Neurologic Events and Outcomes in Patients Receiving Proton and Photon Reirradiation for High Grade Non-Codeleted Gliomas

PURPOSE/OBJECTIVE(S)

Patients undergoing reirradiation (ReRT) for high grade glioma are at risk for tumor progression, pseudoprogression, and radiation necrosis. We investigated factors associated with neurologic events and disease control after re-irradiation with protons and photons at a single academic center.

MATERIALS/METHODS

We reviewed records and MRIs of patients receiving scanning beam proton (since center opening in 2016) and photon (since 2015) reirradiation in ≥10 fractions for grade 3 anaplastic astrocytoma (AA) and grade 4 glioblastoma (GBM), excluding 1p19q co-deleted oligodendrogliomas and extensive multifocal/leptomeningeal disease. The primary endpoint was time from ReRT to ≥ grade 2 pseudoprogression or radiation necrosis (PsP/RN, grade 2: moderate symptoms requiring outpatient steroids/bevacizumab, grade 3: severe symptoms leading to admission or surgical intervention). Dose was converted to EQD2 using a/b = 3. Cox proportional hazards model was used to calculate survival and time to PsP/RN.

RESULTS

A total of 53 patients were included (26 protons, 27 photons, median KPS 80). Patients receiving protons had more favorable features. Compared to the photons, the proton group was younger (48 vs. 58) and more likely to have AA (46% vs. 22%) and resection within 3 months (42% vs 26%). The proton group also had a longer interval from prior RT (57 vs. 39 months) and were less likely to receive bevacizumab at reRT (15% vs. 59%). CTV was 130 cc for protons vs 99 cc for photons, and most had active disease at time of ReRT identified on planning MRI (76% protons, 85% photons). Median OS was 10.5 months (14.1 months protons, 8.1 months photons), with time from initial RT the only significant factor on multivariate analysis. Median PFS was 9.4 months (9.8 months protons, 6.2 months photons). 9 patients (18%) had ≥ grade 3 PsP/RN (8 proton, 1 photon) and 21 patients (41%) had ≥ grade 2 PsP/RN (16 proton, 5 photon). Grade 3 events included 1 seizure (photon group), 1 hemorrhage, 1 thalamic stroke, 1 shunt placement, 1 re-resection, and PSP4 4 PsP/RN requiring admission. Protons were associated shorter time to ≥ grade 2 PsP/RN (4 months vs. not reached, p = 0.027). When accounting for bevacizumab use at time of reRT, the association between protons and PsP/RN lost significance but there remained a trend (grade 2, p = 0.095, HR 2.4; grade 3, p = 0.105, HR 5.8). CTV, MGMT status, EQD2, and interval from prior RT were not associated with PsP/RN.

CONCLUSION

High grade neurologic events were common in patients with predominantly active, unresected high grade gliomas receiving ReRT. Though ascertainment and survival bias are significant limitations, pseudoprogression and necrosis appeared to be more prominent in patients receiving protons. These results contribute to ongoing efforts to both optimize ReRT for high grade glioma and investigate biologic effects of proton therapy.

Advances in Focused Ultrasound for the Treatment of Brain Tumors

Employing the full arsenal of therapeutics to treat brain tumors is limited by the relative impermeability of the blood-brain and blood-tumor barriers. In physiologic states, the blood-brain barrier serves a protective role by passively and actively excluding neurotoxic compounds; however, this functionality limits the penetrance of therapeutics into the tumor microenvironment. Focused ultrasound technology provides a method for overcoming the blood-brain and blood-tumor barriers through ultrasound frequency to transiently permeabilize or disrupt these barriers. Concomitant delivery of therapeutics has allowed for previously impermeable agents to reach the tumor microenvironment. This review details the advances in focused ultrasound in both preclinical models and clinical studies, with a focus on its safety profile. We then turn towards future directions in focused ultrasound-mediated therapies for brain tumors.

Ligand-Gated Ion Channels: Prognostic and Therapeutic Implications for Gliomas

Gliomas are common primary brain malignancies that remain difficult to treat due to their overall aggressiveness and heterogeneity. Although a variety of therapeutic strategies have been employed for the treatment of gliomas, there is increasing evidence that suggests ligand-gated ion channels (LGICs) can serve as a valuable biomarker and diagnostic tool in the pathogenesis of gliomas. Various LGICs, including P2X, SYT16, and PANX2, have the potential to become altered in the pathogenesis of glioma, which can disrupt the homeostatic activity of neurons, microglia, and astrocytes, further exacerbating the symptoms and progression of glioma. Consequently, LGICs, including purinoceptors, glutamate-gated receptors, and Cys-loop receptors, have been targeted in clinical trials for their potential therapeutic benefit in the diagnosis and treatment of gliomas. In this review, we discuss the role of LGICs in the pathogenesis of glioma, including genetic factors and the effect of altered LGIC activity on the biological functioning of neuronal cells. Additionally, we discuss current and emerging investigations regarding the use of LGICs as a clinical target and potential therapeutic for gliomas.

