The effect of type 2 diabetes and diabetic peripheral neuropathy on predictive grip force control

This study investigated the impact of type 2 diabetes and diabetic peripheral neuropathy on grip force control during object manipulation. The study included three age-matched groups: type 2 diabetes alone (n = 11), type 2 diabetes with neuropathy (n = 13), and healthy controls (n = 12). Grip force control variables derived from lifting and holding an experimental cup were the ratio between grip force and load forces during lifting (GFR), latency 1 and latency 2, which represented the time between the object's grip and its lift-off from the table, and the period between object's lift-off and the grip force peak, respectively; time lag, which denoted the time difference between the grip and load force peaks during the lifting phase, and finally static force, which was the grip force average during the holding phase. Grip force control variables were compared between groups using one-way ANOVA and Kruskal-Wallis test. Post-hoc analysis was used to compare differences between groups. GFR and latency 1 showed significant differences between groups; the type 2 diabetes with neuropathy group showed larger GFR than the type 2 diabetes alone and healthy control groups. The latency 1was longer for the group with neuropathy in comparison with the health control group. There were no significant differences between groups for latency 2, time lag, and static force. Our results showed impaired GFR and latency 1 in participants with type 2 diabetes with neuropathy while the time lag was preserved. People with type 2 diabetes alone might not have any deficits in grip force control. Higher grip forces might expose people with type 2 diabetes and diabetic peripheral neuropathy to the risk of fatigue and injuring their hands. Future studies should investigate strategies to help people with type 2 diabetes with neuropathy adjust grip forces during object manipulation.

Racial differences in serum chemokines in prostate cancer patients

BACKGROUND

This study aimed to understand the differential levels of inflammatory chemokines in association with higher prostate cancer incidence and mortality in African American (AA) men than in Caucasians (CA).

METHODS

The authors used a chemokine assay to simultaneously measure 40 chemokines and cytokines levels in the serum of preoperative prostate cancer patients and healthy controls of AA and CA races. Selected chemokines (CXCL2, CXCL5, and CCL23) serum level was validated in 211 serum samples from prostate cancer patients and healthy controls. Differential expression of CXCL5 and CCL23 was analyzed using immunohistochemistry in a representative cohort of prostate tumor tissues of AA and CA races.

RESULTS

Race-specific comparisons from 211 serum samples showed significantly higher levels of CXCL2 (control: 3104.0 pg/mL vs. cancer: 2451.0 pg/mL) and CXCL5 (control: 5189.0 pg/mL vs. cancer: 5459.0 pg/mL) in AA men than in CAs (CXCL2; control: 1155.0 pg/mL vs. cancer: 889.3 pg/mL, and CXCL5; control: 1183.0 pg/mL vs. cancer: 977.5 pg/mL). CCL23 differed significantly within and between the races with a lower level in AA cancer cases (454.5 vs. 966.6 pg/mL) than healthy controls (740.5 vs. 1263.0 pg/mL). Patient age, prostate-specific antigen, or Gleason scores were not significantly associated with these chemokines. Immunostaining for CXCL5 and CCL23 in a representative cohort of archival prostate tissues displayed significantly higher CXCL5 in prostate tumors than in adjacent benign tissues, whereas CCL23 was nondetectable in most of the analyzed tumor tissues.

CONCLUSION

Lower levels of CCL23 in AA prostate cancer patient sera and tumor tissues and high CXCL2 and CXCL5 may contribute to aggressive prostate cancer, as often seen in AA men. The disproportionate levels of serum chemokines associated with race warrant further exploration to improve equitability in precision oncology to benefit prostate cancer patients.

Career disruption and limitation of financial earnings due to cancer

PURPOSE

This study investigated how cancer diagnosis and treatment lead to career disruption and, consequently, loss of income and depletion of savings.

DESIGN

This study followed a qualitative descriptive design that allowed us to understand the characteristics and trends of the participants.

METHOD

Patients recruited (n = 20) for this study were part of the University of Kansas Cancer Center patient advocacy research group (Patient and Investigator Voices Organizing Together). The inclusion criteria were that participants must be cancer survivors or co-survivors, be aged 18 years or older, be either employed or a student at the time of cancer diagnosis, have completed their cancer treatment, and be in remission. The responses were transcribed and coded inductively to identify themes. A thematic network was constructed based on those themes, allowing us to explore and describe the intricacies of the various themes and their impacts.

RESULTS

Most patients had to quit their jobs or take extended absences from work to handle treatment challenges. Patients employed by the same employer for longer durations had the most flexibility to balance their time between cancer treatment and work. Essential, actionable items suggested by the cancer survivors included disseminating information about coping with financial burdens and ensuring that a nurse and financial navigator were assigned to every cancer patient.

CONCLUSIONS

Career disruption is common among cancer patients, and the financial burden due to their career trajectory is irreparable. The financial burden is more prominent in younger cancer patients and creates a cascading effect that financially affects close family members.

Evaluating Work Impairment as a Source of Financial Toxicity in Cancer Healthcare and Negative Impacts on Health Status

How the socioeconomic factors intersect for a particular patient can determine their susceptibility to financial toxicity, what costs they will encounter during treatment, the type and quality of their care, and the potential work impairments they face. The primary goal of this study was to evaluate financial factors leading to worsening health outcomes by the cancer subtype. A logistic model predicting worsening health outcomes while assessing the most influential economic factors was constructed by the University of Michigan Health and Retirement Study. A forward stepwise regression procedure was implemented to identify the social risk factors that impact health status. Stepwise regression was done on data subsets based on the cancer types of lung, breast, prostate, and colon cancer to determine whether significant predictors of worsening health status were different or the same across cancer types. Independent covariate analysis was also conducted to cross-validate our model. On the basis of the model fit statistics, the two-factor model has the best fit, that is, the lowest AIC among potential models of 3270.56, percent concordance of 64.7, and a C-statistics of 0.65. The two-factor model used work impairment and out-of-pocket costs, significantly contributing to worsening health outcomes. Covariate analysis demonstrated that younger patients with cancer experienced more financial burdens leading to worsening health outcomes than elderly patients aged 65 years and above. Work impairment and high out-of-pocket costs were significantly associated with worsening health outcomes among cancer patients. Matching the participants who need the most financial help with appropriate resources is essential to mitigate the financial burden.

Significance

Among patients with cancer, work impairment and out-of-pocket are the two primary factors contributing to adverse health outcomes. Women, African American or other races, the Hispanic population, and younger individuals have encountered higher work impairment and out-of-pocket costs due to cancer than their counterparts.

Financial burden among cancer patients: A national-level perspective

BACKGROUND

This research study aimed to evaluate the financial burden among older cancer patients and its corresponding risk factors. Factors such as increasing treatment costs and work limitations often lead cancer patients to bankruptcy and poor quality of life. These consequences, in turn, can cause higher mortality rates among these patients.

METHODS

This retrospective cohort study utilized data from the Health Retirement Study (HRS), conducted by the University of Michigan (N = 18,109). Eligible participants had responses captured from years 2002 to 2016. Participants were classified according to any self-reported cancer diagnosis (yes or no) and were compared on the basis of financial, work, and health-related outcomes. Propensity score (PS) matching was applied to reduce the effects of potential confounding factors. Also only, individuals with an age ≥50 and ≤85 during Wave 6 were retained.

RESULTS

Multivariate analysis with random effects revealed several indicators of financial burden when comparing participants with a cancer diagnosis to those with no history of cancer. Mean out-of-pocket costs associated with a cancer diagnosis were $1058 higher when compared to participants with no history of cancer, suggesting that even cancer patients with insurance coverage faced out-of-pocket costs. Respondents with cancer patients had higher odds of encountering financial hardship if they are facing Work Limitations (OR = 2.714), Regular use of Medications (OR = 2.518), Hospital Stays (OR = 2.858), Declining Health (OR = 2.349), or were being covered under government health insurance (OR = 5.803) than respondents who did not have cancer, or suffered from mental health issues such as Depression (OR = 0.901).

CONCLUSION

Cancer patients contend with increasing financial costs during their treatment. However, most newly diagnosed patients are not aware of these costs and are given few resources to handle them.

