Framework for Accurate Classification of Self-Reported Stress From Multisession Functional MRI Data of Veterans With Posttraumatic Stress

Background: Posttraumatic stress disorder (PTSD) is a significant burden among combat Veterans returning from the wars in Iraq and Afghanistan. While empirically supported treatments have demonstrated reductions in PTSD symptomatology, there remains a need to improve treatment effectiveness. Functional magnetic resonance imaging (fMRI) neurofeedback has emerged as a possible treatment to ameliorate PTSD symptom severity. Virtual reality (VR) approaches have also shown promise in increasing treatment compliance and outcomes. To facilitate fMRI neurofeedback-associated therapies, it would be advantageous to accurately classify internal brain stress levels while Veterans are exposed to trauma-associated VR imagery. Methods: Across 2 sessions, we used fMRI to collect neural responses to trauma-associated VR-like stimuli among male combat Veterans with PTSD symptoms (N = 8). Veterans reported their self-perceived stress level on a scale from 1 to 8 every 15 s throughout the fMRI sessions. In our proposed framework, we precisely sample the fMRI data on cortical gray matter, blurring the data along the gray-matter manifold to reduce noise and dimensionality while preserving maximum neural information. Then, we independently applied 3 machine learning (ML) algorithms to this fMRI data collected across 2 sessions, separately for each Veteran, to build individualized ML models that predicted their internal brain states (self-reported stress responses). Results: We accurately classified the 8-class self-reported stress responses with a mean (± standard error) root mean square error of 0.6 (± 0.1) across all Veterans using the best ML approach. Conclusions: The findings demonstrate the predictive ability of ML algorithms applied to whole-brain cortical fMRI data collected during individual Veteran sessions. The framework we have developed to preprocess whole-brain cortical fMRI data and train ML models across sessions would provide a valuable tool to enable individualized real-time fMRI neurofeedback during VR-like exposure therapy for PTSD.

EUS-guided fiducial marker insertion for radiotherapy in advanced esophageal carcinoma: submucosal insertion may lead to less migration when compared to intratumoral insertion

BACKGROUND

The use of radiotherapy is frequently required in the treatment of locally advanced esophageal squamous cell carcinoma. However, the margins of the tumor are often difficult to ascertain on computed tomography. Thus, EUS-guided fiducial marker insertion can aid the localization of the margins of the tumor. However, the optimal technique of the procedure is still uncertain.

METHODS

This was a retrospective study of all patients that received EUS-guided fiducial marker insertion between March 2015 and December 2018. All patients suffering from esophageal squamous cell carcinoma scheduled for radiotherapy underwent the procedure within one week of the scheduled appointment. Gold fiducial markers were inserted under EUS guidance either intratumorally or within the submucosa just proximal and distal to the tumor. Outcome parameters included tumor characteristics, early and late migration rates, and tumor response rates.

RESULTS

During the study period, 40 patients were recruited. 10 fiducial markers were placed intratumorally and 30 markers were placed submucosally. When comparing fiducials that were placed in the submucosa versus intratumorally, significantly more fiducials had early (40% vs 0%, RR = 0.6, 95% CI 0.36, 1.00) and late migration (60% vs 0%, RR = 0.33, 95% CI 0.13, 0.84) in the intratumoral group. The submucosal group had significantly more patients intended for curative intent (96.7% vs 70%, RR = 0.34, 95%CI 0.003, 0.361) and more patients with partial and complete response. There was no difference between the gross tumor volume, the clinical target volume, and the total radiation dose.

CONCLUSION

In esophageal carcinomas planned for radiotherapy, fiducial markers placed in the submucosa may lead to less migration.

Prevalence and prognostic impact of comorbidities and peripheral blood indices in sarcomas

Background

The prognostic impact of comorbidities in patients with sarcomas is not well defined. The aims of this study were to examine the implications of comorbidities and abnormal peripheral blood indices in patients with sarcomas.

Methods

A population-based database was assembled to extract patients with sarcoma in Hong Kong between January 2004 and March 2018. Charlson’s Comorbidity Index (CCI) score and prevalence of comorbidities, neutrophil, lymphocyte and platelet counts at diagnosis were assessed. The prognostic values of CCI, neutrophil-lymphocyte (NLR) and platelet-lymphocyte ratios (PLR) were estimated using Cox proportional hazard models. Restricted cubic spline plots were used to explore the association of baseline NLR and PLR with all-cause and cancer-specific mortality.

