Abstract PD3-08: Assessment of the tumor immune environment in inflammatory breast cancer treated with neoadjuvant dual-HER2 blockade

Background: Inflammatory breast cancer (IBC) is an aggressive form of breast cancer that remains relatively understudied. We examined the efficacy of neoadjuvant dual-HER2 blockade (trastuzumab (H) and pertuzumab (P)) combined with paclitaxel (T) in HER2+ IBC, including a planned analysis to elucidate associations between the tumor immune microenvironment profile and response to therapy.

Methods: An IRB-approved, single-arm phase II trial for patients (pts) with newly diagnosed HER2+ IBC was conducted. Pts had a pre-treatment biopsy of the affected breast (D1) followed by a loading dose of HP. A second biopsy was performed 1 week (wk) later (D8), when T (80mg/m2/wk x 16 wks) was added to HP. Responding pts underwent modified radical mastectomy (MRM) where residual disease was collected. The primary objective was to determine the rate of pathologic complete response (pCR) defined as ypT0/isN0. Residual Cancer Burden (RCB) was also determined. Tumor specimens from D1, D8 and MRM were assessed for disease cellularity and scored for percentage of tumor infiltrating lymphocytes (TILs): low=0-10%, intermediate=11-59%, high>60%. RNA-sequencing was performed on tumor tissue from D1 and D8 to explore the impact of short-term HP treatment on the tumor transcriptomic profile and to identify potential predictors of pCR.

Results: 23 pts with HER2+ IBC were enrolled between 8/2013-6/2017. Mean age was 48 years (range 32-74); 11 pts (48%) had estrogen and progesterone receptor (ER/PR) negative disease. Matched tumor biopsies (D1, D8) were obtained in all 23 pts; 21 underwent MRM; 1 was lost to follow-up and 1 had disease progression. In the intent to treat analysis, 10/23 (43%) pts achieved a pCR and 7 (30%) had RCB-1. Ten of the 22 evaluable pts achieved a pCR (45.5%). TILs were evaluable in 20/23 (87%) matched tumor biopsies (D1, D8). Among the D1 biopsy specimens: 19 (95%) had low levels, 2 (10%) had intermediate levels, and none had high levels. When D1 TIL levels were compared with D8 levels, 3(15%) had an increase in TILs, 16(80%) had no change in TIL levels, and 1(5%) had a decrease in the level of TILs. Both samples with intermediate levels and 2 of 3 samples with high levels of TILs on D1 and D8 were seen in ER/PR negative disease. An evaluation of biopsy specimens associated with subsequent pCR using GO enrichment analysis from the RNA-Seq data showed significant upregulation of several immune-process related gene expression signatures both at D1 and D8 (e.g. antigen processing and presentation, TCR signaling, NK cell cytotoxicity, p-value: 2.99E-48 to 1.39E-16) when compared with those associated with residual disease at the time of MRM. Across the entire cohort, D8 biopsies showed evidence of upregulated anti-tumor immunity compared to D1 biopsies (p-value: 9.57E-06 to 0.012). Notably, this change from D1 to D8 was largely restricted to tumors that achieved a pCR.

Conclusion: THP for 16 weeks was a highly effective treatment for HER2+ IBC. Immune activation as determined by gene expression signatures predicted pCR, and moreover upregulation of anti-tumor immunity after 1 wk of HP might further predict a complete pathologic response to therapy. ClinicalTrials.gov identifier: NCT01796197

Citation Format: Pernas S, Goel S, Harrison BT, Hu J, Johnson N, Regan M, Chichester LA, Nakhlis F, Schlosnagle EJ, Winship G, Guerriero JL, Parsons H, Mittendorf EA, Overmoyer B. Assessment of the tumor immune environment in inflammatory breast cancer treated with neoadjuvant dual-HER2 blockade [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 PD3-08.

Has the red sheep tick, Haemaphysalis punctata, recently expanded its range in England?

