Recurrent primary scrotal extramammary Paget disease: a case report and literature review

Extramammary Paget disease (EMPD) is a rare malignant neoplasm arising in apocrine gland-rich skin, which may be classified as either of primary or secondary origin. Management of this condition is predominantly surgical, and is often characterised by lengthy diagnostic delays. Complete surgical excision is challenging, and local recurrence is common. Herein, we discuss a subtle presentation of recurrent scrotal EMPD in a 77-year-old male and review the available literature. Although relatively rare, the indistinct nature of this pathology merits special attention from treating surgeons, who are frequently responsible for initial management and follow-up. The risk of distant metastasis and concomitant prognostic implications necessitate a high clinical index of suspicion, and low threshold for definitive biopsy in similar cases.

Neuronal ER-plasma membrane junctions couple excitation to Ca2+-activated PKA signaling

Junctions between the endoplasmic reticulum (ER) and the plasma membrane (PM) are specialized membrane contacts ubiquitous in eukaryotic cells. Concentration of intracellular signaling machinery near ER-PM junctions allows these domains to serve critical roles in lipid and Ca2+ signaling and homeostasis. Subcellular compartmentalization of protein kinase A (PKA) signaling also regulates essential cellular functions, however, no specific association between PKA and ER-PM junctional domains is known. Here, we show that in brain neurons type I PKA is directed to Kv2.1 channel-dependent ER-PM junctional domains via SPHKAP, a type I PKA-specific anchoring protein. SPHKAP association with type I PKA regulatory subunit RI and ER-resident VAP proteins results in the concentration of type I PKA between stacked ER cisternae associated with ER-PM junctions. This ER-associated PKA signalosome enables reciprocal regulation between PKA and Ca2+ signaling machinery to support Ca2+ influx and excitation-transcription coupling. These data reveal that neuronal ER-PM junctions support a receptor-independent form of PKA signaling driven by membrane depolarization and intracellular Ca2+, allowing conversion of information encoded in electrical signals into biochemical changes universally recognized throughout the cell.

Photobiomodulation in dental extraction therapy: Postsurgical pain reduction and wound healing

BACKGROUND

This scoping review and analysis were designed to assess the amount of time spent delivering photobiomodulation (PBM) light therapy after dental extraction to improve postoperative pain and wound healing.

TYPES OF STUDIES REVIEWED

The scoping review was performed according to the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Publications were specific for human randomized controlled clinical trials, PBM after dental extraction therapy, and related clinical outcomes. Online databases searched included PubMed, Embase, Scopus, and Web of Science. Analyses were conducted to analyze the prescribed intervals of time (seconds) per application of PBM.

RESULTS

Of the 632 studies initially identified, 22 studies fulfilled the inclusion criteria. Postoperative pain and PBM were reported in 20 articles for 24 treatment groups, with treatment times ranging from 17 through 900 seconds and wavelengths from 550 through 1,064 nm. Clinical wound healing outcomes were reported in 6 articles for 7 groups with treatment times ranging from 30 through 120 seconds and wavelengths from 660 through 808 nm. PBM therapy was not associated with adverse events.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

There is future potential to integrate PBM after dental extraction therapy to improve postoperative pain and clinical wound healing. The amount of time spent delivering PBM will vary by wavelength and the type of device. Further investigation is needed to translate PBM therapy into human clinical care.

Acute colonic pseudo-obstruction following spinal fixation for trauma

PURPOSE

Acute colonic pseudo-obstruction (ACPO) is a potentially highly morbid surgical complication. The incidence of ACPO following spinal trauma is unknown, but is likely higher than after elective spinal fusion. The purpose of this study was to establish the incidence of ACPO in patients with major trauma undergoing spinal fusion for unstable thoracic and lumbar fracture. Secondly, to characterise the nature of ACPO in this group, including treatment and complications.

METHODOLOGY

A metropolitan hospital prospective trauma database was utilised to identify all patients from November 2015 to December 2021 meeting major trauma criteria and undergoing thoracic or lumbar spinal fusion for fracture. Individual records were then evaluated for occurrence of ACPO. ACPO was defined as radiological evidence of colonic dilation without mechanical obstruction in symptomatic patients undergoing dedicated abdominal imaging.

RESULTS

After exclusions, 456 patients with major trauma undergoing thoracic or lumbar spinal fusion were identified. ACPO occurred in 34; an incidence rate of 7.5%. There was no evidence of difference in terms of the spinal fracture type, level, surgical approach or number of segments fused. There were no perforations; only two patients required colonoscopic decompression and none required surgical resection.

CONCLUSION

ACPO occurred at a high frequency in this group of patients, although it required relatively simple treatment. High vigilance for ACPO should be maintained in trauma patients requiring thoracic or lumbar fixation, with a view to early intervention. The aetiology driving the high rates of ACPO in this cohort is not understood and would benefit from further investigation.

Improving Titanium Implant Stability with Photobiomodulation: A Review and Meta-Analysis of Irradiation Parameters

Objective: This analysis was designed to present a summary of available evidence that will inform practice and guide future research for photobiomodulation (PBM) after titanium implant placement procedures. Materials and methods: A systematic review was performed according to the Cochrane Collaboration and in line with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) criteria. Two investigators screened the titles and abstracts, and reviewed articles for risk of bias. Online databases searched included PubMed, Embase, Scopus, and Web of Science. Terms were specific to the effects of PBM on dental implant stability. Results: Eight hundred fifty-six studies were identified, and 15 studies fulfilled the inclusion criteria. Light sources included both laser and light emitting diode (LED) devices. Wavelengths ranged from 618 to 1064 nm. The meta-analysis concluded that all 15 published studies were able to safely apply PBM near dental implants without adverse events. Laser and LED wavelengths that reported significant results included 618, 626, 830, 940 (2 × ), and 1064 nm. Conclusions: The use of adjunctive PBM can be safely prescribed after surgical placement of titanium implants. Six groups reported statistical significance for improving implant stability (four laser diode, two LED) in wavelengths ranging from 618 to 1064 nm. The amount of time spent delivering PBM was not a variable that differentiated whether a study reported significant results.

