The precariousness of living with, and caring for people with, dementia: Insights from the IDEAL programme

This paper uses precarity as a framework to understand the vulnerabilities experienced by those living with or caring for someone living with dementia. Drawing on qualitative interview data from the Improving the Experience of Dementia and Enhancing Active Life (IDEAL) programme, we attend to our participants' reflections on how they manage the condition and the wider circumstances in which this occurs. To interrogate the utility of precarity, we focus on our participants' descriptions of needs and challenges and set these alongside both the wider contexts in which they seek or offer care (formal and informal) and the sets of values attributed to different ways of living with dementia. Building on the work of Portacolone, our analysis identified four interconnected themes: uncertainty; experiences of support and services; independence and personhood; and cumulative pressures and concerns. We develop this analysis by reviewing how our themes reflect, extend, or depart from previously identified markers of precarity and consider the specific ways in which these markers shape the lives of those living with dementia.

331 THE USE OF BODY MASS INDEX IN PREDICTING ORTHOSTATIC HYPOTENSION IN OLDER ADULTS

Background

The presence of Orthostatic Hypotension (OH) is known to be associated with an increased mortality risk. Previous Irish research has shown that elevated Body Mass Index (BMI) may be protective against OH, with overweight and obese patients having significantly smaller Systolic Blood Pressure (SBP) drops during Head-Up-Tilt (HUT) Testing.

Methods

Demographics, including age, height and weight, were obtained retrospectively from all head up tilt testing performed in a tertiary Irish hospital between 2000 and 2021. All incomplete records were excluded. A total of 4,717 patients were analysed. Linear regression models were used to examine the relationship between BMI and change in tilt SBP.

Results

2,089 males and 2,628 females over the age of 60 years old were examined. The mean age is 77 years ± 7.8 (S.D.), with majority (51.5%) of the cohort overweight or obese. 69.7% of individuals demonstrated OH. The mean change in tilt SBP was –7mmHg in the underweight and healthy weight group, and –10mmHg in the overweight or obese group. The linear regression model established that BMI significantly predicted a change in tilt SBP (beta=0.394, 95% CI: 0.235 to 0.554, p<0.001), but remains a poor predictive variable (R2=0.004) for this cohort. This correlation was similar for both genders (male: r=0.08, female: r=0.07).

Conclusion

Our findings confirmed a correlation between BMI and its predictive impact on OH in older adults. Future studies should explore targeted populations with multivariate analysis, taking into consideration age and gender, to reduce the heterogeneity of data.

220 RELATIONSHIP BETWEEN HEIGHT AND SYSTOLIC BLOOD PRESSURE IN OLDER ADULTS

Background

Hypertension is common amongst older adults in Ireland and is a major risk factor for both ischaemic and haemorrhagic stroke. Several studies have investigated the relationship between height and hypertension, however results have been inconsistent. In our Irish tertiary hospital patients undergoing tilt table testing have resting blood pressure measured prior to the test, and height recorded. Our aim was to assess whether there is a relationship between height and resting Systolic Blood Pressure (SBP) in patients aged over 60 years.

Methods

All tilt table test results between 2000 and 2021 in a single centre were reviewed retrospectively, collecting data on age, height and resting SBP. Any incomplete records were excluded, as were those from patients under 60 years old. Linear regression modelling was used to assess relationship between height and resting SBP.

Results

A total of 4,729 complete records were included for patients over 60 years old. 2630 (61.5%) of the patients were female. Mean age was 77 ± 7.8 years. 57.7% patients had either an elevated resting systolic and/or diastolic BP ≥130/80 and 28.4% ≥140/90. The linear regression model established that while height could be used to predict resting systolic blood pressure (beta=-0.166, 95% CI: –0.219 to –0.113, p<0.001), height only accounted for 0.8% of variability in resting SBP (R2 = 0.008).

Conclusion

Our large dataset establishes an association but no meaningful causation between height and resting systolic blood pressure. Current antihypertensive treatment was not recorded, which may have affected the results. Future studies will include further multivariate analysis accounting for antihypertensive use and other factors that may impact hypertension such as age, weight and gender.

941 EFFECTIVENESS OF ACUTE GERIATRIC UNIT CARE AMONG HOSPITALISED OLDER ADULTS WITH ACUTE MEDICAL COMPLAINTS: A META-ANALYSIS

Introduction

Older adults are clinically heterogeneous and are at increased risk of adverse outcomes during hospitalisation due to the presence of multiple comorbid and complex conditions. This systematic review and meta-analysis aims to update and synthesise the totality of research evidence on the effectiveness of acute geriatric unit (AGU) care for older adults admitted to hospital with acute medical complaints.

Method

MEDLINE, CINAHL, CENTRAL, and Embase databases were systematically searched from 2008 to February 2021. Screening, data extraction, and quality grading were undertaken by two reviewers. Only trials with a randomised design comparing AGU care and conventional care units were included. Meta-analyses were performed in Review Manager 5.4 and the Grading of Recommendations, Assessment, Development and Evaluations framework was used to assess the certainty of evidence for outcomes reported. The primary outcome measure was incidence of functional decline between baseline two-week prehospital admission status and discharge and at follow-up.

Results

11 trials recruiting 7,496 participants across three countries were included. AGU care was associated with a 23% reduction in functional decline at six-month follow-up (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.64–0.92; moderate certainty evidence), and significant cost savings (mean difference (MD) -538.01USD, 95% CI -571.05USD—-504.96USD; low certainty evidence). No differences were found in functional decline at hospital discharge or at three-month follow-up, length of hospital stay, the likelihood of living at home, mortality, hospital readmission, cognitive function, or patient satisfaction with the index admission.

