Subdural haematoma mimics

A subdural haematoma (SDH) is a frequently encountered pathology seen on an emergency room computed tomography (CT) head scan. An extra-axial crescentic density along the convexity of the brain or within the interhemispheric fissure is generally thought to represent a SDH; however, SDH mimics are known to occur in nature, and can be broadly classified under the subcategories of normal anatomy, artefacts, tumour, inflammation, infection, ischaemia, trauma, and iatrogenic. Understanding the typical characteristics of a SDH, knowledge of normal anatomy, close inspection of the morphology of the subdural process, changes to the adjacent structures, and rigorous attention to clinical details may reveal subtle clues that distinguish a true SDH from a mimic. This is crucial in appropriately directing clinical management. This review amalgamates most of the rare subdural processes that have been reported to mimic SDH, and discusses the imaging and clinical features that help to differentiate between them. This topic is highly valuable for radiology trainees, general radiologists, and emergency room physicians, and may serve as a refresher for the practising neuroradiologist.

Correction: DUB3 and USP7 de-ubiquitinating enzymes control replication inhibitor Geminin: molecular characterization and associations with breast cancer

The final sentence of the Acknowledgements should be as follows: This work was supported by grants from Instituto de Salud Carlos III (BA15/00092), Spanish Ministry of Economy and Competitiveness/EU-ERDF (SAF2016-80626-R, SAF2013-49149-R, BFU2014-51672-REDC), Fundación CajaCanarias (AP2015/008) to RF, and the Australian National Health and Medical Research (NHMRC program grant to SRL and KKK (APP1017028).

Abstract P1-19-02: Innovation in diagnosis and treatment of brain metastases using multifunctional nanomedicines

Systemic therapies have limited efficacy against brain metastases, largely because passive delivery of naked compounds via the bloodstream does not achieve sufficiently high or evenly dispersed intratumoural concentrations. Heterogeneous tissue architecture, abnormal perfusion, hypoxic zones and high interstitial fluid pressure are key factors limiting drug delivery, compounded by patchy blood-tumour-barrier permeability. Also, brain metastases are usually detected late, once patients become symptomatic. We are investigating whether engineered biopharmaceuticals might improve diagnostic sensitivity for earlier detection, as well as therapeutic efficacy and side-effect profiles of existing agents through active tumour targeting, delayed clearance and microenvironment-mediated activation. This study is proceeding with parallel preclinical and clinical tracks.

Preclinical aims: (1) Develop and characterise monoclonal antibody (mAb) fragments (scFvs) that target the brain metastasis markers HER2 and HER3; (2) Functionalise polyethylene glycol (PEG)-based nanocarriers with the scFvs, along with imaging agents to facilitate in vivoand ex vivoanalysis of tissue distribution; (3) Functionalise HER2/3-targeted carriers with doxorubicin via an acid-labile hydrazone bond for release in hypoxic environments, or the endosome compartment after internalization. Results to date. His-tagged HER2- and HER3-targeted scFvs based on ligand-binding sequences of clinically-approved mAbs were expressed and purified from Expi293 suspension cultures. Binding affinities are an order of magnitude stronger than parent mAbs (KD 2-8x10E-11M), determined using surface plasmon resonance analysis. The scFvs are cytostatic and moderately cytotoxic in vitro, with IC50s in order of 0.4-1.0μM. HER2 and HER3 scFvs exhibited dose-dependent, additive growth inhibition when used in combination, and induced internalisation of their receptor ligands within 4 hours in SKBr3 cells. Conclusions.The scFvs are strong carrier-tethering candidates in terms of both extracellular and intracellular payload release. Carrier synthesis is currently underway and preliminary in vivo data will be presented.

Clinical aims: (1) Develop and characterise 89Zirconium-labelled HER2-targeted PET tracers based on parent mAb and scFv; (2) Compare uptake and retention of the tracers in breast cancer patients with brain metastases; (3) Computationally relate tumour uptake to the administered dose, perfusion, tumour size and HER2 expression; (4) Determine the uptake range within and between patients, and the minimum size for reliable detection. Results to date. The mAb tracer has been synthesised, characterised and labelling processes scaled for clinical production. It is stable in physiologic conditions, retains HER2-binding activity and has a favourable biodistribution profile in NOD-SCID mice bearing BT474 xenografts. Conclusions. Australian regulatory approvals are in place and recruitment for the mAb imaging trial ("BoNSAI") has begun. Preliminary data will be presented.

