Transforaminal lumbar interbody fusion with placement of steerable banana cage: A single-center retrospective analysis of radiographic parameters of success

INTRODUCTION

The transforaminal lumbar interbody fusion (TLIF) is among the most utilized methods for the surgical treatment of lumbar degenerative disc disease. The TLIF has advanced significantly with several iterative changes since its inception in the early 1980s, with the advent of several generations of interbody types, shapes, and materials. Steerable curvilinear interbodies are among the most recent innovations in this space and may offer biomechanical advantages, namely in preservation of lumbar and segmental lordosis. While radiographic parameters have been investigated for other cage shapes and lumbar interbody fusion techniques, no study has investigated postoperative radiographic outcomes specific to TLIFs done with curvilinear interbodies.

METHODS

This study is a retrospective review of TLIFs performed with curvilinear interbodies between 2019 and 2022 at a single institution. Upright radiographs were obtained preoperatively and at several timepoints postoperatively. Radiographic variables including interspace height and segmental lordosis were collected.

RESULTS

26 surgeries with 32 curvilinear interbodies were performed across 3 years. There was significant increase in segmental lordosis at the L4-L5 (p = 0.0183) and L5-S1 levels (p = 0.004) as well as interspace height postoperatively at levels L3-L4 (p = 0.011) and L4-L5 (p = 0.002). Pain as measured with the numeric rating scale significantly improved in the overall cohort postoperatively (p<0.001).

CONCLUSIONS

TLIF with curvilinear interbody placement increases segmental lordosis and interspace height at the L4-L5 and L5-S1 levels, and increased interspace height at the L3-L4 and L4-L5 levels. Further investigation into additional radiographic parameters is warranted and expanded cohort size would benefit deeper analysis of other spinal levels.

IMPLICATIONS FOR PRACTICE

As an increasing number of cage designs and materials are brought to market, studies such as this allow for better understanding of cage specific outcomes allowing for better informed device selection.

Radiation Treatment Preparation Safety Risk Prediction

PURPOSE/OBJECTIVE(S)

To determine the effect of delays in radiation treatment preparation task timeliness on reported safety events.

MATERIALS/METHODS

For 2022, all patients treated at four community-based radiation oncology clinics were included for analysis. Safety reports which occurred during treatment preparation tasks (i.e., between CT simulation and the first treatment) were included for this analysis. Patients with a reported safety event were the report cohort and those without were the control cohort. Treatment preparation tasks are completed sequentially and included contouring, treatment planning, Radiation Oncologist review, Medical Physicist review, Therapist quality check. At baseline, each task was scheduled a standard interval for completion based on treatment technique. The time taken to complete each task was captured using ARIA v16.0 Care Path module (Varian Medical Systems, Palo Alto, CA) and extracted through database query. For each task, two metrics were quantified: Task (1) Completion Timeliness: the time (hours) to complete each task, relative to the time allocated to each task. A negative value indicated more time taken than scheduled. (2) Overall Timeliness: specific task timeliness (hours) relative to overall timeliness for the whole Care Path. A negative value indicated the tasks were behind schedule. A student's t-test with an alpha of 0.05 was used to indicate significance.

RESULTS

Over the study period, 66 courses had a reported treatment preparation safety event (report) and 2690 did not (control). Techniques include 54% and 56% 3DCRT, 35% and 35% IMRT, 3% and 3% SRS, and 6% and 8% SBRT, for the report and control groups, respectively. Disease sites include breast, GU, GI, head and neck, CNS, thoracic, skin, secondary, gynecological, sarcoma, and heme. Table 1 displays the timeliness for each of the five tasks. Of the courses with safety events, overall timeliness was significantly behind the control group from the in contouring, treatment planning, Radiation Oncologist review, and Medical Physicist review. Courses with safety events took significantly more time than scheduled early in treatment preparation with a significant increase at treatment planning and significantly less time towards the end with the therapist quality check.

CONCLUSION

Patient courses with reported safety events had significantly longer treatment planning times, and as a result inadequate time to perform each downstream pre-treatment activity. The implication of this analysis is that a flag could be created to indicate risk of a safety event early in the treatment preparation process.

O-147 Genomic analyses in 101,127 UK women show that previously reported monogenic genes are not common causes of premature ovarian insufficiency

Study question

What is the penetrance of variants in previously reported genes for premature ovarian insufficiency (POI) in the general population?

Summary answer

Heterozygous genetic variants in previously reported monogenic genes are not a common, highly penetrant cause of POI.

What is known already

Premature ovarian insufficiency (POI), defined as menopause before 40, has been associated with variants in over 70 genes. However, the evidence to support the causality of individual genetic variants varies between studies. As genomic data becomes more accessible, it is essential to ascertain the penetrance of variants in the absence of family history information. We identified 75 genes associated with POI from the literature, including family segregation studies, consanguineous pedigrees and cohort analyses of whole-exome/targeted sequencing data. Functional evaluation was also available for many of the genes.

Study design, size, duration

We used data from 101,127 females of European ancestry in the UK Biobank, to study the role of previously reported monogenic causal genes on ovarian function. We tested the association of 301 previously reported variants with POI and ANM, plus more than 2.5 million rare variants which were annotated and had not been implicated in POI previously. Genomic variants were tested individually and also combined into a gene burden test.

Participants/materials, setting, methods

Age at natural menopause (ANM) was derived from self-reported questionnaire data from the age at last menstrual period, excluding those with surgical menopause or taking hormone replacement therapy. POI cases were classified as women with ANM under 40 years (N = 2,213). Linked primary care records were used to identify a clinical cohort of POI cases, including primary amenorrhea (N = 113).

Main results and the role of chance

All of the previously reported individual variants we identified in our POI cases were also detected in the control group. Moreover, the gene burden tests were not associated with POI or ANM as a quantitative trait. Our results indicate that autosomal dominant causes of POI are rare; a single predicted loss-of-function (LOF) or non-synonymous genetic variant in one of the previously reported genes is generally not pathogenic.

Limitations, reasons for caution

The penetrance of monogenic disease-causing variants is likely to be lower in population-based cohorts such as UK Biobank than in clinically-ascertained cohorts.

Wider implications of the findings

Heterozygous LOF or non-synonymous variants in previously reported POI genes should be interpreted with caution and are unlikely to cause POI. The findings have implications for clinicians diagnosing causes of POI.

