Abstract P5-20-17: Safety of continuing chemotherapy in overt left ventricular dysfunction using antibodies to human epidermal growth factor receptor-2: A retrospective study

Introduction: Trastuzumab is a monoclonal antibody that targets the human epidermal growth factor receptor (HER)-2 and significantly improves survival in HER-2 positive early stage breast cancer. However, trastuzumab is also known to cause cardiotoxicity. Guidelines recommend withholding or discontinuing trastuzumab if left ventricular ejection fraction (LVEF) falls ≥15% from baseline, or to <50%, but there is little evidence to support this strategy. Additionally, premature discontinuation of trastuzumab may lead to poorer cancer outcomes. Trastuzumab cardiotoxicity is frequently reversible, and the use of angiotensin converting enzyme-inhibitors (ACE-I) and beta blockers is highly effective at treating impaired LVEF in other patient populations. We therefore hypothesize that it is safe to continue trastuzumab in patients with asymptomatic or mildly symptomatic fall in LVEF, when concomitantly treated with ACE-I and beta blockers.

Methods: In this retrospective chart review, we identified 18 consecutive patients with stage 1-3 HER-2 positive breast cancer patients who had a decline in LVEF meeting the criteria above to withhold trastuzumab, and who were referred to our cardio-oncology service from the beginning of 2015 to March 2017. These patients were offered and consented to receive ongoing trastuzumab accompanied by ACE-I and/or beta blocker. Data on patient demographics, cancer therapies, clinical features, LVEF, and cardiac medications were extracted from medical charts.

Results: Among the 18 patients identified, all were women, 12 (67%) were estrogen receptor positive, and 7 progesterone receptor positive (39%). 11 (61%) of patients had a left-sided breast cancer, 6 (33%) had right-sided breast cancer, and 1 (5%) had an unspecified side breast cancer. 17 (94%) of patients had previously undergone radiation therapy, and 4 (22%) had experienced a recurrence. 16 patients had received a prior anthracycline regimen (10 sequentially, 6 concurrently). The patients were treated with one or a combination of the following medications: carvedilol (n=13), ramipril (n=12), bisoprolol (n=1), candesartan (n=2), rosuvastatin (n=2), atorvastatin (n=2). The patients were followed up for an average of 7 months after starting cardiac therapy. Table 1 summarizes the mean±SD LVEF values over the follow up time period. All patient except one (94%) completed trastuzumab treatment successfully. This patient with concomitant moderate-severe mitral regurgitation was hospitalized for pulmonary edema. Trastuzumab was discontinued and LVEF has subsequently returned to normal values.

Table 1: LVEF progression from baseline to end of follow-upMean±SD LVEF at baseline57.59±5.49%Mean±SD LVEF on referral to cardio-oncology clinic50.75±4.76%Mean±SD LVEF at end of follow-up56.35±3.50%

Conclusion: Treating cardiac dysfunction related to trastuzumab in a cardio-oncology clinic, using beta blockers and ACE-I may enable completion of trastuzumab therapy. Randomized trials are necessary before it can be widely recommended, however findings from our experience suggest this may be a promising new treatment strategy.

Citation Format: Bharaj UK, Leong D, Dhesy-Thind S, Ellis P, Mukherjee S, Bordeleau L, Phillips C, Brown M, Kumar Tyagi N. Safety of continuing chemotherapy in overt left ventricular dysfunction using antibodies to human epidermal growth factor receptor-2: A retrospective study [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 P5-20-17.

Abstract P4-04-03: Hyperactive FOXA1 activates super-enhancer-engaged HIF2α/EPAS1 to promote endocrine-resistant metastatic ER-positive breast cancer

Background: We have recently reported that acquired endocrine resistance (Endo-R) in multiple ER+ breast cancer (BC) Endo-R cell models is driven by high levels of FOXA1 (High-FOXA1), via gene amplification and/or overexpression (OE), leading to coordinated reprogramming of the FOXA1 genomic binding (cistrome) and transcriptome. Forced FOXA1 OE in parental (P) cells induced similar transcriptional reprogramming leading to Endo-R and metastasis. Recent clinical data showing enrichment of FOXA1 amplification in ER+ metastases further support the clinical importance of our findings. However, the molecular components and the mechanism of High-FOXA1-induced transcriptional reprogramming in Endo-R and metastasis are unknown.

