Patterns of speciation in a parapatric pair of Saturnia moths as revealed by target capture

The focus of this study has been to understand the evolutionary relationships and taxonomy of a widely distributed parapatric species pair of wild silk moths in Europe: Saturnia pavonia and Saturnia pavoniella (Lepidoptera: Saturniidae). To address species delimitation in these parapatric taxa, target enrichment and mtDNA sequencing was employed alongside phylogenetic, admixture, introgression, and species delimitation analyses. The dataset included individuals from both species close to and farther away from the contact zone as well as two hybrids generated in the lab. Nuclear markers strongly supported both S. pavonia and S. pavoniella as two distinct species, with hybrids forming a sister group to S. pavoniella. However, the Maximum Likelihood (ML) tree generated from mtDNA sequencing data presented a different picture, showing both taxa to be phylogenetically intermixed. This inconsistency is likely attributable to mitonuclear discordance, which can arise from biological factors (e.g., introgressive hybridization and/or incomplete lineage sorting). Our analyses indicate that past introgressions have taken place, but that there is no evidence to suggest an ongoing admixture between the two species, demonstrating that the taxa have reached full postzygotic reproductive isolation and hence represent two distinct biological species. Finally, we discuss our results from an evolutionary point of view taking into consideration the past climatic oscillations that have likely shaped the present dynamics between the two species. Overall, our study demonstrates the effectiveness of the target enrichment approach in resolving shallow phylogenetic relationships under complex evolutionary circumstances and that this approach is useful in establishing robust and well-informed taxonomic delimitations involving parapatric taxa.

Potential value of ctDNA monitoring in metastatic HR + /HER2 - breast cancer: longitudinal ctDNA analysis in the phase Ib MONALEESASIA trial

BACKGROUND

There is increasing interest in the use of liquid biopsies, but data on longitudinal analyses of circulating tumor DNA (ctDNA) remain relatively limited. Here, we report a longitudinal ctDNA analysis of MONALEESASIA, a phase Ib trial evaluating the efficacy and safety of ribociclib plus endocrine therapy (ET) in Asian patients with hormone receptor-positive, human epidermal growth factor receptor-2-negative advanced breast cancer.

METHODS

MONALEESASIA enrolled premenopausal and postmenopausal Japanese and postmenopausal non-Japanese Asian patients. All patients received ribociclib with ET (letrozole, fulvestrant, or tamoxifen with goserelin). ctDNA was analyzed using a targeted next-generation sequencing panel of 572 cancer-related genes and correlated by best overall response (BOR).

RESULTS

Five hundred seventy-four cell-free DNA samples from 87 patients were tested. The most frequently altered genes at baseline included PIK3CA (29%) and TP53 (22%). Treatment with ribociclib plus ET decreased ctDNA in most patients at the first on-treatment time point, regardless of dose or ET partner. Patients with partial response and stable disease had lower ctDNA at baseline that remained low until data cutoff if no progressive disease occurred. Most patients with progressive disease as the best response had higher ctDNA at baseline that remained high at the end of treatment. For patients with partial response and stable disease with subsequent progression, ctDNA increased towards the end of treatment in most patients, with a median lead time of 83 days (14-309 days). In some patients with BOR of partial response who experienced disease progression later, specific gene alterations and total ctDNA fraction increased; this was sometimes observed concurrently with the development of new lesions without a change in target lesion size. Patients with alterations in PIK3CA and TP53 at baseline had shorter median progression-free survival compared with patients with wild-type PIK3CA and TP53, 12.7 and 7.3 months vs 19.2 and 19.4 months, respectively (P = .016 and P = .0001, respectively).

CONCLUSIONS

Higher ctDNA levels and PIK3CA and TP53 alterations detected at baseline were associated with inferior outcomes. On-treatment ctDNA levels were associated with different patterns based on BOR. Longitudinal tracking of ctDNA may be useful for monitoring tumor status and detection of alterations with treatment implications.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02333370 . Registered on January 7, 2015.

Abstract P5-02-14: Identification of mechanisms of acquired resistance to ribociclib plus endocrine therapy using baseline and end-of-treatment circulating tumor DNA samples in the MONALEESA-2, -3, and -7 trials

Background: Genetic alterations that contribute to resistance to therapy may be acquired during treatment (tx) for hormone receptor−positive/human epidermal growth factor receptor−negative (HR+/HER2−) advanced breast cancer (ABC). A previous pooled analysis of circulating tumor DNA (ctDNA) in MONALEESA (ML)-2, -3, and -7 identified potential predictive biomarkers for response and resistance to ribociclib (RIB) at baseline (BL). Here, we describe an analysis of paired BL and end of treatment (EOT) samples from ML-2, -3, and -7 to identify acquired mechanisms that may impact resistance to RIB + endocrine therapy (ET) vs placebo (PBO) + ET. Methods: ML-2 (NCT01958021), ML-3 (NCT02422615), and ML-7 (NCT02278120) evaluated efficacy and safety of RIB + ET vs PBO + ET in pre- and postmenopausal patients (pts) with HR+/HER2− ABC treated in first-line (1L) and second-line (2L) settings. Plasma samples were collected at cycle 1 day 1 (C1D1; prior to first therapy exposure) and at EOT (± 28 days of recorded progression). ctDNA was sequenced using a targeted next-generation sequencing panel of ≈550 genes. Genes with an alteration frequency of >5% at EOT, regardless of their frequency at BL, were included. Tumor mutational burden (TMB) was assessed by tx arm; a TMB cutoff of 10 mutations/MB was used to categorize pts as TMB high vs low. To assess differences in the presence of alterations, a McNemar test was performed on paired samples and adjusted (adj) for multiple testing using the false discovery rate (FDR). A Bayesian mixed effects model was used to account for ctDNA fraction and trial and to test for tx-specific resistance by including a tx × visit interaction term. Results: A total of 905 paired samples from ML-2, -3, and -7 were included in this analysis, 441 and 464 samples from pts treated with RIB + ET and PBO + ET, respectively. Overall, 17 genes had an alteration frequency of >5% at EOT. The ctDNA fraction was higher at EOT vs C1D1 in both the RIB (P=.037) and PBO (P=.033) arms. The frequency of alterations in RB1 (10.4% vs 2.0%), ATM (11.3% vs 8.4%), FAT1 (4.8% vs 3.0%), and FAT3 (5.0% vs 2.5%) was higher at EOT vs C1D1 in the RIB arm (FDR-adj P<.10). Alterations in ESR1 were also higher at EOT vs C1D1 in both the RIB (26.3% vs 9.1%) and PBO arms (28.9% vs 5.4%) (FDR-adj P<.0001). Conversely, alterations in GATA3 were higher at EOT in the PBO arm (FDR-adj P=.11). These results were consistent after adjusting for ctDNA fraction. The most common ESR1 mutations were D538G, Y537S/N/C/D, E380Q, and L536H/P/R. Tx × visit interaction effects were observed for RB1 in the RIB arm and GATA3 in the PBO arm, suggesting tx-specific resistance. A tx × visit interaction for ESR1 was also observed, suggesting a larger relative increase in ESR1 mutations with PBO vs RIB. The percentage of pts with high TMB (>10) at EOT increased from 1.1% to 5.7% in the RIB arm and from 1.7% to 3% in the PBO arm. After accounting for ctDNA fraction and trial, a larger numerical increase in TMB was observed for RIB (odds ratio [OR], 9.0; 95% CI, 2.9-32.7) vs PBO (OR, 2.1; 95% CI, 0.7-6.5); however, the model did not support a differential tx effect. Conclusions: This comprehensive analysis of pooled samples from ML-2, -3, and -7 identified acquired gene alterations in pts with HR+/HER2− ABC treated with 1L or 2L RIB + ET or PBO + ET. The frequency of several genes known to contribute to resistance (ESR1, RB1, ATM, FAT1, and FAT3) was higher at EOT vs C1D1 in pts treated with RIB + ET, while ESR1 and GATA3 alterations were higher at EOT vs C1D1 in pts treated with PBO + ET. This paired dataset of BL and EOT samples from pts with HR+/HER2− ABC treated with a CDK4/6 inhibitor and ET is the largest to date and could be used to validate and confirm acquired resistance mechanisms with low alteration frequency.

