It's time to regulate - The importance of accurate surgical-grade tourniquet autoregulation in blood flow restriction exercise applications

OBJECTIVE

Evaluate the efficacy of five common blood flow restriction (BFR) systems to accurately maintain and autoregulate BFR pressure in the tourniquet cuff near target pressure throughout exercise.

DESIGN

Randomised crossover design.

SETTING

Laboratory.

PARTICIPANTS

15 healthy individuals.

OUTCOME MEASURES

1) Percentage of total BFR time that surgical-grade tourniquet autoregulation, defined as automatic and rapid self-regulation of cuff pressure to within ±15 mmHg of initial target pressure within 1 s in the presence of transient pressure changes associated with exercise, was provided; 2) pressure change in the BFR cuff throughout exercise, by comparing the initial target pressure to the measured pressure at completion of BFR exercise.

RESULTS

One BFR system could provide surgical-grade tourniquet autoregulation for the whole duration (100 ± 0%) of the BFR exercise in all subjects. In two of the five BFR systems evaluated, measured cuff pressure at the end of exercise was not different (p < 0.05) to the initial target pressure.

CONCLUSIONS

Surgical-grade tourniquet autoregulation is important to consistently and reliably apply a targeted BFR pressure stimulus. This may allow BFR methodology and protocols to be accurately implemented and controlled so that the results can be more meaningfully compared, leading to the potential optimization of applications.

239. Acute Thromboembolism in Non-ICU Hospitalized Patients with COVID-19 infection: Examining the Impact of Prior COVID Vaccination

Background

Patients hospitalized with severe COVID-19 infections are at risk for acute thromboembolism. There are few data on the impact of vaccines on COVID-associated acute thromboembolism (CA-ATE) in patients hospitalized with COVID-19 infection.

Methods

Retrospective cohort of CA-ATE between March 2020 and March 2022 (Torrance Memorial Medical Center, pre-pandemic ATE incidence &lt; 1%). Inclusion criteria were confirmed COVID infection, &gt; 18 years, not admitted to ICU, and standard-dose thromboprophylaxis. Exclusion criteria were pregnancy, partial vaccination, and therapeutic dose anticoagulation. Primary outcome was CA-ATE incidence identified by routine clinical testing. We performed a multiple logistic regression for CA-ATE risk factors.

Results

Of 3,218 hospitalized COVID-19 patients, 1,428 patients were included; 185 were vaccinated (13%) and 1,243 unvaccinated (87%). Vaccinated status was associated with older age, diabetes, heart failure, and chronic kidney disease (p&lt; 0.01). CA-ATE was noted in 7.0% (2.2% deep vein thrombosis (DVT), 0.5% pulmonary embolism (PE), 2.7% myocardial infarction (MI), 1.6% Ischemic stroke (IS)) in the vaccinated and 3.9% (2.7% DVT, 1.5% PE, 1.0% MI, 0.8% IS) in the unvaccinated.

In our multivariate model, we found no significant difference in incident CA-ATE between vaccinated and unvaccinated (7.0% vs 3.9%, adj OR=1.35, [95% CI 0.67-2.58], p=0.38). CA-ATE was associated with older age (68 vs 61 years, OR=1.03, [95% CI 1.01-1.05], p=0.01) and heart failure (24% vs 7%, OR=2.84, [95% CI 1.35-6.00], p=0.006).

No significant difference was seen in mortality (3.8% vs 4.8%, OR=0.79, [95% CI 0.35-1.69], p=0.56), CRP AUC24hr (5.7 vs 4.7, p=0.18), or D-dimer AUC24hr (596 vs 653, p=0.77) between vaccinated and unvaccinated patients.

Table 2 Primary Outcomes in SARS-CoV-2 Patients Who Received Standard Chemo-thromboprophylaxis.

After performing a multiple logistic regression, there was no statistically significant difference between vaccinated and unvaccinated groups. Older age (OR=1.03, [95% CI 1.01-1.05], p=0.011) and Heart Failure (OR=2.84, [95% CI 1.35-6.00], p=0.006) were the most influential factors for thrombosis.

Conclusion

Adult, non-ICU, hospitalized, COVID-19 patients are at high risk for ATE. We found no association between vaccination status and ATE, but older age and congestive heart failure were predictive in this population. Decisions to anticoagulate non-ICU patients hospitalized with acute COVID-19 infections may not need to consider COVID vaccination status in as part of medical decision making, but may instead need to focus on underlying, high-risk, co-morbidities.

