Application of ICD-PM to preterm-related neonatal deaths in South Africa and United Kingdom

OBJECTIVE

We explore preterm-related neonatal deaths using the WHO application of the International Classification of Disease (ICD-10) to deaths during the perinatal period: ICD-PM as an informative case study, where ICD-PM can improve data use to guide clinical practice and programmatic decision-making.

DESIGN

Retrospective application of ICD-PM.

SETTING

South Africa, and the UK.

POPULATION

Perinatal death databases.

METHODS

Descriptive analysis of neonatal deaths and maternal conditions present.

MAIN OUTCOME MEASURES

Causes of preterm neonatal mortality and associated maternal conditions.

RESULTS

We included 98 term and 173 preterm early neonatal deaths from South Africa, and 956 term and 3248 preterm neonatal deaths from the UK. In the South African data set, the main causes of death were respiratory/cardiovascular disorders (34.7%), low birthweight/prematurity (29.2%), and disorders of cerebral status (25.5%). Amongst preterm deaths, low birthweight/prematurity (43.9%) and respiratory/cardiovascular disorders (32.4%) were the leading causes. In the data set from the UK, the leading causes of death were low birthweight/prematurity (31.6%), congenital abnormalities (27.4%), and deaths of unspecified cause (26.1%). In the preterm deaths, the leading causes were low birthweight/prematurity (40.9%) and deaths of unspecified cause (29.6%). In South Africa, 61% of preterm deaths resulted from the maternal condition of preterm spontaneous labour. Among the preterm deaths in the data set from the UK, no maternal condition was present in 36%, followed by complications of placenta, cord, and membranes (23%), and other complications of labour and delivery (22%).

CONCLUSIONS

ICD-PM can be used to appraise the maternal and newborn conditions contributing to preterm deaths, and can inform practice.

TWEETABLE ABSTRACT

ICD-PM can be used to appraise maternal and newborn contributors to preterm deaths to improve quality of care.

The WHO application of ICD-10 to deaths during the perinatal period (ICD-PM): results from pilot database testing in South Africa and United Kingdom

OBJECTIVE

To apply the World Health Organization (WHO) Application of the International Classification of Diseases, tenth revision (ICD-10) to deaths during the perinatal period: ICD-Perinatal Mortality (ICD-PM) to existing perinatal death databases.

DESIGN

Retrospective application of ICD-PM.

SETTING

South Africa, UK.

POPULATION

Perinatal death databases.

METHODS

Deaths were grouped according to timing of death and then by the ICD-PM cause of death. The main maternal condition at the time of perinatal death was assigned to each case.

MAIN OUTCOME MEASURES

Causes of perinatal mortality, associated maternal conditions.

RESULTS

In South Africa 344/689 (50%) deaths occurred antepartum, 11% (n = 74) intrapartum and 39% (n = 271) in the early neonatal period. In the UK 4377/9067 (48.3%) deaths occurred antepartum, with 457 (5%) intrapartum and 4233 (46.7%) in the neonatal period. Antepartum deaths were due to unspecified causes (59%), chromosomal abnormalities (21%) or problems related to fetal growth (14%). Intrapartum deaths followed acute intrapartum events (69%); neonatal deaths followed consequences of low birthweight/ prematurity (31%), chromosomal abnormalities (26%), or unspecified causes in healthy mothers (25%). Mothers were often healthy; 53%, 38% and 45% in the antepartum, intrapartum and neonatal death groups, respectively. Where there was a maternal condition, it was most often maternal medical conditions, and complications of placenta, cord and membranes.

CONCLUSIONS

The ICD-PM can be a globally applicable perinatal death classification system that emphasises the need for a focus on the mother-baby dyad as we move beyond 2015.

TWEETABLE ABSTRACT

ICD-PM is a global system that classifies perinatal deaths and links them to maternal conditions.

