Genomic and Immunophenotypic Landscape of Acquired Resistance to PD-(L)1 Blockade in Non-Small-Cell Lung Cancer

PURPOSE

Although immune checkpoint inhibitors (ICI) have extended survival in patients with non-small-cell lung cancer (NSCLC), acquired resistance (AR) to ICI frequently develops after an initial benefit. However, the mechanisms of AR to ICI in NSCLC are largely unknown.

METHODS

Comprehensive tumor genomic profiling, machine learning-based assessment of tumor-infiltrating lymphocytes, multiplexed immunofluorescence, and/or HLA-I immunohistochemistry (IHC) were performed on matched pre- and post-ICI tumor biopsies from patients with NSCLC treated with ICI at the Dana-Farber Cancer Institute who developed AR to ICI. Two additional cohorts of patients with intervening chemotherapy or targeted therapies between biopsies were included as controls.

RESULTS

We performed comprehensive genomic profiling and immunophenotypic characterization on samples from 82 patients with NSCLC and matched pre- and post-ICI biopsies and compared findings with a control cohort of patients with non-ICI intervening therapies between biopsies (chemotherapy, N = 32; targeted therapies, N = 89; both, N = 17). Putative resistance mutations were identified in 27.8% of immunotherapy-treated cases and included acquired loss-of-function mutations in STK11, B2M, APC, MTOR, KEAP1, and JAK1/2; these acquired alterations were not observed in the control groups. Immunophenotyping of matched pre- and post-ICI samples demonstrated significant decreases in intratumoral lymphocytes, CD3e+ and CD8a+ T cells, and PD-L1-PD1 engagement, as well as increased distance between tumor cells and CD8+PD-1+ T cells. There was a significant decrease in HLA class I expression in the immunotherapy cohort at the time of AR compared with the chemotherapy (P = .005) and the targeted therapy (P = .01) cohorts.

CONCLUSION

These findings highlight the genomic and immunophenotypic heterogeneity of ICI resistance in NSCLC, which will need to be considered when developing novel therapeutic strategies aimed at overcoming resistance.

The association between epidural labour analgesia and postpartum depression: a randomised controlled trial

There is conflicting evidence regarding the association between epidural labour analgesia and risk of postpartum depression. Most previous studies were observational trials with limited ability to account for confounders. We aimed to determine if epidural analgesia was associated with a significant change in the incidence of postpartum depression in this randomised controlled trial. We enrolled women aged 21-50 years old with a singleton fetus ≥ 36 weeks gestation. Patients were advised regarding available labour analgesic modalities during enrolment (epidural block; intramuscular pethidine; nitrous oxide; or intravenous remifentanil). On request for analgesia, patients were offered the modality that they had been allocated randomly to first. Blinded investigators recorded patient and obstetric characteristics within 24 h of delivery and assessed for postpartum depression at 6-10 weeks following delivery using the Edinburgh Postnatal Depression Scale (score ≥ 13 considered positive for postpartum depression). The modified intention-to-treat population consisted of all patients who received any form of labour analgesia, while per-protocol consisted of patients who received their randomised modality as their first form of labour analgesia. Of 881 parturients allocated randomly (epidural n = 441, non-epidural n = 440), we analysed 773 (epidural n = 389, non-epidural n = 384); 62 (15.9%) of women allocated to epidural group developed postpartum depression compared with 65 (16.9%) women allocate to the non-epidural group. There were no significant differences in the incidence of postpartum depression between the two groups (adjusted risk difference (95%CI) 1.6 (-3.0-6.3%), p = 0.49). Similar results were obtained with per-protocol analysis (adjusted risk difference (95%CI) -1.0 (-8.3-6.3%), p = 0.79). We found no significant difference in the risk of postpartum depression between patients who received epidural labour analgesia and those who utilised non-epidural analgesic modalities.

