Bovine viral diarrhoea viruses from New Zealand belong predominantly to the BVDV-1a genotype

AIM

To determine which genotypes of bovine viral diarrhoea virus (BVDV) circulate among cattle in New Zealand.

METHODS

Samples comprised BVDV-1-positive sera sourced from submissions to veterinary diagnostic laboratories in 2019 (n = 25), 2020 (n = 59) and 2022 (n = 74) from both beef and dairy herds, as well as archival BVDV-1 isolates (n = 5). Fragments of the 5' untranslated region (5' UTR) and glycoprotein E2 coding sequence of the BVDV genome were amplified and sequenced. The sequences were aligned to each other and to international BVDV-1 sequences to determine their similarities and phylogenetic relationships. The 5' UTR sequences were also used to create genetic haplotype networks to determine if they were correlated with selected traits (location, type of farm, and year of collection).

RESULTS

The 5' UTR sequences from New Zealand BVDV were closely related to each other, with pairwise identities between 89% and 100%. All clustered together and were designated as BVDV-1a (n = 144) or BVDV-1c (n = 5). There was no evidence of a correlation between the 5' UTR sequence and the geographical origin within the country, year of collection or the type of farm. Partial E2 sequences from New Zealand BVDV (n = 76) showed 74-100% identity to each other and clustered in two main groups. The subtype assignment based on the E2 sequence was the same as based on the 5' UTR analysis. This is the first comprehensive analysis of genomic variability of contemporary New Zealand BVDV based on the analysis of the non-coding (5' UTR) and coding (E2) sequences.

CONCLUSIONS AND CLINICAL RELEVANCE

Knowledge of the diversity of the viruses circulating in the country is a prerequisite for the development of effective control strategies, including a selection of suitable vaccines. The data presented suggest that New Zealand BVDV are relatively homogeneous, which should facilitate eradication efforts including selection or development of the most suitable vaccines.

SARS-CoV-2 Antiviral Prescribing Gaps Among Non-Hospitalized High-Risk Adults

Within a multi-state clinical cohort, SARS-CoV-2 antiviral prescribing patterns were evaluated from April 2022-June 2023 among non-hospitalized SARS-CoV-2-infected patients with risk factors for severe COVID-19. Among 3,247 adults, only 31.9% were prescribed an antiviral agent (87.6% nirmatrelvir/ritonavir, 11.9% molnupiravir, 0.5% remdesivir), highlighting the need to identify and address treatment barriers.

Racial and ethnic disparities in acuity of presentation among children with newly diagnosed acute leukemia

We evaluated disparities in disease burden, organ dysfunction, vital signs, and timing of therapy in children newly presenting with acute leukemia. Among 899 patients with acute leukemia diagnosed at two large children's hospitals, a priori lab-based definitions of high disease burden, infection risk, renal dysfunction, and coagulopathy were applied to electronic health record data. Black patients with acute myeloid leukemia had increased prevalence of elevated white blood cell count and uric acid; Black patients with acute lymphoblastic leukemia demonstrated increased prevalence of coagulopathy. Black patients' presentation more frequently included multiple lab abnormalities consistent with advanced physiologic dysfunction. No differences were found in days to therapy initiation.

Rates of laboratory adverse events by course in paediatric leukaemia ascertained with automated electronic health record extraction: a retrospective cohort study from the Children's Oncology Group

BACKGROUND

Adverse events are often misreported in clinical trials, leading to an incomplete understanding of toxicities. We aimed to test automated laboratory adverse event ascertainment and grading (via the ExtractEHR automated package) to assess its scalability and define adverse event rates for children with acute myeloid leukaemia and acute lymphoblastic leukaemia.

METHODS

For this retrospective cohort study from the Children's Oncology Group (COG), we included patients aged 0-22 years treated for acute myeloid leukaemia or acute lymphoblastic leukaemia at Children's Healthcare of Atlanta (Atlanta, GA, USA) from Jan 1, 2010, to Nov 1, 2018, at the Children's Hospital of Philadelphia (Philadelphia, PA, USA) from Jan 1, 2011, to Dec 31, 2014, and at the Texas Children's Hospital (Houston, TX, USA) from Jan 1, 2011, to Dec 31, 2014. The ExtractEHR automated package acquired, cleaned, and graded laboratory data as per Common Terminology Criteria for Adverse Events (CTCAE) version 5 for 22 commonly evaluated grade 3-4 adverse events (fatal events were not evaluated) with numerically based CTCAE definitions. Descriptive statistics tabulated adverse event frequencies. Adverse events ascertained by ExtractEHR were compared to manually reported adverse events for patients enrolled in two COG trials (AAML1031, NCT01371981; AALL0932, NCT02883049). Analyses were restricted to protocol-defined chemotherapy courses (induction I, induction II, intensification I, intensification II, and intensification III for acute myeloid leukaemia; induction, consolidation, interim maintenance, delayed intensification, and maintenance for acute lymphoblastic leukaemia).

