Abstract ES5-3: Management of special subtypes of TNBC

Less common subtypes of triple-negative breast cancer encompass a heterogeneous group of cancers some of which are rare and others which are ultra-rare. Given the high prevalence of breast cancer, less common TNBC subtypes can be encountered with some frequency in clinical practice. These subtypes, which include, metaplastic, medullary, apocrine, mucoepidermoid, secretory, and adenoid cystic breast cancer, have diverse histologies, molecular profiles, and prognoses. This educational discussion will review the distinct features of less common triple-negative breast cancers and will address how these impact current, as well as possible future, management strategies. Possible clinical trial approaches to further understand and better treat special subtypes of TNBC will also be discussed.

Citation Format: A Thomas. Management of special subtypes of TNBC [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr ES5-3.

Five-year outcomes for Aquablation therapy compared to TURP: results from a double-blind, randomized trial in men with LUTS due to BPH

INTRODUCTION

To determine if Aquablation therapy can maintain long term effectiveness in treating men with moderate to severe lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with a baseline prostate volume between 30 and 80 mL at 5 years compared to TURP.

MATERIALS AND METHODS

In a double-blinded, multicenter prospective randomized controlled trial, 181 patients with moderate to severe LUTS secondary to BPH underwent TURP or Aquablation. The primary efficacy endpoint was reduction in International Prostate Symptom Score (IPSS) at 6 months. The primary safety endpoint was the occurrence of Clavien-Dindo persistent Grade 1 or Grade 2 or higher operative complications at 3 months. The assessments included IPSS, Male Sexual Health Questionnaire (MSHQ), International Index of Erectile Function (IIEF) and uroflow (Qmax). The patients were followed for 5 years.

RESULTS

The primary safety endpoint was successfully achieved at 3 months where the Aquablation group had a lower event rate than TURP (26% vs. 42%, p = .0149 for superiority). Procedure-related ejaculatory dysfunction was lower for Aquablation (7% vs. 25%, p = .0004). The primary efficacy endpoint was successfully achieved at 6 months, where the mean IPSS decreased from baseline by 16.9 points for Aquablation and 15.1 points for TURP; the mean difference in change score at 6 months was 1.8 points larger for Aquablation (p < .0001 for non-inferiority, p = .1346 for superiority). At 5 years, IPSS scores improved by 15.1 points in the Aquablation group and 13.2 points in TURP (p = .2764). However, for men with larger prostates (≥ 50 mL), IPSS reduction was 3.5 points greater across all follow up visits in the Aquablation group compared to the TURP group (p = .0123). Improvement in peak urinary flow rate was 125% and 89% compared to baseline for Aquablation and TURP, respectively. The risk of patients needing a secondary BPH therapy, defined as needing BPH medication or surgical intervention, up to 5 years due to recurrent LUTS was 51% less in the Aquablation arm compared to the TURP arm.

CONCLUSIONS

The improvement in net health outcomes from Aquablation therapy outweigh those offered by a TURP when considering the efficacy benefit along with the lower risk of needing a secondary BPH therapy and avoiding retrograde ejaculation. Following Aquablation therapy, symptom reduction and uroflow improvement at 5 years have shown to be durable and consistent across all years of follow up compared to TURP. Larger prostates (≥ 50 mL) demonstrated a larger safety and efficacy benefit for Aquablation over TURP.

The epidemiology of out-of-hospital cardiac arrest in Australia and New Zealand: A binational report from the Australasian Resuscitation Outcomes Consortium (Aus-ROC)

INTRODUCTION

The Australasian Resuscitation Outcomes Consortium (Aus-ROC) out-of-hospital cardiac arrest (OHCA) Epistry (Epidemiological Registry) now covers 100% of Australia and New Zealand (NZ). This study reports and compares the Utstein demographics, arrest characteristics and outcomes of OHCA patients across our region.

METHODS

We included all OHCA cases throughout 2019 as submitted to the Epistry by the eight Australian and two NZ emergency medical services (EMS). We calculated crude and age-standardised incidence rates and performed a national and EMS regional comparison.

RESULTS

We obtained data for 31,778 OHCA cases for 2019: 26,637 in Australia and 5,141 in NZ. Crude incidence was 107.9 per 100,000 person-years in Australia and 103.2/100,000 in NZ. Overall, the majority of OHCAs occurred in adults (96%), males (66%), private residences (76%), were unwitnessed (63%), of presumed medical aetiology (83%), and had an initial monitored rhythm of asystole (64%). In non-EMS-witnessed cases, 38% received bystander CPR and 2% received public defibrillation. Wide variation was seen between EMS regions for all OHCA demographics, arrest characteristics and outcomes. In patients who received an EMS-attempted resuscitation (13,664/31,778): 28% (range across EMS=13.1% to 36.7%) had return of spontaneous circulation (ROSC) at hospital arrival and 13% (range across EMS=9.9% to 20.7%) survived to hospital discharge/30-days. Survival in the Utstein comparator group (bystander-witnessed in shockable rhythm) varied across the EMS regions between 27.4% to 42.0%.

CONCLUSION

OHCA across Australia and NZ has varied incidence, characteristics and survival. Understanding the variation in survival and modifiable predictors is key to informing strategies to improve outcomes.

First completely robot-assisted retroperitoneal nephroureterectomy with bladder cuff: a step-by-step technique

Introduction

While various surgical techniques have been reported for open and minimally invasive treatment of upper tract urothelial cancer (UTUC), the procedure of robot-assisted nephroureterectomy (NU) with bladder cuff has never been reported using only retroperitoneum without entering abdominal cavity. We developed a novel port placement and technique allowing to perform robot-assisted NU by a unique retroperitoneal approach.

Methods

Between February and June 2021 patients with history of UTUC were treated by robot-assisted NU completely restricted to retroperitoneal space using a singular trocar placement and a two-step docking without relocation of the surgical robot. Patient characteristics, perioperative outcomes and short-term follow-up were prospectively analyzed.

