Synthesis and Structure-Activity Relationships of 2,5-Dimethoxy-4-Substituted Phenethylamines and the Discovery of CYB210010: A Potent, Orally Bioavailable and Long-Acting Serotonin 5-HT2 Receptor Agonist

Structure-activity studies of 4-substituted-2,5-dimethoxyphenethylamines led to the discovery of 2,5-dimethoxy-4-thiotrifluoromethylphenethylamines, including CYB210010, a potent and long-acting serotonin 5-HT2 receptor agonist. CYB210010 exhibited high agonist potency at 5-HT2A and 5-HT2C receptors, modest selectivity over 5-HT2B, 5-HT1A, 5-HT6, and adrenergic α2A receptors, and lacked activity at monoamine transporters and over 70 other proteins. CYB210010 (0.1-3 mg/kg) elicited a head-twitch response (HTR) and could be administered subchronically at threshold doses without behavioral tolerance. CYB210010 was orally bioavailable in three species, readily and preferentially crossed into the CNS, engaged frontal cortex 5-HT2A receptors, and increased the expression of genes involved in neuroplasticity in the frontal cortex. CYB210010 represents a new tool molecule for investigating the therapeutic potential of 5-HT2 receptor activation. In addition, several other compounds with high 5-HT2A receptor potency, yet with little or no HTR activity, were discovered, providing the groundwork for the development of nonpsychedelic 5-HT2A receptor ligands.

303 Mapping the Landscape of Surgical Registries in the United Kingdom

Introduction

Well-designed surgical registries are essential for high-quality patient-centred evaluation of implantable devices and surgical procedures. The importance of registries was highlighted in the recent Cumberlege report that detailed important innovation failures such as the use of vaginal mesh. Many surgical registries exist, but it is currently unclear how different registries are funded; designed; what data are collected; how databases are hosted and if the data can be linked to other datasets. There is therefore a need to understand the characteristics of and variation in existing surgical registries to make recommendations for how these could be improved. The aim of this work is to identify existing surgical registries in the UK and describe and summarise their key characteristics to inform recommendations for how surgical registries may be improved.

Method

Existing surgical registries will be identified using multiple different sources, including society websites; search engine review; a targeted search of Medline and Embase databases and expert knowledge. Details of each registry will be extracted using a standardised data extraction proforma developed by the study team. Characteristics of identified registries will be summarised into a narrative review.

Results

Identification of registries is ongoing. Preliminary data extraction has highlighted marked heterogeneity in the design, content, and structure of existing surgical registries. Data extraction is ongoing, but results will be available for presentation at the ASIT meeting.

Conclusions

There is considerable heterogeneity in existing surgical registries. Further work is needed to establish the extent of this variation and identify areas that can be improved.

235 Understanding Stage of Innovation of Invasive Procedures and Devices

Aim

New and modified surgical procedures and devices are often introduced into clinical practice without adequate evidence of their safety and efficacy. To promote systematic evaluation of surgical innovations, the IDEAL and IDEAL-D frameworks outline recommendations for study design and governance for procedures and devices according to their stage of innovation. However, determining stage of innovation can be difficult, hindering use of such frameworks. There is a need for a detailed understanding of what stage of innovation means, and how it can be determined. The aim of this study is to understand the concept of stage of innovation as reported in the literature.

Method

A systematic review is being conducted. Searches of Ovid Medline and Embase databases have been performed. Articles were screened by title and, then by full text. s and foreign language articles were excluded. Data will be extracted verbatim regarding approaches to evaluating surgical innovations and determining stage of innovation. A thematic analysis will be conducted, and findings summarised in a narrative report.

Results

The search returned 2,946 articles, of which 46 were included. Preliminary findings have identified two approaches for evaluating procedures, and one for devices. Following thematic analysis, the narrative report will explore approaches to evaluating surgical innovations and determining stage of innovation, including barriers to implementation and proposed solutions.

