Use of a 3D camera for automated patient positioning for chest-abdomen-pelvis CT scans: Effect on positioning accuracy and patient dose

INTRODUCTION

3D positioning cameras that automate the positioning of patients with respect to the CT isocentre have been developed and are in common use in CT departments. This study aimed to compare the performance of radiographers and a 3D camera system with respect to positioning accuracy and the effect on patient radiation dose for chest-abdomen-pelvis scans.

METHODS

Patient positioning and dose data obtained from a dose management system was evaluated over a two-month period for patients positioned with (CAMon) and without (CAMoff) the positioning camera. Median vertical and lateral offset values were compared between the groups whilst doses were evaluated as a function of patient water equivalent diameter (WED) for the thorax and abdomen-pelvis acquisitions for both cohorts.

RESULTS

Radiographers demonstrated high levels of positioning accuracy, however significant improvements in median vertical offset were identified for the CAMon cohort for both thorax (8 mm vs. 17 mm (p = 0.001)) and abdomen-pelvis (7 mm vs. 16 mm (p = 0.003)) scans. The percentage of patients positioned within 5 mm of the isocentre was 39.0% and 16.1% for the CAMon and CAMoff cohorts. For CAMoff scans, 77.4% of patients were positioned below the isocentre, but this was reduced to 45.8% for CAMon scans. No significant changes in dose as a function of WED were identified related to the camera use (thorax: p = 0.569, abdomen-pelvis: p = 0.760).

CONCLUSION

Use of a 3D camera delivered significant improvements in the accuracy and reproducibility of patient positioning when compared with radiographers.

IMPLICATIONS FOR PRACTICE

Improvements in positioning accuracy were observed at the research site and hence positioning camera use has the potential to become standard practice in CT to help ensure appropriate doses are delivered to patients according to their size.

Integrating circulating T follicular memory cells and autoantibody repertoires for characterization of autoimmune disorders

Introduction

Autoimmune diseases are heterogeneous and often lack specific or sensitive diagnostic tests. Increased percentages of CD4+CXCR5+PD1+ circulating T follicular helper (cTfh) cells and skewed distributions of cTfh subtypes have been associated with autoimmunity. However, cTfh cell percentages can normalize with immunomodulatory treatment despite persistent disease activity, indicating the need for identifying additional cellular and/or serologic features correlating with autoimmunity.

Methods

The cohort included 50 controls and 56 patients with autoimmune cytopenias, gastrointestinal, pulmonary, and/or neurologic autoimmune disease. Flow cytometry was used to measure CD4+CXCR5+ T cell subsets expressing the chemokine receptors CXCR3 and/or CCR6: CXCR3+CCR6- Type 1, CXCR3-CCR6- Type 2, CXCR3+CCR6+ Type 1/17, and CXCR3- CCR6+ Type 17 T cells. IgG and IgA autoantibodies were quantified using a microarray featuring 1616 full-length, conformationally intact protein antigens. The 97.5th percentile in the control cohort defined normal limits for T cell subset percentages and total number (burden) of autoantibodies.

Results

This study focused on CD4+CXCR5+ T cells because CXCR5 upregulation occurs after cognate T-B cell interactions characteristic of autoimmune diseases. We refer to these cells as circulating T follicular memory (cTfm) cells to acknowledge the dynamic nature of antigen-experienced CXCR5+ T cells, which encompass progenitors of cTfh or Tfh cells as well as early effector memory T cells that have not yet lost CXCR5. Compared to controls, 57.1% of patients had increased CXCR5+CXCR3+CCR6+ cTfm1/17 and 25% had increased CXCR5+CXCR3-CCR6+ cTfm17 cell percentages. Patients had significantly more diverse IgG and IgA autoantibodies than controls and 44.6% had an increased burden of autoantibodies of either isotype. Unsupervised autoantibody clustering identified three clusters of patients with IgG autoantibody profiles distinct from those of controls, enriched for patients with active autoimmunity and monogenic diseases. An increased percentage of cTfm17 cells was most closely associated with an increased burden of high-titer IgG and IgA autoantibodies. A composite measure integrating increased cTfm1/17, cTfm17, and high-titer IgG and/or IgA autoantibodies had 91.1% sensitivity and 90.9% specificity for identifying patients with autoimmunity. Percentages of cTfm1/17 and cTfm17 percentages and numbers of high-titer autoantibodies in patients receiving immunomodulatory treatment did not differ from those in untreated patients, thus suggesting that measurements of cTfm can complement measurements of other cellular markers affected by treatment.

Conclusions

This study highlights two new approaches for assessing autoimmunity: measuring CD4+CXCR5+ cTfm subsets as well as total burden of autoantibodies. Our findings suggest that these approaches are particularly relevant to patients with rare autoimmune disorders for whom target antigens and prognosis are often unknown.

ST3 beta-galactoside alpha-2,3-sialyltransferase 1 (ST3Gal1) synthesis of Siglec ligands mediates anti-tumour immunity in prostate cancer

Immune checkpoint blockade has yet to produce robust anti-cancer responses for prostate cancer. Sialyltransferases have been shown across several solid tumours, including breast, melanoma, colorectal and prostate to promote immune suppression by synthesising sialoglycans, which act as ligands for Siglec receptors. We report that ST3 beta-galactoside alpha-2,3-sialyltransferase 1 (ST3Gal1) levels negatively correlate with androgen signalling in prostate tumours. We demonstrate that ST3Gal1 plays an important role in modulating tumour immune evasion through the synthesises of sialoglycans with the capacity to engage the Siglec-7 and Siglec-9 immunoreceptors preventing immune clearance of cancer cells. Here, we provide evidence of the expression of Siglec-7/9 ligands and their respective immunoreceptors in prostate tumours. These interactions can be modulated by enzalutamide and may maintain immune suppression in enzalutamide treated tumours. We conclude that the activity of ST3Gal1 is critical to prostate cancer anti-tumour immunity and provide rationale for the use of glyco-immune checkpoint targeting therapies in advanced prostate cancer.

