Experience of Implementing Deep Learning-Based Automatic Contouring in Breast Radiation Therapy Planning: Insights From Over 2000 Cases

PURPOSE

This study evaluated the impact and clinical utility of an auto-contouring system for radiation therapy treatments.

METHODS AND MATERIALS

The auto-contouring system was implemented in 2019. We evaluated data from 2428 patients who underwent adjuvant breast radiation therapy before and after the system's introduction. We collected the treatment's finalized contours, which were reviewed and revised by a multidisciplinary team. After implementation, the treatment contours underwent a finalization process that involved manual review and adjustment of the initial auto-contours. For the preimplementation group (n = 369), auto-contours were generated retrospectively. We compared the auto-contours and final contours using the Dice similarity coefficient (DSC) and the 95% Hausdorff distance (HD95).

RESULTS

We analyzed 22,215 structures from final and corresponding auto-contours. The final contours were generally larger, encompassing more slices in the superior or inferior directions. Among organs at risk (OAR), the heart, esophagus, spinal cord, and contralateral breast demonstrated significantly increased DSC and decreased HD95 postimplementation (all P < .05), except for the lungs, which presented inaccurate segmentation. Among target volumes, CTVn_L2, L3, L4, and the internal mammary node showed increased DSC and decreased HD95 postimplementation (all P < .05), although the increase was less pronounced than the OAR outcomes. The analysis also covered factors contributing to significant differences, pattern identification, and outlier detection.

CONCLUSIONS

In our study, the adoption of an auto-contouring system was associated with an increased reliance on automated settings, underscoring its utility and the potential risk of automation bias. Given these findings, we underscore the importance of considering the integration of stringent risk assessments and quality management strategies as a precautionary measure for the optimal use of such systems.

Effects of hip joint kinematics on the effective pelvis stiffness and hip impact force during simulated sideways falls

Improved understanding is required on how hip fracture risk is influenced by landing configuration. We examined how hip impact dynamics was affected by hip joint kinematics during simulated sideways falls. Twelve young adults (7 males, 5 females) of mean age 23.5 (SD = 1.5) years, participated in pelvis release experiments. Trials were acquired with the hip flexed 15° and 30° for each of three hip rotations: +15° ("external rotation"), 0°, and -15° ("internal rotation"). During falls, force-deformation data of the pelvis were recorded. Outcome variables included the peak hip impact force (Fexperimental) and effective stiffness of the pelvis (k1st, ksecant, and kms) determined with different methods suggested in literature, and predicted hip impact force during a fall from standing height (F1st, Fsecant and Fms). The two-way repeated-measures ANOVA was used to test whether these variables were associated with hip joint angles. The Fexperimental, ksecant and Fsecant were associated with hip rotation (F = 5.587, p = 0.005; F = 9.278, p < 0.0005; F = 5.778, p = 0.004, respectively), and 15 %, 31 % and 17 % smaller in 15° external than internal rotation (848 versus 998 N; 24.6 versus 35.6 kN/m; 2,637 versus 3,170 N, respectively). However, none of the outcome variables were associated with hip flexion (p > 0.05). Furthermore, there were no interactions between the hip rotation and flexion for all outcome variables (p > 0.05). Our results provide insights on hip impact dynamics, which may help improve a hip model to assess hip fracture risk during a fall.

Efficacy of Radiomics in Predicting Oncologic Outcome of Liver-Directed Combined Radiotherapy in Locally Advanced Hepatocellular Carcinoma

PURPOSE

We investigated whether radiomic features extracted from three-phase dynamic contrast-enhanced computed tomography (CECT) can be used to predict clinical outcomes, including objective treatment response (OR) and in-field failure-free survival rate (IFFR), in patients with hepatocellular carcinoma (HCC) who received liver-directed combined radiotherapy (LD-CRT).

METHODS

We included 409 patients, and they were randomly divided into training (n = 307) and validation (n = 102) cohorts. For radiomics models, we extracted 116 radiomic features from the region of interest on the CECT images. Significant clinical prognostic factors are identified to predict the OR and IFFR in the clinical models. We developed clinical models, radiomics models, and a combination of both features (CCR model).

RESULTS

Among the radiomic models evaluated for OR, the OR-PVP-Peri-1cm model showed favorable predictive performance with an area under the curve (AUC) of 0.647. The clinical model showed an AUC of 0.729, whereas the CCR model showed better performance (AUC 0.759). For the IFFR, the IFFR-PVP-Peri-1cm model showed an AUC of 0.673, clinical model showed 0.687, and the CCR model showed 0.736. We also developed and validated a prognostic nomogram based on CCR models.

CONCLUSION

In predicting the OR and IFFR in patients with HCC undergoing LD-CRT, CCR models performed better than clinical and radiomics models. Moreover, the constructed nomograms based on these models may provide valuable information on the prognosis of these patients.

Evaluation of race/ethnicity-specific survival machine learning models for Hispanic and Black patients with breast cancer

OBJECTIVES

Survival machine learning (ML) has been suggested as a useful approach for forecasting future events, but a growing concern exists that ML models have the potential to cause racial disparities through the data used to train them. This study aims to develop race/ethnicity-specific survival ML models for Hispanic and black women diagnosed with breast cancer to examine whether race/ethnicity-specific ML models outperform the general models trained with all races/ethnicity data.

METHODS

We used the data from the US National Cancer Institute's Surveillance, Epidemiology and End Results programme registries. We developed the Hispanic-specific and black-specific models and compared them with the general model using the Cox proportional-hazards model, Gradient Boost Tree, survival tree and survival support vector machine.

RESULTS

A total of 322 348 female patients who had breast cancer diagnoses between 1 January 2000 and 31 December 2017 were identified. The race/ethnicity-specific models for Hispanic and black women consistently outperformed the general model when predicting the outcomes of specific race/ethnicity.

DISCUSSION

Accurately predicting the survival outcome of a patient is critical in determining treatment options and providing appropriate cancer care. The high-performing models developed in this study can contribute to providing individualised oncology care and improving the survival outcome of black and Hispanic women.

CONCLUSION

Predicting the individualised survival outcome of breast cancer can provide the evidence necessary for determining treatment options and high-quality, patient-centred cancer care delivery for under-represented populations. Also, the race/ethnicity-specific ML models can mitigate representation bias and contribute to addressing health disparities.

Host-derived chimeric peptides clear the causative bacteria and augment host innate immunity during infection: A case study of HLB in citrus and fire blight in apple

Bacterial diseases cause severe losses in the production and revenue of many fruit crops, including citrus and apple. Huanglongbing (HLB) in citrus and fire blight in apple are two deadly diseases without any cure. In this article, we introduce a novel therapy for HLB and fire blight by enhancing the innate immunity of the host plants. Specifically, we constructed in silico a library of chimeras containing two different host peptides with observed or predicted antibacterial activity. Subsequently, we performed bactericidal and toxicity tests in vitro to select a few non-toxic chimeras with high antibacterial activity. Finally, we conducted ex planta studies to show that not only do the chimeras clear the causative bacteria from citrus leaves with HLB and from apple leaves with fire blight but they also augment the host's innate immunity during infection. This platform technology can be extended to design host-derived chimeras against multiple pathogenic bacteria that cause diseases in plants and animals of agricultural importance and in humans.

Blunted atrial reverse remodeling a year after catheter ablation for atrial fibrillation and their long-term rhythm outcome

Background

Although active rhythm control by atrial fibrillation (AF) catheter ablation (AFCA) reduces left atrial (LA) dimension, blunted atrial reverse remodeling can be observed in patients with significant atrial myopathy. We explored the characteristics and long-term outcomes of AF patients who showed blunted atrial reverse remodeling despite no AF recurrence within a year after AFCA.

Methods

Among a total of 2,756 patients with AFCA, we included 1,685 patients (74.8% male, 60.2±10.1 years old, 54.5% paroxysmal AF) who underwent both baseline and 1-year follow-up echocardiogram, baseline LA&gt;40mm, and did not recur within a year. We divided them into tertile groups (T1–T3) based on one-year percent change of LA dimension after propensity matching for age, sex, AF type, and baseline LA dimension. We also investigated the patients' genetic characteristics with blunted LA reverse remodeling (T1) using a genome-wide association study (GWAS).