Conclusions

A report of progress will be presented at the Surgical Innovation Summit. An improved understanding of stage of innovation will facilitate better evaluation of surgical innovations.

127 Electronic Collection of Patient-Reported Outcomes Following Discharge After Surgery: A Systematic Review

Aim

Little is known about the electronic collection and clinical feedback of patient reported outcomes (ePROs) post-surgical discharge. This review summarised the evidence on the collection and uses of electronic systems to collect PROs after discharge from hospital following surgery.

Method

Systematic searches of Medline, Embase, PsycINFO, CINAHL and Cochrane Central were undertaken from database inception to July 2019 using terms for “patient reported outcomes”, “electronic”, “surgery” and “at home”. Primary research of all study designs was included if they used electronic systems to collect PRO data away from formal health care settings. Only studies in adult patients admitted for surgery then discharged from hospital were eligible.

Results

From 9,474 records identified, 15 studies were reviewed including three randomised controlled trials. Seven studies were in orthopaedic surgery. Most studies used commercial ePRO systems (n = 9/12). Six studies reported types of electronic devices used to collect data: tablets or other portable devices (n = 3), smartphones (n = 2), combination of smartphones, tablets/portable devices and computers (n = 1). Systems had limited features or functions such as real-time feedback to clinicians (n = 6) and messaging service for patients to communicate with care teams (n = 3). No studies described integration of the ePRO system with electronic health records to support clinical feedback.

Conclusions

There is limited reporting of ePRO systems in the surgical literature. ePRO systems lack integration with hospital clinical systems. Future research should describe the ePRO system and ePRO questionnaires used, and challenges encountered during the study, to support efficient upscaling of ePRO systems using tried and tested approaches.

Patient-Reported Outcome Measures for Post-mastectomy Breast Reconstruction: A Systematic Review of Development and Measurement Properties

BACKGROUND

Breast reconstruction (BR) is performed to improve outcomes for patients undergoing mastectomy. A recently developed core outcome set for BR includes six patient-reported outcomes that should be measured and reported in all future studies. It is vital that any instrument used to measure these outcomes as part of a core measurement set be robustly developed and validated so data are reliable and accurate. The aim of this systematic review is to evaluate the development and measurement properties of existing BR patient-reported outcome measures (PROMs) to inform instrument selection for future studies.

METHODS

A PRISMA-compliant systematic review of development and validation studies of BR PROMs was conducted to assess their measurement properties. PROMs with adequate content validity were assessed using three steps: (1) the methodological quality of each identified study was assessed using the COSMIN Risk of Bias checklist; (2) criteria were applied for assessing good measurement properties; and (3) evidence was summarized and the quality of evidence assessed using a modified GRADE approach.

RESULTS

Fourteen articles reported the development and measurement properties of six PROMs. Of these, only three (BREAST-Q, BRECON-31, and EORTC QLQ-BRECON-23) were considered to have adequate content validity and proceeded to full evaluation. This showed that all three PROMs had been robustly developed and validated and demonstrated adequate quality.

CONCLUSIONS

BREAST-Q, BRECON-31, and EORTC QLQ-BRECON-23 have been well-developed and demonstrate adequate measurement properties. Work with key stakeholders is now needed to generate consensus regarding which PROM should be recommended for inclusion in a core measurement set.

Optimization of the manufacturing process of a complex amphotericin B liposomal formulation using quality by design approach

