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

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

Early Ascertainment of Breast Cancer Diagnoses Comparing Self-Reported Questionnaires and Electronic Health Record Data Warehouse: The WISDOM Study

PURPOSE

The goal of this study was to use real-world data sources that may be faster and more complete than self-reported data alone, and timelier than cancer registries, to ascertain breast cancer cases in the ongoing screening trial, the WISDOM Study.

METHODS

We developed a data warehouse procedural process (DWPP) to identify breast cancer cases from a subgroup of WISDOM participants (n = 11,314) who received breast-related care from a University of California Health Center in the period 2012-2021 by searching electronic health records (EHRs) in the University of California Data Warehouse (UCDW). Incident breast cancer diagnoses identified by the DWPP were compared with those identified by self-report via annual follow-up online questionnaires.

RESULTS

Our study identified 172 participants with confirmed breast cancer diagnoses in the period 2016-2021 by the following sources: 129 (75%) by both self-report and DWPP, 23 (13%) by DWPP alone, and 20 (12%) by self-report only. Among those with International Classification of Diseases 10th revision cancer diagnostic codes, no diagnosis was confirmed in 18% of participants.

CONCLUSION

For diagnoses that occurred ≥20 months before the January 1, 2022, UCDW data pull, WISDOM self-reported data via annual questionnaire achieved high accuracy (96%), as confirmed by the cancer registry. More rapid cancer ascertainment can be achieved by combining self-reported data with EHR data from a health system data warehouse registry, particularly to address self-reported questionnaire issues such as timing delays (ie, time lag between participant diagnoses and the submission of their self-reported questionnaire typically ranges from a month to a year) and lack of response. Although cancer registry reporting often is not as timely, it does not require verification as does the DWPP or self-report from annual questionnaires.

Aptamer-, heparin- or cocktail-based inhibition of S1-ACE2 protein complexes

The Spike protein (S1) from the Severe acute respiratory syndrome 2 virus binds to angiotensin converting enzyme 2 (ACE2) receptor to initiate infection. Hence, antiviral therapeutic targeting the S1-ACE2 interface is of interest. Herein, we compare the inhibition efficacy of an aptamer to heparin or their cocktail, against wild-type (WT), Omicron, Delta, and Lambda S1-ACE2 complexes. The aptamer-protein complexes had the dissociation constant K_D values in the 2-13 nM range. The aptamer half-maximal inhibitory concentration against WT S1-ACE was 17 nM, with the % inhibition in the 12-35% range. Several aptamer-S1 protein complexes were also stable at low pH with 60% inhibition. Despite the similarity in S1 sequences, the extent of inhibition (2-27%) with heparin was highly dependent on the type of S1 protein. More importantly, heparin did not inhibit the WT S1-ACE2 complex but was effective with mutants. The aptamer-heparin cocktail was less effective compared to aptamer or heparin, individually. Modelling data show that either a direct or proximal binding to RBD sites by aptamer or heparin prevents the ACE2 binding. Overall, heparin was as an effective inhibitor as aptamer against certain variants, and represents the more cost-effective neutralizing agent against emerging coronaviruses.

Abstract P3-03-24: The WISDOM Study: Early Ascertainment of Breast Cancer Diagnoses by Utilizing Self-Reported Questionnaires and Data Warehouse Electronic Health Records

BACKGROUND WISDOM (Women Informed to Screen Depending on Measures of risk) is a pragmatic trial comparing the safety, efficacy, cost, and patient acceptability of personalized versus annual breast cancer screening in women ages 40-74 years with no personal history of breast cancer. Cancer registry reporting is considered the gold standard for ascertaining cancer diagnosis data; however, the time lag between diagnosis and reporting (1-2 years or more) by the California Cancer Registry (CCR) presents challenges. The WISDOM study must quickly ascertain and report accurate cancer diagnoses to the Data Safety Monitoring Board; delays could lead to preventable harm, unnecessary costs, and unwarranted early trial termination. To ascertain cancer diagnoses in a timely manner, we used multiple data collection methods and compared self-reported with Electronic Health Records (EHR) information, and in some cases verified with chart review. Specifically, we conducted a procedural study with WISDOM participants who sought care at a University of California (UC) health system by extracting their data from the University of California Data Warehouse (UCDW) to 1) verify self-reported breast cancer diagnoses in WISDOM; 2) ensure that all on-study breast cancer diagnoses have been captured within the WISDOM study cohort; and 3) assess the accuracy and reliability of self-reported data. The UCDW provides harmonized EHR data from the six University of California (UC) health systems and constitutes ~120 billion data points from 7.8 million patient records. METHODS We provided the UCDW with a list of WISDOM participants who indicated they had sought care from a UC health system. Participants with recorded breast cancer diagnostic code (ICD-10CM C50.) were matched with the WISDOM self-reported cancer dataset to uncover participants who had no recorded breast cancer diagnosis in the study system. For those individuals with no recorded self-report diagnosis, coordinators conducted manual chart review to determine whether the participants had been diagnosed with breast cancer. RESULTS This cohort included 11,314 enrolled WISDOM participants who self-reported care at a UC and had at least one diagnostic or procedural breast care code. Among these participants, 160 had a ICD-10-CM C50 breast cancer diagnostic code of which 132 breast cancer cases were confirmed: 111 were already self-reported through WISDOM and 21 additional confirmed breast cancer cases were identified through the UCDW. As a standard process, only WISDOM self-reported cancer cases that were confirmed by chart review are entered into the study database. The percentage of confirmed UCDW-identified cases that were not also self-reported was greater for recent diagnoses (16% overall and 6% for period prior to June 2020). Among the 11,314 participants in our cohort, the CCR identified 61 pre-June 2020 cancer diagnoses. Of these 61 diagnoses, 92% (56) were identified by the UCDW procedural process. If the UCDW had been used as the single source for cancer diagnosis, 21 participants without cancer and 7 participants with unclear status (unlocated or inaccessible records) would have been classified as cancer cases. DISCUSSION/CONCLUSION Self-reported data provides quick ascertainment with relative accuracy compared to cancer registry. Cancer ascertainment can be further improved by combining self-reported data with EHR data from a health system data warehouse registry, particularly for self-reported questionnaire issues such as timing and lack of response. Accuracy of self-reported cancer diagnosis from annually distributed questionnaires improves over time. Identifying cancer diagnosis discordance between data sources can inform processes to improve self-reported study accuracy.

