O108 Central adiposity influences serum calcium concentrations and increases risk of kidney stone disease

Introduction

Serum calcium (SCa) and adiposity are associated with kidney stone disease (KSD). We used conventional and genetic epidemiological approaches to further understanding of these relationships.

Methods

Waist-hip ratio (WHR), a marker of central adiposity, SCa and KSD data were analysed by adjusted linear regression using UK Biobank participants. Univariable, multivariable and mediation Mendelian randomisation (MR) were undertaken using 316 and 246 genetic instruments for WHR and SCa, respectively.

Results

Observational analyses of 3,466 KSD cases and 489,944 controls showed that participants of normal BMI (20–25kg/m2) but in the fifth quintile for WHR have greater risk of incident KSD compared to the first quintile (HR=1.39 (95%CI=1.18–1.63)). After adjustment for sex, age, serum vitamin D, and phosphate, higher WHR was positively associated with SCa (ß=0.04, 95%=CI 0.04–0.05, P<0.001). Univariable MR demonstrated that relative risk of KSD increases with increasing WHR and SCa; 1 standard deviation (SD) increases relative risk by 46% (95%CI=1.27–1.67, P=5.9e-8) and 63% (95%CI=1.37–1.93, P=2.0E-8), respectively. A 1 SD increase in WHR increases SCa by 0.11mmol/L (95%CI=0.07–0.14, P=1.8e-8). Multivariable MR revealed that SCa and WHR independently increase KSD relative risk (OR=1.71, 95%CI=1.49–1.96, P<0.001 and OR=1.41, 95%CI=1.17–1.69, P<0.001 respectively). Mediation MR established that 14% of the effect of WHR on KSD risk is mediated via alterations in SCa.

Conclusion

Central adiposity is causally linked to KSD, partly by raising SCa. Mechanisms by which central adiposity increases KSD risk, independent of and via SCa, remain to be revealed and may identify novel therapeutic methods for KSD.

Take-home message

Central adiposity and serum calcium are independent, causal risk factors for kidney stone disease. One mechanism by which central obesity increases risk of kidney stone disease is by influencing serum calcium concentrations.

323 Association of Increased Body Mass Index and Waist to Hip Ratio with Kidney Stone Disease: a Prospective Analysis of 493,410 UK Biobank participants

Aim

To investigate the relationship between measures of adiposity and risk of incident kidney stone disease.

Method

The UK Biobank is a prospective cohort study of ∼500,000 participants whose height, weight, BMI, waist circumference, hip circumference, waist:hip ratio (WHR), total fat mass, fat-free mass, body-fat percentage, and percentage truncal fat were measured at enrolment with linkage to medical records. ICD-10 and OPCS codes identified individuals with a new diagnosis of nephrolithiasis from 2006-2010. Individuals with a history of kidney stones or incomplete data were excluded. Multivariate Cox-proportional hazard models were used to assess associations between anthropometric measures and incident kidney stones.

Results

From the UK Biobank, 493,410 individuals were identified for inclusion; 3,466 developed a kidney stone during the study period. Increasing weight, BMI, waist, and hip circumferences, WHR, and body and truncal fat were all associated with increased risk of incident kidney stone disease. However, after adjustment for BMI, only waist circumference and WHR remained significantly associated with risk of nephrolithiasis. In overweight patients, high (men 94-102cm, women 80-88cm) waist circumference or WHR (men >0.9, women >0.85) conferred >40% increased risk of stone formation.

Conclusions

This study indicates that android fat distribution is independently associated with increased risk of developing nephrolithiasis. Kidney stone disease is known to be associated with hypertension, cardiovascular disease, and diabetes, all of which have been linked to android body shape. Our findings provide insight into anthropometric risk factors for stone disease, will facilitate identification of patients at greatest risk of stone recurrence, and will inform prevention strategies.

Nicotine-free vapor inhalation produces behavioral disruptions and anxiety-like behaviors in mice: Effects of puff duration, session length, sex, and flavor

Electronic-cigarette's (ECIGs) popularity has grown over the last decade and changed the way individuals administer nicotine. Preclinical research is imperative for understanding the addictive properties and health-risks associated with ECIG use; however, there is not a standard dosing regimen used across research laboratories. The main objective was to determine how vapor puff durations, administration session length, and flavored e-liquid alter general and mood-disorder related behaviors while providing a foundation of vapor administration parameters. Adult male and female C57BL/6 mice were exposed to several nicotine-free unflavored vapor puff durations (1, 3, 6, or 10 s) and vapor administration session lengths (10 and 30 min) then measured on the following assays: locomotor activity (LMA), tail suspension test (TST), and light-dark test. The effects of mecamylamine and the time-course of vapor-induced depression of LMA also were assessed. Additionally, mice were exposed to flavored (strawberry and adventurers tobacco blend) vapor inhalation and measured on locomotor activity, tail suspension test, and light-dark test. Following both 10 and 30 min vapor administration session, there was a puff duration-dependent decrease in distance traveled, time in center, and rearing. The vapor-induced depression of LMA was not mediated by nicotine or nicotinic acetylcholine receptor (nAChR) activation and lasted 60-90 min. The 10 s puff duration produced an anxiogenic-like effect in the light-dark test by decreasing the time spent in the light side. Vapor inhalation did not significantly alter TST behavior. No significant effects of sex or flavor were found. The anxiogenic-like effects of nicotine-free vapor inhalation are concerning as many adolescents vape nicotine-free flavored e-liquid, and there is an association between ECIGs and mood disorders. Additionally, these studies demonstrate that vapor puff duration, but not vapor administration session length, is an important variable to consider during research design as it can become a confounding variable and alter baseline behaviors.

356 Reducing Long Term Opioid Prescribing Post Thoracic Surgery

Introduction

Patients are routinely started on strong opioid analgesia after surgery with most receiving a prescription for these to continue discharge. We examine the analgesia prescribed in our unit, comparing to ERAS principles from EACTS. We aimed to reduce the total equivalent dose of morphine prescribed on discharge by implementing ERAS principles.

Method

We undertook a retrospective analysis of the analgesia prescribing for patients post open and VATS procedure noting the total dose opioids (using the equivalent dose of morphine). We examined how many patients were still being prescribed opioids analgesia long term, defined as 6 weeks post procedure. We implemented ERAS principles, changing to morphine rather than oxycodone, using short-acting preparations and increasing use of opioid sparing analgesia including NSAIDs.

