Abstract P5-13-15: The value of patient navigation in breast cancer being tested in Rio de Janeiro, Brazil

OBJECTIVES: The main objective of this Patient Navigation Program in Rio de Janeiro (PNP Rio), Brazil, is to promote adherence to the "60 Day Law", which states that all patients with cancer within the public system should start treatment within 60 days after diagnosis of cancer. Thus, the objectives are: 1.) to establish feasibility of PNP in this setting; 2.) to identify barriers to compliance the Law of 60 days and 3.) to ensure that at least 70% of recruited breast cancer patients begin treatment within the mandated 60-day period. One report by FEMAMA states that only 30% of breast cancer patients in Rio de Janeiro to initiate treatment within the 60-day mandate.

METHODS: From August 2017 to May 2018, one hundred patients aged 33-81 years (mean age 59 years) were recruited for navigation at Rio Image - an advanced breast cancer diagnosis center administered by the state health secretary and located in the capital city of Rio de Janeiro, attending patients from the public system from all 92 municipalities in the state. Patient Navigator (PN), a trained social worker, starts navigation from diagnosis, administering questionnaires to collect: patient population data, dates and information of historical milestones, and patient satisfaction. Patients were followed up by phone, e-mail or text message to identify barriers to initiation of treatment.

RESULTS: Patients presented staging 0-I (17%), II-III (78%) and IV (5%). There were two deaths related to breast cancer in this group. All patients reported at least one barrier, ranging from 2 to 12 barriers (M=5). The barriers to compliance with the "Law of 60 days" were: Fear and fatalistic thoughts (99%), Financial problems (79%), Uncoordinated health care (76%), Health professionals ignore the Law of the 60 days (75%), Need to do staging exams again (52%), Concern about communicating with medical staff (52%), Transport (42%), Difficult in obtain surgical risk consultation (12%), Line of surgeries in hospitals (12%), Difficult of insertion in the regulation system in Primary Care(11%), Patient cannot express herself (5%), Social support(4%), Absent of the immunohistochemistry panel (4%), Cognitive problems (3%), Comorbidities (2%). The PNP had 100% patient satisfaction and in 60% of the cases it helped the patients to start treatment within the period established by law.

CONCLUSIONS: In summary, PNP Rio generated a positive experience for patients in the public health system because it is an intentional and proactive process of assisting the individual through the cancer system, accessing services and actively overcoming barriers to quality care. The PNP Rio did not achieve the success rate of 70% of compliance with the Law as intended (achieved 60%). However, the barriers that the PN can not overcome such as lack of human resources and medical supplies, were informed to health authorities and hospital administrators. This is an opportunity for discussion of reallocation of funds, focusing on the use of scarce resources in prevention and early treatment rather than late-stage disease. In the Brazilian context, PNP may represent an opportunity to implement existing legislation adequately, and as such, would have great potential for integration at the federal, state, and local health systems.

Citation Format: Gioia S, Torres C, Cavalcanti J, Brigagao L, Proencio T, Krush L, Goss P. The value of patient navigation in breast cancer being tested in Rio de Janeiro, Brazil [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 P5-13-15.

Brazil Needs Organized Breast Cancer Screening: Pilot Project in Rio De Janeiro

Background: In Rio de Janeiro there is only the opportunistic screening program for women with breast cancer who arrive at health facilities and with a 14% rate of mammography coverage. In countries that have implemented effective screening programs, with coverage of the target population, quality of screening, and adequate treatment, breast cancer mortality has declined. Evidence of the impact of screening on mortality by this neoplasm justifies its adoption as a public health policy, as recommended by WHO. 80% of the population use the public health system (Sistema Unico de Saude - SUS), provided by the government. This system mainly provides conventional mammography. The private insurance system covers the remaining 20%, who have access to modern technologies such as digital mammography or MRI. Aim: The breast cancer organized screening program in the community of the Andaraí, RJ is committed in assisting women asymptomatic 50-69 years from SUS. Methods: The program foresees the participation of these women for an indefinite period, free of charge, and the accomplishment of biennial digital mammography, going through the stages of early detection and diagnosis. In case of positivity for malignant disease, it will be treated properly. Results: Since April 2014 have been 350 women with an average age of 54 years. 100% of them were asymptomatic and 49% had never done before mammography. Only 1 woman presented clinical suspect aged 44 years. The screening program organized by breast cancer in the community of Andaraí, RJ presented a mammographic coverage rate of 70%. The program is contemplated in the healthcare plan of the SUS. Conclusion: Preliminary results of the study suggest that population based organized screening are feasible and age of onset mammography screening should be 50 years in Rio de Janeiro.

