Evaluation of a New Mordant Based Haematoxylin Dye (Haematoxylin X) for Use in Clinical Pathology

Recently, St John's Dermatopathology Laboratory and CellPath Ltd have developed a new patented haematoxylin dye (Haematoxylin X) that utilises a chromium-based mordant (Chromium Sulphate). In this study, the performance of this new haematoxylin (Haematoxylin X) was compared against some commonly utilised alum-based haematoxylins (Carazzi's, Harris' and Mayer's) when used as a part of formalin-fixed paraffin embedded (FFPE) tissue, special stains, immunohistochemical counterstaining and frozen section (Mohs procedure) staining procedures. FFPE sections of different tissue types and frozen skin tissues were sectioned and stained with each haematoxylin subtype to allow for a direct comparison of staining quality. The slides were independently evaluated microscopically by two assessors. A combined score was generated to determine the sensitivity (defined as the intensity of haematoxylin staining being too weak or too strong and the colour of the haematoxylin staining not being blue/black) and specificity (defined as the presence of haematoxylin background staining, uneven staining, and staining deposits) for each of the four haematoxylin subtypes. The scoring criteria were based on the UKNEQAS Cellular pathology techniques assessment criteria. In FFPE tissue, the results for specificity identified Harris haematoxylin scoring the highest (91.2%) followed by Haematoxylin X (88.0%) and Mayer's (87.0%). The sensitivity scores again identified Harris haematoxylin as scoring the highest (95.1%) followed by Haematoxylin X (90.0%) and Mayer's (88.0%). In frozen tissue, the results for specificity identified Haematoxylin X as scoring the highest (85.5%) followed by Carazzi's (80.7%) and Harris' (77.4%). The sensitivity scores again identified Haematoxylin X as scoring the highest (86.8%) followed by Carazzi's (82.0%) and Harris' (81.0%). The results achieved with all four haematoxylins showed a high degree of comparability, with Harris' haematoxylin scoring high scores overall compared to the other four when assessing FFPE sections. This may have been due to familiarity with the use of Harris' haematoxylin in-house. There was also evidence of more pronounced staining of extracellular mucin proteins with Haematoxylin X compared to the other alum haematoxylins that were assessed. Haematoxylin X scored highest when used in frozen section staining. In addition, Haematoxylin X has a potential applications for use in IHC and special stains procedures as a counterstain.

Systematic review of the barriers and facilitators to cross-sector partnerships in promoting physical activity

AIMS

To review the barriers and facilitators that cross-sector partners face in promoting physical activity.

METHODS

We searched Medline, Embase, PsychINFO, ProQuest Central, SCOPUS and SPORTDiscus to identify published records dating from 1986 to August 2021. We searched for public health interventions drawn from partnerships, where the partners worked across sectors and their shared goal was to promote or increase physical activity through partnership approaches. We used the Critical Appraisal Skills Programme UK (CASP) checklist and Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool to guide the critical appraisal of included records, and thematic analysis to summarise and synthesise the findings.

RESULTS

Findings (n = 32 articles) described public health interventions (n = 19) aiming to promote physical activity through cross-sector collaboration and/or partnerships. We identified barriers, facilitators and recommendations in relation to four broad themes: approaching and selecting partners, funding, building capacity and taking joint action.

CONCLUSION

Common challenges that partners face are related to allocating time and resources, and sustaining momentum. Identifying similarities and differences between partners early on and building good relationships, strong momentum and trust can take considerable time. However, these factors may be essential for fruitful collaboration. Boundary spanners in the physical activity system could help translate differences and consolidate common ground between cross-sector partners, accelerating joint leadership and introducing systems thinking.

PROSPERO REGISTRATION NUMBER

CRD42020226207.

A Systematic Review of the Factors Associated with Post-Traumatic Growth in Parents Following Admission of Their Child to the Intensive Care Unit

This systematic review aims to identify the demographic, clinical and psychological factors associated with post-traumatic growth (PTG) in parents following their child's admission to the intensive care unit (ICU). Papers published up to September 2021 were identified following a search of electronic databases (PubMed, Medline, Web of Science, PsycINFO, CINAHL, PTSDpubs and EMBASE). Studies were included if they involved a sample of parents whose children were previously admitted to ICU and reported correlational data. 1777 papers were reviewed. Fourteen studies were eligible for inclusion; four were deemed to be of good methodological quality, two were poor, and the remaining eight studies were fair. Factors associated with PTG were identified. Mothers, and parents of older children, experienced greater PTG. Parents who perceived their child's illness as more severe had greater PTG. Strong associations were uncovered between PTG and post-traumatic stress, psychological well-being and coping. PTG is commonly experienced by this population. Psychological factors are more commonly associated with PTG in comparison with demographic and clinical factors, suggesting that parents' subjective ICU experience may be greater associated with PTG than the objective reality.

Research ethics systems, processes, and awareness across Europe: Radiography research ethics standards for Europe (RRESFE)

INTRODUCTION

The Radiography Research Ethics Standards for Europe (RRESFE) project aims to provide a cross-sectional snapshot of current research ethics systems, processes, and awareness of such, across Europe together with identifying the associated challenges, education, and training needs.

METHODS

A cross-sectional online survey targeting radiography researchers in Europe was conducted. Data collection took place between April 26 and July 12, 2021, using a snowball sampling approach. Descriptive and analytical statistics were used to identify trends in research ethics frameworks across Europe.

RESULTS

285 responses were received across 33 European and 23 non-European countries. Most (n = 221; 95%) European respondents stated ethics approval is required before commencing research in their country. Requirements around research ethics approval and awareness of such requirements varied by European region (X² (2, n = 129) = 7.234, p = 0.013) and were found to differ depending on the type of research participant and study design. Additionally, European respondents reported ethics approval is a national requirement more often than their non-European counterparts (X² (1, n = 282) = 4.316, p = 0.049). Requirements for ethics approval were also associated with the undergraduate programme duration (2-year vs. 3-year vs. 3.5 year vs. 4-year vs. multiple programme durations; X² (4, n = 231) = 10.075, p = 0.016) and availability of postgraduate training (postgraduate training available vs. postgraduate training not available; X² (1, n = 231) = 15.448, p = <0.001) within respondents' country.

CONCLUSION

Respondents from countries with longer programme durations/availability of multiple programme lengths, availability of postgraduate training, and establishment of European Qualifications Framework Level 6 were generally associated with less uncertainty and more comprehensive research ethics requirements.

IMPLICATIONS FOR PRACTICE

Results are informative of the current status of research ethics within evidence-based radiography.

Research ethics training, challenges, and suggested improvements across Europe: Radiography research ethics standards for Europe (RRESFE)

INTRODUCTION

The Radiography Research Ethics Standards for Europe (RRESFE) project aimed to provide a cross-sectional view of the current state of radiography research ethics across Europe. This included investigating education and training in research ethics, and identifying the key challenges and potential improvements associated with using existing research ethics frameworks.

METHODS

This cross-sectional online survey targeting radiography researchers in Europe was conducted between April 26 and July 12, 2021. Descriptive and analytical statistics were used to identify research ethics education and training trends. Content analysis of qualitative responses was employed to identify significant challenges and proposed improvements in research ethics frameworks of practice.

RESULTS

There were 232 responses received across 33 European countries. Most (n = 132; 57%) respondents had received some research ethics training; however, fewer participants had received training on safeguarding vulnerable patients (n = 72; 38%), diversity and inclusivity (n = 62; 33%), or research with healthy volunteers (n = 60; 32%). Training was associated with a greater perceived importance of the need for research ethics review (p = 0.031) and with the establishment of EQF Level 6 training (p = 0.038). The proportion of formally trained researchers also varied by region (p = <0.001). Time-to-ethics-approval was noted as the biggest challenge for professionals making research ethics applications.

CONCLUSION

Early and universal integration of research-oriented teaching within the radiography education framework which emphasises research ethics is recommended. Additionally, study findings suggest research ethics committee application and approval processes could be further simplified and streamlined.

IMPLICATIONS FOR PRACTICE

The survey contributes to a growing body of knowledge surrounding the importance of education and training in research ethics for assuring a high standard of research outputs in Radiography and has identified hurdles to obtaining research ethics approval for further investigation and address.

“I'm at breaking point”; Exploring pharmacists' resilience, coping and burnout during the COVID-19 pandemic

Background

There is a lack of evidence on how the multimodal dynamic process of resilience has impacted personal adaptation of frontline healthcare professionals, working under extreme pressure during the COVID-19 global pandemic.

Objectives

To explore resilience, burnout and wellbeing for UK pharmacists in patient-facing roles, including individual and organisational factors that align to the ABC-X theoretical model of the dynamic process of resilience.

Methods

A non-experimental pragmatist research design was adopted, with a cross-sectional online survey distributed via social media and professional networks between June and July 2020. Quantitative data aligned to a positivist research paradigm was collected using validated scores, to statistically analyse wellbeing, burnout and resilience. Qualitative textual data, consistent with an interpretivist research paradigm, were analysed following an inductive thematic approach.

