Line Treatment Option Research Articles

PASS-01: Pancreatic adenocarcinoma signature stratification for treatment–01.

TPS635 Background: Over 70% of patients with pancreatic ductal adenocarcinoma (PDAC) present with metastatic disease where the mainstay of treatment is combination chemotherapy. Two pivotal phase III trials showed survival benefit of mFOLFIRINOX (mFFX) and gemcitabine/nab-paclitaxel (GnP), respectively, compared to gemcitabine alone. Both are considered standard 1st line treatment options but have not been compared prospectively. Other than the BRCA phenotype there are no predictive molecular markers to identify which patients will benefit from mFFX versus GnP. Growing data suggests that RNA signatures and GATA6 expression may predict response to chemotherapy. Genomic platforms do identify small subsets of patients who may benefit from a targeted approach however, impact has been small. Patient-derived organoids (PDOs) are now feasible to passage for drug pharmacotyping that could inform drug therapy approaches. Combining all molecular strategies in real time including genomics, RNA signatures and adding PDO drug sensitivities could enable better precision choices for more patients with metastatic PDAC. Methods: PASS-01 is a multi-institutional randomized phase II trial evaluating the benefit of 1st line mFFX vs GnP in de novo metastatic PDAC patients with good PS who have undergone baseline tumor biopsies with tissue prepared for whole genome (WGS) and RNA sequencing and PDO generation/pharmacotyping using standard and novel drugs. The 10 objective is to determine the PFS benefit of mFFX compared to GnP as 1st line treatment with 80% power to detect a median PFS of 7 vs 5 months, favoring mFFX. 27 of a planned 150 patients have been accrued to date. Secondary endpoints include ORR (RECIST), DOR, OS by chemotherapy and biomarkers of therapy response including GATA-6 as a surrogate biomarker for the Moffit RNA classifier. Exploratory objectives include: to evaluate if each PDO DNA/RNA signature matches the patient and if the PDO chemotherapy sensitivities correlate to the patient’s 1st line response; to evaluate the benefit in switching patients to 2nd line treatment based on PDO drug sensitivity; to evaluate novel agents derived from PDO pharmacotyping and potential findings from profiling in 2nd/3rd line treatment; to explore retrospectively whether serial cell-free circulating tumor DNA analysis, circulating tumor cells and CA19.9 could reflect potential early predictors of emerging or de novo resistance and explore biomarkers of immune-oncologic sensitivity with multiplex immunohistochemistry. Each patient’s WGS and PDO data is discussed at a combined tumor board with study investigators immediately following their 1st 8-week CT and ongoing as data develops with the goal of recommending precision treatment choices back to their treating investigator.

THE ROLE OF DIGOXIN IN THE SUCCESSFUL TERMINATION OF A RESISTANT MATERNAL ATYPICAL AV NODAL REENTRY TACHYCARDIA

Here, we describe the case of a patient during her gestational period with resistant tachycardia that failed front line treatment options and was treated using an older agent.

Semaglutide, a glucagon like peptide-1 receptor agonist with cardiovascular benefits for management of type 2 diabetes.

Semaglutide, a glucagon like peptide-1 (GLP-1) receptor agonist, is available as monotherapy in both subcutaneous as well as oral dosage form (first approved oral GLP-1 receptor agonist). It has been approved as a second line treatment option for better glycaemic control in type 2 diabetes and currently under scrutiny for anti-obesity purpose. Semaglutide has been proved to be safe in adults and elderly patients with renal or hepatic disorders demanding no dose modification. Cardiovascular (CV) outcome trials established that it can reduce various CV risk factors in patients with established CV disorders. Semaglutide is well tolerated with no risk of hypoglycaemia in monotherapy but suffers from gastrointestinal adverse effects. A large population affected with COVID-19 infection were diabetic; therefore use of semaglutide in diabetes as well as CV patients would be very much supportive in maintaining health care system during this pandemic situation. Hence, this peptidic drug can be truly considered as a quintessential of GLP-1 agonists for management of type 2 diabetes.

