Psychosocial outcomes after varying risk management strategies in women at increased familial breast cancer risk: a mixed methods study of patient and partner outcomes

INTRODUCTION

Female carriers of BRCA1/2 genes have an increased lifetime risk of breast cancer. Options for managing risk include imaging surveillance or risk-reducing surgery (RRS). This mixed methods study aimed to identify factors affecting risk-management decisions and the psychosocial outcomes of these decisions for high-risk women and their partners.

METHODS

Semi-structured qualitative interviews were performed with women at high breast cancer risk who had faced these choices. Partners were also interviewed. Analysis used a framework approach. A bespoke questionnaire was developed to quantify and explore associations.

RESULTS

A total of 32 women were interviewed. Of these, 27 had partners of whom 7 (26%) agreed to be interviewed. Four main themes arose: perception of risk and impact of increased risk; risk-management strategy decision-making; impact of risk-management strategy; support needs and partner relationship issues. The questionnaire response rate was 36/157 (23%). Decision satisfaction was high in both surveillance and RRS groups. Relationship changes were common but not universal. Common causes of distress following RRS included adverse body image changes. Both groups experienced generalised and cancer-specific anxiety. Drivers for surgery included having children, deaths of close family from breast cancer and higher levels of cancer anxiety.

CONCLUSIONS

Levels of psychosocial and decision satisfaction were high for women choosing both RRS and surveillance but, for a minority, risk-reducing measures result in long-term psychosocial morbidity. Efforts to recognise women at increased risk of psychological morbidity may allow targeted support.

Drug Permeability - Best Practices for Biopharmaceutics Classification System (BCS)-Based Biowaivers: A workshop Summary Report

The workshop "Drug Permeability - Best Practices for Biopharmaceutics Classification System (BCS) Based Biowaivers" was held virtually on December 6, 2021, organized by the University of Maryland Center of Excellence in Regulatory Science and Innovation (M-CERSI), and the Food and Drug Administration (FDA). The workshop focused on the industrial, academic, and regulatory experiences in generating and evaluating permeability data, with the aim to further facilitate implementation of the BCS and efficient development of high-quality drug products globally. As the first international permeability workshop since the BCS based biowaivers was finalized as the ICH M9 guideline, the workshop included lectures, panel discussions, and breakout sessions. Lecture and panel discussion topics covered case studies at IND, NDA, and ANDA stages, typical deficiencies relating to permeability assessment supporting BCS biowaiver, types of evidence that are available to demonstrate high permeability, method suitability of a permeability assay, impact of excipients, importance of global acceptance of permeability methods, opportunities to expand the use of biowaivers (e.g. non-Caco-2 cell lines, totality-of-evidence approach to demonstrate high permeability) and future of permeability testing. Breakout sessions focused on 1) in vitro and in silico intestinal permeability methods; 2) potential excipient effects on permeability and; 3) use of label and literature data to designate permeability class.

Polyp characteristics at screening colonoscopy and post-colonoscopy colorectal cancer mortality: a retrospective cohort study

BACKGROUND AND AIMS

Polyp size and high grade dysplasia in polyps at screening colonoscopy are considered risk factors for post-colonoscopy colorectal cancer (PCCRC) development and death, which might be averted by surveillance colonoscopy. However, robust evidence backing these risk factors is lacking. We aimed to investigate whether polyp size or dysplasia grade are associated with PCCRC mortality.

METHODS

This was a retrospective study including individuals of the Austrian Quality Certificate for Screening Colonoscopy scoped between 01/2007 and 12/2020. We investigated the association of polyp size and dysplasia in polyps with PCCRC mortality by Cox regression. Additionally, we assessed whether patients with certain polyp characteristics had similar risk for CRC death compared to the Austrian population by calculating standardized mortality ratios (SMR).

RESULTS

316,001 individuals were included. After a median follow-up time of 5.27 years (95% CI 5.25-5.29), a significant association of polyp size 10-20 mm (HR 4.00, 95% CI 2.46-6.50, p <0.001) as well as high-grade dysplasia (HR 6.61, 95% CI 3.31-13.2, p<0.001) with PCCRC death was observed. PCCRC mortality was significantly lower than the expected CRC mortality in the general population in patients with polyps <10 mm and without high grade dysplasia (SMR 0.27, 95% CI 0.21-0.33, p<0.001), which was not observed for patients with polyps ≥10 mm or with high-grade dysplasia (SMR 2.05, 95% CI 1.64-2.57, p < 0.001).

CONCLUSIONS

Polyp size ≥10 mm and high-grade dysplasia are associated with PCCRC mortality in screening patients. This data suggests that these patients might benefit most from surveillance colonoscopy.

