Identification, validation and biological characterisation of novel glioblastoma tumour microenvironment subtypes: implications for precision immunotherapy

BACKGROUND

New precision medicine therapies are urgently required for glioblastoma (GBM). However, to date, efforts to subtype patients based on molecular profiles have failed to direct treatment strategies. We hypothesised that interrogation of the GBM tumour microenvironment (TME) and identification of novel TME-specific subtypes could inform new precision immunotherapy treatment strategies.

MATERIALS AND METHODS

A refined and validated microenvironment cell population (MCP) counter method was applied to >800 GBM patient tumours (GBM-MCP-counter). Specifically, partition around medoids (PAM) clustering of GBM-MCP-counter scores in the GLIOTRAIN discovery cohort identified three novel patient clusters, uniquely characterised by TME composition, functional orientation markers and immune checkpoint proteins. Validation was carried out in three independent GBM-RNA-seq datasets. Neoantigen, mutational and gene ontology analysis identified mutations and uniquely altered pathways across subtypes. The longitudinal Glioma Longitudinal AnalySiS (GLASS) cohort and three immunotherapy clinical trial cohorts [treatment with neoadjuvant/adjuvant anti-programmed cell death protein 1 (PD-1) or PSVRIPO] were further interrogated to assess subtype alterations between primary and recurrent tumours and to assess the utility of TME classifiers as immunotherapy biomarkers.

RESULTS

TME^High tumours (30%) displayed elevated lymphocyte, myeloid cell immune checkpoint, programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte-associated protein 4 transcripts. TME^High/mesenchymal+ patients featured tertiary lymphoid structures. TME^Med (46%) tumours were enriched for endothelial cell gene expression profiles and displayed heterogeneous immune populations. TME^Low (24%) tumours were manifest as an 'immune-desert' group. TME subtype transitions upon recurrence were identified in the longitudinal GLASS cohort. Assessment of GBM immunotherapy trial datasets revealed that TME^High patients receiving neoadjuvant anti-PD-1 had significantly increased overall survival (P = 0.04). Moreover, TME^High patients treated with adjuvant anti-PD-1 or oncolytic virus (PVSRIPO) showed a trend towards improved survival.

CONCLUSIONS

We have established a novel TME-based classification system for application in intracranial malignancies. TME subtypes represent canonical 'termini a quo' (starting points) to support an improved precision immunotherapy treatment approach.

Moderate continuous- and high-intensity interval training elicit comparable cardiovascular effect among middle-aged men regardless of recovery mode

To assess the effect of active and passive intra-interval recovery modes in time-efficient high-intensity interval training (HIT) on cardiorespiratory fitness, autonomic function, and endothelial function in sedentary middle-aged men.Participants (n = 62; age: 49.5 ± 5.8 y; BMI: 29.7 ± 3.7 kg·m^-2) completed the assessments of cardiorespiratory fitness, flow-mediated dilation (FMD) and heart rate variability before being randomly allocated to control (CON; n = 14), moderate intensity continuous training (MICT; n = 15), HIT with passive (P-HIT; n-15), or active recovery (A-HIT; n = 15). Participants performed thrice weekly exercise sessions for 12 weeks. MICT completed 50-60 min of continuous cycling at 60-70% heart rate (HR) maximum. HIT completed 30-s work intervals (∼85% HR) interspaced with 2.5 min of active or passive recovery.All exercise modalities increased oxygen uptake (V̇O₂) (MD: ≥ 3.1 ml·kg^-1·min^-1, 95%CI: 1.5-4.7 ml·kg^-1·min^-1; P < 0.001), power output (MD: ≥ 26 W, 95%CI: 15-37 W; P < 0.001) and cycle duration (MD: ≥ 62 s, 95%CI: 36-88 s; P < 0.001) at 85% HRM. Significant pre-to-post differences were observed among all exercise groups for FMD (MD: ≥ 3.4%, 95%CI: 0.3-6.5%; P < 0.05), while MICT and P-HIT significantly increased the standard deviation of all NN intervals (SDNN) pre-to-post intervention (MD: ≥ 7 ms, 2-13 ms; P ≤ 0.05).Time-efficient HIT elicits significant improvements in cardiorespiratory fitness, FMD and autonomic modulation following a thrice weekly 12-week exercise intervention among sedentary middle-aged men. Active recovery between successive high-intensity intervals provided no additional benefit among this deconditioned cohort.

Cannabidiol Treatment for Neurological, Cognitive, and Psychiatric Symptoms in Sturge-Weber Syndrome

BACKGROUND

A prior drug trial of cannabidiol for treatment-resistant epilepsy in patients with Sturge-Weber syndrome (SWS), a rare neurovascular condition, implicated improvements in neurological, quality of life (QOL), neuropsychologic, psychiatric, and motor outcomes.

METHODS

Ten subjects with SWS brain involvement, controlled seizures, and cognitive impairments received study drug in this Johns Hopkins institutional review board-approved, open-label, prospective drug trial. Oral cannabidiol was taken for six months (dose ranged from 5 to 20 mg/kg/day). SWS neuroscore, port-wine birthmark score, QOL, and adverse events were recorded every four to 12 weeks. Neuropsychologic, psychiatric, and motor assessments were administered at baseline and six months' follow-up. Most evaluations were conducted virtually due to the coronavirus disease 2019 pandemic.

RESULTS

Cannabidiol was generally well tolerated. Six subjects reported mild to moderate side effects related to study drug and continued on drug; one subject withdrew early due to moderate side effects. No seizures were reported. Significant improvements in SWS neuroscore, patient-reported QOL, anxiety and emotional regulation, and report of bimanual ability use were noted. Migraine QOL scores were high at baseline in these subjects, and remained high. Neuropsychologic and other QOL and motor outcomes remained stable, with some within-subject improvements noted.