Paediatric pancreatic trauma in North Queensland: a 10-year retrospective review

PURPOSE

To establish the incidence of pancreatic trauma in North Queensland to the region's only tertiary paediatric referral centre, and to determine the patient's outcomes based on their management.

METHODS

A single centre, retrospective cohort study of patients < 18 years with pancreatic trauma from 2009 to 2020 was performed. There were no exclusion criteria.

RESULTS

Between 2009 and 2020 there were 145 intra-abdominal trauma cases, 37% from motor vehicle accidents (MVA), 18.6% motorbike or quadbike, and 12.4% bicycle or scooter accidents. There were 19 cases of pancreatic trauma (13%), all from blunt trauma and with associated injuries. There were 5 AAST grade I, 3 grade II, 3 grade III, 3 grade IV injuries, and 4 with traumatic pancreatitis. Twelve patients were managed conservatively, 2 were managed operatively for another reason, and 5 were managed operatively for the pancreatic injury. Only 1 patient with a high grade AAST injury was successfully managed non-operatively. Complications included pancreatic pseudocyst (n = 4/19; 3 post-op), pancreatitis (n = 2/19; 1 post op), and post-operative pancreatic fistula (POPF) (n = 1/19).

CONCLUSION

Due to North Queensland's geography, diagnosis and management of traumatic pancreatic injury is often delayed. Pancreatic injuries requiring surgery are at high risk for complications, prolonged length of stay, and further interventions.

Strategies for the Management of Patients with Pancreatic Cancer with PARP Inhibitors

A subset of patients with pancreatic adenocarcinomas (PDAC) harbor mutations that are exploitable in the context of DNA-damage response and repair (DDR) inhibitory strategies. Between 8-18% of PDACs harbor specific mutations in the DDR pathway such as BRCA1/2 mutations, and a higher prevalence exists in high-risk populations (e.g., Ashkenazi Jews). Herein, we will review the current trials and data on the treatment of PDAC patients who harbor such mutations and who appear sensitive to platinum and/or poly ADP ribose polymerase inhibitor (PARPi) based therapies due to a concept known as synthetic lethality. Although this current best-in-class precision treatment shows clinical promise, the specter of resistance limits the extent of therapeutic responses. We therefore also evaluate promising pre-clinical and clinical approaches in the pipeline that may either work with existing therapies to break resistance or work separately with combination therapies against this subset of PDACs.

Continuous glucose monitoring and metrics for clinical trials: an international consensus statement

Randomised controlled trials and other prospective clinical studies for novel medical interventions in people with diabetes have traditionally reported HbA1c as the measure of average blood glucose levels for the 3 months preceding the HbA1c test date. The use of this measure highlights the long-established correlation between HbA1c and relative risk of diabetes complications; the change in the measure, before and after the therapeutic intervention, is used by regulators for the approval of medications for diabetes. However, with the increasing use of continuous glucose monitoring (CGM) in clinical practice, prospective clinical studies are also increasingly using CGM devices to collect data and evaluate glucose profiles among study participants, complementing HbA1c findings, and further assess the effects of therapeutic interventions on HbA1c. Data is collected by CGM devices at 1-5 min intervals, which obtains data on glycaemic excursions and periods of asymptomatic hypoglycaemia or hyperglycaemia (ie, details of glycaemic control that are not provided by HbA1c concentrations alone that are measured continuously and can be analysed in daily, weekly, or monthly timeframes). These CGM-derived metrics are the subject of standardised, internationally agreed reporting formats and should, therefore, be considered for use in all clinical studies in diabetes. The purpose of this consensus statement is to recommend the ways CGM data might be used in prospective clinical studies, either as a specified study endpoint or as supportive complementary glucose metrics, to provide clinical information that can be considered by investigators, regulators, companies, clinicians, and individuals with diabetes who are stakeholders in trial outcomes. In this consensus statement, we provide recommendations on how to optimise CGM-derived glucose data collection in clinical studies, including the specific glucose metrics and specific glucose metrics that should be evaluated. These recommendations have been endorsed by the American Association of Clinical Endocrinologists, the American Diabetes Association, the Association of Diabetes Care and Education Specialists, DiabetesIndia, the European Association for the Study of Diabetes, the International Society for Pediatric and Adolescent Diabetes, the Japanese Diabetes Society, and the Juvenile Diabetes Research Foundation. A standardised approach to CGM data collection and reporting in clinical trials will encourage the use of these metrics and enhance the interpretability of CGM data, which could provide useful information other than HbA1c for informing therapeutic and treatment decisions, particularly related to hypoglycaemia, postprandial hyperglycaemia, and glucose variability.

Mass Cytometry Reveals Classical Monocytes, NK Cells, and ICOS+ CD4+ T Cells Associated with Pembrolizumab Efficacy in Patients with Lung Cancer

PURPOSE

Immune checkpoint inhibitors (ICI) have revolutionized the treatment of non-small cell lung cancer (NSCLC), but predictive biomarkers of their efficacy are imperfect. The primary objective is to evaluate circulating immune predictors of pembrolizumab efficacy in patients with advanced NSCLC.

EXPERIMENTAL DESIGN

We used high-dimensional mass cytometry (CyTOF) in baseline blood samples of patients with advanced NSCLC treated with pembrolizumab. CyTOF data were analyzed by machine-learning algorithms (Citrus, tSNE) and confirmed by manual gating followed by principal component analysis (between-group analysis).

RESULTS

We analyzed 27 patients from the seminal KEYNOTE-001 study (median follow-up of 60.6 months). We demonstrate that blood baseline frequencies of classical monocytes, natural killer (NK) cells, and ICOS+ CD4+ T cells are significantly associated with improved objective response rates, progression-free survival, and overall survival (OS). In addition, we report that a baseline immune peripheral score combining these three populations strongly predicts pembrolizumab efficacy (OS: HR = 0.25; 95% confidence interval = 0.12-0.51; P < 0.0001).

