Phase II trial of domatinostat (4SC-202) in combination with avelumab in patients with previously treated advanced mismatch repair proficient oesophagogastric and colorectal adenocarcinoma: EMERGE

BACKGROUND

Most oesophagogastric adenocarcinomas (OGAs) and colorectal cancers (CRCs) are mismatch repair proficient (MMRp), responding poorly to immune checkpoint inhibition. We evaluated the safety and efficacy of domatinostat (histone deacetylase inhibitor) plus avelumab (anti-PD-L1 antibody) in patients with previously treated inoperable, advanced/metastatic MMRp OGA and CRC.

PATIENTS AND METHODS

Eligible patients were evaluated in a multicentre, open-label dose escalation/dose expansion phase II trial. In the escalation phase, patients received escalating doses of domatinostat [100 mg once daily (OD), 200 mg OD, 200 mg twice daily (BD)] orally for 14 days followed by continuous dosing plus avelumab 10 mg/kg administered intravenously 2-weekly (2qw) to determine the recommended phase II dose (RP2D). The trial expansion phase evaluated the best objective response rate (ORR) during 6 months by RECIST version 1.1 using a Simon two-stage optimal design with 2/9 and 1/10 responses required to proceed to stage 2 in the OGA and CRC cohorts, respectively.

RESULTS

Patients (n = 40) were registered between February 2019 and October 2021. Patients in the dose escalation phase (n = 12) were evaluated to confirm the RP2D of domatinostat 200 mg BD plus avelumab 10 mg/kg. No dose-limiting toxicities were observed. Twenty-one patients were treated at the RP2D, 19 (9 OGA and 10 CRC) were assessable for the best ORR; 2 patients with CRC did not receive combination treatment and were not assessable for the primary endpoint analysis. Six patients were evaluated in the dose escalation and expansion phases. In the OGA cohort, the best ORR was 22.2% (95% one-sided confidence interval lower bound 4.1) and the median duration of disease control was 11.3 months (range 9.9-12.7 months). No responses were observed in the CRC cohort. No treatment-related grade 3-4 adverse events were reported at the RP2D.

CONCLUSIONS

Responses in the OGA cohort met the criteria to expand to stage 2 of recruitment with an acceptable safety profile. There was insufficient signal in the CRC cohort to progress to stage 2.

TRIAL REGISTRATION

NCT03812796 (registered 23rd January 2019).

Occult tension pneumothorax discovered following imaging for adult trauma patients in the modern major trauma system: a multicentre observational study

BACKGROUND

Tension pneumothorax following trauma is a life-threatening emergency and radiological investigation is normally discouraged prior to treatment in traditional trauma doctrines such as ATLS. Some trauma patients may be physiologically stable enough for diagnostic imaging and occult tension pneumothorax is discovered radiologically. We assessed the outcomes of these patients and compared them with those with clinical diagnosis of tension pneumothorax prior to imaging.

METHODS

A multicentre civilian-military collaborative network of six major trauma centres in the UK collected observational data from adult patients who had a diagnosis of traumatic tension pneumothorax during a 33-month period. Patients were divided into 'radiological' (diagnosis following CT/CXR) or 'clinical' (no prior CT/CXR) groups. The effect of radiological diagnosis on survival was analysed using multivariable logistic regression that included the covariates of age, gender, comorbidities and Injury Severity Score.

RESULTS

There were 133 patients, with a median age of 41 (IQR 24-61); 108 (81%) were male. Survivors included 49 of 59 (83%) in the radiological group and 59 of 74 (80%) in the clinical group (p=0.487). Multivariable logistic regression showed no significant association between radiological diagnosis and survival (OR 2.40, 95% CI 0.80 to 7.95; p=0.130). There was no significant difference in mortality between the groups.

CONCLUSION

Radiological imaging may be appropriate for selected trauma patients at risk of tension pneumothorax if they are considered haemodynamically stable. Trauma patients may be physiologically stable enough for radiological imaging but have occult tension pneumothorax because they did not have the typical clinical presentation. The historical dogma of the 'forbidden scan' no longer applies to such patients.

PRESS survey: PREvention of surgical site infection-a global pan-specialty survey of practice protocol

Background

Surgical site infections (SSI) complicate up to 40% of surgical procedures, leading to increased patient morbidity and mortality. Previous research identified disparities in SSI prevention guidelines and clinical practices across different institutions. The study aims to identify variations in SSI prevention practices within and between specialties and financial systems and provide a representation of existing SSI preventative measures to help improve the standardization of SSI prevention practices.

Methods

This collaborative cross-sectional survey will be aimed at pan-surgical specialties internationally. The study has been designed and will be reported in line with the CROSS and CHERRIES standards. An international study steering committee will design and internally validate the survey in multiple consensus-based rounds. This will be based on SSI prevention measures outlined in the CDC (2017), WHO (2018), NICE (2019), Wounds UK (2020) and the International Surgical Wound Complications Advisory Panel (ISWCAP) guidelines. The questionnaire will include demographics, SSI surveillance, preoperative, peri-operative and postoperative SSI prevention. Data will be collected on participants' surgical specialty, operative grade, of practice and financial healthcare system of practice. The online survey will be designed and disseminated using QualtricsXM Platform™ through national and international surgical colleges and societies, in addition to social media and snowballing. Data collection will be open for 3 months with reminders, and raking will be used to ascertain the sample. Responses will be analyzed, and the chi-square test used to evaluate the impact of SSI prevention variables on responses.