Marie M, Stickney K, VanBuecken D, Vellek B, Webber C, Allen L, Bollyk J, Hilderman N, Ismail H, Lamola S, Sanda S, Vendettuoli H, Tridgell D, Monzavi R, Bock M, Fisher L, Halvorson M, Jeandron D, Kim M, Wood J, Geffner M, Kaufman F, Parkman R, Salazar C, Goland R, Clynes R, Cook S, Freeby M, Gallagher MP, Gandica R, Greenberg E, Kurland A, Pollak S, Wolk A, Chan M, Koplimae L, Levine E, Smith K, Trast J, DiMeglio L, Blum J, Evans-Molina C, Hufferd R, Jagielo B, Kruse C, Patrick V, Rigby M, Spall M, Swinney K, Terrell J, Christner L, Ford L, Lynch S, Menendez M, Merrill P, Pescovitz M, Rodriguez H, Alleyn C, Baidal D, Fay S, Gaglia J, Resnick B, Szubowicz S, Weir G, Benjamin R, Conboy D, deManbey A, Jackson R, Jalahej H, Orban T, Ricker A, Wolfsdorf J, Zhang HH, Wilson D, Aye T, Baker B, Barahona K, Buckingham B, Esrey K, Esrey T, Fathman G, Snyder R, Aneja B, Chatav M, Espinoza O, Frank E, Liu J, Perry J, Pyle R, Rigby A, Riley K, Soto A, Gitelman S, Adi S, Anderson M, Berhel A, Breen K, Fraser K, Gerard-Gonzalez A, Jossan P, Lustig R, Moassesfar S, Mugg A, Ng D, Prahalod P, Rangel-Lugo M, Sanda S, Tarkoff J, Torok C, Wesch R, Aslan I, Buchanan J, Cordier J, Hamilton C, Hawkins L, Ho T, Jain A, Ko K, Lee T, Phelps S, Rosenthal S, Sahakitrungruang T, Stehl L, Taylor L, Wertz M, Wong J, Philipson L, Briars R, Devine N, Littlejohn E, Grant T, Gottlieb P, Klingensmith G, Steck A, Alkanani A, Bautista K, Bedoy R, Blau A, Burke B, Cory L, Dang M, Fitzgerald-Miller L, Fouts A, Gage V, Garg S, Gesauldo P, Gutin R, Hayes C, Hoffman M, Ketchum K, Logsden-Sackett N, Maahs D, Messer L, Meyers L, Michels A, Peacock S, Rewers M, Rodriguez P, Sepulbeda F, Sippl R, Steck A, Taki I, Tran BK, Tran T, Wadwa RP, Zeitler P, Barker J, Barry S, Birks L, Bomsburger L, Bookert T, Briggs L, Burdick P, Cabrera R, Chase P, Cobry E, Conley A, Cook G, Daniels J, DiDomenico D, Eckert J, Ehler A, Eisenbarth G, Fain P, Fiallo-Scharer R, Frank N, Goettle H, Haarhues M, Harris S, Horton L, Hutton J, Jeffrrey J, Jenison R, Jones K, Kastelic W, King MA, Lehr D, Lungaro J, Mason K, Maurer H, Nguyen L, Proto A, Realsen J, Schmitt K, Schwartz M, Skovgaard S, Smith J, Vanderwel B, Voelmle M, Wagner R, Wallace A, Walravens P, Weiner L, Westerhoff B, Westfall E, Widmer K, Wright H, Schatz D, Abraham A, Atkinson M, Cintron M, Clare-Salzler M, Ferguson J, Haller M, Hosford J, Mancini D, Rohrs H, Silverstein J, Thomas J, Winter W, Cole G, Cook R, Coy R, Hicks E, Lewis N, Marks J, Pugliese A, Blaschke C, Matheson D, Sanders-Branca N, Sosenko J, Arazo L, Arce R, Cisneros M, Sabbag S, Moran A, Gibson C, Fife B, Hering B, Kwong C, Leschyshyn J, Nathan B, Pappenfus B, Street A, Boes MA, Eck SP, Finney L, Fischer TA, Martin A, Muzamhindo CJ, Rhodes M, Smith J, Wagner J, Wood B, Becker D, Delallo K, Diaz A, Elnyczky B, Libman I, Pasek B, Riley K, Trucco M, Copemen B, Gwynn D, Toledo F, Rodriguez H, Bollepalli S, Diamond F, Eyth E, Henson D, Lenz A, Shulman D, Raskin P, Adhikari S, Dickson B, Dunnigan E, Lingvay I, Pruneda L, Ramos-Roman M, Raskin P, Rhee C, Richard J, Siegelman M, Sturges D, Sumpter K, White P, Alford M, Arthur J, Aviles-Santa ML, Cordova E, Davis R, Fernandez S, Fordan S, Hardin T, Jacobs A, Kaloyanova P, Lukacova-Zib I, Mirfakhraee S, Mohan A, Noto H, Smith O, Torres N, Wherrett D, Balmer D, Eisel L, Kovalakovska R, Mehan M, Sultan F, Ahenkorah B, Cevallos J, Razack N, Ricci MJ, Rhode A, Srikandarajah M, Steger R, Russell WE, Black M, Brendle F, Brown A, Moore D, Pittel E, Robertson A, Shannon A, Thomas JW, Herold K, Feldman L, Sherwin R, Tamborlane W, Weinzimer S, Toppari J, Kallio T, Kärkkäinen M, Mäntymäki E, Niininen T, Nurmi B, Rajala P, Romo M, Suomenrinne S, Näntö-Salonen K, Simell O, Simell T, Bosi E, Battaglia M, Bianconi E, Bonfanti R, Grogan P, Laurenzi A, Martinenghi S, Meschi F, Pastore M, Falqui L, Muscato MT, Viscardi M, Castleden H, Farthing N, Loud S, Matthews C, McGhee J, Morgan A, Pollitt J, Elliot-Jones R, Wheaton C, Knip M, Siljander H, Suomalainen H, Colman P, Healy F, Mesfin S, Redl L, Wentworth J, Willis J, Farley M, Harrison L, Perry C, Williams F, Mayo A, Paxton J, Thompson V, Volin L, Fenton