Pregnancy and assisted reproductive technology use in Australian female transfusion-dependent haemoglobinopathy patients: a 20-year retrospective analysis

BACKGROUND

In the last few decades, the life expectancy of patients with transfusion-dependent thalassaemia (TDT) and sickle cell disease (SCD) has improved significantly, in part because of improved iron chelation. Fertility challenges and pregnancy complications have historically limited reproductive options in this group; however, improved multi-disciplinary care has made infertility a chronic disease complication requiring attention. Despite this, there are very few reports and no Australian data describing fertility and pregnancy outcomes in this population.

AIMS

To identify the rate of assisted reproductive technologies (ART) utilisation in our female transfusion-dependent haemoglobinopathy patients and to establish the nature of maternal and neonatal complications in this cohort.

METHODS

A 20-year retrospective analysis (1997-2017) at an Australian centre captured data on conception rates, use of assisted reproductive techniques (ART), and pregnancy and neonatal outcomes in female transfusion-dependent haemoglobinopathy patients.

RESULTS

Conception was attempted in 14 women (11 TDT and three SCD) during the study period. A total of 28 pregnancies resulting in 25 live births were recorded. ART supported 13 conceptions. A positive association was not identified between elevated mean serum ferritin and ART use; however, all patients with an established diagnosis of hypogonadotropic hypogonadism (HH) required ART. Maternal complications included gestational diabetes mellitus and post-partum haemorrhage. There were no cardiac complications. Two-thirds of women underwent lower segment caesarean section, with prematurity complicating 20% of births. There were no neonatal or maternal deaths.

CONCLUSION

Pregnancy is an achievable goal for women with transfusion-dependent haemoglobinopathies, although the support of ART may be required in a subset of patients.

Clinical Experience of Axillary Radiotherapy for Node-positive Breast Cancer

AIMS

Patients with breast cancer who have positive lymph nodes are currently recommended axillary node clearance (ANC) or regional nodal irradiation (RNI). ANC is associated with complications such as lymphoedema, brachial plexopathy and shoulder stiffness. The AMAROS Group showed RNI to be non-inferior to ANC with regards to survival and recurrence, and with a better quality of life. We conducted a large real-world population study to show our centre's experience with the use of RNI and to contribute to the current discussion around the management of node-positive breast cancer.

MATERIALS AND METHODS

We evaluated patients who received RNI as opposed to ANC between 2006 and 2009 (n = 190). Patients had a range of cancer subtypes/grades. All had positive axillary disease, identified by axillary node sampling or sentinel lymph node biopsy. Systemic therapy was given as per standard protocol. Our data were compared with those of patients who had RNI (n = 681) in AMAROS. Patients were followed up retrospectively and overall survival, breast cancer-specific survival, distant metastasis-free survival, locoregional recurrence and toxicity were recorded, including lymphoedema, brachial plexopathy and shoulder stiffness. Survival analysis was performed on R via the Kaplan-Meier method. Univariate and multivariate analyses were also performed. Toxicity data were reported as percentages. Patients meeting POSNOC trial criteria (one to two positive sentinel lymph nodes, macrometastasis, receiving adjuvant chemotherapy) including if oestrogen receptor-positive (stratified POSNOC) were identified for subgroup analysis in the regression model.

RESULTS

Locoregional recurrence was 3.16% versus AMAROS RNI of 1.82%. Overall survival was slightly lower in our population, but cancer-specific survival was higher than AMAROS. Lymphoedema rates were 5.8% versus AMAROS 11% in RNI and 23% in ANC arms, respectively. Brachial plexopathy was 1.6% and arm/shoulder stiffness 7.4%. AMAROS conducted a quality of life survey pertaining to arm/shoulder stiffness, mobility and function, which seemed to affect about 18% in the RNI arm. Univariate analysis revealed POSNOC status, especially if also oestrogen receptor-positive, to be a low risk group with hazard ratio 0.42 (0.20-0.83, P = 0.015). Extracapsular extension of lymph node metastasis was a poor prognostic factor; hazard ratio 4.39 (1.45-14.0, P = 0.009).

CONCLUSION

We support the conclusion of the AMAROS trial with survival and recurrence following RNI being non-inferior to ANC, and with similarly favourable toxicity data. We support the continuing use of RNI as a treatment option for patients with node-positive breast cancer. Further research is required to answer the key questions regarding personalised management for node-positive breast cancer, with regards to de-escalation and also intensification for the patients exhibiting adverse tumour biology.

Attention Mobilization as a Modulator of Listening Effort: Evidence From Pupillometry

Listening to speech in noise can require substantial mental effort, even among younger normal-hearing adults. The task-evoked pupil response (TEPR) has been shown to track the increased effort exerted to recognize words or sentences in increasing noise. However, few studies have examined the trajectory of listening effort across longer, more natural, stretches of speech, or the extent to which expectations about upcoming listening difficulty modulate the TEPR. Seventeen younger normal-hearing adults listened to 60-s-long audiobook passages, repeated three times in a row, at two different signal-to-noise ratios (SNRs) while pupil size was recorded. There was a significant interaction between SNR, repetition, and baseline pupil size on sustained listening effort. At lower baseline pupil sizes, potentially reflecting lower attention mobilization, TEPRs were more sustained in the harder SNR condition, particularly when attention mobilization remained low by the third presentation. At intermediate baseline pupil sizes, differences between conditions were largely absent, suggesting these listeners had optimally mobilized their attention for both SNRs. Lastly, at higher baseline pupil sizes, potentially reflecting overmobilization of attention, the effect of SNR was initially reversed for the second and third presentations: participants initially appeared to disengage in the harder SNR condition, resulting in reduced TEPRs that recovered in the second half of the story. Together, these findings suggest that the unfolding of listening effort over time depends critically on the extent to which individuals have successfully mobilized their attention in anticipation of difficult listening conditions.

Professionalism and Safety of DPT Students in First, Full-Time Clinical Experiences: Accelerated Hybrid versus Traditional Programs

PURPOSE

Doctor of Physical Therapy (DPT) education continues to progress with contemporary content and innovative teaching methods. The purpose of this study was to examine clinical assessment data from the Physical Therapist Clinical Performance Instrument (PT-CPI) focused on professionalism and safety in an initial clinical experience between an accelerated-hybrid and traditional DPT program.

METHODS

A retrospective analysis was performed on mid-term and final Safety, Professional Behavior, and Communication PT-CPI scores of each program's first clinical experience. The traditional program served as a control group. A total 186 students were examined: 100 from the traditional program and 86 from the accelerated-hybrid program.

