Evaluation of Twenty Non-Metric Dental Crown Traits in Different Types of Malocclusions in a Sample from India, New Delhi Population

Background

Dental phenotype shows variation in the form of various metric and non-metric traits, primarily due to gene-environment interplay. It gives an insight into the evolutionary trends, ancestry, and food habits. Recently, it has been explored for genetic affinity with several growth anomalies and development of craniofacial skeleton which is also responsible for dental and skeletal malocclusions.

Objectives

the current study aims to investigate the non-metric dental crown traits (NDCTs) using Arizona State University Dental Anthropology system (ASUDAS) in different types of malocclusions in Delhi, National Capital Region (NCR) population.

Materials and methods

The study design was observational and retrospective. The total sample comprised of 240 pairs of dental casts divided into four equal groups of 60 subjects each (30 male and 30 female), based on malocclusion. The four groups of malocclusions were: Angle's Class I, Class II division 1, Class II division 2, Class III. The investigator was blinded for patient ID and sex before recording the data. The data for cast were recorded by three observers independently in a modified malocclusion- non-metric dental crown traits (M-NDCT) anthropological variants chart and statistically analyzed for association with different malocclusions and sex.

Results

Significant differences were found in the expression of several NDCTs (both in presence and scoring) in different malocclusions. Class I malocclusion showed a predominantly winging, shoveling -upper central and lateral incisor, protostylid, hypoconulid absence in lower second molar, and cusp number. Class II malocclusion showed a double shoveling, interrupted groove, tuberculum dentale, canine mesial ridge, premolar accessory cusp, Carabelli's trait, lingual cusp variation, and seventh cusp in the lower left first molar. Class III malocclusion showed the absence of hypocone in upper second molar, deflecting wrinkle, distal trigonid crest, and Y groove in left lower second molar (26.7%). Besides, sexual dimorphism was seen in shoveling -upper central and lateral incisor, canine mesial ridge, Carabelli's trait, 3-cusp in upper second molar, and cusp number.

Conclusions

Significant association was found between non-metric dental traits and malocclusions (Class I, Class division 1, Class II division 2, and Class III). Significant sex-linked differences were also found. Further studies can be performed at multicenter pan-India level with a standard robust protocol and a large sample.

Novel paradigm enables accurate monthly gestational screening to prevent congenital toxoplasmosis and more

Background

Congenital toxoplasmosis is a treatable, preventable disease, but untreated causes death, prematurity, loss of sight, cognition and motor function, and substantial costs worldwide.

Methods/Findings

In our ongoing USA feasibility/efficacy clinical trial, data collated with other ongoing and earlier published results proved high performance of an Immunochromatographic-test(ICT) that enables accurate, rapid diagnosis/treatment, establishing new paradigms for care. Overall results from patient blood and/or serum samples tested with ICT compared with gold-standard-predicate-test results found ICT performance for 4606 sera/1876 blood, 99.3%/97.5% sensitive and 98.9%/99.7% specific. However, in the clinical trial the FDA-cleared-predicate test initially caused practical, costly problems due to false-positive-IgM results. For 58 persons, 3/43 seronegative and 2/15 chronically infected persons had false positive IgM predicate tests. This caused substantial anxiety, concerns, and required costly, delayed confirmation in reference centers. Absence of false positive ICT results contributes to solutions: Lyon and Paris France and USA Reference laboratories frequently receive sera with erroneously positive local laboratory IgM results impeding patient care. Therefore, thirty-two such sera referred to Lyon's Reference laboratory were ICT-tested. We collated these with other earlier/ongoing results: 132 of 137 USA or French persons had false positive local laboratory IgM results identified correctly as negative by ICT. Five false positive ICT results in Tunisia and Marseille, France, emphasize need to confirm positive ICT results with Sabin-Feldman-Dye-test or western blot. Separate studies demonstrated high performance in detecting acute infections, meeting FDA, CLIA, WHO ASSURED, CEMark criteria and patient and physician satisfaction with monthly-gestational-ICT-screening.

Conclusions/Significance

This novel paradigm using ICT identifies likely false positives or raises suspicion that a result is truly positive, rapidly needing prompt follow up and treatment. Thus, ICT enables well-accepted gestational screening programs that facilitate rapid treatment saving lives, sight, cognition and motor function. This reduces anxiety, delays, work, and cost at point-of-care and clinical laboratories.

Author’s Summary

Toxoplasmosis is a major health burden for developed and developing countries, causing damage to eyes and brain, loss of life and substantial societal costs. Prompt diagnosis in gestational screening programs enables treatment, thereby relieving suffering, and leading to > 14-fold cost savings for care. Herein, we demonstrate that using an ICT that meets WHO ASSURED-criteria identifying persons with/without antibody to Toxoplasma gondii in sera and whole blood with high sensitivity and specificity, is feasible to use in USA clinical practice. We find this new approach can help to obviate the problem of detection of false positive anti- T.gondii IgM results for those without IgG antibodies to T.gondii when this occurs in present, standard of care, predicate USA FDA cleared available assays. Thus, this accurate test facilitates gestational screening programs and a global initiative to diagnose and thereby prevent and treat T.gondii infection. This minimizes likelihood of false positives (IgG and/or IgM) while maintaining maximum sensitivity. When isolated IgM antibodies are detected, it is necessary to confirm and when indicated continue follow up testing in ∼2 weeks to establish seroconversion. Presence of a positive ICT makes it likely that IgM is truly positive and a negative ICT makes it likely that IgM will be a false positive without infection. These results create a new, enthusiastically-accepted, precise paradigm for rapid diagnosis and validation of results with a second-line test. This helps eliminate alarm and anxiety about false-positive results, while expediting needed treatment for true positive results and providing back up distinguishing false positive tests.

