Treatment Patterns of Bone-targeting Agents Among Solid Tumor Patients With Bone Metastases: An Analysis of Electronic Health Record Data in the United States From 2014 to 2018

OBJECTIVES

This study evaluated real-world treatment patterns of approved bone-targeting agents (BTAs) with various mechanisms of action-pamidronate, zoledronic acid, and denosumab-for the prevention of skeletal-related events in patients with bone metastases (BM) from solid tumors.

METHODS

Adult patients with BM secondary to solid tumors between January 1, 2014, and December 31, 2018, were identified from the Flatiron Health Oncology Services Comprehensive Electronic Records database and categorized by BTA use and therapy type. Time from diagnosis to initiation, persistence (mean time on treatment), and compliance (≥12 administrations/year) with BTA with up to 4 years of follow-up were examined.

RESULTS

This study included 27,268 patients with BM (breast cancer, 32.7%; lung cancer, 16.5%; prostate cancer, 17.2%; and other solid tumors, 33.6%); of these, 41.4% initiated denosumab after BM diagnosis; 21.3%, zoledronic acid; 0.6%, pamidronate; and 36.7% had no treatment record. Mean (SD) time to initiation for denosumab or zoledronic acid was 68.6 (157.0) days (denosumab, 70.3 (160.4) days; zoledronic acid, 65.2 [150.2] days). Mean persistence and compliance (first year of treatment) were significantly higher for denosumab than for zoledronic acid (22.0 vs. 14.9 mo [ P <0.0001] and 42.3% vs. 34.8% [ P <0.0001], respectively). Treatment compliance was the highest in patients with breast cancer (denosumab, 48.2%; zoledronic acid, 39.1%).

CONCLUSION

Real-world BTA treatment patterns in the United States suggest that over one-third of patients with BM secondary to solid tumors remain untreated and less than 50% of the patients received ≥12 administrations/year of BTA therapy.

Evaluating the use of clinical decision aids in an Australian emergency department: A cross-sectional survey

OBJECTIVE

To identify healthcare professionals' knowledge, self-reported use, and documentation of clinical decision aids (CDAs) in a large ED in Australia, to identify behavioural determinants influencing the use of CDAs, and healthcare professionals preferences for integrating CDAs into the electronic medical record (EMR) system.

METHODS

Healthcare professionals (doctors, nurses and physiotherapists) working in the ED at the Gold Coast Hospital, Queensland were invited to complete an online survey. Quantitative data were analysed using descriptive statistics, and where appropriate, mapped to the theoretical domains framework to identify potential barriers to the use of CDAs. Qualitative data were analysed using content analysis.

RESULTS

Seventy-four healthcare professionals (34 medical officers, 31 nurses and nine physiotherapists) completed the survey. Healthcare professionals' knowledge and self-reported use of 21 validated CDAs was low but differed considerably across CDAs. Only 4 out of 21 CDAs were reported to be used 'sometimes' or 'always' by the majority of respondents (Ottawa Ankle Rule for ankle injury, Wells' criteria for pulmonary embolism, Wells' criteria for deep vein thrombosis and PERC rule for pulmonary embolism). Most respondents wanted to increase their use of valid and reliable CDAs and supported the integration of CDAs into the EMR to facilitate their use and support documentation. Potential barriers impacting the use of CDAs represented three theoretical domains of knowledge, social/professional role and identity, and social influences.

CONCLUSIONS

CDAs are used variably by healthcare professionals and are inconsistently applied in the clinical encounter. Preferences of healthcare professionals need to be considered to allow the successful integration of CDAs into the EMR.

ution of the data and methods in real-world COVID-19 vaccine effectiveness studies on mortality: a oping eview protocol

BACKGROUND

Early evidence on COVID-19 vaccine efficacy came from randomised trials. Many important questions subsequently about vaccine effectiveness (VE) have been addressed using real-world studies (RWS) and have informed most vaccination policies globally. As the questions about VE have evolved during the pandemic so have data, study design, and analytical choices. This scoping review aims to characterise this evolution and provide insights for future pandemic planning-specifically, what kinds of questions are asked at different stages of a pandemic, and what data infrastructure and methods are used?

METHODS AND ANALYSIS

We will identify relevant studies in the Johns Hopkins Bloomberg School of Public Health VIEW-hub database, which curates both published and preprint VE RWS identified from PubMed, Embase, Scopus, Web of Science, the WHO COVID Database, MMWR, Eurosurveillance, medRxiv, bioRxiv, SSRN, Europe PMC, Research Square, Knowledge Hub, and Google. We will include RWS of COVID-19 VE that reported COVID-19-specific or all-cause mortality (coded as 'death' in the 'effectiveness studies' data set).Information on study characteristics; study context; data sources; design and analytic methods that address confounding will be extracted by single reviewer and checked for accuracy and discussed in a small group setting by methodological and analytic experts. A timeline mapping approach will be used to capture the evolution of this body of literature.By describing the evolution of RWS of VE through the COVID-19 pandemic, we will help identify options for VE studies and inform policy makers on the minimal data and analytic infrastructure needed to support rapid RWS of VE in future pandemics and of healthcare strategies more broadly.

ETHICS AND DISSEMINATION

As data is in the public domain, ethical approval is not required. Findings of this study will be disseminated through peer-reviewed publications, conference presentations, and working-papers to policy makers.

REGISTRATION

https://doi.org/10.17605/OSF.IO/ZHDKR.

Assessment of the safety of nivolumab in people living with HIV with advanced cancer on antiretroviral therapy: the AIDS Malignancy Consortium 095 Study

BACKGROUND

Although immunotherapy has emerged as a therapeutic strategy for many cancers, there are limited studies establishing the safety and efficacy in people living with HIV (PLWH) and cancer.

METHODS

PLWH and solid tumors or Kaposi sarcoma (KS) receiving antiretroviral therapy and a suppressed HIV viral load received nivolumab at 3 mg/kg every 2 weeks, in two dose deescalation cohorts stratified by CD4 count (stratum 1: CD4 count > 200/µL and stratum 2: CD4 count 100-199/µL). An expansion cohort of 24 participants with a CD4 count > 200/µL was then enrolled.

RESULTS

A total of 36 PLWH received nivolumab, including 15 with KS and 21 with a variety of other solid tumors. None of the first 12 participants had dose-limiting toxicity in both CD4 strata, and five patients (14%) overall had grade 3 or higher immune related adverse events. Objective partial response occurred in nine PLWH and cancer (25%), including in six of 15 with KS (40%; 95% CI, 16.3-64.7). The median duration of response was 9.0 months overall and 12.5 months in KS. Responses were observed regardless of PDL1 expression. There were no significant changes in CD4 count or HIV viral load.

CONCLUSIONS

Nivolumab has a safety profile in PLWH similar to HIV-negative subjects with cancer, and also efficacy in KS. Plasma HIV remained suppressed and CD4 counts remained stable during treatment and antiretroviral therapy, indicating no adverse impact on immune function.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02408861.

