A role for dopamine in control of the hypoxic ventilatory response via D2 receptors in the zebrafish gill

Dopamine is a neurotransmitter involved in oxygen sensing and control of reflex hyperventilation. In aquatic vertebrates, oxygen sensing occurs in the gills via chemoreceptive neuroepithelial cells (NECs), but a mechanism for dopamine in autonomic control of ventilation has not been defined. We used immunohistochemistry and confocal microscopy to map the distribution of tyrosine hydroxylase (TH), an enzyme necessary for dopamine synthesis, in the gills of zebrafish. TH was found in nerve fibers of the gill filaments and respiratory lamellae. We further identified dopamine active transporter (dat) and vesicular monoamine transporter (vmat2) expression in neurons of the gill filaments using transgenic lines. Moreover, TH- and dat-positive nerve fibers innervated NECs. In chemical screening assays, domperidone, a D2 receptor antagonist, increased ventilation frequency in zebrafish larvae in a dose-dependent manner. When larvae were confronted with acute hypoxia, the D2 agonist, quinpirole, abolished the hyperventilatory response. Quantitative polymerase chain reaction confirmed expression of drd2a and drd2b (genes encoding D2 receptors) in the gills, and their relative abundance decreased following acclimation to hypoxia for 48 h. We localized D2 receptor immunoreactivity to NECs in the efferent gill filament epithelium, and a novel cell type in the afferent filament epithelium. We provide evidence for the synthesis and storage of dopamine by sensory nerve terminals that innervate NECs. We further suggest that D2 receptors on presynaptic NECs provide a feedback mechanism that attenuates the chemoreceptor response to hypoxia. Our studies suggest that a fundamental, modulatory role for dopamine in oxygen sensing arose early in vertebrate evolution.

Identification of signalling pathways involved in gill regeneration in zebrafish

The occurrence of regeneration of the organs involved in respiratory gas exchange amongst vertebrates is heterogeneous. In some species of amphibians and fishes, the gills regenerate completely following resection or amputation, whereas in mammals, only partial, facultative regeneration of lung tissue occurs following injury. Given the homology between gills and lungs, the capacity of gill regeneration in aquatic species is of major interest in determining the underlying molecular or signalling pathways involved in respiratory organ regeneration. In the present study, we used adult zebrafish (Danio rerio) to characterize signalling pathways involved in the early stages of gill regeneration. Regeneration of the gills was induced by resection of gill filaments and observed over a period of up to 10 days. We screened for the effects on regeneration of the drugs SU5402, dorsomorphin and LY411575, which inhibit FGF, BMP or Notch signalling pathways, respectively. Exposure to each drug for 5 days significantly reduced regrowth of filament tips in regenerating tissue, compared with unresected controls. In separate experiments under normal conditions of regeneration, we used reverse transcription quantitative PCR and observed an increased expression of genes encoding for the bone morphogenetic factor, Bmp2b, fibroblast growth factor, Fgf8a, a transcriptional regulator (Her6) involved in Notch signalling, and Sonic Hedgehog (Shha), in regenerating gills at 10 day post-resection, compared with unresected controls. In situ hybridization confirmed that all four genes were expressed in regenerating gill tissue. This study implicates BMP, FGF, Notch and Shh signalling in gill regeneration in zebrafish.

Neurochemical Signalling Associated With Gill Oxygen Sensing and Ventilation: A Receptor Focused Mini-Review

Despite the large body of work describing vertebrate ventilatory responses to hypoxia, remarkably little is known about the receptors and afferent pathways mediating these responses in fishes. In this review, we aim to summarize all receptor types to date implicated in the neurotransmission or neuromodulation associated with O2 sensing in the gills of fish. This includes serotonergic, cholinergic, purinergic, and dopaminergic receptor subtypes. Recent transcriptomic analysis of the gills of zebrafish using single-cell RNA sequencing has begun to elucidate specific receptor targets in the gill; however, the absence of receptor characterization at the cellular level in the gill remains a major limitation in understanding the neurochemical control of hypoxia signalling.

Efficacy of mupirocin, neomycin and octenidine for nasal Staphylococcus aureus decolonisation: a retrospective cohort study

BACKGROUND

Periprosthetic joint infection (PJI) causes significant morbidity. Methicillin sensitive Staphylococcus aureus (MSSA) is the most frequent organism, and the majority are endogenous. Decolonisation reduces PJIs but there is a paucity of evidence comparing treatments. Aims; compare 3 nasal decolonisation treatments at (1) achieving MSSA decolonisation, (2) preventing PJI.