CONCLUSIONS

As this immune monitoring is easy in routine practice, we anticipate our findings may improve prediction of ICI benefit in patients with advanced NSCLC.

P36 Crohn’s-associated inflammatory arthritis treated successfully with upadacitinib

Introduction/Background

Enteropathic arthritis is inflammatory arthritis which is associated with inflammatory bowel disease such as Crohn’s disease and ulcerative colitis. The optimal treatment for patients is one which is effective for both arthritis and bowel disease. First line treatments include DMARDs such as methotrexate and sulfasalazine. Second line options include anti-TNF biologics such as infliximab and adalimumab, and the anti-IL-12/23 biologic ustekinumab. There is currently little guidance on choice of treatment if these options fail. We present a case of Crohn’s-associated inflammatory arthritis which did not respond to two anti-TNFs but was successfully treated with the JAK inhibitor upadacinitib.

Description/Method

A 30-year-old male was referred to gastroenterology with a 4 month history of diarrhoea and weight loss. His faecal calprotectin was raised at 982µg/g. He had a history of seronegative inflammatory arthritis diagnosed 5 years previously. He had been treated initially with methotrexate and sulfasalazine, which were discontinued due to side effects and inefficacy, and his arthritis was subsequently well-controlled on etanercept for the last year.

Colonoscopy showed patchy colitis at the rectum which was continuous in the transverse and ascending colon and caecum. The appearances and mucosal biopsy were consistent with moderately active Crohn’s colitis. In view of this, etanercept was switched to adalimumab, which was administered using the accelerated loading regimen used in IBD.

Five weeks after switching the patient developed a flare of arthritis with knee and ankle inflammation and CRP 30. He was given oral steroids and reviewed in a combined rheumatology/gastroenterology clinic. The frequency of adalimumab was increased to 40mg weekly and subcutaneous methotrexate 10mg weekly was introduced.

Despite this, the patient’s arthritis remained active, although with some improvement in his bowel symptoms and a fall in faecal calprotectin to 117µg/g. Adalimumab was switched to certolizumab and methotrexate increased to 15mg weekly with intra-muscular steroids. On certolizumab he developed progressively more active arthritis with CRP 83, bilateral ankle inflammation and large knee effusions requiring aspiration and steroid injection.

After 8 weeks of certolizumab, there was no improvement and the decision was made to switch to upadacitinib 15mg daily. Within 4 weeks of treatment with upadacitinib he noticed a significant improvement in his arthritis and after 12 weeks was in clinical remission with normal CRP and faecal calprotectin. Methotrexate was later discontinued due to nausea. Over 12 months later the patient remains in remission for both bowel disease and arthritis on upadacitinib monotherapy.

Discussion/Results

In enteropathic arthritis, joint symptoms may precede or follow bowel disease. Etanercept, a recombinant TNF-receptor fusion protein, is not an effective treatment for IBD. Indeed, there are case reports and observational data to suggest that etanercept may be associated with an increased risk of developing IBD in some patients. In our case the patient developed Crohn’s disease while taking etanercept and the switch to adalimumab precipitated a flare of his arthritis which was not controlled by treatment intensification. The failure of two anti-TNF biologics, adalimumab and certolizumab, may point to the activation of alternative cytokine inflammatory pathways as the driver of the patient’s disease.

Our patient was managed in a combined rheumatology/gastroenterology clinic which enabled an inter-specialty approach to managing both aspects of his disease. After the failure of certolizumub we made the decision to trial upadacitinib, a selective JAK1 inhibitor, owing to our experience of its effectiveness in rheumatoid and psoriatic arthritis, and its promising results in Phase 3 trials in Crohn’s disease. We considered ustekinumab but opted against it as in our experience it may be suboptimal in patients in whom arthritis is the most troublesome symptom. Upadacitinib worked quickly and effectively to control our patient’s arthritis alongside his bowel disease and was well tolerated.

There are currently limited treatments which are effective for both IBD and arthritis, and there is little guidance on treatment strategies in enteropathic arthritis if anti-TNF and ustekinumab are unsuccessful. Tofacitinib, a JAK1/3 inhibitor, is licensed for rheumatoid and psoriatic arthritis and ulcerative colitis, but is not effective for Crohn’s disease. Upadacitinib is undergoing Phase 3 trials in Crohn’s disease and our case highlights its potential role in the treatment of patients with Crohn’s disease and inflammatory arthritis in whom anti-TNF therapy is unsuccessful.

Key learning points/Conclusion

1. Etanercept is not an effective treatment for inflammatory bowel disease and may necessitate a change to another anti-TNF biologic such as infliximab or adalimumab.

2. Upadacitinib, a selective JAK1 inhibitor, was successfully used in our case to treat both arthritis and bowel disease. Although this was just one case, the results of Phase 3 trials suggest a promising role for upadacitinib in Crohn’s disease and it is already used in the treatment of rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.

3. Patients with enteropathic arthritis may be best managed in a specialist combined gastroenterology and rheumatology clinic where a holistic approach to the management of both aspects of their disease can be undertaken.

Effects of color-enhancing glasses on color vision in congenital red-green color deficiencies

As commercially available glasses for color vision deficiency (CVD) are classified as low risk, they are not subject to stringent marketing regulations. We investigate how EnChroma and VINO glasses affect performance on the Colour Assessment and Diagnosis (CAD) test in individuals with CVD. Data were obtained from 51 individuals with red-green CVD. Blood or saliva samples were collected to examine the structure of the OPN1LW/OPN1MW array. Individuals completed the CAD test twice without glasses and once with each pair of glasses. Although there was a statistically significant effect of both glasses, only that of VINO could be considered functionally meaningful.

