Single organ metastatic sites in non-small cell lung cancer: Patient characteristics, treatment patterns and outcomes from a large retrospective Canadian cohort

BACKGROUND

There is a paucity of information about the characteristics, treatment patterns, and outcomes of non-small cell lung cancer (NSCLC) patients with single organ metastasis (SOM).

METHODS

This retrospective cohort study includes all patients with a diagnosis of stage IV NSCLC diagnosed from 2014 to 2016 and treated at Princess Margaret Cancer Centre. We compared baseline characteristics and patterns of metastatic sites between patients with SOM versus multiple (M)OM. Additionally, we identified treatment modalities and outcomes for patients with SOM. Cox multivariable models (MVA) were utilized to evaluate differences in overall survival (OS) between the SOM and MOM cohorts.

RESULTS

Of 893 pts analyzed, 457 (51 %) had SOM, while 436 (49 %) had MOM at initial diagnosis. Demographics were comparable between the two groups. Brain was the most common site of metastasis for SOM patients. When compared to the MOM group, the SOM group had lower percentages of liver and adrenal metastases. Amongst SOM patients, 54 % received single modality treatment, and 20 % did not receive any treatment for their SOM. In MVA, patients with liver (HR 2.4), bone (HR 1.8), and pleural (HR 1.7) metastasis as their SOM site had the worst outcomes, with median OS of 6.8 months, 12.1 months, and 13.0 months respectively. Patients with SOM had a significantly improved median OS compared to those with MOM (15.9 months vs. 10.6 months; HR 0.56, 95 % CI 0.47-0.66, p < 0.001).

CONCLUSION

In NSCLC patients who presented with SOM, survival correlated with the initial organ involved and was better overall compared to patients with MOM. SOM NSCLC may benefit from specific management strategies and SOM patients could be considered as a specific subgroup for survival analyses in observational and non-randomized interventional studies. In clinical trials, SOM can be considered as a stratification factor in the future.

Type 2 diabetes-related health measures during the initial COVID-19 surge at an academic internal medicine practice

The COVID-19 pandemic disrupted chronic disease management in the United States and across the world. This study reports minimal effects of the initial COVID-19 surge on body mass index, blood pressure, cholesterol, and blood glucose control in ambulatory general internal medicine patients with Type 2 diabetes at a single academic center.

β-amyloid accumulation enhances microtubule associated protein tau pathology in an APPNL-G-F/MAPTP301S mouse model of Alzheimer's disease

Introduction

The study of the pathophysiology study of Alzheimer's disease (AD) has been hampered by lack animal models that recapitulate the major AD pathologies, including extracellular -amyloid (A) deposition, intracellular aggregation of microtubule associated protein tau (MAPT), inflammation and neurodegeneration.

Methods

The humanized APPNL-G-F knock-in mouse line was crossed to the PS19 MAPTP301S, over-expression mouse line to create the dual APPNL-G-F/PS19 MAPTP301S line. The resulting pathologies were characterized by immunochemical methods and PCR.

Results

We now report on a double transgenic APPNL-G-F/PS19 MAPTP301S mouse that at 6 months of age exhibits robust A plaque accumulation, intense MAPT pathology, strong inflammation and extensive neurodegeneration. The presence of A pathology potentiated the other major pathologies, including MAPT pathology, inflammation and neurodegeneration. MAPT pathology neither changed levels of amyloid precursor protein nor potentiated A accumulation. Interestingly, study of immunofluorescence in cleared brains indicates that microglial inflammation was generally stronger in the hippocampus, dentate gyrus and entorhinal cortex, which are regions with predominant MAPT pathology. The APPNL-G-F/MAPTP301S mouse model also showed strong accumulation of N6-methyladenosine (m6A), which was recently shown to be elevated in the AD brain. m6A primarily accumulated in neuronal soma, but also co-localized with a subset of astrocytes and microglia. The accumulation of m6A corresponded with increases in METTL3 and decreases in ALKBH5, which are enzymes that add or remove m6A from mRNA, respectively.

Discussion

Our understanding of the pathophysiology of Alzheimer's disease (AD) has been hampered by lack animal models that recapitulate the major AD pathologies, including extracellular -amyloid (A) deposition, intracellular aggregation of microtubule associated protein tau (MAPT), inflammation and neurodegeneration. The APPNL-G-F/MAPTP301S mouse recapitulates many features of AD pathology beginning at 6 months of aging, and thus represents a useful new mouse model for the field.

Efficacy of adjunctive octenidine hydrochloride as compared to chlorhexidine and placebo as adjuncts to instrumentation in stage I-II periodontitis: A double-blinded randomized controlled trial

OBJECTIVES

This randomized, controlled, double-blinded clinical trial aimed to evaluate the efficacy of octenidine hydrochloride and chlorhexidine mouthwashes as adjuncts to instrumentation in stage I-II periodontitis patients.

METHODS

Forty-five patients with mild-to-moderate periodontitis were randomly allocated to three groups: 0.1% octenidine dihydrochloride (OCT), placebo, and 0.12% chlorhexidine (CHX) mouthwashes. Patients were instructed to use the mouthwash after instrumentation for twice a day up to 3 weeks. Periodontal parameters such as probing pocket depth (PPD), clinical attachment loss (CAL), O'Leary plaque index (PI), Loe and Silness gingival index (GI), Lobene stain index (SI), and oral soft tissue changes were recorded at baseline and once every week for 3 weeks. The visual analogue scale (VAS) was also recorded as a self-administered questionnaire at the end of the study. The one-way ANOVA was used to compare VAS scores between the groups. The repeated measures ANOVA and post hoc Newman-Keuls tests were used to assess the differences in the periodontal parameters between groups at different time intervals. The Kruskal-Wallis test was used to compare the mean SI.

RESULTS

There was a significant reduction in the mean GI of the OCT and CHX groups compared to placebo (p < 0.05). OCT usage resulted in significantly less staining, according to mean SI, when compared to CHX. Furthermore, VAS scores revealed that OCT was significantly the preferred mouthwash (p < 0.01).

CONCLUSION

Adjunctive octenidine hydrochloride may be an alternative to chlorhexidine in its ability to control the periodontal parameters in patients with stage I-II periodontitis. Further larger studies are necessary to confirm these findings.

Identifying determinants of varenicline adherence using the Theoretical Domains framework: a rapid review

BACKGROUND

Adhering to varenicline has been shown to significantly improve the chances of successfully quitting smoking, with studies indicating a twofold increase in 6-month quit rates. However, despite its potential benefits, many individuals struggle with maintaining good adherence to varenicline; thus there is a need to develop scalable strategies to help people adhere. As a first step to inform the development of an intervention to improve adherence to varenicline, we conducted a rapid literature review to identify: 1) modifiable barriers and facilitators to varenicline adherence, and 2) behaviour change techniques associated with increased adherence to varenicline.

METHODS

We searched MEDLINE, Embase, APA PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials for relevant studies published between 2006 and 2022. Search terms included "varenicline," "smoking cessation," and "adherence," and their respective subject headings and synonyms. We screened and included studies reporting modifiable determinants of adherence to varenicline and then assessed quality, extracted modifiable determinants and mapped them to the Theoretical Domains Framework version 2 and the Behaviour Change Technique Taxonomy version 1.

RESULTS

A total of 1,221 titles were identified through the database searches; 61 met the eligibility criteria. Most of the studies were randomized controlled trials and predominantly focused on barriers to varenicline. Only nine studies explicitly mentioned behaviour change techniques used to help varenicline adherence. Eight domains were identified as barriers to varenicline adherence (behavioural regulation, memory, goals, intentions, beliefs about capabilities, beliefs about consequences, optimism/pessimism, and environmental context) and five as facilitators (knowledge, behavioural regulation, beliefs about capabilities, social influences, and environmental context).

CONCLUSIONS

This study identifies barriers and facilitators that should be addressed when developing a complex adherence intervention tailored to patients' needs based on modifiable determinants of medication adherence, some of which are under- used by existing adherence interventions. The findings from this review will inform the design of a theory-based healthbot planned to improve varenicline adherence in people undergoing smoking cessation treatment.

SYSTEMATIC REVIEW REGISTRATION

This study was registered with PROSPERO (# CRD42022321838).

Sex-specific neuropsychological correlates of apathy and depression across neurodegenerative disorders

BACKGROUND

Apathy and depression are common neuropsychiatric symptoms across neurodegenerative disorders and are associated with impairment in several cognitive domains, yet little is known about the influence of sex on these relationships.

OBJECTIVES

We examined the relationship between these symptoms with neuropsychological performance across a combined cohort with mild or major neurodegenerative disorders, then evaluated the impact of sex.

DESIGN, SETTING AND PARTICIPANTS

We conducted a cohort analysis of participants in the COMPASS-ND study with mild cognitive impairment (MCI), vascular MCI, Alzheimer's disease, mixed dementia, Parkinson's disease, frontotemporal dementia, and cognitively unimpaired (CU) controls.

MEASUREMENTS

Participants with neurodegenerative disease and CU controls were stratified by the presence (severity ≥1 on Neuropsychiatric Inventory Questionnaire) of either depressive symptoms alone, apathy symptoms alone, both symptoms, or neither. A neuropsychological battery evaluated executive function, verbal fluency, verbal learning, working memory, and visuospatial reasoning. Analysis of covariance was used to assess group differences with age, sex, and education as covariates.

