Purpose/Objective(s)Ototoxicity is a well described side effect of cisplatin and up to 88% of SCCHN patients undergoing chemoradiation develop some degree of hearing loss. Clinical trials in pediatric cancer patients receiving high cumulative doses of cisplatin have demonstrated that use of STS infusion 4-8 hours after cisplatin administration led to a significantly lower likelihood of hearing loss. We therefore conducted a prospective pilot clinical trial to assess the feasibility and safety of intravenous STS after cisplatin in locally advanced SCCHN patients undergoing concurrent chemoradiation with cisplatin.Materials/MethodsThis was a pilot study to evaluate feasibility and safety of STS infusion in SCCHN patients, measured by successful completion of at least 200mg/m2 cumulative dose of cisplatin without extended delay of more than 7 days. Assessment of ototoxicity was performed with pure tone audiometry by audiologic evaluation at baseline and at 3 months post-treatment. Intravenous STS of 20g/m2 (for cisplatin 80-100mg/m2) or 10g/m2 (for cisplatin 40mg/m2) was infused 4 hours after completion of cisplatin infusion through a central line over 1-2 hours.ResultsA total of 16 patients were enrolled. All were male (median age: 56 years) with HPV-positive oropharynx squamous cell carcinoma. Three (19%) received weekly cisplatin at 40mg/m2 and 13 (81%) received high dose cisplatin at 100mg/m2. Fifteen patients (94%) completed more than 200mg/m2 of cisplatin and 14 patients (88%) achieved complete metabolic response assessed by 3-month post-chemoradiation FDG PET/CT. No disease progression was detected at a median follow-up of 10.7 months. Ten (63%) patients completed all planned STS infusions, 4 (25%) attempted all planned infusions but had to stop infusion, and 2 (12%) refused to get the planned second dose due to grade 3 nausea. Four patients (25%) developed grade 3 infusion reaction with hypotension and 3 (19%) developed grade 3 nausea with STS infusion. Grade 2 or higher hearing impairment occurred in 3 (19%) patients all of whom received high dose cisplatin; however, 2 of them did not complete planned STS infusion for infusion related adverse events.ConclusionIn this prospective pilot study, STS infusion after cisplatin did not interfere with delivery of target dose of cisplatin of 200mg/m2. The rate of grade ≥2 hearing impairment at 3 months after chemoradiation seems to be favorable at 19%, but severe nausea and infusion reactions precluded completing planned STS infusion in 37% of patients. Further investigation with supportive management strategies to make STS infusion more tolerable would be desirable. Funding: This work was supported by pilot funds received from NRG Oncology (NCORP grant UG1CA189867).

Purpose/Objective(s) NRG-HN005 was a phase II/III randomized study comparing each of two experimental arm(s) against a control arm from RTOG 1016, in patients with p16+, non-smoking associated, locoregionally advanced oropharyngeal cancer. The phase II primary endpoint was non-inferiority (NI) of progression-free survival (PFS). The phase III trial would have included the experimental arm(s) found to be NI in phase II, with co-primary endpoints of NI PFS and superior quality of life. Materials/Methods Eligible patients had p16+ stage T1-2N1M0 or T3N0-N1M0 (AJCC 8th edition) oropharyngeal squamous cell carcinoma and ≤10 pack-year smoking history. Patients were stratified by Zubrod performance status and randomized (1:1:1) to 70 Gy of intensity modulated radiation therapy (IMRT) over 6 weeks + Cisplatin at 100 mg/m2 every 3 weeks (Arm 1) vs 60 Gy IMRT over 6 weeks + Cisplatin at 100 mg/m2 every 3 weeks (Arm 2) vs 60 Gy IMRT over 5 weeks with nivolumab (Arm 3). For trial design, the assumed 9-month PFS was 96.5% and the lower threshold for Arms 2 and 3 was 91.8% (absolute NI margin 4.7%), for a hazard ratio (HR) boundary HR < 2.4 required for noninferiority. With one-sided type I error rate of 10% per test and 80% power, a log-rank test required 22 events from 266 patients per comparison (requiring 133 patients per arm and a total sample size of 399). In phase II, a futility analysis would be triggered for each comparison after 50% of the PFS events (11/22) had been reported. If the observed HR exceeded the NI margin, accrual would be discontinued. All randomized patients were included in analysis. Results Phase II accrued from 7/10/19 to 11/8/23. Accrual was suspended from 2/3/23 to 5/25/23, to discontinue Arm 2, after which randomization continued (1:1) to Arms 1 and 3 to complete the new phase II sample size of 382 patients. The median age was 60 years, 90.6% were male, 87.5% were White, and 84.9% had stage I disease. The first futility analysis was conducted after 11 PFS events (Arm 1: 2, Arm 2: 9) were reported, at a median follow-up of 1.1 years. The estimated HR was 4.34 (1-sided 90% upper confidence limit 11.83). The second futility analysis was triggered after 11 PFS events (Arm 1: 2, Arm 3: 9) were reported, at a median follow-up of 1.7 years. The estimated HR was 4.51 (1-sided 90% upper confidence limit 12.29). Accrual would have stopped but phase II had already completed. At present (median follow-up 2.2 years), 2-year PFS estimates are 98.1% (95% CI 95.4, 100) for Arm 1, 88.6% (95% CI 82.4, 94.7) for Arm 2, and 90.3% (95% CI 84.5, 96.1) for Arm 3. The 2-year overall survival estimates are 99.0% (95% CI 97.0, 100), 98.0% (95% CI 95.2, 100), and 96.1% (95% CI 92.3, 99.9), respectively. Conclusion The failure of the experimental arms to satisfy non-inferiority is due in part to the highly favorable outcome for the RTOG 1016 regimen, which demonstrated a 98% PFS rate through 2 years. A phase III trial will not proceed.

