A Development and Implementation of a Preconception Counseling Program for Black Women and Men in the Southeastern United States: A Pilot Protocol

Introduction

Racial/ethnic disparities in maternal mortality rates represent one of the most significant areas of disparities amongst all conventional population perinatal health measures in the U.S. The alarming trends and persistent disparities of outcomes by race/ethnicity and geographic location reinforce the need to focus on ensuring quality and safety of maternity care for all women. Despite complex multilevel factors impacting maternal mortality and morbidity, there are evidence-based interventions that, when facilitated consistently and properly, are known to improve the health of mothers before, during and after pregnancy. The objective of this project is to test implementation of pre-conception counseling with father involvement in community-based settings to improve cardiovascular health outcomes before and during pregnancy in southeastern United States.

Methods and Analysis

This study has two components: a comprehensive needs and assets assessment and a small-scale pilot study. We will conduct a community informed needs and assets assessment with our diverse stakeholders to identify opportunities and barriers to preconception counseling as well as develop a stakeholder-informed implementation plan. Next, we will use the implementation plan to pilot preconception counseling with father involvement in community-based settings. Finally, we will critically assess the context, identify potential barriers and facilitators, and iteratively adapt the way preconception counseling can be implemented in diverse settings. Results of this research will support future research focused on identifying barriers and opportunities for scalable and sustainable public health approaches to implementing evidence-based strategies that reduce maternal morbidity and mortality in the southeastern United States' vulnerable communities.

Discussion

Findings will demonstrate that preconception counseling can be implemented in community health settings in the southeastern United States. Furthermore, this study will build the capacity of community-based organizations in addressing the preconception health of their clients. We plan for this pilot to inform a larger scaled-up clinical trial across community health settings in multiple southeastern states.

The bifurcation and topography of the posterior tibial artery within the tarsal tunnel

PURPOSE

The tarsal tunnel (TT) is a fibro-osseous anatomical space coursing from the medial ankle to the medial midfoot. This tunnel acts as a passage for both tendinous and neurovascular structures, including the neurovascular bundle containing the posterior tibial artery (PTA), posterior tibial veins (PTVs) and tibial nerve (TN). Tarsal tunnel syndrome (TTS) is the entrapment neuropathy that describes the compression and irritation of the TN within this space. Iatrogenic injury to the PTA plays a significant role in both the onset and exacerbation of TTS symptoms. The current study aims to produce a method to allow clinicians and surgeons to easily and accurately predict the bifurcation of the PTA, to avoid iatrogenic injury during treatment of TTS.

METHODS

Fifteen embalmed cadaveric lower limbs were dissected at the medial ankle region to expose the TT. Various measurements regarding the location of the PTA within the TT were recorded and multiple linear regression analysis performed using RStudio.

RESULTS

Analysis provided a clear correlation (p < 0.05) between the length of the foot (MH), length of hind-foot (MC) and location of bifurcation of the PTA (MB). Using these measurements, this study developed an equation (MB = 0.3*MH + 0.37*MC - 28.24 mm) to predict the location of bifurcation of the PTA within a 23° arc inferior to the medial malleolus.

CONCLUSIONS

This study successfully developed a method whereby clinicians and surgeons can easily and accurately predict the bifurcation of the PTA, to avoid iatrogenic injury that would previously lead to an exacerbation of TTS symptoms.

Effect of residence in nonmetropolitan counties on stage and tumor size at diagnosis in patients with breast cancer: A Surveillance, Epidemiology, and End Results analysis

OBJECTIVE

The aim of this study was to assess the influence of residence in nonmetropolitan versus metropolitan counties on stage and tumor size at diagnosis in patients with breast cancer in the United States.

METHODS

Women with a primary diagnosis of breast cancer between 2010 and 2015 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Logistic regression was used to model the effect of residence in nonmetropolitan counties on cancer stage and tumor size, adjusted for age, marital status, and 2 county-level socioeconomic variables.

RESULTS

The final sample included 267,691 patients. More patients were diagnosed at advanced stages (III-IV vs I-II: 51.11% vs 50.21%) and with larger tumors (>2 cm vs < = 2 cm: 47.62% vs 46.77%) in nonmetropolitan counties. After adjustment, residence in nonmetro counties was not associated with advanced stage at diagnosis (OR = 0.987; 95% CI: 0.959-1.015) or tumor size >2 cm at diagnosis (OR = 0.997; 95% CI: 0.969-1.026). In stratified analysis by race/ethnicity, however, non-Hispanic White patients in nonmetropolitan counties were significantly more likely to have an advanced stage (OR = 1.035, 95% CI: 1.003-1.068) and tumor sizes >2 cm (OR = 1.051; 95% CI: 1.018-1.084) at diagnosis.

CONCLUSIONS

Residence in nonmetropolitan counties in the United States was not associated with advanced stage or tumor size >2 cm at diagnosis in cases of breast cancer, compared to the residence in metropolitan counties. However, among non-Hispanic White females, residence in nonmetropolitan counties was associated with significantly higher odds of having an advanced stage and a tumor size >2 cm at diagnosis.

