Barriers to management of diabetes foot ulcer: Experiential note from a setting with free medical services

The imperative need for behavioral agreement to overcome barriers of self-management of diabetes foot complication was recently articulated. A few journals have done parallel publications, which thereby stresses the significance of the issue. This article is to add to the "Overcoming barriers to self-management: the person-centred diabetes foot behavioural agreement". It presents experiential note with four tabulated cases of clients who have access to free state-of-the-art medical service; and non-adherence as a barrier to self-management is not due to affordances. It is to draw attention to the deliberately non-adherent patients where behavioral agreement process should be really driven by the client as in the real context of person-centered therapy.

Highly multimodal structure of high topological charge extreme ultraviolet vortex beams

Optical beams carrying orbital angular momentum are a very active field of research for their prospective applications, especially at short wavelengths. We consider here such beams produced through high-harmonic generation (HHG) in a rare gas and analyze the characterization of their high-charge vortex structure by an extreme ultraviolet Hartmann wavefront sensor. We show that such HHG beams are generally composed of a set of numerous vortex modes. The sensitivity of the intensity and phase of the HHG beam to the infrared laser aberrations is investigated using a deformable mirror.

Impact of the size of the lesion in prenatal neural tube defect repair on imaging, neurosurgical and motor outcomes: a retrospective cohort study

OBJECTIVES

(1) To compare brain findings between large and non-large neural tube defect (NTD); (2) to evaluate the impact of large lesion on the surgical parameters; (3) to study any associations between the size of the lesions and brain findings 6 weeks postoperatively and neurological short-term outcomes.

DESIGN

Retrospective cohort study.

SETTING

Texas Children's Hospital, between 2011 and 2018.

POPULATION

Patients who underwent prenatal NTD repair.

METHODS

Large lesion was defined when the lesion's surface was >75th centile of our cohorts' lesions.

MAIN OUTCOME MEASURES

Time of referral: ventriculomegaly and anatomical level of the lesion; surgery: duration and need for relaxing incisions. 6 weeks postoperative: hindbrain herniation (HBH) and ventriculomegaly. After delivery: dehiscence, need for hydrocephalus treatment and motor function.

RESULTS

A total of 99 patients were included, 25 of whom presented with large lesions. Type of lesion and ventriculomegaly were comparable between individuals with large and non-large lesions. Individuals with large lesions were associated with increased need for relaxing incisions by 5.4 times (95% CI 1.3-23.2, P = 0.02). Six weeks postoperatively, having a large lesion decreased by ten times the likelihood of having a postoperative reversal of HBH (odds ratio = 0.1, 95% CI 0.1-0.4, P < 0.01). At birth, larger lesions increased the risk for repair dehiscence by 6.1 times (95% CI 1.6-22.5, P < 0.01) and the risk of dehiscence or leakage of cerebrospinal fluid at birth by 5.5 times (95% CI 1.6-18.9, P < 0.01).

CONCLUSION

Prenatal repair of patients with large NTD presents a lower proportion of HBH reversal 6 weeks after the surgery, a higher risk of dehiscence and a higher need for postnatal repair.

TWEETABLE ABSTRACT

Evaluation of the size of fetal NTD can predict adverse neurological outcomes after prenatal NTD repair.

AB1353-HPR EMPOWERING LEARNERS TO “OWN” THEIR PERFORMANCE: PRESENTING EDUCATIONAL PERFORMANCE DATA BACK TO LEARNERS AS A COMPONENT OF AND RATIONALE FOR SUBSEQUENT EDUCATION

Background:

Beginning in 2016, RMEI created multiple accredited online education focused on RA and designed for rheumatologists. In 2018, the educational scope expanded to include live meetings, starting with a symposium at EULAR. For all programming from 2016-18 (6 courses, in both live and online settings), educational content was developed based on performance data from the previous RA courses. During the 2019 EULAR symposium, we presented the outcomes findings - from both the 2018 symposium and online courses – to the assembled rheumatologists, identifying ongoing educational gaps observed in their specialty population. The rationale: to create continuity between symposia over time by demonstrating incremental improvements and continuing areas of need, while also endowing learners with a greater sense of ownership and investment in forthcoming educational content.