METHODS

Our hospital prospectively collected data on our MSSA decolonisation programme since 2013, including; all MSSA carriers, treatment received, MSSA status at time of surgery and all PJIs. Prior to 2017 MSSA carriers received nasal mupirocin or neomycin, from August 2017 until August 2019 nasal octenidine was used.

RESULTS

During the study period 15,958 primary hip and knee replacements were performed. 3200 (20.1%) were MSSA positive at preoperative screening and received decolonisation treatment, 698 mupirocin, 1210 neomycin and 1221 octenidine. Mupirocin (89.1%) and neomycin (90.9%) were more effective at decolonisation than octenidine (50.0%, P < 0.0001). There was no difference in PJI rates (P = 0.452).

CONCLUSIONS

Mupirocin and neomycin are more effective than octenidine at MSSA decolonisation. There was poor correlation between the MSSA status after treatment (on day of surgery) and PJI rates. Further research is needed to compare alternative MSSA decolonisation treatments.

Resistant fabric warming is a viable alternative to forced-air warming to prevent inadvertent perioperative hypothermia during hemiarthroplasty in the elderly

BACKGROUND

Surgical site infection (SSI) is associated with inadvertent perioperative hypothermia (IPH). This can be prevented by active patient warming. However, results from comparisons of warming techniques are conflicting. They are based mostly on elective surgery, are from small numbers of patients, and are dominated by the market leader, forced-air warming (FAW). Furthermore, the definition of hypothermia is debatable and systematic reviews of warming systems conclude that a stricter control of temperature is required to study the benefits of warming.

AIM

To analyse core temperatures in detail in a large subset of elderly patients who took part in a randomized trial of patient warming following hemiarthroplasty who had received constant zero-flux thermometry to record their temperature.

METHODS

Regression models with a fixed effect for warming group and covariates related to temperature were compared for 257 participants randomized to FAW or resistant fabric warming (RFW) from a prior clinical trial.

FINDINGS

Those in the RFW group were -0.08°C cooler and had a cumulative hypothermia score -1.87 lower than those in the FAW group. There was no difference in the proportion of hypothermic patients at either <36.5°C or <36.0°C.

CONCLUSIONS

This is the first study to provide accurate temperature measurements in patients undergoing a procedure predominantly under regional rather than general anaesthetic. It shows that RFW is a viable alternative to FAW for preventing IPH during hemiarthroplasty. Further studies are needed to measure the benefits of patient warming in terms of clinically important outcomes.

Reducing Implant Infection in Orthopaedics (RIIiO): Results of a pilot study comparing the influence of forced air and resistive fabric warming technologies on postoperative infections following orthopaedic implant surgery

BACKGROUND

Active warming during surgery prevents perioperative hypothermia but the effectiveness and postoperative infection rates may differ between warming technologies.

AIM

To establish the recruitment and data management strategies needed for a full trial comparing postoperative infection rates associated with forced air warming (FAW) versus resistive fabric warming (RFW) in patients aged >65 years undergoing hemiarthroplasty following fractured neck of femur.

METHODS

Participants were randomized 1:1 in permuted blocks to FAW or RFW. Hypothermia was defined as a temperature of <36°C at the end of surgery. Primary outcomes were the number of participants recruited and the number with definitive deep surgical site infections.

FINDINGS

A total of 515 participants were randomized at six sites over a period of 18 months. Follow-up was completed for 70.1%. Thirty-seven participants were hypothermic (7.5% in the FAW group; 9.7% in the RFW group). The mean temperatures before anaesthesia and at the end of surgery were similar. For the primary clinical outcome, there were four deep surgical site infections in the FAW group and three in the RFW group. All participants who developed a postoperative infection had antibiotic prophylaxis, a cemented prosthesis, and were operated under laminar airflow; none was hypothermic. There were no serious adverse events related to warming.

CONCLUSION

Surgical site infections were identified in both groups. Progression from the pilot to the full trial is possible but will need to take account of the high attrition rate.