Methods: High-FOXA1-containing MCF7 tamoxifen-resistant (TamR) and P/FOXA1-OE cells were used in this study. An integrative multi-OMICS approach was employed to analyze transcriptome (RNA-seq), FOXA1 cistrome, and histone H3K27 acetylation (ac) (ChIP-seq). Intersection of High-FOXA1-induced transcriptome and distinct FOXA1 cistrome-predicted genes defined a High-FOXA1 core gene signature (CGS). Gene Set Enrichment Analysis (GSEA) and Gene Ontology (GO) were used for functional annotation. Cell growth and migration/invasion were measured by a bright-field automated cell counter and Transwell insert system. Altered gene expression was measured by RT-qPCR. High-FOXA1 signaling inhibition included gene knockdown (siRNA) or pharmacologic blockade (the EPAS1 inhibitor PT2385). The predictive role of EPAS1 and the associated gene signature were analyzed using publicly available BC datasets.

Results: FOXA1 OE reprogrammed the FOXA1 cistrome in P cells to resemble that of the TamR cells. The FOXA1 cistrome was significantly correlated with the deposition of H3K27ac in TamR vs. P cells (P<2.2e-16). Similarly, the differentially expressed genes in TamR vs. P cells were enriched for FOXA1 binding at enhancers demarcated by H3K27ac (P=8e-125). The FOXA1-CGS was linked to multiple metastasis-related GO terms including “hypoxia response”, enriched for the cancer secretome gene set (P=4.1e-16), and highly represented in the Endo-R transcriptome across our multiple cell models (MCF7, 600MPE, and CAMA1) (P<0.01). Integrative analysis of H3K27ac-defined super-enhancers (SEs) and altered cistrome/transcriptome upon High-FOXA1 nominated EPAS1, a hypoxia-inducible transcription factor (TF), as a top candidate of SE-activated TFs amplifying High-FOXA1 signaling. EPAS1 blockade markedly repressed the secretome genes (e.g., IL8 and S100P) and cell migration and invasion in TamR cells. Primary ER+ tumors (TCGA) with high EPAS1 are enriched for a cancer secretome gene set (P=3e-4). High EPAS1 predicts poor distant metastasis-free survival in ER+ BC treated with endocrine therapy (P=.034).

Conclusions: High-FOXA1 induces transcriptional reprogramming by coordinating histone enhancer marks to activate EPAS1 via an SE mechanism, which in turn mediates transcriptional reprogramming, partly via inducing a pro-metastatic secretome, to promote Endo-R and metastasis. Targeting the High-FOXA1/EPAS1 axis to block transcriptional reprogramming may offer a new therapeutic strategy to prevent and treat Endo-R metastatic ER+ BC.

Citation Format: Fu X, Pereira R, De Angelis C, Veeraraghavan J, Shea MJ, Nanda S, Feng Q, Jeselsohn R, O'Malley BW, Brown M, Osborne CK, Schiff R. Hyperactive FOXA1 activates super-enhancer-engaged HIF2α/EPAS1 to promote endocrine-resistant metastatic ER-positive breast cancer [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 P4-04-03.

Pilot feasibility study examining a structured self-management diabetes education programme, DESMOND-ID, targeting HbA1c in adults with intellectual disabilities

AIM

To report on the outcomes of a pilot feasibility study of a structured self-management diabetes education programme targeting HbA_1c .

METHODS

We conducted a two-arm, individually randomized, pilot superiority trial for adults with intellectual disability and Type 2 diabetes mellitus. A total of 66 adults with disabilities across the UK met the eligibility criteria. Of these, 39 agreed to participate and were randomly assigned to either the DESMOND-ID programme (n = 19) or a control group (n = 20). The programme consisted of seven weekly educational sessions. The primary outcome was HbA_1c level, and secondary outcomes included BMI, diabetes illness perceptions, severity of diabetes, quality of life, and attendance rates.

RESULTS

This study found that the DESMOND-ID programme was feasible to deliver. With reasonable adjustments, the participants could be recruited successfully, and could provide consent, complete the outcome measures, be randomized to the groups and attend most of the sessions, with minimal loss to follow-up. The fixed-effects model, the interaction between occasion (time) and condition, showed statistically significant results (0.05 level) for HbA_1c ; however, the CI was large.

