"How to article:" guidelines for serving on an expert panel

Academics in medicine are frequently asked to serve on panels to discuss their clinical, research, education, administrative or personal expertise. While panel discussions are often the highlight of a conference or event, in the medical literature, there is very little published on how an individual can effectively prepare and present as an expert panelist. This paper offers guidelines that will enable academics to prepare, deliver, and engage in active dialogue during a panel discussion. Specific tactics include how to accept invitations to serve on a panel, conducting pre-panel conference meetings and background research, preparing concise opening statements and new insights, connecting with the audience, answering questions in a collaborative spirit, and debriefing after the panel. These guidelines will be valuable to any individual invited to serve on a panel discussion and will promote future panelists in engaging in constructive and fulfilling dialogue, with the ultimate goal of leaving the audience with a greater understanding of the topic of discourse.

The Effects of the COVID-19 Pandemic on Nursing Education Programs

BACKGROUND

The U.S. Boards of Nursing (BONs) collect annual report data from their nursing programs as part of their approval process. This paper highlights the 2020 and 2021 annual report data on the effect of coronavirus disease 2019 (COVID-19) on all nursing programs in 17 BONs in 2020 and 19 in 2021.

METHOD

Nursing programs answered 16 questions on the effect of COVID-19 on their programs. Because BONs require annual report data, all programs in the participating states answered the questions, which included 798 programs in 2020 and 929 in 2021.

RESULTS

Major disruptions in nursing education occurred during the pandemic. Clinical experiences and didactic classes were greatly affected, though alternative strategies were used. Student and faculty attrition rates were particularly high in 2021.

CONCLUSION

The authors call for a national forum where nurse leaders analyze what happened and make recommendations for future crisis events. [J Nurs Educ. 2024;63(5):312-319.].

Workplace Harassment, Cyber Incivility, and Climate in Academic Medicine

Importance

The culture of academic medicine may foster mistreatment that disproportionately affects individuals who have been marginalized within a given society (minoritized groups) and compromises workforce vitality. Existing research has been limited by a lack of comprehensive, validated measures, low response rates, and narrow samples as well as comparisons limited to the binary gender categories of male or female assigned at birth (cisgender).

Objective

To evaluate academic medical culture, faculty mental health, and their relationship.

Design, Setting, and Participants

A total of 830 faculty members in the US received National Institutes of Health career development awards from 2006-2009, remained in academia, and responded to a 2021 survey that had a response rate of 64%. Experiences were compared by gender, race and ethnicity (using the categories of Asian, underrepresented in medicine [defined as race and ethnicity other than Asian or non-Hispanic White], and White), and lesbian, gay, bisexual, transgender, queer (LGBTQ+) status. Multivariable models were used to explore associations between experiences of culture (climate, sexual harassment, and cyber incivility) with mental health.

Exposures

Minoritized identity based on gender, race and ethnicity, and LGBTQ+ status.

Main Outcomes and Measures

Three aspects of culture were measured as the primary outcomes: organizational climate, sexual harassment, and cyber incivility using previously developed instruments. The 5-item Mental Health Inventory (scored from 0 to 100 points with higher values indicating better mental health) was used to evaluate the secondary outcome of mental health.

Results

Of the 830 faculty members, there were 422 men, 385 women, 2 in nonbinary gender category, and 21 who did not identify gender; there were 169 Asian respondents, 66 respondents underrepresented in medicine, 572 White respondents, and 23 respondents who did not report their race and ethnicity; and there were 774 respondents who identified as cisgender and heterosexual, 31 as having LGBTQ+ status, and 25 who did not identify status. Women rated general climate (5-point scale) more negatively than men (mean, 3.68 [95% CI, 3.59-3.77] vs 3.96 [95% CI, 3.88-4.04], respectively, P < .001). Diversity climate ratings differed significantly by gender (mean, 3.72 [95% CI, 3.64-3.80] for women vs 4.16 [95% CI, 4.09-4.23] for men, P < .001) and by race and ethnicity (mean, 4.0 [95% CI, 3.88-4.12] for Asian respondents, 3.71 [95% CI, 3.50-3.92] for respondents underrepresented in medicine, and 3.96 [95% CI, 3.90-4.02] for White respondents, P = .04). Women were more likely than men to report experiencing gender harassment (sexist remarks and crude behaviors) (71.9% [95% CI, 67.1%-76.4%] vs 44.9% [95% CI, 40.1%-49.8%], respectively, P < .001). Respondents with LGBTQ+ status were more likely to report experiencing sexual harassment than cisgender and heterosexual respondents when using social media professionally (13.3% [95% CI, 1.7%-40.5%] vs 2.5% [95% CI, 1.2%-4.6%], respectively, P = .01). Each of the 3 aspects of culture and gender were significantly associated with the secondary outcome of mental health in the multivariable analysis.

Conclusions and Relevance

High rates of sexual harassment, cyber incivility, and negative organizational climate exist in academic medicine, disproportionately affecting minoritized groups and affecting mental health. Ongoing efforts to transform culture are necessary.

Assessing the Impact of the COVID-19 Pandemic on Nursing Education: A National Study of Prelicensure RN Programs

Background

The COVID-19 pandemic has had a profound impact on prelicensure nursing education, leading to widespread disruptions that may have implications for nursing students' learning and engagement outcomes. Understanding how the rapid shift to online and simulation-based teaching methods has affected new graduates' clinical preparedness is critical to ensure patient safety moving forward.

Purpose

To assess the impact of institutional, academic, and demographic characteristics on prelicensure nursing students' academic, initial postgraduation, and early career outcomes during the COVID-19 pandemic.

Methods

We conducted a mixed-methods longitudinal study focused on prelicensure registered nurse (RN) students entering the core of their didactic and clinical nursing coursework during the pandemic. This study uses a combination of real-time student and faculty self-report data, including externally validated instruments, within and end-of-program standardized test scores, and focus group findings. Various statistical methods, ranging from simpler descriptive and non-parametric methods to Generalized Estimating Equation (GEE) models and detailed textual analysis, are applied to assess student, faculty, and institution-level data.