Approaching the Gamow Window with Stored Ions: Direct Measurement of ^{124}Xe(p,γ) in the ESR Storage Ring

We report the first measurement of low-energy proton-capture cross sections of ^{124}Xe in a heavy-ion storage ring. ^{124}Xe^{54+} ions of five different beam energies between 5.5 and 8 AMeV were stored to collide with a windowless hydrogen target. The ^{125}Cs reaction products were directly detected. The interaction energies are located on the high energy tail of the Gamow window for hot, explosive scenarios such as supernovae and x-ray binaries. The results serve as an important test of predicted astrophysical reaction rates in this mass range. Good agreement in the prediction of the astrophysically important proton width at low energy is found, with only a 30% difference between measurement and theory. Larger deviations are found above the neutron emission threshold, where also neutron and γ widths significantly impact the cross sections. The newly established experimental method is a very powerful tool to investigate nuclear reactions on rare ion beams at low center-of-mass energies.

Abstract P2-07-11: Prediction of the Oncotype Dx recurrence score (RS) from clinicopathologic factors

Background: The Oncotype Dx assay is currently used as an aid to therapeutic decisions for the adjuvant treatment of women with ER-positive, Her2-negative, lymph node-negative or -micrometastatic breast cancer. The recently reported TAILORx study showed that no or minimal benefit is derived from adjuvant chemotherapy in patients with an Oncotype Dx Recurrence Score (RS) of 25 or less.

Methods: Charts of breast cancer patients that had the Oncotype Dx test in our cancer center in a nine-year period were reviewed. Data on demographic, and cancer-specific characteristics of the included patients were extracted. Predicted disease recurrence from the Oncotype Dx test was recorded and correlated with select clinicopathologic characteristics.

Results: Two hundred and thirty patients with ER-positive, Her2-negative, lymph node-negative or micrometastatic breast cancer were included. Mean age was 65 years-old (SD 9.9). Two hundred and three patients (88.3%) were post-menopausal and one hundred and thirty-three patients (57.8%) were 65 years-old or older. Two hundred and nine patients (90.9%) had lymph node-negative disease. Oncotype Dx recurrence score was low (&lt;11) in sixty-four patients (27.8%), intermediate (11-25) in one hundred and forty patients (60.9%) and high (&gt;25) in twenty-six patients (11.3%). High tumor grade and low progesterone receptor (PR) staining by IHC were the two clinicopathologic factors most associated with a high Oncotype Dx RS (x2 test p &lt;0.00001 and Fisher's exact test p &lt;0.0001). A predictive index (PI) was constructed, assigning one point each for grade 3 and PR staining in 20% or less of tumor cells. A PI of 0 was observed in one hundred and thirty-eight patients (60%), a PI of 1 was observed in seventy-one patients (30.9%), and a PI of 2 was observed in twenty-one patients (9.1%). One hundred and thirty-four patients (97.1%) with a PI of 0 had a RS of 25 or less. Patients with a PI of 1 and 2 had a RS of &gt;25 in 12.7% and 61.9% of cases, respectively.

Conclusion: The PI based on tumor grade and PR we propose is a simple predictor of Oncotype Dx RS. 97.1% of patients with a grade 1 or 2 tumor and PR positivity in &gt;20% of tumor cells had a RS of 25 or less. The Oncotype Dx test and its associated cost can therefore be avoided in these patients, especially in low-resource settings.

Citation Format: Voutsadakis IA, Thibodeau S, Reed M. Prediction of the Oncotype Dx recurrence score (RS) from clinicopathologic factors [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-07-11.

Recommendations on thromboprophylaxis in major joint arthroplasty - many guidelines, little consensus?

Venous thromboembolic events remain a concern in total hip and knee arthroplasty. Consequently, several guidelines on thromboprophylaxis have been established. However, despite similarities in methodology for evaluation of evidence, discrepancies in guideline recommendations continue to exist. Furthermore, the results of older randomized clinical trials still have significant influence despite major improvements in perioperative care. In contrast, the results of recent large cohort studies with fewer thromboembolic events are mostly used only for background data. Here we outline some of the differences between the guidelines on thromboprophylaxis from the American College of Chest Physicians, the National Institute for Health and Care Excellence and the American Academy of Orthopedic Surgeons. We discuss differences in the methodology and focus of the guidelines potentially influencing the final recommendations. Future analyses are required, including data from modern care with early mobilization and short length of stay.