Citation Format: Katherine Leggat-Barr, Rita H. Ryu, Allison Stover Fiscalini, Tomiyuri Lewis, Rohini S. Bulusu, Samrrah A. Raouf, Hannah Lui Park, Alyssa N. Rocha, Liliana Johansen, Laura Van ’t Veer, Laura J. Esserman, Michael A. Hogarth. The WISDOM Study: Early Ascertainment of Breast Cancer Diagnoses by Utilizing Self-Reported Questionnaires and Data Warehouse Electronic Health Records [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-03-24.

Abstract PD14-07: PD14-07 Associations of Breast Cancer Risk Level and Prediction of Tumor Aggressiveness in the Athena Breast Health Network

Background: The Athena Breast Health Network (Athena) is a University of California (UC) initiative integrating clinical care and research to drive improvements in breast cancer screening. Through standardized, self-reported clinical intake forms, a patient’s breast health status and information regarding their breast cancer risk is captured before each mammography appointment. Breast cancer risk models provide a level of risk to develop breast cancer but do not take into account aggressiveness of breast cancer. Here, we evaluated outcome data of a large screening cohort for association between risk level and aggressiveness at diagnosis. Methods: We calculated Breast Cancer Surveillance Consortium (BCSC) risk scores for a cohort of 8,923 consented UCSF Athena participants from the years 2012-2018 with a median follow-up of 5-years. To identify those who developed invasive breast cancer on or after completing an Athena intake form, we performed a cancer linkage with the San Francisco Mammography Registry (SFMR), a local registry that regularly collects cancer data from the California Cancer Registry. We classified tumors as aggressive if they met one or more of the following criteria: hormone receptor (HR)-negative, HER2-positive, grade 3. All other tumors were classified as non-aggressive. We used student’s t-tests to examine associations between BCSC 5-year risk score, the development of invasive breast cancer, and tumor aggressiveness among cases. To account for the association between older age and higher BCSC risk score (as well as HR-positive subtypes), we stratified by percentiles of BCSC risk by age (top 2.5% vs. bottom 97.5%). The top 2.5% by age threshold consistently identifies women with lifetime risk of 23–28% and was chosen as high-risk threshold to trigger annual screening in the WISDOM study (Dreher: PMID34843026). Results: Of 8,923 participants, 170 (2%) developed breast cancer during the follow-up period. The average 5-year BCSC risk score for women with breast cancer was 1.81% and 1.47% for those without (p< 0.001). Among women with breast cancer, 123 (72%) developed non-aggressive cancers and 47 (28%) developed aggressive cancers. The average 5-year BCSC risk score for women with non-aggressive and aggressive cancers was 1.89% and 1.60%, respectively (p=0.13). In analyses stratified by percentile of BCSC risk by age, 521 (6%) participants had a BCSC 5-year risk score in the top 2.5% by age and 8,402 (94%) participants had a BCSC 5-year risk score in the bottom 97.5%. A higher percentage of women with non-aggressive cancers vs healthy women (controls) were in the top 2.5% by age (p = 0.001), but the percentage of aggressive cancers vs healthy women in the top 2.5% by age was similar (p = 0.61). Conclusion: Through this study we confirmed that higher 5-year BCSC risk scores are associated with higher overall breast cancer development. Interestingly, participants with the highest 5-year BCSC risk scores (top 2.5% by age), are more likely to develop cancers with non-aggressive features (low grade, hormone positive). This suggests that the BCSC model may preferentially predict less aggressive tumors, and those with the highest 5-year BCSC risk may be more likely to benefit from endocrine risk reduction therapy. There remains a gap in our ability to identity those at risk for aggressive cancers. Our findings highlight the need for screening programs to better understand who is at risk for what type of breast cancer. Current work is focused on developing models tailored to risk prediction of aggressive cancers.