RESULTS

Groups included depressive symptoms only (n = 70), apathy symptoms only (n = 52), both (n = 68), or neither (n = 262). The apathy and depression + apathy groups performed worse than the neither group on tests of working memory (t(312)  = -2.4, p = 0.02 and t(328)  = -3.8, p = 0.001, respectively) and visuospatial reasoning (t(301)  = -2.3, p = 0.02 and t(321)  = -2.6, p = 0.01, respectively). The depression, apathy, and depression + apathy groups demonstrated a similar degree of impairment on tests of executive function, processing speed, verbal fluency, and verbal learning when compared to participants without apathy or depression. Sex-stratified analyses revealed that compared to the male neither group, the male apathy and depression + apathy groups were impaired broadly across all cognitive domains except for working memory. Females with depression alone showed deficits on tests of executive function (t(166)  = 2.4, p = 0.01) and verbal learning (t(167)  = -4.3, p = 0.001) compared to the female neither group.

CONCLUSIONS

This study demonstrated that in neurodegenerative diseases, apathy with or without depression in males was associated with broad cognitive impairments. In females, depression was associated with deficits in executive function and verbal learning. These findings highlight the importance of effectively treating apathy and depression across the spectrum of neurodegenerative disorders with the goal of optimizing neuropsychological outcomes.

Functional outcome after selective dorsal rhizotomy: a retrospective case control study

PURPOSE

This study examines long-term benefit on functional outcomes and quality of life after selective dorsal rhizotomy (SDR) in children with spastic diplegia in Hong Kong.

METHOD

This is a case control study. Individuals with spastic diplegia who were at 6 to 12 years post-SDR were recruited. Age, gender, cognition, and Gross Motor Function Classification System level-matched individuals with spastic diplegia who had not undergone SDR were recruited as controls. Outcome measures included physical level, functional level, physiological level, and quality of life. All data were compared by independent t-test.

RESULTS

Individuals post-SDR (n = 15) demonstrated a significantly better range of ankle dorsiflexion in knee extension by - 5.7 ± 10.9° than the control group (n = 12). No other significant differences were observed.

CONCLUSION

SDR is a safe, one-off procedure and provides long-term reduction in spasticity with no major complications. With the heterogeneity, we did not demonstrate between-group differences in long-term functional outcomes.

Development of a single-visit protocol for the management of pregnancy of unknown location following in vitro fertilization: a retrospective study

STUDY QUESTION

Can women with pregnancy of unknown location (PUL) following in vitro fertilization (IVF) be risk-stratified regarding the subsequent need for medical intervention, based on their demographic characteristics and the results of serum biochemistry at the initial visit?

SUMMARY ANSWER

The ratio of serum hCG to number of days from conception (hCG/C) or the initial serum hCG level at ≥5 weeks' gestation could be used to estimate the risk of women presenting with PUL following IVF and needing medical intervention during their follow-up.

WHAT IS KNOWN ALREADY

In women with uncertain conception dates presenting with PUL, a single serum hCG measurement cannot be used to predict the final pregnancy outcomes, thus, serial levels are mandatory to establish a correct diagnosis. Serum progesterone levels can help to risk-stratify women at their initial visit but are not accurate in those taking progesterone supplementation, such as women pregnant following IVF.

STUDY DESIGN, SIZE, DURATION

This was a retrospective study carried out at two specialist early pregnancy assessment units between May 2008 and January 2021. A total of 224 women met the criteria for inclusion, but 14 women did not complete the follow-up and were excluded from the study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We selected women who had an IVF pregnancy and presented with PUL at ≥5 weeks' gestation.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 30/210 (14.0%, 95% CI 9.9-19.8) women initially diagnosed with PUL required surgical intervention. The hCG/C was significantly higher in the group of women requiring an intervention compared to those who did not (P = 0.003), with an odds ratio of 3.65 (95% CI 1.49-8.89, P = 0.004). A hCG/C <4.0 was associated with a 1.9% risk of intervention, which accounted for 25.7% of the study population. A similar result was obtained by substituting hCG/C <4.0 with an initial hCG level <100 IU/l, which was associated with 2.0% risk of intervention, and accounted for 23.8% of the study population (P > 0.05).

LIMITATIONS, REASONS FOR CAUTION

A limitation of our study is that it is retrospective in nature, and as such, we were reliant on existing data.

WIDER IMPLICATIONS OF THE FINDINGS

A previous study in women with PUL after spontaneous conception found that a 2% intervention rate was considered low enough to eliminate the need for close follow-up and serial blood tests. Using the same 2% cut-off, a quarter of women with PUL after IVF could also avoid attending for further visits and investigations.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was required for this study. No conflicts of interest are required to be declared.

TRIAL REGISTRATION NUMBER

N/A.

Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: a systematic review and meta-analysis

There is increasing interest in the use of short-acting opioids such as remifentanil to facilitate tracheal intubation. The aim of this systematic review was to determine the efficacy and safety of remifentanil for tracheal intubation compared with neuromuscular blocking drugs in adult patients. We conducted a systematic search for randomised controlled trials evaluating remifentanil for tracheal intubation. Primary outcomes included tracheal intubation conditions and adverse events. Twenty-one studies evaluating 1945 participants were included in the analysis. Use of remifentanil (1.5-4.0 μg.kg-1 ) showed no evidence of a difference in tracheal intubation success rate compared with neuromuscular blocking drugs (risk ratio (95%CI) 0.97 (0.94-1.01); six studies; 1232 participants; I2 28%; p = 0.16; moderate-certainty evidence). Compared with neuromuscular blocking drugs, the use of remifentanil (2.0-4.0 μg.kg-1 ) makes little to no difference in terms of producing excellent tracheal intubation conditions (risk ratio (95%CI) 1.16 (0.72-1.87); two studies; 121 participants; I2 31%, p = 0.54; moderate-certainty of evidence). There was no evidence of an effect between remifentanil (2.0-4.0 μg.kg-1 ) and neuromuscular blocking drugs for bradycardia (risk ratio (95%CI) 0.44 (0.01-13.90); two studies; 997 participants; I2 81%; p = 0.64) and hypotension (risk ratio (95%CI) 1.05 (0.44-2.49); three studies; 1071 participants; I2 92%; p = 0.92). However, the evidence for these two outcomes was judged to be of very low-certainty. We conclude that remifentanil may be used as an alternative drug for tracheal intubation in cases where neuromuscular blocking drugs are best avoided, but more studies are required to evaluate the haemodynamic adverse events of remifentanil at different doses.

A combined analysis of two prospective randomised studies exploring the impact of extended post-radiation temozolomide on survival outcomes in newly diagnosed glioblastoma

PURPOSE

The optimal duration of post-radiation temozolomide in newly diagnosed glioblastoma remains unclear, with no published phase III randomised trials. Standard-of-care stipulates 6 months. However, in routine care, it is often extended to 12 months, despite lacking robust supporting data.

METHODS

GEINO14-01 (Spain) and EX-TEM (Australia) studies enrolled glioblastoma patients without progression at the end of 6 months post-radiation temozolomide. Participants were randomised 1:1 to six additional months of temozolomide or observation. Primary endpoint was 6-month progression free survival from date of randomisation (6mPFS). Secondary endpoints included overall survival (OS) and toxicity. 204 patients were required to detect an improvement in 6mPFS from 50 to 60% (80% power). Neither study recruited sufficient patients. We performed a combined analysis of individual patient data.

RESULTS

205 patients were recruited: 159 in GEINO14-01 (2014-2018) and 46 in EX-TEM (2019-2022). Median follow-up was 20.0 and 14.5 months. Baseline characteristics were balanced. There was no significant improvement in 6mPFS (57.2% vs 64.0%, OR0.75, p = 0.4), nor across any subgroups, including MGMT methylated; PFS (HR0.92, p = 0.59, median 7.8 vs 9.7 months); or OS (HR1.03, p = 0.87, median 20.1 vs 19.4 months). During treatment extension, 64% experienced any grade adverse event, mainly fatigue and gastrointestinal (both 54%). Only a minority required treatment changes: 4.5% dose delay, 7.5% dose reduction, 1.5% temozolomide discontinuation.

CONCLUSION

For glioblastoma patients, extending post-radiation temozolomide from 6 to 12 months is well tolerated but does not improve 6mPFS. We could not identify any subset that benefitted from extended treatment. Six months should remain standard-of-care.

Effects of flavour and modified risk claims on nicotine pouch perceptions and use intentions among young adults who use inhalable nicotine and tobacco products: a randomised controlled trial

BACKGROUND

Availability of flavours and potential modified risk tobacco product (MRTP) claims may influence young adults' (YAs') perceptions of and intentions to use nicotine pouches ('pouches').

METHODS

YAs aged 21-34 years (N=47, M age=24.5, SD=3.1) with past-month nicotine/tobacco use (10.6% cigarette-only, 51.1% e-cigarette-only, 38.3% dual use) and no intention to quit were randomised to self-administer four Zyn 3 mg nicotine pouches in a 4 (flavour; within-subjects: smooth, mint, menthol, citrus) × 2 (MRTP claim on packaging; between subjects: present or absent) mixed-factorial design. After self-administering each pouch, participants reported appeal, use intentions and perceived harm compared with cigarettes and e-cigarettes. Three mixed-factorial analysis of variances (ANOVAs) examined main and interactive effects of flavour and MRTP claim on appeal, use intentions and comparative harm perceptions.