Abstract 5115: Novel humanized anti-GD2 antibody inhibits GD2-mediated immunosuppression by targeting GD2+ breast cancer stem-like cells

Background: Breast cancer stem-like cells (BCSCs) are reported to be a major contributing factor for tumor growth and chemotherapy resistance in triple-negative breast cancer (TNBC). We reported that the disialoganglioside GD2 is highly expressed on BCSCs and that targeting GD2 with dinutuximab (chimeric anti-GD2 antibody) in combination with NK cells synergistically reduced tumor volumes in TNBC animal models. Here, we hypothesize that naxitamab targets GD2+ BCSCs and inhibits breast cancer (BC) growth by enhancing macrophage mediated phagocytosis and T cell mediated cytotoxicity. In addition, we explore whether addition of an investigational polymer-engineered IL-15 receptor-agonist, NKTR-255 treated NK cells, can further enhance this anti-GD2 mediated anti-cancer activity.

Methods: Naxitamab is a US FDA approved fully humanized anti-GD2 (hu3F8) monoclonal antibody for the treatment of pediatric neuroblastoma. We evaluated the effects of naxitamab treatment on macrophage mediated phagocytosis of BC cells using the live cell imaging system, IncuCyte®. Next, we compared the effects of NKTR-255 treated NK cells with recombinant human IL-15 (rIL-15) treated NK cells in naxitamab induced ADCC in GD2+ BC cells. We also performed immunohistochemistry (IHC) to examine GD2 expression and correlate it with T cell infiltration in primary TNBC patient samples with high and low GD2 levels. The effect of naxitamab treatment on T cell mediated cytotoxicity in BC cells was also observed.

Results: When compared to control, naxitamab treatment promoted macrophage mediated phagocytosis of Hs578T and HCC1395 cells in a dose dependent manner (p <0.001). Additionally, when co-cultured with healthy donor derived macrophages, we found a significant reduction in Hs578T spheroids treated with naxitamab in comparison to IgG control (p<0.001). Furthermore, we observed a significantly higher rate of apoptosis in GD2+ Hs578T and HCC1395 breast cancer cells treated with naxitamab and NK cells generated using NKTR-255, compared to rIL-15 treated NK cells (p<0.0001). Interestingly, IHC analysis showed that TNBC patients with high GD2 expression have significantly lower CD3+ T cell infiltration than patients with low GD2 expression (p<0.05). We also observed increased T cell mediated killing of BT549 and T47D cells treated with naxitamab in comparison to IgG control (p<0.001).

Conclusion: TNBC with high GD2 expression inhibits immune cell infiltration and naxitamab can inhibit BCSC growth by targeting GD2. Combination of naxitamab with macrophages induced macrophage mediated phagocytosis TNBC cells. NK cells were more stable and cytotoxic when generated with NKTR-255 vs. native IL-15, and naxitamab further enhanced NK cell mediated ADCC of GD2+ BCSCs. The increased T cell mediated killing of breast cancer cells treated with naxitamab further supports the immunomodulatory role of GD2.

Citation Format: Vivek Anand, Venkatesh Hegde, Maryam Siddiqui, Anudishi Tyagi, Bolutyfe Oderinde, Mario Marcondes, Willem Overwijk, Venkata Lokesh Battula. Novel humanized anti-GD2 antibody inhibits GD2-mediated immunosuppression by targeting GD2+ breast cancer stem-like cells. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5115.

Magnetic Resonance-Guided High Intensity Focused Ultrasound Generated Hyperthermia: A Feasible Treatment Method in a Murine Rhabdomyosarcoma Model

Magnetic resonance-guided high intensity focused ultrasound (MRgHIFU) is an established method for producing localized hyperthermia. Given the real-time imaging and acoustic energy modulation, this modality enables precise temperature control within a defined area. Many thermal applications are being explored with this noninvasive, nonionizing technology, such as hyperthermia generation, to release drugs from thermosensitive liposomal carriers. These drugs can include chemotherapies such as doxorubicin, for which targeted release is desired due to the dose-limiting systemic side effects, namely cardiotoxicity. Doxorubicin is a mainstay for treating a variety of malignant tumors and is commonly used in relapsed or recurrent rhabdomyosarcoma (RMS). RMS is the most common solid soft tissue extracranial tumor in children and young adults. Despite aggressive, multimodal therapy, RMS survival rates have remained the same for the past 30 years. To explore a solution for addressing this unmet need, an experimental protocol was developed to evaluate the release of thermosensitive liposomal doxorubicin (TLD) in an immunocompetent, syngeneic RMS mouse model using MRgHIFU as the source of hyperthermia for drug release.

Observation of Myocardial Involvement in Patients Recovered From COVID-19 by Using Cardiac Magnetic Resonance Imaging, In a Tertiary Care Hospital, Bangladesh

It was previously reported that coronavirus caused myocardial injury in hospitalized patients. However, delayed cardiac involvement in symptomatic patient recovery from COVID-19 is not yet well known. The objective of this study was to evaluate cardiac involvement by using cardiac magnetic resonance (CMR) in symptomatic post-COVID-19 recovered patients. Thirty (30) patients who recovered from COVID-19 and had recently reported cardiac symptoms were studied in a prospective observational study performed at Popular Medical College Hospital, Dhaka, Bangladesh from March 2021 to September 2021. They underwent CMR examinations. CMR scanning protocol included the following: black blood, cine sequence, both short-axis and long-axis, T2-weight short tau inversion recovery (STIR) sequence, T2- weighted imaging (T2WI) and late gadolinium enhancement (LGE) and quantitative mapping sequences-native T1/T2 mapping and post-contrast T1 mapping. Myocardial edema and late gadolinium enhancement were assessed in all patients. Quantitative evaluation of native T1/T2 and ECV value and cardiac function were evaluated. There were 30 people in all in this study. The average age of the participants in the study was 36.6 years. Fourteen (46.6%) of the patients had abnormal cardiac MRI results, while the remaining 15(53.3%) had negative CMR findings. Among positive findings patients, 8(57.1%) of 14 had increased T2 signal. Increased myocardial edema was found in the same no of patients, involving 53.2% (128 of 224) of LV segments. Only 2 cases (2 of 14) showed mid myocardial and subepicardial LGE, involving 18 of 224, 8.03% of myocardial segments. Global native T1, T2 and ECV values are significantly elevated in all CMR positive findings patients. Native T1 1231ms (IQR: 1281.25-1257.5 versus 1155.5 (IQR: 1137.25-1172.75), T2 40 (IQR: 34.5-43.25) versus 35.5 (IQR: 34-37), ECV 31 (29.75-33.25) versus 23.5 (21.25-24.0), p<0.001; p<0.011 and p<0.001 respectively. Reduced RV functional were found in positive as compared with negative CMR findings patients, EF, 32.05 (IQR: 25.25-39.0) versus 54.5 (IQR: 52.0-57.75) and EDV, 117.5 (IQR: 102.0-134.25) versus 95.0 (IQR: 71.75-99.75), p<0.001 and p<0.001 respectively. In this study cardiac involvement was found in the post-COVID-19 recovered patient with cardiac symptoms. Cardiac MRI findings included myocardial edema, fibrosis and reduced right ventricular function. So attention should be paid to symptomatic post-COVID-19 recovered patients.