Citation Format: Fabrice Andre, Nadia Solovieff, Faye Su, Aditya Bardia, Patrick Neven, Yoon-Sim Yap, Debu Tripathy, Yen-Shen Lu, Dennis Slamon, Stephen K. Chia, Mukta Joshi, Arunava Chakravartty, Agnes Lteif, Tetiana Taran, Carlos Arteaga. Identification of mechanisms of acquired resistance to ribociclib plus endocrine therapy using baseline and end-of-treatment circulating tumor DNA samples in the MONALEESA-2, -3, and -7 trials [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-02-14.

Abstract P4-09-12: Baseline and End-of-Treatment Biomarkers in Patients With PIK3CA-Mutated, Hormone Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Advanced Breast Cancer From BYLieve Study Cohorts A and B

Introduction: Phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) is mutated in ~40% of patients (pts) with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2−) advanced breast cancer (ABC). PIK3CA mutations are associated with resistance to endocrine therapy (ET) and worse overall survival. Alpelisib (ALP), an α-selective PI3K inhibitor and degrader, is indicated in combination with fulvestrant (FUL) for pts with PIK3CA-mutated (mut) HR+, HER2− ABC following progression on/after ET-based treatments. In the Phase 2, open-label, 3-cohort, noncomparative BYLieve study, clinical benefit of ALP in combination with ET was observed in the post-cyclin-dependent kinase 4/6 inhibitor (CDK4/6i) setting in pts with PIK3CA-mut, HR+, HER2− ABC. Here we report the results of a biomarker analysis using paired baseline (Cycle 1 Day 1) and end-of-treatment (EOT) circulating tumor DNA (ctDNA) samples from pts in BYLieve Cohorts A and B.

Methods: In the BYLieve study, pts with PIK3CA-mut, HR+, HER2− ABC had CDK4/6i + aromatase inhibitor (Cohort A; N=127) or CDK4/6i + FUL (Cohort B; N=126) as treatment immediately prior to receiving ALP + FUL and ALP + letrozole, respectively. In this biomarker analysis, gene alterations were detected in ctDNA at baseline and EOT using next-generation sequencing (PanCancer V2 panel). Pts included in this interim analysis had confirmed PIK3CA mutations and matched baseline/EOT samples with enough sequencing coverage and ctDNA fraction to detect mutations at both time points. ctDNA fractions, tumor mutation burden (TMB) distributions, genomic landscapes, gain/loss of PIK3CA and estrogen receptor 1 (ESR1), chromosome 8/11 amplification profiles, and alterations in PI3K pathway and potential CDK4/6i resistance markers were assessed across time points. Sample sizes were small; results should thus be interpreted with caution.

Results: Forty-three pts were included in the Cohort A biomarker population and 40 pts were included in Cohort B. ctDNA fraction was numerically higher at EOT compared with baseline in both cohorts; further analyses will be presented. In Cohort A, no significant differences were observed in TMB at EOT compared with baseline (P=0.21). In Cohort B, TMB was higher at EOT compared with baseline (P=0.053). Chromosome 8/11 amplifications were consistent between baseline and EOT for both cohorts. Small variations were observed in ESR1/PIK3CA mutations between baseline and EOT on both cohorts (Table). The status of potential CDK4/6i resistance markers was relatively unchanged at EOT (Table). Loss-of-function mutations in PTEN, a known PI3K inhibitor resistance marker, increased from 9% at baseline to 14% at EOT in Cohort A and from 12% at baseline to 22% at EOT in Cohort B.

Conclusions: Between baseline and EOT, only small variations in gene alterations in PIK3CA-mutated HR+, HER2– ABC were observed in the post-CDK4/6i setting. As the disease progressed, increases in loss-of-function mutations in PTEN at EOT in both Cohorts A and B suggested loss of PTEN in PI3K pathway may drive resistance to ALP. Early intervention with ALP, when the tumor is particularly driven by PIK3CA oncogenic mutations and before it develops more genomic complexity, may potentially provide better clinical outcomes.

Table. Gene Alteration Gain/Loss at Baseline/EOT Across Cohorts A and B

Citation Format: Dejan Juric, Nicholas Turner, Sherene Loi, Fabrice Andre, Stephen K. Chia, Komal Jhaveri, Patrick Neven, Rebecca Dent, Eva Ciruelos, Mukta Joshi, Estelle Roux, Heather Patino, Murat Akdere, Hope Rugo. Baseline and End-of-Treatment Biomarkers in Patients With PIK3CA-Mutated, Hormone Receptor-Positive, Human Epidermal Growth Factor Receptor 2-Negative Advanced Breast Cancer From BYLieve Study Cohorts A and B [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-09-12.

Alpelisib (ALP) + endocrine therapy (ET) in patients (pts) with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–), PIK3CA-mutated (mut) advanced breast cancer (ABC): Baseline biomarker analysis and progression-free survival (PFS) by duration of prior cyclin-dependent kinase 4/6 inhibitor (CDK4/6i) therapy in the BYLieve study

1018

Background: ALP (PI3K-α selective inhibitor and degrader) + fulvestrant (FUL) is approved for pts with HR+, HER2– ABC and a tumor mutation in PIK3CA (̃ 40% of these pts). Primary analyses from the Phase 2 BYLieve study demonstrated efficacy and safety of ALP + ET in pts with PIK3CA-mut, HR+, HER2– ABC in the post-CDK4/6i setting. Post hoc analyses, including pts with disease progression within 6 mo of CDK4/6i + ET treatment (Tx), confirmed ALP benefit regardless of duration of prior CDK4/6i. Here we assess baseline biomarkers in circulating tumor DNA (ctDNA) by duration of prior CDK4/6i Tx and PFS in pts from BYLieve Cohorts A and B. Methods: In the BYLieve study, pts with PIK3CA-mut, HR+, HER2– ABC had CDK4/6i + aromatase inhibitor (Cohort A) or + FUL (Cohort B) as immediate prior Tx to receiving ALP + FUL and ALP + letrozole (LET), respectively. At data cutoff dates, pts had ≥ 18-mo follow-up in Cohort A and ≥ 6-mo in Cohort B. In each cohort, pts were grouped based on duration of prior CDK4/6i Tx (≤ 6 mo or >6 mo). Alterations were detected on ctDNA using next-generation sequencing (PanCancer V2 Panel). PFS was assessed in each cohort and by duration of prior CDK4/6i Tx. Results: Of 127 and 126 pts enrolled in Cohorts A and B, respectively, 98 (≤ 6-mo: 24; >6-mo: 74) and 94 (≤ 6-mo: 28; >6-mo: 66) were included in this analysis based on availability of ctDNA samples, data on duration of prior CDK4/6i, and centrally confirmed PIK3CA-mut disease. In this population, median (m) PFS (95% CI) was 8.2 mo (5.6 - 9.5) and 5.6 mo (3.7 - 7.1) in Cohorts A and B, respectively. In Cohort A, mPFS (95% CI) was 12.0 mo (5.5-non estimable) and 6.2 mo (5.4 - 8.5) in the ≤ 6-mo and >6-mo groups, respectively. The OncoPrint genomic profiles showed that pts in the ≤ 6-mo vs >6-mo group had a lower median ctDNA fraction and fewer detected gene alterations, including in genes associated with ET and/or CDK4/6i resistance, and fewer chromosomes 8/11 amplifications (linked to early relapse). In Cohort B, mPFS was 5.9 mo (3.5 - 11.0) and 5.6 mo (3.7 - 7.1) in the ≤ 6-mo and >6-mo groups, respectively. Both groups had high median ctDNA fractions and complex tumor mutation profiles reflecting more extensive treatment history. Conclusions: Lower median ctDNA fraction and lower mutational complexity observed in Cohort A ≤ 6-mo vs >6-mo group was associated with numerically longer mPFS, potentially indicating increased dependence on the mutant PI3K-α. In Cohort B, both ≤ 6-mo and >6-mo groups had high median ctDNA fractions and similar tumor mutation profiles. Additional ctDNA and tissue analyses are needed to elucidate the correlation between ALP + ET efficacy and treatment timing and baseline genomic complexity.

POS1565-PARE ASSESSMENT OF QUALITY AND RELIABILITY OF YOUTUBE VIDEOS FOR PATIENT AND PHYSICIAN EDUCATION ON INFLAMMATORY MYOSITIS

Background

Nowadays 80% of internet users access health information online, with YouTube being the second most popular search website worldwide. This study was undertaken to assess the reliability and quality of videos pertaining to myositis on YouTube and identify lacunae in information material on the platform.

