A model for fostering community capacity to support adults with intellectual disabilities who engage in challenging behaviour: A scoping review

Developmental support agencies support many adults with intellectual disabilities in the community. Unfortunately, these adults often exhibit high rates of challenging behaviour, which present significant pressures on these service providers. Agencies need to develop effective means of increasing their capacity to provide quality support. Previous systematic reviews found that training staff in positive behaviour supports can improve outcomes; however, the factors facilitating training's effects, long-term effectiveness, and outcomes for service users have yet to be determined. We conducted a scoping review of 98 journal articles and book chapters to develop a model for fostering capacity development drawing from Organizational Behaviour Management and Knowledge Translation theories. Some relevant factors include features of the inner and outer organizational contexts, training approaches (e.g., behavioural skills training & in-situ coaching), ongoing support and feedback. This model may lead to more effective and enduring treatment programs and improved support for adults with intellectual disabilities.

Training programme for community service providers who support adults with intellectual disabilities: A systematic quantitative literature review of single-case research

BACKGROUND

Research on training direct support professionals to address challenging behaviour exhibited by adults with intellectual disabilities is essential in generating effective training approaches for this sector. This systematic review's objective was to evaluate the effects of training types and whether specific training delivery components influenced outcomes.

METHODS

Following PRISMA (2020) guidelines, 16 single-case design studies were included that directly evaluated behaviour change of service providers training for adults with intellectual disabilities in community settings. Study quality was assessed using Horner et al. (Exceptional Children, 2005, 71(2), 165-180) criteria. The database searched included Academic Search Complete, CINAHL, Embase, ERIC, Psych Info, and Web of Science.

RESULTS

Descriptive analysis of effect size outcomes suggested that all training types were associated with improved outcomes. Further, in situ training was associated with improved service provider performance. Interestingly, feedback was associated with poorer service provider performance.

CONCLUSIONS

We provide possible explanations for this surprising outcome and propose future research.

Intraoperative MRI use in transsphenoidal surgery for pituitary tumors: Trends and healthcare utilization

BACKGROUND

Intraoperative magnetic resonance imaging (iMRI) use in transsphenoidal approach (TSA) for pituitary tumors (PTs) has been reported to improve the extent of resection (EOR). The aim of this study is to report the trends and the impact of iMRI on healthcare utilization in patients who underwent TSA for PTs.

MATERIALS AND METHODS

MarketScan database were queried using the ICD-9/10 and CPT-4, from 2004 to 2020. We included patients ≥ 18 years of age PTs with > 1 year follow-up. Outcomes were length of stay (LOS), discharge disposition, hospital/emergency room (ER) re-admissions, outpatient services, medication refills and corresponding payments.

RESULTS

A cohort of 10,192 patients were identified from the database, of these 141 patients (1.4%) had iMRI used during the procedure. Use of iMRI for PTs remained stable (2004-2007: 0.85%; 2008-2011: 1.6%; 2012-2015:1.4% and 2016-2019: 1.46%). No differences in LOS (median 3 days each), discharge to home (93% vs. 94%), complication rates (7% vs. 13%) and payments ($34604 vs. $33050) at index hospitalization were noted. Post-discharge payments were not significantly different without and with iMRI use at 6-months ($8315 vs. $ 7577, p = 0.7) and 1-year ($13,654 vs. $ 14,054, p = 0.70), following the index procedure.

CONCLUSION

iMRI use during TSA for PTs remained stable with no impact on LOS, complications, discharge disposition and index payments. Also, there was no difference in combined index payments at 6-months, and 1-year after the index procedure in patients with and without iMRI use for PTs.

Female sexual health digital resources: women and health care providers need more options

INTRODUCTION

Female sexual health and female sexual dysfunction (FSD) are usually poorly diagnosed and treated because of the numerous barriers providers and patients face. Internet platforms, such as mobile applications (apps) are potential tools that help overcome these barriers and improve patient access to education and management options for FSD.

OBJECTIVES

The aim of this review was to identify existing applications on female sexual health and evaluate their educational content and services.

METHODS

We searched the internet and Apple App Store using multiple keywords. A panel of physicians specialized in the treatment of FSD reviewed the apps for content quality, the scientific basis of provided information, interactivity, usability, and whether they would recommend it as a reference tool for patients.

RESULTS

Of the 204 apps identified, 17 met the inclusion criteria and were reviewed further. The selected apps were organized into groups based on common themes such as educational (n = 6), emotions and communication (n = 2), relaxation and meditation (n = 4), general sexual health (n = 2), and social and fun (n = 3). All apps from the educational category provided scientific information in collaboration with health experts. When assessed for usability, 1 app received good and 5 received excellent scores based on the System Usability Scale. Most apps (n = 5) provided information on pathology and treatments of orgasmic dysfunction, but only 1 app, created by a physician, provided comprehensive information on all the types of FSD.