p53-dependent activation of the mouse MCK gene promoter: identification of a novel p53-responsive sequence and evidence for cooperation between distinct p53 binding sites

Transcriptional activation by p53 is dependent on the presence of a specific p53 binding site within control sequences of the target gene. One such target gene is the mouse muscle-specific creatine kinase (MCK) gene, which contains a p53 binding site between promoter residues -3182 and -3133 relative to the transcription start site. This DNA sequence is reported to be sufficient to confer p53-dependent activation on the MCK promoter. In contrast to this finding, evidence from promoter deletion studies suggests that sequences in the MCK promoter other than this p53 binding site also permit p53-dependent activation. To investigate this possibility, we have further examined sequences in the MCK promoter required for transcriptional activation by mouse p53. We report here identification of a second p53-responsive sequence within the MCK promoter. This novel sequence is situated between residues -177 and -81, and can confer p53-dependent, position- and orientation-independent activation on a heterologous promoter. Moreover, this sequence can specifically bind mouse and human p53. By promoter deletion studies, we provide evidence that these two elements cooperate to provide high-level, p53-dependent activation of the MCK promoter.

Phenotype and biochemical heterogeneity in late onset Fabry disease defined by N215S mutation

BACKGROUND

Fabry disease (FD) results from X-linked inheritance of a mutation in the GLA gene, encoding for alpha galactosidase A, and is characterized by heterogeneous clinical manifestations. Two phenotypes have been described "Classic" and "late onset" which cannot be predicted exclusively by genotype. The latter has been considered an attenuated form of the disease often affecting a single organ system commonly the heart. Recent studies have demonstrated that cardiac outcomes are similar in patients with classic and late onset mutations. In this study we investigate the relationship between clinical heterogeneity and plasma lyso-Gb3 in a large single centre cohort of N215S patients and compare this to patients with other mutations.

METHODS

In this single-centre, retrospective, cross-sectional study we analysed a cohort of 251 FD patients: 84 N215S mutation (37 males) and 167 non-N215S mutations (58 males). The Mainz severity score index (MSSI) was used as an index of overall disease severity. Cardiac function and morphology were assessed by electrocardiogram and echocardiogram. Left ventricular mass was calculated using the Devereux formula and the left ventricular mass index (LVMI) calculated to adjust for height (g/m2.7). The presence of white matter lesions was assessed by cerebral MRI or computed tomography (CT). GFR was measured by radio-isotope (chromium-EDTA) method and adjusted for patient height (ml/min/m2.7), and urinary protein quantification was undertaken by 24 hour urine collection. Plasma globotriaosylsphingosine (lyso-Gb3) was analysed prior to ERT in 84 patients.

RESULTS

N215S patients showed later symptom onset (males: p< 0.0001, females: p<0.03), later development of left ventricular hypertrophy (LVH) (median survival without LVH: 41 (non-N215S) vs. 64 (N215S) years, p< 0.0001), later development of proteinuria (median survival without proteinuria 43 (non-N215S) vs 71 years (N215S), p< 0.0001), later occurrence of cerebrovascular events (stroke/ Transient Ischaemic Attacks (TIA); median survival without stroke: 74 years (non-N215S) vs. not reached (N215S), p< 0.02), later decline in renal function to GFR <60 ml/min/1.73m2 (median survival: 56 (non-N215S) vs. 72 (N215S) years, p< 0.01), and greater overall survival (median survival 81 (N215S) vs. 66 (non-N215S) years, p< 0.0006). Lyso-Gb3 was found to be less elevated in N215S compared to non-N215S male and female patients. However, the N215S population eventually reached an overall severity measured by MSSI comparable to the non-N215S without equivalent elevation of lyso-Gb3 (means: 6.7 vs. 74.3 nmol/L, p < 0.001). In addition, N215S patients showed strong correlations between lyso-Gb3 levels and LVMI, GFR, and MSSI. These associations became stronger when we investigated individuals' life time exposure to lyso-Gb3 (calculated as [lyso-Gb3]*age): MSSI (r2 = 0.88, p< 0.0001), LVMI (r2 = 0.59, p< 0.005), and GFR (r2 = 0.75, p = 0.0001).

CONCLUSION

These results demonstrate that the N215S mutation results in a late onset phenotype involving the heart and other organs. Correlations between clinical manifestations and plasma lyso-Gb3 variations in this group suggest a Fabry-relevant disease mechanism for the heterogeneity observed in this group.

