Traumatic pedestrian and bicyclist injuries associated with intoxication

BACKGROUND

Drug and alcohol use are risk factors for trauma among operators of motor vehicles and contribute to trauma in pedestrians and bicyclists. We describe the prevalence of drug and alcohol use and clinical consequences in a cohort of pedestrians and bicyclists with trauma.

METHODS

We analyzed a 25-month data set of 916 trauma team activations from January 2017-January 2019 at an urban, level I trauma center. Blood ethanol levels and urine toxicology screens were obtained in 94 pedestrian and bicyclist trauma activations. We compared pedestrians or bicyclists with a positive urine or blood screen (n = 69) to those with negative screens (n = 25). We conducted a retrospective chart review to determine mechanism of injury, injury pattern, and disposition from the emergency department (ED).

RESULTS

Overall, 38 (55%) of injured patients with positive screen were pedestrians and 31 (45%) were bicyclists. Fentanyl was the most commonly detected drug (n = 38; 40%), followed by opiates (n = 27; 29%), and tetrahydrocannabiol (THC) (n = 23; 25%). Twenty-one patients were positive for ethanol. Pedestrians and bicyclists with positive toxicology screens were significantly more likely to sustain fractures (p < .01), require an operative procedure (p < .05), or intensive care unit admission (p < .05).

CONCLUSION

Our study builds on previous literature which suggests that intoxicated bicyclists and pedestrians suffer frequent and more severe injury than their sober counterparts. Public health campaigns should educate bicyclists and pedestrians about the risks of cycling or walking in areas of road traffic while under the influence of alcohol or illicit drugs.

Abstract PD9-01: 5-year outcomes in the NBRST trial: Preoperative MammaPrint and BluePrint breast cancer subtype is associated with neoadjuvant treatment response and survival

Background: MammaPrint (MP) is used to identify breast cancer (BC) patients who can safely forego adjuvant chemotherapy. MP combined with the BluePrint (BP) molecular subtyping signature identifies BC subtypes with distinct therapeutic response rates and survival outcomes. In the Neoadjuvant Breast Symphony Trial (NBRST), MP and BP (MP/BP) predicted rates of pathologic complete response to neoadjuvant chemotherapy (NCT) and partial response to neoadjuvant endocrine therapy (NET). Here, we report 5-year overall survival (OS) and distant metastasis-free survival (DMFS) in patients from the NBRST registry according to MP/BP molecular classification. Methods: The NBRST trial (NCT01479101) prospectively enrolled 1072 patients from 2011 to 2014, who received MP and BP testing. Patients were assigned to receive NCT or NET according to NCCN guidelines and consented to 5 years post-surgery follow-up (FU). Clinical outcomes were available for 913 patients from 67 US institutions. Median FU for OS and DMFS was 5 and 4.6 years, respectively. Tumors classified by MP as High Risk (HR) or Low Risk (LR) were further stratified into four molecular subtypes by BP: Luminal A, Luminal B, HER2, and Basal. Differences in OS and DMFS at 3 and 5 years were assessed by Kaplan Meier analysis and log-rank test. Results: MP results from neoadjuvant patients (N=913) classified 16% of tumors as MP LR and 84% as MP HR. MP and BP classified 15.7% (143/913) of tumors as Luminal A, 32.5% (297/913) as Luminal B, 17.1% (156/913) as HER2, and 34.7% (317/913) as Basal. The 5-year OS and DMFS probabilities were significantly lower in HR compared to LR patients (p &lt; 0.001 for OS and DMFS), and lowest in Basal and Luminal B compared to Luminal A and HER2 subtypes (p &lt; 0.001 for OS and DMFS). Most DMFS events in BP Basal tumors occurred within the first 3 years. Of 841 patients that received NCT with or without HER2-targeted therapy, 12.2% (103/841) were LR and 87.8% (738/841) were HR. MP and BP classified 11.9% (100/841) of these patients as Luminal A, 32.6% (274/841) as Luminal B, 8.3% (154/841) as HER2 subtype, and 37.2% (313/841) as Basal. The 5-year OS and DMFS probabilities were lowest in HR, Basal or Luminal B patients (p &lt; 0.001). In 59 patients who received NET alone, 5-year OS and DMFS were significantly worse in HR patients that had Luminal B or HER2 tumors compared to LR Luminal A patients. In the 39 patients with Luminal A tumors, response to NET at the time of surgery was: 46.2% partial response, 41.0% stable disease, 5.1% progressive disease, 2.6% not reported. Five year DMFS in patients with Luminal A tumors treated with NCT or NET was not significantly different (p=0.67).Conclusions: MammaPrint remained prognostic in BC patients undergoing neoadjuvant therapy. Long -term prognosis was excellent in LR groups who received NCT or NET alone. MP and BP can accurately classify patients into specific subtypes with distinct OS and DMFS outcomes at five years, with BP Basals having the worst outcomes, followed by Luminal B, HER2, and Luminal A subtypes. BP Basal patients had the highest frequency of events within the first 3 years post-surgery, suggesting a genomic risk timeline distinct from other BP subtypes and a potential benefit from a secondary therapeutic immediately post-surgery. Additionally, Luminal A patients had a very low risk of progressive disease while on NET alone prior to surgery, with similar DMFS outcomes to Luminal A-types who received NCT.

