Heparin-mediated PCR interference in SARS-CoV-2 assays and subsequent reversal with heparinase I

Heparin is postulated to block the interaction of SARS-CoV-2 with highly glycosylated proteins which are critical for binding the angiotensin-converting enzyme 2 (ACE2), an essential mechanism for host-cell entry and viral replication. Intranasal heparin is under investigation for use as a SARS-CoV-2 preventative in the IntraNasal Heparin Trial (INHERIT, NCT05204550). Heparin directly interferes with real-time quantitative polymerase chain reaction (RT-qPCR), the gold standard for SARS-CoV-2 detection. This study aimed to investigate the magnitude of heparin interference across various clinical laboratory testing platforms, and the reversal of any interference by degradation of heparin using the heparinase I enzyme in nasopharyngeal swab (NP) samples for SARS-CoV-2 analysis by RT-qPCR. Heparin-mediated PCR interference was evident at heparin concentrations as low as 10 IU/mL across all platforms tested, with the exclusion of the Hologic Panther Aptima SARS-CoV-2 assay. Rates of false negative or invalid results and falsely elevated cycle threshold (Ct) values increased with increasing heparin concentrations on all platforms, except the Hologic Panther Aptima and Roche Cobas LIAT. Heparinase I reversed heparin-mediated PCR inhibition across in all samples tested, except those with initial Ct values >35. Our study shows that the use of heparin-containing nasal sprays interferes with the detection of SARS-CoV-2 in NP swab samples by RT-qPCR, a phenomenon that is not well recognised in the literature. Furthermore, this study has also demonstrated that heparin-mediated PCR inhibition can be prevented through heparinase I treatment, demonstrating restoration of clinically significant results with Ct values <35.

The ATR inhibitor ceralasertib potentiates cancer checkpoint immunotherapy by regulating the tumor microenvironment

The Ataxia telangiectasia and Rad3-related (ATR) inhibitor ceralasertib in combination with the PD-L1 antibody durvalumab demonstrated encouraging clinical benefit in melanoma and lung cancer patients who progressed on immunotherapy. Here we show that modelling of intermittent ceralasertib treatment in mouse tumor models reveals CD8+ T-cell dependent antitumor activity, which is separate from the effects on tumor cells. Ceralasertib suppresses proliferating CD8+ T-cells on treatment which is rapidly reversed off-treatment. Ceralasertib causes up-regulation of type I interferon (IFNI) pathway in cancer patients and in tumor-bearing mice. IFNI is experimentally found to be a major mediator of antitumor activity of ceralasertib in combination with PD-L1 antibody. Improvement of T-cell function after ceralasertib treatment is linked to changes in myeloid cells in the tumor microenvironment. IFNI also promotes anti-proliferative effects of ceralasertib on tumor cells. Here, we report that broad immunomodulatory changes following intermittent ATR inhibition underpins the clinical therapeutic benefit and indicates its wider impact on antitumor immunity.

Isohydric stomatal behaviour alters fruit vascular flows and minimizes fruit size reductions in drought-stressed 'Hass' avocado (Persea americana Mill.)

BACKGROUND AND AIMS

Plant water status is important for fruit development, as many fleshy fruits contain large amounts of water. However, there is no information on vascular flows of Persea americana 'Hass' avocado. The aims of this research were to explore the impact of drought stress on the water relations of the 'Hass' avocado plant, and its fruit growth.

METHODS

Well-watered and water-stressed 'Hass' avocado plants were compared. Over four weeks, water flows through the shoot and fruit pedicel were monitored using external sap flow gauges. Fruit diameter was monitored using linear transducers (LTs), and stomatal conductance (gs), photosynthesis (A) and leaf and stem water potential (Ѱleaf and Ѱstem) were measured to assess the plants' response to water supply.

KEY RESULTS

Under well-watered conditions, the average water inflow to the shoot was 72 g d-1. Fruit water inflow was 2.72 g d-1, but there was water loss of 0.37 g d-1 caused by the outflow (loss back into the tree) through the vascular tissues, and 1.06 g d-1 from the fruit skin. Overall, fruit volume increased by 1.4 cm3 d-1. In contrast, water flow into fruit of water-stressed plants decreased to 1.88 g d-1, with the outflow increasing to 0.61 g d-1. As a result, increases in fruit volume were reduced to 0.4 cm3 d-1. Following re-watering, a substantial recovery in growth rate was observed. A, gs, and sap flow to shoots were also reduced during drought conditions.

CONCLUSIONS

In summary, a reduction in growth of avocado fruit was observed with induced water deficit, but the isohydric stomatal behaviour of the leaves helped to minimize negative changes in water balance. Also, there was substantial recovery after re-watering, hence the short-term water stress did not decrease avocado fruit size. Negative impacts might appear if the drought treatment were prolonged.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Budget impact of oral nirmatrelvir/ritonavir in adults at high risk for progression to severe COVID-19 in the United States

BACKGROUND

Nirmatrelvir/ritonavir (NMV/r) is indicated for the treatment of mild-to-moderate COVID-19 in adults who are at high risk for progression to severe COVID-19. NMV/r has also been authorized for emergency use by the US Food and Drug Administration for the treatment of mild-to-moderate COVID-19 in pediatric patients (aged 226512 years and weighing at least 40 kg) who are at high risk for progression to severe COVID-19. Understanding the budget impact of introducing NMV/r for the treatment of adults with COVID-19 is of key interest to US payers.

OBJECTIVE

To estimate the annual budget impact of introducing NMV/r in a US commercial health plan setting in the current Omicron COVID-19 era.

METHODS

A budget impact model was developed to assess the impact of NMV/r on health care costs in a hypothetical 1-million-member commercial health insurance plan over a 1-year period in the US population; clinical and cost inputs were derived from published literature with a focus on studies in the recent COVID-19 era that included vaccinated population and predominance of the Omicron variant. In the base-case analysis, it was assumed the only effect of NMV/r was a reduction in incidence (not severity) of hospitalization or death; its potential effect on post-COVID conditions was assessed in a scenario analysis. Outcomes included the number of hospitalizations, total cost, per patient per year (PPPY) costs, and per member per month (PMPM) costs. Sensitivity and scenario analyses were conducted to assess uncertainty around key model inputs.

RESULTS

An estimated 29,999 adults were eligible and sought treatment with oral antiviral for COVID-19 over 1 year. The availability of NMV/r was estimated to reduce the number of hospitalizations by 647 with a total budget impact of $2,733,745, $91 PPPY, and $0.23 PMPM. NMV/r was cost saving when including post-COVID conditions with a -$1,510,780 total budget impact, a PPPY cost of -$50, and a PMPM cost of -$0.13. Sensitivity analyses indicated results were most sensitive to the risk of hospitalization under supportive care, risk of hospitalization with NMV/r treatment and cost of NMV/r.

CONCLUSIONS

Treatment with NMV/r in the current COVID-19 era is estimated to result in substantial cost offsets because of reductions in hospitalization and modest budget impact to potential overall cost savings.

Lung recovery utilizing thoracoabdominal normothermic regional perfusion during donation after circulatory death: The Colorado experience

Objective

Donation after circulatory death (DCD) procurement and transplantation after thoracoabdominal normothermic regional perfusion (TA-NRP) remains a novel technique to improve cardiac and hepatic allograft preservation but may be complicated by lung allograft pulmonary edema. We present a single-center series on early implementation of a lung-protective protocol with strategies to mitigate posttransplant pulmonary edema in DCD lung allografts after TA-NRP procurement.

Methods

Data from all lung transplantations performed using a TA-NRP procurement strategy from October 2022 to April 2023 are presented. Donor management consisted of key factors to reduce lung allograft pulmonary edema: aggressive predonation and early posttransplant diuresis, complete venous drainage at TA-NRP initiation, and early pulmonary artery venting upon initiation of systemic perfusion. Donor and recipient characteristics, procurement characteristics such as TA-NRP intervals, and 30-day postoperative outcomes were assessed.

