Biomechanical comparison of bone staple fixation methods with suture material for median sternotomy closure using 3D-printed bone models

AIM

To compare the biomechanical properties of three different sternal closure techniques in a 3D-printed bone model of a sternum from a 30-kg dog.

METHODS

Median sternotomy was performed on a total of 90 three-dimensional (3D) copies of a polycarbonate (PC) model of a sternum, generated from the CT images of the sternum of a 30-kg German Shepherd dog. Three different methods were used to repair the sternotomies: polydioxanone suture (group PDS, n = 30), stainless steel bone staples (group SS, n = 30), and nitinol bone staples (group NS, n = 30). Each repair method was tested by applying tensile force in one of three ways (longitudinally, laterally, or torsionally) resulting in a sample size of n = 10 for each repair method-loading combination. In all experiments, the loads at 1-mm and 2-mm gap formation, failure, and the displacement at the failure point were measured.

RESULTS

In lateral distraction and longitudinal shear tests, NS and SS staple repairs required application of significantly greater force than PDS across all displacement criteria (1 and 2 mm). NS exhibited significantly greater failure load than PDS. In torsion tests, NS required significantly greater application of force compared to SS or PDS at all displacement criteria (1 and 2 mm) and exhibited a greater failure load than PDS. In terms of displacement at failure point, PDS suture showed more displacement than SS or NS across all experiments (laterally, longitudinally, torsionally).

CONCLUSIONS

In this study, bone staples were mechanically superior to PDS suture in median sternotomy closure using 3D-printed bone model in terms of 1-mm, 2-mm displacement loads, and displacement at failure. NS had a higher failure load than PDS under lateral, longitudinal, and torsional distraction.

CLINICAL RELEVANCE

These study results imply that bone staples can be considered as an alternative surgical method for median sternotomy closure in dogs.

Dynamic Fixation versus Static Screw Fixation for Syndesmosis Injuries in Pronation External Rotation Ankle Fractures: A Retrospective Case Control Study

Introduction

The current standard treatment for ankle syndesmosis injury is static screw fixation. Dynamic fixation was developed to restore the dynamic function of the syndesmosis. The purpose of this study was to determine that which of static screw fixation and dynamic fixation is better for treatment of ankle syndesmosis injury in pronation-external rotation fractures.

Materials and methods

Thirty patients were treated with dynamic fixation (DF group) and 28 patients with static screw fixation (SF group). The primary outcome was Olerud-Molander Ankle Outcome Score. The secondary outcome were Visual Analogue Scale score and American Orthopedic Foot and Ankle Society score, radiographic outcomes, complications and cost effectiveness. To evaluate the radiographic outcome, the tibiofibular clear space, tibiofibular overlap, and medial clear space were compared using the pre-operative and last follow-up plain radiographs. To evaluate the cost effectiveness, the total hospital cost was compared between the two groups.

Results

There was no significant difference in primary outcome. Moreover, there were no significant difference in secondary outcome including Visual Analogue Scale score and American Orthopedic Foot and Ankle Society score and radiographic outcome. Two cases of reduction loss and four cases of screw breakage were observed in the SF group. No complication in the DF group was observed. Dynamic fixation was more cost effective than static screw fixation with respect to the total hospital cost.

Conclusion

Although dynamic fixation provided similar clinical and radiologic outcome, dynamic fixation is more cost effective with fewer complications than static screw fixation in ankle syndesmosis injury of pronation-external rotation fractures.

Etiology of lipid-laden macrophages in the lung

Uniquely positioned as sentinel cells constantly exposed to the environment, pulmonary macrophages are vital for the maintenance of the lung lining. These cells are responsible for the clearance of xenobiotics, pathogen detection and clearance, and homeostatic functions such as surfactant recycling. Among the spectrum of phenotypes that may be expressed by macrophages in the lung, the pulmonary lipid-laden phenotype is less commonly studied in comparison to its circulatory counterpart, the atherosclerotic lesion-associated foam cell, or the acutely activated inflammatory macrophage. Herein, we propose that lipid-laden macrophage formation in the lung is governed by lipid acquisition, storage, metabolism, and export processes. The cellular balance of these four processes is critical to the maintenance of homeostasis and the prevention of aberrant signaling that may contribute to lung pathologies. This review aims to examine mechanisms and signaling pathways that are involved in lipid-laden macrophage formation and the potential consequences of this phenotype in the lung.

Mechanical Ventilation Training Curriculum for Pulmonary Critical Care Fellows during the COVID-19 Pandemic

Background

Mechanical ventilation (MV) management is an essential skill for pulmonary and critical care medicine (PCCM) fellows to master during training. The unprecedented emergence of the coronavirus disease (COVID-19) pandemic highlighted the need for advanced operator competency in MV to improve patients' outcomes.

Objective

We aimed to create a standardized case-based curriculum using a blended approach of high-fidelity simulation, rapid-cycle deliberate practice, video didactics, and hands-on small group sessions for rapid accumulation of knowledge and hands-on skills for PCCM fellows before caring for critically ill patients during the COVID-19 pandemic.

Methods

The MV curriculum consisted of the following steps: 1) baseline written knowledge test with 15 multiple-choice questions covering MV, the latest evidence-based practices, and pathophysiology of COVID-19; 2) baseline confidence survey using a 5-point Likert scale; 3) a one-on-one session using a high-fidelity simulation manikin, a lung simulator, and a mechanical ventilator to test baseline competencies; 4) a structured debriefing tailored per fellow's 50-point competency assessment checklist from the simulation using rapid-cycle deliberate practice; 5) video didactics; 6) a hands-on session in small groups for basic knobology, waveforms, and modes of MV; 7) a one-on-one simulation reassessment session; 8) a written knowledge posttest; and 9) a post-training confidence survey using a 5-point Likert scale.

Results

Eight PCCM fellows completed the training. The mean multiple-choice question score increased from 7.4 ± 2.9 to 10.4 ± 2.4 (P < 0.05), and the simulation scores increased from 17.1 ± 4.4 to 30.8 ± 3.7 (P < 0.05). Comparing the simulation reassessment to the baseline, fellows showed significant improvement (P < 0.05) in assessing indications for MV; implementing rapid sequence intubation for patients with COVID-19; initiating MV and ventilator bundle per best practices; recognizing and managing mucous plugging, ventilator dyssynchrony, and evidence-based treatments for acute respiratory distress syndrome; and developing a care plan for proning. The post-training survey revealed improved learner confidence in all competencies.

Conclusion

This pilot MV curriculum using a blended approach was feasible and allowed PCCM fellows to significantly improve their knowledge and hands-on skills, allowing for the appropriate use of MV during the pandemic. Self-reported improvement scores further reinforced this. The emergent need for novice learners may again be necessary for future pandemic settings where standard training models requiring extensive training time are limited.

Graphene oxide classification and standardization

There is a need to classify and standardize graphene-related materials giving the growing use of this materials industrially. One of the most used and more difficult to classify is graphene oxide (GO). Inconsistent definitions of GO, closely relating it to graphene, are found in the literature and industrial brochures. Hence, although they have very different physicochemical properties and industrial applications, commonly used classifications of graphene and GO definitions are not substantial. Consequently, the lack of regulation and standardization create trust issues among sellers and buyers that impede industrial development and progress. With that in mind, this study offers a critical assessment of 34 commercially available GOs, characterized using a systematic and reliable protocol for accessing their quality. We establish correlations between GO physicochemical properties and its applications leading to rationale for its classification.

A167 HISTOLOGICAL REMISSION PLACEBO RATES IN ULCERATIVE COLITIS TRIALS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

High histologic remission rates have been reported with placebos in randomized controlled trials (RCTs) evaluating ulcerative colitis (UC) therapies and have varied based on trial designs. We performed a systematic review and meta-analysis to quantify placebo histological remission rates and identify factors influencing those rates.

Purpose

This systematic review aims to improve future trials design and minimize placebo rates in UC trials.

Method

MEDLINE, EMBASE, and the Cochrane library were searched from inception of the databases until December 2021. We included placebo-controlled RCTs of adult patients with UC treated with aminosalicylates, corticosteroids, immunosuppressives, biologics, and small molecules. We pooled estimates using a random-effects model and performed subgroup analysis as well as meta-regression to evaluate the effect of different covariates on placebo rates.

Result(s)

Thirty-three studies (30 induction and 3 maintenance) were included. The overall placebo histological remission rate was 15.7% [95% CI 12.9-19%] across all 33 studies (Figure). High heterogeneity was observed among studies with I² = 62.10%. In induction studies, the pooled estimate of histological remission was 15.8% [95% CI 12.7-19.5%], while in maintenance studies the pooled estimate was 14.5% [95% CI 8.4-24%]. Subgroup analysis revealed statistically significant differences in placebo rates when accounting for background medications, the intervention drug class, and disease severity [p= 0.041, 0.025, and 0.025, respectively]. There was no statistical difference between induction vs. maintenance studies or between different histological scales [p= 0.771, and 0.075, respectively]. Meta-regression showed similar results except that the therapy used was not statistically significant [p-value= 0.059].