Recurrent MTOR Mutations in Renal Cell Carcinoma With Fibromyomatous Stroma: A Report of 2 Tumors

Renal cell carcinoma with fibromyomatous stroma, recognized as a provisional entity in the current 2022 World Health Organization classification of renal neoplasms, is rare. Recent evidence suggests recurrent alterations in the mTOR pathway, supporting its recognition as a distinct entity. Herein, we report 2 renal cell carcinomas with fibromyomatous stroma with MTOR mutations occurring in 62- and 72-year-old women and review the literature to support its recognition as a distinct entity, focusing on the characteristic morphology, immunohistochemical staining patterns as well as genetic alterations.

Single-Port Robotic-Assisted Excision of the Urachal Remnant in an Adult Female: A Case Report

Urachal anomalies and their associated disease processes are quite rare in pediatric populations and even rarer in adults. Although often asymptomatic, patients with symptoms can be treated with a combination of surveillance, antibiotics, and sometimes surgical resection. In this case, we describe our experience using the single-port robotic approach for the excision of a symptomatic urachal remnant. The patient presented with a chief complaint of urinary frequency, dysuria, intermittent hematuria, and right flank pain. A CT scan of the abdomen and pelvis revealed a bladder wall thickening at the dome of the bladder measuring 2.6 x 3.6 x 1.5 cm with concerns for adenocarcinoma. The patient subsequently underwent a biopsy, which was benign. The patient's symptoms persisted, and she elected to undergo surgical resection. Postoperatively, her symptoms resolved, and she was satisfied with her treatment outcome. This case exemplifies the feasibility of the single-port robotic approach to urachal remnant excision, with further applicability to simple transabdominal robotic bladder surgery.

What Do Psychiatrists Think About Caring for Patients Who Have Extremely Treatment-Refractory Illness?

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments.

Improvements in Survival and Clinical Benefit With Gemcitabine as First-Line Therapy for Patients With Advanced Pancreas Cancer: A Randomized Trial

PURPOSE

Most patients with advanced pancreas cancer experience pain and must limit their daily activities because of tumor-related symptoms. To date, no treatment has had a significant impact on the disease. In early studies with gemcitabine, patients with pancreas cancer experienced an improvement in disease-related symptoms. Based on those findings, a definitive trial was performed to assess the effectiveness of gemcitabine in patients with newly diagnosed advanced pancreas cancer.

PATIENTS AND METHODS

One hundred twenty-six patients with advanced symptomatic pancreas cancer completed a lead-in period to characterize and stabilize pain and were randomized to receive either gemcitabine 1,000 mg/m2 weekly x 7 followed by 1 week of rest, then weekly x 3 every 4 weeks thereafter (63 patients), or to fluorouracil (5-FU) 600 mg/m2 once weekly (63 patients). The primary efficacy measure was clinical benefit response, which was a composite of measurements of pain (analgesic consumption and pain intensity), Karnofsky performance status, and weight. Clinical benefit required a sustained (> or = 4 weeks) improvement in at least one parameter without worsening in any others. Other measures of efficacy included response rate, time to progressive disease, and survival.

RESULTS

Clinical benefit response was experienced by 23.8% of gemcitabine-treated patients compared with 4.8% of 5-FU-treated patients (P = .0022). The median survival durations were 5.65 and 4.41 months for gemcitabine-treated and 5-FU-treated patients, respectively (P = .0025). The survival rate at 12 months was 18% for gemcitabine patients and 2% for 5-FU patients. Treatment was well tolerated.

CONCLUSION

This study demonstrates that gemcitabine is more effective than 5-FU in alleviation of some disease-related symptoms in patients with advanced, symptomatic pancreas cancer. Gemcitabine also confers a modest survival advantage over treatment with 5-FU.

Symptomatic idiopathic intracranial hypertension triggered by Ramadan intermittent fasting: a case report

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a disorder that primarily affects obese women of reproductive age. The exact pathogenesis of IIH is unknown though multiple etiologies have been proposed.

CASE PRESENTATION

We report a case of IIH triggered by first-time Ramadan intermittent fasting (RIF) in an 18-year-old woman. Our patient developed new onset headaches, diplopia, and pulsatile tinnitus with examination notable for bilateral papilledema and lumbar puncture revealing an elevated opening pressure. Her symptoms resolved after cessation of RIF, apart from persistent left sided tinnitus which later resolved with acetazolamide administration.

CONCLUSION

This case report uniquely illustrates that RIF may provoke symptomatic IIH. We hypothesize that a decreased concentration of glucagon-like peptide-1 (GLP-1) induced by fasting results in decreased GLP-1 receptor activation in the choroid plexus, allowing for increased CSF secretion into the ventricles invoking increased intracranial pressure (ICP). This theoretical mechanism provides further insight as to the possible underlying pathophysiology of IIH.

Association between Prostate Carcinoma and Multiple Myeloma

Synchronous or sequential development of multiple myeloma and prostate carcinoma is rare. It is not sure whether these two occur independently or if one influences the development of the other. We reviewed the cases published in the English literature; eight cases of myeloma developing after diagnosis and treatment for prostate carcinoma, five cases of simultaneous occurrence of myeloma and prostate carcinoma, and five cases where the patient with multiple myeloma later developed prostate carcinoma were found. This short review attempts to analyze the occurrence of these two diseases in the same patient and dissect whether there is a close association or it is just a mere coincidence.

