NOD1 mediates interleukin-18 processing in epithelial cells responding to Helicobacter pylori infection in mice

The interleukin-1 family members, IL-1β and IL-18, are processed into their biologically active forms by multi-protein complexes, known as inflammasomes. Although the inflammasome pathways that mediate IL-1β processing in myeloid cells have been defined, those involved in IL-18 processing, particularly in non-myeloid cells, are still not well understood. Here we report that the host defence molecule NOD1 regulates IL-18 processing in mouse epithelial cells in response to the mucosal pathogen, Helicobacter pylori. Specifically, NOD1 in epithelial cells mediates IL-18 processing and maturation via interactions with caspase-1, instead of the canonical inflammasome pathway involving RIPK2, NF-κB, NLRP3 and ASC. NOD1 activation and IL-18 then help maintain epithelial homoeostasis to mediate protection against pre-neoplastic changes induced by gastric H. pylori infection in vivo. Our findings thus demonstrate a function for NOD1 in epithelial cell production of bioactive IL-18 and protection against H. pylori-induced pathology.

The effect of standing posture on amplitude and variability of postural tremor in Parkinson’s disease

INTRODUCTION

This study examined whether altering body position (i.e., sitting or standing) affected the dynamics of physiological tremor for healthy older adults and persons with Parkinson's disease (PD). It was also of interest to determine how consistent the tremor was for both groups as determined by examining changes in within-subject variability of tremor amplitude, regularity and frequency.

METHODS

Ten Parkinsonian participants (65.1±3.2 yrs.) and twelve elderly persons (71.2±2.6 yrs.) participated in this study. Tremor was collected from the index finger and hand segments using lightweight accelerometers during the performance of a bilateral pointing task. Persons performed the pointing task in a standing or sitting position.

RESULTS

As expected, the tremor for the PD persons was greater in magnitude (mean RMS, peak power), more regular (lower SampEn), and more inconsistent from trial-to-trial (increased intra-individual variability, IIV) than the tremor recorded for the elderly. Further, when assessed during standing, the magnitude of the tremor for all individuals (elderly and PD) was greater, more variable, and less complex compared to the tremor when assessed during the sitting posture. The only measure which did not change within each group was the frequency of the major tremor peak which remained consistent, showing no significant change between limbs or as a function of the posture adopted.

CONCLUSION

The findings revealed that tremor increased in amplitude and decreased in regularity for all individuals was assessed when standing compared to sitting. It is likely that these increases were task-related, reflecting the increased physical demands of performing the task when standing rather than being driven by specific age- or disease-related changes in the mechanisms underlying tremorgenesis. Further, the tremor for the PD individuals tended to be more variable from trial-by-trial in terms of both amplitude and regularity as compared to the elderly persons. Interestingly, the only tremor metric which showed no change within each group was the frequency of the major tremor peak which was consistent within both groups irrespective of the posture adopted.

AB0209 PHYSICIAN TRUST RATHER THAN RHEUMATOID ARTHRITIS KNOWLEDGE RELEVANT IN DISEASE OUTCOMES IN ETHNIC MINORITY PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Ethnic minority (EM) patients with Rheumatoid Arthritis (RA) have more severe disease, more disability, and less use of biologic disease modifying anti-rheumatic drugs (bDMARDs). A Treat to target (T2T) strategy has been recommended to improve clinical outcomes but barriers include patient preference, access to specialty care and increased administrative effort. Additionally, EM patients in the US often have low health literacy, express greater reluctance to accept physician recommendations, in part due to sociocultural preference and mistrust of a historically biased healthcare system. It is unknown whether improving knowledge of RA would improve T2T outcomes in EM active RA patients.

Objectives

To assess the proportion of EM RA patients who achieve low disease activity or remission following implementation of a coordinator-based education program highlighting T2T RA strategy.

Methods

Adult participants with active RA (RAPID3>6 or CDAI > 10) were invited to participate in a series of five one-on-one 20-minute educational sessions, co-occurring with scheduled routine clinic visits (6 -12-week intervals). Sessions were facilitated by a rheumatology care coordinator, a non-healthcare professional with intensive training over 4 weeks to conduct RA patient education. Sociodemographic data was collected, and disease activity measures (TJC, SJC, RAPID3, CDAI) and validated patient questionnaires on RA Knowledge (ACREU), compliance (CQR5), and physician trust (Trust in Physician Scale) were recorded at baseline and after the final educational session. Descriptive statistics were applied and medians and ranges for instrument scores are reported. Paired T-test was used to test for significant differences in scores after the education sessions. Correlations between the ACREU scores and clinical-demographic variables were measured using Pearson’s correlation coefficient.

Results

20 EM patients (75% Female, mean age, 58.8 years (12.2) seen by EM physicians were enrolled, with mean RA disease duration of 7 years and poor prognosticators (75% double seropositivity). ACREU scores were low at baseline (mean 0.45 (0.16)), with no significant improvement on completion of educational sessions, and no correlation with years of education or duration of RA. There was a positive correlation between ACREU and compliance scores at baseline (r=0.3). Average duration of the education period was 9.72 months, with a 33% decrease in average RAPID3 over time, and 42% of patients achieving a target of remission or LDA. Trust in Physician scores were high at baseline and persisted with >50% of patients completing at least one medication change during study period.

