Effects of colour-coded compartmentalised syringe trays on anaesthetic drug error detection under cognitive load

BACKGROUND

Anaesthetic drug administration is complex, and typical clinical environments can entail significant cognitive load. Colour-coded anaesthetic drug trays have shown promising results for error identification and reducing cognitive load.

METHODS

We used experimental psychology methods to test the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a simulated visual search task. Effects of cognitive load were also explored through an accompanying working memory-based task. We hypothesised that colour-coded compartmentalised trays would improve drug-detection error, reduce search time, and reduce cognitive load. This comprised a cognitive load memory task presented alongside a visual search task to detect drug errors.

RESULTS

All 53 participants completed 36 trials, which were counterbalanced across the two tray types and 18 different vignettes. There were 16 error-present and 20 error-absent trials, with 18 trials presented for each preloaded tray type. Syringe errors were detected more often in the colour-coded trays than in the conventional trays (91% vs 83%, respectively; P=0.006). In signal detection analysis, colour-coded trays resulted in more sensitivity to the error signal (2.28 vs 1.50, respectively; P<0.001). Confidence in response accuracy correlated more strongly with task performance for the colour-coded tray condition, indicating improved metacognitive sensitivity to task performance (r=0.696 vs r=0.447).

CONCLUSIONS

Colour coding and compartmentalisation enhanced visual search efficacy of drug trays. This is further evidence that introducing standardised colour-coded trays into operating theatres and procedural suites would add an additional layer of safety for anaesthetic procedures.

Involvement of Palliative Care in Malignant Pleural Mesothelioma Patients and Associations with Survival and End-of-Life Outcomes

Malignant pleural mesothelioma is a rare, aggressive, and incurable cancer with a poor prognosis and high symptom burden. For these patients, little is known about the impact of palliative care consultation on outcomes such as mortality, hospital admissions, or emergency department visits. The aim of this study is to determine if referral to supportive and palliative care in patients with malignant pleural mesothelioma is associated with survival and decreased hospital admissions and emergency department visits. This is a retrospective chart review. Study participants include all malignant pleural mesothelioma patients seen at The Ottawa Hospital-an acute care tertiary center-between January 2002 and March 2019. In total, 223 patients were included in the study. The mean age at diagnosis was 72.4 years and 82.5% were male. Of the patients diagnosed between 2002 and 2010, only 11 (9.6%) were referred to palliative care. By comparison, of those diagnosed between 2011 and 2019, 49 (45.4%) were referred to palliative care. Median time from diagnosis to referral was 4.1 months. There was no significant difference in the median survival of patients referred for palliative care compared to those who did not receive palliative care (p = 0.46). We found no association between receiving palliative care and the mean number of hospital admissions (1.04 vs. 0.91) from diagnosis to death, and an increase in mean number of emergency department visits in the palliative care group (2.30 vs. 1.18). Although there was increased utilization of palliative care services, more than half of the MPM patients did not receive palliative care despite their limited survival. There was an increase in emergency department visits in the palliative care group; this may represent an increase in the symptom burden (i.e., indication bias) in those referred to palliative care.

Athletes and Experimental Pain: A Systematic Review and Meta-Analysis

The evidence that athletes respond to and report indices of experimental pain differently to non-athlete populations was analysed. Databases screened were SPORTDiscus, PubMED, PsycArticles, the Cochrane Library (Cochrane Database of Systematic Reviews), Web of Science, Scopus, and CINAHL. Studies that compared experimentally induced pain responses (threshold, tolerance, intensity, unpleasantness, bothersomeness, and effect on performance) in athletes and controls were included. Meta-analyses were performed where appropriate and effects were described as standardised mean differences, pooled using random effects models. Thirty-six studies (2,492 participants) met the inclusion criteria comprising 19 pain tolerance, 17 pain threshold, 21 pain intensity, 5 pain unpleasantness, 2 performance in pain and 1 bothersomeness study. Athletes demonstrated greater pain tolerance (g = .88 [95% confidence interval [CI] .65, .13]) and reported less pain intensity (g = -.80, [95% CI -1.13, -.47]) compared to controls; they also had higher pain threshold but with smaller effects (g = .41, [95% CI .08, .75]). Differences for unpleasantness did not reach statistical significance but the effects were large (g = -1.23 [95% CI -2.29, .18]). Two studies reported that performance in pain was better in contact athletes than non-athletes, and one concluded that athletes find pain less bothersome than controls. There were considerable inconsistencies in the methods employed that were reflected in the meta-analyses' findings. Sub-group analyses of tolerance and intensity were conducted between endurance, contact, and other athlete groups, but were not significant. The data suggest that athletic participation is associated with altered pain responses, but mechanisms remain unclear and more transparent methods are recommended.This study was registered on the PROSPERO site in January 2019 (ref ID: CRD42019119611). PERSPECTIVE: This review examined differences in pain outcomes (threshold, tolerance, intensity, unpleasantness, bothersomeness) and the effect of pain on performance, in athletes versus controls. Meta-analyses revealed athletes had higher threshold and tolerance and found pain less intense than controls; there was some evidence of differences in bothersomeness and performance.

Grade III Splenic Laceration After a Ground-Level Fall in a Pediatric Patient: The Need for Return-to-Play/Activities Protocols for Individuals With Splenic Injury or Splenomegaly

Splenic injury is a potentially fatal injury if left undetected or untreated. Although most splenic injuries result from a traumatic event, it is important to consider if one's history (past or present) increases their risk for splenic injury (i.e., splenomegaly). We present a case regarding a school-age child who presented to the Emergency Department (ED) with abdominal pain following a ground-level fall onto a carpeted stair step. Prior to this injury, the patient had cold-like symptoms for 3 months that were treated solely with supportive care by their pediatrician(s). A transferring hospital's abdominal CT imaging revealed a grade III splenic laceration. The patient was monitored in the pediatric intensive care unit (PICU) by way of serial abdominal examinations, vitals, and labs. When the patient was cleared for discharge, it was recommended to refrain from strenuous activity for 1-2 months due to the risk of repeat splenic injury. Post-discharge, the patient's Epstein-Barr virus (EBV) serology returned and was consistent with a past infection which was an inconclusive finding. Although trauma is most commonly the culprit of splenic injuries, it is important to keep differentials broad when considering causes of splenomegaly as this may allow healthcare providers to potentially prevent injury/provide appropriate management post-injury and guide return-to-play recommendations.

The relevance of false positive acid phosphatase reactions indicative of the presence of seminal fluid from oral and vaginal samples

The Body Fluid Forum of the Association of Forensic Science Providers recognised concerns raised by forensic practitioners regarding the lack of data to inform on the incidence of significant AP (Acid Phosphatase) reactions from vaginal and oral samples, i.e. those which might be misinterpreted as indicating the presence of semen. This is particularly relevant in the light of appeal court rulings regarding the need for data to support evaluations. This paper presents collaborative data on the nature and incidence of AP reactions from vaginal and oral swabs provided by donors. The results demonstrate that caution is required with mid to strong purple AP reactions from direct testing of oral swabs and with mid purple reactions from vaginal swabs. The use of a Bayesian approach to assist with the provision of opinions regarding the presence of seminal fluid is highlighted.

Short Telomere Syndrome presenting with pulmonary fibrosis, liver cirrhosis and hepatopulmonary syndrome: a case report

BACKGROUND

Idiopathic pulmonary fibrosis is thought to result from aberrant post-injury activation of epithelial cells leading to fibroblast proliferation and activation. A number of genetic aetiologies have been implicated in this disease process, including, among others, the short telomere syndromes. Short telomere syndromes follow an autosomal dominant pattern of inheritance resulting in shortened telomere length, which consequently leads to accelerated cell death. Organs with rapid cell turnover are most affected.

