Variability of fibrinolytic activity in pregnant patients exposed to tissue plasminogen activator: an in vitro study utilizing rotational thromboelastometry

BACKGROUND

The investigation into the variability of fibrinolysis in obstetric patients is notably limited despite its relevance to postpartum hemorrhage. We investigate an in vitro model of fibrinolysis measured by rotational thromboelastrometry (ROTEM) in maternal blood samples with lysis stimulated by tissue plasminogen activator (tPA).

METHODS

Written informed consent was obtained from 19 patients at term pregnancy during admission to the labor and delivery unit. Patients who were taking medication affecting coagulation were excluded. Tissue plasminogen activator was added to whole blood samples to a final concentration of 100 or 220 ng/mL prior to ROTEM testing.

RESULTS

The addition of tPA produced high intra-individual fibrinolytic variability for clot firmness and lysis parameters. Patients responded differently to each tPA dose ranging from clot lysis within the range of 0 ng/mL tPA group to complete clot lysis. The coefficient of variation (CV) values for the 220 ng/mL tPA group were: EXTEM MCF 0.510, EXTEM LI30 1.601, FIBTEM MCF 0.349, FIBTEM LI30 2.097. CV values for the 100 ng/mL tPA group were: EXTEM MCF 0.144, EXTEM LI30 1.038, FIBTEM MCF 0.096, FIBTEM LI30 1.238.

CONCLUSION

We demonstrate a wide range of fibrinolytic response in the obstetric population to exogeneous tPA. We found subgroups of patients that were very responsive to tPA and insensitive to tPA. This study represents a preliminary exploration into classifying the obstetric fibrinolytic phenotypes. Further research will integrate relevant coagulation factors to establish a predictive model for testing susceptibility to lysis that can be applied at the point of care.

Coaching Program to Address Burnout, Well-Being, and Professional Development in Pediatric Surgery Trainees: A Randomized Controlled Trial

OBJECTIVE

To assess impact of participation in a positive psychology coaching program on trainee burnout and well-being.

BACKGROUND

Coaching using principles of positive psychology can improve well-being and reduce physician burnout. We hypothesized that participation in a coaching program would improve pediatric surgery trainee well-being.

METHODS

With IRB approval, a coaching program was implemented during the COVID-19 pandemic (9/2020-7/2021) in the American Pediatric Surgical Association. Volunteer pediatric surgery trainees (n=43) were randomized to receive either one-on-one quarterly virtual coaching (n=22) from a pediatric surgeon trained in coaching skills or wellness reading materials (n=21). Participants completed pre- and post-study surveys containing validated measures including PERMA (positive emotion, engagement, relationships, meaning, accomplishment), professional fulfillment, burnout, self-valuation, gratitude, coping skills, and workplace experiences. Results were analyzed using Wilcoxon rank sum test, Kruskal-Wallis test, or chi-square test.

RESULTS

Forty trainees (93%) completed both the baseline and year-end surveys and were included in the analysis. Twenty-five (64%) were female, mean age 35.7 (SD 2.3), 65% first-year fellows. Coached trainees showed an improved change in PERMA (P=0.034), burnout (P=0.024), and gratitude (P=0.03) scores from pre- to post-coaching compared to non-coached trainees. Coping skills also improved. More coaching sessions was associated with higher self-valuation scores (P=0.042), and more opportunities to reflect was associated with improved burnout and self-valuation.

CONCLUSIONS

Despite the stress and challenges of medicine during COVID-19, a virtual positive psychology coaching program provided benefit in well-being and burnout to pediatric surgery trainees. Coaching should be integrated into existing wellness programs to support acquisition of coping skills that help trainees cope with the stressors they will face during their careers.

Is Attachment and Biobehavioral Catch-up effective for parents with insecure attachment states of mind?

Prior research suggests that attachment-based interventions, including Attachment and Biobehavioral Catch-up (ABC), may be less effective at enhancing parenting quality among parents who self-report having an insecure attachment style. The current study tested whether effects of ABC on parental behavior were moderated by categorical and dimensional measures of attachment obtained via Adult Attachment Interviews with 454 parents who were approximately 34 years old, primarily female, and predominantly White or African American. Parents randomized to ABC exhibited higher sensitivity and positive regard, and lower intrusiveness shortly after the intervention than parents randomized to the control intervention (|β|s = .10-.27). The effect of ABC on intrusiveness persisted 2 years later. Effects at either timepoint were not significantly moderated by parents' attachment representations.