The red sheep tick, Haemaphysalis punctata (Ixodida: Ixodidae), has been reported as present in the U.K. for more than a century; however, very little has been written about its distribution. In recent years, numbers of detections of this tick species reported to the Public Health England (PHE) Tick Surveillance Scheme have increased. This rise in the number of records may be attributable to increased tick surveillance activities or to the increased distribution of this species of tick in parts of England. This paper reviews published reports of H. punctata and all data held by the Biological Records Centre and PHE, and summarizes a number of field studies conducted by PHE and the Animal and Plant Health Agency over the past 8 years. It would appear from the evidence presented here that H. punctata may be expanding its range across the eastern part of the South Downs National Park, where there have also been reports of this tick species biting humans. It is possible that the movement of sheep between grassland sites is facilitating this spread. Further studies that better elucidate the ecology of this tick and its possible role as a vector of human and veterinary diseases are now warranted.

Quantifying the Immense Burden of OPMDS and of Oral Cancer in South Asia: Time for Action

Background: Cancer of head and neck is sixth most common malignancy worldwide https://www.ncbi.nlm.nih.gov/pubmed/27245686 . ∼90% are squamous cell carcinomas [HNSCC]. Of H&N sites, mouth is most common [∼300,373 cases pa, cf oropharynx ∼142,387; larynx ∼156,877; nasopharynx 86,691]. Across south Asia, cancer of lip & mouth [oral cancer: OSCC] is a serious public health problem. In many, it is the most common cancer among men, 5th/6th in women, second overall. Five year survival rates are < 50%. Treatment is devastating. It is difficult to get authorities and public to recognize the problem: this is not a “glamorous” cancer. Yet we know the major causes so most disease is preventable. In south Asia, the major causes are tobacco - mostly chewed, areca [erroneously called betel] nut, mostly as component of betel quid, and heavy alcohol use in a background of diets lacking adequate antioxidant vitamins/minerals. To this is added the global epidemic of human papillomavirus [HPV]-driven nonkeratinising squamous epithelial head/neck cancer, particularly in lymphoid tissues of Waldyer's ring. Though data vary by country, high-risk [hr]HPVs are likely associated with up to 30% of OSCC too. We need detailed local information, especially as hrHPV-driven SCC respond well to radio/chemotherapy. Next-generation molecular methods are now examining roles for fungi and bacterial consortia. Across Asia, most OSCC arise from long-standing changes in oral mucosa: oral potentially malignant disorders [OPMD]. Leukoplakia is commonest, though with lowest risk. Risk is greater in red or mixed red/white lesions. Oral submucous fibrosis is prevalent and devastating. It has a high rate of malignant transformation and causes immense suffering: burning mouth, taste disturbances and severe sclerosis of soft tissues resulting in restricted mouth opening. The major etiology is areca nut. There is genetic and inherited propensity: very young children encouraged to chew areca can be seriously affected. There are no truly successful treatments, be it surgery to relieve trismus, physiotherapy to improve mouth opening and dietary supplements with numerous antioxidants, most commonly curcumin. Strategy: Primary prevention is possible. Improve diet; no tobacco; no areca nut [we need a WHO Framework Convention on areca]: to nip in the bud a serious epidemic of HPV-related cancers, sexual hygiene and widespread vaccination of girls - in my opinion also of boys. Public education is key. Legal controls on tobacco, areca & alcohol are needed - a tremendous challenge especially for areca, given the ancient cultural importance of this masticatory in myriad forms. It is time for effective action. Outcomes: In India and Sri Lanka we have made great progress with public awareness and with regulations on advertising and sale of smokeless tobacco and some areca products. Southeast Asia lags behind. HPV vaccination requires greater uptake across the region. What was learned: Both top-down and bottom-up approaches are needed.