Comparison of adenoma detection rate and proximal serrated polyp detection rate and their effect on post-colonoscopy colorectal cancer mortality in screening patients

BACKGROUND

Patients with serrated polyps are at increased risk for post-colonoscopy colorectal cancer (PCCRC); however, evidence for a dedicated serrated polyp detection rate is lacking. The aim of this study was to investigate the association of the proximal serrated polyp detection rate (PSDR) and adenoma detection rate (ADR) with PCCRC death.

METHODS

This was a retrospective analysis within the Austrian quality assurance program for screening colonoscopy. Spearman's rank coefficient was calculated for the assessment of association between ADR and PSDR. Whether ADR or PSDR were associated with colorectal cancer mortality was assessed by Cox proportional hazards model.

RESULTS

229 /729 screening colonoscopies performed by 308 endoscopists were analyzed. The ADR (hazard ratio [HR] per 1 percentage point increase 0.98, 95 %CI 0.96-0.99) as well as the PSDR (HR per 1 percentage point increase 0.97, 95 %CI 0.94-0.99) were significantly associated with PCCRC death. The correlation coefficient of the ADR and PSDR calculated at every colonoscopy was 0.70 (95 %CI 0.70-0.71), and the corresponding PSDR value for an ADR performance standard of 25 % was 11.1 %. At the end of the study period, 86 endoscopists (27.9 %) reached an ADR of > 25 % and a PSDR of > 11.1 %.

CONCLUSIONS

The ADR as well as the PSDR were associated with PCCRC death. Striving for a high PSDR in addition to a high ADR might reduce the risk for PCCRC mortality in patients undergoing screening colonoscopy.

Tibial Component Subsidence in a Total Ankle System Comparing Standard Technique Versus a Hybrid Technique

Total ankle arthroplasty (TAA) is a viable treatment option for end-stage ankle arthritis. However, implant survivorship remains an important consideration. Concerns regarding early component loosening with the low-profile tibial tray utilized by fourth-generation TAA systems have been raised in the literature. We have previously described our preliminary outcomes of a hybrid technique combining a stemmed intramedullary tibial component with a chamfer-cut talar component for TAA. A retrospective study comparing short-term outcomes of the tibial component between a standard fourth-generation TAA system versus our hybrid technique was performed. 46 patients with a minimum of 1-year follow up were included in the analyses. There were 25 subjects in the standard implant cohort utilizing a low-profile tibial tray, and 21 subjects in the hybrid group utilizing a stemmed intramedullary tibial component. No statistically significant difference between the demographics of each group was found. The rate of tibial component subsidence was 8% (n = 2) in the standard implant group, and 0% (n = 0) in the hybrid group, though this did not meet statistical significance (p = .49). Mean time to subsidence was 6 months, and revision rate due to tibial component subsidence was 2.1% (n = 1). Periprosthetic lucency was present on most recent follow-up radiographs in 32% and 9.5% of ankles in the standard and hybrid groups, respectively (p = .08). Despite prior concerns for tibial component subsidence with the standard fourth-generation system, we demonstrated low rates in both implant groups. Additional studies are needed to further explore factors that may predispose patients to early tibial component subsidence and resulting implant failure.

Analysis of rare disruptive germline mutations in 2,135 enriched BRCA-negative breast cancers excludes additional high-impact susceptibility genes

BACKGROUND

Breast cancer has a significant heritable basis, of which approximately 60% remains unexplained. Testing for BRCA1/BRCA2 offers useful discrimination of breast cancer risk within families, and identification of additional breast cancer susceptibility genes could offer clinical utility.

PATIENTS AND METHODS

We included 2,135 invasive breast cancer cases recruited via the BOCS study, a retrospective UK study of familial breast cancer.

ELIGIBILITY CRITERIA

female, BRCA-negative, white European ethnicity, and one of: i) breast cancer family history, ii) bilateral disease, iii) young age of onset (<30 years), iv) concomitant ovarian cancer. We undertook exome sequencing of cases and performed gene-level burden testing of rare damaging variants against those from 51,377 ethnicity-matched population controls from gnomAD.

RESULTS

159/2135 (7.4%) cases had a qualifying variant in an established breast cancer susceptibility gene, with minimal evidence of signal in other cancer susceptibility genes. Known breast cancer susceptibility genes PALB2, CHEK2 and ATM were the only genes to retain statistical significance after correcting for multiple testing. Due to the enrichment of hereditary cases in the series, we had good power (>80%) to detect a gene of BRCA1-like risk (odds ratio = 10.6) down to a population minor allele frequency of 4.6 x 10^-5 (1 in 10,799, less than one tenth that of BRCA1)and of PALB2-like risk (odds ratio = 5.0) down to a population minor allele frequency of 2.8 x 10^-4 (1 in 1,779, less than half that of PALB2). Power was lower for identification of novel moderate penetrance genes (odds ratio = 2-3) like CHEK2 and ATM.

CONCLUSIONS

This is the largest case-control whole-exome analysis of enriched breast cancer published to date. Whilst additional breast cancer susceptibility genes likely exist, those of high penetrance are likely to be of very low mutational frequency. Contention exists regarding the clinical utility of such genes.