Fast-timing measurements in neutron-rich odd-mass zirconium isotopes using LaBr3:Ce detectors coupled with Gammasphere

A fast-timing experiment was performed at the Argonne National Laboratory to measure the lifetimes of the lowest lying states of nuclei belonging to the deformed regions around mass number A≃110 and A≃150. These regions were populated via spontaneous fission of 252Cf and the gamma radiation following the decay of excited states in the fission fragments was measured using 51 Gammasphere detectors coupled with 25 LaBr3:Ce detectors. A brief description of the acquisition system and some preliminary results from the fast-timing analysis of the fission fragment 100Zr are presented. The lifetime value of τ = 840(65) ps was found for the 2+ state in 100Zr consistent within one standard deviation of the adopted value with 791 +26 -35ps. This is associated with a quadrupole deformation parameter of 0.36(2) which is within one standard deviation of the literature value of 0.3556+82 -57.

The effect of operating lights on laminar flow

Aims

The interaction between surgical lighting and laminar airflow is poorly understood. We undertook an experiment to identify any effect contemporary surgical lights have on laminar flow and recommend practical strategies to limit any negative effects.

Materials and Methods

Neutrally buoyant bubbles were introduced into the surgical field of a simulated setup for a routine total knee arthroplasty in a laminar flow theatre. Patterns of airflow were observed and the number of bubbles remaining above the surgical field over time identified. Five different lighting configurations were assessed. Data were analysed using simple linear regression after logarithmic transformation.

Results

In the absence of surgical lights, laminar airflow was observed, bubbles were cleared rapidly and did not accumulate. If lights were placed above the surgical field laminar airflow was abolished and bubbles rose from the surgical field to the lights then circulated back to the surgical field. The value of the decay parameter (slope) of the two setups differed significantly; no light (b = -1.589) versus one light (b = -0.1273, p < 0.001). Two lights touching (b = -0.1191) above the surgical field had a similar effect to that of a single light (p = 0. 2719). Two lights positioned by arms outstretched had a similar effect (b = -0.1204) to two lights touching (p = 0.998) and one light (p = 0.444). When lights were separated widely (160 cm), laminar airflow was observed but the rate of clearance of the bubbles remained slower (b = -1.1165) than with no lights present (p = 0.004).

Conclusion

Surgical lights have a significantly negative effect on laminar airflow. Lights should be positioned as far away as practicable from the surgical field to limit this effect. Cite this article: Bone Joint J 2017;99-B:1061–6.

Comparison of outcomes for cancer patients discussed and not discussed at a multidisciplinary meeting

OBJECTIVES

Comparison of outcomes for cancer patients discussed and not discussed at a multidisciplinary meeting (MDM).

STUDY DESIGN

Retrospective analysis of the association of MDM discussion with survival.

METHODS

All newly diagnosed cancer patients from 2009 to 2012, presenting to a large regional cancer service in South West Victoria, Australia (620 colorectal, 657 breast, 593 lung and 511 haematological) were recorded and followed up to 5 years after diagnosis. Treatment patterns and survival of patients whose treatment was discussed at an MDM compared to those who were not, were explored.

RESULTS

The proportion of patients presented to an MDM within 60 days after diagnosis was 56% (n = 366) for breast cancer, 59% (n = 363) for colorectal cancer, 27% (n = 137) for haematological malignancies and 60% (n = 355) for lung cancer. Seventy-three percent (n = 886) of patients discussed at an MDM had their tumour stage recorded in their medical records while only 52% (n = 604) of patients not discussed had their tumour stage recorded (P < 0.01). We found for haematological and lung cancer patients that those presented to an MDM prior to treatment had a significant reduction in mortality (lung cancer hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.50-0.76, P < 0.01) (haematological cancer HR 0.58, 95% CI 0.35-0.96, P = 0.03) compared to patients whose cases were not discussed at an MDM after adjusting for the potential cofounders of age, stage, comorbidities and treatment. This was not the case for colorectal and breast cancer patients where there was no significant difference.