Theoretical characterisation of electron tunnelling from granular activated carbon to electron accepting organisms in direct interspecies electron transfer

Direct interspecies electron transfer (DIET) has been identified as an efficient metabolism between symbiotically interacting organisms. One method of DIET uses conductive materials (e.g., granular activated carbon (GAC)) as a medium to shuttle electrons from electron donating organisms (eg., Geobacter metallireducens) to electron accepting organisms (e.g., Geobacter sulfurreducens and Methanosarcina barkeri). Conductive materials such as GAC, become negatively charged in DIET processes due to reduction by electron donating organisms. This high excess electron density in GAC leads to quantum tunnelling of electrons being a significant electron transfer mechanism for DIET. Thus, a theoretical model obeying the Wentzel–Kramers–Brillouin (WKB) approximation and Fermi–Dirac statistics was developed and simulated. In the model, the electron tunnelling transfer barrier was described by an effective rectangular barrier. The result of our 1D tunnelling simulations indicates that within 29.4 nm of the GAC, tunnelling can sufficiently supply electrons from GAC to G. sulfurreducens and M. barkeri. The phenomenon of tunnelling may also have significance as a stimulant of chemotaxis for G. sulfurreducens and other electron accepting microbes when attempting to adsorb onto GAC. This study sheds light on quantum tunnelling’s significant potential in both bacterium and archaeon DIET-centric processes.

Phonon anharmonicity in binary chalcogenides for efficient energy harvesting

Thermoelectric (TE) materials have received much attention due to their ability to harvest waste heat energy. TE materials must exhibit a low thermal conductivity (κ) and a high power factor (PF) for efficient conversion. Both factors define the figure of merit (ZT) of the TE material, which can be increased by suppressing κ without degrading the PF. Recently, binary chalcogenides such as SnSe, GeTe, and PbTe have emerged as attractive candidates for thermoelectric energy generation at moderately high temperatures. These materials possess simple crystal structures with low κ in their pristine forms, which can be further lowered through doping and other approaches. Here, we review the recent advances in the temperature-dependent behavior of phonons and their influence on the thermal transport properties of chalcogenide-based TE materials. Because phonon anharmonicity is one of the fundamental contributing factors for low thermal conductivity in SnSe, Sb-doped GeTe, and related chalcogenides, we discuss complementary experimental approaches such as temperature-dependent Raman spectroscopy, inelastic neutron scattering, and calorimetry to measure anharmonicity. We further show how data gathered using multiple techniques helps us understand and engineer better TE materials. Finally, we discuss the rise of machine learning-aided efforts to discover, design, and synthesize TE materials of the future.

Advances in Immunotherapy for the Treatment of Adult Glioblastoma: Overcoming Chemical and Physical Barriers

Simple Summary

The poor prognosis for glioblastoma (GBM) despite the existence of a standard-of-care treatment of resection, radiotherapy, and adjuvant chemotherapy has necessitated the exploration of other therapeutic avenues. One particularly promising avenue is an immunotherapeutic approach in which the body′s immune system is artificially stimulated to directly identify and attack the tumor cells. A variety of methods including immune checkpoint inhibition, T-cell transfer, vaccination, and a viral approach are being developed for GBM. Barriers such as tumor heterogeneity, the physical blood–brain barrier, the immunosuppressive nature of GBM, and the limited number of identifiable GBM-specific targets have reduced the efficacy of the aforementioned approaches. In the following review, we document the advances in immunotherapy, the barriers to implementation, and the development of a new technology (microbubble-enhanced focused ultrasound) to overcome the physical barriers to immunotherapy.

Abstract

Glioblastoma, or glioblastoma multiforme (GBM, WHO Grade IV), is a highly aggressive adult glioma. Despite extensive efforts to improve treatment, the current standard-of-care (SOC) regimen, which consists of maximal resection, radiotherapy, and temozolomide (TMZ), achieves only a 12–15 month survival. The clinical improvements achieved through immunotherapy in several extracranial solid tumors, including non-small-cell lung cancer, melanoma, and non-Hodgkin lymphoma, inspired investigations to pursue various immunotherapeutic interventions in adult glioblastoma patients. Despite some encouraging reports from preclinical and early-stage clinical trials, none of the tested agents have been convincing in Phase III clinical trials. One, but not the only, factor that is accountable for the slow progress is the blood–brain barrier, which prevents most antitumor drugs from reaching the target in appreciable amounts. Herein, we review the current state of immunotherapy in glioblastoma and discuss the significant challenges that prevent advancement. We also provide thoughts on steps that may be taken to remediate these challenges, including the application of ultrasound technologies.

