Comparison between thrombotic risk scores in essential thrombocythemia and survival implications

The conventional thrombotic risk stratification in essential thrombocythemia (ET) distinguishes patients in two risk groups based on previous thrombosis and age (< or >60). The IPSET-thrombosis takes into account four risk factors: age greater than 60 years and the presence of CV risk factors, thrombosis history and JAK2 V617F presence. The revised IPSET-thrombosis uses three adverse variables to delineate four risk categories: age greater than 60, thrombosis history, and JAK2 V617F presence. We compared different risk models in the estimation of thrombotic risk in 191 patients with ET and the role of specific driver mutations affecting overall survival, according to thrombotic risk. We also evaluated the mutational status of patients showing history of thrombosis or cardiovascular events versus patients who did not. Finally, we verified whether the thrombotic risk had a significant impact on survival in our ET patients. The data analysis has been performed through the conventional statistics and overall survival estimated by using the Kaplan-Meyer method. Interestingly, either using the traditional system for thrombotic risk or the IPSET-t prognostic score or the current stratification for the thrombotic risk, high-risk patients are always highly represented. This evidence is of note, being the high-risk category indicated for cytoreduction, affecting quality of life, despite the good overall prognosis of patients with ET diagnosis in general. The analysis of overall survival in our patients, according to different models for thrombotic risk, highlighted the poor prognosis of high-risk patients compared with those with a lower thrombotic risk, in particular when using traditional stratification and current stratification. In conclusion, the occurrence of thrombotic or cardiovascular events represents one of the most severe complications at diagnosis or during follow-up of ET despite current recommendations, having a significant impact on morbidity and survival.

Diagnostic interaction between bovine tuberculosis (bTB) and Johne's disease in bTB highly prevalent dairy farms of Uruguay

The consolidation of the dairy industry, with increase in sizes, density and productivity of the herds, was associated to unprecedented bovine tuberculosis (bTB) prevalence levels in dairy herds in Uruguay, where Johne's disease (JD), another mycobacterial disease, is also prevalent. Here, we aimed to characterize the association between bTB- and JD-diagnostic results in two heavily bTB- and JD-coinfected dairy herds. Results from bTB-intradermal tests and JD-ELISA in 686 cows indicated a significantly (P < 0.001) higher frequency of bTB-positive animals in the JD-positive population, in which a significantly lower agreement between the caudal and cervical comparative intradermal tests was observed, compared to the JD-negative population. These findings suggest a significant association between the detection of these mycobacterial diseases, that may affect the performance of the routine bTB diagnostic tests performed in dairy herds in Uruguay.

Abstract P4-01-07: A comprehensive liquid biopsy in patients undergoing neoadjuvant therapy

Background: Precision medicine is revolutionizing breast cancer (BC) care. Comprehensive liquid biopsies are a tool for personalized care in patients with locally advanced breast cancer (LABC). Identifying robust biomarkers as part of a comprehensive liquid biopsy to predict response to treatment is of immense clinical interest.

Methods: After obtaining IRB approval, serial blood samples were collected from patients with LABC undergoing neoadjuvant therapy. Paired biopsies were collected prior to treatment and were sent to Foundation Medicine for next-generation sequencing (NGS). We used a sized-base microfilter technology to capture circulating tumor cells (CTCs) and circulating cancer associated fibroblasts (cCAFs). Patients with one or more CTCs or cCAFs were deemed positive for these tests. Additionally, in collaboration with Foundation Medicine, we extracted circulating tumor DNA (ctDNA) and we analyzed it using the FoundationACT platform. Patients with a detectable genomic alteration in their plasma were considered as having a positive ctDNA test. Our primary objective is to determine if a comprehensive liquid biopsy can serve as a prognostic marker of pathologic complete response (pCR).