Results

Among 3358 eligible patients with sarcomas, 52.2% died after a median 26 months of follow-up. The most common comorbidities were diabetes mellitus (9.8%) and cerebrovascular disease (4.8%). Patients with higher CCI had higher mortality (CCI=3 vs CCI=2; HR 1.49; 95% CI 1.19 to 1.87; p<0.01; CCI ≥7 vs CCI =2; HR 3.20; 95% CI 2.62 to 3.92; p<0.001). Abnormal NLR and PLR levels were associated with higher all-cause mortality (NLR: HR 1.698, p<0.001, 95% CI 1.424 to 2.025; PLR: HR 1.346, p<0.001, 95% CI 1.164 to 1.555) and cancer-related mortality (NLR: HR 1.648, p<0.001, 95% CI 1.341 to 2.024; PLR: HR 1.430, p<0.001, 95% CI 1.205 to 1.697).

Conclusions

This is the largest population-based soft-tissue or bone sarcoma cohort worldwide. Comorbidities have significant negative prognostic impact on the survival of patients with sarcomas. Moreover, NLR and PLR are robust prognostic factors, and abnormal NLR and PLR have negative effects yet non-linear effects on survival.

Abstract 3646: Synergistic activities of the histone deacetylase inhibitors with conventional cytotoxic chemotherapies in cutaneous angiosarcomas

Background:

Cutaneous Angiosarcoma (CAS) is a rare aggressive malignant tumour typically arising from skin or viscera. The incidence of AS appears more common in Asia, as compared with the West. The prognosis of patients (pts) advanced/inoperable CAS remains poor. The median PFS of first line systemic treatments of 3.8 months and overall survival (OS) of &lt;12 months. Histone deacetylases inhibitors (HDACi) are epigenetic agents which have shown anti-tumour effects as single-agents. In this study, we have shown synergism of panobinostat (LBH589) and vorinostat (SAHA) when combined with doxorubicin in a CAS cell line (ISO-HAS-B). The underlying molecular mechanisms of these findings have yet been explored.

Methods:

We investigated the potential effects of LBH589 and SAHA in ISO-HAS-B. IC50 of two pan-HDACi as single agents were tested, followed by synergism studies in combination with doxorubicin. Synergy effects were calculated by synergy-finder and evaluated by synergy score as follow scale: &lt; -10 (antagonistic); -10 to 10 (additive); &gt; 10 (synergistic).The cell death or cell growth inhibition were recorded by time lapse assay under microscope at 0, 24, 48 hours after treating with SAHA, doxorubicin (DOX) alone and in combination. The inhibitory effect on apoptosis pathway were studied by treating the ISO-HAS-B with two drugs alone and in combination at their respective IC50 concentrations for 48 hours. The detection of Caspase 3 and PARP by Western blotting was used to indicate apoptotic cell death.

Results:

IC50 of two pan-HDACi were determined by Graphpad PRISM 8.0. LBH589 and SAHA were shown to have anti-tumour effects and the combination of two pan-HDACi with doxorubicin showed synergistic growth inhibition than the single agents alone. A higher level of cell death can be seen in the combination of SAHA and DOX in ISO-HAS-B in a time-dependent manner .Cell shrinkage and pyknosis were visible by light microscopy after 48-hour treatment. Apoptosis was indicated by the increase level of cleaved PARP and Cleaved Caspase3, especially in the combination group from Western blot assays.

Conclusions:

The combination of SAHA and DOX induced higher level of apoptosis at 48h incubation. It significantly activated the apoptosis pathway by increasing the expression of Cleaved PARP and Cleaved Caspase3, which suggests its effectiveness in inhibition of protein synthesis. In-vivo experiments to validate these findings are currently on-going. Combination of HDACi and doxorubicin remains a promising treatment approach for CAS.

Citation Format: Yingjun Zhang, Connie Hui, Chi Hang Wong, Chi Tung Choy, Teresa Tse, Teresa Tan, Sampson Kwan, Qian Tao, Herbert Loong. Synergistic activities of the histone deacetylase inhibitors with conventional cytotoxic chemotherapies in cutaneous angiosarcomas [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3646.

Consensus statement on tumour bed localization for radiation after oncoplastic breast surgery

Background

Oncoplastic surgery (ops) is becoming the new standard of care for breast-conserving surgery, leading to some challenges with adjuvant radiation, particularly when accurate tumour bed (tbd) delineation is needed for focused radiation (that is, accelerated partial breast irradiation or boost radiation). Currently, no guidelines have been published concerning tbd localization for adjuvant targeted radiation after ops.

Methods

A modified Delphi method was used to establish consensus by a panel of 20 experts in surgical and radiation oncology at the Canadian Locally Advanced Breast Cancer National Consensus Group and in a subsequent online member survey.

