A Systematic Review of Online Patient Resources to Support Shared Decision Making for Laparoscopic Cholecystectomy

BACKGROUND

RCS Eng, the Royal College of Surgeons of England, has published much information with regard to the consenting process. A majority of patients seek health information through online resources as well as discussing with the care givers. Therefore, it is necessary that online material is both of high quality and reliable for patients. We aimed to evaluate the quality and standard of the online patient information on laparoscopic cholecystectomy to help in the consenting process.

METHODS

A search was carried out as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Sources were assessed using five validated scoring tools: Flesch-Kincaid Reading Ease Score (readability), DISCERN and IPDAS scores (quality of content) and HONcode and the Information Standard Certification (standards of accreditation).

RESULTS

The average readability of all websites was higher than recommended for patient literature. Less than half of the sources had received HONcode or Information Standard accreditation. On grading of quality and content, across validated scoring tools, no source achieved the minimum recommended level.

CONCLUSION

Online patient information related to laparoscopic cholecystectomy is of poor quality. We recommend a multidisciplinary approach to participate in publishing more readable online resources of a higher standard to help patients and clinicians in consent and shared decision making.

Measuring the structure and equation of state of polyethylene terephthalate at megabar pressures

We present structure and equation of state (EOS) measurements of biaxially orientated polyethylene terephthalate (PET, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$({\hbox {C}}_{10} {\hbox {H}}_8 {\hbox {O}}_4)_n$$\end{document}(C10H8O4)n, also called mylar) shock-compressed to (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$155 \pm 20$$\end{document}155±20) GPa and (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$6000 \pm 1000$$\end{document}6000±1000) K using in situ X-ray diffraction, Doppler velocimetry, and optical pyrometry. Comparing to density functional theory molecular dynamics (DFT-MD) simulations, we find a highly correlated liquid at conditions differing from predictions by some equations of state tables, which underlines the influence of complex chemical interactions in this regime. EOS calculations from ab initio DFT-MD simulations and shock Hugoniot measurements of density, pressure and temperature confirm the discrepancy to these tables and present an experimentally benchmarked correction to the description of PET as an exemplary material to represent the mixture of light elements at planetary interior conditions.

Multicentre Investigation of Prognostic Factors Incorporating p16 and Tumour Infiltrating Lymphocytes for Anal Cancer After Chemoradiotherapy

AIMS

Anal squamous cell carcinomas (ASCC) are strongly associated with human papillomaviruses. Standard of care is chemoradiotherapy at uniform doses with no treatment stratification. Immunohistochemical staining for p16INK4A (p16), a surrogate for human papillomaviruses, is prognostic for outcomes. We investigated this alongside clinical-pathological factors, including tumour infiltrating lymphocyte (TIL) scores.

MATERIALS AND METHODS

Using an independent, multicentre cohort of 257 ASCC treated with chemoradiotherapy, pretreatment biopsies were stained and scored for p16 and TIL. Kaplan-Meier curves were derived for outcomes (disease-free survival [DFS], overall survival and cancer-specific survival), by stage, p16 and TIL scores and Log-rank tests were carried out to investigate prognostic effect. A multivariate analysis was carried out using Cox regression.

RESULTS

Stage, sex, p16 and TILs were independently prognostic. Hazard ratios for death (overall survival) were 2.51 (95% confidence interval 1.36-4.63) for p16 negative versus p16 positive, 2.17 (1.34-3.5) for T3/4 versus T1/2, 2.42 (1.52-3.8) for males versus females and 3.30 (1.52-7.14) for TIL1 versus TIL3 (all P < 0.05).

CONCLUSIONS

We have refined prognostic factors in ASCC. p16 adds to stratification by stage with respect to DFS in early disease and overall survival/DFS in locally advanced cancers. Our data support the role of the host immune response in mediating outcomes. These factors will be prospectively evaluated in PLATO (ISRCTN88455282).