CONCLUSION

Digital technology could be an effective way to overcome barriers to accessing information and ultimately care for female sexual health. Our review demonstrated that there is still a need for more accessible educational resources addressing female sexual health and FSD for patients and providers.

Is it time for doctors to Rx vibrators? A systematic review of pelvic floor outcomes

Introduction

Vibrators and similar devices are an underutilized treatment modality in pelvic and sexual medicine, likely because of the limited knowledge on the health benefits of their use.

Objectives

The aim of this study was to review available data regarding the effect of vibrator use on sexual function, pelvic floor function, and chronic unexplained vulvar pain.

Methods

We performed a systematic literature review of PubMed, Embase, and MEDLINE from inception to March 2021 per the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). The search was based on the following keywords: sex toy woman, pelvic vibrator, sexual stimulation vibrator, vaginal vibrator, vibrator pelvic floor, vibrator incontinence, and vulvar pain vibrator. An overall 586 articles were identified. Studies that met inclusion criteria were reviewed: original research, sample of women, vibrator use, and application to the pelvic/genital area. Exclusion criteria included case reports, unrelated content, vibrator not applied to the pelvic/genital area, male participants, or conditions of interest not addressed. A total of 17 original studies met the criteria and were reviewed in depth.

Results

After review of the literature and identification of articles appropriate for the study, there were 8 studies surrounding sexual function, 8 on pelvic floor function (muscle strength/urinary incontinence), and 1 on vulvar pain. Among the identified studies, vibrators were considered an accepted modality to enhance a woman’s sexual experience, improve pelvic floor muscle function, and facilitate treatment of vulvar pain.

Conclusions

Vibrators are not well studied, and given the promising benefits demonstrated in the articles identified, future research efforts should be directed toward investigating their utility. Considering the potential pelvic health benefits of vibrators, their recommendation to women could be included in our pelvic floor disorder treatment armamentarium.

Trends and Outcomes in Patients with Dementia Undergoing Spine Fusions: A Matched Nationwide Inpatient Sample Analysis

BACKGROUND

The aim of our study was to define the trends and outcomes in patients with a preexisting diagnosis of dementia who underwent spine fusions using a large national database.

METHODS

The Nationwide Inpatient Sample database was queried using the International Classification of Diseases, Ninth Revision and Tenth Revision, from 1998 to 2018. We included patients who underwent spine fusions with or without the diagnosis of dementia. Outcomes were trends, complications, length of stay (LOS), discharge disposition, and mortality.

RESULTS

A cohort of 4495 patients (N = 1,390,657; 0.32%) with dementia who underwent spine fusions was identified. There was an increasing trend of spine fusions in patients with the diagnosis of dementia. Most patients with dementia were white (77% vs. 69%), with ≥3 comorbidities (70% vs. 23%), had Medicare insurance (83% vs. 34%) compared with patients without dementia (P < 0.0001). Overall, 38% of patients had complications after spine fusions compared with 21% of patients without dementia during the study period. Median LOS was significantly longer in patients with dementia compared with patients without dementia (6 vs. 4 days). Patients with dementia were less likely to be discharged home (19% vs. 40%) and incurred higher in-hospitalization charges ($139,101 vs. $101,629) compared with patients without dementia. No differences in terms of in-hospital mortality were noted across the cohorts (1.4% vs. 1.6%).

CONCLUSIONS

Patients with dementia had 1.5 times longer LOS and 1.4 times higher index hospitalization charges and were 2.5 times more likely to have complications and 71% less likely to be discharged home, with no difference in mortality compared with patients without dementia after spine fusions.

Causes of loss to follow-up from drug-resistant TB treatment in Khayelitsha, South Africa

Patients initiated on drug-resistant TB(DR-TB) treatment in 2019 in Khayelitsha, South Africa, with a loss to follow-up outcome were evaluated to better understand reasons for loss to follow-up and to determine if any had returned to care. Of a total of 187 patients, 28 (15%) were lost to follow-up (LTFU), 24 (86%) of whom were traced: 20/24 (83%) were found when they re-presented to facilities and 8/28 (29%) were linked back to DR-TB care. People with DR-TB continue to seek care even after being LTFU; thus better coordination between different components of the healthcare system are required to re-engage with these patients. Interventions to mitigate the socio-economic challenges of people on DR-TB treatment are needed. Many people who were LTFU and symptomatic were willing to re-engage with DR-TB care, which highlights the importance of for compassionate interventions to welcome them back.

Construct validation of a 3D printed neonatal thoracoscopic simulator: Can it measure expertise?

BACKGROUND

acquiring technical expertise for neonatal thoracoscopy is challenging. To address this, we designed a fully synthetic thoracoscopic simulator for which we established its construct validity.

METHODS

three thoracoscopic tasks were assessed: ring transfer, needle pass and incision of a blind upper esophageal pouch (EA cut). Participants watched instructional videos with accompanying written instructions for each task before having their attempt video recorded. All tasks were marked by three blinded pediatric surgeons using a modified Objective Structured Assessment of Technical Skills (OSATS). Scores were assessed using appropriate statistical analysis and inter-rater reliability was analyzed by interclass correlation coefficient (ICC).