Online Infectious Diseases Subspecialty Supplementary Curriculum for Medical Students and Residents: Moving Beyond "You Get What You Get"

OBJECTIVES

Students and residents rotating through infectious diseases (ID) electives are instructed primarily by participation in rounds and clinics, with teaching focused on diseases encountered. This "you get what you get" approach allows learners to apply knowledge directly to patient care, however, may miss topics encountered in standardized testing. This multisite study investigates the use of asynchronous web-based learning modules and its impact on student and resident knowledge.

METHODS

Students and residents rotating through an ID elective were assigned to their standard elective (old) or asked to complete asynchronous web-based learning modules in addition to the standard curriculum (new). Learners submitted pre- and post-tests and scores were tabulated. In the following academic year, learners at the host site were provided the learning modules and a post-elective survey.

RESULTS

Nine learners (100%) completed the pre-test and 5 (55.6%) completed the post-test in the standard (old) curriculum group, while 15 (100%) completed the pre-test and post-test in the new curriculum group. The mean percentage change in accuracy was 9% and 5.3% in the old and new curricula, respectively. Most (94%) survey respondents recommended continued use of the curriculum and expansion to other subspecialty electives.

CONCLUSIONS

Subspecialty electives have multiple purposes including assisting learners in exploring careers, providing a well-rounded medical experience, or preparing learners for content in standardized tests. Consistent curricula are not always provided with electives to supplement the clinical experience. Our web curriculum was well-received with perceived knowledge gain, though with very small pre-post-test groups a score improvement could not be determined. An asynchronous online curriculum for learners in ID was feasible and well-received among faculty, and learners felt their knowledge was enhanced. Content areas supplemented those encountered during the ID elective. While an improvement in post-test scores was not demonstrated, learners and faculty felt modules were beneficial.

Optimizing a Bayesian hierarchical adaptive platform trial design for stroke patients

BACKGROUND

Platform trials are well-known for their ability to investigate multiple arms on heterogeneous patient populations and their flexibility to add/drop treatment arms due to efficacy/lack of efficacy. Because of their complexity, it is important to develop highly optimized, transparent, and rigorous designs that are cost-efficient, offer high statistical power, maximize patient benefit, and are robust to changes over time.

METHODS

To address these needs, we present a Bayesian platform trial design based on a beta-binomial model for binary outcomes that uses three key strategies: (1) hierarchical modeling of subgroups within treatment arms that allows for borrowing of information across subgroups, (2) utilization of response-adaptive randomization (RAR) schemes that seek a tradeoff between statistical power and patient benefit, and (3) adjustment for potential drift over time. Motivated by a proposed clinical trial that aims to find the appropriate treatment for different subgroup populations of ischemic stroke patients, extensive simulation studies were performed to validate the approach, compare different allocation rules, and study the model operating characteristics.

RESULTS AND CONCLUSIONS

Our proposed approach achieved high statistical power and good patient benefit and was also robust against population drift over time. Our design provided a good balance between the strengths of both the traditional RAR scheme and fixed 1:1 allocation and may be a promising choice for dichotomous outcomes trials investigating multiple subgroups.

Atypical Ductal Hyperplasia on Percutaneous Breast Biopsy: Scoring System to Identify the Lowest Risk for Upgrade

Background: NCCN guidelines recommend surgical excision for patients with atypical ductal hyperplasia (ADH) on percutaneous biopsy. Improved imaging and biopsy techniques have lower contemporary upgrade rates, challenging standard practice. We sought to identify low-risk features of ADH to define patients who may benefit from active monitoring over surgical excision.Methods: A retrospective analysis identified 87 stereotactic biopsies diagnosing ADH undergoing surgical excision at a single institution from 01/2008 to 10/2015. Imaging was reviewed for lesion size and residual calcifications. Biopsy slides were reviewed for ADH features. Categorical variables were analyzed using Chi-square and Fisher’s exact tests; continuous variables with T- and Wilcoxon tests. Logistic regression model was used to determine the association between the number of low-risk features present and odds of upgrade.Results: Upgrade was identified in 13 cases (14.9%; 11 ductal carcinoma in situ and 2 invasive breast cancer). Low-risk imaging features included imaging size <1cm (P=0.004) and >50% removed by biopsy (P=0.03). The only significant low-risk pathologic feature was the lack of micropapillary features (P=0.10). Focal ADH (1-2 foci, P=0.12) was felt to be clinically significant. Those with the lowest risk of upgrade (0%) had all 4 low-risk features (n=17, 20%). When comparing biopsies that differed by one low-risk feature, the biopsy with one less low-risk feature present had 129% increase in odds of upgrade (exact OR=2.29, 95% CI 1.35, 4.15, P=0.001). Conclusion: Overall upgrade rate was low in this contemporary cohort. Patients at lowest risk for upgrade had all 4 low-risk features and could be safely offered active monitoring over surgical excision.

Unifying the analysis of continuous and categorical measures of weight loss and incorporating group effect: a secondary re-analysis of a large cluster randomized clinical trial using Bayesian approach

Background

Although frequentist paradigm has been the predominant approach to clinical studies for decades, some limitations associated with the frequentist null hypothesis significance testing have been recognized. Bayesian approaches can provide additional insights into data interpretation and inference by deriving posterior distributions of model parameters reflecting the clinical interest. In this article, we sought to demonstrate how Bayesian approaches can improve the data interpretation by reanalyzing the Rural Engagement in Primary Care for Optimizing Weight Reduction (REPOWER).

Methods

REPOWER is a cluster randomized clinical trial comparing three care delivery models: in-clinic individual visits, in-clinic group visits, and phone-based group visits. The primary endpoint was weight loss at 24 months and the secondary endpoints included the proportions of achieving 5 and 10% weight loss at 24 months. We reanalyzed the data using a three-level Bayesian hierarchical model. The posterior distributions of weight loss at 24 months for each arm were obtained using Hamiltonian Monte Carlo. We then estimated the probability of having a higher weight loss and the probability of having greater proportion achieving 5 and 10% weight loss between groups. Additionally, a four-level hierarchical model was used to assess the partially nested intervention group effect which was not investigated in the original REPOWER analyses.

Results

The Bayesian analyses estimated 99.5% probability that in-clinic group visits, compared with in-clinic individual visits, resulted in a higher percent weight loss (posterior mean difference: 1.8%[95% CrI: 0.5,3.2%]), a greater probability of achieving 5% threshold (posterior mean difference: 9.2% [95% CrI: 2.4, 16.0%]) and 10% threshold (posterior mean difference: 6.6% [95% CrI: 1.7, 11.5%]). The phone-based group visits had similar result. We also concluded that including intervention group did not impact model fit significantly.

Conclusions

We unified the analyses of continuous (the primary endpoint) and categorical measures (the secondary endpoints) of weight loss with one single Bayesian hierarchical model. This approach gained statistical power for the dichotomized endpoints by leveraging the information in the continuous data. Furthermore, the Bayesian analysis enabled additional insights into data interpretation and inference by providing posterior distributions for parameters of interest and posterior probabilities of different hypotheses that were not available with the frequentist approach.

Trial registration

ClinicalTrials.gov Identifier NCT02456636; date of registry: May 28, 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01499-0.

Bayesian EMAX model with a mixture of normal distributions for dose-response in clinical trials

When a dose-response relationship is monotonic, the EMAX model has been shown to provide a good empirical fit for designing and analyzing dose-response data across a wide range of pharmaceutical studies. However, the EMAX model has never been applied to a finite mixture distribution. Motivated by a proposal investigating DHA dose effect on preterm birth (PTB, <37 weeks gestation) rate, we developed a Bayesian EMAX mixture model incorporating the three normal components finite mixture model into the EMAX framework. The proposed Bayesian EMAX mixture model analyzes gestational age as a continuous variable, which allows for statistically efficient estimates of PTB rate using various cut point with the same parsimonious model. For example, we can estimate the rate of early PTB (ePTB, <34 weeks gestation), PTB (<37 weeks gestation), and late-term birth (>41 weeks gestation) using the same model. We compared our proposed EMAX mixture model with an EMAX logistic model and an independent doses logistic model for a dichotomized endpoint using extensive simulations. Across the scenarios under consideration, the EMAX mixture model achieved higher power than the EMAX logistic model and the independent doses logistic model in detecting the effect of DHA supplementation on the PTB rate. The EMAX mixture model also resulted in smaller mean squared errors (MSE) in PTB rate estimates.

