Disease Burden, Clinical Outcomes, and Quality of Life in People with Hemophilia A without Inhibitors in Europe: Analyses from CHESS II/CHESS PAEDs

Introduction  Limited data relating to treatment burden, quality of life, and mental health burden of hemophilia A (HA) are currently available. Aim  To provide a comprehensive overview of unmet needs in people with HA (PwHA) using data generated from the Cost of Haemophilia in Europe: a Socioeconomic Survey-II (CHESS II) and CHESS in the pediatric population (CHESS PAEDs) studies. Methods  CHESS II and CHESS PAEDs are cross-sectional surveys of European males with HA or hemophilia B (HB) aged ≥18 and ≤17 years, respectively. Participants with FVIII inhibitors, mild HA, or HB were excluded from this analysis, plus those aged 18 to 19 years. Annualized bleeding rates (ABRs), target joints, and other patient-reported outcomes were evaluated. Results  Overall, 468 and 691 PwHA with available data for the outcomes of interest were stratified by hemophilia severity and treatment regimen in CHESS II and CHESS PAEDs, respectively. In these studies, 173 (37.0%) and 468 (67.7%) participants received FVIII prophylaxis, respectively; no participants received the FVIII mimetic emicizumab or gene therapy. ABRs of 2.38 to 4.88 were reported across disease severity and treatment subgroups in both studies. Target joints were present in 35.7 and 16.6% of participants in CHESS II and CHESS PAEDS; 43.8 and 23.0% had problem joints. Chronic pain was reported by a large proportion of PwHA (73.9% in CHESS II; 58.8% in CHESS PAEDs). Participants also reported low EQ-5D scores (compared with people without HA), anxiety, depression, and negative impacts on their lifestyles due to HA. Conclusions  These analyses suggest significant physical, social, and mental burdens of HA, irrespective of disease severity. Optimization of prophylactic treatment could help reduce the burden of HA on patients.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Surgical Experience from the STASEY Study of Emicizumab Prophylaxis in People with Hemophilia A with Factor VIII Inhibitors

Background  Guidelines surrounding emicizumab prophylaxis and perioperative treatment for people with hemophilia A (PwHA) with factor (F)VIII inhibitors undergoing surgeries are limited. The phase IIIb multicenter, single-arm STASEY study evaluated safety and tolerability of emicizumab prophylaxis in PwHA aged ≥12 years with FVIII inhibitors. This analysis assesses surgeries during study conduct, associated hemophilia medications, and postoperative bleeds (treated and untreated). Methods  PwHA with FVIII inhibitors received emicizumab 3.0 mg/kg/week for 4 weeks, then 1.5 mg/kg/week until 2 years. Surgeries were managed and documented by treating physicians. Bleeds and treatments were recorded by physicians and participants. Results  Forty-six participants had ≥1 on-study surgery, 37 underwent 56 minor surgeries, and 13 underwent 22 major surgeries. Four participants underwent both minor and major surgeries. Of 18 (81.8%) and 4 (18.2%) major surgeries managed with/without additional hemostatic medication, 33.3 and 25.0% were associated with a treated postoperative bleed, respectively. Of 24 (42.9%) and 32 (57.1%) minor surgeries managed with/without additional hemostatic medication, 15.6 and 25.0% were associated with a treated postoperative bleed, respectively. Recombinant activated FVII was the most common medication for prophylaxis and bleed treatment. There were no thrombotic microangiopathies (TMAs). One hypertrophic clot, considered unrelated to emicizumab, occurred following tooth extraction. Conclusion  In this challenging population with a high bleeding risk, major surgeries were performed in PwHA receiving emicizumab with/without additional hemostatic medication. Postoperative bleeds occurred following 59.1% of major surgeries; 53.8% were treated. No arterial/venous thrombotic events or TMAs occurred due to concomitant emicizumab and bypassing agents. Trial registration  This trial is registered at ClinicalTrials.gov (NCT03191799).