Results

A total of 199 surveys from pharmacists working within community, hospital and GP sectors were analysed. Wellbeing scores were strongly correlated to resilience scores. Wellbeing and resilience scores were both inversely correlated with burnout scores. Two-thirds of participants were classified as high-risk within the burnout scales.

Key stressors were highlighted by participants, who described how individual resources and perceptions shaped their experience, which overall contributed to their burnout. Organisations that supported pharmacists embraced change and quickly adopted new ways of working, such as teleconsultations, flexible and remote working, redesign of workflow, alongside clear guidance. However, there was also reported frustration at lack of, slow or conflicting guidance from employers.

Conclusions

This study adds to the growing evidence base for how individuals are affected by adverse events in a dynamic environment, alongside the role that employers can play in supporting individual and organisational resilience. It provides an opportunity to learn from pharmacists' responses to the COVID-19 pandemic, and a call to action for healthcare organisations to rebuild and invest resources into sustained support for staff wellbeing.

Intra and Inter-professional working: how have pharmacists’ working practices changed during the COVID-19 pandemic?

Introduction

COVID-19 has acted as a catalyst for radical changes in the working practices of pharmacists. While there is emerging evidence of adaptability mitigating burnout amongst pharmacists in other countries (1), what has yet to be established is the extent to which the well-being and resilience of pharmacists in the UK may be supported through changes in intra and inter-professional working practices.

Aim

As part of a wider project aiming to explore the impact of COVID-19 on pharmacists’ wellbeing and resilience, in this abstract we present findings exploring the impact on working relationships within pharmacy and multidisciplinary teams.

Methods

An online questionnaire containing validated measures of wellbeing and resilience and free-text open questions exploring the impact of COVID-19 on working practices was piloted on five practising pharmacists. This questionnaire was subsequently distributed via social media and professional networks in June 2020. Convenience sampling was used whereby any UK-registered pharmacist in a patient-facing role was eligible to take part. Inductive thematic analysis of the free text responses was conducted. This abstract presents one key theme; intra and inter-professional relationships.

Results

A total of 202 questionnaires were completed (Table 1), with 192 participants entering free-text responses.

Participants reported pharmacy teams becoming closer, supporting one another and working more cohesively. Work redesign and staff upskilling were given as positive examples of practice change in response to the pandemic. Reported challenges included managing conflict within a team due to heightened stress, sustaining staff morale, exhaustion, and prioritising others to the detriment of their own wellbeing: “I have no time for myself as I'm too busy keeping the day to day working and supporting my team emotionally. I'm emotionally exhausted and at home I withdraw and ignore the outside world as I'm at breaking point but don’t want my colleagues to see this.”

Inter-professional relationships sometimes improved as a result of more effective communication, extended networking and pharmacists feeling valued and recognised as integral to multidisciplinary working. Supportive inter-professional working was described as a “Great sense of comradery - we're in this together”. Yet for others, inter-professional working proved challenging, with non-engagement of clinicians, frequently changing guidance from senior management, and restricted staff interaction due to remote or shift working.

Conclusions

Whilst for some the pandemic facilitated improved inter- and intra- professional interactions, for others this was viewed as challenges of daily practice. Due to recruiting via social media, this study is limited by the response numbers and is therefore not representative of all UK registered pharmacists. However, a key strength is that pharmacists from all sectors of practice responded, in comparison to other studies which have focused solely on community pharmacists. Results from this study can be used to support sustainable change in fostering collaborative working within pharmacy and multi-professional healthcare teams.

References

1. Austin, Z., & Gregory, P. (2020). Resilience in the time of pandemic: The experience of community pharmacists in Ontario during COVID-19. Research in Social and Administrative Pharmacy.

Factors affecting sense of belonging and academic achievement in MPharm students

Introduction

Academic achievement in higher education has been linked to academic ability and a student’s experiences at university. Factors affecting the student experience include demographics (age, gender, ethnicity), and contextual factors (living arrangements, sense of belonging (SOB)).1 Whether SOB is relevant to understanding pharmacy students’ academic achievement has not been investigated.

Aim

This study aims to investigate SOB in students on one MPharm programme and its associations with demographic / contextual factors and academic achievement.

Method

A questionnaire was distributed to all MPharm students at one university (n=601). It included a SOB instrument2 measuring five domains (perceived peer support, faculty support, classroom comfort, isolation, empathetic faculty understanding), demographic and contextual factors, and consent to link responses to end of year marks. Mean marks, % rank, one-way ANOVA with Tukey HST post hoc tests, independent samples t-tests and Pearson’s correlation co-efficient were calculated in SPSS v25 to investigate associations between SOB and demographic / contextual factors and academic achievement. Results: Four-hundred-and-forty-seven students responded (74.4%), of whom 80.1% consented to data linkage with assessment marks. Of the respondents, 317 (71.9%) were female, 408 (91.9%) were younger than 21 when commencing their MPharm, and 275 (61.5%) lived with other students. Respondents’ ethnicity was: 128 (32.8%) white, 158 (40.5%) asian, 53 (13.6%) black, 51 (13.1%) chinese. Analysis suggests SOB domains varied significantly in relation to demographic and contextual factors, with perceived peer support and perceived isolation in particular associated with multiple factors investigated (see Table 1).

Analysis of mean % rank (f=8.601, p=0.001) revealed that white students achieved significantly higher (64.6) than asian (51.5, p= 0.002), black (50.4, p=0.006), and chinese (41.9, p=0.014) students. Students who lived with other students achieved a significantly higher mean % rank (58.3), than those who did not (48.3, t=3.251, p=0.001). A positive correlation was identified between perceived peer support (r=0.211, p=0.001) and % rank. Perceived isolation was negatively correlated to % rank (r= -0.192, p=0.001).

Conclusion

Although limited to one UK school of pharmacy, yet with a good mix of student ethnicity, findings suggest important differences in the student experience, and that for some subgroups this may be associated with their academic achievement. This study offers valuable understanding of factors potentially impacting academic achievement, and provides insights to inform targeted interventions aimed at improving the student experience with a view to addressing SOB and achievement gaps. Further research is required to quantify the effect of the factors and their interdependence.

References

1. Mountford-Zimdars A, Sabri D, Moore J, Sanders J, Jones S, & Higham L. (2015). Causes of differences in student outcomes. Report for HEFCE by Kings College London, ARC Network and the University of Manchester. Available at: https://dera.ioe.ac.uk/23653/1/HEFCE2015_diffout.pdf accessed October 2020.

2. Hoffman M, Richmond J, Morrow J, & Salomone K. (2002). Investigating “Sense of Belonging” in First-Year College Students. Journal of College Student Retention: Research, Theory & Practice, 4(3), pp. 227–256.

Cross-sector pre-registration pharmacist placements in general practice in England: lessons from a national evaluation

Introduction

In 2019/2020, the Pharmacy Integration Fund commissioned delivery of cross-sector pre-registration pharmacist training incorporating 3–6 month placements in general practice (GP). GP placements were managed by Health Education England (HEE) and organised as one (or more) blocks, or as spilt weeks/days across base sector (hospital/community) and GP. Trainees had a pharmacist tutor at base and in GP.

Aim

to evaluate the implementation of cross-sector pre-registration pharmacy placements in GP in England, and to identify barriers and enablers of a successful placement.

Methods

A qualitative approach was taken, with case study sites purposively sampled for maximum variation: pharmacy base (hospital/community), number of pre-registration pharmacist trainees in base doing GP placement, length of GP placement, organisation of GP placement and geographical location. With consent, trainees and tutors identified as meeting sampling criteria were emailed invitation letters and participant information sheets. Where the trainee and their tutor(s) agreed to participate, semi-structured telephone interviews were conducted January - July 2020. Questions developed from literature(1, 2) and the HEE handbook were tailored to understanding trainees’ and tutors’ views on the implementation of pre-registration pharmacist placements in GP, including benefits, unintended consequences and impacts. Thematic analysis across sites was undertaken with a focus on exploring inter and intra group themes.

Results

Thirty-four interviews were completed in 11 study sites (5 GP/hospital; 6 GP/community pharmacy). Trainees and tutors considered GP placements had been successful. Contributing factors were: placement planning (induction, contingency arrangements for cover should GP tutor be unavailable); tutors working together (good communication and collaboration); GP tutor support (regular contact, reflection; identifying learning needs; opportunities for learning); integration of GP placements within training year (specific learning/training activities at base during GP placement); and GP tutors having backing of their organisation to supervise effectively. A lack of these impacted negatively. Trainees completed a wide spectrum of activities and gradually moved from administrative to clinical tasks. They built up confidence to undertake patient-facing activities, with more direct supervision at the beginning moving to indirect supervision using debriefing. Thirteen weeks in GP was considered an appropriate minimum duration by all trainees and tutors; those based in community felt that 26 weeks in GP provided more opportunities for clinical and consultation skills learning. Cross-sector experience facilitated a better understanding of patient pathways and the importance of holistic patient care. All trainees considered working in GP in future but highlighted the lack of a cross-sector GP foundation programme. Base tutors felt the time commitment was comparable to single sector placements. Base and GP tutors felt that a clear set of competencies for GP placements and a broader governance framework would ensure standards and consistency.