CONCLUSIONS

Further studies are needed to determine whether Epidiolex can improve quality of life and be beneficial for neurological, anxiety, and motor impairments in SWS independent of seizure control. Large multicentered studies are needed to extend these preliminary findings.

Does Assessment Format Matter? A Comparison of In-Person Versus Teletesting Scores for Youth with ADHD

OBJECTIVE

This study examined test score equivalency between traditional in-person assessment and teletesting among youth diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD).

METHOD

In all, 896 youth with ADHD, ages 5-21 years, were administered cognitive, academic achievement, and verbal fluency measures via either teletesting (n = 448) or traditional in-person assessment (n = 448). The teletesting and in-person groups were matched on age, sex, and insurance type (as a proxy for income).

RESULTS

Results indicated no significant differences in test scores obtained via in-person and teletesting evaluations across all examined measures.

CONCLUSION

Clinically referred youth with ADHD perform similarly on measures of cognitive functioning, academic achievement, and verbal fluency, regardless of whether these measures are administered in-person or via teletesting. While additional evidence for equivalent psychometric properties of neuropsychological instruments administered remotely is needed, this study offers support for the validity of remote administration among youth with ADHD.

Does participatory ergonomics reduce musculoskeletal pain in sonographers? A mixed methods study

Introduction

Sonographers in the Western New South Wales Local Health District (WNSWLHD) reported a musculoskeletal pain prevalence rate of 95%. Participatory ergonomics, where workers are consulted about improving work conditions, was utilised to identify work-related musculoskeletal disorder (WMSD) risks and potential solutions. The aim of this study was to compare the prevalence of WMSD in a cohort of sonographers before and after implementation of ergonomic changes that were driven by recommendations from a participatory ergonomics approach.

Methods

This observational mixed methods study analysed the impact of participatory ergonomic-driven interventions on changes on musculoskeletal pain in a cohort of sonographers employed within the WNSWLHD. A retrospective analysis of 10 sonographer WMSD pain surveys over five sites was completed, along with semi-structured interviews regarding which interventions were perceived as useful, which interventions were not implemented and any barriers to implementation.

Results

Installation of patient monitors, use of ergonomic scanning techniques and job rotation were perceived as responsible for decreased musculoskeletal pain. Taking lunch breaks and microbreaks, use of antifatigue mats and having two sonographers perform mobile exams were not fully implemented. No interventions were perceived as responsible for increased pain.

Conclusion

This small study provides preliminary evidence that a participatory ergonomics approach facilitated identification of occupation and site-specific risks for WMSD in the WNSWLHD, allowing implementation of ergonomic changes to be tailored to the workplace, resulting in a safer work environment for sonographers.

O78: SARCOPENIA IN LOCALLY ADVANCED BREAST CANCER: PREVALENCE, AND IMPACT ON CLINICAL AND ONCOLOGIC OUTCOMES

Introduction

Sarcopenia in cancer may confer negative outcomes, but its prevalence and impact in the modern multimodal management of locally advanced breast cancer have not been systematically studied.

Method

Patients undergoing neoadjuvant therapy and surgery for locally advanced breast cancer between 2010 and 2015 were studied. Skeletal muscle index (SMI) and lean body mass (LBM) were determined. Sarcopenia was defined by computed tomography (CT) at L3 as SMI&lt;38.5cm2/m2. Multivariable linear, logistic, and Cox regression analysis was undertaken to determine the independent impact of sarcopenia on clinical and oncologic outcome.

Result

258 patients were studied. Sarcopenia was present in 23.0%, 7.8% and 0.0% of patients with normal weight, overweight and obesity, respectively (P=0.001). Sarcopenia was not associated with baseline cT and cN stage, tumour grade, histologic type or receptor status. Patients with sarcopenia exhibited equivalent indices of neoadjuvant therapy response including ypT and ypN stage, pathologic complete response and Sataloff grade following surgical resection. Postoperatively, sarcopenia was not independently associated with comprehensive complications index (P=0.242), length of stay (P=0.716) or overall morbidity (P=0.365). However, on multivariable analysis, lower LBM independently predicted reduced invasive disease-free (P=0.049,HR0.93[95%CI0.87-1.00]) and overall (P=0.028,HR0.92[0.85-0.99]), but not disease-specific survival (P=0.070).

Conclusion

Consistent with a lack of association with baseline and post-treatment pathologic features, sarcopenia in locally advanced breast cancer is associated with reduced overall, but not disease-specific, survival. These data indicate that the prognostic impact of sarcopenia may be mediated by impaired performance status and increased non-cancer mortality.

Take-home message

Consistent with a lack of association with baseline and post-treatment pathologic features, sarcopenia in locally advanced breast cancer is associated with reduced overall, but not disease-specific, survival. These data indicate that the prognostic impact of sarcopenia may be mediated by impaired performance status and increased non-cancer mortality.

O39: THE HISTOPATHOLOGICAL AND MOLECULAR FEATURES OF BREAST CARCINOMA WITH HIGH-GRADE TUMOUR BUDDING

Background

Tumour budding (TB) is an adverse histological feature in many cancers. It is thought to represent epithelial-to-mesenchymal transition, a key step in the metastatic process. The role of TB in breast carcinoma (BC) remains unclear.

Aim

To investigate the relationship between TB and other histological and molecular features of BC.

Method

A systematic search was performed to identify studies that compared features of BC based on the presence or absence of high-grade TB. Dichotomous variables were pooled as odds ratios (OR) using the Cochran–Mantel–Haenszel method. Quality assessment of the included studies was performed using the Newcastle-Ottawa scale (NOS).