DREAM3R: DuRvalumab With chEmotherapy as First Line treAtment in Advanced Pleural Mesothelioma: A Phase 3 Randomised Trial

<b>Purpose/Objective(s):</b> • Platinum-based chemotherapy with pemetrexed is an appropriate first line treatment option for unresectable malignant pleural mesothelioma (MPM) • The DREAM¹ and PrE0505² Phase II trials combined durvalumab (PD-L1 inhibitor) with a platinum and pemetrexed both exceeding pre-specified response with acceptable toxicity • CheckMate 7433 recently reported an overall survival benefit with ipilimumab plus nivolumab vs. chemotherapy (HR 0.74, 95% CI 0.50 to 0.91). However, this benefit was less apparent in the 75% of patients with epithelioid histology (HR 0.86, 95% CI 0.69 to 1.08) • Clinical trials to further explore optimal first line treatment for MPM with immunotherapy are needed <h3>Materials/Methods</h3> International, open label, randomised (2:1), multi-centre, phase 3 trial • 480 patients (320 durvalumab and chemotherapy, 160 chemotherapy) to be recruited over 27 months and followed for another 24 months • This provides over 85% power if the true hazard ratio for overall survival is 0.70 with 2-sided alpha of 0.05, assuming a median survival of 15 months in the chemotherapy group, 21.4 months in the durvalumab and chemotherapy group, with an allowance for crossover <h3>Results</h3> TBD <h3>Conclusion</h3> TBD

Greek physiotherapists’ contemporary knowledge and practice for lateral elbow tendinopathy: An online survey

ObjectivesTo investigate physiotherapists' current knowledge and practice in the management of patients with lateral elbow tendinopathy, to explore associations between the participants’ education and management preferences and to identify potential evidence-to-practice gaps by making comparisons with recent research recommendations. DesignAn on-line cross-sectional survey. SubjectsRegistered physiotherapists working in Greece with previous experience in the management of lateral elbow tendinopathy. ResultsThree hundred and seventy eight responses met the inclusion criteria. Most responders (70.4%–91.5%) use pain provocation tests for the diagnosis of the condition, while a limited proportion uses patient rated outcome measures (6.9%–13%). Supervised exercise is the mainstay of rehabilitation (92.6%), followed by adjunctive research recommended treatment techniques such as manual therapy (72%) and advice (59.5%). Up to 83.6% of participants use adjunctive treatment techniques that are not recommended or without research recommendation (such as electrophysical agents, ice etc.). Physiotherapists with post-graduate education in musculoskeletal physiotherapy are almost three times more likely to choose only research recommended treatment approaches. There is a lack of consensus in an optimal exercise programme (type, volume, duration etc.) in patients with lateral elbow tendinopathy. ConclusionDespite research recommendations a limited use of patient rated outcome measures in lateral elbow tendinopathy is recorded. Supervised exercise is the first line treatment option for most physiotherapists, although the optimal application is still unclear. A large proportion of physiotherapists apply adjunctive treatment techniques that are either ineffective or poorly researched suggesting a substantial evidence-to-practice gap. Better access to knowledge, organisational and peer-support can potentially help to bridge this gap.

Cardiac Postoperative Use of High-Flow Nasal Cannula: A Retrospective Single-Center Study

We aimed to investigate the risk factors and reason for initiation of high-flow nasal cannula (HFNC), its benefit on re-intubation rate, mortality, and length of stay (LOS) in the postoperative cardiac surgery patient in the ICU. Methods: In a retrospective and descriptive study, 200 patients, who underwent cardiac surgery, were randomly included, and screened for initiation of postoperative respiratory support. Demographic patient data and pre-operative patient measurements were sampled. Data concerning the P/F ratio at arrival- and post-extubation, LOS at ICU and overall mortality were sampled. A comparison of those variables was performed between patients with and without need of respiratory support. Results: HFNC was initiated in approximately 22.45% in 2018, and 25% in 2020, of the patients. Comparing both years didn’t reveal a significant rise, but we saw a quicker use of HFNC in 2020. The all-case re-intubation rate and mortality was approximately 3%. The body mass index (BMI) was the only correlation with a higher chance of initiation of HFNC. Other data like age, pre-operative renal- or left ventricle function didn’t show a correlation. Conclusion: In case of respiratory insufficiency in the postoperative cardiac surgery setting, HFNC is a worthy first line treatment option which is initiated if conventional oxygen therapy doesn’t suffice. The mortality was low, and the mean LOS was 4.38 days. If respiratory support was started with HFNC mean LOS rose to 8.35 days. The BMI seems to have a correlation with the development of respiratory failure, which confirms the latest recommendation to start preventive HFNC in the post-extubation cardiac surgery setting and which could be implemented in the daily practice.