Prompt Pain Relief: Advanced Practice Provider Led Rapid Access Palliative Radiotherapy Clinic

PURPOSE/OBJECTIVE(S)

Patients (pts) commonly present to radiation oncology with painful bone metastases requiring urgent palliative radiotherapy (RT). Unfortunately, the pre-existing scheduling workflow for palliative referrals can be inefficient, causing significant delays before pts are seen by a radiation oncologist (RO). Our institution implemented an alternative workflow, which led to the creation of an advanced practice provider (APP) led Rapid Access Palliative RT Clinic (PRC). We investigated the impact of the PRC in reducing time from referral to consultation for pts in need of palliative RT.

MATERIALS/METHODS

In March 2022, we initiated an outpatient APP led PRC focused on the APP driving consultations supervised by the weekly on-call RO. Pts are offered a variety of options for consultation such as virtual, in clinic with reserved simulation time, and when appropriate virtual simulation, using diagnostic imaging for RT planning, and same day treatment requiring only one visit to the department. The clinic provides a point of contact that fosters multidisciplinary interaction and proactive continuity of care and follow up. Following institutional review board approval, pts who received palliative RT for painful bone metastases from June 2021 to December 2022 were retrospectively reviewed. Data was collected with respect to when the referral was placed for palliative RT and when the pts was seen for consultation by a provider. The cohort of pts seen between June 2022 and December 2022 represented the PRC cohort. A comparison cohort of pts treated between June 2021 and December 2021 represented the pre-PRC cohort. Unpaired T-test was used to analyze time from referral to consultation (TTC) between groups. P value < 0.05 was considered statistically significant.

RESULTS

During the pre-PRC period, 91 patients were treated, including 12 inpatients and 79 outpatients, while during the PRC period, 101 pts were treated, including 7 inpatients and 94 outpatients. The median dose was 8 Gy in 1 fraction for both cohorts. During the PRC period, there was a 19% increase in outpatients treated for bone metastases. Restricted to just outpatients, the average TTC was 10.4 days (SD 10.2) for pre-PRC cohort versus 6.3 days (SD 6.6) for the PRC cohort, which was statistically significant (p = 0.003). This was a 39% reduction in TTC. During the PRC period, 17 pts were not seen in the APP led PRC while 77 were seen in the PRC. The most common reason was an erroneous referral for curative intent treatment instead of palliative bone treatment. During the PRC period, those pts seen in the APP led PRC had an average TTC of 5.1 days (SD 4.6) versus 11.5 days (SD 10.64) for those not seen in the PRC (p = 0.03) with a 56% reduction in TTC.

CONCLUSION

The APP led PRC clinic significantly decreased time from referral to consultation for pts requiring urgent palliative RT for painful bone metastases. Further research is underway to determine if the PRC increases referrals, patients treated, patient satisfaction, and the impact on staffing RO.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Prevalence and Phylogenetic Analysis of Bartonella Species of Wild Carnivores and Their Fleas in Northwestern Mexico

The host-parasite-vector relationship of Bartonella spp. system in wild carnivores and their fleas from northwestern Mexico was investigated. Sixty-six carnivores belonging to eight species were sampled, and 285 fleas belonging to three species were collected during spring (April-May) and fall (October-November) seasons. We detected Bartonella species in 7 carnivores (10.6%) and 27 fleas (9.5%) through either blood culture or PCR. Of the 27 Bartonella-positive fleas, twenty-two were Pulex simulans, three were Pulex irritans and one was Echidnophaga gallinacea. The gltA gene and ITS region sequences alignment revealed six and eight genetic variants of Bartonella spp., respectively. These variants were clustered into Bartonella rochalimae, Bartonella vinsonii subsp. berkhoffii and another genotype, which likely represents a novel species of Bartonella spp. Although experimental infection studies are required to prove the vector role of P. simulans, our results suggest that this flea may play an important role in the Bartonella transmission. The results indicated possible host-specific relationships between Bartonella genotypes and the families of the carnivores, but further studies are needed to verify this finding. The presence of zoonotic species of Bartonella spp. in wild carnivores raises the issue of their potential risk for humans in fragmented ecosystems.