RESULTS

Mint (M=55.9, SD=26.4), menthol (M=49.7, SD=26.8) and citrus (M=46.6, SD=24.8) flavours were significantly more appealing than smooth (M=37.6, SD=25.4; p<0.001). MRTP claim did not significantly affect product appeal (p=0.376). Use intentions were greater for mint (M=2.6, SD=1.3) and menthol (M=2.0, SD=1.1) flavours than smooth (M=1.8, SD=1.0; p=0.002). Flavour did not affect comparative harm perceptions (p values>0.418). MRTP claims increased use intention (p=0.032) and perceptions of pouches as less harmful than cigarettes (p=0.011), but did not affect perceived harm relative to e-cigarettes (p=0.142). Flavour × MRTP claim interactions were not significant.

CONCLUSIONS

Flavoured (vs smooth) pouches were more appealing to YAs. MRTP claims reduced perceived harm of pouches compared with cigarettes; however, intentions to switch were low. To protect YAs' health, regulatory restrictions could target flavours and MRTP claims.

Association of Bacterial Composition and Diversity in the Cervical Tumor Microbiome with HPV Genotype in a Large, International Patient Cohort

PURPOSE/OBJECTIVE(S)

Tumor bacterial composition is strongly associated with response to cancer therapy, and is impacted by environment, including geography. Human papillomavirus (HPV) genotypic diversity composition and load are dynamic during pelvic radiation (RT) and correlate with differential responses to RT in cervical cancer patients. In this multi-institutional, collaborative study, we aimed to explore associations between bacterial composition, HPV serotypes, and geographical distribution in an international patient population.

MATERIALS/METHODS

Cervical swabs were collected from 287 patients diagnosed with cervical cancer/ dysplasia in four locations: Houston, USA (TX; N = 94), Ethiopia (ETH; N = 85), Puerto Rico (PR; N = 71), and Botswana (BOT; N = 37). Swabs were collected prior to treatment and were subjected to 16S V4 rRNA gene sequencing and HPV genotyping. We compared HPV types and geography via Chi-squared test. We analyzed bacterial composition, alpha diversity (ANOVA), and beta diversity (principal coordinates analysis [PCoA] with PERMANOVA) for HPV type and geography. We used Linear Discriminant Effect Size (LEfSe) analysis to distinguish taxa associated with HPV types.

RESULTS

Overall, the global bacterial composition for patients with cancer or dysplasia did not significantly vary by location. However, the proportion of patients with each HPV type varied by location (p<0.01); HPV16 was most frequent in TX (54%), BOT (70%) and ETH (61%), while HPV18 was most frequent in PR (62%). The proportion of patients with HPV low-risk/negative tumors was highest in ETH (25%) compared to other sites (2% - 14%). Patients with HPV 16 had significantly higher bacterial alpha diversity across locations (all p<0.01). The bacterial composition also differed by HPV type across locations (p = 0.01). On LEfSe, bacterial genera enriched in HPV 16 samples were Bacteroides, Clostridium, and Prevotella. Non-HPV16 tumors were enriched in species of Lactobacillus and Gardnerella and HPV 18 and high-risk type tumors were enriched in Escherichia.

CONCLUSION

In thislarge, international cohort of cervical cancer and dysplasia patients, bacterial composition was more closely associated with cervical HPV genotype than with geography. This finding has implications for the development of biomarkers and interventions aimed at improving chemotherapy and radiation response through manipulation of the microbiome.

E-cigarette weight and appetite control beliefs and e-cigarette initiation in young adults

E-cigarette use has increased among young adults, and emerging research suggests a subset of young adults report using e-cigarettes for appetite control/weight loss. The current article examined the association of e-cigarette weight control beliefs with subsequent e-cigarette initiation. Data were collected via online surveys from a prospective cohort study of young adults in Southern California (N = 1,368) at baseline (May-October 2020; M [SD]age = 21.2 [0.4]) and 6 months later (January-May 2021). Binary logistic regression models were used to evaluate the association of e-cigarette weight control beliefs (i.e., perceptions that e-cigarettes help people lose weight and satisfy hunger and desire to eat unhealthy foods) with new onset e-cigarette use at follow-up. All models were adjusted for sociodemographic characteristics. Among individuals who had never used e-cigarettes at baseline, those who agreed (vs. disagreed) that e-cigarettes help people lose weight had more than three times the odds of initiating e-cigarette use by follow-up (OR [95% CI]: 3.24 [1.52, 6.62]). Similarly, those who agreed (vs. disagreed) that vaping certain e-cigarette flavors help satisfy hunger and desire to eat unhealthy foods had more than twice the odds of initiating e-cigarette use by follow-up (OR [95% CI]: 2.40 [1.15, 4.82]). Findings highlight that e-cigarette weight control beliefs are an important risk factor for vaping initiation. Future interventions and policies aiming to prevent vaping among young adults should address e-cigarette weight control beliefs and long-term health consequences from related use. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Clinicians' interpretation of ventilation/perfusion lung scan reports: Where are we today?

Background

Clinicians' interpretation of lung scan reports will determine which further management decisions are taken when potentially fatal pulmonary embolism (PE) is suspected.

Objectives

To assess current referring clinicians' interpretation of the terminology used in ventilation/perfusion (V/Q) scan reports, whether this interpretation is affected by experience level, and how it affects clinical management decisions.

Methods

This was a questionnaire-based cross-sectional study. Between September 2020 and May 2021, 300 questionnaires were distributed among clinicians who refer patients for V/Q scans.

Results

Of the 162 clinicians who responded, 94% thought that there is >85% likelihood of PE or definitely PE present when a scan is reported as 'high probability of PE'; 87% interpreted 'low probability of PE' as <10% likelihood of PE or definitely no PE present. Overall, >70% of clinicians across all experience levels correctly interpreted the intended meaning of probability categories according to the Modified Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II criteria. Of the respondents, 77% agreed that clinically significant PE is ruled out by a normal scan. Further investigation for inconclusive findings, features of parenchymal lung disease and cardiomegaly were selected by 72%, 93% and 98% of clinicians, respectively.

Conclusion

The findings of this study regarding high-probability scan results were in line with existing literature on lung scan report interpretation. However, our findings regarding low-probability scan results and negative V/Q scan specificity contrasted with the findings in these articles, suggesting that clinicians are now more familiar with lung scan interpretation guidelines. Experience level did not significantly affect interpretation of reports. Although most clinicians agreed that a negative scan excludes clinically significant PE, two-thirds of them would still subject the patient to further unnecessary investigations to exclude PE.

Study synopsis

What the study adds. Our findings regarding a low-probability ventilation/perfusion (V/Q) scan and the specificity of a negative V/Q scan contrasted with previous articles on lung scan interpretation, suggesting that clinicians are now more familiar with lung scan interpretation guidelines.Implications of the findings. Although most clinicians understood the negative predictive value of a V/Q scan, 20% would still investigate further with computed tomography pulmonary angiography or treat as confirmed pulmonary embolism. Education of clinicians about the negative predictive value of V/Q scans is important to avoid unnecessary radiation or anticoagulation.

Accumulation of m6A exhibits stronger correlation with MAPT than β-amyloid pathology in an APPNL-G-F /MAPTP301S mouse model of Alzheimer's disease

The study for the pathophysiology study of Alzheimer's disease (AD) has been hampered by lack animal models that recapitulate the major AD pathologies, including extracellular β-amyloid (Aβ) deposition, intracellular aggregation of microtubule associated protein tau (MAPT), inflammation and neurodegeneration. We now report on a double transgenic APPNL-G-F MAPTP301S mouse that at 6 months of age exhibits robust Aβ plaque accumulation, intense MAPT pathology, strong inflammation and extensive neurodegeneration. The presence of Aβ pathology potentiated the other major pathologies, including MAPT pathology, inflammation and neurodegeneration. However, MAPT pathology neither changed levels of amyloid precursor protein nor potentiated Aβ accumulation. The APPNL-G-F/MAPTP301S mouse model also showed strong accumulation of N6-methyladenosine (m6A), which was recently shown to be elevated in the AD brain. M6A primarily accumulated in neuronal soma, but also co-localized with a subset of astrocytes and microglia. The accumulation of m6A corresponded with increases in METTL3 and decreases in ALKBH5, which are enzymes that add or remove m6A from mRNA, respectively. Thus, the APPNL-G-F/MAPTP301S mouse recapitulates many features of AD pathology beginning at 6 months of aging.

Anti-hypertensive prescription practices in private hospitals in Malaysia: a prospective, non-interventional, observational study

INTRODUCTION

In managing hypertension, monotherapy and sometimes a combination of more than one agent are used to achieve blood pressure (BP) control. The objective of this prospective, observational, multi-centre study was to assess the level of BP control in patients receiving one or more anti-hypertensive drugs in private medical centres in Malaysia according to the treatment regimens (monotherapy, free drug combinations and single pill combinations).

MATERIALS AND METHODS

Data were collected through medical records and interview sessions with patients on current pharmacotherapy for hypertension management at baseline and 2-3 months later. Results are expressed as mean ± SD for continuous data and as frequencies and percentages for categorical data.