Objectives

This study aims to assess the quality and profile of myositis information videos on YouTube, and to compare and delineate attributes of useful and not useful videos using standard metrics.

Methods

A thorough search was carried out on YouTube using 9 search terms related to myositis. The inclusion criteria were primary English content related to myositis, acceptable audio-video quality, and multi-part videos to be considered as one, while duplicates and advertisements were excluded. The videos were classified as useful, not useful or misleading, and patient experiences (Figure 1).

Figure 1.

Flowchart of selection of YouTube videos for the study

Reliability of the videos was determined using the 5-point modified DISCERN (mDISCERN) criteria and quality by the 5-point Global Quality Scale (GQS) and 4-point JAMA scoring system. Score-based usefulness was defined as mDISCERN >4 or GQS >4 or JAMA >3. All values are in median and IQR.

Results

Of 453 analyzed videos 74% and 2% provided useful and not useful information respectively. 24% were patient experiences, and 324 (71%) were intended specifically for patients while 313 (69%) were for healthcare providers and students. Nearly one-thirds (n=143) reported information related to treatment of myositis.

Noteworthily, useful and not useful videos had similar views count. However, number of likes and daily viewership were higher for useful videos (p=0.024, p=0.046). Nearly half (47%) of useful videos were by professional medical societies/patient support groups while not useful ones were often by nonmedical media (38%).

Useful videos had higher mDISCERN reliability scores [4(3-4) vs 2(1-3), p<0.001] and better quality on GQS [4.5 (3.5-5) vs 1 (1-2.8), p<0.001] and JAMA [3 (3-4) vs 2.25 (2-3), p=0.004]. Physician predicted usefulness was discordant with score-based usefulness(κ=0.129). However, GQS score emerged significant (p=0.008) for predicting video usefulness in multivariate analysis (Table 1).

Table 1.

Factors predicting usefulness of video in binary logistic regression.

VariableB coefficientS.E.Exp (B) and 95% CIp valueIntended audience Anyone/General public-5.452.5860.004 (0.0-0.68)0.035Average GQS-2.861.0760.05 (0.007-0.47)0.008

GQS Global Quality Scale

. Exp (B) is odd’s ratio, p<0.05 is significant

Conclusion

Majority of English YouTube videos on myositis provide useful information for patients, largely related to treatment of myositis. However, the dynamic nature of YouTube could potentially change this equation in the future and physicians should correct any misinformation identified in face-to-face meetings or teleconsultations. High quality useful videos, often predicted by validated scores and produced by professional medical societies should be promoted as the first line of content consumed.

Disclosure of Interests

None declared

Abstract P5-13-03: Alpelisib + endocrine therapy (ET) in patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-), PIK3CA-mutated advanced breast cancer (ABC) previously treated with cyclin-dependent kinase 4/6 inhibitor (CDK4/6i): Biomarker analyses from the Phase II BYLieve study

Introduction: Alpelisib (ALP, a PI3Kα inhibitor and degrader) + ET has demonstrated efficacy in patients (pts) with HR+, HER2-, PIK3CA-mutated ABC progressing on/after CDK4/6i + ET in the ongoing Phase II BYLieve study (NCT03056755). The primary endpoint, in pts with centrally confirmed PIK3CA mutation in tumor tissue (modified full analysis set [mFAS]), was met in Cohorts A (ALP + fulvestrant [FUL]) and B (ALP + letrozole [LET]) with 50.4% (95% CI, 41.2%-59.6%) of 121 pts and 46.1% (36.8%-55.6%) of 115 pts alive and without disease progression at 6 mo, respectively. Activating PIK3CA mutations, occurring in ~40% of tumors, confer worse prognosis in the advanced setting. Here, we assess the correlation between progression-free survival (PFS) and other baseline biomarkers among pts in BYLieve Cohorts A and B. Methods: Enrolled pre-/postmenopausal women with HR+, HER2-, PIK3CA-mutated ABC received CDK4/6i + aromatase inhibitor (Cohort A) or FUL (Cohort B), as immediate prior treatment (Tx). Pts received ALP 300 mg PO QD + FUL 500 mg IM Q28D and C1D15 (Cohort A) or ALP 300 mg PO QD + LET 2.5 mg PO QD (Cohort B) as study Tx. This exploratory analysis of baseline biomarkers identified gene alterations using an error-connected sequencing ctDNA assay (Novartis PanCancer gene-panel) in plasma samples from pts with a centrally confirmed PIK3CA mutation in tumor tissue from Cohorts A and B. PFS was estimated using the Kaplan-Meier method in subgroups of pts based on high (≥10%) or low (&lt;10%) ctDNA fraction, high (≥10) or low (&lt;10) tumor mutation burden (TMB), and amplification (amp) status of chromosomes (chr) 8 or 11 amplicons (frequently observed in breast cancer and usually associated with early relapse). Results: In Cohorts A and B, 102 of 127 enrolled pts and 97 of the 126 enrolled pts were included in this analysis, respectively. In this analysis, median PFS (mPFS) was 7.3 mo in Cohort A and 5.7 mo in Cohort B, consistent with observations in the mFAS (Table 1). Pts with a low ctDNA fraction or TMB at baseline had longer mPFS than pts with high ctDNA fraction or TMB (Table 1). In addition to PIK3CA alterations observed in 73% of tumors from pts in Cohorts A and B, the most frequently altered genes in the studied population were ESR1 (27% and 28%) and TP53 (25% and 26%) in Cohorts A and B, respectively. Across both cohorts, pts whose tumors had loss of function alterations in genes known to mediate resistance to CDK4/6i (PTEN, RB1, CHD4, FAT1, NF1, ATM, CDKN2A-C) derived clinical benefit (partial response or stable disease) from ALP + ET. Amp of known amplicons on chr 8 (eg, FGFR1, TACC1) or 11 (eg, CCND1, FGF3, FGF4) were observed in 5%-8% of pts in Cohort A and 8%-11% of pts in Cohort B. Pts whose tumors had no gene amp on chr 8 and/or 11 had longer mPFS than pts whose tumors had an amp (Table 1). Similar results were observed when analyzing chr 8 (6.33 mo vs 4.92 mo) and chr 11 (6.33 mo vs 4.63 mo) separately in pts from Cohorts A plus B. Conclusion: In pts with HR+, HER2-, PIK3CA-mutated ABC, ALP was effective in the post-CDK4/6i setting regardless of ET partner and tumor genomic profile (including in presence of alterations in genes associated with CDK4/6i resistance). The absence of cross-resistance may allow pts with PIK3CA-mutated disease to benefit from ALP after disease progression on/after CDK4/6i.

Table 1.mPFS in pts from BYLieve Cohorts A and B based on baseline biomarker statusCohort A (ALP + FUL)Cohort B (ALP + LET)nmPFS, mo (95% CI) nmPFS, mo (95% CI)Overall (mFASa)1,21217.3 (5.6-8.3)1155.7 (4.5-7.2)Patients with available plasma sample for the biomarker analysisb1027.37 (5.60-8.67)975.70 (3.77-7.33)ctDNA fractionHigh (≥10%)655.60 (4.00-7.37)685.43 (3.70-7.20)Low (&lt;10%)37NE297.33 (5.83-11.00)TMBHigh (≥10)103.85 (0.47-8.33)154.60 (1.67-5.73)Low (&lt;10)716.13 (5.43-9.60)645.63 (3.73-7.50)Chr 8 or 11 amplificationWith174.23 (1.70-6.13)213.77 (1.93-7.37)Without858.40 (5.70-9.60)766.00 (5.20-7.53)Chr, chromosome; ctDNA, circulating tumor DNA; NE, not estimable; mPFS, median progression-free survival; TMB, tumor mutation burden. aPatients who received at least 1 dose of study treatment and had centrally confirmed PIK3CA mutation by a Novartis-designated laboratory were included in the mFAS. bOnly includes patients with centrally confirmed PIK3CA mutation in tumor tissue. 1. Rugo HS, et al. Lancet Oncol. 2021;22(4):489-498; 2. Rugo HS, et al. SABCS 2020. Poster PD2-07.

