Insights gained from sequencing Australian non-invasive and invasive Streptococcus pyogenes isolates

Epidemiological data have indicated that invasive infections caused by the Gram-positive cocci Streptococcus pyogenes (group A streptococcus, GAS) have increased in many Australian states over the past two decades. In July 2022, invasive GAS (iGAS) infections became nationally notifiable in Australia via public-health agencies. Surveillance for S. pyogenes infections has been sporadic within the state of New South Wales (NSW). This has led to a lack of genetic data on GAS strains in circulation, particularly for non-invasive infections, which are the leading cause of GAS's burden on the Australian healthcare system. To address this gap, we used whole-genome sequencing to analyse the genomes of 318 S. pyogenes isolates collected within two geographical regions of NSW. Invasive isolates were collected in 2007-2017, whilst non-invasive isolates were collected in 2019-2021. We found that at least 66 different emm-types were associated with clinical disease within NSW. There was no evidence of any Australian-specific clones in circulation. The M1UK variant of the emm1 global pandemic clone (M1global) has been detected in our isolates from 2013 onwards. We detected antimicrobial-resistance genes (mainly tetM, ermA or ermB genes) in less than 10 % of our 318 isolates, which were more commonly associated with non-invasive infections. Superantigen virulence gene carriage was reasonably proportionate between non-invasive and invasive infection isolates. Our study adds rich data on the genetic makeup of historical S. pyogenes infections within Australia. Ongoing surveillance of invasive and non-invasive GAS infections within NSW by whole-genome sequencing is warranted to inform on outbreaks, antimicrobial resistance and vaccine coverage.

Epistaxis and Facial Swelling Due to Nasal Blastomycosis in a Cat

A 5 yr old castrated male domestic longhair was examined because of left-sided facial swelling and epistaxis. Head computed tomography with contrast identified a mass within the left nasal cavity and multifocal regions of nasal bone osteolysis. Histopathology of nasal mass biopsies and cytology of the facial swelling revealed pyogranulomatous inflammation due to Blastomyces dermatitidis. The cat experienced resolution of clinical signs following 8 mo of treatment with itraconazole. Although rare, clinicians should include blastomycosis on the differential diagnoses list of infectious causes for feline nasal disease if within an endemic area.

Cultivating an Active Living Plan Through a Social-Ecological Evaluation

Physical activity (PA) social-ecological model (SEM) posits the importance of several levels of influence critical for PA promotion within communities. The purpose of this study was to examine an SEM evaluation informing a county-wide active living plan in McLennan County, Texas in the United States. Mixed-methods evaluation occurred in 4 stages: (1) county policies (n = 15) were evaluated for PA promoting strategies; (2) PA resource assessments (PARAs) were conducted via Google Maps (n = 171); (3) surveys (n = 244) included the International Physical Activity Questionnaire and interpersonal and intrapersonal factors related to PA; and (4) focus groups (n = 5) were conducted with residents (n = 30), discussing barriers and facilitators to being active. Logistic regression determined significant associations between SEM factors and meeting PA recommendations. Policy scans and PARAs identified strengths and areas of improvement (eg, equitable project selection and disparities in resource quality). Residents reporting fewer barriers (OR = 0.89, P =.01), more perceived behavioral control (odds ratio [OR] = 1.38, P = .01), more social co-participation in PA (OR = 1.20, P = .03), and living in zip codes with higher mean PARA score (OR = 1.22, P = .04) were significantly more likely to meet PA recommendations (Nagelkerke R2 = 0.32). Focus groups also discussed safety and disparities in access and quality. This study suggests the utility of the SEM when evaluating and promoting community PA.

Bird clades with less complex appendicular skeletons tend to have higher species richness

Species richness is strikingly uneven across taxonomic groups at all hierarchical levels, but the reasons for this heterogeneity are poorly understood. It is well established that morphological diversity (disparity) is decoupled from taxonomic diversity, both between clades and across geological time. Morphological complexity has been much less studied, but there is theory linking complexity with differential diversity across groups. Here we devise an index of complexity from the differentiation of the fore and hind limb pairs for a sample of 983 species of extant birds. We test the null hypothesis that this index of morphological complexity is uncorrelated with clade diversity, revealing a significant and negative correlation between the species richness of clades and the mean morphological complexity of those clades. Further, we find that more complex clades tend to occupy a smaller number of dietary and habitat niches, and that this proxy for greater ecological specialisation correlates with lower species richness. Greater morphological complexity in the appendicular skeleton therefore appears to hinder the generation and maintenance of species diversity. This may result from entrenchment into morphologies and ecologies that are less capable of yielding further diversity.

Epidemiology of Group A Streptococcal bacteraemia in Hunter New England Local Health District, 2008 to 2019

Invasive Group A Streptococcal infection (iGAS) is an uncommon but serious infection with Streptococcus pyogenes in a normally sterile body site. Manifestations include bacteraemia, necrotising fasciitis and toxic shock syndrome with attendant serious morbidity and mortality. An increasing incidence of iGAS has been observed in some regions of Australia. iGAS became a nationally notifiable condition from 1 July 2021. To determine if regional incidence has increased, and to identify priority populations, we undertook a retrospective data analysis of Group A Streptococcal (GAS) bacteraemia cases in Hunter New England Local Health District (HNELHD), New South Wales, Australia, from 1 January 2008 to 31 December 2019, as identified by NSW Health Pathology, John Hunter Hospital. A total of 486 cases were identified (age-standardised rate: 4.05 cases per 100,000 population per year). Incidence in HNELHD gradually increased over the study period (adjusted incidence rate ratio: 1.04; 95% confidence interval: 1.01-1.07) and was significantly higher in children under 5 years of age; in adults over 70 years of age; in males; and in First Nations peoples. A significant peak occurred in 2017 (9.00 cases per 100,000 population), the cause of which remains unclear. GAS bacteraemia is uncommon but severe, and incidence in HNELHD has slowly increased. Public health and clinical guidelines must address the needs of priority populations, which include young children, older adults and First Nations peoples. Routine surveillance and genomic analysis will help improve our understanding of iGAS and inform best public health management.

