Radiation and anti-PD-L1 synergize by stimulating a stem-like T cell population in the tumor-draining lymph node

Radiotherapy (RT) and anti-PD-L1 synergize to enhance local and distant (abscopal) tumor control. However, clinical results in humans have been variable. With the goal of improving clinical outcomes, we investigated the underlying synergistic mechanism focusing on a CD8+ PD-1+ Tcf-1+ stem-like T cell subset in the tumor-draining lymph node (TdLN). Using murine melanoma models, we found that RT + anti-PD-L1 induces a novel differentiation program in the TdLN stem-like population which leads to their expansion and differentiation into effector cells within the tumor. Our data indicate that optimal synergy between RT + anti-PD-L1 is dependent on the TdLN stem-like T cell population as either blockade of TdLN egress or specific stem-like T cell depletion reduced tumor control. Together, these data demonstrate a multistep stimulation of stem-like T cells following combination therapy which is initiated in the TdLN and completed in the tumor.

Efficacy of immune checkpoint inhibitors in alveolar soft-part sarcoma: results from a retrospective worldwide registry

BACKGROUND

Conventional cytotoxic drugs are not effective in alveolar soft-part sarcoma (ASPS). Immune checkpoint (programmed cell death protein 1/programmed death-ligand 1) inhibitors (ICIs) are promising drugs in ASPS. A worldwide registry explored the efficacy of ICI in ASPS.

MATERIALS AND METHODS

Data from adult patients diagnosed with ASPS and treated with ICI for advanced disease in expert sarcoma centers from Europe, Australia and North America were retrospectively collected, including demographics and data related to treatments and outcome.

RESULTS

Seventy-six ASPS patients, with a median age at diagnosis of 25 years (range 3-61 years), were registered. All patients received ICI for metastatic disease. Immunotherapy regimens consisted of monotherapy in 38 patients (50%) and combination in 38 (50%) (23 with a tyrosine kinase inhibitor). Among the 68 assessable patients, there were 3 complete responses and 34 partial responses, translating into an overall response rate of 54.4%. After a median follow-up of 36 months [95% confidence interval (CI) 32-40 months] since the start of immunotherapy, 45 (59%) patients have progressed on ICI, with a median progression-free survival (PFS) of 16.3 months (95% CI 8-25 months). Receiving ICI in first line (P = 0.042) and achieving an objective response (P = 0.043) correlated with a better PFS. Median estimated overall survival (OS) from ICI initiation has not been reached. The 12-month and 24-month OS rates were 94% and 81%, respectively.

CONCLUSIONS

This registry constitutes the largest available series of ASPS treated with ICI. Our results suggest that the ICI treatment provides long-lasting disease control and prolonged OS in patients with advanced ASPS, an ultra-rare entity with limited active therapeutic options.

Enhancing Specialist Training in Radiation Oncology through the Implementation of Structured Radiotherapy Contouring Workshops

PURPOSE/OBJECTIVE(S)

Contouring tumor volumes and organs at risk is a key component of Radiation Oncology specialist training. As trainees rotate through different tumor sites, they are expected to develop proficiency in contouring skills relevant to their year of training. These skills have historically been acquired in an unstructured manner during supervised clinical work. However, trainees often struggle to learn these skills due to variability in practice and approach amongst senior colleagues. Research has shown that contouring workshops improve the standardization of contouring and can be an effective way of enhancing the learning experience through interaction, instant feedback and reflection. We present our experience of implementing structured contouring workshops and the feedback received from the trainees.

MATERIALS/METHODS

Eight contouring workshops were held in our institution over a period of 3 years between 2019 and 2022. These included Head & Neck (3), Prostate (1), SABR Lung (2), Breast (1), and Esophagus (1). Six were held in-person pre-COVID and two in a virtual format during the pandemic. Each workshop was 2 hours long and attended by trainees with varying levels of contouring experience. All the workshops were facilitated by a consultant radiation oncologist and a clinical tutor and followed a similar format consisting of a brief tutorial on the tumor site, followed by a contouring demonstration on an anonymized case on an Eclipse planning platform referencing published contouring atlases. Each of the trainees had access to a copy of the same case throughout the workshop and their contours were then reviewed both individually and collectively. A key component of the workshops was instant feedback, as trainees could compare their contours to that of the tutors and discuss any differences. Feedback on the contouring workshop was then collected through a post workshop questionnaire.

RESULTS

The workshops were attended by an average of 12 trainees (range 10 to 14). Regardless of their year of training, all trainees rated the content and format of the workshops highly and stated they were relevant to their daily practice. Their subjective level of confidence in contouring in that specific tumor site improved significantly, going from an average of 5.6 out of 10 (range of 4 to 7) before the workshop to 8.7 (range of 8 to 9) after the 8 workshops. All the workshops were conducted at no extra cost as they were held using our existing planning software.

CONCLUSION

The trainees indicated that the workshops were of definite educational benefit and strongly supported incorporating this approach to teaching contouring skills into the curriculum. Based on this feedback, these contouring workshops have been integrated into the recently revised higher specialist training curriculum on a more structured basis. This will ensure that trainees will continue to develop progressive expertise in contouring skills in keeping with best international practice as they advance through their training scheme.

Jaguars in the borderlands: Multinatural conservation for coexistence in the Anthropocene

Conservation in the human-dominated Anthropocene involves negotiations among diverse stakeholders. However, these stakeholder inclusion schemes are often superficial, leading to unsuccessful interventions. Here we apply the theory of multinaturalism as an operational starting point for stakeholder engagement efforts, to deepen local involvement and work towards coexistence. Multinaturalism posits that natures are multiple and can be known in many ways, and that many natures can coexist in the same geographical space. Using the northern jaguar population in the US-Mexico borderlands as a case study, we investigate, through semi-structured interviews, the natural realities (‘natures’) of various stakeholders involved in borderland jaguar conservation. We define a nature as an individual’s or group’s perceptions, knowledge, values, attitudes, and actions towards jaguars. We construct each stakeholder group’s natural reality of this jaguar population through applied thematic analysis, and we identify which aspects of stakeholders’ natures are similar and different, particularly across the international border. For example, we found that many conservationists and activists value the jaguar as an apex predator because its presence signifies ecosystem health and balance, while some ranchers hold existence value for the jaguar’s power and beauty, but resent its role as a predator, due to potential for conflict with livestock. This information provides a greater understanding of differences in realities that may cause conflicts over wildlife-related decisions, and can be used by local conservation actors to facilitate collaboration in a complex transboundary region. This interdisciplinary study highlights the importance of investigating the human dimensions of conservation completely, while treating all forms of knowledge about nature seriously and equally. Due to the unique nature of human-wildlife interactions, each conservation situation requires bespoke consideration, and particularly in diverse landscapes, a multinatural approach offers a novel path towards sustainable human-wildlife coexistence.