Conclusion

AGU care improves clinical and process outcomes for older adults admitted to hospital with acute medical complaints. Future research should focus on greater inclusion of clinical and patient reported outcome measures including quality of life. Use of such measures may lead to a greater focus on patient-centered care and service provision priorities.

77 INCONTINENCE AND DECONDITIONING IN A NONFRAIL SAMPLE OF INPATIENTS AT A UNIVERSITY TEACHING HOSPITAL

Background

Incontinence occurs in 26% of hospitalised adults1. Deconditioning in hospitalised adults is common and contributes to increased hospital stay2. The #endpjparalysis movement motivates us to reduce harms of hospitalisation older adults.

Methods

We surveyed inpatients to capture the point prevalence of incontinence. We also collected information regarding functional status, continence status and use of continence wear. Local ethical review-board approval was obtained. All participants provided informed consent.

Results

There were 86 responses. Mean age of participants was 71.5 years. 45.4% were female, >95% were admitted from home and were functionally independent. Mean length of stay for respondents was 7.4 days ±12. The median Clinical Frailty Scale, for respondents aged >65 years, was 3, indicating this cohort is not frail.

17 respondents reported incontinence on the day of survey; 8 of these reported that incontinence was a new experience for them since their admission. 24 respondents wore incontinence wear at home, 31 were wearing incontinence wear on the day of survey.

Of 80 respondents who could toilet independently at home, 23 (26%) reported a new dependency to toilet. Of 83 respondents who mobilised independently at home (with or without an aid), 11 reported needing assistance of one-person to walk, 3 needed the assistance of two-people to walk or stand, five people required a hoist, while 3 were bedbound on the day of survey.

Conclusion

We describe increased dependency in mobility, toileting and increased use of continence wear in non-frail hospitalised older adults. Future work is needed to maintain function during admission to hospital.

References

1. Condon, M., et al. (2019). ‘Urinary and Faecal Incontinence: Point Prevalence and Predictors in a University Hospital.’ Int J Environ Res Public Health 16.

2. Guilcher, S., et al. (2021). ‘A qualitative study exploring the lived experiences of deconditioning in hospital in Ontario, Canada.’ BMC Geriatrics 21.

241 IMPLEMENTATION OF AN INTRACEREBRAL CEREBRAL HAEMORRHAGE CARE BUNDLE

Background

Mortality for Intracerebral haemorrhage (ICH) is 31% (Irish National Audit Stroke, 2019). An ICH care bundle focusing on acute anticoagulation reversal, blood pressure lowering, and a neurosurgical care pathway was associated with improved survival. Translating evidence-based medicine into clinical practice is challenging. The aim of this study was to determine feasibility and outcomes of implementation of a care bundle.

Methods

An ICH care bundle was developed using an iterative process involving expert stakeholder review of the evidence-based literature. A pre-and-post quasi-experimental research design was employed to evaluate this intervention. Baseline data were collected before implementation (January 2016-June 2018). Implementation took place in a staged manner in a single university teaching hospital with multiple ‘Plan Do Study Act cycles’ (June 2018 to January 2021). Data on compliance, process measures and outcomes were collected.

Results

Systolic blood pressure (first 24-hours) and anticoagulant reversal were significantly better controlled post-implementation (χ2 (1, N = 91) = 5.34, P = 0.02), (χ2 (1, N = 25) = 5.85, P = 0.016), respectively. DNAR orders were significantly lower in the post-implementation group (χ2 (1, N = 25) = 5.85, P = 0.029). However, ‘Do Not Actively Resuscitate’ status did not significantly differ when accounting for low GCS as a surrogate measure for poor prognosis (χ2 (1, N = 34) = 0.00, P = 0.966). Modified Rankin Scale on discharge did not differ significantly pre-and-post-implementation (z = −0.075, P = 0.94). A greater proportion of patients survived in the post-implementation group; however, this was not statistically significant (χ2 (1, N = 133) = 0.77, P = 0.38). Length of stay significantly increased post implementation.

Conclusion

An ICH care bundle was developed based on expert stakeholder feedback. The feasibility of implementing this bundle of care was demonstrated in a real-world clinical practice setting. A cluster-randomized trial or a large registry study is the next step to evaluate the overall impact of this care bundle on patient outcomes.

235 THROMBOLYSIS DOSING AND WEIGHT ESTIMATION IN ACUTE STROKE: A SINGLE CENTRE AUDIT

Background

Stroke is a leading cause of death and disability. Thrombolysis with intravenous (IV) alteplase is the mainstay management of ischaemic stroke. It has a narrow therapeutic window with a high potential for adverse outcomes such as intracranial haemorrhage. The efficacy of alteplase is time and dose dependent with weight-based dosing. National clinical guidelines recommend a dose of 0.9 mg/kg, up to a maximum of 90 mg. (Irish Heart Foundation Council for Stroke 2015). In most hospitals in Ireland however, patients are not weighed prior to thrombolysis. Time pressure and lack of available suitable equipment are factors.

Methods

This retrospective clinical audit evaluated the dosing of alteplase, estimated and actual weight for a convenience sample of stroke thrombolysis patients treated between 2016–2020 at an Irish University Teaching Hospital.

