Identification of Genes with Rare Loss of Function Variants Associated with Aggressive Prostate Cancer and Survival

BACKGROUND

Prostate cancer (PrCa) is a substantial cause of mortality among men globally. Rare germline mutations in BRCA2 have been validated robustly as increasing risk of aggressive forms with a poorer prognosis; however, evidence remains less definitive for other genes.

OBJECTIVE

To detect genes associated with PrCa aggressiveness, through a pooled analysis of rare variant sequencing data from six previously reported studies in the UK Genetic Prostate Cancer Study (UKGPCS).

DESIGN, SETTING, AND PARTICIPANTS

We accumulated a cohort of 6805 PrCa cases, in which a set of ten candidate genes had been sequenced in all samples.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We examined the association between rare putative loss of function (pLOF) variants in each gene and aggressive classification (defined as any of death from PrCa, metastatic disease, stage T4, or both stage T3 and Gleason score ≥8). Secondary analyses examined staging phenotypes individually. Cox proportional hazards modelling and Kaplan-Meier survival analyses were used to further examine the relationship between mutation status and survival.

RESULTS AND LIMITATIONS

We observed associations between PrCa aggressiveness and pLOF mutations in ATM, BRCA2, MSH2, and NBN (odds ratio = 2.67-18.9). These four genes and MLH1 were additionally associated with one or more secondary analysis phenotype. Carriers of germline mutations in these genes experienced shorter PrCa-specific survival (hazard ratio = 2.15, 95% confidence interval 1.79-2.59, p = 4 × 10-16) than noncarriers.

CONCLUSIONS

This study provides further support that rare pLOF variants in specific genes are likely to increase aggressive PrCa risk and may help define the panel of informative genes for screening and treatment considerations.

PATIENT SUMMARY

By combining data from several previous studies, we have been able to enhance knowledge regarding genes in which inherited mutations would be expected to increase the risk of more aggressive PrCa. This may, in the future, aid in the identification of men at an elevated risk of dying from PrCa.

Cognitive decrements in 1991 Gulf War veterans: associations with Gulf War illness and neurotoxicant exposures in the Boston Biorepository, Recruitment, and Integrative Network (BBRAIN) cohorts

BACKGROUND

During deployment, veterans of the 1991 Gulf War (GW) were exposed to multiple war-related toxicants. Roughly a third of these veterans continue to exhibit neurotoxicant induced symptoms of Gulf War Illness (GWI), a multi-faceted condition that includes fatigue, pain and cognitive decrements. When studied empirically, both deployed veterans with exposures and those who meet the criteria for GWI are more likely to show deficits in the area of neuropsychological functioning. Although studies have shown cognitive impairments in small sample sizes, it is necessary to revisit these findings with larger samples and newer cohorts to see if other areas of deficit emerge with more power to detect such differences. A group of researchers and clinicians with expertise in the area of GWI have identified common data elements (CDE) for use in research samples to compare data sets. At the same time, a subgroup of researchers created a new repository to share these cognitive data and biospecimens within the GWI research community.

METHODS

The present study aimed to compare cognitive measures of attention, executive functioning, and verbal memory in a large sample of GWI cases and healthy GW veteran controls using neuropsychological tests recommended in the CDEs. We additionally subdivided samples based on the specific neurotoxicant exposures related to cognitive deficits and compared exposed versus non-exposed veterans regardless of case criteria status. The total sample utilized cognitive testing outcomes from the newly collated Boston, Biorepository, Recruitment, and Integrative Network (BBRAIN) for GWI.

RESULTS

Participants included 411 GW veterans, 312 GWI (cases) and 99 healthy veterans (controls). Veterans with GWI showed significantly poorer attention, executive functioning, learning, and short-and-long term verbal memory than those without GWI. Further, GW veterans with exposures to acetylcholinesterase inhibiting pesticides and nerve gas agents, had worse performance on executive function tasks. Veterans with exposure to oil well fires had worse performance on verbal memory and those with pyridostigmine bromide anti-nerve gas pill exposures had better verbal memory and worse performance on an attention task compared to unexposed veterans.

CONCLUSIONS

This study replicates prior results regarding the utility of the currently recommended CDEs in determining impairments in cognitive functioning in veterans with GWI in a new widely-available repository cohort and provides further evidence of cognitive decrements in GW veterans related to war-related neurotoxicant exposures.

Family History of Prostate Cancer and Survival Outcomes in the UK Genetic Prostate Cancer Study

BACKGROUND

A family history (FH) of prostate cancer (PrCa) is associated with an increased likelihood of PrCa diagnosis. Conflicting evidence exists regarding familial PrCa and clinical outcomes among PrCa patients, including all-cause mortality/overall survival (OS), PrCa-specific survival (PCSS), aggressive histology, and stage at diagnosis.

OBJECTIVE

To determine how the number, degree, and age of a PrCa patient's affected relatives are associated with OS and PCSS of those already diagnosed with PrCa.

DESIGN, SETTING, AND PARTICIPANTS

The UK Genetic Prostate Cancer Study is a longitudinal, multi-institutional, observational study collecting baseline and follow-up clinical data since 1992. We examined OS and PCSS in 16340 men by degree and number of relatives with prostate and genetically related cancers (breast, ovarian, and colorectal).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was all-cause mortality among PrCa patients. The risk of death with respect to FH was assessed by calculating hazard ratios from Cox proportional hazard regression models, adjusting for relevant factors.

RESULTS AND LIMITATIONS

A stronger FH was inversely associated with the risk of all-cause and PrCa-specific mortality. This association was greater in those with an increasing number (p-trend < 0.001) and increasing closeness (p-trend < 0.001) of the diagnosed relatives. Patients with at least one first-degree relative were at a lower risk of all-cause mortality than those with no FH (hazard ratio = 0.82 [95% confidence interval 0.75-0.89]). The population is largely of European ancestry, and this may cause an issue with representation and generalisation. Data are missing on epidemiological risk factors for death such as smoking and on comorbidities. Recall of family members' diagnoses may affect the classification of FH in unconfirmed cases.