712 Gastric Emptying Procedure in Oesophagectomy: Meta-Analysis of Surgical Pyloroplasty vs Nil Intervention

Introduction

Surgical pyloroplasty is often performed to reduce the rate of delayed gastric emptying. However, the clinical significance of this is not clear. The aim of this meta-analysis is to compare the rates of delayed gastric emptying, anastomotic leak, pulmonary complications, need for further pyloric intervention, and mortality in those patients undergoing pyloroplasty following oesophagectomy and those who do not.

Method

Relevant Randomised Control Trials and Cohort Studies were identified. The first group had no drainage procedure following oesophagectomy, whereas the second group underwent a drainage procedure (pyloroplasty). A random effects meta-analysis model was used to compare the outcomes.

Results

12 papers were utilised in the analysis, comprising a total 2567 patients. No significant differences were found between the two groups with regards to delayed gastric emptying (RR 0.87 [95% CI: 0.47 – 1.62], p = 0.66), anastomotic leak (RR 1.20 [95% CI: 0.82 – 1.74], p = 0.34), pulmonary complications (RR 1.04 [95% CI: 0.79 – 1.37], p = 0.79), need for further pyloric intervention (RR 1.44 [95% CI: 0.87 – 2.37], p = 0.16), and mortality (RR 1.18 [95% CI: 0.43 – 3.23], p = 0.75).

Conclusions

Surgical pyloric drainage procedures do not improve outcomes for patients undergoing oesophagectomy, nor does omitting the procedure worsens the outcomes.

Sublethal Impacts of Novaluron on Tarnished Plant Bug (Hemiptera: Miridae) Adults

Tarnished plant bug, Lygus lineolaris Palisot de Beauvois (Hemiptera: Miridae), has become a primary pest of cotton in the Midsouthern United States. Insect growth regulators such as novaluron are an important part of L. lineolaris management. While novaluron is lethal to nymphs, it does not kill adults, so it has been used when nymphs are the primary stage present. However, cotton yield protection was observed from an application of novaluron when adults were the predominant stage present. To explain this, a series of studies were conducted to examine sublethal impacts of novaluron to L. lineolaris adults. Novaluron ingestion by adults reduced hatch rate and sometimes reduced oviposition rate. Ingestion by either males or females reduced hatch rates, but the reduction was greater from female exposure. Contact exposure of adults with novaluron residues within 1 d of application reduced hatch rate by about 50%, but the impact on oviposition was inconsistent. A field study showed reduced hatch rate from contact exposure to mixed-age natural populations, but the overall net reproductive rate was not reduced. Surface exposure of eggs to novaluron did not reduce hatch rate. Overall, exposure of tarnished plant bug adults to novaluron, regardless of adult age or exposure route, reduced egg viability. However, the impact on oviposition rate and net reproductive rate varied with adult age and exposure route. This understanding of sublethal impacts of novaluron, in addition to lethal impacts on nymphs, should be considered when choosing application times to maximize effects on L. lineolaris populations.

Predicting the Risk of Disease Recurrence and Death Following Curative-intent Radiotherapy for Non-small Cell Lung Cancer: The Development and Validation of Two Scoring Systems From a Large Multicentre UK Cohort

AIMS

There is a paucity of evidence on which to produce recommendations on neither the clinical nor the imaging follow-up of lung cancer patients after curative-intent radiotherapy. In the 2019 National Institute for Health and Care Excellence lung cancer guidelines, further research into risk-stratification models to inform follow-up protocols was recommended.

MATERIALS AND METHODS

A retrospective study of consecutive patients undergoing curative-intent radiotherapy for non-small cell lung cancer from 1 October 2014 to 1 October 2016 across nine UK trusts was carried out. Twenty-two demographic, clinical and treatment-related variables were collected and multivariable logistic regression was used to develop and validate two risk-stratification models to determine the risk of disease recurrence and death.