Number of patientsObserved events% at 5 year (95% CI)p-valueAll patients - MammaPrint Risk GroupOS913134p&lt;0.001Low Risk146794.7 (88.4-97.6)High Risk76712781.1 (77.7-84.0)DMFS913182p&lt;0.001Low Risk1461191.2 (84.2-95.2)High Risk76717175.5 (71.9-78.7)All patients - MammaPrint + BluePrint SubtypeOS913134p&lt;0.001Luminal A143794.6 (88.3-97.6)Luminal B2974484.5 (80.0-88.7)Basal3177472.2 (66.2-77.3)HER2156993.4 (87.1-96.7)DMFS913182p&lt;0.001Luminal A1431191.1 (82.1-94.3)Luminal B2976975.2 (68.0-80.4)Basal3178570.4 (64.6-75.5)HER21561787.2 (79.7-92.0)NCT patients - MammaPrint Risk GroupOS841121p&lt;0.001Low Risk103397.4 (90.1-99.4)High Risk73811881.7 (78.3-84.7)DMFS841167p&lt;0.001Low Risk103792.6 (84.1-96.6)High Risk73816076.2 (72.5-79.4)NCT patients - MammaPrint + BluePrint SubtypeOS841121p&lt;0.001Luminal A100395.5 (86.2-98.6)Luminal B2743978.9 (71.7-84.5)Basal3137168.7 (57.9-77.2)HER2154892.8 (85.9-96.4)DMFS841167p&lt;0.001Luminal A100792.4 (83.8-96.5)Luminal B2746375.7 (65.6-76.5)Basal3138171.4 (65.6-76.5)HER21541687.7 (80.2-92.5)NET alone patients - MammaPrintOS597p=0.01Low Risk39293.0 (74.6-98.2)High Risk20580.0 (55.1-92.0)DMFS598p=0.003Low Risk39293.0 (74.6-98.2)High Risk20674.7 (49.4-88.6)NET alone patients - MammaPrint +BluePrint SubtypeOS597p=0.008Luminal A39293.0 (74.6-98.2)Luminal B18483.3 (56.8-94.3)Basal00N/AHER221N/ADMFS598p=0.005Luminal A39293.0 (74.6-98.2)Luminal B18577.4 (50.3-90.9)Basal00N/AHER221N/A

Citation Format: Pat Whitworth, James V Pellicane, Jr., Paul Baron, Peter Beitsch, Laura Lee, Michael Rotkis, Angela Mislowsky, Carrie Dul, Charles Nash, Bichlien Nguyen, Mary Murray, Paul Richards, Mark Gittleman, Stephanie Akbari, Shiyu Wang, Erin B Yoder, Andrea Menicucci, Lisa Blumencranz, William Audeh, NBRST Investigators Group. 5-year outcomes in the NBRST trial: Preoperative MammaPrint and BluePrint breast cancer subtype is associated with neoadjuvant treatment response and survival [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD9-01.

Abstract PS4-04: Molecular subtyping by BluePrint improves prediction of treatment responses and survival outcomes in patients with discordant clinical and genomic classification

