Proteogenomic Approaches for the Identification of NF1/Neurofibromin-depleted Estrogen Receptor-positive Breast Cancers for Targeted Treatment

NF1 is a key tumor suppressor that represses both RAS and estrogen receptor-α (ER) signaling in breast cancer. Blocking both pathways by fulvestrant (F), a selective ER degrader, together with binimetinib (B), a MEK inhibitor, promotes tumor regression in NF1-depleted ER⁺ models. We aimed to establish approaches to determine how NF1 protein levels impact B+F treatment response to improve our ability to identify B+F sensitive tumors. We examined a panel of ER⁺ patient-derived xenograft (PDX) models by DNA and mRNA sequencing and found that more than half of these models carried an NF1 shallow deletion and generally have low mRNA levels. Consistent with RAS and ER activation, RET and MEK levels in NF1-depleted tumors were elevated when profiled by mass spectrometry (MS) after kinase inhibitor bead pulldown. MS showed that NF1 can also directly and selectively bind to palbociclib-conjugated beads, aiding quantification. An IHC assay was also established to measure NF1, but the MS-based approach was more quantitative. Combined IHC and MS analysis defined a threshold of NF1 protein loss in ER⁺ breast PDX, below which tumors regressed upon treatment with B+F. These results suggest that we now have a MS-verified NF1 IHC assay that can be used for patient selection as a complement to somatic genomic analysis.

Significance

A major challenge for targeting the consequence of tumor suppressor disruption is the accurate assessment of protein functional inactivation. NF1 can repress both RAS and ER signaling, and a ComboMATCH trial is underway to treat the patients with binimetinib and fulvestrant. Herein we report a MS-verified NF1 IHC assay that can determine a threshold for NF1 loss to predict treatment response. These approaches may be used to identify and expand the eligible patient population.

Elevated NRAS expression during DCIS is a potential driver for progression to basal-like properties and local invasiveness

BACKGROUND

Ductal carcinoma in situ (DCIS) is the most common type of in situ premalignant breast cancers. What drives DCIS to invasive breast cancer is unclear. Basal-like invasive breast cancers are aggressive. We have previously shown that NRAS is highly expressed selectively in basal-like subtypes of invasive breast cancers and can promote their growth and progression. In this study, we investigated whether NRAS expression at the DCIS stage can control transition from luminal DCIS to basal-like invasive breast cancers.

METHODS

Wilcoxon rank-sum test was performed to assess expression of NRAS in DCIS compared to invasive breast tumors in patients. NRAS mRNA levels were also determined by fluorescence in situ hybridization in patient tumor microarrays (TMAs) with concurrent normal, DCIS, and invasive breast cancer, and association of NRAS mRNA levels with DCIS and invasive breast cancer was assessed by paired Wilcoxon signed-rank test. Pearson's correlation was calculated between NRAS mRNA levels and basal biomarkers in the TMAs, as well as in patient datasets. RNA-seq data were generated in cell lines, and unsupervised hierarchical clustering was performed after combining with RNA-seq data from a previously published patient cohort.

RESULTS

Invasive breast cancers showed higher NRAS mRNA levels compared to DCIS samples. These NRAShigh lesions were also enriched with basal-like features, such as basal gene expression signatures, lower ER, and higher p53 protein and Ki67 levels. We have shown previously that NRAS drives aggressive features in DCIS-like and basal-like SUM102PT cells. Here, we found that NRAS-silencing induced a shift to a luminal gene expression pattern. Conversely, NRAS overexpression in the luminal DCIS SUM225 cells induced a basal-like gene expression pattern, as well as an epithelial-to-mesenchymal transition signature. Furthermore, these cells formed disorganized mammospheres containing cell masses with an apparent reduction in adhesion.

CONCLUSIONS

These data suggest that elevated NRAS levels in DCIS are not only a marker but can also control the emergence of basal-like features leading to more aggressive tumor activity, thus supporting the therapeutic hypothesis that targeting NRAS and/or downstream pathways may block disease progression for a subset of DCIS patients with high NRAS.

Description of a clinical intervention among patients admitted to the medium secure forensic psychiatric services in Central Denmark Region

Introduction

Patients with schizophrenia suffer from increased mortality rates equivalent to 15-20 years shorter life expectancy. Up to 60% of this excess mortality can be explained by preventable, somatic conditions like cardiovascular, metabolic, and respiratory comorbidities. As forensic psychiatric (FP) patients often experience the triple stigmatization of mental illness, substance misuse and criminal conviction, the risk of suboptimal diagnosis and treatment may be high. Although benefits from the addition of general practitioner (GP) services to non-FP wards have been shown elsewhere, this cross-sectoral approach has never been attempted in a Danish FP ward.

Objectives

One purpose of this project is to evaluate the associations between self-reported quality of life and objective measures of somatic health.

Methods

A clinical intervention in which a GP consults patients in all medium secure wards in the Central Denmark Region (N=72). The consultation includes a physical examination, medication review, and evaluation of blood samples. Data is collected from: electronic patient files and questionnaires regarding quality of life (SF-12), lifestyle, and attitude towards GP services.

Results

The population will be described in regards to socio-demographic, clinical, and forensic characteristics. Associations will be made between quality of life (SF-12), metabolic syndrome, blood markers, and heart-SCORE risk. Risk profiles for endocrinologic and coronary illness will be examined.

Conclusions

Results may guide future health interventions and will be used as a basis for adjustments to the current project.

Disclosure

No significant relationships.

Quality of Life, Risk and Recovery in a National Forensic Mental Health Service: A D-FOREST study from DUNDRUM Hospital

Introduction

Secure forensic mental health services have a dual role, to treat mental disorder and reduce violent recidivism. Quality of life is a method of assessing an individual patients’ perception of their own life and is linked to personal recovery. Placement in secure forensic hospital settings should not be a barrier to achieving meaningful quality of life. The WHO-QuOL measure is a self-rated tool, internationally validated used to measure patients own perception of their quality of life.

