Evaluation of two population screening programmes for BRCA1/2 founder mutations in the Australian Jewish community: a protocol paper

INTRODUCTION

People of Ashkenazi Jewish (AJ) ancestry are more likely than unselected populations to have a BRCA1/2 pathogenic variant, which cause a significantly increased risk of breast, ovarian and prostate cancer. Three specific BRCA1/2 pathogenic variants, referred to as BRCA-Jewish founder mutations (B-JFM), account for >90% of BRCA1/2 pathogenic variants in people of AJ ancestry. Current practice of identifying eligible individuals for BRCA testing based on personal and/or family history has been shown to miss at least 50% of people who have one of these variants. Here we describe the protocol of the JeneScreen study-a study established to develop and evaluate two different population-based B-JFM screening programmes, offered to people of Jewish ancestry in Sydney and Melbourne, Australia.

METHODS AND ANALYSIS

To rmeasure the acceptability of population-based B-JFM screening in Australia, two screening programmes using different methodologies have been developed. The Sydney JeneScreen programme provides information and obtains informed consent by way of an online tool. The Melbourne JeneScreen programme does this by way of community sessions attended in person. Participants complete questionnaires to measure clinical and psychosocial outcomes at baseline, and for those who have testing, 2 weeks postresult. Participants who decline testing are sent a questionnaire regarding reasons for declining. Participants with a B-JFM are sent questionnaires 12-month and 24-month post-testing. The questionnaires incorporate validated scales, which measure anxiety, decisional conflict and regret, and test-related distress and positive experiences, and other items specifically developed or adapted for the study. These measures will be assessed for each programme and the two population-based B-JFM screening methods will be compared.

ETHICS AND DISSEMINATION

Institutional Human Research Ethics Committee approval was obtained from the South Eastern Area Health Service Human Research Ethics Committee: HREC Ref 16/125.Following the analysis of the study results, the findings will be disseminated widely through conferences and publications, and directly to participants in writing.

Serum 25-hydroxyvitamin D concentrations and mortality in dogs with blastomycosis

Blastomycosis is a prominent fungal disease in the United States. Vitamin D status has been found to be altered in critical illness and various infectious diseases. The objectives of this study were to compare serum 25-hydroxyvitamin D (25[OH]D) concentrations in dogs with blastomycosis and healthy controls, to assess the change in serum 25(OH)D concentrations in dogs with blastomycosis after 30 days of treatment, and to determine if baseline serum 25(OH)D concentrations in dogs with blastomycosis were associated with in-hospital, 30-day, or end-of-study mortality. In this prospective cohort study, 19 dogs newly diagnosed with blastomycosis had serum 25(OH)D concentrations measured with a commercially available validated radioimmunoassay at the time of diagnosis and 30 days after start of treatment. These values were compared to 24 healthy control dogs. Serum 25(OH)D concentrations at the time of diagnosis were lower in dogs with blastomycosis (median, 203 nmol/L; range, 31-590 nmol/L) than in clinically healthy control dogs (259.5 nmol/L, 97-829 nmol/L; P = 0.01). Despite clinical improvement, there was no significant change in serum 25(OH)D concentrations from baseline to 30-day follow-up. Dogs with baseline serum 25(OH)D concentrations <180.5nmol/L had a greater odds of death during hospitalization (odds ratio [OR], 15.0; 95% confidence interval [CI], 1.4-191.3; P = 0.04) and at 30 days follow-up (OR, 30.0; 95% CI, 2.5-366.7; P = 0.006). These findings highlight the need for further studies evaluating the prognostic value of vitamin D status in dogs with blastomycosis at diagnosis and throughout treatment and remission.

Combined versus single treatment regimens for keloid therapy using serial intralesional corticosteroid injections, surgical excision, silicone- and/or cryotherapy

Efficacy comparison of several regimens in treating keloids as combined or standalone therapies could provide essential information for selecting appropriate therapy. This study retrospectively evaluated the treatment efficacy of corticosteroid injections, excision, silicone, cryotherapy, or combinations of these for treating keloids. Additionally, the use of corticosteroid injection schemes and combined cryotherapy regimens were analysed.

Retrospective chart analysis was performed on 204 keloids treated patients at the plastic surgery department of the Máxima Medical Centre between 2009 and 2018. The patient's age, gender, treatment, anatomic location, scar aetiology, previous therapy, scar recurrence, additional therapy, and follow-up duration were retrieved. Treatment efficacy was assessed through treatment failure, defined by the recurrence or lack of response. Kaplan–Meier and Cox survival analyses were performed to compare treatment efficacy between the different regimens.

Monotherapies exhibited a significantly higher chance of treatment failure (HR 2.4, 95% CI 1.4–4.2, p<0.05) when compared to combined therapies.

Sporadic corticosteroid injections demonstrated more treatment failure overall (HR 3.5 95% CI 1,6–7,3; p=0.001), but did not differ significantly from injection schemes.

Combined cryotherapy efficacy did not differ significantly from the other combined regimens (HR 1,6 95% CI 0,5–5,1; p=0.401).

Combined therapies exhibited clear superiority over monotherapies. Sporadic corticosteroid injections demonstrated inferior results compared to all other therapies. Combined cryotherapy cases were insufficient, and more data are required for proper assessment. Future prospective assessments of corticosteroid injection schemes and combined regimens are warranted.

Health system interventions to integrate genetic testing in routine oncology services: A systematic review

BACKGROUND

Integration of genetic testing into routine oncology care could improve access to testing. This systematic review investigated interventions and the tailored implementation strategies aimed at increasing access to genetic counselling and testing and identifying hereditary cancer in oncology.

METHODS

The search strategy results were reported using the PRISMA statement and four electronic databases were searched. Eligible studies included routine genetic testing for breast and ovarian cancer or uptake after universal tumour screening for colorectal or endometrial cancer. The titles and abstracts were reviewed and the full text articles screened for eligibility. Data extraction was preformed using a designed template and study appraisal was assessed using an adapted Newcastle Ottawa Scale. Extracted data were mapped to Proctor's et al outcomes and the Consolidated Framework for Implementation Research and qualitatively synthesised.

