"There should be one spot that you can go:" BRCA mutation carriers' perspectives on cancer risk management and a hereditary cancer registry

Individuals who carry BRCA1 or BRCA2 pathogenic variants are recommended to have extensive cancer prevention screening and risk-reducing surgeries. Uptake of these recommendations is variable, and there remains room for improvement in the risk management of BRCA carriers. This paper explores female BRCA carriers' experiences with the current model of care and their perspectives on (and interest in) an inherited cancer registry. Findings can inform the development of a dedicated high-risk screening and management program for these patients. Quantitative and qualitative data were gathered through a provincial descriptive survey and semi-structured qualitative interviews to assess BRCA carriers' opinions toward risk management services in the province of Newfoundland and Labrador (NL), Canada. Survey (n = 69) and interview data (n = 15) revealed continuity and coordination challenges with the current system of care of high-risk individuals. Respondents suggested an inherited cancer registry would help identify high-risk individuals and provide a centralized system of risk management for identified carriers. Respondents identified concerns about the privacy of their registry data, including who could access it. Findings suggest BRCA carriers see great value in an inherited cancer registry. Specifically, participants noted it could provide a centralized system to help improve the coordination of burdensome, life-long risk management. Important patient concerns about protecting their privacy and their health data confidentiality must be addressed in patient and public information and informed consent documents about a registry.

Tradeoffs and synergies in wetland multifunctionality: A scaling issue

Wetland area in agricultural landscapes has been heavily reduced to gain land for crop production, but in recent years there is increased societal recognition of the negative consequences from wetland loss on nutrient retention, biodiversity and a range of other benefits to humans. The current trend is therefore to re-establish wetlands, often with an aim to achieve the simultaneous delivery of multiple ecosystem services, i.e., multifunctionality. Here we review the literature on key objectives used to motivate wetland re-establishment in temperate agricultural landscapes (provision of flow regulation, nutrient retention, climate mitigation, biodiversity conservation and cultural ecosystem services), and their relationships to environmental properties, in order to identify potential for tradeoffs and synergies concerning the development of multifunctional wetlands. Through this process, we find that there is a need for a change in scale from a focus on single wetlands to wetlandscapes (multiple neighboring wetlands including their catchments and surrounding landscape features) if multiple societal and environmental goals are to be achieved. Finally, we discuss the key factors to be considered when planning for re-establishment of wetlands that can support achievement of a wide range of objectives at the landscape scale.

Temperature-related chest pain presentations and future projections with climate change

Background

Climate change has led to increased interest in studying adverse health effects relating to ambient temperatures. It is unclear whether incident chest pain is associated with non-optimal temperatures and how chest pain presentation rates might be affected by climate change.

Methods

The study included ambulance data of chest pain presentations in Melbourne, Australia from 1/1/2015 to 30/6/2019 with linkage to hospital and emergency discharge diagnosis data. A time series quasi-Poisson regression with a distributed lag nonlinear model was fitted to assess the temperature-chest pain presentation associations, after adjusting for season, day of the week and long-term trend. Future excess chest pain presentations associated with cold and heat were projected under six general circulation models under medium and high emission scenarios.

Results

In 206,789 chest pain presentations, mean (SD) age was 61.2 (18.9) years and 50.3% were female. Significant heat- and cold-related increased risk of chest pain presentations were observed for mean air temperatures above and below 20.8°C, respectively (Figure 1). Excess chest pain presentations related to heat were observed in all subgroups, but appeared to be attenuated for older patients (≥70 years) and patients of higher socioeconomic status (SES). We projected no significant change in net temperature-related chest pain presentations with climate change under medium- and high-emission scenarios, with increases in heat-related chest pain presentations offset by decreases in chest pain presentations related to cold temperatures.

Conclusions

Heat- and cold-exposure appear to increase risk of chest pain presentations, especially among younger patients and patients of lower SES. In Melbourne, Australia, chest pain presentations overall were not projected to increase with climate change, but increases in heat-related chest pain presentations highlight the importance of risk mitigation strategies to minimise adverse health impacts on hotter days.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Alfred Health.

Impact of ambulance off-load delays on mortality in patients with chest pain

Background

Ambulance off-load delays in transferring patient care to emergency departments (EDs) are increasingly common, but it is unclear whether clinical outcomes are impacted.