CONCLUSIONS

Based on the investigation of the type and timing of relatives' cancers, it is likely that reductions in mortality are due almost completely to a greater awareness of the disease. This study provides information for clinicians guiding patients and their relatives based on their familial risk. It shows the importance of screening and awareness programmes, which are likely to improve survival among men with an FH.

PATIENT SUMMARY

We were interested in how a family history of prostate cancer affects survival in prostate cancer patients. We studied 16340 patients, categorised them according to the strength of their family history, and found that the stronger their family history, the better they did in terms of overall survival. We looked at the type and timing of patients' diagnoses compared with those of their relatives and found that this effect is likely to be explained by awareness, which indicates the importance of screening and awareness programmes.

Boston biorepository, recruitment and integrative network (BBRAIN): A resource for the Gulf War Illness scientific community

AIMS

Gulf War Illness (GWI), a chronic debilitating disorder characterized by fatigue, joint pain, cognitive, gastrointestinal, respiratory, and skin problems, is currently diagnosed by self-reported symptoms. The Boston Biorepository, Recruitment, and Integrative Network (BBRAIN) is the collaborative effort of expert Gulf War Illness (GWI) researchers who are creating objective diagnostic and pathobiological markers and recommend common data elements for GWI research.

MAIN METHODS

BBRAIN is recruiting 300 GWI cases and 200 GW veteran controls for the prospective study. Key data and biological samples from prior GWI studies are being merged and combined into retrospective datasets. They will be made available for data mining by the BBRAIN network and the GWI research community. Prospective questionnaire data include general health and chronic symptoms, demographics, measures of pain, fatigue, medical conditions, deployment and exposure histories. Available repository biospecimens include blood, plasma, serum, saliva, stool, urine, human induced pluripotent stem cells and cerebrospinal fluid.

KEY FINDINGS

To date, multiple datasets have been merged and combined from 15 participating study sites. These data and samples have been collated and an online request form for repository requests as well as recommended common data elements have been created. Data and biospecimen sample requests are reviewed by the BBRAIN steering committee members for approval as they are received.

SIGNIFICANCE

The BBRAIN repository network serves as a much needed resource for GWI researchers to utilize for identification and validation of objective diagnostic and pathobiological markers of the illness.

Impact of left heart disease risk factors on risk stratification and treatment response in pulmonary arterial hypertension

Background

Contemporary registries have documented a change in the epidemiology of PAH patients displaying increasing co-morbidities associated with left heart disease (LHD). These patients are often excluded from randomized clinical trials. It is unclear whether the presence of LHD comorbidities may adversely impact the accuracy of risk stratification and response to PAH therapy.

Method

Data was extracted from the Pulmonary Hypertension Society of Australia and New Zealand registry for incident patients with a diagnosis with idiopathic/heritable/toxin-induced (I/H/D)-PAH and connective tissue disease (CTD) associated PAH from 2011 - 2020. Patients without available medication and follow up data were excluded. We used the AMBITION trial exclusion criteria to define the subpopulation with LHD risk factors and haemodynamic phenotype (PAH-rLHD).

Results

489 patients (I/H/D-PAH=251, CTD-PAH=238) were included in our analysis, with 103 (21.0%) fulfilling the definition of PAH-rLHD (34 had ≥3 risk factors for left heart disease (rLHD-hypertension, diabetes, obesity or ischaemic heart disease) and 76 had borderline haemodynamics (mean capillary wedge pressure 13–15 with pulmonary vascular resistance &lt;500 dynes sec/cm5) including 7 who met both criteria). Compared to classical PAH, patients with PAH-rLHD were older at diagnosis (66±13 vs 58±19, p&lt;0.001), had lower pulmonary vascular resistance (PVR: 393±266 vs 708±391, p=0.031) but worse exercise capacity (6MWD: 286±130m vs 327±136m, p=0.005). PAH-rLHD were more likely to be started on initial monotherapy, compared with “classical” PAH (73% vs 56%, p=0.002). In the monotherapy groups, endothelin receptor antagonists (ERA) were used in 73% PAH-rLHD, compared with 66% in classical PAH group. Both groups exhibited similar response to both mono- and combination therapy with commensurate improvements in WHO functional class (mean change 0.3±0.6 vs 0.3±0.8, p=0.443) and 6-minute walk distance (mean change 44±82 vs 48±101, p=0.723). There was no difference in survival between classical PAH and PAH-rLHD (log rank, p=0.29). The REVEAL 2.0 risk score effectively discriminated risk in both populations at baseline and first follow up (classical PAH: baseline C statistic 0.750, follow up 0.774 and PAH-rLHD: baseline C statistic 0.756, follow up 0.791).

Conclusion

Despite lower PVR at diagnosis, PAH-rLHD patients and “classical” PAH demonstrate similar response to first-line therapy with similar long term survival. The REVEAL 2.0 risk score can be effectively applied to the subpopulation of PAH-rLHD in real life clinical practice.

Funding Acknowledgement

Type of funding sources: None.

UK and Ireland survey of MPharm student and staff experiences of mental health curricula, with a focus on Mental Health First Aid

Background

One in four people experience a mental health problem every year and improving mental health care is an international priority. In the course of their work, pharmacists frequently encounter people with mental health problems. The experience of mental health teaching, including Mental Health First Aid (MHFA) training, in undergraduate pharmacy (MPharm) students in the UK and Ireland is not well documented. Students’ viewpoints, contextualised with curricular overviews provided by staff, were analysed to understand their experience.

Methods

An anonymous, online questionnaire was distributed to MPharm students and staff in the UK and Ireland. Students were asked closed questions regarding their course and exposure to MHFA, which were analysed using descriptive statistics. Open questions were included to enable explanations and these data were used to contextualise the quantitative findings. One member of staff from each university was invited to answer a modified staff version of the questionnaire, to provide a curriculum overview and staff perspective.

Results

232 students and 13 staff, from 22 universities, responded. Three-quarters of students did not agree with the statement that ‘mental health was embedded throughout the MPharm’. Most students (80.6%) stated that they were taught neuropharmacology whilst 44.8% stated that their course included communicating with people about their mental health. One-third (33.2%) of students stated that their degree ‘adequately prepared them to help people with their mental health’. Twenty-six students (11.6%) had completed MHFA training of which 89% would endorse inclusion of this within the MPharm. Of those who had not completed the training, 81% expressed a desire to do so. Those who completed MHFA training self-reported greater preparedness than those who did not, but student numbers were small.