Results

20% of patients started on strong opioids post procedure were still being prescribed these 6 weeks later. We used ERAS principles to reduce the equivalent dose of morphine dispensed on discharge by a third.

Conclusions

We identified a significant issue with long term opioid prescribing and initiated measures which have resulted in positive change. Our next cycle will measure the outcome of our changes on long-term prescribing implement a multi-disciplinary approach to try reducing the burden of long-term opioid prescribing further.

30 Novel Technique of Gastrojejunostomy Tube Insertion to Control Retracted Proximal Stoma

Introduction

Extensive small bowel resection for ischaemia can require formation of a proximal jejunostomy. Depending on length of remaining jejunum, a major potential complication is stoma retraction with resultant peritonitis, intra-abdominal sepsis and enterocutaneous fistula formation.

We describe a case using a novel technique of inserting a retrograde gastrojejunostomy tube to gain control of an acutely retracted stoma in a 61-year-old patient who developed an enterocutaneous fistula shortly after major resection due to ischaemia.

Method

Under fluoroscopic guidance, the retracted proximal limb of the jejunostomy was cannulated antegradely by guide wire. A gastro-jejunostomy tube was inserted retrograde over the guide wire and the tip placed within the stomach. The proximal tube fenestrations were sited within the duodenum and the balloon was inflated to limit enteric content spilling into the peritoneal cavity.

Conclusions

This technique enabled drainage of gastroduodenal fluid, minimised spillage into the peritoneal cavity, reduced fistula output and controlled sepsis. This allowed time for nutritional optimisation, better glycaemic control, and endovascular revascularisation in preparation for restoration of intestinal continuity at an appropriate time.

This method offered a useful alternative to surgery, in a patient for whom emergency re-exploration of the abdomen would carry significant risk of morbidity or mortality.

The most influential papers in mitral valve surgery; a bibliometric analysis

This study is an analysis of the 100 most cited articles in mitral valve surgery. A bibliometric analysis is a tool to evaluate research performance in a given field. It uses the number of times a publication is cited by others as a proxy marker of its impact. The most cited paper Carpentier et al. discusses mitral valve repair in terms of restoring the geometry of the entire valve rather than simply narrowing the annulus (Carpentier, J Thorac Cardiovasc Surg 86:23–37, 1983). The first successful mitral valve repair was performed by Elliot Cutler at Brigham and Women’s Hospital in 1923 (Cohn et al., Ann Cardiothorac Surg 4:315, 2015). More recently percutaneous and minimally invasive techniques that were originally designed as an option for high risk patients are being trialled in other patient groups (Hajar, Heart Views 19:160–3, 2018). Comparison of percutaneous method with open repair represents an expanding area of research (Hajar, Heart Views 19:160–3, 2018). This study will analyse the top 100 cited papers relevant to mitral valve surgery, identifying the most influential papers that guide current management, the institutions that produce them and the authors involved.

Clinical features may help to identify children and adolescents with greatest risk for thyroid nodules

BACKGROUND

Thyroid nodules (TN) are detected in a small number of asymptomatic children and adolescents but are more frequently malignant (22-26%) than in adults leading some clinicians to perform thyroid ultrasound (US) for all children with goiter or autoimmune thyroiditis (AIT). Our study was designed to determine if suspicious clinical features predict the presence of TN in children with goiter or AIT so that US could be performed on those at highest risk.

METHODS

This was a retrospective review of 223 children and adolescents with goiter or AIT evaluated at a single institution. US was not performed on all patients. It is our practice to define glands that are large, firm, or nodular to palpation as "suspicious". Suspicious glands were interrogated by US and if TN was confirmed, this was further evaluated by fine-needle aspiration followed by surgery if indicated.

RESULTS

The median age was 12.9 years with 74.4% female. TN were confirmed by US in 16.6% of all patients but only 4.8% of those with AIT. By univariate analysis, TN were more common in those with family history of TN or differentiated thyroid carcinoma (DTC), thyroid asymmetry, and lower thyrotropin (TSH) levels. Differentiated thyroid carcinoma (DTC) was identified in 10.8% of TN and 1.8% of all patients. Firmness was significantly more common in patients with DTC (p = 0.0013).

CONCLUSION

TN were less common in those with AIT than reported in previous studies, suggesting that clinical features might fail to identify the majority of TN in patients with AIT. However, patients with asymmetric thyroid and a family history of TN or DTC have greatest risk for TN.

CpG-creating mutations are costly in many human viruses

Mutations can occur throughout the virus genome and may be beneficial, neutral or deleterious. We are interested in mutations that yield a C next to a G, producing CpG sites. CpG sites are rare in eukaryotic and viral genomes. For the eukaryotes, it is thought that CpG sites are rare because they are prone to mutation when methylated. In viruses, we know less about why CpG sites are rare. A previous study in HIV suggested that CpG-creating transition mutations are more costly than similar non-CpG-creating mutations. To determine if this is the case in other viruses, we analyzed the allele frequencies of CpG-creating and non-CpG-creating mutations across various strains, subtypes, and genes of viruses using existing data obtained from Genbank, HIV Databases, and Virus Pathogen Resource. Our results suggest that CpG sites are indeed costly for most viruses. By understanding the cost of CpG sites, we can obtain further insights into the evolution and adaptation of viruses.

81 Can Simulation-Based Training be Used to Teach Geriatric Medicine?

Introduction

Health Education England (HEE) and the Joint Royal Colleges of Physicians Training Boards recognise the importance of simulation-based training especially for Core Medical Trainees in improving patient outcomes and enhancing learning (Enhancing UK Core Medical Training through Simulation based training, Health Education England 2016). Research also suggests simulation training can be used to address a wide variety of medical curricula agenda from emergency presentations to breaking bad news (Beaubien 2004, Quality & Safety in healthcare). HEE suggests simulation training can be used to develop understanding but also communication skills and awareness of human factors and are focusing on developing a national strategy.

Geriatric Medicine is complex and trainees are expected to be competent in managing elderly patients in a variety of presentations. Our aim was to ascertain the confidence levels of CMT doctors managing elderly patients and whether simulation-based teaching is effective for geriatric teaching.