Building Programs to Eradicate Toxoplasmosis Part III: Epidemiology and Risk Factors

Purpose of Review

Review comprehensive data on rates of toxoplasmosis in Panama and Colombia.

Recent Findings

Samples and data sets from Panama and Colombia, that facilitated estimates regarding seroprevalence of antibodies to Toxoplasma and risk factors, were reviewed.

Summary

Screening maps, seroprevalence maps, and risk factor mathematical models were devised based on these data. Studies in Ciudad de Panamá estimated seroprevalence at between 22 and 44%. Consistent relationships were found between higher prevalence rates and factors such as poverty and proximity to water sources. Prenatal screening rates for anti-Toxoplasma antibodies were variable, despite existence of a screening law. Heat maps showed a correlation between proximity to bodies of water and overall Toxoplasma seroprevalence. Spatial epidemiological maps and mathematical models identify specific regions that could most benefit from comprehensive, preventive healthcare campaigns related to congenital toxoplasmosis and Toxoplasma infection.

Building Programs to Eradicate Toxoplasmosis Part II: Education

Purpose of Review

Review work to create and evaluate educational materials that could serve as a primary prevention strategy to help both providers and patients in Panama, Colombia, and the USA reduce disease burden of Toxoplasma infections.

Recent Findings

Educational programs had not been evaluated for efficacy in Panama, USA, or Colombia.

Summary

Educational programs for high school students, pregnant women, medical students and professionals, scientists, and lay personnel were created. In most settings, short-term effects were evaluated. In Panama, Colombia, and USA, all materials showed short-term utility in transmitting information to learners. These educational materials can serve as a component of larger public health programs to lower disease burden from congenital toxoplasmosis. Future priorities include conducting robust longitudinal studies of whether education correlates with reduced adverse disease outcomes, modifying educational materials as new information regarding region-specific risk factors is discovered, and ensuring materials are widely accessible.

P-243 Automating tracking of cell division for human embryo development in time lapse videos

Study question

Can tracking cell division and predicting human embryo cleavage stages be automated in time-lapse videos (TLV) using AI object detection methods?

Summary answer

We developed software predicting blastomere count and tracking cell cleavages up until 4-5 stage. The software employs object detection technique called YOLOv5 to detect cells.

What is known already

Embryo morphology plays an important part in determining viability. Parameters such as number of cells present following fertilization, abnormal cell division (reverse/direct) and evaluating cleavage stages have correlation with pregnancy rates. However, continuous manual evaluation can be time-consuming, and automation will assist in embryo viability assessment. YOLOv5 has proven to accurately detect objects in videos. YOLOv5 uses mean average precision (mAP) as a metric to quantify the portions of frames in videos having the correct count of the objects.

Study design, size, duration

We have developed a software that uses YOLOv5 to detect cells present in frames of TLV, then marks each cell boundary with different colored circular overlays using OpenCV. We trained YOLOv5 to detect objects: cell, morula and blastocyst using 150 images of different cell-stages, morula, blastocyst. For object cell mAP was 0.65. Annotated location of objects in images and YOLOv5 predictions were reviewed by embryologists. We evaluated the software on TLV from 11 patients.

Participants/materials, setting, methods

After YOLOv5 detects cells in frames of TLV, our software computes cell count and assigns each cell a different color which is maintained until cell division into daughter cells. Later, daughter cells were also assigned different colors. If the frame has a preceding frame, software calculates detected cells' proximity with each cell in the preceding frame and copies color scheme provided proximity is within some threshold. The software provides TLV with colored overlays as output.

Main results and the role of chance

In starting frames of TLV with single cell, software accurately detected 1-cell (high precision=0.99, high recall=0.83, high F1-score=0.90). We observed some misclassification between 1-cell and morula. The reason could be that compacted morula looks like 1-cell. Best performance is observed for 2-cells (high precision=0.91, high recall=0.98, high F1-score=0.95). 4-cells were sometimes misclassified with 3 or 5-cells (high precision=0.88, low recall=0.59, high F1-score=0.71). One reason for the misclassification can be that overlapping between cells increases with number of cells. 3-cell and 5-cell are confused with other stages, still cleavage stage detection is better than random: 3-cell (average precision=0.43, high recall=0.83, average F1-score=0.49), 5-cell (average precision=0.44, average recall=0.40, average F1-score=0.40). For cell-stages&gt;5, YOLOv5 detects less cells than actual count and software predicts cleavage later than actual by 9-10 frames on average. The proximity threshold used was 0.10 for cell-count&lt;4 and 0.05 for count&gt;4.

In 5 TLV, overlay color for cells changes abruptly between frames, possibly because once YOLOv5 detected a stage, in consecutive frames less cell-number was recorded, and then again reported correct count. Sometimes, software selected the wrong parent for daughter cells (incorrect colored overlay). 2 TLV had direct and reverse cleavages and software could detect these two patterns.