Examination of the psychometric properties of the FORensic oUtcome Measure (FORUM): a new outcome measure for forensic mental health services

Introduction

Forensic mental health services provide care to people in secure psychiatric hospitals and specialised community teams. Measuring outcomes is important to ensure such services perform optimally, however existing measures are not sufficiently comprehensive and are rarely patient reported.

Objectives

To examine a novel instrument for measuring outcomes in forensic mental health services, the FORensic oUtsome Measure (FORUM), which consists of a complementary patient reported questionnaire (FORUM-P) and clinician reported questionnaire (FORUM-C).

Methods

Inpatients at a forensic psychiatric service based in a regional healthcare organization in the UK completed the FORUM-P, while members of their clinical teams completed the FORUM-C. Patients and clinicians also provided feedback on the questionnaires.

Results

Sixty-two patients participated with a mean age of 41.0 years (standard deviation 11.3). For internal consistency, Cronbach’s alpha for the FORUM-P was 0.87 (95% confidence interval (CI) 0.80-0.93) and for the FORUM-C was 0.93 (95% CI 0.91-0.96). For test-retest reliability the weighted kappa for the FORUM-P was 0.44 (95% CI 0.24-0.63) and for the FORUM-C was 0.78 (95% CI 0.73-0.85). For interrater reliability of the FORUM-C the Spearman correlation coefficient was 0.47 (95% CI 0.18-0.69). The FORUM-P received an average rating of 4.0 out of 5 for comprehensiveness, 4.6 for ease of use and 3.9 for relevance, while the FORUM-C received 4.1 for comprehensiveness, 4.5 for ease of use and 4.3 for relevance.

Conclusions

Outcome measures in forensic mental health can be developed with good measures of reliability and validity, and can be introduced into services to monitor patient progress.

Disclosure

No significant relationships.

Photoacoustic discrimination of antibiotic-resistant and sensitive Staphylococcus aureus isolates

OBJECTIVES

Bacteremia is a serious and potentially lethal condition. Staphylococcus aureus is a leading cause of bacteremia and methicillin-resistant S. aureus (MRSA) accounts for more than a third of the cases. Compared to methicillin-sensitive S. aureus, MRSA is more than twice as likely to be fatal. Furthermore, subpopulations of seemingly isogenic bacteria may exhibit a range of susceptibilities, often called heterogenous resistance. These heterogeneous antibiotic-resistant infections are often misdiagnosed as hospital-acquired secondary infections because there are no clinically used tests that can differentiate between homogeneous and heterogeneous antibiotic resistance. We describe the development and proof of concept of rapid bacterial identification using photoacoustic flow cytometry and labeled bacteriophages with the characterization and differentiation of heterogeneous antibiotic-resistant bacterial infections.

METHODS

In photoacoustic flow cytometry, pulsed laser light is delivered to a sample flowing past a focused transducer and particles that absorb laser light create an acoustic response. Optically labeled bacteriophage are added to a bacterial mixture that flows through the photoacoustic chamber. The presence of target bacteria is determined by bound labeled phage which are detected photoacoustically. Incubation of bacterial samples in the presence and absence of the antibiotic daptomycin creates a difference in bacterial cell numbers that is quantified using photoacoustic flow cytometry.

RESULTS

Four clinical isolates were tested in the presence and absence of daptomycin. Photoacoustic events for each isolate were recorded and compared to growth curves. Samples treated with daptomycin fell into three categories: resistant, susceptible, and heterogeneous resistant.

CONCLUSIONS

Here we show a method to determine the presence of bacteria as a marker for bloodstream infection level and antibiotic sensitivity in less than 4 hours. Additionally, these results show an ability to identify heterogeneous resistant strains that are often misidentified.

183 A Systematic Review of Sample Size Calculations in High-Profile Surgical Trials That Use Patient-Reported Outcome Measures

Background

Patient reported outcome measures (PROMs) are increasingly recognised as a measure of treatment efficacy in randomised controlled trials (RCTs). It can be difficult to determine meaningful target differences in PROM scores for sample size calculations and this can risk over-recruitment and/or erroneous trial conclusions. The Difference ELicitation in TriAls (DELTA2) statement sets recommendations for sample size calculations in RCTs including target difference determination. We aimed to evaluate sample size calculations from high-profile surgical RCTs that used PROMs as their primary outcome, against DELTA2 standards, with a focus on target differences.

Method

Pubmed was systematically searched for surgical RCTs published in the five highest ranking journals, by Thomson Reuters impact factor, for medicine and surgery. Studies were included if surgery was the intervention and/or comparator arm, and a PROM was the primary outcome. Surgery was defined as using instrumentation to change macro-anatomy with the aim of improving health. Data were extracted with a piloted data collection sheet that included the DELTA2 reporting recommendations.