RESULTS

23 participants completed the ring transfer and needle pass and 21 the EA cut: 5 experts (consultant surgeons), 5 intermediate (registrars on a training program) and 13 novices (medical students, house surgeons or non-training registrars). All three tasks distinguished between novice and intermediate/expert (ring transfer p = 0.00001, needle pass p = 0.0004 and EA cut p = 0.0014, respectively). Interrater reliability was good for ring transfer and needle pass but poor for EA cut.

CONCLUSION

the tasks distinguished between novice and intermediate/expert but not between expert and intermediate. In needle pass and EA cut, there was a trend for the experts to score higher than intermediate participants. Ring transfer and needle pass tasks achieved construct validity, had good interrater reliability and were found to be useful in assessing a novice surgeon's progression towards the intermediate level. Distinguishing between intermediate and expert may require assessment of more complex tasks such as intracorporeal suturing and tying.

LEVEL OF EVIDENCE

II.

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

BACKGROUND

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

OBJECTIVE

The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

STUDY DESIGN

This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

CONCLUSION

Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

R = MC2 readiness building process: A practical approach to support implementation in local, state, and national settings

Effective implementation of evidence-based interventions is a persistent challenge across community settings. Organizational readiness - or, the motivation and collective capacity of an entity to adopt and sustain an innovation - is important to facilitate implementation. Drawing on the R = MC² readiness framework, we developed a readiness building process to tailor support for implementation. The process is composed of the following stages: assessment, feedback and prioritization, and strategize. In this article, we describe the application of the readiness building process through three case examples representing interventions at different ecological levels: local, state, and national. The case examples illuminate challenges and practical considerations for using the readiness building process, including the significance of on-going leadership engagement and collaboration between support system and delivery system staff. To further the research and practice of implementation readiness, we suggest examining the impact of readiness building on implementation outcomes and developing an empirically-informed repository of change management strategies matched to readiness constructs.

Mucocele-like lesions of the breast - A radiological and clinicopathological analysis

INTRODUCTION

Mucocele-like lesions (MLL) of the breast are rare entities which are considered to harbor uncertain malignant potential. Current UK guidelines recommend vacuum assisted excision (VAE) of all such lesions regardless of whether they display epithelial atypia. This study sought to review the key histological and radiological features of MLLs and compare their differing outcomes based on the presence of epithelial atypia.

METHODS

Pathology records of a single breast cancer screening center were retrospectively searched for all biopsy diagnosed MLLs over an 11-year period. Upgrade rates to malignancy (positive predictive values) were calculated by reviewing histology from the initial core biopsy and comparing with the corresponding excision specimen. Radiological images were simultaneously reviewed to provide radiological-pathological correlation.

RESULTS

Three of 11 patients (27.3%) with atypical MLLs on biopsy had malignant outcomes at excision, compared with only 1 of 36 patients (2.8%) with non-atypical MLLs. The majority of MLLs (93%) were identified as microcalcifications on mammographic imaging. No specific radiological features were predictive of malignancy.

CONCLUSIONS

Our data suggest that MLLs without atypia are potentially overtreated with current protocols and could be managed conservatively with radiological follow up. Radiological-pathological correlation is essential.

Impact of Pharmacy-Led Education Regarding Multimodal Acute Pain Management on Medical Residents’ Prescribing of Opioids

Background:

Opioids are commonly prescribed for patients with acute pain. Guidelines recommend multimodal regimens to synergistically treat pain and provide enhanced recovery.

Objective:

The objective of this study was to assess changes in oral morphine milligram equivalents (MMEs) prescribed by internal medicine (IM) medical residents for acute pain after a series of pharmacist-led in-services on prescribing multimodal pain regimens.

Methods:

Two hundred patients were assessed for changes in oral MMEs prescribed prior to and after a 3-part in-service series on multimodal pain management. Inclusion criteria included those who were admitted with acute pain managed by an IM resident, were prescribed analgesic(s), and were 18 years and older. Patients excluded were those admitted into the intensive care unit, receiving chronic pain management, obstetric patients, cancer patients, patients with previous opioid exposure, and patients using patient-controlled analgesia. The study outcomes were change in oral MMEs prescribed by medical residents for acute pain after the in-services, multimodal regimen use, appropriate analgesics prescribed, prescribing a bowel regimen if the patient was prescribed an opioid, and prescribers’ survey results.

Results:

A total of 6358.6 oral MMEs were prescribed before and 5297 oral MMEs were prescribed after the in-services. Fifty-eight patients before and 70 patients after the in-services were prescribed a multimodal regimen. Ten patients before and 18 patients after the in-services were given a bowel regimen. Eighty percent of the patients before and 85% after the in-services had an appropriate pain scale for their prescriptions. IM medical resident and student survey scores improved after each in-service.