CONCLUSION

This is the first published study to adapt and pilot a national structured self-management diabetes education programme for adults with intellectual disability. This study shows it is possible to identify, recruit, consent and randomize adults with intellectual disabilities to an intervention or control group. Internationally, the results of this pilot are promising, demonstrating that a multi-session education programme is acceptable and feasible to deliver. Its effectiveness should be further tested in an adequately powered trial.

Evaluation of a bioprocessed soybean meal on nursery pig performance and immune status

A total of 239 pigs (initial BW 6.56 ± 0.87 kg, 21 d of age) were used in a 35-d study to investigate the effects of fish meal (FM) and spray dried plasma (SDP) in combination with a bioprocessed soybean meal (SBM) on growth performance and immune responses in weaned pigs. Equal numbers of barrows and gilts were randomly allotted to 1 of 4 dietary treatments (10 pens/treatment) according to initial BW and sex: positive control (CON; corn/SBM diet) containing SDP and FM, the CON with bioprocessed SBM replacing FM (BPSBM), the CON with bioprocessed SBM replacing SDP (BPSBM), and the CON with bioprocessed SBM replacing both SDP and FM (BPSBM). Experimental diets were fed in Phase I (d 1-7 post-wean) and II (d 8-21) followed by a common Phase III diet (d 22-35); changes in BW and feed disappearance were determined accordingly. Pigs were sensitized against ovalbumin (OVA) and Candida albicans (CAA) on d 7 and 21. Assessment of immune response was based on lymphocyte proliferation in response to mitogens Concanavalin A and phytohemagglutinin (d 14 post-wean), dermal hypersensitivity to OVA and CAA (% increase in local swelling at 2, 6, 24, and 48 h post-injection) on d 28, and primary and secondary anti-OVA IgG at d 21 and 28, respectively. Pigs fed CON were heavier (P < 0.01) than pigs fed BPSBM and BPSBM, and not different from pigs fed BPSBM, at the end of Phase I and II (6.99, 6.80, 6.52, or 6.60 kg, pooled SEM 0.08, respectively in Phase I or 12.47, 12.18, 11.42, and 11.85 kg, pooled SEM 0.21, in Phase II, respectively). Hypersensitivity to OVA peaked at 2h in pigs fed CON, BPSBM, and BPSBM or peaked at 6h in pigs fed BPSBM (121.4, 165.6, 139.0, and 144.1%, pooled SEM 22.9, respectively, at 2 h and 86.7, 114.5, 95.0, and 156.8%, pooled SEM 29.4, respectively at 6 h). Peak response to CAA occurred at 2h in all groups (42.6, 55.2, 48.2, and 50.6%, pooled SEM 11.9, respectively, in the CON, BPSBM, BPSBM, and BPSBM, respectively). There was no difference in hypersensitivity due to experimental diet at any time point. Secondary anti-OVA IgG was 2-fold lower based on optical density values in pigs fed CON compared with BPSBM and BPSBM (0.78 vs. 1.56 and 1.55 optical density at 405 nm, pooled SEM 0.42, respectively). Dietary treatment did not impact lymphocyte proliferation. The bioprocessed SBM is a suitable alternative for FM and/or SDP in Phase I and II nursery diets based on pig growth. The prolonged hypersensitivity to OVA indicate that bioprocessed SBM may have a positive impact on pig immune function and the 2-fold increase in anti-OVA IgG warrants further investigation on the impact of bioprocessed SBM on pig immune function.

Diagnostic yield of FDG-PET/CT in fever of unknown origin: a systematic review, meta-analysis, and Delphi exercise

AIM

To perform a systematic review, meta-analysis and Delphi exercise to evaluate diagnostic yield of combined 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography and computed tomography (FDG-PET/CT) in fever of unknown origin (FUO).

MATERIALS AND METHODS

Four databases were searched for studies of FDG-PET/CT in FUO 1/1/2000-1/12/2015. Exclusions were non-English language, case reports, non-standard FDG radiotracer, and significant missing data. Quality was assessed by two authors independently using a standardised tool. Pooled diagnostic yield was calculated using a random-effects model. An iterative electronic and face-to-face Delphi exercise generated interspeciality consensus.