Superficial Siderosis After Traumatic Brain Injury: A Case Report

Superficial siderosis (SS) is a rare condition in which chronic accumulation of the blood in the subarachnoid space over time leads to the buildup of hemosiderin deposits, which in turn cause neurological dysfunction in those affected. While reversibility of the damage done by this condition is nearly impossible, early detection can allow for immediate surgical intervention and thus prevent further progression of ataxia, hearing loss, and other neurological deficits caused by SS. We present a case of a 53-year-old male who was successfully diagnosed with SS secondary to a chronic post-traumatic pseudomeningocele and underwent surgical repair with the resolution of his symptoms. We aim to encourage more extensive workups for common neurological dysfunctions such as tinnitus or vertigo in patients who have a history of traumatic brain injury or any significant motor vehicle accidents.

Congenital Portosystemic Shunts: Variable Clinical Presentations Requiring a Tailored Endovascular or Surgical Approach

Congenital portosystemic shunts (CPSS) are rare developmental anomalies resulting in diversion of portal flow to the systemic circulation. These shunts allow intestinal blood to reach the systemic circulation directly, and if persistent or large, may lead to long-term complications. CPSS can have a variety of clinical presentations that depend on the substrate that is bypassing hepatic metabolism or the degree of hypoperfusion of the liver. Many intrahepatic shunts spontaneously close by 1 year of age, but extrahepatic and persistent intrahepatic shunts require intervention by a single session or staged closure with a multidisciplinary approach. Early detection and appropriate management are important for a good prognosis. The aim of this case series is to describe the varied clinical presentations, treatment approaches, and outcomes of 5 children with CPSS at our institution. Management of these patients should involve a multidisciplinary team, including interventional radiology, surgery, hepatology, and other medical services as the patient's clinical presentation warrants. Regardless of clinical presentation, if a CPSS persists past 1-2 years of age, closure is recommended.

POS1332 TOWARD SAFER GLUCOCORTICOID THERAPY OF POLYMYALGIA RHEUMATICA

Background

SPI-62 is a potent 11β-hydroxysteroid dehydrogenase type 1 (HSD-1) inhibitor entering Phase 2 development as adjunctive therapy to prednisolone in polymyalgia rheumatica, as well as for treatment of Cushing’s syndrome and autonomous cortisol secretion. HSD-1, an intracellular enzyme, activates glucocorticoids in target tissues in which glucocorticoid medicines are associated with morbidity including liver, adipose, muscle, and skin. In Phase 1 clinical trials SPI-62 was generally well tolerated and associated with maximal liver and brain HSD-1 inhibition.

Objectives

To demonstrate mitigation by SPI-62 of corticosterone (CORT) adverse effects in mouse.

Methods

C57BL/6 male mice (age 7 weeks; n=14 per group) were administered CORT (100 g/mL in drinking water) and SPI-62 (by gavage in 0.5% HPMC; 0, 1, or 10 mg/kg/day or 10 mg/kg twice daily) for 35 days. A control group received no CORT or SPI-62. Body weight was assessed daily and food consumption twice weekly. Whole body muscle and fat amounts were measured at Days 0, 14, and 28 using an EchoMRI-130H body composition analyzer. Blood samples for fasting glucose and insulin were obtained at Days 1 (pre-dose), 15, 29, and 35. An open field test was conducted on Day 22. A grip strength test was performed on Day 28. After sacrifice on Day 36, gonadal, subcutaneous, retroperitoneal, and mesenteric fat, quadriceps, and tibialis anterior were dissected and weighed, and skin was formalin fixed and paraffin embedded.

