Does engagement matter? The impact of patient and community engagement on implementation of cardiovascular health materials in primary care settings

BACKGROUND

Engaging patients and community members in healthcare implementation, research and evaluation has become more popular over the past two decades. Despite the growing interest in patient engagement, there is scant evidence of its impact and importance. Boot Camp Translation (BCT) is one evidence-based method of engaging communities in research. The purpose of this report is to describe the uptake by primary care practices of cardiovascular disease prevention materials produced through four different local community engagement efforts using BCT.

METHODS

EvidenceNOW Southwest (ENSW) was a randomized trial to increase cardiovascular disease (CVD) prevention in primary care practices. Because of its study design, Four BCTs were conducted, and the materials created were made available to participating practices in the "enhanced" study arm. As a result, ENSW offered one of the first opportunities to explore the impact of the BCT method by describing the uptake by primary care practices of health messages and materials created locally using the BCT process. Analysis compared uptake of locally translated BCT products vs. all other products among practices based on geography, type of practice, and local BCT.

RESULTS

Within the enhanced arm of the study that included BCT, 69 urban and 13 rural practices participated with 9 being federally qualified community health centers, 14 hospital owned and 59 clinician owned. Sixty-three practices had 5 or fewer clinicians. Two hundred and ten separate orders for materials were placed by 43 of the 82 practices. While practices ordered a wide variety of BCT products, they were more likely to order materials developed by their local BCT.

CONCLUSIONS

In this study, patients and community members generated common and unique messages and materials for cardiovascular disease prevention relevant to their regional and community culture. Primary care practices preferred the materials created in their region. The greater uptake of locally created materials over non-local materials supports the use of patient engagement methods such as BCT to increase the implementation and delivery of guideline-based care. Yes, patient and community engagement matters.

TRIAL REGISTRATION AND IRB

Trial registration was prospectively registered on July 31, 2015 at ClinicalTrials.gov (NCT02515578, protocol identifier 15-0403). The project was approved by the Colorado Multiple Institutional Review Board and the University of New Mexico Human Research Protections Office.

Direct current cardioversion in pregnancy: a multicentre study

OBJECTIVE

Direct current cardioversion (DCCV) in pregnancy is rarely required and typically only documented in single case reports or case series. A recent UK confidential enquiry reported on several maternal deaths where appropriate DCCV appeared to have been withheld.

DESIGN

Retrospective cohort study.

SETTING

Seventeen UK and Ireland specialist maternity centres.

SAMPLE

Twenty-seven pregnant women requiring DCCV in pregnancy.

MAIN OUTCOME MEASURES

Maternal and fetal outcomes following DCCV.

RESULTS

Twenty-seven women had a total of 29 DCCVs in pregnancy. Of these, 19 (70%) initial presentations were to Emergency Departments and eight (30%) to maternity settings. There were no maternal deaths. Seventeen of the women (63%) had a prior history of heart disease. Median gestation at DCCV was 28 weeks, median gestation at delivery was 35 weeks, with a live birth in all cases. The abnormal heart rhythms documented at the first cardioversion were atrial fibrillation in 12/27 (44%) cases, atrial flutter in 8/27 (30%), supraventricular tachycardia in 5/27 (19%) and atrial tachycardia in 2/27 (7%). Fetal monitoring was undertaken following DCCV on 14/29 (48%) occasions (10 of 19 (53%) at ≥26 weeks) and on 2/29 (7%) occasions, urgent delivery was required post DCCV.

CONCLUSIONS

Direct current cardioversion in pregnancy is rarely required but should be undertaken when clinically indicated according to standard algorithms to optimise maternal wellbeing. Once the woman is stable post DCCV, gestation-relevant fetal monitoring should be undertaken. Maternity units should develop multidisciplinary processes to ensure pregnant women receive the same standard of care as their non-pregnant counterparts.

Defining the safe corridor for transcondylar screw placement in the feline humeral condyle

OBJECTIVES

The aim of this study was to develop guidelines for the optimal location of drill entry and exit points for insertion of a transcondylar screw across the feline humeral condyle.

METHODS

Multiplanar reconstruction of feline elbow CT scans performed between 2016 and 2021 at one referral institution were reviewed. The optimum medial and lateral epicondylar entry and exit points for transcondylar screw placement were determined. These values were normalised to the humeral condylar diameter (HCD) for each elbow to determine the transcondylar screw placement guidelines. These guidelines were applied to each elbow and tolerance angles were determined in the transverse and frontal plane CT images to determine the safe corridor for screw placement.

RESULTS

Twenty elbows from 12 cats were evaluated in this study. The guidelines for transcondylar screw placement were as follows: the medial entry/exit point was 0.38 × HCD cranial and 0.16 × HCD distal to the medial epicondyle, and the lateral entry/exit point was 0.3 × HCD cranial and 0.16 × HCD distal to the lateral epicondyle. Tolerance angles were statistically significantly (P <0.05) larger in both frontal (34.5% larger) and transverse (21.1% larger) planes when drilled from a lateral to medial direction compared with drilling from a medial to lateral direction.