Ligand-Gated Ion Channels as Targets for Treatment and Management of Cancers

Ligand-gated ion channels are an ionotropic receptor subtype characterized by the binding of an extracellular ligand, followed by the transient passage of ions through a transmembrane pore. Ligand-gated ion channels are commonly subcategorized into three superfamilies: purinoreceptors, glutamate receptors, and Cys-loop receptors. This classification is based on the differing topographical morphology of the receptors, which in turn confers functional differences. Ligand-gated ion channels have a diverse spatial and temporal expression which implicate them in key cellular processes. Given that the transcellular electrochemical gradient is finely tuned in eukaryotic cells, any disruption in this homeostasis can contribute to aberrancies, including altering the activity of pro-tumorigenic molecular pathways, such as the MAPK/ERK, RAS, and mTOR pathways. Ligand-gated ion channels therefore serve as a potential targetable system for cancer therapeutics. In this review, we analyze the role that each of the three ligand-gated ion channel superfamilies has concerning tumor proliferation and as a target for the treatment of cancer symptomatology.

A Case Study Using Papaya Leaf Extract to Reverse Chemotherapy-Induced Thrombocytopenia in a GBM Patient

Chemotherapy-induced thrombocytopenia (CIT) is a critical condition in which platelet counts are abnormally reduced following the administration of chemotherapeutic compounds. CIT poses a treatment conundrum to clinicians given the increased risk of spontaneous bleeding, obstacles to surgical management of tumors, and exclusion from clinical trials. Treatment of CIT involves the removal of the offending agent combined with platelet infusion or thrombopoietin agonist treatment. However, due to the autoimmune and infection risks associated with infusions, this treatment is only reserved for patients with critically low platelet counts. One potential solution for patients in the mid to low platelet count range is Carica papaya leaf extract (CPLE). In this case, we report the novel use of CPLE as a method of bolstering platelet counts in a patient presenting with CIT. The patient was initiated on CPLE therapy consisting of 1 tablespoon twice daily with meals. Following CPLE treatment, the patient’s platelet counts rebounded from less than 10,000/µL to 113,000/µL. This clinical vignette supports the use of CPLE in the clinical context of CIT when thrombopoietin agonists are not a viable option. The potential benefits of CPLE as a method for increasing platelet count deserve further exploration, especially as a treatment option for refractory patients or those ill-suited for other traditional thrombocytopenia therapies.

Associations of hair dye and relaxer use with breast tumor clinicopathologic features: Findings from the Women's circle of Health Study

BACKGROUND

Building upon our earlier findings of significant associations between hair dye and relaxer use with increased breast cancer risk, we evaluated associations of select characteristics of use with breast tumor clinicopathology.

METHODS

Using multivariable-adjusted models we examined the associations of interest in a case-only study of 2998 women with breast cancer, overall and stratified by race and estrogen receptor (ER) status, addressing multiple comparisons using Bonferroni correction.

RESULTS

Compared to salon application of permanent hair dye, home kit and combination application (both salon and home kit application) were associated with increased odds of poorly differentiated tumors in the overall sample. This association was consistent among Black (home kit: OR 2.22, 95 % CI: 1.21-5.00; combination: OR 2.46, 95 % CI: 1.21-5.00), but not White women, and among ER+ (home kit: OR 1.47, 95 % CI: 0.82-2.63; combination: OR 2.98, 95 % CI: 1.62-5.49) but not ER-cases. Combination application of relaxers was associated with increased odds of tumors >2.0 cm vs. <1.0 cm (OR = 1.82, 95 % CI: 1.23-2.69). Longer duration and earlier use of relaxers and combination application of permanent hair dyes and relaxers were associated with breast tumor features including higher tumor grade and larger tumor size, which often denote more aggressive phenotypes, although the findings did not maintain significance with Bonferroni correction.

CONCLUSIONS

These novel data support reported associations between hair dye and relaxer use with breast cancer, showing for the first time, associations with breast tumor clinicopathologic features. Improved hair product exposure measurement is essential for fully understanding the impact of these environmental exposure with breast cancer and to guide risk reduction strategies in the future.