Citation Format: Katherine Leggat-Barr, Tomiyuri Lewis, Rosalyn Sayaman, Paige Warner, Kathy Malvin, Leah Sabacan, Elene Tsopurashvili, WISDOM Study and Athena Breast Health Network Investigators and Advocate Partners, Allison Stover Fiscalini, Jeffrey Tice, Karla Kerlikowske, Yiwey Shieh, Laura J. Esserman, Laura Van ’t Veer. PD14-07 Associations of Breast Cancer Risk Level and Prediction of Tumor Aggressiveness in the Athena Breast Health Network [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD14-07.

Clinical impact of analgesic-sedative agents and peri-operative clinical status on white matter brain injury in preterm infants following surgical NEC

BACKGROUND

The potential influence of exposure to analgesic-sedative agents (ASA) before, during, and after surgical NEC and peri-operative clinical status on white matter injury (WMI) in preterm infants has not been fully defined, and a comprehensive evaluation may inform future research and clinical interventions.

METHODS

A retrospective study comparing ASA exposure before/during /after surgical NEC and peri-operative clinical status in neonates with and without WMI.

RESULTS

Infants with any WMI (grade 2-4, n = 36/67, 53.7%) had a higher number of surgical procedures receiving ASA (5 [IQR: 3, 8] vs. 3 [2, 4]; p = 0.002) and had a longer duration of hypotension during their first (48.0 hours [26.0, 48.0] vs. 15.5 [6, 48]; p = 0.009) and second surgery (20 hours [0, 48h] vs. 0 [0, 22]; p = 0.017), received more hydrocortisone (35% vs.13.3%,p = 0.04) than those without any WMI. There were no differences in fentanyl/morphine/midazolam exposure before/during/after the NEC onset in the two groups.Infants with severe WMI (19/67, 28.3%, grade 3/4) had a higher incidence of AKI (P = 0.004), surgical morbidity (p = 0.047), more surgical procedures (6.5 [3, 10] vs. 4 [2, 5]; p = 0.012), and received higher mean fentanyl doses(p = 0.03) from birth until NEC onset than those without severe WMI. The univariate associations between these factors and severe WMI remained insignificant after multivariable logistic regression.

CONCLUSION

Infants with WMI had more surgical procedures receiving ASA and had a longer duration of hypotension during surgeries. A large multicenter prospective study is needed to understand the full impact of ASA.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

964 Cheques and Balances: A Five-Year Review of Surgical Settlements

Aim

The litigious burden in the NHS has been increasing yearly, costing an estimated £2.5 billion per year in financial settlements. We investigated the causes of general surgical settlements and attributed costs at a district general hospital over a five-year period.

Method

A retrospective analysis of all general surgical claims between 2016–2021 using the NHS Resolutions Case Management System. Selected cases were those which resulted in out of court financial settlements; whilst these claims have been settled, the trust admitted no negligence in each case.

Results

A total of 12 settlements were made with a total cost of £249,918 (£8000-£60,000, mean £20,827). Eight of the claims (67%) related to elective cases with four (33%) emergency cases. Of the total cases, 41% and 33% related to management of gallstones and appendicitis respectively.

The majority of claims (58%) related to delays in treatment with a total cost of £103,500 (£8000-£35,000), accounting for 41% of total settlement costs. Five cases (42%) were due to harm with a combined total of £146,418 (£9000-£60,000), 59% of the total settlement. Of the claims due to harm, 80% suffered recognised complications of the procedure.

Conclusions

Increasing litigation in the NHS over the last decade now accounts for 2% of the total NHS budget. The majority of settlements reviewed here were for avoidable delays in elective treatment, with higher financial settlements for well documented surgical complications related to the consent process. Better access to investigations, earlier clinical review, and reductions in delays to elective surgeries may reduce the financial burden of litigation.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

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

The pericranial flap for inner lining of full-thickness nasal defects: a retrospective cohort study

BACKGROUND

Effective nasal reconstruction requires skin and soft tissue cover, cartilage or bone structure, and mucosal lining. Ideal lining is thin, pliable and vascularised, making reconstruction challenging. This paper presents the first case series with long-term outcomes of pericranial flaps used as inner lining for nasal reconstruction.

METHODS

Patients undergoing paramedial forehead flaps from 2007 to 2019 were identified using second-stage nasal reconstruction billing codes. Patients with pericranial flaps for lining, for whom there were data on resulting outcomes and complications, were identified.

RESULTS

Sixty-six patients underwent second-stage nasal reconstruction. Eighteen patients had paramedian forehead and pericranial flaps for inner lining reconstruction. The flap lining had no immediate post-operative complications. Three patients suffered partial to major reconstructive failure post radiotherapy. Other complications included nasal stenosis and orocutaneous fistula.

CONCLUSION

Combined with paramedian forehead flaps, the pericranial flap is reliable as inner lining for nasal reconstruction. It is easily accessible and useful in resections with limited mucosal options.