RESULTS

There was a significant effect of learning environment on final test scores while controlling for midterm scores in Safety (p < 0.001), Professional Behavior (p < 0.001), and Communication (p < 0.001) with students in the accelerated-hybrid program scoring higher. Each program showed improvements from midterm to final PT-CPI, outperforming the set benchmark score with the accelerated-hybrid program showing larger growth in Communication and Safety.

CONCLUSION

Students in both DPT programs display acceptable levels of professionalism and safety according to program benchmarks and demonstrate growth in these areas throughout the clinical experiences despite differences in program design.

Mindfulness training is associated with improved quality of life in female collegiate athletes

OBJECTIVE

To examine the effects of a mindfulness intervention on health-related quality of life in female Division I collegiate athletes.

PARTICIPANTS

135 female collegiate athletes, ages 18 - 23 years.

METHODS

Health related quality of life (HRQoL) was reported twice/year in approximately January and July from January 2017 to 2020 with the 12-question Veterans Rand survey (VR-12). Twenty-three of the participants received a 6-week, in-person, group mindfulness training in spring 2019, while 112 did not.

RESULTS

A significant interaction between time and mindfulness was identified with respect to the mental component score of the VR-12 of the VR-12 (MCS; β = 3.86 ± 1 .56, p = 0.012) but no significant relationships were identified with respect to time (pre-mindfulness: β = -2.36 ± 1.38, p = 0.074), mindfulness (yes: β = -2.26 ± 1.54, p = 0.14) or season (winter: β = -0.84 ± 0.57, p = 0.14). With respect to the physical component score (PCS), no significant relationships were identified with respect to time (pre-mindfulness: β = -1.09 ± 1.21, p = 0.37), mindfulness (yes: β = 1.30 ± 1.31, p = 0.32), season (winter: β = 0.50 ± 0.50, p = 0.32), or the interaction between time and mindfulness (β = 0.35 ± 1 .36, p = 0.80).

CONCLUSIONS

Among female collegiate athletes, mindfulness training is associated with significant improvements in mental HRQoL, but not physical HRQoL.

Online prediction tools for melanoma survival: A comparison

BACKGROUND

Breslow thickness, patient age and ulceration are the three most valuable clinical and pathological predictors of melanoma survival. A readily available reliable online tool that accurately considers these and other predictors could be valuable for clinicians managing melanoma patients.

OBJECTIVE

To compare online melanoma survival prediction tools that request user input on clinical and pathological features.

METHODS

Search engines were used to identify available predictive nomograms. For each, clinical and pathological predictors were compared.

RESULTS

Three tools were identified. The American Joint Committee on Cancer tool inappropriately rated thin tumours as higher risk than intermediate tumours. The University of Louisville tool was found to have six shortcomings: a requirement for sentinel node biopsy, unavailable input of thin melanoma or patients over 70 years of age and less reliable hazard ratio calculations for age, ulceration and tumour thickness. The LifeMath.net tool was found to appropriately consider tumour thickness, ulceration, age, sex, site and tumour subtype in predicting survival.

LIMITATIONS

The authors did not have access to the base data used to compile various prediction tools.

CONCLUSION

The LifeMath.net prediction tool is the most reliable for clinicians in counselling patients with newly diagnosed primary cutaneous melanoma regarding their survival prospects.

Efficacy of inguinal buffered lidocaine and intranasal flunixin meglumine on mitigating physiological and behavioral responses to pain in castrated piglets

Managing castration pain on US sow farms is hindered by the lack of Food and Drug Administration (FDA) approved products for mitigating pain. Previous work assessing flunixin meglumine (FM) efficacy in mitigating castration pain has shown the drug to be effective in pigs, meanwhile, results from previous work evaluating lidocaine efficacy are contradictory. Therefore, the objectives of this study were to determine the efficacy of inguinal buffered lidocaine (BL) and FM in mitigating castration pain in piglets. This study was divided into Part I (physiological response) and Part II (behavioral response). For part I piglets were randomly assigned to the following treatments: T1: (C) Castration plus physiological saline; T2: (S) Sham plus physiological saline; T3: (CL) Castration plus BL; T4: (SL) Sham plus BL; T5: (CF) Castration plus FM; T6: (SF) Sham plus FM; T7: (CLF) Castration plus BL and FM; T8: (SLF) Sham plus BL and FM. Blood was collected 24 h prior to castration, 1 h, and 24 h post castration for cortisol quantification. For Part II another cohort of piglets was enrolled and randomly assign to the following treatments: T1: (C) Castration plus physiological saline and T7: (CLF) Castration plus BL and FM. Behavior scoring was obtained in real-time by observing each piglet for 4-min continuously using Unesp-Botucatu pig acute pain scale (UPAPS) at the following timepoints: 1 h before castration (-1 h), immediately post-castration (0 h), and 3 h post-castration (+3 h). Average cortisol concentrations did not differ at -24 h (P > 0.05) or at 24 h post-castration (P > 0.05) between treatments. At 1 h post-castration, castrated piglets (C and CL) demonstrated greater cortisol concentrations (P < 0.05). Castrated piglets in the CF and CLF group had lower cortisol concentrations compared to C and CL-treated pigs (P < 0.05). For behavioral response, there were no differences between treatments on total UPAPS scores (C and CLF, P > 0.05). Intranasal FM was able to effectively reduce the physiological piglet's response immediately post-castration. Inguinal buffered lidocaine had no effect on the either physiological or behavioral response to pain. Long-term research should focus on refining injection techniques for inguinal BL and consider administration frequency and dosing of intranasal FM to control pain for a longer period post-castration.

Exploring views of members of the public and policymakers on the acceptability of population level dietary and active-travel policies: a qualitative study

BACKGROUND

There is limited evidence on what shapes the acceptability of population level dietary and active-travel policies in England. This information would be useful in the decision-making process about which policies should be implemented and how to increase their effectiveness and sustainability. To fill this gap, we explored public and policymakers' views about factors that influence public acceptability of dietary and active-travel policies and how to increase public acceptability for these policies.

METHODS

We conducted online, semi-structured interviews with 20 members of the public and 20 policymakers in England. A purposive sampling frame was used to recruit members of the public via a recruitment agency, based on age, sex, socioeconomic status and ethnicity. Policymakers were recruited from existing contacts within our research collaborations and via snowball sampling. We explored different dietary and active-travel policies that varied in their scope and focus. Interviews were transcribed verbatim and analysed using thematic reflexive analysis with both inductive and deductive coding.

