Exercise combined with Acceptance and Commitment Therapy for chronic pain: One-year follow-up from a randomized controlled trial

BACKGROUND

Acceptance and Commitment Therapy (ACT) is a type of Cognitive Behavioural Therapy, which has demonstrated positive outcomes in individuals with chronic pain. The purpose of this study was to compare the effect of an 8-week programme combining Exercise with Acceptance and Commitment Therapy (ExACT) with a standalone supervised exercise programme at 1-year follow-up.

METHODS

One hundred and seventy-five people with chronic pain were randomly assigned to ExACT or supervised exercise only. The primary outcome was pain interference measured with the Brief Pain Inventory-Interference Scale. Secondary and treatment process outcomes included pain severity, depression, anxiety, pain catastrophizing, pain self-efficacy, fear avoidance, pain acceptance, committed action, healthcare utilization, patient satisfaction, and global impression of change. Estimates of treatment effects at 1-year follow-up were based on intention-to-treat analyses, implemented using a linear mixed-effects model.

RESULTS

Eighty-three participants (47.4%) returned the outcome measures at 1-year follow-up. No significant difference was observed between the groups for the primary outcome, pain interference. There was a statistically significant difference between the groups, in favour of ExACT for pain catastrophizing. Within group improvements that were observed within both groups at earlier timepoints were maintained at 1-year follow-up for many of the secondary and treatment process outcomes. ExACT group participants reported higher levels of satisfaction with treatment and global perceived change.

CONCLUSIONS

The study results showed no significant difference between the two groups for the primary outcome pain interference at 1-year follow-up. Future research could investigate factors that may predict and optimize outcomes from these types of intervention for people living with chronic pain.

SIGNIFICANCE

Few previous randomized controlled trials investigating ACT for chronic pain have included long-term follow-up. This study found that Exercise combined with ACT was not superior to supervised exercise alone for reducing pain interference at 1-year follow-up. Further research is necessary to identify key processes of therapeutic change and to explore how interventions may be modified to enhance clinical outcomes for people with chronic pain.

Overall Survival and Associations of Insurance Status Among Hispanic Men With High-Risk Prostate Cancer

Objectives Our objectives were to (1) determine the association between ethnicity and high-risk prostate cancer (PCa) survival and (2) determine whether this association is modified by insurance status. Methods We performed a retrospective review of the National Cancer Database (NCDB) from 2004 to 2017 of non-Hispanic White (NHW), Hispanic White (HW), or Black men with high-risk PCa. A multivariate Cox regression model was built to test the association between overall survival (OS) and race/ethnicity, insurance status, and their interaction, controlling for various socioeconomic and disease-specific variables. Results A total of 94,708 men with high-risk PCa were included in the analysis. Both HW and Black men had lower socioeconomic status characteristics and lower rates of private insurance. Race/ethnicity was significantly associated with OS in the adjusted analysis. Only Medicare demonstrated significantly worse OS. NHW (covariate-adjusted hazard ratio (aHR): 1.83, 95% CI: 1.45-2.32) and Black (aHR: 1.71, 05% CI: 1.34-2.19) men demonstrated significantly worse survival when compared to HW men. Subgroup analysis demonstrated significant differences occurring among HW men with private insurance/managed care when compared to those not insured, Medicaid, Medicare, and other government insurance types. Conclusion Despite socioeconomic and demographic disadvantages, HW men demonstrate improved OS compared to NHW men. Furthermore, HW men demonstrated improved OS compared to NHW men within nearly each insurance status type. This finding is likely the result of a complex multifactorial web and as such serves as an interesting hypothesis-generating study.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Acute physiological effects following Bacillus subtilis DE111 oral ingestion - a randomised, double blinded, placebo-controlled study

Previous studies using ileostomy samples from study participants demonstrated that the spore-forming probiotic Bacillus subtilis DE111® can germinate in the small intestine as early as 4 hours after ingestion. Metabolomics, proteomics and sequencing technologies, enabled further analysis of these samples for the presence of hypoglycaemic, hypolipidemic, antioxidant, anti-inflammatory and antihypertensive molecules. In the DE111 treatment group, the polyphenols trigonelline and 2,5-dihydroxybenzoic acid, orotic acid, the non-essential amino acid cystine and the lipokine 12,13-diHome were increased. DE111 also reduced acetylcholine levels in the ileostomy samples, and increased the expression of leucocyte recruiting proteins, antimicrobial peptides and intestinal alkaline phosphatases of the brush border in the small intestine. The combination of B. subtilis DE111 and the diet administered during the study increased the expression of the proteins phosphodiesterase ENPP7, ceramidase ASAH2 and the adipokine Zn-alpha-2-glycoprotein that are involved in fatty acid and lipid metabolism. Acute B. subtilis DE111 ingestion had limited detectable effect on the microbiome, with the main change being its increased presence. These findings support previous data suggesting a beneficial role of DE111 in digestion, metabolism, and immune health that appears to begin within hours of consumption.

Use of Impella Devices for Acute Cardiogenic Shock in the Perioperative Period of Cardiac Surgery

INTRODUCTION

The Impella ventricular support system is a device that can be inserted percutaneously or directly across the aortic valve to unload the left ventricle. The purpose of this study is to determine the role of Impella devices in patients with acute cardiogenic shock in the perioperative period of cardiac surgery.

METHODS

A retrospective single-surgeon review of 11 consecutive patients who underwent placement of Impella devices in the perioperative period of cardiac surgery was performed. Patient records were evaluated for demographics, indications for placement, and postoperative outcomes.

RESULTS

Impella devices were placed for refractory cardiogenic shock preoperatively in 6 patients, intraoperatively in 4 patients, and postoperatively as a rescue in 1 patient. Seven patients received Impella CP, 1 Impella RP, 1 Impella CP and RP, and 2 Impella 5.0. Additionally, 3 patients required preoperative venovenous extracorporeal membrane oxygenation (VV-ECMO), and 1 patient required intraoperative venoarterial extracorporeal membrane oxygenation (VA-ECMO). All Impella devices were removed 1 to 28 days after implantation. Length of stay in the intensive care unit stay ranged from 2 to 53 days (average 23.9±14.6). The 30-day and 1-year mortality were 0%. Ten of 11 patients were alive at 2 years. Also, 1 patient died 18 months after surgery from complications of coronavirus disease (Covid-19). Device-related complications included varying degrees> of hemolysis in 8 patients (73%) and device malfunction in 1 patient (9%).