Exact Solutions of Interacting Dissipative Systems via Weak Symmetries

We demonstrate how the presence of continuous weak symmetry can be used to analytically diagonalize the Liouvillian of a class of Markovian dissipative systems with strong interactions or nonlinearity. This enables an exact description of the full dynamics and dissipative spectrum. Our method can be viewed as implementing an exact, sector-dependent mean-field decoupling, or alternatively, as a kind of quantum-to-classical mapping. We focus on two canonical examples: a nonlinear bosonic mode subject to incoherent loss and pumping, and an inhomogeneous quantum Ising model with arbitrary connectivity and local dissipation. In both cases, we calculate and analyze the full dissipation spectrum. Our method is applicable to a variety of other systems, and could provide a powerful new tool for the study of complex driven-dissipative quantum systems.

Metallization of Porous Polyethylene Using a Wire-Arc Spray Process for Heat Transfer Applications

Metallization of polyethylene (PE) using thermal spray techniques has proved difficult due to its low melting point and softness. In this study, metallic coatings were applied on porous polyethylene substrates using a twin wire-arc spray process. Commercially available polyethylene sheets, 3 mm in thickness, were used as substrates. Copper (Cu), aluminum (Al), and zinc (Zn) were successfully deposited on the porous polymer, without prior surface preparation, to form coatings with thickness of about 400 µm. Coating surface morphology and cross-sections were examined using a scanning electron microscope. Individual metal splats on the porous and non-porous substrates were observed to study the differences in the bonding mechanisms. The adhesion strength and electrical resistivity of the coatings on porous PE were evaluated. It was found that the bond strength of all three metallic coatings was found to be higher than the ultimate fracture strength of the porous. These results suggest that porosity in the polymer helps to overcome the challenges of metallizing polyethylene and provides a significant reduction in the weight of the polymer. Therefore, all these properties aided in fabricating an extremely lightweight, composite material with potential use in thermal management applications.

The Influence of Systemic Inflammation on Treatment Response and Survival in Anal Squamous Cell Cancer

AIMS

The incidence of anal squamous cell cancer (SCCA) is rising. Although chemoradiotherapy (CRT) provides a chance of cure, a proportion of patients have an incomplete response or develop recurrence. This study assessed the value of inflammation-based prognostic indicators, including the modified Glasgow Prognostic Score (mGPS) and neutrophil:lymphocyte ratio (NLR), in patients with SCCA treated by CRT with curative intent.

MATERIAL AND METHODS

Patients with histologically confirmed SCCA were identified from pathology records. Medical records were retrospectively reviewed and clinical, pathological and treatment characteristics were abstracted. The mGPS (0 = normal C-reactive protein [CRP] and albumin, 1 = CRP >10 mg/l and 2 = CRP >10 mg/l and albumin <35 mg/l) and NLR were calculated from routine blood tests obtained prior to CRT.

RESULTS

In total, 118 patients underwent CRT for SCCA between December 2007 and February 2018. Of these, 99 patients had appropriate pretreatment blood results available. Systemic inflammation as indicated by NLR >3 and mGPS >0 was present in 41% and 39% of patients, respectively. Most patients had T2 or larger tumours (n = 85, 86%) without nodal involvement (n = 64, 65%). An elevated mGPS was associated with more advanced T-stage (56% versus 35%, P = 0.036). NLR >5 was associated with nodal positivity (56% versus 31%, P = 0.047). On multivariate analysis, more advanced T-stage (odds ratio 7.49, 95% confidence interval 1.51-37.20, P = 0.014) and a raised mGPS (odds ratio 5.13, 95% confidence interval 1.25-21.14, P = 0.024) were independently related to incomplete CRT response. An elevated mGPS was prognostic of inferior survival (hazard ratio 3.09, 95% confidence interval 1.47-6.50, P = 0.003) and cancer-specific survival (hazard ratio 4.32, 95% confidence interval 1.54-12.15, P = 0.006), independent of TNM stage.

CONCLUSION

Systemic inflammation, as measured by the mGPS, is associated with an incomplete CRT response and is independently prognostic of inferior survival in patients with SCCA. The mGPS may offer a simple marker of inferior outcome that could be used to identify high-risk patients.

Temporal changes in soil microbial properties and nutrient dynamics under climate smart agriculture practices