Results: For this analysis we describe our findings in the initial blood draw of the first 18 patients enrolled. The mean age is 54 years (38-70). All patients who had their tumors sequenced had a detectable mutation. Consistent with the findings of others, we found TP53 mutations to be the most prevalent at 83.3%. We found that 44% of patients had ctDNA, 68.4% had cCAFs and 78.9% had CTCs. Many patients also had clusters of cells, consisting of one cell type, or co-clusters, consisting of both. 38.9% had CTC clusters, 16.7% had cCAF clusters and 16.7% had co-clusters (CTCs and cCAFs together). Some patients with CTCs did not have cCAFs and vice versa. The number of CTCs and cCAFS did not correlate with stage of disease or receptor status.

Conclusions: We describe a comprehensive liquid biopsy combining a sized-based microfilter technology for CTC and cCAFs identification and the FoundationACT platform for ctDNA analysis is feasible and these biomarkers can be detected in patients with LABC prior to the initiation of neoadjuvant therapy. Our study is accruing rapidly, and we will update our results with the longitudinal collection and the prognostic value of a comprehensive liquid biopsy at the time of the meeting.

Citation Format: Sandoval Leon AC, Medina Saenz K, Miller P, Benson A, Calfa C, Mahtani R, Slingerland J, Perez A, Vogel C, Valdes-Albini F, El-Ashry D, Lippman M. A comprehensive liquid biopsy in patients undergoing neoadjuvant therapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-01-07.

The role and impact of community health workers in childhood obesity interventions: a systematic review and meta-analysis

Childhood obesity increases the risk for poor health during childhood, as well as for adult obesity and its associated comorbidities. Children from racial/ethnic minority groups or who live in poverty experience elevated rates of obesity. One potential method for reducing childhood obesity disparities is to involve community health workers (frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served). The purpose of this systematic review and meta-analysis was to explore the role and effectiveness of community health workers in childhood obesity interventions. Eleven studies met inclusion criteria, of which nine were eligible for inclusion in the meta-analysis. Results demonstrated that community health workers played various roles in childhood obesity interventions in the home, clinic, school, and community setting. Interventions focused primarily on children from underserved populations. Meta-analytic findings demonstrated a small but significant impact on BMIz and BMI percentile (BMIz [7 studies]: -0.08, 95% CI: -0.15, -0.01, p = 0.03, I2  = 39.4%; BMI percentile [2 studies]: -0.25, 95% CI: -0.38, -0.11, p < 0.01, I2  = 0%). Findings from this review demonstrate that partnering with community health workers may be an important strategy for reducing childhood obesity disparities and advancing health equity.

Prevention of Highly Emetogenic Chemotherapy-Induced Vomiting: A Double Blind, Randomized Crossover Study to Compare Pancopride (LAS 30451) and Pancopride plus Dexamethasone

Aims

Pancopride (PNC) is a new 5HT3 receptor antagonist which has demonstrated complete protection from nausea and vomiting in 25-73% of patients treated with highly emetogenic chemotherapy. A double-blind, randomized crossover study was carried out to assess whether the addition of dexamethasone (DXM) to PNC increases the antiemetic efficacy.

Methods

PNC (0.2 mg/kg. i.v. 30 min before chemotherapy) plus placebo (PLC) was compared with PNC (same dose and schedule) plus DXM (20 mg. i.v. immediately before PNC). In the second cycle, patients received the alternative antiemetic treatment. Eighty patients were included in the study (PNC+DXM=39, PNC+PLC=41), 29 of whom were women and 51 men. Fifty-four percent of the patients in the PNC+DXM group and 59% of those in the PNC+PLC group received chemotherapy containing cisplatin. Seventy-seven patients completed the first cycle and 70 the second.

Results

Complete protection was obtained in 19/16 patients (50/46%) with PNC+PLC and in 32/22 (82/63%) with PNC+DXM (P<0.001). Latency was significantly longer in the PNC+DXM group. The efficacy of both treatments was unaffected by the order of administration. Side effects were mild in both groups.