TB free India: Reaching the unreached tribal population under National Tuberculosis Elimination Programme

India is the highest TB burden country in the world. The burden however is not uniform in different strata including tribal population - one of the key affected populations in the country. As the evidences from tribal population are hardly available, most of the policies and strategies implemented under National Tuberculosis Elimination Programme (NTEP) are usually based on the evidences from general populations. NTEP is continuously taking steps to strengthen TB services in tribal areas. The Social Action Plan including Tribal Action Plan is in place and the appropriate strategies are incorporated in the National Strategic Plan (NSP) to ensure universal access to quality TB services to vulnerable population groups. However, its implementation becomes challenging especially in tribal areas as different tribal groups have their own unique ways of dealing with health issues. These issues are therefore required to be addressed holistically involving all the stakeholders. In view of this a symposium was jointly organized by the Central TB Division (CTD), Govt. of India and ICMR - National Institute of Research in Tribal Health (NIRTH), Jabalpur on 17th and 18th December, 2019 at ICMR - NIRTH, Jabalpur. It provided an excellent platform for all the stakeholders from different parts of the country to share their experiences in tuberculosis particularly among marginalized populations. The recommendations emerged out of this interactive symposium highlight the sincere effort of NTEP to tackle TB situation in tribal population and show the way forward towards India's TB elimination goal by 2025 especially in hard to reach tribal areas.

Costs of TB services in India (No 1)

BACKGROUND:

There is a dearth of economic analysis required to support increased investment in TB in India. This study estimates the costs of TB services from a health systems’ perspective to facilitate the efficient allocation of resources by India’s National Tuberculosis Elimination Programme.

METHODS:

Data were collected from a multi-stage, stratified random sample of 20 facilities delivering TB services in two purposively selected states in India as per Global Health Cost Consortium standards and using Value TB Data Collection Tool. Unit costs were estimated using the top-down (TD) and bottom-up (BU) methodology and are reported in 2018 US dollars.

RESULTS:

Cost of delivering 50 types of TB services and four interventions varied according to costing method. Key services included sputum smear microscopy, Xpert^® MTB/RIF and X-ray with an average BU costs of respectively US$2.45, US$17.36 and US$2.85. Average BU cost for bacille Calmette-Guérin vaccination, passive case-finding, TB prevention in children under 5 years using isoniazid and first-line drug treatment in new pulmonary and extrapulmonary TB cases was respectively US$0.76, US$1.62, US$2.41, US$103 and US$98.

CONCLUSION:

The unit cost of TB services and outputs are now available to support investment decisions, as diagnosis algorithms are reviewed and prevention or treatment for TB are expanded or updated in India.

Hyperinfection with Strongyloides stercoralis presenting as acute abdomen in a patient on corticosteroid therapy: A case report

Infection with Strongyloides stercoralis, a human pathogenic roundworm, is common in tropical countries like India. Owing to its variable clinical presentation and irregular larval output in stool, it often remains neglected and underdiagnosed. Signs and symptoms are largely dependent on the immune status of the infected individual. Alteration in the host immunity due to chronic use of steroids can surge the number of parasites and cause hyperinfection syndrome. This can be catastrophic with a fatal outcome. Focus on early detection and treatment of the parasite in at-risk patients is imperative to reduce mortality. We summarize here an interesting case of hyper infection syndrome of strongyloidiasis with gangrenous bowel changes later progressing to burst abdomen.

Muscle stem cells and rotator cuff injury

The incidence of reinjury after treatment of rotator cuff tears (RCTs) remains very high despite the variety of nonoperative treatments and the high volume of surgical interventions performed. Muscle stem cells (MuSCs), also known as satellite cells, have risen to the forefront of rotator cuff tear research as a potential adjuvant therapy to aid unsatisfactory surgical outcomes. MuSCs are adult stem cells exhibiting the capacity to proliferate and self-renew, both symmetrically and asymmetrically. As part of this niche, they have been shown to adopt an activated phenotype in response to musculoskeletal injury and decrease their cellular populations during aging, implicating them as key players in both pathologic and normal physiological processes. While commonly connected to the regenerative phase of muscle healing, MuSCs also have the potential to differentiate into adverse morphologies. For instance, if MuSCs differentiate into adipocytes, the ensuing fatty infiltration serves as an obstacle to proper muscle healing and has been associated with the failure of surgical management of RCTs. With the potential to both harm and heal, we have identified MuSCs as a key player in RCT repair. To better understand this dichotomy, the following review will identify key studies regarding the morphology, function, and behavior of MuSCs with respect to RCTs and healing.

340 Pre-operative Screening and Treatment of Iron Deficiency Anaemia in Upper GI Cancer Surgery

Introduction

NICE guidelines recommend intravenous iron for patients with iron deficiency anaemia (IDA) before major elective surgery to reduce blood transfusion rate. The aim of this audit was to assess pre-operative screening for anaemia and treatment of IDA in patients undergoing Upper GI (UGI) cancer surgery.

Method

A retrospective audit of all patients who underwent UGI cancer surgery in year 2019 at a tertiary centre. Data were collected from electronic records.

