Investigating the Needs and Concerns of Lesbian, Gay, Bisexual, Transgender, Queer, or Questioning Cancer Patients

The needs and concerns of lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) patients with cancer remain poorly understood. This is important as LGBTQ+ patients have an elevated risk of developing certain cancers and have poorer oncologic outcomes compared to non-LGBTQ+ patients. The lack of research may be linked to the complexity of studying the needs and concerns of this patient population. This review aimed to describe the evidence that sought to identify the needs and concerns of LGBTQ+ cancer patients. Studies were extracted using keywords such as "LGBTQ" and "Oncology." Patient participants were excluded if they did not identify as LGBTQ+ and if they did not have cancer or were not cancer survivors. Healthcare professionals were excluded if they were not oncology specific. A total of 22 studies met our inclusion criteria. LGBTQ+ cancer patients expressed concerns surrounding heteronormative assumptions made by healthcare professionals, a lack of LGBTQ±specific cancer support groups, and psychosexual concerns such as erectile dysfunction following cancer treatment. Oncology healthcare professionals lacked the knowledge and education that are required to manage this patient cohort. Further research is required to investigate the needs and concerns of LGBTQ+ cancer patients specifically in the radiation oncology setting.

In praise of postgraduate career clinics: Translating health professionals' willingness to engagement

AIM

To capture and retain healthcare staff in postgraduate courses relevant to individual career aspirations, service requirements and continuous practice development (CPD) within an English UK university.

DESIGN

Two virtual career clinics for postgraduate practitioners to engage in CPD offers within the university. An online post-enrolment online survey to explore their experiences of engagement with the university.

METHODS

Mixed: qualitative and quantitative methods. Engaging 10 participants attended the career clinics, and 42 participants with an online survey.

RESULTS

The career clinics were well received by participants who mapped CPD requirements and individual career aspirations. The surveys exposed challenges with marketing and enrolment; however, these were mitigated with support. Four recommendations are presented within this paper applicable to the international postgraduate education of all health practitioners.

Risk Factors for Enteric Pathogen Exposure among Children in Black Belt Region of Alabama, USA

We collected stool from school-age children from 352 households living in the Black Belt region of Alabama, USA, where sanitation infrastructure is lacking. We used quantitative reverse transcription PCR to measure key pathogens in stool that may be associated with water and sanitation, as an indicator of exposure. We detected genes associated with > 1 targets in 26% of specimens, most frequently Clostridioides difficile (6.6%), atypical enteropathogenic Escherichia coli (6.1%), and enteroaggregative E. coli (3.9%). We used generalized estimating equations to assess reported risk factors for detecting > 1 pathogen in stool. We found no association between lack of sanitation and pathogen detection (adjusted risk ratio 0.95 [95% CI 0.55–1.7]) compared with specimens from children served by sewerage. However, we did observe an increased risk for pathogen detection among children living in homes with well water (adjusted risk ratio 1.7 [95% CI 1.1–2.5]) over those reporting water utility service.

Cross-Sectional Study of Soil-Transmitted Helminthiases in Black Belt Region of Alabama, USA

We conducted a cross-sectional study to determine the prevalence of soil-transmitted helminthiases (STH) in areas of rural Alabama, USA, that have sanitation deficits. We enrolled 777 children; 704 submitted stool specimens and 227 a dried blood spot sample. We microscopically examined stool specimens from all 704 children by using Mini-FLOTAC for helminth eggs. We tested a subset by using molecular techniques: real-time PCR analysis for 5 STH species, TaqMan Array Cards for enteric helminths, and digital PCR for Necator americanus hookworm. We analyzed dried blood spots for Strongyloides stercoralis and Toxocara spp. roundworms by using serologic testing. Despite 12% of our cohort reporting living in homes that directly discharge untreated domestic wastewater, stool testing for STH was negative; however, 5% of dried blood spots were positive for Toxocara spp. roundworms. Survey data suggests substantial numbers of children in this region may be exposed to raw sewage, which is itself a major public health concern.

Impact of Severe Acute Respiratory Syndrome Coronavirus 2 Variants on Short- and Mid-term Cardiac Outcomes in Multisystem Inflammatory Syndrome in Children

Cardiac outcomes of 131 children with multisystem inflammatory syndrome (MIS-C) were examined. The majority of the cohort was male (66.4%) and half were Black (49.6%). Cardiac involvement was evident in 25% of the cohort at diagnosis. Favorable short- and mid-term outcomes were documented on follow-up, irrespective of the severe acute respiratory syndrome coronavirus 2 variants causing the infection.

246. Cardiac involvement in children with multisystem inflammatory syndrome (MIS-C) following infection with different SARS-CoV-2 variants

Background

MIS-C is a hyper inflammatory condition following SARS-CoV-2 infection. Although COVID-19 infection rates and severity have varied based on circulating SARS-CoV-2 variants, it is unclear if cardiac involvement in MIS-C varies following infection with different SARS-CoV-2 variants. The objective of this study is to describe the severity of cardiac involvement in children with MIS-C following three different waves of SARS-CoV-2 infections.

Methods

Children hospitalized with a diagnosis of MIS-C were enrolled in a prospective observational study. Demographic, clinical, laboratory (troponin I and B-type natriuretic peptide (BNP)), electrocardiogram (EKG) and echocardiogram (ECHO) data for children diagnosed between 4/20 and 12/21 and followed at 1- and 6-months was analyzed. The cohort was divided into 3 groups to represent cases that followed infection with the Wuhan (4/20-10/20, group 1), Alpha (B.1.1.7, 11/20-7/21, group 2) and Delta (B.1. 617.2, 8/21-12/21, group 3) variants. Cardiac involvement during hospitalization and follow-up was compared between the groups.

Results

The cohort includes 131 children with MIS-C (32, 61 and 38 in groups 1, 2 and 3, respectively) with a median age of 10 years. Two-thirds were male (66.4%) and 49.6% were Black. Elevated BNP and troponin I levels were seen in 82% and 52.7% of children at initial diagnosis. A third of the cohort had at least one abnormal EKG finding. The proportion of children with abnormal laboratory and EKG findings was not different between the groups. Decreased left ventricular function on ECHO was seen in 25% (33/131) of the cohort with similar distribution among the three groups (p = 0.79). Trivial-small pericardial effusions were detected in 22% (29/131). Coronary artery abnormalities were detected in 11.45% (15/131), a majority in group 1 (25%; 8/32). At 1- and 6-monthfollow-up visits, BNP and Troponin I were normal in all children. At the 6-month follow-up visit, EKG was normal in all and ECHO was normal in 37/41 children with trivial to mild valvular regurgitation in four children.

