Anaesthetic management of people with multiple sclerosis

There is a lack of published guidelines on the management of patients with multiple sclerosis (MS) undergoing procedures that require anaesthesia and respective advice is largely based on retrospective studies or case reports. The aim of this paper is to provide recommendations for anaesthetists and neurologists for the management of patients with MS requiring anaesthesia. This review covers issues related to the anaesthetic management of patients with MS, with a focus on preoperative assessment, choice of anaesthetic techniques and agents, side-effects of drugs used during anaesthesia and their potential impact on the disease evolution, drug interactions that may occur, and the need to use monitoring devices. A systematic PubMed research was performed to retrieve relevant articles.

Predictive Factors for Magnetic Resonance Imaging Changes Suggestive of Demyelination in Adult Patients with Uveitis Scanned Prior to Commencing Adalimumab Therapy

PURPOSE

To report the predictive clinical factors for abnormal magnetic resonance imaging (MRI) scans suggestive of demyelination by analysis of MRI's performed for adult non-infectious uveitic patients prior to commencing adalimumab therapy.

METHODS

Retrospective case review of 240 patients was conducted in a single tertiary institution between November 2017 and March 2020. Aetiology of underlying disease, clinical characteristics, and MRI outcomes were analysed.

RESULTS

The presence of bilateral idiopathic intermediate uveitis (IIU) (p = .0048) and neurological symptoms (p = .028) were highly predictive of an abnormal MRI strongly suggestive of demyelination (MRSSD); 5 out of 64 scans (7.8%) with these clinical characteristics had MRSSD.

CONCLUSIONS

Tumor necrosis factor antagonist-induced demyelination is a concern in adalimumab use. We propose an MRI screening protocol to identify those at high risk of demyelination; positive results can be maximised by screening all patients with IIU and those with neurological symptoms.

Role of four-dimensional computer tomography (4D-CT) in non-localising and discordant first-line imaging in primary hyperparathyroidism

BACKGROUND

Accurate preoperative localisation of parathyroid adenoma is imperative for the success of minimally invasive parathyroidectomy (MIP).

OBJECTIVE

Our study aimed to evaluate the role of four-dimensional computer tomography (4D-CT) scan as an imaging modality in patients with failed and discordant localisation reported in the first-line imaging modalities (ultrasonography and 99mTc-MIBI-SPECT/CT).

METHODS

This is a prospective cohort study performed at a university teaching centre from March 2013 to July 2021. All patients with primary hyperparathyroidism who had failed localisation by ultrasonography and 99mTc-MIBI-SPECT/CT (SpCT), or discordance between them, had 4D-CT performed in this study.

RESULTS

One hundred and two sporadic cases of pHPT with failed/discordant first-line imaging had 4D-CT imaging prior to parathyroidectomy. In 102 patients, 105 parathyroid adenomas were reported on histopathology. 4D-CT was able to localise 78% of them to the correct side and 64% to the correct quadrant in 102 patients, as compared with US (correct side 21%, correct quadrant 16%) and 99mTc-MIBI-SPECT/CT (correct side 36%, correct quadrant 31%). 4D-CT had a sensitivity, precision, accuracy and F1 score for correct quadrant localisation as 79%, 81%, 66% and 80%; and for correct side localisation as 82%, 98%, 80% and 89%, respectively. 4D-CT was able to identify three ectopic adenomas (two in superior mediastinum and one in the oesophageal wall) which were not detected on US or SpCT.

CONCLUSION

4D-CT was found to be sensitive and accurate in preoperative localising of the diseased parathyroid glands after failed/discordant US and SpCT. This led to more patients being offered MIP as the primary surgery and improved operative outcomes.

Using framework analysis to understand multiple stakeholders' views of vocational rehabilitation following acquired brain injury

PURPOSE

To explore how vocational rehabilitation (VR) is currently delivered for individuals with acquired brain injury (ABI) across multiple stakeholder groups and identify areas for improvement in service delivery using the Consolidated Framework for Implementation Research (CFIR).

METHODS

Seven focus groups were conducted with rehabilitation clinicians; outreach providers, insurers/regulators, VR providers and disability employment service providers (n = 44) experienced in VR of individuals with ABI. All groups were audio-recorded and transcribed verbatim. Data analysis was guided by the CFIR constructs.

RESULTS

All stakeholder groups believed they offered quality VR interventions given available resources and legislation, but many clients fell through the 'cracks'. Themes that were identified included: a) number and complexity of systems supporting VR; b) fractured communication across systems, c) lack of knowledge by both stakeholders and clients in navigating systems, d) lack of expertise in supporting the vocational needs of clients with ABI and e) perceived limited awareness of ABI by employers.

CONCLUSION

Stakeholders and clients need support to navigate Australia's complex VR pathways. Limited specialist ABI clinicians, VR providers and disability employment services were identified as barriers for effective VR. Domains of the CFIR were appropriate for organising and understanding how VR is delivered.

Meta-analysis of lytic catheter-based intervention for acute proximal deep vein thrombosis in the reduction of post-thrombotic syndrome

OBJECTIVE

Post-thrombotic syndrome (PTS) is a common complication of deep vein thrombosis (DVT) that can result in significant morbidity for the patient with detrimental impact on their quality of life. Evidence supporting lytic catheter-based interventions (LCBI) undertaken for early thrombus reduction in acute proximal DVT for the prevention of PTS is conflicting. Despite this, rates of LCBIs are increasing. To summaries the existing evidence and pool treatment effects, a meta-analysis of randomized controlled trials assessing the efficacy of LCBIs in proximal acute DVT for the prevention of PTS was undertaken.

METHODS

This meta-analysis was undertaken aligning with PRISMA guidelines following a protocol pre-registered on PROSPERO. Online searches of Medline and Embase databases, as well as the gray literature, were performed up to December 2022. Included articles were randomized controlled trials that studied the use of LCBIs with additional anticoagulation vs anticoagulation alone and had determined follow-up periods. Outcomes of interest were PTS development, moderate to severe PTS, major bleeding episodes, and quality-of-life measures. Subgroup analyses were performed for DVTs involving the iliac vein and/r common femoral vein. Meta-analysis was performed using a fixed effects model. Quality assessment was performed using the Cochrane Risk of Bias and GRADE assessment tools.