Conclusion:

An educational series on multimodal regimens for acute pain management decreased opioid prescription and increased the use of multimodal regimens for acute pain.

An Adjusted Ideal Body Weight Index Formula With Fresh Frozen Plasma (FFP) Rescue Decreases Fluid Creep During Burn Resuscitation

Severe burn injury requires significant volume resuscitation, but over-resuscitation can be deadly. Accurate resuscitation of obese patients is challenging due to the decreased vascularity of adipose tissue. This study compares an adjusted ideal body weight index formula with fresh frozen plasma rescue to historical controls resuscitated with Parkland-based resuscitation. A retrospective review was conducted of adult patients admitted to our regional burn center with ≥ 20% total body surface area (TBSA) burns from 2010 to 2017 who survived more than 48 hours. Historical controls were resuscitated with Parkland-based resuscitation with occasional albumin. The adjusted ideal body weight (AIBW) patients were resuscitated with 2-4 mL/kg/%TBSA using an adjusted ideal body weight with fresh frozen plasma (FFP) rescue. Outcomes were compared with nonparametric statistics. A total of 161 patients met inclusion criteria: 40 patients received AIBW resuscitation and 121 patients were included as controls. The AIBW group received less fluid (3.30 vs. 4.15 mL/kg/%TBSA, p<0.001). A significant reduction in acute kidney injury requiring dialysis in the AIBW group was appreciated (5% vs. 19%, p=0.03) with improved mortality in AIBW patients as well (5% vs. 20%, p=0.03). Using an adjusted ideal body weight with FFP rescue to resuscitate patients with severe burn injury leads to a significant reduction in fluid administration without increase in acute kidney injury requiring dialysis and with improved mortality.

Modulation of Rb phosphorylation and antiproliferative response to palbociclib: the preoperative-palbociclib (POP) randomized clinical trial

Background

The cyclin-dependent kinase 4 (CDK4)/6 inhibitor Palbociclib is a new standard treatment in hormone-receptor positive breast cancer patients. No predictive biomarkers have been identified and no pharmacodynamics has properly been described so far.

Patients and methods

Patients with early-breast cancer were randomized 3 : 1 to oral palbociclib 125 mg daily for 14 days until the day before the surgery versus no treatment. Primary objective was antiproliferative response defined as a natural logarithm of Ki67 expression at day 15 below 1. Secondary end points were subgroups analyses and safety. Exploratory analyses included search for predictive biomarkers. Immunostainings (Ki67, RB, pRB, p16, pAKT, pER, pCDK2, CyclinD1), FISH (CCND1) and gene expression (GE) arrays were carried out at baseline and at surgery. In addition, activating PIK3CA and AKT1 mutations were assessed at baseline.

Results

74 patients were allocated to palbociclib and 26 to control. Most patients (93%) were hormone-receptor (HR)-positive, whereas 8% were HER2-positive. Palbociclib led to significantly more antiproliferative responses when compared with control (58% versus 12%, P < 0.001), and to a significantly higher Ki67 decrease (P < 0.001). In the HR-positive/HER2-negative subgroup, this antiproliferative effect was even more marked in the palbociclib arm when compared with control (70% versus 9%, P < 0.001). Palbociclib treatment led also to a significantly higher decrease from baseline in phospho-Rb when compared with control (P < 0.001). Among treated patients, changes in Ki67 correlated with changes in phospho-Rb (Spearman rank r = 0.41, P < 0.0001). GE analyses confirmed a major effect on proliferation and cell cycle genes. Among treated patients, CCNE2 expression was significantly more decreased in antiproliferative responders versus nonresponders (P = 0.006).

Conclusion

Short-term preoperative palbociclib decreases Ki67 in early-breast cancer patients. Early decrease of Rb phosphorylation correlates with drug's effect on cell proliferation and could potentially identify patients with primary resistance.

Clinical trial registration

NCT02008734.

Using Collaborative Coalition Processes to Advance Community Health, Well-Being, and Equity: A Multiple-Case Study Analysis From a National Community Transformation Initiative

Spreading Community Accelerators Through Learning and Evaluation (SCALE) was a Robert Wood Johnson Foundation-funded initiative from 2015 to 2017 to build capability of 24 community coalitions to advance health, well-being, and equity. The SCALE theory of change had three components: develop leadership capability, build relationships within and between communities, and create an intercommunity system to spread promising ideas. The theory was operationalized through training academies, coaching, and peer-to-peer learning that explicitly addressed equity and systems change. In this article, we describe how SCALE facilitated community transformation related to Collaborating for Equity and Justice Principles 1, 3, 4, and 6. We conducted a multiple-case study approach with two community coalitions including site visits, interviews, and observation to illuminate underlying mechanisms of change by exploring how and why change occurs. Skid Row Women worked with women experiencing homelessness in Los Angeles to address diabetes and food systems. Healthy Livable Communities of Cattaraugus County used a portfolio of projects in order to create system changes to improve population health and increase access to services for people with disabilities in rural New York State. Through our analysis, we describe how two coalitions used SCALE tools for collaborative coalition processes such as aim setting, relationship building, and shared decision making with community residents. Our findings suggest that advancing Collaborating for Equity and Justice principles requires self-reflection and courage; new ways of being in relationship; learning from failure; productive conflict to explicitly address power, racism, and other forms of oppression; and methods to test systems improvement ideas.

