Supraesophageal Reflux: Validation of a Symptom Questionnaire

OBJECTIVES: To develop and validate a questionnaire for supraesophageal manifestations of reflux (SER) that will facilitate its study in clinical and research settings.

STUDY DESIGN: The Supraesophageal Reflux Questionnaire (SERQ) and previously validated Reflux Symptom Index (RSI) were subjected to multiple types of validity testing, including content validity, concurrent validity, reproducibility, and predictive validity.

RESULTS: The concurrent validity and reproducibility of both instruments was good to excellent for most items tested. The predictive validity of the SERQ was superior to the RSI when it included the covariates of history of sinusitis, use of over-the-counter antacid medications, age, gender, and body mass index.

CONCLUSIONS: The SERQ will serve as both a useful clinical and research tool by offering not only SER symptom information, like the RSI, but also information about the patient's medical history and medication usage that will facilitate use of the SERQ in research protocols.

EBM rating: B-2b

Listening-touch, Affect and the Crafting of Medical Bodies through Percussion

The growing abundance of medical technologies has led to laments over doctors' sensory de-skilling, technologies viewed as replacing diagnosis based on sensory acumen. The technique of percussion has become emblematic of the kinds of skills considered lost. While disappearing from wards, percussion is still taught in medical schools. By ethnographically following how percussion is taught to and learned by students, this article considers the kinds of bodies configured through this multisensory practice. I suggest that three kinds of bodies arise: skilled bodies; affected bodies; and resonating bodies. As these bodies are crafted, I argue that boundaries between bodies of novices and bodies they learn from blur. Attending to an overlooked dimension of bodily configurations in medicine, self-perception, I show that learning percussion functions not only to perpetuate diagnostic craft skills but also as a way of knowing of, and through, the resource always at hand; one's own living breathing body.

Eliciting Sound Memories

Sensory experiences are often considered triggers of memory, most famously a little French cake dipped in lime blossom tea. Sense memory can also be evoked in public history research through techniques of elicitation. In this article I reflect on different social science methods for eliciting sound memories such as the use of sonic prompts, emplaced interviewing, and sound walks. I include examples from my research on medical listening. The article considers the relevance of this work for the conduct of oral histories, arguing that such methods "break the frame," allowing room for collaborative research connections and insights into the otherwise unarticulatable.

Case report of a traumatic rectal neuroma

Traumatic neuroma is a well-recognized complication of lower extremity amputation, yet has also been noted to occur elsewhere. We report a clinical case and English-language literature review of traumatic rectal neuroma, a well-known pathologic entity not previously reported in this anatomic location.

Systematic review of intervention design and delivery in pragmatic and explanatory surgical randomized clinical trials

BACKGROUND

Surgical interventions are complex, with multiple components that require consideration in trial reporting. This review examines the reporting of details of surgical interventions in randomized clinical trials (RCTs) within the context of explanatory and pragmatic study designs.

METHODS

Systematic searches identified RCTs of surgical interventions published in 2010 and 2011. Included studies were categorized as predominantly explanatory or pragmatic. The extent of intervention details in the reports were compared with the CONSORT statement for reporting trials of non-pharmacological treatments (CONSORT-NPT). CONSORT-NPT recommends reporting the descriptions of surgical interventions, whether they were standardized and adhered to (items 4a, 4b and 4c). Reporting of the context of intervention delivery (items 3 and 15) and operator expertise (item 15) were assessed.

RESULTS

Of 4541 abstracts and 131 full-text articles, 80 were included (of which 39 were classified as predominantly pragmatic), reporting 160 interventions. Descriptions of 129 interventions (80.6 per cent) were provided. Standardization was mentioned for 47 (29.4 per cent) of the 160 interventions, and 22 articles (28 per cent) reported measurement of adherence to at least one aspect of the intervention. Seventy-one papers (89 per cent) provided some information about context. For one-third of interventions (55, 34.4 per cent), some data were provided regarding the expertise of personnel involved. Reporting standards were similar in trials classified as pragmatic or explanatory.