RESULTS

Pooled diagnostic yield was 56% (95% confidence interval [CI]: 50-61%, I²=61%) from 18 studies and 905 patients. Only five studies reported results of previous imaging, and subgroup analysis estimated diagnostic yield beyond conventional CT at 32% (95% CI: 22-44%; I²=66%). Consensus was established that FDG-PET/CT is increasingly available with an emerging role, but there is prevailing variability in practice.

CONCLUSION

There is insufficient evidence to support the value of FDG-PET/CT in investigative algorithms of FUO. A paradigm shift in research is needed, involving prospective studies recruiting at diagnosis of FUO, with updated case definitions and hard outcome measures. Although these studies will be a significant undertaking with multicentre collaboration, their completion is vital for balancing both radiation exposure and costs against the possible benefits of utilising FDG-PET/CT.

Caring for a patient with rabies: implications of the Milwaukee protocol for infection control and public health measures

This article discusses the infection control and public health measures taken whilst managing a case of laboratory-confirmed rabies, and the challenges faced in implementing these measures. Case management requires intensive multi-disciplinary co-ordination. The Milwaukee protocol, which to date has five reported human rabies survivors associated with its use, has been suggested as a potential management pathway for human rabies. Consensus among hospital and public health clinicians would aid future deployment of this approach in selected cases.

Improving diabetes care for people with intellectual disabilities: a qualitative study exploring the perceptions and experiences of professionals in diabetes and intellectual disability services

BACKGROUND

Globally, diabetes is increasing with concerns about the impact on outcomes, including premature death and the costs associated with managing the condition. Research indicates that adults with intellectual disabilities (ID) are two to three times more likely to develop diabetes; however, there has been limited focus on diabetes service utilisation in this population. The aim of this study is to explore the perceptions and experiences of diabetes and ID practitioners.

METHODS

A series of 1:1 semi-structured interviews were undertaken in one Scottish health service area. In total, 29 qualitative interviews were conducted: 10 with diabetes practitioners from primary and secondary care, 14 from ID services and 5 from community care services regarding diabetes service provision for this population. Thematic content analysis was undertaken to identify the themes and subthemes.

RESULTS

Three main themes were identified: (1) enabling access to services to meet diabetes-related care needs of people with ID; (2) communication and service improvements between staff, patients and across services; and (3) providing person-centred diabetes care and developing adapted resources to increase patient self-care.

CONCLUSIONS

The findings of this study have important international implications in how diabetes practitioners plan and deliver services for people with ID and other vulnerable groups with limited cognitive ability and communication skills and difficulties in self-management. The findings highlight that access to diabetes education and adapted resources is needed, and if 'reasonable adjustments' are made to service provision and practice, people with ID can benefit from improved healthcare. Developing joint clinics to share knowledge and resources between diabetes and ID practitioners may improve service delivery and continuity of care, and thereby diminish the costs of not providing quality care.

Abstract PD2-04: FOXA1 induces a pro-metastatic secretome through ER-dependent and independent transcriptional reprogramming in endocrine-resistant breast cancer