Conclusions

Mental health teaching for pharmacy undergraduates is more focussed on theoretical aspects rather than applied skills. MHFA was viewed by students as one way to enhance skill application. The association of the increased self-reported preparedness of those who completed MHFA could be confounded by a positive environmental cultural. MPharm programmes need sufficient focus on real-world skills such as communication and crisis response, to complement the fundamental science.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40545-021-00364-1.

P–118 A sperm selection technique to mitigate paternal contributions to embryo aneuploidy

Study question

Can microfluidic sperm selection (MFSS) select male gametes without sperm chromatin fragmentation (SCF) and double-stranded DNA breaks (dsDNA) in order to generate euploid conceptuses?

Summary answer

Couples treated by ICSI with MFSS had significantly improved embryo ploidy rates and pregnancy outcomes, demonstrating the efficacy of this novel selection method.

What is known already

SCF has been linked to infertility, specifically to embryo developmental and implantation failure. This damage can be both single-stranded (ssDNA) or double-stranded (dsDNA). Recent studies have shown that dsDNA in particular causes chromosomal aberrations and contributes to embryo aneuploidy, which leads to implantation failure.

Study design, size, duration

Consenting couples treated at our center by intracytoplasmic sperm injection (ICSI) with spermatozoa selected by MFSS were included. The majority of these couples had a medical history significant for elevated SCF, recurrent implantation failure, and embryo aneuploidy. ICSI clinical outcome, as well as preimplantation genetic testing for aneuploidy (PGT-A) and frozen embryo transfer (FET), was recorded and compared to the couples’ historical treatments following sperm selection by density gradient centrifugation (DGC).

Participants/materials, setting, methods

From 2016 to 2020, 51 consenting men had their ejaculates screened for SCF levels by terminal deoxynucleotidyl dUTP transferase nick-end labeling (TUNEL) using a commercially available kit. At least 500 spermatozoa were assessed per patient, with a normal threshold of ≤ 15%.

To screen for dsDNA, neutral Comet using a modified in-house protocol was also performed in a pilot study. At least 200 spermatozoa were assessed per patient, with a normal threshold of ≤ 3%.

Main results and the role of chance

A total of 51 men (average age, 41.0±8 years) had mean sperm concentrations of 39.0±33x106/mL, 38.4±12% motility, and 2.1±1% normal morphology. Following DGC and MFSS, the concentrations were 4.7±8 and 4.3±8x106/mL and the motility was 64.0±33 and 98.0±3%, respectively (P &lt; 0.0001). The average SCF decreased from 20.1±18% in the ejaculate to 16±3% following DGC, but was 2.9±4% after MFSS. The dsDNA fell from 3.4±3% in raw specimens to 2.9±1% after DGC, and to only 0.5±0.7% following MFSS (P &lt; 0.0001).

These men underwent ICSI with their female partners (average age, 37.3±4 years), with sperm selected by DGC; they achieved a fertilization rate of 56.4% (337/597) with 26.0% euploid embryos (36/139). FET cycles from these embryos yielded an implantation rate of 8.3% (2/24) and a clinical pregnancy rate (CPR) of 15.4% (2/13), but both miscarried.

These couples then underwent ICSI with MFSS, with a fertilization rate of 78.0% (588/754; P &lt; 0.0001) and 50.0% (172/344; P &lt; 0.0001) euploid embryos after PGT-A. A total of 37 embryos have been replaced, with an implantation rate of 67.6% (25/37; P &lt; 0.0001) and a CPR of 73.5% (25/34; P &lt; 0.001), with an ongoing/delivery rate of 70.6% (24/34; P &lt; 0.0001).

Limitations, reasons for caution

While the oocyte contribution cannot be discounted, MFSS was able to yield spermatozoa that had the highest motility and ability to produce euploid embryos following ICSI.

Wider implications of the findings: The genome and epigenome of the spermatozoon, and their contribution to reproductive outcomes, are being vigorously explored and scrutinized. Alternative approaches to gamete selection, such as MFSS, in couples with elevated SCF and dsDNA provide the best chances for future pregnancies by mitigating embryo aneuploidy.

Trial registration number

Not applicable

Clozapine prescribing during follow-up of a first-episode psychosis cohort

Introduction

Of those with schizophrenia, one third develop treatment-resistant illness. Nearly 60% of these benefit from clozapine- the only antipsychotic medication licensed in this group.

Objectives

As treatment-resistant illness developed in the follow-up of a first-episode psychosis (FEP) cohort, clozapine was prescribed. This study retrospectively compared the clozapine prescribing patterns, within this cohort, to National Institute for Health and Care Excellence (NICE) guidelines. In addition, impact on hospitalisation, physical health monitoring and augmentation strategies employed following clozapine initiation were examined. Factors delaying initiation of clozapine treatment or contributing to its discontinuation were also explored.

Methods

The study included 339 individuals resident within an Irish community mental health team catchment area, referred with FEP from 1 January 2005 to 31 August 2016. Data were extracted from electronic medical records.

Results

Within the cohort, clozapine was prescribed to 32 individuals (9.4%). The mean number of adequate trials of antipsychotic prior to starting clozapine was 2.74 (SD 1.13; range 1–5). The mean time to clozapine trial was 2.1 years (SD 1.95; range 0.17–6.25). Following initiation of clozapine, mean hospital admissions per year fell from 2.3 to 0.3 (p=0.00). Mean inpatient days pre- and post-clozapine also decreased (147 vs. 53; p=0.00). In all, 18 patients ceased use of clozapine, 5 temporarily and 13 permanently.

Conclusions

Patients are being prescribed clozapine earlier than previously demonstrated. However, delayed treatment remains common, and many patients discontinue clozapine. Further research is necessary to describe and address factors which contribute to its discontinuation.

Disclosure

No significant relationships.

Mental health curricula and Mental Health First Aid in the MPharm

Introduction

Improving mental health care is an international priority, and one that is championed by the Royal Pharmaceutical Society. (1) In the course of their work, pharmacists frequently encounter people with mental health problems. The extent to which mental health is taught on the undergraduate pharmacy degree in the UK and Ireland, and the inclusion of Mental Health First Aid (MHFA) training, has not be described recently.

