Effect of Various Toothpaste Tablets on Gloss and Surface Roughness of Resin-based Composite Materials

OBJECTIVES

To evaluate the effect of various toothpaste tablets on gloss and surface roughness of resin-based composite.

METHODS AND MATERIALS

Sixty-four resin-based composite specimens were divided into four groups of 16 specimens each. Gloss and roughness were measured before and after simulated brushing with three types of toothpaste tablets and one conventional toothpaste: CT: Chewtab Toothpaste Tablets; AT: Anticavity Toothpaste Tablets; HC: Charcoal Toothpaste Tablets; CP: Cavity Protection toothpaste. The Kruskal- Wallis procedure was performed to compare the differences by groups. Post-hoc comparisons were conducted with Bonferroni corrections (α=0.05).

RESULTS

There was a significant drop in gloss for all groups. CT and AT maintained the highest gloss with means of 81.6 GU and 74.1 GU, respectively. The lowest gloss of 24.5 GU was observed for HC. There was a significant increase in roughness for all groups except for CT. CT had the lowest roughness with a mean of 0.034 μm, while HC had the highest roughness with a mean of 0.074 μm. There was a significant correlation between post-brushing gloss and post-brushing roughness (p<0.001, r=-0.884).

CONCLUSION

Chewtab Toothpaste Tablets had the least effect on gloss and roughness, while Charcoal Toothpaste Tablets had the most negative effect on the surface properties of resin-based composites.

Topical anaesthesia and decongestion in rhinology

Topical anaesthesia and decongestion of the sinonasal mucosa are used commonly in rhinology practice to facilitate nasal endoscopy, as well as debridement and biopsies. Topical agents used for sinonasal anaesthesia include lignocaine, tetracaine and cocaine. Unlike lignocaine and tetracaine, cocaine also has a decongestant effect. Phenylephrine, oxymetazoline, xylometazoline or adrenaline are usually added to lignocaine and tetracaine to provide decongestion. Several studies have been performed seeking to identify the optimal nasal preparation for nasal endoscopy in the clinic setting. However, there remains no clear consensus in the literature resulting in ongoing wide variation between anaesthetic-decongestant preparations used in clinical practice. Indeed, some authors have argued that no anaesthetic is required at all for flexible nasendoscopy despite the apparent consensus that nasal instrumentation is generally uncomfortable, inferred by the persistence of ongoing research in this area. This review provides a practical summary of local anaesthetic and decongestant pharmacology as it relates to rhinologic practice and summarises the literature to date, with the goal of identifying current gaps in the literature and guiding future research efforts.

Diagnostic Accuracy of a Large Language Model in Pediatric Case Studies

This diagnostic study evaluates the accuracy of a large language model against physician diagnoses in pediatric cases.

Provider Adherence to Modular Cognitive Behavioral Therapy for Children and Adolescents

This study explored predictors of community-based providers' adherence to MATCH, a modular cognitive behavioral therapy for children and adolescents. Provider-reported adherence to MATCH was measured using three increasingly strict criteria: (1) session content (whether the session covered MATCH content consistent with the client's target problem), (2) session content and sequencing (whether the session covered MATCH content in the expected sequence for the client's target problem), and (3) session content, sequencing, and participant (whether the session covered MATCH content in the expected sequence and with the expected participant(s) for the client's target problem). Session, client, provider, and organizational predictors of adherence to MATCH were assessed using multilevel modeling. Results revealed that nearly all providers delivered MATCH content that corresponded to the target problem, but only one-third of providers delivered MATCH content in the expected sequence and with the expected participant for the client's target problem. This difference underscores the need for nuanced adherence measurement to capture important implementation information that broad operationalizations of adherence miss. Regardless of the criteria used providers were most adherent to MATCH during sessions when clients presented with interfering comorbid mental health symptoms. This suggests that the design of MATCH, which offers flexibility and structured guidance to address comorbid mental health problems, may allow providers to personalize treatment to address interfering comorbidity symptoms while remaining adherent to evidence-based practices. Additional guidance for providers on managing other types of session interference (e.g., unexpected events) may improve treatment integrity in community settings.

Association of Fitzpatrick Skin Type with metastatic risk from uveal melanoma in 854 consecutive patients at a single center

OBJECTIVE

To assess the association of skin color using Fitzpatrick Skin Type (FST) with metastatic risk of uveal melanoma.

SUBJECTS

854 consecutive patients with uveal melanoma and documented FST.

METHODS

Retrospective detailed review of patient charts was performed for FST (type I- white, II-fair, III-average, IV-light brown, V-brown, VI-black), clinical details of the patient and the uveal melanoma, tumor cytogenetic classification according to The Cancer Genome Atlas (TCGA), and outcome of melanoma-related metastasis and death.

RESULTS

The FST classification was type I (n = 97 patients), type II (n = 665), type III (n = 79), type IV (n = 11), type V (n = 2), type VI (n = 0). A comparison of patient FST (type I vs. II vs. III-V) revealed significant differences in mean age at presentation (64.1 vs. 58.5 vs. 49.8 years, p < 0.001), race white (100% vs. 98% vs. 75%, p < 0.001), presence of ocular melanocytosis (3% vs. 3% vs. 10%, p = 0.01), visual acuity <20/200 at presentation (6% vs. 7% vs. 13%, p = 0.03), genetic results showing TCGA group B tumors (11% vs. 14% vs. 26%, p = 0.01) or TCGA group D tumors (22% vs. 11% vs. 9%, p = 0.01), 10-year incidence of melanoma-related metastasis (25% vs. 15% vs. 14%, p = 0.02) and 10-year incidence of melanoma-related death (9% vs. 3% vs. 4%, p = 0.04). FST was a significant predictor of melanoma-related metastasis (p = 0.02, Hazard ratio 2.3).

CONCLUSIONS

Fitzpatrick skin type may be a predictor of melanoma-related metastasis, with metastasis and TCGA Group D tumors being more common in patients with FST I.

What Is the "Right" First Job?

It is a daunting task to find the "right" first job. However, the foundation of the search is similar to that of the interview and match process for residency and fellowship. Does the job opportunity have the makeup of clinical and research opportunities, case mix, support and culture that will set the trainee up to fulfill his or her early career goals? Does the position seem like a good fit? The variation occurs with (1) the mystery behind it-there are scarce resources available on the topic, and (2) the logistics: where and when to look; the interview process.

Challenging the Chatbot: An Assessment of ChatGPT's Diagnoses and Recommendations for DBP Case Studies

OBJECTIVE

Chat Generative Pretrained Transformer-3.5 (ChatGPT) is a publicly available and free artificial intelligence chatbot that logs billions of visits per day; parents may rely on such tools for developmental and behavioral medical consultations. The objective of this study was to determine how ChatGPT evaluates developmental and behavioral pediatrics (DBP) case studies and makes recommendations and diagnoses.