A framework for personalized mammogram screening

Breast cancer screening guidelines serve as crucial evidence-based recommendations in deciding when to begin regular screenings. However, due to developments in breast cancer research and differences in research interpretation, screening guidelines can vary between organizations and within organizations over time. This leads to significant lapses in adopting updated guidelines, variable decision making between physicians, and unnecessary screening for low to moderate risk patients (Jacobson and Kadiyala, 2017; Corbelli et al., 2014). For analysis, risk factors were assessed for patient screening behaviors and results. The outcome variable for the first analysis was whether the patient had undergone screening. The risk factors considered were age, marital status, education level, rural versus urban residence, and family history of breast cancer. The outcome variable for the second analysis was whether patients who had undergone breast cancer screening presented abnormal results. The risk factors considered were age, Body Mass Index, family history, smoking and alcohol status, hormonal contraceptive use, Hormone Replacement Therapy use, age of first pregnancy, number of pregnancies (parity), age of first menses, rural versus urban residence, and whether or not patients had at least one child. Logistic regression analysis displayed strong associations for both outcome variables. Risk of screening nonattendance was negatively associated with age as a continuous variable, age as a dichotomous variable, being married, any college education, and family history. Risk of one or more abnormal mammogram findings was positively associated with family history, and hormonal contraceptive use. This procedure will be further developed to incorporate additional risk factors and refine the analysis of currently implemented risk factors.

A prenatal group based phone counseling intervention to improve breastfeeding rates and complementary feeding: a randomized, controlled pilot and feasibility trial

Background

Despite numerous benefits for both mom and baby, few infants are exclusively breastfed for the recommended first six months. Additionally, infants are given solids too early. Prenatal education increases rates of breastfeeding initiation and we hypothesize it can also improve exclusive breastfeeding rates and prevent the early introduction of solids. We conducted a randomized controlled pilot and feasibility trial to understand the feasibility and maternal acceptance of a prenatal behavioral lifestyle intervention (PBLI) delivered via group based phone counseling (GBPC) and its effectiveness on rates of exclusive breastfeeding up to six months postpartum. Secondary aims included rates of any breastfeeding up to six months, rates of early introduction of solids, and infant feeding progression.

Methods

Forty-one pregnant women were recruited from a Kansas City Metropolitan Obstetrics and Gynecology office and randomly assigned to a usual care group or a PBLI. Women in the PBLI participated in six GBPC sessions where they learned about breastfeeding and introducing solids. Feeding questionnaires to assess breastfeeding and introduction of solids were sent at two weeks, two months, four months, and six months postpartum. Structured interviews were also conducted after the intervention and at six months postpartum to assess maternal acceptance and intervention feasibility.

Results

Participants overwhelmingly found the intervention acceptable and beneficial.

Rates of exclusive breastfeeding and any breastfeeding did not differ between groups at any time point. No between group differences were found for early introduction of solids or infant feeding progression.

Conclusions

Mothers discontinue breastfeeding earlier than recommended despite high rates of initiation. A PBLI delivered via GBP is feasible, acceptable to participants, and showed positive impacts such as maternal empowerment for both breastfeeding and introducing solids. Future interventions should incorporate both prenatal and postpartum components.

Trial registration

Study protocols were approved by the University of Kansas Medical Center’s Human Subjects Committee (STUDY00140506) and registered at ClinicalTrials.gov on 02/22/2018 (NCT03442517, retrospectively registered). All participants gave written informed consent prior to data collection.

Restart TICrH: An Adaptive Randomized Trial of Time Intervals to Restart Direct Oral Anticoagulants after Traumatic Intracranial Hemorrhage

Anticoagulants prevent thrombosis and death in patients with atrial fibrillation and venous thromboembolism (VTE) but also increase bleeding risk. The benefit/risk ratio favors anticoagulation in most of these patients. However, some will have a bleeding complication, such as the common trip-and-fall brain injury in elderly patients that results in traumatic intracranial hemorrhage. Clinicians must then make the difficult decision about when to restart the anticoagulant. Restarting too early risks making the bleeding worse. Restarting too late risks thrombotic events such as ischemic stroke and VTE, the indications for anticoagulation in the first place. There are more data on restarting patients with spontaneous intracranial hemorrhage, which is very different than traumatic intracranial hemorrhage. Spontaneous intracranial hemorrhage increases the risk of rebleeding because intrinsic vascular changes are widespread and irreversible. In contrast, traumatic cases are caused by a blow to the head, usually an isolated event portending less future risk. Clinicians generally agree that anticoagulation should be restarted but disagree about when. This uncertainty leads to long restart delays causing a large, potentially preventable burden of strokes and VTE, which has been unaddressed because of the absence of high quality evidence. Restart Traumatic Intracranial Hemorrhage (the "r" distinguished intracranial from intracerebral) (TICrH) is a prospective randomized open label blinded end-point response-adaptive clinical trial that will evaluate the impact of delays to restarting direct oral anticoagulation (1, 2, or 4 weeks) on the composite of thrombotic events and bleeding in patients presenting after traumatic intracranial hemorrhage.

Non-cancer clinical trials start-up metrics at an academic medical center: Implications for advancing research

The primary goal for any clinical trial after it receives a funding notification is to receive regulatory approval and initiate the trial for recruitment. Every trial must go through documentation and regulatory process before it can start recruiting participants and collecting data; this initial process of review and approval is known as the study start-up process (SSU). We evaluated the average time taken for studies to receive approvals. Using data from clinical trials conducted at the University of Kansas Medical Center, various times to reach the start of the study were calculated based on the dates of individual study. The results of this analysis showed that chart review studies and investigator-initiated trials had a shorter time to activation than other types of studies. Additionally, single-center studies had a shorter activation time than multi-center studies. The analysis also demonstrated that the overall processing time consistently had been reduced over time.

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The 2018 year’s trend shows reduced time to study start.

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SSU process for non-cancer trial on an average requires four to six months.

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The activation time of the SSU process varied for different study types and scopes.

Abstract PS7-44: Energetics and lifestyle in inherited syndromes (ELLIE'S study)

Background: US women have a 1 in 8 lifetime chance of developing breast cancer (BC), with an estimated 10% resulting from a hereditary BC gene mutation. Individuals with mutations in genes such as BRCA1 and BRCA2 have an increased risk of breast and ovarian cancer, as well as other types of cancers. At present, there are more than a dozen other hereditary cancer related genetic mutations that have an associated moderate to high risk of developing cancer. Along with an ability to identify and characterize risk in individuals with a hereditary cancer mutation, there is a need to study modifiable factors such as dietary intake and physical activity in relation to an individual’s risk for cancer.

Obesity and poor physical fitness are independently associated with an increased risk of BC and recurrence. There is a paucity of data on the impact of BMI, obesity, and physical activity on primary and recurrent BC in genetic mutation carriers. Women with a moderate penetrance gene mutation are at a high risk for BC and yet are likely to have an impact from modifiable risk factors. The impact of obesity, diet, and physical activity on BC risk and outcomes needs to be further characterized in genetic mutation carriers.

Methods: A short REDCap electronic survey was disseminated on social media and through our advocate partner Facing our Risk of Cancer Empowered (FORCE). Eligible participants include males or females, ≥18 years with a hereditary cancer genetic mutation. The survey includes questions regarding personal health, weight, height, metabolic risk factors, reproductive history as well as personal and/or family history of cancer and gene mutation status. In addition, includes a standardized assessment for diet (14-Item Mediterranean Diet Tool) and physical activity (IPAQ and modifiable PAQ). The first 1000 participants are compensated for their time with a $10 e-card. The survey is available in English and Spanish. The Spanish version was developed in collaboration with JUNTOS Kansas City.

Objectives: To establish a cohort and describe obesity rates, physical activity, metabolic factors, and nutrition in a cohort of individuals that have an increased risk of cancer due to a hereditary cancer genetic mutation.

