Leptomeningeal Interfoliar Enhancement on Vessel Wall MR Imaging as a Unique Radiologic Finding of Susac Syndrome

Susac syndrome is a rare disorder affecting the brain, retina, and inner ear, probably triggered by an immune-mediated endotheliopathy. Diagnosis is based on clinical presentation and ancillary test findings (brain MR imaging, fluorescein angiography, and audiometry). Recently, vessel wall MR imaging has shown increased sensitivity in the detection of subtle signs of parenchymal, leptomeningeal, and vestibulocochlear enhancement. In this report, we describe a unique finding identified using this technique in a series of 6 patients with Susac syndrome and discuss its potential value for diagnostic work-up and follow-up.

Categorising commercial sector practices to advance human and planetary health

Background

There is growing interest in the commercial determinants of health, broadly understood as the ways in which commercial actors influence health & health equity. Such actors can impact on health & health inequity, positively or negatively, through two main routes: (1) producing & driving use of/access to products or services potentially damaging or beneficial to health. (2) through diverse commercial practices which range from marketing, through lobbying, to tax & labour practices. Practices are arguably of greater importance given the growing shift to private sector employment & because all industries, not just those whose products are harmful, engage in them. Yet their contribution to physical, mental & planetary ill health is generally under-recognised with a focus hitherto on unhealth commodities. We aim to develop a practical categorisation of commercial sector practices

Methods

Narrative review & content analysis of existing categorisations (those attempting to cover all practices), & taxonomies (those focused on specific practices (e.g., marketing), related academic &grey literatures.

Results

There is dualism between the business studies & public health literatures, the latter tending to dichotomise market & non-market strategies while the former sees this as an outdated approach. While some specific practices are well documented, others remain poorly understood & theorised. A simplified categorisation is proposed which attempts to identify key commercial sector practices that can impact on health, the ways in which they overlap & reinforce each other. Evidence-based taxonomies for specific practices are identified.

Conclusions

Our categorisation provides a simple approach through which the commercial practices that can harm human & planetary health & drive health equity can be understood & addressed. It draws attention to the diverse ways through which corporations can harm health, identifies areas for action & further research.

Key messages

• The ways in which commercial sector practices influence health and health equity are diverse yet poorly understood.

• We offer a simple categorisation of commercial practices which draws attention to the diverse ways through which they can harm health, helps identify solutions and areas for PH action.

Building a qualitative systems map: applying systems thinking to the commercial determinants of health and industry influence on health policy

Background

Unhealthy commodities are major drivers of the global burden of noncommunicable diseases. Commercial actors attempt to influence policy to undermine regulation and existing literature draws attention to the underlying macro-level factors that enable this influence. Public health literature also suggests that industry adapts to regulation and such influence may thus be considered a complex adaptive system. Therefore, this study aimed to build a qualitative systems map to help communicate the complexity of industry influence and develop a tool to facilitate the identification of interventions in follow up research.

Methods

In-person group model grouping workshops were adapted for the online environment. A preliminary qualitative systems map was developed by synthesising two recent studies to facilitate workshop discussions and expedite the mapping process. Twenty-three small group system mapping workshops were conducted with a total of 52 stakeholders, representing researchers, civil society, and public officials from various geographical regions.

Results

The qualitative systems map identifies five pathways through which industry influences policy: a) direct access to public sector decisionmakers; b) creation of confusion and doubt about policy decisions; c) prioritisation of commercial growth; d) industry leveraging the legal and dispute settlement processes; and e) industry leveraging policymaking rules and processes. The pathways contribute to perpetuating macro-level factors that enable industry to deploy practices to influence policy.

Conclusions

A system thinking approach can be applied to industry influence on health policy to depict a complex adaptive system. Interventions need to take into consideration the system's complexity and adaptivity. Further research is needed to test, and improve the systems map and identify interventions to achieve systems change.

Particle Swarm Optimization Artificial Intelligence technique for gene signature discovery in transcriptomic cohorts

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EBPSO identifies unique, accurate, and succinct gene signatures.

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Key genes within the signatures provide biological insights its associated functions.

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A web-based micro-framework developed for ease of use and real-time visualizations.

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A promising alternative to traditional single gene signature generation.

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Downstream analysis will better translate these signatures towards clinical translation.

The development of gene signatures is key for delivering personalized medicine, despite only a few signatures being available for use in the clinic for cancer patients. Gene signature discovery tends to revolve around identifying a single signature. However, it has been shown that various highly predictive signatures can be produced from the same dataset. This study assumes that the presentation of top ranked signatures will allow greater efforts in the selection of gene signatures for validation on external datasets and for their clinical translation. Particle swarm optimization (PSO) is an evolutionary algorithm often used as a search strategy and largely represented as binary PSO (BPSO) in this domain. BPSO, however, fails to produce succinct feature sets for complex optimization problems, thus affecting its overall runtime and optimization performance. Enhanced BPSO (EBPSO) was developed to overcome these shortcomings. Thus, this study will validate unique candidate gene signatures for different underlying biology from EBPSO on transcriptomics cohorts. EBPSO was consistently seen to be as accurate as BPSO with substantially smaller feature signatures and significantly faster runtimes. 100% accuracy was achieved in all but two of the selected data sets. Using clinical transcriptomics cohorts, EBPSO has demonstrated the ability to identify accurate, succinct, and significantly prognostic signatures that are unique from one another. This has been proposed as a promising alternative to overcome the issues regarding traditional single gene signature generation. Interpretation of key genes within the signatures provided biological insights into the associated functions that were well correlated to their cancer type.

A bespoke target selection tool to guide biomarker discovery in tubo-ovarian cancer

Introduction

Cancers presenting at advanced stages inherently have poor prognosis. High grade serous carcinoma (HGSC) is the most common and aggressive form of tubo-ovarian cancer. Clinical tests to accurately diagnose and monitor this condition are lacking. Hence, development of disease-specific tests are urgently required.

Methods

The molecular profile of HGSC during disease progression was investigated in a unique patient cohort. A bespoke data browser was developed to analyse gene expression and DNA methylation datasets for biomarker discovery. The Ovarian Cancer Data Browser (OCDB) is built in C# with a.NET framework using an integrated development environment of Microsoft Visual Studio and fast access files (.faf). The graphical user interface is easy to navigate between four analytical modes (gene expression; methylation; combined gene expression and methylation data; methylation clusters), with a rapid query response time. A user should first define a disease progression trend for prioritising results. Single or multiomics data are then mined to identify probes, genes and methylation clusters that exhibit the desired trend. A unique scoring system based on the percentage change in expression/methylation between disease stages is used. Results are filtered and ranked using weighting and penalties.