Results

Most target differences used in sample size calculations were determined with suboptimal techniques and target difference justification was overall poor. In this sample, £28 million of UK public research spending supported trials with poor target difference justification.

Conclusions

In this sample of trials, sample size calculations were generally not reported to DELTA2 standards. There was frequent use of sub-optimal methods to determine the target difference. This risks over-recruitment and/or erroneous trial conclusions. Clinicians should be aware of these potential pitfalls when interpreting published trials.

The very small angle neutron scattering instrument at the National Institute of Standards and Technology

A description and the performance of the very small angle neutron scattering diffractometer at the National Institute of Standards and Technology are presented.

A description and the performance of the very small angle neutron scattering diffractometer at the National Institute of Standards and Technology are presented. The measurement range of the instrument extends over three decades of momentum transfer q from 2 × 10⁻⁴ to 0.7 Å⁻¹. The entire scattering angle range from 8 × 10⁻⁵ to π/6 rad (30°) can be measured simultaneously using three separate detector carriages on rails holding nine 2D detector arrays. Versatile choices of collimation options and neutron wavelength selection allow the q resolution and beam intensity to be optimized for the needs of the experiment. High q resolution is achieved using multiple converging-beam collimation with circular pinholes combined with refractive lenses and prisms. Relaxed vertical resolution with much higher beam intensity can be achieved with narrow slit collimation and a broad wavelength range chosen by truncating the moderator source distribution below 4 Å with a Be crystalline filter and above 8 Å with a supermirror deflector. Polarized beam measurements with full polarization analysis are also provided by a high-performance supermirror polarizer and spin flipper, capable of producing flipping ratios of over 100, along with a high-efficiency ³He polarization analyzer.

Autonomous Surface and Underwater Vehicles as Effective Ecosystem Monitoring and Research Platforms in the Arctic-The Glider Project

Effective ocean management requires integrated and sustainable ocean observing systems enabling us to map and understand ecosystem properties and the effects of human activities. Autonomous subsurface and surface vehicles, here collectively referred to as “gliders”, are part of such ocean observing systems providing high spatiotemporal resolution. In this paper, we present some of the results achieved through the project “Unmanned ocean vehicles, a flexible and cost-efficient offshore monitoring and data management approach—GLIDER”. In this project, three autonomous surface and underwater vehicles were deployed along the Lofoten–Vesterålen (LoVe) shelf-slope-oceanic system, in Arctic Norway. The aim of this effort was to test whether gliders equipped with novel sensors could effectively perform ecosystem surveys by recording physical, biogeochemical, and biological data simultaneously. From March to September 2018, a period of high biological activity in the area, the gliders were able to record a set of environmental parameters, including temperature, salinity, and oxygen, map the spatiotemporal distribution of zooplankton, and record cetacean vocalizations and anthropogenic noise. A subset of these parameters was effectively employed in near-real-time data assimilative ocean circulation models, improving their local predictive skills. The results presented here demonstrate that autonomous gliders can be effective long-term, remote, noninvasive ecosystem monitoring and research platforms capable of operating in high-latitude marine ecosystems. Accordingly, these platforms can record high-quality baseline environmental data in areas where extractive activities are planned and provide much-needed information for operational and management purposes.

1232 Trust-Wide Assessment of Delirium in Post-Operative Elective Surgery

Aim

Delirium is an acute change in cognition and associated with adverse patient outcomes. The incidence of post-operative delirium after elective non-cardiac surgery is unknown. We aimed to assess the incidence of post-operative delirium in this group and the effect on patient outcomes.

Method

Patients aged 65 and over who underwent elective non-cardiac surgery were identified on post-operative day three. Delirium screening was performed in real time using the validated 4-AT assessment tool. A retrospective review of the patients’ preoperative and perioperative record was conducted to collect demographics and identify risk factors for delirium. Outcome data was collected at 30 days. Patients with a positive delirium score (&gt;4) underwent a more in-depth assessment and managing teams given a delirium management pack.

Results

75 (39 male) consecutive patients were screened over a period of 4 months. Median age 77 years and 18% had frailty assessed as “vulnerable”. The majority of patients (37.3%) underwent thoracic surgery, followed by hepatobiliary (17.3%), gynaecological (17.3%), colorectal (12%), maxillofacial (9.3%) and ENT (4%). 5.3% (4) of patients had a positive 4-AT screen. No patients had a formal delirium screen or diagnosis in the initial 48 hours. The median length of stay for patients with a positive screen was 8.5 days (IQR 7.5-12) compared to 8 days (IQR 5-13) for patients with a negative screen.

Conclusions

Reassuringly, rate of post-operative delirium following elective operations in our Trust are low (5%). Larger numbers of patients are required to assess the impact this has on patient outcomes and identify correlation with risk factors.

