Cancer Type and Histology Influence Cutaneous Immunotherapy Toxicities: A Multi-Institutional Cohort Study

BACKGROUND

Cutaneous immune-related adverse events (cirAEs) are the most common toxicities to occur in the setting of immune checkpoint inhibitor (ICI) therapy. Identifying patients who are at increased risk of developing cirAEs may improve quality of life and outcomes.

OBJECTIVE

To investigate the influence of cancer type and histology on the development of cirAEs in the setting of ICI therapy and survival outcomes.

METHODS

This retrospective cohort study included patients between December 1, 2011, and October 30, 2020. They received ICIs from 2011-2020 with follow-up of outcomes through October 2021. We identified 3,668 ICI recipients who were seen at Mass General Brigham and Dana-Farber. Of these, 669 developed cirAEs. Records that were incomplete or categories of insufficient sample size were excluded from the study cohort. Multivariate Cox proportional hazards models were utilized to investigate the impact of cancer organ system and histology on cirAE development, after adjusting for demographics, Charlson Comorbidity Index, ICI type, cancer stage at ICI initiation, and year of ICI initiation. Time-varying Cox proportional hazards modeling was utilized to examine the impact of cirAE development on mortality.

RESULTS

Compared to other non-epithelial cancers (neuroendocrine, leukemia, lymphoma, myeloma, sarcoma, and central nervous system malignancies), cutaneous squamous cell carcinoma (cSCC) (HR = 3.57, p < 0.001), melanoma (HR = 2.09, p < 0.001), head and neck adenocarcinoma (HR = 2.13, p = 0.009), genitourinary transitional cell carcinoma (HR = 2.15, p < 0.001), and genitourinary adenocarcinoma (HR = 1.53, p = 0.037) were at significantly higher risk of cirAEs in multivariate analyses. The increased risk of cirAEs translated into an adjusted survival benefit for melanoma (HR = 0.37, p < 0.001) and cSCC (HR = 0.51, p = 0.011).

CONCLUSIONS

The highest rate of cirAEs and subsequent survival benefits were observed in cutaneous malignancies treated with ICIs. This study improves our understanding of patients who are at highest risk of developing cirAEs and would, therefore, benefit from appropriate counseling and closer monitoring by their oncologists and dermatologists throughout their ICI therapy. Limitations include its retrospective nature and cohort from one geography.

Compartmentalized ciliation changes of oligodendrocytes in aged mouse optic nerve

Primary cilia are microtubule-based sensory organelles that project from the apical surface of most mammalian cells, including oligodendrocytes, which are myelinating cells of the central nervous system (CNS) that support critical axonal function. Dysfunction of CNS glia is associated with aging-related white matter diseases and neurodegeneration, and ciliopathies are known to affect CNS white matter. To investigate age-related changes in ciliary profile, we examined ciliary length and frequency in the retinogeniculate pathway, a white matter tract commonly affected by diseases of aging but in which expression of cilia has not been characterized. We found expression of Arl13b, a marker of primary cilia, in a small group of Olig2-positive oligodendrocytes in the optic nerve, optic chiasm, and optic tract in young and aged C57BL/6 wild-type mice. While the ciliary length and ciliated oligodendrocyte cells were constant in young mice in the retinogeniculate pathway, there was a significant increase in ciliary length in the anterior optic nerve as compared to the aged animals. Morphometric analysis confirmed a specific increase in the ciliation rate of CC1+ /Olig2+ oligodendrocytes in aged mice compared with young mice. Thus, the prevalence of primary cilia in oligodendrocytes in the visual pathway and the age-related changes in ciliation suggest that they may play important roles in white matter and age-associated optic neuropathies.

Crosstalk between the mTOR pathway and primary cilia in human diseases

Autophagy is a fundamental catabolic process whereby excessive or damaged cytoplasmic components are degraded through lysosomes to maintain cellular homeostasis. Studies of mTOR signaling have revealed that mTOR controls biomass generation and metabolism by modulating key cellular processes, including protein synthesis and autophagy. Primary cilia, the assembly of which depends on kinesin molecular motors, serve as sensory organelles and signaling platforms. Given these pathways' central role in maintaining cellular and physiological homeostasis, a connection between mTOR and primary cilia signaling is starting to emerge in a variety of diseases. In this review, we highlight recent advances in our understanding of the complex crosstalk between the mTOR pathway and cilia and discuss its function in the context of related diseases.

Harnessing the Near-Peer Effect in Anatomy Education

Benefits of near-peer teaching are well-documented, but its time requirements can be prohibitive. We integrated the near-peer effect into a clinical anatomy course with weekly student-developed handouts vetted by faculty to provide an element of near-peer teaching without the burden of extra time.

Reducing Patient Care Delays in Radiation Oncology via Optimization of Insurance Pre-Authorization

PURPOSE/OBJECTIVE(S)

Difficulties and delays in insurance pre-authorization (pre-auth) can negatively impact patient care, resulting in postponing, modifying, or even cancelling radiation therapy for patients. Unfortunately, pre-auth delays are not uncommon. The purpose of our project was to perform a root cause analysis of reasons for pre-auth delays, and implement solutions to optimize our workflow to better serve our patients. Our primary objectives were to decrease the mean time for clinical treatment plan (CTP) completion, and for number of cases delayed/denied, by 50% each.