Free Papers Compiled

Background:Alcohol Dependence is a chronic relapsing-remitting condition which has mostly shown moderate response to first line treatment options. tDCS has been explored as a potential therapeutic augmentation method in recent studies.Aims:To evaluate the effectiveness of tDCS in reducing craving in alcohol dependence syndrome.Methods:A randomized single-blind sham-controlled study was conducted at the CEIMH, ABVIMS and Dr. RML Hospital, New Delhi (1st November 2018 to 31st March 2020). Males (N=46) aged 18-50 years, diagnosed with alcohol dependence by ICD-10 were included in the study after screening for dependence by AUDIT. They were randomized to Groups A:- tDCS Group (n = 23) and B:- Sham tDCS Group (n = 23). A current of 2mA was applied for 20 minutes, twice a day for 5 days with a total 10 sessions on left (cathode) and right (anode) DLPFC. After the final session, VAS (Visual Analogue Scale for alcohol craving) and PACS (PENN Alcohol Craving Scale) were applied to compare the treatment effectiveness.Results:After 10 sessions both VAS and PENN scores (VAS score in Group A [1.17 (±1.11)] and Group B [4.78 (±2.88)] with P = 0.0001; and the PENN score in Group A [6.17 (±4.67)] and Group B [15.43 (±8.15)] with P =0.0002) were significantly reduced in the tDCS group.Conclusion:Study reported significant reduction in craving as reported by the VAS and PACS scores in patients treated with the tDCS. This stimulation protocol is a promising, non-expensive, add-on clinical tool that can help reduce alcohol craving in persons with alcohol dependence syndrome.

Current treatment options and considerations for patients with relapsed/refractory diffuse large B cell lymphoma in North Macedonia

Autologous stem cell transplantation (ASCT) is considered standard therapeutic approach for patients with relapsed and refractory (R/R) diffuse large B cell lymphoma (DLBCL) that are transplant eligible. For transplant ineligible patients there are few therapeutic options and novel targeted therapies and immunotherapy that are still in development. Treatment of such patients with poor prognosis is considered to be a challenge and there is constant need for new salvage treatment regimens. The aim of this study was to evaluate patients’ characteristics and treatment strategies and considerations for diffuse large B cell lymphoma in our department, and to promote new therapeutic possibilities for R/R patients with NHL DLBCL. A total of 308 patients with NHL were treated at University Clinic for hematology from 2008 until 2020 and 49% (151) of patients with NHL DLBCL were included in this study. Survival analysis of all analyzed relapsed/refractory NHL patients revealed statistically significant better survival in patients with low risk IPI score, disease stage I/II and patients with age &lt;60 years. R-CHOP was superior treatment as first line regimen and in the R/R patients, ASCT was statistically superior to other available second line treatment options. Overall survival in patients with DLBCL that achieved complete response after initial treatment was 80%. The incidence of disease relapse after initial treatment in the first 12 months was 18%. Overall survival in all treatment groups was 60% in the evaluated period of 2.5 years follow up. A total of 60% of patients with relapsed forms of NHL DLBCL were candidates for treatment with high-dose chemotherapy and ASCT. Other 40% patients were not candidates for ASCT. In conclusion we confirm the need for new treatment options for patients that relapse after ASCT and that are transplant ineligible. Patients and disease characteristics can be used to identify high-risk patients, classify once relapsed patients and define decision on further treatment.

Immunoadsorption and plasma exchange-Efficient treatment options for neurological autoimmune diseases.