Citation Format: Dejan Juric, Nicholas Turner, Aleix Prat, Stephen Chia, Eva M Ciruelos, Manuel Ruiz-Borrego, Pamela Drullinsky, Florence Lerebours, Thomas Bachelot, O. Alejandro Balbin, Mukta Joshi, Estelle Roux, Christina H Arce, Murat Akdere, Hope S Rugo. Alpelisib + endocrine therapy (ET) in patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-), PIK3CA-mutated advanced breast cancer (ABC) previously treated with cyclin-dependent kinase 4/6 inhibitor (CDK4/6i): Biomarker analyses from the Phase II BYLieve study [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-13-03.

Abstract PD15-01: Impact of ESR1 mutations on endocrine therapy (ET) plus alpelisib benefit in patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-), PIK3CA-mutated, advanced breast cancer (ABC) who progressed on or after prior cyclin-dependent kinase inhibitor (CDK4/6i) therapy in the BYLieve trial

Introduction: Endocrine-based therapy is the standard of care for patients (pts) with HR+ ABC. Acquired ESR1 mutations (mut) have been reported in up to 56% of pts with HR+ ABC progressing after prior treatment with ET, and aromatase inhibitors (AIs) in particular. Alpelisib (ALP) is an α-selective PI3K inhibitor and degrader approved in combination with fulvestrant (FUL) for the treatment of HR+, HER2-, PIK3CA-mut ABC. The primary analysis of Cohorts A and B of the Phase II BYLieve trial demonstrated the safety and efficacy of ALP + ET in the post-CDK4/6i setting. We assessed the association between progression-free survival (PFS) and baseline ESR1 mut among pts in Cohorts A and B of the BYLieve trial. Methods: Cohorts A and B of the BYLieve trial included pre-/postmenopausal women with HR+, HER2-, PIK3CA-mut ABC who received CDK4/6i + AI (Cohort A) or CDK4/6i + FUL (Cohort B) as immediate prior therapy. Pts in Cohort B may have also received prior AI therapy. Pts received ALP 300 mg PO QD + FUL 500 mg IM Q28D and C1D15 (Cohort A) or ALP 300 mg PO QD + LET 2.5 mg PO QD (Cohort B). ESR1 mut was analyzed as an exploratory endpoint, using an error-corrected sequencing ctDNA assay (Novartis PanCancer gene-panel), in baseline plasma samples from pts with centrally confirmed PIK3CA mut in tumor tissue from Cohorts A and B. PFS by mut status was estimated using the Kaplan-Meier method. P values provided are nominal. No multiplicity adjustments were made, therefore, statistical interpretation should be made with caution. Results: 127 pts with ≥6 mo follow-up (median follow-up: 11.7 mo) were enrolled in Cohort A as of the 17 December 2019 data cut-off and 126 pts with ≥6 mo follow-up (median follow-up: 15.0 mo) were enrolled in Cohort B as of the 14 August 2020 data cut-off. 103 (81.7%) pts in Cohort B progressed on prior AI therapy (adjuvant/metastatic setting). 102 pts from Cohort A and 97 pts from Cohort B had available plasma samples and were included in this analysis. Similar outcomes were observed in this analysis and in the overall population (Table 1). At baseline, 26% (27/102) of pts in Cohort A and 26% (25/97) of pts in Cohort B had ESR1 mut detected. In Cohort A (ALP + FUL), a numerically lower PFS was observed in pts with ESR1-mut disease, but the wide confidence interval (CI) suggests no difference in risk of progression between those with and without ESR1 mut. In Cohort B (ALP + LET), pts with ESR1-mut disease had a shorter PFS compared with those without ESR1-mut disease. A possible limitation is that baseline characteristics of these subgroups may not be balanced.

Conclusion: Similar proportion of pts had ESR1-mut disease at baseline in both cohorts. All pts in Cohort A progressed on prior CDK4/6i + AI and most pts enrolled in Cohort B also progressed on prior AI therapy. This analysis suggests that pts with ESR1 mut tend to have lower PFS than those without a mut, and that ALP + LET might be less effective in pts with ESR1 mut. This adds to prior data that ESR1 mut reduce the efficacy of AI-based combination therapy. In pts with ESR1 mut detected after prior CDK4/6i therapy, ALP + FUL (the approved combination for PIK3CA-mut ABC) warrants consideration as an alternative treatment option. Studies of ALP in combination with new oral, selective estrogen-receptor degraders are also ongoing.

Table 1.Median PFS in BYLieve Cohorts A and B.Cohort A (ALP + FUL)Cohort B (ALP + LET)Overall (mFASa), N1,2121115mPFS, months (95% CI)7.3 (5.6-8.3)5.7 (4.5, 7.2)Patients with available plasma samples for ESR1-mutation testing,b N10297mPFS, months (95% CI)7.37 (5.60-8.67)5.70 (3.77-7.33)With ESR1 mutation (n=27)With ESR1 mutation (n=25) Without ESR1 mutation (n=72)mPFS, months (95% CI)5.55 (3.75-8.54)8.28 (5.45-9.46)4.57 (3.06-5.65)7.03 (4.50-8.31)Hazard ratio (95% CI)0.76 (0.44-1.33)0.55 (0.32-0.92)P value (nominal)0.30.02ALP, alpelisib; FUL, fulvestrant; LET, letrozole; mFAS, modified full analysis set; mPFS, median progression-free survival. . aPatients who received at least 1 dose of study treatment and had centrally confirmed PIK3CA mutation by a Novartis-designated laboratory were included in the mFAS. bOnly includes patients with centrally confirmed PIK3CA mutation in tumor tissue.1. Rugo HS, et al. Lancet Oncol. 2021;22(4):489-498; 2. Rugo HS, et al. SABCS 2020. Poster PD2-07.

Citation Format: Nick Turner, Hope S Rugo, Eva M Ciruelos, Manuel Ruiz-Borrego, Pamela Drullinsky, Florence Lerebours, Aleix Prat, Thomas Bachelot, Stephen Chia, Alejandro Balbin, Mukta Joshi, Estelle Roux, Christina H Arce, Murat Akdere, Dejan Juric. Impact of ESR1 mutations on endocrine therapy (ET) plus alpelisib benefit in patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-), PIK3CA-mutated, advanced breast cancer (ABC) who progressed on or after prior cyclin-dependent kinase inhibitor (CDK4/6i) therapy in the BYLieve trial [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD15-01.

Abstract PD13-05: Alpelisib + fulvestrant in patients with PIK3CA-mutated, HR+, HER2— advanced breast cancer (ABC) who received chemotherapy or endocrine therapy (ET) as immediate prior treatment: BYLieve Cohort C primary results and exploratory biomarker analyses