RESULTS

Twenty-seven studies, published up to May 2020, met the inclusion criteria. Twenty-five studies ranged from poor (72%), fair to good (28%) quality. Most interventions identified were complex (multiple components) such as; patient or health professional education, interdisciplinary practice and a documentation or system change. Forty-eight percent of studies with complex interventions demonstrated on average a 35% increase in access to genetic counselling and a 15% increase in testing completion. Mapping of study outcomes showed that 70% and 32% of the studies aligned with either the service and client or the implementation level outcome and 96% to the process or inner setting domains of the Consolidated Framework for Implementation Research.

CONCLUSION

Existing evidence suggests that complex interventions have a potentially positive effect towards genetic counselling and testing completion rates in oncology services. Studies of sound methodological quality that explore a greater breadth of pre and post implementation outcomes and informed by theory are needed. Such research could inform future service delivery models for the integration of genetics into oncology services.

Family communication about genomic sequencing: A qualitative study with cancer patients and relatives

OBJECTIVE

This study explored family communication about undertaking genomic sequencing, and intentions to communicate pertinent heritable results to family members.

METHODS

Semi-structured interviews were conducted with cancer patients (n = 53) and their relatives (n = 20) who underwent germline genome sequencing or molecular tumor testing. Interviews were audio-recorded, transcribed and analyzed using thematic analysis.

RESULTS

Key themes relevant to family communication about undertaking sequencing included: perceiving family member interest, delaying discussion until results were received, having shared capacity to understand and cope, and having open communication in the family. Intended communication subsequent to receiving results was affected by: disease severity, risk management options, degree of closeness in the family, sense of responsibility, and potential adverse impacts on family. Resource and support needs varied based on the complexity of test results, health professionals' availability, and disease severity. Unique subthemes were identified for specific subgroups.

CONCLUSION

Current findings support the need to assess the impact and resource needs specific to each clinical application of genomic sequencing.

PRACTICE IMPLICATIONS

Increasingly sophisticated and complex clinical genomic sequencing warrants development of family-centered interventions and resources to facilitate preference-sensitive communication about genomic sequencing, including disseminating relevant information to family members.

The association between treatment and systemic inflammation in acromegaly

OBJECTIVE

Acromegaly is characterized by an excess of growth hormone (GH) and insulin like growth-factor 1 (IGF1), and it is strongly associated with cardiovascular diseases (CVD). Both acute and long-lasting pro-inflammatory effects have been attributed to IGF1. Previous results suggest the presence of systemic inflammation in treated patients. Here we assessed the association between treatment of acromegaly, systemic inflammation and vascular function.

DESIGN

Ex vivo cytokine production and circulating inflammatory markers were assessed in peripheral blood from treated and untreated acromegaly patients (N = 120), and compared them with healthy controls. A more comprehensive prospective inflammatory and vascular assessment was conducted in a subgroup of six treatment-naive patients with follow-up during treatment.

RESULTS

Circulating concentrations of VCAM1, E-selectin and MMP2 were higher in patients with uncontrolled disease, whereas the concentrations of IL18 were lower. In stimulated whole blood, cytokine production was skewed towards a more pro-inflammatory profile in patients, especially those with untreated disease. Prospective vascular measurements in untreated patients showed improvement of endothelial function during treatment.

CONCLUSIONS

Acromegaly patients are characterized by a pro-inflammatory phenotype, most pronounced in those with uncontrolled disease. Treatment only partially reverses this pro-inflammatory bias. These findings suggest that systemic inflammation could contribute to the increased risk of CVD in acromegaly patients.

Ultrasound-guided cannulation for medical students

BACKGROUND

There is growing recommendation to integrate ultrasound training into undergraduate medical curricula; with limited evidence of its implementation in the United Kingdom. Peripheral intravenous cannulation (PIVC) often has high failure rates-particularly for patients with difficult vascular access. Ultrasound-guided PIVC (US-PIVC) has been shown to increase the rates of success and may reduce dependence on seniors. Teaching US-PIVC to senior medical students may prove a clinically valuable and feasible means of introducing ultrasound into medical programmes.

METHODS

We initially surveyed 18 doctors to assess their perceptions and experience of ultrasound. Thirty-five final-year medical students took part in a novel US-PIVC course. Students' competence was assessed at the end of the session using an objective assessment. Students' pre- and post-course attitudes and confidence were evaluated using questionnaires.

RESULTS

All doctors surveyed reported difficulty performing PIVC since starting work: 66% on a monthly basis. None of the students (0%) and 11% of the doctors had previously received ultrasound training. By the end of the course, all students 'agreed' or 'strongly agreed' that the session was enjoyable and that they felt confident performing US-PIVC. Thirty-four of 35 participants attained the minimum competence standard. Students' confidence performing PIVC, regardless of ultrasound guidance, increased significantly (p = 0.002) following the session.

DISCUSSION

As ultrasound becomes a more readily available point-of-care technology, it should be considered for inclusion in the undergraduate medical curriculum. Our course appears to be an effective model of teaching US-PIVC to final-year medical students. Similar courses could act as a pragmatic and clinically rewarding means of implementing US-PIVC teaching into the latter years of undergraduate curricula.

Influence of a programme for prevention of early childhood caries on early orthodontic treatment needs

OBJECTIVES

The aim of this prospective birth cohort study was to evaluate the effect of the programme for prevention (PP) of early childhood caries and the resulting need for orthodontic treatment in 8-year-old German children.

MATERIAL AND METHODS

Children who had been enrolled in a caries-risk-related recall system with continuous dental care starting at the time of birth (prevention group, PG) were compared with children of the same birth cohort whose parents decided not to participate in the programme (control group, CG). All children (n = 289) participating in the last PP evaluation at the age of 5 years were invited again and examined by blinded clinicians. Dental caries was scored using the WHO diagnostic criteria expanded to d1-level without radiography. Impressions were taken of children with premature tooth loss to analyse space conditions.

RESULTS

Two hundred twenty-seven children (mean age 8.4 ± 0.6 years; 46.7% female) were examined. Children in the PG (n = 127) showed significantly lower caries prevalence and experience (3.1%, 0.4 ± 1.0 d3-4mft) than children in the CG (37.3%, 3.9 ± 3.5 d3-4mft). Orthodontic analysis found a higher prevalence of premature tooth extraction, followed by a greater extent of space loss in the CG (41.0%; 3.3 ± 4.4 mm) vs. PG (7.9%; 0.4 ± 1.9 mm) and an increase in early orthodontic treatment need (KIG P3, IOTN 5).