Results: A total of N = 1,117 surveys have been completed as of June 30, 2020. Of them, 61.2% were removed from final analysis due to incomplete surveys, internet bots, and multiple single-user entries. A total N = 443 surveys have been verified and included in this analysis. Demographics: 98.6% female (n= 437), 94.4% white (n = 418) and median age 46 (range 19 – 77 yrs). Mutations represented in the cohort include: BRCA2 (39.0%), BRCA1 (29.1%), CHEK2 (13.1%), and ATM (5.9%) and &lt; 5%: PALB2, RAD51D, and TP53. Median BMI 24.9 ± 6.06 stdv. BMI 25 to &lt; 30: 26.4% (n = 117). BMI 30 or &gt; 30: 23.47% (n = 104). 61.3% responders are currently trying to lose weight. Attempts at weight loss: No attempts: n = 60 (13.5%), at least 1: n = 55 (12.4%), 2-5: n = 211 (47.6%), 6 or more: n = 117 (26.4%). Limitations to exercise include motivation (26.9%), time (23.5%), not liking exercise (15.6%), and lack of gym memberships (12.4%). 74.9% (n = 332) responded that they are interested in participating in future studies. The Spanish survey was made available 3/3/2020, no responses to date.

Conclusion: Individuals harboring a hereditary cancer genetic mutation are interested and willing to participate in research focused on lifestyle modifications and association with cancer risk. Rates of being overweight or obese are high and many have made multiple attempts at weight loss and find common barriers to exercise. Social media is a feasible platform to recruit to a lifestyle research project in a rare population. Additional steps to limit internet trolls, bots, and repetitive responses are necessary but did not impede recruitment. Further effort and collaboration are needed to expand the survey to underrepresented minorities.

Citation Format: Lauren E Nye, Kendra Cruz, Sue Friedman, Diane Rose, Christie Befort, Debra K Sullivan, Jill M Hamilton-Reeves, Lisa M Harlan-Williams, Fariba Behbod, Jo Wick, Melinda Irwin, Jennifer Klemp. Energetics and lifestyle in inherited syndromes (ELLIE'S study) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-44.

Restarting and timing of oral anticoagulation after traumatic intracranial hemorrhage: a review and summary of ongoing and planned prospective randomized clinical trials

Anticoagulant-associated traumatic intracranial hemorrhage (tICrH) is a devastating injury with high morbidity and mortality. For survivors, treating clinicians face the dilemma of restarting oral anticoagulation with scarce evidence to guide them. Thromboembolic risk is high from the bleeding event, patients’ high baseline risks, that is, the pre-existing indication for anticoagulation, and the risk of immobility after the bleeding episode. This must be balanced with potentially devastating hematoma expansion or new hemorrhagic lesions. Retrospective evidence and expert opinion support restarting oral anticoagulants in most patients with tICrH, but timing is uncertain. Researchers have failed to make clear distinctions between tICrH and spontaneous intracranial hemorrhage (sICrH), which have differing natural histories. While both appear to benefit from restarting, sICrH has a higher rebleeding risk and similar or lower thrombotic risk. Clinical equipoise on restarting is also divergent. In sICrH, equipoise is centered on whether to restart. In tICrH, it is centered on when. Several prospective randomized clinical trials are ongoing or about to start to examine the risk–benefit of restarting. Most of them are restricted to patients with sICrH, with antiplatelet control groups. Most are also restricted to direct oral anticoagulants (DOACs), as they are associated with a lower overall risk of ICrH. There is some overlap with tICrH via subdural hematoma, and one trial is specific to restart timing with DOACs in only traumatic cases. This is a narrative review of the current evidence for restarting anticoagulation and restart timing after tICrH along with a summary of the ongoing and planned clinical trials.

Two-stage Bayesian hierarchical modeling for blinded and unblinded safety monitoring in randomized clinical trials

Background

Monitoring and reporting of drug safety during a clinical trial is essential to its success. More recent attention to drug safety has encouraged statistical methods development for monitoring and detecting potential safety signals. This paper investigates the potential impact of the process of the blinded investigator identifying a potential safety signal, which should be further investigated by the Data and Safety Monitoring Board with an unblinded safety data analysis.

Methods

In this paper, two-stage Bayesian hierarchical models are proposed for safety signal detection following a pre-specified set of interim analyses that are applied to efficacy. At stage 1, a hierarchical blinded model uses blinded safety data to detect a potential safety signal and at stage 2, a hierarchical logistic model is applied to confirm the signal with unblinded safety data.

Results

Any interim safety monitoring analysis is usually scheduled via negotiation between the trial sponsor and the Data and Safety Monitoring Board. The proposed safety monitoring process starts once 53 subjects have been enrolled into an eight-arm phase II clinical trial for the first interim analysis. Operating characteristics describing the performance of this proposed workflow are investigated using simulations based on the different scenarios.

Conclusions

The two-stage Bayesian safety procedure in this paper provides a statistical view to monitor safety during the clinical trials. The proposed two-stage monitoring model has an excellent accuracy of detecting and flagging a potential safety signal at stage 1, and with the most important feature that further action at stage 2 could confirm the safety issue.

Impact of physiologically relevant temperatures on dermal absorption of active substances - an ex-vivo study in human skin

Skin temperature plays a certain role in the dermal absorption of substances, but the extent and mechanisms of skin temperatures-induced modulation in ranges caused by physiological thermoregulation or environmental conditions are largely unknown. The influence of dermal temperature on the absorption of the model lipophilic compound (anisole) and the model hydrophilic compounds (1,4-dioxane, ethanol) through human skin was investigated at three dermal temperatures (25, 32 and 39 °C) in an ex-vivo diffusion cell model. The substances were applied to the skin and transdermal penetration was monitored. All substances showed temperature dependent variations in their penetration behavior (3 h: 25-39 °C: 202-275% increase in cumulative, transdermally penetrated amounts). The relative differences in absorption in relation to temperature were greatest within 45 min after exposure (25-39 °C: 347-653% rise in cumulated penetration), although absolute amounts absorbed were small (45 min vs. 3 h: 4.5-14.5%). Regardless of blood circulation, skin temperature significantly influences the amount and kinetics of dermal absorption. Substance-dependent, temperature-related changes of the lipid layer order or the porous pathway may facilitate penetration. The early-stage modulation of transdermal penetration indicates transappendageal absorption, which may be relevant for short-term exposures. For both, toxicological evaluation and perfusion cell studies, it is important to consider the thermal influence on absorption or to perform the latter at a standardized temperature (32±1 °C).

Bayesian accrual modeling and prediction in multicenter clinical trials with varying center activation times

Investigators who manage multicenter clinical trials need to pay careful attention to patterns of subject accrual, and the prediction of activation time for pending centers is potentially crucial for subject accrual prediction. We propose a Bayesian hierarchical model to predict subject accrual for multicenter clinical trials in which center activation times vary. We define center activation time as the time at which a center can begin enrolling patients in the trial. The difference in activation times between centers is assumed to follow an exponential distribution, and the model of subject accrual integrates prior information for the study with actual enrollment progress. We apply our proposed Bayesian multicenter accrual model to two multicenter clinical studies. The first is the PAIN-CONTRoLS study, a multicenter clinical trial with a goal of activating 40 centers and enrolling 400 patients within 104 weeks. The second is the HOBIT trial, a multicenter clinical trial with a goal of activating 14 centers and enrolling 200 subjects within 36 months. In summary, the Bayesian multicenter accrual model provides a prediction of subject accrual while accounting for both center- and individual patient-level variation.

Utilization of Technology to Improve Efficiency in Investigational Drug Management Processes

Background: Background: An investigational pharmacy is responsible for all tasks related to receiving, storing, and dispensing of any investigational drugs. Traditional methods of inventory and protocol tracking on paper binders are very tedious and could be error-prone. Objective: To evaluate the utilization of the IDS to efficiently manage the inventory within an investigational Pharmacy. We hypothesize that the IDS will reduce the drug processing time. Methods: Our pharmacy tracked the drug processing time before and after using the IDS including the receiving, dispensing, and inventory. As part of the receiving the study drug pharmacists tracked the time it took a pharmacist to complete the tasks of logging the study drug before and after the implementation of the IDS system. In addition, the pharmacy also timed the process for drug dispensing and a full investigational drug inventory check. Wilcoxon signed-rank test was used to compare the difference in the meantime of total processing before and after the IDS. Results: Utilization of the IDS system showed significant reduction in processing time, and improvement of efficiency in inventory management. Additionally, the usability survey of the IDS demonstrated that the IDS system helped pharmacists capture data consistently across every clinical trial. Conclusion: Our results demonstrates how technology helps pharmacists to focus on their actual day to day medication-related tasks rather than worrying about other operational aspects. Informatics team continues to further enhance the features such as monitor portal, and features related to finance - generation of invoices, billing reconciliation, etc.