Citation Format: Saunus JM, Lim M, Puttick S, Kalita-de Croft P, Houston ZH, Jones ML, Latter MJ, Campbell LC, Thomas P, Jeffree RL, Rose SE, Mahler SM, Thurecht KJ, Scott AM, Lakhani SR. Innovation in diagnosis and treatment of brain metastases using multifunctional nanomedicines [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-19-02.

Abstract P3-08-03: Dissecting the heterogeneity of metaplastic breast cancer: A morphological, immunohistochemical and genomic analysis of a large cohort

Although rare, Metaplastic Breast Carcinomas (MBC) account for significant global breast cancer mortality. This subgroup is extremely heterogeneous and by definition exhibits metaplastic change to squamous and/or mesenchymal elements, including but not limited to spindle, squamous, chondroid, osseous and rhabdomyoid elements. The WHO working group recognizes that the current classification is inadequate and in the interim, has suggested a purely descriptive classification. The mixed epithelial-mesenchymal morphology has led to speculation that MBC represent 'stem cell tumours'; in support of this, MBC have been shown to have a CD44+/CD24-/low phenotype. Clinically, patients present with tumours that are larger (higher stage), have increased likelihood of distant metastases at presentation and overall, have a reduced 5-year survival rate compared to Invasive Carcinoma-NST. Hence, this is a unique subtype with poor outcome but without a robust classification or understanding of the biology to aid clinical management. We present a detailed morphological, immunohistochemical and genomic analysis of a large series of MBC (n=347), as amassed through the Asia-Pacific MBC consortium. We consider our morphological dissection using the WHO subtyping guidelines and show that an increasing number of phenotypes in a mixed MBC (classified as WHO_1) significantly associates with a poor prognosis. Immunohistochemical analysis showed that a pure spindle (WHO_5) is significantly less likely to express vimentin, CK5/6, CK14, and CK19 than a mixed WHO_1 with spindle features. Similarly, a WHO_1 with chondroid features is less likely to express EGFR than WHO_1 with chondroid features and rhabdoid or osseous differentiation. Across the cohort, positivity for the AE1/3 antibody and a lack of EGFR expression both significantly associate with a better outcome. We report no significant association between patient age at diagnosis and breast cancer specific survival, nor between age and specific WHO MBC subtypes. We report a significant association between WHO_1 types and increasing tumour grade, and also between tumour size and grade, with tumour size being a highly significant prognostic indicator in this cohort. Our exome sequencing confirms a significant enrichment for TP53 and PTEN mutations in MBC, and intriguingly for concurrent mutations of TP53, PTEN and PIK3CA. A novel enrichment for NF1 mutations is also presented. In summary, we provide a thorough assessment of a large cohort of MBC, including morphology, survival, IHC and exome sequencing, and present our analysis contextualized by the WHO guidelines, extending the existing knowledge base of this rare tumour type.

Citation Format: McCart Reed AE, Kalaw E, Nones K, Bettington M, Lim M, Bennett J, Johnstone K, Kutasovic JR, Kazakoff S, Xu QC, Saunus JM, Reid LE, Black D, Niland C, Ferguson K, Gresshoff I, Raghavendra A, Liu JC, Kalinowski L, Reid AS, Davidson M, Pearson JV, Yamaguchi R, Harris G, Tse G, Papadimos D, Pathmanathan R, Pathmanathan N, Tan PH, Fox S, O'Toole S, Waddell N, Simpson PT, Lakhani SR. Dissecting the heterogeneity of metaplastic breast cancer: A morphological, immunohistochemical and genomic analysis of a large cohort [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-08-03.

Use of respiratory rates and heart rate variability in the assessment and treatment of children and adolescents with functional somatic symptoms

Functional somatic symptoms (FSS) emerge when the stress system is activated in response to physical or emotional stress that is either chronic or especially intense. In such cases, the heightened state of physiological arousal and motor activation can be measured through biological markers. Our team have integrated the use of biological markers of body state - respiratory rate, heart rate (HR) and heart rate variability (HRV) measurements - as a way of helping families to understand how physical symptoms can signal activation of the body's stress systems. This study measured respiratory rates, HR and HRV in children and adolescents with FSS (and healthy controls) during baseline assessment to determine whether these biological markers were effective at differentiating patients with FSS. The study also implemented a biofeedback intervention during the assessment to determine whether patients with FSS were able to slow their respiratory rates and increase HRV. Patients with FSS had faster respiratory rates, faster HR, and lower HRV, suggesting activation of the autonomic nervous system coupled with activation of the respiratory motor system. Like controls, patients were able to slow their respiratory rates, but in contrast to controls, they were unable to increase their HRV. Our findings suggest that patients with FSS present in a state of physiological activation and struggle to regulate their body state. Patients with FSS are likely to need ongoing training and practice to regulate body state coupled with interventions that target regulatory capacity across multiple systems.