Intraosseous Anchorage of a Collagen Matrix Graft to Enhance Repair of Peroneus Brevis Tendon Degeneration

INTRODUCTION

Chronic degeneration of the peroneus brevis tendon (PBT) at its insertion to the base of the fifth metatarsal is uncommon; however, when present it can be a challenge to treat. Repair of the PBT often requires tubularization with or without a peroneus longus tendon transfer. These repairs, however, may not provide resultant full muscle strength, especially if ostectomy of the fifth metatarsal base is required. We report outcomes following a novel technique for anatomic repair of degenerative PBT with intraosseous fifth metatarsal base fixation of a collagen matrix graft.

METHODS

Thirteen consecutive patients (14 procedures) with degeneration of PBT that underwent tendon repair augmented with collagen matrix graft from 2011 to 2019 were reviewed retrospectively. We present outcome data of these 13 patients that were followed for at least 12 months.

RESULTS

Muscle strength, complications, and patient-reported subjective outcomes were reported. There were 10 females and 3 males. Average age was 49.1 years, and average follow-up was 34.9 months. Muscle strength was reported at 5/5 to the PBT by the final follow-up for 92% of patients. There were minimal complications, 84.6% (11/13) of patients had no limitation in activity level, and 92% (12/13) would recommend this procedure to a friend.

CONCLUSION

Outcomes for this novel repair technique for insertional degenerative PBT have never been reported before and show excellent results with long-term follow-up.

Total Ankle Arthroplasty Survivorship: A Meta-analysis

The gold standard for management of end-stage ankle arthritis was previously ankle arthrodesis; however, improvements in total ankle replacements are making this a more viable treatment option. The primary aim of this meta-analysis was to evaluate the survivorship of total ankle replacement implants currently in use. An extensive search strategy initially captured 20,842 citations that were evaluated for relevance. Abstract screening produced 97 articles to be read in entirety, of which 10 articles studying 1963 implants met all prospective inclusion criteria for analysis. Overall survivorship of all implants was 93.0% (95% confidence interval, 85.2-96.9) using a random effect model. There was significant heterogeneity between the studies (Q = 131.504). Meta-regression identified an inverse relationship between survivorship and study follow-up duration (p < .0001). Furthermore, age (p = .36) and implant type (fixed-bearing [95.6%, 95% confidence interval, 85.9-98.7] versus mobile-bearing ]89.4%, 95% confidence interval, 79.6%-94.8%]) did not have a statistically significant impact on survivorship, p = .213. However, patients with higher preoperative functional scores had improved survivorship (p = .001). Complications were inconsistently reported with varied definitions. In order of reported frequency, complications were classified into technical error (28.15%), subsidence (16.89%), implant failure (13.28%), aseptic loosening (6.3%), intraoperative fracture (5.67%), wound problems (4.3%), deep infection (1%), and postoperative fracture (0.0001%). Overall study quality was low, with only 10% being prospective and 90% from nonregistry data. The results from this meta-analysis revealed a promising overall survivorship of current implants in use for total ankle replacement; however higher quality studies with standardized outcomes measures are needed.

436 POSTOPERATIVE SYSTOLIC HYPOTENSION IN FRACTURED NECK OF FEMUR PATIENTS

Introduction

Secondary analysis of outcomes after 11,085 hip fracture operations from the prospective UK Anaesthesia Sprint Audit of Practice (ASAP 2) found an association between reduced intraoperative systolic arterial pressure (SAP) and postoperative mortality at five and 30 days. We sought to determine the incidence of hypotension in the postoperative period, rather than just intraoperatively, in a small sample of patients with fractured neck of femur.

Method

We performed a retrospective review of the notes, electronic vital signs and electronic general practice records from 40 patients with fractured neck of femur. We identified the latest SAP performed at their general practice (if done within one year before admission). We noted the pre-operative baseline SAP reading from the ward as well as the lowest SAP during several time periods: the pre-operative period; the fracture surgery; the recovery room; and during each 24-h period postoperatively until the fifth postoperative day.

Results

A SAP recording from general practice within the previous year was only accessible in 21 (53%) of patients, but where it was accessible, it was within 20% of the immediate preoperative SAP in 14 (66%) of patients. The incidence of relative hypotension (&lt; 80% preoperative SAP) was 54% in the operating theatre, 41% in the recovery room, 65% on the ward during the remainder of the first postoperative 24 h, 55% during postoperative day 2, 53% during day 3, 33% during day 4 and 41% during day 5.

Conclusions

Postoperative hypotension was common in our sample. In our analysis, the highest incidence was on the ward during the first 24 hours postoperatively. However, 41% of patients still had hypotension 5 days postoperatively.