CASE PRESENTATION

We describe a case of a 53-year-old man with a chief complaint of cough and dyspnea on exertion. His presentation was otherwise significant for features of accelerated aging, including a history of osteoporosis and early greying, and a family history of pulmonary fibrosis in his father. Pulmonary function testing revealed a restrictive pattern with severely reduced diffusion capacity and high resolution CT of the chest showed diffuse lung disease with mild fibrosis, in pattern suggesting an alternative diagnosis to IPF. Biopsy of the lung was in keeping with chronic fibrosing interstitial pneumonia. Imaging of the abdomen showed splenomegaly, hepatic cirrhosis and portal hypertension. Transthoracic contrast echocardiogram showed intrapulmonary shunting consistent with hepatopulmonary syndrome. Given the constellation of early aging, idiopathic pulmonary fibrosis, cryptogenic cirrhosis and a family history of pulmonary fibrosis in this patient, the Short Telomere Syndrome was suspected. Peripheral blood was sent for Flow-cytometry FISH, which demonstrated granulocyte telomere length below the 10^th percentile for the patient's age, consistent with a diagnosis of Short Telomere Syndrome in this clinical context. Targeted genetic testing of mutations known to be associated with short telomere was negative though it was acknowledged that the full spectrum of disease-causing mutations remains unknown. Given the extensive fibrosis on biopsy and his progressive hypoxemia he was treated with mycophenolate and prednisone. Ultimately, he developed progressive respiratory failure and underwent double lung and concurrent liver transplant 18 months after the initial diagnosis was made.

CONCLUSIONS

Short Telomere Syndrome is a rare cause of end stage organ disease and testing lacks sensitivity making diagnosis challenging. Organ transplant is still the mainstay of treatment. Nevertheless, disease identification is important because of implications for family member screening and the possibility of future treatment options.

Standardised colour-coded compartmentalised syringe trays improve anaesthetic medication visual search and mitigate cognitive load

BACKGROUND

Anaesthetic procedures are complex and subject to human error. Interventions to alleviate medication errors include organised syringe storage trays, but no standardised methods for drug storage have yet been widely implemented.

METHODS

We used experimental psychology methods to explore the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a visual search task. We hypothesised that colour-coded compartmentalised trays would reduce search time and improve error detection for both behavioural and eye-movement responses. We recruited 40 volunteers to identify syringe errors presented in pre-loaded trays for 16 trials in total: 12 error present and four error absent, with eight trials presented for each tray type.

RESULTS

Errors were detected faster when presented in the colour-coded compartmentalised trays than in conventional trays (11.1 s vs 13.0 s, respectively; P=0.026). This finding was replicated for correct responses for error-absent trays (13.3 s vs 17.4 s, respectively; P=0.001) and in the verification time of error-absent trays (13.1 s vs 17.2 s, respectively; P=0.001). On error trials, eye-tracking measures revealed more fixations on the drug error for colour-coded compartmentalised trays (5.3 vs 4.3, respectively; P<0.001), whilst more fixations on the drug lists for conventional trays (8.3 vs 7.1, respectively; P=0.010). On error-absent trials, participants spent longer fixating on the conventional trials (7.2 s vs 5.6 s, respectively; P=0.002).

CONCLUSIONS

Colour-coded compartmentalisation enhanced visual search efficacy of pre-loaded trays. Reduced fixations and fixation times for the loaded tray were shown for colour-coded compartmentalised trays, indicating a reduction in cognitive load. Overall, colour-coded compartmentalised trays were associated with significant performance improvements when compared with conventional trays.

The ECRG4 cleavage product augurin binds the endotoxin receptor and influences the innate immune response during otitis media

Otitis media (OM), the most common disease of childhood, is typically characterized by bacterial infection of the middle ear (ME). Prominent features of OM include hyperplasia of the ME mucosa, which transforms from a monolayer of simple squamous epithelium with minimal stroma into a full-thickness respiratory epithelium in 2-3 days after infection. Analysis of the murine ME transcriptome during OM showed down-regulation of the tumor suppressor gene Ecrg4 that was temporally related to mucosal hyperplasia and identified stromal cells as the primary ECRG4 source. The reduction in Ecrg4 gene expression coincided with the cleavage of ECRG4 protein to release an extracellular fragment, augurin. The duration of mucosal hyperplasia during OM was greater in Ecrg4 ^-/- mice, the number of infiltrating macrophages was enhanced, and ME infection cleared more rapidly. ECRG4-null macrophages showed increased bacterial phagocytosis. Co-immunoprecipitation identified an association of augurin with TLR4, CD14 and MD2, the components of the lipopolysaccharide (LPS) receptor. The results suggest that full-length ECRG4 is a sentinel molecule that potentially inhibits growth of the ME stroma. Processing of ECRG4 protein during inflammation, coupled with a decline in Ecrg4 gene expression, also influences the behavior of cells that do not express the gene, limiting the production of growth factors by epithelial and endothelial cells, as well as the activity of macrophages.

Microscopic testicular sperm extraction (micro-TESE) for azoospermia at a large tertiary referral centre: Male and female factors and outcomes

Objectives:

To report on the outcomes and demographics of azoospermic couples undergoing microscopic testicular sperm extraction (micro-TESE) in a large tertiary referral centre.

Subjects and methods:

A retrospective study of patients undergoing micro-TESE in a tertiary referral centre from March 2015 to August 2019 was undertaken. Histopathology, patient demographics, comorbidities, patient factors and live birth outcomes were evaluated.

Results:

A total of 102 micro-TESEs were performed with a sperm retrieval rate (SRR) of 30.3%. The successful group had a mean age of 32.7 years and a mean body mass index (BMI) of 26.8 kg/m2. Female partners in the successful group had a mean age of 32.2 years. Twenty percent of female partners had infertility factors, 86.7% had no previous pregnancy and 13.3% had a previous miscarriage. The successful group had 15 live births (50%), while 20% had frozen their sperm. 93.3% achieved live birth from single embryo transfer and currently have unutilised embryos in cryostorage to possibly create siblings in the future. Twenty percent had more than one live birth from a single micro-TESE. Sertoli cell-only syndrome (SCOS) was identified in 57.5% of all cases. This was bilateral in 80% of these cases (four cases only sampled unilaterally due to previous orchidectomies). Of the SCOS group, six men went on to have successful sperm extraction (10%). The presence of previous urologic history/surgery increased the risk of azoospermia by 13%.

Conclusion:

Men with previous urological conditions have an increased risk of azoospermia. SCOS was identified in 57.5% of cases making it the most common histopathological diagnosis in azoospermic men. Based on our cohort, micro-TESE offers potential sperm retrieval in azoospermic men with SCOS. Successful sperm extraction in patients was associated with 50% live births and appeared to be unaffected by the presence of male/female factors. The number of live births could be higher as 20% had frozen their sperm. Concurrent female issues did not appear to affect successful outcome after micro-TESE, although numbers are small.

Level of evidence:

Not applicable

Designing an evidence-based Bayesian network for estimating the risk versus benefits of AstraZeneca COVID-19 vaccine

Uncertainty surrounding the risk of developing and dying from Thrombosis and Thrombocytopenia Syndrome (TTS) associated with the AstraZeneca (AZ) COVID-19 vaccine may contribute to vaccine hesitancy. A model is urgently needed to combine and effectively communicate evidence on the risks versus benefits of the AZ vaccine. We developed a Bayesian network to consolidate evidence on risks and benefits of the AZ vaccine, and parameterised the model using data from a range of empirical studies, government reports, and expert advisory groups. Expert judgement was used to interpret the available evidence and determine the model structure, relevant variables, data for inclusion, and how these data were used to inform the model.

The model can be used as a decision-support tool to generate scenarios based on age, sex, virus variant and community transmission rates, making it useful for individuals, clinicians, and researchers to assess the chances of different health outcomes. Model outputs include the risk of dying from TTS following the AZ COVID-19 vaccine, the risk of dying from COVID-19 or COVID-19-associated atypical severe blood clots under different scenarios. Although the model is focused on Australia, it can be adapted to international settings by re-parameterising it with local data. This paper provides detailed description of the model-building methodology, which can be used to expand the scope of the model to include other COVID-19 vaccines, booster doses, comorbidities and other health outcomes (e.g., long COVID) to ensure the model remains relevant in the face of constantly changing discussion on risks versus benefits of COVID-19 vaccination.