CONCLUSIONS

The Impella ventricular support system can be combined with other mechanical support devices for additional hemodynamic support. All patients demonstrated myocardial recovery with no deaths in the perioperative period and in 1-year of follow-up. Larger studies are necessary to validate these findings.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

222 TOWARDS A DELIRIUM FRIENDLY EMERGENCY DEPARTMENT

Background

Delirium affects approx. 10-30 % of patients over the age of 65. Up to 70% of cases are missed in the Emergency Department (ED). Delirium results in increased morbidity, mortality, increased length of stay and decreased functional status with increased discharges to residential care centres. Delirium in the ED is an independent predictor of death within 6 months.

Methods

We completed an audit which showed 40% of those &gt; 65 years of age in the ED were delirious and 60% of those had dementia. None of these had been identified as delirious prior to review. We have approx. 5,000 patients &gt;75 years of age attending our ED annually (1/7th of presentations). This audit was used as a catalyst for our quality improvement project. We established a steering group with a small quality improvement sub-committee. We combed the literature, identified areas for improvement and costed our project. We also looked at reliance on 1:1 carers for those with delirium and potential benefits to patient, staff and management.

Results

We used the SPARK ignite programme as a means to gain momentum and also educate ourselves on business management and change management. We competed in the finals with our “delirium package” – focussing on orientation, stimulation, safety and education. These 4 pillars of delirium care have been shown to prevent delirium, reduce hospital stay for those with delirium and also augment their delirium cycle. Competing and winning a prize highlighted the importance of delirium care and brought our project to a bigger stage.

Conclusion

Due to our multi-disciplinary team composed of non-consultant hospital doctors, advanced nurse practitioners and occupational therapists, we have been able to introduce the national dementia programme for early identification of delirium in the emergency department. We now have a space for managing those with delirium and have received funding to put our package in place. This can be replicated in hospitals around the country highlighting the non-pharmacological treatments for delirium.

109 FRAILTY CARE BUNDLE EAT WALK TALK: MAKING GERIATRIC ATTUNED CARE EVERYONE'S BUSINESS

Background

Older adults living with frailty are predisposed to functional decline, worsening malnutrition and delirium when admitted to the acute hospital. EAT, WALK and TALK is a comprehensive framework that promotes optimal nutrition and hydration, supports functional recovery and helps prevent delirium [1].

Comprehensive geriatric assessment and interdisciplinary care on an older adult ward can improve outcomes for older adults [2]. However, not all older adults receive care on specialist wards. The frailty care bundle framework could be utilised on general medical wards to apply older adult attuned principles of good care.

Methods

A quality improvement initiative using PDSA was undertaken. Engagement with stakeholders was made through the Quality and Patient Safety Committee. The overall aim was to prevent hospital associated functional decline by increasing mobility, improving nutrition and cognitive engagement on general medical wards. The blue plate initiative, patient mobility and delirium screening was audited.

Results

The audit showed a 13.3% reduction in patients screening positive for delirium and a 100% increase in the use of delirium care plans. Nutritional intake had improved by 50% with the addition of blue crockery. Baseline mobility audit showed gaps in communication between health professionals. Whiteboards were introduced to address this.

Conclusion

The EAT WALK and TALK care bundle prioritises the critical components of good care for the older person living with frailty. The audit data shows improvement in care processes and outcome measurements.

References

1. Mudge AM, et al. Eat Walk Engage: An interdisciplinary Collaborative Model to Improve Care of Hospitalized Elders. American Journal of Medical Quality 2015. Vol. 30(1) 5–13.

2. Ellis G et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane database Syst Rev. 2011(7): CD006211.

Pustular and Erythrodermic Psoriasis in Patients Treated With Oral Glucocorticoids: A Survey of United States Dermatologists

Dermatology dogma has cautioned against the use of orally administered glucocorticoids (OAG) in the treatment of psoriasis, largely due to concerns of life-threatening generalized pustular psoriasis (GPP) and erythrodermic psoriasis (EP). However, studies show that OAG are frequently used for psoriasis, often by dermatologists. Given the widespread use of OAG, we see an urgency in examining the relationship between OAG usage and the development of GPP and EP. This anonymous electronic survey of 50 US dermatologists examines OAG use in the management of psoriasis and the frequency at which dermatologists report seeing associated adverse outcomes of GPP and EP. Overall, 9 out of 50 (18%) respondents occasionally prescribe OAG to patients with psoriasis. Dermatologists who prescribe OAG tended to be younger than those who did not, with two-thirds in clinical practice for 0-10 years. Among all respondents, 16% (8/50) had experienced one or more patients developing GPP/EP in the context of OAG treatment for psoriasis. Our study suggests that OAG for the management of psoriasis is not uncommon among U.S. dermatologists, despite nearly universal awareness of its risks. Our observed low prevalence of GPP and EP emphasizes the need for prospective studies to better characterize OAG&rsquo;s risk/benefit profile in psoriasis. J Drugs Dermatol. 2022;21(4):427-429. doi:10.36849/JDD.6242.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Athletic Training and Population Health Science

OBJECTIVE

To define and discuss the role of population health as a framework to improve care and clinical decision making in athletic training practice.

BACKGROUND

Athletic trainers (ATs) are allied health professionals who are uniquely suited to provide preventive and educational health and wellness programs to improve health outcomes across a physically active population. Athletic trainers are often the first contacts for high school athletes seeking health and wellness education, which may allow ATs to be the first intervention or prevention point for reducing or eliminating negative health behaviors and outcomes among their patients.

CONCLUSIONS

Integrating a population-health framework into the athletic training setting prepares ATs to address complex health concerns in communities that result from factors that influence determinants of health. The field of athletic training could benefit from a population-health approach to care by broadening consideration of the factors that affect the health of homogeneous populations that are served by ATs.

Athletic Trainer-Reported Prevalence of Mental Health, Substance Use, and Barriers to Health in Secondary Schools

CONTEXT

Where a person lives can have a significant effect on health. Limited access to health care, food insecurity, lack of affordable housing, and violence increase a person's likelihood of poor health. Athletic trainers (ATs) can contribute to identifying and improving the determinants of health that affect student-athletes.

OBJECTIVES

(1) What were the current perceptions ATs had about the health behaviors (specifically mental health and substance use) of high school student-athletes? (2) What were the barriers that ATs experienced when providing health services to high school student-athletes? (3) How did the developed environment affect the health behaviors and barriers that ATs observed?

DESIGN

Qualitative study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

Certified National Athletic Trainers' Association members employed in the secondary school setting.

MAIN OUTCOME MEASURE(S)

Demographics of ATs were collected, and the ATs' perceptions of the health of student-athletes across developed environments, prevalence of mental health issues, tobacco and substance use, barriers to health care services, and housing and food insecurities among student-athletes were surveyed. Descriptive statistics for the outcome measures were reported.

