Response adaptive salvage with KTd and ASCT for functional high-risk multiple myeloma-The Australasian Leukemia and Lymphoma Group (ALLG) MM17 Trial

We evaluated re-induction incorporating carfilzomib-thalidomide-dexamethasone (KTd) and autologous stem cell transplantation (ASCT) for newly diagnosed multiple myeloma (NDMM) refractory, or demonstrating a suboptimal response, to non-IMID bortezomib-based induction. KTd salvage consisted of thalidomide 100 mg daily and dexamethasone 20 mg orally combined with carfilzomib 56 mg/m² days 1, 2, 8, 9, 15 and 16, of each 28-day cycle. Following four cycles, patients achieving a stringent complete response proceeded to ASCT whereas those who did not received a further two cycles then ASCT. Consolidation consisted of two cycles of KTd then Td to a total of 12 months post-ASCT therapy. Primary end-point was the overall response rate (ORR) with KTd prior to ASCT. Fifty patients were recruited. The ORR was 78% with EuroFlow MRD negativity of 34% in the intention-to-treat population and 65% in the evaluable population at 12 months post-ASCT. With follow-up >38 months median PFS and OS have not been reached with PFS and OS at 36 months of 64% and 80%, respectively. KTd was well tolerated with grade 3 and grade ≥4 adverse events rates of 32% and 10%, respectively. Response adaptive utilisation of KTd with ASCT is associated with both high-quality responses and durable disease control in functional high-risk NDMM.

Digital filtering of ghost signal in phase measuring deflectometry

We introduce a method of geometric screen modification to remove ghost reflections commonly observed in deflectometry optical testing. The proposed method modifies the optical layout and illumination source area to bypass the generation of reflected rays from the undesired surface. The layout flexibility of deflectometry allows us to design specific system layouts that avoid the generation of interrupting secondary rays. The proposed method is supported by optical raytrace simulations, and experimental results are demonstrated with convex and concave lens case studies. Finally, the limitations of the digital masking method are discussed.

Apolipoprotein A1 Protects Against Necrotic Core Development in Atherosclerotic Plaques: PDZK1-Dependent High-Density Lipoprotein Suppression of Necroptosis in Macrophages

BACKGROUND

Atherosclerosis is a chronic disease affecting artery wall and a major contributor to cardiovascular diseases. Large necrotic cores increase risk of plaque rupture leading to thrombus formation. Necrotic cores are rich in debris from dead macrophages. Programmed necrosis (necroptosis) contributes to necrotic core formation. HDL (high-density lipoprotein) exerts direct atheroprotective effects on different cells within atherosclerotic plaques. Some of these depend on the SR-B1 (scavenger receptor class B type I) and the adapter protein PDZK1 (postsynaptic density protein/Drosophila disc-large protein/Zonula occludens protein containing 1). However, a role for HDL in protecting against necroptosis and necrotic core formation in atherosclerosis is not completely understood.

METHODS

Low-density lipoprotein receptor-deficient mice engineered to express different amounts of ApoA1 (apolipoprotein A1), or to lack PDZK1 were fed a high fat diet for 10 weeks. Atherosclerotic plaque areas, necrotic cores, and key necroptosis mediators, RIPK3 (receptor interacting protein kinase 3), and MLKL (mixed lineage kinase domain-like protein) were characterized. Cultured macrophages were treated with HDL to determine its effects, as well as the roles of SR-B1, PDZK1, and the PI3K (phosphoinositide 3-kinase) signaling pathway on necroptotic cell death.

RESULTS

Genetic overexpression reduced, and ApoA1 knockout increased necrotic core formation and RIPK3 and MLKL within atherosclerotic plaques. Macrophages were protected against necroptosis by HDL and this protection required SR-B1, PDZK1, and PI3K/Akt pathway. PDZK1 knockout increased atherosclerosis in LDLR^KO mice, increasing necrotic cores and phospho-MLKL; both of which were reversed by restoring PDZK1 in BM-derived cells.

CONCLUSIONS

Our findings demonstrate that HDL in vitro and ApoA1, in vivo, protect against necroptosis in macrophages and necrotic core formation in atherosclerosis, suggesting a pathway that could be a target for the treatment of atherosclerosis.

Treatment of Patients with Waldenström Macroglobulinaemia: Clinical practice update from the Myeloma Foundation of Australia Medical and Scientific Advisory Group

Waldenström macroglobulinaemia (WM) is an indolent B-cell malignancy characterised by the presence of IgM paraprotein, bone marrow infiltration by clonal small B lymphocytes with plasmacytic differentiation and the MYD88 L265P mutation in >90% of cases. Traditionally, WM has been treated with chemoimmunotherapy. Recent trials have demonstrated the efficacy and safety of Bruton tyrosine kinase inhibitors in WM, both as monotherapy and in combination with other drugs. There is emerging evidence on use of other agents including BCL2 inhibitors and on treatment of rare presentations of WM. In this update, the Medical and Scientific Advisory Group of Myeloma Australia review the available evidence on the treatment of WM since the last publication in 2017 and provide specific recommendations to assist Australian clinicians in the management of this disease.