Therapeutic plasma exchange (TPE) and immunoadsorption (IA) are first or second line treatment options in patients with neurological autoimmune diseases, including multiple sclerosis, neuromyelitis optica spectrum disorders (NMSOD), chronic inflammatory demyelinating polyneuropathy, acute inflammatory demyelinating polyradiculoneuropathy (Guillain-Barré syndrome), and autoimmune encephalitis. In this prospective randomized controlled monocentric study, we assessed safety and efficacy of therapy with IA or TPE in patients with neurological autoimmune diseases. Treatment response was assessed using various neurological scores as well by measuring immunoglobulin and cytokine concentrations. Clinical outcome was evaluated by application of specific scores for the underlying diseases. A total of 32 patients were analyzed. Among these, 19 patients were treated with TPE and 13 patients with IA. IA and TPE therapy showed a comparable significant treatment response. In patients with MS and NMOSD, mean EDSS before and after treatment showed a significant reduction after treatment with IA. We observed a significant reduction of the pro-inflammatory cytokines IL-12, lL-17, IL-6, INF-γ, and tumor necrosis factor alpha during IA treatment, whereas this reduction was not seen in patients treated with TPE. In summary, both IA and TPE were effective and safe procedures for treating neurological autoimmune diseases. However, there was a trend towards longer therapy response in patients treated with IA compared to TPE, possibly related to a reduction in plasma levels of pro-inflammatory cytokines seen only in the IA-treated group.

Treatment of patients with severe aplastic anaemia with allogeneic stem cell transplantation - single centre experience

Aplastic anemia is a rare hematological syndrome caused by bone marrow failure and pancytopenia. It can be either inherited or acquired, the second one being more common. A variety of trigger factors have been implicated in the etiology of acquired aplastic anemia. However, in around 70% of the cases, the reason remains unknown. The two first line treatment options with competitive rate of success are immunosuppressive therapy (IST) and allogeneic stem cell transplantation (SCT). In this retrospective study we present our experience in the treatment of thirteen patients with severe acquired aplastic anemia. Six of the patients mentioned underwent matched unrelated (MUD) SCT and had all been previously treated with IST, except for one patient. The remaining seven patients included in our study underwent matched related SCT, without previous IST. Conditioning regimen, graft versus host prophylaxis, veno occlusive disease prophylaxis, antimicrobial prophylaxis and treatment, source of stem cells, as well as blood counts were taken into account, within a 7 year follow up period on average. Our findings revealed an overall survival rate of 92%. Three cases of graft versus host disease were observed, two within the MUD SCT group of patients (33%) and one within the matched related SCT group (17%). Faster engraftment was reached in patients treated with matched related SCT. One patient demanded a second allogeneic SCT. Comparable to other findings in literature, our study corroborated the favorable outcome of both allogeneic related and unrelated hematopoietic stem cell transplantation in the treatment of patients with severe aplastic anemia. Key words: aplastic anemia, immunosuppressive therapy, stem cell transplantation

SLFN11 biomarker status predicts response to lurbinectedin as a single agent and in combination with ATR inhibition in small cell lung cancer.

BackgroundLurbinectedin recently received FDA accelerated approval as a second line treatment option for metastatic small cell lung cancer (SCLC). However, there are currently no established biomarkers to predict SCLC sensitivity or resistance to lurbinectedin or preclinical studies to guide rational combinations.MethodsDrug sensitivity was assayed in proliferation assays and xenograft models. Baseline proteomic profiling was performed by reverse-phase protein array. Lurbinectedin-induced changes in intracellular signaling pathways were assayed by Western blot.ResultsAmong 21 human SCLC cell lines, cytotoxicity was observed following lurbinectedin treatment at a low dose (median IC50 0.46 nM, range, 0.06–1.83 nM). Notably, cell lines with high expression of Schlafen-11 (SLFN11) protein, a promising biomarker of response to other DNA damaging agents (e.g., chemotherapy, PARP inhibitors), were more sensitive to single-agent lurbinectedin (FC =3.2, P=0.005). SLFN11 was validated as a biomarker of sensitivity to lurbinectedin using siRNA knockdown and in xenografts representing SLFN11 high and low SCLC. Replication stress and DNA damage markers (e.g., γH2AX, phosphorylated CHK1, phosphorylated RPA32) increased in SCLC cell lines following treatment with lurbinectedin. Lurbinectedin also induced PD-L1 expression via cGAS-STING pathway activation. Finally, the combination of lurbinectedin with the ataxia telangiectasia and Rad3-related protein (ATR) inhibitors ceralasertib and berzosertib showed a greater than additive effect in SLFN11-low models.ConclusionsTogether our data confirm the activity of lurbinectedin across a large cohort of SCLC models and identify SLFN11 as a top candidate biomarker for lurbinectedin sensitivity. In SLFN11-low SCLC cell lines which are relatively resistance to lurbinectedin, the addition of an ATR inhibitor to lurbinectedin re-sensitized otherwise resistant cells, confirming previous observations that SLFN11 is a master regulator of DNA damage response independent of ATR, and the absence of SLFN11 leads to synthetic lethality with ATR inhibition. This study provides a rationale for lurbinectedin in combination with ATR inhibitors to overcome resistance in SCLC with low SLFN11 expression.