Result

Seven studies with a total of 1040 patients (high grade TB n=519, 49.9%; low grade TB n=521, 50.1%) were included. A moderate- to high-risk of bias was noted. The median NOS was 7 (range 6-8). High-grade TB was significantly associated with lymph node involvement (OR 2.28, 95% c.i. 1.74 to 2.98, P&lt;0.001) and lymphovascular invasion (OR 3.08, 95% c.i. 2.13 to 4.47, P&lt;0.001). Regarding molecular subtypes, there was an increased likelihood of high-grade TB in oestrogen- (OR 1.66, 95% c.i. 1.21 to 2.29, P=0.002) and progesterone-receptor positive (OR 1.68, 95% c.i. 1.10 to 2.59, P=0.02) tumours. In contrast triple negative breast cancer had a reduced incidence of high-grade TB (OR 0.46, 95% c.i. 0.30 to 0.72, P=0.0006).

Conclusion

High-grade TB is enriched in hormone-positive BC and is associated with known adverse prognostic variables. TB may offer new insights into the metastatic processes of luminal BC.

Take-home message

High-grade TB is enriched in hormone-positive BC and is associated with known adverse prognostic variables. TB may offer new insights into the metastatic processes of luminal BC.

The effectiveness of ergonomics interventions in reducing upper limb work-related musculoskeletal pain and dysfunction in sonographers, surgeons and dentists: a systematic review

The aim of this systematic review was to summarise the effects of ergonomics interventions on work-related upper limb musculoskeletal pain and dysfunction, and on productivity in sonographers, surgeons and dentists. A total of 31 studies were included. All studies reported effects on upper limb pain. Nine studies reported effects on dysfunction and only two studies reported effects on productivity. Moderately strong evidence in reducing upper limb pain was found for instigation of microbreaks into long duration surgical procedures, and the use of wider, lighter handles in dental instruments. Moderate evidence was also found for use of prismatic glasses and favourable positioning in reducing upper limb pain. Weak, inconsistent or no evidence was found for all other ergonomics interventions in reducing upper limb pain and dysfunction and increasing productivity. The lack of high quality research, particularly in sonographers and in the outcome of productivity, should be addressed. Practitioner summary: This systematic review investigates the effectiveness of ergonomics interventions on upper limb pain, dysfunction and productivity in sonographers, dentists and surgeons. Instigation of microbreaks during long duration procedures and the use of wider, lighter instrument handles were most effective in reducing upper limb work-related pain. Abbreviations: ANOVA: analysis of variance; CLS: conventional laparoscopic surgery; DMAIC: define, measure, analyze, improve and control; GRADE: grading of recommendations, assessment, development and evaluations; HD: high definition; PRISMA: preferred reporting items for systematic reviews and meta-analyses; PROSPERO: The International Prospective Register of Systematic Reviews; RCT: randomised control trial; SILS: single incision laparoscopic surgery; VITOM: video telescopic operative microscope; WNSWLHD: Western New South Wales Local Health District; WMSD: work related musculoskeletal disorder.

Characterization of sperm-associated antigen 6 expression in the reproductive tract of the domestic rooster (Gallus domesticus) and its impact on sperm mobility

Sperm mobility is a major determinant of sperm quality in the domesticated chicken (Gallus domesticus) and is therefore an area of interest for improving fertility. Sperm-associated antigen 6 (SPAG6) is an important flagellar protein implicated to be necessary for flagellar function but negatively associated with rooster fertility. This study was aimed to characterize the expression of SPAG6 and investigate its utility as a protein biomarker of sperm mobility. By western analysis, relative SPAG6 abundances were compared between the testicular, epididymal, and vasal tissues and in sequentially maturing sperm. Immunocytochemistry techniques were used to detect localization of SPAG6 in chicken sperm. Last, western analysis was used to compare relative SPAG6 abundances in sperm of differing mobility. SPAG6 was found in higher abundance in epididymal tissues and in highest abundance in vasal tissues, relative to that of the testis. SPAG6 was also found to sequentially increase in abundance in maturing sperm. SPAG6 localizes between the axonemal central pair of microtubules in the sperm flagella, but it is also found in lower concentration in the acrosomal region. SPAG6 was not a significant predictor of sperm mobility. SPAG6 abundance, alone, is not a strong predictor of sperm mobility. Its impact on rooster fertility is likely unrelated to its impact on sperm mobility.

Pediatric neuropsychological evaluation via telehealth: Novel models of care

Objective: As the coronavirus pandemic extends across the globe, the impacts have been felt across domains of industry. Neuropsychology services are no exception. Methods for neuropsychological assessments, which typically require an in-person visit, must be modified in order to adhere to social distancing and isolation standards enacted in an effort to slow the pandemic. How can providers continue to meet the needs of patients referred for neuropsychology evaluations, while respecting federal and state guidelines for safety and ethical mandates? We offer a novel, tiered model of care, successfully implemented in response to mandated social distancing, in a large, pediatric neuropsychology program.Method: We describe the considerations and challenges to be addressed in transitioning a large neuropsychology department to a new model of care, including triaging referrals, developing -or rediscovering - types of services to meet the needs of a virtual patient population, and helping patients, parents, and providers to adjust to these new models.Conclusions: Lessons learned as a function of rapid changes in care models have implications for the field of neuropsychology as a whole as well as for future flexibility in meeting the needs of pediatric patients and their families.