Trial registration number

Not applicable

1005 HEALTH-RELATED QUALITY OF LIFE AND FUTURE RISK OF HEALTH OUTCOMES AMONG OLDER ADULTS LIVING IN AUSTRALIA AND THE UNITED STATES

Introduction

Poor health-related quality of life (HRQoL) is associated with higher morbidity and mortality in patient populations. However, whether HRQoL is associated with health outcomes among community-dwelling older people requires further investigation. This study aimed to examine whether HRQoL predicts cognitive decline, dementia, cardiovascular disease (CVD), and mortality in community-dwelling older people living in Australia and the United States.

Method

A cohort of 19,106 individuals from the ASPirin in Reducing Events in the Elderly (ASPREE) study, aged 65–98 years, initially free of dementia or CVD, and who completed the HRQoL 12-item short form (SF-12, version-2) at baseline (2010–2014), were followed until June 2017. The physical (PCS) and mental component scores (MCS) of SF-12 were generated using standardized norm-based method.

Results

Over a median of 4.7 years, there were 2,412 cognitive declines, 574 dementia, 922 incident CVD events, and 1,052 deaths. Using Cox proportional-hazard regression adjusted for a range of covariates, every 10-unit increase in PCS was associated with a 6% lower risk of cognitive decline, a 14% lower risk of incident CVD, and 17% lower risk of all-cause mortality, but was not associated with incident dementia. In contrast, higher MCS was only associated with a 12% and 15% lower risk of cognitive decline and dementia, respectively. Findings did not differ by sex.

Conclusion

Our study provides some of the first evidence that HRQoL can be used in combination with clinical data to identify the future risks of health outcomes among older individuals living in the community. Our findings support the decision of the Australian Commission on Safety and Quality in Health Care to incorporate the SF-12 into the annual Patient-Reported Outcome Measures (PROMs assessment.

POS1304 CORRELATION OF SKIN SCORES (LoSCAT) WITH PATIENT REPORTED OUTCOMES IN JUVENILE LOCALISED SCLERODERMA

Background

Juvenile localised scleroderma (JLS) or morphea is a rare condition, causing inflammation and fibrosis in skin and underlying tissues. A validated skin score (Localized Scleroderma Cutaneous Assessment Tool, LoSCAT) has been developed [1]. This tool has both activity (mLoSSi) and damage indices (LoSDI). Several patient-reported outcomes (PRO) have been studied in JLS including visual analogue scales (VAS), functional and health-related quality of life measures.

Objectives

To assess the associations between different PROs and the activity and damage indices of the LoSCAT.

Methods

Participants aged 4 to 17 were recruited from 3 tertiary paediatric rheumatology centres in the UK and attended 4 visits at 3 monthly intervals as part of a program of research on JLS. Patient-reported VAS (6 different scales), the Children’s Dermatology Life Quality Index (CDLQI) and Childhood Health Assessment Questionnaires (CHAQ) were completed at each visit. LoSCAT was completed by the two same clinicians throughout the study (both trained in skin score techniques). Pearson correlation coefficients were calculated between each PRO and each component of the LoSCAT.

Results

24 participants completed all 4 visits and 1 attended 3 visits. 20 participants were female (80%) and 5 were male (20%). Mean age at diagnosis was 7.6 years with mean disease duration of 4.9 years. Subtype of disease was linear head in 5/25 (20%), linear limb 12/25 (48%), generalised morphoea 1/25 (4%), mixed 5/25 (20%) and superficial plaque in 2/25 (8%). Table 1 shows the correlations with figures in bold highlighting positive correlations which were statistically significant (p<0.05) and medium-sized (r>0.3).

Table 1.

Correlation between patient reported outcomes and LoSCAT

PROTotal skin activity (mLoSSi)Total skin damage (LoSDI)r (95% CI)p-valuer (95% CI)p-valueCDLQI0.61 (0.02, 1.20)0.0440.42 (0.01, 0.83)0.044CHAQ0.30 (0.03, 0.57)0.0270.20 (-0.14, 0.54)0.244VAS 1: How much IMPACT has your disease had on your life in the PAST MONTH?0.49 (0.00, 0.98)0.0500.38 (0.06, 0.71)0.021VAS 2: How much has your condition (localized scleroderma) affected you OVERALL in the PAST MONTH?0.59 (0.09, 1.09)0.0220.42 (0.13, 0.72)0.005VAS 3: Have your lesions felt itchy and/or scratchy in PAST MONTH?0.40 (-0.01, 0.81)0.0560.31 (0.03, 0.59)0.028VAS 4: Have you felt numbness, tingling, and/or other “funny” feeling in or around your lesion in PAST MONTH?0.55 (0.04, 1.05)0.0330.33 (-0.04, 0.71)0.084VAS 5: How much WORRY do you have about LONG- -TERM problems from your disease?0.40 (-0.01, 0.81)0.0530.32 (0.00, 0.63)0.047VAS 6: How much WORRY do you have about problems from MEDICATIONS used to treat your condition?0.41 (0.00, 0.82)0.0500.29 (-0.09, 0.66)0.131

The VAS of symptoms of numbness/tingling showed a strong positive correlation with mLoSSi but a weak and/or non-significant correlation with LoSDI. VAS itchy/scratchy did not show a strong correlation with mLoSSi but showed a moderate correlation with LoSDI. Patient global VAS correlated with both mLoSSi and LoSDI, as did CDLQI. CHAQ correlated with activity only.

Conclusion

Symptoms within lesions are often interpreted as indicating disease activity. A previous study in adults and children showed itch positively correlated with mLoSSi suggesting it may be a marker of active disease [2]. However, in our study numbness/tingling correlated with disease activity whereas itch did not. Further work is required to understand whether itch correlates to both activity and damage and whether numbness/tingling is a better indicator of activity than itch. Limitations of our study include a heterogenous group of participants with longstanding high-burden disease.

References

[1]Arkachaisri et al. Rheumatology 2010. 49(2): 373-81.

[2]Klimas et al. Br J Derm 2015; 175:1329-1337

Acknowledgements

This study was funded by Scleroderma & Raynaud’s UK.

Disclosure of Interests

None declared

Vascular risk factors affect different brain regions in people with Alzheimer’s disease

Introduction

Vascular risk factors including hypertension, diabetes and dyslipidaemia promote diverse pathological mechanisms in the brain leading to cerebral hypoperfusion and ultimately cognitive decline in people. Medial temporal, medial frontal and anterior cingulate atrophy has been closely associated with diabetes and medial temporal lobe atrophy is associated with hypertension in people with Alzheimer’s disease (AD).

