Bicycle accidents - do we only see the tip of the iceberg? A prospective multi-centre study in a large German city combining medical and police data

INTRODUCTION

Bicycles are becoming increasingly popular. In Münster, a German town with a population of 273,000, bicycles were the main method of transportation in 2009, used more often (37.8%) than cars (36.4%). Each day in Münster, bicycles are used around 450,000 times. In 1982, they were only used around 270,000 times a day. However, the increased use of bicycles has also led to an increased number of bicycle accidents.

METHODS

Between February 2009 and January 2010, data on bicycle-accidents leading to injuries were collected by the Police of Münster and in all emergency units of the six hospitals in Münster. A systematic acquisition of technical data from the police and the medical data from the hospitals were combined anonymously. None of the forms contained personal data of patients involved, except for patient age and sex as well as time and place of bicycle accidents to match the questionnaires. The data were entered into a central database (MS Access for input/MySQL for data retrieval).

RESULTS

2250 patients were included in this study. For each of these patients either a patient record or a hospital record or a police record or a combination of any of these different records existed in our database. In total, 1767 patients received medical treatment at a hospital and 484 people included in the study did not go to a hospital. Three fatalities occurred as a result of bicycle accidents. Considering reasons for hospital admission, traumatic brain injuries were the leading cause (25.7%). However, the largest resource consumption was attributed to fractures of the upper extremities (36.8%) and lower extremities (29.9%) with major surgery.

DISCUSSION

Bicycle accidents occur more frequently than indicated by police records. The results of the Münster Bicycle Study have shown that the actual number of bicycle accidents exceeds the officially reported number by nearly two times. Since bicycle helmets cannot prevent accidents it is recommended not only to focus on helmet use as the only injury prevention method. Other factors, such as weather, pavement and default of traffic, roadworthiness of the bicycles or alcohol/drug abuse also affect the accident rates.

SU-E-T-228: The Beauty and the Beast: Transition from Film/paper Charts to Paperless Environment with a New TrueBeam/ARIA System in a Small Community Hospital on a Tight Budget

PURPOSE

To review the issues a physicist may encounter in a community hospital during the transition from film/paper charts to a paperless environment with ARIA and a TrueBeam LINAC. With a lean budget, it was necessary for the physics group to take on the project management responsibilities in order save costs. This work highlights the lessons learned during the planning and execution of our project.

METHODS

Like many hospitals around the county, our hospital was caught in the economic downturn and was unable to provide all of the capital necessary to upgrade to the radiation oncology department. However, with the support of the hospital foundation, a total of $6M was secured for new LINAC, ARIA and CT simulator. To save costs on facilities and computers, it was necessary for the physics group to be involved in creating architectural drawings for shielding calculations, finding a vendor to remove the old linac, assisting the foundation to raise money, submission of the 'Certificate of Need' approval with the state, negotiation with vendors, IT infrastructure, reviews with the general contractor and vendor's project team, and ultimately writing the commissioning reports for the new systems as well as developing new policies and procedures.

RESULTS

During a period of 4 months, the old LINAC was removed, facility renovations made, the TrueBeam linac was installed, accepted, and commissioned and first patients were treated. In addition, we transitioned from a film/paper environment to a paperless environment. However, this was very stressful for staff and it may be advisable to stage such a project over a longer period of time. There was also significant lost revenue (∼$2M) during downtime of construction, installation, and commissioning.

CONCLUSIONS

The radiation oncology department was upgraded (The Beauty) on a tight budget but at the cost of added stress (The Beast) to the staff.

P4-03-06: Development and Comparative Characterization of Metastasis in Newly Developed Pre-Clinical Models of Inflammatory Breast Cancer

Background: Inflammatory breast cancer (IBC) is the most metastatic variant of breast cancer. It is associated with a poor survival rate (40% 5-year survival) despite appropriate multidisciplinary care. For such an aggressive type of cancer, IBC has been understudied, in part due to the lack of adequate numbers of cell lines and mouse models that recapitulate the human disease. To expand our understanding of IBC, we have obtained all of the previously developed and characterized IBC cell lines and models including Mary-X, SUM149, SUM190, KPL-4, MDA-IBC-3 and have developed two new IBC models, designated as FC-IBC01 and FC-IBC02, using tumor cells derived from pleural effusion of IBC patients.