METHODS

ChatGPT was asked to list treatment recommendations and a diagnosis for each of 97 DBP case studies. A panel of 3 DBP physicians evaluated ChatGPT's diagnostic accuracy and scored treatment recommendations on accuracy (5-point Likert scale) and completeness (3-point Likert scale). Physicians also assessed whether ChatGPT's treatment plan correctly addressed cultural and ethical issues for relevant cases. Scores were analyzed using Python, and descriptive statistics were computed.

RESULTS

The DBP panel agreed with ChatGPT's diagnosis for 66.2% of the case reports. The mean accuracy score of ChatGPT's treatment plan was deemed by physicians to be 4.6 (between entirely correct and more correct than incorrect), and the mean completeness was 2.6 (between complete and adequate). Physicians agreed that ChatGPT addressed relevant cultural issues in 10 out of the 11 appropriate cases and the ethical issues in the single ethical case.

CONCLUSION

While ChatGPT can generate a comprehensive and adequate list of recommendations, the diagnosis accuracy rate is still low. Physicians must advise caution to patients when using such online sources.

Stress-Dose Steroids: A Potential Therapeutic Option for Refractory Hyperkalemia

Hyperkalemia refractory to standard temporization measures can be life-threatening, and urgent hemodialysis is often utilized as a final resort. Our patient presented with hyperkalemia that was multifactorial in etiology, with acute kidney injury complicated by adrenal insufficiency. Her hyperkalemia was refractory to temporization and excretion agents, and hemodialysis was being considered. Given a recent infection, surgery, and borderline hypotension with low adrenocorticotropic hormone, there was a concern for adrenal insufficiency. However, a full investigation for secondary adrenal insufficiency via magnetic resonance imaging could not be conducted as the patient suffered from claustrophobia. Continued concern for adrenal insufficiency prompted the initiation of intravenous hydrocortisone, and the patient's hyperkalemia resolved within 24 hours. While suspected adrenal insufficiency is already a basis for stress-dose steroids in the setting of pathologies such as severe sepsis, clinicians should have a low threshold for considering refractory hyperkalemia alone as an indication for stress-dose steroids. When dialysis is being considered as an option, this treatment modality should be given even more consideration. Adopting this practice may not only lead to improved mortality from hyperkalemia but also lead to fewer patients being exposed to the risks of dialysis.

Improving Postpartum Depression Screening in the NICU: Partnering with Students to Improve Outreach

Infants born to mothers with postpartum depression (PPD) are at risk for adverse developmental outcomes. Mothers of premature infants are 40% more likely to develop PPD when compared with the general population. Current published studies on implementing PPD screening in the Neonatal Intensive Care Unit (NICU) do not comply with the American Academy of Pediatrics (AAP) guideline, which recommends multiple screening points in the first year postpartum and includes partner screening. Our team implemented PPD screening that follows the AAP guideline and includes partner screening for all parents of infants admitted to our NICU beyond 2 weeks of age.

Methods

The Institute For Healthcare Improvement Model for Improvement was the framework for this project. Our initial intervention bundle included provider education, standardized identification of parents to be screened, and bedside screening performed by the nurse with social work follow-up. This intervention transitioned to weekly screening by phone by health professional students and the use of the electronic medical record for notification of team members of screening results.

Results

Under the current process, 53% of qualifying parents are screened appropriately. Of the parents screened, 23% had a positive Patient Health Questionnaire-9 requiring referral for mental health services.

Conclusions

Implementing a PPD screening program that complies with the AAP standard is feasible within a Level 4 NICU. Partnering with health professional students greatly improved our ability to screen parents consistently. Given the high percentage of parents with PPD uncovered with appropriate screening, this type of program has a clear need within the NICU.

"Wading through the worst that humanity does to each other": New Zealand Crown prosecutors' experiences of working with potentially traumatic material in the criminal justice system

Introduction

Occupational exposure to trauma and its potential impacts on legal professionals working in the criminal justice system is an area that has historically been neglected and has only gained traction in recent years. Crown prosecutors, as a subset of practising criminal lawyers in New Zealand, are arguably at heightened risk of vicarious trauma (VT) due to their occupationally distinct exposure to potentially traumatic material (PTM). However, no research to date has explored the experiences of this group of working with PTM.

Methods

This qualitative study aimed to explore New Zealand Crown prosecutors' experiences of working with PTM. Nineteen Crown prosecutors from four Crown Solicitor firms across New Zealand participated in individual semi-structured interviews. The data was analysed using reflexive thematic analysis.

Results

Three themes were developed that described Crown prosecutors' experiences of work-related exposure to trauma: trauma is everywhere, enduring effects of PTM exposure, and coping in the moment. These findings add to the growing body of literature on legal professionals' work-related wellbeing and highlights how they are an at-risk population for VT, which can be significant and enduring.

Discussion

Further research is needed to understand the unique etiological pathways for both the consequences of working with PTM and effective ways to reduce this occupational risk for legal professionals working in the criminal law.

A machine learning evaluation of patient characteristics associated with prescribing of guideline-directed medical therapy for heart failure

Introduction/background

Patients with heart failure and reduced ejection fraction (HFrEF) are consistently underprescribed guideline-directed medications. Although many barriers to prescribing are known, identification of these barriers has relied on traditional a priori hypotheses or qualitative methods. Machine learning can overcome many limitations of traditional methods to capture complex relationships in data and lead to a more comprehensive understanding of the underpinnings driving underprescribing. Here, we used machine learning methods and routinely available electronic health record data to identify predictors of prescribing.

Methods

We evaluated the predictive performance of machine learning algorithms to predict prescription of four types of medications for adults with HFrEF: angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACE/ARB), angiotensin receptor-neprilysin inhibitor (ARNI), evidence-based beta blocker (BB), or mineralocorticoid receptor antagonist (MRA). The models with the best predictive performance were used to identify the top 20 characteristics associated with prescribing each medication type. Shapley values were used to provide insight into the importance and direction of the predictor relationships with medication prescribing.

Results

For 3,832 patients meeting the inclusion criteria, 70% were prescribed an ACE/ARB, 8% an ARNI, 75% a BB, and 40% an MRA. The best-predicting model for each medication type was a random forest (area under the curve: 0.788-0.821; Brier score: 0.063-0.185). Across all medications, top predictors of prescribing included prescription of other evidence-based medications and younger age. Unique to prescribing an ARNI, the top predictors included lack of diagnoses of chronic kidney disease, chronic obstructive pulmonary disease, or hypotension, as well as being in a relationship, nontobacco use, and alcohol use.

Discussion/conclusions

We identified multiple predictors of prescribing for HFrEF medications that are being used to strategically design interventions to address barriers to prescribing and to inform further investigations. The machine learning approach used in this study to identify predictors of suboptimal prescribing can also be used by other health systems to identify and address locally relevant gaps and solutions to prescribing.