Results

These are the main recommendations:■ Surgical clips are necessary and should, at a minimum, be placed along the 4 side walls of the cavity, plus 1-4 clips at the posterior margin if necessary.■ Operative reports should include pertinent information to help guide the radiation oncologists.■ Breast surgeons and radiation oncologists should have a basic understanding of ops techniques and work on "speaking a common language."■ Careful consideration is needed when determining the value of targeted radiation, such as boost, in higher-level ops procedures with extensive tissue rearrangement.

Conclusions

The panel developed a total of 6 recommendations on tbd delineation for more focused radiation therapy after ops, with more than 80% agreement on each statement. All are summarized, together with the corresponding evidence or expert opinion.

A randomized study of olanzapine-containing versus standard antiemetic regimens for the prevention of chemotherapy-induced nausea and vomiting in Chinese breast cancer patients

OBJECTIVES

Chemotherapy-induced nausea and vomiting (CINV) are distressing symptoms. This randomized study evaluated the antiemetic efficacies of standard antiemetic regimen with/without olanzapine.

PATIENTS AND METHODS

Eligible patients were chemotherapy-naive Chinese breast cancer patients who were planned for (neo)adjuvant doxorubicin/cyclophosphamide. Antiemetic regimen for all studied population included aprepitant, ondansetron and dexamethasone; patients were randomized to Olanzapine (with olanzapine) or Standard arms (without olanzapine). Patients filled in self-reported diaries and completed visual analogue scales for nausea, as well as Functional Living Index-Emesis questionnaires. Blood profiles including fasting glucose and lipids were monitored.

RESULTS

120 patients were randomized. In Cycle 1 doxorubicin/cyclophosphamide, the Olanzapine arm had significantly higher rates of "Complete Response" than the Standard arm: 65.0% vs 38.3% in the overall period (p = 0.0035), 70.0% vs 51.7% in the acute period (p = 0.0397) and 92.9% vs 74.2% in the delayed period (p = 0.0254). Olanzapine arm also had significantly higher rates of "No significant nausea" and "No nausea" during all 3 time-frames and better QOL. Similar findings were also revealed throughout multiple cycles. Pre-study abnormalities in glucose and lipids occurred in 39.7% and 34.2% of the studied population respectively; there were no differences in these parameters between the two arms at end-of-study assessment.

CONCLUSION

The addition of olanzapine to standard aprepitant-based antiemetic regimen provides clinically meaningful improvement in controlling CINV. This was associated with a positive impact on QOL and tolerable toxicity profiles among Chinese breast cancer patients receiving doxorubicin/cyclophosphamide chemotherapy. Further studies on metabolic profiles of breast cancer patients are warranted.

Controversies and consensus of neoadjuvant chemotherapy in soft-tissue sarcomas

Together with surgery and radiotherapy, systemic treatment with cytotoxic chemotherapy and molecular targeted agents is one of the main therapeutic pillars in the treatment of soft-tissue sarcomas and is the mainstay of treatment in patients with advanced or metastatic disease. Unlike other more common malignancies such as breast and colorectal cancer, the role of chemotherapy when used in the adjuvant setting in soft-tissue sarcomas is less well defined. Results from prior studies have been conflicting, in part due to the heterogeneity and rarity of the disease, and large-scale meta-analysis has been performed to address this issue. Neoadjuvant chemotherapy, defined as the use of chemotherapy before definitive treatment with surgery or radiotherapy, has distinct theoretical and practical advantages, which can potentially be beneficial to the patient. However, the currently available evidence to support its use is even more scarce. In this review article, we describe the current established data behind the use of adjuvant chemotherapy in selected patients with localised soft-tissue sarcomas and, through extrapolation of available data, discuss the potential role of it when used in the upfront setting.

A Novel Experimental and Analytical Approach to the Multimodal Neural Decoding of Intent During Social Interaction in Freely-behaving Human Infants

Understanding typical and atypical development remains one of the fundamental questions in developmental human neuroscience. Traditionally, experimental paradigms and analysis tools have been limited to constrained laboratory tasks and contexts due to technical limitations imposed by the available set of measuring and analysis techniques and the age of the subjects. These limitations severely limit the study of developmental neural dynamics and associated neural networks engaged in cognition, perception and action in infants performing “in action and in context”. This protocol presents a novel approach to study infants and young children as they freely organize their own behavior, and its consequences in a complex, partly unpredictable and highly dynamic environment. The proposed methodology integrates synchronized high-density active scalp electroencephalography (EEG), inertial measurement units (IMUs), video recording and behavioral analysis to capture brain activity and movement non-invasively in freely-behaving infants. This setup allows for the study of neural network dynamics in the developing brain, in action and context, as these networks are recruited during goal-oriented, exploration and social interaction tasks.