Outpatient Oral Neuropathic Pain Management with Photobiomodulation Therapy: A Prospective Analgesic Pharmacotherapy-Paralleled Feasibility Trial

Neuropathic pain (NP) can be challenging to treat effectively as analgesic pharmacotherapy (MED) can reduce pain, but the majority of patients do not experience complete pain relief. Our pilot approach is to assess the feasibility and efficacy of an evidence-based photobiomodulation (PBM) intervention protocol. This would be as an alternative to paralleled standard analgesic MED for modulating NP intensity-related physical function and quality of life (QoL) prospectively in a mixed neurological primary burning mouth syndrome and oral iatrogenic neuropathy study population (n = 28). The study group assignments and outcome evaluation strategy/location depended on the individual patient preferences and convenience rather than on randomisation. Our prospective parallel study aimed to evaluate the possible pre/post-benefit of PBM and to allow for a first qualitative comparison with MED, various patient-reported outcome measures (PROMs) based on Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT-II) were used for up to a nine-month follow-up period in both intervention groups (PBM and MED). The PBM protocol applied to the PBM group was as follows: λ810 nm, 200 mW, 0.088 cm2, 30 s/point, 9 trigger and affected points, twice a week for five consecutive weeks, whereas the MED protocol followed the National Institute of Clinical Excellence (NICE) guidelines. Our results showed that despite the severe and persistent nature of the symptoms of 57.50 ± 47.93 months at baseline in the PBM group, a notably rapid reduction in PISmax on VAS from 7.6 at baseline (T0) to 3.9 at one-month post-treatment (T3) could be achieved. On the other hand, mean PISmax was only reduced from 8.2 at baseline to 6.8 at T3 in the MED group. Our positive PBM findings furthermore support more patients' benefits in improving QoL and functional activities, which were considerably impaired by NP such as: eating, drinking and tasting, whereas the analgesic medication regimens did not. No adverse events were observed in both groups. To the best knowledge of the authors, our study is the first to investigate PBM efficacy as a monotherapy compared to the gold standard analgesic pharmacotherapy. Our positive data proves statistically significant improvements in patient self-reported NP, functionality, psychological profile and QoL at mid- and end-treatment, as well as throughout the follow-up time points (one, three, six and nine months) and sustained up to nine months in the PBM group, compared to the MED group. Our study, for the first time, proves the efficacy and safety of PBM as a potent analgesic in oral NP and as a valid alternative to the gold standard pharmacotherapy approach. Furthermore, we observed long-term pain relief and functional benefits that indicate that PBM modulates NP pathology in a pro-regenerative manner, presumably via antioxidant mechanisms.

Short- and long-term effects of whole-body photobiomodulation on pain, functionality, tissue quality, central sensitisation and psychological factors in a population suffering from fibromyalgia: protocol for a triple-blinded randomised clinical trial

Background:

The development of an integral and global treatment to improve the quality of life in those with fibromyalgia syndrome (FMS) is challenging. The aim of this study is to investigate the impact of whole-body photobiomodulation (PBM) on pain perception, functionality, quality of soft tissue, central sensitisation and psychological factors in patients suffering with FMS.

Methods:

This study is a randomised, placebo-controlled clinical trial. A total of 44 participants will be recruited in a private care practice and randomised to receive either a whole-body PBM therapy programme or placebo in the same care centre. The parameters of the PBM programme are as follows: wavelengths of red and near-infrared LEDs 50:50 ratio with 660–850 nanometers; fluence of 25.2 J/cm2; treatment time of 1200 s and a total power emitted of 967 W. Treatment sessions will be 3 times weekly for a period of 4 weeks, totalling 12 treatment sessions. Primary outcome will be pain (Numeric Pain Rating Scale; Widespread Pain Index; Symptom Severity Score). Secondary outcomes will be functionality (Fibromyalgia Impact Questionnaire; the Leisure Time Physical Activity Instrument), quality of soft tissue (elastography), central sensitisation (pain pressure threshold and the Autonomic Symptom Profile) and psychological factors (Pain Catastrophising scale, Tampa Scale, Self-Efficacy questionnaire). Assessments will be at baseline (T1), after session 6 (T2), after treatment (T3) and 2 weeks (T4), 3 (T5) and 6 (T6) month follow-up.

Discussion:

PBM therapy has been shown to reduce pain and inflammation and to increase the rate of tissue repair for a wide range of conditions, but its potential use as a whole-body treatment in FM is yet to be explored. This trial will investigate whether whole-body PBM therapy is effective at reducing pain intensity, improving functionality, quality of soft tissue, central sensitisation symptoms and psychological measurements. Furthermore, 3- and 6-month follow-up will investigate long-term efficacy of this treatment.

Trial registration:

NCT04248972. Registered on January 29, 2020, https://clinicaltrials.gov/ct2/show/NCT04248972?term=navarro-ledesma+santiago&draw=2&rank=2 .

Individualized HbA1c Goals, and Patient Awareness and Attainment of Goals in Type 2 Diabetes Mellitus: A Real-World Multinational Survey

Aims

While glycemic control is key in effective type 2 diabetes mellitus management, many patients fail to reach their individualized glycemic goal. This analysis aimed to describe a real-world picture of diabetes management: individualized hemoglobin A_1c (HbA_1c) goals, rate of goal attainment, HbA_1c at each line of therapy, and patient awareness of their glycemic goal. Secondly, we aimed to understand physician satisfaction with HbA_1c amongst patients aware vs. those unaware of HbA_1c goal.

Methods

Analysis of physicians and the next ten consulting patients with type 2 diabetes mellitus conducted in Europe and the USA including medical record data abstraction/assessment by physicians, a patient-reported survey and a physician survey. Patients were diagnosed for 3 months or more with a known current and target HbA_1c. For the sub-analysis assessment of patient awareness of HbA_1c goal, in addition to the above, these patients had to have completed a patient-reported questionnaire and answer the question on awareness of HbA_1c goal.