Aim

We aimed to determine how mental health teaching is embedded into the MPharm and students’ perception of their own preparedness to help people with their mental health. We explored if and how MHFA training is included, and students’ experience of, or desire to complete this.

Methods

We conducted an anonymous, online questionnaire of UK and Ireland MPharm students, distributed via networks and social media. Students were asked a series of closed questions about mental health teaching in the MPharm, and exposure to MHFA. We analysed answers using descriptive statistics. We included some open-ended questions to enable students to expand on their answers. We used this qualitative data to contextualize findings. We invited one member of staff from each university to answer a modified staff version of the questionnaire, in order to provide a curriculum overview and staff perspective on MHFA provision.

Results

232 students and 13 staff responded, from 22 universities in total. Eighty percent of student participants were female and 70% were in the third or final year of study. Three-quarters of students felt that mental health was not embedded throughout the MPharm. Eighty-percent of students stated that they were taught about neuropharmacology and 44.8% stated that their course included communicating with people about their mental health. One third of students felt that their degree adequately prepared them to help people with their mental health. Twenty-six students (11.6%) had completed MHFA training of which 89% would endorse inclusion of this within the MPharm. Of those who had not completed the training, 81% expressed a desire to do so. Those who completed MHFA training self-reported more preparedness than those who did not, but student numbers were small.

Conclusion

Mental health teaching remains focused on theoretical aspects, such as pharmacology, with less emphasis on practical skills, such as communication skills that might support interactions about mental health. MHFA was viewed by students as one way to enhance this. Of the small number of students who had completed MHFA, they displayed an increased self-reported preparedness. This could, however, be linked to the environmental culture of the programme rather than the training per se. MPharm programmes need sufficient focus on skills including communication and crisis response that may be required by pharmacists, alongside the fundamental scientific knowledge relating to mental health.

References

1. Royal Pharmaceutical Society. No health without mental health: How can pharmacy support people with mental health problems? London: RPS; 2018.

Homeobox B13 G84E Mutation and Prostate Cancer Risk

BACKGROUND

The homeobox B13 (HOXB13) G84E mutation has been recommended for use in genetic counselling for prostate cancer (PCa), but the magnitude of PCa risk conferred by this mutation is uncertain.

OBJECTIVE

To obtain precise risk estimates for mutation carriers and information on how these vary by family history and other factors.

DESIGN, SETTING, AND PARTICIPANTS

Two-fold: a systematic review and meta-analysis of published risk estimates, and a kin-cohort study comprising pedigree data on 11983 PCa patients enrolled during 1993-2014 from 189 UK hospitals and who had been genotyped for HOXB13 G84E.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relative and absolute PCa risks. Complex segregation analysis with ascertainment adjustment to derive age-specific risks applicable to the population, and to investigate how these vary by family history and birth cohort.

RESULTS AND LIMITATIONS

A meta-analysis of case-control studies revealed significant heterogeneity between reported relative risks (RRs; range: 0.95-33.0, p<0.001) and differences by case selection (p=0.007). Based on case-control studies unselected for PCa family history, the pooled RR estimate was 3.43 (95% confidence interval [CI] 2.78-4.23). In the kin-cohort study, PCa risk for mutation carriers varied by family history (p<0.001). There was a suggestion that RRs decrease with age, but this was not significant (p=0.068). We found higher RR estimates for men from more recent birth cohorts (p=0.004): 3.09 (95% CI 2.03-4.71) for men born in 1929 or earlier and 5.96 (95% CI 4.01-8.88) for men born in 1930 or later. The absolute PCa risk by age 85 for a male HOXB13 G84E carrier varied from 60% for those with no PCa family history to 98% for those with two relatives diagnosed at young ages, compared with an average risk of 15% for noncarriers. Limitations include the reliance on self-reported cancer family history.

CONCLUSIONS

PCa risks for HOXB13 G84E mutation carriers are heterogeneous. Counselling should not be based on average risk estimates but on age-specific absolute risk estimates tailored to individual mutation carriers' family history and birth cohort.

PATIENT SUMMARY

Men who carry a hereditary mutation in the homeobox B13 (HOXB13) gene have a higher than average risk for developing prostate cancer. In our study, we examined a large number of families of men with prostate cancer recruited across UK hospitals, to assess what other factors may contribute to this risk and to assess whether we could create a precise model to help in predicting a man's prostate cancer risk. We found that the risk of developing prostate cancer in men who carry this genetic mutation is also affected by a family history of prostate cancer and their year of birth. This information can be used to assess more personalised prostate cancer risks to men who carry HOXB13 mutations and hence better counsel them on more personalised risk management options, such as tailoring prostate cancer screening frequency.

A treatment algorithm for couples with unexplained infertility based on sperm chromatin assessment

OBJECTIVE

To design a reproductive treatment algorithm based on the sperm DNA fragmentation (SDF) for couples with unexplained infertility following a poor intrauterine insemination (IUI) outcome.

DESIGN

Couples that failed IUI with no apparent reproductive issue in both partners were allocated to diverse reproductive treatments on the basis of SDF.

SETTING

Reproductive medical center in an academic setting.

PATIENT(S)

Over 4 years, couples with an unexpected poor IUI outcome and no apparent female or male partner reproductive issues were recruited.

INTERVENTION(S)

IUI, IVF, and ICSI were performed in the standard fashion following sperm SDF assays.

MAIN OUTCOMES MEASURE(S)

Fertilization rate, implantation rate, pregnancy characteristics, and delivery rates.

RESULT(S)

A total of 354 couples with unexplained infertility and normal semen parameters underwent 1133 IUI cycles. Clinical pregnancy rate (CPR) with IUI at our center in an age-matched cohort is 23.9% while the study cohort had 1.8%. Following SDF assessment, couples with failed IUI attempts but normal SDF (SCSA 9.8 ± 4.6%; TUNEL 11.8 ± 6.2%) underwent IVF with a CPR of 12.7%; those with abnormal SDF underwent ICSI with ejaculated spermatozoa, resulting in a CPR of 18.7%. This group included couples with normal SDF that had failed IVF. Couples with abnormal SDF that failed ICSI with ejaculated spermatozoa achieved a CPR of 31.0% with surgically retrieved spermatozoa.