Disclosures

James McKinnell, M.D., Eli Lilly: Grant/Research Support|Eli Lilly: Funds Paid To Instituion for Clinical Research|Genentech: Grant/Research Support|Genentech: Funds to Insitution for Clinical Trial Work|Gilead: Grant/Research Support|Gilead: Paid to Institution for clinical research|Pfizer Pharmaceutc: Grant/Research Support|Pfizer Pharmaceutc: Funds to Institution for FDA Clinical Research|Thermo Fisher: Advisor/Consultant Loren G. Miller, MD MPH, ContraFect: Grant/Research Support|GSK: Grant/Research Support|Medline: Grant/Research Support|Merck: Grant/Research Support Loren G. Miller, MD MPH, ContraFect: Grant/Research Support|GSK: Grant/Research Support|Medline: Grant/Research Support|Merck: Grant/Research Support.

“I'm at breaking point”; Exploring pharmacists' resilience, coping and burnout during the COVID-19 pandemic

Background

There is a lack of evidence on how the multimodal dynamic process of resilience has impacted personal adaptation of frontline healthcare professionals, working under extreme pressure during the COVID-19 global pandemic.

Objectives

To explore resilience, burnout and wellbeing for UK pharmacists in patient-facing roles, including individual and organisational factors that align to the ABC-X theoretical model of the dynamic process of resilience.

Methods

A non-experimental pragmatist research design was adopted, with a cross-sectional online survey distributed via social media and professional networks between June and July 2020. Quantitative data aligned to a positivist research paradigm was collected using validated scores, to statistically analyse wellbeing, burnout and resilience. Qualitative textual data, consistent with an interpretivist research paradigm, were analysed following an inductive thematic approach.

Results

A total of 199 surveys from pharmacists working within community, hospital and GP sectors were analysed. Wellbeing scores were strongly correlated to resilience scores. Wellbeing and resilience scores were both inversely correlated with burnout scores. Two-thirds of participants were classified as high-risk within the burnout scales.

Key stressors were highlighted by participants, who described how individual resources and perceptions shaped their experience, which overall contributed to their burnout. Organisations that supported pharmacists embraced change and quickly adopted new ways of working, such as teleconsultations, flexible and remote working, redesign of workflow, alongside clear guidance. However, there was also reported frustration at lack of, slow or conflicting guidance from employers.

Conclusions

This study adds to the growing evidence base for how individuals are affected by adverse events in a dynamic environment, alongside the role that employers can play in supporting individual and organisational resilience. It provides an opportunity to learn from pharmacists' responses to the COVID-19 pandemic, and a call to action for healthcare organisations to rebuild and invest resources into sustained support for staff wellbeing.

Pregnancy Outcomes After Living Liver Donation: A Multi-Institutional Study

Nearly half of living liver donors in North America are women of child-bearing age. Fetal and maternal outcomes after donation are unknown. We conducted a retrospective cohort study of female living liver donors (aged 18-50 years at donation) from 6 transplant centers. Participants were surveyed about their pregnancies and fertility. Outcomes were compared between predonation and postdonation pregnancies. Generalized estimating equations were clustered on donor and adjusted for age at pregnancy, parity, and pregnancy year. Among the 276 donors surveyed, 151 donors responded (54.7% response rate) and reported 313 pregnancies; 168/199 (68.8%) of the predonation pregnancies and 82/114 (71.9%) of the postdonation pregnancies resulted in live births, whereas 16.6% and 24.6% resulted in miscarriage, respectively. Women with postdonation pregnancies were older (32.0 versus 26.7 years; P < 0.001) and more frequently reported abnormal liver enzymes during pregnancy (3.5% versus 0.0%; P = 0.02) and delivery via cesarean delivery (35.4% versus 19.7%; P = 0.01). On adjusted analysis, there was no difference in cesarean delivery (odds ratio [OR], 2.44; 95% confidence interval [95% CI], 0.98-6.08), miscarriage (OR, 1.59; 95% CI, 0.78-3.24), combined endpoints of pregnancy-induced hypertension and preeclampsia (OR, 1.27; 95% CI, 0.36-4.49), or intrauterine growth restriction and preterm birth (OR, 0.91; 95% CI, 0.19-4.3). Of the 49 women who attempted pregnancy after donation, 11 (22.5%) self-reported infertility; however, 8/11 (72.7%) eventually had live births. Aside from increased reporting of abnormal liver enzymes and cesarean deliveries, there was no significant difference in pregnancy outcomes before and after living liver donation. One-fifth of women who attempt pregnancy after liver donation reported infertility, and although the majority went on to successful live births, further exploration is needed to understand the contributing factors. Future research should continue to monitor this patient-centered outcome across a large cohort of donors.