MATERIALS/METHODS

We performed a root cause analysis of reasons for pre-auth delays and used the PDSA & A3 quality improvement methods. We sampled ∼2 cases per disease site (total 19 cases from July - Aug 2022) to determine the "current state," pre-interventions. Countermeasures included: 1) customizing our CTP templates for each disease site to contain the specific clinical information required by each insurer, 2) formalizing earlier completion of CTPs through task automation at time of scheduling CT simulation in our Care Path, and 3) continuously refining our countermeasures based on monthly status updates and department meetings. We tracked various physician, authorization, and outcome-metrics between October 2022 and January 2023, including mean time for CTP completion, % usage of our Care Path, % usage of revised CTP templates, mean time until pre-auth initiated & completed, % of cases requiring peer-to-peer phone calls, and % of cases denied/delayed.

RESULTS

There were 417 patients from a variety of disease sites who had a CT simulation at our institution between October 1, 2022, and January 31, 2023. Mean time for CTP completion (from the time of CT simulation request) improved from 16 days at baseline to 7 days by the end of the project. In the beginning, only 5% of CTPs were completed within 2 days of scheduling the CT simulation, and this improved to 42-56% during the project period. Percent usage of the Care Path improved dramatically from 16% to 91%, as did % usage of our revised CTP templates, from 0% to 96%. Despite initial lag in pre-authorization team workflow changes, the % of pre-authorizations initiated by day 3 from CT request improved from 32% at baseline to 48% by month 4. Mean time to complete insurance pre-authorizations improved from 16 days at baseline to 10 days. The percent of cases requiring peer to peer or were denied was reduced significantly from 32% at baseline to 4-11%.

CONCLUSION

Improvingtimeliness and details of CTP documentation by using our Care Path and revising CTP templates improved efficiency of insurance pre-auth completion, and reduced the number of cases delayed/denied.

Glaucoma and Myopia: Diagnostic Challenges

The rising global prevalence of myopia is a growing concern for clinicians, as it predisposes patients to severe ocular pathologies including glaucoma. High myopia can be associated with clinical features that resemble glaucomatous damage, which make an accurate glaucoma diagnosis challenging, particularly among patients with normal intraocular pressures. These patients may also present with established visual field defects which can mimic glaucoma, and standard imaging technology is less useful in disease detection and monitoring due to the lack of normative data for these anatomically unique eyes. Progression over time remains the most critical factor in facilitating the detection of early glaucomatous changes, and thus careful longitudinal follow-up of high-risk myopic patients is the most important aspect of management. Here, we review our current understanding of the complex relationship between myopia and glaucoma, and the diagnostic challenges and limitations of current testing protocols including visual field, intraocular pressure, and imaging. Furthermore, we discuss the clinical findings of two highly myopic patients with suspected glaucoma.

[Should we interfere with the interleukin-6 receptor during COVID-19: What do we know?]

COVID-19 is a viral infection with predominant respiratory tropism. In its most severe forms, the initial viral aggression leads to acute respiratory failure due to damage secondary to an exacerbated inflammatory response provoked by the activation of innate, followed by adaptive immunity. The inflammatory response may entail respiratory distress syndrome, if not multivisceral failure and death. IL-6 receptor inhibitors (Tocilizumab and Sarilumab) have been proposed as treatments. Numerous studies have provided new information, which remains heterogeneous and difficult to interpret. This review is aimed at clarifying the potential role of IL-6 receptor inhibitors in severe forms of COVID-19.

Clinical characteristics of high myopia in female carriers of pathogenic RPGR mutations: a case series and review of the literature

BACKGROUND

RPGR mutations are the most common cause of X-linked retinitis pigmentosa (XLRP). High myopia has been described as a very frequent feature among affected female carriers of XLRP. However, the clinical phenotype of female patients presenting with X-linked RPGR-related high myopia has not been well described.

MATERIALS AND METHODS

Retrospective case series of four female patients with RPGR mutations and a diagnosis of high myopia, who presented to two academic eye centers. Clinical data, including age, family history, visual acuity, refractive error, dilated fundus exam, fundus photography, optical coherence tomography, electroretinography, and results of genetic testing, were collected.

RESULTS

Three RPGR variants identified in the present study have not been previously associated with myopia in female carriers. One variant (c.2405_2406delAG, p.Glu802Glyfs *32) has been previously associated with a myopic phenotype in a female patient. Patients became symptomatic between the first and sixth decades of life. Myopia-associated tilted optic discs and posterior staphyloma were present in all patients. Two patients presented with intraretinal migration of the retinal pigment epithelium.

CONCLUSION

RPGR-related high myopia has been associated with mutations in exons 1-14 and ORF15 in heterozygous females. There is a wide range of visual function among carriers. Although the exact mechanism of RPGR-related high myopia is still unclear, continued molecular diagnosis and description of phenotypes remain a crucial step in understanding the impact of RPGR mutations on visual function in female XLRP carriers.

A robust experimental and computational analysis framework at multiple resolutions, modalities and coverages

The ability to study cancer-immune cell communication across the whole tumor section without tissue dissociation is needed, especially for cancer immunotherapy development, which requires understanding of molecular mechanisms and discovery of more druggable targets. In this work, we assembled and evaluated an integrated experimental framework and analytical process to enable genome-wide scale discovery of ligand-receptors potentially used for cellular crosstalks, followed by targeted validation. We assessed the complementarity of four different technologies: single-cell RNA sequencing and Spatial transcriptomic (measuring over >20,000 genes), RNA In Situ Hybridization (RNAscope, measuring 4-12 genes) and Opal Polaris multiplex protein staining (4-9 proteins). To utilize the multimodal data, we implemented existing methods and also developed STRISH (Spatial TRanscriptomic In Situ Hybridization), a computational method that can automatically scan across the whole tissue section for local expression of gene (e.g. RNAscope data) and/or protein markers (e.g. Polaris data) to recapitulate an interaction landscape across the whole tissue. We evaluated the approach to discover and validate cell-cell interaction in situ through in-depth analysis of two types of cancer, basal cell carcinoma and squamous cell carcinoma, which account for over 70% of cancer cases. We showed that inference of cell-cell interactions using scRNA-seq data can misdetect or detect false positive interactions. Spatial transcriptomics still suffers from misdetecting lowly expressed ligand-receptor interactions, but reduces false discovery. RNAscope and Polaris are sensitive methods for defining the location of potential ligand receptor interactions, and the STRISH program can determine the probability that local gene co-expression reflects true cell-cell interaction. We expect that the approach described here will be widely applied to discover and validate ligand receptor interaction in different types of solid cancer tumors.