Methods

Three scenarios addressing common geriatric conditions were developed by a Geriatric Medicine Registrar and overseen by Geriatric Consultant. Scenarios including delirium secondary to sepsis, Opiate toxicity secondary to acute kidney injury (complicated by addressing dementia and risk of self-harm) and identifying and demonstrating appropriate palliative approaches to a catastrophic subdural haemorrhage. Trainees were given a brief summary of a case and asked to review and manage the ‘patient’.

A geriatric registrar alongside two CMT doctors designed a pre and post confidence questionnaire using Likert scales and free text boxes to explore respondents’ views.

Results

100% of trainees found the simulation training useful and would recommend the sessions. 100% of trainees stated preference for simulation-based teaching opposed to lecture and work based assessments. Confidence increased across all three scenarios post simulation. 70% of trainees stated they felt confident to manage delirium with sepsis pre-simulation, this increased to 91% post simulation. Trainees commented ‘feel confident to manage sepsis but not complicated by delirium or AKI’ and ‘prefer simulation to lectures’

Conclusions

CMT doctors enjoy and find simulation training in geriatric medicine useful and show preponderance to this. Simulation training can be used to expose trainees to real life complex geriatric medicine scenarios in a safe environment. This programme will be developed to encompass additional medical scenarios and also to be delivered to foundation year doctors.

Anti-Inflammatory Effects of a Vegan Diet Versus the American Heart Association-Recommended Diet in Coronary Artery Disease Trial

Background

Dietary interventions may play a role in secondary cardiovascular prevention. hsCRP (High‐sensitivity C‐reactive protein) is a marker of risk for major adverse cardiovascular outcomes in coronary artery disease.

Methods and Results

The open‐label, blinded end‐point, EVADE CAD (Effects of a Vegan Versus the American Heart Association‐Recommended Diet in Coronary Artery Disease) trial randomized participants (n=100) with coronary artery disease to 8 weeks of a vegan or American Heart Association–recommended diet with provision of groceries, tools to measure dietary intake, and dietary counseling. The primary end point was high‐sensitivity C‐reactive protein. A linear regression model compared end points after 8 weeks of a vegan versus American Heart Association diet and adjusted for baseline concentration of the end point. Significance levels for the primary and secondary end points were set at 0.05 and 0.0015, respectively. A vegan diet resulted in a significant 32% lower high‐sensitivity C‐reactive protein (β, 0.68, 95% confidence interval [0.49–0.94]; P=0.02) when compared with the American Heart Association diet. Results were consistent after adjustment for age, race, baseline waist circumference, diabetes mellitus, and prior myocardial infarction (adjusted β, 0.67 [0.47–0.94], P=0.02). The degree of reduction in body mass index and waist circumference did not significantly differ between the 2 diet groups (adjusted β, 0.99 [0.97–1.00], P=0.10; and adjusted β, 1.00 [0.98–1.01], P=0.66, respectively). There were also no significant differences in markers of glycemic control between the 2 diet groups. There was a nonsignificant 13% reduction in low‐density lipoprotein cholesterol with the vegan diet when compared with the American Heart Association diet (adjusted β, 0.87 [0.78–0.97], P=0.01). There were no significant differences in other lipid parameters.

Conclusions

In patients with coronary artery disease on guideline‐directed medical therapy, a vegan diet may be considered to lower high‐sensitivity C‐reactive protein as a risk marker of adverse outcomes.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02135939.

Development of a Faraday cup fast ion loss detector for keV beam ions

The development and testing of a Faraday cup fast-ion loss detector capable of measuring sub 100 keV particles is documented. Such measurement capabilities play an important role in the assessment of particle confinement of nuclear fusion experiments. The detector is manufactured using thin-film deposition techniques, building upon previous work using discrete foils. This new manufacturing method allows the form factor of the sensor to become that of essentially a microchip. Analysis of the diagnostic response is performed using Monte-Carlo particle simulations. These simulations show peaks in the detector response at 40 and 70 keV. The sensor is then tested in a tunable linear accelerator capable of accelerating protons from 20 to 120 keV. The detector response was found to be well matched to simulations. Improvements to the design to facilitate robustness are discussed.

Platelet-Derived MRP-14 Induces Monocyte Activation in Patients With Symptomatic Peripheral Artery Disease

BACKGROUND

Peripheral artery disease (PAD), a diffuse manifestation of atherothrombosis, is a major cardiovascular threat. Although platelets are primary mediators of atherothrombosis, their role in the pathogenesis of PAD remains unclear.

OBJECTIVES

The authors sought to investigate the role of platelets in a cohort of symptomatic PAD.

METHODS

The authors profiled platelet activity, mRNA, and effector roles in patients with symptomatic PAD and in healthy controls. Patients with PAD and carotid artery stenosis were recruited into ongoing studies (NCT02106429 and NCT01897103) investigating platelet activity, platelet RNA, and cardiovascular disease.

RESULTS

Platelet RNA sequence profiling mapped a robust up-regulation of myeloid-related protein (MRP)-14 mRNA, a potent calcium binding protein heterodimer, in PAD. Circulating activated platelets were enriched with MRP-14 protein, which augmented the expression of the adhesion mediator, P-selectin, thereby promoting monocyte-platelet aggregates. Electron microscopy confirmed the firm interaction of platelets with monocytes in vitro and colocalization of macrophages with MRP-14 confirmed their cross talk in atherosclerotic manifestations of PAD in vivo. Platelet-derived MRP-14 was channeled to monocytes, thereby fueling their expression of key PAD lesional hallmarks and increasing their directed locomotion, which were both suppressed in the presence of antibody-mediated blockade. Circulating MRP-14 was heightened in the setting of PAD, significantly correlated with PAD severity, and was associated with incident limb events.

CONCLUSIONS

The authors identified a heightened platelet activity profile and unraveled a novel immunomodulatory effector role of platelet-derived MRP-14 in reprograming monocyte activation in symptomatic PAD. (Platelet Activity in Vascular Surgery and Cardiovascular Events [PACE]; NCT02106429; and Platelet Activity in Vascular Surgery for Thrombosis and Bleeding [PIVOTAL]; NCT01897103).

