Clinicopathological Study of Enterocutaneous Fistula in Mymensingh Medical College Hospital

Enterocutaneous fistulae are a major catastrophe to the patients and surgeons and it still has high incidence of morbidity and mortality and their management remains a big challenge. Enterocutaneous fistula presents the surgeon with challenges of metabolic disorders and extensive sepsis. Total management of an intestinal fistula requires skill in nutritional support, stoma therapy, elimination of sepsis, well timed and well carried out surgery. Postoperative enterocutaneous fistulae account for approximately 80% of enterocutaneous fistulae. The majority of the intestinal fistula (75-85%) is iatrogenic occurring in the postoperative period following anastomotic dehiscence. They arise following emergency abdominal surgery for intestinal obstruction, inflammatory bowel disease or cancers. Protein calorie malnutrition alters the patients immune response, inflammatory reactions and tissue regenerations, all of which are essential for wound repair. The present study is an effort to highlight the incidence of enterocutaneous fistula after emergency and elective resection and anastomosis of gut with discussion over recent trends and developments in its management and compare with other studies. Objectives of the study are to determine the various clinicopathological features and management protocol of enterocutaneous fistula. There are recent advances in nutritional support. This descriptive type of cross-sectional study was carried out in the Department of Surgery, Mymensingh Medical College and Hospital, Mymensingh, Bangladesh from October 2010 to September 2011. Total 42 cases of enterocutaneous fistulae were selected purposively. Enterocutaneous fistulae are more common in patients of low economic condition. Enterocutaneous fistulae are more common after emergency abdominal surgery. Spontaneous closure occurred in 17(40.48%) cases and surgery needed in 25(59.52%) cases. Of them 20(80.00%) were healed and 5(20.00%) were expired. In spite of improvement in the management protocol of enterocutaneous fistula, there is still high unacceptable morbidity and mortality rate. Total parenteral nutrition (TPN) is not available and very costly, and health care facilities are also limited in our country. Patients with enterocutaneous fistula require fluid, electrolytes and nutritional support. Anaemia, dehydration, electrolytes imbalance should be corrected prior to abdominal surgery if possible. Surgical treatment for enterocutaneous fistula should be performed only after failure of conservative treatment of more than 12 weeks.

Is VEGF under-expressed in Indian children with Perthes disease?

BACKGROUND

The role of vascular endothelial growth factor (VEGF) after ischaemic necrosis of the femoral head in Legg-Calve-Perthes disease (LCPD) has not been adequately studied in humans, especially in Indian population. Therefore, we aimed to evaluate the serum levels of VEGF-A in Indian children with various stages of LCPD and compare them with those of an age- and sex-matched control group of healthy children.

METHODS

In this case-control study, we enrolled 42 children (below 14 years age) suffering from LCPD and 21 age- and sex-matched healthy controls. Patients were classified radiographically according to Waldenstrom's classification. Serum VEGF-A was estimated by sandwich enzyme-linked immunosorbent assay technique. The serum values were compared between the patient group and the control group, as well as between the Waldenstrom subgroups. Results were expressed as means with ranges or median with interquartile range.

RESULTS

The mean age in the patient as well as the control group was 9 years (range 4-13 years). The median value (interquartile range) of serum VEGF-A was 162.5 pg/ml (673.75 pg/ml) in the patient group and 652 pg/ml (190.5 pg/ml) in the control group (p = 0.013). When compared between lower Waldenstrom stages (initial stage + stage of fragmentation) and higher Waldenstrom stages (re-ossification stage + stage of healing), the mean values of serum VEGF-A were 464.7 pg/ml (range 0-2211 pg/ml) and 301.1 pg/ml (range 0-1910 pg/ml), respectively (p = 0.305).

CONCLUSIONS

VEGF is under-expressed in Indian children suffering from LCPD. As VEGF acts as a key regulator of endochondral ossification, our finding may open new therapeutic approaches to the disease. Also, serum VEGF may act as a valuable marker for the follow-up of the disease. Our study also provides baseline data about serum VEGF-A levels in Indian cohort of LCPD patients. Future multi-centre studies are warranted with a larger sample size to fully appreciate the patho-physiological changes in VEGF occurring in LCPD.