RESULTS

A total of 7600 electronic surveys were distributed to the ATs and 911 responded (females = 62%, average age = 36 years, average experience = 12.5 years). The school setting was identified by 82.5% as public and the environment as suburban by 43.7%, rural by 30.1%, and urban by 26.1%. Participants perceived a high average prevalence of mental health concerns (32%), e-cigarette use (31.7%), and marijuana use (26.9%) among student-athletes. Significant perceived barriers to health included limited access to transportation, poverty, and housing and food insecurities.

CONCLUSIONS

This study highlights the health disparities and barriers ATs observed when addressing the health care needs of student-athletes. Understanding the determinants of health in order to identify the causes of health disparities may better prepare ATs to manage the health needs of underserved student-athletes.

How We Perform a David Procedure With an Upper Hemisternotomy Approach

OBJECTIVE

Valve-sparing aortic root replacement (David procedure) is the technique of choice in appropriately selected patients with aortic root aneurysms. These procedures are seldom performed in a minimally invasive fashion. We describe our systematic approach to the David procedure using an upper hemisternotomy (UHS). Methods: Our method involves a J-type UHS exiting the right third or fourth intercostal space. Ascending aortic and femoral venous cannulation are performed using the Seldinger technique under transesophageal echocardiographic guidance. Between August 2005 and August 2014, 27 patients underwent an isolated elective David procedure using a full sternotomy (FS). Sixteen underwent an isolated elective UHS David procedure from May 2015 to February 2019. Perioperative safety outcomes were compared between the 2 cohorts. Results: The UHS and FS David cohorts were primarily male (87.5% and 85.2%, respectively) and 51 and 50 years old on average, respectively. Custodiol-histidine-tryptophan-ketoglutarate cardioplegia (93.8% vs 37.0%, P < 0.001) and Cor-Knot (100% vs 0%, P < 0.001) were used significantly more in the UHS David cohort. There were no significant differences in cardiopulmonary bypass (200 [183-208] vs 212 [183-223] min, P = 0.309) and aortic cross-clamp (169 [155-179] vs 188 [155-199] min, P = 0.128) times in the UHS and FS cohorts. There were no instances of hospital or 30-day mortality in either cohort. Intensive care unit and hospital stays were comparable between the 2 cohorts. Conclusions: The David procedure via UHS is a safe and reproducible technique for aortic root replacement.

221 PREVALENCE AND DOCUMENTATION OF DELIRIUM IN A UNIVERSITY HOSPITAL

Background

Delirium can complicate approximately 10% of all medical admissions and prevalence increases in those with cognitive impairment, increasing age and medical complexity. Delirium is associated with increased morbidity and mortality as well as increased length of stay. Prompt recognition and treatment is essential. The National Delirium Care Bundle suggests assessment and recognition at the earliest opportunity and documentation of delirium if patients screen positive.

Methods

We carried out an audit among patients admitted in all medical wards to identify delirium and assess if it was documented and a care bundle opened. All patients were screened using the 4AT tool at least once over the space of one week. Medical notes were also screened to assess for documentation of delirium.

Results

95 patients were screened and 32 (33%) of these screened positive. Of these only 11 patients had a diagnosis of delirium documented in medical/nursing notes and a delirium care bundle opened. 50% of CCU patients were delirious. The Geriatric Medicine Ward had a lower prevalence of 19% with 66% identified in medical notes.

Conclusion

These results are disappointing with only 34% of patients identified as having a delirium. This audit is part of a quality improvement project with education sessions ongoing and roll out of the national delirium/dementia pathways across the medical wards. We hope to present our interventions and completed audit loop shortly.

COVID-related anxiety is prevalent and accurately reflects serious COVID risks in breast cancer patients

12053

Background: A current cancer diagnosis is a risk factor for serious COVID-19 complications (CDC). In addition, the pandemic has caused major disruptions in medical care and support networks, resulting in treatment delays, limited access to doctors, worsening health disparities, social isolation; and driving higher utilization of telemedicine and online resources. Breastcancer.org has experienced a sustained surge of new and repeat users seeking urgent information and support. To better understand these unmet needs, we conducted a survey of the Breastcancer.org Community. Methods: Members of the Breastcancer.org Community were invited to complete a survey on the effects of the COVID-19 pandemic on their breast cancer care, including questions on demographics, comorbidities (including lung, heart, liver and kidney disease, asthma, diabetes, obesity, and other chronic health conditions); care delays, anxiety due to COVID-related care delays, use of telemedicine, and satisfaction with care during COVID. The survey was conducted between 4/27/2020-6/1/2020 using Survey Monkey. Results were tabulated and compared by chi square test. A p-value of 0.05 is considered significant. Data were analyzed using Stata 16.0 (Stata Corp., Inc, College Station, TX). Results: Our analysis included 568 breast cancer patients of whom 44% had ≥1 other comorbidities associated with serious COVID-19 complications (per CDC) and 37% had moderate to extreme anxiety about contracting COVID. This anxiety increased with the number of comorbidities (p=0.021), age (p=0.040), and with a current breast cancer diagnosis (p=0.011) (see table). Anxiety was significantly higher in those currently diagnosed, ≥65, or with ≥3 other comorbidities, compared to those diagnosed in the past, age <44, or without other comorbidities. Conclusions: Our survey reveals that COVID-related anxiety is prevalent at any age regardless of overall health status, but it increased with the number of other comorbidities, older age, and a current breast cancer diagnosis. Thus, reported anxiety is proportional to the risk of developing serious complications from COVID. Current breast cancer patients of all ages—especially with other comorbidities—require emotional support, safe access to their providers, and prioritization for vaccination.[Table: see text]

Understanding the effect of mechanical forces on ovarian cancer progression

OBJECTIVE

Mechanical forces including tension, compression, and shear stress are increasingly implicated in tumor progression and metastasis. Understanding the mechanisms behind epithelial ovarian cancer (EOC) progression and metastasis is critical, and this study aimed to elucidate the effect of oscillatory and constant tension on EOC.

METHODS

SKOV-3 and OVCAR-8 EOC cell lines were placed under oscillatory tension for 3 days and compared to cells placed under no tension. Cell proliferation, migration, and invasion were analyzed while RNAseq and Western Blots helped investigate the biological mechanisms underlying the increasingly aggressive state of the experimental cells. Finally, in vivo experiments using SCID mice assisted in confirming the in vitro results.

