Six-year follow-up of the SPHERE RCT: secondary prevention of heart disease in general practice

OBJECTIVE

To determine the long-term effectiveness of a complex intervention in primary care aimed at improving outcomes for patients with coronary heart disease.

DESIGN

A 6-year follow-up of a cluster randomised controlled trial, which found after 18 months that both total and cardiovascular hospital admissions were significantly reduced in intervention practices (8% absolute reduction).

SETTING

48 general practices in the Republic of Ireland and Northern Ireland.

PARTICIPANTS

903 patients with established coronary heart disease at baseline in the original trial.

INTERVENTION

The original intervention consisted of tailored practice and patient plans; training sessions for practitioners in medication prescribing and behavioural change; and regular patient recall system. Control practices provided usual care. Following the intervention period, all supports from the research team to intervention practices ceased.

PRIMARY OUTCOME

hospital admissions, all cause and cardiovascular; secondary outcomes: mortality; blood pressure and cholesterol control.

RESULTS

At 6-year follow-up, data were collected from practice records of 696 patients (77%). For those who had died, we censored their data at the point of death and cause of death was established. There were no significant differences between the intervention and control practices in either total (OR 0.83 (95% CI 0.54 to 1.28)) or cardiovascular hospital admissions (OR 0.91 (95% CI 0.49 to 1.65)). We confirmed mortality status of 886 of the original 903 patients (98%). There were no significant differences in mortality (15% in intervention and 16% in control) or in the proportions of patients above target control for systolic blood pressure or total cholesterol.

CONCLUSIONS

Initial significant differences in the numbers of total and cardiovascular hospital admissions were not maintained at 6 years and no differences were found in mortality or blood pressure and cholesterol control. Policymakers need to continue to assess the effectiveness of previously efficacious programmes.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN24081411.

Can Multiple Mini Interviews work in an Irish setting? A feasibility study

Multiple Mini Interview (MMI) is a new selection tool for medical school applicants. Developed at McMaster University in 2004 it comprises a series of interview stations designed to measure performance across a range of competencies including communication skills, team work, and ethical reasoning. In September 2012, 109 First Year Medical students underwent the MMI. It consisted of 10 stations. The median total score, out of 150, was 100 (min 63, max 129). Cronbach Alphas for the 10 individual stations range from 0.74 to 0.80. Overall Cronbach Alpha of MMI items was 0.78. Staff and student feedback was positive. The outline cost per student was estimated at Euro 145. This study demonstrates that it is feasible to hold a MMI with acceptable levels of reliability and stakeholder approval in an Irish setting. Further work is ongoing to establish the concurrent and predictive validity of MMI in this cohort of medica students.

Acute childhood asthma in Galway city from 1985-2005: relationship to air pollution and climate

We examine the relationship of air pollution and climatic variables to asthma admission rates of children in Galway city over a 21 year period. Paediatric asthma admissions were recorded from 1985-2005, and admission rates per thousand calculated for pre-school (1-4 years), school aged (5-14 years) and all children (1-14 years) on a monthly and annual basis. These data were compared to average monthly and annual climatic variables (rainfall, humidity, sunshine, wind speed and temperature) and black smoke levels for the city. Simple correlation and Poisson Generalized Additive Models (GAM) were used. Admission rates each month are significantly correlated with smoke levels (p = 0.007). Poisson GAM also shows a relationship between admissions and pollution (p = 0.07). Annual smoke levels impact more on admission rates of preschoolers (p = 0.04) than school age children (p = 0.10). These data suggest that air pollution is an important factor in the epidemiology of acute childhood asthma.

Does long-term partial sodium channel blockade alter disease progression in MS? Evidence from a retrospective study

BACKGROUND

There is accumulating evidence that long-term disability and disease progression in multiple sclerosis (MS) are due to prolonged sodium channel opening along demyelinated axons. Despite good evidence in animal models of MS that partial voltage-gated sodium channel (VGSC) blockade reduces disease progression, little is known about its effects in patients, despite widespread use of such agents in the symptomatic management of MS.