CONCLUSION

The lack of detail in trial reports about surgical interventions creates difficulties in understanding which operations were actually evaluated. Methods for designing and reporting surgical interventions in RCTs, contributing to the quality of the overall study design, are required. This should allow better implementation of trial results into practice.

EFNA3 long noncoding RNAs induced by hypoxia promote metastatic dissemination

The presence of hypoxic regions in solid tumors is an adverse prognostic factor for patient outcome. Here, we show that hypoxia induces the expression of Ephrin-A3 through a novel hypoxia-inducible factor (HIF)-mediated mechanism. In response to hypoxia, the coding EFNA3 mRNA levels remained relatively stable, but HIFs drove the expression of previously unknown long noncoding (lnc) RNAs from EFNA3 locus and these lncRNA caused Ephrin-A3 protein accumulation. Ephrins are cell surface proteins that regulate diverse biological processes by modulating cellular adhesion and repulsion. Mounting evidence implicates deregulated ephrin function in multiple aspects of tumor biology. We demonstrate that sustained expression of both Ephrin-A3 and novel EFNA3 lncRNAs increased the metastatic potential of human breast cancer cells, possibly by increasing the ability of tumor cells to extravasate from the blood vessels into surrounding tissue. In agreement, we found a strong correlation between high EFNA3 expression and shorter metastasis-free survival in breast cancer patients. Taken together, our results suggest that hypoxia could contribute to metastatic spread of breast cancer via HIF-mediated induction of EFNA3 lncRNAs and subsequent Ephrin-A3 protein accumulation.

Peripartum hysterectomy in a tertiary hospital in Western Sydney

The aim of this study was to review the incidence, indication, management and complications of peripartum hysterectomy (PH) in a tertiary level hospital over a decade. A retrospective review of all cases of PH performed at Westmead Hospital, Western Sydney, 2003-2012, was undertaken. PH was defined as hysterectomy performed after 20 weeks' gestation or any time after delivery but within 6 weeks' postpartum ( Awan et al. 2011 ). There were 56 cases of peripartum hysterectomy of 46,177 births, a rate of 1.22 per 1,000 births. The most common indication for PH was morbid adherence of the placenta (58.2%) followed by uterine atony. Having a history of both caesarean section and placenta praevia is highly associated with a morbidly adherent placenta in the index pregnancy (p = 0.002). The most common complication was coagulopathy followed by febrile illness and urinary tract injury. Our data showed previous caesarean section and placenta praevia to be associated with abnormal placentation, the leading indication for PH. Since there is an association between a planned caesarean hysterectomy and reduced amount of estimated blood loss and blood transfused, the knowledge of placentation and adequate preoperative planning and consideration for elective hysterectomy could be beneficial. The morbidity associated with PH is considerable.

Autobiologies on YouTube: Narratives of Direct-to-Consumer Genetic Testing

Despite a growing personal genomics market, little is known about how people engage with the possibilities offered by direct-to-consumer (DTC) genetic testing. In order to help address this gap, this study deploys narrative analysis of YouTube videos posted by individuals who have purchased DTC genetic testing for disease. Genetic testing is said to be contributing to new states of illness, where individuals may become "patients-in-waiting." In the videos analyzed, we found a new form of storytelling about this ambiguous state of illness, which we refer to as autobiology. Autobiology - the study of, and story about, one's own biology - concerns narratives of sense-making through forms of biological practice, as well as wayfaring narratives which interweave genetic markers and family histories of disease. These autobiologies - part of a broader shift toward public stories about genetics and other healthcare technologies - exhibit playfulness, as well as being bound with consumerist practices.

