Reducing donor acceptance practice variation - Learnings from a discussion forum

PURPOSE

Although waitlist mortality is unacceptably high, nearly half of donor heart offers are rejected by pediatric heart transplant centers. The Advanced Cardiac Therapy Improving Outcome Network (ACTION) and Pediatric Heart Transplant Society (PHTS) convened a multi-institutional donor decision discussion forum (DDDF) aimed at assessing donor acceptance practices and reducing practice variation.

METHODS

A 1-h-long virtual DDDF for providers across North America, the United Kingdom, and Brazil was held monthly. Each session typically included two case presentations posing a real-world donor decision challenge. Attendees were polled before the presenting center's decision was revealed. Group discussion followed, including a review of relevant literature and PHTS data. Metrics of participation, participant agreement with presenting center decisions, and impact on future decision-making were collected and analyzed.

RESULTS

Over 2 years, 41 cases were discussed. Approximately 50 clinicians attended each call. Risk factors influencing decision-making included donor quality (10), size discrepancy (8), and COVID-19 (8). Donor characteristics influenced 63% of decisions, recipient factors 35%. Participants agreed with the decision made by the presenting center only 49% of the time. Post-presentation discussion resulted in 25% of participants changing their original decision. Survey conducted reported that 50% respondents changed their donor acceptance practices.

CONCLUSION

DDDF identified significant variation in pediatric donor decision-making among centers. DDDF may be an effective format to reduce practice variation, provide education to decision-makers, and ultimately increase donor utilization.

Patient and parent-reported outcomes in paediatric ventricular assist device support: a multi-center ACTION learning network feasibility and pilot experience

BACKGROUND

Patient- and proxy-reported outcomes (PROs) are an important indicator of healthcare quality and can be used to inform treatment. Despite the widescale use of PROs in adult cardiology, they are underutilised in paediatric cardiac care. This study describes a six-center feasibility and pilot experience implementing PROs in the paediatric and young adult ventricular assist device population.

METHODS

The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) is a collaborative learning network comprised of 55 centres focused on improving clinical outcomes and the patient/family experience for children with heart failure and those supported by ventricular assist devices. The development of ACTION's PRO programme via engagement with patient and parent stakeholders is described. Pilot feasibility, patient/parent and clinician feedback, and initial PRO findings of patients and families receiving paediatric ventricular assist support across six centres are detailed.

RESULTS

Thirty of the thirty-five eligible patients (85.7%) were enrolled in the PRO programme during the pilot study period. Clinicians and participating patients/parents reported positive experiences with the PRO pilot programme. The most common symptoms reported by patients/parents in the first month post-implant period included limitations in activities, dressing change distress, and post-operative pain. Poor sleep, dressing change distress, sadness, and fatigue were the most common symptoms endorsed >30 days post-implant. Parental sadness and worry were notable throughout the entirety of the post-implant experience.

CONCLUSIONS

This multi-center ACTION learning network-based PRO programme demonstrated initial success in this six-center pilot study experience and yields important next steps for larger-scale PRO collection, research, and clinical intervention.

Considerations for Advanced Heart Failure Consultation in Individuals With Fontan Circulation: Recommendations From ACTION

Individuals with Fontan circulation are at risk of late mortality from both cardiac and noncardiac causes. Despite the known risk of mortality, referral indications for advanced heart failure care vary between centers, and many individuals die from Fontan circulation-related complications either after late consideration for advanced heart failure therapies or having never seen a heart failure specialist. There is a critical need for guidelines to direct appropriately timed referral for advanced heart failure consultation. The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) Fontan Committee has developed recommended thresholds for advanced heart failure referral to guide primary cardiologists. These recommendations are divided into 4 categories of clinical Fontan circulatory dysfunction including (1) cardiac/systemic ventricular dysfunction, (2) Fontan pathway dysfunction, (3) lymphatic dysfunction, and (4) extracardiac dysfunction.

Heroism and paramedic practice: A constructivist metasynthesis of qualitative research

Objectives

We aimed to identify, appraise, and synthesise the qualitative literature to develop theory on heroism and paramedic practice.

Hypothesis/research question

What does published literature tell us about heroism and paramedic practice?

Setting

Paramedics and other healthcare workers (HCWs) faced an outpouring of public support for them early in the COVID-19 pandemic which brought into focus the relationship between them and society, where they are portrayed as heroes.

Participants

We conducted a metasynthesis using Evolved Grounded Theory and procedural guidelines of Noblit and Hare to guide analysis. Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols (PRISMA-P) guidelines were also applied.

Results

151 papers were retrieved and eleven included in the final sample. Studies were moderate to very low quality, involving a wide range of methodologies and settings; none specifically explored heroism and paramedic practice. The following interrelated themes were constructed on heroism and paramedic practice: (a) Myth, Folk law, and storytelling in heroism and paramedic practice (b) The epic journey of heroism and paramedic practice (c) Heroes and Zeroes: The fluctuating Societal Value in heroism and paramedic practice (d) Politicisation, and objectification in Heroism and Paramedic practice.

Conclusion

Paramedics have long been characterised as heroes, but this may not reflect their everyday experiences. Heroism in paramedic practice can provide scripts for prosocial action, inspiring others, and leading to more social heroic actions. Paramedics may however be ambivalent to such heroism narratives, due to politicisation, and objectification in the media and society. This metasynthesis is only one of many possible constructions of heroism and paramedic practice and is the first point in making sense of and developing theory on heroism and paramedic practice.

Study registration

PROSPERO: CRD42021234851.