Correlation of serum level of squamous cell carcinoma antigen with severity of cutaneous psoriasis, assessed using the simplified psoriasis index

BACKGROUND

Squamous cell carcinoma antigen (SCCA) is a biomarker of disease progression in squamous cell carcinoma but also contributes to the pathogenesis of psoriasis. Eight previous studies have shown a correlation between psoriasis severity, assessed using the Psoriasis Assessment Severity Index or body surface area, and serum level of SCCA, mainly SCCA2, assessed by means of non-commercial tests. We examined the correlation between serum SCCA level, measured with a commercial kit, and psoriasis severity assessed using the Simplified Psoriasis Index (SPI).

METHODS

We conducted a prospective, non-interventional, single-centre study at the University Hospital of Tours over 18 months. The primary endpoint was same-day measurement of serum SCCA level and the psoriasis severity score on the professional version of the SPI (proSPI-s) at both baseline and follow-up. Secondary endpoints were same-day measurement of serum SCCA level and the proSPI psychosocial score (proSPI-p), proSPI treatment score, Dermatology Life Quality Index (DLQI), and inflammation parameters (C-reactive protein level, neutrophil-to-lymphocyte ratio).

RESULTS

We included 50 psoriasis patients. Serum SCCA level was correlated with the proSPI-s at baseline and follow-up (Spearman r = 0.686 and r = 0.674, p < 0.0001) for both. It was correlated with the proSPI-p and DLQI. Serum SCCA level was not correlated with either neutrophil-to-lymphocyte ratio (r = 0.083) or C-reactive protein level (r = 0.192).

CONCLUSION

This study is the first to correlate serum SCCA level with proSPI-s. Moreover, SCCA was measured using a widely available kit. SCCA may be used to assess the severity of psoriasis.

Quality use of publicly subsidised tapentadol in Australia: a population-based analysis

BACKGROUND

Sustained-release (SR) tapentadol was listed on Australia's Pharmaceutical Benefits Scheme (PBS) in 2014 for chronic severe pain requiring long-term opioid treatment. Dispensings have increased since listing despite declining trends in other PBS-listed opioids. Preferential prescribing of SR opioids may increase the risk of dependence and accidental overdose, particularly when used to treat acute pain.

AIMS

To explore the quality use of publicly subsidised tapentadol in Australia.

METHODS

We examined annual initiation rates and patterns of use of tapentadol (SR) in the dispensing records of a 10% random sample of PBS-eligible Australians (2014-2021). We used national tapentadol sales data to assess the proportion of sales attributable to the PBS.

RESULTS

Tapentadol initiation increased from 2014, peaking at 7.5/1000 adult population in 2019 before declining to 5.3/1000 in 2021. We identified 63 766 new users between 2014 and 2020, of whom 92.8% discontinued in the first year following initiation, 58.0% had only a single dispensing and 34.3% had no other opioids dispensed in the 3 months before or after initiation. 27.8% of new users were dispensed tapentadol on the same day as potentially interacting medicines. There was a sustained drop in the proportion of sales attributable to the PBS from June 2020 onwards, from an average of 69.1%, to 63.9% of pack sales.

CONCLUSIONS

Patterns of use suggest tapentadol (SR) is generally used for short duration. Although most tapentadol sold in Australia is subsidised, there is evidence of a shift towards private sales.

Exact Solutions Modelling Nonlinear Atmospheric Gravity Waves

Exact solutions to the governing equations for atmospheric motion are derived which model nonlinear gravity wave propagation superimposed on atmospheric currents. Solutions are explicitly prescribed in terms of a Lagrangian formulation, which enables a detailed exposition of intricate flow characteristics. It is shown that our solutions are well-suited to modelling two distinct forms of mountain waves, namely: trapped lee waves in the Equatorial f-plane, and vertically propagating mountain waves at general latitudes.

Effectiveness of COVID-19 vaccination against COVID-19 specific and all-cause mortality in older Australians: a population based study

Background

Few studies have examined effectiveness of COVID-19 vaccines against COVID-19 and all-cause mortality across different pandemic periods in 2022.

Methods

We used linked whole-of-population data from the 2021 Australian Census, Australian Immunisation Register, death registrations and other national datasets including migration data. Among 3.8 million adults aged 65+ years and >170,000 aged care residents, we used survival analysis to estimate vaccine effectiveness (VE) against COVID-19 specific mortality and all-cause mortality, by vaccine dose and time since receipt, adjusted for age, sex and other factors. We also estimated absolute COVID-19 mortality rates.

Findings

From January-May 2022 (Omicron BA.1/2), 3250 COVID-19 deaths occurred; from June-November (Omicron BA.4/5) 3185 COVID-19 deaths occurred. During January-May, VE of a 3rd COVID-19 vaccine dose within 3 months was 93% (95% CI 93-94%) whilst VE of a 2nd dose >6 months since receipt was 34% (26-42%). During June-November, VE of a 4th COVID-19 vaccine dose within 3 months was 84% (82-86%) whilst VE of a 3rd dose >6 months since receipt was 56% (50-62%). VE estimates for aged care residents were similar, but absolute risk reductions were substantially greater. During June-November 2022, for all-cause mortality, VE of a 4th dose within 3 months was 58% (56-59%) whilst VE of a 3rd dose >6 months since receipt was 19% (16-22%).

Interpretations

COVID-19 vaccination is highly effective against COVID-19 mortality among older adults although effectiveness wanes with time since the last dose. Our findings emphasise the importance of continuing to administer booster doses, particularly to those at highest risk.

Funding

This study was funded by the Health Economics Research Division in the Australian Government Department of Health and Aged Care.

Formulation of zinc foliar sprays for wheat grain biofortification: a review of current applications and future perspectives

Agronomic biofortification of wheat grain with zinc can improve the condition of about one billion people suffering from zinc (Zn) deficiency. However, with the challenge of cultivating high-yielding wheat varieties in Zn-deficient soils and the global need to produce higher-quality food that nourishes the growing population, innovation in the strategies to deliver Zn directly to plants will come into play. Consequently, existing foliar formulations will need further refinement to maintain the high agronomic productivity required in competitive global grain markets while meeting the dietary Zn intake levels recommended for humans. A new generation of foliar fertilisers that increase the amount of Zn assimilated in wheat plants and the translocation efficiency of Zn from leaves to grains can be a promising solution. Research on the efficacy of adjuvants and emerging nano-transporters relative to conventional Zn forms applied as foliar fertilisers to wheat has expanded rapidly in recent years. This review scopes the range of evidence available in the literature regarding the biofortification of bread wheat (Triticum aestivum L.) resulting from foliar applications of conventional Zn forms, Zn nanoparticles and novel Zn-foliar formulations. We examine the foliar application strategies and the attained final concentration of grain Zn. We propose a conceptual model for the response of grain Zn biofortification of wheat to foliar Zn application rates. This review discusses some physiological aspects of transportation of foliarly applied Zn that need further investigation. Finally, we explore the prospects of engineering foliar nano-formulations that could effectively overcome the physicochemical barrier to delivering Zn to wheat grains.