Abstract P5-19-04: The WISDOM study: Reducing sequential steps and implementing parallel workflows in pragmatic trials

Background:The WISDOM Study is a preference-tolerant pragmatic study, comparing annual mammograms to a risk-based screening. Eligibility includes women ages 40-74 years with no history of breast cancer or DCIS. Participants are enrolled to one study arm: annual screening or risk-based screening (includes genetic testing). Pragmatic trials often involve gathering real-time data over multiple time points. Collecting real-time data sequentially can limit enrollment, delay study assignments, and reduce participant engagement. The WISDOM Study has identified such bottlenecks and has implemented parallel workflows, reducing the overall wait time for participants to complete required study steps. These data highlight how moving participants through the study more efficiently can improve enrollment and retention and inform other pragmatic trials. Methods: WISDOM participants have the option to either choose their study arm or be randomized into one as part of the preference tolerant randomized trial design. Participants then complete breast health questionnaires and genetic testing (if in the risk-based arm). This information is analyzed by the WISDOM breast cancer risk assessment algorithm, the result of which is then communicated to the participant through a screening assignment letter (SAL). Specific data elements, such as breast density found participants’ mammogram reports and genetic testing results are required for study randomization process and risk assessment calculations, respectively. The WISDOM randomization algorithm is stratified by several factors, including breast cancer risk estimated using the Breast Cancer Surveillance Consortium (BCSC) model, which uses mammographic density as a key input variable. The study team changed the workflow to allow participants to proceed to randomization without specific information by imputing both density and risk. Additionally, a parallel workflow improvement process was implemented to obtain mammogram reports while genetic testing was being completed. Results: Before the weighted BCSC and imputed density algorithms were introduced, it took an average of 47 days to randomize participants after completion of the baseline enrollment questionnaires. Now, participants are randomized immediately which has reduced delays by 100%. Prior to implementing the parallel workflow for genetic testing and mammogram ascertainment, genetic testing kits were sent only after mammogram reports were collected and validated. The expected turnaround time for genetic testing results was 30-60 days and on average, results were returned to participants in 42 days. Streamlining the study design to obtain mammogram reports while participants complete their genetic testing has shortened the time for participants to receive their screening assignment letters (SALs) from an average of 160 days to 78 days, a reduction by 49%. In comparison, participants in the annual arm of the study who do not complete genetic testing, receive their SALs after an average of 38 days from enrollment. This is due to long wait times to obtain mammographic densities from outside medical facilities. Conclusions: Creating parallel data ascertainment workflows and reducing sequential steps in the study process has increased completion of individual enrollment activities. Participants now are randomized immediately upon joining the study and have access to their SALs and genetic results more rapidly. This approach eliminated randomization wait times and improved efficiency of the early in the enrollment process. We are evaluating the impact on participant retention going forward. Workflow efficiency is critical to improve the patient experience, and our learnings can inform future trial design, particularly for studies requiring data from outside sources.

Citation Format: Tomiyuri Lewis, Stephanie Flores, Leah Sabacan, Patricia Choy, Halle Thannickal, Yiwey Shieh, Jeffrey Tice, Elad Ziv, Lisa Madlensky, Martin Eklund, Christina Yau, Amie Blanco, Barry Tong, Deborah Goodman, Nancy Anderson, Heather Harvey, Steele Fors, Hannah L Park, Samrrah Raouf, Skye Stewart, Janet Wernisch, Barbara Koenig, Celia Kaplan, Robert Hiatt, Neil Wenger, Vivian Lee, Diane Heditsian, Susie Brain, Dolores Moorehead, Barbara A Parker, Alexander Borowsky, Hoda Anton-Culver, Arash Naeim, Andrea Kaster, Laura van ‘t Veer, Andrea Z LaCroix, Olufunmilayo I Olopade, Deepa Sheth, Agustin Garcia, Rachel Lancaster, Michael Plaza, Wisdom Study, Athena Breast Health Network Investigators, Advocate Partners, Allison S Fiscalini, Laura Esserman. The WISDOM study: Reducing sequential steps and implementing parallel workflows in pragmatic trials [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-19-04.

Abstract P5-19-01: The impact of streamlined processes and patient-directed messaging to improve enrollment in a remote, pragmatic clinical trial

Background Recent advances in technology have made it possible to conduct remote clinical trials that allow individuals to participate from home with comfort, privacy, and ease. Despite these advances, challenges persist in running remote trials, such as survey question redundancies, lack of patient-initiated data-sharing tools, and unclear patient communication around critical enrollment steps. The Women Informed to Screen Depending on Measures of risk (WISDOM) Study is a pragmatic, preference-tolerant randomized control breast cancer screening trial comparing personalized risk-based screening to traditional, annual screening. The study population includes women ages 40-74 without a history of breast cancer or DCIS. Since 2016, study enrollment has been available to all women in the U.S. who meet study eligibility criteria. Since October 2020, WISDOM has implemented multiple strategies to improve participant experience: participant-initiated data-sharing tools and clear participant messaging. This abstract presents the efficacy of these interventions as they relate to increasing patient enrollment in remote, pragmatic clinical trials. Methods The WISDOM Study online enrollment process includes registration, participant study arm selection or randomization, online consent, and enrollment (submission of multiple study surveys over a secure, online platform). Barriers to online enrollment were uncovered through an internally-conducted needs assessment of participants who enrolled between 2019-2020, and participant feedback obtained through phone interviews conducted by WISDOM’s embedded ethics study. Improvements to our online enrollment procedures were executed in October 2020 and included: improving the clarity of study arm selection options, streamlining data collection surveys, and enacting a secure, patient-initiated online data-sharing tool and an online portal feature with auto-launch of critical information. Study metrics were obtained through Google Analytics and Salesforce. Results Prior to the end of 2020, only 62% of the 30,046 participants who registered for the WISDOM Study completed study enrollment. After improving the enrollment process, of the 5,334 participants registered for the study between Jan-June 2021, 69% completed the enrollment process finishing both the online consent and survey forms. Conversion from consent to enrollment went from 78% in January 2020 to 93% in June 2021. Currently, 56% participants complete enrollment in one day. Streamlining online patient questionnaires led to an increase in completion rates, with 75% of participants completing their yearly surveys, compared to 59% prior to April 2021. A secure patient upload feature for data sharing led to 1,054 participants successfully sharing their mammogram reports with WISDOM between March - June 2021. Previously, mammogram reports were missing for 20% of enrolled participants. This feature has enabled WISDOM to process 300 additional mammogram reports per month. Integration of an auto-launch feature in the participant’s portal in Feb 2021 has led to a 17% increase in participants viewing their screening recommendations in Yr 1. Prior to auto-launch, only 59% (n=6328) of Yr 1 screening recommendations and 61% (n=3681) of genetic testing reports were viewed by participants. Since implementation, the numbers increased to 78% (n=8406) and 85% (n=5160), respectively. Conclusions. Streamlining data to the most essential elements, and minimizing the steps required to share clinical documents, complete questionnaires and open key study notification is essential to improving enrollment rates in virtual, pragmatic trials. Patient-initiated data-sharing tools such as the ability for participants to share documents through secure, online portals is one example of success.