Optimising the International Classification of Diseases to identify the maternal condition in the case of perinatal death

OBJECTIVE

The WHO application of the tenth edition of the International Classification of Diseases (ICD-10) to deaths during the perinatal period (ICD Perinatal Mortality, ICD-PM) captures the essential characteristics of the mother-baby dyad that contribute to perinatal deaths. We compare the capture of maternal conditions in the existing ICD-PM with the maternal codes from the WHO application of ICD-10 to deaths during pregnancy, childbirth, and the puerperium (ICD Maternal Mortality, ICD-MM) to explore potential benefits in the quality of data received.

DESIGN

Retrospective application of ICD-PM.

SETTING

South Africa and the UK.

POPULATION

Perinatal death databases.

METHODS

The maternal conditions were classified using the ICD-PM groupings for maternal condition in perinatal death, and then mapped to the ICD-MM groupings of maternal conditions.

MAIN OUTCOME MEASURES

Main maternal conditions in perinatal deaths.

RESULTS

We reviewed 9661 perinatal deaths. The largest group (4766 cases, 49.3%) in both classifications captures deaths where there was no contributing maternal condition. Each of the other ICD-PM groups map to between three and six ICD-MM groups. If the cases in each ICD-PM group are re-coded using ICD-MM, each group becomes multiple, more specific groups. For example, the 712 cases in group M4 in ICD-PM become 14 different and more specific main disease categories when the ICD-MM is applied instead.

CONCLUSIONS

As we move towards ICD-11, the use of the more specific, applicable, and relevant codes outlined in ICD-MM for both maternal deaths and the maternal condition at the time of a perinatal death would be preferable, and would provide important additional information about perinatal deaths.

TWEETABLE ABSTRACT

Improving the capture of maternal conditions in perinatal deaths provides important actionable information.

Abstract PD2-02: NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early breast cancer

COX2 has been implicated in breast tumorigenesis, tumour proliferation & invasion. The role of COX2 in carcinogenesis is thought to be related to its abilities to increase production of prostaglandins, convert pro-carcinogens to carcinogens, inhibit apoptosis, promote angiogenesis, modulate inflammation & immune function & increase tumour cell invasiveness. COX2 inhibition may synergise with aromatase inhibition in controlling endocrine responsive breast cancer. The COX2 product prostaglandin E2 (PGE2) & cytokines such as interleukin-6 (IL6) can up regulate aromatase expression suggesting that aromatase inhibition may be more effective in combination with a COX2 inhibitor. There may be additional COX2 mediated anticancer activity. The hypothesis addressed is that activity of aromatase inhibitors(AI) as neoadjuvant endocrine therapy for early breast cancer may be enhanced by the addition of a COX2 inhibitor.

TRIAL OBJECTIVES

To determine whether the activity of AIs as neo-adjuvant endocrine therapy for ER positive breast cancer in postmenopausal women may be enhanced by the addition of the selective COX2 inhibitor celecoxib.

TRIAL DESIGN

Prospective phase III multicentre randomised trial. Patients were randomised to receive 16 weeks of exemestane 25 mg daily or letrozole 2.5 mg daily (open label) and celecoxib 400 mg twice daily or matched placebo (double blinded). Translational research tumour samples were collected before, during & after therapy.

KEY ELIGIBILITY CRITERIA

Post menopausal, ER positive, invasive cancer, 2cms or greater with calipers & visible on USS.

PRIMARY OUTCOME MEASURE

Objective clinical response to neoadjuvant treatment by RECIST criteria.

RESULTS

Primary Outcome; Response to treatment has been calculated for 266 patients (Table 1). Response rate was 73% in the celecoxib arm & 55% in the placebo arm (p=0.0022). The response rates 4 arm comparison are shown in Table 2. After adjustment for AI effect the significant difference in response rates remained (p=0.0023); the difference in response rates was greater in the exemestane treated group (29%) compared to the letrozole group (7%) although heterogeneity between AI arms was statistically non-significant (p=0.06).