Discussion

Current SSI prevention practice in UK Vascular surgery varies considerably, with little consensus on many measures. Given the inconsistency in guidelines on how to prevent SSIs, there is a need for standardization. This survey will investigate the disparity in SSI preventative measures between different surgical fields and countries.

Preliminary assessment of the radiological consequences of the hostile military occupation of the Chornobyl Exclusion Zone

The full-scale invasion of Ukraine by Russian military forces on 24 February 2022 put the radiological well-being of the people in Ukraine under unprecedented threat. Apart from the risks linked to operating nuclear power plants, there was substantial evidence of looting of facilities of all kinds, including those holding radioactive materials, as well as the scope for physical disturbance of radioactively contaminated areas and waste storage facilities. The actions of Russian military personnel invading Ukraine through the territory of the Chornobyl Exclusion Zone (the ChEZ) were of serious concern. Before its shutdown a few days after the beginning of the occupation, the automated radiation monitoring system of the ChEZ recorded sharp increases in the gamma-background in several areas which indicated some non-typical processes taking place on its territory. The State Nuclear Regulatory Inspectorate of Ukraine (SNRIU) and its technical support organisation, the Scientific and Technical Centre for Nuclear and Radiation Safety (SSTC NRS), as well as the rest of the professional nuclear community in Ukraine and worldwide, recognised the potential for movement of the radioactive contamination (reaching 101-104kBq m-2Cs-137 in the most of the territory) by the Russian military machinery and personnel to areas outside the ChEZ, creating locally contaminated spots along the routes taken by the invaders towards Kyiv. Certain apprehensions were caused by the inventory carried out after the liberation of the ChEZ which revealed the theft of calibration sources and radioactive samples from laboratories located in Chornobyl. As soon as this information became available to the public, it caused a wide response and anxiety, as a result of which SNRIU made a decision to conduct a radiation survey of the liberated territories in the Kyiv region. The survey was conducted between June and December 2022 by SSTC NRS specialists with the support of DSA. The scope of the survey was limited by available time and resources; however, the total route of the survey was about 840 km, and covered more than 50 settlements and a limited part of the ChEZ. The radiation survey combined the continuous gamma-dose rate measurements by the detectors installed in the laboratory vehicle and additional manual measurements at specified points. As a result of the radiation survey, no deterioration of the radiation situation was observed in the liberated territories. No contaminated objects, radiation sources, or other radioactive material removed from the ChEZ were found either. Measurements of the Cs-137 soil contamination in the ChEZ, although limited, corresponded to the results which had been obtained before the war. It can be concluded that in the surveyed territories, the direct impact on the public in the form of additional radioactive contamination removed from the ChEZ in February-March 2022 was negligible. The same applies to the radiation consequences of forest fires that occurred in the ChEZ during its occupation. However, due to the damage of the radiation monitoring system, explosive hazard, and destruction of transport infrastructure, the consequences of the occupation of the ChEZ by Russian troops will be long-term.

A multi-organ, lung-derived inflammatory response following in vitro airway exposure to cigarette smoke and next-generation nicotine delivery products

Despite increasing use of in vitro models that closely resemble in vivo human biology, their application in understanding downstream effects of airway toxicity, such as inflammation, are at an early stage. In this study, we used various assays to examine the inflammatory response induced in MucilAir™ tissues and A549 cells exposed to three products known to induce toxicity. Reduced barrier integrity was observed in tissues following exposure to each product, with reduced viability and increased cytotoxicity also shown. Similar changes in viability were also observed in A549 cells. Furthermore, whole cigarette smoke (CS) induced downstream phenotypic THP-1 changes and endothelial cell adhesion, an early marker of atherosclerosis. In contrast, exposure to next-generation delivery product (NGP) aerosol did not induce this response. Cytokine, histological and RNA analysis highlighted increased biomarkers linked to inflammatory pathways and immune cell differentiation following exposure to whole cigarette smoke, including GM-CSF, IL-1β, cleaved caspase-3 and cytochrome P450 enzymes. As a result of similar observations in human airway inflammation, we propose that our exposure platform could act as a representative model for studying such events in vitro. Furthermore, this model could be used to test the inflammatory or anti-inflammatory impact posed by inhaled compounds delivered to the lung.