Implementation of self-monitoring of blood glucose for patients with insulin-dependent diabetes at a rural non-communicable disease clinic in Neno, Malawi

BACKGROUND

Self-monitoring of blood glucose (SMBG) is a widely accepted standard of practice for management of insulin-dependentdiabetes, yet is largely unavailable in rural sub-Saharan Africa (SSA). This prospective cohort study is the first known report ofimplementation of SMBG in a rural, low-income country setting.

OBJECTIVES

To evaluate adherence and change in clinical outcomes with SMBG implementation at two rural hospitals in Neno, Malawi.

METHODS

Forty-eight patients with type 1 and insulin-dependent type 2 diabetes were trained to use glucometers and logbooks. Participantsmonitored preprandial glucose daily at rotating times and overnight glucose once a week. Healthcare providers were trained to evaluateglucose trends, and adjusted insulin regimens based on results. Adherence was measured as the frequency with which patients checked anddocumented blood glucose at prescribed times, while clinical changes were measured by change in glycated haemoglobin (HbA1c) over a6-month period.

RESULTS

Participants brought their glucometers and logbooks to the clinic 95 - 100% of the time. Adherence with measuring glucose valuesand recording them in logbooks eight times a week was high (mean (standard deviation) 69.4% (15.7) and 69.0% (16.6), respectively). MeanHbA1c decreased from 9.0% (75 mmol/mol) at enrolment to 7.8% (62 mmol/mol) at 6 months (mean difference 1.2% (95% confidenceinterval (CI) 0.6 - 2.0; p=0.0005). The difference was greater for type 1 diabetes (1.6%; 95% CI 0.6 - 2.7; p=0.0031) than for type 2 diabetes(0.9%; 95% CI 0.1 - 1.9; p=0.0630). There was no documented increase in hypoglycaemic events, and no hospitalisations or deaths occurred.

CONCLUSION

SMBG is feasible for patients with insulin-dependent diabetes in a rural SSA population, and may be associated with improvedHbA1c levels. Despite common misconceptions, all patients, regardless of education level, can benefit from SMBG. Further research onlong-term retention of SMBG activities and the benefits of increasing frequency of monitoring is warranted.

34 RELATIONSHIP BETWEEN SERUM CAROTENOID CONCENTRATIONS AND FRAILTY, PROBABLE SARCOPENIA, AND PHYSICAL FUNCTION IN THE IRISH LONGITUDINAL STUDY ON AGEING (TILDA)

Background

Lutein and zeaxanthin are antioxidant and anti-inflammatory carotenoids derived from foods such as fruit and vegetables. Serum concentrations of Lutein (Ls) and Zeaxanthin (Zs) reflect habitual dietary intake. This study examined the cross-sectional and longitudinal relationships between Ls and Zs and frailty, probable sarcopenia, and indices of physical function in TILDA.

Methods

The cross-sectional analysis included n=4672 community-dwelling adults aged ≥50 years with Ls and Zs at Wave 1 (2010). For the longitudinal analyses, changes in usual gait speed (at Wave 3, 2014), grip strength (Wave 4, 2016) and Timed Up-and-Go (TUG; Wave 5, 2018), incident probable sarcopenia (defined as grip strength <27 kg in men, <16 kg in women, at Wave 4) and incident frailty (Fried, at Wave 5) were determined. Multivariable linear and logistic regression analyses were adjusted for age, sex, waist circumference, education, malnutrition, smoking, chronic disease, alcohol intake and physical activity.

Results

Cross-sectionally, Ls and Zs were positively associated with gait speed (B [95% CI] per 100-nmol/L higher concentration: Ls 0.67 [0.22, 1.12], Zs 1.3 [0.21, 2.48] cm/s) and inversely associated with TUG time (Ls –0.07 [-0.11, –0.02], Zs –0.14 [-0.25, –0.03] s) and with frailty (OR: Ls 0.61 [0.42, 0.87], Zs 0.23 [0.08, 0.68]), all p <0.05), but not with grip strength or probable sarcopenia. Longitudinally, Ls was inversely associated incident frailty (OR 0.85 [0.04, 0.84], p=0.03), whereas Zs was not (0.83 [0.56, 1.23], p=0.36). Neither Ls or Zs were related to changes in physical function measures or incident probable sarcopenia (p>0.05).

Conclusion

Cross-sectionally, lower Ls and Zs were independently associated with frailty, slower gait speed and worse TUG performance. However, Wave 1 Ls and Zs were not predictive of changes in these outcomes over 4-8 years of follow up, with the exception of Ls which was inversely associated with incident frailty after 8 years.

16 SARS-COV-2 INFECTION AND VACCINATION PATTERNS DETERMINE LONG-TERM ANTIBODY RESPONSES IN NURSING HOME RESIDENTS: DATA FROM NH-COVAIR

Background

Older Nursing Home Residents (NHRs) are at greatest risk of morbidity and mortality from SARS-CoV-2, particularly in the context of both waning vaccine efficacy and the emergence of Variants-of-Concern (VOCs). However, the determinants of long-term vaccine-induced protective antibody responses are yet to be determined in this group.

Methods

NH-COVAIR recruited older NHRs for comprehensive clinical and frailty (NH-FRAIL) assessment. Blood samples were obtained pre-vaccination, at 6-weeks and 6-months following primary vaccination and 6-months following booster vaccination. Antibody titres were measured using both an electrochemiluminescence assay and a custom bead-based array (Luminex™) to measure antibody titre and avidity for Wuhan strain/major VOC antigens. Stepwise adjusted linear regression (log-transformed) assessed longitudinal determinants of vaccine-induced antibody responses.

