Visual hallucinations after resection of cerebral metastases: two patients with complex phantom images

PURPOSE

Complex visual hallucinations are rarely seen in neurooncology. They are commonly observed alongside psychotic symptoms in schizophrenia or dementia, in Parkinson's or Lewy-body disease, after opioid medications or anesthesia, and, in particular, they appear with visual impairments.

METHODS

Here we report two normal-sighted and mentally healthy patients with unusual visual hallucinations after the resection and irradiation of brain metastases, the main features of which were persistent colorful and meaningful images with hallucinatory perseveration.

RESULTS

These cases demonstrate the occurrence of complex visual hallucinations after resection of visual cortices as an effect of deafferentation, so-called visual release hallucinations or phantom images, similar to phantom pain after amputation of a limb.

CONCLUSION

This case serves to heighten awareness in the radiooncology practitioner of the occurrence of visual release hallucinations (Charles Bonnet syndrome) related to multidisciplinary treatment of brain metastases.

The CoREST repressor complex mediates phenotype switching and therapy resistance in melanoma

Virtually all patients with BRAF-mutant melanoma develop resistance to MAPK inhibitors largely through nonmutational events. Although the epigenetic landscape is shown to be altered in therapy-resistant melanomas and other cancers, a specific targetable epigenetic mechanism has not been validated. Here, we evaluated the corepressor for element 1-silencing transcription factor (CoREST) epigenetic repressor complex and the recently developed bivalent inhibitor corin within the context of melanoma phenotype plasticity and therapeutic resistance. We found that CoREST was a critical mediator of the major distinct melanoma phenotypes and that corin treatment of melanoma cells led to phenotype reprogramming. Global assessment of transcript and chromatin changes conferred by corin revealed specific effects on histone marks connected to epithelial-mesenchymal transition-associated (EMT-associated) transcription factors and the dual-specificity phosphatases (DUSPs). Remarkably, treatment of BRAF inhibitor-resistant (BRAFi-R) melanomas with corin promoted resensitization to BRAFi therapy. DUSP1 was consistently downregulated in BRAFi-R melanomas, which was reversed by corin treatment and associated with inhibition of p38 MAPK activity and resensitization to BRAFi therapies. Moreover, this activity was recapitulated by the p38 MAPK inhibitor BIRB 796. These findings identify the CoREST repressor complex as a central mediator of melanoma phenotype plasticity and resistance to targeted therapy and suggest that CoREST inhibitors may prove beneficial for patients with BRAFi-resistant melanoma.

Feasibility of Remote Administration of the Uniform Data Set-Version 3 for Assessment of Older Adults With Mild Cognitive Impairment and Alzheimer's Disease

OBJECTIVE

Assess the feasibility and concurrent validity of a modified Uniform Data Set version 3 (UDSv3) for remote administration for individuals with normal cognition (NC), mild cognitive impairment (MCI), and early dementia.

METHOD

Participants (N = 93) (age: 72.8 [8.9] years; education: 15.6 [2.5] years; 72% female; 84% White) were enrolled from the Wake Forest ADRC. Portions of the UDSv3 cognitive battery, plus the Rey Auditory Verbal Learning Test, were completed by telephone or video within ~6 months of participant's in-person visit. Adaptations for phone administration (e.g., Oral Trails for Trail Making Test [TMT] and Blind Montreal Cognitive Assessment [MoCA] for MoCA) were made. Participants reported on the pleasantness, difficulty, and preference for each modality. Staff provided validity ratings for assessments. Participants' remote data were adjudicated by cognitive experts blinded to the in person-diagnosis (NC [N = 44], MCI [N = 35], Dementia [N = 11], or other [N = 3]).

RESULTS

Remote assessments were rated as pleasant as in-person assessments by 74% of participants and equally difficult by 75%. Staff validity rating (video = 92%; phone = 87.5%) was good. Concordance between remote/in-person scores was generally moderate to good (r = .3 -.8; p < .05) except for TMT-A/OTMT-A (r = .3; p > .05). Agreement between remote/in-person adjudicated cognitive status was good (k = .61-.64).

CONCLUSIONS

We found preliminary evidence that older adults, including those with cognitive impairment, can be assessed remotely using a modified UDSv3 research battery. Adjudication of cognitive status that relies on remotely collected data is comparable to classifications using in-person assessments.