Divergent vertebral formulae shape the evolution of axial complexity in mammals

Complexity, defined as the number of parts and their degree of differentiation, is a poorly explored aspect of macroevolutionary dynamics. The maximum anatomical complexity of organisms has undoubtedly increased through evolutionary time. However, it is unclear whether this increase is a purely diffusive process or whether it is at least partly driven, occurring in parallel in most or many lineages and with increases in the minima as well as the means. Highly differentiated and serially repeated structures, such as vertebrae, are useful systems with which to investigate these patterns. We focus on the serial differentiation of the vertebral column in 1,136 extant mammal species, using two indices that quantify complexity as the numerical richness and proportional distribution of vertebrae across presacral regions and a third expressing the ratio between thoracic and lumbar vertebrae. We address three questions. First, we ask whether the distribution of complexity values in major mammal groups is similar or whether clades have specific signatures associated with their ecology. Second, we ask whether changes in complexity throughout the phylogeny are biased towards increases and whether there is evidence of driven trends. Third, we ask whether evolutionary shifts in complexity depart from a uniform Brownian motion model. Vertebral counts, but not complexity indices, differ significantly between major groups and exhibit greater within-group variation than recognized hitherto. We find strong evidence of a trend towards increasing complexity, where higher values propagate further increases in descendant lineages. Several increases are inferred to have coincided with major ecological or environmental shifts. We find support for multiple-rate models of evolution for all complexity metrics, suggesting that increases in complexity occurred in stepwise shifts, with evidence for widespread episodes of recent rapid divergence. Different subclades evolve more complex vertebral columns in different configurations and probably under different selective pressures and constraints, with widespread convergence on the same formulae. Further work should therefore focus on the ecological relevance of differences in complexity and a more detailed understanding of historical patterns.

Abstract PR003: Multiplexed immune phenotyping and miRNA-ISH in bronchial premalignant lesions reveals a mechanism of immune suppression

Bronchial premalignant lesions (PMLs) are precursors of lung squamous cell carcinoma. Prior work has shown that among proliferative subtype PMLs, progression to or persistence of a high-grade histology is associated with downregulation of an immune-related gene module. Furthermore, microRNA-149 (miR-149) was identified as a candidate negative regulator of this expression program. In this study, we aim to investigate the spatial distribution of miR-149 and its association with the immune environment and PML progression/persistence in PMLs. We identified 19 paraffin embedded bronchial biopsies transcriptionally defined as belonging to the proliferative subtype obtained from 9 subjects. Three consecutive sections were stained with H&E for histology annotation, chromogenic miRNA in situ hybridization (miRNA-ISH) for miR-149 abundance and localization, and with 30 antibodies targeted to epithelial and immune populations using imaging mass cytometry (IMC) to perform phenotyping. We trained a robust pixel classifier to detect foci of miR-149 signal in miRNA-ISH and quantified the density of miR-149 signal. For the IMC data, we used Mesmer for cell segmentation. PhenoGraph clustering based on quantification of each antibody in each cell was used for cell population identification. Ten recurrent cellular neighborhoods were identified by K-means clustering. miR-149 density was greater in the epithelium compared with stromal tissue. The miR-149 density in dysplastic epithelium normalized to miR-149 in normal epithelium is higher in the progressive/persistent PMLs than regressive PMLs. Additionally, in progressive/persistent PMLs, we find lower average epithelial staining for the miR-149 target NLRC5 associated with a cellular neighborhood that is enriched for goblet cells and PDL1+MUC5B+ secretory cells. Cell composition analysis showed that progressive/persistent PMLs have lower CD8 T cell infiltrate in both the stroma and epithelium. These results suggest that increased miR-149 expression in progressive/persistent PMLs contributes to an immune suppressive environment characterized by a shift in secretory cell populations and T cells within the bronchial epithelium. Interventions targeting miR-149 expression may be a potential interception strategy for high-grade PMLs.

Citation Format: Darren J. Chiu, Roxana Pfefferkorn, Emily Green, Boting Ning, Myrtha Constant, Marc Lenburg, Eric Burks, Sarah Mazzilli, Jennifer Beane. Multiplexed immune phenotyping and miRNA-ISH in bronchial premalignant lesions reveals a mechanism of immune suppression. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr PR003.

Right coronary artery to left ventricle coronary cameral fistula in a cat

A six-month-old female intact domestic shorthair cat was presented for evaluation of a loud heart murmur. Transthoracic echocardiography revealed dilation of the left ventricle secondary to an abnormal vessel shunting blood into the left ventricular outflow tract at a high velocity during diastole. Multidetector computed tomography angiography revealed a coronary cameral fistula that originated at the right coronary artery, encircled the heart, and then terminated into the left ventricular outflow tract. This case report documents the first known case of a coronary cameral fistula in a cat. Multimodal imaging was an essential aspect to diagnosing the congenital lesion in this case.