CONCLUSION(S)

Couples with unexplained infertility that present with unexpectedly poor IUI outcomes can be funneled into a treatment algorithm guided by the integrity of the sperm genome for higher chances of pregnancy using an alternate method of insemination.

The PROFILE Feasibility Study: Targeted Screening of Men With a Family History of Prostate Cancer

BACKGROUND

A better assessment of individualized prostate cancer (PrCa) risk is needed to improve screening. The use of the prostate-specific antigen (PSA) level for screening in the general population has limitations and is not currently advocated. Approximately 100 common single nucleotide polymorphisms (SNPs) have been identified that are associated with the risk of developing PrCa. The PROFILE pilot study explored the feasibility of using SNP profiling in men with a family history (FH) of PrCa to investigate the probability of detecting PrCa at prostate biopsy (PB). The primary aim of this pilot study was to determine the safety and feasibility of PrCa screening using transrectal ultrasound-guided PB with or without diffusion-weighted magnetic resonance imaging (DW-MRI) in men with a FH. A secondary aim was to evaluate the potential use of SNP profiling as a screening tool in this population.

PATIENTS AND METHODS

A total of 100 men aged 40-69 years with a FH of PrCa underwent PB, regardless of their baseline PSA level. Polygenic risk scores (PRSs) were calculated for each participant using 71 common PrCa susceptibility alleles. We treated the disease outcome at PB as the outcome variable and evaluated its associations with the PRS, PSA level, and DW-MRI findings using univariate logistic regression.

RESULTS

Of the 100 men, 25 were diagnosed with PrCa, of whom 12 (48%) had clinically significant disease. Four adverse events occurred and no deaths. The PSA level and age at study entry were associated with PrCa at PB (p = .00037 and p = .00004, respectively).

CONCLUSION

The results of the present pilot study have demonstrated that PB is a feasible and safe method of PrCa screening in men with a FH, with a high proportion of PrCa identified requiring radical treatment. It is feasible to collect data on PrCa-risk SNPs to evaluate their combined effect as a potential screening tool. A larger prospective study powered to detect statistical associations is in progress.

IMPLICATIONS FOR PRACTICE

Prostate biopsy is a feasible and safe approach to prostate cancer screening in men with a family history and detects a high proportion of prostate cancer that needs radical treatment. Calculating a polygenic risk score using prostate cancer risk single nucleotide polymorphisms could be a potential future screening tool for prostate cancer.

Multi-centre variability of ISCEV standard ERGs in two normal adults

BACKGROUND

The reproducibility of an individual's full-field ERG between centres has not previously been investigated.

METHODS

ERGs were recorded using both silver thread and skin electrodes from the same two normal adult subjects at 15 UK centres using routine, local protocols and a highly standardised, 'ISCEV-specified' protocol matching the values specified in the ISCEV standard; where the ISCEV standard allows options, a single value was chosen.

RESULTS

Inter-ocular differences were small, and amplitudes were smaller for skin than silver thread electrodes. No centre produced outlying data points, and ERGs across all 15 centres were remarkably similar. Amplitude variability was less for local protocols (using LED flashes) than for the ISCEV-specified protocol using xenon flashes (22 vs. 24 %, p = 0.01), but peak time variability was less for the ISCEV-specified protocol (6.1 vs. 7.4 %, p = 0.001). Only the DA 0.01 ERG correlated with photometric variability. The bifidity of the DA 3 a-wave doubled its peak time variability compared with the DA 10 a-wave.

CONCLUSIONS

Inter-centre amplitude variability was typically within clinically significant thresholds, suggesting that inter-centre variability with suitable standardisation may not add more to total variability than inter-subject variability. Variability improvements gained by the tighter specifications of the ISCEV-specified protocol were possibly more than lost due to imprecisions of xenon flashtubes. Peak time variability was far lower than amplitude variability, corresponding with acceptable variability of biochemical assays. These results represent a vindication of the existence of an ERG standard and suggest that further standardisation would lend itself to greater reproducibility of ERGs worldwide.

Investigation of the first outbreak of OXA-48-producing Klebsiella pneumoniae in Ireland

BACKGROUND

Carbapenemase-producing Enterobacteriaceae (CPE) strains are encountered with increasing frequency in Europe. In November 2010 the European Centre for Disease Control (ECDC) graded Ireland as only having sporadic occurrence of CPE.

AIM

To describe the epidemiological and molecular typing analysis of the first outbreak of OXA-48-producing Klebsiella pneumoniae in an Irish tertiary care referral centre.

METHODS

Sixteen OXA-48-producing K. pneumoniae isolates were detected, from both clinical and screening specimens, and analysed by pulsed-field gel electrophoresis and by multi-locus sequence typing.

FINDINGS

Typing analysis revealed that two outbreak strains were circulating in the hospital, one among surgical patients and one among medical patients. The 'medical strain' ST13 had already been identified as an internationally disseminated clone, whereas the 'surgical strain' ST221 had not previously been reported as an OXA-48-carrying strain.

CONCLUSION

Although the outbreak on surgical wards was successfully controlled by implementing strict infection control measures, intermittent detection of individual patients carrying the 'medical strain' of OXA-48 K. pneumoniae has persisted since then. The experience from this outbreak suggests that OXA-48 K. pneumoniae is endemic at low level in the healthcare setting in the Dublin region.