Preferential reporting of significant p-values in radiology journal abstracts

AIM

To assess the prevalence of publication bias in the radiology literature, data-mining techniques were used to extract p-values in abstracts published in key radiology journals over the past 20 years.

MATERIALS AND METHODS

A total of 34,699 abstracts published in Radiology, Investigative Radiology, European Radiology, American Journal of Roentgenology, and American Journal of Neuroradiology published between January 2000 and December 2019 were included in the analysis. Automated text mining using regular expressions was used to mine abstracts for p-values.

RESULTS

The text mining algorithm detected 43,489 p-values, the majority (82.4%) of which were reported as "significant", i.e., p<0.05. There has also been an increased propensity to report more p-values over time. The distribution of p-values showed a step change at the conventional significance threshold of 0.05. The odds ratio of a "significant" p-value being reported in the abstract compared to the full text was calculated to be 2.52 (95% confidence interval 1.78-3.58; p<0.001). Taken together, these results provide strong evidence for selective reporting of significant p-values in abstracts.

CONCLUSION

Statistically significant p-values are preferentially reported in radiology journal abstracts.

O-123 FMEA analysis of an automatic integration of time-lapse incubators into electronic medical records using CHLOE(Fairtility) shows risk reduction through automation of data capture and processing

Study question

Can integrations and automatic data processing between time-lapse incubators and EMRs reduce the risks associated with manual moving of data from time-lapse incubators to EMRs

Summary answer

Redesigning data workflow using CHLOE(Fairtility) decreased risk occurrence and increased risk detection possibilities associated with embryo classification and selection to freeze, biopsy, transfer and discard.

What is known already

Decisions are made from information derived from time-lapse incubators.  Clinically, embryologists decide which embryos (and when) are suitable for transfer, cryopreservation, biopsy, or discarding based on data derived from time-lapse incubators, manually annotated and summarised into the electronic medical record (EMR) where further information useful for embryo selection is stored.  Manual movement of data from time-lapse incubators to EMRs is time-consuming, administrative, reduces the granularity of the data available and incurs risk of human-error inaccuracies.  These challenges limit the possibilities of how this data can be used to optimise clinical decisions, improve the patient experience and proactively detect operational anomalies.

Study design, size, duration

Failure mode effects analysis (FMEA) analysis was carried out on the workflow integration into a large (&gt;5000 cycles per annum) IVF centre following ESHRE guidelines for laboratory and time-lapse practice (ESHRE,2015,2020), comparing before and after the introduction of CHLOE(Fairtility).  The FMEA analysis evaluated the possible data capture, processing and associated clinical decision risks from embryos entering to leaving the time-lapse incubator.  The Risk Priority Number (RPN=likelihoodxseverityxdetection of incidence) was calculated for each failure mode (Rienzi,2015).

Participants/materials, setting, methods

Through authenticated REST API calls according to the OpenAPI standard, CHLOE(Fairtility) linked the treatment unique identifier from the EMR(LIVO, inhouse developed) to the time-lapse incubator, automatically processed the time-lapse data, captured quantitative and qualitative information (such as morphokinetic time points, PNs, cleavage and blastocyst morphological grades, unusual embryo developmental anomalies and prediction scores for blastulation and implantation) and automatically loaded into the EMR.

Main results and the role of chance

Before CHLOE(Fairtility), 8 process phases were identified, with 81 associated failure modes, among which 45 risks were given a moderate RPN [RPN&gt;15, i.e. data entry error into the EMR; image feature detection missed (i.e. 2PNs, Inner Cell Mass, incorrectly diagnosing fragments as cells and vice versa; incorrectly diagnosing  vacuoles as a PNs, asynchronous PNs missed),with consequences including inaccurate KPI monitoring (n = 20, RPN=4); reduced patient experience and increased stress (n = 18, RPN range 3-16);  wrong embryo being selected (n = 42, RPN range 8-36).  Wrong embryo selection had three possible consequences:  viable embryo discarded leading to a reduction in efficacy of treatment; viable embryo not prioritised for transfer causing reduced chance of pregnancy, or increased time to pregnancy, increasing cost and emotional burden); euploid embryo not prioritised for biopsy, increasing cost.  Overall, RPN ranged from 3 to 36.

After CHLOE(Fairtility), 51 failure modes were eliminated completely, including quantitative and qualitative morphokinetic annotations, entering data into the EMR for daily embryo grades, and embryo fate decisions.  A further 22 failure modes had reduced RPN, including blastocyst morphological grading, number of PNs, identification of unusual embryo cleavages; with 30 low RPNs and 6 moderate RPNs.  Implementation of CHLOE(Fairtility) reduced the highest RPN from 36 to 16.

Limitations, reasons for caution

FMEA is a proactive method to identify potential incidents in order to develop strategies to mitigate risks, forming part of a framework for responsible innovation.  The likelihood of incidences were estimated based on a PUBMED literature review, personal experience and the experience of colleagues.

Wider implications of the findings

CHLOE(Fairtility) has the potential to eliminate risks that exist when manually moving data from time-lapse incubators to EMRs: time-consuming, administrative, reduced data granularity and human-error-based inaccuracies.  CHLOE(Fairtility) optimises clinical decisions, providing an opportunity for personalised patient care, improved patient engagement, and the potential to detect operational non-conformities before impacting clinically.