In this work, the manufacturing process of a complex liposomal amphotericin B (AmB) product was optimized using quality by design (QbD) approach. A comprehensive QbD-based process understanding and design space (DS) to the critical process parameters (CPPs) is essential to the drug development and consistent quality control. The process was based on the acid-aided formation of drug-lipid complexes in a methanol-chloroform mixture (step I) followed by spray drying (step II), hydration and liposome formation by microfluidization (step III), and lyophilization (step IV). Firstly, the risk assessment was conducted to identify the critical process parameters among the four key steps. Nine CPPs and five CQAs (API Monomer identity (absorbance main peak at 321 nm), API Aggregation identity (absorbance peak ratio, OD 415 nm/321 nm), particle size, in-vitro toxicity, and the cake quality) were determined based on their severity and occurrences with their contribution to the quality target product profile (QTPP). Based on the risk assessment results, the final screening design of experiments (DoE) was developed using fractional factorial design. Secondly, the empirical equation was developed for each CQA based on experimental data. The impact of CPPs on the CQAs was analyzed using the coefficient plot and contour plot. In addition to the effect of individual formulation parameters and process parameters, the effects of the four key separate steps were also evaluated and compared. In general, the curing temperature during microfluidization has been identified as the most significant CPP. Finally, design space exploration was carried out to demonstrate how the critical process parameters can be varied to consistently produce a drug product with desired characteristics. The design space size increased at the higher value of the curing temperature, the API to phospholipid ratio (API:PL), and the lower value of the DSPG to phospholipid ratio (PG:PL) and aspirator rate.

Mapping the stem cell state: eight novel human embryonic stem and embryonal carcinoma cell antibodies

The antigenic profile of human embryonic stem (ES) and embryonal carcinoma (EC) cells has served as a key element of their characterization, with a common panel of surface and intracellular markers now widely used. Such markers have been used to identify cells within the 'undifferentiated state', yet it appears that this categorization may be an oversimplification, because a number of sub-states appear to exist within this state. To increase the resolution of the undifferentiated state, we have generated eight novel monoclonal antibodies, all capable of recognizing undifferentiated human ES and EC cells, and herein describe their characterization. The reactivity of these antibodies against a range of cell lines is reported, as well as their developmental regulation, basic biochemistry and reactivity in immunohistochemistry of testicular germ cell tumours. Our data reveal a range of reactivity for all antibodies against both ES and EC cells, suggesting that these markers will afford recognition of unique sub-states within the undifferentiated stem cell compartment.

Health-related quality of life and survival in the 2 years after surgery for gastric cancer

BACKGROUND

This prospective study examined health-related quality of life (HRQL) and survival in patients with potentially curable gastric cancer.

METHODS

Consecutive patients (n=58) selected for curative surgery completed a validated questionnaire (EORTC QLQ-C30) and site-specific module (QLQ-STO22) before surgery and regularly for 2 years afterwards. Changes of 10 or more points on a 0-100 scale were considered clinically significant.

RESULTS

Some 30 patients were alive after 2 years (52%). In the first 3 months after surgery, HRQL was significantly reduced across all dimensions except emotional and cognitive functioning (mean reduction of 10 or more points). Functional aspects of HRQL recovered by 6 months in patients who subsequently were alive at 2 years, although at least a third of patients experienced specific symptoms, even 6 months after surgery, especially diarrhoea. For those dying within 2 years, some postoperative functional HRQL recovery occurred, but many symptoms were common.

CONCLUSIONS

Potentially curative gastrectomy for cancer has a detrimental impact on HRQL that mostly recovers in patients surviving some 2 years. Patients who die within 2 years may experience limited postoperative recovery. It is recommended that patients receive HRQL information about the outcomes of surgery for gastric cancer.

The Arabic ICIQ-UI SF: an alternative language version of the English ICIQ-UI SF

AIMS

Urinary incontinence (UI) is a common and distressing condition. A variety of questionnaires are currently available to assess UI and its impact on patients' lives. However, most have not been adapted for international use. Following a systematic review of the literature and existing questionnaires the International Consultation on Incontinence short form questionnaire (ICIQ-UI SF) was developed, and has since been translated into many languages for local use. This paper reports the development and validation of the first UI questionnaire in the Arabic language. The development of this questionnaire will facilitate the assessment of UI in both clinical practice and research in the Middle-East.

