Salvage therapies including retreatment with BCMA-directed approaches after BCMA CAR-T relapses for multiple myeloma

ABSTRACT

For patients with relapsed/refractory multiple myeloma with a relapse after B-cell maturation antigen (BCMA)-directed chimeric antigen receptor T-cell therapy (CAR-T), optimal salvage treatment strategies remain unclear. BCMA-directed CAR-T and bispecific antibodies (BsAbs) are now commercially available, and the outcomes for retreatment with BCMA-directed approaches are not well studied. We performed a retrospective analysis of 68 patients with relapsed disease after BCMA-directed CAR-T to evaluate outcomes and responses to salvage therapies. With a median follow-up of 13.5 months, median overall survival from time of relapse until death was 18 months (95% confidence interval [CI], 13.2 to not reached [NR]). Fifty-eight patients received subsequent myeloma-directed therapies, with a total of 265 lines of therapy (LOTs). The overall response rate for firstline salvage therapy was 41% (95% CI, 28-55). Among all LOTs, high response rates were observed among those receiving another BCMA-directed CAR-T (89%), BCMA-directed BsAbs (60%), CD38-directed combinations (80% when combined with BsAb; 50% when combined with immunomodulatory drugs and/or proteasome inhibitors), and alkylator-combinations (50% overall; 69% with high-dose alkylators). Thirty-four patients received at least 1 line of salvage BCMA-directed therapy; median progression-free survival was 8.3 months (95% CI, 7.9 to NR), 3.6 months (95% CI, 1.4 to NR), and 1 month (95% CI, 0.9 to NR) with median duration of response (DOR) of 8 months, 4.4 months, and 2.8 months for subsequent BCMA-directed CAR-T, BsAb, and belantamab mafadotin, respectively. Retreatment with BCMA-directed CAR-T and BsAbs can be effective salvage options after BCMA-directed CAR-T relapse; however, DORs appear limited, and further studies with new combinations and alternative targets are warranted.

Impact of Transforming Interface Geometry on Edge States in Valley Photonic Crystals

We investigate how altering the interface geometry from a zigzag to a glide plane interface between two topologically distinct valley Hall emulating photonic crystals (VPC), profoundly affects edge states. We experimentally observe a transition from gapless to gapped edge states, accompanied by the occurrence of slow light within the Brillouin zone, rather than at its edge. We numerically simulate the propagation and measure the transmittance of the modified edge states through a specially designed valley-conserving defect. The robustness to backscattering gradually decreases, suggesting a disruption of valley-dependent transport. We demonstrate the significance of interface geometry to gapless edge states in a VPC.

Is Quadriceps-Strengthening Exercises (QSE) in Medial-Compartment Knee Osteoarthritis with Neutral and Varus Malalignment a Paradox? - A Risk-Appraisal of Strength-Training on Disease Progression

Introduction

The present inquiry seeks to investigate whether the current regimens of QSEs (Quadriceps-Strengthening Exercises) aggravate the disease while mitigating symptoms.

Materials and methods

A comparative study was conducted on 32 patients with medial compartment osteoarthritis of knees. While the neutral group of 16 patients was constituted of those with an anatomical-lateral-femoro-tibial-angle (aFTA) 176-180º, varus group comprised an equal number of patients with an aFTA >180º. A home-based 12-week strength-training program involving weekly visits to hospital for supervised sessions was administered. The outcome measures were visual-analog-scale (VAS), medial patello-femoral joint tenderness (MPFJT), time-up-and-go-test (TUGT), stair-climb test, step test, WOMAC, IKDC scores, aFTA, hip-knee-ankle (HKA) angle, lateral-tibio-femoral-joint-separation (LTFJS), and horizontal-distance-from-centre-of-knee-to-Mikulicz-line.

Results

There was a significant increase in quadriceps strength (p<0.01) in both groups. Values for neutral group with VAS score (p=0.01), MPFJT (p=0.01), TUGT (p=0.01), timing of the stair climb test (p=0.01), WOMAC (p<0.01), and IKDC (p=0.03) were better compared to varus group with VAS score (p=0.13), MPFJT (p=0.03), TUGT (p=0.90), timing of stair climb test (p=0.68), WOMAC (p<0.02), and IKDC (p=0.05). Varus group also showed an increase in aFTA and LTFJS in 12 patients, increase in HKA in 11, and increase in horizontal distance from the centre of knee to the Mikulicz line in 7 patients.

Conclusion

The present study brings to the fore the paradoxical role played by QSEs in management of medial knee OA. While there is a radiological progression of the disease in both neutral and varus mal-aligned knees more so in the latter than the former.

Web-Based Scaffolds: The Feasibility of a Constructivist Approach to Oncology Fellow Learning

In this 2-institution feasibility pilot, oncology fellows used and updated freely available web-based learning tools (scaffolds) in a constructivist fashion.