Results

A total of 730 physicians provided data on 8794 patients with type 2 diabetes mellitus; 5331 patients were eligible for this analysis. Overall, mean (standard deviation, SD) individualized HbA_1c goal was 6.8% (0.68%). Of eligible patients, 39.1% met their HbA_1c goal; of 60.9% of patients not reaching their HbA_1c goal, the mean distance from individualized HbA_1c goal was 0.9% (SD 1.0%). Physicians progressed patients’ antihyperglycemic therapy when HbA_1c was 8% or higher. Among 2560 patients who were included in the sub-analysis assessing the effect of patient awareness of their HbA_1c goal on multiple parameters, 70.5% were aware of their HbA_1c goal; mean HbA_1c goal was 6.8% (0.7%) and current mean HbA_1c value 7.1% (1.2%). A total of 949 patients in the sub-analysis (39.2%) achieved their goal; achieving HbA_1c goal was not related to knowledge of goal. Patients aware of their HbA_1c goal were slightly more adherent to their antihyperglycemic medication. They also were prescribed more antihyperglycemic agents, more often on a later therapy line receiving a GLP-1 receptor agonist, SGLT2i, or insulin, and more often tested their blood glucose levels than patients who were unaware. Physicians were not satisfied with the current blood glucose level of one third of their patients, believing that more of those who were aware of their HbA_1c goal could achieve better glucose control (32.4% of aware vs. 28.2% of unaware patients; p = 0.003).

Conclusions

Our results showed that the proportion of patients with type 2 diabetes mellitus achieving their goals for glycemic control was suboptimal when compared to current guideline criteria, with only about 40% of patients achieving their individualized HbA_1c goal. Treatment intensification was often delayed until HbA_1c was 8% and higher. Patients aware of their HbA_1c goal were slightly more adherent to their antihyperglycemic medication; however, awareness of HbA_1c goal did not enhance goal attainment. This highlights the need for a holistic approach to diabetes management, involving patient education, and patient–physician communication and partnership.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01985-3.

The Impact of Chronic Electronic Cigarette Use on Alveolar Macrophage Lipid Content: Case Report

Background

While acute respiratory distress following electronic cigarette (e-cig) use has been described, the effects of chronic e-cig use on lung health are currently unknown. Acute e-cigarette/vaping product use-associated lung injury (EVALI) has been highlighted recently in numerous cases across the United States. Numerous EVALI case reports highlight alterations in alveolar macrophages, justifying investigation of this key immune sentinel of the lung in habitual e-cig users.

Case Presentation

After informed consent, we performed a bronchoscopy on a 25 year asymptomatic woman who reported daily e-cig use. To evaluate for evidence of abnormal lipid homeostasis, we performed histologic and Oil Red O stain evaluation of alveolar macrophages obtained from bronchoalveolar lavage fluid. Our analyses demonstrate a prevalence of cells with high lipid accumulation in multiple, discrete cytoplasmic foci. We found a high lipid laden macrophage index within alveolar macrophages isolated from a chronic e-cig user. At the ultrastructural level, we found membrane-bound compartments filled with material of various densities segregated along curved phase separation lines reminiscent of suspensions of immiscible fluids.

Conclusions

We found a unique ultrastructural pattern in alveolar macrophages isolated from a chronic e-cig user that is unlike any other previously reported in aspiration syndromes and may represent a defining diagnostic feature of chronic e-cig use.

Theoretical versus empirical measures of retinal magnification for scaling AOSLO images

The adaptive optics scanning light ophthalmoscope (AOSLO) allows cellular resolution imaging of the living retina. The accuracy of many quantitative measurements made from these images requires accurate estimates of the lateral scale of the images. Here, we used trial lenses, which are known to affect the relative magnification of the retinal image, to compare empirical measures of image scale with theoretical estimates from a four-surface optical model. The theoretical optical model overestimated the empirically determined change in image scale in 70% of the subjects examined, albeit to varying degrees. While the origin for the differences between subjects is not known, residual accommodation during imaging likely contributes to this variability in retinal magnification. These data provide an opportunity to derive improved lateral scaling error estimates for structural metrics extracted from AOSLO retinal images.

Functional independence of endogenous µ- and δ-opioid receptors co-expressed in cholinergic interneurons

Class A G-protein-coupled receptors (GPCRs) normally function as monomers, although evidence from heterologous expression systems suggests that they may sometimes form homodimers and/or heterodimers. This study aims to evaluate possible functional interplay of endogenous µ- and δ-opioid receptors (MORs and DORs) in mouse neurons. Detecting GPCR dimers in native tissues, however, has been challenging. Previously, MORs and DORs co-expressed in transfected cells have been reported to form heterodimers, and their possible co-localization in neurons has been studied in knock-in mice expressing genetically engineered receptors fused to fluorescent proteins. Here, we find that single cholinergic neurons in the mouse striatum endogenously express both MORs and DORs. The receptors on neurons from live brain slices were fluorescently labeled with a ligand-directed labeling reagent, NAI-A594. The selective activation of MORs and DORs, with DAMGO (µ-agonist) and deltorphin (δ-agonist) inhibited spontaneous firing in all cells examined. In the continued presence of agonist, the firing rate returned to baseline as the result of receptor desensitization with the application of deltorphin but was less observed with the application of DAMGO. In addition, agonist-induced internalization of DORs but not MORs was detected. When MORs and DORs were activated simultaneously with [Met⁵]-enkephalin, desensitization of MORs was facilitated but internalization was not increased. Together, these results indicate that while MORs and DORs are expressed in single striatal cholinergic interneurons, the two receptors function independently.

Erratum: Azimuthal Anisotropy of K_{S}^{0} and Λ+Λ[over ¯] Production at Midrapidity from Au+Au Collisions at sqrt[s]_{NN}=130 GeV [Phys. Rev. Lett. 89, 132301 (2002)]

This corrects the article DOI: 10.1103/PhysRevLett.89.132301.