Image

Conclusion(s)

Placebo histological remission rates range from 13-19% in UC RCTs, but studies are highly heterogeneous. Factors found to influence placebo rates include presence of background medications, the drug used and the disease severity in UC patients. These observations have important implications in informing future trial designs to minimize placebo rates and reduce heterogeneity.

Disclosure of Interest

M. Youssef: None Declared, K. Dong: None Declared, S. J. Lee: None Declared, N. Narula Speakers bureau of: received honoraria from Janssen, Abbvie, Takeda, Pfizer, Merck, Sandoz, Novartis, and Ferring

Comparing the efficacy of different methods of faecal microbiota transplantation via oral capsule, oesophagogastroduodenoscopy, colonoscopy, or gastric tube

BACKGROUND

The increasing prevalence of multidrug-resistant organism (MDRO) carriage poses major challenges to medicine as healthcare costs increase. Recently, faecal microbiota transplantation (FMT) has been discussed as a novel and effective method for decolonizing MDRO.

AIM

To compare the efficacy of different FMT methods to optimize the success rate of decolonization in patients with MDRO carriage.

METHODS

This prospective cohort study enrolled patients with MDRO carriages from 2018 to 2021. Patients underwent FMT via one of the following methods: oral capsule, oesophagogastroduodenoscopy (EGD), colonoscopy, or gastric tube.

FINDINGS

A total of 57 patients underwent FMT for MDRO decolonization. The colonoscopy group required the shortest time for decolonization, whereas the EGD group required the longest (24.9 vs 190.4 days, P = 0.022). The decolonization rate in the oral capsule group was comparable to that in the EGD group (84.6% vs 85.7%, P = 0.730). An important clinical factor associated with decolonization failure was antibiotic use after FMT (odds ratio = 6.810, P = 0.008). All four groups showed reduced proportions of MDRO species in microbiome analysis after FMT.

CONCLUSION

Compared to other conventional methods, the oral capsule is an effective FMT method for patients who can tolerate an oral diet. The discontinuation of antibiotics after FMT is a key factor in the success of decolonization.

Increasing power generation to a single-chamber compost soil urea fuel cell for carbon-neutral bioelectricity generation: A novel approach

Microbial fuel cells (CS-UFC) utilize waste resources containing biodegradable materials that play an essential role in green energy. MFC technology generates "carbon-neutral" bioelectricity and involves a multidisciplinary approach to microbiology. MFCs will play an important role in the harvesting of "green electricity." In this study, a single-chamber urea fuel cell is fabricated that uses these different wastewaters as fuel to generate power. Soil has been used to generate electrical power in microbial fuel cells and exhibited several potential applications to optimize the device; the urea fuel concentration is varied from 0.1 to 0.5 g/mL in a single-chamber compost soil urea fuel cell (CS-UFC). The proposed CS-UFC has a high power density and is suitable for cleaning chemical waste, such as urea, as it generates power by consuming urea-rich waste as fuel. The CS-UFC generates 12 times higher power than conventional fuel cells and exhibits size-dependent behavior. The power generation increases with a shift from the coin cell toward the bulk size. The power density of the CS-UFC is 55.26 mW/m². This result confirmed that urea fuel significantly affects the power generation of single-chamber CS-UFC. This study aimed to reveal the effect of soil properties on the generated electric power from soil processes using waste, such as urea, urine, and industrial-rich wastewater as fuel. The proposed system is suitable for cleaning chemical waste; moreover, the proposed CS-UFC is a novel, sustainable, cheap, and eco-friendly design system for soil-based bulk-type design for large-scale urea fuel cell applications.

Detection rate of MR myelography without intrathecal gadolinium in patients with newly diagnosed spontaneous intracranial hypotension

AIM

To evaluate the detection rate of magnetic resonance (MR) myelography without intrathecal gadolinium for cerebrospinal fluid (CSF) leakage in patients with newly diagnosed spontaneous intracranial hypotension (SIH) and to validate a published scoring system for predicting CSF leakage.

MATERIALS AND METHODS

This retrospective, observational, single-institution study included patients with newly diagnosed SIH between March 2015 and April 2021. Patients were included if they (a) had newly diagnosed SIH and (b) underwent initial brain MR imaging and preprocedural MR myelography with two- and three-dimensional turbo spin-echo sequences. Patients who underwent spine surgery or procedures including epidural injection and acupuncture were excluded. The detection rate was defined as the proportion of patients with a true-positive MR myelography result among all patients with confirmed CSF leakage. The interobserver agreement for the MR myelography results between two radiologists was analysed using weighted kappa statistics.

RESULTS

A total of 136 patients (mean age, 48 years; 70 women) with suspected SIH were included. Of these patients, 120 (88%, 120/136) were confirmed to have CSF leakage. Of the patients with confirmed CSF leakage, 90 (75%, 90/120) had epidural fluid collection. The detection rate of MR myelography for CSF leakage was 88% (105/120). The interobserver agreement between the two readers for detecting CSF leakage (κ = 0.76) or epidural fluid collection (κ = 0.76) on MR myelography was high. Among 24 patients with normal brain MR imaging results, 16 had CSF leakage (67%, 16/24).

CONCLUSIONS

Non-invasive MR myelography without intrathecal gadolinium should be considered to detect CSF leakage in patients with suspected SIH.

Assessment of aortic valve area on cardiac computed tomography and doppler echocardiography: differences and clinical significance in symptomatic bicuspid aortic stenosis

Backgrounds

This study aimed to investigate the differences and clinical significance of effective orifice area (EOA) on Doppler echocardiography and geometric orifice area (GOA) on cardiac computed tomography (CT) in bicuspid aortic stenosis (AS).

Methods

One-hundred sixty-three consecutive patients (age 64±10 years, 56.4% men) with symptomatic bicuspid AS who were referred for surgery and underwent both cardiac CT and echocardiography within 3 months were studied. For the aortic valve area, GOACT was measured by multiplanar CT planimetry, and EOAEcho was calculated by continuity equation with Doppler echocardiography. The associations of GOACT and EOAEcho with the patients' symptom scale, biomarkers, and left ventricular (LV) functional variables were comprehensively analyzed.

Results

There was a significant but modest correlation between EOAEcho and GOACT (r=0.604, p&lt;0.001). Both EOAEcho and GOACT revealed significant correlations with mean pressure gradient and peak transaortic velocity and the coefficients were higher in EOAEcho than GOACT. EOAEcho of 1.05 cm2 and GOACT of 1.25 cm2 correspond to the hemodynamic cut-off values for diagnosing severe AS. EOAEcho was well correlated with patients' symptom scale and log NT-pro BNP, but GOACT was not. In addition, EOAEcho showed higher correlation coefficient with estimated LV filling pressure and LV global longitudinal strain than GOACT.

Conclusions

Both EOAEcho and GOACT can be used to evaluate the severity of bicuspid AS, however, the threshold for GOACT for diagnosing severe AS should be applied higher than that for EOAEcho. EOAEcho tends to be more correlated with the patients' symptom degree, biomarkers, and LV functional variables than GOACT.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Korean Cardiac Research Foundation

Stent expansion evaluated by optical coherence tomography and subsequent outcomes

Background

Regarding stent expansion indexes, previous optical coherence tomography (OCT) studies have shown minimal stent area (MSA) to be most predictive of adverse events.

Purpose

We sought to evaluate the impact of various stent expansion indexes by post-stent OCT on long-term clinical outcomes, and hence to find OCT-defined optimal stent expansion criteria.

Methods

Of the patients registered in the Yonsei OCT registry, a total of 1071 patients with 1123 native coronary artery lesions treated with new-generation drug-eluting stents under the OCT guidance and analyzable final post-stent OCT were included. Stent expansion indexes and different suboptimal stent expansion criteria were evaluated for their association with device-oriented clinical endpoints (DoCE) including cardiac death, target vessel-related myocardial infarction (TVMI) or stent thrombosis, and target lesion revascularization. Major safety events (MSE) included cardiac death, TVMI or stent thrombosis.

Results

The median follow-up period was 40.6 (interquartile range 22.0–50.0) months. As a continuous variable, MSA, adaptive volumetric stent expansion (stent volume/adaptive reference lumen volume) and overall volumetric stent expansion (stent volume/post-stent lumen volume) were significantly predictive of DoCE. As a categorical criteria, MSA &lt;5.0 mm2 (hazard ratio [HR] 3.80; 95% confidence interval [CI] 1.53–9.45), MSA/distal reference lumen area &lt;90% (HR 2.13; 95% CI 1.10–4.14), and overall volumetric stent expansion ≥96.6% (HR 2.38; 95% CI 1.09–5.22) were independently associated with DoCE after adjusting for confounders, and a total malapposition volume ≥7.0 mm3 (HR 3.38; 95% CI 1.05–10.93) was linked to MSE.