C, Carr L, Lemon E, Swank M, Luidens M, Salgam M, Sharma V, Schade D, King C, Carano R, Heiden J, Means N, Holman L, Thomas I, Madrigal D, Muth T, Martin C, Plunkett C, Ramm C, Auchus R, Lane W, Avots E, Buford M, Hale C, Hoyle J, Lane B, Muir A, Shuler S, Raviele N, Ivie E, Jenkins M, Lindsley K, Hansen I, Fadoju D, Felner E, Bode B, Hosey R, Sax J, Jefferies C, Mannering S, Prentis R, She J, Stachura M, Hopkins D, Williams J, Steed L, Asatapova E, Nunez S, Knight S, Dixon P, Ching J, Donner T, Longnecker S, Abel K, Arcara K, Blackman S, Clark L, Cooke D, Plotnick L, Levin P, Bromberger L, Klein K, Sadurska K, Allen C, Michaud D, Snodgrass H, Burghen G, Chatha S, Clark C, Silverberg J, Wittmer C, Gardner J, LeBoeuf C, Bell P, McGlore O, Tennet H, Alba N, Carroll M, Baert L, Beaton H, Cordell E, Haynes A, Reed C, Lichter K, McCarthy P, McCarthy S, Monchamp T, Roach J, Manies S, Gunville F, Marosok L, Nelson T, Ackerman K, Rudolph J, Stewart M, McCormick K, May S, Falls T, Barrett T, Dale K, Makusha L, McTernana C, Penny-Thomas K, Sullivan K, Narendran P, Robbie J, Smith D, Christensen R, Koehler B, Royal C, Arthur T, Houser H, Renaldi J, Watsen S, Wu P, Lyons L, House B, Yu J, Holt H, Nation M, Vickers C, Watling R, Heptulla R, Trast J, Agarwal C, Newell D, Katikaneni R, Gardner C, Del Rio A, Logan A, Collier H, Rishton C, Whalley G, Ali A, Ramtoola S, Quattrin T, Mastrandea L, House A, Ecker M, Huang C, Gougeon C, Ho J, Pacuad D, Dunger D, May J, O’Brien C, Acerini C, Salgin B, Thankamony A, Williams R, Buse J, Fuller G, Duclos M, Tricome J, Brown H, Pittard D, Bowlby D, Blue A, Headley T, Bendre S, Lewis K, Sutphin K, Soloranzo C, Puskaric J, Madison H, Rincon M, Carlucci M, Shridharani R, Rusk B, Tessman E, Huffman D, Abrams H, Biederman B, Jones M, Leathers V, Brickman W, Petrie P, Zimmerman D, Howard J, Miller L, Alemzadeh R, Mihailescu D, Melgozza-Walker R, Abdulla N, Boucher-Berry C, Ize-Ludlow D, Levy R, Swenson Brousell C, Scott R, Heenan H, Lunt H, Kendall D, Willis J, Darlow B, Crimmins N, Edler D, Weis T, Schultz C, Rogers D, Latham D, Mawhorter C, Switzer C, Spencer W, Konstantnopoulus P, Broder S, Klein J, Bachrach B, Gardner M, Eichelberger D, Knight L, Szadek L, Welnick G, Thompson B, Hoffman R, Revell A, Cherko J, Carter K, Gilson E, Haines J, Arthur G, Bowen B, Zipf W, Graves P, Lozano R, Seiple D, Spicer K, Chang A, Fregosi J, Harbinson J, Paulson C, Stalters S, Wright P, Zlock D, Freeth A, Victory J, Maheshwari H, Maheshwari A, Holmstrom T, Bueno J, Arguello R, Ahern J, Noreika L, Watson V, Hourse S, Breyer P, Kissel C, Nicholson Y, Pfeifer M, Almazan S, Bajaj J, Quinn M, Funk K, McCance J, Moreno E, Veintimilla R, Wells A, Cook J, Trunnel S, Transue D, Surhigh J, Bezzaire D, Moltz K, Zacharski E, Henske J, Desai S, Frizelis K, Khan F, Sjoberg R, Allen K, Manning P, Hendry G, Taylor B, Jones S, Couch R, Danchak R, Lieberman D, Strader W, Bencomo M, Bailey T, Bedolla L, Roldan C, Moudiotis C, Vaidya B, Anning C, Bunce S, Estcourt S, Folland E, Gordon E, Harrill C, Ireland J, Piper J, Scaife L, Sutton K, Wilkins S, Costelloe M, Palmer J, Casas L, Miller C, Burgard M, Erickson C, Hallanger-Johnson J, Clark P, Taylor W, Galgani J, Banerjee S, Banda C, McEowen D, Kinman R, Lafferty A, Gillett S, Nolan C, Pathak M, Sondrol L, Hjelle T, Hafner S, Kotrba J, Hendrickson R, Cemeroglu A, Symington T, Daniel M, Appiagyei-Dankah Y, Postellon D, Racine M, Kleis L, Barnes K, Godwin S, McCullough H, Shaheen K, Buck G, Noel L, Warren M, Weber S, Parker S, Gillespie I, Nelson B, Frost C, Amrhein J, Moreland E, Hayes A, Peggram J, Aisenberg J, Riordan M, Zasa J, Cummings E, Scott K, Pinto T, Mokashi A, McAssey K, Helden E, Hammond P, Dinning L, Rahman S, Ray S, Dimicri C, Guppy S, Nielsen H, Vogel C, Ariza C, Morales L, Chang Y, Gabbay R, Ambrocio L, Manley L, Nemery R, Charlton W, Smith P, Kerr L, Steindel-Kopp B, Alamaguer M, Tabisola-Nuesca E, Pendersen A, Larson N, Cooper-Olviver H, Chan D, Fitz-Patrick D, Carreira T, Park Y, Ruhaak R, Liljenquist D. A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Abstract P4-04-19: Endocrine medical treatment in breast cancer, is that enough?