Improving Sexual Orientation and Gender Identity Documentation at an NCI-Designated Comprehensive Cancer Center

PURPOSE/OBJECTIVE(S)

To increase the rate of sexual orientation and gender identity (SOGI) patient data collection in healthcare software for new patients at a NCI-Designated Comprehensive Cancer Center, via targeted identification of Advanced Practice Providers (APP), development of novel SOGI collection workflows, creation of a real-time SOGI data dashboard, and tailored training utilizing existing High Reliability Organization (HRO) huddles in order to measure, analyze, and improve the quality of care, safety, and patient experiences for Sexual and Gender Minority (SGM) patients.

MATERIALS/METHODS

Prior to interventions, project leadership (PL) and data analytics staff obtained SOGI baseline data, while cancer center clinical leadership, registration, and administrative staff identified APPs as the most appropriate staff to collect patient SOGI data. Intervention 1: PL met with Disease Management Groups (DMG)/HRO leads of thoracic medical oncology to identify a practice-level APP champion. PL and the APP champion scripted language for multiple scenarios when asking SOGI questions, and served as a resource for additional practice APPs. PL provided SGM-focused training during HRO huddles, which included how to ask and document SOGI, and significance of asking SOGI information. SOGI data completion rate was tracked on a HRO scorecard. This intervention was replicated across additional DMG/HROs during the study period. Intervention 2: Breast surgical oncology completed Intervention 1 and added SOGI questions to their new patient-facing intake form, allowing patients to self-identify. PL and data analytics team provided continuous feedback to DMG/HRO leads on provider-level completion rates and additional education as needed.

RESULTS

At the end of the Interventions, there were 9 LGBTQ+ Knowledge and Awareness HRO training sessions completed resulting in over 300 unique individuals receiving advanced SOGI documentation education. For intervention 1, there were 12,322 new patients asked their SOGI information, which was a greater than 300% increase in SOGI documentation (baseline completion rate for sexual orientation and gender identity was 17% and 21%, respectively, which improved to 77% and 84%). For intervention 2, there were 3,217 new patients asked their SOGI information, which was a greater than 400% increase (baseline completion rate for sexual orientation and gender identity was 13% and 16%, respectively, which improved to 81% and 81%).

CONCLUSION

Together, patient self-reporting quickly increased data completion rates from baseline, comparable to clinical sites from Intervention 1, and may decrease the burden of APPs collecting SOGI history; however, clinical review of questions is important and may further increase SOGI data completion. Leadership buy-in, site champions, and active data monitoring are essential to measurable change. Together, improved SOGI data completion will allow for improved equitable cancer care and increased assessment of SGM cancer disparities.

Engineering prostate cancer in vitro: what does it take?

A key challenge in the clinical management and cause of treatment failure of prostate cancer (PCa) is its molecular, cellular and clinical heterogeneity. Modelling systems that fully recapitulate clinical diversity and resistant phenotypes are urgently required for the development of successful personalised PCa therapies. The advent of the three-dimensional (3D) organoid model has revolutionised preclinical cancer research through reflecting heterogeneity and offering genomic and environmental manipulation that has opened up unparalleled opportunities for applications in disease modelling, high-throughput drug screening and precision medicine. Despite these remarkable achievements of organoid technology, several shortcomings in emulating the complex tumor microenvironment and dynamic process of metastasis as well as the epigenome profile limit organoids achieving true in vivo functionality. Technological advances in tissue engineering have enabled the development of innovative tools to facilitate the design of improved 3D cancer models. In this review, we highlight the current in vitro 3D PCa models with a special focus on organoids and discuss engineering approaches to create more physiologically relevant PCa organoid models and maximise their translational relevance that ultimately will help to realise the transformational power of precision medicine.

Increased Bone Marrow Uptake and Accumulation of Very-Late Antigen-4 Targeted Lipid Nanoparticles

Lipid nanoparticles (LNPs) have evolved rapidly as promising delivery systems for oligonucleotides, including siRNAs. However, current clinical LNP formulations show high liver accumulation after systemic administration, which is unfavorable for the treatment of extrahepatic diseases, such as hematological disorders. Here we describe the specific targeting of LNPs to hematopoietic progenitor cells in the bone marrow. Functionalization of the LNPs with a modified Leu-Asp-Val tripeptide, a specific ligand for the very-late antigen 4 resulted in an improved uptake and functional siRNA delivery in patient-derived leukemia cells when compared to their non-targeted counterparts. Moreover, surface-modified LNPs displayed significantly improved bone-marrow accumulation and retention. These were associated with increased LNP uptake by immature hematopoietic progenitor cells, also suggesting similarly improved uptake by leukemic stem cells. In summary, we describe an LNP formulation that successfully targets the bone marrow including leukemic stem cells. Our results thereby support the further development of LNPs for targeted therapeutic interventions for leukemia and other hematological disorders.

All-Epiphyseal Anterior Cruciate Ligament Repair Using Suture Ring Device in the Skeletally Immature Patient

Anterior cruciate ligament (ACL) tears in pediatric patients pose distinct challenges in management, especially in patients with open distal femoral and proximal tibial physes. There are a variety of contemporary reconstruction techniques that attempt to address these challenges. However, with the resurgence of ACL repair in the adult population, it has become apparent that the pediatric patient may also benefit from primary ACL repair rather than reconstruction. ACL repair is a procedure performed to treat ACL tears that avoids the donor-site morbidity seen with ACL reconstruction using autograft. We describe a surgical technique involving FiberRing sutures (Arthrex, Naples, FL) and TightRope-internal brace fixation (Arthrex) for ACL repair with all-epiphyseal fixation in the pediatric patient. The FiberRing is a knotless, tensionable suture device that can be used to stitch the torn ACL and coupled with the TightRope and internal brace to fix the ACL.