Green synthesis of chitosan nanoparticles using tea extract and its antimicrobial activity against economically important phytopathogens of rice

The aim of the present work is to biosynthesize Chitosan nanoparticles (CTNp) using tea (Camellia sinensis) extract, with potent antimicrobial properties towards phytopathogens of rice. Preliminary chemical analysis of the extract showed that they contain carbohydrate as major compound and uronic acid indicating the nature of acidic polysaccharide. The structure of the isolated polysaccharide was analyzed through FTIR and 1H NMR. The CTNp was prepared by the addition of isolated tea polysaccharides to chitosan solution. The structure and size of the CTNp was determined through FTIR and DLS analyses. The surface morphology and size of the CTNp was analysed by SEM and HRTEM. The crystalinity nature of the synthesized nanoparticle was identified by XRD analysis. The CTNp exhibited the antimicrobial properties against the most devastating pathogens of rice viz., Pyricularia grisea, Xanthomonas oryzae under in vitro condition. CTNp also suppressed the blast and blight disease of rice under the detached leaf assay. These results suggest that the biosynthesized CTNp can be used to control the most devastating pathogens of rice.

Mpox: The Reemergence of an Old Disease and Inequities

Mpox, previously known as monkeypox, is caused by an Orthopoxvirus related to the variola virus that causes smallpox. Prior to 2022, mpox was considered a zoonotic disease endemic to central and west Africa. Since May 2022, more than 86,000 cases of mpox from 110 countries have been identified across the world, predominantly in men who have sex with men, most often acquired through close physical contact or during sexual activity. The classical clinical presentation of mpox is a prodrome including fever, lethargy, and lymphadenopathy followed by a characteristic vesiculopustular rash. The recent 2022 outbreak included novel presentations of mpox with a predominance of anogenital lesions, mucosal lesions, and other features such as anorectal pain, proctitis, oropharyngeal lesions, tonsillitis, and multiphasic skin lesions. We describe the demographics and clinical spectrum of classical and novel mpox, outlining the potential complications and management.

Clinicopathologic, Genomic, and Immunophenotypic Landscape of ATM Mutations in Non-Small Cell Lung Cancer

PURPOSE

ATM is the most commonly mutated DNA damage and repair gene in non-small cell lung cancer (NSCLC); however, limited characterization has been pursued.

EXPERIMENTAL DESIGN

Clinicopathologic, genomic, and treatment data were collected for 5,172 patients with NSCLC tumors which underwent genomic profiling. ATM IHC was performed on 182 NSCLCs with ATM mutations. Multiplexed immunofluorescence was performed on a subset of 535 samples to examine tumor-infiltrating immune cell subsets.

RESULTS

A total of 562 deleterious ATM mutations were identified in 9.7% of NSCLC samples. ATM-mutant (ATMMUT) NSCLC was significantly associated with female sex (P = 0.02), ever smoking status (P < 0.001), non-squamous histology (P = 0.004), and higher tumor mutational burden (DFCI, P < 0.0001; MSK, P < 0.0001) compared with ATM-wild-type (ATMWT) cases. Among 3,687 NSCLCs with comprehensive genomic profiling, co-occurring KRAS, STK11, and ARID2 oncogenic mutations were significantly enriched among ATMMUT NSCLCs (Q < 0.05), while TP53 and EGFR mutations were enriched in ATMWT NSCLCs. Among 182 ATMMUT samples with ATM IHC, tumors with nonsense, insertions/deletions, or splice site mutations were significantly more likely to display ATM loss by IHC (71.4% vs. 28.6%; P < 0.0001) compared with tumors with only predicted pathogenic missense mutations. Clinical outcomes to PD-(L)1 monotherapy (N = 1,522) and chemo-immunotherapy (N = 951) were similar between ATMMUT and ATMWT NSCLCs. Patients with concurrent ATM/TP53 mutations had significantly improved response rate and progression-free survival with PD-(L)1 monotherapy.

CONCLUSIONS

Deleterious ATM mutations defined a subset of NSCLC with unique clinicopathologic, genomic, and immunophenotypic features. Our data may serve as resource to guide interpretation of specific ATM mutations in NSCLC.

