Unilateral tonsil enlargement in children and adults: is routine histology tonsillectomy warranted? A multi-centre series of 323 patients

BACKGROUND

This study aimed to establish whether histology tonsillectomy is justified for unilateral tonsil enlargement.

METHODS

A retrospective review was conducted of histology tonsillectomies in three health organisations over five years, with strict exclusion criteria, focusing on benign-appearing unilateral tonsil enlargement.

RESULTS

Ninety paediatric and 233 adult cases were included. No paediatric cases and five adult cases of malignancy were detected. All malignant cases presented with other symptoms. Using binary logistic regression, a history of rapid unilateral tonsil enlargement was the only factor found to be significantly associated with malignant outcome. Thirty-three per cent of subjectively larger tonsils were smaller on post-operative histological measurement. Of the cases, 12.1 per cent re-presented with post-tonsillectomy bleeding.

CONCLUSION

The authors recommend avoiding histology tonsillectomy for unilateral tonsil enlargement unless 'red flag' signs of malignancy are present, with particular attention to rapid unilateral tonsil enlargement. This study demonstrated discrepancy between clinical examination findings and true tonsil asymmetry; there may be a role for cross-sectional imaging prior to histology tonsillectomy in high-risk patients.

The financial and quality of life impact of urgent dental presentations: A cross-sectional study

AIM

This study aimed to: (i) calculate personal financial costs associated with urgent dental attendance; and (ii) investigate the pain-related disability and quality of life impact of dental conditions which result in urgent dental attendance.

METHODOLOGY

Data were collected from those presenting with urgent dental conditions to an out-of-hours dental service, a dental emergency clinic and five primary care general dental practices across North-East England. A pre-operative questionnaire explored the impact of urgent dental conditions on oral health-related quality of life (OHRQoL) using Oral Health Impact Profile-14 (OHIP-14) and modified Graded Chronic Pain Scale (GCPS). OHIP-14 yields a maximum score of 56, with a higher score indicating a lower OHRQoL. Personal financial costs were summed to provide a total. These included travel, appointment fees, childcare costs, medication use and time away from work. Data were analysed using one-way ANOVA and multivariable modelling.

RESULTS

In total, 714 participants were recruited. Mean OHIP-14 score was 25.73; 95% CI [24.67, 26.79], GCPS CPI was 71.69; 95% CI [70.09, 73.28] and GCPS interference was 49.56; 95% CI [47.24, 51.87]. Symptomatic irreversible pulpitis was the most frequently managed dental emergency and was associated with the highest mean OHIP-14 score (31.67; 95% CI [30.20, 33.15]). The mean personal financial cost of urgent dental care was £85.81; 95% CI [73.29, 98.33]. Differences in travel time (F[2, 691] = 10.24, p<.001), transport costs (F[2, 698] = 4.92, p=.004), and appointment time (F[2, 74] = 9.40, p<.001) were significant between patients attending an out-of-hours dental service, dental emergency clinic and dental practices for emergency care, with a dental emergency clinic being associated with the highest costs and dental practices the lowest.

CONCLUSIONS

Diseases of the pulp and associated periapical disease were the most common reason for patients to present for urgent dental care and were the most impactful in terms of OHRQoL and pain in the present sample. Personal financial costs are significant from urgent dental conditions, with centralised services increasing the burden to patients of attending appointments.

Updated guidelines for gene nomenclature in wheat

Here, we provide an updated set of guidelines for naming genes in wheat that has been endorsed by the wheat research community. The last decade has seen a proliferation in genomic resources for wheat, including reference- and pan-genome assemblies with gene annotations, which provide new opportunities to detect, characterise, and describe genes that influence traits of interest. The expansion of genetic information has supported growth of the wheat research community and catalysed strong interest in the genes that control agronomically important traits, such as yield, pathogen resistance, grain quality, and abiotic stress tolerance. To accommodate these developments, we present an updated set of guidelines for gene nomenclature in wheat. These guidelines can be used to describe loci identified based on morphological or phenotypic features or to name genes based on sequence information, such as similarity to genes characterised in other species or the biochemical properties of the encoded protein. The updated guidelines provide a flexible system that is not overly prescriptive but provides structure and a common framework for naming genes in wheat, which may be extended to related cereal species. We propose these guidelines be used henceforth by the wheat research community to facilitate integration of data from independent studies and allow broader and more efficient use of text and data mining approaches, which will ultimately help further accelerate wheat research and breeding.

Metal vs fibre posts - which is clinically superior for the restoration of endodontically treated teeth?

Data sources Medline/PubMed, Web of Science, Scopus and Cochrane Library databases. Grey literature searches (OpenGrey, ProQuest databases), hand searches in the reference list of eligible studies and relevant journals.Study selection Randomised controlled trials (RCTs) and prospective clinical trials (PCTs) with direct comparisons between metal posts (MPs) and fibre posts (FPs). Trials contained a minimum of ten patients and endodontically treated permanent teeth that had received either single crowns or fixed partial dentures (bridges) and followed up for a minimum of one year. The primary outcome compared the difference in failure rates between FPs and MPs, with subgroup analysis comparing location (anterior/posterior), type of MP (cast post core/preformed MP) and most frequent modes of failure (debond/root fracture).Data extraction and synthesis Study selection, data collection and risk of bias assessments were completed independently by two reviewers. Disagreements were discussed with a third reviewer to reach a consensus. The risk of bias was evaluated using the Cochrane risk of bias tool (RCTs) or the ROBINS-I tool (PCTs). The quality of responses was assessed using the Grading of Recommendations Assessment, Development And Evaluation (GRADE) approach. The meta-analysis (MA) was performed using the Mantel-Haenszel method. Trial heterogeneity was assessed using random- and fixed-effects models. Inter-examiner agreement during the database search and study selection process was checked using the kappa statistic.Results After duplicates were removed, 1,026 articles were assessed and screened by title and abstract. Of these, 21 articles underwent full-text evaluation, with ten articles meeting the eligibility criteria. Eligible studies included six RCTs and four PCTs. A total of 844 endodontically treated teeth (ETT) were restored with intra-radicular posts in 704 participants. Four hundred and fifty-three ETT were restored with FPs and 391 with MPs. The mean age of participants was 42.7 (33.95-55.45) years, with a mean follow-up period of 50.95 (12-154) months. Most studies reported failures during the follow-up period, but the MA revealed no significant difference between FPs and MPs in terms of failure rates (P = 0.39; RR: 0.82 mm; CI: 0.52-1.29). Sub-analysis showed no difference in failure rates between anterior and posterior regions and no difference when comparing FPs to cast post and core vs prefabricated MPs. Root fractures and post debondings were the most common modes of failure, but within these failures, no difference was observed between FPs and MPs.Conclusions No evidence was identified for a difference in failure rates between FPs and MPs. This was independent of the type of MP and position within the arch. Reporting of RCTs and PCTs was variable and further high-quality studies are needed.