Results

The OCDB’s utility for biomarker discovery is demonstrated with the identified target OSR2. Trends in OSR2 repression and hypermethylation with HGSC disease progression were confirmed in the browser samples and an independent cohort using bioassays. The OSR2 methylation biomarker could discriminate HGSC with high specificity (95%) and sensitivity (93.18%).

Conclusions

The OCDB has been refined and validated to be an integral part of a unique biomarker discovery pipeline. It may also be used independently to aid identification of novel targets. It carries the potential to identify further biomarker assays that can reduce type I and II errors within clinical diagnostics.

Evolutionary genetic algorithm identifies IL2RB as a potential predictive biomarker for immune-checkpoint therapy in colorectal cancer

Identifying robust predictive biomarkers to stratify colorectal cancer (CRC) patients based on their response to immune-checkpoint therapy is an area of unmet clinical need. Our evolutionary algorithm Atlas Correlation Explorer (ACE) represents a novel approach for mining The Cancer Genome Atlas (TCGA) data for clinically relevant associations. We deployed ACE to identify candidate predictive biomarkers of response to immune-checkpoint therapy in CRC. We interrogated the colon adenocarcinoma (COAD) gene expression data across nine immune-checkpoints (PDL1, PDCD1, CTLA4, LAG3, TIM3, TIGIT, ICOS, IDO1 and BTLA). IL2RB was identified as the most common gene associated with immune-checkpoint genes in CRC. Using human/murine single-cell RNA-seq data, we demonstrated that IL2RB was expressed predominantly in a subset of T-cells associated with increased immune-checkpoint expression (P < 0.0001). Confirmatory IL2RB immunohistochemistry (IHC) analysis in a large MSI-H colon cancer tissue microarray (TMA; n = 115) revealed sensitive, specific staining of a subset of lymphocytes and a strong association with FOXP3+ lymphocytes (P < 0.0001). IL2RB mRNA positively correlated with three previously-published gene signatures of response to immune-checkpoint therapy (P < 0.0001). Our evolutionary algorithm has identified IL2RB to be extensively linked to immune-checkpoints in CRC; its expression should be investigated for clinical utility as a potential predictive biomarker for CRC patients receiving immune-checkpoint blockade.

Focused Acute Medicine Ultrasound (FAMUS): uptake, completion and barriers to accreditation after two years

The Society for Acute Medicine launched their ultrasound accreditation in September 2016, involving a practical course alongside completion of scanning competencies. Candidates require a registered supervisor to oversee their training. We present here the results of a survey of attendees of practical courses approximately 2 years after launch. The majority of respondents were Consultants or trainees within AIM. Fourteen of 76 (18.4%) respondents had completed the whole accreditation process, whilst 51 (67.1%) had not completed any of the three individual modules. The biggest barriers to accreditation were seen to be lack of supervisors, and lack of dedicated training time. There was good uptake of available online learning resources with good feedback. These results will be used to help develop the training pathway further and widen access to ultrasound training within the specialty and beyond.

Regional binding of tau and amyloid PET tracers in Down syndrome autopsy brain tissue

INTRODUCTION

Tau pathology is a major age-related event in Down syndrome with Alzheimer's disease (DS-AD). Although recently, several different Tau PET tracers have been developed as biomarkers for AD, these tracers showed different binding properties in Alzheimer disease and other non-AD tauopathies. They have not been yet investigated in tissue obtained postmortem for DS-AD cases. Here, we evaluated the binding characteristics of two Tau PET tracers (³H-MK6240 and ³H-THK5117) and one amyloid (³H-PIB) ligand in the medial frontal gyrus (MFG) and hippocampus (HIPP) in tissue from adults with DS-AD and DS cases with mild cognitive impairment (MCI) compared to sporadic AD.

METHODS

Tau and amyloid autoradiography were performed on paraffin-embedded sections. To confirm respective ligand targets, adjacent sections were immunoreacted for phospho-Tau (AT8) and stained for amyloid staining using Amylo-Glo.

RESULTS

The two Tau tracers showed a significant correlation with each other and with AT8, suggesting that both tracers were binding to Tau deposits. ³H-MK6240 Tau binding correlated with AT8 immunostaining but to a lesser degree than the ³H-THK5117 tracer, suggesting differences in binding sites between the two Tau tracers. ³H-THK5117, ³H-MK6240 and ³H-PIB displayed dense laminar binding in the HIPP and MFG in adult DS brains. A regional difference in Tau binding between adult DS and AD was observed suggesting differential regional Tau deposition in adult DS compared to AD, with higher THK binding density in the MFG in adult with DS compared to AD. No significant correlation was found between ³H-PIB and Amylo-Glo staining in adult DS brains suggesting that the amyloid PIB tracer binds to additional sites.

CONCLUSIONS

This study provides new insights into the regional binding distribution of a first-generation and a second-generation Tau tracer in limbic and neocortical regions in adults with DS, as well as regional differences in Tau binding in adult with DS vs. those with AD. These findings provide new information about the binding properties of two Tau radiotracers for the detection of Tau pathology in adults with DS in vivo and provide valuable data regarding Tau vs. amyloid binding in adult DS compared to AD.

Understanding corporate influence on science and the use of science - presentation of a new typology

Corporations responsible for so-called 'industrial epidemics' go to great lengths to stifle policymaking concerning their products and practices, including through interactions with science. Here we present a newly-created typology which illustrates the ways in which industries attempt to influence science and the use of science.

Our analysis of the literature identified sectors of industry involved, strategies used by industries, and key relationships between these strategies. Eight sectors of industry attempted to influence science and the use of science: tobacco, alcohol, processed food and drink, pharmaceuticals and medical technologies, gambling, chemicals and manufacturing, fossil fuels, and the extractive industry. We identified five macro strategies widely used by industries: influence on conduct and publication of science, influence on interpretation of science, influence on reach of science, influence on the use of science in policymaking, and over-arching supporting strategies.

Across eight sectors of industry, strategies used in order to influence science are strikingly similar. When taken together, these appear to represent attempts to permeate and mould systems through which science is created, interpreted and used. This typology provides an accessible way to understand the strategies used by industry to influence science and the use of science. It can be used to pre-empt and counter future industry activity within contexts including academia, healthcare, and regulatory decision-making

Changes in industry interference in policy in the United Kingdom 2017-2020

Background

The Tobacco Industry Interference (TII) Index evaluates the implementation of FCTC Article 5.3. The first edition of the Global TII Index was published in 2019, included 33 countries, and covered the years 2017-2018. A second edition, covering 2018-2019, is scheduled to be published in October 2020. This paper reports on findings of the Index for the UK, the changes observed between 2017 and 2020, and the resulting policy recommendations.