Vaccine-induced thrombosis and thrombocytopenia (VITT) in Ireland: A review of cases and current practices

Since the beginning of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2) virus pandemic, several highly effective and safe vaccines have been produced at remarkable speed. Following global implementation of vaccination programmes, cases of thrombosis with thrombocytopenia following administration of adenoviral vector-based vaccines started being reported. In this review we discuss the known pathogenesis and epidemiology of so-called vaccine induced thrombocytopenia and thrombosis (VITT). We consider the available guidelines, diagnostic laboratory tests and management options for these patients. Finally, we discuss important unanswered questions and areas for future research in this novel pathoclinical entity.

Correlation of haemophagocytosis with clinical criteria of haemophagocytic lymphohistiocytosis and recommendations for bone marrow reporting

Haemophagocytic lymphohistiocytosis (HLH) is a rare condition resulting from a dysregulated inflammatory response. Currently there are no guidelines on the reporting of haemophagocytosis on bone marrow biopsy (BM) and lack of evidence on correlation between haemophagocytosis with the clinical diagnostic criteria for HLH. We aimed to assess if the amount of haemophagocytosis identified in the BM correlates with HLH-2004 criteria. Secondary aims were to evaluate inter-observer variability in reporting haemophagocytosis, and to formulate recommendations for screening in bone marrow specimens. A retrospective review of bone marrow biopsies from adult patients under investigation for HLH was undertaken independently by two haematopathologists who were blinded to the original biopsy report. The average number of actively haemophagocytic cells in each slide were quantified. Cases with discordance pertaining to the degree of haemophagocytosis were reviewed by both assessors to reach a consensus. Sixty-two specimens from 59 patients were available for assessment. An underlying haematological condition was identified in 34 cases (58%). There was a significant association between the amount of haemophagocytosis identified on the aspirate samples and the number of HLH-2004 criteria met (p<0.0001). In patients where haemophagocytosis was present (n=31), there was a correlation between the amount of haemophagocytosis and ferritin (p=0.041). Based on our review, we have made recommendations for the reporting of BM haemophagocytosis. Our findings indicate that the amount of haemophagocytosis present on BM samples correlates with the number of HLH-2004 criteria. We found marked interobserver variability which we anticipate can be rectified with our recommendations for reporting.

Time, cost and carbon-efficiency: a silver lining of COVID era virtual urology clinics?

INTRODUCTION

The COVID-19 pandemic has demanded radical changes in service delivery. Our centre adopted the use of outpatient telemedicine to reduce close-contact interactions between patients and staff. We hypothesised that incidental gains may be associated with this. We evaluated financial, practical and environmental implications of substituting virtual clinics (VCs) for in-person urology outpatient appointments.

METHODS

VCs were studied over a 3-month period. Based on patient-reported 'usual mode of transport' to the hospital, travel distance, time, petrol and parking costs, and the carbon emissions avoided by virtue of remote consultations were calculated. The underlying symptom/diagnosis and the 'effectiveness' of the VC were evaluated.

RESULTS

Of 1,016 scheduled consultations, 736 (72.44%) were conducted by VCs over the study period. VCs resulted in an agreed treatment plan in 98.4% of a representative patient sample. The use of VCs was associated with an overall travel distance saving for patients of 31,038 miles (49,951km) over 3 months, with an average round-trip journey of 93.8 miles (151km) avoided for each rural-dwelling patient and an average financial saving of £25.91 (€28.70) per rural-dwelling car traveller. An estimated 1,257.8 hours of patient time were saved by avoidance of travel and clinic waiting times. Based on car-travelling patients alone, a 6.07-tonne reduction in carbon emissions was achieved with the use of VCs.

CONCLUSIONS

In appropriate clinical circumstances, VCs appear to provide efficiency across a number of domains. Future healthcare may involve offering outpatients the option of telemedicine as an alternative to physical attendance.

Protocol for a constructivist metasynthesis of qualitative research of heroism and paramedic practice

Background:

Exceptional demands have been placed on paramedics and other healthcare workers (HCWs) during the COVID-19 pandemic. An overwhelming outpouring of public support has unfolded, bringing into focus the relationship between paramedics, other HCWs and society, where they are portrayed as heroes. Scholars have studied the notion of heroism to society, and characteristics of such heroic status include: the voluntary nature of a heroic act, risk of physical or social harm, willingness to accept the consequences of action, acting for the benefit of others and without the expectation of gain. While some HCWs and paramedics may reflect these characteristics, many may not. Such heroic narratives can be damaging, stifling meaningful discussion around limits to duties, failing to acknowledge the importance of reciprocity and potentially imposing demands on paramedics and HCWs to be heroic.

Aim:

This article prospectively presents the protocol for a metasynthesis which aims to identify, appraise and synthesise the qualitative literature in order to develop theory on heroism and paramedic practice.

Methods:

Evolved grounded theory methodology is followed along with the procedural guidelines of Noblit and Hare (1988) to guide the analysis. The Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols (PRISMA-P) have also been adopted when preparing this protocol and will be followed in the study proper. The protocol has been registered with the International Prospective Register of Systematic Reviews PROSPERO 2021, registration number CRD42021234851.

Results:

We do not currently have results, but PRISMA guidelines will be followed when reporting our findings.

Conclusion:

Current narratives on heroism and paramedic practice are important in terms of the relationship between paramedics and society. The metasynthesis prospectively reported in this article serves as the first point in our journey of making sense of and developing theory on heroism and paramedic practice.

401 Three Birds with One Stone: Ureteric Calculus Precipitates Diagnosis and Resection of Three Primary Neoplasms

A 67 year-old female presented to our centre with a 2 day history of right flank pain, clinically suggestive of ureteric colic. Computed tomography (CT) confirmed a 6mm right ureteric calculus. However, CT also revealed a large 13cm ipsilateral renal mass, concerning for renal cell carcinoma (RCC). At ureteroscopy for management of the obstructing calculus, a small papillary lesion was noted in the bladder, and excised. Histology confirmed pTa low-grade transitional cell carcinoma.

