Motivation and context of concurrent stimulant and opioid use among persons who use drugs in the rural United States: a multi-site qualitative inquiry

BACKGROUND

In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings.

METHODS

We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use.

RESULTS

We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment.

CONCLUSION

In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.

Challenges to genetic testing for germline mutations associated with breast cancer among African Americans Authors

Inequities in preventive cancer screening, diagnosis, treatment, and inferior cancer outcomes continue to pose challenges across the cancer continuum. While the exact reasons for these inferior outcomes are unknown, multiple barriers to various domains of social determinants of health (SDOH) play a vital role, leading to inequities in cancer care. These include barriers to transportation, housing, and food insecurities, contributing to delays in preventive screening and treatment. Furthermore, aggressive biologies also exist across various racial profiles with accompanying germline mutations. For example, African Americans (AAs) have a higher incidence of triple-negative breast cancer subtype and a high prevalence of BRCA1/2 gene mutations, increasing the risk of multiple cancers, warranting high-risk screening for these populations. Unfortunately, other barriers, such as financial insecurities, low health literacy rates, and lack of awareness, lead to delays in cancer screening and genetic testing, even with available high-risk screening and risk reduction procedures. In addition, physicians receive minimal interdisciplinary training to address genetic assessment, interpretation of the results, and almost no additional training in addressing the unique needs of racial minorities, leading to suboptimal delivery of genetic assessment provision resources among AAs. In this review, we discuss the confluence of factors and barriers limiting genetic testing among AAs and highlight the prevalence of germline mutations associated with increased risk of breast cancer among AAs, reflecting the need for multi-panel germline testing as well as education regarding hereditary cancer risks in underserved minorities.

Accuracy of clinical predictions of prognosis at the end-of-life: evidence from routinely collected data in urgent care records

BACKGROUND

The accuracy of prognostication has important implications for patients, families, and health services since it may be linked to clinical decision-making, patient experience and outcomes and resource allocation. Study aim is to evaluate the accuracy of temporal predictions of survival in patients with cancer, dementia, heart, or respiratory disease.

METHODS

Accuracy of clinical prediction was evaluated using retrospective, observational cohort study of 98,187 individuals with a Coordinate My Care record, the Electronic Palliative Care Coordination System serving London, 2010-2020. The survival times of patients were summarised using median and interquartile ranges. Kaplan Meier survival curves were created to describe and compare survival across prognostic categories and disease trajectories. The extent of agreement between estimated and actual prognosis was quantified using linear weighted Kappa statistic.

RESULTS

Overall, 3% were predicted to live "days"; 13% "weeks"; 28% "months"; and 56% "year/years". The agreement between estimated and actual prognosis using linear weighted Kappa statistic was highest for patients with dementia/frailty (0.75) and cancer (0.73). Clinicians' estimates were able to discriminate (log-rank p < 0.001) between groups of patients with differing survival prospects. Across all disease groups, the accuracy of survival estimates was high for patients who were likely to live for fewer than 14 days (74% accuracy) or for more than one year (83% accuracy), but less accurate at predicting survival of "weeks" or "months" (32% accuracy).

CONCLUSION

Clinicians are good at identifying individuals who will die imminently and those who will live for much longer. The accuracy of prognostication for these time frames differs across major disease categories, but remains acceptable even in non-cancer patients, including patients with dementia. Advance Care Planning and timely access to palliative care based on individual patient needs may be beneficial for those where there is significant prognostic uncertainty; those who are neither imminently dying nor expected to live for "years".

Understanding Reentrance in Frustrated Magnets: The Case of the Er_{2}Sn_{2}O_{7} Pyrochlore

Reentrance, the return of a system from an ordered phase to a previously encountered less-ordered one as a controlled parameter is continuously varied, is a recurring theme found in disparate physical systems, yet its microscopic cause is often not investigated thoroughly. Here, through detailed characterization and theoretical modeling, we uncover the microscopic mechanism behind reentrance in the strongly frustrated pyrochlore antiferromagnet Er_{2}Sn_{2}O_{7}. We use single crystal heat capacity measurements to expose that Er_{2}Sn_{2}O_{7} exhibits multiple instances of reentrance in its magnetic field B vs temperature T phase diagram for magnetic fields along three cubic high symmetry directions. Through classical Monte Carlo simulations, mean field theory, and classical linear spin-wave expansions, we argue that the origins of the multiple occurrences of reentrance observed in Er_{2}Sn_{2}O_{7} are linked to soft modes. These soft modes arise from phase competition and enhance thermal fluctuations that entropically stabilize a specific ordered phase, resulting in an increased transition temperature for certain field values and thus the reentrant behavior. Our work represents a detailed examination into the mechanisms responsible for reentrance in a frustrated magnet and may serve as a template for the interpretation of reentrant phenomena in other physical systems.