CONCLUSIONS

The PP was an effective approach for preventing caries-related premature tooth loss in children and conserving relevant arch length.

CLINICAL RELEVANCE

Children who received continuous dental care starting at the time of birth showed better oral health with less premature loss of deciduous teeth and lower need for orthodontic treatment at the age of 8 years.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00003438, https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00003438.

Preparing the genetic counseling workforce for the future in Australasia

Current genetic counseling students will graduate into a workforce involving more opportunities, diversity, and uncertainty than any previous generation. Preparing the future genetic counseling workforce is a dynamic challenge, both for the profession and for educators. The dominance of the medical model in the state funded Australian healthcare system creates a power imbalance between doctors and other health professionals. As a result, professional regulation to protect the public from harm in line with the United States, the UK, and Canada only became mandatory in 2019. Professional regulation has the additional benefit of enhancing professional standing and autonomy, enabling genetic counselors to help shape the future of genetic health care in Australia and New Zealand. Within this rapidly evolving environment, we are establishing a new Masters' program and building a discipline of genetic counseling, working alongside other allied health professionals. Our program involves synchronous and asynchronous learning, greater accessibility, flexibility and, as we have learned in 2020, reduction in disruption during a global pandemic. In this program, we foreground the inherent knowledge, skills, and values of genetic counseling, shifting the focus from provision of genetic and genomic tests, to educating competent, person-centered, research enabled and culturally safe genetic counselors. As educators, we have a responsibility to prepare students to embrace the uncertainties, challenges, and potential of the genomic era, to seize the many possibilities that lie ahead, and to expand their thinking and vision. We ask our students to be courageous, to step into a deep exploration of their own identity, beliefs, understanding, and experiences of oppression, power, and privilege. We are pushing boundaries, and challenging ourselves and our students to remain always open to possibilities. Equipping students with open eyes and listening ears may be the single most important thing we can do to prepare the genetic counseling workforce of the future to provide the best possible care.

A Prospective Study of Diffusion-weighted Magnetic Resonance Imaging as an Early Prognostic Biomarker in Chemoradiotherapy in Squamous Cell Carcinomas of the Anus

AIMS

The use of diffusion-weighted magnetic resonance imaging (DW-MRI) as a prognostic marker of treatment response would enable early individualisation of treatment. We aimed to quantify the changes in mean apparent diffusion coefficient (ΔADC_mean) between a DW-MRI at diagnosis and on fraction 8-10 of chemoradiotherapy (CRT) as a biomarker for cellularity, and correlate these with anal squamous cell carcinoma recurrence.

MATERIALS AND METHODS

This prospective study recruited patients with localised anal cancer between October 2014 and November 2017. DW-MRI was carried out at diagnosis and after fraction 8-10 of radical CRT. A region of interest was delineated for all primary tumours and any lymph nodes >2 cm on high-resolution T₂-weighted images and propagated to the ADC map. Routine clinical follow-up was collected from Nation Health Service electronic systems.

RESULTS

Twenty-three of 29 recruited patients underwent paired DW-MRI scans. Twenty-six regions of interest were delineated among the 23 evaluable patients. The median (range) tumour volume was 13.6 cm³ (2.8-84.9 cm³). Ten of 23 patients had lesions with ΔADC_mean ≤ 20%. With a median follow-up of 41.2 months, four patients either failed to have a complete response to CRT or subsequently relapsed. Three of four patients with disease relapse had lesions demonstrating ΔADC_mean <20%, the other patient with persistent disease had ΔADC_mean of 20.3%.

CONCLUSIONS

We demonstrated a potential correlation between patients with ΔADC_mean <20% and disease relapse. Further investigation of the prognostic merit of DW-MRI change is needed in larger, prospective cohorts.

Anti-cyclic citrullinated peptide antibodies are associated with radiographic damage but not disease activity in early rheumatoid arthritis diagnosed in 2006-2011

Objective: The discovery of anti-citrullinated protein antibodies (ACPAs) and the introduction of new therapeutic options have had profound impacts on early rheumatoid arthritis (RA) care. Since ACPA status, most widely assessed as reactivity to cyclic citrullinated peptides (CCPs), influences treatment decisions in early RA, we aimed to determine whether anti-CCP remains a predictor of disease activity and radiographic joint damage in more recent 'real-world' early RA. Method: Two observational early RA cohorts from Sweden enrolled patients in 1996-1999 (TIRA-1, n = 239) and 2006-2009 (TIRA-2, n = 444). Clinical and radiographic data and ongoing treatment were prospectively collected up to 3 years. Two other cohorts served as confirmation cohorts (TRAM-1, with enrolment 1996-2000, n = 249; and TRAM-2, 2006-2011, n = 528). Baseline anti-CCP status was related to disease activity, pharmacotherapy, and radiographic joint damage according to Larsen score. Results: In the TIRA-1 cohort, anti-CCP-positive patients had significantly higher 28-joint Disease Activity Score, swollen joint count, C-reactive protein level, and erythrocyte sedimentation rate during follow-up compared with anti-CCP-negative patients. In TIRA-2, no such differences were found, but baseline anti-CCP positivity was associated with higher 3 year Larsen score (5.4 vs 3.5, p = 0.039). In TRAM-2, anti-CCP also predicted radiographic damage (8.9 vs 6.7, p = 0.027), with no significant differences in disease activity. Conclusion: In the early RA cohorts recruiting patients in 2006-2011, baseline anti-CCP positivity was not associated with disease activity over time, but was associated with increased radiographic damage at follow-up. Hence, close radiographic monitoring is warranted in early anti-CCP-positive RA regardless of disease activity.

Advanced cancer patient preferences for receiving molecular profiling results

OBJECTIVE

This study aimed to discern preferences for receiving somatic molecular profiling (MP) results in cancer patients who have given consent to undergo testing.

METHODS

We conducted a mixed-methods study to explore patients' views on which MP results they would like to receive and why. Advanced cancer patients (n = 1299) completed questionnaires after giving consent to participate in a parent genomics study and undergoing MP. A subset of patients (n = 20) participated in qualitative interviews.

RESULTS

Almost all (96%) participants were interested in receiving results which would direct cancer treatment (ie, were actionable). A smaller majority wanted to access results which were not actionable (64%) or were variants of unknown significance (60%). Most (86%) were interested in finding out about germline findings, though not as a priority. Themes identified in interview data were: (a) Cancer is the focus; (b) Trust in clinicians; and (c) Respect for a right not to know.