CONCLUSIONS AND RELEVANCE

The guidelines determined from this study may aid clinicians in the placement of humeral transcondylar screws in cats. Where possible, drilling from a lateral to medial direction is recommended owing to the higher tolerance angles reducing the likelihood of articular surface damage. Further studies are warranted to determine whether these guidelines are clinically useful and result in the safe insertion of a transcondylar screw in the clinical setting.

Quantitative analysis of tumour spheroid structure

Tumour spheroids are common in vitro experimental models of avascular tumour growth. Compared with traditional two-dimensional culture, tumour spheroids more closely mimic the avascular tumour microenvironment where spatial differences in nutrient availability strongly influence growth. We show that spheroids initiated using significantly different numbers of cells grow to similar limiting sizes, suggesting that avascular tumours have a limiting structure; in agreement with untested predictions of classical mathematical models of tumour spheroids. We develop a novel mathematical and statistical framework to study the structure of tumour spheroids seeded from cells transduced with fluorescent cell cycle indicators, enabling us to discriminate between arrested and cycling cells and identify an arrested region. Our analysis shows that transient spheroid structure is independent of initial spheroid size, and the limiting structure can be independent of seeding density. Standard experimental protocols compare spheroid size as a function of time; however, our analysis suggests that comparing spheroid structure as a function of overall size produces results that are relatively insensitive to variability in spheroid size. Our experimental observations are made using two melanoma cell lines, but our modelling framework applies across a wide range of spheroid culture conditions and cell lines.

Cholecystectomy in 23 cats (2005-2021)

OBJECTIVE

To describe the clinical presentation, treatments, and long-term outcomes following cholecystectomy in cats.

STUDY DESIGN

Clinical retrospective study.

ANIMALS

Twenty-three client-owned cats.

METHODS

Medical records of all cats undergoing cholecystectomy between 2005 and 2021 at a single referral hospital were retrospectively reviewed. No cats were excluded. An owner questionnaire assessed long-term outcomes.

RESULTS

Vomiting, jaundice, and abdominal pain were the most common clinical signs; median duration of signs was 4 days (range 1-21). Cholelithiasis was the major indication for cholecystectomy followed by cholecystitis. Intraoperative hypotension and postoperative anemia were commonly encountered. Nine cats required a postoperative blood product transfusion. Cardiopulmonary arrest and death occurred in five cats. Eighteen cats (78.3%) survived to discharge. Long-term follow up (>60 days) was available for 16 cats at a median of 1003 days (range 81-4995). Fifteen cats survived over 6 months with eight cats (44.4%) surviving over 3 years. The most common short-term and long-term postoperative complication was vomiting. Owners assessed postoperative outcome as excellent in all cats and quality of life as excellent or good.

CONCLUSION

The most common indication for cholecystectomy was cholelithiasis. Perioperative complications were commonly encountered. Perioperative mortality rate was 21.7%. Long-term owner evaluation of clinical outcome was considered excellent.

CLINICAL SIGNIFICANCE

Cats undergoing cholecystectomy for non-neoplastic causes can have a favorable prognosis for recovery and quality of life. Concurrent extrahepatic biliary duct obstruction is not a contraindication for cholecystectomy provided that patency of the common bile duct is restored.

Transversus abdominis muscle as a gastric or intestinal on-lay flap in two dogs and one cat

Historically, omentalisation and serosal patching have been used to augment gastrointestinal wall defects or incisions where gastrointestinal viability is of concern. This report describes the novel use of a transversus abdominis muscle on-lay flap to augment and provide support to compromised intestine in three cases. The muscle flap was used to support: the ileum following reduction of an intussusception in a dog (case 1), the gastric wall following gastric strangulation, dilation and volvulus in a diaphragmatic rupture in a cat (case 2) and the jejunum following enterotomy and full-thickness ulcer resection with primary repair in a dog (case 3). All animals were discharged within 4 days postoperatively with no short- or long-term complications reported by either the referring veterinary surgeons on routine postoperative examination or on telephone follow-up with the owners (case 1: 10 months, case 2: 30 months, case 3: 6 weeks). The creation of a flap of the transversus abdominis muscle may provide a useful alternative or adjunct to previously described techniques for supporting the gastrointestinal tract when gastrointestinal tissue viability is questionable or resection is not feasible. Further prospective clinical evaluation studies would be indicated to determine whether the muscle flap remains viable or compare whether this technique should be recommended over conventional methods.

Complications associated with bone marrow sampling in dogs and cats

OBJECTIVES

To evaluate the prevalence of complications during bone marrow sampling and associated patient and procedural factors in dogs and cats.

MATERIALS AND METHODS

Retrospective cohort study, records were evaluated to identify dogs and cats that had bone marrow sampling between 2012 and 2019. Data including signalment, the presence of specific clinicopathological findings, anatomical site of bone marrow sampling, number of attempts, diagnostic quality of sampling, analgesia protocol and complications postprocedure were recorded.

RESULTS

A total of 131 dogs and 29 cats were included in the study. Complications were recorded in 22 of 160 (14%) of cases. Pain was the most common complication of bone marrow sampling in 20 of 22 (91%) of cases with bruising reported in the remaining patients. A local anaesthetic block was used in 98 of 160 (61%) of patients.