Estimating kidney function in patients with cancer: A narrative review

AIM

Accurate evaluation of glomerular filtration rate (GFR) is crucial in Oncology as drug eligibility and dosing depend on estimates of GFR. However, there are no clear guidelines on the optimal method of determining kidney function in patients with cancer. We aimed to summarize the evidence on estimation of kidney function in patients with cancer.

METHODS

We searched PubMed for literature discussing the performance of GFR estimating equations in patients with malignancy to create a table of the evidence for creatinine- and cystatin c-based equations. We further reviewed novel estimation techniques such as panel eGFR, real-time measured GFR, and functional magnetic resonance imaging.

RESULTS

The commonly used GFR estimating equations were derived from populations of patients without cancer. These equations may be less applicable in Oncology due to severe sarcopenia, inflammation, and other physiologic changes in patients with cancer. The Cockcroft-Gault equation currently dominates in clinical Oncology despite significant limitations and accumulating evidence for use of the CKD-EPI_Cr formula. Additional considerations in the practice of Oncology include a recently developed equation (CamGFRv2, also called the Janowitz formula) and the use of cystatin c-based equations to overcome some of the barriers to accurate GFR estimation based on creatinine alone.

CONCLUSION

Overall, we suggest using the CKD-EPI equations (either cystatin c or creatinine-based) among patients with cancer in routine clinical practice, and measured GFR for patients at a critical threshold for treatment decisions.

Second-trimester growth velocities in twin and singleton pregnancies

OBJECTIVE

Previous small studies used individualized growth assessment (IGA) to characterize prenatal growth velocities of singletons and twins. We aimed to compare second-trimester growth velocities of individual anatomical parameters between monochorionic diamniotic (MCDA) twins, dichorionic diamniotic (DCDA) twins and singleton fetuses in a larger study.

METHODS

This was a study of a novel cohort of 222 MCDA twins and previously published cohorts of 40 DCDA twins and 118 singletons with serial ultrasound data. Fetal biometric measurements of biparietal diameter, head circumference, abdominal circumference and femur diaphysis length from prenatal ultrasound examinations were used to calculate second-trimester growth velocities using direct calculation or linear regression analysis. Linear fit was assessed based on the coefficient of determination (R² ). Mean growth velocities and variances were compared among the three groups.

RESULTS

The majority of cases underwent three second-trimester ultrasound examinations with fetal biometry available. All fetuses had linear growth, with R² > 99% for all parameters. Only 1-2% of all MCDA and DCDA anatomical parameters had abnormal growth velocity scores outside the 95% reference range for singletons. There were no significant differences in mean growth velocity for any parameter between MCDA twins and singletons. Femur diaphysis length growth velocity was significantly lower in DCDA twins than in both MCDA twins and singletons. There were no other significant differences among the groups.

CONCLUSIONS

Expanding on prior work using IGA, we found that second-trimester growth velocity of the four major anatomical parameters overall was similar between twins and singletons and between MCDA and DCDA twins, supporting the use of singleton-derived growth standards for IGA in twins. Twin growth potential appears to be similar to that of singletons in the second trimester, suggesting that subsequent growth divergence may be due to third-trimester physiological or pathological changes in twin pregnancies. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

POS1411 EARLY IDENTIFICATION OF AXIAL SPONDYLOARTHRITIS IN A MULTI-ETHNIC ASIAN POPULATION

Background:

To facilitate earlier diagnosis of spondyloarthritis (SpA), we have previously cross-culturally adapted a self-administered screening questionnaire.

Objectives:

We aimed to improve the sensitivity of this questionnaire as a screening tool by comparing various scoring methods.

Methods:

Subjects newly referred to a rheumatology clinic self-administered the questionnaire before seeing a rheumatologist. Identification of axial SpA by the questionnaire using original scoring (Method A) and scoring based on Assessment of SpondyloArthritis International Society (ASAS) inflammatory back pain (IBP) criteria (Method B), ASAS referral criteria (Method C), ASAS classification criteria (Method D) and a combination of ASAS referral and classification criteria (Method E) were compared to classification by the ASAS classification criteria and diagnosis by rheumatologist. Since Methods B-E were based on SpA features, we compared self-reported vs rheumatologist-documented features in subjects with axial SpA.

