PFAS soil concentrations surrounding a hazardous waste incinerator in East Liverpool, Ohio, an environmental justice community

Per- and polyfluoroalkyl substances (PFAS) are a class of synthetic compounds widely used in industrial and consumer products. While PFAS provide product durability, these chemicals are ubiquitous, persistent, bioaccumulative, and toxic. These characteristics make the ultimate disposal of PFAS a challenge. One current disposal method is incineration; however, little research has been conducted on the safety and effectiveness of PFAS incineration. The characteristics of communities with hazardous waste incinerators that have received PFAS shipments indicate that more individuals with lower incomes and individuals with less education than the US average are at higher risk of exposure, which presents important environmental justice and health equity concerns of PFAS incineration. Situated in eastern Ohio, East Liverpool is an Appalachian community that is home to a large hazardous-waste incinerator, operated by Heritage WTI, that began accepting PFAS in 2019. Residents are concerned that the disposal lacks the research necessary to assure safety for the residents. Due to both community interest and data gaps regarding PFAS incineration, our research team conducted a pilot study to examine the distribution and concentration of PFAS in soil samples surrounding the incinerator. All 35 soil samples had measurable amounts of PFAS including perfluorobutanesulfonic acid (PFBS), perfluorooctanesulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and hexafluoropropylene oxide dimer acid (HFPO-DA)/GenX. PFOS was measured in the majority of soil samples (97%) with a range of 50-8,300 ng/kg. PFOA was measured in 94% of soil samples with a range of 51 ng/kg to 1300 ng/kg. HFPO-DA/GenX was measurable in 12 soil samples with concentrations of ranging from 150 ng/kg to 1500 ng/kg. Further research on PFAS disposal will advance knowledge and action related to regulatory requirements and exposure prevention, ultimately improving individual and community protections and health equity.

ACR-ARS Practice Parameter for the Performance of Total Body Irradiation

OBJECTIVES

This practice parameter was revised collaboratively by the American College of Radiology (ACR) and the American Radium Society (ARS). This practice parameter provides updated reference literature regarding both clinical-based conventional total body irradiation and evolving volumetric modulated total body irradiation.

METHODS

This practice parameter was developed according to the process described under the heading The Process for Developing ACR Practice Parameters and Technical Standards on the ACR website ( https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards ) by the Committee on Practice Parameters-Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with the ARS.

RESULTS

This practice parameter provides a comprehensive update to the reference literature regarding conventional total body irradiation and modulated total body irradiation. Dependence on dose rate remains an active area of ongoing investigation in both the conventional setting (where instantaneous dose rate can be varied) and in more modern rotational techniques, in which average dose rate is the relevant variable. The role of imaging during patient setup and the role of inhomogeneity corrections due to computer-based treatment planning systems are included as evolving areas of clinical interest notably surrounding the overall dose inhomogeneity. There is increasing emphasis on the importance of evaluating mean lung dose as it relates to toxicity during high-dose total body irradiation regimens.

CONCLUSIONS

This practice parameter can be used as an effective tool in designing and evaluating a total body irradiation program that successfully incorporates the close interaction and coordination among the radiation oncologists, medical physicists, dosimetrists, nurses, and radiation therapists.

A nuclear cAMP microdomain suppresses tumor growth by Hippo pathway inactivation

Cyclic AMP (cAMP) signaling is localized to multiple spatially distinct microdomains, but the role of cAMP microdomains in cancer cell biology is poorly understood. Here, we present a tunable genetic system that allows us to activate cAMP signaling in specific microdomains. We uncover a nuclear cAMP microdomain that activates a tumor-suppressive pathway in a broad range of cancers by inhibiting YAP, a key effector protein of the Hippo pathway, inside the nucleus. We show that nuclear cAMP induces a LATS-dependent pathway leading to phosphorylation of nuclear YAP solely at serine 397 and export of YAP from the nucleus with no change in YAP protein stability. Thus, nuclear cAMP inhibition of nuclear YAP is distinct from other known mechanisms of Hippo regulation. Pharmacologic targeting of specific cAMP microdomains remains an untapped therapeutic approach for cancer; thus, drugs directed at the nuclear cAMP microdomain may provide avenues for the treatment of cancer.

Stage-Dependent Impact of RIPK1 Inhibition on Atherogenesis: Dual Effects on Inflammation and Foam Cell Dynamics

Objective: Atherosclerosis is an arterial occlusive disease with hypercholesterolemia and hypertension as common risk factors. Advanced-stage stenotic plaque, which features inflammation and necrotic core formation, is the major reason for clinical intervention. Receptor interacting serine/threonine-protein kinase 1 (RIPK1) mediates inflammation and cell death and is expressed in atherosclerotic lesions. The role of RIPK1 in advanced-stage atherosclerosis is unknown.