Results

During the study period, 8 lung transplants were performed utilizing TA-NRP procurement from DCD donors. Donor ages ranged from 16 to 39 years and extubation time to declaration of death ranged from 10 to 90 minutes. Time from declaration to TA-NRP initiation was 7 to 17 minutes with TA-NRP perfusion times of 49 to 111 minutes. Median left and right allograft warm ischemia times were 55.5 minutes (interquartile range, 46.5-67.5 minutes) and 41.0 minutes (interquartile range, 39.0-53.0 minutes, respectively, with 2 recipients supported with cardiopulmonary bypass or venoarterial extracorporeal membrane oxygenation during implantation. No postoperative extracorporeal membrane oxygenation was required. There were no pulmonary-related deaths; however, 1 patient died from complications of severe necrotizing pancreatitis with a normal functioning allograft. All patients were extubated within 24 hours. Index intensive care unit length of stay ranged from 3 to 11 days with a hospital length of stay of 13 to 37 days.

Conclusions

Despite concern regarding quality of DCD lung allografts recovered using the TA-NRP technique, we report initial success using this procurement method. Implementation of strategies to mitigate pulmonary edema can result in acceptable outcomes following lung transplantation. Demonstration of short- and long-term safety and efficacy of this technique will become increasingly important as the use of TA-NRP for thoracic and abdominal allografts in DCD donors expands.

Patterns of Relapse in Australian Patients With Clinical Stage 1 Testicular Cancer: Utility of the Australian and New Zealand Urogenital and Prostate Cancer Trials Group Surveillance Recommendations

PURPOSE

International guidelines advocate for active surveillance as the preferred treatment strategy for patients with stage 1 testicular cancer after orchidectomy although a personalized discussion is required.

MATERIALS AND METHODS

We conducted an analysis of individuals registered in iTestis, Australia's testicular cancer registry, to describe the patterns of relapse and outcomes of patients treated in Australia where the Australian and New Zealand Urogenital and Prostate Cancer Trials Group Surveillance Recommendations are widely adopted.

RESULTS

A total of 650 individuals diagnosed between 2000 and 2020 were included, 63% (411 of 650) seminoma and 37% (239 of 650) nonseminoma. The median age was 34 years (range 14-74). 26% (106 of 411) with seminoma and 15% (36 of 239) nonseminoma received adjuvant chemotherapy. After a median follow-up of 43 months (range 0-267) postorchidectomy, relapse occurred in 10% (43 of 411) of seminoma and 18% (43 of 239) of nonseminoma. The two-year relapse-free survival was 92% (95% CI, 89 to 95) and 82% (95% CI, 78 to 87) in seminoma and nonseminoma, respectively. All relapses (86 of 86) were detected at a routine surveillance visit; 98% (85 of 86) were asymptomatic and detected solely through imaging (62 of 86, 72%), tumor markers (6 of 86, 7%), or a combination (17 of 86, 20%). The most common relapse site was isolated retroperitoneal lymphadenopathy (53 of 86, 62%). No nonpulmonary visceral metastases occurred. At relapse, 98% (84 of 86) had International Germ Cell Cancer Collaborative Group (IGCCCG) good prognosis; 2 of 86 intermediate prognosis (both nonseminoma). No deaths occurred.

CONCLUSION

In our cohort of stage 1 testicular cancer, where national surveillance recommendations have been widely adopted, recurrences were detected at routine surveillance visits and, almost exclusively, asymptomatic with IGCCCG good-prognosis disease. This provides reassurance that active surveillance is safe.

The International Initiative to Measure Perceived Risk in Arthroplasty: The Results From a Multinational Survey

BACKGROUND

There is an inherent moral imperative to avoid complications from arthroplasty. Doing so at ideal cost is also associated with surgeon reputation, and, increasingly in health care delivery systems that measure and competitively score outcomes, reimbursement to the surgeons and their hospitals. As a result, patients who are perceived to be in higher risk comorbidity groups, such as the obese and diabetics, as well as those challenged by socioeconomic factors may face barriers to access elective arthroplasty.

METHODS

In this initiative, surveys were sent to surgeons in 8 different countries, each adapted for their own unique payment, remuneration, and punitive models. The questions in the surveys pertained to surgeons' perception of risk regarding medical and socioeconomic factors in patients indicated for total hip or knee arthroplasty. This paper primarily reports on the results from Canada, Ireland, and the United Kingdom.

RESULTS

The health care systems varied between a universal/state funded health care system (Canada) to those that were almost exclusively private (India). Some health care systems have "bundled" payment with retention of fees for postoperative complications requiring readmission/reoperation and including some with public publication of outcome data (United States and the United Kingdom), whereas others had none (Canada). There were some major discrepancies across different countries regarding the perceived risk of diabetic patients, who have variable Hemoglobin A1c cut-offs, if any used. However, overall the perception of risk for age, body mass index, age, sex, socioeconomic, and social situations remained surprisingly consistent throughout the health care systems. Any limitations set were primarily driven by surgeon decision making and not external demands.

CONCLUSION

Surgeons will understandably try and optimize the health status of patients who have reversible risks as shown by best available evidence. The evidence is of variable quality, and, especially for irreversible social risk factors, limited due to concerns over cost and quality outcomes that can be influenced by experience-driven perceptions of risk. The results show that perceptions of risk do have such influence on access across many health care delivery environments. The authors recommend better risk-adjustment models for medical and socioeconomic risk factors with possible stratification/exclusions regarding reimbursement adjustments and reporting to help reverse disparities of access to arthroplasty.

New insights on rural doctors' clinical courage in the context of the unfolding COVID-19 pandemic

Introduction

Rural doctors typically work in low-resource settings and with limited professional support. They are sometimes pushed to the limits of their usual scope of practice to provide the medical care needed by their community. In a previous phenomenological study, we described the concept of clinical courage as underpinning rural doctors' work in this context. In this paper, we draw on rural doctors' experiences during the unfolding COVID pandemic to re-examine our understanding of the attributes of clinical courage.

Methods

Semi-structured interviews were conducted with rural doctors from 11 countries who had experience preparing for or managing patients with COVID-19. Interviews were transcribed verbatim and coded using NVivo. A deductive thematic analysis was undertaken to identify common ideas and responses related to the features of clinical courage.

Results

Thirteen interviews from rural doctors during the unfolding COVID-19 pandemic affirmed and enriched our understanding of the attributes of clinical courage, particularly the leadership role rural doctors can have within their communities.

Conclusion

This study extended our understanding that rural doctors' experience of clinical courage is consistent amongst participants in many parts of the world, including developing countries.

Radiation exposure and leukaemia risk among cohorts of persons exposed to low and moderate doses of external ionising radiation in childhood

BACKGROUND

Many high-dose groups demonstrate increased leukaemia risks, with risk greatest following childhood exposure; risks at low/moderate doses are less clear.

METHODS

We conducted a pooled analysis of the major radiation-associated leukaemias (acute myeloid leukaemia (AML) with/without the inclusion of myelodysplastic syndrome (MDS), chronic myeloid leukaemia (CML), acute lymphoblastic leukaemia (ALL)) in ten childhood-exposed groups, including Japanese atomic bomb survivors, four therapeutically irradiated and five diagnostically exposed cohorts, a mixture of incidence and mortality data. Relative/absolute risk Poisson regression models were fitted.

RESULTS

Of 365 cases/deaths of leukaemias excluding chronic lymphocytic leukaemia, there were 272 AML/CML/ALL among 310,905 persons (7,641,362 person-years), with mean active bone marrow (ABM) dose of 0.11 Gy (range 0-5.95). We estimated significant (P < 0.005) linear excess relative risks/Gy (ERR/Gy) for: AML (n = 140) = 1.48 (95% CI 0.59-2.85), CML (n = 61) = 1.77 (95% CI 0.38-4.50), and ALL (n = 71) = 6.65 (95% CI 2.79-14.83). There is upward curvature in the dose response for ALL and AML over the full dose range, although at lower doses (<0.5 Gy) curvature for ALL is downwards.