Cost-effectiveness of a real-time spatiotemporal mapping surveillance system for meticillin-resistant Staphylococcus aureus prevention

OBJECTIVES

An infection surveillance system based on a hospital's digital twin [4D-Disease Outbreak Surveillance System (4D-DOSS)] is being developed in Singapore. It offers near-real-time infection surveillance and mapping capabilities. This early economic modelling study was conducted, using meticillin-resistant Staphylococcus aureus (MRSA) as the pathogen of interest, to assess the potential cost-effectiveness of 4D-DOSS.

METHODS

A Markov model that simulates the likelihood of MRSA colonization and infection was developed to evaluate the cost-effectiveness of adopting 4D-DOSS for MRSA surveillance from the hospital perspective, compared with current practice. The cycle duration was 1 day, and the model horizon was 30 days. Probabilistic sensitivity analysis was conducted, and the probability of cost-effectiveness was reported. Scenario analyses and a value of information analysis were performed.

RESULTS

In the base-case scenario, with 10-year implementation/maintenance costs of 4D-DOSS of $0, there was 68.6% chance that 4D-DOSS would be cost-effective. In a more pessimistic but plausible scenario where the effectiveness of 4D-DOSS in reducing MRSA transmission was one-quarter of the base-case scenario with 10-year implementation/maintenance costs of $1 million, there was 47.7% chance that adoption of 4D-DOSS would be cost-effective. The value of information analysis showed that uncertainty in MRSA costs made the greatest contribution to model uncertainty.

CONCLUSIONS

This early-stage modelling study revealed the circumstances for which 4D-DOSS is likely to be cost-effective at the current willingness-to-pay threshold, and identified the parameters for which further research will be worthwhile to reduce model uncertainty. Inclusion of other drug-resistant organisms will provide a more thorough assessment of the cost-effectiveness of 4D-DOSS.

Curriculum-based Faculty Training in Networking: Knowledge and Self-efficacy Outcomes

Although the advantages of developmental networks are well-known, most faculty do not know how to participate in such networks actively. Additionally, institutions face challenges in teaching faculty the best practices of networking. This deficiency constitutes a critical gap in the literature, which may slow career advancement for faculty, particularly from underrepresented groups. The study's purpose was to examine the effectiveness of a curriculum-based faculty training in developmental networks, utilizing the Extension for Community Health Outcomes (ECHO) platform. In this pre-post study, 33 faculty members participated in the intervention utilizing eight modules involving four competencies. Each module followed a standard format, including a short didactic, two facilitated case study discussions based on real-life scenarios, and self-reading of selected literature. Outcomes included (i) change in knowledge scores obtained from two questions per module and (ii) self-efficacy scores measured on a scale of 0-100. Paired student's t-test and mixed model regression analyses were used. A significant increase in knowledge score was documented using mixed model regression for 4 of the eight modules (mean change score 0.4-0.8, p≤0.03 for all analyses). The proportion of faculty participants reporting correct knowledge items for all modules increased from 49.8% (pre) to 64.3% (post), which was statistically significant (p<0.001). Significant increases in paired self-efficacy scores were reported for each of the eight modules (mean change score 17-37, p<0.05 for all analyses). This study highlights the importance of curriculum-based training in networking. Participants showed a significant increase in pre-post networking self-efficacy and knowledge scores. Our ECHO-based curriculum, facilitator training, and manual enable easy implementation in other institutions, ensuring scalability and adaptability. Our analysis provides the evidence basis for examining the impact of a developmental network intervention in enhancing individual career networks.

Intensity of cyclophosphamide-based bridging therapy before CAR-T therapy in myeloma

INTRODUCTION

Patients receiving autologous chimeric antigen receptor T-cell (CAR-T) therapies for multiple myeloma (MM) may require bridging therapy (BT) before CAR-T infusion to maintain some level of disease control. Alkylators such as cyclophosphamide (Cy) are often used as parts of BT regimens, either in high-intensity regimens such as modified hyperCVAD or once-weekly regimens such as KCd. However, there is no consensus around the optimal BT alkylator dose intensity in MM.

METHODS

We performed a single-center analysis of all instances of BT before planned autologous CAR-T for MM during a 5-year period ending April 2022. We classified bridging regimens into three cohorts: (1) hyperfractionated Cy (HyperCy) with inpatient Cy every 12-24 hours or as continuous intravenous infusions, (2) less intensive Cy dosing (WeeklyCy) such as KPd or KCd, and (3) NonCy, where no alkylators were used in BT. Demographic, disease-related, and treatment-related characteristics were collected for all patients. The three BT cohorts were compared using Fisher's exact tests, Kruskal-Wallis tests, and log-rank tests where appropriate.