The Lucy Thermal Emission Spectrometer (L'TES) Instrument

The Lucy Thermal Emission Spectrometer (L'TES) will provide remote measurements of the thermophysical properties of the Trojan asteroids studied by the Lucy mission. L'TES is build-to-print hardware copy of the OTES instrument flown on OSIRIS-REx. It is a Fourier Transform spectrometer covering the spectral range 5.71-100 μm (1750-100 cm-1) with spectral sampling intervals of 8.64, 17.3, and 34.6 cm-1 and a 7.3-mrad field of view. The L'TES telescope is a 15.2-cm diameter Cassegrain telescope that feeds a flat-plate Michelson moving mirror mounted on a linear voice-coil motor assembly to a single uncooled deuterated l-alanine doped triglycine sulfate (DLATGS) pyroelectric detector. A significant firmware change from OTES is the ability to acquire interferograms of different length and spectral resolution with acquisition times of 0.5, 1, and 2 seconds. A single ∼0.851 μm laser diode is used in a metrology interferometer to provide precise moving mirror control and IR sampling at 772 Hz. The beamsplitter is a 38-mm diameter, 1-mm thick chemical vapor deposited diamond with an antireflection microstructure to minimize surface reflection. An internal calibration cone blackbody target, together with observations of space, provides radiometric calibration. The radiometric precision in a single spectrum is ≤2.2 × 10-8 W cm-2 sr-1 /cm-1 between 300 and 1350 cm-1. The absolute temperature error is <2 K for scene temperatures >75 K. The overall L'TES envelope size is 37.6 × 29.0 × 30.4 cm, and the mass is 6.47 kg. The power consumption is 12.6 W average. L'TES was developed by Arizona State University with AZ Space Technologies developing the electronics. L'TES was integrated, tested, and radiometrically calibrated on the Arizona State University campus in Tempe, AZ. Initial data from space have verified the instrument's radiometric and spatial performance.

A Scoping Review of the Complementary Feeding Practices and Early Eating Experiences of Children With Down Syndrome

OBJECTIVE

Children with Down syndrome may experience more challenges in their early feeding and may be introduced to complementary foods comparatively later than typically developing (TD) children. This scoping review aimed to identify and synthesize the existing literature that describes feeding problems and early eating experiences relating to the period of complementary feeding for children with Down syndrome.

METHODS

Scopus, PubMed, Medline, Web of Science, and PsycInfo were searched. Journal articles published between January 1991 and June 2022 that reported on the complementary feeding period with children with Down syndrome were included.

RESULTS

Eighteen journal articles met the inclusion criteria. Children with Down syndrome were introduced to complementary foods later than TD children and progressed to more challenging food textures at a slower rate. Gross and fine motor skill delays and sensory difficulties contributed to secondary feeding problems such as difficulties chewing, biting, and reduced awareness of food on lips and tongue. Parents of children with Down syndrome reported exercising more caution and employing more controlling feeding practices compared to TD and had higher levels of concern regarding their child's weight.

CONCLUSIONS

Guidelines and early feeding support specific to children with Down syndrome should be available before the first complementary foods are introduced and throughout this period. Feeding support should aim to address parental concerns and provide assistance when feeding problems occur, to minimize delays and encourage the optimum development of eating abilities. Future research should address the development of feeding problems during this period and explore possible interventions.

What MRI Sequences are Necessary for Automated Neural Network-Based Metastasis Segmentation - An Ablation Study

PURPOSE/OBJECTIVE(S)

Brain metastasis (BM) delineation is a time-consuming process in both daily clinical practice and research. Automated BM segmentation algorithms can be used to assist in this task. Most approaches to brain tumor segmentation, such as algorithms trained on the BraTS challenge, use four magnetic resonance imaging (MRI) sequences as input, making them susceptible to missing or corrupted sequences and increase the number of sequences necessary for MRI RT planning. The goal of this project is to compare neural networks with different combinations of input sequences for the segmentation of the contrast-enhancing metastasis and the surrounding FLAIR hyperintense edema. All models were tested in a multicenter international external test cohort. This allows us to determine which MRI sequences are needed for effective automated segmentations.

MATERIALS/METHODS

In total, we had T1-weighted sequences without (T1) and with contrast enhancement (T1-CE), T2-weighted sequences (T2), and T2 fluid-attenuated inversion recovery (FLAIR) sequences from 339 patients with at least one brain metastasis from seven centers available. Preprocessing yielded co-registered, skull-stripped sequences with an isotropic resolution of 1 millimeter. The contrast-enhancing metastasis as well as the surrounding FLAIR hyperintense edema were manually segmented to create reference labels. A baseline 3D U-Net with all four sequences as well as six additional U-Nets with different clinically plausible combinations (T1-CE; T1; FLAIR; T1-CE+FLAIR; T1-CE+T1+FLAIR; T1-CE+T1) of input sequences were trained on a cohort of 239 patients from two centers and subsequently tested on an external cohort of 100 patients from the remaining five centers.

RESULTS

All models that included T1-CE in their selected sequences showed similar performance for metastasis segmentation with a median Dice similarity coefficient (DSC) of 0.93-0.96. T1-CE alone likewise achieved a performance of 0.96 (IQR 0.93-0.97). The model trained with only FLAIR performed worse (DSC = 0.73, IQR 0.54-0.84). For edema segmentation, models that included both T1-CE and FLAIR performed best (median DSC = 0.93), while the remaining four models without simultaneous inclusion of these two sequences (T1-CE; T1; FLAIR; T1-CE+T1) reached a median DSC of 0.81-0.89.

CONCLUSION

Automatic segmentation of brain metastases with less than four input sequences is feasible with minimal or no loss of quality. A T1-CE-only protocol suffices for metastasis segmentation. In contrast, for edema segmentation, the combination of T1-CE and FLAIR seems to be important. Missing either T1-CE or FLAIR decreases performance. These findings may improve future imaging routines by omitting unnecessary sequences, thus speeding up procedures in daily clinical practice while allowing for optimal neural network-based target definitions.