Results

Pre-operative haemoglobin level was performed in 110/111 (99.1%) patients. 43 (39.1%) patients were found to be anaemic using the WHO definition and 9/43 (20.9%) were severely anaemic (Hb &lt; 100g/L). All anaemic patients had iron status checked and 26/43 (60.5%) patients were diagnosed with IDA. 17/43 (39.5%) anaemic patients received treatment, including IV iron (n = 8), blood transfusion (n = 3), oral iron (n = 3), and both IV iron and blood transfusion (n = 3). Anaemic patients (n = 17) who received treatment had a significant improvement in anaemia (P = 0.005).

Conclusions

This audit has demonstrated good pre-operative anaemia and IDA screening; however anaemic patients are not adequately treated, and IV iron is not routinely offered. Pre-operative anaemia treatment is effective in improving haemoglobin level. We have implemented a new anaemia treatment pathway and MDT proforma to improve the quality of care.

Modelling the potential impact of adherence technologies on tuberculosis in India

BACKGROUND: For patients taking standard first-line tuberculosis treatment, missing 10% or more of their doses increases the risk of relapse six-fold. Digital technologies offer new approaches to adherence support for TB patients. We estimated the potential impact of new adherence technologies in India.METHOD: We developed a mathematical model of TB transmission dynamics in India, capturing the independent effects of missed doses and treatment default on post-treatment recurrence. We simulated the impact of interventions to address both missed doses and treatment default in the public and private healthcare sector.RESULTS: Adherence interventions, if deployed optimally in the public sector alone, would reduce cumulative TB incidence by 7.3% (95% credible intervals [CrI] 4.7-11) between 2020 and 2030, and by 16% (95% CrI 11-23) if also deployed in the private sector. This impact is roughly proportional to the effectiveness of the interventions. Reducing missed doses reduced incidence by 12% (95% CrI 7.0-18), while reducing treatment default reduced incidence by 7.9% (95% CrI 3.2-13).CONCLUSION: Minimising missed doses is at least as important as promoting treatment completion. Our results suggest that emerging technologies to improve treatment adherence could have a substantial impact on TB incidence and mortality in India.

Sleep problems in opioid dependent patients maintained on buprenorphine

Introduction

Opioid dependent individuals frequently complain of sleep problems in withdrawal and during abstinence.

Objectives

The objectives were to assess the subjective sleep parameters among buprenorphine-maintained opioid-dependent patients and to correlate it with socio-demographics, concomitant drug use and treatment related variables

Methods

Using a cross-sectional study design, 106 hundred six opioid-dependent patients maintained on buprenorphine for at least six months and on same dose in past month were interviewed. Sleep was assessed by Pittsburgh sleep quality index (PSQI) and Epworth sleepiness scale. Association between subjective sleep parameters, socio-demographics, concomitant drug use and treatment related variables was also studied.

Results

All participants were males. Their mean age was 41.1 years (SD:14.3). The mean duration of illicit opioid use was 10 years (IQR: 5,22). About 63.2% (n=67) had PSQI scores more than 5 denoting sleep problem. The scores obtained in Epworth Sleeping Scale were in normal range. Mean subjective total sleep time of the sample was 403.5 (SD 94.8) minutes and median sleep latency was 35 (IQR 18.8, 62.5) minutes. Subjective total sleep time was significantly higher in participants who had use tobacco in the past three months (p value=0.03) and who were in moderate ASSIST risk category (p value=0.04). Subjective sleep latency was significantly higher (p value=0.04) in participants who had used opioids in last three months. It was observed that age was a significant predictor of subjective total sleep time and OST compliance was a significant predictor of sleep latency.

Conclusions

A sizeable proportion of opioid dependent patients on buprenorphine have sleep problems

Abstract PO-181: Associations of characteristics of hair dye and relaxer use with tumor clinicopathologic features among Black and White women with breast cancer

Introduction: In our previous findings from the Women’s Circle of Health Study (WCHS), we observed statistically significant associations between use of hair dye and relaxer, which contain potentially mutagenic and endocrine-disrupting chemicals, and increased breast cancer risk. In the current analysis, we sought to expand upon our earlier findings by assessing associations between hair product use and breast tumor clinicopathology. Methods: Risk factor data (including characteristics of hair product use) were collected through in-person interviews, and tumor clinicopathology data were abstracted from available pathology records of 2,998 breast cancer cases (2,227 Black, 771 White). Associations between hair product use and tumor clinicopathology were analyzed using multivariable-adjusted, binomial and multinomial logistic regression models. Further analysis was performed in subsets by race and estrogen receptor (ER) status. Results: Numerous characteristics of hair product use were associated with more aggressive tumor features. Longer (&gt;10 years) use of relaxers and earlier exposure to relaxers (≤12 years old at first use) were associated with increased odds of poorly differentiated tumors (OR 2.15, 95% CI: 1.08-4.28 and OR 2.00, 95% CI: 1.05-3.82, respectively).