CONCLUSIONS

The majority of advanced cancer patients undergoing MP prioritised results which would lead to treatment options. They trusted their oncologists to help them navigate the results return process. While there was interest in knowing about other results, this was a lesser priority. Nevertheless, given high levels of interest in receiving all results, ethical aspects of not providing uninformative results requires further research, including a consideration of patient rationales for desiring this information and what health professionals can and should do to support patients in the absence of meaningful information being available.

Who we are, what we do, and how we add value: The role of the genetic counseling 'philosophy of practice' statement in a changing time

As genetics and genomics are integrated into health care and non-genetic health professionals deliver aspects of genetic counseling, it is increasingly important for genetic counselors to be able to define who we are, what we do, and how we add value to client interactions, both on an individual and professional basis. In this paper, we argue that to understand ourselves as individual practitioners and as a profession, we each need to reflect on, write, and constantly review our own philosophy of practice. A philosophy of practice is a dynamic, personal, and reflective statement or narrative that captures the core ideas, values, and beliefs of the individual about their chosen profession, including concrete examples of what this involves in practice. Here, we consider the nature, purpose, and relevance of a philosophy of genetic counseling practice, drawing on examples from professions such as teaching and nursing, where the exercise of writing a philosophy of practice is more established. We demonstrate how and why we have introduced writing a philosophy of practice into our Master of Genetic Counseling program at University of Technology Sydney and consider the possibilities for introducing such practice into professional registration or certification processes. Finally, we offer our own philosophy of genetic counseling practice as an example. As the roles and scope of practice for genetic counselors expand and diversify, it is increasingly important to understand, own, and retain our core values and principles as individual practitioners and as a profession. Ensuring client-centered practice remains at the heart of genetic health care is vital. We encourage all genetic counselors to write, publish, and share their philosophy of practice, adding to our collective professional identity in this time of change and opportunity.

Mainstreaming genetics and genomics: a systematic review of the barriers and facilitators for nurses and physicians in secondary and tertiary care

PURPOSE

Genetic and genomic health information increasingly informs routine clinical care and treatment. This systematic review aimed to identify the barriers and facilitators to integrating genetics and genomics into nurses' and physicians' usual practice (mainstreaming).

METHODS

A search of MEDLINE, EMBASE, CINAHL, and PsycINFO generated 7873 articles, of which 48 were included. Using narrative synthesis, barriers and facilitators were mapped to the Theoretical Domains Framework (TDF).

RESULTS

Barriers were limitations to genetics knowledge and skill, low confidence initiating genetics discussions, lack of resources and guidelines, and concerns about discrimination and psychological harm. Facilitators were positive attitudes toward genetics, willingness to participate in discussions upon patient initiation, and intention to engage in genetics education.

CONCLUSION

Nurses and physicians are largely underprepared to integrate genetic and genomic health information into routine clinical care. Ethical, legal, and psychological concerns surrounding genetic information can lead to avoidance of genetics discussions. The knowledge-practice gap could limit patients' and families' access to vital genetic information. Building the capacity of the current and next generation of nurses and physicians to integrate genetics and genomics into usual clinical practice is essential if opportunities afforded by precision medicine are to be fully realized.

Neoadjuvant radiotherapy in rectal cancer - less is more?

AIM

There is significant international variation in the use of neoadjuvant radiation prior to total mesorectal excision. The MERCURY group advocate selective neoadjuvant chemoradiotherapy (CRT). We have performed a retrospective, single-centre study of patients treated with CRT, where only the circumferential resection margin is threatened, with the aim of identifying whether a more selective approach to CRT provides acceptable local relapse rates (LRRs).

METHOD

All consecutive patients who underwent radical surgery for rectal adenocarcinoma over a 5-year period (2007-2012) in the Oxford University Trust were considered. Electronic hospital systems were reviewed to obtain patient and tumour demographics, treatment and follow-up information. All patients were classified into risk categories according to National Institute for Health and Care Excellence guidance. Data were analysed using Microsoft Excel and R.

RESULTS

Two hundred and seventy-two patients were identified: 123, 89 and 60 in the high-, intermediate- and low-risk categories, respectively. Seventy-nine per cent of those in the high-risk group, 6% in the intermediate and 5% in the low-risk group underwent CRT. The overall 5-year LRR and distant recurrence rate (DRR) were 5.2% and 17.8%, respectively. The 5-year LRR for those who went straight to surgery was 2.0% and for those who had neoadjuvant CRT it was 7.4%. The DRR for these two groups was 8.5% and 18.9%, respectively.

CONCLUSION

Our series demonstrates that the use of CRT only in margin-threatening tumours, results in an exceptionally low LRR for those without margin-threatening disease. In routine clinical care, this strategy can minimize the significant morbidity of multimodal treatment and allow earlier introduction of systemic therapy to minimize distant recurrence.

Comparison of the Results of CAPD Treatment in “Experienced” versus “Inexperienced” Centres in Europe

Five per cent of almost 80,000 living patients with end stage renal failure (ESRF) in Europe were on CAPD on 31st December, 1982. The use of CAPD has grown dramatically since 1977. Centres which reported the use of CAPD to the EDTA Registry were divided into “experienced” and “inexperienced.” Patients treated in “experienced” centres had less peritonitis and spent less time in hospital because of peritonitis. Patient survival amongst those starting treatment in earlier years was worse in the “inexperienced” centres but improved so that it equalled survival in the “experienced” centres in 1982. At 12 months cumulative patient survival in patients commencing CAPD in 1982 was 87% and technique survival exceeded 95%. It appears that there is now a homogenous population of centres with approximately equal expertise.

The Demography of CAPD in Europe

Five per cent of European patients on therapy for end stage renal failure and reported to the EDTA Registry were treated by CAPD on 31st December, 1982. The percentage varied between 12.7% in the United Kingdom to less than 1% in Eastern European countries. In the total area covered by the Registry (population 574 millions) 5.6 patients pmp commenced CAPD during 1982. Commencements reached 18.9 pmp in Switzerland, 17.4 pmp in the United Kingdom and 9.8 pmp in Italy. National programmes of CAPD fulfil different roles in the pattern of RRT and select different populations of patients. Therefore comparisons of the results achieved have not been made.

