Impact of COVID19 on resident physicians of a community hospital in New York city

Introduction: Novel Corona Virus Disease 19 has created unforeseen burden on health care. New York city is one of the epicenters of pandemic and here we explore physical, mental and social impact of COVID 19 on Resident Physicians (RP) working within the center of this epicenter. Methods: This is a single-center cross-sectional web-based survey involving RP of a community hospital in Brooklyn, New York. Questionnaire was formulated in online platform. We used a convenient sampling method. Univariate analysis was conducted and presented the distribution of qualitative responses as frequency and percentages. Result: COVID19 related symptoms were reported by 39.8% RP. COVID19 IgG and IgM antibodies, both negative were reported by 34.9%, while only 6% RPs were IgG antibody positive. Symptomatic RP tested for COVID19-PCR was positive in 42.42%. Self-isolation from family during the pandemic was reported by only 14.5%. Financial constraints, lack of accommodation, and emotional reasons were main reasons of not being able to self isolate. Being bothered by 'Anxiety' and 'Nervousness' were reported by 8.5% on 'Almost every day' while 46.3% reported on 'several days in the two weeks duration'. 'Uncontrollable worrying', 'Feeling down', 'Depressed,' or 'Hopeless' was reported as 'Not at all' by 78.8% and 3.7% reported it to 'occur nearly every day for the last two weeks'. Conclusion: Aftermath of fight against pandemic has left RP with significant physical, mental, and social impact. Appropriate stress management and safety interventions are urgently needed. Further studies are needed to explore the detailed impact of COIV19 on RP.

Assessment of structural chromosomal instability phenotypes as biomarkers of carboplatin response in triple negative breast cancer: the TNT trial

BACKGROUND

In the TNT trial of triple negative breast cancer (NCT00532727), germline BRCA1/2 mutations were present in 28% of carboplatin responders. We assessed quantitative measures of structural chromosomal instability (CIN) to identify a wider patient subgroup within TNT with preferential benefit from carboplatin over docetaxel.

PATIENTS AND METHODS

Copy number aberrations (CNAs) were established from 135 formalin-fixed paraffin-embedded primary carcinomas using Illumina OmniExpress SNP-arrays. Seven published [allelic imbalanced CNA (AiCNA); allelic balanced CNA (AbCNA); copy number neutral loss of heterozygosity (CnLOH); number of telomeric allelic imbalances (NtAI); BRCA1-like status; percentage of genome altered (PGA); homologous recombination deficiency (HRD) scores] and two novel [Shannon diversity index (SI); high-level amplifications (HLAMP)] CIN-measurements were derived. HLAMP was defined based on the presence of at least one of the top 5% amplified cytobands located on 1q, 8q and 10p. Continuous CIN-measurements were divided into tertiles. All nine CIN-measurements were used to analyse objective response rate (ORR) and progression-free survival (PFS).

RESULTS

Patients with tumours without HLAMP had a numerically higher ORR and significantly longer PFS in the carboplatin (C) than in the docetaxel (D) arm [56% (C) versus 29% (D), PHLAMP,quiet = 0.085; PFS 6.1 months (C) versus 4.1 months (D), Pinteraction/HLAMP = 0.047]. In the carboplatin arm, patients with tumours showing intermediate telomeric NtAI and AiCNA had higher ORR [54% (C) versus 20% (D), PNtAI,intermediate = 0.03; 62% (C) versus 33% (D), PAiCNA,intermediate = 0.076]. Patients with high AiCNA and PGA had shorter PFS in the carboplatin arm [3.4 months (high) versus 5.7 months (low/intermediate); and 3.8 months (high) versus 5.6 months (low/intermediate), respectively; Pinteraction/AiCNA = 0.027, Padj.interaction/AiCNA = 0.125 and Pinteraction/PGA = 0.053, Padj.interaction/PGA = 0.176], whilst no difference was observed in the docetaxel arm.

