Autism and neurodevelopmental disability risks in children with tracheostomies and ventilators

BACKGROUND/OBJECTIVE

Infants who survive prematurity and other critical illnesses and require continued invasive mechanical ventilation (IMV) postdischarge (at home) are at high risk of developmental delays and disabilities. Studies of extremely preterm cohorts (<28-week gestation) demonstrate rates of 25% for intellectual disability (ID) and 7% for autism spectrum disorder (ASD). Rates of ASD and ID in children with IMV are unknown. This study aimed to determine neurodevelopmental disability risk in a cohort of children with postdischarge IMV.

DESIGN/METHODS

A consecutive series of children with IMV were assessed 1 month, 6 months, and 1 year after discharge. Cognitive, social, and communicative domains were assessed by a Developmental and Behavioral Pediatrician using (1) clinical adaptive test/clinical linguistic and auditory milestone scale (CAT/CLAMS) of the capute scales; (2) pediatric evaluation of disability inventory computer adaptive test (PEDI-CAT); and (3) modified checklist for autism in toddlers, revised (MCHAT-R). Red flag signs and symptoms of ASD using DSM-V criteria were noted. Longitudinal testing was reviewed. Expert consensus impressions of evolving ASD and/or ID were determined.

RESULTS

Eighteen children were followed for 1 year; at 1 year, the median age (range) was 23 (17-42) months. Children were 44% male, 33% non-Hispanic White, 39% non-Hispanic Black, and 28% Hispanic. Fifteen (83%) children were prematurity survivors. Median (range) developmental quotients (DQs): full-scale DQ 59 (11-86), CAT DQ 66.5 (8-96), and CLAMS DQ 49.5 (13-100). Twelve (67%) children were highly suspicious for ASD and/or evolving ID.

CONCLUSIONS/SIGNIFICANCE

This cohort of children with at-home IMV demonstrates a higher risk of ASD and ID than prior premature cohorts. Larger investigations with longer follow-up are needed.

Selective internal radiation therapy using yttrium-90 microspheres for treatment of localized and locally advanced intrahepatic cholangiocarcinoma

OBJECTIVES

To evaluate safety and effectiveness of selective internal radiation therapy (SIRT) using yttrium-90 for localized and locally advanced intrahepatic cholangiocarcinoma (iCCA).

METHODS

A retrospective review was performed of patients with localized iCCA treated with SIRT at a single institution. Overall survival (OS), local tumor response, progression-free survival (PFS), and toxicity were collected. Stratified analysis was performed based on surgical resection. Predictor analysis of OS was performed using the Fine-Grey regression analysis model with patients bridged to surgery regarded as competing events.

RESULTS

A total of 28 consecutive patients with localized iCCA were treated with a total of 38 sessions of SIRT (17 segmental, 13 lobar, and 8 combined deliveries) and a mean dominant target dose per session of 238.4 ± 130.0 Gy. The cumulative radiologic response rate was 16/28 (57.1%) with a median PFS of 265 days. Median survival time (MST) was 22.9 months for the entire cohort with 1-year and 3-year survival of 78.4% and 45.1%, respectively. Ten patients (34.5%) were downstaged to surgical intervention (7 resection, 3 transplant) and showed longer OS (p = 0.027). The 1-year and 3-year OS for patients who received surgery were 100% and 62.5% (95% CI: 14.2-89.3%), respectively. Age (p = 0.028), Eastern Cooperative Oncology Group performance status (p = 0.030), and objective radiologic response (p=0.014) are associated with OS. Two ≥grade 3 hyperbilirubinemia, anemia, and one pleuro-biliary fistula occurred post-SIRT.

CONCLUSIONS

SIRT for localized iCCA is safe and effective in achieving radiological response, downstaging to surgery and transplant, and resulting in pathologic necrosis.

CLINICAL RELEVANCE STATEMENT

Selective internal radiation therapy should be considered for patients with localized and locally advanced intrahepatic cholangiocarcinoma.

KEY POINTS

• The effectiveness of radioembolization for intrahepatic cholangiocarcinoma (iCCA) can be underestimated given the inclusion of extrahepatic disease. • Radioembolization is safe and effective for local and locally advanced iCCA. Age, Eastern Cooperative Oncology Group performance status, and radiologic response are associated with survival. • Radioembolization should be considered for patients with localized and locally advanced iCCA.

Age effect on the shared etiology of glycemic traits and serum lipids: evidence from a Chinese twin study

PURPOSE

Diabetes and dyslipidemia are among the most common chronic diseases with increasing global disease burdens, and they frequently occur together. The study aimed to investigate differences in the heritability of glycemic traits and serum lipid indicators and differences in overlapping genetic and environmental influences between them across age groups.

METHODS

This study included 1189 twin pairs from the Chinese National Twin Registry and divided them into three groups: aged ≤ 40, 41-50, and > 50 years old. Univariate and bivariate structural equation models (SEMs) were conducted on glycemic indicators and serum lipid indicators, including blood glucose (GLU), glycated hemoglobin A1c (HbA1c), total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C), in the total sample and three age groups.

RESULTS

All phenotypes showed moderate to high heritability (0.37-0.64). The heritability of HbA1c demonstrated a downward trend with age (HbA1c: 0.50-0.79), while others remained relatively stable (GLU: 0.55-0.62, TC: 0.58-0.66, TG: 0.50-0.63, LDL-C: 0.24-0.58, HDL-C: 0.31-0.57). The bivariate SEMs demonstrated that GLU and HbA1c were correlated with each serum lipid indicator (0.10-0.17), except HDL-C. Except for HbA1c and LDL-C, as well as HbA1c and HDL-C, differences in genetic correlations underlying glycemic traits and serum lipids between age groups were observed, with the youngest group showing a significantly higher genetic correlation than the oldest group.

CONCLUSION

Across the whole adulthood, genetic influences were consistently important for GLU, TC, TG, LDL-C and HDL-C, and age may affect the shared genetic influences between glycemic traits and serum lipids. Further studies are needed to elucidate the role of age in the interactions of genes related to glycemic traits and serum lipids.

Risk perception and surveillance uptake in individuals at increased risk for pancreatic ductal adenocarcinoma

BACKGROUND

Surveillance for pancreatic ductal adenocarcinoma (PDAC) is recommended for high-risk individuals with genetic variants in PDAC-associated genes and/or family history. Surveillance uptake and adherence may depend on the perception of PDAC risk and cancer worry. We aimed to determine PDAC risk perception in at-risk individuals and assess factors associated with PDAC surveillance uptake.

METHODS

At-risk individuals identified from a prospective academic registry were sent a survey electronically. PDAC risk perception, cancer worry and surveillance uptake were surveyed. Factors associated with increased risk perception and surveillance were assessed. Five-year PDAC risk was calculated using the PancPRO risk assessment model, and correlation with subjective risk assessment was assessed.

RESULTS

The overall survey response rate was 34% (279/816). The median perceived PDAC risk was twofold (IQR 1-4) above respondents' estimates of general population risk. Factors significantly associated with higher perceived PDAC risk included non-Hispanic white race, post-graduate education level, PDAC-affected first-degree relative, genetic variants and lack of personal cancer history. Cancer worry had a very weak correlation across PDAC risk estimates (r=0.16). No correlation between perceived PDAC risk and 5-year calculated PDAC risk was found. Older age, having a first-degree relative with PDAC, meeting with a medical provider about PDAC cancer risk and awareness of surveillance modalities were significant predictors of undergoing PDAC surveillance.

CONCLUSIONS

Individuals at risk for PDAC do not report risk perception that correlates with calculated risk. This presents an opportunity for counselling of at-risk patients to individualise management and improve surveillance uptake for eligible individuals.