RESULTS

We identified 70 discrete BT instances among 64 unique patients: 29 (41%) with HyperCy, 23 (33%) with WeeklyCy, and 18 (26%) with NonCy. Median total levels of Cy dosing during BT were 2100 mg/m², 615 mg/m², and 0 mg/m² respectively. Age, number of prior lines, triple-class refractory status, presence of high-risk cytogenetics, extramedullary disease, bone marrow plasma cell burden, involved free light chain (iFLC) kinetics before collection, and other measures of disease aggressiveness were comparable between cohorts. iFLC levels rose ≥25% and ≥100 mg/L during BT (approximating progressive disease) in comparable proportions (p=0.25) between cohorts: 52% HyperCy, 39% WeeklyCy, and 28% NonCy. All BT instances without subsequent CAR-T were due to manufacturing failures. Among 61 instances of bridging followed by CAR-T, vein-to-vein times were slightly longer (p = 0.03) with HyperCy (45 days) vs WeeklyCy (39 days) and NonCy (46.5 days). Neutrophil recovery timeframes were similar between cohorts, but platelet recovery took longer with HyperCy (64 days) vs WeeklyCy (42 days) and NonCy (12 days). PFS was comparable between cohorts, but median OS was not: 15.3 months with HyperCy versus 30.0 months with WeeklyCy and not reached with NonCy.

DISCUSSION

In our retrospective analysis of BT before CAR-T therapy in MM, HyperCy did not result in superior disease control than WeeklyCy despite a threefold higher dose of Cy. In contrast, HyperCy was associated with longer post-CAR-T platelet recovery and worsened OS despite comparable measurements of disease aggressiveness and tumor burden. Study limitations include our small sample size as well as confounding from gestalt markers of MM aggressiveness that might have led both to poorer outcomes as well as physicians' decisions to prescribe HyperCy. Given the rarity of objective disease responses to chemotherapy in relapsed/refractory MM, our analysis suggests that hyperfractionated Cy regimens do not outperform once-weekly Cy regimens for most patients who require BT before CAR-T therapy.

Significance of the pee-value: relevance of 24-hour urine studies for patients with myeloma

International Myeloma Working Group (IMWG) response criteria require refrigerated 24-hour urine specimens for most patients. However, given that serum free light chain testing has been shown to outperform 24-hour urine immunofixation as a prognostic marker, the importance of maintaining urine testing options or requirements within each level of IMWG response criteria has not been investigated. We analyzed responses to induction therapy for all transplant-eligible patients with multiple myeloma at our institution over a 3-year period using traditional versus 'urine-free' IMWG response criteria (where references to urine were removed from the descriptions for every depth of response). Of 281 evaluable patients, responses changed for only 4% of patients (95% confidence interval 2-7%) using urine-free criteria. Our results call into question the continued requirement for 24-hour urine measurements as part of IMWG response assessments for all patients. Research into the prognostic performance of urine-free IMWG criteria is ongoing.

Safety and efficacy of BCMA CAR-T cell therapy in older patients with multiple myeloma

BACKGROUND

Risks of B-cell maturation antigen (BCMA) chimeric antigen receptor T-cell (CAR-T) therapy for patients with multiple myeloma (MM) include cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), cytopenias, and infections. The efficacy and safety of BCMA CAR-T therapy in the geriatric setting, including complications such as falls and delirium which may be more prevalent in older patients, have not been fully analyzed.

OBJECTIVES

To analyze the efficacy and safety of BCMA CAR-T therapy among older patients (age ≥70 at infusion) versus younger patients with MM.

STUDY DESIGN

We analyzed all patients with MM who received any autologous BCMA CAR-T therapy over a 5-year period at our institution. Key endpoints included CRS, ICANS incidence, days to absolute neutrophil count (ANC) recovery, incidence of hypogammaglobulinemia (IgG < 400 mg/dL), infections within 6 months, progression-free survival (PFS), and overall survival (OS).

RESULTS

Of 83 analyzed patients (age range 33-77), 22 (27%) were aged ≥70 at infusion. The older cohort had lower creatinine clearances (median 67.3 vs 91.9 mL/min, p<0.001) and a higher proportion of patients with performance status ≥1 (59% vs 30%, p=0.02) but were otherwise similar. Rates of any-grade CRS, any-grade ICANS, and days to ANC recovery were similar between groups. Rates of baseline hypogammaglobulinemia were 36% in older patients and 30% in younger patients (p=0.60), while post-infusion hypogammaglobulinemia occurred in 82% vs 72% respectively (p=0.57). Infections occurred in 36% (n=8) of the older cohort versus 52% (n=32) of the younger cohort (p=0.22). There were no statistically significant differences between the older and younger cohorts in terms of documented falls (9% vs 15%, p=0.72) or non-ICANS delirium (5% vs 7%, p=1.0). Median PFS was 13.1 months in older patients (95% CI 9.2-not reached [NR]) vs 12.5 months in younger patients (95% CI 11.3-22.5, p=0.42. Median OS was not reached in the older cohort (95% CI: NR-NR) vs 31.4 months in the younger cohort (95% CI 24.8-NR) with p=0.04. However, age ≥70 was not a significant predictor of OS after adjusting for high-risk cytogenetics, triple-class refractoriness, extramedullary disease, and bone marrow plasma cell burden.