Risk factors associated with experienced stigma among people diagnosed with mental ill-health: a cross-sectional study

PURPOSE

to examine the relationship between religiosity, social support, trauma, quality of life and experienced stigma of mental illness amongst a population diagnosed with mental ill-health.

METHODS

A cross-sectional survey of day service users in Northern Ireland (n = 295) covering a range of issues including religiosity, social support, quality of life and prior experience of trauma. Stigma was measured using a recognised stigma scale. We used multinomial logistic regression to examine risk factors associated with experienced stigma.

RESULTS

Univariate analysis showed significant associations between stigma and age, number of friends, social support, quality of life and prior experience of trauma. Age, quality of life, and trauma remained independently associated with stigma in a multivariate logistic regression model (x2(12) = 98.40, p < 0.001).

CONCLUSION

Younger people, those with less social support, prior experience of trauma and with poorer quality of life are at increased risk of experiencing stigma related to their diagnosis of mental illness. The findings provide further understanding of stigma and are useful for those overseeing programmes to improve access to mental health treatment.

649 COVID BOAST In Practice: Our Experience Implementing BOA Recommendations During the UK Coronavirus Pandemic Peak

Background

In anticipation of the UK coronavirus pandemic peak, BOA published new pandemic-specific guidance (“COVID BOAST”) in April 2020. We describe our experience implementing this restructured T&O service in a busy DGH setting during the pandemic peak.

Method

A rapid retrospective audit was conducted of all patients presenting to our T&O service in April 2020, with particular emphasis compliance with COVID BOAST.

Results

Our service conducted 511 outpatient reviews, and 95 operative procedures. 94% of outpatients were treated non-operatively. We provided telephone appointments to 12.8% of follow-up patients, and 39% of new patients. 82% of patients were treated with removable casts/splints/boots. 23% of patients were discharged direct from VFC or after one face-to-face fracture clinic review. Residual deformity was consciously accepted in 13% of patients. Theatre throughput fell significantly due to pandemic precautions however, femoral neck fracture volumes remained constant.

Conclusions

We demonstrate broad compliance with COVID BOAST guidance. The majority of patients were treated non-operatively, including conscious acceptance of residual deformity. Our pre-existing VFC allowed us to provide a significant number of telephone consultations, although despite the practice shift towards removable splintage, face-to-face consultations were required for clinical and/or radiological assessment. The impact of increased conservative management on patients’ long-term outcomes needs further evaluation.

Intra and Inter-professional working: how have pharmacists’ working practices changed during the COVID-19 pandemic?

Introduction

COVID-19 has acted as a catalyst for radical changes in the working practices of pharmacists. While there is emerging evidence of adaptability mitigating burnout amongst pharmacists in other countries (1), what has yet to be established is the extent to which the well-being and resilience of pharmacists in the UK may be supported through changes in intra and inter-professional working practices.

Aim

As part of a wider project aiming to explore the impact of COVID-19 on pharmacists’ wellbeing and resilience, in this abstract we present findings exploring the impact on working relationships within pharmacy and multidisciplinary teams.

Methods

An online questionnaire containing validated measures of wellbeing and resilience and free-text open questions exploring the impact of COVID-19 on working practices was piloted on five practising pharmacists. This questionnaire was subsequently distributed via social media and professional networks in June 2020. Convenience sampling was used whereby any UK-registered pharmacist in a patient-facing role was eligible to take part. Inductive thematic analysis of the free text responses was conducted. This abstract presents one key theme; intra and inter-professional relationships.

Results

A total of 202 questionnaires were completed (Table 1), with 192 participants entering free-text responses.

Participants reported pharmacy teams becoming closer, supporting one another and working more cohesively. Work redesign and staff upskilling were given as positive examples of practice change in response to the pandemic. Reported challenges included managing conflict within a team due to heightened stress, sustaining staff morale, exhaustion, and prioritising others to the detriment of their own wellbeing: “I have no time for myself as I'm too busy keeping the day to day working and supporting my team emotionally. I'm emotionally exhausted and at home I withdraw and ignore the outside world as I'm at breaking point but don’t want my colleagues to see this.”