Conclusions

The combination of PNC+DXM is more efficacious than PNC+PLC in protection against highly emetogenic chemotherapy-induced vomiting.

Sudden paraplegia due to spontaneous bleeding in a thoracic epidural angiolipoma and literature review

BACKGROUND

Spinal angiolipomas are rare epidural tumours that are usually revealed by chronic symptoms of medullar irritation. We report a case of acute paraplegia caused by spontaneous bleeding revealing a thoracic angiolipoma.

CASE DESCRIPTION

A 17-year-old male patient with no previous medical history was admitted for acute onset of paraplegia with bladder retention and loss of sensation in the lower limbs, preceded by dorsal pain during the three previous days. MRI showed an enhanced T1-weighted image of a T7-T12 epidural lesion. The T1-weighted isosignal and the T2-weighted hyposignal suggested haemorrhagic complications. Due to a mass effect on the spinal cord, an emergency laminectomy was performed. Histopathological examination of the lesion revealed an angiolipoma with spontaneous bleeding. Clinical outcome was favourable after two months.

CONCLUSION

This case is one of the first to be reported, although the clinical presentation is similar to that of other rare reported cases of paraplegia due to spinal compression by tumoural bleeding.

Abstract P5-22-04: Efficacy of thoracic paravertebral block for reducing acute post-mastectomy pain

Background: Mastectomy is associated with acute and chronic postoperative pain. This study investigated the efficacy of thoracic paravertebral block (TPB) compared to local anesthetic of surgical wound (LASW) in breast cancer patients undergoing mastectomy.

Methods: This phase 3, randomized controlled, single blind, parallel arms and superiority clinical trial aimed to evaluate the efficacy of TPB compared to LASW on acute pain at rest and motion at 24 hours post-mastectomy, measured by a visual analog scale (VAS). The study size of 60 patients is determined to have 90% power to detect a difference of 20% in acute pain in favor of TPB. In TPB group use of ultrasound was mandatory to guide puncture of intervertebral space T3 for infiltrating 0.5% bupivacaine at dose of 1.5 mg/kg. In LASW group was used bupivacaine 0.5% at dose of 1.5mg/kg on subcutaneous tissue of surgical area. VAS was used to measure surgical pain at rest and motion in 2,4,6,12 and 24 hours post-operatives for both groups. Trial Registry: ClinicalTrials.gov; Identifier:NCT02609321.

Findings: From 08-2015 to 09-2016, 60 breast cancer patients were enrolled; 3 dropped off consent. Mean age was 51 year; 78% had stage II and III; and 65% receive neoadjuvant chemotherapy.There were no significant differences in the VAS pain measurement for the groups of BWT compared to LASW in the 24 hour measurement, neither at rest (P=0.6525) nor in movement (P=0.7929). There were no significant differences in both groups for repeated pain measurements (5 measures mean), total dose of opioid administration, time to first dose of opioids or adverse events.

Conclusions: There were not statistical differences for post-mastectomy acute pain in first 24 hours between TPB and LASW patients. According our findings the use of TPB should not routinely recommended for breast cancer patients undergoing mastectomy.

Citation Format: Herazo-Maya F, Egurrola J, Restrepo CE, Torres L, Palacios L, Ossa CA, Borrero M, Angel GA, Marquez JJ, Valencia S, Perez A, Oyola JC, Lobo L, Gomez R, Garcia H. Efficacy of thoracic paravertebral block for reducing acute post-mastectomy pain [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-22-04.

