The neurocritical care research network: NCRN

Neurocritical care diseases carry a high morbidity and mortality. Therapeutic and technological advances in neurocritical care have greatly improved the outcome of a variety of life-threatening disorders including traumatic brain injury, acute ischemic stroke, intracerebral and subarachnoid hemorrhage, and anoxic injury following cardiac arrest. These advances have stemmed from a better understanding of the physiology of neurocritical care illnesses, improved neuromonitoring techniques, and the introduction of more efficacious treatments. Despite all the advances in neuromonitoring, diagnostic imaging, and emerging treatments, much research needs to be undertaken in neurocritical care. Many of the clinical trials carried out in the general critical care population have excluded neurocritical care patients. For instance, the landmark ARDSNET trial that demonstrated the beneficial effects of low tidal volume ventilation in patients with ARDS cannot be directly applied to neurocritical care patients who frequently may experience this pulmonary complication. There is a need for a more cohesive and integrated research system or network to establish a track record for high-quality, investigator-initiated clinical research in neurocritical care. Such a system may help us overcome potential impediments to the future advancement of neurocritical care research. We propose the creation of the neurocritical care research network. The mission of the Network is to facilitate multicenter and multidisciplinary collaboration and patient enrollment in clinical trials of specific neurocritical care diseases.

Research and technology in neurocritical care

The daily practice of neurointensivists focuses on the recognition of subtle changes in the neurological examination, interactions between the brain and systemic derangements, and brain physiology. Common alterations such as fever, hyperglycemia, and hypotension have different consequences in patients with brain insults compared with patients of general medical illness. Various technologies have become available or are currently being developed. The session on "research and technology" of the first neurocritical care research conference held in Houston in September of 2009 was devoted to the discussion of the current status, and the research role of state-of-the art technologies in neurocritical patients including multi-modality neuromonitoring, biomarkers, neuroimaging, and "omics" research (proteomix, genomics, and metabolomics). We have summarized the topics discussed in this session. We have provided a brief overview of the current status of these technologies, and put forward recommendations for future research applications in the field of neurocritical care.

P4-07-11: Circulating Tumor Cells after Neoadjuvant Therapy Predict Outcome in Stage I to III Breast Cancer

Introduction: Circulating tumor cells (CTCs) predict outcome in metastatic breast cancer, but their significance is unclear in non-metastatic patients. Furthermore, it is unclear if the presence of CTCs after completion of neoadjuvant chemotherapy (NACT) predicts worse outcome. The purpose of this study was to determine if CTCs after NACT predicts worse outcome.

Methods: Clinical stage I-III breast cancer patients seen at a single tertiary cancer center provided informed consent to participate in an IRB-approved study involving collection of blood (7.5 ml x 2 tubes) at the time of surgery for their primary breast cancer. CTCs were detected using the Cell SearchTM system. A positive result was defined as the presence of one or more cells per 7.5 ml blood since the threshold for positivity has not been established in non-metastatic breast cancer. Statistical analyses used chi-square and Fischer's exact test.

Results: One hundred and twenty patients were prospectively enrolled. Median age was 50 years and median follow-up was 33 months. Eight percent of patients had T1 disease, 35% T2, 18% T3, and 39% T4. Fifty-three percent of patients (63/120) had hormone receptor positive disease. Thirty-two percent of patients (38/120) were HER-2 positive. Thirty percent (36/120) were triple negative. Seventy-eight percent (91/120) had lymph node positive disease. Two or more CTCs were present in 9% of patients (11/120). Of the 11 patients who died, 3 had 2 or more CTCs (P=0.08). Of the 20 who relapsed, 6 had 2 or more CTCs (P=0.0019).

Conclusions: Presence of two or more CTCs after NACT predicted worse relapse free survival in patients with stage I-III breast cancer.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-07-11.

P4-07-07: Circulating Tumor Cells Predict Survival in Non-Metastatic Breast Cancer

Background: Circulating tumor cells (CTCs) predict outcome in metastatic breast cancer (BC), but their prognostic significance in non-metastatic BC is unclear. This study determined whether CTCs could be identified in non-metastatic BC patients and 2) if CTCs predict relapse-free and overall survival.