Lipopolysaccharide transport regulates bacterial sensitivity to a cell wall-degrading intermicrobial toxin

Gram-negative bacteria can antagonize neighboring microbes using a type VI secretion system (T6SS) to deliver toxins that target different essential cellular features. Despite the conserved nature of these targets, T6SS potency can vary across recipient species. To understand the functional basis of intrinsic T6SS susceptibility, we screened for essential Escherichia coli (Eco) genes that affect its survival when antagonized by a cell wall-degrading T6SS toxin from Pseudomonas aeruginosa, Tae1. We revealed genes associated with both the cell wall and a separate layer of the cell envelope, lipopolysaccharide, that modulate Tae1 toxicity in vivo. Disruption of genes in early lipopolysaccharide biosynthesis provided Eco with novel resistance to Tae1, despite significant cell wall degradation. These data suggest that Tae1 toxicity is determined not only by direct substrate damage, but also by indirect cell envelope homeostasis activities. We also found that Tae1-resistant Eco exhibited reduced cell wall synthesis and overall slowed growth, suggesting that reactive cell envelope maintenance pathways could promote, not prevent, self-lysis. Together, our study reveals the complex functional underpinnings of susceptibility to Tae1 and T6SS which regulate the impact of toxin-substrate interactions in vivo.

Impact of Controlled Ice Nucleation and Lyoprotectants on Nanoparticle Stability during Freeze-drying and upon Storage

The freezing step of the lyophilization process can impact nanoparticle stability due to increased particle concentration in the freeze-concentrate. Controlled ice nucleation is a technique to achieve uniform ice crystal formation between vials in the same batch and has attracted increasing attention in pharmaceutical industry. We investigated the impact of controlled ice nucleation on three types of nanoparticles: solid lipid nanoparticles (SLNs), polymeric nanoparticles (PNs), and liposomes. Freezing conditions with different ice nucleation temperatures or freezing rates were employed for freeze-drying all formulations. Both in-process stability and storage stability up to 6 months of all formulations were assessed. Compared with spontaneous ice nucleation, controlled ice nucleation did not cause significant differences in residual moisture and particle size of freeze-dried nanoparticles. The residence time in the freeze-concentrate was a more critical factor influencing the stability of nanoparticles than the ice nucleation temperature. Liposomes freeze-dried with sucrose showed particle size increase during storage regardless of freezing conditions. By replacing sucrose with trehalose, or adding trehalose as a second lyoprotectant, both the physical and chemical stability of freeze-dried liposomes improved. Trehalose was a preferable lyoprotectant than sucrose to better maintain the long-term stability of freeze-dried nanoparticles at room temperature or 40°C.

Lipopolysaccharide integrity primes bacterial sensitivity to a cell wall-degrading intermicrobial toxin

Gram-negative bacteria can antagonize neighboring microbes using a type VI secretion system (T6SS) to deliver toxins that target different essential cellular features. Despite the conserved nature of these targets, T6SS potency can vary across recipient species. To understand the molecular basis of intrinsic T6SS susceptibility, we screened for essential Escherichia coli genes that affect its survival when antagonized by a cell wall-degrading T6SS toxin from Pseudomonas aeruginosa , Tae1. We revealed genes associated with both the cell wall and a separate layer of the cell envelope, surface lipopolysaccharide, that modulate Tae1 toxicity in vivo . Disruption of lipopolysaccharide synthesis provided Escherichia coli (Eco) with novel resistance to Tae1, despite significant cell wall degradation. These data suggest that Tae1 toxicity is determined not only by direct substrate damage, but also by indirect cell envelope homeostasis activities. We also found that Tae1-resistant Eco exhibited reduced cell wall synthesis and overall slowed growth, suggesting that reactive cell envelope maintenance pathways could promote, not prevent, self-lysis. Together, our study highlights the consequences of co-regulating essential pathways on recipient fitness during interbacterial competition, and how antibacterial toxins leverage cellular vulnerabilities that are both direct and indirect to their specific targets in vivo .

The KMT2A recombinome of acute leukemias in 2023

Chromosomal rearrangements of the human KMT2A/MLL gene are associated with de novo as well as therapy-induced infant, pediatric, and adult acute leukemias. Here, we present the data obtained from 3401 acute leukemia patients that have been analyzed between 2003 and 2022. Genomic breakpoints within the KMT2A gene and the involved translocation partner genes (TPGs) and KMT2A-partial tandem duplications (PTDs) were determined. Including the published data from the literature, a total of 107 in-frame KMT2A gene fusions have been identified so far. Further 16 rearrangements were out-of-frame fusions, 18 patients had no partner gene fused to 5'-KMT2A, two patients had a 5'-KMT2A deletion, and one ETV6::RUNX1 patient had an KMT2A insertion at the breakpoint. The seven most frequent TPGs and PTDs account for more than 90% of all recombinations of the KMT2A, 37 occur recurrently and 63 were identified so far only once. This study provides a comprehensive analysis of the KMT2A recombinome in acute leukemia patients. Besides the scientific gain of information, genomic breakpoint sequences of these patients were used to monitor minimal residual disease (MRD). Thus, this work may be directly translated from the bench to the bedside of patients and meet the clinical needs to improve patient survival.

Targeting NFE2L2/KEAP1 Mutations in Advanced NSCLC With the TORC1/2 Inhibitor TAK-228

INTRODUCTION

Increased insight into the mutational landscape of squamous cell lung cancers (LUSCs) in the past decade has not translated into effective targeted therapies for patients with this disease. NRF2, encoded by NFE2L2, and its upstream regulator, KEAP1, control key aspects of redox balance and are frequently mutated in NSCLCs.

METHODS

Here, we describe the specific potent activity of TAK-228, a TORC1/2 inhibitor, in NSCLC models harboring NRF2-activating alterations and results of a phase 2 clinical trial of TAK-228 in patients with advanced NSCLC harboring NRF2-activating alterations including three cohorts (NFE2L2-mutated LUSC, KEAP1-mutated LUSC, KRAS/NFE2L2- or KEAP1-mutated NSCLC).

RESULTS

TAK-228 was most efficacious in a LUSC cohort with NFE2L2 alterations; the overall response rate was 25% and median progression-free survival was 8.9 months. Additional data suggest that concurrent inhibition of glutaminase with the glutaminase inhibitor CB-839 might overcome metabolic resistance to therapy in these patients.

CONCLUSIONS

TAK-228 has single-agent activity in patients with NRF2-activated LUSC. This study reframes oncogenic alterations as biologically relevant based on their downstream effects on metabolism. This trial represents, to the best of our knowledge, the first successful attempt at metabolically targeting NSCLC and identifies a promising targeted therapy for patients with LUSC, who are bereft of genotype-directed therapies.

A174 A NOVEL MECHANISM OF CROHN’S DISEASE SEVERITY IN WOMEN: EVALUATING THE IMPACT OF AN ESTROGEN-FARNESOID X RECEPTOR INTERACTION ON INTESTINAL BARRIER FUNCTION

Background

Crohn’s disease (CD) is associated with deficits in intestinal barrier function. Activation of bile acid-sensing nuclear receptor Farnesoid X receptor (NR1H4, FXR) is associated with protective effects against reduced intestinal barrier function; namely through promoting tight junction complex genes (TJCGs) and reducing expression of inflammatory cytokines. The FXR -1G>T variant is associated with decreased FXR activation and increased risk of, and early progression to, CD-related surgery in females only. It is hypothesized an estrogen-FXR interaction is mediating this effect.