Primary care consumers' experiences and opinions of a telehealth consultation delivered via video during the COVID-19 pandemic

This study examined consumers' experiences and opinions of a videoconference with a primary healthcare professional, and estimated the value of travel and time savings for consumers compared with face-to-face consultations. The online survey was conducted in Melbourne, Australia, between October 2020 and May 2021. The sample (n = 499) was highly educated (Bachelor degree or higher, 79%; 393/499), predominately female (70%; 347/499), mainly spoke English at home (78%; 390/499) and had a mean age of 31.8 years (s.d. 11.40). Reduced travel time (27%; 271/499) and avoiding exposure to COVID-19 (23%; 228/499) were the main reasons consumers chose a videoconference. Mental health and behavioural issues were the main reason for the consultation (38%; 241/499) and 69% (346/499) of consultations were with a general practitioner. Perceptions of the quality of care were uniformly high, with 84% (419/499) of respondents believing videoconference was equivalent to a face-to-face consultation. No association was found between reporting that telehealth was equivalent to a face-to-face consultation and education, language, health status, reason for consultation or provider type. The average time saved per consultation was 1 h and 39 min, and the average transport-related saving was A$14.29. High rates of acceptance and substantial cost savings observed in this study warrant further investigation to inform the longer-term role of videoconferences, and telehealth more broadly, in the Australian primary care system.

Risk-benefit analysis of the AstraZeneca COVID-19 vaccine in Australia using a Bayesian network modelling framework

Thrombosis and Thrombocytopenia Syndrome (TTS) has been associated with the AstraZencea (AZ) COVID-19 vaccine (Vaxzevria). Australia has reported low TTS incidence of < 3/100,000 after the first dose, with case fatality rate (CFR) of 5-6%. Risk-benefit analysis of vaccination has been challenging because of rapidly evolving data, changing levels of transmission, and variation in rates of TTS, COVID-19, and CFR between age groups. We aim to optimise risk-benefit analysis by developing a model that enables inputs to be updated rapidly as evidence evolves. A Bayesian network was used to integrate local and international data, government reports, published literature and expert opinion. The model estimates probabilities of outcomes under different scenarios of age, sex, low/medium/high transmission (0.05%/0.45%/5.76% of population infected over 6 months), SARS-CoV-2 variant, vaccine doses, and vaccine effectiveness. We used the model to compare estimated deaths from AZ vaccine-associated TTS with i) COVID-19 deaths prevented under different scenarios, and ii) deaths from COVID-19 related atypical severe blood clots (cerebral venous sinus thrombosis & portal vein thrombosis). For a million people aged ≥ 70 years where 70% received first dose and 35% received two doses, our model estimated < 1 death from TTS, 25 deaths prevented under low transmission, and > 3000 deaths prevented under high transmission. Risks versus benefits varied significantly between age groups and transmission levels. Under high transmission, deaths prevented by AZ vaccine far exceed deaths from TTS (by 8 to > 4500 times depending on age). Probability of dying from COVID-related atypical severe blood clots was 58-126 times higher (depending on age and sex) than dying from TTS. To our knowledge, this is the first example of the use of Bayesian networks for risk-benefit analysis for a COVID-19 vaccine. The model can be rapidly updated to incorporate new data, adapted for other countries, extended to other outcomes (e.g., severe disease), or used for other vaccines.

Real-world prognostic model for malignant pleural mesothelioma

e20562

Background: Two mesothelioma prognostic models have been suggested: European Organisation for Research and Treatment of Cancer (EORTC) and Cancer and Leukaemia Group B (CALGB) models. Both were based on clinical trial patients enrolled in the mid-1980s to early-1990s. Several changes to mesothelioma management have been adopted since publication of these models, including improved surgical and palliative interventions and changes to systemic therapy. Methods: With ethics approval, we collected and analyzed the health data of malignant pleural mesothelioma (MPM) patients with histologically confirmed diagnosis treated at our institution between January 1991 and March 2019. The primary endpoint was overall survival (OS). Univariate analysis was used to identify significant predictors of survival, which were then used to construct a multivariate survival tree with complete case-analysis and bootstrapping. Patients were then stratified into three prognostic groups based on their median OS. Results: 337 patients were included in the study; 309 (91.7%) were dead at last follow-up. The median OS was 9.4 (8.1-11.5) months for the entire population. Eastern Cooperative Oncology Group (ECOG) performance status (PS), histology, white blood count, platelets, International Mesothelioma Interest Group stage, age and hemoglobin were independent predictors of survival. The final pruned survival tree was based on 285 patients and incorporated the first five predictors. Good, intermediate and poor prognostic groups had median OS of > 12 months, 6-12 months, and < 6 months, respectively. Factors associated with the prognostic groups were: good prognosis: ECOG 0-1, normal platelets, stage 1, 2 and epithelioid histology; intermediate prognosis: ECOG 0-1 with either stage 3, 4 and/or sarcomatoid or biphasic histology; poor prognosis: ECOG 2-4 regardless of other factors. Conclusions: In contrast to EORTC/CALGB, real world evidence generates these prognostic groups with face validity but will need independent validation. Our data does not account for recent advances including immunotherapy, and thus patients with non-epithelioid histology may have better survival than predicted.[Table: see text]

Three Decades of Malignant Pleural Mesothelioma: An Academic Center Experience

BACKGROUND

Malignant pleural mesothelioma (MPM) remains a challenging disease to manage. In the past few decades, extrapleural pneumonectomy (EPP), pemetrexed-based chemotherapy, and indwelling pleural catheters were introduced to MPM care with variable levels of efficacy and evidence.

PATIENTS AND METHODS

This was a retrospective review of patients diagnosed with MPM between January 1991 and March 2019. The primary outcome was overall survival (OS). Data were examined by decade to assess trends in MPM demographics, management, and OS. A subgroup analysis was then conducted to examine the impact of EPP, pemetrexed, and indwelling pleural catheters on OS.

RESULTS

The study included 337 patients; 309 patients had died at last follow-up (91.7%). Median age at diagnosis and the proportion of female patients increased from 65.8 years (interquartile range [IQR], 57.1-73.7) and 11.6% female from 1991 to 1999 to 75 years (IQR, 68.1-80.6) and 20.5% female from 2010 to 2019. Median OS was largely unchanged in the three study periods: 9.0 months (95% confidence interval [CI], 6.9-12.7) in the 1991-1999 cohort, 9.3 months (95% CI, 7.6-13.2) in the 2000-2009 cohort, and 10.1 months (95% CI, 7.9-13.6) in the 2010-2019 cohort. Controlling for a number of demographic and prognostic factors, EPP (hazard ratio [HR] = 0.50; 95% CI, 0.3-0.9; P = .02), pemetrexed-based chemotherapy (HR = 0.59; 95% CI, 0.40-0.87; P = .007), and indwelling pleural catheters (HR = 0.3; 95% CI, 0.13-0.71; P = .006) were each associated with improvements in OS.

CONCLUSION

Despite the small incremental improvements in survival shown by the three interventions we examined, prognosis remains guarded for MPM patients. Better modalities of management are needed.

Rate of intra-arrest epinephrine administration and early post-arrest organ failure after in-hospital cardiac arrest

INTRODUCTION

Data supporting epinephrine administration during resuscitation of in-hospital cardiac arrest (IHCA) are limited. We hypothesized that more frequent epinephrine administration would predict greater early end-organ dysfunction and worse outcomes after IHCA.

METHODS

We performed a retrospective cohort study including patients resuscitated from IHCA at one of 67 hospitals between 2010 and 2019 who were ultimately cared for at a single tertiary care hospital. Our primary exposure of interest was rate of intra-arrest epinephrine bolus administration (mg/min). We considered several outcomes, including severity of early cardiovascular failure (modeled using Sequential Organ Failure Assessment (SOFA) cardiovascular subscore), early neurological and early global illness severity injury (modeled as Pittsburgh Cardiac Arrest Category (PCAC)). We used generalized linear models to test for independent associations between rate of epinephrine administration and outcomes.

RESULTS

We included 695 eligible patients. Mean age was 62 ± 15 years, 416 (60%) were male and 172 (26%) had an initial shockable rhythm. Median arrest duration was 16 [IQR 9-25] min, and median rate of epinephrine administration was 0.2 [IQR 0.1-0.3] mg/min. Higher rate of epinephrine predicted worse PCAC, and lower survival in patients with initial shockable rhythms. There was no association between rate of epinephrine and other outcomes.