Need for tracheostomy in major head and neck ablative surgery: a paradigm shift during the COVID-19 pandemic

INTRODUCTION

Management of the airway in the perioperative period for patients requiring major head and neck ablative surgery has commonly included the performance of elective surgical tracheostomy. This has been standard practice in most maxillofacial units across the UK, including ours. However, the COVID-19 pandemic and emerging guidelines on aerosol-generating procedures required us to revisit the need for a perioperative tracheostomy.

METHODS

We present our series of 29 consecutive cases, cared for during the first wave of the COVID-19 pandemic, that were managed either using surgical tracheostomy or overnight tracheal intubation.

RESULTS

Out of 29 patients 3 received a surgical tracheostomy. The average duration of tracheostomy use was 8 days. Twenty patients were managed using a period of overnight tracheal intubation. Average duration of tracheal intubation was 1.2 days, with an average intensive care unit stay of 1.7 days. The average duration of hospital stay was 15.8 days for patients managed with overnight tracheal intubation and 30.1 days for patients who received a surgical tracheostomy. The return to theatre rate was 13.8% for reasons including flap failure and neck space infection. There were no airway issues reported in this series of patients.

CONCLUSIONS

Our findings suggest that overnight tracheal intubation can be a safe alternative to surgical tracheostomy in the majority of cases.

Modeling and characterization of OASIS inflatable primary antenna by dual modality metrology

OASIS (Orbiting Astronomical Satellite for Investigating Stellar Systems) is a space-based observatory with a 14 m diameter inflatable primary antenna that will perform high spectral resolution observations at terahertz frequencies. The large inflatable aperture, non-traditional surface configuration, and the double layered membrane structure afford unique challenges to the modeling and testing of the primary antenna. A 1-meter prototype of the primary antenna (A1) was built to validate our technical approach. A laser radar coordinate measuring system was adopted to measure the shape of A1. In addition, deflectometry was performed to monitor the stability of A1 during the radar measurement. Test cases pertaining to specific operational conditions expected for the 14 m OASIS primary were explored. The measured data were then compared to the Fichter model and Finite-element Analyzer for Inflatable Membranes (FAIM).

Non-planar illumination deflectometry for axicon metrology

We introduce an on-axis deflectometry test configuration for axicon metrology. Axicons are challenging to measure due to their characteristically steep, convex geometry. However, if an axicon is coaxially aligned with a camera and a surrounding cylindrical illumination source, high-resolution surface measurements can be obtained via the principle of deflectometry. Emitted from the temporally modulated source, light deflects at the conical surface and into the entrance pupil of a camera, illuminating the full axicon aperture except the ø 0.5-mm rounded tip. Deflectometry measurements of a 100° and 140° axicon show holistic cone angle agreement within 0.035° against touch probe data and up to 7.93 root μm mean square difference from a best-fit cone. We discuss the non-planar illumination architecture, sensitivity, and experimental results of arbitrary apex angle axicons.

Computational vector fiducial for deflectometry system alignment

One of deflectometry's cardinal strengths is its ability to measure highly dynamically sloped optics without needing physical null references. Accurate surface measurements using deflectometry, however, require precise calibration processes. In this Letter, we introduce an alignment technique using a computational fiducial to align a deflectometry system without additional hardware equipment (i.e., algorithmic innovation). Using the ray tracing program, we build relationships between the plane of the screen and detector and algorithmically generate a fiducial pattern for the deflectometry configuration. Since the fiducial pattern is based on ideal system geometry, misalignment of the unit under test with its target position causes a discrepancy between the actual image on the camera detector and the ideal fiducial image. We leverage G and C vector polynomials to quantify misalignment and estimate the alignment status through a reverse optimization method. Simulation and experimental results demonstrate that the proposed algorithm can align the 195mm×80mm of a rectangular aperture freeform optic within 10 µm of peak-to-valley accuracy. The computational fiducial-based alignment algorithm is simple to apply and can be an essential procedure for conventional methods of deflectometry system alignment.

Gene therapy for cystic fibrosis: new tools for precision medicine

The discovery of the Cystic fibrosis (CF) gene in 1989 has paved the way for incredible progress in treating the disease such that the mean survival age of individuals living with CF is now ~58 years in Canada. Recent developments in gene targeting tools and new cell and animal models have re-ignited the search for a permanent genetic cure for all CF. In this review, we highlight some of the more recent gene therapy approaches as well as new models that will provide insight into personalized therapies for CF.

A Developmental Role of the Cystic Fibrosis Transmembrane Conductance Regulator in Cystic Fibrosis Lung Disease Pathogenesis

The cystic fibrosis (CF) transmembrane conductance regulator (CFTR) protein is a cAMP-activated anion channel that is critical for regulating fluid and ion transport across the epithelium. This process is disrupted in CF epithelia, and patients harbouring CF-causing mutations experience reduced lung function as a result, associated with the increased rate of mortality. Much progress has been made in CF research leading to treatments that improve CFTR function, including small molecule modulators. However, clinical outcomes are not necessarily mutation-specific as individuals harboring the same genetic mutation may present with varying disease manifestations and responses to therapy. This suggests that the CFTR protein may have alternative functions that remain under-appreciated and yet can impact disease. In this mini review, we highlight some notable research implicating an important role of CFTR protein during early lung development and how mutant CFTR proteins may impact CF airway disease pathogenesis. We also discuss recent novel cell and animal models that can now be used to identify a developmental cause of CF lung disease.