LO-Phonon Emission Rate of Hot Electrons from an On-Demand Single-Electron Source in a GaAs/AlGaAs Heterostructure

Using a recent time-of-flight measurement technique with 1 ps time resolution and electron-energy spectroscopy, we develop a method to measure the longitudinal-optical-phonon emission rate of hot electrons traveling along a depleted edge of a quantum Hall bar. Comparison to a single-particle model implies the scattering mechanism involves a two-step process via an intra-Landau-level transition. We show that this can be suppressed by control of the edge potential profile, and a scattering length >1  mm can be achieved, allowing the use of this system for scalable single-electron device applications.

Laparoscopic common bile duct exploration; a preferential pathway for elderly patients

Background

Laparoscopic common bile duct exploration (LCBDE) has emerged as a recommended alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis. However, its use in the elderly has been limited, and evidence of its safety and efficacy in these patients is yet to be established. This study describes our experience of LCBDE in elderly patients, analysing the safety and efficacy of this technique in comparison to younger patients.

Methods

All patients undergoing laparoscopic cholecystectomy (LC) with LCBDE for choledocholithiasis in our unit between January 2015 and January 2017 were included. Data pertaining to patient demographics, comorbidities, investigations, operative technique and outcomes were analysed. Patients were divided into 2 groups based on age (Group A:<65 years vs Group B: >/ = 65 years) for comparative analysis.

Results

124 patients (Group A: 65, Group B: 59) were included. Group B were more co-morbid and had a higher ASA grade than Group A. However, there was no significant difference between groups in rates of conversion to open or complications, including bile leak (3.1% vs 5.1%, p = 0.67), retained stone (4.6% vs 1.7%, p = 0.62), or complications according to Clavien-Dindo classification (p = 0.78). Re-intervention rates were also similar between groups (7.7% vs 3.4%, p = 0.44 and 3.1% vs 3.4%, p = 1.0 respectively), as was length of stay.

Conclusion

Despite higher frequency of comorbidities and ASA grade, LCBDE in elderly patients is safe and effective, and has similar outcomes to younger patients. Therefore elderly patients with choledocholithiasis should be offered LCBDE as an alternative to ERCP.

Low-temperature tolerances of tropical fish with potential transgenic applications in relation to winter water temperatures in Canada

Application of fluorescent protein transgenes in tropical freshwater fish is used in research (e.g., in zebrafish) and in the commercial ornamental aquarium trade. To assess the overwinter potential of such fish in Canada, we examined the minimum temperature tolerance of three wild-type species (zebrafish, Danio rerio (Hamilton, 1822); black tetra, Gymnocorymbus ternetzi (Boulenger, 1895); tiger barb, Puntius tetrazona (Bleeker, 1855)) used as fluorescent models in the aquarium trade, as well as four lines of green fluorescent protein (GFP) transgenic and wild-type zebrafish used in research. Both tetra and barb had lower temperature tolerance limits that were higher than surveyed winter temperatures in Canada, and the lower tolerance limits of zebrafish lines was only within the range of a few surveyed lakes in some years. One line of GFP zebrafish had a lower temperature tolerance limit that was significantly higher than those of other lines, suggesting that some fluorescent transgene constructs may alter tolerance to extreme temperatures. When lines of zebrafish were reared at 8, 10, or 28 °C for 4 months, all lines were capable of producing viable embryos after cold rearing. These results indicate that tropical transgenic fish models used in research and in the aquarium trade are not expected to persist over winter in Canadian water systems.