Purpose/Objective(s) HPV circulating tumor DNA (ctDNA) is a liquid biopsy biomarker that could evaluate treatment response and risk stratify patients after (chemo)radiotherapy ([C]RT). However, HPV ctDNA is undetectable at baseline in up to 15% of pts and needs prospective validation. HPV next-generation sequencing (HPV-seq) offers both genotyping and ultrasensitive quantification of HPV ctDNA. We validated HPV-seq, testing pre-specified hypotheses: (1) pre-RT HPV ctDNA correlates with gross tumor volume (GTV); (2) undetectable post-RT HPV ctDNA predicts favorable 2-year locoregional control (LRC) and progression-free survival (PFS). Materials/Methods We analyzed pre- and post-RT HPV ctDNA in 2 cohorts of non-metastatic p16+ OPC. Cohort 1 (n = 237): single-institution prospective study, standard RT/CRT; HPV ctDNA at pre-RT and ~3 mo post-RT. Cohort 2 (n = 126): secondary endpoint of NRG-HN002, a phase II trial of low-risk p16+ OPC (AJCC 7e T1-T2 N1-N2b or T3 N0-N2b, ≤10 pack-year) randomized to de-escalated RT vs. CRT to 60 Gy; HPV ctDNA at pre-RT and ~4 wk post-RT. HPV ctDNA was measured by HPV-seq, targeting 38 HPV types. Correlations were assessed by Spearman coefficient (r). Associations with LRC/PFS were assessed by Fisher exact test (2-sided α = 0.05). Results Pre-RT HPV ctDNA was detected in 228/237 (96.2%) of Cohort 1 and 126/126 (100%) of Cohort 2 (range = 0.2 to 408147 copies/mL). Across both cohorts, dominant HPV types were HPV-16 (87.1%), 33 (5.0%), 35 (4.8%), 18 (2.0%), 26 (0.6%), 38 (0.3%), and 59 (0.3%). Pre-RT HPV ctDNA was correlated with GTV in both Cohort 1 (r = 0.46 [0.34, 0.56]) and Cohort 2 (r = 0.25 [0.08, 0.41]). In a multivariable model, baseline HPV ctDNA was associated with N category in both Cohort 1 (p<0.001) and Cohort 2 (P = 0.0125) and not with T category or site (tonsil vs. other). At post-RT, HPV ctDNA clearance occurred in 189/237 (79.7% [74.2-84.4]) in Cohort 1 and 88/126 (69.8% [61.3, 77.2]) in Cohort 2. Pts who demonstrated post-RT HPV ctDNA clearance had better 2-yr LRC and PFS (Table) with negative predictive value (NPV) > 96% for LRC and > 94% for PFS. Conclusion This study provides prospective clinical validation of the prognostic value of HPV-seq in two high quality independent cohorts. Pre-RT HPV ctDNA was detected in >96% of pts with p16+ OPC and correlated with GTV and N-category. Post-RT HPV ctDNA clearance was associated with favorable outcomes. Cohort 1 showed more clearance and stronger association with LRC and PFS, possibly due to test timing (3 vs. 1 month post-RT) and sample size.