RESULTS

Oscillatory tension (OT) and constant tension (CT) significantly increased SKOV-3 proliferation, while OT caused a significant increase in proliferative genes, migration, and invasion in this cell line. CT did not cause significant increases in these areas. Neither OT nor CT increased proliferation or invasion in OVCAR-8 cells, while both tension types significantly increased cellular migration. Two proteins involved in metastasis, E-cadherin and Snail, were both significantly affected by OT in both cell lines, with E-cadherin levels decreasing and Snail levels increasing. In vivo, tumor growth and weight for both cell types were significantly increased, and ascites development was significantly higher in the experimental OVCAR-8 group than in the control group.

CONCLUSIONS

This study found that mechanical forces are influential in EOC progression and metastasis. Further analysis of downstream mechanisms involved in EOC metastasis will be critical for improvements in EOC treatment.

Socio-environmental conditions associated with geospatial clusters of urothelial carcinoma: A multi-institutional analysis

392

Background: Industrial byproducts and environmental pollutants (IBP/EP) are associated with the development of urothelial carcinoma (UC). While tobacco exposure (TE) is the major risk factor for UC, the interaction between sources of IBP/EP and incidence of UC in surrounding communities has been infrequently explored. We seek to identify high-density microregions of UC prevalence and spatially-related industrial and environmental risk factors. Methods: We queried a multi-institutional database for patients diagnosed with UC between 2008-2018. Geocoded addresses and ArcGIS software were used to calculate the Getis-Ord-Gi* statistic and perform hotspot analysis on the census-block level to identify UC hotspots. Demographics, clinicopathologic disease characteristics, and proximity to sources of IBP/EP were compared using Pearson’s chi-square and Student’s T-test. Univariate analyses and multivariable multilevel logistic random-intercept regression models were fitted to test the association between patient and census block-level factors and living in a UC hot spot. Results: Of 5,080 patients meeting inclusion/exclusion criteria, 148 patients (2.9%) were associated with one of three UC hotspots. In univariate analyses, hotspot patients were less likely to be tobacco users (OR 0.24, p=0.004) or of white race (OR 0.10, p<0.001) and less likely to have higher income (OR 0.73, p=0.005). They were more likely to be associated with IBP/EP exposure (OR 8.24, p=0.001) (Table). Multivariable analysis confirmed increased likelihood of residing in a UC hotspot and proximity to high-traffic density (OR >999, p=<0.001) and sites of IBP/EP contamination (OR 106.90, p=0.009), with decreased likelihood of tobacco use (OR 0.11, p=0.045) and white race (OR 0.02, p=0.004). Conclusions: Patients residing in geospatial hotspots of UC prevalence are less likely to be white, higher income or tobacco users and more likely to reside in proximity to sources of IBP/EP. Further research is necessary to investigate the interplay between socioeconomic status, race and environmental risk factors in order to better identify at-risk populations and improve screening, referral, diagnosis and timely intervention. [Table: see text]

Assessment of pain, anxiety and depression, and quality of life after minimally invasive aortic surgery

BACKGROUND

Minimally invasive cardiac surgery may reduce surgical trauma, diminish postoperative pain and improve quality of life (QOL). The aim of this study is to assess pain, hospital anxiety and depression scale (HADS), and QOL in patients undergoing minimally invasive aortic surgery.

METHODS

This is a prospective, single-center cohort study of 24 consecutive patients undergoing upper ministernotomy aortic valve, aortic root, and concomitant aortic valve and ascending aorta replacement. Visual analog scale (VAS) pain scores and HADS and Short-Form-36 (SF-36) questionnaires were evaluated at preoperative baseline, during hospitalization, and at 1 and 3 months postoperatively.

RESULTS

At discharge, the average VAS pain score was significantly lower than postoperative Day 1 (2.7 ± 0.4 vs. 6.5 ± 0.4; p ≤ .001). By 1 month, the pain scores were not significantly different from baseline (1.7 ± 0.4 vs. 1.0 ± 0.4; p = 1.000), and by 3 months, pain scores returned to baseline (1.0 ± 0.4; p = 1.000). HADS scores show that compared with preoperative baseline, average anxiety scores decreased by 1 month (3.1 ± 0.7 vs. 4.3 ± 0.6; p = 1.000) and decreased significantly by 3 months (1.8 ± 0.7 vs. 4.3 ± 0.6; p = .012). Additionally, depression scores were unchanged at 1 month (3.0 ± 0.4 vs. 3.1. ± 0.4; p = 1.000) and decreased by 3 months (1.3 ± 0.5 vs. 3.0 ± 0.4; p = .060). SF-36 scores revealed no changes in scores in 7 of 8 domains at 1 month and a significant increase in "physical functioning," "energy," and "general health" domains compared to preoperative baseline at 3 months.

CONCLUSIONS

Following minimally invasive aortic surgery, VAS pain scores, HADS and scores in 7 of 8 SF-36 domains returned to preoperative baseline or improved compared to preoperative baseline at 1 month. At 3 months, scores in 3 of 8 SF-36 domains significantly improved compared to preoperative baseline. Larger studies are necessary for further investigation.

Transcatheter and ministernotomy aortic valve replacement after bioprosthetic valve failure

BACKGROUND

Transcatheter valve-in-valve implantation (TViV) and minimally invasive reoperative aortic valve replacement (MIrAVR) have rapidly increased as alternatives to conventional reoperative surgical AVR. This study reports a single-center experience of patients undergoing TViV and MIrAVR after bioprosthetic valve failure.

METHODS

In this retrospective review between March 2009 and October 2018, 68 patients without reoperative full sternotomies, concomitant procedures, active endocarditis, and prior homografts or coronary artery bypass grafting underwent isolated AVR for degenerated aortic bioprostheses. Society of Thoracic Surgeons (STS) risk scores and age are reported as median (interquartile range [IQR]) and length of stay is reported as mean (standard deviation [SD]) due to their characteristics of the distribution.

RESULTS

Forty-one (60.3%) patients underwent TViV, and 27 (39.7%) patients underwent MIrAVR. Median [IQR] STS risk scores were 5.7 [4.0-7.8] and 2.0 [1.5-3.4] for TViV and MIrAVR, respectively (p ≤ .001). The median [IQR] age for TViV patients was higher (78 [71-84] vs. 66 [53-72] years, p ≤ 0.001). More permanent pacemakers were implanted (22.2% vs. 9.8%) following MIrAVR. The MIrAVR group had a higher rate of atrial fibrillation (18.5% vs. 9.8%, p = .466). Average (SD) length of stay was less in TViV (5.3 days, SD: 3.4 vs. 8.6 days, SD: 7.4, p = .001). Survival at 1 year was not significantly different for TViV and MIrAVR (94.9% [95% confidence interval [CI]: 81.0%, 98.7%] and 86.9% [95% CI: 64.0%, 95.7%], respectively [p = .969]).