Results:

Of 1418 subjects (age: 54 ± 14 years, female: 73%), 39 were classified as axial SpA cases by classification criteria. Methods A-E yielded sensitivities of 39%, 72%, 67%, 49% and 85%, respectively, among patients newly referred to the rheumatology clinic (Table 1). Rheumatologist-documented clinical SpA features exceeded self-report for IBP (62 vs 44%) and uveitis (15 vs 5%). The reverse was true for arthritis (21 vs 80%), enthesitis (28 vs 33%), dactylitis (3 vs 18%), good response to NSAIDs (33 vs 41%) and family history for SpA (5 vs 10%).

Table 1.

Performance of the five scoring methods for the cross-culturally adapted Hamilton axial SpA questionnaire.

Scoring methodSensitivity(95% confidence interval)Specificity(95% confidence interval)Positive predictive value(95% confidence interval)Negative predictive value(95% confidence interval)Method A38.5(23.4 – 55.4)93.7(92.3 – 94.9)14.7(8.5 – 23.1)98.2(97.3 – 98.8)Method B71.8(55.1 – 85.0)73.1(70.7 – 75.4)7.0(4.7 – 10.0)98.9(98.1 – 99.5)Method C66.7(49.8 – 80.9)77.8(75.5 – 80.0)7.8(5.2 – 11.3)98.8(98.0 – 99.4)Method D48.7(32.4 – 65.2)74.9(72.5 – 77.2)5.2(3.2 – 8.0)98.1(97.1 – 98.8)Method E84.6(69.5 – 94.1)37.2(34.6 – 39.8)3.7(2.5 – 5.1)98.8(97.5 – 99.6)

Method A: the original scoring defined by the questionnaire developers; Method B: a scoring based on the ASAS IBP criteria; Method C: a scoring based on the ASAS referral criteria; Method D: a scoring based on the ASAS classification criteria for axial and peripheral SpA; Method E: a scoring based on a combination of the ASAS referral and classification criteria.

Conclusion:

A self-administered questionnaire scored based on a combination of ASAS referral and classification criteria achieved high sensitivity in identifying axial SpA in subjects referred to a rheumatology clinic. This supports its evaluation as a screening tool for axial SpA in the general population.

References:

[1]Xiang L, Teo EPS, Low AHL, Leung YY, Fong W, Xin X, et al. Cross-cultural adaptation of the Hamilton axial spondyloarthritis questionnaire and development of a Chinese version in a multi-ethnic Asian population. Int J Rheum Dis. 2019;22(9):1652-60.

[2]Sieper J, Rudwaleit M, Baraliakos X, Brandt J, Braun J, Burgos-Vargas R, et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Annals of the rheumatic diseases. 2009;68 Suppl 2:ii1-44.

[3]Poddubnyy D, van Tubergen A, Landewe R, Sieper J, van der Heijde D. Development of an ASAS-endorsed recommendation for the early referral of patients with a suspicion of axial spondyloarthritis. Annals of the rheumatic diseases. 2015;74(8):1483-7.

[4]Rudwaleit M, van der Heijde D, Landewe R, Akkoc N, Brandt J, Chou CT, et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Annals of the rheumatic diseases. 2011;70(1):25-31.

Acknowledgements:

This work was supported by a Health Services Research Grant (HSRG) from the Singapore Ministry of Health National Medical Research Council [grant number: NMRC/HSRG/0075/2017].

Disclosure of Interests:

None declared

POS1413 INTERVAL BETWEEN SYMPTOM ONSET AND DIAGNOSIS AMONG PATIENTS WITH AUTOIMMUNE RHEUMATIC DISEASES IN A MULTI-ETHNIC ASIAN POPULATION

Background:

The interval between symptom onset and diagnosis can often be longer than is ideal in autoimmune rheumatic diseases (ARDs).

Objectives:

We aimed to characterise this interval among patients newly diagnosed with ARDs in a multi-ethnic Asian population and to identify factors associated with a longer interval.

