Radioactive seed localization is a safe and effective tool for breast cancer surgery: an evaluation of over 25,000 cases

Radioactive seed localization (RSL) provides a precise and efficient method for removing non-palpable breast lesions. It has proven to be a valuable addition to breast surgery, improving perioperative logistics and patient satisfaction. This retrospective review examines the lessons learned from a high-volume cancer center's RSL program after 10 years of practice and over 25 000 cases. We provide an updated model for assessing the patient's radiation dose from RSL seed implantation and demonstrate the safety of RSL to staff members. Additionally, we emphasize the importance of various aspects of presurgical evaluation, surgical techniques, post-surgical management, and regulatory compliance for a successful RSL program. Notably, the program has reduced radiation exposure for patients and medical staff.

Early-Onset Pancreatic Neuroendocrine Tumors: Clinical Presentation, Pathology Features, and Oncological Outcomes

BACKGROUND

Early-Onset (EO) pancreatic neuroendocrine tumor (PanNET) is a rare disease, but whether it is clinically different from late-onset (LO) PanNET is unknown. Our study aimed to evaluate clinical differences and disease outcomes between EO-PanNET and LO-PanNET and to compare sporadic EO-PanNET with those with a hereditary syndrome.

METHODS

Patients with localized PanNET who underwent pancreatectomy at Memorial Sloan Kettering between 2000 and 2017 were identified. Those with metastatic disease and poorly differentiated tumors were excluded. EO-PanNET was defined as <50 and LO-PanNET >50 years of age at the time of diagnosis. Family history and clinical and pathology characteristics were recorded.

RESULTS

Overall 383 patients were included, 107 (27.9%) with EO-PanNET. Compared with LO-PanNET, EO-PanNET were more likely to have a hereditary syndrome (2.2% vs. 16%, P <0.001) but had similar pathology features such as tumor grade ( P =0.6), size (2.2 Vs. 2.3 cm, P =0.5) and stageof disease ( P =0.8). Among patients with EO-PanNET, those with hereditary syndrome had more frequently a multifocal disease (65% vs. 3.3%, P <0.001). With a median follow-up of 70 months (range 0-238), the 5-year cumulative incidence of recurrence after curative surgery was 19% (95% CI 12%-28%) and 17% (95% CI 13%-23%), in EO-PanNET and LO-PanNET ( P =0.3). Five-year disease-specific survival was 99% (95% CI 98%-100%) with no difference with respect to PanNET onset time ( P =0.26).

CONCLUSIONS

In this surgical cohort, we found that EO-PanNET is associated with hereditary syndromes but has pathologic characteristics and oncological outcomes similar to LO-PanNET. These findings suggest that patients with EO-PanNET can be managed similarly to those with LO-PanNET.

Rapid expansion of Neisseria gonorrhoeae ST7827 clone in Australia, with variable ceftriaxone phenotype unexplained by genotype

BACKGROUND

Neisseria gonorrhoeae is identified as a priority pathogen due to its capacity to rapidly develop antimicrobial resistance (AMR). Following the easing of SARS-CoV-2 pandemic travel restrictions across international borders in the state of New South Wales (NSW), Australia, a surge of gonococcal isolates with raised ceftriaxone MIC values were detected.

METHODS

All N. gonorrhoeae isolates (n = 150) with increased ceftriaxone MIC values in NSW between 1 January 2021 and July 2022 from males and females from all sites were sequenced.

RESULTS

A new emergence and rapid expansion of an N. gonorrhoeae ST7827 clone was documented within NSW, Australia and provides further evidence of the ability of N. gonorrhoeae to undergo sufficient genomic changes and re-emerge as a geographically restricted subclone. Mapping AMR determinants to MIC results did not reveal any genomic pattern that correlated with MIC values.

CONCLUSIONS

The rapid dissemination and establishment of this clone at the population level is a new and concerning demonstration of the agility of this pathogen, and underscores concerns about similar incursions and establishment of MDR clones. Moreover, it is notable that in this context the AMR genotype-phenotype correlates remain unclear, which requires further investigation to enable better understanding of genomic aspects of AMR in N. gonorrhoeae.

Simultaneous Measurement of Muon Neutrino ν_{μ} Charged-Current Single π^{+} Production in CH, C, H_{2}O, Fe, and Pb Targets in MINERvA

Neutrino-induced charged-current single π^{+} production in the Δ(1232) resonance region is of considerable interest to accelerator-based neutrino oscillation experiments. In this Letter, high statistic differential cross sections are reported for the semiexclusive reaction ν_{μ}A→μ^{-}π^{+}+ nucleon(s) on scintillator, carbon, water, iron, and lead targets recorded by MINERvA using a wideband ν_{μ} beam with ⟨E_{ν}⟩≈6  GeV. Suppression of the cross section at low Q^{2} and enhancement of low T_{π} are observed in both light and heavy nuclear targets compared with phenomenological models used in current neutrino interaction generators. The cross sections per nucleon for iron and lead compared with CH across the kinematic variables probed are 0.8 and 0.5 respectively, a scaling which is also not predicted by current generators.

Telehealth experiences in Canadian veterans: associations, strengths and barriers to care during the COVID-19 pandemic

INTRODUCTION

Identifying barriers to care in veteran populations is critical, as veterans face increased social isolation, relationship strains and financial insecurities. For Canadian veterans experiencing barriers to accessing healthcare, telehealth may be a promising alternative with comparable effectiveness to in-person services; however, the potential benefits and limitations of telehealth require further examination to determine its long-term utility, and to inform health policy and planning. The goal of the present research was to identify predictors and barriers to telehealth usage in Canadian veterans in the context of the COVID-19 pandemic.

METHODS

Data were drawn from baseline data of a longitudinal survey examining the psychological functioning of Canadian veterans during the COVID-19 pandemic. Participants were 1144 Canadian veterans aged 18-93 years (M_age=56.24, SD=12.92; 77.4% men). We assessed reported telehealth use (ie, for mental healthcare, physical healthcare), healthcare access (ie, difficulty accessing care, avoidance of care) and mental health and stress since the beginning of the COVID-19 pandemic, sociodemographic variables and open-ended responses about telehealth experiences.

