Unmet Needs, Quality of Life, and Financial Toxicity Among Survivors of Lung Cancer

Importance

Despite a growing population of survivors of lung cancer, there is limited understanding of the survivorship journey. Survivors of lung cancer experience unmet physical, social, emotional, and medical needs regardless of stage at diagnosis or treatment modalities.

Objective

To investigate the association of unmet needs with quality of life (QOL) and financial toxicity (FT) among survivors of lung cancer.

Design, Setting, and Participants

This survey study was conducted at Johns Hopkins Sidney Kimmel Comprehensive Cancer Center thoracic oncology clinics between December 1, 2020, and September 30, 2021, to assess needs (physical, social, emotional, and medical), QOL, and FT among survivors of lung cancer. Patients had non-small cell lung cancer of any stage and were alive longer than 1 year from diagnosis. A cross-sectional survey was administered, which consisted of an adapted needs survey developed by the Mayo Survey Research Center, the Comprehensive Score for Financial Toxicity measure, and the European Organization for Research and Treatment of Cancer QLQ-C30 QOL scale. Demographic and clinical information was obtained through retrospective medical record review. Data analysis was performed between May 9 and December 8, 2022.

Main Outcomes and Measures

Separate multiple linear regression models, treating QOL and FT as dependent variables, were performed to assess the adjusted association of total number of unmet needs and type of unmet need (physical, emotional, social, or medical) with QOL and FT.

Results

Of the 360 survivors of lung cancer approached, 232 completed the survey and were included in this study. These 232 respondents had a median age of 69 (IQR, 60.5-75.0) years. Most respondents were women (144 [62.1%]), were married (165 [71.1%]), and had stage III or IV lung cancer (140 [60.3%]). Race and ethnicity was reported as Black (33 [14.2%]), White (172 [74.1%]), or other race or ethnicity (27 [11.6%]). A higher number of total unmet needs was associated with lower QOL (β [SE], -1.37 [0.18]; P < .001) and higher FT (β [SE], -0.33 [0.45]; P < .001). In the context of needs domains, greater unmet physical needs (β [SE], -1.24 [0.54]; P = .02), social needs (β [SE], -3.60 [1.34]; P = .01), and medical needs (β [SE], -2.66 [0.98]; P = .01) were associated with lower QOL, whereas only greater social needs was associated with higher FT (β [SE], -3.40 [0.53]; P < .001).

Conclusions and Relevance

The findings of this survey study suggest that among survivors of lung cancer, unmet needs were associated with lower QOL and higher FT. Future studies evaluating targeted interventions to address these unmet needs may improve QOL and FT among survivors of lung cancer.

Termination counseling among US perinatal genetic counselors in the setting of second trimester fetal anomalies

Many pregnant people learn of fetal anomalies in the second trimester and subsequently present to prenatal genetic counselors (PGCs) for counseling, including but not limited to a nuanced discussion about whether to continue or terminate pregnancy. In those who choose to terminate, the decision between dilation and evacuation (D&E) or induction is often one of patient preference and as such, is heavily influenced by the quality of counseling received. PGCs are expertly trained to provide values-based counseling, yet little is known about their termination counseling practices, referral practice patterns, and perceived responsibilities in caring for this group of pregnant people. To gain this knowledge, we surveyed a national sample of PGCs in early 2022 and received 70 completed responses. The survey contained open- and closed-ended questions. Data were analyzed using descriptive statistics, and free response data were analyzed using inductive content analysis. Eighty percent (n = 56) of respondents reported that <50% of their patients had previously received termination options counseling. Most strikingly, 15% of respondents provided termination counseling that was beyond their self-identified comfort level. Scenario-based questions assessed respondents' counseling practice patterns in seven real-world situations, presented in order of decreasing severity for the fetus. Respondents were 50% less likely to provide termination options counseling to patients between the most lethal to the least lethal proposed fetal anomaly. The scenario-based analysis revealed two distinct termination counseling approaches: (1) all options counseling with an explicit discussion of options to continue or terminate and (2) discretionary options counseling focused on identifying patient preferences to guide counseling and not explicitly stating all available options. This study highlights the need to ensure PGCs feel well-trained to discuss the general features of second trimester pregnancy termination and, if unable to do so, to practice in systems with timely referral to providers well-versed in the counseling about all methods of termination.

Utility of 68Ga-DOTATATE PET-MRI for Gamma Knife® stereotactic radiosurgery treatment planning for meningioma

OBJECTIVES

To investigate the impact of adding 68Ga-DOTATATE PET/MRI to standard MRI for target volume delineation in Gamma Knife® stereotactic radiosurgery (GKSRS) for meningioma.

METHODS

Seventeen patients with 18 lesions undergoing GKSRS for WHO grade 1 meningioma were enrolled in a prospective study. All patients underwent pre-treatment 68Ga-DOTATATE PET/MRI examination in addition to standard procedures. Five clinicians independently contoured the gross tumour volume (GTV) based on standard MRI (GTVMRI) and PET/MRI (GTVPET/MRI) on separate occasions. Interobserver agreement was evaluated using Cohen's Kappa statistic (CKS), Dice similarity coefficient (DC), and Hausdorff distance (HD). Statistical analysis was performed with paired t-test and Wilcoxon signed rank test.

RESULTS

The addition of PET/MRI significantly increased GTV contour volume (mean GTVPET/MRI 3.59 cm3 versus mean GTVMRI 3.18 cm3, P = .008). Using the treating clinician's pre-treatment GTVMRI as the reference, median CKS (87.2 vs 77.5, P = .006) and DC (87.2 vs 77.4, P = .006) were significantly lower, and median HD (25.2 vs 31.0, P = .001) was significantly higher with the addition of PET/MRI. No significant difference was observed in interobserver contouring reproducibility between GTVMRI and GTVPET/MRI.

CONCLUSION

The addition of 68Ga-DOTATATE PET/MRI for target volume delineation in GKSRS for meningioma is associated with an increase in GTV volume and greater interobserver variation. PET/MRI did not affect interobserver contouring reproducibility.

ADVANCES IN KNOWLEDGE

This study provides novel insights into the impact of 68Ga-DOTATATE PET/MRI on GTV delineation and interobserver agreement in meningioma GKSRS, highlighting its potential for improving GKSRS treatment accuracy.

Lung Cancer Survivorship: Physical, Social, Emotional, and Medical Needs of NSCLC Survivors

BACKGROUND

Newer therapies prolong survival for patients with lung cancer. Beyond extending survival, the needs of lung cancer (LC) survivors are poorly described.

METHODS

We conducted a single-institution needs assessment survey of LC survivors alive ≥1 year from diagnosis. Needs were rated on a 5-point Likert scale for 4 domains (physical, social, emotional, and medical). Multiple regression models identified demographic or treatment characteristics associated with more needs in each category. A subset analysis of survivors with metastatic LC was performed.

RESULTS

Of 360 patients approached, 235 surveys were completed. Among completed survey respondents, the median age was 69 years; most were female (62%), married (71%), and White (74%); and 41% had stage IV cancer. Finding support resources (34%) was the most common medical need. Fatigue (70%), sleep disturbance (60%), memory and concentration (57.5%), weakness (54%), and trouble breathing (51%) were physical needs affecting more than half of respondents. The most common social need was managing daily activities (42%). Emotional needs were highly prevalent, with 79% of respondents reporting a fear of recurrence and 74.5% reporting living with uncertainty. Multiple regression analysis identified that receipt of multiple lines of systemic therapy and lower household income were associated with higher physical and social needs. Younger age was associated with having a greater number of social and emotional needs. Similar results were found in the subset of survivors with metastatic disease at diagnosis.