Climate smart agriculture (CSA) practices are emerging as sustainable alternative to conventional rice-wheat system to pull up natural resources degradation across south Asia. After five years of continuous CSA based experiment, a two years study was conducted to evaluate changes in microbial biomasses (microbial biomass carbon and nitrogen), enzyme activities (alkaline phosphatase, dehydrogenase and β-glucosidase), nutrient release and uptake (N, P and K) at different wheat crop growth stages. Effect of CSA practices was also studied for carbon mineralization in an incubation experiment. Four scenarios (Sc) were included in this study- conventional tillage (CT) based rice-wheat system (Sc1), partial CSA based rice-wheat-mungbean system (Sc2), full CSA based rice-wheat-mungbean system (Sc3), and full CSA based maize-wheat-mungbean system (Sc4). Soil samples were collected from scenarios at 0-15 and 15-30 cm depth at different growth stages of wheat crop namely sowing, crown root initiation (CRI), active tillering, panicle initiation, and harvesting. Analysis of soil was done for chemical properties viz. pH, electrical conductivity, available N, P, K, NPK uptake and mineralizable carbon and biological properties viz., microbial biomass carbon (MBC), microbial biomass nitrogen (MBN), dehydrogenase activity (DHA), alkaline phosphatase activity (APA) and β-glucosidase. Significantly higher microbial biomass carbon (42 %) and nitrogen (79 %) were found in surface soil (0-15 cm depth) under CSA based scenarios (Sc2, Sc3 and Sc4) at harvest stage of wheat over CT based/ conventional scenario (Sc1). At surface soil, alkaline phosphatase, dehydrogenase and β-glucosidase activity was 58, 14 and 13 % higher in CSA based scenarios, respectively than CT based scenario. CSA based scenarios showed significantly higher C mineralization after 3 days of the incubation experiment at harvest. An increase of respectively 15, 48 and 17 % of N, P and K uptake was observed with CSA based scenarios than CT based scenario. At harvest stage, 7 % higher amount of dry matter was reported with full CSA based scenarios (mean of Sc2 to Sc4) compared to Sc1. Higher wheat grain yield of ∼10 % was recorded with CSA based scenarios over CT based scenario. Therefore, CSA based scenarios with improved biological properties and nutrient availability and uptake at different wheat growth stages resulted in higher yields and hence need to be popularized among the farmers.

Mesh inlay, mesh kit or native tissue repair for women having repeat anterior or posterior prolapse surgery: randomised controlled trial (PROSPECT)

OBJECTIVE

To compare standard (native tissue) repair with synthetic mesh inlays or mesh kits.

DESIGN

Randomised controlled trial.

SETTING

Thirty-three UK hospitals.

POPULATION

Women having surgery for recurrent prolapse.

METHODS

Women recruited using remote randomisation.

MAIN OUTCOME MEASURES

Prolapse symptoms, condition-specific quality-of-life and serious adverse effects.

RESULTS

A Mean Pelvic Organ Prolapse Symptom Score at 1 year was similar for each comparison (standard 6.6 versus mesh inlay 6.1, mean difference [MD] -0.41, 95% CI -2.92 to 2.11: standard 6.6 versus mesh kit 5.9, MD -1.21 , 95% CI -4.13 to 1.72) but the confidence intervals did not exclude a minimally important clinical difference. There was no evidence of difference in any other outcome measure at 1 or 2 years. Serious adverse events, excluding mesh exposure, were similar at 1 year (standard 7/55 [13%] versus mesh inlay 5/52 [10%], risk ratio [RR] 1.05 [0.66-1.68]: standard 3/25 [12%] versus mesh kit 3/46 [7%], RR 0.49 [0.11-2.16]). Cumulative mesh exposure rates over 2 years were 7/52 (13%) in the mesh inlay arm, of whom four women required surgical revision; and 4/46 in the mesh kit arm (9%), of whom two required surgical revision.

CONCLUSIONS

We did not find evidence of a difference in terms of prolapse symptoms from the use of mesh inlays or mesh kits in women undergoing repeat prolapse surgery. Although the sample size was too small to be conclusive, the results provide a substantive contribution to future meta-analysis.

TWEETABLE ABSTRACT

There is not enough evidence to support use of synthetic mesh inlay or mesh kits for repeat prolapse surgery.

'We've made the best of it. But we do not have a normal life': families' experiences of tuberous sclerosis complex and seizure management

BACKGROUND

Tuberous sclerosis complex (TSC) is a complex multisystem genetic disorder. Approximately 84% of people with TSC have epilepsy. However, there is little literature available regarding families' experiences with TSC and seizure management. Therefore, the aim of the current study was to explore families' positive and negative experiences, and attitudes towards TSC, epilepsy and medical management of seizures.

METHODS

Framework analysis informed an open exploration of families' experiences with TSC, epilepsy and medical management of seizures. Using structured interviews, 11 parents of people with TSC and 2 people with TSC were interviewed, providing the data set for transcription and thematic analysis.

RESULTS

'TSC rules our life' overarched three subordinate themes: 'Our normal', 'Burnout' and 'Seizure management has given us our life back'. Families had to adapt to the normality of needing to constantly supervise their child even as they become an adult. They express a feeling of fear particularly of seizures, and this has impact throughout the family. There are frequent expressions of exhaustion and struggling to fight for access and support. There are some positives and cautious hope with the gaining of control from seizures as being able to predict or plan improves activity and participation. These interviews provided a rich insight into the lives of those with TSC and their families.

CONCLUSION

There are exciting developments with respect to scientific understanding of the pathophysiology of TSC, which opens opportunity for new treatments. Holistic family centred health care and practical support (e.g. opportunities for parental respite) is as important as medical intervention. As TSC is such a complex condition, there is a need for specialist clinics and TSC-specific research.