A Novel Cadaveric Embalming Technique for Enhancing Visualisation of Human Anatomy

Within the discipline of anatomical education, the use of donated human cadavers in laboratory-based learning activities is often described as the 'gold standard' resource for supporting student understanding of anatomy. Due to both historical and educational factors, cadaveric dissection has traditionally been the approach against which other anatomy learning modalities and resources have been judged. To prepare human donors for teaching purposes, bodies must be embalmed with fixative agents to preserve the tissues. Embalmed cadavers can then be dissected by students or can be prosected or plastinated to produce teaching resources. Here, we describe the history of cadaveric preservation in anatomy education and review the practical strengths and limitations of current approaches for the embalming of human bodies. Furthermore, we investigate the pedagogic benefits of a range of established modern embalming techniques. We describe relevant cadaveric attributes and their impacts on learning, including the importance of colour, texture, smell, and joint mobility. We also explore the emotional and humanistic elements of the use of human donors in anatomy education, and the relative impact of these factors when alternative types of embalming process are performed. Based on these underpinnings, we provide a technical description of our modern Newcastle-WhitWell embalming process. In doing so, we aim to inform anatomy educators and technical staff seeking to embalm human donors rapidly and safely and at reduced costs, while enhancing visual and haptic tissue characteristics. We propose that our technique has logistical and pedagogic implications, both for the development of embalming techniques and for student visualisation and learning.

Biophotonic tools for probing extracellular matrix mechanics

The complex, hierarchical and heterogeneous biomechanics of the extracellular matrix (ECM) are central to the health of multicellular organisms. Characterising the distribution, dynamics and above all else origins of ECM biomechanics are challenges that have captivated researchers for decades. Recently, a suite of biophotonics techniques have emerged as powerful new tools to investigate ECM biomechanics. In this mini-review, we discuss how the non-destructive, sub-micron resolution imaging capabilities of Raman spectroscopy and nonlinear microscopy are being used to interrogate the biomechanics of thick, living tissues. These high speed, label-free techniques are implemented during mechanical testing, providing unprecedented insight into the compositional and structural response of the ECM to changes in the mechanical environment.

OS12.4.A MHC class II-restricted transgenic T cell receptor therapy targeting mutant capicua transcriptional repressor in experimental gliomas

BACKGROUND

Glioma subtypes are classified according to their characteristic mutations and show a high degree of resistance to standard therapeutic interventions such as radiotherapy and alkylating chemotherapy. Some of these characteristic mutations have shown to generate immunogenic neoepitopes that can be targeted with immunotherapy. 70% of oligodendrogliomas carry capicua transcriptional repressor (CIC) inactivating mutations.

RESULTS

In a screen for potential immunogenic glioma neoepitopes we identified recurrent CIC hotspot mutations at position 215 (CICR215W/Q) expressed in a subset of oligodendrogliomas as an immunogenic major histocompatibility complex (MHC) class II-restricted neoepitopes. Peptide-based vaccination of MHC-humanized mice resulted in the generation of robust mutation-specific T cell responses against CICR215W/Q, restricted to MHC class II. Droplet-based single cell T cell receptor (TCR) sequencing from CICR215W-specific T cell lines enabled retrieval of MHC class II-restricted CICR215W-reactive TCRs. By retroviral transduction of T cells, we established a flow cytometry-based testing platform of retrieved TCRs and were able to show the top reactive TCR against CICR215W to be shared between individual mice. Using a newly developed glioma model in MHC-humanized mice induced by CRISPR-based delivery of tumor suppressor targeting guide RNAs, we show that adoptive intraventricular transfer of CICR215W-specific TCR-transgenic T cells exert anti-tumor responses against CICR215W-expressing syngeneic gliomas.

CONCLUSION

The integration of immunocompetent MHC-humanized orthotopic glioma models in the discovery of shared immunogenic glioma neoepitopes facilitates the identification and preclinical testing of HLA-restricted neoepitope-specific TCRs for locoregional TCR-transgenic T cell adoptive therapy.

The developmental biology of Charnia and the eumetazoan affinity of the Ediacaran rangeomorphs

Molecular timescales estimate that early animal lineages diverged tens of millions of years before their earliest unequivocal fossil evidence. The Ediacaran macrobiota (~574 to 538 million years ago) are largely eschewed from this debate, primarily due to their extreme phylogenetic uncertainty, but remain germane. We characterize the development of Charnia masoni and establish the affinity of rangeomorphs, among the oldest and most enigmatic components of the Ediacaran macrobiota. We provide the first direct evidence for the internal interconnected nature of rangeomorphs and show that Charnia was constructed of repeated branches that derived successively from pre-existing branches. We find homology and rationalize morphogenesis between disparate rangeomorph taxa, before producing a phylogenetic analysis, resolving Charnia as a stem-eumetazoan and expanding the anatomical disparity of that group to include a long-extinct bodyplan. These data bring competing records of early animal evolution into closer agreement, reformulating our understanding of the evolutionary emergence of animal bodyplans.

How Can a New Nurse Graduate Secure a Nursing Position in Pediatric Oncology?

I decided to become a nurse after spending much of my adolescence as an inpatient myself. I had to miss out on many important milestones during my adolescence. However, from my time as a patient, I was able to have the most developmentally normal experiences, thanks to care from my nurses.

Evaluation of DISORDER: Retrospective Image Motion Correction for Volumetric Brain MRI in a Pediatric Setting

BACKGROUND AND PURPOSE

Head motion causes image degradation in brain MR imaging examinations, negatively impacting image quality, especially in pediatric populations. Here, we used a retrospective motion correction technique in children and assessed image quality improvement for 3D MR imaging acquisitions.