Conclusion

RA knowledge did not impact RA patient outcomes in this cohort of EM patients. However, patients had high trust in their providers and achieved clinical remission or LDA despite risk for poor outcomes highlighting the importance of the provider- patient relationship in achieving targeted goals of therapy. Limitations include the small sample size from a single institution, and the lengthy time between initial and final assessment of RA knowledge.

References

[1]Lineker SC, Badley EM, Hughes EA, Bell MJ. Development of an instrument to measure knowledge in individuals with rheumatoid arthritis: the ACREU rheumatoid arthritis knowledge questionnaire. The Journal of rheumatology. 1997/04// 1997;24(4):647-653.

[2]Hughes LD, Done J, Young A. A 5 item version of the Compliance Questionnaire for Rheumatology (CQR5) successfully identifies low adherence to DMARDs. BMC Musculoskeletal Disorders. 2013-12-01 2013;14(1):286. doi:10.1186/1471-2474-14-286

[3]Anderson LA, Dedrick RF. Development of the Trust in Physician Scale: A Measure to Assess Interpersonal Trust in Patient-Physician Relationships. Psychological Reports. 1990-12-01 1990;67(3_suppl):1091-1100. doi:10.2466/pr0.1990.67.3f.1091

Acknowledgements

Sincere gratitude to our patients for their participation, and to the team at Bristol Myers Squibb for supporting this research initiative.

Disclosure of Interests

Sharon Dowell Speakers bureau: Horizon Pharma, Aurinia Pharmaceuticals Inc, Abbvie, Grant/research support from: Pfizer, Bristol Myers Squibb, Mercedes Quinones Speakers bureau: Abbvie, Sanofi Genzyme, Grant/research support from: Bristol Myers Squibb, Pfizer, Alani Miller: None declared, Oshoze Kadiri: None declared, Tahereh Jamshidi: None declared, Gail Kerr Speakers bureau: Aurinia Pharmaceuticals Inc, Consultant of: CSL Behring, Janssen, Pfizer, Samumed, UCB, Viela Bio/Horizon, Grant/research support from: Novartis

POS0487 ASSOCIATION OF RHEUMATOID ARTHRITIS WITH MORTALITY IN A COHORT OF CHRONIC KIDNEY DISEASE PATIENTS

Background:

Rheumatoid Arthritis (RA) is associated with an increased risk of cardiovascular disease. RA is also associated with increased risk of chronic kidney disease (CKD) (1, 2), which is a known cardiovascular risk factor (3). We hypothesized that RA (compared with no RA) would be associated with increased risk of mortality among a cohort of patients with CKD.

Objectives:

To determine the risk of mortality in RA patients with CKD.

Methods:

This study was conducted using participants from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) prospective Chronic Renal Insufficiency Cohort (CRIC) study. Approximately 3600 participants were enrolled from seven US clinical centers. Patients aged 21 – 74 years with mild to moderate CKD were eligible for enrollment. The primary outcome of interest was all-cause mortality. Secondary outcomes of interest included: kidney event defined as end stage renal disease (ESRD) or 50% decline in estimated glomerular filtration rate (eGFR), myocardial infarction (MI), cerebrovascular accident (CVA), heart failure and a composite cardiovascular endpoint. The association of RA mortality over time was examined using Cox multivariate proportional hazards regression, adjusting for potential covariates (age, sex, race/ethnicity, BMI, current smoker, education).

Results:

The study cohort included 492 participants with self-reported RA with a mean follow up of 9.5 years. Compared to the non-RA group, RA patients tended to be older, female, Black. Hypertension, diabetes, use of prednisone was more prevalent among the RA cohort. The unadjusted hazards ratio (HR) for mortality based on RA status was 1.45 (1.26, 1.67) but this association was attenuated after adjusting for the confounding factors [aHR 1.09 (0.94, 1.27)] (Table 1). Participants with RA had a significantly higher risk for heart failure than those without RA [aHR 1.17 (1.02, 1.34)]. We did not observe a statistically significant association between RA status and other secondary outcomes.

Conclusion:

RA was not associated with higher mortality among participants with CKD. However, RA was associated with higher rates of heart failure. Further studies evaluating the mechanisms behind this association are needed.

References:

[1]Kochi M, Kohagura K, Shiohira Y, Iseki K, Ohya Y. Chronic kidney disease, inflammation, and cardiovascular disease risk in rheumatoid arthritis. J Cardiol. 2018;71(3):277-83.

[2]Sumida K, Molnar MZ, Potukuchi PK, Hassan F, Thomas F, Yamagata K, et al. Treatment of rheumatoid arthritis with biologic agents lowers the risk of incident chronic kidney disease. Kidney Int. 2018;93(5):1207-16.

[3]Chiu HY, Huang HL, Li CH, Chen HA, Yeh CL, Chiu SH, et al. Increased Risk of Chronic Kidney Disease in Rheumatoid Arthritis Associated with Cardiovascular Complications - A National Population-Based Cohort Study. PLoS One. 2015;10(9):e0136508.

[4]Muthukumar P, Dhanapriya J, Gopalakrishnan N, Dineshkumar T, Sakthirajan R, Balasubramaniyan T. Evaluation of renal lesions and clinicopathologic correlation in rheumatoid arthritis. Saudi J Kidney Dis Transpl. 2017;28(1):44-50.

Table 1.