Citation Format: Patricia Choy, Tomiyuri Lewis, Stephanie Flores, Leah Sabacan, Halle Thannickal, Steffanie Goodman, Yiwey Shieh, Lisa Madlensky, Jeffrey A. Tice, Elad Ziv, Martin Eklund, Amie Blanco, Barry Tong, Deborah Goodman, Nancy Anderson, Heather Harvey, Steele Fors, Hannah Lui Park, Antonia Petruse, Skye Stewart, Samrrah Raouf, Janet Wernisch, Barbara Koenig, Celia Kaplan, Robert Hiatt, Neil Wenger, Vivian Lee, Diane Heditsian, Susie Brain, Dolores Moorehead, Barbara A Parker, Alexander Borowsky, Hoda Anton-Culver, Arash Naeim, Andrea Kaster, Laura van 't Veer, Andrea Z LaCroix, Olufunmilayo I. Olopade, Deepa Sheth, Agustin Garcia, Rachel Lancaster, Jennifer James, Galen Joseph, Wisdom Study, Athena Breast Health Network Investigators and Advocates, Allison Stover Fiscallini, Laura Esserman. The impact of streamlined processes and patient-directed messaging to improve enrollment in a remote, pragmatic clinical trial [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-19-01.

Peroxone activated persulfate oxidation of 1,4-Dioxane under column scale conditions

The research presented herein investigates a peroxone activated persulfate (PAP) oxidant, commercialized under the trade name OxyZone®, and its effects on 1,4-Dioxane (dioxane) contaminated water under column scale conditions in the presence of porous material. There is a limited understanding of the underlying processes that govern PAP oxidation, including the oxidation rates in the presence of aquifer material, and how these reactions proceed once the oxidant is injected into a contaminant plume. Initial batch experiments with porous material (e.g. sand) provided data on the reaction rates of dioxane oxidation as a function of the oxidant: contaminant ratio. The observed degradation rates were approximately 4 times lower than those reported for aqueous solutions containing no porous media. Subsequent column experiments simulated two PAP injections schemes along the flowpath of a dioxane plume to study if the injection of one oxidant slug may yield different results than injecting the same oxidant volume at two separate locations. The injection of one oxidant slug was found more effective, resulting in near complete destruction of dioxane over a prolonged time at a rate more than an order of magnitude greater than in the two-slug injection scenario. Tracer test results suggest that the prolonged oxidant reactivity was in part caused by the high density of the injected oxidant solution. Overall, the results underline the importance of accounting for the properties of both the oxidant solution and the porous material when considering the injection of PAP oxidant into an impacted aquifer.

The introduction of the trauma triage clinic at a district general hospital: safety and efficacy during the first year of implementation

INTRODUCTION

Previously published work has shown that there are no missed injuries following the introduction of a trauma triage clinic (TTC). This study aimed to assess both the safety and efficacy of the TTC model in a district general hospital in the United Kingdom. We aimed to assess the rate of missed 'high-risk' injuries, including posterior shoulder dislocations, talar injuries, Lisfranc injuries and complex carpal instability.

METHODS

Data were collected retrospectively between November 2017 and October 2018 (inclusive). During this time, 3,721 patients were reviewed (mean age 38 years, SD 25.5, range 1-103 years). Case notes and x-rays were reviewed for all patients. Compliance was assessed against British Orthopaedic Association Standards for Trauma (BOAST 7) guidelines for fracture clinic services. The standard for adherence to guidelines was 100%.

RESULTS

Thirty-two of 3,721 patients had a missed injury during the study period, and 66% of these injuries were high risk. TTC was effective in reducing the number of patients seen in the fracture clinic, with 23% of patients discharged directly from the TTC. Eighty-nine per cent of patients were reviewed in clinic within 72 hours of presentation, with a median time to review of 2 days.