The unique antimicrobial peptide repertoire of stick insects

The comparative analysis of innate immunity across different insect taxa has revealed unanticipated evolutionary plasticity, providing intriguing examples of immunity-related effector gene expansion and loss. Phasmatodea, the stick and leaf insects, is an order of hemimetabolous insects that can provide insight into ancestral innate immunity genes lost by later insect clades. We injected the stick insect Peruphasma schultei with a mixture of microbial elicitors to activate a strong immune response, followed by RNA-Seq analysis to screen for induced immunity-related effector genes. This revealed a highly diverse spectrum of antimicrobial peptides (AMPs) belonging to the attacin, coleoptericin, defensin, thaumatin, and tachystatin families. In addition, we identified a large group of short, cysteine-rich putative AMPs, some of which were strongly elicited. The immunity-related effector gene repertoire also included c-type and i-type lysozymes and several pattern-recognition proteins, such as proteins that recognize Gram-negative bacteria and peptidoglycans. Finally, we identified 45 hemolymph lipopolysaccharide-binding protein sequences, an unusually large number for insects. Taken together, our results indicate that at least some phasmids synthesize a broad spectrum of diverse AMPs that deserve further in-depth analysis.

Cancer patients' views and understanding of genome sequencing: a qualitative study

BACKGROUND

Little is known about knowledge of, and attitudes towards, genome sequencing (GS) among individuals with a personal history of cancer who decide to undergo GS. This qualitative study aimed to investigate baseline knowledge and attitudes among individuals previously diagnosed with a cancer of likely genetic origin who have consented to GS.

METHODS

Semistructured interviews were conducted with purposively selected participants (n=20) from the longitudinal Psychosocial Issues in Genomic Oncology study, within a month of consenting to GS and prior to receiving any results. Participants were adults with a cancer of likely genetic aetiology who are undertaking GS as part of a larger genetic study.

RESULTS

Analysis identified three main themes: limited understanding of genomics; multifactorial motivation; and complex decision making. While motivations such as obtaining health information about self and family appear to be the main drivers for undertaking GS, these motivations are sometimes based on limited knowledge of the accuracy and utility of GS, creating unrealistic expectations. This in turn can prolong the deliberation process and lead to ongoing decisional conflict.

CONCLUSION

Understanding the degree and nature of patient understanding of GS, as well as their attitudes and decision-making processes, will enable healthcare professionals to better manage patient expectations and appropriately engage and support patients to make an informed decision when pursuing GS.

Who should access germline genome sequencing? A mixed methods study of patient views

Implementation of any new medical test, including germline genome sequencing (GS) to inform cancer risk, should take place only when a test is effective, ethically justifiable and acceptable to a population. Little empirical evidence exists on patient views regarding GS for cancer risk. The aim of this study was to elicit opinions on who should be offered GS and who should pay for it. Participants with a probable genetic basis for their cancer (n = 335) and blood relatives (n = 199) were recruited to undergo GS and invited to complete questionnaires at baseline. A subset (n = 40) also participated in qualitative interviews about their views regarding access to GS to detect cancer risk. Our response rate was 92% for questionnaires and 100% for interviews. Participants expressed high enthusiasm overall for access to GS for those with a family history of cancer and anyone who requested testing, but enthusiasm was lower for universal access, if opting out was possible and finances not an issue. Rationales for these views reflected maximising the sound use of resources. Challenges to introducing community screening via GS to limit cancer burden were raised, including the current limits of science and individual ability to cope with uncertain results. Participants undergoing GS supported cancer risk testing for those with a family history of cancer but were concerned about the challenges of designing and implementing a population-based GS cancer-screening program.

Characterization of coagulase-negative staphylococci from brining baths in Germany

Brining is an important step in cheese making, and using brine baths for this purpose is common practice in German dairies. Time of brining, brine concentration, and composition of the complex and heterogeneous microbiota, including coagulase-negative staphylococci (CNS), contribute to the ripening and taste of cheese. As well as producing staphylococcal enterotoxins, some CNS show antibiotic resistance; therefore, we isolated 52 strains of presumptive CNS from cheese brines from 13 factories in Germany. Species identification by sodA gene sequencing revealed that 50 isolates were CNS: 31 Staphylococcus saprophyticus, 4 Staphylococcus carnosus, 4 Staphylococcus equorum, 3 Staphylococcus sciuri, 2 Staphylococcus hominis, and 2 Staphylococcus warneri. One isolate each was identified as Staphylococcus epidermidis, Staphylococcus pasteurii, Staphylococcus succinus, and Staphylococcus xylosus. Further subtyping of the Staph. saprophyticus isolates to the subspecies level revealed the presence of 6 Staph. saprophyticus ssp. saprophyticus. Using pulsed-field gel electrophoresis with the identified Staph. saprophyticus strains, 12 independent clones were identified, resulting in the exclusion of 18 strains from further testing. In 19 of the remaining 32 CNS isolates, resistance to antibiotics was observed. Resistance was found against oxacillin (17), penicillin (5), and cefoxitin (1). Four isolates expressed resistance to both oxacillin and penicillin. No resistance was found to enrofloxacin, tetracycline, gentamicin, or erythromycin. Then, PCR analysis for antibiotic resistance genes was performed for 22 different genes. Only genes blaZ and bla_TEM were found in 7 isolates. These isolates were selected for challenge tests with different concentrations of lactic acid and NaCl to examine whether expression of antibiotic resistance was influenced by these stressors. An increase in the minimal inhibitory concentration from 0 to 2.0 µg/mL was seen for trimethoprim/sulfamethoxazole only in one isolate of Staph. saprophyticus at an increased lactic acid concentration. Finally, all isolates were tested for genetic determinants (entA, entB, entC, entD, and entE) of the most common staphylococcal enterotoxins; none of these genes were detected. We found no indication for unacceptable risks originating from the isolated CNS.

Patient perspectives on molecular tumor profiling: "Why wouldn't you?"

Aim

This study explored the attitudes of patients with advanced cancer towards MTP and return of results, prior to undergoing genomic testing within a research program.