Results

Patients with blunted LA reverse remodeling (T1, n=424) were independently associated with body mass index (OR 1.082 [1.010–1.160], p=0.025), LA peak pressure (OR 1.010 [1.002–1.019], p=0.019), LA wall thickness (OR 0.448 [0.252–0.789], p=0.006), LA voltage (OR 0.651 [0.463–0.907], p=0.012), and pericardial fat volume (OR 1.004 [1.001–1.008], p=0.014). Throughout 65.9±37.4 months of follow-up, the incidence of AF recurrence a year after the procedure was significantly higher in the T1 group than in T2 or T3 groups (Log-rank p&lt;0.001). Among 894 patients with GWAS, ATXN1, XPO7, KRR1_PHLDA1, ZFHX3, and their polygenic risk score were associated with blunted LA reverse remodeling.

Conclusions

Patients with blunted LA reverse remodeling after AFCA were independently associated with low LA voltage, thin wall thickness, high LA pressure, and fat volume, and have a genetic background. Long-term clinical recurrence a year after AFCA was higher in this patient group with suspicious atrial myopathy.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health and WelfareNational Research Foundation of Korea

Multilayer Perceptron-Based Real-Time Intradialytic Hypotension Prediction Using Patient Baseline Information and Heart-Rate Variation

Intradialytic hypotension (IDH) is a common side effect that occurs during hemodialysis and poses a great risk for dialysis patients. Many studies have been conducted so far to predict IDH, but most of these could not be applied in real-time because they used only underlying patient information or static patient disease information. In this study, we propose a multilayer perceptron (MP)-based IDH prediction model using heart rate (HR) information corresponding to time-series information and static data of patients. This study aimed to validate whether HR differences and HR slope information affect real-time IDH prediction in patients undergoing hemodialysis. Clinical data were collected from 80 hemodialysis patients from 9 September to 17 October 2020, in the artificial kidney room at Yeungnam University Medical Center (YUMC), Daegu, South Korea. The patients typically underwent hemodialysis 12 times during this period, 1 to 2 h per session. Therefore, the HR difference and HR slope information within up to 1 h before IDH occurrence were used as time-series input data for the MP model. Among the MP models using the number and data length of different hidden layers, the model using 60 min of data before the occurrence of two layers and IDH showed maximum performance, with an accuracy of 81.5%, a true positive rate of 73.8%, and positive predictive value of 87.3%. This study aimed to predict IDH in real-time by continuously supplying HR information to MP models along with static data such as age, diabetes, hypertension, and ultrafiltration. The current MP model was implemented using relatively limited parameters; however, its performance may be further improved by adding additional parameters in the future, further enabling real-time IDH prediction to play a supporting role for medical staff.

Peripherally Inserted Central Catheter by Interventional Nephrologists: Experiences from a Single Center

Purpose

As the number of patients with chronic kidney disease increases, nephrologist activities are gradually expanding. This study evaluated the safety and success of peripherally inserted central catheter (PICC) performed by nephrologists.

Patients and Methods

We retrospectively analyzed the medical records of a medical center. All patients underwent a PICC procedure by two nephrologists. The reasons for catheter removal were classified as accidental removal; treatment termination; catheter occlusion; vessel thrombosis; catheter-related infection, or patient death. Overall catheter complications were defined as catheter occlusion, vessel thrombosis, or catheter-related infection.

Results

A total of 335 catheterizations among 286 patients were performed. Overall, catheter removal was required during follow-up in 251 of 335 cases. The catheter was removed in 48 out of 251 (19.1%) cases with catheter-related complications. In univariate and multivariate analyses, diabetes mellitus was associated with catheter-related infection. The catheter survival rates were 85.3% at 1 month. In univariate and multivariate analyses, diabetes mellitus and fluoroscopy-guided insertion were associated with favorable catheter survival.

Conclusion

The results of our study showed high success and low complication rates for PICC insertion by nephrologists. These findings indicate that interventional nephrologists already skilled in other procedures can expand their field of activity and profit.

Anterior resection syndrome: a randomized clinical trial of a 5-HT3 receptor antagonist (ramosetron) in male patients with rectal cancer

BACKGROUND

No effective treatment exists for anterior resection syndrome (ARS) following sphincter-saving surgery for rectal cancer. This RCT assessed the safety and efficacy of a 5-HT3 receptor antagonist, ramosetron, for ARS.

METHODS

A single-centre, randomized, controlled, open-label, parallel group trial was conducted. Male patients with ARS 1 month after rectal cancer surgery or ileostomy reversal were enrolled and randomly assigned (1 : 1) to 5 μg of ramosetron (Irribow®) daily or conservative treatment for 4 weeks. Low ARS (LARS) score was calculated after randomization and 4 weeks after treatment. The study was designed as a superiority test with a primary endpoint of the proportion of patients with major LARS between the groups. Primary outcome analysis was based on the modified intention-to-treat population. Safety was assessed by monitoring adverse events during the study.

RESULTS

: A total of 100 patients were randomized to the ramosetron (49 patients) or conservative treatment group (51 patients). Two patients were excluded, and 48 and 50 patients were analysed in the ramosetron and control groups, respectively. The proportion of major LARS after 4 weeks was 58 per cent (28 of 48 patients) in the ramosetron group versus 82 per cent (41 of 50 patients) in the control group, with a difference of 23.7 per cent (95 per cent c.i. 5.58 to 39.98, P = 0.011). There were minor adverse events in five patients, which were hard stool, frequent stool or anal pain. These were not different between the two groups. There were no serious adverse events.

CONCLUSION

: Ramosetron could be safe and feasible for male patients with ARS.

TRIAL REGISTRATION NUMBER

NCT02869984 (http://www.clinicaltrials.gov).

Sex differences in mapping and rhythm outcomes of a repeat atrial fibrillation ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction

The risk of procedure-related complications and rhythm outcomes differ between men and women after atrial fibrillation catheter ablation (AFCA). We evaluated whether consistent sex differences existed in mapping and rhythm outcomes in repeat ablation procedures.

Methods

Among 3,282 patients in the registry, we analysed 443 consecutive patients (24.6% female, 58.5 ± 10.3 years old, 61.5% paroxysmal AF) who underwent a second AFCA. We compared the clinical factors, mapping, left atrial (LA) pressure, complications, and long-term clinical recurrences after propensity score matching.

Results

The LA volume index (43.1 ± 18.6 vs. 35.8 ± 11.6 ml/m2, p &lt; 0.001) was higher, but LA dimension (40.0 ± 6.8 vs. 41.6 ± 6.3mm, p = 0.018), LA voltage (0.94 ± 0.55 vs. 1.20 ± 0.68 mV, p = 0.002), and pericardial fat volume (89.5 ± 43.1 vs. 122.1 ± 53.9 cm3, p &lt; 0.001) lower in women with a repeat ablation than in their male counterparts. The pulmonary vein (PV) reconnections were lower (58.7% vs. 74.9%, p = 0.001), but the proportion of extra-PV triggers (27.5% vs. 17.0%, p = 0.026) and elevated LA pulse pressures (79.7% vs. 63.7%, p = 0.019) was significantly higher in women than men. There was no significant sex difference in the procedure-related complication rate (4.6% vs. 4.2%, p = 0.791). During a 31(8∼60) month median follow-up, clinical recurrences were significantly higher in women after both the de novo procedure (log rank p = 0.039, antiarrhythmic drug [AAD]-free log rank p &lt; 0.001) and second procedure (log rank p = 0.006, AAD-free log rank p = 0.093). A female sex (HR 1.51 [1.06-2.15], p = 0.023), non-paroxysmal AF (HR 1.78 [1.30-2.34], p &lt; 0.010), and extra-PV triggers (HR 1.88 [1.28-2.75], p = 0.001) were independently associated with clinical recurrences after repeat procedures.