Methods:

We used Scott’s model of pathways to treatment to characterise the interval between symptom onset and diagnosis into 4 intervals: #1 between symptom onset and first seeking medical attention, #2 between first medical attention and rheumatology referral, #3 between rheumatology referral and first rheumatology assessment, and #4 between first rheumatology assessment and diagnosis. Linear regression models were used to identify factors associated with a longer the overall interval between symptom onset and diagnosis and Interval #1.

Results:

Among 259 patients (age: 51±15 years, female: 71%, most common three ARDs: rheumatoid arthritis (n = 75), axial spondyloarthritis (n = 40) and psoriatic arthritis (n = 35)), the median overall interval was 11.5 months. Interval #1 (median = 4.9 months) was significantly longer than the other intervals (Table 1). Patients with axial spondyloarthritis had a significantly longer overall interval (median = 38.7 months) and Interval #1 (median = 26.6 months) compared to patients with RA (median = 7.6 and 3.5 months, respectively), PsA (median = 7.0 and 2.6 months, respectively) and the other ARDs. Gender was the only patient-related factor significantly associated with the overall interval (reference = male, coefficient = -15.3, p = 0.033) in regression models.

Conclusion:

A longer than ideal interval between symptom onset and diagnosis was observed among patients with ARDs. This was primarily due to a relatively long interval between symptom onset and first seeking medical attention, and highlights the importance of interventions targeting patients prior to first medical attention in reducing the duration between symptom onset and diagnosis.

References:

[1]Scott SE, Walter FM, Webster A, Sutton S, Emery J. The model of pathways to treatment: conceptualization and integration with existing theory. Br J Health Psychol. 2013;18(1):45-65.

Table 1.

Interval between symptom onset and diagnosis

Overall interval, months, median (lower and upper quartiles)†Interval #1, months, median (lower and upper quartiles)Interval #2, months, median (lower and upper quartiles)Interval #3, months, median (lower and upper quartiles)Interval #4, months, median (lower and upper quartiles)Overall(n = 259)11.5(4.7 – 36.0)4.9(1.0 – 24.0)0.3(0.0 – 3.9)1.5(0.8 – 1.8)0.0(0.0 – 1.2)RA(n = 75)7.6(3.1 – 14.8)3.5(1.3 – 11.6)0.2(0.0 – 2.5)1.3(0.6 – 1.6)0.0(0.0 – 0.2)AxSpA(n = 40)38.7(9.6 – 66.7)26.6(4.2 – 56.1)1.6(0.0 – 7.6)1.6(1.2 – 2.3)0.0(0.0 – 2.0)PsA(n = 35)7.0(3.0 – 28.4)2.6(0.2 – 11.3)0.5(0.2 – 3.9)1.6(0.6 – 1.7)0.0(0.0 – 0.0)Seronegative IA(n = 21)12.0(4.7 – 22.8)6.4(1.9 – 34.4)0.1(0.0 – 4.6)1.4(1.3 – 1.5)0.0(0.0 – 0.8)SjS(n = 27)14.2(6.0 – 48.0)4.6(0.6 – 19.0)0.3(0.0 – 3.9)1.6(0.9 – 1.9)0.8(0.0 – 2.3)UCTD(n = 27)15.7(5.1 – 39.8)2.2(0.7 – 24.0)0.8(0.1 – 8.1)1.6(0.5 – 1.8)1.2(0.0 – 2.1)Other ARDs(n = 34)8.1(5.3 – 36.0)6.3(0.9 – 31.7)0.2(0.0 – 1.1)1.5(1.2 – 1.8)0.3(0.0 – 1.1)

Overall interval and Intervals #1-4: refer to abstract for definitions; RA: rheumatoid arthritis; axSpA: axial spondyloarthritis; PsA: psoriatic arthritis; IA: inflammatory arthritis; SjS: Sjögren’s syndrome; UCTD: undifferentiated connective tissue disease; other ARDs: systemic lupus erythematosus, systemic sclerosis, idiopathic inflammatory myopathies, palindromic rheumatism and overlap syndromes.

†Intervals #1-4 did not sum to the overall interval mainly due to the fact that Intervals #1-4 might not available for all patients.