A re-examination of the relationship between Steller sea lion (Eumetopias jubatus) diet and population trend using data from the Aleutian Islands

Prey diversity and energy density have been linked to each other and to population trends in many studies of bird and mammal diets. We re-examined these relationships in Steller sea lions (Eumetopias jubatus (Schreber, 1776)) using data collected from the Aleutian Islands, where there has been a strong longitudinal gradient in population trend. Diet diversity and energy density metrics were similar in the western Aleutians, where sea lion counts declined consistently, and in the easternmost Aleutian area, where population trends improved significantly. We compared traditional deterministic diet diversity metrics with diversity scores based on an occupancy model that accounts for differences in sample size and uncertainty in prey group detection. This analysis indicated that there was no significant change in diet diversity over the 23-year study period or any significant differences across the Aleutian Islands. These results are consistent with prey abundance data from nine groundfish bottom trawl surveys conducted over the same period. While diet studies detail what Steller sea lions eat and provide an estimate of their energy intake, they provide only limited information on the energy expended to obtain their food or the consequences of their diet and foraging ecology on individual or population fitness.

Synchronous renal and para-aortic metastasis in a uterine serous carcinoma: A case review and clinical considerations

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Serous endometrial carcinomas rarely involve the renal system.

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Stage IVB serous endometrial carcinoma with confirmed renal metastasis.

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Paclitaxel/carboplatin treating serous endometrial carcinoma with renal metastasis.

Natural cause mortality in persons with serious mental illness

OBJECTIVE

To identify the determinants of natural cause mortality in a cohort of individuals with serious mental illness assessed prospectively.

METHOD

Persons with schizophrenia (n = 789) and bipolar disorder (n = 498), mean age of 38 (s.d. 12.6) years, underwent an in-person clinical assessment. They also had a blood sample drawn from which infectious disease markers were measured. Mortality was subsequently determined utilizing data from the National Death Index following a period of up to 16.9 years.

RESULTS

A total of 6.8% (87 of 1287) of persons died of natural causes. Mortality was predicted in a multivariate model by baseline cigarette smoking (RR = 6.29, 95% CI 1.41, 3.72, P = 0.00076); divorced or widowed status (RR = 1.90, CI 1.21, 2.99); reduced cognitive score (RR = 0.73, CI 0.61, 0.87); receipt of antidepressant medication (RR = 1.74, CI 1.12, 2.71); elevated levels of antibodies to Epstein-Barr virus (EBV) (RR = 1.29, CI 1.01, 1.66); and a genitourinary (RR = 1.82, CI 1.16, 2.86), respiratory (RR = 1.82, CI 1.16, 2.86), or cardiac (RR = 2.09, CI 1.33, 3.29) condition. There was an additive effect of smoking and both a cardiac and a respiratory condition but not elevated EBV antibody levels.

CONCLUSION

Smoking is a modifiable behaviour which is associated with mortality in this population.

Abstract P6-12-10: The importance of a survivorship coordinator role in the creation of survivorship care plans and maintaining compliance with new accreditation standards

Background: Froedtert Hospital and the Medical College of Wisconsin's Breast Care Center (F&MCWBCC), is a Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC) accredited facility providing care to over 500 patients a year. The F&MCWBCC recognized the importance of following the IOM survivorship recommendations and in 2014 began providing a survivorship care plan (SCP) to patients completing radiation therapy. In 2015, SCP standards for both CoC and NAPBC were established. A redesign of the process was necessary to meet these new requirements.

Methods: A review of accreditation standards was conducted along with an examination of staff availability. A collaborative team of content experts was gathered who worked with an informatics nurse to design content and a template in the EHR that met the elements outlined by the accreditation standards. Initially, treating physicians and advanced practice nurses were responsible for creating the SCP. However, these providers found it to be increasingly difficult to manage on top of their other responsibilities.

In May 2015, an experienced breast cancer technician was identified for the survivorship data coordinator role. The coordinator used available sources, patient lists and clinic schedules, to case find. She developed spreadsheets to assist in tracking patients and measuring compliance. The coordinator communicated with providers to alert them to populate and review the SCP and coordinated the survivorship appointment with the nurse.

Once the SCP is completed, a dedicated RN position is utilized for a survivorship visit with patients. During this visit, the RN reviews the care plan and provides education on follow up care guidelines and overall health and wellness concepts. Assessments for further supportive services are performed, and appropriate referrals made. The RN shares the SCP with the primary care provider. Results are tracked and reported to Cancer Service Line Leadership and the Breast Steering and Cancer Committees.

Results: During the implementation phase, completion of SCPs by physicians and advance practice nurses was inconsistent. Once the survivorship coordinator role was created and implemented, compliance with NAPBC standards improved as SCP delivery numbers increased 141%.

The survivorship coordinator improved delivery of SCPs. In 2014, 130 plans were delivered, and 185 in 2015. In 2016, 314 were delivered, achieving 100% compliance to the NAPBC survivorship standard.

Conclusion:Compliance with NAPBC and CoC standards to deliver SCPs to patients and primary care providers is labor intensive and requires a large number of resources. Use of a survivorship data coordinator has proven successful in determining and tracking eligible patients and ensuring timely delivery of SCPs to patients. The monitoring of new patients through this process has enabled this center to go from estimates of analytic cases, to a current real-time numbers. This is necessary to provide a comprehensive review of care and survivorship guidelines to cancer survivors and meeting accreditation standards. Further work is needed to assess the impact of the SCPs on patient outcomes and satisfaction.

Citation Format: Blissitt J, Scalio R, Myers KB, Sweeney K, Kelly TR, Kong A, Chitambar C, Currey AD. The importance of a survivorship coordinator role in the creation of survivorship care plans and maintaining compliance with new accreditation standards [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-10.

Trends in breast reconstruction practices in a specialized breast tertiary referral centre

BACKGROUND

Breast reconstruction is an important component of multidisciplinary breast cancer management. The practice of breast reconstruction after mastectomy has evolved significantly in the past decade as a result of both increasing mastectomy rates and advances in reconstructive strategy. These changes have significantly influenced the contemporary surgical management of breast cancer. The aim of this study was to examine trends in breast reconstruction after mastectomy in an Irish population.