Radiotherapy Quality Assurance in the PORTEC-3 (TROG 08.04) Trial

AIMS

Quality assurance in radiotherapy (QART) is essential to ensure the scientific integrity of a clinical trial. This paper reports the findings of the retrospective QART assessment for all centres that participated in PORTEC-3; a randomised controlled trial that compared pelvic radiotherapy with concurrent chemoradiotherapy to the pelvis followed by adjuvant chemotherapy. The trial showed an overall survival benefit for the addition of the chemotherapy in the management of women with high-risk endometrial cancer.

MATERIALS AND METHODS

Clinicians were invited to upload a randomly selected case/s treated at each of the participating sites. Panel reviewers analysed the contours to certify that the target volumes and organ at risk structures were contoured according to guidelines. The results were categorised into acceptable, minor variation, major variation or unevaluable. The radiotherapy plans were dosimetrically evaluated using the well-established Trans-Tasman Radiation Oncology Group (TROG) protocol.

RESULTS

Between August 2010 and January 2018, data from 146 patients of 686 consecutively treated patients were retrospectively reviewed. All 16 Australia and New Zealand and 71 of 77 international centres uploaded data for evaluation. In total, 3514 dosimetric and contour variables were reviewed. Of these, 3136 variables were deemed acceptable (89.2%), with 335 minor (9.6%) and 43 major variations (1.2%). Major contour variations included the clinical target volume vaginal vault, clinical target volume parametria and differential planning target volume vault expansion.

CONCLUSION

The results of the QART assessment confirmed high uniformity and low rates of both minor and major deviations in contouring and dosimetry in all sites. This supports the safe introduction of the PORTEC-3 treatment protocol into routine clinical practice.

Economic impact on direct healthcare costs of missing opportunities for diagnosing HIV within healthcare settings

BACKGROUND

The economic consequences of a missed opportunity for HIV testing at an earlier stage of infection within a healthcare setting are poorly described.

METHODS

For all newly diagnosed HIV patients followed at the Southern Alberta HIV/AIDS Clinic (SAC), Calgary, Canada, between 1 April 2011 and 1 April 2016, all clinical encounters occurring < 3 years prior to diagnosis within the region were obtained. The direct costs of HIV care after diagnosis to 31 March 2019 were determined from a payers' perspective and reported as mean cost per patient per month (PPPM) in 2019 Canadian dollars (CDN$). Patients with no encounters for 3 years prior to diagnosis were compared with patients with encounters, with special attention to patients with HIV clinical indicator conditions (HCICs).

RESULTS

Of 388 patients, 60% had one or more prior encounter without HIV testing; 14% had been treated for an HCIC. Females, older patients and heterosexuals were more likely to have prior encounters. At diagnosis, patients with previous encounters presented with lower CD4 counts and higher rates of AIDS. The mean PPPM costs for patients with any prior encounter or for an HCIC-based encounter were 16% and 33% higher, respectively, than for patients with no prior encounters. While mean PPPM costs for antiretroviral drugs and outpatient visits were slightly higher, in-patient costs were 10 times higher for people with HIV who had a previous HCIC encounter vs. those with no encounters (CDN$316 vs. $31, respectively).

CONCLUSIONS

Any healthcare visit, especially for an HCIC, represents relatively easy opportunities for HIV testing. Not testing can result in poorer health and higher costs. Targeted clinical testing and novel interventions to correct overlooked testing opportunities within healthcare settings may be an easy way to implement cost savings.

Effects of a mannan-rich yeast cell wall-derived preparation on cecal concentrations and tissue prevalence of Salmonella Enteritidis in layer chickens

Salmonella Enteritidis (SE) has been the most common Salmonella serotype associated with foodborne infections in the last several years. Dietary applications of yeast-based preparations in feed have shown to reduce Salmonella colonization in chickens augmenting SE control strategies. This study was conducted to evaluate the effects of a mannan-rich yeast cell wall-derived preparation (Actigen^®) administered in feed at a rate of 400 g/ton on SE colonization in the cecum and internal organs of commercial layer chickens. Sixteen week-old layer pullets were orally challenged with a selected nalidixic acid resistant SE strain at a dose of 1.7×10^9 colony forming units (CFU) per bird. SE colonization was assessed by evaluating isolation rates from ovary and pooled liver/spleen samples as well as enumeration of SE in cecal pouches one week post-challenge. Recovery rates of SE from the ovaries of directly challenged birds receiving Actigen^® were significantly lower (P <0.02) than those in directly challenged birds fed an unsupplemented control diet. Recovery rates of SE from pooled liver/spleen samples were not significantly different between Actigen^®-treated pullets and controls (P = 0.22). Using direct plate count methods, cecal SE concentrations were 1 log₁₀ lower (P <0.001) in challenged pullets in the Actigen^®-supplemented group than in the challenged controls. The SE concentration distributions in the ceca were similar in groups testing positive and groups testing negative for SE in the ovaries and liver/spleens tissues. As a result, SE concentrations in the ceca could not be directly related to the occurrence or prevalence of SE in these tissues. In conclusion, Actigen^® supplementation appears to decrease the prevalence of SE in ovarian tissue and concentrations of SE in cecal contents and may be useful as a tool for reducing the risk of eggshell contamination and transovarian transmission of SE in eggs.