This chapter discusses Zeng Guofan's military ethics which the author takes to be the most important Confucian view of military ethics in the late Qing dynasty. Zeng Guofan is regarded as a great politician and strategist, a prominent Confucian scholar and the creator of the Militia Army of Hunan province (the Xiang Army) in the late Qing dynasty. He is well-known for creating the Hunan Militia Army which was built on the basis of Confucian ethical doctrines and defeated the Taiping Rebellion Army after a nine-year battle with the Taiping rebels. Zeng was also well-known for his military writings as they had significant influence on the military thoughts of the then contemporary military leaders such as Zuo Zongtang and Li Hongzhang as well as the military leaders of the Republic of China (1912–49) such as Cai E and Jiang Jieshi (Chiang Kai-shek). In this chapter, the author discusses Zeng's view of military ethics by doing the following things: (1) discussing his reasons for forming the Hunan Militia Army and launching civil war against the Taiping Army; (2) discussing the moral principles which Zeng advocated for governing the build-up of the army; and (3) giving a critical analysis of Zeng's military ethics. The author is thankful to Prof. Barney Twiss for reading the draft of the paper and his valuable suggestions.

Endothelial shear stress (ESS) is a parallel frictional force exerted by blood flow on the coronary luminal surface. Emerging data have shown ESS to be predictive of coronary artery disease (CAD) progression. Computational fluid dynamics (CFD) is used to study fluid flow in engineering and has been increasingly applied in cardiovascular research to estimate ESS. However, there are still concerns over the validity of CFD-derived coronary ESS estimates with no standardised methodology recognised. This study sought to compare coronary CFD-derived ESS estimates with invasive haemodynamic measurements. Six proximal left anterior descending (pLAD) coronary models were segmented from patients who had received same day cardiac computed tomography and invasive coronary haemodynamic (Combowire XT) assessment. Patient-specific coronary data were applied to CFD boundary conditions using ANSYS software to compute individualised ESS pLAD profiles. Simulated parameters were previously validated with experimental work. Mean velocity contours and area-averaged magnitudes were analysed from (Figure 1). Patient-specific average peak velocity (APV) correlated well with simulated velocity average (r=0.9567; p=0.0028) (Figure 2). Simulated CFD-derived ESS correlate well with invasively acquired coronary haemodynamic measurements. These preliminary data suggest that a non-invasive approach to determining patient-specific coronary ESS is possible, which may have potential to better predict patients at risk of rapid CAD progression.

The role of endothelial shear stress (ESS) in coronary artery disease (CAD) has been widely explored and shown to promote vascular remodelling and plaque development. Computational fluid dynamics (CFD) has been increasingly applied in cardiovascular research to compute ESS. However, current CFD models make assumptions resulting in inaccuracies. To overcome this, patient-specific data can be applied but still heavily rely on invasively-acquired coronary haemodynamics, therefore limiting their clinical utilisation. This study aimed to compare non-invasive cardiac computed tomography (CTCA)-derived coronary flow against gold standard invasive coronary haemodynamics. Twenty-two patients underwent same-day CTCA, intravascular coronary ultrasound (IVUS), and invasive coronary haemodynamic (Combowire XT) assessment. Average peak velocities (APV) of the proximal left anterior descending (pLAD) artery were recorded. Mass flow rate (MFR) is a measure of coronary flow per unit and calculated as a product of blood density of pLAD and luminal cross-sectional area (CSA). Non-invasive MFR was derived from allometric scaling laws. The cohort's APV ranged 0.08–0.33 m/s with a mean 0.21 m/s. There was good correlation between invasive MFR (APV x CSA_IVUS) and non-invasive MFR (r=0.98; p<0.0001). In addition, semi-invasive MFR (APV x CSA_CTCA) correlated well with invasive MFR (r=0.95; p<0.0001). Non-invasive CTCA-estimated coronary flow derived from allometric scaling laws correlates well with invasively-acquired data. There is potential that these estimates utilise CFD parameters to compute a fully non-invasive ESS profile.