CONCLUSIONS

The needs of LC survivors are diverse across multiple domains. Several clinical and demographic factors are independently associated with higher numbers of patient-reported needs. Our study identifies critical gaps in survivorship care for LC survivors with all stages of disease and highlights areas of future intervention.

Postpartum readmission in Maryland by race and ethnicity, 2016-2019

BACKGROUND

The majority of maternal deaths occur in the postpartum period. We sought to compare postpartum readmission by race and ethnicity to better understand whether there are disparities in maternal health in the postpartum period as indicated by readmission to the hospital.

OBJECTIVE

This study aimed to use state-wide Maryland data to identify postpartum readmission rates by race and ethnicity, as well as the major risk factors, indications, and timing of readmission.

STUDY DESIGN

In this retrospective study (2016-2019), childbirth hospitalizations for patients of childbearing age were identified from the Maryland State Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Indication for readmission was described. Multivariable logistic regression models were employed to determine racial and ethnic differences in postpartum readmissions, adjusting for maternal and obstetrical characteristics.

RESULTS

Among total deliveries (n=260,778), 3914 patients (1.5%) were readmitted within 60 days of delivery. The most common primary diagnoses at readmission were hypertension and infection. The prevalence of readmission was 1.2% (1306/111,325) for White patients, 2.3% (1786/79,412) for Black patients, 1.2% (485/40,862) for Hispanic patients and 1.2% (337/29,179) for patients of Other race or ethnicity (P<.0001). Black patients had the highest rates of readmission for hypertensive disorders as compared with all other races (37%, P<.0001). In adjusted models, Black patients were more likely to be readmitted than White patients (odds ratio, 1.64; confidence interval, 1.52-1.77). The majority of all readmissions occurred in the first week after delivery with Black patients having higher rates of readmission in the second week relative to all other groups (P<.0001).

CONCLUSION

Hypertension is a leading cause of postpartum readmission in Maryland. Black patients were more likely to be readmitted for hypertensive disorders of pregnancy and to have delayed readmission relative to other race or ethnic groups. Maryland public health officials should address disparities with interventions targeting racial and ethnic minorities, patients at risk for hypertensive disorders, and barriers to timely care.

Pharmacy e-Prescription Dispensing Before and After CancelRx Implementation

Importance

An estimated 1.5% to nearly 5% of medications are dispensed after discontinuation in the electronic health record (EHR), with 34% meeting criteria for high risk of potential harm.

Objective

To evaluate the association of the implementation of e-prescription cancellation messaging (CancelRx) with medication dispensing after discontinuation of e-prescriptions in the EHR.

Design, Setting, and Participants

This case series with interrupted time series analysis included patients who had at least 1 medication e-prescribed in ambulatory care to a health system pharmacy and discontinued in the 2-year study period from 1 year prior to approximately 1 year after CancelRx implementation (January 15, 2018, to December 7, 2019). Prior to CancelRx implementation, changes to e-prescribed medications within the EHR were not electronically communicated to health system pharmacies, which used separate pharmacy management software. Statistical analysis was performed from November 2020 to June 2023 (primary analysis from March 2021 to May 2022).

Exposure

Implementation of CancelRx.

Main Outcomes and Measures

The primary outcome was the proportion of e-prescribed medications dispensed and sold to patients by pharmacies within 6 months after discontinuation in the EHR. A medication was defined as dispensed after discontinuation if the timestamp of dispensing was at least 1 minute and less than 6 months after the timestamp of discontinuation in the EHR. A secondary outcome was the proportion of discontinued medications that was reordered within 120 days.

Results

A total of 53 298 qualifying e-prescriptions that were discontinued were identified for 17 451 unique patients (mean [SD] age, 50.6 [18.2] years; 9332 women [53.5%]). After CancelRx implementation, 22 443 (85.9%) of the 26 127 discontinued e-prescriptions resulted in a CancelRx transaction. In interrupted time series analysis, the proportion of prescriptions dispensed after discontinuation decreased from a baseline of 8.0% (2162 of 27 171) to 1.4% (369 of 26 127; P < .001), without a significant week-to-week trend (β = 0.000158; P = .37).

Conclusions and Relevance

In this case series with interrupted time series analysis, findings suggest that CancelRx implementation was associated with an immediate and persistent reduction in the proportion of e-prescriptions sold after discontinuation in the EHR. Widespread implementation of CancelRx may significantly improve medication safety through the reduction of medication dispensing after discontinuation by prescribers.

Relationships between reading performance and regional spontaneous brain activity following surgical removal of primary left-hemisphere tumors: A resting-state fMRI study

Left-hemisphere intraparenchymal primary brain tumor patients are at risk of developing reading difficulties that may be stable, improve or deteriorate after surgery. Previous studies examining language organization in brain tumor patients have provided insights into neural plasticity supporting recovery. Only a single study, however, has examined the role of white matter tracts in preserving reading ability post-surgery and none have examined the functional reading network. The current study aimed to investigate the regional spontaneous brain activity associated with reading performance in a group of 36 adult patients 6-24 months following left-hemisphere tumor resection. Spontaneous brain activity was assessed using resting-state fMRI (rs-fMRI) regional homogeneity (ReHo) and fractional amplitude low frequency fluctuation (fALFF) metrics, which measure local functional connectivity and activity, respectively. ReHo in the left occipito-temporal and right superior parietal regions was negatively correlated with reading performance. fALFF in the putamen bilaterally and the left cerebellum was negatively correlated with reading performance, and positively correlated in the right superior parietal gyrus. These findings are broadly consistent with reading networks reported in healthy participants, indicating that reading ability following brain tumor surgery might not involve substantial functional re-organization.

The Association of Peripheral and Central Olfaction With Frailty in Older Adults

BACKGROUND

Olfactory impairment is increasingly recognized as a biomarker of frailty, but the relationship between olfactory subdomains that describe peripheral or central dysfunction and frailty remains unexplored.

METHODS

We examined 1 160 older adults from the National Social Life, Health, and Aging Project Wave 3. Olfactory identification (OI): the ability to identify an odorant; and olfactory sensitivity (OS): the ability to detect the presence of an odorant, were assessed using 5- and 6-point measures, respectively. Frailty was operationalized as both a 37-item frailty index (FI) and the 5-item Physical Frailty Phenotype (PFP). Mixed models were fit to examine the association between OI, OS, FI, and PFP, while adjusting for demographic and clinical covariates.

RESULTS

Participants in the most-frail PFP category had lower OI and OS scores (OI: 3.88 vs 4.19, p = .016; OS: 3.15 vs 3.47, p = .031), whereas participants in the most-frail FI category exhibited lower OI scores but not OS scores when compared to nonfrail participants (OI: 3.72 vs 4.27, p = .014; OS: 3.19 vs 3.43, p = .476). Adjusted mixed models showed that a point increase in OI was associated with a lower PFP score (β = -0.107, p = .006) and FI score (β = -0.009, p = .010). A point increase in OS was associated with a lower PFP score (β = -0.058, p = .016) but not FI score (β = -0.004, p = .064).