RESULTS

Among 182 recruited patients, 89 (49%) achieved BP control by the end of the study. Majority (62/89) patients were on single-pill (monotherapy or SPC) antihypertensives. Majority (63/89) required more than two antihypertensives to achieve BP control.

CONCLUSION

Both SPC and free drug combination antihypertensives reduced BPs, but physicians preferred SPC to improve BP control and increase treatment compliance.

Abstract 1785: Multi-step engineering of gene-edited CAR T cells using RNA lipid nanoparticles

Autologous chimeric antigen receptor (CAR) T therapies utilize patient cells and can be limited by cell quality, and the high manufacturing burden of viral vectors. As such, there is a need for allogeneic, “off-the-shelf” CAR T cells to make these transformative treatments widely available. However, allogeneic therapies require multiple genetic engineering steps to express CAR and to delete proteins responsible for graft-versus-host disease. Messenger RNA (mRNA) is a promising approach for expression of therapeutic proteins and gene editing nucleases. In this work, we demonstrate a new method for multi-step engineering of gene-edited CAR T cells using RNA lipid nanoparticles (LNPs).

LNPs encapsulating Spy-Cas9 mRNA, TCR and CD52 guide RNA (sgRNA), and CAR mRNA were produced using microfluidics. The CAR construct contained an anti-CD19 scFv binding domain and CD3ζ/4-1BB co-stimulatory domains. Microgram quantities of RNA LNPs were produced to optimize LNP packaging, cargo ratios, and sgRNA combinations. Lead candidates were scaled to milligrams. Purified human primary T cells were cultured, activated, and expanded in serum-free media in plates, flasks and bioreactors. CAR+, TCR− or CD52− cells were generated by addition of the corresponding LNP to activated cells. Cytotoxic killing was determined by co-culture assays with leukemia cells. Gene knockout, CAR expression, viability and cell killing were measured using flow-cytometry.

CD19 CAR was selected as a relevant protein for expression, with TCR and CD52 proteins as gene knockout targets. Single-step addition of CAR LNPs to T cells resulted in transfection efficiencies of 95.0 ± 2.1% and high protein expression. Upon TCR or CD52 LNP addition to T cells, the onset of gene editing was within 48 hours, reaching single target knockout efficiencies of 92.3 ± 3.0% (TCR−), and double knockouts (TCR−/CD52−) of 74.5 ± 6.1%. Similar results were obtained when comparing different LNP batch sizes (microgram to milligram RNA) and cell culture vessels (125,000 to 45 million cells), demonstrating scalability of both the LNP production and cell treatment. Cell viabilities above 90% were maintained at all steps and for all RNA LNPs. Finally, as proof-of-concept for multi-step engineering, sequential addition of TCR LNPs and CAR LNPs resulted in simultaneous CAR expression and TCR gene knockout. These “off-the-shelf” gene-edited CAR T cells were functionally equivalent to non-edited cells in a B cell killing assay, efficiently clearing over 80% of leukemia target cells at a 1:1 ratio.

Our findings demonstrate the advantages of LNPs for RNA delivery to T cells. The simple and gentle nature of LNP cell treatment allows for multiple genetic engineering steps for simultaneous expression and deletion of proteins. Furthermore, LNPs can be easily manufactured using microfluidics, enabling small-scale screening of RNA libraries and rapid scale-up of lead candidates for clinical translation.

Citation Format: Samuel Clarke, R Geczy, A Balgi, S Park, R Zhao, M Swaminathan, R Tieu, N Hoang, C Webb, E Watt, M Wong, M Fujisawa, N Jain, Angela Zhang, Anitha Thomas. Multi-step engineering of gene-edited CAR T cells using RNA lipid nanoparticles [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1785.

Young adults' beliefs about modern oral nicotine products: Implications for uptake in nonvapers, dual use with e-cigarettes, and use to reduce/quit vaping

Modern oral nicotine products (ONPs; nontherapeutic nicotine pouches, gums, lozenges, and gummies) may be perceived in ways that could promote uptake in nonvapers, dual use with e-cigarettes, or use to quit vaping. In this cross-sectional digital remote survey of 1,460 respondents aged 21-24 from Southern California, we examined beliefs about ONPs among past-30-day e-cigarette nonusers, users unmotivated to quit vaping, and users motivated to quit vaping. Positive beliefs about ONPs were reported by 31.8% of the overall sample and higher in past-30-day e-cigarette users (with or without quit motivation) than nonusers. Perceiving ONPs to be easy to conceal, convenient, and able to be used where vaping/smoking is not allowed were the most common types of beliefs reported. Among e-cigarette users with quit motivation (n = 142), interest in using ONPs to quit/reduce vaping (44.4%) was higher than interest in using medicinal nicotine gum/lozenges (23.4%), nicotine patch (17.6%), or prescription medications (16.6%). Interest in using ONPs to reduce/quit vaping (vs. no interest) was greater among participants who reported vaping ≥ 20 (vs. < 10) days in the past month, vaping ≥ 10 (vs. < 10) times per day, low/moderate (vs. high) quit vaping self-efficacy, and low/moderate (vs. high) desire to quit vaping. These findings suggest that: (a) appreciable subsets of the young adult population may hold positive beliefs about ONPs that could promote ONP uptake, particularly e-cigarette users and (b) some young adult e-cigarette users may be interested in using ONPs to reduce/quit vaping, particularly frequent vapers with relatively lower self-efficacy and desire to quit vaping. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Associations between anxiety symptoms and barriers to smoking cessation among African Americans who smoke cigarettes daily

BACKGROUND

African Americans who smoke cigarettes and experience heightened anxiety symptoms may have low quit smoking rates. Identifying which particular barriers to cessation are associated with specific types of anxiety symptoms in African Americans could inform cessation treatments for this population. This cross-sectional, correlational study examined associations of anxiety-related symptoms and distinct barriers to cessation among non-treatment-seeking African Americans who smoke cigarettes daily.

METHODS

African Americans who smoke (N = 536) enrolled in a clinical research study on individual differences in tobacco addiction between 2013 and 2017 completed self-report measures of anxiety-related symptoms (i.e., social anxiety, panic, and posttraumatic intrusions) and types of barriers to cessation (i.e., addiction-related, social-related, and affect-related barriers). Linear regression models tested associations of anxiety symptoms with cessation barriers with and without adjusting for age, sex, depressive symptoms, and nicotine dependence.

RESULTS

All anxiety-related symptoms were associated with each cessation barrier (βs = 0.240-0.396). After covariate adjustment, panic and trauma-related symptoms were not associated with cessation barriers, and the strength of association of social anxiety with external barriers was reduced but remained significant (β = 0.254).

CONCLUSION

Symptoms of social anxiety, but not trauma or panic-related symptoms, may play a unique, but modest, role in certain barriers to cessation in non-treatment-seeking African Americans who smoke cigarettes over. Further research is needed to uncover why African Americans who smoke and have anxiety might experience these barriers, and how future interventions can mitigate these obstacles.

Pelvic pain and venous congestion revisited: examining relationship between chronic pelvic pain and uterine venous size and blood flow

OBJECTIVE

To investigate the relationship between increased uterine venous plexus diameter and chronic pelvic pain in women attending a gynecology clinic.

METHODS

This was a retrospective study of patients attending a tertiary university hospital in London, UK. Women presenting to the gynecology clinic undergoing transvaginal ultrasound examination were recruited into the study. The largest trunk of the uterine venous plexus was measured on each side. Blood flow within the uterine veins was categorized into continuous or interrupted flow and evaluated using color and spectral Doppler ultrasound during normal respiration and on Valsalva maneuver to demonstrate the presence of venous reflux. The largest uterine vein diameter and its blood flow were used for the analysis. The main variables of interest were chronic pelvic pain, uterine vein diameter and type of blood flow.

RESULTS

We included 1500 women in the study, of whom 584 (38.9% (95% CI, 36.5-41.5%)) reported chronic pelvic pain. Dysmenorrhea was the most common type of pelvic pain. Age (P < 0.001), menopausal status (P = 0.02), varicose veins (P = 0.01), adenomyosis (P < 0.001) and endometriosis (P < 0.001) were found to be independently associated with the occurrence of pain on multiple logistic regression analysis. There was no difference in uterine vein diameter between women with and those without pain (P = 0.10). Neither uterine vein diameter (P = 0.47) nor type of blood flow (P = 0.07) was significantly associated with the occurrence of pelvic pain on multiple logistic regression.

CONCLUSIONS

Our findings show that uterine vein diameter is not associated with pelvic pain. However, we found other important clinical and demographic factors that are associated with chronic pelvic pain. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Accumulation of m6A exhibits stronger correlation with MAPT than β-amyloid pathology in an APPNL-G-F /MAPTP301S mouse model of Alzheimer's disease

The study for the pathophysiology study of Alzheimer's disease (AD) has been hampered by lack animal models that recapitulate the major AD pathologies, including extracellular β-amyloid (Aβ) deposition, intracellular aggregation of microtubule associated protein tau (MAPT), inflammation and neurodegeneration. We now report on a double transgenic APPNL-G-F MAPTP301S mouse that at 6 months of age exhibits robust Aβ plaque accumulation, intense MAPT pathology, strong inflammation and extensive neurodegeneration. The presence of Aβ pathology potentiated the other major pathologies, including MAPT pathology, inflammation and neurodegeneration. However, MAPT pathology neither changed levels of amyloid precursor protein nor potentiated Aβ accumulation. The APPNL-G-F/MAPTP301S mouse model also showed strong accumulation of N6-methyladenosine (m6A), which was recently shown to be elevated in the AD brain. M6A primarily accumulated in neuronal soma, but also co-localized with a subset of astrocytes and microglia. The accumulation of m6A corresponded with increases in METTL3 and decreases in ALKBH5, which are enzymes that add or remove m6A from mRNA, respectively. Thus, the APPNL-G-F/MAPTP301S mouse recapitulates many features of AD pathology beginning at 6 months of aging.