RESULTS

We identified four themes that informed public acceptability of dietary and active-travel policies: (1) perceived policy effectiveness, i.e., policies that included believable mechanisms of action, addressed valued co-benefits and barriers to engage in the behaviour; (2) perceived policy fairness, i.e., policies that provided everyone with an opportunity to benefit (mentioned only by the public), equally considered the needs of various population subgroups and rewarded 'healthy' behaviours rather than only penalising 'unhealthy' behaviours; (3) communication of policies, i.e., policies that were visible and had consistent and positive messages from the media (mentioned only by policymakers) and (4) how to improve policy support, with the main suggestion being an integrated strategy addressing multiple aspects of these behaviours, inclusive policies that consider everyone's needs and use of appropriate channels and messages in policy communication.

CONCLUSIONS

Our findings highlight that members' of the public and policymakers' support for dietary and active-travel policies can be shaped by the perceived effectiveness, fairness and communication of policies and provide suggestions on how to improve policy support. This information can inform the design of acceptable policies but can also be used to help communicate existing and future policies to maximise their adoption and sustainability.

Systemic Exophiala equina infection in an Eastern box turtle (Terrapene carolina carolina): a case report and literature review

Phaeohyphomycosis is an infection caused by melanized fungi. This disease has been reported in several animal species including invertebrates, cold-blooded vertebrates, mammals, and humans. Melanized fungi have similar phenotypical features and confirmation requires culture and molecular diagnostics. To exemplify this we present a case of a 333 g adult of unknown age, free-ranging, male Eastern box turtle (Terrapene carolina carolina) that was referred to the Turtle Rescue Team at North Carolina State University for evaluation of multilobulated masses occupying the entire left orbit and at the right forelimb on the plantarolateral aspect of the foot. A fine needle aspirate cytologic examination of the mass on the right forelimb revealed large numbers of inflammatory cells and fungal organisms. Histopathology of the skin biopsies from the right forefoot was consistent with phaeohyphomycosis. A course of antifungal medication was started (Fluconazole 21 mg/kg loading dose IV then 5 mg/kg PO SID q 30 days). Due to concern for the patient's quality of life and the lack of a curative treatment plan, humane euthanasia was elected. Gross and histological postmortem examination confirmed the presence of multiple coelomic masses similar in appearance to those observed in the left orbit and right forefoot indicating disseminated phaeohyphomycosis. A swab of the periocular mass was submitted for fungal culture and phenotypic identification. The isolate was later identified as Exophiala equina through a combination of phenotypic characterization and sequencing of the ITS region of the nuclear rDNA. Exophiala is a genus in the family Herpotrichiellaceae, order Chaetothyriales and is considered an opportunistic "black yeast" causing infection in aquatic invertebrates, fish, amphibians, reptiles, and mammals including humans. Exophiala equina is infrequently reported in animals, with only three cases in the literature including the herein report.

Adult Traumatic Brain Injury and Likelihood of Routine Discharge: Do Comorbidities Matter?

The current literature demonstrates an association between both size and presence of traumatic brain injury (TBI) and its effects on mortality, however it does not readily address the morbidity and associated functional outcomes of those who survive. We hypothesize that the likelihood of discharge to home decreases with advancement of age in the presence of TBI. This is a single-center study of Trauma Registry data, inclusive years July 1, 2016 to October 31, 2021. The inclusion criteria was based upon age (≥40 years), and ICD10 diagnosis of a TBI. Disposition to home without services was the dependent variable. 2031 patients were included in the analysis. We hypothesized correctly that the likelihood of discharge to home decreases (by 6%) with advancement of age (per year) in the presence of intracranial hemorrhage.

Traumatic Brain Injury Under Triage Risk: A Rural Trauma System Experience

BACKGROUND

The process of interfacility transfer may cause a delay in the necessary medical treatment, which could lead to poor outcomes and increased mortality rates. The ACS-COT considers an acceptable under triage rate of <5%. The aim of this research was to identify the likelihood of under triage among transferred-in traumatic brain injury (TBI) patients.

METHODS

This is a single-center study of Trauma Registry data, from July 1, 2016, to October 31, 2021. The inclusion criteria were based upon age (≥40 years), ICD10 diagnosis of TBI, and interfacility transfer. Under triage using the Cribari matrix method was the dependent variable. A logistic regression was performed to identify additional predictor variables on the likelihood that an adult TBI trauma patient experienced under triage.

RESULTS

878 patients were included in the analysis; 168 (19%) experienced an under triage. The logistic regression model was statistically significant (N = 837, P < .01). In addition, several significant increases in odds for under triage were identified, which included increasing injury severity score (ISS; OR 1.40, P < .01), increasing AIS head region (OR 6.19, P < .01), and personality disorders (OR 3.61, P = .02). In addition, a reduction in odds in TBI adult trauma under triage is the comorbidity of anticoagulant therapy (OR .25, P < .01).

CONCLUSIONS

The likelihood of under triage in the adult TBI trauma population is associated with increasing AIS head injuries and increasing ISS and among those with mental health comorbidities. This evidence and additional protective factors, such as patients on anticoagulant therapy, may aid in education and outreach efforts to reduce under triage among the regional referring centers.

1998. Association of Infection Recurrence with Oral Step-Down vs Continued Intravenous Antimicrobial Therapy in Patients with Complicated Intra-Abdominal Infection

Background

Complicated intra-abdominal infections (cIAIs) require a combined strategy of source control and antimicrobial therapy. Guidelines recommend initial intravenous (IV) therapy with oral step-down therapy following source control. Due to limited data supporting this strategy, we aimed to evaluate the safety and efficacy of oral step-down antimicrobial therapy in cIAIs after initial IV antimicrobial therapy.

Methods

This retrospective cohort study included hospitalized patients ≥ 18 years of age diagnosed with a cIAI who received &gt; 7 days of IV therapy during index hospitalization at quaternary hospital from March 2017 to October 2021. Patients were excluded for primary or peritoneal dialysis-related peritonitis, necrotizing pancreatitis, fistulizing inflammatory bowel disease, or upper gastrointestinal tract infection; repeat hospitalization during study period; or transfer from another facility after &gt; 24 hours of care. Patients were assigned into two treatment groups: IV-only or oral step-down therapy. The primary outcome was infection recurrence defined as re-initiation of antimicrobials after a treatment-free period of ≥ 3 days. Secondary outcomes included treatment escalation, repeat source control procedure, treatment-related complications, and all-cause mortality.