Post-Operative Stereotactic Radiotherapy for Resected Brain Metastases: Results of the Multicenter Analysis (AURORA) of the German Working Group "Stereotactic Radiotherapy"

PURPOSE/OBJECTIVE(S)

While the results of prospective studies support the use of postoperative stereotactic radiotherapy (RT) to the resection cavity (RC) as the standard of care after surgery, there are several issues that need to be investigated such as factors for improving local control, risk of leptomeningeal disease and radiation necrosis. Further, the optimal dose and fractionation is still under debate.

MATERIALS/METHODS

The working group "Stereotactic Radiotherapy" of the German Society of Radiation Oncology (DEGRO) analyzed its multi-institutional database with 661 patients who received postoperative stereotactic RT to the RC. Treatment was performed at 13 centers between 2008 and 2021. Patient characteristics, treatment details, and follow-up data including overall survival (OS), local control (LC) were evaluated. Cox Regression and Kaplan-Meier curves with Log-rank Tests were calculated for selected variables.

RESULTS

In this retrospective study, overall survival was 61.5% at 1 year, 47.6% at 2 years, and 35.5% at 3 years, and local control was 84.6% at 1 year, 74.8% at 2 years, and 72.8% at 3 years. 96% of patients were treated with hypofractionated stereotactic radiotherapy (HSRT), only 26 patients received single fraction radiosurgery (4%). Prognostic factors associated with overall survival were Karnofsky Performance Status, RPA and GPA class, controlled primary tumor and absence of extracranial metastases, whereas prognostic factor associated with local control was planning target volume (23 mL or less).

CONCLUSION

HSRT is the most common fractionation form in the treatment of RCs in this multicenter analysis. This approach results in excellent OS and LC outcomes. OS in patients with resected brain metastases is mainly influenced by performance status. In regard to local control, RT of large cavities remain a challenge with significantly worse outcome.

Parenteral Nutrition in the Neonatal Intensive Care Unit: Intravenous Lipid Emulsions

Intravenous lipid emulsions (ILEs) are a source of nonprotein calories and fatty acids and help promote growth in preterm infants and infants with intestinal failure. An ILE dose and oil source determines its fatty acid, phytosterol, and vitamin E delivery. These factors play a role in the infant's risk for essential fatty acid deficiency and cholestasis, and help modulate inflammation, immunity, and organ development. This article reviews different ILEs and their constituents and their relationship with neonatal health.

Induction of cancer neoantigens facilitates development of clinically relevant models for the study of pancreatic cancer immunobiology

Neoantigen burden and CD8 T cell infiltrate are associated with clinical outcome in pancreatic ductal adenocarcinoma (PDAC). A shortcoming of many genetic models of PDAC is the lack of neoantigen burden and limited T cell infiltrate. The goal of the present study was to develop clinically relevant models of PDAC by inducing cancer neoantigens in KP2, a cell line derived from the KPC model of PDAC. KP2 was treated with oxaliplatin and olaparib (OXPARPi), and a resistant cell line was subsequently cloned to generate multiple genetically distinct cell lines (KP2-OXPARPi clones). Clones A and E are sensitive to immune checkpoint inhibition (ICI), exhibit relatively high T cell infiltration, and have significant upregulation of genes involved in antigen presentation, T cell differentiation, and chemokine signaling pathways. Clone B is resistant to ICI and is similar to the parental KP2 cell line in terms of relatively low T cell infiltration and no upregulation of genes involved in the pathways noted above. Tumor/normal exome sequencing and in silico neoantigen prediction confirms successful generation of cancer neoantigens in the KP2-OXPARPi clones and the relative lack of cancer neoantigens in the parental KP2 cell line. Neoantigen vaccine experiments demonstrate that a subset of candidate neoantigens are immunogenic and neoantigen synthetic long peptide vaccines can restrain Clone E tumor growth. Compared to existing models, the KP2-OXPARPi clones better capture the diverse immunobiology of human PDAC and may serve as models for future investigations in cancer immunotherapies and strategies targeting cancer neoantigens in PDAC.

Impact of Undergoing Thoracolumbar Surgery on Patient Psychosocial Profiles

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

Investigate the impact of thoracolumbar surgery on patients' psychosocial profiles.

METHODS

A prospective cohort study of thoracolumbar surgery patients (N = 177). Measures of interest collected at baseline and 24-months after surgery were: modified Oswestry Disability Index (mODI), Numerical Rating Scores for Back Pain (NRS-B), Leg Pain (NRS-L), Pain Catastrophizing Scale (PCS), Tampa Scale of Kinesiophobia (TSK), Chronic Pain Acceptance Questionnaire-8 (CPAQ-8), Multidimensional Scale of Perceived Social Support (MSPSS), Mental Component Summary (MCS) and patient expectations for surgery impacts on mental well-being. Cohorts were separated based on attaining meaningful change defined as either 30% improvement or minimal scores in NRS-B, NRS-L and mODI. Mixed measures ANOVAs were run (α = .05).