Erratum: Azimuthal Anisotropy at the Relativistic Heavy Ion Collider: The First and Fourth Harmonics [Phys. Rev. Lett. 92, 062301 (2004)]

This corrects the article DOI: 10.1103/PhysRevLett.92.062301.

Evaluation of a Hyperbaric Oxygen Therapy Intervention in Individuals with Fibromyalgia

OBJECTIVE

To evaluate the feasibility and safety of hyperbaric oxygen therapy (HBOT) in patients with fibromyalgia (FM).

DESIGN

A cohort study with a delayed treatment arm used as a comparator.

SETTING

Hyperbaric Medicine Unit, Toronto General Hospital, Ontario, Canada.

SUBJECTS

Eighteen patients diagnosed with FM according to the American College of Rheumatology and a score ≥60 on the Revised Fibromyalgia Impact Questionnaire.

METHODS

Participants were randomized to receive immediate HBOT intervention (n = 9) or HBOT after a 12-week waiting period (n = 9). HBOT was delivered at 100% oxygen at 2.0 atmospheres per session, 5 days per week, for 8 weeks. Safety was evaluated by the frequency and severity of adverse effects reported by patients. Feasibility was assessed by recruitment, retention, and HBOT compliance rates. Both groups were assessed at baseline, after HBOT intervention, and at 3 months' follow-up. Validated assessment tools were used to evaluate pain, psychological variables, fatigue, and sleep quality.

RESULTS

A total of 17 patients completed the study. One patient withdrew after randomization. HBOT-related adverse events included mild middle-ear barotrauma in three patients and new-onset myopia in four patients. The efficacy of HBOT was evident in most of the outcomes in both groups. This improvement was sustained at 3-month follow-up assessment.

CONCLUSION

HBOT appears to be feasible and safe for individuals with FM. It is also associated with improved global functioning, reduced symptoms of anxiety and depression, and improved quality of sleep that was sustained at 3-month follow-up assessment.

Measurement of the Positive Muon Anomalous Magnetic Moment to 0.46 ppm

We present the first results of the Fermilab National Accelerator Laboratory (FNAL) Muon g-2 Experiment for the positive muon magnetic anomaly a_{μ}≡(g_{μ}-2)/2. The anomaly is determined from the precision measurements of two angular frequencies. Intensity variation of high-energy positrons from muon decays directly encodes the difference frequency ω_{a} between the spin-precession and cyclotron frequencies for polarized muons in a magnetic storage ring. The storage ring magnetic field is measured using nuclear magnetic resonance probes calibrated in terms of the equivalent proton spin precession frequency ω[over ˜]_{p}^{'} in a spherical water sample at 34.7 °C. The ratio ω_{a}/ω[over ˜]_{p}^{'}, together with known fundamental constants, determines a_{μ}(FNAL)=116 592 040(54)×10^{-11} (0.46 ppm). The result is 3.3 standard deviations greater than the standard model prediction and is in excellent agreement with the previous Brookhaven National Laboratory (BNL) E821 measurement. After combination with previous measurements of both μ^{+} and μ^{-}, the new experimental average of a_{μ}(Exp)=116 592 061(41)×10^{-11} (0.35 ppm) increases the tension between experiment and theory to 4.2 standard deviations.

Takotsubo cardiomyopathy complicating acute pancreatitis: a case report

Background

Acute pancreatitis as a trigger of Takotsubo cardiomyopathy has been infrequently described in the literature. Misdiagnosis of this phenomenon can often occur due to overlap in symptomology, particularly in those outside of the usual patient demographic.

Case presentation

A 27-year-old man with a history of alcohol abuse presented with epigastric and chest pain. Electrocardiography showed ischemic changes, and laboratory workup revealed elevated lipase and troponin. He was diagnosed with acute pancreatitis and managed presumptively as acute coronary syndrome. Subsequent coronary angiography was negative for obstructive coronary artery disease, and left ventriculography demonstrated basal hyperkinesis and apical akinesis, characteristic of Takotsubo cardiomyopathy.

Conclusions

Takotsubo cardiomyopathy is a rare complication of acute pancreatitis. Increased awareness of this phenomenon is required to prevent delays in diagnosis and avoid unnecessary interventions and complications.

137 Specialist Medication Review as Part of the Comprehensive Geriatric Assessment in the Day Hospital Setting

Introduction

Medication use in older people is complex. Consequently, regular medication reviews as an integral part of healthcare provision for older people are necessary. Patients attending consultant-led, multidisciplinary, day hospital clinics have specialist medication reviews undertaken by our senior clinical pharmacist. “Pharmacy Interventions” (PIs) are suggested and typed prior to physician-led patient review.

Method

Data collected by our senior clinical pharmacist were reviewed including patient demographics, clinical characteristics, types of prescribed drugs and PIs. Clinical severity of PIs was assessed using the NCC MERP Medication error index and American Journal Health-Syst Pharm Medication error index. Scores, ranging in clinical severity from A-I (A = capacity to cause error, I = may have contributed to death) and 0–10 (0 = no potential effect, 10 = death) were assigned by the pharmacist and two physicians.

Results

100 patients were included, mean age 82y (range 65-99y). 62% were female and 63% were first time attenders. Mean number of regularly prescribed medications was 7.2 (range 1–16), 10% reported compliance issues. The most commonly prescribed drugs belonged to the “Alimentary tract and metabolism” class (24%), including PPIs, laxatives and blood-glucose lowering medications. 16% and 15% were on regularly prescribed neuroactive and psychoactive medications, respectively. Of suggested PIs, 46% were acted upon during physician review, a further 4% were acknowledged in clinical notes. PIs covered many prescribing issues including drug–drug interactions, incorrect dosing, drug monitoring and administration timing. The average PI scores assigned by the pharmacist, physicians 1 and 2 differed, at 6.4, 3.2 and 4.8, respectively.

Conclusion

PIs suggested at senior pharmacy level are an important component of the comprehensive geriatric assessment, highlighting multiple complex prescribing issues. Clinical severity of PIs was scored lower by physicians, perhaps indicating an underestimation of prescribing errors. Senior pharmacy involvement in the care of frail older outpatients is an invaluable resource.