Incidence and mortality trends and geographic patterns of follicular lymphoma in Canada

Background

Follicular lymphoma (fl) is the most common indolent lymphoma and the 2nd most common non-Hodgkin lymphoma, accounting for 10%-20% of all lymphomas in the Western world. Epidemiologic and geographic trends of fl in Canada have not been investigated. Our study's objective was to analyze incidence and mortality rates and the geographic distribution of fl patients in Canada for 1992-2010.

Methods

Demographic and geographic patient data for fl cases were obtained using the Canadian Cancer Registry, the Registre québécois du cancer, and the Canadian Vital Statistics database. Incidence and mortality rates and 95% confidence intervals were calculated per year and per geographic area. Rates were plotted using linear regression models to assess trends over time. Overall data were mapped using Microsoft Excel mapping software (Redmond, WA, U.S.A.) to identify case clusters across Canada.

Results

Approximately 22,625 patients were diagnosed with fl during 1992-2010. The age-standardized incidence rate of this malignancy in Canada was 38.3 cases per million individuals per year. Geographic analysis demonstrated that a number of Maritime provinces and Manitoba had the highest incidence rates, and that the provinces of Nova Scotia and Quebec had the highest mortality rates in the nation. Regional data demonstrated clustering of fl within cities or regions with high herbicide use, primary mining, and a strong manufacturing presence.

Conclusions

Our study provides a comprehensive overview of the fl burden and its geographic distribution in Canada. Regional clustering of this disease in concentrated industrial zones strongly suggests that multiple environmental factors might play a crucial role in the development of this lymphoma.

Parallel replica dynamics simulations of reactions in shock compressed liquid benzene

The study of the long-term evolution of slow chemical reactions is challenging because quantum-based reactive molecular dynamics simulation times are typically limited to hundreds of picoseconds. Here, the extended Lagrangian Born-Oppenheimer molecular dynamics formalism is used in conjunction with parallel replica dynamics to obtain an accurate tool to describe the long-term chemical dynamics of shock-compressed benzene. Langevin dynamics has been employed at different temperatures to calculate the first reaction times in liquid benzene at pressures and temperatures consistent with its unreacted Hugoniot. Our coupled engine runs for times on the order of nanoseconds (one to two orders of magnitude longer than traditional techniques) and is capable of detecting reactions that are characterized by rates significantly slower than we could study before. At lower pressures and temperatures, we mainly observe Diels-Alder metastable reactions, whereas at higher pressures and temperatures we observe stable polymerization reactions.

Direct observation of electrons in microwave vacuum components

Apparatus which is used to directly observe electrons in microwave vacuum components was designed and implemented into a WR-284 like waveguide operated at 2.85 GHz with up to approx. 1 MW power. To generate desired electric field levels for driving secondary emission, the waveguide structure is manipulated by reducing the test section height to 6 mm from the standard WR-284 rectangular waveguide height of 34 mm. Both test and standard sections were operated in the dominant TE₁₀ mode. A 1 mm aperture was cut into the broadside wall of the waveguide section enabling a portion of electrons in the waveguide to enter a properly biased electron multiplier tube mounted atop of the test section. Waveforms are presented showing the direct measurement of electrons, providing a local detection method with nanosecond temporal resolution. Future work will incorporate the test setup for multipactor studies.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

"Safe Foods" or "Fear Foods": the implications of food avoidance in college students from low- and middle-income countries

PURPOSE

The primary objective of this study was to explore if self-reported food avoidance (fats, carbohydrates and protein) exists among college students in low- and middle-income countries (LMICs) and its relationship with body mass index (BMI), dieting, mood/anxiety symptoms, physical activities and general health knowledge.

METHODS

This study is a subset (N = 6096) of a larger 26 LMICs cross-sectional survey, which consisted of 21,007 college students. We ascertained socio-demographic information, food avoidance, physical activities, dieting behaviours, depressive and PTSD symptoms, and recorded anthropometric measurements. Chi-square analyses assessed the relationship between predictor variables and food categories eliminated from participants' diet. Multiple logistic regression assessed if food avoidance predicts outcome variables such as binge drinking, high physical activity, being underweight, exhibiting significant depressive and PTSD symptoms.

RESULTS

Food avoidance exists in as many as one-third of college students in low- and middle-income countries, with this being more likely in persons who are trying to lose weight whether by dieting or otherwise. Food avoidance was associated with higher BMI, depressive symptoms, and high intensity exercises, as well as the level of health knowledge influencing the types of food avoided. A significant difference was noted between lower middle-income and upper middle-income countries with respect to the foods they avoided.

CONCLUSION

Despite being knowledgeable about health-related behaviours, we found that college students in our sample were not that different from those in developed countries and may be influenced by a similar advice given by non-experts about macronutrients. These results hold implications for intervention programmes and policy makers.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional survey.