An interprofessional approach to managing children with treatment-resistant enuresis: an educational review

Enuresis (intermittent urinary incontinence during sleep in a child aged ≥ 5 years) is commonly seen in paediatric practice. Despite the availability of effective interventions, treatment resistance is encountered in up to 50% of children. In this educational review we attempt to provide insight into the causes of treatment resistance, and offer practical suggestions for addressing this condition using an interprofessional approach. We explore the pathophysiology of and standard treatments for enuresis and discuss why standard treatments may fail. An interprofessional approach to treatment resistance is proposed which utilises the expertise of professionals from different disciplines to address the problems and barriers to treatment. The two interprofessional approaches include a multidisciplinary approach that involves the patient being sent to experts in different disciplines at different times to address their treatment resistance utilising the skills of the respective experts, and an interdisciplinary approach that involves a patient being managed by members of interdisciplinary team who integrate their separate discipline perspectives into a single treatment plan. Although an interdisciplinary approach is ideal, interdisciplinary teams may not be available in all circumstances. Understanding the roles of other disciplines and engaging clinicians from other disciplines when appropriate can still be helpful when treatment resistance is encountered.

Vessel Wall MRI for Targeting Biopsies of Intracranial Vasculitis

Central nervous system vasculitides are elusive diseases that are challenging to diagnose because brain biopsies have high false-negative rates. We sought to test the ability of contrast-enhanced, high-resolution 3D vessel wall MR imaging to identify vascular inflammation and direct open biopsies of intracranial target vessels and adjacent brain parenchyma. Eight of 9 specimens revealed vascular inflammation. We conclude that vessel wall MR imaging can identify inflamed intracranial vessels, enabling precise localization of biopsy targets.

Contrast-Enhanced CISS Imaging for Evaluation of Neurovascular Compression in Trigeminal Neuralgia: Improved Correlation with Symptoms and Prediction of Surgical Outcomes

BACKGROUND AND PURPOSE

Thin-section MR imaging through the posterior fossa is frequently used for trigeminal neuralgia. Typical heavily T2-weighted imaging methods yield high anatomic detail and contrast between CSF and neurovascular structures, but poor contrast between vessels and nerves. We hypothesized that the addition of gadolinium-based contrast material to 3D-constructive interference in steady-state imaging would improve the characterization of trigeminal compression.

MATERIALS AND METHODS

Retrospective review of high-resolution MRIs was performed in patients without prior microvascular decompression. 3D-CISS imaging without contrast and with contrast for 81 patients with trigeminal neuralgia and 15 controls was intermixed and independently reviewed in a blinded fashion. Cisternal segments of both trigeminal nerves were assessed for the grade of neurovascular conflict, cross-sectional area, and degree of flattening. Data were correlated with symptom side and pain relief after microvascular decompression using the Fisher exact test, receiver operating curve analysis, and a paired t test.

RESULTS

Contrast-enhanced CISS more than doubled the prevalence of the highest grade of neurovascular conflict (14.8% versus 33.3%, P = .001) and yielded significantly lower cross-sectional area (P = 8.6 × 10^-6) and greater degree of flattening (P = .02) for advanced-grade neurovascular conflict on the symptoms side compared with non-contrast-enhanced CISS. Patients with complete pain relief after microvascular decompression had significantly lower cross-sectional area on contrast-enhanced CISS compared with non-contrast-enhanced CISS on preoperative imaging (P = 2.0 × 10^-7). Performance based on receiver operating curve analysis was significantly improved for contrast-enhanced CISS compared with non-contrast-enhanced CISS.

CONCLUSIONS

The addition of contrast material to 3D-CISS imaging improves the performance of identifying unilateral neurovascular compression for symptomatic trigeminal neuralgia and predicting outcomes after microvascular decompression.

Midwives' and women's views on accessing dental care during pregnancy: an Australian qualitative study

BACKGROUND

Maternal behaviours during pregnancy are likely to play a significant role in the development of dental caries in children. Although midwives are well placed to discuss oral health and provide information to women, dental attendance by women during pregnancy is minimal. This study aimed to explore midwives' experience of facilitating pregnant women's access to dental care and to document women's experience of receiving dental information and care during pregnancy.

METHODS

Focus groups with midwives and telephone interviews with women who were referred to Monash Health Dental Services were conducted to explore their perspectives and experiences. The qualitative data was thematically analysed.