Objectives:

To evaluate the impact of presenting learner’s educational performance data to them before education addressing persistent gaps identified in their performance the year prior.

Methods:

Data collected during the 2018 EULAR symposium was analyzed to understand the underlying drivers impacting poor performance in an identified area of ongoing educational need (cycling versus switching TNF inhibitors). A linear regression model was run including all non-related curriculum, demographic, and evaluation questions as possible drivers against those related low-scoring (at Post-Test) curriculum questions. The content of RMEI’s 2019 symposium at EULAR was developed to address the identified significant drivers to improve population proficiency in cycling versus switching. In addition to developing content based on the above findings, that data was also presented to learners in poster format prior to their participation in the 2019 symposium. During the period between on-site registration and the start of the symposium, attendees had the opportunity to explore data-driven insights, via audio-guided posters located around the meeting room. These insights included discussion of 2018 data analysis, identified drivers of poor performance, introduced the iterative data-driven methodology employed, and rationale behind content development for the 2019 symposium. At the conclusion of the 2019 symposium learners were asked to describe the impact/relevance of being presented with their performance data, their intention of incorporating course content into practice, and what specifically they intended to change.

Results:

Data was collected on 135 clinicians (primarily physicians who actively treat patients with rheumatoid arthritis) who attended, and participated in, the symposium. With specific regard to the impact of seeing their own data presented back to them, 80% reported that seeing the learner data from the 2018 symposium enhanced their current learning experience. Further, 86% reported that they intended to incorporate course content into their clinical practice. Specifically, this population reported an intent to change their treatment approach and patient education practices.

Conclusion:

Education is only as effective as the degree to which the audience is engaged. While year over year data from 2016 through 2018 demonstrated that an iterative approach facilitated the meaningful and necessary reinforcement of challenging concepts, learners in prior years were not aware of the methodological underpinnings of the educational offerings. Presenting this population with findings derived from their performance - as a rationale for the education they were about to participate in proved a compelling motivator for active learner engagement, and may have had a positive influence on the degree to which learners implemented course content into their clinical practice.

Disclosure of Interests:

None declared

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

Generation of nonlinear internal waves by flow over topography: Rotational effects

We use the forced Ostrovsky equation to investigate the generation of internal waves excited by a constant background current flowing over localized topography in the presence of background rotation. As is now well known in the absence of background rotation, the evolution scenarios fall into three cases, namely subcritical, transcritical, and supercritical. Here an analysis of the linearized response divides the waves into steady and unsteady waves. In all three cases, steady waves occur downstream but no steady waves can occur upstream, while unsteady waves can arise upstream only when there is a negative minimum of the group velocity. The regions occupied by the steady and unsteady waves are determined by their respective group velocities. When the background current is increased, the wave number of the steady waves decreases. In addition, the concavity (canyon or sill), the topographic width, and the relative strength of the rotation play an important role in the generation mechanism. Nonlinear effects modulate the wave amplitude and lead to the emergence of coherent wave packets. All these findings are confirmed by numerical simulations.

The Regulation of Reactive Neuroblastosis, Neuroplasticity, and Nutraceuticals for Effective Management of Autism Spectrum Disorder