Results

One control mouse died due to accidental gavage injury. Two mice who received CORT + 0.5% HPMC died on Days 11 and 19. CORT resulted in increased food consumption which was normalized by SPI-62 in a dose-dependent manner. CORT-treated mice showed reduced body weight gain for 2 weeks then accelerated body weight gain. SPI-62 prevented body weight gain acceleration in a dose-dependent manner. CORT effects on dermal thickness and structure were less prominent in mice who also received SPI-62. No effect of CORT or SPI-62 was observed in the open field test. SPI-62 prevented CORT adverse effects of insulin resistance, increased adiposity, skeletal myoatrophy, and grip strength reduction (Table 1).

Table 1.

Observed percentage difference of treatment group mean, compared to control group mean, in CORT-treated mice

SPI-62 treatmentnone1 mg/kg1x/day10 mg/kg1x/day10 mg/kg2x/dayHOMA-IR Day 15+422+428+104+8HOMA-IR Day 29+788+472+204+14HOMA-IR Day 35+3620+1270+324+92Body fat content Day 14*+110+72-13-7Body fat content Day 28*+166+102+63-12Gonadal fat weight*+151+74+39-1Subcutaneous fat weight*+471+121+83+7Retroperitoneal fat weight*+227+89+36+25Mesenteric fat weight*+240+133+124+71Body muscle content Day 14*-10-70+1Body muscle content Day 28*-15-8-6+3Quadriceps weight*-54-43-24-16Tibialis anterior weight*-35-29-5+5Grip strength-12+16+15+26

*Normalized by body weight.

Conclusion

SPI-62 prevented several CORT adverse effects in mouse, demonstrating that blockade of local intracellular glucocorticoid activation by a HSD-1 inhibitor in target tissues can mitigate glucocorticoid toxicity. These results suggest that SPI-62 has potential to similarly mitigate adverse effects of glucocorticoid medications in human. A placebo-controlled Phase 2 clinical trial has been initiated to compare prednisolone effects with and without SPI-62. Up to 48 patients diagnosed with polymyalgia rheumatica, on stable prednisolone 10 mg daily for at least 2 weeks, and with stable disease inactivity based on acute phase biomarkers will continue prednisolone 10 mg daily for 4 weeks, during which they will receive SPI-62 or placebo for 2 weeks each. Acute phase and other immune function biomarkers, symptom measures, and biomarkers of prednisolone adverse effects will be assessed at baseline and after each 2-week period. After analysis of data from a first cohort of 12 patients the prednisolone dose might be adjusted, in blinded fashion, during the SPI-62 period to maintain equipotency on acute phase biomarker suppression.

Disclosure of Interests

Xingyu Pan: None declared, Qiongqiong Hou: None declared, Jiahui Xu: None declared, Yake Ma: None declared, Jiawen Li: None declared, Min Li: None declared, Jing Su: None declared, Xuerou Shi: None declared, William Bracken Consultant of: Sparrow Pharmaceuticals, David Katz Shareholder of: Sparrow Pharmaceuticals, Employee of: Sparrow Pharmaceuticals

Timing of adoption is associated with electrophysiological brain activity and externalizing problems among children adopted internationally

This study investigated middle childhood resting electroencephalography (EEG) and behavioral adjustment in 35 internationally adopted children removed from early caregiving adversity between 6 and 29 months of age. Older age of adoption was associated with more immature or atypical profiles of middle childhood cortical function, based on higher relative theta power (4-6 Hz), lower relative alpha power (7-12 Hz), lower peak alpha frequency, and lower absolute beta (13-20 Hz) and gamma (21-50 Hz) power. More immature or atypical EEG spectral power indirectly linked older age of adoption with increased risk for externalizing problems in middle childhood. The findings add to existing evidence linking duration of early adverse exposures with lasting effects on brain function and behavioral regulation even years after living in a stable adoptive family setting. Findings underscore the need to minimize and prevent children's exposures to early caregiving adversity, especially in the first years of life. They call for innovative interventions to support neurotypical development in internationally adopted children at elevated risk.

Prospective risk from prenatal anxiety to post traumatic stress following childbirth: The mediating effects of acute stress assessed during the postnatal hospital stay and preliminary evidence for moderating effects of doula care

OBJECTIVE

Growing literature has identified childbirth as a potentially traumatic event, following which mothers may develop symptoms of Post-Traumatic-Stress-Following-Childbirth. The current study is the first to prospectively examine a pathway of risk from mothers' prenatal trait-anxiety, to Acute-Stress-Immediately-Following-Childbirth, and later symptoms of Post-Traumatic-Stress-Following-Childbirth, in a low-risk community sample. Auxiliary analyses explored whether doula care during childbirth moderated risk.