Abstract OT3-1-08: A phase II, randomized study of T-DM1 versus T-DM1 plus short induction with docetaxel in first line treatment for locally advanced or metastatic HER2+ breast cancer (SOLTI-1203)

Background: This study is founded upon the hypothesis that the addition of a short induction phase with docetaxel to the treatment with T-DM1 can improve efficacy with respect to T-DM1 administered as a single agent, in patients with advanced HER2 positive breast cancer who have not received previous treatment for the advanced disease. The rational for this approach is based on the results of the phase II randomized study of T-DM1 versus docetaxel trastuzumab, in which the administration of T-DM1 to the patients resulted in a statistically significant and clinically relevant improved progression free survival (PFS). One important observation with respect to this comparative study is that, in the T-DM1 arm, a higher number of patients progressed during the first six months than in the docetaxel trastuzumab arm. The existence of T-DM1 resistant patients, who progress during the first 6 months, highlights the need to explore new combinations with cytotoxic agents to induce an early response.

Study design: This is a phase II, prospective, randomized, open label, research study with two groups designed to assess the efficacy of T-DM1 together with short induction with docetaxel (SI docetaxel) versus T-DM1monotherapy treatment, in patients recently diagnosed with locally advanced or metastatic, progressive or recurrent, HER2+ breast cancer, who have not received previous chemotherapy for the advanced disease. The randomization will be carried out at a 1:1 ratio to one of the following two groups: 1.Monotherapy treatment regimen with T-DM1 at a dose of 3.6 mg/kg every 3 weeks until treatment finalization, 2.T-DM1 at a dose of 3.6 mg/kg on Day 1 and every 3 weeks until treatment finalization, together with docetaxel 60 mg/mg2 on Day 1 and every 3 weeks for a total of 4 treatment cycles.

Eligibility criteria: Female adults recently diagnosed with progressive or recurrent, locally advanced or metastatic HER2+ breast cancer, who have not received previous chemotherapy for the advanced disease.

Endpoints: The primary endpoint is to compare the early efficacy of the combination of T-DM1 together with SI docetaxel versus monotherapy treatment with T-DM1 measured as the PFS rate at 4 months. Secondary endpoints include comparison of the ORR, CBR, DR and OS of the combination versus monotherapy treatment Exploratory endpoints consist to assess if the PAM50 intrinsic subtypes (HER2-enriched in comparison with the rest) predict benefit of T-DM1 plus SI docetaxel or T-DM1 as monotherapy treatment, in terms of ORR and PFS.

Statistical methods: The considerations for the sample size are based on obtaining a statistical power of 80 % to be able to detect a difference in the rate of PFS at 4 months of 8% (83% in group A and 91% in group B), with a bilateral significance level of 5% and supposing a patient withdrawal rate of 10%. According to these calculations, the sample size is estimated at 236 patients. The analysis of the primary endpoint will be based on the Kaplan Meier estimate analysis.

Target accrual: Approximately 40 European sites from Spain, Portugal and Austria will be participating. The FPI is planned in October 2014.

Citation Format: Antonio Llombart, Javier Cortés, Eva Ciruelos, Xavier González, Lorena de la Peña, Patricia Villagrasa, Elena Bernedo, Katya Moreno, Susanne Meya, Jose Baselga. A phase II, randomized study of T-DM1 versus T-DM1 plus short induction with docetaxel in first line treatment for locally advanced or metastatic HER2+ breast cancer (SOLTI-1203) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr OT3-1-08.

Early-time symmetry tuning in the presence of cross-beam energy transfer in ICF experiments on the National Ignition Facility

On the National Ignition Facility, the hohlraum-driven implosion symmetry is tuned using cross-beam energy transfer (CBET) during peak power, which is controlled by applying a wavelength separation between cones of laser beams. In this Letter, we present early-time measurements of the instantaneous soft x-ray drive at the capsule using reemission spheres, which show that this wavelength separation also leads to significant CBET during the first shock, even though the laser intensities are 30× smaller than during the peak. We demonstrate that the resulting early drive P2/P0 asymmetry can be minimized and tuned to <1% accuracy (well within the ±7.5% requirement for ignition) by varying the relative input powers between different cones of beams. These experiments also provide time-resolved measurements of CBET during the first 2 ns of the laser drive, which are in good agreement with radiation-hydrodynamics calculations including a linear CBET model.