RESULTS

Three focus groups with 13 midwives and telephone interviews with eight women who recently gave birth were conducted. Three key themes were identified: maternal oral health knowledge; barriers to accessing dental information and care during pregnancy; and suggested recommendations.

CONCLUSIONS

This study highlighted the barriers that exist for midwives to discuss oral health with women and refer women to dental care, and women's experiences of accessing dental care during pregnancy. Ongoing collaboration between the maternity and dental services is required to strengthen midwives' knowledge, confidence and practise in supporting women to access dental care during pregnancy.

Abstract P6-08-17: Pregnancy associated breast cancer: Evaluating maternal outcomes. A multicentre study

Background

Pregnancy associated breast cancer (PABC) is defined as breast cancer (BC) diagnosed during the gestational period (GP) or in the first year postpartum (PP). Despite its infrequent occurrence, the incidence of PABC appears to be rising due to the increasing propensity for women to delay childbirth. We have established the first combined prospective and retrospective registry study of PABC in Ireland to examine specific clinicopathological characteristics, treatments and maternal outcomes. We present the retrospective findings to date.

Methods

We performed a retrospective multicentre observational study of patients (pts) with PABC treated in the eight Irish cancer centres from August 2001 to March 2017. Data extracted included information on pt demographics, tumour biology, staging, treatment administered and maternal outcomes. Standard biostatistical methods were used for analysis.

Results

111 PABC patients were identified. Sixty pts (54%) were diagnosed during the GP and 51 (46%) within 1 year PP. Median age at diagnosis was 36 years (yrs). Table 1 illustrates baseline characteristics. Two thirds of pts were node positive and a similar proportion had grade 3 pathology. Seventy pts (63%) were estrogen receptor (ER) positive, 36 (32%) HER2 positive, 25 (22%) triple negative. Twenty-two pts (20%) were metastatic at presentation. Seven pts (6%) had a known BRCA 1/2 mutation. The median OS (overall survival) and DFS (disease free survival) for the entire cohort was 107.4 and 94.2 months respectively (resp). There was no survival difference between those diagnosed during the GP versus PP. 5 yr DFS and OS was 68.6% and 69.2% resp. This compares unfavourably to results reported by the National Cancer Registry of Ireland in a similar age-matched BC population between 2000-2012 where the 5 yr OS was 86.5%. Variables in our study associated with poorer outcomes included younger age, tumour size, node positivity and lack of estrogen expression.

Baseline characteristics PABC patients (n=11) %(n)Diagnosed in GP (n=60) %(n)Diagnosed 1yr PP (n=51) %(n)p valueDemographic    Age at diagnosis3636(25-49)36(21-44)0.31Stage    I-II54(60)55(33)53(27)0.85III23(26)23(14)23(12)1IV20(22)18(11)22(11)0.81Unknown3(3)3(2)2(1)1Pathology    Grade 366(74)70(42)63(32)0.43Node positive66(73)68(41)63(32)0.55ER+/HER2-41(45)38(23)43(22)0.69ER+/HER2+23(25)28(17)16(8)0.17ER-/HER2+14(16)17(10)12(6)0.59Triple negative22(25)17(10)29(15)0.11Surgery    Breast conservation23(26)25(15)21(11)0.82Mastectomy56(63)57(34)59(30)0.84Adjuavnt/Neoadjuvant treatment    Chemotherapy73(81)77(46)69(35)0.39Anthracycline68(55)78(36)54(19)0.03Taxane89(72)93(43)83(29)0.16Anti HER2 agent21(23)18(11)24(12)0.63Endocrine therapy64(52)63(29)66(23)0.84Radiotherapy79(64)74(34)86(30)0.85Relapse in Stage I-III    Local relapse15(13)12(6)18(7)0.55Distant relapse24(21)22(11)25(10)0.80

Conclusions

PABC patients may have a poorer outcome. Our study reported higher rates of triple negative and HER2 positive breast cancer which are associated with more aggressive biology. Prospective evaluation of clinicopathological features, pharmacokinetics of treatments selected and maternal and fetal outcomes is imperative in this distinct pt group.

Citation Format: Prior L, Teo M, Greally M, Ward C, O'Leary C, Aslam R, Darwish W, Ahmed N, Watson G, Kelly D, Kiely L, Hassan A, Gleeson J, Featherstone H, Lim M, Murray H, Gallagher D, Westrup J, Hennessy B, Leonard G, Grogan L, Breathnach O, Horgan A, Coate L, O'Mahony D, Coate L, O'Reilly S, Gupta R, Keane M, Duffy K, O'Connor M, Kennedy J, McCaffrey J, Higgins M, Kelly C, Carney D, Gullo G, Crown J, Walshe J. Pregnancy associated breast cancer: Evaluating maternal outcomes. A multicentre study [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 P6-08-17.