CLINICAL SIGNIFICANCE

Excluding pain, complications associated with bone marrow sampling were rare and no clear association were detected between patient or procedural variables. Haemorrhage and infection are rare complications in dogs and cats when thrombocytopenia and neutropenia are present. Peri-procedure analgesia is strongly recommended to minimise complications.

Report of a case involving novel use of a post-operative esophagogastroduodenoscopy to re-evaluate a duodenal ulcer bleed

•

Acute duodenal ulcer bleeds can be life-threatening.

•

The best initial management is by endoscopy or Interventional Radiology.

•

Emergency surgical intervention is indicated if unable to control.

•

Post-surgical endoscopy in an OR setting was used to re-evaluate.

•

May be a viable option for post-surgical re-evaluation in the absence of IR.

Introduction

Acute gastrointestinal (GI) bleeding can be a life-threatening condition. This is usually diagnosed and managed by an upper GI tract endoscopy. When treating actively bleeding duodenal ulcers, surgical intervention, or arterial embolization by Interventional Radiology (IR) is warranted in the event of failed initial management. We present a patient with a significant GI bleed and failure of management through endoscopy, necessitating emergent surgical intervention.

Presentation of case

An 87-year-old female presented to the emergency department after a fall. Her hemoglobin level dropped significantly and an esophagogastroduodenoscopy (EGD) revealed a large pool of blood in the stomach but had a limited view of an active bleed. The patient was taken emergently to the operating room (OR) where she underwent an exploratory laparotomy, gastroduodenostomy, suture ligation, and pyloroplasty. The following day, she had increased sanguineous output from her nasogastric (NG) tube. Re-evaluation was done with an EGD in the OR. The patient tolerated all procedures well and was transferred to a facility with IR capabilities for further management.

Discussion

An EGD hours after gastroduodenostomy runs a high risk for perforation and is not the typical course of action. Given the lack of IR availability and concern for rebleeding, this procedure was performed in the OR to minimize risk.

Conclusion

A favorable outcome was achieved with this patient and hemostasis was confirmed with the post-operative EGD. Further studies will determine whether this approach is a viable option for facilities without IR until the patient can be transferred.

What Works for Managing Chronic Pain: An Appreciative Inquiry Qualitative Analysis

Background: Chronic pain is a prevalent and dynamic condition for both patients and providers. Learning how patients with chronic pain successfully manage their pain may prove helpful in guiding health care providers in their treatment of other patients with chronic pain. This research sought to identify successful strategies for managing chronic pain from interviews with individuals experiencing chronic pain who were able to do “most of what they want on most days.” Methods: Qualitative, descriptive study. Patients were from metro Denver, Colorado, USA and were recruited from community and health care settings. Appreciative inquiry (AI) was used as an approach to elicit stories of successful pain management. We conducted one-on-one, in person interviews using a semistructured interview guide. Analysis was completed using a grounded hermeneutic editing approach. Results: Twenty-four interviews were completed representing a range of adult ages, genders, race/ethnicities, and underlying reasons for chronic pain. Consistent themes were found in that all patients had developed multiple strategies for ongoing pain management and prevention, as well as a mental approach embedded with elements of positive beliefs and determination. Friends, family, support group members, and health care providers were key in support and ongoing management. Although 10 patients regularly used opioid pain medications, none were dependent, and all stated an active desire to avoid these medications. Conclusions: Successful chronic pain management seems possible as displayed from the patient narratives but requires persistence through individual trial and error. Recommendations for health care provider teams are made to apply these findings to assist patients with chronic pain.

Local anaesthetic resistance in a patient with Ehlers-Danlos syndrome undergoing caesarean section with continuous spinal anaesthesia

A patient with a diagnosis of Ehlers-Danlos syndrome was scheduled to undergo elective caesarean section with a combined spinal-epidural anaesthetic technique. The epidural attempt resulted in an inadvertent dural puncture, and we decided subsequently to place an intrathecal catheter. She required high repeated doses of hyperbaric bupivacaine (32.5 mg over 1 h) through the catheter to establish adequate sensory blockade, together with supplemental analgesic techniques. Soon after the procedure, she recovered motor function rapidly and required further supplemental analgesia. We believe this is the first report of possible local anaesthetic resistance with an intrathecal catheter anaesthetic technique for a patient with Ehlers-Danlos syndrome. If there is resistance to the first dose of intrathecal local anaesthetic, a general anaesthetic may be the best option for such patients.

0636 Using AI To Predict Future CPAP Adherence and the Impact of Behavioral and Technical Interventions

Introduction

Clinical management of CPAP adherence remains an ongoing challenge. Behavioral and technical interventions such as patient outreach, coaching, troubleshooting, and resupply may be deployed to positively impact adherence. Previous authors have described adherence phenotypes that retrospectively categorize patients by discrete usage patterns. We design an AI model that predictively categorizes patients into previously studied adherence phenotypes and analyzes the statistical significance and effect size of several types of interventions on subsequent CPAP adherence.