Optimizing Retrieval of Biospecimens Using the Curated Cancer Clinical Outcomes Database (C3OD)

To fully support their role in translational and personalized medicine, biorepositories and biobanks must continue to advance the annotation of their biospecimens with robust clinical and laboratory data. Translational research and personalized medicine require well-documented and up-to-date information, but the infrastructure used to support biorepositories and biobanks can easily be out of sync with the host institution. To assist researchers and provide them with accurate pathological, epidemiological, and bio-molecular data, the Biospecimen Repository Core Facility (BRCF) at the University of Kansas Medical Center (KUMC) merges data from medical records, the tumor registry, and pathology reports using the Curated Cancer Clinical Outcomes Database (C3OD). In this report, we describe the utilization of C3OD to optimally retrieve and dispense biospecimen samples using these 3 data sources and demonstrate how C3OD greatly increases the efficiency of obtaining biospecimen samples for the researchers.

The impact of diabetic peripheral neuropathy on pinch proprioception

This study aims to investigate the impact of type 2 diabetes (T2D) and diabetic peripheral neuropathy (DPN) on pinch proprioception and to establish the correlations with sensory impairments. We collected data from a total of 36 participants (healthy, n = 12; T2D without DPN, n = 11; and T2D + DPN, n = 13), all matched for age, 60 ± 6 years. Pinch proprioception was determined through 3 trials of attempts to actively reproduce 15° of pinch position without visual feedback. Target accuracy and precision was compared between groups using Kruskal-Wallis test. Sensation was tested through the two-point discrimination and Semmes-Weinstein monofilaments applied on the fingers. Sensory measures were correlated with pinch proprioception measures via Spearman's rank test. The T2D + DPN group showed significant decrements in accuracy and precision as compared to the T2D-only (p = 0.003 and p = 0.006, respectively) and the healthy groups (both p = 0.002); no significant differences were found between T2D-only and healthy. Spearman's rank showed moderate (r = 0.45-0.66, p < 0.001) correlations between pinch proprioception and sensory measures. Our results showed pinch proprioception disruption in people with T2D + DPN, but not in people with T2D-only. The awareness of pinch proprioceptive deficits is paramount for the safety of individuals with T2D and DPN. Moderate correlations between sensory impairments and pinch proprioceptive deficits suggest that not only superficial/discriminative sensation is implicated in proprioceptive decrements. Other mechanisms such as damage to muscle spindles or central nervous system associated with T2D + DPN warrant further investigations.

Effect of Prenatal Docosahexaenoic Acid Supplementation on Blood Pressure in Children With Overweight Condition or Obesity: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

The blood pressure-lowering property of docosahexaenoic acid (DHA) in children and adults is known, and an observational study from the Netherlands has linked higher intrauterine DHA exposure to lower childhood blood pressure. However, the association of prenatal intake of DHA supplement with childhood blood pressure has not been evaluated in randomized clinical trials.

OBJECTIVE

To determine the effect of DHA supplementation during pregnancy on childhood blood pressure.

DESIGN, SETTING, AND PARTICIPANTS

This prespecified secondary analysis of the Kansas University DHA Outcome Study (KUDOS), a phase 3, double-blind, randomized, placebo-controlled clinical trial was conducted at several local hospitals in the Kansas City, Kansas, metropolitan area. Pregnant women (n = 350) were enrolled in the KUDOS trial between January 10, 2006, and November 17, 2009, and were followed up until their children were 18 months of age. During pregnancy, the women received either 3 capsules per day of placebo or 600 mg per day of DHA from a mean (SD) of 14.5 (3.7) weeks' (all before 20 weeks) gestation until birth. The parents of 190 children consented to additional follow-up of their children until 6 years, which ended April 29, 2016. Study personnel involved in testing were blind to the randomization until all children had completed the trial. Data analysis was performed from May 23, 2017, to July 10, 2018.

INTERVENTIONS

Pregnant women were assigned to either 600 mg per day of DHA or a placebo that was half soy and half corn oil. Both placebo and DHA were provided in 3 capsules per day.

MAIN OUTCOMES AND MEASURES

Childhood blood pressure was a planned secondary outcome of a study powered to measure cognitive development. The hypothesis was that DHA would lower blood pressure prior to data analysis. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured at 4, 4.5, 5, 5.5, and 6 years and were analyzed for possible covariates using mixed models to generate a final model.

RESULTS

In total, 171 children (88 [51.5%] female) were included in this analysis. Of these children, 89 (52.0%) were randomized to the DHA group and 82 (47.9%) to the placebo group. A statistically significant interaction was found between treatment (placebo or DHA) and child weight status (5-year body mass index ≤85th or >85th percentile) for both SBP and DBP. Children who were overweight or obese whose mothers received placebo during pregnancy had higher SBP and DBP compared with children who were overweight or obese whose mothers received DHA (mean [SE] SBP, 104.28 [1.37] mm Hg vs 100.34 [1.02] mm Hg; DBP, 64.7 [1.23] mm Hg vs 59.76 [0.91] mm Hg). No differences in the SBP and DBP were found between children who were overweight or obese whose mothers received DHA and children who were not overweight or obese. In the mixed model analysis, the child's age at blood pressure measurement and the maternal prepregnancy body mass index were the only other statistically significant variables (child age, SBP: F = 7.385; P = .001; DBP: F = 7.39; P = .001; prepregnancy BMI, SBP: r = 0.284; P = .001; DBP: r = 0.216; P = .01).

CONCLUSIONS AND RELEVANCE

Maternal docosahexaenoic acid intake during pregnancy appeared to mitigate the association between childhood overweight condition or obesity and blood pressure.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02487771.

Maternal Vitamin D Status and Infant Infection

Maternal vitamin D status during pregnancy may modulate fetal immune system development and infant susceptibility to infections. Vitamin D deficiency is common during pregnancy, particularly among African American (AA) women. Our objective was to compare maternal vitamin D status (plasma 25(OH)D concentration) during pregnancy and first-year infections in the offspring of African American (AA) and non-AA women. We used medical records to record frequency and type of infections during the first year of life of 220 term infants (69 AA, 151 non-AA) whose mothers participated in the Kansas University DHA Outcomes Study. AA and non-AA groups were compared for maternal 25(OH)D by Mann-Whitney U-test. Compared to non-AA women, AA women were more likely to be vitamin D deficient (<50 nmol/L; 84 vs. 37%, p < 0.001), and more of their infants had at least one infection in the first 6 months (78.3% and 59.6% of infants, respectively, p = 0.022). We next explored the relationship between maternal plasma 25(OH)D concentration and infant infections using Spearman correlations. Maternal 25(OH)D concentration was inversely correlated with the number of all infections (p = 0.033), eye, ear, nose, and throat (EENT) infections (p = 0.043), and skin infection (p = 0.021) in the first 6 months. A model that included maternal education, income, and 25(OH)D identified maternal education as the only significant predictor of infection risk in the first 6 months (p = 0.045); however, maternal education, income, and 25(OH)D were all significantly lower in AA women compared to non-AA women . The high degree of correlation between these variables does not allow determination of which factor is driving the risk of infection; however, the one that is most easily remediated is vitamin D status. It would be of value to learn if vitamin D supplementation in this at-risk group could ameliorate at least part of the increased infection risk.