Purpose/Objective(s) The combination of radiotherapy (RT)/cetuximab has demonstrated superiority over RT alone for locally advanced non-operative SCCHN. We performed a definitive randomized trial to test this hypothesis in completely resected, intermediate-risk SCCHN. Materials/Methods Enrolled patients had SCCHN of the oral cavity, oropharynx or larynx (hypopharynx was excluded); complete resection with negative margins and no evidence of nodal extracapsular spread; but one or more risk factors warranting postoperative RT. Patients were randomized 1:1 to IMRT (60-66 Gy) with cetuximab (C) (loading dose 400 mg/m2 pre-RT plus weekly 250 mg/m2 up to 11 total doses) (RT+C) or without C (RT). Patients were stratified by tumor site/ HPV status, clinical T-stage, EGFR expression level, and use of daily IGRT. The primary hypothesis was that RT+C would achieve superior overall survival (OS) in eligible patients. The trial was designed to detect a hazard ratio of 0.74 with 80% power, and 1-sided alpha of 0.025 (372 OS events, target enrollment of 700 patients). Disease-free-survival (DFS) and toxicity were secondary endpoints. Late toxicity was defined as >90 days after start of RT. OS and DFS between arms were compared via stratified log-rank test; toxicity was compared via Fisher's exact test. Locoregional failure was a tertiary/exploratory endpoint. Results The study enrolled 702 pts from 11/2009-3/2018; 627 were randomized, and 577 were eligible (287 RT and 290 RT+C). Most patients (64%) had oral cavity cancer, and 52% had clinical AJCCv6 stage IV(M0) cancer; a large majority (84.6%) had high EGFR expression. Due to substantially lower than expected event (death) rates, the protocol was amended to perform a time-driven analysis with data as of 06/05/2023 (184 OS events). At a median follow-up of 7.2 years, OS was not significantly improved, but DFS was (see table). Grade 3-4 acute toxicity rates were 70.3% (RT+C) versus 39.7% (RT), (p<0.0001), mostly related to skin and/or mucosal effects. Late Grade ≥3 toxicity rate was 33.2% (RT+C) versus 29.0% (RT) (p=0.3101). There were no Grade 5 toxicities in either arm. Conclusion Radiotherapy + cetuximab (RT+C) did not show OS superiority but significantly improved DFS, compared to RT alone for patients with resected, intermediate-risk SCCHN. Acute but not late toxicity was increased with RT+C. RT+C may be considered for this patient population, but it will be critical to identify subgroups achieving benefit from this combined-modality therapy. The combination of radiotherapy (RT)/cetuximab has demonstrated superiority over RT alone for locally advanced non-operative SCCHN. We performed a definitive randomized trial to test this hypothesis in completely resected, intermediate-risk SCCHN. Enrolled patients had SCCHN of the oral cavity, oropharynx or larynx (hypopharynx was excluded); complete resection with negative margins and no evidence of nodal extracapsular spread; but one or more risk factors warranting postoperative RT. Patients were randomized 1:1 to IMRT (60-66 Gy) with cetuximab (C) (loading dose 400 mg/m2 pre-RT plus weekly 250 mg/m2 up to 11 total doses) (RT+C) or without C (RT). Patients were stratified by tumor site/ HPV status, clinical T-stage, EGFR expression level, and use of daily IGRT. The primary hypothesis was that RT+C would achieve superior overall survival (OS) in eligible patients. The trial was designed to detect a hazard ratio of 0.74 with 80% power, and 1-sided alpha of 0.025 (372 OS events, target enrollment of 700 patients). Disease-free-survival (DFS) and toxicity were secondary endpoints. Late toxicity was defined as >90 days after start of RT. OS and DFS between arms were compared via stratified log-rank test; toxicity was compared via Fisher's exact test. Locoregional failure was a tertiary/exploratory endpoint. The study enrolled 702 pts from 11/2009-3/2018; 627 were randomized, and 577 were eligible (287 RT and 290 RT+C). Most patients (64%) had oral cavity cancer, and 52% had clinical AJCCv6 stage IV(M0) cancer; a large majority (84.6%) had high EGFR expression. Due to substantially lower than expected event (death) rates, the protocol was amended to perform a time-driven analysis with data as of 06/05/2023 (184 OS events). At a median follow-up of 7.2 years, OS was not significantly improved, but DFS was (see table). Grade 3-4 acute toxicity rates were 70.3% (RT+C) versus 39.7% (RT), (p<0.0001), mostly related to skin and/or mucosal effects. Late Grade ≥3 toxicity rate was 33.2% (RT+C) versus 29.0% (RT) (p=0.3101). There were no Grade 5 toxicities in either arm. Radiotherapy + cetuximab (RT+C) did not show OS superiority but significantly improved DFS, compared to RT alone for patients with resected, intermediate-risk SCCHN. Acute but not late toxicity was increased with RT+C. RT+C may be considered for this patient population, but it will be critical to identify subgroups achieving benefit from this combined-modality therapy.