Observation of the effect of gravity on the motion of antimatter

Einstein's general theory of relativity from 19151 remains the most successful description of gravitation. From the 1919 solar eclipse2 to the observation of gravitational waves3, the theory has passed many crucial experimental tests. However, the evolving concepts of dark matter and dark energy illustrate that there is much to be learned about the gravitating content of the universe. Singularities in the general theory of relativity and the lack of a quantum theory of gravity suggest that our picture is incomplete. It is thus prudent to explore gravity in exotic physical systems. Antimatter was unknown to Einstein in 1915. Dirac's theory4 appeared in 1928; the positron was observed5 in 1932. There has since been much speculation about gravity and antimatter. The theoretical consensus is that any laboratory mass must be attracted6 by the Earth, although some authors have considered the cosmological consequences if antimatter should be repelled by matter7-10. In the general theory of relativity, the weak equivalence principle (WEP) requires that all masses react identically to gravity, independent of their internal structure. Here we show that antihydrogen atoms, released from magnetic confinement in the ALPHA-g apparatus, behave in a way consistent with gravitational attraction to the Earth. Repulsive 'antigravity' is ruled out in this case. This experiment paves the way for precision studies of the magnitude of the gravitational acceleration between anti-atoms and the Earth to test the WEP.

Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

Impact of post-transplant diabetes on left ventricular function following heart transplantation

Background

Orthotopic heart transplantation (OHT) is an end-stage treatment option for heart failure (HF). Although post-transplant diabetes (PTDM) is a well-described complication following immunosuppressive treatment, the impact on LV function post-OHT has not been evaluated. The purpose of this study was to analyse the influence of PTDM on LV function in OHT patients using conventional and speckle tracking echocardiography. Furthermore, we aimed to compare echocardiographic LV function parameters to HbA1c levels in OHT recipients with or without PTDM.

Methods

The study included 104 (n=77 male, mean age 51±15 years) consecutive OHT patients (PTDM n=36) examined at their routine 3-year follow-up. Blood pressure, heart rate, and HbA1c levels were recorded in conjunction with the echocardiographic examination.

Results

Participants with PTDM demonstrated impaired LV function measured by global longitudinal strain (p=0.002). Patients with PTDM also revealed increased septum diameter (p=0.008), and a lower diastolic EA-ratio (p=0.04) compared to the non-PTDM patients. A weak correlation between high HbA1c levels and poor LVGLS was detected (r=0.30, p<0.05). No correlation was found when comparing echocardiographic parameters to blood pressure and heart rate.

Conclusion

A subtle LV dysfunction, including remodelling of the heart (i.e., increased wall thickness), reduced longitudinal contractile function, and altered diastolic function, was present in OHT patients with PTDM. Our findings suggest that sub-clinical myocardial dysfunction is present in OHT patients with PTDM and may progress to clinical LV dysfunction and HF. Hence, analysing secondary cardiac effects of PTDM in OHT patients may have a therapeutic and prognostic value and could potentially influence long-term patient survival.

Funding Acknowledgement

Type of funding sources: None.

Feasibility of tumour-focused adaptive radiotherapy for bladder cancer on the MR-linac

Bladder tumour-focused magnetic resonance image-guided adaptive radiotherapy using a 1.5 Tesla MR-linac is feasible. A full online workflow adapting to anatomy at each fraction is achievable in approximately 30 min. Intra-fraction bladder filling did not compromise target coverage with the class solution employed.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

OP0012 INTERFERON-α MEDIATED THERAPEUTIC RESISTANCE IN EARLY RA IMPLICATES EPIGENETIC REPROGRAMMING

Background

An interferon gene signature (IGS) is present in approximately 50% of early, treatment naive rheumatoid arthritis (eRA) patients. We previously demonstrated it negatively impacts on initial disease outcomes.

Objectives

To 1) reproduce previous findings demonstrating the harmful effects of the IGS on early RA clinical outcomes, 2) identify which IFN class is responsible for the IGS and 3) seek evidence that IFN-α exposure contributes to harmful epigenetic footprint at disease onset.

Methods

In a large multicentre inception cohort (n=190) of eRA patients (RA-MAP TACERA) whole blood transcriptome, IGS (MxA, IFI44L, OAS1, ISG15, IFI6) and circulating interferons (IFN)-α, -β, -γ and -λ was examined at baseline and 6 months in conjunction with disease activity and clinical characteristics. A separate eRA cohort of paired methylome and transcriptome from CD4 T and CD19 B cells (n=41 for each) was used to explore any epigenetic influence of the IGS.

Results

The baseline IGS reproducibly and significantly negatively impacts on 6-month clinical outcomes. In the high IGS cohort there was increased DAS-28 (p=0.025) and reduced probability of achieving a good EULAR response (p=0.034) at 6-months. In addition, the IGS in eRA is shown for the first time to predominantly reflect raised circulating IFN-α protein, not other classes of IFN and examination of whole blood upstream nucleic acid sensors expression suggest a RNA trigger. Both the IGS and IFN-α significantly fell in parallel at 6 months (p<0.0001), whereas other classes of IFN remained statistically static. There was a significant association with IFN-α and RF titre but not ACPA. Comparison of CD4 T and CD19 B cells between IGS high and low eRA patients demonstrated differentially methylated CPG sites and altered transcript expression of disease relevant genes e.g. PARP9, STAT1, EPTSI1 which was similarly, and persistently, altered 6 months in the separate TACERA cohort. Differentially methylated CPGs implicated altered transcription factor binding in B cells (GATA3, ETSI, NFATC2, EZH2) and T cells (p300, HIF1α) which cumulatively suggested IFN-α induced epigenetic changes promoting increased, and sustained, lymphocyte activation, proliferation and loss of anergy in the IGS high cohort.