Results

Of 86 participants (81.1 ± 10.8 years; 65% female), just under half (45.4%) had evidence of previous SARS-CoV-2 infection. All NHRs mounted a significant antibody-response to vaccination at 5 weeks followed by a significant decrease in antibody titre by 6 months. Previous SARS-CoV-2 infection was the strongest predictor of antibody waning at all timepoints (β: 3.59; 2.89, 4.28; P < 0.001 for 6-months). Independent of infection history, both age (β: –0.05; –0.08, –0.02; p<0.001) and frailty (β: –0.22; –0.33, –0.11; p<0.001) were associated with faster antibody waning at 6-months. Cross-reactivity and avidity were significantly lower for Beta (B.1.351) and Gamma (P.1) VOC strains (all p<0.001). Additionally, there was faster antibody waning and significantly reduced antibody avidity to Beta and Gamma VOCs in SARS-CoV-2 naïve NHRs.

Conclusion

Older NHRs are capable of mounting protective antibody responses to SARS-CoV-2 vaccination. Responses were more durable, with a greater cross-reactivity to and avidity for VOCs in those with previous SARS-CoV-2 infection. Increasing age and greater frailty in NHRs was associated with faster antibody waning. Our findings support ongoing serological surveillance and use of additional vaccine doses in older NHRs, particularly in those without previous SARS-CoV-2 exposure.

298 AN AUDIT OF HEALTH PROFESSIONALS’ KNOWLEDGE OF PARKINSON’S DISEASE AND ITS MEDICATION MANAGEMENT FOR HOSPITALISED PATIENTS

Background

Studies have shown that patients with Parkinson’s Disease (PD) have a higher rate of hospitalisation and longer lengths of stay than their age matched controls. Good inpatient management is key to maintaining functional ability and preventing complications, but many PD patients deteriorate while in hospital. Patients with PD are often on multiple time sensitive medications. This study aims to assess healthcare workers knowledge of PD, medications used to treat it and how they should be prescribed and administered.

Methods

A convenience sample survey was distributed to doctors, nurses and other health care professionals over a five-week period. This survey included multiple choice questions and open-ended short answer questions. Results were collated and analysed on Microsoft Excel.

Results

71 surveys were returned - 34 from doctors, 23 from nurses and the 14 others included pharmacists, physios and dieticians. Only 11 (15%) participants correctly identified all PD medications listed in the survey with Sinemet being the most recognised drug (n= 68). Non motor symptoms of PD correctly identified by participants included constipation (n=54, 76%), hallucinations (n=48, 68%) and anosmia (n=18, 25%). 32 participants (45%) were unable to correctly identify when to administer PD medications in relation to mealtimes. 29 participants surveyed (41%) would consider inserting a nasogastric tube for a patient who was fasting and unable to take oral medications. 12 participants (17%) did not know that Sinemet could be given via nasogastric tube.

Conclusion

This survey highlights a gap in knowledge of Parkinson’s Disease and its management. Participants displayed poor knowledge regarding optimum timing of medication administration and management of patients who are fasting. These findings suggest that education sessions and hospital specific guidelines regarding the management and administration of PD medications would assist healthcare professionals with a view to improving patient outcomes and preventing complications.

286 PERCEPTIONS OF RESEARCH AMONGST OLDER ADULTS

Background

Older adults are often excluded from healthcare research, particularly those with cognitive impairment. It is crucial that study participants have given informed consent and partake in research of their own free will. People with cognitive impairment are not always able to engage in the informed consent process. This can lead to under-representation of this cohort in studies. Understanding older people’s perceptions of research is important to better design policies and research studies that are inclusive of older adults. This pilot study aimed to gain a better understanding of older adults’ views about healthcare research and what they imagine their wishes would be if they were unable to consent themselves due to memory problems.

Methods

In this prospective observational study, participants were recruited from outpatient clinics. Consenting participants were surveyed over the phone to ascertain their perceptions of healthcare research.

Results

Twenty-five interviews were conducted. Median age was 76.24 years (range 68-85 years). Most respondents reached at least second level education (80%), and most volunteered knowing very little about healthcare research. All participants had a nominated next of kin. Of 23 participants who had not previously been involved in healthcare research, none had been asked to do so.

Most participants would be interested or very interested in participating in research if the study involved either survey questions (64%), chart review (88%), or additional investigations (68%), however only a minority were interested or very interested in partaking in research involving a trial drug (16%). Most participants (88%) would be happy or very happy for their next of kin to ‘consent’ on their behalf (if they themselves were unable to do so).

Conclusion

In this study, older adults had clear views about healthcare research and a keenness to participate. This group of older adults expressed trust in their next of kin to make decisions on their behalf regarding research participation. More research is required to explore this area further.

27 ASSOCIATIONS BETWEEN ORTHOSTATIC BLOOD PRESSURE BEHAVIOUR AND PROGRESSION OF AGE-RELATED MACULAR DEGENERATION IN THE IRISH LONGITUDINAL STUDY ON AGEING (TILDA)

Background

Age-Related Macular Degeneration (AMD) is a progressive disease and the leading cause of vision loss in over 50’s in developed countries. Age-related changes in the neuro-cardiovascular system, at times manifesting as exaggerated blood pressure drops on standing (orthostatic hypotension) may be associated with end-organ damage. The aim of this study was to examine if the pattern of recovery of blood pressure upon standing from a supine position (orthostatic blood pressure behaviour), was associated with progression of AMD.

Methods

We utilised data from TILDA participants who had AMD at the wave 1 health assessment and returned for retinal image grading during the wave 3 health assessment, four years later. Beat-to-beat BP data was measured non-invasively by digital photoplethysmography (Finometer® MIDI) during the wave 1 Active Stand (AS) test. Measures recorded during AS included Systolic (SBP) and Diastolic (DBP) blood pressure. Associations between systolic and diastolic orthostatic BP behaviour and AMD progression were examined using generalised linear models (GLM). Baseline characteristics were compared between progression groups with the 2-samples Mann-Whitney U test and the Chi-squared test.

Results

Of the 191 included participants, 46 (24%) were found to have progression of AMD, while 145 (76%) had no change or regression of the disease. GLMs revealed no significant differences in SBP orthostatic behaviour across groups. However, those with AMD progression had lower orthostatic DBP values (tests of between-subjects effects p=0.005), particularly between 30-60 seconds post-stand (AMD progression: 72±10mmHg vs. No AMD progression: 79±12mmHg; p&lt;0.001). Of the baseline participant characteristics considered, only age was associated with AMD progression (AMD progression: 66±8yrs vs. No AMD progression: 62±9yrs; p=0.005).