Endocrine treatment has been in the management of hormone receptor breast cancer for a few decades, but never as the first line of treatment. Now in the biomolecular era, we are able to select patients where endocrine treatment can be considered the first line of treatment.

Methods: During the months of May 2011 until June 2017, patients with ductal/lobular, in-situ and invasive cancer were treated medically with endocrine treatment as first choice of treatment (Tamoxifen/AI), due to medical morbidity or as requested by patients. The use of biomolecular assays helped to support the treatment decision. The infrastructure of ABC as a comprehensive center with all the modalities for diagnostic and interventional breast imaging center allow us to do all the follow up with the same health professionals. The assessments of the follow-ups were based on clinical, imaging (MRI, ultrasound and mammogram), and pathological responses.

We use the term "complete clinical response" on patients where the clinical history and the physical examination demonstrate complete improvement of the breast cancer. "Complete imaging response" is referred to those patients that before treatment had a breast MRI with enhancement lesions and in the follow-ups show no more enhancements. "Complete pathological response" refers to patients which had no residual cancer on the surgical specimen.

Results: We followed a total of 32 patients for an average period of 20.12 months (range=2-63 months), and an average age of 69.69 (range=45-86). Twenty-six of these patients (81.2 %) had Invasive Ductal Carcinoma, 6 patients (18.7%)had DCIS, 23 of the patients (71.88%), were only treated with endocrine treatment.Nine patients (28.13%) were treated with endocrine therapy plus surgery. The decision for surgery was a personal request of the patient, not a failure of the endocrine treatment.

The 32 patients (100%) had a complete clinical response. Twenty-five patients (78.13%) presented a complete imaging response.From the patients who had surgery,1 patient (11.11%) presented a complete pathological response, 6 patients (66.67%) presented down staging of the tumor, and 2 patients (22.22%) presented no change.

Twenty-nineof the 32 patients (90.63%) were able to obtain the recurrence score by Twenty-one Genes.Twenty-four of those had a low recurrence score, 4 had an intermediate score, and 1 patient had a high recurrence score.