Reducing radiation exposure with iterative reconstruction: an inter- and intra-scanner analysis

Our purpose in this study was to compare delivered radiation exposure via computed tomography dose index volume (CTDI_vol) and dose length production (DLP) measurements from computed tomography (CT) examinations performed on scanners with and without image-quality enhancing iterative reconstruction (IR) software. A retrospective analysis was conducted on randomly selected chest, abdomen, and/or pelvis CT examinations from three different scanners from 1 January 2013 to 31 December 2013. CTDI_vol and DLP measurements were obtained from two CT scanners with and one CT scanner without IR software. To evaluate inter-scanner variability, we compared measurements from the same model CT scanners, one with and one without IR software. To evaluate intra-scanner variability, we compared measurements between two scanners with IR software from different manufacturers. CT scanners with IR software aided in the overall reduction in radiation exposure, measured as CTDI_vol by 30% and DLP by 39% when compared to a scanner without IR. There was no significant difference in CTDl_vol or DLP measurements across different manufacturers with IR software. As a result, IR software significantly decreased the radiation exposure to patients, but there were no differences in radiation measurements across CT manufacturers with IR software.

A novel evaluation of optimality for randomized controlled trials

Balanced two-arm designs are more powerful than unbalanced designs and, consequently, Bayesian adaptive designs (BADs) are less powerful. However, when considering other subject- or community-focused design characteristics, fixed two-arm designs can be suboptimal. We use a novel approach to identify the best two-arm study design, taking into consideration both the statistical perspective and the community's perception. Data envelopment analysis (DEA) was used to estimate the relative performance of competing designs in the presence of multiple optimality criteria. The two-arm fixed design has enough deficiencies in subject- and community-specific benefit to make it the least favorable study design.

The degree of intratumor mutational heterogeneity varies by primary tumor sub-site

In an era where mutational profiles inform treatment options, it is critical to know the extent to which tumor biopsies represent the molecular profile of the primary and metastatic tumor. Head and neck squamous cell carcinoma (HNSCC) arise primarily in the mucosal lining of oral cavity and oropharynx. Despite aggressive therapy the 5-year survival rate is at 50%. The primary objective of this study is to characterize the degree of intratumor mutational heterogeneity in HNSCC. We used multi-region sequencing of paired primary and metastatic tumor DNA of 24 spatially distinct samples from seven patients with HNSCC of larynx, floor of the mouth (FOM) or oral tongue. Full length, in-depth sequencing of 202 genes implicated in cancer was carried out. Larynx and FOM tumors had more than 69.2% unique SNVs between the paired primary and metastatic lesions. In contrast, the oral tongue HNSCC had only 33.3% unique SNVs across multiple sites. In addition, HNSCC of the oral tongue had fewer mutations than larynx and FOM tumors. These findings were validated on the Affymetrix whole genome 6.0 array platform and were consistent with data from The Cancer Genome Atlas (TCGA). This is the first report demonstrating differences in mutational heterogeneity varying by subsite in HNSCC. The heterogeneity within laryngeal tumor specimens may lead to an underestimation of the genetic abnormalities within tumors and may foster resistance to standard treatment protocols. These findings are relevant to investigators and clinicians developing personalized cancer treatments based on identification of specific mutations in tumor biopsies.

Economic Costs Avoided by Diagnosing Melanoma Six Months Earlier Justify >100 Benign Biopsies

New melanoma drugs bring enormous benefits but do so at significant costs. Because melanoma grows deeper and deadlier over time, deeper lesions are costlier due to increased sentinel lymph node biopsy, chemotherapy, and disease-associated income loss. Prior studies have justified pigmented lesion biopsies on a "value per life" basis; by contrast we sought to assess how many biopsies are justified per melanoma found on a purely economic basis. We modeled how melanomas in the United States would behave if diagnosis were delayed by 6 months, eg, not biopsied, only observed until the next surveillance visit. Economic loss from delayed biopsy is the obverse of economic benefit of performing biopsy earlier. Growth rates were based on Liu et al. The results of this study can be applied to all patients presenting to dermatologists with pigmented skin lesions suspicious for melanoma. In-situ melanomas were excluded because no studies to date have modeled growth rates analogous to those for invasive melanoma. We assume conservatively that all melanomas not biopsied initially will be biopsied and treated 6 months later. Major modeled costs are (1) increased sentinel lymph node biopsy, (2) increased chemotherapy for metastatic lesions using increased 5-yr death as metastasis marker, and (3) income loss per melanoma death at $413,370 as previously published. Costs avoided by diagnosing melanoma earlier justify 170 biopsies per melanoma found. Efforts to penalize "unnecessary" biopsies may be economically counterproductive.

J Drugs Dermatol. 2016;15(5):527-532.

Abstract B12: Macrophage inhibitory cytokine-1 as a potential biomarker for racial disparity in prostate cancer

Macrophage inhibitory cytokine-1 (MIC-1) has drawn significant attention due to its association with the development and progression of prostate cancer (PCa). Recent studies have projected MIC-1 as a potential biomarker for various disease conditions including PCa. Given evidence for more aggressive disease among African American (AA) men, we aimed to investigate if MIC-1 was differentially expressed among AA and Caucasian men. We measured serum MIC-1 levels by sandwich ELISA in samples collected during the diagnosis of PCa (pre-surgical). Our data consists of information on 40 Caucasian and 40 AA men between the ages of 43 and 75 years (Median = 60 years). Based on the analysis of log transformation of the data, significant differences among the two races were found, with AA having higher MIC-1 expression (Median 1220.4 versus 790.8, p=0.0001), Gleason scores (Median 7 versus 6, p=0.0009) and PSA (Median 6.72 versus 6.35 ng/ml, p = 0.04) than Caucasians. No differences in age or pathological stage of disease were observed between groups (p &gt; 0.05). Higher levels of MIC-1 and Gleason scores were associated (p&lt;0.001 and p&lt;0.05, respectively) with older patients among Caucasians. In contrast, among AA samples, MIC-1 and Gleason scores were not differentially expressed based on age. This phenomenon was not observed when examining PSA expression levels by age among AA and Caucasians. Altogether, these observations indicate that MIC-1 may play a role in more aggressive disease among younger AA men and addition of MIC−1 may help to improve the discrimination of aggressive disease at least in AA men. Further analysis of the mechanism of activity of MIC-1 and validation in a larger dataset is required.

Citation Format: Dev Karan, Seema Dubey, Jo Wick, Ossama Tawfik, Guru Sonpavde, Peter VanVeldhuizen. Macrophage inhibitory cytokine-1 as a potential biomarker for racial disparity in prostate cancer. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B12.

Prevalence of Exercise-Induced Bronchoconstriction Measured by Standardized Testing in Healthy College Athletes

BACKGROUND

Exercise-induced bronchoconstriction (EIB) can lead to long-term respiratory illness and even death. EIB prevalence rates are both high and variable in college athletes. Prevalence rates may be underestimated due to ineffective testing and screening. The purpose of this study was to investigate the prevalence of EIB in college athletes by a standardized EIB test that can be used on many college campuses. In addition, we assessed the usefulness of self-reporting EIB/asthma (1) history, (2) symptoms, and (3) respiratory medication obtained from a simple screening questionnaire for predicting an EIB-positive athlete.

METHODS

A standardized EIB test and self-report questionnaire were administered to college athletes on 10 different sports teams. Information collected included pulmonary function (spirometry), expired gas analysis (maximal oxygen uptake), CO2 production, minute ventilation, EIB/asthma history, current symptoms, and medication use.

RESULTS

Results showed that 34 of 80 athletes (42.5%) were EIB-positive by standardized exercise testing. The majority (76.5 and 58.8%) of the 34 athletes who tested positive self-reported a negative history or no symptoms, respectively. Also, 79.4% of the athletes who tested positive for EIB reported not using a respiratory medication. There were no significant differences in a positive EIB test when assessing interactions for history (P = .93), current symptoms (P = .12), or respiratory medication use (P = .66).

CONCLUSIONS

A high proportion of college athletes tested positive for EIB when using a standardized test. Positive history, current symptoms of EIB/asthma, and respiratory medication use were not predictive of a positive test. Many EIB-positive athletes are not using a respiratory medication. More work is needed to develop an effective screening tool and improve education for EIB in college athletes.

Impact Study: MK-0646 (Dalotuzumab), Insulin Growth Factor 1 Receptor Antibody Combined with Pemetrexed and Cisplatin in Stage IV Metastatic Non-squamous Lung Cancer

BACKGROUND

Insulin-like growth factor 1 receptor (IGF-1R) regulates cell growth, proliferation, and apoptosis. Adenocarcinoma and never-smokers have a higher expression of IGF-1R, which is associated with worse overall survival. Dalotuzumab-MK0646 (D) is a humanized monoclonal antibody that targets IGF-1R. Pemetrexed (P) has higher activity in non-squamous lung cancer (NSQL). We initiated a randomized phase II trial to test the combination of P and Cisplatin (C) ± D in NSQL.