Inter-professional relationships sometimes improved as a result of more effective communication, extended networking and pharmacists feeling valued and recognised as integral to multidisciplinary working. Supportive inter-professional working was described as a “Great sense of comradery - we're in this together”. Yet for others, inter-professional working proved challenging, with non-engagement of clinicians, frequently changing guidance from senior management, and restricted staff interaction due to remote or shift working.

Conclusions

Whilst for some the pandemic facilitated improved inter- and intra- professional interactions, for others this was viewed as challenges of daily practice. Due to recruiting via social media, this study is limited by the response numbers and is therefore not representative of all UK registered pharmacists. However, a key strength is that pharmacists from all sectors of practice responded, in comparison to other studies which have focused solely on community pharmacists. Results from this study can be used to support sustainable change in fostering collaborative working within pharmacy and multi-professional healthcare teams.

References

1. Austin, Z., & Gregory, P. (2020). Resilience in the time of pandemic: The experience of community pharmacists in Ontario during COVID-19. Research in Social and Administrative Pharmacy.

Expansion of Patient Education Programming Regarding Live Donor Liver Transplantation via Virtual Group Encounters During the COVID-19 Pandemic

During the coronavirus 2019 pandemic we converted our liver transplant waitlist candidate education and support program to a virtual format and expanded it to include ongoing engagement sessions aimed to educate and empower patients to maximize opportunity for live donor liver transplantation. Over a period of 6 months from April 2020 to Sept 2020 we included 21 patients in this pilot quality improvement program. We collected data regarding patient response and potential donor referral activity. Overall, patient response was positive, and some patients saw progress toward live donor liver transplantation by fostering inquiry of potential live liver donors. Optimization of logistical aspects of the program including program flow, technology access, and utilization is required to enhance patient experience. Long-term follow-up is needed to assess impact on the outcome of transplantation rates. Future data collection and analysis should focus on assessment of any potential disparity that may result from utilization of virtual programming. Herein we provide a framework for this type of virtual program and describe our experience.

Antibiofilm Activity of Heather and Manuka Honeys and Antivirulence Potential of Some of Their Constituents on the DsbA1 Enzyme of Pseudomonas aeruginosa

Heather honey was tested for its effect on the formation of biofilms by Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Enterococcus faecalis, Salmonella Enteriditis and Acinetobacter baumanii in comparison with Manuka honey. At 0.25 mg/mL, Heather honey inhibited biofilm formation in S. aureus, A. baumanii, E. coli, S. Enteriditis and P. aeruginosa, but promoted the growth of E. faecalis and K. pneumoniae biofilms. Manuka honey inhibited biofilm formation in K. pneumoniae, E. faecalis, and S. Enteriditis, A. baumanii, E. coli and P. aeruginosa, but promoted S. aureus biofilm formation. Molecular docking with Autodock Vina was performed to calculate the predictive binding affinities and ligand efficiencies of Manuka and Heather honey constituents for PaDsbA1, the main enzyme controlling the correct folding of virulence proteins in Pseudomonas aeruginosa. A number of constituents, including benzoic acid and methylglyoxal, present in Heather and/or Manuka honey, revealed high ligand efficiencies for the target enzyme. This helps support, to some extent, the decrease in P. aeruginosa biofilm formation observed for such honeys.

Imaging-Based Localization of His Bundle Pacing Electrodes: Results From the Prospective IMAGE-HBP Study

OBJECTIVES

This study sought to evaluate the correlation between His bundle (HB) pacing (HBP) implantation characteristics, lead-tip location, and association of intraprocedural His recordings with approximated HB anatomic landmarks using computed tomography (CT) imaging.

BACKGROUND

HBP continues to grow in clinical practice due to offering true physiological pacing. However, a clear understanding of HB anatomy and the lead-tip location's influence on pacing characteristics is lacking.

METHODS

The IMAGE-HBP study (Imaging Study of Lead Implant for His Bundle Pacing) was a prospective, multicenter study designed to assess implantation characteristics of the SelectSecure Model 3830 lead placed at the HB, evaluate protocol-specified HBP success (His recording present on electrogram and HBP threshold ≤2.5 V at 1 ms), and correlation between lead-tip location by CT imaging and HBP characteristics as well as lead-related complications through 12 months.