Neonatal outcomes of elective early-term births after demonstrated fetal lung maturity

BACKGROUND

Studies of early-term birth after demonstrated fetal lung maturity show that respiratory and other outcomes are worse with early-term birth (37⁰-38⁶ weeks) even after demonstrated fetal lung maturity when compared with full-term birth (39⁰-40⁶ weeks). However, these studies included medically indicated births and are therefore potentially limited by confounding by the indication for delivery. Thus, the increase in adverse outcomes might be due to the indication for early-term birth rather than the early-term birth itself.

OBJECTIVE

We examined the prevalence and risks of adverse neonatal outcomes associated with early-term birth after confirmed fetal lung maturity as compared with full-term birth in the absence of indications for early delivery.

STUDY DESIGN

This is a secondary analysis of an observational study of births to 115,502 women in 25 hospitals in the United States from 2008 through 2011. Singleton nonanomalous births at 37-40 weeks with no identifiable indication for delivery were included; early-term births after positive fetal lung maturity testing were compared with full-term births. The primary outcome was a composite of death, ventilator for ≥2 days, continuous positive airway pressure, proven sepsis, pneumonia or meningitis, treated hypoglycemia, hyperbilirubinemia (phototherapy), and 5-minute Apgar <7. Logistic regression and propensity score matching (both 1:1 and 1:2) were used.

RESULTS

In all, 48,137 births met inclusion criteria; the prevalence of fetal lung maturity testing in the absence of medical or obstetric indications for early delivery was 0.52% (n = 249). There were 180 (0.37%) early-term births after confirmed pulmonary maturity and 47,957 full-term births. Women in the former group were more likely to be non-Hispanic white, smoke, have received antenatal steroids, have induction, and have a cesarean. Risks of the composite (16.1% vs 5.4%; adjusted odds ratio, 3.2; 95% confidence interval, 2.1-4.8 from logistic regression) were more frequent with elective early-term birth. Propensity scores matching confirmed the increased primary composite in elective early-term births: adjusted odds ratios, 4.3 (95% confidence interval, 1.8-10.5) for 1:1 and 3.5 (95% confidence interval, 1.8-6.5) for 1:2 matching. Among components of the primary outcome, CPAP use and hyperbilirubinemia requiring phototherapy were significantly increased. Transient tachypnea of the newborn, neonatal intensive care unit admission, and prolonged neonatal intensive care unit stay (>2 days) were also increased with early-term birth.

CONCLUSION

Even with confirmed pulmonary maturity, early-term birth in the absence of medical or obstetric indications is associated with worse neonatal respiratory and hepatic outcomes compared with full-term birth, suggesting relative immaturity of these organ systems in early-term births.

Abstract PD4-10: FGFR1 / ZNF217 copy numbers and outcome in patients with node positive, HR+/Her2- early breast cancer: A genomic analysis of PACS04 trial

Purpose: There is a need to identify which patients present a high risk of relapse after optimal adjuvant therapies, in order to better define which population of early breast cancer patients is eligible to new drugs. Previous studies have shown that gene copy numbers drive breast cancer progression. In the BIG1-98 trial, FGFR1 (8p11) and ZNF217 (20q13) amplifications were associated with poor outcome in patients with HR+/Her2- early breast cancers. In the present study, we aim to validate these findings using retrospective analysis of samples prospectively collected in a randomized trial (PACS04).

Patients and methods: Tumor DNA was extracted from FFPE samples obtained from patients included in PACS04 trial. This trial compared FEC to ED75 in patients with node positive, early breast cancer and included 3000 patients between 2001 and 2004. The biomarker study focuses on HR+/Her2- breast cancer. 500 samples were collected and hybridization was performed on 390. DNA copy numbers were assessed on 900 genes using Oncoscan FFPE assay kit. Prognostic value of FGFR1 (8p11) and ZNF217 (20q13) copy numbers was assessed in a Cox model that included prognostic parameters. Prognostic value was assessed using CNA as continuous variable, and with a predefined cut-off (CN&gt;=3). Metastases-free survival (MFS) was chosen as endpoint for this biomarker study.