Objectives

To assess if hypertension, diabetes and dyslipidaemia have differential effects on different brain locations using brain imaging in people with AD.

Methods

The current study is based on [¹⁸F] fluorodeoxyglucose- positron emission tomography (FDG-PET) data of 970 participants from two large Phase III multi-centre clinical trials of a novel tau aggregation inhibitor drug Leuco-Methylthioninium (LMTX)meeting research criteria for mild to moderate AD. Vascular risk factor data including hypertension, diabetes and dyslipidaemia were collected and quantification of FDG PET hypo-metabolism was done by calculating Standardized Uptake Value Ratio(SUVR).

Results

Hypertension, diabetes and dyslipidaemia were found to have differential effects on brain locations in people with AD. When people with hypertension, diabetes and dyslipidaemia were compared to those without, mean SUVR was increased significantly in both left and right parietal and occipital lobes and decreased in left and right anterior cingulate gyri in hypertensives. SUVR was significantly higher in both left and right temporal lobes in diabetics andlower in both left and right anterior cingulate gyri in people with dyslipidaemia.

Conclusions

Vascular risk factors including hypertension, diabetes and dyslipidaemia have differential effects on different brain regions, measured using SUVR analysis of FDG-PET.

Disclosure

The FDG-PET data was taken from participants of two large phase III clinical trials sponsored by TauRx Therapeutics (Singapore). TauRx Therapeutics has contributed towards my studentship during my PhD but the data related to drug used in the clinical tria

POS0168 NON-INVASIVE IMAGING IN JUVENILE LOCALISED SCLERODERMA: HIGH-FREQUENCY ULTRASOUND, THERMOGRAPHY, LASER DOPPLER & MULTISPECTRAL IMAGING

Background

Outcome measures which can differentiate activity (inflammation) from damage (fibrosis/atrophy) would facilitate development of new treatment strategies in juvenile localized scleroderma (JLS) to target the inflammatory phase of the disease.

Objectives

To evaluate whether in JLS, non-invasive imaging modalities (high frequency ultrasounds (HFUS), multispectral imaging (MSI), laser doppler imaging (LDI) & infra-red thermography (IRT)) can detect differences between affected & non-affected skin, as a next step in developing these as outcome measures. Our hypothesis was that blood flow (and therefore temperature & oxygenation) would be increased in lesional skin.

Methods

Participants aged 4-17 were recruited from 3 paediatric rheumatology centres in the UK. For each participant, a single lesion was selected. HFUS (30MHz), MSI (bespoke camera and tuneable liquid crystal filter, coupled to custom analysis software, 500nm/710nm wavelengths), LDI and IRT imaging were performed at four sites relating to each lesion: two of affected skin (centre & inner edge of lesion) and two of non-affected skin (one cm from edge of lesion (‘outer’) & contralateral unaffected side). Imaging was performed at 4 visits at 3 monthly intervals. Mean values were compared between the four sites using data from all visits by mixed-effects linear regression to account for individual-level clustering.

Results

24 participants completed all 4 visits and 1 attended 3. 20 participants were female (80%) & 5 male (20%). Mean age at diagnosis was 7.6 years & disease duration 4.9 years. Subtype of disease was linear head in 5/25 (20%), linear limb 12/25 (48%), generalised morphea 1/25 (4%), mixed 5/25 (20%) and superficial plaque in 2/25 (8%).

Table 1 shows a subset of data. All 4 imaging techniques could detect differences between healthy (outer/contralateral) & affected skin (centre/inner edge). For HFUS, there was strong evidence of a difference between affected & unaffected skin (p<0.001) indicating affected skin is thinner than unaffected. Higher mean values of oxygenation, perfusion & temperature were observed in affected compared to non-affected skin in MSI, LDI and IRT respectively. There was no statistical difference seen between inner edge and centre of the lesion in any of the methods.

Table 1.

Mean differences between different locations for each imaging technique

Imaging techniqueLocationOverall mean difference (95% CI)p-valueHFUS (mm)Centre - Contralateral-0.34 (-0.46, -0.22)<0.001Inner edge - Contralateral-0.30 (-0.40, -0.20)<0.001Centre - Outer-0.35 (-0.46, -0.24)<0.001Inner edge - Outer-0.31 (-0.40, -0.21)<0.001Centre - Inner edge-0.04 (-0.10, 0.02)0.168MSI (rel units)Centre - Contralateral0.06 (0.03, 0.10)<0.001Inner edge - Contralateral0.06 (0.03, 0.09)<0.001Centre - Outer0.04 (0.01, 0.07)0.012Inner edge - Outer0.03 (0.00, 0.06)0.028Centre - Inner edge0.01 (0.00, 0.02)0.251LDI Relative perfusion unitsCentre - Contralateral44.8 (24.4, 65.2)<0.001Inner edge - Contralateral47.9 (21.0, 74.8)<0.001Centre - Outer19.1 (1.0, 37.1)0.039Inner edge - Outer24.8 (6.7, 42.9)0.007Centre - Inner edge-3.5 (-20.3, 13.2)0.679IRT oCCentre - Contralateral0.58 (0.24, 0.91)0.001Inner edge - Contralateral0.44 (0.13, 0.75)0.005Centre - Outer0.44 (0.22, 0.66)<0.001Inner edge - Outer0.30 (0.09, 0.52)0.006Centre - Inner edge0.14 (-0.05, 0.32)0.153

The overall mean difference is the measurement of the first location minus the measurement from the second location (e.g. centre minus contralateral), averaged across the four visits.

Conclusion

Our results suggest non-invasive imaging can detect differences between healthy & unaffected skin in JLS. Whether each technique is only measuring activity & not damage requires further evaluation. The leading edge of lesions has historically been considered as most active compared to the centre. However, no difference was seen between centre & inner edge measurements suggesting that in future studies, imaging protocols can be simplified.

Acknowledgements

This study was funded by Scleroderma & Raynaud’s UK.

Disclosure of Interests

None declared

Melanoma secretion of transforming growth factor-β2 leads to loss of epidermal AMBRA1 threatening epidermal integrity and facilitating tumour ulceration

BACKGROUND

For patients with early American Joint Committee on Cancer (AJCC)-stage melanoma the combined loss of the autophagy regulatory protein AMBRA1 and the terminal differentiation marker loricrin in the peritumoral epidermis is associated with a significantly increased risk of metastasis.