CONCLUSION

Higher rates of epinephrine administration during IHCA are associated with more severe early global illness severity.

The logistical management of tertiary urethral disease in the United Kingdom: Implications from an online audit of male reconstructive urethral surgery

Objective:

To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons.

Methods:

Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups.

Results:

More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures.

Conclusion:

Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology.

Level of evidence:

Level IV

Exposure to Contact Sports Results in Maintained Performance During Experimental Pain

During pain, motor performance tends to decline. However, athletes who engage in contact sports are able to maintain performance despite the inherent pain that accompanies participation. This may be the result of being challenged rather than threatened by pain; adaptive coping strategies; habituation to pain; or finding pain less bothersome. This study aimed to measure performance of a novel motor task both in pain and not in pain within experienced contact athletes (n = 40), novice contact athletes (n = 40), and noncontact athletes (n = 40). Challenge and threat perceptions were manipulated during the pain condition and measures of pain tolerance, perception, coping styles, and bothersomeness were taken. Results indicated that contact athletes, regardless of experience, were able to maintain their performance during painful stimulation. Noncontact athletes, conversely, performed significantly worse during pain stimulation. In addition, contact athletes tended to be more challenged and the noncontact athletes more threatened within the pain condition. Experienced contact athletes demonstrated higher levels of pain tolerance and direct coping, and reported lower levels of pain bothersomeness and intensity than the other groups. The results suggest that even relatively brief exposure to contact sports may be enough to help maintain performance in pain. Being in a challenged state appears to be an important factor during performance in pain. Moreover, pain tolerance, intensity, and bothersomeness may differentiate novice and experienced athletes. PERSPECTIVE: Exposure to voluntary pain and challenge states are associated with adaptive responses to pain. Motor task performance may be maintained in individuals with more experience of sports-related pain.

Innovation in Urology: Three Dimensional Printing and Its Clinical Application

Three-dimensional (3D) printing allows rapid prototyping of novel equipment as well as the translation of medical imaging into tangible replicas of patient-specific anatomy. The technology has emerged as a versatile medium for innovation in medicine but with ever-expanding potential uses, does 3D printing represent a valuable adjunct to urological practice? We present a concise systematic review of articles on 3D printing within urology, outlining proposed benefits and the limitations in evidence supporting its utility. We review publications prior to December 2019 using guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Of 117 identified articles, 67 are included highlighting key areas of research as the use of patient-specific models for patient education, surgical planning, and surgical training. Further novel applications included printed surgical tools, patient-specific surgical guides, and bioprinting of graft tissues. We conclude to justify its adoption within standard practice, further research is required demonstrating that use of 3D printing can produce; direct and measurable improvements in patient experience, consistent evidence of superior surgical outcomes or simulation which surpasses existing means' both in fidelity and enhancement of surgical skills. Although exploration of 3D printing's urological applications remains nascent, the seemingly limitless scope for innovation and collaborative design afforded by the technology presents undeniable value as a resource and assures a place at the forefront of future advances.

Precious cargo: Modulation of the mesenteric lymph exosome payload after hemorrhagic shock

BACKGROUND

Trauma/hemorrhagic shock (T/HS) causes a release of proinflammatory mediators into the mesenteric lymph (ML) that may trigger a systemic inflammatory response and subsequent organ failure. Recently, we showed that exosomes in postshock ML are biologically active mediators of this inflammation. Because the specific inflammatory mediators in postshock ML exosomes have yet to be characterized, we hypothesized that T/HS would lead to a distinct ML proinflammatory exosome phenotype that could be identified by proteomic analysis. We further hypothesized that their regulation by the neuroenteric axis via the vagus nerve would modify this proinflammatory profile.

METHODS

Male rats underwent an established T/HS model including 60 minutes of HS followed by resuscitation. Mesenteric lymph was collected before HS (preshock) and after resuscitation (postshock). A subset of animals underwent cervical vagus nerve electrical stimulation (VNS) after the HS phase. Liquid chromatography with tandem mass spectroscopy (LC-MS/MS) followed by protein identification, label free quantification, and bioinformatic analysis was performed on exosomes from the pre-shock and post-shock phases in the T/HS and T/HS + vagus nerve electrical stimulation groups. Biological activity of exosomes was evaluated using a monocyte nuclear factor kappa B (NF-κB) activity assay.

RESULTS

ML exosomes express a distinct protein profile after T/HS with enrichment in pathways associated with cell signaling, cell death and survival, and the inflammatory response. Stimulation of the vagus nerve following injury attenuated the transition of ML exosomes to this T/HS-induced inflammatory phenotype with protein expression remaining similar to pre-shock. Monocyte NF-κB activity was increased after exposure to ML exosomes harvested after T/HS, while ML exosomes from preshock had no effect on monocyte NF-κB expression.

CONCLUSION

Postshock ML exosomes carry a distinct, proinflammatory protein cargo. Stimulating the vagus nerve prevents the T/HS-induced changes in ML exosome protein payload and suggests a novel mechanism by which the neuroenteric axis may limit the systemic inflammatory response after injury.

Risk score and prognostication modeling based on mRNA expressivity in the tumor microenvironment of hepatocellular carcinoma

e16658

Background: Stromal elements in the tumor microenvironment (TME) impact prognosis and response to therapy. Advances in mRNA-sequencing improved understanding of gene expressivity, but few models exist to model prognosis in association with mRNA expression. Methods: Clinical data and mRNA-seq of 256 patients (pts) with hepatocellular carcinoma (HCC) were obtained from TCGA. The expressivity of 191 genes enriched in cellular and structural components of the TME and clinical data were analyzed using machine learning, multivariable COX model, and Kaplan-Meier (KM) analysis to model risk score (RS) for prediction of prognosis. Results: Prognostication was modeled with higher risk score (RS) representing worse prognosis. Gene expression associated with poor (P) and good (G) in stage 1 and 2 HCC was identified (refer to presentation). RS (stage 1) = 5.997 - 0.589 × (Age at diagnosis−7.979E-06) - 4.818 × (P/G−0.009); RS (stage 2) = -5.704 - 0.780 × (Age at diagnosis−9.383E-06) + 7.228 × (P/G−0.004). Based on RS, pts were clustered into 2 groups in each stage - high and low RS groups, showing two KM curves with P < 0.05, HR = 3.213 (95% CI 2.212 – 4.347) in stage 1; HR = 2.733 (95% CI 2.131 – 3.426) in stage 2, confirming the validity of RS modeling. Analysis of immune profiles in high and low RS groups shows that expression of genes associated with immunosuppressive factors, desmoplastic reaction, neutrophils, and co-inhibitory factors of T-cells are higher in high RS group in both stages (p < 0.05). Conclusions: Machine learning-assisted mathematical modeling of RS and gene analysis identified TME-related genes and gene groups that are strongly associated with worse prognosis in stage 1 and 2 of HCC. RS could potentially prognosticate pts in the clinic with available genomic profiles.

Obesity in Total Hip Arthroplasty: Demographic Disparities and Outcome Incongruities

Introduction

As morbid obesity disproportionately affects minorities and those of lower socioeconomic status, body mass index (BMI) restrictions on total hip arthroplasty (THA) may harm populations already facing disparities in care. Therefore, this study analyzed demographics and outcomes in morbidly obese primary THA patients.

Methods

The National Inpatient Sample was queried for THAs performed between 2009 and 2016. Of 2,676,086 patients identified, 453,250 had a BMI over 25 kg/m². Patients were stratified by BMI into overweight (BMI=25.0-29.9 kg/m²), non-morbidly obese (BMI=30.0-40.0 kg/m²), and morbidly obese (BMI>40.1 kg/m²). Patient demographics (age, sex, race, insurance, income, and Charlson Comorbidity Index) and outcomes (length of stay [LOS], mortality, disposition, complications, charges, and costs) were assessed. Categorical and continuous data were analyzed with chi-square analyses and one-way analyses of variance, respectively.

Results

The number of overweight, non-morbidly obese, and morbidly obese patients increased by 299.0%, 109.3%, and 90.9%, respectively, between 2009 and 2016 (p<0.001). Morbidly obese patients were younger than non-morbidly obese and overweight patients (p<0.001) and had a higher proportion of females (p<0.001) and black patients (p<0.001). Morbidly obese patients most frequently used Medicaid and private insurance (p<0.001). Morbidly obese patients demonstrated a longer LOS, a higher mortality rate, a lower rate of home discharges and the most complications (all, p<0.001). 