CONCLUSIONS

Patients with tumours lacking HLAMP and demonstrating intermediate CIN-measurements formed a subgroup benefitting from carboplatin relative to docetaxel treatment within the TNT trial. This suggests a complex and paradoxical relationship between the extent of genomic instability in primary tumours and treatment response in the metastatic setting.

Using Video-Assisted Laryngoscope (GlideScope®) to Insert a Nasogastric Tube and Prevent Pneumothorax From Incorrectly Inserted Nasogastric Tubes

When indicated, nasogastric tubes (NGT) are often inserted blindly, and the positioning is later confirmed using a chest X-ray (CX-ray). This case describes the blind insertion of an NGT in an 85-year-old nonverbal woman with advanced dementia who developed a pneumothorax (PTX) following NGT insertion. The patient had sepsis due to pneumonia and an infected decubitus ulcer. Because the patient had difficulty swallowing, NGT insertion was blindly performed by a house staff resident, and the tube entered the left lung. A portable bedside CX-ray was performed post-insertion and confirmed that the NGT was in the left lung, with left-sided PTX. An immediate CT of the chest revealed a partial collapse of the left lung. The patient was placed on a nonrebreather mask with 80% oxygen, and immediate insertion of a chest tube (12 Fr catheter) resulted in a subcomplete resolution of the PTX on the left side, with remaining apical PTX. Because an NGT was still required to feed the patient, we used a video-assisted laryngoscope (VAL) to assist with the insertion of the NGT the second time and prevent insertion in the incorrect location. We encourage physicians to consider the insertion of NGT under direct observation using VAL.

Incidence, Predictors, Causes, and Cost of 30-Day Hospital Readmission in Chronic Obstructive Pulmonary Disease Patients Undergoing Bronchoscopy

Introduction

Chronic obstructive pulmonary disease (COPD) has a significant disease burden and is among the leading causes of hospital readmissions, adding a significant burden on healthcare resources. The association between 30-day readmission in a COPD patient undergoing bronchoscopy and a wide range of modifiable potential risk factors, after adjusting for sociodemographic and clinical factors, has been assessed, and comparison has been made with COPD patients not undergoing bronchoscopy.

Methods

We conducted a comprehensive analysis of the 2016 Nationwide Readmission Database (NRD) of 30-day all-cause readmission among COPD patients undergoing bronchoscopy. A Cox’s proportional hazards model was used to obtain independent relative risks of readmission following bronchoscopy in COPD patients as compared to patients not undergoing bronchoscopy. Our primary outcome was the 30-day all-cause readmission rate in both groups. Other secondary outcomes of interest were the 10 most common reasons for readmission, resource utilization, independent predictors of readmission, and relative proportion of comorbidities between the index admission (IA) and the readmission in both groups.

Results

The overall rate of readmission following bronchoscopy in COPD patients as compared to patients not undergoing bronchoscopy was 17.32% and 15.87%, respectively. The final multivariate model in the bronchoscopy group showed that the variables found to be an independent predictor of readmission were: pulmonary hypertension (hazard ratio [HR] 2.35; 95% confidence interval [CI] 1.26-4.25; P < .01), adrenal insufficiency (HR 4.47; 95% CI 1.44-13.85; P = .01) and discharge to rehab status. Independent predictor variables of admission in Group B were gender (women < men; HR 0.91; 95% CI 0.88-0.93; P < .01), and type of insurance (Medicaid > Medicare > private insurance).

For all patients undergoing bronchoscopy, the mean length of stay (LOS) for IA was 11.91 ± 20.21 days, and LOS for readmission was 5.87 ± 5.48 days. The mean total cost of IA for patients undergoing bronchoscopy was much higher than that of readmission ($26,916 vs. $12,374, respectively). The entire LOS for readmission was 1,265 days, with a total cost of $2.66 million.

For patients not undergoing bronchoscopy during the IA, mean LOS for IA was 4.26 ± 4.27 days, and mean LOS for readmission was 5.39 ± 5.51 days, which was longer than the IA in Group B but still shorter than LOS for readmission in Group A (patients undergoing bronchoscopy). The mean total cost of readmission was higher than the IA ($8,137 for IA vs. $10,893 for readmission). The total LOS in this group of patients was 313,287 days, with the total cost of readmission at $628 million.