RESULTS

In total, 898 patients were included in the study. The mean age was 72 years, 63% (562/898) had a good performance status (0-1) and 43% (388/898), 15% (134/898) and 42% (376/898) were clinical stage I, II and III, respectively. Thirty-six per cent (322/898) suffered disease recurrence and 41% (369/898) died in the first 2 years after radiotherapy. The ASSENT score (age, performance status, smoking status, staging endobronchial ultrasound, N-stage, T-stage) was developed, which stratifies the risk for disease recurrence within 2 years, with an area under the receiver operating characteristic curve (AUROC) for the total score of 0.712 (0.671-0.753) and 0.72 (0.65-0.789) in the derivation and validation sets, respectively. The STEPS score (sex, performance status, staging endobronchial ultrasound, T-stage, N-stage) was developed, which stratifies the risk of death within 2 years, with an AUROC for the total score of 0.625 (0.581-0.669) and 0.607 (0.53-0.684) in the derivation and validation sets, respectively.

CONCLUSIONS

These validated risk-stratification models could be used to inform follow-up protocols after curative-intent radiotherapy for lung cancer. The modest performance highlights the need for more advanced risk prediction tools.

Mapping frailty concepts to SNOMED CT

BACKGROUND

Frailty is considered an emerging syndrome characterized by a decrease in physiological ability to respond to stressors, leading to increased morbidity and mortality rates. Frailty is distinguished from normal age-associated decline because it is a sharp and often rapid decline rather than a gradual slowing down of general functioning. The comprehensive geriatric assessment is currently considered the gold standard for identifying frailty in older adults. The electronic version of this tool is called the eCGA and is commonly included in electronic medical records (EMR) in primary care settings.

OBJECTIVES

We explored the adequacy of SNOMED CT to represent frailty concepts by addressing three research questions: 1) What are the defining characteristics of frailty most commonly used in frailty assessment tools? 2) Are these characteristics captured within one or many frailty assessment tools? 3) Which data elements from existing tool(s) can be reliably mapped to existing SNOMED CT terms?

METHODS

We conducted a literature search to explore the defining characteristics of frailty and the most commonly used assessment tools. We compared these findings to the components of frailty captured within the eCGA. We then used a descriptive study design to manually map concepts from the eCGA to SNOMED CT.

RESULTS

Our literature review demonstrated that the eCGA contains all common defining characteristics of frailty. Unique assessment questions from the eCGA (n = 133) were manually mapped to SNOMED CT, using expert consensus. Of these, 72 % were direct matches, 17 % were one-to-many matches, and the remaining 11 % were non-matches. Two rounds of expert clinician mapping occurred; inter-rater reliability between the two clinicians was 0.75 (kappa).

CONCLUSIONS/IMPLICATIONS

The resulting list of mapped eCGA elements to SNOMED CT terms can inform revisions to existing chronic disease databases to include frailty monitoring and surveillance.

Left ventricular function and clinical heart failure after myocardial infarction revascularized with percutaneous coronary intervention - comparison between STEMI and NSTEMI in modern practice

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left ventricular systolic dysfunction (LVSD) is a common consequence of myocardial infarction (MI). Data from historic series identified LVSD in up to 60% of patients post-MI. However, in modern practice, with high-sensitivity cardiac biomarkers leading to early detection of MI and widespread use of early revascularization, the prevalence of LVSD in the acute phase of MI and its impact on subsequent clinical heart failure remains unknown.

Purpose

To ascertain the prevalence of LVSD on pre-discharge echocardiography and its impact on subsequent clinical heart failure after type 1 MI treated with percutaneous coronary intervention (PCI) in a UK tertiary cardiac centre.

Methods

A retrospective electronic patient records review of consecutive patients with type 1 MI treated with PCI between January 2016 - December 2017. Patients treated conservatively or with surgical revascularization were excluded.

Results

1000 consecutive patients were identified and 948/1000 who had an inpatient echocardiogram prior to discharge were included in this analysis – 413 ST elevation MI (STEMI) and 535 non-ST elevation (NSTEMI). Median door to balloon time for STEMI was 42 minutes (IQR 28-79). Median time from symptom onset to intervention for NSTEMI was 3 days (IQR 1-6). LVSD was defined as left ventricular ejection fraction (LVEF) &lt;50% on transthoracic echocardiogram carried out during the hospital episode. LVSD was significantly more prevalent in patients with STEMI compared to NSTEMI (37.4% vs 17.3%, p &lt; 0.001). Median LVEF was significantly lower in the STEMI population (55%, IQR 45-60) compared to patients with NSTEMI (60%, IQR 54-65), p &lt; 0.001. However, rates of clinical heart failure at index presentation with MI did not vary significantly between STEMI and NSTEMI patients (6.1% vs 4.9%, p = 0.414). In stepwise multivariate regression models: age, peak troponin and previous coronary artery bypass grafting were predictors of LVEF, whereas LVEF and previous MI were predictors of clinical heart failure