Conclusion

We validate that the IGS is a robust prognostic biomarker in eRA predicting poor therapeutic response. Its persistent harmful effects may be driven via epigenetic modifications. These data have relevance for other IFN-α states, such as COVID-19, but also provide a rationale for the initial therapeutic targeting of IFN-α signalling, such as with JAKi, at disease onset in stratified eRA subsets.

References

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Acknowledgements

JDI is a National Institute for Health Research (NIHR) Senior Investigator. The authors acknowledge the support of TACERA Principal Investigators from all contributing NHS sites and the members of the TACERA Study Steering and Data Monitoring Committee. Additional acknowledgements include patient volunteers and administrative support from Ben Hargreaves. Newcastle researchers received infrastructural support via the Versus Arthritis Research into Inflammatory Arthritis Centre (Ref 22072), funding from The Medical Research Council; Academy of Medical Sciences; British Society of Rheumatology; The Wellcome Trust; JGW Patterson Foundation; Immune-Mediated Inflammatory Disease Biobank in the UK (IMID-Bio-UK), ANR and RTCure. This work was supported by the NIHR Newcastle Biomedical Research Centre at Newcastle Hospitals Foundation Trust and Newcastle University; views expressed are the authors’ and not necessarily those of the National Health Service, the National Institute of Health Research or the Department of Health.

Disclosure of Interests

Faye Cooles Speakers bureau: Astrazeneca: December 2021, Jessica Tarn: None declared, Dennis Lendrem: None declared, Najib Naamane: None declared, Alice Lin: None declared, Ben Millar: None declared, Nicola Maney: None declared, Nishanthi Thalayasingam: None declared, Vincent Bondet: None declared, Darragh Duffy: None declared, Michael Barnes: None declared, Graham Smith: None declared, Sandra Ng: None declared, David Watson: None declared, Rafael Henkin: None declared, Andrew Cope: None declared, Louise Reynard: None declared, Arthur Pratt: None declared, RA-MAP Consortium: None declared, John Isaacs Speakers bureau: speaker/consulting fees from AbbVie, Gilead, Roche and UCB., Grant/research support from: JDI discloses research grants from Pfizer, Janssen and GSK.

Evidence for X(3872) in Pb-Pb Collisions and Studies of its Prompt Production at sqrt[s_{NN}]=5.02 TeV

The first evidence for X(3872) production in relativistic heavy ion collisions is reported. The X(3872) production is studied in lead-lead (Pb-Pb) collisions at a center-of-mass energy of sqrt[s_{NN}]=5.02  TeV per nucleon pair, using the decay chain X(3872)→J/ψπ^{+}π^{-}→μ^{+}μ^{-}π^{+}π^{-}. The data were recorded with the CMS detector in 2018 and correspond to an integrated luminosity of 1.7  nb^{-1}. The measurement is performed in the rapidity and transverse momentum ranges |y|<1.6 and 15<p_{T}<50  GeV/c. The significance of the inclusive X(3872) signal is 4.2 standard deviations. The prompt X(3872) to ψ2S yield ratio is found to be ρ^{Pb-Pb}=1.08±0.49(stat)±0.52(syst), to be compared with typical values of 0.1 for pp collisions. This result provides a unique experimental input to theoretical models of the X(3872) production mechanism, and of the nature of this exotic state.

Delayed Hematogenous Metastasis Versus Second Primary Squamous Cell Carcinoma of the Neck in a Patient With Previous Cancer of the Cervix

Squamous cell carcinoma (SCC) of the uterine cervix commonly spreads through direct infiltration and disseminates by lymphatic or hematogenous pathways. The most frequent locations for metastasis are lungs, liver, and bone. Other distant metastatic sites are rare, with only 1 reported case of neck metastasis. We present here a 73-year-old female with a prior human papillomavirus (HPV) + SCC of the cervix that had metastasized to her peri-aortic lymph nodes. Eight years after diagnosis and treatment, she returned with a hypermetabolic supraclavicular lymph node and new left-sided neck mass. Biopsy of the neck mass revealed invasive SCC positive for high-risk HPV genotype. The presence of high-risk HPV genotypes in both the cervix and supraclavicular lymph node, without evidence of second primary tumor, implies that the neck mass is a delayed metastasis of the patient's previous cervical cancer. This marks the second recorded case of neck metastasis from a SCC of the cervix.

1026 Assessing the Reliability of 3D Imaging for Wound Measurements

Aim

To investigate the inter and intra reliability of using 3D imaging to measure wounds.

Method

20 wound models of 4 different shaped wounds in 5 different colours were created from plastic mouldable beads. 3D images were taken using the BlasterX Senz3D camera and measured using the GPC Wound Measure application (version 3.15.0.0, UK). Intra-user reliability was determined comparing 20 wound measurements of each wound model. Inter-user reliability was determined by 5 different clinicians photographing each model and independently measuring each wound photo. The inter- and intra-rater measurements for wound surface area and volume were compared using the ICC and differences from the overall mean plotted on Bland-Altman graphs.