Results

The analysis included five patients [median age: 73 years; BMI: 27.2 kg/m²; Charlson comorbidity index 5]. All five patients had UTUC with a mean tumor size of 3.02 cm (range 0.9–6.0). UTUC was localized to distal ureter in two and to kidney in three cases. No positive surgical margins were noted for all patients with UTUC [1 low-grade and 4 high-grade]. Retroperitoneal lymphadenectomy in three patients did not reveal positive nodes. No intraoperative adverse events exceeding EAUiaiC classification ≥ 2 were observed, while median EBL was 150 ml (IQR 100–250). No patient experienced postoperative complications exceeding Clavien–Dindo classification ≥ 3a. Median hospital stay was 5.4d without any 30-d readmission.

Conclusion

We demonstrate safety and feasibility of the first entire robot-assisted retroperitoneal nephroureterectomy (RRNU) with bladder cuff. This surgical technique is easily reproducible, while surgical outcomes are similar to other established techniques.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03920-1.

Prospective Hybrid Molecules with Dual Anti-Viral and Anti-Thrombotic Activity Against the SARS- CoV-2 Infection and Its Associated Complications Employing in Silico Studies

Covid-19, a SARS-CoV virus-based disease, was identified in Wuhan, China, in December 2019. Initially, it was considered just an infection of the respiratory system, but due to its transmittable nature, it was declared a pandemic. A variety of treatment options were implemented, including antivirals like remdesvir, favipiravir along with vitamins and antioxidants. Further investigations revealed that the Covid-19 infection results in thrombotic cardiovascular complications, which are the major concern for the increased mortality associated with this disease. This study investigates the in Silico design of hybrid molecules with antiviral and an-tithrombotic properties. A docking study was performed using Autodock Vina software, and binding energies of the designed compounds were determined for papain-like protease (PDB: 3E9S) and 3-chymotrypsin-like cysteine protease (PDB: 6LU7). The docked poses and amino acids interactions were verified using Biovia Discovery studio 4.5. The binding energies of all designed compounds were compared with the standards, Compound RL1 (2-(5-(3-carbamoyl-1H-1,2,4-triazol-1-yl)-3,4-dihydroxytetrahydrofuran-2-yl)methoxy)-carbonyl)amino)(hydroxy)methyl)carbamoyl)phenyl acetate) and Compound FL2 (8-hydroxy-2-(3-hydroxy-4-methoxyphenyl)-4-oxochroman-6-yl(2-(6-flouro-3-oxo-3,4-dihydropyrazine-2-carboxamido)-1-hydroxy-3-phenylpropyl)carbamate) proved to be promising agents with strong binding interactions. Hybrid molecules that inhibit viral replication, possibly as transition state inhibitors, may be investigated further for use in the treatment of SARS-Co-V infection and its associated complications.

Association of a MIND Diet with Brain Structure and Dementia in a French Population

BACKGROUND

Adherence to the Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet, which combines higher consumption of vegetables, berries, nuts, whole grains, olive oil, fish, beans and poultry, with lower consumption of meat, sugars and saturated fats, is a promising strategy to prevent dementia. However, evidence in populations with non-US food culture, especially from Europe, is limited.

OBJECTIVES

To evaluate the association of a French-adapted MIND diet score with gray matter volumes, white matter microstructure and incident dementia.

DESIGN AND SETTING

This longitudinal study included participants from the population-based Three-City Bordeaux cohort (≥65 years), with a follow-up from June 2001 to February 2018.

PARTICIPANTS

Dementia-free participants at dietary assessment, in 2001-2002, who underwent systematic detection of incident dementia (over up to 7 visits). A subset of the cohort was included in an ancillary MRI study in 2010-2011.

MEASUREMENTS

A French-adapted MIND diet score (range, 0-15) was computed from a 148-item Food Frequency Questionnaire and a 24-hour recall administered at home. Incident dementia and its subtypes were adjudicated by an expert committee; and gray matter volumes and white matter microstructure were assessed by 3D-T1 MRI and diffusion-MRI.

RESULTS

Among 1,412 participants (mean age, 75.8 [SD, 4.8]; 63% women), followed for a median of 9.7 years (maximum 16.3 years), 356 (25.2%) developed incident dementia. In multivariable-adjusted Cox model, a higher French MIND diet score was associated with lower risks of dementia and AD (hazard ratios for 1-point of score = 0.89 [95% confidence interval, 0.83-0.95] and 0.88 [0.81-0.96], respectively). In Tract-Based Spatial Statistics analysis of 175 participants included in the MRI sub-study, a higher MIND diet score was associated with lower diffusivity values in the splenium of the corpus callosum (P < .05 after Family-Wise Error-correction). In contrast, there was no significant association of the adapted MIND diet score with gray matter volumes in Voxel-Based Morphometry analysis.

CONCLUSION

In this cohort of French older adults, higher adherence to the French MIND diet was associated with a lower dementia risk and with preserved white matter microstructure. These results provide further evidence for a role of the MIND diet in the prevention of dementia.

First Observation of the Four-Proton Unbound Nucleus ^{18}Mg

^{18}Mg was observed, for the first time, by the invariant-mass reconstruction of ^{14}O+4p events. The ground-state decay energy and width are E_{T}=4.865(34)  MeV and Γ=115(100)  keV, respectively. The observed momentum correlations between the five particles are consistent with two sequential steps of prompt 2p decay passing through the ground state of ^{16}Ne. The invariant-mass spectrum also provides evidence for an excited state at an excitation energy of 1.84(14) MeV, which is likely the first excited 2^{+} state. As this energy exceeds that for the 2^{+} state in ^{20}Mg, this observation provides an argument for the demise of the N=8 shell closure in nuclei far from stability. However, in open systems this classical argument for shell strength is compromised by Thomas-Ehrman shifts.