CONCLUSIONS

While limited by small sample size and unmeasured confounders, our retrospective analysis did not demonstrate significant increases in CAR-T toxicity among older patients. This included toxicities associated with geriatric populations such as falls and delirium. Our paradoxical finding of borderline better OS among patients aged ≥70, which was not significant in regression modeling, may have been due to selection bias in favor of disproportionately healthy CAR-T candidates in the geriatric population. Overall, BCMA CAR-T remains a safe and effective option for older patients with MM.

Cytomegalovirus seropositivity is associated with improved responses to CD38 monoclonal antibody therapies in multiple myeloma: A single-centre retrospective study

The CD38-targeting monoclonal antibodies (CD38 mAbs) are well-established therapies in multiple myeloma (MM), but responses to treatment are not always deep or durable. Natural killer (NK) cells deficient in Fc epsilon receptor gamma subunits, known as g-NK cells, are found in higher numbers among individuals exposed to cytomegalovirus (CMV) and are able to potentiate the efficacy of daratumumab in vivo. Here, we present a single-centre, retrospective analysis of 136 patients with MM with known CMV serostatus who received a regimen containing a CD38 mAb (93.4% daratumumab and 6.6% isatuximab). CMV seropositivity was associated with an increased overall response rate to treatment regimens containing a CD38 mAb (odds ratio 2.65, 95% confidence interval [CI] 1.17-6.02). However, CMV serostatus was associated with shorter time to treatment failure in a multivariate Cox model (7.8 vs. 8.8 months in the CMV-seropositive vs. CMV-seronegative groups respectively, log-rank p = 0.18, hazard ratio 1.98, 95% CI 1.25-3.12). Our data suggest that CMV seropositivity may predict better response to CD38 mAbs, although this did not correspond to longer time to treatment failure. Larger studies directly quantitating g-NK cells are required to fully understand their effect on CD38 mAb efficacy in MM.

Daratumumab Plus Bortezomib and Dexamethasone in Newly Diagnosed Systemic Light Chain Amyloidosis

Light chain amyloidosis (AL) is a plasma cell dyscrasia characterized by organ dysfunction, morbidity, and early mortality. Daratumumab in combination with cyclophosphamide, bortezomib, and dexamethasone is now standard frontline AL therapy; however, not all patients are candidates for this intensive regimen. Given the potency of Daratumumab, we evaluated an alternative frontline regimen: daratumumab, bortezomib, and limited-duration dexamethasone (Dara-Vd). Over a 3 year period, we treated 21 patients with Dara-Vd. At baseline, all patients had cardiac and/or renal dysfunction, including 30% of patients with Mayo stage IIIB cardiac disease. Nineteen of 21 patients (90%) achieved a hematologic response with 38% achieving a complete response. The median time to response was 11 days. Ten of 15 (67%) evaluable patients achieved a cardiac response and 7 of 9 (78%) achieved a renal response. The 1-year overall survival was 76%. In untreated systemic AL amyloidosis, Dara-Vd produces rapid and deep hematologic and organ responses. Dara-Vd was well-tolerated and efficacious, even among patients with extensive cardiac dysfunction.

Production and characterization of sustainable vermimanure derived from poultry litter and rice straw using tiger worm Eisenia fetida

Poultry litter (PL) and rice straw (RS), commonly available waste materials, pose severe threat to environment, if not properly managed. As viable waste treatment method, vermi-transformation of PL into enriched vermimanure was done using RS and cow dung (CD) with different feedstocks (FS) combinations like FS0_{(CD without earthworm),} FS1_(CD), FS2_{(1CD: 1RS)}, FS3_{(1CD: 1PL)} and FS4_{(1CD: 1RS: 1PL)} for 110 days. Increased growth performance (P < 0.05) of Eisenia fetida, macronutrient levels, and a consistently lower carbon-to-nitrogen ratio (C/N) emphasize the importance of RS and PL in the vermimanuring process. Several analytical techniques have revealed the presence of functional groups, nitrate (NO₃^-), phosphate (PO₄^3-), and potassium ions (K⁺) as well as the high porosity of the matured vermimanures. Therefore, using earthworms, the feedstock FS4_{(1CD: 1RS: 1PL)} could be successfully biotransformed into sustainable manure lowering the usage of chemical fertilizers and rice straw burning.

Healthcare use by children in North West London 2015-2019 by deprivation and integrated care access

Background

England has a health system offering universal coverage, but disparities in healthcare use are increasing. Between 2007-2017, children living in more deprived areas had higher rates of unplanned care (Emergency Department (ED) attendance and hospital admissions), whereas children from less deprived areas had higher rates of planned care (General Practitioner (GP) contact and outpatient appointments). More detailed research to find solutions for this divergent pattern is required.

Aim

To assess the rates of GP contact, outpatient appointments, hospital admissions and ED attendance in North West London, by Index of Multiple Deprivation (IMD) decile of home postcode and access to an integrated care service providing linked care between multiple child health professionals ‘Connecting Care for Children (CC4C)', for children aged 0-18 years between 2015-2019.