Background: The risk of distant recurrence gene signature, MammaPrint (MP), together with the molecular subtyping gene signature, BluePrint (BP), stratifies breast tumors into Luminal A, Luminal B, HER2, and Basal subtypes, independent of immunohistochemistry (IHC) or fluorescent in situ hybridization (FISH) expression. In the Neoadjuvant Breast Registry Symphony Trial (NBRST), MP and BP identified patients likely to respond to neoadjuvant treatment with higher accuracy compared to conventional methods. Here, we report 5-year follow up (FU) data in breast cancer (BC) patients from the NBRST registry with discordant clinical and genomic subtyping.Methods: This prospective study enrolled 1072 early-stage BC patients from 2009-2014 who received MP and BP testing. Patients received neoadjuvant therapy following standard of care and consented to 5 years post-surgery FU. IHC determined hormone receptor (HR) status, including ER and PR, and IHC and/or FISH determined HER2 status. Median FU for distant metastasis free survival (DMFS) and overall survival (OS) was 4.6 and 5 years, respectively. Differences in DMFS and OS was assessed by Kaplan Meier analysis and log-rank test.Results: Overall, BP reclassified 22% of tumors into different molecular subtypes compared to IHC/FISH (Table). BP reclassified 17% of ER+HER2- tumors as BP Basal, with higher pathological complete response (pCR) rates compared to ER+/BP Luminal tumors (36% vs. 4%). ER+/BP Basal patients had similar pCR rates as triple negative BC (TNBC)/BP Basal patients (36% vs. 37%) following neoadjuvant treatment, and pCR correlated with improved survival outcomes. The 5-year DMFS and OS probabilities were lower in ER+/BP Basal patients compared to TNBC/BP Basal patients and were substantially lower compared to ER+/BP Luminal patients (P &lt; 0.001). There were 106 HR-HER2+ patients, of whom BP reclassified 23.6% to Basal and 2.8% as Luminal B; the remaining 73.6% were confirmed HER2 by BP. The 5-year DMFS and OS probabilities were worse in HER2+/BP Basal patients compared to HER2+/BP HER2 patients. Of 142 triple positive (TP, ER+PR+HER2+) patients, BP classified 55% as Luminal, 39% as HER2, and 6% as Basal, with higher pCR rates observed in BP Basal and BP HER2 tumors compared to BP Luminal. The 5-year DMFS and OS probabilities were substantially lower in TP/BP Basal patients compared to TP/BP HER2 and TP/BP Luminal patients (P &lt; 0.05 and P &lt; 0.04). Of clinical HER2+ patients (HR+ or HR-) that received pertuzumab, patients that reclassified as BP Basal had worse OS compared to BP HER2 patients (P &lt; 0.04).Conclusion: ER+HER2- and HER2+ patients that reclassified as BP Basal are more likely to achieve pCR and have improved survival, demonstrating the clinical utility of BP in the neoadjuvant setting. These patients may benefit from optimized chemotherapy used for TNBC, including novel emerging treatments such as PD-1 and PARP1 inhibitors, in addition to HER2-targeted therapy. Furthermore, HER2+ tumors that were confirmed HER2 by BP may have high response rates to regimens containing TDM-1. Lastly, BP identified a subgroup of triple positive BC patients, who reclassified as BP Luminal, that may avoid overtreatment. Overall, molecular subtyping using MP and BP is more accurate in stratifying patients and predicting treatment responses and 5-year disease outcomes than conventional methods and thus, facilitates successful treatment decisions.

Clinical subtypeFrequency of BP classificationBluePrint subtypepCR%5-yr DMFS (95% CI)5-yr OS (95% CI)TNBC (n=236)0.42% (1/236)Luminal A100% (1/1)N/AN/A2.54% (6/236)Luminal B16.67% (1/6)N/AN/A1.27% (3/236)HER233.33% (1/3)N/AN/A95.76% (226/236)Basal36.73% (83/226)100% (pCR)100% (pCR)60.5% (50.5-69.1)(non-PCR)64.3%(52.1-71.2) (non-PCR)ER+HER2- (n=520)28.84% (152/520)Luminal A1.97% (3/152)91.1% (84.0-95.2)94.6% (88.3-97.6)52.37% (276/520)Luminal B5.43% (15/276)75.2% (69.0-80.4)84.5% (79.0-88.7)1.33% (7/520)HER214.29% (1/7)N/AN/A17.46% (92/520)Basal35.9%(33/92)84.1% (67.8-92.5) (pCR)86.3% (70.1-94.1) (pCR)54.6% (42.0-65.5) (non-pCR)57% (43.7-68.2) (non-pCR)HR-HER2+ (n=106)2.83% (3/106)Luminal B66.67% (2/3)100%100%73.59% (78/106)HER269% (54/78)82.8% (69.9-90.5)88.6% (76.0-94.8)23.58% (25/106)Basal40% (10/25)79.0% (52.5-91.7)79.0% (52.5-91.7)Triple Positive (n=142)12.68% (18/142)Luminal A22.22% (4/18)88.8% (76.5-94.8)94.5% (83.8-98.2)42.25% (60/142)Luminal B11.67%(7/60)38.73% (55/142)HER244.44% (24/55)87.5% (72.0-94.7)97.9% (83.8-98.2)6.34% (9/142)Basal55.56%(5/9)62.5% (22.9-86.1)70.0% (22.5-91.8)HER2+ (HR+ or HR-)treated with pertuzumab (n=105)28.6%(30/105)Luminal37% (11/30)84.7% (63.8-94.1)92.2%(71.8-98.0)57%(60/105)HER282% (49/60)91.4% (78.3-96.8)92.9%(79.2-97.7)14%(15/105)Basal40% (6/15)66.0%(31.1-86.3)64.0% (29.1-85.1)

Citation Format: Pat Whitworth, James Pellicane, Jr, Paul Baron, Peter Beitsch, Laura Lee, Michael Rotkis, Angela Mislowsky, Carrie Dul, Charles Nash, Bichlien Nguyen, Mary Murray, Paul Richards, Mark Gittleman, Stephanie Akbari, Shiyu Wang, Andrea Menicucci, Erin B Yoder, Lisa Blumencranz, William Audeh. Molecular subtyping by BluePrint improves prediction of treatment responses and survival outcomes in patients with discordant clinical and genomic classification [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS4-04.