Methods

We collected a cross-sectional cohort of subjects (N = 13,917) with 455 days of daily CPAP usage data acquired. Patient outreach notes and resupply data were temporally synchronized with daily CPAP usage. Each 30-days of usage was categorized into one of four adherence phenotypes as defined by Aloia et al. (2008) including Good Users, Variable Users, Occasional Attempters, and Non-Users. Cross-validation was used to train and evaluate a Recurrent Neural Network model for predicting future adherence phenotypes based on the dynamics of prior usage patterns. Two-sided 95% bootstrap confidence intervals and Cohen’s d statistic were used to analyze the significance and effect size of changes in usage behavior 30-days before and after administration of several resupply interventions.

Results

The AI model predicted the next 30-day adherence phenotype with an average of 90% sensitivity, 96% specificity, 95% accuracy, and 0.83 Cohen’s Kappa. The AI model predicted the number of days of CPAP non-use, use under 4-hours, and use over 4-hours for the next 30-days with OLS Regression R-squared values of 0.94, 0.88, and 0.95 compared to ground truth. Ten resupply interventions were associated with statistically significant increases in adherence, and ranked by adherence effect size using Cohen’s d. The most impactful were new cushions or masks, with a mean post-intervention CPAP adherence increase of 7-14% observed in Variable User, Occasional Attempter, and Non-User groups.

Conclusion

The AI model applied past CPAP usage data to predict future adherence phenotypes and usage with high sensitivity and specificity. We identified resupply interventions that were associated with significant increases in adherence for struggling patients. This work demonstrates a novel application for AI to aid clinicians in maintaining CPAP adherence.

Support

 

Genome editing in wheat microspores and haploid embryos mediated by delivery of ZFN proteins and cell-penetrating peptide complexes

Recent advances in genome engineering technologies based on designed endonucleases (DE) allow specific and predictable alterations in plant genomes to generate value-added traits in crops of choice. The EXZACT Precision technology, based on zinc finger nucleases (ZFN), has been successfully used in the past for introduction of precise mutations and transgenes to generate novel and desired phenotypes in several crop species. Current methods for delivering ZFNs into plant cells are based on traditional genetic transformation methods that result in stable integration of the nuclease in the genome. Here, we describe for the first time, an alternative ZFN delivery method where plant cells are transfected with ZFN protein that eliminates the need for stable nuclease genomic integration and allows generation of edited, but not transgenic cells or tissues. For this study, we designed ZFNs targeting the wheat IPK1 locus, purified active ZFN protein from bacterial cultures, complexed with cell-penetrating peptides (CPP) and directly transfected the complex into either wheat microspores or embryos. NGS analysis of ZFN-treated material showed targeted edits at the IPK1 locus in independent experiments. This is the first description of plant microspore genome editing by a ZFN when delivered as a protein complexed with CPP.

Engaging Communities in Preventing Human Papillomavirus-Related Cancers: Two Boot Camp Translations, Colorado, 2017-2018

Since 2006, a vaccine to prevent human papillomavirus (HPV) infection has been available; however, uptake is suboptimal. To encourage HPV vaccine uptake, we employed Boot Camp Translation (BCT) to develop locally relevant materials in 2 Colorado communities, Mesa County and the Denver metropolitan area (Denver metro). The Mesa County group focused on 2 populations, parents of vaccine-eligible children and young adults. The group identified posters, social media, and educational materials for pediatric primary care settings as venues to deliver their messages. The Denver metro group focused on parents of children with low health literacy. Four messages explain the vaccine and call the selected audience to action. Delivery tactics for that group are social media venues and print education materials, including refrigerator magnets, to remind parents about follow-up dosing. BCT can be adapted to develop locally relevant messages and intervention strategies to address HPV vaccination. Future studies should evaluate the effectiveness of community-derived messages to increase HPV vaccination rates.

qEEG Measures of Attentional and Memory Network Functions in Medical Students: Novel Targets for Pharmacopuncture to Improve Cognition and Academic Performance

Objectives

Attentional and memory functions are important aspects of neural plasticity that, theoretically, should be amenable to pharmacopuncture treatments. A previous study from our laboratory suggested that quantitative electroencephalographic (qEEG) measurements of theta/beta ratio (TBR), an index of attentional control, may be indicative of academic performance in a first-semester medical school course. The present study expands our prior report by extracting and analyzing data on frontal theta and beta asymmetries. We test the hypothesis that the amount of frontal theta and beta asymmetries (fTA, fBA), are correlated with TBR and academic performance, thereby providing novel targets for pharmacopuncture treatments to improve cognitive performance.

Methods

Ten healthy male volunteers were subjected to 5–10 min of qEEG measurements under eyes-closed conditions. The qEEG measurements were performed 3 days before each of first two block examinations in anatomy-physiology, separated by five weeks. Amplitudes of the theta and beta waveforms, expressed in μV, were used to compute TBR, fTA and fBA. Significance of changes in theta and beta EEG wave amplitude was assessed by ANOVA with post-hoc t-testing. Correlations between TBR, fTA, fBA and the raw examination scores were evaluated by Pearson’s product-moment coefficients and linear regression analysis.

Results

fTA and fBA were found to be negatively correlated with TBR (P<0.03, P<0.05, respectively) and were positively correlated with the second examination score (P<0.03, P=0.1, respectively).

Conclusion

Smaller fTA and fBA were associated with lower academic performance in the second of two first-semester medical school anatomy-physiology block examination. Future studies should determine whether these qEEG metrics are useful for monitoring changes associated with the brain’s cognitive adaptations to academic challenges, for predicting academic performance and for targeting phamacopuncture treatments to improve cognitive performance.