METHOD

149 pregnant women were randomly selected. Prenatal trait-anxiety was assessed toward the end of pregnancy, Acute-Stress-Immediately-Following-Childbirth at two-days post-partum, and symptoms of Post-Traumatic-Stress-Following-Childbirth at one-month post-partum.

RESULTS

Results indicated a significant indirect pathway from prenatal trait-anxiety to Post-Traumatic-Stress-Following-Childbirth, through Acute-Stress-Immediately-Following-Childbirth. Two groups were generated ad hoc for auxiliary analyses: participants who opted to receive doula care during childbirth (n=21; 14%) versus participants who received care as usual (n=128; 86%). Analyses provided preliminary support for doula care as a potential moderator of risk.

CONCLUSIONS

Results point toward prenatal trait-anxiety and Acute-Stress-Immediately-Following-Childbirth as significant risk factors for Post-Traumatic-Stress-Following-Childbirth. Findings inform preventive screening implicating the prenatal period as well as the postnatal hospital stay as important time windows for preventive screening. Finally, preliminary support for moderating effects of doula care suggest that preventive interventions administered during the perinatal period may effectively reduce anxiety-related risk for Post-Traumatic-Stress-Following-Childbirth.

Cystic papillary adenoma of the seminal vesicle

Background

Primary Seminal Vesicle (SV) tumours are a rare entity, with most SV masses representing invasion of the SV by malignancy originating in an adjacent organ, most often the prostate. Previously reported primary SV epithelial tumours have included adenocarcinoma and cystadenoma, with limited prior reports of inracystic papillary structures.

Case presentation

A 35-year-old male presented with azoospermia, intermittent macroscopic haematuria, and mild right iliac fossa and groin pain. A papillary appearing seminal vesicle mass was found on imaging and seminal vesicoscopy. The mass was robotically excised with diagnosis of benign cystic papillary adenoma made.

Conclusion

In this manuscript we describe a rare case of a benign cystic papillary adenoma of the seminal vesicle, a unique histological entity differentiated from cystadenoma of the Seminal Vesicle by its papillary component.

Can measuring blood loss at delivery reduce hemorrhage-related morbidity?

Quantitation of blood loss after vaginal and cesarean delivery has been advocated for the timely detection of postpartum hemorrhage and activation of protocols for resuscitation. Morbidity and mortality from postpartum hemorrhage is considered to be largely preventable and is attributed to delayed recognition with under-resuscitation or inappropriate resuscitation. Optimizing detection of postpartum hemorrhage through refining how blood loss is measured is therefore clinically relevant. In this review on quantitative blood loss for postpartum hemorrhage, recent advances in the methods used to quantitate blood loss will be reviewed, with a comparison of utility and precision for blood loss measurement after vaginal and cesarean delivery. Considerations for the implementation of a quantitative blood loss system on the labor and delivery unit, including its benefits and challenges, will be discussed. The existing evidence for impact of blood loss quantitation in obstetrics on hemorrhage-related morbidity will be delineated, along with knowledge gaps and future research priorities.

Pain expectancy, prevalence, severity, and patterns following donor nephrectomy: Findings from the KDOC Study

Postoperative pain is an outcome of importance to potential living kidney donors (LKDs). We prospectively characterized the prevalence, severity, and patterns of acute or chronic postoperative pain in 193 LKDs at six transplant programs. Three pain measurements were obtained from donors on postoperative Day (POD) 1, 3, 7, 14, 21, 28, 35, 41, 49, and 56. The median pain rating total was highest on POD1 and declined from each assessment to the next until reaching a median pain-free score of 0 on POD49. In generalized linear mixed-model analysis, the mean pain score decreased at each pain assessment compared to the POD3 assessment. Pre-donation history of mood disorder (adjusted ratio of means [95% confidence interval (CI)]: 1.40 [0.99, 1.98]), reporting "severe" on any POD1 pain descriptors (adjusted ratio of means [95% CI]: 1.47 [1.12, 1.93]) and open nephrectomy (adjusted ratio of means [95% CI]: 2.61 [1.03, 6.62]) were associated with higher pain scores across time. Of the 179 LKDs who completed the final pain assessment, 74 (41%) met criteria for chronic postsurgical pain (CPSP), that is, any donation-related pain on POD56. Study findings have potential implications for LKD education, surgical consent, postdonation care, and outcome measurements.