Results

The final sample includes more than 1,100 student and faculty participants affiliated with 51 prelicensure RN programs located across 27 states. Leveraging more than 4,000 course observations collected from fall 2020 to spring 2022 and supplemented by the rich personal narratives of over 60 focus group participants, this study illuminates the breadth, scale, and ever-evolving nature of prelicensure RN programs' efforts to maintain the continuity of nursing students' education during the public health crisis. In doing so, it captures the many ways in which nursing administrators, faculty, and students sought to address the unparalleled challenges they confronted on a day-to-day basis. In particular, the findings provide critical insights into the efficacy of the changes nursing programs made to their course delivery formats to adjust to the confluence of rapidly evolving federal, state, and private restrictions to stem the spread of COVID-19.

Conclusion

This study stands as the most comprehensive assessment of prelicensure nursing education in the United States since the onset of COVID-19. It extends knowledge by linking potential deficiencies in students' didactic and clinical education during the pandemic and their early career preparedness, clinical competence, and the patient safety implications therein.

Applying Principles of a Fair and Just Culture to a Student Scenario

BACKGROUND

This article reviews national efforts toward promoting fair and just cultures in schools of nursing. A real-life vignette in which a nursing student made a medication error is presented, and the nursing program contacted the nursing regulatory body for advice on how to handle the situation.

METHOD

A framework was used to analyze the causes of the error. Commentary is offered regarding how applying the principles of a fair and just culture could improve student performance and advance the school's culture to reflect one that was fair and just.

RESULTS

A fair and just culture requires a commitment of all leaders and faculty within a school of nursing. Administrators and faculty must recognize that errors are part of the learning process, that errors can be minimized but not eliminated, and that learning can occur from each incident to prevent similar occurrences in the future.

CONCLUSION

Academic leaders must engage faculty, staff, and students in a dialogue about the principles of a fair and just culture to develop a tailored plan of action. [J Nurs Educ. 2023;62(3):139-145.].

Nursing Student Errors and Near Misses: Three Years of Data

BACKGROUND

Understanding the magnitude of errors and near misses in all health care situations is crucial to preventing them from occurring in the future. However, little research is available on the type or extent of nursing student errors in the United States.

METHOD

Nursing student error and near miss data were submitted by more than 200 participating prelicensure nursing programs via a secured online repository.

RESULTS

Medication errors represented more than half (58.8%, n = 613) of the total error and near-miss data (n = 1,042) submitted. Errors and near misses were attributed to students not adhering to three major patient safety procedures: checking the patient's identification, checking the patient's allergy status, and following the rights of medication administration.

CONCLUSION

Results indicate collecting data on nursing students' errors and near misses can help nursing programs identify system issues, promote transparency, and make quality improvements. [J Nurs Educ. 2023;62(1):12-19.].

Association Between Parent Comfort With English and Adverse Events Among Hospitalized Children

IMPORTANCE

Children of parents expressing limited comfort with English (LCE) or limited English proficiency may be at increased risk of adverse events (harms due to medical care). No prior studies have examined, in a multicenter fashion, the association between language comfort or language proficiency and systematically, actively collected adverse events that include family safety reporting.

OBJECTIVE

To examine the association between parent LCE and adverse events in a cohort of hospitalized children.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter prospective cohort study was conducted from December 2014 to January 2017, concurrent with data collection from the Patient and Family Centered I-PASS Study, a clinician-family communication and patient safety intervention study. The study included 1666 Arabic-, Chinese-, English-, and Spanish-speaking parents of general pediatric and subspecialty patients 17 years and younger in the pediatric units of 7 North American hospitals. Data were analyzed from January 2018 to May 2020.

EXPOSURES

Language-comfort data were collected through parent self-reporting. LCE was defined as reporting any language besides English as the language in which parents were most comfortable speaking to physicians or nurses.

MAIN OUTCOMES AND MEASURES

The primary outcome was adverse events; the secondary outcome was preventable adverse events. Adverse events were collected using a systematic 2-step methodology. First, clinician abstractors reviewed patient medical records, solicited clinician reports, hospital incident reports, and family safety interviews. Then, review and consensus classification were completed by physician pairs. To examine the association of LCE with adverse events, a multivariable logistic regression was conducted with random intercepts to adjust for clustering by site.

RESULTS

Of 1666 parents providing language-comfort data, 1341 (80.5%) were female, and the mean (SD) age of parents was 35.4 (10.0) years. A total of 147 parents (8.8%) expressed LCE, most of whom (105 [71.4%]) preferred Spanish. Children of parents who expressed LCE had higher odds of having 1 or more adverse events compared with children whose parents expressed comfort with English (26 of 147 [17.7%] vs 146 of 1519 [9.6%]; adjusted odds ratio, 2.1; 95% CI, 1.2-3.7), after adjustment for parent race and education, complex chronic conditions, length of stay, site, and the intervention period. Similarly, children whose parents expressed LCE were more likely to experience 1 or more preventable adverse events (adjusted odds ratio, 2.3; 95% CI, 1.2-4.2).

CONCLUSIONS AND RELEVANCE

Hospitalized children of parents expressing LCE were twice as likely to experience harms due to medical care. Targeted strategies are needed to improve communication and safety for this vulnerable group of children.

Nutrient patterns and brain biomarkers of Alzheimer's disease in cognitively normal individuals

OBJECTIVES

Epidemiological evidence linking diet, one of the most important modifiable lifestyle factors, and risk of Alzheimer's disease (AD) is rapidly increasing. However, there is little or no evidence for a direct association between dietary nutrients and brain biomarkers of AD. This study identifies nutrient patterns associated with major brain AD biomarkers in a cohort of clinically and cognitively normal (NL) individuals at risk for AD.