1425 Surgical Management of a Long-Standing Temporomandibular Joint Dislocation: A Case Report

Background

Temporomandibular joint (TMJ) dislocation is a common presentation to Oral & Maxillofacial Surgery. In most cases, the condylar head is displaced anterior to the articular eminence and can be relocated by closed reduction. Severe dislocation into the infratemporal fossa is uncommon. Long-standing dislocation is rare and makes closed reduction difficult to achieve.

Presentation

A 60-year-old female presented to the outpatient clinic with long-standing bilateral TMJ dislocation which onset months prior following a seizure. Both condylar heads could be palpated superior to the zygomatic arches and could not be reduced under local anaesthetic. Mandibular range of movement was severely limited and creating an oral seal was not possible, affecting speech function. There was a history of discomfort and declining oral intake. Computed tomography revealed both condyles were displaced into the infratemporal fossa.

Management

The patient and family expressed a desire to avoid risk of damage to the facial nerve and therefore surgery was limited to an intra-oral approach only. Closed reduction was impossible due to the degree of muscle fibrosis present. Bilateral coronoidectomies were performed under a short general anaesthetic which immediately improved range of movement. Full articulation and occlusion were achieved by performing bilateral condylotomies.

Outcome

The patient was reviewed by video consultation 2 weeks later and had recovered well. They reported good masticatory function and improved dietary intake. No additional physiotherapy or surgical input was required, and they have been discharged from further review.

Discrepancies in response and immune-related adverse events (irAE) of anti-PD-1 monotherapy between races and primary sites in patients (pts) with advanced nonacral cutaneous melanoma (NACM)

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Background: Ultraviolet (UV)-induced high tumor mutation burden (TMB) of NACM is associated with response to anti-PD-1 monotherapy (aPD-1). Anatomic location of the primary lesion (reflecting UV exposure) and race (reflecting eumelanin level) may serve as surrogates for TMB and be associated with varying response and irAE patterns. Methods: Pts with advanced NACM receiving aPD-1 between 2009-2019 were retrospectively analyzed from 5 institutions in the US, Australia and China. Best response, survival (PFS and OS), and organ/system-specific irAEs were compared by race (Caucasian [C] vs non-Caucasian [NC]) and primary anatomic site. Results: Among 697 patients, 616 were C, 81 were NC. Complete response rate (CRR) was 24.8% (95%CI, 21.4-28.4) and 2.6% (95%CI, 0.3-9.1) and ORR was 54.9% (95%CI, 50.9-58.9) and 15.6% (95%CI, 8.3-25.6) in C and NC, respectively (both P<.001). Median PFS was 16.5 (95%CI, 12.0-23.1) and 5.2 (95%CI, 3.6-7.6) months, median OS was 60.5 (95%CI, 49.9-not reached [NR]) and 29.2 (95%CI, 17.9-NR) months, in C and NC, respectively (P<.001 and =.04). In multivariate analyses, C had significantly higher CRR (OR 13.4, 95%CI 3.1-57.4), ORR (OR 10.6, 95%CI 4.6-24.5), and longer PFS (HR 0.5, 95%CI 0.4-0.7) than NC. Compared to a head primary site, NACM from less UV-exposed regions had significantly lower CRR (upper trunk, OR 0.6, 95%CI 0.4-0.96; lower limb, OR 0.5, 95%CI 0.2-0.9), ORR (lower limb, OR 0.6, 95%CI 0.3-0.9) and poorer PFS (perineum/buttock, HR 2.1, 95%CI 1.2-3.5; lower limb, HR 1.6, 95%CI 1.2-2.2) and OS (perineum/buttock, HR 3.8, 95%CI 2.2-6.8; lower limb, HR 1.7, 95%CI 1.2-2.4). Overall irAE incidence was similar between C and NC but irAE subtypes varied. C had significantly higher incidence of GI (12.2%, 95%CI 9.5-15.3% vs 1.2%, 95%CI, 0.03-6.7%, P=.001), respiratory (10.3%, 95%CI 7.8-13.2% vs 0, P<.001) and grade 3/4 (15.4%, 95%CI 12.4-18.8% vs 6.2%, 95%CI 2.0-13.8%, P=.03) irAEs; and lower incidence of endocrine (13.8%, 95%CI 10.9-17.0% vs 32.1%, 95%CI 22.2-43.4%, P<.001) and liver (4.8%, 95%CI 3.2-7.1% vs 13.6%, 95%CI, 7.0-23.0%, P=.005) irAEs. IrAEs did not vary by primary NACM site. Conclusions: Race and primary site are independently correlated with distinct response and survival outcomes in pts with advanced NACM receiving aPD-1. IrAE subtypes vary by race although overall irAE incidence does not.

Occupational performance issues in older adults with subjective cognitive decline

PURPOSE

To describe and categorize difficulties in daily activities of older adults with subjective cognitive decline (SCD) compared to individuals with mild cognitive impairment (MCI).

METHODS

Deductive quantitative content analysis was used to classify reported issues in the performance of meaningful daily activities, in older adults with SCD (n = 67; age= 70 ± 6.3) or MCI (n = 42; age= 72 ± 6.6). The occupational performance issues were identified using the Canadian Occupational Performance Measure, a semi-structured interview, and categorised using the International Classification of Functioning, Disability and Health (ICF).

