The changing face of fractures of the hip in Northern Ireland: a 15-year review

AIMS

We reviewed all patients who sustained a fracture of the hip and were treated in Northern Ireland over a period of 15 years to identify trends in incidence, the demographics of the patients, the rates of mortality, the configuration of the fracture and the choice of implant.

PATIENTS AND METHODS

Since 01 January 2001 data about every fracture of the hip sustained in an adult have been collected centrally in Northern Ireland. All adults with such a fracture between 2000 and 2015 were included in the study. Temporal changes in their demographics, the mode of treatment, and outcomes including mortality were analysed.

RESULTS

The incidence of fractures of the hip, in Northern Ireland, rose from 54 in 100 000 in 2000 to 86 in 100 000 in 2015. If these trends continue, we predict this rising to 128 in 100 000 in 2030. We found that these patients are becoming older and increasingly frail, as assessed by the American Association of Anesthesiology grade. Complex extracapsular fractures have become more common since 2009, which may explain the increased use of cephalomedullary nails. Despite increasing frailty, the 30-day and 12-month rates of mortality fell significantly (p = 0.002 and 0.001, respectively).

CONCLUSION

Fractures of the hip are becoming more common and more complex in an aging, increasingly frail population. We expect these trends to continue. This will place an increasing economic and clinical strain on healthcare systems. Forward planning is essential to put systems in place that can deal with the increasing demand. Cite this article: Bone Joint J 2017;99-B:1223-31.

Epilepsy and Pregnancy: For healthy pregnancies and happy outcomes. Suggestions for service improvements from the Multispecialty UK Epilepsy Mortality Group

Between 2009 and 2012 there were 26 epilepsy-related deaths in the UK of women who were pregnant or in the first post-partum year. The number of pregnancy-related deaths in women with epilepsy (WWE) has been increasing. Expert assessment suggests that most epilepsy-related deaths in pregnancy were preventable and attributable to poor seizure control. While prevention of seizures during pregnancy is important, a balance must be struck between seizure control and the teratogenic potential of antiepileptic drugs (AEDs). A range of professional guidance on the management of epilepsy in pregnancy has previously been issued, but little attention has been paid to how optimal care can be delivered to WWE by a range of healthcare professionals. We summarise the findings of a multidisciplinary meeting with representation from a wide group of professional bodies. This focussed on the implementation of optimal pregnancy epilepsy care aiming to reduce mortality of epilepsy in mothers and reduce morbidity in babies exposed to AEDs in utero. We identify in particular -What stage to intervene - Golden Moments of opportunities for improving outcomes -Which Key Groups have a role in making change -When - 2020 vision of what these improvements aim to achieve. -How to monitor the success in this field We believe that the service improvement ideas developed for the UK may provide a template for similar initiatives in other countries.

Abstract P4-09-14: PhosphohistoneH3 as a prognostic marker in breast cancer: High expression is associated with younger age, triple negative subtype, and disease specific survival

BACKGROUND PhosphohistoneH3 (PPH3) is an emerging marker in breast cancer and has been linked to both patient survival and age. Phosphorylation of HistoneH3 is an important step during the cell cycle leading to proper compaction of the chromatin during late G2 and early mitosis. Here we assessed the use of PPH3 as a prognostic marker within a group of invasive breast cancers in the Clinical Breast Care Project (CBCP).

METHODS CBCP participants and their samples were collected following IRB-approved, HIPAA-compliant protocols. Samples from 157 CBCP patients were selected for tissue whole section immunohistochemistry (IHC), using antibodies to PPH3, ER, PR, Ki67, and Her2. For each sample, staining of PPH3 was assessed across 5 high powered microscope fields and was considered positive if there was on average >2 stained cells per field. ER and PR were considered positive when there was >5% nuclear staining, and Ki67 was positive when there was >15% nuclear staining. Her2 was considered positive with an IHC score of 3+ or 2+ with a FISH score above 2.2. The samples were subtyped as Luminal A (LA: ER+/HER2-/Ki67-), Luminal B1 (LB1: ER+/HER2-/Ki67+), Luminal B2 (LB2: ER+/HER2+), Her2+ (ER-/PR-/HER2+), and Triple Negative (TN: ER-/PR-/HER2-). PPH3 was tested for associations with age and subtype using a stratified univariate Wilcoxon rank-sum analysis and a multivariate analysis controlling for subtype. To test the efficacy of PPH3 as a prognostic marker, Kaplan-Meier curves for disease specific survival were analyzed and the cox proportional hazard regression model was calculated. Further analysis addressing population demographics and additional cancer characteristics is ongoing.