Allogeneic Human Umbilical Cord Mesenchymal Stem Cells for the Treatment of Autism Spectrum Disorder in Children: Safety Profile and Effect on Cytokine Levels

Individuals with autism spectrum disorder (ASD) suffer from developmental disabilities that impact communication, behavior, and social interaction. Immune dysregulation and inflammation have been linked to children with ASD, the latter manifesting in serum levels of macrophage‐derived chemokine (MDC) and thymus, and activation‐regulated chemokine (TARC). Mesenchymal stem cells derived from umbilical cord tissue (UC‐MSCs) have immune‐modulatory and anti‐inflammatory properties, and have been safely used to treat a variety of conditions. This study investigated the safety and efficacy of UC‐MSCs administered to children diagnosed with ASD. Efficacy was evaluated with the Autism Treatment Evaluation Checklist (ATEC) and the Childhood Autism Rating Scale (CARS), and with measurements of MDC and TARC serum levels. Twenty subjects received a dose of 36 million intravenous UC‐MSCs every 12 weeks (four times over a 9‐month period), and were followed up at 3 and 12 months after treatment completion. Adverse events related to treatment were mild or moderate and short in duration. The CARS and ATEC scores of eight subjects decreased over the course of treatment, placing them in a lower ASD symptom category when compared with baseline. MDC and TARC inflammatory cytokine levels also decreased for five of these eight subjects. The mean MDC, TARC, ATEC, and CARS values attained their lowest levels 3 months after the last administration. UC‐MSC administration in children with ASD was therefore determined to be safe. Although some signals of efficacy were observed in a small group of children, possible links between inflammation levels and ASD symptoms should be further investigated. stem cells translational medicine2019;8:1008–1016

Exercise stress echocardiography: Impact on clinical decision-making in pediatric patients

BACKGROUND

The role of exercise stress echocardiography (ESE) in the pediatric population is less well defined as compared to adults. We aimed to determine the utility and impact of ESE on clinical decision-making in pediatric patients.

METHODS

We identified patients who underwent an ESE at our center from 2011 to 2015. Test indications were categorized into symptoms with exercise; sports/activity clearance; hypertrophic cardiomyopathy (HCM) or suspected HCM; coronary anomalies; or abnormal electrocardiogram (EKG). Change in clinical management was assessed by comparing pre- and post-test activity restrictions, which were categorized into unrestricted from exercise or activity; restricted from exercise or activity; and surgical referral.

RESULTS

During the study period, 353 ESEs met inclusion criteria. Of all ESEs performed, 263 (75%) were normal. Clinical management changed as a result of ESE in 144 (40%). Of the abnormal ESEs, 44 were restricted from activity, including 25 (56.8%) restricted from competitive or varsity athletics, 14 (31.8%) restricted from recreational sports, and 5 (11.4%) restricted from all activity. Surgical referrals included valve repair/replacement in 7 (50%), ICD placement in 5 (35.8%), coronary re-implantation in 1 (7.1%), and atrial septal defect repair in 1 (7.1%).

CONCLUSION

Exercise stress echocardiography provides the pediatric cardiologist with useful information that impacts management in a wide variety of cardiac disorders. Clinical management changed in nearly half the patients that were subjected to an ESE at our center. This supports the value of ESE for informing clinical decision-making. Future studies should aim to refine patient selection and examine its impact on patient outcomes.

Human low-affinity IgG receptor FcγRIIA polymorphism H131R associates with subclinical atherosclerosis and increased platelet activity in systemic lupus erythematosus

Essentials Systemic lupus erythematosus (SLE) patients are at increased risk for premature CVD. Platelet activity, vascular dysfunction and carotid artery plaque are associated with FcγRIIA genotype in SLE. FcγRIIA genotype was not associated with platelet activity or carotid plaque in healthy controls. FcγRIIA represents a link that connects platelet activity, vascular health and CVD in SLE. SUMMARY: Background Systemic lupus erythematosus (SLE) is a complex autoimmune disease associated with an elevated risk of premature cardiovascular disease. Platelets express receptors contributing to inflammation and immunity, including FcγRIIA, the low affinity receptor of the Fc portion of IgG antibodies. The variation at a single amino acid substitution, H131R, in the extracellular binding domain alters the affinity for IgG, which may account for individual variation in platelet activity and platelet-mediated disease. Objectives This study was performed to investigate the association between FcγRIIA genotype, preclinical atherosclerosis, platelet reactivity and vascular health. Methods FcγRIIA was genotyped in 80 SLE patients and 30 healthy controls. Carotid ultrasound plaque, soluble E-selectin and platelet aggregability were evaluated in SLE and matched controls. Results Carotid plaque was significantly more prevalent in SLE patients carrying a variant allele compared to those with a homozygous ancestral allele (58% vs. 25%, P = 0.04). In contrast, prevalent carotid plaque was not associated with genotype in controls. Consistently, SLE variant FcγRIIA carriers vs. ancestral allele carriers had a significant increase in the levels of soluble E-selectin, which was not observed in controls. Monocyte and leukocyte-platelet aggregation and platelet aggregation in response to submaximal agonist stimulation were significantly elevated in SLE patients with the variant vs. ancestral genotype. Conclusions Carotid ultrasound plaque, soluble E-selectin levels and platelet activity were more frequently prevalent in SLE patients carrying variant FcγRIIA. The interplay between FcγRIIA-mediated platelet activation and endothelial cells might represent a mechanism underlying the pathogenesis of cardiovascular disease in SLE patients.

Abstract P5-18-08: Defining molecular signatures to personalise management of patients with early breast cancer

Background

A review of breast screening highlighted the need to reduce overdiagnosis. Ductal Carcinoma In-Situ (DCIS) contributes significantly to this overdiagnosis. Epithelial cells in DCIS are as genetically advanced as those in invasive disease, focusing attention on the tumour microenvironment (ME). A key components of the ME in DCIS is the myoepithelial cell(MEC). These cells lie at the interface of the epithelial and stromal compartments, regulating cell function. We previously have identified changes in the MEC that contribute to tumour progression. Here we investigate the functional and clinical significance of a novel change in MEC phenotype: loss of Galectin-7 (Gal-7) expression. Gal-7 is proposed to play a role in apoptosis. We hypothesise that changes in MEC phenotype in DCIS alter the ME towards a pro-invasive phenotype, and hypothesise that loss of Gal-7 modifies the ME, destabilizes the MEC interface and ultimately may lead to loss of the MEC population through apoptosis.