Conclusion

This is the first national evaluation of cross-sector pre-registration pharmacists in general practice placements in England. Sampling as case studies enabled data triangulation and generated a multi-faceted understanding on factors impacting GP placements. A key limitation was the volunteer bias associated with recruitment. Key attributes of a successful pre-registration cross-sector training experience are highlighted and can inform policy reforms including change from pre-registration to foundation year training.

References

1. Gray N. Review of Experience of Pre-registration Pharmacist Placements in the General Practice Setting – Final Report. 2019.

2. Jee SD, Schafheutle EI, Noyce PR. Is pharmacist pre-registration training equitable and robust? Higher Education, Skills and Work-Based Learning. 2019;9(3):347–58.

The status of the radiation safety culture within the higher education, research and teaching sectors in the UK

This article reports on the research by a working group, comprising members from the Association of University Radiation Protection Officers, on the radiation safety culture in the UK higher education, research and teaching (HERT) sectors. The impetus for this research arises from the work of the International Radiation Protection Association and their emphasis that embedding radiation safety culture within an organisation is the most effective way of delivering the standards of radiation safety and security that society expects. The deficiency in radiation safety culture has been a large contributor to major nuclear disasters, such as Chernobyl and Fukushima Daiichi. The working group designed an online survey aimed at higher education students, higher education academics, and researchers. The survey did not try to obtain an indication of safety performance, but of people's views on behaviours and attitudes of radiation safety that reflect the current radiation safety culture in their organisation. The findings of the survey are reported in this article along with a discussion of the analysis and recommendations for improving radiation safety culture. The responses from the survey strongly indicate that the radiation safety culture in UK HERT sectors has worrying shortfalls, particularly in communication and training.

Cost-effectiveness of alternative changes to a national blood collection service

Objectives

To evaluate the cost‐effectiveness of changing opening times, introducing a donor health report and reducing the minimum inter‐donation interval for donors attending static centres.

Background

Evidence is required about the effect of changes to the blood collection service on costs and the frequency of donation.

Methods/Materials

This study estimated the effect of changes to the blood collection service in England on the annual number of whole‐blood donations by current donors. We used donors' responses to a stated preference survey, donor registry data on donation frequency and deferral rates from the INTERVAL trial. Costs measured were those anticipated to differ between strategies. We reported the cost per additional unit of blood collected for each strategy versus current practice. Strategies with a cost per additional unit of whole blood less than £30 (an estimate of the current cost of collection) were judged likely to be cost‐effective.

Results

In static donor centres, extending opening times to evenings and weekends provided an additional unit of whole blood at a cost of £23 and £29, respectively. Introducing a health report cost £130 per additional unit of blood collected. Although the strategy of reducing the minimum inter‐donation interval had the lowest cost per additional unit of blood collected (£10), this increased the rate of deferrals due to low haemoglobin (Hb).

Conclusion

The introduction of a donor health report is unlikely to provide a sufficient increase in donation frequency to justify the additional costs. A more cost‐effective change is to extend opening hours for blood collection at static centres.

Abstract P2-09-02: Blinded molecular subtyping analysis from RNA-Seq of FFPE samples in the GeparQuinto trial reveals predictive value of VEGFA metagene for bevacizumab treatment

Background:

RNA-Seq from total RNA in FFPE tissue can be more challenging due to limited capture of partially degraded RNA. Exome-capture based RNA-Seq may circumvent such problems and allow reproducible complete molecular characterization of low-quality RNA from small clinical samples.

Methods:

HER2 negative patients within the GeparQuinto trial were treated with neoadjuvant anthracycline-taxane-based chemotherapy +/- bevacizumab. Patients with bevacizumab therapy had a significantly higher pCR rate, especially within the triple negative subgroup. We performed exome-capture RNA-Seq on 5µm FFPE sections from pre-therapeutic cores of 400 HER2 negative samples from this trial. In a prospectively planned, blinded study we correlated molecular subtypes and metagenes for proliferation, stroma, MHC2, and VEGFA with clinical and histopathological data. Molecular subtypes were defined using the AIMS methods. Metagenes were calculated as mean values corresponding to previously described gene clusters after platform transfer (Rody et al. 2011 PMID 21978456, Hu et al. 2009 PMID 19291283) and then z-transformed.

Results:

296 samples with RNA-Seq data were classified as either of high (n=226) or of limited quality (n=70). For 22 samples RNA yield was insufficient and 82 did not pass initial QC. 121 (41%), 63 (21%), 34 (11.5%), 46 (15.5%), and 32 (11%) samples were defined as basal-like, HER2-enriched, luminal A, luminal B, and normal-like, respectively. Subtyping was robust with regard to gene filtering, normalization, and sample quality. ER and PR status from local IHC strongly correlated with gene expression (overall correctness 84% and 80% for ER, and 85% and 74% for PR, in samples with high and limited quality, respectively) and luminal subtypes (95% ER positive). Proliferation metagene correlated with histological grade (median -0.73, -0.39, and 0.53 in G1, G2, and G3, respectively; P&lt;0.001) and MHC2 metagene correlated strongly with TIL counts (Rho=0.53, P&lt;0.001). Among the high quality samples response rates (49.3% pCR overall) differed significantly by subtype, with higher pCR rates in basal-like (68.9%) and HER2-enriched (45.5%) than in luminal B (35.7%), luminal A (17.9%), and normal-like (20.0%). MHC2- (OR 1.60, 95%CI 1.21-2.12, P=0.001), proliferation- (OR 2.88, 95%CI 2.00-4.16, P&lt;0.001), and VEGFA-metagenes (OR 1.92, 95%CI 1.41-2.60, P&lt;0.001) were significant predictors for pCR. In a multivariate logistic regression (adjusted for bevacizumab treatment and hormone receptor status) both VEGFA metagene (OR 2.59, 95%CI 1.40-4.77, P=0.002) and the interaction between the VEGFA-metagene and bevacizumab treatment arm (P=0.023) significantly predicted pCR.

Conclusions:

Exome-capture RNA-Seq allows robust genomic characterization of clinical samples with limited FFPE material from core biopsies, and molecular subtypes and immune metagenes are predictive for pCR. The VEGFA metagene is a specific predictor for response to neoadjuvant bevacizumab treatment.

Citation Format: Karn T, Meissner T, Weber K, Sinn B, Denkert C, Budczies J, Nekljudova V, Fasching PA, Holtrich U, Schem C, Solbach C, Hartmann A, Röcken C, Untch M, Young BM, Willis S, Leyland-Jones B, von Minckwitz G, Loibl S. Blinded molecular subtyping analysis from RNA-Seq of FFPE samples in the GeparQuinto trial reveals predictive value of VEGFA metagene for bevacizumab treatment [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-09-02.

Abstract PD8-10: APOBEC mutation signature in breast cancer correlates with tumor mutation burden and poor responses to therapy

Introduction

Mutational processes can be characterized by unique combinations of mutation types in the form of mutational signatures and have been associated with age, known mutagenic exposures, defects in DNA maintenance, or the APOBEC family of cytidine deaminases. We asked whether mutation signatures could be extracted from DNA sequence information in a targeted 434 gene panel covering 297 breast cancer specimens.

Materials and Methods

Targeted whole exome sequencing (Illumina, 2x50bp) of a 434 gene panel was performed on a set of 297 primary and metastatic breast tumor samples. Tissue of origin included breast (56%), liver (15%), lymph node (10%), lung (3%) and others (16%). Alignment was done with BWA against the human reference hg19 and variant calling was performed using VarDict. Germline variants were filtered based on allele frequencies, cohort specific population frequencies, as well as using 1000 Genomes and ExAC population frequencies. For somatic signature inference, only single nucleotide variants were retained. Panel specific trinucleotide frequencies were computed and normalized towards whole genome frequencies and somatic signatures were inferred using deconstructSigs method.