METHODS

Eligibility criteria were untreated NSQL stage IV, ECOG 0 or 1, measurable disease, adequate renal, hepatic and hematologic function, and no other intercurrent illness. P at 500 mg/m(2) and C at 75 mg/m(2) IV were given every 3 weeks. D was given at 10 mg/kg IV weekly on days 1, 8, and 15 of every 3-week cycle in the experimental group. The patients had a radiographic assessment after every two cycles and were treated for a maximum of six cycles if there was a response or stable disease. The primary objective of the study was to compare the clinical response rates of PC vs. PC + D.

RESULTS

From 1/2009 to 2/2011, the study accrued 26 subjects: 16 male and 10 female, with a median age of 59; 14 were treated with PC and 12 were treated with PC + D. We observed two partial responses (PR), seven stable disease (SD), three progressive disease (PD), and two not evaluable (NE) in the PC arm. In comparison, for the PC + D arm, there were three PR, four SD, four PD, and one NE. The hematologic toxicity was similar in both groups. There was higher incidence of hyperglycemia in the experimental group; four cases with grade 3 and one case with grade 4.

CONCLUSION

PC + D had a similar response rate compared to PC, with a higher rate of hyperglycemia. Identification of responders using predictive markers would be key to continuing the study of D in NSQL.

TRIAL REGISTRATION

NCT00799240, clinicaltrials.gov.

Reproducible Novel Transcriptional Differences Between Psoriatic Lesional and Non-Lesional Skin Show Increased Inflammation and Metabolism

BACKGROUND

Psoriasis is a common but complex chronic inflammatory skin Disease. Array-based studies can help identify therapeutic targets.

OBJECTIVE

To reproducibly assess single-gene transcriptional changes in psoriatic skin.

METHODS

We evaluated 210 top candidate genes from a first psoriasis study group (population 1), and then confirmed differential expression in a second independent psoriasis study group (population 2).

RESULTS

One hundred and thirty-eight differentially expressed genes were replicated in the 2 studies, of which 57 have not previously been reported as associated with psoriasis. This is significantly greater than the 10 expected false positives. Lesional skin vs uninvolved areas showed inflammatory and cell regulation changes.

CONCLUSION

Previously undescribed psoriasis-associated genes revealed in this study may provide potential future targets for development and assessment of novel therapeutic agents for psoriasis.

Biopsy rates vary with patient profile across different physicians in an academic dermatology practice

Current healthcare trends promote data-driven "benchmarking" to decrease cost and increase quality. Dermatologists perform 79% of skin biopsies and biopsy rate is an easily measured benchmark. To reduce the risk of a misguided "one size fits all" benchmark for biopsies, it will help to document the factors driving divergent biopsy rates.This letter compares biopsy rates and high-risk patient ratios for 1000 sequential patients from two academic dermatologists. Elevated biopsy rates (0.55 vs 0.42, p &lt; 0.001) were associated with elevated ratios of high-risk patients (.52 versus .30, p&lt; 0.001). Although limited by small sample size, this research takes a first step toward future efforts to improve accuracy of biopsy benchmarking.

Preclinical and phase I results of decitabine in combination with midostaurin (PKC412) for newly diagnosed elderly or relapsed/refractory adult patients with acute myeloid leukemia

PURPOSE

To determine the preclinical activity, clinical maximum tolerated dose (MTD), and recommended phase II dose of midostaurin (MS) combined either sequentially or concurrently with intravenous decitabine (DAC) in newly diagnosed patients 60 years or older or relapsed/refractory adult patients (18 years or older) with acute myeloid leukemia (AML).

PATIENTS AND METHODS

Cultured and primary AML cells were treated with DAC and/or MS and analyzed by flow cytometry and immunoblot analyses. In the phase I study, 16 patients were enrolled; 8 were newly diagnosed patients 60 years or older and 8 were 18 years or older with relapsed AML. Only 2 of 16 patients (13%) had FLT3-internal tandem duplication (ITD) mutations, and no patient had KIT mutations.

RESULTS

Compared with treatment with either agent alone, sequential treatment with DAC and MS exerted superior anti-AML activity in cultured and primary FLT3-ITD-expressing AML cells. In the subsequent phase I study, the MTD and schedule of administration of the combination was identified as DAC followed by MS. Three patients developed dose-limiting toxicities: two patients developed pulmonary edema requiring mechanical ventilation and one patient developed a prolonged QTc greater than 500 msec. Based on an intent-to-treat analysis, 57% of the patients achieved stable disease or better while enrolled in the trial; 25% had a complete hematologic response. Pharmacokinetic analysis revealed results similar to those previously reported for MS.

CONCLUSION

The in vitro combination of DAC and MS is synergistically active against FLT3-ITD mutations expressing AML cells. In a clinical setting, the combination of sequentially administered DAC followed by MS is possible without significant unexpected toxicity, but the concurrent administration of DAC and MS led to pulmonary toxicity after only a few doses. On the basis of these results, additional studies exploring the sequential combination of untreated AML in elderly patients are warranted to further evaluate this combination at the MTD.

Early treatment with nonsucrose intravenous immunoglobulin in a burn unit reduces toxic epidermal necrolysis mortality

BACKGROUND

Intravenous immunoglobulin (IVIG) can be used to treat potentially deadly toxic epidermal necrolysis (TEN), milder Stevens Johnson Syndrome (SJS) and intermediate TEN/SJS overlap. Some formularies now deny IVIG for TEN based on the EuroSCAR TEN/SJS study that reported a nonsignificant trend toward increased mortality in 75 IVIG-treated TEN/SJS patients; of note the IVIG patients had more TEN and less SJS than patients in other treatment arms. EuroSCAR data on mortality among the 25 IVIG-treated TEN patients, use of nonsucrose IVIG, and admission to specialized settings such as burn units was not disclosed. The impact of treatment setting (specialized unit vs general ward) on IVIG efficacy has not previously been studied.

OBJECTIVE

To evaluate efficacy of treating TEN with early nonsucrose IVIG in a burn unit.

METHODS

Data were retrospectively collected from 13 IVIG-treated TEN patients admitted to a burn unit over a 6-year period.

RESULTS

We report 0% mortality among 13 IVIG-treated TEN patients. Mortality was significantly lower than predicted by SCORTEN. Mortality was also significantly lower than the EuroSCAR groups receiving IVIG (P<.005), supportive care (P<.018), and corticosteroids only (P<.046).

CONCLUSION

TEN patients may benefit from early nonsucrose IVIG administered in burn units or other specialized settings.

Phase I clinical trial of the intraperitoneal (IP) administration of a novel nanoparticle formulation of paclitaxel (NTX)

2558

Background: IP therapy is an attractive option for patients with IP carcinomatosis as many of these malignancies remain confined IP. Agents whose plasma clearance rates substantially exceed their rates of uptake from the peritoneal cavity are especially suited for IP administration. Pre-clinical studies of a novel formulation of nanoparticulate paclitaxel in animal tumor models demonstrated superior activity and substantially reduced systemic toxicity. This allowed for significant IP doses and concentrations, yet yielded very low systemic concentrations of paclitaxel. We report here the results of a Phase I trial of IP administered NTX. Methods: Patients (ECOG≤2) had relapsed, treatment refractory solid IP tumors and adequate organ function. NTX was administered IP as a bolus injection after 500 ml saline followed by IP administration of up to 2 L of saline. We utilized an accelerated dose escalation scheme until one DLT occurred during cycle 1, followed by a standard dose escalation (3+3 design) based on CTCAE V3 toxicities. The pharmacokinetics of IP administered NTX were characterized in plasma and ascites fluid. Secondary objectives were to define the recommended phase 2 dose of NTX, and characterize preliminary activity and toxicity. Results: 20 patients were treated at dose levels from 50 – 275 mg/M2 q 28 days. Primary malignancy was ovarian cancer (74%). Treatment was well tolerated at all dose levels. Common toxicities potentially related to NTX were: gastrointestinal (68%), constitutional (42%), and pain (42%). Average number of cycles received was 2 (range 1 to 6). Best response was stable disease (4 patients, 21%). Median length of disease stability was 99 days (range 85 to 151 days); median time on study patients with stable disease was 313 days (range 142 to 740 days). All Cmax in plasma were less than 35 ng/mL, with ascites fluid Cmax generally greater than 1000 ng/mL. Conclusions: IP NTX is well tolerated. MTD has not yet been reached. Pharmacokinetic data demonstrate significant, persistent IP exposure to paclitaxel with minimal systemic exposure. Accrual at the 275 mg/M2 dose level continues; updated results will be presented. Further clinical development of NTX is indicated. Clinical trial information: NCT00666991.

