Abstract P6-12-03: Delays in diagnosis and treatment of breast cancer patients: A safety-net population profile

Background: Timely detection and treatment of breast cancer patients is important in survival and recurrence. Given disparities in breast cancer outcomes based on socioeconomic status, we examined the time to diagnosis and treatment in a safety net hospital.

Methods: We conducted a retrospective review of all breast cancer patients identified by cancer registry records from 7/1/2010 to 6/30/2012 (n=124). We excluded patients with primary stage IV (n=8) and those with recurrent breast cancer within 5 years of primary diagnosis (n=4). We determined intervals between presentation to diagnosis, diagnosis to first treatment, last surgery to chemotherapy start, and last surgery to radiation start. We used logistic regression to calculate unadjusted odds of receiving timely treatment (< median time) versus more delayed treatment (≥ median time) as a function of age, language, ethnicity, insurance, Charlson co-morbidity index, cancer stage, method of first presentation (screening mammography vs. care provider), symptoms at presentation, and type of surgical treatment.

Results: Of 112 patients, the median age was 59. 42.9% were Hispanic, 29.5% were White, and 24.1% were African American. Clinical stage distribution was 20.0% stage 0, 31.8% stage I, 40.9% stage II, and 8% stage III. 83.9% of patients had surgery, of which 51.1% had breast conservation. The median time from presentation to diagnosis, time from diagnosis to first treatment, and time from surgery to chemotherapy start, fell within recommended intervals (Table 1). The time from last surgery to radiation start was greater than recommended intervals. Variables with significantly increased odds of taking longer than the median time include: stage, method of presentation, language, Charlson index, surgical treatment, ethnicity, symptoms at presentation (Table 2).

Conclusion: Acceptable diagnosis and treatment intervals were obtained for disadvantaged patients, except for time to radiation therapy. Room for improvement exists: focused interventions to facilitate access to radiation therapy, aid providers in accessing imaging more quickly, aid non-English speaking and Hispanic patients could lead to improved breast cancer care.

Table 1. Intervals of CareMeasure: Time From...Median (days)25th, 75th % (days)Recommended Intervals (days)Presentation to Diagnosis197, 4360Diagnosis to 1st Treatment3730, 4821-60Presentation to 1st Treatment6247, 83n/aLast Surgery to Chemo Start4831, 5928-90Last Surgery to Radiation Start*6853,7942-56* for patients needing surgery and radiation only

Table 2. Un-adjusted Odds Ratio of Taking Longer than Median TimeIntervalVariableReferenceO.R.p-valuePresentation to DiagnosisStage II or IIIStage 0 or I2.880.008 Method of Presentation: Care ProviderMethod of Presentation: Screening Mammogram4.270.0004Diagnosis to First TreatmentAge< 55Age ≥ 552.180.070 English-speakingNon-English speaking0.220.005 Charlson Index ≥ 3Charlson Index <30.420.040 Symptomatic PresentationAsymptomatic Presentation2.830.040 Breast ConservationMastectomy2.840.020Presentation to First TreatmentHispanicNon-Hispanic2.650.022 Charlson Index ≥ 3Charlson Index <30.520.120 Method of Presentation: Care ProviderMethod of Presentation: Screening Mammogram3.160.008

Citation Format: Jaiswal KR, Furniss A, Doyle R, Gayou N, Bayliss EA. Delays in diagnosis and treatment of breast cancer patients: A safety-net population profile. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-03.

The Porphyromonas gingivalis hemagglutinins HagB and HagC are major mediators of adhesion and biofilm formation

Porphyromonas gingivalis is a bacterium associated with chronic periodontitis that possesses a family of genes encoding hemagglutinins required for heme acquisition. In this study we generated ΔhagB and ΔhagC mutants in strain W83 and demonstrate that both hagB and hagC are required for adherence to oral epithelial cells. Unexpectedly, a double ΔhagB/ΔhagC mutant had less severe adherence defects than either of the single mutants, but was found to exhibit increased expression of the gingipain-encoding genes rgpA and kgp, suggesting that a ΔhagB/ΔhagC mutant is only viable in populations of cells that exhibit increased expression of genes involved in heme acquisition. Disruption of hagB in the fimbriated strain ATCC33277 demonstrated that HagB is also required for stable attachment of fimbriated bacteria to oral epithelial cells. Mutants of hagC were also found to form defective single and multi-species biofilms that had reduced biomass relative to biofilms formed by the wild-type strain. This study highlights the hitherto unappreciated importance of these genes in oral colonization and biofilm formation.