A137 COLONOSCOPY RELATED ADVERSE EVENTS IN A POPULATION-BASED COLON SCREENING PROGRAM

Background

The British Columbia Colon Screening Program (BCCSP) is a population-based program enrolling 50–74 year old individuals for biennial FIT (OC-Sensor, cut-off 10 mcg/g) with follow-up colonoscopy for positive FIT. The neoplasia detection rate is 50–55% and over 75% of colonoscopies have a specimen taken. Previously reported colonoscopy adverse event rates for FIT based screening programs vary widely: 0.03–6.2% and 0–2.7% for bleeding and perforation, respectively. Mortality as a result of colonoscopy is rare but has been reported in 0.0004%-0.0074% of colonoscopies. The rate of colonoscopy related adverse events in BCCSP participants is unknown.

Aims

To determine the rate of colonoscopy related serious adverse events within the BCCSP.

Methods

This is a retrospective cohort study of all participants undergoing colonoscopy in BCCSP from November 15, 2013 to December 31, 2017. BCCSP contacts screening participants by phone 14 days post colonoscopy to determine unplanned medical visits the day prior (during bowel preparation) or following the colonoscopy. Unplanned events underwent chart review if the event was a perforation, cardiovascular or respiratory event, or resulted in death, hospitalization, or significant intervention including repeat colonoscopy, interventional radiology, surgery, blood transfusion, cardioversion, casting of a fracture or suturing of a laceration. Chart review was conducted by a Colonoscopy Lead and reviewed by BCCSP Quality Committee. Unplanned events were defined as serious adverse events (SAE) if they resulted in death, hospitalization or significant intervention and further classified as probably, possibly, or unlikely related to the colonoscopy.

Results

A total of 108,004 colonoscopies were performed. Unplanned events were reported in 1753 participants, of which 586 met criteria for review. Of these, 578 were confirmed unplanned events and 409 were SAEs of which 367 (89.7%) were probably, 22 (5.4%) possibly and 20 (4.9%) unlikely associated with colonoscopy. 36/10,000 colonoscopies were associated with a SAE that was probably or possibly related: perforation in 5/10,000, bleeding 22/10,000. Three deaths occurred in the 14 days following colonoscopy that were probably (2 perforations) or possibly related to the colonoscopy (0.3/10,000).

Conclusions

The BCCSP has a colonoscopy SAE rate in keeping with previous publications, particularly in the context of a very high proportion of procedures associated with polypectomy, a known risk factor for perforation and bleeding. This study will help inform screening participants about the risks of colonoscopy in the BC program. Future studies are required to confirm these rates using hospital admission data.

Funding Agencies

None

Chemosensitivity and Endocrine Sensitivity in Clinical Luminal Breast Cancer Patients in the Prospective Neoadjuvant Breast Registry Symphony Trial (NBRST) Predicted by Molecular Subtyping

PURPOSE

Hormone receptor-positive (HR+) tumors have heterogeneous biology and present a challenge for determining optimal treatment. In the Neoadjuvant Breast Registry Symphony Trial (NBRST) patients were classified according to MammaPrint/BluePrint subtyping to provide insight into the response to neoadjuvant endocrine therapy (NET) or neoadjuvant chemotherapy (NCT).

OBJECTIVE

The purpose of this predefined substudy was to compare MammaPrint/BluePrint with conventional 'clinical' immunohistochemistry/fluorescence in situ hybridization (IHC/FISH) subtyping in 'clinical luminal' [HR+/human epidermal growth factor receptor 2-negative (HER2-)] breast cancer patients to predict treatment sensitivity.

METHODS

NBRST IHC/FISH HR+/HER2- breast cancer patients (n = 474) were classified into four molecular subgroups by MammaPrint/BluePrint subtyping: Luminal A, Luminal B, HER2, and Basal type. Pathological complete response (pCR) rates were compared with conventional IHC/FISH subtype.

RESULTS

The overall pCR rate for 'clinical luminal' patients to NCT was 11 %; however, 87 of these 474 patients were reclassified as Basal type by BluePrint, with a high pCR rate of 32 %. The MammaPrint index was highly associated with the likelihood of pCR (p < 0.001). Fifty-three patients with BluePrint Luminal tumors received NET with an aromatase inhibitor and 36 (68 %) had a clinical response.

CONCLUSIONS

With BluePrint subtyping, 18 % of clinical 'luminal' patients are classified in a different subgroup, compared with conventional assessment, and these patients have a significantly higher response rate to NCT compared with BluePrint Luminal patients. MammaPrint/BluePrint subtyping can help allocate effective treatment to appropriate patients. In addition, accurate identification of subtype biology is important in the interpretation of neoadjuvant treatment response since lack of pCR in luminal patients does not portend the worse prognosis associated with residual disease in Basal and HER2 subtypes.