FINDINGS

Laboratory adverse event data from 1077 patients (583 from Children's Healthcare of Atlanta, 200 from the Children's Hospital of Philadelphia, and 294 from the Texas Children's Hospital) who underwent 4611 courses (549 for acute myeloid leukaemia and 4062 for acute lymphoblastic leukaemia) were extracted, processed, and graded. Of the 166 patients with acute myeloid leukaemia, 86 (52%) were female, 80 (48%) were male, 96 (58%) were White, and 132 (80%) were non-Hispanic. Of the 911 patients with acute lymphoblastic leukaemia, 406 (45%) were female, 505 (55%) were male, 596 (65%) were White, and 641 (70%) were non-Hispanic. Patients with acute myeloid leukaemia had the most adverse events during induction I and intensification II. Hypokalaemia (one [17%] of six to 75 [48%] of 156 courses) and alanine aminotransferase (ALT) increased (13 [10%] of 134 to 27 [17%] of 156 courses) were the most prevalent non-haematological adverse events in patients with acute myeloid leukaemia, as identified by ExtractEHR. Patients with acute lymphoblastic leukaemia had the greatest number of adverse events during induction and maintenance (eight adverse events with prevalence ≥10%; induction and maintenance: anaemia, platelet count decreased, white blood cell count decreased, neutrophil count decreased, lymphocyte count decreased, ALT increased, and hypocalcaemia; induction: hypokalaemia; maintenance: aspartate aminotransferase [AST] increased and blood bilirubin increased), as identified by ExtractEHR. 187 (85%) of 220 total comparisons in 22 adverse events in four AAML1031 and six AALL0923 courses were substantially higher with ExtractEHR than COG-reported adverse event rates for adverse events with a prevalence of at least 2%.

INTERPRETATION

ExtractEHR is scalable and accurately defines laboratory adverse event rates for paediatric acute leukaemia; moreover, ExtractEHR seems to detect higher rates of laboratory adverse events than those reported in COG trials. These rates can be used for comparisons between therapies and to counsel patients treated on or off trials about the risks of chemotherapy. ExtractEHR-based adverse event ascertainment can improve reporting of laboratory adverse events in clinical trials.

FUNDING

US National Institutes of Health, St Baldrick's Foundation, and Alex's Lemonade Stand Foundation.

Automated Ascertainment of Typhlitis From the Electronic Health Record

PURPOSE

Adverse events (AEs) on Children's Oncology Group (COG) trials are manually ascertained using Common Terminology Criteria for Adverse Events. Despite significant effort, we previously demonstrated that COG typhlitis reporting sensitivity was only 37% when compared with gold standard physician chart abstraction. This study tested an automated typhlitis identification algorithm using electronic health record data.

METHODS

Electronic health record data from children with leukemia age 0-22 years treated at a single institution from 2006 to 2019 were included. Patients were divided into derivation and validation cohorts. Rigorous chart abstraction of validation cohort patients established a gold standard AE data set. We created an automated algorithm to identify typhlitis matching Common Terminology Criteria for Adverse Events v5 that included antibiotics, neutropenia, and non-negated mention of typhlitis in a note. We iteratively refined the algorithm using the derivation cohort and then applied the algorithm to the validation cohort; performance was compared with the gold standard. For patients on trial AAML1031, COG AE report performance was compared with the gold standard.

RESULTS

The derivation cohort included 337 patients. The validation cohort included 270 patients (961 courses). Chart abstraction identified 16 courses with typhlitis. The algorithm identified 37 courses with typhlitis; 13 were true positives (sensitivity 81.3%, positive predictive value 35.1%). For patients on AAML1031, chart abstraction identified nine courses with typhlitis, and COG reporting correctly identified 4 (sensitivity 44.4%, positive predictive value 100.0%).

CONCLUSION

The automated algorithm identified true cases of typhlitis with higher sensitivity than COG reporting. The algorithm identified false positives but reduced the number of courses needing manual review by 96% (961 to 37) by detecting potential typhlitis. This algorithm could provide a useful screening tool to reduce manual effort required for typhlitis AE reporting.

Incidence and risk factors for hypoglycemia during maintenance chemotherapy in pediatric acute lymphoblastic leukemia

BACKGROUND

Fasting hypoglycemia is a recognized occurrence among pediatric patients with acute lymphoblastic leukemia (ALL) during maintenance therapy. Existing publications describing this finding are limited to small studies and case reports. Our objective was to determine the incidence of hypoglycemia during maintenance chemotherapy and to investigate the association of age, as well as other potential risk factors, with this outcome in pediatric patients with ALL.

PROCEDURE

This retrospective cohort study included individuals 1 to 21 years of age with ALL treated with antimetabolite-containing maintenance chemotherapy at a large children's hospital between January 2011 and December 2014. The primary endpoint was time to first documented episode of hypoglycemia during maintenance therapy, defined as single measurement of plasma glucose <60 mg/dL. Cox regression was used to evaluate the association with age and identify other potential risk factors.

RESULTS

We identified 126 eligible patients, of whom 63% were documented as White, non-Hispanic, 28% as non-White, non-Hispanic, and 9% as Hispanic. Twenty-eight children (22%) had documented hypoglycemia during maintenance therapy. Younger age at the start of maintenance and hepatotoxicity documented during chemotherapy prior to maintenance initiation were associated with hypoglycemia (adjusted HR age = 0.88; 95% CI, 0.78-0.99; adjusted HR prior hepatotoxicity = 3.50; 95% CI, 1.47-8.36).