Precision shock tuning on the national ignition facility

Ignition implosions on the National Ignition Facility [J. D. Lindl et al., Phys. Plasmas 11, 339 (2004)] are underway with the goal of compressing deuterium-tritium fuel to a sufficiently high areal density (ρR) to sustain a self-propagating burn wave required for fusion power gain greater than unity. These implosions are driven with a very carefully tailored sequence of four shock waves that must be timed to very high precision to keep the fuel entropy and adiabat low and ρR high. The first series of precision tuning experiments on the National Ignition Facility, which use optical diagnostics to directly measure the strength and timing of all four shocks inside a hohlraum-driven, cryogenic liquid-deuterium-filled capsule interior have now been performed. The results of these experiments are presented demonstrating a significant decrease in adiabat over previously untuned implosions. The impact of the improved shock timing is confirmed in related deuterium-tritium layered capsule implosions, which show the highest fuel compression (ρR~1.0 g/cm(2)) measured to date, exceeding the previous record [V. Goncharov et al., Phys. Rev. Lett. 104, 165001 (2010)] by more than a factor of 3. The experiments also clearly reveal an issue with the 4th shock velocity, which is observed to be 20% slower than predictions from numerical simulation.

Assembly of high-areal-density deuterium-tritium fuel from indirectly driven cryogenic implosions

The National Ignition Facility has been used to compress deuterium-tritium to an average areal density of ~1.0±0.1 g cm(-2), which is 67% of the ignition requirement. These conditions were obtained using 192 laser beams with total energy of 1-1.6 MJ and peak power up to 420 TW to create a hohlraum drive with a shaped power profile, peaking at a soft x-ray radiation temperature of 275-300 eV. This pulse delivered a series of shocks that compressed a capsule containing cryogenic deuterium-tritium to a radius of 25-35 μm. Neutron images of the implosion were used to estimate a fuel density of 500-800 g cm(-3).

202 EFFECTS OF ASCORBIC ACID ON IN VITRO CULTURE OF CATTLE PREANTRAL FOLLICLES

The mechanisms that regulate the gradual exit of ovarian follicles from the nongrowing, primordial pool are poorly understood. The objective of this study was to evaluate the effects of adding ascorbic acid to the media for in vitro culture of cattle ovarian fragments and to determine the effects of this addition on the growth activation and viability of preantral follicles. The ovarian cortex was divided into small fragments; 1 fragment was immediately fixed in Bouin’s solution (control). The other fragments were cultured for 2, 4, 6, or 8 days on culture plates in minimum essential medium (MEM) supplemented with insulin-transferrin-selenium (ITS), pyruvate, glutamine, hypoxantine, BSA, and antibiotics (MEM+) or in MEM+ plus ascorbic acid (5, 25, 50, 100, or 200 μg mL-1). Ovarian tissue was processed for classical histology, TEM, and immunohistochemical demonstration of proliferating cell nuclear antigen (PCNA). Preantral follicles were classified according to their development stage (primordial, intermediate, primary, and secondary) and on the basis of morphological features (normal or degenerated). Pair-wise comparisons were done using Tukey’s procedure. Chi-square test was used to compare percentages of follicles with PCNA-positive granulosa cells. All analyses were done with Statistical Analysis System (SAS Institute, Cary, NC, USA); P ≤ 0.05 was considered significant. Compared with control fragments, the percentage of primordial follicles was reduced (P ≤ 0.05) and the percentage of growing follicles was increased (P ≤ 0.05) in cultured cortical fragments, independent of the tested medium or incubation time. Furthermore, compared with control tissue, culture of ovarian cortex for 8 days reduced the percentages of healthy, viable follicles (P ≤0.05), but not when cultures were supplemented with 25, 50, and 100 μg mL-1 of ascorbic acid. Ultrastructural and immunohistochemical analysis of ovarian cortical fragments cultured for 8 days, however, showed the integrity and viability of follicles only when fragments were cultured in the presence of 50 μg mL-1 of ascorbic acid. In conclusion, this study demonstrated that addition of ascorbic acid to MEM at a concentration of 50 μg mL-1 not only stimulates the activation and subsequent growth of cattle primordial follicles that are cultured in vitro for 8 days but also safeguards the viability of these preantral follicles. E. R. Andrade and A. A. Alfieri are recipients of the PRODOC/CAPES fellowship.