RESULTS

Findings suggest that sociodemographic factors and previous telehealth use were significantly associated with telehealth use during the COVID-19 pandemic. Qualitative evidence highlighted both the benefits (eg, reducing barriers of access) and drawbacks (eg, not all services can be delivered) of telehealth services.

CONCLUSIONS

This paper provided a deeper understanding of Canadian veterans' experiences with accessing telehealth care during the COVID-19 pandemic. While for some, the use of telehealth mitigated perceived barriers (eg, safety concerns of leaving home), others felt that not all health services could be appropriately carried out through telehealth. Altogether, findings support the use of telehealth services in increasing care accessibility for Canadian veterans. Continued use of quality telehealth services may be a valuable form of care that extends the reach of healthcare professionals.

Antibody landscape of C57BL/6 mice cured of B78 melanoma via immunotherapy

Hoefges et al. utilized a whole-proteome peptide array approach to show that C57BL/6 mice develop a large repertoire of antibodies against linear peptide sequences of their melanoma after receiving a curative immunotherapy regimen consisting of radiation and an immunocytokine. Antibodies can play an important role in innate and adaptive immune responses against cancer, and in preventing infectious disease. Flow cytometry analysis of sera of immune mice that were previously cured of their melanoma through a combined immunotherapy regimen with long-term memory showed strong antibody-binding against melanoma tumor cell lines. Using a high-density whole-proteome peptide array, we assessed potential protein-targets for antibodies found in immune sera. Sera from 6 of these cured mice were analyzed with this high-density, whole-proteome peptide array to determine specific antibody-binding sites and their linear peptide sequence. We identified thousands of peptides that were targeted by 2 or more of these 6 mice and exhibited strong antibody binding only by immune, not naive sera. Confirmatory studies were done to validate these results using 2 separate ELISA-based systems. To the best of our knowledge, this is the first study of the "immunome" of protein-based epitopes that are recognized by immune sera from mice cured of cancer via immunotherapy.

Suggestions for modifications to the Female Sexual Function Index based on cognitive interviews with sexual and gender minority individuals and cisgender, heterosexual persons

BACKGROUND

Patient-reported outcome measures for sexual health were often designed for research studies that included only heterosexual, partnered, and cisgender participants; as such, they may have limited applicability for clinical use among sexual and gender minority (SGM) individuals or those without a partner.

AIM

We aimed to conduct cognitive interviews with SGM persons and heterosexual women to determine the readability, comprehension, and applicability of questionnaire items to assess sexual function among diverse sexual and gender identities.

METHODS

We conducted 4 rounds of cognitive interviews with 52 participants (28 SGM; 24 cisgender, heterosexual) who provided feedback on the comprehension and wording of questionnaire items and response scales. We used items from the Female Sexual Function Index (FSFI) and focused on establishing content validity of a modified measure. Participants made recommendations for changes to the questionnaire, which was iteratively revised between interview rounds. Two independent coders analyzed the transcripts using structural coding based on 5 predefined codes: satisfaction with item, specificity/language change needed, missing/suggested item, patient definitions of concepts, and confusion with item.

OUTCOMES

Content validity.

RESULTS

After 3 rounds of cognitive interviews and revisions to the questionnaire, participants found the final version acceptable and understandable, thereby reaching thematic saturation and establishing content validity of the modified FSFI. Modifications included the following: replacing all instances of "sexual stimulation" and "intercourse" with "sexual activity (alone or with a partner)," broadening the definition of "vaginal penetration" beyond penile-vaginal penetration, and adding skip logic to include the option "no sexual activity." Participants identified missing concepts important to their sexual health, such as use of an external lubricant.

CLINICAL IMPLICATIONS

The FSFI and similar questionnaires need to be adapted to broader clinical practice populations such that all persons' experiences are accurately reflected and assessed, ensuring that sexual health needs can be met more inclusively.

STRENGTH AND LIMITATIONS

A strength of the study was using cognitive interviews engaging patient perspectives, which is considered the gold standard for establishing content validity. One limitation is that participants included predominantly White and highly educated women.

CONCLUSION

Feedback from interviews supports modifying FSFI items and further psychometric testing, and future studies should evaluate the measure among racially and educationally diverse groups.

Patient Perceptions of a Decision Support Tool for Men with Localized Prostate Cancer

Purpose. To evaluate patient perceptions of a Web-based decision aid for the treatment of localized prostate cancer. Methods. We assessed patient perceptions of a multicomponent, Web-based decision aid with a preference elicitation/values clarification exercise using adaptive conjoint analysis, the generation of a summary report, and provision of information about localized prostate cancer treatment options. Using a think-aloud approach, we conducted 21 cognitive interviews with prostate cancer patients presented with the decision aid prior to seeing their urologist. Thematic content analysis was used to examine patient perceptions of the tool's components and content prior to engaging in shared decision making with their clinician. Results. Five themes were identified: 1) patients had some negative emotional reactions to the tool, pointing out what they perceived to be unnecessarily negative framing and language used; 2) patients were forced to stop and think about preferences while going through the tool and found this deliberation to be useful; 3) patients were confused by the tool; 4) patients tried to discern the intent of the conjoint analysis questions; and 5) there was a disconnect between patients' negative reactions while using the tool and a contrasting general satisfaction with the final "values profile" created by the tool. Conclusions. Studies are needed to explore the disconnect between patients' expressing negative reactions while going through some components of decision aids but satisfaction with the final output. In particular, we hypothesize that this effect might be explained by cognitive biases such as choice-supportive bias, hindsight bias, and the "IKEA effect." This is one of the first projects to elicit patient reactions while they were completing a decision aid, and we recommend further similar, qualitative postprocess evaluation studies.