RESULTS

Patients who showed meaningful change had significant improvements in PCS, TSK and CPAQ-8 scores but not in MSPSS scores. Patients had improvement in MCS scores over 24-months follow-up, but this change was not significantly different based on attainment of meaningful change. Overall, 75.9% of patients reported their mental well-being expectations were met. Patients who did not achieve meaningful change showed no change on any psychosocial measures with only 55.9% reporting their mental well-being expectations met.

CONCLUSION

Thoracolumbar surgery results in significant improvement of psychosocial variables for patients who experienced meaningful change for pain and disability. Worsening of psychosocial health was not evident in patients who did not attain meaningful change.

Changes to household food shopping practices during the COVID-19 restrictions: Evidence from the East of England

Measures to control the spread of COVID-19 have changed the way we shop for food and interact with food environments. This qualitative study explored food shopping practices in the East of England, a large diverse region including coastal, urban and rural settings. In 2020/2021 we interviewed 38 people living in the region and 27 professionals and volunteers providing local support around dietary health. Participants reported disruption to supermarket shopping routines; moving to online shopping; and increased reliance on local stores. COVID-19 has impacted disproportionately upon lower-income households and neighbourhoods. The longer-term implications for dietary health inequalities must be investigated.

Stereotactic radiosurgery and radiotherapy for resected brain metastases: current pattern of care in the Radiosurgery and Stereotactic Radiotherapy Working Group of the German Association for Radiation Oncology (DEGRO)

PURPOSE

Preoperative stereotactic radiosurgery (SRS) of brain metastases may achieve similar local control and better leptomeningeal control rates than postoperative fractionated stereotactic radiotherapy (FSRT) in patients treated with elective metastasectomy. To plan a multicentre trial of preoperative SRS compared with postoperative FSRT, a survey of experts was conducted to determine current practice.

METHODS

A survey with 15 questions was distributed to the DEGRO Radiosurgery and Stereotactic Radiotherapy Working Group. Participants were asked under what circumstances they offered SRS, FSRT, partial and/or whole brain radiotherapy before or after resection of a brain metastasis, as well as the feasibility of preoperative stereotactic radiosurgery and neurosurgical resection within 6 days.

RESULTS

Of 25 participants from 24 centres, 22 completed 100% of the questions. 24 respondents were radiation oncologists and 1 was a neurosurgeon. All 24 centres have one or more dedicated radiosurgery platform and all offer postoperative FSRT. Preoperative SRS is offered by 4/24 (16.7%) centres, and 9/24 (37.5%) sometimes recommend single-fraction postoperative SRS. Partial brain irradiation is offered by 8/24 (33.3%) centres and 12/24 (50%) occasionally recommend whole-brain irradiation. Two centres are participating in clinical trials of preoperative SRS. SRS techniques and fractionation varied between centres.

CONCLUSION

All responding centres currently offer postoperative FSRT after brain metastasectomy. Approximately one third offer single-fraction postoperative SRS and four already perform preoperative SRS. With regard to potential co-investigators, 18 were identified for the PREOP‑2 multicentre trial, which will randomise between preoperative SRS and postoperative FSRT.

The experiences of new mothers accessing feeding support for infants with down syndrome during the COVID-19 pandemic

Infants with Down syndrome are more likely to experience feeding problems and mothers are likely to require more feeding support than mothers of typically developing infants. During the COVID-19 pandemic, many feeding support services changed from face-to-face to online, which impacted some maternal feeding experiences negatively, but no studies to date have explored the impact for mothers of infants with Down syndrome. Thematic analysis was conducted on semi-structured interviews from thirteen new mothers of infants (aged 8-17 months) with Down syndrome in the UK. Three superordinate themes were generated: (1) Every baby with Down syndrome has a unique journey, (2) There's no point asking, they won't know, (3) Lack of in-person support. Many mothers expressed frustrations over health professionals' lack of Down syndrome specific knowledge resulting in unmet needs, further magnified due to the nature of the virtual support being offered. Moreover, mothers struggled with reduced social support from other mothers when encountering feeding problems. These results hold real-world implications for health professionals who could provide more specialised face-to-face feeding support to mothers of infants with Down syndrome. This should be prioritised for children's overall development and mothers' wellbeing.

Hypertensive Aspects of Cardiometabolic Disorders Are Associated with Lower Brain Microstructure, Perfusion, and Cognition

BACKGROUND

Cardiometabolic disorders (hypertension, diabetes) are key modifiable risk factors for Alzheimer's disease and related disorders. They often co-occur; yet, the extent to which they independently affect brain structure and function is unclear.

OBJECTIVE

We hypothesized their combined effect is greater in associations with cognitive function and neuroimaging biomarkers of white matter (WM) health and cerebral perfusion in a diverse older adult cohort.

METHODS

Participants aged 50-85 years received: clinical evaluation, oral glucose tolerance testing, neuroimaging, cognitive testing, and adjudication. Neuroimaging included: T1 (gray [GM]/WM segmentation, regional volumes/thicknesses); FLAIR (WM hyperintensity volume [WMHv]; arterial spin labeling (cerebral blood flow); diffusion tensor imaging (fractional anisotropy [FA]); and neurite orientation dispersion and density imaging (Free Water). Hypertension (HTN) and impaired glucose tolerance (IGT) were staged and cardiometabolic status was categorized (HTN only, IGT only, IGT+HTN, neither). Multivariable linear regression modeled associations with cognitive and neuroimaging measures (covariates: age, gender, race).