Abstract 930: Production of functionally active recombinant FOXA1: The first step towards targeted drug discovery

Expression of transcription factor estrogen receptor (ER) drives and defines almost three-fourth of all breast cancer (BC). Endocrine therapies such as tamoxifen and aromatase inhibitors form the backbone of therapeutic regimen in treatment of ER-positive (ER+) BC. However, some ER+ BC patients do not respond well to these therapies and develop endocrine resistance. Mechanisms of endocrine resistance is multi-faceted and may require inhibition of multiple pathways. FDA-approved inhibitors of CDK4/6 and mTOR pathways have improved outcomes in ER+ metastatic BC patients. However, additional therapeutic agents targeting novel and essential nodes of endocrine resistance are needed for better management of ER+ BC. Recent research has shown that ER coregulators play a crucial role in endocrine resistance. The DNA interactions and transcriptional potential of ER rely on the pioneer factor Forkhead Box A1 (FOXA1), which plays an essential role in determining tumor growth and progression especially in the endocrine resistance setting. FOXA1 is gene amplified and/or overexpressed in multiple preclinical models and clinical samples of endocrine-resistant BC. Overexpression of FOXA1 promotes metastasis in animal models even during tamoxifen treatment, making it an attractive drug target to overcome endocrine resistance. However, no pharmacologic inhibitors of FOXA1 are currently available. To launch the drug discovery efforts to identify novel FOXA1 inhibitors, we aimed to express and purify functionally active full-length human FOXA1 protein that can be used for high-throughput drug screening in this research. We utilized various protein production strategies that we explored using baculovirus, bacterial, and mammalian expression system to achieve highly stable recombinant FOXA1 in an active form. While the baculovirus system had high protein expression, the yield, stability and purity of the recombinant FOXA1 was substandard. We maximized the yield and purity of FOXA1 with the bacterial expression system, but the protein functionality was lost due to misfolding. The mammalian expression system, which is well-known for its ability to properly recapitulate the protein posttranslational modifications, yielded stable FOXA1 protein. The recombinant FOXA1 expressed and purified in mammalian cells was functionally active as determined by the DNA-binding activity using enzymatic mobility shift assay (EMSA). However, the purity achieved was suboptimal for drug discovery application. Ongoing efforts are focused on optimizing the protein purification strategies that could ensure optimal yield of functional protein with highest purity for downstream applications.

Citation Format: Hariprasad Thangavel, Yingmin Zhu, Kurt R. Christensen, Xiaoyong Fu, Dean Edwards, Rachel Schiff, Meghana V. Trivedi. Production of functionally active recombinant FOXA1: The first step towards targeted drug discovery [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 930.

Norwich COVID-19 testing initiative pilot: evaluating the feasibility of asymptomatic testing on a university campus

Background

There is a high prevalence of COVID-19 in university-age students, who are returning to campuses. There is little evidence regarding the feasibility of universal, asymptomatic testing to help control outbreaks in this population. This study aimed to pilot mass COVID-19 testing on a university research park, to assess the feasibility and acceptability of scaling up testing to all staff and students.

Methods

This was a cross-sectional feasibility study on a university research park in the East of England. All staff and students (5625) were eligible to participate. All participants were offered four PCR swabs, which they self-administered over two weeks. Outcome measures included uptake, drop-out rate, positivity rates, participant acceptability measures, laboratory processing measures, data collection and management measures.

Results

798 (76%) of 1053 who registered provided at least one swab; 687 (86%) provided all four; 792 (99%) of 798 who submitted at least one swab had all negative results and 6 participants had one inconclusive result. There were no positive results. 458 (57%) of 798 participants responded to a post-testing survey, demonstrating a mean acceptability score of 4.51/5, with five being the most positive.

Conclusions

Repeated self-testing for COVID-19 using PCR is feasible and acceptable to a university population.

Characteristics and health status of patients with and without confirmed HFpEF

Aims

Patients with heart failure with preserved ejection fraction (HFpEF) are usually older and multi-morbid and diagnosis can be challenging. The aims of this cohort study were to confirm diagnosis of HFpEF in patients with possible HFpEF recruited from primary care, to compare characteristics and health status between those with and without HFpEF, and to determine factors associated with health status in patients with HFpEF.

Methods

Patients with presumed HFpEF were recruited from primary care practices and underwent clinical assessment and diagnostic evaluation as part of a longitudinal cohort study. Health status was measured by Montreal Cognitive Assessment (MOCA), 6-minute walk test, symptoms, and the Kansas City Cardiomyopathy Questionnaire (KCCQ), and quality of life (QoL) by EQ-5D-5L visual analogue scale (VAS).

Results

151 patients (mean age 78.5±8.6 years, 40% women, mean EF 56% + 9.4) were recruited and 93 (61.6%) were confirmed HFpEF (those without HFpEF had other HF and cardiac diagnoses). Patients with and without HFpEF did not differ by age, MOCA, blood pressure, heart rate, NYHA class, proportion with atrial fibrillation, Charlson Comorbidity Index, or NT-ProBNP levels. Patients with HFpEF were more likely to be women, overweight or obese, frail, and to be more functionally impaired by 6 minute walk distance and gait speed than those without. Although not statistically significant, patients with HFpEF had clinically significant differences (&gt;5 points) on the physical limitations, symptom burden and clinical summary subscales of the KCCQ, but did not differ by other subscales or by EQ-5D-5L VAS (70±17 vs 73±19, p=0.385). More patients with HFpEF reported daytime dyspnoea (63% vs 46%, p=0.035) and fatigue (81% vs 61%, p=0.008), but not other symptoms compared to those without HFpEF. For both groups BMI was moderately negatively correlated with KCCQ subscale scores, and 6 minute walk distance was positively correlated with KCCQ subscales.

