The impact of rare cancer and early-line treatments on the benefit of comprehensive genome profiling-based precision oncology

BACKGROUND

Comprehensive genome profiling (CGP) serves as a guide for suitable genomically matched therapies for patients with cancer. However, little is known about the impact of the timing and types of cancer on the therapeutic benefit of CGP.

MATERIALS AND METHODS

A single hospital-based pan-cancer prospective study (TOP-GEAR; UMIN000011141) was conducted to examine the benefit of CGP with respect to the timing and types of cancer. Patients with advanced solid tumors (>30 types) who either progressed with or without standard treatments were genotyped using a single CGP test. The subjects were followed up for a median duration of 590 days to examine therapeutic response, using progression-free survival (PFS), PFS ratio, and factors associated with therapeutic response.

RESULTS

Among the 507 patients, 62 (12.2%) received matched therapies with an overall response rate (ORR) of 32.3%. The PFS ratios (≥1.3) were observed in 46.3% (19/41) of the evaluated patients. The proportion of subjects receiving such therapies in the rare cancer cohort was lower than that in the non-rare cancer cohort (9.6% and 17.4%, respectively; P = 0.010). However, ORR of the rare cancer patients was higher than that in the non-rare cancer cohort (43.8% and 20.0%, respectively; P = 0.046). Moreover, ORR of matched therapies in the first or second line after receiving the CGP test was higher than that in the third or later lines (62.5% and 21.7%, respectively; P = 0.003). Rare cancer and early-line treatment were significantly and independently associated with ORR of matched therapies in multivariable analysis (P = 0.017 and 0.004, respectively).

CONCLUSION

Patients with rare cancer preferentially benefited from tumor mutation profiling by increasing the chances of therapeutic response to matched therapies. Early-line treatments after profiling increase the therapeutic benefit, irrespective of tumor types.

Investigation of distress during diffusion-weighted whole-body magnetic resonance imaging among women with breast cancer and the effectiveness of a new technology in alleviating patient's anxiety by approaching the human senses

INTRODUCTION

Breast cancer is a common malignant tumor among women, and the effectiveness of diagnosing its metastasis and recurrence has been demonstrated using diffusion-weighted whole-body imaging with background body signal suppression (DWIBS). However, DWIBS causes distress to patients due to the unique circumstances of magnetic resonance imaging (MRI). This study aimed to investigate the various distress factors caused by DWIBS among women with breast cancer and assess the effectiveness of a new MRI system designed with an environment incorporating relaxing technology.

METHODS

From May to September 2022, we conducted a questionnaire survey regarding DWIBS-related distress among women with breast cancer. The questionnaire was administered to participants who underwent DWIBS on a conventional MRI system (19 women) and on a new system (20 women) equipped with relaxing technology equipped features, including projection images, illumination, and sound. Participants rated the degree of various stress factors on a face-scale rating scale (0-10). The scores of both systems were compared using the Mann-Whitney U test.

RESULTS

In the conventional system, women experienced distress due to MRI-specific situations, such as immobility in a confined space, noise, feeling trapped, and concerns about not moving. These results did not show a specific tendency among women with breast cancer undergoing DWIBS. For almost all distress parameters, the new system had significantly lower distress scores than the conventional system (p > 0.05).

CONCLUSIONS

A comfortable environment using new and relaxing technology is effective in alleviating patient's anxiety by approaching the human senses.

IMPLICATIONS FOR PRACTICE

Reducing distress caused by DWIBS among women with breast cancer could provide a comfortable examination environment, potentially assisting them during longer treatment periods.

Comparison of clinical outcomes of osimertinib and first-generation EGFR-tyrosine kinase inhibitors (TKIs) in TKI-untreated EGFR-mutated non-small-cell lung cancer with leptomeningeal metastases

BACKGROUND

Leptomeningeal metastases (LM) are devastating complications of epidermal growth factor receptor (EGFR)-mutated non-small-cell lung cancer (NSCLC). Although osimertinib, a third-generation EGFR-tyrosine kinase inhibitor (TKI), has better penetration into the central nervous system than first-generation EGFR-TKIs, data on the distinct activity of EGFR-TKIs in untreated advanced EGFR-mutated NSCLC with LM are lacking.

PATIENTS AND METHODS

We retrospectively reviewed patients treated with EGFR-TKIs for TKI-untreated common EGFR-mutated NSCLC with LM between July 2002 and July 2021 at the National Cancer Center Hospital. The patients were divided into two groups: patients treated with osimertinib (Osi group) and those treated with gefitinib or erlotinib [first-generation (1G)-TKI group].