Results

The cohort consisted of 248 patients (199 IV-only and 49 oral step-down). Baseline, infection, and treatment characteristics were similar between groups, except for gender, length of stay, and overall treatment duration (Table 1). Patients receiving IV-only therapy had a shorter median antimicrobial duration than the oral step-down group (13 vs. 23 days; P &lt; 0.001). Infection recurrence occurred in 26 (13.1%) and six (12.2%) patients in the IV-only and oral step-down groups, respectively (P = 0.88). Treatment escalation, repeat source control, and 28-day mortality were similar between groups (Table 1). Oral step-down therapy resulted in more adverse drug events (10.2% vs. 3.0%; P = 0.04).

Table 1: Baseline and infection-related characteristics for IV only and oral step-down therapy groups aDefined as: solid organ transplant, hematopoietic stem cell transplant within the last 1 year, long-term high-dose steroids (prednisone &gt;10 mg, or equivalent, for ≥2 weeks), concomitant immunosuppressive medication, or HIV (CD4 count &lt;200 cells/µL) bOther antimicrobials included cephalexin, cefpodoxime, doxycycline, fluconazole, and sulfamethoxazole-trimethoprim cAdverse drug events included dermatologic reactions, gastrointestinal upset, nausea/vomiting, diarrhea, fatigue, thrombocytopenia, and acute kidney injury

Conclusion

Transition to oral step-down after initial IV antimicrobial therapy may be an alternative strategy for the management of cIAIs; however, larger non-inferiority studies are warranted to confirm the safety and efficacy of this approach.

Disclosures

James Sanders, PhD, PharmD, Merck & Co., Inc.: Grant/Research Support|Shionogi Inc.: Grant/Research Support Sara Hennessy, M.D., Boston Scientific: Advisor/Consultant Sara Hennessy, M.D., Boston Scientific: Advisor/Consultant.

Case Report: Novel Disseminated Paecilomyces formosus Infection in a Dog

A 2.5-year-old, 25.5 kg, spayed female Australian Shepherd dog had a 2-month history of shifting leg lameness in all limbs, tetraparesis, progressive lethargy, and severe pain. On the physical examination, fever (40.61°C), tachycardia, tachypnea, mild diffuse pelvic limb muscular atrophy, left prescapular and right popliteal lymphadenomegaly were observed. Due to the poor prognosis and difficult pain management, humane euthanasia was elected. Macroscopic and histological findings revealed multifocal to coalescing granulomas with central areas of lytic necrosis within the right femur, left humerus, left scapula, left biceps brachii, right semimembranosus muscle, liver, spleen, and lymph nodes. The necrotic areas contained myriad intralesional, intracellular, and extracellular negatively stained, non-pigmented, septate acute angle branching hyphae with parallel walls measuring 3–6 μm in width with polar bulbous projections measuring 7–13 μm in width. Fresh samples of the liver were submitted for fungal culture. Panfungal PCR targeting the major conserved genes-ITS, TUB, CAL-confirmed Paecilomyces formosus. Paecilomyces spp. are members of anamorphic fungi classified under the phylum Ascomycota. Paecilomycosis is an uncommon fungal infection caused by Paecilomyces spp with a disease reported in humans and animals ranging from superficial to systemic clinical forms affecting both immunocompromised and immunocompetent individuals. In dogs, disseminated paecilomycosis has been reported, but the species of fungi are not always determined. To our knowledge, this is the first case of disseminated paecilomycosis caused by P. formosus infection in a dog.

Arginase 1 Deficiency: using genetic databases as a tool to establish global prevalence

BACKGROUND/OBJECTIVE

Arginase 1 Deficiency (ARG1-D) is a rare inherited metabolic disease with progressive, devastating neurological manifestations with early mortality and high unmet need. Information on prevalence is scarce and highly variable due to limited newborn screening (NBS) availability, variability of arginine levels in the first days of life, and high rates of misdiagnosis. US birth prevalence was recently estimated via indirect methods at 1.1 cases per million live births. Due to the autosomal recessive nature of ARG1-D we hypothesize that the global prevalence may be more accurately estimated using genetic population databases.

METHODS

MEDLINE and EMBASE were systematically searched for previously reported disease variants. Disease variants in ARG1-D were annotated wherever possible with allele frequencies from gnomAD. Ethnicity-specific prevalence was calculated using the Hardy-Weinberg equation and applied to generate country-specific carrier frequencies for 38 countries. Finally, documented consanguinity rates were applied to establish a birth prevalence for each country.

RESULTS

133 of 228 (58%) known causative alleles were annotated with ethnic-specific frequencies. Global birth prevalence for ARG1-D was estimated at 2.8 cases per million live births (country-specific estimates ranged from 0.92 to 17.5) and population prevalence to be 1.4 cases per million people (approximately 1/726,000 people). Birth prevalence estimates were dependent on population demographics and consanguinity rate.

CONCLUSION

Birth prevalence of ARG1-D based on genetic database analysis was estimated to be more frequent than previous NBS studies have indicated. There was a higher degree of confidence in North American and European countries due to availability of genetic databases and mutational analysis versus other regions. These findings suggest the need for greater disease education around signs and manifestations of ARG1-D, as well as more widespread testing and standardization of screening for this severe disease in order to appropriately identify patients prior to disease progression.

Visual estimate of coronary artery calcium predicts prevalent coronary artery disease in patients with respiratory disease

Background

Coronary artery calcification (CAC) measured using ECG-triggered coronary computed tomography correlates strongly with overt cardiovascular disease risk. Evidence is emerging to suggest CAC measured on non-gated thoracic CT scans may also correlate with cardiovascular disease. Herein, we sought to ascertain the utility of Weston scoring (visual score for CAC) in predicting prevalent coronary artery disease (CAD) and incident cardiovascular disease (CVD) for patients undergoing lung cancer screening or follow-up for interstitial lung disease with a non-triggered high-resolution CT (HRCT) thorax.

Methods

The Computerised Radiology Information Service (CRIS) database was manually searched to determine all HRCT scans performed in a single UK trust from 01/05/2016 to 01/05/2017 for the aforementioned indications. Radiology reports and images of selected studies were reviewed. For patients with evidence of CAC, we calculated the calcium score using the Agatston and Weston methods. Clinical events were determined from the electronic medical record without knowledge of patients' CAC findings. At baseline, significant CAC was defined as Agatston &gt;400 and Weston &gt;7.