Antiangiogenic Properties of Axitinib versus Sorafenib Following Sunitinib Resistance in Human Endothelial Cells-A View towards Second Line Renal Cell Carcinoma Treatment.

Tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors predominate as first-line therapy options for renal cell carcinoma. When first-line TKI therapy fails due to resistance development, an optimal second-line therapy has not yet been established. The present investigation is directed towards comparing the anti-angiogenic properties of the TKIs, sorafenib and axitinib on human endothelial cells (HUVECs) with acquired resistance towards the TKI sunitinib. HUVECs were driven to resistance by continuously exposing them to sunitinib for six weeks. They were then switched to a 24 h or further six weeks treatment with sorafenib or axitinib. HUVEC growth, as well as angiogenesis (tube formation and scratch wound assay), were evaluated. Cell cycle proteins of the CDK-cyclin axis (CDK1 and 2, total and phosphorylated, cyclin A and B) and the mTOR pathway (AKT, total and phosphorylated) were also assessed. Axitinib (but not sorafenib) significantly suppressed growth of sunitinib-resistant HUVECs when they were exposed for six weeks. This axinitib-associated growth reduction was accompanied by a cell cycle block at the G0/G1-phase. Both axitinib and sorafenib reduced HUVEC tube length and prevented wound closure (sorafenib > axitinib) when applied to sunitinib-resistant HUVECs for six weeks. Protein analysis revealed diminished phosphorylation of CDK1, CDK2 and pAKT, accompanied by a suppression of cyclin A and B. Both drugs modulated CDK-cyclin and AKT-dependent signaling, associated either with both HUVEC growth and angiogenesis (axitinib) or angiogenesis alone (sorafenib). Axitinib and sorafenib may be equally applicable as second line treatment options, following sunitinib resistance.

Real World Experience on the Use of Ibrutinib Monotherapy in Waldenström Macroglobulinemia