Conclusion

These results reflect the worsening obesity epidemic and may be useful in counseling preoperative weight loss to morbidly obese patients to reduce mortality and complications.

CHRFAM7A reduces monocyte/macrophage migration and colony formation in vitro

OBJECTIVE AND DESIGN

CHRFAM7A is a unique human gene that encodes a dominant negative inhibitor of the α7 nicotinic acetylcholine receptor. We have recently shown that CHRFAM7A is expressed in human leukocytes, increases cel-cell adhesion, and regulates the expression of genes associated with leukocyte migration.

MATERIAL

Human THP-1, RAW264.7 and HEK293 cells.

METHODS

Cell migration, cell proliferation and colony formation in soft agar to compare the biological activity of vector vs. CHRFAM7A-transduced cells.

RESULTS

We show that gene delivery of CHRFAM7A into the THP-1 human monocytic cell line reduces cell migration, reduces chemotaxis to monocyte chemoattractant protein, and reduces colony formation in soft agar.

CONCLUSION

Taken together, the findings demonstrate that CHRFAM7A regulates the biological activity of monocytes/macrophages to migrate and undergo anchorage-independent growth in vitro.

ECRG4 regulates neutrophil recruitment and CD44 expression during the inflammatory response to injury

The complex molecular microenvironment of the wound bed regulates the duration and degree of inflammation in the wound repair process, while its dysregulation leads to impaired healing. Understanding factors controlling this response provides therapeutic targets for inflammatory disease. Esophageal cancer-related gene 4 (ECRG4) is a candidate chemokine that is highly expressed on leukocytes. We used ECRG4 knockout (KO) mice to establish that the absence of ECRG4 leads to defective neutrophil recruitment with a delay in wound healing. An in vitro human promyelocyte model identified an ECRG4-mediated suppression of the hyaluronic acid receptor, CD44, a key receptor mediating inflammation resolution. In ECRG4 KO mouse leukocytes, there was an increase in CD44 expression, consistent with a model in which ECRG4 negatively regulates CD44 levels. Therefore, we propose a previously unidentified mechanism in which ECRG4 regulates early neutrophil recruitment and subsequent CD44-mediated resolution of inflammation.

Prognostication model based on genomic expression in the tumor microenvironment of ER-positive, HER2-negative stage III breast cancer via machine learning

3

Background: Stroma in the tumor microenvironment (TME) is known to impact prognosis and responses to therapy. Few mathematical models exist to prognosticate patients, based on mRNA expressivity in the TME. Methods: Clinical outcomes data and mRNA-seq of 98 patients with stage III estrogen receptor (ER) positive (+) and HER2 negative (-) breast cancer were obtained from TCGA. Twenty six gene groups composed of 191 genes (refer to presentation) enriched in cellular and non-cellular elements of TME, mutational burden (MB), and clinical data were analyzed by Kaplan-Meier (KM) analysis and multivariate nonlinear regression assisted by machine learning to achieve confined optimization with model-data minimization among multiple distribution functions. Results: Prognostication was modeled with higher risk score (RS) representing worse prognosis in stage 3 ER+HER2- breast cancer. Fifteen genes (CD8A, CD8B, FCRL3, GZMK, CD3E, CCL5, TP53, ICAM3, CD247, IFNG, IFNGR1, ICAM4, SHH, HLA-DOB, CXCR3) and five genes (LOXL2, PHEX, ACTA2, MEGF9, TNFSF4) out of 191 genes associated with good and poor prognosis were identified. Genomic expression of the fifteen and five gene groups were labeled as G and P, respectively. RS = 9.3185 – 0.3250 × (Age at diagnosis0.0001) – 8.2979 × (P/G−0.0051). Based on RS, patients were clustered into two groups; high and low RS groups, showing two KM curves with P = 0.05, HR = 2.878 (95% CI 1.903 – 3.471), confirming the validity of RS modeling. Analysis of immune profiles in high and low RS groups shows that expression of genes associated with desmoplastic reaction, neutrophils, and immunosuppressive cytokines are higher in high RS groups; and those related to immune system activation are higher in low RS groups (p < 0.05). Conclusions: Machine learning-assisted mathematical modeling of RS and gene analysis identified TME-related genes and gene groups that are strongly associated with worse prognosis in stage 3 ER+HER2- breast cancer. RS could potentially prognosticate patients in the clinic with available genomic profiles.

Management of renal injury in a UK major trauma centre

Introduction

This study reviews the type, severity, management and follow-up of renal trauma presenting to a major trauma centre in the northwest of England in the four years following inception of the major trauma centre. Given the recent introduction of major trauma centres nationally, research is needed within every specialty to ensure that the centralisation of services benefits all patients affected by these changes.

Methods

Patients presenting to Aintree University Hospital with renal trauma between June 2012 and June 2016 were identified using the Trauma Audit and Research Network (TARN) database. The data gathered retrospectively for each patient included mechanism of injury, injury severity score, American Association for the Surgery of Trauma (AAST) grading, management of injury, and follow-up.

Results

Out of a total of 2595 trauma patients, 33 renal injuries were identified. The 31 patients who received imaging were classified according to AAST grading, with 8 Grade I (25.8%), 4 Grade II (12.9%), 8 Grade III (25.8%), 4 Grade IV (12.9%), and 7 Grade V (22.6%) injuries. Twenty-five out of the 30 surviving patients received conservative treatment, three patients received angioembolisation (AE), one patient received a laparotomy with renal suturing, and one patient required a nephrectomy. Of these 30 surviving patients, seven received urology follow-up in clinic (23%).

Conclusion

The findings appear to support the growing trend towards the conservative management of high-grade renal injuries, and provide further evidence for the value of AE in renal trauma. The success of AE in this study appears to support the centralisation of services in renal trauma; however, the low nephrectomy rate could be interpreted as suggestive of the opposite. The study revealed that improvements to follow-up are needed, and that further research should seek to inform the optimal radiological follow-up of high-grade renal injury.

Abstract 136: Modeling of prognostication and immune profiling, based on genomic analysis in the tumor microenvironment of pancreatic adenocarcinoma via machine learning

The extensive tumor microenvironment (TME) in pancreatic adenocarcinoma (PAD) modulates cancer progression and impact prognosis. Although gene analysis has enhanced understanding of cancer biology, few models exist to model prognosis in association with mRNA expression in the TME. Clinical outcomes data and mRNA-seq of 156 and 64 patients (pts) were obtained from TCGA and Bailey at el. [1] for testing and validation, respectively. Expressivity of 191 genes enriched in cellular and structural elements of TME and clinical data were analyzed by multivariate nonlinear regression aided by machine learning for confined optimization with model-data error minimization. Statistics including Kaplan-Meier (KM), Cox Hazard (CH), and correlation analysis was used. Most pts (85.89% and 85.94%, respectively) were in stage II, and pts in stage I/III/IV were excluded. Prognostication was modeled with higher risk score (RS) representing worse prognosis: RS = -7.6526 x (Age-5.5679) + 0.0813 x (P/G0.3677) + 0.7069, where P/G is a ratio of genes associated with poor to good prognosis (Table 1). Based on RS, pts were clustered into 2 groups (high and low RS) with 2 KM curves showing p&lt;0.0001 and p=0.014 in test and validation sets. Immune profiling of high and low RS groups in both test and validation sets shows that in low RS group, genes related to both immune activation (IA) and inhibition (II) (Table 2) are highly co-expressed, implying that co-expression of IA and II contributes to PAD’s poor prognosis even in pts with immune system activation. In high RS group, genes related to cancer stem cells (CD44 and EPCAM) significantly contributed to poor prognosis. Machine learning-assisted modeling of RS and gene analysis suggest that IA genes are suppressed by co-expression of high degree of II, contributing to poor prognosis in PAD. RS enables prognostication of pts encountered in the clinic when genomic profiles are provided. [1] Nature 531, 47-52 (2016).