Highlights

We explored perceptions of a decision aid with education about localized prostate cancer treatment and preference elicitation using adaptive conjoint analysis.Patients found the tool useful but were also confused by it, tried to discern the intent of the questions, and expressed negative emotional reactions.In particular, there was a disconnect between patients' negative reactions while using the tool and general satisfaction with the final values profile generated by the tool, which is an area for future research.

What are the ideal systolic and diastolic blood pressure which do not injure the intima of iliac and coronary arteries?

 

For patients with coronary artery disease, hypertension (HTN) is a major risk factor. How could uncontrolled HTN start atherosclerosis? In our prior research, laminar flow in coronary arteries prevented the formation of plaques while turbulent flow injured the intima and triggered atherosclerosis. In this present study our question was: Which blood pressure (BP) level is optimal in not producing turbulence and so not injuring the intima?

Methods

At first, a systolic BP&lt;120mmHg and diastolic BP&lt;75mmHg) were arbitrarily set as controlled (group A) while a BP of &gt;160/105mmHg as uncontrolled (group B). All patients underwent a dynamic coronary angiogram recorded at 15 images/second or 0.06 seconds per image. The first image was of the index artery completely filled with contrast. In subsequent images the blood in white color moved in over a background of black contrast (Figure 1A). In 1B, 0.06 seconds later, the blood arrived at the mid segment (white arrow). In 1C, the flood moved forward, however there was darker contrast hanging at the mid segment, marking the location of collision from the retrograde against the antegrade flow (white arrow). The reason was that in uncontrolled BP the contraction of the left ventricle was stronger so in systole, the coronary blood could reverse its course, run on a retrograde direction, collide against the antegrade flow and create turbulence (1C).

At the end, before deploying a vascular closure device, an iliac angiogram was performed. In Figure 2, on a black background of contrast, the blood in white color moved forward with a pointed tip of laminar flow. 0.06 seconds later, the laminar tip was stopped abruptly with all the layers recoiling on each other like a falling stack of dominoes. In the next image. a large swirl of disorganized mixing of blood and contrast suggested the presence of turbulence caused by the collision.

The data to be collected were (1) the duration of the antegrade and retrograde flow, (2) duration of the collision (turbulence at the collision site)

Results

In the group A (BP &lt;120/75 mmHg), 90% of 20 patients had no retrograde flow nor collision in the iliac and short collision in coronary arteries (&lt;0.12 secs). In 30 patients of group B (BP &gt;160/105 mmHg), the duration of retrograde flow and collision in the iliac artery were prolonged at &gt;0.24 msecs. In the coronary arteries, the duration was prolonged at 0.18 msecs (all p&lt;0.05 compared with group A). These locations of turbulence correlated with the location of plaques in our prior studies.

Conclusion

In patients with uncontrolled HTN, the retrograde flow was prolonged, and the turbulence was intense. In contrary, for patients with controlled BP, there was no retrograde flow and weaker collision in coronary arteries. The results suggest that a BP of &lt;120/75 mmHg may not trigger the atherosclerotic process. New clinical trials with larger number of patients should be performed in search for the lowest ideal blood pressure.

Funding Acknowledgement

Type of funding sources: None.

A Randomized Trial Evaluating Patient Experience and Preference Between Octreotide Long-Acting Release and Lanreotide for Treatment of Well-Differentiated Neuroendocrine Tumors

PURPOSE

Somatostatin analogs octreotide long-acting release (octLAR) and lanreotide are equally acceptable in National Comprehensive Cancer Network guidelines for neuroendocrine tumors (NETs). Lanreotide is more expensive and given by deep subcutaneous injection, whereas octLAR is given intramuscularly. We evaluated patient preference between these agents in terms of injection site pain.

MATERIALS AND METHODS

Randomized, single-blinded study. Patients with NETs received injections every 4 weeks. Arm 1: octLAR × 3, then lanreotide × 3; arm 2: reverse order. Self-reported injection site pain scores (range, 0-10) were obtained after each of the first three injections. Primary end point was comparison of mean pain scores over the first three injections. Secondary end points included patient-reported preference.

RESULTS

Fifty-one patients enrolled (26 in arm 1 and 25 arm 2), all evaluable for primary end point. No significant difference was identified in the mean pain score over the first three injections (2.4 ± 1.9 v 1.9 ± 1.5, P = .5). Thirty-four of 51 (67%) patients (15 in arm 1 and 19 in arm 2) completed post-therapy questionnaires and were evaluable for secondary end points. Seven patients (47%) in arm 1 and eight patients (42%) in arm 2 indicated no drug preference at the end of treatment. In the other 19 patients, more patients indicated mild or strong preference for octLAR over lanreotide.

CONCLUSION

We found minimal pain with octLAR and lanreotide and no significant pain score differences between the two. Patients indicating a drug preference trended toward favoring octLAR.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Understanding Caregiver Perspectives on an Electronic Consultation and Referral System

This study examined caregiver impressions of an electronic consultation and referral (ECR) system. Participants included 56 caregivers of primary care patients referred through the ECR system. Semistructured interviews and surveys were conducted between August 2018 and April 2019. Transcripts were coded and themes developed using thematic content analysis. A total of 51% of caregivers stated that they would prefer to see their child's primary care provider (PCP) for a specialty issue if they could receive the same quality of care. All caregivers who received an electronic consult (n = 28) said that they would utilize that process again. Three themes emerged: (1) caregivers expect immediate action prior to or instead of a specialty referral; (2) caregiver preferences for PCP versus specialist are mediated by both child and provider characteristics; (3) caregiver attitudes toward the ECR system are influenced by external considerations and experiences with the system. Results suggest caregivers value enhanced communication and immediate access to specialty input facilitated by the ECR system.