Results

We identified a total of 26 signatures from the set of 30 known signatures in our patient samples. Due to the small panel size, there was only a limited number of mutations available per patient to infer somatic signatures. On average, we identified two somatic signatures per sample. Most common mutation signatures identified were: Signature 1 (90.8%) - result of an endogenous mutational process initiated by spontaneous deamination of 5-methylcytosine; Signature 6 (21.8%) - defective DNA mismatch repair; Signature 15 (15.6%) - defective DNA mismatch repair; Signatue 7 (9.9%) - ultraviolet light exposure; and Signature 10 (6.5%) - altered activity of POLE. An APOBEC specific signature was identified in 20 (7%) samples. APOBEC positive samples showed significantly higher tumor mutational burden (10.7 vs. 5.7 mutations/mb) as compared to APOBEC negative samples (p&lt;=0.001). PIK3CA was found to be mutated in 80% of APOBEC positive samples, compared to 36% of APOBEC negative samples. In addition, we found higher rates of mutations in TP53 (70% vs. 50%), MLL3 (50% vs. 19%) and MLL2 (25% vs 14%) of APOBEC positive patients. Response rates of APOBEC positive patients were significantly worse than of APOBEC negative patients, with 50 percent of patients having progressive disease compared to 25 percent of APOBEC negative patients(p=0.07, borderline).

Conclusions

We demonstrate the feasibility of a targeted sequencing approach to extract somatic mutation signatures from breast tumor samples, and we highlight the potential of using the APOBEC signature to predict therapeutic responses.

Citation Format: Meissner T, Amallraja A, Willis S, Harris R, Leyland-Jones B, Williams C. APOBEC mutation signature in breast cancer correlates with tumor mutation burden and poor responses to therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD8-10.

Abstract P1-06-08: Independent validation of EarlyR gene signature in E2197: A randomized clinical trial comparing doxorubicin plus docetaxel to doxorubicin plus cyclophosphamide as adjuvant chemotherapy in breast cancer

Background: EarlyR is a prognostic gene signature score in ER+ breast cancer (BC) computed from the expression values of ESPL1, SPAG5, MKI67, PLK1 and PGR using a nonlinear mathematical formula. EarlyR has been validated in multiple cohorts profiled on Affymetrix and Illumina microarrays and by RNA-seq. This study sought to assess the prognostic features of EarlyR in a cohort of E2197.

Patients and Methods: Illumina DASL assay was used to measure gene expression in FFPE tissue of primary BC from a case-cohort sampling subset of women in E2197 treated with doxorubicin plus docetaxel (AT) or doxorubicin plus cyclophosphamide (AC). ER+ patients received hormone therapy at physician's discretion. After 79.5 months median follow-up, disease-free survival was 85% in both treatment arms. Among patients centrally reviewed with sufficient RNA material for the DASL assay, 319 with ER+ status and assessed for EarlyR are included in the analytic cohort. EarlyR scores and pre-specified risk strata (≤25=low, 26-75=intermediate, &gt;75=high) were computed, while blinded to clinical data. The analysis endpoint was disease-free survival (DFS), defined as the time from randomization to date of invasive BC recurrence or death from any cause within 8 years. Weighted Cox proportional hazards models were used to associate EarlyR score or risk strata with DFS. Variances of the estimated coefficients were adjusted to account for the case-cohort design.

Results: The distribution of the EarlyR risk groups was 59% low, 11% intermediate and 30% high risk in this ER+ cohort. The continuous EarlyR score was significantly prognostic of DFS up to 8 years after randomization (p = 0.02). Patients with low EarlyR score (≤ 25) had significantly lower risk of BC recurrence within 8 years (p = 0.031, univariate HR=0.562, 95%CI: 0.334-0.948) compared to those with high EarlyR score (&gt; 75). Analysis within the AC arm showed that patients with low EarlyR score had significantly lower risk of 8-year BC recurrence (p = 0.023, univariate HR=0.392, 95%CI: 0.175-0.878) compared to those with high EarlyR score. Within the AT arm there was no significant difference in 8-year DFS prognosis between any of the EarlyR risk groups.

Conclusions: This study confirmed the prognostic significance of EarlyR using FFPE tissue in a cohort of patients treated with AC chemotherapy from E2197. Patients with high EarlyR score who were treated with AC had significantly higher risk of recurrence than low EarlyR score patients treated with AC. On the other hand, prognosis of high EarlyR score AT-treated patients was not significantly lower than the prognosis of low EarlyR score AT-treated patients. Further study in a larger cohort is needed to assess the relative benefits of AC versus AT within the EarlyR high risk group and the EarlyR low risk group.

Citation Format: Badve S, Wang V, Willis S, Leyland-Jones B, Gokmen-Polar Y, Shulman L, Martino S, Sparano J, Davidson N, Goldstein L, Buechler S. Independent validation of EarlyR gene signature in E2197: A randomized clinical trial comparing doxorubicin plus docetaxel to doxorubicin plus cyclophosphamide as adjuvant chemotherapy in breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-06-08.

Open Right Hemicolectomy Is a Safe and Suitable Procedure for Surgical Training: A Comparative Study With 133 Patients

BACKGROUND AND AIMS

A right hemicolectomy is a technically demanding procedure and the quality of the operation influences the short- and long-term outcomes. An increasing number of certified centers employ surgeons who are specialized in this procedure. Residency training is obligatory, but trainee surgeons often cannot perform technically demanding procedures because of economical and certification requirements imposed on the center. This study was performed to evaluate the suitability of right hemicolectomy as a training procedure.

MATERIAL AND METHODS

Between 2009 and 2013, 133 patients received a right hemicolectomy during cancer treatment. Patient data were analyzed in two cohorts: cohort 1 contained 90 patients who were operated by a resident under supervision, and cohort 2 included 43 patients who were operated by a specialized senior surgeon. Outcome and safety were evaluated by mortality rate, anastomotic leakage, complication rate, and operation time. The resection status and the number of resected lymph nodes were surrogate parameters for oncological quality. Gender, age, American Society of Anesthesiologists classification, body mass index, and general risk factors were compared in both cohorts.

RESULTS

There was no significant difference in the rate of anastomotic leakage between the two groups (p = 0.799). Oncological criteria were met in both cohorts and the oncological quality was similar between groups. Furthermore, there were no significant differences in risk factors, operating time, postoperative complications, and mortality between the groups.

CONCLUSION

Oncological open right hemicolectomy is a safe and suitable training procedure for residency training under standardized conditions.

Abstract P6-08-07: Gain and amplification of RAC1 GTP-ase in BC: Explaining alterations in patients by experiments using TNBC model

INTRODUCTION: RAC1-GTPase which transduces signals from cell surface integrins, have been implicated in metastasis. We reported that Wnt-beta-catenin pathway (WP) that signals metastasis (BMC Cancer, 2013), is one of the salient genetic features of Triple-Negative Breast Cancer (TNBC) (PlosOne, 2013).AIM: We demonstrated that TNBC cells acquire integrin-directed metastasis-associated (ID-MA) phenotypes following an upregulation of the WP (Oncotarget, In Press). Here we examined how WP signals are transduced in the context of ID-MA phenotypes in TNBC.METHOD: We documented gain and amplification of RAC1 gene in Breast Invasive Carcinoma subtypes from cBioPortal. The outcome for RFS was studied in the Hungarian ER-ve BC cohort.Mechanistically, we studied fibronectin-directed (1) migration, (2) matrigel- invasion, (3) RAC1 activation, (4) actin dynamics (confocal microscopy) and (5) podia-parameters using pharmacological agents (sulindac sulfide), genetic tools (beta-catenin siRNA), WP modulators (Wnt-C59, XAV939), RAC1 inhibitors (NSC23766, W56) and WP stimulations (LWnt3ACM, Wnt3A recombinant) in a panel of 6-7 TNBC cell lines, RESULTS: The collective percentage of gain and amplification of RAC1 were (1) 31% of total 1105 breast invasive carcinoma samples, (2) 29% of total 594 ER+ve samples, (3) 39% of total 174 ER-ve samples, (4) 38% of total 120 HER2+ve samples and (4)35% of total 82 TNBC samples (brca/tcga/pub2015; Cell 2015).In invasive ductal BC subtypes, gain and amplification of RAC1 were (1) 32% of total 201 Luminal A samples, (2) 37% of total 122 PAM50 Luminal B samples, (3) 47% of total 51 PAM50 Her2-enriched samples and (4) 33% of total 107 PAM50 Basal-like samples. In invasive lobular cancers, gain and amplification of RAC1 were 24% of total 127 samples.Involvement of WP in different TNBC cells was tested following stimulation by LWnt3ACM and Wnt3Arecombinant protein and different inhibitors of WP by both qRT-PCR and WB for beta-catenin, active beta-catenin, cMYC, cyclin D1and WP specific several stem cell markers. The WP attenuation, which (a) decreased cellular levels of beta-catenin, as well as its nuclear active-form, (b) decreased fibronectin-induced migration & invasion, (c) altered actin dynamics and (d) decreased podia-parameters was successful in blocking fibronectin-mediated RAC1/Cdc42 activity. Both Wnt-antagonists and RAC1 inhibitors blocked fibronectin-induced RAC1 activation and inhibited fibronectin-induced ID-MA phenotypes following WP stimulation by LWnt3ACM and Wnt3Arecombinant protein. High expression of RAC1 was associated with poor outcome for RFS with HR=1.48 [CI: 1.15-1.9] p=0.0019 in the Hungarian ER-veBC cohort.CONCLUSION:In TNBC model, the activation of RAC1 signals downstream of WP mediated ID-MA phenotypes. The identification of the functional relationship between RAC1 signaling and the WP activation in the control of ID-MA mechanistically explains how the activation of WP in TNBC is associated with the high metastatic incidences and a dismal outcome.