OBJECTIVES

The aim of the present study was to evaluate the potential contribution of melanoma paracrine transforming growth factor (TGF)-β signalling to the loss of AMBRA1 in the epidermis overlying the primary tumour and disruption of epidermal integrity.

METHODS

Immunohistochemistry was used to analyse AMBRA1 and TGF-β2 in a cohort of 109 AJCC all-stage melanomas, and TGF-β2 and claudin-1 in a cohort of 30 or 42 AJCC stage I melanomas, respectively, with known AMBRA1 and loricrin (AMLo) expression. Evidence of pre-ulceration was analysed in a cohort of 42 melanomas, with TGF-β2 signalling evaluated in primary keratinocytes.

RESULTS

Increased tumoral TGF-β2 was significantly associated with loss of peritumoral AMBRA1 (P < 0·05), ulceration (P < 0·001), AMLo high-risk status (P < 0·05) and metastasis (P < 0·01). TGF-β2 treatment of keratinocytes resulted in downregulation of AMBRA1, loricrin and claudin-1, while knockdown of AMBRA1 was associated with decreased expression of claudin-1 and increased proliferation of keratinocytes (P < 0·05). Importantly, we show loss of AMBRA1 in the peritumoral epidermis was associated with decreased claudin-1 expression (P < 0·05), parakeratosis (P < 0·01) and cleft formation in the dermoepidermal junction (P < 0·05).

CONCLUSIONS

Collectively, these data suggest a paracrine mechanism whereby TGF-β2 causes loss of AMBRA1 overlying high-risk AJCC early-stage melanomas and reduced epidermal integrity, thereby facilitating erosion of the epidermis and tumour ulceration.

The detection of germline and somatic BRCA1/2 genetic variants through parallel testing of patients with high-grade serous ovarian cancer: a national retrospective audit

Objective

To determine the frequency of germline and somatic pathogenic BRCA1 and BRCA2 variants in patients with high‐grade serous ovarian cancer tested by next‐generation sequencing (NGS), with the aim of defining the best strategy to be implemented in future routine testing.

Design

National retrospective audit.

Setting

The All Wales Medical Genomics Service (AWMGS).

Population

Patients with high‐grade serous ovarian/fallopian tube/peritoneal cancer referred by oncologists to the AWMGS between February 2015 and February 2021 for germline and/or tumour testing of the BRCA1 and BRCA2 genes by NGS.

Methods

Analysis of NGS data from germline and/or tumour testing.

Main outcome measures

Frequency of BRCA1 and BRCA2 pathogenic variants.

Results

The overall observed germline/somatic pathogenic variant detection rate was 11.6% in the 844 patients included in this study, with a 9.2% (73/791) germline pathogenic variant detection rate. Parallel tumour and germline testing was carried out for 169 patients and the overall pathogenic variant detection rate for this cohort was 14.8%, with 6.5% (11/169) shown to have a somatic pathogenic variant. Two BRCA1 dosage variants were found during germline screens, representing 2.0% (2/98) of patients with a pathogenic variant that would have been missed through tumour testing alone.

Conclusions

Parallel germline and tumour BRCA1 and BRCA2 testing maximises the detection of pathogenic variants in patients with high‐grade serous ovarian cancer.

Tweetable abstract

Parallel germline and tumour testing maximises BRCA pathogenic variant detection in ovarian cancer.

Parallel germline and tumour testing maximises BRCA pathogenic variant detection in ovarian cancer.

Linked article This article is commented on by C Gourley, p. 443 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16978.

Accelerated Epigenetic Aging in Peripheral Blood does not Predict Dementia Risk

BACKGROUND

There is strong evidence that epigenetic age acceleration is associated with increased risk of later-life diseases and all-cause mortality. However, there is currently limited evidence that suggests accelerated epigenetic age is associated with dementia risk.

OBJECTIVE

This study aims to clarify whether epigenetic biomarkers of accelerated aging can predict dementia risk, which is an important consideration as aging is the greatest risk factor for the disease.

METHODS

DNA methylation was measured in peripheral blood samples provided by 160 participants from the ASPirin in Reducing Events in the Elderly study, including 73 pre-symptomatic dementia cases and 87 controls matched for age, sex, and smoking and education status. Epigenetic age was calculated using Horvath, Hannum, GrimAge and PhenoAge DNA methylation clocks, and age acceleration (the disparity between chronological age and epigenetic age) was determined.

RESULTS

There was no difference in age acceleration between dementia cases and controls. In males, only Hannum's intrinsic epigenetic age acceleration was increased in pre-symptomatic dementia cases compared to controls (Δ +1.8 years, p = 0.03).

CONCLUSION

These findings provide no strong evidence that accelerated epigenetic aging measured in peripheral blood can predict dementia risk.

Temperature response to cold challenge and mobile phone thermography as outcome measures for systemic sclerosis-related Raynaud's phenomenon

Objectives: Objective outcome measures of systemic sclerosis (SSc)-related Raynaud's phenomenon (RP) are badly needed. Our objectives were to validate the thermographic response to a standard hand cold challenge as an outcome measure by assessing sensitivity to change, and to explore mobile phone thermography as a feasible, ambulatory tool.Method: Twelve patients with an SSc-spectrum disorder admitted for intravenous iloprost infusions underwent a standard cold challenge before and after one infusion. Thermographic measurements included area under the rewarming curve (AUC) and maximum rewarming temperature (MAX). Before and during another infusion, each patient underwent monitoring of finger skin temperature by two methods: continuous thermocouple recording (standard method) and mobile phone thermography.Results: All cold challenge summary measures, including AUC and MAX, increased after iloprost (most not significantly). However, when the response curves were modelled after averaging across fingers (linear mixed models, three versions), significant change was detected. For example, with Model 1 (no interaction between period and time), temperature was on average 1.67ºC [95% confidence interval (CI) 1.49-1.85, p < 0.001] higher post-iloprost. Mobile phone and thermocouple temperature measurements showed a strong estimated latent correlation (0.88, 95% CI 0.81-0.92). The estimated increases/hour were 0.25ºC (95% CI 0.05-0.45) for the thermocouple and 0.36ºC (95% CI 0.13-0.60) for mobile phone thermography.Conclusion: Our pilot study suggests that the thermographic response to a cold challenge is sensitive to change and mobile phone thermography could bring feasibility to thermographic parameters as outcome measures in later-phase, large-scale, community-based clinical trials of RP.