Methods: Clinical stage I-III BC patients seen at a single tertiary cancer center provided informed consent to participate in an IRB-approved study involving collection of blood (7.5 ml x 2 tubes) before systemic therapy and at the time of surgery for their primary BC. CTCs were detected using the Cell SearchTM system. A positive result was defined as the presence of two or more cells per 7.5 ml blood since a threshold for positivity has not been established in primary BC. Statistical analyses were done using STATA-IC 11 software.

Results: We prospectively evaluated 291 patients. Mean age was 54 years, and median follow-up was 30 months. 54% (157) had T1 tumors, 36%(104) T2, 6% (18) T3, and 4%(12) had T4 disease; 37% (107/289) were clinically node-positive (LNs) by axillary ultrasound and FNA. Two or more CTCs were identified in 10% (29) patients. Seventy-seven percent (225) patients were hormone receptor positive, 11% (32) were HER2 positive while 16% (48) expressed no receptors. Sixteen percent (48) were tumor grade 1, 50% (143) were grade 2 and 34% (98) were grade 3. Systemic chemotherapy and/or endocrine therapy were administered in 80% (233/289) of patients. Sixty-eight percent (167/244) of patients were post-menopausal. Additionally, there was no significant correlation between CTCs with primary tumor size, lymph node status, estrogen or progesterone receptor status, HER2 amplification or tumor grade. Thirty-eight percent (6/16) of all relapses occurred in patients with 2 or more CTCs (HR: 4.48 (95% C.I. 1.61−12.45), Logrank P 0.002) while 40% (4/10) of all deaths occurred in patients with 2 or more CTCs (HR: 4.54 (95% C.I. 1.27−16.25), Logrank P 0.011).

Conclusions: CTCs were a significant predictor of disease-free and overall survival in non-metastatic breast cancer.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-07-07.

P5-01-17: HER2 Amplification in Primary Tumor: A Potential Marker for Presence of Circulating Tumor Cells in Inflammatory Breast Cancer Patients?

Background: Inflammatory breast cancer (IBC) is a rare but aggressive form of invasive breast cancer accounting for 3–6% of all cases and have higher rates of distant recurrence. Circulating tumor cells (CTCs) are known to predict outcome in metastatic breast cancer (BC) patients, but little is known about their prognostic significance in non-metastatic BC. We hypothesized that CTCs can be identified in patients with IBCs and may correlate with primary tumor characteristics. Methods: All patients had blood samples collected at the time of primary surgery. CTCs (per 7.5 ml blood) were detected using the Cell Search™ system (Veridex) and were defined as nucleated cells lacking CD45 but expressing cytokeratins (CK) 8, 18, or 19. The presence of ≥ 1 epithelial cells meeting morphologic criteria for malignancy was considered a positive result. Statistical analyses employed Chi square and Fisher's exact tests using STATA IC 11. Results: We prospectively evaluated 41 IBC patients enrolled in an IRB approved protocol undergoing surgery for stage I-III breast cancer. Median follow-up was 30 months. Mean age was 52 years. Thirty five patients (94%) had positive lymph nodes (LNs) at presentation, 30 (75%) had high-grade tumors and 20 (53%) had lymphovascular invasion. Eleven patients (28%) were ER positive, 11 (27%) were PR positive and 18 (44%) were HER2 positive. IBCs were more likely to be high grade (P<0.0001), ER negative (P<0.0001), PR negative (P<0.0001), HER2 positive (P<0.0001), High Ki-67 (P= 0.005) and had a BMI of more than 25kg/m2 (P=0.04). Eleven (27%) patients were CTC positive. CTCs were more likely be found in HER2 positive (8/18; 44%) vs. HER2 negative primary tumors (3/20; 15%) [OR= 4.53; 95% C.I. = 1.02−19.52; P= 0.04]. We found no statistically significant correlations between primary tumor characteristics (ER, PR, LNs, high grade) and presence of CTCs. Conclusions: About a quarter of IBC patients had CTCs at the time of primary surgery. In these patients HER2 overexpression predicted the presence of CTCs. Studies with longer follow-ups is needed to determine if CTCs predicted survival.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-01-17.