Abstract P5-20-08: HER2 in-Situ hybridization positive breast cancers with HER2/CEP17 ratio ≥2.0 and average HER2 copy number &lt;4.0 are frequently discordant with HER2 immunohistochemistry results: Implications for potential modification of testing algorithm

Background: The current ASCO/CAP guidelines for the determination of HER2 status indicate that dual-probe in-situ hybridization (ISH) samples demonstrating a HER2/CEP17 ratio ≥ 2.0 and average HER2 copy number &lt;4.0 must be reported as positive. Patients with tumors showing these rare features were included in the first generation adjuvant trastuzumab clinical trials. In the absence of data showing lack of efficacy of HER2-targeted in this small subset of patients, these cases continue to be classified as positive without requiring additional work-up. Given that the HER2/CEP17 ratio is skewed in these cases by complex segmental deletions in chromosome 17, additional work-up may improve the final HER2 classification of these tumors. The objective of this study is to assess the potential impact of integrating HER2 IHC into the testing algorithm for these tumors by correlating the HER2 IHC results with ISH positive breast cancers demonstrating HER2/CEP17 ratio ≥2.0 and average HER2 copy number &lt;4.0.

Methods: All invasive mammary carcinomas demonstrating a HER2/CEP17 ratio ≥2.0 and average HER2 copy number &lt;4.0 were identified from our database for years 2009-2017. All ISH testing was performed using the PathVysion HER2 DNA probe kit (Abbott Molecular). During the study interval, HER2 FISH was the institutional primary testing methodology to determine HER2 status. HER2 IHC (Ventana 4B5) was performed on the same sample for all identified cases and scored using 2013 ASCO/CAP scoring guidelines.

Results: A total of 96 (1.4%) of 6,976 consecutive FISH cases met criteria for inclusion into the study. The majority of cases tested negative (67%) or equivocal (29%) by IHC. HER2 protein overexpression was observed in 4% of cases. The results of HER2 IHC testing are summarized below.

HER2 IHC results for HER2 ISH positive tumors showing ratio≥2.0 and average HER2 copy number &lt;4.0Cases (n)IHC Score 0IHC score 1+IHC score 2+IHC score 3+9612 (13%)52 (54%)28 (29%)4 (4%)

Conclusions: HER2 ISH positive breast cancers demonstrating a HER2/CEP17 ratio ≥2.0 and average HER2 copy number &lt;4.0 are rare (1.4% of cases in this study). HER2 IHC results for these tumors are negative in majority of cases. The observed HER2 protein overexpression rate was only 4% in this study. Integration of HER2 IHC into the testing algorithm for tumors demonstrating these uncommon ISH findings would result in reclassification of HER2 status to negative for most tumors.

Citation Format: Livasy C, Johnson N, Domfeh A. HER2 in-Situ hybridization positive breast cancers with HER2/CEP17 ratio ≥2.0 and average HER2 copy number &lt;4.0 are frequently discordant with HER2 immunohistochemistry results: Implications for potential modification of testing algorithm [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 P5-20-08.

Distribution of the tick Dermacentor reticulatus in the United Kingdom

The recent implication of Dermacentor reticulatus (Ixodida: Ixodidae) in the transmission of canine babesiosis in the U.K. has highlighted the lack of accurate published data on its distribution in this country. This paper aims to collate and appraise historical data for D. reticulatus, to supplement such data with more recent surveillance data and to report on field sampling conducted during 2009-2016. These updated data facilitate better understanding of the current distribution of this tick in the U.K., which will better inform disease risk assessments. There appear to be four known regions of the U.K. in which D. reticulatus currently occurs, including western Wales, North and South Devon, and Essex. The majority of foci are located in coastal sand dunes and maritime grasslands, including grazing marsh. However, more recently the tick has been detected in urban greenspace in Essex. The emergence of this tick as a vector of babesiosis in the U.K. and its recent apparent spread in Essex into urban greenspace highlight the need for continued surveillance and for further research into its status as a vector of human and veterinary pathogens.