RESULTS

Three trials were included in the final meta-analysis, the Post-thrombotic Syndrome after Catheter-directed Thrombolysis for Deep Vein Thrombosis (CaVenT), Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT), and Ultrasound-accelerated Catheter-directed Thrombolysis Versus Anticoagulation for the Prevention of Post-thrombotic Syndrome (CAVA) trials, comprising 987 patients. Patients undergoing LCBIs had a reduced risk of PTS (relative risk [RR], 0.84; 95% confidence interval [CI], 0.74-0.95; P = .006) and a lower risk of developing moderate to severe PTS (RR, 0.75; 95% CI, 0.58-0.97; P = .03). LBCIs increased the risk of having a major bleed (RR, 2.03; 95% CI, 1.08-3.82; P = .03). In the iliofemoral DVT subgroup analysis, there was a trend toward decreasing the risk of developing PTS and moderate to severe PTS (P = .12 and P = .05, respectively). There was no significant difference in quality-of-life score (as measured by the Venous Insufficiency Epidemiological and Economic Study - Quality of Life/Symptoms) between the two groups (P = .51).

CONCLUSIONS

Pooling of current best evidence suggests that LCBIs in acute proximal DVT decreases the rate of PTS and moderate to severe PTS with a number needed to treat of 12 and 18, respectively. However, this is complicated by a significantly higher rate of major bleeding with a number needed to treat of 37. This evidence supports the use of LCBIs in selected patients, including those who are at low risk of major bleeding.

Enhancing diabetes care for the most vulnerable in the 21st century: Interim findings of the National Advisory Panel on Care Home Diabetes (NAPCHD)

Older adults with diabetes may carry a substantial health burden in Western ageing societies, occupy more than one in four beds in care homes, and are a highly vulnerable group who often require complex nursing and medical care. The global pandemic (COVID-19) had its epicentre in care homes and revealed many shortfalls in diabetes care resulting in hospital admissions and considerable mortality and comorbid illness. The purpose of this work was to develop a national Strategic Document of Diabetes Care for Care Homes which would bring about worthwhile, sustainable and effective quality diabetes care improvements, and address the shortfalls in care provided. A large diverse and multidisciplinary group of stakeholders (NAPCHD) defined 11 areas of interest where recommendations were needed and using a subgroup allocation approach were set tasks to produce a set of primary recommendations. Each subgroup was given 5 starter questions to begin their work and a format to provide responses. During the initial phase, 16 key findings were identified. Overall, after a period of 18 months, 49 primary recommendations were made, and 7 major conclusions were drawn from these. A model of community and integrated diabetes care for care home residents with diabetes was proposed, and a series of 5 'quick-wins' were created to begin implementation of some of the recommendations that would not require significant funding. The work of the NAPCHD is ongoing but we hope that this current resource will help leaders to make these required changes happen.

Normalising interdisciplinary role-based goal setting in inpatient brain injury rehabilitation: reflections and recommendations of clinicians

PURPOSE

Person-centred goal setting with people with brain injury, by interdisciplinary teams has benefits including improved communication between patients, families and clinicians, person-centred care, and improved engagement in rehabilitation. Exploring the experiences of team members who have adopted interdisciplinary, person-centred goal setting may assist in understanding what is needed to implement this complex, core component of rehabilitation practice. This study explored experiences of clinicians working in an extended inpatient brain injury rehabilitation unit about implementing a role-based goal planning approach within an interdisciplinary team.

MATERIALS AND METHODS

Semi-structured interviews with 13 clinicians working at the rehabilitation unit explored their experiences about the cognitive participation and collective actions required to carry out the practice, with data analysed using inductive content analysis guided by Normalisation Process Theory.

RESULTS

Three primary themes were identified: putting the person at the centre, accepting the mind-shift to participation focused goals and working collaboratively.

CONCLUSIONS

This study has elucidated some key processes that occurred and were necessary to carry out goal setting. A mind-shift towards holistic, participation-focussed goal setting was described as "unlearning" discipline-specific goal setting. Development and ownership by the team, acceptance of team members and willingness to share, and structured processes and resources were necessary.IMPLICATIONS FOR REHABILITATIONNormalising interdisciplinary role-based goal setting in multi-professional teams requires a mind-shift away from traditional, discipline-specific goal setting.Implementation of interdisciplinary, collaborative team goal setting within health service settings requires collective actions including collaborative working by team members, structured processes including organised time for collaborative team and family meetings, practical resources and training to support processes.Clinicians perceived the goal setting approach to put the person at the centre resulting in a deep understanding of the person, shared understanding, and motivation for rehabilitation.

Higher Hepatitis C Cure Rates in a Patient-Centered Medical Home Compared to Specialist Care

PURPOSE

The new era of direct-acting antivirals (DAAs) against the hepatitis C virus (HCV) has led many primary care clinicians to begin treating HCV. Nevertheless, many patients are referred to specialists due to comorbidities, care complexities, and knowledge gaps of the primary care provider. We compared clinical outcomes for patients treated within a Family Medicine Residency Program (FMRP) affiliated patient-centered medical home (PCMH) with those referred to a specialist.

METHODS

Following didactic education and development of practice resources we conducted a single-center quasi-experimental study of adults with HCV referred for treatment either internally or externally to a specialist between January 2019 and December 2020. The primary outcome was the number of patients with a sustained virologic response at 12 weeks after treatment (SVR12), utilizing an intention-to-treat analysis.

RESULTS

During the study period 107 patients were assessed by the PCMH, of whom 24 were deemed not a good candidate for treatment. Of the 83 patients referred for treatment, 36 patients were referred externally and 47 were treated internally. While the rate of SVR12 was 100% for both groups when analyzed per protocol (ie, only patients who completed treatment and attended all follow-ups), the rate of SVR12 was 31% for patients referred externally and 62% for patients treated internally when analyzed by intention to treat (relative risk [RR] 2.02, 95% CI 1.18-3.47, P = .01). This difference was entirely attributable to differences in lost to follow-up rates.

CONCLUSIONS

Following education and creation of practice resources, achievement of SVR12 among patients with HCV treated by an internal interdisciplinary family medicine team was superior to those who were externally referred. This was primarily attributable to differences in follow-up rates.

213 Improving the investigation and management of papilloedema in an acute medical setting

Aim

To streamline and improve the investigation of patients with papilloedema presenting to the acute medical take in a large teaching hospital.

Methods

Patients seen on the acute medical take at the Royal London Hospital with suspected papil- loedema were identified retrospectively. A total of 19 patients were seen between April and November 2019. A number of modifiable delays to initial investigations and areas for improvement were identified from these data. A simple flowchart explaining key points in investigation and initial management of patients with papilloedema was devised and distributed to those involved in the acute take.

Results

The identified areas for improvement included delays to lumbar puncture, failure to discuss management with neurologists after identification of raised intracranial pressure, and ensuring initial management was started in those with suspected idiopathic intracranial hypertension. There were also a number of instances in which papilloedema was not confirmed by an ophthalmologist prior to inap- propriate invasive investigations. Education and provision of better information to acute medics improved many of these outcomes.