Results

107 patients were audited (62 males, 45 females). Actual and estimated weights were available in 92/107. Weight was not documented (n = 15) due to severe stroke/palliative management (n = 6) or omission (n = 9). 21% (19/92) received the correct dose of 0.9 mg/kg. A further 54% (50/92) received a dose within the range of 0.81–0.99 mg/kg (±10%). 25% received a dose outside this range (> ± 10%). 11% (10/92) were under-thrombolysed and 14% (13/92) over-thrombolysed. 17/92 patients had an intracranial haemorrhage. 35% (n = 6/17) of patients who had an intracranial haemorrhage received a higher dose of thrombolysis (>10%).

Conclusion

A quarter of patients received inappropriate dosing of alteplase that was outside the range of ±10% of 0.9 mg/kg. While stroke thrombolysis must be completed urgently, an accurate weight should be determined to avoid errors in dosing. A process evaluation of stroke thrombolysis would provide information on how best to incorporate an objective means of weight measurement without delaying treatment.

Ductal Carcinoma in Situ in Ireland, 2008-2020: Screening Data related to Low-Risk Management Trials

Background

Four clinical trials are on-going to determine if active surveillance is a feasible management option for patients with low-risk ductal carcinoma in situ (DCIS), in response to concerns that breast cancer screening programmes have increased the incidence of DCIS, some of which may never progress to invasive cancer. This study aimed to describe the epidemiology of screen-detected DCIS in Ireland through the BreastCheck, the national breast screening programme in Ireland (commenced 2000 but fully national since 2008).

Methods

This was a cross-sectional analysis of anonymised BreastCheck data provided by the National Screening Service, including all cases of screen-detected DCIS between 2008 and 2020. Statistical tests included Mann-Whitney U, Chi square, and multivariable logistic regression.

Results

2,240 women were diagnosed with DCIS through BreastCheck between 2008 and 2020 (1353 (60.4%) high-grade and 876 (39.1%) low/intermediate grade). The overall rate of screen-detected DCIS incidence has remained relatively stable during this time. Women with high- grade DCIS were older than women with low/intermediate DCIS (57 (IQR 53-61) years v 56 (IQR 56-61) years; p < 0.001). They were also more likely to have been diagnosed at a subsequent screening episode than at an initial episode (71.0% v 57.5%; p < 0.001). After adjustment (deprivation score, screening unit and year) the odds ratio for high-grade was 1.62 (95% CI 1.30-2.03; p < 0.001) for subsequent compared with initial screening episode.

Conclusions

When trial results are available, these data will assist with service planning should active surveillance be approved as a management option. Based on trial inclusion criteria, up to 40% of women diagnosed with DCIS through BreastCheck may be eligible for consideration for active surveillance. These women are younger and often diagnosed on initial screening episode, so may require longer active follow-up.

Key messages

Majority of DCIS in national screening programme is high grade. Randomised controlled trial evidence will provide guidance on management of low-risk DCIS.

The role of non-invasive devices for the telemonitoring of heart failure patients

Heart failure (HF) patients represent one of the most prevalent as well as one of the most fragile population encountered in the cardiology and internal medicine departments nowadays. Estimated to account for around 26 million people worldwide, diagnosed patients present a poor prognosis and quality of life with a clinical history accompanied by repeated hospital admissions caused by an exacerbation of their chronic condition. The frequent hospitalizations and the extended hospital stays mean an extremely high economic burden for healthcare institutions. Meanwhile, the number of chronically diseased and elderly patients is continuously rising, and a lack of specialized physicians is evident. To cope with this health emergency, more efficient strategies for patient management, more accurate diagnostic tools, and more efficient preventive plans are needed. In recent years, telemonitoring has been introduced as the potential answer to solve such needs. Different methodologies and devices have been progressively investigated for effective home monitoring of cardiologic patients. Invasive hemodynamic devices, such as CardioMEMS™, have been demonstrated to be reducing hospitalizations and mortality, but their use is however restricted to limited cases. The role of external non-invasive devices for remote patient monitoring, instead, is yet to be clarified. In this review, we summarized the most relevant studies and devices that, by utilizing non-invasive telemonitoring, demonstrated whether beneficial effects in the management of HF patients were effective.

The approach to an isolated close anterior margin in breast conserving surgery

INTRODUCTION

Although close radial margins after breast-conserving surgery routinely undergo re-excision, appropriate management of patients with close anterior margins remains a topic of controversy. An increasing body of literature suggests that re-excision of close anterior margins yields low rates of residual malignancy and may only be necessary in selected patients. The aim of this study was to examine the management of close anterior margins after breast conserving surgery in a single institution and to analyse the rate of residual disease in re-excised anterior margins.

METHODS

All patients having breast conserving surgery at St Vincent's University Hospital from January 2008 to December 2012 were reviewed retrospectively. Data collected included patient demographics, tumour characteristics, margin positivity, re-excision rates and definitive histology of the re-excision specimens. A close margin was defined as les than 2 mm.

RESULTS

A total of 930 patients were included with an average age of 65 years (range 29-94 years). Of these, 121 (13%) had a close anterior margin. Further re-excison of the anterior margin was carried out in 37 patients (30.6%) and a further 16 (13.2%) proceeded to mastectomy. Residual disease was found in 18.5% (7/36) of those who underwent re-excision and 7/16 (43.75%) of those who underwent mastectomy. Overall, 11.57% (14/121) of patients with close anterior margins were subsequently found to have residual disease.