Methods

Retrospective analysis of a de-identified database of integrated care records for 495,357 children.

Results

Children from the most deprived decile had higher rates of emergency admissions (0.070 per child per year vs. overall mean 0.040), elective admissions (0.076 vs. 0.032), ED attendances (0.754 vs. 0.358) and outpatient appointments (1.702 vs. 0.756) between 01.01.2015- 31.12.2019. Children from the least deprived decile had the second highest rates of outpatient appointments (0.911 vs. 0.756) and GP contact (8.192 vs. 5.390) between 01.01.2015- 31.12.2019. Children with access to the CC4C service, despite being from more deprived backgrounds, had lower rates of emergency admissions (0.028 vs. 0.037) compared to patients with access to usual care. P values &lt;0.001 in all cases.

Conclusions

Greater deprivation was linked to higher rates of emergency admissions, but this was partially mitigated by access to more integrated healthcare models. Children from the least deprived decile continued to have disproportionately higher use of planned care.

Key messages

• Despite universal health coverage, children from more deprived areas continue to have disproportionately higher use of unplanned care.

• Further research is required to explore whether integrated care solutions can reduce the burden on unplanned health services and inequalities in access to care.

Implication and utility of DAS-28 squeeze in rheumatoid arthritis: an Indian experience

The purpose of this study was to compare and correlate disease activity score including 28 joints counts (DAS-28) Squeeze with DAS-28 and clinical disease activity index (CDAI) to assess disease activity (DA) in rheumatoid arthritis (RA) patients. A total of 100 RA patients were included in the study. All subjects were evaluated for disease activity using the DAS-28 Squeeze, DAS-28, and CDAI. Spearman’s rho (ρ) was calculated to determine the correlation between DAS-28 Squeeze, DAS-28, and CDAI. Cross-tabulation was performed to compare and calculate the kappa coefficient for the link between two indices. For each scale, Cronbach’s alpha was also calculated to test dependability. The average age of the study group was 43.9±11.3. The mean scores on the DAS-28 Squeeze, DAS-28, and CDAI were, respectively, 3.58±1.06, 5.06±1.56, and 22.81±14.92. p=0.001 indicated a significant correlation between DAS-28 Squeeze and DAS-28 (ρ=0.986) and CDAI (ρ=0.939) for DAS-28 Squeeze. There was a considerable correlation between all three measures at various DA levels. Cronbach’s alpha for DAS-28 Squeeze, DAS-28, and CDAI were respectively 0.716, 0.663, and 0.734. DAS-28 Squeeze exhibited a substantial positive association with DAS-28 and CDAI for assessing disease activity and appears to be a more useful and reliable method than DAS-28 and CDAI for monitoring disease activity in RA patients.

Antibody and T-cell responses by ultra-deep T-cell receptor immunosequencing after COVID-19 vaccination in patients with plasma cell dyscrasias

We investigated antibody and coronavirus disease 2019 (COVID‐19)‐specific T‐cell mediated responses via ultra‐deep immunosequencing of the T‐cell receptor (TCR) repertoire in patients with plasma cell dyscrasias (PCD). We identified 364 patients with PCD who underwent spike antibody testing using commercially available spike‐receptor binding domain immunoglobulin G antibodies ≥2 weeks after completion of the initial two doses of mRNA vaccines or one dose of JNJ‐78436735. A total of 56 patients underwent TCR immunosequencing after vaccination. Overall, 86% tested within 6 months of vaccination had detectable spike antibodies. Increasing age, use of anti‐CD38 or anti‐B‐cell maturation antigen therapy, and receipt of BNT162b2 (vs. mRNA‐1273) were associated with lower antibody titres. We observed an increased proportion of TCRs associated with surface glycoprotein regions of the COVID‐19 genome after vaccination, consistent with spike‐specific T‐cell responses. The median spike‐specific T‐cell breadth was 3.11 × 10⁻⁵, comparable to those in healthy populations after vaccination. Although spike‐specific T‐cell breadth correlated with antibody titres, patients without antibody responses also demonstrated spike‐specific T‐cell responses. Patients receiving mRNA‐1273 had higher median spike‐specific T‐cell breadth than those receiving BNT162b2 (p = 0.01). Although patients with PCD are often immunocompromised due to underlying disease and treatments, COVID‐19 vaccination can still elicit humoral and T‐cell responses and remain an important intervention in this patient population.