Methods

Gal-7 expression and function was investigated in clinical samples and in-vitro model systems, respectively.

Gal-7 expression was assessed in a series of pure DCIS samples (low risk model) and DCIS with co-existant invasion (high risk model). Tissue sections were stained for Gal-7 and MEC expression scored on a duct-by-duct basis as positive, heterogeneous or negative.

An in-vitro model of normal primary myoepithelial cells isolated from reduction mammoplasty was used to investigate the functional impact of loss of Gal-7. These cells have high endogenous levels of Gal-7. Gal-7 was knocked down using siRNA and apoptosis assessed using cleaved caspase-3. The effect of Gal-7 on MEC layer integrity was assessed using immunofluorescence and adhesion assays.

The global impact of loss of Gal-7 was investigated using RNA sequencing.

Results

In the tissue analysis 1926 DCIS ducts were scored for MEC expression of Gal-7. Significantly more ducts showed loss of Gal-7 in DCIS with co-existant invasion, with pure DCIS showing 388 ducts positive and DCIS with invasion 144 DCIS ducts positive (p=0.0014). Pure DCIS and DCIS with invasion had 99 and 646 negative DCIS ducts respectively (p=0.0002).

In model systems of primary MEC, knockdown of Gal-7 resulted in increased expression of cleaved caspase-3, suggesting lower levels of Gal-7 increases apoptosis. In functional assays silencing Gal-7 reduces adhesion to both fibronectin and laminin extracellular matrices (p-value 0.005 and 0.001 respectively)

RNA sequencing indicates silencing Gal-7 increases LOX expression - a key regulator of the collagen matrix of the microenvironment.

Conclusion

Normal MEC strongly express Gal-7. Expression is lost in DCIS, with significantly more frequent loss in DCIS with co-existant invasion, suggesting that loss is associated with a more advanced phenotype. Functional assays indicate that loss of MEC Gal-7 enhances MEC apoptosis, which may be one mechanism by which this interface is lost during progression. Gal-7 negative MEC also show impaired adhesion to matrix proteins and lead to up-regulation of LOX, an enzyme key in promoting tumourigenesis. The incorporation of Gal-7 expression into a risk stratification algorithm has functional evidence and is currently being investigated.

Citation Format: Allen N, Allen M, Ahmed K, Gomm J, Nelan R, Nagano A, Chelala C, Gadaleta E, Thorat M, Cuzick J, Jones LJ. Defining molecular signatures to personalise management of patients with early breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-18-08.

Circulating monocyte-platelet aggregates are a robust marker of platelet activity in cardiovascular disease

BACKGROUND AND AIMS

Platelets are a major culprit in the pathogenesis of cardiovascular disease (CVD). Circulating monocyte-platelet aggregates (MPA) represent the crossroads between atherothrombosis and inflammation. However, there is little understanding of the platelets and monocytes that comprise MPA and the prevalence of MPA in different CVD phenotypes. We aimed to establish (1) the reproducibility of MPA over time in circulating blood samples from healthy controls, (2) the effect of aspirin, (3) the relationship between MPA and platelet activity and monocyte subtype, and (4) the association between MPA and CVD phenotype (coronary artery disease, peripheral artery disease [PAD], abdominal aortic aneurysm, and carotid artery stenosis).

METHODS AND RESULTS

MPA were identified by CD14⁺ monocytes positive for CD61⁺ platelets in healthy subjects and in patients with CVD. We found that MPA did not significantly differ over time in healthy controls, nor altered by aspirin use. Compared with healthy controls, MPA were significantly higher in CVD (9.4% [8.2, 11.1] vs. 21.8% [11.5, 44.1], p < 0.001) which remained significant after multivariable adjustment (β = 9.1 [SER = 3.9], p = 0.02). We found PAD to be associated with a higher MPA in circulation (β = 19.3 [SER = 6.0], p = 0.001), and among PAD subjects, MPA was higher in subjects with critical limb ischemia (34.9% [21.9, 51.15] vs. 21.6% [15.1, 40.6], p = 0.0015), and significance remained following multivariable adjustment (β = 14.77 (SE = 4.35), p = 0.001).

CONCLUSIONS

Circulating MPA are a robust marker of platelet activity and monocyte inflammation, unaffected by low-dose aspirin, and are significantly elevated in subjects with CVD, particularly those with PAD.

The high-k poloidal scattering system for NSTX-U

An 8-channel, high-k poloidal far-infrared (FIR) scattering system is under development for the National Spherical Torus eXperiment Upgrade (NSTX-U). The 693 GHz poloidal scattering system replaces a 5-channel, 280 GHz high-k toroidal scattering system to study high-k electron density fluctuations on NSTX-U. The FIR probe beam launched from Bay G is aimed toward Bay L, where large aperture optics collect radiation at 8 simultaneous scattering angles ranging from 2° to 15°. The reduced wavelength in the poloidal system results in less refraction, and coupled with a new poloidal scattering geometry, extends measurement of poloidal wavenumbers from the previous limit of 7 cm^-1 up to >40 cm^-1. Steerable launch optics coupled with receiver optics that can be remotely translated in 5 axes allow the scattering volume to be placed from r/a = 0.1 out to the pedestal region (r/a ∼ 0.99) and allow for both upward and downward scattering to cover different regions of the 2D fluctuation spectrum.

Integrated plasma facing component calorimetry for measurement of shot integrated deposited energy in the NSTX-U

The upgrade to the National Spherical Torus eXperiment (NSTX-U) [J. Menard et al., Nucl. Fusion 52, 083015 (2012)] increases the injected neutral beam power up to 12 MW and the plasma current up to I_p = 2 MA for plasma durations up to 5 s. The graphite plasma facing components have been re-designed to handle greater heat and energy fluxes than were seen in NSTX using a castellated design. We present the experimental testing and validation of a castellated graphite target, similar to the prototype tile design, instrumented with thermocouples at various depths in the castellation. During testing, incident heat flux is provided by a programmed electron beam system and surface temperatures are measured via infrared thermography directly viewing the target surface. It was found that the thermocouple response scaled linearly with the measured surface temperature rise regardless of thermocouple depth in the castellation. A sensitivity of 14.3 °C/kJ of deposited energy was found when treating individual castellations as a semi-infinite solid.