Foot-and-mouth disease virus transmission dynamics and persistence in a herd of vaccinated dairy cattle in India

Foot-and-mouth disease (FMD) is an important transboundary disease with substantial economic impacts. Although between-herd transmission of the disease has been well studied, studies focusing on within-herd transmission using farm-level outbreak data are rare. The aim of this study was to estimate parameters associated with within-herd transmission, host physiological factors and FMD virus (FMDV) persistence using data collected from an outbreak that occurred at a large, organized dairy farm in India. Of 1,836 regularly vaccinated, adult dairy cattle, 222 had clinical signs of FMD over a 39-day period. Assuming homogenous mixing, a frequency-dependent compartmental model of disease transmission was built. The transmission coefficient and basic reproductive number were estimated to be between 16.2-18.4 and 67-88, respectively. Non-pregnant animals were more likely to manifest clinical signs of FMD as compared to pregnant cattle. Based on oropharyngeal fluid (probang) sampling and FMDV-specific RT-PCR, four of 36 longitudinally sampled animals (14%) were persistently infected carriers 10.5 months post-outbreak. There was no statistical difference between subclinical and clinically infected animals in the duration of the carrier state. However, prevalence of NSP-ELISA antibodies differed significantly between subclinical and clinically infected animals 12 months after the outbreak with 83% seroprevalence amongst clinically infected cattle compared to 69% of subclinical animals. This study further elucidates within-herd FMD transmission dynamics during the acute-phase and characterizes duration of FMDV persistence and seroprevalence of FMD under natural conditions in an endemic setting.

Cervical pedicular agenesis: Case report and a review of the literature

Cervical pedicular agenesis, an unusual disorder, is a rare clinical and radiological finding, which can lead to misdiagnosis, moreover in a traumatic situation. The authors report the case of a young woman with a C3 right congenital absence of the cervical pedicle. A systematic review of literature found more than 70 reported cases. In patients with congenital agenesis of the cervical pedicle, the two most common levels of this congenital absence are C6 and C5. The three radiological findings were: the false appearance of an enlarged ipsilateral neural foramen due to the absent pedicle; a dysplastic, dorsally displaced ipsilateral articular pillar and lamina; and a dysplastic ipsilateral transverse process. These pedicle ageneses are a stable congenital anomaly.

Inferring source attribution from a multiyear multisource data set of Salmonella in Minnesota

Salmonella enterica is a global health concern because of its widespread association with foodborne illness. Bayesian models have been developed to attribute the burden of human salmonellosis to specific sources with the ultimate objective of prioritizing intervention strategies. Important considerations of source attribution models include the evaluation of the quality of input data, assessment of whether attribution results logically reflect the data trends and identification of patterns within the data that might explain the detailed contribution of different sources to the disease burden. Here, more than 12,000 non-typhoidal Salmonella isolates from human, bovine, porcine, chicken and turkey sources that originated in Minnesota were analysed. A modified Bayesian source attribution model (available in a dedicated R package), accounting for non-sampled sources of infection, attributed 4,672 human cases to sources assessed here. Most (60%) cases were attributed to chicken, although there was a spike in cases attributed to a non-sampled source in the second half of the study period. Molecular epidemiological analysis methods were used to supplement risk modelling, and a visual attribution application was developed to facilitate data exploration and comprehension of the large multiyear data set assessed here. A large amount of within-source diversity and low similarity between sources was observed, and visual exploration of data provided clues into variations driving the attribution modelling results. Results from this pillared approach provided first attribution estimates for Salmonella in Minnesota and offer an understanding of current data gaps as well as key pathogen population features, such as serotype frequency, similarity and diversity across the sources. Results here will be used to inform policy and management strategies ultimately intended to prevent and control Salmonella infection in the state.

Vaccination as a control strategy against Salmonella infection in pigs: A systematic review and meta-analysis of the literature