Uterine Fibroid Prevalence in a Predominantly Black, Chicago-Based Cohort

(1) Objectives: To investigate the effect of individual-level, neighborhood, and environmental variables on uterine fibroid (UF) prevalence in a Chicago-based cohort. (2) Methods: Data from the Chicago Multiethnic Prevention and Surveillance Study (COMPASS) were analyzed. Individual-level variables were obtained from questionnaires, neighborhood variables from the Chicago Health Atlas, and environmental variables from NASA satellite ambient air exposure levels. The Shapiro-Wilk test, logistic regression models, and Spearman's correlations were used to evaluate the association of variables to UF diagnosis. (3) Results: We analyzed 602 participants (mean age: 50.3 ± 12.3) who responded to a question about UF diagnosis. More Black than White participants had a UF diagnosis (OR, 1.32; 95% CI, 0.62-2.79). We observed non-significant trends between individual-level and neighborhood variables and UF diagnosis. Ambient air pollutants, PM2.5, and DSLPM were protective against UF diagnosis (OR 0.20, CI: 0.04-0.97: OR 0.33, CI: 0.13-0.87). (4) Conclusions: Associations observed within a sample in a specific geographic area may not be generalizable and must be interpreted cautiously.

Tumor Size and Watershed Area Correlate with Incomplete Treatment and Tumor Progression after Selective Radioembolization for Hepatocellular Carcinoma

PURPOSE

To identify factors of incomplete treatment after segmental transarterial radioembolization (TARE) for treatment-naive and solitary hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

A total of 75 consecutive patients (age, 68.5 years [SD ± 8.0]; 25/75 [33.3%] women) with treatment-naive, solitary HCC underwent segmental or subsegmental TARE with glass microspheres (tumor size, 3.8 cm [SD ± 2.2]; administered dose, 222.6 Gy [SD ± 123.9]) at a single institution from November 2015 to June 2022. Radiologic response and progression-free survival (PFS) were assessed as per modified Response Evaluation Criteria in Solid Tumors.

RESULTS

Complete treatment was achieved in 48 of 75 (64.0%) patients (mean follow-up, 33.2 months [SD ± 27.4]). Patients with incomplete treatment (27/75, 36%) presented with larger tumor size (5.0 [SD ± 2.5] vs 3.1 [SD ± 1.6] cm; P = .0001), with more tumors located in the watershed zone (81.5% vs 41.7%; P = .001). These patients were less likely to be bridged to transplant or resection (22.2% vs 52.1%; P = .015). Watershed tumors demonstrated worse target tumor PFS (median PFS, 19 months vs not reached; P = .0104) and overall PFS (9.1 months vs not reached; P = .0077). Watershed location was associated with worse PFS among tumors >3 cm in size (8.4 months vs not reached; P = .035) but not in tumors ≤3 cm in size (52.2 months vs not reached; P = .915).

CONCLUSIONS

Tumor size and watershed location were associated with incomplete treatment after segmental TARE for HCC. Watershed tumors were associated with worse PFS, particularly tumors larger than 3 cm. These tumors may require careful treatment planning and repeated treatments to ensure a durable response.

Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery

Importance

General anesthesia for cesarean delivery is associated with increased maternal morbidity, and Black and Hispanic pregnant patients have higher rates of general anesthesia use compared with their non-Hispanic White counterparts. It is unknown whether risk factors and indications for general anesthesia differ among patients of differing race and ethnicity.

Objective

To evaluate differences in general anesthesia use for cesarean delivery and the indication for the general anesthetic by race and ethnicity.

Design, Setting, and Participants

In this retrospective, cross-sectional, single-center study, electronic medical records for all 35 117 patients who underwent cesarean delivery at Northwestern Medicine's Prentice Women's Hospital from January 1, 2007, to March 2, 2018, were queried for maternal demographics, clinical characteristics, obstetric and anesthetic data, the indication for cesarean delivery, and the indication for general anesthesia when used. Data analysis occurred in August 2023.

Exposure

Cesarean delivery.

Main Outcomes and Measures

The rate of general anesthesia for cesarean delivery by race and ethnicity.

Results

Of the 35 117 patients (median age, 33 years [IQR, 30-36 years]) who underwent cesarean delivery, 1147 (3.3%) received general anesthesia; the rates of general anesthesia were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for non-Hispanic White patients (542 of 19 479), and 3.8% (153 of 4016) for all other groups (including those who declined to provide race and ethnicity information) (P < .001). A total of 19 933 pregnant patients (56.8%) were in labor at the time of their cesarean delivery. Of those, 16 363 (82.1%) had neuraxial labor analgesia in situ. Among those who had an epidural catheter in situ, there were no racial or ethnic differences in the rates of general anesthesia use vs neuraxial analgesia use (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; non-Hispanic White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P = .16). Indications for cesarean delivery and for general anesthesia were not different when stratified by race and ethnicity.

Conclusions and Relevance

Racial disparities in rates of general anesthesia continue to exist; however, this study suggests that, for laboring patients who had labor epidural catheters in situ, no disparity by race or ethnicity existed. Future studies should address whether disparities in care that occur prior to neuraxial catheter placement are associated with higher rates of general anesthesia among patients from ethnic and racial minority groups.

Genomic epidemiological investigation of an outbreak of Serratia marcescens neurosurgical site infections associated with contaminated haircutting toolkits in a hospital barber shop

BACKGROUND

Nine surgical site infections caused by Serratia marcescens were diagnosed in neurosurgical patients in a 3500-bed hospital between 2nd February and 6th April 2022.

OBJECTIVE

To trace the source of infections caused by S. marcescens to expedite termination of the outbreak and prevent future epidemics.

METHODS

A review of all surgical procedures and cultures yielding S. marcescens since February 2022 was conducted. Samples were collected from patients and environmental sources. S. marcescens isolates were characterized by antibiotic susceptibility testing. Whole-genome sequencing (WGS) was used to investigate genetic relationships. Resistance genes, virulence genes and plasmid replicons were identified.

RESULTS

S. marcescens was isolated from patients' puncture fluid, cerebrospinal fluid and other secretions, and was also cultured from the barbers' haircutting tools, including leather knives, slicker scrapers and razors. In total, 15 isolates were obtained from patients and eight isolates were obtained from haircutting tools. All isolates exhibited identical antibiotic resistance patterns. WGS revealed close clustering among the 23 isolates which differed significantly from previous strains. Three resistance genes and nine virulence-associated genes were detected in all isolates, and 19 of 23 isolates harboured an MOBP-type plasmid. The results confirmed an outbreak of S. marcescens, which was traced to contaminated haircutting tools in the hospital barber shop. The outbreak ended after extensive reinforcement of infection control procedures and re-education of the barbers.

CONCLUSIONS

These results highlight the risk of postoperative infections related to pre-operative skin preparation, and demonstrate the value of next-generation sequencing tools to expedite outbreak investigations.

Long-term effects of pancreatic islet transplantation on polyneuropathy in patients with brittle diabetes: A single-center experience

INTRODUCTION/AIMS

Pancreatic islet transplantation (ITx) is increasingly used in patients with brittle type 1 diabetes (T1D). If successful, ITx results in insulin-free euglycemia, but its application is limited by a need for lifelong immunosuppression. The aim of this study was to assess the long-term effects of ITx on the occurrence and course of polyneuropathy in a cohort of patients with brittle T1D.

METHODS

In this prospective, single-center study, 13 patients (4 males and 9 females) with brittle T1D had a baseline neurological exam with the calculation of Utah Neuropathy Scale (UNS) and a limited nerve conduction study before ITx, and about yearly after in the patients who achieved insulin independence.

RESULTS

Patients were followed for a period of 17 to 133 months. There was no significant difference between UNS and nerve conduction study parameters at baseline and at the end of follow-up, except for significant decreases in peroneal (50.34 ± 6.12 vs. 52.42 ± 6.47 ms, P = 0.005) and ulnar (27.5 ± 2.15 vs. 29.45 ± 2.10 ms, P = 0.009) F-wave latencies and an increase in ulnar sensory nerve conduction velocity (49.98 ± 6.27 vs. 47.19 ± 5.36 m/s, P = 0.04).

DISCUSSION

If successful, ITx has a good long-term safety profile for peripheral nerve toxicity, and a favorable effect on diabetic neuropathy.

Using Downgaze Palsy Progression Rate to Model Survival in Progressive Supranuclear Palsy-Richardson Syndrome

BACKGROUND

Rapid development of downgaze palsy, the most specific symptom of progressive supranuclear palsy (PSP), has been associated with shorter survival in small studies.