METHODS

Data were reviewed from a database of all patients who had mastectomy with or without breast reconstruction at Galway University Hospital, a tertiary breast cancer referral centre, between 2004 and 2014. Trends in breast reconstruction after mastectomy were explored with respect to patient demographics, clinicopathological features, and neoadjuvant and adjuvant therapy.

RESULTS

Of 1303 patients who underwent mastectomy during interval studied, 706 (54.2 per cent) had breast reconstruction after mastectomy. In 629 patients (89·1 per cent), breast reconstruction was performed in the immediate setting. Reconstruction rates increased over time from 20·5 per cent in 2004 to 44·7 per cent in 2014. Reconstruction was more commonly performed in younger patients and those with benign, in situ and early-stage disease. A negative relationship between radiotherapy and reconstruction was observed. A pedicled flap with or without an implant was the most commonly used reconstructive approach in patients receiving radiotherapy.

CONCLUSION

Breast reconstruction after mastectomy has become the standard of care in the surgical treatment of breast cancer. Recent trends show a transition favouring implant-based approaches.

Population Pharmacokinetics, Pharmacodynamics, and Exploratory Exposure-Response Analyses of Apixaban in Subjects Treated for Venous Thromboembolism

Apixaban is approved for treatment of venous thromboembolism (VTE) and prevention of recurrence. Population pharmacokinetics, pharmacokinetics-pharmacodynamics (anti-FXa activity), and exposure-response (binary bleeding and thromboembolic endpoints) of apixaban in VTE treatment subjects were characterized using data from phase I-III studies. Apixaban pharmacokinetics were adequately characterized by a two-compartment model with first-order absorption and elimination. Age, sex, and Asian race had less than 25% impact on exposure, while subjects with severe renal impairment were predicted to have 56% higher exposure than the reference subject (60-year-old non-Asian male weighing 85 kg with creatinine clearance of 100 mL/min). The relationship between apixaban concentration and anti-FXa activity was described by a linear model with a slope estimate of 0.0159 IU/ng. The number of subjects with either a bleeding or thromboembolic event was small, and no statistically significant relationship between apixaban exposure and clinical endpoints could be discerned with a logistic regression analysis.

Abstract P5-02-06: The impact of the introduction of breast cancer screening on a symptomatic breast cancer unit

This abstract was not presented at the symposium.

Congenital Epulis: a clinical case presentation

Congenital Epulis (CE) is a rare, benign tumour of the mucosa of the mouth in a neonate. It presents as an intraoral tumour and is rarely diagnosed prenatally. Complications include neonatal airway compromise, difficulty feeding and aesthetic considerations. Ultrasound is useful in aiding decisions regarding site, age, method of delivery and preparing parents and staff for the appearances of the tumour at birth. We present a case where CE was identified at 35 weeks gestational age during a routine third trimester prenatal ultrasound. The patient was scanned at a rural centre, referred to a tertiary institution for follow up and delivered at a specialist perinatal surgical centre, in preparation for neonatal surgery. The outcome was excellent and this case is a good example of multi-centre cooperation.

Establishing best practices and guidance in population modeling: an experience with an internal population pharmacokinetic analysis guidance

This tutorial describes the development of a population pharmacokinetic (Pop PK) analysis guidance within Pfizer, which strives for improved consistency and efficiency, and a more systematic approach to model building. General recommendations from the Pfizer internal guidance and a suggested workflow for Pop PK model building are discussed. A description is also provided for mechanisms by which conflicting opinions were captured and resolved across the organization to arrive at the final guidance.

CPT: Pharmacometrics & Systems Pharmacology (2013) 2, e51; doi:10.1038/psp.2013.26; advance online publication 3 July 2013

The Relationship between Breast Cancer and Research; a Bibliometric Study

Background: Thousands of articles are published every year in the medical literature relating to the diagnosis and treatment of cancer patients. An area of contention of late has been the amount of research time and money being devoted to breast cancer, to what some believe is to the detriment of research into other forms of malignancy. The aims of this study were to further investigate the relationship between malignancy and research, in order to better quantify the degree to which breast cancer is being over- or under-represented in the research world.Methods: Bibliometrics is the science of studying written communication by systematic measurement and analysis of research publications. In this study, we examined research output over a one-year period for the 26 most commonly diagnosed cancers in the UK. Our strategy was based on that employed by a group in Edinburgh in 2001, and involved correlating research output with incidence and mortality statistics. In addition, we sought to elucidate changes in research output over time and then to correlate these changes with improvements in survival. The survival data used was that published by Coleman et al in 2004, and represents changes in survival over 5 year periods between 1986 and 1999 in England and Wales.Results: A total of 73,798 publications were included in this study. Breast cancer received more research attention than any other malignancy in the time period of this study. Proportional to its incidence and associated mortality, however, breast cancer was markedly underrepresented. This relationship was consistent across publication and study types, and in the higher impact journals. There was a strong positive correlation between improvement in 5-year survival and research output (p = 0.003). Those malignancies enjoying the greatest increases in output included those involving the prostate, non-hodgkins lymphoma, breast and vaginal cancer.Conclusions: This study was intended to provide a snapshot-in-time of research output in malignancy. It has shown that, on the basis of both incidence and mortality, breast cancer is not receiving disproportionate attention by the research community, contrary to popular opinion. Whilst the absolute figures clearly reflect the success of the breast cancer advocacy community in raising and maintaining the profile of the disease, the evidence suggests that, if anything, breast cancer is not receiving the interest it deserves, based on its burden to society.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1080.