Conclusions

Nearly 40% were not confirmed as HFpEF indicating the challenges of diagnosis. Patients with confirmed HFpEF differed by sex, overweight/obesity, frailty, functional impairment, and symptoms but not by age or comorbidities from those without HFpEF. These differences were reflected in some subscale scores of the KCCQ, but not how patients reported their quality of life on the KCCQ QoL subscale and EQ-5D-5L VAS. Older patients with HFpEF reported relatively high QoL despite poor health status by functional impairment, frailty and symptoms.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Research School of Primary Care Research

Calcium phosphate injection of symptomatic bone marrow lesions of the knee: what is the current clinical evidence?

BACKGROUND

Chronic bone marrow lesions (BML) in the weight-bearing portions of the knee are often associated with symptomatic degenerative arthritis resulting in pain and dysfunction. Injection of bone substitute material like calcium phosphate has been described. Whilst some studies have reported encouraging results others have shown limited benefit of this technique.

AIM

The aim was to collate the available evidence on the injection of calcium phosphate and systematically evaluate the results to answer the questions encountered in clinical decision making: (1) does it provide effective long-lasting pain relief to avoid further surgical intervention? (2) which factors (patient/surgical) significantly influence the outcome? and (3) does it adversely affect the outcomes of subsequent arthroplasty?

METHODS

A literature search was performed to identify the studies describing the clinical outcomes of calcium phosphate injection for treatment of BML. We evaluated the reported clinical outcomes with respect to pain, function and complications. Isolated case reports and studies with no objective assessment of clinical outcomes were excluded.

RESULTS

We noted 46 articles in the current literature of which 8 described clinical outcomes of calcium phosphate injection. Mean (plus/minus SD) score on the visual analog scale (VAS) has been reported to improve from 7.90 (± 0.38) to 2.76 (± 0.90), whereas the International Knee Documentation Committee (IKDC) score improved from 30.5 (SD not reported (NR)) to 53.0 (SD NR). Pre and post procedure Short form survey (SF-12) scores were 29.8 (SD NR) and 36.7 (SD NR), respectively. In one study, scores on the Tegner Lysholm knee scoring scale improved in 12 out of 22 patients, whereas the remainder had no change in symptoms. Extravasation of calcium phosphate into the joint was the most common complication, whereas no adverse effect has been reported on subsequent arthroplasty.

CONCLUSION

Limited data from the published studies would suggest that calcium phosphate injection of BML may potentially improve pain and function. However, no evidence is currently available to clearly identify patient/surgical factors that may influence the long-term outcomes of this procedure. Hence pragmatic, prospective studies with stratified patient cohorts and robust reporting of outcome measures are essential to improve the understanding of the indications and clinical effectiveness of this novel procedure.

Characteristics and outcomes of clusters of multimorbid patients in UK general practice

Background

Current clinical specialities, guidelines and quality of care metrics are organised around single diseases and treatments of multiple conditions are rarely coordinated, resulting in insufficient or even conflicting care. This study uses large scale English general practice (GP) records to identify and characterise clusters of patients based on their multimorbidity to allow better design of health services and highlight groups that require additional interventions.

Methods

This is a retrospective cohort study that includes multimorbid adult patients (N = 113,211), from a random sample of 391,669 English patients with valid GP records in 2012 where 38 long-term conditions were defined. Latent class analysis, stratified by age groups, was used to identify multimorbidity clusters. Class solutions are validated and associations between multimorbidity clusters, patient characteristics, public health service utilisation and mortality are assessed.

Results

Poor socioeconomic status is associated with clusters with higher service use and mortality risk. Physical-mental health co-morbidity is a major component of multimorbidity across all age strata. The clusters with highest age-stratified mortality risk in under 65 year olds were linked to alcohol and substance misuse, whereas in over 65 year olds they were linked to cardiovascular disease. The largest cluster in the 85+ years strata (58%) has the lowest number of morbidities, a low degree of service use and mortality. Consistency was seen across identification and validation data.

Conclusions

We find a clear distinction between morbidity clusters, both in the prevalence of long term conditions within them, and in their associations with outcomes (service use and mortality). Specific health services and interventions might be more effective when targeted on the distinct types of multimorbidity we have identified, with a particular focus on the morbidity clusters associated with the worst patient outcomes.

Key messages

The first study to derive age stratified multimorbidity clusters from a large GP record system, whose patients are representative of the English population. Knowledge about particularly dangerous clusters of multimorbidity, such as those involving alcohol and drug use in 18–64 years old, and cardiovascular disease in those 65 years or older.

Transcriptional signature primes human oral mucosa for rapid wound healing

Oral mucosal wound healing has long been regarded as an ideal system of wound resolution. However, the intrinsic characteristics that mediate optimal healing at mucosal surfaces are poorly understood, particularly in humans. We present a unique comparative analysis between human oral and cutaneous wound healing using paired and sequential biopsies during the repair process. Using molecular profiling, we determined that wound-activated transcriptional networks are present at basal state in the oral mucosa, priming the epithelium for wound repair. We show that oral mucosal wound-related networks control epithelial cell differentiation and regulate inflammatory responses, highlighting fundamental global mechanisms of repair and inflammatory responses in humans. The paired comparative analysis allowed for the identification of differentially expressed SOX2 (sex-determining region Y-box 2) and PITX1 (paired-like homeodomain 1) transcriptional regulators in oral versus skin keratinocytes, conferring a unique identity to oral keratinocytes. We show that SOX2 and PITX1 transcriptional function has the potential to reprogram skin keratinocytes to increase cell migration and improve wound resolution in vivo. Our data provide insights into therapeutic targeting of chronic and nonhealing wounds based on greater understanding of the biology of healing in human mucosal and cutaneous environments.