CONCLUSION

MDM discussion has been recommended as best practice in the management of cancer patients, however, from a public health perspective this creates potential issues around access and resources. It is likely that MDM presentation patterns and outcomes across tumour streams are linked in complex ways. We believe that our data would demonstrate that these patterns differ across tumour streams and that more detailed work is required to better allocate relatively scarce and potentially costly MDM resources to tumour streams and patient groups that may get the most benefit.

Abstract OT1-03-01: The UK LORIS trial: Randomizing patients with low or low intermediate grade ductal carcinoma in situ (DCIS) to surgery or active monitoring

Background: The independent review of the UK National Health Service Breast Screening Programme reported (The Lancet, Volume 380, Issue 9855, Page 1778, 17 Nov 2012) on the benefits and harms of breast screening. It concluded that breast screening saves lives and acknowledged the existence of overtreatment. It encouraged randomized trials to elucidate the appropriate treatment of screen-detected DCIS to gain a better understanding of its natural history. The LORIS trial addresses the possible overtreatment of low and low/intermediate grade screen-detected (low risk) DCIS by randomizing patients to standard surgical treatment or active monitoring, each with long term follow up.

Trial Design: LORIS is a phase III, multicentre, 2 arm study, with a built in 2 year Feasibility Phase, in patients confirmed to have low risk DCIS defined by strict criteria and determined by central pathology review. Patients will be randomized between standard surgery and active monitoring with annual mammography. Patients will be followed up for a minimum of 10 years.

Eligibility Criteria:

1) Female, age ≥ 46 years

2) Screen-detected or incidental microcalcification (with no mass lesion clinically or on imaging)

3) Low risk DCIS on large volume vacuum-assisted biopsy, confirmed by central pathology review

4) Patient fit to undergo surgery

5) No previous breast cancer or ipsilateral DCIS diagnosis

6) Written informed consent

Specific Aims: The LORIS Trial aims to establish whether patients with newly diagnosed low risk DCIS can safely avoid surgery without detriment to their wellbeing (psychological and physical) and whether those patients that do require surgery can be identified by pathological and radiological means.

Primary endpoint: Ipsilateral invasive breast cancer free survival time

Secondary endpoints: Overall survival; mastectomy rate; time to mastectomy; time to surgery; patient reported outcomes; health resource utilisation and assessment of predictive biomarkers.

A digital image data repository and tissue bank will provide a prospective resource for both translational and imaging studies.

Statistical Methods: A total of 932 patients will be randomized to a non-inferiority design to test the null hypothesis that active monitoring of women diagnosed with low risk DCIS is not non-inferior in terms of ipsilateral invasive breast cancer free survival (iiBCFS) time compared to treatment with surgery. The iiBCFS time will be compared across the two arms on a per protocol and intent-to-treat basis, using a 1-sided (α=0.05) log-rank test for non-inferiority. The iiBCFS rate is assumed to be 97.5% in the surgery arm at 5 years, utilizing 80% power to exclude a difference of more than 2.5% in the active monitoring arm.

Present Accrual and Target Accrual: 32 UK centres are open for the Feasibility Phase of the trial which is nearing completion. The web-based central pathology review process is functioning efficiently, with a one week maximum turn around. Registrations and sites randomizing patients are on or above target. Randomizations are currently approximately 70% of target. A total of 60 centres will open in the main trial.

Contact Information: For further information, please email the LORIS Trial Office LORIS@trials.bham.ac.uk.

Citation Format: Francis A, Bartlett J, Billingham L, Bowden S, Brookes C, Dodwell D, Evans A, Fairbrother P, Fallowfield L, Gaunt C, Hanby A, Jenkins V, Matthews L, Pinder S, Pirrie S, Rea D, Reed M, Roberts T, Thomas J, Wallis M, Wilcox M, Young J. The UK LORIS trial: Randomizing patients with low or low intermediate grade ductal carcinoma in situ (DCIS) to surgery or active monitoring [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 OT1-03-01.

Tolerability and Adherence Problems in Patients on a Stable Dose of Methotrexate: Results of a Multicentre Survey

INTRODUCTION

Methotrexate is commonly used in patients with inflammatory arthritis. The aim of the present study was to ascertain the prevalence of side effects that patients on methotrexate were tolerating and to establish their adherence to the medication.

METHOD

A questionnaire was developed for completion by the healthcare professional with the patient, and piloted in one centre. The questionnaire was then used in six other centres, with the addition of a question about the attractiveness of stopping methotrexate treatment. Efficacy and toxicities were scored for severity on a 10-cm visual analogue scale (VAS). Adherence to the drug was also explored.