Bilateral Breast Cancer: Analysis of Incidence, Characteristics and Outcome of the Disease

Background: Despite the widespread adoption of breast conservation therapy in breast cancer, there is a dramatic increase in the rate of bilateral mastectomy in USA. The aim of this study was to address the incidence of bilateral breast cancer (BBC) and to investigate its characteristics, survival and outcome compared to unilateral breast cancer.Methods: Data was acquired from the prospectively maintained NUI Galway breast cancer database between 1988 and 2008. BBC were then categorized as synchronous (within 12 months) or metachronous cancer (after 12 months of first tumour). SPSS was used for data analysis.Results: The incidence of bilateral breast cancer in our population was 4.4% (112 of 2524). Of those 2.1% were synchronous while 2.3% were metachronous. Compared to unilateral cases, bilateral cancer patients were younger (0=0.021) and had smaller size (p=0.001) and earlier stage (p&lt;0.001) tumours at diagnosis. There were no differences in histological type (p=0.630) and grade (p=0.054)). While there was no significant difference in survival for patients with bilateral compared to unilateral tumour (p&gt;0.05), the synchronous bilateral tumour was associated with poor overall survival (p=0.010) and disease free survival (p=0.013) in comparison to metachronous bilateral tumour.Conclusion: We observed significant differences in bilateral tumour characteristics compared to unilateral disease. Although bilateral synchronous tumour was associated with poor outcome and overall survival, patients with metachronous disease do as well as patients with unilateral tumour. The increasing practice of bilateral mastectomy is not supported by this large single centre experience.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5033.

Age-structured modeling reveals long-term declines in the natality of western Steller sea lions

Since the mid-1970s, the western Steller sea lion (Eumetopias jubatus), inhabiting Alaskan waters from Prince William Sound west through the Aleutian Islands, has declined by over 80%. Changing oceanographic conditions, competition from fishing operations, direct human-related mortality, and predators have been suggested as factors driving the decline, but the indirect and interactive nature of their effects on sea lions have made it difficult to attribute changes in abundance to specific factors. In part, this is because only changes in abundance, not changes in vital rates, are known. To determine how vital rates of the western Steller sea lion have changed during its 28-year decline, we first estimated the changes in Steller sea lion age structure using measurements of animals in aerial photographs taken during population surveys since 1985 in the central Gulf of Alaska (CGOA). We then fit an age-structured model with temporally varying vital rates to the age-structure data and to total population and pup counts. The model fits indicate that birth rate in the CGOA steadily declined from 1976 to 2004. Over the same period, survivorship first dropped severely in the early 1980s, when the population collapsed, and then survivorship steadily recovered. The best-fitting model indicates that in 2004, the birth rate in the central Gulf of Alaska was 36% lower than in the 1970s, while adult and juvenile survivorship were close to or slightly above 1970s levels. These predictions and other model predictions concerning population structure match independent field data from mark-recapture studies and photometric analyses. The dominant eigenvalue for the estimated 2004 Leslie matrix is 1.0014, indicating a stable population. The stability, however, depends on very high adult survival, and the shift in vital rates results in a population that is more sensitive to changes in adult survivorship. Although our modeling analysis focused exclusively on the central Gulf of Alaska, the western Gulf of Alaska and eastern Aleutians show a similar pattern of declining pup fraction with no increase in the juvenile, or pre-breeding, fraction. This suggests that declining birth rate may be a problem for western Steller sea lions across the Gulf of Alaska and into the Aleutian Islands.

E1A-expressing adenoviral E3B mutants act synergistically with chemotherapeutics in immunocompetent tumor models

The majority of clinical trials evaluating replication-selective oncolytic adenoviruses utilized mutants with immunomodulatory E3B genes deleted, likely contributing to the attenuated efficacy. We investigated whether an intact immune response could contribute to the observed improved efficacy in response to combinations with chemotherapeutics. Seven carcinoma cell lines were evaluated by combining viral mutants; dl309 (DeltaE3B), dl704 (DeltaE3gp19K), dl312 (DeltaE1A) or wild-type Ad5 with the commonly used clinical drugs cisplatin and paclitaxel. Synergistic effects on cell death were determined by generation of combination indexes in cultured cells. In vivo tumor growth inhibition was achieved by virotherapy alone and was most efficacious with wild-type virus and least with the DeltaE3B mutant. Significantly higher efficacy was observed when the viruses were combined with drugs. The greatest enhancement of tumor inhibition was in combination with the DeltaE3B mutant restoring potency to that of Ad5 wild-type levels, observed only in animals with intact immune response. Increases in infectivity, viral gene expression and replication were identified as potential mechanisms contributing to the synergistic effects. Our results suggest that the attenuation of DeltaE3B mutants can be overcome by low doses of chemotherapeutics only in the presence of an intact immune response indicating a role for T-cell-mediated functions.

Thorough QT Study with Recommended and Supratherapeutic Doses of Tolterodine

The objective of our study was to determine the QTc effects of tolterodine. A crossover-design thorough QT study of recommended (2 mg twice daily) and supratherapeutic (4 mg twice daily) doses of tolterodine, moxifloxacin (400 mg once daily), and placebo was performed. Electrocardiograms (ECGs) and pharmacokinetic samples were obtained on days 1-4; time-matched baseline ECGs were taken on day 0. Mean placebo-subtracted change from baseline Fridericia-corrected QT (QTcF) during peak drug exposure on day 4 was the primary end point. Mean QTcF prolongation of moxifloxacin was 8.9 ms (machine-read) and 19.3 ms (manual-read). At recommended and supratherapeutic tolterodine doses, mean QTcF prolongation was 1.2 and 5.6 ms (machine-read), respectively, and 5.0 and 11.8 ms (manual-read), respectively. The QTc effect of tolterodine was lower than moxifloxacin. No subject receiving tolterodine exceeded the clinically relevant thresholds of 500 ms absolute QTc or 60 ms change from baseline. In conclusion, tolterodine does not have a clinically significant effect on QT interval.