Initial insights on the biodiversity potential of biosolar roofs: a London Olympic Park green roof case study

Cities dominated by impervious artificial surfaces can experience a multitude of negative environmental impacts. Restoration of green infrastructure has been identified as a mechanism for increasing urban resilience, enabling cities to transition towards sustainable futures in the face of climate-driven change. Building rooftops represent a viable space for integrating new green infrastructure into high-density urban areas. Urban rooftops also provide prime locations for photovoltaic (PV) systems. There is an increasing recognition that these two technologies can be combined to deliver reciprocal benefits in terms of energy efficiency and biodiversity targets. Scarcity of scientific evaluation of the interaction between PVs and green roofs means that the potential benefits are currently poorly understood. This study documents evidence from a biodiversity monitoring study of a substantial biosolar roof installed in the Queen Elizabeth Olympic Park. Vegetation and invertebrate communities were sampled and habitat structure measured in relation to habitat niches on the roof, including PV panels. Ninety-two plant species were recorded on the roof and variation in vegetation structure associated with proximity to PV panels was identified. Almost 50% of target invertebrate species collected were designated of conservation importance. Arthropod distribution varied in relation to habitat niches on the roof. The overall aim of the Main Press Centre building green roof design was to create a mosaic of habitats to enhance biodiversity, and the results of the study suggest that PV panels can contribute to niche diversity on a green roof. Further detailed study is required to fully characterise the effects of PV panel density on biodiversity.

Impact of Tumor Size on Probability of Pathologic Complete Response After Neoadjuvant Chemotherapy

BACKGROUND

The prospective Neoadjuvant Breast Symphony Trial (NBRST) study found that MammaPrint/BluePrint functional molecular subtype is superior to conventional immunohistochemistry/fluorescence in situ hybridization subtyping for predicting pathologic complete response (pCR) to neoadjuvant chemotherapy. The purpose of this substudy was to determine if the rate of pCR is affected by tumor size.

METHODS

The NBRST study includes breast cancer patients who received neoadjuvant chemotherapy. MammaPrint/BluePrint subtyping classified patients into four molecular subgroups: Luminal A, Luminal B, HER2 (human epidermal growth factor receptor 2), and Basal type. Probability of pCR (ypT0/isN0) as a function of tumor size and molecular subgroup was evaluated.

RESULTS

A total of 608 patients were evaluable with overall pCR rates of 28.5 %. Luminal A and B patients had significantly lower rates of pCR (6.1 and 8.7 %, respectively) than either basal (37.1 %) or HER2 (55.0 %) patients (p < 0.001). The probability of pCR significantly decreased with tumor size >5 cm [p = 0.022, odds ratio (OR) 0.58, 95 % confidence interval (CI) 0.36, 0.93]. This relationship was statistically significant in the Basal (p = 0.026, OR 0.46, 95 % CI 0.23, 0.91) and HER2 (p = 0.039, OR 0.36, 95 % CI 0.14, 0.95) subgroups. In multivariate logistic regression analyses, the dichotomized tumor size variable was not significant in any of the molecular subgroups.

DISCUSSION

Even though tumor size would intuitively be a clinical determinant of pCR, the current analysis showed that the adjusted OR for tumor size was not statistically significant in any of the molecular subgroups. Factors significantly associated with pCR were PR status, grade, lymph node status, and BluePrint molecular subtyping, which had the strongest correlation.

Development and validation of a VISA tendinopathy questionnaire for greater trochanteric pain syndrome, the VISA-G

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is common, resulting in significant pain and disability. There is no condition specific outcome score to evaluate the degree of severity of disability associated with GTPS in patients with this condition.

OBJECTIVE

To develop a reliable and valid outcome measurement capable of evaluating the severity of disability associated with GTPS.

METHODS

A phenomenological framework using in-depth semi structured interviews of patients and medical experts, and focus groups of physiotherapists was used in the item generation. Item and format clarification was undertaken via piloting. Multivariate analysis provided the basis for item reduction. The resultant VISA-G was tested for reliability with the inter class co-efficient (ICC), internal consistency (Cronbach's Alpha), and construct validity (correlation co-efficient) on 52 naïve participants with GTPS and 31 asymptomatic participants.

RESULTS

The resultant outcome measurement tool is consistent in style with existing tendinopathy outcome measurement tools, namely the suite of VISA scores. The VISA-G was found to be have a test-retest reliability of ICC2,1 (95% CI) of 0.827 (0.638-0.923). Internal consistency was high with a Cronbach's Alpha of 0.809. Construct validity was demonstrated: the VISA-G measures different constructs than tools previously used in assessing GTPS, the Harris Hip Score and the Oswestry Disability Index (Spearman Rho:0.020 and 0.0205 respectively). The VISA-G did not demonstrate any floor or ceiling effect in symptomatic participants.