O40: PRE-OPERATIVE MANAGEMENT AND SENSITISATION IN VASCULARIZED COMPOSITE ALLOTRANSPLANTATION: A SYSTEMATIC REVIEW

Introduction

Vascularised composite allotransplantation (VCA) permits like-for-like reconstruction following extensive soft tissue injuries. The initial management of extensive soft tissue injury can lead to the development of anti-HLA antibodies through injury, transfusion and cadaveric grafting. The role of antibody-mediated rejection, donor-specific antibodies and graft rejection in the context of VCA remains unclear. This systematic review aimed to determine whether pre-operative management strategies influence immunological outcome following VCA.

Method

A systematic review of MEDLINE, EMBASE and CINAHL using a PRISMA-compliant methodology up to February 2019 was conducted. Pre-operative, procedural and long-term outcome data were collected and recorded for all VCA recipients on an individual patient basis.

Result

The search revealed 3,847 records of which 114 met inclusion criteria and reported clinical data related to 100 patients who underwent 129 VCA transplants. Trauma (50%) and burns (15%) were the most frequent indications for VCA. Of all 114 studies, only one reported acute resuscitative management. Fifteen patients (14.7%) were sensitized prior to reconstructive transplantation with an 80% incidence of acute rejection in the first post-operative year. Seven patients demonstrated graft vasculopathy, only one of whom had demonstrated panel reactive antibodies.

Conclusion

Currently employed acute management strategies predispose to the development of anti-HLA antibodies, adding to the already complex immunological challenge of VCA. Early appropriate care is warranted in patients with extensive soft tissue loss where the resuscitative needs should be balanced against strategies to mitigate the immunological burden, particularly as reconstructive transplantation becomes a feasible option for future soft tissue coverage.

Take-home message

Acute resuscitative management may sensitise potential transplant recipients following major soft tissue injury. Early appropriate care is warranted.

Herd manager attitudes and intentions regarding the selection of high-fertility EBV sires in Australia

Reproductive performance in dairy cattle has declined over the last 50 years as an unintended consequence of selection for high milk yield. Since the early 2000s, dairy geneticists have released successive versions of fertility estimated breeding values (EBV) to assist in reversing this trend. At the herd level, fertility EBV can help managers accelerate improvements in reproductive performance by acting as a second selection criteria when used in tandem with a breeding index. However, use of the fertility EBV in sire selection currently varies between herd managers. The aim of this study was to better understand the reasons why herd managers choose or do not choose to select high-fertility EBV sires, using the Theory of Planned Behavior (TPB) as a social research framework. Thirty-five Victorian dairy herd managers were recruited as part of a larger study investigating the daughter fertility Australian Breeding Value and interviewed using a series of questions examining TPB constructs. The interviews were recorded and transcribed using template analysis. A wide range of herd manager types were enrolled into the study, with representation from diverse systems. Out of the 35 herd managers, 27 included fertility in their list of high-priority breeding objectives. A wide variation in results was consistent with previous studies that have demonstrated marked heterogeneity in herd manager attitudes toward bull selection. Herd manager-perceived barriers to selection of sires with high daughter fertility EBV included a lack of high daughter fertility bulls with other desirable traits, a lack of trust in the fertility EBV or in the Australian EBV system, difficulty in interpreting international proofs, information overload, semen prices, low bull reliability, and difficulty in understanding bull catalogs. Not all herd managers found the process problematic, however, particularly if a breeding consultant was employed to select all or most of the sires. Herd manager-perceived barriers for choosing to select daughter fertility as a breeding objective include a lack of awareness of the EBV, a lack of interest in genetics in general, low confidence in the impact of genetic selection for fertility, and a feeling that fertility was not important for their production system. The results of this study suggest that animal geneticists and on-farm service providers need to work together to allow the opportunities arising from appropriate use of fertility EBV to be realized more broadly across the dairy industry.

Evaluation of the clinical and economic impact of delays to surgery in patients with periampullary cancer

Background

Early treatment is the only potential cure for periampullary cancer. The pathway to surgery is complex and involves multiple procedures across local and specialist hospitals. The aim of this study was to analyse variability within this pathway, and its impact on cost and outcomes.

Methods

Patients undergoing surgery for periampullary cancer (2011–2016) were identified retrospectively and their pathway to surgery was analysed. Patients who had early surgery (shortest quartile, Q1) were compared with those having late surgery (longest quartile, Q4).

Results

A total of 483 patients were included in the study, with 121 and 124 patients in Q1 and Q4 respectively. The median time from initial CT to surgery was 21 days for Q1 versus 112 days for Q4 (P < 0·001). Diagnostic delays were common in Q4; these patients required significantly more investigations than those in Q1 (endoscopic ultrasonography (EUS): 74·2 versus 18·2 per cent respectively, P < 0·001; MRI: 33·6 versus 20·6 per cent, P = 0·036). The median time to diagnostic EUS was 13 days in Q1 versus 59 days in Q4 (P < 0·001). Some 42·1 per cent of jaundiced patients in Q1 underwent preoperative biliary drainage, compared with all patients in Q4. There were significantly more unplanned admissions and associated longer duration of hospital stay per patient and costs in Q4 than in Q1 (median: 8 versus 3 days respectively; €5652 versus €2088; both P < 0·001). There was a higher likelihood of potentially curative surgery in Q1 (82·6 per cent versus 66·9 per cent in Q4; P = 0·005).

Conclusion

There is wide variation across the entire pathway, suggesting that multiple strategies are required to enable early surgery. Defining an effective pathway by anticipating the need for investigations and avoiding biliary drainage reduces unplanned admissions and costs and increases resection rates.

Transcriptomic analysis of circulating neutrophils in metabolically stressed peripartal grazing dairy cows

The high metabolic demand during the transition into lactation places cows at greater risk of metabolic and infectious disease than at any other time in their lactation cycle. Additionally, a change occurs in the innate immune response during this period, which contributes to increased risk of disease. In the current study, we compared the transcriptomes of neutrophils from dairy cows divergent in their metabolic health post-calving. Cows (n = 5 per risk group) were selected from a parent experiment (n = 45 cows). Those with high or low concentrations of plasma nonesterified fatty acids, plasma β-hydroxybutyrate, and liver triacylglycerol in both wk 1 and 2 were deemed to be at "high risk" (HR) or "low risk" (LR) of metabolic dysfunction, respectively. Circulating neutrophils were isolated at 3 time points during the transition period (d 0 and wk 1 and 4 post-calving), and gene expression was analyzed using RNA sequencing. Differential gene expression between the risk groups was determined using edgeR (http://bioconductor.org), and pathway analysis was conducted using Ingenuity Pathway Analysis (Ingenuity Systems, Qiagen, Valencia, CA). Statistical analysis indicated no interaction between risk and week. Therefore, the overall effect of risk was analyzed across all time points. In total, 3,500 genes were differentially expressed between the HR and LR cows (false discovery rate < 0.05). Of these, 2,897 genes were identified by Ingenuity Pathway Analysis and used for pathway analysis. Of the relevant pathways identified, neutrophils isolated from HR cows showed downregulation of genes involved in the recruitment of granulocytes, interferon signaling, and apoptosis, and upregulation of genes involved in cell survival. The results indicate that metabolically stressed cows had reduced neutrophil function during the peripartum period, highlighting a potential relationship between subclinical metabolic disease and innate immune function that suggests that metabolic health negatively affects the innate immune system and may contribute to the state of immunosuppression during the peripartum period. In this way, the metabolic stress among the HR cows may reduce their ability to combat infection during the transition period.