Table 1genes associated with good and poor prognosis out of 191 genes (identification via KM and CH with p&lt;0.05)Good prognosisFCRL3, LILRA4, IL3RA, IL10, CCL22, DOK3, CXCR4, PDGFA, ICOSLG, TNFRSF4Poor prognosisTNFSF10, CD44

Table 2gene groups of immune activation (IA) and immune inhibition (II)IA gene groupscytotoxic T, B, NK, T-helper 1 cells, IFN, cytolytic activity, T cell co-stimulation, and antigen presentationII gene groupsregulatory T cells, desmoplasia, immunosuppressive chemokines, immune checkpoints, angiogenesis, cancer stem cells, epithelial-mesenchymal transition, and neutrophils

Note: This abstract was not presented at the meeting.

Citation Format: Sunyoung S. Lee, Seok Joon Kwon, Ahmed Elkhanany, Andrew Baird, Seongwon Lee, Jillian Dolan, Stuart Baird, Shinyoung Park, Renuka Iyer. Modeling of prognostication and immune profiling, based on genomic analysis in the tumor microenvironment of pancreatic adenocarcinoma via machine learning [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 136.

Immune landscape of the tumor microenvironment to predict prognosis and DNA mutations in patients with lung adenocarcinoma

8544

Background: The tumor microenvironment (TME) influences prognosis and response to therapy. The correlation between immune profiles in the TME and cancer DNA mutations is not well established. Methods: Clinical outcomes data, mRNA-seq, and DNA mutation of 480 patients (pts) with lung adenocarcinoma (LAD) were obtained from TCGA. Pts were clustered into 4 groups using unsupervised machine learning, based on mRNA expression of genes related to antigen presentation (AP) and cytolytic activity (CA): group (G) 1 with high AP and CA (52 pts); G2, high AP, low CA (82); G3, low AP, high CA (66); G4, low AP and CA (280). Analysis of the immune landscape was performed using mRNA-seq of 191 genes enriched in cellular and structural elements of TME. DNA mutations were analyzed using the R package ggpubr and correlated in G1-G4. Results: Pts in G1 have high expression of genes related to immune activation (IA) and decreased expression of immune suppression (IS) and have the best prognosis. Pts in G2 have intermediate prognosis with decreased IA genes and intermediate expression of genes related to IS and immune checkpoints. Pts in G3 have the worst prognosis with very high expression of genes related to immune checkpoints, desmoplasia, T cell co-inhibition, and IS. They also have low CD39 expression implying low cancer antigen-driven T cells. Pts in G4 have intermediate prognosis with highly depressed IA genes. Out of 70,199 non-synonymous mutations, the top 50 mutated genes in each pt group were identified: 36, 26, 31, and 17 DNA mutations were only found in G1, G2, G3, and G4 (refer to presentation). EGFR mutation was only found in G2; KRAS in G2/4; TP53 in G2/3/4. Conclusions: Our correlation analysis of mRNA-seq and DNA mutation shows that the immune landscape of TME can predict DNA mutations and prognosis. It further demonstrates a close connection between DNA mutations and changes in TME mRNA expressivity which appear to have valuable prognostication potential in the clinical setting with now widely available genomic testing.

TBC1D3 regulates the payload and biological activity of extracellular vesicles that mediate tissue repair

Healthy repair of cutaneous injury is a coordinated response of inflammatory cells, secreted factors, and biologically active extracellular vesicles (EVs). Although constitutive release of EVs into biologic fluids is a hallmark of cultured cells and tumors, their payload and biologic activity appears to be tightly regulated. We show that Tre-2/Bub2/Cdc16 (TBC1) domain family member 3 (TBC1D3) drives the release of an EV population that causes a decrease in phosphorylation of the transcription factor signal transducer and activator of transcription 3 in naive recipient cells. To explore the biologic activity of EVs in vivo, we used a mouse model of sterile subcutaneous inflammation to determine the payload and biologic activity of EVs released into the microenvironment by committed myeloid lineages and stroma. Expression of TBC1D3 in macrophages altered the payload of their released EVs, including RNA-binding proteins, molecular motors, and proteins regulating secretory pathways. A wound-healing model demonstrated that closure was delayed by EVs released under the control of TBC1D3. We show that modulating the secretory repertoire of a cell regulates EV payload and biologic activity that affects outcomes in tissue repair and establishes a strategy for modifying EVs mediating specific biologic responses.-Qin, S., Dorschner, R. A., Masini, I., Lavoie-Gagne, O., Stahl, P. D., Costantini, T. W., Baird, A., Eliceiri, B. P. TBC1D3 regulates the payload and biological activity of extracellular vesicles that mediate tissue repair.

Modeling of prognostication based on genomic expression in the tumor microenvironment of muscle invasive urothelial carcinoma via machine learning

64

Background: Stroma in the tumor microenvironment (TME) influences prognosis and response to therapy. Few mathematical models exist to prognosticate patients (pts), based on mRNA expressivity in the TME. Methods: Clinical outcomes data and mRNA-seq of 401 pts with muscle invasive urothelial carcinoma were obtained from TCGA. Expressivity of 191 genes enriched in cellular and structural elements of TME and clinical data were analyzed by Kaplan-Meier (KM) analysis, correlation analysis, and multivariate nonlinear regression assisted by machine learning to achieve confined optimization with model-data minimization among multiple distribution functions. Results: Prognostication was modeled with higher risk score (RS) representing worse prognosis in stage 2-4 (Table, stage 1 data not available from TCGA). P/G is the ratio of genes associated with poor (19 genes) to good (11) prognosis (refer to presentation). Based on RS, pts in each stage were clustered into 2 groups (high and low RS), showing 2 KM curves with p < 0.01 in each stage, confirming the validity of RS modeling. Analysis of immune profiles in these 2 groups shows that regardless of stage, expression of genes associated with Desmoplasia, Angiogenesis, and Epithelial-mesenchymal transition (DAE) is higher in high RS groups. Furthermore, expression of DEA genes in stage 4 correlated more strongly with poor prognosis than observed in stage 2-3 as evidenced by smaller p-value. Among stage 4 tumors, expression of genes related to IFN response, NK cells, and T1 helper cells is higher in low RS groups. In stage 2 and 3, genes related to immune activation and inhibition have no association with prognosis (p > 0.05). Conclusions: Machine learning-assisted mathematical modeling of RS and gene analysis show that genes related to immune activation are associated with better prognosis, while DAE genes correlate with poorer prognosis among advanced stages. RS enables prognostication of pts encountered in the clinic, given genomic profiles. [Table: see text]

Modeling of prognostication and differential genomic expression in the tumor microenvironment of clear cell renal cell carcinoma

557

Background: Stroma in the tumor microenvironment (TME) influences prognosis and response to therapy. Few mathematical models exist to prognosticate patients (pts), based on mRNA expressivity in the TME. Methods: Clinical outcomes data and mRNA-seq of 533 pts with clear cell renal cancer were obtained from TCGA. Expressivity of 191 genes enriched in cellular and structural elements of TME and clinical data were analyzed via machine learning, multivariate nonlinear regression with confined optimization, and Kaplan-Meier (KM) analysis. Results: Prognostication was modeled with higher risk score (RS) representing worse prognosis in each stage (Table). P/G is the ratio of genes associated with poor (61 genes) to good (14) prognosis (refer to presentation). Based on RS, pts in each stage were clustered into 2 groups (high and low RS), showing 2 KM curves with p < 0.001 in each stage. Analysis of immune profiles in these 2 groups shows that in stage 1, expression of genes related to immune activation (IA) is not statistically different in high and low RS groups, but expression of genes related to immune inhibition (II) is higher in high RS group. In high RS groups of stage 2-4, IA genes are highly co-expressed with II genes. In high RS groups of all stages, expression of both IA and II genes increases as stage increases. In low RS groups, IA genes increase as stage increases, but II genes do not. Conclusions: Machine learning and mathematical modeling of RS and gene analysis show that IA genes are suppressed by high degree of II in high RS groups of advanced stages, contributing to worse prognosis. RS enables prognostication of pts encountered in the clinic, given genomic profiles. [Table: see text]

Risk score and prognosis modeling based on mRNA expressivity in the tumor microenvironment of GI cancers