Conclusions

During the repeat AFCA procedures, PV reconnections were lower in women than men, and the existence of extra-PV triggers and an LA pressure elevation was more significant, which resulted in poor rhythm outcomes.

Artificial intelligence-predicted poor responders to catheter ablation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Although atrial fibrillation (AF) catheter ablation is effective for rhythm control, in some patients it is hard to maintain sinus rhythm in spite of repeated AF catheter ablation (AFCA) procedures and anti-arrhythmic drugs (AADs). We explored the pre-procedural predictors for poor responders to AFCA and tested whether artificial intelligence (AI) assists the prediction of poor responders in the independent cohort by determining the invasive parameters.

Methods

Among 1,214 patients who underwent AFCA and regular rhythm follow-up for 56.2 ± 33.8 months (59 ± 11 years, 73.5% male, 68.6% paroxysmal AF), we differentiated 92 poor responders defined as those with sustained AF despite repeat AFCAs, AADs, or electrical cardioversion. Using the Youden index, we identified advanced LA remodeling with lower LA voltage under 1.109mV. AI model, which was derived from development cohort using medical record, was applied to predict LA voltage &lt;1.109mV in the independent cohort (n = 634, poor responders = 24) using a grad-cam score.

Results

The patients with lower LA voltage under 1.109mV showed significantly poorer rhythm outcomes (Log-rank p &lt; 0.001). We determined invasive parameter LA voltage by using the multiple variables (age, female sex, AF type, CHA2DS2VASc score, LA dimension, E/em, hemoglobin, PR interval) and achieved relatively good prediction power of AI for LA voltage &lt;1.109mV (AUC = 0.734, sensitivity 0.729, specificity 0.643) in the test cohort. In the independent cohort, the AI model showed good discrimination power for poor responders (AUC 0.751, p &lt; 0.001) by estimating LA voltage, which is an invasive variable. The patients with predicted lower LA voltage (grad-cam score &lt;0) showed poorer rhythm outcome after active rhythm control (Log-rank p &lt; 0.001)

Conclusions

The patients with advanced atrial remodeling with low LA voltage, which can be predicted by an AI, showed significantly higher recurrence of AF after AFCA with AADs or cardioversion. AI may assist to select these poor responder patients before the AFCA procedure. Abstract Figure.

The reduction of body mass index and risk of incidence of cardiovascular events in the elderly population

Funding Acknowledgements

Type of funding sources: None.

Introduction

Obesity is known to be risk factor for incidence of cardiovascular (CV) events. However, the association between the reduction of body mass index (BMI) and incidence of cardiovascular event is not well established in elderly Asian population.

Methods

From the National Health Insurance Service-Senior (≥60 years) cohort from 2002 to 2013, 13,038 participants over 75 years old without baseline comorbidities (mean age: 78.4 ± 3.2 years 5243 (40.2%) male) were included in this study. We measured the change of BMI from first to second visit for health check-up within mean 23.6 ± 5.8months of follow-up. We categorized the reduction of BMI as five group according to the amount of change in BMI in overall patients (group 1: BMI change &lt;-10%, group 2: -10%≤BMI change&lt;-3%, group 3: -3% ≤ BMI change &lt; 3%, group 4: 3% ≤BMI change &lt; 10%, group 5: 10% ≤BMI change). We investigated the influence of change in BMI on the incidence of new-onset AF, stroke, acute myocardial infarction (MI), and CV mortality

Results

In the overall patients, new-onset AF, stroke, acute MI, and CV death was occurred in the 494 patients (3.5%), 775 patients (5.9%), 16 patients (0.1%), and 458 patients (3.5%) respectively. The Kaplan-Meier curve showed significant cumulative incidence rate of CV death in group 1 (Log rank p &lt; 0.001). The multivariate cox regression after adjusting for compound clinical covariates showed the risk of stroke (HR 1.43, 95% CI [1.09-1.89], p = 0.01) and CV death (HR 2.06, 95% CI [1.49-2.84] were significant higher in the group 1 as compared with group 3. In the high BMI (≥25) group, the risk of AF was significant higher in the group 5 as compared with group 3 (HR 2.38, 95% CI [1.02-5.54], p = 0.04). In contrast, the risk of stroke (HR 1.70, 95% CI [1.07-2.71], p = 0.02) and CV death (HR 3.27, 95% CI [1.66-6.41], p &lt; 0.001) was significant higher in the group 1 than in group 3.

Conclusions

In the elderly Asian population over 75 years old, the reduction of body weight affected worse effect on the incidence of stroke and CV death in overall patient and high BMI (≥25) group. It needs careful consideration to reduce BMI in the elderly Asian population even with high BMI (≥25) for purpose of CV events.

A study of the microbiological profile of filler-induced skin necrosis

Skin necrosis is one of the most severe complications following filler injections, and can result in permanent aesthetic defects. Although an increasing number of studies have addressed the management of dermal filler complications, no study has described the spectrum of microbial pathogens. The aim of this study was to delineate the bacterial profile and prognostic factors of filler-related skin necrosis by reviewing the clinical and microbiological features of these patients. A retrospective medical record review of patients undergoing treatment for skin necrosis induced by fillers was conducted. In total, 10 cases were identified, with injection sites being the nasolabial fold (70%; n = 7), nasal dorsum (20%; n = 2) and nasal tip (10%; n = 1). Reviewing the culture results, the true culture-positive rate was found to be 50% after cases of contamination were excluded. To avoid permanent sequelae, all physicians should be aware of possible secondary infections when treating filler-induced skin necrosis.

Acute antibody-mediated rejection limited to medullary lesions in following ABO-incompatible living donor kidney transplantation

Anatomical differences between the renal cortex and medulla may influence inflammatory responses. Owing to the difficulty in diagnosing rejections from the medulla, rejection is usually diagnosed through the cortex. However, previous studies have shown that there are no significant differences in renal cortical and medullary lesions in acute allograft rejection. A 60-year-old man with a history of diabetic nephropathy underwent kidney transplant from a living unrelated donor at our hospital in August 2019. Three days after surgery, his urine output suddenly decreased, whereas the serum creatinine levels increased. A kidney biopsy showed only medullary lesions with positive C4d-staining and a Banff score of PTC grade 3. He was diagnosed with acute antibody-mediated rejection (AMR) and treatment was initiated. He did not respond to conventional treatments, including plasma exchange and intravenous immunoglobulin, but his general condition improved after bortezomib administration. There have been a few cases of acute AMR limited to medullary lesions. We consider that rejection cannot be excluded even if the lesions are confined to the medulla.

Timing and clinical outcomes of tracheostomy in patients with COVID-19

In this retrospective multicentre cohort study that included 27 COVID-19 patients who underwent tracheostomy, the mean time between intubation and tracheostomy was 15.8 days and the negative conversion time of COVID-19 was 43.1 days. Eleven patients (40.7%) died of COVID-19 and the use of percutaneous dilatation tracheostomy was significantly associated with in-hospital death. Timely tracheostomy could be performed in COVID-19 patients, regardless of duration of intubation or positivity of COVID-19 test, with an open surgical tracheostomy as a preferable technique.

FAST: a randomised phase II study of zolbetuximab (IMAB362) plus EOX versus EOX alone for first-line treatment of advanced CLDN18.2-positive gastric and gastro-oesophageal adenocarcinoma

BACKGROUND

Claudin 18.2 (CLDN18.2) is contained within normal gastric mucosa epithelial tight junctions; upon malignant transformation, CLDN18.2 epitopes become exposed. Zolbetuximab, a chimeric monoclonal antibody, mediates specific killing of CLDN18.2-positive cells through immune effector mechanisms.