Trial registration number

NA

P-269 A validation study for artificial intelligence (AI) compared with manual annotation, using donor eggs reveals that AI accurately predicts blastulation

Study question

Are the annotations produced by AI comparable to manual annotations? Does AI accurately assess fertilisation checks, and predict embryo usage and blastulation compared to embryologists?

Summary answer

Automatic annotations by AI was consistent with manual annotations. AI implantation algorithms had strong prediction of blastulation and embryo usage.

What is known already

Currently, embryos are manually annotated for specific morphokinetic features during embryo development. This is a labour-intensive process, and dependent on training and experience, leading to inter and intra clinic variation.

The decision to transfer, freeze or discard embryos relies heavily on these annotations. It is paramount that we develop a tool that will provide consistency and accuracy in annotation and produce scores that can facilitate decisions around embryo usage.

AI has demonstrated its potential to achieve this, but first must be validated before its integration into clinical practice. There have been no such studies demonstrating this so far.

Study design, size, duration

Retrospective cohort study, that took place between September to December 2021 at a private fertility clinic in Spain. To control for embryo variability, this study only included 179 time-lapse videos for embryos created from donor eggs. This was based on the understanding that donor eggs are more likely to produce better quality blastocysts and embryos and thus will give the most optimal conditions for annotation in a validation framework.

Participants/materials, setting, methods

The same time-lapse cultured embryos were annotated manually and automatically by CHLOE(Fairtility, an AI-based tool). Manual and CHLOE annotations were compared to assess the strength of agreement (i) using intra-class correlation (ICC), and (ii) the proportion of corrections required at the pronuclei (PN) stage. AI accuracy in predicting blastulation at 30hours, and blastulation before 116 hours, was also assessed using AUC as the efficacy metric. Embryo usage was compared with the AI-generated ranking of embryos.

Main results and the role of chance

The majority of morphokinetic variables showed a very-strong agreement, with an ICC range of (0.81-1.00), namely for; tPNf, t2, t3, t5, t7, tSB, tB and tEB. Only t4 (0.5) showed a moderate agreement. On average (Mean+-Standard deviation), AI annotated t4 later than embryologists (36+-5vs39+-10 (hours)). All other variables fell within a strong ICC of (0.61-0.8). There were no very weak (0-0.2) or weak (0.21-0.4) variables. PN agreement between AI and embryologists was 93%: PN’s had to be corrected by an embryologist only 7%(n = 179) of the time.

AI predicted blastulation on day 3 with a high level of sensitivity 0.77 and specificity 0.82, (AUC: 0.84,p&lt;0.0001). Furthermore, the blastulation score given on day 3 was a predictor of blastulation before 116 hours with a high sensitivity 0.77 and specificity 0.80, (AUC: 0.81,p&lt;0.0001).

Similarly, AI-generated ranking accurately correlated with embryologist decisions to freeze, transfer or discard embryos, with an overall high sensitivity 0.88 and specificity 0.67, (AUC: 0.84,p&lt;0.0001). A rank of 1 was seen in 14%(n = 113) of embryos, all of which were frozen or transferred. Some embryos that scored a rank of 2 were discarded, but this was significantly lower than those that scored a rank of 3 or more (3%vs32%,p=0.0004).

Limitations, reasons for caution

This study only included embryos from donor eggs. Furthermore, this study occurred at a single site and is planned to be replicated at several clinics. Where there are discrepancies between human and AI, further studies are required to determine the ground truth.

Wider implications of the findings

This study demonstrates an AI framework to safely introduce AI in the fertility clinic. AI will accurately annotate embryos and give reliable scores to predict good quality blastulation, and inform decisions around embryo usage determination. AI provides a time-effective, objective tool in decision-making, with the potential to optimise success.

Trial registration number

not applicable

Abstract 247: Reducing Repeat Echocardiography Testing In Hospitalized Patients

Background/Problem: Medicare spends more than $900 million annually on cardiac echocardiography. Despite the development of appropriate use criteria for echocardiography to limit inappropriate testing, at least 5% to 20% of studies may remain inappropriate. For simple indications or repeat serial exams, a brief, limited transthoracic echocardiogram (TTE) with minimal views and measurements may answer the diagnostic question. In the current state, there are no guidelines of when to order a comprehensive TTE vs limited TTE or a reminder in our electronic health record system (EPIC) that a TTE has already been done. Few physicians are aware of the possibility of even ordering a limited TTE.

Intervention: Patient encounters with repeat comprehensive TTE orders were randomized (in real-time) to the intervention, an electronic reminder or best practice alert (BPA), or control, no reminder. The reminder interrupted the ordering process and notified the ordering provider that a comprehensive TTE result was available within the prior 3 months. The reminder provided a link to the result and offered a limited study order as an alternative. The primary outcome was the number of full versus limited TTEs.

Results: Over one year in a tertiary care medical center, 3314 patient encounters were randomized to the intervention (N=1661) with a BPA or control group (N=1653) without a reminder. In the control group, there were 1803 full TTE and 222 limited TTE. In the intervention group, there were 1647 full TTE and 379 limited TTE. Analysis with chi-square testing resulted in a p<0.0001.

Conclusion: In this randomized trial, a BPA or interruptive reminder in an EHR reduced repeat comprehensive echo testing. The reduced repeat testing can decrease the cost of care, increase access by decreasing wait times for other patients, and potentially improve the patient experience by avoiding any discomfort associated with testing.