Discussion: Even though this is a small group of patients, there was no failure of treatment, mortality or progress of the disease. It demonstrated that, on selective patients, the effectiveness of endocrine treatment is possible, and can be used as the first line treatment. The selection of those patients was supported with the use of the 21 genes.

Conclusion:Now days endocrine treatment, based on clinical and biomolecular assays, can be considered safe to use as first line of treatment for invasive and non-invasive breast cancer for those patients that refuse surgery or chemotherapy.

Citation Format: Rosario V, Torres C, Santiago CP. Endocrine medical treatment in breast cancer, is that enough? [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 P4-04-19.

Aerogels made of chitosan and chondroitin sulfate at high degree of neutralization: Biological properties toward wound healing

In this study, highly neutralized, highly porous, and ultralight polymeric aerogels prepared from aqueous colloidal suspensions of chitosan (CS) and chondroitin sulfate (ChS) nanocomplexes, formulated as quasi-equimolar amounts of both, are described. These aerogels were designed as healing agents under the inspiration of minimizing the amount of matter applied to wounds, reducing the electrostatic potential of the material and avoiding covalent cross-linkers in order to decrease metabolic stress over wounds. Aerogels synthesized under these criteria are biocompatible and provide specific properties for the induction of wound healing. They do not affect neither the metabolic activity of cultured 3T3 fibroblasts nor the biochemical parameters of experimental animals, open wounds close significantly faster and, unlike control wounds, complete reepithelialization and scarring can be attained 14 days after surgery. Because of its hydration abilities, rapid adaptation to the wound bed and the early accelerator effect of wound closure, the CS/ChS aerogels appear to be functional inducers of the healing. Previous information show that CS/ChS aerogels improve wound bed quality, increase granulation tissue and have pain suppressive effect. CS/ChS aerogels are useful as safe, inexpensive and easy to handle materials for topical applications, such as skin chronic wounds. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2464-2471, 2018.

182 In Vitro Derivation of Male Germ Cells from Bovine Bone Marrow-Derived Mesenchymal Stem Cells

During the last few years, the in vitro derivation of germ cell lineages from stem cells has emerged as an exciting new strategy for obtaining mature gametes. In vitro gamete derivation technology has potential applications as an alternative method for dissemination of elite animal genetics, production of transgenic animals, and conservation of endangered species. Germ cell differentiation and gametogenesis is a complex process and potential of different stem cell donors (i.e. SSC, ESC, iPSC) for in vitro male germ cell derivation has been inconsistent. Mesenchymal stem cells (MSC) may be suitable candidates for in vitro gamete derivation considering their (1) plasticity that is not limited to mesodermal derivatives, (2) availability of abundant tissues sources for isolation, (3) high proliferative potential, (4) simple and inexpensive isolation, and (5) high potential for cell therapy, including autologous or allogenic transplantation. The present study aimed to induce differentiation of MSC isolated from bone marrow derived from bovine male fetuses (bfMSC) into the germ cell lineage using an in vitro approach based on the exogenous effect of retinoic acid (RA) and bone morphogenetic protein 4 (BMP4). Differentiation media consisted in control media (DMEM with high glucose plus 10% fetal bovine serum, 100 IU mL−1 penicillin, 100 μg mL−1 streptomycin, and 0.25 μg mL−1amphotericin B) supplemented with RA (0.01, 0.1, or 1 µM) or BMP4 (10, 50, or 100 ng mL−1). Cell samples were obtained from differentiating and control bfMSC cultures and analysed for expression of housekeeping genes β-ACTIN and GAPDH, pluripotent genes OCT4 and NANOG, germ cell genes FRAGILLIS, STELLA, and VASA, male germ cell genes DAZL, PIWIl2, and STRA8, and meiotic biomarker SCP3 by quantitative-PCR (Q-PCR). OCT4, NANOG, and DAZL were immunodetected in undifferentiated and differentiated bfMSC using flow-cytometry analysis. The mRNA expression of DAZL was activated by RA or BMP4 supplementation, although no differences (P > 0.05) were detected among different concentrations. DAZL and NANOG mRNA levels increased (P < 0.05) from Day 7 to Day 21 during supplementation of RA (0.1 μM). In comparison, DAZL mRNA levels increased (P < 0.05) at Day 14 during supplementation of BMP4 (100 ng). OCT4 and SCP3 mRNA levels were not affected by RA or BMP4 treatments. Transcripts of FRAGILLIS, STELLA, VASA, PIWIl2, and STRA8 were not detected in control or differentiated bfMSC. Higher (P < 0.05) percentages of undifferentiated bfMSC were positive for NANOG (80.6%) and OCT4 (83.4%). DAZL- and NANOG-positive cells were 2.1% and 2.9%, and 95.9% and 97.8% at Days 0 and 21 of RA treatment, respectively. Data indicated that expression of germ cell biomarker DAZL in bfMSC is activated and increased after in vitro supplementation of RA and BMP4. Moreover, NANOG mRNA levels were regulated by RA treatment. Similar levels of SCP3 mRNA expression suggest that differentiated bfMSC were not induced into meiosis. Thus, exposure of bfMSC to RA or BMP4 under in vitro conditions might induce an early stage of premeiotic germinal differentiation.