MATERIALS AND METHODS

We prospectively acquired brain MR imaging at 3T using 3D sequences, T1-weighted MPRAGE, T2-weighted TSE, and FLAIR in 32 unsedated children, including 7 with epilepsy (age range, 2-18 years). We implemented a novel motion correction technique through a modification of k-space data acquisition: Distributed and Incoherent Sample Orders for Reconstruction Deblurring by using Encoding Redundancy (DISORDER). For each participant and technique, we obtained 3 reconstructions as acquired (Aq), after DISORDER motion correction (Di), and Di with additional outlier rejection (DiOut). We analyzed 288 images quantitatively, measuring 2 objective no-reference image quality metrics: gradient entropy (GE) and MPRAGE white matter (WM) homogeneity. As a qualitative metric, we presented blinded and randomized images to 2 expert neuroradiologists who scored them for clinical readability.

RESULTS

Both image quality metrics improved after motion correction for all modalities, and improvement correlated with the amount of intrascan motion. Neuroradiologists also considered the motion corrected images as of higher quality (Wilcoxon z = -3.164 for MPRAGE; z = -2.066 for TSE; z = -2.645 for FLAIR; all P < .05).

CONCLUSIONS

Retrospective image motion correction with DISORDER increased image quality both from an objective and qualitative perspective. In 75% of sessions, at least 1 sequence was improved by this approach, indicating the benefit of this technique in unsedated children for both clinical and research environments.

"It Just Hit Me Like a Ton of Bricks": Improving the Patient Experience of Receiving a Breast Cancer Diagnosis at an Older Age

The purpose of the current study was to describe the experiences of older women receiving a diagnosis of early-stage breast cancer. Thematic analysis informed by techniques from constructivist grounded theory was used to analyze interviews with 54 women aged ≥65 years an average of 19.6 months after diagnosis. Two themes were identified: The Overwhelming Shock of Receiving a Diagnosis and Contextualizing the Diagnosis in Relation to Age. Results suggest these participants were deeply shocked by a diagnosis that clinicians may view as highly treatable. Age-related factors impacting how the bad news was received include misunderstanding risk factors, the impact of comorbidities, concurrent life events, and evolving perceptions of cancer at her life stage. To establish a solid foundation for age-appropriate communication when giving bad news, these participants help clinicians acknowledge what women may be thinking. Potential clinician responses to the variety of concerns are presented. [Research in Gerontological Nursing, 14(2), 79-89.].

Precision Health: Bringing Oral Health into the Context of Overall Health

Unprecedented advances in genomics, data science, and biotechnology have ushered in a new era of health care in which interventions are increasingly tailored to individual patients. Precision-based approaches extend to oral health, which is essential to overall health. Harnessing the full potential of precision oral health will depend on research to more fully understand the factors that underlie health and contribute to disease-including the human genome, microbiome, epigenome, proteome, and others.

Aromatase inhibitors: The unexpected breast cancer treatment

OBJECTIVE

Suboptimal adherence with endocrine treatment for breast cancer is influenced by a number of factors but remains poorly understood. We sought to describe the prior knowledge about and expectations of breast cancer treatments among older women retrospecting on their diagnosis and treatment.

METHODS

Thematic analysis was used to systematically analyze data obtained with face-to-face, open-ended interviews conducted with 54 women who had filled at least one prescription for an aromatase inhibitor. The average age was 71.9 (65-93) years at diagnosis.

RESULTS

Three salient themes were described: the sources of information on which preknowledge and expectations surrounding treatment were founded, and two phases of treatment, primary (surgery, chemotherapy and radiation therapy) and anti-hormonal. The main source of information was from family and friends who had been treated for cancer. These peers reported both positive and negative experiences and in many cases contributed to the women having some degree of misinformation. A foundational knowledge of primary treatments was evident (necessity, duration, intensity, side-effects) and that receiving one or more treatments was needed. Compared to primary treatments, anti-hormonal treatment (AHT) was unexpected, the women knew less about it, and felt comparatively under-prepared for this treatment.

CONCLUSIONS

The transition from primary treatments to adjuvant AHT therapy with receiving a prescription for an aromatase inhibitor caught many participants off guard. Our findings elucidate areas to enhance clinical practice, expand the research agenda to more thoroughly explore AHT information and design of an age-appropriate supportive intervention to improve continuation with AHT.

Research priorities for the pan-Canadian Oncology Symptom Triage and Remote Support practice guides: a modified nominal group consensus

Introduction

The pan-Canadian Oncology Symptom Triage and Remote Support (costars) team is studying how to improve the quality and consistency of cancer symptom management.

Methods

A 1-day invitational meeting was held 24 October 2017 in Ottawa, Ontario, to review the current evidence from costars projects and to establish research priorities for a future largescale implementation study. The meeting included 36 participants who were clinicians from adult oncology, pediatric oncology, and homecare; policymakers from national, provincial, and regional organizations; researchers; and a patient. Half the day involved summarizing evidence from four costars studies and experiences with implementing the costars symptom practice guides. The second half of the day used a modified nominal group technique to generate research questions within small groups, presentation of research questions to all participants, and two rounds of voting to reach consensus on research priorities.

Results

Participants proposed 4 research categories:■ User-centred augmentation to enhance usability (for example, designing a mobile costars solution)■ Outcome measurement (for example, determining key competencies for clinicians)■ Regular renewal of costars to keep pace with evolving evidence (for example, updates for novel therapies)■ Integration into clinical practice (for example, meaningful engagement of patients and caregivers in study design).

Conclusions

Across categories, the top 3 priorities were effect on health services use, competency development, and a mobile costars solution. Future research will address identified priorities, reflecting the needs and perspectives of diverse stakeholders. Stakeholder collaboration will continue to guide our approach to operationalizing this priority research agenda.