Abstract P3-12-24: Tumor-secreted predictive biomarkers of response to radiotherapy in breast cancer

Background:In breast cancer (BC), radiotherapy (RT) is used adjuvantly to prevent recurrence and also in the palliative setting. Clinical signs of RT response are often not apparent for several weeks post-treatment and we currently lack tools to predict or monitor tumor response to RT early during treatment. The aim was to identify tumor-secreted biomarkers whose release reflects response to RT, which could be monitored during treatment in the blood or intratumorally by an implantable biosensor, currently under development within the Implantable Microsystems for Personalised Anti-Cancer Therapy (IMPACT) program.

Methods: A series of experiments assessed the effect of different radiation doses (2-10Gy) on 3 human BC cell lines – MDA-MB-231 (ER-), MCF-7 (ER+) and HBL-100 (ER-) –, 1 canine breast cancer and 2 sheep lung cancer lines. Culture media was collected from each dose experiment at a range of post-radiation time-points (1-24 hours). Proteins were isolated from collected media for secretome mass spectrometry (MS) analysis. A subset of treatment/time conditions were repeated in the same BC cell lines and radioresistant (RR) derivatives from which RNA was extracted and analysed using Lexogen QuantSeq for whole-genome transcriptomics.In-lab candidate biomarker validation was carried out using immuhistochemistry (IHC), immunofluorescence (IF) and western blotting (WB) using validated antibodies. Levels of candidate biomarkers were also assessed in normal and untreated BC tissues using IHC. ELISA-based methods are currently under investigation for detection of the lead candidate biomarkers in the blood of large animal cancer models treated with RT.

Results: Biomarker discovery using the MS data revealed 4 promising candidates: EIF3G, SEC24C, YBX3 and TK1. These are released from BC and animal cancer cells sensitive to radiation in a dose-dependent manner 24 hours after treatment. Analysis of the transcriptomic data showed an 8-fold higher expression of the genes encoding the 4 candidates in the radio-sensitive parental cell lines compared to the RR cell lines. IF and WB confirmed lower intracellular expression of the 4 proteins in RR cells compared to the parental lines. WB of collected culture media confirmed release of each of the 4 candidates 24 hours after a 2Gy dose of radiation in only the parental lines. GAPDH was not found in these media samples, demonstrating that protein release was not due to cell lysis.

Conclusions:

· We have identified 4 promising biomarkers which are released from cancer cells sensitive to RT and not released from RR derivatives.

· All 4 candidates are released 24 hours after a 2Gy radiation dose, which fits with the current clinical dosing schedule where radiation is administered at 24 hour intervals. Ongoing work will elucidate if these biomarkers can be reliably detected in blood or intratumorally using implantable biosensors.

· There are currently no validated predictive tools to monitor RT response during treatment. If successfully validated, these biomarkers could have a clinical role in personalising RT dosing schedules and durations for solid tumors in the neoadjuvant and palliative setting, thus optimising treatment and preventing the administration of ineffective RT and its associated side effects.

Citation Format: Meehan J, Gray M, Turnbull AK, Martinez-Perez C, Bonello M, Ward C, Langdon SP, McLaughlin S, MacLennan M, Dixon JM, Wills J, Quinn N, Finich AJ, von Kriegsheim A, Cameron D, Kunkler IH, Murray A, Argyle D. Tumor-secreted predictive biomarkers of response to radiotherapy in breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-24.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

A feasibility study of a novel low-level light therapy for digital ulcers in systemic sclerosis

Background: Locally acting, well-tolerated treatments for systemic sclerosis (SSc) digital ulcers (DUs) are needed.

Objectives: Our primary aim was to investigate the safety, feasibility, and tolerability of a novel low-level light therapy (LTTT). A secondary aim was to tentatively assess efficacy.

Methods: A custom-built device comprising infrared (850 nm), red (660 nm), and violet (405 nm) LEDs was utilized. DUs were irradiated with 10 J/cm² twice weekly for 3 weeks, with follow-up at weeks 4 and 8. Any safety concerns were documented. Patient opinion on time to deliver, feasibility, and pain visual analogue score (VAS; 0–100, 100 most severe) was collected. Patient and clinician DU global assessment VAS were documented. DUs were evaluated by laser Doppler perfusion imaging pre- and post-irradiation.

Results: In all, 14 DUs in eight patients received a total of 46 light exposures, with no safety concerns. All patients considered LTTT ‘took just the right amount of time’ and was ‘feasible’, with a low associated mean pain VAS of 1.6 (SD: 5.2). Patient and clinician global DC VAS improved during the study (mean change: –7.1 and –5.2, respectively, both p < .001). DU perfusion significantly increased post-irradiation.

Conclusions: LTTT for DUs is safe, feasible, and well tolerated. There was an early tentative suggestion of treatment efficacy.

Analysis of the Temporal Compressibility of Breast Tumour Marker Assays: Development of a “Near Patient” Assay

The aim of this study was to investigate whether immunoassays for circulating MUC1 antigen in breast cancer could be compressed in time so that serum level results would be made available during the time of the patient's visit to clinic.

Two assays were used: - The EMCA (Euro DPC) is a liquid phase immunoassay and the ELSA CA15-3 (CIS) is a double determinant solid phase immunoradiometric assay. The effects of shortened incubation times were investigated by assaying standards and unknown samples and comparing the results with those using the standard kit protocols. The binding kinetics of the monoclonal antibodies employed in the assays were analysed separately.