CONCLUSIONS

Nearly one quarter of children in our cohort had hypoglycemia documented during maintenance chemotherapy. Younger age at maintenance initiation and hepatotoxicity during chemotherapy prior to maintenance initiation emerged as risk factors. These findings highlight the importance of counseling about the risk of, and monitoring for, hypoglycemia, particularly in young children.

Surgical insights and management in patients with the 22q11.2 deletion syndrome

PURPOSE

22q11.2 deletion syndrome (22q11.2DS) can present with a variety challenges to patients and their caregivers, many of which require surgical evaluation and intervention. Surgical needs can also extend long into adulthood, prompting evaluation and intervention throughout development and beyond. Here, we identify common concerns and patient needs associated with the 22q11.2DS from a general surgery perspective, their management, and typical management based on our institution's experience with 1263 patients.

METHODS

1263 patients evaluated and treated at the 22q And You Center at the Children's Hospital of Philadelphia were enrolled and included in the study, from January 1992 to May 2017 Co-morbidities, procedures, and imaging studies performed were quantified and assessed via descriptive analysis.

RESULTS

Gastroesophageal reflux disease (GERD) and feeding difficulties were the most common surgical issues identified, while gastrostomy tube placement, anorectal procedures, and hernia repairs were the most common surgical interventions performed by general surgeons.

CONCLUSIONS

General surgical procedures are commonly needed in this population and are part of the complex needs these patients and their surgeons may encounter in the setting of a 22q11.2DS diagnosis. These findings will help to inform a well-coordinated, multidisciplinary approach to care.

Breaking the myths of competition: a cross-sectional analysis of injuries among CrossFit trained participants

Objectives

The purpose of this study was to examine the injury rates of individuals engaged in CrossFit training and examine the risk of injury associated with competition.

Study design

Cross-sectional analysis.

Methods

Descriptive statistics, including injury incidence and rates, were examined for individuals reporting participation in a CrossFit sanctioned competition between 2013 and 2017. To examine the odds of being injured, we considered logistic regression models, where the primary independent measure was participation length—individual measures of interest included age, sex, body mass index, CrossFit affiliation and competition status.

Results

3049 individuals completed the survey (60% completion rate). All competitors, regardless of competition level, had similar incidence of injury (χ²=1.1, p=0.571). For those who reported competing, our calculated injury rate was 0.21–0.54 injuries per 1000 training hours, while for those not competing, the injury rate was calculated as 0.39–1.30 injuries per 1000 training hours. Logistic regression demonstrated short length of participation in CrossFit training as the main factor associated with the odds of being injured (OR=1.82; 95% CI: 1.15 to 2.92). Additionally, training at an official CrossFit affiliate appeared to have a protective effect from injury (OR=0.85; 95% CI: 0.65, 1.10).

Conclusion

Our findings provide evidence of the low risk of injury related to these events. Moreover, these findings support the notion that musculoskeletal injuries may be the result of poor progression plans, which may be minimised by participating in an official CrossFit affiliate.

Anomalies of the genitourinary tract in children with 22q11.2 deletion syndrome

The 22q11.2 deletion syndrome (22q11.2DS) involves multiple organ systems with variable phenotypic expression. Genitourinary tract abnormalities have been noted to be present in up to 30-40% of patients. At our institution, an internationally recognized, comprehensive, and multidisciplinary 22q11.2DS care center has been providing care to these children. We sought to report on the incidence of genitourinary tract anomalies in this large cohort and, therefore, retrospectively reviewed all patients who underwent a complete evaluation from 1992 to March 2017. We identified all children with any genital or urinary tract anomaly. For all children with a diagnosis of hydronephrosis, the underlying etiology was determined, when possible. Overall, 1,073 of 1,267 children with 22q11.2DS underwent renal evaluations at our institution. Hundered Sixty-Two (15.1%) children had structural abnormalities of their kidneys/urinary tracts. The majority of children with hydronephrosis (63%) had isolated upper tract dilation without any additional diagnoses. Boys were significantly more likely to be diagnosed with a genital abnormality than girls (7.7 vs. 0.5%, p < 0.001). Of the 649 boys in the entire cohort, 24 (3.7%) had cryptorchidism and 24 (3.7%) had hypospadias, which was noted to be mild in all except one boy. Overall, findings of hydronephrosis, unilateral renal agenesis, and multicystic dysplastic kidney occur at higher rates than expected in the general population. Given these findings, in addition to routine physical examination, we believe that all patients with 22q11.2DS warrant screening RBUS at time of diagnosis.