Approach and Results: To investigate the effect of RIPK1 inhibition in advanced atherosclerotic plaque formation, we used ApoE^SA/SA mice, which exhibit hypercholesterolemia, and develop angiotensin-II mediated hypertension upon administration of doxycycline in drinking water. These mice readily develop severe atherosclerosis, including that in coronary arteries. Eight-week-old ApoE^SA/SA mice were randomized to orally receive a highly selective RIPK1 inhibitor (RIPK1i, GSK547) mixed with a western diet, or control diet. RIPK1i administration reduced atherosclerotic plaque lesion area at 2 weeks of treatment, consistent with suppressed inflammation (MCP-1, IL-1β, TNF-α) and reduced monocyte infiltration. However, administration of RIPK1i unexpectedly exacerbated atherosclerosis at 4 weeks of treatment, concomitant with increased macrophages and lipid deposition in the plaques. Incubation of isolated macrophages with oxidized LDL resulted in foam cell formation in vitro. RIPK1i treatment promoted such foam cell formation while suppressing the death of these cells. Accordingly, RIPK1i upregulated the expression of lipid metabolism-related genes (Cd36, Ppara, Lxrα, Lxrb, Srebp1c) in macrophage foam cells with ABCA1/ABCG1 unaltered. Furthermore, RIPK1i treatment inhibited ApoA1 synthesis in the liver and reduced plasma HDL levels.

Conclusion: RIPK1 modulates the development of atherosclerosis in a stage-dependent manner, implicating both pro-atherosclerotic (monocyte infiltration and inflammation) and anti-atherosclerotic effects (suppressing foam cell accumulation and promoting ApoA1 synthesis). It is critical to identify an optimal therapeutic duration for potential clinical use of RIPK1 inhibitor in atherosclerosis or other related disease indications.

Bariatric surgery is associated with lower risk of acute cardiovascular events in patients with obesity and hypertrophic cardiomyopathy

Background

Prior studies have suggested causal relationships between obesity and acute cardiovascular events (e.g., acute coronary syndrome, hypertensive crisis, and heart failure exacerbation). It has been known that the risk of cardiovascular events is reduced by bariatric surgery, the most effective method for substantial and sustained weight loss. However, little is known about whether bariatric surgery lowers the risk of acute cardiovascular events in the hypertrophic cardiomyopathy (HCM) population.

Purpose

To test the hypothesis that patients with obesity and HCM who underwent bariatric surgery have lower risk of developing acute cardiovascular events than those who did not.

Methods

In this population-based study of adults with obesity and HCM, the bariatric surgery group consisted of patients who underwent bariatric surgery from January 2004 to December 2014, whereas the control group included those who received non-bariatric elective intra-abdominal surgery during the same period. The outcome was an acute cardiovascular event – defined as emergency department (ED) visit or unplanned hospitalization for cardiovascular disease – during a 1-year post-surgery period. We used the SPARCS database, a population-based ED and inpatient database that captures all the ED visits and hospitalizations in New York State. We constructed logistic regression models with generalized estimating equations to compare the risk of the outcome events during sequential 6-month periods. We conducted multivariable analysis, adjusting for age, sex, number of ED visits and hospitalizations for cardiovascular disease within 2 years before the index surgery, and the Elixhauser comorbidity measures. We also performed additional analyses with propensity score (PS)-matching at 2:1 ratio and inverse probability treatment weighting (IPTW) using these variables.

Results

The analytic cohort consisted of 207 adults with obesity and HCM, including 147 patients who underwent bariatric surgery and 60 who had non-bariatric elective intra-abdominal surgery. In the 7–12 months post-surgery period, the risk of acute cardiovascular event was significantly lower in the bariatric surgery group (adjusted OR 0.23; 95% CI, 0.068–0.71; P=0.01; Figure) compared to the control group. In the PS-matched cohort (n=82 vs. 47), there were no significant differences in the baseline characteristics (P>0.50 for all comparisons). Similar to the main analysis, the PS-matched analysis demonstrated lower risk of the outcome event in the bariatric surgery group in the 7–12 months post-surgery period (OR 0.26; 95% CI, 0.083–0.73; P=0.01). The IPTW analysis also replicated the findings (OR 0.33; 95% CI, 0.16–0.71; P=0.004 during the 7–12 months post-surgery period).