RESULTS

MRI was available for 478 participants (35% mild cognitive impairment, 10% dementia) with mean age 70±8 years, 74% with HTN, 61% with IGT, and 15% self-identified as Black/African-American. IGT+HTN was significantly associated with cognitive impairment, higher WM Free Water and WMHv, lower FA, and lower GM perfusion compared to neither factor. HTN alone was associated with poorer cognition and lower GM perfusion. Cardiometabolic factors were not associated with GM macrostructure (volumes, temporal lobe cortical thickness) or cognitive status.

CONCLUSION

HTN and its co-occurrence with IGT (HTN+IGT) were associated with lower global cognitive performance and reduced GM perfusion and impaired WM microstructure.

Vascular and microstructural markers of cognitive pathology

Introduction

Arterial stiffness may play a role in the development of dementia through poorly understood effects on brain microstructural integrity and perfusion.

Methods

We examined markers of arterial stiffness (carotid‐femoral pulse wave velocity [cfPWV]) and elevated systolic blood pressure (SBP) in relation to cognitive function and brain magnetic resonance imaging macrostructure (gray matter [GM] and white matter [WM] volumes), microstructure (diffusion based free water [FW] and fractional anisotropy [FA]), and cerebral blood flow (CBF) in WM and GM in models adjusted for age, race, sex, education, and apolipoprotein E ε4 status.

Results

Among 460 participants (70 ± 8 years; 44 dementia, 158 mild cognitive impairment, 258 normal cognition), higher cfPWV and SBP were independently associated with higher FW, higher WM hyperintensity volume, and worse cognition (global and executive function). Higher SBP alone was significantly associated with lower WM and GM CBF.

Discussion

Arterial stiffness is associated with impaired WM microstructure and global and executive cognitive function.

1082 Are Trauma and Orthopaedics Consultant Posts Decreasing in Frequency and Increasing in Subspecialisation?

Aim

Changes to the configuration of the NHS Trauma Services in T&O and the level of subspecialisation are changing and could impact training and the number of consultant posts available at CCT. The aim of this study was to review the number of T&O Consultant posts and determine the frequency of the subspecialist requirements of these posts from 2011 to 2020, to assess the perceived reduction in advertised numbers and the increasing sub specialisation as a whole.

Method

451 volumes of the BMJ were reviewed over Jan 2011 - April 2020. The total number of jobs advertised were recorded. Additionally, for each post, sub-specialism, regional analysis and substansive or locum tenure were recorded.

Results

1141 jobs were advertised during this period. There has been a decreasing trend in the total number of advertised posts of 13% per annum. Proportion of specialty jobs remain constant yearly. However, jobs listing Trauma clearly decreased after 2012, when trauma centres were initiated. Clear decreases were present in North-west and Scotland in number of jobs. There has also been an increasing trend of advertisement of substantive posts, with locum posts forming less than 13% of total advertisements.

Conclusions

We found no significant increase in job specialism contradicting previous research. Overall, the total number of Consultant jobs in Trauma and Orthopaedics is decreasing, especially in the north-west and Scotland, two of the biggest employers. Questions must be asked for the future of training in T&O to meet service needs.

Five fraction stereotactic radiotherapy after brain metastasectomy: a single-institution experience and literature review

PURPOSE

The outcomes of five fraction stereotactic radiotherapy (hfSRT) following brain metastasectomy were evaluated and compared with published series.

METHODS

30 Gy in 5 fractions HfSRT prescribed to the surgical cavity was reduced to 25 Gy if the volume of 'brain-GTV' receiving 20 Gy exceeded 20 cm³. Endpoints were local recurrence, nodular leptomeningeal recurrence, new brain metastases and radionecrosis. The literature was searched for reports of clinical and dosimetric outcomes following postoperative hfSRT in 3-5 fractions.

RESULTS

39 patients with 40 surgical cavities were analyzed. Cavity local control rate at 1 year was 33/40 (82.5%). 3 local failures followed 30 Gy/5 fractions and 4 with 25 Gy/5 fractions. The incidence of leptomeningeal disease (LMD) was 7/40 (17.5%). No grade 3-4 toxicities, particularly no radionecrosis, were reported. The incidence of distant brain metastases was 15/40 (37.5%). The median overall survival was 15 months. Across 13 published series, the weighted mean local control was 83.1% (adjusted for sample size), the mean incidence of LMD was 14.9% (7-34%) and the mean rate of radionecrosis was 10.3% (0-20.6%).

CONCLUSION

Postoperative hfSRT can be delivered with 25-30 Gy in 5 fractions with efficacy in excess of 82% and no significant toxicity when the dose to 'brain-GTV' does not exceed 20 cm³.

P–123 How to develop accurate Computer Assisted Sperm Analysis (CASA) AI in the absence of protocol standardization and abundance of human error when performing semen analyses?

Study question

How can an automation & artificial intelligent tools be developed to perform according to WHO recommendations?

Summary answer

Developing CASA performs at &lt; 20% error margin requires AI trained with high quality datasets and a robotic system adheres to WHO guidelines.