DISCUSSION

We found increased ERR/Gy for all major types of radiation-associated leukaemia after childhood exposure to ABM doses that were predominantly (for 99%) <1 Gy, and consistent with our prior analysis focusing on <100 mGy.

A vanguard randomised feasibility trial comparing three regimens of peri-operative oxygen therapy on recovery after major surgery

International recommendations encourage liberal administration of oxygen to patients having surgery under general anaesthesia, ostensibly to reduce surgical site infection. However, the optimal oxygen regimen to minimise postoperative complications and enhance recovery from surgery remains uncertain. The hospital operating theatre randomised oxygen (HOT-ROX) trial is a multicentre, patient- and assessor-blinded, parallel-group, randomised clinical trial designed to assess the effect of a restricted, standard care, or liberal peri-operative oxygen therapy regimen on days alive and at home after surgery in adults undergoing prolonged non-cardiac surgery under general anaesthesia. Here, we report the findings of the internal vanguard feasibility phase of the trial undertaken in four large metropolitan hospitals in Australia and New Zealand that included the first 210 patients of a planned overall 2640 trial sample, with eight pre-specified endpoints evaluating protocol implementation and safety. We screened a total of 956 participants between 1 September 2019 and 26 January 2021, with data from 210 participants included in the analysis. Median (IQR [range]) time-weighted average intra-operative Fi O2 was 0.30 (0.26-0.35 [0.20-0.59]) and 0.47 (0.44-0.51 [0.37-0.68]) for restricted and standard care, respectively (mean difference (95%CI) 0.17 (0.14-0.20), p < 0.001). Median time-weighted average intra-operative Fi O2 was 0.83 (0.80-0.85 [0.70-0.91]) for liberal oxygen therapy (mean difference (95%CI) compared with standard care 0.36 (0.33-0.39), p < 0.001). All feasibility endpoints were met. There were no significant patient adverse events. These data support the feasibility of proceeding with the HOT-ROX trial without major protocol modifications.

Rucaparib for the Treatment of Metastatic Castration-resistant Prostate Cancer Associated with a DNA Damage Repair Gene Alteration: Final Results from the Phase 2 TRITON2 Study

BACKGROUND

Initial TRITON2 (NCT02952534) results demonstrated the efficacy of rucaparib 600 mg BID in patients with metastatic castration-resistant prostate cancer (mCRPC) associated with a BRCA1 or BRCA2 (BRCA) or other DNA damage repair (DDR) gene alteration.

OBJECTIVE

To present the final data from TRITON2.

DESIGN, SETTING, AND PARTICIPANTS

TRITON2 enrolled patients with mCRPC who had progressed on one or two lines of next-generation androgen receptor-directed therapy and one taxane-based chemotherapy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was objective response rate (ORR; as per the modified Response Evaluation Criteria in Solid Tumor Version 1.1/Prostate Cancer Clinical Trials Working Group 3 criteria in patients with measurable disease by independent radiology review [IRR]); prostate-specific antigen (PSA) response rate (≥50% decrease from baseline [PSA50]) was a key secondary endpoint.

RESULTS AND LIMITATIONS

As of July 27, 2021 (study closure), TRITON2 had enrolled 277 patients, grouped by mutated gene: BRCA (n = 172), ATM (n = 59), CDK12 (n = 15), CHEK2 (n = 7), PALB2 (n = 11), or other DDR gene (Other; n = 13). ORR by IRR was 46% (37/81) in the BRCA subgroup (95% confidence interval [CI], 35-57%), 100% (4/4) in the PALB2 subgroup (95% CI, 40-100%), and 25% (3/12) in the Other subgroup (95% CI, 5.5-57%). No patients within the ATM, CDK12, or CHEK2 subgroups had an objective response by IRR. PSA50 response rates (95% CI) in the BRCA, PALB2, ATM, CDK12, CHEK2, and Other subgroups were 53% (46-61%), 55% (23-83%), 3.4% (0.4-12), 6.7% (0.2-32%), 14% (0.4-58%), and 23% (5.0-54%), respectively.

CONCLUSIONS

The final TRITON2 results confirm the clinical benefit and manageable safety profile of rucaparib in patients with mCRPC, including those with an alteration in BRCA or select non-BRCA DDR gene.

PATIENT SUMMARY

Almost half of TRITON2 patients with BRCA-mutated metastatic castration-resistant prostate cancer had a complete or partial tumor size reduction with rucaparib; clinical benefits were also observed with other DNA damage repair gene alterations.

Smoking reduction using electronic nicotine delivery systems in combination with nicotine skin patches

RATIONALE

Electronic nicotine delivery systems (ENDS) are used by smokers seeking to reduce combustible cigarette (CC) use, but the role of nicotine replacement vs. behavioral and sensory factors is still poorly understood. We hypothesized that providing nicotine from ENDS in addition to nicotine skin patches would promote smoking reduction relative to non-nicotine control ENDS.

OBJECTIVES

To assess the effects on smoking behavior of using nicotine vs. placebo ENDS in smokers using nicotine vs. placebo patches.

METHODS

Ninety-four daily smokers were enrolled in a study that randomly assigned them to receive ENDS with nicotine vs. without nicotine and skin patches with vs. without nicotine. Smoking reduction and cessation were assessed over an 8-week period by self-report and by expired air carbon monoxide (CO) measurements. The primary outcome was defined as reduction in expired air CO.

RESULTS

The use of nicotine in ENDS led to significant reductions in smoking (ENDS nicotine vs. placebo difference in CO change = -9.2 ppm; 90% CI (-1.5 ppm, -16.9 ppm)) and was highly correlated with reductions in self-reported cigarettes per day (r=0.6). The effect of nicotine in nicotine patches was not statistically significant (patch nicotine vs. placebo difference in CO change = -0.1 ppm; 90% CI (-7.8 ppm, 7.6 ppm)).

CONCLUSIONS

The presence of nicotine in ENDS was associated with a large reduction in smoking. Additional studies will be needed to determine whether there may be additive effects of nicotine ENDS and nicotine patches on smoking abstinence.

Rapid Establishment of a Biospecimen Resource To Study the Global Impact of COVID-19 Vaccines

The emergence and explosive spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 2019 highlighted the need to rapidly develop curated biobanks to inform the etiology, diagnosis, and treatment options for global outbreaks of communicable diseases. Recently, we undertook efforts to develop a repository of biospecimens from individuals aged 12 and older who were to be vaccinated against coronavirus disease 19 (COVID-19) with vaccines developed with support from the United States Government. We planned to establish 40 or more clinical study sites in at least six countries to collect biospecimens from 1,000 individuals, 75% of whom were to be SARS-CoV-2 naive at the time of enrollment. Specimens would be used to (i) ensure quality control of future diagnostic tests, (ii) understand immune responses to multiple COVID-19 vaccines, and (iii) provide reference reagents for the development of new drugs, biologics, and vaccines. Biospecimens included serum, plasma, whole blood, and nasal secretions. Large-volume collections of peripheral blood mononuclear cells (PBMCs) and defibrinated plasma were also planned for a subset of subjects. Participant sampling was planned at intervals prior to and following vaccination over a 1-year period. Here, we describe the selection of clinical sites for specimen collection and processing, standard operating procedure (SOP) development, design of a training program for tracking specimen quality, and specimen transport to a repository for interim storage. This approach allowed us to enroll our first participants within 21 weeks from the study's initiation. Lessons learned from this experience should benefit the development of biobanks in response to future global epidemics. IMPORTANCE The ability to rapidly create a biobank of high-quality specimens in response to emergent infectious diseases is critical to allow for the development of prevention and treatment, as well as to effectively monitor the spread of the disease. In this paper, we report on a novel approach to getting global clinical sites up and running within a short time frame and to monitor the quality of specimens collected to ensure their value in future research efforts. Our results have important implications for the monitoring of the quality of biospecimens collected and to design effective interventions to address shortcomings, where needed.