Validation of the "smart" minimum FFR Algorithm in an unselected all comer population of patients with intermediate coronary stenoses

Using data from a commercial pressure wire system (St. Jude Medical) we previously developed an automated "smart" algorithm to determine a reproducible value for minimum FFR (smFFR) and confirmed that it correlated very closely with measurements made off-line by experienced coronary physiology core laboratories. In this study we used the same "smart" minimum algorithm to analyze data derived from a different, commercial pressure wire system (Philips Volcano) and compared the values obtained to both operator-defined steady state FFR and the online automated minimum FFR reported by the pressure wire analyser. For this analysis, we used the data collected during the VERIFY 2 study (Hennigan et al. in Circ Cardiovasc Interv, doi: 10.1161/CIRCINTERVENTIONS.116.004016 ) in which we measured FFR in 257 intermediate coronary stenoses (mean DS 48%) in 197 patients. Maximal hyperaemia was induced using intravenous adenosine (140 mcg/kg/min). We recorded both the online minimum FFR generated by the analyser and the operator-reported steady state FFR. Subsequently, the raw pressure tracings were coded, anonymised and 256/257 were subjected to further off-line analysis using the smart minimum FFR (smFFR) algorithm. The operator-defined steady state FFR correlated well with smFFR: r = 0.988 (p < 0.001), average bias 0.008 (SD 0.014), 95% limits of agreement -0.020 to 0.036. The online automated minimum FFR also correlated well with the smFFR: r = 0.998 (p < 0.001), average bias 0.004 (SD 0.006), 95% limits of agreement -0.016 to 0.008. Finally, the online automated minimum FFR correlated well the operator-reported steady state FFR: r = 0.988 (p < 0.001), average bias 0.012 (SD 0.014), 95% limits of agreement -0.039 to 0.015. In 95% of lesions studied (244/256), the operator reported steady-state FFR, smFFR, and online automated minimum FFR agreed with each other to within 0.04, which is within the previously reported test/retest limits of agreement of FFR reported by an experienced core lab. Disagreements >0.05 among methods were rare but in these cases the two automated algorithms almost always agreed with each other rather than with the operator-reported value. Within the VERIFY 2 dataset, experienced operators reported a similar FFR value to both an online automated minimum (Philips Volcano) and off-line "smart" minimum computer algorithm. Thus, treatment decisions and clinical studies using either method will produce nearly identical results.

Blood-feeding patterns of native mosquitoes and insights into their potential role as pathogen vectors in the Thames estuary region of the United Kingdom

BACKGROUND

The range of vertebrate hosts on which species of mosquito blood-feed is an important parameter for identifying potential vectors and in assessing the risk of incursion and establishment of vector-borne pathogens. In the United Kingdom, studies of mosquito host range have collected relatively few specimens and used techniques that could only broadly identify host species. This study conducted intensive collection and analysis of mosquitoes from a grazing marsh environment in southeast England. This site provides extensive wetland habitat for resident and migratory birds and has abundant human nuisance biting mosquitoes. The aim was to identify the blood-feeding patterns of mosquito species present at the site which could contribute to the transmission of pathogens.

METHODS

Twice-weekly collections of mosquitoes were made from Elmley Nature Reserve, Kent, between June and October 2014. Mosquitoes were collected using resting boxes, by aspiration from man-made structures and using a Mosquito Magnet Pro baited with 1-octen-3-ol. Blood-fed specimens were classified according to the degree of blood meal digestion using the Sella scale and vertebrate origin determined using sequencing of a fragment of the mitochondrial cytochrome C oxidase subunit I gene. Mosquitoes that were morphologically cryptic were identified to species level using multiplex PCR and sequencing methods.

RESULTS

A total of 20,666 mosquitoes of 11 species were collected, and 2,159 (10.4%) were blood-fed (Sella scale II-VI); of these 1,341 blood-fed specimens were selected for blood meal analysis. Vertebrate origin was successfully identified in 964 specimens (72%). Collections of blood-fed individuals were dominated by Anopheles maculipennis complex (73.5%), Culiseta annulata (21.2%) and Culex pipiens form pipiens (10.4%). Nineteen vertebrate hosts comprising five mammals and 14 birds were identified as hosts for mosquitoes, including two migratory bird species. Feeding on birds by Culex modestus and Anopheles atroparvus populations in England was demonstrated.