Conclusions

Patients undergoing bronchoscopy have a slightly higher rate of 30-day readmissions as compared to patients not undergoing bronchoscopy, and the LOS is also slightly higher in this group during subsequent readmissions as compared to readmission in patients not undergoing bronchoscopy in IA. The readmission rate in COPD patients is impacted by a variety of social, personal, and medical factors. Patients with multiple medical comorbidities have a higher risk of readmission. In our understanding, bronchoscopy in a patient with acute exacerbation of COPD should be reserved for selected patients, and the rationale should be clarified, as it affects the overall LOS and healthcare expenditure.

Pulmonary Kaposi Sarcoma: an uncommon presentation in HIV heterosexual female on antiretroviral therpay

Kaposi sarcoma (KS) is caused by Human Herpesvirus 8 (HHV-8), and it affects 15 times more common in men than women. It has varied clinical presentation from classic, endemic, organ transplant-related, and acquired immunodeficiency syndrome (AIDS)-related.

Clinical features of pulmonary KS might be challenging to distinguish from pneumonia in immunocompromised patients and could lead to diagnostic challenges. Hence Pulmonary KS should also be considered in the differential when HIV-infected patients develop rapidly progressive respiratory symptoms after the initiation of glucocorticoid therapy and immunocompromised not responding to antibiotic treatment for pneumonia, especially when CD4 < 100 and viral load >10,000. Early diagnosis and treatment are essential for a better outcome and prevent morbidity and mortality. Highly active antiretroviral therapy (HAART) is the only proven therapy to prevent Kaposi sarcoma. We report the case of a young woman who presented with symptoms of pneumonia and was later found to have pulmonary KS (PKS).

Endobronchial valves for persistent air leak all-cause mortality and financial impact: US trend from 2012-2016

Background: Endobronchial valves (EBV) are considered an innovation in the management of the persistent air leak (PAL). They offer a minimally invasive alternative to the traditional approach of pleurodesis and surgical intervention. We examined trends in mortality, length of stay (LOS), and resources utilization in patients who underwent EBV placement for PAL in the US.

Methods: We utilized discharge data from the Nationwide Inpatient Sample (NIS) for five years (2012–2016). We included adults diagnosed with a pneumothorax who underwent EBV insertion at ≥ 3 days from the day of chest tube placement; or following invasive thoracic procedure. We analyzed all-cause mortality, LOS, and resources utilization in the study population.

Results: A total of 1,885 cases met our inclusion criteria. Patients were mostly middle-aged, males, whites, and had significant comorbidities. The average LOS was 21.8 ± 20.5 days, the mean time for chest tube placement was 3.8 ± 5.9 days, and the mean time for EBV insertion was 10.5 ± 10.3 days. Pleurodesis was performed before and after EBV placement and in 9% and 6%, respectively.

Conclusions: Our study showed that the all-cause mortality rate fluctuated throughout the years at around 10%. Despite EBV being a minimally invasive alternative, its use has not trended up significantly during the study period. EBVs are also being used off-label in the US for spontaneous pneumothorax. This study shall provide more data to the scarce literature about EBV for PAL.

A symptomatic gastric sarcoidosis and asymptomatic pulmonary sarcoidosis: a rare manifestation

Sarcoidosis is a granulomatous disease of unknown etiology which may present with systemic manifestations. The diagnosis of gastric sarcoidosis needs much effort to accomplish as it is exceedingly rare, and the treatment is usually recommended exclusively for symptomatic disease. Here, we present a case of gastric sarcoidosis in a 31-year old black female patient with symptoms of nausea and epigastric pain. A diagnosis of gastric sarcoidosis was mainly based on the presence of non-necrotizing granulomas on biopsy following esophagogastroduodenoscopy (EGD). She was treated with steroid with high dose at first, followed by a slow taper and the symptoms responded to the treatment.