RESULTS

Of the 967 patients, 71 were eligible, including 29 in the Osi group and 42 in the 1G-TKI group. The median progression-free survival (PFS) and overall survival (OS) in the Osi group were better than those in the 1G-TKI group (PFS: 16.9 months versus 8.6 months, P = 0.007, and OS: 26.6 months versus 20.0 months, P = 0.158). The LM-overall response rate (ORR) and LM-PFS were significantly better in the Osi group than in the 1G-TKI group (LM-ORR: 62.5% versus 25.7%, P = 0.007; LM-PFS: 23.4 months versus 12.1 months, P = 0.021). In the subgroup analysis of EGFR mutation status, LM-PFS for patients with exon 19 deletion was significantly longer in the Osi group than in the 1G-TKI group (32.7 months versus 13.4 months, P = 0.013), whereas those with L858R mutation in exon 21 did not differ between the two groups. In the multivariate analysis, osimertinib and exon 19 deletion were significant factors for better LM-PFS and OS.

CONCLUSION

Osimertinib can be more effective for untreated common EGFR-mutated NSCLC patients with LM, especially those with exon 19 deletion, compared to first-generation TKIs.

Measurement of Direct-Photon Cross Section and Double-Helicity Asymmetry at sqrt[s]=510 GeV in p[over →]+p[over →] Collisions

We present measurements of the cross section and double-helicity asymmetry A_{LL} of direct-photon production in p[over →]+p[over →] collisions at sqrt[s]=510  GeV. The measurements have been performed at midrapidity (|η|<0.25) with the PHENIX detector at the Relativistic Heavy Ion Collider. At relativistic energies, direct photons are dominantly produced from the initial quark-gluon hard scattering and do not interact via the strong force at leading order. Therefore, at sqrt[s]=510  GeV, where leading-order-effects dominate, these measurements provide clean and direct access to the gluon helicity in the polarized proton in the gluon-momentum-fraction range 0.02<x<0.08, with direct sensitivity to the sign of the gluon contribution.

Probing Gluon Spin-Momentum Correlations in Transversely Polarized Protons through Midrapidity Isolated Direct Photons in p^{↑}+p Collisions at sqrt[s]=200 GeV

Studying spin-momentum correlations in hadronic collisions offers a glimpse into a three-dimensional picture of proton structure. The transverse single-spin asymmetry for midrapidity isolated direct photons in p^{↑}+p collisions at sqrt[s]=200  GeV is measured with the PHENIX detector at the Relativistic Heavy Ion Collider (RHIC). Because direct photons in particular are produced from the hard scattering and do not interact via the strong force, this measurement is a clean probe of initial-state spin-momentum correlations inside the proton and is in particular sensitive to gluon interference effects within the proton. This is the first time direct photons have been used as a probe of spin-momentum correlations at RHIC. The uncertainties on the results are a 50-fold improvement with respect to those of the one prior measurement for the same observable, from the Fermilab E704 experiment. These results constrain gluon spin-momentum correlations in transversely polarized protons.

Bystander dispatcher-assisted cardiopulmonary resuscitation for the likelihood of an initial shockable rhythm after out-of-hospital cardiac arrest

Background/Introduction

The association of bystander dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) and no bystander CPR with the likelihood of an initial shockable rhythm at emergency medical services (EMS) arrival or the likelihood of reduced time interval to initiation of CPR after out-of-hospital cardiac arrest (OHCA) is poorly explored. We hypothesised that more patients who received bystander DA-CPR would have an initial shockable rhythm than those without bystander CPR (NO-CPR) and that DA-CPR would reduce the time to initiation of CPR (collapse-to-first CPR time) compared with NO-CPR.

Purpose

To study the incidence rate of initial shockable rhythm recorded by EMS personnel and the collapse-to-first CPR time in the DA-CPR and NO-CPR cohorts

Methods

Our study included 97,690 patients (age, ≥18 years), who had an OHCA with a presumed cardiac origin witnessed by a layperson, from a prospectively recorded Japanese nationwide Utstein-style database between 2013 and 2017. The patients were divided into the DA-CPR (n=42,767) and NO-CPR (n=54,923) groups. The primary endpoints were initial shockable rhythm recorded by the EMS after arrival and the time from collapse to CPR initiation. The secondary endpoints were 1-month survival and neurologically intact survival. A Cox proportional hazards model was used to compare the incidence rate of initial shockable rhythm before/after propensity score (PS) matching.