Estimated hazard ratios (HR) for various outcomes from Cox proportional hazards regression for RA status

UnadjustedModel 1Model 2HR (95% CI)HR (95% CI)HR (95% CI)Death1.45 (1.26, 1.67)1.09 (0.94, 1.27)1.13 (0.97, 1.32)MI or death1.43 (1.25, 1.63)1.09 (0.95, 1.26)1.15 (0.99, 1.33)CVA or death1.42 (1.24, 1.63)1.07 (0.92, 1.24)1.11 (0.95, 1.29)CHF or death1.54 (1.35, 1.75)1.17 (1.02, 1.34)1.22 (1.06, 1.40)Composite1.49 (1.31, 1.69)1.13 (0.99, 1.30)1.18 (1.03, 1.35)Kidney event1.09 (0.94, 1.27)0.91 (0.78, 1.07)1.01 (0.85, 1.20)

Model 1 adjusted for: age, sex, race/ethnicity, BMI, current smoker, education

Model 2 adjusted for: model 1 + cardiovascular risk factors (urine albumin creatinine ratio, systolic blood pressure, estimated glomerular filtration rate)

Disclosure of Interests:

None declared

The Importance of Prostate-specific Antigen (PSA) Nadir and Early Identification of PSA Relapse after 10 Years of Prostate Iodine 125 Seed Brachytherapy in Edinburgh

AIMS

To analyse our 5 and 10 year prostate brachytherapy outcome data and to assess the impact of PSA nadir on relapse free survival and whether an alternative definition of PSA relapse could detect men destined to fail by the Phoenix definition at an earlier time point.

MATERIALS AND METHODS

474 men were treated over a 10 year period between 20012 and 2011 and divided into 2 five year cohorts for the purpose of the analysis.

RESULTS

The risk of relapse is strongly predicted by post treat prostate-specific antigen (PSA) nadir. After 3 years post-treatment, PSA nadir plus 0.4 ng/ml identified men at risk of relapse 17 months earlier than the Phoenix definition.

CONCLUSION

The Phoenix definition of nadir plus 2.0 ng/ml does not allow the early identification of men destined to relapse. The initiation of salavage therapy at the earliest opportunity could potentially affect subsequent survival and an outline randomised controlled trial proposal is presented.

The perspectives of adults with venous leg ulcers on exercise: an exploratory study

OBJECTIVE

Exercise has the potential to offer a range of health benefits in addition to improving healing outcomes for people with venous leg ulcers (VLUs). However, despite evidence-based recommendations, most of these individuals do not engage in regular exercise. The aim of this study was to gain an understanding of the perspectives of adults with VLUs, in relation to exercise.

METHOD

This was a qualitative design using semi-structured interviews and discussions. Ten participants with venous leg ulceration volunteered to participate. Recruitment was through a specialist wound clinic. Verbatim data were collected by an experienced moderator using a semi-structured guide. Data saturation was reached after three group discussions and two interviews. A random selection of transcripts was sent back to the participants for verification. Thematic content analysis was used to determine major themes and categories. Two transcripts were independently analysed, categories and themes independently developed, cross checked and found comparable. Remaining transcripts were analysed using the developed categories and codes.

RESULTS

Regardless of their current exercise routine, participants reported exercising before venous leg ulceration and expressed an interest in either becoming active or maintaining an active lifestyle. Overall, four themes emerged from the findings: i) participant understanding of the relationship between chronic venous insufficiency and exercise patterns; ii) fear of harm impacts upon positive beliefs and attitudes to exercise; iii) perceived factors limit exercise; and iv) structured management facilitates exercise.

CONCLUSION

The value of exercise in improving outcomes in VLUs lies in its capacity to promote venous return and reduce the risk of secondary conditions in this population. Despite motivation and interest in being exercise active, people with VLUs report many obstacles. Further exploration of mechanisms that assist this patient population and promote understanding about management of barriers, coupled with promotion of enabling factors, is vital for improving their exercise participation.

The pattern of coupling dynamics between postural motion, isotonic hand movements and physiological tremor

This study was designed to examine differences in the coupling dynamics between upper limb motion, physiological tremor and whole body postural sway in young healthy adults. Acceleration of the hand and fingers, forearm EMG activity and postural sway data were recorded. Estimation of the degree of bilateral and limb motion-postural sway coupling was determined by cross correlation, coherence and Cross-ApEn analyses. The results revealed that, under postural tremor conditions, there was no significant coupling between limbs, muscles or sway across all metrics of coupling. In contrast, performing a rapid alternating flexion/extension movement about the wrist joint (with one or both limbs) resulted in stronger coupling between limb motion and postural sway. These results support the view that, for physiological tremor responses, the control of postural sway is maintained independent to tremor in the upper limb. However, increasing the level of movement about a distal segment of one arm (or both) leads to increased coupling throughout the body. The basis for this increased coupling would appear to be related to the enhanced neural drive to task-specific muscles within the upper limb.

Malnutrition and falls risk in community-dwelling older adults

BACKGROUND AND AIMS

Falls and fall-related injuries result in reduced functioning, loss of independence, premature nursing home admissions and mortality. Malnutrition is associated with falls in the acute setting, but little is known about malnutrition and falls risk in the community. The aim of this study was to assess the association between malnutrition risk, falls risk and falls over a one-year period in community-dwelling older adults.

METHODS

Two hundred and fifty four subjects >65 years of age were recruited to participate in a study in order to identify risk factors for falls. Malnutrition risk was determined using the Mini Nutritional Assessment-Short Form.