CONCLUSIONS

Despite being at higher-risk, patients undergoing TViV had reduced rates of permanent pacemaker implantations and atrial fibrillation, and a shorter hospital stay as compared to MIrAVR. Survival at 1-year was similar between the two groups.

Factors Influencing Fluoroscopy Use During Ureteroscopy at a Residency Training Program

Introduction: Ionizing radiation is used throughout urologic surgery and is known to cause a greater cancer risk with increasing exposure. The International Commission on Radiological Protection states that "it is the control of radiation dose that is important, no matter the source." However, there are few reports on the amount of radiation used by urology residents during ureteroscopy (URS). We present the largest database evaluating fluoroscopy (fluoro) use during URS at a resident training program. Our objective is to assess the amount of fluoro use at varying levels of experience and to identify factors that lead to increased fluoro use. Methods: Retrospective data from 242 URSs performed at two resident training sites were collected. In total, 105 surgeries were done by two attending physicians without and 137 surgeries with residents (Uro1-Uro3). Patient data were collected from the electronic medical record. Statistical analyses included analysis of variance, Spearman correlations, and multiple linear regression (MLR). Results: Comparisons between years 1 and 2 revealed significantly (p < 0.05) decreased fluoro time (20.0 seconds) and operative time (OT) (12.2 minutes) for the year 2 resident. Total OT was significantly (p < 0.05) decreased (11.1 minutes) for attending physicians operating on their own compared with a year 1 resident. Significant (p < 0.05) correlations with fluoro time were demonstrated for OT, stone size, ureteral dilation, ureteral access sheath use, presence of a preoperative stent, resident year, and resident month. OT, ureteral dilation, and a preoperative stent placement were significant predictors of fluoro time on MLR (p < 0.05). Conclusion: Fluoro time during retrograde URS was significantly reduced as residents gained more experience in the operating room. An increase in fluoro time was also associated with ureteral dilation, access sheath use, increasing stone size, and lack of prestenting. With knowledge of these factors, emphasis can be placed on using and teaching techniques that limit radiation exposure.

A survey of breast cancer patients’ use of cannabis before, during, and after treatment

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Background: The availability of cannabis is rapidly expanding and cancer is a qualifying condition in all states allowing medical cannabis. However, there are many unknowns with respect to patterns of cannabis use among breast cancer patients. The goal of this study was to better understand how and when cannabis is used among breast cancer patients. Methods: Between 12/16/2019 and 1/19/2020, U.S.-based members of Breastcancer.org and the Healthline communities were invited to participate in a cannabis survey. Subjects confirmed they were age ≥18 and diagnosed with breast cancer within 5 years. After informed consent, data were collected, de-identified and analyzed in aggregate. The study was led by Socanna, conducted by Outcomes Insights, and supported by a grant from Ananda Health/Ecofibre. Results: A total of 3522 persons initiated screening, 832 completed screening, and 725 met eligibility criteria, of whom 612 completed the survey (84%). The results showed that 42% of participants had used medical cannabis products to relieve symptoms, including insomnia (70%), pain (59%), anxiety (57%), stress (51%), and nausea/vomiting (46%). Additionally, cannabis was used prior to treatment in 24%, during treatment in 79%, and after treatment in 54%. Of subjects reporting cannabis use during treatment: 86% used it during chemotherapy, 71% during HER2 therapy, 65% during hormonal therapy, 49% during breast radiation, and 47% during radiation for metastatic sites. Post-surgical use was reported in 51% after mastectomy alone, 40% after lumpectomy, and 38% after mastectomy/reconstruction. An average of 3-4 cannabis products were utilized. Products were sourced from medical dispensaries (54%), family/friends (33%), and recreational sources (27%). Although cannabis using subjects strongly preferred medical sources, 77% had also utilized recreational sources. Conclusions: This survey shows that almost half of breast cancer patients reported using cannabis to help relieve common symptoms from breast cancer or its treatments. Of those, 79% used cannabis during active treatment, which can impact efficacy and safety. To date, studies have not investigated drug interactions between cannabis and these therapeutic agents. Furthermore, there is a concern regarding contaminants. Although most medical cannabis is tested for pathogens and contaminants, this is not the case for cannabis obtained from other sources. The results of this study highlight the need for research regarding cannabis for medical purposes, including safety and interaction studies.

A survey of cannabis use for symptom palliation in breast cancer patients by age and stage

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Background: Most US states have legalized medical cannabis for the treatment of serious conditions, including cancer. It is not well known which symptoms breast cancer patients seek to control with cannabis. Methods: Members of the Breastcancer.org and Healthline communities were invited to participate in this survey between 12/16/2019 and 1/19/2020. Eligibility criteria included age ≥18 years, resident of the US and a breast cancer diagnosis within the past 5 years. Eligible respondent data were analyzed for the symptomatic profile of cannabis users. Symptoms were compared between two groups using a Chi-square test of independence. The survey was led by Socanna, conducted by Outcomes Insights, and supported by a grant from Ananda Health/Ecofibre. Results: Among the 832 respondents who completed screening, 725 met the eligibility criteria, and 612 (84%) completed the survey. The median age of respondents was 57 years, and 85% had non-metastatic disease An estimated 42% of respondents have used medical cannabis to treat symptoms or side effects of breast cancer. Medical cannabis users reported using cannabis to treat insomnia (70%), joint and muscle aches, discomfort, stiffness, or pain (59%), anxiety (57%), and stress (51%). The medical cannabis users less than 50-year-old were more likely to use cannabis to treat these symptoms than their over 50-year-old counterparts, however, the differences were not statistically significant. Medical cannabis users under age 50 used cannabis significantly more than over 50 to treat nausea/vomiting (58% vs 40%; p = 0.010) and inflammation (34% vs 20%; p = 0.021). Medical cannabis users with metastatic disease were more likely to use medical cannabis to treat chronic pain 60% vs 41%; p = 0.017) than non-metastatic users. Post-surgery patients were most likely to use cannabis for nerve pain; and those who were beyond treatment, for stress. Patients suffered an average of 5 symptoms. Conclusions: A significant proportion of breast cancer patients reported using cannabis to treat a combination of symptoms from their cancer and its treatment. Although younger patients are somewhat more likely to use this form of palliative management, older patients are suffering from the same symptoms and their use is nearly as high. More research is needed on the personalization of safe and effective symptomatic management with medical cannabis, for people of all ages, stages, and forms of treatment.