Following discussion at the Urology multidisciplinary tumour board, MRI venogram (MRV) was recommended to delineate the extension of tumour into the renal vein, and to characterise a pelvic mass seen on original CT. MRV showed enhancing material extending into the IVC, consistent with tumour thrombus. However, it also identified a concerning 6cm solid ovarian mass.

The patient proceeded to open right radical nephrectomy and IVC thrombectomy, hysterectomy, bilateral salpingo-oopherectomy, and omental biopsy, with combined input from Urological, Gynaecological and Vascular surgical teams. Post-operative course was uneventful. Histology showed an 11cm pT3a G2 clear cell RCC, and 7.5cm ovarian fibroma, both fully excised. This case demonstrated the serendipity of a simple ureteric calculus precipitating a cascade of investigations, that ultimately led to complete resection of three primary neoplasms.

Collaboration and new data in ACTION: a learning health care system to improve pediatric heart failure and ventricular assist device outcomes

Outcomes in pediatric heart failure and ventricular assist devices (VADs) remain suboptimal. Given the complexity and limited numbers, centers cannot be expected to acquire mastery and generalizable knowledge independently. Recognizing this problem, the community has formed Advanced Cardiac Therapies Improving Outcomes Network (ACTION), a collaborative learning health care system committed to unrelenting collaboration and continuous learning to improve critical outcomes in pediatric heart failure. ACTION is inclusive of all interested parties and believes the fastest and most effective way to make progress is through working together. ACTION's approaches to collaboration and data sharing will be highlighted.

Intensive care utilization and outcomes after high-risk surgery in Scotland: a population-based cohort study

BACKGROUND

The optimal perioperative use of intensive care unit (ICU) resources is not yet defined. We sought to determine the effect of ICU admission on perioperative (30 day) and long-term mortality.

METHODS

This was an observational study of all surgical patients in Scotland during 2005-7 followed up until 2012. Patient, operative, and care process factors were extracted. The primary outcome was perioperative mortality; secondary outcomes were 1 and 4 yr mortality. Multivariable regression was used to construct a risk prediction model to allow standard-risk and high-risk groups to be defined based on deciles of predicted perioperative mortality risk, and to determine the effect of ICU admission (direct from theatre; indirect after initial care on ward; no ICU admission) on outcome adjusted for confounders.

RESULTS

There were 572 598 patients included. The risk model performed well (c-index 0.92). Perioperative mortality occurred in 1125 (0.2%) in the standard-risk group (n=510 979) and in 3636 (6.4%) in the high-risk group (n=56 785). Patients with no ICU admission within 7 days of surgery had the lowest perioperative mortality (whole cohort 0.7%; high-risk cohort 5.3%). Indirect ICU admission was associated with a higher risk of perioperative mortality when compared with direct admission for the whole cohort (20.9 vs 12.1%; adjusted odds ratio 2.39, 95% confidence interval 2.01-2.84; P<0.01) and for high-risk patients (26.2 vs 17.8%; adjusted odds ratio 1.64, 95% confidence interval 1.37-1.96; P<0.01). Compared with direct ICU admission, indirectly admitted patients had higher severity of illness on admission, required more organ support, and had an increased duration of ICU stay.

CONCLUSIONS

Indirect ICU admission was associated with increased mortality and increased requirement for organ support.

TRIAL REGISTRATION

UKCRN registry no. 15761.

Abstract 2166: Dasatinib displays antitumor efficacy in an orthotopic xenograft mouse model of histiocytic sarcoma

Histiocytic sarcoma (HS) is an orphan hematological malignancy with an incidence of less than 1% of all non-Hodgkin's lymphoma, affecting both children and adults. It is a highly metastatic disease, and can affect any organ in the body including spleen, lungs, bone marrow, liver and lymph nodes. It is associated with a poor prognosis as treatment options are scarce and responses are short lived. Dogs spontaneously develop a similar form of HS with an appreciable frequency, and therefore present a unique translational model to investigate better treatments. Preliminary data from in vitro studies identified dasatinib, a multi tyrosine kinase inhibitor, as a highly potent drug against HS cell lines derived from tumors in dogs, but non-toxic to normal normal tissue surrogate fibroblasts. The current study was undertaken to evaluate if the efficacy of dasatinib could be re-capitulated in an in vivo orthotopic xenograft model of HS. The mouse model was generated in NOD-SCID mice by surgical injection of HS cells, transfected with a luciferase reporter construct, into their spleen. Tumor growth was monitored using In Vivo Imaging System. Mice were treated with 30 mg/kg of dasatinib intraperitoneally once a day or vehicle control, with five mice in each group. Dasatinib treated mice had a significantly decreased tumor growth rate in comparison to untreated mice. Most importantly, treatment with dasatinib significantly increased their survival time. All mice from the vehicle control group reached humane endpoints for euthanasia by day 27, while treated mice were clinically stable at day 53, with the difference in survival being highly significant (p&lt;0.0001). In conclusion, here we report the first orthotopic xenograft mouse model of HS, that offers the possibility to test therapeutic response to novel agents, such as dasatinib. Our findings indicate that dasatinib is a promising treatment option for HS, and provide a rational for the initiation of clinical trials.

Citation Format: Marilia Takada, Lauren Smyth, Vilma Yuzbasiyan-Gurkan. Dasatinib displays antitumor efficacy in an orthotopic xenograft mouse model of histiocytic sarcoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2166.

Effect of day of the week on short- and long-term mortality after emergency general surgery

BACKGROUND

The effect of day of the week on outcome after surgery is the subject of debate. The aim was to determine whether day of the week of emergency general surgery alters short- and long-term mortality.