Methods

Participants were recruited as part of the longitudinal PiGeOn (Psychosocial Issues in Genomics in Oncology) study involving patients with advanced/metastatic solid cancer who had exhausted therapeutic options and who were offered MTP in order to identify cognate therapies. Twenty patients, selected by purposive sampling, were interviewed around the time they gave consent to MTP. Interviews were audio recorded, transcribed and analysed using thematic analysis. Themes identified in the transcripts were cross-validated via qualitative responses to the PiGeOn study survey (n = 569; 63%).

Results

All interviewed participants gave consent to MTP without reservation. Three themes were identified and further supported via the survey responses: (1) Obvious agreement to participate, primarily because of desire for new treatments and altruism. (2) The black box – while participant knowledge of genomics was generally poor, faith in their oncologists and the scientific process encouraged them to proceed with testing; and (3) Survival is the priority – receiving treatment to prolong life was the priority for all participants, and other issues such as identification of a germline variant were generally seen as ancillary.

Conclusion

Having advanced cancer seemed to abrogate any potential concerns about MTP. Participants valued the research for varied reasons, but this was secondary to their priority to survive. While no negative attitudes toward MTP emerged, limitations in understanding of genomics were evident.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5920-x) contains supplementary material, which is available to authorized users.

Genetics in palliative care: too much to ask?

People with an inherited condition who receive palliative care may be missing out on the opportunity to store a DNA sample for future use by their families and offspring. A DNA sample from a family member affected with an inherited condition can help at-risk relatives to access accurate risk assessment and, where relevant, enhanced surveillance and risk-reducing measures. As genetic and genomic testing becomes increasingly important in all aspects of healthcare, health professionals specialising in palliative care will be asked to communicate about family history risk and testing. This article highlights the importance of discussing genetics and genomics issues for people receiving palliative care, their families and the health professionals caring for them.

Attitude towards and factors affecting uptake of population-based BRCA testing in the Ashkenazi Jewish population: a cohort study

OBJECTIVE

To evaluate factors affecting unselected population-based BRCA testing in Ashkenazi Jews (AJ).

DESIGN

Cohort-study set within recruitment to the GCaPPS trial (ISRCTN73338115).

SETTING

North London AJ population.

POPULATION OR SAMPLE

Ashkenazi Jews women/men >18 years, recruited through self-referral.

METHODS

Ashkenazi Jews women/men underwent pre-test counselling for BRCA testing through recruitment clinics (clusters). Consenting individuals provided blood samples for BRCA testing. Data were collected on socio-demographic/family history/knowledge/psychological well-being along with benefits/risks/cultural influences (18-item questionnaire measuring 'attitude'). Four-item Likert-scales analysed initial 'interest' and 'intention-to-test' pre-counselling. Uni- and multivariable logistic regression models evaluated factors affecting uptake/interest/intention to undergo BRCA testing. Statistical inference was based on cluster robust standard errors and joint Wald tests for significance. Item-Response Theory and graded-response models modelled responses to 18-item questionnaire.

MAIN OUTCOME MEASURES

Interest, intention, uptake, attitude towards BRCA testing.

RESULTS

A total of 935 individuals (women = 67%/men = 33%; mean age = 53.8 (SD = 15.02) years) underwent pre-test genetic-counselling. During the pre-counselling, 96% expressed interest in and 60% indicated a clear intention to undergo BRCA testing. Subsequently, 88% opted for BRCA testing. BRCA-related knowledge (P = 0.013) and degree-level education (P = 0.01) were positively and negatively (respectively) associated with intention-to-test. Being married/cohabiting had four-fold higher odds for BRCA testing uptake (P = 0.009). Perceived benefits were associated with higher pre-counselling odds for interest in and intention to undergo BRCA testing. Reduced uncertainty/reassurance were the most important factors contributing to decision-making. Increased importance/concern towards risks/limitations (confidentiality/insurance/emotional impact/inability to prevent cancer/marriage ability/ethnic focus/stigmatisation) were significantly associated with lower odds of uptake of BRCA testing, and discriminated between acceptors and decliners. Male gender/degree-level education (P = 0.001) had weaker correlations, whereas having children showed stronger (P = 0.005) associations with attitudes towards BRCA testing.

CONCLUSIONS

BRCA testing in the AJ population has high acceptability. Pre-test counselling increases awareness of disadvantages/limitations of BRCA testing, influencing final cost-benefit perception and decision-making on undergoing testing.

TWEETABLE ABSTRACT

BRCA testing in Ashkenazi Jews has high acceptability and uptake. Pre-test counselling facilitates informed decision-making.

Is There a Role for an 18F-fluorodeoxyglucose-derived Biological Boost in Squamous Cell Anal Cancer?

AIMS

To investigate the potential role for a biological boost in anal cancer by assessing whether subvolumes of high 18F-fluorodeoxyglucose (FDG) avidity, identified at outset, are spatially consistent during a course of chemoradiotherapy (CRT).

MATERIALS AND METHODS

FDG-positron emission tomography (FDG-PET) scans from 21 patients enrolled into the ART study (NCT02145416) were retrospectively analysed. In total, 29 volumes including both primary tumours and involved nodes >2 cm were identified. FDG-PET scans were carried out before treatment and on day 8 or 9 of CRT. FDG subvolumes were created using a percentage of maximum FDG avidity at thresholds of 34%, 40%, 50%, on the pre-treatment scans, and 70% and 80% on the subsequent scans. Both FDG-PET scans were deformably registered to the planning computed tomography scan. The overlap fraction and the vector distance were calculated to assess spatial consistency. FDG subvolumes for further investigation had an overlap fraction >0.7, as this has been defined in previous publications as a 'good' correlation.

RESULTS

The median overlap fractions between the diagnostic FDG-PET subvolumes 34%, 40% and 50% of maximum standardised uptake value (SUVmax) and subsequent FDG-PET subvolumes of 70% of SUVmax were 0.97, 0.92 and 0.81. The median overlap fraction between the diagnostic FDG-PET subvolumes 34%, 40% and 50% and subsequent FDG-PET subvolumes of 80% were 1.00, 1.00 and 0.92. The median (range) vector distance values between diagnostic FDG-PET subvolumes 34%, 40% and 50% and subsequent FDG-PET subvolumes of 80% were 0.74 mm (0.19-2.94) 0.74 mm (0.19-3.39) and 0.71 mm (0.2-3.29), respectively. Twenty of 29 volumes (69.0%) achieved a threshold > 0.7 between the FDG 50% subvolume on the diagnostic scan and the FDG 80% subvolume on the subsequent scan.

