Evaluating the clinical utility of the Atopic Dermatitis Control Tool: measurement properties and agreement between patients' responses and clinicians' impressions of atopic dermatitis control

Previous analyses have demonstrated the validity and reliability of the Atopic Dermatitis Control Tool (ADCT) in assessing patient-perceived control of atopic dermatitis (AD). We evaluated levels of agreement between patient and clinician assessments of AD control using the ADCT and clinician global assessment of control, respectively, providing further support to the measurement properties of the ADCT.

Correlation of the Geriatric Assessment with Overall Survival in Older Patients with Cancer

AIMS

Global guidelines recommend that all older patients with cancer receiving chemotherapy should undergo a geriatric assessment. However, utilisation of the geriatric assessment is often constrained by its time-intensive nature, which limits its adoption in settings with limited resources and high demand. There is a lack of evidence correlating the results of the geriatric assessment with survival from the Indian subcontinent. Therefore, the aims of the present study were to assess the impact of the geriatric assessment on survival in older Indian patients with cancer and to identify the factors associated with survival in these older patients.

MATERIALS AND METHODS

This was an observational study, conducted in the geriatric oncology clinic of the Tata Memorial Hospital (Mumbai, India). Patients aged 60 years and older with cancer who underwent a geriatric assessment were enrolled. We assessed the non-oncological geriatric domains of function and falls, nutrition, comorbidities, cognition, psychology, social support and medications. Patients exhibiting impairment in two or more domains were classified as frail.

RESULTS

Between June 2018 and January 2022, we enrolled 897 patients. The median age was 69 (interquartile range 65-73) years. The common malignancies were lung (40.5%), oesophagus (31.9%) and genitourinary (12.1%); 54.6% had metastatic disease. Based on the results of the geriatric assessment, 767 (85.4%) patients were frail. The estimated median overall survival in fit patients was 24.3 (95% confidence interval 18.2-not reached) months, compared with 11.2 (10.1-12.8) months in frail patients (hazard ratio 0.54; 95% confidence interval 0.41-0.72, P < 0.001). This difference in overall survival remained significant after adjusting for age, sex, primary tumour and metastatic status (hazard ratio 0.56; 95% confidence interval 0.41-0.74, P < 0.001). In the patients with a performance status of 0 or 1 (n = 454), 365 (80.4%) were frail; the median overall survival in the performance status 0-1 group was 33.0 months (95% confidence interval 24.31-not reached) in the fit group versus 14.4 months (95% confidence interval 12.25-18.73) in the frail patients (hazard ratio 0.50; 95% confidence interval 0.34-0.74, P = 0.001). In the multivariate analysis, the geriatric assessment domains that were predictive of survival were function (hazard ratio 0.68; 95% confidence interval 0.52-0.88; P = 0.003), nutrition (hazard ratio 0.64; 95% confidence interval 0.48-0.85, P = 0.002) and cognition (hazard ratio 0.67; 95% confidence interval 0.49-0.91, P = 0.011).

DISCUSSION

The geriatric assessment is a powerful prognostic tool for survival among older Indian patients with cancer. The geriatric assessment is prognostic even in the cohort of patients thought to be the fittest, i.e. performance status 0 and 1. Our study re-emphasises the critical importance of the geriatric assessment in all older patients planned for cancer-directed therapy.

Prevalence and morphological analysis of isthmuses in mandibular molars of the Indian population: A micro-computed tomographic study

Objectives

This study evaluated the prevalence, configurations, and correlation of isthmuses at coronal, middle, and apical root 3rd in mandibular molars of the Indian population using micro-computed tomography μCT).

Materials and Methods

One hundred and five permanent mandibular molar teeth were scanned under μCT. The axial sections were analyzed at the coronal, middle, and apical thirds of the root for isthmus types and classified according to Hsu and Kim's classification. Descriptive statistics for each isthmus type were calculated. The correlations between the apical, middle, and coronal thirds of the root were determined using Pearson's correlation coefficient.

Results

Type IV isthmus was the most common in the coronal third of the mesial root of mandibular 1st molar (42.9%), while Type V was prevalent in the coronal third of the mesial root of 2nd molar (42.9%). Type I isthmus was found to be highly prevalent in the middle 3rd (71.4%) and apical 3rd (61.9%) of mesial roots of 1st molars, and in the middle 3rd (71.4%) and apical 3rd (42.9%) of mesial roots of 2nd molars. Type V isthmus was the most prevalent in all the thirds of the distal roots of both 1st and 2nd molars, ranging from 40% to 50%. Furthermore, a strong correlation of 0.965 (P < 0.01) was found between the isthmuses in the apical and middle thirds of roots.

Conclusion

There are variations in the prevalence and type of isthmuses across different sections of the root, including the presence of atypical isthmuses. Micro-CT with high-resolution imaging and three-dimensional reconstruction is crucial for investigating root canal morphology. Clinicians could benefit from considering demographic characteristics to better predict the presence of isthmus variations.

Clinical Relevance

The isthmus configurations and frequency differ at each section of mandibular teeth.