Purpose

We aimed to assess the combined effect of estrogen and FXR genetic variation on intestinal barrier function using a cell-based model and its impact in a clinical cohort.

Method

Caco-2 cells were characterized for expression of TJCGs (zonula occludens-1, occludin, junctional adhesion molecule A, and claudin-1 and claudin-2), FXR, and nuclear estrogen receptors (ERα, ERβ) by qPCR. The influence of FXR activation on TJCGs was characterized by incubation of Caco-2 cells with chenodeoxycholic acid (CDCA). FXR-knockout stable Caco-2 line was developed using CRISPR-Cas9 methods and verified by qPCR and genotyping. The effect of estradiol on expression of TJCGs in FXR-knockout and wildtype Caco-2 cell monolayers was compared by qPCR. Future experiments include comparison of FXR-knockout and wildtype monolayer permeability with estrogen exposure by transwell permeability assay.

The effect of FXR genotype and exogenous estrogen CD severity (surgery, hospitalization, fistulizing disease) was evaluated in our female cohort by multivariate analysis.

Result(s)

Increased expression of TJCGs was seen in native Caco-2 monolayers incubated with CDCA. FXR-knockout cell line was then successfully created and confirmed. FXR-knockout cells showed decreased expression of TJCGs with the exception of zonula occludens-1. Estradiol exposure resulted in a dose-dependent decline in TJCGs expression in the wildtype Caco-2 cell line, however this effect was lost in the FXR-knockout cell line.

Preliminary analysis of patient cohort data (n=359) showed exogenous estrogen was associated with lower surgery risk (OR = 0.603, 95% CI= 0.373–0.964, p < 0.05; Fischer’s exact test) and trended towards decreasing fistulizing disease risk in a multiple logistic regression model which included FXR genotype. The association of FXR genotype with increased surgery risk was also confirmed in this logistic regression model.

Conclusion(s)

Herein, we show that FXR activity affects expression of TJCGs, and this effect is attenuated by estrogen interactions. Our patient cohort preliminary analysis confirmed an increased CD severity risk associated with FXR genotype and demonstrated a trend of decreasing CD severity with exogenous estrogen exposure. Further studies will assess the mechanisms by which FXR and estrogen interact to influence intestinal permeability.

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Department of Medicine, Western University

Disclosure of Interest

D. Taylor: None Declared, L. Donovan: None Declared, J. Choi: None Declared, R. Kim: None Declared, U. Schwarz: None Declared, A. Wilson Consultant of: Consulting fees from Fresenius Kabi, Speakers bureau of: Speaking fees from Takeda and Pfizer

Lewy Body Pathology and Alzheimer Disease in Down Syndrome

Introduction/Objective

Aging adults with Down syndrome (DS) develop Alzheimer disease neuropathology (AD) by the age of 40 years, primarily due to the overexpression of the amyloid precursor protein on chromosome 21. Lewy bodies (LBs), containing alpha-synuclein protein, are observed in 7-60% of AD patients in the amygdala and in cortex. Prior DS studies (n=20-56 cases) find the frequency of LB pathology to range between 8-50% of cases being affected. We hypothesized that LB pathology would also be present in DS brain with similar locations and prevalence to AD. Thus, we evaluated the frequency of LB in our UCI cohort of DS cases that we have collected over the past 25 years.

Methods/Case Report

Neuropathology reports from 55 cases with DS from the UCI-ADRC were included in this study. Cases were stained for beta-amyloid, phosphor-tau, alpha-synuclein and TDP-43 as per NACC protocols (one case each v7,8,9 and three v11).

Results (if a Case Study enter NA)

We identified 6 cases (10.9%), all male, with a mean age of 57 years (SD=3) that showed LB and/or Lewy neurites. LB pathology was classified as amygdala predominant in 3 cases, brainstem predominant in one, intermediate/transitional in one, and diffuse/neocortical in one. Five cases were BRAAK stage 6 and one was stage 5. Five cases had CERAD neuritic plaque score C and one case had a B score. Two of 3 cases were Thal phase 5, and one was phase 4. The case with diffuse/neocortical LB pathology demonstrated hippocampal sclerosis.

Conclusion

The observation that all our LB positive cases were male may reflect a sample bias. In our study, Lewy pathology was most common in amygdala but other sites of involvement are seen similar to a prior DS study and AD studies. Prior DS studies (n=20-56 cases) find the frequency of LB pathology to range between 8-50% of cases being affected. The prevalence of LB in our DS cohort (10.9%) is in the low end of the range seen in other DS and AD studies.

Phase I trial of the TNF-α inhibitor certolizumab plus chemotherapy in stage IV lung adenocarcinomas

We previously identified a chemotherapy-induced paracrine inflammatory loop that paradoxically mitigates the anti-tumor effect of chemotherapy and triggers metastatic propagation in breast and lung cancer models. Therefore, we sought to further validate and translate these findings into patient care by coupling the anti-TNF-α drug certolizumab pegol with standard cisplatin doublet chemotherapy. Here we first validate the anti-metastatic effect of certolizumab in a liver-metastatic Lewis Lung Carcinoma model. We then evaluate the safety, efficacy, and pharmacodynamic effects of certolizumab with cisplatin and pemetrexed in an open label Phase 1 clinical trial (NCT02120807) of eighteen adult patients with stage IV lung adenocarcinomas. The primary outcome is maximum tolerated dose. Secondary outcomes are response rate and progression-free survival (PFS); pharmacodynamic changes in blood and tumor are evaluated as a correlative outcome. There were nine partial responses among 16 patients evaluable (56%, 95% CI 30 to 80%). The median duration of response was 9.0 months (range 5.9 to 42.6 months) and median PFS was 7.1 months (95% CI 6.3 to NR). The standard 400 mg dose of certolizumab, added to cisplatin and pemetrexed, is well-tolerated and, as a correlative endpoint, demonstrates potent pharmacodynamic inhibition of peripheral cytokines associated with the paracrine inflammatory loop.

Validation of the KELIM score as a predictor of response to neoadjuvant treatment in patients with advanced high grade serous ovarian cancer

OBJECTIVE

The objective of this study is to externally validate the KELIM (rate of elimination of CA-125 elimation) score in patients with high grade serous ovarian cancer(HGSC)undergoing NACT and determine its relation to outcome of cytoreduction, platinum sensitivity, progression free(PFS) and overall survival(OS).

METHODS

This is a retrospective cohort study of patients with Stage III-IV HGSC diagnosed between January 1, 2010 and December 31, 2019 and treated with NACT. KELIM score was calculated using at least 3 CA-125 values within the first 100 days of chemotherapy. Demographic parameters were collected and Kaplan Meier survival analyses were performed for PFS and OS. This study was approved by local ethics board.