CONCLUSION

FDG-avid subvolumes identified at baseline were spatially consistent during a course of CRT treatment. The subvolume of 50% of SUVmax on the pre-treatment scan could be considered as a potential target for dose escalation.

Erratum to: Three-dimensional thoracoscopic vertebral body replacement at the thoracolumbar junction

Erratum to:Oper Orthop Traumatol 2018 https://doi.org/10.1007/s00064-018-0559-3 The article was wrongly published under the article type "Review". Please note that the article is an "Original Paper".The publisher apologizes to authors and ….

Staphylococcus aureus versus Staphylococcus epidermidis in periprosthetic joint infection-Outcome analysis of methicillin-resistant versus methicillin-susceptible strains

Periprosthetic joint infections (PJIs) are a major complication in total joint arthroplasty. Staphylococcus aureus and coagulase-negative staphylococci are known to cause the majority of all PJIs. This study aimed to analyze the eradication rates of S. aureus and S. epidermidis with methicillin susceptibility and methicillin resistance in a 2-stage therapy algorithm. Seventy-four patients with PJI caused by methicillin-resistant S. aureus (MRSA), methicillin-resistant coagulase-negative staphylococci (MRSE), methicillin-susceptible S. aureus (MSSA), and methicillin-susceptible coagulase-negative staphylococci (MSSE) were included, and the outcome was analyzed retrospectively. After a minimal follow-up of 2 years, n = 56 patients (75.7%) were definitively free of infection. The analysis revealed significant differences between the groups, with eradication rates as follows: MSSA (92.6%), MSSE (95.2%), MRSA (80%), and MRSE (54.2%). MRSE showed a significantly lower rate of patients graded as "definitively free of infection" as compared to patients with infections caused by MSSA, MSSE, and MRSA.

Three-dimensional thoracoscopic vertebral body replacement at the thoracolumbar junction

OBJECTIVE

The aim is to stabilize the thoracolumbar spine with a thoracoscopically implanted vertebral body replacement (VBR). To improve intraoperative depth perception and orientation, implantation is performed under three-dimensional (3D) thoracoscopic vision.

INDICATIONS

Vertebral burst fractures at the thoracolumbar junction (A4 AOSpine classification), pseudarthrosis, and posttraumatic instability with increasing kyphosis.

CONTRAINDICATIONS

Severe pulmonary dysfunctions, pulmonary or thoracic infections, previous thoracic surgery, and pulmonary adhesions.

SURGICAL TECHNIQUE

The patient is lying in a right lateral decubitus position. Localization of the fractured vertebra. Minimally invasive transthoracic approach. Perform single lung ventilation and insert the 3D thoracoscope two intercostal spaces above the working portal. Utilization of special binocular glasses for 3D vision of the operation field and secure resection of the fractured vertebra. Measurement of the bony defect and insertion of the expandable cage. Control of correct cage position under fluoroscopy. Insertion of a chest tube and inflate the left lung.

POSTOPERATIVE MANAGEMENT

Chest × ray Remove chest tube when output is <500 ml/24 h Early mobilization on the ward 6 weeks no weight-bearing >5 kg RESULTS: Between 2012 and 2017, 12 patients received a VBR under 3D thoracoscopic vision. After a mean follow up of 26 months, no cage dislocation was noticed and all patients recovered from the initial back pain. Complications were notable in two cases (17%) with a small pneumothorax after removal of the chest tube and postoperative pneumonia in one patient (8%). All responded to conservative treatment. Revision surgery was not necessary.

Current detection rates and time-to-detection of all identifiable BRCA carriers in the Greater London population

BACKGROUND

BRCA carrier identification offers opportunities for early diagnoses, targeted treatment and cancer prevention. We evaluate BRCA- carrier detection rates in general and Ashkenazi Jewish (AJ) populations across Greater London and estimate time-to-detection of all identifiable BRCA carriers.

METHODS

BRCA carrier data from 1993 to 2014 were obtained from National Health Service genetic laboratories and compared with modelled predictions of BRCA prevalence from published literature and geographical data from UK Office for National Statistics. Proportion of BRCA carriers identified was estimated. Prediction models were developed to fit BRCA detection rate data. BRCA carrier identification rates were evaluated for an 'Angelina Jolie effect'. Maps for four Greater London regions were constructed, and their relative BRCA detection rates were compared. Models developed were used to predict future time-to-identify all detectable BRCA carriers in AJ and general populations.

RESULTS

Until 2014, only 2.6% (3072/111 742 estimated) general population and 10.9% (548/4985 estimated) AJ population BRCA carriers have been identified in 16 696 608 (AJ=190 997) Greater London population. 57% general population and 54% AJ mutations were identified through cascade testing. Current detection rates mirror linear fit rather than parabolic model and will not identify all BRCA carriers. Addition of unselected ovarian/triple-negative breast cancer testing would take >250 years to identify all BRCA carriers. Doubling current detection rates can identify all 'detectable' BRCA carriers in the general population by year 2181, while parabolic and triple linear rates can identify 'detectable' BRCA carriers by 2084 and 2093, respectively. The linear fit model can identify 'detectable' AJ carriers by 2044. We did not find an Angelina Jolie effect on BRCA carrier detection rates. There was a significant difference in BRCA detection rates between geographical regions over time (P<0.001).

CONCLUSIONS

The majority of BRCA carriers have not been identified, missing key opportunities for prevention/earlier diagnosis. Enhanced and new strategies/approaches are needed.

Fluid collection bags pose a threat for bacterial contamination in primary total hip arthroplasty: a prospective, internally controlled, non-blinded trial

INTRODUCTION

Surgical equipment, and especially the so-called 'splash basins' that are used intraoperatively, are a potential source of bacterial contamination in primary total hip arthroplasty (THA). With this risk in mind, many commercially available draping kits include plastic bags that can be used to collect fluid or to temporarily store instruments. Following this rationale, we hypothesised that first: the fluid collection bags are a potential reservoir of bacteria and second: there is a time dependency for bacterial contamination.

MATERIALS AND METHODS

After ethics approval, we investigated in a prospective, internally controlled, non-blinded trial 43 patients who received primary THA. At the beginning of the surgery, we took deep, representative, intracapsular tissue samples, which served as negative controls. At the end of surgery, tissue samples were taken from the bottom of the 'fluid collection bag' for microbiological analysis.