Conclusion

In this sample of TILDA participants with AMD, lower orthostatic DBP values were associated with AMD progression over four years. Reduced orthostatic diastolic perfusion may be a novel modifiable risk factor for AMD progression.

Systemic treatment of advanced clear cell sarcoma: results from a retrospective international series from the World Sarcoma Network

Background

Clear cell sarcoma (CCS) is a translocated aggressive malignancy with a high incidence of metastases and poor prognosis. There are few studies describing the activity of systemic therapy in CCS. We report a multi-institutional retrospective study of the outcomes of patients with advanced CCS treated with systemic therapy within the World Sarcoma Network (WSN).

Materials and methods

Patients with molecularly confirmed locally advanced or metastatic CCS treated with systemic therapy from June 1985 to May 2021 were included. Baseline demographic and treatment information, including response by Response Evaluation Criteria in Solid Tumours (RECIST) 1.1, was retrospectively collected by local investigators. Descriptive statistics were carried out.

Results

Fifty-five patients from 10 institutions were included. At diagnosis, the median age was 30 (15-73) years and 24% (n = 13/55) had metastatic disease. The median age at diagnosis was 30 (15-73) years. Most primary tumours were at aponeurosis (n = 9/55, 16%) or non-aponeurosis limb sites (n = 17/55, 31%). The most common fusion was EWSR1–ATF1 (n = 24/55, 44%). The median number of systemic therapies was 1 (range 1-7). The best response rate was seen for patients treated with sunitinib (30%, n = 3/10), with a median progression-free survival of 4 [95% confidence interval (CI) 1-7] months. The median overall survival for patients with advanced/metastatic disease was 15 months (95% CI 3-27 months).

Conclusions

Soft tissue sarcoma-type systemic therapies have limited benefit in advanced CCS and response rate was poor. International, multicentre prospective translational studies are required to identify new treatments for this ultra-rare subtype, and access to early clinical trial enrolment remains key for patients with CCS.

•

This is the largest reported series of advanced CCS patients treated with systemic therapy.

•

The activity of sarcoma-type systemic therapy is poor and modest responses were seen only with sunitinib.

•

Effective therapies are needed to improve outcomes for patients with this ultra-rare sarcoma type.

165 WHAT FACTORS ARE ASSOCIATED WITH ADVANCED CARE PLANNING IN COMMUNITY-DWELLING OLDER PEOPLE?

Background

Advance Care Planning (ACP) involves expressing wishes regarding your future medical care and/or preferences about your end-of-life in the event of serious illness.

The aim of this study was to clarify the proportion of community-dwelling older people who engage in ACP and what factors are independently associated with ACP.

Methods

Participants aged ≥60 years (n = 4,831, mean age 71 years) at Wave 4 of the Irish Longitudinal Study on Ageing were asked: Have you made your wishes/preferences known about the kind of care that you would like to receive in the event of serious illness? If yes, they were asked if this had been documented informally (family/carers or medical professionals) or formally (by written advanced care plan).

Logistic regression models assessed the association of covariates of interest with ACP.

Results

One quarter of the study sample (1,153/4,831) had an ACP. Only 10% (119/1,153) had ACP documented in writing, while only 2% (27/1,153) had discussed ACP with a healthcare professional.

Age ≥ 80 years (OR 1.63 (1.31–2.02)), female sex (OR 1.58 (1.37–1.83)), higher educational attainment (OR 1.42 (1.18–1.71), poorer self-rated health (OR 1.58 (1.04–2.39) and lower levels of religiosity (OR 1.50 (1.03–2.19) were independently associated with ACP.

Conclusion

While ACP may have benefits in extending autonomy and facilitating decision-making, only 1 in 4 of this population-representative sample of older people had engaged in ACP, with only 1 in 50 having their ACP documented in writing.

Further work is therefore required to educate the public and healthcare professionals regarding the benefits of ACP.

Analysis of naloxone access and primary medication nonadherence in a community pharmacy setting

BACKGROUND

Access to naloxone is a primary public health strategy to prevent opioid overdose death. Factors associated with primary medication nonadherence (PMN) to naloxone are underreported in the literature.

OBJECTIVE

The objective of this study was to evaluate naloxone dispensing trends and PMN in a community pharmacy setting.

METHODS

This retrospective analysis included patients of a community pharmacy chain in Maine and New Hampshire (57 and 29 pharmacy locations, respectively) for whom a claim for a naloxone prescription was billed between January 1, 2019, and July 31, 2020.

RESULTS

A total of 2152 patients associated with 2606 naloxone claims were identified for analysis. A majority of the subjects were women (52.7%) and the mean age of all the subjects was 46.4 ± 16.0 years. Of the 2606 naloxone claims, 565 prescriptions were returned to stock and never dispensed to the patient for a PMN rate of 21.7%. Gender and age were not associated with naloxone PMN. Factors associated with naloxone PMN were urban location [x²(1) = 12.49, P = 0.0004], concomitant opioid analgesic [x²(1) = 4.56, P = 0.0328], and payment method [x²(4) = 251.07, P < 0.0001]. Regarding payment method, nonadherence was higher among cash (138 of 386, 35.8%) and private insurance (191 of 455, 42.0%) transactions whereas lower among Medicare (132 of 681, 19.4%) and Medicaid (89 of 899, 9.9%) transactions. Concomitant buprenorphine [x²(1) = 44.57, P < 0.0001] and the use of a naloxone standing order [x²(1) = 4.79, P = 0.0162] were associated with primary adherence to take-home naloxone.

CONCLUSION

A notable portion of naloxone prescribed and filled in the community pharmacy setting was never obtained by the patient. Factors associated with PMN in this study included geographic location, use of a standing order, concomitant prescriptions for buprenorphine or opioid analgesic medications, and payment method. Underlying causes of PMN must be addressed (e.g., removing financial barriers and optimizing the use of standing orders) to increase naloxone access for persons at risk of opioid overdose.