Objectives

This aim of this study was to assess self-reported quality of life in a complete National cohort of forensic in-patients, and ascertain the associations between quality of life and measures of violence risk, recovery and functioning.

Methods

This is a cross sectional study, set in Dundrum Hospital, the site of Ireland’s National Forensic Mental Health Service. It therefore includes a complete national cohort of forensic in-patients. The WHO-QuOL was offered to all 95 in-patients in Dundrum Hospital during December 2020 – January 2021, as was PANSS (Positive and Negative Symptoms for Schizophrenia Scale). During the study period the researchers collated the scores from HCR-20 (violence risk), therapeutic programme completion (DUNDRUM-3) and recovery (DUNDRUM-4). Data was gathered as part of the Dundrum Forensic Redevelopment Evaluation Study (D-FOREST).

Results

Lower scores on dynamic violence risk, better recovery and functioning scores were associated with higher self-rated quality of life.

Conclusions

The quality of life scale was meaningful in a secure forensic hospital setting. Further analysis will test relationships between symptoms, risk and protective factors and global function.

Disclosure

No significant relationships.

Sedentary Behaviour in the Secure Forensic Hospital Setting: A Study from Dundrum Hospital Ireland

Introduction

Secure forensic mental health services offer care and treatment to mentally disordered offenders, with high rates of schizophrenia and major mental illness in these groups. Much of the excess morbidity and mortality seen among patients with schizophrenia is due to cardiovascular disease and obesity. Sedentary behaviour is associated with negative symptoms of schizophrenia and obesity.

Objectives

The aim of this study was to ascertain the level of sedentary behaviour among inpatients in a secure forensic psychiatric hospital, Dundrum, Ireland, using a structured self-report measure of sedentary behaviours, the SIT-Q tool.

Methods

A cross sectional study of self-reported sedentary behaviour was completed amongst the secure forensic inpatient population of Dundrum Hospital (N=94). Demographic details, details pertaining to diagnoses, ward level of dependency and length of stay were collated.

Results

The majority of patients in the sample were male (89%) and the most common diagnosis was schizophrenia (71.7%). Mean age was 44.7 years (SD 11.42). 58.2% met criteria for obesity. We found high rates of self-reported sedentary behaviour across all wards of the service, with significantly high rates of sedentary behaviour being associated with screen time use in the hospital, including both personal screen time and therapeutic sessions based on screen time.

Conclusions

Sedentary behaviour among in-patients in secure forensic hospitals is a significant issue. Measuring sedentary behaviour in a systematic manner is possible and identifies a potentially modifiable target to reduce co-morbidity and pre-mature mortality independent of other risk factors in this vulnerable patient group.

Disclosure

No significant relationships.

Frailty in Secure Forensic Mental Health Settings: A Study from Dundrum Hospital, Ireland

Introduction

Frailty is defined as a clinical syndrome that encompasses a combination of decreased physiological reserve and low resistance to stressors. There is an association between mental illness and frailty among elderly cohorts. Frailty is also associated with obesity and smoking. There are high rates of treatment resistant schizophrenia among patients in secure forensic services. Patients with schizophrenia have high rates of morbidity and early mortality.

Objectives

The primary aim of this study was to examine the rates of frailty present in a complete cohort of forensic in-patients.

Methods

An assessment using Fried Frailty criteria was offered to all in-patients (n=95) in Ireland’s National Forensic Service, which included measures of walking speed, grip strength, low physical activity and exhaustion. Demographic details and details pertaining to diagnoses and medications were also gathered.

Results

Of the 95 in-patients, 92 patients agreed to participate. The majority were male (89%). The most common diagnosis was schizophrenia (71.7%). Mean age was 44.7 years (SD 11.42), and 58.2% met criteria for obesity. Of the total group, 47 patients met criteria for ‘pre-frail’ and 10 met criteria for ‘frail’ using Fried criteria.

Conclusions

This is the first study examining frailty in a cohort of patients in secure forensic settings. We found high rates of patients meeting frailty criteria at very young ages. Rates of frailty in this group were comparable to those found amongst elders in community settings. We consider this demonstrates significant medical vulnerability in this patient group.

Disclosure

No significant relationships.

Decision-making capacity regarding healthcare, welfare and finances in a secure forensic setting

Introduction

Impairment in decision-making capacity is a serious consequence of executive dysfunction secondary to serious mental disorders like schizophrenia. Functional mental capacity (FMC) refers to an individual’s ability to make and communicate legally competent decisions autonomously. Studies have shown that FMC is dependent on severity of psychosis and can improve with treatment.

Objectives

To ascertain the correlation between the scores on a structured judgement tool, namely the Dundrum Capacity Ladders (DCL) with level of acuity of treatment setting and length of stay in a secure forensic hospital.

Methods

Sixty-two patients were interviewed using the DCL across three domains – healthcare, welfare and finances. Correlation between DCL scores, length of hospital stay and level of acuity of treatment setting was assessed.

Results

As patients moved from higher to lower dependency wards, mean DCL score increased, indicating a higher level of capacity. Patients in high dependency wards were most impaired while those in the low dependency wards performed significantly better (r_s=0.472, p<0.001). The longer the patients stayed in the hospital, up until five years, the higher the mean welfare domain score (r_s=0.402, p=0.011) and mean DCL score (r_s=0.376, p=0.018). Beyond five years of hospital stay, those who had lower DCL scores and did not improve had longer length of stay.

Conclusions

Patients’ FMC improve as they progress from high to low level of acuity of treatment setting. However, this is dependent on the length of hospital stay. FMC may be a measure of recovery in the forensic setting.

Disclosure

No significant relationships.

Zero violence or zero seclusion. Which is more acceptable in our hospitals?

Introduction

There is an established association between serious mental illness and violence. Secure forensic psychiatric services provide care and treatment to mentally disordered offenders. The majority of patients in forensic services suffer from severe mental illnesses such as schizophrenia, with co-morbid polysubstance abuse and maladaptive personality traits. Psychiatric services are under significant pressure to reduce the use of seclusion and restrictive practices, whilst mandated to provide safe environments for patients and staff.