SOCE and STIM1 signaling in the heart: Timing and location matter

Store operated Ca²⁺ entry (SOCE) is an ancient and ubiquitous Ca²⁺ signaling pathway discovered decades ago, but the function of SOCE in human physiology is only now being revealed. The relevance of this pathway to striated muscle was solidified with the description of skeletal myopathies that result from mutations in STIM1 and Orai1, the two SOCE components. Here, we consider the evidence for STIM1 and SOCE in cardiac muscle and the sinoatrial node. We highlight recent studies revealing a role for STIM1 in cardiac growth in response to developmental and pathologic cues. We also review the role of STIM1 in the regulation of SOCE and Ca²⁺ store refilling in a non-Orai dependent manner. Finally, we discuss the importance of this pathway in ventricular cardiomyocytes where SOCE contribute to developmental growth and in pacemaker cells where SOCE likely has a fundamental to generating the cardiac rhythm.

Mood, body image, fear of kidney failure, life satisfaction, and decisional stability following living kidney donation: Findings from the KDOC study

Prior studies demonstrate that most living kidney donors (LKDs) report no adverse psychosocial outcomes; however, changes in psychosocial functioning at the individual donor level have not been routinely captured. We studied psychosocial outcomes predonation and at 1, 6, 12, and 24 months postdonation in 193 LKDs and 20 healthy controls (HCs). There was minimal to no mood disturbance, body image concerns, fear of kidney failure, or life dissatisfaction, indicating no incremental changes in these outcomes over time and no significant differences between LKDs and HCs. The incidence of any new-onset adverse outcomes postdonation was as follows: mood disturbance (16%), fear of kidney failure (21%), body image concerns (13%), and life dissatisfaction (10%). Multivariable analyses demonstrated that LKDs with more mood disturbance symptoms, higher anxiety about future kidney health, low body image, and low life satisfaction prior to surgery were at highest risk of these same outcomes postdonation. It is important to note that some LKDs showed improvement in psychosocial functioning from pre- to postdonation. Findings support the balanced presentation of psychosocial risks to potential donors as well as the development of a donor registry to capture psychosocial outcomes beyond the mandatory 2-year follow-up period in the United States.

Vaginal film for prevention of HIV: using visual and tactile evaluations among potential users to inform product design

Topical prevention of HIV and other STIs is a global health priority. To provide options for users, developers have worked to design safe, effective and acceptable vaginal dissolving film formulations. We aimed to characterize user experiences of vaginal film size, texture and color, and their role in product-elicited sensory perceptions (i.e. perceptibility), acceptability and willingness to use. In the context of a user-centered product evaluation study, we elicited users' 'first impressions' of various vaginal film formulation designs via visual and tactile prototype inspection during a qualitative user evaluation interview. Twenty-four women evaluated prototypes. Participants considered size and texture to be important for easy insertion. Color was more important following dissolution than prior to insertion. When asked to combine and balance all properties to arrive at an ideal film, previously stated priorities for individual characteristics sometimes shifted, with the salience of some individual characteristics lessening when multiple characteristics were weighted in combination. While first impressions alone may not drive product uptake, users' willingness to initially try a product is likely impacted by such impressions. Developers should consider potential users' experiences and preferences in vaginal film design. This user-focused approach is useful for characterizing user sensory perceptions and experiences relevant to early design of prevention technologies.