The Mount Sinai Patient-Centered Preoperative Criteria Meant to Optimize Outcomes Are Less of a Barrier to Care Than WPATH SOC 7 Criteria Before Transgender-Specific Surgery

Objectives: With expanding coverage of gender-affirming care in the United States, many insurers default to the World Professional Association for Transgender Health (WPATH) Standards of Care 7 (SOC 7) to establish eligibility requirements for surgery coverage. Informed by bariatric and transplant surgery evaluation models, the Mount Sinai Center for Transgender Medicine and Surgery (CTMS) developed patient-centered criteria to assess readiness for surgery, focusing on concerns that could impair recovery. To make recommendations for the next version of the WPATH SOC, SOC 8, we compared Mount Sinai patient-centered surgical readiness criteria with the WPATH SOC 7 criteria. Methods: Data were extracted from a deidentified data set developed as part the quality dashboard for CTMS. The data set included all patients seeking vaginoplasty who were evaluated by a single mental health provider, from July 2016 through August 2018, and who completed the full CTMS assessment. The number of patients eligible for surgery based on the Mount Sinai CTMS criteria was compared with the number of patients eligible for surgery according to WPATH SOC 7 criteria. Results: Of 139 patients identified, 63 (45%) were ready for surgery immediately based on the Mount Sinai patient-centered model. By contrast, only 21 (15%) out of the 139 met criteria for surgery based on WPATH SOC 7. Fifty patients (40%) were ready for surgery as per Mount Sinai patient-centered readiness review but not WPATH criteria. Conclusion: An assessment designed to better prepare patients for surgery may also result in fewer barriers to care than existing criteria used by insurance companies in the United States.

Antifungal stewardship in critical care: Implementing a diagnostics-driven care pathway in the management of invasive candidiasis

Background

Invasive candidiasis (IC) is the most common invasive fungal disease in patients admitted to critical care and is associated with high mortality rates. Diagnosis can be delayed by the poor sensitivity of culture-based methods, leading to unnecessary use of empirical antifungal therapy (EAFT). The fungal biomarker (1–3)-β-d-glucan (BDG) has been shown to aid in the diagnosis of IC in critical care and has been incorporated into antifungal stewardship (AFS) programmes.

Aim

To describe our experience using a diagnostics-driven AFS programme incorporating the fungal biomarker BDG, analyse its impact on antifungal therapy (AFT), and gain an improved understanding of the epidemiology of IC in our critical care unit (CrCU).

Methods

An AFS care pathway incorporating BDG was introduced in the CrCU in St James's Hospital, Dublin. Following an educational programme, compliance with the pathway was prospectively audited between December 1st, 2017 and July 31^st, 2018.

Results and Conclusion

One hundred and nine AFT episodes were included, of which 95 (87%) had a BDG sent. Of those with BDG results available at the time of decision-making, 38 (63%) were managed in accordance with the care pathway. In compliant episodes without IC, median EAFT duration was 5.5 days [IQR 4–7] and no increase in mortality or subsequent IC was observed. Although adopting a diagnostics-driven approach was found to be useful in the cohort of patients with BDG results available, the use of once-weekly BDG testing did not result in an observed reduction in the consumption of anidulafungin, highlighting an important limitation of this approach.

EXTH-12. RADIATION ENHANCES MELANOMA RESPONSE TO IMMUNOTHERAPY AND SYNERGIZES WITH BENZODIAZEPINES TO PROMOTE ANTI-TUMOR ACTIVITY

Melanoma brain metastases (MBM) occur in ~50% of advanced melanoma patients. It is unclear if systemic therapies synergize with radiotherapy (RT) and what the impact of RT timing has on efficacy. We find that RT followed by ICI (immune checkpoint inhibitors) (RTàICI) improves MBM patient survival compared to other combination strategies, also shown here in a murine melanoma model. RNA-seq of MBM tumors in the RTàICI group exhibit overrepresentation of genes implicated in NFKB signaling. There is also expression of GABAA receptor subunits across both treatment groups. We show that melanoma cells express functional GABAA receptors and that benzodiazepines impair tumor growth. Combination of sub-lethal RT doses with benzodiazepine results in significant ipsilateral and out of field abscopal anti-tumor activity, which is associated with enhanced tumor infiltration with poly-functional CD8 T-cells. This study provides evidence that RT enhances MBM response to ICI and synergizes with benzodiazepines to promote anti-tumor activity.

Abstract P2-03-01: Akt inhibition associated with change in immunophenotype of tumor microenvironment (TME) in breast cancer (BC)

Background: The PI3K/Akt/mTOR pathway is a known oncogenic pathway in BC. In addition, this pathway has demonstrated capacity to modulate host immune activity and may indirectly affect tumorigenesis. Clinicopathologic studies have demonstrated that lymphocyte density within the TME is predictive of chemosensitivity and improved prognosis in BC, while myeloid infiltration may play a deleterious role. To define the impact of Akt inhibition on the TME, we analyzed tumor tissue from patients (pts) with early-stage BC treated with single agent MK-2206, an Akt inhibitor, enrolled on a presurgical trial (NCT01319539).

Methods: Quantitative immunofluorescence (qmIF) was performed for CD3, CD8, CD4, FOXP3, CD68, Pancytokeratin on 4uM sections from biopsy and surgical specimens of MK-2206 (n=5) and control (n=5) pts. Images were analyzed using Vectra/inForm software (PerkinElmer), allowing for multiparameter phenotyping. Transcriptomic analysis was performed on surgical specimens to assess if differences exist in mRNA expression of tumor-associated and immune genes between pts treated with MK-2206 (n=5) and untreated matched controls (n=5) (nanoString). Statistical analysis was performed using t-Test, NetBID, and multiple comparison analysis by Benjamini-Hochberg. Gene set enrichment analysis (GSEA) was performed within R with gene sets from Molecular Signatures Database (Hallmark, Reactome, GO).