Objectives

To determine the number and characteristics of violent incidents in a secure forensic hospital in Ireland.

Methods

A retrospective review of all incidents in Central Mental Hospital, Ireland between 1^st March 2019 and 31^st August 2021 was completed. Incidents were categorised into physical assaults and other violent incidents. Demographic measures and measures of violence risk (HCR-20), functioning (GAF), programme completion and recovery (DUNDRUM tool) were collated.

Results

A total of 321 incidents took place during the period examined, of which 47 (14.6%) involved physical assaults perpetrated by patients. Between March 2020 and August 2021, numbers of assaults increased by 50% and 78% compared to the preceding six-month period respectively. The majority of assaults were committed by a relatively small group of patients. Victims of assaults were more likely to be patients (n=27, 57.4%) and more likely to be males (n=43, 91.9%).

Conclusions

Physical assaults and other violent incidents happen in forensic and general psychiatric units. Restrictive practices, used in accordance with the law, are necessary at times to prevent serious harm to patients and staff in psychiatric hospitals.

Disclosure

No significant relationships.

The characteristics of homicide perpetrators in a medium secure forensic hospital: A study from dundrum hospital

Introduction

The majority of homicides in society are not associated with mental illness, however there is an established association between homicide and schizophrenia. Homicide perpetrated by mentally disordered offenders is a leading reason for admission to secure forensic psychiatric hospitals.

Objectives

To investigate the clinical characteristics of those with a history of completed homicide in the CMH Dundrum.

Methods

This study was a cross sectional study of a cohort of patients in the Central Mental Hospital who had completed homicide (n=63).

Results

A total of 136 patients were included, 46.3% (n=63) of whom had committed homicide. Mean age of homicide perpetrators at admission was 34.6 years old (median 33.4, s.d. = 9.72). The most common diagnosis was schizophrenia (n=40, 63.5%). 73.0% (n=46) had a history of substance misuse. 36.5% (n=23) had a diagnosis of a personality disorder, including traits only. The most common victim type was a family member (n=32, 50.8%). Patients with a history of homicide had better scores on dynamic risk of violence (F=8.553, p=0.004), programme completion (F=8.258, p=0.005) and recovery (F=3.666, p=0.058) compared to non-homicide offenders, however they also had significantly longer mean length of stay, 12.7 years v 7.5 years (F=9.634,p=0.002).

Conclusions

Homicide perpetrators with a mental illness constitute a significant portion of the forensic mental health population and a high number of these offences were against family members. A history of homicide among forensic in-patients is associated with a longer length of stay which has implications for service development into the future.

Abstract 2490: Optimizing treatment strategy for NF1-depleted estrogen receptor positive breast cancer

Background: Germline mutations in the NF1 gene are responsible for neurofibromatosis type 1, which is the world's most common genetic disorder. NF1 is also a key tumor suppressor gene that is frequently somatically mutated in a wide range of cancers. Approximately 80% of breast cancer is driven by the estrogen receptor α (ER), encoded by the ESR1 gene, and ER-positive (ER+) breast cancer can be treated by endocrine therapy targeting the ER transcriptional pathway. NF1 encodes neurofibromin, which is best known as a GTPase Activating Protein (GAP) for repressing Ras signaling. However, in a recent study we presented evidence supporting the model that NF1 has a GAP-independent activity by also acting as a transcriptional co-repressor for ER. NF1 loss enhanced ER transcription causing resistance to tamoxifen and aromatase inhibition.

Approach and Results: In this study, we examined patient data from TCGA cohort and found that low NF1 mRNA levels associated with recurrence in luminal breast cancer, particularly in the luminal B subtype. Using purified components, we showed that full-length NF1 can directly bind ER. The ESR1-pE380Q mutation is a recurrent event in metastatic ER+ breast cancer. Our two-hybrid data showed that NF1 interacted less with the ER-E380Q than wild type ER, which agrees with structural analysis predicting co-repressors binding to be mediated by the ER-E380 residue. To assess how NF1-loss impacts ER-dependent gene expression in ER+ breast cancer cells, our ER ChIP-seq data showed that in the presence of estradiol, NF1-depletion promoted global ER recruitment to estrogen response elements (EREs) on chromatin. Expression of ERE-bound genes showed concordant expression changes by RNA-seq, confirming genome-wide transcriptional dysregulation of ER targeted genes by NF1 loss. ER+ NF1-depleted breast cancer cells responded initially to a selective ER degrader (SERD), such as fulvestrant and an oral SERD AZD9496, but acquired resistance with prolonged treatment. Resistance may be dependent on CDK4/6, a common growth pathway controlled by both Ras and ER. We showed that fulvestrant together with a CDK4/6 inhibitor Palbociclib can efficiently inhibit the growth of ER+ NF1-depleted breast cancer leading to tumor regression in a patient derived xenograft model.

Conclusion: The loss of the full length NF1 can stimulate both ER and Ras signaling, and it is possible to efficiently treat ER+ NF1-depleted breast cancer by a SERD, in combination with CDK4/6 inhibitor.

Citation Format: Zeyi Zheng, Jonathan T. Lei, Meenakshi Anurag, Long Feng, Purba Singh, Hilda Kennedy, Jin Cao, Xi Chen, Matthew J. Ellis, Eric C. Chang. Optimizing treatment strategy for NF1-depleted estrogen receptor positive breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2490.

Care & custody: E-sport and patient-professional power-relations in forensic psychiatry. A qualitative study

Introduction

Recovery orientated care emphasizes equality in relations. Forensic psychiatric professionals need to engage in care-relationships with patients in ways where power is symmetrically distributed among them. However, professionals also need to focus on security at the ward. This promotes patient-professional power-relations that are asymmetrically skewed towards professionals. New practical ways of balancing between the power-relations defined by a care and custody dichotomy in forensic care need to be developed and studied to guide clinical practice.

Objectives

To study how power-relations are articulated between patient-professional within a social gaming activity (E – sport) in a Danish medium secure forensic psychiatric ward.