Prioritizing potential endocrine active high resolution mass spectrometry (HRMS) features in Minnesota lakewater

Liquid chromatography high-resolution mass spectrometry (LC-HRMS) shows great potential for expanding our understanding of relevant unknown chemical components present within complex environmental mixtures. This study identified potentially endocrine active components within Minnesota lakewater by prioritizing LC-HRMS features uniquely present at sunfish spawning habitats where male fish showed signs of estrogen agonism. Porewater samples from four locations within the same lake were analyzed using liquid chromatography quadrupole time of flight mass spectrometry (LC-QToF/MS) with positive (ESI+) and negative (ESI-) electrospray ionization. Plasma vitellogenin concentrations of captured male sunfish was used to designate sites as either endocrine active (ACT; 2 sites) or reference (REF; 2 sites). Assuming unique chemical presence at active sites contributed to endocrine activity, features at significantly higher intensities (p-value < 0.05, t-value > t-critical, log-fold change > 0.1; equal variance t-test of log2 transformed data) in ACT sites were then compiled into a suspect search list for feature identification. Adducts and isotopes of prioritized features were deprioritized using pattern recognizing algorithms using mass, retention time, and intensity. Feature identities were reported according to established confidence metrics using spectral libraries and elemental composition algorithms. This LC-HRMS approach identified a number of features omitted by targeted analysis with higher relative abundances in ACT sites, including plant essential oils, fatty acids, and mycotoxins. Multivariate analysis determined whether features were either present at both sites (AB) or unique to individual ACT sites (A or B). Detection frequency across datasets indicated bias in feature prioritization influenced by the chosen sampling method and sample acquisition mode. The majority of features prioritized by this workflow remain tentatively identified or unidentified masses of interest, reflective of current limitations in shared spectral libraries for soft ionization analyses. Strategies similar to this workflow have the potential to reduce bias in database-driven toxicological prioritization frameworks.

U.S. prevalence of endocrine therapy-naïve locally advanced or metastatic breast cancer

Background

Variations in treatment choice, or late stage at first diagnosis, mean that, despite guideline recommendations, not all patients with hormone receptor (hr)-positive locally advanced or metastatic breast cancer (la/mbca) will have received endocrine therapy before disease progression. In the present study, we aimed to estimate the proportion of women with postmenopausal hr-positive la/mbca in the United States who are endocrine therapy-naïve.

Methods

Women in the Optum Electronic Health Record (ehr) database with a breast cancer (bca) diagnosis (January 2008-March 2015) were included. Patient and malignancy characteristics were identified using structured data fields and natural-language processing of free-text clinical notes. The proportion of women with postmenopausal hr-positive, human epidermal growth factor 2 (her2)-negative (or unknown) la/mbca who had not received prior endocrine therapy was determined. Results were extrapolated to the entire U.S. population using the U.S. National Cancer Institute's Surveillance, Epidemiology, and End Results database. Results are presented descriptively.

Results

In the ehr database, 11,831 women with bca had discernible information on postmenopausal status, hr status, and disease stage. Of those women, 1923 (16.3%) had postmenopausal hr-positive, her2-negative (or unknown) la/mbca, and 70.7% of those 1923 patients (n = 1360) had not received prior endocrine therapy, accounting for 11.5% of the overall population. Extrapolating those estimates nationally suggests an annual incidence of 14,784 cases, and a 5-year limited duration prevalence of 50,638 cases.

Conclusions

A substantial proportion of women with postmenopausal hr-positive la/mbca in the United States could be endocrine therapy-naïve.

Cambrian Sessile, Suspension Feeding Stem-Group Ctenophores and Evolution of the Comb Jelly Body Plan

The origin of ctenophores (comb jellies) is obscured by their controversial phylogenetic position, with recent phylogenomic analyses resolving either sponges or ctenophores as the sister group of all other animals. Fossil taxa can provide morphological evidence that may elucidate the origins of derived characters and shared ancestries among divergent taxa, providing a means to "break" long branches in phylogenetic trees. Here we describe new fossil material from the early Cambrian Chengjiang Biota, Yunnan Province, China, including the putative cnidarian Xianguangia, the new taxon Daihua sanqiong gen et sp. nov., and Dinomischus venustus, informally referred to as "dinomischids" here. "Dinomischids" possess a basal calyx encircled by 18 tentacles that surround the mouth. The tentacles carry pinnules, each with a row of stiff filamentous structures interpreted as very large compound cilia of a size otherwise only known in ctenophores. Together with the Cambrian tulip animal Siphusauctum and the armored Cambrian scleroctenophores, they exhibit anatomies that trace ctenophores to a sessile, polypoid stem lineage. This body plan resembles the polypoid, tentaculate morphology of cnidarians, including a blind gastric cavity partitioned by mesenteries. We propose that comb rows are derived from tentacles with paired sets of pinnules that each bear a row of compound cilia. The scleroctenophores exhibit paired comb rows, also observed in Siphusauctum, in addition to an organic skeleton, shared as well by Dinomischus, Daihua, and Xianguangia. We formulate a hypothesis in which ctenophores evolved from sessile, polypoid suspension feeders, sharing similarities with cnidarians that suggest either a close relationship between these two phyla, a striking pattern of early convergent evolution, or an ancestral condition for either metazoans or eumetazoans.

A qualitative comparison of how older breast cancer survivors process treatment information regarding endocrine therapy

BACKGROUND

It remains unclear how information about aromatase inhibitors (AI) impacts women's decision-making about persistence with endocrine therapy.

PURPOSE

To describe and compare how women treated for primary early stage breast cancer either persisting or not persisting with an AI received, interpreted, and acted upon AI-related information.

DESIGN

Thematic analysis was used to sort and compare the data into the most salient themes.

PARTICIPANTS

Women (N = 54; 27 persisting, 27 not persisting with an AI) aged 65-93 years took part in qualitative interviews.