Chaperoning of specific tau structure by immunophilin FKBP12 regulates the neuronal resilience to extracellular stress

Alzheimer's disease and related tauopathies are characterized by the pathogenic misfolding and aggregation of the microtubule-associated protein tau. Understanding how endogenous chaperones modulate tau misfolding could guide future therapies. Here, we show that the immunophilin FKBP12, the 12-kDa FK506-binding protein (also known as FKBP prolyl isomerase 1A), regulates the neuronal resilience by chaperoning a specific structure in monomeric tau. Using a combination of mouse and cell experiments, in vitro aggregation experiments, nuclear magnetic resonance-based structural analysis of monomeric tau, site-specific phosphorylation and mutation, as well as structure-based analysis using the neural network-based structure prediction program AlphaFold, we define the molecular factors that govern the binding of FKBP12 to tau and its influence on tau-induced neurotoxicity. We further demonstrate that tyrosine phosphorylation of tau blocks the binding of FKBP12 to two highly specific structural motifs in tau. Our data together with previous results demonstrating FKBP12/tau colocalization in neurons and neurofibrillary tangles support a critical role of FKBP12 in regulating tau pathology.

Phase 1b study to assess the safety of neoadjuvant trifluridine/tipiracil with concurrent radiation in resectable stage II/III rectal cancer

TPS274

Background: Treatment of locally advanced rectal cancer currently involves tri-modal therapy with pre-operative chemo-radiation (CRT), surgery, and combination chemotherapy. Total neoadjuvant therapy (TNT) is emerging as an important treatment pathway that can increase rates of complete response (CR) leading to better overall outcomes. Novel radio-sensitizing agents may improve rates of CR. Trifluridine/tipiracil (TFD/TPI) is a novel fluoropyrimidine that has demonstrated clinical efficacy in patients with treatment-refractory metastatic colorectal cancer. Importantly, TFD/TPI has superior radio-sensitization in vitro compared to 5-fluorouracil, and we hypothesize that this can improve the tumor response of patients. This phase 1 study assesses the safety and preliminary efficacy of using TFD/TPI for long-course CRT for rectal cancer followed by FOLFOX chemotherapy in the TNT setting. Methods: NCT04104139 is a prospective, dose-finding phase I study using Bayesian Optimal Interval (BOIN) design to determine the maximum tolerated dose (MTD) of TFD/TPI with concurrent standard dose/fractionation radiation for resectable rectal cancer. Adults with previously untreated rectal adenocarcinoma, with clinical stage II (T3-4aN0) and stage III (T1-4aN1+) by MRI and endoscopy are eligible. Patients must first receive CRT with standard radiation (45-50 Gy over 25-28 fractions) followed by up to 8 cycles of standard FOLFOX, or alternatively 5 cycles of CAPOX chemotherapy. During CRT, the first dose level of TFD/TPI is PO 25mg/m2 twice a day from Mon to Fri (5 weekdays) alternating on weeks 1, 3, and 5 concurrent with 5-6 weeks of radiation. The second dose level is 30mg/m2, and third dose level is 35mg/m2. The MTD of TFD/TPI in combination with radiation is the dose corresponding to a dose limiting toxicity (DLT) probability of 30% using the BOIN design with escalation/de-escalation of each dose level occurring in cohorts of 3 participants until a maximum total of 18 participants, sub-total of 12 patients within one dose level, or another stopping rule based on serious toxicities. The primary endpoint is proportion of DLTs for TFD/TPI at MTD. Secondary endpoints include overall tolerability profile, delayed toxicities during FOLFOX, rates of clinical CR, rates of pathologic CR, and correlative biomarkers. The study was activated December 2019 and has accrued 8 of intended 18 patients. Clinical trial information: NCT04104139 .

Prevention and screening during the COVID-19 pandemic: qualitative findings from the BETTER WISE project

BACKGROUND

The COVID-19 pandemic challenged healthcare systems worldwide and disrupted primary care, particularly prevention, screening, and lifestyle counselling. BETTER WISE is a comprehensive and structured approach that proactively addresses cancer and chronic disease prevention and screening (CCDPS), including cancer survivorship and screening for poverty and lifestyle risks for patients aged 40 to 65. Patients from 13 primary care clinics (urban, rural, and remote) in Alberta, Ontario, and Newfoundland & Labrador, Canada were invited for a 1-hour visit with a prevention practitioner (PP), a member of the primary care team with specialized training in CCDPS to provide patients an overview of eligible screening and assist with lifestyle counselling. This qualitative sub-study describes how the COVID-19 pandemic impacted BETTER WISE in a constantly changing medical landscape.

METHODS

We conducted 17 focus groups and 48 key informant interviews with a total of 132 primary care providers (PPs, physicians, allied health professionals, and clinic staff) over three different time points to better understand their perspectives on the BETTER WISE project. We also received 585 patient feedback forms of the 1005 patients who agreed to participate in the study. We also collected field notes and memos and employed thematic analysis using a constant comparative method focused on the impact of the pandemic on BETTER WISE.

RESULTS

We identified four themes related to how the COVID-19 pandemic impacted the BETTER WISE study: 1) Switch of in-person visits to visits over the phone; 2) Lack of access to preventive care and delays of screening tests; 3) Changes in primary care providers' availability and priorities; 4) Mental health impacts of the pandemic on patients and primary care providers.

CONCLUSIONS

The COVID-19 pandemic had and, at the time of writing, continues to have an impact on primary care, particularly on prevention, screening, and lifestyle counselling. Despite structural, procedural, and personal challenges throughout different waves of the pandemic, the primary care clinics participating in BETTER WISE were able to complete the study. Our results underscore the importance of the role of primary care providers in adapting to changing circumstances and support of patients in these challenging times.

TRIAL REGISTRATION

This qualitative study is a sub-component of the BETTER WISE pragmatic, cRCT, trial registration ISRCTN21333761 (date of registration 19/12/2016).

Dose-response effects of two nicotine salt formulations on electronic cigarette appeal and sensory attributes

OBJECTIVES

Various organic acids are used to create nicotine salt formulations, which may improve the appeal and sensory experience of vaping electronic cigarettes (e-cigarettes). This clinical experiment examined the effects of partially and highly protonated forms of two nicotine salt formulations (nicotine lactate and benzoate) versus free-base (no acid additive) on the appeal and sensory attributes of e-cigarettes.

METHODS

Current adult tobacco product users (n=116) participated in an online remote double-blind within-subject randomised experiment involving standardised self-administration of e-cigarette solutions varying in nicotine formulation (free-base, 50% nicotine lactate -1:2 lactic acid to nicotine molar ratio, 100% nicotine lactate - 1:1 ratio, 50% nicotine benzoate and 100% nicotine benzoate). Each formulation had equivalent nicotine concentrations (27.0-33.0 mg/mL) and was administered in four flavours in a pod-style device. After each administration, participants rated appeal (liking, disliking and willingness to use again) and sensory attributes (0-100 scale).

RESULTS

Compared with free-base nicotine, 50% and 100% nicotine lactate and benzoate yielded higher appeal, smoothness and sweetness and lower harshness and bitterness. Dose-response analyses found 100% vs 50% nicotine salt improved appeal, smoothness, bitterness and harshness for nicotine lactate and sweetness, smoothness and harshness for nicotine benzoate. Solutions with higher pH were associated with worse appeal and sensory attributes across nicotine formulations. Nicotine formulation effects did not differ by tobacco use status and flavours.

CONCLUSION

Restricting benzoic acid or lactic acid additives or setting minimal pHs in e-cigarettes merits consideration in regulations designed to reduce vaping among populations deterred from using e-cigarettes with aversive sensory properties.

TRIAL REGISTRATION NUMBER

This study was registered under ClinicalTrials.gov Identifier: NCT03742817 under the title 'Effects of e-Cigarettes on Perceptions and Behavior'.