Striatal dopamine in anhedonia: A simultaneous [11C]raclopride positron emission tomography and functional magnetic resonance imaging investigation

BACKGROUND

Anhedonia is hypothesized to be associated with blunted mesocorticolimbic dopamine (DA) functioning in samples with major depressive disorder. The purpose of this study was to examine linkages between striatal DA, reward circuitry functioning, anhedonia, and, in an exploratory fashion, self-reported stress, in a transdiagnostic anhedonic sample.

METHODS

Participants with (n = 25) and without (n = 12) clinically impairing anhedonia completed a reward-processing task during simultaneous positron emission tomography and magnetic resonance (PET-MR) imaging with [11C]raclopride, a DA D2/D3 receptor antagonist that selectively binds to striatal DA receptors.

RESULTS

Relative to controls, the anhedonia group exhibited decreased task-related DA release in the left putamen, caudate, and nucleus accumbens and right putamen and pallidum. There were no group differences in task-related brain activation (fMRI) during reward processing after correcting for multiple comparisons. General functional connectivity (GFC) findings revealed blunted fMRI connectivity between PET-derived striatal seeds and target regions in the anhedonia group. Associations were identified between anhedonia severity and the magnitude of task-related DA release to rewards in the left putamen, but not mesocorticolimbic GFC.

CONCLUSIONS

Results provide evidence for reduced striatal DA functioning during reward processing and blunted mesocorticolimbic network functional connectivity in a transdiagnostic sample with clinically significant anhedonia.

Laser-accelerated electron beams at 1 GeV using optically-induced shock injection

In recent years, significant progress has been made in laser wakefield acceleration (LWFA), both regarding the increase in electron energy, charge and stability as well as the reduction of bandwidth of electron bunches. Simultaneous optimization of these parameters is, however, still the subject of an ongoing effort in the community to reach sufficient beam quality for next generation's compact accelerators. In this report, we show the design of slit-shaped gas nozzles providing centimeter-long supersonic gas jets that can be used as targets for the acceleration of electrons to the GeV regime. In LWFA experiments at the Centre for Advanced Laser Applications, we show that electron bunches are accelerated to [Formula: see text] using these nozzles. The electron bunches were injected into the laser wakefield via a laser-machined density down-ramp using hydrodynamic optical-field-ionization and subsequent plasma expansion on a ns-timescale. This injection method provides highly controllable quasi-monoenergetic electron beams with high charge around [Formula: see text], low divergence of [Formula: see text], and a relatively small energy spread of around [Formula: see text] at [Formula: see text]. In contrast to capillaries and gas cells, the scheme allows full plasma access for injection, probing or guiding in order to further improve the energy and quality of LWFA beams.

Military concerns for chronic pain stimulator devices

Spinal cord stimulators (SCS) and peripheral nerve stimulators (PNS) are increasingly used in the treatment of chronic pain, allowing more patients to resume working and return to activities. Military service members face environmental and occupational hazards that expose them to mechanical and electromagnetic forces, both clinical and industrial, that could potentially alter their function. While there are reports of individual hazards, the risk appears to be nominal based on the large number of devices in use and the limited reported complications with these devices. Since a variety of hazards encountered by military patients have the potential to alter SCS and PNS devices, a brief discussion of each patient's specific exposures and related hazards should occur prior to placement. Overall, these devices have demonstrated safety in hazardous areas and few military patients have contraindications for placement based on these factors alone.

CATALYST: challenging antibiotic allergy status

OBJECTIVES

To develop a transferable process, CATALYST (challenging antibiotic allergy  status), to assess and challenge penicillin allergy status of inpatients within an NHS Foundation Hospital.

METHODS

A multidisciplinary team (MDT) steering group reviewed existing literature and protocols enabling penicillin allergy assessment, challenge and de-labelling. Using this, they identified five key steps forming the basis of CATALYST: clinical assessment of the nature of allergy; inclusion/exclusion criteria; consent; direct oral penicillin challenge; and removal of allergy label. A pharmacist-led pilot was conducted to assess the process, during which a continuous PDSA (plan-do-study-act) cycle was observed. This included formally auditing endpoint data such as accuracy of allergy status in medical records post-intervention.

RESULTS

CATALYST was successfully developed with key resources produced to support clinicians. It was piloted in 304 patients, with 172 patients excluded and 132 successful allergy challenges. There was one incident of an adverse event (acute kidney injury) in the 132 successful patients, which occurred as a delayed reaction following 22 days of penicillin therapy. Only 64% of permanent records (held by GP) were appropriately updated when audited at the end of the pilot.

CONCLUSIONS

CATALYST is a transferable process to facilitate safe assessment, challenge and removal of spurious penicillin allergy labels. Handover between care sectors forms a key element of allergy removal to ensure all records are updated and work is needed to ensure this process is done effectively.

Diabetes care among individuals with and without schizophrenia in three Canadian provinces: A retrospective cohort study

OBJECTIVE

Diabetes is present in approximately 10% of people living with schizophrenia and substantially contributes to early mortality, but some aspects of diabetes care among those with schizophrenia have been inadequately investigated to date. We assessed diabetes care and comorbidity management among people with and without schizophrenia.

METHODS

We conducted a cohort study with data obtained from primary care electronic medical records stored in the Diabetes Action Canada (DAC) National Repository from Alberta, Ontario, and Quebec, Canada. The population studied included patients with diabetes, with and without schizophrenia, who had at least 3 primary care visits in a 2 year period between July 2017 and June 2019. Outcomes included glycemia; diabetes complication screening and monitoring; antihyperglycemic and cardioprotective medication prescription; health service use.

RESULTS

We identified 69,512 patients with diabetes; 911 (1.3%) of whom also had schizophrenia. Prevalence of high HbA1C (>8.5%) (9083/68601; 13.2% vs. 137/911; 15.0%) and high blood pressure (>130/80 mmHg) (4248/68601; 6.2% vs. 73/911; 8.0%) was similar between the two groups. Half (50.0%) of patients with schizophrenia (n = 455) had 11 or more primary care visits in the past year, compared with 27.8% of people without schizophrenia. (p < 0.0001). Patients with schizophrenia had lower odds of ever having blood pressure recorded (OR = 0.81, 95% CI 0.71-0.94) and fewer of those with chronic kidney disease (CKD) were prescribed renin-angiotensin aldosterone system inhibitors, compared to patients without schizophrenia (10.3% vs 15.8%, p = 0.0005).

CONCLUSIONS

Patients with diabetes and schizophrenia achieved similar blood glucose and blood pressure levels to those without schizophrenia, and had more primary care visits. However, they had fewer blood pressure readings and lower prescription of recommended medications among those who also had CKD. These results are both encouraging and represent opportunities for improvement in care.