End-of-life solar photovoltaic panel waste management in India: forecasting and environmental impact assessment

Presently, India is in the stage of installation of solar photovoltaic panels and no focus is being given towards the impending problem of handling solar waste. The absence of adequate regulations, guidelines and operational infrastructure for photovoltaic waste in the country may lead to waste being inappropriately landfilled or incinerated in a manner that may be detrimental to human health and the environment. Business as usual projection estimates 6.64 million tonnes and 5.48 million tonnes of waste generation due to the early and regular losses using the Weibull distribution function, respectively by 2040 in India. The current study also systematically investigates various policies and legislation developments on the end-of-life of photovoltaic modules in various regions of the world, to identify gaps for further assessment. Using life cycle assessment methodology, this paper compares the environmental impacts of landfilling end-of-life crystalline silicon panels with avoided burden approach due to the recycling of materials. It has been demonstrated that solar photovoltaic recycling and reusing the recovered materials will result in impact reduction in the forthcoming production phase by as high as 70%. Further, the outcomes of carbon footprint, single score indicator with the application of Intergovernmental Panel on Climate Change also predicts lower values for avoided burden approach due to recycling (15,393.96 kgCO2 eq) in comparison to landfill approach (19,844.054 kg CO2 eq). The outcomes of this study aim to illuminate the importance of the sustainable management of photovoltaic panels at end-of-life.

Transcatheter aortic valve implantation outcomes compared between bicuspid aortic and tricuspid aortic valve stenosis: an updated systematic review and meta-analysis

Background

TAVI has emerged as an attractive treatment modality based on promising recent trial data. Patients with BAV, a commonly encountered clinical condition have largely been excluded from a majority of trials.

Purpose

Elderly patients with BAV and severe AS are increasingly encountered in clinical practice. This meta-analysis compares clinical outcomes between bicuspid and tricuspid AV patients to address the current knowledge-gap and identify optimal management strategies of these patients.

Methods

A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify the available observational studies comparing outcomes of TAVI in BAV and TAV patients. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints.

Results

16 Observational studies met inclusion criteria, comprising 10,053 patients with BAV and 173,307 patients with TAV that underwent TAVI. No significant differences in 30-day and long-term mortality rates were observed. Patients with BAV had an increased risk of stroke (OR 1.23; 95% CI [1.06–1.44], p=0.007), re-intervention (OR 1.90; 95% CI [1.15–3.15], p=0.01), paravalvular leak (OR 1.42; 95% CI [1.25–1.61], p&lt;0.ehab724.22251), conversion to open surgery (OR 1.93; 95% CI [1.21–3.07], p=0.006), and new pacemaker implantation (1.57; 95% CI (1.06 - 2.33, p=0.02). Adverse event rates are lower with the use of newer generation of valves. No significant difference in major vascular complications, major bleeding, or incidence of AKI was noted.

Conclusions

Complication rates for BAV TAVI are higher, but mortality is similar to TAV TAVI indicating TAVI is an appropriate alternative for intermediate-high risk patients with BAV. A better understanding of valve anatomy, physician expertise, the use of newer-generation valves can help reduce these complications.

Funding Acknowledgement

Type of funding sources: None.

Outcomes of permanent pacemaker insertion after TAVR: a systematic review and meta-analysis

Background/Introduction

Conduction abnormalities are frequently encountered after transcatheter aortic valve replacement (TAVR) performed for severe aortic stenosis, leading to post-procedure permanent pacemaker (PPM) insertion. Although the predictors of- and factors leading to post-TAVR PPM have been studied extensively, its short-term and long-term outcomes have not been established.

Purpose

PPM placement can lead to significant changes in outcomes in post-TAVR patients, which remain unclear. With this analysis, we aim to evaluate the differences between outcomes of patients requiring PPM and those not requiring PPM post-TAVR.

Methods

A comprehensive literature search was performed in PubMed, EMBASE, and Cochrane to identify relevant trials. Outcomes were compared between the two groups of patients- those requiring post-TAVR PPM and those not requiring post-TAVR PPM. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio (OD) with 95% confidence intervals (CI) for all the clinical endpoints.

Results

34 studies, including observational and prospective studies, met our inclusion criteria, with a total of 76,402 patients undergoing TAVR and 10,381 requiring post-TAVR PPM. There were no significant differences between 30-days (OR 1.04; 95% CI 0.96–1.13) and 1-year (OR 1.09; 95% CI 0.72–1.03) all-cause mortality rates, and 30-days (OR 0.86; 95% CI 0.72–1.03) and 1-year (OR 0.85; 95% CI 0.70–1.04) cardiovascular deaths among the two groups. Incidence of heart failure was higher in the post-TAVR PPM group at 30 days (OR 1.26; 95% CI 1.05–1.51) but not at 1 year (OR 1.21; 95% CI 0.93–1.57). No significant difference was noted between the two groups in 30-days or 1-year stroke, 30-days or 1-year myocardial infarction, 30-days or 1-year atrial fibrillation, 30-days or 1-year major bleeding, or 30-days and 1-year readmission rate. Other outcomes, including post-procedure aortic regurgitation, major vascular complications, minor bleeding, valve migration, and device success, also did not have any statistically significant difference in the two patient groups (Figure 1). Of all the patients who received post-TAVR PPM, an average of 46.4% and 58.5% patients had &gt;40% ventricular pacing, and 48.9% and 41.4% had &lt;40% ventricular pacing at 1-month, and 1-year follow up respectively.

Conclusions

Although there were no differences in the outcomes between the two groups at 30-days and 1-year follow-ups (except the higher incidence of heart failure at 30 days in the post-TAVR PPM group), long-term follow-up studies would be needed to identify any possible adverse events after one year. Also, a significant number of patients requiring post-TAVR PPM had &lt;40% ventricular pacing at 1-month and even at 1-year intervals, which might suggest adopting an alternate approach of closely monitoring any conduction disturbances and avoiding early PPM implantation in post-TAVR patients, if possible.