Prevalence of and disparities in adolescents' susceptibility to novel oral nicotine products marketed as "tobacco-free"

Non-therapeutic, novel oral nicotine products are convenient, discreet to use, and flavored, with increasing sales in the United States. It is unclear whether these products appeal predominantly to adolescents already susceptible to inhalable nicotine products, or whether they attract adolescents who would not otherwise use nicotine. This study examined prevalence and correlates of susceptibility to inhalable and oral nicotine product use among adolescents. Ninth- and tenth-grade students from Southern California who had never used any nicotine product (N = 3129) completed an online survey in Fall 2021 assessing susceptibility to inhalable (i.e., cigarettes, e-cigarettes) and oral (e.g., pouches, gum, gummies) nicotine products. Multinomial logistic regression analyses estimated associations of demographic characteristics with odds of susceptibility to oral, inhalable, or both products. Susceptibility was highest for e-cigarettes (19.7%), followed by cigarettes (15.0%) and nicotine gum, lozenges, tablets and/or gummies (15.0%), and nicotine pouches (8.7%). Dual susceptibility to oral and inhalable products (vs. neither product type) was higher in cisgender female and non-cisgender (vs. cisgender male) adolescents (odds ratios [ORs] = 1.36-2.02; ps < 0.05). Hispanic adolescents (vs. Asian) were more susceptible to both products (OR = 1.47; p < .05). Lower-socioeconomic status (SES) and sexual minority adolescents were more susceptible to oral (ORs = 1.76-1.87; ps < 0.05) and both products (ORs = 1.32-1.88; ps < 0.05), compared to higher-SES and heterosexual adolescents. Adolescents in Southern California may be more susceptible to e-cigarettes than other nicotine/tobacco products. However, appreciable numbers may be susceptible to oral nicotine products, including some youth who might not otherwise use nicotine and youth from populations historically impacted by tobacco-related health disparities.

Feasibility and acceptability of remote procedures to study tobacco product use and respiratory health: an observational study

OBJECTIVE

Obtaining ecologically valid biological samples is critical for understanding respiratory effects of tobacco use, but can be burdensome. In two diverse samples, we examined feasibility and acceptability of studying pulmonary function and respiratory health entirely remotely.

DESIGN

Observational feasibility and acceptability study.

SETTING AND PARTICIPANTS

Adults age 18-25 (Biomedical Respiratory Effects Associated through Habitual Use of E-Cigarettes [BREATHE] Study) and 21-65 (Adult IQOS Respiratory [AIRS] Study) recruited from previous research studies and advertisements in Southern California, USA (BREATHE (AIRS): N=77 (N=31) completed baseline, n=64 (n=20) completed feasibility and acceptability measures). Shared inclusion criteria for the two studies were ownership of a smartphone, willingness to download applications and English fluency. In addition, BREATHE participants reported one of three tobacco use patterns. AIRS participants smoked daily and were willing to use a heated tobacco product. Exclusion criteria were medical contraindications.

INTERVENTIONS

A 4-week study consisted of five virtual study visits, twice daily ecological momentary assessment diaries and spirometry assessments, and weekly Nasal Epithelial Lining Fluid and saliva collection. All study visits were conducted via video conference; study materials and biospecimens were exchanged via mail. Participants reported feasibility and acceptability of daily diaries, breath tests, biospecimen collection and shipments.

MEASURES

Surveys assessed perceptions of timing and overall experience of daily diaries and breath tests, difficulty of and overall experience with biospecimen collection, and experience sending and receiving shipments.

RESULTS

Most participants evaluated daily diaries and breath tests as manageable (62.5%-95.0%) and likeable (54.7%-70.0%). Breath tests were frequently described as 'interesting' (55.0%-57.8%) and 'easy' (25.0%-48.4%). Most participants reported that biospecimen collection was easy (50.0%-85.0%), and that shipments were easy to send (87.5%-95.0%), receive (95.3%-95.0%) and schedule (56.3%-60.0%). No participants received shipments in poor condition.

CONCLUSIONS

Remote research procedures may be feasible and acceptable to facilitate tobacco research studies, potentially resulting in more diverse samples of participants and more generalisable research results.

Third-generation cephalosporin resistant gram-negative bacteraemia in patients with haematological malignancy; an 11-year multi-centre retrospective study

Objectives

Among patients with haematological malignancy, bacteraemia is a common complication during chemotherapy-induced neutropenia. Resistance of gram-negative bacteria (GNB) to third-generation cephalosporins (3GC) is increasing. In order to explore the value of using surveillance cultures to guide empirical treatment e.g. choosing between carbapenem versus ceftazidime- we aimed to assess the distribution of pathogens causing bacteraemia in patients with haematological malignancy, and the proportion of 3GC-resistant GNB (3GC-R GNB) bacteraemia that was preceded by 3GC-R GNB colonization.

Methods

Using 11 years of data (2008–2018) from the Dutch national antimicrobial resistance surveillance system, we assessed the prevalence of 3GC-R GNB in episodes of bacteraemia, and the proportion of 3GC-R GNB bacteraemia that was preceded by 3GC-R GNB colonization. Colonization was defined as availability of any GNB surveillance isolate in the year before, independent of the causative micro-organism (time-paired isolates).

Results

We included 3887 patients, representing 4142 episodes of bacteraemia. GNB were identified in 715/4142 (17.3%), of which 221 (30.9%) were 3GC-R GNB. In 139 of these 221 patients a time-paired surveillance culture was available. In 76.2% (106/139) of patients these surveillance cultures already showed 3GC-R GNB isolates in the year prior to the culture date of the 3GC-R GNB positive blood isolate.

Conclusions

This multi-centre study shows that in patients with haematological malignancy, the majority of 3GC-R GNB bacteraemia is preceded by 3GC-R GNB colonization. Prospective clinical studies are needed to assess the safety and benefits of the use of surveillance-cultures to guide empirical therapy to restrict the empirical use of carbapenems in this population.

The association between native myocardial T1 relaxation times and left atrial phasic structure and function: the UK Biobank Imaging Enhancement study

Introduction

Left ventricular (LV) myocardial fibrosis is posited to result in left atrial (LA) changes via LV remodelling and diastolic dysfunction, though the association remains poorly characterised. Native myocardial T1 mapping is a non-invasive modality that quantifies diffuse myocardial fibrosis. This study examines the relationship between LV fibrosis (quantified by native T1 times) and LA function, drawing upon data from the UK Biobank.

Methods

40,818 participants underwent cardiovascular magnetic resonance (CMR) using steady-state free precession imaging at 1.5 Tesla. Native T1-mapping was performed using the Shortened Modified Look-Locker Inversion recovery technique (ShMOLLI), with global myocardial T1 estimated by an automatic segmentation framework. Nine parameters of LA phasic function were calculated (representing global, reservoir, conduit and booster components) from normalised LA volume-time curves. LV parameters (LV Mass, end-diastolic volume and ejection fraction) were extracted by a convolutional neural network. Multivariable logistic regression models were used to assess the association between T1 (exposure) and LA function (outcome). Mediation analysis was performed to assess the role of LV parameters as a mediator for the association between T1 and LA function. Lastly, potential non-linear relationships between T1 and LA function were investigated using Restrictive Cubic Spline (RCS) modelling, with model fit assessed via the Akaike Information Criterion (AIC).

Results

Higher T1 values were positively associated with larger LA volumes, and negatively associated with markers of LA global, reservoir and booster function. In the fully adjusted model, T1 was positively associated with larger LA minimum size (Beta: +0.034 SD per T1 SD; Confidence Interval (CI): 0.024, 0.045), and negatively associated with LA emptying volume (Beta: −0.017; CI: −0.027, −0.006), LA booster volume (Beta: −0.019; CI: −0.030, −0.008), LA emptying fraction (Beta: −0.052; CI: −0.062, −0.041), and LA reservoir function (Beta: −0.028; CI: −0.039, −0.017). Though adjustment for LV parameters did not fully attenuate the above relationships, LV parameters were consistent mediators between T1 and LA function, with proportional mediative effects ranging from 15% to 75%. Lastly, there is evidence of an inverted J-shaped relationship between T1 and LA function, with the associations becoming more apparent in the upper half of T1 ranges (turning points within 925–950 ms, median T1 = 930 ms) (p&lt;0.05).

Conclusion

This study demonstrates a consistent association between higher native T1 values (as a marker of myocardial fibrosis) and lower LA global and phasic functions. We also highlighted an interplay between T1 values, LV remodelling and LA dysfunction. These findings will facilitate our understanding of the disease processes underlying cardiac dysfunction and myocardial remodelling at an early, subclinical stage.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This work was part of the portfolio of translational research of the National Institute for Health Research Biomedical Research Centre at Barts and The London School of Medicine and DentistryDr Nay Aung is supported by a Wellcome Trust Research Training Fellowship (203553/Z/16/Z)

Child self-reported quality of life in pediatric intestinal failure

BACKGROUND

Recent studies have focused on parent-reported health-related quality of life (HRQOL) in children with intestinal failure (IF). However, there is a paucity of data on HRQOL from the perspective of the child with IF.

METHODS

A prospective study of child self-reported HRQOL was performed in a regional intestinal rehabilitation program from 2015 to 2019. The PedsQL 4.0 Generic Core Scales were administered annually to children with IF ages five years and older along with their parents. Survey data was stratified by age and compared with parent-proxy scores and reference populations of healthy and chronically ill children. Linear mixed-effect models were constructed to identify associations with child self-reported HRQOL.

RESULTS

A total of 140 surveys were administered to 69 children and their parents. Median child age at survey was 8 (IQR 6-10) years. Child self-reported HRQOL scores increased with each increasing age range. Children reported higher HRQOL scores compared to parent-proxy data in all age groups. Children with IF had lower HRQOL scores compared to healthy children in all survey dimensions (p < 0.001) and to children with chronic illness in the school and social functioning dimensions (p < 0.05). In adjusted analysis, longer remnant bowel length was independently associated with decreased HRQOL scores in children (p < 0.05).

CONCLUSIONS

Children with IF reported better HRQOL compared to parent-proxy data. While these HRQOL scores improved with age, they remain significantly lower than healthy and chronically ill peers. The association between bowel length and child-reported HRQOL deserves further investigation.