Primary colorectal linitis plastica presenting as rapid acute deterioration: a diagnostic dilemma

We present a rare case of primary colorectal linitis plastica presenting as an acute admission to hospital with a wide range of systemic symptoms, sudden rapid deterioration and subsequent mortality. A postmortem examination revealed a primary linitis plastica of the colon and rectum with diffuse metastatic disease. To our knowledge, this is the first report of primary colorectal linitis plastica presenting as an acute deterioration as a result of extensive metastatic disease.

Total Arch Replacement with Hypothermic Circulatory Arrest, Antegrade Cerebral Perfusion and the Y-graft

This study examines postoperative morbidity and mortality and long-term survival after total arch replacement (TAR) using deep to moderate hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and the Y-graft. Seventy-five patients underwent TAR with the Y graft. Deep to moderate HCA was initiated at 18-22°C. ACP was either initiated immediately (early ACP) or after the distal anastomosis was performed (late ACP). The arch vessels were then serially anastomosed to the individual limbs of the Y-graft. The median age was 66 years (range = 32-82). Etiology of aneurysmal dilatation included 20 (27%) patients with medial degenerations, 25 (33%) with chronic dissections, 14 (19%) with acute dissections, 9 (12%) with atherosclerosis and 2 (3%) with Marfan syndrome. In-hospital mortality was 5%. Neurologic complications occurred in 8 (11%) patients; 2 (3%) had strokes and 6 (8%) had transient neurologic deficits. Patients undergoing TAR with moderate hypothermia had a significantly higher incidence of new-onset renal insufficiency (3 [23%] vs [0%], P < 0.001) and TND (3 (23%) vs 3 (5%), P = 0.028) than the profound and deep hypothermia cohort. Excluding the 1 patient who died intraoperatively, 89% (95%CI: 79-94%) were alive at 1 year, 78% at 5 years (95%CI: 66-86%), and 73% at 10 years (95%CI: 59-82%). The combination of deep to moderate HCA, ACP, and the Y-graft is a safe and reproducible technique. Further inquiry is needed to assess if early ACP provides superior clinical outcomes.

Incidence, Natural History, and Factors Associated With Paravalvular Leak Following Surgical Aortic Valve Replacement

Objective: Our study investigates the incidence, cumulative incidence, natural history, and factors associated with intraoperative paravalvular leak (PVL) and the development of a postoperative PVL in a contemporary consecutive cohort of patients following surgical aortic valve replacement. Methods: A total of 636 patients underwent surgical aortic valve replacement from 2006 to 2016; 410 (64.5%) underwent minimally invasive aortic valve replacement and 226 (35.5%) underwent conventional aortic valve replacement. Primary outcomes were the incidence of intraoperative PVL and cumulative incidence of postoperative PVL. Secondary outcomes were the incidence of in-hospital and long-term death and need for reoperation. Results: The overall incidence of intraoperative PVL was 1.4% (95% confidence interval [CI]: 1% to 3%). All intraoperative PVLs developed in the hand-tied group. The overall incidence of postoperative PVL was 5.3% (95% CI: 4% to 7%). In the univariable and multivariable analyses, postoperative renal failure was the only factor significantly associated with the development of a postoperative PVL. Conclusions: The incidence of intraoperative PVL is low. Cumulative incidence of postoperative PVL was 3.1% (95% CI: 1.0% to 13.6%), 4.3% (95% CI: 1.3% to 16.5%), and 5.0% (95% CI: 1.4% to 17.9%) at 1, 3, and 5 years, respectively. All intraoperative PVLs occurred with hand-tied knots. A larger cohort may identify additional risk factors.

Stromal inflammatory cells are associated with poorer prognosis in primary cutaneous melanoma

We observed that non-tumor-infiltrating inflammatory cells are often present in the stroma of melanoma. The role of these stromal inflammatory cells (SIC) in cancer has not been studied. We evaluated the prognostic significance of SIC in 299 patients with vertical growth phase primary melanomas with at least 10 years of clinical follow-up. Lymphatic density and lymphatic invasion in the areas with SIC was quantified. The prognostic significance of these factors was evaluated using univariable and multivariable Cox models for melanoma-specific death and the time to first recurrence. Of the 299 melanomas, 161 exhibited areas with SIC. Percentages of vertical growth phase tumor-infiltrating lymphocytes and radial growth phase regression were significantly higher in cases with SIC compared to those without SIC (P = .005); lymphatic invasion was also detected more frequently in cases with SIC (P = .001). Lymphatic density in SIC areas was higher than that in other areas of the melanomas. Patients with SIC had poorer clinical outcome. Vascular endothelial growth factor-C (VEGFC) staining in a subset of these melanoma patients showed that VEGFC expression in the stromal macrophages was associated with lymphatic invasion in SIC areas. In conclusion, SIC in melanoma is associated with poorer prognosis, and the prognostic effect is partially mediated through induction of lymphangiogenesis with increased lymphatic invasion.

Urban rats have less variable, higher protein diets

Over the past 1000 years, rats (Rattus spp.) have become one of the most successful and prolific pests in human society. Despite their cosmopolitan distribution across six continents and ubiquity throughout the world's cities, rat urban ecology remains poorly understood. We investigate the role of human foods in brown rat (Rattus norvegicus) diets in urban and rural areas over a 100 year period (ca AD 1790–1890) in Toronto, Canada using stable carbon (δ¹³C) and nitrogen (δ¹⁵N) isotope analyses of archaeological remains. We found that rat diets from urban sites were of higher quality and were more homogeneous and stable over time. By contrast, in rural areas, they show a wide range of dietary niche specializations that directly overlap, and probably competed, with native omnivorous and herbivorous species. These results demonstrate a link between rodent diets and human population density, providing, to our knowledge, the first long-term dietary perspective on the relative value of different types of human settlements as rodent habitat. This study highlights the potential of using the historical and archaeological record to provide a retrospective on the urban ecology of commensal and synanthropic animals that could be useful for improving animal management and conservation strategies in urban areas.

Histological immune response patterns in sentinel lymph nodes involved by metastatic melanoma and prognostic significance

BACKGROUND

To further characterize the micromorphometric immunological pattern to metastatic melanoma in sentinel lymph node (SLN) biopsies and completion lymph node (CLN) dissections and their relation to 5-year overall survival (OS).

METHODS

Retrospective cohort of 49 patients from 1996 to 2005 with a positive SLN who underwent CLN dissection (CLD) was studied. Micromorphometric characteristics included follicular center count (FCC)/profile, sinus histiocytosis, metastatic size, tumor infiltrating lymphocytes (intranodal), paracortical dendritic cells, germinal center reaction and morphology. Comparison of Kaplan-Meier survival curves used the exact log-rank statistic.