OBJECTIVE

We hypothesized that the progression rate of downgaze palsy and other disease features could predict survival if assessed soon after the onset of downgaze palsy in a large data set.

METHODS

We used a longitudinal database of 414 patients with probable PSP-Richardson syndrome from 1994 to 2020. The data set comprised demographics and, for each visit, 28 PSP Rating Scale (PSPRS) items and PSP stage scores. We calculated the rate of progression of each PSPRS item as its item score when the downgaze item first reached 1 or more (on a 0-4 scale) divided by disease duration at that point. Multivariate Cox regression was applied to identify variables independently associated with survival. We also explored the progression pattern of total PSPRS and downgaze palsy scores with disease course.

RESULTS

Independently associated with shorter survival were older onset age and faster progression of downgaze palsy, dysphagia for liquids, difficulty in returning to seat, and PSP stage. Patients with survival duration within 1 year of the median survival (6.58 years) showed approximately linear progression of the PSPRS score and downgaze palsy score during years 2 through 6 of the disease course.

CONCLUSIONS

Older onset age and faster progression of downgaze palsy and several axial features are associated with shorter survival. The disease typically progresses in approximately linear fashion during years 2 through 6. These results may aid study design and patient counseling. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Gender Bias in Judging Frailty and Fitness for Lung Surgery

BACKGROUND

Disparities in surgical care for lung cancer have been well documented, and unconscious bias may be a source of inequity. We assessed whether gender biases exist when nonclinical decision makers render decisions about major lung surgery.

METHODS

Amazon Mechanical Turk workers, remotely located "crowdworkers" readily available for hire to perform discrete on-demand tasks on the Amazon Mechanical Turk platform, were each shown 4 videos of different standardized patients (SPs) in a clinic setting, 1 video in each energy level (vigorous or frail) and race category (White or Black), randomized to male or female. Workers scored video characteristics and whether they would support the SP's decision to undergo a major lung operation.

RESULTS

A total of 855 workers were recruited. The frail White male SP was more likely to have support to undergo lung surgery than the frail White female SP, while the frail Black male SP was much less likely to have support to undergo lung surgery than the frail Black female SP. There were no significant differences in support for surgery between the vigorous male and female SPs and ratings by male and female workers in their recommendations.

CONCLUSIONS

Biases related to patient gender exist in the general population and affect views on surgery, particularly in the setting of frailty. Understanding such differences may aid in educational efforts directed at reducing gender-based biases in treatment recommendations.

[Prenatal genetic diagnosis of the fetuses with isolated corpus callosum abnormality]

Objective: To explore the application value of chromosome karyotype analysis, chromosomal microarray analysis (CMA) and whole exome sequencing (WES) in prenatal diagnosis of isolated corpus callosum abnormality (CCA) fetus. Methods: Fetuses diagnosed with isolated CCA by ultrasound and MRI and receiving invasive prenatal diagnosis in Guangzhou Women and Children's Medical Center and Qingyuan People's Hospital from January 2010 to April 2021 were selected. Karyotype analysis and/or CMA [or copy number variation sequencing (CNV-seq)] were performed on all fetal samples, and WES was performed on fetal samples and their parents whose karyotype analysis and/or CMA (or CNV-seq) results were not abnormal. Results: Among 65 fetuses with isolated CCA, 38 cases underwent karyotype analysis, and 3 cases were detected with abnormal karyotypes, with a detection rate of 8% (3/38). A total of 49 fetuses with isolated CCA underwent CMA (or CNV-seq) detection, and 6 cases of pathogenic CNV were detected, the detection rate was 12% (6/49). Among them, the karyotype analysis results were abnormal, and the detection rate of further CMA detection was 1/1. The karyotype results were normal, and the detection rate of further CMA (or CNV-seq) detection was 14% (3/21). The detection rate of CMA as the first-line detection technique was 7% (2/27). A total of 25 fetuses with isolated CCA with negative results of karyotyping and/or CMA were tested by WES, and 9 cases (36%, 9/25) were detected with pathogenic genes. The gradient genetic diagnosis of chromosomal karyotyping, CMA and WES resulted in a definite genetic diagnosis of 26% (17/65) of isolated CCA fetuses. Conclusions: Prenatal genetic diagnosis of isolated CCA fetuses is of great clinical significance. The detection rate of CMA is higher than that of traditional karyotyping. CMA detection could be used as a first-line detection technique for fetuses with isolated CCA. WES could increase the pathogenicity detection rate of fetuses with isolated CCA when karyotype analysis and/or CMA test results are negative.

Pre-exposure Prophylaxis Persistence Among Greek Sexual Minority Men: Results from PrEP for Greece (P4G) Study

Nearly half the new HIV infections in Greece occur in sexual minority men, yet pre-exposure prophylaxis is not currently supported in the national HIV program. We examined factors associated with PrEP persistence among Greek SMM in PrEP for Greece, the first PrEP study in Greece. Participants (n = 100) were recruited from 2016 to 2018 through respondent-driven sampling among SMM in Athens, receiving supplies for daily PrEP at interval visits over 12-months. PrEP persistence, operationalized as Total PrEP Time, was high, 74% of participants achieving perfect persistence. Higher alcohol risk scores (OR 1.27, 95% CI 1.08-1.49) and adherence to HIV testing guidelines (OR 1.23, 95% CI 1.00-1.51) were associated with persistence. Housing impermanence (OR 0.14, 95% CI 0.04-0.48) and serostatus disclosure concerns (OR 0.77, 95% CI 0.60-0.97) were associated with limited PrEP persistence. While PrEP persistence among Greek SMM is high, socioeconomic factors and societal attitudes may challenge prevention efforts.

[Molecular studies on parental origin and cell stage of nondisjunction in sex chromosome aneuploidies]

To study the parental origin and cell stage of nondisjunction in sex chromosome aneuploidies. Retrospectiving and analyzing the results of 385 cases of SCA confirmed by QF-PCR and karyotype analysis in the prenatal diagnosis center of Guangzhou Women and Children Medical Center from January 2015 to December 2020. The types of samples and prenatal diagnosis indications were analyzed. The parental origin and cell stage of nondisjunction in sex chromosome aneuploidies analyzed by comparing the short tandem repeat (STR) peak patterns of samples from fetuses and maternal peripheral blood. The results show that (1) There were 324 cases of nonmosaic SCA, 113 cases (113/324, 34.9%) were 45, XO, 118 cases (118/324, 36.4%) were 47, XXY, 48 cases (48/324, 14.8%) were 47, XXX and 45 cases (45/324, 13.9%) were 47, XYY. 68 (45/324, 60.2%) cases of 45, X were detected in villus samples. The other SCA cases were mainly detected in amniotic fluid samples. There were 61 mosaic SCA samples, 58(58/61, 95.1%) of mosaic SCA samples were mosaic 45, X. (2) The top two indications of 45, X cases are increased nuchal translucency(53/113, 46.9%) and fetal cystic hygroma (41/113, 36.3%), while the most common indication of other types of SCA was high risk of NIPT(170/272, 62.5%). (3) Among 45, X cases, there were 88 cases (88/113, 77.9%) inherit their single X chromosome from their mother and 25 cases (25/119, 22.1%) from their father. In 47, XXY samples, 47 cases (47/118, 39.8%) of chromosome nondisjunction occurred in meiosis stage Ⅰ of oocytes, 51 cases (51/118, 43.2%) occurred in meiosis stage Ⅰ of spermatocytes, and 20 cases (20/118, 16.9%) occurred in meiosis stage Ⅱ of oocytes. Among 47, XXX samples, 29 cases (29/48, 60.4%) of X chromosome nondisjunction occurred in meiosis stage Ⅰof oocytes, 15 cases (15/48, 31.3%) occurred in meiosis stage Ⅱ of oocytes, and 4 cases (4/48, 8.3%) occurred in meiosis stage Ⅱ of spermatocytes. In summary, the cases of 45, X were mainly diagnosed by villous samples for abnormal ultrasound findings. The other cases of SCA were mainly diagnosed by amniocentesis samples for abnormal NIPT results. Different types of SCA, the origin and occurrence period of sex chromosome nondisjunction were different.