RESULTS

Both groups identified issues in all nine ICF "Activities and Participation" domains, with no significant group effects on seven of them. The most frequently affected "Activities and Participation" domains in both groups were "Self-care" (e.g. exercise and diet); "Community, social and civic life" (e.g. social-leisure activities); and "General tasks and demands" (e.g. time management). Over 90% of the issues in both groups were described in the context of difficulties in "Mental functions" (e.g. memory and higher-level cognitive functions).

CONCLUSIONS

Older adults with SCD, although independent, identified a variety of daily activities that they are not performing satisfactorily, remarkably similar in nature to the occupational performance issues described by older adults with MCI.Implications for RehabilitationOlder adults with SCD identified difficulties in performing social and leisure activities, maintaining healthy lifestyle behaviours, and managing multiple daily tasks.The daily challenges described by older adults with SCD are similar in nature to those identified by those with MCI.Older adults with SCD and MCI describe their daily challenges are related not only to memory problems, but also to executive dysfunction.Interventions for older adults with SCD should aim to improve self-identified problems in everyday functioning.

Advances in reconfigurable optical design, metrology, characterization, and data analysis

Reconfigurable freeform optical systems greatly enhance imaging performance within non-symmetric, compact, and ergonomic form factors. In this paper, several advances improve design, testing, and monitoring of these systems. Specific enhancements include definition of polynomials for fast and efficient parameterizations of vector distributions in non-circular apertures and merit based function optimization. Deflectometry system improvements enable metrology for almost any conceivable optic shape and guide deterministic optical figuring process during the coarse grinding phase by including modulated infrared sources. As a demonstration of these improvements, parametric optimization is tested with the tomographic ionized-carbon mapping experiment, a reconfigurable optical system. Other case studies and demonstrations include metrology of a fast, f/1.26 convex optic, an Alvarez lens, and real-time monitoring of an array of independently-steerable hexagonal mirror segments as well as an induction formed surface and inflatable Mylar mirror.

Calcium channel blocker induced gingival enlargement following implant placement in a fibula free flap reconstruction of the mandible: a case report

Background

Gingival tissue enlargement is a common side effect of antiepileptic medications (e.g. phenytoin and sodium valproate), immunosuppressing drugs (e.g. cyclosporine) and calcium channel blockers (e.g. nifedipine, verapamil, amlodipine) (Murakami et al. 2018, Clin Periodontol 45:S17–S27, 2018). The clinical and histological appearances of lesions caused by these drugs are indistinguishable from one another (Murakami et al. 2018, Clin Periodontol 45:S17–S27, 2018). Drug-induced gingival enlargement is rarely seen in edentulous patients.

Case presentation

This case presents a 72-year-old female with a history of squamous cell carcinoma of the floor of the mouth treated with surgical excision and fibula-free flap reconstruction. Following the uncovering of osseointegrated implants placed in the fibular-free flap, the patient developed gingival enlargement of the floor of the mouth. Cessation of amlodipine and switching to an alternative medication lead to a resolution of the enlarged tissue.

Conclusions

This case illustrates that gingival enlargement can occur around dental implants, most notably in rehabilitation cases in patients who have had head and neck cancer. Clinicians should be aware of the risk of gingival enlargement in hypertensive patients taking calcium channel blockers prior to implant placement.

Survivorship in immune therapy: Assessing toxicities, body composition and health-related quality of life among long-term survivors treated with antibodies to programmed death-1 receptor and its ligand

AIM

Antibodies to programmed death-1 receptor and its ligand (anti-PD-1/PD-L1) produce durable responses in many cancers. However, the long-term effects of anti-PD-1/PD-L1 blockade are not well defined. We identified the toxicities, health outcomes and health-related quality of life (HRQoL) amongst long-term survivors treated with anti-PD-1/PD-L1.

METHODS

We assessed 217 patients who received anti-PD-1/PD-L1 for melanoma, renal cell carcinoma or non-small-cell lung carcinoma between 2009 and 2017, with survival greater than two years after treatment. Patient and tumour characteristics, immune-related adverse events (irAEs), cardiometabolic parameters (glucose, blood pressure, body mass index [BMI]), body composition (using automated body composition analyser, computed tomography and Slice-o-matic software) and HRQoL outcomes were tracked.

RESULTS

Among the included patients, most were men (70.3%) and at anti-PD-1/PD-L1 initiation had an average age of 61.0 years and median BMI of 28.5. Median overall survival was not reached; 33 (15.2%) died during the follow-up primarily from progressive cancer (n = 28). At the last follow-up, most patients' Eastern Cooperative Oncology Group performance status was 0 (38%) or 1 (41%). There was no difference in blood pressure, glucose or BMI from baseline to two years after treatment initiation. Body composition showed increased adiposity (p = 0.05), skeletal muscle mass (p = 0.03) and skeletal muscle gauge (p = 0.04). We observed chronic irAEs at the last follow-up including hypothyroidism (10.6%), arthritis (3.2%), adrenal insufficiency (3.2%) and neuropathy (2.8%). New diagnoses of type 2 diabetes (6.5%) and hypertension (6.0%) were observed, with uncertain relationship to anti-PD-1/PD-L1. Patient-reported outcomes compared favourably with cancer and general populations, although younger age (p = 0.003) and need for subsequent therapy (p = 0.03) were associated with worse HRQoL outcomes.