Clinical feasibility of umbilical cord tissue-derived mesenchymal stem cells in the treatment of multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is a progressively debilitating neurological condition in which the immune system abnormally erodes the myelin sheath insulating the nerves. Mesenchymal stem cells (MSC) have been used in the last decade to safely treat certain immune and inflammatory conditions.

METHODS

A safety and feasibility study was completed on the use of umbilical cord MSC (UCMSC) as a treatment for MS. In this 1-year study, consenting subjects received seven intravenous infusions of 20 × 10⁶ UCMSC over 7 days. Efficacy was assessed at baseline, 1 month and 1 year after treatment, including magnetic resonance imaging (MRI) scans, Kurtzke Expanded Disability Status Scale (EDSS), Scripps Neurological Rating Scale, Nine-Hole Peg Test, 25-Foot Walk Test, and RAND Short Form-36 quality of life questionnaire.

RESULTS

Twenty subjects were enrolled in this study. No serious adverse events were reported. Of the mild AEs denoted as possibly related to treatment, most were headache or fatigue. Symptom improvements were most notable 1 month after treatment. Improvements were seen in EDSS scores (p < 0.03), as well as in bladder, bowel, and sexual dysfunction (p < 0.01), in non-dominant hand average scores (p < 0.01), in walk times (p < 0.02) and general perspective of a positive health change and improved quality of life. MRI scans of the brain and the cervical spinal cord showed inactive lesions in 15/18 (83.3%) subjects after 1 year.

CONCLUSIONS

Treatment with UCMSC intravenous infusions for subjects with MS is safe, and potential therapeutic benefits should be further investigated. Trial registration ClinicalTrials.gov NCT02034188. Registered Jan 13, 2014. https://clinicaltrials.gov/ct2/show/NCT02034188.

Platelet Transcriptome Profiling in HIV and ATP-Binding Cassette Subfamily C Member 4 (ABCC4) as a Mediator of Platelet Activity

An unbiased platelet transcriptome profile identified ATP binding cassette subfamily C member 4 (ABCC4) as a novel mediator of platelet activity in virologically suppressed human immunodeficiency virus (HIV)-infected subjects on antiretroviral therapy. Using ex vivo and in vitro cellular and molecular assays we demonstrated that ABCC4 regulated platelet activation by altering granule release and cyclic nucleotide homeostasis through a cAMP-protein kinase A (PKA)-mediated mechanism. Platelet ABCC4 inhibition attenuated platelet activation and effector cell function by reducing the release of inflammatory mediators, such as sphingosine-1-phosphate. ABCC4 inhibition may represent a novel antithrombotic strategy in HIV-infected subjects on antiretroviral therapy.

The Effect of a Vegan versus AHA DiEt in Coronary Artery Disease (EVADE CAD) trial: study design and rationale

BACKGROUND

Multiple studies demonstrate the benefit of a vegan diet on cardiovascular risk factors when compared to no intervention or usual dietary patterns. The aim of this study is to evaluate the effect of a vegan diet versus the American Heart Association (AHA)-recommended diet on inflammatory and glucometabolic profiles in patients with angiographically defined coronary artery disease (CAD).

STUDY DESIGN

This study is a randomized, open label, blinded end-point trial of 100 patients with CAD as defined by ≥50% diameter stenosis in a coronary artery ≥2 mm in diameter on invasive angiography. Participants are randomized to 8 weeks of either a vegan or AHA-recommended diet (March 2014 and February 2017). Participants are provided weekly groceries that adhere to the guidelines of their diet. The primary endpoint is high sensitivity C-reactive concentrations. Secondary endpoints include anthropometric data, other markers of inflammation, lipid parameters, glycemic markers, endothelial function, quality of life data, and assessment of physical activity. Endpoints are measured at each visit (baseline, 4 weeks, and 8 weeks). Dietary adherence is measured by two weekly 24-hour dietary recalls, a 4-day food record during the week prior to each visit, and both plasma and urine levels of trimethylamine-N-oxide at each visit.

CONCLUSION

This study is the first to comprehensively assess multiple indices of inflammation and glucometabolic profile in a rigorously conducted randomized trial of patients with CAD on a vegan versus AHA-recommended diet.

Agreement between renal prescribing references and determination of prescribing appropriateness in hospitalized patients with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is a risk factor for adverse drug events. The clinical significance of discordance between renal prescribing references is unknown.

AIM

We determined the prevalence of potentially inappropriate prescribing (PIP) in CKD, measured agreement between two prescribing references, and assessed potential for harm consequent to PIP.

DESIGN

Single-centre observational study.

METHODS

A random sample of hospitalized patients with CKD were grouped according to baseline CKD stage (3, 4, or 5). Prescriptions requiring caution in CKD were referenced against the Renal Drug Handbook (RDH) and British National Formulary (BNF) to identify PIP (non-compliance with recommendations). Inter-reference agreement was measured using percentage agreement and Kappa coefficient. Potential for harm consequent to PIP was assessed by physicians and pharmacists using a validated scale. One-year mortality was compared between patients with or without PIP during admission.

RESULTS

Among 119 patients (median age 73 years, 50% male), 136 cases of PIP were identified in 78 (65.5%) patients. PIP prevalence, per patient, was 64.7% using the BNF and 28.6% using the RDH (fair agreement, Kappa 0.33, P <  0.001). The majority (63.2%) of PIP cases detected exclusively by the BNF carried minimal or no potential for harm. PIP was not significantly associated with one-year mortality (34.7% vs. 21.1%, P = 0.14).

CONCLUSIONS

PIP was common in hospitalized patients with CKD. Substantial discordance between renal prescribing references was apparent. The development of universally-adopted, evidence-based, prescribing guidelines for CKD might optimize medications safety in this vulnerable group.

Acute kidney injury electronic alerts in primary care - findings from a large population cohort

BACKGROUND

Electronic reporting of AKI has been used to aid early AKI recognition although its relevance to CA-AKI and primary care has not been described.

AIMS

We described the characteristics and clinical outcomes of patients with CA-AKI, and AKI identified in primary care (PC-AKI) through AKI e-Alerts.

DESIGN

A prospective national cohort study was undertaken to collect data on all e-alerts representing adult CA-AKI.