Results: Tumor copy numbers alterations were obtained in 390 patients with HR+/Her2-, node positive, early breast cancer. 31% of the patients presented more than 3 lymph node involved, and 25% a poorly differenciated tumor. The median tumor size was 20 mm. 120 (30%) and 112 (28%) patients presented FGFR1 and/or ZNF217 gene gain with a cut-off for amplification predefined at 3 copies. When assessed as continuous variable, FGFR1 (HR: 1.02, 95%CI:1.007-1.04, p=0.0045) and ZNF217 (HR: 1.011, 95%CI:1.003-1.01, p=0.006) copy numbers were associated with MFS. The 10 years MFS rates were 68% (95%CI: 59-78%) and 85% (95%CI: 81-91%) in patients with FGFR1-gained and FGFR1-normal tumors respectively (HR: 2.51, 95%CI:1.56-4.01, p=0.0001). The 10 years MFS rates were 72% (95%CI:65%-83%) and 83% (95%CI: 77-87%) in patients with ZNF217-gained and ZNF217-normal tumors (HR: 1.79, 95%CI:1.12-2.86, p=0.013). In a multivariate analysis, FGFR1-gain (HR: 2.45, 95%CI:1.42-4.22, p=0.0012) and ZNF217-gain (HR:1.78, 95%CI:1.00-3.17, p=0.049) were associated with a higher likelihood of metastases and/or death. The 10 MFS rate was 88% (95%CI: 83-94%) for patients who presented FGFR1- and ZNF217-normal tumor (n=191), and 71% (95%CI: 66-76%) in patients presenting FGFR1 and/or ZNF217 gene gain.

Conclusion: Using samples prospectively collected in a randomized trial, this study validates the prognostic value of FGFR1- and ZNF217- copy numbers in patients who present HR+/Her2- early breast cancer. Exploratory analyses on copy number alterations, together with targeted sequencing are ongoing and will be presented.

Citation Format: Andre F, Penault Llorca F, Carene D, Roche H, Delaloge S, Lacroix L, Scott V, Richon C, Lacroix-Ticrit M, Lemonnier J, Michiels S. FGFR1 / ZNF217 copy numbers and outcome in patients with node positive, HR+/Her2- early breast cancer: A genomic analysis of PACS04 trial [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 PD4-10.

Quantitative ligand and receptor binding studies reveal the mechanism of interleukin-36 (IL-36) pathway activation

IL-36 cytokines signal through the IL-36 receptor (IL-36R) and a shared subunit, IL-1RAcP (IL-1 receptor accessory protein). The activation mechanism for the IL-36 pathway is proposed to be similar to that of IL-1 in that an IL-36R agonist (IL-36α, IL-36β, or IL-36γ) forms a binary complex with IL-36R, which then recruits IL-1RAcP. Recent studies have shown that IL-36R interacts with IL-1RAcP even in the absence of an agonist. To elucidate the IL-36 activation mechanism, we considered all possible binding events for IL-36 ligands/receptors and examined these events in direct binding assays. Our results indicated that the agonists bind the IL-36R extracellular domain with micromolar affinity but do not detectably bind IL-1RAcP. Using surface plasmon resonance (SPR), we found that IL-1RAcP also does not bind IL-36R when no agonist is present. In the presence of IL-36α, however, IL-1RAcP bound IL-36R strongly. These results suggested that the main pathway to the IL-36R·IL-36α·IL-1RAcP ternary complex is through the IL-36R·IL-36α binary complex, which recruits IL-1RAcP. We could not measure the binding affinity of IL-36R to IL-1RAcP directly, so we engineered a fragment crystallizable-linked construct to induce IL-36R·IL-1RAcP heterodimerization and predicted the binding affinity during a complete thermodynamic cycle to be 74 μm The SPR analysis also indicated that the IL-36R antagonist IL-36Ra binds IL-36R with higher affinity and a much slower off rate than the IL-36R agonists, shedding light on IL-36 pathway inhibition. Our results reveal the landscape of IL-36 ligand and receptor interactions, improving our understanding of IL-36 pathway activation and inhibition.

A novel role for ceramide synthase 6 in mouse and human alcoholic steatosis

Perilipin 2 (PLIN2) is a lipid-droplet protein that is up-regulated in alcoholic steatosis and associated with hepatic accumulation of ceramides, bioactive lipids implicated in alcoholic liver disease pathogenesis. The specific role of ceramide synthetic enzymes in the regulation of PLIN2 and promotion of hepatocellular lipid accumulation is not well understood. We examined the effects of pharmacologic ceramide synthesis inhibition on hepatic PLIN2 expression, steatosis, and glucose and lipid homeostasis in mice with alcoholic steatosis and in ethanol-incubated human hepatoma VL17A cells. In cells, pharmacologic inhibition of ceramide synthase reduced lipid accumulation by reducing PLIN2 RNA stability. The subtype ceramide synthase (CerS)6 was specifically up-regulated in experimental alcoholic steatosis in vivo and in vitro and was up-regulated in zone 3 hepatocytes in human alcoholic steatosis. In vivo ceramide reduction by inhibition of de novo ceramide synthesis reduced PLIN2 and hepatic steatosis in alcohol-fed mice, but only de novo synthesis inhibition, not sphingomyelin hydrolysis, improved glucose tolerance and dyslipidemia. These findings implicate CerS6 as a novel regulator of PLIN2 and suggest that ceramide synthetic enzymes may promote the earliest stage of alcoholic liver disease, alcoholic steatosis.-Williams, B., Correnti, J., Oranu, A., Lin, A., Scott, V., Annoh, M., Beck, J., Furth, E., Mitchell, V., Senkal, C. E., Obeid, L., Carr, R. M. A novel role for ceramide synthase 6 in mouse and human alcoholic steatosis.