608

Background: Stromal elements in the tumor microenvironment (TME) impact prognosis and response to therapy. Advances in mRNA-seq improved understanding of gene expressivity, but few models exist to model prognosis in association with mRNA expression. Methods: Clinical data and mRNA-seq of 1,715 patients (pts) – pancreatic adenocarcinoma (PAAD), colorectal adenocarcinoma (CRC), hepatocellular carcinoma (HCC), gastric adenocarcinoma (GAAD), esophageal adenocarcinoma (EsoAd), and esophageal squamous cell carcinoma (EsoSCC) – were obtained from TCGA. The expressivity of 191 genes enriched in cellular and structural components of the TME and clinical data were analyzed using machine learning, multivariable COX model, and Kaplan-Meier (KM) analysis to model risk score (RS) to predict prognosis. Results: Genes associated with good and poor prognosis were identified via machine learning and statistic methods. Higher RS represents worse prognosis with max RS = 1 (Table). In all 6 cancers, high P/G (the expression ratio of genes associated with poor to good prognosis) and old age are related to worse survival except EsoAd with younger pts having worse prognosis. The location of tumors in CRC and sex in HCC impact RS. When pts are grouped into 3 pt groups in each cancer, KM curves in pts with low, intermediate, and high RS are statistically different (p < 0.0001) with high hazard ratio (HR > 2). Conclusions: Analysis of large data was assisted by machine learning and statistics, identifying genes associated with survival and creating RS as a tool to predict prognosis. This provides valuable information about prognosis for pts encountered in the clinic when genomic profiles are given. Computational modeling to predict response to chemotherapy and immunotherapy is underway. [Table: see text]

Motor performance during experimental pain: The influence of exposure to contact sports

BACKGROUND

Athletes who play contact sports are regularly exposed to pain, yet manage to perform complex tasks without significant decrement. Limited research has suggested that superior pain tolerance in contact athletes may be important in this context and this may be altered via experience of pain. Other psychological variables such as challenge states, pain bothersomeness and coping style may also influence skill execution during pain.

METHODS

Forty experienced contact athletes (>3 years experience), 40 novice contact athletes (<6 months experience) and 40 non-contact athletes performed a motor task both in pain and without pain. During the pain condition, pressure pain was induced and half of each group were given challenge instructions and the other half threat based instructions. Measures of cognitive appraisal, heart rate variability, pain bothersomeness, tolerance and intensity and coping styles were taken.

RESULTS

Contact athletes, regardless of experience, performed better during pain compared to the non-contact athletes, this relationship was mediated by pain tolerance and physical bothersomeness. During the threat condition, experience of contact sports moderated performance. Contact athletes were challenged by the pain, regardless of the instructions given, had higher direct coping and found pain less psychologically bothersome. Experienced contact athletes had higher pain tolerance and reported pain as less intense than the other groups.

CONCLUSIONS

Athletes who play contact sports may have better coping and adjustment to experimental pain, especially during threatening conditions. Performance during experimental pain is mediated by pain tolerance and physical pain bothersomeness.

SIGNIFICANCE

Athletes with even relatively small amounts of contact sport experience perform better during experimental pain than athletes who play non-contact sports. Experienced contact athletes had higher levels of direct coping and were more challenged and less threatened by pain than non-contact athletes.

Effects of a novel peptide Ac-SDKP in radiation-induced coronary endothelial damage and resting myocardial blood flow

Background

Cancer survivors treated with thoracic ionizing radiation are at higher risk of premature death due to myocardial ischemia. No therapy is currently available to prevent or mitigate these effects. We tested the hypothesis that an endogenous tetrapeptide N-acetyl-Ser-Asp-Lys-Pro (Ac-SDKP) counteracts radiation-induced coronary vascular fibrosis and endothelial cell loss and preserves myocardial blood flow.

Methods

We examined a rat model with external-beam-radiation exposure to the cardiac silhouette. We treated a subgroup of irradiated rats with subcutaneous Ac-SDKP for 18-weeks. We performed cardiac MRI with Gadolinium contrast to examine resting myocardial blood flow content. Upon sacrifice, we examined coronary endothelial-cell-density, fibrosis, apoptosis and endothelial tight-junction proteins (TJP). In vitro, we examined Ac-SDKP uptake by the endothelial cells and tested its effects on radiation-induced reactive oxygen species (ROS) generation. In vivo, we injected labeled Ac-SDKP intravenously and examined its endothelial localization after 4-h.

Results

We found that radiation exposure led to reduced resting myocardial blood flow content. There was concomitant endothelial cell loss and coronary fibrosis. Smaller vessels and capillaries showed more severe changes than larger vessels. Real-time PCR and confocal microscopy showed radiation-induced loss of TJ proteins including- claudin-1 and junctional adhesion molecule-2 (JAM-2). Ac-SDKP normalized myocardial blood flow content, inhibited endothelial cell loss, reduced coronary fibrosis and restored TJ-assembly. In vitro, Ac-SDKP localized to endothelial cells and inhibited radiation-induced endothelial ROS generation. In vivo, labeled Ac-SDKP was visualized into the endothelium 4-h after the intravenous injection.

Conclusions

We concluded that Ac-SDKP has protective effects against radiation-induced reduction of myocardial blood flow. Such protective effects are likely mediated by neutralization of ROS-mediated injury, preservation of endothelial integrity and inhibition of fibrosis. This demonstrates a strong therapeutic potential of Ac-SDKP to counteract radiotherapy-induced coronary disease.

Electronic supplementary material

The online version of this article (10.1186/s40959-018-0034-1) contains supplementary material, which is available to authorized users.

Choroid plexus genes for CSF production and brain homeostasis are altered in Alzheimer's disease

Background

The roles of the choroid plexus (CP) and cerebrospinal fluid (CSF) production have drawn increasing attention in Alzheimer’s disease (AD) research. Specifically, studies document markedly decreased CSF production and turnover in moderate-to-severe AD. Moreover, reduced CP function and CSF turnover lead to impaired clearance of toxic metabolites, likely promote neuroinflammation, and may facilitate neuronal death during AD progression. We analyzed CP gene expression in AD compared with control subjects, specifically considering those genes involved with CSF production and CP structural integrity.

Methods

The Brown-Merck Gene Expression Omnibus (GEO) database (CP transcripts) was mined to examine changes in gene expression in AD compared to controls with a focus on assorted genes thought to play a role in CSF production. Specifically, genes coding for ion transporters in CP epithelium (CPE) and associated enzymes like Na–K-ATPase and carbonic anhydrase, aquaporins, mitochondrial transporters/enzymes, blood–cerebrospinal fluid barrier (BCSFB) stability proteins, and pro-inflammatory mediators were selected for investigation. Data were analyzed using t test p-value and fold-change analysis conducted by the GEO2R feature of the GEO database.

Results

Significant expression changes for several genes were observed in AD CP. These included disruptions to ion transporters (e.g., the solute carrier gene SLC4A5, p = 0.004) and associated enzyme expressions (e.g., carbonic anhydrase CA4, p = 0.0001), along with decreased expression of genes involved in BCSFB integrity (e.g., claudin CLDN5, p = 0.039) and mitochondrial ATP synthesis (e.g., adenosine triphosphate ATP5L, p = 0.0004). Together all changes point to disrupted solute transport at the blood–CSF interface in AD. Increased expression of pro-inflammatory (e.g., interleukin IL1RL1, p = 0.00001) and potential neurodegenerative genes (e.g., amyloid precursor APBA3, p = 0.002) also implicate disturbed CP function.

Conclusions

Because the altered expression of numerous transcripts in AD-CP help explain decreased CSF production in AD, these findings represent a first step towards identifying novel therapeutic targets in AD.

Electronic supplementary material

The online version of this article (10.1186/s12987-018-0120-7) contains supplementary material, which is available to authorized users.

CHRFAM7A alters binding to the neuronal alpha-7 nicotinic acetylcholine receptor

INTRODUCTION

CHRFAM7A is a uniquely-human gene that encodes a human-specific variant of the alpha-7 nicotinic acetylcholine receptor (α7nAchR). While the homopentameric α7nAChR consists of 5 equal subunits, previous studies demonstrated that CHRFAM7A expression disrupts the formation of α7nAChR homopentamers. Here we use a rat neuronal cell line expressing CHRFAM7A and a transgenic mouse expressing CHRFAM7A to define the alpha-bungarotoxin (α-BTX) binding in vitro and in vivo.