Results

The crude rate of the initial shockable rhythm in the DA-CPR group was significantly higher than that in the NO-CPR group: before PS matching, 21.7% (9270/42,767) vs. 17.5% (9605/54,923); after PS matching, 22.2% (8965/39,426) vs. 17.1% (6728/39,426), both p&lt;0.0001. The Cox proportional hazards model showed that DA-CPR was associated with the likelihood of initial shockable rhythm before (adjusted hazard ratio [aHR], 95% confidence interval [CI]: 1.23, 1.21–1.25; p&lt;0.0001) and after PS matching (aHR, CI: 1.05, 1.03–1.06; p&lt;0.0001) compared with NO-CPR. Collapse-to-first CPR time in the DA-CPR group was significantly shorter than that in the NO-CPR group regardless of PS matching: before PS matching, mean 4.2 (SD 6.0) min vs. 11.7 (8.0) min; after PS matching, 4.1 (5.6) min vs. 12.6 (8.6) min, both p&lt;0.0001. One-month survival and neurologically intact survival rates were significantly higher in the DA-CPR group than in the NO-CPR group after PS matching: survival, 11.5% (4520/39,426) vs. 8.3% (3255/39,426); neurologically intact survival, 7.5% (2944/39,426) vs. 4.4% (1719/39,426), p&lt;0.0001.

Conclusions

Patients who received DA-CPR after experiencing OHCA due to presumed cardiac causes were more likely to have an initial shockable rhythm than those who did not receive bystander CPR. Moreover, first CPR was performed approximately 8 min earlier in the DA-CPR group than in the NO-CPR group.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science (Grant-in-Aid for Scientific Research)

Subsequent shock delivery and outcomes in out-of-hospital cardiac arrests with initial unshockable rhythm

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Japan Society for the Promotion of Science (Grant-in-Aid for Scientific Research)

Background

The conversion from initial non-shockable to shockable rhythms during cardiopulmonary resuscitation (CPR) by emergency medical service (EMS) providers may be associated with neurologically intact survival after out-of-hospital cardiac arrest (OHCA). However, the prognostic significance of rhythm conversion according to the type of initial nonshockable rhythm is unclear.

Purpose

To determine the association between shock after conversion to shockable rhythm with neurologically intact survival after OHCA and shock delivery time (time from EMS-initiated CPR to first shock delivery) in patients with two types of initial unshockable rhythm.

Methods

We analyzed the records of 90,334 adult patients with witnessed OHCA of cardiac origin who were treated by EMS providers and had an initial unshockable rhythm. Data were obtained from a prospectively recorded Japanese nationwide Utstein-style database for a 5-year period (2013–2017). The primary outcome was 1-month neurologically intact survival, defined as a cerebral performance categories score from 1 to 2. Patients were divided into initial pulseless electrical activity (PEA) (n = 37,977 [42.0%]) and initial asystole (n = 52,357 [58.0%]) groups.

Results

In the initial PEA group, the crude rate of 1-month neurologically intact survival was significantly higher in the subsequently shocked than in the non-shocked patients (4.2% [121/2,896]) vs. 2.4% [857/35,081], p &lt;0.0001). After adjustment for ten prehospital variables, the adjusted odds ratios (aORs) of subsequent shock for 1-month neurologically intact survival compared to no shock delivery were as follows: shock delivery time &lt;10 min, 2.21 (95% confidence interval [CI], 1.77–2.77, p&lt; 0.0001); 10–14 min, 1.43 (0.89–2.28, p = 0.14); and ≥15 min, 0.36 (0.16–0.81; p = 0.013). In the initial asystole group, the crude rate of 1-month neurologically intact survival was significantly higher in the subsequently shocked than in the non-shocked (1.7% [47/2,687] vs. 0.4% [203/49,670], p &lt;0.0001). A multivariate logistic regression model showed that subsequent shock with a shock delivery time &lt;10 min was associated with increased odds of neurologically intact survival compared to no shock delivery (aOR, 5.67; 95% CI, 3.92–8.18; p &lt;0.0001). However, there were no significant differences in neurological outcomes between subsequently shocked and non-shocked patients when the shock delivery time was 10–14 min (p = 0.21) or ≥15 min (p = 0.91).

Conclusions

In patients with witnessed OHCA of cardiac origin and initial nonshockable rhythm, subsequent shock after conversion to shockable rhythm during CPR was associated with increased odds of 1-month neurologically intact survival only when shock was delivered &lt;10 min from EMS-initiated CPR, regardless of the type of initial rhythm. Further, in patients with initial PEA, subsequent shock was associated with decreased odds of neurologically intact survival when shock was delivered ≥15 min from EMS-initiated CPR.

Association of subsequent shock after conversion to shockable rhythm with outcomes stratified by the type of initial non-shockable rhythm in children with out-of-hospital cardiac arrest

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Japan Society for the Promotion of Science (Grant-in-Aid for Scientific Research)

Background/Introduction: The rhythm conversion from initial non-shockable to shockable rhythm during cardiopulmonary resuscitation (CPR) by emergency medical services (EMS) providers may be associated with neurologically intact survival after out-of-hospital cardiac arrest (OHCA) in children with an initial non-shockable rhythm. However, the prognostic significance of rhythm conversion stratified by the type of initial non-shockable rhythm is still unclear.