Online scaffolds: A constructivist approach to oncology fellow learning

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Background: Oncology is a vast and fast-paced field. Fellows must expend significant effort to learn and stay updated. Up-to-date learning tools covering core oncology content in a digestible manner are lacking. Additionally, passive lectures are common in oncology, while constructivist approaches that may improve learning are rare. Therefore, we piloted updatable online modules (“scaffolds”) as a learning tool for oncology fellows. Methods: Author SB, a University of California, San Francisco (UCSF) solid-tumor oncologist, designed 12 scaffolds (breast, non-small cell lung, small cell lung, head/neck, salivary/thyroid, upper gastrointestinal, lower gastrointestinal, germ cell, bladder/renal/adrenal, prostate, melanoma, and sarcoma) using Google Slides between 12/2018 and 6/2019. The scaffolds included bullet points and tables/figures synthesized from the ASCO self-evaluation program textbook’s solid tumor chapters and the National Comprehensive Cancer Network (NCCN) guidelines. We emailed scaffold links to all UCSF and Stanford oncology fellows in 2019-2020, including instructions for fellows to update the scaffolds without exceeding 20 slides per scaffold, 5 lines per slide, or 7 words per line. The scaffolds were reintroduced to new fellows at the beginning of each academic year. SB audited to ensure no erroneous information was added. In December 2021 we reviewed updates tracked in Google Slides and conducted one UCSF and one Stanford focus group with four 1st-3rd year fellows each. Results: Between 7/2019 and 12/2021, fellows made 60 updates to the scaffolds, with a mean of 5 updates per scaffold ranging from new trials to changes in management. During the same period, the auditor made 9 updates and found no erroneous fellow updates. Fellow updates occasionally exceeded specified limits, requiring correction. Content analysis revealed that fellows considered the scaffolds to be accessible and succinct learning tools that 1) addressed a dearth of similar resources, 2) served as effective preparation for clinical work and examinations, 3) provided structured information for rapid review, and 4) made subsequent interactions with complex resources such as NCCN guidelines easier. Barriers to fellows updating the scaffolds included lack of ownership and low confidence in judgment regarding appropriate updates. Conclusions: In this two-institution pilot, oncology fellows used and subsequently updated online scaffolds in a constructivist fashion. This model has the potential to fill a crucial gap in available learning resources and can be applied to other specialties. Assigning scaffolds to fellows with faculty mentorship may facilitate ownership and bolster fellow confidence in updating these tools. Individual institutions may update their own versions of the scaffolds to align with institution-specific needs.

Breakdown of Spin-to-Helicity Locking at the Nanoscale in Topological Photonic Crystal Edge States

We measure the local near-field spin in topological edge state waveguides that emulate the quantum spin Hall effect. We reveal a highly structured spin density distribution that is not linked to a unique pseudospin value. From experimental near-field real-space maps and numerical calculations, we confirm that this local structure is essential in understanding the properties of optical edge states and light-matter interactions. The global spin is reduced by a factor of 30 in the near field and, for certain frequencies, flipped compared to the pseudospin measured in the far field. We experimentally reveal the influence of higher-order Bloch harmonics in spin inhomogeneity, leading to a breakdown in the coupling between local helicity and global spin.

COVID-19 in vaccinated versus unvaccinated hematologic malignancy patients

The effect of vaccination on severity of subsequent COVID-19 in patients with hematologic malignancies (HMs) is unknown. In this single-center retrospective cohort study, we found no difference in severity of COVID-19 disease in vaccinated (n = 16) versus unvaccinated (n = 54) HM patients using an adjusted multiple logistic regression model. Recent anti-B-cell therapy was associated with more severe illness.

INFLUENCE OF THE DURATION OF DIABETES AND VIBRATION PERCEPTION THRESHOLD ON THE SEVERITY OF ERECTILE DYSFUNCTION IN PATIENTS WITH TYPE 2 DIABETES MELLITUS

BACKGROUND

Erectile dysfunction(ED) in men is a frequent under-reported complication of diabetes mellitus, which is becoming significant health problem worldwide.

AIMS

The study aims to determine the prevalence and risk factors for development of ED in North Indian patients with type 2 diabetes mellitus.

METHODS

We used international index of erectile function (IIEF-5) for the assessment of ED in 796 patients with type 2 diabetes mellitus. We recorded the age, duration of diabetes, glycemic status, body mass index, diabetes medications, microvascular and macrovascular complications.

RESULTS

The mean age of patients in the study was 49.38 ± 9.52 years. The prevalence of ED in patients with type 2 diabetes mellitus was 79.4%. Logistic regression analysis revealed that age, body mass index, glycemic control, insulin therapy, retinopathy and nephropathy was not significantly associated with erectile dysfunction in patients with type 2 diabetes mellitus. Duration of diabetes (OR = 1.054, 95% CI 1.007 to 1.102, P=0.023) and vibration perception threshold (OR = 1.071, 95% CI 1.042 to 1.102, P=0.000) were identified as key risk factors for development of ED.

CONCLUSION

Duration of diabetes and peripheral neuropathy emerged as significant risk factors for development of severe erectile dysfunction.

Airway Complications After Lung Transplant for Post Coronaviral Disease (COVID-19) Acute Respiratory Distress Syndrome (ARDS) Related End Stage Lung Disease: Single Centre Experience

Purpose

Severe COVID-19 ARDS related end stage lung fibrosis with irreversible changes is a newer indication for lung transplantation with acceptable survival rate. Airway complication post lung transplant is a major source of morbidity and mortality with incidence as high as 25 to 49 percent. Patients with end stage COVID-19 fibrosis are likely to be clinically deconditioned with long duration of extracorporeal oxygenator (ECMO) support, high burden of sepsis and prolonged respiratory support which may affect the airways post lung transplantation.