CONCLUSION

Durable responses to anti-PD-1/PD-L1 therapy and favourable HRQoL outcomes are encouraging. Chronic events may be more common than previously thought although no clear chronic adverse cardiometabolic effects were observed.

Characterizing toxicities, body composition, and health-related quality of life (HRQoL) among long-term survivors treated with anti-PD-1

e15158

Background: Anti-PD-1 agents produce durable responses in many cancers. However, the long-term impact of PD-1 blockade in terms of chronic toxicities, medical comorbidities, and HRQoL are not well-defined. Methods: We assessed 217 patients (pts) who received anti-PD-1 for melanoma, renal cell carcinoma or non-small cell lung carcinoma, with survival of > 2 years after treatment. Pt and tumor characteristics, immune related adverse events (irAEs), cardiometabolic parameters, body composition measurements (BCM), and HRQoL outcomes were tracked. Results: Median overall survival (OS) was not reached; 33 (15.2%) died during follow-up primarily from progressive cancer (n = 28). Acute irAEs developed during treatment in 65% of pts, 45.2% were grade 1/2, 35.5% required steroids, and most commonly presented with dermatitis (18.4%), thyroiditis (12.9%), or arthritis (9.7%). At last follow up, most pts were ECOG 0 (38%) or 1 (41%). There was no difference in blood pressure, glucose, or weight from baseline to 2 years after treatment initiation. BCM showed increased adiposity (140.1 vs. 144 cm2/m2, p = 0.05), skeletal muscle mass (47.05 vs. 47.72 cm2/m2, p = 0.03), and skeletal muscle gauge (1653.9 vs. 1671 AU, p = 0.04). The most common chronic irAEs at last follow-up included hypothyroidism (10.6%), arthritis (3.2%), adrenal insufficiency (3.2%), neuropathy (2.8%), pneumonitis (1.8%), and type 1 diabetes (0.8%). No pts died from chronic irAEs although one pt had fatal CNS radiation necrosis (with unknown contribution of ICI). Chronic irAEs were more common in pts treated with ipilimumab/nivolumab (49%) vs. those with monotherapy (26%). New comorbidities included type 2 diabetes (6.5%) and hypertension (6.0%). HRQoL at 2 years compared favorably to cancer and general populations, although younger age (p < 0.01) and need for subsequent therapy (p = 0.03) were associated with worse HRQoL using Functional Assessment of Cancer-General questionnaire (FACT-G). Acute irAEs were associated with worse National Comprehensive Cancer Network distress scores (p = 0.019). Conclusions: Durable responses to anti-PD-1 therapy and favorable HRQoL outcomes are encouraging in this long-term survivor population. Chronic irAEs may be more common than previously thought although no clear chronic adverse cardiometabolic effects were observed.

Heterogeneous response and irAE patterns in advanced melanoma patients treated with anti-PD-1 monotherapy from different ethnic groups: Subtype distribution discrepancy and beyond

10020

Background: Programmed cell death receptor-1 (PD-1) monotherapy is the standard first line therapy for advanced cutaneous melanoma, with efficacy, toxicity, and their correlations well established. Yet these remain poorly characterized for non-Caucasians and for certain rarer melanoma subtypes. Methods: Clinical data from melanoma patients treated with anti-PD-1 monotherapy between 2009 and 2018 was collected retrospectively from three independent institutions from the US and China. Tumor response, survival outcome, and organ/system-specific immune-related adverse effects (irAEs) were directly compared between different subgroups. Results: Among 626 patients, 411 were Caucasian, 214 non-Caucasian; 369 had cutaneous melanoma, and 257 other subtypes. Both ethnicity and melanoma subtype were independently associated with benefit and irAEs. In multivariate analyses, Caucasians had significantly higher objective response rate (ORR) (OR 2.0, 95% CI 1.1-3.5), but this did not translate into a survival advantage (PFS, HR 0.8, 95% CI 0.6-1.1; OS, HR 1.0, 95% CI 0.7-1.4); melanoma of unknown primary shared similar response and survival profile with cutaneous, while acral (ORR, OR 0.4, 95% CI 0.2-0.9; PFS, HR 1.6, 95% CI 1.1-2.2; OS, HR 1.3, 95% CI 0.8-1.9), mucosal (ORR, OR 0.4, 95% CI 0.2-0.9; PFS, HR 1.4, 95% CI 1.0-2.0; OS, HR 1.7, 95% CI 1.1-2.6) and ocular (ORR, OR 0.1, 95% CI 0-0.6; PFS, HR 2.3, 95% CI 1.4-3.6; OS, HR 2.2, 95% CI 1.3-3.6) melanomas had inferior outcomes. Non-Caucasian cutaneous patients had a significantly worse ORR than Caucasians with cutaneous melanoma (P < .01). Distinct irAE patterns were observed, exemplified by lower incidence of most irAEs (although more frequent pneumonitis) in Caucasians, and higher and lower liver irAE incidence in ocular and mucosal melanomas, respectively. Endocrine, musculoskeletal and skin irAEs were associated with improved PFS and OS across ethnicities and nearly all melanoma subtypes, whereas heterogeneity existed for other irAE types. Conclusions: Ethnicity and melanoma subtype are associated with distinct response patterns, survival outcomes, and irAE profiles in the setting of anti-PD-1 monotherapy. More research is needed to elucidate the molecular and immunologic determinants of these variable outcomes.