Decoding of intentional actions from scalp electroencephalography (EEG) in freely-behaving infants

The mirror neuron system (MNS) in humans is thought to enable an individual's understanding of the meaning of actions performed by others and the potential imitation and learning of those actions. In humans, electroencephalographic (EEG) changes in sensorimotor a-band at central electrodes, which desynchronizes both during execution and observation of goal-directed actions (i.e., μ suppression), have been considered an analog to MNS function. However, methodological and developmental issues, as well as the nature of generalized μ suppression to imagined, observed, and performed actions, have yet to provide a mechanistic relationship between EEG μ-rhythm and MNS function, and the extent to which EEG can be used to infer intent during MNS tasks remains unknown. In this study we present a novel methodology using active EEG and inertial sensors to record brain activity and behavioral actions from freely-behaving infants during exploration, imitation, attentive rest, pointing, reaching and grasping, and interaction with an actor. We used 5-band (1-4Hz) EEG as input to a dimensionality reduction algorithm (locality-preserving Fisher's discriminant analysis, LFDA) followed by a neural classifier (Gaussian mixture models, GMMs) to decode the each MNS task performed by freely-behaving 6-24 month old infants during interaction with an adult actor. Here, we present results from a 20-month male infant to illustrate our approach and show the feasibility of EEG-based classification of freely occurring MNS behaviors displayed by an infant. These results, which provide an alternative to the μ-rhythm theory of MNS function, indicate the informative nature of EEG in relation to intentionality (goal) for MNS tasks which may support action-understanding and thus bear implications for advancing the understanding of MNS function.

Paediatric burn prevention: An epidemiological approach

OBJECTIVE

To study the mechanism of burn in hospitalized paediatric burn patients in order to develop a focused burn prevention campaign.

METHODS

Acute paediatric burn patients were identified from the unit admission records. Detailed medical records were reviewed to identify the key demographic and management information including the country of residence, age, gender, extent of injury, specific treatment and hospital stay. Parents were then contacted to provide detailed information about the mechanism of the accident, first aid given, living density and parent's educational level.

RESULTS

Two hundred and eighty-four admissions were identified in a 5-year period. Two hundred and twenty-four of these patients came from a defined regional population served by the hospital. The median age of patients was 3 and male to female ratio 1:0.74. The most common age group for burns was 1-2 years. The most common type of burns were scalds. Domestic burns accounted for 84.7% of admissions. Median burn area was 4% of the total body surface area with a range of 0.2-45%. Fifty percent of patients had no first aid treatment prior to presentation at the hospital. More accidents happened in homes with a high living density and the majority of parents had both completed secondary education. The most dangerous location in the house was the living room, followed by the bathroom, kitchen then bedroom. The majority of burns were related to hot drinks, followed by hot food and then bathing.

CONCLUSION

Detailed investigation of burn incidents can reveal repeated mechanisms of injury, which direct the focus of preventive strategies.

Usability issues in developing a Web-based consumer health site

ClinicalTrials.gov is a Web-based system intended for a diverse audience, including patients, family members and other members of the public. Throughout the system design and development process, our decisions have been driven by usability concerns. We first describe the overall design of the site, including the home page, which provides a site overview and rapid access to the information contained within it. Next we discuss the data presentation format which has been standardized in spite of data coming to us from many different sources. We provide a detailed description of the search and browse features that are intended to simplify the complexities of medical terminology and support information discovery. We conclude with a review of our evaluation activities and future plans.

Initiating a drug blood level monitoring program through CQI

A blood level monitoring program was developed at St. James Hospital and Health Centers--a 472-bed community hospital located in Chicago Heights, IL. The primary goal of the program was to improve patient care by ensuring that drug levels were within their target range for the condition being treated. Additional benefits obtained from the program included meeting Joint Commission on Accreditation of Healthcare Organization's standards for medication monitoring and generating additional revenue for the institution from pharmacokinetic consults. Highlights of the service and its implementation are presented in this article.

Strategic planning for the management of biotechnologic products: development of a biotech committee

Strategies and tactics for managing biotechnologic products are critical to cope with the increasing number and cost of such products. One strategy is to develop a biotech committee to formulate long-term goals for managing biotechnologic products and to evaluate controversial or extremely expensive new products and recommend their formulary status to the P & T Committee. Involvement of the P & T Committee is crucial to establish strict criteria and monitors to ensure the appropriate and cost-effective use of these products. Involvement of the pharmacy department is also essential to detect usage patterns and reimbursement profiles of approved biotechnologic products in the hospital, as well as their potential financial impact on the hospital's budget.