METHODS

Translation and validation of the Arabic version of the ICIQ-UI is described. Standard methods of translation by native Arabic and English speakers (including translation and back translation) are followed. The psychometric properties of the questionnaire, including its validity, reliability and sensitivity to change, are examined. The validation of the questionnaire involved patients attending urology outpatient clinics in two Middle-Eastern countries.

RESULTS

The Arabic ICIQ-UI SF was found to be valid, reliable and responsive, indicating that the psychometric properties of the questionnaire have remained constant throughout the adaptation process. Furthermore, the findings of the psychometric testing confirm those found for the UK-English ICIQ-UI SF.

CONCLUSIONS

The development of this questionnaire will allow the study of Arabic speaking groups with UI in many countries around the world. This may act as an example to initiate the translation and validation of other patient reported outcomes into the Arabic language, thereby enabling more multinational and cross-cultural research into diseases in given areas.

Development and psychometric evaluation of the ICIQ Vaginal Symptoms Questionnaire: the ICIQ-VS

OBJECTIVES

To develop and validate a self-completion questionnaire for comprehensive assessment of the severity and impact of vaginal symptoms and related sexual matters, particularly those attributed to pelvic organ prolapse. To provide an instrument that can characterise the severity of these symptoms, measure their impact and evaluate treatment outcome.

DESIGN

Prospective development of the content of the questionnaire and testing of its psychometric properties including validity.

SETTING

Two hospital-based urogynaecology clinics and one community general practice in the South of England.

POPULATION

One hundred and forty-one urogynaecology clinic attendees with varying degrees of pelvic organ prolapse and 77 randomly selected women registered with a general practice.

METHODS

The questionnaire was developed through a literature review, consultation with clinicians and health scientists and structured interviews with patients. Content validity, construct validity, stability, internal consistency and sensitivity to change were examined by comparing the responses from the urogynaecology clinic with responses from the general community. Sensitivity to change was assessed using responses from women undergoing surgical treatment for pelvic organ prolapse before and 3 months after surgery. A final version of the questionnaire was obtained after factor analysis to assist item reduction and refinement of the scoring system.

MAIN OUTCOME MEASURES

Content validity, construct validity, stability (test-retest reliability), internal consistency and sensitivity to change.

RESULTS

The questionnaire exhibited good validity, reliability and sensitivity to change. Excellent internal consistency was demonstrated for vaginal (Cronbach's alpha 0.79) and sexual (Cronbach's alpha 0.84) symptoms. Reliability was good. The questionnaire was able to identify changes in symptoms following surgical treatment. The final ICIQ-VS questionnaire had 14 items and a simple scoring system. CONCLUSION; The ICIQ-VS self-completion questionnaire meets the need for a robust instrument for assessing a range of vaginal and sexual symptoms, in particular those of pelvic organ prolapse. It will be of use in both routine clinical practice and epidemiological research, particularly when there is a need to assess the severity of these symptoms or the efficacy of treatment.

Hyperthermic "dose" dependent changes in intralesional pH

Following hyperthermia a dramatic drop in intra-lesional pH has occurred in a variety of experimental tumor systems. To date, no direct observations have been made that document the time course of such changes or the recovery from such changes over prolonged periods of time. These experiments were designed to measure intralesional pH as a function of time following "doses" of hyperthermia related to specific biological end points. All studies were conducted in the C3H-mammary carcinoma tumor model system. Intralesional temperature was continuously monitored throughout treatment and post treatment pH was measured with microelectrodes at several specific time points ranging from 4 hrs to 7 days. The pretreatment control value of mean pH was 6.73. At the TCD90 "dose" level the mean value of pH dropped to a level of 6.22 +/- .095 while following the TCD10 "dose" the value obtained was 6.55 +/- .148. Recovery of the pH to higher values followed similar time courses returning to maximum values approximately 3 days post treatment. The recovery, plateau levels of pH were however, separated by approximately .3 pH units with the higher "dose" curve always at lower values than that achieved following the lower "dose".