DESIGN

Cross-sectional study.

SETTING

Manhattan (broader area).

PARTICIPANTS

Fifty-two NL individuals (age 54+12 y, 70% women, Clinical Dementia Rating=0, MMSE>27, neuropsychological test performance within norms by age and education) with complete dietary information and cross-sectional, 3D T1-weighted Magnetic Resonance Imaging (MRI; gray matter volumes, GMV, a marker of brain atrophy), 11C-Pittsburgh compound-B (PiB; a marker of fibrillar amyloid-β, Aβ) and 18F-fluorodeoxyglucose (FDG; a marker of glucose metabolism, METglc) Positron Emission Tomography (PET) scans were examined.

MEASUREMENTS

Dietary intake of 35 nutrients associated with cognitive function and AD was assessed using the Harvard/Willet Food Frequency Questionnaire. Principal component analysis was used to generate nutrient patterns (NP) from the full nutrient panel. Statistical parametric mapping and voxel based morphometry were used to assess the associations of the identified NPs with AD biomarkers.

RESULTS

None of the participants were diabetics, smokers, or met criteria for obesity. Five NPs were identified: NP1 was characterized by most B-vitamins and several minerals [VitB and Minerals]; NP2 by monounsaturated and polyunsaturated fats, including ω-3 and ω-6 PUFA, and vitamin E [VitE and PUFA]; NP3 by vitamin A, vitamin C, carotenoids and dietary fibers [Anti-oxidants and Fibers]; NP4 by vitamin B12, vitamin D and zinc [VitB12 and D]; NP5 by saturated, trans-saturated fats, cholesterol and sodium [Fats]. Voxel-based analysis showed that NP4 scores [VitB12 and D] were positively associated with METglc and GMV, and negatively associated with PiB retention in AD-vulnerable regions (p<0.001). In addition, both METglc and GMV were positively associated with NP2 scores [VitE and PUFA], and negatively associated with NP5 scores [Fats] (p<0.001), and METglc was positively associated with higher NP3 scores [Anti-oxidants and Fibers] (p<0.001). Adjusting for age, gender, ethnicity, education, caloric intake, BMI, alcohol consumption, family history and Apolipoprotein E (APOE) status did not attenuate these relationships. The identified 'AD-protective' nutrient combination was associated with higher intake of fresh fruit and vegetables, whole grains, fish and low-fat dairies, and lower intake of sweets, fried potatoes, high-fat dairies, processed meat and butter.

CONCLUSION

Specific dietary NPs are associated with brain biomarkers of AD in NL individuals, suggesting that dietary interventions may play a role in the prevention of AD by modulating AD-risk through its effects on Aβ and associated neuronal impairment.

Reduced glucose uptake and Aβ in brain regions with hyperintensities in connected white matter

Interstitial concentration of amyloid beta (Aß) is positively related to synaptic activity in animal experiments. In humans, Aß deposition in Alzheimer's disease overlaps with cortical regions highly active earlier in life. White matter lesions (WML) disrupt connections between gray matter (GM) regions which in turn changes their activation patterns. Here, we tested if WML are related to Aß accumulation (measured with PiB-PET) and glucose uptake (measured with FDG-PET) in connected GM. WML masks from 72 cognitively normal (age 61.7 ± 9.6 years, 71% women) individuals were obtained from T2-FLAIR. MRI and PET images were normalized into common space, segmented and parcellated into gray matter (GM) regions. The effects of WML on connected GM regions were assessed using the Change in Connectivity (ChaCo) score. Defined for each GM region, ChaCo is the percentage of WM tracts connecting to that region that pass through the WML mask. The regional relationship between ChaCo, glucose uptake and Aß was explored via linear regression. Subcortical regions of the bilateral caudate, putamen, calcarine, insula, thalamus and anterior cingulum had WM connections with the most lesions, followed by frontal, occipital, temporal, parietal and cerebellar regions. Regional analysis revealed that GM with more lesions in connecting WM and thus impaired connectivity had lower FDG-PET (r = 0.20, p<0.05 corrected) and lower PiB uptake (r = 0.28, p<0.05 corrected). Regional regression also revealed that both ChaCo (β = 0.045) and FDG-PET (β = 0.089) were significant predictors of PiB. In conclusion, brain regions with more lesions in connecting WM had lower glucose metabolism and lower Aß deposition.

Mediterranean Diet and Magnetic Resonance Imaging-Assessed Brain Atrophy in Cognitively Normal Individuals at Risk for Alzheimer's Disease

OBJECTIVES

Epidemiological evidence linking diet, one of the most important modifiable environmental factors, and risk of Alzheimer's disease (AD) is rapidly increasing. Several studies have shown that higher adherence to a Mediterranean diet (MeDi) is associated with reduced risk of AD. This study examines the associations between high vs. lower adherence to a MeDi and structural MRI-based brain atrophy in key regions for AD in cognitively normal (NL) individuals with and without risk factors for AD.

DESIGN

Cross-sectional study.

SETTING

Manhattan (broader area).

PARTICIPANTS

Fifty-two NL individuals (age 54+12 y, 70% women) with complete dietary information and cross-sectional, 3D T1-weighted MRI scans were examined.

MEASUREMENTS

Subjects were dichotomized into those showing higher vs. lower adherences to the MeDi using published protocols. Estimates of cortical thickness for entorhinal cortex (EC), inferior parietal lobe, middle temporal gyrus, orbitofrontal cortex (OFC) and posterior cingulate cortex (PCC) were obtained by use of automated segmentation tools (FreeSurfer). Multivariate general linear models and linear regressions assessed the associations of MeDi with MRI measures.