Background: Metastasis in ER-positive (+) breast cancer (BC) occurring years to decades after initial diagnosis presents a daunting challenge for clinical care and preclinical research due to limited known key players and experimental models. FOXA1 is a pioneer factor for ER-chromatin binding and function, and is highly expressed in ER+ BC metastases, yet the underlying mechanism is unclear. Tumor-secreted proteins play a crucial role in the reciprocal interplay between cancer cells and host microenvironmental factors at both primary and secondary sites. We hypothesized that high FOXA1 provokes an ER-dependent transcriptional program that includes a unique pro-tumorigenic secretome essential for promoting ER+ BC metastasis. Methods: A lentiviral doxycycline (Dox)-inducible FOXA1 overexpression vector and a dual luciferase/GFP (LG) tracking vector were integrated to construct a stable MCF7-LG/FOXA1 cell model. Ovariectomized nude mice bearing MCF7-LG/FOXA1 xenografts in the presence of exogenous estrogen (E2) were randomized to ± Dox, each with continued E2, E2 deprivation (ED), or tamoxifen (Tam). Survival surgery removing the therapy-naïve (E2 arm) and relapsed (ED/Tam arms) tumors was performed when tumors reached ∼1000 mm3. All mice then received ED/Tam 'adjuvant' therapy, with longitudinal luminescence imaging to monitor local/distant recurrences. Mice were or will be euthanized at the ethical end-point. Integrative bioinformatics was performed using RNA-seq and FOXA1/ER ChIP-seq data from our preclinical models to identify secretome targets for functional intervention. Times to tumor regression (TTR) and progression (TTP) were defined by when the tumor reached half or twice the volume at randomization. Results: Median (m) TTR was achieved in ED (31/34 days, -/+Dox, P = 0.184) but not in Tam groups — Tam delayed tumor growth but failed to prevent progression in all mice with mTTP of 94/93 days (-/+Dox, P = 0.517). Despite no difference in mTTP at Tam-/+Dox, a quarter of +Dox tumors (3/12) had volume doubled by day 11. No metastases were observed by imaging in any of the mice before surgery ('neoadjuvant' setting). Local relapse and lymph-node/lung metastases were detected after surgery ('adjuvant' setting). At day 90 in the adjuvant Tam group with previously relapsed tumors, +Dox mice succumbed to metastasis more often than -Dox mice (7/8 vs. 3/10, P = 0.023). Compared to the adjuvant Tam+Dox mice with previous therapy-naïve tumors, the Tam+Dox with previously relapsed tumors showed higher distant metastasis rate (7/8 vs. 5/14, P = 0.026). Analysis of the ED setting is pending due to late recurrence. Data integration and functional study revealed a set of cytokines, growth factors, and extracellular matrix components (including IL-8, CTGF, and LOX), regulated by FOXA1 often in conjunction with ER, that are highly involved in FOXA1-induced metastasis. Global secretome profiling by mass spectrometry and target validation are ongoing. Conclusions: FOXA1 overexpression increases metastatic potential in ER+ BC. We established a pertinent metastatic xenograft mouse model to characterize a pro-metastatic secretome with diagnostic and therapeutic potential for treating metastatic ER+ BC.

Citation Format: Fu X, Pereira R, Zhao D, Jung SY, Jeselsohn R, Creighton CJ, Shea M, Nardone A, Angelis CD, Tsimelzon A, Wang T, Gutierrez C, Huang S, Edwards DP, Rimawi MF, Hilsenbeck SG, Brown M, Chen K, Osborne CK, Schiff R. FOXA1 induces a pro-metastatic secretome through ER-dependent and independent transcriptional reprogramming in endocrine-resistant breast cancer [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 PD2-04.

Abstract P1-04-05: RNA immunoprecipitation reveals lncRNA-protein interactions in basal-like breast cancer

Interactions between long non-coding RNAs (lncRNAs) and proteins contribute to the epigenetic regulation of gene expression, and defects in such interactions have been implicated in several diseases, including cancer. Basal-like breast cancer accounts for approximately 15% of all breast cancer and is a major clinical problem given its poor survival and lack of responsiveness to targeted breast cancer treatments. DNA methylation is non-random and is much more pronounced in basal-like breast cancer (BLBC) compared to other molecular subtypes of breast cancer, raising the possibility that hypermethylation could be important in the genesis of BLBCs. LncRNAs are aberrantly expressed in multiple subtypes of breast cancer, including BLBC, and are considered to have significant prognostic potential. In order to explore the potential roles of DNA methylation and lncRNAs in BLBC, we investigated lncRNA-protein interactions using bioinformatics and molecular techniques, focusing on proteins that actively perform DNA methylation - the DNA methyltransferase (DNMT) family. Our novel bioinformatic methods revealed that BLBC may be sub-classified according to methylation profile in a way that could predict disease survival. We then identified candidate lncRNAs that are over-expressed in BLBC and statistically predicted to interact with DNMT proteins. Using RNA immunoprecipitation of BLBC cell lines, we have identified potential lncRNA-protein interactions that may be involved in epigenetic remodelling in BLBC. The role of these lncRNAs in epigenetic gene regulation and BLBC is currently being explored.