CONCLUSION

Both OS and OI, predominantly peripheral and central measures of olfaction, respectively, are associated with frailty implicating olfaction as a potential biomarker and risk factor for frailty.

Chronic aphasias after left-hemisphere resective surgery

Surgical resection of brain tumours is associated with an increased risk of aphasia. However, relatively little is known about outcomes in the chronic phase (i.e., >6 months). Using voxel-based lesion symptom mapping (VLSM) in 46 patients, we investigated whether chronic language impairments are related to the location of surgical resection, residual tumour characteristics (e.g., peri-resection treatment effects, progressive infiltration, oedema) or both. Approximately 72% of patients scored below the cut-off for aphasia. Action naming and spoken sentence comprehension deficits were associated with lesions in the left anterior temporal and inferior parietal lobes, respectively. Voxel-wise analyses revealed significant associations between ventral language pathways and action naming deficits. Reading impairments were also associated with increasing disconnection of cerebellar pathways. The results indicate chronic post-surgical aphasias reflect a combination of resected tissue and tumour infiltration of language-related white matter tracts, implicating progressive disconnection as the critical mechanism of impairment.

A retrospective cohort study assessing geometrical parameters related to visual deterioration in pituitary macroadenoma

PURPOSE

We aim to identify specific parameters that will allow identification of those patients at greater risk of vision loss, specifically variables such as geometry, volume and size of the pituitary tumour.

METHODOLOGY

Volume measurements were made with both manual (using the formula width × height × length × 0.5) and video size, sub-voxel interpolation using Brainlab software. The shape of the tumour was divided into four categories, ovoid, dumbbell, pyramidal and other. Chiasmal compression was divided into central and lateral compression and the chiasm location was classified based on pre/post and normal fixed chiasm in relation to the tuberculum sella. We used a visual impairment score ranging from (0-100), which was then further subdivided in to four grades: Grade I - 0-25 (mild); Grade II - 26-50 (moderate); Grade III - 51-75 (severe); Grade IV - 76-100 (subtotal or complete).

RESULTS

Univariate analysis of variables related to vision loss found tumour volume, suprasellar growth and lateral chiasmal compression related to pre-operative vision loss. On multivariate regression analysis tumour volume and lateral chiasmal compression remained significant (p < 0.008). In relation to post-operative vision, univariate analysis indicated that variables such as giant macroadenoma, pre-operative visual impairment score and suprasellar growth were significant. Multivariate analysis showed pre-operative visual impairment and suprasellar growth as the only statistically significant variables.

CONCLUSION

Our ROC analysis suggests tumours with suprasellar extension 16 mm (sensitivity 85 %, specificity 67 %) in sagittal plane are more likely to result in moderate to severe grade vision loss (VIS grade ≥ 2).

A Medical-Grade Polycaprolactone and Tricalcium Phosphate Scaffold System With Corticoperiosteal Tissue Transfer for the Reconstruction of Acquired Calvarial Defects in Adults: Protocol for a Single-Arm Feasibility Trial

Background

Large skull defects present a reconstructive challenge. Conventional cranioplasty options include autologous bone grafts, vascularized bone, metals, synthetic ceramics, and polymers. Autologous options are affected by resorption and residual contour deformities. Synthetic materials may be customized via digital planning and 3D printing, but they all carry a risk of implant exposure, failure, and infection, which increases when the defect is large. These complications can be a threat to life. Without reconstruction, patients with cranial defects may experience headaches and stigmatization. The protection of the brain necessitates lifelong helmet use, which is also stigmatizing.

Objective

Our clinical trial will formally study a hybridized technique's capacity to reconstruct large calvarial defects.

Methods

A hybridized technique that draws on the benefits of autologous and synthetic materials has been developed by the research team. This involves wrapping a biodegradable, ultrastructured, 3D-printed scaffold made of medical-grade polycaprolactone and tricalcium phosphate in a vascularized, autotransplanted periosteum to exploit the capacity of vascularized periostea to regenerate bone. In vitro, the scaffold system supports cell attachment, migration, and proliferation with slow but sustained degradation to permit host tissue regeneration and the replacement of the scaffold. The in vivo compatibility of this scaffold system is robust—the base material has been used clinically as a resorbable suture material for decades. The importance of scaffold vascularization, which is inextricably linked to bone regeneration, is underappreciated. A variety of methods have been described to address this, including scaffold prelamination and axial vascularization via arteriovenous loops and autotransplanted flaps. However, none of these directly promote bone regeneration.

Results

We expect to have results before the end of 2023. As of December 2020, we have enrolled 3 participants for the study.

Conclusions

The regenerative matching axial vascularization technique may be an alternative method of reconstruction for large calvarial defects. It involves performing a vascularized free tissue transfer and using a bioresorbable, 3D-printed scaffold to promote and support bone regeneration (termed the regenerative matching axial vascularization technique). This technique may be used to reconstruct skull bone defects that were previously thought to be unreconstructable, reduce the risk of implant-related complications, and achieve consistent outcomes in cranioplasty. This must now be tested in prospective clinical trials.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620001171909; https://tinyurl.com/4rakccb3

International Registered Report Identifier (IRRID)

DERR1-10.2196/36111

Defining the needs of lung cancer survivors: Physical, social, emotional, and medical needs

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Background: Lung cancer survivors (LCS) are a rapidly growing population. Cancer survivors benefit from dedicated survivorship care, but the physical, psychosocial, and medical needs of LCS are poorly defined. Methods: Non-small cell LCS (defined as alive ≥1 years from diagnosis) of any stage treated at Johns Hopkins were invited to complete an IRB-approved cross-sectional survey of needs of 4 subscales (physical, social, emotional, and medical needs) rated on a 5-point Likert scale (1 = no need, 5 = highest need). Demographic and clinical information were collected by chart review and patient reported questionnaire. Multiple regression models identified factors that were significantly associated with greater total number of needs on each subscale. Results: 235 surveys were completed. We excluded surveys with < 80% completion. Non-Caucasian race was associated with a significantly lower rate of survey completion (p = 0.002). Median age of LCS who completed the survey was 69, most were female (62%), Caucasian (74%), married (71%), or had stage III/IV cancer (60%). More than half of respondents reported emotional needs of fear of recurrence (79%) and living with uncertainty (74%). Common physical needs included fatigue (70%), sleep disturbance (60%), memory and concentration (57%), and weakness (54%). Multivariate analysis identified factors associated with higher needs in physical, social, and emotional needs (Table). We did not identify any factors associated with differences in medical needs. NS – non-significant value. Conclusions: We identified physical, emotional, social, and medical needs that burden survivors of NSCLC. Emotional needs are prevalent. Clinical and demographic factors are independently associated with higher needs in physical, social, and emotional domains. These results are critical in identifying high-impact gaps in providing survivorship care for lung cancer survivors. Future work to identify interventions to address needs is crucial.[Table: see text]

The use of prophylactic antiepileptic medication and driving restrictions for craniotomies among Australian and New Zealand neurosurgeons

Prophylactic antiepileptic drug (pAED) use for craniotomy surgery is currently not supported in literature [1-5] except possibly in traumatic brain injury (TBI) [6]. Post craniotomy driving restrictions using the Austroad guidelines are based upon literature on TBI and not specifically craniotomy [16-18]. This study was to review Australian and New Zealand neurosurgeons on their use of pAED and advice on driving restrictions post craniotomy surgery. A voluntary and anonymous survey link was distributed to the members of the Neurosurgical Society of Australasia (NSA) through the NSA newsletter. The survey was available on the SurveyMonkey platform in the year 2021 August to December. Questions regarding the use of pAED and duration of driving restrictions were presented to survey participants. Sixty-one (26 %) out of 231 neurosurgeons responded to the survey. Thirty-six percent of respondents stated that they prescribed pAEDs regularly whilst thirty-two percent of respondents did not routinely prescribe pAEDs for craniotomy surgery. Driving restrictions varied but the most common driving restriction post craniotomy surgery was 6 months. There were divided opinions among NSA members in regards to pAED use and driving restrictions. The rationale for pAED use and prolonged driving restrictions for craniotomy surgery needs to be re-evaluated with current literature. The significant effect this may have on the well-being and quality life of patients need to be considered before prescribing pAEDs or long driving restrictions.