Novel arginase inhibitor, AZD0011, demonstrates immune cell stimulation and anti-tumor efficacy with diverse combination partners

Anti-tumor immunity can be hampered by immunosuppressive mechanisms in the tumor microenvironment including recruitment of arginase (ARG) expressing myeloid cells which deplete L-arginine essential for optimal T cell and natural killer cell function. Hence, ARG inhibition can reverse immunosuppression enhancing anti-tumor immunity. We describe AZD0011, a novel peptidic boronic acid prodrug to deliver an orally available, highly potent, ARG inhibitor payload (AZD0011-PL). We demonstrate that AZD0011-PL is unable to permeate cells, suggesting this compound will only inhibit extracellular ARG. In vivo, AZD0011 monotherapy leads to arginine increases, immune cell activation, and tumor growth inhibition (TGI) in various syngeneic models. Anti-tumor responses increase when AZD0011 is combined with anti-PD-L1 treatment, correlating with increases in multiple tumor immune cell populations. We demonstrate a novel triple combination of AZD0011, anti-PD-L1 and anti-NKG2A, and combination benefits with type I interferon (IFN) inducers including polyI:C and radiation. Our pre-clinical data demonstrates AZD0011's ability to reverse tumor immunosuppression and enhance immune stimulation and anti-tumor responses with diverse combination partners providing potential strategies to increase immuno-oncology therapies clinically.

Genetic subgroups inform on pathobiology in adult and pediatric Burkitt lymphoma

Burkitt lymphoma (BL) accounts for most pediatric non-Hodgkin lymphomas, being less common but significantly more lethal when diagnosed in adults. Much of the knowledge of the genetics of BL thus far has originated from the study of pediatric BL (pBL), leaving its relationship to adult BL (aBL) and other adult lymphomas not fully explored. We sought to more thoroughly identify the somatic changes that underlie lymphomagenesis in aBL and any molecular features that associate with clinical disparities within and between pBL and aBL. Through comprehensive whole-genome sequencing of 230 BL and 295 diffuse large B-cell lymphoma (DLBCL) tumors, we identified additional significantly mutated genes, including more genetic features that associate with tumor Epstein-Barr virus status, and unraveled new distinct subgroupings within BL and DLBCL with 3 predominantly comprising BLs: DGG-BL (DDX3X, GNA13, and GNAI2), IC-BL (ID3 and CCND3), and Q53-BL (quiet TP53). Each BL subgroup is characterized by combinations of common driver and noncoding mutations caused by aberrant somatic hypermutation. The largest subgroups of BL cases, IC-BL and DGG-BL, are further characterized by distinct biological and gene expression differences. IC-BL and DGG-BL and their prototypical genetic features (ID3 and TP53) had significant associations with patient outcomes that were different among aBL and pBL cohorts. These findings highlight shared pathogenesis between aBL and pBL, and establish genetic subtypes within BL that serve to delineate tumors with distinct molecular features, providing a new framework for epidemiologic, diagnostic, and therapeutic strategies.

The association between psychostimulant use in pregnancy and adverse maternal and neonatal outcomes: results from a distributed analysis in two similar jurisdictions

BACKGROUND

Conflicting evidence suggests a possible association between use of prescribed psychostimulants during pregnancy and adverse perinatal outcomes.

METHODS

We conducted population-based cohort studies including pregnancies conceived between April 2002 and March 2017 (Ontario, Canada; N = 554 272) and January 2003 to April 2011 [New South Wales (NSW), Australia; N = 139 229]. We evaluated the association between exposure to prescription amphetamine, methylphenidate, dextroamphetamine or lisdexamfetamine during pregnancy and pre-eclampsia, placental abruption, preterm birth, low birthweight, small for gestational age and neonatal intensive care unit admission. We used inverse probability of treatment weighting based on propensity scores to balance measured confounders between exposed and unexposed pregnancies. Additionally, we restricted the Ontario cohort to social security beneficiaries where supplementary confounder information was available.

RESULTS

In Ontario and NSW respectively, 1360 (0.25%) and 146 (0.10%) pregnancies were exposed to psychostimulants. Crude analyses indicated associations between exposure and nearly all outcomes [OR range 1.15-2.16 (Ontario); 0.97-2.20 (NSW)]. Nearly all associations were attenuated after weighting. Pre-eclampsia was the exception: odds remained elevated in the weighted analysis of the Ontario cohort (OR 2.02, 95% CI 1.42-2.88), although some attenuation occurred in NSW (weighted OR 1.50, 95% CI 0.77-2.94) and upon restriction to social security beneficiaries (weighted OR 1.24, 95% CI 0.64-2.40), and confidence intervals were wide.

CONCLUSIONS

We observed higher rates of outcomes among exposed pregnancies, but the attenuation of associations after adjustment and likelihood of residual confounding suggests psychostimulant exposure is not a major causal factor for most measured outcomes. Our findings for pre-eclampsia were inconclusive; exposed pregnancies may benefit from closer monitoring.

Changes in dispensing of medicines proposed for re-purposing in the first year of the COVID-19 pandemic in Australia

Background

Since COVID-19 was first recognised, there has been ever-changing evidence and misinformation around effective use of medicines. Understanding how pandemics impact on medicine use can help policymakers act quickly to prevent harm. We quantified changes in dispensing of common medicines proposed for “re-purposing” due to their perceived benefits as therapeutic or preventive for COVID-19 in Australia.

Methods

We performed an interrupted time series analysis and cross-sectional study using nationwide dispensing claims data (January 2017-November 2020). We focused on six subsidized medicines proposed for re-purposing: hydroxychloroquine, azithromycin, ivermectin, colchicine, corticosteroids, and calcitriol (Vitamin D analog). We quantified changes in monthly dispensing and initiation trends during COVID-19 (March-November 2020) using autoregressive integrated moving average models and compared characteristics of initiators in 2020 and 2019.

Results

In March 2020, we observed a 99% (95%CI: 96%-103%) increase in hydroxychloroquine dispensing (approximately 22% attributable to new users), and a 199% increase (95%CI: 184%-213%) in initiation, with an increase in prescribing by general practitioners (42% in 2020 vs 25% in 2019) rather than specialists. These increases subsided following regulatory restrictions on prescribing. There was a small but sustained increase in ivermectin dispensing over multiple months, with an 80% (95%CI 42%-118%) increase in initiation in May 2020 following its first identification as potentially disease-modifying in April. Other than increases in March related to stockpiling, we observed no change in the initiation of calcitriol or colchicine during COVID-19. Dispensing of corticosteroids and azithromycin was lower than expected from April through November 2020.