RESULTS

217 patients met inclusion criteria. Median follow-up was 28.93 months(range 2.86-135.06). There was no significant difference in stage, functional status, cytoreductive outcome or BRCA status(germline or somatic) between patients with a KELIM ≥ 1 and <1. Patients with a KELIM<1 had a lower median PFS (13.58 vs 19.69, p < 0.001), median platinum free interval(PFI) (7.66 vs 13.64, p < 0.001) and 5-year OS (57% vs 72%, p = 0.0140) compared to patients with KELIM≥1 . After adjusting for stage, treatment delays, bevacizumab or poly adenosine diphosphate-ribose polymerase(parp)-inhibitor use, and BRCA status, patients with KELIM<1 had a high risk of disease progression(HR = 1.57 (95% CI 1.08-2.28) and death(HR = 1.99 (95% CI 1.01-3.95) compared to KELIM≥1. BRCA status was independently associated to an increase on KELIM score (OR = 1.917, 95% CI 1.046-3.512, p = 0.035).

CONCLUSION

Patients with advanced HGSC undergoing NACT with a KELIM <1 were more likely to have platinum-resistant disease, worse PFS and worse OS when compared to patients with KELIM≥1. The KELIM score can be a helpful tool to predict chemo-response and aid in treatment decision making.

Qualitative Evaluation of an Artificial Intelligence–Based Clinical Decision Support System to Guide Rhythm Management of Atrial Fibrillation: Survey Study

Background

Despite the numerous studies evaluating various rhythm control strategies for atrial fibrillation (AF), determination of the optimal strategy in a single patient is often based on trial and error, with no one-size-fits-all approach based on international guidelines/recommendations. The decision, therefore, remains personal and lends itself well to help from a clinical decision support system, specifically one guided by artificial intelligence (AI). QRhythm utilizes a 2-stage machine learning (ML) model to identify the optimal rhythm management strategy in a given patient based on a set of clinical factors, in which the model first uses supervised learning to predict the actions of an expert clinician and identifies the best strategy through reinforcement learning to obtain the best clinical outcome—a composite of symptomatic recurrence, hospitalization, and stroke.

Objective

We qualitatively evaluated a novel, AI-based, clinical decision support system (CDSS) for AF rhythm management, called QRhythm, which uses both supervised and reinforcement learning to recommend either a rate control or one of 3 types of rhythm control strategies—external cardioversion, antiarrhythmic medication, or ablation—based on individual patient characteristics.

Methods

Thirty-three clinicians, including cardiology attendings and fellows and internal medicine attendings and residents, performed an assessment of QRhythm, followed by a survey to assess relative comfort with automated CDSS in rhythm management and to examine areas for future development.

Results

The 33 providers were surveyed with training levels ranging from resident to fellow to attending. Of the characteristics of the app surveyed, safety was most important to providers, with an average importance rating of 4.7 out of 5 (SD 0.72). This priority was followed by clinical integrity (a desire for the advice provided to make clinical sense; importance rating 4.5, SD 0.9), backward interpretability (transparency in the population used to create the algorithm; importance rating 4.3, SD 0.65), transparency of the algorithm (reasoning underlying the decisions made; importance rating 4.3, SD 0.88), and provider autonomy (the ability to challenge the decisions made by the model; importance rating 3.85, SD 0.83). Providers who used the app ranked the integrity of recommendations as their highest concern with ongoing clinical use of the model, followed by efficacy of the application and patient data security. Trust in the app varied; 1 (17%) provider responded that they somewhat disagreed with the statement, “I trust the recommendations provided by the QRhythm app,” 2 (33%) providers responded with neutrality to the statement, and 3 (50%) somewhat agreed with the statement.

Conclusions

Safety of ML applications was the highest priority of the providers surveyed, and trust of such models remains varied. Widespread clinical acceptance of ML in health care is dependent on how much providers trust the algorithms. Building this trust involves ensuring transparency and interpretability of the model.

P-739 Social and treatment characteristics of women with Uterine Fibroid (UF) with/without Heavy Menstrual Bleeding (HMB), in a commercially insured US population

Study question

Are there differences in patient’s social demographic, clinical and treatment characteristics among patients diagnosed with HMB and/or UF?

Summary answer

Baseline characteristics were similar across all UF-status defined-groups. Differences were observed in education, net-worth and 12-monthfollow-up characteristics. Nearly 60% were prescribed pain meds pre-diagnosis.

What is known already

Uterine leiomyomas (or fibroids) are benign neoplasm that affect women of reproductive age1. In the US, treatment for UF is individualized, dependent on size and location of the fibroids, patient profile, symptom severity and type of diagnosis. Patients may be diagnosed with HMB before UF (HMB-UF), diagnosed with UF first and then HMB (UF-HMB), diagnosed with only HMB (HMB-Only) or UF only (UF-Only). Previous studies indicated that the majority (70%) of women received no prescription medications regardless of surgery status and 40% had pain at time of diagnosis.2,3

Study design, size, duration

Our retrospective real-world observational study included 295,400 women across four cohorts between 10/1/2012 -12/31/2020. The majority (96,961; 44%) had HMB-Only, 46,763 (21%) UF-Only, 35,421 (16%) HMB-UF, and 40,806 (19%) UF-HMB. Patients required 12 months continuous enrollment before index date (earlier of HMB or UF diagnosis date based on cohorts) and 12-months of follow-up unless hysterectomy was observed before 12 months. Surgical and pharmacologic agents explored were based on ACOG guidelines for UF.

Participants/materials, setting, methods

Optum® Socio-Economic Status claims database was used to identify newly diagnosed women 18-55 years old with UF and/or HMB claims, without history of conservative/radical surgery or non-dermatological cancers.

Descriptive analyses were performed for patients’ social demographics and treatment characteristics during pre- and post-index period.

Main results and the role of chance

Across all cohorts,

During the 12-month follow-up, nearly 80% of patients used at least 1 prescribed pain medication compared to nearly 60% at baseline. The increase in pain medication use was mainly driven by increase in NSAIDs, opioids, analgesics, and anti-migraine in all cohorts except HMB-O (Opioids: baseline 24-30% to follow up 41-55%; NSAIDs: 20-21% to 44-53%; analgesics: 6-8% to 19%-33%; anti-migraine: 8-11% to 16-29%).

Limitations, reasons for caution

True incidence of index claims are difficult to estimate. Over-the-counters medications or claims made outside the study period are not captured. Pain medication may be unrelated to UF-associated pain.

Findings only reflect the commercially insured population and may not be generalizable. Claims data provide limited clinical profile and prescribing rationales.

Wider implications of the findings

The majority of the patients in these cohorts experienced pain and were prescribed opioids. Determining the link between the use of pain medication and symptoms of UF and HMB is important, as pain medications do not address HMB.