A multi-criteria decision-making approach to rank supplier selection criteria for hospital waste management: A case from Pakistan

To address environmental issues and cost effectiveness, waste management is necessary for healthcare facilities. Most importantly, segregation of hazardous and non-hazardous waste must be done as in many developing countries; disposal of both types of healthcare waste is done together, which is an unsafe practice. Waste generated in hospitals needs proper management to minimise hazards for patient and healthcare workers. At the same time, it is quite difficult for hospitals to find a systematic way to select appropriate suppliers for hospital waste management. Therefore, the purpose of this article is to identify, validate, and rank criteria that are essential for hospital waste management suppliers' selection. The analytical hierarchal process approach has been used and a survey from Pakistan's largest city (Karachi) has been considered to rank the most appropriate criteria that is necessary to select the supplier, especially in a developing country like Pakistan. Results show that waste management cost (45.5%) and suppliers' details (31.5%) are the top two main criteria for supplier selection; and storage cost (15.7%), waste handling cost (14.7%), and qualification of the suppliers (10.9%) are the top three most important overall sub-criteria for supplier selection for hospital waste management.

D-Meson Azimuthal Anisotropy in Midcentral Pb-Pb Collisions at sqrt[s]_{NN}=5.02 TeV

The azimuthal anisotropy coefficient v_{2} of prompt D^{0}, D^{+}, D^{*+}, and D_{s}^{+} mesons was measured in midcentral (30%-50% centrality class) Pb-Pb collisions at a center-of-mass energy per nucleon pair sqrt[s_{NN}]=5.02  TeV, with the ALICE detector at the LHC. The D mesons were reconstructed via their hadronic decays at midrapidity, |y|<0.8, in the transverse momentum interval 1<p_{T}<24  GeV/c. The measured D-meson v_{2} has similar values as that of charged pions. The D_{s}^{+} v_{2}, measured for the first time, is found to be compatible with that of nonstrange D mesons. The measurements are compared with theoretical calculations of charm-quark transport in a hydrodynamically expanding medium and have the potential to constrain medium parameters.

First report of Chikungunya virus circulation during a dengue outbreak in Arunachal Pradesh, a Northeastern state of India

Dengue has become a major public health problem in Pasighat, Arunachal Pradesh since 2012 outbreak. This region is rich in Aedes mosquitoes, the common vector for Dengue and Chikungunya (CHIK), however, active surveillance of CHIK is lacking in this part of India. Therefore, this study has been undertaken to detect the presence of CHIKV infection during 2014 and 2015 dengue outbreak in Arunachal Pradesh. A total of 116 (52 during 2014 and 64 during 2015 outbreak) dengue negative serum samples were collected from General Hospital, Pasighat and were screened for the presence of CHIK IgM antibodies. All the samples were further processed for CHIKV RNA detection by RT-PCR using specific primers. Phylogenetic tree was constructed by Neighbor Joining method using Kimura-2 parameter model. A total of 8 samples were found to be positive for IgM antibodies. RT-PCR showed CHIKV RNA positivity in 2 samples. Both of these samples belonged to 2014 outbreak. Phylogenetic tree revealed that the CHIKV circulating during the outbreak belonged to Eastern, Central and Southern African genotype. Sequence analysis showed two uniform nucleotide substitutions. Circulation of CHIKV masked by dengue is reported from this study. Therefore, CHIKV diagnosis should be made as a routine test in areas where dengue is already endemic so as to prevent misdiagnosis of the disease and to check its accomplishment before commencing an outbreak.

Abstract P6-07-09: Attenuation of progesterone driven mammary stem cell expansion by telapristone acetate

Purpose: The interplay of the ovarian hormones estradiol (E2) and progesterone (P4) contributes to the development of breast cancer, potentially aided by P4-induced expansion in mammary stem cells as observed in diestrous phase in mice, as well as the luteal phase and during pregnancy in women. Telapristone Acetate (TPA), a selective progesterone receptor modulator (SPRM), exhibits a protective effect against mammary carcinogenesis in rodents. TPA has been shown to display a more specific PR blockade and less toxicity when compared to RU486. We have examined the mammary stem cell pool expansion upon exposure to E2+P4 in mice and compared its attenuation by both TPA and RU486.