RESULTS

The prevalence of 'any side effect' ranged from 57% to 86%. The most frequent side effects were fatigue (53%); nausea (38%); mouth ulcers (23%) and hair loss (23%). Efficacy averaged 6.5 cm on the VAS. Results from the combined survey revealed that toxicity averaged 5.9 cm for fatigue, 4.8 cm for nausea, 4.4 for mouth ulcers, 3.9 cm for hair loss and 5.7 cm for 'other' side effects. 13.5% of patients revealed that they had forgotten to take the drug for an average of two weeks, and 25% for an average of 2.5 weeks in the previous year. Participants were more likely to reveal this to a nurse than a doctor.

CONCLUSION

Patients put up with a considerable number of side effects in order to benefit from methotrexate therapy. Adherence to this drug merits further study. Copyright © 2015 John Wiley & Sons, Ltd.

Abstract OT2-02-04: The LORIS trial: A multicentre, randomised phase III trial of standard surgery versus active monitoring in women with newly diagnosed low risk ductal carcinoma in situ

Background: The independent review of the UK National Health Service Breast Screening Programme reported (The Lancet, Volume 380, Issue 9855, Pages 1778 - 1786, 17 November 2012) on the benefits & harms of breast screening. It concluded that breast screening saves lives & acknowledged overtreatment. It encouraged randomized trials to elucidate the appropriate treatment of screen-detected ductal carcinoma in situ (DCIS) to gain a better understanding of its natural history. The LORIS trial addresses overtreatment of low & low/Intermediate grade screen detected (low risk) DCIS by randomizing patients to standard surgical treatment or active monitoring.

Trial Design: LORIS is a phase III, multicentre, 2 arm study, with a 2 year feasibility phase, in patients confirmed to have low risk DCIS by central pathology review. Patients are randomised to standard surgery or active monitoring with annual mammography. Patients will be followed up for a minimum of 10 years.

Key Eligibility Criteria:

1) Female 46 years or over.

2) Screen-detected or incidental microcalcification (with no mass lesion clinically or on imaging)

3) Low risk DCIS on large volume vacuum-assisted biopsy, confirmed by central pathology review

4) Patient fit to undergo surgery

Specific Aims: The LORIS Trial aims to establish whether patients with newly diagnosed low risk DCIS can safely avoid surgery without detriment to their wellbeing (psychological and physical) & whether those patients that do require surgery can be identified by pathological and radiological means.

Primary endpoint: Ipsilateral invasive breast cancer free survival rate at 5 years

Secondary endpoints: Overall survival; mastectomy rate; time to mastectomy; time to surgery; patient reported outcomes & health resource utilisation.

A digital image data repository and tissue bank provide a prospective resource for both translational & imaging studies.

Statistical Methods: A total of 932 patients will be randomized to a non-inferiority design to test the null hypothesis that active monitoring of women diagnosed with low risk DCIS is not non-inferior in terms of 5 year ipsilateral invasive breast cancer free survival (iiBCFS) rate compared to treatment with surgery. The iiBCFS rate will be compared across the two arms on a per protocol and intent-to-treat basis, using a 1-sided (α=0.05) log-rank test for non-inferiority. The iiBCFS rate is assumed to be 97.5% in the surgery arm giving 80% power to exclude a difference of more than 2.5% in the active monitoring arm at 5 years.

Present Accrual and Target Accrual: 21 UK centres are open & the feasibility phase of the trial is recruiting to target. The web based central pathology review process is functioning well with a one week maximum turn around. A further 40 centres will be opened on completion of the feasibility phase.

Contact: LORIS@trials.bham.ac.uk

This project was funded by the National Institute for Health Research [Health Technology Assessment Programme] (project number 11/36/16)

Department of Health Disclaimer: The views & opinions expressed therein are those of the authors & do not necessarily reflect those of the Health Technology Assessment Programme, NIHR, NHS or the Department of Health.

Citation Format: Francis A, Fallowfield L, Bartlett J, Thomas J, Wallis M, Hanby A, Pinder S, Evans A, Billingham L, Brookes C, Dodwell D, Fairbrother P, Gaunt C, Jenkins V, Matthews L, Pirrie S, Reed M, Roberts T, Wilcox M, Young J, Rea D. The LORIS trial: A multicentre, randomised phase III trial of standard surgery versus active monitoring in women with newly diagnosed low risk ductal carcinoma in situ. [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 OT2-02-04.