Disclosure of Interests:

None declared

Measuring TB drug levels in the hair in adults and children to monitor drug exposure and outcomes

INTRODUCTION: Testing for anti-TB drugs in small hair samples may serve as a non-invasive tool to measure cumulative drug exposure and/or adherence, as these determine treatment success. We aimed to assess how well hair assays of TB drugs predict TB treatment outcomes.METHODS: A small thatch of hair, ~30 strands, was cut from the occipital region in adults and children from a prospective TB cohort in India. Isoniazid (INH), acetyl-INH and pyrazinamide (PZA) were extracted from the hair samples and quantified using liquid-chromatography-tandem mass spectrometry. The relationship between drug concentrations in hair and time to unfavourable outcomes was assessed using Cox-proportional hazards regression models.RESULTS: A two-fold increase in hair acetyl-INH concentrations in the 264 participants in our cohort with hair assays for TB drugs indicated a lower hazard of unfavourable TB treatment outcomes (aHR 0.67, 95%CI 0.44-1.02) and TB treatment failure (aHR 0.65, 95%CI 0.42-1.01). Higher summed concentrations (a summed measure of INH and acetyl-INH) indicated a lower hazard of treatment failure (aHR 0.69, 95%CI 0.45-1.05)CONCLUSION: Hair levels of INH and its metabolite may predict TB treatment outcomes, indicating the potential utility of this measure to assess and optimise TB treatment outcomes.

Fetal heart rate mirrors maternal temperature during posterior fossa craniotomy: a case report

While it is well known that maternal temperature affects fetal heart rate, the exact relationship is not well described. The circumstances accompanying most cases of maternal hypothermia and rewarming (e.g. a drowning event) have precluded a precise quantitative description of this relationship. We describe hypothermia and controlled rewarming during resection of a maternal brain stem tumor in the early third trimester. Continuous electronic fetal heart rate and core temperature monitoring demonstrated a near linear relationship during the development of hypothermia and rewarming. Recognition of the close relationship between maternal temperature and fetal heart rate can help safeguard maternal and fetal health, and prevent unnecessary delivery during non-obstetric surgery in pregnancy.

A115 A SYSTEMATIC REVIEW AND META-ANALYSIS OF LOWER GASTROINTESTINAL BLEEDING RISK SCORES TO PREDICT ADVERSE OUTCOMES

Background

Acute lower gastrointestinal bleeding (LGIB) is a common reason for emergency hospitalization. In most patients, bleeding resolves spontaneously but some cases can be fatal. Risk prediction scores can be useful in risk stratifying patients with LGIB at the time of presentation although the most discriminative LGIB risk score is unknown.

Aims

To perform a systematic review and meta-analysis comparing LGIB risk prediction scores.

Methods

Following the PRISMA statement, a systematic search for relevant publications after 1990 was conducted in Ovid Medline, EMBASE, Web of Science and CENTRAL electronic databases. We also searched published conference abstracts over the past 5 years. Studies with a primary aim of deriving or validating a LGIB risk score were included. Title and abstracts were reviewed by two independent reviewers followed by full text review and data extraction by both reviewers. Diagnostic classification data for combinations of risk score and clinical outcome were meta-analyzed using a hierarchical summary receiver operator characteristic curve (ROC) model, allowing for random-effects by study, and fixed-effect of the risk score thresholds to influence both sensitivity and specificity. Area under the summary ROC were estimated from model parameters for the pre-specified LGIB risk score thresholds-of-interest.