Autism spectrum disorder (ASD) encompasses a cluster of neurodevelopmental and genetic disorders that has been characterized mainly by social withdrawal, repetitive behavior, restricted interests, and deficits in language processing mainly in children. ASD has been known to severely impair behavioral patterns and cognitive functions including learning and memory due to defects in neuroplasticity. The biology of the ASD appears to be highly complex and heterogeneous, and thus, finding a therapeutic target for autism remains obscure. There has been no complete prevention or disease-modifying cure for this disorder. Recently, individuals with autism have been characterized by reactive neurogenesis, obstructions in axonal growth, heterotopia, resulting from dysplasia of neuroblasts in different brain regions. Therefore, it can be assumed that the aforementioned neuropathological correlates seen in the autistic individuals might originate from the defects mainly in the regulation of neuroblasts in the developing as well as adult brain. Nutrient deficiencies during early brain development and intake of certain allergic foods have been proposed as main reasons for the development of ASD. However, the integrated understanding of neurodevelopment and functional aspects of neuroplasticity working through neurogenesis in ASD is highly limited. Moreover, neurogenesis at the level of neuroblasts can be regulated by nutrition. Hence, defects in neuroblastosis underlying the severity of autism potentially could be rectified by appropriate implementation of nutraceuticals.

P2272Determinants of left ventricular ATP availability measured in vivo and ex vivo in patients with severe aortic stenosis: correlation of creatine kinase activity with LVEF and ATP diffusion distance

Introduction

The transition to systolic failure in severe aortic stenosis (AS) increases mortality. There are currently no reliable markers of transition, and the guideline LVEF <50% threshold for intervention in asymptomatic severe AS does not capture all subjects at increased risk. In animal models, reduced ATP delivery capacity through creatine kinase (CK) is important, with modest increases in CK capacity conferring cardioprotection. ATP may also diffuse (independent of CK) from mitochondria to the contractile site. We have performed the first human study to test whether ATP diffusion distance relates to CK activity and whether CK activity is reduced in low LVEF severe AS.

Methods

19 patients with severe AS, LVEF ≥55% (AS-pEF, mean±SD LVEF 63±5%, mean gradient 48±14 mmHg) and 10 with severe AS, LVEF <55% (AS-rEF, LVEF 42±8%, mean gradient 32±11) underwent 31P-MRS for CK rate constant (kf) and phosphocreatine/ATP (PCr/ATP) ratio, and MRI for LV volumes. LV biopsies were taken during AVR and analysed for CK total activity, CK isoforms, total creatine, and citrate synthase (CS) activity. 9 biopsies also underwent serial block face scanning electron microscopy and mitochondria-sarcomere 3D distance distributions were plotted. Results were compared to 24 controls (LVEF 61±4%), of which 4 had LV biopsy (3 severe MS, 1 LA myxoma, MS-pEF). Surgical patients had flow-limiting atheroma excluded with invasive angiography and prior myocardial infarction excluded with late gadolinium enhancement MRI.

Results

When compared to controls, both CK total activity and CS activity were lower in AS-pEF (by 27% and 23% respectively, both p<0.05, Panels A-B). Although PCr/ATP reduced in AS-pEF (by 20%, p<0.001, panel C), kf (panel D) and CK flux estimated by kf × total creatine were not different. CK-MB expression reduced in AS-pEF (19 vs 27% of total CK, p=0.003), reflecting compensatory increases in CK-MM (p=0.26) and CK-BB (p=0.18) in the face of reduced CK activity.

AS-rEF was associated with further reduction in both CK and CS activities (by 32% and 22% respectively, both p<0.05, Panels A-B), but no differences in PCr/ATP, CK kf or relative CK isozyme expression were seen. There were no significant between-group differences in total creatine (Panel E). Overall this suggests that CK reserve and oxidative capacity potentially reduce in pressure overload, with further falls commensurate with systolic dysfunction.

When median mitochondria-sarcomere ATP diffusion distances were plotted against CK total activity a strong positive correlation was observed (r=0.86, p=0.003, Panel F). This suggests a compensatory reduction in diffusion distance develops when CK activity falls.

Conclusions

Transition to failure in severe AS is associated with lower oxidative capacity and maximal ATP delivery capacity through CK. Despite compensatory falls in ATP diffusion distance and altered CK isozyme expression, these changes may underlie susceptibility to EF decline in AS.

Acknowledgement/Funding

British Heart Foundation Clinical Research Training Fellowship (FS/15/80/31803) and Programme Grant (RG/18/12/34040).

