Outcomes of tumour related epilepsy in a specialised epilepsy surgery unit

INTRODUCTION

Seizures are an important cause of morbidity in patients with low grade gliomas with approximately 40% of cases drug resistant. The pathogenesis is quite complex and poorly understood. The treatment aims vary between almost purely epilepsy considerations and those that are primarily oncologic.

AIM

To determine whether patients who present with seizures and are found to have a low grade glioma have better outcomes when managed through a specialized epilepsy unit compared to the general neurosurgical service.

METHODS

A review of the prospectively collected database was performed over a 10 year period to identify 48 adult patients who present with a seizure and were subsequently found to have a low grade glioma. These patients were analysed with respect to management through the specialized epilepsy service or the general neurosurgical service. The primary outcome was Engel classification between the two groups. Secondary outcomes included recurrence, postoperative deficits, delay to surgery, histology, grade and extent of resection.

OUTCOMES

The patients managed through the epilepsy service had significantly higher rate of favourable Engel outcomes (I and II) compared to the general neurosurgery service (OR: 13.2, 95% CI: 1.239-140.679; P = 0.033). The epilepsy surgery group patients had a significantly higher delay to surgery (P < 0.001). The patients in the epilepsy service had a significantly higher resection ratio compared to the general neurosurgery service (73% vs 127%, P = 0.014). Rates of recurrence were not different between the two groups.

CONCLUSION

Patients with tumour related epilepsy who undergo an intensive presurgical evaluation may obtain better seizure related outcomes.

Standard vs. intensified management of heart failure to reduce healthcare costs: results of a multicentre, randomized controlled trial

Aims

To determine if an intensified form of heart failure management programme (INT-HF-MP) based on individual profiling is superior to standard management (SM) in reducing health care costs during 12-month follow-up (primary endpoint).

Methods and results

A multicentre randomized trial involving 787 patients (full analysis set) discharged from four tertiary hospitals with chronic HF who were randomized to SM (n = 391) or INT-HF-MP (n = 396). Mean age was 74 ± 12 years, 65% had HF with a reduced ejection fraction (31.4 ± 8.9%) and 14% were remote-dwelling. Study groups were well matched. According to Green, Amber, Red Delineation of rIsk And Need in HF (GARDIAN-HF) profiling, regardless of location, patients in the INT-HF-MP received a combination of face-to-face (home visits) and structured telephone support (STS); only 9% (`low risk') were designated to receive the same level of management as the SM group. The median cost in 2017 Australian dollars (A$1 equivalent to ∼EUR €0.7) of applying INT-HF-MP was significantly greater than SM ($152 vs. $121 per patient per month; P < 0.001), However, at 12 months, there was no difference in total health care costs for the INT-HF-MP vs. SM group (median $1579, IQR $644 to $3717 vs. $1450, IQR $564 to $3615 per patient per month, respectively). This reflected minimal differences in all-cause mortality (17.7% vs. 18.4%; P = 0.848) and recurrent hospital stay (18.6 ± 26.5 vs. 16.6 ± 24.8 days; P = 0.199) between the INT-HF-MP and SM groups, respectively.

Conclusion

During 12-months follow-up, an INT-HF-MP did not reduce healthcare costs or improve health outcomes relative to SM.

Abstract P6-03-11: Differences in serum miRNA signatures in women with pathology-confirmed breast cancer, benign breast diseases and healthy individuals with no cancer history

[INTRODUCTION] Mammography is the principal non-invasive imaging method of screening for breast cancer around the world. Mammography has been shown to be effective in reducing breast cancer deaths in randomized studies (Tabar et al., 2011 and Duffy et al., 2002). However, screening mammography can result in false positives that require subsequent interventions such as biopsy or interval repeat mammography.

Recently, circulating micro RNAs (miRNAs) have been cited as promising minimally invasive markers for breast cancer as well as for various other types of malignancies (Shimomura et al., 2016; Lawrie et al., 2008; Wang et al., 2009; Zhang et al., 2010; Mitchell et al., 2008). In this study, we have developed a new molecular diagnostic platform for the measurement of circulating (serum) miRNAs to assist with the management of women with abnormal screening mammograms.