Characteristics of 30-day readmission in spontaneous pneumothorax in the United States: a nationwide retrospective study

Objective: Our study aimed to determine the national estimates of the 30-day all-cause readmission rate among patients with spontaneous pneumothorax and to investigate the burden of these readmissions in terms of mortality, length of stay and hospitalization costs in the USA.

Methods: We utilized the Nationwide Readmission Database for 2013–2014 and identified adults with a primary diagnosis of spontaneous pneumothorax. We analyzed and reported patient- and hospital-level variables of the study cohort. Our primary outcome was 30-day readmission rate, including the reasons for readmission. Our secondary outcomes included all-cause mortality, resources utilization and predictors of readmissions.

Results: We identified 47,108 index admissions with spontaneous pneumothorax. The 30-day readmission rate was 13.6%. The most common reason for admission was recurrent pneumothorax. In index admissions, the in-hospital mortality rate was 3.1%; whereas, in readmissions, the mortality was higher (4.6%, p < 0.001). Both age group 45–64 (HR: 1.31, 95% CI: [1.15–1.49], p < 0.001) and history of cancer (HR: 1.34, 95% CI: [1.17–1.53], p < 0.001) were found to predict the risk of 30-day readmission.

Conclusion: The 30-day readmission rate in patients with spontaneous pneumothorax was 13.6%, and a recurrent event was the most likely cause. The 30-day readmissions were associated with higher mortality and hospitalization charges. Middle age and history of cancer increase likelihood of 30-day readmission.

Polysomnographic variables in Alternate overlap syndrome: data from sleep heart health study

Objective: To evaluate influence of asthma on polysomnographic variables of patients with obstructive sleep apnea (OSA).Methods: A longitudinal retrospective study using data collected from the Sleep Heart Health Study (SHHS).Results: All 2822 patients included had OSA, 2599 were non-asthmatic whereas 223 were asthmatics. Average BMI for non-asthmatics was 28.8 kg/m² whereas asthmatics had 29.5 kg/m². Median pack-years of smoking was 1.42 vs. 1.98 in non-asthmatic and asthmatic groups, respectively. Sex distribution, age (in years), BMI, FEV₁, FVC, AHI ≥ 4% (all apneas, hypopneas with ≥4% oxygen desaturation or arousal per hour of sleep), RDI ≥ 3% (overall respiratory distribution index at ≥3% oxygen desaturation or arousal), sleep latency, percentage of sleep time in apnea/hypopnea and Epworth sleep scale score were all statistically significant. Non-asthmatics had greater AHI (12.63/hr) compared to asthmatics (11.34/hour), p = 0.0015. RDI in non-asthmatics and asthmatics was (23.07 vs 20.53; p = 0.009). Sleep latency was found to be longer in asthmatics 19.8 minutes vs. 16 minutes (p = 0.008). Epworth sleepiness scale score was high in asthmatics (9 vs. 8, p = 0.002).Conclusion: OSA was found more severe in non-asthmatic subgroup, but asthmatics had statistically significant higher Epworth sleepiness scale score and sleep latency. Clinicians should be vigilant and keep low threshold to rule out OSA particularly on patients with difficult to control asthma, smoker, GERD, obese and nasal disease.

Abstract P1-06-07: Characterization of chromosomal instability in the TNT trial: A randomized phase III trial of carboplatin compared with docetaxel for patients with metastatic or recurrent locally advanced triple negative or BRCA1/2 breast cancer (CRUK/07/012)

Background

A distinctive trait of triple negative breast cancer (TNBC) is the acquisition of genome wide highly aberrant copy number states, which is more evident in metastatic settings. The level of copy number alterations can be characterized by quantitative estimates of chromosomal instability, such as allelic imbalanced copy number aberrations, telomeric allelic imbalance (NtAI), homologous recombination deficiency (HRD) score, referred here as genomic scars. Several of these scars are reported as being indicative of BRCAness and potential predictive and/or prognostic biomarkers of chemotherapy response, currently mostly demonstrated in neoadjuvant settings in TNBC.

Aims

Using several genomic scar measures, we aim to capture chromosomal instability and test their predictive and prognostic value in metastatic or recurrent locally advanced triple negative or BRCA1/2 mutated breast cancer in the TNT trial.