C-42 Is “Clinical Impairment” Normative in College Populations? Identifying Base Rates of Self-Reported Impairment in a Non-Treatment Seeking Population

Objective

Individuals presenting with concerns of Attention Deficit Hyperactivity Disorder (ADHD) report impairment and may seek academic or disability accommodations related to perceived impairment. Problematically, the legal definition of impairment remains poorly understood by clinicians, and there is little consensus regarding credibility of self-reported impairment. Furthermore, many impairments reported by individuals seeking evaluation for ADHD appear to be general and non-specific, but base rates of reports of these impairments in non-treatment seeking populations remain unclear. We examined base rates of impairment associated with ADHD in a sample of non-treatment seeking college students.

Method

Participants were undergraduate students who completed online surveys (N = 175). Participants who failed measures of validity, reported a past diagnosis of ADHD, or endorsed clinically significant symptoms of ADHD were excluded from analyses (final N = 89). Participants largely identified as white (88.8%) and female (85.4). Participants completed measures of impairment (Barkley Functional Impairment Scale) and ADHD symptoms (Conners’ Adult Attention Rating Scale). Base rates of clinically significant impairment among this sample were analyzed.

Results

Clinically significant levels of impairment were reported at high levels within the following categories; at home (15.1%), interacting with strangers (13.5%) and friends (20.2%), performing daily self-care (7.9%), and managing health (12.4%).

Conclusions

Base rates of clinically significant self-reported impairment are high among a non-clinical, non-treatment seeking sample of college students without ADHD symptoms. Results raise questions about the validity of self-reported impairment in diagnostic decision making, suggesting that experiences of difficulty in these areas may be normative among college populations and not specific to ADHD.

A-82 Neuropsychological Assessment in the Age of Technology: Comparing Traditional Paper versus Electronic Administration

Objective

As society becomes more interconnected with technology, it is important to examine how traditional “paper and pencil” administered neuropsychological tests can be utilized in digital electronic forms (e.g., computers, touch screen tablets, and smartphones). Literature has shown somewhat mixed outcomes for the validity of computerized tests. Gathering data electronically has been found to reduce human error in both test administration and in data collection itself. Digitizing carries benefits in the research field where electronic administration may make it possible to gather data on a larger scale numerically and geographically. However, in some conversions to digital versions of a task, changes may be made to the stimuli and procedure that might seemingly be benign, but could activate different cognitive responses, potentially compromising construct validity. This study examined the comparability of paper and electronic forms of the Stroop task, which is used widely and has been previously validated in paper form.

Method

Electronic Stroop tests were examined for concurrent validity with a paper version. Two touch-screen based apps were examined: BrainBaseline for the iPad and EncephalApp for smartphone. Young and older adults (n = 58) completed paper and an electronic version of the Stroop.

Results

Correlation analyses revealed a significant, but modest relationship between paper Stroop and the BrainBaseline version (r = .54; p = .001), while the EncephalApp correlation was non-significant (r = .44; p = .18).

Conclusions

These results need to be verified in a larger sample, but the implication is that some paper and electronic versions of cognitive tests are not necessarily interchangeable, and caution should be used.

Genetic reprogramming of somatic cells into neuroblasts through a co-induction of the doublecortin gene along the Yamanaka factors: A promising approach to model neuroregenerative disorders

Neural stem cell (NSC) mediated adult neurogenesis represents the regenerative plasticity of the brain. The functionality of the neurogenic process appears to be operated by neuroblasts, the multipotent immature neuronal population of the adult brain. While neuroblasts have been realized to play a major role in synaptic remodeling and immunogenicity, neurodegenerative disorders have been characterized by failure in the terminal differentiation, maturation, integration and survival of newborn neuroblasts. Advancement in understanding the impaired neuroregenerative process along the neuropathological conditions has currently been limited by lack of an appropriate experimental model of neuroblasts. The genetic reprogramming of somatic cells into pluripotent state offers a potential strategy for the experimental modeling of brain disorders. Thus, the induced pluripotent stem cell (iPSC) based direct reprogramming of somatic cells into neuroblasts would represent a potential tool to understand the regenerative biology of the adult brain. Therefore, this concise article discusses the significance of iPSCs, the functional roles of neuroblasts in the adult brain and provides a research hypothesis for the direct reprogramming of somatic cells into neuroblasts through the co-induction of a potential proneurogenic marker, the doublecortin (DCX) gene along with the Yamanaka factors. The proposed cellular model of adult neurogenesis may provide us with further insights into neuropathogenesis of many neurodegenerative disorders and will provide a potential experimental platform for diagnostic, drug discovery and regenerative therapeutic strategies.