Conclusions

While most increases in dispensing observed early on during COVID-19 were temporary and appear to be related to stockpiling among existing users, we observed increases in the initiation of hydroxychloroquine and ivermectin and a shift in prescribing patterns which may be related to the media hype around these medicines. A quick response by regulators can help limit inappropriate repurposing to lessen the impact on medicine supply and patient harm.

Towards the Integration of an Islet-Based Biosensor in Closed-Loop Therapies for Patients With Type 1 Diabetes

In diabetes mellitus (DM) treatment, Continuous Glucose Monitoring (CGM) linked with insulin delivery becomes the main strategy to improve therapeutic outcomes and quality of patients' lives. However, Blood Glucose (BG) regulation with CGM is still hampered by limitations of algorithms and glucose sensors. Regarding sensor technology, current electrochemical glucose sensors do not capture the full spectrum of other physiological signals, i.e., lipids, amino acids or hormones, relaying the general body status. Regarding algorithms, variability between and within patients remains the main challenge for optimal BG regulation in closed-loop therapies. This work highlights the simulation benefits to test new sensing and control paradigms which address the previous shortcomings for Type 1 Diabetes (T1D) closed-loop therapies. The UVA/Padova T1DM Simulator is the core element here, which is a computer model of the human metabolic system based on glucose-insulin dynamics in T1D patients. That simulator is approved by the US Food and Drug Administration (FDA) as an alternative for pre-clinical testing of new devices and closed-loop algorithms. To overcome the limitation of standard glucose sensors, the concept of an islet-based biosensor, which could integrate multiple physiological signals through electrical activity measurement, is assessed here in a closed-loop insulin therapy. This investigation has been addressed by an interdisciplinary consortium, from endocrinology to biology, electrophysiology, bio-electronics and control theory. In parallel to the development of an islet-based closed-loop, it also investigates the benefits of robust control theory against the natural variability within a patient population. Using 4 meal scenarios, numerous simulation campaigns were conducted. The analysis of their results then introduces a discussion on the potential benefits of an Artificial Pancreas (AP) system associating the islet-based biosensor with robust algorithms.

OUP accepted manuscript

Background

Persons living with human immunodeficiency virus are an underserved population for evidence-based cancer treatment. Paclitaxel and carboplatin (PCb) is an active regimen against a variety of solid tumors, including several seen in excess in patients with HIV infection. We performed a pilot trial to evaluate the safety of full-dose PCb in people living with human immunodeficiency virus and cancer.

Methods

Eligible patients, stratified by concurrent antiretroviral therapy (ART) that included CYP3A4 inhibitors or not, received paclitaxel (175 mg/m²) in combination with carboplatin (target AUC 6) intravenously every 3 weeks for up to 6 cycles.

Results

Sixteen evaluable patients received 64 cycles of PCb, including 6 patients treated with CYP3A4 inhibiting ART (ritonavir). The adverse event profile was consistent with the known toxicity profile of PCb, with no differences between the 2 strata. There were 4 partial responses (25%, 95% CI: 7%-52%), and overall, CD4+ lymphocyte count was similar after completion of therapy (median: 310/μL) compared with baseline values (median: 389/μL). Pharmacokinetic studies in 6 patients revealed no significant differences in C_max or AUC_inf for paclitaxel between the 2 cohorts.

Conclusion

Full doses of PCb chemotherapy are tolerable when given concurrently with ART in people living with human immunodeficiency virus with cancer, including patients receiving CYP3A4 inhibitors.

ClinicalTrials.gov Identifier

NCT01249443.

Assessment of the Retinal Toxicity and Sealing Strength of Tissue Adhesives

PURPOSE

The purpose of this in vitro prospective nonrandomized study is to compare the toxicity and strength of cyanoacrylate and hydrogel adhesives on human retinal pigment epithelium (RPE) cells and porcine retina, respectively.

METHODS

The toxicity of cyanoacrylate (histoacryl, dermabond, superglue), ReSure PEG, and Tisseel fibrin glue on human RPE cells was determined by growing RPE cells in vitro, applying the different adhesives to the cells, and monitoring for disruption of growth over 3 days. The relative strength of these adhesives was tested by gluing a 3 mm piece of foam to a porcine retina and determining the amount of force needed to break the attachment.

RESULTS

0.085 N of force was required to break the porcine retinal tissue (p = .913). Histoacryl adhesive exhibited high strength (0.247 N) and high RPE toxicity (0.55 mm inhibition zone after 24 hrs). The strength of Tisseel fibrin glue was 0.078 N while that of ReSure was only 0.053 N. Both Tisseel and ReSure were nontoxic to the RPE cells.

CONCLUSIONS

Tisseel VH fibrin sealant may provide the best option for sealing retinal breaks because of its high strength and low retinal toxicity.

On the energy of nonlinear water waves

This article presents results concerning the excess kinetic and potential energies for exact nonlinear water waves. In particular, it is proven, for periodic travelling irrotational water waves, that the excess kinetic energy density is always negative, whereas the excess potential energy density is always positive, in the steady reference frame. A characterization of the total excess energy density as a weighted mean of the kinetic energy along the wave surface profile is also presented.

Transference of skills in robotic vs. laparoscopic simulation: a randomized controlled trial

BACKGROUND

Elucidating how robotic skills are best obtained will enable surgeons to best develop future robotic training programs. We perform a randomized controlled trial to assess the performance of robotic compared to laparoscopic surgery, transference of pre-existing skills between the two modalities, and to assess the learning curve between the two using novice medical students.

METHODS

Forty students were randomized into either Group A or B. Students practiced and were tested on a peg transfer task in either a laparoscopic simulator (LS) and robotic simulator (RS) in a pre-defined order. Performance, transference of skills and learning curve were assessed for each modality. Additionally, a fatigue questionnaire was issued.

RESULTS

There was no significant difference between overall laparoscopic scores (219 ± 19) and robotic scores (227 ± 23) (p = 0.065). Prior laparoscopic skills performed significantly better on robotic testing (236 ± 12) than without laparoscopic skills (216 ± 28) (p = 0.008). There was no significant difference in scores between students with prior robotic skills (223 ± 16) than without robotic skills (215 ± 22) (p = 0.162). Students reported no difference in fatigue between RS and LS. The learning curve plateaus at similar times between both modalities.

CONCLUSION

Novice medical students with laparoscopic skills performed better on a RS test than students without laparoscopic training, suggesting a transference of skills from laparoscopic to robotic surgery. These results suggest laparoscopic training may be sufficient in general surgery residencies as the skills transfer to robotic if used post-residency.

Integrating an Islet-Based Biosensor in the Artificial Pancreas: In Silico Proof-of-Concept

OBJECTIVE

Current treatment of type 1 diabetes by closed-loop approaches depends on continuous glucose monitoring. However, glucose readings alone are insufficient for an artificial pancreas to truthfully restore glucose homeostasis where additional physiological regulators of insulin secretion play a considerable role. Previously, we have developed an electrophysiological biosensor of pancreatic islet activity, which integrates these additional regulators through electrical measurement. This work aims at investigating the performance of the biosensor in a blood glucose control loop, to establish an in silico proof-of-concept.