Abstract PD7-11: Therapeutic strategy for ESR1 mutation driven-endocrine resistance in ER-positive breast cancers

Background: Endocrine therapy is used in estrogen receptor (ER)-positive breast cancers, however, 25% of these patients are at risk of distant relapse and the development of acquired endocrine resistance. Recently mutations in the ER gene (ESR1) have been validated to be acquired during the development of endocrine resistance. The most frequent ESR1 mutation, Y537S, promotes ligand-independent ER activity and emerges subclonally during aromatase inhibitor treatment. In this study, we examined the effects of the Y537S ESR1 mutation on cell cycle signaling and therapeutic response to a novel checkpoint inhibitor.

Material and Methods: MCF-7 cells expressing the Y537S ESR1 mutation were generated by CRISPR-Cas9 knock-in techniques. Cells were incubated in steroid deprived conditions. Cell cycle analysis and apoptosis were examined by flow cytometry annnexin-V assays. Proliferation was analyzed by BrdU incorporation. Cell cycle checkpoint kinases were examined by western blot analysis. Cell growth was analyzed using soft agar and MTT assays. Replication stress was identified by RPA32 and gamma-H2AX foci formation assay. For in vivo studies, MCF-7 ESR1 Y537S mutant cells were injected into female athymic nude mice with 17β-estradiol (E2) supplemented water. When tumors reached 350 mm3, tamoxifen (20 mg/kg; s.c.; three times a week), fulvestrant (200 mg/kg; s.c; once a week) and/or PF477736 Chk1 inhibitor (7.5 mg/kg; i.p.; twice a day and twice a week) was treated without E2.

Results: ESR1 Y537S mutant cells accumulated approximately 5 fold in S phase and 1.7 fold in G2/M phase compared to control cells in estrogen-deprived (ED) conditions. BrdU incorporation also increased about 2.5-fold, however, apoptosis was decreased about 60 % compared with wild-type ER parental cells. ESR1 Y537S mutant cells induced significant replication stress, showing increased RPA32 foci together with increased gamma H2AX foci, a marker of DNA double-stranded breaks. ChIP-seq analysis revealed binding sites on ATR and CHEK1 genomic locations. ATR/Chk1-mediated checkpoint signaling was activated in ESR1 Y537S mutant cells, and was repressed with fulvestrant, tamoxifen, or ESR1 siRNA treatment. The Chk1 inhibitor, PF477736, sensitized MCF-7 expressing the ESR1 Y537S mutation to endocrine treatments such as fulvestrant, tamoxifen, and the ER degrader AZD9496 in cell proliferation assays. In MCF-7 ESR1 Y537S mutant xenograft and patient derived mouse models, tamoxifen treatment combined with the Chk1 inhibitor PF477736 repressed primary xenograft tumor doubling times (P=0.038, Wilcoxon test). Treatment of mutant tumors with PF477736 together with fulvestrant significantly inhibited the frequency of distant lung metastases by 80% (P=0.0031, t-test), suggesting that these combinations may be useful in second line treatment of metastatic breast cancer patients resistant to endocrine therapies.

Conclusion: These preclinical results suggest that ESR1 mutant tumors have a therapeutic vulnerability to combination endocrine therapy with cell cycle checkpoint kinase inhibitors. These data demonstrate that this new therapeutic approach may be useful to restore endocrine sensitivity in metastatic breast cancer patients with ESR1 mutation driven-endocrine resistance.

Citation Format: Kim J-A, Dustin D, Gu G, Corona-Rodriguez A, Edwards D, Coarfa C, Keyomarsi K, Fuqua SA. Therapeutic strategy for ESR1 mutation driven-endocrine resistance in ER-positive breast cancers [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD7-11.

Outpatient negative pressure dressing therapy for pretibial lacerations in a patient with high anaesthetic risk: a case study

Pretibial lacerations are a common cause of presentation to accident and emergency departments. The management of these wounds is contentious with a variation in practise between individual institutions. We present the case of a 49-year-old female with a background of pulmonary atresia and associated pulmonary hypertension, who underwent successful outpatient negative pressure wound therapy (NPWT) for three pretibial lacerations. We would propose that this therapy is an effective option for the management of these wounds in independently mobile patients who are at high-risk when under anaesthetic.

The tooth, the whole tooth and nothing but the tooth: tooth shape and ontogenetic shift dynamics in the white shark Carcharodon carcharias

Results from this study of the white shark Carcharodon carcharias include measurements obtained using a novel photographic method that reveal significant differences between the sexes in the relationship between tooth cuspidity and shark total length, and a novel ontogenetic change in male tooth shape. Males exhibit broader upper first teeth and increased distal inclination of upper third teeth with increasing length, while females do not present a consistent morphological change. Substantial individual variation, with implications for pace of life syndrome, was present in males and tooth polymorphism was suggested in females. Sexual differences and individual variation may play major roles in ontogenetic changes in tooth morphology in C. carcharias, with potential implications for their foraging biology. Such individual and sexual differences should be included in studies of ontogenetic shift dynamics in other species and systems.

A new mild hyperthermia device to treat vascular involvement in cancer surgery

Surgical margin status in cancer surgery represents an important oncologic parameter affecting overall prognosis. The risk of disease recurrence is minimized and survival often prolonged if margin-negative resection can be accomplished during cancer surgery. Unfortunately, negative margins are not always surgically achievable due to tumor invasion into adjacent tissues or involvement of critical vasculature. Herein, we present a novel intra-operative device created to facilitate a uniform and mild heating profile to cause hyperthermic destruction of vessel-encasing tumors while safeguarding the encased vessel. We use pancreatic ductal adenocarcinoma as an in vitro and an in vivo cancer model for these studies as it is a representative model of a tumor that commonly involves major mesenteric vessels. In vitro data suggests that mild hyperthermia (41-46 °C for ten minutes) is an optimal thermal dose to induce high levels of cancer cell death, alter cancer cell's proteomic profiles and eliminate cancer stem cells while preserving non-malignant cells. In vivo and in silico data supports the well-known phenomena of a vascular heat sink effect that causes high temperature differentials through tissues undergoing hyperthermia, however temperatures can be predicted and used as a tool for the surgeon to adjust thermal doses delivered for various tumor margins.