Conclusion

In this single center prospective study, while a significant proportion of children with MIS-C had evidence of cardiac involvement at diagnosis, most resolved on follow-up demonstrating good outcomes.

Disclosures

Claudette Poole, MD, Therapy Brands: Stocks/Bonds Scott H. James, MD, Bayer: Advisor/Consultant|Pantheon Biosciences: Grant/Research Support Suresh Boppana, MD, Merck, Inc: Advisor/Consultant|Merck, Inc: Grant/Research Support|Pfizer: Grant/Research Support.

Is it safe to perform elective orthopaedic surgery with high community rates of COVID-19? An observational cohort study

INTRODUCTION

During the first wave of the COVID-19 pandemic, University Hospitals Birmingham NHS Foundation trust was able to recommence elective orthopaedic surgery using private hospitals procured by the NHS as COVID-19 free 'green' sites. We report on the safety of elective orthopaedic surgery with high rates of community transmission.

METHODS

We conducted an observational cohort study on consecutive NHS patients attending three private hospitals between 4 May 2020 and 16 June 2020. Patients attended preoperative assessment, including coronavirus disease (COVID-19) symptom screening, were instructed to self-isolate for 14 days and had a negative COVID-19 swab within 72 hours of surgery. Patient age, American Society of Anesthesiologists (ASA) grade, body mass index, surgery performed, type of anaesthetic and length of stay were collected. Our primary outcome was a positive COVID-19 swab, secondary outcomes were COVID-19 symptoms, readmission, surgical complications and mortality.

RESULTS

Between 4 May 2020 and 16 June 2020, 191 patients were admitted to three private hospitals for elective surgery; 121 (67%) patients underwent general or regional anaesthetic, 179 patients were ASA grades 1 or 2 (94%) and 12 (6%) were ASA 3. In total, 187 (98%) patients were successfully contacted at 30 days postoperative and no COVID-19 symptoms, positive COVID-19 swabs or mortality or were recorded. One patient was readmitted following a pulmonary embolism and two patients were treated as outpatients for a deep vein thrombosis and a superficial infection.

CONCLUSION

With 'green pathways' elective orthopaedic surgery can safely be performed while rates of COVID-19 in the community are high.

Taking therapeutic apheresis services to patients in South Africa: An eight year review of SANBS mobile therapeutic apheresis service, 2013-2020

INTRODUCTION

A 20 year review of health and health care presents the multiple challenges faced by South Africans. Health and poverty is highlighted with 45% of population living on approximately US$ 2 per day and 10 million living on less than US$ 1 per day. Widening disparities in health care provision between public and private sector hospital services exist. The South African population includes the largest number of people living with HIV infection/AIDS of any country in the world, with a 70% estimate of 7.5 million people living with HIV on antiretroviral therapy. The South African National Blood Service provides a mixed model therapeutic apheresis service including mobile service and fixed-site therapeutic apheresis and an apheresis collection of hematopoietic stem cell (HPC-A) service. Therapeutic apheresis modalities offered by SANBS include plasmapheresis, red cell exchange, leukocyte and platelet reduction. In addition, collection of plasma, thrombocytes, mononuclear cells including CD34+ cells (HPCs) and granulocytes by apheresis for plasma and cellular therapies, and customised apheresis products for research purposes is offered. An operational database for the period 2013 to 2020 was reviewed to characterise the SANBS's mixed therapeutic apheresis service and HPC-A service from 2013 to 2020 in terms of patient numbers, patient demographics, patient procedures, therapeutic apheresis indication or diagnosis, therapeutic apheresis modality, hospital service type, and the American Society for Apheresis (ASFA) category of diagnosis.

METHODS

A retrospective review of therapeutic apheresis patients referred to SANBS characterising patient numbers, patient demographics, patient procedures, therapeutic apheresis indication or diagnosis, therapeutic apheresis modality (Linz, 2017), hospital service type, and the ASFA category of diagnosis (Padmanabhan et al., 2019) for the period 01 January 2013 to 31 December 2020 was completed. Data is obtained from a SANBS operational routinely utilised to record patient procedure data. Patient procedure data is manually recorded by apheresis nurses and indexed on to the operational database, with both processes audited. The review period is a convenience sample. Storage of the database and access of the operational database is in compliance with the Protection of Personal Information Act (Government Gazette, 2013). Therapeutic apheresis modalities analysed include Plasmapheresis, Red Cell Exchange, Leukopheresis, Thrombocytapheresis, Lymphocyte collection, Granulocyte collection, Haematopoietic stem cell collection by apheresis and customised apheresis products for research purposes. Customised apheresis products for research purposes is excluded from this review. Descriptive statistics is used.

RESULTS

For the review period, 2,485 unique patients with 120 unique indications as recorded by referring clinicians received 13,518 procedures involving 7 therapeutic apheresis modalities at 78 hospitals (21 public sector and 57 private sector) and at 3 SANBS blood donor centres in 7 provinces of South Africa. The age range of patients serviced is 4 months to 90 years (median = 39.5 years) (figure 1), 91% by procedure count was for patients 21 years of age or older, 62% were female, with 10,783 (79.6%) procedures performed in public sector hospitals. In all patients, the most common indications was plasmapheresis for thrombotic thromobocytopaenic purpura (52.5% of cumulative procedures), HPC-A for multiple myeloma (7.86%) and Antibody-mediated kidney transplant rejection (4.90%). Plasmapheresis was the most common therapeutic apheresis modality used (82.5% of cumulative procedures) followed by HPC-A (13.7%) and leukoreduction (3.39%). A range of indications for plasmapheresis (n = 65) and HPC-A (n = 41) were observed. Red cell exchange procedures was performed for patients with severe malaria and sickle cell disease indications. For leukoreduction indications, all patients were adults managed in public sector facilities and all were symptomatic. The most common indications were Chronic Myelogenous Leukemia, Chronic Lymphocytic Leukaemia and Multiple Myeloma. A pooled, total white cell count average of 457 × 10⁹/L (range 141-689 × 10⁹/L) prior to first procedure. Despite complex challenges for a national mixed model service, successful patient outcomes in emergent indications such as TTP (Louw et al., 2018; Swart et al., 2019) and engraftment post HPC-A in HSCT in multiple centres (Glatt, personal communication) are reported.

CONCLUSION

The review confirms that apheresis medicine is increasingly used in South Africa in patients in both public and private sector, with the most common modalities being plasmapheresis, HPC-A and leukoreduction. Patients with HIV-associated TTP is the most commonly referred patient in both paediatric and adult patients and this is anticipated to continue. A growing HSCT transplant network capacity in South Africa is augmented through the mixed model mobile and fixed-site therapeutic apheresis services, including a mobile HPC-A service. The increasing number of HPC-A is a trend towards increasing numbers of patients support to HSCT for both adults and paediatric patients in private and public sector hospitals.