Conclusion

A clear and easy to use flowchart for those involved in the acute take minimised errors identified and improved the initial investigation and management of papilloedema presenting to the acute medical take.

catherine.hornby2@nhs.net

Personalised immunotherapy in active multiple sclerosis using injectable cladrib- ine: Follow-up of the BartsMS cohort

Introduction

Cladribine tablets (Mavenclad®) are licensed for treating people with relapsing multiple sclerosis (pwRMS). We treated people with relapsing (pwRMS) and progressive MS (pwPMS) using sub- cutaneously administered cladribine (SCAC) since 2014. Here, we present up to five year follow-up on safety and efficacy.

Methods

SCAC 10mg was given on 3–4 days during week 1. 0–3 doses were administered at week 5, according to week 4 lymphocyte count. A second cycle of SCAC was administered 11 months later. Follow-up included clinical outcome evaluation and pharmacovigilance. The proportion of pwMS with no evidence of (i) disease activity (NEDA) and (ii) progression or active disease (NEPAD) was calculated.

Results

211 pwMS received SCAC. 154/211 completed two treatment cycles. At baseline age was 44 (17–72) years, EDSS 1–8.5. Tolerability was good. One myocardial infarction and one breast cancer occurred. Two severely disabled pwMS died (one of influenza, one of encephalitis). Lymphopenia grade 3 was detected in <3%. At 2 years, 71% (CI 54%, 85%) of pwRMS had NEDA; 38% (CI 23%, 54%) of pwPMS had NEPAD.

Conclusions

SCAC was well tolerated. Frequency of significant lymphopenia was low. Efficacy in pwRMS corresponds with trial data. NEPAD rates in pwPMS were similar to licensed DMT.

k.allen-philbey@nhs.net

349 Improving Surgical Teaching for Junior Trainees Internationally in Light of Covid-19

Aim

During the Covid-19 pandemic there has been a gross effect on surgical training at all grades. A cohort that has been affected but reported less frequently are medical students and foundation doctors (junior trainees), whose interest in the field and clinical skills may have been affected by reduced service provision.

Method

A survey of junior trainees was conducted to analyse their perceived adequacy of surgical teaching in light of the effect of Covid-19. An online teaching course was then designed to target areas of weakness identified in the survey. The content was designed with the Imperial College London surgery curriculum and was vetted by a consultant surgeon.

Results

Of the 713 people surveyed, 393 (55%) had received little or no surgical teaching and 496 (70%) respondents said they were “not” or “slightly” confident in managing common and emergency surgical presentations. A free text box highlighted that deteriorating patients, clinical decision-making, and initiating management were the greatest concerns. This was used to design an international online teaching course for junior trainees, that focused explicitly on clinical care. The sessions were run live on MindTheBleep via Facebook live, to answer questions in real time and examine cases with live audience participation, receiving feedback after every session. This model has reached trainees in &gt;30 countries with &gt;200 feedback responses and an average rating of 4.5/5.

Conclusions

Junior trainees are a key cohort whose interest and education in surgery has suffered due to the pandemic. An innovative, online, clinically orientated course is assisting to re-engage trainees internationally.

1113 Surgical Innovators or Spin Doctors: Reporting of Expectations for Robotic Gastrointestinal Surgery

Introduction

The use of robotics in gastrointestinal surgery is an increasingly popular area of surgical innovation. Despite uncertainty regarding clinical benefits, gastrointestinal surgery centres continue to introduce robotic services. This may be motivated by perceived benefits, in lieu of substantial empirical benefits. We aimed to summarise the expected advantages and disadvantages of robotic techniques in gastrointestinal surgery, as reported by study authors.

Method

A systematic review was undertaken by the trainee led RoboSurg Collaborative. Searches were conducted on of Embase, Medline, the Cochrane Library and Web of Science. Articles were double screened by abstract, then full text. All primary studies reporting outcomes following robotic cholecystectomy or oesophagectomy were included. Reports of expected benefits and disadvantages or robotic techniques were extracted verbatim, and summarised using descriptive statistics.

Results

We included 192 studies. An expected benefit was reported in 161 (84%). Of those, 127 (79%) expected robotics to have an intra-operative advantage, such as reduced operative time, improved dexterity and improved visualisation. Post-operative benefits, such as reduced recovery time and shorter length of hospital stay, were expected in 72 (45%). Expected disadvantages were reported in 96 (50%) of the included studies. Of those, 74 (77%) expected robotics to have intra-operative disadvantages such as increased operative times and lack of tactile feedback. Increased cost was another commonly expected limitation.

Conclusions

Study authors reported perceived benefits more frequently than disadvantages. Perceived benefits were more commonly advantageous to the surgeon rather than the patient. There were directly conflicting perceptions of how robotic techniques affect operative times.

Neutron calorimeter design for pulsed neutron experiment diagnostics

Neutron calorimeter for diagnostic support of both fission- and fusion-based pulsed neutron experiments is described. The calorimeter generates a voltage signal output via a pair of thermocouples contacting a sample material, which experiences a temperature increase due to interactions with an incident neutron fluence. Advantages of the calorimeter include the versatility derived from its small size, modularity, and the variety of employable neutron absorber materials and sizes. These characteristics permit use with neutron energies between the thermal and fast (up to 14 MeV) spectra. Design overview and requirements, Monte Carlo particle transport simulation results, test data, and possibilities for calorimeter development are provided and discussed.

Autologous Haematopoietic Stem Cell Transplantation in Active Multiple Sclerosis: a Real-world Case Series

OBJECTIVE

to examine outcomes in people with multiple sclerosis (PwMS) treated with autologous hematopoietic stem cell transplantation (AHSCT) in a real-world setting.

METHODS

retrospective cohort study on PwMS treated with AHSCT at two centers in London, UK, consecutively between 2012 and 2019 who had ≥ 6 months of follow-up or died at any time. Primary outcomes were survival free of MS relapses, MRI new lesions and worsening of expanded disability status scale (EDSS). Adverse events rates were also examined.

RESULTS

the cohort includes 120 PwMS; 52% had progressive MS (primary or secondary) and 48% had relapsing-remitting MS (RRMS). At baseline, the median expanded disability status scale (EDSS) was 6.0; 90% of the evaluable cases showed MRI activity in the 12 months preceding AHSCT. Median follow-up after AHSCT was 21 months (range 6-85). MS relapse-free survival was 93% at 2 years and 87% at 4 years after AHSCT. No new MRI lesions were detected in 90% of subjects at 2 years and 85% at 4 years. EDSS progression-free survival (PFS) was 75% at 2 years and 65% at 4 years. EBV reactivation and monoclonal paraproteinemia were associated with worse PFS. There were 3 transplant-related deaths within 100 days (2.5%), all following fluid overload and cardiac or respiratory failure.

CONCLUSIONS

efficacy outcomes of AHSCT in this real-world cohort are similar to those reported in more stringently selected clinical trial populations, although the risks may be higher.