METHODS

Two islet algorithm models were identified on experimental data recorded with the biosensor. First, we validated electrical measurement as a means to exploit the inner regulation capabilities of islets for intravenous glucose measurement and insulin infusion. Then, an artificial pancreas integrating the islet-based biosensor was compared to standard treatment approaches using subcutaneous routes. The closed-loop simulations were performed in the UVA/Padova T1DM Simulator where a series of realistic meal scenarios were applied to virtual diabetic patients.

RESULTS

With intravenous routes, the endogenous islet algorithms successfully restored glucose homeostasis for all patient categories (mean time in range exceeds 90%) while mitigating the risk of adverse glycaemic events (mean BGI < 2). Using subcutaneous routes, the biosensor-based artificial pancreas was as performing as standard treatments, and outperformed them under challenging conditions.

CONCLUSION

This work validates the concept of using pancreatic islets algorithms in an artificial pancreas in silico.

SIGNIFICANCE

Pancreatic islet endogenous algorithms obtained via an electrophysiological biosensor successfully regulate blood glucose levels of virtual type 1 diabetic patients.

Improvement in pain interference and function by an allied health pain management program: Results of a randomized trial

BACKGROUND

Chronic pain is a significant health problem worldwide and requires a biopsychosocial treatment approach. Access to traditional pain medicine specialist services is limited and innovative treatment models are required to support patients in tertiary care. The study evaluated the clinical effectiveness and safety of the Treatment Access Pathway (TAP), an allied health expanded scope model of care which included innovative group assessment and collaboration with patients to create individualized treatment plans.

METHODS

One hundred and eighty-one patients referred to a tertiary level chronic pain service were randomly allocated to either the TAP or the waitlist study groups. Primary (pain interference) and secondary outcome measures were collected at recruitment and again at 6 months. Per-protocol analyses were utilized due to high participant attrition (46% across groups).

RESULTS

The TAP group reported greater reductions in pain interference at 6 months than waitlist group (0.9, 95% CI: 0.2-1.6), with more than half of the TAP group (52%) reporting clinically significant improvement. In addition, statistically significant differences between the TAP and waitlist groups were observed for objective measurements of walking endurance (5.4 m, 95% CI: 1.7-9.1); and global impressions of change (1.4 unit decrease, 95% CI: 1-1.9). Nil adverse events were recorded.

CONCLUSIONS

The study suggests that an expanded scope allied health model of care prioritizing patient choice and group-based interventions provides modest benefits for tertiary-referral chronic pain patients. TAP warrants further investigation as a potentially viable alternative for tertiary healthcare where traditional pain services are unavailable or have long waiting lists.

SIGNIFICANCE

The study tests effectiveness and safety of an expanded scope allied health-led chronic pain program. Despite a high attrition rate, the study showed reduced pain interference and increased physical function in those who completed the protocol. The results are promising and support introduction of this model as an adjunct to existing traditional chronic pain models of care, with a particular focus on improving participant retention in the program. Additionally, the model of care can be used as a standalone chronic pain model of care where no other pain management resources are available. The study was registered on ANZCTR (Trial ID: ACTRN12617001284358).

Intravenous ferric derisomaltose for the treatment of iron deficiency anemia

Intravenous (IV) iron is the therapy of choice when oral iron is ineffective or poorly tolerated, yet use has been limited by fears of hypersensitivity reactions (HSRs). Newer formulations that bind iron more tightly and release it more slowly have made the risk of serious or severe HSRs very low. One such formulation, ferric derisomaltose, has been approved in the United States for delivery of 1000 mg iron in a single IV infusion. Ferric derisomaltose rapidly repletes iron parameters with low rates of serious or severe HSRs. Single-infusion iron repletion offers convenience, eliminates adherence concerns, and reduces healthcare resource utilization.

On the synthesis of a sliding-mode-observer-based adaptive fault-tolerant flight control scheme

This paper presents an active Fault-Tolerant Control (FTC) framework to accommodate the actuator faults by using a Fault Estimation (FE) module fitted with an adaptive control law. It focuses on the problem of fault estimation based fault tolerant control for linear uncertain system with mitigation of the reconfiguration transients. In this work, a second-order sliding mode observer is designed to reconstruct the Loss of Effectiveness (LoE) of the actuators. The use of a bumpless strategy to cleverly manage the transient behavior where fault estimation is different from the real one due to an abrupt fault occurrence. Signals provided by the FE module are next used by an augmented fault-tolerant control allocation scheme to accommodate the fault. More precisely, the flight state tracking problem has been addressed with a robust adaptive model-reference Integral Sliding Mode (ISM) control law in a state feedback setting. Next, the problem of stability and performance of the overall FTC scheme with taking into account both FE performance and control law is rigorously considered. At the end, simulation examples on an aircraft from a European program are used to illustrate the effectiveness of the proposed approach.

Maternal and Neonatal Outcomes Associated with Psychostimulant Use in Pregnancy

IntroductionRecent evidence from the USA and Nordic countries suggests a possible association between psychostimulant use during gestation and adverse pregnancy and birth outcomes. Objectives and ApproachWe employed a distributed cohort analysis using linked administrative data for women who gave birth in New South Wales (NSW; Australia) and Ontario (Canada), whereby a common protocol was implemented separately in each jurisdiction. The study population comprised women who were hospitalized for a singleton delivery over an 8 (NSW) and 4 (Ontario) year period, respectively, with the NSW cohort restricted to social security beneficiaries. Psychostimulant exposure was defined as at least one dispensing of methylphenidate, amphetamine, dextroamphetamine or lisdexamfetamine during pregnancy. We examined the risk of maternal and neonatal outcomes among psychostimulant exposed mothers compared with unexposed mothers. ResultsThere were 140,356 eligible deliveries in NSW and 449,499 in Ontario during the respective study periods. Fewer than 1% of these pregnancies were exposed to psychostimulants during gestation, although use was higher in Ontario (0.30% vs 0.11% in NSW). Preliminary unadjusted analyses indicated possible associations between psychostimulant use in pregnancy and higher risks of pre-term birth (relative risk [RR] 1.7, 95% confidence interval [CI] 1.4-2.0 (Ontario); RR 1.8, 95% CI 1.2-2.6 (NSW)) and pre-eclampsia (RR 2.0, 95% CI 1.5-2.6 (Ontario); RR 2.0, 95% CI 1.2-3.5 (NSW)). Similarly, psychostimulant use was associated with higher risks of low birthweight (RR 1.6, 95% CI 1.3-1.9 (Ontario); RR 2.0, 95% CI 1.3-3.0 (NSW)) and admission to neonatal intensive care (RR 2.1, 95% CI 1.9-2.3 (Ontario); RR 1.5, 95% CI 1.1-1.9 (NSW)). Conclusion / ImplicationsUnadjusted analyses indicate an increased risk of adverse maternal and birth outcomes associated with psychostimulant exposure during pregnancy, potentially representing a placental effect. We are currently refining the analyses, employing propensity score methods to adjust for confounding.