Early-onset well differentiated pancreatic neuroendocrine tumors: Clinical presentation, pathologic features, and oncological outcomes

507

Background: Young onset of several gastrointestinal cancers is associated with more advanced disease and poor oncological outcomes, however, this association has not been fully investigated for well differentiated pancreatic neuroendocrine tumors (PanNET). Our study aimed to evaluate clinical and pathological differences as well as disease outcomes between young-onset PanNET (YO-PanNET) and late-onset PanNET (LO-PanNET). Methods: Patients with localized PanNET who underwent surgery at Memorial Sloan Kettering Cancer Center between 2000 to 2017 were identified. Those with hereditary syndromes, metastatic disease, and postoperative mortality were excluded. YO-PanNET was defined as <50 and LO-PanNET >50 years of age at time of diagnosis. Family history, clinical and pathology characteristics, were recorded. Fisher’s exact test was used to detect difference between the age groups. Kaplan-Meier method was used to investigate age prognostic significance. Results: A total of 366 patients were identified, 84 (23%) with YO-PanNET. Compared with LO-PanNET, YO-PanNET were less likely to have a personal history of another cancer (p<0.001) and a first-line relative with cancer (p<0.015). We did not observe any significant differences between YO-PanNET and LO-PanNET with regards to pathology features such as tumor grade (p=0.7), size (p=0.5), nodal metastases (p=0.8), and stage of disease (p=0.7). With a median follow-up of 68 months (range 0-238), 5-year recurrence-free survival was 76% and 83%, and 10-year RFS was 69% and 78%, respectively, in YO-PanNET and LO-PanNET (p=0.12; see Table) with similar 5- and 10-year overall survival (p=0.31). Conclusions: In this large retrospective surgical series, we found that YO-PanNET is not associated with an increased rate of personal or familial history of cancer. Pathological characteristics and long-term oncological outcomes do not significantly differ between YO-PanNET and LO-PanNET. Current efforts include next-generation sequencing analysis in the resected surgical specimens to evaluate for genomic biomarkers of recurrence.[Table: see text]

Treatment response and clinical outcomes of neuroendocrine neoplasms treated with immune checkpoint inhibitors: A single-institution experience

506

Background: Immune checkpoint inhibitors (ICIs) have antitumor activity in some solid tumors, however a role for ICI’s in the treatment of neuroendocrine neoplasms (NENs) is uncertain. We analyzed response and outcomes of NENs, both well differentiated neuroendocrine tumors (WDNET) and poorly differentiated neuroendocrine carcinomas (PDNEC), treated with ICIs at Memorial Sloan Kettering Cancer Center during the past decade. Methods: Patients with NENs who received ICIs between 2010-2021 were identified. Demographics, pathology characteristics, treatment response and outcomes were recorded. Progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan-Meier methods. Analysis of next-generation sequencing (NGS) results from archival tumor tissue was performed. Results: 57 patients with NENs treated with ICIs were identified (WDNET-16; PDNEC-41). All patients had heavily-treated metastatic disease (median number of prior systemic treatments, WDNET-4, PDNEC-2). Median time from diagnosis to ICI treatment was 41.5 months in WDNET, 8 months in PDNEC. WDNET response: 1 (6%) partial response (PR), 4 (25%) stable disease (SD), 10 (63%) progressive disease (PD). PDNEC response: 6 (15%) PR (5 microsatellite stable, 1 unknown), 3 (7%) SD, 32 (78%) PD. Median duration of ICI treatment: 2 months (range 0-27) in WDNET, 1 month (range 0-16) in PDNEC; median duration of treatment for the 7 responders was 11 months (range 2-27). While receiving ICIs, 3 PDNEC responders developed PD in an escape lesion (2 brain, 1 nodal) after response in all other disease sites and successfully continued ICI treatment post-RT of escape lesion. Six-month PFS was 20% [95%CI: 7%-55%] and 9.8% [95%CI: 4%-25%], OS 60% [95%CI: 40%-91%] and 37% [95%CI: 25%-56%], respectively in WDNET and PDNEC. NGS results were available in archival tumor tissue of 35 patients (61%); most common alterations were TP53 (20/26, 77%) and RB1 (14/26, 54%) in PDNEC versus ATM, SMAD4, CREBBP, and IRS2 (all 1/9, 11%) in WDNET. Conclusions: We observed limited activity for ICI’s in NEN treatment, primarily restricted to a subset of PDNEC. PFS/OS findings were consistent with historical data, reflecting the pathogenesis of distinct NEN subtypes.

Treatment Response and Clinical Outcomes of Well-Differentiated High-Grade Neuroendocrine Tumors to Lutetium-177-DOTATATE

INTRODUCTION

Lutetium-177 (177Lu)-DOTATATE received FDA approval in 2018 to treat somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (NETs). Little data are available on response and outcomes for well-differentiated (WD) high-grade (HG) NETs treated with 177Lu-DOTATATE.

MATERIALS AND METHODS

Patients with WD HG NETs treated with 177Lu-DOTATATE at MSK from 2018 to 2020 were identified. Demographics, response (RECIST 1.1), and progression-free survival (PFS) were determined. Next-generation sequencing (NGS) was performed in the archival tumor.

RESULTS

Nineteen patients, all with progressive, heavily treated disease, were identified. Sites of tumor origin were: pancreas (74%), small bowel (11%), rectum (11%), and lung (5%); median Ki-67 was 32% (range 22-56). Thirteen patients (68%) completed all four 177Lu-DOTATATE cycles. Best response (N = 18 evaluable) was: 5/18 (28%) partial response, 8/18 (44%) stable disease, and 5/18 (28%) disease progression. Median PFS was 13.1 months (95% CI: 8.7-20.9). Most common treatment-related toxicities were thrombocytopenia (9 patients, 47%; G3/4, 1 patient, 5%), anemia (7 patients, 37%; G3/4, 2 patients, 11%), leukopenia (6 patients, 32%; G3/4, 0 patients), and liver function test elevation (4 patients, 21%; G3/4, 0 patients). NGS results were available from 13/19 tumors (68%). The most observed alterations were in MEN1 (6/13, 46%) and DAXX (4/13, 31%). No RB1 alterations identified.