Methods: 8 week old female ovariectomized FVB mice weighing above 20g, were randomized into 4 treatment groups: sham (skin incision only, no pellets), E2+P4, E2+P4+Telapristone Acetate (TPA), E2P4+ Mifepristone (RU486). Eight experimental replicates were performed. At age 10 weeks, the mice were implanted with subcutaneous 30-day release pellets of E2 and P4 (0.3 mg E2 & 30.0 mg P4), E2P4+TPA (30.0 mg) and E2P4+RU486 (30.3 mg) in either flank. The mice were euthanized at day 15 of treatment. Single cell suspensions of the 4th inguinal mammary gland pair and one thoracic gland were prepared and labeled with cell surface markers. Lineage negative mammary gland cells were sorted into luminal and basal population subsets. The basal cell niche was identified as CD24+CD49fhi, the mammary stem cells (MaSC) within this niche are identified by CD61+CD49fhi. The cells were sorted on BD FACSAria 5-Laser and the data was analyzed using BD FACSDIVA.The D'Agostino-Pearson test was performed to determine the normal distribution and once normal distribution was confirmed one-way ANOVA (repeated measures) was performed to examine differences in percent cell populations with Tukey test for post-hoc analysis.

Results: The mammary stem cells (MaSC, CD61+CD49fhi) within the basal cell (CD24+CD49fhi) niche showed significant expansion at day 15 in mice implanted with Estrogen and Progesterone 30-day release pellet compared to sham (64.2%, 45.07% respectively; p=0.0392). This expansion was significantly attenuated in both TPA (-38.21%, p=0.011) and RU486 (-34.30%, p=0.002) treated mice compared to MaSC in mice treated with E2+P4 alone (+45.07%). Simultaneously, luminal progenitor cells (CD61+CD49flo) show a marked reduction in E2+P4 treated mice compared to sham (17.77%, 45.54%, respectively; p=0.0375). Luminal mature cells (CD61-CD49flo) show an expansion in E2+P4 treated mice compared to sham (82.23%, 54.41% respectively; %, p=0.0371). TPA significantly (58.40 %, p=0.061) suppresses LM cells expansion observed in the E2+P4 group. TPA and RU486 show significant suppression of the MaSC population in mouse mammary gland compared to the EP-treated mice.

Conclusion: TPA and RU486 alter the P4 driven changes in mammary gland cellular composition and in a manner consistent with the hypothesis that they will inhibit hormone-induced tumorigenesis in the mammary gland. To gain a better insight into this phenomenon, a high throughput transcriptomic profiling (RNASeq) of mammary stem cells isolated from the treatment groups is being performed.

Citation Format: Ranjan M, Lee O, Sun L, Karavites L, Clare S, Khan SA. Attenuation of progesterone driven mammary stem cell expansion by telapristone acetate [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 P6-07-09.

Abstract P5-14-01: Telapristone acetate abrogates PR-dependent paracrine-mediated mammary cell proliferation

Background: Blockade of the progesterone (P)-progesterone receptor (PR) axis is a novel but untested strategy for breast cancer prevention. We report preclinical data evaluating telapristone acetate (TPA) compared with mifepristone (MFP), the prototype PR-antagonist. We hypothesize that the progesterone-PR blockade by TPA will inhibit PR-dependent paracrine expression (RANKL, WNT4, ID4, and calcitonin) attenuating cell proliferation and abrogating side branching and alveoli formation of mammary glands induced by hormones similar in extent or superior to MFP.

Methods:Adult virgin FVB mice at 12 weeks of age were randomized to four treatment groups: no treatment control, EP (0.3 mg E + 30 mg P), EP + TPA (30mg), and EP + MFP (30mg). Hormone and drug pellets were subcutaneously implanted in flank area between the neck and shoulder. After 28-day treatments, the mice were euthanized to collect mammary glands, and processed as mammary whole mounts and as formalin-fixed paraffin embedding (FFPE) specimens. We evaluated cell proliferation (Ki67) by immunohistochemistry. Total RNA was extracted from FFPE specimens and the Nanostring nCounter assay was utilized to assess paracrine gene expression. The Mann Whitney test was used to calculate statistical significance (p&lt;0.05).