Citation Format: Dey N, Carlson JH, Jepperson T, Willis S, De P, Leyland-Jones B. Gain and amplification of RAC1 GTP-ase in BC: Explaining alterations in patients by experiments using TNBC model [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-08-07.

Abstract P4-12-01: Independent validation of EarlyR gene signature in BIG 1-98: A randomized, double-blind, phase III trial comparing letrozole and tamoxifen as adjuvant endocrine therapy for postmenopausal women with hormone receptor-positive, early breast cancer

Background: EarlyR is a prognostic gene signature score in ER+ breast cancer (BC) computed from the expression values of ESPL1, SPAG5, MKI67, PLK1 and PGR using a novel algorithm. EarlyR has been validated in multiple cohorts profiled on Affymetrix and Illumina microarrays. This study sought to verify prognostic features of EarlyR in a cohort of BIG 1-98.

Patients and Methods: Illumina DASL assay was used to measure gene expression in FFPE tissue of primary BC from a case-cohort sampling subset of postmenopausal women in BIG 1-98 treated with adjuvant endocrine therapy (letrozole or tamoxifen). Chemotherapy treatment was at the discretion of individual physicians and patients. Among the 1218 patients centrally reviewed with sufficient RNA material for the DASL assay, 1174 with ER+ status and assessed for EarlyR are included in the analytic cohort. EarlyR scores and pre-specified risk strata (≤25=low, 26-75=intermediate, &gt;75=high) were computed, while blinded to clinical data. The analysis endpoints included distant recurrence free interval (DRFI) defined as time from randomization to BC recurrence at a distant site within 8 years and BC free-interval (BCFI) defined as time from randomization to first invasive BC recurrence at a local, regional or distant site or invasive contralateral BC within 8 years. Weighted proportional hazards models (univariate and multivariate, stratified by treatment assignment) were used to adjust for Kaplan-Meier, hazard ratio estimates and Wald test statistics to obtain unbiased analyses and to give consistent estimates.

Results: The distribution of the EarlyR risk groups was 67% low, 19% intermediate and 14% high risk in this ER+ cohort. EarlyR was prognostic for 8-year DRFI (P-trend=0.008). Patients with high EarlyR risk score (&gt;75) had significantly increased risk of distant recurrence within 8 years (univariate HR=1.73, 95%CI: 1.14-2.64) compared to low EarlyR risk group (≤25). The estimated 8-year DRFI (95%CI) is 84%(80%-88%) for high risk vs. 91%( 89%-92%) for low risk, corresponding to an absolute DRFI risk reduction of 7% (low vs high). EarlyR is also prognostic of 8-year BCFI in ER+ (P-trend=0.002) with the estimated 8-year BCFI (95%CI) 79%(75%-84%) for high risk vs. 88%( 86%-89%) for low risk. Consistent results were observed in ER+, HER2- (P-trend=0.01 for DRFI, P-trend=0.004 for BCFI), in ER+, LN- (P-trend=0.05 for DRFI, P-trend=0.03 for BCFI) and ER+, LN+ (P-trend=0.08 for DRFI, P-trend=0.03 for BCFI) subsets.

Conclusions: This study confirmed the prognostic significance of EarlyR using FFPE tissue from the BIG 1-98 trial. In analyses of all ER+ patients and subsets LN-, LN+ and HER2-, EarlyR classifies 65%-70% of patients as low risk, 11-16% as high risk, and &lt; 20% as intermediate risk. In these subsets, the size of the low risk group is larger and the size of the intermediate risk group is smaller than those reported for commercially available signatures. EarlyR identifies a set of high-risk patients with relatively poor prognosis who may be considered for additional treatment. The clinical utility of EarlyR requires further study.

Citation Format: Buechler S, Gray KP, Gökmen-Polar Y, Willis S, Thürlimann B, Kammler R, Leyland-Jones B, Badve SS, Regan MM. Independent validation of EarlyR gene signature in BIG 1-98: A randomized, double-blind, phase III trial comparing letrozole and tamoxifen as adjuvant endocrine therapy for postmenopausal women with hormone receptor-positive, early breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-12-01.

Neural modulation for hypertension and heart failure

Hypertension (HTN) and heart failure (HF) have a significant global impact on health, and lead to increased morbidity and mortality. Despite recent advances in pharmacologic and device therapy for these conditions, there is a need for additional treatment modalities. Patients with sub-optimally treated HTN have increased risk for stroke, renal failure and heart failure. The outcome of HF patients remains poor despite modern pharmacological therapy and with established device therapies such as CRT and ICDs. Therefore, the potential role of neuromodulation via renal denervation, baro-reflex modulation and vagal stimulation for the treatment of resistant HTN and HF is being explored. In this manuscript, we review current evidence for neuromodulation in relation to established drug and device therapies and how these therapies may be synergistic in achieving therapy goals in patients with treatment resistant HTN and heart failure. We describe lessons learned from recent neuromodulation trials and outline strategies to improve the potential for success in future trials. This review is based on discussions between scientists, clinical trialists, and regulatory representatives at the 11th annual CardioVascular Clinical Trialist Forum in Washington, DC on December 5-7, 2014.

Abstract P3-07-36: Immune related gene expression signatures predict benefit of letrozole over tamoxifen in BIG 1-98

Background: The prognostic significance of increased levels of CD8+ tumor infiltrating lymphocytes(TILs) in ER- breast cancer has been described. We sought to identify possible immune-related biomarkers for predicting benefit from letrozol(LET) or tamoxifen(TAM) for recurrence in ER+ breast cancer.

Patient and Methods: We used Illumina DASL Assay to measure gene expression in FFPE primary breast cancers from a subset of postmenopausal patients enrolled in the BIG 1-98 randomized phase 3 trial comparing 5 years LET (n=344) vs TAM (n=381) as adjuvant endocrine therapy. Gene sets (n=1910) that represent cell states and perturbations within the immune system from the Human Immunology Project Consortium were used in an exploratory analysis to identify possible predictive signatures.

Results: We identified five distinct gene signatures from previously reported laboratory experiments associated with immune cell differentiation that are highly predictive of benefit (reduced breast cancer recurrence risk) of LET over TAM, each with gene signature p-values&lt;1E-5 and signature-by-treatment interaction p&lt;1E-6. The signatures predict a similar pattern that patients at low-risk score benefit from LET and patients with high-risk score appear to have an advantage with TAM after 5 years. The gene signatures originate as a result of being differentially expressed in the following previously reported experiments. [RAP2A EEF2K TRAF3IP2 GPR37L1 DDX54] down regulated comparing TLR3 and TLR9 agonists in dendritic cells. [RPA1 DUSP4 NUDT18 ZFYVE28] up regulated in comparison of T follicular helper versus Th17 cells. [MAPK15 CCR4 SORCS2 RAMP1 SH3PXD2A] up regulated in regulatory T cell versus CD4+ T cells. [NDUFA6 GIMAP1 CPNE3 ST3GAL6 CCDC88A] down regulated in comparison of untreated CD8+ dendritic cells versus treated with IFNG. [GPN1 COX17 CUL2 CDSA] down regulated in naïve vs stimulated CD8 T cells after 48 hours. We further investigated the signatures using Hungarian Academy of Sciences (HAS) cohort (Gyorffy B 2010), which is a collection of smaller published affymetrix cohorts combined into a larger ER+, TAM treated cohort (n=700). One signature was not tested because two genes were not present in the affymetrix cohort. Three of the remaining four signatures gave informative prognostic results in the HAS cohort, and the signature associated with differentiation of CD8+ dendritic cells was highly prognostic with HR=0.36 (0.26-0.49) p=1E-11.

Conclusion: The role of selective estrogen receptor modulators on immune response has been well described, where TAM has been shown to prevent differentiation and activation of dendritic cells (Naibandian 2005). Similarly, it has been shown that MET inhibitors negatively regulate neutrophils suggesting that anti-MET drugs in cancer could impact immune response (Finisquerra 2015). These findings suggest that if TAM is a negative regulator of immune response why in the ATAC clinical trial, the combination therapy of anastrozole plus TAM were not significantly different from TAM alone were anastrozole was superior. With the increasing importance of understanding the role of immune response on outcome and the use of combination therapies the assessment of TILs in the neoadjuvant setting will be critical for guiding therapy.

Citation Format: Willis S, Gray KP, Regan MM, Rae JM, Kammler R, Young B, Ditzel HJ, Lyng MB, Colleoni M, Viale G, Leyland-Jones B. Immune related gene expression signatures predict benefit of letrozole over tamoxifen in BIG 1-98. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-36.