1141 Robotic Assisted Surgery in Horseshoe Kidneys: A Safety and Feasibility Multicentre Case Series

Introduction

Horseshoe kidneys (HSK) are the most common renal fusion abnormality. However, they are only present in 0.2% of the population. Due to anatomical variation in vasculature, ectopia and malrotation, surgery has traditionally been performed via an open approach. We aimed to assess the safety and feasibility of robot-assisted surgery for HSK.

Method

Six patients (four female, two male) with HSKs were operated on between 2016 and 2019 across two high-volume centres by high-volume surgeons. All operations were robot-assisted, with three partial nephrectomies and one nephroureterectomy for renal masses and two benign nephrectomies for non-functioning kidneys. 3D reconstruction using CT renal angiograms was used to help identify vasculature and tumour location (where appropriate).

Results

The median age was 53 years (IQR 47-58.3) and the median BMI was 25 (IQR 25-25.8). Median tumour size in the four patients with renal masses was 35.5 mm (IQR 25.3-44.8). Median console time was 120 minutes (IQR 117-172.5) and the median estimated blood loss was 150 mL (IQR 112.5-262.5). The median pre-operative eGFR was 76 (IQR 70-86.5) and median post-operative eGFR was 65.5 (IQR 59.3-80.8). All operations were uneventful, there were no perioperative transfusions and no complications reported. Length of stay was two days for all patients.

Conclusions

We report the largest series of mixed robotic-assisted surgery on HSK. Robotic surgery is safe and feasible for HSK in high-volume centres with acceptable perioperative outcomes. Further prospective, longer-term, multi-centre studies are required to evaluative if robotic surgery for HSK is superior to open surgery.

The effect of high-pressure jet processing on cocoa stability in chocolate milk

Fat-free chocolate milk formulations containing skim milk, cocoa powder, and sugar were thermally treated and then processed using high-pressure jet (HPJ) technology from 125 to 500 MPa. The rheological properties and stability of HPJ-treated chocolate milks were compared with controls (no HPJ processing) prepared both with and without added κ-carrageenan. As expected, carrageenan-free chocolate milk exhibited immediate phase separation of the cocoa powder, whereas formulations containing κ-carrageenan were stable for 14 d. An increased stability was observed with increasing HPJ processing pressure, with a maximum observed when chocolate milk was processed at 500 MPa. The apparent viscosity at 50 s^-1 of HPJ-processed samples increased from ~3 mPa·s to ~9 mPa·s with increasing pressure, and shear-thinning behavior (n < 0.9) was observed for samples processed at HPJ pressures ≥250 MPa. We suggest that HPJ-induced structural changes in casein micelles and new casein-cocoa interactions increased cocoa stability in the chocolate milk. Because casein seemed to be the major component enhancing cocoa stability in HPJ-treated samples, a second study was conducted to determine the effect of additional micellar casein (1, 2, or 4%) and HPJ processing (0-500 MPa) on the stability of fat-free chocolate milk. Formulations with 4% micellar casein processed at 375 and 500 MPa showed no phase separation over a 14-d storage period at 4°C. The addition of micellar casein together with HPJ processing at 500 MPa resulted in a higher apparent viscosity (~17 mPa·s at 50s^-1) and more pronounced shear-thinning behavior (n ≤ 0.81) compared with that without added micellar casein. The use of HPJ technology to improve the dispersion stability of cocoa provides the industry with a processing alternative to produce clean-label, yet stable, chocolate milk.

Throwing cardiac rehabilitation into the 21st Century: a focus group study exploring the impact of COVID-19 on cardiac rehabilitation delivery in Victoria, Australia

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac rehabilitation (CR) education and exercise are predominantly delivered in group face-to-face settings. This delivery model was challenged during the COVID-19 pandemic due to government enforced lockdowns which restricted the delivery of these models of care. The Australian state of Victoria experienced the longest and most severe local restrictions and was in lockdown for approximately 26 weeks of 2020. 

Purpose

We aimed to explore the experience, barriers and enablers of delivering CR during a pandemic, and identify strategies for future COVID-safe programs among cardiac rehabilitation clinicians.

Methods

Victorian members of the Australian Cardiovascular Health and Rehabilitation Association (ACRA) were invited to attend an exploratory qualitative online focus group in November 2020. An inductive thematic analysis was undertaken before deductively applying the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework to identify barriers and enablers for technology adoption in CR.

Results

30 members participated in a 106 minute focus group. 17 members who provided demographics represented multiple disciplines (nursing n = 13, exercise physiology n = 3, physiotherapy n = 1) and geographical settings (metropolitan n = 10, regional n = 4, rural n = 3). Four main themes were identified: Consequences of sudden service delivery change; Technology use – challenges and benefits; Capacity (program and staff); and The way forward. The deductive NASSS analysis demonstrated the main challenges of continuing remotely delivered CR lie with all adopters (staff, patients, carers) and with organisations. Future CR strategies included the importance of resuming face-to-face programs but important barriers including finding capacity, particularly staffing, to run concurrent telehealth programs remain to be addressed. 

Conclusion

The COVID-19 pandemic forced and expedited significant changes to CR delivery models. While clinicians agreed that delivery of CR via telehealth will continue, it is now timely to review remote models of care and plan how they will integrate alongside traditional face-to-face programs.

Immune profiling of lupus miliaris disseminatus faciei and successful management with anti-tumour necrosis factor therapy

Lupus miliaris disseminatus faciei (LMDF) is a chronic inflammatory dermatosis of unknown aetiology, most often seen in young adults. Although many treatments for LMDF exist, treatment guidelines have not been developed, and response to therapy is generally unpredictable. We present the results of transcriptomic analysis of LMDF lesional skin, which revealed a variety of differentially expressed genes linking LMDF to alterations in innate and adaptive T helper 1 immunity. Immunohistochemical analysis was also performed, identifying similar changes in T-cell immune responses. Given evidence for increased tumour necrosis factor (TNF) pathway activity, our patient, who had previously been refractory to multiple treatments, was initiated on TNF inhibitor therapy with excellent response. This characterization of the LMDF immune response may lead to improved treatment of this condition.