Community-Designed Messaging Interventions to Improve Cost-of-Care Conversations in Settings Serving Low-Income, Latino Populations

BACKGROUND

Little is known about how to promote cost-of-care conversations in health care settings.

OBJECTIVE

To develop and evaluate community-designed messages promoting cost-of-care conversations.

DESIGN

Focus groups and point-of-care surveys.

SETTING

Three pediatric clinics, a family community health clinic, and a community health worker (promotora) program serving predominately low-income, Latino populations in Adams County, Colorado.

PARTICIPANTS

Focus groups included staff (n = 22) and patients or community members (n = 15). At baseline, 107 patients and 9 providers completed surveys, and 111 patients and 11 providers did so postintervention.

INTERVENTION

Setting-specific, community-designed messages about cost-of-care conversations delivered to patients on fliers.

MEASUREMENTS

Qualitative themes about the frequency and nature of cost-of-care conversations, and frequencies of patient- and provider-reported cost-of-care conversations before and after the intervention.

RESULTS

Five themes emerged from the focus groups, and the groups reported more discussion of costs after distribution of the messaging interventions than before in the clinical but not the community setting. Lack of transparent pricing tools was a barrier, and consideration of incidental costs was important. In cross-sectional, point-of-care surveys, fewer patients reported talking about costs with providers at baseline (44.4%) than after the messaging intervention (73.7%). Providers reported similar frequency of talking about costs with patients before (41.0%) and after (44.9%) the intervention. Nearly one third of patient and provider reports were discordant regarding whether costs were discussed.

LIMITATIONS

The response rate was low, cost-of-care conversations were self-reported, generalizability of the findings to other settings is uncertain, and the sample was small. The survey proved infeasible in the promotora setting.

CONCLUSION

Participants reported some favorable perceptions of cost-of-care conversations after implementation of community-designed messages, suggesting promise for this approach to promoting conversations about costs of care in settings serving low-income, uninsured Latino populations.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation.

Maternal and fetal outcomes in pregnancies complicated by the inherited aortopathy Loeys-Dietz syndrome

OBJECTIVE

Pregnancies in women with Loeys-Dietz syndrome (LDS) are rare and are typically documented in case reports only. Early reports suggested high rates of maternal complications during pregnancy and the puerperium, including aortic dissection and uterine rupture, but information on fetal outcomes was very limited.

DESIGN

A retrospective cohort study.

SETTING

Eight specialist UK centres.

SAMPLE

Pregnant women with LDS.

METHODS

Data was collated on cardiac, obstetric, and neonatal outcomes.

MAIN OUTCOME MEASURES

Maternal and perinatal outcomes in pregnancies complicated by LDS.

RESULTS

Twenty pregnancies in 13 women with LDS were identified. There was one miscarriage, one termination of pregnancy, and 18 livebirths. In eight women the diagnosis was known prior to pregnancy but only one woman had preconception counselling. In four women the diagnosis was made during pregnancy through positive genotyping, and the other was diagnosed following delivery. Five women had a family history of aortic dissection. There were no aortic dissections in our cohort during pregnancy or postpartum. Obstetric complications were common, including postpartum haemorrhage (33%) and preterm delivery (50%). In all, 14/18 (78%) of deliveries were by elective caesarean section, at a median gestational age at delivery of 37 weeks. Over half the infants (56%) were admitted to the neonatal unit following delivery.

CONCLUSION

Women with LDS require multidisciplinary specialist management throughout pregnancy. Women should be referred for preconception counselling to make informed decisions around pregnancy risk and outcomes. Early elective preterm delivery needs to be balanced against a high infant admission rate to the neonatal unit.

TWEETABLE ABSTRACT

Pregnancy outcomes in women with Loeys-Dietz syndrome.

Zinc finger nuclease-mediated targeting of multiple transgenes to an endogenous soybean genomic locus via non-homologous end joining

Emerging genome editing technologies hold great promise for the improvement of agricultural crops. Several related genome editing methods currently in development utilize engineered, sequence-specific endonucleases to generate DNA double strand breaks (DSBs) at user-specified genomic loci. These DSBs subsequently result in small insertions/deletions (indels), base substitutions or incorporation of exogenous donor sequences at the target site, depending on the application. Targeted mutagenesis in soybean (Glycine max) via non-homologous end joining (NHEJ)-mediated repair of such DSBs has been previously demonstrated with multiple nucleases, as has homology-directed repair (HDR)-mediated integration of a single transgene into target endogenous soybean loci using CRISPR/Cas9. Here we report targeted integration of multiple transgenes into a single soybean locus using a zinc finger nuclease (ZFN). First, we demonstrate targeted integration of biolistically delivered DNA via either HDR or NHEJ to the FATTY ACID DESATURASE 2-1a (FAD2-1a) locus of embryogenic cells in tissue culture. We then describe ZFN- and NHEJ-mediated, targeted integration of two different multigene donors to the FAD2-1a locus of immature embryos. The largest donor delivered was 16.2 kb, carried four transgenes, and was successfully transmitted to T1 progeny of mature targeted plants obtained via somatic embryogenesis. The insertions in most plants with a targeted, 7.1 kb, NHEJ-integrated donor were perfect or near-perfect, demonstrating that NHEJ is a viable alternative to HDR for gene targeting in soybean. Taken together, these results show that ZFNs can be used to generate fertile transgenic soybean plants with NHEJ-mediated targeted insertions of multigene donors at an endogenous genomic locus.