[METHODS] Peripheral venous blood samples were collected in BD Red/Gray gel barrier tubes from patients with untreated breast cancer, patients with benign breast diseases and healthy individuals with no cancer history. The processing from blood to serum was done within six hours of collection and stored at -80°C. Total RNA was extracted from 300uL of the resulting serum using 3D-Gene®RNA extraction reagent (Toray Industries, Inc). Comprehensive miRNA expression analysis was then performed using 3D-Gene® Human miRNA Oligo Chip (Toray Industries, Inc). The average of three pre-selected internal control miRNA (miR-149-3p, miR-2861 and miR-4463) was used to normalize the signals across the different microarrays tested.

[RESULTS] RESULTS] All serum specimens used in this study were from subjects enrolled at US clinical sites (83% Caucasian, 15% African American, 2% Asian and others). One hundred fifteen (115) specimens (breast cancer: 40, healthy: 45, benign breast lesions: 30) were selected as a training cohort and used to develop comprehensive discriminants with 1–5 miRNAs using Fisher's linear discriminant analysis. The analysis identified a combination of five miRNAs that could detect breast cancer, and the resulting discriminant equation showed a sensitivity of 90.5%, specificity of 89.5% and accuracy of 89.8%. As test cohorts, (A) 381 subjects (breast cancer: 63, healthy: 160, benign breast lesions: 152), independent from subjects in the training cohort, and (B) 35 subjects who had been referred for breast biopsy were tested. The discrimination performance of the equation for each breast cancer stage (Stage 0: 1, Stage 1: 20, Stage 2: 17, Stage 3: 14, Stage 4: 11) was examined in the test cohorts. Also, information from breast cancer types as well as from benign breast lesions have been used to assess the performance of the discriminant score. The results of these analyses along with a discussion of the potential significance and plans for expanded clinical trials will be presented.

Citation Format: Akiyama H, Manlapaz V, Wong C, Yamazaki Y, Knapp M, Ohara S. Differences in serum miRNA signatures in women with pathology-confirmed breast cancer, benign breast diseases and healthy individuals with no cancer history [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 P6-03-11.

Abstract P4-10-07: Patient-centered initiatives for improving trial participation of diverse patient populations in the open-label phase 3b compLEEment-1 study of ribociclib plus letrozole in the treatment of HR+/HER2- advanced breast cancer

Background: Reported 10-year survival rates in Caucasian, black, and Hispanic women with breast cancer are 80%, 66%, and 78%, respectively. One barrier to understanding disparities in these survival rates is the lack of data due to underrepresentation in clinical trials (including black, Hispanic, Native American, and Pacific Islander populations). US physicians at sites that treat minority patients with breast cancer identified lack of access to and financial burden of clinical trials as 2 key barriers to enrollment. Insufficient knowledge of genetic mutations specific to breast cancer is also a key barrier to identifying ideal treatment to extend survival in minorities. Patient-specific initiatives for the CompLEEment-1 study (CLEE011A2404; NCT02941926), a single-arm, international Phase 3b study of ribociclib (600 mg/d, 3 weeks on/1 week off) plus letrozole (2.5 mg/d) in adults with hormone receptor–positive, human epidermal growth factor–negative advanced breast cancer, were developed in the United States to increase the enrollment of diverse populations and better understand the disease and patient response to treatment.

Methods: The enrollment initiatives included formation of a board of leading physicians and academics to advise on awareness initiatives and the cultural competency of tools used in clinical trials, a site selection process that brought the trial to the patient's clinic, a simplified expense reimbursement program to reduce patient economic burden, and partnerships with the Bridge Group and the National Black Church Initiative to bring clinical trial awareness and education to the African American church community. A tumor collection companion study (NCT03050398) was created to identify mechanisms of resistance among racial and ethnic groups. These initiatives aimed to increase the percentage of minorities from previous trials (eg, 5.7% in the MONALEESA-2 trial) and identify potential biological differences associated with race or ethnicity that might affect treatment response.

Results: Enrollment in the CompLEEment-1 study is ongoing. Among the first 57 US patients enrolled, 8 (14.0%) were minorities (not identified as Caucasian or Asian), 32 (56.1%) were &lt;65 years old, 7 (12.3%) were premenopausal women, and 2 (3.5%) were men. Thirty-one patients were enrolled in the simplified expense reimbursement program. Of the open study sites, 35 (52.2%) were located &gt;30 miles outside of metropolitan areas. Of the open study sites with enrolled patients, 16 enrolled 1, 8 enrolled 2, and 5 enrolled ≥3 patients.