Validation of PigBal model predictions for pig manure production

PigBal is a mass balance model that uses pig diet, digestibility and production data to predict the manure solids and nutrients produced by pig herds. It has been widely used for designing piggery effluent treatment systems and sustainable reuse areas at Australian piggeries. More recently, PigBal has also been used to estimate piggery volatile solids production for assessing greenhouse gas emissions for statutory reporting purposes by government, and for evaluating the energy potential from anaerobic digestion of pig effluent. This paper has compared PigBal predictions of manure total, volatile, and fixed solids, and nitrogen (N), phosphorus (P) and potassium (K), with manure production data generated in a replicated trial, which involved collecting manure from pigs housed in metabolic pens. Predictions of total, volatile, and fixed solids and K in the excreted manure were relatively good (combined diet R2 ≥ 0.79, modelling efficiency (EF) ≥ 0.70) whereas predictions of N and P, were generally less accurate (combined diet R2 0.56 and 0.66, EF 0.19 and –0.22, respectively). PigBal generally under-predicted lower N values while over-predicting higher values, and generally over-predicted manure P production for all diets. The most likely causes for this less accurate performance were ammonium-N volatilisation losses between manure excretion and sample analysis, and the inability of PigBal to account for higher rates of P uptake by pigs fed diets containing phytase. The outcomes of this research suggest that there is a need for further investigation and model development to enhance PigBal’s capabilities for more accurately assessing nutrient loads. However, PigBal’s satisfactory performance in predicting solids excretion demonstrates that it is suitable for assessing the methane component of greenhouse gas emission and the energy potential from anaerobic digestion of volatile solids in piggery effluent. The apparent overestimation of N and P excretion may result in conservative nutrient application rates to land and the over-prediction of the nitrous oxide component of greenhouse gas emissions.

The advantages of creating a positive radiation safety culture in the higher education and research sectors

The safety culture of any organisation plays a critical role in setting the tone for both effective delivery of service and high standards of performance. By embedding safety at a cultural level, organisations are able to influence the attitudes and behaviours of stakeholders. To achieve this requires the ongoing commitment of heads of organisations and also individuals to prioritise safety no less than other competing goals (e.g. in universities, recruitment and retention are key) to ensure the protection of both people and the environment. The concept of culture is the same whatever the sector, e.g. medical, nuclear, industry, education, and research, but the higher education and research sectors within the UK are a unique challenge in developing a strong safety culture. This report provides an overview of the challenges presented by the sector, the current status of radiation protection culture, case studies to demonstrate good and bad practice in the sector and the practical methods to influence change.

Abstract POSTER-CTRL-1205: Neurocognitive evaluation of a cognitive training intervention in ovarian and gynecologic cancer survivors

Purpose: Our prior work indicates that a group-based cognitive training intervention can improve memory and attention in cancer survivors. This study examined potential for training transfer on two cognitive tasks and corresponding changes in neural activation patterns as measured by fMRI prior to and following the cognitive training intervention.

Methods: Seven gynecologic cancer (ovarian, breast, uterine) survivors (mean age: 64 years, mean time since primary treatment: 7.2 years) underwent a 7-week cognitive rehabilitation intervention delivered in group format. Participants were evaluated with a comprehensive cognitive battery and two experimental cognitive tasks prior to and following treatment. A word pair task required participants to learn pairs of words and later indicate whether words had been seen before (Item condition) or whether words had been paired together at learning (Relational condition). A verbal working memory task required participants to learn a set of 3, 5, or 7 letters and confirm or deny the presence of a probe letter. Participants also underwent fMRI scanning during word pair and verbal working memory tasks prior to and following treatment.

Results: Participants showed significant improvement following intervention in accuracy in the Relational condition, in which strong associations between presented word pairs were required for successful performance, t(3)=5.21, p&lt; .05. By contrast, accuracy did not increase significantly in the Item condition following intervention, t(3)=.48, p=.66). There was also a significant improvement in accuracy for the intermediate load (5-item) condition of the verbal working memory task following intervention, t(3)=4.17, p&lt;.05. fMRI analyses revealed activation in a frontoparietal network during both the word pairs and verbal working memory tasks. Future analyses will investigate changes in recruitment of this network following intervention.

Conclusions: Cancer survivors show evidence of specific transfer of memory skills following a group-based cognitive training intervention as demonstrated by improvement on the word memory task- relational item. In addition, there was a trend toward improvement on a working memory task. Neuroimaging results suggest frontoparietal network involvement for the cognitive task as well as some indication of a more efficient neural response following training. These results suggest that cognitive training may have a beneficial impact on both behavioral measures of cognition as well as neural activation markers.

Citation Format: H. Gray, M. K. Askren Thomas, K. Anderson, D. David, A. Singh, K. Murphy, S. Willis, H. Mendoza, M.M. Cherrier. Neurocognitive evaluation of a cognitive training intervention in ovarian and gynecologic cancer survivors [abstract]. In: Proceedings of the 10th Biennial Ovarian Cancer Research Symposium; Sep 8-9, 2014; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2015;21(16 Suppl):Abstract nr POSTER-CTRL-1205.

[Can Topical Negative Pressure Therapy be Performed as a Cost-Effective General Surgery Procedure in the German DRG System?]

INTRODUCTION

Topical negative pressure therapy (TNPT) has been established for surgical wound therapy with different indications. Nevertheless, there is only sparse evidence regarding its therapeutic superiority or cost-effectiveness in the German DRG system (G-DRG). This study was designed to analyse the cost-effectiveness of TNPT in the G-DRG system with a focus on daily treatment costs and reimbursement in a general surgery care setting.

PATIENTS/MATERIALS AND METHODS

In this retrospective study, we included 176 patients, who underwent TNPT between 2007 and 2011 for general surgery indications. Analysis of the cost-effectiveness involved 149 patients who underwent a simulation to calculate the reimbursement with or without TNPT by a virtual control group in which the TNP procedure was withdrawn for DRG calculation. This was followed by a calculation of costs for wound dressings and TNPT rent and material costs. Comparison between the "true" and the virtual group enabled calculation of the effective remaining surplus per case.

RESULTS

Total reimbursement by included TNPT cases was 2,323 ,70.04 €. Costs for wound dressings and TNPT rent were 102,669.20 €. In 41 cases there was a cost-effectiveness (27.5%) with 607,422.03 € with TNP treatment, while the control group without TNP generated revenues of 442,015.10 €. Costs for wound dressings and TNPT rent were 47,376.68 €. In the final account we could generate a cost-effectiveness of 6759 € in 5 years per 149 patients by TNPT. In 108 cases there was no cost-effectiveness (72.5%).

CONCLUSION

TNPT applied in a representative general surgery setting allows for wound therapy without a major financial burden. Based on the costs for wound dressings and TNPT rent, a primarily medically based decision when to use TNPT can be performed in a balanced product cost accounting. This study does not analyse the superiority of TNPT in wound care, so further prospective studies are required which focus on therapeutic superiority and cost-effectiveness.

Economic modelling of diagnostic and treatment pathways in National Institute for Health and Care Excellence clinical guidelines: the Modelling Algorithm Pathways in Guidelines (MAPGuide) project

BACKGROUND

National Institute for Health and Care Excellence (NICE) clinical guidelines (CGs) make recommendations across large, complex care pathways for broad groups of patients. They rely on cost-effectiveness evidence from the literature and from new analyses for selected high-priority topics. An alternative approach would be to build a model of the full care pathway and to use this as a platform to evaluate the cost-effectiveness of multiple topics across the guideline recommendations.

OBJECTIVES

In this project we aimed to test the feasibility of building full guideline models for NICE guidelines and to assess if, and how, such models can be used as a basis for cost-effectiveness analysis (CEA).

DATA SOURCES

A 'best evidence' approach was used to inform the model parameters. Data were drawn from the guideline documentation, advice from clinical experts and rapid literature reviews on selected topics. Where possible we relied on good-quality, recent UK systematic reviews and meta-analyses.

REVIEW METHODS

Two published NICE guidelines were used as case studies: prostate cancer and atrial fibrillation (AF). Discrete event simulation (DES) was used to model the recommended care pathways and to estimate consequent costs and outcomes. For each guideline, researchers not involved in model development collated a shortlist of topics suggested for updating. The modelling teams then attempted to evaluate options related to these topics. Cost-effectiveness results were compared with opinions about the importance of the topics elicited in a survey of stakeholders.

RESULTS

The modelling teams developed simulations of the guideline pathways and disease processes. Development took longer and required more analytical time than anticipated. Estimates of cost-effectiveness were produced for six of the nine prostate cancer topics considered, and for five of eight AF topics. The other topics were not evaluated owing to lack of data or time constraints. The modelled results suggested 'economic priorities' for an update that differed from priorities expressed in the stakeholder survey.