Methods

The UK Index was based on a questionnaire covering different forms of tobacco industry interference. Lower scores indicate better compliance with Article 5.3. In order to complete the questionnaire, an expert consultation was conducted with UK's leading tobacco control specialists. This was supplemented by a scoping review of academic literature, media websites, government websites, and the Tobacco Tactics resource.

Results

In the 2019 Index the UK has achieved the lowest score among 33 countries surveyed. Strengths of the UK system included the exclusion of TI from government bodies that set public health policy and from FCTC COP delegations; the obligation of the government to publish information on all meetings with TI; and guidelines stipulating that its diplomats must not engage on behalf of TI. Nevertheless, weaknesses were also identified; including only partial implementation of the above obligations, the absence of an effective lobbying register, and the ongoing involvement of parliamentary consultative bodies, individual politicians and political parties with TI and affiliated organisations.

Discussion

The change of government in the UK in 2019, the shifting policy framework resulting from Brexit, and the increasing use by the tobacco industry of third parties to access policymakers, bring new challenges to the maintenance of robust Article 5.3 compliance. The presentation will analyse how this has affected the change in the UK's performance between the 2019 and the 2020 Tobacco Industry Interference Index.

Key messages

The need to strengthen transparency regulations for policymakers. A need for continued monitoring against an agreed framework in the light of very fluid political developments.

Tobacco content in video on demand services in low- and middle-income countries

Background

There is clear evidence that exposure to tobacco is linked to smoking uptake. The economic and social burden of diseases associated with smoking is particularly high in low-and middle-income countries, where smoking uptake is high and exposure to tobacco use and branded content is widespread. Streamed content exhibits consistently higher levels of tobacco content than broadcast media and these levels have increased. The prevalence of smoking and tobacco content in video-on-demand (VOD) services is troubling given their popularity with youth audiences and the ease with which content can be accessed by children. This is because barriers to youth consumption that exist for film or broadcast media, including content gatekeepers, are absent.

Methods

The most popular VOD series from 10 low- and middle-income countries (Bangladesh, Brazil, China, India, Indonesia, Mexico, Pakistan, Philippines, Ukraine and Vietnam) were identified based on demand expressions and coded for individual depictions of tobacco. 18 series were analysed, representing a mix of international content in several languages. 111 episodes, totalling 81.4 hours of coded content, were analysed for tobacco depictions and characterisation of smoking characters.

Results

Tobacco content was prevalent and particularly prominent in non-English language series, where readily identifiable “stars” frequently partook in smoking. Cigarettes dominated tobacco imagery, with other forms (pipes and electronic nicotine delivery systems) rarely appearing. Notably, there were several incidents featuring well-known brands. Given that access to VOD services is difficult to moderate, youth audiences can easily access programming featuring high levels of tobacco use by identifiable characters, played by well-known actors. A lack of control regarding consumption of streamed content means that it is extremely important for content producers like Netflix and Amazon to ensure VOD content is suitable for youth audiences.

Key messages

Tobacco content in video-on demand services is increasing. Tobacco exposure is linked to smoking uptake.

The brand narratives of Philip Morris International: developing methods to identify corporate voices

Background

Existing research into marketing and advertising of tobacco companies shows the industry continues to spend huge sums of money promoting harmful products. In the face of increasing controls on the advertising of these products, and restrictions on their participation in policy development enshrined in a global treaty, tobacco companies must adapt to remain competitive in an unfavourable climate. Although there has been much engagement with the development of corporate messages by the 4 big tobacco brands, no systematic review of textual and visual corporate messaging used by these companies exists. This research presents the case of Philip Morris International (PMI), and maps out its key messages to investors and public audiences.

Methods

This research combines corpus linguistics with inductive coding to illustrate key topics, themes and the linguistic habits of PMI. A linguistic comparison with the messaging of 40 other transnational corporations provides a reference from which the unique characteristics of PMI's language can be identified.

Results

Thematic analysis of written and visual content highlights several dominant themes, namely Science, Transformation, Sustainability and Permissibility. Redemptive tropes were common in the sample, apparent in repeated reference to a desire to be and do better and to improve the lives of smokers around the world. Similarly, a strong emphasis on science was apparent in both the use of imagery and language, including scientific notation, laboratories and individual scientists.

The identification of linguistic and visual brand strategies will facilitate the education of advocates and consumers about the approach of the tobacco industry in their pursuit of continued business. Identifying the core values PMI is actively promoting could help to identify emerging corporate strategies in influencing public health policy, including the promotion of corporate goodwill in markets where product-specific advertising is banned.

Key messages

Big tobacco using new platforms to influence policy making. Corporate narratives impact perception of tobacco harm.

How upstream policy reforms enable the use of industry data and science

Corporations have worked to promote and embed policymaking reforms which increase reliance on and provide a conduit for industry-favourable science. Such systems have become increasingly mainstream in policy making across the world, yet most are unaware of the corporate influence behind them.

We will present evidence that diverse corporations worked collectively to promote and embed 'Better Regulation' (now known as 'Smart Regulation') in the European Union. The desired outcome was to reduce policymakers' ability to pass public health policies which could be detrimental to corporate interests and profits. We will illustrate how these regulatory frameworks have now been embedded. Delegates will hear examples of the ways in which corporations have gone on to use these systems to feed misleading science into the policymaking process, ultimately in attempts to dilute, delay or prevent public health policies.

NUQA: Estimating Cancer Spatial and Temporal Heterogeneity and Evolution through Alignment-Free Methods

Longitudinal next-generation sequencing of cancer patient samples has enhanced our understanding of the evolution and progression of various cancers. As a result, and due to our increasing knowledge of heterogeneity, such sampling is becoming increasingly common in research and clinical trial sample collections. Traditionally, the evolutionary analysis of these cohorts involves the use of an aligner followed by subsequent stringent downstream analyses. However, this can lead to large levels of information loss due to the vast mutational landscape that characterizes tumor samples. Here, we propose an alignment-free approach for sequence comparison-a well-established approach in a range of biological applications including typical phylogenetic classification. Such methods could be used to compare information collated in raw sequence files to allow an unsupervised assessment of the evolutionary trajectory of patient genomic profiles. In order to highlight this utility in cancer research we have applied our alignment-free approach using a previously established metric, Jensen-Shannon divergence, and a metric novel to this area, Hellinger distance, to two longitudinal cancer patient cohorts in glioma and clear cell renal cell carcinoma using our software, NUQA. We hypothesize that this approach has the potential to reveal novel information about the heterogeneity and evolutionary trajectory of spatiotemporal tumor samples, potentially revealing early events in tumorigenesis and the origins of metastases and recurrences. Key words: alignment-free, Hellinger distance, exome-seq, evolution, phylogenetics, longitudinal.