OBJECTIVE

To determine if long-term exposure to the VGSC-blocking drug carbamazepine (CBZ) alters disease progression in MS.

METHODS

Using a retrospective chart review of patients diagnosed with MS, we compared progression of disability between patients exposed the VGSC blocker CBZ with those who were not exposed to the drug. Both whole-group and matched case-control analyses were performed after correcting for the influence of age, gender, MS subtype, expanded disability status score at diagnosis, use of disease-modifying therapy, and year of initial therapy. The multiple sclerosis severity scale (MSSS) was used as a measure of disease severity. The primary outcome measure was MSSS score difference between groups.

RESULTS

Four hundred patients were included; 51 received CBZ symptomatic therapy (average duration of therapy 27 months). There was no significant difference in mean MSSS between the two groups in either the whole group comparison (p = 0.63) or the matched analysis (p = 0.12).

CONCLUSION

Despite preclinical evidence suggesting a neuroprotective role of VGSC blockers in animal models of MS, this retrospective study suggests that long-term exposure to the VGSC-blocking drug CBZ fails to alter long-term disability and disease progression in MS patients.

ATLANTIC DIP: simplifying the follow-up of women with previous gestational diabetes

OBJECTIVE

Previous gestational diabetes (GDM) is associated with a significant lifetime risk of type 2 diabetes. In this study, we assessed the performance of HbA1c and fasting plasma glucose (FPG) measurements against that of 75 g oral glucose tolerance testing (OGTT) for the follow-up screening of women with previous GDM.

METHODS

Two hundred and sixty-six women with previous GDM underwent the follow-up testing (mean of 2.6 years (s.d. 1.0) post-index pregnancy) using HbA1c (100%), and 75 g OGTT (89%) or FPG (11%). American Diabetes Association (ADA) criteria for abnormal glucose tolerance were used.

DESIGN, COHORT STUDY, AND RESULTS

The ADA HbA1c high-risk cut-off of 39 mmol/mol yielded sensitivity of 45% (95% CI 32, 59), specificity of 84% (95% CI 78, 88), negative predictive value (NPV) of 87% (95% CI 82, 91) and positive predictive value (PPV) of 39% (95% CI 27, 52) for detecting abnormal glucose tolerance. ADA high-risk criterion for FPG of 5.6 mmol/l showed sensitivity of 80% (95% CI 66, 89), specificity of 100% (95% CI 98, 100), NPV of 96% (95% CI 92, 98) and PPV of 100% (95% CI 91, 100). Combining HbA1c ≥39 mmol/mol with FPG ≥5.6 mmol/l yielded sensitivity of 90% (95% CI 78, 96), specificity of 84% (95% CI 78, 88), NPV of 97% (95% CI 94, 99) and PPV of 56% (95% CI 45, 66).

CONCLUSIONS

Combining test cut-offs of 5.6 mmol/l and HbA1c 39 mmol/mol identifies 90% of women with abnormal glucose tolerance post-GDM (mean 2.6 years (s.d.1.0) post-index pregnancy). Applying this follow-up strategy will reduce the number of OGTT tests required by 70%, will be more convenient for women and their practitioners, and is likely to lead to increased uptake of long-term retesting by these women whose risk for type 2 diabetes is substantially increased.