What is known already

A survey of 40 andrology laboratories, in 22 countries, revealed that &gt; 90% had nonconformities in correct use of equipment, standardisation of protocols and quality control, leading to a lack of compliance to WHO protocols. Conventional CASA systems can standardize analysis, but controversy has occurred due to differences between manual and automated analyses stemming from: 1) all cells in a semen sample are detected including debris; 2) protocol variation when compared to top-notch manual analysis. The first point can be addressed by AI. The second point can be addressed by robotics designed to adhere to WHO guidelines.

Study design, size, duration

A mojo AISA (AI-powered semen analysis) system was placed in four clinical laboratories mentioned above capturing images of over 300 samples, one million images were generated over a course of 2 years. Mojo AISA’s AI was trained on data collected from the four clinics using robotic system is developed according to WHO guidelines.

Participants/materials, setting, methods

For an AI to detect sperm accurately, sperm samples were captured using mojo AISA smart microscopy and then the extracted sperm images expertly annotated. To evaluate the system-ability for semen analysis, fresh sample were analysed for concentration and motility by a manual operator and compared to a mojo AISA test.

Main results and the role of chance

To train the sperm detection AI, representative sperm images were carefully captured using mojo AISA and processed according to the following criteria: the number of images and videos to train and to test the model: 50,000 spermatozoon head and tails with various variations the variety of images: data used to train the AI has to be representative of the population that will undergo the analysis: 1) wide concentration ranges from 0 to 300 M/ml, 2) high and low density of debris and cells, 3) Presence of slight aggregations careful and precise annotation: expert andrology scientists annotated sperm images and identify objects to exclude, such as debris in seminal plasma, Mojo AISA is an attempt strictly build CASA AI system to WHO-guidelines. The marriage of AI and robotics automation has shown a promising results to mimic humans when measuring a semen sample and attempt to obtain results comparable to the manual analysis.

mojo AISA’s performance improved three-fold (from 0,85 to 0,95 Pearson sperm count correlation and from &gt;100% means relative error to 25% mean relative error).

Limitations, reasons for caution

Lack of standardization for semen analysis laboratory process globally is a bottleneck towards building a robust multi-center study, on-site CASA testing and generating an actionable data pool for studying the causes behind male fertility declineWider implications of the findings: Key learnings for parties advancing developing AI based on images and videos for application in the fertility space.

Trial registration number

Not applicable

Adiposity Is Positively Associated With AD-Signature Cortical Thickness in Older Adults

Mid-life obesity is associated with a higher risk for Alzheimer’s disease (AD). However, this association is attenuated or even reversed in late-life, when weight loss may be a preclinical sign of AD. While neuropathological changes likely occur alongside aging-related changes in body composition, this has not been largely investigated. We aimed to determine the association between adiposity and a specific pattern of reduced cortical thickness associated with AD risk and progression. Global and regional adiposity (via dual-energy x-ray absorptiometry) and AD-signature cortical thickness (via surface-based cortical analysis of 3T brain MRI scans) were measured in 35 middle-aged and older adults from the Wake Forest Alzheimer’s Disease Clinical Core (mean age: 69.4±7.8 years, 80% female, 91% White, 29% cognitively impaired). Partial correlations adjusted for age, sex, and cognitive status were examined overall and stratified by age (0.59, p≤0.05). No significant associations were observed in middle-aged adults. These findings suggest that AD-related cortical thinning may be accompanied by a global reduction in body fat among older adults.

Referral, Assessment and Use of Screening Measures Related to Autism Spectrum Disorder at a Tertiary Hospital Setting

Children with developmental concerns in Australia continue to experience inequitable healthcare and service-related delays, even when diagnostic risk is identified. This study sought to explore service and demographic pathway factors leading up to autism spectrum disorder (ASD) assessment, including value of screening measures applied at triage. Following a trial of centralised intake for referred young children with suspected ASD, observational, retrospective pathway data was explored using bivariate and regression analyses. The mean age of 159 children referred with autism symptoms was 3.6 years, and 64% were diagnosed with ASD. Service allocation was associated with diagnosis, whilst screening tool results were not. Improved pathways are needed to limit wasted waiting times and direct each child to needs-based services.

Imaging digital arteries in systemic sclerosis by tomographic 3-dimensional ultrasound

Objective methods are needed to quantify digital artery disease in systemic sclerosis (SSc) for clinical trials of vascular therapies. Our primary aim was to examine feasibility of a novel tomographic three-dimensional-(3-D) ultrasound (tUS) with high-frequency ultrasound (HFUS) or ultra-high-frequency ultrasound (UHFUS) to assess the digital arteries in patients with SSc compared to healthy controls. A secondary objective was to compare the total wall volume (TWV) as a measure of intimal/medial thickness. Eighteen patients with a confirmed diagnosis of SSc were studied by tUS HFUS (17.5 MHz, n = 10) or tUS UHFUS (48 and 70 MHz, n = 8) with equal numbers of healthy controls of similar age and gender. The majority of patients had limited cutaneous SSc and were representative of a spectrum of digital vasculopathy, with over half (n = 6 HFUS and n = 5 UHFUS) having previous digital ulceration. Over half were receiving oral vasodilatory therapy. TWV was measured in both digital arteries of the middle finger bilaterally. At least, two digital arteries could be identified at 17.5 MHz in all patients and healthy controls. Whereas, at least two digital arteries could be identified in relatively fewer patients compared to healthy controls using 48 MHz (n = 6 and 10) and especially 70 MHz (n = 4 and 10) UHFUS. The median difference in TWV between patients and healthy controls was -6.49 mm³ using 17.5 MHz, 1.9 mm³ at 48 MHz, and -0.4 mm³ at 70 MHz. tUS using UHFUS is a feasible method to measure TWV of digital arteries in SSc. Transducer frequency plays an important factor in successful digital artery measurement, with 48 MHz being the optimal frequency.