CLASSIFICATION OF EVIDENCE

this study is rated Class IV because of the uncontrolled, open-label design.

P11 A systematic review of the reporting of robotic cholecystectomy

Introduction

Robotic cholecystectomy (RC) is reported to be an innovative alternative to laparoscopic cholecystectomy for the surgical management of gallbladder disease. Perceived technical benefits of RC include enhanced ergonomic capabilities and visualisation. Whilst RC is becoming increasingly widespread, there is a paucity of high-quality data supporting its use, and conflicting evidence of outcomes in current literature. With accumulating reports citing complications associated with novel invasive procedures, experts have suggested that robust clinical evaluation is required. It is vital that techniques such as RC are evaluated consistently, in order for surgeons to fully educate patients about the treatment and obtain informed consent. This study aims to summarise and appraise the reporting of studies of RC.

Methods

Systematic searches identified all published studies reporting RC. Data collection was based on the IDEAL (Idea, Development, Exploration, Assessment, Long-term follow-up) framework. This will be used to identify key areas of reporting including; general study characteristics, patient selection, regulatory and governance arrangements, operator and centre expertise, technique description, and outcome reporting. Because the study will not aim to draw conclusions about the effectiveness of robotic surgery, meta-analyses will not be not performed.

Results

Systematic searches identified 1425 abstracts; 90 full-text papers were included. Results will be summarised in a narrative synthesis and further data will be analysed prior to presentation.

Conclusion

This in-depth analysis of the published literature on RC will provide evidence to understand how this innovative procedure has been introduced and evaluated in relation to the IDEAL recommendations.

Exploring the lived return-to-work experience of individuals with acquired brain injury: use of vocational services and environmental, personal and injury-related influences

PURPOSE

To explore work outcomes, vocational services, barriers and facilitators for returning to work in individuals with acquired brain injury (ABI) in Queensland, Australia and to identify areas for improvement.

DESIGN AND METHODS

Ten semi-structured interviews were conducted with individuals with ABI (stroke, traumatic brain injury, tumour). Interviews were analysed using a realist thematic analysis approach.

RESULTS

Participants either returned to the same work, different work, did not maintain work or did not have any work since their injury. Use of vocational services depended on participants' needs and insurance. Facilitators for return to work (RTW) were a supportive workplace and family, vocational rehabilitation that met the individual's needs, insurance coverage and self-motivation. Workplaces that were not understanding of brain injury, employment service providers who were unable to find work for participants, and physical and cognitive deficits were barriers to RTW. Workplaces, employment service providers and individuals require more information about the deficits associated with brain injury.

CONCLUSIONS

The use and effectiveness of vocational services were variable across participants and depended on insurance coverage and needs. Barriers and facilitators for RTW were affected by both the environment and the individual. Implications for vocational rehabilitation were identified.Implications for RehabilitationA supportive workplace and family, and access to appropriate vocational rehabilitation are important environmental facilitators for RTW in individuals with ABI.Workplaces with a poor understanding of ABI and employment service providers unable to find work for individuals with ABI are environmental barriers to RTW.Workplaces, employment service providers and individuals with ABI require more information about the physical and cognitive deficits associated with ABI.Employment service providers need more training to develop comprehensive strategies to help individuals with ABI find new employment.

Analysis of Vasopressor Discontinuation and the Incidence of Rebound Hypotension in Patients With Septic Shock

Purpose: The purpose of this study was to examine the incidence of rebound hypotension in patients with septic shock requiring both norepinephrine and vasopressin infusions once discontinuation of 1 of these agents is warranted. Methods: A multicenter, retrospective study was conducted in 3 hospitals within a single health system between January 1, 2016, and December 31, 2017. The study population included adults, 18 years and older, diagnosed with septic shock and requiring concurrent infusions of norepinephrine and vasopressin. The primary outcome evaluated the incidence of rebound hypotension within 24 hours after the first vasopressor was discontinued. Secondary outcomes included intensive care unit length of stay, hospital length of stay, total vasopressor duration, and the time to rebound hypotension after first vasopressor discontinuation. Results: A total of 69 patients were included in the study, 38 in the vasopressin discontinued first group and 31 in the norepinephrine discontinued first group. Rebound hypotension occurred in 82% of patients in the vasopressin discontinued first group compared with 48% in the norepinephrine discontinued first group ( P = .004). No differences were observed in secondary outcomes, including intensive care unit or hospital length of stay, total vasopressor duration, or the time to rebound hypotension. Conclusions: Discontinuation of norepinephrine before vasopressin may lead to less incidence of rebound hypotension in patients with septic shock who require concurrent norepinephrine and vasopressin infusions. Similar to previous studies, this study found no difference in secondary outcomes.

Role of long-term supplementation of 25-hydroxyvitamin D3 on egg production and egg quality of laying hen

A study was conducted to evaluate the effect of dietary 25-hydroxyvitamin D₃ (25OHD) on pullet and egg-laying hen growth performance, egg production, and egg quality. Three hundred and ninety 1-day-old Hy-Line W36 pullets were randomly allocated to 3 treatments with 10 replicated cages and 13 birds per cage. Dietary treatments were vitamin D₃ at 2,760 IU/kg (D); vitamin D₃ at 5,520 IU/kg (DD), and vitamin D₃ at 2,760 IU/kg plus 25OHD at 2,760 IU (69 μg)/kg (25D). Body weight and feed intake were recorded at the end of each stage: starter 1 (0–3 wk), starter 2 (4–6 wk), grower (7–12 wk), developer (13–15 wk), prelay (15–17 wk), peaking (18–38 wk), layer 2 (39–48 wk), layer 3 (49–60 wk), layer 4 (61–75 wk), and layer 5 (76–95 wk). Egg production was recorded daily. Egg quality was evaluated every 8 wk starting from 25 wk. There was no difference in growth performance during the rearing period (0–17 wk). In the laying period (18–95 wk), DD showed lower feed intake at layer 2, but higher intake at layer 3 along with lower hen day production (HDP) from 22 to 48 wk compared to the other treatments. During the same period, the DD group laid smaller eggs with higher specific gravity and shell thickness compared with the other treatments or D alone at 40 wk, which may be partly due to the lower body weight. In contrast, 25D had better feed conversion ratio (feed intake per dozen of eggs) at layer 2, and higher overall (22–60 wk) HDP compared with DD. For the egg quality analysis, at 25 and 33 wk, both DD and 25D had higher Haugh unit compared with D. However, 25OHD has no effects on eggshell quality during the entire production period and no beneficial effects on egg production during the later laying period (after 60 wk). In summary, long-term and early supplementation of 25OHD has positive effects on egg production and egg quality, and the beneficial effects were mainly observed during the early laying stage.