The PROFILE feasibility study: Genetic prostate cancer risk stratification for targeted screening

22

Background: Prostate cancer (PC) screening is controversial and a better assessment of individualized PC risk is needed. Several single nucleotide polymorphisms (SNPs) conferring a cumulative risk of PC have been identified. We have explored the potential role of genetic markers for targeted screening in a population with increased risk of PC due to family history (FH). Methods: PROFILE was developed as a pilot study to determine the feasibility of targeted PC screening using prostatic biopsy (PB) and its association with specific genetic profiles in men with FH. We also evaluated the role of PSA and Diffusion Weighted MRI (DW-MRI) as screening tools. One hundred sixteen men age 40 to 69 with FH of PC were enrolled between October 2009 and December 2012. Cumulative SNP risk scores were calculated by summing 59 risk alleles for each locus using the weighted effect (log-additive model). DW-MRI was performed in 50 patients. Participants were asked to undergo a 10 core PB regardless of baseline PSA. Results: Median age 53 (40 to 69) and median PSA was 1.15. One hundred and two men accepted to undergo a PB as primary PC screening. Twenty-three tumours were found (22.5% of biopsies) as well as seven men diagnosed with atypical small acinar proliferation (ASAP) (6.8%) and eight men with high-grade prostatic intraepithelial neoplasia (HG-PIN) (7.8%). In total 37.1% received an abnormal result. Out of the diagnosed PC 41% were intermediate or high risk and requiring treatment, which compares with 24% in general population screening. The predictive performance of DW-MRI, PSA, genetic model and genetic model plus PSA measured by AUC were: 0.85, 0.73, 0.57 and 0.74, respectively. The genetic model performed best in men with a normal PSA of <3(AUC 0.63). Analyses of a 78 SNP profile from the recent COGS results are underway. Conclusions: Ourresults indicate that PB is acceptable for PC screening in men with FH of PC. The significant AUC for DW-MRI would warrant a larger study. The incidence of ASAP is higher in this group than the general population.The SNP risk score was more predictive in men with PSA less than three where PB would not normally be undertaken, therefore an expanded study to investigate the role of genetic profiling in directing PB in PC screening is indicated.

Profile study: Genetic prostate cancer risk stratification for targeted screening

5054

Background: Prostate cancer (PC) screening is controversial and better approaches are needed, including a better assessment of individualized PC risk. Several studies have identified a number of common single nucleotide polymorphisms (SNPs) that confer a cumulative risk of PC. We have explored the potential role of genetic markers in identifying men who should be selectively targeted for screening in a population with increased risk of PC due to family history (FH) of the disease. Methods: PROFILE has been developed as a pilot study. The primary aim is to determine the feasibility of targeted PC screening using prostatic biopsy (PB) and its association with specific genetic profiles in men with FH. Secondary aims are to evaluate the role of PSA and Diffusion Weighted MRI (DW-MRI) as screening tools in this population. From December 2010 men aged 40-69 with FH of PC were invited into the study until 100 men were enrolled. Blood samples were provided for PSA and DNA extraction. The cumulative SNP risk scores for each patient were calculated by summing 59 risk alleles for each locus using the weighted effect as estimated in previous studies (log-additive model). DW-MRI was performed in 50 patients. All participants were asked to undergo a 10 core PB regardless of baseline PSA. Those who declined PB have been excluded from this analysis. Data on side effects and cancer worry were also collected. Results: 35% of invited men entered the study. Median age was 53 yrs (40-69) and median PSA was 1.15. Ninety men accepted to undergo a PB as primary PC screening. Twenty-two tumours were found and 45% of them were clinically significant [Median age 64yrs (47-69), median PSA 5.4 (0.91-9.3)]. The predictive performance of DW-MRI, PSA, genetic model and genetic model plus PSA measured by AUC were: 0.85, 0.73, 0.57 and 0.74, respectively. The genetic model performed better in men with PSA<3(AUC 0.63). No severe side effect or adverse psychosocial variables were noted. Conclusions: Our results indicate that PB is acceptable as a means of PC screening in men with FH of PC. Overall, DW-MRI and PSA were more predictive of PC than the genetic risk score. As more SNPs are found, a larger study is warranted to evaluate their role in the PC screening algorithm.

The safety and efficacy of dexmedetomidine for postoperative sedation in the cardiac surgery intensive care unit

INTRODUCTION

The α2-adrenoceptor agonist dexmedetomidine is an effective postoperative sedative without clear advantages over midazolam or propofol. We hypothesized that routine use of dexmedetomidine allows early extubation in cardiac surgery patients. Secondary outcomes included the use of narcotic and non-narcotic analgesics during the first 48 hours, early postoperative functional status, and the incidence of bradycardia or hypotension.

METHODS

We retrospectively analyzed patients admitted to a cardiothoracic intensive care unit after cardiac surgery. Patient charts and the Society of Thoracic Surgery National database were reviewed. Patients who received no sedation were compared to those who received dexmedetomidine.

RESULTS

Ninety-nine patients (52 receiving no sedation and 47 receiving dexmedetomidine) were included in this study. The median time to extubation was 3.9 (2.8-5.4) hours in the control group versus 4.7 (3.45-6.52) hours in the dexmedetomidine (P=.16). The incidence of bradycardia, hypotension, the ability to ambulate, and Glascow Coma Scores = 15 on postoperative day 0 did not differ significantly. Acetaminophen was used more frequently in the first 48 hours postoperatively in dexmedetomidine patients (P=.02) and a trend toward higher opioid (P=.09) and ketorolac use (P=.30) over the first 48 hours was noted.

CONCLUSIONS

The use of dexmedetomidine did not allow earlier extubation or less use of analgesics when compared to no sedation. Bradycardia and hypotension were not a problem with the use of dexmedetomidine.

Abstract 2612: The PROFILE study; Germline genetic profiling: Correlation with targeted prostate cancer screening and treatment