Learning in lockdown: Using the COVID-19 crisis to teach children about food and climate change

Food systems are significant sources of global greenhouse gas emissions (GHGE). Since emission intensity varies greatly between different foods, changing food choices towards those with lower GHGE could make an important contribution to mitigating climate change. Public engagement events offer an opportunity to communicate these multifaceted issues and raise awareness about the climate change impact of food choices. An interdisciplinary team of researchers was preparing food and climate change educational activities for summer 2020. However, the COVID-19 pandemic and lockdown disrupted these plans. In this paper, we report on shifting these events online over the month of June 2020. We discuss what we did and the reception to our online programme. We then reflect on and highlight issues that arose. These relate to: (1) the power dynamics of children, diet and climate change; (2) mental health, diet and COVID-19; (3) engaging the wider science, agriculture and food communities; (4) the benefits of being unfunded and the homemade nature of this programme; (5) the food system, STEAM (science, technology, engineering, arts and mathematics) and diversity; and (6) how our work fits into our ongoing journey of food and climate change education.

A prototype rapid dual energy X-ray absorptiometry (DEXA) system can predict the CT composition of beef carcases

The development of a novel rapid dual energy X-ray absorptiometry (DEXA) system provides the opportunity to improve measurement of beef carcase composition. A prototype rapid DEXA system was built in a shipping container to scan 51 beef carcases selected for a wide range in weight and fatness. One side of each carcase was spray chilled and the other conventionally chilled overnight before being quartered for DEXA scanning and then being cut into 16 pieces for CT scanning to determine carcase composition. Spray chilling did not impact DEXA prediction of CT composition, with the DEXA system describing 89%, 95%, and 87% of the variation in beef carcase CT lean %, fat % and bone %, with a root mean square error of prediction of 2.31 lean %, 2.15 fat %, and 1.12 bone % units. These results demonstrate that the novel rapid DEXA system has excellent capacity to predict CT composition in beef carcases.

Evaluation of the 30km/h speed limit trial in the City of Yarra, Melbourne, Australia

OBJECTIVE

Safe vehicle speeds were identified as a key element in a safe system approach to road safety. The City of Yarra in Melbourne, Australia has a 40 km/h default speed limit across their municipality, but wished to reduce the speed limit in local residential streets to 30 km/h. The Monash University Accident Research Center provided Council with a design for a demonstration trial and agreed to evaluate its safety benefits over 12 months. The trial was expected to show significant reductions in speed and increased community support.

METHOD

A before and after design was employed with a control (untreated) area to evaluate the safety outcomes of the trial. Speed limits were reduced to 30 km/h in the trial area for 12 months but kept at kept at the current 40 km/h (25 mph) limit in the control region. Vehicle speeds were measured at around 100 selected sites in the trial and control areas, and resident surveys were undertaken in both regions before and after the trial.

RESULTS

The findings showed a small but modest reduction of 1.1% in average speed in the trial region but a surprising 2.7% in the control region. On further examination, significant reductions were observed in the percent of vehicles exceeding 40 km/h (25 mph) and 50 km/h (31 mph) in both the treated and control regions, but not at 30 km/h (19 mph). A regression analysis further showed a significant treatment effect of 11% at 40 km/h and 25% at 50 km/h when adjusting for differences between treated and controls. Among other findings, the survey results found increased support for the lower speed limit of 17% with little adverse consequences.

CONCLUSION

The findings give support for the likely safety benefits of the 30 km/h trial with increased support from the residents. Speed reductions in the control region suggested a carry-over of the effects of the trial but also added support by local residents for reduced speed limits in the region. Potential injury savings were estimated at a 4% reduction in the risk of a pedestrian injury from the observed treatment effect in the trial region.

Ice algal bloom development on the surface of the Greenland Ice Sheet

It is fundamental to understand the development of Zygnematophycean (Streptophyte) micro-algal blooms within Greenland Ice Sheet (GrIS) supraglacial environments, given their potential to significantly impact both physical (melt) and chemical (carbon and nutrient cycling) surface characteristics. Here, we report on a space-for-time assessment of a GrIS ice algal bloom, achieved by sampling an ∼85 km transect spanning the south-western GrIS bare ice zone during the 2016 ablation season. Cell abundances ranged from 0 to 1.6 × 104 cells ml-1, with algal biomass demonstrated to increase in surface ice with time since snow line retreat (R2 = 0.73, P < 0.05). A suite of light harvesting and photo-protective pigments were quantified across transects (chlorophylls, carotenoids and phenols) and shown to increase in concert with algal biomass. Ice algal communities drove net autotrophy of surface ice, with maximal rates of net production averaging 0.52 ± 0.04 mg C l-1 d-1, and a total accumulation of 1.306 Gg C (15.82 ± 8.14 kg C km-2) predicted for the 2016 ablation season across an 8.24 × 104 km2 region of the GrIS. By advancing our understanding of ice algal bloom development, this study marks an important step toward projecting bloom occurrence and impacts into the future.