Results

The interclass co-efficient (ICC) for inter-rater reliability in measuring surface area was 0.958 (95% CI 0.919-0.981, p &lt; 0.005). The intra-rater reliability when measuring wound surface area was 0.996 (95% CI 0.993-0.998, p &lt; 0.005). For wound volume, the ICC for inter-rater reliability was 0.925 (95% CI 0.857-0.967, p &lt; 0.005) and 0.999 (95% CI 0.998-0.999, p &lt; 0.005) for intra-user reliability. 5.5% of measurements were outside 2 SD of the mean for wound volume.

Conclusions

3D imaging offers a quick, reliable, and easy to use solution to measuring wounds. We have shown it is a reliable and reproducible method of measuring wounds between different clinicians.

1031 A Mixed Methods Feasibility Study of Extracorporeal Shockwave Therapy for Diabetic Foot Ulcers

Aim

The purpose of this mixed methods feasibility study was to assess the feasibility of delivering ESWT to patients with DFUs. It also aimed to explore any potential clinical effect of ESWT on wound healing and investigate whether ESWT may offer any patient reported benefits.

Method

A single centre mixed methods feasibility study. Patients with a DFU who met the eligibility criteria underwent ESWT 3 times in over 7 days. Primary outcome was feasibility of delivering the intervention. Secondary outcomes included wound size, number of DFU healed at 12 weeks and quality of life. Semi-structured interviews explored participants experience of undergoing ESWT.

Results

22.6% (24/106) of patients screened were recruited. The mean attendance to clinic was 90.9% and 65.1% to follow up. The mean score for acceptability and tolerability was 9.86 (SD 0.48, 95% CI 9.62-10.01) and 9.15 (SD 2.57, 95% CI 7.87-10.42) respectively. There were no serious adverse events or side effects. 45.5% of DFU healed during follow up and quality of life scores improved until 8 weeks. Key themes identified from the qualitative interviews were desire for the fast healing, improved quality of life, new treatments must be flexible and accessible on transport.

Conclusions

This study has shown it is possible to recruit and retain patents into this research. This study supports development of a large randomised control trial to determine the clinical and cost effectiveness of ESWT for DFU healing.

803 Management of An Intra-Oral Resection with Integra® Dermal Regeneration Template – Worth A Bite?

Introduction

There are a spectrum of treatment options available for reconstruction of oral mucosal defects including secondary healing, skin grafts, local flaps and microvascular free flaps. We present the use of an alternative intra-oral reconstruction with Integra® Dermal Regeneration Template.

Case Report

An 85-year-old patient with a severe gag reflex and history of oral cancer presented with biopsy proven severe dysplasia of the right palate extending to the hamular notch. She was treated with wide local excision, extraction of teeth, buccal fat pad advancement for closure of an oral-antral communication and placement of Integra® Dermal Regeneration Template. Discharge was possible the same day as the patient was able to eat and had minimal pain.

Discussion

Integra® Dermal Regeneration Template is a bilayer wound matrix consisting of silicone in the outer layer with bovine collagen and glycosaminoglycan from shark cartilage in the inner layer. Oral cancer predominantly affects the older population, and this method can reduce surgical time, remove donor site pain, reduce post-operative pain and avoid use of a cover plate where a strong gag reflex was present. The area heals quickly and aids quick restoration of oral function.

Conclusion

Integra® Dermal Regeneration Template has been used for head and neck defects with good outcomes. It is being increasingly used intra-orally with good outcomes, suggesting a further application of the material with advantages over traditional techniques in specific patient groups.

933 The Glass Half Full? A Case Of Cutaneous Neuroma Formation Post Laceration Of First Web-Space Of The Hand

Introduction

neuromas are lesions resulting from abnormal nerve regeneration following a peripheral nerve injury and may cause severe pain.

Method

we present a case of a 54-year-old female who developed a painful cutaneous lesion over the first web-space of the hand following an untreated glass laceration 3 years previously.

Results

surgical resection revealed a 100% transection of ulnar digital nerve (UDN) of thumb with regeneration into the skin. A posterior interosseous nerve (PIN) nerve graft was required to bridge the resulting 15mm gap. Histopathology revealed a 12x12mm neuroma extending into dermis.

Conclusions

cutaneous neuroma is a rare consequence of penetrating trauma. This case highlights the need for prompt assessment of penetrating injuries to reduce risk of neuroma formation.

Right ventricular stroke work index in adult patients with pulmonary arterial hypertension: - a comparison between echocardiography and right heart catheterization

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Swedish Society of Pulmonary Hypertension

Background

In adult patients with pulmonary arterial hypertension (PAH), right ventricular (RV) failure may worsen rapidly, constituting a negative prognostic factor.  In this population, non-invasive assessment of RV function is challenging. RV stroke work index (RVSWI) reflects right ventricular function and has been proposed to predict outcome in PAH. However, RVSWI assessed by echocardiography (ECHO) has not been thoroughly compared to measures with right heart catheterization (RHC) in adults. The aim of the present study was to therefore evaluate RVSWI derived by echocardiography (RVSWIECHO) vs. RHC (RVSWIRHC).