Safety of research bronchoscopy with BAL in stable adult patients with cystic fibrosis

Data on adverse events from research bronchoscopy with bronchoalveolar lavage (BAL) in patients with cystic fibrosis (CF) is lacking. As research bronchoscopy with BAL is useful for isolation of immune cells and investigation of CF lung microbiome, we sought to investigate the safety of bronchoscopy in adult patients with CF. Between November 2016 and September 2019, we performed research bronchoscopies on CF subjects (32) and control subjects (82). Control subjects were nonsmokers without respiratory disease. CF subjects had mild or moderate obstructive lung disease (FEV1 > 50% predicted) and no evidence of recent CF pulmonary exacerbation. There was no significant difference in the age or sex of each cohort. Neither group experienced life threatening adverse events. The number of adverse events was similar between CF and control subjects. The most common adverse events were sore throat and cough, which occurred at similar frequencies in control and CF subjects. Fever and headache occurred more frequently in CF subjects. However, the majority of fevers were seen in CF subjects with FEV1 values below 65% predicted. We found that CF subjects had similar adverse event profiles following research bronchoscopy compared to healthy subjects. While CF subjects had a higher rate of fevers, this adverse event occurred with greater frequency in CF subjects with lower FEV1. Our data demonstrate that research bronchoscopy with BAL is safe in CF subjects and that safety profile is improved if bronchoscopies are limited to subjects with an FEV1 > 65% predicted.

Detection of EGFR Mutations in cfDNA and CTCs, and Comparison to Tumor Tissue in Non-Small-Cell-Lung-Cancer (NSCLC) Patients

Lung cancer is the leading cause of cancer-related mortality worldwide. Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) therapies, based on the evaluation of EGFR mutations, have shown dramatic clinical benefits. EGFR mutation assays are mainly performed on tumor biopsies, which carry risks, are not always successful and give results relevant to the timepoint of the assay. To detect secondary EGFR mutations, which cause resistance to 1st and 2nd generation TKIs and lead to the administration of a 3rd generation drug, effective and non-invasive monitoring of EGFR mutation status is needed. Liquid biopsy analytes, such as circulating tumor cells (CTCs) and circulating tumor DNA (cfDNA), allow such monitoring over the course of the therapy. The aim of this study was to develop and optimize a workflow for the evaluation of cfDNA and CTCs in NSCLC patients all from one blood sample. Using Vortex technology and EntroGen ctEGFR assay, EGFR mutations were identified at 0.5 ng of DNA (∼83 cells), with a sensitivity ranging from 0.1 to 2.0% for a total DNA varying from 25 ng (∼4 CTCs among 4000 white blood cells, WBCs) to 1 ng (∼4 CTCs among 200 WBCs). The processing of plasma-depleted-blood provided comparable capture recovery as whole blood, confirming the possibility of a multimodality liquid biopsy analysis (cfDNA and CTC DNA) from a single tube of blood. Different anticoagulants were evaluated and compared in terms of respective performance. Blood samples from 24 NSCLC patients and 6 age-matched healthy donors were analyzed with this combined workflow to minimize blood volume needed and sample-to-sample bias, and the EGFR mutation profile detected from CTCs and cfDNA was compared to matched tumor tissues. Despite the limited size of the patient cohort, results from this non-invasive EGFR mutation analysis are encouraging and this combined workflow represents a valuable means for informing therapy selection and for monitoring treatment of patients with NSCLC.

Hyperbaric oxygen and focused rehabilitation program: a feasibility study in improving upper limb motor function after stroke

Neuroplasticity and recovery after stroke can be enhanced by a rehabilitation program pertinent to upper limb motor function exercise and mental imagery (EMI) as well as hyperbaric oxygen therapy (HBOT). We assessed feasibility and safety of the combined approach utilizing both HBOT and EMI, and to derive preliminary estimates of its efficacy. In this randomized controlled trial, 27 patients with upper extremity hemiparesis at 3-48 months after stroke were randomized to receive either a complementary rehabilitation program of HBOT-EMI (intervention group), or EMI alone (control group). Feasibility and safety were assessed as total session attendance, duration of sessions, attrition rates, missing data, and intervention-related adverse events. Secondary clinical outcomes were assessed with both objective tools and self-reported measures at baseline, 8 weeks (end of treatment), and 12-weeks follow-up. Session attendance, duration, and attrition rate did not differ between the groups; there were no serious adverse events. Compared with baseline, there were significant sustained improvements of objective and subjective outcomes' measures in the intervention group, and a single improvement in an objective measure in the control group. Between-group outcome comparisons were not statistically significant. This study demonstrated that the combination HBOT-EMI was a safe and feasible approach in patients recovering from chronic stroke. There were also trends for improved motor function of the affected upper limb after the treatments. ClinicalTrials.gov registration no.: NCT02666469. Novelty HBOT combined with an upper limb exercise and mental imagery rehabilitation program is feasible and safe in chronic stroke patients. This combined approach showed trends for improved functional recovery.