Purpose

We aimed to investigate the association of subsequent shock after rhythm conversion to shockable rhythm with neurologically intact survival and shock delivery time (time from EMS-initiated CPR to first shock delivery) by the type of initial non-shockable rhythm in children with OHCA.

Methods

We analysed the records of 19,095 children (age &lt;18 years) with OHCA treated by EMS providers. Data were obtained from a prospectively recorded Japanese nationwide Utstein-style database for a 13-year period (2005–2017). The primary outcome measure was 1-month neurologically intact survival, defined as cerebral performance category score of 1 to 2. Patients were divided into the initial pulseless electrical activity (PEA) (n = 3,326 [17.4%]) and initial asystole (n = 15,769 [82.6%]) groups.

Results

The proportion of patients who received subsequent shock after conversion to shockable rhythm was significantly higher in the initial PEA than in the initial asystole groups (3.3% [109/3,326] vs. 1.4% [227/15,769], p &lt; 0.0001). The shock delivery time was significantly shorter in the initial PEA than in the initial asystole groups (median [IQR], 8 min [5 min – 12 min] vs. 10 min [6 min – 16 min], p &lt; 0.01). Among the initial PEA patients, there was no significant difference between subsequently shocked (10.0% [11/109]) and subsequently non-shocked patients (6.0% [192/3,217], p = 0.10) regarding the rate of 1-month neurologically intact survival. However, after adjusting for 9 pre-hospital variables, subsequent shock with a delivery time of &lt;10 min was associated with increased odds of neurologically intact survival compared with no shock delivery (adjusted odds ratio [OR], 2.45; 95% confidence interval [CI], 1.16–5.16], p = 0.018). Among the initial asystole patients, the rate of 1-month neurologically intact survival was significantly higher in the subsequently shocked (4.4% [10/227]) than in the subsequently non-shocked (0.7% [106/15,542], p &lt; 0.0001). A multivariate logistic regression model showed that subsequent shock with a delivery time of &lt;10 min was associated with increased odds of neurologically intact survival compared with no shock delivery (adjusted OR, 9.77 [95% CI, 4.2–22.5], p &lt; 0.0001).

Conclusions

In children with OHCA with an initial non-shockable rhythm, subsequent shock after conversion to shockable rhythm during CPR was associated with increased odds of 1-month neurologically intact survival only when shock was delivered &lt;10 min from EMS-initiated CPR regardless of the type of initial rhythm.

A multicenter cohort study of osimertinib compared with afatinib as first-line treatment for EGFR-mutated non-small-cell lung cancer from practical dataset: CJLSG1903

Background

FLAURA, the prospective trial of osimertinib as a first-line therapy compared with first-generation epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs), did not show superior survival benefit for osimertinib in either the subgroup of Asians or the subgroup with the L858R mutation. In addition, the superiority of osimertinib compared with second-generation EGFR-TKI is thus far unclear.

Patients and methods

We reviewed the clinical data of all consecutive patients who were treated with osimertinib or afatinib as first-line therapy between May 2016 and October 2019 from 15 institutions in Japan. We defined the groups based on first-line EGFR-TKI as the afatinib group and the osimertinib group. Outcomes included time to discontinuation of any EGFR-TKI (TD-TKI), overall survival (OS), and time to treatment failure, with propensity score analysis carried out as an exploratory analysis in the survival and subgroup analyses.

Results

A total of 554 patients were enrolled. Data on 326 patients in the osimertinib group, and 224 patients in the afatinib group were analyzed. TD-TKI adjusted by propensity score in the afatinib and osimertinib groups was 18.6 months (95% confidence interval 15.8 to 22.0) and 20.5 months (95% confidence interval 13.8 to not reached), respectively, without significant difference (P = 0.204). OS adjusted by propensity score favored the afatinib group with a significant difference (P = 0.018). Subgroup analysis with propensity score showed that patients with L858R and without brain metastasis had superior survival benefit with afatinib compared with osimertinib (P < 0.001).

Conclusions

TD-TKI in the afatinib group was not significantly prolonged compared with the osimertinib group in the practical data. In the exploratory analysis of patients with L858R-mutated non-small-cell lung cancer without brain metastasis, afatinib showed more benefit in OS over osimertinib.

•

The large-scale practical data of 550 patients who were treated with osimertinib or afatinib as first-line therapy were analyzed.

•

The superiority of osimertinib compared with afatinib could not be demonstrated in all populations.

•

Osimertinib therapy showed effectiveness in patients with brain metastasis.

•

Afatinib therapy showed potential benefit in patients with L858R mutation and without brain metastasis.