Supporting Drug Regulators Through Simple Rapid Cycle Analyses

IntroductionDrug regulators require timely, relevant information to address questions about the safety of prescribed medicines. Some questions can be informed by initial rapid and simple analyses of linked exposure/outcome data. These analyses will establish how many individuals have received the drug, their characteristics, the availability of follow up time and the frequency of the event of interest in the exposed cohort. This approach does not enable causal inferences but establishes the need for, and feasibility of, more complex controlled analyses. Discovery that the exposure or outcome are uncommon can allay initial fears about the extent of a problem. Objectives and ApproachA pilot network to support the Australian drug regulator (TGA, Department of Health) was established among three research institutions in Australia and Canada. Initial queries were identified and prioritised by staff at the TGA. Academic staff at the partner institutions performed a rapid feasibility assessment based on existing knowledge and expertise. Following this, initial exposure/outcome analyses were undertaken on selected queries using routinely collected data from Canada and Australia. Updates were provided to the TGA at each stage to ensure that decision-makers were fully informed and participated in decision making. ResultsTo date, the network has assessed 20 queries. Seven were deemed infeasible and 4 queries were being addressed by studies that were already planned or underway; in these cases, arrangements were made to provide early results directly to the regulator. The final four queries progressed to an initial exposure/outcome analysis, and one such study was expanded to a fully adjusted controlled analysis. Conclusion / ImplicationsThis framework has proven to be agile and responsive and has strengthened the relationship between academia and the TGA. It may serve as a model for others who wish to engage more closely with governments or other decision makers.

Tuning of an Artificial Pancreas Controller: an in silico methodology based on clinically-relevant criteria

This paper presents a methodology to tune an artificial pancreas controller by minimizing the time spent in endangering glycaemic ranges (hypo- and hyperglycaemia). The risk associated to the patient's glycaemia is evaluated with an objective metric (the blood glucose risk index), which has an established clinical relevance. The tuned controller is validated in the UVA/Padova environment where the resulting artificial pancreas achieves minimal glucose risk index in realistic 24-hour long scenarios with unannounced glucose intake.

Tolerancing and characterization of curved image sensor systems

Curved image sensors, not having to correct the field curvature, are considered a relevant solution for improving the vast majority of optical systems. They offer the possibility of designing compact aberration-free optical systems. In this work, we explain the advantage of the curved sensor system using the aberration theory. A complete procedure was developed to produce functional curved sensors and functional prototypes were carried out. This paper focuses on the tolerancing process of curved sensors and its inclusion in optical design. A compact objective prototype designed and produced demonstrates the advantage of curvature and the impact of tolerancing.

The Longitudinal Relation Between Community Violence Exposure and Academic Engagement During Adolescence: Exploring Families' Protective Role

Few published studies have examined the interaction between community violence exposure, academic engagement, and parental involvement, despite theory suggesting that these three domains of development are interrelated during adolescence. This study had two related objectives: (a) to assess the temporal ordering of the relation between community violence exposure and academic engagement over the course of mid-adolescence and (b) to examine whether the pattern of these relations varies by level of parental involvement. The study sample included 273 ethnic minority males (33.4% Latino and 65.6% African American) and their caregivers living in impoverished urban neighborhoods. The present study drew on data collected through in-home surveys on violence exposure, school experiences, and family functioning at three time points during mid-adolescence. Cross-lagged model results suggest that at Time 1 (M age = 13.5), community violence exposure predicted lower academic engagement at Time 2 (M age = 14.8). Between Time 2 and Time 3 (M age = 15.8), it was academic engagement that predicted lower community violence. Parental involvement moderated these relations such that academic engagement at Time 2 only reduced the risk of violence exposure at Time 3 in the presence of families with high levels of involvement relative to others in the sample. Findings suggest that practitioners might seek to promote positive school experiences as youth move into high school to reduce risk of violence exposure. Results also indicate the importance of designing interventions that target both positive family and school functioning.

Variations in hospitalization and emergency department/observation stays using the oncology care model methodology in Medicare data

OBJECTIVE

To assess variations in hospitalizations, emergency department/observational (ED/OB) stays not resulting in hospitalization, reasons for hospitalization, and hospitalization discharge destinations after chemotherapy, information not provided as part of Oncology Care Model (OCM) baseline data.

METHODS

OCM methodology was applied to the Medicare 20% sample data to identify 6-month patient episodes triggered by chemotherapy in 2012-2015. Proportions of episodes with hospitalization or ED/OB stays, reasons for hospitalization, and discharge destinations were summarized.

RESULTS

Of 485,186 6-month episodes for 255,229 patients in 13,823 practices, 25% of episodes led to ≥1 hospitalization (from 14% in breast cancer to 56% in acute leukemia), and 23% to ED/OB stays (from 18% in breast cancer to 36% in liver cancer). In 2995 practices with ≥20 total episodes, practice-level proportions of episodes with hospitalization ranged from 14% to 31% (20th-80th percentile) and with ED/OB stays from 17% to 29%. For all cancers combined, the most frequent reasons for hospitalization were infection (13%), anemia (7%), dehydration (5%), and congestive heart failure (3%); the most common discharge destinations were home (71%) followed by a skilled nursing facility (13%), death (6%), and hospice (5%). Reasons for hospitalization and discharge destinations varied by cancer type; acute leukemia episodes led to the highest rates of infection and anemia, and central nervous system tumor episodes to the highest proportions of death or hospice discharge.

CONCLUSION

The variations in frequency of and reasons for hospitalization, ED/OB stays, and hospitalization discharge destinations across cancer types should be considered when evaluating OCM practice performance.

Association between the regional variation in premature mortality and immigration in Ontario, Canada

Objectives

Health region differences in immigration patterns and premature mortality rates exist in Ontario, Canada. This study used linked population-based databases to describe the regional proportion of immigrants in the context of provincial health region variation in premature mortality.

Methods

We analyzed all adult premature deaths in Ontario from 1992 to 2012 using linked population files, Canadian census, and death registry databases. Geographic boundaries were analyzed according to 14 health service regions, known as Local Health Integration Networks (LHINs). We assessed the role of immigrant status and regional proportion of immigrants in the context of these health region variations and assessed the contribution using sex-specific multilevel negative binomial models, accounting for age, individual- and area-level immigration, and area-level material deprivation.

Results

We observed significant premature mortality variation among health service regions in Ontario between 1992 and 2012. Average annual rates ranged across LHINs from 3.03 to 6.40 per 1000 among males and 2.04 to 3.98 per 1000 among females. The median rate ratio (RR) decreased for men from 1.14 (95% CI 1.06, 1.19) to 1.07 (95% CI 1.00, 1.11) after adjusting for year, age, area-based material deprivation, and individual- and area-level immigration, and among females reduced from 1.13 (95% CI 1.05, 1.18) to 1.04 (95% CI 1.00, 1.05). These adjustments explained 84.1% and 94.4% of the LHIN-level variation in males and females respectively. Reduced premature mortality rates were associated with immigrants compared with those for long-term residents in the fully adjusted models for both males 0.43 (95% CI 0.42, 0.44) and females 0.45 (0.44, 0.46).