RESULTS

All 86 control samples were negative. Out of the samples taken from the bags, a pathogen could be detected in four patients (9.3%). All pathogens were detected after a surgery time lasting longer than 90 min.

CONCLUSION

We were able to show that fluid collection bags are a potential reservoir for bacteria in THA when surgery time was greater than a 90-min threshold. Our data suggest that the risks from fluid collection bags outweigh the advantages of using them. Therefore, we recommend against the use of fluid collection bags intraoperatively in primary THA.

Borealis-1: a randomized, first-line, placebo-controlled, phase II study evaluating apatorsen and chemotherapy for patients with advanced urothelial cancer

Background

Five-year survival of patients with inoperable, advanced urothelial carcinoma treated with the first-line chemotherapy is 5%-15%. We assessed whether the Hsp27 inhibitor apatorsen combined with gemcitabine plus cisplatin (GC) could improve overall survival (OS) in these patients.

Patients and methods

This placebo-controlled, double-blind, phase II trial randomized 183 untreated urothelial carcinoma patients (North America and Europe) to receive GC plus either placebo (N = 62), 600 mg apatorsen (N = 60), or 1000 mg apatorsen (N = 61). In the experimental arm, treatment included loading doses of apatorsen followed by up to six cycles of apatorsen plus GC. Patients receiving at least four cycles could continue apatorsen monotherapy as maintenance until progression or unacceptable toxicity. The primary end point was OS.

Results

OS was not significantly improved in the single or combined 600- or 1000-mg apatorsen arms versus placebo [hazard ratio (HR), 0.86 and 0.90, respectively]. Exploratory study of specific statistical modeling showed a trend for improved survival in patients with baseline poor prognostic features treated with 600 mg apatorsen compared with placebo (HR = 0.72). Landmark analysis of serum Hsp27 (sHsp27) levels showed a trend toward survival benefit for poor-prognosis patients in 600- and 1000-mg apatorsen arms who achieved lower area under the curve sHsp27 levels, compared with the placebo arm (HR = 0.45 and 0.62, respectively). Higher baseline circulating tumor cells (≥5 cells/7.5 ml) was observed in patients with poor prognosis in correlation with poor survival. Treatment-emergent adverse events were manageable and more common in both apatorsen-treatment arms.

Conclusions

Even though apatorsen combined with standard chemotherapy did not demonstrate a survival benefit in the overall study population, patients with poor prognostic features might benefit from this combination. Serum Hsp27 levels may act as a biomarker to predict treatment outcome. Further exploration of apatorsen in poor-risk patients is warranted.

The PiGeOn project: protocol of a longitudinal study examining psychosocial and ethical issues and outcomes in germline genomic sequencing for cancer

Background

Advances in genomics offer promise for earlier detection or prevention of cancer, by personalisation of medical care tailored to an individual’s genomic risk status. However genome sequencing can generate an unprecedented volume of results for the patient to process with potential implications for their families and reproductive choices. This paper describes a protocol for a study (PiGeOn) that aims to explore how patients and their blood relatives experience germline genomic sequencing, to help guide the appropriate future implementation of genome sequencing into routine clinical practice.

Methods

We have designed a mixed-methods, prospective, cohort sub-study of a germline genomic sequencing study that targets adults with cancer suggestive of a genetic aetiology. One thousand probands and 2000 of their blood relatives will undergo germline genomic sequencing as part of the parent study in Sydney, Australia between 2016 and 2020. Test results are expected within12–15 months of recruitment. For the PiGeOn sub-study, participants will be invited to complete surveys at baseline, three months and twelve months after baseline using self-administered questionnaires, to assess the experience of long waits for results (despite being informed that results may not be returned) and expectations of receiving them. Subsets of both probands and blood relatives will be purposively sampled and invited to participate in three semi-structured qualitative interviews (at baseline and each follow-up) to triangulate the data. Ethical themes identified in the data will be used to inform critical revisions of normative ethical concepts or frameworks.

Discussion

This will be one of the first studies internationally to follow the psychosocial impact on probands and their blood relatives who undergo germline genome sequencing, over time. Study results will inform ongoing ethical debates on issues such as informed consent for genomic sequencing, and informing participants and their relatives of specific results. The study will also provide important outcome data concerning the psychological impact of prolonged waiting for germline genomic sequencing. These data are needed to ensure that when germline genomic sequencing is introduced into standard clinical settings, ethical concepts are embedded, and patients and their relatives are adequately prepared and supported during and after the testing process.

The PiGeOn project: protocol for a longitudinal study examining psychosocial, behavioural and ethical issues and outcomes in cancer tumour genomic profiling

Background

Genomic sequencing in cancer (both tumour and germline), and development of therapies targeted to tumour genetic status, hold great promise for improvement of patient outcomes. However, the imminent introduction of genomics into clinical practice calls for better understanding of how patients value, experience, and cope with this novel technology and its often complex results. Here we describe a protocol for a novel mixed-methods, prospective study (PiGeOn) that aims to examine patients’ psychosocial, cognitive, affective and behavioural responses to tumour genomic profiling and to integrate a parallel critical ethical analysis of returning results.

Methods

This is a cohort sub-study of a parent tumour genomic profiling programme enrolling patients with advanced cancer. One thousand patients will be recruited for the parent study in Sydney, Australia from 2016 to 2019. They will be asked to complete surveys at baseline, three, and five months. Primary outcomes are: knowledge, preferences, attitudes and values. A purposively sampled subset of patients will be asked to participate in three semi-structured interviews (at each time point) to provide deeper data interpretation. Relevant ethical themes will be critically analysed to iteratively develop or refine normative ethical concepts or frameworks currently used in the return of genetic information.

Discussion

This will be the first Australian study to collect longitudinal data on cancer patients’ experience of tumour genomic profiling. Findings will be used to inform ongoing ethical debates on issues such as how to effectively obtain informed consent for genomic profiling return results, distinguish between research and clinical practice and manage patient expectations. The combination of quantitative and qualitative methods will provide comprehensive and critical data on how patients cope with ‘actionable’ and ‘non-actionable’ results. This information is needed to ensure that when tumour genomic profiling becomes part of routine clinical care, ethical considerations are embedded, and patients are adequately prepared and supported during and after receiving results.

Trial registration

Not required for this sub-study, parent trial registration ACTRN12616000908437.