PURL: Do probiotics reduce C diff risk in hospitalized patients?

A systematic review and meta-analysis says, "Yes," but that doesn't necessarily mean they will start appearing on hospital formularies.

Abstract 4253: Anal cancer survivorship: Clinical and nonclinical factors

Purpose: An estimated 8,200 cases of anal cancer will be diagnosed in 2017, accounting for nearly 1,100 deaths. Though anal cancer is a relatively rare malignancy, its increasing incidence has coincided with the increase in prevalence of risky sexual practices associated with anal human papillomavirus (HPV) infection, especially among men. At least 9 in 10 anal cancers are associated with HPV. Due to the rarity of anal cancer, little is known about factors affecting survivorship of anal cancer patients. The aim of this study was to evaluate clinical and nonclinical factors associated with anal squamous cell carcinoma (ASCC) survival in the United States.

Methods: A retrospective cohort study of patients aged ≥18 years with ASCC in the National Cancer Institute Surveillance, Epidemiology, and End Results registry (2004-2014) was analyzed. ASCC (site codes C21.0-C21.9 and C20.9), were coded for invasive squamous cell carcinomas per the International Classification of Diseases for Oncology, third edition. The outcome was survival (alive or dead) and the exposures were clinical (stage of presentation and treatment modality), and nonclinical (marital status, age, sex, race/ethnicity). Fine and Gray proportional hazards regression model were used to assess differences in survival among sociodemographic and clinical factors.

Results: There were 13,142 patients diagnosed with ASCC between 2004 and 2014. Mortality rate during the study period was 34.9% and median survival time was 113 months. In the adjusted model, a one-year increase in age was associated with 2% increased risk of death (adjusted hazard ratio (aHR) =1.02; 95% confidence interval (CI): 1.02-1.03). Compared with female patients, male patients (aHR=1.54; 95% CI: 1.40-1.70) had higher hazard of death, as did patients who were non-Hispanic black (aHR=1.40; 95% CI: 1.23-1.60) or non-Hispanic other (aHR=1.34; 95% CI: 1.09-1.65) versus non-Hispanic white. Patients who were never married (aHR=1.29; 95% CI: 1.15-1.44) or widowed (aHR=1.37; 95% CI: 1.18-1.59) had higher hazard of death compared to married patients. Patients had higher hazard of death if they were had stage II (aHR=2.01; 95% CI: 1.62-2.49), stage III (aHR=4.58; 95% CI: 3.70-5.67) or stage IV cancer (aHR=13.43; 95% CI: 10.74-16.78); and had not received surgery (aHR=1.41; 95% CI: 1.26-1.57).

Conclusion: Besides the clinical factors known to impact survival, including stage and treatment modality, several nonclinical factors are associated with the survival of anal cancer in the United States: age, sex, race/ethnicity, and marital status. It is important that interventions considering these factors are developed to improve survivorship, especially among the unmarried, males, and minority patients.

Citation Format: Eric Adjei Boakye, Matthew Simpson, Rebecca Rohde, Lauren Anderson, Betelihem B. Tobo, Thomas E. Burroughs, Nosayaba Osazuwa-Peters. Anal cancer survivorship: Clinical and nonclinical factors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4253.

Safety and dose-dependency of eptacog beta (activated) in a dose escalation study of non-bleeding congenital haemophilia A or B patients, with or without inhibitors

INTRODUCTION

Varying initial doses of activated eptacog beta (recombinant human FVIIa, rhFVIIa) may provide therapeutic options when treating bleeding in patients with congenital haemophilia who have developed inhibitory antibodies to factor VIII (FVIII) or factor IX (FIX). This study evaluated escalated doses of a new rhFVIIa product as a prelude to selecting the doses for clinical efficacy evaluation in haemophilia patients.

AIM

To assess the safety, pharmacokinetics, and laboratory pharmacodynamics of 3 doses of rhFVIIa in non-bleeding patients with congenital haemophilia A or B with or without inhibitors.

METHODS

Adult male patients (18-75 years old) with congenital haemophilia A or B (with or without inhibitors) received infusions of rhFVIIa at doses of 25, 75 or 225 μg/kg body weight. Ten patients were treated at each dose level, and each patient received 2 different dose levels. Descriptive methods were used to analyse the data.

RESULTS

Administration of rhFVIIa at all doses was well tolerated. Pharmacokinetic analyses showed that peak FVIIa plasma levels (C_max ) were approximately proportional to dose and correlated well with peak thrombin generation. Total AUC_0-inf also was approximately dose proportional. Clot formation and duration correlated with FVIIa activity. Repeat doses did not produce an immunological response.

CONCLUSION

In the first dose-escalation study of rhFVIIa to support product registration, eptacog beta at doses of 25, 75, and 225 μg/kg was pharmacodynamically active and well tolerated in non-bleeding patients with congenital haemophilia A or B.