Abstract B04: Preclinical activity and safety profile or JANX008, a novel EGFR-targeting tumor-activated T cell engager for treatment of solid tumors

Introduction: Epidermal growth receptor (EGFR) is the most expressed membrane oncogenic protein in human cancers. KRAS and BRAF mutations are significant drivers of resistance to EGFR-targeted therapies. Unlike other treatments, EGFR-targeting, CD3 bispecific T cell engagers (TCEs) can potentially retain activity against tumors bearing resistance mutations. However, cytokine release syndrome (CRS), on-target off-tumor toxicities, and poor pharmacokinetics (PK) properties present significant clinical limitations for these potent immunomodulators. To overcome these challenges, Janux has developed JANX008, an EGFR- and CD3-targeted tumor-activated T cell engager (TRACTr). JANX008 is a humanized tri-specific protein that contains EGFR- and CD3-binding domains, an albumin binding domain to extend circulating half-life, and two different peptide masks fused to the molecule through tumor protease cleavable linkers. One peptide mask inhibits EGFR engagement on target cells, and the other inhibits CD3 engagement on T cells. Once the cleavage sequences undergo proteolysis by tumor proteases, the EGFR and CD3 masks are released, and the resulting active molecule can bind EGFR and CD3 on target cells. Methods: Peptide masks against EGFR- and CD3-binding domains were identified via phage display. The efficiency of the masks was evaluated using human EGFR and CD3 ELISAs. JANX008-induced cleavage-dependent T cell killing was evaluated in human PBMC/tumor cell co-culture assays. Anti-tumor efficacy of JANX008 was tested in multiple preclinical models, including EGFR antibody-resistant KRAS- and PIK3CA-mutant mouse colon cancer model (HCT116) and a fully human primary colorectal cancer (CRC) tumoroid system. The pharmacokinetic and safety profile of JANX008 was evaluated in non-human primate studies. Results: JANX008 target engagement was cleavage-dependent where masking reduced EGFR and CD3 binding by &gt;300x and &gt;1,000x, respectively. JANX008 exhibited potent cleavage- and dose-dependent activity in multiple preclinical models, including EGFR antibody-resistant tumor and T cell co-culture assays, humanized mouse CRC model, and a human primary CRC tumoroids with an intact tumor microenvironment. JANX008 showed a significantly enhanced safety profile in NHPs compared to non-masked EGFR-TCE, including decreased CRS-associated cytokines and healthy tissue toxicities at high exposures. Clinical chemistry, hematology, and pathology measurements all supported No-Observed-Adverse-Effect-Level ≥ 0.6 mg/kg/dose. Finally, the cleavable albumin-binding domain extended the half-life of JANX008 to ~94h, relative to the ~1.3h half-life of non-masked TCE, supporting its weekly clinical dosing. Conclusions: Preclinical data demonstrate key characteristics of JANX008, including cleavage-dependent activity, half-life extended PK, the potential for superior safety, and manufacturability properties that could mitigate significant limitations of TCEs and support JANX008 clinical development.

Citation Format: Thomas R DiRaimondo, Natalija Budimir, Lina Ma, Simon Shenhav, Vanessa Cicchini, Hu Wu, Renee Jocic, Fabrece Roup, Calvin Campbell, Carolina Caffaro, Hans Aerni, Ugur Eskiocak, Wayne Godfrey, Charles Winter, Marc Nasoff, Neil Gibson, David Campbell, shahram Salek-Ardakani. Preclinical activity and safety profile or JANX008, a novel EGFR-targeting tumor-activated T cell engager for treatment of solid tumors [abstract]. In: Proceedings of the AACR Special Conference: Tumor Immunology and Immunotherapy; 2022 Oct 21-24; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2022;10(12 Suppl):Abstract nr B04.

Sustained Suppression of Premature Ventricular Contractions by a Three-Month Pacing Adjustment

Premature ventricular contractions (PVCs) that comprise more than 15% of total heartbeats can induce cardiomyopathy in patients with systolic dysfunction, and cardiac ablation is frequently used to reduce PVCs in this patient group. However, cardiac ablation is not entirely without hazards. We report a noninvasive method that dramatically reduced PVCs in a cardiac pacemaker patient from 31% to 3% in seven days by increasing the lower limit pacing rate from 50 beats per minute (bpm) to 60 bpm. Not only were our patient's PVCs reduced by the initial pacing elevation, but PVC levels were maintained below 5% even after the pacemaker's lower limit was returned to its original value of 50 bpm. This irreversible suppression of PVC activity following a three-month pacing elevation is a novel result that might be caused by ventricular remodeling of the original ectopic focus.

Tranexamic Acid Should be Considered for High Risk Arthroplasty Patients

Background Tranexamic acid significantly reduces blood loss and transfusion requirements in arthroplasty patients.  However, it is often avoided in patients who have had previous arterial and thromboembolic disease despite the absence of evidence of hazard in this group of patients. We examined the use of tranexamic acid in unselected hip and knee arthroplasty patients including those considered to be ‘high risk’.   Methods A 2-year retrospective multicentre study was performed with patients who underwent hip or knee arthroplasty surgery. A blood management protocol included universal tranexamic acid use for all patients. Blood loss, transfusion volumes and complications were analysed.   Results A total of 958 patients were included in the study, 130 patients were considered ‘high risk’ of thromboembolic complications and 828 patients were considered ‘low risk’. 879 patients received tranexamic acid with a significant reduction in blood loss (p<0.001) in these patients. Two of 130 (1.5%) ‘high risk’ patients and 14 of 828 (1.7%) ‘low risk’ patients had post-operative VTE. There was no significant difference in rate of VTE between the ‘high risk’ and ‘low risk’ patients (p=0.6) or in the subgroup of ‘high risk’ patients who had received TXA (p=1).   Conclusions The efficacy of tranexamic acid is overwhelming and outweighs any potential risks. Tranexamic acid should be considered for use in all arthroplasty patients including those with prior history of venous or arterial thrombosis.

Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

Access to unpublished protocols and statistical analysis plans of randomised trials

BACKGROUND

Access to protocols and statistical analysis plans (SAPs) increases the transparency of randomised trial by allowing readers to identify and interpret unplanned changes to study methods, however they are often not made publicly available. We sought to determine how often study investigators would share unavailable documents upon request.

METHODS

We used trials from two previously identified cohorts (cohort 1: 101 trials published in high impact factor journals between January and April of 2018; cohort 2: 100 trials published in June 2018 in journals indexed in PubMed) to determine whether study investigators would share unavailable protocols/SAPs upon request. We emailed corresponding authors of trials with no publicly available protocol or SAP up to four times.

RESULTS

Overall, 96 of 201 trials (48%) across the two cohorts had no publicly available protocol or SAP (11/101 high-impact cohort, 85/100 PubMed cohort). In total, 8/96 authors (8%) shared some trial documentation (protocol only [n = 5]; protocol and SAP [n = 1]; excerpt from protocol [n = 1]; research ethics application form [n = 1]). We received protocols for 6/96 trials (6%), and a SAP for 1/96 trial (1%). Seventy-three authors (76%) did not respond, 7 authors responded (7%) but declined to share a protocol or SAP, and eight email addresses were invalid (8%). A total of 329 emails were sent (an average of 41 emails for every trial which sent documentation). After emailing authors, the total number of trials with an available protocol increased by only 3%, from 52% in to 55%.

CONCLUSIONS

Most study investigators did not share their unpublished protocols or SAPs upon direct request. Alternative strategies are needed to increase transparency of randomised trials and ensure access to protocols and SAPs.

Staff and patient experience of the implementation and delivery of a virtual health care home monitoring service for COVID-19 in Melbourne, Australia

BACKGROUND

Provision of virtual health care (VHC) home monitoring for patients who are experiencing mild to moderate COVID-19 illness is emerging as a central strategy for reducing pressure on acute health systems. Understanding the enablers and challenges in implementation and delivery of these programs is important for future implementation and re-design. The aim of this study was to explore the perspectives of staff involved with the implementation and delivery, and the experience of patients managed by, a VHC monitoring service in Melbourne, Australia during the COVID-19 pandemic.

METHODS

A descriptive qualitative approach informed by naturalist inquiry was used. Staff interviews were analysed using the Consolidated Framework for Implementation Research (CFIR). Patient experience was captured using a survey and descriptive statistics were used to describe categorical responses while content analysis was used to analyse free text responses as they related to the CFIR. Finally, data from the interviews and patient experience were triangulated to see if patient experience validated data from staff interviews.

RESULTS

All 15 staff were interviewed, and 271 patients were surveyed (42%). A total of four final overarching themes emerged: service implementation enablers, service delivery benefits for patients, fragmentation of care, and workforce strengths. 19 subthemes aligned with 18 CFIR constructs from staff and patient data.