Materials and Methods: Each of these IBC cell lines has been luciferase (LUC)-tagged, allowing the growth of orthotopic injection or subcutaneous implantation to be evaluated by bioluminescent imaging (BLI). Alternatively, the LUC-tagged IBC cells can by injected via either intra-cardiac or intravenous route of delivery, which promotes rapid tumor colonization, resulting in both visceral and skeletal metastasis. Growth of IBC tumors can then be monitored immediately using BLI, thus eliminating the lag time needed for the physical detection of palpable tumors. BLI imaging also allows for monitoring of the kinetics and location of development of metastatic lesions. Whole transcriptome analysis was performed on IBC cell lines and xenograft tissues to define the heterogeneity of IBC as a distinct variant of breast cancer

Results: These models have allowed us to identify micro-metastatic foci in multiple sites distant from the IBC primary tumor in each of these models of IBC and allow the quantitation of anti-tumor and anti-metastatic effects of targeted therapeutics as single agents as well as the potential synergy of combinations of agents. As an example, injection of LUC-tagged IBC cell lines such as SUM149-Luc, into the left ventricle of NOD.Cg-Prkdcscid Il2rgtm1Wjl/SzJ mice allows the metastatic tumor burden to be monitored longitudinally by whole animal BLI, which can be validated at necropsy and by immunohistochemical analysis. Whole transcriptome analysis of pre-clinical models of IBC reflect the molecular subtypes observed in IBC patients, with the majority of IBC models being of the basal like, luminal B and Her2 amplified. Discussion: First time analysis of known and newly developed pre-clinical models of IBC allows a more complete analysis of IBC as a distinct variant of breast cancer. Furthermore, these approaches allow rapid evaluation of the promising targeted therapeutics identified based on whole transcriptome analysis of both IBC patient tumors and pre-clinical models developed from IBC patients. We believe that this extensive collection of LUC-tagged IBC cell lines is an invaluable tool for IBC research since the cell lines encompass the broad spectrum of IBC heterogeneity.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-03-06.

P2-05-04: Mapping the Specific Gene Families Activated in the Lymphangiogenesis and Vasculogenic Mimicry Exhibited by Inflammatory Breast Cancer

Background: Inflammatory breast cancer (IBC) is the most metastatic variant of locally advanced breast cancer. Although IBC is diagnosed less commonly than other types of breast cancer, it is extremely aggressive, and accounts for a disproportionate number of breast cancer related deaths annually. IBC exhibits very specific patterns of lymphangiogenesis and vasculogenic mimicry, however detailed studies of the genes and proteins involved in these angiogenic processes are lacking. This study performed whole unbiased gene transcription studies with validation by protein arrays using all available pre-clinical cell lines and in vivo xenograft models of IBC, including a new model of IBC, FC-IBC01, which exhibits lymphovascular invasion, to identify the specific pathways involved in the distinctive angiogenesis observed in IBC.

Materials and Methods: Real-time quantitative RT-PCR, cDNA microarray gene profiling, immunofluorescence with confocal imaging and protein arrays were used to examine differential expression of specific angiogenic gene families including VEGFA,B,C,D, VEGF Receptor genes, and ANG/TIE genes linked to angiogenesis and lymphangiogenesis.

Results: Activity of the matrix metalloproteinase, MMP-2, is required for IBC tumor cells to undergo vasculogenic mimicry (VM), which is associated with a loss of TIMP-2, a well known inhibitor of angiogenesis. Therapeutics that target MMP activity can successfully inhibit this VM. Furthermore, pre-clinical models of IBC that form IBC tumor emboli exhibit lymphovascular invasion that is associated with distinct patterns of expression of genes that encode for distinct receptor tyrosine kinases that may represent important therapeutic targets for IBC.

Discussion: Identification of the distinct angiogenic pathways that are activated in IBC provides insight into the therapeutic targets that may abrogate the distinct lymphovascular invasion and vasculogenic mimicry that are linked to the aggressive metastasis of IBC.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-05-04.