Conclusions: Following discussions with physicians and assessments of patient feedback to identify reasons for underrepresentation of minority patient populations in clinical trials, patient-centered initiatives were developed for the CompLEEment-1 study in the United States to simultaneously reduce barriers to trial participation, reduce economic burden of enrolled patients, and identify biomarkers of therapeutic sensitivity and resistance. These initiatives resulted in an initial increase in the percentage of minorities enrolled to better reflect real-world populations.

Citation Format: Small T, Marsano-Feeley J, Fernandez A, Grasso T, Feldman K, Petrone S, Bugazia N, Wong C, Meyer J, Schutta K, Purkayastha D, Saintil K, Spatz Caplan E, Waltman-Johnson K. Patient-centered initiatives for improving trial participation of diverse patient populations in the open-label phase 3b compLEEment-1 study of ribociclib plus letrozole in the treatment of HR+/HER2- advanced breast cancer [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 P4-10-07.

Diagnostic performance of cytology for assessment of hepatic lipid content in dairy cattle

The objective of our study was to characterize the diagnostic performance of cytology for assessing hepatic lipid content (HLC) in dairy cows by comparing microscopic evaluation of lipid vacuolation in touch imprint slide preparations of liver biopsies with quantitative measurement of triglyceride concentration ([TG]; mg/mg of wet weight) in paired biopsy samples. Our study also sought to compare the diagnostic performance of liver cytology, plasma nonesterified fatty acid concentration ([NEFA]), and plasma β-hydroxybutyrate concentration ([BHB]) derived from a measurement performed on whole blood, for assessing HLC. Chemical extraction of TG from liver tissue remains the gold standard for quantifying HLC, largely because available blood tests, although useful for detecting some types of pathology, such as increased lipid mobilization, ketosis, or hepatocellular injury, are nonspecific as to etiology. Veterinary practitioners can sample bovine liver for cytological evaluation in a fast, minimally invasive, and inexpensive manner. Thus, if highly predictive of HLC, cytology would be a practical diagnostic tool for dairy veterinarians. In our study, liver biopsy samples from Holstein cows (219 samples from 105 cows: 52 from cows 2 to 20 d prepartum, 105 from cows 0 to 10 d in milk, 62 from cows 18 to 25 d in milk) were used to prepare cytology slides and to quantify [TG] using the Folch extraction method followed by the Hantzch condensation reaction and spectrophotometric measurement. An ordinal scale (0-4) based on amount of hepatocellular cytoplasm occupied by discrete clear vacuoles was used by 3 blinded, independent observers to rank HLC in Wright-Giemsa-stained slides. Interobserver agreement in cytology scoring was good. Corresponding plasma [NEFA] and [BHB] measurements were available for 187 and 195 of the 219 samples, respectively. Liver [TG] correlated more strongly with cytology score than with NEFA or BHB, and receiver operating characteristic curve analysis showed that cytology had better diagnostic performance than either NEFA or BHB for correctly categorizing [TG] at thresholds of 5, 10, and 15%. Hepatic lipidosis in high-producing dairy cows is of major clinical and economic importance, and this study demonstrates that cytology is an accurate means of assessing HLC. Additional work is indicated to evaluate the diagnostic utility of liver cytology.

A whole system approach to improving mortality associated with acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is in the main managed by non-nephrologists, many who feel challenged by or lack awareness of the complexity that the renal element adds to their patients' care. National reports have raised major concerns about the quality of care and have predicted that mortality reductions of 30% are achievable with good medical practice.

AIM

This quality improvement project evaluated whether a whole system approach could improve outcomes for patients with AKI.

DESIGN AND METHODS

Quality improvement methodology was used to understand hospital patterns, processes and professional knowledge. Change concepts were developed which included management of patients at risk, staff education and awareness program, development of a patient specific electronic alert to prompt diagnosis, easy to remember care bundle (ABCDE-IT), dedicated outreach team and patient and family empowerment leaflet.

RESULTS

Statistical process control analysis was used to verify outcomes over time. A shift in the in-hospital mortality rate corresponded to a relative 23.2% reduction in mortality and was sustained over the next 33 months (P < 0.0001). The favourable shift in mortality was temporally distinct from the improved AKI detection rate. This timeframe corresponded to lying below the 99.8% lower confidence limit in comparison with all English acute trusts for comparative AKI specific SHMI/HSMR mortality rates. Length of stay also reduced shortly after onset of the project by 14.1% or 2.6 day reduction (P < 0.0001).

CONCLUSION

This project demonstrated that an integrated, whole-system approach is necessary to ensure sustained improvements in AKI mortality and length of stay.