Methods

 Fifty-four consecutive treatment naïve adult patients with PAH, were retrospectively analysed. All patients performed echocardiography and RHC with a median time of 1 day [IQR 0-1 days]. RVSWIRHC was calculated as: (mean pulmonary arterial pressure (mPAP) – mean right atrial pressure (mRAP)) x stroke volume index (SVI)RHC. Four methods for RVSWIECHO were evaluated: RVSWIECHO-1 = Tricuspid regurgitant maximum pressure gradient (TRmaxPG) x SVIECHO, RVSWIECHO-2=(TRmaxPG-mRAPECHO) x SVIECHO, RVSWIECHO-3 = TR mean gradient (TRmPG) x SVIECHO and RVSWIECHO-4=(TRmPG–mRAPECHO) x SVIECHO. Vena cava inferior diameter and its collapsibility were used for estimation of mRAPECHO.. Pearson’s correlation coefficients were used and data was expressed as mean ± standard deviation.

Results

Mean RVSWIRHC was 1132 ± 352 mmHg*mL*m-2.  Mean RVSWIECHO-1-4 was: 1904 ± 568, 1732 ± 531, 1090 ± 366 and 918 ± 336 mmHg*mL*m-2, respectively. There was no significant difference between RVSWIRHC and RVSWIECHO-3 in mean values, although they exhibited the lowest correlation, but moderate (r = 0.66). The strongest correlation was demonstrated for  RVSWIECHO-2 (r = 0.78, p &lt; 0.001), followed by a moderate correlation for  RVSWIECHO-1 and RVSWIECHO-4 (r = 0.75 and r = 0.69, p &lt; 0.001). The absolute (relative) bias for RVSWIECHO-1 was  -772 ± 385 (-50 ± 20%) mmHg*mL*m-2, RVSWIECHO-2 -600 ± 339 (-41 ± 20%) mmHg*mL*m-2, RVSWIECHO-3 42 ± 286 (5 ± 25%) mmHg*mL*m-2 and for RVSWIECHO-4 214 ± 273 (23 ± 27%) mmHg*mL*m-2.

Conclusion

RVSWIECHO-3, using the mean tricuspid gradient and SVIECHO, showed no significant difference to RVSWIRHC, albeit a moderate correlation between the methods. RVSWIECHO-1, RVSWIECHO- 2 and RVSWIECHO-4 exhibited moderate to strong correlations to RVSWIRHC, but poor concordance between absolute values. The clinical utility of RVSWIECHO and RVSWIRHC in assessing RV function in relation to PAH prognosis, risk stratification and treatment response remains to be evaluated in a larger clinical context.

Measurement of single-diffractive dijet production in proton-proton collisions at s = 8 Te with the CMS and TOTEM experiments

Measurements are presented of the single-diffractive dijet cross section and the diffractive cross section as a function of the proton fractional momentum loss ξ and the four-momentum transfer squared t. Both processesp p → p X andp p → X p , i.e. with the proton scattering to either side of the interaction point, are measured, whereX includes at least two jets; the results of the two processes are averaged. The analyses are based on data collected simultaneously with the CMS and TOTEM detectors at the LHC in proton-proton collisions ats = 8 Te during a dedicated run withβ ∗ = 90 m at low instantaneous luminosity and correspond to an integrated luminosity of 37.5 nb - 1 . The single-diffractive dijet cross section σ jj p X , in the kinematic region ξ < 0.1 ,0.03 < | t | < 1 Ge 2 , with at least two jets with transverse momentump T > 40 Ge , and pseudorapidity | η | < 4.4 , is 21.7 ± 0.9 (stat) - 3.3 + 3.0 (syst) ± 0.9 (lumi) nb . The ratio of the single-diffractive to inclusive dijet yields, normalised per unit of ξ , is presented as a function of x, the longitudinal momentum fraction of the proton carried by the struck parton. The ratio in the kinematic region defined above, for x values in the range - 2.9 ≤ log 10 x ≤ - 1.6 , is R = ( σ jj p X / Δ ξ ) / σ jj = 0.025 ± 0.001 (stat) ± 0.003 (syst) , where σ jj p X and σ jj are the single-diffractive and inclusive dijet cross sections, respectively. The results are compared with predictions from models of diffractive and nondiffractive interactions. Monte Carlo predictions based on the HERA diffractive parton distribution functions agree well with the data when corrected for the effect of soft rescattering between the spectator partons.