Effects of tillage, crop establishment and diversification on soil organic carbon, aggregation, aggregate associated carbon and productivity in cereal systems of semi-arid Northwest India

Intensive tillage based management practices are threatening soil quality and systems sustainability in the rice-wheat belt of Northwest India. Furthermore, it is accentuated with puddling of soil, which disrupts soil aggregates. Conservation agriculture (CA) practices involving zero tillage, crop residue management and suitable crop rotation can serve as better alternative to conventional agriculture for maintaining soil quality. Soil organic carbon is an important determinant of soil quality, playing critical role in food production, mitigation and adaptation to climate change as well as performs many ecosystem functions. To understand the turnover of soil carbon in different forms (Total organic carbon-TOC; aggregate associated carbon-AAC; particulate organic carbon- POC), soil aggregation and crop productivity with different management practices, one conventional agriculture based scenario and three CA based crop management scenarios namely conventional rice-wheat system (Sc1), partial CA based rice-wheat-mungbean system (Sc2), full CA-based rice-wheat-mungbean system (Sc3) and maize-wheat-mungbean system (Sc4) were evaluated. TOC was increased by 71%, 68% and 25% after 4 years of the experiment and 75%, 80% and 38% after 6 years of the experiment in Sc4, Sc3 and Sc2, respectively, over Sc1 at 0-15 cm soil depth. After 4 years of the experiment, 38.5% and 5.0% and after 6 years 50.8% and 24.4% improvement in total water stable aggregates at 0-15 and 15-30 cm soil depth, respectively was observed in CA-based scenarios over Sc1. Higher aggregate indices were associated with Sc3 at 0-15 cm soil depth than others. Among the size classes of aggregates, highest aggregate associated C (8.94 g kg^-1) was retained in the 1-0.5 mm size class under CA-based scenarios. After 6 years, higher POC was associated with Sc4 (116%). CA-based rice/maize system (Sc3 and Sc4) showed higher productivity than Sc1. Therefore, CA could be a potential management practice in rice-wheat cropping system of Northwest India to improve the soil carbon pools through maintaining soil aggregation and productivity.

Achieving Self-Directed Integrated Cancer Aftercare (ASICA) in melanoma: protocol for a randomised patient-focused pilot trial of delivering the ASICA intervention as a means to earlier detection of recurrent and second primary melanoma

BACKGROUND

Melanoma is common; 15,906 people in the UK were diagnosed with melanoma in 2015 and incidence has increased fivefold in 30 years. Melanoma affects old and young people, with poor prognosis once metastatic. UK guidelines recommend people treated for cutaneous melanoma receive extended outpatient, hospital follow up to detect recurrence or new primaries. Such follow up of the growing population of melanoma survivors is burdensome for both individuals and health services. Follow up is important since approximately 20% of patients with early-stage melanoma experience a recurrence and 4-8% develop a new primary; the risk of either is highest in the first 5 years. Achieving Self-directed Integrated Cancer Aftercare (ASICA) is a digital intervention to increase total-skin-self-examination (TSSE) by people treated for melanoma, with usual follow up.

METHODS

We aim to recruit 240 adults with a previous first-stage 0-2C primary cutaneous melanoma, from secondary care in North-East Scotland and the East of England. Participants will be randomised to receive the ASICA intervention (a tablet-based digital intervention to prompt and support TSSE) or control group (treatment as usual). Patient-reported and clinical data will be collected at baseline, including the modified Melanoma Worry Scale (MWS), the Hospital Anxiety and Depression Scale (HADs), the EuroQoL 5-dimension 5-level questionnaire (EQ-5D-5 L), and questions about TSSE practice, intentions, self-efficacy and planning. Participants will be followed up by postal questionnaire at 3, 6 and 12 months following randomization, along with a 12-month review of clinical data. The primary timepoint for outcome analyses will be12 months after randomisation.

DISCUSSION

If the ASICA intervention improves the practice of TSSE in those affected by melanoma, this may lead to improved psychological well-being and earlier detection of recurrent and new primary melanoma. This could impact both patients and National Health Service (NHS) resources. This study will determine if a full-scale randomised controlled trial can be undertaken in the UK NHS to provide the high-quality evidence needed to determine the effectiveness of the intervention. ASICA is a pilot study evaluating the effectiveness of the practice of digitally supported TSSE in those affected by melanoma.

TRIAL REGISTRATION

Clinical Trials.gov, NCT03328247 . Registered on 1 November 2017.

Protocol for a Randomised controlled trial to Evaluate the effectiveness and cost benefit of prescribing high dose FLuoride toothpaste in preventing and treating dEntal Caries in high-risk older adulTs (reflect trial)

BACKGROUND

Dental caries in the expanding elderly, predominantly-dentate population is an emerging public health concern. Elderly individuals with heavily restored dentitions represent a clinical challenge and significant financial burden for healthcare systems, especially when their physical and cognitive abilities are in decline. Prescription of higher concentration fluoride toothpaste to prevent caries in older populations is expanding in the UK, significantly increasing costs for the National Health Services (NHS) but the effectiveness and cost benefit of this intervention are uncertain. The Reflect trial will evaluate the effectiveness and cost benefit of General Dental Practitioner (GDP) prescribing of 5000 ppm fluoride toothpaste and usual care compared to usual care alone in individuals 50 years and over with high-risk of caries.