Table 1 Primary Outcome Results: response ratesOUTCOMEPLACEBO N (%)CELECOXIB N (%)TOTAL N (%)X2statisticP-valueRESPONSE73(55)97(73%)170 (64%)9.38820.0022NO RESPONSE60 (45%)36 (27%)96 (36%)  TOTAL133133266  

Table 2: Response Rates 4 Arm Comparison EXEMESTANELETROZOLERESPONSEPLACEBO n(%)CELECOXIB n(%)TOTAL n(%)PLACEBO n(%)CELECOXIB n(%)TOTAL n(%)RESPONSE33 (49)52(78)85(63)40(61)45(68)85(64)NO RESPONSE34(51)15(22)49(37)26(39)21(32)47(36)TOTAL67671346666132

Secondary outcome; There was an USS response rate of 42% v 37% for celecoxib & placebo arms respectively (p=0.2513)

CONCLUSION

The addition of the COX2 inhibitor celecoxib to an AI significantly & substantially increased the clinical response from 55% to 73%. Effect on tumour size assessed with USS is less marked with a non-significant increase in responses from 37% to 42%.

This work was supported by CRUK: CRUK/06/005 and Pfizer.

Citation Format: Rea D, Francis A, Poole C, Brookes C, Stein R, Bartlett J, Dunn J, Canney P, Sutton R, Daoud R, Hallissey M, Achuthan R, Grant M, Babrah J, Smith S, Fraser J, Desai A, Al Dubaisi M, Patel A, Bristol J, Chandrasekharan S, Prest C, Jewkes A. NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early 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 PD2-02.

Abstract OT3-02-12: OPTIMA (optimal personalised treatment of early breast cancer usIng multi-parameter analysis), a prospective trial to validate the predictive utility and cost-effectiveness of gene expression test-directed chemotherapy decisions

Background: Multi-parameter gene expression assays (MPAs) are widely used to estimate individual patient residual risk and to guide chemotherapy use in hormone-sensitive HER2-negative node-negative early breast cancer. These uses of MPAs have not yet been prospectively validated. OPTIMA aims to validate the use of MPA testing to predict chemotherapy sensitivity in a largely node-positive breast cancer population.

Methods: OPTIMA is a partially blinded multi-center, phase 3 randomized controlled trial with an adaptive two-stage design. The preliminary phase (OPTIMA prelim) evaluated the performance of MPAs to identify a suitable test(s) to be used in the main efficacy trial and assessed the feasibility and acceptability of a large UK trial. Eligible patients are men or women aged 40 years or older who have surgically resected early stage breast cancer, which is ER-positive and HER2-negative and who have either 1-9 involved axillary lymph nodes or tumors of at least 30mm diameter. Randomization is to standard management (chemotherapy followed by endocrine therapy) or to MPA-directed treatment. Those with a tumor categorized as "high-risk" by the test will be assigned to standard management whilst those at "low-risk" will be treated with endocrine therapy alone. OPTIMA prelim used Oncotype DX as the primary discriminator; the main trial will use Prosigna (PAM50). The co-primary outcomes are (1) Invasive Disease Free Survival (IDFS) and (2) cost-effectiveness of test-directed therapy compared to standard practice. Secondary outcomes include IDFS in "low-risk" patients, distant disease free survival, breast cancer specific survival, overall survival and quality of life. An integrated qualitative recruitment study will identify and address challenges to recruitment and informed consent. Tumor blocks from all consenting participants will be banked allowing the performance of alternative MPA technologies to be evaluated. Recruitment of 4500 patients over 4 years will permit demonstration of 3% non-inferiority of test-directed treatment, with 5% significance and 85% power, assuming 3 years follow-up and a control arm 5-year IDFS of at least 85%. The addition of patients from OPTIMA prelim will allow non-inferiority to be assessed with 2.5% significance.

Results: OPTIMA-prelim recruited 412 patients in 23 months from 35 sites. It confirmed the acceptability of randomization to patients with a 47% acceptance rate, and to clinicians and hence the feasibility of a large prospective trial of test-directed treatment running in 100-plus UK sites. It showed that investment into research on test-directed therapy, especially with Prosigna, should be of substantial value to the NHS.