PATIENTS AND METHODS

The FAST study enrolled advanced gastric/gastro-oesophageal junction and oesophageal adenocarcinoma patients (aged ≥18 years) with moderate-to-strong CLDN18.2 expression in ≥40% tumour cells. Patients received first-line epirubicin + oxaliplatin + capecitabine (EOX, arm 1, n = 84) every 3 weeks (Q3W), or zolbetuximab + EOX (loading dose, 800 mg/m² then 600 mg/m² Q3W) (arm 2, n = 77). Arm 3 (exploratory) was added after enrolment initiation (zolbetuximab + EOX 1000 mg/m² Q3W, n = 85). The primary endpoint was progression-free survival (PFS) and overall survival (OS) was a secondary endpoint.

RESULTS

In the overall population, both PFS [hazard ratio (HR) = 0.44; 95% confidence interval (CI), 0.29-0.67; P < 0.0005] and OS (HR = 0.55; 95% CI, 0.39-0.77; P < 0.0005) were significantly improved with zolbetuximab + EOX (arm 2) compared with EOX alone (arm 1). This significant PFS benefit was retained in patients with moderate-to-strong CLDN18.2 expression in ≥70% of tumour cells (HR = 0.38; 95% CI, 0.23-0.62; P < 0.0005). Significant improvement in PFS was also reported in the overall population of arm 3 versus arm 1 (HR = 0.58; 95% CI, 0.39-0.85; P = 0.0114) but not in high CLDN18.2-expressing patients; no significant improvement in OS was observed in either population. Most adverse events (AEs) related to zolbetuximab + EOX (nausea, vomiting, neutropenia, anaemia) were grade 1-2. Grade ≥3 AEs showed no substantial increases overall (zolbetuximab + EOX versus EOX alone).

CONCLUSIONS

In advanced gastric/gastro-oesophageal junction and oesophageal adenocarcinoma patients expressing CLDN18.2, adding zolbetuximab to first-line EOX provided longer PFS and OS versus EOX alone. Zolbetuximab + EOX was generally tolerated and AEs were manageable. Zolbetuximab 800/600 mg/m² is being evaluated in phase III studies based on clinical benefit observed in the overall population and in patients with moderate-to-strong CLDN18.2 expression in ≥70% of tumour cells.

Hemolytic uremic syndrome caused by sea anemone sting: a case report

Background

Some sea anemone toxins cause renal injuries resembling hemolytic uremic syndrome (HUS). To date, only a few cases of HUS caused by sea anemone stings have been reported. In this case report, we have described an HUS case caused by a sea anemone sting.

Case presentation

In November 2019, a 37-year-old man with no underlying disease was admitted to our hospital. He presented with intense pain, a rash on, and swelling in his right thigh. Two days prior, he had been stung by a sea anemone while scuba diving in Cebu, Philippines. His blood tests revealed renal dysfunction, and his platelet count was normal. However, on day three, the platelet count decreased rapidly. His blood haptoglobin level decreased, and schistocytes were identified on the peripheral blood smear. We suspected thrombotic microangiopathy and started the conventional treatment, comprising hemodialysis, blood transfusion, and antibiotic administration. ADAMTS-13 and genetic test results associated with atypical HUS were normal. Therefore, the patient was diagnosed with HUS caused by a sea anemone toxin.

Conclusions

HUS caused by a sea anemone toxin is rare, but it is a serious medical disease. Clinicians should consider HUS in patients with such clinical presentations, and they should make prompt treatment-related decisions.

Association between Chronic Kidney Disease or Acute Kidney Injury and Clinical Outcomes in COVID-19 Patients

BACKGROUND

A population-based study would be useful to identify the association between chronic kidney disease (CKD) or acute kidney injury (AKI) and prognosis of coronavirus disease 2019 (COVID-19) patients.

METHODS

This retrospective study utilized the claim data from Korea. Patients who underwent COVID-19 testing and were confirmed to be positive were included and divided into the following three groups based on the presence of CKD or requirement of maintenance dialysis: Non-CKD (participants without CKD), non-dialysis CKD (ND-CKD), and dialysis-dependent CKD (DD-CKD) patients. We collected data on the development of severe clinical outcomes and death during follow-up. Severe clinical outcomes were defined as the use of inotropics, conventional oxygen therapy, high-flow nasal cannula, mechanical ventilation, or extracorporeal membrane oxygenation and the development of AKI, cardiac arrest, myocardial infarction, or acute heart failure after the diagnosis of COVID-19. AKI was defined as the initiation of renal replacement therapy after the diagnosis of COVID-19 in patients not requiring maintenance dialysis. Death was evaluated according to survival at the end of follow-up.

RESULTS

Altogether, 7,341 patients were included. The median duration of data collection was 19 (interquartile range, 11-28) days. On multivariate analyses, odds ratio (OR) for severe clinical outcomes in the ND-CKD group was 0.88 (95% confidence interval [CI], 0.64-1.20; P = 0.422) compared to the Non-CKD group. The DD-CKD group had ORs of 7.32 (95% CI, 2.14-33.90; P = 0.004) and 8.32 (95% CI, 2.37-39.21; P = 0.002) compared to the Non-CKD and ND-CKD groups, respectively. Hazard ratio (HR) for death in the ND-CKD group was 0.79 (95% CI, 0.49-1.26; P = 0.318) compared to the Non-CKD group. The DD-CKD group had HRs of 2.96 (95% CI, 1.09-8.06; P = 0.033) and 3.77 (95% CI, 1.29-11.06; P = 0.016) compared to the Non-CKD and ND-CKD groups, respectively. DD-CKD alone was associated with severe clinical outcomes and higher mortality. There was no significant difference in frequency of severe clinical outcomes or mortality rates between the Non-CKD and ND-CKD groups. In patients not requiring maintenance dialysis, AKI was associated with old age, male sex, and high Charlson's comorbidity index score but not with the presence of CKD. HRs for patients with AKI were 11.26 (95% CI, 7.26-17.45; P < 0.001) compared to those for patients without AKI in the multivariate analysis. AKI was associated with severe clinical outcomes and patient survival, rather than underlying CKD.

CONCLUSION

CKD requiring dialysis is associated with severe clinical outcomes and mortality in patients with COVID-19; however, the development of AKI is more strongly associated with severe clinical outcomes and mortality.

Systemic contact dermatitis induced by Rhus allergens in Korea: exercising caution in the consumption of this nutritious food

Systemic contact dermatitis (SCD) develops when a person who was previously sensitized to an allergen is exposed to the same allergen via the systemic route. In East Asia, the use of lacquer for polishing furniture is common and a part of the traditional culture. Contact exposure to tableware polished with Rhus lacquer may lead to sensitization. In Korea, SCD is commonly observed after systemic exposure to Rhus, a nutritious food item consumed because of the common belief of it improving the immune system. In this study, we reviewed the medical records of 21 Korean patients with SCD caused by Rhus ingestion. We found that the most significant epidemiological factor for SCD was the season of the year. Furthermore, 66.67% of the patients presented with leucocytosis and 23.81% showed increased liver enzyme levels. It is important to educate people on the risks associated with the systemic ingestion of Rhus.

Is there an association between metformin use and clinical outcomes in diabetes patients with COVID-19?

Aim

Previous studies have reported inconsistent results regarding the association between metformin use and clinical outcomes in diabetes mellitus (DM) patients with coronavirus disease 2019 (COVID-19). This study aimed to evaluate the association between metformin use and clinical outcomes in DM patients with COVID-19.

Methods

This retrospective study was based on claims data. All diseases, including COVID-19, were defined using International Classification of Diseases 10th Revision (ICD-10) codes. Patients were divided into three groups depending on metformin use: CON (those not taking DM medication); N-MFOM (those taking DM medications other than metformin); and MFOM (those taking metformin for DM). Ultimately, 1865 patients were included; CON, N-MFOM and MFOM groups comprised 1301, 95 and 469 patients, respectively.

Results

Kaplan–Meier analyses showed that MFOM patients had poorer survival rates than those in the CON group, but there were no significant differences in survival rates between MFOM and N-MFOM groups. Multivariate Cox regression analyses revealed more favourable survival in CON than in N-MFOM patients, but there was no statistically significant difference in MFOM vs the other groups. Also, there were no significant differences in rates of use of inotropes, extracorporeal membrane oxygenation, conventional oxygen therapy, high-flow nasal cannulas or mechanical ventilators, nor in the rates of acute kidney injury or cardiac events across all study groups.