Results: On qmIF analysis, MK-2206 treated pts exhibited a significant increase in median cytotoxic T-cell (CD3+CD8+, CTL) density between pretreatment biopsy and surgical excision specimens, as compared to the control pts (87% vs.0.2%, p &lt; 0.05). Mean macrophage density (CD68+) was numerically lower in surgical specimens of pts who received MK-2206 vs. control pts, although CD68+ infiltration was overall low (p=ns). mRNA expression supports in vivo activity of MK-2206 with lower expression levels of cell cycle, proliferation and anti-apoptotic genes (e.g. CTNNB1, CCND2, BAX) and greater expression of pro-apoptotic genes (e.g. BAD) associated with MK-2206 treatment (raw p-value &lt;0.05). Additionally, greater mRNA copy number of IGF1R, a receptor tyrosine kinase (RTK) previously identified as upregulated in BC in the context of Akt inhibition, was found in post-MK-2206 surgical specimens as compared to control, non-MK-2206 specimens (raw p-value &lt;0.05). MK-2206 was also associated with reduced expression of myeloid markers (e.g. CSF1R, CD163) (raw p-value &lt;0.05). By GSEA, canonical gene sets related to interferon signaling were increased in post-MK-2206 specimens as compared to non-MK-2206 specimens, whereas monocyte chemotaxis genes were decreased in treated pts (adj p-value &lt;0.05). RT-PCR is currently underway to compare biopsy and surgical specimens for a subset of RTK, immune and apoptosis related genes identified above.

Conclusion: mRNA and qmIF analysis suggest that Akt inhibition, may increase interferon signaling, CTL density, and decrease myeloid infiltration. Thus, Akt inhibition may promote a favorable TME. At present, there are both FDA approved and investigational agents that target the PI3K/mTOR pathway. Further investigation is warranted to understand the impact of Akt inhibition on the TME and potential therapeutic implications.

Citation Format: Marks DK, Gartrell RD, Pan Q, El Asmar M, Hart TD, Esancy CL, Lu Y, Yu J, Hibshoosh H, Connolly E, Kalinsky K, Saenger YM. Akt inhibition associated with change in immunophenotype of tumor microenvironment (TME) in breast cancer (BC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-03-01.

Pre-surgical trial of the AKT inhibitor MK-2206 in patients with operable invasive breast cancer: a New York Cancer Consortium trial

INTRODUCTION

The PI3K/AKT/mTOR pathway is an oncogenic driver in breast cancer (BC). In this multi-center, pre-surgical study, we evaluated the tissue effects of the AKT inhibitor MK-2206 in women with stage I-III BC.

MATERIALS AND METHODS

Two doses of weekly oral MK2206 were administered at days - 9 and - 2 before surgery. The primary endpoint was reduction of pAkt^Ser473 in breast tumor tissue from diagnostic biopsy to surgery. Secondary endpoints included changes in PI3K/AKT pathway tumor markers, tumor proliferation (ki-67), insulin growth factor pathway blood markers, pharmacokinetics (PK), genomics, and MK-2206 tolerability. Paired t tests were used to compare biomarker changes in pre- and post-MK-2206, and two-sample t tests to compare with prospectively accrued untreated controls.

RESULTS

Despite dose reductions, the trial was discontinued after 12 patients due to grade III rash, mucositis, and pruritus. While there was a trend to reduction in pAKT after MK-2206 (p = 0.06), there was no significant change compared to controls (n = 5, p = 0.65). After MK-2206, no significant changes in ki-67, pS6, PTEN, or stathmin were observed. There was no significant association between dose level and PK (p = 0.11). Compared to controls, MK-2206 significantly increased serum glucose (p = 0.02), insulin (p < 0.01), C-peptide (p < 0.01), and a trend in IGFBP-3 (p = 0.06).

CONCLUSION

While a trend to pAKT reduction after MK-2206 was observed, there was no significant change compared to controls. However, the accrued population was limited, due to toxicity being greater than expected. Pre-surgical trials can identify in vivo activity in the early drug development, but side effects must be considered in this healthy population.

Proteomic modulation in breast tumors after metformin exposure: results from a "window of opportunity" trial

PURPOSE

Reverse Phase Protein Array (RPPA) is a high-throughput antibody-based technique to assess cellular protein activity. The goal of this study was to assess protein marker changes by RPPA in tumor tissue from a pre-surgical metformin trial in women with operable breast cancer (BC).

METHODS

In an open-label trial, metformin 1500-mg PO daily was administered prior to resection in 35 non-diabetic patients with stage 0-III BC, body mass index ≥25 kg/m². For RPPA, formalin-fixed paraffin-embedded (FFPE) samples were probed with 160 antibodies. Paired and two-sample t-tests were performed (p ≤ 0.05). Multiple comparisons were adjusted for by fixing the false discovery rate at 25 %. We evaluated whether pre- and post-metformin changes of select markers by RPPA were identified by immunohistochemistry (IHC) in these samples. We also assessed for these changes by western blot in metformin-treated BC cell lines.

RESULTS

After adjusting for multiple comparisons in the 32 tumors from metformin-treated patients vs. 34 untreated historical controls, 11 proteins were significantly different between cases vs.

CONTROLS

increases in Raptor, C-Raf, Cyclin B1, Cyclin D1, TRFC, and Syk; and reductions in pMAPK^pT202,Y204, JNK^pT183,pT185, Bad^pS112, PKC.alpha^pS657, and Src^pY416. Cyclin D1 change after metformin by IHC was not observed. In cell lines, reductions in JNK^pT183 and Bad^pS112 were seen, with no change in Cyclin D1 or Raptor.

CONCLUSIONS

These results suggest that metformin modulates apoptosis/cell cycle, cell signaling, and invasion/motility. These findings should be assessed in larger metformin trials. If confirmed, associations between these changes and BC clinical outcome should be evaluated. CLINICALTRIALS.

GOV IDENTIFIER

NCT00930579.

Abstract P3-07-52: Identification of serum biomarkers associated with Akt inhibitor MK-2206-induced toxicity in a pre-surgical breast cancer (BC) trial

Background: The PI3K/Akt/mTOR pathway is an important oncogenic driver in BC. A major hurdle in clinical Akt inhibitor development has been dose-limiting toxicities, such as rash. To facilitate the risk assessment of Akt inhibitor associated toxicity, we hypothesize that circulating biomarkers can be identified in proteins secreted by the tumor or tumor microenvironment and systemic response after treatment. Exosomes are small membrane bound vesicles containing proteins, mRNA, miRNA, and lipids that are secreted from host cells and remain viable after long-term storage of blood. In this study, we focused on identifying biomarkers associated with drug rash from serum exosomes in BC patients treated with the Akt inhibitor MK-2206.