Macrophages play a pathogenic role in IL-23 mediated psoriasiform skin inflammation

Psoriasis (Ps) is an immune-mediated inflammatory skin disease that affects millions worldwide. Studying immune cells involved in Ps pathogenesis is essential to identify effective and safe therapeutics for the disease. Recent studies have demonstrated the involvement of macrophages in human Ps skin. Using an IL-23 murine model of psoriasiform dermatitis, which closely models human Ps, we have characterized the cellular lineage during disease progression and found continuous infiltration of macrophage as dominant immune population. Depletion of macrophages in the IL-23 murine model significantly reduced the inflammation as well as inflammatory mediators, such as TNFa, in the skin. This strongly suggests a pathogenic role of macrophages in the psoriasiform skin inflammation. Further characterization of this model revealed a number of phenotypically distinct macrophage populations suggesting they may play different roles in disease progression. Collectively, our data suggests that targeting macrophages may have therapeutic benefit for Ps patients.

IL-23 mediated skin inflammation is dependent on the expansion and function of RORγt expressing cells

While playing an important role in host defense against extracellular pathogens, the IL-23/IL-17 axis is inherently linked to autoimmune disease. Biologic therapies have been developed that target the p19 subunit of IL-23 and IL-17A or IL-17R; and show remarkable efficacy against a range of autoimmune conditions including Psoriasis (PsO). Despite this clinical validation, the cellular pathways induced by IL-23 remain poorly defined. In order to better understand the role of RORγt in this pathway, we administered a potent and selective inhibitor of RORγt in a model of IL-23 mediated skin inflammation, which closely models human PsO. Looking specifically at skin, to differentiate from previous studies, we show that the accumulation of RORγt expressing cells is an early event following exogenous IL-23 exposure. Expansion of these RORγt expressing cells paralleled disease progression (inflammation) with both αβ and γδ T cells contributing to this population. Inhibition of RORγt with a novel small molecule inverse agonist significantly attenuated ear inflammation and histological endpoints related to human PsO. Furthermore, use of this compound attenuated both the accumulation of RORγt positive cells and their effector function (IL-17A production). Finally, inhibition of RORγt had profound downstream consequences, leading to significant recovery of keratinocyte dysregulation and normalization of anti-microbial gene expression. Collectively our studies confirm that RORγt expressing cells are an early feature of IL-23 mediated skin inflammation, reside predominantly in the T cell compartment, and play an active role in keratinocyte biology and disease pathology.

Prolactin regulation of oxytocin neurone activity in pregnancy and lactation

KEY POINTS

During lactation, prolactin promotes milk synthesis and oxytocin stimulates milk ejection. In virgin rats, prolactin inhibits the activity of oxytocin-secreting neurones. We found that prolactin inhibition of oxytocin neurone activity is lost in lactation, and that some oxytocin neurones were excited by prolactin in lactating rats. The change in prolactin regulation of oxytocin neurone activity was not associated with a change in activation of intracellular signalling pathways known to couple to prolactin receptors. The change in prolactin regulation of oxytocin neurone activity in lactation might allow coordinated activation of both populations of neurones when required for successful lactation.

ABSTRACT

Secretion of prolactin for milk synthesis and oxytocin for milk secretion is required for successful lactation. In virgin rats, prolactin inhibits oxytocin neurones but this effect would be counterproductive during lactation when secretion of both hormones is required for synthesis and delivery of milk to the newborn. Hence, we determined the effects of intracerebroventricular (i.c.v.) prolactin on oxytocin neurones in urethane-anaesthetised virgin, pregnant and lactating rats. Prolactin (2 μg) consistently inhibited oxytocin neurones in virgin and pregnant rats (by 1.9 ± 0.4 and 1.8 ± 0.5 spikes s^-1 , respectively), but not in lactating rats; indeed, prolactin excited six of 27 oxytocin neurones by >1 spike s^-1 in lactating rats but excited none in virgin or pregnant rats (χ²₂  = 7.2, P = 0.03). Vasopressin neurones were unaffected by prolactin (2 μg) in virgin rats but were inhibited by 1.1 ± 0.2 spikes s^-1 in lactating rats. Immunohistochemistry showed that i.c.v. prolactin increased oxytocin expression in virgin and lactating rats and increased signal transducer and activator of transcription 5 phosphorylation to a similar extent in oxytocin neurones of virgin and lactating rats. Western blotting showed that i.c.v. prolactin did not affect phosphorylation of extracellular regulated kinase 1 or 2, or of Akt in the supraoptic or paraventricular nuclei of virgin or lactating rats. Hence, prolactin inhibition of oxytocin neurones is lost in lactation, which might allow concurrent elevation of prolactin secretion from the pituitary gland and activation of oxytocin neurones for synthesis and delivery of milk to the newborn.