Abstract P3-10-16: Competing mortality risks: Cardiovascular risk versus risk of metastatic disease in breast cancer patients receiving adjuvant therapy

Background

Breast cancer is the most commonly diagnosed cancer in women in Ireland. The 5 year net survival is over 80%. Most women diagnosed with breast cancer do not die from the disease and instead cardiovascular disease (CVD) remains the most frequent cause of death. Many breast cancer patients are older and have established CVD risk factors. They are at further risk of a cardiovasular (CV) event due to exposure to anthracyclines, HER2 targeted agents, endocrine therapy and radiotherapy. In this study, we aimed to compare the 10 year risk of breast cancer mortality versus that of a CV event or death in an oncology day ward population at our centre through the use of online prognostic risk calculators. Furthermore, we sought to investigate the predicted outcome of lifestyle changes on their overall CV risk and level of interest in addressing these risk factors.

Methods

This was a cross cohort study of all breast cancer patients attending for adjuvant chemotherapy at our institution from September 2015 to September 2016. To calculate patients' 10 year CVD risk, we used the JBS3 online calculator. Using this calculator we could also predict patient's lifetime CV risk. To calculate patients' 10 year mortality risk from breast cancer we used NHS predict! These calculators incorporate several variables which we identified from chart review, the use of questionnaires and the performance of a serum lipid test.

Results

101 subjects were identified. All patients (pts) completed questionnaires. Eighteen pts were excluded from CV risk analysis due to lack of lipid profile. Of 83 pts, 83% (n=69) were >50 years of age and 17% (n=14) pts were <50 years of age. The median age in the >50 age group (grp) was 59 and 42 in the <50 age grp. The median BMI in the >50 and <50 grp was 29.2 and 26.4 respectively. Forty-two percent (n=29) of pts in the >50 grp were smokers/ex smokers and 49% (n=7) were in the <50 grp. Twenty-nine percent (n=20) in the >50 grp were on statins and 25% (n=17) were on antihypertensives. Fifty-two percent (n=36) of pts in the >50 grp and 66% (n=10) received anthracyclines. Fifty percent in both grps received left sided radiotherapy. Ninety five percent (n=63) were on endocrine therapy in the >50 grp and 93% (n=13) in the <50 grp. Forty-one percent in the >50 grp (n=28) and 29% (n=4) of patients in the <50 grp received Trastuzumab. In the >50 grp, 13% (n=9) were found to have a high 10 year cardiovascular risk (>20% risk of CV event) and 28% were found to be at moderate risk (n=19). Ten percent of patients were found to have a CV risk that exceeded their breast cancer mortality risk (n=7). Even though the 10 year CV risk was low in patients <50, their median lifetime risk was calculated at 52%. Eighty seven percent of pts were interested in receiving advice on reducing their cardiovascular risk. The predicted median 10 year cardiovascular risk of age>50 patients in the high risk group post CV risk modification was 8.8% (+/-5.6) versus 28% (+/-8) at baseline.

Conclusion

This patient population has significant CV risk factors at baseline. Benefits predicted with CV risk intervention model and significant patient interest indicates that formalised CV risk prevention strategy is needed.

Citation Format: Prior L, Featherstone H, Nugent K, Lim M, Kelly C. Competing mortality risks: Cardiovascular risk versus risk of metastatic disease in breast cancer patients receiving adjuvant therapy [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 P3-10-16.

Psychogenic non-epileptic seizures in children and adolescents: Part II - explanations to families, treatment, and group outcomes

Psychogenic non-epileptic seizures (PNES) - time-limited disturbances of consciousness and motor-sensory control, not accompanied by ictal activity on electroencephalogram (EEG) - are best conceptualized as atypical neurophysiological responses to emotional distress, physiological stressors and danger. Patients and families find the diagnosis of PNES difficult to understand; the transition from neurology (where the diagnosis is made) to mental health services (to which patients are referred for treatment) can be a bumpy one. This study reports how diagnostic formulations constructed for 60 consecutive children and adolescents with PNES were used to inform both the explanations about PNES that were given to them and their families and the clinical interventions that were used to help patients gain control over PNES. Families were able to accept the diagnosis of PNES and engage in treatment when it was explained how emotional distress, illness and states of high arousal could activate atypical defence responses in the body and brain - with PNES being an unwanted by-product of this process. Patients and their families made good use of therapeutic interventions. A total of 75% of children/adolescents (45/60) regained normal function and attained full-time return to school. Global Assessment of Functioning scores increased from 41 to 67 ( t(54) = 10.09; p < .001). Outcomes were less favourable in children/adolescents who presented with chronic PNES and in those with a chronic, comorbid mental health disorder that failed to resolve with treatment. The study highlights that prompt diagnosis, followed by prompt multidisciplinary assessment, engagement, and treatment, achieves improved outcomes in children/adolescents with PNES.