A novel technique for subscapularis repair in total shoulder arthroplasty

Anatomic total shoulder arthroplasty, when used for treatment of primary glenohumeral arthritis, is historically very successful. We propose a novel technique for subscapularis repair during closure of a deltopectoral approach to the shoulder with subscapularis peel. Our technique allows for early motion following surgery and also provides for improved subscapularis repair integrity and resilience during postoperative rehabilitation. Postoperatively, we allow passive and active assisted range of motion at week 1, limited active range of motion at week 2, and unrestricted external rotation range of motion beginning at week 6. The use of our technique has led to improved patient outcomes with regard to range of motion postoperatively following anatomic total shoulder arthroplasty and we recommend its adoption into practice.

hiPSC-derived bone marrow milieu identifies a clinically actionable driver of niche-mediated treatment resistance in leukemia

Leukemia cells re-program their microenvironment to augment blast proliferation and enhance treatment resistance. Means of clinically targeting such niche-driven treatment resistance remain ambiguous. We develop human induced pluripotent stem cell (hiPSC)-engineered niches to reveal druggable cancer-niche dependencies. We reveal that mesenchymal (iMSC) and vascular niche-like (iANG) hiPSC-derived cells support ex vivo proliferation of patient-derived leukemia cells, affect dormancy, and mediate treatment resistance. iMSCs protect dormant and cycling blasts against dexamethasone, while iANGs protect only dormant blasts. Leukemia proliferation and protection from dexamethasone-induced apoptosis is dependent on cancer-niche interactions mediated by CDH2. Consequently, we test CDH2 antagonist ADH-1 (previously in Phase I/II trials for solid tumors) in a very aggressive patient-derived xenograft leukemia mouse model. ADH-1 shows high in vivo efficacy; ADH-1/dexamethasone combination is superior to dexamethasone alone, with no ADH-1-conferred additional toxicity. These findings provide a proof-of-concept starting point to develop improved, potentially safer therapeutics targeting niche-mediated cancer dependencies in blood cancers.

Luxatio Erecta Humeri After a Ground-Level Fall in an Elderly Woman With a History of Ipsilateral Rotator Cuff Repair: A Case Report

Luxatio erecta humeri is an infrequent type of glenohumeral dislocation. The pathophysiologic mechanism responsible for luxatio erecta humeri is a traumatic incident of direct axial loading or a rapid hyperabduction injury. Patients commonly present with severe shoulder pain and the classic appearance of their arm externally rotated and stuck in abduction overhead. Radiographs help confirm the diagnosis by showing the humeral shaft parallel to the scapular spine and the humeral head inferior to the glenoid. Prompt recognition, neurovascular assessment, and reduction are necessary. This case details an incident of luxatio erecta humeri in an 83-year-old female after a ground-level fall with a history of ipsilateral rotator cuff repair greater than 20 years ago. She had subjective numbness in her fingers that resolved post-reduction. Anesthesia assisted in safely sedating the patient for orthopedics to successfully perform a closed reduction by combining techniques from the two most described maneuvers. The patient was discharged in a shoulder immobilizer for follow-up outpatient and later scheduled for reverse total shoulder arthroplasty.

Development of a Practical Synthesis of the Fragment of OPC-167832

A concise and practical synthesis has been developed to provide the 8-fluoro-5-hydroxy-3,4-diydrocarbostyril (8-FDC) fragment of OPC-167832 in 41% yield and in >99% purity over four steps from 3-amino-4-fluorophenol. The key feature of this process is the development of a telescoped one-pot synthesis of the quinolone via a chemoselective amidation/acid-induced cyclization that allows for simple product isolation without the need for column chromatography.

Evidence for osteocyte-mediated bone-matrix degradation associated with periprosthetic joint infection (PJI)

Osteomyelitis associated with periprosthetic joint infection (PJI) signals a chronic infection and the need for revision surgery. An osteomyelitic bone exhibits distinct morphological features, including evidence for osteolysis and an accelerated bone remodelling into poorly organised, poor-quality bone. In addition to immune cells, various bone cell-types have been implicated in the pathology. The present study sought to determine the types of bone-cell activities in human PJI bones. Acetabular biopsies from peri-implant bone from patients undergoing revision total hip replacement (THR) for chronic PJI (with several identified pathogens) as well as control bone from the same patients and from patients undergoing primary THR were analysed. Histological analysis confirmed that PJI bone presented increased osteoclastic activity compared to control bone. Analysis of osteocyte parameters showed no differences in osteocyte lacunar area between the acetabular bone taken from PJI patients or primary THR controls. Analysis of bone matrix composition using Masson's trichrome staining and second-harmonic generation microscopy revealed widespread lack of mature collagen, commonly surrounding osteocytes, in PJI bone. Increased expression of known collagenases, such as matrix metallopeptidase (MMP) 13, MMP1 and cathepsin K (CTSK), was measured in infected bone compared to non-infected bone. Human bone and cultured osteocyte-like cells experimentally exposed to Staphylococcus aureus exhibited strongly upregulated expression of MMP1, MMP3 and MMP13 compared to non-exposed controls. In conclusion, the study identified previously unrecognised bone-matrix changes in PJI caused by multiple organisms deriving from osteocytes. Histological examination of bone collagen composition may provide a useful adjunct diagnostic measure of PJI.