CONCLUSION

The VISA-G is a reliable and valid score for measuring the severity of disability associated GTPS.

Chemosensitivity predicted by BluePrint 80-gene functional subtype and MammaPrint in the Prospective Neoadjuvant Breast Registry Symphony Trial (NBRST)

Purpose

The purpose of the NBRST study is to compare a multigene classifier to conventional immunohistochemistry (IHC)/fluorescence in situ hybridization (FISH) subtyping to predict chemosensitivity as defined by pathological complete response (pCR) or endocrine sensitivity as defined by partial response.

Methods

The study includes women with histologically proven breast cancer, who will receive neoadjuvant chemotherapy (NCT) or neoadjuvant endocrine therapy. BluePrint in combination with MammaPrint classifies patients into four molecular subgroups: Luminal A, Luminal B, HER2, and Basal.

Results

A total of 426 patients had definitive surgery. Thirty-seven of 211 (18 %) IHC/FISH hormone receptor (HR)+/HER2− patients were reclassified by Blueprint as Basal (n = 35) or HER2 (n = 2). Fifty-three of 123 (43 %) IHC/FISH HER2+ patients were reclassified as Luminal (n = 36) or Basal (n = 17). Four of 92 (4 %) IHC/FISH triple-negative (TN) patients were reclassified as Luminal (n = 2) or HER2 (n = 2). NCT pCR rates were 2 % in Luminal A and 7 % Luminal B patients versus 10 % pCR in IHC/FISH HR+/HER2− patients. The NCT pCR rate was 53 % in BluePrint HER2 patients. This is significantly superior (p = 0.047) to the pCR rate in IHC/FISH HER2+ patients (38 %). The pCR rate of 36 of 75 IHC/FISH HER2+/HR+ patients reclassified as BPLuminal is 3 %. NCT pCR for BluePrint Basal patients was 49 of 140 (35 %), comparable to the 34 of 92 pCR rate (37 %) in IHC/FISH TN patients.

Conclusions

BluePrint molecular subtyping reclassifies 22 % (94/426) of tumors, reassigning more responsive patients to the HER2 and Basal categories while reassigning less responsive patients to the Luminal category. These findings suggest that compared with IHC/FISH, BluePrint more accurately identifies patients likely to respond (or not respond) to NCT.

Zero temperature phase diagram of the Kitaev model

We show that the zero-temperature phase diagram of the vortex free sector of the Kitaev model is in one-to-one correspondence with that of the classical dimer model on the same lattice. We find that the model generically has three distinct phases. On a honeycomb lattice with a 3 x 3 fundamental domain all three phases are accessible. As the couplings are varied, there are two distinct transitions. The new transition is one to a gapped phase that opens up in the interior of the B phase.

Cutaneous Salmonella infection

Pustular dermatitis caused by Salmonella stanley developed on the arm of a veterinary surgeon after the delivery of a dead bovine calf. The vet did not develop any systemic symptoms and made a full recovery. This is the only report of cutaneous infection caused by this organism.

Clinical decision-making in hypertension using an automated (BpTRU) measurement device

Mercury sphygmomanometers are being removed from clinical practice in the United States due to environmental concerns about mercury toxicity. Accurate blood pressure measurement is central to high-quality hypertension management. In this study of 106 patients, the BpTRU(TM) device was compared to nurse blood pressure measurements that complied with all the JNC VII/American Heart Association guidelines in evaluation of a random casual blood pressure. The intermethod difference in systolic blood pressure was +1.8+/-5.1 mmHg, and for diastolic blood pressure it was 4.8+/-5.1 mmHg (both P<0.001). For the primary study end point of clinical decision-making, there was 92% (97/106) agreement between the hypertension nurse specialist and the BpTRU (kappa 0.8280, 95% confidence interval, 0.721-0.9350). The oscillometric blood pressure measurement with the BpTRU is recommended as a replacement for poorly performed auscultatory blood pressure measurement in clinical practice.

Axonal regeneration and functional recovery after complete spinal cord transection in rats by delayed treatment with transplants and neurotrophins

Little axonal regeneration occurs after spinal cord injury in adult mammals. Regrowth of mature CNS axons can be induced, however, by altering the intrinsic capacity of the neurons for growth or by providing a permissive environment at the injury site. Fetal spinal cord transplants and neurotrophins were used to influence axonal regeneration in the adult rat after complete spinal cord transection at a midthoracic level. Transplants were placed into the lesion cavity either immediately after transection (acute injury) or after a 2-4 week delay (delayed or chronic transplants), and either vehicle or neurotrophic factors were administered exogenously via an implanted minipump. Host axons grew into the transplant in all groups. Surprisingly, regeneration from supraspinal pathways and recovery of motor function were dramatically increased when transplants and neurotrophins were delayed until 2-4 weeks after transection rather than applied acutely. Axonal growth back into the spinal cord below the lesion and transplants was seen only in the presence of neurotrophic factors. Furthermore, the restoration of anatomical connections across the injury site was associated with recovery of function with animals exhibiting plantar foot placement and weight-supported stepping. These findings suggest that the opportunity for intervention after spinal cord injury may be greater than originally envisioned and that CNS neurons with long-standing injuries can reinitiate growth, leading to improvement in motor function.