Conclusions

This OCT study highlights that sufficient stent expansion to achieve adequate absolute MSA and relative MSA by distal reference lumen area and alleviate significant malapposition is important to improve clinical outcome, but overall stent overexpansion may have deleterious effect.

Funding Acknowledgement

Type of funding sources: None.

Attributable Mortality and Excess Length of Stay associated with Third-Generation Cephalosporin Resistant Enterobacterales Bloodstream Infections - a prospective cohort study in Suva, Fiji

OBJECTIVES

There are scant primary clinical data on antimicrobial resistance (AMR) burden from low- and middle-income countries (LMICs). We adapted recent World Health Organization methodology to measure the impact of third-generation cephalosporin resistance (3GC-R) on mortality and excess length of hospital stay in Fiji.

METHODS

We conducted a prospective cohort study of inpatients with Enterobacterales bloodstream infections (BSIs) at Colonial War Memorial Hospital, Suva. We used cause-specific Cox proportional hazards models to estimate the effect of 3GC-R on the daily risk (hazard) of in-hospital mortality and being discharged alive (competing risks), and multistate modelling to estimate the excess length of hospital stay.

RESULTS

From July 2020 to February 2021 we identified 162 consecutive Enterobacterales BSIs, 3GC-R was present in 66 (40.7%). Crude mortality for patients with 3GC-susceptible and 3GC-R BSIs was 16.7% (16/96) and 30.3% (20/66), respectively. 3GC-R was not associated with the in-hospital mortality hazard rate (adjusted hazard ratio (aHR) 1.13, 95% CI 0.51-2.53) or being discharged alive (aHR 0.99, 95% CI 0.65-1.50), whereas Charlson comorbidity index score (aHR 1.62, 95% CI 1.36-1.93) and Pitt bacteraemia score (aHR 3.57, 95% CI 1.31-9.71) were both associated with an increased hazard rate of in-hospital mortality. 3GC-R was associated with an increased length of stay of 2.6 days (95% CI 2.5-2.8). 3GC-R was more common among hospital-associated infections, but genomics did not identify clonal transmission.

CONCLUSION

Patients with Enterobacterales BSIs in Fiji had high mortality. There were high rates of 3GC-R, which was associated with increased hospital length of stay but not with in-hospital mortality.

Electrophilic and Drug-Induced Stimulation of NOTCH3 N-terminal Fragment Oligomerization in Cerebrovascular Pathology

Small vessel disease is a prevalent age-related condition linked to increased risk of dementia and stroke. We investigate the most commonly inherited form, CADASIL, caused by cysteine-involving mutations in NOTCH3. Recent studies highlight accumulation of NOTCH3 N-terminal fragmentation product (NTF) in disease. In vitro, NTF is capable of both spontaneous and catecholamine-enhanced cysteine-mediated oligomerization. Despite well-characterized genetic influence on CADASIL, environmental effects, including medication usage, on disease remain unclear. We studied effects of assorted electrophilic compounds and drugs on NTF oligomerization by SDS-PAGE and dynamic light scattering. We then examined direct proton pump inhibitor-NTF binding with antibodies designed against proton pump inhibitor-labeled proteins and mass spectrometry. Finally, we used monoclonal NTF antibodies with Proximity Ligation Assay to identify NTF oligomers in 3 CADASIL and 2 age-matched control brains. We identified enhancement of NTF oligomerization by two electrophilic cysteine-modifying compounds, N-ethylmaleimide and iodoacetamide, and an electrophilic compound capable of oxidizing cysteines, ferric chloride. Electrophilic clinical drugs (fenoldopam, omeprazole, tenatoprazole, lansoprazole, and rabeprazole) also promoted oligomerization, and we identified direct omeprazole-NTF and tenatoprazole-NTF complexes. Additionally, we provide novel evidence of NTF multimers in human CADASIL brains. A broad array of electrophilic chemicals, including clinically relevant drugs, influences oligomerization of a pathological CADASIL protein, providing mechanistic insight into disease protein oligomerization. We posit that environmental influences, which may include usage of electrophilic drugs, may affect CADASIL presentations.

When Azoles Cannot Be Used: The Clinical Effectiveness of Intermittent Liposomal Amphotericin Prophylaxis in Hematology Patients

Background

Patients unable to take azoles are a neglected group lacking a standardized approach to antifungal prophylaxis. We evaluated the effectiveness and safety of intermittent liposomal amphotericin B (L-AMB) prophylaxis in a heterogenous group of hematology patients.

Methods

A retrospective cohort of all hematology patients who received a course of intravenous L-AMB, defined as 1 mg/kg thrice weekly from July 1, 2013 to June 30, 2018, were identified from pharmacy records. Outcomes included breakthrough-invasive fungal disease (BIFD), reasons for premature discontinuation, and acute kidney injury.

Results

There were 198 patients who received 273 courses of L-AMB prophylaxis. Using a conservative definition, the BIFD rate was 9.6% (n = 19 of 198) occurring either during L-AMB prophylaxis or up to 7 days from cessation in patients who received a course. Probable/proven BIFD occurred in 13 patients (6.6%, 13 of 198), including molds in 54% (n = 7) and non-albicans Candidemia in 46% (n = 6). Cumulative incidence of BIFD was highest in patients with acute myeloid leukemia (6.8%) followed by acute lymphoblastic leukemia (2.7%) and allogeneic stem cell transplantation (2.5%). The most common indication for L-AMB was chemotherapy, or anticancer drug-azole interactions (75% of courses) dominated by vincristine, or acute myeloid leukemia clinical trials, followed by gut absorption concerns (13%) and liver function abnormalities (8.8%). Acute kidney injury, using a modified international definition, complicated 27% of courses but was not clinically significant, accounting for only 3.3% (9 of 273) of discontinuations.

Conclusions

Our findings demonstrate a high rate of BIFD among patients receiving L-AMB prophylaxis. Pragmatic trials will help researchers find the optimal regimen of L-AMB prophylaxis for the many clinical scenarios in which azoles are unsuitable, especially as targeted anticancer drugs increase in use.

Results on Low-Mass Weakly Interacting Massive Particles from an 11 kg d Target Exposure of DAMIC at SNOLAB

We present constraints on the existence of weakly interacting massive particles (WIMPs) from an 11 kg d target exposure of the DAMIC experiment at the SNOLAB underground laboratory. The observed energy spectrum and spatial distribution of ionization events with electron-equivalent energies >200  eV_{ee} in the DAMIC CCDs are consistent with backgrounds from natural radioactivity. An excess of ionization events is observed above the analysis threshold of 50  eV_{ee}. While the origin of this low-energy excess requires further investigation, our data exclude spin-independent WIMP-nucleon scattering cross sections σ_{χ-n} as low as 3×10^{-41}  cm^{2} for WIMPs with masses m_{χ} from 7 to 10  GeV c^{-2}. These results are the strongest constraints from a silicon target on the existence of WIMPs with m_{χ}<9  GeV c^{-2} and are directly relevant to any dark matter interpretation of the excess of nuclear-recoil events observed by the CDMS silicon experiment in 2013.

Evaluation of camera-based freehand SPECT in preoperative sentinel lymph node mapping for melanoma patients

BACKGROUND

Assessment of lymphatic status via sentinel lymph node (SLN) biopsy is an integral and crucial part of melanoma surgical oncology. The most common technique for sentinel node mapping is preoperative planar scintigraphy of an injected gamma-emitting lymphatic tracer followed by intraoperative node localization using a non-imaging gamma probe with auditory feedback. In recent years, intraoperative visualization of SLNs in 3D has become possible by coupling the probe to an external system capable of tracking its location and orientation as it is read out, thereby enabling computation of the 3D distribution of the tracer (freehand SPECT). In this project, the non-imaging probe of the fhSPECT system was replaced by a unique handheld gamma camera containing an array of sodium iodide crystals optically coupled to an array of silicon photomultipliers (SiPMs). A feasibility study was performed in which preoperative SLN mapping was performed using camera fhSPECT and the number of detected nodes was compared to that visualized by lymphoscintigraphy, probe fhSPECT, and to the number ultimately excised under non-imaging probe guidance.

RESULTS

Among five subjects, SLNs were detected in nine lymphatic basins, with one to five SLNs detected per basin. A basin-by-basin comparison showed that the number of SLNs detected using camera fhSPECT exceeded that using lymphoscintigraphy and probe fhSPECT in seven of nine basins and five of five basins, respectively. (Probe fhSPECT scans were not performed for four basins.) It exceeded the number excised under non-imaging probe guidance for seven of nine basins and equaled the number excised for the other two basins.

CONCLUSIONS

Freehand SPECT using a prototype SiPM-based gamma camera demonstrates high sensitivity for detection of SLNs in a preoperative setting. Camera fhSPECT is a potential means for efficiently obtaining real-time 3D activity distribution maps in applications such as image-guided percutaneous biopsy, and surgical SLN biopsy or radioguided tumor excision.