Limitations, reasons for caution

Overall, our software can precisely detect cells, cell divisions and cleavage stages up to 4-cell stages. We hypothesize that training YOLOv5 on a bigger dataset and including several focal plane information will enable our software to detect overlapping cells and cleavage stages &gt; =5.

Wider implications of the findings

Object detection proved to be pragmatic for ART and tracking cell division using our software will reduce time consumed in manual annotations, easier prediction of abnormal cleavages and more objective assessments. Qualitative evaluation by embryologists resulted in the overall verdict that this is useful and promising for further development.

Trial registration number

not applicable

The Impact of COVID-19 Pandemic on Individuals With Pre-existing Obsessive-Compulsive Disorder in the State of Qatar: An Exploratory Cross-Sectional Study

BACKGROUND

Published evidence about the impact of the COVID-19 pandemic on Obsessive-Compulsive Disorder (OCD) is conflicting. Most studies suggest an increase in the severity of OCD in people with pre-existing OCD, whereas some do not.

AIM

Given the conflicting evidence globally and lack of data from the Arab world, we aimed to explore the impact of the pandemic on obsessive-compulsive symptoms in adults with pre-existing OCD.

METHODS

A telephonic questionnaire-based cross-sectional study among adults with pre-existing OCD and specifically with fear of contamination and washing compulsions being major symptom dimensions of OCD. The severity of OCD during the pandemic was compared with their pre-pandemic scores. The severity of OCD was assessed using the Yale-Brown Obsessive-Compulsive Scale (YBOCS).

RESULTS

Those with the duration of diagnosis of OCD of<10 years showed a statistically significant increase in the mean YBOCS score of 5.54 from pre-pandemic to during pandemic, which was significant at p = 0.006. This significance was maintained across the Compulsive and Obsessive subsets of the scale.

CONCLUSION

Adults with pre-existing OCD with fear of contamination reported a statistically significant increase in severity of obsessive-compulsive symptoms only if the duration of their OCD diagnosis was relatively shorter (<10 years). In the context of the conflicting evidence regarding the worsening of OCD symptoms due to the unique infection control measures of this pandemic, this study highlights the importance of the impact of the duration of the disorder and the subtype of the disorder. Such classification might help public health resources to be directed better at those most at risk and also help us understand the very nature of this disorder better.

Healthy ageing: Assessment of health-promoting lifestyle among the elderly population in Karachi Pakistan

BACKGROUND

The growth in the elderly population is predicted to expand exponentially and developing countries like Pakistan have about two-third of the global elderly population. It is vital to maintain the health of the elderly aged population to reduce disabilities and health-care cost.

AIM

This study aimed to determine the health promotion practices among the older aged population in Pakistan and to explore the factors associate with adopting healthy lifestyle practices.

MATERIALS AND METHODS

This was a cross-sectional study spanning from 2019 to 2020 conducted on 317 participants of age more than 60 years in Pakistan. The participants included healthy attendants of patients visiting the outpatient clinics of different disciplines in the Liaquat National Hospital Karachi through purposive sampling technique. The health-promoting practices were assessed using Health-Promoting Lifestyle Profile II Questionnaire. The factors that determined the healthy practices among the elderly population were identified using independent t-test and analysis of variance and Tukey test, with a significance level of P < 0.05. IBM SPSS Statistics 22 was used for data entry and analysis.

RESULTS

The highest subscale was detected from interpersonal relationships and spiritual growth. The lowest score was detected from physical activity. The scores differed significantly by occupation, education, and the marital status of the participants. Females, unmarried people, those who were less educated, and participants relying on others for financial support had lower health-promoting lifestyle scores.

CONCLUSION

The overall health-promoting practices were good among the old-aged population of Pakistan. These practices differed particularly for physical activity, spiritual growth, and interpersonal relationships.

1294 Online Education for Patients Undergoing Elective Orthopaedic Surgery During A Global Pandemic

Introduction

lective hip and knee joint replacement patients at the East Lancashire Hospitals NHS Trust (ELHT) are required to attend the ‘Hip and Knee Joint School’. This is an award-winning patient education programme. Pre-pandemic, it was a day at the hospital dedicated to introducing patients to the specifics of a hip and knee joint replacement surgery. This takes the patient from the process of anaesthesia to post-operative ward care.

Method

Due to the virulent transmission of COVID-19, strict social distancing rules have been implemented. Therefore, it was decided that converting the joint school into online videos would be the best medium for patient education. Various healthcare professionals contributed to the videos included orthopaedic surgeons, anaesthetists, specialist nurses, healthcare assistants, occupational therapists, and physiotherapists.

Results

Eleven videos were filmed, edited, and approved by the trust’s communications team. These included, ‘Introduction to the Joint School’, ‘You and your surgery’, ‘Leading up to your operation’, ‘Your Operation Journey’, ‘Introducing the Anaesthetist’ ‘Total Hip Replacement Surgery’, ‘Total Knee Replacement Surgery’, ‘Post-op Wound Care’, ‘Your Safe Discharge Home’, ‘FAQ’s’ and ‘COVID-19 Green Pathway’.

Conclusions

The global pandemic has driven innovation and novel ideas in medicine. We have seen similar changes in our trust with the online patient education videos being a prime example. This joint school was originally started in our trust, but now as it had been converted to videos, we believe that it can be modified and used across all trusts in the NHS.

Tolvaptan-induced Liver Injury: Who is at Risk? A Case Report and Literature Review

Hyponatremia is a common clinical condition encountered in the hospital setting. Syndrome of inappropriate antidiuretic hormone (SIADH) is an important and one of the most common causes of hyponatremia. SIADH accounts for approximately one-third of all cases of hyponatremia. Tolvaptan is a vasopressin receptor antagonist used to treat SIADH. Hepatoxicity is a rare yet dangerous side effect from Tolvaptan use. We present a case of cholestatic liver injury in an elderly female who presented with hyponatremia. She received two doses of tolvaptan 15mg and developed worsening in her total bilirubin (T Bili) and alkaline phosphatase (Alk Phos) levels. Tolvaptan is known to cause elevated transaminase levels and the mechanism of action is thought to be idiosyncratic. Fortunately, the patient responded with an improvement in T Bili and Alk Phos levels after stopping tolvaptan. This case highlights the cautious use of tolvaptan in elderly patients with SIADH as even small doses can potentiate hepatotoxicity. 