Defining the molecular evolution of extrauterine high grade serous carcinoma

OBJECTIVE

High grade serous carcinoma (HGSC) is the most common and most aggressive, subtype of epithelial ovarian cancer. It presents as advanced stage disease with poor prognosis. Recent pathological evidence strongly suggests HGSC arises from the fallopian tube via the precursor lesion; serous tubal intraepithelial carcinoma (STIC). However, further definition of the molecular evolution of HGSC has major implications for both clinical management and research. This study aims to more clearly define the molecular pathogenesis of HGSC.

METHODS

Six cases of HGSC were identified at the Northern Ireland Gynaecological Cancer Centre (NIGCC) that each contained ovarian HGSC (HGSC), omental HGSC (OMT), STIC, normal fallopian tube epithelium (FTE) and normal ovarian surface epithelium (OSE). The relevant formalin-fixed paraffin embedded (FFPE) tissue samples were retrieved from the pathology archive via the Northern Ireland Biobank following attaining ethical approval (NIB11:005). Full microarray-based gene expression profiling was performed on the cohort. The resulting data was analysed bioinformatically and the results were validated in a HGSC-specific in-vitro model.

RESULTS

The carcinogenesis of HGSC was investigated and showed the molecular profile of HGSC to be more closely related to normal FTE than OSE. STIC lesions also clustered closely with HGSC, indicating a common molecular origin.

CONCLUSION

This study provides strong evidence suggesting that extrauterine HGSC arises from the fimbria of the distal fallopian tube. Furthermore, several potential pathways were identified which could be targeted by novel therapies for HGSC. These findings have significant translational relevance for both primary prevention and clinical management of the disease.

Abstract 2787: Artificial intelligence approach identifies IL2RB as a common prognostic and potential predictive biomarker associated with immune checkpoints in colorectal cancer

Identifying robust predictive biomarkers to enable stratification of colorectal cancer (CRC) patients, based on their response to immune checkpoint therapy, is an area of unmet clinical need. Genetic algorithms represent an exciting branch of artificial intelligence which can be used to extract meaningful associations from ‘big data’ now emerging more frequently in oncological research. We have employed Atlas Correlation Explorer (ACE), a user-friendly workbench that utilises a genetic algorithm to mine data deposited in The Cancer Genome Atlas (TCGA). Our aim was to establish common intersections between gene expression analyses in ACE using nine well established immune checkpoint markers (CD274, PDCD1, CTLA4, LAG3, TIM3, TIGIT, ICOS, IDO1 and BTLA). We observed IL2RB to be the common gene associated with immune checkpoints in both microarray and RNA sequencing data from the TCGA (7/9 gene lists). Assessment of IL2RB indicates that it is highly expressed on CD56+ natural killer cells and is associated with an increased infiltration of cytotoxic lymphocytes and a decreased infiltration of fibroblasts. It is also significantly enriched in the immune consensus molecular subtype group CMS1. We next demonstrated that patients with high IL2RB gene expression have better relapse free survival in the TCGA CRC cohort (n = 322, log-rank p = 0.011) and an all stage CRC validation cohort GSE39582 (n = 519, log-rank p = 0.006). It is also an independent prognostic factor by multivariate analysis (p = 0.01). We next observed strong correlations between IL2RB gene expression in CRC and previously published predictive gene signatures for anti-PD1 therapies in other solid tumours (Pearson correlation, R = 0.88). Finally, we optimised assessment of IL2RB immunohistochemistry in a large CRC cohort (n=661) using a digital pathology approach with the open-source QuPath software. To conclude, we have validated IL2RB as prognostic biomarker and have provided evidence to demonstrate that IL2RB expression could be used for CRC patient stratification in future immunotherapy based clinical trials.

Citation Format: Matthew Alderdice, Stephanie Craig, Matt Humphries, Alan Gilmore, Victoria Bingham, Nicole Johnston, Stephen McQuaid, Manuel Salto-Tellez, Mark Lawler, Darragh G. McArt. Artificial intelligence approach identifies IL2RB as a common prognostic and potential predictive biomarker associated with immune checkpoints in colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2787.

Impact of Variable RNA-Sequencing Depth on Gene Expression Signatures and Target Compound Robustness: Case Study Examining Brain Tumor (Glioma) Disease Progression

Purpose

Gene expression profiling can uncover biologic mechanisms underlying disease and is important in drug development. RNA sequencing (RNA-seq) is routinely used to assess gene expression, but costs remain high. Sample multiplexing reduces RNA-seq costs; however, multiplexed samples have lower cDNA sequencing depth, which can hinder accurate differential gene expression detection. The impact of sequencing depth alteration on RNA-seq–based downstream analyses such as gene expression connectivity mapping is not known, where this method is used to identify potential therapeutic compounds for repurposing.

Methods

In this study, published RNA-seq profiles from patients with brain tumor (glioma) were assembled into two disease progression gene signature contrasts for astrocytoma. Available treatments for glioma have limited effectiveness, rendering this a disease of poor clinical outcome. Gene signatures were subsampled to simulate sequencing alterations and analyzed in connectivity mapping to investigate target compound robustness.

Results

Data loss to gene signatures led to the loss, gain, and consistent identification of significant connections. The most accurate gene signature contrast with consistent patient gene expression profiles was more resilient to data loss and identified robust target compounds. Target compounds lost included candidate compounds of potential clinical utility in glioma (eg, suramin, dasatinib). Lost connections may have been linked to low-abundance genes in the gene signature that closely characterized the disease phenotype. Consistently identified connections may have been related to highly expressed abundant genes that were ever-present in gene signatures, despite data reductions. Potential noise surrounding findings included false-positive connections that were gained as a result of gene signature modification with data loss.

Conclusion

Findings highlight the necessity for gene signature accuracy for connectivity mapping, which should improve the clinical utility of future target compound discoveries.

A quantitative method for the radiological assessment of skeletal maturity using the distal femur

Aims

Using 90% of final height as a benchmark, we sought to develop a quick, quantitative and reproducible method of estimating skeletal maturity based on topographical changes in the distal femoral physis.