Diagnostic Accuracy of Centrally Restricted Diffusion in the Differentiation of Treatment-Related Necrosis from Tumor Recurrence in High-Grade Gliomas

BACKGROUND AND PURPOSE

Centrally restricted diffusion has been demonstrated in recurrent high-grade gliomas treated with bevacizumab. Our purpose was to assess the accuracy of centrally restricted diffusion in the diagnosis of radiation necrosis in high-grade gliomas not treated with bevacizumab.

MATERIALS AND METHODS

In this prospective study, we enrolled patients with high-grade gliomas who developed a new ring-enhancing necrotic lesion and who underwent re-resection. The presence of a centrally restricted diffusion within the ring-enhancing lesion was assessed visually on diffusion trace images and by ADC measurements on 3T preoperative diffusion tensor examination. The percentage of tumor recurrence and radiation necrosis in each surgical specimen was defined histopathologically. The association between centrally restricted diffusion and radiation necrosis was assessed using the Fisher exact test. Differences in ADC and the ADC ratio between the groups were assessed via the Mann-Whitney U test, and receiver operating characteristic curve analysis was performed.

RESULTS

Seventeen patients had re-resected ring-enhancing lesions: 8 cases of radiation necrosis and 9 cases of tumor recurrence. There was significant association between centrally restricted diffusion by visual assessment and radiation necrosis (P = .015) with a sensitivity of 75% and a specificity of 88.9%, a positive predictive value 85.7%, and a negative predictive value of 80% for the diagnosis of radiation necrosis. There was a statistically significant difference in the ADC and ADC ratio between radiation necrosis and tumor recurrence (P = .027).

CONCLUSIONS

The presence of centrally restricted diffusion in a new ring-enhancing lesion might indicate radiation necrosis rather than tumor recurrence in high-grade gliomas previously treated with standard chemoradiation without bevacizumab.

Antibiogramj: A tool for analysing images from disk diffusion tests

BACKGROUND AND OBJECTIVES

Disk diffusion testing, known as antibiogram, is widely applied in microbiology to determine the antimicrobial susceptibility of microorganisms. The measurement of the diameter of the zone of growth inhibition of microorganisms around the antimicrobial disks in the antibiogram is frequently performed manually by specialists using a ruler. This is a time-consuming and error-prone task that might be simplified using automated or semi-automated inhibition zone readers. However, most readers are usually expensive instruments with embedded software that require significant changes in laboratory design and workflow.

METHODS

Based on the workflow employed by specialists to determine the antimicrobial susceptibility of microorganisms, we have designed a software tool that, from images of disk diffusion tests, semi-automatises the process. Standard computer vision techniques are employed to achieve such an automatisation.

RESULTS

We present AntibiogramJ, a user-friendly and open-source software tool to semi-automatically determine, measure and categorise inhibition zones of images from disk diffusion tests. AntibiogramJ is implemented in Java and deals with images captured with any device that incorporates a camera, including digital cameras and mobile phones. The fully automatic procedure of AntibiogramJ for measuring inhibition zones achieves an overall agreement of 87% with an expert microbiologist; moreover, AntibiogramJ includes features to easily detect when the automatic reading is not correct and fix it manually to obtain the correct result.

CONCLUSIONS

AntibiogramJ is a user-friendly, platform-independent, open-source, and free tool that, up to the best of our knowledge, is the most complete software tool for antibiogram analysis without requiring any investment in new equipment or changes in the laboratory.

TGFβ engages MEK/ERK to differentially regulate benign and malignant pancreas cell function