Kinetic Control of the Li0.9Mn1.6Ni0.4O4 Spinel Structure with Enhanced Electrochemical Performance

The development of more sustainable societies has become an urgent goal worldwide. Electrical batteries are currently seen as one of the most important energy storage technologies for the development of decarbonized societies. However, many lithium-ion battery manufacturers currently utilize cobalt, a toxic and hazardous mineral, in their batteries. Lithium-deficient manganese nickel oxide spinels are considered promising candidates owing to their high potential and environmental friendliness. Their electrochemical performance highly depends on their average and local structures, such as phase purities, lattice parameters, and cation sites. Thus, a synthesis protocol should be designed to control these structural parameters to improve their electrochemical performance. In this study, we controlled the average and local structures of Li_0.9Mn_1.6Ni_0.4O₄ spinels obtained by co-precipitation by optimizing their cooling rates. High-resolution techniques, including transmission electron microscopy, synchrotron X-ray diffraction, and Auger-composition analysis combined with density functional theory calculations, X-ray absorption spectroscopy, and electrochemical analysis, were used to understand the average and local structural variations and their effects on the electrochemical properties. As a result, the control of oxygen diffusion at different cooling rates can promote the rearrangement of the structure, resulting in a cation-disordered spinel with minimal variations in lattice parameters and composition. Excellent electrochemical properties were noted in the cation-disordered spinel with high crystallinity and a slightly oxygen-rich surface produced via optimized cooling rates.

Loss of Ftsj1 perturbs codon-specific translation efficiency in the brain and is associated with X-linked intellectual disability

FtsJ RNA 2'-O-methyltransferase 1 (FTSJ1) gene has been implicated in X-linked intellectual disability (XLID), but the molecular pathogenesis is unknown. We show that Ftsj1 is responsible for 2'-O-methylation of 11 species of cytosolic transfer RNAs (tRNAs) at the anticodon region, and these modifications are abolished in Ftsj1 knockout (KO) mice and XLID patient-derived cells. Loss of 2'-O-methylation in Ftsj1 KO mouse selectively reduced the steady-state level of tRNA^Phe in the brain, resulting in a slow decoding at Phe codons. Ribosome profiling showed that translation efficiency is significantly reduced in a subset of genes that need to be efficiently translated to support synaptic organization and functions. Ftsj1 KO mice display immature synaptic morphology and aberrant synaptic plasticity, which are associated with anxiety-like and memory deficits. The data illuminate a fundamental role of tRNA modification in the brain through regulation of translation efficiency and provide mechanistic insights into FTSJ1-related XLID.

Effect of chest-compression-only bystander cardiopulmonary resuscitation on the likelihood of initial shockable rhythm after out-of-hospital cardiac arrest: a propensity matching analysis

Background/Introduction

Shockable rhythm after cardiac arrest is highly expected after early initiation of bystander cardiopulmonary resuscitation (CPR) owing to increased coronary perfusion. However, the relationship between bystander CPR and initial shockable rhythm in patients with out-of-hospital cardiac arrest (OHCA) remains unclear. We hypothesized that chest-compression-only CPR (CC-CPR) before emergency medical service (EMS) arrival has an equivalent effect on the likelihood of initial shockable rhythm to the standard CPR (chest compression plus rescue breathing [S-CPR]).

Purpose

We aimed to examine the rate of initial shockable rhythm and 1-month outcomes in patients who received bystander CPR after OHCA.

Methods

The study included 59,688 patients (age, ≥18 years) who received bystander CPR after an OHCA with a presumed cardiac origin witnessed by a layperson in a prospectively recorded Japanese nationwide Utstein-style database from 2013 to 2017. Patients who received public-access defibrillation before arrival of the EMS personnel were excluded. The patients were divided into CC-CPR (n=51,520) and S-CPR (n=8168) groups according to the type of bystander CPR received. The primary end point was initial shockable rhythm recorded by the EMS personnel just after arrival at the site. The secondary end point was the 1-month outcomes (survival and neurologically intact survival) after OHCA. In the statistical analyses, a Cox proportional hazards model was applied to reflect the different bystander CPR durations before/after propensity score (PS) matching.

Results

The crude rate of the initial shockable rhythm in the CC-CPR group (21.3%, 10,946/51,520) was significantly higher than that in the S-CPR group (17.6%, 1441/8168, p&lt;0.0001) before PS matching. However, no significant difference in the rate of initial shockable rhythm was found between the 2 groups after PS matching (18.3% [1493/8168] vs 17.6% [1441/8168], p=0.30). In the Cox proportional hazards model, CC-CPR was more negatively associated with the initial shockable rhythm before PS matching (unadjusted hazards ratio [HR], 0.97; 95% confidence interval [CI], 0.94–0.99; p=0.012; adjusted HR, 0.92; 95% CI, 0.89–0.94; p&lt;0.0001) than S-CPR. After PS matching, however, no significant difference was found between the 2 groups (adjusted HR of CC-CPR compared with S-CPR, 0.97; 95% CI, 0.94–1.00; p=0.09). No significant differences were found between C-CPR and S-CPR in the 1-month outcomes after PS matching as follows, respectively: survival, 8.5% and 10.1%; adjusted odds ratio, 0.89; 95% CI, 0.79–1.00; p=0.07; cerebral performance category 1 or 2, 5.5% and 6.9%; adjusted odds, 0.86; 95% CI, 0.74–1.00; p=0.052.