miR-130b directly targets ARHGAP1 to drive activation of a metastatic CDC42-PAK1-AP1 positive feedback loop in Ewing sarcoma

Ewing Sarcoma (ES) is a highly aggressive bone tumor with peak incidence in the adolescent population. It has a high propensity to metastasize, which is associated with dismal survival rates of approximately 25%. To further understand mechanisms of metastasis we investigated microRNA regulatory networks in ES. Our studies focused on miR-130b due to our analysis that enhanced expression of this microRNA has clinical relevance in multiple sarcomas, including ES. Our studies provide insights into a novel positive feedback network involving the direct regulation of miR-130b and activation of downstream signaling events contributing toward sarcoma metastasis. Specifically, we demonstrated miR-130b induces proliferation, invasion, and migration in vitro and increased metastatic potential in vivo. Using microarray analysis of ES cells with differential miR-130b expression we identified alterations in downstream signaling cascades including activation of the CDC42 pathway. We identified ARHGAP1, which is a negative regulator of CDC42, as a novel, direct target of miR-130b. In turn, downstream activation of PAK1 activated the JNK and AP-1 cascades and downstream transcriptional targets including IL-8, MMP1 and CCND1. Furthermore, chromatin immunoprecipitation of endogenous AP-1 in ES cells demonstrated direct binding to an upstream consensus binding site within the miR-130b promoter. Finally, small molecule inhibition of PAK1 blocked miR-130b activation of JNK and downstream AP-1 target genes, including primary miR-130b transcripts, and miR-130b oncogenic properties, thus identifying PAK1 as a novel therapeutic target for ES. Taken together, our findings identify and characterize a novel, targetable miR-130b regulatory network that promotes ES metastasis.

Abstract 1056: Inhibition of hexose monophosphate pathway promotes castration resistant prostate cancer

Prostate Cancer (PCa) is the second highest cause of cancer-related death in men in the US. PCa is androgen dependent when organ-confined and is conventionally treated using surgery or using a combination of anti-androgens and radiation therapy. However, in about 30% of the patients tumor recurs and are initially administered androgen deprivation therapy (ADT). Majority of the patients become resistant to ADT and develop hormone-refractory disease also termed castration-resistant prostate cancer (CRPC), which is lethal. Currently, the molecular and biochemical alterations driving CRPC are not well understood. Using a novel network-based integrative approach, we show distinct alterations in the Hexosamine Biosynthetic Pathway (HBP) to be critical for sustaining the castrate resistant state. Our data suggests expression of key HBP enzymes to be significantly elevated in androgen dependent (AD) PCa while interestingly enough, relatively diminished in CRPC. Genetic loss of function experiments for these HBP enzymes in CRPC-like cells had tumor promoting effect both in vitro and in vivo. This was mediated by alterations in either PI3K-AKT pathway or SP1-ChREBP (SP1- carbohydrate response element binding protein) network in CRPC cells containing full length androgen receptor (AR) or its splice variant AR-V7, respectively. Strikingly, addition of HBP metabolite UDP-N-acetylglucosamine (UDP-GlcNAc) or glucosamine (GlcN) to CRPC-like cells attenuated tumor cell proliferation, both in vitro and in animal studies. Interestingly, these metabolites demonstrated additive efficacy when combined with enzalutamide in vitro. These findings are particularly significant given that the CRPC-like cells tested, inclusive of those containing AR-V7 variant, are inherently resistant to enzalutamide. These observations demonstrate the therapeutic value of targeting altered HBP in CRPC.

Citation Format: Akash K. Kaushik, Ali Shojaie, Katrin Panzitt, Rajni Sonavane, Harene Venghatakrishnan, Mohan Manikkam, Alexander Zaslavsky, Vasanta Putluri, Vihas Vasu, Yiqing Zhang, Ayesha Khan, Stacy Lloyd, Adam Szafran, Subhamoy Dasgupta, David Bader, Fabio Stossi, Hangwen Li, Susmita Samanta, Xuhong Cao, Efrosini Tsouko, Shixia Huang, Daniel Frigo, Lawrence Chan, Dean Edwards, Benny Kaipparettu, Nicholas Mitsiades, Nancy Weigel, Michael Mancini, Michael Ittmann, Arul Chinnaiyan, Nagireddy Putluri, Ganesh Palapattu, George Michailidis, Arun Sreekumar. Inhibition of hexose monophosphate pathway promotes castration resistant prostate cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1056.

People with dementia: what is known about their experience of cancer treatment and cancer treatment outcomes? A systematic review

OBJECTIVE

The objective of the study is to report a systematic review of what is currently known about the experience of cancer treatment and cancer treatment in adults with dementia.

METHODS

The analytic plan and inclusion/exclusion criteria were specified in advance of the search process in a protocol. Searches were conducted in MEDLINE, CINAHL, PsycINFO and the Cochrane Library for publications about people with cancer and a pre-existing dementia. Limits were English language; 2000 to 12/2015; adults; >18 years old. The search identified 5214 titles and abstracts that were assessed against eligibility criteria and 101 were selected for full-text examination by two researchers who agreed inclusion of nine papers, extracted data independently then conducted a content analysis and narrative synthesis.

RESULTS

Nine studies conducted in four resource rich countries were included in the review. These studies evidence that when compared with other cancer patients, those with dementia are diagnosed at a later stage, receive less treatment, are more likely to experience complications from treatment and have poorer survival. The experience of supportive care and preferences of people with dementia receiving cancer services and cancer treatment have not been investigated. Research into how the cancer team manage the particular needs of people with dementia and their family members has been limited to one study that reported how a cancer team managed the particular needs of seven people with dementia.

CONCLUSION

Further work is needed to establish practice guidelines for the management of cancer in people with dementia. Copyright © 2016 John Wiley & Sons, Ltd.