CONCLUSION

Rapid implementation was enabled through shared resources, dividing implementation tasks between senior personnel, engaging furloughed healthcare staff in design and delivery, and having a flexible approach that allowed for ongoing improvements. Benefits for patients included early identification of COVID-19 deterioration, as well as provision of accurate and trustworthy information to isolate safely at home. The main challenges were the multiple agencies involved in patient monitoring, which may be addressed in the future by attributing responsibility for monitoring to a single agency.

A Healthy Food Prescription Incentive Program for Adults With Type 2 Diabetes Who Are Experiencing Food Insecurity: Protocol for a Longitudinal Qualitative Study

Objectives

Food insecurity is inadequate or insecure access to food due to financial constraints. Individuals experiencing food insecurity tend to have poorer diet quality compared to their food secure peers. Given the importance of maintaining healthful dietary patterns for optimal glycemic control, food insecurity is a considerable barrier to managing type 2 diabetes (T2DM). Healthy food prescription incentive programs aim to reduce such barriers by providing financial incentives to purchase healthy foods. The purpose of this study is to conduct longitudinal qualitative shop-along interviews among adults with T2DM who are experiencing food insecurity. We will explore experiences of redeeming healthy food incentives and factors influencing food purchasing patterns during participation in a healthy food prescription program in Alberta, Canada.

Methods

The healthy food prescription incentive program consists of two core elements: 1) A one-time healthy food prescription pamphlet outlining an evidence-based healthy dietary pattern; and 2) A healthy food incentive of $1.50/day/household member to purchase healthy foods in participating supermarkets for 6 months. Thirty participants aged 18–85 years will be purposefully recruited from primary care clinics. At baseline and 6-month follow-up, participants will take part in supermarket-based shop-along qualitative interviews. Participants will be asked to complete a usual grocery shop alongside a researcher. Using think-aloud principles, they will be asked to verbalize their thought processes for the shop's duration. Researchers will also collect naturalistic observations of participants, such as consulting nutrition labels. A post-shop interview will be completed to discuss experiences, decision-making rationale, and potential barriers and facilitators to food purchasing. Data will be analyzed iteratively and inductively at each time point. Further, a longitudinal analysis will compare emerging themes and identify changes occurring over time.

Results

N/A

Conclusions

This study will generate key data regarding if, how, and why such programs may address barriers to maintaining healthful dietary patterns. These findings will help to understand experiences of participating in healthy food incentive programs that can be used to improve future programs.

Funding Sources

Alberta Innovates.

Experiences and Perceived Outcomes of a Grocery Gift Card Program for Low-Income Households at Risk of Food Insecurity

Objectives

Household food insecurity negatively affects children's diet quality, physical and mental health, and academic performance. I Can for Kids’ (IC4K) grocery gift card (GGC) program provides GGC to low-income households with school-aged children at risk of household food insecurity in Calgary, Canada. This study described program recipients’ and facilitators’ experiences and perceived outcomes of accessing or facilitating IC4K's GGC program.

Methods

This study used qualitative descriptive methodology. Data generation and analysis were guided by Freedman et al's theoretical framework of nutritious food access. Semi-structured interviews were conducted between August and November 2020 with 37 program recipients and 17 program facilitators who were purposively recruited. Directed content analysis was used to analyze the data using a deductive-inductive approach. Codes were combined into subthemes and themes that summarized program recipients’ and facilitators’ experiences and perceived outcomes of receiving or distributing GGC, and suggestions to improve IC4K's GGC program.

Results

Three themes were generated from the data: 1) IC4K's GGC program promoted a sense of autonomy and dignity among program recipients; 2) recipients used GGC to purchase foods that improved household dietary patterns and food skills, including foods that aligned with health-related food needs and cultural foodways and; 3) program logistical strengths and limitations, including the program's impact on facilitators’ connection with clients and their workload, experiences of differential access to GGC among recipients, and the importance of increasing program awareness to reach more food insecure households.

Conclusions

IC4K's GGC program enhanced recipients’ access to nutritious foods, had positive impacts on household finances and diet quality, as well as recipients’ social health and emotional wellbeing. However, differential access to GGC among recipients was also identified. Study findings were used to inform three recommendations to improve IC4K's GGC program: 1) increase the number of GGC that recipients can receive; 2) establish concrete guidelines governing GGC distribution and; 3) increase program awareness.

Funding Sources

O'Brien Institute for Public Health.

Beyond standard data collection – the promise and potential of BRAIN (Brain tumour Registry Australia INnovation and translation registry)

Background

Real-world data (RWD) is increasingly being embraced as an invaluable source of information to address clinical and policy-relevant questions that are unlikely to ever be answered by clinical trials. However, the largely unrealised potential of RWD is the value to be gained by supporting prospective studies and translational research. Here we describe the design and implementation of an Australian brain cancer registry, BRAIN, which is pursuing these opportunities.

Methods

BRAIN was designed by a panel of clinicians in conjunction with BIOGRID to capture comprehensive clinical data on patients diagnosed with brain tumours from diagnosis through treatment to recurrence or death. Extensive internal and external testing was undertaken, followed by implementation at multiple sites across Victoria and Tasmania.

Results

Between February 2021 and December 2021, a total of 350 new patients from 10 sites, including one private and two regional, were entered into BRAIN. Additionally, BRAIN supports the world’s first registry trial in neuro-oncology, EX-TEM, addressing the optimal duration of post-radiation temozolomide; and BioBRAIN, a dedicated brain tumour translational program providing a pipeline for biospecimen collection matched with linked clinical data.

Conclusions

Here we report on the first data collection effort in brain tumours for Australia, which we believe to be unique worldwide given the number of sites and patients involved and the extent to which the registry resource is being leveraged to support clinical and translational research. Further directions such as passive data flow and data linkages, use of artificial intelligence and inclusion of patient-entered data are being explored.

Prostate cancer survival in South West Victoria

OBJECTIVE

To explore reasons for survival disparities for patients with prostate cancer in the Barwon South West area of Victoria.

DESIGN, SETTING AND PARTICIPANTS

We have described incidence, diagnostics, treatment pathways, and survival for four regions of the Barwon South Western Victoria. Analysis included all newly diagnosed prostate cancer patients from 2009 to 2015 in the Evaluation of Cancer Outcomes Barwon South West Registry. Regions included 1: Queenscliffe 2: Geelong, Colac Otway and Corangamite 3: Moyne, Warrnambool and Southern Grampians and 4: Glenelg. Across the four regions, variables were compared using a chi square statistic or analysis of variance and survival data was assessed with the Kaplan-Meier curves.

MAIN OUTCOME MEASURES

Incidence, treatment pathways and survival for prostate cancer patients.

RESULTS

A total of 1776 patients were diagnosed with prostate cancer from 2009 to 2015 in the Barwon South West area. In regions 1-4, there were 298 (1.04%), 1085 (0.92%), 273 (0.97%) and 120 (1.2%) cases, respectively. There was no significant difference in Gleason score and treatment. The 5-year survival rate was 85%, 76%, 71% and 80%, respectively, as compared with the national average of 95%. PSA scores >20 ng/ml at diagnosis, as a surrogate for high-risk disease, occurred in 23%, 29%, 22% and 21%, respectively (p < 0.01). The proportions presenting with stage IV disease were 17%, 26%, 21% and 6%, respectively (p = 0.10).

CONCLUSION

Men diagnosed with prostate cancer in South West Victoria have a considerably lower 5-year survival compared with the national average with later disease at presentation in some areas.

Do Women Undertake Interdisciplinary Research More Than Men, and Do Self-citations Bias Observed Differences?