METHODS/DESIGN

A pragmatic, open-label, randomised controlled trial involving adults aged 50 years and above attending NHS dental practices identified by their dentist as having high risk of dental caries. Participants will be randomised to prescription of 5000 ppm fluoride toothpaste (frequency, amount and duration decided by GDP) and usual care only. 1200 participants will be recruited from approximately 60 dental practices in England, Scotland and Northern Ireland and followed up for 3 years. The primary outcome will be the proportion of participants receiving any dental treatment due to caries. Secondary outcomes will include coronal and root caries increments measured by independent, blinded examiners, patient reported quality of life measures, and economic outcomes; NHS and patient perspective costs, willingness to pay, net benefit (analysed over the trial follow-up period and modelled lifetime horizon). A parallel qualitative study will investigate GDPs' practises of and beliefs about prescribing the toothpaste and patients' beliefs and experiences of the toothpaste and perceived impacts on their oral health-related behaviours.

DISCUSSION

The Reflect trial will provide valuable information to patients, policy makers and clinicians on the costs and benefits of an expensive, but evidence-deficient caries prevention intervention delivered to older adults in general dental practice.

TRIAL REGISTRATION

ISRCTN: 2017-002402-13 registered 02/06/2017, first participant recruited 03/05/2018. Ethics Reference No: 17/NE/0329/233335. Funding Body: Health Technology Assessment funding stream of National Institute for Health Research. Funder number: HTA project 16/23/01. Trial Sponsor: Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL. The Trial was prospectively registered.

Impact of Carbamide Peroxide Whitening Agent on Dentinal Collagen

Carbamide peroxide (CP) is widely used as a tooth-whitening agent in self-administered tooth-bleaching products. In this study, the effects of 5% and 10% CP on dentinal collagen structure and chemical properties were evaluated in vitro. Thirty-five intact teeth were exposed to 2 whitening protocols (2 or 4 h daily) with either 5% or 10% CP gel for 1 wk. Shade changes before and after the whitening protocol were captured colorimetrically using a spectroshade. Collagen scaffold models and demineralized dentine disc samples were prepared and exposed to CP droplets (5% or 10%). Structural changes were investigated using electron microscopy. Finally, mineralized dentine disc samples were prepared postbleaching to assess chemical changes resulting from CP exposure in dentinal collagen using Raman spectroscopy. Results showed a difference in tooth shade when exposed to 5% and 10% CP whitening protocols, with a significantly ( P ≤ 0.01) greater change reported for the 10% CP/4-h group. Imaging of the collagen scaffold model following exposure to CP showed a gelatinization process indicating that the free radical by-products from CP are able to disrupt the quaternary structure of noncrosslinked collagen. The most significant damage on the collagen scaffold was seen for the 10% CP exposure for 4 h. Imaging of the demineralized discs displayed the same glassy amorphous layer appearance as found in the collagen scaffold. Raman spectra of the mineralized dentine discs showed a significant decrease ( P ≤ 0.01) in the integrated area of amide I and amide III values in the 4 test groups following CP application. Amide I was more affected as both the exposure time and concentration of CP increased. Despite the claimed safety of whitening agents, this in vitro study concludes that even low concentrations of CP result in a deleterious change in dentinal collagen.

Early barriers to neonatal porcine islet engraftment in a dual transplant model

Porcine islet xenografts have the potential to provide an inexhaustible source of islets for β cell replacement. Proof-of-concept has been established in nonhuman primates. However, significant barriers to xenoislet transplantation remain, including the poorly understood instant blood-mediated inflammatory reaction and a thorough understanding of early xeno-specific immune responses. A paucity of data exist comparing xeno-specific immune responses with alloislet (AI) responses in primates. We recently developed a dual islet transplant model, which enables direct histologic comparison of early engraftment immunobiology. In this study, we investigate early immune responses to neonatal porcine islet (NPI) xenografts compared with rhesus islet allografts at 1 hour, 24 hours, and 7 days. Within the first 24 hours after intraportal infusion, we identified greater apoptosis (caspase 3 activity and TUNEL [terminal deoxynucleotidyl transferase dUTP nick end labeling])-positive cells) of NPIs compared with AIs. Macrophage infiltration was significantly greater at 24 hours compared with 1 hour in both NPI (wild-type) and AIs. At 7 days, IgM and macrophages were highly specific for NPIs (α1,3-galactosyltransferase knockout) compared with AIs. These findings demonstrate an augmented macrophage and antibody response toward xenografts compared with allografts. These data may inform future immune or genetic manipulations required to improve xenoislet engraftment.