Patients with LVSD on pre-discharge echocardiography had significantly higher rates of 30-day readmission with heart failure (2.9% vs 0.7%, p = 0.017), 30-day all-cause mortality (6.1% vs 2%, p = 0.001), 30-day cardiac mortality (5.7% vs 1%, p &lt; 0.001) and 2-year all-cause mortality (5.7% vs 1.6%, p = 0.001). However, at 2-years, there was no difference in hospital readmission with heart failure (0.8% vs 0.3%, p = 0.276). There were no significant differences between STEMI and NSTEMI patients for these endpoints.

Conclusions

Early revascularisation with PCI has led to a reduction in the prevalence of early LVSD post-MI compared to historical data. However, the presence of LVSD remains a powerful predictor of adverse clinical outcomes. Despite lower rates of LVSD on pre-discharge echocardiography in patients with NSTEMI compared with STEMI, the incidence of subsequent clinical heart failure is similar. This however may be underestimated due to survival bias.

Clinical utility of skin cancer and melanoma risk scores for population screening: TRoPICS study

BACKGROUND

Screening for skin cancer can be cost-effective if focused on high-risk groups. Risk prediction tools have been developed for keratinocyte cancers and melanoma to optimize advice and management. However, few have been validated in a clinical setting over the past few years.

OBJECTIVES

To assess the clinical utility of risk assessment tools to identify individuals with prevalent skin cancers in a volunteer-based screening clinic.

METHODS

Participants were adults presenting for a skin check at a volunteer-based skin cancer screening facility. We used previously published tools, based on questionnaire responses, to predict melanoma and keratinocyte cancers [KCs; basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)] and classified each participant into one of five risk categories. Participants subsequently underwent a full skin examination by a dermatologist. All suspicious lesions were biopsied, and all cancers were histopathologically confirmed.

RESULTS

Of 789 people who presented to the clinic, 507 (64%) consented to the study. Twenty-two BCCs, 19 SCCs and eight melanomas were diagnosed. The proportion of keratinocyte cancers diagnosed increased according to risk category from <1% in the lowest to 24% in the highest risk category (P < 0.001). Subtype analysis revealed similar proportionate increases in BCC or SCC prevalence according to risk category. However, a similar proportion of melanoma cases were detected in the low-risk and high-risk groups.

CONCLUSION

The risk prediction model for keratinocyte cancers can reliably identify individuals with a significant skin cancer burden prior to a skin examination in the community setting. The prediction tool for melanoma needs to be tested in a larger sample exposed to a wider range of environmental risk factors.

The Impact of Maltreatment on Internalizing Symptoms for Foster Youth: an Examination of Spirituality and Appraisals as Moderators

Research shows that exposure to child maltreatment increases the risk of internalizing symptoms for youth, and that youth in foster care are at a particularly high risk of symptoms. However, not all youth who experience maltreatment evidence maladjustment, making the link between exposure and mental health outcomes unclear and creating a need to examine what factors buffer against symptomatology. A sample of youth in foster care was used to provide a new examination of the relation between child maltreatment exposure and internalizing symptoms, to test the possible moderating effects of both appraisals and spirituality, and examine differences between children and adolescents. Participants were 486 youth in foster care (M age = 13; 204 children; 282 adolescents). Youth completed self-report measures through the SPARK project (Studying Pathways to Adjustment and Resilience in Kids). Although appraisals and spirituality were not significant moderators, significant main effects emerged. For children, regression analyses showed that maltreatment exposure and lower scores on spiritual prosocial attitudes accounted for the majority of the 21% of the variance in internalizing symptoms. For adolescents 28% of the variance in internalizing symptoms was accounted for by greater maltreatment exposure, lower scores on spiritual prosocial attitudes, higher scores on relationship with a God/Higher Power, and more negative appraisals of stressful life events. The current study provides support for cognitive-based interventions for adolescents aimed at increasing appraisal flexibility and suggests that both children and adolescents could benefit from the development of prosocial attitudes often tied to spirituality but could be reinforced in additional settings.