Abstract P2-06-11: Wild type N-Ras, overexpressed in basal-like breast cancer, promotes tumor formation by inducing IL8 secretion via JAK2 activation

"Basal-like" breast cancer (BLBC) is a very aggressive subtype of breast cancer. BLBC has very poor prognosis — median time to distant recurrence is just 2.6 years vs. 5 years overall, and survival time from diagnosis of distant metastatic disease is 9 months vs. 22 months. BLBC tumors usually do not express ER, Her2, or progesterone receptor. As such, they cannot be treated by the current targeted therapies, which target these molecules. What drive the formation and progression of BLBCs is largely unclear.

Ras GTPases are best known for mediating growth factor signaling. Oncogenic mutations in the RAS genes, K-RAS in particular, are found in more than 30% of human tumors. Surprisingly, oncogenic RAS mutations are rare in breast cancer. However, we found that wild-type N-RAS is overexpressed in BLBCs, possibly partly via promoter demethylation, but not in other breast cancer subtypes. Repressing N-RAS inhibits transformation and tumor growth, while overexpressing it enhances these processes even in preinvasive BLBC cells. In contrast, in breast cancer cells of other subtypes, repressing N-RAS expression does not affect growth and transforming activities. We identified N-Ras-responsive genes, most of which encode chemokines and cytokines, e.g., IL8. High expression levels of these N-Ras-responsive genes as well as of N-RAS itself in tumors correlate with poor patient outcome. N-Ras, but not K-Ras, induces IL8 by binding and activating the cytoplasmic pool of JAK2; IL8 then acts on both the cancer cells and stromal fibroblasts.

In conclusion, N-Ras drives BLBC by promoting transformation in epithelial cells, which may in turn remodel the tumor microenvironment to create a proinvasive state. Although oncogenic mutations affecting RAS are common in many other human cancers, tumorigenesis in an important subset of breast cancers is driven instead by increasing activity of wild-type N-Ras. Thus, to fully assess the impact of Ras on tumorigenesis, the role of wild-type as well as mutant Ras proteins must be carefully examined.

Citation Format: Zheng Z-Y, Bu W, Tian L, Fan C, Gao X, Zhang X, Yu C, Wang H, Liao Y-H, Li Y, Lewis MT, Edwards D, Zwaka TP, Hilsenbeck SG, Medina D, Perou CM, Creighton CJ, Zhang XH, Chang EC. Wild type N-Ras, overexpressed in basal-like breast cancer, promotes tumor formation by inducing IL8 secretion via JAK2 activation. [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 P2-06-11.

Abstract B01: B cell lymphoma 9 mediates a cross talk between the canonical Wnt and EGFR signaling in breast cancer

Human ductal carcinoma in situ (DCIS) are the most common type of non-invasive breast cancers. The five-year survival rate for women diagnosed with non-invasive DCIS is 98% while the five-year survival plummets to 83-27% for breast cancers that have become invasive and have spread to distant sites [also referred to as invasive ductal carcinoma (IDC)]. To study DCIS pathobiology and factors that promote their transition to IDC, we have developed a novel in vivo DCIS model, MIND (mouse-intraductal), that involves intraductal injection of epithelial cells derived from primary human DCIS biopsy and surgical samples thus mimicking the entire process of DCIS to IDC transition. As a complementary approach, we have utilized human DCIS/IDC tandem lesions, which are patient DCIS that show a transition to IDC within the same breast. Analysis of RNA and protein at distinct stages of in situ to IDC using both models showed B cell lymphoma-9 (BCL9) up-regulation to be associated with DCIS transition to IDC. BCL9 is a recently identified co-activator of Wnt-stimulated beta-catenin-mediated transcription. Our studies showed that in vivo silencing of BCL9 led to inhibition of DCIS invasion and reversal of EMT. We have also demonstrated a direct binding interaction between BCL9 and beta-catenin and showed suppression of beta-catenin-mediated transcription by BCL9 knockdown. Analysis of patient DCIS samples revealed a significant correlation between high nuclear BCL9 expression and pathologic characteristics associated with DCIS recurrence: Estrogen receptor (ER) negative and Ki67. Furthermore, analysis of the TCGA data showed BCL9 gene to be upregulated in 26% of breast cancers. This is a significant gene alteration when compared to HER2 (ERBB2) gene (19%) and estrogen receptor (ESR1) gene (8%) alterations in breast cancers. Interestingly, a significantly higher proportion of basal like invasive breast cancers compared to luminal breast cancers showed BCL9 amplification suggesting that BCL9 may predispose to the development of basal breast cancers. We have performed an RPPA analysis on our DCIS cell lines KD BCL9 vs. control. This analysis indicated that BCL9 KD showed down-regulation in a number of genes in the EGFR signaling pathway including p-EGFR, p-HER2, p-STAT3, and p-Src. Conclusion: BCL9 is a molecular driver of DCIS invasive progression. The molecular mechanism for BCL9's role in breast cancer progression is through the enhancement in the canonical Wnt and EGFR signaling.

Citation Format: Hanan Elsarraj, Hong Yan, Jennifer Knapp, Anna Tsimelzon, Shixia Huang, Andrew Godwin, Sue Hilsenbeck, Dean Edwards, Fariba Behbod. B cell lymphoma 9 mediates a cross talk between the canonical Wnt and EGFR signaling in breast cancer. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research; Oct 17-20, 2015; Bellevue, WA. Philadelphia (PA): AACR; Mol Cancer Res 2016;14(2_Suppl):Abstract nr B01.

Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition?

Vaginal dryness is a common condition that is particularly prevalent during and after the menopause, and is one of the symptoms of vulvovaginal atrophy/genitourinary syndrome of menopause. The impact of vaginal dryness on interpersonal relationships, quality of life, daily activities, and sexual function can be significant, but is frequently underestimated. Furthermore, barriers exist to treatment-seeking, and this condition is often underreported and undertreated. Greater education about vaginal dryness and the range of available treatments is essential to encourage more women to seek help for this condition.