Methods

Three months of observational data, collected via anthropological fieldwork Interviews with 3 professionals and 6 patients Data was analyzed using sociologist Pierre Bourdieu’s notions of field, capital and power

Results

The E-sport intervention consists of two fields “in-game” and “over-game” In-game concerns the practice of gaming Over-game concerns the interventions organization Power in each field is driven by specific values and access to certain competencies Power in-game was equally open to patients and professionals leading to symmetric power relations Power over-game was open to professionals only leading to asymmetrical power relations Professionals may allow power distribution to patients during gameplay, while still retaining the overall power over the intervention

Conclusions

It is possible to balance between care-and-custody in forensic psychiatry. This study provides important insights to guide further practice.

Tidier. e-sport; a recovery oriented intervention in forensic psychiatry

Introduction

Recently video gaming, have attracted considerable attention for its possible beneficial therapeutic effects, the possibility for testing behavior in safe artificial environments and as a tool for professionals and patients to build specific competencies for the everyday life. Also, a substantial amount of research suggests that videogaming might improve the participants social and cognitive skills and emotional regulation. There is little or no evidence that videogaming increases long term aggression or leads to physical aggression. At a medium secure forensic psychiatric in-patient ward, the patients and staff engage in weekly E – Sport sessions (primarily counterstrike) to further the recovery process.

Objectives

To provide a standardized description of how E-sport is organized and used in the recovery process among forensic psychiatric patients.

Methods

The Template for Intervention Description and Replication (TIDieR) checklist and guide is widely used to in health research to describe interventions in clinical trials and other health research contexts. By use of TIDieR we describe a newly developed E-sport intervention, in which staff members and patients in a medium secure forensic psychiatric ward engage in weekly E-Sport sessions (primarily counterstrike) to improve patient–staff relationship.

Results

The E-sport intervention is detailed by use of the 12 TIDieR items and practical experiences and insights will be described.

Conclusions

This standardized and detailed description of how is used in a recovery-oriented process in forensic psychiatry can be used for future studies that wishes to implement the intervention or for research studies replicating the treatment.

Conflict of interest

No significant relationships.

Modernized architecture may reduce coercion

Introduction

Prevention and treatment of aggression in psychiatric hospitals is achieved through appropriate medical treatment, professional skills, and optimized physical environment and architecture. Coercive measures are used as a last resort. In 2018 Aarhus University Hospital Psychiatry moved from 19th-century asylum buildings to a newly built modern psychiatric hospital. Advances within psychiatric care have rendered the old psychiatric asylum hospitals inadequate for modern treatment of mental disorders.

Objectives

To examine if relocating from a psychiatric hospital, dating from 19th century to a new, modern psychiatric hospital decreased the use of coercive measures.

Methods

This is a retrospective longitudinal study, with a follow-up from 2017 to 2019. We use two designs; 1) a pre-post analysis of the use of coercive measures at Aarhus University Hospital Psychiatry before and after the relocation and 2) a case-control analysis of Aarhus University Hospital Psychiatry and the other psychiatric hospitals in the Central Region. Data will be analyzed in STATA using an interrupted time-series analysis or similar method. Additionally case-mix and sensitivity analysis will be performed.

Results

Preliminary results show a 45% decrease in the total number of coercive measures and a 52% decrease in the use of mechanical restraint. The reduction that may reasonably be attributed to the relocation is still to be determined and will be presented at the congress.

Conclusions

The study may illuminate how future development and planning of psychiatric facilities might improve psychiatric treatment and increase the understanding of how structural changes might contribute the prevention of the use of coercive measures.

Disclosure

No significant relationships.

Stratification of a medium secure forensic care pathway according to risk and need: A study from dundrum hospital

Introduction

Secure forensic mental health services have a dual role, to treat mental illness and reduce violent recidivism. Those admitted to secure forensic services have a significant history of violence and treatment needs in multiple domains including psychiatric illness, violence and other areas such as substance misuse and physical health.

Objectives

The aim of this study was to ascertain if the units in a medium secure forensic hospital are stratified according to individual risks and needs. We also aimed to clarify if there were differences in the symptom level, risks and needs of those with and without community leave and to clarify the risks and needs of the female patients and ID patients.

Methods

This is a cross sectional study a cohort of patients (n=138) in a secure forensic hospital.

Results

There was a total of 138 patients, the majority of whom were male (n=123, 89.1%). The most common diagnosis was schizophrenia (n=99, 71.7%). Placements in the care pathway of the medium secure forensic hospital were associated with level of symptomatology (PANSS positive), dynamic violence risk (F=26.880,P<0.001), DUNDRUM-3 therapeutic programme completion (F=44.067,P<0.001), and DUNDRUM 4 recovery (F=59.629,P<0.001). Patients with community leave had better scores than those without leave on violence risk (F=77.099, P<0.001), therapeutic programme completion (F=116.072, P<0.001) and recovery (F=172.211, P<0.001).

Conclusions

Stratifying secure forensic psychiatric hospitals according to individual risks and needs provides in-patient care in the least restrictive setting appropriate for individuals, however niche groups such as female forensic patients and ID patients may need special consideration.

COVID-19 in forensic psychiatry settings: The unique vulnerability of patients in secure services

Introduction

Secure forensic mental health services treat patient with high rates of treatment resistant psychoses, typically schizophrenia. These groups have high rates of obesity and medical co-morbidities. Population based studies have identified high risk groups in the event of SARS-CoV-2 infection, including those with long term medical conditions.

Objectives

The aim of this study was to compare the vulnerability to serious adverse outcome in the event of COVID-19 infection in a forensic psychiatric patient population.

Methods

All patients of a complete National Forensic Mental Health Service (n=141) were rated for risk of adverse outcome in the event of SARS-CoV-2 infection, using two structured tools, the COVID-AGE tool and the COVID-Risk tool.