Trial registration number

Not applicable

P-315 The importance of treatment features beyond pain reduction associated with gonadotropin-releasing hormone analogues from the patient perspective

Study question

Beyond reducing pain, how do women with moderate-severe-endometriosis pain prioritize treatment features and outcomes associated with gonadotropin-releasing hormone (GnRH) analogues?

Summary answer

Moderate-severe-endometriosis patients prioritized safe long-term treatment, feeling treatment-effects within a few cycles, being able to maintain employment, reducing fatigue, depression, and headaches, and improving libido.

What is known already

The importance of pain management in endometriosis treatment is well-established. Poor health-related quality of life has been attributed to endometriosis pain, with greater impact as the number of endometriosis symptoms and symptom severity increase. Endometriosis treatment options include analgesics for acute pain episodes and surgery in more severe cases, as well as hormone therapies, including GnRH analogues. The potential risks, benefits, and outcomes associated with currently available GnRH analogues for endometriosis treatment can vary. Data are lacking on the patient perspective with respect to potential treatment features and outcomes beyond just pain reduction.

Study design, size, duration

Treatment-naïve patients with moderate-severe-endometriosis pain (rating scale ≥4 for menstrual pain) in the United States completed a cross-sectional online survey. Best-worst scaling (BWS) was used to assess preferences for key non-pain treatment attributes that were identified based on the literature. Cognitive pre-test interviews were conducted to confirm content validity of the questionnaire. Data collection for this ongoing survey was initiated in December 2021.

Participants/materials, setting, methods

Patients (English-speaking, premenopausal, 18-50 years-old) were recruited via healthcare research panel. Eligible patients self-reported laparoscopy-confirmed-endometriosis, no endometriosis/other gynecological surgery in past 3 months, no osteoporosis/bone disease/uterine fibroids history, and healthcare coverage for previous 3 years. Treatment features in the BWS exercise included dosage flexibility, short treatment onset, reversibility of side effects, reducing fatigue, depression, headache, impact on libido, impact on sleep, ability to maintain employment, duration of treatment, and additional need for contraceptive use.

Main results and the role of chance

Overall, 115 patients (31.1±7.5 years-old) were included in the analyses. On a 0 (no pain) to 10 (pain as bad as you can imagine) scale, the mean worst menstrual and non-menstrual pelvic pain (during past month) were 7.7±1.6 and 5.4±2.7, respectively. The most common endometriosis treatments ever used included over-the-counter pain medications (90.4%) and prescription contraceptives (74.8%).

Of 11 BWS features tested, patients prioritized:

“You can safely take the treatment for a long period of time” (relative importance=11.4%) “Your ability to get or maintain a job” (11.1%) “When starting a treatment, you will begin to feel the treatment’s effects within the first few menstrual cycles” (10.9%) “You will be less depressed” (10.8%) “Your interest in sex will not be affected” (10.7%) “Any side-effects you may experience are resolved quickly after treatment stops” (10.1%) “You will be less fatigued or tired” (9.5%) “You will have fewer headaches or migraines” (8.6%)

Least important to patients were:

“Your sleep will not be affected” (6.8%) “Your doctor offers different options for the dose strength and how often you take it, as appropriate to your needs” (5.9%) “You are not required to take additional contraceptives along with the treatment” (4.0%)

Limitations, reasons for caution

The preferences of patients who participated may differ from those who did not participate, thereby reducing the ability to generalize results. All data were self-reported; diagnosis and treatment could not be independently confirmed. The BWS exercise cannot include all possible attributes and outcomes relevant to patients.

Wider implications of the findings

Beyond pain reduction, patients most highly valued having safe long-term treatment, feeling treatment effects within a few cycles, rapid resolution of side effects, being able to work, maintaining libido, and reducing fatigue, depression, and headaches. These factors can help physicians to better align endometriosis treatment decision-making with patient preferences.

Trial registration number

Not applicable

Antibacterial potency of Type VI amidase effector toxins is dependent on substrate topology and cellular context

Members of the bacterial T6SS amidase effector (Tae) superfamily of toxins are delivered between competing bacteria to degrade cell wall peptidoglycan. Although Taes share a common substrate, they exhibit distinct antimicrobial potency across different competitor species. To investigate the molecular basis governing these differences, we quantitatively defined the functional determinants of Tae1 from Pseudomonas aeruginosa PAO1 using a combination of nuclear magnetic resonance and a high-throughput in vivo genetic approach called deep mutational scanning (DMS). As expected, combined analyses confirmed the role of critical residues near the Tae1 catalytic center. Unexpectedly, DMS revealed substantial contributions to enzymatic activity from a much larger, ring-like functional hot spot extending around the entire circumference of the enzyme. Comparative DMS across distinct growth conditions highlighted how functional contribution of different surfaces is highly context-dependent, varying alongside composition of targeted cell walls. These observations suggest that Tae1 engages with the intact cell wall network through a more distributed three-dimensional interaction interface than previously appreciated, providing an explanation for observed differences in antimicrobial potency across divergent Gram-negative competitors. Further binding studies of several Tae1 variants with their cognate immunity protein demonstrate that requirements to maintain protection from Tae activity may be a significant constraint on the mutational landscape of tae1 toxicity in the wild. In total, our work reveals that Tae diversification has likely been shaped by multiple independent pressures to maintain interactions with binding partners that vary across bacterial species and conditions.

Symptomatic, clinical and biomarker associations for mortality in hospitalized COVID-19 patients enriched for African Americans

BACKGROUND AND AIMS

Initial reports on US COVID-19 showed different outcomes in different races. In this study we use a diverse large cohort of hospitalized COVID-19 patients to determine predictors of mortality.

METHODS

We analyzed data from hospitalized COVID-19 patients (n = 5852) between March 2020- August 2020 from 8 hospitals across the US. Demographics, comorbidities, symptoms and laboratory data were collected.

RESULTS

The cohort contained 3,662 (61.7%) African Americans (AA), 286 (5%) American Latinx (LAT), 1,407 (23.9%), European Americans (EA), and 93 (1.5%) American Asians (AS). Survivors and non-survivors mean ages in years were 58 and 68 for AA, 58 and 77 for EA, 44 and 61 for LAT, and 51 and 63 for AS. Mortality rates for AA, LAT, EA and AS were 14.8, 7.3, 16.3 and 2.2%. Mortality increased among patients with the following characteristics: age, male gender, New York region, cardiac disease, COPD, diabetes mellitus, hypertension, history of cancer, immunosuppression, elevated lymphocytes, CRP, ferritin, D-Dimer, creatinine, troponin, and procalcitonin. Use of mechanical ventilation (p = 0.001), shortness of breath (SOB) (p < 0.01), fatigue (p = 0.04), diarrhea (p = 0.02), and increased AST (p < 0.01), significantly correlated with death in multivariate analysis. Male sex and EA and AA race/ethnicity had higher frequency of death. Diarrhea was among the most common GI symptom amongst AAs (6.8%). When adjusting for comorbidities, significant variables among the demographics of study population were age (over 45 years old), male sex, EA, and patients hospitalized in New York. When adjusting for disease severity, significant variables were age over 65 years old, male sex, EA as well as having SOB, elevated CRP and D-dimer. Glucocorticoid usage was associated with an increased risk of COVID-19 death in our cohort.