Personal lubricants and moisturizers are effective at relieving discomfort and pain during sexual intercourse for women with mild to moderate vaginal dryness, particularly those who have a genuine contraindication to estrogen, or who choose not to use estrogen. However, there is a distinction between lubricants and moisturizers, and notable differences between commercially available products. Women should be advised to choose a product that is optimally balanced in terms of both osmolality and pH, and is physiologically most similar to natural vaginal secretions. A series of recommendations for the use of vaginal lubricants and moisturizers, either on their own or in combination with systemic or topical hormone replacement therapy, is presented.

Mammary Stem Cells and Tumor-Initiating Cells Are More Resistant to Apoptosis and Exhibit Increased DNA Repair Activity in Response to DNA Damage

Adult stem cells and tumor-initiating cells (TICs) often employ different mechanisms of DNA damage response (DDR) as compared to other tissue cell types. However, little is known about how mammary stem cells (MaSCs) and mammary TICs respond to DNA damage. Using the mouse mammary gland and syngeneic p53-null tumors as models, we investigated the molecular and physiological consequences of DNA damage in wild-type MaSCs, p53-null MaSCs, and p53-null TICs. We showed that wild-type MaSCs and basal cells are more resistant to apoptosis and exhibit increased non-homologous end joining (NHEJ) activity. Loss of p53 in mammary epithelium affected both cell-cycle regulation and DNA repair efficiency. In p53-null tumors, we showed that TICs are more resistant to ionizing radiation (IR) due to decreased apoptosis, elevated NHEJ activity, and more-rapid DNA repair. These results have important implications for understanding DDR mechanisms involved in both tumorigenesis and therapy resistance.

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MaSCs are more resistant to apoptosis and exhibit increased NHEJ activity

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Loss of p53 in MECs impairs cell-cycle regulation and DNA repair efficiency

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TICs exhibit decreased apoptosis, increased DNA repair efficiency, and NHEJ activity

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TICs are highly proliferative and exhibit improper cell-cycle regulation after IR

Abstract 2139: Wild type N-Ras, overexpressed in basal-like breast cancer, promotes tumor formation by inducing IL8 secretion via JAK2 activation

“Basal-like” breast cancer (BLBC) is the most aggressive breast cancer subtype, with a very poor prognosis _ median time to distant recurrence is just 2.6 years vs. 5 years overall, and survival time from diagnosis of distant metastatic disease is 9 months vs. 22 months. BLBC tumors usually do not express ER, Her2, or progesterone receptor. As such, they cannot be treated by the current targeted therapies, which target these molecules. What drive the formation and progression of BLBCs is largely unclear.

Ras GTPases are best known for mediating growth factor signaling, and oncogenic mutations in the RAS genes, and K-RAS in particular, are found in more than 30% of human tumors. Surprisingly, oncogenic RAS mutations are rare in breast cancer. However, we found that wild-type N-RAS is overexpressed in BLBCs, partly via promoter demethylation, but not in other breast cancer subtypes. Repressing N-RAS inhibits transformation and tumor growth, while overexpression enhances these processes even in preinvasive BLBC cells. In contrast, repressing N-RAS expression does not affect growth and transforming activities of breast cancer cells of other subtypes. We identified N-Ras-responsive genes, most of which encode chemokines, e.g., IL8. High expression levels of these N-Ras-responsive genes as well as of N-RAS itself in tumors correlate with poor patient outcome. N-Ras, but not K-Ras, induces IL8 by binding and activating the cytoplasmic pool of JAK2; IL8 then acts on both the cancer cells and stromal fibroblasts. Thus N-Ras drives BLBC by promoting transformation in epithelial cells, which in turn remodels the tumor microenvironment to create a proinvasive state.

These results illustrate an N-Ras-dependent convergence between the growth factor and cytokine pathways to enable efficient transformation of epithelial cells, which then orchestrate the remodeling of the tumor microenvironment. Although oncogenic mutations affecting RAS are common in many other human cancers, tumorigenesis in an important subset of breast cancers is driven instead by increasing activity of wild-type N-Ras. Thus, to fully assess the impact of Ras on tumorigenesis, the role of wild-type as well as mutant Ras proteins must be carefully examined.

Citation Format: Ze-Yi Zheng, Wen Bu, Lin Tian, Cheng Fan, Xia Gao, Cuijuan Yu, Liu Jun, Xiaomei Zhang, Yi-Hua Liao, Yi Li, Michael T. Lewis, Dean Edwards, Susan G. Hilsenbeck, Daniel Medina, Thomas P. Zwaka, Charles M. Perou, Chad J. Creighton, Xiang Zhang, Eric C. Chang. Wild type N-Ras, overexpressed in basal-like breast cancer, promotes tumor formation by inducing IL8 secretion via JAK2 activation. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2139. doi:10.1158/1538-7445.AM2015-2139

Assessing pesticide risks to threatened and endangered species using population models: Findings and recommendations from a CropLife America Science Forum

This brief communication reports on the main findings and recommendations from the 2014 Science Forum organized by CropLife America. The aim of the Forum was to gain a better understanding of the current status of population models and how they could be used in ecological risk assessments for threatened and endangered species potentially exposed to pesticides in the United States. The Forum panelists' recommendations are intended to assist the relevant government agencies with implementation of population modeling in future endangered species risk assessments for pesticides. The Forum included keynote presentations that provided an overview of current practices, highlighted the findings of a recent National Academy of Sciences report and its implications, reviewed the main categories of existing population models and the types of risk expressions that can be produced as model outputs, and provided examples of how population models are currently being used in different legislative contexts. The panel concluded that models developed for listed species assessments should provide quantitative risk estimates, incorporate realistic variability in environmental and demographic factors, integrate complex patterns of exposure and effects, and use baseline conditions that include present factors that have caused the species to be listed (e.g., habitat loss, invasive species) or have resulted in positive management action. Furthermore, the panel advocates for the formation of a multipartite advisory committee to provide best available knowledge and guidance related to model implementation and use, to address such needs as more systematic collection, digitization, and dissemination of data for listed species; consideration of the newest developments in good modeling practice; comprehensive review of existing population models and their applicability for listed species assessments; and development of case studies using a few well-tested models for particular species to demonstrate proof of concept. To advance our common goals, the panel recommends the following as important areas for further research and development: quantitative analysis of the causes of species listings to guide model development; systematic assessment of the relative role of toxicity versus other factors in driving pesticide risk; additional study of how interactions between density dependence and pesticides influence risk; and development of pragmatic approaches to assessing indirect effects of pesticides on listed species.