Correction to: Topical antimicrobial prophylaxis in colorectal surgery for the prevention of surgical wound infection: a systematic review and meta-analysis

Unfortunately, an author name (Nuzhat Iqbal) was missed out in the original publication. The complete updated author list is given below.

Abstract P6-18-33: GI toxicities in metastatic breast cancer: A comprehensive literature review

Background

Treatments for advanced or metastatic breast cancer (aBC/mBC) are associated with gastrointestinal (GI) toxicities. The objective of this study was to assess the association between GI toxicities in mBC/aBC and health-related quality of life (HRQoL) and economic burden.

Methods

We conducted a comprehensive literature search of the Cochrane Central Register of Controlled Trials (2017), NHS Economic Evaluation Database (2016), Embase (1988 – 2017 week 34), and Ovid MEDLINE (1946 to August 2017). Eligible studies evaluated an intervention/comparator treatment in adult patients (age ≥18 years) with aBC/mBC and reported a direct connection between GI toxicities (ie, diarrhea, constipation, nausea, vomiting) and HRQoL and economic evidence. All studies published from January 2000 to August 2017 were assessed for eligibility. Editorials, case reports, conference abstracts, and studies of early, locally advanced, or inflammatory BC were excluded. Abstract and title screening, and full-text screening were conducted by single reviewers. Data were extracted by a single reviewer and verified by a second. Results were synthesized narratively.

Results

Database searches identified 3,428 articles; an additional 16 articles were identified through other sources. Ninety-four studies underwent full-text review, of which 27 reported a direct connection between GI toxicities and HRQoL (n = 11) and economic burden (n = 19). Some studies reported both HRQoL and economic data.

Patients identified treatment-related adverse events (AEs), such as GI events, as an important aspect of treatment that can affect therapy choice, discontinuation, and switching. Generally, patients with mBC had lower HRQoL than other BC groups, and increasing toxicity was associated with a greater degree of HRQoL impairment. When patients were asked to rank which AEs they most wanted to avoid, only pain ranked higher than nausea and vomiting. In a willingness to pay study, women with mBC were willing to pay $3,894 (2014 USD) per year to avoid severe diarrhea and $3,211 to avoid severe nausea.

Gastrointestinal events were among the costliest class of AEs, with mean costs as high as $4,809 (2016 USD) per episode; costs increased by 24% if events were persistent or recurrent.

Conclusions

Gastrointestinal toxicities are common in patients with aBC/mBC and have significant consequences for HRQoL and system-level economic outcomes. Frequency and implications of GI effects of treatment regimens should be considered carefully during patient counseling,, prescribing and coverage decisions in metastatic breast cancer.

Citation Format: Disher T, Siddiqui M, Mitra D, Cameron C, Zhan L, Iyer S. GI toxicities in metastatic breast cancer: A comprehensive literature review [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 P6-18-33.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Population-based study of the impact of surgical and adjuvant therapy at the same or a different institution on survival of patients with pancreatic adenocarcinoma

Background

Pancreatic cancer surgery is increasingly regionalized in high‐volume centres. Provision of adjuvant chemotherapy in the same institution can place a burden on patients, whereas receiving adjuvant chemotherapy at a different institution closer to home may create disparities in care. This study compared long‐term outcomes of patients with pancreatic adenocarcinoma receiving adjuvant chemotherapy at the institution where they had undergone surgery with outcomes for those receiving chemotherapy at a different institution.

Methods

This was a population‐based study of patients receiving adjuvant chemotherapy after resection of pancreatic adenocarcinoma performed at ten designated hepatopancreatobiliary centres in Ontario, Canada, between 2004 and 2014. Patients were divided into those receiving chemotherapy at the same institution as surgery or a different institution from where surgery was performed. The primary outcome was overall survival (OS). Multivariable Cox regression assessed the association between OS and each chemotherapy group, adjusted for potential confounders.

Results

Of 589 patients, 374 (63·5 per cent) received adjuvant chemotherapy at the same institution as surgery. After adjusting for age, sex, co‐morbidity, socioeconomic status, rural living, tumour stage, margin positivity and year of surgery, the location of adjuvant chemotherapy was not independently associated with OS (hazard ratio 1·03, 95 per cent c.i. 0·85 to 1·24). For patients who underwent chemotherapy at a different institution, mean travel distance to receive chemotherapy was less (22·9 km) than that needed for surgery (106·7 km).

Conclusion

After pancreatectomy for pancreatic adenocarcinoma at specialized hepatopancreatobiliary surgery centres, OS was not affected by the location of the centre delivering adjuvant chemotherapy. Receiving this treatment in a local centre reduced patients' travel burden.

Geographic variation in surgical practice patterns and outcomes for resected nonmetastatic gastric cancer in Ontario

Background

Gastrectomy with negative resection margins and adequate lymph node dissection is the cornerstone of curative treatment for gastric cancer (gc). However, gastrectomy is a complex and invasive operation with significant morbidity and mortality. Little is known about surgical practice patterns or short- and long-term outcomes in early-stage gc in Canada.

Methods

We undertook a population-based retrospective cohort study of patients with gc diagnosed between 1 April 2005 and 31 March 2008. Chart review provided clinical and operative details such as disease stage, primary tumour location, surgical approach, operation, lymph nodes, and resection margins. Administrative data provided patient demographics, geography, and vital status. Variations in treatment and outcomes were compared for 14 local health integration networks. Descriptive statistics and log-rank tests were used to examine geographic variation.

Results

We identified 722 patients with nonmetastatic resected gc. We documented significant provincial variation in case mix, including primary tumour location, stage at diagnosis, and tumour grade. Short-term surgical outcomes varied across the province. The percentage of patients with 15 or fewer lymph nodes removed and examined varied from 41.8% to 73.8% (p = 0.02), and the rate of positive surgical margins ranged from 15.2% to 50.0% (p = 0.002). The 30-day surgical mortality rates did not vary statistically significantly across the province (p = 0.13); however, rates ranged from 0% to 16.7%. Overall 5-year survival was 44% and ranged from 31% to 55% across the province.