P1450Deep vein thrombosis after right sided catheter ablation; more common then previously thought?

Funding Acknowledgements

Bristol-Myers Squibb

Background

Right sided cardiac catheter ablation has become an indispensable tool to treat supraventricular cardiac dysrhythmias, with ablation of certain arrhythmias having cure rates over 90%. Due to this the frequency of these procedures is increasing annually and it is imperative we understand the incidence of all complication. One lesser studied complication is that of deep vein thrombosis (DVT), for which catheter ablation demonstrates all elements of Virchow"s triad.  As right sided ablations are carried out to treat troublesome palpitations, not to reduce mortality, it is important all risks are identified, especially those which are themselves potentially life threatening and can be modified.

Purpose

 

To determine the incidence of DVT after right sided cardiac catheter ablation.

Methods

 

We undertook a prospective multi-center study recruiting adult patients undergoing clinically indicated cardiac ablation for atrioventricular nodal re-entrant tachycardia and atrioventricular re-entrant tachycardia with right sided accessory pathway. Important exclusion criteria included patients on anticoagulation or antiplatelet therapy. Participants underwent bilateral compression venous duplex ultrasonography from the inferior vena cava to the popliteal vein to access for DVT at 24 hours and between 10 to 14 days post-procedure. The uncannulated contralateral leg acted as a control.

Result

 

At interim analysis 71 participants had completed the study with average age 47 year (+/- 14), procedure duration 67 minutes, and with a female predominance. Seven patients developed acute DVT in either the femoral or internal iliac vein in the access leg. No thrombus was seen in the control leg. This gives an incidence of 10% (95% CI 4-19%) with p value of 0.023 on Chi-square testing.

Conclusion

We found a statistically significant proportion of patients undergoing right sided cardiac catheter ablation developed acute proximal DVT on ultrasound. All patients were treated with 3 to 6 months of anticoagulation therapy in accordance with NICE guidelines. These results suggest that DVT may occur at a high frequency then previously thought in this cohort and supports the consideration of peri-procedural prophylactic anticoagulation.

Abstract Figure. Acute thrombus in the femoral vein

Enumeration of Total Coliforms and E. coli in Foods by the SimPlate® Coliform and E. coli Color Indicator Method and Conventional Culture Methods: Collaborative Study

The relative effectiveness of the SimPlate® Coliform and E. coli Color Indicator (CEc-CI) method was compared to the AOAC 3-tube Most Probable Number (MPN) methods for enumerating and confirming coliforms and Escherichia coli in foods (966.23 and 966.24). In this study, test portions were prepared and analyzed according to the conditions stated in both the AOAC methods and SimPlate directions for use. Six food types were artificially contaminated with coliform bacteria and E. coli: frozen burritos, frozen broccoli, fluid pasteurized milk, whole almond nut meats, cheese, and powdered cake mix. Method comparisons were conducted. Overall, the SimPlate method demonstrated &lt;0.3 log difference for total coliform and E. coli counts compared to the AOAC reference methods for the majority of food types and levels analyzed. In all cases, the repeatability and reproducibility of the SimPlate CEc-CI method were not different from those of the reference methods and in certain cases, were statistically better than those of the AOAC 3-tube MPN methods. These results indicate that the SimPlate CEc-CI method and the reference culture methods are comparable for enumeration of both total coliforms and E. coli in foods.

Abstract 511: An assessment of pre-conditioning regimens for optimal hCD34+ hematopoietic stem cell humanization of NSGTMmice

Humanized immune system (HIS) mice - immunocompromised Nod.Cg-Prkdcscid Il2rgtm1Wjl/SzJ animals in which the immune system has been humanized by the engraftment of CD34+ hematopoietic stem cells (HSC), peripheral blood mononuclear cells (PBMC), or other human cells/tissues - represent an important tool in pre-clinical oncology research. Here we investigated several pre-conditioning regimens (Busulfan pre-treatment or total body irradiation (TBI)) to determine which would yield maximum human leukocyte engraftment and lineage diversity. Animals were pre-treated either one or two doses of Busulfan (25 mg/kg) or varying doses of TBI (1.75, 2.0, or 2.5 Gy). One to two days later, animals received an adoptive transfer of native hCD34+ HSCs. Engraftment was monitored by flow cytometry assessment of peripheral blood four weeks after adoptive-transfer, and every four weeks thereafter through experiment termination at Week 16. Upon termination, spleen and bone-marrow were assessed for various leukocyte populations by flow cytometry. Animals undergoing pre-conditioning displayed increased human CD45+ cell engraftment at all timepoints as compared to animals without pre-conditioning, with animals treated with two doses of Busulfan demonstrating the greatest human CD45+ engraftment at all timepoints and reaching statistical significance at endpoint (vs no pre-conditioning; p&lt;0.05). Diversity of leukocyte cell types (B cells, T cells, NK cells, and other hCD45+) in the bone-marrow was similar across pre-treatment paradigms, however for some lineages, representation in the bone-marrow was significantly altered between pre-conditioning type. The absolute number of T or B cells were increased in TBI and Busulfan treated groups, respectively, whereas NK cells as a percentage of singlets were increased in TBI treated groups. The diversity of leukocyte cell types in the spleen was likewise similar across groups, with B cells dominating. These data provide important insights into the utility of various pre-conditioning regimens for the humanization of NSG mice for pre-clinical oncology research, and demonstrate that the optimum pre-conditioning regimens should be selected based on treatment target.