Methods

Patients recruited to TNT (n=376) had ER-/PR-/Her2- breast cancer or were germline BRCA mutation carriers. Genome-wide copy numbers (CN) were derived from FFPE samples including primary tumours and positive lymph nodes (n=183, docetaxel=93, carboplatin=90; BRCA1 mut=25). Genomic scars were generated using ASCAT (Van loo et al., PNAS 2010) CN profiles. HRD scores were established by Myriad Genetics, Inc. assay (n=272). BRCA1-like classifier was applied as described in Schouten et al., Mol Onc 2015. Shannon diversity index was calculated using ASCAT raw CN profiles. Association of genomic scars with PAM50 subtypes and BRCA1 deficiency status were evaluated using Kruskal-Wallis test; p-values were adjusted for multiple comparisons (Dunn's test). Statistical significance was defined as p&lt;0.05. Association of genomic scars with objective tumour response rate (ORR) and Progression Free Survival (PFS) was assessed using logistic regression and restricted mean survival analysis, respectively.

Results

HRD and NtAI scores were higher in basal like samples compared to non-basal like (median diff. HRD=11.5, p=0.005; NtAI=3, p=0.04). HRD (p=2e-14) and NtAI (p=0.003) scores were also higher in BRCA1 deficient (BRCA1 germline/somatic mutant or BRCA1 methylated) samples compared to non-deficient. Using the BRCA1-like classifier, 42 out of 50 BRCA1 deficient samples and 93 out of 133 BRCA1 non-deficient/undetermined samples were identified as BRCA1-like. The Shannon diversity index, measuring CN heterogeneity, clustered samples into 3 groups. Analysis of ORR showed non-significant trends to preferential response rates with docetaxel in cluster 1 and 3. Membership of cluster 2 predicted higher ORR to carboplatin over docetaxel (interaction p=0.017). PFS indicated a treatment effect in cluster 2, but not in cluster 1 or 3; there was no evidence of interaction between subgroups and treatment (p=0.15).

Conclusions

Our results suggest that the overall heterogeneity of the copy number landscape is a promising area for seeking predictive/prognostic biomarkers in metastatic TNBC, and combined with other modalities of high-dimensional omics data could provide essential treatment response information.

Citation Format: Sipos O, Tovey H, Quist J, Haider S, Nowinski S, Gazinska P, Kernaghan S, Toms C, Timms KM, Lanchbury JS, Linn SC, Pinder SE, Bliss JM, Tutt A, Cheang MC, Grigoriadis A, On behalf of the TNT Trial Management Group and Investigators. Characterization of chromosomal instability in the TNT trial: A randomized phase III trial of carboplatin compared with docetaxel for patients with metastatic or recurrent locally advanced triple negative or BRCA1/2 breast cancer (CRUK/07/012) [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 P1-06-07.

Predictors of hospital stay in normotensive acute pulmonary embolism: a retrospective pilot study

Introduction: The aim of our study is to determine the clinical, biochemical, and imaging factors that affect the duration of hospital stay in patients admitted with normotensive acute pulmonary embolism.

Methods: This was a single-center retrospective study conducted in a community hospital in New York metropolitan area for patients admitted from October 2015 to October 2017.

Results: A total of 79 patients were included, the mean age was 55.76 (SD = 17.33), 29 cases were males (37%) and 50 cases were females (63%). Among all patients, 17 cases had short length of stay (LOS) (≤2 days) and 62 cases had long LOS (>2 days). There were statistically significant differences in age (p = .041), presence of lung disease (p = .036), number of comorbidities (p = .043), and pulmonary embolism severity index (PESI) scores (original and simplified; p = .002 and .001, respectively). Logistic regression analysis showed that PESI score significantly predicted long LOS (OR 1.067, 95% CI [1.001, 1.137], p = .048). Similarly, sPESI significantly predicted long LOS (OR 0.223, 95% CI [0.050, 0.999], p = .050). Both regression models were adjusted for age, lung disease, and number of comorbidities.