Conclusion

No definite association could be found between metformin use and clinical outcomes, including survival. However, given the disproportionate participant numbers in our groups and small number of events, further studies are needed to determine whether the use of metformin has favourable or unfavourable effects in DM patients with COVID-19.

Carbon Nanotube-Based Sulfur Cathode with a Mesoporous Carbon-Silica Composite for Long Cycle Life Li-S Batteries

The use of carbon nanotube (CNT) films as a sulfur host is a promising approach to improve the sulfur loading and energy density of Li-S batteries. However, the inability to durably incorporate polysulfides within the cathode structure results in a limited cycle life. Herein, we propose a CNTbased sulfur cathode with carbon-coated ordered mesoporous silica (c-OMS) to overcome the cycle performance issue. Scanning electron microscopy and X-ray diffraction studies on the c-OMS prepared in this work revealed that the wall surface of OMS was evenly coated with an extremely thin carbon layer. The sulfur-CNT cathode with c-OMS retained a remarkably improved capacity (942 mAh g^-1) with excellent cycling stability (91%) after 100 cycles as well as significantly high sulfur utilization in the first cycle compared with the sulfur-CNT cathode with OMS. This result may stem from the surface property of c-OMS with high chemical affinity towards electrolyte solvents.

Three-Layer Sulfur Cathode with a Conductive Material-Free Middle Layer

An ingenious design for a three-layer sulfur cathode is demonstrated, in which the pure sulfur layer is sandwiched between carbon nanotube (CNT) films. The unique feature of this particular model is that the sulfur layer does not contain any conductive materials, and therefore, the top CNT film of the prepared three-layer CNT/S/CNT electrode is electrically isolated from the bottom CNT film. Scanning electron microscopy studies revealed that the three-layer cathode was transformed into a single CNT cathode, with proximate contact between the two CNT films in the upper plateau of the first discharge. The lithium-sulfur cells employing a CNT/S/CNT cathode exhibited remarkably enhanced performance in terms of the specific capacity, rate property, and cycling stability compared to the cells with a sulfur-coated CNT cathode. This can mainly be attributed to the top CNT film, which serves not only as an interlayer to trap the migrating polysulfides, but also as an electrode to facilitate the redox reaction of active materials. Such an innovative approach is promising as it may promote the rational design of high-performance sulfur cathodes.

Comparison of peritoneal dialysis catheter insertion techniques by nephrologists: Surgical vs blind methods

BACKGROUND

The aim of the present study was to perform a comparative analysis of peritoneal dialysis catheter (PDC) insertion between blind and surgical methods by nephrologists.

PATIENTS AND METHODS

The present study enrolled 249 peritoneal dialysis patients who received first-time PDC insertion. All PDC insertions were performed using either the blind or surgical method. In our hospital during the study period, two of three nephrologists performed the blind method routinely in all eligible patients (blind group), and one of three nephrologists performed the surgical method in all eligible patients (surgical group). Catheter outcomes, including infectious or mechanical complications, functional parameters, and catheter survival, were evaluated.

RESULTS

The numbers of patients underwent surgical or blind methods were 105 and 144, respectively. The use of systemic analgesics in the surgical group was higher than that in the blind group. The operation time was longer in the blind group than in the surgical group. The D0 level and peritoneal Kt/V were similar between the two groups. There was no significant difference in infectious and mechanical complications between the two groups. The catheter survival and intervention-free survival were similar between the two groups (P = .995 for catheter survival and P = .723 for intervention-free survival).

CONCLUSION

Our study shows that catheter outcomes are similar between blind and surgical insertion techniques performed by nephrologists. These findings reveal that patients without previous major abdominal surgery would be suitable to receive any one of the two methods according to the operator-friendly technique.

Melatonin in the colon modulates intestinal microbiota in response to stress and sleep deprivation

BACKGROUND/AIMS

Stress is closely related to the deterioration of digestive disease. Melatonin has potent anti-inflammatory properties. The objective of this study was to determine the effect of water stress (WS) and sleep deprivation (SD) on intestinal microbiota and roles of melatonin in stressful condition.

METHODS

We used C57BL/6 mice and specially designed water bath for stress and SD for 10 days. We measured melatonin concentrations in serum, feces, and colon tissues by high-performance liquid chromatography. Genomic DNA was extracted from feces and amplified using primers targeting V3 to V4 regions of bacterial 16S ribosomal RNA genes.

RESULTS

Compared to the control, melatonin concentration was lower in the WS and SD. Fecal concentration was 0.132 pg/mL in control, 0.062 pg/mL in WS, and 0.068 pg/mL in SD. In colon tissue, it was 0.45 pg/mL in control, 0.007 pg/mL in WS, and 0.03 pg/mL in SD. After melatonin treatment, melatonin concentrations in feces and colon tissue were recovered to the level of control. Metagenomic analysis of microbiota showed abundance in colitogenic microbiota in WS and SD. Melatonin injection attenuated this harmful effect. WS and SD showed decreased Lactobacillales and increased Erysipelotrichales and Enterobacteriales. Melatonin treatment increased Akkermansia muciniphila and Lactobacillus and decreased Bacteroides massiliensis and Erysipelotrichaceae.

CONCLUSIONS

This study showed that stress and SD could affect intestinal dysbiosis and increase colitogenic microbiota, which could contribute to the aggravating digestive disease. Melatonin concentrations in feces and colon tissue decreased under WS and SD. Melatonin treatment brought recovery of melatonin concentration in colon tissue and modulating dysbiosis of intestinal microbiota.

P1568EFFECTS OF VOLUME STATUS ON BODY COMPOSITION IN INCIDENT PERITONEAL DIALYSIS PATIENTS

Background and Aims

Volume control is the most important issue in peritoneal dialysis (PD). Inadequate fluid removal or high water intake leads to overhydration, which result in malnutrition. Sarcopenia (SP) as a result of malnutrition is more prevalent in PD than in the general population, and is associated with high mortality and low quality of life in PD patients. The aim of the present study was to evaluate the effects of volume status on body composition in incident PD patients.

Method

This retrospective study was performed at a tertiary medical center from January 2001 to March 2015. All incident PD patients who survived ≥1 year after PD initiation were considered eligible. 366 incident PD patients were finally included and divided into 3 tertiles according to the time-averaged-edema index (TA-EI). Edema index was calculated by dividing extracellular water values by total body water values. The mean of the EI values at 1 month and 1 year was defined as TA-EI. The body composition parameters measured using bioimpedance analysis included the EI, fat mass index (FMI, kg/m2), and appendicular muscle mass index (AMMI, kg/m2). dFMI and dAMMI were defined as delta values for each variable. The cutoff value for sarcopenia (SP) was defined as previously reported (The cutoff value for SP was defined as AMMI ≤ 7.0 kg/m2 in men and ≤ 5.7 kg/m2 in women). Patients with AMMI below the cut-off values were defined as having SP.

Results

The number of participants in the low, middle, and high tertiles was 126, 100, and 140, respectively. The TA-EI in the low, middle, and high tertiles was 0.384 ± 0.006, 0.398 ± 0.003, and 0.413 ± 0.009, respectively (P &lt; 0.001). A high volume status was associated with high solute clearance, peritoneal albumin loss, and glucose absorption through the peritoneal membrane, which led to high dialysate glucose. In addition, volume status was inversely associated with increases in AMMI, but was not associated with changes in FMI. SP as a categorical variable was positively associated with a high volume status. On subgroup analyses, TA-EI had the greatest negative correlation coefficients for dAMMI.

Conclusion

Overhydration in PD patients was associated with decrease in muscle mass indices and the development of SP.

Hemodialysis with Cohort Isolation to Prevent Secondary Transmission during a COVID-19 Outbreak in Korea

BACKGROUND

Health care-associated infections during previous coronavirus epidemics involving severe acute respiratory syndrome and Middle East respiratory syndrome resulted from human-to-human transmission in hemodialysis (HD) facilities. The effect of a strategy of HD with cohort isolation-separate dialysis sessions for close contacts of patients with confirmed coronavirus disease 2019 (COVID-19)-on the prevention of secondary transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in HD units is unknown.