Conclusion

In this population-based study of 207 adults with obesity and HCM, bariatric surgery was associated with a lower risk of acute cardiovascular events in the 7–12 months post-surgery period in real-world settings.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health (USA) and American Heart Association

Digital breast tomosynthesis: sensitivity for cancer in younger symptomatic women

OBJECTIVE

Full-field digital mammography (FFDM) has limited sensitivity for cancer in younger women with denser breasts. Digital breast tomosynthesis (DBT) can reduce the risk of cancer being obscured by overlying tissue. The primary study aim was to compare the sensitivity of FFDM, DBT and FFDM-plus-DBT in women under 60 years old with clinical suspicion of breast cancer.

METHODS

This multicentre study recruited 446 patients from UK breast clinics. Participants underwent both standard FFDM and DBT. A blinded retrospective multireader study involving 12 readers and 300 mammograms (152 malignant and 148 benign cases) was conducted.

RESULTS

Sensitivity for cancer was 86.6% with FFDM [95% CI (85.2-88.0%)], 89.1% with DBT [95% CI (88.2-90%)], and 91.7% with FFDM+DBT [95% CI (90.7-92.6%)]. In the densest breasts, the maximum sensitivity increment with FFDM +DBT over FFDM alone was 10.3%, varying by density measurement method. Overall specificity was 81.4% with FFDM [95% CI (80.5-82.3%)], 84.6% with DBT [95% CI (83.9-85.3%)], and 79.6% with FFDM +DBT [95% CI (79.0-80.2%)]. No differences were detected in accuracy of tumour measurement in unifocal cases.

CONCLUSIONS

Where available, DBT merits first-line use in the under 60 age group in symptomatic breast clinics, particularly in women known to have very dense breasts.

ADVANCES IN KNOWLEDGE

This study is one of very few to address the accuracy of DBT in symptomatic rather than screening patients. It quantifies the diagnostic gains of DBT in direct comparison with standard digital mammography, supporting informed decisions on appropriate use of DBT in this population.

Daily Ultrasound Imaging for Patients Undergoing Postprostatectomy Radiation Therapy Predicts and Ensures Dosimetric Endpoints

Purpose

Patients who receive radiation therapy (RT) for prostate cancer are routinely positioned through radiographic means. We set out to establish a data-driven process that defines bladder volume required to meet V40/65 constraints using daily bladder ultrasound (US) and comparative cone beam CT (CBCT) before placing a patient on the treatment table.

Methods and Materials

This was a single institution retrospective study of 20 patients (390 CBCT scans) who received postprostatectomy RT. Each patient received a daily US before treatment. CBCT alignment was performed 3 times a week. The bladder and rectum were contoured on each CBCT and a session dose was recorded. A mixed-effect model was used to estimate trajectory slopes of radiation exposure with organs-at-risk volume increase. Slope differences by V40/65 for prostate fossa (PF) and pelvic lymph nodes (PF/pLN) were tested using a 3-way-interaction term with Bonferroni correction.

Results

For the 20 patients, 10 received treatment to PF and 10 received RT to the PF/pLN. Predefined bladder constraints were V65 < 50%, V40 < 70%, and rectal constraints were V65 < 35%, V40 < 55%. The CBCT bladder volume (76-578 cm³) was greater than the pretreatment bladder US (87-466 cm³) due to volume filling between measurements (r = 0.8 ± 0.05). Mixed model detected a statistically significant 3-way interaction (P < .01) for bladder volume and V40/65. Both PF and PF/pLN patients showed improvement in V40/65 with an increase in bladder volume. For PF patients, bladder constraints were met when the US volume was >108 cm³ and for PF/pLN patients when the US bladder volume was >200 cm³. Rectal filling showed no association with CBCT volume.

Conclusions

Daily US of the bladder before postprostatectomy RT allows for dosimetric predictions before daily treatment. This should translate into fewer CBCT for the patient and improved machine throughput. This technique is easy to institute and ensures organs-at-risk volumetric constraints are met based on daily US measurements.