RESULTS

Sixty-nine patients underwent a lead implantation attempt at the HB. Of these, 61 patients (88%) had a lead successfully implanted at the HB, and 52 patients (75%) met the pre-specified definition of successful HBP. In 51 patients with CT imaging, 11 leads (22%) were placed in the atrial aspect of the HB region (36% selective HBP), and 40 leads (78%) were placed in the ventricular aspect (28% selective HBP). Four of the 51 patients had P-wave oversensing, all with leads in the atrium. Freedom from lead-related complication at 12 months was 93%.

CONCLUSIONS

Successful HBP could be achieved at lead-tip locations in the atrium or ventricle but is preferable in the ventricle to eliminate risk of oversensing. The IMAGE-HBP study offers better insight into approximated HB anatomic landmarks, lead-tip location, and correlation with pacing characteristics. (Imaging Study of Lead Implant for His Bundle Pacing [IMAGE-HBP]; NCT03294317).

Functional organisation of the endomembrane network in the digestive gland of the Venus flytrap: revisiting an old story with a new microscopy toolbox

Up-to-date imaging approaches were used to address the spatiotemporal organisation of the endomembrane system in secretory cells of Dionaea muscipula. Different 'slice and view' methodologies were performed on resin-embedded samples to finally achieve a 3D reconstruction of the cell architecture, using ultrastructural tomography, array tomography, serial block face-scanning electron microscopy (SBF-SEM), correlation, and volume rendering at the light microscopy level. Observations of cryo-fixed samples by high-pressure freezing revealed changes of the endomembrane system that occur after trap activation and prey digestion. They provide evidence for an original strategy that adapts the secretory machinery to a specific and unique case of stimulated exocytosis in plant cells. A first secretion peak is part of a rapid response to deliver digestive fluids to the cell surface, which delivers the needed stock of digestive materials 'on site'. The second peak of activity could then be associated with the reconstruction of the Golgi apparatus (GA), endoplasmic reticulum (ER) and vacuolar machinery, in order to prepare for a subsequent round of prey capture. Tubular continuum between ER and Golgi stacks observed on ZIO-impregnated tissues may correspond to an efficient transfer mechanism for lipids and/or proteins, especially for use in rapidly resetting the molecular GA machinery. The occurrence of one vacuolar continuum may permit continuous adjustment of cell homeostasy. The subcellular features of the secretory cells of Dionaea muscipula outline key innovations in the organisation of plant cell compartmentalisation that are used to cope with specific cell needs such as the full use of the GA as a protein factory, and the ability to create protein reservoirs in the periplasmic space. Shape-derived forces of the pleiomorphic vacuole may act as signals to accompany the sorting and entering flows of the cell.

Clinical Utility of Radioimmunoscintigraphy of Non-Hodgkin's Lymphoma with Radiolabelled LL2 Monoclonal Antibody., Lymphoscan™: Preliminary Results

Aims and Background

Adequate clinical staging of non-Hodgkin's lymphoma patients is essential because only localized disease can be treated satisfactorily. Many imaging procedures are necessary to stage the disease accurately. The objective of this study was to evaluate the efficacy of an anti-lymphoma antibody in the Fab’ fragment form, labelled with 99mTc, to detect malignant lesions.

Methods

Radioimmunodetection (RAID) with 99mTc-labelled B-cell lymphoma monoclonal antibody IMMU-LL2-Fab’ (LymphoSCAN™; Immunomedics, Morris Plain, NJ, USA) was investigated in 10 patients (5 females and 5 males; age range, 20-72 years) with histologically proved non-Hodgkin's lymphoma. Of the 10 lymphomas, 7 were intermediate grade and 3 were low grade. Whole body images with multiple planar views were obtained at 30 min, 4-6 and 24 h after i.v. injection of 1 mg LL2-Fab’ labelled with 740-925 MBq of 99mTc. SPET of the chest or abdomen was performed in all patients 5-8 h after the immunoreagent injection.

Results

No adverse reactions were observed in any patient after Mab infusion, and no appreciable changes were seen in the blood counts, renal or liver function tests. A total of 18 of 21 (85.7%) lymphoma lesions were detected by RAID. All the tumor localizations were confirmed by clinical examination and with other imaging techniques, such as CT scan, MRI or gallium scan. In this series of patients no false-positive results were noted. As regards the biodistribution of the immunoreagent, no appreciable bone marrow activity was seen; splenic targeting was demonstrated in all patients; the tumor-to-non-tumor ratios ranged from 1.2 to 2.8 ad measured by the ROI technique; no difference in uptake was noted for different tumor grades. The images obtained 24 h after injection did not reveal new lesions, but areas of doubtful uptake were seen as positive focal areas in the delayed scan.