METHODS

Our multicenter cohort study of an HD with cohort isolation strategy enrolled close contacts of patients with confirmed COVID-19, including patients on HD and health care workers in HD units. Close contacts had been identified by epidemiologic investigation and tested negative on an immediate screening test for SARS-CoV-2.

RESULTS

As of March 14, 11 patients on HD and 7 health care workers from 11 HD centers were diagnosed as having COVID-19. The immediate screening test was performed in 306 people, and among them, 302 close contacts with negative test results were enrolled. HD with cohort isolation was performed among all close contacts for a median of 14 days in seven centers. During cohort isolation, nine patients showed symptoms but tested negative for SARS-CoV-2. Two health care workers in the HD units (0.66% of the total group) were diagnosed at the termination test for SARS-CoV-2.

CONCLUSIONS

The transmission of COVID-19 can be controlled without closure of HD centers by implementing preemptive activities, including early detection with rapid testing, cohort isolation, collaboration between institutions, and continuous monitoring of infection. Our strategy and experience may provide helpful guidance for circumstances involving the rapid spread of infectious diseases such as COVID-19.

P1220COMPARISON OF PERITONEAL DIALYSIS CATHETER INSERTION TECHNIQUES BY NEPHROLOGISTS: SURGICAL METHOD VS BLIND METHOD USING A TROCAR

Background and Aims

Successful PD requires timely peritoneal dialysis catheter (PDC) insertion and management of PDC related complications. Some societies have recently made an effort to increase PD and PDC insertion by nephrologists is an important issue. The aim of the present study was to evaluate comparative analysis of PDC insertion between blind and surgical methods by nephrologists.

Method

We reviewed medical records at a tertiary medical center in Korea and identified 249 adults who underwent first-time PDC insertion. All PDC insertions were performed using the blind or surgical methods. In our hospital during study period, two of three nephrologists performed the blind method routinely in all of eligible patients (blind group, n = 144). One of three nephrologists performed the surgical method in all of eligible patients (surgical group, n = 105). During follow-up, we collected data regarding peritoneal dialysis peritonitis (PDP), exit site and/or tunnel infection (ESI/TI). Catheter survivor was defined as maintaining of PD at July 2019 or PDC removal by PDC unrelated problems such as patient death due to PDC unrelated factors, kidney transplantation, patient demand, inadequate PD, improved renal function, poor oral intake due to abdominal distension, and colon cancer. Catheter non-survivor and/or PDC associated removal was defined as PDC removal by PDC related problems such as PDP, ESI/TI or PDC malfunction. Intervention-free non-survivor was defined as PDC revision, removal, or exchange by PDC related problems.

Results

Mean age at the PDC insertion in blind and surgical groups were 57.5 ± 13.7 and 56.3 ± 12.9 years, respectively (P = 0.640). There were no significant differences in age, sex, body mass index, underlying disease of ESRD, and Davies comorbidity index between the 2 groups. Mean follow-up durations were 37.0 ± 26.3 and 32.6 ± 23.4 months in the blind and surgical groups, respectively (P = 0.172). Total numbers of patients with one or more PDP events during follow-up period were 72 (50.0%) and 42 (40.0%) in blind and surgical groups (P = 0.118). Total numbers of PDP episodes were 157 and 100, respectively. Total numbers of patients with one or more ESI/TI events during follow-up period were 14 (9.7%) and 7 (6.7%) in blind and surgical groups (P = 0.392). Total numbers of ESI/TI episodes were 27 and 8, respectively. The 5-year PDC survival rates were 87.0% and 91.1% in the blind and surgical groups, respectively (P = 0.995, Figure 1). The 5-year intervention-free survival rates were 79.6% and 77.0% in the blind and surgical groups, respectively (P = 0.723). The leading cause of PDC removal was patient death. There was no significant difference in the distributions of cause of PDC removal in the 2 groups (P = 0.335). PDC associated removal rates in blind and surgical groups were 14 (18.4%) and 9 (16.4%), respectively (P = 0.760).

Conclusion

Our study shows that catheter outcomes including infectious and mechanical complications and catheter survival are similar between blind and surgical insertion techniques by nephrologists.

A Mesoporous Chelating Polymer-Carbon Composite for the Hyper-Efficient Separation of Heavy Metal Ions

The removal of heavy-metal ions from wastewater is an important objective from a public-health perspective, and chelating agents can be used to achieve this aim. Herein, we report the synthesis of mesoporous carbon as a chelating polymer host using nanoarchitectonics approach. Carboxymethylated polyethyleneimine, a chelating polymer, was incorporated into the mesopore walls of mesoporous carbon to create a polymer-mesoporous-carbon composite. Nitrogen adsorption- desorption experiments and scanning electron microscopy (SEM) were used to illustrate the structural advantages of the composite. Co²⁺ adsorption by the composite material was examined using cobalt nitrate solutions at pH 3. The study revealed that the Co²⁺-absorption data are most closely modeled by the Langmuir isotherm. The maximum adsorption capacity, calculated by linear regression, was determined to be about 40 mg-Co/g-composite at pH 3. The composite exhibited about a six-times higher adsorption capacity toward a dilute Co solution (12.5 ppm) than that of the pristine mesoporous carbon. In addition, the composite showed a substantially higher distribution coefficient (K_d = 1.54×10⁵) compared to that (K_d = 2.05×10²) of the mesoporous carbon. Overall, we expect that the mesoporous composite, with its large mesopores (~20 nm), will be in high demand for adsorption applications.

HELP-(Heparin-induced Extracorporeal LDL Precipitation)-apheresis in heart recipients with cardiac allograft vasculopathy and concomitant hypercholesterolemia: Influence of long-term treatment on the microcirculation

Hyperlipidemic heart transplant patients who develop cardiac allograft vasculopathy (CAV) benefit from HELP-apheresis (Heparin-induced Extracorporeal LDL Precipitation) which enables drastic lowering of plasma low-density lipoprotein, lipoprotein (a), and fibrinogen. There is evidence that HELP-apheresis also improves microcirculation by an immediate improvement of impaired endothelial-dependent vasodilatation and additive hemorheological effects.Therefore, cutaneous microcirculation was examined before, during, and after the first HELP-apheresis in eight hyperlipidemic cardiac transplant recipients with CAV. To study the long-term effect the intravital microscopy was repeated after three and 12 months of weekly apheresis treatment.In CAV patients the baseline mean erythrocyte velocity was pathologically reduced with 0.13±0.07 mm/s. During the first HELP-apheresis the erythrocyte velocity increased significantly (p = 0.0001) and remained increased until the end of the HELP procedure (p < 0.05). After three months of weekly apheresis treatment a decrease of temporary flow stops in the capillaries with a progressive homogenization (concordance) of the cutaneous microcirculation was observed. After one year of weekly treatment a markedly increase in mean erythrocyte velocity under resting conditions occurred. In addition, a reactive post-ischemic hyperemia could be established for the first time.Even the first single HELP-apheresis resulted in a significant improvement of the cutaneous microcirculation. The long-term treatment of these patients resulted in a marked improvement of the cutaneous microcirculation with the tendency to a normalization of the regulation of the capillary perfusion.

Effects of tranilast on the epithelial-to-mesenchymal transition in peritoneal mesothelial cells

Background

We investigated the effects of tranilast on epithelial-to-mesenchymal transition (EMT) in an animal model and on the EMT signaling pathway in human peritoneal mesothelial cells (HPMCs).

Methods

We performed in vitro studies (cytotoxicity, cell morphology, and western blot analyses) on HPMCs from human omenta, along with in vivo studies (peritoneal membrane function and morphometric and immunohistochemical analyses) on Sprague Dawley rats. Thirty-two rats were divided into three groups: control (C) group (peritoneal dialysis [PD] catheter but not infused with dialysate), PD group (4.25% glucose-containing dialysate), and PD + tranilast group (4.25% glucose-containing dialysate along with tranilast).