Abstract 287: A nuclear cAMP microdomain suppresses tumor growth by Hippo Pathway inactivation

Cyclic AMP can both promote and suppress tumor growth; however, how this single second messenger can simultaneously have such disparate effects on cancer remains largely undefined. It is well appreciated that cAMP does not diffuse within a cell but is made in microdomains, which consist of a unique adenylyl cyclase, one or more phosphodiesterases, and cAMP effector proteins, but the role of specific cAMP microdomains in cancer is unclear. Examination of human tissue biopsies revealed that the nuclear cAMP microdomain, defined by the soluble adenylyl cyclase (sAC), is upregulated early in tumorigenesis, but is lost with melanoma invasion and metastasis. Further, we showed that loss of sAC led to the transformation of melanocytes and reintroduction of sAC, only into the nucleus, was sufficient to block tumorigenesis in vitro and in mice. Neither mitochondrial, nor cytoplasmic cAMP microdomains affected tumor cell growth. Activation of nuclear sAC led to significant changes in chromatin accessibility suggesting that this cAMP microdomain regulates numerous transcription factors. Specifically, activation of nuclear sAC led to reduced chromatin accessibility for the TEAD and SMAD family of transcription factors, the key effectors of the Hippo Pathway. Consistent with those data, nuclear sAC suppressed TEAD-dependent pro-cancer gene expression profiles (e.g., MYC) by inhibiting YAP, one of the main oncoproteins in this signaling cascade. Moreover, we showed that nuclear cAMP evokes the same YAP-dependent inhibition of the Hippo Pathway in a variety of cancers, suggesting tumor suppression by nuclear sAC is not limited to melanoma. These studies reveal that a cAMP microdomain wholly contained within the nucleus is a pivotal a tumor suppressor that acts via Hippo Pathway inactivation.

Citation Format: Marek M. Drozdz, Ashley Doane, Garrett Desman, Jenny Wang, Michael Reilly, Kelsey Aguirre, Elsbeth Kane, Jedd Wolchok, Taha Merghoub, Olivier Elemento, Elena Piskounova, Jonathan Zippin. A nuclear cAMP microdomain suppresses tumor growth by Hippo Pathway inactivation [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 287.

Computational musculoskeletal modeling of compensatory movements in the upper limb

It is well documented that most upper limb amputees utilize compensatory movement strategies to accomplish everyday tasks when using a prosthetic device and that musculoskeletal complaints (MSCs) are more common in this population. However, little information is available on how the loss of distal degrees of freedom (DOFs) in the arm impact muscle force, thereby limiting our understanding of the mechanism by which these MSCs are manifesting. Knowledge of how a loss of DOFs may lead to MSCs can enable clinicians to provide more targeted guidance on how best to restore functional ability while addressing pain, and may serve as a tool for prescriptive decision-making when determining the impact of device selection on long-term clinical needs. 3D motion capture data were collected from 12 right-handed subjects with no upper limb disability using an 8-camera Vicon™ motion analysis system as they performed the targeted Box and Blocks test under normal and braced conditions to simulate a loss of DOFs in the wrist and fingers. Muscle force data were calculated using AnyBody Modeling Software™ for four different muscles: erector spinae, infraspinatus, deltoid, and trapezius. Linear mixed effects models were generated using the peak force data and mean force data for a given muscle fascicle. The fixed effect coefficient and 95% confidence intervals were reported for each muscle fascicle. Overall, a strong effect of condition on muscle force was seen for most muscles in the right side of the body (specifically deltoid and infraspinatus), with greater forces generated during the braced condition.

FRI0611-HPR EUROPEAN PRESCRIBERS’ PERSPECTIVES ON BIOSIMILARS

Background:

Biosimilars are highly similar, but not identical to originator biologics. In an increasingly resource-constrained environment, switching patients from originator biologics to biosimilars is a growing practice in many jurisdictions. Though automatic substitution of originator biologics with biosimilars is rare in Europe, this practice excludes physicians from decisions regarding the treatment of their patients.

Objectives:

As countries seek to control health costs and expand access to biologic therapies, building physician confidence in biosimilars is critical to promoting their use and reaping the cost benefits. This survey will empirically document their perspectives on biologic substitution. These findings may serve as a resource for countries in developing biosimilar policies which build physician confidence in biosimilars.

Methods:

The Alliance for Safe Biologic Medicines (ASBM) commissioned 15-minute web-based surveys among biologic prescribers in 6 Western European countries. Respondents must prescribe biologic medicines, must practice in France, Germany, Italy, Spain, Switzerland, or United Kingdom, must specialize in one of 10 practice areas: Dermatology, Endocrinology, Gastroenterology, Hematology Oncology, Immunology, Nephrology, Neurology, Oncology, Ophthalmology, Rheumatology. This survey is a refresh of one conducted in 2013 (n=470) available atwww.safebiologics.org/surveys.