People with Type Diabetes Mellitus (T1DM) self-reported views on their own condition management reveal links to potentially improved outcomes and potential areas for service improvement

BACKGROUND

The self-management of type 1 diabetes (T1DM) has moved forward in many areas over the last 40 years. Our study asked people with T1DM what is their experience of blood glucose (BG) monitoring day to day and how this influences decisions about insulin dosing.

METHODS

An on-line self-reported questionnaire containing 44 questions prepared after consultation with clinicians and patients was circulated to people with T1DM 116 responders provided completed responses. Fixed responses were allocated specific values (e.g. not confident = 0 fairly confident = 1). Multivariate regression analysis was carried out. Only those 5 factors with p-value <0.05 were retained.

RESULTS

59% of respondents were >50 years old and 66% had diabetes for >20 years, with 63% of patients reporting HbA1c results ≤8% or 64 mmol/mol. Findings included; 75% used only 1 m; 56% had used the same meter for ≥3 years; 10% had tried flash monitors; 47% were concerned about current BG level; 85% were concerned about long-term impact of higher BG. 72% of respondents keep BG level high to avoid hypoglycaemia; 25% used ≥7 mmol/L as pre-meal BG target to calculate dose; 65% were concerned they might be over/under-dosing; 83% did not discuss accuracy when choosing meter. However 85% were confident in their meter's performance. The factors that linked to LOWER HbA1c included LESS units of basal insulin (p < 0.001), HIGHER number of daily BG tests (p = 0.008), LOWER bedtime blood glucose (p = 0.009), HIGHER patient's concern over long-term impact of high BG (BG) (p < 0.009 but LOWER patient's concern over current BG values (p = 0.009). The final statistical model could explain 41% of the observed variation in HbA1c.

CONCLUSION

Many people still run their BG high to avoid hypoglycaemia. Concern about the longer-term consequences of suboptimal glycaemic control was associated with a lower HbA1c and is an area to explore in the future when considering how to help people with T1DM.

Ischaemic mitral regurgitation: incidence, clinical and angiographic characteristics of 1000 patients with type 1 myocardial infarction undergoing percutaneous coronary intervention

Background

Previous studies of the incidence and severity of mitral regurgitation (MR) following acute myocardial infarction (MI) were limited by the study population (ST-elevation MI only), by diagnostic methods (lack of multiparametric quantification), or by the time-frame of study (late assessment post-MI). The true incidence of ischaemic MR (IMR) immediately following type 1 MI [non-ST-elevation (NSTEMI) and ST-elevation (STEMI)] patients in the modern era of universal early revascularisation remains unclear. Since even mild IMR confers a poor prognosis, factors which promote or protect against the development of MR require further evaluation.

Purpose

To determine the incidence, clinical and angiographic characteristics of patients with IMR following type 1 MI treated with PCI.

Methods

This was a single-centre study of 1000 consecutive, prospectively recruited patients admitted to the Queen Elizabeth Hospital Birmingham with type 1 MI who underwent PCI. Early inpatient transthoracic echocardiography (TTE) was performed by accredited echocardiographers using standard multiparametric quantification.

Results

MR was observed in 294/1000 patients (29.4%) post-MI, graded as mild (76%), moderate (21%) and severe (3%). Median time from symptom onset to PCI was 1 day (IQR 0–4) and to TTE 2 days (IQR 1–3).

Compared to patients without MR (MR-), those with MR (MR+) were older (73±12 years vs 66±13 years; p&lt;0.001), male (75% vs 64%; p&lt;0.001) and more likely to have a history of hypertension (HTN) (63% vs 55%; p=0.0117), heart failure (HF) (3.4% vs 1.1%; p=0.0140) and previous MI (28% vs 20%; p&lt;0.005). MR+ patients more frequently presented with HF (8.5% vs 4.2%; p=0.0075), lower LV ejection fraction (LVEF) (50±14% vs 55±11%; p&lt;0.001) and higher peak high sensitivity troponin T (765ng/L, IQR 170–3032 vs 400ng/L, IQR 51–1966; p&lt;0.0001).