Use of virtual magnetic resonance imaging to compensate for brain shift during image-guided surgery: illustrative case

BACKGROUND

Maximal safe resection is the paramount objective in the surgical management of malignant brain tumors. It is facilitated through use of image-guided neuronavigation. Intraoperative image guidance systems use preoperative magnetic resonance imaging (MRI) as the navigational map. The accuracy of neuronavigation is limited by intraoperative brain shift and can become less accurate over the course of the procedure. Intraoperative MRI can compensate for dynamic brain shift but requires significant space and capital investment, often unavailable at many centers.

OBSERVATIONS

The authors described a case in which an image fusion algorithm was used in conjunction with an intraoperative computed tomography (CT) system to compensate for brain shift during resection of a brainstem hemorrhagic melanoma metastasis. Following initial debulking of the hemorrhagic metastasis, intraoperative CT was performed to ascertain extent of resection. An elastic image fusion (EIF) algorithm was used to create virtual MRI relative to both the intraoperative CT scan and preoperative MRI, which facilitated complete resection of the tumor while preserving critical brainstem anatomy.

LESSONS

EIF algorithms can be used with multimodal images (preoperative MRI and intraoperative CT) and create an updated virtual MRI data set to compensate for brain shift in neurosurgery and aid in maximum safe resection of malignant brain tumors.

A Mixed-Methods Study on Use of Different Tobacco Products among Younger and Older Adults with Lower and Higher Levels of Nicotine Exposure in California in 2019-2020

An increasing number of tobacco products are entering the market, offering a variety of options to attain desired nicotine intake. However, little is known about the effect of this diverse marketplace on the experiences and nicotine exposure among tobacco users. A mixed-methods study examined experiences with tobacco products among individuals with relatively lower or higher levels of biomarkers of nicotine exposure. Semi-structured interviews were conducted with younger and older adults to examine tobacco use behaviors, addiction to tobacco products, and nicotine effects. Younger and older adults provided similar narratives about addiction and nicotine effects, which were similar across age groups, product types (i.e., ENDS, combustible cigarettes, or oral tobacco products), and having lower or higher nicotine exposure. Some individuals with higher nicotine exposure who switched from combustible cigarettes to another product (e.g., ENDS) found similar or greater access and perceived addiction to nicotine. Adults with higher and lower levels of nicotine exposure provided narratives consistent with features of nicotine addiction, regardless of age and products used. Availability of multiple tobacco products may be associated with greater access and exposure to nicotine. Addiction may occur at low levels of use and with non-cigarette products.

Characterization of Lung Transplant COVID19+ Patients and Mortality Outcomes

Purpose

The aim of this study is to report the characteristic and mortality outcomes of lung transplant patients that contracted COVID19.

Methods

A retrospective chart review was conducted of lung transplant recipients who tested positive for COVID19 from 6/1/2020 to 9/1/2021.

Results

Forty-five patients were included for mortality incidence review with 2 patients who were admitted to outside facilities during their COVID diagnosis with limited treatment data. Mortality incidence was 15.5% with cohort mean age of 62 (±11.7). Median time from transplant to infection was 1281 days (223-5800). Five patients required O2 and n=5 were intubated with 80% mortality (n=4) among those intubated. Baseline demographics of age, gender, indication for transplant or race were not statistically different among patients that died vs those that survived. Vaccinations (2 doses) prior to infection were evident in n=35 (77.8%) of the patients. Maintenance immunosuppressants and covid therapies (table 1) did not have an associated difference in survival from infection. A significant association with mortality was found from the time of reported symptoms to triage or hospitalization in those that survived vs died, 3.3 vs 9.4 days (p=0.003).

Conclusion

This is one of the largest cohorts reporting lung transplant recipients who contracted COVID19, and despite lungs being the organ directly affected by COVID19, mortality rates are comparable to rates reported in other solid organ transplants. Time to triage from symptom onset to clinic management or hospital admission for COVID appears to be associated with improved mortality rates.

Characterization of volumetric growth of intracranial meningiomas in Māori and Pasifika populations in New Zealand

BACKGROUND

Māori and Pasifika populations in New Zealand have a higher incidence and prevalence of intracranial meningioma (IM). We sought to evaluate the volumetric growth rate of meningiomas under surveillance in these populations.

METHODS

From July 2002 to October 2020, 336 patients with a total of 408 IM underwent conservative management with serial radiological surveillance at Auckland City Hospital and met the criteria for the study. Inclusion criteria included: age >16 at diagnosis, ≥2 appropriate scans one or more years apart. Exclusion criteria included previous cranial irradiation, a diagnosis of Neurofibromatosis and prior treatment of meningioma. Demographic and clinical data were obtained from the electronic medical records. Imaging data were recorded from the first and last scans. We utilized open-source image processing software (3D Slicer) for semi-automated segmentation and volume calculation. Consistent with previous literature, we calculated the relative growth rate (RGR, %/year) and annual volume change (AVC, cm³ /year) over time.

RESULTS

Four hundred and eight meningiomas were volumetrically characterized for a mean duration of 6.2 years. The Māori and Pasifika populations (n = 134/393) demonstrated a higher RGR (31.41 versus 14.33%/year) (P = 0.026) and AVC (2.05 versus 0.95 cm³ ) (P = 0.025) compared to the control population. They also presented at a younger age and had a higher rate of tumour multiplicity. Males represented only 17.6% of the cohort but exhibited a higher growth rate (AVC = 2.52 cm³ /year) than females (AVC = 0.99 cm³ /year) (P = 0034).

CONCLUSIONS

Māori and Pasifika populations in New Zealand have a higher incidence and volumetric growth rate of IM compared to a control population. This warrants further clinical, histopathological and genomic analysis.

Availability of Medications for the Treatment of Opioid Use Disorder Among Pregnant and Postpartum Individuals in US Jails

Importance

Thousands of pregnant people with opioid use disorder (OUD) enter US jails annually, yet their access to medications for OUD (MOUD) that meet the standard of care (methadone and/or buprenorphine) is unknown.

Objective

To assess the availability of MOUD for the treatment of pregnant individuals with OUD in US jails.