While TGFβ signals are anti-proliferative in benign and well-differentiated pancreatic cells, TGFβ appears to promote the progression of advanced cancers. To better understand dysregulation of the TGFβ pathway, we first generated mouse models of neoplastic disease with TGFβ receptor deficiencies. These models displayed reduced levels of pERK irrespective of KRAS mutation. Furthermore, exogenous TGFβ led to rapid and sustained TGFBR1-dependent ERK phosphorylation in benign pancreatic duct cells. Similar to results that our group has published in colon cancer cells, inhibition of ERK phosphorylation in duct cells mitigated TGFβ-induced upregulation of growth suppressive pSMAD2 and p21, prevented downregulation of the pro-growth signal CDK2 and ablated TGFβ-induced EMT. These observations suggest that ERK is a key factor in growth suppressive TGFβ signals, yet may also contribute to detrimental TGFβ signaling such as EMT. In neoplastic PanIN cells, pERK was not necessary for either TGFβ-induced pSMAD2 phosphorylation or CDK2 repression, but was required for upregulation of p21 and EMT indicating a partial divergence between TGFβ and MEK/ERK in early carcinogenesis. In cancer cells, pERK had no effect on TGFβ-induced upregulation of pSMAD2 and p21, suggesting the two pathways have completely diverged with respect to the cell cycle. Furthermore, inhibition of pERK both reduced levels of CDK2 and prevented EMT independent of exogenous TGFβ, consistent with most observations identifying pERK as a tumor promoter. Combined, these data suggest that during carcinogenesis pERK initially facilitates and later antagonizes TGFβ-mediated cell cycle arrest, yet remains critical for the pathological, EMT-inducing arm of TGFβ signaling.

Clozapine induced diarrhea

Introduction

Clozapine (CZP) is the only antipsychotic approved for resistant schizophrenia 1. Due to its side effects, CZP is not the first therapeutic option in a psychotic episode. Its anticholinergic effects often cause constipation, however, diarrhea have also been described in literature.

Objectives

We describe a patient with two episodes of severe diarrhea after clozapine initiation, which lead to CZP discontinuation.

Aims

Discuss about the differential diagnosis of diarrhea in CZP patients and the needing of a further studies for clarify the more appropriate management in CZP induced diarrhea.

Methods

We present a case report of a 46 years man diagnosed with schizoaffective disorder who presented two episodes of severe diarrhea with fever, which forced his transfer to internal medicine and UCI after CZP initiation.

Results

At the first episode analytical, radiological and histological findings led to Crohn's disease diagnosis, which required budesonide and mesalazine treatment. In the second episode, the digestive team concluded that the episode was due to clozapine toxicity despite the controversial findings (clostridium toxin and Crohn's compatible biopsies)

Conclusions

Diarrhea caused by CZP has been controversial in the literature. However due to the severity of digestive episodes and the paucity of alternative treatments further studies for a better understanding of its physiopathology are warranted.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Polydipsia and intermittent hyponatremia

Introduction

Hyponatraemia occurs in 4% of schizophrenic patients. Dilutional hyponatraemia, due to inappropriate retention of water and excretion of sodium, occurs with different psychotropic medications and could lead to hippocampal dysfunction. This complication is usually asymptomatic but can cause severe problems, as lethargy and confusion, difficult to diagnose in mentally ill patients.

Objectives

To describe a case of a patient with psychotropic poli-therapy, admitted three times due to hyponatremia and the pharmacological changes that improved his condition.

Aims

To broadcast the intermittent hyponatraemia and polydipsia (PIP), a not rare condition, suffered by treated schizophrenic patients and discuss its physiopathology and treatment thorough a case report.

Methods

A 56-year schizophrenic male was admitted for presenting disorganized behavior, agitation, auditory hallucinations, disorientation, ataxia, vomits and urinary retention. He was on clomipramine, haloperidol and clotiapine (recently added), quetiapine, fluphenazine and clonazepam. After water restriction his symptoms improved and he was discharged. Twenty-five days later, he was readmitted for presenting the same symptoms and after water restriction, he was discharged. Five days later, he was again admitted and transferred to the psychiatric ward.

Results

Haloperidol, fluphenazine and clomipramine were replaced by clozapine. These changes lead him to normalize the hypoosmolality and reduce his water-voracity. Endocrinology team did not label this episode of SIADH due to its borderline blood and urine parameters.

Conclusions

Hyponatremia is frequent in schizophrenic patients and may have severe consequences. Therefore, a prompt recognition and treatment is warranted.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Clinical impact and prevalence of MRSA CC398 and differences between MRSA-TetR and MRSA-TetS in an area of Spain with a high density of pig farming: a prospective cohort study

OBJECTIVES

Tetracycline resistance (Tet^R) is a phenotypic marker of the livestock-associated methicillin-resistant Staphylococcus aureus (MRSA) CC398 clone. The aim of this study was to analyse the prevalence of MRSA CC398 in patients in contact with healthcare facilities and differences between patients with MRSA-Tet^R and MRSA tetracycline-susceptible (Tet^S) strains.

METHODS

Patients diagnosed with MRSA from January 2012 to December 2015 were divided into two groups, MRSA-Tet^R and MRSA-Tet^S. Epidemiologic and clinical data were evaluated. Molecular analysis was performed (multilocus sequence typing, spa typing) on MRSA-Tet^R strains.