Methods: In an open-label pre-surgical trial, 2 doses of weekly MK2206 were administered to patients (pts) with stage I-III invasive BC: first at day -9 and second at day -2 from surgery. Sera were collected before and after MK2206. 200 μL of serum was used to isolate total exosomes by precipitation and centrifugation, followed by trypsin digestion and multiplexing labeling analysis. The Orbitrap mass spectrometer was used to acquire LC-MS/MS data. 1,053 unique proteins were identified from the uniProt database. Maximum false discovery rate level (FDR) for predictive biomarkers was controlled at 26% (q&lt;0.26). Analysis was conducted on pre-MK-2206 and post-MK-2206 treated sera from pts to develop a protein signature associated with rash and identify candidate biomarkers of MK-2206-associated rash.

Results: The study was discontinued after 12 pts were enrolled due to toxicity. Notably, an acneiform/maculopapular rash was observed in 5 pts. Unsupervised principal component analysis on the pre-MK-2206 specimens and the entire set of 1,053 proteins demonstrated that 4 of the 5 pts with rash formed a distinct cluster. 30 proteins were differentially expressed in pre-MK-2206 samples from pts who developed rash vs. no rash (q&lt;0.26), with ≥1.5 fold difference in expression level in those with rash after MK-2206. Ingenuity pathway analysis revealed statistically significant over-representation of pathways involved in lipid metabolism (including MALRD1, AWAT2), nucleic acid synthesis (PPAT, ADSLL1), and protein synthesis (PPIB). 45 proteins were significantly different in post-MK-2206 samples (q&lt;0.285). Lipid metabolism was the most significantly over-represented pathway in post-MK-2206 samples.

Conclusions: We demonstrated that mass spectrometry-based proteomic analysis of patient-derived serum exosomes is a promising approach to study drug-induced toxicity. We found significant changes of circulating proteins before and after MK-2206. Increased expression of different proteins involved in lipid metabolism appears to predict skin toxicity, commonly seen with PI3K/Akt pathway inhibitors. Since the PI3K/Akt signaling pathway plays a role in physiological regulation of lipid metabolism, lipid metabolic profiles of BC patients might be important for predicting the risk and controlling toxicity induced by Akt inhibitors. These toxicity-associated biomarkers should be validated and then assessed prospectively in clinical trials.

Citation Format: Mundi PS, Chen E, Sparano J, Andreopoulou E, Taback B, Wiechmann L, Feldman S, Ananthakrishnan P, Hibshoosh H, Connolly E, Crew K, Maurer M, Hershman DL, Kalinsky K. Identification of serum biomarkers associated with Akt inhibitor MK-2206-induced toxicity in a pre-surgical breast cancer (BC) trial. [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 P3-07-52.

The Porphyromonas gingivalis hemagglutinins HagB and HagC are major mediators of adhesion and biofilm formation

Porphyromonas gingivalis is a bacterium associated with chronic periodontitis that possesses a family of genes encoding hemagglutinins required for heme acquisition. In this study we generated ΔhagB and ΔhagC mutants in strain W83 and demonstrate that both hagB and hagC are required for adherence to oral epithelial cells. Unexpectedly, a double ΔhagB/ΔhagC mutant had less severe adherence defects than either of the single mutants, but was found to exhibit increased expression of the gingipain-encoding genes rgpA and kgp, suggesting that a ΔhagB/ΔhagC mutant is only viable in populations of cells that exhibit increased expression of genes involved in heme acquisition. Disruption of hagB in the fimbriated strain ATCC33277 demonstrated that HagB is also required for stable attachment of fimbriated bacteria to oral epithelial cells. Mutants of hagC were also found to form defective single and multi-species biofilms that had reduced biomass relative to biofilms formed by the wild-type strain. This study highlights the hitherto unappreciated importance of these genes in oral colonization and biofilm formation.

Trade-offs between performance and variability in the escape responses of bluegill sunfish (Lepomis macrochirus)

Successful predator evasion is essential to the fitness of many animals. Variation in escape behaviour may be adaptive as it reduces predictability, enhancing escape success. High escape velocities and accelerations also increase escape success, but biomechanical factors likely constrain the behavioural range over which performance can be maximized. There may therefore be a trade-off between variation and performance during escape responses. We have used bluegill sunfish (Lepomis macrochirus) escape responses to examine this potential trade-off, determining the full repertoire of escape behaviour for individual bluegill sunfish and linking this to performance as indicated by escape velocity and acceleration. Fish escapes involve an initial C-bend of the body axis, followed by variable steering movements. These generate thrust and establish the escape direction. Directional changes during the initial C-bend were less variable than the final escape angle, and the most frequent directions were associated with high escape velocity. Significant inter-individual differences in escape angles magnified the overall variation, maintaining unpredictability from a predator perspective. Steering in the latter stages of the escape to establish the final escape trajectory also affected performance, with turns away from the stimulus associated with reduced velocity. This suggests that modulation of escape behaviour by steering may also have an associated performance cost. This has important implications for understanding the scope and control of intra- and inter-individual variation in escape behaviour and the associated costs and benefits.

TGF-β-induced activation of mTOR complex 2 drives epithelial-mesenchymal transition and cell invasion

In cancer progression, carcinoma cells gain invasive behavior through a loss of epithelial characteristics and acquisition of mesenchymal properties, a process that can lead to epithelial-mesenchymal transition (EMT). TGF-β is a potent inducer of EMT, and increased TGF-β signaling in cancer cells is thought to drive cancer-associated EMT. Here, we examine the physiological requirement for mTOR complex 2 (mTORC2) in cells undergoing EMT. TGF-β rapidly induces mTORC2 kinase activity in cells undergoing EMT, and controls epithelial cell progression through EMT. By regulating EMT-associated cytoskeletal changes and gene expression, mTORC2 is required for cell migration and invasion. Furthermore, inactivation of mTORC2 prevents cancer cell dissemination in vivo. Our results suggest that the mTORC2 pathway is an essential downstream branch of TGF-β signaling, and represents a responsive target to inhibit EMT and prevent cancer cell invasion and metastasis.

Is Metabolic Syndrome and Central Obesity Relevent to Biology and Progression of Postmenopausal Breast Cancer?