Improving the Efficiency, Stability, and Adhesion of Perovskite Solar Cells Using Nanogel Additive Engineering

Additive engineering has been applied widely to improve the efficiency and/or stability of perovskite solar cells (PSCs). Most additives used to date are difficult to locate within PSCs as they are small molecules or linear polymers. In this work, we introduce, for the first time, carboxylic acid-functionalized nanogels (NGs) as additives for PSCs. NGs are swellable sub-100 nm gel particles. The NGs consist of poly(2-(2-methoxyethoxy) ethyl methacrylate)-co-methacrylic acid-co-ethylenegylcol dimethacrylate (PMEO₂MA-MAA-EGD) particles prepared by a scalable synthesis, which have a diameter of 40 nm. They are visualized in the perovskite films using SEM and are located at the grain boundaries. X-ray photoelectron and FTIR spectroscopy reveal that the NGs coordinate with Pb²⁺ via the -COOH groups. Including the NGs within the PSCs increased the grain size, decreased nonradiative recombination, and increased the power conversion efficiency (PCE) to 20.20%. The NGs also greatly increase perovskite stability to ambient storage, elevated temperature, and humidity. The best system maintained more than 80% of its original PCE after 180 days of storage under ambient conditions. Tensile cross-cut tape adhesion tests are used to assess perovskite film mechanical integrity. The NGs increased both the adhesion of the perovskite to the substrate and the mechanical stability. This study demonstrates that NGs are an attractive alternative to molecularly dispersed additives for providing performance benefits to PSCs. Our study indicates that the NGs act as a passivator, stabilizer, cross-linker, and adhesion promoter.

Controlling the Thermoelectric Properties of Nb-Doped TiO2 Ceramics through Engineering Defect Structures

Donor-doped TiO₂ ceramics are promising high-temperature oxide thermoelectrics. Highly dense (1 - x)TiO₂-xNb₂O₅ (0.005 ≤ x ≤ 0.06) ceramics were prepared by a single-step, mixed-oxide route under reducing conditions. The microstructures contained polygonal-shaped grains with uniform grain size distributions. Subgrain structures were formed in samples with low Nb contents by the interlacing of rutile and higher-order Magnéli phases, reflecting the high density of shear planes and oxygen vacancies. Samples prepared with a higher Nb content showed no subgrain structures but high densities of planar defects and lower concentrations of oxygen vacancies. Through optimizing the concentration of point defects and line defects, the carrier concentration and electrical conductivity were enhanced, yielding a much improved power factor of 5.3 × 10^-4 W m^-1 K^-2 at 823 K; lattice thermal conductivity was significantly reduced by enhanced phonon scattering. A low, temperature-stable thermal conductivity of 2.6 W m^-1 K^-1 was achieved, leading to a ZT value of 0.17 at 873 K for compositions with x = 0.06, the highest ZT value reported for single Nb-doped TiO₂ ceramics without the use of spark plasma sintering (SPS). We demonstrate the control of the thermoelectric properties of Nb-doped TiO₂ ceramics through the development of balanced defect structures, which could guide the development of future oxide thermoelectric materials.

M, P. S. Teachers’ View on Online Classes during COVID-19 Lockdown – A Cross-Sectional Study

Background: Online classes have been started in many colleges amidst the COVID-19 lock-down. Our study aimed to evaluate the opinions of medical teachers who conducted online classes and to determine their views on the viability of these classes in a post-COVID-19 era. Methods: We carried out a cross-sectional study using an online survey. Teachers working in medical colleges who conducted online classes during COVID-19 lockdown were included. Questionnaires were shared in the WhatsApp groups of the medical teachers belonging to the states of Kerala and Tamil Nadu, India. Sampling was consecutive and convenient. Results: Respondents were 101 teachers among which 89 were included in the analysis. The majority of the teachers gave classes after intense preparation.  The participants felt that the quality of their work would have been better with enhanced Information Technology (IT) infrastructure.  One of the major reasons for favoring online classes was the opportunity it gave them to access the content later (56.2%, n=50). More than half 63% (n=56) of the teachers faced network issues and felt discouraged by lack of interaction. 36% (n=32) of the teachers opined that online classes were very poor, compared with regular classes.  However, 49.4% (n=44) favored the continuation of online classes after the COVID-19 lockdown. Conclusion: Despite experiencing problems, most participants in our survey wanted to continue online classes in the future. The participants felt that the classes were less interactive and educational institutions should improve their IT infrastructure to address the increasing need for online education.

HIV-infected patients display increased proatherogenic anti-apolipoprotein A1 autoantibodies, inflammatory and metabolomic markers

Background

HIV-infected patients display an increased risk of cardiovascular events. HIV and antiretroviral therapy (ART) have both been suggested to increase this risk but their specific role remains unclear. Autoantibodies against apolipoprotein A1 (anti-apoA1 IgG) are also associated with cardiovascular risk. The aim of this study was to analyse anti-apoA1 IgG levels and inflammatory markers as well as the metabolomic profile in a cohort of HIV-free, ART-experienced and naïve HIV-infected patients.

Methods

144 participants from a South African cohort were categorised into HIV-free (n=50), HIV-infected/ART-experienced (n=50) and HIV-infected/ART-naïve (n=44) groups. The levels of anti-apoA1 IgG were assessed by homemade ELISA assays. We performed targeted metabolomic analyses using standard operating procedures and measured inflammatory biomarkers using the Meso Scale Discovery® platform. Additionally, we conducted in vitro experiments on human aortic endothelial cells treated with anti-apoA1 IgG and assessed levels of adhesion molecules.

Results

Inflammatory markers (IFNg, IL-6, IL-10, TNFa, CRP all p&lt;0.05), circulating adhesion molecules (ICAM-1 and VCAM-1, p&lt;0.05), anti-apoA1 IgG levels were increased in HIV-infected patients compared to HIV-free participants.

While ART treatment significantly reduced IFNg, IL-10, TNFa, VCAM-1, anti-apoA1 IgG levels, no significant differences were observed in other biomarkers between ART-experienced and naïve participants. Treatment of human aortic endothelial cells with anti-apoA1 IgG (40μg/ml) induced a significant increase in these adhesion molecules compared to cells treated with control IgG (40μg/ml). Metabolomic analyses identified 257 endogenous circulating metabolites in plasma. Among these metabolites, we found that in HIV-free and infected patients 14 and 17 metabolites were significantly correlated with anti-apoA1 IgG levels, respectively. Among these 17 metabolites, 2 were positively correlated with the tryptophan pathway; kynurenine (r=0.292, p=0.0069) and 5-hydroxyindolacetate (r=0.316, p=0.0019). Interestingly, kynurenine was not significantly correlated with anti-apoA1 IgG levels in HIV-free patients.