RESULTS

28.6% had experienced a fall and according to the Mini Nutritional Assessment-Short Form 3.9% (n=10) of subjects were at risk of malnutrition. There were no associations between malnutrition risk, the risk of falls, nor actual falls in healthy older adults in the community setting.

CONCLUSIONS

There was a low prevalence of malnutrition risk in this sample of community-dwelling older adults and no association between nutritional risk and falls. Screening as part of a falls prevention program should focus on the risk of developing malnutrition as this is associated with falls.

Variability, regularity and coupling measures distinguish PD tremor from voluntary 5Hz tremor

A characteristic of Parkinson's disease (PD) is the development of tremor within the 4-6Hz range. One method used to better understand pathological tremor is to compare the responses to tremor-type actions generated intentionally in healthy adults. This study was designed to investigate the similarities and differences between voluntarily generated 4-6Hz tremor and PD tremor in regards to their amplitude, frequency and coupling characteristics. Tremor responses for 8 PD individuals (on- and off-medication) and 12 healthy adults were assessed under postural and resting conditions. Results showed that the voluntary and PD tremor were essentially identical with regards to the amplitude and peak frequency. However, differences between the groups were found for the variability (SD of peak frequency, proportional power) and regularity (Approximate Entropy, ApEn) of the tremor signal. Additionally, coherence analysis revealed strong inter-limb coupling during voluntary conditions while no bilateral coupling was seen for the PD persons. Overall, healthy participants were able to produce a 5Hz tremulous motion indistinguishable to that of PD patients in terms of peak frequency and amplitude. However, differences in the structure of variability and level of inter-limb coupling were found for the tremor responses of the PD and healthy adults. These differences were preserved irrespective of the medication state of the PD persons. The results illustrate the importance of assessing the pattern of signal structure/variability to discriminate between different tremor forms, especially where no differences emerge in standard measures of mean amplitude as traditionally defined.

Evaluating a community-based dental registration program for preschool children living in areas of high social deprivation

AIM

This was to evaluate the effectiveness of a community-based program to promote dental registration and access to dental services for preschool children residing in areas of high social deprivation using monthly registration data provided by the Central Services Agency (CSA).

DESIGN

A quasi-experimental non-equivalent two group comparison.

SETTING

Areas of high social deprivation in the greater Belfast area.

METHODS

The dental registration program was conducted by community-based nurses (health visitors). The health visitors provided oral health education and distributed registration vouchers to mothers of new babies during home visits. The mothers exchanged the vouchers for motivational materials from the participating dental practices. Preschool child registration data were obtained from the CSA to evaluate the effectiveness of the program.

RESULTS

The registration rates were significantly greater 5 months after the program for 0-2-year old children residing in the intervention wards compared with control wards. During the program the rate of change in registration for the 0-2-year-old group residing in the intervention wards was significantly greater compared with those residing in the control wards (t [DF:21]=4.26: p<0.001). There was a significant increase in registration rate 5 months after the program compared with 6 months before the study started for the 0-2 year old group residing in the intervention wards compared with those residing in the control wards (t [df: 21]=3.33: P=0.003). There were no equivalent effects for the 3-5-year old group.

CONCLUSION

The adoption of a community-based approach assisted in promoting dental registration and access to dental services for preschool children residing in areas of high social deprivation.

Benefit of chemotherapy as part of treatment for HPV DNA-positive but p16-negative squamous cell carcinoma of the oropharynx

Background:

To determine (a) the cause of an improvement in survival from oropharyngeal squamous cell carcinoma (OSCC) in South East Scotland and (b) whether this improvement was human papillomavirus (HPV) and p16 subtype-dependent.

Methods:

Clinicopathological characteristics and outcome data for patients referred with OSCC from 1999 to 2001 (Cohort-1) and 2003 to 2005 (Cohort-2) were obtained. Molecular HPV detection and immunohistochemistry for p16 were performed from paraffin blocks.

Results:

Cohort-1 and Cohort-2 contained 118 and 136 patients, respectively. Kaplan–Meier analysis revealed significantly improved survival in Cohort-2 (P<0.0001). Sub-classification according to HPV and p16 status revealed no improvement in survival in Class-I (HPV−ve/p16−ve; 47 patients) or Class-III (HPV+ve/p16+ve; 77 patients). However in Class-II (HPV+ve/p16−ve; 56 patients) an increase in 5-year cause-specific survival from 36% in Cohort-1 to 73% in Cohort-2 was detected (P=0.0001).

Proportional hazards analysis of 217 patients treated radically demonstrated that significant variables were p16 (P<0.0001), N stage (P=0.0006) and cohort (P=0.0024). Removing cohort from the variables offered to the model showed that, whereas p16 (P<0.0001) and N stage (P=0.0016) remain significant, chemotherapy (P=0.0163) and T stage (P=0.0139) are now significant. This suggests that much of the cohort effect is due to the higher use of chemotherapy in the second cohort.

Conclusion:

These data suggest that HPV+ve/p16−ve patients constitute a separate subclass of OSCC who may particularly benefit from chemotherapy. They imply that p16 status cannot be considered a surrogate for HPV status, and those trials to de-escalate treatment in HPV+ve OSCC should take p16 status into account.