PA3 Using the lived experience of volunteers to enhance the care of dying patients and their families

BACKGROUND

In the UK, the majority of people die in hospital.(1) Community presence is considered to be a significant component to achieving a "good death",(2,3) however many patients die with no/few visitors, spending their last weeks of life isolated or alone.

AIM

To establish a Volunteer Service and offer: A presence to dying patients. A connexion to the community outside the Hospital. Support to families, unable to visit or emotionally exhausted from their bedside vigil.

METHODS

The Service was piloted on 6 wards (October 2012-March 2013) within a large NHS Trust, in the North of England. This was followed by a comprehensive evaluation, according to MRC guidance.

RESULTS

Analysis of the service evaluation indicated that the service was extremely beneficial, meeting its aims in providing an emotional support and spiritual presence to dying patients, and their families.

CONCLUSION

The Service provides a model of best practice that could be replicated in other Trusts and within other care settings. There are plans to further develop and expand service provision across the Trust.

REFERENCES

National End of Life Care Intelligence Network. What we know now. 2013. http://www.endoflifecare-intelligence.org.uk/resources/publications/what_we_know_now_2013 Department of Health. End of Life Care Strategy. 2008. https://www.gov.uk/government/publications/end-of-life-care-strategy-promoting-high-quality-care-for-adults-at-the-end-of-their-life Kellehear A. The end of death in late modernity, an emerging public health challenge. Crit Public Health 2007;17(1):71-79.

A double-edged sword: review of the interplay between physical health and mental health

It is widely acknowledged that there is interplay between physical and mental health, with causality in both directions. A common theme across countries is the uncertainty surrounding who should act as gatekeeper for physical health matters in psychiatry. Much of the metabolic monitoring is carried out by psychiatrists who often feel ill equipped to treat medical problems such as abnormal cholesterol or disturbances of glucose metabolism. However many patients do not attend primary care on a regular basis and may not be likely to follow through on referral to primary care. This review aims to examine the interplay between co-morbid physical and mental health conditions, identify the physical health conditions particularly associated with severe affective and psychotic illness and briefly discuss interventions and recommendations in this area. As people with severe mental illness die 10-20 years younger than their peers, with much of this premature mortality due to cardiovascular disease, this topic is emerging as one of great importance amongst clinicians and policymakers internationally.

A case of malignancy-associated cryoglobulinemia

We present a case of type 1 cryoglobulinemia with an underlying hematological malignancy. Unusually, the entire unifying diagnosis was made on the basis of the renal biopsy. Initially, serum cryoglobulin was not identified; repeat samples were positive. It is important to note that there is a significant false-negative rate with laboratory testing for cryoglobulin, due, at least in part, to the specific conditions required for collection and processing. With that in mind, in all cases with strong clinical or histological evidence of cryoglobulin but negative testing, carefully repeated samples should be sent.

Relationship between cancer and psychology: an updated history

The mechanism and formation of cancer have always been topics of interest for scientists, even for doctors in ancient times. Nowadays a great role for cancer is played by psychological stress which promotes relevant changes in neuronal activity and gene regulations across the different brain areas. It has been reported by many authors that stress can have an important role in the immune system and may be relevant in the formation of cancer. Our observations, in accordance with other research studies, confirm the importance of the influence of depression, linked to neuroendocrine stress, on the enhancement of cancer pathogenesis by inhibiting anti-tumor immune responses. In this article we review the past and present history of the relationship between cancer and psychology.