LIMITATIONS

We did not conduct systematic reviews to inform the model parameters, and so the results might not reflect all current evidence. Data limitations and time constraints restricted the number of analyses that we could conduct. We were also unable to obtain feedback from guideline stakeholders about the usefulness of the models within project time scales.

CONCLUSIONS

Discrete event simulation can be used to model full guideline pathways for CEA, although this requires a substantial investment of clinical and analytic time and expertise. For some topics lack of data may limit the potential for modelling. There are also uncertainties over the accessibility and adaptability of full guideline models. However, full guideline modelling offers the potential to strengthen and extend the analytical basis of NICE's CGs. Further work is needed to extend the analysis of our case study models to estimate population-level budget and health impacts. The practical usefulness of our models to guideline developers and users should also be investigated, as should the feasibility and usefulness of whole guideline modelling alongside development of a new CG.

FUNDING

This project was funded by the Medical Research Council and the National Institute for Health Research through the Methodology Research Programme [grant number G0901504] and will be published in full in Health Technology Assessment; Vol. 17, No. 58. See the NIHR Journals Library website for further project information.

MAPT STUDY: A MULTIDOMAIN APPROACH FOR PREVENTING ALZHEIMER'S DISEASE: DESIGN AND BASELINE DATA

OBJECTIVE

The Multidomain Alzheimer Preventive Trial (MAPT study) was designed to assess the efficacy of isolated supplementation with omega-3 fatty acid, an isolated multidomain intervention (consisting of nutritional counseling, physical exercise, cognitive stimulation) or a combination of the two interventions on the change of cognitive functions in frail subjects aged 70 years and older for a period of 3 years. Ancillary neuroimaging studies were additionally implemented to evaluate the impact of interventions on cerebral metabolism (FDG PET scans) and atrophy rate (MRIs), as well as brain amyloïd deposit (AV45 PET scans).

DESIGN PATIENTS

1680 subjects (mean age: 75.3 years; female: 64.8 %), enrolled by 13 memory clinics, were randomized into one of the following four groups: omega-3 supplementation alone, multidomain intervention alone, omega-3 plus multidomain intervention, or placebo. Participants underwent cognitive, functional and biological assessments at M6, M12, M24 and M36 visits. The primary endpoint is a change of memory function at 3 years, as assessed by the Free and Cued Selective Reminding test. All participants will be followed for 2 additional years after the 3-years intervention (MAPT PLUS extension study).

INTERVENTIONS

1/Omega-3 supplementation: two soft capsules daily as a single dose, containing a total of 400 mg docosahexaenoic acid (DHA), i.e., 800 mg docosahexaenoic acid per day, for 3 years. 2/ Multidomain intervention: collective training sessions conducted in small groups (6-8 participants) in twelve 120-minute sessions over the first 2 months (two sessions a week for the first month, and one session a week the second month) then a 60-minute session per month in the following three areas: nutrition, physical activity, and cognition until the end of the 3 years. In addition to the collective sessions, individualized preventive outpatient visits exploring possible risk factors for cognitive decline are performed at baseline, M12 and M24.

BASELINE POPULATION

For cognition, the mean MMSE at baseline was 28.1 (± 1.6). About 58% and 42% of participants had a CDR score equal to 0 and 0.5, respectively. Regarding mobility status, 200 (11.9%) had a 4-m gait speed lower or equal to 0.8 m/s. According to the Fried criteria, 673 (42.1%) participants were considered pre frail, and 51 (3.2%) frail. The red blood cell DHA content was 26.1 ± 8.1 µg/g. Five hundred and three participants underwent baseline MRI. AV45 PET scans were performed in 271 individuals and preliminary results showed that 38.0% had a cortical SUVR > 1.17, which gave an indication of significant brain amyloïd deposit. DISCUSSION: The MAPT trial is presently the first largest and longest multidomain preventive trial relevant to cognitive decline in older adults with subjective memory complaints. The multidomain intervention designed for the MAPT trial is likely to be easily implemented within the general population.

Update Narbenhernie Parastomale Hernie

Parastomal herniation is a frequent complication when an artificial anus is constructed. As a tunnel through the abdominal wall is nonphysiological, there is an inherent trend to enlargement of the aperture with any artificial stoma. However, none of the technical modifications tried has proved reliable in reducing the incidence of parastomal herniation. The only clear-cut indications for repair are ileus and incarceration or serious problems with the colostomy bags. There are three basic methods of repair: fascial closure, stoma relocation and augmentation of the abdominal wall by nonabsorbable meshes, and any of the three can be combined in many ways. The first two techniques each have a recurrence rate of 40%-80%, and neither can therefore any longer be recommended for use in isolation. Only with the last technique of abdominal wall reinforcement it is possible to achieve a recurrence rate of under 20%. The best type of mesh and the optimal implantation technique are still under discussion.

MAPT STUDY: A MULTIDOMAIN APPROACH FOR PREVENTING ALZHEIMER’S DISEASE: DESIGN AND BASELINE DATA

Objective: The Multidomain Alzheimer Preventive Trial (MAPT study) was designed to assess the efficacy of isolated supplementation with omega-3 fatty acid, an isolated multidomain intervention (consisting of nutritional counseling, physical exercise, cognitive stimulation) or a combination of the two interventions on the change of cognitive functions in frail subjects aged 70 years and older for a period of 3 years. Ancillary neuroimaging studies were additionally implemented to evaluate the impact of interventions on cerebral metabolism (FDG PET scans) and atrophy rate (MRIs), as well as brain amyloïd deposit (AV45 PET scans). Design, patients: 1680 subjects (mean age: 75.3 years; female: 64.8 %), enrolled by 13 memory clinics, were randomized into one of the following four groups: omega-3 supplementation alone, multidomain intervention alone, omega-3 plus multidomain intervention, or placebo. Participants underwent cognitive, functional and biological assessments at M6, M12, M24 and M36 visits. The primary endpoint is a change of memory function at 3 years, as assessed by the Free and Cued Selective Reminding test. All participants will be followed for 2 additional years after the 3-years intervention (MAPT PLUS extension study). Interventions: 1/ Omega-3 supplementation: two soft capsules daily as a single dose, containing a total of 400 mg docosahexaenoic acid (DHA), i.e., 800 mg docosahexaenoic acid per day, for 3 years. 2/ Multidomain intervention: collective training sessions conducted in small groups (6–8 participants) in twelve 120-minute sessions over the first 2 months (two sessions a week for the first month, and one session a week the second month) then a 60-minute session per month in the following three areas: nutrition, physical activity, and cognition until the end of the 3 years. In addition to the collective sessions, individualized preventive outpatient visits exploring possible risk factors for cognitive decline are performed at baseline, M12 and M24. Baseline population: For cognition, the mean MMSE at baseline was 28.1 (± 1.6). About 58% and 42% of participants had a CDR score equal to 0 and 0.5, respectively. Regarding mobility status, 200 (11.9%) had a 4-m gait speed lower or equal to 0.8 m/s. According to the Fried criteria, 673 (42.1%) participants were considered pre frail, and 51 (3.2%) frail. The red blood cell DHA content was 26.1 ± 8.1 µg/g. Five hundred and three participants underwent baseline MRI. AV45 PET scans were performed in 271 individuals and preliminary results showed that 38.0% had a cortical SUVR > 1.17, which gave an indication of significant brain amyloïd deposit. Discussion: The MAPT trial is presently the first largest and longest multidomain preventive trial relevant to cognitive decline in older adults with subjective memory complaints. The multidomain intervention designed for the MAPT trial is likely to be easily implemented within the general population.

Abstract S6-05: High levels of APOBEC3B, a DNA deaminase and an enzymatic source of C-to-T transitions, are a validated marker of poor outcome in estrogen receptor-positive breast cancer

Two recent observations have connected the innate immune DNA cytosine deaminase APOBEC3B to the genetic evolution of breast cancer. First, APOBEC3B was shown to be up-regulated in the majority of breast cancers, and, in breast cancer cell lines, its activity was causally linked to a doubling of the number of C-to-T transitions over time and to a delay in cell cycle progression (1). Second, sequencing of the complete genome of 21 breast cancers independently suggested that APOBEC deaminase activity could be responsible for 2 of 5 mutational imprints identified, which involved clustered (also called kataegis) and dispersed C-to-T transition mutations in the context of 5’TC dinucleotide motifs (2).

In the current study, we addressed a possible association of APOBEC3B expression with outcome in clinical breast cancer. For this we measured using real-time RT-PCR APOBEC3B mRNA levels in 1,491 primary invasive breast cancers and correlated these levels with disease-free survival (DFS), metastasis-free survival (MFS) and overall survival (OS) using univariate and multivariable Cox regression analysis. In addition, we independently validated our findings in available gene expression datasets with appropriate follow-up.