Intestinal permeability is increased in a proportion of spouses of patients with Crohn's disease

OBJECTIVE

Increased small intestinal permeability has been found in patients with Crohn's disease and in a proportion of their healthy relatives. This may reflect a shared environment or shared genes. The finding of abnormal permeability in the healthy spouses of patients would favor an environmental cause for this observation.

METHODS

The healthy spouses of patients with Crohn's disease attending three gastroenterology clinics were invited to participate. Eligible subjects consumed a 350-ml solution containing lactulose, mannitol, and sucrose before bedtime. All overnight urine was collected, assayed by high performance liquid chromatography, and the ratio of fractional excretion of lactulose to mannitol was calculated as an index of permeability. The results were compared with those of a previously determined control group.

RESULTS

Sixty spouses completed the study. Increased permeability was present in eight (13.3%, 95% CI = 6.0-24.6%). The presence of increased permeability was not related to age, gender, duration of cohabitation, alcohol use, nonsteroidal anti-inflammatory drug use or to disease activity in the patient with Crohn's disease. There was a nonsignificant trend for abnormal permeability to occur in those spouses cohabiting with the patient with Crohn's disease at the time of disease diagnosis (p = 0.128).

CONCLUSIONS

Small intestinal permeability is increased in a proportion of healthy spouses of patients with Crohn's disease. The presence of abnormal permeability studies in patients with Crohn's disease and a proportion of their healthy close contacts suggests that this phenomenon is caused by environmental factors.

Focal brachial cutaneous neuropathy associated with Norplant use: suggests careful consideration of the recommended site for inserting contraceptive implants

A case of neuropathy in the medial antebrachial cutaneous nerve of the forearm following a Norplant(R) removal is described. The incidence of this problem is uncertain. The suggested sitting of the contraceptive implants directly over the bicipital groove is questioned.

Hippocampal system and declarative (relational) memory: summarizing the data from functional neuroimaging studies

In the last several years there have been impressive strides in the ability to explore the nature of hippocampal system functioning in humans by employing functional neuroimaging methods, permitting such methods to be used in conjunction with neuropsychological methods to better understand the role of the hippocampal system in memory. In this paper, we review the literature on functional imaging studies of the hippocampal system, summarizing the data and testing these data against a number of theories or explanatory accounts of hippocampal function. We consider five alternative explanatory accounts of, or ideas about, hippocampal function- some from already existing work, for which the functional imaging data can provide a new test, and others that have emerged directly from the functional imaging work, and that have yet to be tested for their fit of data from neuropsychological methods. We conclude that the relational (declarative) memory account, in which it is proposed that the hippocampal system plays a critical role in binding together multiple inputs to permit representations of the relations among the constituent elements of scenes or events, can better accommodate the full range of imaging (and other existing) data than any other explanatory account of hippocampal function.

Reflective practice

Christine Nash exemplifies reflective practice as a frequently used but infrequently defined concept in nursing (Jarvis 1992), with intuition seldom granted legitimacy as a sound approach to clinical judgement (Benner and Tanner 1987). She follows with a personal account of how she used reflective practice and intuitive skills in reassessing an A&E attender.

Smoking: attitudes of Costa Rican physicians and opportunities for intervention

The aim of this study was to obtain information, using a written questionnaire, on the knowledge, smoking behaviour, and attitudes of Costa Rican physicians about smoking as a health issue. A random sample of 650 physicians was chosen from a list of active physicians; 287 of them were covered by survey between August 1993 and October 1994, and 217 (76%) responded with data for the study. While 40% of the physicians who participated were ex-smokers, 19% were current smokers; 67% of these two groups combined reported smoking in the workplace. Only 49% believed that physicians could be a nonsmoking role model; the majority (87%) had asked patients about their smoking status. The only cessation technique consistently used (90%) was counselling about the dangers of smoking. Measures such as setting a date to quit smoking and nicotine replacement were rarely recommended (< or = 2%). Nearly all the physicians (99%) considered smoking to be a major health issue. These results showed a high prevalence of smoking among Costa Rican physicians, with little recognition of the need for them to set an example as a role model. While they were knowledgeable about the health risks of smoking, they did not recommend any of the proven techniques to help their patients to quit smoking. A clear consensus for more strict tobacco regulation exists, but to date little has been done to act on this.