Conclusions

LymphoSCAN™ seems to be useful for detection, staging and follow-up of non-Hodgkin's lymphoma patients.

Determination of the absolute oral bioavailability of niraparib by simultaneous administration of a 14C-microtracer and therapeutic dose in cancer patients

Introduction

Niraparib (Zejula™) is a poly(ADP-ribose) polymerase inhibitor recently approved by the US Food and Drug Administration for the maintenance treatment of patients with recurrent platinum-sensitive epithelial ovarian, fallopian tube, or primary peritoneal cancer who are in a complete or partial response to platinum-based chemotherapy. The pivotal phase III clinical trial has shown improved progression-free survival in patients receiving niraparib compared with those receiving placebo.

Purpose

Since niraparib is administered orally, it is of interest to investigate the oral bioavailability (F_po) of this novel compound, which is the aim of this study.

Methods

Six patients received an oral therapeutic dose of 300 mg niraparib, followed by a 15-min intravenous infusion of 100 µg ¹⁴C-niraparib with a radioactivity of approximately 100 nCi. The niraparib therapeutic dose was measured in plasma using a validated liquid chromatography–tandem mass spectrometry method, whereas the total ¹⁴C-radioactivity and ¹⁴C-niraparib plasma levels were measured by accelerator mass spectrometry and a validated high performance liquid chromatography assay with AMS.

Results

The F_po of niraparib was determined to be 72.7% in humans.

The Impact of Cardiac Radiation Dosimetry on Survival After Radiation Therapy for Non-Small Cell Lung Cancer

PURPOSE

The heart receives high radiation doses during radiation therapy of advanced-stage lung cancer. We have explored associations between overall survival, cardiac radiation doses, and electrocardiographic (ECG) changes in patients treated in IDEAL-CRT, a trial of isotoxically escalated concurrent chemoradiation delivering tumor doses of 63 to 73 Gy.

METHODS AND MATERIALS

Dosimetric and survival data were analyzed for 78 patients. The whole heart, pericardium, AV node, and walls of left and right atria (LA/RA-Wall) and ventricles (LV/RV-Wall) were outlined on radiation therapy planning scans, and differential dose-volume histograms (dDVHs) were calculated. For each structure, dDVHs were approximated using the average dDVH and the 10 highest-ranked structure-specific principal components (PCs). ECGs at baseline and 6 months after radiation therapy were analyzed for 53 patients, dichotomizing patients according to presence or absence of "any ECG change" (conduction or ischemic/pericarditis-like change). All-cause death rate (DR) was analyzed from the start of treatment using Cox regression.

RESULTS

38% of patients had ECG changes at 6 months. On univariable analysis, higher scores for LA-Wall-PC6, Heart-PC6, "any ECG change," and larger planning target volume (PTV) were significantly associated with higher DR (P=.003, .009, .029, and .037, respectively). Heart-PC6 and LA-Wall-PC6 represent larger volumes of whole heart and left atrial wall receiving 63 to 69 Gy. Cardiac doses ≥63 Gy were concentrated in the LA-Wall, and consequently Heart-PC6 was highly correlated with LA-Wall-PC6. "Any ECG change," LA-Wall-PC6 scores, and PTV size were retained in the multivariable model.

CONCLUSIONS

We found associations between higher DR and conduction or ischemic/pericarditis-like changes on ECG at 6 months, and between higher DR and higher Heart-PC6 or LA-Wall-PC6 scores, which are closely related to heart or left atrial wall volumes receiving 63 to 69 Gy in this small cohort of patients.

REMOVED: Do Impulsive Individuals Respond Better to Cognitive Bias Modification Treatment for Alcohol Dependence?