CONCLUSION

Among this large cohort of hospitalized COVID-19 patients enriched for African Americans, our study findings may reflect the extent of systemic organ involvement by SARS-CoV-2 and subsequent progression to multi-system organ failure. High mortality in AA in comparison with LAT is likely related to high frequency of comorbidities and older age among AA. Glucocorticoids should be used carefully considering the poor outcomes associated with it. Special focus in treating patients with elevated liver enzymes and other inflammatory biomarkers such as CRP, troponin, ferritin, procalcitonin, and D-dimer are required to prevent poor outcomes.

Trastuzumab deruxtecan (T-DXd) versus trastuzumab emtansine (T-DM1) in patients (pts) with HER2-positive (HER2+) unresectable and/or metastatic breast cancer (mBC): Safety follow-up of the randomized, phase 3 study DESTINY-Breast03

1000

Background: In the DESTINY-Breast03 (NCT03529110) primary analysis (data cutoff [DCO], May 21, 2021), T-DXd showed superiority over T-DM1 in pts with HER2+ mBC, with a significant improvement of progression-free survival by blinded independent central review (HR, 0.284; 95% CI, 0.217-0.373; P < 0.001), and a safety profile consistent with prior studies. This analysis provides updated safety data with longer follow-up. Methods: Pts were randomized 1:1 to T-DXd or T-DM1. Prespecified safety analysis of treatment-emergent adverse events (TEAEs) was conducted; endpoints included time to event, duration of event, and resolution. Results: At DCO (September 7, 2021), 116 (45.1%) pts vs 39 (14.9%) pts remained on treatment in the T-DXd vs T-DM1 arms; median treatment duration was 16.1 mo (range, 0.7-33.0) for T-DXd vs 6.9 mo (range, 0.7-28.5) for T-DM1. Any-grade (G), G≥3, and serious AE (SAE) rates were similar for T-DXd vs T-DM1 (99.6% vs 95.4%; 53.3% vs 49.8%; and 21.0% vs 19.2%), while exposure-adjusted incidence rates (EAIRs; per pt-year) for G≥3 and SAEs were lower for T-DXd vs T-DM1 (0.42 vs 0.70 and 0.17 vs 0.27). Median time to TEAE associated with drug discontinuation or dose reduction was longer with T-DXd vs T-DM1 (224.0 vs 147.0 d and 96.0 v 19.0 d, respectively). Most TEAEs in ≥20% of pts were hematologic or gastrointestinal. Median time to first onset of select any-G TEAEs was 70.0 vs 42.0 d for anemia, 196.0 vs 168.0 d for lymphopenia, 132.0 vs 8.0 d for thrombocytopenia, 22.0 vs 24.0 d for fatigue, 74.5 vs 92.0 d for leukopenia, and 64.0 vs 105.0 d for neutropenia, with T-DXd vs T-DM1, respectively. In both arms, most nausea and vomiting events were G1/2; while G≥3 events with T-DXd vs T-DM1 were 6.6% vs 0.4% for nausea and 1.6% vs 0.8% for vomiting, respectively. Rates of nausea, vomiting, and alopecia were highest in cycle 1 and lower in subsequent cycles for T-DXd. Rates of hematologic events were generally lower in earlier cycles vs cycle ≥8 in both arms. Rates of adjudicated, drug-related ILD/pneumonitis were 10.9% (1 G2 event since previous DCO) with T-DXd vs 1.9% with T-DM1, with no G4/5 events. Median time to first adjudicated, drug-related ILD/pneumonitis event was 5.9 vs 9.5 mo for T-DXd vs T-DM1, respectively; at DCO, most events resolved (57.1% vs 80.0%), and follow-up is ongoing. Conclusions: In this updated safety analysis, T-DXd demonstrated a tolerable safety profile consistent with prior studies. Despite longer treatment duration with T-DXd, EAIRs of G≥3 and SAEs were lower for T-DXd vs T-DM1. Rates of ILD/pneumonitis for T-DXd were similar to those in the previous DCO. Nausea, vomiting, and alopecia rates decreased over time. This longer safety update reinforces the consistent safety profile of T-DXd, supporting the clinical benefit of T-DXd over T-DM1 in patients with HER2+ mBC. Clinical trial information: NCT03529110.

SCARF1-Induced Efferocytosis Plays an Immunomodulatory Role in Humans, and Autoantibodies Targeting SCARF1 Are Produced in Patients with Systemic Lupus Erythematosus

Deficiency in the clearance of cellular debris is a major pathogenic factor in the emergence of autoimmune diseases. We previously demonstrated that mice deficient for scavenger receptor class F member 1 (SCARF1) develop a lupus-like autoimmune disease with symptoms similar to human systemic lupus erythematosus (SLE), including a pronounced accumulation of apoptotic cells (ACs). Therefore, we hypothesized that SCARF1 will be important for clearance of ACs and maintenance of self-tolerance in humans, and that dysregulation of this process could contribute to SLE. In this article, we show that SCARF1 is highly expressed on phagocytic cells, where it functions as an efferocytosis receptor. In healthy individuals, we discovered that engagement of SCARF1 by ACs on BDCA1+ dendritic cells initiates an IL-10 anti-inflammatory response mediated by the phosphorylation of STAT1 and STAT3. Unexpectedly, there was no significant difference in SCARF1 expression in samples of patients with SLE compared with healthy donor samples. However, we detected anti-SCARF1 autoantibodies in 26% of patients with SLE, which was associated with dsDNA Ab positivity. Furthermore, our data show a direct correlation of the levels of anti-SCARF1 in the serum and defects in the removal of ACs. Depletion of Ig restores efferocytosis in SLE serum, suggesting that defects in the removal of ACs are partially mediated by SCARF1 pathogenic autoantibodies. Our data demonstrate that human SCARF1 is an AC receptor in dendritic cells and plays a role in maintaining tolerance and homeostasis.

Process optimization in breast imaging: Exploring advanced roles for medical radiation technologists

INTRODUCTION

Medical imaging (MI) is a critical service that underpins the care journey for many who enter the healthcare system. The subspecialty of Breast Imaging (BI) represents a complex and multi-modality MI setting with a well-defined role in the healthcare system. BI holds great potential as a setting to consider opportunities for a medical radiation technologist's (MRT) current role to be modified and leveraged to fulfill novel and advanced roles to optimize patient-centered service.