Circulating tumor cells (CTC) as a biomarker of response in patients with extensive-stage small cell lung cancer (EX-SCLC)

e22048

Background: SCLC, a variant of lung cancer marked by early metastases, accounts for 13% of all lung cancers diagnosed in US. Despite high response rates to treatment, it is an aggressive disease with a median survival of 9-11 months for patients with EX-SCLC. Detection of CTCs is a novel laboratory technique currently in use to determine response to therapy and to predict prognosis in breast, colorectal and prostate cancer. We initiated a study to study the role of CTC as a biomarker of response and relapse in patients with EX-SCLC. Methods: We collected blood sample from chemotherapy naïve patients with EX-SCLC prior to initiation of therapy, following completion of systemic therapy, follow up every 6-8 weeks and at relapse. The CTC was determined using the Cell Search system in a central laboratory. The study was conducted in 4 different sites and it was reviewed and approved by respective Research Review Committee and IRBs. Results: We enrolled 27 patients with EX-SCLC, 1 was excluded due ineligibility, all patients were treated with platinum and etoposide. We observed partial response in 16 patients (61%), stable disease in 3 patients, 1 with progression of disease and not assessed in 7 patients (5 deceased, 2 not available); the baseline CTC of 2 patient were not measured (one due instrument failure and one due insufficient blood). The overall median number of CTCs in 24 patients measured at baseline and post-tx was 75 (range 0 to 3430) and 2 (range 0 to 526), respectively. A significant reduction in CTCs from baseline to post-tx was identified; for the 14 subjects with pre and post treatment CTC, the median reduction was 51.5% (51.5% decrease, range -2904% to +5%, p< 0.001). Conclusions: We were able to demonstrate feasibility of using CTC as a biomarker of response in patients with EX-SCLC in clinical setting. CTC could be a useful biomarker in the management of SCLC to predict response to therapy.

MK-0646 (MK), insulin growth factor 1 receptor (IGF-1R) antibody combined with pemetrexed (P) and cisplatin (C) in stage IIIb or IV metastatic nonsquamous lung cancer (NSQL)

e13551

Background: IGF-1R regulates cell growth, proliferation and apoptosis. Adenocarcinoma and never smokers have higher expression of IGF-1R and it is associated with worse survival. MK is a humanized monoclonal antibody that targets IGF-1R. P has higher activity in NSQL. We initiated a randomized phase II trial to evaluate the combination of P and C +/- MK in NSQL. Methods: Eligibility criteria: untreated NSQL stage IIIB or IV, ECOG 0 or 1, measurable disease, adequate organ function and no other intercurrent illness. Standard B12 and folic acid were given. P at 500mg/m2 and C at 75mg/m2 IV were given every 3 weeks. MK was given at the dose of 10mg/kg IV weekly on days 1, 8 and 15 of every 3 week cycle in the experimental group. The patients had radiographic assessment after every 2 cycles and treated for a maximum of 6 cycles if there was either response or stable disease. The primary objective of the study was to estimate the individual response rate of standard and experimental arm. IRB reviewed and approved the study at participating institutions. Results: From 1/2009 to 2/2011, the study accrued 26 patients, 16 male, 10 female, median age 59 yo. 14 patients were treated with PC and 12 patients were treated with PC +MK. In the PC arm we observed 2 partial responses (PR), 7 stable disease (SD), 3 had progression (PD) and 2 were not evaluable (NE). In the MK arm there were 3 PRs, 4 SD, 4 PD and 1 NE. In both arms, hematologic adverse events(AE) observed were: grade 3 neutropenia(5), hemoglobin (3), febrile neutropenia (2), platelet (2) leukopenia (1), lymphopenia (1); grade 4 platelet (2), hemoglobin (1); Grade 3 non-hematological AE were: hyperglycemia (4) and 1 occurrence each of hearing deficit, pain in extremity, hyponatremia, urinary tract infection, fatigue, dyspnea, laboratory, hypokalemia, esophageal stenosis, hypoxia, dysphagia and muscle weakness; Grade 4 hypoxia and hyperglycemia. The study was closed due to termination of funding. Conclusions: PC with MK had a similar response rate to PC. There was a higher rate of hyperglycemia in the MK group. Identification of a response predictive marker would be critical in order to continue the study of this agent.

Potentiation of dietary restriction-induced lifespan extension by polyphenols

Dietary restriction (DR) extends lifespan across multiple species including mouse. Antioxidant plant extracts rich in polyphenols have also been shown to increase lifespan. We hypothesized that polyphenols might potentiate DR-induced lifespan extension. Twenty week old C57BL/6 mice were placed on one of three diets: continuous feeding (control), alternate day chow (Intermittent fed, IF), or IF supplemented with polyphenol antioxidants (PAO) from blueberry, pomegranate, and green tea extracts (IF+PAO). Both IF and IF+PAO groups outlived the control group and the IF+PAO group outlived the IF group (all p<0.001). In the brain, IF induced the expression of inflammatory genes and p38 MAPK phosphorylation, while the addition of PAO reduced brain inflammatory gene expression and p38 MAPK phosphorylation. Our data indicate that while IF overall promotes longevity, some aspects of IF-induced stress may paradoxically lessen this effect. Polyphenol compounds, in turn, may potentiate IF-induced longevity by minimizing specific components of IF-induced cell stress.

Metabolic syndrome in South Asian immigrants: more than low HDL requiring aggressive management

Aggressive clinical and public health interventions have resulted in significant reduction in coronary artery disease (CAD) worldwide. However, South Asian immigrants (SAIs) exhibit the higher prevalence of CAD and its risk factors as compared with other ethnic populations. The objective of the current study is to assess the prevalence of metabolic syndrome (MS), its association with high density Lipoprotein (HDL) function, Apo lipoprotein A-I (APOA1) gene polymorphisms, and sub-clinical CAD using common carotid intima-media thickness (CCA-IMT) as a surrogate marker. A community-based cross-sectional study was conducted on SAIs aged 35-65 years. Dysfunctional/pro-inflammatory (Dys-HDL) was determined using novel cell free assay and HDL inflammatory index. Six intronic APOA1 gene polymorphisms were analyzed by DNA sequencing. According to the International Diabetes Federation definition, MS prevalence was 29.7% in SAIs without CAD and 26% had HDL inflammatory index ≥ 1 suggesting pro-inflammatory Dys-HDL. Six novel APOA1 single nucleotide polymorphisms (SNPs) were analyzed with logistic regression, three SNPs (G2, G3, and G5) were found to be significantly associated with MS (p = 0.039, p = 0.038, p = 0.054). On multi-variate analysis, MS was significantly associated with BMI > 23 (P = 0.005), Apo-A-I levels (p = 0.01), and Lp [a] (p < 0.0001). SAIs are known to be at a disproportionately high risk for CAD that may be attributed to a high burden for MS. There is need to explore and understand non-traditional risk factors with special focus on Dys-HDL, knowing that SAIs have low HDL levels. Large prospective studies are needed to further strengthen current study results.

Use of decompressive craniectomy after severe head trauma

Ten percent of head injuries quality as "severe," requiring prompt diagnosis and treatment. This level I trauma center uses an aggressive approach to treatment of severe head injuries and, when indicated, intervenes with decompressive craniectomy. This article explains decompressive craniectomy, including indications, procedures, and protocols. The case studies presented highlight two patients with profound head injuries. Additionally, cranioplasty replacement of autograft flap is explained and discussed.