Conclusion: OPTIMA, as one of two large scale prospective trials validating the use of test-guided chemotherapy in node-positive hormone-sensitive early breast cancer will have a global impact on patient treatment. Recruitment into the main efficacy trial will commence in October 2015.

Funding: Project funded by the UK NIHR HTA Programme (10/34/501). Views expressed are those of the authors and not those of the HTA Programme, NIHR, NHS or the DoH.

Citation Format: Stein RC, Marshall A, Hall PS, Bartlett JMS, Rooshenas L, Campbell A, Cameron DA, Rea D, Macpherson I, Earl HM, Poole CJ, Francis A, Morgan A, Harmer V, Pinder SE, Stallard N, Donovan J, Hulme C, McCabe C, Hughes-Davies L, Makris A, Dunn JA. OPTIMA (optimal personalised treatment of early breast cancer usIng multi-parameter analysis), a prospective trial to validate the predictive utility and cost-effectiveness of gene expression test-directed chemotherapy decisions. [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 OT3-02-12.

Abstract OT2-02-04: The LORIS trial: A multicentre, randomised phase III trial of standard surgery versus active monitoring in women with newly diagnosed low risk ductal carcinoma in situ

Background: The independent review of the UK National Health Service Breast Screening Programme reported (The Lancet, Volume 380, Issue 9855, Pages 1778 - 1786, 17 November 2012) on the benefits & harms of breast screening. It concluded that breast screening saves lives & acknowledged overtreatment. It encouraged randomized trials to elucidate the appropriate treatment of screen-detected ductal carcinoma in situ (DCIS) to gain a better understanding of its natural history. The LORIS trial addresses overtreatment of low & low/Intermediate grade screen detected (low risk) DCIS by randomizing patients to standard surgical treatment or active monitoring.

Trial Design: LORIS is a phase III, multicentre, 2 arm study, with a 2 year feasibility phase, in patients confirmed to have low risk DCIS by central pathology review. Patients are randomised to standard surgery or active monitoring with annual mammography. Patients will be followed up for a minimum of 10 years.

Key Eligibility Criteria:

1) Female 46 years or over.

2) Screen-detected or incidental microcalcification (with no mass lesion clinically or on imaging)

3) Low risk DCIS on large volume vacuum-assisted biopsy, confirmed by central pathology review

4) Patient fit to undergo surgery

Specific Aims: The LORIS Trial aims to establish whether patients with newly diagnosed low risk DCIS can safely avoid surgery without detriment to their wellbeing (psychological and physical) & whether those patients that do require surgery can be identified by pathological and radiological means.

Primary endpoint: Ipsilateral invasive breast cancer free survival rate at 5 years

Secondary endpoints: Overall survival; mastectomy rate; time to mastectomy; time to surgery; patient reported outcomes & health resource utilisation.

A digital image data repository and tissue bank provide a prospective resource for both translational & imaging studies.

Statistical Methods: A total of 932 patients will be randomized to a non-inferiority design to test the null hypothesis that active monitoring of women diagnosed with low risk DCIS is not non-inferior in terms of 5 year ipsilateral invasive breast cancer free survival (iiBCFS) rate compared to treatment with surgery. The iiBCFS rate will be compared across the two arms on a per protocol and intent-to-treat basis, using a 1-sided (α=0.05) log-rank test for non-inferiority. The iiBCFS rate is assumed to be 97.5% in the surgery arm giving 80% power to exclude a difference of more than 2.5% in the active monitoring arm at 5 years.

Present Accrual and Target Accrual: 21 UK centres are open & the feasibility phase of the trial is recruiting to target. The web based central pathology review process is functioning well with a one week maximum turn around. A further 40 centres will be opened on completion of the feasibility phase.

Contact: LORIS@trials.bham.ac.uk

This project was funded by the National Institute for Health Research [Health Technology Assessment Programme] (project number 11/36/16)

Department of Health Disclaimer: The views & opinions expressed therein are those of the authors & do not necessarily reflect those of the Health Technology Assessment Programme, NIHR, NHS or the Department of Health.