Investigation of association between bovine viral diarrhoea virus and cervid herpesvirus type-1, and abortion in New Zealand farmed deer

This study tested for association between bovine viral diarrhoea virus (BVDv) and cervid herpesvirus type-1 (CvHV-1) exposure and abortion in New Zealand farmed red deer. Rising two-year-old (R2, n = 22,130) and mixed-age (MA, n = 36,223) hinds from 87 and 71 herds, respectively, throughout New Zealand were pregnancy tested using ultrasound early in gestation (Scan-1) and 55-89 days later (Scan-2) to detect mid-term abortion. Sera from aborted and non-aborted hinds at Scan-2 were tested for BVDv and CvHV-1 using virus neutralisation tests. Available uteri from aborted hinds and from hinds not rearing a calf to weaning were tested by PCR for herpesvirus DNA. In herds with aborted hinds, 10.3% of 639 R2 and 17.2% of 302 MA hinds were sero-positive for BVDv and 18.6% of 613 R2 and 68.5% of 232 MA hinds were sero-positive for CvHV-1. There was no association between BVDv sero-status and abortion at animal level (R2 p = 0.36, MA p = 0.76) whereas CvHV-1 sero-positivity was negatively associated with abortion in MA hinds (p = 0.01) but not in R2 hinds (p = 0.36), MA). Eleven of 108 uteri from aborted R2 hinds but no MA hinds were positive for herpesvirus DNA. Vaginal samples from four R2 and one MA aborted hinds tested were negative for herpesvirus DNA. A Cervid Rhadinovirus type-2 (CRhV-2) was identified in seven PCR positive uteri samples. Findings suggest that BVDv and CvHV-1 may not be associated with abortion in R2 hinds, but association needs to be tested further in MA hinds. The role of CRhV-2 requires clarification.

A longitudinal analysis of data quality in a large pediatric data research network

Objective

PEDSnet is a clinical data research network (CDRN) that aggregates electronic health record data from multiple children's hospitals to enable large-scale research. Assessing data quality to ensure suitability for conducting research is a key requirement in PEDSnet. This study presents a range of data quality issues identified over a period of 18 months and interprets them to evaluate the research capacity of PEDSnet.

Materials and Methods

Results were generated by a semiautomated data quality assessment workflow. Two investigators reviewed programmatic data quality issues and conducted discussions with the data partners' extract-transform-load analysts to determine the cause for each issue.

Results

The results include a longitudinal summary of 2182 data quality issues identified across 9 data submission cycles. The metadata from the most recent cycle includes annotations for 850 issues: most frequent types, including missing data (>300) and outliers (>100); most complex domains, including medications (>160) and lab measurements (>140); and primary causes, including source data characteristics (83%) and extract-transform-load errors (9%).

Discussion

The longitudinal findings demonstrate the network's evolution from identifying difficulties with aligning the data to a common data model to learning norms in clinical pediatrics and determining research capability.

Conclusion

While data quality is recognized as a critical aspect in establishing and utilizing a CDRN, the findings from data quality assessments are largely unpublished. This paper presents a real-world account of studying and interpreting data quality findings in a pediatric CDRN, and the lessons learned could be used by other CDRNs.

Brucellosis in Endangered Hector's Dolphins (Cephalorhynchus hectori)

Brucella spp infections of marine mammals are often asymptomatic but have been associated with reproductive losses and deaths. Zoonotic infections originating from marine isolates have also been described. Hector's dolphins (Cephalorhynchus hectori) are an endangered species with a declining population, and the role of infectious disease in population dynamics is not fully understood. In this study, 27 Hector's dolphins found dead around the New Zealand coastline between November 2006 and October 2010 were evaluated for lesions previously associated with cetacean brucellosis. Tissues were examined using histological, immunohistochemical, and molecular (polymerase chain reaction [PCR]) techniques. Seven of 27 dolphins (26%) had at least 1 tissue that was positive on PCR for Brucella spp. Lesions consistent with brucellosis were present in 10 of 27 (37%) dolphins, but in 8 of these dolphins Brucella infection could not be demonstrated in lesional tissues. Two dolphins (7%) were diagnosed with active brucellosis: 1 female with placentitis and metritis, and 1 stillborn male fetus. Brucella identified in these 2 dolphins had genetic similarity (99%) to Brucella pinnipedialis. The omp2a gene amplicon from the uterus of the female had 100% homology with ST27 genotype isolates from a human in New Zealand and a bottlenose dolphin of Pacific origin. The remaining 5 PCR-positive dolphins were assessed as having asymptomatic or latent infection. While most Brucella infections identified in this study appeared to be subclinical, the finding of 2 dolphins with reproductive disease due to Brucella infection suggests that this disease has the potential to affect reproductive success in this species.

Using electronic medical record data to report laboratory adverse events

Despite the importance of adverse event (AE) reporting, AEs are under-reported on clinical trials. We hypothesized that electronic medical record (EMR) data can ascertain laboratory-based AEs more accurately than those ascertained manually. EMR data on 12 AEs for patients enrolled on two Children's Oncology Group (COG) trials at one institution were extracted, processed and graded. When compared to gold standard chart data, COG AE report sensitivity and positive predictive values (PPV) were 0-21·1% and 20-100%, respectively. EMR sensitivity and PPV were >98·2% for all AEs. These results demonstrate that EMR-based AE ascertainment and grading substantially improves laboratory AE reporting accuracy.