Longer-term risk of Mycobacterium bovis in Irish cattle following an inconclusive diagnosis to the single intradermal comparative tuberculin test

In Ireland, new bovine tuberculosis (bTB) cases are detected using both field and abattoir surveillance. During field surveillance, an animal may be deemed a 'standard inconclusive reactor' (SIR) to the single intradermal comparative tuberculin test (SICTT) if the bovine response is >2mm, and from 1 to 4mm greater than the avian response. Little is known about the future infection risk posed by SIR animals that pass a subsequent retest, so-called 'transient SIR' (TIR) animals. The objective of this study was to critically evaluate the future bTB status of TIR animals, by examining the future risk of bTB diagnosis over the 4 years following initial SIR diagnosis and clearance at the subsequent retest. The study included all TIRs that were identified as SIRs in 2005 in otherwise free herds at tests with no other reactors at that test and that were clear at the subsequent retest. The analysis was restricted to cows that were neither sold, other than direct to slaughter, nor exported from the herd during the follow up period (to the end of 2009). Five control cows were randomly selected from each study herd. A parametric survival model with shared frailties, to account for clustering within herds, was developed to model time from passing a retest to future bTB diagnosis. The final parametric survival model contained the variables: TIR status in 2005, inconclusive status during the follow-up period, location, herd restricted during the study, time since last restriction within the herd and age. The time ratio for the TIR status variable was significant (p<0.001) indicating that on average the time to diagnosis with bTB for TIRs was 78% shorter compared to the non-TIRs. The frailty term was significant (p<0.001) indicating that animals within some herds were more likely to become reactors compared to other herds. These results have important implications for national policy and future management of TIR animals. Further, private veterinary practitioners and their clients should be aware of the increased risk associated with TIRs.

Psychological stress and vitamins

Conditions of stress and anxiety have complex interactions with insufficient vitamin intake and malnutrition. This study, based on literature research in Medline, analyzes the inter-relationship between vitamins and stress. This report concerns a number of vitamins that have been receiving much attention in earlier reviews of the literature, for their potential to protect against stress-related events, and focus is placed upon recent findings.

Use of a biodegradable self-expanding stent in the management of a benign oesophageal stricture in a cat

An 11-year-old domestic shorthair cat presented with a six-week history of regurgitation following a dental procedure. Endoscopy identified a single oesophageal stricture in the cervical oesophagus. Stricture reformation occurred following endoscopic balloon catheter dilation on two occasions. Following a third balloon dilation a biodegradable polydioxanone self-expanding stent was placed across the stricture site. Following the implantation the cat was able to eat soft canned food orally without regurgitation. Fluoroscopic examination performed four months after placement indicated that the stent was no longer present and the cervical oesophagus was able to pass boluses of canned food with no signs of obstruction.

Autism and immunity: revisited study

Autism spectrum disorder is of interest neurochemically because it represents a relatively homogeneous disorder with regard to disease development, abnormal cognitive development and intellectual development disturbance. A consistent finding in autistic children is a high number of mast cells and a high level of serotonin which is also found at elevated concentrations in the urine of autistic patients. In addition, a dysfunction of clinical conditions, such as gastrointestinal and immunological symptoms, is frequently noted in autistic children, however, IgE does not appear to be prevalent in these children but probably an increase of cytokines/chemokines produced by mast cells at an early age may play an important role. Therefore an immune hypothesis, involving also autoimmunity, is one possible pathogenetic mechanism in autism. In conclusion, mast cell activation could contribute to immune and neuroinflammatory abnormalities that are evident in patients with autism spectrum disorders.

Biology of neurotensin: revisited study

The tridecapeptide neurotensin (NT) acts in the mammalian brain as a primary neurotransmitter or neuromodulator of classical neurotransmitters. Morphological and functional in vitro and in vivo studies have demonstrated the existence of close interactions between NT and dopamine both in limbic and in striatal brain regions. Additionally, biochemical and neurochemical evidence indicates that in these brain regions NT also plays a crucial role in the regulation of the aminoacidergic signalling. Immune cells, such as lymphocytes, macrophages and mast cells are reported to be activated by neuropeptides, such as neurotensin; this activation leads to cytokine and immunoglobulin production. In addition, neurotensin increases calcium level and the production of nitric oxide. Therefore neurotensin is deeply involved in immunity and inflammation but its real function still remains to be elucidated.