Abstract P2-03-08: A retrospective study to identify the frequency of discordant HER2 results using both immunohistochemistry (IHC) and in-situ hybridization (ISH) assays

Background

HER2 targeted therapies have substantially improved survival outcomes for patients with breast cancer and HER2 amplification of their tumour. The recently updated American Society of Clinical Oncology/College of American Pathologists (ASCO CAP) guidelines recommend that HER2 testing to be performed on all invasive breast cancers and that positive HER2 status is defined by either evidence of HER2 protein over-expression measured by immunohistochemistry status (IHC 3+) or by in-situ hybridisation (ISH) amplification. Equivocal results require further testing with the alternative assay.

In Australia, Medicare-funded access to HER2 targeted therapies requires demonstration of HER2 positivity by ISH, regardless of IHC status. Thus, currently most breast units perform IHC and ISH on all breast cancers. Given this discrepancy in practice and significant additional cost of performing ISH, this study evaluated the frequency of discordance and the cost burden in using both assays in a historical series of patients with breast cancer.

Methods

A retrospective audit of HER2 histopathology reports was performed for all breast cancers diagnosed between 2007 and 2016 at a single tertiary hospital in Melbourne, Australia (The Austin Hospital). HER2 IHC results were classified as negative (0 or 1+), equivocal (2+) or positive (3+). An analysis was performed to assess the proportion of concordant (defined as samples with IHC 0/1+ and negative ISH, samples with IHC3+ and positive ISH, and samples with IHC2+ regardless of ISH) and discordant results (defined as IHC 3+ and ISH non-amplified or IHC 0/1+ and ISH amplified). Tumour blocks and slides from discordant cases were reviewed by a breast cancer histopathologist. The cost of additional testing in concordant cases was performed based on the Australian Medicare Benefits Schedule (MBS).

Results

Eight hundred and forty-six histopathology reports were reviewed from 786 patients, all of whom had both IHC and ISH assays. There were 832 (98.8%) concordant cases. There were 10 discordant cases (1.2%) in total, including three cases (0.4%) with a negative IHC (1+) result but positive ISH, and 7 cases (0.8%) with a positive IHC but negative ISH result. A detailed analysis of 10 discordant cases will be presented. HER2 status and subsequent treatment remain unchanged with the addition of ISH testing in 665 (79.0%) cases, which amounted to an additional $209,741 (AUD) being spent on unnecessary ISH testing. Given an estimated incidence of 17,730 new cases of breast cancer per year in Australia, the population cost of performing additional HER2 ISH testing ($315.40 per case) in concordant cases would equate to $4.4 million (AUD) per year.

Conclusion

These results describe an extremely low rate of HER2 IHC/ISH discordance suggesting that routine use of both assays is unnecessary in cases with an unequivocal IHC result. The fiscal burden and potential delays to deciding treatment provide a strong rationale for access to HER2 targeted therapies to be based IHC or ISH, as advised by the ASCO CAP guidelines. Our results will be used to support a national review of IHC and ISH discordance using Australian national registry data.

Citation Format: Balasubramanian A, Ireland-Jenkin K, McDonald A, Khor R, Yeo B, Leong T. A retrospective study to identify the frequency of discordant HER2 results using both immunohistochemistry (IHC) and in-situ hybridization (ISH) assays [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 P2-03-08.

Abstract P2-09-30: A gene expression signature that predicts for trastuzumab response in HER2+ breast cancer

Background: Approximately 15-20% of breast cancers overexpress HER2. These patients are eligible for trastuzumab in combination with chemotherapy. However, some patients are extreme responders to single agent trastuzumab and we wanted to identify differences in cancer gene expression that could predict response to single agent trastuzumab.

Methods: We performed paired-end RNAseq on an isogenic cellular model of trastuzumab sensitivity and resistance. We reasoned that the isogenic nature of the cellular clones used in this study would enrich for differentially-expressed genes (DEGs) that were associated with response to single-agent trastuzumab. DEGs where chosen based upon either i) large fold changes in resistant vs. sensitive clones, ii) high frequency in human HER2+ breast cancers, or iii) were found to be enriched with other DEGs in signaling pathways selected by Ingenuity Pathway Analysis (IPA). DEGs were further scrutinized based upon associations with overall survival (OS) in HER2+ human breast cancers. The resulting genes were validated using qPCR and in several independent sample sets containing gene expression profiles of human breast cancers.

Results: Discovery: RNAseq yielded 3,241 statistically-significant DEGs. We used two independent filtering pipelines to obtain 175 DEGs. Ingenuity Pathway Analysis found signaling pathways associated with eukaryotic initiation factor, lysine specific demethylase 5B, and estrogen receptor alpha to be enriched in DEGs associated with trastuzumab resistance. Of these DEGs, six genes correlated with a statistically significant change in OS in the training dataset, and were validated by qPCR in the cell lines used for the analysis. We further determined that the six-gene signature was a negative predictor of overall survival in HER2+ breast cancer patients whose cancers carried at least one DEG. Validation: Using independent cohorts from TCGA and the website KMplot.com, we validated the predictive power of the six-gene signature. Of the 47 HER2+ patients from TCGA, eight patients carried two more DEGs, while 39 carried ≤ 1 DEG. Although the numbers are small, of the 8 patients followed for four or more years, only one patient was alive as compared with 7 out of 39 patients without the signature. Similarly, Kaplan Meier analysis of gene expression data from KMplot.com revealed that only 1 out of 23 patients (4.3%) who carried high mean expression of the six-gene signature were free of distant metastases after 87 months, compared to 4 out of 43 patients (9.3%) from the cohort carrying low mean expression of the six-gene signature. In both validation cohorts, the six DEG signature was not predictive in HER2-negative breast cancers.