Conclusions

Compared with S-CPR, the CC-CPR before EMS arrival had an equivalent multivariable-adjusted association with the likelihood of initial shockable rhythm in the patients with OHCA due to presumed cardiac causes that was witnessed by a layperson.

Funding Acknowledgement

Type of funding source: None

Erratum: Evolution of π^{0} Suppression in Au+Au Collisions from sqrt[s_{NN}]=39 to 200 GeV [Phys. Rev. Lett. 109, 152301 (2012)]

This corrects the article DOI: 10.1103/PhysRevLett.109.152301.

Transverse Single-Spin Asymmetry for Very Forward Neutral Pion Production in Polarized p+p Collisions at sqrt[s]=510 GeV

Transverse single-spin asymmetries of very forward neutral pions generated in polarized p+p collisions allow us to understand the production mechanism in terms of perturbative and nonperturbative strong interactions. During 2017, the RHICf Collaboration installed an electromagnetic calorimeter in the zero-degree region of the STAR detector at the Relativistic Heavy Ion Collider (RHIC) and measured neutral pions produced at pseudorapidity larger than 6 in polarized p+p collisions at sqrt[s]=510  GeV. The large nonzero asymmetries increasing both in longitudinal momentum fraction x_{F} and transverse momentum p_{T} have been observed at low transverse momentum p_{T}<1  GeV/c for the first time, at this collision energy. The asymmetries show an approximate x_{F} scaling in the p_{T} region where nonperturbative processes are expected to dominate. A non-negligible contribution from soft processes may be necessary to explain the nonzero neutral pion asymmetries.

P492Estimation of no-flow duration and survival in patients with an initial shockable rhythm after out-of-hospital cardiac arrest

Funding Acknowledgements

Japan Society for the Promotion of Science (KAKENHI Grant No. 18K09999)

Background

In patients with unwitnessed out-of-hospital cardiac arrest (OHCA), the actual no-flow duration (the time with no organ perfusion) is unclear. However, when these patients have a shockable rhythm as an initial recorded rhythm, the no-flow duration may be relatively short as compared with other initial rhythms, and some patients can obtain a good functional outcome after OHCA.

Purpose

The purpose of the present study was to estimate the no-flow duration and to determine the relationship between no-flow duration and neurologically intact survival in patients with an initial shockable rhythm after OHCA.

Methods

We reviewed 82,464 patients with OHCA (aged ≥18 years, non-traumatic, witnessed, and without any bystander interventions) who were included in the All-Japan Utstein-style registry from 2013 to 2017. The study end point was 1-month neurologically intact survival (Cerebral Performance Category scale 1 or 2). No-flow duration was defined as the time from emergency call to emergency medical services (EMS) arrival at the patient site.

Results

The rate of 1-month neurologically intact survival in the patients with an initial shockable rhythm (n = 10,384, 12.6% of overall patients) was 16.5% (1718/10,384). No-flow duration was significantly and inversely associated with 1-month neurologically intact survival (adjusted odds ratios for 1-minute increments: 0.85, 95% confidence interval: 0.84–0.86). The proportion of patients with a shockable rhythm to the overall patients (y, %) had a high correlational relationship with no-flow duration (x, min), depicted by y = 21.0 - 0.95 × x, R² = 0.935. In this analytical model, the number of patients with shockable rhythm reached null at 22 minutes of no-flow duration. The no-flow durations, beyond which the chance for initial shockable rhythm diminished to &lt;10%, &lt;5%, and &lt;1%, were 12, 13, and 17 minutes, respectively. The rate of neurologically intact survival in the patients with shockable rhythm (y, %) and no-flow duration (x, min) were also found to have a strong correlation, depicted by y = 0.16 × x² - 5.12 × x + 45.0, R² = 0.907. The no-flow durations, beyond which the chance for 1-month neurologically intact survival diminished to &lt;10%, &lt;5%, and &lt;1%, were 10, 11, and 15 minutes, respectively.

Conclusions

In OHCA patients without any bystander interventions before EMS personnel arrival, when a shockable rhythm is recorded by EMS personnel as an initial rhythm, the no-flow duration after cardiac arrest is highly likely to be &lt;17 minutes regardless of the layperson witness status. The limitation of no-flow duration to obtain a 1-month neurologically intact survival after OHCA may be 15 minutes when the patients have an initial shockable rhythm.