Comparison of microarray preprocessing methods

Data preprocessing in microarray technology is a crucial initial step before data analysis is performed. Many preprocessing methods have been proposed but none has proved to be ideal to date. Frequently, datasets are limited by laboratory constraints so that the need is for guidelines on quality and robustness, to inform further experimentation while data are yet restricted. In this paper, we compared the performance of four popular methods, namely MAS5, Li & Wong pmonly (LWPM), Li & Wong subtractMM (LWMM), and Robust Multichip Average (RMA). The comparison is based on the analysis carried out on sets of laboratory-generated data from the Bioinformatics Lab, National Institute of Cellular Biotechnology (NICB), Dublin City University, Ireland. These experiments were designed to examine the effect of Bromodeoxyuridine (5-bromo-2-deoxyuridine, BrdU) treatment in deep lamellar keratoplasty (DLKP) cells. The methodology employed is to assess dispersion across the replicates and analyze the false discovery rate. From the dispersion analysis, we found that variability is reduced more effectively by LWPM and RMA methods. From the false positive analysis, and for both parametric and nonparametric approaches, LWMM is found to perform best. Based on a complementary q-value analysis, LWMM approach again is the strongest candidate. The indications are that, while LWMM is marginally less effective than LWPM and RMA in terms of variance reduction, it has considerably improved discrimination overall.

Medication safety improves after implementation of positive patient identification

OBJECTIVE

To report the incidence and severity of medication safety events before and after initiation of barcode scanning for positive patient identification (PPID) in a large teaching hospital.

METHODS

Retrospective analysis of data from an existing safety reporting system with anonymous and non-punitive self-reporting. Medication safety events were categorized as "near-miss" (unsafe conditions or caught before reaching the patient) or reaching the patient, with requisite additional monitoring or treatment. Baseline and post-PPID implementation data on events per 1,000,000 drug administrations were compared by chi-square with p<0.05 considered significant.

RESULTS

An average of 510,541 doses were dispensed each month in 2008. Total self-reported medication errors initially increased from 20 per million doses dispensed pre-barcoding (first quarter 2008) to 38 per million doses dispensed immediately post-intervention (last quarter 2008), but errors reaching the patient decreased from 3.26 per million to 0.8 per million despite the increase in "near-misses". A number of process issues were identified and improved, including additional training and equipment, instituting ParX scanning when filling Pyxis machines, and lobbying for a manufacturing change in how bar codes were printed on bags of intravenous solutions to reduce scanning failures.

CONCLUSION

Introduction of barcoding of medications and patient wristbands reduced serious medication dispensing errors reaching the patient, but temporarily increased the number of "near-miss" situations reported. Overall patient safety improved with the barcoding and positive patient identification initiative. These results have been sustained during the 18 months following full implementation.

Expression Levels of Co-Regulators in Early Breast Cancer

Introduction: The p160 (SRC) family of estrogen receptor (ER) co-activators have important implications in tamoxifen resistance. The SRC family play a central role in ER mediated transcription. There are three family members; SRC-1, SRC-2 and AIB1. AIB1 is amplified in 5-10% of human breast cancers. SRC-1 expression is associated with HER2 expression, increased risk of recurrence and insensitivity to endocrine treatment. Co-factors interact with the ER and basal transcriptional machine to activate or repress ER-mediated transcription. To investigate the role of ER and its co-factors in breast cancer we have carried out quantitative RT-PCR (qRT-PCR) to measure the relative expression of ERa and its co-factors.Methods: In this study we examined patients which were untreated or treated with chemotherapy or hormonal therapy following breast conservation surgery. RNA was extracted from 340 early breast cancer specimens from the Edinburgh Breast Conserving Surgery cohort (BCS). The BCS is a fully documented consectutive cohort of breast cancers treated by conservation surgery, axillary node sampling or clearance, and whole breast radiotherapy between 1981-1998. Clinico-pathological features and complete follow up (duration &gt;10 years) is available for this cohort. qRT-PCR was carried out using primers for ER, SRC-1, SRC-2, AIB1, NCoR1 and SMRT.Results: This study demonstrated SRC-1 expression to be negatively correlated with both SRC-2 and AIB1 expression. SRC-1 expression was also negatively correlated with the co-repressors NCoR1 and SMRT expression. There was a strong correlation between the co-repressors, NCoR1 and SMRT and the co-activators SRC-2 and AIB1. Relapse-free survival (RFS) was estimated using Kaplan-Meier curves. Patients who had high expression of all three co-activators had reduced relapse-free survival (HR: 2.15 95%C.I. 1.175-3.921, p=0.01). No significant association was noted with overall survival. Exploratory subgroup analysis was under powered and showed no significant association with outcome.Conclusion: In conclusion, our study of expression levels of ER and its cofactors by quantitative RT-PCR in breast cancer samples revealed a correlation between the co-factors and co-repressors. These findings would suggest that ER and cofactors may play a synergistic role in the development and progression of breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2127.

The Expression of Insulin-Like Growth Factor-1 Receptor (IGF-1R) in Early Breast Cancer