Methods

Population-based cohort study of ambulance attendances for non-traumatic chest pain transported to ED in Victoria, Australia (1/1/2015–30/6/2019) excluding patients transported to hospital with “lights and sirens” or triaged as ED category 1. Multivariable models were used to assess the relationship between ambulance off-load times and 30-day mortality and ambulance re-attendance for chest pain.

Results

The study included 213,544 ambulance attendances for chest pain (mean age 62 [SD 18] years; 51% female). Median ambulance off-load times increased across the study period from 21 minutes (interquartile range [IQR] 15–30) in 2015 to 24 minutes (IQR 17–37) in 2019. Patients were divided into tertiles according to off-load times with 69,247 patients included in tertile 1 (0–17 minutes), 73,109 patients in tertile 2 (18–28 minutes), and 71,188 patients in tertile 3 (>28 minutes). In multivariable models, ambulance off-load delays were associated with higher unadjusted and adjusted rates of 30-day mortality (1.57% tertile 3 vs. 1.29% tertile 1, adjusted risk difference 0.28% [95% CI 0.16% - 0.42%], p<0.001) and ambulance re-attendance for chest pain (9.89% tertile 3 vs. 8.59% tertile 1, adjusted risk difference 1.30% [95% CI 1.00% - 1.61%], p<0.001). Similarly, in analysis using off-load times as a continuous variable with restricted cubic splines, a non-linear increase in adjusted odds ratio for mortality was observed (Figure 1).

Conclusions

Delays in ambulance off-load times appear to be associated with increased mortality and ambulance re-attendance risk among chest pain cohorts. This study has important policy implications given the increasing frequency of off-load delays in many healthcare settings.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Alfred health

Variation in health-care quality and outcomes according to time of chest pain presentation: a state-wide prospective cohort study

Background

Previous studies examining temporal variation in cardiovascular care have largely been limited to assessing weekend and after-hours effects whereby those presenting on the weekend or after-hours have a poorer outcome. However, emerging evidence suggests more complex patterns in patterns and outcomes may exist.

Purpose

We aimed to determine patterns of temporal variation in chest pain presentations and subsequent health-care quality and outcomes.

Methods

This was an observational, prospective-cohort study of adult patients aged 18 and over who were attended by emergency medical services for non-traumatic chest pain between 1 January 2015 and 30 June 2019 in Victoria, Australia. Major exclusion criteria included pre-hospital diagnosis of ST elevation myocardial infarction or an out of hospital cardiac arrest. The exposure variable was time of day and day of week stratified into 168 hourly time periods. The primary outcome measure was 30-day mortality.

Results

The study cohort comprised 196,365 ambulance attendances for acute non-traumatic chest pain; mean age 62.4 years (SD 18.3) and 99,497 (50.7%) females. Three temporal patterns were observed for chest pain presentations (Figure 1): (1) a diurnal pattern with a sharp increase in presentations from 8 am, peaking around midday, before decreasing into late evening with a nadir between 3–4 am, (2) a weekend effect where Saturday and Sunday had a relatively lower rate of presentations compared to during the week, and (3) a Monday – Sunday gradient where more presentations were likely earlier in the week, than later. Six patterns were identified across pre-hospital and hospital key performance indicators (KPI) (diurnal, in/after-hours, weekend effect, Monday – Sunday gradient, a peak period and morning vs afternoon/evening effect. Risk of 30-day mortality was associated with weekend presentation (OR 1.15, 95% CI 1.06–1.24, p=0.001) and morning presentation between midnight and midday (OR 1.17, 95% CI 1.09–1.25, p<0.001) (Figure 2).

Conclusion

Chest pain presentations, care quality and outcomes demonstrate complex temporal variation beyond the already established weekend and after-hours effect. Such relationships should be considered during resource allocation and quality improvement programs in order to improve treatment quality across all days and times of the week.

Funding Acknowledgement

Type of funding sources: None.

Blood Indices In Adult Acute Burn: A Window Into Milieu Interieur - The Future Biomarkers?