Abstract P5-09-09: Functional IGF1R variant predicts preeclampsia protection from invasive breast cancer: Novel California teachers study findings

Many studies have reported lower breast cancer risk in women who develop hypertension in pregnancy with a meta-analysis reporting hazard ratios of 0.86 for preeclampsia and 0.83 for gestational hypertension. Our prior work in the Marin Women's Study (MWS) demonstrated both a lower breast density and a lower risk of breast cancer in women with pregnancy-induced hypertension (PIH) if they possess the TT genotype of IGF1R SNP rs2016347.

Breast cancer in MWS women with PIH by IGF1R genotypers2016347 genotype# with genotype# breast cancer cases% breast cancer casesGG9188.79%GT195147.18%TT8800.00%Fisher's exact = 0.008

The current study was designed to validate and expand upon these findings in the larger California Teachers Study (CTS) which consists of &gt;130,000 female educators. From original participants a case-control study was established in 2012 consisting of all non-Hispanic white women with DNA samples that became cases since entry into the study (N = 2030) and controls without invasive or in situ breast cancer (N = 1552). The current study nests within this case control study. All participants with a self-reported history of preeclampsia were selected (81 cases/56 controls). IGF1R SNP rs2016347 was assessed by Taqman assay.

Results: Women with the TT genotype had an odds ratio (OR) of 0.38 when compared to the GG genotype after adjusting for potential confounders. Stratification by HR+/HR- cases and by age of first birth (AFB) resulted in statistically significant adjusted OR's of 0.26 for HR+ positive cases and 0.15 for women with AFB &lt;30. Both showed significant trend effect for number of T alleles as shown below:

Preeclampsia and breast cancer in CTSrs2016347 genotypeAll cases (N=137)HR+ cases (N=118)AFB &lt;30 (N=106)TT vs GG0.38 (0.13, 1.14)0.26 (0.07, 0.89)*0.15 (0.04, 0.56)*GT vs GG0.53 (0.19, 1.46)0.57 (0.19, 1.74)0.34 (0.12, 1.12)Trend analysisp = 0.09p = 0.03*p = 0.005** p &lt; .05

Overall in the CTS, the adjusted hazard ratio for women with vs without preeclampsia was 0.94 (0.81, 1.08).

Conclusions: These results suggest significant breast cancer protection in women with preeclampsia that possess the TT genotype, specifically in those women with AFB &lt;30, and for the development of HR+ breast cancer. The overall OR for all women with the TT genotype was low at 0.38 but did not reach statistical significance. This analysis in a second cohort again demonstrates a lower risk of breast cancer in women with a hypertensive disorder of pregnancy possessing the same IGF1R variant.

Recent studies have associated the rs2016347 T allele with lower normal tissue expression of IGF1R mRNA, better survival in HR+ breast cancer, and improved pathological response to neoadjuvant chemotherapy. The protective T allele creates a new microRNA (miR-432) binding site within the IGF1R 3'UTR, offering a potential functional explanation for reduced mammary gland expression of this cancer-associated growth factor. This may interact with alterations of growth and metabolic factors characteristic of preeclampsia to imprint the immature gland with a lasting protective effect from later life breast tumorigenesis. If mechanistically substantiated, these findings could lead to a novel breast cancer prevention strategy.

Citation Format: Powell M, Von Behren J, Neuhausen S, Reynolds P, Benz C. Functional IGF1R variant predicts preeclampsia protection from invasive breast cancer: Novel California teachers study findings [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 P5-09-09.

Association between ratio indexes of body composition phenotypes and metabolic risk in Italian adults

The ratio between fat mass (FM) and fat-free mass (FFM) has been used to discriminate individual differences in body composition and improve prediction of metabolic risk. Here, we evaluated whether the use of a visceral adipose tissue-to-fat-free mass index (VAT:FFMI) ratio was a better predictor of metabolic risk than a fat mass index to fat-free mass index (FMI:FFMI) ratio. This is a cross-sectional study including 3441 adult participants (age range 18-81; men/women: 977/2464). FM and FFM were measured by bioelectrical impedance analysis and VAT by ultrasonography. A continuous metabolic risk Z score and harmonised international criteria were used to define cumulative metabolic risk and metabolic syndrome (MetS), respectively. Multivariate logistic and linear regression models were used to test associations between body composition indexes and metabolic risk. In unadjusted models, VAT:FFMI was a better predictor of MetS (OR 8.03, 95%CI 6.69-9.65) compared to FMI:FFMI (OR 2.91, 95%CI 2.45-3.46). However, the strength of association of VAT:FFMI and FMI:FFMI became comparable when models were adjusted for age, gender, clinical and sociodemographic factors (OR 4.06, 95%CI 3.31-4.97; OR 4.25, 95%CI 3.42-5.27, respectively). A similar pattern was observed for the association of the two indexes with the metabolic risk Z score (VAT:FFMI: unadjusted b = 0.69 ± 0.03, adjusted b = 0.36 ± 0.03; FMI:FFMI: unadjusted b = 0.28 ± 0.028, adjusted b = 0.38 ± 0.02). Our results suggest that there is no real advantage in using either VAT:FFMI or FMI:FFMI ratios as a predictor of metabolic risk in adults. However, these results warrant confirmation in longitudinal studies.