In this cohort, HU differences in sCTs were observed but did not translate into a reduction in gamma pass rates and OAR/PTV DVH metrics. The acquisition of additional training data such as ultrashort echo time MRI could improve bone/air contrast and reduce bone/air sCT misclassifications. Further studies will establish the variation in sCT dosimetric accuracy using a larger retrospective cohort to inform QA limits on clinical sCT usage.

Social Engineering has emerged as a significant threat in cyber security. In a dialog based attack, by having enough of a potential victim's personal data to be convincing, a social engineer impersonates the victim in order to manipulate the attack's target into revealing sufficient information for accessing the victim's accounts etc. We utilise the developing understanding of human information processing in the Information Sciences to characterise the vulnerability of the target to manipulation and to propose a form of countermeasure. Our focus is on the possibility of the social engineer being able to build the victim's profile by, in part, inferring personal attribute values from statistical information available either informally, from general knowledge, or, more formally, from some public database. We use an orthogonalised log linear analysis of data in the form of a contingence table to develop a measure of how susceptible particular subtables are to probabilistic inference as the basis for our proposed countermeasure. This is based on the observation that inference relies on a high degree of non-uniformity and exploits the orthogonality of the analysis to define the measure in terms of subspace projections.

Influenza immunisation reduces the risk of cardiovascular events among those with cardiovascular disease (CVD) however up to 50% do not take it up. We sought to determine the understanding and perceptions of seasonal influenza immunisation among patients with CVD. A cross sectional, voluntary and anonymous survey was administered to cardiology inpatients and outpatients attending a large health system in Melbourne, Victoria, Australia during the 2022 influenza season, May 2022 to September 2022. Demographics, educational and employment status, and prior immunisation behaviours were collected. Questions on perceptions and beliefs around seasonal influenza immunisation and influenza-related illness were presented with a 5-point Likert scale (strongly disagree through to strongly agree). A total of 181 surveys were completed: median age 64 (50.5%<65 years), 65.0% (115/177) of the population were inpatients, 82.2% (143/174) had completed high school; 35.0% (63/180) female and 24.2% (43/178) spoke a language other than English at home. Over one third of respondents did not receive the seasonal influenza immunisation in the prior year (63/181, 34.5%). Only half (97/179, 54.2%) agreed that their heart condition increased the risk of complications if they contracted influenza. While 73.3% (132/180) agreed that immunisation would help prevent serious illness, only 26.8% (48/179) agreed that it would help to prevent myocardial infarction. Nearly a quarter (24.0%, 43/179) were concerned about side effects while 1 in 10 (12.8%, 23/179) patients raised cost as a barrier despite it being free-of-charge. If asked to receive the immunisation, 86% (154/179) would agree if their cardiologist suggested it. Despite guideline recommendations, most cardiology patients are uninformed of the benefits of influenza immunisation, but the vast majority would accept the immunisation if recommended by their cardiologist.