Effect of a novel pharmacist-led reporting system on appropriate use of direct-acting oral anticoagulants (DOACs) in a patient-centered medical home

Recent analyses demonstrate roughly 16-24% of patients taking direct-acting oral anticoagulants (DOACs) are prescribed an inappropriate dose, exposing patients to increased risk of thrombosis or bleeding. The use of reporting systems in the outpatient setting can efficiently identify potential medication errors and safety concerns. The purpose of this study was to evaluate the effect of a novel pharmacist-driven reporting system on appropriate prescribing of DOACs in the outpatient setting. This single-center qualitative study was conducted within a patient-centered medical home (PCMH). Reports were generated monthly to include all new DOAC prescriptions. Branching logic and filters were utilized within a secure web application to make the reporting process more efficient and identify regimens needing an intervention. Pharmacists reviewed the regimens populated by filters and made recommendations to prescribers as appropriate. The number of interventions proposed was captured as the primary outcome. Secondary outcomes include the nature of drug therapy problems identified and number of interventions accepted by prescribers. A total of 107 patients were analyzed for appropriateness from November 2017 to February 2019. Of the regimens included for review, 15 regimens were identified as potentially inappropriate. The nature of drug therapy problems identified include under dosing (4.25%), overdosing (2.13%), correction of documentation (2.13%), clarification of indication (3.19%), and ordering laboratory studies (3.19%). Of the interventions recommended, fourteen (93%) were accepted. Pharmacists integrated in a PCMH are well positioned to monitor and resolve DOAC drug therapy problems using local clinical reports.

Abstract P4-02-03: Impact of the 2018 ASCO/CAP HER2 focused update on human epidermal growth factor receptor-2 (HER2) testing in breast cancer: A retrospective review of a single institutional cohort

Background: In the 2013 ASCO/CAP HER2 update, new recommendations for HER2 diagnostic criteria in breast cancer organized in situ hybridization (ISH) results into five categories; group1 (amplified), group 2 (monosomy), group 3 (co-amplified), group 4 (equivocal) and group 5 (non-amplified). Patients falling into groups 2, 3 and 4 were potentially eligible for HER2 targeted therapy, however, there is uncertainty from limited prospective clinical trials that show patients in these uncommon groups would receive the same benefit as group 1. Concern over whether the interpretation criteria should be modified for these uncommon groups led to the recent publication of the 2018 HER2 focused update. This update has modified ISH criteria for groups 2, 3 and 4, recommending the final diagnosis take into consideration both immunohistochemistry (IHC) and ISH results. The publication of this new guideline has prompted us to investigate what impact this would have on our institution.

Materials & Methods: A retrospective review of the URMC pathology database revealed 2,281 cases that had undergone HER2 FISH analysis since the 2013 update. IHC for initial HER2 screening was used, followed by reflex testing of all 2+ results and cases with histopathologic discordance. All 2,281 FISH cases were sorted into their 5 HER2 categories based on the 2013 guidelines. The final HER2 diagnosis for groups 2, 3 and 4 were then re-determined after applying the new criteria presented in the 2018 focused update.

Results: The results from the 2,281 HER2 FISH cases are shown in Tables 1 and 2. The results for group 1 and group 5 cases remained the same. However, for ISH cases in groups 2, 3 and 4, there were alterations in the final HER2 results. All 25 monosomy cases, originally interpreted as HER2 positive by the 2013 guidelines, were now considered HER2 negative. All group 3 (co-amplified) cases remained positive (due to IHC 2+ results). The largest change was that the original 199 equivocal cases, based on the 2013 guidelines, became split into 198 HER2 negative (99.5%) and 1 HER2 positive (0.5%).

Conclusion: Comparison of the HER2 FISH cases between 2013 and 2018 revealed differences in the final HER2 status. Using the 2018 guideline, 13.72% (313 cases) of the 2281 cases were HER2 positive in contrast to 14.77% (337 cases) from 2013. While that is only a difference of 1.05%, the reclassification of 198 of 199 equivocal cases to negative indicates that 9.82% of the final HER2 results for the entire patient cohort was affected. With 266,000 new cases of breast cancer annually, the final HER2 status of approximately 26,000 patients and their potential eligibility for targeted-therapy would change. Further study of the clinical significance of these changes is warranted.

Final ISH HER2 Status (2013)AmplifiedMonosomyCo-AmplifiedEquivocalNon-Amplified272 cases (11.93%)25 cases (1.10%)40 cases (1.75%)199 cases (8.72%)1,745 cases (76.50%)

Citation Format: Hicks DG, D'Aguiar M, Henry J, McMahon L, Buscaglia B, Turner B. Impact of the 2018 ASCO/CAP HER2 focused update on human epidermal growth factor receptor-2 (HER2) testing in breast cancer: A retrospective review of a single institutional cohort [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-02-03.

Abstract P1-03-02: ASCO/CAP human epidermal growth factor receptor-2 (HER2) in situ hybridization (ISH) categories evaluated by quantitative HER2 protein diagnostic methodologies: A comparative analysis

Background: In 2013, the ASCO/CAP consensus panel published updated guidelines for HER2 testing in breast cancer that modified the definition of HER2 amplification by in situ hybridization (ISH), creating five new prognostic categories (group 1: classic amplified, group 2: monosomy, group 3: co-amplified (polysomy), group 4: equivocal, and group 5: classic non-amplified). Patients determined to be ISH amplified, were considered eligible for HER2-directed therapy. Concern over whether patients from non-classic groups 2-4 would benefit from treatment has led to the recent publication of the 2018 HER2 focused update. This update has modified the criteria for interpreting these ISH categories, recommending that the final diagnosis take into consideration a combination of HER2 immunohistochemistry (IHC) and ISH results. With increased emphasis on the HER2 protein assessment, it has prompted us to quantitatively examine HER2 protein expression in the ISH categories, using two different novel technologies. Materials & Methods: A cohort of 170 cases (URMC) and 102 cases (PSHMC) of invasive breast cancers, which had previously undergone HER2 IHC and ISH testing, were selected for this study. Cases were sorted and categorized into the HER2 ISH categories defined by ASCO/CAP. HER2 protein expression was quantitatively measured in the URMC and PSHMC cohorts using a novel immunodetection methodology (streptavidin-coated Phosphor-Integrated Dot (PID) fluorescent nanoparticles), and a novel dual-antibody, proximity-binding immunoassay (HERmark® Breast Cancer Assay, Monogram Biosciences, South San Francisco, California), respectively. HER2 protein expression was compared to the HER2 FISH and IHC results by ASCO/CAP category. Results: Cases in group 1 had a significantly (p &lt; 0.01) higher average PID/cell and HERmark compared to cases in groups 2-5 (Table 1). Cases in groups 2-4 showed lower quantitative levels of HER2 protein expression, similar to the classic non-amplified cases (group 5). Group 1 was further divided into three subgroups (Table 2): Group A - ISH high-level amplified (ratio &gt; 2, HER2 &gt; 6, CEP17 &lt; 2.7), Group B - amplified with elevated CEP17 (ratio &gt; 2, CEP17 &gt; 2.7), and Group C - low-level amplified (ratio &gt; 2, HER2 &gt; 4 and &lt; 6). Group A and B had a significantly (p &lt; 0.01) higher average PID/cell and HERmark compared to Group C. Group C was more comparable to cases in groups 2-5 (Table 1). Conclusion: Our results suggest that quantitative assessment of HER2 protein expression may help to further classify cases for HER2 status for targeted therapy, supporting the 2018 ASCO/CAP recommendation that non-classic ISH results might be resolved by evaluating protein expression. Follow up studies with a larger patient cohort and dual quantitative assessment are warranted.