Introduction: Alpelisib (ALP), an inhibitor and degrader of phosphatidylinositol-3-kinase α (PI3Kα), + fulvestrant (FUL) demonstrated efficacy in PIK3CA-mutated, HR+, HER2- ABC in the phase 3 SOLAR-1 trial, which included only 20 patients (pts) with prior CDK4/6 inhibitor (CDKi) in the PIK3CA-mutated cohort. BYLieve (NCT03056755), a phase 2, open-label, 3-cohort noncomparative study, evaluates ALP + endocrine therapy (ET; FUL or letrozole [LET]) in pts with PIK3CA-mutated, HR+, HER2- ABC, progressing on/after prior therapies, including CDKi + ET. Cohorts A and B were restricted to pts receiving CDKi + (aromatase inhibitor [AI] or FUL), respectively, as immediate prior therapy, but Cohort C included pts whose cancer progressed on/after AI (in adjuvant or metastatic setting), and who received chemotherapy (CT; any line), or ET (FUL or LET monotherapy or with targeted therapy, including CDKi + FUL, but not CDKi + AI) as immediate prior treatment. Cohorts A and B demonstrated efficacy and safety of ALP + ET after prior CDKi. Here, we report primary results and biomarker analyses from Cohort C.. Methods: Pts in Cohort C received ALP 300 mg orally QD + FUL 500 mg intramuscular Q28D + C1D15. The primary endpoint was assessed in each cohort separately and is the proportion of pts with centrally confirmed PIK3CA mutation alive and without disease progression at 6 mo per local assessment; 95% CIs are calculated using Clopper and Pearson (1934) exact method. The 95% CI lower bound of the primary endpoint &gt;30% is clinically meaningful evidence of treatment effect. In an exploratory analysis of baseline biomarkers using ctDNA, progression-free survival (PFS) was estimated in pt subgroups per high (≥10%) or low (&lt;10%) ctDNA fraction and ESR1 mutational status via Kaplan-Meier estimation.. Results: 127 pts were enrolled in Cohort C (1 pt discontinued prior to treatment start) with ≥6 mo follow-up by the cutoff date (14 Jun 2021); 115 had a centrally confirmed PIK3CA mutation. Median follow-up was 11.4 mo (range, 0-23 mo); 79 (62.7%) pts had ≥2 prior lines of therapy in the metastatic setting, 58 (46.0%) pts had prior CT exposure in the metastatic setting, and 41 (32.5%) pts had prior FUL exposure in the metastatic setting. The primary endpoint was met, with 48.7% (95% CI, 39.3%-58.2%) of pts alive and without disease progression at 6 mo. Median PFS (mPFS) was 5.6 mo (95% CI, 5.4-8.1 mo). The most common all-grade adverse events (AEs) by preferred term were hyperglycemia (n=82, 65.1%), diarrhea (n=66, 52.4%), nausea (n=51, 40.5%), and rash (n=49, 38.9%). Grade ≥3 AEs (≥10%) included hyperglycemia (n=30, 23.8%) and rash (n=17, 13.5%). AEs leading to discontinuation occurred in 15.1% (n=19) of pts; most frequent AEs leading to discontinuation were rash (n=5, 4.0%) and hyperglycemia (n=4, 3.2%). Exploratory biomarker analyses in 74 pts who had available baseline biomarker samples at data cutoff showed that pts with a low ctDNA fraction (n=23) had longer mPFS than pts with high ctDNA fraction (n=51; 16.7 [95% CI, 10.4-19.5] vs 5.4 [95% CI, 2.9-7.2] mo; p&lt;0.001, HR=0.31 [95% CI, 0.2-0.6]). Efficacy was similar in pts with (n=20) and without (n=54) ESR1-mutated tumors (6.3 [95% CI, 2.8-8.3] vs 8.3 [95% CI, 5.5-16.7] mo; p=0.095, HR=0.59 [95% CI, 0.3-1.1]).. Conclusion: In Cohort A of BYLieve, efficacy of ALP + FUL suggests clinical benefit immediately after CDKi + AI; Cohort C confirms clinically relevant activity of ALP + FUL in a heterogeneous population, primarily treated in the third line or later, and potentially regardless of ESR1 status or ctDNA fraction, with no new safety signals detected. Together, these data confirm that ALP targets the effects of the PIK3CA-driver oncogene in HR+, HER2- ABC.

Citation Format: Hope S Rugo, Patrick Neven, Isabel Saffie, Yeon Hee Park, Michelino De Laurentiis, Florence Lerebours, Eva Maria Ciruelos, Nicholas Turner, Dejan Juric, Ennan Gu, Christina H Arce, Mukta Joshi, Estelle Roux, Murat Akdere, Stephen Chia. Alpelisib + fulvestrant in patients with PIK3CA-mutated, HR+, HER2— advanced breast cancer (ABC) who received chemotherapy or endocrine therapy (ET) as immediate prior treatment: BYLieve Cohort C primary results and exploratory biomarker analyses [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD13-05.

Genomics Reveal Admixture and Unexpected Patterns of Diversity in a Parapatric Pair of Butterflies

We studied the evolutionary relationship of two widely distributed parapatric butterfly species, Melitaea athalia and Melitaea celadussa, using the ddRAD sequencing approach, as well as genital morphology and mtDNA data. M. athalia was retrieved as paraphyletic with respect to M. celadussa. Several cases of mito-nuclear discordance and morpho-genetic mismatch were found in the contact zone. A strongly diverged and marginally sympatric clade of M. athalia from the Balkans was revealed. An in-depth analysis of genomic structure detected high levels of admixture between M. athalia and M. celadussa at the contact zone, though not reaching the Balkan clade. The demographic modelling of populations supported the intermediate genetic make-up of European M. athalia populations with regards to M. celadussa and the Balkan clade. However, the dissimilarity matrix of genotype data (PCoA) suggested the Balkan lineage having a genetic component that is unrelated to the athalia-celadussa group. Although narrowly sympatric, almost no signs of gene flow were found between the main M. athalia group and the Balkan clade. We propose two possible scenarios on the historical evolution of our model taxa and the role of the last glacial maximum in shaping their current distribution. Finally, we discuss the complexities regarding the taxonomic delimitation of parapatric taxa.

Stepwise interventions for improving hand hygiene compliance in a level 3 academic neonatal intensive care unit in north India

OBJECTIVE

We evaluated effect of sequentially introducing four WHO-recommended interventions to promote hand-hygiene compliance in tertiary-care NICU.

STUDY DESIGN

Four dedicated research nurses directly observed doctors and nurses to record success in hand-hygiene opportunities at randomly selected NICU beds and randomly sampled time-slots in four phases (of 4-weeks each): I-Baseline, II-Self-directed learning; III-Participatory learning; IV-Closed-Circuit Television (CCTV); and V-CCTV-plus (with feedback).

FINDINGS

Hand-hygiene compliance changed from 61.8% (baseline) to 77% (end) with overall relative change: 24.6% (95% CI 18, 32; p value= 0.003); compared with preceding phase, relative changes of 21% (15, 28; <0.001), 4% (0, 8; 0.008), -10% (-13, -6; <0.001), and 10% (5, 15; <0.001) during phases II, III, IV, and V, respectively were observed. Rise in hand-hygiene compliance was higher for after-WHO-moments (12.7%; upto 2.5-folds for moment 5, <0.001) compared to before-WHO-moments (5.2%). Educational interventions, feedback and monitoring WHO moments can improve hand-hygiene compliance significantly among health-care providers in NICU.

Strength of Association between Infarct Volume and Clinical Outcome Depends on the Magnitude of Infarct Size: Results from the ESCAPE-NA1 Trial

BACKGROUND AND PURPOSE

Infarct volume is an important predictor of clinical outcome in acute stroke. We hypothesized that the association of infarct volume and clinical outcome changes with the magnitude of infarct size.

MATERIALS AND METHODS

Data were derived from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, in which patients with acute stroke with large-vessel occlusion were randomized to endovascular treatment plus either nerinetide or a placebo. Infarct volume was manually segmented on 24-hour noncontrast CT or DWI. The relationship between infarct volume and good outcome, defined as mRS 0-2 at 90 days, was plotted. Patients were categorized on the basis of visual grouping at the curve shoulders of the infarct volume/outcome plot. The relationship between infarct volume and adjusted probability of good outcome was fitted with linear or polynomial functions as appropriate in each group.

RESULTS

We included 1099 individuals in the study. Median infarct volume at 24 hours was 24.9 mL (interquartile range [IQR] = 6.6-92.2 mL). On the basis of the infarct volume/outcome plot, 4 infarct volume groups were defined (IQR = 0-15 mL, 15.1-70 mL, 70.1-200 mL, >200 mL). Proportions of good outcome in the 4 groups were 359/431 (83.3%), 219/337 (65.0%), 71/201 (35.3%), and 16/130 (12.3%), respectively. In small infarcts (IQR = 0-15 mL), no relationship with outcome was appreciated. In patients with intermediate infarct volume (IQR = 15-200 mL), there was progressive importance of volume as an outcome predictor. In infarcts of > 200 mL, outcomes were overall poor.

CONCLUSIONS

The relationship between infarct volume and clinical outcome varies nonlinearly with the magnitude of infarct size. Infarct volume was linearly associated with decreased chances of achieving good outcome in patients with moderate-to-large infarcts, but not in those with small infarcts. In very large infarcts, a near-deterministic association with poor outcome was seen.

Effectiveness and safety of dolutegravir two-drug regimens in virologically suppressed people living with HIV: a systematic literature review and meta-analysis of real-world evidence

Objectives

Dolutegravir (DTG) is widely recommended within three‐drug regimens. However, similar efficacy and tolerability have also been achieved with DTG within two‐drug regimens in clinical trials. This study evaluated the real‐world effectiveness and discontinuations in people living with HIV‐1 (PLHIV) switching to DTG with lamivudine (3TC) or rilpivirine (RPV).

Methods

This was a one‐arm meta‐analysis utilizing data from a systematic literature review. Data from real‐world evidence studies of DTG + RPV and DTG + 3TC were extracted, pooled and analysed. The primary outcome was the proportion of patients with viral failure (VF; ≥ 50 copies/mL in two consecutive measurements and/or ≥ 1000 copies/mL in a single measurement) at week 48 (W48) and week 96 (W96). Other outcomes included virological suppression (VS; < 50 copies/mL) and discontinuations (W48 and W96). Estimates were calculated for VF, VS as per snapshot (VSS) and on treatment analysis (VSOT), and discontinuations.