Conclusion

The findings demonstrate that health region differences in premature mortality in Ontario are in part explained by individual-level effects associated with the health advantage of immigrants, as well as contextual area-level effects that are associated with regional differences in the immigrant population. These factors should be considered in addition to health system factors when looking at health region variation in premature deaths.

Electronic supplementary material

The online version of this article (10.17269/s41997-020-00330-5) contains supplementary material, which is available to authorized users.

How do trainee doctors learn about research? Content analysis of Australian specialist colleges' intended research curricula

OBJECTIVES

Patients do better in research-intense environments. The importance of research is reflected in the accreditation requirements of Australian clinical specialist colleges. The nature of college-mandated research training has not been systematically explored. We examined the intended research curricula of Australian trainee doctors described by specialist colleges, their constructive alignment and the nature of scholarly project requirements.

DESIGN

We undertook content analysis of publicly available documents to characterise college research training curricula.

SETTING

We reviewed all publicly accessible information from the websites of Australian specialist colleges and their subspecialty divisions. We retrieved curricula, handbooks and assessment-related documents.

PARTICIPANTS

Fifty-eight Australian specialist colleges and their subspecialty divisions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Two reviewers extracted and coded research-related activities as learning outcomes, activities or assessments, by research stage (using, participating in or leading research) and competency based on Bloom's taxonomy (remembering, understanding, applying, analysing, evaluating, creating). We coded learning and assessment activities by type (eg, formal research training, publication) and whether it was linked to a scholarly project. Requirements related to project supervisors' research experience were noted.

RESULTS

Fifty-five of 58 Australian college subspecialty divisions had a scholarly project requirement. Only 11 required formal research training; two required an experienced research supervisor. Colleges emphasised a role for trainees in leading research in their learning outcomes and assessments, but not learning activities. Less emphasis was placed on using research, and almost no emphasis on participation. Most learning activities and assessments mapped to the 'creating' domain of Bloom's taxonomy, whereas most learning outcomes mapped to the 'evaluating' domain. Overall, most research learning and assessment activities were related to leading a scholarly project.

CONCLUSIONS

Australian specialist college research curricula appear to emphasise a role for trainees in leading research and producing research deliverables, but do not mandate formal research training and supervision by experienced researchers.

Identifying the most effective essential medicines policies for quality use of medicines: A replicability study using three World Health Organisation data-sets

Background

Poor quality use of medicines (QUM) has adverse outcomes. Governments’ implementation of essential medicines (EM) policies is often suboptimal and there is limited information on which policies are most effective.

Methods

We analysed data on policy implementation from World Health Organisation (WHO) surveys in 2007 and 2011, and QUM data from surveys during 2006–2012 in developing and transitional countries. We compared QUM scores in countries that did or did not implement specific policies and regressed QUM composite scores on the numbers of policies implemented. We compared the ranking of policies in this and two previous studies, one from the same WHO databases (2003–2007) the other from data obtained during country visits in South-East Asia (2010–2015). The rankings of a common set of 17 policies were correlated and we identified those that were consistently highly ranked.

Findings

Fifty-three countries had data on both QUM and policy implementation. Forty policies were associated with effect sizes ranging from +13% to -5%. There was positive correlation between the composite QUM indicator and the number of policies reported implemented: (r) = 0.437 (95% CI 0.188 to 0.632). Comparison of policy rankings between the present and previous studies showed positive correlation with the WHO 2003–7 study: Spearman’s rank correlation coefficient 0.498 (95% CI 0.022 to 0.789). Across the three studies, five policies were in the top five ranked positions 11 out of a possible 15 times: drugs available free at the point of care; a government QUM unit; undergraduate training of prescribers in standard treatment guidelines, antibiotics not available without prescription and generic substitution in the public sector.

Interpretation

Certain EM policies are associated with better QUM and impact increases with co-implementation. Analysis across three datasets provides a policy short-list as a minimum investment by countries trying to improve QUM and reduce antimicrobial drug misuse.

Intraperitoneal paclitaxel and cisplatin compared with dose-dense paclitaxel and carboplatin for patients with stage III ovarian cancer

Introduction

Patients diagnosed with stage III ovarian cancer are at high risk of recurrence and optimal adjuvant therapy is often debated. There is limited literature that directly compares intraperitoneal paclitaxel and cisplatin with dose-dense paclitaxel and carboplatin.

Objectives

The primary objective was to compare progression-free survival, overall survival, and tolerability of adjuvant intraperitoneal paclitaxel and cisplatin to dose-dense paclitaxel and carboplatin in stage III ovarian cancer patients.

Methods

A retrospective, IRB-approved, single center chart review was conducted reviewing adult patients with stage III ovarian cancer undergoing adjuvant intraperitoneal therapy or dose-dense therapy between 2010 and 2018.

Results

Eighty-two patients were included in the final analysis; 44 in the intraperitoneal group and 38 in the dose-dense group. Intraperitoneal therapy was not associated with a longer progression-free survival (35.4 vs. 31.1 months; P = 0.97). The duration of overall survival did not differ between intraperitoneal and dose-dense (56.3 vs. 54.5 months; P = 0.55). Dose reductions were less frequent with intraperitoneal than dose-dense (11.36% vs. 31.58%; P = 0.02). No difference in treatment delays (45.5% vs. 65.8%; P = 0.07), dose cancellations (59.1% vs. 57.9%; P = 0.91), supportive care additions (95.5% vs. 84.2%; P = 0.09), or therapy discontinuation (59.1% vs. 39.5%; P = 0.07) between groups was noted.

Conclusions

Intraperitoneal therapy with paclitaxel and cisplatin, as compared with dose-dense paclitaxel and carboplatin, did not prolong progression-free or overall survival in the adjuvant setting among stage III ovarian cancer patients. A trend towards decreased tolerability was noted with intraperitoneal therapy.