Results: We observed a considerable increase in side branches and alveoli in EP treatment group compared to the controls. The growth of the mammary gland stimulated by EP treatment was corroborated by a significant increase in Ki67 compared to control mice (median 41% vs 24%, respectively, p &lt; 0.0001). Both TPA and MFP treatment abrogated side branching and alveoli formation and significantly reduced median Ki67 to 1/3 of that of control mice having endogenous estrus cycle hormone levels (24%, 8%, and 9% for control, EP+TPA and EP+MFP groups, respectively).TPA induced greater Ki67 reduction than MFP (7.5 ± 1.9% vs. 9.4 ± 1.9%, p= 0.04). As expected, EP treatment upregulated the RANKL expression compared to the control group while the administration of TPA and MFP significantly inhibited the RANKL expression stimulated by EP treatment. The mRNA expression measurement revealed that Rankl expression was 18 fold increased by EP treatment but completely inhibited by TPA and MFP treatment (p&lt;0.001 for both drugs). Similarly the Rank expression was increased two-fold by EP treatment (p&lt; 0.05) but down-regulated by TPA and MFP treatment (p&lt;0.01 for both drugs). We observed significant upregulation of Wnt4, and Calca expression by EP treatment compared to controls (p&lt;0.01 for both). Id4 expression showed the same trend but the change was non-significant. The addition of TPA completely opposed the hormone-stimulated increase of three paracrine molecules (Wnt4, Calca, and Id4) to a level below control group (p&lt; 0.001 for all).

Conclusions: We have demonstrated that TPA abrogates cell proliferation induced by exogenous EP hormones in an ovary intact mouse model. The blockade of PR-P binding was evident by complete inhibition of paracrine expression (not only RANKL/RANK expression but also WNT4, Calcitonin, and ID4 expression). TPA was efficacious as MFP in opposing paracrine-induced mammary cell proliferation, and warrants further testing in a breast cancer prevention trial.

Citation Format: Lee O, Sun L, Karavites LC, Clare SE, Khan SA. Telapristone acetate abrogates PR-dependent paracrine-mediated mammary cell proliferation [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 P5-14-01.

Abstract ES11-2: Local therapy of limited disease in ABC: what is the evidence?

Surgery and radiotherapy have been used as adjunctive treatments for women with Stage IV breast cancer and a low volume of disease, for many years. This encompasses patients with intact or recurrent disease at the primary site, as well as those with oligometastatic distant disease. The evidence to support local therapy (LT) approaches in this group of patients is largely retrospective, although randomized trials are ongoing. For patients with an intact primary tumor, over 20 retrospective analyses suggest that women undergoing primary site LT (PSLT) experience longer survival than those whose primary tumor receives no LT, with one meta-analysis of these data reporting a hazard ratio (HR) of 0.69 (95%CI 0.63, 0.77). However, a concern about selection bias as the explanation for this apparent benefit has led to several randomized trials. Two of these were reported recently, with mixed results. The design and the results of the two completed trials were different. In Mumbai, India (NCT00193778), initial therapy consisted of chemotherapy followed by randomization to PSLT or not; results showed no overall survival difference, but local control was improved in the PSLT arm. In Turkey, MF07-01 randomized Stage IV patients to PSLT or not, followed by usual systemic therapy; results suggest an improvement in overall survival at 5 years for women in the PSLT arm. Two other randomized trials are ongoing, both designed with initial systemic therapy. In the meantime, existing data do not clearly support the use of PSLT as a means of improved survival, but the local control advantage was clear in both trials, and therefore PSLT may be offered to women whose primary tumors do not respond well to systemic therapy.

For women with oligometastatic disease, the data supporting LT measures is again retrospective, and consists of small, highly selected series. However, interest in LT approaches spans back many decades, and studies suggest that various strategies of surgery, radiotherapy, and more recently stereotactic body radiotherapy (SBRT), are associated with prolonged survival. The distant sites that have been subjected to these approaches include isolated metastases in lung, liver, bone, and brain. For isolated lung lesions in particular, resection also allows a clear distinction between primary and metastatic disease, since a large fraction of solitary lung lesions may in fact be primary lung tumors. In the liver, small retrospective series of highly selected patients undergoing resection suggest that longer-than-expected median survival can be observed in patients with limited disease and a long disease-free interval. Minimally invasive ablation techniques are being used with similar intent. For osseous sites, retrospective analyses of high-dose radiotherapy with ablative intent reflect similar caveats and similar results to the data on lung and liver. An important ongoing trial (NCT02364557) is randomizing women with a controlled primary tumor site and ≤2 metastatic lesions that are amenable to treatment with SBRT or surgery, to usual care or usual care with the addition LT to distant sites that must be separated by a distance of &gt;5 cm. These ongoing studies will bring much-needed clarity to the role pf LT approaches to both the primary site and limited distant disease.

Citation Format: Khan SA. Local therapy of limited disease in ABC: what is the evidence? [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 ES11-2.

A study of relationship between perceived stress, coping pattern, burnout, and general psychopathology among the postgraduate medical students

INTRODUCTION

Medical postgraduate student experience considerable stress during their training, which may cause agony to the individual or affect care rendered to the patient. Significant burnout and psychopathology has not been uncommon.