Virological Characteristics of Hospitalized Children With SARS-CoV-2 Infection

BACKGROUND AND OBJECTIVES

In children with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, virological characteristics and correlation with disease severity have not been extensively studied. The primary objective in this study is to determine the correlation between SARS-CoV-2 viral load (VL) in infected children with age, disease severity, and underlying comorbidities.

METHODS

Children <21 years, screened for SARS-CoV-2 at the time of hospitalization, who tested positive by polymerase chain reaction were included in this study. VL at different sites was determined and compared between groups.

RESULTS

Of the 102 children included in this study, 44% of the cohort had asymptomatic infection, and children with >1 comorbidity were the most at risk for severe disease. VL in children with symptomatic infection was significantly higher than in children with asymptomatic infection (3.0 × 105 vs 7.2 × 103 copies per mL; P = .001). VL in the respiratory tract was significantly higher in children <1 year, compared with older children (3.3 × 107 vs 1.3 × 104 copies per mL respectively; P < .0001), despite most infants presenting with milder illness. Besides the respiratory tract, SARS-CoV-2 RNA was also detectable in samples from the gastrointestinal tract (saliva and rectum) and blood. In 13 children for whom data on duration of polymerase chain reaction positivity was available, 12 of 13 tested positive 2 weeks after initial diagnosis, and 6 of 13 continued to test positive 4 weeks after initial diagnosis.

CONCLUSIONS

In hospitalized children with SARS-CoV-2, those with >1 comorbid condition experienced severe disease. SARS-CoV-2 VL in the respiratory tract is significantly higher in children with symptomatic disease and children <1 year of age.

Management of Cepacia Syndrome With a Combination of Intravenous and Inhaled Antimicrobials in a Non-Cystic Fibrosis Pediatric Patient

Burkholderia cepacia complex (Bcc) is an opportunistic pathogen, posing little risk to healthy individuals. The presentation of Bcc can vary from a virtually asymptomatic chronic infection, to an acute, life-threatening necrotizing pneumonia, acute respiratory distress syndrome, and bacteremia (cepacia syndrome) associated with a mortality rate up to 75%. We present the successful treatment of a 17-year-old male with chronic granulomatous disorder who presented with cepacia syndrome and confirmed Bcc pneumonia using a novel antimicrobial approach. Despite initial IV antimicrobial therapy, our patient continued to decline, developing hypotension requiring pressor support and eventually extracorporeal membrane oxygenation. An aggressive, multimechanistic approach including the combination of nebulized tobramycin, IV sulfamethoxazole-trimethoprim, ceftazidime, enteral minocycline, and corticosteroids was implemented. This multimechanistic antimicrobial approach in combination with systemic corticosteroids led to the successful treatment of cepacia syndrome in the setting of necrotizing pneumonia due to B cepacia with full respiratory recovery. We suggest that in patients with cepacia syndrome who continue to decline despite IV antimicrobial therapy, using multiple antimicrobial mechanisms of action may improve clinical outcomes.

Strategies to Improve Recruitment to a De-escalation Trial: A Mixed-Methods Study of the OPTIMA Prelim Trial in Early Breast Cancer

AIMS

De-escalation trials are challenging and sometimes may fail due to poor recruitment. The OPTIMA Prelim randomised controlled trial (ISRCTN42400492) randomised patients with early stage breast cancer to chemotherapy versus 'test-directed' chemotherapy, with a possible outcome of no chemotherapy, which could confer less treatment relative to routine practice. Despite encountering challenges, OPTIMA Prelim reached its recruitment target ahead of schedule. This study reports the root causes of recruitment challenges and the strategies used to successfully overcome them.

MATERIALS AND METHODS

A mixed-methods recruitment intervention (QuinteT Recruitment Intervention) was used to investigate the recruitment difficulties and feedback findings to inform interventions and optimise ongoing recruitment. Quantitative site-level recruitment data, audio-recorded recruitment appointments (n = 46), qualitative interviews (n = 22) with trialists/recruiting staff (oncologists/nurses) and patient-facing documentation were analysed using descriptive, thematic and conversation analyses. Findings were triangulated to inform a 'plan of action' to optimise recruitment.

RESULTS

Despite best intentions, oncologists' routine practices complicated recruitment. Discomfort about deviating from the usual practice of recommending chemotherapy according to tumour clinicopathological features meant that not all eligible patients were approached. Audio-recorded recruitment appointments revealed how routine practices undermined recruitment. A tendency to justify chemotherapy provision before presenting the randomised controlled trial and subtly indicating that chemotherapy would be more/less beneficial undermined equipoise and made it difficult for patients to engage with OPTIMA Prelim. To tackle these challenges, individual and group recruiter feedback focussed on communication issues and vignettes of eligible patients were discussed to address discomforts around approaching patients. 'Tips' documents concerning structuring discussions and conveying equipoise were disseminated across sites, together with revisions to the Patient Information Sheet.

CONCLUSIONS

This is the first study illuminating the tension between oncologists' routine practices and recruitment to de-escalation trials. Although time and resources are required, these challenges can be addressed through specific feedback and training as the trial is underway.

Challenges and impact of patient obesity in radiation therapy practice

INTRODUCTION

The prevalence of obesity is rapidly increasing globally and has tripled between 1975 and 2016. Obesity is reported within the literature as having a significant impact on medical practice, professionals, imaging departments and healthcare systems. It is not known how this epidemic will impact radiation therapists' working environment and practice. The aim of this study is to explore the perceived challenges and impacts of patient obesity on radiation therapy practice from the perception of radiation therapists.

METHODS

All radiation therapists working in the Republic of Ireland were invited to participate. Two focus groups were conducted with 6 and 7 participants respectively. A seven staged method of analysis, using a computerised long table approach was developed and used to analyse the data and create themes related to radiation therapists' perception of managing obese patients.

RESULTS

Perceived challenges from the radiation therapists were difficulties; (1) Setting up the patient (2) Imaging (3) communication and emotional impact.

CONCLUSION

An array of concerns were raised during this research about the increase and impact of obese patients on radiation therapists working environment. This study suggests that obese patients can present additional challenges to radiation therapists' current work practices. It is imperative that we recognise the additional challenges this patient cohort add to daily workflow. Further research is needed to identify the common key issues and how to manage this specific patient group.