LEVEL OF EVIDENCE

Level II.

Adolescent Use of Flavored Non-Tobacco Oral Nicotine Products

BACKGROUND AND OBJECTIVES

Flavored non-tobacco oral nicotine products (eg, nicotine pouches and nontherapeutic nicotine gum, lozenges, tablets, gummies), are increasingly marketed in the United States. Prevalence of non-tobacco oral nicotine product use among adolescents is unknown.

METHODS

We calculated prevalence of ever and past 6-month use of nicotine pouches, other non-tobacco oral nicotine products (ie, gum, lozenges, tablets, and/or gummies), e-cigarettes, cigarettes, hookah or waterpipe, cigars, cigarillos, and snus among high school students in Southern California between September and December 2021. Generalized linear mixed models tested associations of sociodemographic factors and tobacco-product use with use of any non-tobacco oral nicotine product.

RESULTS

Among the sample (n = 3516), prevalence was highest for e-cigarettes (ever: 9.6%, past 6-month: 5.5%), followed by non-tobacco oral nicotine products (ever: 3.4%, past 6-month: 1.7%), and <1% for other products. Ever users of combustible tobacco (adjusted odds ratio [aOR] = 77.6; 95% confidence interval [CI] = 39.7-152) and ever users of noncombustible tobacco (aOR = 40.4; 95% CI= 24.3-67.0) had higher odds of ever using non-tobacco oral nicotine products, compared to never users of combustible and noncombustible tobacco. Use of any non-tobacco oral nicotine product was greater for Hispanic (versus all other races/ethnicities except Asian, aOR = 2.58; 95% CI = 1.36-4.87), sexual minority (versus heterosexual, aOR=1.63; 95% CI = 1.03-2.57), gender minority (versus male, aOR = 2.83; 95% CI = 1.29-6.19), and female (versus male, aOR=1.92, 95% CI = 1.20-3.06) participants.

CONCLUSIONS

Non-tobacco oral nicotine products were the second most prevalent nicotine product used by adolescents. They were disproportionately used by certain racial or ethnic, sexual, or gender minority groups, and those with a history of nicotine use. Adolescent non-tobacco oral nicotine product use surveillance should be a public health priority.

Efficacy of transrectal ultrasound in assessing endometrium of postmenopausal women with axial uterus

OBJECTIVE

To evaluate the acceptance and efficacy of transrectal ultrasound (TRS) in assessing the endometrium in postmenopausal women with an axial uterus.

METHODS

This was a prospective cross-sectional study conducted between October 2015 and October 2018 of consecutive postmenopausal women with an axial uterus on transvaginal ultrasound (TVS). Women with a known diagnosis of gynecological malignancy were excluded. TRS was offered immediately after TVS without prior bowel preparation. A single operator determined subjectively whether the endometrium was visualized satisfactorily on TVS and TRS. In women with postmenopausal bleeding (PMB), endometrial thickness (ET) was measured and endometrial morphology was categorized as atrophic, uniformly thickened, benign endometrial polyp or endometrial cancer, based on subjective pattern recognition. All women with PMB and a non-atrophic endometrium underwent outpatient endometrial biopsy, hysteroscopy or hysterectomy. The success rate of TRS in assessing satisfactorily the endometrium was compared with that of TVS. In patients with PMB, ET measurements and subjective diagnosis of endometrial cancer on TVS vs TRS were compared.

RESULTS

Of the 1553 women who underwent TVS examination, 103 (6.6%) had an axial uterus, of whom 76 (73.8%) presented with PMB. TRS was accepted by 66/103 (64.1%) women with an axial uterus. TRS assessed satisfactorily a significantly higher proportion of endometria compared with TVS (90.9% vs 62.1%; χ²  = 14.1, P < 0.001). In 50 women with PMB and an axial uterus who underwent both TVS and TRS, TVS failed to visualize the endometrium satisfactorily in 15 (30.0%) women, whilst TRS provided satisfactory images in all cases. Among the 35 women with PMB and a satisfactory endometrial assessment on TVS and TRS, measurements of ET on TRS were significantly lower compared to those on TVS (median difference, -1.2 (interquartile range, -3.0 to -0.4) mm). The overall agreement of TVS and TRS on the presence or absence of endometrial cancer using subjective pattern recognition was 30/35 (85.7%; 95% CI, 74.1-97.3%). While all seven cases of histologically confirmed endometrial cancer were diagnosed correctly on TRS, four were misdiagnosed on TVS as benign polyps or uniformly thickened endometrium.

CONCLUSIONS

TRS is an acceptable and effective way to assess the endometrium in postmenopausal women with an axial uterus. Among women presenting additionally with PMB, TRS is associated with a higher proportion of satisfactory endometrial assessments and fewer misdiagnoses of endometrial cancer by subjective pattern recognition compared with TVS. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Non-Native Amino Acid Click Chemistry-Based Technology for Site-Specific Polysaccharide Conjugation to a Bacterial Protein Serving as Both Carrier and Vaccine Antigen

Surface-expressed bacterial polysaccharides are important vaccine antigens but must be conjugated to a carrier protein for efficient antigen presentation and development of strong memory B cell and antibody responses, especially in young children. The commonly used protein carriers include tetanus toxoid (TT), diphtheria toxoid (DT), and its derivative CRM197, but carrier-induced epitopic suppression and bystander interference may limit the expanded use of the same carriers in the pediatric immunization schedule. Recent efforts to develop a vaccine against the major human pathogen group A Streptococcus (GAS) have sought to combine two promising vaccine antigens-the universally conserved group A cell wall carbohydrate (GAC) with the secreted toxin antigen streptolysin O (SLO) as a protein carrier; however, standard reductive amination procedures appeared to destroy function epitopes of the protein, markedly diminishing functional antibody responses. Here, we couple a cell-free protein synthesis (CFPS) platform, allowing the incorporation of non-natural amino acids into a C-terminally truncated SLO toxoid for the precise conjugation to the polyrhamnose backbone of GAC. The combined immunogen generated functional antibodies against both conserved GAS virulence factors and provided protection against systemic GAS challenges. CFPS may represent a scalable method for generating pathogen-specific carrier proteins for multivalent subunit vaccine development.

Biofluid markers of blood-brain barrier disruption and neurodegeneration in Lewy body spectrum diseases: A systematic review and meta-analysis

BACKGROUND

Mixed evidence supports blood-brain barrier (BBB) dysfunction in Lewy body spectrum diseases.

METHODS

We compare biofluid markers in people with idiopathic Parkinson's disease (PD) and people with PD dementia (PDD) and/or dementia with Lewy bodies (DLB), compared with healthy controls (HC). Seven databases were searched up to May 10, 2021. Outcomes included cerebrospinal fluid to blood albumin ratio (Q_alb), and concentrations of 7 blood protein markers that also reflect BBB disruption and/or neurodegenerative co-pathology. We further explore differences between PD patients with and without evidence of dementia. Random-effects models were used to obtain standardized mean differences (SMD) with 95% confidence interval.

RESULTS

Of 13,949 unique records, 51 studies were meta-analyzed. Compared to HC, Q_alb was higher in PD (N_PD/N_HC = 224/563; SMD = 0.960 [0.227-1.694], p = 0.010; I² = 92.2%) and in PDD/DLB (N_PDD/DLB/N_HC = 265/670; SMD = 1.126 [0.358-1.893], p < 0.001; I² = 78.2%). Blood neurofilament light chain (NfL) was higher in PD (N_PD/N_HC = 1848/1130; SMD = 0.747 [0.442-1.052], p < 0.001; I² = 91.9%) and PDD/DLB (N_PDD/DLB/N_HC = 183/469; SMD = 1.051 [0.678-1.423], p = 0.004; I² = 92.7%) than in HC. p-tau 181 (N_PD/N_HC = 276/164; SMD = 0.698 [0.149-1.247], p = 0.013; I² = 82.7%) was also higher in PD compared to HC. In exploratory analyses, blood NfL was higher in PD without dementia (N_PDND/N_HC = 1005/740; SMD = 0.252 [0.042-0.462], p = 0.018; I² = 71.8%) and higher in PDD (N_PDD/N_HC = 100/111; SMD = 0.780 [0.347-1.214], p < 0.001; I² = 46.7%) compared to HC. Q_alb (N_PDD/N_PDND = 63/191; SMD = 0.482 [0.189-0.774], p = 0.010; I²<0.001%) and NfL (N_PDD/N_PDND = 100/223; SMD = 0.595 [0.346-0.844], p < 0.001; I² = 3.4%) were higher in PDD than in PD without dementia.

CONCLUSIONS

Biofluid markers suggest BBB disruption and neurodegenerative co-pathology involvement in common Lewy body diseases. Greater evidence of BBB breakdown was seen in Lewy body disease with cognitive impairment.

Polycomb contraction differentially regulates terminal human hematopoietic differentiation programs

Background

Lifelong production of the many types of mature blood cells from less differentiated progenitors is a hierarchically ordered process that spans multiple cell divisions. The nature and timing of the molecular events required to integrate the environmental signals, transcription factor activity, epigenetic modifications, and changes in gene expression involved are thus complex and still poorly understood. To address this gap, we generated comprehensive reference epigenomes of 8 phenotypically defined subsets of normal human cord blood.