Consumption or handling of improperly processed or cooked pork is considered one of the top sources for foodborne salmonellosis, a common cause of intestinal disease worldwide. Asymptomatic carrier pigs may contaminate pork at slaughtering; therefore, pre-harvest reduction of Salmonella load can contribute to reduce public health risk. Multiple studies have evaluated the impact of vaccination on controlling Salmonella in swine farms, but results are highly variable due to the heterogeneity in vaccines and vaccination protocols. Here, we report the results of an inclusive systematic review and a meta-analysis of the peer-reviewed scientific literature to provide updated knowledge on the potential effectiveness of Salmonella vaccination. A total of 126 articles describing the use of Salmonella vaccines in swine were identified, of which 44 fulfilled the inclusion criteria. Most of the studies (36/44) used live vaccines, and S. Typhimurium and S. Choleraesuis were the predominant serotypes evaluated. Vaccine efficacy was most often measured through bacteriological isolation, and pooled estimates of vaccine efficacy were obtained as the difference in the percentage of positive animals when available. Attenuated and inactivated vaccines had similar efficacy [Risk Difference=-26.8% (-33.8, -19.71) and -29.5% (-44.4, -14.5), respectively]. No serotype effect was observed on the efficacy recorded for attenuated vaccines; however, a higher efficacy of inactivated vaccines against S. Choleraesuis was observed, though in a reduced sample. Results from the meta-analysis here demonstrate the impact that vaccination may have on the control of Salmonella in swine farms and could help in the design of programs to minimize the risk of transmission of certain serotypes through the food chain.

Quantitative characteristics of the foot-and-mouth disease carrier state under natural conditions in India

The goal of this study was to characterize the properties and duration of the foot-and-mouth disease (FMD) carrier state and associated serological responses subsequent to vaccination and naturally occurring infection at two farms in northern India. Despite previous vaccination of cattle in these herds, clinical signs of FMD occurred in October 2013 within a subset of animals at the farms containing juvenile-yearling heifers and steers (Farm A) and adult dairy cattle (Farm B). Subsequent to the outbreak, FMD virus (FMDV) asymptomatic carriers were identified in both herds by seroreactivity to FMDV non-structural proteins and detection of FMDV genomic RNA in oropharyngeal fluid. Carriers' seroreactivity and FMDV genome detection status were subsequently monitored monthly for 23 months. The mean extinction time of the carrier state was 13.1 ± 0.2 months, with extinction having occurred significantly faster amongst adult dairy cattle at Farm B compared to younger animals at Farm A. The rate of decrease in the proportion of carrier animals was calculated to be 0.07 per month. Seroprevalence against FMDV non-structural proteins decreased over the course of the study period, but was found to increase transiently following repeated vaccinations. These data provide novel insights into viral and host factors associated with the FMDV carrier state under natural conditions. The findings reported herein may be relevant to field veterinarians and governmental regulatory entities engaged in FMD response and control measures.

The role of Intraoperative 3D navigation for pelvic bone tumor resection

Interventional 3D analysis is often used for surgery of the spine. The goal of this study was to describe the technique and initial results of intraoperative 3D CT navigation (O-Arm, Medtronic, Louisville, CO, USA) for surgery of the pelvis. Six patients were included, five with primary bone tumors and one with post-traumatic non-union. All CT procedures were completed without modifying the surgical technique, except one case in which the device had to be reinstalled during surgery. The duration of surgery was not increased and lasted for a mean 224minutes (96-380). Recorded radiation was between 450-1125mGrey/cm. All procedures were performed according to the preoperative plan resulting in systematic resection with a safe surgical margin (R0). One surgical site infection occurred. Although these operations could have been performed without 3-D navigation, this technique provided continuous intraoperative control and safety.

LEVEL OF EVIDENCE

IV.

Ten-year observational follow-up of PROactive: a randomized cardiovascular outcomes trial evaluating pioglitazone in type 2 diabetes

AIMS

To conduct a 10-year, observational follow-up of patients completing PROactive to investigate whether trends of cardiovascular benefit with pioglitazone and imbalances in specific malignancies persisted over time.

METHODS

Macrovascular endpoints and malignancies were compared based on original randomization to pioglitazone or placebo and 'any' versus 'no' pioglitazone use for bladder and prostate cancer.