Incarcerated paraesophageal hernia complicated by pancreatic damage and unusual comorbidity: Two retrospective case series

•

We present two cases of paraesophageal hernia that both needed total gastrectomy due to gangrene.

•

Both patients had clinical relevant comorbidities, respectively trisomy 21 and hereditary spastic paresis.

•

Due to compression from the dilated stomach one of the patients developed ischemia of the pancreas with leakage of peptidases which in turn caused anastomotic dehisence and intraabdominal abscess.

•

The pancreatic damage and anastomotic leakage was treated conservatively with repeated stenting and percutaeous drainage.

•

Immediate diagnosis and treatment for incarcerated paraesophageal hernias are vital to reduce morbidity and mortality.

Introduction: About 1% of paraesophageal hernias (PEH) require emergency surgery due to obstruction or gangrene. We present two complicated cases of incarcerated PEH.

Presentation of cases: A patient aged 18 with trisomy 21 was admitted after four days of vomiting and epigastric pain. CT scan revealed a large PEH. The stomach was massively dilated with compression of adjacent viscera and the celiac trunk. The stomach was repositioned laparoscopically and deflated by endoscopy in an attempt to avoid resection. During second look laparoscopy a gastrectomy was necessary. The patient was reoperated for intestinal obstruction, and treated for dehiscence of the esophagojejunostomy and a pancreatic fistula. A patient aged 65 with hereditary spastic paresis had two days history of emesis and epigastric pain. Upon arrival he was hemodynamically unstable and a CT scan revealed perforation of the herniated stomach. A subtotal gastrectomy without reconstruction was performed with vacuum closure of the abdomen. Later a gastrectomy was completed with a Roux-en-Y reconstruction. Except from reoperation for wound dehiscence after 14 days, the recovery was uneventful.

Discussion: Trisomy 21 and hereditary spastic paresis may increase the risk of developing PEH. Challenges in regard to symptom evaluation may delay diagnosis. The pressure of the dilated stomach can give rise to ischemic and mechanical damage from compression of major blood vessels and organs. Urgent diagnosis and gastric deflation is required.

Conclusions: In patients with known PEH or with comorbidity that may increase the risk of PEH, this diagnosis should be considered early on.

[Funding for national ethics committees for health research in Member States of the Economic Community of West African States]

BACKGROUND

The financing of national research ethics committees for health is a decisive factor in their proper functioning and independence. Little information is available concerning the funding of these committees in West Africa.

AIM

To analyze the funding of national research ethic committees for health in the Member States of the Economic Community of West African States.

METHODS

A review of the documents from two regional workshops with the participation of the representatives of the national ethics committees of each ECOWAS Member State was carried out. These workshops enabled the collection and validation of data on the status of national ethics committees. These data were used to conduct a descriptive analysis of the funding sources of the committees.

RESULTS

Three sources of funding for national ethics committees were identified. The first source was the support of the state or a national structure. The second source was the fee for reviewing the submitted protocols and the last source was the support of external donors. The collection of audit fees and the support of external donors were the main sources of funding for most of the national committees. In only one state, there were no fees for review of submitted protocols and all the ethic committee member were motivated by the government.

CONCLUSION

In order to ensure the autonomy and independence of the national committees, state support for the funding of these committees should improve. The establishment of a regional network and its recognition by the Assembly of Ministers of Health of ECOWAS allowed for advocacy by WAHO, which should help achieve better results in the future.