MATERIALS AND METHODS

A study was done to assess the relation between perceived stress, coping pattern, burnout, and general psychopathology among the postgraduate medical students.

RESULTS

Perceived stress was associated with higher scores on general psychopathology and burnout. Postgraduate students who displayed positive coping strategies had lesser perceived stress. Females had higher scores on perceived stress and psychopathology.

CONCLUSION

Stress is one of the major growing mental problems among highly educated health professional, and it should not be ignored as it can cause many other health issues.

J/ψ Elliptic Flow in Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

We report a precise measurement of the J/ψ elliptic flow in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV with the ALICE detector at the LHC. The J/ψ mesons are reconstructed at midrapidity (|y|<0.9) in the dielectron decay channel and at forward rapidity (2.5<y<4.0) in the dimuon channel, both down to zero transverse momentum. At forward rapidity, the elliptic flow v_{2} of the J/ψ is studied as a function of the transverse momentum and centrality. A positive v_{2} is observed in the transverse momentum range 2<p_{T}<8  GeV/c in the three centrality classes studied and confirms with higher statistics our earlier results at sqrt[s_{NN}]=2.76  TeV in semicentral collisions. At midrapidity, the J/ψ  v_{2} is investigated as a function of the transverse momentum in semicentral collisions and found to be in agreement with the measurements at forward rapidity. These results are compared to transport model calculations. The comparison supports the idea that at low p_{T} the elliptic flow of the J/ψ originates from the thermalization of charm quarks in the deconfined medium but suggests that additional mechanisms might be missing in the models.

Correlation between MRI and hip arthroscopy in children with Legg-Calve-Perthes disease

BACKGROUND

Most of the information available about Legg-Calve-Perthes disease (LCPD) at present is gained through imaging modalities including plain radiographs and magnetic resonance imaging (MRI). But the accuracy of MRI in this disease and its predictive value to reveal various intra-articular pathologies is not known. We correlated the findings of MRI with those seen on hip arthroscopy in children with active stage of LCPD.

METHODS

We conducted a prospective observational study in which MRI findings were correlated with corresponding findings on hip arthroscopy in a cohort of 25 patients of active LCPD below 12 years of age. The parameters noted on MRI included status of ligamentum teres, status of the labrum, synovial effusion if any, condition of the femoral and acetabular articular cartilage including chondral flaps, chondral indentation and intra-articular loose bodies. The indication of performing hip arthroscopy was persistent severe hip pain (Wong-Baker FACES pain scale ≥ 3) after 6 months of conservative management. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for MRI considering arthroscopy as a gold standard.

RESULTS

Synovial effusion was seen in a large number of patients on both MRI (17) and hip arthroscopy (24). The sensitivity (95% confidence interval) of MRI was found to be low, especially with respect to labral tears [25% (0.63-80.6)] and intra-articular loose bodies [20% (0.51-71.6)]. NPV for synovial effusion was also found to be low [12.5% (0.32-52.7)], although specificity and PPV of MRI were found to be good for all the parameters.

CONCLUSIONS

MRI cannot be completely relied upon for identifying all the intra-articular pathologies in children with LCPD, although it has a good complimentary role. In patients with severe persistent pain with suspicion for joint changes, hip arthroscopy can provide a safe and efficient procedure (better than MRI) for eliciting the associated joint pathology.

Anomalous Evolution of the Near-Side Jet Peak Shape in Pb-Pb Collisions at sqrt[s_{NN}]=2.76 TeV

The measurement of two-particle angular correlations is a powerful tool to study jet quenching in a p_{T} region inaccessible by direct jet identification. In these measurements pseudorapidity (Δη) and azimuthal (Δφ) differences are used to extract the shape of the near-side peak formed by particles associated with a higher p_{T} trigger particle (1<p_{T,trig}<8  GeV/c). A combined fit of the near-side peak and long-range correlations is applied to the data allowing the extraction of the centrality evolution of the peak shape in Pb-Pb collisions at sqrt[s_{NN}]=2.76  TeV. A significant broadening of the peak in the Δη direction at low p_{T} is found from peripheral to central collisions, which vanishes above 4  GeV/c, while in the Δφ direction the peak is almost independent of centrality. For the 10% most central collisions and 1<p_{T,assoc}<2  GeV/c, 1<p_{T,trig}<3  GeV/c a novel feature is observed: a depletion develops around the center of the peak. The results are compared to pp collisions at the same center of mass energy and ampt model simulations. The comparison to the investigated models suggests that the broadening and the development of the depletion is connected to the strength of radial and longitudinal flow.