Ganglion cells in larval zebrafish retina integrate inputs from multiple cone types

We recently showed the presence of seven physiological cone opsins-R1 (575 nm), R2 (556 nm), G1 (460 nm), G3 (480 nm), B1 (415 nm), B2 (440 nm), and UV (358 nm)-in electroretinogram (ERG) recordings of larval zebrafish (Danio rerio) retina. Larval ganglion cells (GCs) are generally thought to integrate only four cone opsin signals (red, green, blue, and UV). We address the question as to whether they may integrate seven cone spectral signals. Here we examined the 127 possible combinations of seven cone signals to find the optimal representation, as based on impulse discharge data sets from GC axons in the larval optic nerve. We recorded four varieties of light-response waveform, sustained-ON, transient-ON, ON-OFF, and OFF, based on the time course of mean discharge rates to all stimulus wavelengths combined. Modeling of GC responses revealed that each received 1-6 cone opsin signals, with a mean of 3.8 ± 1.3 cone signals/GC. Most onset or offset responses were opponent (ON, 80%; OFF, 100%). The most common cone signals were UV (93%), R2 (50%), G3 (55%), and G1 (60%). Seventy-three percent of cone opsin signals were excitatory, and 27% were inhibitory. UV signals favored excitation, whereas G3 and B2 signals favored inhibition. R1/R2, G1/G3, and B1/B2 opsin signals were selectively associated along a nonsynergistic/opponent axis. Overall, these results suggest that larval zebrafish GC spectral responses are complex and use inputs from the seven expressed opsins.NEW & NOTEWORTHY Ganglion cells in larval zebrafish retina have complex spectral responses driven by seven different cone opsin types. UV cone inputs are significant and excitatory to ganglion cells, whereas green and blue cone inputs favor inhibition. Most dramatic are the pentachromatic cells. These responses were identified at 5-6 days after fertilization, reflecting an impressive level of color processing not seen in older fish or mammals.

134 Quantitative Assessment of Visual Function for Pituitary Macroadenomas: A Practical Scoring Algorithm

Introduction

There is a myriad of existing terms by which visual capacity is recorded. The lack of a standardised categorisation of observations commonly results in ambiguities. We report the utility of a visual function score (VFS) in patients managed by transsphenoidal surgery.

Method

A VFS (expressed as a percentage) with a maximum score of 20 was calculated for each eye using the Snellen VA (40% weighting: score 0-8) and Humphrey Allergan 30-2 automated visual field (60% weighting: score 0-12).

Results

280 patients (560 eyes) underwent transsphenoidal pituitary adenoma resections with complete pre- and post-operative visual function assessment. Mean age 56 years; 56.4% male. 26.1% were treated by endoscopic technique and 73.9% were treated by microscopic technique. Pre-operative vision was normal in 38.0% eyes. All these had full post-operative vision. In patients with pre-operative visual loss (347 eyes), the mean pre-operative VFS rose from 70.8% to 87.5% post-operatively. 43.8% eyes attained full post-operative vision, 28% improved, and 25.6% remained unchanged. 9 patients (2.6%) had worse immediate post-operative vision.

Conclusions

The VFS is a convenient single measure of visual function that may facilitate local and national audit of transsphenoidal surgery. Studies are planned to correlate this with patient reported visual quality of life measures.

A Pseudo-Infarction Pattern in the Setting of Esophageal Malignancy

A 57-year-old African American male was admitted for workup of unintentional weight loss. He was found to have an esophageal squamous cell carcinoma. Electrocardiogram (ECG) readings demonstrated deep Q waves in leads V1-V2 with T wave flattening, which raised concern for a septal infarct. Myocardial infarction (MI) was subsequently ruled out through clinical, imaging, and laboratory analysis. The ECG findings were deemed as a pseudo-infarct pattern in the setting of squamous cell carcinoma of the esophagus.

Sustaining tuberculosis preventive therapy scale-up through direct supportive supervision

Background

Tuberculosis preventive therapy (TPT) is recommended for tuberculosis (TB) prevention among people living with HIV (PLHIV) and other high-risk groups. The Nigerian Military HIV Program embarked on TPT-specific 'direct supportive supervision' (DSS) in May 2018 to increase TPT initiation and completion rates.

Methods

Interventional approaches included site visits to conduct root cause analysis, didactic teaching approach on the concepts of quality improvement and mentorship to address barriers. The DSS introduced TPT monitoring tools, sticker reminders on clients' folders, and bi-weekly data collection and review for decision making.

Results

TPT initiation increased from a monthly pre-intervention median of 323 clients to monthly medians of 2611 during the 'surge' and 1212 clients during the 'sustained' phases. Due to an isoniazid stock-out, a 'dip phase', with a median of 559 clients was recorded. Overall, 10 463 clients were started on TPT in fiscal year (FY) 2018 and 12 596 in FY2019, with an overall initiation rate of 79%. Completion rates were respectively 73% and 70% for FY2018 and FY2019.

Conclusion

With the implementation of a tailored DSS, programmatic barriers to TPT were easily identified and quickly addressed to increase initiation and completion rates.

Removal of Ioban May Pull Bacteria to the Surface of the Skin: Lessons Learned

CONTEXT

METHODS

RESULTS

CONCLUSIONS

Improving indicators of tuberculosis program cascades by leveraging HIV program strategies

Background

To improve rates of human immunodeficiency virus (HIV) case detection and treatment, the Nigerian Ministry of Defense Health Implementation Program and the US Army Medical Research Directorate-Africa/Nigeria introduced a HIV standard of care (SOC) package. Given the integration of tuberculosis (TB) and HIV programs and evolving policies, we evaluated the impact of this strategy on TB program indicators.

Methods

Routine, de-identified program data from 27 Nigerian military hospitals were analyzed. Using Wilcoxon signed-rank test, bivariate analyses were performed to compare data from 12 months before and after implementation of the SOC package.