RESULTS

Of the 52 participants, 20 (39%) showed higher MeDi adherence (MeDi+) and 32 (61%) showed lower adherence (MeDi-). Groups were comparable for clinical, neuropsychological measures, presence of a family history of AD (FH), and frequency of Apolipoprotein E (APOE) ε4 genotype. With and without controlling for age and total intracranial volume, MeDi+ subjects showed greater thickness of AD-vulnerable ROIs as compared to MeDi- subjects (Wilk's Lambda p=0.026). Group differences were most pronounced in OFC (p=0.001), EC (p=0.03) and PCC (p=0.04) of the left hemisphere. Adjusting for gender, education, FH, APOE status, BMI, insulin resistance scores and presence of hypertension did not attenuate the relationship.

CONCLUSION

NL individuals showing lower adherence to the MeDi had cortical thinning in the same brain regions as clinical AD patients compared to those showing higher adherence. These data indicate that the MeDi may have a protective effect against tissue loss, and suggest that dietary interventions may play a role in the prevention of AD.

MEDITERRANEAN DIET AND MAGNETIC RESONANCE IMAGING-ASSESSED BRAIN ATROPHY IN COGNITIVELY NORMAL INDIVIDUALS AT RISK FOR ALZHEIMER’S DISEASE

OBJECTIVES: Epidemiological evidence linking diet, one of the most important modifiable environmental factors, and risk of Alzheimer’s disease (AD) is rapidly increasing. Several studies have shown that higher adherence to a Mediterranean diet (MeDi) is associated with reduced risk of AD. This study examines the associations between high vs. lower adherence to a MeDi and structural MRI-based brain atrophy in key regions for AD in cognitively normal (NL) individuals with and without risk factors for AD. DESIGN: Cross-sectional study. SETTING: Manhattan (broader area). PARTICIPANTS: Fifty-two NL individuals (age 54+12 y, 70% women) with complete dietary information and cross-sectional, 3D T1-weighted MRI scans were examined. MEASUREMENTS: Subjects were dichotomized into those showing higher vs. lower adherences to the MeDi using published protocols. Estimates of cortical thickness for entorhinal cortex (EC), inferior parietal lobe, middle temporal gyrus, orbitofrontal cortex (OFC) and posterior cingulate cortex (PCC) were obtained by use of automated segmentation tools (FreeSurfer). Multivariate general linear models and linear regressions assessed the associations of MeDi with MRI measures. RESULTS: Of the 52 participants, 20 (39%) showed higher MeDi adherence (MeDi+) and 32 (61%) showed lower adherence (MeDi-). Groups were comparable for clinical, neuropsychological measures, presence of a family history of AD (FH), and frequency of Apolipoprotein E (APOE) ε4 genotype. With and without controlling for age and total intracranial volume, MeDi+ subjects showed greater thickness of AD-vulnerable ROIs as compared to MeDi- subjects (Wilk’s Lambda p=0.026). Group differences were most pronounced in OFC (p=0.001), EC (p=0.03) and PCC (p=0.04) of the left hemisphere. Adjusting for gender, education, FH, APOE status, BMI, insulin resistance scores and presence of hypertension did not attenuate the relationship. CONCLUSION: NL individuals showing lower adherence to the MeDi had cortical thinning in the same brain regions as clinical AD patients compared to those showing higher adherence. These data indicate that the MeDi may have a protective effect against tissue loss, and suggest that dietary interventions may play a role in the prevention of AD

Abstract P2-16-23: The ENCHANT-1 trial (NCT01677455): An open label multicenter phase 2 proof of concept study evaluating first line ganetespib monotherapy in women with metastatic HER2 positive or triple negative breast cancer (TNBC)

Background: Hsp90 is a molecular chaperone protein required for the stabilization and activation of many proteins, referred to as Hsp90 ‘clients’, such as HER2, HIF1-a, EGFR, ER, PI3K, AKT, P53 and VEGFR. The drug candidate, ganetespib is a novel triazolone inhibitor of Hsp90, with over 700 patients treated to date. Ganetespib has shown activity in preclinical models of HER2+, ER+/PR+ and TNBC. Early clinical trials documented ganetespib single agent activity in heavily pretreated HER2+ and TNBC patients. Ganetespib has been well tolerated in clinical trials with a favorable safety profile. This efficacy-screening study is designed to provide further evidence of ganetespib activity and identify potentially predictive biomarkers in metastatic breast cancer (BC).

Methods: The ENCHANT-1 Trial is an international, first-line 2-cohort Phase 2 study in BC patients: Cohort A, HER2 amplified (n = 35), and Cohort B, TNBC (n = 35). Patients who present with previously untreated metastatic disease are eligible for treatment with ganetespib at 150 mg/m2 twice weekly on 3 out of 4 wks, for a total of up to 12 wks. Primary endpoint: ORR assessed using RECIST1.1 criteria. Key secondary endpoints include metabolic response as assessed by PET/CT at wk 3 utilizing modified EORTC criteria. Disease progression (PD) at wk 3 by PET imaging indicates discontinuation of study therapy, and is performed to quickly offer patients with metabolic PD a standard of care treatment.

The study is designed as Simon 2-stage requiring at least one OR in 15 patients for the respective cohort to expand to 35 patients. A Steering Committee is established to oversee the overall study and review the interim results.

Results: The study was initiated in 23 centers globally. At the time of submission, a total of 17 patients had been enrolled; TNBC (n = 15) and HER2 (n = 2). Here we report the interim analysis in the TNBC cohort. The median age was 54 years (range 30 -77) with ECOG PS 0 (n = 7/15). Most patients (n = 9) presented with de novo metastatic disease. 5 patients were not evaluable for PET assessment (3 had not yet reached wk 3 and 2 withdrawn before wk 3 for clinical progression), and 9 patients were not evaluable for objective response at wk 6 (3 withdrawn before or at wk 3 for clinical progression and 6 had not yet reached wk 6 evaluation). In the 10 patients with evaluable PET imaging, 9 patients achieved metabolic (m) response (2 mPR, 4 mSD with dominant tumor shrinkage and 3 SD) and one patient with mPD. In the 6 patients evaluable for OR at wk 6, one patient achieved PR, 2 SD and 3 PD. Treatment with ganetespib was well tolerated; the most common AEs were mild or moderate diarrhea (8/15, 53%), fatigue (5/15, 33%), decreased appetite (4/15, 27%), insomnia (4/15, 27%), and nausea (4/15, 27%).