Results

In in vitro experiments, transforming growth factor-beta 1 (TGF-β1) increased α-smooth muscle actin and Snail expression and reduced E-cadherin expression in HPMCs. TGF-β1 also reduced cell contact, induced a fibroblastoid morphology, and increased phosphorylation of Akt, Smad2, and Smad3 in HPMCs. Tranilast significantly inhibited TGF-β1-induced EMT and attenuated these morphological changes in HPMCs. In in vivo studies, after 6 weeks of experimental PD, the peritoneal membrane was significantly thicker in the PD group than in the C group. Tranilast protected against PD-induced glucose mass transfer change and histopathological changes in rats.

Conclusion

Tranilast prevented EMT both in HPMCs triggered with TGF-β1 and in rats with PD-induced peritoneal fibrosis. Thus, tranilast may be considered a therapeutic intervention that enables long-term PD by regulating TGF-β1 signaling pathways.

Correction to: CD4 T cell count is positively associated with lumbar spine bone mass in HIV-infected men under the age of 50 years

Two sentences in the Discussion section were incorrect.

A multicentre, phase IIa study of zolbetuximab as a single agent in patients with recurrent or refractory advanced adenocarcinoma of the stomach or lower oesophagus: the MONO study

BACKGROUND

Claudin 18.2 (CLDN18.2) is physiologically confined to gastric mucosa tight junctions; however, upon malignant transformation, perturbations in cell polarity lead to CLDN18.2 epitopes being exposed on the cancer cell surface. The first-in-class monoclonal antibody, zolbetuximab (formerly known as IMAB362), binds to CLDN18.2 and can induce immune-mediated lysis of CLDN18.2-positive cells.

PATIENTS AND METHODS

Patients with advanced gastric, gastro-oesophageal junction (GEJ) or oesophageal adenocarcinomas with moderate-to-strong CLDN18.2 expression in ≥50% of tumour cells received zolbetuximab intravenously every 2 weeks for five planned infusions. At least three patients were enrolled in two sequential cohorts (cohort 1300 mg/m2; cohort 2600 mg/m2); additional patients were enrolled into a dose-expansion cohort (cohort 3600 mg/m2). The primary end point was the objective response rate [ORR: complete and partial response (PR)]; secondary end points included clinical benefit [ORR+stable disease (SD)], progression-free survival, safety/tolerability, and zolbetuximab pharmacokinetic profile.

RESULTS

From September 2010 to September 2012, 54 patients were enrolled (cohort 1, n = 4; cohort 2, n = 6; cohort 3, n = 44). Three patients in cohort 1 and 25 patients in cohorts 2/3 received at least 5 infusions. Antitumour activity data were available for 43 patients, of whom 4 achieved PR (ORR 9%) and 6 (14%) had SD for a clinical benefit rate of 23%. In a subgroup of patients with moderate-to-high CLDN18.2 expression in ≥70% of tumour cells, ORR was 14% (n = 4/29). Treatment-related adverse events occurred in 81.5% (n = 44/54) patients; nausea (61%), vomiting (50%), and fatigue (22%) were the most frequent.

CONCLUSIONS

Zolbetuximab monotherapy was well tolerated and exhibited antitumour activity in patients with CLDN18.2-positive advanced gastric or GEJ adenocarcinomas, with response rates similar to those reported for single-agent targeted agents in gastric/GEJ cancer trials.

CLINICALTRIALS.GOV NUMBER

NCT01197885.

High-Energy-Density Li-S Batteries with Additional Elemental Sulfur Coated on a Thin-Film Separator

For the development of high-areal-capacity Li-S batteries, sulfur-coated separators were utilized between the cathode and anode. It was found that (1) the additional sulfur on the separator participated at the electrode reaction occurring in the cathode region, contributing to the improvement of the areal capacity of Li-S batteries, and (2) the areal capacity significantly increased with the mass ratio of sulfur on the separator (S_sep) to sulfur in cathode (S₊). At the high S_sep/S₊ mass ratio of 5.0, the Li-S cell delivered fourfold higher areal capacity of 4.28 mAh/cm² than that of the control cell, along with excellent capacity retention of 90% after 50 cycles, demonstrating that the new concept for Li-S cells could be highly advantageous in boosting the Li-S battery cell performance. The new approach can be widely applied to increase the areal capacity and volumetric energy density of Li-S batteries.

Facile and Low-Cost Fabrication of Cathode Protection Thin Layer for Durable Li-S Batteries

A new and cost-efficient way of confining the diffusing polysulfides within the sulfur cathode is presented on the basis of employing a porous diatomite that is highly abundant in nature. The sulfur cathode coated with diatomite layer exhibited a significantly reduced capacity fade during the first two cycles, implying that the loss of active materials due to the migration of polysulfides can be mitigated by the protective layer. The diatomite-layered cathode demonstrated excellent cycling stability as high as 85% after 100 cycles. These results clearly indicate that the polysulfide diffusion is effectively blocked and the dissolved polysulfides are well confined within the protected cathode region.

CD4 T cell count is inversely associated with lumbar spine bone mass in HIV-infected men under the age of 50 years

HIV-infected men under the age of 50 years had a lower bone mass compared to that of HIV-uninfected men. Lower CD4 T cell counts, independent of whether antiretroviral therapy (ART) was used, were associated with lower BMD. HIV-infected patients with low CD4 T cell counts may need follow-up and intervention regarding bone health, including younger patients.

INTRODUCTION

HIV-infected patients have a low bone mineral density (BMD) owing to multifactorial interaction between common osteoporosis risk factors and HIV-related factors, including chronic inflammation and ART. Although HIV infection and ART might affect bone metabolism, little data is available for patients aged under 50 years. We aimed to investigate the association of HIV infection-induced low CD4 T cell counts and ART with BMD in men aged under 50 years.

METHODS

We performed an age- and body mass index-matched case-control study. BMD values of HIV-infected and HIV-uninfected men (< 50 years) were compared, and HIV-infected men were stratified by CD4 T cell counts and ART use.

RESULTS

After adjusting confounders, HIV-infected men with CD4 T cell counts ≥ 500 cells/μL (n = 28) and < 500 cells/μL (n = 139) had lower BMD at the femoral neck (FN, p < 0.001) and total hip (TH, p < 0.001) than HIV-uninfected men (n = 167). HIV-infected men with CD4 T cell counts < 500/μL had lower BMD at the lumbar spine (LS, p = 0.034) than those with counts of ≥ 500 cells/μL, but not at FN and TH. The CD4 T cell count (γ = 0.169, p = 0.031) was positively correlated with BMD at LS. There was no significant difference in the BMD (p = 0.499-> 0.999) between the ART-naïve (n = 75) and ART-user group (n = 92).

CONCLUSIONS

Despite their relatively younger age, HIV-infected men had a lower BMD than HIV-uninfected men. Lower CD4 T cell counts, irrespective of ART, might result in lower bone mass.

Abstract P2-14-01: The impact of local therapy on locoregional recurrence in women with high risk breast cancer in the neoadjuvant I-SPY2 TRIAL

Background: In women with breast cancer receiving neoadjuvant chemotherapy, residual cancer burden (RCB) predicts distant recurrence and survival. In those with high risk tumors, locoregional recurrence (LRR) remains a concern, and has been associated with type of local therapy received. We evaluated the impact of local therapy on LRR in the ISPY-2 TRIAL.

Methods: Data were analyzed in Stata 14.2, using Chi2 test, log rank test, and a Cox proportional hazards model. RCB was considered a categorical variable (0/1 versus 2/3), as described in prior publications. Breast surgery categories were lumpectomy +/- radiotherapy, or mastectomy +/- radiotherapy. Axillary surgery was defined as sentinel lymph node (SLN) surgery (≤6 nodes removed) or axillary dissection (&gt;6 nodes).