We conclude that the EMCA assay can be shortened to 35 min and we have attributed this to the fast binding kinetics inherent in a liquid phase assay. This shortened assay may produce the basis for a useful “near patient” assay. By comparison, the solid phase ELSA CA15-3 assay cannot be compressed without loss in assay performance.

External Trabeculectomy with T-Flux Implant

PURPOSE

To evaluate the efficacy and safety of T-Flux implant in nonpenetrating glaucoma surgery.

METHODS

This clinical interventional case series study included 35 eyes of 35 patients with medically uncontrolled primary open angle glaucoma. External trabeculectomy with T-Flux (ETTF) is a technique of nonpenetrating glaucoma surgery, in which after removing deep scleral tissue and un-roofing the canal of Schlemn (CS) the external trabecular tissue is peeled off to enhance the aqueous drainage without opening the anterior chamber. A non-absorbable T-Flux implant (IOL TECH Laboratories, France) was sutured in deep intrascleral space to keep it patent. Snellen's best-corrected visual acuity, slit lamp biomicroscopy, intraocular pressure (IOP), gonioscopy, funduscopy, and optic disc assessment were performed preoperatively and postoperatively at 1 day, 1 week, and 1, 3 , 6, and 12 months. Visual field testing was performed preoperatively and at 6 and 12 months postoperatively.

RESULTS

For three eyes, surgery was converted to standard trabeculectomy owing to the perforation of trabeculo-Descemet's membrane and iris prolapse and excluded from the study. The results of the remaining 32 eyes were included in the study. Preoperative IOP (mean +/- SD) of 32.88 +/- 5.7 mmHg decreased to 15.44 +/- 1.6 mmHg after 12 months. Ten eyes (28.6%) had microhyphema that resolved spontaneously; 3 eyes (8.6%) had microperforation without iris prolapse so ETTF was proceeded routinely. The preoperative number of antiglaucoma medications per patient reduced from (mean +/- SD) 2.74 +/- 0.61 to 0.11 +/- 0.32 postoperatively at 12 months. Visual acuity and visual fields remained stable.

CONCLUSIONS

ETTF appears to provide significant control of IOP and have low incidence of complications.

Effect of circulating exosomes from transition cows on Madin-Darby bovine kidney cell function

The greatest risk of metabolic and infectious disease in dairy cows is during the transition from pregnancy to lactating (i.e., the transition period). The objective of this experiment was to determine the effects of extracellular vesicles (microvesicles involved in cell-to-cell signaling) isolated from transition cows on target cell function. We previously identified differences in the protein profiles of exosomes isolated from cows divergent in metabolic health status. Therefore, we hypothesized that these exosomes would affect target tissues differently. To investigate this, 2 groups of cows (n = 5/group) were selected based on the concentration of β-hydroxybutyrate and fatty acids in plasma and triacylglycerol concentration in liver at wk 1 and 2 postcalving. Cows with high concentrations of β-hydroxybutyrate, fatty acids, and triacylglycerol were considered at increased risk of clinical disease during the transition period (high-risk group; n = 5) and were compared with cows that had low concentrations of the selected health indicators (low-risk group; n = 5). At 2 time points during the transition period (postcalving at wk 1 and 4), blood was sampled and plasma exosomes were isolated from the high-risk and low-risk cows. The exosomes were applied at concentrations of 10 and 1 µg/mL to 5 × 10³ Madin-Darby bovine kidney cells grown to 50% confluence in 96-well plates. Results indicate a numerical increase in cell proliferation when exosomes from high-risk cows were applied compared with those from low-risk cows. Consistent with an effect on cell proliferation, quantitative reverse transcriptase PCR indicated a trend for upregulation of 3 proinflammatory genes (granulocyte colony-stimulating factor, ciliary neurotrophic factor, and CD27 ligand) with the application of high-risk exosomes, which are involved in cellular growth and survival. Proteomic analysis indicated 2 proteins in the low-risk group that were not identified in the high-risk group (endoplasmin and catalase), which may also be indicative of the metabolic state of origin. It is likely that the metabolic state of the transition cow affects cellular function through exosomal messaging; however, more in-depth research into cross-talk between exosomes and target cells is required to determine whether exosomes influence Madin-Darby bovine kidney cells in this manner.

Effects of precalving body condition and prepartum feeding level on gene expression in circulating neutrophils

Extensive metabolic, physiological, and immunological changes are associated with calving and the onset of lactation. As a result, cows transitioning between pregnancy and lactation are at a greater risk of metabolic and infectious diseases. The ability of neutrophils to mount an effective immune response to an infection is critical for its resolution, and increasing evidence indicates that precalving nutrition affects postpartum neutrophil function. The objectives of the current study were to investigate the effect of 2 precalving body condition scores (BCS; 4 vs. 5 on a 10-point scale) and 2 levels of feeding (75 vs. 125% of estimated maintenance requirements) on gene expression in circulating neutrophils. We isolated RNA from the neutrophils of cows (n = 45) at 5 time points over the transition period: precalving (-1 wk), day of calving (d 0), and postcalving at wk 1, 2, and 4. Quantitative reverse transcriptase PCR with custom-designed primer pairs and Roche Universal Probe Library (Roche, Basel, Switzerland) chemistry, combined with microfluidics integrated fluidic circuit chips (96.96 dynamic array), were used to quantify the expression of 78 genes involved in neutrophil function and 18 endogenous control genes. Statistical significance between time points was determined using repeated measures ANOVA with Tukey-Kramer multiple-testing correction to determine treatment effects among weeks. Precalving BCS altered the inflammatory state of neutrophils, with significant increases in overall gene expression of antimicrobial peptides (BNBD4 and DEFB10) and the anti-inflammatory cytokine IL10, and significantly decreased expression of proinflammatory cytokine IL23A in thinner cows (BCS 4) compared with cows calving at BCS 5. Feeding level had a time-dependent effect on gene expression; for example, increased expression of genes involved in leukotriene synthesis (PLA2G4A and ALOX5AP) occurred only at 1 wk postcalving in cows overfed (125% of requirements) precalving compared with those offered 75% of maintenance requirements. Results indicate that precalving body condition and changes in prepartum energy lead to altered gene expression of circulating neutrophils, highlighting the importance of transition cow nutrition for peripartum health.

Reduced perfusion in systemic sclerosis digital ulcers (both fingertip and extensor) can be increased by topical application of glyceryl trinitrate

Objectives

In patients with systemic sclerosis (SSc), fingertip digital ulcers (DUs) are believed to be ischaemic, and extensor surface DUs a result of mechanical factors/microtrauma. Our aim was to assess blood flow response to topical glyceryl trinitrate (GTN) compared to placebo in SSc DUs, looking for differences in pathophysiology between fingertip and extensor lesions.