Citation Format: Francis A, Fallowfield L, Bartlett J, Thomas J, Wallis M, Hanby A, Pinder S, Evans A, Billingham L, Brookes C, Dodwell D, Fairbrother P, Gaunt C, Jenkins V, Matthews L, Pirrie S, Reed M, Roberts T, Wilcox M, Young J, Rea D. The LORIS trial: A multicentre, randomised phase III trial of standard surgery versus active monitoring in women with newly diagnosed low risk ductal carcinoma in situ. [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 OT2-02-04.

Associations of family characteristics with perceptions of care among parents of children with autism

BACKGROUND

Although autism spectrum disorder (ASD) is an increasingly common chronic disability, primary care provider (PCPs) report deficits in providing primary care for children with ASD, and parents report lapses in receipt of medical home services. In this study, we describe parental experiences with specific medical home components for their children with ASD.

METHODS

We analysed data from all children within the National Survey of Children with Special Health Care Needs database with ASD and a usual place for care (n = 2859). We evaluated the receipt of core medical home components: accessible, comprehensive, coordinated, family centred and compassionate and culturally sensitive care.

RESULTS

Children were mean age 10.1 years, and respondents were 75% mothers and 95% reported having a primary care provider (PCP). Seventy-one percent reported care to be usually comprehensive, over three-fourths of respondents reported care to be family centred and compassionate and 87% reported care to be culturally sensitive. Of the parents who reported a need for care coordination (n = 1049), only 14% of parents reported usually getting the help they needed. More educated, English-speaking, non-Hispanic White mothers of older children supported by private insurance were more likely to report never getting as much help coordinating care as desired. Coordination with education services are especially important for children with ASD, yet 27% of parents reported dissatisfaction with PCPs' communication with schools or early intervention.

CONCLUSION

Although parents report a high level of access to PCPs and places for care as well as receiving most core components of the medical home, care coordination activities are lacking for children with ASD. More resourced families are particularly likely to report unmet needs.

Iron and iron-based alloys for temporary cardiovascular applications

In the last decade, biodegradable metals have emerged as a topic of interest for particular biomedical applications which require high strength to bulk ratio, including for cardiovascular stents. The advantages of biodegradable materials are related to the reduction of long term risks associated with the presence of permanent metal implants, e.g. chronic inflammation and in-stent restenosis. From a structural point of view, the analysis of the literature reveals that iron-based alloys used as temporary biodegradable stents have several advantages over Mg-based alloys in terms of ductility and strength. Efforts on the modification and tunability of iron-based alloys design and compositions have been mainly focused on controlling the degradation rate while retaining the mechanical integrity within a reasonable period. The early pre-clinical results of many iron-based alloys seem promising for future implants developments. This review discusses the available literature focusing mainly on: (i) Fe and Fe-based alloys design and fabrication techniques; (ii) in vitro and in vivo performance; (iii) cytotoxicity and cell viability tests.

Effectiveness of folic acid supplementation in pregnancy on reducing the risk of small-for-gestational age neonates: a population study, systematic review and meta-analysis

OBJECTIVES

To assess the effect of timing of folic acid (FA) supplementation during pregnancy on the risk of the neonate being small for gestational age (SGA).

DESIGN

A population database study and a systematic review with meta-analysis including the results of this population study.

SETTING AND DATA SOURCES

A UK regional database was used for the population study and an electronic literature search (from inception until August 2013) for the systematic review.

PARTICIPANTS AND INCLUDED STUDIES

Singleton live births with no known congenital anomalies; 111,736 in population study and 188,796 in systematic review.

OUTCOME MEASURES, DATA EXTRACTION AND ANALYSIS

The main outcome was SGA based on customised birthweight centile. Associations are presented as odds ratios (OR) and adjusted odds ratios (aOR), adjusted for maternal and pregnancy-related characteristics.