Results

Pooled mean estimates of VF for DTG + 3TC and DTG + RPV were 0.8% [95% confidence interval (CI): 0.4–1.3] and 0.6% (95% CI: 0.0–1.6), respectively, at W48. VSS rate at W48 was 85.0% (95% CI: 82.3–87.5) for DTG + 3TC regimen and 92.4% (95% CI: 85.0–97.7) in the DTG + RPV regimen. The DTG + 3TC and DTG + RPV regimens led to discontinuations in 13.6% (95% CI: 11.1–16.2) and 7.2% (95% CI: 2.1–14.4) of patients, respectively, at W48. Similar results were observed at W96.

Conclusions

Treatment with DTG + 3TC or DTG + RPV in clinical practice provides a low rate of VF and a high rate of VS when initiated in virologically suppressed PLHIV with diverse backgrounds.

130 Expression of selected biomarker candidate genes to confer invitro maturation in Indian buffaloes

Invitro maturation (IVM) of oocytes is a crucial step and is directly related to better embryo production in buffaloes. Therefore, we planned to study gene expression of GDF9, HAS2, SPRY1, ARHGAP22, COL18A1, and GPC4 genes in IVM and immature cumulus–oocyte complexes (COCs). The COCs were recovered from follicles of slaughter origin ovaries of native buffaloes. COCs were observed under stereo zoom microscope and categorized in four grades according to morphology. Of the four grades, the first three grade COCs were considered and randomly allotted in two groups: immature treatment group (n=263) and IVM treatment group (n=272). IVM of COCs was carried out in 100-μL drops of BO-IVM medium overlaying embryo tested oil in a 35-mm petri dish under 5% CO2 in a 39.0°C incubator for 24h. Cumulus of COCs of both groups were removed by treating with 0.25% trypsin, and oocytes were stored in RNALater for future use. The expression of genes was evaluated using quantitative PCR, and the relative expression of each gene was calculated using the ΔΔCt method with efficiency correction. The logarithmic transformation of fold change (log2FC) of each candidate gene in the IVM oocyte group was computed against the immature oocyte group based on the observed cycle threshold values. Appropriate standard deviations were determined based on the observed deviations among the triplicates. The expression in the IVM treatment group of previously reported upregulated genes (GDF9, HAS2, SPRY1) was higher (up to 10-fold) compared with the immature treatment group (reference group). In the present study, relatively lower expression was observed for the other candidate genes (ARHGAP22, COL18A1, GPC4) in the bovine transcripts of oocyte, which were previously also reported as being downregulated.

Identification of Latent Classes of Motor Performance in a Heterogenous Population of Adults

OBJECTIVE

To determine classes of motor performance based on community deployable motor impairment and functional tests in a heterogeneous adult population.

DESIGN

Sixteen tests of limb-specific and whole-body measures of motor impairment and function were obtained. Linear regression analysis was used to dichotomize performance on each test as falling within or outside the age- and sex-predicted values. Latent class analysis was used to determine 3 classes of motor performance. The chi-square test of association and the Fisher exact test were used for categorical variables, and analysis of variance and the Kruskal-Wallis test were used for continuous variables to evaluate the relationship between demographic characteristics and latent classes.

SETTING

General community.

PARTICIPANTS

Individuals (N=118; 50 men) participated in the study. Quota sampling was used to recruit individuals who self-identified as healthy (n=44) or currently living with a preexisting chronic health condition, including arthritis (n=19), multiple sclerosis (n=18), Parkinson disease (n=17), stroke (n=18), or low functioning (n=2).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURE

Latent classes of motor performance.

RESULTS

Across the entire sample, 3 latent classes of motor performance were determined that clustered individuals with motor performance falling: (1) within predicted values on most of the tests (expected class), (2) outside predicted values on some of the tests (moderate class), and (3) outside predicted values on most of the tests (severe class).The ability to distinguish between the respective classes based on the percent chance of falling outside predicted values was achieved using the following community deployable motor performance tests: 10-meter walk test (22%, 80%, and 100%), 6-minute walk test (14.5%, 37.5%, and 100%), grooved pegboard test (23%, 38%, and 100%), and modified physical performance test (3%, 54%, and 96%).

CONCLUSIONS

In this heterogeneous group of adults, we found 3 distinct classes of motor performance, with the sample clustering into an expected test score group, a moderate test score deficiency group, and a severed test score deficiency group. Based on the motor performance tests, we established that community deployable, easily administered testing could accurately predict the established clusters of motor performance.

Obese patients and robotic colorectal surgery: systematic review and meta-analysis

BACKGROUND

Obesity is a major health problem, demonstrated to double the risk of colorectal cancer. The benefits of robotic colorectal surgery in obese patients remain largely unknown. This meta-analysis evaluated the clinical and pathological outcomes of robotic colorectal surgery in obese and non-obese patients.

METHODS

MEDLINE, Embase, Global Health, Healthcare Management Information Consortium (HMIC) and Midwives Information and Resources Service (MIDIRS) databases were searched on 1 August 2018 with no language restriction. Meta-analysis was performed according to PRISMA guidelines. Obese patients (BMI 30 kg/m2 or above) undergoing robotic colorectal cancer resections were compared with non-obese patients. Included outcome measures were: operative outcomes (duration of surgery, conversion to laparotomy, blood loss), postoperative complications, hospital length of stay and pathological outcomes (number of retrieved lymph nodes, positive circumferential resection margins and length of distal margin in rectal surgery).

RESULTS

A total of 131 full-text articles were reviewed, of which 12 met the inclusion criteria and were included in the final analysis. There were 3166 non-obese and 1420 obese patients. A longer duration of surgery was documented in obese compared with non-obese patients (weighted mean difference -21·99 (95 per cent c.i. -31·52 to -12·46) min; P < 0·001). Obese patients had a higher rate of conversion to laparotomy than non-obese patients (odds ratio 1·99, 95 per cent c.i. 1·54 to 2·56; P < 0·001). Blood loss, postoperative complications, length of hospital stay and pathological outcomes were not significantly different in obese and non-obese patients.

CONCLUSION

Robotic surgery in obese patients results in a significantly longer duration of surgery and higher conversion rates than in non-obese patients. Further studies should focus on better stratification of the obese population with colorectal disease as candidates for robotic procedures.

Remote wireless vital signs monitoring on the ward for early detection of deteriorating patients: A case series

INTRODUCTION

Remote wireless monitoring is a new technology that allows the continuous recording of ward patients' vital signs, supporting nurses by measuring vital signs frequently and accurately. A case series is presented to illustrate how these systems might contribute to improved patient surveillance.

METHODS AND RESULTS

Five hospitals in three European countries installed a remote wireless vital signs monitoring system on medical or surgical wards. Heart rate, respiratory rate and temperature were measured by the system every 2 min. Four cases of (paroxysmal) atrial fibrillation are presented, two cases of sepsis and one case each of pyrexia, cardiogenic pulmonary edema and pulmonary embolisms. All cases show that the remote monitoring system revealed the first signs of ventilatory and circulatory deterioration before a change in the trends of the respective values became obvious by manual vital signs measurement.

DISCUSSION

This case series illustrates that a wireless remote vital signs monitoring system on medical and surgical wards has the potential to reduce time to detect deteriorating patients.

The desert hamster Phodopus roborovskii (Satunin, 1903) (Rodentia, Cricetidae) from north-western Tibetan plateau, Ladakh, India: an addition to the mammalian fauna of the Indian subcontinent

During a systematic survey of the small mammals in the relatively unexplored north-western regions of the Tibetan plateau in India, we captured and identified the desert hamster Phodopus roborovskii using molecular phylogenetic methods. We also provide revised distributional estimates for this species using niche modelling (Maxent and 19 bioclimatic variables), taking into account sampling bias. We evaluated suitable habitats for the species, identifying regions in the Trans-Himalayas that may harbour this species. This study improves the knowledge of the desert hamster’s range and is a new record and an addition to the Indian sub-continental mammalian fauna, ~750 km southward extension from its known range.