Optimal treatment of sepsis in burned patients depends on early diagnosis and includes prompt administration of antimicrobials as well as management of hemodynamic alterations and other organ dysfunctions. The role of red blood cell distribution width (RDW) and platelet indices in prognosticating and identifying sepsis in acute burn patients is studied. This study was done as a prospective study over 18 months, including patients in the age group >18 or <60 years, with burns >20% and <70% TBSA, burn time to resuscitation time 24 hours or less and with thermal and scald burns. Data of 157 patients were analyzed and the following observations were made. The mean age of the study population was 31.36 years (18-59 years). RDW values were higher in the non-survivor group. Platelet count and plateletcrit were higher in the survivor group and the no sepsis group. Positive rising trends of platelet count and plateletcrit were seen in the survivor group. Day 1, 3, 7 values of RDW, platelet count and plateletcrit were significant in determining the outcome of the patient on mortality and sepsis related morbidity of the patient. RDW, platelet count and plateletcrit in combination can predict mortality and sepsis as early as the third day, thus giving a clinical advantage of initiating targeted treatment to the at-risk burn population before sepsis is detected clinically. This could better the outcomes in treatment of burn patients.

ICONIC study—conservative versus conventional oxygenation targets in intensive care patients: study protocol for a randomized clinical trial

Background

Oxygen therapy is a widely used intervention in acutely ill patients in the intensive care unit (ICU). It is established that not only hypoxia, but also prolonged hyperoxia is associated with poor patient-centered outcomes. Nevertheless, a fundamental knowledge gap remains regarding optimal oxygenation for critically ill patients. In this randomized clinical trial, we aim to compare ventilation that uses conservative oxygenation targets with ventilation that uses conventional oxygen targets with respect to mortality in ICU patients.

Methods

The “ConservatIve versus CONventional oxygenation targets in Intensive Care patients” trial (ICONIC) is an investigator-initiated, international, multicenter, randomized clinical two-arm trial in ventilated adult ICU patients. The ICONIC trial will run in multiple ICUs in The Netherlands and Italy to enroll 1512 ventilated patients. ICU patients with an expected mechanical ventilation time of more than 24 h are randomized to a ventilation strategy that uses conservative (PaO₂ 55–80 mmHg (7.3–10.7 kPa)) or conventional (PaO₂ 110–150 mmHg (14.7–20 kPa)) oxygenation targets. The primary endpoint is 28-day mortality. Secondary endpoints are ventilator-free days at day 28, ICU mortality, in-hospital mortality, 90-day mortality, ICU- and hospital length of stay, ischemic events, quality of life, and patient opinion of research and consent in the emergency setting.

Discussion

The ICONIC trial is expected to provide evidence on the effects of conservative versus conventional oxygenation targets in the ICU population. This study may guide targeted oxygen therapy in the future.

Trial registration

Trialregister.nl NTR7376. Registered on 20 July, 2018.

Colchicine and quality of life in patients with acute coronary syndromes: results from the COPS randomized trial

Background

Recent data suggest that colchicine may reduce cardiovascular events among patients presenting with acute coronary syndromes. This sub-study of the Australian COPS trial aimed to assess whether colchicine affects health status outcomes.

Methods

Health status was assessed at baseline and 12-months using the EuroQol-5 Dimension 5-level (EQ-5D-5L) score and the full 19-question Seattle Angina Questionnaire (SAQ). Data were available for 786 patients (388 randomized to colchicine, 398 to placebo).

Results

Baseline characteristics were well matched between groups; mean age was 60.1 (SD 14.8) years, and 20% were female. Baseline health status scores were impaired, and most parameters demonstrated significant improvement from baseline to 12-months (EQ-5D-5L Visual Analogue Score [VAS] 69.3 to 77.7; SAQ angina frequency score 83.0 to 95.3, both p&lt;0.001). No significant differences in adjusted mean score change among any of the EQ-5D-5L or SAQ dimensions were observed between treatment groups in either intention-to-treat or per-protocol analysis. There were borderline interactions in EQ-5D-5L scores for those with previous MI vs not, and in SAQ scores for those with obesity vs not. In categorical analysis using observed data, patients treated with colchicine were more likely to have clinically significant improvement in physical limitation score over the period (36% improved vs. 28%, P&lt;0.05). Baseline health status scores were not associated with the primary endpoint at 12 months.