In univariate analyses including all patients, increasing levels of APOBEC3B mRNA analyzed as a continuous variable were significantly associated with shorter DFS, MFS and OS (Hazard Ratio [HR] = 1.29, 1.31 and 1.36, respectively, all P&lt;0.001). To determine the relation of APOBEC3B mRNA expression with the natural course of the disease without the potential confounding effects of systemic adjuvant therapy, we restricted our next analyses to MFS in 829 patients with lymph node-negative disease who had not received any (neo)adjuvant systemic therapy. This analysis showed that APOBEC3B mRNA expression was, in univariate, and in multivariable analysis, including the traditional prognostic factors (age, menopausal status, tumor size, grade and steroid hormone receptors), a marker of pure prognosis specifically in patients with estrogen receptor-positive (ER+) disease (univariate HR = 1.30; P = 0.003; multivariate HR = 1.22, P = 0.042).

To substantiate and validate our findings, we analysed 4 independent available datasets containing in total 5,760 breast cancer cases in which APOBEC3B mRNA expression was measured by probes on microarrays and found that higher APOBEC3B mRNA expression (dichotomised by mean) was significantly associated with poor outcome in all 4 cohorts ([Metabric, 1,491 ER+ cases, HR = 1.82; P&lt;0.001], [Affymetrix compiled dataset-1, 2,407 cases, HR = 2.22; P = 0.001], and [BIG 1-98; 1,207 cases, HR = 2.13; P&lt;0.001 of late recurrence&gt;5 years], and [Affymetrix dataset-2, 643 ER+ cases, HR = 2.04; P = 0.001]).

Altogether, our analyses show that APOBEC3B mRNA - and as a result likely DNA deamination – is a validated predictor of poor outcome in breast cancer, supporting the notion that APOBEC3B is a potentially interesting clinical target for therapeutic intervention to prevent breast cancer progression and metastasis, particularly in ER+ disease.

1. Burns, M.B. et al. Nature 494, 366-70 (2013); 2. Nik-Zainal, S. et al. Cell 149, 979-93 (2012).

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr S6-05.

The incidence of serious eye injury in Scotland: a prospective study

PURPOSE

Ocular trauma remains an important cause of visual morbidity worldwide. A previous population-based study in Scotland reported a 1-year cumulative incidence of 8.14 per 100 000 population. The purpose of this study was to identify any change in the incidence and pattern of serious ocular trauma in Scotland.

METHODS

This study was a 1-year prospective observational study using the British Ophthalmological Surveillance Unit reporting scheme among Scottish ophthalmologists. Serious ocular trauma was defined as requiring hospital admission. Data were collected using two questionnaires for each patient 1 year apart.

RESULTS

The response rate from ophthalmologists was 77.1%. There were 102 patients reported with complete data giving an incidence of 1.96 per 100 000 population, four times less than in 1992. In patients younger than 65 years, the age-adjusted incidence ratio (males/females) indicated a ninefold higher risk of trauma in males. In 25 patients (27.2%), the injured eye was blind (final visual acuities (FVA) <6/60), 24 being attributable to the eye injury. Standardised morbidity ratios suggested a threefold decrease in risk of poor visual outcome in 2009 compared with 1992.

CONCLUSIONS

The incidence of serious ocular trauma has fallen; this study has shown hospital admission for serious eye injury in Scotland has decreased fourfold in 17 years. Young adult males continue to be at highest risk, which needs to be specifically addressed in future health-prevention strategies. This study also observed a reduction in visual loss from serious ocular injuries, although the reasons for this require further exploration.

[Primary interdisciplinary reconstruction of perineal defects to reduce wound complications after abdominoperineal resection]

BACKGROUND

Multimodal treatment options for ultra-low neoplasms of the rectum or anal cancer include chemotherapy, radical abdominoperineal resection and/or radiation. Primary wound closure increases the risk of perineal wound complications that require secondary revision. Perineal wound complications may trigger delay of adjacent tumor therapy and thus have an impact on rate of local recurrence and long-term survival for rectal cancer. Simultaneous primary reconstruction of the perineal defect has been shown to reduce the incidence of perineal wound complications as well as hospital stay which enables timely adjacent therapy and may improve prognosis.

PATIENTS AND METHODS

This study was designed to retrospectively evaluate wound complications after abdominoperineal resection by comparing a group with and one without primary perineal reconstruction. Between 2005 and 2011, patients were analysed and divided into cohorts 1 and 2. Cohort 1 included n = 33 patients without primary perineal reconstruction. Cohort 2 included n = 4 patients with primary perineal reconstruction. Risk factors were identified for increased wound complications and delay of adjacent therapy.

RESULTS

Subgroup analysis revealed that 18 out of 33 patients of cohort 1 had wound complications. In five cases, prolonged wound healing resulted in a delay of adjacent therapies. Four patients suffered from progression of tumour, 2 out of these 4 patients had a history of delayed adjacent therapy. The main risk factor for prolonged wound healing due to postoperative complications was a history of neoadjuvant treatment resulting in a rate of 64.7 %. Cohort 2 undergoing primary reconstruction presented without wound complications or delay in adjuvant therapy.

DISCUSSION

A primary perineal reconstruction after APRE can reduce the rate of perineal wound complications. Furthermore, neoadjuvant treatment was shown to carry a major risk for wound complications. Patients after radio-/chemotherapy should undergo a primary reconstruction to prevent procedure-related perioperative morbidity. Subsequently, delays in adjuvant therapy, and prolonged hospital stay can be inhibited. Moreover, quality of life can be increased. The interdisciplinary approach aims at identifying high-risk patients for perineal wound complications who may benefit from primary reconstruction in order to reduce rate of wound complications with potential impact on rate of local recurrence. All these measures contribute to an optimized surgical standard.

[Laparoscopic splenectomy for sclerosing angiomatoid nodular transformation]

Sclerosing angiomatoid nodular transformation (SANT) is a benign lesion of the spleen which can be cured by splenectomy. In the literature about 45 cases have been reviewed. Although it is defined by the morphological details, data regarding surgical therapy are scarce. To the best of our knowledge, a laparoscopic approach has not been published before. We investigated in one case of SANT the feasibility of a laparoscopic approach. Histological investigations confirmed the diagnosis of a SANT which was resected in toto. This report shows that the laparoscopic splenectomy is a feasible, safe and effective method for treatment of SANT.

Molecular characterisation of formalin-fixed paraffin-embedded (FFPE) breast tumour specimens using a custom 512-gene breast cancer bead array-based platform

Background:

Formalin-fixed, paraffin-embedded (FFPE) tumour tissue represents an immense but mainly untapped resource with respect to molecular profiling. The DASL (cDNA-mediated Annealing, Selection, extension, and Ligation) assay is a recently described, RT–PCR-based, highly multiplexed high-throughput gene expression platform developed by Illumina specifically for fragmented RNA typically obtained from FFPE specimens, which enables expression profiling. In order to extend the utility of the DASL assay for breast cancer, we have custom designed and validated a 512-gene human breast cancer panel.

Methods:

The RNA from FFPE breast tumour specimens were analysed using the DASL assay. Breast cancer subtype was defined from pathology immunohistochemical (IHC) staining. Differentially expressed genes between the IHC-defined subtypes were assessed by prediction analysis of microarrays (PAM) and then used in the analysis of two published data sets with clinical outcome data.

Results:

Gene expression signatures on our custom breast cancer panel were very reproducible between replicates (average Pearson's R²=0.962) and the 152 genes common to both the standard cancer DASL panel (Illumina) and our breast cancer DASL panel were similarly expressed for samples run on both panels (average R²=0.877). Moreover, expression of ESR1, PGR and ERBB2 corresponded well with their respective pathology-defined IHC status. A 30-gene set indicative of IHC-defined breast cancer subtypes was found to segregate samples based on their subtype in our data sets and published data sets. Furthermore, several of these genes were significantly associated with overall survival (OS) and relapse-free survival (RFS) in these previously published data sets, indicating that they are biomarkers of the different breast cancer subtypes and the prognostic outcomes associated with these subtypes.

Conclusion:

We have demonstrated the ability to expression profile degraded RNA transcripts derived from FFPE tissues on the DASL platform. Importantly, we have identified a 30-biomarker gene set that can classify breast cancer into subtypes and have shown that a subset of these markers is prognostic of OS and RFS.

[Protective ileostoma versus protective transverse stoma. What evidence is available?]

The clinical outcome of anastomotic leakage in colorectal and coloanal anastomoses necessitates a loop stoma for fecal diversion. Controversy remains of the most suitable position of the stoma. In this respect a loop ileostomy or loop colostomy can be performed. The aim of this study was to determine the advantages and disadvantages of both surgical strategies from the literature and to derive possible recommendations. Both methods provide a good operative outcome with low complication rates. Overall there is a trend towards ileostomy because of lower complication rates after stoma creation and the incidence of sepsis and stoma prolapse in particular is significantly reduced after ileostomy. Concerning stoma reversal both methods seem to be equivalent. As long as no large evidenced-based, randomized studies are available loop ileostomy seems to be the most appropriate surgical procedure.