Funding Acknowledgement

Type of funding sources: None. Forest plot of differences in outcomes

Comparative Evaluation of Dentinal Microcrack Formation before and after Root Canal Preparation Using Rotary, Reciprocating, and Adaptive Instruments at Different Working Lengths-A Micro-computed Tomographic Study

INTRODUCTION

This study aimed to compare root dentinal microcrack formation after root canal shaping using rotary, reciprocating, and adaptive instruments at different working lengths using micro-computed tomographic imaging.

METHODS

One hundred eighty extracted mature mandibular molar mesial roots with 2 separate canals were selected. The mesial roots were resected at the cementoenamel junction and randomly divided into 4 groups (n = 45) based on the nickel-titanium file system used: ProTaper Universal (Dentsply Maillefer, Ballaigues, Switzerland), ProTaper Gold (Dentsply Maillefer), Twisted File Adaptive (SybronEndo, Orange, CA), and Reciproc Blue (VDW, Munich, Germany). Each of the 4 groups were then subdivided into 3 groups (n = 15) depending on the working length used for root canal preparation (ie, instrumentation 1 mm short, flush, and 1 mm beyond the major apical foramen). The roots were imaged with micro-computed tomographic scanning before and after root canal preparation. The cross-sectional images generated were screened to detect the presence of new microcracks.

RESULTS

The ProTaper Universal system significantly increased the number of postinstrumentation microcracks at all working lengths (P ≤ .05). No significant increase (P > .05) in postinstrumentation microcracks was observed in the ProTaper Gold, Twisted File Adaptive, or Reciproc Blue groups.

CONCLUSIONS

Rotary instrumentation induced a higher number of dentinal microcracks compared with reciprocating and adaptive instruments. Instrumentation at different working lengths did not significantly influence the formation of dentinal microcracks.

Data Mining of Free-Text Responses: An Innovative Approach to Analyzing Patient Perspectives on Treatment for Chronic Rhinosinusitis with Nasal Polyps in a Phase IIa Proof-of-Concept Study for Dupilumab

PURPOSE

Patient perspective is an important and increasingly sought-after complement to clinical assessment. The aim of this study was to transcribe individual patients' experience of treatment in a dupilumab clinical trial through free-text responses with analysis using natural language processing (NLP) to obtain the unique perspective of patients on disease impact and unmet needs with existing treatment to inform future trial design.

PATIENTS AND METHODS

Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) who were enrolled in a Phase IIa randomized controlled trial comparing dupilumab with placebo (NCT01920893) were invited to complete a self-assessment of treatment (SAT) tool at the end of treatment, asking, "What is your opinion on the treatment you had during the trial? What did you like or dislike about the treatment?" Free-text responses were analyzed for the overall cohort and according to treatment assignment using natural language processing including sentiment scoring. In a mixed-methods approach, quantitative patient-reported outcome (PRO) results were utilized to complement the qualitative analysis of free-text responses.

RESULTS

Of 60 patients enrolled in the study, 43 (71.6%) completed the SAT and responses from 37 patients were analyzed (placebo, n = 16; dupilumab, n = 21). Word analyses showed that the most common words were "smell," "improve," "staff," "great," "time," and "good." Across the whole cohort, "smell" was the most common symptom-related word. The words "smell" and "experience" were more likely to occur in patients treated with dupilumab. Patients treated with dupilumab also had more positive sentiment in their SAT responses than those who received placebo. The results from this qualitative analysis were reflected in quantitative PRO results.

CONCLUSION

"Smell" was important to patients with CRSwNP, highlighting its importance as a patient-centric efficacy outcome measure in the context of clinical trials in CRSwNP.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01920893. Registered 12 August 2013, https://www.clinicaltrials.gov/ct2/show/NCT01920893.

Nanotechnology and its challenges in the food sector: a review

Antibacterial activity of nanoparticles has received significant attention worldwide because of their great physical and chemical stability, excellent magnetic properties, and large lattice constant values. These properties are predominate in the food science for enhancing the overall quality, shelf life, taste, flavor, process-ability, etc., of the food. Nanoparticles exhibit attractive antibacterial activity due to their increased specific surface area leading to enhanced surface reactivity. When nanoparticles are suspended in the biological culture, they encounter various biological interfaces, resulting from the presence of cellular moieties like DNA, proteins, lipids, polysaccharides, etc., which helps antibacterial properties in many ways. This paper reviews different methods used for the synthesis of nanoparticles but is specially focusing on the green synthesis methods owing to its non-toxic nature towards the environment. This review highlights their antibacterial application mainly in the food sector in the form of food-nanosensors, food-packaging, and food-additives. The possible mechanism of nanoparticles for their antibacterial behavior underlying the interaction of nano-particles with bacteria, (i) excessive ROS generation including hydrogen peroxide (H₂O₂), OH^- (hydroxyl radicals), and O^- ₂ ² (peroxide); and (ii) precipitation of nano-particles on the bacterial exterior; which, disrupts the cellular activities, resulting in membranes disturbance. All these phenomena results in the inhibition of bacterial growth. Along with this, their current application and future perspectives in the food sector are also discussed. Nanoparticles help in destroying not only pathogens but also deadly fungi and viruses. Most importantly it is required to focus more on the crop processing and its containment to stop the post-harvesting loss. So, nanoparticles can act as a smart weapon towards the sustainable move.