Determination of Fat in Olestra-Containing Savory Snack Products by Capillary Gas Chromatography

A quantitative method to determine fat in olestra-containing savory snack products was validated within the AOAC Peer-Verified Methods Program. The method may be used to demonstrate compliance with the guidelines of the U.S. Nutrition Labeling and Education Act for labeling products as "fat free" or "low fat." The method can measure total and saturated fat in savory snacks when present at levels of 0.2-10 g total fat and 0.1-3 g saturated fat per 30 g serving. The method is standardized to measure C6- C24 fatty acids. Extraction of olestra-containing savory snack samples with chloroform-methanol (modified AOAC Official Method 983.23) yields a lipid extract containing the total fat and olestra. The extracted lipid is hydrolyzed by lipase, yielding fatty acids and unreacted olestra. The fatty acids are precipitated as calcium soaps. Olestra is extracted from insoluble soaps with hexane and then discarded. The isolated soaps are converted back into fatty acids with hydrochloric acid and extracted with hexane. The isolated fatty acids are converted to methyl esters with boron trifluoride-methanol and quantitated by capillary gas chromatography using internal standard. Test samples were prepared by blending olestra-containing and full-fat (triglyceride) snacks to obtain 6 levels of spiking (0-10 g total fat added/30 g serving) in potato chips, potato crisps, cheese puffs, and nacho cheese-flavored corn chips. Results were linear (r2 &gt; 0.997) between 0 and 10 g fat/30 g serving for each product matrix. Mean recovery was 101 6% standard deviation (SD) for total fat and 104 ± 6% SD for saturated fat. Mean recovery by peer laboratory was 88 ± 5% SD for total fat and 95 ± 4% SD for saturated fat in potato chips (0-3 g total fat added/30 g serving). Two sets of 10 replicates of potato chips (0.5 g total fat/30 g serving and 0.16 g saturated fat/30 g serving) and potato crisps (0.5 g total fat/30 g serving and 0.16 g saturated fat/30 g serving) were analyzed by submitting and peer laboratories. Repeatability relative standard deviations ranged from 3.90 to 7.33% for total fat and from 4.01 to 11.53% for saturated fat. Reproducibility relative standard deviations were 7.33% (total fat, potato chips), 7.15% (total fat, potato crisps), 11.36% (saturated fat, potato chips), and 13.50% (saturated fat, potato crisps)

Patterns of granulocyte colony-stimulating factor prophylaxis in patients with cancer receiving myelosuppressive chemotherapy

Purpose

To evaluate patterns of primary prophylactic (PP) granulocyte colony–stimulating factor (G-CSF) use following chemotherapy by cancer type and febrile neutropenia (FN) risk.

Methods

Using a commercial administrative database, we identified adult patients diagnosed with breast, colorectal, lung, ovarian cancer, or non-Hodgkin lymphoma (NHL) who initiated chemotherapy with high risk (HR) or intermediate risk (IR) for FN between January 1, 2013, and August 31, 2017. We describe use of PP-G-CSF, proportion completing all their cycles with pegfilgrastim, timing of pegfilgrastim, and duration of short-acting G-CSF.

Results

Among 22,868 patients (breast 11,513; colorectal 3765; lung 4273; ovarian 1287; and NHL 2030), 36.8% received HR and 63.2% received IR (64.4% of whom had ≥ 1 risk factor [RF] for FN). Proportions of patients receiving PP-G-CSF in the first cycle were 76.1%, 28.2%, and 26.4% among patients receiving HR, IR, and IR plus ≥ 1 RF, respectively. Among breast cancer patients receiving HR regimens and initiating PP-pegfilgrastim, 60.4% (95% confidence interval [CI] 57.2–63.6%) initiating via on-body injector (OBI) and 51.9% (95% CI 48.0–55.8%) initiating via prefilled syringe (PFS) completed all their cycles with OBI and PFS, respectively. Among all cycles with PP-PFS, 8.5% received PFS on the same day as chemotherapy completion. Mean administrations/cycle were 3.2 (standard deviation [SD] 2.3) for filgrastim, 3.0 (SD 1.6) for filgrastim-sndz, and 4.3 (SD 2.5) for tbo-filgrastim.

Conclusions

There is under- and mistimed use of PP-G-CSF among patients at HR for FN. Novel pegfilgrastim delivery devices could help breast cancer patients at HR for FN complete all their cycles with timely prophylaxis.

Electronic supplementary material

The online version of this article (10.1007/s00520-020-05295-2) contains supplementary material, which is available to authorized users.

Family Support and Connection Groups: Long-Term Benefits for Inner-City Children?

Relatively few prevention trials have had long-term follow-up to determine if immediate impact translates to and explains long-term impact. The present report summarizes the long-term influence (measured when students are near the end of high school) of the SAFEChildren preventive intervention, which was applied during first grade. This program aims to facilitate and support developmental management, school-family connection, and social support among neigbhors through family groups and student tutoring and is focused on familes raising children in inner-city neighborhoods. Of the 424 families randomly assigned prior to first grade to intervention or no-intervention control, outcome data on at least one outcome was obtained for 375 (88.4%). Results indicate no long-term direct effects and a single mediated effect, with those in the intervention less likely to engage in risky sexual practices. Similar but non-significant trends were found for alcohol use and violence. These mixed results may suggest that family focused intervention that is relatively brief is not adequate to protect against multiple and ongoing developmental risk that arises in such communities. The limited impact is discussed in light of the uncertainty of subsequent condition on initial preventive benefits and the developmental ecology of the inner city. Implications for preventive intervention programming and for long-term evaluation are also addressed.

Identification of Actionable Fusions as an Anti-EGFR Resistance Mechanism Using a Circulating Tumor DNA Assay

PURPOSE

Gene fusions are established oncogenic drivers and emerging therapeutic targets in advanced colorectal cancer. This study aimed to detail the frequencies and clinicopathological features of gene fusions in colorectal cancer using a circulating tumor DNA assay.

METHODS

Circulating tumor DNA samples in patients with advanced colorectal cancer were analyzed at 4,581 unique time points using a validated plasma-based multigene assay that includes assessment of fusions in FGFR2, FGFR3, RET, ALK, NTRK1, and ROS1. Associations between fusions and clinicopathological features were measured using Fisher's exact test. Relative frequencies of genomic alterations were compared between fusion-present and fusion-absent cases using an unpaired t test.

RESULTS

Forty-four unique fusions were identified in 40 (1.1%) of the 3,808 patients with circulating tumor DNA detected: RET (n = 6; 36% of all fusions detected), FGFR3 (n = 2; 27%), ALK (n = 10, 23%), NTRK1 (n = 3; 7%), ROS1 (n = 2; 5%), and FGFR2 (n = 1; 2%). Relative to nonfusion variants detected, fusions were more likely to be subclonal (odds ratio, 8.2; 95% CI, 2.94 to 23.00; P < .001). Mutations associated with a previously reported anti-epidermal growth factor receptor (anti-EGFR) therapy resistance signature (subclonal RAS and EGFR mutations) were found with fusions in FGFR3 (10 of 12 patients), RET (nine of 16 patients), and ALK (seven of 10 patients). For the 27 patients with available clinical histories, 21 (78%) had EGFR monoclonal antibody treatment before fusion detection.

CONCLUSION

Diverse and potentially actionable fusions can be detected using a circulating tumor DNA assay in patients with advanced colorectal cancer. Distribution of coexisting subclonal mutations in EGFR, KRAS, and NRAS in a subset of the patients with fusion-present colorectal cancer suggests that these fusions may arise as a novel mechanism of resistance to anti-EGFR therapies in patients with metastatic colorectal cancer.