Laparoscopic repair of type III/IV giant para-oesophageal herniae with biological prosthesis: a single centre experience

PURPOSE

Repair of giant paraoesophageal herniae (GPEH) is technically challenging and requires significant experience in advanced foregut surgery. Controversy continues on suture versus mesh cruroplasty with the most recent systematic review and meta-analysis putting the onus on the operating surgeon. Study aim was to review whether the biological prosthesis (non-cross-linked bovine pericardium and porcine dermis) and the technique adopted for patients with GPEH had an influence on clinical and radiological recurrences.

METHOD

A retrospective analysis of a prospectively collected data of 60 consecutive patients with confirmed 5 cm hiatus hernia and ≥ 30% stomach displacement in the thorax that were operated in the upper gastrointestinal unit of a large district general hospital between September 2010 and August 2017. Pre and post-surgery Gastro-Oesophageal Reflux Disease Questionnaire [(GORD-HRQOL)] and a follow up contrast study were completed.

RESULTS

60 included 2 (3%) and 58 (97%) emergency and elective procedures respectively with a male: female ratio of 1:3, age 71* (Median) (42-89) years, BMI 29* (19-42) and 26 (43%) with ASA III/IV. Investigations confirmed 46* (37-88) mm and 42* (34-77) mm transverse and antero-posterior hiatal defect respectively with 60* (30-100)% displacement of stomach into chest. Operative time and length of stay was 180* (120-510) minutes and 2* (1-30) days respectively. One (2%) converted for bleeding and 2 (3%) peri-operative deaths. Five (8%), 5 (8%) and 4 (7%) have dysphagia, symptomatic and radiological recurrences respectively. GORD-HRQOL recorded preoperatively was 27* (10-39) dropping significantly postoperatively to 0* (0-21) (P < 0.005) with 95% patient satisfaction at a follow up of 60* (36-84) months.

CONCLUSIONS

Our technique of laparoscopic GPEH repair with biological prosthesis is safe with a reduced symptomatic and radiological recurrence and an acceptable morbidity and mortality.

In search of effective H1N1 neuraminidase inhibitor by molecular docking, antiviral evaluation and membrane interaction studies using NMR

Considering the need for discovery of new antiviral drugs, in view to combat the issue of resistance particularly to anti-influenza drugs, a series of 2'-amino, 3'-amino and 2', 4'-dihydroxy chalcone derivatives were designed. Structure-based drug design was used to design inhibitors of influenza virus - H1N1 neuraminidase enzyme. These were further optimized by a combination of iterative medicinal chemistry principles and molecular docking. Based on the best docking scores, some chalcone derivatives were synthesized and characterized by infrared spectroscopy (IR) and proton nuclear magnetic resonance (NMR). The molecules were evaluated for their anti-influenza action against influenza A/Pune isolate/2009 (H1N1) virus by in vitro enzyme-based assay (neuraminidase inhibition assay). We have then selected few of them for multinuclear NMR studies, 31P NMR, in order to probe the molecular mechanism of their antiviral action. Reasonably good correlation between docking scores; anti-influenza activity; and 31P NMR results were observed. The computational predictions were in consensus with the experimental results. It was observed that among tested compounds, derivative 1A, viz. 2', 4'-dihydroxy-4-methoxy chalcone, showed highest activity (IC50 = 2.23 μmol/l) against the virus under study. This derivative 1A can be explored further to provide a future therapeutic option for the treatment and prophylaxis of H1N1 viral infections.

Developing tool and Measuring Integration Characteristics of Basic Science Curriculum to Improve Curriculum Integration

Background Integrated curriculum enhances students' learning and the retention of knowledge. At Patan Academy of Health Sciences, integrated organ system based curriculum is used with Problem Based Learning as the principle teaching learning method to foster students' learning. In addition, other approaches of integration were under taken such as integrated assessment; logical arrangement teaching learning methods (lectures and practicals); joint effort of faculty in curriculum planning and delivery; conducive environment to foster hidden curriculum. This study describes the perception of faculty and students on integration characteristics of Basic Science curriculum. Objective To measure the integration characteristics of Basic Science Curriculum. Method Tool was developed to measure integration characteristics of Basic Science Curriculum and ensure whether such planned integration has been achieved. Mixed method was used to measure the perception of the integration characteristics i) quantitatively by questionnaire survey to faculty and students ii) qualitatively by in-depth interview of students. Result Both faculty and students perceived that all the blocks in Basic Science was well integrated in the quantitative questionnaire survey. But, in the in-depth interview, students perceived integration of curriculum in organ system blocks were better integrated compared to Principle of Human Biology blocks where fundamentals of basic science disciplines were delivered. Students reflected that Problem Based Learning not only integrated Basic Science disciplines but also with clinical sciences and the social context. But, students perceived that Community Health Sciences curriculum was not so well integrated with Basic Science subjects. Conclusion Overall, this study showed that planned integration in Basic Science curriculum was successfully executed during curriculum implementation.

Blazar spectral variability as explained by a twisted inhomogeneous jet

Blazars are active galactic nuclei, which are powerful sources of radiation whose central engine is located in the core of the host galaxy. Blazar emission is dominated by non-thermal radiation from a jet that moves relativistically towards us, and therefore undergoes Doppler beaming. This beaming causes flux enhancement and contraction of the variability timescales, so that most blazars appear as luminous sources characterized by noticeable and fast changes in brightness at all frequencies. The mechanism that produces this unpredictable variability is under debate, but proposed mechanisms include injection, acceleration and cooling of particles, with possible intervention of shock waves or turbulence. Changes in the viewing angle of the observed emitting knots or jet regions have also been suggested as an explanation of flaring events and can also explain specific properties of blazar emission, such as intra-day variability, quasi-periodicity and the delay of radio flux variations relative to optical changes. Such a geometric interpretation, however, is not universally accepted because alternative explanations based on changes in physical conditions-such as the size and speed of the emitting zone, the magnetic field, the number of emitting particles and their energy distribution-can explain snapshots of the spectral behaviour of blazars in many cases. Here we report the results of optical-to-radio-wavelength monitoring of the blazar CTA 102 and show that the observed long-term trends of the flux and spectral variability are best explained by an inhomogeneous, curved jet that undergoes changes in orientation over time. We propose that magnetohydrodynamic instabilities or rotation of the twisted jet cause different jet regions to change their orientation and hence their relative Doppler factors. In particular, the extreme optical outburst of 2016-2017 (brightness increase of six magnitudes) occurred when the corresponding emitting region had a small viewing angle. The agreement between observations and theoretical predictions can be seen as further validation of the relativistic beaming theory.

Vemurafenib-resistance via de novo RBM genes mutations and chromosome 5 aberrations is overcome by combined therapy with palbociclib in thyroid carcinoma with BRAFV600E

PURPOSE

Papillary thyroid carcinoma (PTC) is the most frequent endocrine tumor. BRAFV600E represents the PTC hallmark and is targeted with selective inhibitors (e.g. vemurafenib). Although there have been promising results in clinical trials using these inhibitors, most patients develop resistance and progress. Tumor clonal diversity is proposed as one mechanism underlying drug resistance. Here we have investigated mechanisms of primary and secondary resistance to vemurafenib in BRAFWT/V600E-positive PTC patient-derived cells with P16-/- (CDKN2A-/-).

EXPERIMENTAL DESIGN

Following treatment with vemurafenib, we expanded a sub-population of cells with primary resistance and characterized them genetically and cytogenetically. We have used exome sequencing, metaphase chromosome analysis, FISH and oligonucleotide SNP-microarray assays to assess clonal evolution of vemurafenib-resistant cells. Furthermore, we have validated our findings by networks and pathways analyses using PTC clinical samples.

RESULTS

Vemurafenib-resistant cells grow similarly to naïve cells but are refractory to apoptosis upon treatment with vemurafenib, and accumulate in G2-M phase. We find that vemurafenib-resistant cells show amplification of chromosome 5 and de novo mutations in the RBM (RNA-binding motifs) genes family (i.e. RBMX, RBM10). RBMX knockdown in naïve-cells contributes to tetraploidization, including expansion of clones with chromosome 5 aberrations (e.g. isochromosome 5p). RBMX elicits gene regulatory networks with chromosome 5q cancer-associated genes and pathways for G2-M and DNA damage-response checkpoint regulation in BRAFWT/V600E-PTC. Importantly, combined therapy with vemurafenib plus palbociclib (inhibitor of CDK4/6, mimicking P16 functions) synergistically induces stronger apoptosis than single agents in resistant-cells and in anaplastic thyroid tumor cells harboring the heterozygous BRAFWT/V600E mutation.