Abstract P3-19-07: Hypofractionated and conventional whole-breast radiotherapy for breast cancer patients: Financial risk and expenditures in the U.S. 2008-2017

Background: Rising cancer care expenditures and technological advancement of shorter radiotherapy regimens have drawn significant attention to the use of hypofractionated radiotherapy in clinical care. We examine the costs of hypofractionated (HF-WBI) compared to conventional whole breast irradiation (CF-WBI) in the U.S. through 2017 and investigate the influences of patient characteristics and commercial insurance on HF-WBI use. Methods: In a retrospective study using private employer-sponsored insurance claims, a pooled cross-sectional evaluation of radiotherapy in patients with commercial insurance was performed from 2008-2017. The study population included female patients with early-stage breast cancer treated with lumpectomy and whole-breast irradiation. HF-WBI is defined as receipt of 15-24 radiation fractions and/or radiation fractions delivered between 21-31 days. CF-WBI is defined as receipt of 25-40 fractions and/or radiation fractions delivered between 39-120 days. The primary outcomes and measures were the use of HF-WBI and CF-WBI and total radiotherapy expenditures, including costs incurred by insurers and patient out-of-pocket expenses. Results: A total of 15,869 women received HF-WBI and 59,328 received CF-WBI. HF-WBI use increased from 2008 to 2017. Community-level factors like a higher proportion of college graduates and greater mixed racial composition were associated with increased HF-WBI use. No association was observed between insurance plan characteristics and the likelihood of receiving HF-WBI. The mean insurer-paid radiotherapy expenditures were significantly lower for HF-WBI vs. CF-WBI (adjusted difference $6,375, 95% CI $6,147-$6,603). The mean patient out-of-pocket expenditure for HF-WBI was $139 less than that of CF-WBI (Table 1). Geographic variation existed across U.S. states in HF-WBI use (range: 9.6%-36.2%). There was no consistent relationship across states between the utilization of HF-WBI and the corresponding average cost differences for HF-WBI relative to CF-WBI.

Conclusions: If trends continue, HF-WBI will soon become the dominant form of radiation treatment in the U.S. Although HF-WBI represents significant savings to the health care system and individual patients, no evidence indicated that a financial disincentive slowed the adoption of HF-WBI. Therefore, multi-level approaches, including individuals, the community, and health policy, should be utilized to promote cost-effective cancer care.

Table 1.Radiotherapy-related expenditures for breast cancer patients aged &lt;65 yrs with commercial insurance plans.aRadiotherapy TypeDifferences, US $bCF-WBIHF-WBIa2008-2017 [Adjusted Mean (95% CI), US $b]Total costs23,286 (23,158 to 23,415)16,763 (16,583 to 16,945)6,253 (6,294 to 6,751)Insurer paid22,751 (22,623 to 22,880)16,376 (16,196 to 16,557)6,375 (6,147 to 6,603)Patient OOP costs502 (491 to 513)363 (206 to 229)139 (119 to 160)aMultivariable generalized linear models with Gamma distribution and log link, with the adjustment for year of radiotherapy, state of beneficiary health plan, age at the time of radiotherapy, type of breast cancer diagnosis, receipt of chemotherapy, Charlson comorbidity index, community education level (% in the community with a college degree or higher), and type of insurance plan. All the differences were statistically significant with p&lt;0.0001. bAll expenditures were rounded up to the nearest dollar amount in 2017 U.S. dollars after adjusting for inflation. CF-WBI: conventional fractionated whole breast irradiation therapy. HF-WBI: hypofractionated WBI. OOP: out of pocket. CI: confidence intervals.

Citation Format: Loren Saulsberry, Chuanhong Liao, Dezheng Huo. Hypofractionated and conventional whole-breast radiotherapy for breast cancer patients: Financial risk and expenditures in the U.S. 2008-2017 [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-07.

Room temperature two terminal tunnel magnetoresistance in a lateral graphene transistor

We investigate the behavior of both pure spin and spin-polarized currents measured with four-probe non-local and two probe local configurations up to room temperature and under an external gate voltage in a lateral graphene transistor, produced using a standard large-scale microfabrication process. The high spin diffusion length of pristine graphene in the channel, measured both directly and by the Hanle effect, and the tuning of the relationship between the electrode resistance areas present in the device architecture allowed us to observe local tunnel magnetoresistance at room temperature, a new finding for this type of device. The results also indicate that while pure spin currents are less sensitive to temperature variations, spin-polarized current switching by an external voltage is more efficient, due to a combination of the Rashba effect and a change in carrier mobility by a Fermi level shift.

Are skin color and body mass index associated with social network structure? Findings from a male sex market study

Objectives: There is a growing burden of HIV and sex-related diseases in South Asia and India. Sociological research illustrates that key axes of social stratification, such as race and ethnicity, affect social network structure which, in turn, impacts sexual health and wellbeing. Research on networks has increasingly begun to examine the ways in which networks drive or harness sexual behaviors, but has largely neglected the influence of culture and cultural markers in this continuum. Furthermore, much of the existing scholarship has been conducted in the U.S. or in Western contexts.Design: As part of an exploratory effort, we examined how skin color and body mass index (BMI) affected networks among 206 men who have with men (MSM) frequenting sex markets in Hyderabad, India. A novel phone-based network generation method of respondent-driven sampling was used for recruitment. In assessing how skin color and BMI drive these structures, we also compared how these factors contribute to networks relative to two more commonly referenced markers of social difference among Indians, caste and religion.Results: Our findings suggest that skin color and BMI contribute significantly more to network structure than do caste and religion.Conclusions: These findings tentatively illuminate the importance of individual-level heterogeneity in bodily attributes, factors which are seldom considered in conventional approaches to researching how social stratification and health inequalities are animated during the formation of networks.

[Analysis of families with fetal congenital abnormalities but negative prenatal diagnosis by whole exome sequencing]

Objective: To evaluate the value of whole exome sequencing (WES) in prenatal clinical application. Methods: A total of 1 152 cases of congenital abnormal [including structural malformation, nuchal translucency (NT) thickening and intrauterine growth restriction] with traditional prenatal diagnosis [including G-band karyotype analysis and chromosome microarray analysis (CMA)] negative were analyzed. The congenital abnormal fetuses were divided into retrospective group and prospective group according to the time of WES detection, that is whether the pregnancy termination or not. According to the specific location of fetal malformation and their family history, the cohort was divided into subgroups. The clinical prognosis of all fetuses were followed up, and the effect of WES test results on pregnancy decision-making and clinical intervention were analyzed. According to the follow-up results, the data of fetuses with new phenotypes in the third trimester or after birth were re-analyzed. Results: Among 1 152 families who received WES, 5 families were excluded because of nonbiological parents. Among the remaining 1 147 families, 152 fetuses obtained positive diagnosis (13.3%,152/1 147), including 74 fetuses in the retrospective group (16.1%,74/460) and 78 fetuses in the prospective group (11.4%,78/687). In fetuses with negative CMA and G-band karyotype analysis results but new phenotypes in the third trimester or after birth, the positive rate by WES data re-analysis was 4.9% (8/163). A total of 34 (21.3%, 34/160) fetuses were directly affected by the corresponding positive molecular diagnosis. Among 68 cases of live births with diagnostic variation grade 4, 29 cases (42.7%, 29/68) received appropriate medical intervention through rapid review of WES results. Conclusions: WES could increase the detection rate of abnormal fetuses with negative G-banding karyotype analysis and CMA by 13.3%. Prenatal WES could guide pregnancy decision-making and early clinical intervention. It might be an effective strategy to pay attention to the special follow-up of the third trimester and postnatal fetus and to re-analyze the WES data.