Conclusions

Treatment with colchicine did not appear to affect change in measures of health status following acute coronary syndromes, but it did lead to a greater likelihood of improvement in physical limitation scores.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Peninsula Health, Monash University

110 Pregnancy rate and embryo viability in response to chorionic gonadotrophins given for oestrus induction and gonadotrophin-releasing hormone 5 days after timed laparoscope-aided insemination of lactating and non-lactating goats

Gonadotrophins are included in oestrous/ovulation synchronization (E/OS) regimens when breeding early in the transitional phase to promote follicular development. However, the time of use has been a matter of debate. Hence, the objective of this study was to determine whether equine and human chorionic gonadotrophins (eCG and hCG, respectively) given 24h before or 24h after concurrent removal of intravaginal progestagen (P4) and prostaglandin (PGF2α) delivery influences pregnancy rate (PR) and/or embryo viability (EV). Relatedly, the influence of gonadotrophin-releasing hormone (GnRH) 5 days post-breeding (dpb) on PR and/or EV was also considered. A prospective randomised control trial was conducted using lactating and non-lactating Alpine breed goats of different parity, average±s.e. age, and bodyweight (3.7±2.6), and (52.5±7), respectively. Goats were time-bred at 48h after P4 removal by laparoscopy (LAI; n=75) or by natural service (NS; n=29) during the early transitional breeding phase in mid-September through mid-December (corresponding to 12:12h daylight/darkness). E/OS used an intravaginal device containing 300mg of P4 for 12±1d. At P4 removal, 2mL of PGF2α was administered IM. Twenty-four hours before (E) or 24h after (L) P4 removal, an IM dose of 1.5mL containing 120IU of eCG and 60IU of hCG was given. A third control (C) group (n=38) was not exposed to gonadotrophins. GnRH analogue was given (n=51) 5 days after insemination, and the remaining goats (n=53) received an IM dose of 2mL of saline solution. PR was evaluated at 18 to 24 (dpb) by non-return to oestrus (NRE), at 30 dpb by pregnancy-specific protein B (PSPB), and at 40 dpb by ultrasound imaging (UI). EV was determined from the difference between pregnancy outcomes for NRE and PSPB, and PSPB and UI. Statistical analysis (JMP/SAS vs.11; SAS Institute Inc.) were obtained using logistic regression. All concomitant variables (i.e. parity, bodyweight, days of P4 exposure, and lactation were not influenced by PR or EV; P&gt;0.07). The overall PR was 71% for LAI and 69% for NS and, as shown in Table 1, was similar (P&gt;0.49) at all times (at 18 to 24, 30, and 40 dpb). Likewise, the breeding procedure did not influence the levels of EV at 30 or 40 dpb. E/OS protocol or the use of GnRH 5 dpb did not affect PR or EV at any of the time points evaluated. Table 1. Main effect mean comparisons and logistic model probabilities for pregnancy rate (PR) and embryo viability (EV) by main treatment effect Response variable (days post-breeding) Breeding procedure E/OS Protocol Gonadotrophin LAI NS P&gt; Control Early Late P&gt; GnRH Placebo P&gt; PR at 18–24 77 72 0.49 76 73 78 0.83 78 74 0.49 PR at 30 68 66 0.65 66 65 70 0.82 71 64 0.43 PR at 40 69 69 0.78 66 69 73 0.77 73 66 0.43 EV at 30 89 90 0.94 86 94 90 0.65 92 87 0.46 EV at 40 88 95 0.42 86 89 94 0.73 92 87 0.43

111 Use of gonadotrophin-releasing hormone (GnRH) or equine and human chorionic gonadotrophins for oestrus synchronization and their influence on embryo viability and progesterone levels on day 16 and 30 of goats receiving GnRH 5 days after intrauterine insemination or natural service