METHODS

Rat PC12 cells were stably transfected with human CHRFAM7A. α-BTX, a protein that irreversibly binds the α7nAchR, was utilized to assess the capacity for CHRFAM7A to interfere with α 7AchR subunits using immunohistochemistry and flow cytometry. To evaluate the effects of CHRFAM7A on α7nAchR at the neuromuscular junction in vivo, transgenic mice were engineered to express the uniquely human gene CHRFAM7A under the control of the EF1-α promoter. Using this model, muscle was harvested and CHRFAM7A and CHRNA7 gene expression evaluated by PCR. Binding of α-BTX to the α7nAchR in muscle was compared in sibling-matched wild-type C57 mice by immunostaining the neuromuscular junction using α-BTX and neurofilament antibodies.

RESULTS

Expression of CHRFAM7A in transfected, but not vector cells, was confirmed by PCR and by immunoblotting using an antibody we raised to a peptide sequence unique to CHRFAM7A. CHRFAM7A decreased α-BTX binding as detected by immunohistochemistry and flow cytometry. In vivo, α-BTX co-stained with neurofilament at the neuromuscular junction in wild-type mice, however, α-BTX staining was decreased at the neuromuscular junction of CHRFAM7A transgenic mice.

CONCLUSION

CHRFAM7A expression interferes with the binding of α7nAchR to α-BTX. Understanding the contribution of this uniquely human gene to human disease will be important in the identification of potential therapeutic targets.

Avoid reinventing the wheel: implementation of the Ottawa Clinic Assessment Tool (OCAT) in Internal Medicine

BACKGROUND

Workplace based assessment (WBA) is crucial to competency-based education. The majority of healthcare is delivered in the ambulatory setting making the ability to run an entire clinic a crucial core competency for Internal Medicine (IM) trainees. Current WBA tools used in IM do not allow a thorough assessment of this skill. Further, most tools are not aligned with the way clinical assessors conceptualize performances. To address this, many tools aligned with entrustment decisions have recently been published. The Ottawa Clinic Assessment Tool (OCAT) is an entrustment-aligned tool that allows for such an assessment but was developed in the surgical setting and it is not known if it can perform well in an entirely different context. The aim of this study was to implement the OCAT in an IM program and collect psychometric data in this different setting. Using one tool across multiple contexts may reduce the need for tool development and ensure that tools used have proper psychometric data to support them.

METHODS

Psychometrics characteristics were determined. Descriptive statistics and effect sizes were calculated. Scores were compared between levels of training (juniors (PGY1), seniors (PGY2s and PGY3s) & fellows (PGY4s and PGY5s)) using a one-way ANOVA. Safety for independent practice was analyzed with a dichotomous score. Variance components were generated and used to estimate the reliability of the OCAT.

RESULTS

Three hundred ninety OCATs were completed over 52 weeks by 86 physicians assessing 44 residents. The range of ratings varied from 2 (I had to talk them through) to 5 (I did not need to be there) for most items. Mean scores differed significantly by training level (p < .001) with juniors having lower ratings (M = 3.80 (out of 5), SD = 0.49) than seniors (M = 4.22, SD = - 0.47) who had lower ratings than fellows (4.70, SD = 0.36). Trainees deemed safe to run the clinic independently had significantly higher mean scores than those deemed not safe (p < .001). The generalizability coefficient that corresponds to internal consistency is 0.92.

CONCLUSIONS

This study's psychometric data demonstrates that we can reliably use the OCAT in IM. We support assessing existing tools within different contexts rather than continuous developing discipline-specific instruments.

Abstract 2095: Automated mapping and analysis of stromal cells in tumor microenvironment in pancreatic adenocarcinoma andcholangiocarcinoma using deep learning

Objective: A characteristic histologic feature of pancreatic adenocarcinoma (PAD) and cholangiocarcinoma (COL) is extensive desmoplasia (DP) alongside leukocytes and stromal cells (SCs). Advances in mRNA-sequencing have enhanced our understanding of cancer biology in relation to selective changes in expressivity amongst SCs. DP changes secondary to aberrant expression in SCs creates a barrier to absorption and penetration of therapeutic drugs, but few models exist to analyze the spatial and architectural elements composing the complex tumor microenvironment (TME) in association with mRNA levels.

Methods: The histopathology images (H&E stain) and mRNA-seq of 178 PAD and 36 COL patients (pts) were obtained from the Cancer Genome Atlas (TCGA) and analyzed with the deep learning (DL) algorithm, which characterizes histological features in comparison to the corresponding mRNA-seq, allowing for rapid automated analysis of large quantities of data. Ninety genes enriched in leukocytes (CD8+ T cells, B cells, CD4+ regulatory T cells, macrophages, neutrophils, NK cells, and plasmacytoid dendritic cells), 7 genes for cytolytic activities (GZMA, PRF1, GZMH, GZMK, NKG7, CD3E, and CD247), and 5 genes involved with fibroblastic and DP changes (PDFGRA, ACTA2, COL1A1, COL1A2, and PDPN) were analyzed. For each pt, mRNA levels of select genes were analyzed against histologic features, including degree of DP reaction, number of leukocytes, and degree of leukocyte clustering and isolation from tumor cells.

Results: DL analysis demonstrates that the number of fibroblasts and degree of DP correlates with and predicts the mRNA expression of genes associated with fibroblastic and DP changes. The mRNA level of CXCL12 correlates with the degree of leukocyte clustering and spatial isolation in PAD and COL. The 5 genes associated with DP and fibrosis do not have a linear relationship with CXCL12 mRNA levels (R2 &lt;0.1) in COL and (R2=0.2196 to 0.6279) in PAD. Cytolytic activity, measured by the mRNA levels from 7 genes, does not correlate with CXCL12 expression (R2 &lt;0.1) in COL, and (R2=0.3530 to 0.6060) in PAD.

Conclusion: A DL model enables automated analysis and mapping of DP changes within stromal and malignant cells, revealing the spatial and architectural relationship in the TME with varying gene expression. This demonstrates that the degree of leukocyte clustering and isolation from tumor cells correlates with CXCL12 mRNA levels in PAD and COL. CXCL12 expressivity appears to be a contributing factor, limiting access of leukocytes to tumor cells and diminishing an important mechanism combating tumor progression. Varying degrees of DP and cytolytic activities of immune cells within the TME were also observed in association with CXCL12 expression in PAD and COL. Further biomarker-driven prospective studies in the context of immunotherapy and anti-fibrosis are warranted.

Citation Format: Sunyoung S. Lee, Jin Cheon Kim, Seongwon Lee, Jilliam Dolan, Andrew Baird. Automated mapping and analysis of stromal cells in tumor microenvironment in pancreatic adenocarcinoma andcholangiocarcinoma using deep learning [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2095.

The use of an e-learning module on return to work advice for physiotherapists - A prospective cohort study

Background: Nonspecific low back pain (LBP) can progress to chronic disability and prolonged absence from work. Despite clinical and professional guidelines, physiotherapists often fail to address return to work outcomes. Aims: The aim of this exploratory study was to determine whether an e-learning resource tailored to physiotherapy practice could affect physiotherapists' attitudes and beliefs regarding return to work advice for their patients. Design: A prospective interventional cohort study (pilot). Methods: Participants were recruited via the Chartered Society of Physiotherapy website. Responses on a clinical vignette, the Health Care Providers' Pain and Impairment Scale (HC-Pairs), and the Behavioral Constructs Questionnaire (BCQ) were collected online at baseline (Q1) and 2-months post-intervention (Q2). Results: Fifty-four physiotherapists completed Q1 and the response rate for Q2 was 44/54 (81%). Changes in the degree of agreement with guidelines indicated that the intervention made an impact on respondents (kappa 0.345; p = 0.003). HC-Pairs and BCQ results showed a nonstatistically significant trend toward the target behavior. Conclusions: There is a need for interventions to improve adherence with advice for return to work following nonspecific LBP. An e-learning tool for physiotherapists on advising patients regarding return to work has potential to positively affect self-reported clinical behavior.