Method

This was a double-blind, randomised, crossover, placebo-controlled study. Sixteen (6 fingertip, 10 extensor) DUs were each studied twice (one day apart): once with GTN and once with placebo ointment. Perfusion at the DU centre (‘DUCore’) and periphery (‘DUPeriphery’), as measured by laser Doppler imaging was performed before and immediately after ointment application, then every 10 min, up to 90 min post-application. We calculated the area under the response curve (AUC) and the ratio of peak perfusion to baseline, then compared these between GTN and placebo.

Results

Perfusion was lower in the DUCore compared to the DUPeriphery (ratio of 0.52). The microvessels of the DUCore were responsive to GTN, with an increase in perfusion, with a similar effect in both fingertip and extensor DUs. The AUC and peak/baseline perfusion difference in means (ratio, 95% confidence interval) between GTN and placebo at the DUCore were 1.2 (1.0–1.6) and 1.2 (1.0–1.5) respectively, and at the DUPeriphery were 1.1 (0.8–1.6) and 1.0 (0.9–1.2) respectively.

Conclusion

DUs (both fingertip and extensor) were responsive to topical GTN, with an increase in perfusion to the ischaemic DU centre. If both fingertip and extensor DUs have a (potentially reversible) ischaemic aetiology, this has important treatment implications.

•

SSc fingertip DUs are believed to be ischaemic, whereas, extensor surface DUs are a result of mechanical factors/microtrauma.

•

DUs (both fingertip and extensor) were responsive to topical GTN, in particular the ischaemic centre.

•

If both fingertip and extensor DUs have a ischaemic aetiology, this has important treatment implications.

Mutant p53: a novel target for the treatment of patients with triple-negative breast cancer?

The identification and validation of a targeted therapy for patients with triple-negative breast cancer (TNBC) is currently one of the most urgent needs in breast cancer therapeutics. One of the key reasons for the failure to develop a new therapy for this subgroup of breast cancer patients has been the difficulty in identifying a highly prevalent, targetable molecular alteration in these tumors. Recently however, the p53 gene was found to be mutated in approximately 80% of basal/TNBC, raising the possibility that targeting the mutant p53 protein product might be a new approach for the treatment of this form of breast cancer. In this study, we investigated the anti-cancer activity of PRIMA-1 and PRIMA-1^MET (APR-246), two compounds which were previously reported to reactivate mutant p53 and convert it to a form with wild-type (WT) properties. Using a panel of 18 breast cancer cell lines and 2 immortalized breast cell lines, inhibition of proliferation by PRIMA-1 and PRIMA-1^MET was found to be cell-line dependent, but independent of cell line molecular subtype. Although response was independent of molecular subtype, p53 mutated cell lines were significantly more sensitive to PRIMA-1^MET than p53 WT cells (p = 0.029). Furthermore, response (measured as IC₅₀ value) correlated significantly with p53 protein level as measured by ELISA (p = 0.0089, r=-0.57, n = 19). In addition to inhibiting cell proliferation, PRIMA-1^MET induced apoptosis and inhibited migration in a p53 mutant-dependent manner. Based on our data, we conclude that targeting mutant p53 with PRIMA-1^MET is a potential new approach for treating p53-mutated breast cancer, including the subgroup with triple-negative (TN) disease.

Does the Clinical Context Improve the Reliability of Rheumatologists Grading Digital Ulcers in Systemic Sclerosis?

OBJECTIVE

Digital ulcers (DUs) are often a primary end point in systemic sclerosis (SSc; scleroderma) clinical trials, although the reliability of rheumatologists grading DUs is poor to moderate at best. DU assessment in recent trials has been based upon visual inspection alone, which potentially misses "real-world" clinical contextual information. Our aim was to investigate whether this clinical information improves the reliability of rheumatologists grading DUs. A secondary aim was to assess agreement between patients and rheumatologists.

METHODS

Eighty images of a range of digital lesions were collected from patients with SSc with the clinical context: pain (severity and temporal relationship), lesion duration, and discharge (patient reported and clinician observed). Raters received all images either with or without the clinical context, and graded these images (using a custom-built interface) on an ordinal scale of severity: no ulcer, inactive ulcer, or active ulcer. Patients also graded their lesion(s) on the same scale.

RESULTS

Fifty-one rheumatologists from 15 countries completed the study (26 without and 25 with context): 4,590 (including 510 repeated) image gradings were obtained. Context did not significantly increase (without and with context) either intra- (0.64, 0.71) or interrater (0.32, 0.36) reliability. Pain (visual analog scale and temporal relationship) and discharge (patient reported and clinician observed) were associated with increased lesion severity, and duration with reduced severity. Agreement between individual patients and rheumatologists was poor without and with context (0.19, 0.28).

CONCLUSION

The overall intra- and interrater reliability of DU grading did not significantly improve with the clinical context. Agreement between patients and rheumatologists was poor.

Cognitive Aging: Activity Patterns and Maintenance Intentions

This study examined relationships between cognitive functioning in older people and 1) levels of mental, physical and social activities, and 2) intentions regarding maintenance of cognitive functioning. Participants ( N = 145) were 70–91 years of age, varied in health status and socio-economic backgrounds. Current cognitive functioning was assessed by psychometric tests and real world problem solving tasks. Crystallized ability was indexed by the National Adult Reading Test (NART). Degree of involvement in mentally demanding activities was positively related to a fluid cognitive factor after effects of age, prior functioning, gender, health, and socio-economic status were accounted for. Social and physical activities were not related to the cognitive measures. Age effects on cognitive functioning were reduced among participants who reported undertaking activities intentionally to maintain cognitive functioning.

Suspending Tonsillectomy: The Effects on Primary and Secondary Acute Care in Scotland

For the first six months of 2001, tonsillectomy operations were effectively suspended in Scotland. This was due to concern regarding the potential transmission of vCJD prions by surgical instruments, and the subsequent gradual introduction of disposable instruments. The number of patients awaiting tonsillectomy therefore increased and theoretically there should have been an increase in the number of tonsillitis episodes in the community, or even in the number of tonsillitis-related complications seen in secondary care. We examined for these effects using available national data sources which record primary and secondary care activity. No increases in the incidences of acute tonsillitis or tonsillitis-related complications were found for this period. The reasons and implications are discussed.