BACKGROUNDIbrutinib is approved as a second line treatment option for Waldenström Macroglobulinemia (WM) patients in the United Kingdom and for patients unsuitable for chemo-immunotherapy. In a clinical trial setting, Ibrutinib monotherapy produced a major response rate (MRR) of 79.4% and a predicted five-year overall survival (OS) rate of 87%1. Valuable insights can be gained on the response and tolerability outcomes of Ibrutinib monotherapy in WM outside of the clinical trial setting. This study aimed to evaluate these outcomes in a large specialist centre which receives referrals from across the UK.METHODSA retrospective analysis was performed on consecutive patients with WM who commenced Ibrutinib between December 2014 and February 2021; all included patients were treated for at least 3 months. Data were collated from the WMUK Rory Morrison Registry. The primary outcomes were depth of response, event free survival (EFS, defined as time from commencement to permanent ibrutinib discontinuation due to toxicity, disease progression or death), duration of response (time from best response to progressive disease, PD), progression free survival (PFS) and overall survival (OS). Response was determined in accordance with the Sixth International Workshop on WM (IWWM) response criteria 2. Baseline characteristics and toxicity data were also collated.RESULTSOf the 84 patients who had commenced ibrutinib, sufficient data was available for 62 patients; median age was 69 years (range 44 - 85) and 40 (64.5%) were male. Among the 50 patients for whom International Prognostic Scoring System for WM (IPSSWM) data were available, the IPSSWM risk score at the time of ibrutinib initiation was low (n=8, 16%), intermediate (n=25, 50%) and high (n=17, 34%). The median number of prior therapy lines was 2 (range 1 - 7). The median time from diagnosis to commencement of ibrutinib was 70 months (Range 2 - 243).The median follow-up was 29 months (Range 3 - 71). Objective response rate (≥MR) was 79% (n=49) and MRR was 62.9% (n=39). Best response achieved was CR in 12.9%, VGPR in 24.2%, PR in 25.8%, MR in 16.1% and SD in 11.2%; 9.7% of patients experienced PD. The median time to best response was 5 months (Figure 1A) and the median EFS was 37 months (Range 3 - 71). Of the 49 patients who achieved an objective response, the median PFS was not reached and the two-year predicted PFS rate was 73.5%. At the time of analysis, 15 patients (24.2%) had discontinued ibrutinib due to disease progression, 5 (8.1%) due to adverse effects and 4 (6.5%) due to death. The median OS was not reached, and the predicted two-year OS rate was 87.8% (Figure 1B).The most common adverse effects were diarrhoea (14.5%), atrial fibrillation (AF, 9.7%) and rash (9.7%). Six of the seven patients who developed treatment-emergent AF continued ibrutinib with concurrent anticoagulants and either rate or rhythm control. Ibrutinib was permanently discontinued due to heart failure/AF (n=1), intracranial haemorrhage whilst taking ibrutinib and warfarin concurrently for brittle antiphospholipid syndrome and WM (n=1), significant liver function derangement (n=2) and intractable diarrhoea (n=1). Ibrutinib dose was reduced to 280 mg daily (n=13) and 140 mg daily (n=4) due to adverse reactions.CONCLUSIONIn a real-world setting, ibrutinib produces clinically meaningful objective responses in patients with relapsed WM; these response rates are comparable to those achieved in a clinical trial setting. Ibrutinib can produce durable disease control with long remission intervals. The toxicity profile is acceptable.REFERENCES1. Treon, S., Meid, K., Gustine, J., Yang, G., Xu, L., & Liu, X. et al. (2021). Long-Term Follow-Up of Ibrutinib Monotherapy in Symptomatic, Previously Treated Patients With Waldenström Macroglobulinemia. Journal Of Clinical Oncology, 39(6), 565-575. doi: 10.1200/jco.20.005552. Owen, S., Kyle, R., Stone, M., Rawstron, A., Leblond, V., Merlini, G. et al. (2013). Response assessment in Waldenström Macroglobulinemia: updated from the VIth International Workshop. British Journal of Haematology, 60, 171-176. doi: 10.1111/bjh.12102 [Display omitted] DisclosuresD'Sa: Sanofi: Honoraria; BeiGene: Honoraria, Research Funding; Janssen Cilag: Honoraria, Research Funding.

A Case Report on Methimazole Induced Anti-Thyroid Arthritis Syndrome: A Rare Drug Induced Migratory Polyarthritis

Antithyroid drugs (ATD’s) are widely used as the first line treatment option for the management of hyperthyroidism, especially for patients with Graves’ disease. They are classified into thionamide (Methimazole, Carbimazole and Propylthiouracil) and Non-thionamide (Iodine containing compounds) ATD’s. These drugs are associated with various types of adverse effects ranging from mild to potentially life threatening. Antithyroid arthritis syndome (AAS) is one of the major and uncommon side effects of ATD therapy requiring immediate drug discontinuation and hospitalization presents itself with myalgia, arthralgia and arthritis along with fever and rash of varying severity and non-specific laboratory findings, making its diagnosis and management clinically challenging. Here we report the case of 32 year old female with Graves’ disease who experienced severe migratory polyarthritis after the initiation of methimazole therapy. Her symptoms started to disappear after the prompt withdrawal of methimazole. We also concluded that this adverse effect of ATD’s might not be dose dependent by comparing our case with 6 other case reports of AAS. Here our objective is to raise awareness among the clinicians regarding the differential diagnosis and management of this major, uncommon and potentially life threatening adverse effect of ATD therapy.