CONCLUSION

This study has shown that TTC is efficient in reducing the burden of patients seen in the fracture clinic, but it is not as safe as reported previously. Although the prevalence of missed injuries is low, hospitals introducing a TTC model should consider departmental processes to help accurately identify and triage high-risk injuries.

Pharmacoepidemiology of Drug Exposure in Intubated and Non-Intubated Preterm Infants With Severe Bronchopulmonary Dysplasia

Background: Infants with severe bronchopulmonary dysplasia (BPD) are commonly treated with off-label drugs due to lack of approved therapies. To prioritize drugs for rigorous efficacy and safety testing, it is important to describe exposure patterns in this population.

Objective: Our objective was to compare rates of drug exposure between preterm infants with severe bronchopulmonary dysplasia based on respiratory support status at or beyond 36 weeks post-menstrual age.

Methods: A cross-sectional cohort study was performed on October 29, 2019. Preterm infants with severe BPD were eligible and details of respiratory support and drug therapy were recorded. Wilcoxon paired signed rank test was used to compare continuous variables between the invasive and non-invasive groups. Fisher’s exact test was used to compare binary variables by respiratory support status.

Results: 187 infants were eligible for the study at 16 sites. Diuretics were the drug class that most subjects were receiving on the day of study comprising 54% of the entire cohort, followed by inhaled steroids (47%) and short-acting bronchodilators (42%). Infants who were invasively ventilated (verses on non-invasive support) were significantly more likely to be receiving diuretics (p 0.013), short-acting bronchodilators (p < 0.01), long-acting bronchodilators (p < 0.01), systemic steroids (p < 0.01), systemic pulmonary hypertension drugs (p < 0.01), and inhaled nitric oxide (p < 0.01).

Conclusion: Infant with severe BPD, especially those who remain on invasive ventilation at 36 weeks, are routinely exposed to multiple drug classes despite insufficient pharmacokinetic, safety, and efficacy evaluations. This study helps prioritize sub-populations, drugs and drug classes for future study.

Genetic improvement of canine hip dysplasia through sire selection across countries

Breeding against canine hip dysplasia (HD) may benefit from the importation of foreign sires. When foreign sires are evaluated on a different HD scale, this may diminish the efficacy. Using stochastic simulations, we evaluated genetic change and inbreeding levels for different scenarios of importing sires with high genetic merit for HD. Population size and genetic parameters (e.g. heritability, accuracy of selection, genetic correlation) were based on actual data for HD in Golden retrievers and Labrador retrievers in the UK and Sweden. For countries with different HD scales and an estimated breeding value (EBV) evaluation in place, the importation was useful if imported sires had EBV rankings in the top 50% and if genetic correlations between EBV systems were above 0.85. When importing sires with EBV rankings in the top 10%, moderate accuracies of EBVs (>0.40) and moderately strong genetic correlations (>0.70) were needed. Selection against HD without the importation of sires may increase inbreeding levels, while the importation of sires can decrease inbreeding levels. For national genetic evaluation and selection programmes, importing sires with high genetic merit can be an effective breeding strategy, but care is needed to estimate reliable EBVs.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Genetic correlations of hip dysplasia scores for Golden retrievers and Labrador retrievers in France, Sweden and the UK

In order to reduce the prevalence of inherited diseases in pedigree dogs, the feasibility of implementation of an international breeding program was investigated. One prerequisite is a strong genetic correlation between countries and our objective was to estimate this correlation for canine hip dysplasia (HD) across three countries to evaluate the feasibility of an international genetic evaluation. Data were provided by the Société Centrale Canine (SCC, France), Svenska Kennelklubben (SKK, Sweden) and The Kennel Club (KC, UK) on Golden retriever and Labrador retriever dogs. Trivariate analysis on the three different modes of scoring HD in France, Sweden and the UK was performed using a mixed linear animal model. Heritability, genetic correlation, number of common sires, genetic similarity, selection differentials and accuracy of selection were calculated. The estimated heritabilities of Golden retrievers (Labrador retrievers) for HD scores were 0.28 (0.15), 0.28 (0.29) and 0.41 (0.34) in France, Sweden and the UK, respectively. The feasibility of performing a genetic evaluation of HD across countries was indicated by the favourable genetic correlations estimated between score modes (ranged from 0.48 to 0.99). The accuracy of selection for the most recent birth year cohorts of male dogs was not improved by international evaluation compared to national evaluation. Improvement in genetic progress can however be achieved by selection across populations in different countries, particularly for small populations, which were indicated by the large difference between selection differentials based on the national and international evaluations.

Replication stalling and DNA microsatellite instability

Microsatellites are short, tandemly repeated DNA motifs of 1-6 nucleotides, also termed simple sequence repeats (SRSs) or short tandem repeats (STRs). Collectively, these repeats comprise approximately 3% of the human genome Subramanian et al. (2003), Lander and Lander (2001) [1,2], and represent a large reservoir of loci highly prone to mutations Sun et al. (2012), Ellegren (2004) [3,4] that contribute to human evolution and disease. Microsatellites are known to stall and reverse replication forks in model systems Pelletier et al. (2003), Samadashwily et al. (1997), Kerrest et al. (2009) [5-7], and are hotspots of chromosomal double strand breaks (DSBs). We briefly review the relationship of these repeated sequences to replication stalling and genome instability, and present recent data on the impact of replication stress on DNA fragility at microsatellites in vivo.