Psychogenic non-epileptic seizures in children and adolescents: Part I - Diagnostic formulations

Psychogenic non-epileptic seizures (PNES) are a nonspecific, umbrella category that is used to collect together a range of atypical neurophysiological responses to emotional distress, physiological stressors and danger. Because PNES mimic epileptic seizures, children and adolescents with PNES usually present to neurologists or to epilepsy monitoring units. After a comprehensive neurological evaluation and a diagnosis of PNES, the patient is referred to mental health services for treatment. This study documents the diagnostic formulations - the clinical formulations about the probable neurophysiological mechanisms - that were constructed for 60 consecutive children and adolescents with PNES who were referred to our Mind-Body Rehabilitation Programme for treatment. As a heuristic framework, we used a contemporary reworking of Janet's dissociation model: PNES occur in the context of a destabilized neural system and reflect a release of prewired motor programmes following a functional failure in cognitive-emotional executive control circuitry. Using this framework, we clustered the 60 patients into six different subgroups: (1) dissociative PNES (23/60; 38%), (2) dissociative PNES triggered by hyperventilation (32/60; 53%), (3) innate defence responses presenting as PNES (6/60; 10%), (4) PNES triggered by vocal cord adduction (1/60; 2%), (5) PNES triggered by activation of the valsalva manoeuvre (1/60; 1.5%) and (6) PNES triggered by reflex activation of the vagus (2/60; 3%). As described in the companion article, these diagnostic formulations were used, in turn, both to inform the explanations of PNES that we gave to families and to design clinical interventions for helping the children and adolescents gain control of their PNES.

Cryo-conditioned rocky coast systems: A case study from Wilczekodden, Svalbard

This paper presents the results of an investigation into the processes controlling development of a cryo-conditioned rock coast system in Hornsund, Svalbard. A suite of nested geomorphological and geophysical methods have been applied to characterise the functioning of rock cliffs and shore platforms influenced by lithological control and geomorphic processes driven by polar coast environments. Electrical resistivity tomography (ERT) surveys have been used to investigate permafrost control on rock coast dynamics and reveal the strong interaction with marine processes in High Arctic coastal settings. Schmidt hammer rock tests, demonstrated strong spatial control on the degree of rock weathering (rock strength) along High Arctic rock coasts. Elevation controlled geomorphic zones are identified and linked to distinct processes and mechanisms, transitioning from peak hardness values at the ice foot through the wave and storm dominated scour zones to the lowest values on the cliff tops, where the effects of periglacial weathering dominate. Observations of rock surface change using a traversing micro-erosion meter (TMEM) indicate that significant changes in erosion rates occur at the junction between the shore platform and the cliff toe, where rock erosion is facilitated by frequent wetting and drying and operation of nivation and sea ice processes (formation and melting of snow patches and icefoot complexes). The results are synthesised to propose a new conceptual model of High Arctic rock coast systems, with the aim of contributing towards a unifying concept of cold region landscape evolution and providing direction for future research regarding the state of polar rock coasts.

Clostridium difficile Infection in Hematopoietic Stem Cell Transplant Patients: A Single-center Experience

Background

C. difficile infection (CDI) is the most common cause of nosocomial infections in U.S. and leading cause of gastroenteritis associated death. Incidence of CDI in hematopoietic stem cell transplant (HSCT) patients has been reported between 5.7% to 24.7% during first year after HSCT. Literature review reveals many risk factors i.e., allogenic-HSCT, extremes of age, myeloablative conditioning, prior vancomycin resistance (VRE) colonization, pre-transplant C. difficile colonization, severe mucositis, graft vs. host disease (GVHD), duration and type of antibiotics used, immunosuppression, proton pump inhibitor use and NAP1 C. difficile strain.

Methods

To study incidence and different variables for CDI, we performed a retrospective review of medical records of adult patients who underwent HSCT between 2013 and 2016 at our center. REDCap database was used to record key variables related to each patient’s HSCT and CDI, keeping in mind HIPPA guidelines. Categorical data were summed up as percentages and counts and numeric data as means, medians, standard deviations and ranges.