Abstract Background Seasonal influenza immunisation reduces the risk of cardiovascular events. Patients with established cardiovascular disease (CVD) derive a greater benefit than those without yet up to 50% globally do not take up the immunisation. Purpose To describe the understanding and perceptions of seasonal influenza immuni2ation among patients CVD. Methods A cross sectional, voluntary and anonymous survey was administered to cardiology inpatients and outpatients attending a large health system in Australia during the 2022 influenza season, May 1st 2022 to August 31st 2022. Demographics, educational and employment status and prior immunisation behaviours were collected. Questions on perceptions and beliefs around seasonal influenza immunisation and influenza-related illness were presented with 5-point Likert scale (strongly disagree through to strongly agree). Results A total of 181 surveys were completed; median age was 64 (50.5% <65 years), 65.0% (115/177) of the population were inpatients, 82.2% (143/174) had completed high school or more; 35.0% (63/180) were female and 24.2% (43/178) spoke a language other than English at home. Over one third of respondents did not receive the seasonal influenza immunisation in the prior year (63/181, 34.5%). Only half (97/179, 54.2%) of patients agreed that their heart condition placed them at higher risk of complications and serious illness if they contracted influenza. While 73.3% (132/180) agreed that immunisation would help prevent risk of serious illness, only 26.8% (48/179) agreed that it would help to prevent myocardial infarction. Nearly a quarter of patients (24.0%, 43/179) were concerned about side effects while 1 in 10 (12.8%, 23/179) patients raised cost as a barrier despite being free-of-charge to all patients with CVD in Australia. If asked to receive the seasonal influenza immunisation, 86% (154/179) patients would agree if their cardiologist recommended it. Conclusions Despite guideline recommendations, most cardiology patients are uninformed of the cardiovascular benefits of seasonal influenza immunisation with many unaware they are at higher risk of influenza-related, preventable illness. The vast majority of patients would accept the immunisation if recommended by their cardiologist highlighting their important role in improving uptake among this high-risk group.

Three novelists have written major works on the Malayan Emergency: Jin Zhimang (The People’s Writer Jin Zhimang’s Selected Anti-British War Novels 人民文學家金枝芒 抗英 戰爭小說選, Anthony Burgess (Time for a Tiger and The Enemy in the Blanket), and Han Suyin (And the Rain My Drink). This article examines how historical fiction engaged with the Emergency. Jin displayed a commitment to a socialist realism, Burgess to a comic mode, while Han assumed a blend of ethnographic detail and metafiction to render the period. All three writers assumed a variety of strategies to capture the political intensity of the period and the multi-ethnicity and multilingualism of Malaya. These works, each written during the Emergency itself, contribute to a multiplicity of ways of engaging with the period from various linguistic vantage points, resisting hegemonic pronouncements surrounding its historical legacy.

Exercise stress echocardiography (ESE) is often used for pre-renal transplant risk stratification. Nearly 20% of ESE may be non-diagnostic, resulting in delays to transplant and increased healthcare cost. A simple, reliable tool for predicting non-diagnostic ESE may streamline assessment. A retrospective analysis was performed of 898 kidney transplant candidates between 2013 and 2020 who underwent exercise stress echocardiography for pre-transplant cardiovascular assessment. The cohort was divided into chronic kidney disease (CKD) due to vascular disease (defined as hypertensive, diabetic, and vasculitis) and then the scoring system was validated in the entire cohort. Multivariable logistic regression identified predictors of non-diagnostic ESE. Covariates associated with non-diagnostic ESE (p<0.10) on univariate analysis were included in the multivariable model. From this model, only variables with p<0.05 were included for score development. Multicollinearity was assessed in the final model, with cut-offs of an R2 >0.75 or variance inflation factor >4.0. Non-diagnostic ESE occurred in 17% (151 of 898). Derived from regression analysis, a score was created (Table). This scoring system had excellent discriminative ability in both groups of patients with CKD due to vascular disease (AUROC 0.844) and validated in the whole cohort (AUROC 0.81). A score of ≥8 had a specificity of 94% and a positive likelihood ratio of 5.9 for non-diagnostic ESE. A simple clinical scoring system may identify patients likely to have non-diagnostic ESE and can be utilised to identify patients who may benefit from alternative risk-stratification investigations.Tabled 1VariableScoreSex (female)1 pointMass (BMI >402 pointsAge>551 pointRate (resting heart rate)<75 bpm 2 points<65 bpm 3 points<55 bpm 4 pointsThickness (LV hypertrophy)2 pointsDiabetesType 1, 3 pointsType 2, 1 pointLV Dysfunction2 pointsDialysis requiring1 point Open table in a new tab