Discussion: Patients whose tumors lack this gene expression signature are more likely to experience a favorable response to trastuzumab therapy. This signature requires validation in a clinical cohort treated with trastuzumab monotherapy.

Citation Format: Abukhdeir AM, Najor MS, Turturro SB, Armstrong AR, McDonald A, Fogg L, Cobleigh MA. A gene expression signature that predicts for trastuzumab response in HER2+ 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 P2-09-30.

Assessing soil properties and nutrient availability under conservation agriculture practices in a reclaimed sodic soil in cereal-based systems of North-West India

Soil quality degradation associated with resources scarcity is the major concern for the sustainability of conventional rice-wheat system in South Asia. Replacement of conventional management practices with conservation agriculture (CA) is required to improve soil quality. A field experiment was conducted to assess the effect of CA on soil physical (bulk density, penetration resistance, infiltration) and chemical (N, P, K, S, micronutrients) properties after 4 years in North-West India. There were four scenarios (Sc) namely conventional rice-wheat cropping system (Sc1); partial CA-based rice-wheat-mungbean system (RWMS) (Sc2); CA-based RWMS (Sc3); and CA-based maize-wheat-mungbean (Sc4) system. Sc2 (1.52 Mg m^-3) showed significantly lower soil bulk density (BD). In Sc3 and Sc4, soil penetration resistance (SPR) was reduced and infiltration was improved compared to Sc1. Soil organic C was significantly higher in Sc4 than Sc1. Available N was 33% and 68% higher at 0-15 cm depth in Sc3 and Sc4, respectively, than Sc1. DTPA extractable Zn and Mn were significantly higher under Sc3 and Sc4 compared to Sc1. Omission study showed 30% saving in N and 50% in K in wheat after four years. Therefore, CA improved soil properties and nutrient availability and have potential to reduce external fertilizer inputs in long run.

Carbon dating cancer: defining the chronology of metastatic progression in colorectal cancer

Background

Patients often ask oncologists how long a cancer has been present before causing symptoms or spreading to other organs. The evolutionary trajectory of cancers can be defined using phylogenetic approaches but lack of chronological references makes dating the exact onset of tumours very challenging.

Patients and methods

Here, we describe the case of a colorectal cancer (CRC) patient presenting with synchronous lung metastasis and metachronous thyroid, chest wall and urinary tract metastases over the course of 5 years. The chest wall metastasis was caused by needle tract seeding, implying a known time of onset. Using whole genome sequencing data from primary and metastatic sites we inferred the complete chronology of the cancer by exploiting the time of needle tract seeding as an in vivo 'stopwatch'. This approach allowed us to follow the progression of the disease back in time, dating each ancestral node of the phylogenetic tree in the past history of the tumour. We used a Bayesian phylogenomic approach, which accounts for possible dynamic changes in mutational rate, to reconstruct the phylogenetic tree and effectively 'carbon date' the malignant progression.

Results

The primary colon cancer emerged between 5 and 8 years before the clinical diagnosis. The primary tumour metastasized to the lung and the thyroid within a year from its onset. The thyroid lesion presented as a tumour-to-tumour deposit within a benign Hurthle adenoma. Despite rapid metastatic progression from the primary tumour, the patient showed an indolent disease course. Primary cancer and metastases were microsatellite stable and displayed low chromosomal instability. Neo-antigen analysis suggested minimal immunogenicity.

Conclusion

Our data provide the first in vivo experimental evidence documenting the timing of metastatic progression in CRC and suggest that genomic instability might be more important than the metastatic potential of the primary cancer in dictating CRC fate.

Long-term results and recurrence patterns from SCALOP: a phase II randomised trial of gemcitabine- or capecitabine-based chemoradiation for locally advanced pancreatic cancer

BACKGROUND

SCALOP, a randomised, phase II trial, tested the activity and safety of gemcitabine (GEM)-based and capecitabine (CAP)-based chemoradiation (CRT) for locally advanced pancreatic cancer (LAPC). Here we present the long-term outcomes.

METHODS

Eligibility: histologically proven LAPC ⩽7 cm. Following 12 weeks of induction GEMCAP chemotherapy (three cycles: GEM 1000 mg m-2 days 1, 8, 15; CAP 830 mg m-2 days 1-21 q28 days) patients with stable/responding disease, tumour ⩽6 cm, and WHO Performance Status 0-1 were randomised to receive one cycle GEMCAP followed by CAP (830 mg m-2 b.d. on weekdays only) or GEM (300 mg m-2 weekly) with radiation (50.4 Gy per 28 fractions).