Territorial Justice and Thatcherism

Changes in the level of territorial justice in the construction of new dwellings during the 1980s are examined. It has been widely argued that spatial equity has declined since the 1970s, particularly in the context of the ‘north–south divide’. Thus, it may be expected that territorial justice—spatial equity at the local authority level—also declined during the Thatcher years. The general arguments and evidence on spatial equity are critically reviewed, and then the relationship between housing needs and housing provision is analysed empirically. The results indicate that there was less territorial justice in private provision, and there were conflicting trends in public provision: Territorial justice declined in the local authority sector, but increased in the housing association sector. However, in total, Thatcherism was associated with less territorial justice.

ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: diagnosis, treatment and follow-up

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11-13 December 2014 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of endometrial cancer. Before the conference, the expert panel prepared three clinically relevant questions about endometrial cancer relating to the following four areas: prevention and screening, surgery, adjuvant treatment and advanced and recurrent disease. All relevant scientific literature, as identified by the experts, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. Results of this consensus conference, together with a summary of evidence supporting each recommendation, are detailed in this article. All participants have approved this final article.

Prediction model for regional or distant recurrence in endometrial cancer based on classical pathological and immunological parameters

Background:

Adjuvant therapy increases disease-free survival in endometrial cancer (EC), but has no impact on overall survival and negatively influences the quality of life. We investigated the discriminatory power of classical and immunological predictors of recurrence in a cohort of EC patients and confirmed the findings in an independent validation cohort.

Methods:

We reanalysed the data from 355 EC patients and tested our findings in an independent validation cohort of 72 patients with EC. Predictors were selected and Harrell's C-index for concordance was used to determine discriminatory power for disease-free survival in the total group and stratified for histological subtype.

Results:

Predictors for recurrence were FIGO stage, lymphovascular space invasion and numbers of cytotoxic and memory T-cells. For high risk cancer, cytotoxic or memory T-cells predicted recurrence as well as a combination of FIGO stage and lymphovascular space invasion (C-index 0.67 and 0.71 vs 0.70). Recurrence was best predicted when FIGO stage, lymphovascular space invasion and numbers of cytotoxic cells were used in combination (C-index 0.82). Findings were confirmed in the validation cohort.

Conclusions:

In high-risk EC, clinicopathological or immunological variables can predict regional or distant recurrence with equal accuracy, but the use of these variables in combination is more powerful.

Tuberculosis in the pituitary fossa: a common pathology in an uncommon site

Tuberculosis (TB) is an important cause of mortality and morbidity across the world. In 2–5% of all cases of systemic TB, the C is affected, with lesions reported in the meninges, cortex and ventricles. Intrasellar tuberculomas, however, are extremely rare. We report the interesting case of a young female patient who presented with secondary hypothyroidism and hyperprolactinaemia. She was treated successfully for pituitary TB. We also highlight and discuss some interesting (and hitherto unreported) endocrine issues. Radiological and histological features and treatment of pituitary TB are discussed using this case as an example.

The Effect of Open-Ended High Tunnels in Western Washington on Late Blight and Physiological Leaf Roll Among Five Tomato Cultivars

A 3-year study in western Washington from 2010 to 2012 evaluated five tomato cultivars for tomato disease development and yield in open-ended high-tunnel versus open-field settings. Findings in 2010 revealed that severity of late blight, caused by Phytophthora infestans (US-11), was significantly (P = 0.002) lower in high-tunnel compared with open-field experimental plots based on area under disease progress curve (AUDPC) values of 0.02 versus 321, respectively. In spite of rescue foliar fungicide applications to open-field plots in 2011 and 2012, the mean number of late blight infections across cultivars was 1.8 to 30.8 compared with only 0 to 6.5 in high tunnels for these years. Furthermore, accumulated hours of leaf wetness were fewer in high tunnels than the open field each year (857 versus 1,060 in 2010, 598 versus 998 in 2011, and 885 versus 923 in 2012). Cultivar susceptibility to late blight could not be differentiated in high tunnels due to low disease pressure. However, all five cultivars proved susceptible in the open field, with 'Oregon Spring' consistently having the most lesions. In contrast, high-tunnel production contributed to an increased severity of physiological leaf roll compared with open-field production each year, and these values differed significantly (P = 0.0335 and 0.0252) in 2011 and 2012, respectively. AUDPC values for physiological leaf roll showed that Oregon Spring was significantly (P = <0.0001) less susceptible than other cultivars each year. Physiological leaf roll correlated positively (r values of 0.758 to 0. 960) and significantly (P < 0.05) with leaf wetness and air temperature in all years in both high-tunnel and open-field settings but the same was not true for relative humidity. Even with severe physiological leaf roll, high-tunnel production in 2010 resulted in significantly (P < 0.0001) greater total tomato yield than open-field production (35.0 versus 10.6 t ha^-1). Although a significant interaction between production system and cultivar occurred in 2011 and 2012, tomato yield always was greater in high-tunnel than open-field plots. Open-ended high tunnels offer tomato growers a potential tool for managing late blight in western Washington while also increasing yield, and could be especially useful in organic production.