Impact of Lepeophtheirus salmonis infestations on migrating Atlantic salmon , Salmo salar L., smolts at eight locations in Ireland with an analysis of lice-induced marine mortality

Sea lice infestation as a source of marine mortality of outwardly migrating Atlantic salmon smolts has been investigated by treating groups of ranched salmon, prior to release, with a prophylactic sea lice treatment conferring protection from sea lice infestation. A number of studies have been carried out in Ireland using both established ranched populations and groups of hatchery reared fish imprinted for 5-8 weeks in the sites of experimental releases. In this study, data on 352 142 migrating salmon from twenty-eight releases, at eight locations along Ireland's South and West coasts covering a 9-year period (2001 to 2009) are reviewed. Both published and new data are presented including a previously unpublished time series. The results of a meta-analysis of the combined data suggest that while sea lice-induced mortality on outwardly migrating smolts can be significant, it is a minor and irregular component of marine mortality in the stocks studied and is unlikely to be a significant factor influencing conservation status of salmon stocks.

Sea lice levels on wild Atlantic salmon, Salmo salar L., returning to the coast of Ireland

The sea lice population structure, prevalence and intensity of Lepeophtheirus salmonis have been studied over a period extending from 2004 to 2011. Infestation data were collected from the interceptor drift net fishery from 2004 until it was closed in 2006. From 2010, data were collected from the inshore draft net fishery. In all, 34 samples from the drift and draft net fisheries have been analysed to date. Prevalence of infestation with L. salmonis regularly approached 100% in samples of hosts recovered from the offshore drift net fishery. Abundance was variable both within and between years with a maximum mean abundance of 25.8 lice per fish recorded in 2004. The population structure of L. salmonis on hosts recovered in the inshore and estuarine draft net fisheries was different from that observed in the more offshore drift net samples. There is clear evidence of recent infestation with L. salmonis in the draft net samples.

Cyclosporin A impairs the secretion and activity of ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeat)

The protease ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeat) cleaves multimers of von Willebrand factor, thus regulating platelet aggregation. ADAMTS13 deficiency leads to the fatal disorder thrombotic thrombocytopenic purpura (TTP). It has been observed that cyclosporin A (CsA) treatment, particularly in transplant patients, may sometimes be linked to the development of TTP. Until now, the reason for such a link was unclear. Here we provide evidence demonstrating that cyclophilin B (CypB) activity plays an important role in the secretion of active ADAMTS13. We found that CsA, an inhibitor of CypB, reduces the secretion of ADAMTS13 and leads to conformational changes in the protein resulting in diminished ADAMTS13 proteolytic activity. A direct, functional interaction between CypB (which possesses peptidyl-prolyl cis-trans isomerase (PPIase) and chaperone functions) and ADAMTS13 is demonstrated using immunoprecipitation and siRNA knockdown of CypB. Finally, CypB knock-out mice were found to have reduced ADAMTS13 levels. Taken together, our findings indicate that cyclophilin-mediated activity is an important factor affecting secretion and activity of ADAMTS13. The large number of proline residues in ADAMTS13 is consistent with the important role of cis-trans isomerization in the proper folding of this protein. These results altogether provide a novel mechanistic explanation for CsA-induced TTP in transplant patients.

Predictors of quality of life gains among people with type 1 diabetes participating in the Dose Adjustment for Normal Eating (DAFNE) structured education programme

AIMS

To examine predictors of quality of life gains among people with type 1 diabetes following the Dose Adjustment for Normal Eating (DAFNE) self-management training programme.

METHODS

Clinical and questionnaire data were collected from 437 patients from 6 hospital centres before, and 18 months post-DAFNE intervention. Glycated haemoglobin (HbA(1c)), weight, height, and blood pressure levels were recorded by clinicians during clinic appointments. Questionnaires included the Diabetes-Specific Quality of Life Scale (DSQOLS), the Problem Areas in Diabetes Scale (PAID) and the Hospital Anxiety and Depression Scale (HADS). Basic demographics were recorded at baseline. Linear mixed models were fitted to identify predictors of change in quality of life at an 18 month follow-up assessment.

RESULTS

Patients with high levels of diabetes-related distress experienced greatest improvement in DSQOLS quality of life scores (p = 0.001). Patients with poor glycaemic control (higher levels of HbA(1c); p = 0.03) and those with high levels of anxiety (p = 0.001) experienced the greatest reductions in diabetes-related distress.