Comparison of Levonorgestrel-releasing Intrauterine System (LNG-IUS) against Laparoscopic Assisted Supracervical Hysterectomy (LASH) for menorrhagia treatment: An economic evaluation

BackgroundThis economic evaluation and literature review was conducted with the primary aim to compare the cost-effectiveness of laparoscopic assisted supracervical hysterectomy (LASH) with NICE's gold-standard treatment of Levonorgestrel-releasing intrauterine system (LNG-IUS) for menorrhagia. Materials and methodsA cost-utility analysis was conducted from an NHS perspective, using data from two European studies to compare the treatments. Individual costs and benefits were assessed within one year of having the intervention. An Incremental Cost-Effectiveness Ratio (ICER) was calculated, followed by sensitivity analysis. Expected Quality Adjusted Life Years (QALYS) and costs to the NHS were calculated alongside health net benefits (HNB) and monetary net benefits (MNB). ResultsA QALY gain of 0.069 was seen in use of LNG-IUS compared to LASH. This yielded a MNB between -£44.99 and -£734.99, alongside a HNB between –0.0705 QALYs and –0.106 QALYS. Using a £20,000-£30,000/QALY limit outlined by NICE,this showed the LNG-IUS to be more cost-effective than LASH, with LASH exceeding the upper bound of the £30,000/QALY limit. Sensitivity analysis lowered the ICER below the given threshold. ConclusionsThe ICER demonstrates it would not be cost-effective to replace the current gold-standard LNG-IUS with LASH, when treating menorrhagia in the UK. The ICER's proximity to the threshold and its high sensitivity alludes to the necessity for further research to generate a more reliable cost-effectiveness estimate. However, LASH could be considered as a first line treatment option in women with no desire to have children.

Editor's Choice – Four Fenestration Endovascular Aortic Aneurysm Repair Without Stenting of the Coeliac Artery in Selected Cases

Editor's Choice – Four Fenestration Endovascular Aortic Aneurysm Repair Without Stenting of the Coeliac Artery in Selected Cases

V07-10 SEMINAL VESICULOSCOPY FOR DIAGNOSIS AND MANAGEMENT OF HEMATOSPERMIA

You have accessJournal of UrologySexual Dysfunction & Transgender (V07)1 Sep 2021V07-10 SEMINAL VESICULOSCOPY FOR DIAGNOSIS AND MANAGEMENT OF HEMATOSPERMIA Aaron Brant, Nahid Punjani, Christopher Gaffney, Jonathan Fainberg, and James Kashanian Aaron BrantAaron Brant More articles by this author , Nahid PunjaniNahid Punjani More articles by this author , Christopher GaffneyChristopher Gaffney More articles by this author , Jonathan FainbergJonathan Fainberg More articles by this author , and James KashanianJames Kashanian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002034.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Hematospermia is an uncommon urologic complaint but a cause of significant distress in affected patients. It is associated with bothersome symptoms such as dysorgasmia and chronic pelvic pain. First line treatment options include antibiotics, non-steroidal anti-inflammatory drugs (NSAIDS), alpha blockers, and 5-alpha reductase inhibitors. For patients with refractory symptoms, operative intervention with transurethral resection of ejaculatory ducts (TURED) and seminal vesiculoscopy has been described. METHODS: We provide a step-by-step description of seminal vesiculoscopy, TURED, and seminal vesicle (SV) balloon dilation in a 28-year old male presenting with five years of refractory hematospermia and dysorgasmia. He had failed treatment with antibiotics, NSAIDS, tamsulosin, and finasteride. His infectious and sexually-transmitted infection work-up was normal. His semen analysis was notable for 16% motility, 3.4 million WBC/mL, and cloudy brown color. Imaging with ultrasound and MRI revealed right SV dilation and clot in the left SV. RESULTS: After a normal cystoscopy, the verumontanum was identified, and the left ejaculatory duct was successfully cannulated with a 5-french open-ended catheter over a 0.014-inch micro-guidewire. Transrectal ultrasound was used to confirm correct placement. After dilation with a percutaneous transluminal angioplasty balloon dilator, the left seminal vesicle was entered under direct vision with a 4.5 french semi-rigid ureteroscope. Significant debris were noted and removed via irrigation through a luer-lock syringe. Both ejaculatory ducts were resected using a monopolar loop. The right SV was then cannulated, dilated, and entered under direct vision. Blood clot and debris were removed via irrigation. There were no post-operative complications. At six- and twelve-months follow-up, the patient reported significant improvement in dysorgasmia and complete resolution of hematospermia. CONCLUSIONS: Seminal vesiculoscopy with transurethral resection of ejaculatory ducts and balloon dilation is an effective procedure for hematospermia refractory to medical therapy in the appropriately selected patient. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e553-e554 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aaron Brant More articles by this author Nahid Punjani More articles by this author Christopher Gaffney More articles by this author Jonathan Fainberg More articles by this author James Kashanian More articles by this author Expand All Advertisement PDF downloadLoading ...