CONCLUSION

We observed a meaningful disease control rate of 72% during treatment of WD HG NETs with 177Lu-DOTATATE. In this heavily pre-treated population, more than half of patients received all four treatment cycles with toxicities largely bone marrow-related. As would be expected in WD NETs, the vast majority had alterations in chromatin remodeling genes and no RB1 alterations.

Socio-demographic factors related to parent engagement in the NICU and the impact of the SENSE program

BACKGROUND

Early parent engagement in the neonatal intensive care unit (NICU) is important for both parent and infant mental health and for improving developmental outcomes. It remains unclear how different programs, such as the Supporting and Enhancing NICU Sensory Experiences (SENSE) program, may empower parents from various socio-demographic groups to engage in the NICU. An improved understanding could aid in individualizing interventions for those at the highest risk for health disparities.

AIMS

This exploratory study, which was part of a larger study, sought to explore 1) socio-demographic factors related to parent presence and engagement in the NICU and 2) if the SENSE program related to increased parent presence and engagement among different socio-demographic groups.

METHODS

Seventy parent-infant dyads (born ≤ 32 weeks gestation) were randomized to SENSE programming (parent education and age-appropriate, positive sensory interventions for parents to conduct with their infants every day of hospitalization) or standard care after admission to the NICU. The amount of parent presence and participation in sensory activities was tracked using bedside logs, nursing records, and research team documentation.

RESULTS

Being married (p = 0.048; p = 0.01), having private insurance (p < 0.001; p = 0.01), and having fewer children (p = 0.004; p = 0.03) related to more parent presence and engagement respectively. Parents who were Black had less presence and engagement in the NICU (p = 0.04; p = 0.02). Participation in the SENSE program was related to more parent presence and engagement among younger mothers (p = 0.002; p ≤0.001) and among parents living farther distances from the hospital (p < 0.001; p = 0.004).

CONCLUSION

Programming, such as the SENSE program, can improve parent engagement in the NICU among high-risk groups.

Colony-stimulating factor 3 receptor gene (CSF3R) T618I mutated chronic myelomonocytic leukemia: A proliferative subtype with a distinct mutational profile

Introduction/Objective

Chronic myelomonocytic leukemia (CMML) is a myeloid neoplasm characterized by sustained monocytosis, ranging from cytopenia with a dysplastic subtype to leukocytosis with a proliferative subtype, with a typical mutational profile involving TET2, ASXL1, and SRSF2. Mutation in colony-stimulating factor 3 receptor gene (CSF3R) is commonly associated with chronic neutrophilic leukemia (CNL) but exceedingly rare in CMML, particularly CSF3R T618I (~10 cases described, ~30 cases of CSF3R non-T618I mutations). We report a case of CSF3R T618I mutated CMML and compare the clinicopathologic features to reported CMML cases with and without CSF3R T618I mutations.

Methods/Case Report

A 27-year-old woman presented for evaluation of leukocytosis, sustained monocytosis, and anemia. Peripheral blood (PB) revealed leukocytosis (white cell count 35x109/L), left-shifted and dysplastic neutrophils (myelocytes and metamyelocytes, 5%), absolute and relative monocytosis (7x109/L, 29%), anemia (Hgb 4.3 g/dL), and thrombocytopenia. Bone marrow aspirate and core biopsy demonstrated a hypercellular marrow with increased myeloblasts (~3%, immunophenotypically aberrant by flow cytometry), increased myelomonocytic cells, and multilineage dysplasia, including ring sideroblasts and hypolobated megakaryocytes. Cytogenetic and molecular studies revealed a normal karyotype and mutations in CSF3R T618I, ASXL1, SETBP1, BCORL1, KRAS, and PTPN11. Despite the presence of a CSF3R T618I mutation, CMML was diagnosed given marked monocytosis, left- shifted neutrophils in PB, multilineage dysplasia, and immunophenotypically aberrant myeloblasts.

Results (if a Case Study enter NA)

NA

Conclusion

Our case demonstrates clinicopathological features similar to those of reported CSF3R T618I mutated CMML, i.e., a proliferative subtype and less likely to have co-occurring mutations in TET2 or SRSF2, which is distinct from CSF3R non-T618I mutated CMML; the latter often has a dysplastic subtype and mutational profile of frequent TET2 and SRSF2 mutations, similar to CSF3R unmutated CMML. While additional cases with this unusual mutation need to be studied to arrive at a more definitive conclusion, the CSF3R T618I mutation seems to define a unique proliferative subtype CMML with a distinct mutational profile.

Core-binding factor leukemia hijacks the T-cell-prone PU.1 antisense promoter

The blood system serves as a key model for cell differentiation and cancer. It is orchestrated by precise spatiotemporal expression of crucial transcription factors. One of the key master regulators in the hematopoietic systems is PU.1. Reduced levels of PU.1 are characteristic for human acute myeloid leukemia (AML) and are known to induce AML in mouse models. Here, we show that transcriptional downregulation of PU.1 is an active process involving an alternative promoter in intron 3 that is induced by RUNX transcription factors driving noncoding antisense transcription. Core-binding factor (CBF) fusions RUNX1-ETO and CBFβ-MYH11 in t(8;21) and inv(16) AML, respectively, activate the PU.1 antisense promoter that results in a shift from sense toward antisense transcription and myeloid differentiation blockade. In patients with CBF-AML, we found that an elevated antisense/sense transcript and promoter accessibility ratio represents a hallmark compared with normal karyotype AML or healthy CD34+ cells. Competitive interaction of an enhancer with the proximal or the antisense promoter forms a binary on/off switch for either myeloid or T-cell development. Leukemic CBF fusions thus use a physiological mechanism used by T cells to decrease sense transcription. Our study is the first example of a sense/antisense promoter competition as a crucial functional switch for gene expression perturbation by oncogenes. Hence, this disease mechanism reveals a previously unknown Achilles heel for future precise therapeutic targeting of oncogene-induced chromatin remodeling.