Why general practitioners do not implement evidence: qualitative study

OBJECTIVES

To explore the reasons why general practitioners do not always implement best evidence.

DESIGN

Qualitative study using Balint-style groups.

SETTING

Primary care.

PARTICIPANTS

19 general practitioners.

MAIN OUTCOME MEASURES

Identifiable themes that indicate barriers to implementation.

RESULTS

Six main themes were identified that affected the implementation process: the personal and professional experiences of the general practitioners; the patient-doctor relationship; a perceived tension between primary and secondary care; general practitioners' feelings about their patients and the evidence; and logistical problems. Doctors are aware that their choice of words with patients can affect patients' decisions and whether evidence is implemented.

CONCLUSIONS

General practitioner participants seem to act as a conduit within the consultation and regard clinical evidence as a square peg to fit in the round hole of the patient's life. The process of implementation is complex, fluid, and adaptive.

The practice accreditation and improvement survey (PAIS). What patients think

BACKGROUND

The Practice Accreditation and Improvement Survey (PAIS) is an endorsed instrument by the Australian General Practice Accreditation Limited (AGPAL) for seeking patient views as part of the accreditation of Australian general practices.

METHOD

From September 1998 to August 2000, a total of 53,055 patients completed the PAIS within 449 general practices across Australia, which is about 8% of all Australian general practices. The validity and reliability of the PAIS instrument was assessed during the study. Patient views were also analysed via 27 items relating to doctors' interpersonal skills, access, availability and patient information.

RESULTS

PAIS was found to have sound validity and reliability measures. Patient evaluations showed a range of scores for the 27 items (69-91%). Lower scoring areas were issues about access, availability and availability of information for patients.

DISCUSSION

Users of general practice rate the doctors' interpersonal skills (capability) more highly than other practice service issues (capacity). There is, in patients' views, much more room for improving these capacity aspects of general practice.

CONCLUSION

Future research should explore how practices act on the results of patient feedback, and which practice based strategies are more effective in raising standards of care from a patient's perspective.

Non-LTR retrotransposons encoding a restriction enzyme-like endonuclease in vertebrates

All autonomous non-long terminal repeat (non-LTR) retrotransposons reported to date in vertebrates encode an apurinic/apyrimidinic endonuclease-like enzyme necessary for target sequence cleavage and subsequent target-primed reverse transcription. We describe here vertebrate non-LTR retrotransposons encoding another type of endonuclease more related to type IIS restriction enzymes. Such retrotransposons have been detected until now only in trypanosomes, nematodes, and arthropods. The retrotransposon Rex6 was identified in the genome of several teleost fish including Xiphophorus maculatus (platyfish), Oryzias latipes (medakafish), Oreochromis niloticus (Nile tilapia), and Fugu rubripes (Japanese pufferfish). Rex6 encodes a reverse transcriptase and a putative restriction enzyme-like endonuclease and is a member of the R4 family of non-LTR retrotransposons containing the Dong and R4 elements found in nematodes and insects. Rex6 was active in many species during teleost evolution and underwent several bursts of retrotransposition (some of them being relatively recent) leading to a high copy number of Rex6 in the genome of numerous fish. Extremely truncated Rex6-related sequences were detected by database screening in reptiles, including the snake Trimeresus flavoviridis and the lizard Anolis carolinensis, but not in sequences from the human genome project, suggesting that this element might have been lost from certain vertebrate lineages.

Jule from the fish Xiphophorus is the first complete vertebrate Ty3/Gypsy retrotransposon from the Mag family

Jule is the second complete long-terminal-repeat (LTR) Ty3/Gypsy retrotransposon identified to date in vertebrates. Jule, first isolated from the poeciliid fish Xiphophorus maculatus, is 4.8 kb in length, is flanked by two 202-bp LTRs, and encodes Gag (structural core protein) and Pol (protease, reverse transcriptase, RNase H, and integrase, in that order) but no envelope. There are three to four copies of Jule per haploid genome in X. maculatus. Two of them are located in a subtelomeric region of the sex chromosomes, where they are associated with the Xmrk receptor tyrosine kinase genes, of which oncogenic versions are responsible for the formation of hereditary melanoma in Xiphophorus. One almost intact copy of Jule was found in the first intron of the X-chromosomal allele of the Xmrk proto-oncogene, and a second, more corrupted copy is present only 56 nt downstream of the polyadenylation signal of the Xmrk oncogene. Jule-related elements were detected by Southern blot hybridization with less than 10 copies per haploid genome in numerous other poeciliids, as well as in more divergent fishes, including the medakafish Oryzias latipes and the tilapia Oreochromis niloticus. Database searches also identified Jule-related sequences in the zebrafish Danio rerio and in both genome project pufferfishes, Fugu rubripes and Tetraodon nigroviridis. Phylogenetic analysis revealed that Jule is the first member of the Mag family of Ty3/Gypsy retrotransposons described to date in vertebrates. This family includes the silkworm Mag and sea urchin SURL retrotransposons, as well as sequences from the nematode Caenorhabditis elegans. Additional related elements were identified in the genomes of the malaria mosquito Anopheles gambiae and the nematode Ascaris lumbricoides. Phylogeny of Mag-related elements suggested that the Mag family of retrotransposons is polyphyletic and is constituted of several ancient lineages that diverged before their host genomes more than 600 MYA.

A preliminary study of the decision-making process within general practice

OBJECTIVE

The aim of the present study was to explore the factors that contribute to the process of decision making within general practice, over and above evidence-based information.

METHODS

A qualitative study was conducted using semi-structured interviews on a purposeful sample of GPs, based in the South West of England. Each interview was tape-recorded and transcribed verbatim.

RESULTS

Five broad categories emerged from the data: practitioner; patient; practitioner-patient relationship; verbal and non-verbal communication; evidence-based medicine; and external factors.