Sociodemographic factors associated with developing head and neck and esophageal cancers following breast cancer

e13063

Background: Breast cancer survivors may develop other primary malignancies due to several factors. However, sociodemographic factors associated with the development of head and neck (HN) and esophageal second primary malignancies (SPMs) following management of primary breast cancer (BC) have not been well studied. This study examined the association between BC patients’ sociodemographic characteristics and the development of an esophageal or HN SPM. Methods: Patients ( n= 505,641) diagnosed with breast cancer between 1973 and 2013 in the Surveillance, Epidemiology, and End Results (SEER) 9 program were used for this analysis. HN SPMs included oral cavity, pharynx, larynx, and sinuses. Cox proportional hazards regression was used to evaluate estimators of survival based on age at diagnosis, race, marital status, treatment type, and year of diagnosis. Results: A total of 284 BC patients developed an esophageal SPM, and 969 developed HN SPM. In the adjusted model, increased age at BC diagnosis was a significant predictor for developing both HN and esophageal SPMs. For every 1-year increase in age at diagnosis, the hazard of developing an esophageal SPM increased (HR: 1.05; 95% CI: 1.04-1.06) and HN SPM increased (HR: 1.02; 95% CI: 1.02 -1.03). Hispanic women had a decreased hazard (HR: 0.63; 95% CI: 0.47-0.85) of developing HN SPM compared to non-Hispanic White women, however there was no significant difference for esophageal SPM. Women that were married had a decreased hazard (HR: 0.70; 95% CI: 0.55-0.90) of developing esophageal SPM compared to unmarried women. Conclusions: Sociodemographic factors may be important in the development of SPMs after treatment for breast cancer. While older women with BC were more likely to develop SPMs of the HN and esophagus, Hispanic breast cancer survivors and married women were less likely to develop SPMs of the HN and esophagus. To optimize survival benefits in the breast cancer population, there is need to further explore these sociodemographic factors associated with developing SPMs.

Incidence of esophageal and head and neck cancers among breast cancer survivors in the United States

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Background: Late sequelae of breast cancer therapies potentially impact morbidity and mortality with increasing numbers of survivors. Radiation exposure has been linked to increased incidence of second primary cancers (SPC). However, to date, there is limited literature describing incidence of head and neck (HN) and esophageal cancers in patients with an index breast cancer (BC). This study aimed to describe the incidence of esophageal and HN cancers following breast cancer diagnosis. Methods: Standardized incidence ratios (SIRs) were calculated using the Surveillance, Epidemiology, and End Results (SEER) 9 database for BC patients diagnosed from 1973-2013. SIRs compared incidence of HN and esophageal cancer after an initial BC diagnosis to the general population. HN included oral cavity, pharynx, and larynx. BC patients were grouped into those who received radiotherapy for their breast cancer (n = 216,045) and those who did not (n = 289,596). SIRs were calculated in 5-year intervals. SEER does not contain information on chemotherapy. Results: Less than 1% of BC patients developed HN (0.3%) or esophageal cancers (0.1%), irrespective of radiation treatment. However, among patients with an index BC who received radiation therapy, there was significant but small increased incidence of HN and esophageal cancers five to nine years following treatment (HN SIR: 1.22; 95% CI, 1.04-1.43 and esophagus SIR: 1.44; 95% CI, 1.09-1.87). Esophageal cancer incidence continued to increase through 15 years of follow-up, however incidence of HN was not significant beyond ten years after the index BC diagnosis and radiation treatment. Conclusions: Compared to the general population, breast cancer patients have elevated incidence of HN and esophageal cancers detected five to nine years after receiving radiation treatment, but only the incidence of second primary esophageal cancer remains elevated at 15 years. These findings warrant further investigations of breast cancer radiation and future malignancies.

Comparative pharmacokinetics of rVIII-SingleChain and octocog alfa (Advate(®) ) in patients with severe haemophilia A

BACKGROUND

rVIII-SingleChain, a novel recombinant factor VIII (rFVIII), has been designed as a B-domain truncated construct with covalently bonded heavy and light chains, aiming to increase binding affinity to von Willebrand factor (VWF). Preclinical studies confirmed greater affinity for VWF, giving improved pharmacokinetic and pharmacodynamic properties compared with full-length rFVIII.

AIM

To investigate the pharmacokinetics of rVIII-SingleChain and compare them against those of full-length rFVIII.

METHODS

This study enrolled 27 patients with severe haemophilia A in the AFFINITY clinical trial programme. After a 4-day washout period, all patients received a single infusion of 50 IU kg(-1) octocog alfa (Advate(®) ); after a ≥4-day postinfusion washout period, they received a single infusion of 50 IU kg(-1) rVIII-SingleChain. Blood samples for pharmacokinetic assessments of each product were collected before infusion (predose) and at 0.5, 1, 4, 8, 10, 24, 32, 48 and 72 h postinfusion for both products.