P498External validation of a field termination-of-resuscitation rule for refractory out-of-hospital cardiac arrests in Japan

Background

A universal basic life support termination-of-resuscitation (BLS-TOR) rule was developed to identify patients with out-of-hospital cardiac arrest (OHCA) eligible for field termination of cardiopulmonary resuscitation (CPR). In Japan, however, emergency medical service (EMS) providers are not allowed field termination of CPR and must transport all patients with OHCA to hospitals, regardless of return of spontaneous circulation (ROSC). Therefore, we previously developed a Japanese TOR (JP-TOR) rule in the field for refractory OHCAs using data from the All-Japan Utstein registry between 2011 and 2015, when CPR was performed according to the 2010 guidelines. The JP-TOR rule recommends CPR termination when patients meet all the following criteria: initial asystole, unwitnessed arrest, age ≥81 years, no bystander interventions before EMS arrival, and no ROSC after EMS-initiated CPR for 14 min.

Purpose

To validate the JP-TOR rule using more recent data where CPR was performed according to the 2015 guidelines, comparing the relevance of JP-TOR rule with the BLS-TOR rule, which consists of the following criteria: no prehospital ROSC after 6-min EMS-initiated CPR, arrest unwitnessed by EMS providers, and no shock received.

Methods

We analysed the records of 242,184 patients (age ≥18 years) who experienced OHCA treated by EMS providers. Data were obtained from a prospectively recorded Japanese nationwide Utstein-style database from 2016 to 2017. The primary endpoints were specificity and positive predictive value (PPV) for predicting the 1-month mortality after OHCA with the JP-TOR and BLS-TOR rules.

Results

The overall 1-month survival rate was 5.3% (12,847/242,184). The proportions of patients with OHCA fulfilled the JP-TOR and BLS-TOR criteria were 10.4% and 89.3%, respectively. The specificity and PPV of the JP-TOR and BLS-TOR rules for predicting 1-month mortality were 99.5% (95% confidence interval [CI], 99.4%–99.5%) and 99.8% (95% CI, 99.7%–99.8%) and 44.7% (95% CI, 43.8%–45.5%) and 96.7% (95% CI, 96.6%–96.8%), respectively.

Conclusions

The JP-TOR rule for EMS providers treating patients with OHCA in the field was successfully validated using more recent data from a Japanese registry where CPR was performed according to the 2015 guidelines. The JP-TOR rule was superior to the BLS-TOR rule in Japanese EMS systems, having both high specificity and PPV of &gt;99% for predicting 1-month mortality. The JP-TOR rule may help EMS providers decide whether to terminate resuscitation efforts for unresuscitable patients with OHCA in the field. Prospective validation studies and establishment of prehospital EMS protocol are required before implementing this rule in Japan.

P489Survival in children with out-of-hospital cardiac arrest after standard or chest compression-only bystander cardiopulmonary resuscitation before emergency medical services arrival

Funding Acknowledgements

Japan Society for the Promotion of Science (KAKENHI Grant No. 18K09999)

Background

For out-of-hospital cardiac arrest (OHCA), current cardiopulmonary resuscitation (CPR) guidelines recommend chest compression-only bystander CPR (C- BCPR) for both untrained and trained bystanders unwilling to perform rescue breaths before emergency medical services personnel arrival. However, during 3 consecutive guideline periods, changes in type of BCPR and neurologically intact survival rate are unclear in paediatric OHCA cases.

Purpose

We aimed to determine the change in the rate and type of BCPR in correlation to the 1-month neurologically intact survival and causes of OHCA.

Methods

We reviewed 5461 children with bystander witnessed OHCA included in the All-Japan Utstein-style registry from 2005 to 2017. Patients were divided into 3 groups according to the type of BCPR: no BCPR (NO-BCPR), standard BCPR with rescue breaths (S-BCPR), and C-BCPR. Guideline periods 2005 to 2010 (pre-G2010), 2011 to 2015 (G2010), and 2016 to 2017 (G2015) were used for comparison over time. The study endpoint was 1-month neurologically intact survival (Cerebral Performance Category [CPC] scale 1 or 2; CPC 1–2).