Impact of fractures on quality of life in patients with osteoporosis: a US cross-sectional survey

Objective: To evaluate the impact of osteoporosis-related fractures on health-related quality of life (HRQoL). Methods: Data were obtained from the 2016 Adelphi US Osteoporosis Disease Specific Programme™, a cross-sectional survey of physicians and their male and female patients with osteoporosis. Patient-reported outcomes (PRO) measures included the European Quality of Life 5 Domains (EQ-5D), European Quality of Life Visual Analog Scale (EQ-VAS), and Osteoporosis Assessment Questionnaire short-version (OPAQ-SV; physical, emotional, and symptom domains). Associations between PRO scores and the number and site of fractures were evaluated using ANOVA. Multivariate analyses were conducted using linear regression. Results: Physicians provided records for 1848 patients with osteoporosis. Of these, 981 (53.1%) completed the patient survey, data for the number of fractures were available for 935/981 (95.3%), and 185/935 (19.8%) had a history of fracture. Experiencing fractures significantly influenced scores on all PRO measures (p < .0001). Hip and spine fractures were associated with the greatest reduction in most PRO scores. The number of fractures, age, body mass index, and Charlson Comorbidity Index (CCI) were significantly associated with PRO measures (p < .05) in multivariate analyses. In patients with a fracture, fracture site, CCI, gender (EQ-5D and EQ-VAS), and age (OPAQ-SV physical only) were significantly associated with PRO measures. Conclusions: In patients with osteoporosis, fractures are associated with lower HRQoL and lower overall health status. Fracture history, fracture site, age, and comorbidity burden significantly influence HRQoL in individuals with osteoporosis. These data suggest the need for interventions to reduce the risk of fractures in patients with osteoporosis.

Tumor Characteristics Associated with Benefit from Pembrolizumab in Advanced Non-Small Cell Lung Cancer

PURPOSE

Several biomarkers have been individually associated with response to PD-1 blockade, including PD-L1 and tumor mutational burden (TMB) in non-small cell lung cancer (NSCLC), and CD8 cells in melanoma. We sought to examine the relationship between these distinct variables with response to PD-1 blockade and long-term benefit.

EXPERIMENTAL DESIGN

We assessed the association between baseline tumor characteristics (TMB, PD-L1, CD4, and CD8) and clinical features and outcome in 38 patients with advanced NSCLC treated with pembrolizumab (median follow-up of 4.5 years, range 3.8-5.5 years).

RESULTS

PD-L1 expression and CD8 infiltration correlated with each other and each significantly associated with objective response rate (ORR) and progression-free survival (PFS). TMB was independent of PD-L1 and CD8 expression, and trended towards association with ORR and PFS. There was no association between CD4 infiltration and outcomes. Only PD-L1 expression was correlated with overall survival (OS). Among 5 patients with long-term survival >3 years with no additional systemic therapy, PD-L1 expression was the only discriminating feature. The increased predictive value for PFS and OS of composite biomarker inclusive of PD-L1, CD8, CD4, and TMB was limited.

CONCLUSIONS

In patients with NSCLC treated with PD-1 blockade with long-term follow up, TMB, PD-L1, and CD8 were each associated with benefit from PD-1 blockade. Pretreatment PD-L1 expression was correlated with T lymphocyte infiltration and OS, whereas models incorporating TMB and infiltrating CD4 and CD8 lymphocytes did not substantially add to the predictive value of PD-L1 alone for OS.

Abstract P5-05-03: Estrogen receptor beta elicits anti-cancer effects in triple negative breast cancer through suppression of NFκB signaling

Background: Triple Negative Breast Cancer (TNBC) affects approximately 15-20% of BC patients, yet accounts for a disproportionately higher rate of BC morbidity and mortality, in part due to lack of targeted therapies. Using well-validated antibodies, Estrogen Receptor Beta (ERβ) protein has been shown to be expressed in approximately 25% of TNBCs and is associated with improved patient outcomes. Using multiple ERβ +/- TNBC cell lines and PDX models, we have demonstrated that ligand-mediated activation of ERβ by estradiol (E2) decreases cell proliferation, invasion, and migration in vitro, as well as primary tumor growth and metastatic spread in vivo.

Methods: To determine the mechanisms by which ERβ elicits these anti-cancer effects, we elucidated the ERβ transcriptome and cistrome via Microarray and ChIPseq, respectively, in TNBC cells stably expressing ERβ in a doxycycline-inducible manner. We also performed gene expression and luciferase assays to assess the impact of ERβ on NFκB signaling, followed by ChIP-PCR and ChIPseq to assess how ERβ modifies chromatin architecture near NFκB target genes.

Results: Pathway analysis of ERβ-regulated genes identified NFκB signaling as one of the most suppressed pathways in response to E2 treatment. Indeed, numerous NFκB target genes were among the most down-regulated genes following E2 treatment but only in the presence of ERβ expression. Chromatin Immunoprecipitation followed by sequencing (ChIPseq) revealed that ERβ primarily associated with estrogen response elements (EREs), but was also enriched around NFκB binding sites following E2 treatment. In fact, 12% of all ERβ binding sites were enriched for NFκB response elements and ERβ was shown to physically associate with NFκB protein. Using an NFκB reporter construct and qPCR, ERβ was shown to block TNFα-mediated induction of NFκB signaling and NFκB target gene expression. Globally, RNAseq identified 200 genes to be significantly regulated by TNFα in TNBC cells, of which 81 were significantly altered in the presence of E2+TNFα. ChIPseq demonstrated that ligand-mediated activation of ERβ significantly diminished an activating histone mark (H3K27Ac) at many of these NFκB target genes while enhancing a repressive mark (H3K27Me3). These modifications are also associated with recruitment of the histone methyltransferase, EZH2, to enhancer elements of these NFκB target genes. Drug-mediated blockade of HDAC and EZH2 activity reversed suppression of NFκB target gene expression by ERβ.

Conclusions: Our data suggest that ERβ may elicit its anti-cancer effects in part via formation of a novel co-repressor complex consisting of ERβ, NFκB, and EZH2. These data are in keeping with prior observations of the importance of NFκB signaling as it relates to TNBC cell proliferation and invasion, and that decreased expression of NFκB target genes is associated with improved outcomes in TNBC patients. Currently, a Mayo Breast SPORE prospective study is underway to investigate the role of estradiol in ERβ expressing TNBC and to further evaluate the cross-talk between ERβ and NFκB signaling in TNBC.

Citation Format: Aspros K, Nelson A, Ye Z, Sun Z, Chernukhin I, Carroll J, Ingle J, Goetz M, Hawse J. Estrogen receptor beta elicits anti-cancer effects in triple negative breast cancer through suppression of NFκB signaling [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-05-03.