MR+ patients were more likely to have severe disease in the left circumflex (LCx) (50% vs 33%; p&lt;0.0001) or right coronary artery (RCA) (51% vs 43%; p=0.0135). Incidence of severe disease in the left main stem and left anterior descending artery (LAD) did not significantly differ between the two groups.

Incidence of MR was equal (29%) amongst STEMI (126/431) and NSTEMI (168/569) patients. While the time to revascularisation did not affect the prevalence of MR following STEMI (linear regression analysis of door-to-balloon time in MR+ and MR- patients p=0.843), NSTEMI patients were more likely to develop MR if revascularisation was delayed (linear regression analysis of symptom onset to PCI time MR+ vs MR- p=0.061).

Conclusion

Almost 1/3 of patients with type 1 MI undergoing revascularisation have MR evident on pre-discharge TTE. Factors promoting MR include older age, male sex, HTN, HF, larger non-LAD territory infarct, and depressed LVEF. The incidence of MR following STEMIs and NSTEMIs is equal. Earlier revascularisation is unlikely to reduce MR in STEMI patients but may improve MR prevalence following NSTEMI.

Funding Acknowledgement

Type of funding source: None

Risk stratification on echocardiography and outcome in ischaemic mitral regurgitation

Background

Ischaemic mitral regurgitation (IMR) confers a poor prognosis. Transcatheter intervention may improve survival but benefit is likely to depend on severity of IMR relative to LV remodelling following myocardial infarction (MI). In theory, those with “discordant” IMR (significant regurgitant volume without severe LV dilatation or impairment), are expected to benefit most from mitral intervention. While subcategorization may help to inform treatment, there are no data on post-MI patients in this respect.

Purpose

To determine the incidence of discordant & concordant IMR categorised on echocardiography post-MI and impact on outcomes.

Methods

1000 consecutive patients admitted to our hospital with myocardial infarction who underwent coronary angioplasty were included. Early inpatient TTE was performed by accredited echocardiographers using standard multiparametric quantification.

Using TTE parameters, 4 subgroups were identified (figure) according to the degree of MR relative to LV remodelling. Thresholds were based on European guidelines (± 2SD from normal) and median value among survivors for vena contracta (VC):

– LVEF: 52% (♂), 54% (♀)

– Indexed LV end diastolic volume (LVEDVi): 74ml/m2 (♂), 61ml/m2 (♀)

– Effective regurgitant orifice area (EROA) ≥0.2cm2

– Regurgitant volume (RVol) ≥30ml

– VC ≥0.5cm

Results

MR was seen in 294/1000 patients (29.4%) with a severity of mild (76%), moderate (21%) and severe (3%). Concordant and discordant IMR were each seen in 16/294 (5%) of IMR patients post-MI.

After a mean follow up of 3.2 years, IMR patients had a 3% rate of heart failure (HF) within 1 year and 19% mortality. Non-survivors had significantly worse IMR (PISA 0.65±0.25cm vs 0.54±0.19cm; p=0.033; VC 0.63±0.25cm vs 0.49±0.18cm; p=0.014), worse LV function (LVEF 44±17% vs 51±13%; p&lt;0.001), larger LV (LVEDVi 67±23ml/m2 vs 60±22ml/m2; p=0.032) and larger indexed LA volume (LAVi) (44±22ml vs 35±15ml; p&lt;0.001). Those with concordant IMR had the worst survival (50%) although almost 1 in 5 of those with discordant MR died within the follow up period (19%). Using multivariable Cox regression, significant predictors of mortality included LVEF (p&lt;0.001; HR 0.96, 0.94–0.98) and LAVi (p&lt;0.001; HR 1.02, 1.01–1.03) but not LVEDVi.

Conclusion

1) Significant predictors of mortality in IMR include LA dilatation and decline in LVEF, but not LV dilatation.

2) Although discordant severe IMR is uncommon following MI, mortality if left untreated remains high. Attention should be paid to early selection of this cohort for intervention.