Results

2152 scans were analysed. Data at follow up was available for 100% of patients, with a median duration of follow up of 3.6 years. A history of CAD was reported by 8% (172) of subjects at baseline, who were subsequently excluded from analysis. Significant CAC was found in 450 (22.5%) and 650 (32.5%) by Weston and Agatston scores respectively, with a significant correlation between the two scores (r-0.71, p&lt;0.01). During follow up 7.4% (160) of patients developed incident CVD. Patients with low Weston scores of ≤7 and Agatston scores of ≤400 had a lower incidence of CVD compared to those with Weston &gt;7 and Agatston &gt;400 (31 [19.3%] vs 129 [80.6%]; P=0.003 for Weston scores; 37 [23.1%] vs 123 [76.9%] for Agatston scores; P&lt;0.001).

Conclusion

In this retrospective study of patients with respiratory disease attending for HRCT scanning, the Weston visual score for CAC performs well in predicting prevalent CAD and future CVD events. With previous data demonstrating excellent inter- and intra- observer agreement, our study demonstrates Weston scoring is a valid tool in reporting non-gated CT scans, removing the need for dedicated software analysis as required with the Agatston score, and has a high overall positive and negative predictive value for future CVD. Further multi-centre prospective studies of this strategy, should be conducted to clarify the utility of Weston CAC scoring in non-gated CTs as a prediction tool which may be used to modify cardiac risk and reduce the risk of incident cardiovascular events.

Funding Acknowledgement

Type of funding sources: None.

An evaluation of patient outcomes following transcatheter pulmonary valve implantation: a meta-analysis

Background

Transcatheter pulmonary valve implantation has emerged as an effective alternative to surgery in patients with congenital Right Ventricular Outflow Tract Dysfunction (RVOT). There is demonstrable evidence that Percutaneous Pulmonary Valve Implantation (PPVI) effectively restores conduit graft viability with a consequent improvement in right ventricular pressures.

Aim

The objective of this study was to perform a meta-analysis of all previously published studies examining the outcome of PPVI and the associated early and late peri-procedural factors in patients with RVOT dysfunction. Data from procedures performed within our own centre have also been included.

Methodology

We performed a meta-analysis of all observational studies investigating early and late outcomes following PPVI. Risk ratios and risk differences were pooled in a random-effects model. The I2 statistic was used to quantify heterogeneity between studies. We searched EMBASE, MEDLINE, CINAHL, PsychInfo and Cochrane databases from their inception until 2021. Studies were included if they reported any comparative data regarding study endpoints. Primary endpoint was mean RVOT gradient. Secondary end points include pulmonary regurgitation fraction, left and right ventricular end-diastolic and systolic volume indexes, and left ventricular ejection fraction. Complication rates were considered a safety endpoint.

Results

A total of 23 studies with 1501 participants enrolled were included in the final meta-analysis. The RVOT gradient decreased significantly [weighted mean difference (WMD) = −20.32 mmHg; 95% confidence interval (CI): −22.15, −19.11; p&lt;0.001]. Mean right ventricular (RV) systolic pressures fell significantly [(WMD)= −18.4 mmHg; 95% CI: −16.4, −20.2; p&lt;0.001) and RV diastolic pressures decreased significantly [(WMD) = −6.3 mmHg, 95% CI: −4.3, −8.9; p&lt;0.001). Pulmonary regurgitation fraction (PRF) also decreased notably (WMD = −24.38%, 95% CI: −28.27, −17.32; p&lt;0.001).The incidence of infective endocarditis was 1.8% (95% CI: 0.7–3.8).

Conclusion

PPVI is an effective and safe strategy in relieving right ventricular remodelling and improving haemodynamic and clinical outcomes in patients with RVOT dysfunction. Multi-centre collaborations are essential to further determine the long-term effects of PPVI on cardiac function, exercise tolerance and quality of life in RVOT dysfunction.

Funding Acknowledgement

Type of funding sources: None.

Metabolic maturation of differentiating cardiosphere-derived cells

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Collagen IV promotes proliferation of cardiosphere-derived cells.

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Fibronectin supports differentiation of cardiosphere-derived cells.

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Oxidative metabolism increases as cardiac progenitors mature.

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Stimulating fatty acid oxidation promotes cardiac progenitor cell maturation.

Cardiosphere-derived cells (CDCs) can be expanded in vitro and induced to differentiate along the cardiac lineage. To recapitulate the phenotype of an adult cardiomyocyte, differentiating progenitors need to upregulate mitochondrial glucose and fatty acid oxidation. Here we cultured and differentiated CDCs using protocols aimed to maintain stemness or to promote differentiation, including triggering fatty acid oxidation using an agonist of peroxisome proliferator-activated receptor alpha (PPARα). Metabolic changes were characterised in undifferentiated CDCs and during differentiation towards a cardiac phenotype. CDCs from rat atria were expanded on fibronectin or collagen IV via cardiosphere formation. Differentiation was assessed using flow cytometry and qPCR and substrate metabolism was quantified using radiolabelled substrates. Collagen IV promoted proliferation of CDCs whereas fibronectin primed cells for differentiation towards a cardiac phenotype. In both populations, treatment with 5-Azacytidine induced a switch towards oxidative metabolism, as shown by changes in gene expression, decreased glycolytic flux and increased oxidation of glucose and palmitate. Addition of a PPARα agonist during differentiation increased both glucose and fatty acid oxidation and expression of cardiac genes. We conclude that oxidative metabolism and cell differentiation act in partnership with increases in one driving an increase in the other.

Gene alteration in zebrafish exposed to a mixture of substances of abuse

A recent surge in the use and abuse of diverse prescribed psychotic and illicit drugs necessitates the surveillance of drug residues in source water and the associated ecological impacts of chronic exposure to the aquatic organism. Thirty-six psychotic and illicit drug residues were determined in discharged wastewater from two centralized municipal wastewater treatment facilities and two wastewater receiving creeks for seven consecutive days in Kentucky. Zebrafish (Danio rerio) larvae were exposed to the environmental relevant mixtures of all drug residues, all illicit drugs, and all prescribed psychotic drugs. The extracted RNA from fish homogenates was sequenced, and differentially expressed sequences were analyzed for known or predicted nervous system expression, and screened annotated protein-coding genes to the true environmental cocktail mixture. Illicit stimulant (cocaine and one metabolite), opioids (methadone, methadone metabolite, and oxycodone), hallucinogen (MDA), benzodiazepine (oxazepam and temazepam), carbamazepine, and all target selective serotonin reuptake inhibitors including sertraline, fluoxetine, venlafaxine, and citalopram were quantified in 100% of collected samples from both creeks. The high dose cocktail mixture exposure group revealed the largest group of differentially expressed genes: 100 upregulated and 77 downregulated (p ≤ 0.05; q ≤ 0.05). The top 20 differentially expressed sequences in each exposure group comprise 82 unique transcripts corresponding to 74% annotated genes, 7% non-coding sequences, and 19% uncharacterized sequences. Among 61 differentially expressed sequences that corresponded to annotated protein-coding genes, 23 (38%) genes or their homologs are known to be expressed in the nervous system of fish or other organisms. Several of the differentially expressed sequences are associated primarily with the immune system, including several major histocompatibility complex class I and interferon-induced proteins. Interleukin-1 beta (downregulated in this study) abnormalities are considered a risk factor for psychosis. This is the first study to assess the contributions of multiple classes of psychotic and illicit drugs in combination with developmental gene expression.