Results

Our data showed improvements post-implementation as follows: the number of individuals receiving antiretroviral therapy (ART) screened for TB increased from 14 530 to 29 467 (P < 0.001); the number of individuals with presumptive TB identified increased from 803 to 1800 (P < 0.001); the number of ART clients bacteriologically tested for TB increased from 746 to 1717 (P < 0.001); and the number of ART clients treated for TB increased from 152 to 282 (P < 0.001). Newly registered or relapsed TB cases increased from 436 to 906 (P < 0.001), the number of TB cases with known HIV status increased from 437 to 837 (P < 0.001), the number of TB-HIV co-infected cases increased from 182 to 301 (P = 0.006), and the number of TB-HIV co-infected clients who started ART increased from 101 to 176 (P = 0.003).

Conclusion

The implementation of the updated HIV SOC package led to the improvement in key TB diagnosis and treatment indicators. When emulated, this could help improve the performance of other TB programs in countries other than Nigeria.

Economic benefits of adaptive abiraterone therapy for advanced prostate cancer

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Background: We recently completed a study showing that adaptive abiraterone therapy (AT) led to more than a doubling of the time to radiographic progression (TTP) compared to continuous therapy (CT) in patients with metastatic castration resistant prostate cancer (mCRPC), [Nat Commun. 2017; 1816]. This study compared the cost of care in the AT cohort versus the standard of care CT cohort. Methods: We conducted a retrospective economic analysis of mCRPC patients receiving intermittent AT compared to patients receiving CT abiraterone. The study followed the adaptive therapy trial protocol (NCT02415621). The primary endpoints were costs of care per patient per year and cost per treatment month. We used itemized billing data and standardized to Medicare reimbursement rates to determine the pharmacy, lab, and imaging costs. Results: Patients receiving adaptive abiraterone therapy (N = 15) had a mean annual cost of care of $80,668 compared to a mean annual cost of care of $132,631 for CT patients. The cost of treatment per month was $6,713 for the AT versus $11,088 for the CT. The economic benefits persisted even after taking into account the cost of abiraterone (Table). Conclusions: The reduction in cost of care in patients with mCRPC with nearly an additional year of TTP from adaptive abiraterone therapy demonstrates the potential value of novel precision medicine approaches. If confirmed by other, larger scale studies, AT may provide significant economic value from far more effective therapy. [Table: see text]

Clinical Utility of Pharmacogenetic Testing and a Clinical Decision Support Tool to Enhance the Identification of Drug Therapy Problems Through Medication Therapy Management in Polypharmacy Patients

BACKGROUND

In polypharmacy patients, medication therapy management (MTM) services provide a comprehensive review of current medications and future treatment goals. Pharmacogenetics (PGx) may further optimize the identification of potential drug therapy problems (DTPs); however, the clinical utility of PGx information with a clinical decision support tool (CDST) in an MTM setting in identifying DTPs has not been systematically assessed.

OBJECTIVE

To assess the clinical utility of an MTM service enhanced by pharmacogenetic test results and a clinical decision support tool.

METHODS

This study was a post hoc analysis of the data obtained from an open-label, randomized, observational trial. Polypharmacy patients eligible for MTM service were randomly assigned to 3 intervention arms: standard MTM (SMTM), MTM incorporating CDST (CMTM), and CMTM further enhanced by PGx test results of CYP450 and VKORC1 enzymes (PGxMTM). Allocation for this post hoc analysis was based on patient adherence to the research protocol and completion of a PGx test. The number of DTPs per patient was compared across the 3 arms using analysis of variance. In addition, the frequency of serious DTPs as a categorical variable (grade 3 or above vs. lower grade) was compared across the 3 arms between PGx driven and non-PGx driven DTP recommendations. Statistical significance was tested using the chi-square test. The level of agreement between the DTP seriousness and the acceptance made by prescribers was presented as Cohen's kappa coefficient.

RESULTS

Numbers of patients after cohort reallocation based on completion of PGx testing were 104, 180, and 58 for the SMTM, CMTM, and PGxMTM arms, respectively. On average, 3.08 DTPs were identified for each patient, which was nearly identical across all 3 arms. Blinded clinical pharmacists considered seriousness (grade 3 or 4) in 31% of the PGx-related DTPs in comparison with 4.9% of the non-PGx DTPs (P < 0.001). The more serious (i.e., grade 3 or above) DTP recommendations were more likely to be accepted by prescribers with the odds ratios of 1.95 (P = 0.05) and 2.39 (P = 0.15), when the analysis was performed for all DTPs and DTPs from the PGxMTM arm only, respectively.

CONCLUSIONS

MTM enhanced by PGx testing and the clinical decision support tool did not increase the number of DTPs identified. However, PGx testing and the decision support software helps pharmacists determine more serious DTPs, and resulting subsequent recommendations were more readily accepted by a prescriber. Future study of the patient safety outcomes and overall health care costs associated with the utility of the decision support is warranted.

DISCLOSURES

No funding was received for conducting the post hoc analysis presented in this study. Magness is employed by Magellan Health, which received funding from Genelex for costs to administrate the medication management program. The open-label randomized trial was sponsored by Genelex (Clinicaltrials.gov ID number NCT02428660). PGx tests were provided and laboratory analysis was performed by Genelex. Valerie Baron is an employee of YouScript, which created the clinical decision support tool used in this study and formerly was part of Genelex. The other authors have nothing to disclose.