Patients and Methods

Serial radiographs of the distal femoral physis three years prior to, during, and two years following the chronological age associated with 90% of final height were analyzed in 81 healthy children. The distance from the tip of the central peak of the distal femoral physis to a line drawn across the physis was normalized to the physeal width.

Results

A total of 389 radiographs of the distal femur with corresponding Greulich and Pyle bone ages and known chronological ages were measured. Children reached 90% of final height at a mean age of 11.3 years (sd 0.8) for girls and 13.2 years (sd 0.6) for boys. Linear regression analysis showed higher correlation coefficent in predicting the true age at 90% of final height using chronological age + gender + central peak value (R² = 0.900) than chronological age + gender (R² = 0.879) and Greulich and Pyle bone age + gender (R² = 0.878).

Conclusion

Chronological age + gender + central peak value provides more accurate prediction of 90% of final height compared with chronological age + gender and Greulich and Pyle bone age + gender. Cite this article: Bone Joint J 2018;100-B:1106-11.

Abstract 290: Integrative analytics: A framework for precision medicine

Technology advancements have enhanced our abilities to gain greater insight to the tumor environment. However, such emergent methods have brought new considerations in data storage, access and analysis. Modern large data projects and clinical trial materials could be explored to a greater degree if appropriate infrastructure could be built to support efforts. Such a scaffold would be an integrated and dynamic framework where novel hypotheses could be investigated in modern big data collections. Placing discovery back in the hands of the researcher through a reactive and supportive framework will enhance our understanding of cancer aetiology. The Cancer Integromics Research Application Framework (CIRAFm) was created to emulate current platforms that have a rigid analytical interface. We designed a robust architecture that supports a reactive user-friendly interface blended to several cross-platform coding technologies. It has been developed to accommodate an individualised framework where we can create an ‘app-store' of key software to fit research questions. In efforts to encapsulate and accelerate differing data types it sits astride of two NoSQL based database management systems, minimising data redundancy. Initial requirements have begun to create algorithms to investigate alignment-free applications on next generation sequencing (NGS) data enhancing analysis of spatial and temporal heterogeneity in cancer. Key drivers can be explored by assisting software to build correlative marker associations using Darwinian approaches such as genetic algorithms. Information requirements from external platforms are assisted through a novel domain specific language (DSL) to enable a singular interface. The modularised architecture of the platform is enabled through an Angular framework supported by interactive and dynamic data visualisation software, D3.js. Data analytics can be explored through the ‘apps' created, investigating new markers in large data and enhancing our understanding of tumor heterogeneity. Alignment-free phylogenetics of NGS data harnesses our capabilities to display fully sequence evolution in patient data. This highlights possible sub-types, markers of interest and maps to therapeutic compounds via the DSL to our externally developed drug discovery software, QUADrATiC. Future scientific endeavours further defining new tumor subtypes are paramount in efforts to help uncover treatment strategies. Unburdened by legacy pipelines and data, flexible and robust models of architecture provide an effective and efficient framework for research on our ever increasing search for precision medicine.

Citation Format: Darragh G. McArt, Seedevi Senevirathne, Aideen Roddy, Jessica Black, Alan Gilmore, Suneil Jain, Philip Dunne, David Waugh. Integrative analytics: A framework for precision medicine [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 290.

Bcl-xL as a poor prognostic biomarker and predictor of response to adjuvant chemotherapy specifically in BRAF-mutant stage II and III colon cancer

Purpose

BRAF mutation occurs in 8-15% of colon cancers (CC), and is associated with poor prognosis in metastatic disease. Compared to wild-type BRAF (BRAFWT) disease, stage II/III CC patients with BRAF mutant (BRAFMT) tumors have shorter overall survival after relapse; however, time-to-relapse is not significantly different. The aim of this investigation was to identify, and validate, novel predictors of relapse of stage II/III BRAFMT CC.

Experimental design

We used gene expression data from a cohort of 460 patients (GSE39582) to perform a supervised classification analysis based on risk-of-relapse within BRAFMT stage II/III CC, to identify transcriptomic biomarkers associated with prognosis within this genotype. These findings were validated using immunohistochemistry in an independent population-based cohort of Stage II/III CC (n = 691), applying Cox proportional hazards analysis to determine associations with survival.

Results

High gene expression levels of Bcl-xL, a key regulator of apoptosis, were associated with increased risk of relapse, specifically in BRAFMT tumors (HR = 8.3, 95% CI 1.7-41.7), but not KRASMT/BRAFWT or KRASWT/BRAFWT tumors. High Bcl-xL protein expression in BRAFMT, untreated, stage II/III CC was confirmed to be associated with an increased risk of death in an independent cohort (HR = 12.13, 95% CI 2.49-59.13). Additionally, BRAFMT tumors with high levels of Bcl-xL protein expression appeared to benefit from adjuvant chemotherapy (P for interaction = 0.006), indicating the potential predictive value of Bcl-xL expression in this setting.

Conclusions

These findings provide evidence that Bcl-xL gene and/or protein expression identifies a poor prognostic subgroup of BRAFMT stage II/III CC patients, who may benefit from adjuvant chemotherapy.

Focused Acute Medicine Ultrasound (FAMUS)

Point of care ultrasound (POCUS) has seen steady growth in its use and applications in aiding clinicians in the management of acutely unwell patients. Focused Acute Medicine Ultrasound (FAMUS) is the standard created specifically for Acute Medicine physicians and is endorsed by the Society for Acute Medicine and recognised by the Acute Internal Medicine (AIM) training committee as a specialist skill. In this document we present a curriculum mapping exercise which utilises a 'knowledge, skills and behaviours' framework and incorporates the GMC's 'Good Medical Practice' (GMP) domains. We believe this will provide a standard for consideration of integrating focused ultrasound in AIM training programmes, with the aim of ultimately incorporating FAMUS as a core skill for all AIM trainees.

Curriculum mapping for Focused Acute Medicine Ultrasound (FAMUS)

Point of care ultrasound (POCUS) in the hands of the non-radiologist has seen a steady growth in popularity amongst emergency, intensive care and acute medical physicians. Increased accessibility to portable, purpose-built ultrasound machines has meant that clinicians often have access to a safe and non-invasive tool to enhance their management of the unwell.

Patient (Pt)-reported symptoms of chemotherapy (chemo) and VEGFR/EGFR antibody therapies for the treatment of metastatic colorectal cancer (MCRC) in a U.S. community-based oncology practice network

575

Background: Targeted therapies for MCRC have increased treatment (Tx) options in multiple therapy lines. Symptoms associated with MCRC Tx have not been well studied from the Pt perspective. Objective: To characterize symptoms reported by MCRC Pts treated with chemotherapy and/or targeted drugs at a large US oncology network.