Pet health insurance reduces the likelihood of pre-surgical euthanasia of dogs with gastric dilatation-volvulus in the emergency room of an Australian referral hospital

AIMS

To determine the association between the presence of pet health insurance and the risk of euthanasia at the time of diagnosis for dogs with gastric dilatation-volvulus (GDV).

METHODS

Insurance status at the time of GDV diagnosis was sought for a cohort of 147 non-referred, confirmed cases of GDV that presented to the emergency department of a university-based veterinary hospital in Australia between 2008 and 2017. Insurance status was obtained from the medical record (n=18) or after contacting the owners by phone using a standardised questionnaire (n=129). Animal, clinical and outcome data was retrospectively compiled in a research database. The primary outcome measure was whether or not the dog was euthanised before surgery. The Mantel-Haenszel procedure was used to quantify the association between the presence of pet health insurance and the risk of euthanasia at the time of diagnosis for dogs with GDV, adjusting for the confounding effect of age at the time of presentation using Bayesian methods.

RESULTS

Of the 69 dogs for which insurance information could be obtained, 10 (14%) cases were insured at the time of the GDV event and 59 (86%) cases were not. The majority of non-insured dogs (37/59; 63 (95% CI=50-74)%) were euthanised before surgery, while none (0 (95% CI=0-28)%) of the insured dogs were euthanised at that time (p<0.001). Of the 32 insured and non-insured dogs that underwent surgery, four dogs (13 (95% CI=5-28)%) did not survive to hospital discharge. Three dogs (9%) were euthanised during or after surgery and one dog (3%) experienced cardiopulmonary arrest during treatment. The majority of dogs for which insurance status was known did not survive to hospital discharge (41/69; 59%), and 90 (95% CI=7-96)% of deaths were caused by euthanasia prior to surgery. Uninsured dogs were 5.0 (95% credible interval=1.8-26) times more likely to undergo presurgical euthanasia compared with insured dogs.

CONCLUSIONS

Euthanasia prior to treatment was most common cause of death in non-referred dogs with GDV; such euthanasia was entirely absent in the cohort of dogs that were insured.

CLINICAL RELEVANCE

Financial considerations significantly contribute to mortality of dogs with GDV presented to an emergency room. Financial instruments to reduce the out-of-pocket expense for pet owners confronted with unexpected veterinary expenses have potential to reduce pet mortality.

Penile cancer in Ireland - A national review

OBJECTIVE

Penile cancer is a rare malignancy, with a reported incidence of 1.5/100,000 males in the Republic of Ireland in 2015. The aim of this study was to perform the first national review and to evaluate clinicopathological factors affecting survival.

SUBJECTS AND METHODS

All cases of penile cancer in Ireland between 1995 and 2010 were identified through the National Cancer Registry Ireland (NCRI) and analysed to identify factors affecting survival.

RESULTS

360 cases of penile cancer were identified, with a mean age at diagnosis of 65.5 years and 88% (n = 315) of cases occurred in those over 50. 91% (n = 328) of cases were squamous cell carcinomas (SCC). The majority of patients were treated surgically (n = 289), with 57% (n = 206) and 24% (n = 87) undergoing partial penectomy and total penectomy respectively. Only 18% (n = 65) received radiotherapy, and 8% (n = 27) received chemotherapy. Mean overall survival (OS) was 113 months, and five year disease specific survival (DSS) was 70% (95%CI: 59.1-77.8%). Age at diagnosis, nodal status and presence of metastatic disease were independent prognostic markers on multivariate analysis.

CONCLUSION

This study represents the first national review of penile cancer in Ireland. The annual incidence and survival rates are comparable to European figures, though superior DSS has previously been reported from our institution, highlighting the role for centralisation of care in Ireland.

LEVEL OF EVIDENCE

2b.

The potential utility of end-binding protein 1 (EB1) as response-predictive biomarker for lisavanbulin: A phase 2 study of lisavanbulin (BAL101553) in adult patients with recurrent glioblastoma

TPS2068

Background: Lisavanbulin (BAL101553, prodrug of BAL27862) is a novel tumor checkpoint controller that promotes tumor cell death by modulating the spindle assembly checkpoint. BAL27862 is a lipophilic, small molecule (MW 387) shown in rodents to penetrate the brain (1:1 plasma ratio) with promising antitumor activity in orthotopic models of glioblastoma (GB) as monotherapy or in combination with radiotherapy (RT) ± chemotherapy. In a completed phase 1 study (Lopez et al. ESMO 2020, NCT02490800) with daily oral lisavanbulin in patients with recurrent GB or high-grade glioma, the RP2D was determined at 25 mg/day. In this phase 1 study, two patients (out of 20 patients) with GB show a long-lasting (> 2 years) clinical benefit with improvement in clinical symptoms and in target and/or non-target GB lesions as per RANO criteria. Both patients show strong end-binding protein 1 (EB1) expression in their GB tissues as assessed by immunohistochemistry staining. EB1, a protein located on the plus-ends of microtubules, is involved in microtubule (MT) function and has been associated with stemness of glioma cells and a more aggressive disease. Data from GB mouse models suggest that EB1 is a predictive marker for response to lisavanbulin. The prevalence of EB1-positivity in GB is estimated at ̃5%. This ongoing phase 2 study is an extension of the completed Phase 1 study and is conducted to confirm prospectively whether EB1 is a response-predictive biomarker for lisavanbulin in GB. Methods: This is an ongoing multicenter, open-label, phase 2 study using a Simon Two-Stage design to assess the efficacy of lisavanbulin in patients with recurrent GB. The study is being performed in the UK, Switzerland and Germany. Patients with histologically-confirmed GB and recurrent disease after prior RT with alkylating chemotherapy (de-novo/primary GB) or after prior chemotherapy or RT (secondary GB), are eligible for enrollment if their GB archival tumor tissue is EB1-positive. EB1-positivity is defined as moderate to strong EB1-staining in at least 70% of GB tumor cells using a CE-marked immunohistochemistry Clinical Trial Assay (Targos Molecular Pathology GmbH). The primary study objective is the overall response rate by RANO, with MRI scans being performed every 8 weeks. Secondary endpoints include progression-free survival and overall survival. Adverse events are assessed using CTCAEv5. To develop a potential RNA-based response signature, molecular profiling of tumor tissue is performed using whole transcriptome sequencing (RNAseq) in each patient enrolled in the study to define the genomic expression profiles in patients with EB1-positive GB. Nine evaluable patients are to be enrolled in Stage 1, and an additional 10 patients will be enrolled in stage 2 if at least 2 objective responses per RANO criteria are observed in stage 1. Clinical trial information: 02490800.