Results

Eighty-two patients (58.2%) met criteria for obesity, 32 had type II diabetes and 28 were hypertensive. Mean chronological age was 45.5 years (SD 11.4, median 44.1), while mean COVID-AGE was 59.1 years (SD 19.4, median 58.0), mean difference 13.6 years (SD 15.6) paired t=10.9, df=140, p=0.000. Three patients (2.1%) were chronologically over 70 years compared to 40 (28.4%) with a COVID-AGE over 70 (X2=6.99, df=1, p=0.008, Fishers exact test p=0.027).

Conclusions

These risk assessments may identify the extent of increased risk among a uniquely medically vulnerable patient group. Patients in secure forensic psychiatric services represent a high-risk group for adverse outcomes in the event of SARS-COV-2 infection. Population based cocooning and self-isolating guidance based on chronological age may not be sufficient. There is an urgent need for better physical health research and treatment in this group.

Changes in BMI and blood pressure after implementing a complete smoking ban in a medium secure forensic setting: A study from dundrum hospital dublin

Introduction

In February 2020, the Central Mental Hospital Dundrum moved to a complete ban on cigarette smoking. Concerns were raised that this might represent a ‘restrictive practice’ and that patients might gain weight or see changes in their blood pressure if they were not permitted to smoke.

Objectives

The aim of the study was to ascertain if there were changes in the blood pressure readings or body mass index of a group of patients in a secure forensic hospital after the implementation of a complete campus-wide smoking ban

Methods

All patients (n=20) working with one medium cluster team were included in the study. Demographic details and data pertaining to legal status, diagnosis and length of stay in the hospital were obtained. BMI, blood pressure and medications were reviewed at the time of introduction of the smoking ban, 1^st February 2020 and again 5 months later.

Results

All those included in the study were male. The median age was 35 years, most common diagnosis was schizophrenia and mean length of stay was 4.23 years. 20% of patients were prescribed anti-hypertensives at the time of introduction of the smoking ban. All of the patients on anti-hypertensives were overweight. At follow up there was no increase in BMI noted in the patient group. Two patients had dose reductions in anti-hypertensives, three had discontinuation of bronchodilators.

Conclusions

Introducing a campus wide smoking ban in a secure forensic psychiatric hospital is both clinically positive and practically possible. There was no noted increase in incidents in the hospital during this period.

Surprise Diagnosis of COVID-19 following Neuroimaging Evaluation for Unrelated Reasons during the Pandemic in Hot Spots

During the height of the recent outbreak of coronavirus 19 (COVID-19) in New York City, almost all the hospital emergency departments were inundated with patients with COVID-19, who presented with typical fever, cough, and dyspnea. A small number of patients also presented with either unrelated conditions (such as trauma) or other emergencies, and some of which are now known to be associated with COVID-19 (such as stroke). We report such a scenario in 17 patients who were admitted and investigated with CT spine imaging and CT angiography for nonpulmonary reasons (trauma = 13, stroke = 4). Their initial work-up did not suggest COVID-19 as a diagnosis but showed unsuspected/incidental lung findings, which led to further investigations and a diagnosis of COVID-19.

Neurofibromin Is an Estrogen Receptor-α Transcriptional Co-repressor in Breast Cancer

We report that neurofibromin, a tumor suppressor and Ras-GAP (GTPase-activating protein), is also an estrogen receptor-α (ER) transcriptional co-repressor through leucine/isoleucine-rich motifs that are functionally independent of GAP activity. GAP activity, in turn, does not affect ER binding. Consequently, neurofibromin depletion causes estradiol hypersensitivity and tamoxifen agonism, explaining the poor prognosis associated with neurofibromin loss in endocrine therapy-treated ER⁺ breast cancer. Neurofibromin-deficient ER⁺ breast cancer cells initially retain sensitivity to selective ER degraders (SERDs). However, Ras activation does play a role in acquired SERD resistance, which can be reversed upon MEK inhibitor addition, and SERD/MEK inhibitor combinations induce tumor regression. Thus, neurofibromin is a dual repressor for both Ras and ER signaling, and co-targeting may treat neurofibromin-deficient ER⁺ breast tumors.

Hepatitis and HIV in Northern Ireland prisons: a cross-sectional study

A study was undertaken in Northern Ireland (NI) prisons to (i) determine prevalence of bloodborne viruses among inmates, (ii) estimate the extent of self-reported risk behaviours. All three prisons in NI were included in the study. Outcome measures included (i) antibodies to hepatitis C (HCV), hepatitis B (HBV) core antigen, HIV, (ii) self-reported risk behaviour. Five prisoners (0.75%) tested positive for HBV, seven (1.1%) for HCV and none for HIV. Eleven per cent reported ever having injected drugs. Of these, 20% had started injecting while in prison, and 12% shared injecting equipment in prison. Two per cent had completed HBV immunisation. Injecting drugs was associated with HCV (adjusted prevalence ratio=5.2; 95% CI 0.9-16) and HBV infection (adjusted prevalence ratio=4.1; 95% CI 0.7-23). The low prevalence of bloodborne viruses within NI prisons is not consistent with findings of studies in other countries, possibly reflecting the unique sociopolitical situation in NI. In spite of knowledge of the risks of transmission of bloodborne viruses in prison, high-risk practices are occurring. Preventing risk behaviours and transmission of infection in prisons now poses a challenge for health services in the United Kingdom.

Growth and hormone profiling in children with congenital melanocytic naevi

Background

Multiple congenital melanocytic naevi (CMN) is a rare mosaic RASopathy, caused by postzygotic activating mutations in NRAS. Growth and hormonal disturbances are described in germline RASopathies, but growth and hormone status have not previously been investigated in individuals with CMN.

Objectives

To explore premature thelarche, undescended testes, and a clinically abnormal fat distribution with CMN through prospective endocrinological assessment of a cohort of subjects with CMN, and a retrospective review of longitudinal growth of a larger group of patients with CMN from outpatient clinics (which included all subjects in the endocrinological assessment group).