Mammographically detected breast arterial calcification (BAC) is a risk marker for cardiovascular disease, but not routinely reported. With the advent of artificial intelligence (AI) in medical imaging: automated, quantitative BAC assessment may facilitate seamless integration into clinical workflow and allow personalised risk assessment. We conducted external validation of a novel AI software designed to quantify mammographic BAC. We obtained full-field digital mammograms from 285 women. BAC was evaluated as present/absent by two experienced mammographers with discordance adjudicated by third observer. AI algorithm (cmAngio, CureMetrix, USA) produced a quantitative BAC score (scale 0–100) based on area, extent and intensity, internally validated on 17,000 accessions. Agreement measured by kappa-coefficient, and diagnostic performance by area under the curve (AUC). A total of 1,232 images were evaluated with excellent interobserver agreement (kappa 0.96, p<0.001). The visual prevalence of BAC was 30% and 55% with AI software. Algorithm performance was excellent (AUC 0.91, 0.87–0.95) compared to human identification (Figure). Discordant cases (algorithm positive, human negative) all demonstrated low BAC scores (<26), which may suggest limitation of human detection for faint BAC. Sensitivity, specificity, positive and negative predictive value was 92%, 61%, 51%, 95% respectively. Average image analysis time was 34 seconds for humans and 2.5 seconds for software. Our results demonstrate high diagnostic performance of rapid AI-based BAC detection software, that additionally provides quantitative scoring and capable of detecting fainter lesions. Automated BAC detection may offer an efficient and superior method than human identification without impacting clinical workflow for radiologists. Further study to assess this impact on cardiac risk prediction is needed.

This study suggests that HDR-BT for reRT of small recurrent or second primary HNC can provide similar LC without excess high-grade toxicities as compared to historical outcomes with EBRT reRT. Delivery of equivalent doses higher than 30Gy in 5 fractions should be approached with caution.

Abstract Background Seasonal influenza immunisation reduces cardiovascular events by 30% in those with atherosclerotic cardiovascular disease (ASCVD) and up to 50% in those with recent acute coronary syndrome. However, uptake in high-risk patients remains poor. Clinician recommendation has been shown to increase adoption of influenza immunisation in the general population; thus, cardiologists are well-placed to promote uptake in patients with cardiovascular disease. Purpose To describe the attitudes and behaviours of Australian cardiologists regarding seasonal influenza immunisation. Methods We used an exploratory sequential mixed methods design. Semi-structured interviews of 10 cardiologists were performed to identify themes for quantitative evaluation in an online survey. Multiple choice and Likert scale questions explored (a) attitudes and behaviours regarding influenza immunisation, (b) engagement with colleagues and professional bodies and (c) preventative care in cardiology. The survey was administered to 63 cardiologists between November 2020 and January 2021 and respondents received an honorarium for their time. Results The majority of respondents were general cardiologists (50/63) – compared with subspecialist cardiologists, and had spent an average of 21 years in practice. Less than half of the cardiologists surveyed asked patients about their vaccination status always or most of the time (46%, 29/63). Only one quarter (25.4%, 16/63) of cardiologists recommended influenza immunisation to all of their patients while higher proportions recommended it among patients with ASCVD (49.2%, 31/63), heart failure (69.8%, 44/63) and those over the age of 65 years (68.3%, 44/63). Just over half of the cardiologists (57.1%, 36/63) agreed that influenza immunisation was important/very important for prevention of cardiac events, however this was of lower priority compared with other components of preventive care including smoking cessation (100% agreed important, 63/63), anti-hypertensives (96.8%, 61/63), statins (94.3%, 60/63), exercise (80.9%, 51/63), anticoagulants (74.6%, 47/63), SGLT2 inhibitors (69.8%, 44/63) and diet (68.2%, 43/63). Three quarters of cardiologists (76.2%, 48/63) believed that the clinician predominantly responsible for ensuring that patients received the immunisation was the general practitioner, with only a minority (12.7%, 8/63) reporting that it was the role of the cardiologist. Conclusions Despite a relative risk reduction exceeding that of statins and antihypertensives for patients with CVD, influenza immunisation is not prioritized or recommended by many cardiologists. Efforts at increasing awareness and advocacy among cardiologists may assist in broadening uptake among high-risk patients with cardiovascular disease.