Growth, morphometrics, and nutrient content of farmed eastern oysters, Crassostrea virginica (Gmelin), in New Hampshire, USA

When harvested, oysters represent a removal from the ecosystem of nutrients such as nitrogen (N) and carbon (C). A number of factors potentially affect nutrient content, but a quantitative understanding across the geographic range of the eastern oysters is lacking. The present study was designed to quantify the relationships among various metrics of farmed eastern oysters near its northern geographic range focusing on nutrient content. Hatchery-reared oysters were deployed in polyethylene bags at six sites, and were measured on multiple occasions from 2010-2012. A quadratic polynomial fit to the combined datasets for shell height indicated that on average a 'cocktail' size oyster (63 mm shell height) would be reached after 2 yr, and 'regular' size (76 mm) would require 3 yr. There were significant differences in growth rates and oyster nutrient content among the sites; means for %N in soft tissue ranged from 6.9 to 8.6, and 0.07 to 0.18 in shell. Percent N in soft tissue and shell were highest at two sites at the mouths of rivers with elevated dissolved inorganic N concentrations in the water. Grand means (all sites, seasons and years combined) of soft tissue N and C for regular size oysters were 7.3% and 38.5%, respectively; and for shell N and C were 0.13% and 12.0%, respectively. Our study extends the range of data on nutrient content of the eastern oyster to northern New England, and indicates that oyster size, seasonality, and nutrient concentration in ambient water potentially affect %N and %C content of oysters.

Abstract P2-12-01: Comprehensive genomic profiling of 34 cases of breast angiosarcoma

Background: Angiosarcoma of the breast (BAS) is a rare but lethal neoplasia, either arising de novo or secondary to radiation therapy, with incidence of the latter disease increasing. We queried a database of more than 70,000 advanced cancer patients assayed with comprehensive genomic profiling (CGP) in the course of clinical care to uncover the frequency, type and associated genomic alterations (GA) in BAS and to highlight possible routes to benefit from targeted therapy.

Methods: CGP was performed for 34 BAS cases using a hybrid-capture, adaptor ligation based next generation sequencing assay of up to 315 genes to a mean coverage depth of >500X. The results were analyzed for base substitutions, short insertions and deletions, selected rearrangements, and copy number changes. RNA sequencing for 265 genes was also performed for 24 cases. Limited clinical histories from submitted pathology reports were reviewed under IRB permission.

Results: Clinical specimens from 34 BAS patients, all females, were assayed. The cases harbored 87 total GA for a mean of 2.59 per case, 25% of which were copy number amplifications. The most commonly altered genes were MYC (41%, 14/34), PIK3CA (26%, 9/34), and KDR (26%, 9/34). All MYC alterations were amplifications with a mean copy number of 39, and alterations in other MYC family members (MYCN and MYCL1) were not observed. KDR was recurrently altered as T771R (7/9) and T771K (1/9) and amplified in one case (1/9).

MYC and KDR alterations were mutually exclusive (p<0.0001). 6/14 MYC amplified cases had prior histories of breast carcinoma, with 3/6 noted as being treated with radiation therapy. For the remainder of MYC amplified cases (8/14), no relevant clinical history was available.

Two cases harboring gene fusions were identified including CIC-MEGF8 and NTRK1-PEAR1. Two rearrangements of potential functional significance including CIC-DEDD2 and HT-ALK (exon1 HT - exon5-29 ALK including kinase domain) were also observed. The case harboring HT-ALK also had MYC amplification and known prior radiation therapy. Two other MYC amplified cases also harbored targetable kinase alterations, including FLT4 amplification (described as targetable in Ravi et al JNCCN 2016) and FGFR3 S249C, a known activating mutation.

Conclusions: MYC amplification defines over 40% (14/34) of advanced BAS cases. Of MYC amplified cases, 28% (4/14) harbored targetable alterations of tyrosine kinases including a potential novel ALK fusion. FLT4 amplification only co-occurred with MYC amplification, but this result was not statistically significant in this small series. KDR and MYC alteration were mutually exclusive, and 45% of non-MYC altered cases (9/20) harbored KDR alterations, which were predominantly mutations of T771. Further clinico-pathologic correlation, particularly history of radiation therapy, will be explored in this series, as well defining BAS that harbor neither MYC nor KDR alterations.

Citation Format: Ravi V, Madison R, Schrock AB, Cote G, Millis S, Alvarez R, Choy E, Katz D, Chung J, Gay L, Miller VA, Ross JS, Ali SM, Schnitt S. Comprehensive genomic profiling of 34 cases of breast angiosarcoma [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-12-01.