Patients and methods

Longitudinal growth in a cohort of 202 patients with single or multiple CMN was compared with the U.K. National Child Measurement Programme 2010. Forty‐seven children had hormonal profiling including measurement of circulating luteinizing hormone, follicle‐stimulating hormone, thyroid stimulating hormone, adrenocorticotrophic hormone, growth hormone, prolactin, pro‐opiomelanocortin, estradiol, testosterone, cortisol, thyroxine, insulin‐like growth factor‐1 and leptin; 10 had oral glucose tolerance testing 25 had dual‐energy X‐ray absorptiometry scans for body composition.

Results

Body mass index increased markedly with age (coefficient 0·119, SE 0·016 standard deviation scores per year), at twice the rate of the U.K. population, due to increased adiposity. Three per cent of girls had premature thelarche variant and 6% of boys had persistent undescended testes. Both fat and muscle mass were reduced in areas underlying large naevi, resulting in limb asymmetry and abnormal truncal fat distribution. Anterior pituitary hormone profiling revealed subtle and variable abnormalities. Oral glucose tolerance tests revealed moderate–severe insulin insensitivity in five of 10, and impaired glucose tolerance in one.

Conclusions

Interpersonal variation may reflect the mosaic nature of this disease and patients should be considered individually. Postnatal weight gain is potentially related to the underlying genetic defect; however, environmental reasons cannot be excluded. Naevus‐related reduction of fat and muscle mass suggests local hormonal or metabolic effects on development or growth of adjacent tissues, or mosaic involvement of these tissues at the genetic level. Premature thelarche and undescended testes should be looked for, and investigated, as for any child.

What's already known about this topic?

CMN are caused by postzygotic mutations in the gene NRAS in the majority of cases, classifying it within the group of mosaic RASopathies.

Other germline and mosaic RASopathies are known to have growth and hormonal abnormalities.

No studies have been done on growth or endocrinology in children with CMN.

What does this study add?

Average body mass index increases markedly with age compared with the normal population; this is due to increased adiposity, and can be associated with insulin insensitivity.

Premature thelarche variant and persistent undescended testes are not infrequent findings, but puberty appears to develop normally.

Both fat and muscle mass can be reduced in areas underlying large naevi, resulting in asymmetry.

Linked Comment:Millington, Br J Dermatol 2015; 173: 1366–67.

Regulation of alternative VEGF-A mRNA splicing is a therapeutic target for analgesia

Vascular endothelial growth factor-A (VEGF-A) is best known as a key regulator of the formation of new blood vessels. Neutralization of VEGF-A with anti-VEGF therapy e.g. bevacizumab, can be painful, and this is hypothesized to result from a loss of VEGF-A-mediated neuroprotection. The multiple vegf-a gene products consist of two alternatively spliced families, typified by VEGF-A₁₆₅a and VEGF-A₁₆₅b (both contain 165 amino acids), both of which are neuroprotective. Under pathological conditions, such as in inflammation and cancer, the pro-angiogenic VEGF-A₁₆₅a is upregulated and predominates over the VEGF-A₁₆₅b isoform.

We show here that in rats and mice VEGF-A₁₆₅a and VEGF-A₁₆₅b have opposing effects on pain, and that blocking the proximal splicing event – leading to the preferential expression of VEGF-A₁₆₅b over VEGF₁₆₅a – prevents pain in vivo. VEGF-A₁₆₅a sensitizes peripheral nociceptive neurons through actions on VEGFR2 and a TRPV1-dependent mechanism, thus enhancing nociceptive signaling. VEGF-A₁₆₅b blocks the effect of VEGF-A₁₆₅a.

After nerve injury, the endogenous balance of VEGF-A isoforms switches to greater expression of VEGF-A_xxxa compared to VEGF-A_xxxb, through an SRPK1-dependent pre-mRNA splicing mechanism. Pharmacological inhibition of SRPK1 after traumatic nerve injury selectively reduced VEGF-A_xxxa expression and reversed associated neuropathic pain. Exogenous VEGF-A₁₆₅b also ameliorated neuropathic pain.

We conclude that the relative levels of alternatively spliced VEGF-A isoforms are critical for pain modulation under both normal conditions and in sensory neuropathy. Altering VEGF-A_xxxa/VEGF-A_xxxb balance by targeting alternative RNA splicing may be a new analgesic strategy.

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The different vegf-a splice variants, VEGF-A₁₆₅a and VEGF-A₁₆₅b have pro- and anti-nociceptive actions respectively.

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Pro-nociceptive actions of VEGF-A₁₆₅a are dependent on TRPV1.

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Alternative pre-mRNA splicing underpins peripheral sensitization by VEGF-A isoforms in normal and neuropathic animals.

A weighted and directed interareal connectivity matrix for macaque cerebral cortex

Retrograde tracer injections in 29 of the 91 areas of the macaque cerebral cortex revealed 1,615 interareal pathways, a third of which have not previously been reported. A weight index (extrinsic fraction of labeled neurons [FLNe]) was determined for each area-to-area pathway. Newly found projections were weaker on average compared with the known projections; nevertheless, the 2 sets of pathways had extensively overlapping weight distributions. Repeat injections across individuals revealed modest FLNe variability given the range of FLNe values (standard deviation <1 log unit, range 5 log units). The connectivity profile for each area conformed to a lognormal distribution, where a majority of projections are moderate or weak in strength. In the G_{29 × 29} interareal subgraph, two-thirds of the connections that can exist do exist. Analysis of the smallest set of areas that collects links from all 91 nodes of the G_{29 × 91} subgraph (dominating set analysis) confirms the dense (66%) structure of the cortical matrix. The G_{29 × 29} subgraph suggests an unexpectedly high incidence of unidirectional links. The directed and weighted G_{29 × 91} connectivity matrix for the macaque will be valuable for comparison with connectivity analyses in other species, including humans. It will also inform future modeling studies that explore the regularities of cortical networks.

Aspirin in the aetiology of Crohn's disease and ulcerative colitis: a European prospective cohort study

BACKGROUND

Aspirin has detrimental effects on the gastrointestinal tract mucosa and may play a role in the aetiology of inflammatory bowel disease.

AIM

To investigate if the regular use of aspirin is associated with the development of Crohn's disease (CD) and ulcerative colitis (UC) using, for the first time, a prospective cohort study design.