What is the quality of economic evaluations of non-drug therapies? A systematic review and critical appraisal of economic evaluations of radiotherapy for cancer

BACKGROUND

Breast, cervical and colorectal cancers are the three most frequent cancers in women, while lung, prostate and colorectal cancers are the most frequent in men. Much attention has been given to the economic evaluation of pharmaceuticals for treatment of cancer by the National Institute for Health and Care Excellence (NICE) in the UK and similar authorities internationally, while economic analysis developed for other types of anti-cancer interventions, including radiotherapy and surgery, are less common.

OBJECTIVES

Our objective was to review methods used in published cost-effectiveness studies evaluating radiotherapy for breast, cervical, colorectal, head and neck and prostate cancer, and to compare the economic evaluation methods applied with those defined in the guidelines used by the NICE technology appraisal programme.

METHODS

A systematic search of seven databases (MEDLINE, EMBASE, CDSR, NHSEED, HTA, DARE, EconLit) as well as research registers, the NICE website and conference proceedings was conducted in July 2012. Only economic evaluations of radiotherapy interventions in individuals diagnosed with cancer that included quality-adjusted life-years (QALYs) or life-years (LYs) were included. Included studies were appraised on the basis of satisfying essential, preferred and UK-specific methods requirements, building on the NICE Reference Case for economic evaluations and on other methods guidelines.

RESULTS

A total of 29 studies satisfied the inclusion criteria (breast 14, colorectal 2, prostate 10, cervical 0, head and neck 3). Only two studies were conducted in the UK (13 in the USA). Among essential methods criteria, the main issue was that only three (10%) of the studies used clinical-effectiveness estimates identified through systematic review of the literature. Similarly, only eight (28%) studies sourced health-related quality-of-life data directly from patients with the condition of interest. Other essential criteria (e.g. clear description of comparators, patient group indication and appropriate time horizon) were generally fulfilled, while most of the UK-specific requirements were not met.

CONCLUSION

Based on this review there is a dearth of up-to-date, robust evidence on the cost effectiveness of radiotherapy in cancer suitable to support decision making in the UK. Studies selected did not fully satisfy essential method standards currently recommended by NICE.

The dynamic changes of zinc transporter 8 autoantibodies in Czech children from the onset of Type 1 diabetes mellitus

AIMS

The prevalence of autoantibodies to zinc transporter 8 (ZnT8) in Czech children at the onset of Type 1 diabetes mellitus and dynamic changes in ZnT8 autoantibody levels during disease progression were studied. The value of ZnT8 autoantibody measurements in diagnosis of Type 1 diabetes was assessed.

METHODS

Serum samples from 227 children with newly diagnosed Type 1 diabetes and from 101 control children without diabetes were analysed in a retrospective cross-sectional study. One hundred and seventy-one samples from 116 of the patients with diabetes were analysed in a follow-up study at (median) intervals of 1, 3, 5 and 10 years after onset of Type 1 diabetes. ZnT8 autoantibodies were measured using a bridging enzyme-linked immunosorbent assay, while antibodies to glutamic acid decarboxylase, insulinoma antigen 2 and insulin were measured by radioimmunoassays.

RESULTS

ZnT8 autoantibodies were detected in 163/227 (72%) of children at Type 1 diabetes onset and in 1/101 (1%) of the control subjects. Sixteen out of 227 (7%) patients with Type 1 diabetes were antibody negative based on three antibodies (glutamic acid decarboxylase, insulinoma antigen 2 and insulin). This false-negative rate was reduced to 10/227 (4.4%) (P < 0.05) after inclusion of ZnT8 autoantibody measurements. Of the children, 142/227 (63%) were positive for at least three antibodies and the most common combination was insulinoma antigen 2, glutamic acid decarboxylase and ZnT8. ZnT8 autoantibody levels decreased over time after Type 1 diabetes onset and the presence and level of ZnT8 autoantibodies correlated with IA-2 autoantibodies.

CONCLUSIONS

A ZnT8 autoantibody enzyme-linked immunosorbent assay showed 72% disease sensitivity and 99% specificity at Type 1 diabetes onset. Measurements of ZnT8 autoantibodies are important for Type 1 diabetes diagnosis and should be included in the panel of autoantibodies tested at the onset of Type 1 diabetes.