Pazopanib in advanced vascular sarcomas: an EORTC Soft Tissue and Bone Sarcoma Group (STBSG) retrospective analysis

BACKGROUND

Pazopanib is a multitargeted tyrosine kinase inhibitor approved for the treatment of patients with selective subtypes of advanced soft tissue sarcoma (STS) who have previously received standard chemotherapy including anthracyclines. Data on the efficacy in vascular sarcomas are limited. The main objective of this study was to investigate the activity of pazopanib in vascular sarcomas.

PATIENTS AND METHODS

A retrospective study of patients with advanced vascular sarcomas, including angiosarcoma (AS), epithelioid hemangioendothelioma (HE) and intimal sarcoma (IS) treated with pazopanib in real life practice at EORTC centers as well as patients treated within the EORTC phase II and III clinical trials (62043/62072) was performed. Patient and tumor characteristics were collected. Response was assessed according to RECIST 1.1. and survival analysis was performed.

RESULTS

Fifty-two patients were identified, 40 (76.9%), 10 (19.2%) and two (3.8%) with AS, HE and IS, respectively. The response rate was eight (20%), two (20%) and two (100%) in the AS, HE and IS subtypes, respectively. There was no significant difference in response rate between cutaneous and non-cutaneous AS and similarly between radiation-associated and non-radiation-associated AS. Median progression-free survival (PFS) and median overall survival (OS; from commencing pazopanib) were three months (95% CI 2.1-4.4) and 9.9 months (95% CI 6.5-11.3) in AS, respectively.

CONCLUSION

The activity of pazopanib in AS is comparable to its reported activity in other STS subtypes. In this study, the activity of pazopanib was similar in cutaneous/non-cutaneous and in radiation/non-radiation-associated AS. In addition, pazopanib showed promising activity in HE and IS, worthy of further evaluation.

Pazolimus: pazopanib plus sirolimus following progression on pazopanib, a retrospective case series analysis

Background

To explore the activity of pazopanib (P) + sirolimus (S) in patients who progressed after previous clinical benefit on pazopanib.

Methods

Eight patients with progressing metastatic high grade soft tissue sarcoma (STS) whose disease advanced on P following a response duration of at least 4 months were offered re-challenge of P supplemented by off-label S and a single patient with progressing metastatic chondrosarcoma was offered the combination as compassionate treatment. Patients were treated in two centers: Hadassah Medical Center and Tel Aviv Medical Center. Patients received oral P 200–600 mg once a day supplemented by S 3–4 mg taken separately, 12 h after the P dose.

Results

Patients received treatment from December 2012 to February 2016. Four progressed on the combination and their treatment was terminated. Two patients were undergoing treatment when data was summarized. Best Response Evaluation Criteria in Solid Tumour (RECIST) responses were: one partial response (PR), four stable disease (SD), and four progressive disease (PD), corresponding to five PR and four PD on the Choi criteria. Median progression free survival was 5.5 months (range 4–17).

Conclusions

Our series showed that the combination of P + S has activity in STS patients selected by previous response to P and in a patient with chondrosarcoma, suggesting this can serve as a mechanism to reverse resistance to P and extend the chemotherapy-free window.

The creation of the client reflexivity scale: A measure of minute fluctuations in self-awareness and exploration

OBJECTIVE

to design and pilot a reliable observer-based scale of client reflexivity that can be used on short segments of time ("coding intervals") across therapy sessions. Reflexivity was defined as the level of a client's awareness and exploration of his or her interiority. Interiority was defined as thoughts, feelings, sensations, intentions, and desires.

METHOD

The Client Reflexivity Scale (CRS) was designed through the coding of public access therapy videos featuring demonstrations of therapy. Along with the Experiencing Scale, the CRS was then piloted on one good outcome and one poor outcome session of cognitive-behavioural therapy for anxiety. Each session of therapy featured the same therapist but different clients. Two raters coded the sessions.