Results: Follow up data from the I-SPY2 TRIAL were available for 630 patients (median follow up 2.76 yrs, range 0.4-7.2). Type of local therapy was significantly associated with clinical stage at presentation, with stage III patients most frequently undergoing mastectomy + radiation (p&lt;0.001). Women with higher RCB were more likely to undergo mastectomy than those with lower RCB (61.3% vs 48.8% mastectomy rate, p=0.002), and more likely to receive adjuvant radiotherapy (62.0% vs 53.9%, p=0.048). There was no association between clinical stage, type of surgery, or radiotherapy and LRR (Table). Higher RCB was significantly associated with LRR, with 3 year locoregional recurrence free rate of 95.1% in RCB 0/1 versus 89.9% in RCB 2/3 (p=0.003).

In a Cox model adjusting for clinical stage, tumor subtype, surgical therapy, RCB status, nodal radiation, and age, significant predictors for LRR were tumor subtype and RCB status. Hazard ratio (HR) for LRR in those with RCB 0/1 was 0.39 compared to those with RCB 2/3 (95% CI 0.17-0.87, p=0.021). There was no difference in LRR between breast conservation and mastectomy; within the breast conservation group, those who had lumpectomy alone had higher hazard of LRR compared to those having lumpectomy + radiation (HR 3.1, 95% CI 1.1-9.2, p=0.043).

Conclusions: Extent of surgical therapy was not associated with local tumor control, regardless of advanced tumor stage at presentation. Rather, tumor biology and response to therapy were the best predictors of LRR. These data highlight the opportunity to minimize the morbidity of extensive surgical therapy for patients with excellent response to systemic therapy.

LRR rates by clinical features and treatment status FrequencyLRR RateP valueClinical Stage  0.5I240 (47.5%)5.8% II185 (36.6%)8.7% III80 (15.8%)6.3% Tumor Subtype  0.014ER+PR+Her2-161 (26.4%)3.1% ER+PR-Her2-56 (9.2%)3.6% Her2+176 (28.9%)6.3% Triple negative216 (35.5%)11.1% Local therapy  0.169Lumpectomy85 (13.5%)11.8% Lumpectomy with radiation198 (31.4%)5.6% Mastectomy173 (27.5%)5.2% Mastectomy with radiation174 (27.6%)8.6% Axillary surgery  0.23None5 (0.8%)20% SLN329 (52.2%)5.8% ALND296 (47%)8.5% Axillary radiation  0.535Yes42 (6.7%)9.5% No588 (93.3%)7.0% Axillary management  0.2No surgery or radiation5 (0.8%)20.0% SLN312 (50%)5.3% SLN+Axillary radiation17 (2.7%)8.3% ALND271 (43%)10.3% ALND+Axillary radiation25 (4%)5.4% RCB  0.0020/1293 (50.1%)3.8% 2/3292 (49.9%)10.3% 

Citation Format: Silverstein J, Suleiman L, Yau C, Price ER, Singhrao R, Yee D, DeMichele A, Isaacs C, Albain KS, Chien AJ, Forero-Torres A, Wallace AM, Pusztai L, Ellis ED, Elias AD, Lang JE, Lu J, Han HS, Clark AS, Korde L, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Wood WC, Park JW, Liu MC, Olopade O, Leyland-Jones B, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, I-SPY 2 TRIAL Consortium, Berry DA, Asare SM, Esserman LJ, Boughey JC, Mukhtar RA. The impact of local therapy on locoregional recurrence in women with high risk breast cancer in the neoadjuvant I-SPY2 TRIAL [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 P2-14-01.

Abstract P2-07-03: Refining neoadjuvant predictors of three year distant metastasis free survival: Integrating volume change as measured by MRI with residual cancer burden

Background: Patients achieving a pathologic complete response (pCR) following neoadjuvant therapy have significantly improved event-free survival relative to those who do not; and pCR is an FDA-accepted endpoint to support accelerated approval of novel agents/combinations in the neoadjuvant treatment of high risk early stage breast cancer. Previous studies have shown that recurrence risk increased with increasing burden of residual disease (as assessed by the RCB index). As well, these studies suggest that patients with minimum residual disease (RCB-I class) also have favorable outcomes (comparable to those achieving a pCR) within high risk tumor subtypes. In this study, we assess whether integrating RCB with MRI functional tumor volume (FTV), which in itself is prognostic, can improve prediction of distant recurrence free survival (DRFS); and identify a subset of patients with minimal residual disease with comparable DRFS as those who achieved a pCR. Imaging tools can then be used to identify the subset that will do well early and guide the timing of surgical therapy.

Method: We performed a pooled analysis of 596 patients from the I-SPY2 TRIAL with RCB, pre-surgical MRI FTV data and known follow-up (median 2.5 years). We first assessed whether FTV predicts residual disease (pCR or pCR/RCB-I) using ROC analysis. We applied a power transformation to normalize the pre-surgical FTV distribution; and assessed its association with DRFS using a bi-variate Cox proportional hazard model adjusting for HR/HER2 subtype. We also fitted a bivariate Cox model of RCB index adjusting for subtype; and assessed whether adding pre-surgical FTV to this model further improves association with DRFS using a likelihood ratio (LR) test. For the Cox modeling, penalized splines approximation of the transformed FTV and RCB index with 2 degrees of freedom was used to allow for non-linear effects of FTV and RCB on DRFS.

Result: Pre-surgical MRI FTV is significantly associated with DRFS (Wald p&lt;0.00001), and more effective at predicting pCR/RCB-I than predicting pCR alone (AUC: 0.72 vs. 0.65). Larger pre-surgical FTV remains associated with worse DRFS adjusting for subtype (Wald p &lt;0.00001). The RCB index is also significantly associated with DRFS adjusting for subtype (Wald p&lt;0.00001). Adding FTV to a model containing RCB and subtype further improves association with DRFS (LR p=0.0007). RCB-I patients have excellent DRFS (94% at 3 years compared to 95% in the pCR group). Efforts are underway to identify an optimal threshold for dichotomizing pre-surgical FTV and FTV change measures for use in combination with pCR/RCB-I class to generate integrated RCB (iRCB) groups as a composite predictor of DRFS.

Conclusion: Pre-surgical MRI FTV is effective at predicting minimal residual disease (RCB0/I) in the I-SPY 2 TRIAL. Despite the association between FTV and RCB, FTV appears to provide independent added prognostic value (to RCB and subtype), suggesting that integrating MRI volume measures and RCB into a composite predictor may improve DRFS prediction.

Citation Format: Hylton NM, Symmans WF, Yau C, Li W, Hatzis C, Isaacs C, Albain KS, Chen Y-Y, Krings G, Wei S, Harada S, Datnow B, Fadare O, Klein M, Pambuccian S, Chen B, Adamson K, Sams S, Mhawech-Fauceglia P, Magliocco A, Feldman M, Rendi M, Sattar H, Zeck J, Ocal I, Tawfik O, Grasso LeBeau L, Sahoo S, Vinh T, Yang S, Adams A, Chien AJ, Ferero-Torres A, Stringer-Reasor E, Wallace A, Boughey JC, Ellis ED, Elias AD, Lang JE, Lu J, Han HS, Clark AS, Korde L, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Wood WC, Park JW, Liu MC, Olopade O, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, Haugen PK, van't Veer LJ, Perlmutter J, Melisko ME, Wilson A, Peterson G, Asare AL, Buxton MB, Paoloni M, Clennell JL, Hirst GL, Singhrao R, Steeg K, Matthews JB, Sanil A, Berry SM, Abe H, Wolverton D, Crane EP, Ward KA, Nelson M, Niell BL, Oh K, Brandt KR, Bang DH, Ojeda-Fournier H, Eghtedari M, Sheth PA, Bernreuter WK, Umphrey H, Rosen MA, Dogan B, Yang W, Joe B, I-SPY 2 TRIAL Consortium, Yee D, Pusztai L, DeMichele A, Asare SM, Berry DA, Esserman LJ. Refining neoadjuvant predictors of three year distant metastasis free survival: Integrating volume change as measured by MRI with residual cancer burden [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 P2-07-03.