Results:

579 responses were received, 14% from Rheumatologists (n=80). Biosimilar familiarity was high, increasing from 76% to 90% from the 2013 survey; with Rheumatologists the most familiar (99%). Similarly, the % of physicians who felt sole treatment decision authority was very important or critical had increased from 72% to 82%; among Rheumatologists again this figure was higher (85%). This pattern was found across many questions, for example the importance of retaining authority to prevent a substitution (a jump from 74% in 2013 to 84% in 2019 saying “very important or critical”, with Rheumatologists higher than average at 90%). Rheumatologists had a higher than average comfort level prescribing biosimilars to new patients, but were the least comfortable with a third party switching their patient for non-medical reasons (e.g. cost): 49% were “very uncomfortable” compared to an average of 29% across specialties.

Conclusion:

European physicians have increased their familiarity with biosimilars since 2013, with Rheumatologists the practice area with greatest familiarity. After 13 years of experience with biosimilars, Europe’s prescribers consider maintaining physician control of treatment decisions to be highly and increasingly important; Remain uncomfortable with switching a patient to a biosimilar for non-medical reasons; Are highly (and increasingly) uncomfortable with a non-medical substitution performed by a third party. When looking specifically at Rheumatologists, these trends are even more pronounced.

Disclosure of Interests:

Michael Reilly Grant/research support from: The organization of which I am executive director (ASBM) has received general grants from pharmaceutical companies., Madelaine Feldman: None declared

Destruction of Staphylococcus aureus and the impact of chlortetracycline on biomethane production during anaerobic digestion of chicken manure

Research was undertaken to ascertain the effect on biogas potential during the anaerobic digestion of chicken manure containing Staphylococcus aureus and chlortetracycline (antibiotic) from infected chicken flocks. S. aureus is a pathogenic bacteria in chicken flocks that is usually treated with the broad-spectrum antibiotic, chlortetracycline. Veterinary antibiotics are often prescribed in the poultry sector for on-farm use at the flock level to control disease; consequently, significant quantities of antibiotics are excreted from the bird into the manure. Subsequent anaerobic digestion of this chicken manure could lead to pathogens and antibiotics affecting the digestion process. Anaerobic digestion biochemical methane potential assays were completed at 35°C for 39 days, with some assays receiving S. aureus and some receiving S. aureus and chlortetracycline. No viable S. aureus cells were detected after Day 0 of the experiment. A further experiment utilising an order of magnitude greater concentration of S. aureus demonstrated a significant reduction (>400 fold) in S. aureus within 24 h when inoculated into anaerobic digestate, with no viable S. aureus cells detected by the end of 3 days. Furthermore, the efficacy of chlortetracycline was significantly reduced when applied to anaerobic digestate compared to water alone. Total biogas yields from chicken manure were significantly lowered by the addition of S. aureus, with and without chlortetracycline. However, there was no significant difference in methane yields between treatments. The cellulose control assays showed a lag phase in methane production after receiving chlortetracycline. In comparison, the absence of a lag phase when the antibiotic were added to chicken manure may have been due to the relatively high nitrogen content of the feedstock reducing the inhibition of chlortetracycline on methanogens. Therefore, this study demonstrates that the addition of S. aureus and chlortetracycline does not have a commercially relevant effect on the digestion of chicken manure.

Abstract LB-081: A nuclear cAMP microdomain functions as a tumor suppressor in melanoma

Cyclic AMP (cAMP), a ubiquitous second messenger, has a broad impact on cellular processes such as proliferation, differentiation, apoptosis, migration, and gene expression. It has been widely linked to melanomagenesis; however, studies often report contradictory functions for cAMP (e.g., cancer promotion, but also tumor suppression and therapy resistance). Thus, a huge conundrum exists in the field of cAMP signaling and melanoma – one that might be explained by examining cAMP at the level of microdomains. In mammalian cells, two classes of adenylyl cyclases synthesize cAMP: the transmembrane adenylyl cyclases (tmACs) and the soluble adenylyl cyclase (sAC). Unlike tmACs, which are tethered to the plasma membrane, sAC is expressed throughout the cell and within organelles (e.g., nucleus and mitochondria). Thus, sAC and tmACs define distinct sources that generate cAMP in spatially separated cell regions, further restricted by the cAMP catabolizing enzymes phosphodiesterases (PDEs). Since cAMP signaling cascades can be evoked and restricted to small compartments, it is imperative that we interrogate all available cAMP microdomains to truly unravel their role in melanoma.