Flow Dominance and Factorization of Transverse Momentum Correlations in Pb-Pb Collisions at the LHC

We present the first measurement of the two-particle transverse momentum differential correlation function, P_{2}≡⟨Δp_{T}Δp_{T}⟩/⟨p_{T}⟩^{2}, in Pb-Pb collisions at sqrt[s_{NN}]=2.76  TeV. Results for P_{2} are reported as a function of the relative pseudorapidity (Δη) and azimuthal angle (Δφ) between two particles for different collision centralities. The Δϕ dependence is found to be largely independent of Δη for |Δη|≥0.9. In the 5% most central Pb-Pb collisions, the two-particle transverse momentum correlation function exhibits a clear double-hump structure around Δφ=π (i.e., on the away side), which is not observed in number correlations in the same centrality range, and thus provides an indication of the dominance of triangular flow in this collision centrality. Fourier decompositions of P_{2}, studied as a function of the collision centrality, show that correlations at |Δη|≥0.9 can be well reproduced by a flow ansatz based on the notion that measured transverse momentum correlations are strictly determined by the collective motion of the system.

Abstract ES5-3: ES5-3 Targeting the breast, locally: Old and new approaches

The oldest local approach to breast cancer prevention is surgery. The largest and most rigorous description of this procedure in a high risk population comes from the Mayo Clinic, where 639 women underwent bilateral mastectomy for prevention between 1960 and 1993. Of these procedures, 90% were subcutaneous mastectomies, i.e. ∼90% of the breast was removed, with preservation of the nipple and areola. The breast cancer incidence in this population, with 13 year follow-up, was 90% of the expected incidence. A subset was tested for BRCA1/2 mutations, and among 26 mutations carriers, no cancers were observed. Subsequent studies have focused on more defined high risk populations, mainly carriers of BRCA1/2 mutations. In one recent meta-analysis, the pooled relative risk (RR) was 0.11; 95% CI, 0.04-0.32. However, all-cause mortality was unaffected by mastectomy. Nipple-sparing mastectomy has emerged as an option for mutation carriers recently, and data are beginning to accumulate that overall satisfaction with reconstruction results, and sexual well-being, are greater with the nipple-sparing procedures. The long-term cancer risk data following nipple-sparing procedures are not yet mature.

However, mastectomy carries a large physical and emotional cost, which could be avoided if effective non-surgical prevention options were available. Breast cancer prevention in high risk women and those with carcinoma in situ requires that the breast be exposed to an effective agent; systemic exposure is unnecessary, and its harms lead many eligible women to decline preventive therapy. Local transdermal therapy (LTT) to the breast involves the application of active drugs to the breast skin, resulting in high concentrations in the breast but low systemic exposure. It is non-invasive, self-delivered, and not dependent on hepatic metabolism. Existing data on LTT include two pre-surgical window trials of topical 4-hydroxytamoxifen (an active tamoxifen metabolite) in women with invasive breast cancer, and duct carcinoma in situ (DCIS). These demonstrate that LTT with 4-OHT decreases proliferation of invasive and non-invasive cancer cells to a similar degree as oral tamoxifen, with low systemic levels, and no effect on coagulation proteins. These data are promising regarding the use of LTT with 4-OHT for breast cancer prevention, and for therapy of DCIS, but also suggest that LTT could be developed for any small, lipophilic molecule with good dermal permeation, thus greatly expanding the menu of drugs that could be tested for breast cancer prevention. Another locally targeted approach involves the intraductal delivery of active drugs, using a catheter to cannulate the nipple duct orifice. Preliminary studies using Doxil in rodents and in humans have shown this is feasible, but concerns have been raised regarding carcinogenicity of cytotoxic drugs. More recently, RNA interference therapy, and trastuzumab conjugated to a cytotoxic alpha-emitter 225Ac, have been tried in mouse models of DCIS with some success. A trial of intraductal fulvestrant is on-going. Both transdermal and intraductal local therapy approaches hold promise, but are challenging in distinct ways. Nevertheless, ongoing research suggests that local therapy options for breast cancer prevention can move beyond surgical resection of breast tissue.

Citation Format: Khan SA. ES5-3 Targeting the breast, locally: Old and new approaches [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr ES5-3.