METHODS

This study was conducted in three interrelated BI clinics, all at large urban academic hospitals with a common operational infrastructure. It involved three phases; (i) mapping processes and workflows in BI (ii) identification and characterization of care delivery problems (CDPs) within these process maps, and prioritization of opportunities where task shifting might leverage enhanced knowledge, skills, and judgement of MRTs to optimize care. The PEPPA framework - a systematic planning tool for the development and implementation of advanced practice nursing (APN) roles⁵ - was used, with the first five of nine steps considered in scope for this pilot project.

RESULTS

Twelve distinct BI processes were identified and mapped as swimlane charts; a single clerical workflow leading up to patient check-in to the BI department, and 11 subsequent clinical processes. Each map included swimlanes for MRTs, radiologists, and clerical staff, as relevant, and included processes ranging from routine mammogram and ultrasound orders to stereotactic-guided core biopsies and rapid diagnostic workflows. Across the maps, 9 CDPs were identified; scheduling, radiologist availability, incorrect orders, and coordination of externally-acquired imaging and consults. The inpatient process map had the most instances of CDP identified, and the radiologist availability CDP was flagged most frequently across processes. Characterization of the root causes of each CDP led to common reflections on team and task factors, including inefficiencies in communication or division of responsibilities, or availability of resources or team members to support workflows. Consultations based on the resultant maps and CDPs led to identification of the following potential advanced roles for MRTs; review and decision-making relating to imaging acquired externally prior to patient appointments, exam ordering and protocoling in defined scenarios, and task-shifting of certain clinical procedures such as breast screening ultrasounds and contrast-enhanced mammography.

CONCLUSION

Advanced practice for MRTs holds great potential to address system inefficiencies in breast imaging, if approached systematically and with the primary objective to optimize care. Future work will consider trial and evaluation of pilot roles that incorporate advanced opportunities identified in this project.

Impact of formulation on the quality and stability of freeze-dried nanoparticles

Freeze-drying is an effective approach to improve the long-term stability of nanomedicines. Lyoprotectants are generally considered as requisite excipients to ensure that the quality of nanoparticles is maintained throughout the freeze-drying process. However, depending on the type of nanoparticles, the needs for lyoprotectants or the challenges they face during freeze-drying may be different. In this study, we compared and identified the impact of freeze-drying on key characteristics of three types of nanoparticles: solid lipid nanoparticles (SLNs), polymeric nanoparticles (PNs), and liposomes. Sucrose, trehalose, and mannitol were added to nanoparticle suspensions before freeze-drying. The same conservative freeze-drying conditions with controlled ice nucleation at -8 °C were employed for all formulations. The collapse temperatures of nanoparticle formulations were found to be the same as those of the lyoprotectant added, except PN formulation. Likely the poly(vinyl alcohol) (PVA) in the formulation induced a higher collapse temperature and retardation of drying of PNs. Freeze-drying of both SLNs and liposomes without lyoprotectants increased particle size and polydispersity, which was resolved by adding amorphous disaccharides. Regardless of the addition of lyoprotectants, freeze-drying did not alter the size of PNs possibly due to the protection from PVA. However, lyoprotectants were still necessary to shorten the reconstitution time and reduce the residual moisture. In conclusion, different types of nanoparticles face distinct challenges for freeze-drying, and lyoprotectants differentially affect various stability and quality attributes of freeze-dried nanoparticles.

Phase II study of ceralasertib (AZD6738) in combination with durvalumab in patients with advanced/metastatic melanoma who have failed prior anti-PD-1 therapy

BACKGROUND

Modulating the DNA damage response and repair (DDR) pathways is a promising strategy for boosting cancer immunotherapy. Ceralasertib (AZD6738) is an oral inhibitor of the serine/threonine protein kinase ataxia telangiectasia and Rad3-related protein, which is crucial for DDR.

PATIENTS AND METHODS

This phase II trial evaluated ceralasertib plus durvalumab for the treatment of patients with metastatic melanoma who had failed anti-programmed cell death protein 1 therapy.

RESULTS

Among the 30 patients, we observed an overall response rate of 31.0% and a disease control rate of 63.3%. Responses were evident across patients with acral, mucosal, and cutaneous melanoma. The median duration of response was 8.8 months (range, 3.8-11.7 months). The median progression-free survival was 7.1 months (95% confidence interval, 3.6-10.6 months), and the median overall survival was 14.2 months (95% confidence interval, 9.3-19.1 months). Common adverse events were largely hematologic and manageable with dose interruptions and reductions. Exploratory biomarker analysis suggested that tumors with an immune-enriched microenvironment or alterations in the DDR pathway were more likely to respond to the study treatment.

CONCLUSION

We conclude that ceralasertib in combination with durvalumab has promising antitumor activity among patients with metastatic melanoma who have failed anti-programmed cell death protein 1 therapy, and constitute a population with unmet needs.

COVID-19 among African Americans and Hispanics: Does gastrointestinal symptoms impact the outcome?

BACKGROUND

The coronavirus disease 2019 (COVID-19) disproportionately affected African Americans (AA) and Hispanics (HSP).

AIM

To analyze the significant effectors of outcome in African American patient population and make special emphasis on gastrointestinal (GI) symptoms, laboratory values and comorbidities.

METHODS

We retrospectively evaluated the medical records of 386 COVID-19 positive patients admitted at Howard University Hospital between March and May 2020. We assessed the symptoms, including the GI manifestations, comorbidities, and mortality, using logistic regression analysis.

RESULTS

Of these 386 COVID-19 positive patients, 257 (63.7%) were AAs, 102 (25.3%) HSP, and 26 (6.45%) Whites. There were 257 (63.7%) AA, 102 (25.3%) HSP, 26 (6.45%) Whites. The mean age was 55.6 years (SD = 18.5). However, the mean age of HSP was the lowest (43.7 years vs 61.2 for Whites vs 60 for AAs). The mortality rate was highest among the AAs (20.6%) and lowest among HSP (6.9%). Patients with shortness of breath (SOB) (OR2 = 3.64, CI = 1.73-7.65) and elevated AST (OR2 = 8.01, CI = 3.79-16.9) elevated Procalcitonin (OR2 = 8.27, CI = 3.95-17.3), AST (OR2 = 8.01, CI = 3.79-16.9), ferritin (OR2 = 2.69, CI = 1.24-5.82), and Lymphopenia (OR2 = 2.77, CI = 1.41-5.45) had a high mortality rate. Cough and fever were common but unrelated to the outcome. Hypertension and diabetes mellitus were the most common comorbidities. Glucocorticoid treatment was associated with higher mortality (OR2 = 5.40, CI = 2.72-10.7). Diarrhea was prevalent (18.8%), and GI symptoms did not affect the outcome.

CONCLUSION

African Americans in our study had the highest mortality as they consisted of an older population and comorbidities. Age is the most important factor along with SOB in determining the mortality rate. Overall, elevated liver enzymes, ferritin, procalcitonin and C-reactive protein were associated with poor prognosis. GI symptoms did not affect the outcome. Glucocorticoids should be used judiciously, considering the poor outcomes associated with it. Attention should also be paid to monitor liver function during COVID-19, especially in AA and HSP patients with higher disease severity.