Introduction: Men with a first degree relative with prostate cancer (PC) have twice the general population risk. This risk is greater amongst young cases and amongst men with more affected relatives. Genome Wide Association studies have identified a number of common single nucleotide polymorphisms (SNPs) that confer small but cumulatively substantial risks of PC. These findings open the possibility for exploring the use of SNPs in PC risk stratification for targeted screening. Objectives: PROFILE has been developed as a pilot study; the primary aim is to determine the acceptability and feasibility of targeted PC screening using prostatic biopsy in men with a family history and its association with specific genetic profiles. The secondary aims are to: (1) determine PC risk related SNPs signatures in men with a family history; (2) study the correlation between specific PC risk related SNP signatures and prostate biopsy (PB) outcomes; (3) estimate the sensitivity and specificity of PSA screening and the optimal PSA threshold for PB in men with a family history of PC; (4) to assess the value of Diffusion Weighted Magnetic Resonance Imaging (DW-MRI) as a PC screening tool in men with a family history of PC. Method: Eligible men were aged 40-69 years with i) first degree relative (FDR) with PC &lt;70 years, or ii) two relatives FDR or second degree relatives (SDR) with PC, at least one &lt;70 years, or iii) 3 relatives (FDR or SDR) with PC at any age. After informed consent, patients provided blood samples to measure PSA level and for DNA extraction. All participants were asked to undergo a ten core trans-rectal ultrasound guided PB regardless of baseline PSA result. Participants without previous PB or who underwent PB &gt;1 year ago were offered a DW-MRI prior to biopsy. Blood DNA from each participant was analysed for a panel of 39 SNPs associated with increased risk of PC using iPLEX Sequenom technology. The results were fed back to participants and an associated psycho-social study has collected data on cancer worry, anxiety and depression and illness perceptions. We aim to enrol 100 men Results: 70 men had been recruited by 1st November 2011. 45 PB have been performed, finding 10 (22.2%) PC, 5 (11.1%) ASAP and 2 (4.4%) high grade PIN. The results of SNP profiling, risk prediction modelling and clinical parameters will be presented alongside the outcome of the baseline psychosocial measures Conclusions: Our preliminary results indicate that PB as a means of PC screening is feasible and acceptable in men with a family history of the disease. The incidence of PC and ASAP in this group of men is higher than expected in the general population. No adverse psychosocial variables were noted. These results support the development of a larger national study.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2612. doi:1538-7445.AM2012-2612

IVI epoprostenol as salvage therapy in pulmonary arterial hypertension: an Australian perspective

BACKGROUND

IVI epoprostenol is the only therapy for pulmonary arterial hypertension (PAH) with a randomized controlled trial demonstrating improved survival, when used as first-line monotherapy. In Australia it is used as salvage therapy for those failing treatment with other targeted therapies or presenting in World Health Organization functional class (FC) IV.

AIMS

Report experience with IVI epoprostenol, administered as salvage therapy for the treatment of adults with PAH in a single Australian PAH centre.

METHODS

Retrospective case series of all patients commenced on IVI epoprostenol for PAH, between 2002 and 2010. Review of case notes with collection of data at baseline and after treatment, including FC, 6-min walk test (6MWT), right ventricular systolic pressure (RVSP) on echocardiogram, patient survival and treatment complications. Change in indices was assessed using the Wilcoxon Sign Rank Test and is expressed as median (inter-quartile range).

RESULTS

A total of 23 patients was included. Treatment was generally well tolerated with few major complications. At the end of the study period, nine patients were successfully bridged to transplant, five had a sustained response to IVI epoprostenol, six had an incomplete response but were clinically stabilized, two died awaiting transplant and one died who was not a candidate for transplantation. Overall, when measured at best level post initiation of IVI epoprostenol, there were significant improvements in FC -1 [0 to -1] (P < 0.0001), 6MWT (m) +117 [70-264] (P= 0.002) and RVSP (mmHg) -7.0 [4.0 to -45] (P= 0.03).

CONCLUSION

Findings support efficacy of epoprostenol as salvage therapy for patients with PAH.

Integrating the implementation of the European Union Water Framework Directive and Floods Directive in Ireland

Water Framework Directive (WFD) statutory authorities and stakeholders in Ireland are now challenged with the issue of how the proposed programmes of measures in the newly required River Basin Management Plans - designed to protect and restore good ecology by reverting as closely as possible back to natural conditions - are to be implemented in a way that concurrently complies with other existing and emerging intersecting European Union legislation, such as the Floods Directive (FD). The WFD is driven largely by ecological considerations, whereas the FD and other legislation are more geared towards protecting physical property and mitigating public safety risks. Thus many of the same waterbodies, especially heavily modified waterbodies, arguably have somewhat competing policy objectives put upon them. This paper explores the means by which Ireland might best achieve the highest degrees of cost effectiveness, economic efficiency and institutional durability in pursuing the common and overarching objective of the WFD and FD - to ensure Irish waterways are put to their highest valued uses.

Lung transplantation in pulmonary fibrosis: challenging early outcomes counterbalanced by surprisingly good outcomes beyond 15 years

Interstitial lung disease (ILD) has been reported to have a poor outcome following lung transplantation due to difficulties getting ill recipients to transplantation and challenging early postoperative outcomes. To assess long-term outcomes for this cohort, we performed a retrospective 18-year chart review of all ILD lung transplant recipients. ILD single (SLT) and bilateral sequential lung transplantations (BSLT) were compared with all other lung transplant patients and International Society for Heart and Lung Transplantation (ISHLT) Registry data over the same time period. Of 585 lung transplantations, 90 (15%) were ILD (53 SLT, 37 BSLT); 67 (74%) were idiopathic pulmonary fibrosis (IPF), 9 (10%) were sarcoidosis, 9 (10%) were lymphangioleiomyomatosis, and 5 (6%) had other indications. Mean age was 52 years (range, 34-69 years). Actuarial survival at 1, 5, 10, 15, and 18 years compared favorably to all other lung transplantations performed (77% vs 83%, 51% vs 50%, 42% vs 26%, 28% vs 17%, and 28% vs 8%, respectively). IPF actuarial survival at 1, 5, and 10 years appeared superior to ISHLT Registry data (76% vs 72%, 50% vs 44%, and 34% vs 20%, respectively). There was equivocal survival between SLT and BSLT at 1, 5, and 10 years (78% vs 68%, 49% vs 50%, and 29% vs 50%, respectively). Our ILD figures compared favorably to lung transplantation for other diseases and international standards, while survival from SLT was as successful as BSLT both in the short and the longer term. Consideration should be given to utilizing SLT to maximize the allocation of donor lungs and to decrease waiting list mortality associated with IPF.

Retinal toxicity during pegylated alpha-interferon therapy for chronic hepatitis C: a multifocal electroretinogram investigation

BACKGROUND

Ocular side-effects in the form of retinal ischaemia and haemorrhages have been reported in patients undergoing standard alpha-interferon therapy.

AIM

To assess the ocular impact of therapy with sustained release pegylated alpha-2a interferon (Pegasys) for chronic hepatitis C.