Biologic Disease-Modifying Antirheumatic Drug Prescription Patterns Among Rheumatologists in Europe and Japan

INTRODUCTION

Tumor necrosis factor inhibitors (TNFi) are commonly used as first-line therapy (biologic disease-modifying antirheumatic drug [bDMARD] and targeted synthetic DMARD [tsDMARD]: defined as targeted therapy) for patients with moderate-to-severe rheumatoid arthritis (RA), usually combined with conventional synthetic DMARDs (csDMARDs) but sometimes as monotherapy. If treatment fails, patients cycle to another TNFi (cycling) or switch to a targeted therapy with a different mode of action (MOA; switching). The study aimed to examine prescribing patterns and reasons for current RA treatment practice in Europe (EU5: France, Germany, Italy, Spain, UK) and Japan.

METHODS

Data were collected from the Adelphi Disease Specific Programme™ (DSP; Q1-Q2 2017). Rheumatologists seeing ≥ 10 (EU5) and ≥ 5 (Japan) patients with RA a month completed Patient Record Forms. Patients ≥ 18 years old, with RA diagnosis and complete RA-targeted therapy history were included. Patients were grouped based on first-line targeted therapy class, and on whether first-line targeted therapy was monotherapy (targeted therapy alone) or combination therapy (targeted therapy and csDMARD). Those patients receiving TNFi at first-line and with ≥ 1 targeted therapy were classified as TNFi cyclers or MOA switchers. Univariate analysis compared factors across groups. Patient demographics and characteristics compared across groups; physician reasoning for targeted therapy change; and time to discontinuation of targeted therapy.

RESULTS

In EU5 and Japan, respectively, 1741 and 147 patients were included; at first-line, 80.8% and 64.6% received TNFi and 76.0% and 77.6% received combination therapy. Overall in EU5, more combination therapy than monotherapy patients reached maximum csDMARD dose before first-line targeted therapy (P < 0.05); disease severity was higher in patients initiating TNFi versus non-TNFi (P < 0.05). In Japan, trends were similar but not significant. The most common reason physicians gave for changing therapy following first-line targeted therapy was 'secondary lack of efficacy' (EU5: 46.2%; Japan: 53.8%). In EU5 and Japan, respectively, of 365 and 22 patients who received second-line targeted therapy, 52.1% and 54.5% were MOA switchers. In EU5, TNFi cyclers had longer time from diagnosis to second-line targeted therapy initiation than MOA switchers (P = 0.04).

CONCLUSIONS

TNFis were the most commonly prescribed targeted therapy at first-line. Between 10 and 20% of patients prescribed a TNFi as first-line targeted therapy did so without concomitant csDMARD. Almost half of patients cycled to another TNFi at second-line.

Evaluating patient-perceived control of atopic dermatitis: design, validation, and scoring of the Atopic Dermatitis Control Tool (ADCT)

Objectives: The Atopic Dermatitis Control Tool (ADCT) was designed to evaluate patient-perceived AD control and facilitate patient-physician discussion on long-term disease control.Methods: The study was performed in adult patients with AD. Development of the ADCT followed US Food and Drug Administration (FDA) guidelines on patient-reported outcome measures (PROMs). Qualitative research, including targeted literature review, interviews with clinical experts, and combined concept elicitation/cognitive debriefing with patients with AD, was conducted to provide a list of comprehensive concepts capturing AD control per physician and patient perspectives. Quantitative methods assessed psychometric properties of the instrument and defined the threshold for AD control.Results: The resulting pilot six-item ADCT, reflecting key concepts related to AD control, had 7-day recall and assessed symptoms and impacts on patients' everyday lives by severity and/or frequency. The ADCT showed good content validity (well understood by adult patients with AD), and quick completion time (<2 min). Psychometric analysis indicated no floor/ceiling effects for response distributions, particularly strong (r ≥ 0.80) inter-item correlations for the six ADCT items, robust construct validity (r > 0.50), and item-level discriminating ability (p < .03); this supported the derivation of a total score based on responses to all items. ADCT total score showed evidence of strong internal consistency reliability (Cronbach's alpha >0.80). A score ≥7 points was identified as an optimum threshold to identify patients whose AD is "not in control."Conclusions: No single validated instrument has been available to holistically evaluate patient-perceived AD control. The newly developed ADCT displays good-to-excellent content validity, construct validity, internal consistency, reliability, and discriminating ability.

Dupilumab improves health-related quality of life in patients with chronic rhinosinusitis with nasal polyposis

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRSwNP) negatively affects health-related quality of life (HRQoL). In a previously reported randomized clinical trial (NCT01920893), addition of dupilumab to mometasone furoate in patients with CRSwNP refractory to intranasal corticosteroids (INCS) significantly improved endoscopic, radiographic, and clinical endpoints and patient-reported outcomes. The objective of this analysis was to examine the impact of dupilumab treatment on HRQoL and productivity using secondary outcome data from this trial.

METHODS

Following a 4-week mometasone furoate nasal spray run-in, patients were randomized to commence subcutaneous dupilumab (600 mg loading dose, then 300 mg once weekly for 15 weeks [n = 30], or matched placebo [n = 30]). Outcomes included scores on the CRS disease severity visual analog scale (VAS), 22-item Sino-Nasal Outcome Test (SNOT-22), 5-dimension EuroQoL (EQ-5D) general health status VAS, and 36-item Short-Form Health Survey (SF-36) for HRQoL and nasal polyp-related healthcare resource use questionnaires.

RESULTS

Following 16 weeks of treatment, the proportion of patients with moderate-to-severe CRSwNP (VAS > 3-10) decreased from 86.2% to 21.4% with dupilumab and 88.0% to 84.2% with placebo. Dupilumab (vs placebo) resulted in significantly greater improvement in HRQoL, based on SNOT-22, SF-36, and EQ-5D VAS scores. The dupilumab group had a significantly lower adjusted annualized mean number of sick leave days (0.09, vs 4.18 with placebo, P = .015) and significantly greater improvement (vs placebo) in the SNOT-22 item "reduced productivity."