IMPLICATIONS FOR PRACTICE

At the moment there are no specific management strategies/policies in place for managing obese patients; this study suggests that it is something we need to consider implementing as standard in radiation therapy departments.

Association among pasture-level variables and dairy cow responses to supplements

In grazing systems, the marginal milk-production response to additional feed (i.e. supplement) is dependent on the relative feed deficit of the cow. We hypothesised that the relative feed deficit could be defined by post-grazing residual (PGR), with a greater PGR indicating a smaller relative feed deficit. The objective of our study, therefore, was to determine the relationship between post-grazing residual and the marginal milk-production response to supplements. We undertook a computerised literature search utilising keywords associated with grazing systems and supplementary feed. We collated data from 26 experiments and 90 treatments, wherein pasture-level, supplementary-feed, and milk-production variables were reported. A meta-analysis was undertaken using random coefficient regression fitted as a mixed model to determine the marginal milk-production response to supplements. On average, pasture DM intake declined (P &lt; 0.001; –0.28 kg/kg supplement DM) and milk, fat and protein yields increased (P &lt; 0.001; 0.64 kg, 20 g and 30 g/kg supplement DM respectively) with an increased supplement use. For every kilogram of DM supplement consumed, PGR pasture height and mass increased by 1.4 mm and 42 kg DM/ha. Associated with every 10-mm increase in post-grazing pasture height in the control treatment, marginal milk response declined (P &lt; 0.05) by 9%. These results will enable farmers to use the change in PGR when feeding supplements, to estimate likely marginal milk-production response to supplementary feeds.

Quench, Normal Zone Propagation Velocity, and the Development of an Active Protection Scheme for a Conduction Cooled, R&W, MgB2 MRI Coil Segment

The development of coils that can survive a quench is crucial for demonstrating the viability of MgB₂-based main magnet coils used in MRI systems. Here we have studied the performance and quench properties of a large (outer diameter: 901 mm; winding pack: 44 mm thick × 50.6 mm high) conduction-cooled, react-and-wind (R&W), MgB₂ superconducting coil. Minimum quench energy (MQE) values were measured at several coil operating currents (I _op ), and distinguished from the minimum energy needed to generate a normal zone (MGE). During these measurements, normal zone propagation velocities (NZPV) were also determined using multiple voltage taps placed around the heater zone. The conduction cooled coil obtained a critical current (I _c ) of 186 A at 15 K. As the operating currents (I _op ) varied from 80 A to 175 A, MQE ranged from 152 J to 10 J, and NZPV increased from 1.3 to 5.5 cm/s. Two kinds of heater were involved in this study: (1) a localized heater ("test heater") used to initiate the quench, and (2) a larger "protection heater" used to protect the coil by distributing the normal zone after a quench was detected. The protection heater was placed on the outside surface of the coil winding. The test heater was also placed on the outside surface of the coil at a small opening made in the protection heater. As part of this work, we also developed and tested an active protection scheme for the coil. Such active protection schemes are of great interest for MgB₂-based MRIs because they permit exploitation of the relatively large MQE values of MgB₂ to enable the use of higher J _e values which in turn lead to competitive MgB₂ MRI designs. Finally, the ability to use a quench detection voltage to fire a protection heater as part of an active protection scheme was also demonstrated.

Towards the future of blood transfusion - the South African National Blood Service's perspectives on cellular therapeutic services and products

Blood transfusion services are the cornerstone of the healthcare delivery system, and need to stay abreast of advances in technology to ensure relevance to the needs of the country. In this review, we examine the current status of blood transfusion systems and discuss their possible future role in cellular therapies.

Weyl Consistency Conditions and γ_{5}

The treatment of γ_{5} in dimensional regularization leads to ambiguities in field-theoretic calculations, of which one example is the coefficient of a particular term in the four-loop gauge beta functions of the standard model. Using Weyl consistency conditions, we present a scheme-independent relation between the coefficient of this term and a corresponding term in the three-loop Yukawa beta functions, where a semi-naïve treatment of γ_{5} is sufficient, thereby fixing this ambiguity. We briefly outline an argument by which the same method fixes similar ambiguities at higher orders.

Pathogenesis of Non-Zika Congenital Viral Infections

A widespread epidemic of Zika virus (ZIKV) infection was reported in 2015 from South and Central America and the Caribbean. Although the full spectrum of ZIKV infection of the newborn has yet to be determined, other maternal viral infections resulting in transmission to the fetus provide instructive lessons that can be applied to the prospective evaluation of individuals with ZIKV infection. This review focuses on those other congenital infections, including rubella, congenital cytomegalovirus, human immunodeficiency virus, hepatitis B virus, and neonatal herpes simplex virus, from which lessons for the evaluation of ZIKV in the newborn can be applied.

A nationwide investigation of radiation therapy event reporting-and-learning systems: Can standards be improved?

INTRODUCTION

Variation exists between event reporting-and-learning systems utilised in radiation therapy. Due to the impact of errors associated with this field of medicine, evidence-based and rigorous systems are imperative. The implementation of such systems facilitates the reactive enhancement of patient safety following an event. The purpose of this study was to evaluate Irish event reporting-and-learning procedures against the current literature using a developed evidence-based process map, and to propose recommendations as to how the national standard could be improved.

METHODS

Radiation Therapy Service Managers of all Irish radiation therapy institutions (n = 12) were invited to participate in an anonymous online questionnaire. Included in the questionnaire was a reporting-and-learning process map developed from evidence-based literature, which was used to assess the institution's practice through the use of vignettes. Frequency analysis of closed-ended questions and thematic analysis of open-ended questions was performed to assess the data.

RESULTS

A 91.7% response rate was achieved. The following areas were found to have the most variation with the evidence-based process map: event classification, external reporting, and dissemination of lessons-learned to a wider audience. Recommendations to standardise practice were made.

CONCLUSION

Opportunities for improvement exist within event reporting-and-learning systems of Irish radiation therapy institutions and recommendations have been made on these. These findings can provide learning for other countries with similar reporting systems.

Characterization of the Development of Acute-on-Chronic Exertional Compartment Syndrome A Case Report of Symmetric Compartment Syndromes and Review of the Literature

Acute-on-chronic exertional compartment syndrome is a rare and severe progression of the likely common and more benign chronic exertional compartment syndrome. This is a report of one 17-year-old male on a pediatric inpatient service with bilateral anterior leg pain of unknown origin. Because of the nonspecific nature of pain, a high level of suspicion is required for timely diagnosis to avoid compartment ischemia and irreversible soft tissue and nerve damage. While high-energy orthopaedic trauma, orthopaedic surgery, or closed reduction and casting are common preceding events for compartment syndrome, this patient presented with acute-on-chronic exertional compartment syndrome. A dearth of literature of this condition hampered its morbiditysparing diagnosis. While there is a spectrum of clinical findings for the acute decompensation of chronic exertional compartment syndrome, like any compartment syndrome, pain disproportionate to physical exam is the most sensitive sign. Understanding the exertional compartment syndrome spectrum is tantamount to avoid the devastating complications of a missed diagnosis of acute compartment syndrome.