METHODS

This was an observational study of all patients undergoing emergency general surgery in Scotland between 1 January 2005 and 31 December 2007, followed to 2012. Multilevel logistic and Cox proportional hazards regression were used to assess the effect of day of the week of surgery on outcome after adjustment for case mix and risk factors. The primary outcome was perioperative mortality; the secondary outcome was overall survival.

RESULTS

A total of 50 844 patients were identified, of whom 31 499 had an emergency procedure on Monday to Thursday and 19 345 on Friday to Sunday. Patients undergoing surgery at the weekend were younger (mean 45·9 versus 47·5 years; P < 0·001) and had fewer co-morbidities, but underwent riskier and/or more complex procedures (P < 0·001). Patients who had surgery at the weekend were more likely to have been operated on sooner than those who had weekday surgery (mean time from admission to operation 1·2 versus 1·6 days; P < 0·001). No difference in perioperative mortality (odds ratio 1·00, 95 per cent c.i. 0·89 to 1·13; P = 0·989) or overall survival (hazard ratio 1·01, 0·97 to 1·06; P = 0·583) was observed when surgery was performed at the weekend. There was no difference in overall survival after surgery undertaken on any particular day compared with Wednesday; a borderline reduction in perioperative mortality was seen on Tuesday.

CONCLUSION

There was no difference in short- or long-term mortality following emergency general surgery at the weekend, compared with mid-week.

Abstract P4-21-34: Phase II study of gemcitabine, trastuzumab, and pertuzumab for HER2-Positive metastatic breast cancer after prior pertuzumab-based therapy

Background: The combination of taxanes with trastuzumab (H) and pertuzumab (P) for first line treatment of HER2-positive metastatic breast cancer (MBC) is associated with improved progression-free survival (PFS) and overall survival (OS). Treatment per physician's choice with anti-HER2 therapy after second line therapy is associated with a median PFS of 3 months. While continued use of H in therapeutic combinations after progression on H-based therapy is common, the efficacy of continuing HP-based treatment after progression on P-based therapy is unknown.

Methods: This is a single arm phase II trial of gemcitabine (G) with HP. Eligible patients had HER2-positive (IHC 3+ or FISH ≥ 2.0) MBC with prior HP-based treatment and ≤ 3 prior chemotherapies. Patients received G (1200 mg/m2) on days 1 and 8 of a q 3 week (w) cycle, and H (8 mg/kg load → 6 mg/kg) and P (840 mg load → 420 mg) q3w. The primary endpoint is PFS at 3 months. Secondary endpoints include OS, safety and tolerability. An exploratory endpoint is to compare PFS by RECIST criteria versus 18-F FDG-PET response criteria. Using a Simon optimal 2-stage design, 21 patients were enrolled in stage 1. The successful 3-month PFS rate for stage 1 was set at 57% to allow accrual to stage 2 for a total of 45 patients. The study therapy will be considered successful if at least 27/45 (60%) patients are progression free at 3 months.

Results: As of June 9, 2016, 28 patients are enrolled; 21 are evaluable at 3 months and 7 have not had 3-month evaluation. At 3 months, 16/21 (76%) are progression free; 5 patients have progressed. The 3 month-PFS results for evaluable patients will be updated. There are no cardiac or febrile neutropenic events to date. Initially, 5 of 22 (23%) patients required G dose reduction (4 due to grade 3 neutropenia and 1 due to grade 3 vomiting) and the study was amended to lower initial G dose to 1000 mg/m2.

Conclusions: The preliminary 3 month-PFS is 76% (95% CI 55% to 89%) in evaluable patients, and updated data will be presented. These findings suggest clinical benefit when P is continued beyond progression.

Citation Format: Iyengar NM, Smyth L, Lake D, Gucalp A, Singh JC, Traina TA, DeFusco P, Dickler MN, Fornier MN, Goldfarb S, Jhaveri K, Modi S, Troso-Sandoval T, Argolo D, Jack K, Ulaner G, Jochelson M, Baselga J, Norton L, Hudis CA, Dang CT. Phase II study of gemcitabine, trastuzumab, and pertuzumab for HER2-Positive metastatic breast cancer after prior pertuzumab-based therapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-34.

Prevalence and significance of CYP2C19*2 and CYP2C19*17 alleles in a New Zealand acute coronary syndrome population

BACKGROUND

High on-treatment platelet reactivity has been associated with poor outcomes following acute coronary syndromes (ACS). Both the loss of function CYP2C19*2 allele and the gain of function CYP2C19*17 allele along with a range of clinical characteristics have been associated with variation in the response to clopidogrel.

AIM

The study aims to examine the frequency of CYP2C19 variants and understand the factors associated with on-treatment platelet reactivity in a New Zealand ACS population.

METHODS

We prospectively enrolled 312 ACS patients. We collected clinical characteristics and measured on-treatment platelet reactivity using two validated point-of-care assays, VerifyNow and Multiplate. DNA was extracted and CYP2C19*2 and *17 alleles were identified using real-time polymerase chain reaction.

RESULTS

CYP2C19*2 or CYP2C19*17 alleles were observed in 101 (32%) and 106 (34%) of patients, respectively, with significant differences in distribution by ethnicity. In Maori and Pacific Island patients, 47% (confidence interval (CI) 31-63%) had CYP2C19*2 and 11% (CI 4-19%) CYP2C19*17 compared with 26% (CI 19-32%) and 41% (CI 32-49%) in white people. Carriage of CYP2C19*2 alleles was associated with higher levels of platelet reactivity measured by either assay, but we observed no relationship between platelet reactivity and CYP2C19*17. In multivariate analysis diabetes, clopidogrel dose and CYP2C19*2 status were all significant independent predictors of platelet reactivity.