RESULTS

Of 108,525 pregnancies with information about FA supplementation, 92,133 (84.9%) had taken FA during pregnancy. Time of commencement of supplementation was recorded in 39,416 pregnancies, of which FA was commenced before conception in 10,036, (25.5%) cases. Preconception commencement of FA supplementation was associated with reduced risk of SGA <10th centile (aOR 0.80, 95% CI 0.71-0.90, P < 0.01) and SGA <5th centile (aOR 0.78, 95% CI 0.66-0.91, P < 0.01). This result was reproduced when the data were pooled with other studies in the systematic review, showing a significant reduction in SGA (<5th centile) births with preconception commencement of FA (aOR 0.75, 95% CI 0.61-0.92, P < 0.006). In contrast, postconception folate had no significant effect on SGA rates.

CONCLUSION

Supplementation with FA significantly reduces the risk of SGA at birth but only if commenced preconceptually independent of other risk factors.

SYSTEMATIC REVIEW REGISTRATION

This systematic review was prospectively registered with PROSPERO number CRD42013004895.

Time to stop operating on breast cancer patients with pathological complete response?

Surgery is an obligatory component of treatment for early breast cancer. The last 20 years developments in systemic neoadjuvant therapy have progressively increased pathological complete response (pCR). Pathological complete response is associated with excellent prognosis especially for hormone receptor negative cancers. Therapeutic advances and recognition of the importance of pathological subtype in predicting pCR facilitate identification of subgroups with very high pCR rates. Treatment of HER2 positive hormone receptor negative cancers with combination chemotherapy and multiple targeted anti-HER2 agents results in consistently high pCR rates of 60-83%. Routine surgery in this setting where most patients have no potential to benefit is of questionable value and the option of omitting surgery in these patients should now be explored in a randomized trial. For HER2 positive disease not achieving pCR after neoadjuvant treatment the outcomes are poor. Trials are underway to determine if outcomes for these patients can be improved with alternative targeted therapy.

Selecting breast cancer patients for chemotherapy: the opening of the UK OPTIMA trial

The mortality from breast cancer has improved steadily over the past two decades, in part because of the increased use of more effective adjuvant therapies. Thousands of women are routinely treated with intensive chemotherapy, which can be unpleasant, is expensive and is occasionally hazardous. Oncologists have long known that some of these women may not need treatment, either because they have a low risk of relapse or because they have tumour biology that makes them less sensitive to chemotherapy and more suitable for early adjuvant endocrine therapy. There is an urgent need to improve patient selection so that chemotherapy is restricted to those patients who will benefit from it. Here we review the emerging technologies that are available for improving patient selection for chemotherapy. We describe the OPTIMA trial, which has just opened to recruitment in the UK, is the latest addition to trials in this area, and is the first to focus on the relative cost-effectiveness of alternate predictive assays.

P5-12-02: Vacuum Assisted Biopsies of Ductal Carcinoma In Situ and Concordance with Post-Operative Histology: Implications for the Low Risk DCIS Trial

Aim The enormous increase in the diagnosis of ductal carcinoma in situ (DCIS) by the NHS Breast screening has not lead to an expected decrease in the incidence of invasive breast cancer. It is not clear if all grades of DCIS progress inexorably to invasive cancer if left untreated. There is recognition that DCIS is overtreated, ie if left alone may not cause harm during the woman's lifetime. In the absence of new clinical trial data, surgery still remains the universal treatment. It is known that a higher proportion of patients with screen detected DCIS receive mastectomy than those with screen detected invasive cancer. Recently a randomized trial called the Low risk DCIS Trial has been proposed which intends to specifically compare the current treatment of low grade DCIS ie surgery with active monitoring using annual mammography. In order to effectively implement this, concordance between diagnostic biopsy and excision histology is vital and therefore vacuum assisted mammotome biopsy (VAB) and a central pathology review of diagnostic biopsy specimens prior to randomization will be mandatory. Therefore, in this study, we assessed the concordance between diagnostic biopsies performed by VAB technique and the post operative histology for DCIS in our institution.

Methods Retrospective data of all diagnostic breast biopsies specifically using the VAB technique with the primary diagnosis of DCIS from year 2001 to 2010 in our institution was collected. Both screening and symptomatic patients were included. Concordance between diagnostic histology and post operative excision histology was assessed for high, intermediate and low grade DCIS. Demographic details and potential factors influencing concordance including number of cores taken and lesion size were also collected for analysis.