Results

The rates of patients receiving any BCPR and 1-month CPC 1–2 by year significantly increased from 46.2% and 9.4% in 2005 to 61.3% and 15.7% in 2017 (all P for trend &lt;0.0001), respectively. The rates of patients receiving C-BCPR in the pre-G2010 period significantly increased from 21.6% to 35.5% in the G2010 period, and to 40.4% in the G2015 period (P for trend &lt;0.0001); the overall proportion of cases with 1-month CPC 1–2 increased from 9.1% to 10.8% and 14.7%, respectively (P for trend &lt;0.0001). Particularly, in patients receiving C-BCPR, CPC 1–2 rate significantly increased from 9.5% in the pre-G2010 period to 19.0% in the G2015 period (P for trend &lt;0.0001). For all time periods, 1-month CPC 1–2 rate in the S-BCPR (17.2%) cohort was significantly higher than those in the C-BCPR (12.5%) and NO-BCPR (6.4%) cohorts (adjusted odds ratio [aOR] of S-BCPR compared with C-BCPR, 1.59; 95% confidence interval [CI], 1.25–2.01; P &lt; 0.0001; compared with NO-BCPR, aOR 2.31; 95% CI, 1.82–2.94; P &lt; 0.0001). No significant difference between S-BCPR and C-BCPR was found in 1-month CPC 1–2 rate for patients with non-traumatic origin (17.7% vs. 16.3%; aOR, 1.23, 95% CI, 0.95–1.59, all P &gt;0.05). However, in patients with traumatic origin, S-BCPR was superior to C-BCPR (15.1% vs. 3.4%; aOR, 4.53, 95% CI, 2.39–8.61, all P &lt;0.0001). During the 3 guidelines periods, the CPC 1–2 rate in patients with non-traumatic origin significantly increased from 11.8% to 19.7% (P for trend &lt; 0.0001), but not in patients with traumatic origin (from 4.9% to 4.1%, P for trend = 0.29).

Conclusions

During the 3 guidelines periods, the rate of C-BCPR and 1-month CPC 1–2 increased by approximately 2-fold each over time. C-BCPR was associated with increased odds of 1-month CPC 1–2 similar to S-BCPR for children with non-traumatic origin but not in those with traumatic origin.

P490Time boundaries of three-phase time-sensitive model for ventricular fibrillation cardiac arrest

Funding Acknowledgements

Japan Society for the Promotion of Science (KAKENHI Grant No. 18K09999)

Background

Recent clinical evidence has suggested that the pathophysiology of ventricular fibrillation (VF) cardiac arrest may consist of three time-sensitive phases, namely electrical, circulatory, and metabolic. According to this model of cardiopulmonary resuscitation (CPR), the optimal treatment of cardiac arrest is phase-specific. The potential survival benefit of bystander cardiopulmonary resuscitation (BCPR) depends in part on ischemic time (i.e., the collapse-to-shock interval), with the greatest benefit occurring during the circulatory (second) phase. However, the time boundaries between phases are not precisely defined in the current literature.

Purpose

The purpose of the present study was to determine the time boundaries of the three-phase time-sensitive model for VF cardiac arrest.

Methods

We reviewed 20,741 adult patients with initial VF after witnessed out-of-hospital cardiac arrest from a presumed cardiac origin who were included in the All-Japan Utstein-style registry from 2013 to 2017. We excluded patients who underwent bystander defibrillation prior to arrival of emergency medical services personnel. The study end point was 1-month neurologically intact survival (Cerebral Performance Category scale 1 or 2). Collapse-to-shock interval was defined as the time from collapse to first shock delivery by emergency medical services personnel. Patients were divided into two groups, BCPR (n = 11,606, 56.0%) and non-BCPR (n = 9135, 44.0%), according to whether they had received BCPR or not.

Results

The rate of 1-month neurologically intact survival in the BCPR group was significantly higher than that in the non-BCPR group (27.9% [3237/11,606] vs 17.9% [1632/9135], P &lt; 0.0001; adjusted odds ratio [OR], 1.90; 95% confidence interval [CI], 1.75–2.07; P &lt; 0.0001). Overall, increased collapse-to-shock interval was associated with significantly decreased adjusted odds of 1-month neurologically intact survival (adjusted OR for each 1-minute increase, 0.94; 95% CI, 0.93–0.95; P &lt; 0.0001). In the BCPR group, the ranges of collapse-to-shock interval that were associated with increased adjusted 1-month neurologically intact survival were from 7 minutes (adjusted OR, 1.95; 95% CI, 1.44–2.63; P &lt; 0.0001) to 17 minutes (adjusted OR, 2.82; 95% CI, 1.62–4.91; P = 0.0002) as compared with those in the non-BCPR group. However, the increase in neurologically intact survival of the BCPR group became statistically insignificant as compared with that of the non-BCPR group when the collapse-to-shock interval was outside these ranges.

Conclusions

The above-mentioned findings suggest that the time boundaries of the three-phase time-sensitive model for VF cardiac arrest may be as follows: electrical phase, from collapse to &lt;7 minutes; circulatory phase, from 7 to 17 minutes; and metabolic phase, &gt;17 minutes onward from collapse.