Merging pedigree databases to describe and compare mating practices and gene flow between pedigree dogs in France, Sweden and the UK

Merging pedigree databases across countries may improve the ability of kennel organizations to monitor genetic variability and health-related issues of pedigree dogs. We used data provided by the Société Centrale Canine (France), Svenska Kennelklubben (Sweden) and the Kennel Club (UK) to study the feasibility of merging pedigree databases across countries and describe breeding practices and international gene flow within the following four breeds: Bullmastiff (BMA), English setter (ESE), Bernese mountain dog (BMD) and Labrador retriever (LBR). After merging the databases, genealogical parameters and founder contributions were calculated according to the birth period, breed and registration country of the dogs. Throughout the investigated period, mating between close relatives, measured as the proportion of inbred individuals (considering only two generations of pedigree), decreased or remained stable, with the exception of LBR in France. Gene flow between countries became more frequent, and the origins of populations within countries became more diverse over time. In conclusion, the potential to reduce inbreeding within purebred dog populations through exchanging breeding animals across countries was confirmed by an improved effective population size when merging populations from different countries.

The Rough-Toothed Dolphin, Steno bredanensis, in the Eastern Mediterranean Sea: A Relict Population?

Only recently included among the cetacean species thought to regularly occur in the Mediterranean, the rough-toothed dolphin (Steno bredanensis) is an obscure and enigmatic member of this ensemble. Preliminary genetic evidence strongly indicates an Atlantic origin, yet the Mediterranean distribution for this species is conspicuously detached from the Atlantic, with all authenticated records during the last three decades being east of the Sicilian Channel and most within the bounds of the Levantine Basin. These dolphins are apparently a small, relict population, probably the remnant of a larger one, contiguous with that in the Atlantic and nowadays entrapped in the easternmost and warmest province. Abundance data are lacking for the species in the Mediterranean. Configuring acoustic detection software to recognise the apparently idiosyncratic vocalisations of rough-toothed dolphins in past and future acoustic recordings may prove useful for potential acoustic monitoring. Evidence accumulated so far, though scant, points to seasonal occupation of shallow coastal waters. Vulnerability to entanglement in gill-nets, contaminants in the region, and the occurrence of mass strandings (possibly in response to anthropogenic noise), are major conservation concerns for the population in the Mediterranean Sea.

The Factorisation of the rectangular distribution

Questions of the decomposability of distribution functions into real-valued components of bounded variation were discussed by P. Lévy (1964) in relation to the nature of the components, whether non-decreasing (distribution functions in particular) or absolutely continuous (a.c.) or both. Hanson (1965), in a review of Lévy's paper, raised the question of whether or not a rectangular distribution could be decomposed into two a.c. distributions. In fact, D. G. Kendall had conjectured earlier (Kendall (1960)) that no such decomposition is possible. The object of this paper is to state and prove the truth of Kendall's conjecture. “Decomposition” or “factorisation” will be understood throughout the paper to mean decomposition into distributions. Decompositions of the rectangular distribution into one a.c. and one discrete factor are well known (see, e.g., Lukacs (1960) pp. 128–9), and decompositions in which both factors are singular continuous (s.c.) have been discovered by Kendall and by P. M. Lee; it is shown here that no other combinations of factor-type can exist. References to other work on related decomposability properties are given in the papers by Lévy and Kendall cited above.

Spleen preserving management of a non-parasitic splenic cyst in pregnancy

Non-parasitic splenic cysts are rare entities. In pregnancy, they are rarer still, with as few as seven cases reported in the literature. There is little consensus regarding the optimal management of this condition in pregnancy. Although small, the theoretical risk of intrapartum splenic rupture is associated with a fetal mortality rate as high as 70%. The authors of at least three case reports advocate total splenectomy as first-line management of splenic cyst in pregnancy. Paradoxically, spleen conserving surgery is the recognised gold standard treatment for symptomatic splenic cysts in non-pregnant patients. We present a case of a large maternal splenic cyst that was treated successfully with a laparoscopic cystectomy.

Genetic determinants of fetal opiate exposure and risk of neonatal abstinence syndrome: Knowledge deficits and prospects for future research

Opiate-dependent pregnant women receive opiate maintenance medications to prevent illicit use and withdrawal. Fetal opiate exposure causes central nervous system (CNS) alterations which manifest as postnatal physical withdrawal. The extensive variability in the Neonatal Abstinence Syndrome phenotype remains unexplained and may be related to variability in fetal exposure and response. Improved understanding of functionally significant genetic variants in pathways influencing placental opiate transfer and fetal response can lead to personalized maternal therapy and optimized neonatal outcomes.

Heightened response of eosinophilic asthmatic patients to the CRTH2 antagonist OC000459

BACKGROUND

The CRTH2 antagonist OC000459 has previously been demonstrated to reduce airway inflammation and improve lung function in moderate persistent asthma. A study was conducted to determine the effect of lower once daily doses of OC000459 and to define the phenotype of subjects most responsive to treatment.