RESULTS

Weighted kappas for inter-rater reliability ranged from 0.74 to 0.81. The level of reflexivity was significantly higher in the good outcome session than the poor outcome session, though the trajectory of reflexivity for both sessions was the same. The CRS was also compared to the Experiencing Scale in order to determine similarities and differences between the scales.

CONCLUSIONS

the CRS reliably measured reflexivity within the therapy sessions, and in the future can be layered with other process measures in order to map interactions across therapy sessions.

Direct and Indirect Costs Following Living Kidney Donation: Findings From the KDOC Study

Some living kidney donors (LKDs) incur costs associated with donation, although these costs are not well characterized in the United States. We collected cost data in the 12 mo following donation from 182 LKDs participating in the multicenter prospective Kidney Donor Outcomes Cohort (KDOC) Study. Most LKDs (n = 167, 92%) had one direct cost or more following donation, including ground transportation (86%), health care (41%), meals (53%), medications (36%), lodging (23%), and air transportation (12%). LKDs missed 33 072 total work hours, 40% of which were unpaid and led to $302 175 in lost wages (mean $1660). Caregivers lost $68 655 in wages (mean $377). Although some donors received financial assistance, 89% had a net financial loss in the 12-mo period, with one-third (33%) reporting a loss exceeding $2500. Financial burden was higher for those with greater travel distance to the transplant center (Spearman's ρ = 0.26, p < 0.001), lower household income (Spearman's ρ = -0.25, p < 0.001), and more unpaid work hours missed (Spearman's ρ = 0.52, p < 0.001). Achieving financial neutrality for LKDs must be an immediate priority for the transplant community, governmental agencies, insurance companies, nonprofit organizations, and society at large.

Predonation Direct and Indirect Costs Incurred by Adults Who Donated a Kidney: Findings From the KDOC Study

Limited information exists on the predonation costs incurred by eventual living kidney donors (LKDs). Expenses related to completion of the donation evaluation were collected from 194 LKDs participating in the multi-center, prospective Kidney Donor Outcomes Cohort (KDOC) Study. Most LKDs (n = 187, 96%) reported one or more direct costs, including ground transportation (80%), healthcare (24%), lodging (17%) and air transportation (14%), totaling $101 484 (USD; mean = $523 ± 942). Excluding paid vacation or sick leave, donor and companion lost wages totaled $35 918 (mean = $187 ± 556) and $14 378 (mean = $76 ± 311), respectively. One-third of LKDs used paid vacation or sick leave to avoid incurring lost wages. Few LKDs reported receiving financial support from the transplant candidate (6%), transplant candidate's family (3%), a nonprofit organization (3%), the National Living Donor Assistance Center (7%), or transplant center (3%). Higher total costs were significantly associated with longer distance traveled to the transplant center (p < 0.001); however, total costs were not associated with age, sex, race/ethnicity, household income, marital status, insurance status, or transplant center. Moderate predonation direct and indirect costs are common for adults who complete the donation evaluation. Potential LKDs should be advised of these possible costs, and the transplant community should examine additional strategies to reimburse donors for them.

Longevity loss among cured tuberculosis patients and the potential value of prevention

BACKGROUND

Evidence of substantial, quantifiable and preventable burdens of mortality hazard even after anti-tuberculosis treatment and cure would be a compelling, concrete, and useful measure of the value of prevention.

METHODS

We compared years of potential life lost between a cohort of 3 933 cured tuberculosis (TB) patients and 9 166 persons with latent tuberculous infection. We constructed a regression model to predict the expected years of potential life lost in each cohort and for demographic subgroups.

RESULTS

Among decedents, a history of fully treated TB is associated with a predicted average 3.6 more years of potential life loss than a comparable population without active TB. Greater longevity losses were predicted among those identified as White and Hispanic than among Black and Asian counterparts.

CONCLUSION

We found significant differences in predicted longevity of treated TB survivors relative to a similar group without active TB. These excess losses are substantial: a total of 14 158 life-years or the equivalent of more than 188 75-year lifespans. These findings illustrate an important opportunity cost associated with each preventable TB case - an average of 3.6 potential years of life. We conclude that substantial preventable mortality burdens remain despite adequate anti-tuberculosis treatment, a compelling rationale for more widespread and systematic use of prevention.