Disruptive space telescope concepts, designs, and developments: OASIS and Nautilus -INVITED

Two disruptive space telescope concepts are being designed and developed at the University of Arizona; these are the 20-meter OASIS (Orbiting Astronomical Satellite for Investigating Stellar Systems) and 8.5-meter Nautilus. OASIS combines break-through inflatable aperture and adaptive optics techniques to realize the dream of a 20+ meter class spaceborne terahertz/far-infrared telescope. In the Nautilus visible/near-infrared telescope concept, conventional primary mirrors are replaced by an ~8.5-meter MODE (Multi-order diffractive engineered) lens with 10 times lower areal density and up to 100 times lower mis-alignment sensitivity over traditional systems, enabling large-diameter optical space telescopes. The OASIS and Nautilus concepts have the potential to greatly reduce mission costs and risks compared to the current state of the art.

High contrast thermal deflectometry using long-wave infrared time modulated integrating cavity source

We introduce a scalable temporally modulated long-wave infrared source design. The design makes use of an array of resistive blackbody heating elements which radiate into a custom aluminum integrating cavity. The output of the box is a rectangular slit, built to match the traditional tungsten ribbon profile for an infrared deflectometry source. Temporal modulation allows for signal isolation and improved resilience to background fluctuations in an infrared deflectometry source. Infrared deflectometry measurements using the new source design and a traditional tungsten ribbon, both with similar radiant flux, were compared for a ground glass surface, an aluminum blank, and an aluminum blank under thermal load (150 °C). Signal-to-noise ratio was ∼4 times higher for the new design and demonstrated improved source temporal stability and geometry. Further, the new design successfully measured the previously untestable hot aluminum flat. The new design improves infrared deflectometry and allows for high contrast thermal deflectometry measurements of optics under thermal load.

Infinite deflectometry enabling 2π-steradian measurement range

We present a novel deflectometry implementation termed Infinite Deflectometry. The technique provides a full aperture surface reconstruction sag map of freeform surfaces, including previously challenging to measure optics such as highly convex surfaces. The method relies on the creation of a virtual source enclosure around the tested optic, which creates a virtual 2π-steradian measurement range. To demonstrate the performance, a fast f/1.26 convex optical surface was measured with a commercial interferometer and with the Infinite Deflectometry system. After removing Zernike terms 1 through 37, the metrology tests resulted in absolute RMS surface values of 18.48 nm and 16.26 nm, respectively. Additionally, a freeform Alvarez lens was measured with the new technique and measured 22.34 𝜇m of surface sag RMS after piston, tip/tilt, and defocus had been removed. The result deviated by 488 nm RMS from a profilometer measurement while standard interferometry failed to measure the Alvarez lens due to its non-nulled wavefront dynamic range limitation.

The motivation and actions of Australians concerning brain health and dementia risk reduction

ISSUE ADDRESSED

Alzheimer's disease and dementia are recognised as critical public health priorities. This study investigated intentions and behaviours concerning brain health and dementia risk reduction among Australians.

METHODS

A cross-sectional survey of 1000 persons aged 20-75 years measured knowledge, beliefs, intentions and behaviours concerning brain health and dementia. The demographic, experiential and cognitive factors associated with intentions and actions were examined.

RESULTS

Around half of respondents were motivated to improve brain health. Behaviours most often reported were mental activity (19%), physical activity (9.6%) and dietary action (6.5%). Actions were most likely among women (OR 1.59, 95% CI 1.19-2.14), those aged 60 years and over (OR 3.07, 95% CI 2.01-2.58), with university education (OR 1.67, 95% CI 1.08-2.58) or with prior contact with a person with dementia (OR 1.99, 95% CI 1.12-3.56). Both intentions and actions were associated with moderate to high knowledge, and beliefs and confidence that favoured dementia risk reduction.

CONCLUSIONS

A lower proportion of Australians reported taking action to improve brain health than who expressed intentions in this regard. Strategies are needed to improve knowledge about the range of behaviours that contribute to dementia risk reduction and to increase confidence that this outcome is personally achievable. SO WHAT? The burden of disease due to Alzheimer's disease and dementia is growing dramatically. It is essential to promote awareness that dementia is not an inevitable result of ageing and to increase understanding that action can be taken throughout the life course to promote brain health.

Management of systemic AL amyloidosis: recommendations of the Myeloma Foundation of Australia Medical and Scientific Advisory Group

Systemic AL amyloidosis is a plasma cell dyscrasia with a characteristic clinical phenotype caused by multi-organ deposition of an amyloidogenic monoclonal protein. This condition poses a unique management challenge due to the complexity of the clinical presentation and the narrow therapeutic window of available therapies. Improved appreciation of the need for risk stratification, standardised use of sensitive laboratory testing for monitoring disease response, vigilant supportive care and the availability of newer agents with more favourable toxicity profiles have contributed to the improvement in treatment-related mortality and overall survival seen over the past decade. Nonetheless, with respect to the optimal management approach, there is a paucity of high-level clinical evidence due to the rarity of the disease, and enrollment in clinical trials is still the preferred approach where available. This review will summarise the Clinical Practice Guidelines on the Management of Systemic Light Chain (AL) Amyloidosis recently prepared by the Medical Scientific Advisory Group of the Myeloma Foundation of Australia. It is hoped that these guidelines will assist clinicians in better understanding and optimising the management of this difficult disease.