Impacts of major health conditions affecting the Australian sheepmeat value chain: a review

Major health conditions in sheep contribute to substantial economic losses throughout the sheepmeat supply chain in Australia. A systematic review was undertaken to explore the measurable impact of six conditions: arthritis, sheep measles, pleurisy, pneumonia, grass seeds and rib fractures, on the production of lamb and mutton across the meat value chain. Peer-reviewed scientific literature from three databases and non-peer-reviewed articles and reports from Australian government and non-government websites were searched between 11 and 17 November 2019. Original articles, including studies conducted in Australia and New Zealand, that had measurable impacts on conditions of interest were included. The search yielded 16 articles and reports and were classified as producer impact and/or processor impact studies. Mortalities were quantified for pneumonia and arthritis, with pneumonia having the highest impact for producers. Grass seed infestation resulted in the highest impact on carcase and liveweight losses compared to arthritis and pneumonia. Arthritis had the highest trim weight losses for both lamb and mutton and the highest rate of carcase condemnation. Grass seed was the only condition where other impacts on the processor (chain speed and staff relocation to the boning room) were quantified. Although quantifiable production and processing losses were available for some conditions, this review has highlighted that limited quantifiable data based on scientifically sound research were not available for other conditions. The evidence for some conditions found in this review can be used to target future research activities and to further assist producers in making informed management decisions on prevention and control.

Use of phenytoin for treatment of tacrolimus toxicity with superimposed sepsis

A 40-year-old woman with a history of chronic graft-versus-host-disease on immunosuppression with tacrolimus presented to the hospital with somnolence, confusion and muscle cramps over a few days. She was found to have hypertension, hyperglycaemia and acute kidney injury with an elevated blood tacrolimus level of greater than 120 ng/mL (reference range 5-15 ng/mL). Discontinuation of tacrolimus with concomitant administration of intravenous phenytoin led to the successful reduction of elevated tacrolimus concentrations and the resolution of her symptoms. Tacrolimus is metabolised by the cytochrome P (CYP) 450 3A enzyme system, and utilisation of CYP 3A inducers to accelerate its clearance may be used as a successful therapy to treat tacrolimus toxicity.

Clinical features of subungual melanoma according to the extent of Hutchinson's nail sign: a retrospective single-centre study

BACKGROUND

Hutchinson's nail sign (HS) is among the diagnostic criteria for subungual melanoma (SUM). However, there is minimal evidence supporting the overall clinical significance of HS in SUM.

OBJECTIVES

To identify clinicopathological features of SUM according to the extent of HS.

METHODS

Retrospective cohort study was performed with consecutive SUM patients at a single centre from January 2006 to December 2017. The extent of HS was defined by the number of affected nail folds (range 0-4). Comparison groups were organized as follows: patients with HS (affecting ≥1 nail folds) vs. without HS; patients with HS affecting ≥2 nail folds vs. HS affecting <2 nail folds; patients with HS affecting ≥3 nail folds vs. HS affecting <3 nail folds. Clinicopathological characteristics of SUM were compared between the groups.

RESULTS

Sixty-one SUM patients were included. Forty-six (75.4%) exhibited HS; 22 (47.8%) on a toe and 24 (52.2%) on a finger. In multivariate analysis, nail destruction [hazard ratio (HR), 10.00; 95% confidence interval (CI), 2.61-38.30; P = 0.001] was significantly associated with the presence of HS and amputation was significantly associated with HS affecting ≥2 nail folds (HR, 4.75; 95% CI, 1.36-16.61; P = 0.015). High T stage (HR, 1.85; 95% CI, 1.20-2.85; P = 0.005, Fig. 2) was significantly associated with HS appearing in ≥3 nail folds.

CONCLUSION

Besides its value of detecting SUM, HS provides useful clinical information. The number of nail folds exhibiting HS could be a useful clinical clue for planning therapeutic strategies for SUM.

Measurement of the Lund Jet Plane Using Charged Particles in 13 TeV Proton-Proton Collisions with the ATLAS Detector

The prevalence of hadronic jets at the LHC requires that a deep understanding of jet formation and structure is achieved in order to reach the highest levels of experimental and theoretical precision. There have been many measurements of jet substructure at the LHC and previous colliders, but the targeted observables mix physical effects from various origins. Based on a recent proposal to factorize physical effects, this Letter presents a double-differential cross-section measurement of the Lund jet plane using 139  fb^{-1} of sqrt[s]=13  TeV proton-proton collision data collected with the ATLAS detector using jets with transverse momentum above 675 GeV. The measurement uses charged particles to achieve a fine angular resolution and is corrected for acceptance and detector effects. Several parton shower Monte Carlo models are compared with the data. No single model is found to be in agreement with the measured data across the entire plane.

Measurement of Azimuthal Anisotropy of Muons from Charm and Bottom Hadrons in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

The elliptic flow of muons from the decay of charm and bottom hadrons is measured in pp collisions at sqrt[s]=13  TeV using a data sample with an integrated luminosity of 150  pb^{-1} recorded by the ATLAS detector at the LHC. The muons from heavy-flavor decay are separated from light-hadron decay muons using momentum imbalance between the tracking and muon spectrometers. The heavy-flavor decay muons are further separated into those from charm decay and those from bottom decay using the distance-of-closest-approach to the collision vertex. The measurement is performed for muons in the transverse momentum range 4-7 GeV and pseudorapidity range |η|<2.4. A significant nonzero elliptic anisotropy coefficient v_{2} is observed for muons from charm decays, while the v_{2} value for muons from bottom decays is consistent with zero within uncertainties.

Search for Magnetic Monopoles and Stable High-Electric-Charge Objects in 13 Tev Proton-Proton Collisions with the ATLAS Detector

A search for magnetic monopoles and high-electric-charge objects is presented using 34.4  fb^{-1} of 13 TeV pp collision data collected by the ATLAS detector at the LHC during 2015 and 2016. The considered signature is based upon high ionization in the transition radiation tracker of the inner detector associated with a pencil-shape energy deposit in the electromagnetic calorimeter. The data were collected by a dedicated trigger based on the tracker high-threshold hit capability. The results are interpreted in models of Drell-Yan pair production of stable particles with two spin hypotheses (0 and 1/2) and masses ranging from 200 to 4000 GeV. The search improves by approximately a factor of 5 the constraints on the direct production of magnetic monopoles carrying one or two Dirac magnetic charges and stable objects with electric charge in the range 20≤|z|≤60 and extends the charge range to 60<|z|≤100.

Constraints on Light Dark Matter Particles Interacting with Electrons from DAMIC at SNOLAB

We report direct-detection constraints on light dark matter particles interacting with electrons. The results are based on a method that exploits the extremely low levels of leakage current of the DAMIC detector at SNOLAB of 2-6×10^{-22}  A cm^{-2}. We evaluate the charge distribution of pixels that collect <10e^{-} for contributions beyond the leakage current that may be attributed to dark matter interactions. Constraints are placed on so-far unexplored parameter space for dark matter masses between 0.6 and 100  MeV c^{-2}. We also present new constraints on hidden-photon dark matter with masses in the range 1.2-30  eV c^{-2}.

P783Guideline-directed therapy at discharge is important in patients with heart failure and atrial fibrillation

Background

There are limited and conflicting data regarding the prognostic implication of guideline-directed therapy, especially in heart failure (HF) patients with atrial fibrillation (AF). Thus, this study evaluated the relationship between guideline adherence to recommended therapy at discharge and relevant 60-day clinical outcomes in acute HF patients with AF having reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF).

Methods and results

Of 5,625 acute HF patients in the Korean Acute Heart Failure Registry, 2,071 with documented AF (HFrEF, n=986; HFpEF, n=1,085) were separately analysed. A guideline adherence score was calculated for the prescription of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists, and anticoagulants. In HFrEF patients with AF, there was significant trend of increase in mortality (p for trend <0.001) and composite endpoint (p for trend = 0.002) according to guideline adherence. Poor adherence was associated with a significantly high risk of mortality (hazard ratio [HR], 4.75; 95% confidence interval [95% CI], 1.77–12.74) and composite endpoint (HR, 2.36; 95% CI, 1.33–4.18). In HFpEF patients with AF, there was a significant increasing trend for rehospitalization (p for trend = 0.04) and composite endpoint (p for trend = 0.03). However, the beneficial effect of good guideline adherence was statistically non-significant for all clinical outcomes

Conclusion

Better adherence to guidelines was associated with a better 60-day prognosis in both HFrEF and HFpEF patients with AF. However, the beneficial effect of guideline adherence was more pronounced in HFrEF patients with AF.