Directed Acyclic Graphs for Oral Disease Research

Directed acyclic graphs (DAGs) are nonparametric graphical tools used to depict causal relations in the epidemiologic assessment of exposure-outcome associations. Although their use in dental research was first advocated in 2002, DAGs have yet to be widely adopted in this field. DAGs help identify threats to causal inference such as confounders, bias due to subject selection, and inappropriate handling of missing data. DAGs can also inform the data analysis strategy based on relations among variables depicted on it. This article uses the example of a study of temporomandibular disorders (TMDs), investigating causal effects of facial injury on subsequent risk of TMD. We illustrate how DAGs can be used to identify 1) potential confounders, 2) mediators and the consequences of attempt to estimate direct causal effects, 3) colliders and the consequences of conditioning on colliders, and 4) variables that are simultaneously mediators and confounders and the consequences of adjustment for such variables. For example, one DAG shows that statistical adjustment for the pressure pain threshold would necessarily bias the causal relation between facial injury and TMD. Finally, we discuss the usefulness of DAGs during study design, subject selection, and choosing variables to be measured in a study.

Abstract PD2-02: NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early breast cancer

COX2 has been implicated in breast tumorigenesis, tumour proliferation & invasion. The role of COX2 in carcinogenesis is thought to be related to its abilities to increase production of prostaglandins, convert pro-carcinogens to carcinogens, inhibit apoptosis, promote angiogenesis, modulate inflammation & immune function & increase tumour cell invasiveness. COX2 inhibition may synergise with aromatase inhibition in controlling endocrine responsive breast cancer. The COX2 product prostaglandin E2 (PGE2) & cytokines such as interleukin-6 (IL6) can up regulate aromatase expression suggesting that aromatase inhibition may be more effective in combination with a COX2 inhibitor. There may be additional COX2 mediated anticancer activity. The hypothesis addressed is that activity of aromatase inhibitors(AI) as neoadjuvant endocrine therapy for early breast cancer may be enhanced by the addition of a COX2 inhibitor.

TRIAL OBJECTIVES

To determine whether the activity of AIs as neo-adjuvant endocrine therapy for ER positive breast cancer in postmenopausal women may be enhanced by the addition of the selective COX2 inhibitor celecoxib.

TRIAL DESIGN

Prospective phase III multicentre randomised trial. Patients were randomised to receive 16 weeks of exemestane 25 mg daily or letrozole 2.5 mg daily (open label) and celecoxib 400 mg twice daily or matched placebo (double blinded). Translational research tumour samples were collected before, during & after therapy.

KEY ELIGIBILITY CRITERIA

Post menopausal, ER positive, invasive cancer, 2cms or greater with calipers & visible on USS.

PRIMARY OUTCOME MEASURE

Objective clinical response to neoadjuvant treatment by RECIST criteria.

RESULTS

Primary Outcome; Response to treatment has been calculated for 266 patients (Table 1). Response rate was 73% in the celecoxib arm & 55% in the placebo arm (p=0.0022). The response rates 4 arm comparison are shown in Table 2. After adjustment for AI effect the significant difference in response rates remained (p=0.0023); the difference in response rates was greater in the exemestane treated group (29%) compared to the letrozole group (7%) although heterogeneity between AI arms was statistically non-significant (p=0.06).

Table 1 Primary Outcome Results: response ratesOUTCOMEPLACEBO N (%)CELECOXIB N (%)TOTAL N (%)X2statisticP-valueRESPONSE73(55)97(73%)170 (64%)9.38820.0022NO RESPONSE60 (45%)36 (27%)96 (36%)  TOTAL133133266  

Table 2: Response Rates 4 Arm Comparison EXEMESTANELETROZOLERESPONSEPLACEBO n(%)CELECOXIB n(%)TOTAL n(%)PLACEBO n(%)CELECOXIB n(%)TOTAL n(%)RESPONSE33 (49)52(78)85(63)40(61)45(68)85(64)NO RESPONSE34(51)15(22)49(37)26(39)21(32)47(36)TOTAL67671346666132

Secondary outcome; There was an USS response rate of 42% v 37% for celecoxib & placebo arms respectively (p=0.2513)

CONCLUSION

The addition of the COX2 inhibitor celecoxib to an AI significantly & substantially increased the clinical response from 55% to 73%. Effect on tumour size assessed with USS is less marked with a non-significant increase in responses from 37% to 42%.

This work was supported by CRUK: CRUK/06/005 and Pfizer.

Citation Format: Rea D, Francis A, Poole C, Brookes C, Stein R, Bartlett J, Dunn J, Canney P, Sutton R, Daoud R, Hallissey M, Achuthan R, Grant M, Babrah J, Smith S, Fraser J, Desai A, Al Dubaisi M, Patel A, Bristol J, Chandrasekharan S, Prest C, Jewkes A. NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD2-02.

A survey of etiologic hypotheses among testicular cancer researchers

Basic research results can provide new ideas and hypotheses to be examined in epidemiological studies. We conducted a survey among testicular cancer researchers on hypotheses concerning the etiology of this malignancy. All researchers on the mailing list of Copenhagen Testis Cancer Workshops and corresponding authors of PubMed-indexed articles identified by the search term 'testicular cancer' and published within 10 years (in total 2750 recipients) were invited to respond to an e-mail-based survey. Participants of the 8th Copenhagen Testis Cancer Workshop in May 2014 were subsequently asked to rate the plausibility of the suggested etiologic hypotheses on a scale of 1 (very implausible) to 10 (very plausible). This report describes the methodology of the survey, the score distributions by individual hypotheses, hypothesis group, and the participants' major research fields, and discuss the hypotheses that scored as most plausible. We also present plans for improving the survey that may be repeated at a next international meeting of experts in testicular cancer. Overall 52 of 99 (53%) registered participants of the 8th Copenhagen Testis Cancer Workshop submitted the plausibility rating form. Fourteen of 27 hypotheses were related to exposures during pregnancy. Hypotheses with the highest mean plausibility ratings were either related to pre-natal exposures or exposures that might have an effect during pregnancy and in post-natal life. The results of the survey may be helpful for triggering more specific etiologic hypotheses that include factors related to endocrine disruption, DNA damage, inflammation, and nutrition during pregnancy. The survey results may stimulate a multidisciplinary discussion about new etiologic hypotheses of testicular cancer.