Design, Setting, and Participants

In this cross-sectional study, electronic and paper surveys were sent to all 2885 identifiable US jails verified in the National Jails Compendium between August 19 and November 7, 2019. Respondents were medical and custody leaders within the jails.

Main Outcomes and Measures

The primary outcome was the availability of MOUD (methadone and/or buprenorphine) for the treatment of pregnant people with OUD in US jails. Availability of MOUD was assessed based on (1) continuation of MOUD for pregnant incarcerated individuals (if the individual was receiving MOUD before incarceration), with or without initiation of MOUD; (2) both initiation and continuation of MOUD for pregnant individuals; (3) only continuation of MOUD for pregnant individuals; and (4) management of opioid withdrawal for pregnant individuals. Secondary outcomes included MOUD availability during the postpartum period and logistical factors associated with the provision of MOUD. Multivariate logistic regression analysis was used to assess factors associated with MOUD availability during pregnancy.

Results

Among 2885 total surveys sent, 1139 (39.5%) were returned; of those, 836 surveys (73.4%; 29.0% of all surveys sent) could be analyzed, with similar proportions from metropolitan (399 jails [47.7%]) and rural (381 jails [45.6%]) settings. Overall, 504 jails (60.3%) reported that MOUD was available for medication continuation, with or without medication initiation, during pregnancy. Of those, 267 jails (53.0%; 31.9% of surveys included in the analysis) both initiated and continued MOUD, and 237 jails (47.0%; 28.3% of surveys included in the analysis) only continued MOUD; 190 of 577 jails (32.9%; 22.7% of surveys included in the analysis) reported opioid withdrawal as the only management for pregnant people with OUD. Among the 504 medication-providing jails, only 120 (23.8%) continued to provide MOUD during the postpartum period. Methadone was more commonly available at jails that only continued MOUD (84 of 123 jails [68.3%]), whereas buprenorphine was more commonly available at jails that both initiated and continued MOUD (73 of 119 jails [61.3%]). In an adjusted model, jails with higher odds of MOUD availability were located in the Northeast (odds ratio [OR], 10.72; 95% CI, 2.43-47.36) or metropolitan areas (OR, 1.92; 95% CI, 1.31-2.83), had private health care contracts (OR, 1.49; 95% CI, 1.03-2.14) and a higher number of women (≥70) reported in the female census (OR, 1.69; 95% CI, 1.02-2.80), and provided pregnancy testing within 2 weeks of arrival at the jail (OR, 2.66; 95% CI, 1.69-4.17).

Conclusions and Relevance

In this cross-sectional study, a substantial proportion of US jails did not provide access to MOUD to pregnant people with OUD. Although most jails reported continuing to provide MOUD to individuals who were receiving medication before incarceration, few jails initiated MOUD, and most medication-providing jails discontinued MOUD during the postpartum period. These results suggest that many pregnant and postpartum people with OUD in US jails do not receive medication that is the standard of care and are required to endure opioid withdrawal, signaling an opportunity for intervention to improve care for pregnant people who are incarcerated.

Outcomes Following Hypofractionated Stereotactic Radiotherapy to the Cavity After Surgery for Melanoma Brain Metastases

AIMS

Hypofractionated stereotactic radiotherapy (HSRT) to the cavity after surgical resection of brain metastases improves local control. Most reported cohorts include few patients with melanoma, a population known to have high rates of recurrence and neurological death. We aimed to assess outcomes in patients with melanoma brain metastases who received HSRT after surgery at two Australian institutions.

MATERIALS AND METHODS

A retrospective analysis was carried out including patients treated between January 2012 and May 2020. HSRT was recommended for patients with melanoma brain metastases at high risk of local recurrence after surgery. Treatment was delivered using appropriately commissioned linear accelerators. Routine follow-up included surveillance magnetic resonance imaging brain every 3 months for at least 2 years. Primary outcomes were overall survival, local control, incidence of radiological radionecrosis and symptomatic radionecrosis.

RESULTS

There were 63 cavities identified in 57 patients. The most common HSRT dose prescriptions were 24 Gy in three fractions and 27.5 Gy in five fractions. The median follow-up was 32 months in survivors. Local control was 90% at 1 year, 83% at 2 years and 76% at 3 years. Subtotal brain metastases resection (hazard ratio 12.5; 95% confidence interval 1.4-111; P = 0.0238) was associated with more local recurrence. Overall survival was 64% at 1 year, 45% at 2 years and 40% at 3 years. There were 10 radiological radionecrosis events (16% of cavities) during the study period, with 5% at 1 year and 8% at 2 years after HSRT. The median time to onset of radiological radionecrosis was 21 months (range 6-56). Of these events, three became symptomatic (5%) during the study period at a median time to onset of 26 months (range 21-32).

CONCLUSION

Cavity HSRT is associated with high rates of local control in patients with melanoma brain metastases. Subtotal resection strongly predicts for local recurrence after HSRT. Symptomatic radionecrosis occurred in 5% of cavities but increased to 8% of longer-term survivors.

Pregnancy alters interleukin-1 beta expression and antiviral antibody responses during severe acute respiratory syndrome coronavirus 2 infection

BACKGROUND

Severe acute respiratory syndrome coronavirus 2, the disease-causing pathogen of the coronavirus disease 2019 pandemic, has resulted in morbidity and mortality worldwide. Pregnant women are more susceptible to severe coronavirus disease 2019 and are at higher risk of preterm birth than uninfected pregnant women. Despite this evidence, the immunologic effects of severe acute respiratory syndrome coronavirus 2 infection during pregnancy remain understudied.

OBJECTIVE

This study aimed to assess the impact of severe acute respiratory syndrome coronavirus 2 infection during pregnancy on inflammatory and humoral responses in maternal and fetal samples and compare antibody responses to severe acute respiratory syndrome coronavirus 2 among pregnant and nonpregnant women.

STUDY DESIGN

Immune responses to severe acute respiratory syndrome coronavirus 2 were analyzed using samples from pregnant (n=33) and nonpregnant (n=17) women who tested either positive (pregnant, 22; nonpregnant, 17) or negative for severe acute respiratory syndrome coronavirus 2 (pregnant, 11) at Johns Hopkins Hospital. We measured proinflammatory and placental cytokine messenger RNAs, neonatal Fc receptor expression, and tetanus antibody transfer in maternal and cord blood samples. In addition, we evaluated antispike immunoglobulin G, antispike receptor-binding domain immunoglobulin G, and neutralizing antibody responses to severe acute respiratory syndrome coronavirus 2 in serum or plasma collected from nonpregnant women, pregnant women, and cord blood.

RESULTS

Pregnant women with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection expressed more interleukin-1 beta, but not interleukin 6, in blood samples collected within 14 days vs >14 days after performing severe acute respiratory syndrome coronavirus 2 test. Pregnant women with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection also had reduced antispike receptor-binding domain immunoglobulin G titers and were less likely to have detectable neutralizing antibody than nonpregnant women. Although severe acute respiratory syndrome coronavirus 2 infection did not disrupt neonatal Fc receptor expression in the placenta, maternal transfer of severe acute respiratory syndrome coronavirus 2 neutralizing antibody was inhibited by infection during pregnancy.

CONCLUSION

Severe acute respiratory syndrome coronavirus 2 infection during pregnancy was characterized by placental inflammation and reduced antiviral antibody responses, which may impact the efficacy of coronavirus disease 2019 treatment in pregnancy. In addition, the long-term implications of placental inflammation for neonatal health require greater consideration.