Quality of life in non-allergic rhinitis depends on the predominant inflammatory cell type

Three main types of inflammatory Non-Allergic Rhinitis (NAR) have been defined: NAR infiltrated by eosinophils (NARES), by mast cells (NARMA), and by neutrophils (NARNE). In the absence of studies that investigated the Quality of Life (QoL) in NAR, the present work is aimed at evaluating the Quality of Life of patients with NARES, NARMA, and NARNE. One hundred thirty one (131) NAR patients were prospectively and consecutively evaluated: 54 patients with NARES, 38 with NARMA, and 39 with NARNE. Their history, nasal infiltration and rhinomanometry were characterized, and Quality of Life (using 2 instruments) was evaluated, and associated to clinical and histological features. Quality of Life was significantly different in the 3 groups (p less than 0.001); NARES patients had the worst Quality of Life. Nasal resistances were significantly higher in the NARES group. Significant associations were shown in NARES patients between Quality of Life and nasal function. This study provides the first evidence that Quality of Life is impaired in NAR as well as in allergic rhinitis. Furthermore, Quality of Life impairment differs among the various forms of NAR, and there is a correlation with the cellular infiltrating type.

Multilocus sequence typing of Campylobacter jejuni isolates from New South Wales, Australia

AIMS

Multilocus sequence typing (MLST) was used to examine the diversity and population structure of Campylobacter jejuni isolates associated with sporadic cases of gastroenteritis in Australia, and to compare these isolates with those from elsewhere.

METHODS AND RESULTS

A total of 153 Camp. jejuni isolates were genotyped. Forty sequence types (STs) were found, 19 of which were previously undescribed and 21 identified in other countries. The 19 newly described STs accounted for 43% of isolates, 16 of which were assigned to known clonal complexes. Eighty-eight percent of isolates were assigned to a total of 15 clonal complexes. Of these, four clonal complexes accounted for 60% of isolates. Three STs accounted for nearly 40% of all isolates and appeared to be endemic, while 21 STs were represented by more than one isolate. Seven infections were acquired during international travel, and the associated isolates all had different STs, three of which were exclusive to the travel-acquired cases. Comparison of serotypes among isolates from clonal complexes revealed further diversity. Eight serotypes were identified among isolates from more than one clonal complex, while isolates from six clonal complexes displayed serotypes not previously associated with those clonal complexes.

CONCLUSIONS

Multilocus sequence typing is a useful tool for the discrimination of subtypes and examination of the population structure of Camp. jejuni associated with sporadic infections.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study highlights the genotypic diversity of Camp. jejuni in Australia, demonstrating that STs causing disease have both a global and a local distribution evident from the typing of domestically and internationally acquired Camp. jejuni isolates.

Study of the pharmacokinetic interaction between simvastatin and prescription omega-3-acid ethyl esters

The coadministration of prescription omega-3-acid ethyl esters (P-OM3) with a statin may present a treatment option for patients with mixed hyperlipidemia. This open-label, randomized, 2-way crossover, drug-drug interaction study evaluated the impact of P-OM3 capsules on plasma simvastatin pharmacokinetics in 24 healthy volunteers. Under fasted conditions, 80 mg simvastatin was administered with or without 4 g P-OM3 for two 14-day periods. After 14 days of dosing to achieve steady state, no significant differences were found in either the extent (AUC(tau)) or rate (Cmax) of exposure to simvastatin or its major beta-hydroxy metabolite after coadministration of P-OM3 with simvastatin compared with administration of simvastatin alone. At steady state, the coadministration of P-OM3 capsules did not appear to affect the pharmacokinetics of simvastatin tablets. The combination of P-OM3 capsules and simvastatin appeared to be well tolerated.