Prevalence of human papillomavirus among oesophageal squamous cell carcinoma cases: systematic review and meta-analysis

Background:

Oncogenic human papillomavirus (HPV) has been hypothesised as a risk factor for oesophageal squamous cell carcinoma (OSCC), but aetiological research has been limited by the varying methodology used for establishing HPV prevalence. The aims of this systematic review and meta-analysis were to estimate the prevalence of HPV DNA detected in OSCC tumours and the influence of study characteristics.

Methods:

Study-level estimates of overall and type-specific HPV prevalence were meta-analysed to obtain random-effects summary estimates.

Results:

This analysis included 124 studies with a total of 13 832 OSCC cases. The average HPV prevalence (95% confidence interval) among OSCC cases was 0.277 (0.234, 0.320) by polymerase chain reaction; 0.243 (0.159, 0.326) by in situ hybridisation; 0.304 (0.185, 0.423) by immunohistochemistry; 0.322 (0.154, 0.490) by L1 serology; and 0.176 (0.061, 0.292) by Southern/slot/dot blot. The highest HPV prevalence was found in Africa and Asia, notably among Chinese studies from provinces with high OSCC incidence rates.

Conclusions:

Future research should focus on quantifying HPV in OSCC cases using strict quality control measures, as well as determining the association between HPV and OSCC incidence by conducting large, population-based case–control studies. Such studies will provide a richer understanding of the role of HPV in OSCC aetiology.

Nocturnal Anxiety in a Youth with Rapid-onset Obesity, Hypothalamic Dysfunction, Hypoventilation, and Autonomic Dysregulation (ROHHAD)

OBJECTIVE

Behavioral and psychiatric disorders are common in youth with rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD). We outline a rational approach to psychiatric treatment of a patient with a complex medical condition.

METHODS

We report the course of symptoms in a teen with ROHHAD, the inpatient treatment, and review current evidence for use of psychopharmacologic agents in youth with sleep and anxiety disturbances.

RESULTS

A 14-year-old female began rapidly gaining weight as a preschooler, developed hormonal imbalance, and mixed sleep apnea. Consultation was requested after a month of ROHHAD exacerbation, with severe anxiety, insomnia, and auditory hallucinations. Olanzapine and citalopram were helpful in controlling the symptoms. Following discharge, the patient gained weight and olanzapine was discontinued. Lorazepam was started in coordination with pulmonary service. Relevant pharmacologic considerations included risk of respiratory suppression, history of paradoxical reaction to hypnotics, hepatic isoenzyme interactions and side effects of antipsychotics.

CONCLUSIONS

Core symptoms of ROHHAD may precipitate psychiatric disorders. A systematic evidence-based approach to psychopharmacology is necessary in the setting of psychiatric consultation.

Selecting breast cancer patients for chemotherapy: the opening of the UK OPTIMA trial

The mortality from breast cancer has improved steadily over the past two decades, in part because of the increased use of more effective adjuvant therapies. Thousands of women are routinely treated with intensive chemotherapy, which can be unpleasant, is expensive and is occasionally hazardous. Oncologists have long known that some of these women may not need treatment, either because they have a low risk of relapse or because they have tumour biology that makes them less sensitive to chemotherapy and more suitable for early adjuvant endocrine therapy. There is an urgent need to improve patient selection so that chemotherapy is restricted to those patients who will benefit from it. Here we review the emerging technologies that are available for improving patient selection for chemotherapy. We describe the OPTIMA trial, which has just opened to recruitment in the UK, is the latest addition to trials in this area, and is the first to focus on the relative cost-effectiveness of alternate predictive assays.

The cost-effectiveness of adjuvant chemotherapy for early breast cancer: A comparison of no chemotherapy and first, second, and third generation regimens for patients with differing prognoses

BACKGROUND

The risk of recurrence following surgery in women with early breast cancer varies, depending upon prognostic factors. Adjuvant chemotherapy reduces this risk; however, increasingly effective regimens are associated with higher costs and toxicity profiles, making it likely that different regimens may be cost-effective for women with differing prognoses. To investigate this we performed a cost-effectiveness analysis of four treatment strategies: (1) no chemotherapy, (2) chemotherapy using cyclophosphamide, methotrexate, and fluorouracil (CMF) (a first generation regimen), (3) chemotherapy using Epirubicin-CMF (E-CMF) or fluorouracil, epirubicin, and cyclophosphamide (FEC60) (a second generation regimens), and (4) chemotherapy with FEC60 followed by docetaxel (FEC-D) (a third generation regimen). These adjuvant chemotherapy regimens were used in three large UK-led randomised controlled trials (RCTs).

METHODS

A Markov model was used to simulate the natural progression of early breast cancer and the impact of chemotherapy on modifying this process. The probability of a first recurrent event within the model was estimated for women with different prognostic risk profiles using a parametric regression-based survival model incorporating established prognostic factors. Other probabilities, treatment effects, costs and quality of life weights were estimated primarily using data from the three UK-led RCTs, a meta-analysis of all relevant RCTs, and other published literature. The model predicted the lifetime costs, quality adjusted life years (QALYs) and cost-effectiveness of the four strategies for women with differing prognoses. Sensitivity analyses investigated the impact of uncertain parameters and model assumptions.

FINDINGS

For women with an average to high risk of recurrence (based upon prognostic factors and any other adjuvant therapies received), FEC-D appeared most cost-effective assuming a threshold of £20,000 per QALY for the National Health Service (NHS). For younger low risk women, E-CMF/FEC60 tended to be the optimal strategy and, for some older low risk women, the model suggested a policy of no chemotherapy was cost-effective. For no patient group was CMF chemotherapy the preferred option. Sensitivity analyses demonstrated cost-effectiveness results to be particularly sensitive to the treatment effect estimate for FEC-D and the future price of docetaxel.

INTERPRETATION

To our knowledge, this analysis is the first cost-effectiveness comparison of no chemotherapy, and first, second, and third generation adjuvant chemotherapy regimens for early breast cancer patients with differing prognoses. The results demonstrate the potential for different treatment strategies to be cost-effective for different types of patients. These findings may prove useful for policy makers attempting to formulate cost-effective treatment guidelines in the field of early breast cancer.

A phase II trial evaluating two schedules of sagopilone (ZK-EPO), a novel epothilone, in patients with platinum-resistant ovarian cancer

BACKGROUND

Sagopilone, the first fully synthetic epothilone, has shown promising preclinical activity in tumour models. This open-label randomised phase II study investigated two infusion schedules of sagopilone in women with ovarian cancer.