Normal ranges of global left ventricular myocardial work indices in adults: a meta-analysis

Background

Non-invasive global myocardial work recently emerged as new parameter to characterize left ventricle function with potential advantages over both ejection fraction and global longitudinal strain.

Purpose

We aimed to perform a meta-analysis of normal ranges of non-invasive left ventricular myocardial work (MW) indices including global constructive work (GCW), global work index (GWI), global wasted work (GWW), and global work efficiency (GWE) and to identify confounding factors that may contribute to variance in reported measures.

Methods

The authors searched four databases, Pubmed, Scopus, Embase, and Cochrane Library through January 2021 using the key terms “myocardial work”,“global constructive work”, “global wasted work”, “global work index”, “global work efficiency”. Studies were included if the articles reported LV myocardial work using 2D transthoracic echocardiography in healthy normal subjects, either in the control group or comprising the entire study cohort. The weighted mean was estimated by using the random effect model with a 95% confidence interval. Heterogeneity across studies was assessed using the I2 test. Publication bias was examined by funnel plot and Egger's regression test.

Results

The search yielded 476 articles. After abstract and full text screening we included 13 datasets with 1665 patients for meta-analysis. The reported normal mean values of GCW and GWI among the studies were 2278 (95% CI, 2167 to 23878; I2=95%), and 2.010 (95% CI, 1922 to 2098, I2=97%), respectively. The mean GWE was 96.0 (95% CI, 95.6% to 96.5; I2=92%), and the mean GWW was 79.7% (95% CI, 68.8% to 90.7%; I2=90%) (Figure). Furthermore, age and gender did not significantly contribute to variations in normal values. No evidence of significant publication bias was observed in the funnel plots and the Egger test.

Conclusion

In this meta-analysis, we provide echocardiographic reference ranges for non-invasive indices of MW. These normal values should serve as a template for clinical and research use for this promising technology.

Funding Acknowledgement

Type of funding sources: None.

Randomized blinded study comparing injection site pain from octreotide long-acting-release (LAR) versus lanreotide during the treatment of well differentiated neuroendocrine tumors (WDNETs)

e16204

Background: The somatostatin analogs (SSAs) octreotide LAR and lanreotide are equally acceptable in the NCCN guidelines to treat WDNETs. Average Sales Price for 1 year of lanreotide at 120mg is $106,802 versus $53,471 for 1 year of octreotide LAR 20mg and $80,206 for 1 year of 30mg. Lanreotide is given by “deep subcutaneous injection” while octreotide LAR is given intramuscularly. We conducted a randomized, blinded trial evaluating patient (pt) experience, as measured by injection site pain, with octreotide LAR and lanreotide, during the treatment of advanced, nonfunctional, WDNETs. We also investigated drug preference and financial toxicity in this pt population. Methods: This randomized single-blinded pilot study enrolled 51 pts recommended to begin SSA therapy. Pts received injections q 4 weeks and received 6 injections on study; Arm 1: octreotide LAR for 3 injections then lanreotide for 3 injections; Arm 2: lanreotide for 3 injections then octreotide LAR for 3 injections. Pts were blinded as to which agent they received throughout the study. Self-reported injection site pain scores were obtained after each of the first 3 injections using a 0 to 10 scale (0: “I didn’t feel it”; 10: “worst pain ever”). Primary endpoint was comparison of mean pain scores over the first 3 injections of octreotide LAR (Arm 1) or lanreotide (Arm 2). Secondary endpoints, evaluated with descriptive statistics, included pt-reported preference of octreotide LAR versus lanreotide, and willingness to pay for the preferred therapy, both assessed after 6 months of therapy by questionnaire. Results: 51 pts were enrolled (Arm 1: N = 26, Arm 2: N = 25). All pts were evaluable for the study primary endpoint. All pts received lanreotide at a dose of 120mg monthly; among those pts (49) receiving octreotide LAR, 30 (61%) received 20mg, 18 (37%) received 30mg, 1 (2%) received 10mg. No significant difference was identified in mean pain scores over the first 3 SSA injections; Arm 1: mean 2.4, standard deviation 1.9 versus Arm 2: mean 1.9, standard deviation 1.5 (p = 0.5). 34/51 (67%) pts (15 pts in Arm 1; 19 pts in Arm 2) were evaluated for secondary endpoints and completed post-therapy questionnaires. 7 (47%) in Arm 1 and 8 (42%) in Arm 2 indicated no drug preference at the end of the 6 months. There was a trend towards preference for octreotide LAR versus lanreotide in both arms, with more pts indicating mild or strong preference for octreotide LAR. 7 (50%) and 10 (56%) of pts in Arms 1 and 2, respectively, were unwilling to pay more for their preferred SSA; the rest of the cohort was willing to experience increased financial toxicity to receive their preferred SSA. Conclusions: This randomized, blinded study evaluating pt comfort with SSAs found minimal pain with both agents and no significant differences in pain scores between octreotide LAR versus lanreotide. Clinical trial information: NCT03289741.

Clinical characteristics and disease burden in prurigo nodularis

BACKGROUND

Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized by intense pruritus, but information on patient experience and impact on quality of life (QoL) remains understudied.

AIM

To characterize disease characteristics and QoL in a global sample of patients with PN.

METHODS

An anonymous survey was distributed via patient support groups for PN.

RESULTS

In total, 231 members responded to the survey. The majority of respondents reported itch localized both to nodules and to intervening skin (67.0%). Associated symptoms included prickling, pain, stinging and burning. The extensor lower legs (69% right, 67.3% left) and flexor forearms (66.1% right, 62% left) were the most common sites of itch. Participants reported frequent healthcare utilization, with 36.3% visiting a doctor ≥ 10 times in the past year. Physician-diagnosed anxiety (45.4%), depression (16.4%) and the atopic triad (18.7%) were commonly reported. Patients with PN had mean scores of 16.4, 11.6 and 16.8 on the Dermatology Life Quality Index, Pittsburgh Sleep Quality Index and 5-Dimensions Itch, respectively.

