human equilibrative nucleoside transporters (hENTs) are transmembranous proteins that facilitate the uptake of nucleosides and nucleoside analogues, such as gemcitabine, into the cell. The abundance of hENT1 transporters in resected pancreatic ductal adenocarcinoma (PDAC) might make hENT1 a potential biomarker of response to adjuvant chemotherapy. The aim of this study was to see whether hENT1 expression, as determined by immunohistochemistry, was a suitable predictive marker for subsequent treatment with gemcitabine-based adjuvant chemotherapy.

METHODS

A systematic review was performed, searching databases from January 1997 to January 2016. Articles pertaining to hENT1 immunohistochemical analysis in resected PDAC specimens from patients who subsequently underwent adjuvant gemcitabine-based chemotherapy were identified. Eligible studies were required to contain survival data, reporting specifically overall survival (OS) and disease-free survival (DFS) with associated hazard ratios (HRs) stratified by hENT1 status.

RESULTS

Of 42 articles reviewed, eight were suitable for review, with seven selected for quantitative meta-analysis. The total number of patients included in the meta-analysis was 770 (405 hENT1-negative, 365 hENT1-positive). Immunohistochemically detected hENT1 expression was significantly associated with both prolonged DFS (HR 0·58, 95 per cent c.i. 0·42 to 0·79) and OS (HR 0·52, 0·38 to 0·72) in patients receiving adjuvant gemcitabine but not those having fluoropyrimidine-based adjuvant therapy.

CONCLUSION

Expression of hENT1 is a suitable prognostic biomarker in patients undergoing adjuvant gemcitabine-based chemotherapy.

Role of staging laparoscopy in the stratification of patients with perihilar cholangiocarcinoma

BACKGROUND

Cholangiocarcinoma is a rare cancer with a poor prognosis. Radical surgical resection is the only option for curative treatment. Optimal determination of resectability is required so that patients can be stratified into operative or chemotherapeutic treatment cohorts in an accurate and time-efficient manner. Staging laparoscopy is utilized to determine the presence of radiologically occult disease that would preclude further surgical treatment. The aim of this study was to analyse the utility of staging laparoscopy in a contemporary cohort of patients with perihilar cholangiocarcinoma.

METHODS

Patients diagnosed with potentially resectable perihilar cholangiocarcinoma between January 2010 and April 2015 were analysed retrospectively from a prospective database linked to UK Hospital Episode Statistics data. Patients with distal cholangiocarcinoma and gallbladder cancer were excluded from analysis.

RESULTS

A total of 431 patients with perihilar cholangiocarcinoma were referred for assessment of potential resection at a supraregional referral centre. Some 116 patients with potentially resectable disease subsequently underwent surgical assessment. The cohort demonstrated an all-cause yield of staging laparoscopy for unresectable disease of 27·2 per cent (31 of 114). The sensitivity for detection of peritoneal disease was 71 per cent (15 of 21; P < 0·001). The accuracy for all-cause non-resection for staging laparoscopy was 66 per cent (31 of 47) with a positive predictive value of progress to resection of 81 per cent (69 of 85). Neither the Bismuth-Corlette nor the Memorial Sloan Kettering Cancer Center preoperative scoring system was contingent with cause of unresectability at staging laparoscopy (P = 0·462 and P = 0·280 respectively).

CONCLUSION

In the present cohort, staging laparoscopy proved useful in determining the presence of radiologically occult metastatic disease in perihilar cholangiocarcinoma.

Long-term, high-level hepatic secretion of acid α-glucosidase for Pompe disease achieved in non-human primates using helper-dependent adenovirus

Pompe disease (glycogen storage disease type II (GSD-II)) is a myopathy caused by a genetic deficiency of acid α-glucosidase (GAA) leading to lysosomal glycogen accumulation causing muscle weakness, respiratory insufficiency and death. We previously demonstrated in GSD-II mice that a single injection of a helper-dependent adenovirus (HD-Ad) expressing GAA resulted in at least 300 days of liver secretion of GAA, correction of the glycogen storage in cardiac and skeletal muscles and improved muscle strength. Recent reports suggest that gene therapy modeling for lysososomal storage diseases in mice fails to predict outcomes in larger animal models. We therefore evaluated an HD-Ad expressing GAA in non-human primates. The baboons not only tolerated the procedure well, but the results also confirmed that a single dose of the HD-Ad allowed the livers of the treated animals to express and secrete large amounts of GAA for at least 6 months, at levels similar to those achieved in mice. Moreover, we detected liver-derived GAA in the heart, diaphragm and skeletal muscles of the treated animals for the duration of the study at levels that corrected glycogen accumulation in mice. This work validates our proof-of-concept studies in mice, and justifies future efforts using Ad-based vectors in Pompe disease patients.