To address this question, we have created a panel of virally-encoded, doxycycline-inducible sAC cDNAs, targeted to specific cellular compartments, i.e. nucleus, cytoplasm or mitochondria. We infected a melanoma sAC knock-out cell line with these cDNAs and have established single clone cell lines where sAC activity can be rapidly restored, only in a specific microdomain, at near pharmacologic time scales. Utilizing these model cell lines, we showed that only the nuclear sAC-dependent cAMP microdomain inhibits melanoma growth, both in vitro and in mice. Neither mitochondrial, nor cytoplasmic sAC cAMP microdomains affected tumor cell growth. Using ATACseq and RNAseq, we discovered that the nuclear cAMP microdomain leads to specific changes in chromatin landscape and a unique gene expression profile, distinct from the canonical MC1R/cAMP-dependent gene expression profile, that encompasses a range of genes with both established and potentially new roles in melanomagenesis. Immunohistochemical analysis of melanoma patient biopsies revealed that sAC localization in melanocytes is not static; while sAC is mostly cytoplasmic in benign melanocytes, it becomes nuclear as melanocytes undergo early malignant transformation (in situ disease and radial growth phase) but is lost from the nucleus upon transition to vertical growth phase. These data suggest that nuclear sAC expression is an early tumor suppressive pathway that is lost in melanoma cells capable of dermal invasion. Thus the pattern of cellular localization of sAC during different stages of melanoma may be a prognostic marker.

Taken together, our findings support a novel tumor suppressor pathway that relies on the expression of sAC in specific cellular microdomains.

Citation Format: Marek M. Drozdz, Jenny Wang, Michael Reilly, Elsbeth Kane, Kelsey Aguirre, Ashley Doane, Jedd D. Wolchok, Olivier Elemento, Garrett Desman, Taha Merghoub, Elena Piskounova, Jonathan Zippin. A nuclear cAMP microdomain functions as a tumor suppressor in melanoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-081.

Clozaril Withdrawal Induced Catatonia

Aim To describe an uncommon side effect of sudden withdrawal of Clozapine. Method This case describes the occurrence of catatonia following the sudden discontinuation of long term Clozapine therapy. Results Symptoms resolved with treatment with benzodiazepines and IV fluids. Discussion In conclusion, catatonia can occur on sudden discontinuation of Clozapine therapy. Caution should be exercised when reducing or discontinuing this medication.

FM1-2 A prospective study on surgical management of foot deformities in charcot marie tooth disease

Objectives

Charcot-Marie-Tooth (CMT) Disease is the most common inherited peripheral neuropathy. Foot deformities are frequently observed in CMT patients and orthopaedic surgery is often required. Currently the evidence base on surgical management is limited. We prospectively studied surgical management of CMT patients attending our centre.

Subjects

Patients were assessed at baseline and yearly after surgery.

Methods

Assessment and data included: history of ankle instability, pain, skin condition, lower limb strength assessment, Charcot-Marie-Tooth Examination Score, Foot Posture Index, ankle dorsiflexion range of movement, questionnaires, details of surgical procedures.

Results

29 feet in 24 CMT patients (17 males, 7 females, mean age: 38.6±13) were evaluated prior to surgery. All patients but one had genetically confirmed CMT (18 CMT1A; 4 CMTX; 1 CMT4A). 17 feet in 12 pts were evaluated after 1 year; 10 feet in 9 pts were evaluated after 2 years; 8 feet in 7 pts were evaluated after 3 years. A wide range of surgical procedures were performed by one dedicated orthopaedic surgeon. There was significant improvement of foot alignment (p<0.001), callosities (p=0.002) and pain (p=0.022) after surgery. Surgery had no significant effect on strength, ankle range of movement, falls and fatigue.

Conclusions

The findings showed significant improvement of foot alignment, callosities and pain after surgery. Data acquired from this study will help developing orthopaedic intervention guidelines and identify areas for further research.

RIP1 Kinase Drives Macrophage-Mediated Adaptive Immune Tolerance in Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDA) is characterized by immune tolerance and immunotherapeutic resistance. We discovered upregulation of receptor-interacting serine/threonine protein kinase 1 (RIP1) in tumor-associated macrophages (TAMs) in PDA. To study its role in oncogenic progression, we developed a selective small-molecule RIP1 inhibitor with high in vivo exposure. Targeting RIP1 reprogrammed TAMs toward an MHCII^hiTNFα⁺IFNγ⁺ immunogenic phenotype in a STAT1-dependent manner. RIP1 inhibition in TAMs resulted in cytotoxic T cell activation and T helper cell differentiation toward a mixed Th1/Th17 phenotype, leading to tumor immunity in mice and in organotypic models of human PDA. Targeting RIP1 synergized with PD1-and inducible co-stimulator-based immunotherapies. Tumor-promoting effects of RIP1 were independent of its co-association with RIP3. Collectively, our work describes RIP1 as a checkpoint kinase governing tumor immunity.