Evaluating the Effectiveness of NoteAid in a Community Hospital Setting: Randomized Trial of Electronic Health Record Note Comprehension Interventions With Patients

Background

Interventions to define medical jargon have been shown to improve electronic health record (EHR) note comprehension among crowdsourced participants on Amazon Mechanical Turk (AMT). However, AMT participants may not be representative of the general population or patients who are most at-risk for low health literacy.

Objective

In this work, we assessed the efficacy of an intervention (NoteAid) for EHR note comprehension among participants in a community hospital setting.

Methods

Participants were recruited from Lowell General Hospital (LGH), a community hospital in Massachusetts, to take the ComprehENotes test, a web-based test of EHR note comprehension. Participants were randomly assigned to control (n=85) or intervention (n=89) groups to take the test without or with NoteAid, respectively. For comparison, we used a sample of 200 participants recruited from AMT to take the ComprehENotes test (100 in the control group and 100 in the intervention group).

Results

A total of 174 participants were recruited from LGH, and 200 participants were recruited from AMT. Participants in both intervention groups (community hospital and AMT) scored significantly higher than participants in the control groups (P<.001). The average score for the community hospital participants was significantly lower than the average score for the AMT participants (P<.001), consistent with the lower education levels in the community hospital sample. Education level had a significant effect on scores for the community hospital participants (P<.001).

Conclusions

Use of NoteAid was associated with significantly improved EHR note comprehension in both community hospital and AMT samples. Our results demonstrate the generalizability of ComprehENotes as a test of EHR note comprehension and the effectiveness of NoteAid for improving EHR note comprehension.

From the lecture theatre to your digital device: Reflections on the production of educational podcasts within undergraduate psychiatry training

Introduction

The COVID-19 pandemic has highlighted a need for engaging online resources to enrich psychiatry training for undergraduate medical students. Podcasting is a well-established digital communication platform utilised daily in a myriad of capacities, including education. A group of medical students were tasked with creating their own educational podcasts covering specific aspects of psychiatry.

Objectives

Each pair was set a sub-topic of psychiatry and utilised software to produce educational resources. The objective of this project was to reflect upon production as well as explore the efficacy of podcasting as a tool within undergraduate training.

Methods

The medical students conducted research and contacted experts within the field to contribute to their podcasts. The majority of the students then conducted reviews of the literature surrounding podcasting within medical education, which informed the production of their own podcasts. From this, it was discussed how this project could impact future practice, and indicated that podcasts may become crucial asynchronous learning tools in medical education.

Results

Literature review and first-hand experience of podcast production enabled the students to appreciate the advantages of podcasting and the potential for its widespread future applications. Their wider reading revealed that podcast-using study participants outperformed or matched their peers in assessments, and overwhelmingly enjoyed using podcasts over traditional teaching methods.

Conclusions

The use of podcasting can complement traditional psychiatry training and appeal to a generation of digital natives that prefer this learning style. Podcast production is also an excellent revision method, highlighting the advantages of peer-to-peer education in both learning and increasing engagement with psychiatry.

Disclosure

No significant relationships.

Efficacy of HLA-compatible Platelet Transfusion for Patients with Acute Myeloid Leukemia Refractory to Platelet Transfusion

Introduction/Objective

Acute myeloid leukemia (AML) patients often require transfusion support during induction chemotherapy. Platelet transfusion refractoriness (PTR) may develop due to HLA alloimmunization. Management of immune-refractory patients with HLA-compatible platelet transfusions is labor intensive and associated with increased costs. The purpose of this study is to evaluate the efficacy of HLA-compatible platelet units in AML patients.

Methods

Newly diagnosed AML patients undergoing induction chemotherapy in our institute between 2015 and 2018 were identified. Platelet counts and platelet transfusion data from initiation of chemotherapy until platelet recovery (&gt; 20K/µL and increased consistently) were extracted. A 24-hour posttransfusion corrected count increment (CCI) was calculated to evaluate the efficacy of each platelet transfusion. PTR was declared if a patient had a 24-hour CCI &lt; 4K following two consecutive transfusions. Student’s t-test was used for statistical analysis. Results were presented as mean ± SE, * if p &lt; 0.05.

Results

We identified 39 patients with newly diagnosed AML. PTR developed in 22/39 (56%) patients during induction chemotherapy. The average CCI was higher among those without PTR compared to those with PTR (8,408 ± 585 vs. 2,923 ± 360*), and overall platelet transfusion burden (in number of units) was lower (7.29 ± 1.0 vs. 18.55 ± 1.71*). HLA antibodies were identified in 3/22 (14%) PTR patients, as 6/22 (27%) were tested. The average CCI during HLA matched transfusions for these 3 patients was higher than that with random units (2,059 ± 149 vs. -126 ± 306*). Compared to HLA-negative PTR patients receiving random units, the average CCI for HLA-compatible transfusions was still lower, though not significantly (2,059 ± 149 vs. 3,099 ± 390, p = 0.33), while the number of HLA- compatible units transfused was significantly higher (31.0 ± 3.0 vs. 16.6 ± 1.45*).

Conclusion

In a cohort of newly diagnosed AML patients undergoing induction chemotherapy whose PTR was associated with detectable HLA antibodies, transfusion support with HLA-matched products did not lead to reduced overall platelet transfusion rates and CCI remains in the refractory range. This suggests that use of HLA matched platelets among newly diagnosed AML patients with PTR, even in the setting of detectable HLA antibodies, does not appear to result in reduced overall product utilization.