METHOD

The study utilized the biochemistry based AKI electronic (e)-alert system that is established across the Welsh National Health Service.

RESULTS

28.8% of the 22 723 CA-AKI e-alerts were classified as PC-AKI. Ninety-day mortality was 24.0% and lower for PC-AKI vs. non-primary care (non-PC) CA-AKI. Hospitalization was 22.3% for PC-AKI and associated with greater disease severity, higher mortality, but better renal outcomes (non-recovery: 18.1% vs. 21.6%; progression of pre-existing CKD: 40.5% vs. 58.3%). 49.1% of PC-AKI had a repeat test within 7 days, 42.5% between 7 and 90 days, and 8.4% was not repeated within 90 days. There was significantly more non-recovery (24.0% vs. 17.9%) and progression of pre-existing CKD (63.3% vs. 47.0%) in patients with late repeated measurement of renal function compared to those with early repeated measurement of renal function.

CONCLUSION

The data demonstrate the clinical utility of AKI e-alerts in primary care. We recommend that a clinical review, or referral together with a repeat measurement of renal function within 7 days should be considered an appropriate response to AKI e-alerts in primary care.

Australian adolescents' beliefs and help-seeking intentions towards peers experiencing symptoms of depression and alcohol misuse

BACKGROUND

Many young people are reluctant to seek professional help for mental health problems, preferring to rely on their friends for support. It is therefore important to ensure that adolescents can identify signs of psychological distress in their peers, talk to them about these, and help them access appropriate services when necessary. The current study examined adolescents' ability to recognise symptoms of depression and alcohol misuse, perceived barriers to help-seeking, and their intentions to encourage a peer to seek help from a range of informal and formal help sources.

METHOD

The current study used baseline data from a randomised controlled trial of a school-based intervention that teaches adolescents how to overcome barriers to accessing professional help for mental health and substance use problems (MAKINGtheLINK). Participants (n = 2456) were presented with two vignettes portraying depression and alcohol misuse, respectively, and were asked to identify the problems described. Participants provided data on their past help-seeking behaviour, confidence to help a peer, perceived barriers to help-seeking, and intentions to encourage a peer to seek help.

RESULTS

Health professionals were the main source of help that participants had relied on for depressive symptoms, followed by friends and parents. In contrast, friends were the main source of help that participants had relied on for alcohol and other drug problems, followed by health professionals and parents. Just over half of the sample correctly identified the problems described in the two vignettes, although the majority of participants were confident that they could talk to a peer and help them seek professional help if needed. Most agreed that the vignettes described problems that warranted professional help, however approximately half the sample was unsure or considered it unlikely that they would seek help if they experienced similar problems. For both disorders, participants were most likely to encourage a peer to seek help from their family, followed by formal help sources and friends.

CONCLUSIONS

While the results point towards a greater willingness to approach formal help sources, particularly for depression, peers remain an important source of support for young people experiencing mental health and substance use problems.

Correlates of Disclosure Cessation After Sexual Assault

Contacts with responders after sexual assault may influence further disclosure, but this possibility has not been explored empirically. Thus, this study investigates associations between survivors' contacts with responders and their decisions to discontinue disclosure. Fifty-four college students with a history of unwanted sexual experiences described 94 ordered contacts with responders. Results indicate that survivors' perceptions of responsiveness were not associated with continued disclosure, but survivors were more likely to continue disclosing when they perceived more rape myth acceptance from responders and when the assault was more recent. These findings highlight survivors' tenacity in meeting their needs, even after problematic responses.

Abstract 113: Platelet and Monocyte Activity in Carotid Artery Stenosis Treated with Carotid Endarterectomy

Background: Carotid artery stenosis (CAS) is a marker of atherosclerosis, a disease mediated by abnormalities in platelet and monocyte function, and a significant cause of stroke. Moreover, the effect of carotid artery revascularization via carotid endarterectomy (CEA) on platelet and monocyte markers is unknown.

Objective: This study aims to investigate platelet activity, monocyte subsets and monocyte platelet aggregates (MPA) in CAS and changes with CEA.

Methods: This prospective cohort study evaluated 48 patients who underwent non emergent CEA. Peripheral venous blood samples were obtained before, immediately postoperative and at 24 hours postoperative. Twenty healthy subjects served as controls. Platelet surface expression of P-selectin and PAC-1, monocyte subsets, and MPA were assessed using flow cytometry. Three distinct monocyte subsets were measured: anti-inflammatory (i.e. classical CD14 ++ CD16 - ) and pro-inflammatory (i.e. intermediate CD14 ++ CD16 + and nonclassical CD14 + CD16 ++ ) monocytes. Differences between two matched samples and between the study and control groups were statistically analyzed.

Results: Compared to healthy subjects, CAS subjects had significantly greater markers of platelet activity (P-selectin [p=0.003] and PAC-1 [p=0.01]), pro-inflammatory monocytes (intermediate [p<0.0001] and nonclassical [p=0.009]) and MPA (p=0.0002). Following CEA, anti-inflammatory monocytes increased and pro-inflammatory monocytes decreased (Figure 1A). Platelet expression of P-selectin and MPA did not change, while PAC-1 transiently increased but then returned to baseline by 24 hours postoperative (Figure 1B &C).

Conclusions: Subjects with CAS have elevated markers of thrombosis, inflammation, and their interface. However, only the pro-inflammatory monocytes are significantly reduced following CEA. Future studies investigating the clinical consequences of this reduction are warranted.

Abstract 505: Circulating Monocyte-Platelet Aggregates are Different Across Phenotypes of Vascular Disease

Background: Platelets are a major culprit in the pathogenesis of cardiovascular disease (CVD). Although vascular disease in different arterial beds share common risk factors, the role of platelet activity may differ by vascular bed. Clinical trials suggest that more potent antiplatelet therapy is needed in lower extremity peripheral artery disease (PAD) than coronary artery disease (CAD). We investigated circulating monocyte platelet aggregates (MPA), a reproducible ex vivo measurement of platelet activity, in patients with CVD (PAD, CAD, carotid artery stenosis [CAS], and abdominal aortic aneurysm [AAA]) and disease controls.