Average PID/cell and HERmark in ASCO category groupsASCO category groupN (URMC)PID/cell (URMC)*N (PSHMC)HERmark (PSHMC)*18888.07761.521011.20N/A32016.0213.84238.5315.95296.3208.3*averageTable 2:Average PID/cell and HERmark in subgroups of Group 1SubgroupN (URMC)PID/cell (URMC)*N (PSHMC)HERmark (PSHMC)*A24157.66465.7B34101.61044.1C3016.9329.8*average

Citation Format: Buscaglia B, Turner B, Goda H, Huang W, Leitzel K, Natori T, Nakano Y, Okada H, Sperinde J, Ali S, Vasekar M, D'Aguiar M, McMahon L, Henry J, Lipton A, Hicks D. ASCO/CAP human epidermal growth factor receptor-2 (HER2) in situ hybridization (ISH) categories evaluated by quantitative HER2 protein diagnostic methodologies: A comparative analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-03-02.

Early onset cerebral amyloid angiopathy following childhood exposure to cadaveric dura

Amyloid-β transmission has been described in patients both with and without iatrogenic Creutzfeldt-Jakob disease; however, there is little information regarding the clinical impact of this acquired amyloid-β pathology during life. Here, for the first time, we describe in detail the clinical and neuroimaging findings in 3 patients with early onset symptomatic amyloid-β cerebral amyloid angiopathy following childhood exposure to cadaveric dura (by neurosurgical grafting in 2 patients and tumor embolization in a third). Our observations provide further in vivo evidence that cerebral amyloid angiopathy might be caused by transmission of amyloid-β seeds (prions) present in cadaveric dura and have diagnostic relevance for younger patients presenting with suspected cerebral amyloid angiopathy. Ann Neurol 2019; 1-7 ANN NEUROL 2019;85:284-290.

Evidence of Clostridium perfringens epsilon toxin associated with multiple sclerosis

Background:

It was recently reported that, using Western blotting, some multiple sclerosis (MS) patients in the United States had antibodies against epsilon toxin (Etx) from Clostridium perfringens, suggesting that the toxin may play a role in the disease.

Objective:

We investigated for serum antibodies against Etx in UK patients with clinically definite multiple sclerosis (CDMS) or presenting with clinically isolated syndrome (CIS) or optic neuritis (ON) and in age- and gender-matched controls.

Methods:

We tested sera from CDMS, CIS or ON patients or controls by Western blotting. We also tested CDMS sera for reactivity with linear overlapping peptides spanning the amino acid sequence (Pepscan) of Etx.

Results:

Using Western blotting, 24% of sera in the combined CDMS, CIS and ON groups (n = 125) reacted with Etx. In the control group (n = 125), 10% of the samples reacted. Using Pepscan, 33% of sera tested reacted with at least one peptide, whereas in the control group only 16% of sera reacted. Out of 61 samples, 21 (43%) were positive to one or other testing methodology. Three samples were positive by Western blotting and Pepscan.

Conclusion:

Our results broadly support the previous findings and the role of Etx in the aetiology of MS warrants further investigation.

QueF-Like, a Non-Homologous Archaeosine Synthase from the Crenarchaeota

Archaeosine (G⁺) is a structurally complex modified nucleoside ubiquitous to the Archaea, where it is found in the D-loop of virtually all archaeal transfer RNA (tRNA). Its unique structure, which includes a formamidine group that carries a formal positive charge, and location in the tRNA, led to the proposal that it serves a key role in stabilizing tRNA structure. Although G⁺ is limited to the Archaea, it is structurally related to the bacterial modified nucleoside queuosine, and the two share homologous enzymes for the early steps of their biosynthesis. In the Euryarchaeota, the last step of the archaeosine biosynthetic pathway involves the amidation of a nitrile group on an archaeosine precursor to give formamidine, a reaction catalyzed by the enzyme Archaeosine Synthase (ArcS). Most Crenarchaeota lack ArcS, but possess two proteins that inversely distribute with ArcS and each other, and are implicated in G⁺ biosynthesis. Here, we describe biochemical studies of one of these, the protein QueF-like (QueF-L) from Pyrobaculum calidifontis, that demonstrate the catalytic activity of QueF-L, establish where in the pathway QueF-L acts, and identify the source of ammonia in the reaction.

Protein hydration in living cells probed by Fourier transform infrared (FT-IR) spectroscopic imaging

FT-IR spectra of a HEK cell were analyzed with 2D disrelation mapping to reveal molecular states of water and protein hydration.

The new system of health accounts in Ireland: what does it all mean?

BACKGROUND

The Central Statistics Office released new figures on Ireland's health spending in December 2015, based on the System of Health Accounts (SHA2011). These figures differ from previous figures, by virtue of an expanded definition of what constitutes health care. The new figures also provide more detail on health expenditure than the previous figures allowed.

AIMS

This article examines the new figures, drawing out findings of note and discussing the implications of these for the Irish health care system. It also compares Ireland with international health systems, highlighting where Ireland is unusual or comparable to international norms.

FINDINGS

Healthcare spending in Ireland as a percentage of GDP is higher than in many other countries, having increased during the economic downturn, although this was due more to the contraction in GDP than an increase in spending. While the majority of healthcare expenditure in Ireland comes from the Government, the share of private expenditure on healthcare in Ireland has increased, with implications for equity in the system. Over half of the expenditure is on curative and rehabilitative services, broadly in line with other countries. The proportion of spending going to long-term care facilities is relatively high by international standards.

CONCLUSION

Suggestions that Ireland is over-spending on health need to be tempered by cognisance that the Irish health system is under-resourced in a number of areas (particularly the number of doctors and the number of hospital beds) and has not fully recovered from cutbacks in the late 1980s and early 1990s.