Conclusion

HIV-infected patients displayed a more proatherogenic profile compared to HIV-free subjects. Anti-apoA1 IgG induced adhesion molecules expression. Metabolomics identified metabolites that were significantly associated with anti-apoA1 IgG levels and inflammatory biomarkers known to underlie atherosclerosis burden.

Funding Acknowledgement

Type of funding sources: None.

Placental expression of miR-21-5p, miR-210-3p and miR-141-3p: relation to human fetoplacental growth

BACKGROUND/OBJECTIVES

Dysregulation of microRNAs (miRNAs) and their target genes in placental tissue is associated with foetal growth restriction. We aimed to evaluate associations of placental miR-21-5p, miR-141-3p and miR-210-3p expression with maternal, placental and newborn parameters and with placental expression of their potential target genes PTEN, VEGF, FLT and ENG in a set of well-characterized small- (SGA) and appropriate- (AGA) for gestational age full-term singleton pregnancies.

SUBJECTS/METHODS

Placental samples (n = 80) from 26 SGA and 54 AGA were collected from full-term singleton pregnancies. Placental transcript abundances of miR-21-5p, miR-141-3p and miR-210-3p were assessed after normalization to a reference miRNA, mir-16-5p by real-time quantitative PCR. Placental transcript abundances of PTEN, VEGF, FLT and ENG were assessed after normalizing to a panel of reference genes.

RESULTS

Placental miR-21-5p transcript abundance was negatively associated with placental weight (n = 80, r = -0.222, P = 0.047) and this association was specific to the AGA births (n = 54, r = -0.292, P = 0.032). Placental transcript abundances of miR-210-3p and miR-141-3p were not associated with placental weight or birth weight in all 80 births. However, placental miR-210-3p transcript abundance was positively associated with birth weight specifically in the SGA births (n = 26, r = 0.449, P = 0.021). Placental transcript abundance of miR-21-5p was negatively associated with PTEN transcript abundance (Spearman's ρ = -0.245, P = 0.028) while that of miR-141-3p was positively associated with FLT (Spearman's ρ = 0.261, P = 0.019) and ENG (Spearman's ρ = 0.259, P = 0.020) transcript abundances in all 80 births.

CONCLUSION

We conclude that placental miR-21-5p and miR-210-3p may be involved in fetoplacental growth. However, this regulation is unlikely to be mediated through placental expression of PTEN, VEGF, FLT or ENG.

Placental expression of RNU44, RNU48 and miR-16-5p: stability and relations with fetoplacental growth

BACKGROUND/OBJECTIVES

The current study aimed to identify suitable reference miRNA for placental miRNA expression analysis in a set of well-characterized and fetal-sex balanced small- (SGA) and appropriate- (AGA) for gestational age full-term singleton pregnancies.

SUBJECTS/METHODS

In this retrospective study, placental samples (n = 106) from 35 SGA (19 male and 16 female) and 71 AGA (30 male and 41 female) full-term singleton pregnancies were utilized. Placental transcript abundance of three widely used reference miRNAs [miR-16-5p and Small nucleolar RNAs (snoRNAs) RNU44 and RNU48] were assessed by real-time quantitative PCR. Raw cycle threshold (C_t) analysis and RefFinder tool analysis were conducted for evaluating stability of expression of these miRNAs.

RESULTS

Raw C_t values of miR-16-5p were similar between SGA and AGA births (P = 0.140) and between male and female births within SGA (P = 0.159) and AGA (P = 0.060) births while that of RNU44 and RNU48 were higher in SGA births (P = 0.008 and 0.006 respectively) and in male births within the SGA group (P = 0.005) for RNU44 and in female births within the AGA group (P = 0.048) for RNU48. Across all 106 samples tested using the RefFinder tool, miR-16-5p and RNU44 were equally stable reference miRNAs.

CONCLUSION

We recommend miR-16-5p and RNU44 as suitable reference miRNAs for placental samples from settings similar to our study.

Simultaneous determination of melatonin and 6-hydroxymelatonin in human overnight urine by LC-MS/MS

For the quantification of the pineal hormone melatonin and its metabolite, 6-hydroxymelatonin, in human overnight urine, a single accurate method by liquid chromatography-tandem mass spectrometry (LC-MS/MS) has been developed. Urine samples were deconjugated using β-glucuronidase/arylsulfatase from Helix pomatia before solid phase extraction (SPE) purification. Chromatographic separation was performed using a reverse phase C18 column with a 7-minute gradient elution. Water was used as matrix to prepare the calibration standards, and deuterated analogues of melatonin and 6-hydroxymelatonin were used as internal standards. This newly developed method was validated in terms of linearity, accuracy, repeatability, intermediate precision, recovery, matrix effect, and stability according to the guidelines of the European Medicines Agency. The method was successfully applied to the analysis of overnight urine samples from 12 healthy volunteers, showing significant correlations of urinary melatonin and 6-hydroxymelatonin excretion rates with age. The urinary 6-hydroxymelatonin to melatonin ratio was also established and will be assessed in further studies as a potential endogenous metric of CYP1A2 activity.

Capromorelin, a ghrelin receptor agonist, increases feed intake and body weight gain in broiler chickens (Gallus gallus domesticus)

Ghrelin is a hormone that induces orexigenic effects in mammals. However, in avian species, there is scant and conflictive results on the effect of ghrelin on feed intake (FI). Therefore, we evaluated the effect of a ghrelin receptor agonist (capromorelin) on FI, ADG, water intake (WI), animal behavior and concentrations of ghrelin, glucose, growth hormone (GH) and insulin in broiler chickens. One-day-old male broilers were reared as recommended by the industry. At 4 wk of age (experimental day 0; D0), birds were blocked by weight and randomly assigned to 3 treatments in 2 identical trials. Control birds received a vehicle control solution containing 0 mg/kgBW/d of capromorelin. Birds in treatments 2 and 3 received capromorelin at target doses of 6 or 12 mg/kgBW/d of capromorelin (n = 27). FI and WI were measured 3 times a day at 0700 h (Period 1; P1), 1200 h (P2) and 1700 h (P3), while BW was recorded daily. Blood samples were collected on D-1 and D5. Bird behavior (pecking, sitting and standing) was evaluated for 9 h on D2. Data were analyzed using a randomized complete block design with repeated measures over time. Orthogonal polynomial contrasts were used to determine linear and quadratic effects of increasing levels of capromorelin. Polynomial contrasts showed that capromorelin doses linearly increased FI (P = 0.002) and ADG (P = 0.019). There were no treatment, day or treatment x d interactions on glucose, ghrelin and GH concentrations. However, there was a treatment x d interaction (P = 0.041) on insulin concentrations. Concentrations of insulin were higher on D5 for the 0 and 12 mg/kgBW/d treatments as compared with D-1. Polynomial contrasts showed that capromorelin doses linearly increased number of pecks/h (P = 0.018). Per hour FI and WI was higher during P1 (i.e., 0700-1200) as compared to P2 and P3 (P < 0.001). Our observations suggest that capromorelin linearly increases feed intake; thus, the same effect of that reported in mammalian species.