Molecular and genomic characterization of invasive circulating tumor cells (iCTCs) from men with metastatic castration-resistant prostate cancer (mCRPC)

120

Background: Identification, enumeration, and genomic analysis of circulating tumor cells (CTCs) may allow for a better understanding of the mechanisms of resistance to therapies in metastatic castration-resistant prostate cancer (mCRPC). The Vitatex VitaAssay platform captures invasive CTCs (iCTCs) in a cell surface marker-independent fashion based on their ability to invade a fluorescently-labeled cell-adhesion matrix (CAM), allowing for the analysis of multiple CTC subpopulations. Here we sought to estimate epithelial, mesenchymal, and stem-like iCTC subpopulation diversity in men with CRPC starting abiraterone acetate therapy, to compare the genomic profiles of iCTCs to matched metastatic biopsies, and to explore the potential for 2D and 3D CTC culture. Methods: iCTCs were isolated from men with mCRPC using the CAM platform, and paired metastatic biopsies were performed. iCTCs were defined as CAM+/CD45-/CD14-/DAPI+, mesenchymal iCTCs as vimentin+/CAM+/CD45-/CD14-/DAPI+, and stem-like iCTCs as CD44+/CAM+/CD45-/CD14-/DAPI+. iCTCs were enumerated and purified using FACS. Agilent array comparative genomic hybridization (aCGH) of iCTCs and paired biopsies was performed, and to explore the potential for ex-vivo cell expansion and spheroid formation, iCTCs were cultured separately in CAM and in matrigel for up to 10 days. Results: iCTCs were isolated using the CAM platform from 29 men, of whom seven have undergone paired metastatic biopsy. The median pre-FACS purity was 1.06% (range 0.11%-10.16%). Post-FACS purity was increased to greater than 90%, and a median of 60 (range 2 to 1,314) iCTCs/7.5ml were detected by FACS. Both vimentin+ and CD44+ iCTCs are detectable, and compromise between 10 to 50% of total iCTCs. iCTC aCGH profiles resemble paired soft tissue biopsy, in vitro iCTCs culture is feasible, and iCTC spheroids were observed. Conclusions: Multiple CRPC iCTC subpopulations are identifiable from men starting abiraterone therapy, and cell sorting techniques increase iCTC purity. iCTCs resemble metastatic CRPC tissue and can be expanded in culture. Further enumeration, genomic profiling, and clinical correlation of paired iCTCs taken from men with abiraterone-resistant CRPC is underway, and may shed light on mechanisms of abiraterone resistance.

Surgical correction of scoliosis in Rett syndrome: cord monitoring and complications

AIM

Rett syndrome is a progressive neurodevelopmental disorder that predominantly affects females and is associated with a high incidence of scoliosis and epilepsy. There is scant published work about intraoperative spinal cord monitoring in these patients and little more regarding the rate of perioperative complications. We investigated our institutions' experience with both.

METHODS

We retrospectively reviewed the records of 11 patients with Rett syndrome who underwent surgical correction of scoliosis at our institution between 2004 and 2010.

RESULTS

Eleven patients underwent successful correction of their scoliosis at an average age of 12. Eight of the patients suffered one or more significant complications. The average curve was corrected from 71° to 27°. Successful spinal cord monitoring was achieved in eight of the nine patients where it was attempted. No patient suffered any neurological complications. Average inpatient stay was 18.2 days.

CONCLUSION

Scoliosis surgery in patients with Rett syndrome carries a very high rate of complications and an average hospital stay approaching 3 weeks. Both caregivers and surgeons should be aware of this when planning any intervention. These patients frequently have useful lower limb function and spinal cord monitoring is a valid tool to aid in its preservation. We would suggest aggressive optimisation of these patients prior to surgery, with an emphasis on nutrition.

Abstract A153: Isolation and characterization of high-purity invasive CTCs from men with metastatic castration-resistant prostate cancer (mCRPC)

Introduction: As metastatic biopsies are often difficult and impractical to obtain; isolation, characterization, and genomic profiling of circulating tumor cells (CTCs) from men with metastatic castration resistant prostate cancer (mCRPC) is critical for understanding tumor progression and mechanisms of resistance to treatment. The Vitatex cell-adhesion matrix (CAM) platform captures invasive CTCs in both a cell surface marker- and size-independent manner based on the ability of CTCs to invade a fluorescently-labeled CAM. This platform allows for isolation and characterization of viable CTC sub-populations from individual patients with mCRPC. In this study, we sought to optimize CTC isolation and purification for downstream genomics and to explore epithelial-mesenchymal and stem-like CTC subtypes, all in the context of treatment resistance to Abiraterone, a novel inhibitor of androgen synthesis.