Leksell Gamma Knife® - The first 1000 patients from the radiation therapist's perspective

The Princess Alexandra Hospital (PAH) Gamma Knife® Centre of Queensland (GKCoQ) began operations in October of 2015 as a sub-specialty located within a larger radiation oncology service at PAH. It is uniquely positioned as the only Leksell Gamma Knife® (LGK) treatment unit available in the public hospital system in Australia, and the first and only service in Queensland. The GKCoQ treated the 1000th patient on 23 January 2019. LGK is a non-invasive alternative to neurosurgery which uses radioactive cobalt sources to treat a variety of intracranial conditions ranging from tumours and metastases to functional disorders. It is a platform for stereotactic radiosurgery, a highly precise form of radiotherapy utilising very high doses to the target while maximally sparing surrounding normal brain. LGK enables patient planning and treatment to be done in one day as an outpatient procedure. This paper will outline our LGK service and provide insight into the expanded role that radiation therapists have within the multidisciplinary team required to deliver radiosurgery in a timely manner. The training programme and radiation licensing pathway that have been established for radiation therapists will also be described.

Pulmonary hypoplasia correlates with the length of anhydramnios in patients with early pregnancy renal anhydramnios (EPRA)

BACKGROUND

Early pregnancy renal anhydramanios (EPRA) occurs when the fetus is anuric before 22 weeks gestational age (GA) and is considered universally lethal. Serial amnioinfusions have successfully ameliorated the lethal pulmonary hypoplasia associated with EPRA and have resulted in cases of neonatal survival, peritoneal dialysis, and renal transplant.

OBJECTIVE

We sought to evaluate the lung pathology of untreated fetuses and neonates that had EPRA.

STUDY DESIGN

This is a retrospective case series of all fetuses and neonates diagnosed with isolated EPRA that underwent autopsy at a single tertiary care center between 1987 and 2018. Autopsy data were correlated with ultrasound findings and GA at delivery. Fetal weights, lung weights, and lung developmental stage were recorded.

RESULTS

Nineteen cases met criteria for analysis and ranged from 16 to 38 weeks GA at termination or birth. The observed-to-expected (O/E) lung-to-body-weight ratio was significantly associated with GA (r = -0.51, p = 0.03), such that as GA increased the O/E ratio decreased. When limited to patients >22 weeks, this relationship strengthened (r = -0.75, p = 0.01). Importantly, overall O/E body weight had no relationship with GA.

CONCLUSION

This study shows that the degree of pulmonary hypoplasia in EPRA increases with the length of anhydramnios. This suggests that amnioinfusions are likely to be of most benefit the soonest they can feasibly be initiated.

The relationship between early post-operative ACTH / cortisol following pituitary surgery and long-term glucocorticoid requirement - Do ultradian rhythms matter?

OBJECTIVE

To determine whether early (4-8h) post-operative ACTH after trans-sphenoidal surgery (TSS) predicts long-term hypothalamic-pituitary-adrenal (HPA) axis function and to investigate early morning day 1 ACTH/cortisol variability using rapid sampling.

DESIGN

Prospective observational study.

METHODS

Participants undergoing TSS were included; those treated with glucocorticoids pre-operatively received 100 mg intravenous hydrocortisone on anaesthetic induction. ACTH and cortisol were measured post-operatively at + 4h and + 8h after induction and on day 1 every 10 minutes between 0700h and 0900h.

PRIMARY OUTCOME

glucocorticoid requirement at 6 months.

RESULTS

Nineteen participants (10F, 9M): 6/19 (32%) were treated with replacement glucocorticoids pre-operatively; 4 had ceased by 6 weeks post-operatively. One patient developed new hypopituitarism post-operatively meaning 3/19 (16%) required glucocorticoids at 6 months. Post-operative + 4h ACTH < 14.3 pmol/L (65 ng/L) predicted secondary adrenal insufficiency (SAI) (sensitivity 100%, specificity 75%), whilst no participant with a post-operative + 4h ACTH ≥ 14.3 pmol/L (65 ng/L) required glucocorticoids at 6 months. Day 1 ACTH and cortisol showed a significant circadian fall between 0700h-0900h; ACTH 4.2 pmol/L (IQR 2.9-5.9) to 3.7 pmol/L (IQR 2.9-5.1) P = .006 and cortisol 549 nmol/L (IQR 337-618) to 439 nmol/L (IQR 315-606) P < .001, with clinically insignificant ultradian secretory pulses.

CONCLUSIONS

No participant with a post-operative + 4h ACTH ≥ 14.3 pmol/L (65 ng/L) required glucocorticoids at 6 months; however, given only 3/19 participants had the primary outcome of interest, this must be confirmed in a larger cohort. The timing of a day 1 morning cortisol between 0700h and 0900h influences the accuracy of a single cut-off to diagnose SAI after pituitary surgery.

Association of severe lymphopenia and disease progression in unresectable locally advanced non-small cell lung cancer treated with definitive chemoradiation and immunotherapy

BACKGROUND

Definitive chemoradiation with consolidative immunotherapy offers the best chance for cure in patients with unresectable, locally advanced non-small cell lung cancer (NSCLC). However, treatment-related lymphopenia (TRL) may negatively impact outcomes.

METHODS

Patients definitively treated with chemoradiation and immunotherapy from 2015 to 2019 at a single tertiary academic center were identified. Severe lymphopenia was defined as <0.5 × 10⁹ cells/L. Progression-free survival (PFS) was calculated by Kaplan Meier methodology. Univariate and multivariate Cox Proportional Hazard modeling was used to correlate clinical variables with disease outcome. Immune-related adverse events (irAEs) were assessed according to CTCAE version 5.0 criteria.

RESULTS

Seventy-eight patients were included in the final cohort. The median age was 66 years (IQR: 58-73), 55 % were males, and 88 % had a KPS of >70. At baseline, 90 % (n = 70/78) of patients had a normal ALC and one patient had severe lymphopenia. After chemoradiation, the median ALC decreased from 1.52 × 10⁹cells/L (IQR: 1.23-1.98) to 0.72 × 10⁹cells/L (IQR: 0.52-0.94) (p < 0.001), 22 % (n = 17/78) of patients had a normal ALC, and 23 % (n = 18/78) of patients developed severe lymphopenia. Patients who initiated consolidative immunotherapy with severe lymphopenia had worse PFS than those who did not (median 217 days [IQR: 120-434] vs. 570 days [IQR: 401-NR], p < 0.001). On multivariate modeling, severe lymphopenia at the time of immunotherapy initiation remained an independent predictor of worse PFS (HR 4.90, p < 0.001).

CONCLUSIONS

This is the first report to associate severe TRL with disease progression in patients with locally advanced NSCLC receiving consolidative immunotherapy. Factors associated with development of lymphopenia and strategies to mitigate lymphopenic effects should be considered.

Dysregulated immunity in SARS-CoV-2 infected pregnant women

Importance

The effects of SARS-CoV-2 infection on immune responses during pregnancy have not been systematically evaluated.

Objective

To assess the impact of SARS-CoV-2 infection during pregnancy on inflammatory and humoral responses in maternal and fetal samples and compare antibody responses to SARS-CoV-2 among pregnant and non-pregnant women.