Methods: Pt reported symptom data were linked to electronic medical records and Pt charts from Georgia Cancer Specialists in Southeast US. MCRC Pts aged ≥18 years with ≥1 administration of chemo or targeted therapy between 1/2007-3/2009 were included. Pt reports captured 13 symptoms, onset, and severity. Due to small sample sizes, no statistical comparisons were conducted.

Results: 332 MCRC Pts were included (median age 62 years, 47% male, median weight 74 kg, 48% ECOG PS 0 or 1). Amongst Pts receiving 1L Tx (n=299), 78% received bevacizumab (BV) +/- chemo, 4% cetuximab (CX) +/- chemo, 15% chemo only, and 2% other. 162 Pts received 2L Tx: 49% BV +/- chemo, 17% chemo only, 28% CX +/- chemo, and 6% other. The 5 most common symptoms in 1L Tx for all severity ratings were 36% fatigue, 20% nausea, 17% weight (wt) loss, 15% diarrhea, and 9% constipation. The 5 most common symptoms in all 2L Tx groups were 44% fatigue, 27% nausea, 19% diarrhea, 16% wt loss, and 11% abdomen pain. 2L moderate, severe, or disabling symptoms reported in >10% Pts receiving BV +/- chemo, CX +/- chemo, and chemo only Tx are shown in the table.

Conclusions: The most commonly reported symptoms by 1L and 2L MCRC Pts were fatigue, nausea, diarrhea, and weight loss. Overall, a numerically higher % of 2L Pts treated with CX +/- chemo reported moderate, severe, and disabling symptoms than Pts receiving BV +/- chemo and chemo alone. Rash was not observed in the BV +/- chemo group. Further research of MCRC Pt reported symptoms in a larger sample size are warranted.

[Table: see text]

[Table: see text]

Evaluating social and behavioural impacts of English smoke-free legislation in different ethnic and age groups: implications for reducing smoking-related health inequalities

OBJECTIVE

To explore social and behavioural impacts of English smoke-free legislation (SFL) in different ethnic groups.

DESIGN

A longitudinal, qualitative panel study of smokers using in-depth interviews conducted before and after introduction of SFL.

PARTICIPANTS

A purposive sample of 32 smokers selected from three ethnic groups in deprived London neighbourhoods with approximately equal numbers of younger and older, male and female respondents.

RESULTS

SFL has had positive impacts with half smoking less and three quitting. Although there were no apparent differences in smoking and quitting behaviours between groups, there were notable differences in the social impacts of SFL. The greatest negative impacts were in smokers over 60 years, potentially increasing their social isolation, and on young Somali women whose smoking was driven more underground. In contrast, most other young adult smokers felt relatively unaffected by SFL, describing unexpected social benefits. Although there was high compliance, reports of illegal smoking were more frequent among young, ethnic minority smokers, with descriptions of venues involved suggesting they are ethnically distinct and well hidden. Half of respondents reported stopping smoking in their own homes after SFL, but almost all were Somali or Turkish. White respondents tended to report increases in home smoking.

DISCUSSION

Although our study suggests that SFL can lead to reductions in tobacco consumption, it also shows that impacts vary by ethnicity, age and sex. This study highlights the importance of understanding the meaning of smoking in different social contexts so future tobacco control interventions can be developed to reduce health and social inequalities.

Smoke-free homes in England: prevalence, trends and validation by cotinine in children

OBJECTIVE

To examine the prevalence of smoke-free homes in England between 1996 and 2007 and their impact on children's exposure to second-hand smoke via a series of annual cross-sectional surveys: the Health Survey for England. These comprised nationally representative samples of non-smoking children aged 4-15 (n = 13 365) and their parents interviewed in the home. Main outcome measures were cotinine measured in saliva, smoke-free homes defined by "no" response to "Does anyone smoke inside this house/flat on most days?", self-reported smoking status of parents and self-reported and cotinine validated smoking status in children.

RESULTS

The proportion of homes where one parent was a smoker that were smoke free increased from 21% in 1996 to 37% in 2007, and where both parents were smokers from 6% to 21%. The overwhelming majority of homes with non-smoking parents were smoke free (95% in 1996; 99% in 2007). For children with non-smoking parents and living in a smoke-free home the geometric mean cotinine across all years was 0.22 ng/ml. For children with one smoking parent geometric mean cotinine levels were 0.37 ng/ml when the home was smoke free and 1.67 ng/ml when there was smoking in the home; and for those with two smoking parents, 0.71 ng/ml and 2.46 ng/ml. There were strong trends across years for declines in cotinine concentrations in children in smoke-free homes for the children of smokers and non-smokers.

CONCLUSIONS

There has been a marked secular trend towards smoke-free homes, even when parents themselves are smokers. Living in a smoke-free home offers children a considerable, but not complete, degree of protection against exposure to parental smoking.

Smoking uptake and prevalence in Ghana

BACKGROUND

Developing countries are at high risk of epidemic increases in tobacco smoking, but the extent of this problem is not clearly defined because few collect detailed smoking data. We have surveyed tobacco smoking in the Ashanti region of Ghana, a rapidly developing African country with a long-established tobacco industry.

METHODS

We took a random sample of 30 regional census enumeration areas, each comprising about 100 households, and a systematic sample of 20 households from each. These were visited, a complete listing of residents obtained and questionnaire interviews on current and past smoking, age at smoking uptake, sources of cigarettes and other variables carried out in all consenting residents aged 14 or over.

RESULTS

Of 7096 eligible individuals resident in the sampled households, 6258 (88%; median age 31 (range 14-105) years; 64% female) participated. The prevalence of self-reported current smoking (weighted for gender differences in response) was 3.8% (males 8.9%, females 0.3%) and of ever smoking 9.7% (males 22.0%, females 1.2%). Smoking was more common in older people, those of Traditionalist belief, those of low educational level, the unemployed and the less affluent. Smokers were more likely to drink alcohol and to have friends who smoke. About 10% of cigarettes were smuggled brands. About a third of smokers were highly or very highly dependent.

CONCLUSIONS

Despite rapid economic growth and a sustained tobacco industry presence, smoking prevalence in Ghana is low, particularly among younger people. This suggests that progression of an epidemic increase in smoking has to date been avoided.

Smoking in Ghana: a review of tobacco industry activity

Background:

African countries are a major potential market for the tobacco industry, and the smoking epidemic is at various stages of evolution across the continent. Ghana is an African country with a low prevalence of smoking despite an active tobacco industry presence for over 50 years. This study explores potential reasons for this apparent lack of industry success.