Some studies have shown that women undertake interdisciplinary research more than men, whereas other studies have shown no difference by gender. Women have also been shown to self-cite less often than men, a difference at least partly mediated through differences in career stages and prior productivity. Existing evidence on gender-based differences in interdisciplinarity may therefore be biased. If interdisciplinarity is inferred from the disciplinary diversity of a paper’s cited references, a greater share of self-citations by men could decrease their measured interdisciplinarity relative to women. Such biases could lead to erroneous conclusions, because after correcting for self-citations one might uncover that women participate in interdisciplinary research equally to, or less than, men. Given that funding for interdisciplinary research is gaining in importance, obtaining accurate measurements of interdisciplinarity by gender is highly relevant for funders so they can take appropriate action(s) in leveling the playing field across gender. For instance, evidence suggests women are sometimes advised not to participate in interdisciplinary research due to the risk it represents for their career progression. This study shows that a paper’s interdisciplinarity increases with the presence of women authors, accounting or not for self-citations in the interdisciplinarity measurement.

Peer Review

https://publons.com/publon/10.1162/qss_a_00191

Social attitudes and activities associated with loneliness: Findings from a New Zealand national survey of the adult population

There has been growing recognition of the harmful consequences of loneliness for health and well-being, and the need for community intervention, particularly in times of global crisis such as the Covid-19 pandemic with its imperatives of distancing, isolation, and quarantine. Social capital and a sense of social cohesion are known to have roles in buffering against the effects of adverse life circumstances. Our study sought to investigate the association of a range of social attitudes and activities - as proxies for social capital - with loneliness while taking into account socio-demographic factors. We undertook a national survey on a stratified random sample of the New Zealand (NZ) adult population aged 18+ in 2017 (n = 1,358), data from which included the requisite variables. The prevalence of loneliness was highest in young adults (18-30), falling with age until a slight rise in older people (76+). Loneliness was associated with socio-demographic factors, being more prevalent in the more disadvantaged groups: the deprived, Māori (the indigenous people of NZ), the non-partnered, and the less educated. Controlling for these socio-demographic factors, pro-social attitudes (that is towards political efficacy, trust in others, not feeling exploited, or being committed to family) and participation in social activities (that is being employed or being involved in recreation groups) - were protective against loneliness. Our study supports asset-based approaches to tackling loneliness - with implications for health and social care - that emphasise mobilising existing social resources, building social capital, and raising social cohesion in our communities. Such intervention on loneliness would help to prevent and ameliorate its detrimental consequences for public health.

Determining the Association Between Continuity of Primary Care and Acute Care Use in Chronic Kidney Disease: A Retrospective Cohort Study

PURPOSE

Acute care use is high among individuals with chronic kidney disease (CKD). It is unclear how relational continuity of primary care influences downstream acute care use. We aimed to determine if poor continuity of care is associated with greater rates of acute care use and decreased prescriptions for guideline-recommended drugs.

METHODS

We conducted a population-based retrospective cohort study of adults with stage 3-4 CKD and ≥3 visits to a primary care clinician during the period April 1, 2011 to March 31, 2014 in Alberta, Canada. Continuity was calculated using the Usual Provider Continuity index. Descriptive statistics were used to summarize patient and acute care encounter characteristics. Adjusted rates and incidence rate ratios for all-cause and CKD-related ambulatory care-sensitive condition (ACSC) hospitalizations and emergency department (ED) visits were estimated using negative binomial regression. Adjusted odds ratios for prescription use were estimated by multivariable logistic regression.

RESULTS

Among 86,475 patients with CKD, 51.3%, 30.0%, and 18.7% had high, moderate, and poor continuity of care, respectively. There were 77,988 all-cause hospitalizations, 6,489 ACSC-related hospitalizations, 204,615 all-cause ED visits, and 8,461 ACSC-related ED visits during a median follow-up of 2.3 years. Rates of all-cause and ACSC hospitalization and ED use increased with poorer continuity of care in a stepwise fashion across CKD stages. Patients with poor continuity were less likely to be prescribed a statin.

CONCLUSIONS

Poor continuity of care is associated with increased acute care use among patients with CKD. Targeted strategies that strengthen patient-physician relationships and guide physicians regarding guideline-recommended prescribing are needed.

Colonoscope "Looping" During Ileo-Colonoscopy in Children is Significantly Different to that Observed in Adult Practice

OBJECTIVES

Ileo-colonoscopy (IC) can be technically challenging because of unpredictable colonoscope loop formation. Aims of this study were to assess the risk of loop formation and to attempt to understand which factors were likely to predispose to which subtype of loop.

METHODS

Prospective study conducted on children referred for an IC at Sheffield Children's Hospital. Presence and type of loop was objectively assessed using the magnetic endoscope imaging tool.

RESULTS

Three hundred procedures were prospectively evaluated. Only 9% of paediatric ICs were loop-free. Alpha loops were the most common loop in children older than 5, whereas reverse alpha loops and a wider variety of complex and repetitive loops were observed in younger patients. Once a specific type of loop has formed, the risk of re-looping in a different way or in a different position of the colon is reduced. Left lateral starting position was found to increase the risk of reverse alpha loops and re-looping. Challenging loops, such as reverse alpha, were more frequent in males. Higher body mass index (BMI) was associated with an increased risk of alpha and deep transverse loops formation, while lower BMI with a higher incidence of reverse alpha and N loop. Loop formation did not prevent 100% ileal intubation.

CONCLUSIONS

This study represents the first attempt to describe loop formation according to patient characteristics in a large paediatric series. Further studies are needed in order to establish if these findings could be helpful in simplifying the execution of IC procedures in children and facilitate the learning curve during endoscopy training programs.

Exploring rural doctors’ early experiences of coping with the emerging COVID‐19 pandemic

Purpose

To understand how rural doctors (physicians) responded to the emerging COVID‐19 pandemic and their strategies for coping.

Methods

Early in the pandemic doctors (physicians) who practise rural and remote medicine were invited to participate through existing rural doctors’ networks. Thirteen semi‐structured interviews were conducted with rural doctors from 11 countries. Interviews were transcribed verbatim and coded using NVivo. A thematic analysis was used to identify common ideas and narratives.

Findings

Participants’ accounts described highly adaptable and resourceful responses to address the crisis. Rapid changes to organizational and clinical practices were implemented, at a time of uncertainty, anxiety, and fear, and with limited information and resources. Strong relationships and commitment to their colleagues and communities were integral to shaping and sustaining these doctors’ responses. We identified five common themes underpinning rural doctors’ shared experiences: (1) caring for patients in a context of uncertainty, fear, and anxiety; (2) practical solutions through improvising and being resourceful; (3) gaining community trust and cooperation; (4) adapting to unrelenting pressures; and (5) reaffirming commitments. These themes are discussed in relation to the Lazarus and Folkman stress and coping model.

Conclusions

With limited resources and support, these rural doctors’ practical responses to the COVID‐19 crisis underscore strong problem‐focused coping strategies and shared commitments to their communities, patients, and colleagues. They drew support from sharing experiences with peers (emotion‐focused coping) and finding positive meanings in their experiences (meaning‐based coping). The psychosocial impact on rural doctors working at the limits of their adaptive resources is an ongoing concern.

Predictors of treatment success following peri-prosthetic joint infection: 24-month follow up from a multi-center prospective observational cohort study of 653 patients

Background

Periprosthetic joint infection (PJI) is a devastating condition and there is a lack of evidence to guide its management. We hypothesized that treatment success is independently associated with modifiable variables in surgical and antibiotic management.

Methods

The is a prospective, observational study at 27 hospitals across Australia and New Zealand. Newly diagnosed large joint PJIs were eligible. Data were collected at baseline and at 3, 12, and 24 months. The main outcome measures at 24 months were clinical cure (defined as all of the following: alive, absence of clinical or microbiological evidence of infection, and not requiring ongoing antibiotic therapy) and treatment success (clinical cure plus index prosthesis still in place).

Results

Twenty-four-month outcome data were available for 653 patients. Overall, 449 patients (69%) experienced clinical cure and 350 (54%) had treatment success. The most common treatment strategy was debridement and implant retention (DAIR), with success rates highest in early postimplant infections (119 of 160, 74%) and lower in late acute (132 of 267, 49%) and chronic (63 of 142, 44%) infections. Selected comorbidities, knee joint, and Staphylococcus aureus infections were independently associated with treatment failure, but antibiotic choice and duration (including rifampicin use) and extent of debridement were not.