CONCLUSIONS

Severe pruritus with accompanying pain, stinging and burning is characteristic of PN, with the majority of patients experiencing itch in both nodular and interlesional skin. Patients further report decreased QoL scores and impaired sleep. Patient experiences should guide future management of PN.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Treatment response and clinical outcomes of well-differentiated high-grade neuroendocrine tumors to 177Lu-DOTATATE

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Background: 177Lu-DOTATATE is an approved therapy for somatostatin receptor (sstr) positive gastroenteropancreatic neuroendocrine tumors (NETs). There are little data available on response and outcomes for well differentiated (WD) high grade (HG) NETs treated with 177Lu-DOTATATE. Methods: Pts with WD HGNETs treated with 177Lu-DOTATATE at MSK from 2018-2020 were identified. Demographics, response to treatment, and progression-free survival (PFS) were determined. In pts with archival tumor tissue, next-generation sequencing (NGS) was performed through an institutional platform (MSK-IMPACT). Results: 19 pts were identified (mean age 54, 63% female). Site of tumor origin included: pancreas (14/19, 74%), small bowel (2/19, 10.5%), rectal (2/19, 10.5%), lung (1/19, 5%). Average tumor Ki-67 was 34.8 (range 22-56). All tumors were sstr avid on pre-treatment Ga68-DOTATATE PET/CT; none of the patients had sstr negative lesions detected. Median number of prior treatments (systemic and/or liver-directed) was 4 (range 2-7). All pts had progressive disease prior to initiation of 177Lu-DOTATATE. 13 pts (68%) completed all four treatment cycles; treatment was incomplete in 6 pts due to treatment-related toxicities (n = 3) and clinical progression (n = 3). Best response by radiographic report was available in 16 patients (84%):10/16 (63%) with partial response, 1/16 (6%) with stable disease, 5/16 (31%) with disease progression. One pt with stable disease as best response received two additional cycles of 177Lu-DOTATATE at progression. Median PFS (from date of first treatment with 177Lu-DOTATATE until progression/death) was 11.1 months (95% CI 10.6 to NA). Five pts (26%) experienced dose modifying toxicity with 177Lu-DOTATATE. The most common treatment-related toxicities were thrombocytopenia (9 pts, 47%; G3/4 in 1 pt, 5%), anemia (7 pts, 37%; G3/4 in 2 pts, 10.5%), leukopenia (6 pts, 32%; G3/4 in 0 pts), and AST/ALT elevation (4 pts, 21%; G3/4 in 0 pts). NGS results were available in the tumor tissue of 13 pts (68%). The most commonly observed alterations were in MEN1 (6/13, 46%) and DAXX (4/13, 31%). No RB1 alterations were identified. Conclusions: We observed a meaningful disease control rate of 69% during treatment of WD HGNETs with 177Lu-DOTATATE. In this heavily pre-treated population, more than half of pts received all four treatment cycles with treatment-related toxicities largely bone-marrow related, as expected, based on historical data. As would be expected in sstr avid tumors, the vast majority had alterations in chromatin remodeling genes (MEN1, DAXX) consistent with WD NETs, with no RB1 alterations identified.

Clinical epidemiology and outcome of HIV-associated talaromycosis in Guangdong, China, during 2011-2017

OBJECTIVES

Talaromycosis is an invasive mycosis endemic to Southeast Asia. This study aimed to investigate the epidemiology, clinical features and prognostic factors of HIV-associated talaromycosis in Guangdong, China.

METHODS

We retrospectively evaluated HIV patients hospitalized with histopathology- or culture-confirmed talaromycosis between 2011 and 2017. Factors associated with poor prognosis were identified using logistic regression.

RESULTS

Overall, 1079 patients with HIV-associated talaromycosis were evaluated. Both the number and prevalence of talaromycosis among HIV admissions increased from 125 and 15.7% in 2011 to 253 and 18.8% in 2017, respectively, reflecting the increase in HIV admissions. Annual admissions peaked during the rainy season between March and August. Common clinical manifestations included fever (85.6%), peripheral lymphadenopathy (72.3%), respiratory symptoms (60.8%), weight loss (49.8%), skin lesions (44.5%) and gastrointestinal symptoms (44.3%). Common laboratory abnormalities were hypoalbuminaemia (98.6%), anaemia (95.6%), elevated aspartate aminotransferase level (AST) (76.9%), elevated alkaline phosphatase level (55.8%) and thrombocytopenia (53.7%). The median CD4 count was 9 cells/μL. Talaromyces marneffei was isolated from blood and bone marrow cultures of 66.6% and 74.5% of patients, respectively. The rate increased to 86.6% when both cultures were performed concurrently. At discharge, 14% of patients showed worsening conditions or died. Leucocytosis, thrombocytopenia, elevated AST, total bilirubin, creatinine and azole monotherapy independently predicted poor prognosis.

CONCLUSIONS

The incidence of HIV-associated talaromycosis has increased in Guangdong with the high HIV burden in China. Skin lesions were seen in less than half of patients. Induction therapy with azole alone is associated with higher mortality. Findings from this study should help to improve treatment of the disease.

0439 Nonlinear Dynamics Forecasting for Personalize Prognosis of Obstructive Sleep Apnea Onsets

Introduction

The emphasis on disease prevention, early detection, and preventive treatments will revolutionize the way sleep clinicians evaluate their patients. Obstructive Sleep Apnea (OSA) is one of the most prevalent sleep disorders with approximately 100 millions patients been diagnosed worldwide. The effectiveness of sleep disorder therapies can be enhanced by providing personalized and real-time prediction of OSA episode onsets. Previous attempts at OSA prediction are limited to capturing the nonlinear, nonstationary dynamics of the underlying physiological processes.