First line Treatment of Traumatic Carotid Cavernous Fistulas Using Covered Stents at Level 1 Regional Trauma Center.

ObjectiveThe widely accepted treatment option of a traumatic carotid cavernous fistula (TCCF) has been detachable balloon or coils based fistula occlusion. Recently, covered stent implantation has been proving an excellent results. The purpose of this study is to investigate our experiences with first line choice of covered stent implantation for TCCF at level 1 regional trauma center. MethodsFrom November 2004 to February 2020, 19 covered stents were used for treatment of 19 TCCF patients. Among them, 15 cases were first line treatment using covered stents. Clinical and angiographic data were retrospectively reviewed. ResultsProcedures were technically successful in all 15 cases (100%). Immediate angiographic results after procedure were total occlusion in 12 patients (80%). All patients except two expired patients had image follow-up (mean 15 months). Recurred symptomatic three patients underwent additional treatments and achieved complete occlusion. Mean clinical follow-up duration was 32 months and results were modified Rankin Scale 1–2 in five, 3–4 in five, and 5 in three patients. ConclusionThe covered stent could be considered as fist line treatment option for treating TCCF patients especially in unstable vital sign. Larger samples and expanded follow-up are required to further develop their specifications and indications.

Dry needling in lateral epicondylitis: A prospective controlled study

Lateral epicondylitis is a chronic disease characterized by inflammation and pain at origin of extensor muscles of forearm. Anti-inflammatory drugs, brace, physiotherapy and curtailing repetitive activities are some of the conservative first line treatment options available. Our study compared the pain relief and the improvement in functional disability with dry needling (group I) as compared to NSAIDS with brace (group II) in lateral epicondylitis patients. Patients were enrolled consecutively and randomized into two groups. After calculating and noting PRTEE (Patient rated tennis elbow evaluation score) scores in both groups, patients in group I were treated with dry needling and patients in group II were given NSAIDS with brace. Patients were instructed not to use any other measure for relief of pain. They were re-evaluated at 3 weeks and 6 months using PRTEE. The statistical analysis was performed using SPSS software. In both groups significant differences were detected at 3 weeks follow up. Dry needling was found to be effective at both 3 weeks and 6 months but the group II (NSAIDS and forearm brace) showed no effects at 6 months follow up. We conclude that dry needling is a viable treatment modality for lateral epicondylitis.

Hepatocellular carcinoma in children. Liver resection and liver transplantation outcomes

Hepatocellular carcinoma (HCC) in childhood is a rare type of malignant tumor of the liver. Childhood HCC is usually found in older children (10-15 years), rarely in children younger than 5. HCC is the second most common pediatric primary liver tumor accounting to around 25% following hepatoblastoma that accounts almost 70%. In children the only curative treatment of HCC is complete resection of the tumor and/or liver transplantation (LT). Traditionally some groups use Milan criteria (single tumor <5 cm, or no more than 3 each ≤3 cm in diameter). We collect patients data from January 2018 to January 2021. Our general policy is to offer LT to those patients with unresectable HCC (estimated liver remnant < 20%) without extrahepatic involvement. Liver resection remains the best approach and first line treatment option. Seven patients mean age 13.6 (range 1 to 16 years). Liver resection in 5 (71.4%) and LT in 2 (28.5%). Liver resection group underwent right extended hepatectomy in 3 (60%), right hepatectomý in 1 (20%) and left hepatectomy (20%). LT group exceeded Milan and Total Tumor Volume criteria. Liver resection group overall survival at 1 and 3-year were 100% and 60% respectively. Liver transplant group 1 and 3-year survival were 100%. HCC is a rare malignancy in children, occurring mainly in normal liver, its clinical behavior is different from adult HCC. Children LT criteria for HCC should not be the same as in adults. Management of childhood HCC includes chemotherapy, ablative procedures, surgical resection and LT.