PATIENTS AND METHODS

Women with ovarian cancer recurring within 6 months of end of last platinum-containing treatment received sagopilone 16 mg/m(2) as a 3- or 0.5-h i.v. infusion every 21 days for up to 6 weeks.

RESULTS

Sixty-three patients received sagopilone as a 3-h (n=38) or 0.5-h (n=25) infusion. There were nine confirmed tumour responses [by modified RECIST (n=8) and by Gynecologic Cancer Intergroup CA-125 criteria (n=1)] in 57 patients assessable for efficacy overall [three (13%) with 0.5-h and six (18%) with 3-h infusions]. The 0.5-h arm was closed when it failed to meet its target efficacy. Main drug-related adverse events were peripheral sensory neuropathy (73%; 16% grade 3), nausea (37%; 2% grade 3), fatigue (35%; 3% grade 3) and arthralgia (30%; 5% grade 3). Overall incidence of peripheral sensory neuropathy was similar in both treatment arms, with no grade 4 neuropathy events. No acute allergic infusion reactions were observed.

CONCLUSION

Sagopilone is effective, with balanced tolerability, in patients with recurrent platinum-resistant ovarian cancer.

Abstract P5-10-11: Ongoing Evaluation of Capecitabine-Based Therapy in Early Breast Cancer (EBC)

Background: Capecitabine (C) is an established agent in MBC & is being evaluated in anthracycline/taxane-based adjuvant (adj) & neoadjuvant (neoadj) regimens.

Methods: We summarise available data for C from randomised phase III studies in EBC.

Results: Significant efficacy benefits were reported with two C-based regimens in EBC: recurrence-free survival (RFS) was significantly improved when C was added to an adj regimen in the FinXX trial (3-year RFS: 93% vs 89% control; HR 0.66 [95% CI: 0.47-0.94]; p=0.02) [Lancet Oncol 2009;10:1145-51]. Pathological complete response (pCR) was significantly higher when C was integrated into a standard neoadj regimen in the ABCSG-24 study (24.3% vs 16.0% control; p=0.02) [ECCO-ESMO 2009; Abst 4BA]. Two studies were negative: one adj [Muss et al. NEJM 2009;360:2055-65] & one neoadj [GeparQuattro JCO 2010;2024-31].

D=docetaxel; Cyc=cyclophosphamide; E=epirubicin; F=5-FU; A=doxorubicin; P=paclitaxel; bev=bevacizumab; G=gemcitabine; M=methotrexate; DFS=disease-free survival; EFS=event-free survival

Safety data are available from 3 other adj studies: in the GEICAM trial, ED→C was generally well tolerated and associated with significantly better hair recovery than control (incomplete hair recovery: 28% ECyc→D vs 11% ED→C; p=0.0004); in the GAIN study, haematological toxicities were more common in the E→P→Cyc arm & discontinuations more frequent with ECyc→CP; in the ICE study in pts aged &gt;65 yrs, a low incidence of grade 3/4 AEs was reported with C & significantly higher global QoL scores were attained with C vs control (week 20, p=0.008). Several phase III trials are ongoing (table): US Oncology is conducting a study in high-risk EBC, which will report efficacy data shortly; CIBOMA collaborative group is conducting a trial of C maintenance therapy after adj anthracycline/taxane in triple-negative EBC; the TACT2 study has a 2x2 factorial design in resected/operable EBC; safety data are expected from both studies: MINDACT is an EORTC/collaborative group study in node-negative EBC and compares a 70-gene signature with traditional methods of risk evaluation; pts with high-risk disease receive anthracyclines or CD.

Conclusions: The ongoing evaluation of C in EBC encompasses &gt;20,000 pts. Following initial positive data for C in EBC, further results of these trials are eagerly awaited to define the clinical utility of C-based therapy in this setting.

Duplication of Chromosome 17 CEP Predicts for Anthracycline Benefit: A Meta-Analysis of 4 Trials

ABSTRACT WITHDRAWN: This abstract was withdrawn by the authors prior to the start of the Symposium.

Background: Current evidence for HER2/TOP2A as predictive biomarkers of anthracycline response is conflicting. An interim meta-analysis (Di Leo et al Cancer Res;69:99S SABCS2009) suggested a weak, statistically significant, association between TOP2A and anthracycline benefit. We previously showed duplication of chromosome 17 alpha satellite (CEP17) predicted sensitivity to anthracyclines independently in three trials (BR9601, NEAT and MA.5, Bartlett et al Cancer Res 69:74S/364S). We performed a retrospective meta-analysis, incorporating data from 4 trials (including the Belgium study), to test the hypothesis that CEP17 is a predictive biomarker for anthracycline benefit in order to provide a unifying hypothesis in trials for which previous biomarker data is conflicting.Methods: FISH was performed in 2 labs (Bartlett lab for BR9601/NEAT & Belgian studies & O'Malley lab for MA5). ER/PgR (IHC) etc were collected from trial Case Report Forms. BR9601/NEAT and Belgian study tumors were scored counting all cells with a minimum of one CEP17 signal/cell: in MA.5 a minimum of 2 CEP17 signals were required for cells to be scored. These methodological differences did not affect HER2/CEP17 ratios but necessitated different definitions for CEP17 duplication defined as &gt;1.86 observed copies/cell for BR9601, NEAT and JB (Watters BCRT 2003 77:109-14) and &gt;2.25 for MA.5 (Goetz 2004).Results: FISH was successful in 85% (2531/2975) of cases. CEP17 duplication was detected in 27.5% of tumors (BR9601=37.6%, NEAT=20.0%, MA5=40.2% & JB=28.5%) and was associated with poorer RFS & OS (HR 0.80 95%CI 0.7-0.92 p=0.011 & HR 0.79, 95%CI 0.68-9.92, p=0.018, respectively).A significant treatment*marker interaction was observed in a meta-analysis of all data (2531 cases) as univariate(p&lt;0.005) & multivariate adjusted for treatment, grade, size, ER, nodes CEP17, CEP17*treatment & HER2 and for recurrence free (HR 1.67 95%CI 1.25-2.22, p=0.0006) & overall (1.63 95%CI 1.18-2.25, p=0.003) survival. In the two largest studies, NEAT (n=1462) and MA5 (n=622), this treatment*marker interaction (CEP17) was significant for RFS (p&lt;0.05) in all other analyses non-significant trends for RFS & OS were seen. (Trial specific HRs with 95%CIs RFS: 1.37 (0.56-3.15), 1.77 (1.07-2.90), 1.62 (1.02-2.58) & 1.69 (0.43-6.68), OS: 1.35 (0.54-3.38), 1.64 (0.96-2.80), 1.67 (0.99-2.84) & 2.05 (0.43-9.69); BR9601, NEAT, MA5 & Belgian respectively) analyses.Conclusions: Combined meta-analysis of 4 adjuvant trials demonstrated a highly significant treatment by marker effect for CEP17 duplication as a predictor of benefit from anthracyclines for both RFS in both univariate and multivariate regression analyses. HER2 (all 4 trials) and TOP2A (NEAT/BR9601) did not show any significant interactions. CEP17 duplication may reflect either chromosomal instability or polyploidy and further analysis is warranted to explore the underlying mechanisms for this effect. CEP17 is readily assessed in ISH analysis of HER2 status and may represent a clinically useful biomarker for selection of patients likely to benefit from anthracycline containing chemotherapies.