P645Low levels of low density lipoprotein cholesterol and cardiovascular, cancer and all-cause mortality outcomes

Aims

The effect of low concentrations of low density lipoprotein-cholesterol (LDL-C) on cardiovascular disease (CVD) cancer and all-cause mortality is still controversial. In a large, young, well characterized, relatively healthy occupational cohort (Kangbuk Samsung health study, KSHS), we tested associations between low levels of LDL-C concentration, and CVD, cancer and all- cause mortality. To validate these associations, we analyzed data from another cohort (Korean genome and epidemiology study, KoGES).

Methods and results

347,971 subjects in KSHS (mean age 39.6 years, 57.4% men) were studied over a mean follow up of 5.64±3.27 years. All subjects treated with any lipid lowering therapy were excluded. After excluding the data from subjects who died during the first 3 years of follow up, five groups were defined according to baseline LDL-C concentration (<70, 70–99, 100–129, 130–159, ≥160 mg/dL). Hazard ratios (HR and 95% CIs) for all-cause mortality, CVD and cancer mortality were estimated using Cox proportional hazards models. In the KoGES validation cohort, 182,943 subjects (mean age 53.1 years, 34.6% men) were studied over a mean follow up of 8.57±2.59 years with same methods. 2,028 deaths (897 from cancer and 282 from CVD) occurred during follow-up in KSHS. The lowest LDL-C group (LDL<70 mg/dL) had a higher risk of all-cause mortality (HR 1.95, 1.55–2.47), CVD mortality (HR 2.02, 1.11–3.64) and cancer mortality (HR 2.06, 1.46–2.90) compared to the reference group (LDL 120–139 mg/dL). This association was more prominent in men than in women. In the validation cohort, 2,338 deaths (1,823 from cancer and 199 from CVD) occurred during follow-up. The lowest LDL-C group (LDL<70 mg/dL) had a higher risk of all-cause mortality (HR 1.81, 1.44–2.28). Men in the lowest LDL-C group had a higher risk of CVD mortality (HR 3.15, 1.21–8.21) and cancer mortality (1.34, 0.99–1.82) in the KoGES cohort.

Conclusions

Low levels of LDL-C concentration are strongly and independently associated with increased risk of cancer, CVD and all-cause mortality especially in men.

2205Caregivers with persistent depressive symptoms are at high risk of having poor health status over 1 year of caregiving

Background

Depressive symptoms are a substantial psychological problem in caregivers of stroke survivors, but there is limited knowledge about the trajectory of depressive symptoms and the consequence in longitudinal study. The purposes of this study were to (1) identify patterns for trajectory of depressive symptoms in caregivers who provided caregiving for stroke survivors for 1 year post-discharge, and (2) examine associations of depressive symptom trajectories with caregivers' burden, family function, social support, and health status over time.

Methods

In this secondary analysis of a longitudinal study, caregivers of stroke survivors completed a survey at post-discharge and 1 year follow up. Depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression scale (CES-D). Caregiving burden, family function, and social support were assessed using the Zarit Burden Interview, the Family Assessment Device, and the Interpersonal Support Evaluation List. Health status was assessed using two items from the SF-36. Pattern of depressive symptom trajectory (i.e., symptom-free, symptom improved, symptom developed, and persistent symptom) were identified by the presence of depressive symptoms (CES-D ≥16) at post-discharge and 1 year follow up. ANOVA, and multinomial logistic regression were used.

Results

Of the 102 caregivers (mean age=58 years, 66% female), 32.4% experienced depressive symptoms at post-discharge; 30.4% experienced depressive symptoms at 1-year follow up. During the first year of the caregiving experience, 57.8% of caregivers were symptom-free but 20.6% experienced persistent depressive symptoms; 11.8% had improved depressive symptoms, and 9.8% developed depressive symptoms. Caregivers with persistent depressive symptoms reported the highest level of burden (p<0.001), and the lowest levels of family function (p=0.02) and interpersonal support (p=0.0001) among the 4 groups at post-discharge and the results were unchanged at 1 year follow up. Furthermore, 33% of caregivers with persistent depressive symptoms reported their health as fair or poor at 1 year follow up and 42% of them reported their health became worse at 1 year follow up. Caregivers who developed depressive symptoms had the 2nd lowest score of interpersonal support (p=0.047) at 1 year follow up. Compared to symptom-free caregivers, caregivers with persistent depressive symptoms were 7 times more likely to have fair or poor health at 1 year follow up (95% CI, 1.55–32.87, p=0.012).

Conclusions

Trajectory of depressive symptoms was associated with caregiving burden, family function, and interpersonal support. The persistence of depressive symptoms is substantial for caregivers of stroke survivors and they are at high risk to have poor health status at 1 year of caregiving. Management of depressive symptoms at the early caregiving stage may be beneficial to prevent the development and persistence of depressive symptoms in caregivers of stroke survivors.

Acknowledgement/Funding

National Institute for Nursing Research R01NR02416

Association between time to treatment and functional outcomes according to the Diffusion-Weighted Imaging Alberta Stroke Program Early Computed Tomography Score in endovascular stroke therapy

BACKGROUND AND PURPOSE

The rate at which the chance of a good outcome of endovascular stroke therapy (EVT) decays with time when eligible patients are selected by baseline diffusion-weighted magnetic resonance imaging (DWI-MRI) and whether ischaemic core size affects this rate remain to be investigated.

METHODS

This study analyses a prospective multicentre registry of stroke patients treated with EVT based on pretreatment DWI-MRI that was categorized into three groups: small [Diffusion-Weighted Imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS)] (8-10), moderate (5-7) and large (<5) cores. The main outcome was a good outcome at 90 days (modified Rankin Scale 0-2). The interaction between onset-to-groin puncture time (OTP) and DWI-ASPECTS categories regarding functional outcomes was investigated.

RESULTS

Ultimately, 985 patients (age 69 ± 11 years; male 55%) were analysed. Potential interaction effects between the DWI-ASPECTS categories and OTP on a good outcome at 90 days were observed (P_interaction  = 0.06). Every 60-min delay in OTP was associated with a 16% reduced likelihood of a good outcome at 90 days amongst patients with large cores, although no associations were observed amongst patients with small to moderate cores. Interestingly, the adjusted rates of a good outcome at 90 days steeply declined between 65 and 213 min of OTP and then remained smooth throughout 24 h of OTP (P_nonlinearity  = 0.15).

CONCLUSIONS

Our study showed that the probability of a good outcome after EVT nonlinearly decreased, with a steeper decline at earlier OTP than at later OTP. Discrepant effects of OTP on functional outcomes by baseline DWI-ASPECTS categories were observed. Thus, different strategies for EVT based on time and ischaemic core size are warranted.

Efficacy and safety of CT-P6 versus reference trastuzumab in HER2-positive early breast cancer: updated results of a randomised phase 3 trial

PURPOSE

Neoadjuvant CT-P6, a trastuzumab biosimilar, demonstrated equivalent efficacy to reference trastuzumab in a phase 3 trial of HER2-positive early-stage breast cancer (EBC) (NCT02162667). We report post hoc analyses evaluating pathological complete response (pCR) and breast pCR alongside additional efficacy and safety measures.

METHODS

Following neoadjuvant treatment and surgery, patients received adjuvant CT-P6 or trastuzumab (6 mg/kg) every 3 weeks for ≤ 1 year.

RESULTS

In total, 271 and 278 patients received CT-P6 and trastuzumab, respectively. pCR and breast pCR rates were comparable between treatment groups regardless of age, region, or clinical stage. Overall, 47.6% (CT-P6) and 52.2% (trastuzumab) of patients experienced study drug-related treatment-emergent adverse events (TEAEs), including 17 patients reporting heart failure (CT-P6: 10; trastuzumab: 7). Two CT-P6 and three trastuzumab patients discontinued adjuvant treatment due to TEAEs.

CONCLUSION

Adjuvant CT-P6 demonstrated comparable efficacy and safety to trastuzumab at 1 year in patients with HER2-positive EBC, supporting CT-P6 and trastuzumab comparability.

Observation of Light-by-Light Scattering in Ultraperipheral Pb+Pb Collisions with the ATLAS Detector

This Letter describes the observation of the light-by-light scattering process, γγ→γγ, in Pb+Pb collisions at sqrt[s_{NN}]=5.02  TeV. The analysis is conducted using a data sample corresponding to an integrated luminosity of 1.73  nb^{-1}, collected in November 2018 by the ATLAS experiment at the LHC. Light-by-light scattering candidates are selected in events with two photons produced exclusively, each with transverse energy E_{T}^{γ}>3  GeV and pseudorapidity |η_{γ}|<2.4, diphoton invariant mass above 6 GeV, and small diphoton transverse momentum and acoplanarity. After applying all selection criteria, 59 candidate events are observed for a background expectation of 12±3 events. The observed excess of events over the expected background has a significance of 8.2 standard deviations. The measured fiducial cross section is 78±13(stat)±7(syst)±3(lumi)  nb.