Peak cortisol response to corticotropin-releasing hormone is associated with age and body size in children referred for clinical testing: a retrospective review

Background

Corticotropin-Releasing Hormone (CRH) testing is used to evaluate suspected adrenocorticotropic hormone (ACTH) deficiency, but the clinical characteristics that affect response in young children are incompletely understood. Our objective was to determine the effect of age and body size on cortisol response to CRH in children at risk for ACTH deficiency referred for clinical testing.

Methods

Retrospective, observational study of 297 children, ages 30 days – 18 years, undergoing initial, clinically indicated outpatient CRH stimulation testing at a tertiary referral center. All subjects received 1mcg/kg corticorelin per institutional protocol. Serial, timed ACTH and cortisol measurements were obtained. Patient demographic and clinical factors were abstracted from the medical record. Patients without full recorded anthropometric data, pubertal assessment, ACTH measurements, or clear indication for testing were excluded (number remaining = 222). Outcomes of interest were maximum cortisol after stimulation (peak) and cortisol rise from baseline (delta). Bivariable and multivariable linear regression analyses were used to assess the effects of age and size (weight, height, body mass index (BMI), body surface area (BSA), BMI z-score, and height z-score) on cortisol response while accounting for clinical covariates including sex, race/ethnicity, pubertal status, indication for testing, and time of testing.

Results

Subjects were 27 % female, with mean age of 8.9 years (SD 4.5); 75 % were pre-pubertal. Mean peak cortisol was 609.2 nmol/L (SD 213.0); mean delta cortisol was 404.2 nmol/L (SD 200.2). In separate multivariable models, weight, height, BSA and height z-score each remained independently negatively associated (p < 0.05) with peak and delta cortisol, controlling for indication of testing, baseline cortisol, and peak or delta ACTH, respectively. Age was negatively associated with peak but not delta cortisol in multivariable analysis.

Conclusions

Despite the use of a weight-based dosing protocol, both peak and delta cortisol response to CRH are negatively associated with several measures of body size in children referred for clinical testing, raising the question of whether alternate CRH dosing strategies or age- or size-based thresholds for adequate cortisol response should be considered in pediatric patients, or, alternatively, whether this finding reflects practice patterns followed when referring children for clinical testing.

Electronic supplementary material

The online version of this article (doi:10.1186/s13633-015-0018-y) contains supplementary material, which is available to authorized users.

Soil warming alters nitrogen cycling in a New England forest: implications for ecosystem function and structure

Global climate change is expected to affect terrestrial ecosystems in a variety of ways. Some of the more well-studied effects include the biogeochemical feedbacks to the climate system that can either increase or decrease the atmospheric load of greenhouse gases such as carbon dioxide and nitrous oxide. Less well-studied are the effects of climate change on the linkages between soil and plant processes. Here, we report the effects of soil warming on these linkages observed in a large field manipulation of a deciduous forest in southern New England, USA, where soil was continuously warmed 5°C above ambient for 7 years. Over this period, we have observed significant changes to the nitrogen cycle that have the potential to affect tree species composition in the long term. Since the start of the experiment, we have documented a 45% average annual increase in net nitrogen mineralization and a three-fold increase in nitrification such that in years 5 through 7, 25% of the nitrogen mineralized is then nitrified. The warming-induced increase of available nitrogen resulted in increases in the foliar nitrogen content and the relative growth rate of trees in the warmed area. Acer rubrum (red maple) trees have responded the most after 7 years of warming, with the greatest increases in both foliar nitrogen content and relative growth rates. Our study suggests that considering species-specific responses to increases in nitrogen availability and changes in nitrogen form is important in predicting future forest composition and feedbacks to the climate system.

Abstract P1-14-01: Phosphatidylinositol 3-Kinase (PI3K) Pathway Activation in Breast Cancer Brain Metastases

Background:

Brain metastases (BM) are a devastating consequence of advanced breast cancer (BC) for which novel, targeted therapies are urgently needed. The PI3K pathway plays a critical role in the initiation and progression of BC. Alterations in this pathway are implicated in approximately 50% of BC. The role of PI3K activation in BCBM has yet to be explored. Material and Methods:

Under IRB approval (UNC and Duke), we established a clinically-annotated tumor bank including 54 BCBM and 15 matched primary BC. Activation of the PI3K pathway including pAKT, pS6K, and PTEN was assessed via immunohistochemistry (IHC, score 0-3+). BC subtype was assigned by IHC: HR+ (hormone receptor, ER+ and/or PR+)/HER2-, triple-negative (TN; ER-/PR-/HER2-), and HR +or-/HER2+. Overall survival (OS), recurrence patterns and survival following BM was evaluated by the Kaplan-Meier method and compared by the log-rank test.