325 VIABILITY AND GROWTH OF CATTLE PREANTRAL FOLLICLES AFTER IN VITRO CULTURE OF OVARIAN FRAGMENTS IN α-TOCOPHEROL

The development of culture systems to support the initiation of growth of primordial follicles is important to the study of the factors that control the earliest stages of folliculogenesis. The aims of the present study were to investigate the effects of α-tocopherol on survival, activation, and growth of cattle preantral follicles using histological and immunohistochemistry proliferating cell nuclear antigen (PCNA) studies. The ovarian cortex was divided into small fragments; one fragment was immediately fixed in Bouin (control). The other fragments were cultured for 2, 4, 6, or 8 d in culture plates with Minimum Essential Medium supplemented with insulin-transferrin-selenium (ITS), pyruvate, glutamine, hypoxanthine, BSA, and antibiotics (MEM+); and MEM+ plus α-tocopherol (5, 25, 50, 100, or 200 ng mL-1). Preantral follicles were classified according to their developmental stage (primordial, intermediate, primary, or secondary) and on the basis of morphological features (normal or degenerated). Pair-wise comparisons were done using Tukey’s procedure. Chi-square test was used to compare the percentage of follicles with PCNA-positive granulosa cells. All analyses were done with the SAS software (SAS Institute, Cary, NC, USA), and P < 0.05 was considered significant. The results showed that, compared with non-cultured cortical tissue (Day 0), the culture of ovarian tissue significantly reduced (P < 0.05) the percentage of normal follicles in all media tested, except for tissue cultured in the presence of 200 ng mL-1 of a-tocopherol. Furthermore, in all media tested, the percentage of primordial follicles was significantly reduced (P < 0.05), with a concomitant increase in the percentage of developing follicles. The highest percentage of secondary follicles was observed after 6 days of culture in MEM plus 200 ng mL-1 of a-tocopherol. The PCNA analysis confirmed the viability of follicles cultured with 200 ng mL-1 of a-tocopherol after 6 d. After 8 days of in vitro culture, we observed severe follicular degeneration in all media tested, suggesting that other supplements are recommended for longer periods of culture. In conclusion, the results of the present study indicate that 200 ng mL-1 of a-tocopherol maintains the survival of cattle preantral follicles and promotes activation of primordial follicles after 6 days of in vitro culture. Financial support: L. A. Lisboa is a recipient of CAPES support; E. R. Andrade and A. A. Alfieri are recipients of PRODOC/CAPES fellowships.

Oral glutamine in addition to parenteral nutrition improves mortality and the healing of high-output intestinal fistulas

OBJECTIVE

Anastomotic leakage is one of the most important causes of morbidity and mortality in gastrointestinal surgery. We investigated the effect of oral glutamine on the healing of high-output intestinal fistula.

SETTING

A tertiary Universitary Hospital of the University of Mato Grosso, Cuiaba, Brazil.

PATIENTS AND METHODS

28 patients (25 males and 3 females; median age = 45 [18-71] years old) admitted with high output post-operative small bowel fistulas (median volume in 24 h: 850 [600-2,200] mL) during a 4 years period were retrospectively studied.

INTERVENTIONS

In the first two years 19 (67.9%) patients received only TPN as the initial nutritional support. In the last two years however, due to a change in the protocol for the nutritional support in cases of intestinal fistula 9 patients (32.1%) received oral glutamine (0.3 g/kg/day; 150 mL/day) in addition to TPN. Endpoints of the study were mortality, resolution of the fistula, and length of hospital stay (LOS).

RESULTS

The overall mortality was 46.4% (13 patients). Fistula closure was observed in all other 15 patients (53.6%) that survived. In the subset of survived patients LOS was similar in those who received or not received glutamine. The multivariate regression analysis showed that resolution of the fistula was 13 times greater in patients that received oral glutamine (OR = 13.2 (95% CI = 1.1-160.5); p = 0.04) and 15 times greater in non-malnourished patients (OR = 15.4 [95% CI = 1.1-215.5]; p = 0.04).

CONCLUSIONS

We conclude that oral glutamine accelerated the healing and diminished the mortality in this series of patients with post-operative high-output intestinal fistula receiving TPN.