Psychometric comparison of students in medicine and other faculties: social factors and psychologic symptoms

Few studies have investigated personality and psychopathological profiles associated to the choice of university education. Our study examined students from four faculties of Turin University, in Turin, Italy (Medicine, Engineering, Education, Law), comparing sociodemographic features, personality characteristics and psychiatric symptoms. A heterogeneous group of 1,323 students were assessed using a semistructured interview, the Personality Diagnostic Questionnaire-Revised (PDQ-R), and the Symptoms Checklist 90 (SCL-90). Statistical analysis included four logistic regression models, each fitted for one faculty, considering the other three as a control group. Associations were found in Medical and Engineering students concerning type of high school, school final score, and father?s socioeducational level. Factors associated with students of Law and Education included socioeducational characteristics, but stronger correlations were seen with PDQ-R personality scales and SCL-90 symptom clusters. In conclusion, four different profiles were identified. Medicine was not significantly related to personality and psychiatric factors. Engineering was related to male gender, choice of technical high school and father?s social level. Law was related to female gender and narcissistic personality profile. These data may be useful for counseling activities addressed to high school and university students.

Circulating levels of beta2-glycoprotein I in thrombotic disorders and in inflammation

Beta2-glycoprotein I (beta2GPI) is a plasma protein suspected to have a role in inhibition of thrombosis. This suspicion is reinforced by the observation that beta2GPI is the major target for autoantibodies in the antiphospholipid syndrome. However, little is known about its circulating levels in common thrombotic diseases or inflammation. We measured beta2GPI levels in 344 healthy controls, 58 normal pregnancies, 102 patients with non-haemorrhagic stroke, 121 patients with acute coronary syndrome and 200 patients with elevated C-reactive protein (CRP). In healthy individuals, we found a strong positive correlation between age and beta2GPI concentration (r = 0.274, P < 0.001) and that beta2GPI levels fall significantly after the eighth week of pregnancy (P = 0.002). We also found significantly reduced levels of beta2GPI in patients with stroke and in elderly patients with myocardial syndrome (P = 0.013 and 0.043). However, in neither group did beta2GPI levels change in the following six months, suggesting that the reduced levels were not a transient post-event phenomenon. In patients with inflammation, beta2GPI levels showed a significant negative correlation with CRP (r = -0.284, P < 0.001) and positively correlated with albumin and transferrin (r = 0.372 and 0.453, respectively with P < 0.001 for both). Furthermore, the largest reduction in beta2GPI levels occurred in patients with the highest CRP values (P < 0.001).

Adrenoceptor blockade alters plasma gelatinase activity in patients with heart failure and MMP-9 promoter activity in a human cell line (ECV304)

This study assessed the effects of short-term adrenoceptor blockade on plasma matrix metalloproteinase (MMP) activity in patients with heart failure, and the ability of adrenoceptor stimulation to modulate matrix metalloproteinase-9 (MMP-9) promoter activity in vitro. Patients with heart failure received standard therapy or standard therapy plus carvedilol. Plasma MMP activity was determined by zymography and tissue inhibitor (TIMP-1) expression was measured by immunoblotting. MMP-9 promoter activity was assessed in transfected ECV304 cells following exposure to isoprenaline or phenylephrine in the absence or presence of either propranolol or prazosin. In patients with heart failure, carvedilol attenuated the increase in proMMP-9 activity observed at 4 and 12 weeks in non-beta-blocker-treated patients (44.0 +/- 4.9 AU versus 60.8 +/- 6.7 AU; P < 0.05). Although TIMP-1 expression was unaltered, the MMP-9:TIMP-1 ratio was lower in those receiving carvedilol at 4 and 12 weeks (0.54 +/- 0.07 versus 1.04 +/- 0.17; P < 0.05). Isoprenaline transiently increased MMP-9 promoter activity after 4 h exposure (80.6 +/- 14.8-fold; P < 0.001) before returning to baseline. The response to isoprenaline was prevented by propranolol (P < 0.01). Phenylephrine caused a biphasic increase in MMP-9 promoter activity, with the greatest increase occurring at 24 h (23 +/- 3.7-fold) compared to baseline. This response was unaffected by co-incubation with prazosin. In conclusion, treatment with a mixed alpha1/beta-adrenoceptor antagonist attenuates MMP activity and tips the degradative balance to a less degradative phenotype in heart failure patients. Furthermore, adrenoceptor stimulation increases MMP-9 promoter activity, which is inhibited by beta- but not alpha-adrenoceptor blockade. Therefore, mixed adrenoceptor blockade may reduce remodeling in heart failure as a direct consequence of a beta-adrenoceptor-mediated reduction in MMP-9 transcription.