Ras oncoprotein inhibitors: the discovery of potent, ras nucleotide exchange inhibitors and the structural determination of a drug-protein complex

The nucleotide exchange process is one of the key activation steps regulating the ras protein. This report describes the development of potent, non-nucleotide, small organic inhibitors of the ras nucleotide exchange process. These inhibitors bind to the ras protein in a previously unidentified binding pocket, without displacing bound nucleotide. This report also describes the development and use of mass spectrometry, NMR spectroscopy and molecular modeling techniques to elucidate the structure of a drug-protein complex, and aid in designing new ras inhibitor targets.

HLA DR4 is associated with the development of multiple basal cell carcinomas and malignant melanoma

An association between HLA DR4 and the development of multiple basal cell carcinomas (BCC) and malignant melanoma (MM) was detected in southern Australia. There were highly significant differences in HLA DR frequencies between patients with multiple BCCs and MM and matched patients with multiple BCCs only. These findings suggest that hereditary factors associated with the HLA system influence what types of multiple skin cancers people develop.

Basal cell carcinoma in tropical Australia

A survey of people with skin cancer in tropical Australia detected a change in site of the prevalent cancer. In the post-war generation more basal cell carcinomas are occurring on the back and fewer on the head and neck. A reversal of the sex ratio was also detected, with more women being afflicted.

HLA-DR1 is not a sign of poor prognosis for the development of multiple basal cell carcinomas

BACKGROUND

HLA-DR1 is associated with the development of multiple basal cell carcinomas (BCC). However, the association is weak.

OBJECTIVE

The purpose of our study was to determine whether HLA-DR1 is a marker for susceptibility to the development of many BCCs during a lifetime.

METHODS

Persons with multiple BCCs were placed into two groups: those with less than 10 and those with 20 or more. In addition, the HLA-DR1 frequencies were analyzed.

RESULTS

HLA-DR1 was associated with multiple BCCs in the group with less than 10 BCCs but not with the other group. These patients were significantly younger on average than those with 20 or more BCCs.

CONCLUSION

HLA-DR1 is associated with the development of multiple BCCs at an early age but it is not associated with development of large numbers of BCCs. The amount of UV light a person receives appears to be more important.

Basal-cell carcinoma in temperate and tropical Australia

The clinical features of patients with basal-cell carcinoma (BCC) living in temperate and tropical Australia were studied. In the temperate zone the patients were considerably older on average, men outnumbered women and there were differences between the sexes in the site of the prevalent BCC. In the tropics the patients were significantly younger on average, the male-to-female ratio approached unity and there were no differences between the sexes with regard to the site of the BCC.

The changing face of skin cancer in Australia

A survey of patients with basal cell carcinomas (BCCs) revealed that major changes have occurred since the World War II. In the pre-World War II generations, men out-number women and most BCCs occur on the head and neck. Men had more BCCs on the ear and trunk, while women had more on the head and leg. In the post-World War II generation, women outnumbered men and most BCCs occurred on the trunk.

Newborn screening in the 80's--the automation of follow-up

The Genetic Diseases Program of the Illinois Department of Public Health has completed the requirements for automation of its newborn screening follow-up services. The integration of two databases containing laboratory and follow-up elements allows the system to: (1) process on-line information about both normal and abnormal results on every baby screened in Illinois, (2) recall data previously entered and add follow-up criteria, (3) generate form letters, (4) track treatment and developmental progress of confirmed clients, (5) maintain permanent demographic registries, (6) transfer records to microfiche, and (7) generate reports for statistical analysis. The intent of this paper is to describe each of the above capabilities and demonstrate how automation has enhanced the follow-up component of newborn screening.

Interferon administered in the cerebrospinal space and its effect on rabies in rabbits

Because combined administration of intramuscular and intravenous interferon has been partially successful in the incubationary treatment of rabies, the effect of direct interferon administration into the cerebrospinal fluid space was tested. After injecting 1,800 U of interferon into the cisterna magna or the lateral ventricle, periodic samples, obtained by cisternal taps, showed that 1 to 5% remained after 24 h, as opposed to the known clearance of interferon from the bloodstream to this level within minutes. The distributions of interferon and (131)I-labeled albumin were similar as demonstrated by kinetics of clearance monitored over 24 h. Beginning with and after experimental infection of rabbits, daily intraventricular injections of one million units of interferon were given for as long as 3 weeks. Interferon was prepared from cell culture fluids after pressure dialysis and chromatography on Sephadex G-100. This intensive treatment did not prevent encephalitis, but prolonged the length of the incubation period by one- to two-thirds. The outcome after intraventricular administration was not as favorable as when one million units equally divided between intramuscular and intravenous injections were given at the time of challenge. Interferon administered in the subarachnoid space in this fashion is apparently inadequate to protect the rabbit against rabies. Its role as an adjunct measure, or other methods of administration in the nervous system, remains to be examined.