History of regular relaxer use (OR 1.51, 95% CI: 1.23-1.87) and dual use of both hair dyes and relaxers (OR 1.40, 95% CI: 1.02-1.92) were associated with increased odds of ER- status. Compared to sole salon application, utilization of both salon and home- kit application types for hair dyes was associated with increased odds of higher tumor grade (moderately differentiated: OR 1.74, 95% CI: 1.05-2.87; poorly differentiated: OR 2.52, 95% CI: 1.51-4.20). These associations were consistent among Black, but not White, women. Combination use of salon and home-kit relaxer application types was associated with increased odds of tumors &gt;2.0 cm (OR 1.88, 95% CI: 1.27-2.77). Conclusions: While recent research has supported a connection between hair product use and breast cancer risk, this is the first study to examine the associations of hair product use with breast tumor features. Our findings showed that certain characteristics, particularly the magnitude of exposure to these products and application types of hair dye and relaxer, are associated with tumor features that are indicative of more aggressive phenotypes, including higher grade and ER- status. These findings generate new hypotheses about the potential impact of hair product use on breast cancer outcomes, warranting further study.

Citation Format: Rohan Rao, Jasmine A. McDonald, Emily S. Barrett, Dede Teteh, Susanne Montgomery, Bo Qin, Yong Lin, Chi-Chen Hong, Christine B. Ambrosone, Kitaw Demisse, Elisa V. Bandera, Adana A.M. Llanos. Associations of characteristics of hair dye and relaxer use with tumor clinicopathologic features among Black and White women with breast cancer [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-181.

Phonon-based partition of (ZnSe-like) semiconductor mixed crystals on approach to their pressure-induced structural transition

The generic 1-bond → 2-mode "percolation-type" Raman signal inherent to the short bond of common A_1-xB_xC semiconductor mixed crystals with zincblende (cubic) structure is exploited as a sensitive "mesoscope" to explore how various ZnSe-based systems engage their pressure-induced structural transition (to rock-salt) at the sub-macroscopic scale-with a focus on Zn_1-xCd_xSe. The Raman doublet, that distinguishes between the AC- and BC-like environments of the short bond, is reactive to pressure: either it closes (Zn_1-xBe_xSe, ZnSe_1-xS_x) or it opens (Zn_1-xCd_xSe), depending on the hardening rates of the two environments under pressure. A partition of II-VI and III-V mixed crystals is accordingly outlined. Of special interest is the "closure" case, in which the system resonantly stabilizes ante transition at its "exceptional point" corresponding to a virtual decoupling, by overdamping, of the two oscillators forming the Raman doublet. At this limit, the chain-connected bonds of the short species (taken as the minor one) freeze along the chain into a rigid backbone. This reveals a capacity behind alloying to reduce the thermal conductivity as well as the thermalization rate of photo-generated electrons.

Diagnosis and Screening of Patients with Hereditary Transthyretin Amyloidosis (hATTR): Current Strategies and Guidelines

The outlook for transthyretin amyloidosis (ATTR) is changing with the availability of new and emerging treatments. ATTR now appears to be more common than previously thought and is no longer viewed as an obscure diagnosis with a grim prognosis. Now more than ever, there is growing emphasis on the need for early diagnosis because the treatments appear to be most effective if started in earlier stages of the disease. Diagnosing ATTR is a challenge as it may initially present with nonspecific symptoms and it is often thought of as a diagnosis of exclusion. Increased awareness is imperative as new treatments offer hope and have the potential to change the disease trajectory. ATTR commonly presents with neurological and cardiac features. Transthyretin (TTR) is a protein produced in the liver which misfolds either due to genetic mutations or due to aging and results in deposition of amyloid fibrils in organs and tissues. Apart from the traditional imaging modalities, newer techniques including echocardiographic strain imaging, magnetic resonance imaging (MRI), and nuclear scintigraphy, as well as the increased availability of genetic testing are aiding in making a timely diagnosis. In this review, we present the current understanding of the ATTR disease process, diagnostic and surveillance approaches, newer treatment modalities, and the future directions.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Endoscopic Botulinum toxin as a treatment for delayed gastric emptying following oesophagogastrectomy

INTRODUCTION

The incidence of delayed gastric emptying (DGE) following oesophagogastrectomy with gastric conduit reconstruction is reported to be between 1.7% and 50%. This variation is due to differing practices of intraoperative pylorus drainage procedures, which increase the risk of postoperative biliary reflux and dumping syndrome, resulting in significant morbidity. The aim of our study was to establish rates of DGE in people undergoing oesophagogastrectomy without routine intraoperative drainage procedures, and to evaluate outcomes of postoperative endoscopically administered Botulinum toxin into the pylorus (EBP) for people with DGE resistant to systemic pharmacological treatment.