CONCLUSIONS

In adults with CRSwNP refractory to treatment with INCS alone, the addition of dupilumab reduced disease severity, significantly improved HRQoL, and improved productivity.

Validation of the Atopic Dermatitis Control Tool (ADCT©) using a longitudinal survey of biologic-treated patients with atopic dermatitis

BACKGROUND

The Atopic Dermatitis Control Tool (ADCT©) is a brief patient self-administered instrument designed and validated to assess atopic dermatitis (AD) control; six AD symptoms and impacts are evaluated over the past week, including overall severity of symptoms, days with intense episodes of itching, intensity of bother, problem with sleep, impact on daily activities, and impact on mood or emotions. This study assessed the reliability, validity, and responsiveness of the ADCT in a longitudinal context, and provided thresholds to identify meaningful within-person change.

METHODS

Data were from a prospective, longitudinal patient survey study of real-world effectiveness of dupilumab in patients with AD. Eligible patients completed a baseline survey before starting dupilumab and were followed at Months 1, 2, 3, and 6 post-initiation as they became eligible.

RESULTS

Psychometric analyses confirmed internal consistency; Cronbach's α coefficients were consistently above the threshold of 0.70 across each follow-up; item-to-total correlations were above the threshold of r ≥ 0.50. High correlations between the ADCT and the Dermatology Life Quality Index (DLQI) and skin pain supported construct validity, while known-group validity was shown on Patient Global Assessment of Disease (PGAD) overall well-being subgroups with worse AD-related overall well-being having higher mean ADCT total scores at all time points. The ability of the ADCT to detect change was confirmed; the threshold for meaningful within-person change was estimated to be 5 points. Finally, test-retest reliability was confirmed in subgroups of patients with stable PGAD responses.

CONCLUSIONS

Our findings confirm that the ADCT is a valid and reliable tool for assessing AD control.

Abstract 4874: Incidental gallbladder cancer: Best step forward

Objective: There is a rising trend of Incidental Gall Bladder Cancer (IGBC) with increase in laparoscopic cholecystectomy. Objective of our study was to evaluate the efficacy of further management (completion surgery and adjuvant chemotherapy) in IGBC in terms of long-term survival (&gt; 5 years).

Material and Method: Clinic-pathological and survival data of 145 IGBC patients was analysed from a prospectively maintained database of GBC. Patients investigated with triple phase CT abdomen and if required PET-CT. Diagnostic laparoscopy with Completion extended cholecystectomy performed in patients amenable for resection. Adjuvant therapy consisted of gemcitabine and cisplatin. Patients followed up with OPD visits and telephonic enquiry.

Results: 864 patients of GBC were treated during the period of January 1989 to December 2012. Out of these 145 patients were IGBC [113 women (77%), median age; 52 years)]. 96 patients were detected on histopathology while 49 were diagnosed intra-operatively. Open cholecystectomy was done in 88, laparoscopic in 45 while 12 underwent laparoscopic converted to open cholecystectomy. Commonest T stage was T3 (n=71). All patients were re-evaluated after diagnosis of IGBC. 80 patients (55%) were taken up for surgery of which, 50 (62.5%) underwent completion extended cholecystectomy (rest had metastases or locally advanced unresectable disease). Median time interval between index surgeries to re-exploration was 35 days (0-250). It was longer in patients who could not undergo completion extended cholecystectomy (70 days vs. 49 days). Overall 5-year survival in pT1b, pT2 and pT3 stage was 49.5%, 36.1% and 8.4% respectively, but was considerably better in patients who underwent completion extended cholecystectomy compared with those who did not undergo re-surgery [pT1; 62.5% vs. 29.1%, pT2; 52.2% vs. 15.9%, pT3; 22.6% vs. 7.2%, p&lt;0.001]. Prognostic factors associated with poor prognosis were higher T stage, R1 resection, bile spillage during index surgery, no completion surgery and residual disease on re-exploration on univariate analysis. On multivariate analysis factors portending poor prognosis were higher T stage, R1 resection and residual disease.

Conclusion: Early recognition, early completion radical surgery and adjuvant therapy lends considerable survival benefit to patients of incidental carcinoma gall bladder. Residual disease and R1 resection portends a poorer survival. High index of suspicion should be kept in patients with thick walled GB to avoid missing a malignancy at index surgery.

Citation Format: Saurabh Galodha, Puneet Mahajan. Incidental gallbladder cancer: Best step forward [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4874.

Tryptophan-Mediated Interactions between Tristetraprolin and the CNOT9 Subunit Are Required for CCR4-NOT Deadenylase Complex Recruitment

The zinc-finger protein tristetraprolin (TTP) binds to AU-rich elements present in the 3' untranslated regions of transcripts that mainly encode proteins of the inflammatory response. TTP-bound mRNAs are targeted for destruction via recruitment of the eight-subunit deadenylase complex "carbon catabolite repressor protein 4 (CCR4)-negative on TATA-less (NOT)," which catalyzes the removal of mRNA poly-(A) tails, the first obligatory step in mRNA decay. Here we show that a novel interaction between TTP and the CCR4-NOT subunit, CNOT9, is required for recruitment of the deadenylase complex. In addition to CNOT1, CNOT9 is now included in the identified CCR4-NOT subunits shown to interact with TTP. We find that both the N- and C-terminal domains of TTP are involved in an interaction with CNOT9. Through a combination of SPOT peptide array, site-directed mutagenesis, and bio-layer interferometry, we identified several conserved tryptophan residues in TTP that serve as major sites of interaction with two tryptophan-binding pockets of CNOT9, previously found to interact with another modulator GW182. We further demonstrate that these interactions are also required for recruitment of the CCR4-NOT complex and TTP-directed decay of an mRNA containing an AU-rich element in its 3'-untranslated region. Together the results reveal new molecular details for the TTP-CNOT interaction that shape an emerging mechanism whereby TTP targets inflammatory mRNAs for deadenylation and decay.