Measurement of single-diffractive dijet production in proton-proton collisions at s = 8 Te with the CMS and TOTEM experiments

Measurements are presented of the single-diffractive dijet cross section and the diffractive cross section as a function of the proton fractional momentum loss ξ and the four-momentum transfer squared t. Both processes p p → p X and p p → X p , i.e. with the proton scattering to either side of the interaction point, are measured, where X includes at least two jets; the results of the two processes are averaged. The analyses are based on data collected simultaneously with the CMS and TOTEM detectors at the LHC in proton-proton collisions at s = 8 Te during a dedicated run with β ∗ = 90 m at low instantaneous luminosity and correspond to an integrated luminosity of 37.5 nb - 1 . The single-diffractive dijet cross section σ jj p X , in the kinematic region ξ < 0.1 , 0.03 < | t | < 1 Ge 2 , with at least two jets with transverse momentum p T > 40 Ge , and pseudorapidity | η | < 4.4 , is 21.7 ± 0.9 (stat) - 3.3 + 3.0 (syst) ± 0.9 (lumi) nb . The ratio of the single-diffractive to inclusive dijet yields, normalised per unit of ξ , is presented as a function of x, the longitudinal momentum fraction of the proton carried by the struck parton. The ratio in the kinematic region defined above, for x values in the range - 2.9 ≤ log 10 x ≤ - 1.6 , is R = ( σ jj p X / Δ ξ ) / σ jj = 0.025 ± 0.001 (stat) ± 0.003 (syst) , where σ jj p X and σ jj are the single-diffractive and inclusive dijet cross sections, respectively. The results are compared with predictions from models of diffractive and nondiffractive interactions. Monte Carlo predictions based on the HERA diffractive parton distribution functions agree well with the data when corrected for the effect of soft rescattering between the spectator partons.

Feasibility of magnetic resonance guided radiotherapy for the treatment of bladder cancer

Whole bladder magnetic resonance image-guided radiotherapy using the 1.5 Telsa MR-linac is feasible. Full online adaptive planning workflow based on the anatomy seen at each fraction was performed. This was delivered within 45 min. Intra-fraction bladder filling did not compromise target coverage. Patients reported acceptable tolerance of treatment.

A Deep Neural Network for Simultaneous Estimation of b Jet Energy and Resolution

We describe a method to obtain point and dispersion estimates for the energies of jets arising from b quarks produced in proton-proton collisions at an energy ofs = 13 TeV at the CERN LHC. The algorithm is trained on a large sample of simulated b jets and validated on data recorded by the CMS detector in 2017 corresponding to an integrated luminosity of 41fb - 1 . A multivariate regression algorithm based on a deep feed-forward neural network employs jet composition and shape information, and the properties of reconstructed secondary vertices associated with the jet. The results of the algorithm are used to improve the sensitivity of analyses that make use of b jets in the final state, such as the observation of Higgs boson decay to b b ¯ .

Studies of Charm Quark Diffusion inside Jets Using Pb-Pb and pp Collisions at sqrt[s_{NN}]=5.02 TeV

The first study of charm quark diffusion with respect to the jet axis in heavy ion collisions is presented. The measurement is performed using jets with p_{T}^{jet}>60  GeV/c and D^{0} mesons with p_{T}^{D}>4  GeV/c in lead-lead (Pb-Pb) and proton-proton (pp) collisions at a nucleon-nucleon center-of-mass energy of sqrt[s_{NN}]=5.02  TeV, recorded by the CMS detector at the LHC. The radial distribution of D^{0} mesons with respect to the jet axis is sensitive to the production mechanisms of the meson, as well as to the energy loss and diffusion processes undergone by its parent parton inside the strongly interacting medium produced in Pb-Pb collisions. When compared to Monte Carlo event generators, the radial distribution in pp collisions is found to be well described by pythia, while the slope of the distribution predicted by sherpa is steeper than that of the data. In Pb-Pb collisions, compared to the pp results, the D^{0} meson distribution for 4<p_{T}^{D}<20  GeV/c hints at a larger distance on average with respect to the jet axis, reflecting a diffusion of charm quarks in the medium created in heavy ion collisions. At higher p_{T}^{D}, the Pb-Pb and pp radial distributions are found to be similar.

Search for physics beyond the standard model in events with jets and two same-sign or at least three charged leptons in proton-proton collisions at s = 13 TeV

A data sample of events from proton-proton collisions with at least two jets, and two isolated same-sign or three or more charged leptons, is studied in a search for signatures of new physics phenomena. The data correspond to an integrated luminosity of 137 fb - 1 at a center-of-mass energy of 13 TeV , collected in 2016-2018 by the CMS experiment at the LHC. The search is performed using a total of 168 signal regions defined using several kinematic variables. The properties of the events are found to be consistent with the expectations from standard model processes. Exclusion limits at 95% confidence level are set on cross sections for the pair production of gluinos or squarks for various decay scenarios in the context of supersymmetric models conserving or violating R parity. The observed lower mass limits are as large as 2.1 TeV for gluinos and 0.9 TeV for top and bottom squarks. To facilitate reinterpretations, model-independent limits are provided in a set of simplified signal regions.