Abstract P4-16-08: A regional audit of 6-hour monitoring for administration related reactions during the first administration of subcutaneous trastuzumab

Introduction

In 2012, Subcutaneous Trastuzumab (TSC) was introduced as an alternative to Intravenous Trastuzumab (TIV) for HER2+ breast cancer. The pivotal HannaH study demonstrated that TSC was non-inferior to TIV, was preferred by patients, and serious administration related reactions (ARRs) were not reported. However, the Summary of Product Characteristics (SPC) advises that patients be observed for ARRs for 6 hours post-first administration (and 2 hours post-subsequent administrations), similar to TIV.

Aim

To assess the frequency and tolerability of ARRs during the 6-hour observation period post first administration of TSC in patients with HER2+ breast cancer.

Method:

A retrospective audit of TSC was conducted in Southwest Ireland across five centers from 2014-2016. Patient charts were reviewed to record ARRs reported on the first-administration or at subsequent visit. In addition a subset of patients were interviewed regarding their recollection of ARRs with first or subsequent injections.

Results:

The study is ongoing having identified 192 patients. These centers have administered 2111 TSC injections in total, associated with 4998 hours of observation as per SPC. From the 385 injections given over the first two TSC administrations, 13 injections (3.4%) were associated with ARRs within 24 hours. Nine patients (2.3%) experienced injection site reactions immediately post injection, one injection site pain (0.3%), and one experienced petechiae on subsequent exposure (0.3%). Three patients experienced pyrexia and dry cough 24 hours post-injection and were hospitalized for respiratory tract infection. There were no reactions experienced between 2 and 6 hours post-first injection. There were no serious ARRs. Telephone interviews are ongoing and these results will be reported.

Conclusion:

ARRs related to TSC are usually immediate, mild and self-limiting. Observing patients for 6 hours post-first injection and 2 hours post-subsequent injections represents an inefficient use of healthcare resources.

Citation Format: Karmali S, Hughes N, Kinneally A, Kroes J, Cook J, Killian M, Shafiq T, O'Mahony D, Bird B, O'Connor M, O'Reilly S, Galiauskas R, Murphy CG. A regional audit of 6-hour monitoring for administration related reactions during the first administration of subcutaneous trastuzumab [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-16-08.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Long-Term Outcomes of Corrective Osteotomies Using Porous Titanium Wedges for Flexible Flatfoot Deformity Correction

Common corrective osteotomies used in flexible flatfoot deformity reconstruction include Cotton and Evans osteotomies, which require structural graft to maintain correction. Auto-, allo-, and xenografts are associated with a number of limitations, including disease transmission, rejection, donor site morbidity, technical challenges related to graft fashioning, and graft resorption. Porous titanium is a synthetic substance designed to address these flaws; however, few studies have been reported on the efficacy, safety, and long-term outcomes. A multicenter retrospective cohort of 63 consecutive preconfigured porous titanium wedges (PTWs) used in flexible flatfoot reconstructions from June 1, 2009 to June 30, 2015 was evaluated. The primary outcome measure was the pre- to postdeformity correction efficacy. The secondary outcomes included maintenance of correction at a minimum follow-up point of 12 months, complications, graft incorporation, and graft safety profile. Multivariate linear regression found a statistically significant improvement in all radiographic parameters from preoperatively to the final weightbearing radiographs (calcaneocuboid 18.850 ± 4.020 SE, p < .0001; Kite's, 7.810 ± 3.660 SE, p = .04; Meary's 13.910 ± 3.100 SE, p = .0001; calcaneal inclination, 5.550 ± 2.140 SE, p = .015). When restricted to patients with >4 years of follow-up data, maintenance of correction appeared robust in all 4 measurements, demonstrating a lack of bone or graft resorption. No patients were lost to follow-up, no major complications or implant explantation or migration occurred, and all implants were incorporated. Minor complications included hardware pain from plates over grafts (8%), 1 case of scar neuritis, and a 5% table incidence of transfer pain associated with the PTWs. These results support the use of PTWs for safety and degree and maintenance of correction in flatfoot reconstruction.

From high to low malaria transmission in Zanzibar-challenges and opportunities to achieve elimination

BACKGROUND

Substantial global progress in the control of malaria in recent years has led to increased commitment to its potential elimination. Whether this is possible in high transmission areas of sub-Saharan Africa remains unclear. Zanzibar represents a unique case study of such attempt, where modern tools and strategies for malaria treatment and vector control have been deployed since 2003.

METHODS

We have studied temporal trends of comprehensive malariometric indices in two districts with over 100,000 inhabitants each. The analyses included triangulation of data from annual community-based cross-sectional surveys, health management information systems, vital registry and entomological sentinel surveys.