Conclusion: Ganetespib single agent was generally well tolerated and showed anti-tumor activity TNBC patients as early as 3 weeks following treatment. PET seems to be a good tool to screen antitumor activity of new agents in early settings rather that in heavily pretreated patients. The TNBC cohort has met the protocol criteria for proceeding to stage 2.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-16-23.

Abstract S4-03: Exome sequencing reveals clinically actionable mutations in the pathogenesis and metastasis of triple negative breast cancer

Triple negative breast cancer (TNBC) represents a particularly aggressive and difficult to treat form of breast cancer. No specific genetic alterations have been described as characteristic of the disease, with the exception of association with BRCA1/2, EGFR, and KRAS mutations. In this study, we sought to define clinically actionable mutations in untreated metastatic tumors as well as compare the mutational status of metastatic samples with germ-line and primary tumors using whole exome sequencing.

We prospectively enrolled 38 patients with newly diagnosed metastatic TNBC and collected matched specimens of germ-line DNA, primary tumor and metastatic tumor. Median DFI from time of initial primary diagnosis to recurrence was 18 months (IQR = 1-24 months) and 9 patients presented with de novo metastatic disease. 34/38 patients went on to receive first-line treatment with nab-paclitaxel, carboplatin, and bevacizumab and ORR/PFS/OS are available.

Sites of TNBC metastatic tissue (n = 31) included: liver (10), chest wall (13), non-regional lymph nodes (4), and lung (4). 7 patients had inadequate metastatic tumor for sequencing. We performed whole-exome sequencing for all samples using the Agilent solution-based system of exon capture, which uses RNA baits to target all protein coding genes (CCDS database), as well as ∼700 human miRNAs from miRBase (v13). In all, we generated over 10 GB of sequencing data using high throughput sequencing on the Illumina platform.

We observed striking genetic heterogeneity among the metastatic and primary tumors. There was no single driver mutation that was common to the metastatic tumors indicating the diverse genetic pathways that contribute to metastasis. Early analysis suggests that mutations in APC and MTOR occur more frequently in metastatic tumors than in primary tumors. Nonsense mutations of ER were detected in both primary and metastatic tumors but not in germ-line DNA. EGFR and HER2 mutations were not found in any of the primary or metastatic TNBC samples.

This data provides the most comprehensive genetic portrait of metastatic and primary TNBC to date, and represents a significant first step in identifying the genetic causes of the disease, drivers of recurrence, and potential therapeutic targets. Full results, including the primary versus metastatic tumor mutational analysis will be presented.

This study was funded by a Susan G. Komen Grant SAC 100001.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr S4-03.

The current state of ICD-10 & preparing for it

The AMA continues to harbor serious concerns and reservations with the significant burden of the ICD-10 mandate and continues to convey these points to policymakers in Washington. The AMA is well aware of the concerns of physicians related to the growing number of burdens being placed on their practices, of which ICD-10 is a large one, and continues to advocate for overall regulatory relief. While the AMA has been working for many years to hold back the implementation of ICD-10, at this time, it does remain a regulatory mandate. Because of this, it is important that physicians prepare for its implementation in order to avoid the rejection of claims and cash flow interruptions.

Abstract P4-08-07: Novel insight into the tumor “flare” phenomenon and lapatinib resistance

BACKGROUND: Resistance to lapatinib generally develops in approximately half of patients within one year of initiating treatment. When lapatinib is withdrawn, there is often a rapid progression of disease which is associated with high mortality rates. This “flare” phenomenon has also been observed upon discontinuation of other tyrosine kinase inhibitors (TKIs) in lung cancer, renal cell carcinoma, and gastrointestinal stromal tumors.

METHODS: Using the HER2+ cell lines SKBR3 and BT474, we developed both in vitro and in vivo models demonstrating lapatinib resistance and the tumor “flare” phenomenon. Parental HER2+ cell lines were gradually exposed to increasing doses of lapatinib (100nM to 5uM) to develop a lapatinib-resistant form which was ultimately maintained in 1uM of lapatinib. Lapatinib-”released” cell lines were developed by removing lapatinib exposure from resistant cell lines and allowing the cells to grow for at least two weeks. Cell lines were grown in vitro using traditional monolayer cell culturing techniques and mammosphere technology. A comprehensive analysis of parental, lapatinib-resistant, and lapatinib-released cell lines was performed using microscopy, protein/phosphoprotein analysis, cell cycle, cancer stem cell markers by FACS, and invasion assays. Parental cells served as the control in all experiments. In vivo models were performed by injecting 10,000 cells of parental, resistant, and released cell lines in the mammary fat pads of SCID mice. Tumors were surgically resected after approximately sixty days and volume recorded. All experiments were repeated three times and calculated for statistical significance.

RESULTS: Cell cycle analysis and proliferation assays demonstrate that lapatinib-resistant and released cell lines continue to proliferate despite the addition of 1uM lapatinib. Released cells also demonstrate less of a response to retreatment with lapatinib. Tumor volume of lapatinib-released cell lines were significantly larger than parental and resistant counterparts [parental: 39.9mm3, SD 9.48; resistant: 71.8mm3, SD 62.33; released: 943.4mm3, SD 100.1] and this difference was statistically significant (p &lt; 0.01). After three series of passages, mammosphere forming efficiency (MFE) was higher among lapatinib-released cell lines [parental: 1.03%; resistant: 1.93% released: 7.23%] and was statistically significant (p &lt;0.01). Lapatinib-released mammosphere phenotypes appeared larger and less organized than the parental and resistant counterparts. MFE did not correlate with ALDH expression by FACS, and expression varied based on cell line. Western blot analysis revealed loss of E-cadherin among lapatinib-released cells which was not demonstrated in parental or resistant counterparts. Invasion assays demonstrated increased migration among resistant and released cell lines.