Design and statistical analysis of oral medicine studies: common pitfalls

A growing number of articles are emerging in the medical and statistics literature that describe epidemiologic and statistical flaws of research studies. Many examples of these deficiencies are encountered in the oral, craniofacial, and dental literature. However, only a handful of methodologic articles have been published in the oral literature warning investigators of potential errors that may arise early in the study and that can irreparably bias the final results. In this study, we briefly review some of the most common pitfalls that our team of epidemiologists and statisticians has identified during the review of submitted or published manuscripts and research grant applications. We use practical examples from the oral medicine and dental literature to illustrate potential shortcomings in the design and analysis of research studies, and how these deficiencies may affect the results and their interpretation. A good study design is essential, because errors in the analysis can be corrected if the design was sound, but flaws in study design can lead to data that are not salvageable. We recommend consultation with an epidemiologist or a statistician during the planning phase of a research study to optimize study efficiency, minimize potential sources of bias, and document the analytic plan.

Modelling the cost-effectiveness of first, second and third generation polychemotherapy regimens in women with early breast cancer who have differing prognoses

Abstract #6106

Purpose: To use individual patient data from three sequential large UK randomised trials to facilitate an integrated comparison of the cost-effectiveness of three generations of chemotherapy plus a no treatment option. The ABC trial compared CMF versus no chemo (1991 patients), NEAT trial Epirubicin-CMF versus CMF (2391 patients) and TACT FEC-Docetaxel vs FEC or epi-CMF (4162 patients)&#x2028; Methods: The model estimates lifetime costs and Quality-Adjusted Life Years (QALYs). Model inputs include transition probabilities which are estimated from a longitudinal observational study using parametric survival models incorporating characteristics such as number of positive lymph nodes, ER status, grade and tumour size that allow analyses to be conducted for women with differing baseline prognoses. The effects of each chemotherapy regimen on preventing recurrence are taken from the above UK trials and are assumed to be additive on the log scale to facilitate previously untested comparisons. Costs and utility decrements associated with chemotherapy, its toxicity, and type of recurrent disease, are informed from the trial data and published literature. A secondary analysis is performed by basing the effects of each chemotherapy regimen on published meta-analyses based on individual level data that include RCTs conducted in a range of multi-national settings.&#x2028; Results: For a woman aged 50 years with 1 positive node, grade 2 tumour size 2cm, ECMF is expected to be the most cost-effective regimen. However, the cost-effectiveness of the chemotherapy options varies between women with different risk factors. On the basis of the results of the TACT trial, 3rd generation chemotherapy is not cost-effective, but including evidence of the relative risk of recurrence from non-UK trials, particularly those with ER- and HER2+ phenotype, may alter this conclusion.&#x2028; Indicative lifetime costs and QALYs for a woman aged 50 years, with 1 positive node, grade 2 tumor size 2cm, with and without ER+ are shown:&#x2028; &#x2028; &#x2028; &#x2028; Conclusions: Evaluating the cost-effectiveness of chemotherapy regimens in women with early breast cancer who have differing prognoses is feasible using an integrative synthesis and model. Thought does, however, need to be given to how best present cost-effectiveness results when there are differing levels of baseline risk.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6106.

Proviral position effects: possible probes for genes that suppress transcription

Rous sarcoma virus, an oncogenic avian retrovirus, readily causes morphological transformation of chick cells, but in infected rat cells transformation is rare because proviral transcription is inefficient. This constraint is not due to a lack of positive transcriptional factors, or an excess of negative ones, but reflects the site of proviral integration in rat cell DNA. In most sites the provirus is almost invariably silent, in others it is correspondingly active, whilst in a third category expression fluctuates in concert with transitions in chromatin structure. Transcriptional fluctuations are mediated both by flanking cell DNA in cis and by trans-acting cell genes, suggesting that proviral position effects are sensors for genes that down-regulate transcription, perhaps by determining chromatin configuration. We have tried to identify such genes by gene transfer, karyology and insertional mutagenesis. The variable success of these three approaches indicates that the transcriptional down-regulator(s) need act only transiently. This is consistent with a function that operates in ontogeny or differentiation to down-regulate genes whose silence is then perpetuated by other means. The loss of such functions may predispose to neoplasia.

Characterization and comparison of health-related utility in people with diabetes with various single and multiple vascular complications

AIMS

To characterize and compare health-related utility in a large cohort of patients treated in hospital with diabetes and with single and multiple comorbidities.

METHODS

The study was conducted in Cardiff and the Vale of Glamorgan, UK. Health-related utility was measured using the EQ5D(index), a standardized instrument for measuring health outcome. Patients from the Health Outcomes Data Repository (HODaR) were surveyed by postal questionnaire 6 weeks post discharge for in-patients and during clinics for patients attending as out-patients between January 2002 and July 2005. Patients with diabetes were identified by a previous history of in-patient admission with diabetes or as an out-patient with diabetes recorded as a coexisting diagnosis.

RESULTS

We identified 4502 patients with diabetes. Mean ages were 65.4 and 64.2 years for males and females, respectively. Of these, 2003 (45%) had no recorded vascular complication. Overall, the EQ5D(index) was 0.584 (sd 0.325) for males and 0.533 (sd 0.351) for females. For those without any vascular complications the mean EQ5D(index) was 0.735 (sd 0.288). In a general linear model, the presence of single and multiple complications had a detrimental impact on the EQ5D(index).

CONCLUSION

The results of this study provide an indication of the true impact of diabetes in terms of health-related utility. There was a decrease in the mean EQ5D(index) for those with vascular complications. Economic models of diabetes that have used additive or multiplicative methods to assess utility in individuals with several complications may be unreliable, and direct measurements, such as this, are recommended.