Economic Evaluation of Dupilumab for the Treatment of Moderate-to-Severe Atopic Dermatitis in Adults

Introduction

Dupilumab significantly improves signs and symptoms of atopic dermatitis (AD), including pruritus, symptoms of anxiety and depression, and health-related quality of life versus placebo in adults with moderate-to-severe AD. Since the cost-effectiveness of dupilumab has not been evaluated, the objective of this analysis was to estimate a value-based price range in which dupilumab would be considered cost-effective compared with supportive care (SC) for treatment of moderate-to-severe AD in an adult population.

Methods

A health economic model was developed to evaluate from the US payer perspective the long-term costs and benefits of dupilumab treatment administered every other week (q2w). Dupilumab q2w was compared with SC; robustness of assumptions and results were tested using sensitivity and scenario analyses. Clinical data were derived from the dupilumab LIBERTY AD SOLO trials; healthcare use and cost data were from health insurance claims histories of adult patients with AD. The annual price of maintenance therapy with dupilumab to be considered cost-effective was estimated for decision thresholds of US$100,000 and $150,000 per quality-adjusted life-year (QALY) gained.

Results

In the base case, the annual maintenance price for dupilumab therapy to be considered cost-effective would be $28,770 at a $100,000 per QALY gained threshold, and $39,940 at a $150,000 threshold. Results were generally robust to parameter variations in one-way and probabilistic sensitivity analyses.

Conclusion

Dupilumab q2w compared with SC is cost-effective for the treatment of moderate-to-severe AD in US adults at an annual price of maintenance therapy in the range of $29,000–$40,000 at the $100,000–$150,000 per QALY thresholds.

Funding

Sanofi and Regeneron Pharmaceuticals, Inc.

Impact of atopic dermatitis on health-related quality of life and productivity in adults in the United States: An analysis using the National Health and Wellness Survey

BACKGROUND

Given its public health impact, there is need for broad and representative data on the humanistic burden of atopic dermatitis (AD).

OBJECTIVE

To establish the humanistic burden of AD in US adults.

METHODS

Data were from the 2013 US National Health and Wellness Survey; AD self-reports were propensity-matched with non-AD controls and with psoriasis controls. Bivariate analyses were conducted on burden outcomes between the AD and control groups.

RESULTS

Demographics and baseline characteristics were comparable between matched groups. Subjects with AD (n = 349) versus non-AD controls (n = 698) had significantly higher rates of anxiety, depression, and sleep disorders (29.8%, 31.2%, and 33.2% vs 16.1%, 17.3%, and 19.2%, respectively [all P < .001]); a lower Short Form-36 v2 mental component summary score (44.5 vs 48.0, respectively [P < .001]); a lower physical component summary score (47.6 vs 49.5, respectively [P = .004]), and lower health utilities (0.67 vs 0.72, respectively [P < .001]) in addition to a higher work absenteeism rate (9.9% vs 3.6%, respectively [P < .001]) and activity impairment rate (33.6% vs 25.2%, respectively [P < .001]). Subjects with AD and psoriasis controls (n = 260 each) showed similar impairment in health-related quality of life and productivity.

LIMITATIONS

Data were self-reported.

CONCLUSION

AD is associated with a substantial humanistic burden that is similar in magnitude to that of psoriasis, which is also recognized for its debilitating symptoms, indicating the need for more effective treatments for AD.

AKT is indispensable for coordinating Par-4/JNK cross talk in p21 downmodulation during ER stress

The double-edged role of p21 to command survival and apoptosis is emerging. The current investigation highlights ER stress-mediated JNK activation that plausibly triggers cell death by attenuating endogenous p21 level. Here, we demonstrated that ER stress activator 3-AWA diminishes the p21 levels in cancer cells by averting the senescent phenotype to commence G2/M arrest. In essence, the deceleration in p21 level occurs through ER stress/JNK/Caspase-3 axis via activation/induction of proapoptotic Par-4 and inhibition of AKT. The molecular dynamics studies identified important interactions, which may be responsible for the AKT inhibition and efficacy of 3-AWA towards AKT binding pocket. Interestingly, the p21 deceleration was rescued by incubating the cells with 3-AWA in the presence of an ER stress inhibitor, Salubrinal. Furthermore, we demonstrated that p21 expression decreases solitarily in Par-4^+/+ MEFs; albeit, ER stress-induced JNK activation was observed in both Par-4^+/+ and Par-4^−/− MEFs. Par-4 knockdown or overexpression studies established that ectopic Par-4 along with ER stress are not sufficient to downregulate p21 in PC-3 cells but are adequate for DU-145 cells and that the ER stress inflicted activation of JNK, inhibition of AKT and Par-4 induction are all crucial to p21 downmodulation by 3-AWA. By using isogenic cell lines, such as HCT-116 p53^+/+ and HCT-116 p53^−/−, we found that deceleration in p21 expression due to ER stress is p53 independent. Moreover, in orthotopic carcinogen-induced rat colorectal carcinoma model, we found that 3-AWA inhibits colorectal tumor growth and formation of colorectal polyps at a tolerable dose, similar to the first-line drug for colorectal cancer-5-fluorouracil.