CONCLUSION

The nature of general practice is such that the process of making clinical decisions is complex. In an era when GPs are being overwhelmed by evidence-based information, consideration needs to be given to the implications that the nature of the decision-making process has upon the way 'evidence' is constructed and promoted within general practice.

Improving foot care for people with diabetes mellitus--a randomized controlled trial of an integrated care approach

AIMS

To evaluate a model of integrated diabetic footcare, for identification and clinical management of the high risk diabetic foot, centred on the primary care-based diabetic annual review.

METHODS

A pragmatic randomized controlled study was undertaken with matched cluster randomization of practices from 10 towns drawn from mid and east Devon responsible for the care of 1,939 people with diabetes (age > or =18 years). Outcome measures were patients' attitudes regarding the value and importance of footcare, patients' footcare knowledge, healthcare professionals' footcare knowledge and pattern of service utilization.

RESULTS

Attitudes towards footcare improved in both intervention and control groups (mean percentage change 3.91, 0.68) with a significant difference in change of 3.18 (95% confidence interval (CI) 1.29-5.07) between the groups. Patients' knowledge about diabetic foot problems improved significantly in both groups (mean percentage change 1.09, 1.32) but with no significant difference in change: -0.09 (95% CI -1.81-1.63) between groups. Health professionals' knowledge scores improved in the intervention group (mean percentage change 13.2; P < 0.001). No improvement was seen in the control group (mean percentage change -0.2; P = 0.1) with a significant difference in change of 13.46 (95% CI 8.30-18.62) between groups. Appropriate referrals from intervention practices to the specialized foot clinic rose significantly (P = 0.05) compared with control practices (P = 0.14).

CONCLUSIONS

Provision of integrated care arrangements for the diabetic foot has a positive impact on primary care staffs' knowledge and patients' attitudes resulting in an increased number of appropriate referrals to acute specialist services.

The non-LTR retrotransposon Rex3 from the fish Xiphophorus is widespread among teleosts

Rex3, the first reverse transcriptase (RT)-encoding retrotransposon isolated from the melanoma fish model Xiphophorus, is a non-long-terminal-repeat element related to the RTE family. The essential features of Rex3 are (1) an endonuclease and a reverse transcriptase, (2) 5' truncations of most of the copies, (3) a 3' tail consisting of tandem repeats of the sequence GATG, and (4) short target site sequence duplications of variable length. Compilation of Rex3 sequences from the pufferfish genome project suggested that, as observed for other members of the RTE family, no additional large open reading frame was present upstream of the endonuclease/reverse transcriptase open reading frame. There are about a thousand copies of Rex3 in the haploid genome of Xiphophorus, some of them probably resulting from recent retrotransposition events. Rex3 RNA was detected by RT-PCR in melanoma and in nontumorous tissues, as well as in melanoma-derived and embryonic cell lines. Rex3 is present in a broad panel of teleost species and was found in the promoter region and in introns of various genes. To our knowledge, Rex3 is the first autonomous retrotransposon described to date which is widespread in teleosts. This wide distribution and occasional association with coding sequences may confer on Rex3 a predisposition to play a role in genome evolution in teleosts.

The health of their nation: how would citizens develop England's health strategy?

BACKGROUND

England's first health strategy, The Health of the Nation, was formulated without systematic input from the citizens whose health it targeted. Several studies indicate that citizens, when asked to prioritize services, rank interventions for acute and life-threatening conditions highest. But how they view and what they want in the areas of prevention, public health, or care for the chronically and mentally ill is not known.

AIM

To explore citizens' attitudes towards England's health strategy as set out in The Health of the Nation and to elicit their ideas for developing it further.

METHOD

The study was conducted in four general practices and a secondary school in southwest England. The design was a qualitative analysis of testimony from 24 audiotaped focus groups. Twenty-three groups were drawn from lists of National Health Service registered patients, stratified by The Health of the Nation target category, and one group was drawn from 13 to 15 year-old girls at a mixed secondary school. In all, 173 citizens took part in the 24 focus group meetings.

RESULTS

In group discussions, these citizens demonstrated an understanding of The Health of the Nation strategy, which enabled them to form views and develop relevant arguments. They produced 26 specific ideas for developing the strategy across its five key areas. There was congruence with the action plans of a national expert group convened by the Department of Health and charged with reviewing the strategy's progress. The focus groups went beyond the experts' proposals, with further practical ideas to achieve The Health of the Nation targets.

CONCLUSION

Citizens in this study contributed a broad range of relevant, appropriate, and innovative ideas on how to develop health strategy. The use of focus groups to achieve this is practical and efficient.

Levels of physical activity, physical fitness and their relationship in the Northern Ireland Health and Activity Survey

The aim of the study was to describe the physical activity and physical fitness profile of the population of Northern Ireland and to explore the relationship between physical activity and physical fitness. This was a cross sectional population study using a two stage probability sample of the adult population of Northern Ireland (aged 16+). The main outcome measures were physical activity profile based on computer assisted interview. Physical fitness using estimation of VO2max by extrapolation from submaximal oxygen uptake while walking on a motor driven treadmill. We found that males were more vigorously active than females (M 21%:F 6%) with a steep gradient of decreasing activity with age: 49% (M 52%:F 46%) were regularly active up to at least moderate intensity. Males (mean predicted VO2max 44.4 mls/kg/min; 16-74 years) were fitter than females (mean predicted VO2max 34.0 mls/kg/min; 16-74 years) and while there was a decline in predicted VO2max with age, there was wide variation within each age category. There was no statistically significant relationship between current or past activity and fitness after adjustment for possible confounding factors, with the exception of a relationship between fitness and activity in males so that the difference between no activity and habitual vigorous activity in predicted VO2max was 4.4mls/kg/min (10.1%).