Recovery from aortic valve surgery: the trajectory of muscle mass, strength, and quality, and health-related quality of life (HRQoL)

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Barts Charity

OnBehalf

Queen Mary University of London (QMUL) and Barts Health NHS Trust

Background/Introduction:

The impact of intensive care unit-acquired weakness (ICUAW) is considerable and is associated with reduced physical function and impaired health-related quality of life (HRQoL). Patients’ undergoing elective cardiac surgery are known to lose significant muscle mass and strength in the first seven days after surgery, but little is known beyond that time. 

Purpose

We sought to investigate the effect of cardiac surgery on ICUAW (including muscle mass, strength, muscle quality) and HRQoL (including anxiety and depression and reintegration into society) until out-patient follow-up.

Methods

Eligible patients included adults undergoing a surgical elective aortic valve replacement without any pre-existing causes of severe muscle weakness or wasting. Muscle mass was measured using ultrasound of the rectus femoris cross-sectional area (RFcsa). Muscle quality was calculated using histogram analysis, specifically pixel intensity (PI), whereby a lower value is indicative of healthier muscle tissue. Muscle strength was measured using hand-held dynamometry specifically grip strength. HRQoL (EQ5D), anxiety and depression (hospital anxiety and depression scale (HADS)) and reintegration to normal living (RNLI index) were also collected. Measurements were assessed preoperatively, at day 7 and at out-patient follow-up.

Results

Thirty-one patients were recruited, with 22 (70.9%) patients attending follow-up. Patients lost 6.5% RFcsa (p= &lt;0.0001) in the first seven days post-surgery and 10.1% (p = 0.0014) between preoperative assessment and follow-up. Hand-held grip strength decreased significantly (10.6%, p= &lt;0.0001) in the first seven days post-surgery, however, differing to RFcsa, recovered considerably between day 7 and follow-up (7.7%, p = 0.018). Decreased muscle quality was observed solely in the first seven days after surgery (8.3%, p = 0.0094). The EQ5D visual analogue scale and crosswalk index increased significantly from preoperative assessment to follow-up (10%, p = 0.0250; 17.6%, p = 0.022 respectively) and day 7 to follow-up (11.7%, p = 0.0311; 27.9%, p = 0.011 respectively). While depression scores significantly decreased between the same time points as the EQ5D, changes in anxiety and RNLI scores, were non-significant.

Conclusion

Patients undergoing surgical aortic valve replacements lose considerable muscle mass in hospital, failing to recover even at out-patient follow-up. Furthermore, muscle quality decreases in the first seven days after surgery in line with the acute muscle loss. However, the impact on strength is less extensive as patients appear to recover the loss by follow-up. Patients’ health scores, function index and depression scores also improve, suggesting that muscle mass is the only outcome to not recover at follow-up. Therefore, patients appear to recover well from AVR surgery even surpassing some of their preoperative results, with the exception of the RFcsa.

Enantiomeric methadone quantitation on real post-mortem dried matrix spots samples: Comparison of liquid chromatography and supercritical fluid chromatography coupled to mass spectrometry

This study describes two bioanalytical methods for the quantitation of the two methadone enantiomers in dried matrix spots using high performance liquid chromatography coupled to tandem mass spectrometry (HPLC-MS/MS) and high performance supercritical chromatography tandem mass spectrometry (HPSFC-MS/MS). Dried matrix spots were obtained by spotting 10 µL of each sample fluid on a Whatman paper. Methadone and its main metabolite, EDDP, were extracted with 100 µL methanol and subsequently injected into the LC-MS/MS and SFC-MS/MS systems. Enantiomeric separation was achieved with AGP-column for the LC conditions and with Chiralpak IH-3 in SFC. The two methods were fully validated and 93 post-mortem samples were analysed with both analytical methods. Results from validation parameters and results obtained for all post-mortem samples were compared with a significant spearman correlation of r_s = 0.9978 for R-methadone and r_s = 0.9981 for S-methadone. The LC method provided better results in terms of uncertainty, retention factor and resolution, whereas SFC provides better sensitivity, with lower LOD. Median R-/S-methadone ratio in peripheral blood was found equal to 1.60 (N = 32), varying from 0.79 to 4.23. The reported values were in good agreement with previously published results. Based on the results obtained here, SFC-MS/MS can be considered a reliable alternative to the widely used LC-MS/MS for the quantitation of methadone enantiomers in bioanalysis and should be evaluated for other bioanalytical methods. Both methods can be easily and quickly used in toxicological routine analysis for the methadone quantitation in human fluids matrices, even if considering that the polysaccharide coated column IH-3 used in SFC does not allow the enantiomeric EDDP separation.

Single π 0 production off neutrons bound in deuteron with linearly polarized photons

The quasifree γ → d → π 0 n ( p ) photon beam asymmetry, Σ , has been measured at photon energies, E γ , from 390 to 610 MeV, corresponding to center of mass energy from 1.271 to 1.424 GeV, for the first time. The data were collected in the A2 hall of the MAMI electron beam facility with the Crystal Ball and TAPS calorimeters covering pion center-of-mass angles from 49 ∘ to 148 ∘ . In this kinematic region, polarization observables are sensitive to contributions from the Δ ( 1232 ) and N(1440) resonances. The extracted values of Σ have been compared to predictions based on partial-wave analyses (PWAs) of the existing pion photoproduction database. Our comparison includes the SAID, MAID and Bonn-Gatchina analyses; while a revised SAID fit, including the new Σ measurements, has also been performed. In addition, isospin symmetry is examined as a way to predict π 0 n photoproduction observables, based on fits to published data in the channels π 0 p , π + n and π - p .