CONCLUSIONS

Critically, our findings suggest for the first time that targeting BRAFWT/V600E and CDK4/6 represents a novel therapeutic strategy to treat vemurafenib-resistant or vemurafenib-naïve radioiodine-refractory BRAFWT/V600E-PTC. This combined therapy could prevent selection and expansion of aggressive PTC cell sub-clones with intrinsic resistance, targeting tumor cells either with primary or secondary resistance to BRAFV600E inhibitor.

Assigning conservation value and identifying hotspots of endemic rattan diversity in the Western Ghats, India

Rattans, or canes, are one of the most important non-timber forest products supporting the livelihood of many forest-dwelling communities in South and North-eastern India. Due to increased demand for rattan products, rattans have been extracted indiscriminately from the Western Ghats, a 1600-km mountain chain running parallel to the west coast of India. Extensive harvesting, loss of habitat and poor regeneration has resulted in dwindling rattan populations, necessitating an urgent attempt to conserve existing rattan resources. In this study, using niche-modelling tools, an attempt has been made to identify areas of high species richness of rattans in the Western Ghats, one of the mega-diversity regions of the world. We have also developed conservation values for 21 economically important and endemic rattans of the Western Ghats. We identified at least two to three sites of extremely high species richness outside the existing protected area network that should be prioritized for in situ conservation. This study emphasizes the need to develop strategies for the long-term conservation of rattans in the Western Ghats, India.

Deposition and spatial variation of thoron decay products in a thoron experimental house using the Direct Thoron Progeny Sensors

Experiments have been carried out using the deposition-based Direct Thoron Progeny Sensors (DTPS) in a thoron experimental house. The objective was to study the thoron decay product characteristics such as the deposition velocities, spatial variability and dependence on aerosol particle concentrations. Since the deposition velocity is an important characteristic in the calibration of the DTPS, it is very important to study its dependence on aerosol concentration in a controlled environment. At low aerosol concentration (1500 particles/cm³) the mean effective deposition velocity was measured to be 0.159 ± 0.045 m h^-1; at high aerosol concentration (30 000 particles/cm³) it decreased to 0.079 ± 0.009 m h^-1. The deposition velocity for the attached fraction of the thoron decay products did not change with increasing aerosol concentration, showing measurement results of 0.048 ± 0.005 m h^-1 and 0.043 ± 0.014 m h^-1, respectively. At low particle concentration, the effective deposition velocity showed large scattering within the room at different distances from center. The attached fraction deposition velocity remained uniform at different distances from the wall. The measurements in the thoron experimental house can be used as a sensitivity test of the DTPS in an indoor environment with changing aerosol concentration. The uniform spatial distribution of thoron decay products was confirmed within the experimental house. This indicates that direct measurement of thoron decay product concentration should be carried out instead of inferring it from thoron gas concentration, which is very inhomogeneous within the experimental house.

Effectiveness of amitriptyline and lamotrigine in traumatic spinal cord injury-induced neuropathic pain: a randomized longitudinal comparative study

STUDY DESIGN

Randomized longitudinal comparative study.

OBJECTIVES

To compare the efficacy of lamotrigine and amitriptyline in the management of traumatic spinal cord injury (SCI)-induced neuropathic pain (NP).

SETTING

Sawai Man Singh Medical College and Hospital, Jaipur, India.

METHODS

A total of 147 individuals with NP were randomized for a 3-week trial of either amitriptyline or lamotrigine. Amitriptyline was administered orally at doses of 25, 50 and 100 mg once daily at night time, and lamotrigine was administered orally at doses of 25, 50 and 100 mg twice daily, both for 1 week by means of optional titration. Assessment of NP was done at baseline and thereafter at 1, 2 and 3 weeks using Short-form MC Gill Pain Questionnaire-2 (SFMPQ2) scores.

RESULTS

There was a significant difference between the mean values of the SFMPQ2 score at baseline and those at each follow-up for amitriptyline. Similar results were seen in the lamotrigine group. When the differences in mean SFMPQ2 scores at different time frames from baseline were compared with those of the other group, values were found to be nonsignificant as seen on the Mann-Whitney U-test.

CONCLUSIONS

These findings support the use of both amitriptyline and lamotrigine in the management of NP after traumatic SCI.

Effect of 220Rn gas concentration distribution on its transmission from a delay chamber: evolving a CFD-based uniformity index

(220)Rn mitigation can be achieved by delay chamber technique, which relies on the advantage of its short half-life. However, flow rate as well as inlet-outlet position for the delay chamber can have a significant impact on (220)Rn concentration distribution patterns and hence transmission factor. In the present study, computational fluid dynamics simulations to estimate the concentration distribution has been carried out in a chamber of 0.5 m(3) for the combination of six different inlet-outlet positions and five different flow rates. Subsequently, the transmission factor (TF) for the chamber was evaluated and found to be highly dependent on the flow rate and inlet-outlet positions. For ease of scale up, the dependency of TF on the flow rate and the inlet-outlet positions is best summarised by relative transmission factor (RTF), which is the ratio of the TFs for the case of inlet and outlet on different faces to that on the same face.

NMR-based metabonomics for understanding the influence of dormant female genital tuberculosis on metabolism of the human endometrium

STUDY QUESTION

Does investigation of metabolic perturbations in endometrial tissue of women with dormant genital tuberculosis (GTB) during the window of implantation (WOI) assist in improving the understanding of endometrial receptivity?

SUMMARY ANSWER

In dormant GTB cases significant alterations in endometrial tissue metabolites occur, largely related to energy metabolism and amino acid biosynthesis in dormant GTB cases.

WHAT IS KNOWN ALREADY

As an intracellular pathogen, Mycobacterium tuberculosis strongly influences the metabolism of host cells causing metabolic dysregulation. It is also accepted that dormant GTB impairs the receptive status of the endometrium. Global metabolic profiling is useful for an understanding of disease progression and distinguishing between diseased and non-diseased groups.

STUDY DESIGN, SIZE, DURATION

Endometrial tissue samples were collected from patients reporting at the tertiary infertility care center during the period September 2011-March 2013. Women having tested positive for GTB were considered as the study group (n = 24). Normal healthy women undergoing sterilization (n = 26) and unexplained infertile women with repeated IVF failure (n = 21) volunteered to participate as controls.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Endometrial tissue samples were collected 6-10 days after confirmation of ovulation. PCR and BACTEC-460 culture were used for diagnosing GTB. Proton nuclear magnetic resonance (1H NMR) spectra of tissue were recorded using a 700 MHz Bruker Avance AV III spectrometer. Following phase and baseline correction of all NMR spectra by Bruker Topspin 2.1 software, spectral peak alignment of the data was performed. Multivariate analysis was applied to all spectra and individual metabolites identified and multiple correlation analysis was performed.

MAIN RESULTS AND THE ROLE OF CHANCE

Leucine, isoleucine, acetate, lactate, glutamate, glutamine, methionine, lysine, creatine, glycogen, glycine, proline and choline were found to be significantly increased (P < 0.05) in endometrial tissue of women with dormant GTB compared with unexplained infertile women with repeated implantation failure. Valine, citrate, succinate and aspartate were also observed to be significantly up-regulated (P < 0.01). Furthermore, a significant decrease in glucose (P < 0.05), threonine (P < 0.05), tyrosine (P < 0.01) and phenylalanine (P < 0.0001) was observed in women with dormant GTB. Pearson's correlation analysis between the expression of various endometrial receptivity markers and metabolites showed a significant negative correlation (-0.236 to -0.545, P < 0.05). Also, the metabolites were positively correlated with endometrial receptivity markers (0.207 to 0.618, P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

It is often difficult to diagnose dormant GTB because it tends to exist without any clinical signs or symptoms. In addition, the diagnosis of GTB by culture remains a challenge due to low detection rates and its paucibacillary nature. Testing for prostate-specific antigen or the Y chromosome in order to account for the possible influences of recent exposure to semen on endometrial metabolism would be important.

WIDER IMPLICATIONS OF THE FINDINGS

The metabolic changes associated with the dormant tubercle infection are of potential relevance to clinicians for the treatment of dormant GTB-related infertility.

STUDY FUNDING/COMPETING INTERESTS

Government of India, Indian Council of Medical Research. There are no conflicts of interest.