RESULTS

Women in both subgroups described information similarly in terms of its value, volume, type, and source. Aspects of AI-related information that either differed between the subgroups or were misunderstood by one or both subgroups included: (1) knowledge of AI or tamoxifen prior to cancer diagnosis, (2) use of online resources, (3) misconceptions about estrogen, hormone replacement therapies and AI-related symptoms, and (4) risk perception and the meaning and use of recurrence statistics such as Oncotype DX.

CONCLUSIONS

Persisters and nonpersisters were similar in their desire for more information about potential side effects and symptom management at AI prescription and subsequent appointments. Differences included how information was obtained and interpreted. Interactive discussion questions are shared that can incorporate these findings into clinical settings.

Hostility, forgiveness, and cognitive impairment over 10 years in a national sample of American adults

OBJECTIVE

We examined the extent to which self-forgiveness and forgiveness of others moderated the association of hostility with changes in cognitive impairment over 10 years in a nationally representative sample of adults in the United States.

METHOD

Participants were 1,084 respondents to the Americans' Changing Lives survey, a longitudinal study of American adults. Hostility, self-forgiveness, forgiveness of others, and cognitive impairment were measured at baseline, and cognitive impairment was assessed again at follow-up. Moderated multiple regression analyses tested whether self-forgiveness and forgiveness of others moderated the association of hostility with changes in cognitive impairment over time, controlling for baseline cognitive impairment and relevant sociodemographic and clinical factors.

RESULTS

As hypothesized, greater hostility levels at baseline predicted more cognitive impairment 10 years later, β = .08, p < .01. In addition, self-forgiveness at baseline moderated the association between baseline hostility and cognitive impairment at follow-up, β = -.07, p < .01. Decomposing this interaction revealed that hostility significantly predicted increased cognitive impairment at follow-up for individuals with low, β = .15, p < .001, and average, β = .08, p = .001, levels of self-forgiveness but not for persons with high levels of self-forgiveness, β = .03, p = .34. In contrast, forgiveness of others was not a significant moderator.

CONCLUSIONS

Greater hostility is associated with the development of more cognitive impairment over 10 years, and being more self-forgiving appears to mitigate these hostility-related effects on cognition. Enhancing self-forgiveness may thus represent one possible strategy for promoting cognitive resilience in adulthood. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Understanding the Experiences of Cancer Patients as They Transition From Treatment to Primary and Community Care: A Pan-Canadian Study of Over 13,000 Cancer Survivors

Background: Being diagnosed with cancer can be overwhelming, with many physical and emotional challenges. As needs of survivors shift from disease management to recovery, the adjustment is often not seamless. Ideally, a health care system is integrated and responsive to the needs of survivors, however, when cancer treatment is complete, they often face lingering concerns. Limited patient-reported data were available in Canada on experiences and barriers survivors face posttreatment. Aim: The Experiences of Cancer Patients in Transition study is the first national survey gathering data from cancer survivors in Canada as they transition from cancer care to the broader health care system. Methods: A survey was developed in consultation with patients/survivors, health care providers and researchers to address experiences related to physical, emotional, informational and practical needs. Ethics approvals were obtained and 10 provinces participated. Cancer survivors expected to have completed treatment within 1-3 years were identified from provincial cancer registries. Included were those aged 30+ at diagnosis of nonmetastatic breast, colorectal, prostate, melanoma or hematologic cancer; or aged 15-29 at diagnosis of any nonmetastatic cancer or metastatic testicular cancer. Despite the intention of the sampling, the final sample included some survivors diagnosed with a site other than the target sites, and some whose time since treatment was outside 1-3 years. All respondents are included in this analysis. Results are not weighted to represent the true distribution of cancer survivors. Results: From a total survey population of 40,790 Canadian cancer survivors, 33% completed the survey. The respondents were 48% male, 51% female; 2.5% were under 30 years old, 60% were 65+. 68% of respondents reported challenging periods posttreatment, with 48% of these saying that the first 6 months to 1 year were most challenging. Cancer survivors continued to live with side-effects: 87% reported physical challenges; 78% reported emotional challenges; 45% reported practical challenges. The most prevalent concerns were fatigue (68%), anxiety about cancer returning (68%) and returning to work/school (23%). Less than half of those with emotional or practical concerns received useful information (42% and 46%, respectively). 42% of respondents could not get help to address their most difficult concern. Of those who could get help, 10.7% waited a year or more. Conclusion: The results provide insight into the nature of challenges cancer survivors face, as well as needed supports and barriers faced in accessing them. There is a clear need for health systems to ensure a seamless patient experience throughout the cancer journey, for instance, through development and adoption of resources to help health care providers and their patients identify and address challenges from diagnosis through to survivorship.