Methods

This paper reports an investigation into heart rate dynamics aiming to predict in real time the onsets of OSA episode before the clinical symptoms appear. The method includes (a) a representation of a transition state space network to characterize dynamic transition of apneic states (b) a Dirichlet-Process Mixture-Gaussian-Process prognostic method for estimating the distribution of the time estimate the remaining time until the onset of an impending OSA episode by considering the stochastic evolution of the normal states to an anomalous (apnea)

Results

The approach was tested using three datasets including (1) 20 records from 14 OSA subjects in benchmark ECG apnea databases (Physionet.org), (2) records of eight subjects from previous work. The average prediction accuracy (R2) is reported as 0.75%, with 87% of observations within the 95% confidence interval. Estimated risk indicators at 1 to 3 min till apnea onset are reported as 85.8 %, 80.2 %, and 75.5 %, respectively.

Conclusion

The present prognosis approach can be integrated with wearable devices to facilitate individualized treatments and timely prevention therapies.

Support

N/A

High-Statistics Measurement of Neutrino Quasielasticlike Scattering at 6 GeV on a Hydrocarbon Target

We measure neutrino charged-current quasielasticlike scattering on hydrocarbon at high statistics using the wideband Neutrinos at the Main Injector beam with neutrino energy peaked at 6 GeV. The double-differential cross section is reported in terms of muon longitudinal (p_{∥}) and transverse (p_{⊥}) momentum. Cross section contours versus lepton momentum components are approximately described by a conventional generator-based simulation, however, discrepancies are observed for transverse momenta above 0.5  GeV/c for longitudinal momentum ranges 3-5 and 9-20  GeV/c. The single differential cross section versus momentum transfer squared (dσ/dQ_{QE}^{2}) is measured over a four-decade range of Q^{2} that extends to 10  GeV^{2}. The cross section turnover and falloff in the Q^{2} range 0.3-10  GeV^{2} is not fully reproduced by generator predictions that rely on dipole form factors. Our measurement probes the axial-vector content of the hadronic current and complements the electromagnetic form factor data obtained using electron-nucleon elastic scattering. These results help oscillation experiments because they probe the importance of various correlations and final-state interaction effects within the nucleus, which have different effects on the visible energy in detectors.

Synthetic aperture magnetometry and excess kurtosis mapping of Magnetoencephalography (MEG) is predictive of epilepsy surgical outcome in a large pediatric cohort

OBJECTIVE

Resective surgery is the most effective treatment option for patients with refractory epilepsy; however identification of patients who will benefit from epilepsy surgery remains challenging. Synthetic aperture magnetometry and excess kurtosis mapping (SAM(g2)) of magnetoencephalography (MEG) is a non-invasive tool that warrants further examination in the pediatric epilepsy population. Here, we examined the utility of MEG with SAM(g2) to determine if MEG epileptiform foci correlates with surgical outcome and to develop a predictive model incorporating MEG information to best assess likelihood of seizure improvement/freedom from resective surgery.

METHODS

564 subjects who had MEG at the Children's Hospital of Philadelphia between 2010-2015 were screened. Clinical epilepsy history and prior electrographic records were extracted and reviewed and correlated with MEG findings. MEG assessments were made by both a neurologist and neuroradiologist. Predictive models were developed to assess the utility of MEG in determining Engel class at one year and five years after resective epilepsy surgery.

RESULTS

The number of MEG spike foci was highly associated with Engel class outcome at both one year and five years; however, using MEG data in isolation was not significantly predictive of 5 year surgical outcome. When combined with clinical factors; scalp EEG (single ictal onset zone), MRI (lesional or not), age and sex in a logistic regression model MEG foci was significant for Engel class outcome at both 1 year (p = 0.03) and 5 years (0.02). The percent correctly classified for Engel class at one year was 78.43% and the positive predictive value was 71.43.

SIGNIFICANCE

MEG using SAM(g2) analysis in an important non-invasive tool in the identification of those patients who will benefit most from surgery. Integrating MEG data analysis into pre-surgical evaluation can help to predict epilepsy outcome after resective surgery in the pediatric population if utilized with skilled interpretation.

Real-world outcomes of nivolumab and cabozantinib in metastatic renal cell carcinoma: results from the International Metastatic Renal Cell Carcinoma Database Consortium

Objectives

In the present study, we explored the real-world efficacy of the immuno-oncology checkpoint inhibitor nivolumab and the tyrosine kinase inhibitor cabozantinib in the second-line setting.

Methods

Using the International Metastatic Renal Cell Carcinoma Database Consortium (imdc) dataset, a retrospective analysis of patients with metastatic renal cell carcinoma (mrcc) treated with nivolumab or cabozantinib in the second line after prior therapy targeted to the vascular endothelial growth factor receptor (vegfr) was performed. Baseline characteristics and imdc risk factors were collected. Overall survival (os) and time to treatment failure (ttf) were calculated using Kaplan-Meier curves. Overall response rates (orrs) were determined for each therapy. Multivariable Cox regression analysis was performed to determine survival differences between cabozantinib and nivolumab treatment.

Results

The analysis included 225 patients treated with nivolumab and 53 treated with cabozantinib. No significant difference in median os was observed: 22.10 months [95% confidence interval (ci): 17.18 months to not reached] with nivolumab and 23.70 months (95% ci: 15.52 months to not reached) with cabozantinib (p = 0.61). The ttf was also similar at 6.90 months (95% ci: 4.60 months to 9.20 months) with nivolumab and 7.39 months (95% ci: 5.52 months to 12.85 months) with cabozantinib (p = 0.20). The adjusted hazard ratio (hr) for nivolumab compared with cabozantinib was 1.30 (95% ci: 0.73 to 2.3), p = 0.38. When adjusted by imdc criteria and age, the hr was 1.32 (95% ci: 0.74 to 2.38), p = 0.35.

Conclusions

Real-world imdc data indicate comparable os and ttf for nivolumab and cabozantinib. Both agents are reasonable therapeutic options for patients progressing after initial first-line vegfr-targeted therapy.