Results:

Median age was 48 years (range 26-72). Sixty-eight percent of patients (pts) were Caucasian, 30% African-American, and 2% other ethnicities. At median follow-up of 5.9 years (yrs), 70% (38/54) of pts had died. BC subtype was confirmed among 47 pts: 30% (14/47) HR+/HER2-, 45% (21/47) TN and 25% (12/47) HR +or-/HER2+. Subtype concordance between primary BC and BM was 89% (8/9). High expression (IHC score 2-3+) of pAKT and pS6K was observed in 50% (27/54) and 72% (38/54) of the BCBM, respectively. Low expression of PTEN (IHC score 0-1) was observed in 31% (17/54) of BCBM. Concordance of PI3K biomarkers between primary BC and matched BCBM was 47% (7/15), 40% (6/15) and 80% (12/15) for pAKT, pS6K and PTEN, respectively. Both gain and loss of protein expression between primary BC and BCBM was observed in each biomarker evaluated. No significant correlation between BC subtypes and activation status of the PI3K pathway (IHC score 0-1 vs. 2-3+) was observed for pAKT, pS6K or PTEN. Median OS was 7.09 yrs (3.52, 9.21), 4.27 yrs (95% CI 1.84, 5.18), and not reached (NR) for HR+/HER2-, TN and HR +or-/HER2+, respectively (p=0.009). Median OS after BCBM diagnosis was 1.54 yrs (0.27, 2.45), 0.91 yrs (0.51, 1.49) and NR for HR+/HER2-, TN and HR +or-/HER2+, respectively (p=0.0003). Expression (0-1+ vs. 2-3+) of pAKT and pS6K in BCBM was not predictive of OS, time to BCBM recurrence or survival after BCBM (all P&gt;0.1). Although not predictive of inferior survival following BCBM (1.2 vs. 1.5 yrs, p=0.7), low expression (0-1+ vs. 2-3+) of PTEN in BCBM predicted for inferior OS from primary BC diagnosis (5.1 vs. 6.3 yrs, p=0.03) and shorter time to BCBM (2.5 vs. 3.4 yrs, p=0.008). Conclusions:

The PI3K pathway is active in most BCBM regardless of subtype. Considerable discordance exists between PI3K pathway biomarkers in the primary BC and BCBM from the same patient. Low expression of PTEN in BCBM may be prognostic. Given that small molecule inhibitors of the PI3K pathway in clinical development cross the blood brain barrier, inhibition of the PI3K pathway represents a promising therapeutic strategy for a group of patients whose prognosis is poor and for whom systemic therapies are limited.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-14-01.

Improved clinical response from neoadjuvant taxane chemotherapy across breast cancer subtypes

576

Background: Adjuvant trials suggest that taxane (T) after doxorubicin and cyclophosphamide (AC) has little benefit in hormone receptor positive (HR+) patients compared to hormone receptor negative (HR-) patients, particularly if HER2 negative. Primary chemotherapy sensitivity is best determined from the neoadjuvant setting, therefore we sought to determine if HR+ primary tumors are less sensitive to taxane chemotherapy than HR- tumors. Methods: Clinical stage II-III breast cancer patients from the UNC Neoadjuvant Database who received sequential AC and T chemotherapy were evaluated. Clinical and radiographic responses were determined after AC and again after T allowing intrapatient sensitivity comparison, and included RECIST-defined complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD). Hormone receptor status was determined at diagnosis, and subtypes included ER or PR positive, HER2 negative (HR+), ER and PR negative, HER2 positive (HER2+/ER-), and ER, PR and HER2 negative (TN). The ER or PR+, HER2+ group was too small for analysis. Patients who received neoadjuvant trastuzumab were excluded. Relationships of subtype and clinical response to AC and to T were assessed using Fisher's exact test. Results: 157 patients received neoadjuvant AC sequentially followed by T and were eligible for analysis. The majority of TN patients had PR to AC (56%), while the majority of HR+ patients had SD (54%). Of those with measurable disease after AC (n=127), a higher proportion of TN and HER2+/ER- patients had CR to T (43% and 45%, respectively) than HR+ patients (13%, p = 0.008 and p = 0.0393, respectively). While the majority of HR+ patients again had SD (52%), 42% responded to T. Conclusions: Our data suggests that TN and HER2+/ER- patients benefit more from neoadjuvant taxane chemotherapy than HR+ patients, however HR+ patients clearly derived benefit from T administered after AC.

[Table: see text]

No significant financial relationships to disclose.

Differential timing and patterns of recurrence among breast cancer subtypes

1076

Background: At present, effects of heterogeneity among breast cancer subtypes on timing and patterns of relapse are not fully understood. We characterized timing and patterns of distant recurrence among subtypes in women followed from initial diagnosis of breast cancer. Methods: 345 pts with newly diagnosed predominantly stage II-III breast cancer were treated with multiagent neoadjuvant therapy and subtyped by IHC: LumA (ER/PR+, HER2-); LumB (-ER/PR+, HER2+); Basal (triple neg); HER2 (HER2+,ER/PR-). Site-specific patterns of distant metastasis (DM) were examined among pts with single site of first DM. Sites of relapse were bone, CNS, viscera, lymph node, and soft tissue. Time to progression (TTP) was from date of initial diagnosis. Results: 108 patients developed metastatic disease; 65 demonstrated a single site of first DM. Basal subtype was associated with greater CNS and visceral metastases and fewer bone metastases than other subtypes. LumA subtype was associated with fewer CNS and greater bone metastases than other subtypes. [See table]. Dichotomizing as Basal v. non-Basal, bone v. no bone and CNS v. no CNS revealed identical trends with increased significance (p=0.01–0.03). TTP trended toward Basals demonstrating earliest DM and LumA latest. Excluding pts with DM at diagnosis, TTP differed between Basals and non-Basals within viscera (p=0.002, n=14/21, median TTP=10/21); CNS (p=0.047, n=8/7, median TTP=11/27); and bone (p=0.002, n=8/31, median TTP=9/21). Conclusions: Subtypes exhibit distinct timing and patterns of relapse within this largely homogeneous cohort of pts with predominantly locally advanced breast cancer, despite modern multiagent neoadjuvant therapy. Specifically, Basal cancers exhibit earlier recurrence and greater involvement of sites more difficult to treat than non-Basals. Within individual sites TTP differences between Basal and non-Basal tumors persist and are even more pronounced, suggesting that tumor microenvironment does not appear to be driving these differences.