Background: The insulin-like growth factor-1 receptor (IGF-1R) is expressed in normal breast epithelial cells and breast carcinomas. A number of studies have examined the over-expression of IGF-1R in breast cancer with the range of between 39% to 93%. However, many of these studies were carried out using ELISAs, radioimmunoassay with small patient cohorts. Phosphorylation of IGF-1R results in the activation of the MAPK and PI3K/Akt pathway. Activation of the PI3K/Akt pathway under the influence of IGF-1R plays an important role in maintaining the proliferation of breast cancer cells that are resistant to gefitnib, trastuzumab or chemoradiotherapy in vitro and in vivo. In the present study, we examined the expression of IGF-1R in early breast cancer and investigated the clinicopathological implications using immunohistochemistry and FISH.Methods: TMAs from a consecutive series (1981-98) of 1,812 women managed by wide local excision and postoperative radiotherapy (45Gy in 20-25 fractions) were collected following appropriate ethical review. Of 1686 cases stained, 198 received no adjuvant hormonal or chemotherapy, 1106 received tamoxifen only as adjuvant therapy and 144 received a combination of hormonal and chemotherapy. Median age at diagnosis was 56, 72% were post-menopausal, 23.9% node positive, median size was 1.5 cm. Samples were stained, using triplicate 0.6mm2 TMA cores for IGF-1R.Results: FISH for IGF1R gene amplification was successful in 343/408 cases (84%). Only 7 cases of IGF1R amplification were observed (2%). IGF1R expression was successfully evaluated in 1597 of 1686 (94.7%) cases. High levels of IGF-1R expression was weakly associated with tumour ER-a (correlation coefficient, 0.108; p=2.2 x 10-5) and PgR levels (correlation coefficient 0.162; p=1.86x10-10) and inversely correlated with EGFR expression (correlation coefficient -0.189; p=6.33x10-6). No association was noted between IGF1R expression and other molecular or clinical markers, such as tumour size. There was a trend for over-expression of IGF-1R to link with increased distant relapse free survival, particularly in ER positive breast cancers. This trend is time dependent, such that no difference in outcome is observed at 15 years.Conclusions: We have demonstrated in a large cohort of patients that IGF-1R gene amplification is a rare event, and over-expression is weakly associated with good prognostic features (ERa and PgR, lack of EGFR and better outcome).

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2128.

Mammostrat® as a tool to stratify patients at risk of recurrence during endocrine therapy

Abstract #3026

Background: Patients with early stage ER+ve breast cancer have excellent prognosis with ca 90% 5 year disease free survival when treated with endocrine therapy. However for patients who relapse during endocrine therapy additional adjuvant therapy options, such as chemotherapy, are indicated. The challenge is to prospectively identify such patients. The Mammostrat® test comprises 5 simple immunohistochemical markers (p53, HTF9C, CEACAM5, NDRG1, SLC7A5) which stratify node negative tamoxifen treated patients into low, moderate and high risk groups. We have now tested the efficacy of this panel in a mixed population of node positive/node negative cases treated in a single centre (Edinburgh Breast Unit) with breast conserving surgery.&#x2028; Methods: TMAs from a consecutive series (1981-98) of 1,812 women managed by wide local excision and postoperative radiotherapy (45Gy in 20-25 fractions) were collected following appropriate ethical review. Of 1390 cases stained, 197 received no adjuvant hormonal or chemotherapy, 1044 received tamoxifen only as adjuvant therapy and 149 received a combination of hormonal and chemotherapy. Median age at diagnosis was 57, 71% were post-menopausal, 23.9% node positive, median size was 1.5 cm. Samples were stained, using triplicate 0.6mm2 TMA cores and positivity for p53, HTF9C, CEACAM5, NDRG1, SLC7A5 recorded as previously described. Each case was assigned a Mammostrat score and RFS and OS analysed by marker positivity and Mammostrat score.&#x2028; Results: Staining for all 5 antibodies was successful in 1174/1390 (84%) of cases. In the primary analysis of 531 N0/ER+ve Tamoxifen only treated patients Mammostrat was significantly associated with relapse free survival (RFS) in univariate (p=0.025) & multivariate proportional hazards analysis (p=0.01, HR=1.3, 95%C.I. 1.08-1.74). PgR, multifocality and menopausal status were significant co-variates (p&lt;0.05, HR 0.89, 2.0 & 0.6 respectively). The Nottingham prognostic index was non-significant. Of the 5 antibodies, only p53 (p=0.04) was independently predictive of survival.&#x2028; In a secondary univariate analysis of 781 patients (including N+ve and chemo/tam treated patients) Mammostrat was predictive of RFS & OS (p&lt;0.01) with NDRG1/CEACAM5/p53 also predictive of RFS(p&lt;0.05). However Mammostrat was not independent of nodal status, pathological size, grade or multifocality in a proportional hazards analysis.&#x2028; Discussion: In the Edinburgh BCS population Mammostrat was predictive of RFS (both local and distant relapses) in N-ve/ER+ve patients treated with tamoxifen alone irrespective of menopausal status. There was a strong correlation between Mammostrat scores and grade, however, in a multivariate analysis Mammostrat contributed significantly to prognostication along with PgR, multifocality and menopausal status.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3026.

Autologous olfactory ensheathing cell transplantation in human paraplegia: a 3-year clinical trial