METHODS

A total of 135,780 men and women in Europe, aged 30-74years, were recruited into the European Prospective Investigation into Cancer and Nutrition study. Participants completed questionnaires at baseline detailing their regular aspirin use and were then followed up to identify those who developed either incident CD or UC. Each case was matched with four controls and odds ratios (OR) were calculated, adjusting for cigarette smoking. Potential interactions between aspirin and smoking were assessed.

RESULTS

A total of 35 participants developed CD and a further 84 were diagnosed with UC. Regular aspirin intake was positively associated with the risk of developing CD (OR=6.14, 95% CI=1.76-21.35). In those who took aspirin and smoked there was no detectable increased risk of CD (OR=0.30, 95% CI=0.03-3.08). No association was found between regular aspirin use and UC (OR=1.29, 95% CI=0.67-2.46).

CONCLUSIONS

A strong positive association between regular aspirin use and CD, but not UC, was observed. The data suggest that regular aspirin use should be measured in epidemiological work on CD. If such findings are consistent in other work then aspirin may affect the development of CD in a middle-aged to elderly population.

Long-term clinical outcome of oestrogen receptor-positive operable primary breast cancer in older women: a large series from a single centre

INTRODUCTION

A Cochrane review of seven randomised trials (N=1571) comparing surgery and primary endocrine therapy (PET) (oestrogen receptor (ER) unselected) shows no difference in overall survival (OS). We report outcome of a large series with ER-positive (ER+) early invasive primary breast cancer.

METHODS

Between 1973 and 2009, 1065 older (≥ 70 years) women (median age 78 years (70-99)) had either surgery (N=449) or PET (N=616) as initial treatment.

RESULTS

At 49-month median follow-up (longest 230 months), the 5-year breast cancer-specific survival (BCSS) and OS were 90 and 62%, respectively. Majority (74.2%) died from causes other than breast cancer. The rates (per annum) of local/regional recurrence (<1%) (following surgery), contralateral tumour (<1%) and metastases (<3%) were low. For patients on PET, 97.9% achieved clinical benefit (CB) at 6 months, with median time to progression of 49 months (longest 132 months) and significantly longer BCSS when compared with those who progressed (P<0.001). All patients with strongly ER+ (H-score >250) tumours achieved CB and had better BCSS (P<0.01). Patients with tumours having an H-score >250 were found to have equivalent BCSS regardless of treatment (surgery or PET; P=0.175), whereas for those with H-score ≤ 250, surgery produced better outcome (P<0.001).

CONCLUSION

Older women with ER+ breast cancer appear to have excellent long-term outcome regardless of initial treatment. Majority also die from non-breast cancer causes. Although surgery remains the treatment of choice, patients with ER-rich (H-score >250) tumours tend to do equally well when treated by PET. This should be taken into account when therapies are considered.

Weight consistency specifies regularities of macaque cortical networks

To what extent cortical pathways show significant weight differences and whether these differences are consistent across animals (thereby comprising robust connectivity profiles) is an important and unresolved neuroanatomical issue. Here we report a quantitative retrograde tracer analysis in the cynomolgus macaque monkey of the weight consistency of the afferents of cortical areas across brains via calculation of a weight index (fraction of labeled neurons, FLN). Injection in 8 cortical areas (3 occipital plus 5 in the other lobes) revealed a consistent pattern: small subcortical input (1.3% cumulative FLN), high local intrinsic connectivity (80% FLN), high-input form neighboring areas (15% cumulative FLN), and weak long-range corticocortical connectivity (3% cumulative FLN). Corticocortical FLN values of projections to areas V1, V2, and V4 showed heavy-tailed, lognormal distributions spanning 5 orders of magnitude that were consistent, demonstrating significant connectivity profiles. These results indicate that 1) connection weight heterogeneity plays an important role in determining cortical network specificity, 2) high investment in local projections highlights the importance of local processing, and 3) transmission of information across multiple hierarchy levels mainly involves pathways having low FLN values.

Linoleic acid, a dietary n-6 polyunsaturated fatty acid, and the aetiology of ulcerative colitis: a nested case-control study within a European prospective cohort study

OBJECTIVE

Dietary linoleic acid, an n-6 polyunsaturated fatty acid, is metabolised to arachidonic acid, a component of colonocyte membranes. Metabolites of arachidonic acid have pro-inflammatory properties and are increased in the mucosa of patients with ulcerative colitis. The aim of this investigation was to conduct the first prospective cohort study investigating if a high dietary intake of linoleic acid increases the risk of developing incident ulcerative colitis.

DESIGN AND SETTING

Dietary data from food frequency questionnaires were available for 203 193 men and women aged 30-74 years, resident in the UK, Sweden, Denmark, Germany or Italy and participating in a prospective cohort study, the European Prospective Investigation into Cancer and Nutrition (EPIC). These participants were followed up for the diagnosis of ulcerative colitis. Each case was matched with four controls and the risk of disease calculated by quartile of intake of linoleic acid adjusted for gender, age, smoking, total energy intake and centre.

RESULTS

A total of 126 participants developed ulcerative colitis (47% women) after a median follow-up of 4.0 years (range, 1.7-11.3 years). The highest quartile of intake of linoleic acid was associated with an increased risk of ulcerative colitis (odds ratio (OR) = 2.49, 95% confidence interval (CI) = 1.23 to 5.07, p = 0.01) with a significant trend across quartiles (OR = 1.32 per quartile increase, 95% CI = 1.04 to 1.66, p = 0.02 for trend).

CONCLUSIONS

The data support a role for dietary linoleic acid in the aetiology of ulcerative colitis. An estimated 30% of cases could be attributed to having dietary intakes higher than the lowest quartile of linoleic acid intake.