Association between 18F-FDG uptake in PET/CT, Nrf2, and NQO1 expression and their prognostic significance in non-small cell lung cancer

Two pentose phosphate pathway-related proteins, NF-E2-related factor 2 (Nrf2)/ NAD(P)H dehydrogenase (Quinone) 1 (NQO1) regulate the expression of glucose metabolism and antioxidant genes. We evaluated the prognostic significance of NRF2, NQO1 and 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) parameter and their relationship with non-small cell lung cancer (NSCLC) histology. A total of 241 patients, who underwent surgical resection for NSCLC, were reviewed retrospectively. Preoperative 18F-FDG PET and immunohistochemical results of Nrf2 and NQO1 were evaluated. In SQCC, the maximum standardized uptake value (SUVmax) was significantly higher in NQO1-high than in NQO1-low expression (p=0.023). In adenocarcinoma, SUVmax was not correlated with NQO1 expression. Patients with a high NQO1 expression showed poor recurrence-free survival (RFS) and overall survival (OS) than patients with a low NQO1 expression in squamous cell carcinoma (SQCC) (p=0.002 and p=0.014, respectively). NQO1 expression was not associated with clinical outcome in adenocarcinoma. Nrf2 expression was not correlated with prognosis in two types of NSCLC. High SUVmax was associated with poor RFS (p=0.03) but is not related to poor OS (p=0.569) in SQCC. In multivariate analyses, NQO1 expression and SUVmax were not independent prognostic factors in SQCC. However, in multivariate analysis combining NQO1 and SUVmax values, both low SUVmax and low NQO1 was independent prognostic factor for RFS and OS (HR= 3.790, p = 0.033 and HR= 2.961, p = 0.045, respectively). In conclusion, both low SUVmax and low NQO1 was an independent prognostic factor in SQCC alone. The sample size was small but there was a positive correlation between NQO1 expression and SUVmax in SQCC.

Combination of Searches for Invisible Higgs Boson Decays with the ATLAS Experiment

Dark matter particles, if sufficiently light, may be produced in decays of the Higgs boson. This Letter presents a statistical combination of searches for H→invisible decays where H is produced according to the standard model via vector boson fusion, Z(ℓℓ)H, and W/Z(had)H, all performed with the ATLAS detector using 36.1  fb^{-1} of pp collisions at a center-of-mass energy of sqrt[s]=13  TeV at the LHC. In combination with the results at sqrt[s]=7 and 8 TeV, an exclusion limit on the H→invisible branching ratio of 0.26(0.17_{-0.05}^{+0.07}) at 95% confidence level is observed (expected).

[The correlation between plasma fibrinogen level and different types of sudden sensorineural hearing loss]

Objective: To investigate the correlation between plasma fibrinogen level and the incidence of sudden hearing loss. Method: A total of 225 patients (age ranging from 18 to 70 years) with sudden sensorineural hearing loss(SSNHL) were selected. The disease onset was within 2 weeks. No patient received previous medical intervention. Depending on the types of auditory threshold curve, SSNHL was divided into low frequency descending type, high frequency descending type, flat desending type and total deafness type. Two hundred and twenty-nine cases with normal hearing and no inflammatory diseases in the same period was selected as control group. Fibrinogen level and Blood Routine Indexes were detected for the purpose of retrospective cohort study.Result: The levels of fibrinogen in SSNHL group(2.98±0.59) g/L were significantly higher than that in control group(2.66±0.36) g/L (P<0.01). According to the types of auditory threshold curve, SSNHL groups were divided into group A(55 cases, 24.44%), Group B(36 cases, 16.00%), Group C(43 cases,19.11%) and Group D(91 cases, 40.44%). The average fibrinogen levels before treatment were at(2.75±0.46)g/L, (3.16±0.61) g/L, (3.02±0.63) g/L and(3.03±0.63) g/L respectively. There was no significant difference in fibrinogen level(P=0.286) between group A and the control group. Fibrinogen levels of group B, group C and group D were significantly elevated compared to control group (P<0.01). Conclusion: The level of fibrinogen is not significantly correlated with development of sudden deafness of low frequency descending type. The incidence of high frequency descending type, flat descending type and profound deafness type are all correlated with the level of high fibrinogen at the onset of sudden deafness. The classification of sudden deafness based on audiogram curves could be of great significance for analysis of possible causes and selection of treatment options.

Abstract P2-08-53: Tumor elasticity and clinicopathologic factors affecting neoadjuvant chemotherapy response in breast cancer patients

Background: Neoadjuvant chemotherapy for breast cancer has been increased. Many studies have reported on clinicopathologic factors to predict neoadjuvant chemotherapy response. Elastography, which is usually used to differentiate benign and malignant tumors, can be performed to evaluate tissue elasticity during conventional ultrasonography. The purpose of this study was to determine the clinicopathologic factors, including tumor elasticity, that affect neoadjuvant chemotherapy response in stage II or III breast cancer patients.

Methods: From April 2014 to March 2017, 95 patients received neoadjuvant chemotherapy for clinical stage IIa-IIIc primary breast cancer. To evaluate tumor elasticity, strain elastography was performed in 74 patients before neoadjuvant chemotherapy. Patients were divided into two groups by the Tsukuba elasticity scoring system (soft group ≤3 vs. hard group ≥4). Histologic type, nuclear grade, tumor infiltrating lymphocytes (TILs), tumor cellularity, characteristics of stroma, and hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) status were evaluated using core needle biopsy specimens obtained before neoadjuvant chemotherapy. Pathologic complete response (pCR) was defined as the absence of invasive carcinoma in breast (ypT0 and ypTis) and axillary lymph node (ypN0). Residual cancer burden (RCB) was also calculated in 79 cases and the cases were categorized into 2 groups; favorable RCB group (RCB-0 and I) and unfavorable RCB group (RCB-II and III).

Results: The mean age of patients was 46.43±8.62 years (range, 27-71 years) and the mean initial tumor size was 3.63±1.95cm (range, 2.1-12.8cm). Twenty-four patients (32.4%) were categorized into the soft group and 50 patients (67.6%) into the hard group. The mean tumor cellularity on core needle biopsy specimens and characteristics of stroma were not significantly different between the two groups (p=0.35 and p=0.79, respectively). Twenty-two patients achieved pCR (23.2%). The patients with pCR were more likely to have estrogen receptor (ER) or progesterone receptor (PR) negative breast cancer (p=0.04 and p=0.03). The rate of nuclear grade 3 was higher in patients with pCR than those without (p=0.03). Tumor elasticity was not correlated with pCR (p=0.28). Thirty patients (38.0%) achieved favorable RCB and forty-nine patients (62.0%) had unfavorable RCB. Not only the rates of ER negativity (p=0.05), PR negativity (p=0.03), nuclear grade 3 (p=0.01), and high TILs level (≥ 10%) (p=0.04) but also the mean TILs level (p=0.05) were significantly higher in the favorable RCB group compared withthe unfavorable RCB group. No significant difference in tumor elasticity was observed between the two groups (p=0.30). In univariate analyses, nuclear grade 3 (p=0.03), and high TILs level (≥10%) (p=0.04) were significantly correlated with favorable RCB. HR negativity was an independent predictor of favorable RCB in multivariate analysis (odds ratio, 2.93; 95% confidence interval, 1.04-8.28; p=0.04).

Conclusion: Tumor elasticity was not associated with pCR or RCB. HR negativity was an independent predictor for favorable RCB.Nuclear grade and TILs were also potential predictive factors for neoadjuvant chemotherapy response.

Citation Format: Park JY, Choi JE, Bae YK, Lee SJ. Tumor elasticity and clinicopathologic factors affecting neoadjuvant chemotherapy response in breast cancer patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-53.

Abstract P6-02-08: SUV max of 18F FDG-PET/CT: A predictive factor associated with pathologic complete response in luminal HER2–negative breast cancer patients (receiving neoadjuvant chemotherapy)

Purpose Neoadjuvant chemotherapy (NAC) is considered to be the standard of care for locally advanced breast cancer. When pathological complete response (pCR) is obtained with NAC it is a predictor of better outcome and often used as a surrogate for survival. However, response to NAC of luminal type breast cancer is variable and mostly limited. This study investigated the predictive relevance of several clinicopathological factors, including parameters of 18F FDG-PET/CT, on the pCR to NAC in patients with luminal HER2–negative breast cancer.

Methods From 2009 to 2015, 117 hormone receptor-positive, HER2-negative breast cancer patients who were treated with NAC followed by curative surgery at the Kyungpook National University Hospital (Daegu, Korea) were retrospectively analyzed. pCR was defined as the absence of cancer cells in breast and axillary node. 18F FDG-PET/CT maximum standardized uptake value (SUV max) was measured at baseline. Patients received from 6 to 8 cycles of anthracycline-based and taxane-based NAC.

Results The median age of the patients was 48 years (range-29-68 years). 104 patients (88.9%) were PR-positive, and forty-nine (41.9%) patients showed high ki-67 expression at initial diagnosis. After NAC, nine patients (7.7%) achieved pCR and patients who had high initial SUV max (≥ 9.09) achieved improved pCR rate compared to low initial SUV max (&lt; 9.09) patients (77.8 % vs. 22.2%).