Conclusions

This cohort of patients with resected stages i-iii gc is the largest analyzed in Canada, providing important historical information about treatment outcomes. Understanding the causes of regional variation will support interventions aiming to improve gc operative outcomes in the cancer system.

An Ecosystem for Comprehensive Cervical Cancer Prevention in India: Formative Study in India

Background: Despite being preventable, cervical cancer is the third most common cancer in India, accounting for the highest number of cancer deaths. India has made limited progress toward introducing the safe and effective vaccine to prevent human papilloma virus (HPV) infections, which has been available for a decade. Aim: Using qualitative research, we examined opportunities for comprehensive cervical cancer prevention, including HPV vaccination in two Indian states - Tamil Nadu (TN) and Karnataka (KA). Methods: We used a socio-ecological framework to identify and map key stakeholders and structures that create the ecosystem for comprehensive cervical cancer prevention. Data were collected through semistructured in-depth interviews and focus group discussions. Key stakeholders included women and men (30-45 years) residing in selected slums/villages, community influencers (village government, self-help group members), district and state-level government health and education officials, specialist doctors, frontline health workers, staff of cancer-related nongovernmental organizations, and journalists. Results: As neither state had initiated public provision of the HPV vaccine, discussions focused on stakeholders' knowledge about the vaccine and factors that could inform a policy decision and facilitate or pose barriers to roll-out. Government officials and specialists in both states were aware of HPV vaccination for primary prevention of cervical cancer. Officials in KA noted concerns about the vaccine's safety and efficacy more emphatically than officials in TN. Specialists, particularly those in leadership positions in the Federation of Obstetrics and Gynecology Societies of India and the Indian Academy of Pediatrics were strong advocates of vaccination. Several specialists contrasted the numerous implementation challenges of cervical cancer screening with India's successes in routine immunization. However, a few specialists also expressed concerns regarding safety of the HPV vaccine. Community members lacked awareness about the vaccine and raised concerns on its safety, side effects and benefits as they would have for any new vaccine. All stakeholders highlighted cost as a major barrier to public provision of the vaccine. Government officials were concerned about how a vaccine program could be financed and sustained. The consensus, particularly in TN, was that the HPV vaccine would need to be introduced through the Universal Immunization Program as a partnership between the health and education departments to ensure widespread access. Conclusion: State-level implementation of comprehensive cervical cancer prevention hinges on the inclusion of HPV vaccination in the national immunization program. Cultivating vaccine champions and identifying appropriate financing mechanisms to implement and sustain comprehensive cervical cancer prevention along with careful planning and implementation has the potential to save the lives of many women.

A Research Agenda for Cancer and Noncommunicable Disease Prevention and Control in India

Background: Noncommunicable diseases (NCDs), including cancer, account for approximately 38 million deaths each year, and almost 75% of these deaths occur in low and middle-income countries. NCDs contribute to 60% of total deaths in India, and of concern are the premature deaths, which account for a staggering 48% mortality and can be prevented. Aim: Establish a consensus research agenda for cancer and NCD prevention and control that has the potential to impact polices, programs and health care delivery. Methods: To develop a NCD research agenda for India, we engaged our community collaborative board (CCB), which included NCD-focused global, national- and state-level stakeholders, and our scientific advisory group (SAG), which included global and national NCD experts, in a three-step process using two Web-based surveys and one in-person meeting. First, we used Delphi methodology to generate topics. Eighteen stakeholders from both CCB and SAG responded to the first Web-based survey generating 165 research ideas during the first round. After accounting for clustering and duplication, we had 56 unique research ideas. Second, these ideas were deliberated upon during the in-person meeting where each participant with a set of 10 stickers placed them next to the research priority(ies) that they felt are important for prevention and control of cancer and NCDs in India. This generated 23 research ideas, which were subjected to SWOT analysis in pairs by the stakeholders using Snowcard methodology with SAG and CCB. The stakeholders prioritized the shortlisted topics based on level of effort and potential to impact NCDs in India. Finally, 15 low effort, high impact priority research ideas for various health outcomes across research disciplines were identified based on discussion with the larger group to reach consensus. The second Web-based survey resulted in identification of 5 key priority research ideas by all stakeholders as being the most important. Results: The 5 prioritized research ideas in order of importance are: (1) development of interventions to empower primary physicians and health workers in early diagnosis of NCDs; (2) evaluation of health system strengthening programs for NCD control; (3) feasibility of integrated care models at primary care level to address multimorbid chronic conditions; (4) development of India specific methods and tools for monitoring trends on NCD morbidity, mortality and risk factors; and (5) identification of effective strategies to mobilize individuals toward NCD screening activities. Conclusion: Development of a consensus research agenda for India is a critical gap needed to pursue resources required to address pressing needs in cancer and other NCDs. The rising mortality and morbidity resulting from cancer and NCDs with similar risk factors, warrants the timely implementation of this agenda. This will generate the evidence-base from which new policies and practices can be used to reduce cancer and other NCDs in India.

Topical antimicrobial prophylaxis in colorectal surgery for the prevention of surgical wound infection: a systematic review and meta-analysis

BACKGROUND

Among the techniques investigated to reduce the risk of surgical wound infection or surgical space infection (SSI) in patients having colorectal surgery are topical application of antimicrobials (antibiotics and antiseptics) to the open wound or immediately after closure. The aim of the present study was to perform a systematic review of the literature on those treatments, with the exception of antibiotic ointments applied to closed skin, which are adequately assessed elsewhere, and a meta-analysis.