Methods: Forty ml of blood was collected from 23 patients with mCRPC. The CTCs were isolated using the VitaAssay platform and paired metastatic biopsies were obtained for a subset of men. Fluorescence-activated cell sorting (FACS) was coupled with the VitaAssay platform to increase cell purity. Invasive CTCs having ingested the fluorescent CAM were sorted based on CAM+/CD45-/CD14-/DAPI- staining. To complement the FACS data and for quality control, a subset of cases (N=11) were also enumerated using Immunocytochemistry (ICC), where CTCs were identified as CAM+/CD45-/CD14-/DAPI+. Healthy donor blood was used as a control. FACS-sorted stem-like CTCs were defined as CD44+/CAM+/CD45-/CD14-/DAPI- and mesenchymal CTCs were identified with ICC as vimentin+/CAM+/CD45-/DAPI+. Array comparative genomic hybridization (aCGH) of FACS-sorted CAM-avid amplified CTCs using Agilent microarrays was performed to obtain the CTC and matched biopsy genomic profiles.

Results: Enumeration of CTCs by VitaAssay coupled with FACS yielded an average of 72 CTCs per 7.5 ml blood (range 1 to 338) for the 23 patients. Only 4 of the 23 patients had ≤ 2 CTCs per 7.5 ml blood. No CTCs were detected in the healthy control subject after cell sorting. The CTC purity increased post-FACS to ∼90% from ∼1% pre-FACS. Enumeration along with genomic analysis (copy number aberrations) of CTCs and their subpopulations, comparison with matched biopsies and clinical data are currently being investigated.

Conclusions: Combining the VitaAssay platform with FACS allows for recovery of high purity mCRPC CTC subpopulations suitable for downstream molecular and genomic analysis. Ultimately, studies incorporating these optimized CTC methods will allow for better understanding of mechanisms of treatment resistance, disease progression and potentially identify new drug targets for CRPC.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):A153.

Citation Format: Gayatri Premasekharan, Terence W. Friedlander, Vy T. Ngo, Elizabeth Gilbert, Priya Sathaye, Anna Harris, Charles J. Ryan, Pamela L. Paris. Isolation and characterization of high-purity invasive CTCs from men with metastatic castration-resistant prostate cancer (mCRPC). [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr A153.

Exposure to anthrax toxin alters human leucocyte expression of anthrax toxin receptor 1

Anthrax is a toxin-mediated disease, the lethal effects of which are initiated by the binding of protective antigen (PA) with one of three reported cell surface toxin receptors (ANTXR). Receptor binding has been shown to influence host susceptibility to the toxins. Despite this crucial role for ANTXR in the outcome of disease, and the reported immunomodulatory consequence of the anthrax toxins during infection, little is known about ANTXR expression on human leucocytes. We characterized the expression levels of ANTXR1 (TEM8) on human leucocytes using flow cytometry. In order to assess the effect of prior toxin exposure on ANTXR1 expression levels, leucocytes from individuals with no known exposure, those exposed to toxin through vaccination and convalescent individuals were analysed. Donors could be defined as either 'low' or 'high' expressers based on the percentage of ANTXR1-positive monocytes detected. Previous exposure to toxins appears to modulate ANTXR1 expression, exposure through active infection being associated with lower receptor expression. A significant correlation between low receptor expression and high anthrax toxin-specific interferon (IFN)-γ responses was observed in previously infected individuals. We propose that there is an attenuation of ANTXR1 expression post-infection which may be a protective mechanism that has evolved to prevent reinfection.