Results

A total of 181 HSCT recipients were included. Incidence of CDI was 10% (18 Patients). Cohort’s most common underlying malignancy was multiple myeloma (35.4%). 70% had autologous HSCT and 30% had allogenic HSCT. Among allogenic transplants, 53% had matched unrelated donor. Peripheral blood was the most common stem cell source (93%). Most common myeloablative conditioning regimen was melphalan (70%). 27% patients were on PPIs. 4% had PEG/NG tube placed and 12% were on TPN. 10% had diabetes mellitus. 5 patients had previous episodes of CDI. 69% developed mucositis. 5% patients developed acute GVHD. 6% had VRE colonization while 66% had no documentation for VRE. Out of positive CDI cases, 17% were NAP1 positive. No episode of ileus or mega colon was documented. Most common treatment regimen were metronidazole 500 mg per orally every 8 hourly (65%) and vancomycin 125 mg per orally four times a day (58.8%).

Conclusion

This single-center study demonstrates that CDI has 10% incidence in patients undergoing HSCT. Risk factors include neutropenia, high dose chemotherapy, mucosal damage and provision of broad spectrum antibiotic prophylaxis. Data on CDI prophylaxis in these patients is emerging and randomized prospective trials are needed.

Disclosures

All authors: No reported disclosures.

DUB3 and USP7 de-ubiquitinating enzymes control replication inhibitor Geminin: molecular characterization and associations with breast cancer

This corrects the article DOI: 10.1038/onc.2017.21.

Ubiquitin ligase RNF146 coordinates bone dynamics and energy metabolism

Cleidocranial dysplasia (CCD) is an autosomal dominant human disorder characterized by abnormal bone development that is mainly due to defective intramembranous bone formation by osteoblasts. Here, we describe a mouse strain lacking the E3 ubiquitin ligase RNF146 that shows phenotypic similarities to CCD. Loss of RNF146 stabilized its substrate AXIN1, leading to impairment of WNT3a-induced β-catenin activation and reduced Fgf18 expression in osteoblasts. We show that FGF18 induces transcriptional coactivator with PDZ-binding motif (TAZ) expression, which is required for osteoblast proliferation and differentiation through transcriptional enhancer associate domain (TEAD) and runt-related transcription factor 2 (RUNX2) transcription factors, respectively. Finally, we demonstrate that adipogenesis is enhanced in Rnf146-/- mouse embryonic fibroblasts. Moreover, mice with loss of RNF146 within the osteoblast lineage had increased fat stores and were glucose intolerant with severe osteopenia because of defective osteoblastogenesis and subsequent impaired osteocalcin production. These findings indicate that RNF146 is required to coordinate β-catenin signaling within the osteoblast lineage during embryonic and postnatal bone development.

RANKL coordinates multiple osteoclastogenic pathways by regulating expression of ubiquitin ligase RNF146

Bone undergoes continuous remodeling due to balanced bone formation and resorption mediated by osteoblasts and osteoclasts, respectively. Osteoclasts arise from the macrophage lineage, and their differentiation is dependent on RANKL, a member of the TNF family of cytokines. Here, we have provided evidence that RANKL controls the expression of 3BP2, an adapter protein that is required for activation of SRC tyrosine kinase and simultaneously coordinates the attenuation of β-catenin, both of which are required to execute the osteoclast developmental program. We found that RANKL represses the transcription of the E3 ubiquitin ligase RNF146 through an NF-κB-related inhibitory element in the RNF146 promoter. RANKL-mediated suppression of RNF146 results in the stabilization of its substrates, 3BP2 and AXIN1, which consequently triggers the activation of SRC and attenuates the expression of β-catenin, respectively. Depletion of RNF146 caused hypersensitivity to LPS-induced TNF-α production in vivo. RNF146 thus acts as an inhibitory switch to control osteoclastogenesis and cytokine production and may be a control point underlying the pathogenesis of chronic inflammatory diseases.

DUB3 and USP7 de-ubiquitinating enzymes control replication inhibitor Geminin: molecular characterization and associations with breast cancer