RESULTS

In the high-FCC (n = 5-51) vs the low-FCC (n < 5) lymph nodes, a delayed separation occurred at 3 years, with 5-year OS rates being 73% vs 54% in the high- and low-FCC groups, respectively. Improved survival up to 3 years was also noted in CLDs that showed a higher FCC when compared to the prior SLN. Patients with metastatic deposits >2 mm had significantly lower 5-year survival (both <.001).

CONCLUSIONS

Nodal micromorphometric features (ie, FCC) are probably related to host immune response to metastasis. Quantitative evaluation of lymphoid follicular centers could provide valuable prognostic information to help to stratify patients.

A Multicenter Phase I Study Evaluating Dual PI3K and BRAF Inhibition with PX-866 and Vemurafenib in Patients with Advanced BRAF V600-Mutant Solid Tumors

Purpose: The objectives of the study were to evaluate the safety of daily oral PX-866 in combination with twice daily vemurafenib and to identify potential predictive biomarkers for this novel combination.Experimental Design: We conducted a phase I, open-label, dose-escalation study in patients with advanced BRAF V600-mutant solid tumors. PX-866 was administered on a continuous schedule in combination with vemurafenib. Patients underwent a baseline and on-treatment biopsy after 1-week of PX-866 monotherapy for biomarker assessment.Results: Twenty-four patients were enrolled. The most common treatment-related adverse events were gastrointestinal side effects. One dose-limiting toxicity (DLT) of grade 3 rash and one DLT of grade 3 pancreatitis were observed in cohort 2 (PX-866 6 mg daily; vemurafenib 960 mg twice daily) and cohort 3 (PX-866 8 mg daily; vemurafenib 960 mg twice daily), respectively. Of 23 response-evaluable patients, seven had confirmed partial responses (PR), 10 had stable disease, and six had disease progression. Decreases in intratumoral pAKT expression were observed following treatment with PX-866. Patients who achieved PRs had higher rates of PTEN loss by IHC (80% vs. 58%) and pathogenic PTEN mutations and/or deletions (57% vs. 25%). Two patients with durable PRs had an increase in intratumoral CD8⁺ T-cell infiltration following treatment with PX-866.Conclusions: PX-866 was well tolerated at its maximum tolerated single-agent dose when given in combination with a modified dose of vemurafenib (720 mg twice daily). Response to treatment appeared to be associated with PTEN loss and treatment with PX-866 seemed to increase CD8⁺ T-cell infiltration in some patients. Clin Cancer Res; 24(1); 22-32. ©2017 AACR.

ALDH1A1 and HLTF modulate the activity of lysosomal autophagy inhibitors in cancer cells

Lysosomal autophagy inhibitors (LAI) such as hydroxychloroquine (HCQ) have significant activity in a subset of cancer cell lines. LAIs are being evaluated in cancer clinical trials, but genetic determinants of sensitivity to LAIs are unknown, making it difficult to predict which tumors would be most susceptible. Here we characterize differentially expressed genes in HCQ-sensitive (-S) and -resistant (-R) cancer cells. Notably, expression of canonical macroautophagy/autophagy genes was not associated with sensitivity to HCQ. Expression patterns of ALDH1A1 (aldehyde dehydrogenase 1 family member A1) and HLTF (helicase like transcription factor) identified HCQ-S (ALDH1A1_high HLTF_low; ALDH1A1_low HLTF_low) and HCQ-R (ALDH1A1_low HLTF_high) cells. ALDH1A1 overexpression was found to enhance LAI cell entry and cytotoxicity without directly affecting lysosome function or autophagic flux. Expression of HLTF allows repair of DNA damage caused by LAI-induced reactive oxygen species, leading to HCQ resistance. Sensitivity to HCQ is increased in cells where HLTF is silenced by promoter methylation. HLTF overexpression blunted the antitumor efficacy of chloroquine derivatives in vitro and in vivo. Analysis of tumor RNA sequencing data from >700 patients in the Cancer Genome Atlas identified cancers including colon cancer, renal cell carcinoma, and gastric cancers, that were enriched for the HCQ-S or HCQ-R signature. These results provide mechanistic insights into LAI efficacy, and guidance for LAI clinical development.

Diagnostic accuracy of IgG-specific versus polyspecific enzyme-linked immunoassays in heparin-induced thrombocytopenia: a systematic review and meta-analysis

Essentials Immunoassay specificity varies in heparin-induced thrombocytopenia (HIT) testing. This meta-analysis examined 9 studies that tested samples by both IgG and polyspecific methods. IgG-specific assays confer superior diagnostic accuracy compared with polyspecific assays. These results further support recommendations in favor of IgG-specific testing.

SUMMARY

Background There are conflicting data on whether the IgG-specific or polyspecific antiplatelet factor 4/heparin (PF4/H) enzyme-linked immunosorbent assay (ELISA) is preferred for the laboratory diagnosis of heparin-induced thrombocytopenia (HIT). Objectives To directly compare diagnostic accuracy of IgG-specific versus polyspecific ELISA in HIT. Patients/Methods A systematic search yielded nine studies comprising 1948 patients with suspected HIT tested by both IgG-specific and polyspecific ELISAs and a reference standard against which the diagnostic accuracy of the ELISAs could be measured. Study quality was assessed by QUADAS-2 criteria. Results There was identical sensitivity for IgG-specific and polyspecific ELISAs (0.97; 95% confidence interval (CI), 0.95-0.99) and superior specificity of IgG-specific compared with polyspecific ELISA (0.87 [0.85-0.88] vs. 0.82 [0.80-0.84], respectively). Performance was similar in subgroups using the serotonin release assay and a single commercial ELISA manufacturer. The negative predictive values of IgG-specific and polyspecific ELISA were similarly high (0.99, [0.99-1.00], but the positive predictive value was superior with IgG-specific compared with polyspecific ELISA (0.56 [0.52-0.61] vs. 0.32 [0.28-0.35], respectively). The positive likelihood ratio (LR) was higher in IgG-specific than polyspecific ELISA, although negative LRs were similar. There was high risk of quality concerns in domains of index test and reference standard. Conclusions The superior diagnostic accuracy of IgG-specific ELISA reinforces the ISTH-SSC recommendation for standardization of laboratory testing for HIT. Likelihood ratios of individual assays may be used in combination with clinical scoring systems as part of an integrated diagnostic algorithm for HIT.