METHODS

All patients undergoing oesophagogastrectomy between 1 January 2016 and 31 March 2018 at our unit were included. No intraoperative pyloric drainage procedures were performed, and DGE resistant to systemic pharmacotherapy was managed with EBP.

RESULTS

Ninety-seven patients were included. Postoperatively, 29 patients (30%) were diagnosed with DGE resistant to pharmacotherapy. Of these, 16 (16.5%) were diagnosed within 30 days of surgery. The median pre-procedure nasogastric tube aspirate was 780ml; following EBP, this fell to 125ml (p<0.001). Median delay from surgery to EBP in this cohort was 13 days (IQR 7-16 days). Six patients required a second course of EBP, with 100% successful resolution of DGE before discharge. There were no procedural complications.

CONCLUSIONS

This is the largest series of patients without routine intraoperative drainage procedures. Only 30% of patients developed DGE resistant to pharmacotherapy, which was managed safely with EBP in the postoperative period, thus minimising the risk of biliary reflux in people who would otherwise be at risk following prophylactic pylorus drainage procedures.

Structural investigation of borosilicate glasses containing lanthanide ions

High level radioactive actinides are produced as a side product in reprocessing spent nuclear fuel, for which safe long-term-inert immobilizer matrices are needed. Borosilicate glasses are of great potential amongst the candidates of suitable inert materials for radioactive waste immobilization. Understanding the effects of actinide addition to a borosilicate glass matrix is of great importance in view of waste immobilization. Here we present structural studies of a simplified glass-matrix, - 55SiO₂·10B₂O₃·25Na₂O·5BaO·5ZrO₂ - upon adding lanthanide (Ln-)oxides: CeO₂, Nd₂O₃, Eu₂O₃, in two different concentrations 10% and 30w% each, to investigate the effects of lanthanides (Ln) taken as chemical surrogates for actinides. Neutron diffraction combined with of Reverse Monte Carlo simulations show that all investigated glass structures comprise tetrahedral SiO₄, trigonal BO₃ and tetrahedral BO₄ units, forming mixed ^[4]Si-O-^[3]B and ^[4]Si-O-^[4]B linkages. ¹¹B Magic Angle Spinning Nuclear Magnetic Resonance is indicative of simultaneous presence of trigonal BO₃ and tetrahedral BO₄ units, with spectral fractions strongly dependent on the Ln addition. Ln-addition promote the BO₃ + O^-→[BO₄]^- isomerization resulting in lower fraction of boron in BO₃, as compared to BO₄ units. Raman spectra, in full agreement with neutron diffraction, confirm that the basic network structure consists of BO₃/trigonal and SiO₄/BO₄ tetrahedral units. Second neighbour atomic pair correlations reveal Ce, Nd, Eu to be accommodated in both Si and B sites, supporting that the borosilicate-matrix well incorporates Ln-ions and is likely to similarly incorporate actinides, opening a way to radioactive nuclear waste immobilization of this group of elements in a borosilicate glass matrix.

P5497The gender paradox in non-ST-segment elevation acute coronary syndrome: an outdated paradigm or a persistent reality-an analysis of contemporary practice from an integrate health care system

Introduction

Although sex related differences in Non-ST-Segment elevation (NSTEMI) acute coronary syndrome (ACS) have been well delineated in the past, there is a paucity of data from contemporary practice on the evolutions of this paradox and its clinical practice implications.

Purpose

We hypothesized that in the era of guideline driven contemporary practice, and in the setting of an integrated heath care model, gender related differences in care and outcomes would be marginal at best if no altogether absent.

Methods

We utilized data from an integrated health care system to identify 4099 patients with NSTEMI-ACS (1531 women; 2561 men). The patients were stratified by gender and a comparative analysis was performed on guideline directed medical therapy, revascularization strategy and major adverse cardiac events between the two groups.

Results

There were significant difference in pharmacologic treatment, catheter based interventions and surgical revascularizations strategies. Underutilization of guideline directed medical therapy was demonstrated in women specifically vis a vis angiotensin converting enzyme inhibitor (ACE-I) (p=0.0014), statins (p=0.0001), and antiplatelet therapy: clopodigrel (p=0.0004), prasugrel (p=0.0012), and ticagrelor (p=0.03). Additionally, clear differences emerged in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) options despite similarities in high risk status at index presentation by well validated risk algorithms. Specifically, men were more likely to undergo PCI (p=0.021) and CABG (p<0.001) than women. Finally, women had a greater incidence of bleeding complications (p=0.0003) and stroke (p=0,038).