P4-06-02: Microscopic Disease in Blood and Bone Marrow Predicts Survival in Early Stage Breast Cancer

Background

Disseminated tumor cells (DTCs) in the bone marrow have been identified in 30% of stage I - III breast cancer (BC) patients and predict survival. Circulating tumor cells (CTCs) in the blood predict outcome in metastatic BC, but their prognostic significance in primary BC is unclear. This study determined whether: 1) DTCs and CTCs could be identified in significant numbers of non-metastatic BC patients and 2) if these cells predict relapse-free (RFS) and overall survival (OS).

Methods: Clinical stage I-III BC patients seen at a single tertiary cancer center provided informed consent to participate in an IRB-approved study involving collection of blood (7.5 ml x 2 tubes) and bone marrow (10 ml from bilateral iliac crests), and at the time of surgery for their primary BC. DTCs were assessed using an anti-cytokeratin antibody cocktail (MNF 116, CK 8,18, and 19, CAM 5.2, and AE1/AE3) following ficoll enrichment and cytospin. A positive result for DTCs was defined by presence of one or more CK-positive cells meeting morphologic criteria for malignancy. CTCs were detected using the Cell SearchTM system. A positive result was defined as the presence of one or more cells per 7.5 ml blood since a threshold for positivity has not been established in non-metastatic BC. Statistical analyses used chi-square and Fischer's exact test.

Results: We prospectively evaluated 313 patients. Mean age was 53 years, and median follow-up was 32 months. Forty-two percent of patients (131) had T1 tumors, 36% (112) T2, 10% (30) T3, and 13% (40) had T4 disease. Forty-five percent of patients (141/312) had positive lymph nodes. DTCs were identified in 29% (91/313) and CTCs in 25% (79/313) of all patients. Seven percent (21/313) of patients had both DTCs and CTCs. In the overall cohort, 26 (8%) patients relapsed and 15 (5%) died. Ten percent (9/91) of DTC positive patients died compared to 3% (6/222) of those who did not have DTCs (p=0.01). Similarly, 6% (7/79) of those who had CTCs died compared to 3% (8/234) of those who did not (p=0.03). Fifteen percent (12/79) of CTC positive patents relapsed compared to 6% (14/234, P=0.01) of those who were CTC negative. Simultaneous presence of DTCs and CTCs was a strong predictor of RFS (log rank p=0.030, HR= 2.8, 95% C.I. 1.20- 8.10) as well as OS (log rank p=0.026, HR= 3.66, 95% C.I. 1.03- 13.00) at 2 years. Combined presence of DTCs and CTCs was a predictor of outcome and these findings persisted after adjusting for variables including hormone receptor status, HER2 status, primary tumor size, grade, and preoperative lymph node status. There was no significant correlation between DTCs and/or CTCs with other primary tumor characteristics.

Conclusions: Circulating and disseminated tumor cells can be identified in a significant number of non-metastatic breast cancer patients. Both CTCs and DTCs predicted outcome, and their combined presence was an independent predictor of survival.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-06-02.

Differential response between diabetes and stress-induced hyperglycaemia to algorithmic use of detemir and flexible mealtime aspart among stable postcardiac surgery patients requiring intravenous insulin

AIM

To determine whether an insulin algorithm could be used in a similar manner in the setting of diabetes and stress hyperglycaemia following cessation of intravenous (IV) insulin after cardiac surgery.

METHODS

Subjects who were clinically stable, requiring ≥ 1 unit/h of IV insulin 48 h after surgery, were randomized to once daily detemir at 50, 65 or 80% of IV insulin requirements and received aspart according to carbohydrate intake. Diabetes was defined as any history of diabetes or preoperative HbA1c 6.5%.

RESULTS

The morning glucose in patients with diabetes was 143 mg/dl (n = 61) vs. 124 mg/dl in those with stress hyperglycaemia (n = 21,p = 0.05) on day 1 and 127 vs. 110 mg/dl over 72 h (p = 0.01). This was unaffected by adjustment for initial dosing group. At 72 h, 56% of patients with stress hyperglycaemia reached AM (80-130 mg/dl) and 87% reached overall (80-180 mg/dl) glucose targets, compared to 90 and 100% of patients with stress hyperglycaemia, respectively. There was no difference in hypoglycaemia in patients with stress hyperglycaemia or diabetes. The percentage of patients with diabetes receiving insulin was 46% on admission and 77% at discharge, compared to 0 and 42% of patients with stress hyperglycaemia.