Citation Format: Caitlin S. Parello, Benjamin G. Cuiffo, Alexandria Kury, Kasey Reardon, Brett Van Dam, Sallyann Vu, Catarina Costa, Veronica Ritchie, Gavin Gagnon, Timothy Bateson, Samantha Rogers, Gregory D. Lyng, Stephen T. Sonis. An assessment of pre-conditioning regimens for optimal hCD34+ hematopoietic stem cell humanization of NSGTMmice [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 511.

Mechanism of E. coli Inactivation by Direct-in-liquid Electrical Discharge Plasma in Low Conductivity Solutions

This work investigates and reveals the main mechanism(s) responsible for inactivation of E. coli by in-liquid pulsed electrical discharge plasma in low conductivity solutions. Experiments were designed and performed to explore the effects of plasma-emitted UV light, oxidative radicals, and electric field on E. coli inactivation curves, rate of DNA leakage and visual appearance of the treated microorganisms. Results showed that electric field had the main role in inactivation; scanning electron microscopy images revealed that both plasma and the isolated electric field result in extensive cell wall disruptions. While this damage in the case of plasma treatment was extensive and distributed randomly along the envelope, the electric field-induced damage resulted in disruption primarily at the poles of the bacterial rods. Subsequent experiments conducted with an oxidative radical scavenger suggested that plasma-generated radicals do not contribute directly to the inactivation but assist in cell wall deterioration and extension of the ruptures first generated by the electric field.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Improving the spectral resolution in fluorescence microscopy through shaped-excitation imaging

The visualization of distinct molecular species represents an important challenge of bio-imaging research. In past decades, the development of multicolor fluorescent (FL) labels has greatly improved our ability to track biological analytes, paving the way for important advances in understanding the cell dynamics. It remains challenging, however, to visualize a large number of different fluorephores simultaneously. Owing to a spectrally broad absorption of fluorescent dyes, only up to five color categories can be resolved at once. Here, we demonstrate a general strategy for distinguishing between multiple fluorescent targets in acquired microscopy images with improved accuracy. The present strategy is enabled through spectral shaping of the excitation light with an optical filter that uniquely attenuates the light absorption of each fluorophore in the investigated sample. The resulting emission changes, induced by such excitation modulation, are therefore target-specific and can be used for identifying various fluorescent species. The technique is demonstrated through an accurate identification of 8 different CdSe dyes with absorption maxima spanning the 520-620 spectral range. It is subsequently applied for accurate measurements of the pH balance in buffers emulating a metabolism of tumor cells.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Carotid plaque volume in patients undergoing carotid endarterectomy

BACKGROUND

The main indication for carotid endarterectomy (CEA) is severity of carotid artery stenosis, even though most strokes in carotid disease are embolic. The relationship between carotid plaque volume (CPV) and symptoms of cerebral ischaemia, and the measurement of CPV by minimally invasive tomographic ultrasound imaging, were investigated.

METHODS

The volume of the endarterectomy specimen was measured using a validated saline suspension technique in patients undergoing CEA. Time from last symptom and severity of stenosis measured by duplex ultrasonography were recorded. Middle cerebral artery emboli were counted using transcranial Doppler imaging (TCD) in a subset of patients.

RESULTS

Some 339 patients were included, 270 with symptomatic and 69 with asymptomatic carotid stenosis. Mean(s.d.) CPV was higher in symptomatic than in asymptomatic patients (0·97(0·43) versus 0.74(0·41) cm³ ; P < 0·001). CPV did not correlate with severity of carotid stenosis (P = 0·770). Mean CPV was highest at 1·03(0·46) cm³ in the 4 weeks following cerebral symptoms, declining to 0·78(0·36) cm³ beyond 8 weeks. Among 33 patients who had TCD, mean CPV was 1·00(0·48) cm³ in the 27 patients with ipsilateral cerebral emboli compared with 0·67(0·16) cm³ in those without (P = 0·142). There was excellent correlation between CPV measured by tomographic ultrasound imaging and the endarterectomy specimen in 34 patients (r = 0·93, P < 0·001).

CONCLUSION

CPV correlated with symptoms of cerebral ischaemia, but not carotid stenosis. It could be a potential indicator for CEA.