CONCLUSIONS

Patients with higher baseline levels of anxiety, higher levels of diabetes-related distress and higher baseline levels of HbA(1c) are most likely to experience quality of life gain from participation in self-management programmes such as DAFNE.

G, Shapiro A, Okunji C, Kosti I, Shomron N, Grigoryan V, Przytycka TM, Sauna ZE, Salari R, Mandel-Gutfreund Y, Komar AA, Kimchi-Sarfaty C. Characterization of coding synonymous and non-synonymous variants in ADAMTS13 using ex vivo and in silico approaches

Synonymous variations, which are defined as codon substitutions that do not change the encoded amino acid, were previously thought to have no effect on the properties of the synthesized protein(s). However, mounting evidence shows that these “silent” variations can have a significant impact on protein expression and function and should no longer be considered “silent”. Here, the effects of six synonymous and six non-synonymous variations, previously found in the gene of ADAMTS13, the von Willebrand Factor (VWF) cleaving hemostatic protease, have been investigated using a variety of approaches. The ADAMTS13 mRNA and protein expression levels, as well as the conformation and activity of the variants have been compared to that of wild-type ADAMTS13. Interestingly, not only the non-synonymous variants but also the synonymous variants have been found to change the protein expression levels, conformation and function. Bioinformatic analysis of ADAMTS13 mRNA structure, amino acid conservation and codon usage allowed us to establish correlations between mRNA stability, RSCU, and intracellular protein expression. This study demonstrates that variants and more specifically, synonymous variants can have a substantial and definite effect on ADAMTS13 function and that bioinformatic analysis may allow development of predictive tools to identify variants that will have significant effects on the encoded protein.

P1-09-05: A 3′UTR Functional Variant in BRCA1: A Predictor of Poor Outcome in Breast Cancer

Background: MicroRNAs (miRNAs) are class of gene regulators which exert their effects through binding with partial complementarity to sequences in the 3'untranslated region (3'UTR) of the target mRNA. Single nucleotide polymorphisms (SNPs) in the 3'UTR of target mRNA have the potential to disrupt or create new illegitimate miRNA targets and have been associated with cancer predisposition as well as tumor biology. An association between rs8176318 and risk for familial breast and ovarian cancer as well as risk for triple negative breast cancer in African American women has previously been established. We aimed to evaluate the phenotypic effect of rs8176318 in a west of Ireland breast cancer cohort, and also its role as a biomarker of prognosis.

Methods: DNA from 727 unselected breast cancer cases and 387 controls were extracted from whole blood and genotyped for rs8176318 in the 3'UTR of the BRCA1 oncogene. The association with disease specific parameters and outcome were evaluated.

Results: Overall, there was a significant difference in the distribution of the three genotypes between cases and controls (p=0.035). The dominant variant model was predictive of breast cancer (OR=1.4, 95% CI 1.1−1.8). Fifty-two percent of breast cancer cases had the variant, with similar prevalence between subtypes: Luminal A (279 [54%] of 519 cases), Luminal B (37 [43%] of 85 cases), HER2 (21 [53%] of 40 cases) and triple negative breast cancer (41 [49%] of 83 cases). Comparing the prevalence of the variant within respective subtypes with controls however, Luminal A breast cancer was most strongly associated with rs8176318 (OR=1.5, 95%CI 1.1−1.9). The variant was not significantly associated with disease free survival (DFS) in all cancer cases (Log-rank test=0.084). However, rs8176318 was predictive of a poorer DFS (Log-rank test=0.041) in Luminal A patients with a 10-year DFS of 54% (95% CI 0.4−0.7) and 77% (95%CI 0.7−0.9) for the variant versus the non-variant, respectively. In addition, patients with Stage IV disease had a 6-fold increased risk of carrying the variant (p = 0.035), with 17 (73%) of 23 patients with metastasis at presentation positive for the variant compared to 324 (50%) of 642 patients without metastasis (p=0.034). Luminal A patients with Stage IV disease had a 13-fold risk of carrying the variant (p=0.043) in regression analysis, controlling for all other clinicopathological variables. Similarly, the variant was associated with distant metastasis in Luminal A patients, with 11 (92%) of 12 patients with metastasis positive for the variant compared to 242 (52%) of 463 patients without metastasis (p=0.028).