Clinical and microbiological evaluation of epidural and regional anaesthesia catheters in injured UK military personnel

INTRODUCTION

The adoption of regional and epidural analgesia in UK military personnel injured in action during Op HERRICK increased from 2008, in line with structural and environmental developments in the UK medical treatment facility. Historically, there have been concerns that invasive analgesic techniques could carry an increased risk of infection, due to the mechanism of injury and the environmental conditions in which the injuries were sustained. Consequently, the epidural and continuous peripheral nerve blockade (CPNB) catheters that were inserted in UK military personnel during a 33-month period of Op HERRICK were clinically and microbiologically examined, after subsequent admission to the University Hospitals Birmingham (UHB) NHS Trust.

METHODS

Data on epidural and CPNB insertions were collected via the specialist pain service at UHB over the study period, including de novo and replacement insertions performed in both Afghanistan and the UK. Patients were regularly reviewed and relevant clinical concerns were documented in patients' case notes as necessary. The anatomical site, duration of placement and the results of microbiological culture of the epidural and CPNB catheter tips were all recorded.

RESULTS

Overall, 236 catheters were assessed, of which 151 catheter tips (64%) were cultured (85 epidural, 66 CPNB). Of these, 48 grew bacteria (34% of cultured epidurals and 29% of cultured CPNB). There was no difference between the colonisation rates of epidurals inserted in Afghanistan and the UK. Only one infection related to a misplaced epidural catheter was confirmed.

CONCLUSIONS

With the exception of the epidural (34%) and proximal sciatic (42%) catheters, these figures, in a military cohort characterised by significant injury scores, are consistent with those reported for civilian surgical patients. The results strongly support the expansion of regional analgesia during Op HERRICK from 2008 onwards. The outcomes suggest a possible translation into civilian major trauma practice.

Pharmacometrics Markup Language (PharmML): Opening New Perspectives for Model Exchange in Drug Development

The lack of a common exchange format for mathematical models in pharmacometrics has been a long-standing problem. Such a format has the potential to increase productivity and analysis quality, simplify the handling of complex workflows, ensure reproducibility of research, and facilitate the reuse of existing model resources. Pharmacometrics Markup Language (PharmML), currently under development by the Drug Disease Model Resources (DDMoRe) consortium, is intended to become an exchange standard in pharmacometrics by providing means to encode models, trial designs, and modeling steps.

Oral disease profiles in chronic graft versus host disease

At least half of patients with chronic graft-versus-host-disease (cGVHD), the leading cause of morbidity and non-relapse mortality after allogeneic stem cell transplantation, have oral manifestations: mucosal lesions, salivary dysfunction, and limited mouth-opening. cGVHD may manifest in a single organ or affect multiple organ systems, including the mouth, eyes, and the skin. The interrelationship of the 3 oral manifestations of cGVHD with each other and with the specific manifestations of extraoral cGVHD has not been studied. In this analysis, we explored, in a large group of patients with cGVHD, the potential associations between: (1) oral mucosal disease and erythematous skin disease, (2) salivary gland dysfunction and lacrimal gland dysfunction, and (3) limited mouth-opening and sclerotic skin cGVHD. Study participants, enrolled in a cGVHD Natural History Protocol (NCT00331968, n = 212), underwent an oral examination evaluating: (1) mucosal cGVHD [NIH Oral Mucosal Score (OMS)], (2) salivary dysfunction (saliva flow and xerostomia), and (3) maximum mouth-opening measurement. Parameters for dysfunction (OMS > 2, saliva flow ≤ 1 mL/5 min, mouth-opening ≤ 35 mm) were analyzed for association with skin cGVHD involvement (erythema and sclerosis, skin symptoms), lacrimal dysfunction (Schirmer's tear test, xerophthalmia), Lee cGVHD Symptom Scores, and NIH organ scores. Oral mucosal disease (31% prevalence) was associated with skin erythema (P < 0.001); salivary dysfunction (11% prevalence) was associated with lacrimal dysfunction (P = 0.010) and xerostomia with xerophthalmia (r = 0.32, P = 0.001); and limited mouth-opening (17% prevalence) was associated with skin sclerosis (P = 0.008) and skin symptoms (P = 0.001). There was no association found among these 3 oral cGVHD manifestations. This analysis supports the understanding of oral cGVHD as 3 distinct diseases: mucosal lesions, salivary gland dysfunction, and mouth sclerosis. Clear classification of oral cGVHD as 3 separate manifestations will improve clinical diagnosis, observational research data collection, and the definitions of outcome measures in clinical trials.

Quality-of-life for individuals with a vestibular impairment following an acquired brain injury (ABI); the clients' perspective

PRIMARY OBJECTIVE

To investigate how a vestibular deficit following an acquired brain injury (ABI) affects an individuals' quality-of-life.

RESEARCH DESIGN

A qualitative exploratory design.

PARTICIPANTS

Nine community dwelling individuals who experienced significant symptoms and limitations as a result of their vestibular deficits.

METHODS

The individuals participated in face-to-face interviews with open ended questions. Data was analysed initially using a case study research approach, exploring the experience for each individual and then cross-case analysis to determine common themes for the group with the assistance of nVivo 10 qualitative analysis software.

RESULTS

Thematic analysis determined four main themes arising from the interviews; (1) validation, (2) definitive diagnosis is more difficult amongst an array of ABI symptoms, (3) vestibular adaptation is more difficult in the presence of an ABI and (4) emotional and social.

CONCLUSION

Individuals who suffer a brain injury and experience vestibular symptoms as part of their overall presentation are not diagnosed in a timely manner, with individuals, their families, associates and even health professionals feeling uncertain of the legitimacy of their reported symptoms. It is important that all patients who experience an acquired brain injury are screened for vestibular impairment and, if necessary, receive vestibular rehabilitation including explanation and education.