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Human mass balance study and metabolite profiling of 14C-niraparib, a novel poly(ADP-Ribose) polymerase (PARP)-1 and PARP-2 inhibitor, in patients with advanced cancer

Niraparib is an investigational oral, once daily, selective poly(ADP-Ribose) polymerase (PARP)-1 and PARP-2 inhibitor. In the pivotal Phase 3 NOVA/ENGOT/OV16 study, niraparib met its primary endpoint of improving progression-free survival (PFS) for adult patients with recurrent, platinum sensitive, ovarian, fallopian tube, or primary peritoneal cancer in complete or partial response to platinum-based chemotherapy. Significant improvements in PFS were seen in all patient cohorts regardless of biomarker status. This study evaluates the absorption, metabolism and excretion (AME) of ¹⁴C-niraparib, administered to six patients as a single oral dose of 300 mg with a radioactivity of 100 μCi. Total radioactivity (TRA) in whole blood, plasma, urine and faeces was measured using liquid scintillation counting (LSC) to obtain the mass balance of niraparib. Moreover, metabolite profiling was performed on selected plasma, urine and faeces samples using liquid chromatography - tandem mass spectrometry (LC-MS/MS) coupled to off-line LSC. Mean TRA recovered over 504 h was 47.5% in urine and 38.8% in faeces, indicating that both renal and hepatic pathways are comparably involved in excretion of niraparib and its metabolites. The elimination of ¹⁴C-radioactivity was slow, with t_1/2 in plasma on average 92.5 h. Oral absorption of ¹⁴C-niraparib was rapid, with niraparib concentrations peaking at 2.49 h, and reaching a mean maximum concentration of 540 ng/mL. Two major metabolites were found: the known metabolite M1 (amide hydrolysed niraparib) and the glucuronide of M1. Based on this study it was shown that niraparib undergoes hydrolytic, and conjugative metabolic conversions, with the oxidative pathway being minimal.

Liquid chromatography-tandem mass spectrometry assay for the quantification of niraparib and its metabolite M1 in human plasma and urine

Niraparib (MK-4827) is a novel poly(ADP-Ribose) polymerase (PARP) inhibitor currently investigated in phase III clinical trials to treat cancers. The development of a new drug includes the characterisation of absorption, metabolism and excretion (AME) of the compound. AME studies are a requirement of regulatory agencies and for this purpose bioanalytical assays are essential. This article describes the development and validation of a bioanalytical assay for niraparib and its carboxylic acid metabolite M1 in human plasma and urine using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Sample pre-treatment involved protein precipitation for plasma and dilution of urine samples using acetonitrile-methanol (50:50, v/v). Final extracts were injected onto a SunFire C18 column and gradient elution using 20mM ammonium acetate (mobile phase A) and formic acid:acetonitrile:methanol (0.1:50:50, v/v/v) (mobile phase B) was applied. Detection was performed on an API5500 tandem mass spectrometer operating in the positive electrospray ionisation mode applying multiple reaction monitoring (MRM). The assay was successfully validated in accordance with the Food and Drug Administration and latest European Medicines Agency guidelines on bioanalytical method validation and can therefore be applied in pharmacological clinical studies.

Surgeon Volume, Patient Age, and Tumor-Related Factors Influence the Need for Re-Excision After Breast-Conserving Surgery

BACKGROUND

Breast-conserving surgery (BCS) is the preferred surgical approach for the majority of patients with early-stage breast cancer. There are frequent issues regarding pathologic margin status, requiring margin re-excision, and, in the literature, there is significant variability in re-excision rates, suggesting this is a potential quality-of-care issue. Understanding the patient-, disease-, and physician-related factors influencing reoperation rates is of importance in an effort to minimize this occurrence.

METHODS

A retrospective analysis of all patients referred to our cancer center over a 3-year period (1 January 2011-31 December 2013) was performed. Surgeon volume, and patient- and tumor-related factors were assessed for their impact on re-excision rates. Multivariate logistic regression analysis was performed to identify variables of significance influencing reoperation rates after attempted BCS.

RESULTS

Overall, 594 patients underwent initial BCS, with 159 (26.8%) patients requiring at least one re-excision to ensure negative pathologic margins. On multivariate analysis, low surgeon case volume, patient age (under 46 years of age), tumor size (>2 cm), and lobular carcinoma were associated with an increased re-excision rate.

CONCLUSION

Re-excisions are frequent after BCS and are influenced by surgeon volume, patient age, and tumor-related factors. These factors should be considered when counseling patients considering BCS, and also for quality assurance.

Serial block face scanning electron microscopy and the reconstruction of plant cell membrane systems

Serial block face imaging with the scanning electron microscope has been developed as an alternative to serial sectioning and transmission electron microscopy for the ultrastructural analysis of the three-dimensional organization of cells and tissues. An ultramicrotome within the microscope specimen chamber permits sectioning and imaging to a depth of many microns within resin-embedded specimens. The technology has only recently been adopted by plant microscopists and here we describe some specimen preparation procedures suitable for plant tissue, suggested microscope imaging parameters and discuss the software required for image reconstruction and analysis.