Gonadotrophin-releasing hormone (GnRH) or equine and human chorionic gonadotrophins (eCG and hCG) were evaluated for oestrus/ovulation synchronization (E/OS), as well as the influence of GnRH 5 days post-breeding (dpb) on embryo viability (EV), and progesterone (P4) levels on Day 16 and 30 after laparoscopic AI (LAI) or natural service (NS). Fifty-four lactating/non-lactating Alpine breed goats (average of 3.82±1.2s.d. years of age) of mixed parity were E/OS during the early transitional breeding phase using 12±1 day of 300mg of P4 and 2mL of prostaglandin F2α analogue given at P4 removal. The experiment included a sub-group from a larger study in which a completely randomised design was used. The germane data were arranged as a 2×2×2 factorial. This study focused on goats receiving 120IU of eCG and 60IU of hCG (n=40), or GnRH analogue (n=14) 24h after P4 removal. At 5 dpb, 25 goats received 1mL (IM) of GnRH and the control (n=29) received 1mL of physiologic saline. Goats were time-bred 48h after P4 withdrawal by LAI (n=33) or NS (n=21). Pregnancy was diagnosed at 18 to 24, 30, and 40 dpb by non-return to oestrus, pregnancy-specific protein B, and ultrasound, respectively. EV was evaluated as the difference between pregnancy diagnosis results. Blood serum P4 was evaluated at 5, 16, and 30 dpb. A logistic regression model was used for statistical analysis. Pregnancy rate (PR) for LAI or NS, at 18–24, 30, and 40 days was 73 vs. 76%, 67 vs. 62%, and 64 vs. 67%, respectively (P&gt;0.72). In contrast, when GnRH was used for E/OS, the 5 dpb GnRH influenced EV at 30 days (95 vs. 81%; P=0.06) but not at 40 days (89 vs. 86%; P&gt;0.35), compared with placebo. Similarly, with the exception of PR at 40 days (43 vs. 72%; P=0.05), for the GnRH and eCG/hCG E/OS groups, respectively, PR was not affected (P&gt;0.12) by either E/OS or GnRH 5 dpb or their interaction (P&gt;0.35) at any pregnancy diagnosis (i.e. 18–24, 30, or 40 dpb). Likewise, levels of P4 at 5, 16, and 30 dpb did not affect PR at 18–24, 30, and 40 dpb (P&gt;0.92, 0.71, and 0.11). As shown in Table 1, the level of P4 was not influenced for goats receiving GnRH or placebo at 5, 16, or 30 dpb. The baseline mean P4 blood serum level for goats receiving GnRH 5 dpb differed at 16 but not at 30 dpb (P&lt;0.001). Table 1 Blood serum progesterone (P4, ng mL−1) in response to gonadotrophin-releasing hormone (GnRH) or placebo given 5 days post-breeding Sampling day GnRH Placebo P &gt;1 Mean ±SE Mean ±SE 5 (baseline) 6.2a 0.83 5.7a 0.72 0.66 16 11.7b 1.11 11.0b 1.05 0.65 30 6.2a 0.89 7.6c 0.84 0.26 a–cMean values with different superscripts within a column signify statistical difference for GnRH (P&lt;0.001) and placebo (P&lt;0.02). 1Probability for mean differences in the same row.

National cardiac registries: a systematic review

Background

Over the last thirty years, there has been exponential growth in the number and scale of national cardiovascular disease registries. We aimed to provide a comprehensive outline of contemporary national cardiac registries across all subspecialties.

Methods

We performed a systematic literature review by searching OvidMedline in August 2019 to identify registries relating to six pre-specified domains (Table). For inclusion, registries had to be national in nature, actively collecting data, and publishing either peer-reviewed publications or online reports.

Results

A total of 24,076 records were identified from six domain-specific Medline searches; 24,057 abstracts were screened with 19,435 non-relevant records excluded; 4,624 full texts were screened with 4,473 non-relevant texts excluded; and 151 registries met inclusion criteria representing 51 countries. Of these, 15 related to cardiac surgery, 27 to arrhythmia (17 device, 5 ablation, 7 atrial fibrillation), 21 to congenital heart disease (14 general, 2 interventional, 4 surgical, and 1 disease specific), 43 to coronary disease or percutaneous coronary intervention (22 PCI, 21 CAD), 27 to heart failure (13 heart failure, 5 transplant, 2 mechanical support, 7 disease specific), and 18 related to structural intervention (3 any, 13 transcatheter aortic valve replacement, 2 mitral intervention). Nine national registries (USA, Sweden, Finland, Denmark, UK, Portugal, Norway, Taiwan, and Singapore) covered multiple domains. Quality scoring using the Monash University Clinical Quality Registry Grading System (a composite score of recruitment, and data completeness, definitions, reliability and validation), demonstrated marked heterogeneity in quality between registries.

Conclusions

Cardiac registries have seen rapid growth, however the use and quality among various subspecialties differs markedly across world regions. Given the multiple benefits, clinicians, funders and health bureaucrats should be encouraged to focus on the range, quality and uptake of national registries.

Figure 1

Funding Acknowledgement

Type of funding source: None

Long-term outcomes following percutaneous coronary intervention for patients with rheumatoid arthritis

Background

Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Despite this, data regarding long-term outcomes following percutaneous coronary intervention (PCI) are limited.

Methods

We identified 756 patients with RA from the Melbourne Interventional Group PCI registry (2005–2018) and compared outcomes to the remaining cohort (N=38,579). Cox regression analysis was performed to assess risk of adverse cardiac events including long-term mortality (derived from linkage with the National Death Index [NDI]).