Nicotinamide improves NAD+ levels to protect against acetaminophen-induced acute liver injury in mice

Acetaminophen (APAP) overdose causes acute liver injury (ALI). Nicotinamide adenine dinucleotide (NAD) is an essential coenzyme, and NAD⁺ is oxidized type which synthesized from nicotinamide (NAM). The present study aimed to investigate the role of NAD⁺ in ALI and protective property of NAM. The mice were subjected to different doses APAP. After 8 hours, the serum activities of alaninetransaminase (ALT) and aspartate aminotransferase (AST), the hepatic NAD⁺ level and nicotinamide phosphoribosyltransferase (NAMPT) expression were determined. Then, the mice were pretreated with NAM (800 mg/kg), the hepatoprotective effects and the key antioxidative molecules were evaluated. Our findings indicated that APAP resulted in remarkable NAD⁺ depletion in a dose-dependent manner accompanied by NAMPT downregulation, and NAM pretreatment significantly elevated the NAD⁺ decline due to upregulation of NAMPT. Moreover, the downregulated Kelch-like ECH-associated protein-1 (Keap1), upregulated nuclear factor erythroid 2-related factor 2 (Nrf2) and its translocation activation after NAM administration were confirmed, which were in accordance with improved superoxide dismutase (SOD) and glutathione (GSH) levels. Finally, NAM dramatically exhibited hepatoprotective effects by reducing the liver index and necrotic area. This study has suggested that APAP impairs liver NAD⁺ level and NAM is able to improve hepatic NAD⁺ to activate antioxidant pathway against APAP-induced ALI.

Chemotherapy response score as a prognostic tool in patients with advanced stage endometrial carcinoma treated with neoadjuvant chemotherapy

BACKGROUND

Chemotherapy response score (CRS) applied to interval debulking specimens quantifies histopathologic response to neoadjuvant chemotherapy in patients with advanced ovarian carcinoma and correlates with progression-free and overall survival.

OBJECTIVE

To investigate whether the chemotherapy response score could be applied to interval debulking specimens in patients with advanced endometrial carcinoma and be a prognostic indicator.

METHODS

The study included patients with clinical stage III-IV endometrial carcinoma who received neoadjuvant chemotherapy followed by interval debulking surgery. Chemotherapy response scores were assigned to omental and adnexal metastases, and categorized as no/minimal (CRS1), partial (CRS2), and complete/near-complete (CRS3) response to neoadjuvant chemotherapy. Descriptive statistics were used to evaluate baseline characteristics and feasibility of chemotherapy response score assessment. Univariate analyses were used to evaluate associations between the chemotherapy response score, complete cytoreduction, and survival.

RESULTS

This study included 40 patients. The median age was 63.5 years, and 31 patients (78%) had stage IV disease. Thirty patients had an omentectomy, 22 patients (73%) had an omental chemotherapy response score assigned. Thirty-nine patients had a bilateral salpingo-oophorectomy, 28 patients (72%) had an adnexal chemotherapy response score assigned. Omental CRS2 and CRS3 were associated with improved progression-free survival (CRS2: HR=0.18, p<0.01; CRS3: HR=0.11, p<0.01) and overall survival (CRS2: HR=0.10, p<0.01; CRS3: HR=0.16, p=0.04). Adnexal CRS2 and CRS3 were associated with improved progression-free survival (CRS2: HR=0.23, p<0.01; CRS3: HR=0.20, p=0.03). Chemotherapy response scores were also associated with an increased likelihood of having a complete cytoreduction.

CONCLUSION

Chemotherapy response score can be applied to omental and adnexal metastases in patients with advanced endometrial carcinoma and was associated with survival and complete cytoreduction. The score may be a prognostic indicator and help to guide first-line treatment of patients with endometrial carcinoma.

MiR-449b-5p inhibits human glioblastoma cell proliferation by inactivating WNT2B/Wnt/β-catenin signaling pathway

OBJECTIVE

As the most common primary brain cancer in adults, glioblastoma shows an extremely poor prognosis. Glioblastoma-associated deaths account for approximately 3%-4% of all malignancy-associated deaths. Numerous microRNAs (miRNAs) play important roles in the occurrence and progression of solid tumors. Herein, identifying functional miRNAs and the central molecular mechanisms would provide novel proofs for the development of targeted cancer therapies. In this study, we described the role of miR-449b-5p in restraining ontogenesis and progression of glioblastoma.

PATIENTS AND METHODS

Human glioblastoma tissues were provided by our hospital. Human U251 glioblastoma cells were infected with lentivirus induced miR-449b-5p mimics or miR-449b-5p siRNA. Real-time qPCR was carried out to determine miRNA expression. Tumor spheres formation, MTT assay, and BrdU cell proliferation assay were used to evaluate the growth ability of U251 cells. Western blot assay was performed to measure protein expression. ChIP was used to detect the capacity of β-catenin to recruit its downstream genes. Dual-Luciferase assay was conducted to detect the ability of miR-449b-5p to regulate the 3'UTR (untranslated regions) of WNT2B. TOP/FOP ratio was used to evaluate the activity of Wnt/β-catenin signaling pathway.

RESULTS

Down-regulation of miR-449b-5p expression was found in both human glioblastoma tissues and cell lines, which was negatively associated with the clinical stages. Up-regulation of miR-449b-5p inhibited tumor spheres formation, cell viability and proliferation ability of glioblastoma cells. The expression levels of WNT2B and nuclear β-catenin were negatively associated with miR-449b-5p levels in glioblastoma cells. MiR-449b-5p inhibited Wnt/β-catenin signaling by targeting WNT2B.

CONCLUSIONS

MiR-449b-5p acts as a tumor suppressor and retards the oncogenesis of glioblastoma, which is achieved via inactivation of Wnt/β-catenin signaling by directly targeting WNT2B.

Presence of opioid safety initiatives, prescribing patterns for opioid and naloxone, and perceived barriers to prescribing naloxone: Cross-sectional survey results based on practice type, scope, and location

BACKGROUND AND OBJECTIVES

The opioid epidemic is a public health crisis in the United States (US) and is associated with devastating consequences, including opioid misuse and related overdose. In response to the opioid crisis, the US Department of Health and Human Services is advancing improved practices in pain management. Strategies to help mitigate opioid risks include physician safety programs, hospital- or practice-based initiatives, patient education, and harm reduction campaigns that include the use of naloxone. To date, little information is available regarding the use of these strategies among healthcare providers. A survey was conducted to identify the presence of opioid safety initiatives, prescribing patterns of opioids and naloxone, and perceived barriers to prescribing naloxone. The presence of these strategies was compared between different practice types (hospital-based/academic vs. private practice), practice scope (chronic pain vs. "other"), and practice location (in the US vs. outside the US) Regarding "outside the US," the actual geographical distribution of those countries was not captured by respondents.

METHODS

A 13-question web-based anonymous cross-sectional survey was sent to members of the American Society of Regional Anesthesia and Pain Medicine and the Women in Pain Medicine online community via email and social media (Twitter and Facebook). Survey questions were designed to ascertain the presence of opioid safety initiatives, opioid and naloxone prescribing patterns, and perceived barriers to prescribing naloxone based on practice type (hospital-based/academic vs. private practice), scope (chronic pain vs. "other"), and location (in the US vs. outside the US).

RESULTS

Opioid safety initiatives: The presence of physician safety initiatives was found to be statistically higher among hospital-based/academic practices. No statistical difference was found for hospital- or practice-based, patient education, or harm reduction initiatives for different practice types (hospital-based/academic vs. private practice). The presence of patient education initiatives is statistically higher for chronic pain providers versus others. No statistical difference was found for physician safety, hospital- or practice-based, or harm reduction initiatives among the different practice scopes (chronic pain vs. others). The presence of opioid safety initiatives is statistically higher in the US compared with outside the US Prescribing patterns for opioids: Hospital-based/academic practices are more likely to prescribe opioids to patients suspected of the following: illicit or nonmedical drug use, recently released from prison or correctional facility, in opioid detoxification, a mandatory medication treatment program, and/or a current methadone maintenance program, and those having difficulty accessing emergency medical services. Chronic pain providers are more likely to prescribe opioids to patients taking antidepressants compared with "other" providers. Other providers are more likely to prescribe opioids to patients suspected of the following: illicit or nonmedical drug use, recently released from prison or correctional facility, in opioid detoxification, in mandatory medication treatment programs, in current methadone maintenance programs, and patients having difficulty accessing emergency medical services. There is no difference in opioid prescribing patterns based on practice location. Prescribing pattern for naloxone: Chronic pain providers and providers in the US are more likely to prescribe/recommend naloxone and are more aware of a state's medical board guidelines on naloxone prescribing. There is no statistical difference between practice types. Most providers, regardless of practice type, scope, or location, will coprescribe naloxone at a morphine milligram equivalent per day threshold of >50. Hospital-based/academic practices are more likely to prescribe naloxone to patients with opioid prescriptions and coexisting respiratory disease. Chronic pain providers are more likely to prescribe naloxone for patients with methadone prescriptions in opioid-naïve populations, coexisting respiratory, hepatic and/or renal dysfunction, known or suspected alcohol use, coprescribed benzodiazepine or antidepressants, and those having difficulty accessing emergency medical services. Based on practice location, providers in the US are more likely to prescribe naloxone for patients with opioid prescriptions and coexisting hepatic and/or renal dysfunction, known or suspected alcohol use, coprescribed benzodiazepine or antidepressants, recently released from a correctional facility, opioid detoxification program or mandatory abstinence program, and those having difficulty accessing emergency medical services. Perceived barriers to prescribing naloxone: We found no statistical difference regarding obstacles to prescribing naloxone based on practice type. The cost of the medication and lack of interest from patients are perceived barriers encountered by chronic pain providers versus other providers who do not have enough knowledge regarding when and how to prescribe for a patient. Based on practice location, perceived barriers for providers in the US are related to medication costs and lack of interest from patients.