P1-02-03: The Reciprocal Roles of E-Cadherin and ZEB1 Demonstrate the Mesenchymal-Epithelial Transition as a Primary Characteristic of Inflammatory Breast Cancer

Background: Inflammatory breast cancer (IBC) is a rare but very aggressive form of breast cancer. IBC is characterized by nests of tightly aggregated cells, defined as tumor emboli, that exhibit characteristics of cancer stem cells (CSCs). IBC tumor emboli express E-cadherin which is required to maintain their integrity and our recent evidence demonstrates that expression of E-cadherin by tumor emboli is associated with lack of ZEB1 expression, a transcriptional repressor of E-cadherin. This is at odds with the current hypothesis that metastatic progression is associated with the process of epithelial mesenchymal transition (EMT), with loss of E-cadherin and gain of transcription factors including ZEB1, acquisition of CSC characteristics and enhanced invasive capabilities.

Materials and Methods: shRNA knockdown and over-expression methods, real time PCR arrays, western blotting, and in vitro assays to evaluate proliferation, invasion, growth in soft agar and clonogenicity and in vivo animal studies were used.

Results: Expression of E-cadherin was reduced by shRNA and ZEB1 was expressed in SUM149 IBC tumor cells. Numerous EMT-related genes were upregulated with loss of E-cadherin and gain of ZEB1, including N-cadherin and vimentin. However, there were marginal differences in the in vitro parameters of proliferation, Matrigel invasion and anchorage independent growth in soft agar between SUM149-shECad or SUM149-ZEB1 clones and their respective vector control cells. The loss of E-cadherin and gain of ZEB1 altered the morphology of SUM149 cells when cultured under low adherence conditions permissive for the enrichment of CSC, exhibiting a reversion in grape-like morphology to more well defined spheres, which was accompanied by increased clonogenicity in both SUM149-shECad and SUM149-ZEB1 cells. The loss of E-cadherin and the gain of ZEB1 significantly inhibited tumor growth of cells injected in the mammary fat pad of NOD.Cg-Prkdcscid Il2rgtm1Wjl/SzJ mice. Tumor volume at 56 days for E-cadherin vector control cells was 771.9 mm3 +/− 185.6 compared to shECadherin tumors, which was 13.6 mm3 +/− 7.2. Tumor volume of ZEB1 vector control tumors was 346.1 mm3 +/− 96 compared to volume of ZEB1 expressing tumors, which was 21.5 mm3 +/− 7.2.Conclusions: E-cadherin with lack of ZEB1 expression in IBC is consistent with a mesenchymal-epithelial transition (MET), consistent with the retention of the epithelial phenotype while maintaining a program of rapid metastasis and colonization of lymph nodes and distant organ sites. Furthermore, we demonstrate that the E-cadherin-ZEB1 axis is critical for the in vivo growth of IBC tumor cells. Although SUM149 cells are fully capable of undergoing an EMT process, which is under negative regulation by E-cadherin, the process of EMT does not drive in vivo tumor growth in IBC.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-02-03.

Prognostic factors for stage IV gastric cancer

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Background: In general, the most significant prognostic factor for gastric cancer is tumor stage. In a patient with stage IV gastric cancer, other prognostic factors would be helpful to guide appropriate therapy and to avoid unnecessary suffering as well as fruitless and expensive therapy.

Methods: Data of all patients with gastric cancer managed at the Department of Surgery of The University of Hong Kong are entered prospectively into a computer database. Between January 1996 and December 2007, 1,109 patients who have not received prior treatment for their gastric cancer are included in the present study. Factors correlated with tumor stage as well as factors associated with survival are studied with univariate analysis. Significant factors are then subjected to multivariate analysis. In patients with stage IV disease, significant factors associated with survival are then studied with univariate and multivariate Cox regression analysis.

Results: 1,109 patients with age of 66 ± 14 years were included. There was a male predominance (M:F = 705:404). 18.1%, 10.3%, 28.3%, and 43.2% have stage I, II, III, and IV diseases, respectively. Spearman's rank correlation analysis identified haemoglobin, lymphocyte/WCC ratio (LWR), platelet count, albumin, CEA, CA19-9, and C-reactive protein (CRP) to be significantly correlated with tumor stage. Multivariate analysis identified LWR, platelet count, albumin, CA 19-9 and CRP as independent factors associated with tumor stage. On the other hand, CA19-9, CRP, LWR and tumor stage were found to be independent prognostic factors associated with overall survival. Among the group of patients with stage IV disease, ECOG status (OR 1.265, 95% CI 1.025 – 1.562), CA 19-9 (OR 1.0, 95% CI 1.0 – 1.0), CRP (OR 1.050, 95% CI 1.021 – 1.081) as well as LWR (OR 0.076, 95% CI 0.011 – 0.552) were found to be independent prognostic factors for survival.