CONCLUSIONS

Both CYP2C19*2 and *17 were common in a New Zealand ACS population, with CYP2C19*2 observed in almost half the Maori and Pacific Island patients. CYP2C19*2, diabetes and clopidogrel dose were independent contributors to on-treatment platelet reactivity.

Abstract P1-14-17: Pathologic complete response rate with doxorubicin and cyclophosphamide followed by weekly paclitaxel with trastuzumab and pertuzumab in patients with HER2-positive early stage breast cancer: A single institution experience

Background:

Trastuzumab and pertuzumab (HP) with standard chemotherapy is approved for use in the neoadjuvant setting. We performed a retrospective analysis of patients (pts) treated with dose-dense doxorubicin and cyclophosphamide (AC) → paclitaxel, trastuzumab, pertuzumab (THP) in the neoadjuvant setting. Here we report the pathologic complete response (pCR) rate.

Methods:

We abstracted medical records of patients who were treated with pertuzumab-based therapy in the neoadjuvant setting from September 1, 2013 to March 1, 2015. Charts were analyzed for pt demographics, stage of breast cancer, pathology reports, surgical data, and information on systemic therapy.

Results:

Charts from 66 pts were reviewed; 60 pts were evaluable for pCR defined as absence of invasive disease in the breast, and 6 were not (3-no anthracycline, 1-incomplete chart, 1-no surgery yet, 1-metastatic). Median age was 47 years (range 28-68 years). Of 60 pts, 52 (86%) had operable breast cancer (T1-3, N0-1, M0) of which 7 had clinical stage I disease (T1N0)]; 7 (12%) had locally advanced disease (T2-3, N2-3, M0 or T4a-c, any N, M0), and 1 (2%) had inflammatory breast cancer (T4d, any N, M0). 49 (82%) and 11 (18%) had hormone receptor (HR)-positive and negative diseases, respectively. All patients had HER2-positive breast cancer defined as immunohistochemistry (IHC) 3+ and/or fluorescent in-situ hybridization (FISH) of &gt; 2.0. 30 pts (50%) underwent mastectomy and lumpectomy, respectively. Out of 60 evaluable pts, 41 (68%) had pCR; 32/49 (65%) with HR-positive and 9/11 (82%) with HR-negative diseases had pCR, respectively. Overall 58/60 (97%) pts completed neoadjuvant therapy; 2 did not (1 developed Steven Johnson Syndrome after one cycle of AC and 1 developed pneumonitis after third weekly dose of T with HP).

Conclusions:

At our single center experience the pCR rate of dose dense AC→THP is high at 68 %. These data are similar to results seen in the TRYPHAENA study, and we await the results from the BERENICE trial evaluating pCR as a secondary endpoint.

Patient Demographics Age, years &lt;4525 (42%)45-5419 (32%)&gt;5516 (26%) ECOG Performace Status 031 (52%)129 (48%) Hormone receptor (HR) status HR+ Her2+49 (82%)HR- Her2+11 (18%) Status of Her-2 Positivity IHC positive52 (86%)FISH positive8 (14%) Median tumor size2.6cm (range: 1-8.4cm) Stage Operable (T1-2, N0-1, M0)52 (86%)Operable Stage I7 (12%)Operable Stage II/III45 (74%)Locally advanced (T2-3, N2-3, M0 or T4a-c, any N, M0))7 (12%)Inflammatory (T4d, any N, M0)1 (2%) Type of surgery Lumpectomy30 (50%)Mastectomy30 (50%)

Citation Format: Singh JC, Sugarman S, Jones L, Boafo C, Patil S, Schweber S, Yu A, Argolo D, Modi S, Iyengar N, Smyth L, Norton L, Baselga J, Hudis C, Dang C. Pathologic complete response rate with doxorubicin and cyclophosphamide followed by weekly paclitaxel with trastuzumab and pertuzumab in patients with HER2-positive early stage breast cancer: A single institution experience. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-14-17.

Abstract P4-13-20: Activity of HP-based therapies as third and later lines for the treatment of HER2-positive metastatic breast cancer: A retrospective study from a single institution

Background: Dual anti-HER2 blockade with trastuzumab and pertuzumab (HP) plus chemotherapy is an effective therapy (Rx) in the 1st-line setting for HER2-positive metastatic breast cancer (MBC). Our single arm phase II study included patients (pts) treated with HP plus paclitaxel in the 2nd-line setting with progression-free survival (PFS) benefit. Recently, we reported results from a retrospective study of pts treated at our institution, suggesting a longer PFS for those who received HP-based Rxs when compared to any other anti-HER2 based Rxs in the 2nd-line setting. To further assess the activity of this combination in later Rx lines, we conducted a retrospective analysis of pts with HER2-positive MBC who had progressive disease after 2nd-line and were treated with HP-based Rxs in the 3rd and later lines at MSKCC. Historically, the median (med) PFS in this setting with trastuzumab-based Rx is about 3-4 months.

Methods: Pts diagnosed with HER2-positive MBC and treated with HP-based Rxs at MSKCC between 1-1-2011 and 03-30-2015 and who progressed on 2nd-line Rx were identified through an institutional database. Primary endpoint was PFS in 3rd and later treatment lines.

Results: 70 pts who received any HP-based Rx in the 3rd or later lines of treatment were eligible. The med number of prior anti-HER2 Rx was 3. The baseline characteristics and Rxs are summarized in Table 1. The med PFS for the entire cohort was 5.7 months (95% CI, 4.8-6.5).

Conclusions: In this retrospective analysis involving heavly pretreated patients, HP-based Rx appears to be an active regimen and compares favorably to historical data. This supports the NCCN endorsement of HP-based Rx in later lines if HP has not been delivered previously.