CONCLUSIONS

Following cardiac surgery, patients with stress hyperglycaemia may be converted from IV insulin to detemir with a 50% conversion factor, while patients with diabetes may require a higher conversion factor. Stress hyperglycaemia may be prolonged; the intensity and duration of insulin therapy required for optimal outcomes warrants further examination.

Observation of two-neutrino double-beta decay in 136Xe with the EXO-200 detector

We report the observation of two-neutrino double-beta decay in (136)Xe with T(1/2) = 2.11 ± 0.04(stat) ± 0.21(syst) × 10(21) yr. This second-order process, predicted by the standard model, has been observed for several nuclei but not for (136)Xe. The observed decay rate provides new input to matrix element calculations and to the search for the more interesting neutrinoless double-beta decay, the most sensitive probe for the existence of Majorana particles and the measurement of the neutrino mass scale.

A magnetically driven piston pump for ultra-clean applications

A magnetically driven piston pump for xenon gas recirculation is presented. The pump is designed to satisfy extreme purity and containment requirements, as is appropriate for the recirculation of isotopically enriched xenon through the purification system and large liquid xenon time projection chamber of EXO-200. The pump, using sprung polymer gaskets, is capable of pumping more than 16 standard liters per minute of xenon gas with 750 Torr differential pressure.

Dominantly acting ABCC8 mutations in patients with medically unresponsive hyperinsulinaemic hypoglycaemia

Recessive inactivating mutations in the ABCC8 and KCNJ11 genes encoding the adenosine triphosphate-sensitive potassium (K(ATP)) channel subunit sulphonylurea receptor 1 (SUR1) and inwardly rectifying potassium channel subunit (Kir6.2) are the most common cause of hyperinsulinaemic hypoglycaemia (HH). Most of these patients do not respond to treatment with the (K(ATP)) channel agonist diazoxide. Dominant inactivating ABCC8 and KCNJ11 mutations are less frequent, but are usually associated with a milder form of hypoglycaemia that is responsive to diazoxide therapy. We studied five patients from four families with HH who were unresponsive to diazoxide and required a near total pancreatectomy. Mutations in KCNJ11 and ABCC8 were sought by sequencing and dosage analysis. Three novel heterozygous ABCC8 mis-sense mutations (G1485E, D1506E and M1514K) were identified in four probands. All the mutations affect residues located within the Nucleotide Binding Domain 2 of the SUR1 subunit. Testing of family members showed that the mutations had arisen de novo with dominant inheritance in one pedigree. This study extends the clinical phenotype associated with dominant (K(ATP)) channel mutations to include severe congenital HH requiring near total pancreatectomy in addition to a milder form of diazoxide responsive hypoglycaemia. The identification of dominant vs recessive mutations does not predict clinical course but it is important for estimating the risk of HH in future siblings and offspring.

Perceptions of disease risk: from social construction of subjective judgments to rational decision making

Many factors influence how people form risk perceptions. Farmers' perceptions of risk and levels of risk aversion impact on decision-making about such things as technology adoption and disease management practices. Irrespective of the underlying factors that affect risk perceptions, those perceptions can be summarized by variables capturing impact and uncertainty components of risk. We discuss a new framework that has the subjective probability of disease and the cost of decision errors as its central features, which might allow a better integration of social science and epidemiology, to the benefit of plant disease management. By focusing on the probability and cost (or impact) dimensions of risk, the framework integrates research from the social sciences, economics, decision theory, and epidemiology. In particular, we review some useful properties of expected regret and skill value, two measures of expected cost that are particularly useful in the evaluation of decision tools. We highlight decision-theoretic constraints on the usefulness of decision tools that may partly explain cases of failure of adoption. We extend this analysis by considering information-theoretic criteria that link model complexity and relative performance and which might explain why users reject forecasters that impose even moderate increases in the complexity of decision making despite improvements in performance or accept very simple decision tools that have relatively poor performance.

The low uptake of breast screening in cities is a major public health issue and may be due to organisational factors: a Census-based record linkage study

BACKGROUND

Cancer screening uptake is generally lower in UK cities but quantifying city-level effects from causes due to population composition that comprise cities is hampered by data limitations.

METHODS

A unique data linkage project combining a 2001 Census-based longitudinal study in Northern Ireland with the NHS Breast Screening Program. Validated uptake in the three years following the Census for Belfast Metropolitan Urban Area was compared against the rest of the country with adjustment for cohort attributes defined at Census.