CONCLUSIONS

This study expands the vertebrate host range of mosquitoes in the Thames estuary region of the UK. Feeding on both resident and migratory bird species by potential arbovirus vectors including Cx. pipiens f. pipiens and Cx. modestus indicates the potential for enzootic transmission of an introduced arbovirus between migratory and local bird species by native mosquito species.

Are radiographic measurements of the displacement of a distal radial fracture reliable and reproducible?

AIMS

The degree of displacement of a fracture of the distal radius is an important factor which can be assessed using simple radiographic measurements. Our aim was to investigate the reliability and reproducibility of these measurements and to determine if they should be used clinically.

PATIENTS AND METHODS

A 10% sample was randomly generated from 3670 consecutive adult patients who had presented to University Hospitals of Leicester NHS Trust between 2007 and 2010 with a fracture of the distal radius. Radiographs of the 367 patients were assessed by two independent reviewers. Four measurements of displacement of the fracture were recorded and the inter-observer correlation assessed using the intra-class correlation coefficient.

RESULTS

Inter-observer correlation was high (> 0.8) for three of the four measurements. Repeat measurements of a further randomly generated 10% sample (37) were made four weeks later to assess intra-observer agreement, which was again high (> 0.8) for the same three parameters (radial height, radial inclination and dorsal/palmar tilt). Correlation was poor for articular step and gap.

CONCLUSION

Radiographic assessment of radial angle, radial inclination and dorsal/palmar tilt is a reliable method of determining the degree of displacement of a fracture of the distal radius. Cite this article: Bone Joint J 2016;98-B:1069-73.

Discordance Between Resting and Hyperemic Indices of Coronary Stenosis Severity

Background—

Distal coronary to aortic pressure ratio (Pd/Pa) and instantaneous wave-free ratio (iFR) are indices of functional significance of a coronary stenosis measured without hyperemia. It has been suggested that iFR has superior diagnostic accuracy to Pd/Pa when compared with fractional flow reserve (FFR).

We hypothesized that in comparison with FFR, revascularization decisions based on either binary cutoff values for iFR and Pd/Pa or hybrid strategies incorporating iFR or Pd/Pa will result in similar levels of disagreement.

Methods and Results—

This is a prospective study in consecutive patients undergoing FFR for clinical indications using proprietary software to calculate iFR. We measured Pd/Pa, iFR, FFR, and hyperemic iFR. Diagnostic accuracy versus FFR ≤0.80 was calculated using binary cutoff values of ≤0.90 for iFR and ≤0.92 for Pd/Pa, and adenosine zones for iFR of 0.86 to 0.93 and Pd/Pa of 0.87 to 0.94 in the hybrid strategy. One hundred ninety-seven patients with 257 stenoses (mean diameter stenosis 48%) were studied. Using binary cutoffs, diagnostic accuracy was similar for iFR and resting Pd/Pa with misclassification rates of 21% versus 20.2% ( P =0.85). In the hybrid analysis, 54% of iFR cases and 53% of Pd/Pa cases were outside the adenosine zone and rates of misclassification were 9.4% versus 11.9% ( P =0.55).

Conclusions—

Binary cutoff values for iFR and Pd/Pa result in misclassification of 1 in 5 lesions. Using a hybrid strategy, approximately half of the patients do not receive adenosine, but 1 in 10 lesions are still misclassified. The use of nonhyperemic indices of stenosis severity cannot be recommended for decision making in the catheterization laboratory.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT02377310.

Wrist function in malunion: Is the distal radius designed to retain function in the face of fracture?