CONCLUSION

The low yield of residual disease in re-excised anterior margins specimens supports the concept that routine re-excision of close anterior margins is not necessary. Further research is required to definitively assess its influence on the risk of local recurrence.

Abstract P3-06-13: Whole exome sequencing of HER2+ metastatic breast cancer (MBC) patients (pts) with extraordinary durable complete responses (ExdCR) to trastuzumab (T)

Background: Trastuzumab (T) has shown clinical efficacy in early-stage and MBC. However, within 1-year 40-50% develop resistance to T. The exact mechanism of the development of T resistance is not completely understood. Anecdotal observations suggest that a small fraction of patients with HER2+ MBC may be "extraordinary durable complete responders (ExdCR)". Indeed, we previously reported that 9% of MBC achieve dCR following T and chemotherapy. Understanding the genomic mechanisms underlying exceptional dCR to T may improve patient selection and treatment rationale to identify HER2+ MBC pts who are more likely to achieve dCR following T treatment.

Methods: Genomic DNA was extracted from paraffin embedded formalin fixed (FFPE) tissue. Whole exome sequencing (WES) on primary tumours from 9 MBC ExdCR > 60 mo (5 matched T:N) and 6 non-responders (NR) or PR < 6 mo (3 matched T:N). Tumours were analysed for single nucleotide variants (SNVs) point mutations, insertions/deletions (indels), copy number alterations (CNA), and tumour mutational burden. Detailed clinicopathologic data was collected for each patient and linked to the genomic information.

Results: WES of matched tumour:normal samples revealed differences in SNVs and indels between the ExdCR pts compared to NR. Mutations in TP53 were found in 2/5 ExdCR pts and in 0/3 NR. Initial analysis of CNA revealed that HER2 is significantly more amplified in ExdCR pts compared to NR, and this was also shown by IHC and FISH.

Conclusions: We present a genomic landscape of extraordinary durable complete responders compared to non-responders using WES. High variability exists in mutation profile of ExdCR pts with few overlapping genes. Further analysis into clinically relevant genomic and molecular alterations will be performed to potential aid in patient selection and choice of therapy, and novel drug targets.

Citation Format: Walsh N, Gullo G, Quinn C, Furney SJ, Crown J. Whole exome sequencing of HER2+ metastatic breast cancer (MBC) patients (pts) with extraordinary durable complete responses (ExdCR) to trastuzumab (T) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-06-13.

Abstract P4-08-31: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Loughman T, Wang C-JA, Dynoodt P, Fender B, Lopez-Ruiz C, Barron S, Stapleton S, O'Leary D, Fabre A, Quinn C, Nodin B, Jirström K, Bracken A, Gallagher WM. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-08-31.

Alternative metrics for assessing clinical benefit with immunotherapy in oncology

Therapies for cancer have traditionally been assessed with metrics such as the response rate, hazard ratio, or median survival. Such metrics have value in measuring the outcomes of conventional therapies, but may not be the most appropriate for new therapies. Immuno-oncology therapies offer a new approach to treating cancer by stimulating patients' immune systems to fight cancer. The value of these novel therapies has so far been assessed with traditional metrics, but the different ways in which immuno-oncology therapies work can mean the full value is not captured. Immuno-oncology therapies can produce longer survival times but this effect can be delayed or even preceded by an apparent phase of progression, which median survival or response rates may not reflect. This paper discusses a range of traditional and alternative metrics and their benefits or disadvantages in measuring the effects of immuno-oncology therapies, using examples of several novel drugs as case studies.

Abstract P5-20-05: Impact of type of (neo)adjuvant systemic therapy (AdjTx) and total exposure to trastuzumab (TET) on long-term outcome of HER2-positive (HER2+) early stage breast cancer (ESBrCa)

Background

Trastuzumab (T) administered for 12 months (mos) as part of a taxane (Tax)– or Tax+anthracycline (Anthra)–based AdjTx is the standard of care as (neo)AdjTx of HER2+ ESBrCa. Several prospective randomized trials have investigated a shorter duration of Adj T (i.e. 9 weeks or 6 mos) compared to standard 12 mos of T. However, the results have not been conclusive so far. The impact of administering non-Tax/non-Anthra-based AdjTx and single-agent T on long-term outcome of HER2+ ESBrCa is not fully known.

Methods

We conducted a retrospective analysis on a prospectively maintained departmental database of all patients (pts) with Stage I-III HER2+ ESBrCa treated with at least one dose of (neo)Adj T. Pre-planned duration of T was 12 mos for all pts. TTE was defined as the interval in weeks between the first and the last dose of T. In order to ensure that most pts had a minimum FU of 3 yrs we included all pts who received 1st T before March 31st 2014. The database was locked for outcome analyses on March 31st 2017.