Outcomes of tumor necrosis factor inhibitor cycling versus switching to a disease-modifying anti-rheumatic drug with a new mechanism of action among patients with rheumatoid arthritis

OBJECTIVES

To examine treatment patterns, treatment effectiveness, and treatment costs for 1 year after patients with rheumatoid arthritis switched from a tumor necrosis factor inhibitor (TNFi) (adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab), either cycling to another TNFi ("TNFi cyclers") or switching to a new mechanism of action (abatacept, tocilizumab, or tofacitinib) ("new MOA switchers").

METHODS

This retrospective cohort study used administrative claims data for a national insurer. Treatment persistence (without switching again, restarting, or discontinuing), treatment effectiveness (defined below), and costs were assessed for the 12-month post-switch period. Patients were "effectively treated" if they satisfied all six criteria for a treatment effectiveness algorithm (high adherence, no dose increase, no new conventional synthetic disease-modifying anti-rheumatic drug, no subsequent switch in therapy, no new/increased oral glucocorticoids, and <2 glucocorticoid injections). Multivariable logistic models were used to adjust for baseline factors.

RESULTS

The database included 581 new MOA switchers and 935 TNFi cyclers. New MOA switchers were 39% more likely than TNFi cyclers to persist after the switch (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.12-1.74; p = .003) and 36% less likely to switch therapy again (OR = 0.64; 95% CI = 0.51-0.81; p < .001). New MOA switchers were 43% more likely than TNFi cyclers to be effectively treated (OR = 1.43; 95% CI = 1.11-1.85; p = .006). New MOA switchers had 16% lower drug costs than TNFi cyclers (cost ratio = 0.84; 95% CI = 0.79-0.88; p < .001) and 11% lower total costs of rheumatoid arthritis-related medical care (cost ratio = 0.89; 95% CI = 0.84-0.94; p < .001).

LIMITATIONS

Claims payments may not reflect rebates or other cost offsets. Medical and pharmacy claims do not include clinical end-points or reasons that lead to new MOA switching vs TNFi cycling.

CONCLUSIONS

These results support switching to a new MOA after a patient fails treatment with a TNFi, which is consistent with recent guidelines for the pharmacologic management of established rheumatoid arthritis.

Functional Outcome of Bipolar Prosthesis versus Total Hip Replacement in the Treatment of Femoral Neck Fracture in Elderly Patients

Introduction

The present study was performed to compare cemented total hip replacement (THR) with cemented bipolar prosthesis in the treatment of displaced fracture neck of femur in elderly patients.

Materials and Methods

This prospective study included 47 patients of greater than 60 years of age and having fracture of neck of femur, out of which 25 patients were managed by cemented bipolar prosthesis and remaining 22 were managed by cemented THR between June 2011 and June 2013. These patients were followed up post-operatively for two years, at 6, 12 and 24 months, for functional analysis using Modified Harris Hip Score.

Results

Modified Harris Hip Score was significantly higher in the THR group as compared to the bipolar prosthesis group at 6, 12 and 24 months post-operatively. Pain was almost similar in both the groups at all follow-up periods. Gait and range of motion was significantly higher in THR group as compared to bipolar prosthesis group at all-time point intervals.

Conclusion

Cemented THR is a better option as compared to cemented bipolar prosthesis based on our short term functional outcome for the management of fracture of neck of femur in elderly patients.

Treatment effectiveness and treatment patterns among rheumatoid arthritis patients after switching from a tumor necrosis factor inhibitor to another medication

Objectives

After treatment failure with a tumor necrosis factor inhibitor (TNFi), patients with rheumatoid arthritis (RA) can switch to another TNFi (TNFi cyclers) or to a targeted disease-modifying antirheumatic drug (DMARD) with a non-TNFi mechanism of action (non-TNFi switchers). This study compared treatment patterns and treatment effectiveness between TNFi cyclers and non-TNFi switchers in patients with RA.

Methods

The analysis included a cohort of patients from the Truven Health Analytics MarketScan Commercial database with RA who switched from a TNFi (adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab) either to another TNFi or to a non-TNFi targeted DMARD (abatacept, tocilizumab, or tofacitinib) between January 1, 2010 and September 30, 2014. A claims-based algorithm was used to estimate treatment effectiveness based on six criteria (adherence, no dose increase, no new conventional therapy, no switch to another targeted DMARD, no new/increased oral glucocorticoid, and intra-articular injections on <2 days).

Results

The cohort included 5,020 TNFi cyclers and 1,925 non-TNFi switchers. Non-TNFi switchers were significantly less likely than TNFi cyclers to switch therapy again within 6 months (13.2% vs 19.5%; P<0.001) or within 12 months (29.7% vs 34.6%; P<0.001) and significantly more likely to be persistent on therapy at 12 months (61.8% vs 58.2%; P<0.001). Non-TNFi switchers were significantly more likely than TNFi cyclers to achieve all six of the claims-based effectiveness algorithm criteria for the 12 months after the initial switch (27% vs 24%; P=0.011).

Conclusion

Although the absolute differences were small, these results support switching to a non-TNFi targeted DMARD instead of TNFi cycling when patients with RA require another therapy after TNFi failure.

Reasons why patients fail screening in Indian breast cancer trials

Introduction:

An increased number of screen failure patients in a clinical trial increases time and cost required for the recruitment. Assessment of reasons for screen failure can help reduce screen failure rates and improve recruitment.