Results

Our search identified 2,331 citations for review, of which 100 remained after the title and abstract screen, and 18 ultimately met criteria for inclusion in the meta-analysis after full text review. From these, we identified 21 risk prediction scores for LGIB, although only four had sufficient number of papers to meta-analyze (Oakland, Strate, NOBLADS, and BLEED score). For the outcome safe discharge from hospital, the Oakland score had an area under the receiver operating characteristics curve (AUROC) of 85.5% (95% CI: 82.1%, 88.3%). For the outcome major bleeding, the Oakland score had an AUROC of 78.9% (95% CI: 75.1%, 82.2%); the Strate score had an AUROC of 74.4% (95% CI: 70.4%, 78.0%); the NOBLADS score had an AUROC of 60.3% (95% CI: 55.9%, 64.5%); and the BLEED score had an AUROC of 65.6% (95% CI: 61.4%, 69.7%). For the outcome, need for hemostasis, the Oakland had an AUROC of 99.0% (95% CI: 97.7%, 99.6%); the Strate score had an AUROC of 82.1% (95% CI: 78.5%, 85.2%); the NOBLADS score had an AUROC of 23.9% (95% CI: 20.3%, 27.8%). For the outcome, need for transfusion, the Oakland score had an AUROC of 99.0% (95% CI: 97.7%, 99.6%); the NOBLADS score had an AUROC of 87.7% (95% CI: 84.5%, 90.3%).

Conclusions

The Oakland score was the most discriminative risk prediction model for safe discharge from hospital, major bleeding, need for hemostasis, and need for transfusion.

Funding Agencies

None

Elective delivery at 34 weeks vs routine obstetric care in fetal gastroschisis: randomized controlled trial

OBJECTIVE

To evaluate whether elective preterm delivery (ED) at 34 weeks is of postnatal benefit to infants with isolated gastroschisis compared with routine obstetric care (RC).

METHODS

Between May 2013 and September 2015, all women with a sonographic diagnosis of fetal gastroschisis referred to a single tertiary center, before 34 weeks' gestation, were invited to participate in this study. Eligible patients were randomized to ED (induction of labor at 34 weeks) or RC (spontaneous labor or delivery by 37-38 weeks, based on standard obstetric indications). The primary outcome measure was length of time on total parenteral nutrition (TPN). Secondary outcomes were time to closure of gastroschisis and length of stay in hospital. Outcome variables were compared using appropriate statistical methods. Analysis was based on intention-to-treat.

RESULTS

Twenty-five women were assessed for eligibility, of whom 21 (84%; 95% CI, 63.9-95.5%) agreed to participate in the study; of these, 10 were randomized to ED and 11 to RC. The trial was stopped at the first planned interim analysis due to patient safety concerns and for futility; thus, only 21 of the expected 86 patients (24.4%; 95% CI, 15.8-34.9%) were enrolled. Median gestational age at delivery was 34.3 (range, 34-36) weeks in the ED group and 36.7 (range, 27-38) weeks in the RC group. One patient in the ED group delivered at 36 weeks following unsuccessful induction at 34 weeks. Neonates of women who underwent ED, compared to those in the RC group, showed no difference in the median number of days on TPN (54 (range, 17-248) vs 21 (range, 9-465) days; P = 0.08), number of days to closure of gastroschisis (7 (range, 0-15) vs 5 (range, 0-8) days; P = 0.28) and length of stay in hospital (70.5 (range, 22-137) vs 31 (range, 19-186) days; P = 0.15). However, neonates in the ED group were significantly more likely to experience late-onset sepsis compared with those in the RC group (40% (95% CI, 12.2-73.8%) vs 0%; P = 0.03).

CONCLUSION

This study demonstrates no benefit of ED of fetuses with gastroschisis when postnatal gastroschisis management is similar to that used in routine care. Rather, the data suggest that ED is detrimental to infants with gastroschisis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Isoniazid hair concentrations in children with tuberculosis: a proof of concept study

Assessing treatment adherence and quantifying exposure to anti-tuberculosis drugs among children is challenging. We undertook a 'proof of concept' study to assess the drug concentrations of isoniazid (INH) in hair as a therapeutic drug monitoring tool. Children aged <12 years initiated on a thrice-weekly treatment regimen including INH (10 mg/kg) for newly diagnosed tuberculosis were enrolled. INH concentrations in hair were measured using liquid chromatography-tandem mass spectrometry at 1, 2, 4 and 6 months after initiating anti-tuberculosis treatment. We found that INH hair concentrations in all children on thrice-weekly INH were detectable and displayed variability across a dynamic range.