Citation Format: Northwood K, Saunus J, Milevskiy M, Lakhani S, Brown M. RNA immunoprecipitation reveals lncRNA-protein interactions in basal-like breast cancer [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 P1-04-05.

Abstract S5-05: Impact of pre-operative exercise on breast cancer gene expression

Background: Exercise is linked to a lower risk of developing and dying from breast cancer, but the biological mechanisms through which exercise could impact breast cancer are unclear. In animal models, exercise impacts tumor formation and progression, but there are few data regarding direct effects of exercise on tumor tissue in humans. The Pre-Operative Health and Body (PreHAB) Study was a randomized window of opportunity trial designed to explore the impact of exercise on molecular pathways in women with breast cancer.

Methods: Inactive women with Stage I-III breast cancer were enrolled through Dana-Farber Cancer Institute and Yale University prior to surgery. Participants were randomized 1:1 to an aerobic and strength training exercise intervention or mind body control intervention and participated in the interventions between enrollment and the time of surgery. Tumor tissue was collected at enrollment and surgery; samples were reviewed by a breast pathologist and were macrodissected to include sections of tumor with at least 10% cellularity. Capture RNA-sequencing of the transcriptome coding regions was performed using the Illumina Truseq RNA access platform.

Results: 49 women were randomized (27 exercise and 22 control). At baseline, mean age was 52.6, BMI was 30.2kg/m2 and exercise was 49 min/wk. Mean time between enrollment and surgery was 4.2 weeks. Participants in the exercise arm significantly increased exercise vs. controls (increase of 203 vs. 23 min/wk, p&lt;0.0001). Transcriptomic analysis was performed on the tumors from the pre and post intervention biopsies from 32 patients (16 exercise and 16 control). Quality Control analysis of the RNA-sequencing data showed an average read depth of 25 million reads per sample, mapping ∼79% to exonic regions. Principal Component Analysis revealed no read bias or batch effects and unsupervised clustering showed that pre- and post-operative samples clustered together by patient. Differential gene expression analysis by DEseq2 revealed a limited number of individual genes with significant changes after the intervention. KEGG pathway analysis, however, of 214 KEGG pathways using the bioconductor package GAGE (Generally Applicable Gene-Set Enrichment for Pathway Analysis) demonstrated upregulation of 13 unique pathways between the baseline biopsy and surgical excision in exercise participants and none in mind body participants (q&lt;0.1). The top ranked upregulated pathway was cytokine-cytokine receptor interactions (q=6.93E-05, set size=238 genes). Il6, CCL3 and other cytokines are among the genes upregulated in this pathway. Analysis also demonstrated downregulation of 13 unique pathways (q&lt;0.1) including cell cycle, RNA transport and DNA replication pathways, in exercise participants over the intervention period.

Conclusions: A pre-operative exercise intervention led to alterations in gene expression in tumor tissue in women with breast cancer. Validation in additional data sets and an analysis of which cellular compartments within the tumor are responsible for the changes is needed. These findings demonstrate that exercise may have a direct effect on breast tumor tissue in humans, providing new insights into the biologic mechanisms through which exercise could lower the risk of developing and dying from breast cancer.

Citation Format: Ligibel JA, Irwin M, Dillon D, Barry W, Giobbie-Hurder A, Frank E, Winer EP, McTiernan A, Cornwell M, Pun M, Brown M, Jeselsohn R. Impact of pre-operative exercise on breast cancer gene expression [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 S5-05.