RESULTS Wilcoxon analysis revealed an association between higher PPH3 levels and younger age (P=.0038). Subtype was also found to be associated with PPH3, with the TN subtype 6.26 times more likely to have higher PPH3 expression than LA (P=.005). The association with age was confirmed by repeating the analysis and stratifying into non-TN subtypes (P=.05) and TN only subtype (P=.017). Non-TN subtypes positive for PPH3 expression had median age of 53.18 at diagnosis and 63.29 for negative PPH3 expression; TN subtypes that were positive for PPH3 had a median age of 50.44 and 72.9 for negative PPH3. Multivariate analysis with age and subtype as the variables also supported these results (age P=.017; TN vs LA P=.022). Disease specific survival analysis showed that a shorter survival time was associated with positive PPH3 protein levels (P=0.03; hazard ratio=6.97).

CONCLUSIONS High expression of PPH3 is associated with a younger age, poorer survival rate, and the TN subtype. These results corroborate the use of PPH3 as a prognostic marker for breast cancer patients.

The views expressed in this article are those of the author and do not reflect the official policy of the Department of Defense, or U.S. Government.

Citation Format: Craig J, Kovatich AJ, Hooke JA, Kvecher L, Liu J, Fantacone-Campbell JL, Rui H, Shriver CD, Hu H. PhosphohistoneH3 as a prognostic marker in breast cancer: High expression is associated with younger age, triple negative subtype, and disease specific survival. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-09-14.

Isolated brain metastases as first site of recurrence in prostate cancer: case report and review of the literature

Fewer than 2% of patients with metastatic prostate cancer (pca) develop brain metastases. Autopsy series have confirmed the rarity of brain metastases. When present, brain metastases occur in end stage, once the pca is castrate-resistant and spread to other sites is extensive. Here, we present a rare case of a patient with pca who developed a solitary parenchymal brain metastasis as first site of relapse 9 years after radical therapy. The patient underwent craniotomy and excision of the tumour. A second recurrence was also isolated to the brain. In the literature, pca patients with brain metastases have a poor mean survival of 1-7.6 months. The patient in our case report experienced a relatively favourable outcome, surviving 19 months after his initial brain relapse.

Malformation risks of antiepileptic drug monotherapies in pregnancy: updated results from the UK and Ireland Epilepsy and Pregnancy Registers

OBJECTIVES

Antiepileptic drug (AED) exposure during pregnancy increases the risk of major congenital malformations (MCMs). The magnitude of this risk varies by AED exposure. Here we provide updated results from the UK Epilepsy and Pregnancy Register of the risk of MCMs after monotherapy exposure to valproate, carbamazepine and lamotrigine.

METHODS

Fifteen-year prospective observational study from 1996 until 2012. The main outcome measure is the MCM rate.

RESULTS

Informative outcomes were available for 5206 cases. 1290 women were exposed to valproate monotherapy, 1718 to carbamazepine monotherapy and 2198 to lamotrigine monotherapy. The MCM risk with valproate monotherapy exposure in utero was 6.7% (95% CI 5.5% to 8.3%) compared with 2.6% with carbamazepine (95% CI 1.9% to 3.5%) and 2.3% with lamotrigine (95% CI 1.8% to 3.1%). A significant dose effect was seen with valproate (p=0.0006) and carbamazepine (p=0.03) exposed pregnancies. A non-significant trend towards higher MCM rate with increasing dose was found with lamotrigine. MCM rate for high-dose lamotrigine (>400 mg daily) was lower than the MCM rate for pregnancies exposed to <600 mg daily of valproate, but this was not significant (3.4% vs 5.0%, p=0.31).

CONCLUSIONS

In utero exposure to valproate carries a significantly higher MCM risk than lamotrigine (p=0.0001) and carbamazepine (p=0.0001) monotherapy. In contrast to prior findings, high-dose lamotrigine was associated with fewer MCMs than all doses of valproate. While lamotrigine has a favourable profile compared with valproate for adverse pregnancy outcomes, the requirements for seizure control should not be overlooked.

Recurrent mutations, including NPM1c, activate a BRD4-dependent core transcriptional program in acute myeloid leukemia

Recent evidence suggests that inhibition of bromodomain and extra-terminal (BET) epigenetic readers may have clinical utility against acute myeloid leukemia (AML). Here we validate this hypothesis, demonstrating the efficacy of the BET inhibitor I-BET151 across a variety of AML subtypes driven by disparate mutations. We demonstrate that a common 'core' transcriptional program, which is HOX gene independent, is downregulated in AML and underlies sensitivity to I-BET treatment. This program is enriched for genes that contain 'super-enhancers', recently described regulatory elements postulated to control key oncogenic driver genes. Moreover, our program can independently classify AML patients into distinct cytogenetic and molecular subgroups, suggesting that it contains biomarkers of sensitivity and response. We focus AML with mutations of the Nucleophosmin gene (NPM1) and show evidence to suggest that wild-type NPM1 has an inhibitory influence on BRD4 that is relieved upon NPM1c mutation and cytosplasmic dislocation. This leads to the upregulation of the core transcriptional program facilitating leukemia development. This program is abrogated by I-BET therapy and by nuclear restoration of NPM1. Finally, we demonstrate the efficacy of I-BET151 in a unique murine model and in primary patient samples of NPM1c AML. Taken together, our data support the use of BET inhibitors in clinical trials in AML.