METHODS

Ten patients receiving Pegasys and ribavirin and 10 healthy volunteers were recruited. Patients underwent full ophthalmic investigations and multifocal electroretinogram testing at baseline, at regular intervals during treatment and post-treatment. The multifocal electroretinogram maps retinal function. Responses were compared with sequential recordings from healthy volunteers.

RESULTS

All patients had normal clinical ophthalmic investigations at baseline. During therapy a single patient experienced central visual disturbance lasting 24 h with no prolonged ill effect. No other patient was aware of any change in vision. Fundal abnormalities appeared in five patients during treatment. The multifocal electroretinogram showed reductions in retinal function in five patients. Nine of 10 patients exhibited abnormalities on at least one multifocal electroretinogram or fundoscopic investigation.

CONCLUSIONS

Subclinical retinal toxicity during anti-viral therapy with pegylated alpha-interferon and ribavirin was frequent in this study and it suggests that patients should be warned of this risk and monitored during therapy.

The effects of pupil size on the multifocal electroretinogram

This is an investigation of the effect of changing the pupil diameter on the P1 amplitude and latency of the multifocal electroretinogram (mfERG). MfERGs were recorded using a custom built wide field electrophysiological system. An array of 61 empirically scaled hexagons was used to stimulate the visual field. The duration of overall recording period was 8 min, segmented into 16 intervals each lasting 30 s. A combination of mydriatics and miotics were used to pharmacologically alter the pupil size and diameters between 1 and 10 mm were measured. There was a reduction in mfERG P1 amplitude in some cases greater than 50% (mfERG P1 amplitude 53 nV at 8 mm to 25 nV at 1 mm), with a change in pupil diameter of 7 mm. The mfERG P1 latency increased in some cases by as much as 8 ms in the central 40 degrees (mfERG P1 latency 39 ms at 8 mm to 47 ms at 1 mm). These results suggest that pupil size has significant effects on mfERG P1 amplitude and latency.

Secondary retinal changes associated with choroidal naevi and melanomas documented by optical coherence tomography

AIMS

To establish the characteristics of secondary retinal changes associated with the presence of choroidal melanomas and choroidal naevi as documented by optical coherence tomography (OCT).

METHODS

Twenty patients with untreated choroidal melanoma and 40 patients with presumed choroidal naevi managed by regular observation were included in the study. OCT scans across the surface of the tumour and surrounding tissue were acquired for all participants. The appearance of retinal tissue on the OCT scans was considered to be abnormal if it did not display the well defined band structure characteristic of normal tissue on OCT scans.

RESULTS

Serous retinal detachments were observed in all patients with choroidal melanoma and 18 out of 20 also had abnormal retinal structure or intra-retinal splitting in the tissue overlying the tumour. Out of the 40 patients with presumed choroidal naevi, 12 had serous detachments and three had either abnormal retinal structure or intra-retinal splitting overlying the lesion.

CONCLUSIONS

Secondary retinal changes associated with choroidal lesions can be documented by OCT. These changes were observed in most patients with choroidal melanoma included in the study group but were far less prevalent in the patients with presumed choroidal naevi. OCT is also able to identify the presence of small serous detachments before they become clinically visible. Follow up of these patients is required to determine whether the OCT results may be of use in the differential diagnosis of small choroidal lesions.

Peripheral retinal dysfunction in patients taking vigabatrin

OBJECTIVE

To assess the wide-field multifocal electroretinogram (WF-mfERG) for assessment of retinal function in vigabatrin-treated patients.

METHODS

Thirty-two adults who had taken vigabatrin for at least 3 years for localization-related epilepsy underwent WF-mfERG, ERG, logMar visual acuity and color vision evaluation, Humphrey visual field analysis (static perimetry), and funduscopy. The group was matched with a cohort of patients who had never received vigabatrin. Results were compared with a normative data set (120 drug-free controls) with respect to potential bilateral abnormalities in response timing.

RESULTS

There were no significant differences between groups in visual acuity or color vision testing. Of the vigabatrin patients, 19 (59%) had bilateral visual field defects compared to none of the controls. Using WF-mfERG, all patients on vigabatrin with visual field defects showed abnormalities (100% sensitivity) and only 2 of the 13 patients without a field defect showed retinal abnormalities (86% specificity).

CONCLUSIONS

WF-mfERG may be useful for detecting retinal pathology in patients taking vigabatrin. The majority of previous reports based on subjective testing may have underestimated the prevalence of peripheral retinal toxicity related to the drug.

Identification of appropriate primitive polynomials to avoid cross-contamination in multifocal electroretinogram responses

Abstract-The basis of the multifocal/electroretinogram is the use of a decimated m-sequence for simultaneous and independent stimulation of many areas of the visual pathway. The purpose of this study was to investigate the effects of cross-contamination from higher orders of the response. A series of primitive polynomials were found by construction of finite fields. The first-order ERG response was formed by cross-correlation of m-sequence with the physiological response. A second-order response was formed by investigation of particular flash sequences of the stimulation sequence and cross-correlation of a second-order m-sequence with the physiological response. Zech logarithms were used to identify cross-contamination between the various first and second-order sequences. Tables of good and bad primitive polynomials were constructed for degrees 12-16, and the effects of window length and decimation length were examined. When the sequence was decimated into 128 areas, and a window of length 16 was examined, cross-contamination occurred in all sequences generated from primitive polynomials of degree less than or equal to 12, but in only 26% of degree 14, and 5.6% of degree 16. A photodiode (artificial eye) was used in an experiment to construct trace arrays showing responses from 61 individual areas. Additional waveforms were present on the trace array when the experiment was carried out with a bad primitive polynomial. The use of finite field theory to generate primitive polynomials and Zech logarithm analysis allowed prediction of which primitive polynomials were suitable for m-sequence generation for multifocal electroretinography. Practical investigations supported the theoretical analysis. This has important implications for developers of multifocal electrophysiology systems.

An instrument to investigate temporal processing mechanisms with the multifocal ERG

The multifocal ERG technique is a powerful method of studying the function of different areas of the retina. Display systems such as the CRT, which are commonly used for stimulation, are subject to limitations such as those imposed by the raster method of scanning. This work describes a novel stimulating display using LEDs that retains the established hexagonal areas but overcomes some of the limitations of the CRT display systems. The design and construction of the instrument is described together with some preliminary results.