CONCLUSIONS: We demonstrate the first in vitro and in vivo models of the tumor “flare” phenomenon using HER2+ breast cancer cell lines. This model demonstrates that lapatinib-resistant cells released from the exposure to lapatinib are propelled into a unique and more aggressive phenotype. This model has potential to elucidate new mechanisms of resistance to TKI therapy and provide novel preclinical data that may help in the understanding of disease progression.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-08-07.

Quinolone prophylaxis in neutropenic patients - efficacy versus resistance

To assess the efficacy of quinolones in the prophylaxis of infections in neutropenic patients with acute non-lymphocytic leukemia, and to evaluate the emergence of quinolone resistance in two University Hospitals in Brazil, we retrospectively compared 101 consecutive episodes of neutropenia managed with quinolone prophylaxis between 1989 and November 1993, and 26 previous episodes without prophylaxis, and reviewed the results of in vitro sensitivity of Gram-negative strains to quinolones in the same period. Prophylaxis with quinolones resulted in less episodes of bacteremias (21% vs. 69%, p=10(-7)), including Gram-negative bacteremias (6% vs. 38%, p=10(-5)), with no statistically significant difference in the death rate (18% vs. 31%, p=0.14, 95% confidence interval -6-32). The resistance of Gramnegative strains to quinolones rose from 7% to 18% between 1990 and 1993 (p=10(-5)). The resistance against ceftazidime and amikacin, the agents used in the empirical antibiotic therapy, increased in the same proportion as the quinolones. Given the limited benefit of quinolones as prophylaxis and the increasing number of quinolone-resistant Gram-negative strains observed in our hospitals, the use of quinolones as prophylaxis must be seriously questioned. A stricter control of the use of quinolones in these hospitals might decrease resistance.

Guidelines for using electronic and social media: the regulatory perspective

Social media can be a very effective way of communicating in nursing, but guidelines for appropriate use by healthcare providers are essential. This article briefly introduces the phenomenon of social media and introduces three actual scenarios where nurses unintentionally violated appropriate use of social media in healthcare. The scenarios are discussed related to social media, career, concerns, and nursing regulation. Incorporating these and other examples with data from board of nursing cases, the nature of complaints against nurses is explored as well as common myths and misunderstandings about using social media platforms. Guidelines for appropriate use by nurses and available resources to inform policy are highlighted. Next steps in social media in nursing should include development of organizational level policies and educational programs on the use of social media.

Vitamins

• Based on strong research evidence, all infants should receive 400 IU/day of vitamin D beginning in the first few days of age to prevent vitamin D deficiency and rickets. • Based on strong research evidence, children and adolescents age >1 year may require as much as 600IU/day of vitamin D. • Based on strong research evidence, all newborns should receive 1 mg of vitamin K at birth to prevent vitamin K deficiency bleeding. • Based on strong research evidence, preconceptional and pregnant women should be supplemented with folate to decrease the likelihood of neural tube defects.

Lack of association of tumor-associated macrophages with clinical outcome in patients with classical Hodgkin's lymphoma

BACKGROUND

A recent study demonstrated that an increased number of CD68+ macrophages were correlated with primary treatment failure, shortened progression-free survival (PFS) and disease-specific survival (DSS) in patients with classical Hodgkin's lymphoma (cHL).

PATIENTS AND METHODS

The aim of the present study was to verify the relationship between the number of CD68+ and CD163+ macrophages with clinical outcomes in a cohort of 265 well-characterized patients with cHL treated uniformly with the standard doxorubicin, bleomycin, vinblastine and dacarbazine chemotherapy regimen. Two pairs of hematopathologists carried out independent pathological evaluations of tissue microarray slides.

RESULTS

There were no associations between clinical characteristics and the expression of CD68 or CD163. However, higher levels of CD68 and CD163 expression were correlated with the presence of Epstein-Barr virus-positive Hodgkin tumor cells (P = 0.01 and 0.037, respectively). The expression of CD68 or CD163 was not associated with either the PFS or the DSS.

CONCLUSION

CD68 and CD163 expression require further evaluation before their use can be recommended for prognostic stratification of patients with cHL.

Uses of tuberculosis mortality surveillance to identify programme errors and improve database reporting

BACKGROUND

In 2006, 848 persons died from tuberculosis (TB) in Rio de Janeiro, Brazil, corresponding to a mortality rate of 5.4 per 100 000 population. No specific TB death surveillance actions are currently in place in Brazil.

SETTING

Two public general hospitals with large open emergency rooms in Rio de Janeiro City.

OBJECTIVE

To evaluate the contribution of TB death surveillance in detecting gaps in TB control.

METHODS

We conducted a survey of TB deaths from September 2005 to August 2006. Records of TB-related deaths and deaths due to undefined causes were investigated. Complementary data were gathered from the mortality and TB notification databases.

RESULTS

Seventy-three TB-related deaths were investigated. Transmission hazards were identified among firefighters, health care workers and in-patients. Management errors included failure to isolate suspected cases, to confirm TB, to correct drug doses in underweight patients and to trace contacts. Following the survey, 36 cases that had not previously been notified were included in the national TB notification database and the outcome of 29 notified cases was corrected.

CONCLUSION

TB mortality surveillance can contribute to TB monitoring and evaluation by detecting correctable and specific programme- and hospital-based care errors, and by improving the accuracy of TB database reporting. Specific local and programmatic interventions can be proposed as a result.