Results

Patients with RA were older (68.9±10.0 vs. 64.6±12.0 years) and more often female (40% vs. 23%), with higher rates of hypertension (70% vs 67%), previous stroke (9% vs 6%), peripheral vascular disease (9% vs 6%), obstructive sleep apnoea (10% vs 5%), chronic lung disease (22% vs 12%), prior myocardial infarction (32% vs 27%), and impaired renal function (eGFR&lt;60 ml/min/1.73m2 in 31% vs 24%), while rates of current smoking were lower (20% vs. 25%), all p&lt;0.05. Lesions were more frequently complex (ACC/AHA type B2/C in 61% vs 57%), required longer stents (&gt;20mm in 39% vs 35%), and rates of no reflow were higher (5% vs 3%), all p&lt;0.05. 30-day mortality was higher (4.4% vs. 3.3%, p=0.04) mainly owing to higher non-cardiac mortality (1.6% vs. 0.8%, p=0.01). National Death Index-linked long-term mortality was 28% vs. 19% (p&lt;0.01) with mean follow-up 4.6 vs. 5.4 years. Risk of 30-day and long-term mortality (including by indication subgroup) are presented in the Table.

Conclusions

Patients with RA undergoing PCI have more comorbidities and longer, more complex coronary lesions. After adjustment, risk of short-term adverse outcomes are similar, while risk of long-term mortality is higher, particularly among patients with acute coronary syndromes.

Funding Acknowledgement

Type of funding source: None

151 Influence of chorionic gonadotrophin, breeding procedure, and gonadotrophin-releasing hormone on pregnancy, embryo viability, and kidding rate of lactating Alpine goats time inseminated during the early transitional reproductive phase

Oestrus and ovulation synchronisation (E/OS) regimens containing equine chorionic gonadotrophin (ECG) are used for follicular stimulation during the early transitional reproductive phase and goat anestrus. However, the effects of ECG when applied at different times are unknown. Thus, the objective was to evaluate the influence of ECG, breeding procedure, and gonadotrophin-releasing hormone (GnRH) on pregnancy, embryonic viability, and kidding rate in dairy goats. We used 41 alpine goats (mean±standard deviation: 3.82±1.2 years old; 57.0±6.0kg of bodyweight; 1.75-2.25 body condition score; 195±16.7 days in milk; range of 1-4 kiddings). This study took place during the transitional phase (12h of daylight, 12h of dark) in September (35.9° N, 97.3° W) using controlled internal drug release intravaginal inserts (300mg of progestagen; P4) for 11, 12, or 13 days with a 2-mL intramuscular dose containing 10mg of dinoprost tromethamine at P4 removal. The E/OS protocols differed on the time when the 1-mL intramuscular dose of P.G. 600© (Merck Animal Health; 120 and 60IU of ECG and human chorionic gonadotrophin, respectively) was given (i.e. early=24h before P4 removal; late=24h after P4 removal), and the traditional control group did not receive P.G. 600. Time breeding, either by laparoscopic-aided insemination using frozen-thawed semen (n=28) or natural (n=13), was scheduled 48h after P4 removal. To improve embryo survival, 5 days post-breeding (dpb) 21 goats received 1mL of GnRH analogue intramuscularly as 50µgmL−1 gonadorelin diacetate tetrahydrate, and 20 control goats received 1mL of placebo intramuscularly. Pregnancy rate (PR) was evaluated at d 18-24 by non-return to oestrus, d 30 by pregnancy-specific protein B, and d 40 by ultrasound. Kidding rate was determined for females with at least one newborn. Logistic regression was used to establish statistical significance. Days of P4 exposure did not influence any response variable (P&gt;0.20). Table 1 summarises the results; age influenced all PR evaluations. The number of kiddings and administration of GnRH at 5 dpb had a significant effect on PR, whereas bodyweight, days in milk, E/OS protocol, and breeding procedure were not influential. Embryo viability and kidding rate were not influenced by any variable. In short, P.G. 600 had no bearing on any response variable analysed. Late-lactating goats can be evaluated early in the transitional breeding phase using PR at 18-24, 30, or 40 dpb. As indicated by the lack of effect on embryo viability at 30 and 40 days, the mechanism by which GnRH increases PR was not by decreasing embryo mortality. Table 1.Logistic model independent variable probabilities on response variables1 Response variable Age (years) BW Kidding DIM E/OS protocol GnRH Breeding procedure PR 18-24 d 0.02 0.65 0.15 0.52 0.37 0.21 0.30 PR 30 d 0.01 0.56 0.05 0.58 0.61 0.05 0.39 PR 40 d 0.001 0.12 0.01 0.60 0.62 0.02 0.35 EV 30 d 0.62 0.96 0.61 0.63 0.30 0.32 0.36 EV 40 d 0.44 0.90 0.26 0.36 0.46 0.17 0.40 KR 0.83 0.93 0.63 0.86 0.42 0.29 0.35 1BW=body weight; DIM=days in milk; E/OS=oestrus/ovulation synchronisation; GnRH=gonadotrophin-releasing hormone; PR=pregnancy rate; EV=embryo viability at 30 and 40 d; KR=kidding rate.