Results

506 pts treated between October 2001 and March 2014 were included in the study. Main pts characteristics: median age: 55 years (range: 26-85), oestrogen (ER) and/or progesterone (PR) receptors positive: 321 (63%), axillary lymph nodes positive: 266 (52%), Adj T: 386 (76%), neoAdj T: 120 (24%), Tax- and Tax/Anthra–based AdjTx: 457 (90%), non-Tax/non-Anthra AdjTx and single-agent T (without chemotherapy): 49 (10%). Median FU is 73.3 months (range: 1.4-176.3). In the overall population, DFS and OS rates are 83% and 91%, respectively. Pts treated with non-Tax/non-Anthra AdjTx had a significantly higher risk of BrCa relapse [DFS: HR 3.54 (95%CI:1.24 to 10.06, p=0.018)], and death [OS: HR 2.73 (95%CI:0.63 to 11.77 p=0.176)] compared to those treated with Tax–based AdjTx (e.g. TCH [docetaxel/carboplatin/T]). Pts who received single-agent T also had highly significantly worse DFS [HR 4.21 (95%CI:2.18 to 8.38, p<0.0001)] and OS [HR 6.75 (95%CI:3.13 to 14.6 p=<0.0001)] compared to those treated with Tax-based AdjTx. When adjusted for age (<55 vs >55 yrs), the detrimental impact of type of AdjTx remained highly statistically significant (p<0.0001). Patients with TTE<24 weeks had a highly significantly worse DFS [HR 4.7 (95%CI:2.34-9.47, p<0.0001)] and OS [HR 5.36 (95%CI:2.39-12.01, p<0.0001)] compared to pts with TTE>24weeks. In most cases, shorter duration of T was due to reduction in LVEF or patients refusal. In the multivariate model, positive lymph nodes, type of (neo)AdjTx and TET (<24 weeks vs >24 weeks) remained all significant and independent variables associated with worse DFS and OS.

Conclusions

Our mature results indicate that the administration of non-Tax/non-Anthra-based AdjTx and single-agent T is associated with a significant increase in the risk of disease relapse and death and should not be considered as therapeutic options for pts with HER2+ ESBrCa. The administration of T for <24weeks irrespective of the type of AdjTx is also associated with significantly worse outcome.

Citation Format: Gullo G, Walsh N, Fennelly D, Walshe J, O'Mahony K, Silva N, Ballot J, Calzaferri G, Quinn C, McDonnell D, Crown J. Impact of type of (neo)adjuvant systemic therapy (AdjTx) and total exposure to trastuzumab (TET) on long-term outcome of HER2-positive (HER2+) early stage breast cancer (ESBrCa) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-20-05.

Development and evaluation of an ultrasonic personal aerosol sampler

Assessing personal exposure to air pollution has long proven challenging due to technological limitations posed by the samplers themselves. Historically, wearable aerosol monitors have proven to be expensive, noisy, and burdensome. The objective of this work was to develop a new type of wearable monitor, an ultrasonic personal aerosol sampler (UPAS), to overcome many of the technological limitations in personal exposure assessment. The UPAS is a time-integrated monitor that features a novel micropump that is virtually silent during operation. A suite of onboard environmental sensors integrated with this pump measure and record mass airflow (0.5-3.0 L/min, accurate within 5%), temperature, pressure, relative humidity, light intensity, and acceleration. Rapid development of the UPAS was made possible through recent advances in low-cost electronics, open-source programming platforms, and additive manufacturing for rapid prototyping. Interchangeable cyclone inlets provided a close match to the EPA PM_2.5 mass criterion (within 5%) for device flows at either 1.0 or 2.0 L/min. Battery life varied from 23 to 45 hours depending on sample flow rate and selected filter media. Laboratory tests of the UPAS prototype demonstrate excellent agreement with equivalent federal reference method samplers for gravimetric analysis of PM_2.5 across a broad range of concentrations.

Abstract P1-05-18: Genomic copy number alterations (CNA) associated with pCR in HER2-positive (HER2+) early-stage breast cancer (BrCa) patients receiving neoadjuvant trastuzumab (T)

Introduction: Genetic alterations such as amplifications and deletions frequently contribute to tumorigenesis. These alterations can change gene expression which alters the normal cell growth and survival regulatory mechanisms. Characterisation of DNA copy number alterations (CNA) is important to understand cancer progression and response to therapy. The aim of this study is to determine patterns of CNAs in HER2+ early-stage BrCa patients achieving pathological complete response (pCR) to neoadjuvant T therapy.

Methods: Retrospective analysis of our database of 95 HER2+ BrCa (stages I-III) who received T neoadjuvantly revealed 46 % (44/95) achieved pCR compared with 53 % (51/95) who did not respond (NR). DNA from pre-treatment tumour biopsy specimens from neoadjuvant T therapy patients was extracted, and array-based comparative genomic hybridization (aCGH, n = 8; 6 pCR:2 NR) was used to identify CNAs, which correlated with pCR. Pathway analysis was then used to identify functionally relevant genes in aberrant regions.

Results: aCGH analysis of DNA from pCR and NR identified distinct patterns of CNAs. HER2 amplicon was confirmed by IHC and aCGH in all samples. Although there was no significant difference in the average CNAs between groups (20±17 vs 17±2), there was greater variation in the range of CNAs in pCR (8-56 CNA) compared to NR (15-19 CNA). More gains and amplifications were observed in pCR patients with more deletions in the NR group. The most common chromosomal amplification region included chr8q12.1-q24 with 87.5% of all cases displaying gains. Of the 6 patients who achieved pCR, 50% displayed a deletion in chr9 spanning p24.3-p21.3, consistent with a deletion of tumour suppressor CDKN2A. No aberrations in chr9 were observed in NR cohort. The deleted genomic region contained 65 common protein-coding genes, with the interferon biological pathway as the most significant (p=1.03E-36).