Introduction Fractures of the distal radius are the most common fracture in humans and are the sempiternal hazard of 3.5 million years of bipedalism. Despite the antiquity of the injury, one of the most controversial topics in current orthopaedics is the management of distal radius fractures. It has been suggested that radiographic appearances rarely correlate with functional outcomes. As the success of the human species is predicated almost exclusively on its dexterity and intelligence, it is conceivable that the distal radius has evolved to preserve function even in the face of injury. We therefore hypothesise that the distal radius is designed to accommodate the possibility of fracture. Methods We conducted a review of studies comparing fracture pattern and form with function. We also explore the paleoanthropological evidence and comparative studies with other primates. Findings The evidence points to the human distal radius being highly tolerant of post-fracture deformity in terms of preservation of function. In addition, the distal radius appears to have apparently anatomically 'redundant' features that confer this capability. We believe these phenomena to be an evolved trait that developed with bipedalism, increasing the chances of survival for a species whose success depends upon its dexterity.

Does physical activity moderate the association between alcohol drinking and all-cause, cancer and cardiovascular diseases mortality? A pooled analysis of eight British population cohorts

OBJECTIVE

To examine whether physical activity (PA) moderates the association between alcohol intake and all-cause mortality, cancer mortality and cardiovascular diseases (CVDs) mortality.

DESIGN

Prospective study using 8 British population-based surveys, each linked to cause-specific mortality: Health Survey for England (1994, 1998, 1999, 2003, 2004 and 2006) and Scottish Health Survey (1998 and 2003).

PARTICIPANTS

36 370 men and women aged 40 years and over were included with a corresponding 5735 deaths and a mean of 353 049 person-years of follow-up.

EXPOSURES

6 sex-specific categories of alcohol intake (UK units/week) were defined: (1) never drunk; (2) ex-drinkers; (3) occasional drinkers; (4) within guidelines (<14 (women); <21 (men)); (5) hazardous (14-35 (women); 21-49 (men)) and (6) harmful (>35 (women) >49 (men)). PA was categorised as inactive (≤7 MET-hour/week), active at the lower (>7.5 MET-hour/week) and upper (>15 MET-hour/week) of recommended levels.

MAIN OUTCOMES AND MEASURES

Cox proportional-hazard models were used to examine associations between alcohol consumption and all-cause, cancer and CVD mortality risk after adjusting for several confounders. Stratified analyses were performed to evaluate mortality risks within each PA stratum.

RESULTS

We found a direct association between alcohol consumption and cancer mortality risk starting from drinking within guidelines (HR (95% CI) hazardous drinking: 1.40 (1.11 to 1.78)). Stratified analyses showed that the association between alcohol intake and mortality risk was attenuated (all-cause) or nearly nullified (cancer) among individuals who met the PA recommendations (HR (95% CI)).

CONCLUSIONS

Meeting the current PA public health recommendations offsets some of the cancer and all-cause mortality risk associated with alcohol drinking.

Rapid assessment of salivary MMP-8 and periodontal disease using lateral flow immunoassay

OBJECTIVE

The objective of this study was to determine the efficacy of a novel point-of-care immunoflow device (POCID) for detecting matrix metalloproteinase (MMP)-8 concentrations in oral fluids in comparison with a gold standard laboratory-based immunoassay.

METHODS

Oral rinse fluid and whole expectorated saliva samples were collected from 41 participants clinically classified as periodontally healthy or diseased. Samples were analyzed for MMP-8 by Luminex immunoassay and POCID. Photographed POCID results were assessed by optical scan and visually by two examiners. Data were analyzed by Pearson's correlation and receiver-operating characteristics.

RESULTS

MMP-8 was readily detected by the POCID, and concentrations correlated well with Luminex for both saliva and rinse fluids (r = 0.57-0.93). Thresholds that distinguished periodontitis from health were delineated from both the optical scans and visual reads of the POCID (sensitivity: 0.7-0.9, specificity: 0.5-0.7; P < 0.05).

CONCLUSIONS

Performance of this POCID for detecting MMP-8 in oral rinse fluid or saliva was excellent. These findings help demonstrate the utility of salivary biomarkers for distinguishing periodontal disease from health using a rapid point-of-care approach.