Public knowledge and beliefs about dementia risk reduction: a national survey of Australians

Background

With the dramatically increasing contribution of Alzheimer’s Disease and other forms of dementia to the global burden of disease, countries are being urged to address this as a public health priority. This study investigated whether Australian adults recognise this as an important health issue, and hold beliefs and knowledge that are consistent with recommendations concerning dementia risk reduction. This research was undertaken to guide national brain health awareness and education strategies.

Methods

A cross-sectional telephone survey was undertaken of 1,003 Australians aged 20–75 years. This measured the importance placed on dementia, beliefs and confidence related to risk reduction, knowledge of risk reduction methods, and the perceived age-relevance of these. In analysis the data were stratified by sex, age, educational attainment, household income, language preference and previous exposure to dementia. Multivariable logistic regression was undertaken to identify variables independently associated with beliefs and knowledge.

Results

People aged 60 years and over identified dementia as very important (17.2%) more often than those aged 40–59 years (5.1%) or 20–39 years (2.1%). While 41.5% of respondents believed the risk of dementia could be reduced, 26.9% were very confident that they could achieve this. Mental activity (57.1%) was identified as beneficial much more often than physical activity (31.3%), healthy eating (23.3%) and other cardiovascular health behaviours. Women, people of English-speaking origin, and those having contact with a person with dementia, showed better knowledge of several health behaviours.

Conclusions

Growing attention is being given to population risk reduction to combat the dramatic increase in the burden of disease due to dementia. In Australia many people do not yet hold beliefs and knowledge that support this, which highlights the need for concerted awareness raising that dementia is not an inevitable aspect of ageing, and for education about the role of vascular health in dementia risk reduction.

Natural killer T cell defects in multiple myeloma and the impact of lenalidomide therapy

The causes of multiple myeloma (MM) remain obscure and there are few known risk factors; however, natural killer T (NKT) cell abnormalities have been reported in patients with MM, and therapeutic targeting of NKT cells is promoted as a potential treatment. We characterized NKT cell defects in treated and untreated patients with MM and determined the impact of lenalidomide therapy on the NKT cell pool. Lenalidomide is an immunomodulatory drug with co-stimulatory effects on NKT cells in vitro and is an approved treatment for MM, although its mode of action in that context is not well defined. We find that patients with relapsed/progressive MM had a marked deficiency in NKT cell numbers. In contrast, newly diagnosed patients had relatively normal NKT cell frequency and function prior to treatment, although a specific NKT cell deficiency emerged after high-dose melphalan and autologous stem cell transplantation (ASCT) regimen. This also impacted NK cells and conventional T cells, but the recovery of NKT cells was considerably delayed, resulting in a prolonged, treatment-induced NKT cell deficit. Longitudinal analysis of individual patients revealed that lenalidomide therapy had no in-vivo impact on NKT cell numbers or cytokine production, either as induction therapy, or as maintenance therapy following ASCT, indicating that its clinical benefits in this setting are independent of NKT cell modulation.

Testing the NKT cell hypothesis in lenalidomide-treated myelodysplastic syndrome patients

Myelodysplastic syndrome (MDS) comprises a group of clonal bone marrow disorders characterized by ineffective hematopoiesis and increased predisposition to acute myeloid leukemia. The causes of MDS remain poorly defined, but several studies have reported the NKT cell compartment of patients with MDS is deficient in number and functionally defective. In support of a central role for NKT cells, a pilot clinical study reported that lenalidomide (an approved treatment for MDS) increased NKT cell numbers in patients with MDS, and several in vitro studies showed lenalidomide specifically promoted NKT cell proliferation and cytokine production. We tested this in a much larger study and confirm a moderate in vitro augmentation of some NKT cell functions by lenalidomide, but find no impact on the NKT cell compartment of patients treated with lenalidomide, despite a consistently positive clinical response. We further show that the frequency and cytokine production of NKT cells is normal in patients with MDS before treatment and remains stable throughout 10 months of lenalidomide therapy. Collectively, our data challenge the concept that NKT cell defects contribute to the development of MDS, and show that a clinical response to lenalidomide is not dependent on modulation of NKT cell frequency or function.

Safety and efficacy results from an international expanded access programme to bortezomib for patients with relapsed and/or refractory multiple myeloma: a subset analysis of the Australian and New Zealand data of 111 patients

BACKGROUND

Bortezomib has been shown to be a safe and efficacious for the treatment of relapsed and refractory multiple myeloma (MM). Here we report a subset analysis of Australian and New Zealand data from the International Extended Access Programme for bortezomib.

METHODS

Patients with more than or equal to two prior lines of therapy were given bortezomib 1.3 mg/m(2) (i.v. bolus days 1, 4, 8, 11) for up to eight 21-day cycles (C). Dexamethasone, 20 mg/day p. o. on the day of, and day after, bortezomib was added after C2 for progressive disease or after C4 for stable disease. Efficacy was assessed using modified Southwest Oncology Group criteria in the intent-to-treat group. Results were compared between the Australian and New Zealand and international cohort.