An extranet architecture for inter-operability among healthcare systems

Most federations of healthcare systems have operated in an in-house environment where local area networks coupled with layers of interoperability were used to connect various information systems. More recently, a need has arisen to connect large institutions such as hospitals, with wider area applications such as general practice systems in order to create the complete patient record. In this paper we present a model and architecture, which addresses the problem of connecting all parties involved in patient healthcare.

Abstract 1024: Expression pattern of ALDH1A1 and HLTF predicts sensitivity to lysosomal autophagy inhibitors in cancer cells

Autophagy inhibition with hydroxychloroquine (HCQ)is cytotoxic to only a subset of cancer cell lines. Clinical trials involving HCQ in cancer patients are underway, but predictive biomarkers to identify patients most likely to respond are unavailable. To identify determinants of sensitivity to HCQ, an mRNA microarray analysis of HCQ-sensitive(S) compared to HCQ- resistant (R) colon and lung cancer cell lines identified differentially expressed genes in HCQ-S cells. Immunoblotting against the 2 most upregulated (Lysozyme (LYZ); aldehyde dehydrogenase 1 (ALDH1A1)) and 2 most down regulated proteins (helicase like transcription factor (HLTF); p-glycoprotein (ABCB1)) was performed in 35 human cancer cell lines. The IC50 and slope of the HCQ dose response curve (72 h MTT) were used to create a composite score to categorize cell lines as -S or -R, and correlated to protein expression of the 4 genes. Classification and regression tree (CART) analysis determined that high expression of the stem cell marker ALDH1A1 or low expression of both ALDH1A1 and HLTF identified 100% of sensitive cell lines. To understand how ALDH1A1 mechanistically interacts with HCQ, the aldefluor assay determined that a more potent dimeric CQ (Lys21) did not impair ALDH1A1 enzymatic function, however knockdown or chemical inhibition of ALDH1A1 impaired cellular uptake of fluorescently tagged Lys21 and conferred resistance to HCQ. Overexpression of ALDH1A1 conferred HCQ sensitivity in HCQ-R cells. To understand the interaction between HLTF and HCQ, we determined that HLTF promoter methylation correlated with silenced expression and sensitivity to HCQ. Forced expression of HLTF or treatment with a demethylating agent conferred resistance to HCQ-S cells. Knockdown of HLTF in HCQ-R cells conferred sensitivity. HCQ produced reactive oxygen species (ROS) irrespective of HLTF status. Cotreatment with a ROS scavenger mitigated HCQ cytotoxicity in HLTF silenced cells. DNA damage (p-H2AX) was observed at 100-fold lower HCQ concentrations in HLTF silenced compared to HLTF expressed cells. Overexpression of HLTF significantly reduced HCQ associated double strand breaks (Rad52 foci). Knockdown of DNA polymerase eta, a low fidelity DNA polymerase involved in translesion synthesis (TLS) completely abrogated HLTF-associated HCQ resistance. In vivo expression of HLTF mitigated the antitumor activity of the dimeric CQ Lys05 in a HCQ-S colon cancer xenograft. These results indicate ALDH1A1 acts as a sink for CQ derivatives to enter the cell, localize to the lysosome, and produce ROS-mediated DNA damage. The DNA damage can be counteracted by intact HLTF/Pol eta-dependent TLS. Analysis of the TCGA found that the ALDH1A1 high and HLTF low phenotype is prevalent across 10 human cancers. In conclusion this study identifies a 2 gene signature that can be translated into an IHC-based assay to identify patients most likely to respond to lysosomal autophagy inhibitors.

Citation Format: Shengfu Piao, Arabinda Samanta, Xiaohong Ma, Quentin W. Mcafee, Vito W. Rebecca, Meghan Buckley, Eric J. Brown, Phyllis A. Gimotty, Ravi K. Amaravadi. Expression pattern of ALDH1A1 and HLTF predicts sensitivity to lysosomal autophagy inhibitors in cancer cells. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1024.

Enhancements to the JET poloidally scanning vacuum ultraviolet∕visible spectrometers

Enhancements to the JET poloidally scanning spectrometers are presented, which will aid the exploitation of the recently installed ITER-like wall in JET. They include the installation of visible filter∕photomultiplier tube assemblies and spectrometers and the replacement of large rotating mirrors in the JET vacuum with small oscillating mirrors outside. The upgrade has resulted in a more robust and reliable diagnostic than before, which is described. Drifts in the mirror angle reconstructed from quadrature encoder signals are found, a reference signal being required. The use of the small scanning mirrors necessitated the inclusion of focusing mirrors to maintain throughput into the vacuum ultraviolet spectrometers. The mirror design has taken account of the extreme sensitivity of the focusing to the grazing angle of incidence, an aspect of importance in the design of grazing incidence focusing components on future machines, such as ITER. The visible system has been absolutely calibrated using an in-vessel light source.

Pancreatico pleural fistula: an unusual complication of chronic pancreatitis

Pancreatico-pleural fistula secondary to chronic pancreatitis is a rare cause of pleural effusion. This case report presents a case of a middle aged female, a known case of chronic pancreatitis who presented with severe epigastric pain and progressive shortness of breath. CT and MRCP were useful in visualising the fistulous communication between the pancreas and pleural cavity. Treatment consisted of ERCP placement of a pancreatic stent, which facilitated internal drainage of pancreatic fluid thus resolving the pleural effusion and promoting healing of the fistula.

Protein and mineral characterisation of rendered meat and bone meal

We report the characterisation of meat and bone meal (MBM) standards (Set B-EFPRA) derived from cattle, sheep, pig and chicken, each rendered at four different temperatures (133, 137, 141 and 145 °C). The standards, prepared for an EU programme STRATFEED (to develop new methodologies for the detection and quantification of illegal addition of mammalian tissues in feeding stuffs), have been widely circulated and used to assess a range of methods for identification of the species composition of MBM. The overall state of mineral alteration and protein preservation as a function of temperature was monitored using small angle X-ray diffraction (SAXS), amino acid composition and racemization analyses. Progressive increases in protein damage and mineral alteration in chicken and cattle standards was observed. In the case of sheep and pig, there was greater damage to the proteins and alteration of the minerals at the lowest treatment temperature (133 °C), suggesting that the thermal treatments must have been compromised in some way. This problem has probably impacted upon the numerous studies which tested methods against these heat treatments. We use protein mass spectrometric methods to explore if thermostable proteins could be used to identify rendered MBM. In more thermally altered samples, so-called 'thermostable' proteins such as osteocalcin which has been proposed as a ideal target to speciate MBM were no longer detectable, but the structural protein type I collagen could be used to differentiate all four species, even in the most thermally altered samples.