Glucometers for Patients with Type 2 Diabetes Mellitus: Are they helpful?

Background: The effectiveness of self-monitoring of blood glucose (SMBG) in type 2 diabetes mellitus (T2DM) patients is debated in the literature. We aimed at elucidating the association and patterns of complications between SMBG use and plasma glucose values. Methods: This cross-sectional study comprised 303 participants from outpatient departments with T2DM for over 12 months. We analyzed sociodemographic and clinical variables including: anthropometry, SMBG use, disease duration, treatment modality, complications, plasma glucose level, and glycated hemoglobin level (%). Results: The mean duration of T2DM was 93±76 months. Participants were grouped into SMBG users (n=115, 38%) and non-SMBG users (n=188, 62%). The mean fasting plasma glucose levels of SMBG and non-SMBG users were 140.7±42.7 (95% Confidence Interval [95%CI]: 132.72;148.67) mg/dl and 145.4±50 (95%CI: 138.12;152.67) mg/dl (p=0.03), respectively. The mean post-prandial plasma glucose levels of the SMBG and non-SMBG groups were 202±63.42 (95%CI: 190.23;213.76) mg/dl and 209±84.54 (95%CI: 196.56;221.43) mg/dl (p=0.002), respectively. The mean difference in HbA1c among the groups were 8.14±1.69% (95%CI: 7.59;8.68) and 8.15±1.98% (95%CI: 7.27;9.02) (p=0.4), respectively. Hypoglycemia (n=50, 43.5%) was the most common complication. The prevalence of neuropathy (n=5, 4.3%, p=0.036) and cardiovascular disease (n=21, 18.3%, p=0.042) were significantly higher in the SMBG group. Conclusion: Although plasma glucose values were significantly lower in the SMBG group, its clinical significance remains questionable. Furthermore, many participants in both the groups had shortfalls in awareness, monitoring, and glycemic control. SMBG use needs to be evaluated in a cohort of patients with T2DM with adequate health awareness.

401 Three Birds with One Stone: Ureteric Calculus Precipitates Diagnosis and Resection of Three Primary Neoplasms

A 67 year-old female presented to our centre with a 2 day history of right flank pain, clinically suggestive of ureteric colic. Computed tomography (CT) confirmed a 6mm right ureteric calculus. However, CT also revealed a large 13cm ipsilateral renal mass, concerning for renal cell carcinoma (RCC). At ureteroscopy for management of the obstructing calculus, a small papillary lesion was noted in the bladder, and excised. Histology confirmed pTa low-grade transitional cell carcinoma.

Following discussion at the Urology multidisciplinary tumour board, MRI venogram (MRV) was recommended to delineate the extension of tumour into the renal vein, and to characterise a pelvic mass seen on original CT. MRV showed enhancing material extending into the IVC, consistent with tumour thrombus. However, it also identified a concerning 6cm solid ovarian mass.

The patient proceeded to open right radical nephrectomy and IVC thrombectomy, hysterectomy, bilateral salpingo-oopherectomy, and omental biopsy, with combined input from Urological, Gynaecological and Vascular surgical teams. Post-operative course was uneventful. Histology showed an 11cm pT3a G2 clear cell RCC, and 7.5cm ovarian fibroma, both fully excised. This case demonstrated the serendipity of a simple ureteric calculus precipitating a cascade of investigations, that ultimately led to complete resection of three primary neoplasms.

FOREARM AND BICEPS CIRCUMFERENTIAL VARIATIONS IN SKIN TISSUE DIELECTRIC CONSTANT AND FIRMNESS

Tissue dielectric constant (TDC) and skin firmness assessed via indentation force (FORCE) help quantify lymphedema and track changes. We sought to determine potential differences in these parameters dependent on arm circumferential locations. Thus, TDC and FORCE were measured in 40 healthy women at medial, anterior and lateral locations on forearm and biceps. In five other women with unilateral lymphedema (68.6±7.6 years), TDC was measured at corresponding circumferential forearm positions. Measurements were done in triplicate using compact noninvasive devices. Results for healthy women (23.8±2.7 years) showed forearm medial TDC values (26.7±2.2) were less than anterior (28.0±2.4) or lateral (28.0±2.5) positions (p&lt;0.001). Lymphedema patients had elevated values but similar medial-anterior-lateral patterns (33.7±8.0, 39.8±10.2 and 42.9±10.0). Biceps medial TDC values (24.1±2.2) were also less than either anterior (27.0±2.1) or lateral (28.2±3.3). Contrastingly, medial FORCE values at forearm and biceps were less than at anterior and lateral locations (p&lt;0.001) and increased in the order of medial-anterior-lateral on forearm (p&lt;0.001). The present findings provide reference values for both TDC and FORCE of commonly measured arm sites with specificity as to circumferential variations. This observed variation indicates the need for care in locating measurement positions for tracking patients with lymphedema.

Vertical Tropia Following Horizontal Transposition Surgery

Aim

The aim of this study was to determine the prevalence of vertical tropia following horizontal transposition of both vertical rectus muscles (HToVR) in patients with Duane syndrome or sixth nerve palsy.

Methods

This retrospective study included patients with Duane syndrome or sixth nerve palsy who had undergone HToVR muscles. Data collected included: age, gender, diagnosis, laterality, pre-operative angle of deviation, type of surgery and post-operative angle of deviation at one week, three months and six months. Information on the use of botulinum toxin (BT) ipsilateral medial rectus (MR), additional surgery was performed, and the presence of preoperative and postoperative binocular function and any vertical deviation was collected.