Olfactory ensheathing cells show promise in preclinical animal models as a cell transplantation therapy for repair of the injured spinal cord. This is a report of a clinical trial of autologous transplantation of olfactory ensheathing cells into the spinal cord in six patients with complete, thoracic paraplegia. We previously reported on the methods of surgery and transplantation and the safety aspects of the trial 1 year after transplantation. Here we address the overall design of the trial and the safety of the procedure, assessed during a period of 3 years following the transplantation surgery. All patients were assessed at entry into the trial and regularly during the period of the trial. Clinical assessments included medical, psychosocial, radiological and neurological, as well as specialized tests of neurological and functional deficits (standard American Spinal Injury Association and Functional Independence Measure assessments). Quantitative test included neurophysiological tests of sensory and motor function below the level of injury. The trial was a Phase I/IIa design whose main aim was to test the feasibility and safety of transplantation of autologous olfactory ensheathing cells into the injured spinal cord in human paraplegia. The design included a control group who did not receive surgery, otherwise closely matched to the transplant recipient group. This group acted as a control for the assessors, who were blind to the treatment status of the patients. The control group also provided the opportunity for preliminary assessment of the efficacy of the transplantation. There were no adverse findings 3 years after autologous transplantation of olfactory ensheathing cells into spinal cords injured at least 2 years prior to transplantation. The magnetic resonance images (MRIs) at 3 years showed no change from preoperative MRIs or intervening MRIs at 1 and 2 years, with no evidence of any tumour of introduced cells and no development of post-traumatic syringomyelia or other adverse radiological findings. There were no significant functional changes in any patients and no neuropathic pain. In one transplant recipient, there was an improvement over 3 segments in light touch and pin prick sensitivity bilaterally, anteriorly and posteriorly. We conclude that transplantation of autologous olfactory ensheathing cells into the injured spinal cord is feasible and is safe up to 3 years of post-implantation, however, this conclusion should be considered preliminary because of the small number of trial patients.

Bilateral tremor relations in Parkinson's disease: effects of mechanical coupling and medication

The aim of the present study was to examine the dynamics of bilateral multiple segment resting and postural tremor in 12 young, older subjects and eight Parkinson's (PD) patients in their different medication states. A second aim was to investigate whether bilateral independence of upper limb tremor was preserved for PD patients with amplified tremor under conditions where no upper limb segment was supported. Under these conditions, the likelihood for mechanical transmission between segments was increased. Tremor was recorded, bilaterally, from the hand and finger segments of all subjects. In addition to the PD subjects exhibiting greater tremor under both on/off medication states than the young/old control subjects, the tremor increase within limb from the hand to the finger was 2-3 times greater for the PD group in comparison to the healthy subjects. Despite this increased tremor, no differences were observed in the level of coupling between limbs across groups. Furthermore, the degree of coupling between limbs for the PD group was unaffected by their medication state. Overall, these results demonstrate that bilateral independence of tremor in PD participants is preserved despite conditions which maximised the chance of increased coupling.

Quantitative assessment of driving performance in Parkinson's disease

OBJECTIVES

The primary aim of this study was to determine how Parkinson's disease (PD) affects driving performance. It also examined whether changes in driver safety were related to specific clinical disease markers or an individual's self rating of driving ability.

METHODS

The driving performance of 25 patients with idiopathic PD and 21 age matched controls was assessed on a standardised open road route by an occupational therapist and driving instructor, to provide overall safety ratings and specific driving error scores.

RESULTS

The drivers with PD were rated as significantly less safe (p<0.05) than controls, and more than half of the drivers with PD would not have passed a state based driving test. The driver safety ratings were more strongly related to disease duration (r = -0.60) than to their on time Unified Parkinson's Disease Rating Scale (r = -0.24). Drivers with PD made significantly more errors than the control group during manoeuvres that involved changing lanes and lane keeping, monitoring their blind spot, reversing, car parking, and traffic light controlled intersections. The driving instructor also had to intervene to avoid an incident significantly more often for drivers with PD than for controls. Interestingly, driver safety ratings were unrelated to an individual's rating of their own driving performance, and this was the case for all participants.

CONCLUSIONS

As a group, drivers with PD are less safe to drive than age matched controls. Standard clinical markers cannot reliably predict driver safety. Further studies are required to ascertain whether the identified driving difficulties can be ameliorated.

Surgical workload from an integrated UK field hospital during the 2003 Gulf conflict

AIMS

This paper reports the surgical experience of a UK reserve field surgical hospital during military operations in Iraq during March and April 2003. Particular reference is given to the integration of the surgical specialities, consultant led and multidisciplinary teamworking in the treatment of military and civilian casualties from all sources and of all causes. METHODS All surgical workload data was collected prospectively for the warfighting (Phase One) and specialist referral (Phase Two) phases of the operation. Standard military and Red Cross protocols were used for all injuries and microbiology studies were undertaken for penetrating ballistic injuries. Operations were classified by anatomical region; upper or lower limb; head and neck; thoracic; abdominal, including genitourinary; ophthalmic; and burns, and by whether they were primary; secondary planned or secondary unplanned.

RESULTS

A wide range of patterns of wounding arising from combat and non-combat related military and civilian trauma and burns were seen and treated. 323 operations were performed. There were 116 operations in phase one and 207 operations in phase two. There were 160 primary procedures (new patients), 146 secondary planned and 17 unplanned procedures (range one to eight procedures per patient). Close integration of general, orthopaedic, plastic, maxillofacial, ophthalmic and neurological surgeons and general and ITU anaesthetists allowed the delivery of a range of specialist treatment to a heterogenous patient population, including children as young as 6 months and a lady in the advanced stages of pregnancy.

CONCLUSIONS

Patterns of wounding in casualties surviving to reach specialist field hospital care were similar to those reported in other high intensity conflicts. A consultant led, multidisciplinary approach with field intensive care facilities allowed combined, staged and safe surgery for complex, multi-organ and multi-limb trauma in an austere environment.