0195 Social Determinants of Sleep: Inside Relationships with Significant Others

Introduction

Social relationships impact health through different mechanisms. Sleep problems are prevalent among adults in the USA, negatively impacting all-cause mortality, and increasing the risk for chronic diseases such as depression, cardiovascular disease, and cancer. This study aimed to assess whether the quality of an individual’s relationship with their significant other including support and strain, subjective relationship quality, joint decision making, marital risk, and conflict are associated with clinical, subjective, and objective measures of sleep.

Methods

Participants were selected from the Midlife in the United States (MIDUS) study if they had complete data on subjective sleep quality from the MIDUS II biomarker project and shared a bed with their partner (n=751, 49.5% female, Mage=53.4, SDage=11.2, range= 34–83). Subjective sleep quality was measured using the PSQI. A subset of these participants (n=246, 50.8% female) also completed 7-days of daily diary and actigraphy.

Results

Sleep disturbances were pervasive; 44.1% (n=331) of participants reported clinically meaningful sleep disturbances (PSQI&gt;=5). Among the smaller sample of participants with 7-day sleep data, sleep disturbances were even more prevalent (60.9%). There were significant bivariate associations between higher support and lower strain with better subjectively and objectively sleep outcomes. Better subjective relationship quality was also associated with better subjectively measured sleep outcomes. Higher marital risk and more disagreement with partner were associated with poorer sleep. When accounting for all marital relationship factors, participants with higher support and lower strain given to partner had a better long-term sleep quality, b= 1.93, SE= .54, p&lt;.001. Relationship quality was also associated with better daily sleep quality and daily reports of feeling rested, b = -.12, SE= .05, p=.023, and b= .11, SE = .048, p=.023, respectively. These relationships remained significant after accounting for age, current employment status, recent major health events, average daily caffeine, alcohol, exercise, and napping.

Conclusion

These findings support the importance of considering social determinants of sleep, suggesting that relationships with significant others may impact health through sleep quality. This highlights the importance of sleep as a transdiagnostic physiological mechanism that could be enhanced through improvements to relationships with significant others.

Support

N/A

Cholécystite aiguë de réanimation

La cholécystite aiguë de réanimation (0,2 à 1 % des patients) est liée à des facteurs de risque spécifiques (jeûne, nutrition parentérale, ventilation mécanique) et systémiques (instabilité, brûlures graves, catécholamines) conduisant à des phénomènes d’ischémie-reperfusion de la paroi vésiculaire, à l’origine d’une cholécystite classiquement alithiasique. Toutefois, les données récentes retrouvent une participation lithiasique dans 50%des cas environ. Il s’agit d’une maladie grave dont le diagnostic est difficile et la mortalité élevée (40 %). Chez ces patients graves, aucun critère clinicobiologique ne permet un diagnostic de certitude. L’imagerie du patient de réanimation peut être prise à défaut par les anomalies fréquemment retrouvées en réanimation ; les signes les plus évocateurs sont un épaississement pariétal vésiculaire supérieur à 4 mm, un hydrocholécyste ou un défaut de rehaussement de la paroi au scanner. Le traitement en urgence repose sur une antibiothérapie à large spectre ciblée sur les germes digestifs et nosocomiaux ainsi que sur une optimisation hémodynamique. La cholécystectomie (laparoscopique, voire sous-costale) représente le traitement de référence en empêchant la récidive. Mais la gravité des patients amène souvent à envisager une solution moins lourde que la chirurgie avec un drainage de la vésicule. Le drainage par voie percutanée est l’alternative de choix en raison de sa disponibilité et de son efficacité, il existe toutefois un risque théorique de récidive à l’ablation du drain, surtout en cas de cholécystite lithiasique. Le drainage interne par voie endoscopique (transpapillaire ou transdigestif) est une possibilité prometteuse, mais réservée à l’heure actuelle aux centres experts.

Human stroma and epithelium co-culture in a microfluidic model of a human prostate gland

The prostate is a walnut-sized gland that surrounds the urethra of males at the base of the bladder comprising a muscular portion, which controls the release of urine, and a glandular portion, which secretes fluids that nourish and protect sperms. Here, we report the development of a microfluidic-based model of a human prostate gland. The polydimethylsiloxane (PDMS) microfluidic device, consisting of two stacked microchannels separated by a polyester porous membrane, enables long-term in vitro cocultivation of human epithelial and stromal cells. The porous separation membrane provides an anchoring scaffold for long-term culturing of the two cell types on its opposite surfaces allowing paracrine signaling but not cell crossing between the two channels. The microfluidic device is transparent enabling high resolution bright-field and fluorescence imaging. Within this coculture model of a human epithelium/stroma interface, we simulated the functional development of the in vivo human prostate gland. We observed the successful differentiation of basal epithelial cells into luminal secretory cells determined biochemically by immunostaining with known differentiation biomarkers, particularly androgen receptor expression. We also observed morphological changes where glandlike mounds appeared with relatively empty centers reminiscent of prostatic glandular acini structures. This prostate-on-a-chip will facilitate the direct evaluation of paracrine and endocrine cross talk between these two cell types as well as studies associated with normal vs disease-related events such as prostate cancer.

Abstract P1-09-07: Breast cancer characteristics and outcomes in patients with TP53 germline mutation

Introduction

Li-Fraumeni syndrome (LFS) resulting from monoallelic germline TP53 gene mutation is a rare hereditary cancer predisposition. Breast cancer (BC) is the most common cancer among women with TP53 germline mutation with a risk ranging from 49% to 85% by the age of 60 years old. Most of these cancers are early onset. Few patients' cases have been reported so far in the literature. Our aim was to describe the medical history of a cohort of LFS women diagnosed with BC recruited from a single institution. The characteristics combined were genetic alteration diagnosis, tumor characteristics, treatment, outcome, and LFS associated cancers.