Conclusion In luminal HER2-negative breast cancer, 18F FDG-PET/CT SUV max was useful for predicting pathologic complete response after NAC

Table 1Characteristics of study populationMedian, range48 (29-68)Initial clinical T stage 1 2 3 48 (6.8) 83 (70.9) 19 (16.2) 7 (6.0)Initial clinical N stage 0 1 2 310 (8.5) 49 (41.9) 47 (40.2) 11 (9.4)Initial ER expression Negative (0-2) Weak (3-5) Strong (6-8)8 (6.8) 14 (12) 95 (81.2)Initial PR expression Negative (0-2) Weak (3-5) Strong (6-8)13 (11.1) 20 (17.1) 84 (71.8)Initial Ki-67 expression &lt;14% ≥14% Not assessed55 (47) 49 (41.9) 13 (11.1)Pathologic T stage 0 I II III16 (13.7) 50 (42.7) 42 (35.9) 9 (7.7)Pathologic Stage (AJCC) pCR 1A 1B 2A 2B 3A 3C9 (7.7) 23 (19.7) 7 (6.0) 27 (23.1) 21 (17.9) 23 (19.7) 7 (6.0)Histologic grade 1 2 322 (18.8) 61 (52.1) 14 (12)Nuclear Grade 1 2 316 (13.7) 9 (7.7) 50 942.7)Pathologic complete response Yes9 (7.7)Recurrence18 (15.4)Death10 (8.5)table 2Association between pathologic complete response and clinicopathologic featuresFactorsPathologic CR NoPathologic CR YesP- valueAll patients108 (92.3)9 (7.7) Age &lt;40 40-55 56-7016 (18.2) 54(61.4) 18 (20.5)2 (22.2) 6 (66.7) 1 (11.1)0.789Initial clinical T stage 1 2 3 48 (7.4) 76 (70.4) 7 (6.5) 17 (15.7)0 (0) 7 (77.8) 2 (22.2) 0 (0)0.676Initial ER expression Negative (0-2) Weak (3-5) Strong (6-8)7 (6.5) 12 (11.1) 89 (8.4)1 (11.1) 2 (22.2) 6 (66.7)0.504Initial PR expression Negative (0-2) Weak (3-5) Strong (6-8)11 (10.2) 20 (18.5) 77 (71.3)2 (22.2) 0 (0) 7 (77.8)0.247Initial Ki-67 expression &lt;14% ≥14%52 (54.7) 43 (45.3)3 (33.3) 6 (66.7)0.301SUV max (tumor) &lt; 9.09 ≥ 9.0972 (66.7) 36 (33.3)2 (22.2) 7 (77.8)0.012SUV max (axilla) &lt; 6.08 ≥ 6.0858 (67.4) 28 (32.6)3 (42.9) 4 (57.1)0.228

Citation Format: Lee IH, Lee SJ, Lee J, Lee RK, Jung J, Park H, Lee S-w, Chae YS. SUV max of 18F FDG-PET/CT: A predictive factor associated with pathologic complete response in luminal HER2–negative breast cancer patients (receiving neoadjuvant chemotherapy) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-02-08.

Abstract P3-11-07: Exploratory biomarker analysis from a phase II, multicenter, randomized trial of eribulin plus gemcitabine(EG) versus paclitaxel plus gemcitabine(PG) as first-line chemotherapy for human epidermal growth factor receptor 2 (HER2)- negative metastatic breast cancer(MBC): Korean cancer study group trial (KCSG BR13-11)

Introduction : A phase II, multicenter, randomized clinical trial of the comparison between eribulin plus gemcitabine (EG) and paclitaxel plus gemcitabine (PG) as first-line chemotherapy for patients with human epidermal growth factor receptor 2 (HER2)-negative metastatic breast cancer (MBC) found EG was less neurotoxic, but had similar efficacy of PG. In this study, we performed exploratory biomarker analysis of the impact of genetic alterations on the efficacy according to EG and PG chemotherapy.

Methods : This biomarker study was conducted using tumor samples from 40patients. When tissue collection was possible after disease progression, we performed paired sample analysis. Tumor DNA and RNA were extracted from formalin-fixed, paraffin-embedded tissues. To perform targeted deep sequencing, we used CancerScanTM, a 375 cancer gene panel. And we performed an nCounter expression assay for gene expression analysis using 730 PanCancer panel and 730 Immune panel.

Results: In total, we obtained 44 tissue samples from 40 patients. Twenty two patients were assigned in EG arm and 18 patients were in PG arm. Thirty-eight were at baseline and six after disease progression. Gene expression assay were performed in 44 tissue samples but only 31 samples were possible to be targeted deep sequencing.

We performed differently expressed gene(DEG) analysis for detecting the association between level of gene expression and disease progression. In this analysis, high expression of CCNE1, TGFB4 and BAMBI and low expression of DDB2, CD14 and SHC3 were associated with disease progression among 730 PanCancer panel genes (p&lt;0.05, respectively). In terms of immune panel genes, most of immune related genes were highly expressed in a group without disease progression compared with that with disease progression. Only 2 genes, C8G and CD24 were highly expressed in a group with disease progression. Paired sample analysis showed that expression levels of THBS4 and CD27 decreased after disease progression while those of CCNE2 and FGFR4 increased.

In targeted deep sequencing, FAT3 (42.3%) was most frequently mutated gene followed by PKHD1, PIK3CA and TP53. Among mutated genes, EWSR1 mutation and upstream mutation of ETV1 were associated with disease progression, respectively (p&lt;0.05, respectively). In mutation signature analysis, signature 1 (S, age related), S3(homologous recombination deficiency, HRD), S6 (mismatch repair, MMR), S20(MMR) and S21(microsatellite instability, MSI) were enriched in this population. Mutation signature 3 related to short disease free survival (p=0.0026).

Conclusion: In gene expression analysis, high expression of TGF-B signaling pathway related genes was associated with disease progression while high expression of immune related genes were related to prolonged disease free survival. In mutation analysis, EWSR1 and ETV1 mutations indicated short disease free interval and HRD mutation signature was also related to poor prognosis.

Citation Format: Kim J-Y, Lee EJ, Park KH, Im S-A, Kim S-B, Sohn SH, Lee KS, Chae YS, Lee KH, Kim JH, Im Y-H, Kim T-Y, Lee K-H, Ahn J-H, Kim GM, Park IH, Lee SJ, Han HS, Kim SH, Jung KH, Park YH. Exploratory biomarker analysis from a phase II, multicenter, randomized trial of eribulin plus gemcitabine(EG) versus paclitaxel plus gemcitabine(PG) as first-line chemotherapy for human epidermal growth factor receptor 2 (HER2)- negative metastatic breast cancer(MBC): Korean cancer study group trial (KCSG BR13-11) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-11-07.

Abstract P6-05-10: MicroRNA-137 inhibits cancer progression by targeting DEL-1 in triple negative breast cancer cells, MDA-MB-231

Background: This study aimed to investigate the function of microRNA-137 in Del-1 expression in triple negative breast cancer (TNBC) cells and tissues.

Methods: The Del-1 mRNA and microRNA levels were measured using a qRT-PCR in breast cancer cells (MDA-MB-231, MCF7, SK-BR3, and T-47D) and tissues from 20 patients with TNBC. The effects of miR-137 on cell proliferation, migration, and invasion were determined using MTT, wound healing, and Matrigel Transwell assays.

Results: microRNA-137 (miR-137) levels were remarkably low and Del-1 mRNA expression was higher in MDA-MB-231 cells as compared to other breast cancer cell lines. The luciferase reporter assay revealed that miR-137 binds directly at the 3¢-UTR of Del-1 and that Del-1 expression was downregulated by miR-137 mimics and rescued by its inhibitors. Furthermore, miR-137 inhibited the cell proliferation, migration, and invasion of MDA-MB-231 cells. Moreover, among the 30 TNBC specimens, miR-137 was downregulated (p &lt;0.0001) and the level of Del-1 in plasma was significantly elevated as compared to normal controls (p &lt; 0.0001).

Conclusions: In conclusion, miR-137 regulates Del-1 expression in TNBC via directly binding to the Del-1 gene, and thereby affects cancer progression. This suggests that miR-137 may be a new therapeutic biomarker for patients with TNBC.

Keywords: Del-1, triple negative breast cancer, miR-137, biomarker

Citation Format: Chae YS, Baek DW, Lee IH, Lee SJ, Lee RK, Lee J, Jung J, Park H, Jeong J-H, Kang J, Park J. MicroRNA-137 inhibits cancer progression by targeting DEL-1 in triple negative breast cancer cells, MDA-MB-231 [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-05-10.