METHODS

Only randomized trials of patients having only colorectal surgery were included in this review. Studies were sought in MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, Clinical Trials.gov, and the World Health Organization Internet clinical trials register portal. In addition, reference lists of included studies and other published reviews were screened. Meta-analysis was performed for all included studies and subgroup analyses done for each individual intervention. Risk of bias was assessed for each included study, paying particular attention to the preoperative antibiotic prophylaxis used in each study. Sensitivity analyses were done to investigate heterogeneity of the analyses, excluding those studies with a significant risk of bias issues. Absolute risk reduction (RR) was calculated. The overall quality of the evidence for each individual intervention was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, and was classified as high, moderate, low or very low.

RESULTS

A total of 30 studies are included in this review with 5511 patients, 665 of whom had SSI. The interventions included: 10 studies of gentamicin impregnated sponge or beads wound inlays, 4 studies of chlorhexidine impregnated suture, 11 studies of direct wound lavage or powder application or injection of antibiotics before closure, 4 studies of ionized silver dressing applied to the closed skin, and 1 study of vitamin E oil applied to the open wound. All but one study used preoperative antibiotic prophylaxis in addition to topical procedures, although, in some studies, the systemic antibiotic prophylaxis was not the same between groups or varied significantly from the recommended guidelines. Use of gentamycin sponge did not decrease SSI (RR 0.93, 95% CI 0.75-1.16; low-quality evidence) even after including only the studies of abdominal wounds (RR 1.02, 95% CI 0.80-1.30; low-quality evidence). However, sensitivity analysis excluding studies at high risk of bias decreased the heterogeneity and increased the effect of the prophylaxis for all wounds (RR 0.5, 95% CI 0.33-0.78; low-quality evidence) and for abdominal wounds only (RR 0.38, 95% CI 0.20-0.72; moderate-quality evidence). Chlorhexidine impregnated suture showed no effect on SSI (RR 0.79, 95% CI 0.56-1.10; low-quality evidence) and an increased efficacy after sensitivity analysis (RR 0.42, 95% CI 0.22-0.79; low-quality evidence). Antibiotic lavage showed a significant decrease in SSI (RR 0.45, 95% CI 0.26-0.79; low-quality evidence) which increased after sensitivity analysis (RR 0.33, 95% CI 0.15-0.72; moderate-quality evidence). Application of silver dressing to the closed wound resulted in a decrease of SSI (RR 0.55, 95% CI 0.35-0.85; moderate-quality evidence). The one study of topical vitamin E oil applied to the open wound showed a significant risk reduction (RR 0.22, 95% CI 0.05-0.98; low-quality evidence).

CONCLUSIONS

Each of these interventions appears to be effective in decreasing SSI, but the number of studies for each is small and the quality of evidence is very low to moderate. Within the various outcomes of GRADE assessment, even a moderate classification suggests that further studies may well have very different results.. No randomized trials exist of combinations of two or more of the above interventions to see if there is a combined effect. Future studies should make sure that the antibiotic used preoperatively is uniform within a study and is consistent with the current guidelines. Deviation from this leads to a significant heterogeneity and risk of bias.

Session 2: What causes liver metastases - lymph nodes or is it something else?

The traditional view of progression of disease in cancer is the sequential spread of tumour to locoregional lymph nodes and then to distant metastases. However, this view may need to be challenged and modern pathology techniques such as immunohistochemistry and tumour profiling can provide us with a greater insight into the pathways and mechanisms of distant spread. Professor Nagtegaal discusses the evidence for reconsidering the current paradigm and reflects on the need for further investigation into mechanisms of distant metastatic spread.

Session 2: Mutational discordance: the big challenge in personalized treatments - any solutions?

The great challenge for oncologists treating patients who are developing or progressing with metastatic disease is to be able to offer a truly personalized and targeted therapy that can have an early and meaningful effect on the course of the disease. At present the known molecular markers are limited in their frequency and reliability in determining the use of newer chemotherapies. Professor Eng discusses the challenges faced in ensuring timely and effective treatments based on the molecular profile of the tumour and the potential role of real-time analysis of mutational changes in the tumour when progression occurs.

Increased Perinatal Morbidity and Mortality Among Asian American and Pacific Islander Women in the United States

BACKGROUND

Asian American/Pacific Islanders (AAPIs) are the fastest-growing racial group in the United States. Despite a higher socioeconomic status, AAPI women experience higher rates of maternal morbidity and mortality.

METHODS

Using the National Inpatient Sample, we performed a retrospective cohort analysis of women who were hospitalized for delivery from 2002 to 2013. The primary outcome variable was inpatient mortality rate, and the presence of severe maternal morbidities was estimated using the Bateman Comorbidity Index, a validated tool for predicting obstetric morbidity.

RESULTS

AAPI women presenting for delivery between 2003 and 2012 were older, more likely to reside in a zip code in the top quartile of annual income, be privately insured than Caucasian women, and less likely to have a higher Bateman Comorbidity Index. However, AAPI women had a higher likelihood of postpartum hemorrhage (3.4% vs 2.7%, P < .001), uterine atony, severe perineal lacerations, and severe maternal morbidities. Procedures such as transfusion, hysterectomy, and mechanical ventilation were also more common in AAPI women. Furthermore, AAPI women had a higher mortality rate that persisted despite adjustment for an apparently higher income and comorbidities (odds ratio 1.72, 95% confidence interval: 1.14-2.59, P = .01).

CONCLUSIONS

Despite having a higher socioeconomic status, AAPI women had higher rates of maternal mortality during hospitalization for delivery. This increase persisted even after adjustment for factors known to affect peripartum outcomes. Further investigation is needed to better clarify the causes of racial differences in maternal morbidity and mortality.

Rapid-eye-movement sleep-predominant central sleep apnea relieved by positive airway pressure: a case report

Central Sleep Apnea (CSA) is characterized by intermittent apneas and hypopneas during sleep that result from absent central respiratory drive. CSA occurs almost exclusively during non‐rapid‐eye‐movement (NREM) sleep due to enhanced neuronal ventilatory drive during REM sleep that makes central apneas highly unlikely to form. A 45‐year‐old obese African American female presented with co‐existing Obstructive Sleep Apnea (OSA) and CSA, not in the form of mixed or complex sleep apnea. Peculiarly, her CSA occurred only during rapid‐eye‐movement (REM) sleep, which is exceedingly rare. The patient's CSA was resolved when appropriate positive airway pressure (PAP) was prescribed. Our patient remains stable and has reported significant benefit from PAP usage. We offer possible neuro‐physiological mechanisms herein, including enhanced loop gain and/or malfunction or malformation of the pre‐Botzinger nucleus or other neurological process, that could explain the unique findings of this case.