[Table: see text]

No significant financial relationships to disclose.

Phospholipase C-beta1 knockout mice exhibit endophenotypes modeling schizophrenia which are rescued by environmental enrichment and clozapine administration

Phospholipase C-beta1 (PLC-beta1) is a rate-limiting enzyme implicated in postnatal-cortical development and neuronal plasticity. PLC-beta1 transduces intracellular signals from specific muscarinic, glutamate and serotonin receptors, all of which have been implicated in the pathogenesis of schizophrenia. Here, we present data to show that PLC-beta1 knockout mice display locomotor hyperactivity, sensorimotor gating deficits as well as cognitive impairment. These changes in behavior are regarded as endophenotypes homologous to schizophrenia-like symptoms in rodents. Importantly, the locomotor hyperactivity and sensorimotor gating deficits in PLC-beta1 knockout mice are subject to beneficial modulation by environmental enrichment. Furthermore, clozapine but not haloperidol (atypical and typical antipsychotics, respectively) rescues the sensorimotor gating deficit in these animals, suggesting selective predictive validity. We also demonstrate a relationship between the beneficial effects of environmental enrichment and levels of M1/M4 muscarinic acetylcholine receptor binding in the neocortex and hippocampus. Thus we have demonstrated a novel mouse model, displaying disruption of multiple postsynaptic signals implicated in the pathogenesis of schizophrenia, a relevant behavioral phenotype and associated gene-environment interactions.

Sodium channel blockers for cystic fibrosis

BACKGROUND

People with cystic fibrosis (CF) have increased transport of the salt, sodium across their airway lining. Over-absorption of sodium results in the dehydration of the liquid that lines the airway surface and is a primary defect in people with CF.

OBJECTIVES

To determine whether the topical administration of drugs that block sodium transport improves the respiratory condition of people with CF.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We contacted principal investigators known to work in the field, previous authors and pharmaceutical companies who manufacture ion transport agents for unpublished or follow-up data. Most recent search of the Group's register: March 2006

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) or quasi-randomised controlled trials of sodium channel blockers compared to placebo or another sodium channel blocker or the same sodium channel blocker at a different dosing regimen.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. Meta-analysis was limited due to differing study designs.

MAIN RESULTS

Four RCTs, with a total of 205 participants, examining the topical administration of the short-acting sodium channel blocker, amiloride, compared to placebo were identified as eligible for inclusion in the review. For three studies, interventions for six months were completed and it was possible to calculate relative change in respiratory function (FVC). There was a significant difference found in relative change in FVC in favour of placebo (GIV analysis of weighted mean difference for FVC; 1.51% (95% confidence interval -2.77 to -0.25). There were no significant differences identified in other clinically relevant outcomes.

AUTHORS' CONCLUSIONS

We found no evidence that the topical administration of a short-acting sodium channel blocker improves respiratory condition in people with cystic fibrosis and some limited evidence of deterioration in lung function.

Differences in eating pattern labels between maintainers and nonmaintainers in the Women's Health Initiative

OBJECTIVE

To describe how a sample of women in the Women's Health Initiative Dietary Modification Trial (WHIDM) labeled a healthy eating pattern and to compare these labels to their dietary maintenance.

DESIGN

Participants completed a food frequency questionnaire and were divided into two maintenance groups, based on the percentage of energy derived from fat in their diets. Individual, semistructured interviews with the same subjects elicited information on labels they use to describe a healthy eating pattern.

SUBJECTS/SETTINGS

Subjects were 100 postmenopausal women, 50 to 79 years of age, free of breast and colorectal cancer, and participating in a dietary intervention that consisted of 20% or less energy from fat.

MAIN OUTCOME MEASURES

Percentage of energy from fat in the diet and labels used to define a healthy eating pattern.

STATISTICAL ANALYSES PERFORMED

Multivariate analysis.

RESULTS

The label "consistent/patterned" was a predictor of dietary nonmaintenance (p <.05).

IMPLICATIONS

Future studies should use this information to re-educate nonmaintainers on compliance issues.

Physical growth and current health status of infants who were of extremely low birth weight and controls at adolescence

OBJECTIVES

To compare the physical growth, current health status, and utilization of health care resources by extremely low birth weight (ELBW) and control (C) adolescents and to look at changes over time.

METHODS

A longitudinal regional cohort study was conducted. Growth measures were converted to z scores on the National Center for Health Statistics growth curves. Information regarding current health status/health care utilization was obtained by parental interviews.