Baseline Characteristics and treatments (n=70)Characteristic(n)(%)Age  Median56 Range27-83 Gender  Female70100.0Male00.0Race  Black1014.3White5477.1Other68.6Ethnicity  Non Hispanic6694.3Hispanic45.7ER/PR status  ER and PR negative2738.6ER and/or PR positive4361.4Type of disease  Non visceral1622.9Visceral5477.1Visceral CNS2130.0Anti-HER2 in early stage  Yes2941.4No4158.6Line of therapy  3rd line1927.14th line1521.45th line912.96th line912.97th line811.48th line and beyond1014.3HP-based regimens  Chemotherapy + HP5477.1Endocrine therapy + HP57.1HP alone912.9Other22.9

Citation Format: Argolo D, Friedman M, Smyth L, Iyengar N, Singh J, Patil S, Norton L, Baselga J, Hudis C, Dang C. Activity of HP-based therapies as third and later lines for the treatment of HER2-positive metastatic breast cancer: A retrospective study from a single institution. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-20.

Abstract OT3-01-09: Phase II study of gemcitabine, trastuzumab, and pertuzumab in the treatment of metastatic HER2-positive breast cancer after prior trastuzumab/pertuzumab- or pertuzumab-based therapy

Background: Despite significant therapeutic advances in the treatment of breast cancers that overexpress human epidermal growth factor receptor-2 (HER2), the large majority of patients (pts) with metastatic disease will experience progression. The development of new HER2 directed therapies has led to improvements in progression free and overall survival; however optimal therapeutic sequencing remains under study. The combination of taxanes with trastuzumab (H) and pertuzumab (P) is active in the first line setting; however the efficacy of continuing dual anti-HER2 therapy with HP after initial progression is unknown.

Trial design: This is a single arm phase II trial of gemcitabine (G) with HP for pts with metastatic HER2-positive breast cancer who have had prior HP-based treatment. G is administered at 1200 mg/m2 on days 1 and 8 of an every 3 week cycle. H is given 8 mg/kg load → 6 mg/kg every 3 weeks or 4 mg/kg load → 2 mg/kg every week. P is given 840 mg load → 420 mg every 3 weeks. All agents will be given intravenously. This trial is currently enrolling pts.

Eligibility criteria: Eligible pts are adults with stage IV HER2-positive (3+ IHC or FISH ≥ 2.0 of primary or metastatic site) breast cancer. Pts may have received prior treatment with HP- or P-based therapy in the (neo)adjuvant, unresectable, locally advanced, or metastatic setting. In the metastatic setting, ≤ 3 prior chemotherapies are permitted. Prior G is allowed only if it was not combined with P. Bone-only non-measurable disease is permitted. Adequate organ and bone marrow function, left ventricular ejection fraction &gt; 50%, and ECOG status ≤ 1 are required. Pts with previously treated brain metastases stable for ≥ 2 months may be enrolled.

Specific aims: The primary objective is to determine the progression free survival (PFS) at 3 months. Secondary objectives include overall survival, safety and tolerability. An exploratory endpoint is to compare PFS determined by RECIST criteria versus 18-F FDG-PET response criteria.

Statistical methods: Based on historical data, the anticipated median PFS in this setting is 3 months. The study will be considered positive if the 3-month PFS is ≥ 70%. A Simon optimal 2-stage design will be used. If 12/21 pts in stage 1 are alive and progression free at 3 months, stage 2 will accrue for a total of 45 pts. If at least 27/45 pts are alive and progression free, the trial will be deemed a success. This design assumes a 10% type I and type II error.

Present accrual and target accrual: 3 out of a planned 45 pts have been enrolled.

Contact information: For more information, please visit clinicaltrials.gov (NCT02252887).

Citation Format: Iyengar NM, Argolo D, Smyth L, Chen MF, Hudis CA, Dang CT. Phase II study of gemcitabine, trastuzumab, and pertuzumab in the treatment of metastatic HER2-positive breast cancer after prior trastuzumab/pertuzumab- or pertuzumab-based therapy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT3-01-09.

Diversity of gut microflora is required for the generation of B cell with regulatory properties in a skin graft model

B cells have been reported to promote graft rejection through alloantibody production. However, there is growing evidence that B cells can contribute to the maintenance of tolerance. Here, we used a mouse model of MHC-class I mismatched skin transplantation to investigate the contribution of B cells to graft survival. We demonstrate that adoptive transfer of B cells prolongs skin graft survival but only when the B cells were isolated from mice housed in low sterility "conventional" (CV) facilities and not from mice housed in pathogen free facilities (SPF). However, prolongation of skin graft survival was lost when B cells were isolated from IL-10 deficient mice housed in CV facilities. The suppressive function of B cells isolated from mice housed in CV facilities correlated with an anti-inflammatory environment and with the presence of a different gut microflora compared to mice maintained in SPF facilities. Treatment of mice in the CV facility with antibiotics abrogated the regulatory capacity of B cells. Finally, we identified transitional B cells isolated from CV facilities as possessing the regulatory function. These findings demonstrate that B cells, and in particular transitional B cells, can promote prolongation of graft survival, a function dependent on licensing by gut microflora.

Imaging findings in recurrent extramedullary leukaemias

Acute leukaemias are relatively common malignancies. Treatment has advanced significantly in the recent past and there has been improved patient survival. This improved initial response is leading to an increasing number of cases of relapse. Extramedullary relapse occurs in a wide variety of locations with varying presentations, imaging findings and differentials. The pathophysiology and clinical course of recurrent extramedullary myeloid and lymphocytic leukaemias are reviewed in this article. The wide variety of imaging findings associated with many important sites of recurrence and the associated differential diagnosis are discussed and illustrated.