Conclusion: These findings suggest that rs8176318, a variant in the 3'UTR of BRCA1, is a genetic marker for modest breast cancer risk but aggressive tumor biology in breast cancer, and highlights the need for further clinical and biological evaluation of such markers.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-09-05.

P2-12-15: GAINS: A Breast Cancer Prognostic Index Utilizing Lymph Node Ratio

Introduction: Axillary lymph node status is an important predictor of overall survival (OS), hence its inclusion in clinical prognostic tools. The Nottingham Prognostic Index (NPI) which incorporates Lymph Node (LN) stage, tumor size and grade generates a score which predicts a percentage 10-year survival. Despite its status as a benchmark model for breast cancer prognosis, newer prognostic factors do exist. Lymph Node Ratio (LNR) is a superior prognostic indicator compared to absolute positive lymph node number, warranting re-evaluation of breast cancer prognostication. The aims of this study were threefold: identify the strength of LNR as a prognostic indicator compared to LN stage and NPI; establish a new prognostic index (Galway Index of Survival [GAINS]), taking into account the effect of LNR and breast cancer subtype on traditional clinicopathological features in breast cancer prognostication; and evaluate the prognostic efficacy of the new index compared to NPI.

Methods: Two cohorts were used: Galway Cohort-a prospectively compiled cohort of 1668 cases with histologically proven Stage 1, 2 and 3 primary operable breast cancer treated between 1990–2010 in a single institution; and ONCOPOOL-a retrospectively compiled database of 16944 cases treated across 12 European breast cancer units between 1990–1999. A Cox Proportional Hazards model was fitted to evaluate the strength of LNR compared to LN stage (within the NPI model) in both cohorts. The effect of clinicopathological variables on OS was analyzed using multivariable analysis in the Galway cohort. Three models were created (Model 1: Traditional prognostic variables excluding NPI and LNR; Model 2: Model 1 and LNR; Model 3: Model 1 and NPI) and compared using Likelihood-ratio tests.

Relationship between CCL5 and transforming growth factor-β1 (TGFβ1) in breast cancer

PURPOSE

Investigate circulating CCL5 in breast cancer patients and healthy controls, along with gene expression levels in corresponding tumour tissue and isolated primary stromal cells. Hormonal control of CCL5, and a potential relationship with TGFβ1, was also investigated.

METHODS

Circulating levels of CCL5 and TGFβ1 were measured in 102 breast cancer patients and 66 controls using ELISA. Gene expression levels (CCL5, CCR5, TGFβ1, TGFβRII) were quantified in corresponding tumour tissue (n = 43), normal tissue (n = 16), and isolated tumour (n = 22) and normal (n = 3) stromal cells using RQ-PCR. CCL5 and circulating menstrual hormones (LH, FSH, Oestradiol, Progesterone) were analysed in serum samples from healthy, premenopausal volunteers (n = 60).

RESULTS

TGFβ1 was significantly higher in breast cancer patients (Mean(SEM) 27.4(0.9)ng/ml) compared to controls (14.9(0.9)ng/ml). CCL5 levels decreased in the transition from node negative (59.6(3.7)ng/ml) to node positive disease (40.5(6.3)ng/ml) and increased again as the number of positive lymph nodes increased (⩾3 positive 50.95(9.8)ng/ml). A significant positive correlation between circulating CCL5 and TGFβ1 (r = 0.423, p<0.0001) was observed, and mirrored at the gene expression level in tumour tissue from the same patients (r = 0.44, p<0.001). CCL5, CCR5 and TGFβ1 expression was significantly higher in tumour compared to normal breast tissue (p < 0.001). A significant negative correlation was observed between circulating CCL5, Oestradiol and Progesterone (r = -0.50, r = -0.39, respectively, p < 0.05).