Lateral cutaneous nerve of thigh injury following TEPP laparoscopic inguinal hernia repair

A 40-year-old gentleman underwent a routine TEPP (trans-extraperitoneal) procedure without the use of staples to fix the mesh. He presented with symptoms of lateral cutaneous nerve of the thigh injury. We present this rare complication and its management.

New anti-resorptives and antibody mediated anti-resorptive therapy

The ageing population and an increase in both the incidence and prevalence of cancer pose a healthcare challenge, some of which is borne by the orthopaedic community in the form of osteoporotic fractures and metastatic bone disease. In recent years there has been an increasing understanding of the pathways involved in bone metabolism relevant to osteoporosis and metastases in bone. Newer therapies may aid the management of these problems. One group of drugs, the antibody mediated anti-resorptive therapies (AMARTs) use antibodies to block bone resorption pathways. This review seeks to present a synopsis of the guidelines, pharmacology and potential pathophysiology of AMARTs and other new anti-resorptive drugs. We evaluate the literature relating to AMARTs and new anti-resorptives with special attention on those approved for use in clinical practice. Denosumab, a monoclonal antibody against Receptor Activator for Nuclear Factor Kappa-B Ligand. It is the first AMART approved by the National Institute for Health and Clinical Excellence and the US Food and Drug Administration. Other novel anti-resorptives awaiting approval for clinical use include Odanacatib. Denosumab is indicated for the treatment of osteoporosis and prevention of the complications of bone metastases. Recent evidence suggests, however, that denosumab may have an adverse event profile similar to bisphosphonates, including atypical femoral fractures. It is, therefore, essential that orthopaedic surgeons are conversant with these medications and their safe usage.

TAKE HOME MESSAGE

Denosumab has important orthopaedic indications and has been shown to significantly reduce patient morbidity in osteoporosis and metastatic bone disease.

Time-of-Flight Measurements of Single-Electron Wave Packets in Quantum Hall Edge States

We report time-of-flight measurements on electrons traveling in quantum Hall edge states. Hot-electron wave packets are emitted one per cycle into edge states formed along a depleted sample boundary. The electron arrival time is detected by driving a detector barrier with a square wave that acts as a shutter. By adding an extra path using a deflection barrier, we measure a delay in the arrival time, from which the edge-state velocity v is deduced. We find that v follows 1/B dependence, in good agreement with the E[over →]×B[over →] drift. The edge potential is estimated from the energy dependence of v using a harmonic approximation.

Impacts of Groundwater Constraints on Saudi Arabia's Low-Carbon Electricity Supply Strategy

Balancing groundwater depletion, socioeconomic development and food security in Saudi Arabia will require policy that promotes expansion of unconventional freshwater supply options, such as wastewater recycling and desalination. As these processes consume more electricity than conventional freshwater supply technologies, Saudi Arabia's electricity system is vulnerable to groundwater conservation policy. This paper examines strategies for adapting to long-term groundwater constraints in Saudi Arabia's freshwater and electricity supply sectors with an integrated modeling framework. The approach combines electricity and freshwater supply planning models across provinces to provide an improved representation of coupled infrastructure systems. The tool is applied to study the interaction between policy aimed at a complete phase-out of nonrenewable groundwater extraction and concurrent policy aimed at achieving deep reductions in electricity sector carbon emissions. We find that transitioning away from nonrenewable groundwater use by the year 2050 could increase electricity demand by more than 40% relative to 2010 conditions, and require investments similar to strategies aimed at transitioning away from fossil fuels in the electricity sector. Higher electricity demands under groundwater constraints reduce flexibility of supply side options in the electricity sector to limit carbon emissions, making it more expensive to fulfill climate sustainability objectives. The results of this analysis underscore the importance of integrated long-term planning approaches for Saudi Arabia's electricity and freshwater supply systems.