Conclusions: Distinct genomic CNAs were observed between patients achieving pCR compared to NR. However, of the 8 pts characterised here, none have relapsed. Follow-up data revealed a relapse rate of 6.8 % (3/44) vs 11.8 % (6/51) in the pCR and NR groups, respectively. To further elucidate the immunological response, we will present CNA data patterns on relapse and response and compare the impact of CNAs, immune-related proteins and pCR as surrogate predictors for outcome.

Citation Format: Walsh N, Gullo G, Maguire A, O'Donovan N, Quinn C, Crown J. Genomic copy number alterations (CNA) associated with pCR in HER2-positive (HER2+) early-stage breast cancer (BrCa) patients receiving neoadjuvant trastuzumab (T) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-05-18.

The reliability of the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) among dermatologists, rheumatologists and neurologists

BACKGROUND

Previous studies have shown that skin disease in dermatomyositis (DM) is best assessed using the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI). Although the CDASI has been validated for use by dermatologists, it has not been validated for use by other physicians such as rheumatologists and neurologists, who also manage patients with DM and assess skin activity in clinical trials.

OBJECTIVES

To assess the reliability of the CDASI among dermatologists, rheumatologists and neurologists.

METHODS

Fifteen patients with cutaneous DM were assessed using the CDASI and the Physician Global Assessment (PGA) by five dermatologists, five rheumatologists and five neurologists.

RESULTS

The mean CDASI activity scores for dermatologists, rheumatologists and neurologists were 21·0, 21·8 and 20·8, respectively. These mean scores were not different among the specialists. The CDASI damage score means for dermatologists, rheumatologists and neurologists were 5·3, 7·0 and 4·8, respectively. The mean scores between dermatologists and rheumatologists were significantly different, but the means between dermatologists and neurologists were not. The intraclass correlation coefficients (ICCs) for interrater reliability for CDASI activity and damage were good to excellent for dermatologists and rheumatologists, and moderate to excellent for neurologists. The ICCs for intrarater reliability for CDASI activity and damage were excellent for dermatologists and rheumatologists and moderate to excellent for neurologists. The PGA displayed lower interrater and intrarater reliability relative to the CDASI.

CONCLUSIONS

Our results confirm the reliability of the CDASI when used by dermatologists and rheumatologists. The data for its use by neurologists were not as robust.

Comparison of feeding behavior between black and red Angus feeder heifers

The objective of this study was to compare feeding behavior between red and black Angus heifers during a 161-d finishing period as a potential explanation for performance differences. Sixty-eight single-sourced purebred red (n = 35) and black (n = 33) Angus heifers, leptin genotype TT, and average starting weight 360 kg (±19 kg) were used. Heifers were randomly and equally allocated into one of two feedlot pens, equipped with five feed bunks that recorded feeding behavior. Individual time spent at the feed bunk, interval between feeding events, feed intake, and meal frequency were recorded daily, and eating rate was calculated. Heifers were fed a barley-based diet (>75% concentrate). After 161 d, at the end of the feeding period, feedlot performance was calculated as average daily gain (ADG) and gain to feed conversion rate. Additionally, carcass data were obtained from the abattoir. Overall, black Angus heifers ate more, spent more time at the feed bunk, and had more meals compared with red Angus (P < 0.001). Red Angus heifers had better gain to feed ratios (P < 0.02) and significantly more red heifers were assigned to Canadian yield category 1 (≥59% lean meat) compared with black heifers (P = 0.02), whereas black heifers had higher back fat thickness throughout the study (P ≤ 0.04). All other performance parameters (ADG and carcass weight) were not different.

Combined education and skin antisepsis intervention for persistently high blood-culture contamination rates in neonatal intensive care

Contaminated blood cultures represent challenges regarding diagnosis, duration of hospitalization, antimicrobial use, pharmacy and laboratory costs. Facing problematic neonatal blood culture contamination (3.8%), we instigated a successful intervention combining skin antisepsis using sterile applicators with 2% chlorhexidine gluconate in 70% isopropanol prior to phlebotomy (replacing 70% isopropanol) and staff education. In the six months prior to intervention, 364 neonatal peripheral blood samples were collected. Fourteen (3.8%) were contaminated. In the post-intervention six months, 314 samples were collected. Three (0.96%) were contaminated, representing significant improvement (Fisher's exact test: P = 0.0259). No dermatological sequelae were observed. The improvement has been sustained.

Abstract P4-14-15: Pre-treatment stromal tumour-infiltrating lymphocytes (S-TILs) are correlated with complete response (CR) to chemotherapy (Chemo) plus trastuzumab (T) in HER2-positive (H+) metastatic breast cancer (MBC)

Background. We have previously reported that ChemoT produces durable (&gt;5 years) CR in a minority of pts with H+MBC, prompting a search for predictive markers. Extensive lymphocytic infiltration of cancers is correlated with high levels of immune gene signatures. International consensus guidelines on TILs define "lymphocyte-predominant BC" at a threshold of S-TILs of 50-60% versus tumour cells. High levels of S-TILs has been correlated with improved outcome in HER2+ early stage BC pts treated with ChemoT. We investigated the degree of S-TIL infiltration in metastatic biopsies from pts with HER2+MBC prior to ChemoT, and attempted to determine whether S-TILs predicted CR in HER2+MBC.