North European comparison of treatment strategy and survival in older patients with resectable gastric cancer: A EURECCA upper gastrointestinal group analysis

BACKGROUND

As older gastric cancer patients are often excluded from randomized clinical trials, the most appropriate treatment strategy for these patients remains unclear. The current study aimed to gain more insight in treatment strategies and relative survival of older patients with resectable gastric cancer across Europe.

METHODS

Population-based cohorts from Belgium, Denmark, The Netherlands, Norway, and Sweden were combined. Patients ≥70 years with resectable gastric cancer (cT1-4a, cN0-2, cM0), diagnosed between 2004 and 2014 were included. Resection rates, administration of chemotherapy (irrespective of surgery), and relative survival within a country according to stage were determined.

RESULTS

Overall, 6698 patients were included. The percentage of operated patients was highest in Belgium and lowest in Sweden for both stage II (74% versus 56%) and stage III disease (57% versus 25%). For stage III, chemotherapy administration was highest in Belgium (44%) and lowest in Sweden (2%). Three year relative survival for stage I, II, and III disease in Belgium was 67.8% (95% CI:62.8-72.6), 41.2% (95% CI:37.3-45.2), 17.8% (95% CI:12.5-24.0), compared with 56.7% (95% CI:51.5-61.7), 31.3% (95% CI:27.6-35.2), 8.2% (95% CI:4.4-13.4) in Sweden. There were no significant differences in treatment strategies of patients with stage I disease.

CONCLUSION

Substantial treatment differences are observed across North European countries for patients with stages II and III resectable gastric cancer aged 70 years or older. In the present comparison, treatment strategies with a higher proportion of patients undergoing surgery seemed to be associated with higher survival rates for patients with stages II or III disease.

International comparison of treatment strategy and survival in metastatic gastric cancer

Background

In the randomized Asian REGATTA trial, no survival benefit was shown for additional gastrectomy over chemotherapy alone in patients with advanced gastric cancer with a single incurable factor, thereby discouraging surgery for these patients. The purpose of this study was to evaluate treatment strategies for patients with metastatic gastric cancer in daily practice in five European countries, along with relative survival in each country.

Methods

Nationwide population‐based data from Belgium, Denmark, the Netherlands, Norway and Sweden were combined. Patients with primary metastatic gastric cancer diagnosed between 2006 and 2014 were included. The proportion of gastric resections performed and the administration of chemotherapy (irrespective of surgery) within each country were determined. Relative survival according to country was calculated.

Results

Overall, 15 057 patients with gastric cancer were included. The proportion of gastric resections varied from 8·1 per cent in the Netherlands and Denmark to 18·3 per cent in Belgium. Administration of chemotherapy was 39·2 per cent in the Netherlands, compared with 63·2 per cent in Belgium. The 6‐month relative survival rate was between 39·0 (95 per cent c.i. 37·8 to 40·2) per cent in the Netherlands and 54·1 (52·1 to 56·9) per cent in Belgium.

Conclusion

There is variation in the use of gastrectomy and chemotherapy in patients with metastatic gastric cancer, and subsequent differences in survival.

The VCCC Research & Education Lead Program: Collective Leadership in Cancer Across Multiple Organisations