RESULTS

One hundred and eleven patients from 16 centres (55% men, median age 61.9 years) had a median of 5.2 +/- 2.8 treatment cycles of bortezomib. Among them, 82% had > or =3 prior therapies. Grade 3-4 treatment-related adverse events were reported in 57 patients (52%); the most common were thrombocytopenia (25.7%), anaemia (8.3%), peripheral neuropathy (7.3%) and diarrhoea (7.3%). Responses were evaluable in 106 patients: 22% achieved a best response of complete response/response and 20% partial response (overall response rate of 42%). Median times to first and best responses were 42 days and 69 days, respectively. Compared with the international cohort, the cohorts from Australian and New Zealand showed inferior overall response rates (54 vs 42%, P = 0.001), possibly due to heavier pretreatment (82% greater than or equal to three prior therapies vs 68%, P < 0.001).

CONCLUSION

Our analysis confirms that bortezomib is safe and effective in relapsed and refractory MM in a real-life clinical setting.

Maternal transmission disequilibrium of the glutamate receptor GRIK2 in schizophrenia

Schizophrenia is characterized by thought disorders, hallucinations and delusions. Genetic studies have shown a high linkage at chromosome 6q16-21. Among the genes located in this region is the glutamate receptor ionotropic kainate 2 gene (GRIK2 or GLUR6), a functional candidate for susceptibility to schizophrenia. In this study, transmission of GRIK2 was evaluated in 356 schizophrenic patients from three different clinical centers. Whereas paternal transmission shows equilibrium, we observed maternal transmission disequilibrium of GRIK2 in the largest population (p=0.03), which was still significant when all populations were added (p=0.05). These results are similar to the maternal GRIK2 transmission disequilibrium previously reported for autism, and support the presence of a susceptibility gene for schizophrenia at 6q16.

Transduction of the human gene FAM8A1 by endogenous retrovirus during primate evolution

Capture of cellular mRNA by mobile elements has been an evolutionary catalyst for the spread of genes and a cause of cancer development. Here we present evidence that an orphan gene, FAM8A1 (family with sequence similarity 8), was captured by a retrovirus, followed by multiple retrotransposition events, during primate evolution between 45 and 58 million years ago. This represents the first record of cellular mRNA transduction in humans. The human gene is localized on chromosome 6p23 with five related pseudogenes (FAM8A2P-A6P), each inserted within a human endogenous retrovirus (HERV). Only the functional FAM8A1 gene is expressed and displays a ubiquitous mRNA and a testis-specific transcript present in the haploid phase of spermatogenesis. The structural features of the FAM8A1 pseudogenes include two short sequences of similarity between the FAM8A1 mRNA and the HERV sequences at both the 5' and 3' integration sites. These hallmarks suggest an alternative model to account for the capture of FAM8A1 cellular mRNA by HERV-K, involving illegitimate recombination events at the two sites of sequence similarity during reverse transcription. Unlike previous models, which assume at least one step of retroviral integration in the genome, our model is consistent with in vitro observations showing that multiple template switches occur among packaged viral transcripts. This leads to the speculation that, in some cases, cellular mRNAs may have been captured through similar processes involved in the retroviral life cycle.

Identification of the human KIF13A gene homologous to Drosophila kinesin-73 and candidate for schizophrenia

Several studies have reported significant linkage for schizophrenia on 6p23, with a maximum lod score between D6S274 and D6S285. In this paper, we present a new human kinesin gene localized in this 2-cM interval. This gene, termed KIF13A, belongs to the unc-104/KIF1A kinesin subfamily and represents the orthologue of Drosophila kinesin-73. Several alternative transcripts are differentially expressed in human tissues, probably reflecting differences in cargo binding and transport of corresponding proteins. During early mouse development, its homologue (Kif13A) is expressed essentially in the central nervous system. In Caenorhabditis elegans, the unc-104 gene is involved in axonal anterograde transport, and null mutants present several behavioral defects. The putative function and genomic localization of KIF13A make this gene an interesting candidate for genetic predisposition to schizophrenia. We provide sequences of 20 single-nucleotide polymorphisms localized within KIF13A to test for association studies between this gene and schizophrenia.

Neonatal jitteriness of unknown origin and circulating catecholamines

Jitteriness is a common problem affecting neonates. Although the cause can sometimes be determined by history or conventional laboratory evaluations, nevertheless, in many instances the cause of the jitteriness is unknown. To determine if either intracranial hemorrhage (ICH) or elevated catecholamines are responsible for jitteriness in neonates, we studied 34 healthy term neonates with normal hematocrits, serum glucose, Ca, Mg, Na, K and P. Thirteen of the infants had jitteriness as their only clinical problem. There were no differences in Apgar scores, birthweight, or gestational age in the two groups. Norepinephrine levels were significantly elevated in the jittery group as compared to the control group: 1276 +/- 574 vs. 914 +/- 338, p less than 0.05. Epinephrine levels were not different in the two groups. Intracranial hemorrhage was not found in any of the patients. Jittery neonates have increased sympathetic activity. What influence the increased levels have on other metabolic and hormonal systems is yet to be determined.