Expression of end-binding protein 1 (EB1), a potential response-predictive biomarker for lisavanbulin, in glioblastoma and various other solid tumor types

3118

Background: EB1, a protein located on the plus-ends of microtubules is involved in microtubule function and has been associated with glioblastoma (GBM) stem-cell-ness and more aggressive disease. Lisavanbulin (BAL101553) is a prodrug of the lipophilic small molecule BAL27862, that promotes tumor cell death by modulating the spindle assembly checkpoint and has been shown in rodents to efficiently penetrate the brain. Data from GBM mouse models and recent phase 1 clinical data (Lopez et al. ESMO 2020) suggest that EB1 is a response-predictive marker for lisavanbulin in GBM. A phase 2 study is ongoing to confirm this hypothesis (NCT02490800). A proof-of-concept in GBM would support an expansion of EB1-directed lisavanbulin clinical development in non-GBM tumors, which requires prevalence estimates of EB1-positivity in non-GBM tumor types. Methods: Tissue samples from GBM and other tumor types were stained for EB1 using a CE-marked immunohistochemistry Clinical Trial Assay (Targos Molecular Pathology GmbH, Kassel Germany). EB1-positivity was assessed by a board-certified pathologist based on the percentage of tumor cells showing moderate or strong staining for EB1, using thresholds of ≥50%, ≥60% and ≥70% of tumor cells with EB1 positivity. Whole transcriptome sequencing (WTS) using RNAseq was performed in a subset of tissue samples to develop a potential RNA-based predictive response signature for lisavanbulin. Results: 73 GBM tissue samples and 333 tissue samples from 13 other cancer types were stained for EB1. The strongest overall signal for EB1-positivity was obtained for medulloblastoma, neuroblastoma and GBM. In addition, moderate or strong EB1-staining in ≥50% of tumor cells was observed in samples from colorectal cancer (CRC), non small-cell lung cancer (NSCLC), metastatic melanoma, small-cell lung cancer (SCLC) and triple-negative breast cancer (TNBC). An expanded staining campaign is ongoing in these cancer types. Initial results from the ongoing WTS analyses show marked differences in gene expression profiles between EB1-positive and -negative cases. Conclusions: Strong EB1-positivity is infrequent but occurs in a variety of tumor types, with the strongest signals in medulloblastoma, neuroblastoma and GBM. A phase 2 study is ongoing to assess prospectively whether EB1 is a response-predictive biomarker for lisavanbulin in GBM.[Table: see text]

Hyperpolarized 13 C magnetic resonance imaging for noninvasive assessment of tissue inflammation

Inflammation is a central mechanism underlying numerous diseases and incorporates multiple known and potential future therapeutic targets. However, progress in developing novel immunomodulatory therapies has been slowed by a need for improvement in noninvasive biomarkers to accurately monitor the initiation, development and resolution of immune responses as well as their response to therapies. Hyperpolarized magnetic resonance imaging (MRI) is an emerging molecular imaging technique with the potential to assess immune cell responses by exploiting characteristic metabolic reprogramming in activated immune cells to support their function. Using specific metabolic tracers, hyperpolarized MRI can be used to produce detailed images of tissues producing lactate, a key metabolic signature in activated immune cells. This method has the potential to further our understanding of inflammatory processes across different diseases in human subjects as well as in preclinical models. This review discusses the application of hyperpolarized MRI to the imaging of inflammation, as well as the progress made towards the clinical translation of this emerging technique.

Beyond-use Date of Trimix: A Reproducible Stability Study Using Bracketing Design

Trimix is a widely prescribed penile injection for patients with erectile dysfunction and is only available as a compounded medication. The instability of alprostadil, one of the major ingredients of Trimix, has been a limiting factor in its utilization. There are published stability data for Trimix formulations that have been used to establish a beyond-use-date. However, a robust bracketed study that is shown to be reproducible is highly desirable and meaningful. The purpose of this study was to test the reproducibility of a bracketed stability study when the preparations were made by two different entities to provide beyond-use date information of Trimix preparations that cover a wide range of strengths. A validated stability indicating method was used to compare the stability of a bracketed Trimix - alprostadil 5 µg/mL to 45 µg/mL, papaverine 15 mg/mL to 30 mg/mL, and phentolamine 0.4 mg/mL to 5 mg/mL, and a single-strength preparation containing alprostadil 30 µg/mL, papaverine 30 mg/mL, and phentolamine 2 mg/mL that were compounded and stored following the same methods and conditions, but at two different practice settings. Beyond-use dates of 60 days and 64 days at cold temperature were obtained for the two preparations from two different settings. The consistent results confirmed the reproducibility of the bracketing designs used to determine the beyond-use dates of Trimix. The clinical value of these results stems from the availability of accurate and widely applicable stability data that can be referenced to establish beyond use dates of a number of Trimix preparations with various strength combinations.