Background and context: The Victorian Comprehensive Cancer Centre (VCCC) is Australia´s first formally constituted comprehensive cancer center, based on NCI principles. It is an alliance of 10 organizations: 7 hospitals, 2 medical research institutes and a university, based in Melbourne, Australia. A key goal for the VCCC is to create meaningful collaborations across partner organizations. Aim: The VCCC established the Research & Education Lead (R & E Lead) Program to build leadership capability who can harness the critical mass of talent across the VCCC alliance to work toward optimal integration of cancer research and education into routine patient care. Strategy/Tactics: This VCCC Research & Education Lead Program manifests the foundational principles of the VCCC by systematising and normalizing collaborative activities across the VCCC alliance. The program is a vehicle that allows the VCCC to address its strategic priorities to enable: - better integration of research, education and clinical care - sharing of ideas and knowledge to improve patient outcomes - shared education and training across member organizations Program/Policy process: Clinicians-scientists were appointed to each tumor stream as VCCC R & E Leads (approx. 0.2 EFT). Their role is to build networks of expertise and to drive change that is evidence-based, strategic and agreed across the VCCC alliance, with a focus on the end goal of better outcomes for cancer patients. The program provides the basis for a model of distributed leadership, wherein champions invested in the VCCC concept are embedded in partner organizations. Outcomes: Three R & E Leads were initially appointed as a pilot for 2 years, with a further three leads appointed during this period. Following the pilot, the program has been expanded to encompass 10 tumor streams as well as leads in primary care integration and cancer nursing. Achievements to date have included the development of a Massive Online Open Course in Cancer Survivorship, conduct of numerous symposia and events that upskill the cancer workforce in niche areas identified by the leads as needs, and consensus on the clinical challenges and research priorities to be tackled collectively within each tumor stream. Overarching program benefits included increased engagement and collaboration across partner organizations, more sharing of knowledge, and more participation in collaborative efforts including VCCC strategy development and advocacy. What was learned: A key finding of an interim program evaluation identified that the appointment of clinician-scientists as the leads was an important factor in their ability to cross the boundaries between research and clinical practice and between organizations, and to work closely and cohesively with clinical service leads for the tumor streams.

Measurement of the Effective Weak Mixing Angle in pp[over ¯]→Z/γ^{*}→ℓ^{+}ℓ^{-} Events

We present a measurement of the effective weak mixing angle parameter sin^{2}θ_{eff}^{ℓ} in pp[over ¯]→Z/γ^{*}→μ^{+}μ^{-} events at a center-of-mass energy of 1.96 TeV, collected by the D0 detector at the Fermilab Tevatron Collider and corresponding to 8.6  fb^{-1} of integrated luminosity. The measured value of sin^{2}θ_{eff}^{ℓ}[μμ]=0.23016±0.00064 is further combined with the result from the D0 measurement in pp[over ¯]→Z/γ^{*}→e^{+}e^{-} events, resulting in sin^{2}θ_{eff}^{ℓ}[comb]=0.23095±0.00040. This combined result is the most precise measurement from a single experiment at a hadron collider and is the most precise determination using the coupling of the Z/γ^{*} to light quarks.

Hartmann wavefront sensor characterization of a high charge vortex beam in the extreme ultraviolet spectral range

We demonstrate for the first time, to the best of our knowledge, the ability of extreme ultraviolet (XUV) Hartmann wavefront sensors to characterize high charge vortex beams produced by high-order harmonic generation up to the order of 25. We also show that phase matched absorption limited high harmonic generation is able to maintain the high charge vortex structure of the XUV beam even in a rather long (1 cm) generation medium.

Modeling underwater noise propagation from marine hydrokinetic power devices through a time-domain, velocity-pressure solution

Marine hydrokinetic (MHK) devices generate electricity from the motion of tidal and ocean currents, as well as ocean waves, to provide an additional source of renewable energy available to the United States. These devices are a source of anthropogenic noise in the marine ecosystem and must meet regulatory guidelines that mandate a maximum amount of noise that may be generated. In the absence of measured levels from in situ deployments, a model for predicting the propagation of sound from an array of MHK sources in a real environment is essential. A set of coupled, linearized velocity-pressure equations in the time-domain are derived and presented in this paper, which are an alternative solution to the Helmholtz and wave equation methods traditionally employed. Discretizing these equations on a three-dimensional (3D), finite-difference grid ultimately permits a finite number of complex sources and spatially varying sound speeds, bathymetry, and bed composition. The solution to this system of equations has been parallelized in an acoustic-wave propagation package developed at Sandia National Labs, called Paracousti. This work presents the broadband sound pressure levels from a single source in two-dimensional (2D) ideal and Pekeris wave-guides and in a 3D domain with a sloping boundary. The paper concludes with demonstration of Paracousti for an array of MHK sources in a simple wave-guide.