Abstract P5-09-17: Risk reducing interventions among BRCA 1 and 2 female carriers in Newfoundland and Labrador: A provincial analysis

Introduction

Germline mutations in the tumour suppressor genes BRCA 1 and 2 result in a significant increase in cancer predisposition. Female carriers can have up to a 50-70% chance of developing a breast malignancy in their life time and a risk of 20-40% for ovarian cancer. Management options for women with a BRCA mutation include screening with annual mammography and magnetic resonance imaging (MRI), prophylactic surgery and chemoprevention. There is substantial evidence that preventative strategies may reduce the risk of developing breast and ovarian cancer and in some cases improve survival.

Newfoundland and Labrador (NL) is the most easterly province in Canada with a population of 525 983. It is geographically and genetically isolated with the majority of residents from English and Irish ancestry. While no one single founder effect has been identified, geographically distinct mutations for both BRCA 1 and 2 have been described. The objective of this study is to characterize the population of BRCA mutation carriers in NL and to evaluate their uptake of risk reducing interventions.

Methods

All BRCA 1 and 2 carriers tested through the Provincial Medical Genetics program between 1996 - 2018 were captured. Inclusion criteria for this study were females ≥ 18 years of age residing in the province. Demographic, clinical history and information on uptake of risk reducing interventions were abstracted from the electronic medical record. Descriptive statistical analysis was performed.

Results

One hundred and sixty one women were identified that met inclusion criteria (38% of patients had BRCA1 and 62% had BRCA 2 mutations). Of those unaffected carriers eligible for mammography and MRI screening, only 58% were adherent in the last 18 months. Consultation with a medical or gynecological oncologist increased mammogram screening within the last 18 months to 71% compared with 29% of women who did not see an oncologist. MRI screening increased to 80% for those assessed by oncology versus 20% who did not. For those women who underwent prophylactic surgeries, 27% had bilateral mastectomies with the majority having breast reconstruction (&gt;70%). Fifty two percent of carriers had bilateral salpingo-oophorectomies (BSO) at a median age of 45 years in BRCA 1 and 51 years in BRCA 2.

Fifty-three women had a diagnosis of breast cancer and 8 had ovarian cancer. In this cohort, most underwent genetic testing after their diagnosis of cancer (&gt;80%). Median age at presentation of breast cancer was 44 years versus 54 years for ovarian cancer.

Conclusion

This study demonstrates that women with BRCA 1 and 2 mutations are not adequately availing of risk reducing interventions for breast and ovarian cancer. Furthermore, most patients with malignancy did not undergo genetic testing until after they were diagnosed with cancer. Patient focused research designed to explore factors which may contribute is planned. Consultation with an oncologist increased the likelihood of adherence to breast cancer screening. This highlights the importance of specialty care for patients with a hereditary predisposition to breast and ovarian cancer.

Citation Format: Seal MD, Roebothan A, Gabriel A, Dawson L. Risk reducing interventions among BRCA 1 and 2 female carriers in Newfoundland and Labrador: A provincial analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-09-17.

The Overseas Registration Examination of the General Dental Council

The Overseas Registration Examination is a route to entry to the UK Dentists Register for dentists who have qualified outside the European Economic Area. The role of the examination is to protect the public by ensuring that such dentists meet minimum standards of competence. Candidates invest considerable time and resource in attempting the examination. For these reasons it is essential that the examination is both robust and fair. This paper describes the fundamental principles of assessment underpinning the design of the examination and the steps taken by the General Dental Council's ORE Advisory Group to assure its ongoing quality.