Results A total of 161 cases were identified out of which 102 (63%) were of high grade, 35 (22%) of intermediate grade and 24 (15%) were of low grade histology. In the High grade group, the concordance with final histology was 70% (72/102). In this group, the diagnosis was upgraded to invasive carcinoma in 21% (21/102). 9% (9/102) were downgraded to intermediate or low grade. In the intermediate grade group, the concordance with final histology was 66% (23/35). In this group, the diagnosis was upgraded to invasive carcinoma in 11% (4/35) and to high grade in 17% (6/35). 6% (2/35) were downgraded to low grade. In the low grade group, the concordance with final histology was 71% (17/24). In this group, the diagnosis was upgraded to intermediate grade in 17% (4/24) and invasive carcinoma in 12% (3/24). All factors associated with lack of concordance were noted.

Conclusion Concordance between VAB diagnostic biopsies of high, intermediate and low grade DCIS and post operative histology is good in this series and is to our knowledge the first to be reported using only large volume biopsies by VAB techniques. This audit has identified possible factors influencing the lack of concordance and these results with concordance data from other UK centres will be used by trial pathologists to refine protocols for the Low risk DCIS trial.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-12-02.

Sensitivity of intravenous and oral alfentanil and pupillary miosis as minimal and noninvasive probes for hepatic and first-pass CYP3A induction

Systemic and oral clearances of alfentanil (ALF) are in vivo probes for hepatic and first-pass cytochrome P450 (CYP) 3A. Both ALF single-point plasma concentrations and miosis are surrogates for area under the concentration-time curve (AUC) and clearance and are minimal and noninvasive CYP3A probes. This investigation determined ALF sensitivity for detecting graded CYP3A induction and compared it with that of midazolam (MDZ). Twelve volunteers (sequential crossover) received 0, 5, 10, 25, or 75 mg oral rifampin for 5 days. MDZ and ALF were given intravenously and orally on sequential days. Dark-adapted pupil diameter was measured with blood sampling. Graded rifampin decreased plasma MDZ AUCs to 83, 76, 62, and 59% (intravenous (i.v.)) and 78, 66, 39, and 24% (oral) of control. Hepatic and first-pass CYP3A induction were detected comparably by plasma MDZ and ALF AUCs. Single ALF concentrations detected all CYP3A induction, whereas MDZ was less sensitive. ALF miosis detected induction of first-pass but not hepatic CYP3A.

Abnormalities of the corpus callosum in non-psychotic high-risk offspring of schizophrenia patients

Alterations in the structure of the corpus callosum (CC) have been observed in schizophrenia. Offspring of schizophrenia parents have 10-15 times higher risk for developing schizophrenia. We examined CC volume in offspring at genetic high-risk (HR) subjects. Since the sub-regions of the CC are topographically mapped to cortical brain regions, we hypothesized that HR subjects may show a decrement in total volume and differential volume decreases in sub-regions of the CC. The offspring of schizophrenia parents (HR; n=70; 36 males) and healthy volunteers with no family or personal history of psychotic disorders (healthy controls (HC); n=73; 37 males) matched for age, gender and education were selected for the study. Magnetic resonance images were collected using a GE 1.5 T scanner and processed using FreeSurfer image analysis software. The CC was divided into five neuroanatomically based partitions. The volume of total CC and the five sub-regions were measured blind to clinical information. With covariation for intracranial volume, HR subjects had significantly reduced total CC, more prominently observed in the anterior splenium. An age-related increase in CC volume was found in the anterior and posterior splenium of healthy controls but not in HR subjects. The volume reduction was greater in male than female HR subjects. The volume reduction in the CC may reflect a reduction in axonal fibers crossing the hemispheres and/or myelination between the left and right temporo-parietal cortices. The absence of an age-related volume increase suggests an abnormal developmental trajectory that may underlie susceptibility to schizophrenia.