Magnetic resonance imaging in the diagnosis and surgical management of sacral osteochondrosis in a mastiff dog

The clinical, radiographic, magnetic resonance imaging (MRI), surgical and pathological findings related to an osteochondral lesion of the sacrum in a mastiff dog are described. The dog showed chronic signs of pain in its pelvic limbs. Radiography revealed a triangular mineralised opacity at the craniodorsal aspect of the sacrum consistent with sacral osteochondrosis. A T2-weighted spin-echo MRI revealed dorsal and lateral compression of the cauda equina. The osteochondral fragment was removed via a dorsal laminectomy, and the clinical signs resolved. Histological abnormalities in the fragment were consistent with a diagnosis of osteochondrosis.

Re-examining comorbidity of Obsessive Compulsive and Attention-Deficit Hyperactivity Disorder using an empirically derived taxonomy

BACKGROUND

Using an empirically derived instrument to reduce the assessor bias inherent in structured diagnostic interviews, we sought to re-examine and validate the putative comorbidity between Obsessive Compulsive Disorder (OCD) and Attention-Deficit/Hyperactivity Disorder (ADHD) in children and adolescents.

METHOD

We examined the correlation between Child Behavior Checklist (CBCL) syndrome, competence, and composite scores in children with: 1) OCD plus ADHD (OCD + ADHD), N = 47; 2) OCD without comorbid ADHD (OCD), N = 33; 3) ADHD without comorbid OCD (ADHD) N = 43; and 4) comparison controls recruited from general pediatric clinics,N = 32.

RESULTS

CBCL findings in our ADHD children were similar to previous findings reported in ADHD youth, irrespective of the presence or absence of comorbid OCD. Comorbid youth generally had additive scores on the CBCL scales, reflecting the independent contribution of symptomatic and functional impairment from each disorder.

CONCLUSION

These findings suggest that when ADHD-like symptoms are seen in OCD youth, they reflect a true comorbid state of OCD plus ADHD. The CBCL may provide a rapid assessment tool to identify comorbid ADHD in OCD youth.

Low serum cholesteryl ester-docosahexaenoic acid levels in Alzheimer's disease: a case-control study

Low n-3 polyunsaturated fatty acid (PUFA) status may be associated with neuro-degenerative disorders, in particular Alzheimer's disease, which has been associated with poor dietary fish or n-3 PUFA intake, and low docosahexaenoic acid (DHA) status. The present case-control study used an established biomarker of n-3 PUFA intake (serum cholesteryl ester-fatty acid composition) to determine n-3 PUFA status in patients with Alzheimer's disease, who were free-living in the community. All cases fulfilled the National Institute of Neurological and Communicative Disorders and Stroke and Alzheimer's Disease and Related Disorders Association criteria for Alzheimer's disease. Detailed neuropsychological testing and neuroimaging established the diagnosis in all cases. The subjects (119 females and twenty-nine males) aged 76.5 (SD 6.6) years had a clinical dementia rating (CDR) of 1 (SD 0.62) and a mini mental state examination (MMSE) score of 19.5 (SD 4.8). The control subjects (thirty-six females and nine males) aged 70 (SD 6.0) years were not cognitively impaired (defined as MMSE score <24): they had a mean MMSE score of 28.9 (SD 1.1). Serum cholesteryl ester-eicosapentaenoic acid and DHA levels were significantly lower (P<0.05 and P<0.001 respectively) in all MMSE score quartiles of patients with Alzheimer's disease compared with control values. Serum cholesteryl ester-DHA levels were progressively reduced with severity of clinical dementia. DHA levels did not differ in patients with Alzheimer's disease across age quartiles: all were consistently lower than in control subjects. Step-wise multiple regression analysis showed that cholesteryl ester-DHA and total saturated fatty acid levels were the important determinants of MMSE score and CDR. It remains to be determined whether low DHA status in Alzheimer's disease is a casual factor in the pathogenesis and progression of Alzheimer's disease.