Abstract P3-07-03: Insulin-like growth factor-1 receptor variant associated with decreased breast cancer risk in women with pregnancy-induced hypertension

Introduction: Studies have reported a lower breast cancer risk in women who have experienced pregnancy induced hypertension (PIH). Current hypotheses for these observations center on placental dysfunction and a subsequent alteration of levels of circulating hormones, growth factors, and angiogenic and immune modulators.

The Marin Women's Study (MWS) was initiated in 2006 to examine breast cancer in Marin County, an area with historically high breast cancer rates. Enrollment of 13,365 women occurred at mammography sites that participate in the San Francisco Mammography Registry (SFMR), one of seven registries included in the NCI Breast Cancer Consortium. In a prior analysis of MWS data, we demonstrated that PIH is associated with reduced breast density later in life, and the current two-phased study was designed to assess whether this apparent protective effect is modified by individual genetic differences.

Methods: Participants self-reported reproductive history and risk factors on the MWS questionnaire at the time of enrollment. Compositional breast density using single X-ray absorptiometry (SXA) was measured on digital mammography. These readings and breast cancer case status data obtained from the California Cancer Registry was acquired by cooperative agreements with the SFMR. DNA for SNP analyses was extracted from donated saliva specimens.

The first phase analysis focused on breast density and assessed the interaction of 7 SNPs of specific selected genes with a history of PIH. A second phase analysis focused on breast cancer case status for any SNP which appeared to demonstrate interaction in the initial analysis.

Results: After adjusting for potential confounders, only the IGF1R SNP (rs2016347) demonstrated a statistically significant interaction with PIH on mammographic density (GT, p = 0.01, and TT, p = 0.07 compared to baseline GG), although the VEGF SNP (rs3025039) approached statistical significance (CT, p = 0.06 compared to baseline CC) in our sample size of 1240 women.

The second phase of the analysis examined the association of the VEGF and IGF1R SNPs with breast cancer case status in all women in the MWS with a history of PIH, saliva specimen, and case status data (n = 374). There was a statistically significant decrease in breast cancer risk in women with PIH and the IGF1R SNP as shown below:

Breast cancer cases in women with PIH by IGF1R genotypeIGF1R GenotypeNumber with genotypeNumber breast cancer cases% breast cancer casesGG9188.79%GT195147.18%TT8800.00%Fisher's exact = 0.008

There was no statistical association between this SNP and PIH incidence or case status in women without PIH, where 27.1% of breast cancer cases had the IGF1R TT genotype (108/398).

Conclusions: Women with a history of PIH had a lower risk of breast cancer if they had the TT genotype of the IGF1R SNP (rs2016347), and this genotype was also associated with lower breast density. Since this IGF1R variant has previously been associated with mammographic density and found to be an independent prognostic marker for breast cancer recurrence, its expression may play a breast cancer protective role by reducing mammographic density in women with PIH.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-07-03.

First Report of Tomato Pith Necrosis (Pseudomonas corrugata) on Tomato (Solanum lycopersicum) in Washington

Tomato pith necrosis was observed on 2.7% of tomatoes grown in rows covered with black polyethylene, various biodegradable plastics, and an experimental spunbond poly(lactic) acid agricultural mulch in high tunnel and open field experimental plots, in western Washington in 2011. Symptoms developed on 3-month-old plants and progressed acropetally until night temperatures dropped to 10°C. Affected plants had chlorotic leaves, produced adventitious roots, and pith tissue was brown and either corrugated or rotted. Similar symptoms were observed again in 2012 on 2.0% of plants, but only in experimental plots with black polyethylene mulch. Diseased stem tissue was homogenized with a mortar and pestle in sterile water and the extract was streaked onto King's medium B (KMB) agar. Colonies were white and smooth initially, and after 5 days had an irregular surface and margin and produced a tan diffuse pigment. One isolate, Pc.Sl.2011, was gram-negative, grew at 37°C on nutrient broth yeast (NBY) agar, did not fluoresce on KMB (3), and was arginine dihydrolase positive. A partial 16S fragment, 1,387 bp, was obtained via PCR with universal 27f and 1492f primers. The resulting sequence exhibited 99% identity to Pseudomonas corrugata Roberts & Scarlett, and has been assigned GenBank Accession KC812729. Pathogenicity of Pc.Sl.2011 was tested in two greenhouse trials with five replications of one tomato plant per treatment. Seeds of 'Celebrity' were surface sterilized by soaking in 70% EtOH for 30 s and then 10% NaOCl for 30 s, then rinsed with sterile water and sown into 14 cm diameter pots filled with non-sterile Sunshine Mix #1 (SunGro Horticulture Distribution Inc., Bellevue, WA). Seedlings were inoculated at the four leaf stage using 5 ml NBY broth cultures of Pc.Sl.2011 grown at 28°C for 12 h with agitation. A sterile needle was used to inject 10 μl of either sterile water or a bacterial suspension of 1.0 × 10¹⁰ CFU/ml into the axil of the second true leaf. Inoculum concentration was confirmed by NBY dilution plate counts. The plants were incubated in clear polyethylene bags for 4 days and placed in a greenhouse at 21.1 ± 1.2°C with a 14-h photoperiod. The first and second trials were sampled at 8 and 9 weeks after inoculation, respectively. Plants inoculated with sterile water had green pith tissue. However, 60 and 40% of inoculated plants had brown pith tissue around the inoculation site in the first and second trial, respectively, but wilting and adventitious roots were not observed. Stem tissue from the inoculation site of symptomatic plants was homogenized as above, and the extract streaked onto NBY agar plates. Three isolates recovered from inoculated plants from both trials had the same characteristics as the original isolate, including similar colony morphology, ability to grow on NBY at 37°C, and lack of fluorescence on KMB. To our knowledge, this is the first documented report of tomato pith necrosis in Washington. Pith necrosis has been reported previously in high tunnel tomato production (4), where excess nitrogen fertilization occurs with cool evening temperatures (3), and when plastic mulch is utilized (2). In the cool climate of western Washington, successful tomato production requires the use of agricultural mulches and covers that trap heat. Since P. corrugata has been isolated from soil and the tomato seeds of inoculated plants (1), local growers attempting to manage pith necrosis need to select tomato seed lots carefully and avoid applying excess nitrogen, especially when using plastic mulch. References: (1) V. Catara. Mol. Plant Pathol. 8:233, 2007. (2) E. J. Sikora and W. S. Gazaway. Online. ACES.edu ANR-0797, 2009. (3) C. M. Scarlett and J. T. Fletcher. Ann. Appl. Biol. 88:105, 1978. (4) X. Xu et al. Plant Dis. 97:988, 2013.