Study of central exclusive production in proton-proton collisions at s = 5.02 and 13TeV

Central exclusive and semiexclusive production of pairs is measured with the CMS detector in proton-proton collisions at the LHC at center-of-mass energies of 5.02 and 13TeV. The theoretical description of these nonperturbative processes, which have not yet been measured in detail at the LHC, poses a significant challenge to models. The two pions are measured and identified in the CMS silicon tracker based on specific energy loss, whereas the absence of other particles is ensured by calorimeter information. The total and differential cross sections of exclusive and semiexclusive central production are measured as functions of invariant mass, transverse momentum, and rapidity of the system in the fiducial region defined as transverse momentum and pseudorapidity . The production cross sections for the four resonant channels , , , and are extracted using a simple model. These results represent the first measurement of this process at the LHC collision energies of 5.02 and 13TeV.

Measurements of tt[over ¯]H Production and the CP Structure of the Yukawa Interaction between the Higgs Boson and Top Quark in the Diphoton Decay Channel

The first observation of the tt[over ¯]H process in a single Higgs boson decay channel with the full reconstruction of the final state (H→γγ) is presented, with a significance of 6.6 standard deviations (σ). The CP structure of Higgs boson couplings to fermions is measured, resulting in an exclusion of the pure CP-odd structure of the top Yukawa coupling at 3.2σ. The measurements are based on a sample of proton-proton collisions at a center-of-mass energy sqrt[s]=13  TeV collected by the CMS detector at the LHC, corresponding to an integrated luminosity of 137  fb^{-1}. The cross section times branching fraction of the tt[over ¯]H process is measured to be σ_{tt[over ¯]H}B_{γγ}=1.56_{-0.32}^{+0.34}  fb, which is compatible with the standard model prediction of 1.13_{-0.11}^{+0.08}  fb. The fractional contribution of the CP-odd component is measured to be f_{CP}^{Htt}=0.00±0.33.

A randomised phase II trial of hydroxychloroquine and imatinib versus imatinib alone for patients with chronic myeloid leukaemia in major cytogenetic response with residual disease

In chronic-phase chronic myeloid leukaemia (CP-CML), residual BCR-ABL1+ leukaemia stem cells are responsible for disease persistence despite TKI. Based on in vitro data, CHOICES (CHlorOquine and Imatinib Combination to Eliminate Stem cells) was an international, randomised phase II trial designed to study the safety and efficacy of imatinib (IM) and hydroxychloroquine (HCQ) compared with IM alone in CP-CML patients in major cytogenetic remission with residual disease detectable by qPCR. Sixty-two patients were randomly assigned to either arm. Treatment 'successes' was the primary end point, defined as ≥0.5 log reduction in 12-month qPCR level from trial entry. Selected secondary study end points were 24-month treatment 'successes', molecular response and progression at 12 and 24 months, comparison of IM levels, and achievement of blood HCQ levels >2000 ng/ml. At 12 months, there was no difference in 'success' rate (p = 0.58); MMR was achieved in 80% (IM) vs 92% (IM/HCQ) (p = 0.21). At 24 months, the 'success' rate was 20.8% higher with IM/HCQ (p = 0.059). No patients progressed. Seventeen serious adverse events, including four serious adverse reactions, were reported; diarrhoea occurred more frequently with combination. IM/HCQ is tolerable in CP-CML, with modest improvement in qPCR levels at 12 and 24 months, suggesting autophagy inhibition maybe of clinical value in CP-CML.

Mixed higher-order anisotropic flow and nonlinear response coefficients of charged particles in PbPb collisions at s NN = 2.76 and 5.02 TeV

Anisotropies in the initial energy density distribution of the quark-gluon plasma created in high energy heavy ion collisions lead to anisotropies in the azimuthal distributions of the final-state particles known as collective anisotropic flow. Fourier harmonic decomposition is used to quantify these anisotropies. The higher-order harmonics can be induced by the same order anisotropies (linear response) or by the combined influence of several lower order anisotropies (nonlinear response) in the initial state. The mixed higher-order anisotropic flow and nonlinear response coefficients of charged particles are measured as functions of transverse momentum and centrality in PbPb collisions at nucleon-nucleon center-of-mass energies s NN = 2.76 and 5.02 TeV with the CMS detector. The results are compared with viscous hydrodynamic calculations using several different initial conditions, as well as microscopic transport model calculations. None of the models provides a simultaneous description of the mixed higher-order flow harmonics and nonlinear response coefficients.

Measurement of the Jet Mass Distribution and Top Quark Mass in Hadronic Decays of Boosted Top Quarks in pp Collisions at sqrt[s]=13 TeV

A measurement is reported of the jet mass distribution in hadronic decays of boosted top quarks produced in pp collisions at sqrt[s]=13  TeV. The data were collected with the CMS detector at the LHC and correspond to an integrated luminosity of 35.9  fb^{-1}. The measurement is performed in the lepton+jets channel of tt[over ¯] events, where the lepton is an electron or muon. The products of the hadronic top quark decay t→bW→bqq[over ¯]^{'} are reconstructed as a single jet with transverse momentum larger than 400 GeV. The tt[over ¯] cross section as a function of the jet mass is unfolded at the particle level and used to extract a value of the top quark mass of 172.6±2.5  GeV. A novel jet reconstruction technique is used for the first time at the LHC, which improves the precision by a factor of 3 relative to an earlier measurement. This highlights the potential of measurements using boosted top quarks, where the new technique will enable future precision measurements.