Methods. We searched a database of all pts with HER2+ MBC treated at our institution with anti-HER2 therapy over 15yrs to identify pts who achieved CR according to RECIST 1.0 criteria, which lasted for at least 6 months. We matched them with an equal number of pts from the database who were treated during the same period, but who had progressive (POD) or stable disease (SD) as best response to T. Pts must have at least one pre-treatment tumour sample available for S-TILs assessment, and adequate clinical and follow-up information. S-TILs (mononuclear cells including lymphocytes and plasma cells) contained within the boundaries of invasive tumour were identified on a representative haematoxylin and eosin stained slide and scored as a percentage of the stromal area alone, according to the International TILs Working Group 2014 methodology [Salgado R, 2015]. S-TILs were assessed specifically for this study by a senior pathologist who scored the samples and who was blinded to pts response and clinical details.

Results. Out of 246 MBC pts registered in the HER2+ database we identified 31 CR pts with at least one available pre-treatment metastatic sample. A cohort of 31 matching POD-SD pts was randomly obtained from the same database. In 8 cases (7 CR / 1 POD-SD) S-TILs could not be assessed due to inadequate material, or for other technical reasons. The final study sample is 54 pts (24 CR / 30 POD-SD). Pts characteristics are as follows: median age (range): CR 55 (29-78) / POD-SD 56 (26-89), hormone receptor (HR) pos: CR 12 (50%) / POD-SD 18 (60%), De Novo MBC at diagnosis: CR 13 (54%) / POD-SD 8 (27%) [p&lt;0.05]. All pts received chemotherapy with T (+ lapatinib in 3 pts as part of a clinical trial), and continued on T until POD. Pre-treatment S-TILs &gt;50% were statistically significantly more frequent in CR (50% of pts) than POD/SD (20%) [chi-square p=0.02]. No statistically significant difference in the HR status was observed between the two groups (CR vs POD-SD) or between the high and low S-TILs pts.

Conclusions. S-TILs &gt;50% in the pre-treatment tumour biopsy of HER2+MBC were significantly correlated with subsequent CR to ChemoT, supporting the hypothesis that the immunological effects of T may play a role in determining response. Speculatively, S-TILs might identify pts with a higher likelihood of benefit from T. Further study of the potential role of S-TILs as predictors of T benefit are required.

Citation Format: Gullo G, Quinn C, Zacchia A, Fennelly D, Defrein A, Ballot J, Zanoni D, Walshe J, Maltese M, McDermott E, Crown J. Pre-treatment stromal tumour-infiltrating lymphocytes (S-TILs) are correlated with complete response (CR) to chemotherapy (Chemo) plus trastuzumab (T) in HER2-positive (H+) metastatic breast cancer (MBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-14-15.

Abstract P1-07-09: Retrospective cohort study of patients (pts) diagnosed with breast cancer (BC) &lt;40 yrs: 2000 to 2015⟨

Background

Young women (&lt;40 yrs) with breast cancer (YWBC) account for 7-12% of BC diagnoses. BC is the leading cause of cancer death in this group (G). Age-specific data on outcome and appropriate treatment (Rx) are lacking. YWBC appear to have more biologically aggressive subtypes and a higher risk of relapse and death. We studied the clinico-pathological (ClinPath) characteristics in YWBC, examining how outcomes/Rx have evolved.

Methods

YWBC were identified from pathology databases at 2 tertiary centers. Pts were divided into 2 cohorts: BC diagnoses from 2000-2007 (G1) and 2008-2015 (G2). ClinPath and Rx data were retrieved from clinical, radiology and histology databases. Statistical analysis was performed using SPSS.

Results

We identified 347 pts. Tumor features are shown in Table I. Median age is 36 (23-39). By histology, 90.8% (n=315) had invasive ductal carcinoma, 53.1% (n=181) had Grade III BC and 56.3% (n=171) had lymphovascular invasion. Pregnancy-associated BC occurred in 10.7% (n=34). Mastectomy (MX) was performed in 53% (n=176) and axillary lymph node clearance (ALNC) in 63.8% (n=192 [G1: 84.3% vs. G2: 48.6%, p&lt;0.001]).

Table 1Tumor features Group 1 (n=149)Group 2 (n=198)Total (n=347)p-valueMedian tumor size (mm) 252222.5p=0.115Node positivity 88 (60.3%)100(51.5%)188 (55.3%)p=0.109Median node count 4 (1-44)1 (1-30)2 (1-44)p&lt;0.001StageI  99(29%)  II  148 (43.3%)  III  70 (20.5%)  IV  23(7.3%) Biomarker status*ER+/HER2-76 (53.1%)120 (60.6%)196 (56%)p=0.086 HER2+41 (28.7%)45 (22.8%)86 (27%)p=0.031 Triple negative (TN)26 (18.2%)33 (16.8%)59 (17%)p=0.291* Missing data n=6

Rx characteristics are shown in Table 2. 85 pts received neo-adjuvant therapy (NAT); 48.3% (n=41) ER+/HER2-, 27% (n=23) HER2+ and 24.7% (n=21) TNBC. Pts receiving NAT in G2 trended towards improved pCR rate (G2: 24.6% vs G1: 8.3%, p=0.057). Endocrine Rx alone was received by 9.8% (n=22); 13.6% (n=18) in G2 vs 4.3% (n=4) in G1. OncotypeDx(ODx) was used in 23 pts (14.9%) (median score 17), 1 had a DR (ODx Score = 18).