Development of an excitatory kisspeptin projection to the oxytocin system in late pregnancy

KEY POINTS

Oxytocin release from the posterior pituitary gland stimulates uterine contraction during birth but the central mechanisms that activate oxytocin neurones for birth are not well characterized. We found that that kisspeptin fibre density around oxytocin neurones increases in late-pregnant rats. These kisspeptin fibres originated from hypothalamic periventricular nucleus neurones that upregulated kisspeptin expression in late pregnancy. Oxytocin neurones were excited by central kisspeptin administration in late-pregnant rats but not in non-pregnant rats or early- to mid-pregnant rats. Our results reveal the emergence of a new excitatory kisspeptin projection to the oxytocin system in late pregnancy that might contribute to oxytocin neurone activation for birth.

ABSTRACT

The hormone oxytocin promotes uterine contraction during parturition. Oxytocin is synthesized by magnocellular neurones in the hypothalamic supraoptic and paraventricular nuclei and is released into the circulation from the posterior pituitary gland in response to action potential firing. Systemic kisspeptin administration increases oxytocin neurone activity to elevate plasma oxytocin levels. Here, immunohistochemistry revealed that rats on the expected day of parturition (day 21 of gestation) had a higher density of kisspeptin-positive fibres in the perinuclear zone surrounding the supraoptic nucleus (which provides dense glutamatergic and GABAergic innervation to the supraoptic nucleus) than was evident in non-pregnant rats. Retrograde tracing showed the kisspeptin projections to the perinuclear zone originated from the hypothalamic periventricular nucleus. Quantitative RT-PCR showed that kisspeptin receptor mRNA, Kiss1R mRNA, was expressed in the perinuclear zone-supraoptic nucleus and that the relative Kiss1R mRNA expression does not change over the course of pregnancy. Finally, intracerebroventricular administration of kisspeptin increased the firing rate of oxytocin neurones in anaesthetized late-pregnant rats (days 18-21 of gestation) but not in non-pregnant rats, or in early- or mid-pregnant rats. Taken together, these results suggest that kisspeptin expression is upregulated in the periventricular nucleus projection to the perinuclear zone of the supraoptic nucleus towards the end of pregnancy. Hence, this input might activate oxytocin neurones during parturition.

A formative multi-method approach to evaluating training

This article describes how we used a formative multi-method evaluation approach to gather real-time information about the processes of a complex, multi-day training with 24 community coalitions in the United States. The evaluation team used seven distinct, evaluation strategies to obtain evaluation data from the first Community Health Improvement Leadership Academy (CHILA) within a three-prong framework (inquiry, observation, and reflection). These methods included: comprehensive survey, rapid feedback form, learning wall, observational form, team debrief, social network analysis and critical moments reflection. The seven distinct methods allowed for both real time quality improvement during the CHILA and long term planning for the next CHILA. The methods also gave a comprehensive picture of the CHILA, which when synthesized allowed the evaluation team to assess the effectiveness of a training designed to tap into natural community strengths and accelerate health improvement. We hope that these formative evaluation methods can continue to be refined and used by others to evaluate training.

BIRC5 (survivin): a pejorative prognostic marker in stage II/III breast cancer with no response to neoadjuvant chemotherapy

PURPOSE

Neoadjuvant systemic therapy (NAC) is currently used in the treatment of stage II/III breast cancer. Pathological complete response as a surrogate endpoint for clinical outcomes is not completely validated for all subgroups of breast cancers. Therefore, there is a need for reliable predictive tests of the most effective treatment.

METHODS

We used a combination of predictive clinical, pathological, and gene expression-based markers of response to NAC in a prospective phase II multicentre randomized clinical trial in breast cancer patients, with a long follow-up (8 years). This study concerned the subpopulation of 188 patients with similar levels of pathological response rates to sequential epirubicin/cyclophosphamide and docetaxel to determine predictive marker of pCR and DFS. We used a set of 45 genes selected from high throughput analysis and a standardized RT-qPCR. We analyzed the predictive markers of pathological complete response (pCR) and DFS in the overall population and DFS the subpopulation of 159 patients with no pCR.

RESULTS

In the overall population, combining both clinical and genomic variables, large tumor size, low TFF1, and MYBL2 overexpression were significantly associated with pCR. T4 Stage, lymphovascular invasion, negative PR status, histological type, and high values of CCNB1 were associated with DFS. In the no pCR population, only lymphovascular invasion and high values of BIRC5 were associated with DFS.

CONCLUSIONS

We confirm the importance of ER-related and proliferation genes in the prediction of pCR in NAC-treated breast cancer patients. Furthermore, we identified BIRC5 (survivin) as a main pejorative prognostic factor in patients with breast cancers with no pCR. These results also open perspective for predictive markers of new targeted therapies.