A Prospective Study to Evaluate the Management of Sub-trochanteric Femur Fractures with Long Proximal Femoral Nail

Introduction: Sub-trochanteric fractures of the femur remains one of the most challenging fractures faced by orthopaedic surgeons. This study was done to analyse the management and complications of sub-trochanteric fractures using long proximal femoral nail (PFN). Materials and Methods: This was a prospective study of 50 patients with sub-trochanteric fractures of femur who were treated with long PFN at a tertiary care center from July 2012 to June 2016. The fractures were classified according to Seinsheimer classification. All patients were assessed functionally by Harris Hip Score. Results: Average duration of union was 17.08 weeks (range 13 to 32 weeks), union was achieved in 92% cases. Closed reduction was achieved in 68% cases and open reduction was required in 32% cases. Various intraoperative complications were seen in 12% and delayed complications in 26% of cases. Good anatomical results were achieved in 86% of cases and 14% were fair. As per Harris Hip score, excellent results were noted in 28% cases, good in 56% cases and fair in 16% cases. Conclusion: The long PFN is a reliable implant for subtrochanteric femur fractures, with high rate of bone union and minimal soft tissue damage. Intramedullary fixation has biological and biomechanical advantages, but the surgery is technically demanding.

Prevalence of Human Herpesvirus-8 Salivary Shedding in HIV Increases with CD4 Count

Human herpesvirus-8 (HHV-8) is the etiologic agent of Kaposi’s sarcoma (KS), which occurs in epidemic form in human immunodeficiency virus(HIV)-infected individuals. Saliva is the only mucosal fluid in which infectious HHV-8 has been identified, although factors associated with HHV-8 salivary shedding remain unclear. Our study performed PCR analysis for HHV-8 DNA in saliva (and other body fluids) in 66 HIV- and HHV-8-co-infected women without KS so that we could examine predictors for HHV-8 DNA detection. CD4 count was the most significant predictor of HHV-8 salivary shedding, with increased prevalence of HHV-8 salivary DNA at higher CD4 counts. The odds of salivary HHV8 shedding at CD4 counts > = 350 cells/μL was 63 times the odds of shedding at CD4 < 350 (95%CI, 1.3–3078), with an increase in effect size when the analysis was restricted to those with a CD4 nadir > 200. Analysis of these data suggests an increased potential for HHV-8 transmission early in HIV infection, with implications for HHV-8 prevention.

Frailty and Constellations of Factors in Aging HIV-infected and Uninfected Women--The Women's Interagency HIV Study

BACKGROUND

Biological similarities are noted between aging and HIV infection. Middle-aged adults with HIV infection may present as elderly due to accelerated aging or having more severe aging phenotypes occurring at younger ages.

OBJECTIVES

We explored age-adjusted prevalence of frailty, a geriatric condition, among HIV+ and at risk HIV- women.

DESIGN

Cross-sectional.

SETTING

The Women's Interagency HIV Study (WIHS).

PARTICIPANTS

2028 middle-aged (average age 39 years) female participants (1449 HIV+; 579 HIV-).

MEASUREMENTS

The Fried Frailty Index (FFI), HIV status variables, and constellations of variables representing Demographic/health behaviors and Aging-related chronic diseases. Associations between the FFI and other variables were estimated, followed by stepwise regression models.

RESULTS

Overall frailty prevalence was 15.2% (HIV+, 17%; HIV-, 10%). A multivariable model suggested that HIV infection with CD4 count<200; age>40 years; current or former smoking; income ≤$12,000; moderate vs low fibrinogen-4 (FIB-4) levels; and moderate vs high estimated glomerular filtration rate (eGFR) were positively associated with frailty. Low or moderate drinking was protective.

CONCLUSIONS

Frailty is a multidimensional aging phenotype observed in mid-life among women with HIV infection. Prevalence of frailty in this sample of HIV-infected women exceeds that for usual elderly populations. This highlights the need for geriatricians and gerontologists to interact with younger 'at risk' populations, and assists in the formulation of best recommendations for frailty interventions to prevent early aging, excess morbidities and early death.