A Pan-Canadian Framework for Cancer Survivorship Research

Background and context: Across all cancer types, two-thirds of Canadians diagnosed with cancer today will survive long-term, reflecting great progress in cancer detection and treatment. Many survivors, however, will experience substantial and long-term impacts of their diagnosis and treatment. Within this context, the Canadian Cancer Research Alliance (CCRA) sought to inform the cancer research funding community on how, and what kinds of research are needed, to enable research that will make a difference to patients as they move from treatment to the posttreatment phase. Aim: To develop and implement a national framework and recommendations to enable coordinated and strategic action among cancer research funders that advances cancer survivorship research in Canada in ways that improve survivors' care and experiences. Strategy/Tactics: Multiple approaches were used to inform framework development: a strategic literature review; an analysis of cancer survivorship research funding from 2005-13; and an online survey and key informant interviews from the broader stakeholder community. An Expert Panel and Patient Advisory Committee were also engaged to provide guidance and feedback. Program/Policy process: Over the course of one year, the project team and a working group of CCRA members met regularly to steer framework development. This involved activities such as developing data collection approaches and tools, reviewing data and emerging findings, and translating findings into priority areas and recommendations. In total, > 200 Canadian and international stakeholders provided input through the survey and interviews. Outcomes: Released March 2017, the Pan-Canadian Framework for Cancer Survivorship Research provides four recommendations for cancer research funders: 1) ensure ongoing and meaningful involvement of cancer survivors; 2) align funding calls with existing needs and potential for impact; 3) create opportunities for the translation of research into practice and policy; and 4) build and maintain infrastructure and expertise to advance research. Specific research priorities were emphasized across three research domains: survivors' experiences and outcomes; late and long-term effects; and models of care. The priorities ranged from investigating the mechanisms of late/long-term effects to conducting intervention research to improve psychosocial outcomes, prevent and ameliorate late effects, and improve integration of follow-up care. What was learned: A broad range of stakeholders came together to develop a national framework to maximize the impact of shared targeted research investment in cancer survivorship research. Survivors' voices were key to agreeing on definitional issues of survivorship, identifying priority research areas, and ultimately lending credibility to the resulting framework. Implementation of the framework is the next step of work for CCRA members. Planning has commenced on identifying an initial priority for joint action.

Acute-Care Hospital Use Patterns Near End-of-Life for Cancer Patients Who Die in Hospital in Canada

Background: Acute-care hospitals have a role in managing the needs of people with cancer when they are at the end-of-life; however, overutilization of hospital care at the end-of-life results in poorer quality of life and can worsen the patient's experience. Early integration of comprehensive palliative care can greatly reduce unplanned visits to the emergency department, reduce avoidable admissions to hospital, shorten hospital stays, and increase the number of home deaths as well as improve the quality of life of patients with advanced cancer. Aim: To describe the current landscape of acute-care hospital utilization near the end-of-life across Canada and indirectly examine access to palliative care in cancer patients who die in hospital. Methods: Data were obtained from the Canadian Institute for Health Information. The analysis was restricted to adults aged 18+ who died in an acute care hospital in 2014/15 and 2015/16 for nine provinces and three territories. The Discharge Abstract Database was used to extract acute-care cancer death abstracts. Data on intensive care unit (ICU) admissions includes only facilities that report ICU data. Results: Acute care utilization at end-of-life remains commonplace. In Canada (excluding Québec), 43% (48,987) of deaths from cancer occurred in acute-care hospitals, with 70% admitted through the emergency department (ED). In the last six months of life, cancer patients dying in hospital had a median cumulative length of stay ranging from 17 to 25 days, depending on the province. Between 18.1% and 32.8% of patients experienced two or more admissions to the hospital in the last month of life. The proportion of cancer patients admitted to the ICU in the last 14 days of life ranged from 6.4% to 15.1%. Patient demographics (age, sex, place of residence) and clinical factors (cancer type) were often predictors of hospital utilization at end-of-life and likely point to inequities in access to palliative and end-of-life care. Conclusion: Despite previous patient surveys indicating that patients would prefer to receive care and spend their finals days at home or in a hospice, there appears to be overuse of and overreliance on acute care hospital services near the end-of-life in Canada. The high rates of hospital deaths and admissions through the ED at the end-of-life for cancer patients may signal a lack of planning for impeding death and inadequate availability of or access to community- and home-based palliative and end-of-life care services. Acute care hospitals may have a role in managing the health care needs of people affected by cancer; however, end-of-life care should be an option in other settings that align with patient preferences. Standards or practice guidelines to identify, assess and refer patients to palliative care services earlier in their cancer journey should be developed and implemented to ensure optimal quality of life.

Trace organic contaminant (TOrC) mixtures in Minnesota littoral zones: Effects of on-site wastewater treatment system (OWTS) proximity and biological impact

On-site wastewater treatment systems (OWTSs) are an international wastewater management strategy for rural and semi-rural communities without access to centralized sewage treatment. These systems are a suspected source of trace organic contaminants (TOrCs) that may be responsible for endocrine disrupting effects to resident fish species in Minnesota Lakes. This study assessed localized porewater concentrations of TOrCs in near-shore environments across five Minnesota Lakes. Sampling sites were designated as either likely (HOME) or unlikely (REF) to receive OWTS discharges based on their proximity to shoreline households. Sampling sites also served as sunfish spawning habitats concurrently studied for biological impacts to resident adult males. Two-group hypothesis tests demonstrated significantly (p = .02) higher total TOrC concentrations in HOME (Mean = 841 ng/L) versus REF (Mean = 222 ng/L) sites. HOME sites also contained a wider suite of TOrC detections relative to REF sites. The distance to the nearest household (most proximal distance; MPD) negatively correlated (r = -0.62) with total TOrC concentrations. However, 2,4-D and DEET were major contributors to these total concentrations, suggesting that anthropogenic influence from households may not be exclusively attributed to OWTS discharges. Further, TOrC presence and elevated nitrogen concentrations in REF site porewater suggest additional, non-household TOrC discharges to these lakes. Significantly higher blood concentrations of vitellogenin (p = .03) and 11-ketotestosterone (p = .01) were observed in adult male sunfish captured from HOME versus REF sites. Comparisons between chemical and biological data indicate enhanced bioactive effects of co-contaminants. The findings from this study demonstrate multiple diffuse transport pathways contribute to the presence of biologically active TOrC mixtures in Minnesota Lakes, and mitigation efforts should consider minimizing residential inputs of chemicals associated with both outdoor and OWTS activity.