Table 2Tx characteristics n=347 Chemotherapy Total300(86.4%)  NAT85 (28.3%)Pathological Complete Response (pCR)* pCR (n=16, 19.8%)No pCR (n=65, 80.2%) ER+/HER2-18.8%(n=3)53.9% (n=35) HER2+/ER+18.8%(n=3)13.8% (n=9) HER2+/ER-31.2% (n=5)9.2% (n=6) TNBC31.2%(n=5)23.1%(n=15)Local relapse 1 (6.2%)1(1.5%)Distant relapse (DR) 022(33.8%)*Data incomplete n=4

DR occurred in 50 pts (16%), including 13 (20.3%) HER2+ pts. Of note, 92.3% (n=12) of these were in G1. Relapse rates (RR) in TN and ER+/HER- pts were 19.6% (n=11) and 13.7% (n=26) respectively. There was a higher RR in G1 (34.8% vs 11.4%, p&lt;0.001). Overall survival in pts with stage IV dx was 32 mos in G1 and 48 mos in G2.

Conclusion

In line with existing data, locally advanced dx is more prevalent in YWBC. MX and ALNC rates were high and most received multimodal Rx. The extent of axillary surgery declined. Pts in G2 had lower volume BC at diagnosis suggesting increasing awareness. TN and HER2+ subtypes accounted for a slightly higher proportion of BC cases. Pts with PCR had better outcomes. Only 16% relapsed with metastatic dx. The impact of HER2 Rx is highlighted by reduced RR in HER2+ G2 pts. Outcomes were unchanged in pts with ER+/HER2- and TNBC. These remain a priority for future research.

Citation Format: Greally M, Kielty J, Das G, Malouf C, O'Riordan L, Coleman N, Quinn C, McDermott E, Gullo G, Kelly C, Crown J, Prichard R, Walshe J. Retrospective cohort study of patients (pts) diagnosed with breast cancer (BC) &lt;40 yrs: 2000 to 2015⟨. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-07-09.

Using realist review to inform intervention development: methodological illustration and conceptual platform for collaborative care in offender mental health

BACKGROUND

This paper reports how we used a realist review, as part of a wider project to improve collaborative mental health care for prisoners with common mental health problems, to develop a conceptual platform. The importance of offenders gaining support for their mental health, and the need for practitioners across the health service, the criminal justice system, and the third sector to work together to achieve this is recognised internationally. However, the literature does not provide coherent analyses of how these ambitions can be achieved. This paper demonstrates how a realist review can be applied to inform complex intervention development that spans different locations, organisations, professions, and care sectors.

METHODS

We applied and developed a realist review for the purposes of intervention development, using a three-stage process. (1) An iterative database search strategy (extending beyond criminal justice and offender health) and groups of academics, practitioners, and people with lived experience were used to identify explanatory accounts (n = 347). (2) From these accounts, we developed consolidated explanatory accounts (n = 75). (3) The identified interactions between practitioners and offenders (within their organisational, social, and cultural contexts) were specified in a conceptual platform. We also specify, step by step, how these explanatory accounts were documented, consolidated, and built into a conceptual platform. This addresses an important methodological gap for social scientists and intervention developers about how to develop and articulate programme and implementation theory underpinning complex interventions.

RESULTS

An integrated person-centred system is proposed to improve collaborative mental health care for offenders with common mental health problems (near to and after release) by achieving consistency between the goals of different sectors and practitioners, enabling practitioners to apply scientific and experiential knowledge in working judiciously and reflectively, and building systems and aligning resources that are centred on offenders' health and social care needs.

CONCLUSIONS

As part of a broader programme of work, a realist review can make an important contribution to the specification of theoretically informed interventions that have the potential to improve health outcomes. Our conceptual platform has potential application in related systems of health and social care where integrated, and person-centred care is a goal.

A comparison of clinical-pathological characteristics between symptomatic and interval breast cancer

BACKGROUND

An association between interval breast cancers (cancer detected after a normal mammogram and before the next scheduled mammogram) and tumour aggressiveness has been postulated which may reflect their relatively poor overall prognosis. The aim of this study was to evaluate known prognostic features of screen detected breast cancers compared to interval breast cancers.

METHODS

Patients diagnosed with breast cancer between January 2010 and 2013 at a single unit of the National Breast Screening Program (NBSP) in Ireland and those between the ages of 50 and 65 diagnosed at a symptomatic breast clinic were included in the study. Patients who had not had a screening mammogram within the proceeding two years or had a previous history of breast cancer were excluded. Data were retrospectively collected on patient demographics, tumour type, grade, hormone receptor status and stage of disease at presentation.

RESULTS

There were 915 patients included in the study, with 92% (n = 844) diagnosed through the NBSP. Ductal carcinoma in-situ accounted for 19% (n = 160) of screen-detected breast cancers but only 2.8% of interval cancers (p < 0.05). The most common type of invasive cancer was invasive ductal carcinoma. Tumour grade was significantly higher in interval breast cancers (p < 0.05). Interval cancers were identified at a significantly higher stage (Stage 1 versus 2; p < 0.001) than screen-detected cancers. Interval breast cancers were less likely to be ER positive (76% versus 81%; p < 0.05) and significantly more likely to over-express HER2 (20% vs 10%, p < 0.05) than screen-detected cancers.

CONCLUSION

This study highlights the fact that interval cancers appear to have a number of adverse prognostic markers for overall breast cancer survival when compared to women with screen-detected breast cancers. Interval cancers were more likely to be invasive, of a higher grade and stage and with a greater predominance of HER2 and triple negative molecular subtypes. Therefore this heterogeneous group of tumours may be biologically more aggressive and account disproportionately to overall breast cancer mortality.