Funding Acknowledgement

Type of funding source: None

Clinical and molecular characteristics and treatment outcomes of advanced right-colon, left-colon and rectal cancers: data from 1180 patients in a phase III trial of panitumumab with an extended biomarker panel

BACKGROUND

Primary tumour location (PTL) is being adopted by clinicians to guide treatment decisions in metastatic colorectal cancer (mCRC). Here we test PTL as a predictive marker for panitumumab efficacy, and examine its relationship with an extended biomarker profile. We also examine rectal tumours as a separate location.

PATIENTS AND METHODS

mCRC patients from the second-line PICCOLO trial of irinotecan versus irinotecan/panitumumab (IrPan). PTL was classified as right-PTL, left-PTL or rectal-PTL. PTL was assessed as a predictive biomarker for IrPan effect in RAS-wild-type (RAS-wt) patients (compared with irinotecan alone), then tested for independence alongside an extended biomarker profile (BRAF, epiregulin/amphiregulin (EREG/AREG) and HER3 mRNA expression).

RESULTS

PTL data were available for 1180 patients (98.5%), of whom 558 were RAS-wt. High HER3 expression was independently predictive of panitumumab overall survival improvement, but PTL and EREG/AREG were not. IrPan progression-free survival (PFS) improvement compared with irinotecan was seen in left-PTL [hazard ratio (HR) = 0.61, P = 0.002) but not right-PTL (HR = 0.98, P = 0.90) (interaction P = 0.05; RAS/BRAF-wt interaction P = 0.10), or in rectal-PTL (HR = 0.82, P = 0.20) (interaction P = 0.14 compared with left-PTL; RAS/BRAF-wt interaction P = 0.04). Patients with right-PTL and high EREG/AREG or HER3 expression, had IrPan PFS improvement (high EREG/AREG HR = 0.20, P = 0.04; high HER3 HR = 0.33, P = 0.10) compared with irinotecan. Similar effect was seen for rectal-PTL patients (high EREG/AREG HR = 0.44, P = 0.03; high HER3 HR = 0.34, P = 0.05).

CONCLUSIONS

RAS-wt patients with left-PTL are more likely to have panitumumab PFS advantage than those with right-PTL or rectal-PTL. However, an extended biomarker panel demonstrated significant heterogeneity in panitumumab PFS effect within a tumour location. AREG/EREG and HER3 mRNA expression identifies patients with right-PTL or rectal-PTL who achieve similar PFS effect with panitumumab as left-colon patients. Testing could provide a more reliable basis for clinical decision making. Further validation and development of these biomarkers is required to optimise routine patient care.

CLINICAL TRIAL REGISTRATION

ISRCTN identifier: ISRCTN93248876.

Parasite-modified behaviour in non-trophic transmission: trematode parasitism increases the attraction between snail intermediate hosts

Many parasites with complex life cycles cause host behavioural changes that increase the likelihood of transmission to the next host. Parasite modification is often found in trophic transmission, but its influence on non-trophic transmission is unclear. In trematodes, transmission from the first to second intermediate host is non-trophic, suggesting that free-swimming larvae (cercariae) emerging in closer proximity to the next host would have higher transmission success. We performed a series of behavioural experiments with echinostome trematodes and their snail hosts to determine if potential second hosts (ramshorn snail, genus Planorbella Haldeman, 1842) were more attracted to parasitized first hosts (marsh pondsnail, Lymnaea elodes Say, 1821). In a Y maze, a responding snail (Planorbella sp.) was placed in the base and its response to five treatments was assessed: no stimulus, turion duckweed (Lemna turionifera Landolt; a food item), non-parasitized L. elodes, parasitized L. elodes, and finally parasitized versus non-parasitized L. elodes. Snails showed some attraction to uninfected snails, but had a stronger response to infected first host snails. These results indicate that potential second host snails were more attracted to parasitized, heterospecific first host snails over non-parasitized heterospecific snails. This study demonstrates that echinostome trematodes alter snail behaviour by changing navigational choices in uninfected potential hosts through a chemical communication mechanism.