Mammalian pigmentation is regulated by a distinct cAMP-dependent mechanism that controls melanosome pH

The production of melanin increases skin pigmentation and reduces the risk of skin cancer. Melanin production depends on the pH of melanosomes, which are more acidic in lighter-skinned than in darker-skinned people. We showed that inhibition of soluble adenylyl cyclase (sAC) controlled pigmentation by increasing the pH of melanosomes both in cells and in vivo. Distinct from the canonical melanocortin 1 receptor (MC1R)-dependent cAMP pathway that controls pigmentation by altering gene expression, we found that inhibition of sAC increased pigmentation by increasing the activity of tyrosinase, the rate-limiting enzyme in melanin synthesis, which is more active at basic pH. We demonstrated that the effect of sAC activity on pH and melanin production in human melanocytes depended on the skin color of the donor. Last, we identified sAC inhibitors as a new class of drugs that increase melanosome pH and pigmentation in vivo, suggesting that pharmacologic inhibition of this pathway may affect skin cancer risk or pigmentation conditions.

Randomized clinical study of safety, pharmacokinetics, and pharmacodynamics of RIPK1 inhibitor GSK2982772 in healthy volunteers

GSK2982772 is a highly selective inhibitor of receptor‐interacting protein kinase 1 (RIPK1) being developed to treat chronic inflammatory diseases. This first‐in‐human study evaluated safety, tolerability, pharmacokinetics (PK), and exploratory pharmacodynamics (PD) of GSK2982772 administered orally to healthy male volunteers. This was a Phase I, randomized, placebo‐controlled, double‐blind study. In Part A, subjects received single ascending doses of GSK2982772 (0.1‐120 mg) or placebo in a crossover design during each of 4 treatment periods. In Part B, subjects received repeat doses of GSK2982772 (20 mg once daily [QD] to up to 120 mg twice daily [BID]) or placebo for 14 days. Part C was an open‐label relative bioavailability study comparing 20‐mg tablets vs capsules. Safety, tolerability, pharmacokinetics (PK), RIPK1 target engagement (TE), and pharmacodynamics (PD) were assessed. The most common adverse events (AEs) were contact dermatitis and headache. Most AEs were mild in intensity, and there were no deaths or serious AEs. The PK of GSK2982772 was approximately linear over the dose range studied (up to 120 mg BID). There was no evidence of drug accumulation upon repeat dosing. Greater than 90% RIPK1 TE was achieved over a 24‐hour period for the 60‐mg and 120‐mg BID dosing regimens. Single and repeat doses of GSK2982772 were safe and well tolerated. PK profiles showed dose linearity. The high levels of RIPK1 TE support progression into Phase II clinical trials for further clinical development.

Is the matched extreme case-control design more powerful than the nested case-control design?

For time-to-event data, the study sample is commonly selected using the nested case-control design in which controls are selected at the event time of each case. An alternative sampling strategy is to sample all controls at the same (pre-specified) time, which can either be at the last event time or further out in time. Such controls are the long-term survivors and may therefore constitute a more 'extreme' comparison group and be more informative than controls from the nested case-control design. We investigate this potential information gain by comparing the power of various 'extreme' case-control designs with that of the nested case-control design using simulation studies. We derive an expression for the theoretical average information in a nested and extreme case-control pair for the situation of a single binary exposure. Comparisons reveal that the efficiency of the extreme case-control design increases when the controls are sampled further out in time. In an application to a study of dementia, we identified Apolipoprotein E as a risk factor using a 1:1 extreme case-control design, which provided a hazard ratio estimate with a smaller standard error than that of a 2:1 nested case-control design.

A qualitative exploration of techniques used by expert midwives to preserve the perineum intact

BACKGROUND

The perineum stretches during birth to allow passage of the baby, but 85% of women sustain some degree of perineal trauma during childbirth, which is painful post-partum. Episiotomy rates vary significantly, with some countries having rates of >60%. Recent Irish and New Zealand studies showed lower severe perineal trauma and episiotomy rates than other countries.

AIM

To explore expert Irish and New Zealand midwives' views of the skills that they employ in preserving the perineum intact during spontaneous vaginal birth.

METHODS

Following ethical approval a qualitative, descriptive study was undertaken. Semi-structured, recorded, interviews were transcribed and analysed using the constant comparative method. Expert midwives employed in New Zealand and one setting in Ireland, were invited to join the study. "Expert" was defined as achieving, in the preceding 3.5 years, an episiotomy rate for nulliparous women of <11.8%, a 'no suture' rate of 40% or greater, and a severe perineal tear rate of <3.2%. Twenty-one midwives consented to join the study.