Calcium phosphate/thermoresponsive hyaluronan hydrogel composite delivering hydrophilic and hydrophobic drugs

BACKGROUND/OBJECTIVE

Advanced synthetic biomaterials that are able to reduce or replace the need for autologous bone transplantation are still a major clinical need in orthopaedics, dentistry, and trauma. Key requirements for improved bone substitutes are optimal handling properties, ability to fill defects of irregular shape, and capacity for delivering osteoinductive stimuli.

MATERIALS AND METHODS

In this study, we targeted these requirements by preparing a new composite of β-tricalcium phosphate (TCP) and a thermoresponsive hyaluronan (HA) hydrogel. Dissolution properties of the composite as a function of the particle size and polymeric phase molecular weight and concentration were analysed to identify the best compositions.

RESULTS

Owing to its amphiphilic character, the composite was able to provide controlled release of both recombinant human bone morphogenetic protein-2 and dexamethasone, selected as models for a biologic and a small hydrophobic molecule, respectively.

CONCLUSION

The TCP-thermoresponsive HA hydrogel composite developed in this work can be used for preparing synthetic bone substitutes in the form of injectable or mouldable pastes and can be supplemented with small hydrophobic molecules or biologics for improved osteoinductivity.

Using visual art and collaborative reflection to explore medical attitudes toward vulnerable persons

BACKGROUND

Vulnerable persons often face stigma-related barriers while seeking health care. Innovative education and professional development methods are needed to help change this.

METHOD

We describe an interdisciplinary group workshop designed around a discomfiting oil portrait, intended to trigger provocative conversations among health care students and practitioners, and we present our mixed methods analysis of participant reflections.

RESULTS

After the workshop, participants were significantly more likely to endorse the statements that the observation and interpretive skills involved in viewing visual art are relevant to patient care and that visual art should be used in medical education to improve students' observational skills, narrative skills, and empathy with their patients. Subsequent to the workshop, significantly more participants agreed that art interpretation should be required curriculum for health care students. Qualitative comments from two groups from two different education and professional contexts were examined for themes; conversations focused on issues of power, body image/self-esteem, and lessons for clinical practice.

CONCLUSIONS

We argue that difficult conversations about affective responses to vulnerable persons are possible in a collaborative context using well-chosen works of visual art that can stand in for a patient.

Genetic variation in IL-16 miRNA target site and time to prostate cancer diagnosis in African-American men

BACKGROUND

Men with a family history of prostate cancer and African-American men are at high risk for prostate cancer and in need of personalized risk estimates to inform screening decisions. This study evaluated genetic variants in genes encoding microRNA (miRNA) binding sites for informing of time to prostate cancer diagnosis among ethnically diverse, high-risk men undergoing prostate cancer screening.

METHODS

The Prostate Cancer Risk Assessment Program (PRAP) is a longitudinal screening program for high-risk men. The eligibility includes men aged between 35 and 69 years with a family history of prostate cancer or African descent. Participants with 1 follow-up visit were included in the analyses (n=477). Genetic variants in genes encoding miRNA binding sites (ALOX15 (arachidonate 15-lipooxygenase), IL-16, IL-18 and RAF1 (v-raf-1 murine leukemia viral oncogene homolog 1)) previously implicated in prostate cancer development were evaluated. Genotyping methods included Taqman SNP Genotyping Assay or pyrosequencing. Cox models were used to assess time to prostate cancer diagnosis by risk genotype.

RESULTS

Among 256 African Americans with one follow-up visit, the TT genotype at rs1131445 in IL-16 was significantly associated with earlier time to prostate cancer diagnosis vs the CC/CT genotypes (P=0.013), with a suggestive association after correction for false discovery (P=0.065). Hazard ratio after controlling for age and PSA for TT vs CC/CT among African Americans was 3.0 (95% confidence interval: 1.26-7.12). No association with time to diagnosis was detected among Caucasians by IL-16 genotype. No association with time to prostate cancer diagnosis was found for the other miRNA target genotypes.

CONCLUSIONS

Genetic variation in IL-16 encoding miRNA target site may be informative of time to prostate cancer diagnosis among African-American men enrolled in prostate cancer risk assessment, which may inform individualized prostate cancer screening strategies in the future.