RESULTS

The interventions, with sustained high-community uptake, were temporally associated with a major malaria decline, most pronounced between 2004 and 2007 and followed by a sustained state of low transmission. In 2015, the Plasmodium falciparum community prevalence of 0.43% (95% CI 0.23-0.73) by microscopy or rapid diagnostic test represented 96% reduction compared with that in 2003. The P. falciparum and P. malariae prevalence by PCR was 1.8% (95% CI 1.3-2.3), and the annual P. falciparum incidence was estimated to 8 infections including 2.8 clinical episodes per 1000 inhabitants. The total parasite load decreased over 1000-fold (99.9%) between 2003 and 2015. The incidence of symptomatic malaria at health facilities decreased by 94% with a trend towards relatively higher incidence in age groups > 5 years, a more pronounced seasonality and with reported travel history to/from Tanzania mainland as a higher risk factor. All-cause mortality among children < 5 years decreased by 72% between 2002 and 2007 mainly following the introduction of artemisinin-based combination therapies whereas the main reduction in malaria incidence followed upon the vector control interventions from 2006. Human biting rates decreased by 98% with a major shift towards outdoor biting by Anopheles arabiensis.

CONCLUSIONS

Zanzibar provides new evidence of the feasibility of reaching uniquely significant and sustainable malaria reduction (pre-elimination) in a previously high endemic region in sub-Saharan Africa. The data highlight constraints of optimistic prognostic modelling studies. New challenges, mainly with outdoor transmission, a large asymptomatic parasite reservoir and imported infections, require novel tools and reoriented strategies to prevent a rebound effect and achieve elimination.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Quantifying proximal patellar tendon changes during adolescence in elite ballet dancers, a 2-year study

Patellar tendon pathology appears to develop in young athletes. It is not known how this tendon develops through adolescence. This longitudinal study investigated proximal patellar tendon development during the adolescent growth spurt in young ballet dancers and identified whether puberty (estimated by maturity offset) had an effect on tendon development. Fifty two dancers (32 female and 20 male dancers, ages 11-18 at baseline) had ultrasound images of their tendons every 6 months for 2 years. Changes in tendon size (anterior-posterior diameter) on grayscale images and echogenicity, as quantified using ultrasound tissue characterization, were recorded each time. Maturity offset was calculated used to estimate peak height velocity (adolescent growth spurt). Maturity offset did not affect effect tendon composition before peak height velocity; however, after participants passed peak height velocity, maturity offset increased the composition of stable echopattern (P < .05): a 4% differential increase in type I echopattern, indicative of normal tendon structure, and a decrease in type III echopattern (more disorganized echopattern) by 0.7% per year. Anterior-posterior thickness increased by 0.2 mm/y (P < .05) measured 2 cm below the patella. Following peak height velocity, the proximal patellar tendon attachment increased in thickness and demonstrated a more stable echopattern representative of aligned fibrillar structure. Future research is required to further understand this normal maturation and the factors that support this process, with the aim of reducing the development of patellar tendon pathology in the adolescent jumping athlete.

The prevalence of Achilles and patellar tendon injuries in Australian football players beyond a time-loss definition

Little is known about the prevalence and associated of morbidity of tendon problems. With only severe cases of tendon problems missing games, players that have their training and performance impacted are not captured by traditional injury surveillance. The aim of this study was to report the prevalence of Achilles and patellar tendon problems in elite male Australian football players using the Oslo Sports Trauma Research Centre (OSTRC) overuse questionnaire, compared to a time-loss definition. Male athletes from 12 professional Australian football teams were invited to complete a monthly questionnaire over a 9-month period in the 2016 pre- and competitive season. The OSTRC overuse injury questionnaire was used to measure the prevalence and severity of Achilles and patellar tendon symptoms and was compared to traditional match-loss statistics. A total of 441 participants were included. Of all participants, 21.5% (95% CI: 17.9-25.6) and 25.2% (95% CI 21.3-29.4) reported Achilles or patellar tendon problems during the season, respectively. Based on the traditional match-loss definition, a combined 4.1% of participants missed games due to either Achilles or patellar tendon injury. A greater average monthly prevalence was observed during the pre-season compared to the competitive season. Achilles and patellar tendon problems are prevalent in elite male Australian football players. These injuries are not adequately captured using a traditional match-loss definition. Prevention of these injuries may be best targeted during the off- and pre-season due to higher prevalence of symptoms during the pre-season compared to during the competitive season.

High power single-mode delivery of mid-infrared sources through chalcogenide fiber

Mechanically robust and low loss single-mode arsenic sulfide fibers are used to deliver high power mid-infrared sources. Anti-reflection coatings were deposited on the fiber facets, enabling 90% transmission through 20 cm length fibers. 10.3 W was transmitted through an anti-reflection coated fiber at 2053 nm, and uncoated fibers sustained 12 MW/cm² intensities on the facet without failure. A Cr:ZnSe laser transmitted >1 W at 2520 nm, and a Fe:ZnSe laser transmitted 0.5 W at 4102 nm. These results indicate that by improving the anti-reflection coatings and using a high beam quality mid-infrared source, chalcogenide fibers can reliably deliver ≥10 W in a single mode, potentially out to 6.5 µm.