CONCLUSION

While some improvements have been achieved in the fight against the opioid epidemic, our survey results indicate that further knowledge is needed to determine the potential obstacles to implementing opioid safety initiatives, understanding prescribing practices for opioids and naloxone, and lowering the barriers to prescribing naloxone based on practice type, scope, and location.

Effect of computer-assisted design and manufacturing cutting and drilling guides accompanied with pre-bent titanium plates on the correction of skeletal class II malocclusion: a randomized controlled trial

This study was performed to assess the effect of correcting skeletal class II malocclusion based on the application of computer-assisted design and manufacturing (CAD/CAM) cutting and drilling guides accompanied with pre-bent titanium plates. Fifty patients with skeletal class II malocclusion were recruited into this prospective randomized controlled clinical trial and assigned to two groups. Patients underwent bilateral sagittal split ramus osteotomy directed by CAD/CAM cutting and drilling guides accompanied with pre-bent titanium plates (group A) or CAD/CAM splints (group B). Postoperative assessments were performed. Differences between the virtually simulated and postoperative models were measured. Patients in both groups had a satisfactory occlusion and appearance. More accurate repositioning of the proximal segment was found in group A than in group B when comparing linear and angular differences to reference planes; however, no significant difference was revealed for the distal segment. In conclusion, CAD/CAM cutting and drilling guides with pre-bent titanium plates can provide considerable surgical accuracy for the positional control of the proximal segments in bilateral sagittal split ramus osteotomy for the correction of skeletal class II deformities.

Development and Pilot Study of an iOS Smartphone Application for Perioperative Functional Capacity Assessment

BACKGROUND

Functional capacity assessment plays a core role in the preoperative evaluation. The Duke Activity Status Index (DASI) and the 6-minute walk test (6MWT) are 2 methods that have demonstrated the ability to evaluate functional capacity and predict perioperative outcomes. Smartphones offer a novel method to facilitate functional capacity assessment as they can easily administer a survey and accelerometers can track patient activity during a 6MWT. We developed a smartphone application to administer a 6MWT and DASI survey and performed a pilot study to evaluate the accuracy of a smartphone-based functional capacity tool in our Anesthesia and Perioperative Medicine Clinic.

METHODS

Using the Apple ResearchKit software platform, we developed an application that administers a DASI survey and 6MWT on an iOS smartphone. The DASI was presented to the patient 1 question on the screen at a time and the application calculated the DASI score and estimated peak oxygen uptake (VO2). The 6MWT used the CMPedometer class from Apple's core motion facility to retrieve accelerometer data collected from the device's motion coprocessor to estimate steps walked. Smartphone estimated steps were compared to a research-grade pedometer using the intraclass correlation coefficient (ICC). Distance walked was directly measured during the 6MWT and we performed a multivariable linear regression with biometric variables to create a distance estimation algorithm to estimate distance walked from the number of steps recorded by the application.

RESULTS

Seventy-eight patients were enrolled in the study and completed the protocol. Steps measured by the smartphone application as compared to the pedometer demonstrated moderate agreement with an ICC (95% CI) of 0.87 (0.79-0.92; P = .0001). The variables in the distance estimation algorithm included (β coefficient [slope], 95% CI) steps walked (0.43, 0.29-0.57; P < .001), stride length (0.38, 0.22-0.53; P < .001), age in years (-1.90, -3.06 to -0.75; P = .002), and body mass index (-2.59, -5.13 to -0.06; P = .045). The overall model fit was R = 0.72, which indicates a moderate level of goodness of fit and explains 72% of the variation of distance walked during a 6MWT.

CONCLUSIONS

Our pilot study demonstrated that a smartphone-based functional capacity assessment is feasible using the DASI and 6MWT. The DASI was easily completed by patients and the application clearly presented the results of the DASI to providers. Our application measured steps walked during a 6MWT moderately well in a preoperative patient population; however, future studies are needed to improve the smartphone application's step-counting accuracy and distance estimation algorithm.

[Long-term outcome of childhood T-cell acute lymphoblastic leukemia treated with modified national protocol of childhood leukemia in China-acute lymphoblastic leukemia 2008]

Objective: To analyse the long-term efficacy in childhood T-cell acute lymphoblastic leukemia (T-ALL) cases enrolled in the national protocol of childhood leukemia in China-acute lymphoblastic leukemia (NPCLC-ALL) 2008. Methods: Clinical data of 96 patients diagnosed as T-ALL and treated with NPCLC-ALL2008 protocol between January 2009 and December 2017 in the Department of Hematology-Oncology, the Children's Hospital, Zhejiang University School of Medicine were analyzed retrospectively. Predictive value of minimal residual disease (MRD) monitored by flow cytometry was analyzed. Kaplan-Meier method was used for long-term survival analysis. Results: A total of 96 evaluable patients with newly diagnosed T-ALL were analysed, including 72 males and 24 females. The age was 9.5 (ranged from 1.0 to 16.0) years. The follow-up time was 5.7 (ranged from 1.0 to 9.7) years. Among 96 patients, 92 (96%) achieved complete remission. The 5-year event free survival (EFS) and overall survival (OS) rates were (61±6) % and (70±5) %, respectively. Relapse occurred in 18 cases and the 5-year cumulative incidence of relapse was (27±6) %. Twenty-four patients died. The 5-year OS rates of patients with MRD>5% on day 15 of induction therapy was significantly worse than those with MRD≤5% ((60±12) % vs. (72±6) %, χ(2)=3.904, P=0.048) . The 5-year EFS and OS rates were obviously lower in patients with MRD>10% before the consolidation therapy ((50±35) %). The 5-year OS rates of patients with relapsed disease was significantly worse than those without ((26±13) % vs. (81±5) %, χ(2)=18.411, P<0.01). The earlier the relapse, the worse the prognosis. The 5-year OS rates for patients relapsed within 6 months, within 3 years and more than 3 years, were (25±22) %, (30±14) % and (50±35) % respectively (χ(2)=13.207, P<0.01). Conclusions: NPCLC-ALL2008 protocol is effective for childhood T-ALL. The MRD guided accurate risk stratification and individualized treatment can reduce the relapse and improve the survival rate of pediatric T-ALL.