Pharmacokinetics and tolerability of LIQ861, a novel dry-powder formulation of treprostinil

A dry-powder inhaled formulation of treprostinil (LIQ861) produced using PRINT® technology offers a substantial advantage over current nebulized therapy. Treprostinil is a synthetic prostacyclin analogue that is currently approved for inhalation administration to patients with pulmonary arterial hypertension via nebulized Tyvaso® inhalation solution. LTI-101 was a phase 1, placebo-controlled, double-blind, randomized, single-center study that evaluated the ascending single-dose pharmacokinetics of LIQ861 in healthy subjects. Six sequential, escalating doses (25, 50, 75, 100, 125, and 150 mcg) were studied to investigate treprostinil exposure from LIQ861 inhalation. Subjects (n = 57) were randomly assigned in a 3:1 ratio to receive a single dose of either LIQ861 (n = 43) or placebo (n = 14); 56 subjects completed all protocol-defined assessments. Following single-dose administration, treprostinil exposure from LIQ861 increased proportionally across the dose range studied, and the pharmacokinetics profile of treprostinil administered as LIQ861 was similar to prior reports of inhaled treprostinil. All doses of LIQ861 were generally well-tolerated with no deaths, serious adverse events, or dose-limiting toxicities. The most frequently reported treatment-emergent adverse events related to study drug administration were coughing and throat irritation, which are common to dry-powder formulations. Treatment-related treatment-emergent adverse events were reported more frequently at higher dose levels; however, all were assessed as mild in severity. We conclude that the pharmacokinetics profile of treprostinil using a dry-powder inhaled formulation increased in proportion to dose as anticipated and was similar to earlier reports of inhaled, nebulized treprostinil (Tyvaso®). Based on these results, a phase 3 study (INSPIRE; Clinicaltrials.gov Identifier NCT03399604) evaluating the long-term safety and tolerability of LIQ861 in patients with pulmonary arterial hypertension was initiated.

Comorbidities of alopecia areata: a population-based cohort study

BACKGROUND

Previous studies have associated alopecia areata (AA) with a number of comorbidities. However, the timing between AA and the development of such comorbidities remains poorly understood.

AIM

To examine the temporal relationship between AA diagnosis and comorbidity development in Denmark.

METHODS

A Danish nationwide register-based cohort study was performed on all individuals diagnosed with AA between 2007 and 2016 (n = 1843), and each patient was matched for age and sex with 10 healthy controls (HCs). Time between AA and comorbidity development was assessed, and incidence rate ratios (IRRs) were calculated to assess risk of comorbidity following initial AA diagnosis.

RESULTS

Use of antidepressant and anxiolytic drugs were mostly started prior to AA diagnosis, and these drugs were used more frequently before than after diagnosis with AA. Additional frequent comorbidities included thyroid disease, hyperlipidaemia, type 2 diabetes and asthma. Most comorbidities occurred prior to AA diagnosis; however, among those that occurred after AA diagnosis, antidepressants (IRR = 1.26, 95% CI 1.01-1.56), anxiolytics (IRR = 1.55, 95% CI 1.17-2.05), atopic dermatitis (AD; IRR = 9.41, 95% CI 4.00-22.16), asthma (IRR = 2.17, 95% CI 1.46-3.21), vitiligo (IRR = 30.35, 95% CI 6.13-150.39), Crohn disease (CD; IRR = 3.04; 95% CI 1.22-7.56) and thyroid disease (IRR = 2.38; 95% CI 1.72-3.29) occurred more frequently among patients with AA compared with controls.

CONCLUSION

A diagnosis of AA was significantly associated with risk of several comorbidities, most notably vitiligo, AD and CD. Nonetheless, the majority of patients appeared to have developed these comorbidities prior to AA diagnosis, suggesting that a thorough medical history screening by dermatologists at the initial visit may be appropriate.

A systematic review and meta-analysis of laparotomy compared with laparoscopic management of interstitial pregnancy

BACKGROUND

Interstitial pregnancy is a rare but life-threatening condition accounting for 1-4% of all types of tubal ectopic pregnancies. It can be managed by open and minimally invasive surgical techniques. Our goal was to compare laparoscopic and open surgery for managing interstitial pregnancy.

SEARCH STRATEGY

We searched PubMed, Scopus, Web of Science, and Cochrane up to May 2020.

SELECTION CRITERIA

1) Women with interstitial pregnancy, 2) Intervention: laparoscopic surgery, 3) Comparator: open surgery, 4) Outcomes: Hospital stay, operation time, pain scale, blood loss. Secondary outcomes: any other reported 5) Study designs: interventional and observational.

DATA COLLECTION AND ANALYSIS

Data was extracted from the relevant articles and was pooled as mean difference (MD) or relative risk (RR) with a 95% confidence interval (CI).

MAIN RESULTS

We included six studies, three of which provided eligible data. The duration of hospital stay was lower in the laparoscopic surgery group (MD = -1.42, 95% CI [-1.72, -0.76], P < 0.0001). There was no significant difference in operative time (MD = 5.90, 95% CI [-11.30, 23.09], P = 0.50, blood loss (MD = -9.43, 95% CI [-214.18, 195.32], P = 0.93), complications (RR = 1.54, 95% CI [0.20, 11.85], P = 0.68), or blood transfusions (RR = 0.77, 95% CI [0.50, 1.25], P = 0.30).

CONCLUSION

Laparoscopic surgery is associated with shorter hospital stay, with no difference in terms of blood loss, post-, and intraoperative complications, and need for blood transfusion compared with laparotomy.

Phase 1/2a trial of intravenous BAL101553, a novel controller of the spindle assembly checkpoint, in advanced solid tumours

BACKGROUND

BAL101553 (lisavanbulin), the lysine prodrug of BAL27862 (avanbulin), exhibits broad anti-proliferative activity in human cancer models refractory to clinically relevant microtubule-targeting agents.

METHODS

This two-part, open-label, phase 1/2a study aimed to determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLTs) of 2-h infusion of BAL101553 in adults with advanced or recurrent solid tumours. The MTD was determined using a modified accelerated titration design in phase I. Patients received BAL101553 at the MTD and at lower doses in the phase 2a expansion to characterise safety and efficacy and to determine the recommended phase 2 dose (RP2D).

RESULTS

Seventy-three patients received BAL101553 at doses of 15-80 mg/m2 (phase 1, n = 24; phase 2a, n = 49). The MTD was 60 mg/m2; DLTs observed at doses ≥60 mg/m2 were reversible Grade 2-3 gait disturbance with Grade 2 peripheral sensory neuropathy. In phase 2a, asymptomatic myocardial injury was observed at doses ≥45 mg/m2. The RP2D for 2-h intravenous infusion was 30 mg/m2. The overall disease control rate was 26.3% in the efficacy population.

CONCLUSIONS

The RP2D for 2-h infusion of BAL101553 was well tolerated. Dose-limiting neurological and myocardial side effects were consistent with the agent's vascular-disrupting properties.

CLINICAL TRIAL REGISTRATION

EudraCT: 2010-024237-23.