Methods

This is a retrospective observational study after obtaining institutional ethical clearance. We reviewed electronic medical data of patients who underwent lung transplantation for post COVID-19 ARDS related fibrosis. We evaluated the incidence and type of airway complications and the various therapeutic interventions applied for its management.

Results

Between May 2020 and September 2021 our centre performed 23 bilateral lung transplants for end stage COVID-19 ARDS related fibrosis. 22 patients were on ECMO support with mean duration of 50.9 days before transplantation. All patients underwent lung transplantation with central Veno-Arterial ECMO support with mean organ ischaemia time of 360±154 minutes. The incidence of airway complication in our study group was 56%. We observed anastomotic narrowing in 3(13%), distal airway narrowing in 4(17%) and sloughing/coating of anastomotic site in 5(22%) patients. Nonspecific inflammatory polypi around the bronchial anastomotic site were noticed in 4(17%) and mild airway anastomotic dehiscence in 2 subjects. 8(34%) patients required serial bronchoscopy and balloon dilatation; 2 among them mandated additional cautery usage. 2 cases underwent polypectomy, further 4 subjects needed bronchial stent placement. 5 (21%) recipients were discharged with Tracheostomy while rest were successfully decannulated in the ward.

Conclusion

We observed a high incidence of airway complications in post lung transplant for COVID-19 ARDS related fibrosis. Early detection, timely management and serial follow up is of paramount importance in this subset of patients.

Digital Life Coaching during Stem Cell Transplantation: A Pilot Feasibility Study

BACKGROUND

For patients with multiple myeloma receiving high-dose chemotherapy followed by autologous stem cell transplantation (SCT), acute life disruptions and symptom burden may lead to worsened quality of life (QOL) and increased emotional distress. Digital life coaching (DLC), whereby trained coaches deliver personalized wellbeing-related support via phone calls and text messages, has been shown to improve QOL among SCT survivors. However, DLC has not been investigated during the acute peri-SCT period which is generally characterized by symptomatic exacerbations and 2-week hospitalizations.

OBJECTIVE

We launched a single-arm pilot study to investigate the feasibility of patient engagement with DLC during this intensive period.

METHODS

We approached English-speaking adult patients with multiple myeloma undergoing autologous SCT at our center. Enrolled patients received 16 weeks of virtual access to a life coach beginning at Day -5 before SCT. Coaches used structured frameworks to help patients identify and overcome personal barriers to wellbeing. Patients chose the coaching topics and preferred communication styles. Our primary endpoint was ongoing DLC engagement, defined as bidirectional conversations occurring at least once every four weeks during the study period. Secondary endpoints were electronic patient-reported outcome (ePRO) assessments of QOL, distress, and sleep disturbances. Our study was registered as clinicaltrials.gov identifier NCT04432818.

RESULTS

Of 20 screened patients, 17 patients chose to enroll and 15 underwent SCT as planned. Of these 15 patients (median age 65, range 50-81), 73% (n = 11) demonstrated ongoing DLC engagement. The median frequency of bidirectional conversations during the 3-month study period was once per 6.2 days (range: 3.9-28). During index hospitalizations with median lengths of stay 16 days (range 14-31), the median frequency of conversations was once per 5.3 days (range 2.7-15). ePRO assessments (94% adherence) demonstrated an expected QOL nadir during the second week following SCT. The prevalence of elevated distress was highest immediately before and after SCT, with 69% of patients exhibiting elevated distress at Day -5 and at Day +2.

CONCLUSIONS

DLC may be feasible for older patients during intensive hospital-based cancer treatments such as autologous stem cell transplantation for multiple myeloma. Limitations of our study include small sample size, selection bias among enrolled patients, and heterogeneity in DLC usage. Based on the positive results of this pilot study, a larger phase 2 randomized study of DLC during SCT is under way to investigate its efficacy with regard to patient wellbeing.

CLINICALTRIAL

Our study was registered as clinicaltrials.gov identifier NCT04432818.

Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity

OBJECTIVE

The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates.

METHODS

Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees.

RESULTS

Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation.

CONCLUSION

Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

Fibrosis assessment in patients with nonalcoholic fatty liver disease: Adherence to proposed algorithms and barriers to complying with them

INTRODUCTION AND AIMS

Fibrosis staging in patients with nonalcoholic fatty liver disease (NAFLD) is carried out through the application of stepwise algorithms but there is little real-world data on their use. Our aim was to calculate the number of patients with NAFLD and indeterminate or high risk for fibrosis, assessed through noninvasive scores, that consequently underwent further staging evaluation.