Assessment of serum apolipoprotein B and apolipoprotein A-1 and their ratio in healthy full term small for gestational age newborns

BACKGROUND

Programmed changes in growth restricted fetuses can increase the risk of adulthood diseases due to elevated serum cholesterol and apolipoprotein-B (Apo-B) concentrations. Increasing evidence demonstrated the role of apoB/apoA-I ratio as a strong risk factor for cardiovascular diseases.

OBJECTIVE

To determine the concentration of cord blood lipoproteins and apolipoproteins as well as their correlation with birth weight.

METHODS

This cross-sectional study was conducted in a teaching institution in central India. Healthy full-term newborns, born out of normal vaginal deliveries, were recruited. Cases include term small for gestational age (SGA) babies while term appropriate for gestational age (AGA) babies were taken as controls. Their umbilical venous blood was collected and sent for biochemical analysis.

RESULTS

Out of 126 healthy newborns, 66 were cases and 60 were controls. Mean values of serum triglyceride (141.56±69.67 mg/dl vs. 113.67±33.38 mg/dl; p < 0.006; 95% CI = 8.31 to 47.46) and serum apo-B/apo-A-1 ratio (0.67±0.28 vs. 0.55±0.20; p < 0.007; 95% CI = 0.033 to 0.206) were significantly high and that of serum high density cholesterol (35.84±10.42 mg/dl vs. 40.73±11.70 mg/dl; p < 0.014; 95% CI = -8.79 to -0.98) and Apo-A1 [87.59±12.44 mg/dl vs. 101.87±35.07 mg/dl; p = 0.002; 95% CI = -23.39 to -5.16) were significantly low in SGA newborns. Serum cholesterol, very low-density cholesterol rlow-density cholesterol rand Apo-B did not show any significant difference. Among SGA newborns significant negative correlation was seen between birth weight and apo-B/apo-A1 and serum triglyceride, while birth weight and serum apo-A1 level showed significant positive correlation. There was no statistically significant correlation between birth weight and other parameters.

CONCLUSION

These findings further support the association of prenatal factors with lipid profile rand can serve as starting point for studying lipid transport system changes during early life in Indian population.

Randomised clinical study: GR-MD-02, a galectin-3 inhibitor, vs. placebo in patients having non-alcoholic steatohepatitis with advanced fibrosis

BACKGROUND

Non-alcoholic steatohepatitis (NASH) and resultant liver fibrosis is a major health problem without approved pharmacotherapy. Pre-clinical results of GR-MD-02, a galectin-3 inhibitor, suggested potential efficacy in NASH with advanced fibrosis/cirrhosis and prompted initiation of a clinical development programme in NASH with advanced fibrosis.

AIM

To evaluate the safety, pharmacokinetics and exploratory pharmacodynamic markers of GR-MD-02 in subjects having NASH with bridging fibrosis.

METHODS

The GT-020 study was a first-in-human, sequential dose-ranging, placebo controlled, double-blinded study with the primary objective to assess the safety, tolerability and dose limiting toxicity of GR-MD-02, in subjects with biopsy-proven NASH with advanced fibrosis (Brunt stage 3). The secondary objectives were to characterise first-dose and multiple-dose pharmacokinetic profiles and to evaluate changes in potential serum biomarkers and liver stiffness as assessed by FibroScan.

RESULTS

GR-MD-02 single and three weekly repeated of 2, 4 and 8 mg/kg revealed no meaningful clinical differences in treatment emergent adverse events, vital signs, electrocardiographic findings or laboratory tests. Pharmokinetic parameters showed a dose-dependent relationship with evidence of drug accumulation following 8 mg/kg (~twofold).

CONCLUSIONS

GR-MD-02 doses were in the upper range of the targeted therapeutic dose determined from pre-clinical data and were safe and well tolerated with evidence of a pharmacodynamic effect. These results provide support for a Phase 2 development programme in advanced fibrosis due to NASH.

Current trends of seroprevalence of transfusion transmitted infections in Pakistani β-thalassaemic patients

BACKGROUND

Though regular blood transfusion improves the survival, it carries the unavoidable risk of transfusion transmitted infections (TTI) in β-thalassaemic patients. Owing to the lack of uniformity in blood screening practices in Pakistan, TTI is still a major challenge.

OBJECTIVES

To study the current trends of TTI in regularly transfused β-thalassaemics and their correlation with age, number of transfusions, hematological and biochemical markers.

METHODS

We carried out a prospective case-control study. 100 β-thalassemic patients and 200 healthy donors were recruited from June 2011 to June 2014. HCV antibodies, Hepatitis B surface antigen and human immunodeficiency virus antibodies (I & II) were evaluated. Complete blood counts, LFTs and serum ferritin were tested on all patients.

RESULTS

Mean age of patients and controls was 11.18±5.07 and 20.5±1.87 years respectively. In patients, 54% and 46% were males and females respectively. Anti-HCV antibody and HbsAg were positive in 27% versus 3% and 3% versus 2% in patients and controls respectively. None of the patients and controls was HIV reactive. Seropositivity of Anti-HCV was significantly higher in patients than that of controls (P<0.001). Anti-HCV positively correlated with age above 10 years, numbers of transfusions (≥150 units), high serum ferritin, elevated ALT and alkaline phosphatase (P<0.001).

CONCLUSIONS

Over the decade, TTI magnitude has significantly reduced, but hepatitis C is still a main hazard. Further preventive measures including nucleic acid testing, voluntary donation and stringent donor selection will be required for reducing TTI in β-thalassaemics.