Introduction: Obesity isassociated with both an increased risk of postmenopausal breast cancer and increased mortality rates. The mechanism is unclear, and central (visceral) obesity, insulin resistance, altered sex steroids, and altered adipokines, are mooted as possible factors. These features may cluster in the so-called Metabolic Syndrome (MetS), and the focus of this study was to systematically relate MetS to standard clinicopathological indices of breast cancer.Methods: Postmenopausal women with newly diagnosed breast cancer (n=105) were prospectively recruited. A detailed clinical and dietary history was performed, as well as body composition analysis, metabolic screen, and plasma measurement of adipokines and inflammatory markers. MetS was defined according to the International Diabetes Federation definition.Results: One hundred and five patients were recruited, the median age was 68 years (40-94) and the mean BMI was 28.3 ± 5.2 kg/m2, with 87% of patients centrally obese. MetS was diagnosed in 39% of patients, and was significantly (p&lt;0.005) associated with 13cm greater waist circumference, higher total and trunk fat mass and increased inflammation with CRP levels almost double for MetS patietns compared to non MetS (10.3 ± 2.7 V's 5.8 ± 1.0 mg/L; p=0.084).Patients with later pathological stage (II- IV) were significantly more likely to be obese (BMI) (45% Vs 16%; p=0.007), centrally obese (waist circumference) (94% Vs 72%; p=0.009), hyperglycaemic (31% Vs 12%; p=0.047), hyperinsulinaemia (19% Vs 0; p=0.026) and 51% had MetS compared to 12% for early stage disease (Path stage 0-I). Patients with node positive disease were significantly more likely to be hyperinsulaemic (22% V's 5%; p=0.030) and have MetS (50% V's 30%; p=0.028) than node negative disease.MetS was not associated with hormone receptor status or serum levels of oestradiol, progesterone, testosterone, or SHBG levels. However, SHBG levels decreased with obesity (p=0.002) and as the number of features of MetS increased (0 features: 87 ± 15.8 compared to 5 features: 32 ±2.7; p=0.003). Insulin levels increased with obesity (p=0.006), and with increasing number of features of MetS.Discussion: MetS and central obesity are common in Irish postmenopausal breast cancer patients. MetS appears to be associated with aggressive tumour biology, and this may have significance in preventive and novel treatment approaches.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1051.

Adverse Clinico-Pathological Features in Breast Cancer Patients under the Age of 35

IntroductionBreast cancer in younger patients is a unique disease entity, associated with aggressive biologic phenotype and poorer prognosis. The aim of this study was to analyse age as a prognostic factor in pre-menopausal breast cancer specifically in regards to pre-menopausal patients under the age of 35.MethodsA 7 year prospective audit of pre-menopausal patients presenting to the symptomatic breast clinic in St. James's Hospital between 2001 and 2008 was conducted. The Clinico-pathological features of pre-menopausal patients presenting under the age of 35 versus over 35 where compared. All cancer diagnoses were discussed at the breast multidisciplinary conference, and all clinico-pathological treatment details and follow-up information were entered by a full-time data manager.ResultsPre-menopausal patients under the age of 35 (n=55) were more likely to present with higher grade (p&lt;0.05), oestrogen receptor negative (p&lt;0.05), HER-2 receptor negative (p&lt;0.05) and stage IV disease (p&lt;0.05) relative to the older premenopausal group (n=250). This group also had a non-significant increased rate of lymphovascular invasion and negative progesterone receptor status compared to the older premenopausal group (p&gt; 0.05). Pre-menopausal patients over the age of 35 were twice as likely to have lobular carcinoma as opposed to their younger counterparts. Tumour size, nodal status and axillary node burden was not significantly different between groups. Patients under-35 with breast cancer were more likely to be nulliparous.ConclusionThis data demonstrates that breast cancer in pre-menopausal patients under the age of 35 is associated with adverse clinicopathological features relative to the older pre-menopausal patients. Further studies should be aimed at assessing the prognosis, disease recurrence, disease free survival and distinct genetic profile in age related breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3043.

Elevated expression of the miR-17-92 polycistron and miR-21 in hepadnavirus-associated hepatocellular carcinoma contributes to the malignant phenotype

Alterations in microRNA (miRNA) expression in both human and animal models have been linked to many forms of cancer. Such miRNAs, which act directly as repressors of gene expression, have been found to frequently reside in fragile sites and genomic regions associated with cancer. This study describes a miRNA signature for human primary hepatitis B virus-positive human hepatocellular carcinoma. Moreover, two known oncomiRs--miRNAs with known roles in cancer--the miR-17-92 polycistron and miR-21, exhibited increased expression in 100% of primary human and woodchuck hepatocellular carcinomas surveyed. To determine the importance of these miRNAs in tumorigenesis, an in vitro antisense oligonucleotide knockdown model was evaluated for its ability to reverse the malignant phenotype. Both in human and woodchuck HCC cell lines, separate treatments with antisense oligonucleotides specific for either the miR-17-92 polycistron (all six members) or miR-21 caused a 50% reduction in both hepatocyte proliferation and anchorage-independent growth. The combination of assays presented here supports a role for these miRNAs in the maintenance of the malignant transformation of hepatocytes.

Clinical ethicists' perspectives on organisational ethics in healthcare organisations

BACKGROUND

Demand for organisational ethics capacity is growing in health organisations, particularly among managers. The role of clinical ethicists in, and perspective on, organisational ethics has not been well described or documented in the literature.

OBJECTIVE

To describe clinical ethicists' perspectives on organisational ethics issues in their hospitals, their institutional role in relation to organisational ethics, and their perceived effectiveness in helping to address organisational ethics issues.

DESIGN AND SETTING

Qualitative case study involving semi-structured interviews with 18 clinical ethicists across 13 health organisations in Toronto, Canada.

RESULTS

From the clinical ethicists' perspective, the most pressing organisational ethics issues in their organisations are: resource allocation, staff moral distress linked to the organisation's moral climate, conflicts of interest, and clinical issues with a significant organisational dimension. Clinical ethicists were consulted in particular on issues related to staff moral distress and clinical issues with an organisational dimension. Some ethicists described being increasingly consulted on resource allocation, conflicts of interest, and other corporate decisions. Many clinical ethicists felt they lacked sufficient knowledge and understanding of organisational decision-making processes, training in organisational ethics, and access to organisational ethics tools to deal effectively with the increasing demand for organisational ethics support.

CONCLUSION

Growing demand for organisational ethics expertise in healthcare institutions is reshaping the role of clinical ethicists. Effectiveness in organisational ethics entails a re-evaluation of clinical ethics training to include capacity building in organisational ethics and organisational decision-making processes as a complement to traditional clinical ethics education.