RESULTS

A total of 154 (91%) of 169 ELBW survivors between 12 and 16 years and 125 (86%) of 145 controls participated. Neurosensory impairments were present in 28% of ELBW survivors and 2% of control participants. Mean z scores for both height and weight were below 0 for ELBW survivors (weight: -0.35; height: -0.55) compared with control participants (weight: 0.40; height: 0.28). However, among ELBW survivors, significant catch-up growth occurred in both parameters between age 8 and adolescence but remained stable among control participants. ELBW survivors had a higher prevalence of visual problems (57% vs 21%), seizures (7% vs 1%), developmental delay (26% vs 1%), learning disabilities (34% vs 10%), and hyperactivity (9% vs 2%) and used more specialists and community resources than did control participants.

CONCLUSIONS

Although physical growth continues to be compromised and substantial morbidity remains among ELBW survivors at adolescence, there seems to be some catch-up growth, a reduction in the prevalence of acute health problems, and a decrease in the utilization of medical resources.

Attitudes of parents and health care professionals toward active treatment of extremely premature infants

OBJECTIVES

To compare the attitudes of neonatologists, neonatal nurses, the parents of extremely low birth weight (ELBW) children, and the parents of normal birth weight children toward saving infants of borderline viability and who should be involved in the decision-making process and to compare physicians' and nurses' estimates of the proportion of infants who are born at various gestational ages with regard to survival, morbidity, and treatment.

METHODS

A questionnaire was given to 169 parents of ELBW children and 123 parents of term children, who were part of a longitudinal study of the outcome of ELBW infants. A similar questionnaire was completed by 98 Canadian neonatologists and 99 neonatal nurses.

RESULTS

Physicians tended to be more optimistic than nurses regarding the probability of survival and freedom from serious disabilities and would recommend to parents life-saving interventions for their child at earlier gestational ages. A significant majority of parents believed that attempts should be made to save all infants, irrespective of condition or weight at birth, compared with only 6% of health professionals who endorsed this. In contrast to parents, health professionals believed that economic costs to society should be a factor in deciding whether to save an ELBW infant. However, health professionals did not believe that the economic status of the parents should be a factor, although the stress of raising an infant with disabilities should be. Most respondents believed that the parents and physicians should make the final decision but that other bodies, such as ethics committees or the courts, should not.

CONCLUSION

Health care professionals must recognize that their attitudes toward saving ELBW infants differ from those of parents. Parents, whether of term or extremely premature children, are more in favor of intervening to save the infant irrespective of its weight or condition at birth than are professionals. It therefore is imperative that there be joint decision making, combining the knowledge of the physician with the wishes of the parents.

Interventions for treating cholestasis in pregnancy

BACKGROUND

Cholestasis of pregnancy has been linked to adverse maternal and fetal/neonatal outcomes. As the pathophysiology is unresolved, therapies have been empiric.

OBJECTIVES

The objective of the review is to evaluate the effectiveness and safety of therapeutic interventions in women with a clinical diagnosis of cholestasis of pregnancy (CIP) SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register, MEDLINE and PREMEDLINE, EMBASE, CINAHL and Current Contents. Date of last search: March 2001.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared an intervention to either a placebo or alternative treatment in women with a diagnosis of intrahepatic cholestasis of pregnancy. Trials published only as abstracts were excluded.

DATA COLLECTION AND ANALYSIS

Reviewers assessed identified trials for 1) eligibility and 2) methodological quality. Attempts were made to contact authors for missing data.

MAIN RESULTS

Nine RCTs involving 227 women were included but adequate data for appropriate comparisons in pruritus, bile acids or liver enzymes were not consistently reported. S-adenosylmethionine (SAMe) versus placebo (four trials, 82 women): only one trial showed significantly greater improvements in pruritus, bile salts and liver enzymes with SAMe. Ursodeoxycholic acid (UDCA) versus placebo (three trials, 56 women): in two trials a significant difference in pruritus relief was not detected. One trial observed greater reductions in bile salts and liver enzymes with UDCA. Preterm births were fewer with UDCA in one study while two studies reported no difference in fetal distress incidence. Guar gum versus placebo (one trial, 48 patients): no differences in pruritus, bile salts, or fetal/neonatal outcomes were observed. Activated charcoal versus no treatment (one trial, 20 patients): the reduction in bile salts was greater with charcoal, but no difference in pruritus relief: relative risk (RR) 9.0 95% confidence interval (CI) 0.6 - 148 or fetal/neonatal outcomes. UDCA versus SAMe (two trials, 36 patients): pruritus relief was better with UDCA in one study and with SAMe in the other. UDCA was better in reducing bile acids but not liver enzymes in one trial. UDCA + SAMe versus placebo, UDCA or SAMe (one study, eight patients/arm): UDCA + SAMe versus placebo or UDCA resulted in greater improvements in pruritus, bile salts and selected liver function assays; UDCA + SAMe versus SAMe resulted in greater improvements in bile salts and ALP only. No treatments were found to be unsafe.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to recommend guar gum, activated charcoal, SAMe and UDCA alone or in combination in treating women with CIP. Inconsistent and inadequate reporting of results precluded pooling the results of small studies.