Pleural fluid ADA, IgA‐ELISA and PCR sensitivities for the diagnosis of pleural tuberculosis

The diagnosis of pleural tuberculosis (pTB) is difficult, and more sensitive and specific techniques are needed. In the period August 1998 to November 2002, we evaluated 132 patients with a pleural effusion submitted to a thoracentesis and pleural biopsy in a tertiary care hospital in Rio de Janeiro, Brazil. Three tests were performed and compared in the pleural fluid: ADA activity measurement, IgA-ELISA for two combined specific Mycobacterium tuberculosis antigens, and polymerase chain reaction (PCR) for detection of M. tuberculosis DNA. Ninety-five patients (72%) were given a final diagnosis of pTB. Overall histopathologic sensitivity was 77%. The sensitivities of pleural fluid culture and AFB smear were 42% and 1%, respectively. Twenty-one (22%) additional patients had a clinical diagnosis of pTB. Median follow-up time of all TB patients after the completion of antituberculous treatment was 13 months. Sensitivities of ADA, IgA-ELISA and PCR were 91%, 78% and 82%, while specificities were 93%, 96% and 85%, respectively. Only ADA sensitivity was significantly higher than the histopathologic examination (McNemar chi2 test; p = 0.002) and also significantly higher than ELISA (p = 0.049), but not higher than PCR (p = 0.143). We conclude that the routine use of ADA activity measurement in pleural fluid can obviate the need for a pleural biopsy in the initial diagnostic approach to pleural effusions, while IgA-ELISA and PCR techniques, potentially more specific tests, need further refinement to improve their accuracy.

Dyspnea: applying research to bedside practice

Dyspnea is a common symptom in patients with acute and chronic critical illness as well as in patients receiving palliative care. While dyspnea can be found in a variety of clinical arenas and across many specialties, the mechanisms that cause dyspnea are similar. Although not often the cause for admission to critical care, it may complicate and extend length of stay. This article defines and describes dyspnea and its pathophysiology. Critical care nurses should strive to implement interventions supported by evidence whenever possible. An evidence-based plan of care for the assessment, planning, intervention, and evaluation of the patient with dyspnea is outlined, using levels of recommendation based on the strength of available evidence. Two case studies are presented to illustrate its application to clinical practice.

Exit Exams from a Regulatory Perspective

When programs do have problems with NCLEX-RN pass rates, the state boards of nursing often work with the program administrators and provide them with reasonable time to make changes. In the end, educators and regulators have the same goal: graduating safe and competent nurses in sufficient numbers to meet the needs of the public. NCSBN is committed to this goal and will continue to conduct research and disseminate information and data that will support the state boards of nursing and help nursing programs make innovative changes. We all share the common interest of promoting quality education for future nurses.

Outcomes of critically ill patients with lung cancer

16001

Background: Recent advances in oncology and critical care have resulted in improved survival in critically ill cancer patients. An appraisal of the prognosis of critically ill patients with lung cancer is timely. Methods: The aim of this study was to evaluate the outcomes and prognostic factors of critically ill cancer patients with lung cancer. From 2000 to 2005, patients with either small-cell (SCLC) or non-small-cell lung cancer (NSCLC) admitted at two intensive care units (ICU) in Brazil and France were included. Patients with postoperative care, ICU stay <24 h and readmissions were excluded. Demographics, clinical, cancer related and outcome variables were collected. Hospital mortality was the outcome variable of interest. Variables selected in the univariate analysis (p < 0.25) and those considered clinically relevant were entered in a multivariable logistic regression analysis [results were expressed as odds-ratios (OR), 95% confidence interval (CI)]. Results: A total of 132 patients were studied (INCA = 87, St Louis Hospital = 45). Their mean age was 61 ± 10 years and 73% were males. Twenty-five (19%) had SCLC and 107 (81%), NSCLC. The SAPS II score was 48 ± 21 points. The main reasons for ICU admission were severe sepsis (45%) and acute respiratory failure (33%). During ICU stay, 96 (73%) patients received mechanical ventilation, 76 (58%) vasopressors and 11 (8%) dialysis; 15 (11%) patients were treated with chemotherapy and 6 (5%), radiation therapy. Thirty-eight (29%) patients had end-of-life decisions. ICU and hospital mortality were 43% and 60%, respectively. Multivariable analysis identified three independent determinants of hospital mortality: airway obstruction/infiltration by cancer [OR = 2.87 (1.34–8.13), p < 0.001], number of organ failures [OR = 1.91 (1.01–2.74), p = 0.047] and performance status 3–4 before admission [OR = 2.90 (0.94–8.95), p = 0.065]. Conclusions: Improved survival in overall ICU cancer patients extends to patients with lung cancer, including those needing mechanical ventilation. Interestingly, the characteristics of the cancer are not associated with the outcome and should not be the grounds for the ICU decision making. Mortality is increased with the number of organ dysfunctions, in particular when respiratory failure is due to cancer progression.

No significant financial relationships to disclose.

Therapeutic implications for acquired resistance and heart toxicity using targeted therapy to erbB2