Methods

We retrospectively identified breast cancer patients with TP53 germline mutation from the Institut Curie (Paris, France) database and described their cancer characteristics and medical history.

Results

From 1989 to 2015, 25 patients affected with BC (31 tumors) and TP53 germline mutation carrier were identified, with a median follow up of 6.5 years. Median age at BC diagnosis was 30.5 years. All patients were women. 33% had a previously identified TP53 mutation in their family. 70% of them had BC as their first cancer event. 60% of the patients presented with another LFS associated cancer or non-related cancers: osteosarcoma (22%), glioblastoma (18%), pulmonary carcinoma (13%), gastric linitis plastica (9%), malignant hemopathy (9%), soft tissue sarcoma (9%), adrenocortical carcinoma (4%), ovarian cystadenocarcinoma (4%), renal tumor (4%), choroid plexus carcinoma (4%).

92% of the breast tumors were ductal carcinoma (28% DCIS and 64% IDC), 7% were sarcoma (1 phyllodesarcoma, 1 pleiomorphic liposarcoma); there were no lobular carcinoma. Among the IDC, 50% were HER2 positive, 72% were hormone-receptor positive.

Most patients had a mastectomy (64%), and most of them received radiation (55%). However, when TP53 mutation had been identified prior to the treatment, none of the patients received radiotherapy (5 patients). Most patients received chemotherapy (70%) (37% in neoadjuvant setting, 33% in adjuvant setting, 25% for metastatic setting). 40% of the patients received hormone therapy (37% as adjuvant treatment, 7% for metastatic disease)

Most of the patients did not relapse from BC (75%). Overall, only 17% of the patients had metastatic BC. To date, 12 patients of our series have died (48%), 6 patients (24%) from other LFS-associated cancers and 4 patients from BC (16%).

Conclusion

To the best of our knowledge, this descriptive series is the largest study of tumor characteristics and medical history of LFS-women with BC, the most frequent cancer among women with TP53 germline mutation. It confirms the higher HER2 overexpression rate observed in LFS-patients BC, as suggested in the literature and showed a high rate of DCIS at initial presentation. Most of the patients developed other LFS-associated cancers. In depth molecular analysis of these BC will be performed in order to gain insight into their biological specificities and to adapt the therapeutic management of this poor prognosis syndrome.

Citation Format: Tran M, Loirat D, Colas C, Bozec L, Laurence V, Lerebours F, Cabel L, Bidard F-C, Stoppa-Lyonnet D, Vincent-Salomon A, Gauthier-Villars M, Lavigne M, De Pauw A. Breast cancer characteristics and outcomes in patients with TP53 germline mutation [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 P1-09-07.

The Rare Lesser Metatarsal Bipartite Sesamoid A Case Report

Sesamoid bones and accessory ossicles are common incidental findings on radiographs. These can occasionally become symptomatic, usually after a precipitating event such as an injury or overuse, or they can be incidental findings unrelated to the presenting pathology. The aim of this study was to highlight a rare case of a bipartite fifth metatarsal sesamoid bone and to review previous literature regarding sesamoid bones and accessory ossicles.

Tunable room-temperature magnetic skyrmions in Ir/Fe/Co/Pt multilayers

Magnetic skyrmions are nanoscale topological spin structures offering great promise for next-generation information storage technologies. The recent discovery of sub-100-nm room-temperature (RT) skyrmions in several multilayer films has triggered vigorous efforts to modulate their physical properties for their use in devices. Here we present a tunable RT skyrmion platform based on multilayer stacks of Ir/Fe/Co/Pt, which we study using X-ray microscopy, magnetic force microscopy and Hall transport techniques. By varying the ferromagnetic layer composition, we can tailor the magnetic interactions governing skyrmion properties, thereby tuning their thermodynamic stability parameter by an order of magnitude. The skyrmions exhibit a smooth crossover between isolated (metastable) and disordered lattice configurations across samples, while their size and density can be tuned by factors of two and ten, respectively. We thus establish a platform for investigating functional sub-50-nm RT skyrmions, pointing towards the development of skyrmion-based memory devices.

Statistical testing of baseline differences in sports medicine RCTs: a systematic evaluation

Background/Aim

The CONSORT (Consolidated Standards of Reporting Trials) statement discourages reporting statistical tests of baseline differences between groups in randomised controlled trials (RCTs). However, this practice is still common in many medical fields. Our aim was to determine the prevalence of this practice in leading sports medicine journals.

Methods

We conducted a comprehensive search in Medline through PubMed to identify RCTs published in the years 2005 and 2015 from 10 high-impact sports medicine journals. Two reviewers independently confirmed the trial design and reached consensus on which articles contained statistical tests of baseline differences.

Results

Our search strategy identified a total of 324 RCTs, with 85 from the year 2005 and 239 from the year 2015. Overall, 64.8% of studies (95% CI (59.6, 70.0)) reported statistical tests of baseline differences; broken down by year, this percentage was 67.1% in 2005 (95% CI (57.1, 77.1)) and 64.0% in 2015 (95% CI (57.9, 70.1)).

Conclusions

Although discouraged by the CONSORT statement, statistical testing of baseline differences remains highly prevalent in sports medicine RCTs. Statistical testing of baseline differences can mislead authors; for example, by failing to identify meaningful baseline differences in small studies. Journals that ask authors to follow the CONSORT statement guidelines should recognise that many manuscripts are ignoring the recommendation against statistical testing of baseline differences.