CONCLUSION

CCL5 expression is elevated in the tumour microenvironment. The data support a role for hormonal control of circulating CCL5 and also highlight a potentially important relationship between CCL5 and TGFβ1 in breast cancer.

Abstract P3-10-02: Circulating miRNA Signature: Potential Screening and Prognostic Tool for Breast Cancer

Introduction: Genetic profiling of breast tumors revolutionized the classification of breast cancer and unravelled the complexity of this phenotypically diverse disease. However there appears to be discordance between the various mRNA-based single sample predictors which stratify tumors into subgroups. Clinical decision making based on a tumor's mRNA expression is therefore concerning. The potential of mi(cro) RNAs as novel tumor markers has been the focus of recent scrutiny due to their tissue specificity, stability and superiority to mRNA in tumor classification. Additionally, the ability to quantify tumor-associated miRNAs in the circulation and their correlations with clinicopathologic variables, highlights their potential to improve upon existing breast tumor classification methods. Systemic miR-195 and let-7a have been shown to hold properties as breast tumor markers. The aim of this study was to identify a larger panel of miRNAs which augment the sensitivity and specificity of circulating miRNAs as diagnostic and prognostic markers for breast cancer.

Methods: The expression levels of 9 miRNAs were evaluated in 345 preoperative cancer patients including 265 breast cancers and 80 non-breast malignancies, and 63 age-matched disease-free controls using RQ-PCR. MiRNA quantification was also performed on tumor tissue from 83 age and stage matched breast cancer patients. Advanced QBase Plus software and SPSS were used for biostatistical analysis of the data and correlation with clinicopathologic variables.

Results: This study confirmed significantly deranged expression levels of systemic miR-195 and let-7a in an independent validation cohort of breast cancer patients (p &lt; 0.001 and p &lt; 0.001 respectively). In addition miR-181c and miR-342 were identified as breast cancer specific biomarkers. Elevated levels of this 4-miRNA signature in breast cancer patients, including those with in-situ carcinoma, increased the discriminatory power of this test for breast cancer (all types) to 94% (P&lt;0.001).

Circulating levels of these 4 miRNAs correlated with tumor miRNA expression, and decreased to basal levels by 2 weeks following curative tumor resection. Additionally circulating miRNA levels correlated with clinicopathological variables such as tumor size and hormone receptor status. A subset of 2 systemic miRNAs was predictive of the Luminal A subtype of breast cancer (ER/PR positive, Her2/neu negative) with 91% accuracy.

Conclusion: This study validates the recent novel finding of dysregulated tumor-specific miRNAs in the circulation of breast cancer patients. Considering that the sensitivity of mammography is 75-90%, this circulating miRNA signature could improve upon existing breast cancer screening methods, given that it was significantly altered even in patients with in-situ carcinoma. These results indicate that circulating miRNA analysis holds immense potential in the future individualized management of breast cancer patients.

A splice variant of ADAMTS13 is expressed in human hepatic stellate cells and cancerous tissues

Although ADAMTS13, the von Willebrand factor (VWF)-cleaving protease, is expressed in a range of tissues, the physiological significance of tissue-specific ADAMTS13 alternative splicing isoforms have yet to be clarified. Screening a panel of human tissues and cell lines revealed a spliced ADAMTS13 transcript in hepatic stellate cells and a hepatoma cell line that retains the 25th intron. A nonsense codon within the intron truncates the protease, which gains 64 novel amino acids in lieu of both CUB domains. This isoform, while retaining VWF-cleaving capability, accumulates intracellularly and its biological inaccessibility may prevent its participation in regulating haemostasis and other physiologic functions.