Conclusions: Within the group of patients with stage IV gastric cancer, ECOG status, lymphocyte/ WCC ratio, serum CA19.9 and C-reactive protein level were found to be independent prognostic factors for survival.

No significant financial relationships to disclose.

Abstract P6-04-13: Gene and microRNA Signatures of the Mesenchymal Epithelial Transition in Pre-Clinical Models of Inflammatory Breast Cancer

Inflammatory breast cancer (IBC) is the most aggressive form of locally advanced breast cancer The pathological hallmark of IBC is lymphovasculogenesis resulting in the invasion of tightly adhered cells, defined as tumor emboli, into lymphovascular spaces of the dermis. IBC tumor emboli have been reported to over-express the glycoprotein E-cadherin, which is at odds with the current hypothesis that tumors with a metastatic phenotype lose E-cadherin, and gain expression of specific transcription factors and microRNAs (miRs) that mediate the process of epithelial mesenchymal transition (EMT). Immunohistochemical staining confirms the presence of E-cadherin on tumor emboli in IBC patient tissues as well as in Mary-X tumor xenografts, which is the only model to recapitulate tumor emboli in vivo. Using unbiased global transcriptional profiling, microRNA microarrays, real time PCR, Western blot validation, immunohistochemistry, immunofluorescence and confocal microscopy, we found that IBC cell lines, and Mary-X tumor emboli from xenografts had significantly elevated expression of genes and their corresponding proteins that collectively mediate tight homotypic cell:cell aggregation, including CDH1 which encodes for E-cadherin, DSC2, which encodes for Desmocollin 2 and JUP/CTNNG1, which encodes for junctional plakoglobin/gamma catenin. Regardless of molecular subtype, IBC cell lines and Mary-X tumor spheroids lacked detectable mRNA or protein for zinc finger E-box binding homeobox 1 gene, ZEB1, with very low levels of ZEB2 gene expression. The expression of CDH1, loss of ZEB1 and low gene expression of ZEB2 by IBC cell lines and Mary-X tumor spheroids was associated with increased expression of specific families of microRNAs including the miR 200 family known to be transcriptional regulators of E-cadherin. In contrast to lack of ZEB1 expression, IBC cell lines expressed either one or all of the SNAI1, SNAI2 and TWIST1 genes, which encode for transcription factors that have been associated with the process of EMT. IBC cell lines that contained ZEB1 cDNA lacked expression of CDH1 and did not produce E-cadherin protein, however the IBC/ZEB1 clones exhibited little difference in their ability to invade across an artificial Matrigel membrane compared to either vector control cells or the parental IBC cells. Taken together, the present observations suggest that pre-clinical models of IBC have distinct gene and microRNA signatures characterized by expression of genes and miRs that collectively support the persistence of compact tightly aggregated tumor cells within IBC tumor emboli, while maintaining an invasive and metastatic phenotype, suggesting that IBC tumor emboli display characteristics of the process of mesenchymal-epithelial transition (MET). Supported in part by the American Airlines-Komen For the Cure Foundation Promise Grant KGO81287 (FMR, MC) and The State of Texas Fund for Rare and Aggressive Breast Cancer (FMR, SK).

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-04-13.

Imaging protein statistical substate occupancy in a spectrum-function phase space

Hemeprotein ligand rebinding studies reveal varying IR absorbance and rebinding functions across a cryogenic ensemble. Since IR-active vibrations and rebinding barriers couple to structural coordinates, spectral and functional heterogeneity arise from conformational heterogeneity. Modeling rebinding data as a spectrally resolved superposition of first-order rate processes and employing maximum entropy regularization, protein heterogeneity is imaged as an ensemble occupancy of a spectrum-function phase space. Results from myoglobin rebinding carbon monoxide are discussed.