Multiple schwannomas of the median nerve: a case report and literature review

We report a case of multiple schwannomas of the median nerve. Multiple schwannomas can be difficult to diagnose on clinical grounds and can be mistakenly diagnosed as carpal tunnel syndrome or ganglia as in our case. Nerve conduction studies helped locate non-visible tumours. Magnetic resonance imaging (MRI) is useful in the preoperative planning of these tumours. The appearances on scanning however can be sometimes confused for ganglia as in this case. Intraneural dissection of the schwannomas was carried out and the pathology is described.

Moderate neutropenia with adjuvant CMF confers improved survival in early breast cancer

Despite the extensive literature clearly demonstrating the survival benefit for adjuvant chemotherapy in women with operable breast cancer, there are few data confirming this in routine practice. Some studies have suggested that not all women gain to the same extent, with older women showing a smaller benefit and lower doses achieving poorer outcomes. We therefore reviewed the case notes of 750 women treated over a 15-year period at The Edinburgh Cancer Centre with the same intravenous CMF (cyclophosphamide, methotrexate and 5-fluorouracil) regimen, to identify patient- and treatment-related factors influencing outcome in routine practice.The actuarial 10-year survival for these women was 59.3%, with the anticipated poorer outcome for those with more involved ipsilateral axillary nodes, higher grade and ER-negative tumours. There was no evidence that a lower delivered dose intensity or older age at presentation resulted in a poorer survival. Of particular interest was the observation that 45% of patients who had grade 2/3 neutropenia had a 10% absolute survival advantage over those with no neutropenia (P<0.001). This strongly suggests that some degree of neutropenia has more influence on outcome than age or delivered dose intensity.

Nosocomial transmission of influenza

Influenza is a common nosocomial infection. Serious outbreaks occur typically in elderly long-term patients, but have also been reported in renal, transplant and oncology units, neonatal intensive care and paediatrics. It is likely that staff-patient cross-infection is common. Prompt diagnosis of an outbreak lies at the heart of an effective influenza control programme. This requires effective virological surveillance. There are a variety of strategies that can help to prevent spread of influenza in health care settings. Basic infection control should include isolating infected residents, restricting circulation of nursing staff between patients, and restriction of visitors. Annual influenza immunization should be offered to elderly patients, subjects with chronic disease, and those in long-term residential or nursing home care. Vaccination of health care workers has been shown to be effective in protecting elderly patients in long-term care. Use of oral amantadine or rimantadine is an additional possible strategy for prophylaxis or treatment during an outbreak.

Influence of HLA-DR phenotype on the risk of hepatitis C virus-associated mixed cryoglobulinemia

OBJECTIVE

Circumstances predisposing hepatitis C virus (HCV)-infected patients to develop mixed cryoglobulinemia (MC), which may manifest as a small-vessel systemic vasculitis (MC vasculitis), remain unclear. Previous studies have failed to demonstrate a clear role of either viral factors (genotype, viral load) or host factors (lymphocytes or immunoglobulin subsets). This study was undertaken to examine a possible role of HLA class II alleles in HCV-associated MC.

METHODS

One hundred fifty-eight HCV-infected patients, of whom 76 had MC (56 with type II MC and 20 with type III MC) and 82 did not have MC, were studied prospectively. MC vasculitis was noted in 35 HCV-infected patients with type II IgMkappa-containing cryoglobulins. HLA-DRB1 and HLA-DQB1 polymorphism was analyzed by hybridization using allele-specific oligonucleotides, after gene amplification. The odds ratio (OR) was calculated with Woolf's method. Then, using multivariate analysis, demographic, biologic, immunologic, virologic, and liver histologic factors associated with the presence of MC and MC vasculitis were investigated.

RESULTS

HLA-DR11 was significantly more frequent in patients with type II MC than in those without MC (41.1% versus 17.1%; OR 3.4, corrected P [Pcorr] = 0.017), regardless of the presence of vasculitis accompanying the MC (37.1% of those with MC vasculitis, 34.1% of those with MC but no vasculitis). HLA-DR7 was less frequent in HCV-infected patients with MC than in those without MC (13.2% versus 30.5%; OR 0.34, P = 0.012, Pcorr not significant), with a particularly lower frequency in those with type II MC and those with MC vasculitis (12.5% and 8.6%, respectively). There was no significant difference in HLA-DQB1 distribution between the different patient groups. By univariate and multivariate analysis, HLA-DR11 was the only positive predictive factor, besides female sex and advanced age, for the presence of MC and HCV-associated MC vasculitis (OR 2.58).

CONCLUSION

Our results indicate that the presence of the DR11 phenotype is associated with a significantly increased risk for the development of type II MC in patients with chronic HCV infection. In contrast, HLA-DR7 appears to protect against the production of type II MC. These results suggest that the host's immune response genes may play a role in the pathogenesis of HCV-associated MC.

Spectrum of giant cell vasculitis

Giant cell arteritis (GCA) is the commonest primary systemic vasculitis in the United States. Severe outcomes include blindness and stroke, and death may result from aortic dissection. Temporal artery biopsy remains the gold standard for diagnosis. Magnetic resonance imaging (MRI) of involved vessels shows promise as a useful noninvasive method for diagnosis and assessment of disease activity. Corticosteroid therapy is effective but is associated with considerable morbidity. Longitudinal studies with large numbers of patients are required to identify appropriate steroid-sparing agents. New insights into the immunopathogenesis of GCA have allowed us to identify heterogeneous subsets of patients with varying clinical presentations corresponding to specific cytokine profiles. The concept of the involved artery as an active participant in the events leading to luminal obstruction has been realized and provides the opportunity to evaluate novel therapies to modify the course of the disease.