Results

There were 11 patients, eight patients with a diagnosis of Duane syndrome and three patients with a diagnosis of sixth nerve palsy. The mean age of the patients was 13 ± 14.79 years (range 5-55 years), four were female. The prevalence of post-operative vertical tropia was 54%. The mean vertical deviation for distance, was 7.6^ ± 2.94 (SD) (range 3^-9^). Stereoacuity was present preoperatively in 5 patients and 8 postoperatively. No patient developed diplopia or received further surgery for the vertical tropia. Of the six patients who had intraoperative BT at the time of the HToVR, four developed a vertical deviation.

Conclusion

The prevalence of vertical deviation following HToVR muscles was 54% in our series. None of the patients with an induced postoperative vertical deviation reported diplopia or required further surgery for it.

Systematic analysis of the methodological structure of the lean literature

Purpose

The purpose of this paper is to analyse and evaluate the methodological structure of the lean literature, so that its characteristics and influence among academics and practitioners might be better understood. The authors define “methodological structure” to be comprising six categorical components: publication category, degree of methodological disclosure, research strategies and data collection instruments (DCIs), type of data collected and analysed and type of research informants.

Design/methodology/approach

This study is a systematic bibliometric analysis of the lean literature. It has a two-stage research design. The first stage involves the identification of the top 50 most highly cited publications on “Lean”, with the resultant reference details being entered into a focal population set (FPS) spread sheet. The second stage involves coding and adding the six component fields of the methodological structure for each of the FPS entries. Both citation analysis (CA) and publication counting are then used to analyse patterns in these six components of methodological structure.

Findings

The top 50 publications in the FPS represent over 52,700 citations. All are either journal papers or books, but books are the most influential. Based upon this FPS sample, the lean literature is found to be both largely atheoretical in nature and also methodologically weak. Over half of the FPS publications are viewpoint-type publications and 46% have no methodological disclosure. The lean literature is predominantly qualitative in nature. Where disclosed, the most common research strategy is the case study and the most common DCI is the interview. High- and mid-level managers are the most frequently encountered research informants, while shop floor workers are infrequently used.

Originality/value

This paper starts with the most extensive known systematic review of systematic reviews of the lean literature; the result of which is the characterisation of a number of gaps in this body of knowledge. One of these gaps is the lack of any previous CA. The paper then proceeds to address this gap by providing the first CA within the lean literature. This is also the most comprehensive known CA within the field of operations and supply chain management more generally. As a consequence of this analysis, previously unknown patterns and insights into the methodological structure of the lean literature are revealed.

Introduction of an assessment toolkit associated with increased rate of DLB diagnosis

Background

Dementia with Lewy bodies (DLB) and dementia in Parkinson’s disease (PDD) are recognised to be under-recognised in clinical practice in the UK, with only one third to a half of expected cases diagnosed. We aimed to assess whether clinical diagnostic rates could be increased by the introduction of a structured assessment toolkit for clinicians.

Methods

We established baseline diagnostic rates for DLB and PDD in four memory clinics and three movement disorder/Parkinson’s disease (PD) clinics in two separate geographical regions in the UK. An assessment toolkit specifically developed to assist with the recognition and diagnosis of DLB and PDD was then introduced to the same clinical teams and diagnostic rates for DLB and PDD were reassessed.

For assessing DLB diagnosis, a total of 3820 case notes were reviewed before the introduction of the toolkit, and 2061 case notes reviewed after its introduction. For PDD diagnosis, a total of 1797 case notes were reviewed before the introduction of the toolkit and 3405 case notes after it. Mean values and proportions were analysed using Student’s t test for independent samples and χ² test, respectively.

Results

DLB was diagnosed in 4.6% of dementia cases prior to the introduction of the toolkit, and 6.2% of dementia cases afterwards, an absolute rise of 1.6%, equal to a 35% increase in the number of DLB cases diagnosed when using the toolkit (χ² = 4.2, P = 0.041).

The number of PD patients diagnosed with PDD was not found overall to be significantly different when using the toolkit: 9.6% of PD cases before and 8.2% of cases after its introduction (χ² = 1.8, P = 0.18), though the ages of PD patients assessed after the toolkit’s introduction were lower (73.9 years vs 80.0 years, t = 19.2, p < 0.001).

Conclusion

Introduction of the assessment toolkit was associated with a significant increase in the rate of DLB diagnosis, suggesting that a structured means of assessing symptoms and clinical features associated with DLB can assist clinicians in recognising cases. The assessment toolkit did not alter the overall rate of PDD diagnosis, suggesting that alternate means may be required to improve the rate of diagnosis of dementia in Parkinson’s disease.

SATB2 induction of a neural crest mesenchyme-like program drives melanoma invasion and drug resistance

Recent genomic and scRNA-seq analyses of melanoma demonstrated a lack of recurrent genetic drivers of metastasis, while identifying common transcriptional states correlating with invasion or drug resistance. To test whether transcriptional adaptation can drive melanoma progression, we made use of a zebrafish mitfa:BRAFV600E;tp53-/- model, in which malignant progression is characterized by minimal genetic evolution. We undertook an overexpression-screen of 80 epigenetic/transcriptional regulators and found neural crest-mesenchyme developmental regulator SATB2 to accelerate aggressive melanoma development. Its overexpression induces invadopodia formation and invasion in zebrafish tumors and human melanoma cell lines. SATB2 binds and activates neural crest-regulators, including pdgfab and snai2. The transcriptional program induced by SATB2 overlaps with known MITF^lowAXL^high and AQP1⁺NGFR1^high drug-resistant states and functionally drives enhanced tumor propagation and resistance to Vemurafenib in vivo. In summary, we show that melanoma transcriptional rewiring by SATB2 to a neural crest mesenchyme-like program can drive invasion and drug resistance in autochthonous tumors.

Longitudinal characterisation of haematological and biochemical parameters in cancer patients prior to and during COVID-19 reveals features associated with outcome

BACKGROUND

Cancer patients are at increased risk of death from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Cancer and its treatment affect many haematological and biochemical parameters, therefore we analysed these prior to and during coronavirus disease 2019 (COVID-19) and correlated them with outcome.

PATIENTS AND METHODS

Consecutive patients with cancer testing positive for SARS-CoV-2 in centres throughout the United Kingdom were identified and entered into a database following local governance approval. Clinical and longitudinal laboratory data were extracted from patient records. Data were analysed using Mann-Whitney U test, Fisher's exact test, Wilcoxon signed rank test, logistic regression, or linear regression for outcomes. Hierarchical clustering of heatmaps was performed using Ward's method.