Abstract P2-03-06: Draft recommendations for human epidermal growth factor receptor 2 (HER2) testing in breast cancer will decrease HER2 positivity rates

Introduction: A focused update of American Society of Clinical Oncology (ASCO) and College of American Pathologist's (CAP) guideline recommendations for HER2 testing in breast cancer (BrCa) was published in May, 2017 for public comment (http://www.cap.org/ShowProperty?nodePath=/UCMCon/Contribution Folders/WebContent/pdf/her2-breast-summary-draft-recommendations-2017.pdf). The focused update for in situ hybridization (ISH) addresses following uncommon scenarios: 1) HER2/CEP17 ratio ≥ 2.0, and HER2 /cell &lt;4.0; 2) HER2/CEP17 ratio &lt;2.0 and HER2 /cell ≥6.0; 3) HER2/CEP17 &lt;2.0 and HER2 /cell ≥4.0 and &lt;6.0. The first two groups are currently reported as positive, the third as equivocal. It is recommended that immunohistochemistry (IHC) performed by the same lab for all these groups. If the IHC testing is 3+ or 0/1+ the final diagnosis will be reported as positive or negative respectively. If the reflex IHC is 2+, a recount of the original ISH area of carcinoma with IHC 2+ staining is recommended. The purpose of this study is to review the results of targeted FISH testing following IHC to predict the effects of proposed guidelines in a high volume national reference lab.

Materials and methods: HER2 FISH tests performed on BrCa between 4/2015-5/2017 are included. Our lab offers HER2 testing by IHC (HercepTest™ Dako) and dual probe FISH (Dako IQ). Equivocal (2+) cases showing ≥10% weak or moderate circumferential membrane staining or intense but &lt;10% circumferential staining are circled by a pathologist and reflexed to HER2 FISH with preferential counting performed in the circled areas. Equivocal FISH cases are re-tested with the alternate RAI1 probe (Agilent Technologies). FISH scoring is done manually by 2 people following 2013 ASCO/CAP guidelines with at least 20 cells counted in amplified and non-amplified cases and 40 cells counted in equivocal cases.

Results: 2460 HER2 FISH test requests were received during the study period. 7 cases failed at initial testing and 13 cases failed at repeat testing of equivocal cases with reflex probe. 389 (16.2%) cases were amplified, 1686 (68.7%) non amplified, and 369 (15.0%) were equivocal with FDA approved probe set. 116 (32.6%) of equivocal cases re-tested with alternate probe were amplified increasing overall amplification rate to 21%. The table below shows cases that fall under 3 uncommon categories that are proposed for changes in draft guidelines.

HER2/CEP17 RatioAverage HER2/CellNumber of Cases with IHC (Total Number)IHC n(result)Results per 2013 ASCO/CAP before Reflex ProbeResults per 2013 ASCO/CAP after Reflex ProbeProposed Guidelines≥ 2&lt; 48 (28)7 (2+)POSITIVE-NEGATIVE   1 (1+)          &lt; 2≥ 69 (31)9 (2+)POSITIVE-NEGATIVE       &lt; 2≥ 4-698 (372)96 (2+)EQUIVOCAL32/98 (32.7%) POSITIVE1/98 (1%) POSITIVE   1 (3+)      1 (0)   

Conclusions: In our lab where all FISH tests with prior IHC are counted on targeted areas, all of the cases within the first two groups will be reclassified as negative. The use of reflex probe in equivocal cases is not recommended in the draft recommendations further decreasing positivity rates. Approximately 5% decrease is expected in HER2 FISH positivity rates following proposed recommendations in reference laboratory setting.

Citation Format: Johnson E, Gulbahce E. Draft recommendations for human epidermal growth factor receptor 2 (HER2) testing in breast cancer will decrease HER2 positivity rates [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 P2-03-06.