RESULTS

Belfast Metropolitan Urban Area contained 34.8% of invited women but a greater proportion who rented their accommodation (40.3%) or who did not have a car (47.1%). After full adjustment for demographic and socio-economic factors, Belfast Metropolitan Urban Area uptake was lower for first and subsequent screen (Odds ratio (OR) 0.72; 95% CIs 0.66, 0.78 and OR 0.58; 95% CIs 0.55, 0.62 respectively). There were no significant interactions between patient characteristics and area of residence indicating that all residents in Belfast Metropolitan Urban Area are equally affected.

CONCLUSION

The reduced uptake of screening in cities is a major public health issue; the effects are large and a large proportion of the population are affected, organisational factors appear to be the primary cause. Strategies to correct this imbalance might help reduce inequalities in health.

Guided imagery to improve functional outcomes post-anterior cruciate ligament repair: randomized-controlled pilot trial

Imagery can improve functional outcomes post-anterior cruciate ligament repair (ACLR). Research is needed to investigate potential mechanisms for this effect. The aim of this study was to (a) evaluate the effectiveness of an imagery intervention to improve functional outcomes post-ACLR, and (b) explore potential mechanisms. A randomized-controlled pilot trial was conducted. Participants were randomized to guided imagery and standard rehabilitation or standard rehabilitation alone (control). The primary outcome was knee strength 6-month post-operatively. Secondary outcomes were knee laxity at 6-months, and change in psychological (self-efficacy) and neurohormonal (adrenaline, noradrenaline, dopamine) variables. Participants (n=21; 62% male) were 34.86 (SD 8.84) years. Following the intervention, no statistical differences between groups for knee strength extension at 180°/s (t=-0.43, P=0.67), or at 60°/s (t=-0.72, P=0.48) were found. A statistically significant effect was found for knee laxity, F=4.67, P<0.05, mean difference of -3.02 (95% CI -4.44 to -1.60), favoring the intervention. No differences were found for self-efficacy; however, an overall effect was found for noradrenaline, F(1, 19) 19.65, P<0.001, η(2) =0.52, and dopamine, F(1, 19) 6.23, P=0.02, η(2) =0.29, favoring the intervention. This imagery intervention improved knee laxity and healing-related neurobiological factors.

An objective study of acid reflux and cough in children using an ambulatory pHmetry-cough logger

OBJECTIVE

There are no objective ambulatory studies on the temporal relationship between reflux and cough in children. Commercial pHmetry loggers have slow capture rates (0.25 Hz) that limit objective quantification of reflux and cough. The authors aimed to evaluate if there is a temporal association between cough and acid pH in ambulatory children with chronic cough.

DESIGN, SETTING AND PATIENTS

The authors studied children (aged <14 years) with chronic cough, suspected of acid reflux and considered for pHmetry using a specifically built ambulatory pHmetry-cough logger that enabled the simultaneous ambulatory recording of cough and pH with a fast (10 Hz) capture rate.

MAIN OUTCOME MEASURES

Coughs within (before and after) 10, 30, 60 and 120 s of a reflux episode (pH<4 for >0.5 s).

RESULTS

Analysis of 5628 coughs in 20 children. Most coughs (83.9%) were independent of a reflux event. Cough-reflux (median 19, IQR 3-45) and reflux-cough (24.5, 13-51) sequences were equally likely to occur within 120 s. Within the 10 and 30 s time frame, reflux-cough (10 s=median 2.5, IQR 0-7.25; 30 s=6.5, 1.25-22.25) sequences were significantly less frequent than reflux-no cough (10 s=27, IQR 15-65; 30 s=24.5, 14.5-55.5) sequences, (p=0.0001 and p=0.001, respectively). No differences were found for 60 and 120 s time frame. Cough-reflux sequence (median 1.0, IQR 0-8) within 10 s was significantly less (p=0.0001) than no cough-reflux sequences (median 29.5, 15-67), within 30 s (p=0.006) and 60 s (p=0.048) but not within 120 s (p=0.47).

CONCLUSIONS

In children with chronic cough and suspected of having gastro-oesophageal reflux disease, the temporal relationship between acid reflux and cough is unlikely causal.