Chemotherapy response score as a prognostic tool in advanced-stage endometrial cancer patients treated with neoadjuvant chemotherapy

e18095

Background: Chemotherapy response score (CRS) applied to omental metastases obtained at the time of interval debulking surgery (IDS) has been used to quantify response to neoadjuvant chemotherapy (NACT) in advanced stage ovarian cancer patients. The score has been correlated with both progression free survival (PFS) and overall survival (OS). This CRS score has not been studied in advanced stage endometrial cancer. The aim of the current study is 1) to apply the CRS to omental and adnexal metastases obtained at IDS of advanced stage endometrial cancer patients and 2) to investigate the association between the CRS score and surgical outcome, PFS and OS. Methods: Patients with clinical stage III-IV endometrial cancer (endometrioid, serous, clear cell, carcinosarcoma) were identified through the endometrial cancer database, billing data and tumor board notes (2003-2019) from the University of Chicago. Patients were included if they received NACT followed by IDS (R0 no gross residual, optimal < 1 cm residual or suboptimal ≥ 1 cm residual disease). Patients who received pre-operative radiotherapy were excluded. Pathology specimens from primary and metastatic sites were reviewed by the study pathologist blinded to clinical outcome. Histologic specimens from the omental and adnexal metastases were assigned a single quantitative score of 1 (no/minimal tumor response), 2 (appreciable tumor response with viable tumor) or 3 (complete/near complete response) using the CRS system as previously described by Bohm et al (JCO 2015; 33:2457-63). Results: A total of 40 patients were available for analysis. Median age 63.5, median BMI 32 kg/m2. There is a significant association between omental CRS and optimal IDS (p = 0.029) but no significant association between the adnexal CRS and optimal IDS (p = 0.145). Cox regression analysis identified CRS omentum [2: HR = 0.095, p = 0.001; 3 HR = 0.088, p = 0.004] and CRS adnexa [2: HR = 0.24, p = 0.007] predictive of PFS. There was not enough evidence to comment on any association between CRS with OS. Conclusions: Omental CRS2, CRS3 are associated with optimal IDS. Omental CRS2, CRS3 and adnexal CRS2 are prognostic for improved PFS in stage III – IV endometrial cancer patients after neoadjuvant chemotherapy. [Table: see text]

AXIN2 gene silencing reduces apoptosis through regulating mitochondria-associated apoptosis signaling pathway and enhances proliferation of ESCs by modulating Wnt/β-catenin signaling pathway

OBJECTIVE

Embryonic stem cells (ESCs) mainly originate from totipotent cells in early-stage of mammalian embryo and could proliferate in a manner of un-limitation. This study aimed to investigate roles of Axin2 in proliferation of ESCs and explore the associated mechanisms.

MATERIALS AND METHODS

Axis inhibition protein 2 (AXIN2) over-expression (LV5-AXIN2) and AXIN2 RNA interfere (LV3-AXIN2-RNAi) vectors were structured and transfected into H9 cells. 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide (MTT) was used to evaluate cell proliferative activity. Flow cytometry analysis was employed to measure apoptosis of H9 cells. AXIN2, β-catenin, transcription factor 4 (TCF4), c-myc, c-jun and Cyclin D mRNA levels and protein expressions were determined using quantitative real-time PCR (qRT-PCR) and Western blotting assay.

RESULTS

LV5-AXIN2 and LV3-AXIN2-RNAi were successfully structured with higher transfecting efficacy. AXIN2 gene silencing remarkably increased proliferative activity and AXIN2 treatment significantly induced apoptosis of H9 cells, comparing with blank vector group (p<0.05). AXIN2 gene silencing significantly enhanced B-cell lymphoma-2 (Bcl-2) expression and remarkably inhibited cleaved caspase-3 expression comparing to that in blank vector group (p<0.05). AXIN2-RNAi treatment significantly enhanced and AXIN2 over-expression significantly reduced β-catenin and TCF4 expression, comparing to that in blank vector group (p<0.05). AXIN2 gene silence activated down-stream molecules of Wnt/β-catenin signaling pathway, including c-jun, c-myc, and Cyclin D1 (p<0.05).

CONCLUSIONS

AXIN2 gene silencing reduced apoptosis by regulating mitochondria-associated apoptosis signaling pathway and enhanced proliferation by modulating molecules in Wnt/β-catenin signaling pathway. Therefore, targeting of aberrant apoptosis and AXIN2 might be a novel clinical strategy to inhibit aging and enhance self-renewal of ESCs.

Adaptive regulation of detoxification enzymes in Helicoverpa armigera to different host plants

Cotton plants produce gossypol as a major secondary metabolite to resist insect herbivores and pathogens. Helicoverpa armigera may employ multigene families of detoxification enzymes to deal with this metabolite. So far, the strength of the transcriptional response to gossypol detoxification in the cotton bollworms remains poorly understood. Here, we investigated the genomewide transcriptional changes that occur in cotton bollworm larvae after one generation feeding on various host plants (cotton, corn, soybean and chili) or an artificial diet. Six genes potentially involved in detoxification of xenobiotics were highly upregulated in bollworms fed on cotton, and the expression of five of these differed significantly in insects that fed on gossypol diet compared with the artificial diet. When these six genes were downregulated using RNA interference, downregulation only of CYP4L11, CYP6AB9 and CCE001b led to reduced growth of bollworm larvae feeding on gossypol diets. These data suggest that the three genes are involved in response of H. armigera to gossypol of cotton. Our results proved that H. armigera may have a broad mechanism for gossypol detoxification.

[Clinical analysis of Langerhans cell histiocytosis originating in the base of nasal skull]

Objective:To summarize the clinical features, diagnosis and treatment of Langerhans histiocytosis（LCH） which first appeared in the nasal skull base. Method:Ten cases of LCH with nasal and skull base symptoms were analyzed retrospectively. The clinical characteristics of LCH with nasal and skull base symptoms were summarized. The correlation of other systems involved in LCH was analyzed. Result:Among the 10 patients, the youngest was 1 year and 5 months, and the oldest was 8 years, the average age was 3 years. The main imaging manifestations were osteolytic changes and soft tissue invasion. Seven patients were monofocal and three patients were multifocal. For localized lesions, radical resection and follow-up chemotherapy were performed, and conservative treatment was performed for patients with multiple system involvement and obvious systemic symptoms. Eight patients survived, 2 died. Conclusion:LCH occurs frequently in children and has certain clinical characteristics. Single system and single lesion surgery have a better therapeutic effect, and can achieve a greater survival rate with follow-up chemotherapy.

Partially Covered Versus Uncovered Self-Expandable Metal Stents: Coating Nor Diameter Affect Clinical Outcomes

INTRODUCTION

Jaundice is a common initial presentation of malignant biliary stricture. In patients with life expectancies that are greater than 3 months, self-expanding metal stents (SEMS) offer a larger diameter stent with longer patency and fewer complications compared to plastic stents. There have been conflicting results in the published literature as to efficacy and safety between the various SEMS types and diameters. We compared stent coating (PCSEMS vs USEMS) and diameter on clinical outcomes regarding management of malignant biliary obstruction.

METHODS

A retrospective cohort study was conducted using a database of consecutive patients who underwent an ERCP with biliary SEMS placement (only 8 and 10 mm) between 2009 and 2017.

RESULTS

In total, 278 patients who had SEMS at ERCP for malignant biliary obstruction were included (213 PCSEMS vs 65 USEMS). The groups were demographically evenly matched. Clinical success rates and patency duration were not statistically significant between PCSEMS and USEMS (98.1% vs 95.5%, P = 0.36, and 302.5 vs 225.5 days, P = 0.72, respectively). Adverse event rates were similar between both PCSEMS and USEMS with regard to overall adverse events. Stent diameter did not have an impact on overall clinical success (98.9% vs 95.3%, P = 0.11) or patency duration (239 days vs 336 days, P = 0.51).

CONCLUSIONS

Our comparison of PCSEMS versus USEMS and 8 mm versus 10 mm showed no difference in clinical efficacy or adverse events between the two SEMS coatings and diameter, illustrating that coating and size do not matter in regard to stent choice, despite prior suggestive data.

Gender Bias Affects Assessment of Frailty and Recommendations for Surgery

BACKGROUND

Physician gender bias in surgical treatment recommendations is recognized but not well understood. This study hypothesized that gender differences may exist in interpretation of patients' physical behaviors and that these differences may be associated with decision making by providers and surrogate decision makers.

METHODS

A pool of Amazon Mechanical Turk workers was solicited to participate in an online assessment. Workers viewed 3 short videos of standardized patients (SPs) trained to exhibit physical characteristics of vigorous, frail, and neither vigorous nor frail (average) behavior and then answered survey questions related to video characteristics and whether they would support the SP's decision to undergo an indicated major lung resection.