RESULTS

Of 4873 patients completing the PROactive trial, 74% entered the follow-up. During follow-up (mean 7.8 years), there were no statistically significant differences in the primary [all-cause mortality, myocardial infarction (MI), cardiac intervention, stroke, major leg amputation, leg revascularization] or main secondary (death, MI, stroke) endpoints for subjects originally randomized to pioglitazone and placebo, except for leg amputations during follow-up [4.1% pioglitazone, 5.6% placebo; hazard ratio 0.74, 95% confidence interval (CI) 0.55-0.99; p = 0.046]. During follow-up, the incidence of total malignancies was similar between groups; bladder cancer was reported in 0.8% of patients (n = 14) in the pioglitazone versus 1.2% (n = 21) in the placebo group [relative risk (RR) 0.65, 95% CI 0.33-1.28], and prostate cancer was reported in 44 men (3.7%) in the pioglitazone versus 29 men (2.5%) in the placebo group (RR 1.47, 95% CI 0.93-2.34).

CONCLUSIONS

The trends of macrovascular benefits of pioglitazone compared with placebo during PROactive did not persist in the absence of continued pioglitazone during this 10-year follow-up. Trends of decreased bladder cancer and increased prostate cancer were observed in the pioglitazone group during follow-up; however, these imbalances should be interpreted with caution because of the limitations of the observational study design.

Abstract P5-04-18: Extracts derived from fungi and plants demonstrate specificity for subtyptes of triple negative breast cancer

New effective therapies are needed for patients with triple negative breast cancers (TNBC). The identification by Lehmann and Bauer1 of distinct subtypes of TNBC and representative cell lines that are driven by different defects and signaling pathways provided the opportunity, for the first time, to screen for selective activities against these subtypes of TNBC. Using this knowledge, we initiated a screen of diverse natural product extract libraries with the goal of identifying extracts selective for subtypes of TNBC. The compounds with this selective activity will then be purified using bioassay-guided fractionation. Drugs derived from plants and fungi have provided some of the most important pharmaceuticals used today, including numerous anticancer agents.2 Natural products occupy a biologically validated chemical space that does not overlap with compounds found in most synthetic chemical libraries.3 Additionally, there are differences in chemical space between plant and fungal-derived compounds4 and different compound classes are expected to be isolated from these two sources. A total of 1,953 extracts of fungi collected from diverse environments, including Great Lakes sediments and 2,200 plant extracts from tropical environments have been screened for selective cytotoxic activities against cell lines representing 5 subtypes of TNBC. These subtypes are the basal-like 1 and 2 (BL1, BL2), mesenchymal (M), mesenchymal stem-like (MSL) and luminal androgen receptor (LAR). The initial screening using one concentration, 2 µg/ml for fungal extracts and 20 µg/ml for plant extracts, identified many extracts with selective activity against the TNBC subtypes. Detailed dose response curves were then generated with these extracts in each of the TNBC cell lines. A total of 4 fungal extracts and 7 plant extracts with selective cytotoxic activities were identified with selectivity up to 100-fold for 3 of the extracts. Bioassay-guided fractionation is ongoing to identify the active constituents. These results demonstrate that natural product extracts can yield selective actions against TNBC subtypes. We expect that these plant and fungal extracts will yield compounds that target molecular drivers specific to the TNBC subtypes. It is our expectation that compounds with selective, targeted activities will continue to be isolated from these extract collections.

1. Lehman BD and Bauer JA et al. J Clin Invest: 121, 2750-2767, 2011.

2. Newman DJ and Cragg GM. J Nat Prod: 75, 311-335, 2012.

3. Feher M and Schmidt JM. J Chem Inf Comput Sci: 43, 218-227, 2003.

4. El-Elimat, T et al. ACS Med Chem Lett: 3, 645-649, 2012.

Citation Format: Shaffer CV, Cai S, Perez A, Risinger AL, Du L, O'Keefe BR, Cichewicz RH, Mooberry SL. Extracts derived from fungi and plants demonstrate specificity for subtyptes of triple negative breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-04-18.