An approach to monitoring influenza vaccination uptake across Europe

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An approach to monitoring influenza vaccination uptake across Europe

Currently, the monitoring of influenza vaccination uptake is mainly a national issue. As influenza infection easily crosses international borders, it is in the interest of all countries to have a high vaccine uptake in people who may be vulnerable when influenza spreads. A Europe-wide monitoring system can provide insight into the strengths and weaknesses of uptake rates in countries and, on ce sufficient levels are achieved, can safeguard the continuation of the achieved levels. This paper aims to address the following issues: a) How is influenza vaccination uptake monitored in Europe? b) What methods to monitor vaccination uptake are available and what are their limitations? c) What steps should be taken to implement a European-wide influenza vaccination uptake monitoring system? Based on existing literature and experiences in monitoring influenza vaccination uptake, an approach to set up a European-wide monitoring system is proposed. The following issues were identified as relevant for influenza vaccination uptake monitoring: a) Agreement on the population groups in which vaccination uptake should be monitored; b) The frequency of data collection; c) The importance of sharing experiences regarding existing influenza vaccination campaigns in order to learn from each other, and develop 'best practices'; d) The need to publish uptake data in close relation with influenza surveillance data and other European efforts on dissemination of vaccination knowledge. To stimulate the discussion on implementing a pan-European influenza uptake monitoring scheme the following recommendations were suggested : a) Develop a common set of variables; b) Build on experience from individual countries; c) Create a coordinating body; d) Create or identify a platform to publish the data; e) Start small and expand rapidly.

Association of plasma phospholipid transfer protein activity with IDL and buoyant LDL: impact of gender and adiposity

Current data suggest that phospholipid transfer protein (PLTP) has multiple metabolic functions, however, its physiological significance in humans remains to be clarified. To provide further insight into the role of PLTP in lipoprotein metabolism, plasma PLTP activity was measured, and lipoproteins were analyzed in 134 non-diabetic individuals on a controlled diet. Insulin sensitivity index (Si) and body fat composition were also determined. Plasma PLTP activity was comparable between men (n=56) and women (n=78). However, in women but not in men, plasma PLTP activity was positively correlated with cholesterol, triglyceride, low density lipoprotein (LDL) cholesterol, and apolipoprotein (apo) B (r=0.38-0.45, P< or =0.001), and with body mass index (BMI), subcutaneous and intra-abdominal fat (SCF, IAF) (r=0.27-0.29, P<0.02). Among the different apo B-containing lipoproteins (LpB) in women, PLTP was most highly correlated with intermediate density lipoproteins (IDL) and buoyant LDL (r=0.45-0.46, P<0.001). The correlation with IDL was significant only in women with BMI < or =27.5 kg/m(2) (n=56). In men with BMI < or =27.5 kg/m(2) (n=35), PLTP activity was significantly correlated with buoyant LDL (r=0.40, P<0.02) and high density lipoprotein (HDL) (r=0.43, P<0.01). These data provide evidence for a role of PLTP in LpB metabolism, particularly IDL and buoyant LDL. They also suggest that gender and obesity-related factors can modulate the impact of PLTP on LpB.

Pre- and post-mitotic events contribute to the progressive acquisition of area-specific connectional fate in the neocortex

The adult primary motor cortex (area 6) is characterized by a stronger projection to the spinal cord than the primary somatosensory cortex (area 3). Here we have explored the progressive and regressive phenomena that determine these areal differences in the number of corticospinal neurons (CSNs). CSNs were birthdated with [(3)H]thymidine and subsequently retrogradely labeled from the spinal cord. The time window of CSN production is identical in both areas. The probability that a cohort of neuroblasts project to the spinal cord is indicated by the percentage of [(3)H]thymidine-positive neurons that can be back-labeled from the spinal cord. In the neonate this fate index is significantly higher in area 6 compared with area 3, indicating that early regionalization of cell fate contributes to areal differences in CSN number. In neonatal reeler mice, an increase in CSN number was accompanied by an increased fate index, showing that the integrity of the post-mitotic environment is required for the specification of the appropriate number of neurons expressing a given connectional phenotype. Postnatal development in reeler and normal is characterized by an area-specific elimination of CSN axons, which reduces areal differences in CSN number. These results show a progressive acquisition of CSN fate in the neocortex and indicate that both early regionalization and late environmental signals contribute to determining areal differences of connectional phenotype.

Plasma phospholipid transfer protein activity in patients with low HDL and cardiovascular disease treated with simvastatin and niacin

Plasma phospholipid transfer protein (PLTP) is an important modulator of high-density lipoprotein (HDL) metabolism, regulating its particle size, composition, and mass. In patients with low HDL and cardiovascular disease (CVD), plasma PLTP activity is positively correlated with the concentration of HDL particles containing apo A-I but not apo A-II (Lp(A-1)). We recently completed a study to determine the effect of simvastatin and niacin (S-N) therapy on disease progression/regression in these patients, and found that this therapy selectively increased Lp(A-I). To determine if PLTP was also increased with this drug therapy, we measured the PLTP activity in the plasma of 30 of these patients obtained at baseline and after 12 months of therapy, and compared the changes to a similar group of 31 patients who received placebo for the drugs. No significant increase in PLTP activity was observed in either group of patients. However, changes in apo A-I and A-II between these two time points were correlated with the corresponding change in PLTP activity. The correlation coefficients were r=0.57 (P=0.001) and r=0.43 (P=0.02) for apo A-I, and r=0.54 (P=0.002) and r=0.41 (P=0.02) for apo A-II in the placebo and S-N group, respectively. At baseline, PLTP activity correlated positively with the percent of plasma apo A-I associated with Lp(A-I) (r=0.38, P=0.04) and the amounts of apo A-I in these particles (r=0.43, P=0.02). These relationships persisted in patients who took placebo for 12 months (r=0.46, P=0.009 and r=0.37, P=0.04, respectively), but was attenuated in those treated with S-N. These data indicate that S-N-induced increase in Lp(A-I) was PLTP-independent. It also confirms our previous observation that an interrelationship exists between PLTP and apo-specific HDL particle subclasses in CVD patients with low HDL, and that this relationship is altered by drug intervention.

Implanon: when is the ideal time to insert?

The single rod implant was introduced to the UK in October 1999. This case illustrates a problem encountered with the timing of its insertion and highlights a possible note of caution.