Objective:

To explore the history of tobacco industry activity in Ghana and to identify potential reasons for the current low prevalence of smoking.

Methods:

A search was made of tobacco industry archives and other local sources to obtain data relevant to marketing and consumption of tobacco in Ghana.

Findings:

British American Tobacco, and latterly the International Tobacco Company and its successor the Meridian Tobacco Company, have been manufacturing cigarettes in Ghana since 1954. After an initial sales boom in the two decades after independence in 1957, the sustained further increases in consumption typical of the tobacco epidemic in most countries did not occur. Possible key reasons include the taking of tobacco companies into state ownership and a lack of foreign exchange to fund tobacco leaf importation in the 1970s, both of which may have inhibited growth at a key stage of development, and the introduction of an advertising ban in 1982. BAT ceased manufacturing cigarettes in Ghana in 2006.

Conclusion:

The tobacco industry has been active in Ghana for over 50 years but with variable success. The combination of an early advertising ban and periods of unfavourable economic conditions, which may have restricted industry growth, are likely to have contributed to the sustained low levels of tobacco consumption in Ghana to date.

Public attitudes towards smoking and tobacco control policy in Russia

BACKGROUND

Since the political transition in 1991, Russia has been targeted intensively by the transnational tobacco industry. Already high smoking rates among men have increased further; traditionally low rates among women have more than doubled. The tobacco companies have so far faced little opposition as they shape the discourse on smoking in Russia. This paper asks what ordinary Russians really think about possible actions to reduce smoking.

METHODS

A representative sample of the Russian population (1600 respondents) was interviewed face to face in November 2007.

RESULTS

Only 14% of respondents considered tobacco control in Russia adequate, while 37% thought that nothing was being done at all. There was support for prices keeping pace with or even exceeding inflation. Over 70% of all respondents favoured a ban on sales from street kiosks, while 56% believed that existing health warnings (currently 4% of front and back of packs) were inadequate. The current policy of designating a few tables in bars and restaurants as non-smoking was supported by less than 10% of respondents, while almost a third supported a total ban, with 44% supporting provision of equal space for smokers and non-smokers. Older age, non-smoking status and living in a smaller town all emerged as significantly associated with the propensity to support antismoking measures. The tobacco companies were generally viewed as behaving like most other companies in Russia, with three-quarters of respondents believing that these companies definitely or maybe bribe politicians. Knowledge of impact of smoking on health was limited with significant underestimation of dangers and addictive qualities of tobacco. A third believed that light cigarettes are safer than normal cigarettes.

CONCLUSION

The majority of the Russian population would support considerable strengthening of tobacco control policies but there is also a need for effective public education campaigns.

Adherence to combined Lamivudine+Zidovudine versus individual components: A community-based retrospective medicaid claims analysis

Adherence to a fixed dose combination of dual nucleoside antiretroviral therapy was compared between human immunodeficiency virus (HIV)-infected patients newly started on a fixed dosed combination of lamivudine (3TC) 150 mg/zidovudine (ZDV) 300 mg versus its components taken as separate pills. Medicaid pharmacy claims data were used for analyses. To examine the association between treatment group and medication adherence, three types of multivariate regressions were employed. In addition, all regressions were conducted for the whole population using data from 1995 to 2001 as well as a subpopulation, which excluded data prior to September 1997. Model covariates included patient characteristics, healthcare utilization, and non-study antiretroviral therapy use. The likelihood of > or =95% adherence among patients on combination therapy was three times greater than patients taking 3TC and ZDV in separate pills. Also, combination therapy patients had on average 1.4 fewer adherence failures per year of follow-up and nearly double the time to adherence failure compared to the separate pills group. Consistency among study results suggests that fixed dose combination therapies such as lamivudine (3TC) 150 mg/ zidovudine (ZDV) 300 mg should be considered when prescribing HIV treatment that includes an appropriate dual nucleoside.

Oestrous cycle of captive southern hairy-nosed wombats (Lasiorhinus latifrons) in South Australia, Australia

There is limited information available on the oestrous cycle of female southern hairy-nosed wombats (Lasiorhinus latifrons). This is mainly due to an extremely poor breeding success in captivity and the difficulty in routine recapturing of these cryptic, semi-fossorial animals in the wild. The aim of this study was to characterise the oestrous cycle of this species by monitoring peripheral plasma concentrations of progesterone and oestradiol, assessing changes in vaginal cytology, pouch condition and the urogenital sinus. Eight adult female wombats were monitored during the breeding season (July-December) over 2 years (2002-2003). Samples were collected up to three times a week. Vaginal smears contained several cell types, categorised by morphology, as either superficial epithelial cells or parabasal-intermediate cells. Leucocytes were also counted. Plasma progesterone profiles showed a mean oestrous cycle length of 36.33+/-0.67 days with a peak progesterone concentration of 139.53+/-10.62nmol/L. Levels of oestradiol peaked at a mean level of 467.33+/-44.32pmol/L on average 5 days before a rise in plasma progesterone values. The proportion of epithelial cells in vaginal smears varied throughout the cycle, with a high percentage of superficial epithelial cells observed during the follicular phase. During periods when progesterone concentrations were high, a greater percentage of parabasal-intermediate cells was observed. In conclusion, this study has characterised the oestrous cycle of the southern hairy-nosed wombat and confirmed that changes in vaginal smears together with pouch and urogenital sinus details could be used to determine signs of oestrus in this species.

Changes in smoking prevalence in Russia, 1996-2004

OBJECTIVES

In Russia, smoking prevalence has historically been high in men and relatively low in women. Female smoking prevalence is predicted to rise but assessment of changes has been limited by the lack of comparable data. Changes in the prevalence of smoking in Russia between 1996 and 2004, and whether theses changes differed by sociodemographic groups, were investigated.

DESIGN

Repeated national interview surveys in 1996 (731 men and 868 women) and 2004 (727 men and 864 women) aged 18 years or more.

MAIN OUTCOME MEASURE

Prevalence of current smoking.

RESULTS

The age standardised prevalence of smoking in 1996 and 2004 was 61% and 63%, respectively in men and 15% and 16%, respectively in women (both p values > 0.4). In men, the prevalence of smoking seemed to decline in those with university education (from 51% to 40%, p = 0.085). Among women, smoking appeared to increase in those with university education (from 10% to 17%, p = 0.071) and low levels of self-reported material deprivation (from 11% to 18%, p = 0.053). There was a pronounced increase in prevalence among women living in villages (from 8% to 14%, p = 0.049); the strong urban/rural gradient seen in 1996 became considerably weaker by 2004.