Breast Cancer in the Bahamas in 2009-2011

BACKGROUND

Breast cancer is the most common form of cancer affecting women in the Bahamas, which consists of many islands. This is the first attempt to identify which island has the highest occurrence of breast cancer.

OBJECTIVE

The aim of this study was to describe the sociodemographical and spatial features of breast cancer in the Bahamas in 2009-2011.

METHODS

A review of the medical records of all women with a confirmed diagnosis of breast cancer during the period January 1, 2009-December 31, 2011, was undertaken. Data were first obtained from the National Oncology Board of the Bahamas and validated by a review of the medical records. The patient address was geocoded and mapped using ArcGIS 10.0 Environmental Systems Research Institute (ESRI) to satellite images obtained from The Nature Conservancy in the Bahamas.

RESULTS

We recruited 270 patients who satisfied the entry criteria. The cumulative incidences of breast cancer for the years 2009-2011 were 51.4, 45.4, and 51.4, respectively. Breast cancer occurred most often in women of African origin with a mean age at diagnosis of 56.6 ± 13.8 years. Ductal carcinoma was the most common histological type observed with most cancers occurring in Grade II or higher and presenting as late stage (≥ Stage II). Surgery was the preferred method of treatment with modified radical mastectomy being the procedure of choice. Spatial distribution of cases across the Bahamas revealed one cluster, which is present on the island of New Providence. Further analysis of New Providence showed a consistently skewed kernel density in the central and eastern regions, compared with a scattered distribution in the southern and western regions.

CONCLUSION

The island of New Providence had the highest occurrence of breast cancer among all the islands of the Bahamas. The increasing incidence of breast cancer in young women is likely to impose a significant burden on the future of Bahamian health care.

Meta-analysis of vagus nerve stimulation treatment for epilepsy: correlation between device setting parameters and acute response

BACKGROUND

Vagus nerve stimulation (VNS) is an adjunctive neurophysiological treatment for those patients who have pharmacoresistant or surgically resistant partial onset epilepsy.

OBJECTIVE

The aim of this study is to determine the effects of high and low stimulation paradigms on a responder rate of ≥50 and ≥75% reduction in seizure frequency and associated adverse effects in adults and children.

METHOD

A literature search was performed using Medline, PubMed, EMBASE, and Cochrane library for studies using vagus nerve stimulation published from January 1980 until July 2014 for medically or surgically resistant partial onset seizures, in children and adults. No restrictions on languages were imposed.

DATA COLLECTION AND ANALYSIS

Four authors reviewed and selected studies for inclusion and exclusion. The search identified five randomized control trials that fit with our inclusion criteria. The following outcomes were evaluated: 50% or greater reduction in total seizure frequency, 75% or greater reduction in total seizure frequency, and adverse effects.

RESULTS

Four randomized controlled trials were analyzed in this meta-analysis. Results indicate high stimulation is more effective in adult patients who experienced ≥50 and ≥75% reduction in seizure frequency with a significant difference within both high and low stimulation groups. In children, there was no significant difference between the two groups and patients with ≥50 % reduction in seizures. Adverse effects such as hoarseness and dyspnea were more common in the high stimulation group where the remaining side effects were not statistically different among both groups.

CONCLUSION

High stimulation is more effective than low stimulation in producing a greater reduction in seizure frequency in patients with medically and surgically resistant epilepsy.

A decade in diabetes specialist services, 2000 to 2011, in England: the views of consultant diabetologists and diabetes specialist nurses amidst persistent healthcare delivery change

AIMS

To assess the impact of continual major National Health Service reorganization on commissioning, organizational and delivery arrangements for secondary care diabetes services. To explore how consultant diabetologists and diabetes specialist nurses perceive the issues facing diabetes specialist services in 2011 and how these have changed in the preceding decade.

METHODS

We used a longitudinal case study approach that combined quantitative and qualitative methods. Five locations in England were purposively selected to represent the wider diabetes specialist community, and seven semi-structured interviews were conducted. Interviews were recorded, transcribed verbatim and analysed using Framework analysis. Findings were compared with and contrasted to results from national quantitative surveys of diabetes specialist services undertaken in 2000 and 2006.

RESULTS

Clinicians viewed positively the expertise and commitment of multidisciplinary teams and their ability to adapt to new situations. Negative perceptions persisted throughout the decade, relating to the continual change that threatens to dismantle relationships and services which had taken many years to establish. Lack of resources, inadequate manpower planning and poor access to psychological support for people with diabetes remained constant themes from 2000 to 2011.

CONCLUSIONS

A willingness to innovate and work differently to improve services was identified; however, clinicians must be supported through organizational changes to ensure people with diabetes receive high-quality care. The disruptive nature of organizational change was a recurrent theme throughout the decade. Periods of stability must exist within commissioning to allow relationships, which are key to integration, to be maintained and permit service improvements to develop.

Hope: A further dimension for engaging family members of people with ABI

BACKGROUND

Family member engagement is increasingly recognised as an influential factor in the rehabilitation continuum following Acquired Brain Injury, including the inpatient setting and longer-term community integration phases.

OBJECTIVE

To explore the experiences of patients and family members about their involvement in brain injury rehabilitation.

METHODS

This study comprised individual and group interviews with 14 ex-patients and family members. Interviews explored effects of inpatient rehabilitation on family relationships. Interview audio recordings were analysed using an interpretive approach by two independent researchers.

RESULTS

Findings clearly confirmed the significance of engaging family members in inpatient rehabilitation, and specifically reinforced the importance of informational, emotional, practical and peer support. However, the key finding of the study was the importance of hope, and the need for rehabilitation professionals to foster hope. Despite not having included any questions on this topic, all interviewees noted the importance of hope, some saw it as fundamental to positive outcomes, and many were unconvinced of rehabilitation professionals' concern to avoid false hope. Various dimensions of hope are explored.

CONCLUSIONS

The study notes that hope has been identified as highly important in many areas beyond brain injury rehabilitation. Based on this small preliminary study, the issue of hope is seen as a key focus for future research.

Diabetes UK Position Statement. Competency frameworks in diabetes

The quality, skills and attitudes of staff working in the healthcare system are central to multidisciplinary learning and working, and to the delivery of the quality of care patients expect. Patients want to know that the staff supporting them have the right knowledge and attitudes to work in partnership, particularly for conditions such as diabetes where 95% of all care is delivered by the person with diabetes themselves. With the current changes in the NHS structures in England, and the potential for greater variation in the types of 'qualified provider', along with the recent scandal at Mid-Staffordshire Hospital, staff need to be shown to be competent and named/accredited or recognized as such. This will help to restore faith in an increasingly devolved delivery structure. The education and validation of competency needs to be consistently delivered and assured to ensure standards are maintained for different roles and disciplines across each UK nation. Diabetes UK recommends that all NHS organizations prioritize healthcare professional education, training and competency through the implementation of a National Diabetes Competency Framework and the phased approach to delivery to address this need.