METHODS

Adult subjects (percentage of predicted forced expiratory volume in 1 s (FEV1 ) 60-85%) were randomized to OC000459 at three dose levels (25 mg once daily, 200 mg once daily or 100 mg twice daily) or placebo for 12 weeks (n = 117-125 per group, full analysis set). The primary endpoint was the change from baseline in prebronchodilator FEV1 , and secondary endpoints included Asthma Control Questionnaire (ACQ) and Standardised Asthma Quality of Life Questionnaire [AQLQ(S)], and incidence of exacerbations and respiratory tract infections.

RESULTS

OC459 caused a significant improvement in FEV1 compared with placebo at a dose of 25 mg once daily (P = 0.028). A similar increase was observed in the other dose groups, and the mean change in FEV1 in the pooled dose groups at endpoint was 95 ml greater than placebo (P = 0.024). In a post hoc analysis of atopic eosinophilic subjects with uncontrolled asthma, a mean increase in FEV1 of 220 ml was observed compared with placebo (P = 0.005). The mean increase in FEV1 was more marked in younger subjects in this group: for subjects aged ≤40 years, there was a mean increase of 355 ml compared with placebo (P = 0.007). Improvements in ACQ and AQLQ(S) were observed in both the full analysis set and the atopic eosinophilic subgroup. There was a lower incidence of exacerbations and respiratory infections in subjects treated with OC000459. There were no drug-related serious adverse events.

CONCLUSIONS

OC000459 is a safe and effective oral anti-inflammatory agent, which achieved clinically meaningful improvements in lung function and asthma control in allergic asthmatics with an eosinophil-dominant form of the disease. A dose of 25 mg given once daily was as effective as the higher doses studied.

The CRTH2 antagonist OC000459 reduces nasal and ocular symptoms in allergic subjects exposed to grass pollen, a randomised, placebo-controlled, double-blind trial

BACKGROUND

CRTH2 mediates activation of Th2 cells, eosinophils and basophils in response to prostaglandin D(2). The CRTH2 antagonist OC000459 has previously been demonstrated to reduce airway inflammation and improve lung function in moderate persistent asthma. The objective of the present study was to determine the involvement of CRTH2 in promoting nasal and ocular symptoms in allergic subjects exposed to grass pollen.

METHODS

A single centre, randomised, double-blind, placebo-controlled, two-way crossover study was conducted in 35 male subjects allergic to grass pollen comparing OC000459 200 mg bid with placebo for 8 days. Subjects were exposed to grass pollen (≥ 1400 grains/m(3)) for 6 h on the 2nd and 8th days of treatment and assessed for nasal symptoms, ocular symptoms, other symptoms, nasal secretion weight and rhinomanometry over the 6-h period. After a washout period of 3 weeks, subjects were switched to the alternative treatment for a further 8 days. The trial was registered on the clinical trials.gov database (Identifier NCT01448902).

RESULTS

During the first treatment period, treatment with OC000459 significantly reduced both nasal and ocular symptoms in allergic subjects compared with placebo after challenge with grass pollen. A significant effect was observed on the 2nd day of dosing which was increased on the 8th day of dosing. The therapeutic effects of OC000459 persisted into the second treatment period despite a 3-week washout phase. The safety profile of OC000459 was similar to that of placebo.

CONCLUSION

Treatment with OC000459 was well tolerated and led to a significant and persistent reduction in the symptoms of rhinoconjunctivitis.

Sources, concentrations, and risks of naphthalene in indoor and outdoor air

Naphthalene is a ubiquitous pollutant, and very high concentrations are sometimes encountered indoors when this chemical is used as a pest repellent or deodorant. This study describes the distribution and sources of vapor-phase naphthalene concentrations in four communities in southeast Michigan, USA. Outdoors, naphthalene was measured in the communities and at a near-road site. Indoors, naphthalene levels were characterized in 288 suburban and urban homes. The median outdoor concentration was 0.15 μg/m(3), and a modest contribution from rush-hour traffic was noted. The median indoor long-term concentration was 0.89 μg/m(3), but concentrations were extremely skewed and 14% of homes exceeded 3 μg/m(3), the chronic reference concentration for non-cancer effects, 8% exceeded 10 μg/m(3), and levels reached 200 μg/m(3). The typical excess individual lifetime cancer risk was about 10(-4) and reached 10(-2) in some homes. Important sources include naphthalene's use as a pest repellent and deodorant, migration from attached garages and, to lesser extents, cigarette smoke and vehicle emissions. Excessive use as a repellent caused the highest concentrations. Naphthalene presents high risks in a subset of homes, and policies and actions to reduce exposures, for example, sales bans or restrictions, improved labeling, and consumer education, should be considered.

PRACTICAL IMPLICATIONS

Long-term average concentrations of naphthalene in most homes fell into the 0.2-1.7 μg/m(3) range reported as representative in earlier studies. The highly skewed distribution of concentrations results in a subset of homes with elevated concentrations and health risks that greatly exceed US EPA and World Health Organization (WHO) guidelines. The most important indoor source is the use of naphthalene as a pest repellant or deodorant; secondary sources include presence of an attached garage, cigarette smoking, and outdoor sources. House-to-house variation was large, reflecting differences among the residences and naphthalene use practices. Stronger policies and educational efforts are needed to eliminate or modify indoor usage practices of this chemical.