RESULTS

One-hundred fourteen patients (28 UK centres) were registered between 24 December 2009 and 25 October 2011, and 74 were randomised (CAP-RT=36; GEM-RT=38). At the time of this analysis, 105 of the 114 patients had died and the surviving 9 patients had been followed up for a median of 10.9 months (IQR: 2.9-18.7). Updated median OS was 17.6 months (95% CI: 14.6-22.7) in the CAP-CRT arm and 14.6 months (95% CI: 11.1-16.0) in the GEM-CRT arm (intention-to-treat adjusted hazard ratio (HR): 0.68 (95% CI: 0.38-1.21, P=0.185)); median progression-free survival (PFS) was 12.0 months (95% CI: 10.0-15.2) in the CAP-CRT arm and 10.4 months (95% CI: 8.8-12.7) in the GEM-CRT arm (intention-to-treat adjusted HR: 0.60 (95% CI: 0.32-1.14, P=0.120)). In baseline multivariable model, age ⩾65 years, better performance status, CA19.9<613 IU l-1, and shorter tumour diameter predicted improved OS. CAP-CRT, age ⩾65 years, better performance status, CA19.9 <46 IU ml-1 predicted improved OS and PFS in the pre-radiotherapy model. Nine-month PFS was highly predictive of OS.

CONCLUSIONS

CAP-CRT remains the superior regimen. SCALOP showed that patients with CA19.9 <46 IU ml-1 after induction chemotherapy are more likely to benefit from CRT.

Runx1 Orchestrates Sphingolipid Metabolism and Glucocorticoid Resistance in Lymphomagenesis

The three‐membered RUNX gene family includes RUNX1, a major mutational target in human leukemias, and displays hallmarks of both tumor suppressors and oncogenes. In mouse models, the Runx genes appear to act as conditional oncogenes, as ectopic expression is growth suppressive in normal cells but drives lymphoma development potently when combined with over‐expressed Myc or loss of p53. Clues to underlying mechanisms emerged previously from murine fibroblasts where ectopic expression of any of the Runx genes promotes survival through direct and indirect regulation of key enzymes in sphingolipid metabolism associated with a shift in the “sphingolipid rheostat” from ceramide to sphingosine‐1‐phosphate (S1P). Testing of this relationship in lymphoma cells was therefore a high priority. We find that ectopic expression of Runx1 in lymphoma cells consistently perturbs the sphingolipid rheostat, whereas an essential physiological role for Runx1 is revealed by reduced S1P levels in normal spleen after partial Cre‐mediated excision. Furthermore, we show that ectopic Runx1 expression confers increased resistance of lymphoma cells to glucocorticoid‐mediated apoptosis, and elucidate the mechanism of cross‐talk between glucocorticoid and sphingolipid metabolism through Sgpp1. Dexamethasone potently induces expression of Sgpp1 in T‐lymphoma cells and drives cell death which is reduced by partial knockdown of Sgpp1 with shRNA or direct transcriptional repression of Sgpp1 by ectopic Runx1. Together these data show that Runx1 plays a role in regulating the sphingolipid rheostat in normal development and that perturbation of this cell fate regulator contributes to Runx‐driven lymphomagenesis. J. Cell. Biochem. 118: 1432–1441, 2017. © 2016 The Authors. Journal of Cellular Biochemistry Published by Wiley Periodicals, Inc.

Testosterone deficiency and quality of life in Australasian testicular cancer survivors: a prospective cohort study

This is the first prospective study in a contemporary Australian/New Zealand population to determine the prevalence of testosterone deficiency in testicular cancer survivors at 12 months from treatment, and any association with poorer quality of life. Hormone assays from 54 evaluable patients in a prospective cohort study revealed biochemical hypogonadism in 18 patients (33%) and low-normal testosterone in 13 patients (24%). We found no association between testosterone levels and quality of life (all P > 0.05). Hypogonadal patients should be considered for testosterone replacement to prevent long-term morbidity.

Colonisation of dentures by Staphylococcus aureus and MRSA in out-patient and in-patient populations

Methicillin-resistant Staphylococcus aureus (MRSA) is an important human pathogen, and colonisation with this organism can result in localised or systemic infections which may be fatal. One hundred in-patients admitted to a London teaching hospital and 100 out-patients attending prosthetic dentistry clinics were recruited into this study. Of the 100 out-patients, 27 % harboured S. aureus on their dentures, compared to 33 % of in-patients. Only one out-patient had MRSA colonising their dentures whereas 12 % of the in-patients harboured MRSA. The median total bacterial count of the denture plaque samples was 6.2 × 10(7) cfu/sample and 6.9 × 10(7) cfu/sample for the out-patient and in-patient populations, respectively. In most instances, where present, S. aureus comprised less than 1 % of the total viable denture microbiota. Phage typing demonstrated that EMRSA-15 and non-typeable strains were harboured on dentures. The results of this study have revealed that dentures are a potential reservoir of MRSA and so account should be taken of these findings when planning decontamination procedures for elimination of this pathogen.