Correct control of DNA replication is crucial to maintain genomic stability in dividing cells. Inappropriate re-licensing of replicated origins is associated with chromosomal instability (CIN), a hallmark of cancer progression that at the same time provides potential opportunities for therapeutic intervention. Geminin is a critical inhibitor of the DNA replication licensing factor Cdt1. To properly achieve its functions, Geminin levels are tightly regulated through the cell cycle by ubiquitin-dependent proteasomal degradation, but the de-ubiquitinating enzymes (DUBs) involved had not been identified. Here we report that DUB3 and USP7 control human Geminin. Overexpression of either DUB3 or USP7 increases Geminin levels through reduced ubiquitination. Conversely, depletion of DUB3 or USP7 reduces Geminin levels, and DUB3 knockdown increases re-replication events, analogous to the effect of Geminin depletion. In exploring potential clinical implications, we found that USP7 and Geminin are strongly correlated in a cohort of invasive breast cancers (P<1.01E-08). As expected, Geminin expression is highly prognostic. Interestingly, we found a non-monotonic relationship between USP7 and breast cancer-specific survival, with both very low or high levels of USP7 associated with poor outcome, independent of estrogen receptor status. Altogether, our data identify DUB3 and USP7 as factors that regulate DNA replication by controlling Geminin protein stability, and suggest that USP7 may be involved in Geminin dysregulation during breast cancer progression.

Abstract P5-11-16: Do patients and nurses outside clinical trial prefer subcutaneous trastuzumab over conventional intravenous infusion? Instituto Oncologico Nacional experience

Background In the PrefHer study, subcutaneous administration of trastuzumab was preferred over intravenous administration (iv). In 2014 our hospital approved subcutaneous (sc) trastuzumab for use in patients with early or metastatic Her 2 positive breast cancer. The aim of this study was to evaluate patients (pts) and nurses´s preferences in our institution.

Methods Patients with Her2 postive breast cancer and nurses who had received or administered both sc and iv trastuzumab were interviewed to evaluate their preference. Preference for sc was compared with a linear chi squared test.

Results 55 pts were interviewed. Median age was 53 years (30-83). 30 patients in adjuvant/neoad setting and 25 pts in the palliative setting. 41 pts (74.5%) preferred sc 95% CI (63-86) , 3 pts (5.5%) preferred iv 95% CI (-0.5-11.5) and 11 pts (20%) did not have preference 95% CI (9.4-20%) p&lt; 0.0001. 72% of pts considered that sc trastuzumab was more convenient (p&lt;0.0001). 11 nurses experienced with both iv and sc trastuzumab administration answered the questionnaire. Median age 41 years (30-55). 10/11 nurses preferred sc administration, 1/10 indicated no preference. All nurses considered that sc was the most convenient administration method for the patients and is highly recommended. The main reason for patients and nurses preference was that sc administration saved time.

Conclusion Patients and nurses prefer s.c over iv trastuzumab. Our results are consistent with PrefHer study. Incorporation of sc trastuzumab could improve quality of care in patients with Breast Cancer Her 2 positive.

Citation Format: Castillo-Fernandez O, Cabreja A, Arauz E, Bellido D, Lim M, Lopez R, Montano L. Do patients and nurses outside clinical trial prefer subcutaneous trastuzumab over conventional intravenous infusion? Instituto Oncologico Nacional experience [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-11-16.

Integrated multidisciplinary community service for chronic obstructive pulmonary disease reduces hospitalisations

BACKGROUND

Hospitalisations for chronic obstructive pulmonary disease (COPD) exacerbation affect patient outcomes and healthcare costs. The long-term impact of an integrated COPD disease-management approach on hospitalisation remains controversial.

AIM

The aim of this study was to evaluate whether a multidisciplinary community service reduces respiratory hospitalisations for COPD patients.

METHODS

A total of 346 patients was followed for a mean duration of 27.3 months. The number of admissions, total bed days for respiratory (COPD exacerbation or pneumonia) or general medical causes and length of stay (LOS) per respiratory admission was compared before and after referral with the service. A secondary multivariate analysis examined which clinical parameters best predict benefit from such service.

RESULTS

The total respiratory admission and hospital bed days after referral were reduced by 31% (288 vs 417, P < 0.001) and 40.4% (1637 vs 2746, P < 0.0001) respectively, compared with the equivalent duration prior. The average LOS for each respiratory admission was also significantly reduced after referral (6.61 vs 5.70, P = 0.02). Overall, 55% patients experienced a reduction in admission frequency and hospital days. The impact on admission frequency and hospital days was the greatest in those with an at least moderate disease (GOLD ≥2, odds ratio (OR): 3.2, 95% confidence interval (CI): 1.2, 8.9; P = 0.019) and those who completed pulmonary rehabilitation (PR) (OR: 1.7, 95% CI: 1.1, 2.8; P = 0.04). In contrast, general medical admissions increased, one-third attributable to a cardiovascular cause both before and after referral.

CONCLUSIONS

The implementation of COPD multidisciplinary community service was associated with reduced respiratory hospitalisations in the long term. Patients with moderate or severe disease and who are able to complete PR are much more likely to benefit.