Impact of glioblastoma (GBM)-related cognitive dysfunction (CD) on caregiver burden: Preliminary results from multi-site study in the U.S

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Background: GBM is a largely incurable, highly aggressive cancer with high incidence of CD. Caregivers face heightened stress with loved one’s limited life expectancy and additional duties. To better understand this unique group, a survey tool was developed to examine effect of CD on caregiver burden. Methods: Four of 10 planned academic centers are enrolling towards achieving 200+ completed surveys. The survey was developed step-wise: 1) literature review of primary brain tumors, Alzheimer’s disease, and dementia to identify domains; 2) focus groups with neurooncologists and American Brain Tumor Association advocates to narrow domains; 3) caregiver interviews to verify selected domains; 4) single-site pilot study to confirm content (n=20). Dyads with caregiver survey and respective patient’s clinical data are created as possible. Results: Complete data from 31 caregivers and 28 dyads enrolled at Huntsman Cancer Institute, University of Utah and University of California, Los Angeles are currently available. Response rate was 88% for caregivers and 90% for patients. Among caregivers, 87% were patient spouse/partner, 84% female, average age 56 years, 42% currently employed, 32% have no additional help, and 26% are primary caregivers for others. Patients were male (74%), average age 59 years, not working (84%), and being treated for initial diagnosis (67%). Proportion of caregivers performing ≥ 1 caregiving task, i.e. meal preparation, doubled from before to after diagnosis (48% vs. 97%). The majority of caregivers (90%) perceived memory problems in a loved one over last 14 days. Trouble remembering recent events or things interfered with 71% of caregivers’ daily life "somewhat", "quite a bit", or "very much". When ranking effect of CD on caregiver’s general quality of life on a scale of 0 (none) to 10 (significant), 60% and 23% of caregivers indicated ≥ 5 and ≥ 8, respectively. Caregivers’ responses to survey satisfaction questions showed only 23% feel enough is being done to understand caregiving in GBM and 76% were satisfied overall with the survey. Conclusions: Caregivers are affected daily and significantly by GBM-related CD. Results will be updated at time of presentation.

Real-world outcomes of unrestricted direct-acting antiviral treatment for hepatitis C in Australia: The South Australian statewide experience

In March 2016, the Australian government offered unrestricted access to direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) to the entire population. This included prescription by any medical practitioner in consultation with specialists until sufficient experience was attained. We sought to determine the outcomes and experience over the first twelve months for the entire state of South Australia. We performed a prospective, observational study following outcomes of all treatments associated with the state's four main tertiary centres. A total of 1909 subjects initiating DAA therapy were included, representing an estimated 90% of all treatments in the state. Overall, SVR12 was 80.4% in all subjects intended for treatment and 95.7% in those completing treatment and follow-up. 14.2% were lost to follow-up (LTFU) and did not complete SVR12 testing. LTFU was independently associated with community treatment via remote consultation (OR 1.50, 95% CI 1.04-2.18, P = .03), prison-based treatment (OR 2.02, 95% CI 1.08-3.79, P = .03) and younger age (OR 0.98, 95% CI 0.97-0.99, P = .05). Of the 1534 subjects completing treatment and follow-up, decreased likelihood of SVR12 was associated with genotype 2 (OR 0.23, 95% CI 0.07-0.74, P = .01) and genotype 3 (OR 0.23, 95% CI 0.12-0.43, P ≤ .01). A significant decrease in treatment initiation was observed over the twelve-month period in conjunction with a shift from hospital to community-based treatment. Our findings support the high responses observed in clinical trials; however, a significant gap exists in SVR12 in our real-world cohort due to LTFU. A declining treatment initiation rate and shift to community-based treatment highlight the need to explore additional strategies to identify, treat and follow-up remaining patients in order to achieve elimination targets.

Physiologic assessment of moderate coronary lesions: a step towards complete revascularization in coronary artery bypass grafting

Background

An accurate diagnostic assessment of coronary artery disease is crucial for patients undergoing coronary artery bypass grafting (CABG). Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) to guide complete revascularization have not been adequately studied in patients prior to CABG. We compared an anatomic to a physiologic assessment of moderate coronary lesions (40-70% stenosis) in patients referred for CABG.

Methods

We retrospectively reviewed 109 medical records of patients who underwent CABG at Tulane Medical Center from 2014 to 2016. Patients were divided into an FFR/iFR-guided and an angiography-guided group. Clinical characteristics, procedural outcomes, and clinical outcomes for the two groups were compared over an 18-month follow-up period.

Results

There were significantly higher rates of three-vessel anastomoses (85.7% vs. 74.7%, P<0.05) and venous grafting (85.7% vs. 76.8%, P<0.05) in the FFR/iFR group. The FFR/iFR group had a lower rate of grafts placed to the left anterior descending artery (LAD) distribution than the angiography group (7.1% vs. 29.5%, P<0.05). The FFR/iFR group had a higher rate of grafts placed to the left circumflex (LCx) artery distribution than the angiography group (28.6% vs. 9.5%, P<0.05). We observed a trend toward reduction in major adverse cardiac events (MACEs) (7.1% vs. 11.6%, P=0.369) and angina (0.0% vs. 6.3%, P=0.429) in the FFR/iFR group compared to the angiography group over 18 months.

Conclusions

Physiologic assessment of coronary lesions can effectively guide complete revascularization in patients undergoing CABG. Moreover, FFR/iFR-guided CABG was associated with significantly higher rates of three-vessel anastomoses, venous grafting, and graft distribution to the circumflex system.