RESULTS

In total, 302 patients were included in three cohorts: Manchester (n = 67), Liverpool (n = 62), and UK (n = 173). In the entire cohort (N = 302), median age was 69 (range 19-93 years), including 163 males and 139 females; of these, 216 were diagnosed with a solid tumour and 86 with a haematological cancer. Preinfection lymphopaenia, neutropaenia and lactate dehydrogenase (LDH) were not associated with oxygen requirement (O2) or death. Lymphocyte count (P < 0.001), platelet count (P = 0.03), LDH (P < 0.0001) and albumin (P < 0.0001) significantly changed from preinfection to during infection. High rather than low neutrophils at day 0 (P = 0.007), higher maximal neutrophils during COVID-19 (P = 0.026) and higher neutrophil-to-lymphocyte ratio (NLR; P = 0.01) were associated with death. In multivariable analysis, age (P = 0.002), haematological cancer (P = 0.034), C-reactive protein (P = 0.004), NLR (P = 0.036) and albumin (P = 0.02) at day 0 were significant predictors of death. In the Manchester/Liverpool cohort 30 patients have restarted therapy following COVID-19, with no additional complications requiring readmission.

CONCLUSION

Preinfection biochemical/haematological parameters were not associated with worse outcome in cancer patients. Restarting treatment following COVID-19 was not associated with additional complications. Neutropaenia due to cancer/treatment is not associated with COVID-19 mortality. Cancer therapy, particularly in patients with solid tumours, need not be delayed or omitted due to concerns that treatment itself increases COVID-19 severity.

Patient Suffering in Chronic Digestive Diseases: Will Primary Care-Specialist Collaboration With Effective Interactive Communication and Integrative Medicine in the Plan of Care Improve Quality of Life?

Acute and chronic digestive diseases are causing increased burden to patients and are increasing the United States health care spending. The purpose of this case report was to present how nonconfirmatory and conflicting diagnoses led to increased burden and suffering for a patient thus affecting quality of life. There were many physician visits and multiple tests performed on the patient. However, the primary care physician and specialists could not reach a confirmatory diagnosis. The treatment plans did not offer relief of symptoms, and the patient continues to experience digestive symptoms, enduring this burden for over 2 years. The central theme of this paper is to inform health care providers the importance of utilizing evidence-based primary care specialist collaboration models for better digestive disease outcomes. Consistent with patient’s experience, the authors propose to pilot/adopt the integrative health care approaches that are proven effective for treating digestive diseases.

[Quality of care criteria in the treatment of penile cancer]

BACKGROUND

Penile cancer is a rare malignancy and the wide range of quality of care associated with it often results in inferior oncologic and functional treatment outcomes.

OBJECTIVES

Assessment of the current healthcare situation in clinical routine and identification of the relevant key features and reference values for quality of care.

MATERIALS AND METHODS

Search for relevant peer-reviewed articles and published congress abstracts in Medline, Embase and other databases as well as Google web search engine.

RESULTS

Key quality features of penile cancer management include organ-sparing surgery of the primary tumor, invasive inguinal lymph node staging and systemic treatment. Adherence to treatment guidelines is currently low. Centralization of care has already led to a considerable improvement in the quality of care in some areas and increasing conformity with the guidelines' recommendations.

CONCLUSION

Centralization of care and networks based on this can significantly improve patient outcomes. Thus, reference values for core parameters of quality cancer care can be generated and validated. Moreover, organ-sparing surgery, invasive lymph node staging and systemic therapy should be increasingly utilized. As a reference value, 90% adherence to the guidelines for these three features is recommended. However, before centralization of care can be introduced, aspects relevant to practical implementation must be addressed, such as the reimbursement of travel costs for those affected, infrastructure costs and instruments to measure quality of life and patient satisfaction after centralization.

Response to the Letter to the Editor Regarding "Survey among Medical Students during COVID-19 Lockdown: The Online Class Dilemma"

We thank the editor for allowing us to respond to the comments by Akshara et al. The authors concur with us on unpreparedness and goes on to highlight how female doctors are over-worked during the pandemic. In this response, we also discuss why providing free data will not bring about significant change in students’ perception of online classes. We then advise how students can learn basic examination skills during the pandemic. Finally, we express our views on government and universities and finish with a recommendation that would help future doctors in times like the COVID-19 pandemic.  

Concordance between a neuroradiologist, a consultant radiologist and trained reporting radiographers interpreting MRI head examinations: An empirical study

INTRODUCTION

This study assessed agreement between MRI reporting radiographers and a consultant radiologist compared with an index neuroradiologist when reporting MRI head (brain/internal auditory meati [IAMs]) examinations. The effect on patient management of any discordant reports was also examined.

METHODS

Two trained MRI reporting radiographers (RRs), a consultant radiologist (CR) and an index neuroradiologist (INR) reported on a random sample of 210 MRI examinations. The radiographers reported during clinical practice and the radiologists in clinical practice conditions. Two independent consultant physicians (neuro-rehabilitation and neuropsychiatry) compared these reports with the index neuroradiologist report for agreement and the clinical importance of discrepant reports.

RESULTS

Overall observer agreement between the RRs and CR was comparable in relation to agreement with the INR: RR; 93/210 (44.3%); and the CR; 83/210 (39.4%) for all head MRI examinations (p = 0.32). For brain examinations the difference was similar: RR; 64/180 (35.6%); and CR; 54/190 (30.0%), p = 0.26. Agreement rates for the IAMs examinations were identical, 29/30 (97.7%). For all head MRI examinations (n = 210) there was a very small observed difference of <0.5% in mean agreement between the reporting radiographers and the consultant radiologist (p = 0.92) for examinations where a major disagreement would have been likely to have led to a change in patient management.

CONCLUSION

MRI reporting radiographers reported during clinical practice on MRI head examinations to a level of agreement comparable with a consultant radiologist.

IMPLICATIONS FOR PRACTICE

This is an area in which radiographers could provide additional reporting roles to the reporting service to increase capacity. Wider potential benefits include cost-effectiveness and role development/retention of radiographers.