Effects of acute lipopolysaccharide-induced toxemia model on some neglected blood parameters

The presence of lipopolysaccharide (LPS) in blood induces an inflammatory response which leads to multiple organ dysfunction and numerous metabolic disorders. Uncontrolled, improper or late intervention may lead to tissue hypoxia, anaerobic glycolysis and a disturbance in the acid -base balance. The effects of LPS-induced toxemia on biological and immunological markers were well studied. However, parameters such as base excess, ions, and acid-base balance were not fully investigated. Therefore, the objective of this study was to examine these blood parameters collectively in LPS-induced inflammatory toxemia in rat's model. After induction of toxemia by injecting LPS at a rate of 5 mg/kg body weight intravenously, blood was collected from the tail vein of twenty rats and immediately analyzed. After 24 hours, the animals were sacrificed and the blood was collected from the caudal vena cava. The results revealed that the levels of pH, bicar- bonate, partial pressure of oxygen, oxygen saturation, Alveolar oxygen, hemoglobin, hematocrit, magnesium (Mg2+), and calcium (Ca2+) were significantly decreased. On the other side, the levels of Base excess blood, Base excess extracellular fluid, partial pressure of carbon dioxide, lactate, Ca2+/Mg2+, potassium, and chloride were significantly increased compared to those found pre toxemia induction. However, sodium level showed no significant change. In conclusion, Acute LPS-toxemia model disturbs acid-base balance, blood gases, and ions. These parameters can be used to monitor human and animal toxemic inflammatory response induced by bacterial LPS conditions to assist in the management of the diagnosed cases.

A 10-min Targeted Geriatric Assessment Predicts Mortality in Fast-Paced Acute Care Settings: A Prospective Cohort Study

OBJECTIVES

To estimate whether a 10-minute Targeted Geriatric Assessment (10-TaGA) adds utility to sociodemographic characteristics and comorbidities in predicting one-year mortality in busy acute care settings. We have also compared the performance of 10-TaGA with the Identification of Seniors at Risk (ISAR) scale.

DESIGN

Prospective cohort study.

SETTING

Geriatric day hospital specializing in acute care in Brazil.

PARTICIPANTS

751 older adults aged 79.4 ± 8.4 years (64% female), presenting non-surgical, medical illness requiring hospital-level care (e.g., intravenous therapy, laboratory test, radiology) for ≤ 12 hours.

MEASUREMENTS

The 10-TaGA, an easy-to-administer screening tool based on the comprehensive geriatric assessment (CGA), provided a measure of cumulative deficits ranging from 0 (no deficits) to 1 (highest deficit) on admission. Standard risk factors, including sociodemographics (age, gender, ethnicity, income) and the Charlson comorbidity index, were evaluated. The ISAR, a well-validated screening tool, was used for comparison.

RESULTS

During one year of follow-up, 130 (17%) participants died. Compared to the ISAR, 10-TaGA offered better accuracy in identifying older patients at risk of death (area under the receiver operating characteristic curve: [AUC] 0.70 vs 0.65; P = 0.03). In a Cox regression model adjusted for sociodemographics and comorbidities, each 0.1 increment in the 10-TaGA score (range 0-1) was associated with increased mortality (hazard ratio = 1.42, 95% confidence interval 1.27-1.59). The addition of 10-TaGA markedly improved the discrimination of the model, which already incorporated standard risk factors (AUC 0.76 vs 0.71; P = 0.005); adding ISAR (AUC 0.73 vs 0.71; P = 0.09) did not have this marked effect.

CONCLUSION

The 10-TaGA is an independent predictor of one-year mortality in acute care patients. This multidimensional screening tool offers better accuracy than ISAR when differentiating between older people at low and high risk of death in healthcare settings where providers have limited time and resources.

The impact of intrinsic motivation on session attendance and reliable cognitive improvement in cognitive remediation in schizophrenia

OBJECTIVE

Cognitive remediation (CR) is considered a potentially effective method of improving cognitive function in people with schizophrenia. Few studies, however, have explored the role of intrinsic motivation on treatment utilization or training outcomes in CR in this population. This study explored the impact of task-specific intrinsic motivation on attendance and reliable cognitive improvement in a controlled trial comparing CR with a computer game (CG) playing control.

METHODS

Forty-nine participants with schizophrenia or schizoaffective disorder, allocated to 10 weeks of group-based CR (n = 25) or CG control (n = 24), provided complete outcome data at baseline. Forty-three participants completed their assigned intervention. Cognition, psychopathology and intrinsic motivation were measured at baseline and end-treatment. Regression analyses explored the relative contribution of baseline motivation and other clinical factors to session attendance as well as the association of baseline and change in intrinsic motivation with the odds of reliable cognitive improvement (calculated using reliable change indices).

RESULTS

Baseline reports of perceived program value were the only significant multivariable predictor of session attendance when including global cognition and psychiatric symptomatology. The odds of reliable cognitive improvement significantly increased with greater improvements in program interest and value from baseline to end-treatment. Motivational changes over time were highly variable between participants.

CONCLUSION

Task-specific intrinsic motivation in schizophrenia may represent an important patient-related factor that contributes to session attendance and cognitive improvements in CR. Regular evaluation and enhancement of intrinsic motivation in cognitively enhancing interventions may optimize treatment engagement and the likelihood of meaningful training outcomes.

Allium hookeri supplementation improves intestinal immune response against necrotic enteritis in young broiler chickens

Three hundred birds (1 day old) were randomly assigned to 6 groups (n = 50 birds/treatment) and fed a basal diet (control) or basal diet supplemented with Allium hookeri (AH) root (1 or 3%). At day 14, half of the birds in each group were orally challenged with E. maxima 41A (1 × 104 cells/chicken), followed by C. perfringens infection (1 × 109 cfu/chicken) on day 18. Necrotic enteritis (NE)-associated infections and intestinal immune response were assessed by average body weight gain, lesion score, and oocyst shedding. The effect of dietary supplementation, AH, on transcript levels of pro-inflammatory cytokines, and tight junction proteins and mucin protein in the jejunum, were quantified by quantitative real-time (qRT)-PCR. At day 20, birds fed with diet supplementation (3% of AH) significantly weighted more than the control group. Although the NE-challenged had significantly reduced average body weight gain, there was no significance in the effect between diet × NE-challenge interactions on the average body weight gain. Among the NE-challenged groups, gut lesion score and oocyst shedding were significantly decreased in birds given AH (1 or 3%) compared to the control group. There was a correlation between diet and NE infection with regards to interleukin (IL)-17A, and inducible nitric oxide synthase (iNOS). The up-regulated transcript levels of cytokines IL-8, IL-17A, iNOS, and LITAF by NE challenged groups were significantly reduced by AH (1 or 3%) supplementation. Down-regulated expression levels of tight junction (TJ) proteins: junctional adhesion molecule 2 (JAM2), occluding, and intestinal mucin 2 (MUC2) by NE challenge, was up-regulated by the addition of AH (1 or 3%) supplementation. All TJ proteins (JAM2, ZO1, Ocluddin and MUC2) in the jejunum had a significant diet × NE-challenge interaction. These findings demonstrate that dietary supplementation of AH in chicken feed could be beneficially used to improve chicken health against NE.

Seven Years of Experiences of Preclinical Experiments of Xeno-Heart Transplantation of Pig to Non-Human Primate (Cynomolgus Monkey)

BACKGROUND

The absolute shortage of donors compared with patients requiring transplantation is currently an unsolved problem, and the only possible solution may be xenotransplantation. To establish a successful clinical trial, a preclinical study using nonhuman primates is essential. Starting in November 2011, our team initiated heterotopic abdominal heart xenotransplantation, the first in the Republic of Korea. We present here the initial 7-year results.

METHODS

A total of 22 xenotransplantation procedures have been performed since 2011. Single transgenic pig (alpha-galactosidase transferase knockout [GalT KO], n = 16), double transgenic pig (GalT KO + CD46, n = 3, and GalT KO + CD39, n = 2), and triple transgenic pig (GalT KO + CD46 + CD70, n = 1) models were used. Our baseline regimen of immunosuppressants comprised CD154 ab, rituximab, anti-thymocyte globulin, tacrolimus, mycophenolate mofetil, and steroids.

RESULTS

The mean graft survival was 16 ± 16.27 days, and the mean graft survival was significantly longer in cases performed since 2014 (7.5 ± 8.03 days vs 24.67 ± 17.50; P = .01). Although the donor heart ischemic time was decreased per annum, no correlations could be found between ischemic time and survival days of the graft. Double or triple genetic manipulated hearts exhibited significantly better survival (11.63 ± 11.29 days vs 30.83 ± 20.34 days; P = .03). When the ratio of heart weight (grams) to nonhuman primate weight (kilograms) was lower, the results tended to be better (P < .05). The rate of immediate postoperative bleeding (9%, n = 2) causing death was relatively high in the earlier period, but there have been no serious surgical complications affecting graft survival since 2013.

CONCLUSIONS

Investigation of effective and optimal target genes for each organ to further progression toward better results is important. In addition, the immunosuppressive regimen needs to be further studied and constantly refined.