Methods: Subjects with CVD (n=351) and disease controls (n=73) had MPA measured using strict quality control, all of whom were on aspirin monotherapy. MPA were identified by CD14/CD61 positivity. Data is represented as median (IQR, interquartile range). Wilcoxon rank sum, Wilcoxon signed rank, and multivariable linear regression were used to analyze data.

Results: Platelets aggregated with monocytes had a higher platelet surface expression of PAC-1, P-selectin, and CD40 versus platelets not aggregated with monocytes (P<0.05 for each comparison). Compared with controls, MPA was significantly higher in CVD (14.5 [10.3, 27.8] vs. 9.4 [8.2, 11.5], P<0.001) which remained significant after multivariable adjustment for demographics and risk factors (β=9.1 (SER=3.9), P=0.02). For each vascular disease phenotype, MPA was higher than controls ( Figure ). In a multivariable linear regression model including demographics, risk factors and each vascular bed, PAD was the only vascular disease associated with a higher value of MPA (β=10.2 (SER=2.4), P<0.001).

Conclusions: Platelets aggregated with monocytes have increased platelet activity and are significantly elevated in subjects with PAD. Future studies understanding the platelet profile in PAD and its clinical relevance are needed.

Malaria in the returning older traveler

BACKGROUND

Increased co-morbidities and physiological changes mean older patients may be at higher risk of adverse outcomes from certain imported illnesses. One of the most commonly diagnosed imported infections in returning travelers is malaria. Increasing age is strongly and independently associated with increasing morbidity and mortality from malaria. Delayed diagnosis leads to higher risks of poor clinical outcomes in older patients presenting with malaria. The objective of this study was to quantify malaria presentations in older patients as a percentage of total malaria presentations, compare length of hospital stay (LOS) between the older and younger cohort, and to describe medical co-morbidities, length of time to diagnosis and factors contributing to delayed diagnosis and increased LOS in the older cohort.

METHODS

A retrospective cohort study was undertaken in two university hospitals of all patients aged 65 years or older presenting with malaria from 2002-2012. A national hospital inpatient database was used to identify patients of all ages with a discharge diagnosis of malaria over this ten year period, and quantify LOS in those aged <65 and those aged 65 years or older. The case-notes for all of the older cohort were reviewed.

RESULTS

There were a total of 203 cases, 12 of whom were aged ≥65 years (5.9 %- total). Median time to diagnosis in this older group was two days (range 0-35), median LOS was eight days (range 1-77), compared to a median LOS of three days in those aged <65 years. All patients aged ≥65 years presented with fever. Travel history was documented in only 6/12 charts, and 11/12 had two or more co-morbid illnesses. Six of the 12 patients were not diagnosed or treated within 48 h of presentation.

CONCLUSIONS

This case series highlights the need for appropriate history-taking and timely diagnosis of the older traveler returning with fever, as delayed diagnosis and treatment can contribute to prolonged hospital stay and increased morbidity. With increasing numbers of older travelers, physicians must remain vigilant to the presence of imported illnesses, particularly malaria, in older patients with unexplained fever.

Effect of Colchicine on Platelet-Platelet and Platelet-Leukocyte Interactions: a Pilot Study in Healthy Subjects

The cardioprotective mechanisms of colchicine in patients with stable ischemic heart disease remain uncertain. We tested varying concentrations of colchicine on platelet activity in vitro and a clinically relevant 1.8-mg oral loading dose administered over 1 h in 10 healthy subjects. Data are shown as median [interquartile range]. Colchicine addition in vitro decreased light transmission platelet aggregation only at supratherapeutic concentrations but decreased monocyte- (MPA) and neutrophil-platelet aggregation (NPA) at therapeutic concentrations. Administration of 1.8 mg colchicine to healthy subjects had no significant effect on light transmission platelet aggregation but decreased the extent of MPA (28 % [22-57] to 22 % [19-31], p = 0.05) and NPA (19 % [16-59] to 15 % [11-30], p = 0.01), platelet surface expression of PAC-1 (370 mean fluorescence intensity (MFI) [328-555] to 333 MFI [232-407], p = 0.02) and P-selectin (351 MFI [269-492] to 279 [226-364], p = 0.03), and platelet adhesion to collagen (10.2 % [2.5-32.6] to 2.0 % [0.2-9.5], p = 0.09) 2 h post-administration. Thus, in clinically relevant concentrations, colchicine decreases expression of surface markers of platelet activity and inhibits leukocyte-platelet aggregation but does not inhibit homotypic platelet aggregation.

The assessment of thrombotic markers utilizing ionic versus non-ionic contrast during coronary angiography and intervention trial

OBJECTIVE

To determine how two different types of iodinated contrast media (CM), low-osmolar ionic dimer ioxaglate (Hexabrix) and iso-osmolar non-ionic dimer iodixanol (Visipaque), affect multiple indices of hemostasis.

BACKGROUND

In vitro models demonstrate differential effects of ionic and non-ionic CM on markers of hemostasis.

METHODS

This blinded endpoint trial randomized 100 patients to ioxaglate or iodixanol. The primary endpoint was change in endogenous thrombin potential (ETP) following diagnostic angiography. Secondary endpoints included change in markers of fibrinolysis [tissue plasminogen activator (tPA) and plasminogen activator inhibitor 1 (PAI-1)] and platelet aggregation following diagnostic angiography and percutaneous coronary intervention (PCI) with bivalirudin. Data are presented as median [interquartile range].

RESULTS

ETP significantly decreased after diagnostic angiography in both ioxaglate (baseline 1810 nM*minute [1540-2089] to post-angiography 649 nM*minute [314-1347], p < 0.001) and iodixanol groups (baseline 1682 nM*minute [1534-2147] to post-angiography 681 nM*minute [229-1237], p < 0.001), but the decrease was not different between CM (p = 0.70). There was a significant increase in ETP during PCI (n = 45), despite the use of bivalirudin, suggesting a prothrombotic effect of PCI (post-angiography 764 nM*minute [286-1283] to post-PCI 1081 nM*minute [668-1552], p = 0.02). There were no significant differential effects on tPA, PAI-1, and markers of platelet activity.

CONCLUSION

There were no significant differential effects between ioxaglate and iodixanol. Both CM led to significant reductions in thrombin generation and no significant effects on fibrinolytic activity or platelet activity, thereby contributing to a favorable antithrombotic milieu. © 2016 Wiley Periodicals, Inc.