3084

Background: ErbB2 overexpression predicts for a poor prognosis in breast cancer making it an attractive therapeutic target. Molecules such as EGFR/ErbB2 tyrosine kinase inhibitors (TKI’s), lapatinib/GW2974 and antibodies such as trastuzumab are currently used in clinical trials. Clinical responses to TKI’s have been observed, but are short-lived. Our data elucidates the pathway of acquired resistance to TKI’s and the underlying pathway associated with cardiac toxicity after trastuzumab treatment. Finally, we show the clinical implications and the therapeutic approaches to overcome this. Methods: Immunostaining and Western Blot were performed for HER2, EGFR, ER, PR, Bcl-2, FOXO3a, ERRα, ERR, PGC-1α, p-AKT and pERK. AU565, MCF7, BT-474, MCF7/HER2 and AU/BCL2 were treated with ß-estradiol, tamoxifen citrate, GW2974 and trastuzumab. Results: We show that upregulation of ERα and ER-regulated genes contribute to the resistance to HER1/HER2 inhibitors. Although the ErbB2 pathway is inhibited by lapatinib, the dependence of tumor cell survival in resistant cancer cells switches from ErbB2 to ER pathway. By inhibiting ErbB2/P13/AKT signaling, the inhibitors upregulate FOXO3a, which upregulates ER and ER-regulated genes, such as BCL2, contributing to cellular resistance. We also show that this occurs in patients with ErbB2/EGFR overexpressing ER positive cancers treated with lapatinib. By combining EGFR/HER2 inhibitors or antibodies with interventions that down regulate ER activity or estrogen deprivation, we were able to delay ER-mediated resistance. In addition, we have shown that the genes associated with the fatty acid metabolic pathway are upregulated by trastuzumab, but not lapatinib. Conclusion: Our results show that activation of ER and ER-regulated genes (BCL2) that contributed to the development of resistance to ErbB inhibitors in AU and BT474 cells also occurred in patients treated by lapatinib whose breast cancers expressed a similar phenotype. Identifying the mechanisms involved in the development of resistance and toxicities to ErbB inhibitors will lead to rational therapeutic strategies and improve their efficacy. In addition, less cardiac toxicity is anticipated in patients treated with lapatinib.

No significant financial relationships to disclose.

Autoresistance to ErbB2 kinase inhibitors: Elucidating mechanisms and identfying strategies to prevent its onset in breast cancer

2075

Background: Clinical efficacy of ErbB1/ErbB2 kinase inhibitors is limited by the development of acquired autoresistance. Developing clinically relevant models to study the mechanism(s) of acquired autoresistance will identify therapeutic strategies to prevent its onset. Methods: BT474 cells, an ErbB2-overexpressing/ER+ breast cancer line sensitive to lapatinib-induced apoptosis were chronically exposed to lapatinib, simulating chronic administration of lapatinib in the clinic. Lapatinib-resistant cells (rBT474) and single cell clones were established. Baseline gene expression in parental BT474 and rBT474 cells was compared using Human Affymetrix oligonucleotide arrays. Sequential tumor biopsies were analyzed by quantitative IHC as part of a clinical trial using lapatinib monotherapy (1500mg/d) in patients with metastatic breast cancer. Results: Gene expression and protein analysis indicates that acquired resistance to lapatinib is mediated by increased estrogen receptor (ER) signaling rather than loss of ErbB2 expression or insensitivity of the ErbB2-MAPK-PI3K pathways to lapatinib. Activation of ER signaling results from de-repression of FOXO3a and transient up-regulation of caveolin-1, both facilitating ER transcriptional activity. Gene interference studies confirm that acquired resistance involves a switch in survival dependence and regulation of survivin from ErbB2 to ER. Since ErbB2 signaling is operative in rBT474 cells, treating parental BT474 cells with lapatinib plus (i) fulvestrant, or (ii) estrogen deprivation prevents the onset of acquired lapatinib resistance compared with either therapy alone. Importantly, increased ER signaling occurs in patients with ErbB2-overexpressing/ER+ breast cancers treated with lapatinib monotherapy, consistent with changes in cell lines. Conclusions: Chronic lapatinib monotherapy induces a shift in the dependence of cell survival from ErbB2 to ER. Combining lapatinib with selected anti-estrogens prevents its onset in cell lines and warrants clinical validation. Establishing models of acquired resistance simulating the clinic provides a tool to identify strategies to improve treatment options for patients with ErbB2-overexpressing breast cancers.

[Table: see text]

Prognostic factors for patients with lymphoma requiring intensive care

17519

Background: Prognosis of patients (pts) with hematological malignancies (HM) in the intensive care unit (ICU) seems to be improving, despite different biological behaviors and outcomes. The study of homogenous groups of pts might provide useful clinical insights. The aim of this study was to evaluate the outcomes of critically ill patients with lymphomas (CIPL). Methods: During 66 months, all consecutive CIPL admitted to an oncologic ICU were studied. Variables collected were: age, gender, performance status, type and status of lymphoma, neutropenia, infection at admission, use of mechanical ventilation (MV), the Acute Physiology and Chronic Health Evaluation (APACHE) II score, comorbidities and number of acute organ failures (AOF). Variables selected in the univariate analysis (p < 0.25) and those clinically relevant were entered in a multivariable logistic regression analysis [results expressed as odds-ratios (OR), 95% confidence interval (CI)]. The end-point was hospital mortality. Results: A total of 120 CIPL were studied. Mean age was 51 ± 20 years and 54% were males. APACHE II was 19 ± 7 points. Diagnoses were High Grade Non-Hodgkin’s Lymphoma (77.5%), Hodgkin’s disease (17.5%) and Low Grade Non-Hodgkin’s Lymphoma (5%). Reasons for ICU admission were severe sepsis (62%) and acute respiratory failure (22%). During ICU stay 90% pts received MV, 71% vasopressors and 27.5% dialysis. Twenty-three (19%) pts had neutropenia. End-of-life decisions were implemented in 31% pts and all of them died at the ICU. The ICU and hospital mortality rates were 53% and 67% respectively, with no difference among the groups of lymphomas (p = 0.877). Variables identified in the multivariate analysis were: age [OR = 1.03 (95% CI = 1.01–1.06)], male gender [3.72 (1.27–10.90)], uncontrolled disease [OR = 6.28 (1.80–21.95), for pts with newly diagnosed disease and OR = 5.33 (1.45–19.47), for those with recurrence/progression, sepsis [OR = 5.31 (1.62–17.37)] and AOF [OR = 2.35 (1.53–3.61)]. Conclusions: Higher age, male gender, the severity of organ failures, sepsis and disease status were the main adverse factors. Type of lymphoma and neutropenia had no impact in the outcome. The appropriate use of such easily available clinical characteristics may avoid forgoing intensive care for lymphoma pts with a chance of survival.

No significant financial relationships to disclose.