Lateralized Center of Rotation and Lower Neck-Shaft Angle Are Associated With Lower Rates of Scapular Notching and Heterotopic Ossification and Improved Pain for Reverse Shoulder Arthroplasty at 1 Year

Heterotopic ossification and scapular notching are common following reverse total shoulder arthroplasty. Compared with the original Grammont-style prosthesis with a medialized center of rotation (COR) and a 155° neck-shaft angle, lateralization of COR and reduction of neck-shaft angle have been associated with decreased incidence of scapular notching. The authors hypothesized that these design features may also be effective in reducing heterotopic ossification after reverse total shoulder arthroplasty. Ninety-seven consecutive patients who underwent reverse total shoulder arthroplasty performed by a single surgeon were included in the study. Forty-eight patients received a Grammont-style prosthesis, and 49 received a prosthesis with either 6 mm or 10 mm of lateral COR offset and a 135° neck-shaft angle. Radiographs at 1-year follow-up were reviewed by 2 surgeons for notching and heterotopic ossification. Patient-reported outcome scores and range of motion were also compared between the groups. More patients in the Grammont-style group showed scapular notching (Grammont, 35.4%; lateral COR, 12.2%; P=.018) and heterotopic ossification (Grammont, 47.9%; lateral COR, 22.4%; P=.009). The lateralized COR group reported lower pain on the visual analog scale (Grammont mean, 1.1; lateral COR mean, 0.5; P=.01) and trended toward better American Shoulder and Elbow Surgeons scores (Grammont mean, 77.2; lateral COR mean, 83.4; P=.05). However, range of motion was similar between the 2 groups. Compared with the Grammont-style prosthesis, the lateralized COR prosthesis with a decreased neck-shaft angle resulted in a lower incidence of both scapular notching and heterotopic ossification as well as better pain scores and a trend toward improved function at 1 year after reverse total shoulder arthroplasty. [Orthopedics. 2018; 41(4):230-236.].

Amyloid Precursor Protein Haploinsufficiency Preferentially Mediates Brain Iron Accumulation in Mice Transgenic for The Huntington's Disease Mutation

BACKGROUND

Huntington's disease (HD) is an autosomal dominant disorder caused by a CAG expansion in the huntingtin gene that results in expression of mutant huntingtin protein. Iron accumulates in HD brain neurons. Amyloid precursor protein (APP) promotes neuronal iron export. However, the role of APP in brain iron accumulation in HD is unclear.

OBJECTIVE

To determine the effects of APP insufficiency on HD in YAC128 mice.

METHODS

We crossed APP hemizygous mice (APP+/-) with YAC128 mice that are transgenic (Tg) for human mutant huntingtin (hmHTT) to generate APP+/+ hmHTT-/-, APP+/- hmHTT-/-, APP+/+ hmHTT+/- and APP+/- hmHTT+/- progeny. Mice were evaluated for behavioral, biochemical and neuropathology HD outcomes at 2-12 months of age.

RESULTS

APP heterozygosity decreased cortical APP 25% and 60% in non-Tg and Tg mice, respectively. Cerebral and striatal iron levels were increased by APP knockdown in Tg mice only. Nest-building behavior was decreased in Tg mice; APP knockdown decreased nest building in non-Tg but not Tg mice. Rota-rod endurance was decreased in Tg mice. APP+/- hHTT+/- mice demonstrated additional decreases in rota-rod endurance from 4-10 months of age. Tg mice had smaller striatal volumes and fewer striatal neurons but were not affected by APP knockdown.

CONCLUSIONS

APP heterozygosity results in greater decreases of cortical APP in Tg versus non-Tg mice. Mutant huntingtin transgenic mice develop brain iron accumulation as a result of greater suppression of APP levels. Elevated brain iron in Tg mice was associated with a decline in motor endurance consistent with a disease promoting effect of iron in the YAC128 model of human HD.

Robotic Assisted Radical Cystoprostatectomy and Intracorporeal Ileal Conduit Urinary Diversion for a Kidney Transplant Recipient

Introduction and Objectives:

Robotic assisted radical cystectomy (RARC) is an alternative to open radical cystectomy. As experience is gained with the RARC approach the technique is being applied to more complex surgical cases. We describe here our technique for RARC with intracorporeal ileal conduit urinary diversion for a renal transplant recipient.

Materials and Methods:

The patient is a 60-year old man with high-grade muscle invasive bladder cancer. He has a history of renal failure due to polycystic kidney disease and received a deceased donor renal transplant in 2008. His hospital course at time of transplant was complicated by low-level BK virus viremia. Interestingly his trans-urethral bladder tumor resection specimen at time of bladder cancer diagnosis stained positive for SV40. His native kidneys were anuric so bilateral laparoscopic nephrectomy was performed in a staged fashion 2 weeks prior to RARC. Our surgical technique utilizes 6 trocars, of note a 12-mm assistant trocar is placed 1 cm superior to the pubic symphysis, and this trocar is solely used to pass a laparoscopic stapler to facilitate the excision of the ileal segment and the stapled enteric anastomosis. Surgical steps include: identification of native ureters bilaterally (removed en bloc with the bladder specimen); identification of the transplanted ureter at the right bladder dome; posterior bladder and prostate dissection along Denonvilliers’ fascia; development of the space of Retzius; ligation and transection of the bladder and prostate vascular bundles; apical prostate dissection and transection of urethra; left pelvic lymphadenectomy; ilium resection for creation of the ileal conduit; stapled enteric anastomosis; ureteroileal anastomosis; maturation of the ileal conduit stoma.

Results:

The surgery had no intraoperative complications. Operative time was 443 minutes (7.4 hours). Estimated blood loss was 250 cc. Length of hospital stay was 5 days. The patient did not experience any postoperative complications. The patient maintained good renal graft function with no decline in eGFR to date.

Conclusions:

As surgeon comfort and experience with robotic assisted surgery grows, robotic surgery can successfully be applied to less frequently performed procedures. Here we successfully performed a robotic assisted radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion for a renal transplant recipient.