Gingival Fluid Inflammatory Biomarkers and Hypertension in African Americans

Hypertension and periodontitis are highly prevalent among African Americans. This cross-sectional study investigated the relationships among inflammatory biomarkers in the gingival fluid, periodontitis, and blood pressure in these individuals. Twenty-one subjects who reported a diagnosis of hypertension and a comparison group of 26 nonhypertensive participants were enrolled. All were African Americans, non-cigarette smoking, and free from other systemic illness. Blood pressure and body mass index were assessed. A comprehensive periodontal examination was performed. Gingival fluid was collected from 3 healthy sites and 3 diseased sites when available. Samples were assessed for 8-isoprostane, interleukin 1β, monocyte chemoattractant protein 1, tumor necrosis factor-alpha (TNFα), C-reactive protein (CRP), and matrix metalloproteinase 8. Regardless of hypertension status, diseased sites were associated with increased levels of these biomarkers. CRP and TNFα levels were also significantly higher in hypertensive than nonhypertensive individuals without diseased sites. After adjusting for demographics and body mass index, periodontal attachment loss was higher among hypertensive than nonhypertensive subjects. TNFα and CRP levels and hypertension were in the same association pathway with attachment loss. Elevated blood pressure may increase the risk of periodontitis through a localized inflammatory mechanism. Knowledge Transfer Statement: The results of this study can be used by clinicians to better understand the etiology and pathogenesis of periodontitis in hypertensive individuals in general and African Americans in particular. The information could lead to better management of periodontal disease.

A retrospective study of seven-day consultant working: reductions in mortality and length of stay

Weekend admission is associated with higher in-hospital mortality than weekday admission. Whether providing enhanced weekend staffing for acute medical inpatient services reduces mortality or length of stay is unknown.

METHODS

This paper describes a retrospective analysis of in-hospital mortality and length of stay before and after introduction of an enhanced, consultant-led weekend service in acute medicine in November 2012. In-hospital mortality was compared for matching admission calendar months before and after introduction of the new service, adjusted for case volume. Length of stay and 30-day postdischarge mortality were also compared; illness severity of patients admitted was assessed by cross-sectional acuity audits.

RESULTS

Admission numbers increased from 6,304 (November 2011-July 2012) to 7,382 (November 2012-July 2013), with no change in acuity score in elderly medical patients but a small fall in younger patients. At the same time, however, a 57% increase in early-warning score triggered calls was seen in 2013 (410 calls vs 262 calls in 2012; p<0.01). Seven-day consultant working was associated with a reduction in in-hospital mortality from 11.4% to 8.8% (p<0.001). Mortality within 30 days of discharge fell from 2.4% to 2.0% (p=0.12). Length of stay fell by 1.9 days (95% CI 1.1-2.7; p=0.004) for elderly medicine wards and by 1.7 days (95% CI 0.8-2.6; p=0.008) for medical wards. Weekend discharges increased from general medical wards (from 13.6% to 18.8%, p<0.001) but did not increase from elderly medicine wards.

CONCLUSIONS

Introduction of an enhanced, consultant-led model of working at weekends was associated with reduced in-hospital and 30-day post discharge mortality rates as well as reduced length of stay. These results require confirmation in rigorously designed prospective studies.

Italian translation and cross-cultural comparison with the Childhood Attachment and Relational Trauma Screen (CARTS)

Background: The Childhood Attachment and Relational Trauma Screen (CARTS) is a computer-administered survey designed to assess retrospectively the socio-ecological context in which instances of child abuse may have occurred. To date, studies supporting the validity of the CARTS have only been undertaken in English-speaking North American populations. Validation projects in other countries and cross-cultural comparisons are therefore warranted. Objective: Develop and preliminarily evaluate the psychometric properties of an Italian version of the CARTS on college students and compare such observations to data acquired from Canadian students. Method: Seventy-nine undergraduate students from the University of Padua (Italy) completed an Italian translation of the CARTS as well as measures of childhood experiences, mental health and attachment, responses to which were compared to those obtained in 288 Canadian students who completed the CARTS in English. Results: Internal consistency and convergent validity with the Childhood Trauma Questionnaire and Parental Bonding Instrument were found to be acceptable for the Italian translation. Within the Italian sample, correlation analyses suggested that CARTS Mother ratings referring to attachment and abuse were associated with romantic attachment, whereas CARTS Father ratings were significantly correlated to PTSD symptoms and other symptoms of psychopathology-distress. Significant differences between Italian and Canadian students across the relationship types for the CARTS abuse and attachment scales were found, indicating that Italian students rated their mothers and fathers as simultaneously less abusive, but also less as a source of secure attachment. Conclusions: The results of this preliminary study seem to suggest convergent validity of the Italian CARTS and the association between childhood attachment-related experiences and romantic attachment. Cultural variations were identified between Canadian and Italian students in both attachment and abuse scales. Future studies to investigate cross-cultural variations in the relational context of childhood abuse and in order to boost Italian CARTS psychometric features are warranted.