Materials and Methods:

We collected retrospective data of human epidermal growth factor receptor (HER2) positive Indian breast cancer patients, who failed screening for phase 3 clinical trials and ascertained their reasons for screen failure from screening logs. Statistical comparison was done to ascertain if there are any differences between private and public sites.

Results:

Of 727 patients screened at 14 sites, 408 (56.1%) failed screening. The data on the specific reasons for screen failures was not available at one of the public sites (38 screen failures out of 83 screened patients). Hence, after excluding that site, further analysis is based on 644 patients, of which 370 failed screening. Of these, 296 (80%) screen failure patients did not meet selection criteria. The majority -266 were HER2 negative. Among logistical issues, 39 patients had inadequate breast tissue sample. Sixteen patients withdrew their consent at private sites as compared to six at public sites. The difference between private and public sites for the above three reasons was statistically significant.

Conclusion:

Use of prescreening logs to reduce the number of patients not meeting selection criteria and protocol logistics, and patient counseling to reduce consent withdrawals could be used to reduce screen failure rate.

Association of CYP2C19, CYP3A5 and GPIIb/IIIa gene polymorphisms with Aspirin and Clopidogrel Resistance in a cohort of Indian patients with Coronary Artery Disease

INTRODUCTION

Dual antiplatelet therapy with clopidogrel and aspirin is the current standard of care in the management of patients with coronary artery disease (CAD) and acute coronary syndrome (ACS). The variability in response to these antiplatelet agents may be due to the underlying genetic diversity. This study was designed to determine the resistance to aspirin and clopidogrel in Indian patients and to look for correlation, if any, with selected polymorphisms.

METHODS

Platelet function testing by light transmission aggregometry was performed on 72 patients with CAD/ACS who were stable on dual antiplatelet therapy (clopidogrel 75 mg OD and aspirin 150 mg OD) along with 72 controls. Aspirin resistance was considered as mean platelet aggregation ≥ 70% with 10 μm ADP and ≥ 20% with 0.75 mm arachidonic acid. Clopidogrel resistance was defined as <10% decrease from the baseline in platelet aggregation in response to ADP 10 μm and semi-response as <30% decrease from the baseline. Polymorphisms CYP2C19*2, *3, CYP3A5*3 and PLA1/A2 were genotyped.

RESULTS

We found 51.4% patients with inadequate response to clopidogrel (1.4% resistant and 50% semi-responders) and 5.5% patients semi-responders to aspirin, none being completely resistant. The genotype and allele frequencies of CYP2C19*2 and PLA1/A2 gene polymorphisms were significantly different between clopidogrel semi-responders and responders. Carriers of CYP2C19*2 and CYP3A5*3 showed diminished inhibition of platelet aggregation. No significant correlation was found between coronary events, type of coronary intervention with clopidogrel nonresponsiveness.

CONCLUSION

Unlike aspirin, a high proportion of partial responders to clopidogrel were identified. In an interim analysis on 72 Indian patients, a significant association was found between CYP2C19*2 and PLA1/A2 in clopidogrel semi-responders.

Cutaneous metastasis of renal cell carcinoma masquerading as scrotal growth

Cutaneous metastases are an uncommon manifestation of visceral malignancy. We report a case of a 56-year-old male who presented with an ulcerated scrotal mass and inguinal swelling on the left side. Fine needle aspiration from both the sites revealed deposits of renal cell carcinoma though the patient had no urologic symptoms. Subsequent work-up revealed a renal mass. This case emphasizes the importance of keeping renal cell carcinoma as differential in cases who present with cutaneous metastases.

Telescopic overdenture: Perio-prostho concern for advanced periodontitis

The crown- and sleeve-coping denture is a removable prosthesis that is supported by both selectively retained teeth and the residual ridge or mucosa. It is a versatile and successful means of achieving long-term restoration of a partially edentulous jaw. Insertion and removal of the denture and routine oral hygiene are easy to perform. The beneficial results of this form of treatment can be considered for a wide variety of clinical applications for the severely advanced periodontitis case. This paper presents a case report on the prosthetic rehabilitation of a partially edentulous patient with a telescopic overdenture for the mandible and complete denture for the maxilla.

Comparison of periosteal pedicle graft and subepithelial connective tissue graft for the treatment of gingival recession defects

BACKGROUND

The use of periosteum as a pedicle graft in the treatment of gingival recession defects is a recent advancement. The subepithelial connective tissue graft (SCTG) is considered the gold standard for the treatment of gingival recession defects. The present randomized controlled trial was done to compare periosteal pedicle graft (PPG) with SCTG for the treatment of gingival recession defects.

METHODS

10 males and 10 females between the ages of 16 and 40 years (mean age 25.2 years) with Miller's Class I and II recessions ≥3 mm participated in this one-year clinical study. They were assigned randomly to test group (PPG) and control group (SCTG). Results were evaluated based on parameters measuring patient satisfaction and clinical outcomes associated with two treatment procedures. Significance was set at p < 0.05.

RESULTS

At the end of the study, the defect coverage was 3.1 ± 0.13 mm or 92.6% in the test group compared to the control group in which the defect coverage was 2.70 ± 0.11 mm or 88.5%. The difference between the two groups was statistically significant (p < 0.0001). The average residual defect was comparable between the two groups, i.e. 0.3 ± 0.67 and 0.5 ± 0.84 in the PPG and SCTG group respectively. The test group was rated higher in terms of overall patient satisfaction (p < 0.02) and comfort during and after the procedure (p < 0.001).

CONCLUSIONS

PPG and SCTG have comparable clinical effectiveness, but PPG is superior to SCTG in terms of patient-centred outcomes, reflecting improved patient comfort and overall patient satisfaction.