The palmar metric: A novel radiographic assessment of the equine distal phalanx

Digital radiographs are often used to subjectively assess the equine digit. Recently, quantitative and objective radiographic measurements have been reported that give new insight into the form and function of the equine digit. We investigated a radio-dense curvilinear profile along the distal phalanx on lateral radiographs we term the Palmar Curve (PC) that we believe provides a measurement of the concavity of the distal phalanx of the horse. A second quantitative measurement, the Palmar Metric (PM) was defined as the percent area under the PC. We correlated the PM and age from 544 radiographs of the distal phalanx from the left and right front feet of various breed horses of known age, and 278 radiographs of the front feet of Quarter Horses. The PM was negatively correlated with age and decreased at a rate of 0.28 % per year for horses of various breeds and 0.33 % per year for Quarter Horses. Therefore, veterinarians should be aware of age related change in the concave, parietal solar aspect of the distal phalanx in the horse.

The high cost to health and social care of managing falls in older adults living in the community in Scotland

Background and aims

Estimate costs for health and social care services in managing older people in the community who fall.

Method and results

Analyses of predominantly national databases using cost of illness methodologies. In Scotland, 294,000 (34%) of people over 65 years and living in the community fall at least once a year. Of these 20%, almost 60,000 people contacted a medical service for assistance. There were almost 30,000 attendances at GP practices, over 36,100 calls to the Scottish Ambulance Service and 46,816 people presenting at A&E, with 16,549 admitted, 30% with a hip fracture. Mortality was high, 7% during the hospital stay, rising to over 12% at 1 year. Over 20% of patients were unable to return to their homes. Associated costs were over £470 million, with 60% incurred by social services, mainly providing long-term care. Cost per person falling was over £1720, rising to over £8600 for those seeking medical assistance. A hip fracture admission cost £39,490, compared with £21,960 for other falls-related admissions.

Conclusions

Transparent, robust cost information demonstrates the substantial burden of falls for health and social care services and should be a driver for implementing evidence-based interventions to reduce falls.

The effect of socioeconomic status on treatment and pregnancy outcomes in women with epilepsy in Scotland

Compared to the background population, people with epilepsy tend to have lower rates of education and employment, lower rates of marriage and childbearing, and lower overall socioeconomic status (SES). Disparities in epilepsy care based on sociodemographic factors have been observed in the literature, but it is not known whether any such disparities exist in the UK. The UK Epilepsy and Pregnancy Register is a prospective, observational, registration and follow-up study that was set up to determine the relative safety of all AEDs taken in pregnancy. Here, we report outcomes of registered pregnancies to women with epilepsy living in Scotland from December 1996 to June 2012, based on the degree of socioeconomic deprivation of their postcode area. The Scottish Index of Multiple Deprivation (SIMD) quintile scores from 2006 were used to determine degree of socioeconomic deprivation, and group 1 (most deprived) and group 5 (least deprived) were compared. There were 1526 pregnancies with complete outcome data to women living in Scotland. Of these, 1453 (95.1%) resulted in a live birth and 68 (4.7%) had a major congenital malformation (MCM). Postcodes could not be reliably identified or verified for an additional three women, who have been excluded from SIMD group analysis. Of all women included in this study, 32.4% were in group 1 and 13.2% in group 5. No difference in MCM rate was observed between the two groups (4.4% in group 1 compared to 4.7% in group 5, p=0.84). Women in group 5 were more likely to take preconceptual folic acid (56.8% compared to 14.0%, relative risk: 4.1; 95% CI: 3.1-5.2) and less likely to have generalized tonic-clonic seizures in pregnancy (13.0% compared to 29.2%, relative risk: 0.4; 95% CI: 0.3-0.7) than those in group 1. Women in group 5 were more likely to be on monotherapy regimens (80.2% compared to 65.9%, relative risk: 1.2; 95% CI: 1.1-1.3), less likely to be on valproate (19.5% compared to 28.0%, p=0.05), and more likely to be on lower doses of the drug (825.9mg/day compared to 1012.0mg/day, p=0.05) compared to those in group 1. Although no change in MCM rate was seen based on SES, differences in treatment between socioeconomic groups do exist, particularly for preconceptual folic acid consumption, AED regimen, and seizure frequency. Greater emphasis on the importance of preconceptual counseling, both to discuss AED choice and folic acid intake, would be of benefit, particularly to those living in areas of high socioeconomic deprivation, to improve equity of healthcare delivery for women with epilepsy in Scotland.