MATERIALS AND METHODS

A cross-sectional multicenter cohort study was conducted on patients with NAFLD evaluated by hepatologists within the time frame of June 1 and July 31, 2018. The FIB-4 and NAFLD fibrosis scores were calculated in all the patients, and if at least one of the scores suggested indeterminate or high risk for fibrosis, we believed the patient should have undergone additional fibrosis staging assessment.

RESULTS

The study included 238 patients. The median time interval from NAFLD diagnosis and inclusion in the analysis was 12.2 months (IQR 3.0-36.5). A total of 128 (54%) patients had at least one noninvasive score that suggested indeterminate or high risk for fibrosis but studies to confirm the fibrosis grade (elastography, biopsy, etc.) were performed on only 72 (56%). The main barriers encountered by the physicians for applying the staging algorithms were related to health insurance coverage and imaging study costs.

CONCLUSIONS

A high percentage of patients with NAFLD were at indeterminate or high risk for fibrosis, according to noninvasive scores, but additional studies were carried out on only half of them, showing low adherence to current recommendations.

Prognostic significance of polyvascular disease in patients admitted with acute decompensated heart failure: the ARIC Study Community Surveillance

Introduction

The prevalence and outcomes of polyvascular disease (PVD) in patients admitted with acute decompensated heart failure (ADHF) have not been previously reported, nor is it known whether associations differ for heart failure (HF) with reduced vs. preserved ejection fraction (HFrEF vs HFpEF, respectively).

Purpose

To investigate the relationship between atherosclerotic involvement of multiple arterial territories and mortality in patients hospitalized with ADHF.

Methods

The Atherosclerosis Risk in Communities (ARIC) study conducted hospital surveillance of adjudicated heart failure in 4 US areas from 2005–2014, with events verified by physician review. Medical histories were abstracted from the hospital record. PVD was defined by coexisting disease in ≥2 arterial beds, identified by prevalent coronary artery disease, peripheral arterial disease, and cerebrovascular disease. Mortality hazards of PVD vs. no PVD were analyzed separately for HFpEF and HFrEF, with adjustment for age, race, sex, year of admission and geographic region. All analyses were weighted by the inverse of the sampling probability.

Results

Of 24,936 ADHF hospitalizations (52% female, 32% Black, mean age 75 years), 19% had PVD (22% among HFrEF hospitalizations, 17% among HFpEF hospitalizations), Figure 1. There was an increasing trend in 1-year mortality with 0, 1 and ≥2 arterial bed involvement, both for patients with HFrEF (29% to 32% to 38%; P-trend=0.0006) and HFpEF (26% to 32% to 37%; P-trend &lt;0.0001). After adjustments, PVD was associated with a 20% higher hazard of 1-year mortality in patients with HFrEF (HR=1.23; 95% CI: 1.06–1.44) and a 30% higher hazard in patients with HFpEF (HR=1.33; 95% CI: 1.09–1.63), with no significant interaction by HF type (P-interaction = 0.5).

Conclusion

Patients hospitalized with ADHF and coexisting PVD have an increased risk of death, irrespective of HF type. Clinical attention should be directed toward PVD, with secondary prevention strategies enacted to improve the prognosis of this vulnerable population.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Institutes of Health Distributions of arterial diseaseTrends in 1-year mortality outcomes

The morphological and morphometric analysis of the variant patterns of the tricipital aponeurosis: a new anatomical classification with possible clinical implications

BACKGROUND

Tricipital aponeurosis (TA) has gained attraction as a constant and reliable landmark to identify the location of radial nerve in the setting of fracture distal humeri. The aponeurosis itself shows variant anatomical patterns. In this study, we intend to provide a comprehensive description and functional classification of observed anatomical variations with possible clinical implications.

MATERIALS AND METHODS

Sixty arms belonging to 30 adult cadavers were studied. TA was examined grossly to document variations in its shape and classified accordingly. Subsequently, length and breadth of TA were measured. The distance of the radial nerve (RN) from the point of confluence and from the lateral border of TA was also measured (tricepso-radial distance [TRD]). These distances were correlated with the different patterns of TA obtained.

RESULTS

Based on the shape of the proximal apex of TA or point of confluence and frequency of their occurrence, we propose a new classification of 4 patterns for the TA anatomy. Pattern I: classically seen as the triangular proximal apex (76.67%); pattern II: tongue shaped or blunt proximal apex (18.33%); pattern III: bifurcated or dual proximal apex (3.33%); pattern IV: as the absence of TA (1.67%). The mean of length and breadth of TA was 16.58 ± 2.05 cm and 3.61 ± 0.61 cm, respectively. The mean distance of RN from point of confluence and lateral border of TA was 3.57 ± 0.19 cm and 2.04 ± 0.56 cm, respectively. The length, breadth of TA and TRD differs amongst the different patterns of TA.

CONCLUSIONS

Anatomical variations in the shape and size of TA are frequently encountered. The proposed, hitherto undescribed, classification may make operating surgeon aware of these morphological variations and help prevent iatrogenic injury to RN. Such classification is simple and unique; however, its success relies upon universal acceptance.