Design

Immune responses to SARS-CoV-2 were analyzed using samples from pregnant and non-pregnant women who had either tested positive or negative for SARS-CoV-2. We measured, proinflammatory and placental cytokine mRNAs, neonatal Fc receptor (FcRn) receptor expression, and tetanus antibody transfer in maternal and cord blood samples. Additionally, we measured anti-spike (S) IgG, anti-S-receptor binding domain (RBD) IgG, and neutralizing antibody (nAb) responses to SARS-CoV-2 in serum or plasma collected from non-pregnant women, pregnant women, and cord blood.

Setting

Johns Hopkins Hospital (JHH).

Participants

Pregnant women were recruited through JHH outpatient obstetric clinics and the JHH Labor & Delivery unit. Non-pregnant women were recruited after receiving outpatient SARS-CoV-2 testing within Johns Hopkins Health System, USA. Adult non-pregnant women with positive RT-PCR results for SARS-CoV-2, within the age range of 18-48 years, were included in the study.

Exposures

SARS-CoV-2.

Main Outcomes and Measures

Participant demographic characteristics, antibody titers, cytokine mRNA expression, and FcRn receptor expression.

Results

SARS-COV-2 positive pregnant women expressed more IL1β , but not IL6 , in blood samples collected within 14 days versus > 14 days after a confirmed SARS-CoV-2 test, with similar patterns observed in the fetal side of placentas, particularly among asymptomatic pregnant women. Pregnant women with confirmed SARS-CoV-2 infection also had reduced anti-S-RBD IgG titers and were less likely to have detectable nAb as compared with non-pregnant women. Although SARS-CoV-2 infection did not disrupt FcRn expression in the placenta, maternal transfer of nAb was inhibited by SARS-CoV-2 infection during pregnancy.

Conclusions and Relevance

SARS-CoV-2 infection during pregnancy was characterized by placental inflammation and reduced antiviral antibody responses, which may impact the efficacy of COVID-19 therapeutics in pregnancy. The long-term implications of placental inflammation for neonatal health also requires greater consideration.

Unboxed: US Young Adult Tobacco Users' Responses to a New Heated Tobacco Product

The heated tobacco product (HTP) IQOS was authorized for sale in the US in 2019. We investigated how young adults with experience using multiple tobacco products reacted to, perceived, and developed interest in IQOS, informing policies that might prevent HTPs from becoming ubiquitous. We used a novel qualitative method in which 33 young adult tobacco users in California (fall 2019) "unboxed" an IQOS device, tobacco sticks, and marketing materials and narrated their impressions and opinions. We conducted content and thematic analyses of participants' reactions, sensory experiences, and interest. Multiple attributes influenced appeal for participants, including sleek electronic design, novel technology, perceived harmfulness, complexity, and high cost. The "no smoke" claim and heating technology suggested that smoking IQOS was safer than smoking cigarettes. Public health programs should closely monitor HTP marketing and uptake, particularly as "reduced exposure" claims were authorized in July 2020. Evidence-based regulations (e.g., requiring plain packaging for tobacco sticks), actions addressing IQOS' unique attributes (e.g., regulating device packaging to reduce high-tech appeal), and public education might help to counter the appeal generated by potentially misleading IQOS marketing tactics.

The role of the genital hiatus and prolapse symptom bother

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) severity is poorly correlated with prolapse symptoms. The objective of this study was to investigate the association between genital hiatus (GH) size and presence and severity of bulge symptoms.

METHODS

This analysis utilized data from a longitudinal study of parous women. Women underwent annual assessment of POP, GH size, and bulge symptoms. "Bother" was scored by participants reporting bulge symptoms. Three analyses evaluated the association between GH size and bulge symptoms, each using linear mixed models. First, we compared case visits (bulge symptoms reported) to control visits (bulge symptoms never reported), matching for stage. Second, among women who reported bulge sensation at least once during the study, we compared GH size at visits with and without bulge symptoms. Third, among women who reported bulge sensation, we investigated whether GH size was associated with "bother" score, controlling for stage.

RESULTS

Of 1528 women (7440 visits), 148 women (803 visits) reported bulge symptoms at ≥ 1 visit and 1380 women never reported bulge symptoms (6637 visits). Comparing 315 case visits (bulge symptoms reported) to 1260 control visits (bulge symptoms never reported), GH size was significantly greater among case visits (3.05 cm versus 2.85 cm, p ≤ 0.0001). In the case-crossover analysis, GH size was similar for visits with and without bulge symptoms (p = 0.63). When evaluating GH size and degree of bulge symptom bother, bother severity was significantly associated with GH size (p = 0.003).

CONCLUSIONS

Independent of stage, GH size was significantly associated with prolapse bulge symptoms and bother severity.

Stereotactic radiotherapy for large vestibular schwannomas: Volume change following single fraction versus hypofractionated approaches

Hypofractionated stereotactic radiotherapy is a treatment option for large vestibular schwannomas supported by an increasing evidence. A single institution retrospective review of large (>3.5cc) vestibular schwannomas treated with hypofractionated stereotactic radiotherapy and single-session radiosurgery was conducted. Using serial follow up scans, a volumetric analysis of tumor volume change over time was performed. Vestibular schwannomas treated with hypofractionated stereotactic radiotherapy appeared to reduce in volume significantly faster than those treated with single-session radiosurgery. Cystic lesions reduced in volume faster than solid lesions. There was no significant difference in the rates of radiological and symptomatic oedema, nor subsequent dexamethasone requirement between the two treatment modalities.

B-62 Using Single-Item Reporting on the Neurobehavioral Symptom Inventory to Determine Minimum Thresholds of Clinical Anxiety in a Polytrauma Veteran Sample

Objective

The Neurobehavioral Symptom Inventory (NSI) is a self-report measure used to evaluate physical and mental health symptoms secondary to traumatic brain injury (TBI) in the Department of Veterans Affairs health care system. There has been little research examining the relationship between anxiety reported on the NSI and other anxiety screening measures. The purpose of the study was to compare single-item response on item 19 (i.e., feeling anxious or tense) of the NSI to symptoms as reported on the Beck Anxiety Inventory (BAI).

Method

Retrospective data collected from veteran patients (N = 321) of a polytrauma outpatient clinic were used in the analyses. Veterans whose cutoff scores exceeded an embedded validity scale (i.e., NSI Validity-10) or had missing data were excluded. Receiver Operating Curve (ROC) analysis was conducted to determine which item score (i.e., score of 0-4) on the NSI best classified the presence of anxiety as measured by a BAI cut-off score greater than 7 (i.e., mild anxiety).

Results

There were 82 subjects who tested positive for anxiety based on a score of 3 on item 19 of the NSI. The ROC analysis was significant (AUC = .692, p < .001; 95% CI = .633 - .750). A score greater than 7 on the BAI yielded a sensitivity rate of .976 and a specificity rate of .711.

Conclusions

These results indicate that item 19 of the NSI is suggestive of a positive screen for mild anxiety in polytrauma samples with scores of 3 or greater indicating that further assessment of anxiety is recommended.

B-61 Single-Item Reporting on the Neurobehavioral Symptom Inventory to Determine Clinical Levels of Depression: How Brief is too Brief?