Conclusions

Treatment success in PJI is associated with (1) selecting the appropriate treatment strategy and (2) nonmodifiable patient and infection factors. Interdisciplinary decision making that matches an individual patient to an appropriate management strategy is a critical step for PJI management. Randomized controlled trials are needed to determine the role of rifampicin in patients managed with DAIR and the optimal surgical strategy for late-acute PJI.

Efficacy and cost-effectiveness of an online mindfulness program (MindOnLine) to reduce fear of recurrence among people with cancer: study protocol for a randomised controlled trial

INTRODUCTION

Fear of cancer recurrence (FCR) is a common condition among cancer survivors that can lead to significant levels of distress, anxiety and depression. Online mindfulness programmes may provide the mechanism to support cancer survivors manage FCR and distress, and improve people's well-being over the short, medium and long term. The primary aim of this study is to determine the potential efficacy of MindOnLine, a 9 session mindfulness-based programme for survivors of breast, prostate and colorectal cancer. A formal economic programme will also be conducted.

METHODS AND ANALYSIS

A single-blind randomised controlled trial to determine the efficacy and cost-efficacy of a MindOnLine programme for cancer survivors. A total of 400 people living with cancer will be recruited via online advertisements on social media platforms, peak consumer advocacy groups or through outpatient services at healthcare providers across Victoria, Australia. People will be randomly allocated to either the MindOnLine programme (n=200) or waitlist control (n=200). Participant assessments will occur at baseline, at 9 weeks and 9-month follow-up. The primary outcome is change in Fear of Recurrence Index Score total score between baseline and 9 weeks; secondary outcomes are changes in depression and anxiety, quality of life and mindfulness. The economic analysis comprises a cost-consequences analysis where all outcomes will be compared with costs.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Peter MacCallum Cancer Centre (20-53) and Deakin University (2020-284). All participants will be required to provide written informed consent. Findings will be disseminated in peer reviewed journals and among key stakeholder organisations including hospitals, cancer and community organisations and Government. If successful the project will be rolled out nationally with a formal implementation plan.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (12620000645954); Pre-results. Registered 6 June 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379520&isReview=true.

Does Lateralizing the Glenosphere Center of Rotation by 4 mm Decrease Scapular Notching in Reverse Shoulder Arthroplasty with a 135° Humeral Component?

Background

Scapular notching continues to be associated with reverse shoulder arthroplasty (RSA) and is thought to lead to fewer outcomes. Decreasing the humeral neck-shaft angle (NSA) has been associated with decreased incidence of scapular notching. Lateralizing the glenosphere center of rotation (COR) has also been proposed to decrease notching; however, its effect in lower NSA RSA is less understood. The purpose of this study was to compare the impact of the medial (0 mm) and lateral (4 mm) COR on the incidence of scapular notching and clinical outcomes after RSA with a 135° NSA humeral component.

Methods

We performed a multicenter retrospective comparative cohort of 82 patients with cuff tear arthropathy (41 in each cohort) who underwent RSA with a 135° NSA humeral component and a glenosphere COR of either 0 mm (medialized COR [MCOR]) or 4 mm (lateralized COR [LCOR]) of lateralization. RSA was performed using the same 135° humeral system and baseplate design. All patients had 2-year radiographic and clinical follow-up. Postoperative radiographs were evaluated for scapular notching. Clinical outcomes included American Shoulder and Elbow Surgeons scores, visual analog pain scale, Simple Assessment Numeric Evaluation, and active range of motion.

Results

The overall incidence of scapular notching was 22.0%. There was no significant difference in scapular notching between cohorts: 24.4% in the MCOR and 19.5% in the LCOR (P = .625). Both cohorts had significant improvements in American Shoulder and Elbow Surgeons scores, visual analog pain scale, Simple Assessment Numeric Evaluation, and active range of motion postoperatively (P < .005). Improvements did not significantly differ between cohorts. The presence of scapular notching did not have a significant negative effect on any clinical outcome measure. Complications occurred in 5 patients (2 MCORs and 3 LCORs), none of which occurred in patients with scapular notching.

Discussion and conclusion

Lateralizing the glenosphere COR by 4 mm does not significantly affect the incidence of scapular notching in RSA when using a 135° NSA humeral component at short-term follow-up. Furthermore, such offset does not significantly improve functional outcome scoring systems or range of motion when compared with the MCOR (0 mm). Scapular notching did not have a negative impact on any clinical outcome measure or complication rate in this series.

Impact of COVID-19 on emergency department attendance in an Australia hospital: a parallel convergent mixed methods study

OBJECTIVES

The COVID-19 pandemic has changed the way people are accessing healthcare. The aim of this study was to examine the impact of COVID-19 on emergency department (ED) attendance for frequent attenders and to explore potential reasons for changes in attendance.

DESIGN

This convergent parallel mixed methods study comprised two parts.

SETTING

An interrupted time-series analysis evaluated changes in ED presentation rates; interviews investigated reasons for changes for frequent ED users in a culturally and linguistically diverse setting.

PARTICIPANTS

A total of 4868 patients were included in the time series. A subgroup of 200 patients were interviewed, mean age 66 years (range 23-99).

RESULTS

Interrupted time-series analysis from 4868 eligible participants showed an instantaneous decrease in weekly ED presentations by 36% (p<0.001), with reduction between 45% and 67% across emergency triage categories. 32% did not know they could leave home to seek care with differences seen in English versus non-English speakers (p<0.001). 35% reported postponing medical care. There was a high fear about the health system becoming overloaded (mean 4.2 (±2) on 6-point scale). Four key themes emerged influencing health-seeking behaviour: fear and/or avoidance of hospital care; use of telehealth for remote assessment; no fear or avoidance of hospital care; not leaving the house for any reason.

CONCLUSIONS

This study demonstrated reduced ED use by a vulnerable population of previously frequent attenders. COVID-19 has resulted in some fear and avoidance of hospitals, but has also offered new opportunity for alternative care through telehealth.

Response to Rucaparib in BRCA-Mutant Metastatic Castration-Resistant Prostate Cancer Identified by Genomic Testing in the TRITON2 Study

PURPOSE

The PARP inhibitor rucaparib is approved in the United States for patients with metastatic castration-resistant prostate cancer (mCRPC) and a deleterious germline and/or somatic BRCA1 or BRCA2 (BRCA) alteration. While sequencing of tumor tissue is considered the standard for identifying patients with BRCA alterations (BRCA+), plasma profiling may provide a minimally invasive option to select patients for rucaparib treatment. Here, we report clinical efficacy in patients with BRCA+ mCRPC identified through central plasma, central tissue, or local genomic testing and enrolled in TRITON2.

PATIENTS AND METHODS

Patients had progressed after next-generation androgen receptor-directed and taxane-based therapies for mCRPC and had BRCA alterations identified by central sequencing of plasma and/or tissue samples or local genomic testing. Concordance of plasma/tissue BRCA status and objective response rate and prostate-specific antigen (PSA) response rates were summarized.

RESULTS

TRITON2 enrolled 115 patients with BRCA+ identified by central plasma (n = 34), central tissue (n = 37), or local (n = 44) testing. Plasma/tissue concordance was determined in 38 patients with paired samples and was 47% in 19 patients with a somatic BRCA alteration. No statistically significant differences were observed between objective and PSA response rates to rucaparib across the 3 assay groups. Patients unable to provide tissue samples and tested solely by plasma assay responded at rates no different from patients identified as BRCA+ by tissue testing.

CONCLUSIONS

Plasma, tissue, and local testing of mCRPC patients can be used to identify men with BRCA+ mCRPC who can benefit from treatment with the PARP inhibitor rucaparib.