Abstract OT3-02-09: Phase II pre-surgical window trial of telapristone acetate (TPA) in early breast cancer and DCIS patients: Distribution of TPA in plasma, normal breast tissue and tumors

Background:In vitro and preclinical data support the notion that anti-progesterone therapy will have activity against both estrogen and progesterone receptors (ER/PR) positive and negative breast cancer, but biomarkers of efficacy may differ in different types of breast cancer. We have conducted a pre-surgical window trial of oral telapristone acetate (TPA, CDB-4124) treatment in early breast cancer patients. This first ever trial of oral TPA for breast cancer and DCIS patients will provide us pilot biologic data that will help select the right population and the right biomarkers for future trials. Here we report distribution of TPA in plasma and breast normal tissue and tumors collected at surgery.

Methods:our trial was a 1:1 randomized, double-blind, and placebo-controlled pre-surgical window trial of oral TPA 12mg (Proellex, CDB-4124, Repros Therapeutics Inc.) treatment for 2-10 weeks. 70 pre and postmenopausal women undergoing surgery for Stage 0-II breast cancer were recruited to the study. The surgical samples of 61 patients were used to determine the concentrations of TPA and its mono-demethylated metabolite (dTPA, CDB-4453) in plasma and matched normal tissue and tumor by Liquid chromatography–tandem mass spectrometry at the Illinois Institute of Technology, while maintaining the blind for the primary endpoint of cell proliferation. Statistical significance and analysis were calculated by Wilcoxon matched-pairs signed rank test and non-parametric Spearman correlation.

Results: We found that 32/61 women displayed detectable plasma concentrations of TPA and dTPA (median with IQR) 109ng/mL (71.3, 216) and 46.5 ng/mL (34.2, 73.7), respectively. TPA concentration was 2.3 times higher than dTPA in plasma (p&lt;0.0001). The normal and tumor tissue samples of these 32 women were further analyzed. In normal tissue samples, the concentrations of TPA and dTPA were 283 ng/g (70.7, 326) and 51.0 ng/g (24.4, 122), respectively. TPA concentration was 5.5 fold higher than dTPA in normal tissue (p&lt;0.0001). In tumors, the TPA and dTPA concentrations were 137 ng/g (31.1, 278) and 36.4 ng/g (17.3, 68.7), respectively. TPA concentration was 3.8 fold higher than dTPA in tumors (p&lt;0.0001).Interestingly, TPA and dTPA were more abundant in normal tissue than in tumors (p=0.0005 for TPA, and p=0.0013 for dTPA). We found that TPA and dTPA was highly correlated in plasma (r=0.492, p=0.0042). Plasma TPA concentration was highly correlated with normal tissue concentration (r=0.61, p=0.0003) but non-significantly correlated with tumor concentration (r=0.32, p=0.147). However, the normal and tumor tissue concentrations of TPA and dTPA were highly correlated (r=0.71, p=0.0002 for TPA and r=0.556, p=0.0072 for dTPA).

Conclusions: Plasma TPA concentrations reflect concentration in normal breast tissue better than in tumors. However, within the breast, TPA concentration in normal and tumor tissue is correlated. Our trial is to be unblended shortly, and we plan to relate these results to the proliferative rates in tumor and normal tissue. The variability observed in plasma and tissue concentrations also suggests that pharmacogenomics studies may be appropriate in the future.

Citation Format: Lee O, Muzzio M, Ivancic D, Rogers C, Allu S, Khan SA. Phase II pre-surgical window trial of telapristone acetate (TPA) in early breast cancer and DCIS patients: Distribution of TPA in plasma, normal breast tissue and tumors [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-02-09.

Correlated Event-by-Event Fluctuations of Flow Harmonics in Pb-Pb Collisions at sqrt[s_{NN}]=2.76 TeV

We report the measurements of correlations between event-by-event fluctuations of amplitudes of anisotropic flow harmonics in nucleus-nucleus collisions, obtained for the first time using a new analysis method based on multiparticle cumulants in mixed harmonics. This novel method is robust against systematic biases originating from nonflow effects and by construction any dependence on symmetry planes is eliminated. We demonstrate that correlations of flow harmonics exhibit a better sensitivity to medium properties than the individual flow harmonics. The new measurements are performed in Pb-Pb collisions at the center-of-mass energy per nucleon pair of sqrt[s_{NN}]=2.76  TeV by the ALICE experiment at the Large Hadron Collider. The centrality dependence of correlation between event-by-event fluctuations of the elliptic v_{2} and quadrangular v_{4} flow harmonics, as well as of anticorrelation between v_{2} and triangular v_{3} flow harmonics are presented. The results cover two different regimes of the initial state configurations: geometry dominated (in midcentral collisions) and fluctuation dominated (in the most central collisions). Comparisons are made to predictions from Monte Carlo Glauber, viscous hydrodynamics, ampt, and hijing models. Together with the existing measurements of the individual flow harmonics the presented results provide further constraints on the initial conditions and the transport properties of the system produced in heavy-ion collisions.