CONCLUSIONS

Overall smoking prevalence in both men and women in Russia remained stable between 1996 and 2004 but, given the sample size, a moderate increase in female smoking cannot be ruled out. In men, smoking increased among the least educated and declined in the most educated. In women the opposite appeared to occur, in addition to an increase in smoking in rural areas. More long term monitoring of smoking patterns in Russia, especially among women, using sufficiently large surveys, is required.

Insights into training and examination performance from the first UK National Public Health Training Audit

OBJECTIVES

To investigate predictors of a supportive training relationship and examination success using data from the first UK Public Health Training Audit.

STUDY DESIGN

Secondary analysis of data from a national cross-sectional survey of UK public health trainees, conducted in April 2003.

METHODS

All UK public health trainees were sent a questionnaire including questions on training experience and examination performance. Possible predictive factors of a supportive trainer-trainee relationship and success at Part I and Part II of Membership of Faculty of Public Health examinations were first investigated in univariate analyses, and subsequently using logistic regression.

RESULTS

Two hundred and ninety responses were received (62% response). Supportive trainers gave feedback [odds ratio (OR) = 11.2, 95% confidence interval (CI) 3.7-34.0, P<0.001], spent at least 1 h/week with their trainee (OR = 5.2, 95% CI 1.7-15.4, P = 0.003), held 3-monthly progress meetings (OR = 2.9, 95% CI 1.4-6.1, P = 0.006), and encouraged wide training experience (OR = 2.5, 95% CI 1.2-5.4, P = 0.016). Predictors of success in the Part I examination by the end of the second year of training were medical background (OR = 4.4, 95% CI 1.6-12.2, P = 0.004) and perceived adequacy of examination support (OR = 4.2, 95% CI 1.7-10.0, P = 0.001). Predictors of success in the Part II examination by the end of the fourth year of training were access to examiners (OR = 4.6, 95% CI 1.3-16.2) and wide experience (OR = 4.1, 95% CI 1.1-14.5).

CONCLUSION

Trainees feel supported when provided with adequate trainer contact time, feedback and wide experience. Part I examination success appears to be more likely amongst trainees with a medical background and those given examination support. Part II success is related to the breadth of a trainee's experience and access to examiner support.

Quality of training in public health in the UK: results of the first national training audit

OBJECTIVES

Since 1997, UK public health training has undergone major changes, including the creation of specialist registrars (SpRs), introduction of a competency framework, admission of non-medical (specialist) trainees and National Health Service organizational change. It was therefore considered timely to audit the quality of this training.

STUDY DESIGN

Cross-sectional survey of all UK public health trainees, conducted in April 2003.

METHODS

The survey questions were based on 75 previously identified standards, with three sections: induction (30 standards), health protection (13 standards) and general training (32 standards). Results were calculated for the UK. Deaneries were compared on 10 key standards, as was the training of SpRs and specialist trainees.

RESULTS

Two hundred and ninety responses were received (62% response rate). Only 16 (21%) of 75 standards were met by at least 80% of respondents, with problems in induction, health protection, secretarial facilities and examination support. Across 10 key standards (including initial welcome, trainer support, breadth/relevance of work and facilities), 59% indicated that their training had met at least eight standards. Results for individual deaneries were significantly different (P = 0.02), although 13 of 16 had median scores of eight out of 10, or over. Deaneries with specialists scored lower than those without (median scores eight vs nine, P = 0.003). Median specialist and SpR scores on the 10 key standards were seven and eight, respectively (P<0.001). In addition, SpRs were more likely to be 'on-call' [odds ratio (OR) = 66.8, 95% confidence interval (CI) 17.2-259.4, P<0.001] and to feel prepared for this role (OR = 10.7, 95% CI 1.4-79.8) than specialists.

CONCLUSION

This was the first UK National Audit of Public Health Training. Few standards were achieved amongst respondents, although the levels set may be considered to be high and the response rate (62%) was less than optimal, potentially biasing results. Despite these caveats, recent organizational change in England appears to have led to significant training disruption among respondents. Nevertheless, repeating such an audit annually within deaneries could help to improve public health training throughout the UK.

Anti-mullerian hormone as a marker of ovarian reserve*

OBJECTIVE

To analyse the usefulness of plasma anti-mullerian hormone (AMH) measurement as a tool for assessing ovarian reserve in a general infertility population.

MATERIALS AND METHODS

Plasma AMH levels were analysed in 238 women aged 18-46 years during day 3-5 of their menstrual cycle. All 238 patients had follicle stimulating hormone (FSH) levels less than 10 i.u./L, suggesting normal ovarian reserve on traditional FSH criteria. Eighty-seven patients gave their consent to correlate their AMH levels with IVF oocyte retrieval outcome. Patients producing > or = 8 oocytes were classified as having normal ovarian reserve, while those producing < or = 4 oocytes were classified as having poor ovarian reserve.

RESULTS

Plasma AMH levels remained relatively static (20-25 pmol/L) from 18 to 29 years of age. By 30 years of age, plasma AMH levels start to drop rapidly, reaching only 10 pmol/L by 37 years. Despite this 50% fall in AMH levels between 29 and 37 years of age, minimal changes in FSH levels were observed. Using a cut off value of 8.1 pmol/L, plasma AMH assessment could predict poor ovarian reserve on a subsequent IVF cycle with a sensitivity of 80% and a specificity of 85%.

CONCLUSIONS

Plasma AMH assessments are superior to FSH in identifying women with reduced ovarian reserve. Anti-mullerian hormone assessment should be considered as a useful adjunct to FSH/oestradiol levels and antral follicle count when estimating ovarian reserve.

A three-dimensional study of calcaneonavicular tarsal coalitions

The authors studied 37 presumed calcaneonavicular tarsal coalitions from the Hamann-Todd Osteological Collection at the Cleveland Museum of Natural History. The anatomy of the coalitions and the associated subtalar and transverse tarsal joints was quite variable. The coalitions in 8 specimens completely spared the anterior facet of the calcaneus and in 7 specimens it was partially replaced by the navicular portion of the coalition, whereas in 22 specimens the anterior calcaneal facet was completely replaced by the navicular portion of the coalition. The authors suggest that the pathoanatomy of calcaneonavicular coalitions is not uniform and may involve the subtalar and transverse tarsal joints. This may have clinical relevance and contribute to the unsatisfactory results in feet undergoing coalition resection and soft tissue interposition.