Case-mix analysis and variation in rates of non-surgical treatment of older women with operable breast cancer

BACKGROUND

Non-surgical management of older women with oestrogen receptor (ER)-positive operable breast cancer is common in the UK, with up to 40 per cent of women aged over 70 years receiving primary endocrine therapy. Although this may be appropriate for frailer patients, for some it may result in treatment failure, contributing to the poor outcomes seen in this age group. Wide variation in the rates of non-operative management of breast cancer in older women exists across the UK. Case mix may explain some of this variation in practice.

METHODS

Data from two UK regional cancer registries were analysed to determine whether variation in treatment observed between 2002 and 2010 at hospital and clinician level persisted after adjustment for case mix. Expected case mix-adjusted surgery rates were derived by logistic regression using the variables age, proxy Charlson co-morbidity score, deprivation quintile, method of cancer detection, tumour size, stage, grade and node status.

RESULTS

Data on 17,129 women aged 70 years or more with ER-positive operable breast cancer were analysed. There was considerable variation in rates of surgery at both hospital and clinician level. Despite adjusting for case mix, this variation persisted at hospital level, although not at clinician level.

CONCLUSION

This study demonstrates variation in selection criteria for older women for operative treatment of early breast cancer, indicating that some older women may be undertreated or overtreated, and may partly explain the inferior disease outcomes in this age group. It emphasizes the urgent need for evidence-based guidelines for treatment selection criteria in older women with breast cancer.

Patient satisfaction with total knee replacement cannot be predicted from pre-operative variables alone: A cohort study from the National Joint Registry for England and Wales

Pre-operative variables are increasingly being used to determine eligibility for total knee replacement (TKR). This study was undertaken to evaluate the relationships, interactions and predictive capacity of variables available pre- and post-operatively on patient satisfaction following TKR. Using nationally collected patient reported outcome measures and data from the National Joint Registry for England and Wales, we identified 22 798 patients who underwent TKR for osteoarthritis between August 2008 and September 2010. The ability of specific covariates to predict satisfaction was assessed using ordinal logistic regression and structural equational modelling. Only 4959 (22%) of 22 278 patients rated the results of their TKR as 'excellent', despite the majority (71%, n = 15 882) perceiving their knee symptoms to be much improved. The strongest predictors of satisfaction were post-operative variables. Satisfaction was significantly and positively related to the perception of symptom improvement (operative success) and the post-operative EuroQol-5D score. While also significant within the models pre-operative variables were less important and had a minimal influence upon post-operative satisfaction. The most robust predictions of satisfaction occurred only when both pre- and post-operative variables were considered together. These findings question the appropriateness of restricting access to care based on arbitrary pre-operative thresholds as these factors have little bearing on post-operative satisfaction.

Enhanced differentiation of osteoclasts from mononuclear precursors in patients with Gaucher disease

Gaucher disease (GD) is an autosomal recessive disorder caused by deficiency of β-glucocerebrosidase. Storage of glucosylceramide in reticuloendothelial cells results in multiorgan pathology including bone disease. Established skeletal disease may remain problematic despite Gaucher-specific treatment. Both osteopenia and osteonecrosis have been described but the underlying pathophysiology, in particular the role of monocyte-derived osteoclasts is not well defined. The objective of this study was to explore the effect of glucocerebrosidase deficiency, inhibition and replacement on osteoclast development and function. In cultures derived from GD patients, or where GBA was chemically inhibited multinucleate giant cells expressing markers of osteoclast differentiation occurred earlier and in greater numbers compared to normal controls and the functional capacity of osteoclasts for bone resorption was enhanced. Increases in osteoclast number and activity correlated with radiological markers of active bone disease. Abnormalities were reversed by addition of specific therapies and were attenuated by co-culture with cells derived from healthy controls (HCs). Numbers of osteoblast lineage cells in the peripheral blood were mismatched to osteoclast precursors indicating uncoupling of osteoblast-osteoclast regulation which may further impact on bone remodelling. Elucidation of the underlying mechanisms of these changes will suggest rational therapies for the most disabling aspect of this condition.