RESULTS

Data from 288 MRSA patients were obtained, and 106 (36.8%) carried MRSA-Tet^R (93 typed as CC398 (87.7%); the remaining 13 isolates were ascribed to CC9, CC1, CC121, CC30, CC97, CC146 and CC152). The most frequent spa type was t011 (56.6%, 61/106). Detection of MRSA-Tet^R increased over the years (21.9%, 16/73, in 2012; 50.7%, 36/71, in 2015; p <0.001). Hospital acquisition was found in 16.7% (19/114) of MRSA-Tet^R patients vs. 83.3% (95/114) in MRSA-Tet^S patients (p <0.001). Frequency of MRSA-Tet^R patients in nursing homes was lower than in MRSA-Tet^S patients (4.7%, 5/106, vs. 27.5%, 50/182, p <0.001). MRSA-Tet^R as distinct from MRSA-Tet^S was associated with workers on pig farms (49.0%, 52/106, vs. 1.0%, 2/182; p <0.001), fewer admissions to hospital (46.2%, 49/106, vs. 68.1%, 124/182; p <0.001) and fewer comorbidities (81.1%, 86/106, vs. 59.9%, 109/182; p <0.001). Sixty cases of MRSA-CC398 infection were diagnosed, including, among others, endocarditis, septic arthritis, prosthetic joint infection, pneumonia and bacteraemia.

CONCLUSIONS

Prevalence of MRSA-Tet^R (especially CC398) at the hospital level in a Spanish region with intensive pig farming activity is high and is responsible for severe infections. Significant differences were detected in clinical and epidemiologic characteristics among MRSA-Tet^R and MRSA-Tet^S patients.

New intravascular contrast agent applied to dynamic contrast enhanced MR imaging of human breast cancer

Purpose: To evaluate the feasibility of using dynamic contrast-enhanced MR imaging with a new intravascular contrast agent in grading human breast cancer.

Material and Methods: 23 patients with 27 breast tumors (21 carcinomas and 6 fibroadenomas) were examined with dynamic MR imaging after administration of Clariscan, an iron oxide nanoparticle with large T1 relaxivity and a long plasma half life. A 3D T1-weighted gradient echo sequence with an acquisition time of 60 s was repeated at regular intervals of 3–5 min before and up to 1 h after injection of 2 mg/kg b.w. of Clariscan. The endothelial transfer constant, Kps, which reflects overall vascular permeability, and the fractional plasma volume, fPV, were estimated from time-intensity curves acquired from three separate regions of interest (ROIs): whole tumor, a permeability hot spot, and a blood volume hot spot. Kps and fPV were compared to the results of histologic tumor grading (Scarff-Bloom-Richardson, SBR) and microvascular density, MVD.

Results: A statistically significant correlation between the MR-derived Kps parameters and the SBR score was obtained for the whole tumor ROI ( R = 0.70), and for the permeability hot spot ROIs ( R = 0.67). A correlation between fPV and SBR was detected for the blood volume hot spot ROIs ( R = 0.48). There was no statistically significant correlation between Kps or fPV with MVD.

Conclusion: The results support the hypothesis that dynamic MR with the intravascular contrast agent Clariscan may be used for non-invasive tumor grading.

Diagnosis and outcome of childhood perineurioma

INTRODUCTION

Intraneural perineurioma is a rare peripheral nerve tumor of childhood and early adulthood. Patients demonstrate progressive muscle weakness and atrophy largely without sensory complaints.

CASE

We report two children with perineurioma affecting the radial and femoral nerves. Electromyography (EMG), ultrasound, and 3-T MR imaging were important tools for localizing perineurioma and permitting its differentiation from other nerve lesions. The first patient underwent surgical excision of the perineurioma and a traditional nerve graft. At 10 months post-operative follow-up, she demonstrated no meaningful recovery of muscle strength compared to her pre-operative assessment. EMG did confirm axonal continuity indicating that reinnervation had occurred via the nerve graft. The second patient underwent a two-staged surgical procedure that included an end-to-side nerve transfer. At 18 months post-operative follow-up, she demonstrated mild improvement in muscle strength and EMG evidence of ongoing reinnervation.

CONCLUSION

The surgical management of perineurioma remains controversial, and reports of clinical recovery after nerve grafts and nerve transfers vary. Nerve transfers have been reported to provide superior results to traditional nerve grafting in adults with post-traumatic plexus injuries. The modest gain in strength of our patient who underwent a nerve transfer raises the question if this may also apply to patients with perineurioma. Additional studies will be required, which must also take into consideration that features of long-standing neuropathy (i.e., limb length discrepancy) have the potential to reduce the likelihood of reinnervation and clinical recovery.