The potency of allospecific Tregs cells appears to correlate with T cell receptor functional avidity

CD4(+) CD25(+) regulatory T cells (T(reg) cells) are an attractive adoptive cell therapy in mediating transplantation tolerance. T-cell receptor (TcR) activation is critical for T(reg) function, suggesting that the TcR avidity of T(reg) cells used in therapy may affect the therapeutic outcome. To address this, we compared the regulatory capacity of T(reg) lines expressing TcRs derived from two TcR transgenic mice shown to have the same specificity but different functional avidities. T(reg) lines generated from CD4(+)CD25(+) T cells from C57BL/6 mice were transduced with one of either of these TcRs. The antigen specificity of the transduced T(reg) lines was confirmed in vitro. T(reg) lines expressing the TcR with higher functional avidity showed stronger suppressive capacity in a linked suppression model in vitro. Furthermore, the same T(reg) lines demonstrated a stronger proliferation in vivo following antigen exposure. Pretreatment of recipient BL/6 mice with these T(reg) cells, together with anti-CD8 antibody and Rapamycin therapies, prolonged survival of BALB/c skins, as compared with mice that received T(reg) lines with lower TcR avidity. Taken together, these data suggest that the TcR functional avidity may be important for T(reg) function. It highlights the fact that strategies to select T(reg) with higher functional avidity might be beneficial for immunotherapy in transplantation.

Narratives of Irishness and the problem of abortion: the X case 1992

This paper considers the ways in which discourses of abortion and discourses of national identity were constructed and reproduced through the events of the X case in the Republic of Ireland in 1992. This case involved a state injunction against a 14-year-old rape victim and her parents, to prevent them from obtaining an abortion in Britain. By examining the controversy the case gave rise to in the national press, I will argue that the terms of abortion politics in Ireland shifted from arguments based on rights to arguments centred on national identity, through the questions the X case raised about women's citizenship status, and women's position in relation to the nation and the state. Discourses of national identity and discourses of abortion shifted away from entrenched traditional positions, towards more liberal articulations.

Dietary epoxy fatty acids are absorbed in healthy women

BACKGROUND

Epoxy fats in the diet may adversely affect human health. There are no data on the absorption of these fats in humans.

METHODS

Triglycerides were synthesized containing two U-13C-labelled monoepoxy or diepoxy stearic acid molecules. Apparently healthy women consumed a standardized fatty meal (30 g fat) containing either 20 mg monoepoxy or 25 mg diepoxy fat (n = 6 and n = 7, respectively). Plasma lipid [U-13C]monoepoxy and diepoxy stearate concentrations were determined (0-24 h) by gas chromatography-mass spectrometry.

RESULTS

Plasma triglycerides increased from 1.05 +/- 0.12 to 1.83 +/- 0.13 mmol L-1 (n = 6) and from 1.10 +/- 0.19 to 1.41 +/- 0.27 mmol L-1 (n = 7) (both P < 0.001). Plasma [U-13C]monoepoxy and diepoxy stearate levels increased to 0.18 +/- 0.07 micromol L-1 (n = 6) and to 0.08 +/- 0.03 micromol L-1 (n = 7), respectively. Monoepoxy triglyceride was better absorbed than diepoxy triglyceride: 17 +/- 4 vs. 8 +/- 1% of dose (determined from area under curve (plasma 13C) normalized to that of absorbed triglycerides (plasma 12C); P < 0.02 after log transformation). The absorption of monoepoxy- and diepoxy-labelled triglycerides was related to that of normal triglycerides (r = 0.80, P < 0.05 and r = 0.91, P < 0.001, respectively).

CONCLUSIONS

Monoepoxy fats are better absorbed than diepoxy fats in women (17 +/- 4 vs. 8 +/- 1% of dose, P = 0.02). This difference in absorption is important when considering the relative toxicity of epoxidized material in the food chain.

Cotransmission from sympathetic vasoconstrictor neurons: differences in guinea-pig mesenteric artery and vein

Vasoconstrictor responses to electrical field stimulation (EFS, 0.2-32 Hz, 0.1 ms, 12 V, for 1 min) were measured in endothelium-denuded segments of guinea-pig mesenteric vein and compared to responses in mesenteric artery. The distribution of both tyrosine-hydroxylase-like immunoreactivity (TH-LI) and neuropeptide Y-like immunoreactivity (NPY-LI) was also studied using anti-TH and anti-NPY antibodies. The effect of exogenous NPY (10 nM) on EFS (8 Hz, 0.3 ms, 12 V, for 1 min)-evoked overflow of noradrenaline (NA) was also studied using an HPLC technique with electrochemical detection. Veins responded with contractions at lower frequencies of stimulation than arteries. Prazosin (0.1 microM) abolished the EFS-evoked contractions in artery at 0.5-32 Hz and in vein at 0.2-1 Hz of stimulation. However, in vein, the contractile responses to EFS at 2-32 Hz of stimulation were only reduced by prazosin. Phentolamine (1 microM) abolished the responses to 0.5-4 Hz and reduced the responses to 8-32 Hz of EFS in artery. In vein, phentolamine (1 microM) abolished the responses to 0.2-1 Hz and facilitated the contractions elicited by 16-32 Hz. The NPY-receptor antagonist BIBP3226 (1 microM), in combination with phentolamine, abolished contractions in vein. Yohimbine (0.1 microM) abolished the responses to lower frequencies of stimulation in both artery (0.5-2 Hz) and vein (0.2-1 Hz). The responses to greater frequency stimulation were not affected by yohimbine in artery, and were facilitated in vein. Pre-treatment of animals for 24 h with reserpine abolished contractile responses to EFS in artery, whereas in vein, responses to 0.2-2 Hz were abolished while responses to 4-32 Hz were unchanged. Suramin (100 microM) or alpha,beta-methylene ATP (alpha,beta MeATP; 10-100 microM) treatment did not affect the contractile responses to EFS in either artery or vein. Pyridoxal-phosphate-6-azophenyl-2',4'-disulfonic acid tetrasodium (PPADS; 30 microM), even potentiated the responses to 2-16 Hz in vein. However, following resperine-treatment, both PPADS and suramin reduced the nerve-evoked contractions of vein. Either BIBP3226 (1 microM) alone or BIBP3226 in combination with PPADS or suramin abolished the contractile response to EFS in reserpine-treated veins. NPY (100 nM) produced significantly more contraction in vein than in artery (i.e., 93 +/- 2.5 versus 7 +/- 4% of the response to 70 mM KCl, respectively). NPY (10 nM) significantly reduced the NA overflow evoked by EFS at 8 Hz. Flat mount preparations and cryostat sections of both mesenteric artery and vein revealed that TH-LI and NPY-LI were co-localized in a dense network of fibers within the adventitial layer. In conclusion, NA exclusively mediates the contractile response to sympathetic nerve stimulation in guinea-pig mesenteric artery, whereas at least three neurotransmitters [i.e., NA, adenosine 5'-triphosphate (ATP) and NPY] are involved in the neural response of mesenteric vein.