RESULTS

There were 724 participating workers; their mean age was 42.6 ± 11.8 years, and 386 were women. Men judged the average SP to be younger (P = .025), and women were more likely to recognize weight loss in the frail SP (P = .009). Overall, men and women were equally supportive of lung resection when indicated. The likelihood of supporting a decision to proceed with resection was inversely related to SP distress (P < .001) and was directly related to increasing gait speed (P < .001), energy (P < .001), and strength (P < .001). Male participants were less likely to support resection related to higher energy (P = .02) and strength levels (P = .016).

CONCLUSIONS

Gender differences exist in how video portrayal of patient frailty is perceived and affects surgical recommendations. Understanding such differences may aid in educational efforts directed at reducing gender-based biases in treatment recommendations by physicians and surrogate decision makers.

Effect of infectious bursal disease virus infection on energy metabolism in embryonic chicken livers

1. The purpose of this study was to investigate ATP levels and the activities of important enzymes involved in glycolysis and TCA cycle in livers of embryonated chicken eggs infected by infectious bursal disease virus (IBDV).2. Embryonated chicken eggs (9 days) were randomly divided into two groups (50 eggs per group). The first group was inoculated with a very virulent IBDV (vvIBDV) isolate into the chorioallantoic membrane. The second group was maintained as uninfected control eggs and inoculated with physiological saline. Embryo survival was assessed daily, and six embryos were sacrificed at 24, 48, 72, 96, and 120 hpi for examining livers. Viral loads in the livers were evaluated by qRT-PCR. A comparative analysis of markers associated with the regulation of energy metabolism across several functional classes (ATP, pyruvic and lactic acids, mitochondrial protein, NAD+/NADH ratios, and enolase, lactic acid dehydrogenase and the respiratory chain complex I activities) were examined in the context of IBDV infection.3. The results indicated that increases in the enzymatic activities associated with glycolytic metabolism in turn affected the synthesis and cytoplasmic concentrations of ATP at early timepoints in infected chicken embryos. Subsequently, energy metabolism was inhibited through the pathological perturbations of metabolic enzymes and mitochondrial damage, as inferred from reduced ATP generation.4. These results suggested impaired bioenergetics, which may lead to liver dysfunction consequent to IBDV infection, contributing to the disease pathogenesis.

Impact of Angiotensin II Signaling Blockade on Clinical Outcomes in Patients with Inflammatory Bowel Disease

BACKGROUND

Preclinical data demonstrate that activation of the renin-angiotensin system (RAS) contributes to mucosal inflammation, and RAS inhibition by angiotensin-converting-enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) improves colitis in animal models. Less is known regarding the effects of RAS inhibition on clinical outcomes in inflammatory bowel disease (IBD) patients.

AIM

Evaluate the impact of ACEI and ARB on clinical outcomes in IBD.

METHODS

Rates of IBD-related hospitalizations, operations, and corticosteroid use were evaluated retrospectively in two groups. First, 111 IBD patients taking an ACEI or ARB were compared to nonusers matched 1:1 based on sex, age, diagnosis, disease location, and hypertension diagnosis. Second, outcomes in a cohort of 130 IBD patients were compared prior to and during ACEI/ARB exposure.

RESULTS

Compared to matched controls, all IBD patients together with ACEI/ARB exposure had fewer hospitalizations (OR 0.26, p < 0.01), operations (OR 0.08, p = 0.02), and corticosteroid prescriptions (OR 0.5, p = 0.01). Comparing outcomes before and during ACEI/ARB use, there were no differences in hospitalizations, operations, or corticosteroid use for all IBD patients together, but patients with UC had increased hospitalizations (0.08 pre- vs. 0.16 during ACEI/ARB exposure, p = 0.03) and decreased corticosteroid use (0.24 pre-ACEI/ARB vs. 0.12 during ACEI/ARB exposure, p < 0.01) during ACEI/ARB use.

CONCLUSIONS

IBD patients with ACEI/ARB exposure had fewer hospitalizations, operations, and corticosteroid use compared to matched controls. No differences in outcomes were observed in individuals on ACEI/ARB therapy when compared to a period of time prior to medication exposure.

Investigation of a multimedia, computer-based approach to improve knowledge, attitudes, self-efficacy, and receptivity to cancer clinical trials among newly diagnosed patients with diverse health literacy skills

BACKGROUND

Enrollment in therapeutic cancer trials remains low, and is especially challenging for patients with low health literacy. The authors tested an interactive technology designed for patients with diverse health literacy skills with the aim of improving patient receptiveness, willingness, knowledge, self-efficacy, and positive attitudes regarding clinical trials.

METHODS

Patients presenting for their first oncology appointment were eligible. Patients viewed an interactive teaching video concerning clinical trials that was adapted from the National Institutes of Health. Validated surveys assessing receptiveness, willingness, knowledge, self-efficacy, and positive attitudes regarding clinical trials were administered before and after the test.

RESULTS

A total of 120 patients with cancer were enrolled. Approximately 80% were non-Hispanic white, 33% were female, 69% had >high school education, and 8% reported an income <$20,000. Approximately 33% scored within the low health literacy range. Changes between pretest and posttest demonstrated increases in knowledge (P < .001), self-efficacy (P < .001), and positive beliefs (P = .004); a slight decrease in willingness (P = .009); and no difference in patient receptivity (P = .31). Higher health literacy was associated with improved willingness (P = .049) and non-Hispanic white race was associated with improved receptivity (P = .034).

CONCLUSIONS

Interactive technology that was designed for patients with diverse health literacy skills demonstrated the ability to improve knowledge, self-efficacy, and positive beliefs regarding cancer clinical trials. Contrary to the hypothesis of the current study, patients with lower health literacy did not appear to derive a greater advantage from this technology. There was no improvement noted with regard to patient willingness or receptivity, and clinical trial enrollment remained at historical institutional levels. Talking touchscreen technology has a potential role as an important element in informed decision making for patients, but likely needs to be coupled with more robust and multitargeted interventions.

Colorism Demonstrates Dampened Effects Among Young Black Men Who Have Sex with Men in Chicago

BACKGROUND/PURPOSE

Colorism is a well documented phenomenon affecting the health, income, education, and psychological wellbeing of African Americans with differing skin tones. There is little research, however, around how colorism may operate among intersectional racial sexual minorities, who additionally face both racism and homophobia, despite evidence that different forms of oppression interact with each other and may have modulating effects in this population. This study aims to clarify the effect colorism has on a variety of life and health outcomes in young black men who have sex with men (YBMSM).

METHODS

Data were obtained from interviews conducted as part of the uConnect study, a longitudinal cohort study of YBMSM on the South Side of Chicago. Skin color of participants was rated by independent raters.

RESULTS

While some previously found patterns in African American heterosexuals were observed in this population, most were not.

CONCLUSION

The effects of colorism did not appear to have a significant role among this population across a wide set of social and health domains.

CommunityRx: A Real-World Controlled Clinical Trial of a Scalable, Low-Intensity Community Resource Referral Intervention

OBJECTIVES

To test the effect of CommunityRx, a scalable, low-intensity intervention that matches patients to community resources, on mental health-related quality of life (HRQOL) (primary outcome), physical HRQOL, and confidence in finding resources.

METHODS

A real-world trial assigned publicly insured residents of Chicago, Illinois, aged 45 to 74 years to an intervention (n = 209) or control (n = 202) group by alternating calendar week, December 2015 to August 2016. Intervention group participants received usual care and an electronic medical record-generated, personalized list of community resources. Surveys (baseline, 1-week, 1- and 3-months) measured HRQOL and confidence in finding community resources to manage health.

RESULTS

At 3 months, there was no difference between groups in mental (-1.03; 95% confidence interval [CI] = -3.02, 0.96) or physical HRQOL (0.59; 95% CI = -0.98, 2.16). Confidence in finding resources was higher in the intervention group (odds ratio = 2.08; 95% CI = 1.18, 3.63); the effect increased at each successive time point. Among intervention group participants, 65% recalled receiving the intervention; 48% shared community resource information with others.

CONCLUSIONS

CommunityRx did not increase HRQOL, but its positive effect on confidence in finding resources for self-care suggests that this low-intensity intervention may have a role in population health promotion.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02435511.