Results

We describe a striking contraction of H3K27me3 density in differentiated myelo-erythroid cells that resembles a punctate pattern previously ascribed to pluripotent embryonic stem cells. Phenotypically distinct progenitor cell types display a nearly identical repressive H3K27me3 signature characterized by large organized chromatin K27-modification domains that are retained by mature lymphoid cells but lost in terminally differentiated monocytes and erythroblasts. We demonstrate that inhibition of polycomb group members predicted to control large organized chromatin K27-modification domains influences lymphoid and myeloid fate decisions of primary neonatal hematopoietic progenitors in vitro. We further show that a majority of active enhancers appear in early progenitors, a subset of which are DNA hypermethylated and become hypomethylated and induced during terminal differentiation.

Conclusion

Primitive human hematopoietic cells display a unique repressive H3K27me3 signature that is retained by mature lymphoid cells but is lost in monocytes and erythroblasts. Intervention data implicate that control of this chromatin state change is a requisite part of the process whereby normal human hematopoietic progenitor cells make lymphoid and myeloid fate decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12915-022-01315-1.

Early Discontinuation, Results Reporting, and Publication of Pediatric Clinical Trials

BACKGROUND AND OBJECTIVES

Unique ethical, epidemiological, and economic factors are barriers to performing research in children. The landscape of pediatric clinical trials, including drivers of completion and timely dissemination of results, is not well understood. We aimed to characterize the prevalence of and factors associated with early discontinuation, results reporting, and publication of pediatric clinical trials registered at ClinicalTrials.gov.

METHODS

Cross-sectional analysis of clinical trials enrolling participants <18 years old registered at ClinicalTrials.gov from October 2007 to March 2020. Multivariable logistic regressions were performed to assess the association between trial characteristics and primary outcomes. Publication data were obtained through PubMed, ClinicalTrials.gov, Embase, and Scopus.

RESULTS

Overall, 11.1% trials were stopped early, with recruitment failure being the predominant reason for discontinuation. Only 23.5% of completed trials reported results, and 38.8% were published within 3 years of completion. Rates of discontinuation and publication significantly improved over the study period. Among funding sources, government-sponsored trials (adjusted odds ratio [aOR], 0.72; 95% CI, 0.47-0.97) and academic trials (aOR, 0.64; 95% CI, 0.50-0.82) had lower odds of discontinuation compared with industry trials and were more likely to be published (government: aOR, 1.94 [95% CI, 1.52-2.48] academic: aOR, 1.61 [95% CI, 1.35-1.92). Academic trial investigators were the least likely to report results (aOR, 0.34; 95% CI, 0.31-0.52).

CONCLUSIONS

Early discontinuation and nonreporting/nonpublication of findings remain common in registered pediatric clinical trials and were associated with funding source and other trial features. Targeted efforts are needed to support trial completion and timely results dissemination toward strengthening evidence-based pediatric medicine.

Abstract 073: A Mediterranean Diet Pattern Is Associated With Lower Risk Of Adverse Pregnancy Outcomes In US Women: Results From The NuMoM2b Cohort

Introduction: Adverse pregnancy outcomes (APOs) are associated with an increased risk of developing cardiovascular disease (CVD). While the Mediterranean diet pattern has been inversely related to CVD outcomes, its association with APOs in US women has not been previously evaluated.

Hypothesis: Adherence to a Mediterranean diet pattern during the periconception period is associated with lower risk of APOs.

Methods: Racially and ethnically diverse women (n=8075, mean age: 27±6y) from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) cohort were enrolled across 8 US medical centers from 2010-13. An Alternate Mediterranean Diet (aMed) score was computed from data on habitual diet in the 3 months around conception, assessed using a semi-quantitative food frequency questionnaire in the first trimester. APOs were prospectively ascertained and defined as developing 1 or more of the following: gestational hypertension, preeclampsia/eclampsia, gestational diabetes, preterm delivery, small for gestational age, or stillbirth. Multivariable logistic regression was used to examine associations of the aMed score and its components with any APO and individual APOs.

Results: Women in the highest vs. lowest quintile of the aMed score had 21% lower odds of developing any APO, and 36% and 52% lower odds of preeclampsia/eclampsia and gestational diabetes, respectively; a linear trend across aMed score categories was detected (p-trend<0.05) ( Figure ). When aMed score components were examined separately, higher intakes of vegetables, fruits, legumes, and fish and lower intakes of red meat were related to up to 26% lower odds of APOs.

Conclusions: Greater adherence to a Mediterranean diet pattern is related to lower risk of APOs, with evidence of a dose-response relationship, highlighting the potential of this diet pattern in CVD primordial prevention efforts in US women. Long-term studies are needed to assess whether dietary modification in the periconception period can reduce risk of APOs and future CVD.

A8 REPEATED SUBMERGENCE OF AIR-LIQUID INTERFACE COLONOID CULTURES IMPAIRS INFLAMMATORY AND REGENERATIVE RESPONSES

Background

Damage in the intestinal epithelium is repaired via de-differentiation of mature intestinal epithelial cells to a stem-like state. Indeed, literature has primarily focused on acute forms of intestinal damage, but there is a lack of models to study how intestinal stem cells function after chronic injury, such as in inflammatory bowel disease (IBD). A previous report found that growth of mouse intestinal organoids in air-liquid interface (ALI) follows by submergence caused differentiation and reversible injury, but this has not been demonstrated in human cells or with repeated cycles of injury. Understanding how chronic damage alters human intestinal stem cell fate and function is imperative to developing novel therapies that repair the epithelium in people with IBD

Aims

To develop a robust in vitro model to differentiate and damage human intestinal epithelial cells, with or without the addition of bacterial flagellin to mimic pathogen exposure.

Methods

Human colonoid monolayers were seeded on Transwell inserts for 10 days until fully confluent and then differentiated by removing the apical media to create ALI growth conditions for 7 days. To induce damage, media was added to the apical side of the Transwell, with or without the addition of flagellin in the basolateral compartment. Following submergence induced damage, the apical media was removed and collected for chemokine analysis, and the cells were grown back in ALI for 3 days to recover them from injury. This cycle was repeated 5 times to induce chronic damage. Cells were collected for qPCR analysis, immunofluorescence imaging, RNA sequencing and DNA methylation analysis

Results

Repeated rounds of damage impaired the ability of intestinal epithelial cells (IECs) to respond to TLR stimulation (a decrease in basolateral IL-8 with each round), likely due to a decrease in TLR signaling pathways, as demonstrated by GSEA and qPCR. Chronic submergence damage led to an increase in differentiation of cells expressing MUC2, SLC26a3 and CHGA, and a decrease in stemness as shown by qPCR for BMI1, HOPX, and LGR5. After several rounds of damage, colonoid monolayers were unable to regrow as monolayers after passaging, likely due to a decrease in YAP signaling. We also identified mRNA expression and DNA methylation changes in genes associated with IBD and colon cancer.

Conclusions

We have developed a novel chronic damage model of recurrent IEC injury, which possibly mimics pathologies seen in people with inflammatory bowel disease. This model can be used to understand how chronic damage alters the ability of IECs to respond to pathogens and regenerate to repair and protect the epithelium from further damage.

Funding Agencies

CCC

HELIX-ICC: An-open label phase II trial of induction systemic mFOLFIRINOX followed by concurrent hepatic arterial infusion of floxuridine and systemic mFOLFIRI for unresectable intrahepatic cholangiocarcinoma

TPS500

Background: The majority of patients with intrahepatic cholangiocarcinoma (ICC) present with advanced liver dominant disease rendering them unresectable. The current standard of care supports palliative treatment of unresectable ICC with gemcitabine plus cisplatin. Alternatively, continuous liver-directed therapy using a surgically implanted hepatic arterial infusion (HAI) pump allows for maximal treatment of liver tumors with limited systemic side-effects and can facilitate conversion to a resectable status. No prospective clinical trial has utilized FOLFIRINOX in combination with HAI floxuridine-dexamethasone for ICC. Methods: HELIX-ICC is a first-line, single-center, single-arm, phase II clinical trial enrolling patients with liver-dominant unresectable or multifocal ICC. Only patients with microsatellite stable cancer and no prior liver radiotherapy will be included. Patients are administered dose-modified FOLFIRINOX systemically for 4 cycles over 8 weeks. Those with evidence of disease control on restaging imaging and laparoscopy will proceed to HAI pump placement. Treatment continues with two 28-day cycles of combined HAI floxuridine (1.08 mg/kg) with dexamethasone for 14 days and systemic dose-modified FOLFIRI starting on day 15. The primary objectives are to evaluate the safety and efficacy (disease control rate [DCR] at 6 months) of this novel treatment approach that utilizes our institutional dose-reduced HAI floxuridine protocol in combination with modified systemic regimens to facilitate control of liver disease and maximize patient quality of life (QoL). HELIX-ICC includes many exploratory analyses through longitudinal collection of blood samples, liver biopsies (including an end of trial research biopsy), and QoL metrics (Table). The study is open to n = 30 with an initial safety run-in of 6 patients, of which 4 have enrolled at the time of submission. This study is designed to allow for drop out of 9 patients, with total accrual of 21 patients to protocol completion achieving 80.2% power at 0.05 significance to detect a 25% increase in DCR at 6 months. Clinical trial information: NCT04251715. [Table: see text]