Objective

The Neurobehavioral Symptom Inventory (NSI) is frequently used in the Department of Veterans Affairs as a self-report measure to assess for a variety of medical and mental health concerns in veterans who have suffered traumatic brain injury (TBI). Only one item on the NSI (item 20) relates to depressive symptoms (i.e., feeling depressed or sad). The purpose of the study was to compare responses on the Beck Depression Inventory-II (BDI-II) with item 20 of the NSI to determine classification for mild depressive symptomatology.

Method

Retrospective data collected from veteran patients (N = 325) of a polytrauma outpatient clinic were used in the analysis. Veterans were excluded if cutoff scores exceeded an embedded validity scale (i.e., NSI Validity-10) or had missing data. Receiver Operating Curve (ROC) analysis was conducted to determine which item score (i.e., score of 0-4) on the NSI best classified the presence of depressive symptoms as measured by a BDI-II cut-off score greater than 13 (i.e., mild depression).

Results

There were 55 subjects who tested positive for depression based on a cut-off score of 3 on the NSI. The ROC analysis was significant (AUC = .822, p < .001; 95% CI = .774 - .871). A cut-off score of greater than 13 on the BDI-II yielded a sensitivity rate of .982 and a specificity rate of .607.

Conclusions

These results indicate that item 20 of the NSI is indicative of a positive screen for depressive symptomatology with scores of 3 or greater indicating that further evaluation for depression is warranted.

Use of aspirin, other nonsteroidal anti-inflammatory drugs and acetaminophen and risk of endometrial cancer: the Epidemiology of Endometrial Cancer Consortium

BACKGROUND

Regular use of aspirin has been associated with a reduced risk of cancer at several sites but the data for endometrial cancer are conflicting. Evidence regarding use of other analgesics is limited.

PATIENTS AND METHODS

We pooled individual-level data from seven cohort and five case-control studies participating in the Epidemiology of Endometrial Cancer Consortium including 7120 women with endometrial cancer and 16 069 controls. For overall analyses, study-specific odds ratios (ORs) and 95% confidence intervals (CI) were estimated using logistic regression and combined using random-effects meta-analysis; for stratified analyses, we used mixed-effects logistic regression with study as a random effect.

RESULTS

At least weekly use of aspirin and non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) was associated with an approximately 15% reduced risk of endometrial cancer among both overweight and obese women (OR = 0.86 [95% CI 0.76-0.98] and 0.86 [95% CI 0.76-0.97], respectively, for aspirin; 0.87 [95% CI 0.76-1.00] and 0.84 [0.74-0.96], respectively, for non-aspirin NSAIDs). There was no association among women of normal weight (body mass index < 25 kg/m2, Pheterogeneity = 0.04 for aspirin, Pheterogeneity = 0.003 for NSAIDs). Among overweight and obese women, the inverse association with aspirin was stronger for use 2-6 times/week (OR = 0.81, 95% CI 0.68-0.96) than for daily use (0.91, 0.80-1.03), possibly because a high proportion of daily users use low-dose formulations. There was no clear association with use of acetaminophen.

CONCLUSION

Our pooled analysis provides further evidence that use of standard-dose aspirin or other NSAIDs may reduce risk of endometrial cancer among overweight and obese women.

Mythical androids and ancient automatons Adrienne Mayor Princeton University Press, 2018. 291 pp

Technology tales from classical literature reveal the storied history of artificial intelligence

Radiological Kinetics of Brain Metastases and Clinical Implications for Patients Treated With Stereotactic Radiosurgery

AIMS

Select patients with brain metastases receive stereotactic radiosurgery (SRS) with the objective of improving survival and intracranial disease control. Brain metastases number and volume are prognostic factors used to inform patient selection. The aim of this study was to assess the rate of change of brain metastases size and number (growth kinetics) between the diagnostic and day of SRS magnetic resonance imaging (MRI) scans.

MATERIALS AND METHODS

All patients treated with Gamma Knife SRS between October 2015 and April 2017 were included in this single-centre retrospective analysis. Brain metastases number and diameter were recorded at diagnosis and treatment. For patients with multiple brain metastases, the largest lesion was the index lesion. Distant intracranial control and overall survival were reported from the date of SRS.

RESULTS

In total, 146 patients received 156 episodes of SRS. The median interval between diagnostic and SRS MRI was 20 days (range 1-68). Interval growth in the index lesion of at least 3 mm or the development of a new brain metastasis was noted in 60.2% of patients. This was associated with age less than 60 years (P = 0.001), Eastern Cooperative Oncology Group (ECOG) performance status 2 or above (P = 0.04), non-small cell lung carcinoma (NSCLC) (P = 0.03) or melanoma histologies (P = 0.05) and uncontrolled extracranial disease (P = 0.05). These patients were also more likely to develop distant intracranial recurrence (P = 0.046). Clinically significant growth was not associated with scan interval or differences in overall survival. The Kaplan-Meier estimate of probability of survival at 12 months was 59.3% (95% confidence interval 46.7-75.2%) for all patients.

CONCLUSION

Intracranial progression between diagnosis and day of SRS is common. Risk factors are uncontrolled extracranial disease, poorer performance status, NSCLC or melanoma histologies and age less than 60 years. These patients would benefit from an MRI closer to treatment to inform patient selection and target delineation for SRS planning.

Genome-wide association study across European and African American ancestries identifies a SNP in DNMT3B contributing to nicotine dependence

Cigarette smoking is a leading cause of preventable mortality worldwide. Nicotine dependence, which reduces the likelihood of quitting smoking, is a heritable trait with firmly established associations with sequence variants in nicotine acetylcholine receptor genes and at other loci. To search for additional loci, we conducted a genome-wide association study (GWAS) meta-analysis of nicotine dependence, totaling 38,602 smokers (28,677 Europeans/European Americans and 9925 African Americans) across 15 studies. In this largest-ever GWAS meta-analysis for nicotine dependence and the largest-ever cross-ancestry GWAS meta-analysis for any smoking phenotype, we reconfirmed the well-known CHRNA5-CHRNA3-CHRNB4 genes and further yielded a novel association in the DNA methyltransferase gene DNMT3B. The intronic DNMT3B rs910083-C allele (frequency=44-77%) was associated with increased risk of nicotine dependence at P=3.7 × 10-8 (odds ratio (OR)=1.06 and 95% confidence interval (CI)=1.04-1.07 for severe vs mild dependence). The association was independently confirmed in the UK Biobank (N=48,931) using heavy vs never smoking as a proxy phenotype (P=3.6 × 10-4, OR=1.05, and 95% CI=1.02-1.08). Rs910083-C is also associated with increased risk of squamous cell lung carcinoma in the International Lung Cancer Consortium (N=60,586, meta-analysis P=0.0095, OR=1.05, and 95% CI=1.01-1.09). Moreover, rs910083-C was implicated as a cis-methylation quantitative trait locus (QTL) variant associated with higher DNMT3B methylation in fetal brain (N=166, P=2.3 × 10-26) and a cis-expression QTL variant associated with higher DNMT3B expression in adult cerebellum from the Genotype-Tissue Expression project (N=103, P=3.0 × 10-6) and the independent Brain eQTL Almanac (N=134, P=0.028). This novel DNMT3B cis-acting QTL variant highlights the importance of genetically influenced regulation in brain on the risks of nicotine dependence, heavy smoking and consequent lung cancer.