Pathologic diagnosis, immunohistochemistry, multigene assays and breast cancer treatment: progress toward "precision" cancer therapy

Clinical decisions regarding the suitability of adjuvant systemic therapy for individual patients with breast cancer depends on comprehensive assessment of the underlying biology of each patient's tumor. The previous clinical-pathologic paradigm for treatment, which had been used for decades, now has been augmented by significant advances in molecular analysis of breast tumor tissue samples. Molecular testing has the potential to understand better both tumor biology and clinical behavior, which enables more appropriate therapy choices to be made. We review the rapid evolution in profiling breast cancer tissues, and discuss the current evidence for clinical use of this information and how the emerging molecular paradigm can be integrated into the clinical-pathologic context as we progress toward "precision" therapy for patients with breast cancer and other solid tumors.

Pharmacological treatment of patients with advanced prostate cancer

Prostate cancer is linked to the male sex hormone testosterone. In advanced disease, blocking the production of testosterone using androgen deprivation therapy causes regression of prostate cancer and minimises or prevents symptoms associated with the disease. Luteinising hormone-releasing hormone agonists are commonly used in the management of prostate cancer, however less is known about the role of the newer gonadotrophin-releasing hormone (GnRH) antagonists. This article focuses on the differences between the two treatments and provides nurses with the knowledge to explain the use of GnRH antagonists to patients and administer this therapy effectively.

Assessing treatment response to interferon-β: is there a role for MRI?

OBJECTIVE

Interferon-β (IFN-β) has been shown to reduce relapse rates in multiple sclerosis; however, the clinical response appears to vary among individuals. Can early MRI be used to identify those patients who have a poor response to treatment?

METHODS

A systematic review of studies examining differential treatment response and clinical endpoints in groups defined as responders or nonresponders to IFN-β was performed. Meta-analytic techniques were used to combine study results where appropriate.

RESULTS

Patients with MRI evidence of poor response to IFN-β treatment as defined by either ≥2 new hyperintense T2 lesions or new gadolinium-enhancing lesions had significantly increased risk of both future relapses and progression as defined by the Expanded Disability Status Scale. There appeared to be an increased risk of poor outcomes 16 years after treatment initiation in those with an initial poor response to treatment. Previous evidence has shown this not to be the case in placebo arms of clinical trials.

CONCLUSIONS

For those patients starting IFN-β, early MRI, within 6 to 24 months after starting treatment, has the potential to provide important information when counseling patients about the likelihood of future treatment failure. This can inform treatment decisions before clinical relapses or disease progression.

Oxidative burst intensity of peripheral phagocytic cells and periodontitis in Down syndrome

BACKGROUND

This study investigated the oxidative burst function of peripheral phagocytic cells (granulocytes and monocytes) and assessed the relation between oxidative burst and periodontal status in adult individuals with Down syndrome (DS) vs. other groups.

METHODS

Of 55 DS individuals (18-56 years old), 74 individuals with mental retardation (MR) and 88 medically healthy controls (HC) participated in the study. The MR and HC groups were age, race and gender matched with the DS group. Gingival index, plaque index, probing depth, attachment level and bleeding on probing were recorded for each subject. Whole blood was collected for granulocyte/monocyte oxidative burst tests. Oxidative burst was determined by flow cytometry in terms of percentage of cells actively involved in oxidative burst, and oxidative intensity (magnitude of ROIs per cell).

RESULTS

The basal oxidative burst intensity of DS granulocytes was higher than that of HC and MR granulocytes (p = 0.05). The Escherichia coli stimulated oxidative burst intensity of DS monocytes was higher than that of HC and MR monocytes (p = 0.05). Regression analysis controlling for age, sex, race and plaque levels showed a significant association between monocyte oxidative burst intensity and loss of periodontal attachment in DS subjects (p < 0.01). Regression analysis also showed a significant association between granulocyte oxidative burst intensity and bleeding on probing in all subjects (p < 0.05).

CONCLUSIONS

Oxidative burst activity of peripheral monocytes and granulocytes is elevated in DS affected individuals and may contribute to periodontal tissue inflammation and loss of periodontal attachment in this susceptible group.

Abstract OT3-4-04: InVite: an observational pilot study evaluating the feasibility of genome-wide association studies using self-reported data from patients with metastatic breast cancer treated with bevacizumab

Background: Personalized healthcare tailors treatments to patients and their disease characteristics through the use of genetics and other biomarkers. Genetic differences among individuals may explain variations in drug treatment response, including side effects. With such information physicians could make more informed decisions about drugs and dosing for a given individual, thereby improving patient care. Although there has been some success, to a large extent genetic variation related to drug response remains unexplained.

Bevacizumab, a humanized monoclonal antibody against the angiogenic factor VEGF, has demonstrated activity in patients with metastatic breast cancer (MBC). The InVite study will evaluate the feasibility of performing genomewide association studies using self-reported information collected via an online platform from patients with MBC who have been treated with bevacizumab. Using novel methodology in a convenient, user-friendly, and scientifically rigorous format, InVite ultimately aims to identify potential pharmacogenetic associations in this patient population.

Trial design: InVite is a pilot, non-interventional, observational, web-based, prospective cohort study designed to collect patient-reported safety, efficacy, and genetic data from patients with MBC treated with bevacizumab. Data on demographics, breast cancer disease status, cancer treatment history, bevacizumab-related outcomes, and certain safety events will be collected directly from patients entirely via online surveys. Patients will be asked to complete surveys at the time of enrollment and then every 3 months for 1 year after enrollment. A saliva sample for DNA collection will be gathered using an at-home kit. Evaluations of data quality and collection feasibility will be conducted intermittently. There will be an optional substudy to allow for blood sample collection for DNA analysis.

Eligibility criteria: ≥18 years of age, residing in the US, locally recurrent breast cancer or MBC, currently being or having been treated with bevacizumab starting on or before Dec 31, 2011, fluent in English, and access to a computer with an internet connection.

Specific aims: The primary objective is to assess the feasibility of recruiting subjects and collecting biospecimens and self-reported data online. The secondary objective is to characterize the patient population. Exploratory objectives include analyzing potential associations between genetic polymorphisms and 1) bevacizumab-induced hypertension, the most common bevacizumab-related adverse event, and 2) patient-reported time-to-progression.

Statistical methods: Baseline demographics, clinical and treatment characteristics of enrolled patients will be summarized. Each polymorphism genotyped will be tested for association with the defined endpoint using appropriate statistical modeling.

Present and target accrual: Accrual as of May 23, 2012 is 82 patients. Target accrual is 1000 patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT3-4-04.