First Report of Verticillium Wilt on Lettuce (Lactuca sativa) in Washington Caused by Verticillium tricorpus

Symptoms of Verticillium wilt were observed on lettuce (Lactuca sativa L.) harvested from high tunnel and open field experimental plots in annual, consecutive spring plantings in western Washington from 2010 to 2012. Leaves had v-shaped, chlorotic lesions, and yellow or brown vascular tissue was noted in the crowns. Total disease incidence increased from 0.2% in 2010 to 1.9% in 2011 and to 14.4% in 2012. Verticillium spp. obtained from infected crown tissues and cultured on half-strength potato dextrose agar medium produced yellow pigment, black microsclerotia, white mycelia, tan chlamydospores, and uniseptate conidia averaging 10.6 × 3.7 μm. Isolates were identified tentatively as Verticillium tricorpus I. (3). Three isolates, Vt.Ls.2010, Vt.Ls.2011-1, and Vt.Ls.2011-2, were evaluated for pathogenicity on 4-week-old 'Coastal Star' seedlings in two greenhouse trials. In Trial I, four replicates of two duplicate plants per each isolate, and in Trial II, five replicates of one plant per each isolate were inoculated with conidial suspensions adjusted to 2.0 × 10⁶ and 5.0 × 10⁶ conidia/ml, respectively. Additionally, in each trial, two sets of control treatments of five plants each were inoculated with either an isolate of V. dahliae at the same conidial concentration or with sterile water. Root tips were cut and exposed to the suspensions for 5 s, then seedlings were transplanted into Sunshine Mix #1 (SunGro Horticulture Distribution Inc., Bellevue, WA), and kept in a greenhouse at 17.7 ± 3.4°C. Plants were harvested 8 to 9 weeks post-inoculation, and symptoms were rated visually. Vt.Ls.2010, Vt.Ls.2011-1, and Vt.Ls.2011-2 caused chlorosis and vascular discoloration on 25, 13, and 13% of the plants in Trial I; and 40, 60, and 20% of plants in Trial II, respectively. V. dahliae caused similar symptoms on 25 and 40% of the plants in the two trials, respectively, but these plants had greater intensity and length of vascular discoloration compared with the three test isolates. None of the water control plants were symptomatic. All V. tricorpus isolates were recovered from inoculated plants, and colony morphologies were similar to the original isolates. The internal transcribed spacer (ITS) rDNA of isolate Vt.Ls.2010 was amplified with ITS4 and ITS6 primer sets. ITS rDNA sequences between Vt.Ls.2010 and two isolates of V. tricorpus in GenBank (Accession Nos. FJ900211 and AB353343) were 100% identical. V. tricorpus is considered a weak pathogen of lettuce crops in California (2), but authors in Japan recently reported pathogenic isolates of V. tricorpus on lettuce (4). To our knowledge, this is the first report of Verticillium wilt caused by V. tricorpus in Washington. Lettuce is the number two crop grown in high tunnels in the United States (1), and cropping lettuce continuously in them can increase the risk of this and other soilborne pathogens. References: (1) E. E. Carey et al. HortTechnology 19:37, 2009. (2) Q.-M. Qin et al. Plant Dis. 92:69, 2008. (3) H. C. Smith. N. Z. J. Agric. Res. 8:450, 1965. (4) T. Usami et al. J. Gen. Plant Pathol. 77:17, 2010.