Importance of papillary muscle infarction detected by cardiac magnetic resonance imaging in predicting cardiovascular events

BACKGROUND

Recent studies suggest that papillary muscle infarction (PMI) following recent myocardial infarction (MI) correlates with adverse cardiovascular outcomes. The purpose of this study is to determine the prevalence and prognostic significance of PMI by cardiac magnetic resonance (CMR) in a large cohort of patients.

METHODS

Retrospective study of patients who underwent CMR between January 2007 and December 2009 were evaluated for the presence of PMI in one or both of the left ventricle papillary muscles. The primary outcome was a time to a combined endpoint of all-cause mortality and worsening heart failure. Secondary outcomes were time to individual components of the combined outcome.

RESULTS

419 patients were included in our analysis, 232 patients (55%) had ischemic cardiomyopathy. Patients were followed at six-month intervals for a median follow-up time of 3.7 (interquartile range (IQR): 1.6; 6.3) years after initial imaging. During this period 196 patients (46.8%) had a primary outcome and 92 patients (22%) died. PM infarct was identified in 204 (48.7%) patients with twice as many posteromedial (PRM) (27%) than anterolateral (ARL) lesions (11%) and a similar number with infarct in both (11%). There was no association between studied outcomes and the presence of PMI in either PRM or ARL PM. The presence of infarct in both PM was a predictor of both the primary outcome (HR 1.69, CI[1.01-2.86], p<0.049.) and mortality (HR 1.69, CI[1.01-4.2], p<0.046).

CONCLUSION

The presence of infarct in either papillary muscle was not associated with outcomes. However, infarct involving both papillary muscles was associated with worse outcomes.

Centrality Dependence of the Charged-Particle Multiplicity Density at Midrapidity in Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

The pseudorapidity density of charged particles, dN_{ch}/dη, at midrapidity in Pb-Pb collisions has been measured at a center-of-mass energy per nucleon pair of sqrt[s_{NN}]=5.02  TeV. For the 5% most central collisions, we measure a value of 1943±54. The rise in dN_{ch}/dη as a function of sqrt[s_{NN}] is steeper than that observed in proton-proton collisions and follows the trend established by measurements at lower energy. The increase of dN_{ch}/dη as a function of the average number of participant nucleons, ⟨N_{part}⟩, calculated in a Glauber model, is compared with the previous measurement at sqrt[s_{NN}]=2.76  TeV. A constant factor of about 1.2 describes the increase in dN_{ch}/dη from sqrt[s_{NN}]=2.76 to 5.02 TeV for all centrality classes, within the measured range of 0%-80% centrality. The results are also compared to models based on different mechanisms for particle production in nuclear collisions.

Measurement of an Excess in the Yield of J/ψ at Very Low p_{T} in Pb-Pb Collisions at sqrt[s]_{NN}=2.76 TeV

We report on the first measurement of an excess in the yield of J/ψ at very low transverse momentum (p_{T}<0.3  GeV/c) in peripheral hadronic Pb-Pb collisions at sqrt[s_{NN}]=2.76  TeV, performed by ALICE at the CERN LHC. Remarkably, the measured nuclear modification factor of J/ψ in the rapidity range 2.5<y<4 reaches about 7 (2) in the p_{T} range 0-0.3  GeV/c in the 70%-90% (50%-70%) centrality class. The J/ψ production cross section associated with the observed excess is obtained under the hypothesis that coherent photoproduction of J/ψ is the underlying physics mechanism. If confirmed, the observation of J/ψ coherent photoproduction in Pb-Pb collisions at impact parameters smaller than twice the nuclear radius opens new theoretical and experimental challenges and opportunities. In particular, coherent photoproduction accompanying hadronic collisions may provide insight into the dynamics of photoproduction and nuclear reactions, as well as become a novel probe of the quark-gluon plasma.