RESULTS

Four core themes emerged: 'Calm, controlled birth', 'Position and techniques in early second stage', 'Hands on or off?' and 'Slow, blow and breathe the baby out.' Using the techniques described enabled these midwives to achieve rates, in nulliparous women, of 3.91% for episiotomy, 59.24% for 'no sutures', and 1.08% for serious lacerations.

CONCLUSIONS

This study provides further understanding of the techniques used by expert midwives at birth. These findings, combined with existing quantitative research, increases the evidence on how to preserve the perineum intact during spontaneous birth.

Identification of a TLR2-regulated gene signature associated with tumor cell growth in gastric cancer

Toll-like receptors (TLRs) are key regulators of innate immune responses, and their dysregulation is observed in numerous inflammation-associated malignancies, including gastric cancer (GC). However, the identity of specific TLRs and their molecular targets which promote the pathogenesis of human GC is ill-defined. Here, we sought to determine the clinical utility of TLR2 in human GC. TLR2 mRNA and protein expression levels were elevated in >50% of GC patient tumors across multiple ethnicities. TLR2 was also widely expressed among human GC cell lines, and DNA microarray-based expression profiling demonstrated that the TLR2-induced growth responsiveness of human GC cells corresponded with the up-regulation of six anti-apoptotic (BCL2A1, BCL2, BIRC3, CFLAR, IER3, TNFAIP3) and down-regulation of two tumor suppressor (PDCD4, TP53INP1) genes. The TLR2-mediated regulation of these anti-apoptotic and tumor suppressor genes was also supported by their increased and reduced expression, respectively, in two independent genetic GC mouse models (gp130^F/F and Gan) characterized by high tumor TLR2 expression. Notably, enrichment of this TLR2-regulated gene signature also positively correlated with augmented TLR2 expression in human GC tumors, and served as an indicator of poor patient survival. Furthermore, treatment of gp130^F/F and cell line-derived xenograft (MKN1) GC mouse models with a humanized anti-TLR2 antibody suppressed gastric tumor growth, which was coincident with alterations to the TLR2-driven gene signature. Collectively, our study demonstrates that in the majority of GC patients, elevated TLR2 expression is associated with a growth-potentiating gene signature which predicts poor patient outcomes, thus supporting TLR2 as a promising therapeutic target in GC.

Commissioning and initial experience with the first clinical gantry-mounted proton therapy system

The purpose of this study is to describe the comprehensive commissioning process and initial clinical experience of the Mevion S250 proton therapy system, a gantry‐mounted, single‐room proton therapy platform clinically implemented in the S. Lee Kling Proton Therapy Center at Barnes‐Jewish Hospital in St. Louis, MO, USA. The Mevion S250 system integrates a compact synchrocyclotron with a C‐inner gantry, an image guidance system and a 6D robotic couch into a beam delivery platform. We present our commissioning process and initial clinical experience, including i) CT calibration; ii) beam data acquisition and machine characteristics; iii) dosimetric commissioning of the treatment planning system; iv) validation through the Imaging and Radiation Oncology Core credentialing process, including irradiations on the spine, prostate, brain, and lung phantoms; v) evaluation of localization accuracy of the image guidance system; and vi) initial clinical experience. Clinically, the system operates well and has provided an excellent platform for the treatment of diseases with protons.

PACS number(s): 87.55.ne, 87.56.bd

Survey of infection control and antimicrobial stewardship practices in Australian residential aged-care facilities

This study assessed infection prevention and antimicrobial stewardship (AMS) practices in Australian residential aged-care facilities (RACF). Two hundred and sixty-five surveys (15.6%) were completed with all states represented and the majority (177 (67.3%)) privately run. Only 30.6% RACF had infection control trained staff on site. Few facilities had AMS policies, only 14% had antimicrobial prescribing restrictions. Most facilities offered vaccination to residents (influenza vaccination rates >75% in 73% of facilities), but pneumococcal vaccination was poor.

Dorsal Hump Reduction and Osteotomies

This article discusses the technique for planning, executing, and troubleshooting dorsal hump reduction for the cosmetic rhinoplasty patient. Details of the discussion include the necessary elements of the preoperative consultation with the patient, the specific instruments used to effectively and reproducibly create osteotomies, the anatomic and patient variables that require special attention, and the necessary measures to guard against potential complications.