RESULTS

rVIII-SingleChain had a longer mean half-life (t1/2 ) (14.5 vs. 13.3 h), lower mean clearance (CL) (2.64 vs. 3.68 mL h(-1) kg(-1) ), higher mean residence time (20.4 vs. 17.1 h) and larger mean AUCinf (2090 vs. 1550 IU?h dL(-1) ) than octocog alfa, respectively. The mean AUCinf after rVIII-SingleChain infusion was ~35% larger than after octocog alfa. A similar pattern was observed for AUC0-last . No serious adverse events or inhibitors were reported.

CONCLUSIONS

rVIII-SingleChain has a favourable pharmacokinetic profile compared with octocog alfa and was well tolerated. The prolonged t1/2 , larger AUC and reduced CL of rVIII-SingleChain may permit longer dosing intervals, thereby improving patient adherence to prophylactic treatment.

Prophylactic antibiotics after acute stroke for reducing pneumonia in patients with dysphagia (STROKE-INF): a prospective, cluster-randomised, open-label, masked endpoint, controlled clinical trial

BACKGROUND

Post-stroke pneumonia is associated with increased mortality and poor functional outcomes. This study assessed the effectiveness of antibiotic prophylaxis for reducing pneumonia in patients with dysphagia after acute stroke.

METHODS

We did a prospective, multicentre, cluster-randomised, open-label controlled trial with masked endpoint assessment of patients older than 18 years with dysphagia after new stroke recruited from 48 stroke units in the UK, accredited and included in the UK National Stroke Audit. We excluded patients with contraindications to antibiotics, pre-existing dysphagia, or known infections, or who were not expected to survive beyond 14 days. We randomly assigned the units (1:1) by computer to give either prophylactic antibiotics for 7 days plus standard stroke unit care or standard stroke unit care only to patients clustered in the units within 48 h of stroke onset. We did the randomisation with minimisation to stratify for number of admissions and access to specialist care. Patient and staff who did the assessments and analyses were masked to stroke unit allocation. The primary outcome was post-stroke pneumonia in the first 14 days, assessed with both a criteria-based, hierarchical algorithm and by physician diagnosis in the intention-to-treat population. Safety was also analysed by intention to treat. This trial is closed to new participants and is registered with isrctn.com, number ISRCTN37118456.

FINDINGS

Between April 21, 2008, and May 17, 2014, we randomly assigned 48 stroke units (and 1224 patients clustered within the units) to the two treatment groups: 24 to antibiotics and 24 to standard care alone (control). 11 units and seven patients withdrew after randomisation before 14 days, leaving 1217 patients in 37 units for the intention-to-treat analysis (615 patients in the antibiotics group, 602 in control). Prophylactic antibiotics did not affect the incidence of algorithm-defined post-stroke pneumonia (71 [13%] of 564 patients in antibiotics group vs 52 [10%] of 524 in control group; marginal adjusted odds ratio [OR] 1·21 [95% CI 0·71-2·08], p=0·489, intraclass correlation coefficient [ICC] 0·06 [95% CI 0·02-0·17]. Algorithm-defined post-stroke pneumonia could not be established in 129 (10%) patients because of missing data. Additionally, we noted no differences in physician-diagnosed post-stroke pneumonia between groups (101 [16%] of 615 patients vs 91 [15%] of 602, adjusted OR 1·01 [95% CI 0·61-1·68], p=0·957, ICC 0·08 [95% CI 0·03-0·21]). The most common adverse events were infections unrelated to post-stroke pneumonia (mainly urinary tract infections), which were less frequent in the antibiotics group (22 [4%] of 615 vs 45 [7%] of 602; OR 0·55 [0·32-0·92], p=0·02). Diarrhoea positive for Clostridium difficile occurred in two patients (<1%) in the antibiotics group and four (<1%) in the control group, and meticillin-resistant Staphylococcus aureus colonisation occurred in 11 patients (2%) in the antibiotics group and 14 (2%) in the control group.

INTERPRETATION

Antibiotic prophylaxis cannot be recommended for prevention of post-stroke pneumonia in patients with dysphagia after stroke managed in stroke units.

FUNDING

UK National Institute for Health Research.

Anaesthetic and pharmacological techniques to decrease blood loss in liver surgery: a systematic review

BACKGROUND

There is increasing evidence that perioperative blood loss and blood transfusions are associated with poorer short- and long-term outcomes in patients undergoing hepatectomy. The aim of this study was to systematically review the literature for non-surgical measures to decrease intraoperative blood loss during liver surgery.

METHODS

The literature search was performed using PubMed, Embase, Cochrane Library, CINAHL and Google Scholar databases. The primary outcome measures were perioperative blood loss and transfusion requirements. A secondary outcome measure was development of ischaemia-reperfusion injury.

RESULTS

Seventeen studies met the inclusion criteria and included 1573 patients. All were randomized controlled studies. In eight studies (n = 894), pharmacological methods, and in another nine studies (n = 679), anaesthetic methods to decrease blood loss were investigated. Anti-fibrinolytic drugs, acute normovolaemic haemodilution, autologous blood donation and use of inhalational anaesthetic agent may affect blood loss and post-operative hepatic function.

CONCLUSIONS

There is potential for use of non-surgical techniques to decrease perioperative bleeding. However, on the basis of this review alone, due to heterogeneity of randomized trials conducted, no particular strategy can be recommended. Future studies should be conducted looking at pathways to decrease bleeding in liver surgery.