Anaesthesia for magnetic resonance imaging: a survey of current practice in the UK and Ireland

The lack of information about standards for anaesthetic practice in magnetic resonance imaging is of concern, since increasing requests are being made for this service, often in units not designed for the purpose. An overview of current practice was sought by conducting a postal survey of magnetic resonance units in the UK and Ireland. Replies were received from 100 units (79%), 46 of which had an anaesthetic service provided. A wide diversity of practice and opinion on the conduct of anaesthesia in this field was evident from the replies received. The survey highlighted particular areas of concern about the personal safety of anaesthetists within such units, including exposure to magnetic fields, noise and unscavenged anaesthetic gases. The evidence for such concerns is reviewed.

Neuropeptide Y is a cotransmitter with norepinephrine in guinea pig inferior mesenteric vein

Neuropeptide Y (NPY) is a cotransmitter with noradrenaline in guinea pig inferior mesenteric vein. Tyrosine hydroxylase-like immunoreactivity and NPY-like immunoreactivity were colocalized in a dense network of fibers within the adventitial layer of guinea-pig inferior mesenteric vein. Vasoconstrictor responses to electrical field stimulation (0.2-64 Hz, 0.1 ms, 12 V, for 10 s) appear to be mediated primarily by norepinephrine at 0.2 to 4 Hz and by NPY at 8 to 64 Hz. NPY Y1 receptors mediate the contractile responses to both endogenous and exogenous NPY. Norepinephrine and NPY are involved in neuromuscular transmission in guinea pig mesenteric vein suggesting that the sympathetic nervous system requires the coordinated action of norepinephrine and NPY to serve capacitance.

The Genome Sequence DataBase (GSDB): meeting the challenge of genomic sequencing

The genome sequence database (GSDB) is a complete, publicly available relational database of DNA sequences and annotation maintained by the National Center for Genome Resources (NCGR) under a Cooperative Agreement with the US Department of Energy (DOE). GSDB provides direct, client- server access to the database for data contributions, community annotation and SQL queries. The GSDB Annotator, a multi-platform graphic user interface, is freely available. Automatically updated relational replicates of GSDB are also freely available.

From the Canadian Dietetic Association. Concept of dietetic practice and framework for undergraduate education for the 21st century

Rapid change and marked diversity are expected to characterize the 21st century. If dietitians are to serve as change facilitators in this environment they will have to demonstrate greater flexibility and creativity, practise critical analysis and problem solving and employ creative thinking. Although provision of quality nutrition care will remain the unique contribution of dietitians, practitioners in the future will require a greater understanding of the impact of social, economic and political systems on food availability and food consumption and, in turn, health and well-being. Critical to the future practice of dietetics will be a greater understanding of research methodology, computer technology, quality improvement processes and risk management, principles governing learning and behaviour, personnel management and organizational behaviour, family and group dynamics, interpersonal communication and their application to dietetic practice. The Canadian Dietetic Association recently adopted a framework for the development of baccalaureate programs in dietetics designed to enable the dietetic practitioner to continue to make a unique contribution in the 21st century. The framework allows individual institutions the freedom and flexibility to plan programs that are compatible with their philosophy and organizational structure. In addition, it is predicted on the principle that a career in dietetics entails a lifetime commitment to education, of which the baccalaureate program is only the beginning.

Self-reactivity and the expression of memory markers vary independently in MRL-Mp+/+ and MRL-Mp-lpr/lpr mice

MRL-Mp-lpr/lpr mice contain phenotypically abnormal populations of T cells, and exhibit an SLE-like autoimmune disease in which autoantibodies are a prominent feature. We analyzed the phenotype and T-cell receptor V beta expression pattern in CD4+ T cells of this mutant mouse strain to detect abnormalities that could explain the autoimmunity. The CD4+ T cells contain two distinct abnormal populations. One of these expresses B220 and HSA, and in these and other respects closely resembles the accumulating CD4-CD8- population. The other expresses a high level of CD44 (Pgp-1), and a high level of the 16A epitope of CD45, and so resembles post-activation T cells. Both of these cell types are exclusive to MRL-Mp-lpr/lpr. We also identified V beta 5- and V beta 11-positive CD4+ T cells, in both MRL-Mp-lpr/lpr and MRL-Mp-+/+ mice. We conclude that autoimmune T cells can be detected in these mice, but that they are not the cause of the accumulation of abnormal CD4+ and CD4-CD8- cells.