ESPAC-4: A multicenter, international, open-label randomized controlled phase III trial of adjuvant combination chemotherapy of gemcitabine (GEM) and capecitabine (CAP) versus monotherapy gemcitabine in patients with resected pancreatic ductal adenocarcinoma

LBA4006

Background: The ESPAC-3 trial compared adjuvant GEM with 5-fluorouracil/folinic acid for resected pancreatic cancer. GEM is the standard of care based on similar survival and less toxicity. ESPAC-4 aimed to determine whether combination chemotherapy with GEM/CAP improved survival compared to GEM monotherapy. Methods: Patients with pancreatic ductal adenocarcinoma were randomized within 12 weeks of surgery (stratified for R0/R1 resection margin status and country) to have either six 4 week cycles of IV GEM alone or GEM with oral CAP. The primary endpoint was overall survival; secondary endpoints were toxicity, relapse free survival, 2 and 5 year survival and quality of life. 722 patients (480 expected events), 361 in each arm, were needed to detect a 10% difference in 2 year survival rates with 90% power (log-rank test with 5% two-sided alpha). Results: Between Nov 10 2008 and Sep 11 2014, 732 patients were randomized with 730 included in the full analysis set (366 GEM, 364 GEM/CAP). Median age was 65 years, 57% were men. WHO performance status was 0, 1 or 2 in 42% 55% and 3% respectively. Postoperative median CA19-9 was 19 kU/L. Median maximum tumor size was 30 mm, 60% were R1 resections, 80% were node positive and 40% were poorly differentiated. On Dec 11 2015 the Independent Trial Steering Committee requested that the trial proceed to full analysis. The data freeze was on March 2 2016. Median survival (months) for patients treated with GEM/CAP was 28.0 (95% CI, 23.5 – 31.5) and 25.5 (22.7 – 27.9) for GEM. Stratified log-rank analysis revealed an HR=0.82 [95% CI, 0.68 – 0.98]; χ2 (1) = 4.61, P=0.032. 196 out of 366 GEM patients in the safety set reported 481 grade 3/4 adverse events, while 226 out of 359 GEM/CAP patients reported 608 grade 3/4 adverse events ( P=0.242). Conclusions: Adjuvant GEM/CAP for pancreatic cancer had a statistically significant improvement in survival compared to GEM monotherapy. Clinical trial information: ISRCTN96397434.

Cardiovascular response to exercise training in the systemic right ventricle of adults with transposition of the great arteries

KEY POINTS

Patients with transposition of the great arteries (TGA) and systemic right ventricles have premature congestive heart failure; there is also a growing concern that athletes who perform extraordinary endurance exercise may injure the right ventricle. Therefore we felt it essential to determine whether exercise training might injure a systemic right ventricle which is loaded with every heartbeat. Previous studies have shown that short term exercise training is feasible in TGA patients, but its effect on ventricular function is unclear. We demonstrate that systemic right ventricular function is preserved (and may be improved) in TGA patients with exercise training programmes that are typical of recreational and sports participation, with no evidence of injury on biomarker assessment. Stroke volume reserve during exercise correlates with exercise training response in our TGA patients, identifying this as a marker of a systemic right ventricle (SRV) that may most tolerate (and possibly even be improved by) exercise training.

ABSTRACT

We aimed to assess the haemodynamic effects of exercise training in transposition of the great arteries (TGA) patients with systemic right ventricles (SRVs). TGA patients have limited exercise tolerance and early mortality due to systemic (right) ventricular failure. Whether exercise training enhances or injures the SRV is unclear. Fourteen asymptomatic patients (34 ± 10 years) with TGA and SRV were enrolled in a 12 week exercise training programme (moderate and high-intensity workouts). Controls were matched on age, gender, BMI and physical activity. Exercise testing pre- and post- training included: (a) submaximal and peak; (b) prolonged (60 min) submaximal endurance and (c) high-intensity intervals. Oxygen uptake (V̇O2; Douglas bag technique), cardiac output (Q̇c, foreign-gas rebreathing), ventricular function (echocardiography and cardiac MRI) and serum biomarkers were assessed. TGA patients had lower peak V̇O2, Q̇c, and stroke volume (SV), a blunted Q̇c/V̇O2 slope, and diminished SV response to exercise (SV increase from rest: TGA = 15.2%, controls = 68.9%, P < 0.001) compared with controls. After training, TGA patients increased peak V̇O2 by 6 ± 8.5%, similar to controls (interaction P = 0.24). The magnitude of SV reserve on initial testing correlated with Q̇c training response (r = 0.58, P = 0.047), though overall, no change in peak Q̇c was observed. High-sensitivity troponin T (hs-TnT) and N-terminal prohormone of brain naturetic peptide (NT pro-BNP) were low and did not change with acute exercise or after training. Our data show that TGA patients with SRVs in this study safely participated in exercise training and improved peak V̇O2. Neither prolonged submaximal exercise, nor high-intensity intervals, nor short-term exercise training seem to injure the systemic right ventricle.