Measuring patient-reported outcomes to improve cancer care in Canada: an analysis of provincial survey data

Patient-reported outcomes measures (proms) are an important component of the shift from disease-centred to person-centred care. In oncology, proms describe the effects of cancer and its treatment from the patient perspective and ideally enable patients to communicate to their providers the physical symptoms and psychosocial concerns that are most relevant to them. The Edmonton Symptom Assessment System-revised (esas-r) is a commonly used and validated tool in Canada to assess symptoms related to cancer. Here, we describe the extent to which patient-reported outcome programs have been implemented in Canada and the severity of symptoms causing distress for patients with cancer. As of April 2017, 8 of 10 provinces had implemented the esas-r to assess patient-reported outcomes. Data capture methods, the proportion of cancer treatment sites that have implemented the esas-r, and the time and frequency of screening vary from province to province. From October 2016 to March 2017 in the 8 reporting provinces, 88.0% of cancer patients were screened for symptoms. Of patients who reported having symptoms, 44.3% reported depression, with 15.5% reporting moderate-to-high levels; 50.0% reported pain, with 18.6% reporting moderate-to-high levels; 56.2% reported anxiety, with 20.4% reporting moderate-to-high levels; and 75.1% reported fatigue, with 34.4% reporting moderate-to-high levels. There are some notable areas in which the implementation of proms could be improved in Canada. Findings point to a need to increase the number of cancer treatment sites that screen all patients for symptoms; to standardize when and how frequently patients are screened across the country; to screen patients for symptoms during all phases of their cancer journey, not just during treatment; and to assess whether giving cancer care providers real-time patient-reported outcomes data has led to appropriate interventions that reduce the symptom burden and improve patient outcomes. Continued measurement and reporting at the system level will allow for a better understanding of progress in proms activity over time and of the areas in which targeted quality improvement efforts could ensure that patient symptoms and concerns are being addressed.

Prognostic value of primary tumour resection in synchronous metastatic colorectal cancer: Individual patient data analysis of first-line randomised trials from the ARCAD database

Indication for primary tumour resection (PTR) in asymptomatic metastatic colorectal cancer (mCRC) patients is unclear. Previous retrospective analyses suggest a survival benefit for patients who underwent PTR. The aim was to evaluate the prognostic value of PTR in patients with synchronous mCRC by analysis of recent large RCTs including systemic therapy with modern targeted agents. Individual patient data (IPD) of 3423 patients enrolled into 8 randomised controlled trials (RCTs) with first-line systemic therapy in the ARCAD (Aide et Recherche en Cancérologie Digestive) database were analysed. The number of patients with unresected synchronous mCRC, resected synchronous mCRC and metachronous mCRC was 710 (21%), 1705 (50%) and 1008 (29%), respectively. Adjusting for age, gender, performance status (PS) and prior chemotherapy, the unresected group had a significantly worse median overall survival (16.4 m) compared with the synchronous resected (22.2 m; hazard ratio [HR] 1.60, 95% CI 1.43-1.78) and metachronous (22.4 m; HR 1.81, 95% CI 1.58-2.07) groups. Similarly, median progression-free survival was significantly worse for the unresected group compared with the synchronous resected (HR 1.31, 95% CI 1.19-1.44) and metachronous (HR 1.47, 95% CI 1.30-1.66) groups. In a multivariate analysis, the observed associations remained significant. This largest IPD analysis of mCRC trials to date demonstrates an improved survival in synchronous mCRC patients after PTR. These results may be subject to bias since reasons for (non)resection were not available. Until results of ongoing RCTs are available, both upfront PTR followed by systemic treatment and upfront systemic treatment are considered appropriate treatment strategies.

Tracking evolution of aromatase inhibitor resistance with circulating tumour DNA analysis in metastatic breast cancer

Background

Selection of resistance mutations may play a major role in the development of endocrine resistance. ESR1 mutations are rare in primary breast cancer but have high prevalence in patients treated with aromatase inhibitors (AI) for advanced breast cancer. We investigated the evolution of genetic resistance to the first-line AI therapy using sequential ctDNA sampling in patients with advanced breast cancer.

Patients and methods

Eighty-three patients on the first-line AI therapy for metastatic breast cancer were enrolled in a prospective study. Plasma samples were collected every 3 months to disease progression and ctDNA analysed by digital droplet PCR and enhanced tagged-amplicon sequencing (eTAm-Seq). Mutations identified in progression samples by sequencing were tracked back through samples before progression to study the evolution of mutations on therapy. The frequency of novel mutations was validated in an independent cohort of available baseline plasma samples in the Study of Faslodex versus Exemestane with or without Arimidex (SoFEA) trial, which enrolled patients with prior sensitivity to AI.

Results

Of the 39 patients who progressed on the first-line AI, 56.4% (22/39) had ESR1 mutations detectable at progression, which were polyclonal in 40.9% (9/22) patients. In serial tracking, ESR1 mutations were detectable median 6.7 months (95% confidence interval 3.7-NA) before clinical progression. Utilising eTAm-Seq ctDNA sequencing of progression plasma, ESR1 mutations were demonstrated to be sub-clonal in 72.2% (13/18) patients. Mutations in RAS genes were identified in 15.4% (6/39) of progressing patients (4 KRAS, 1 HRAS, 1 NRAS). In SoFEA, KRAS mutations were detected in 21.2% (24/113) patients although there was no evidence that KRAS mutation status was prognostic for progression free or overall survival.

Conclusions

Cancers progressing on the first-line AI show high levels of genetic heterogeneity, with frequent sub-clonal mutations. Sub-clonal KRAS mutations are found at high frequency. The genetic diversity of AI resistant cancers may limit subsequent targeted therapy approaches.