Conclusions

There were treatment disparities in pharmacologic interventions, catheter based interventions, surgical revascularization access and clinical outcomes among patients with NSTEMI-ACS. The persistence of this gender paradox in contemporary practice and despite increasing education and awareness should potentiate further public policy initiatves as well as reinforce the need for geneder specific guidelines

Towards accessible nanophotonics: multimode interferometer on strip-loaded slot waveguide

Nano- and micro-photonics are the key-enabling tools for future integrated components and circuitry operating at low power and high speed. By using a strip-loaded platform, we show how we can dramatically reduce the complexity, in terms of fabrication and tolerances, of the most advanced devices. Different configurations of multimode interference devices are presented. We show the design, fabrication, and optical characterization of these components.

Abstract P2-09-08: Imprime PGG, a novel innate immune modulator, combined with pembrolizumab in a phase 2 multicenter, open label study in chemotherapy-resistant metastatic triple negative breast cancer (TNBC)

Background: CPI monotherapy provides substantial clinical benefit to patients (pts) in multiple cancers, yet response rates are limited (˜15-30%) and fails to benefit the majority. In these pts there is limited or no ongoing T cell-based immune response. Imprime PGG (Imprime), a novel beta glucan derived from Saccharomyces, may expand the clinical benefit of CPI therapy by stimulating an anti-cancer immune response. Acting as a pathogen-associated molecularpattern (PAMP), Imprime enlists innate immune functions including cytotoxic effector mechanisms, reversal of immunosuppression and cross-talk with the adaptive immune system.Imprime-mediated innate immune activation requires formation of an immune complex with naturally-occurring anti-beta glucan antibodies (ABA); sufficient ABA levels is required for complex formation. Imprime is now being studied in combination with pembrolizumab (KEYTRUDA®,Pembro), a humanized mAb against PD-1 which has been previously studied in TNBC pts.

Methods: In this study of patients who previously failed chemotherapy for metastatic TNBC, Imprime is being used in combination with Pembro in a Simon 2 stage design. Asample size of 12 evaluable pts in Stage 1 was planned.Evaluable pts received at least one dose of study treatment (tx), had measurable disease at baseline per RECIST v1.1, had at least one post-baseline scan or discontinued tx as a result of progressive disease, death, or a tx-related adverse event before the first post-baseline scan.Pts received Imprime (4 mg/kg IV days 1, 8, 15 of each 3-week cycle) + Pembro 200 mg on D1 of each cycle. Criteria to advance to Stage 2 were ≤4 grade 3/4 AEs during the first tx cycle (other than infusion reactions) and ≥1 objective response. Study primary endpoints are ORR and safety; secondary endpoints are TTR, CRR, DoR, PFS, and OS. Exploratory endpoints include ORR and PFS per irRECIST. Biopsies and blood samples are being collected to assess tx impact on immune activating events at the tumor site and in the periphery.

Results: A review of efficacy and safety data was conducted at the end of Stage 1. Thirteen pts (12 evaluable) were enrolled into Stage 1. Safety review noted 2 grade 3 adverse events that met protocol definition of Stage 1 events (1 pt: cellulitis and 1 pt: pleural infusion; both unrelated to treatment). Two events lead to 2 pts discontinuing treatment (infusion reaction and pancreatitis) and only 1 autoimmune event was observed (pancreatitis). Observed efficacy responses in the evaluable pts included 1 complete response (CR; ongoing) and 2 partial responses (PR; ongoing). Secondary efficacy endpoints have not been assessed. Early translational results support proposed MOA and analysis of Stage 1 translational data is ongoing.

Conclusion: The use of Imprime with Pembro was well tolerated and met both safety and efficacy requirements to move forward with Stage 2 of the study. No significant safety concerns were identified in Stage 1. Further investigation is thus warranted and enrollment into Stage 2 is ongoing. Updated data will be presented.

Citation Format: O'Day S, Borges V, Chmielowski B, Rao R, Abu-Khalaf M, Stopeck A, Lowe J, Mattson P, Breuer K, Gargano M, Bose N, Uhlik M, Graff J, Chisamore M, Cox J, Osterwalder B. Imprime PGG, a novel innate immune modulator, combined with pembrolizumab in a phase 2 multicenter, open label study in chemotherapy-resistant metastatic triple negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-09-08.

Diffuse hepatic haemangiomatosis: A case report and review of literature

Hepatic haemangioma is a solitary liver lesion and prevalent among the female patients. We report a case of diffuse hepatic haemangiomatosis in a 62-year-old man, who was referred for an incidental finding of multiple liver nodules. History and physical examinations were unremarkable. Computed tomography and magnetic resonance imaging of the liver were performed and showed multiple haemangiomatosis. In view of the rarity of this condition in men, a liver biopsy was done and confirmed haemangiomas. Available published literature on diffuse hepatic haemangiomatosis was reviewed.