Conclusion: Both original and simplified PESI scores were statistically significant predictors of duration of hospital stay. Patients with multiple comorbidities or with chronic lung disease were also likely to have prolonged hospital stay. None of the cardiac biomarkers affected the duration of hospital stay, neither did the presence of right ventricular dysfunction nor treatment modality.

Pseudo-thrombotic thrombocytopenic purpura presenting as multi-organ dysfunction syndrome: A rare complication of pernicious anemia

Objective:

We present a rare case of pernicious anemia presented as multi-organ dysfunction syndrome, later found to have pseudo-thrombotic thrombocytopenic purpura.

Methods:

An 86-year-old female presented with respiratory distress, altered mental status, acute renal failure and was intubated in emergency room. She was found to have severe anemia, thrombocytopenia, high lactate, high lactate dehydrogenase and low haptoglobin. Peripheral smear revealed multilobulated neutrophils with schistocytes, poikilocytes and anisocytes.

Results:

She was admitted to intensive care unit for altered mental status, multi-organ dysfunction syndrome with severe metabolic acidosis in setting of hemolysis. She was intubated and managed with intravenous antibiotics and blood transfusion. Patient improved significantly after blood transfusion. Lactic acid normalized, acute kidney injury resolved and mentation improved after transfusion. Laboratory investigation revealed low vitamin B12, high methylmalonic acid, high homocysteine, high lactate dehydrogenase, low haptoglobin, high anti-parietal antibody and high anti-intrinsic factor antibody. Patient was diagnosed with pernicious anemia and pseudo-thrombotic thrombocytopenic purpura with concomitant intramedullary hemolysis. Her hematological parameters and her clinical condition improved significantly after starting therapy with cyanocobalamin.

Conclusion:

Pernicious anemia is a chronic disease with subtle presentation but may present as life-threatening complications. Hemolysis and pseudo-thrombotic thrombocytopenic purpura may present as multi-organ dysfunction syndrome which has dramatic response to appropriate therapy.

Functional redundancy between Apc and Apc2 regulates tissue homeostasis and prevents tumorigenesis in murine mammary epithelium

Aberrant Wnt signaling within breast cancer is associated with poor prognosis, but regulation of this pathway in breast tissue remains poorly understood and the consequences of immediate or long-term dysregulation remain elusive. The exact contribution of the Wnt-regulating proteins adenomatous polyposis coli (APC) and APC2 in the pathogenesis of human breast cancer are ill-defined, but our analysis of publically available array data sets indicates that tumors with concomitant low expression of both proteins occurs more frequently in the 'triple negative' phenotype, which is a subtype of breast cancer with particularly poor prognosis. We have used mouse transgenics to delete Apc and/or Apc2 from mouse mammary epithelium to elucidate the significance of these proteins in mammary homeostasis and delineate their influences on Wnt signaling and tumorigenesis. Loss of either protein alone failed to affect Wnt signaling levels or tissue homeostasis. Strikingly, concomitant loss led to local disruption of β-catenin status, disruption in epithelial integrity, cohesion and polarity, increased cell division and a distinctive form of ductal hyperplasia with 'squamoid' ghost cell nodules in young animals. Upon aging, the development of Wnt activated mammary carcinomas with squamous differentiation was accompanied by a significantly reduced survival. This novel Wnt-driven mammary tumor model highlights the importance of functional redundancies existing between the Apc proteins both in normal homeostasis and in tumorigenesis.

Abstract P1-07-03: Mesenchymal subtype negatively associates with the presence of immune infiltrates within a triple negative breast cancer classifier

Introduction: Lehmann and colleagues (Lehmann et al., 2011) devised a gene expression classification system for triple negative breast cancer (TNBC) consisting of seven subtypes—IM, BL1, BL2, LAR, M, MSL, and UNS (unselected). We (Ring et al., 2016) recently modified this original algorithm of 2188 gene subtyping into a 101-gene algorithm. In addition to a reduction of genes, the 101-gene algorithm has two methodological differences: first, the immunomodulatory (IM) signature was treated not as a subtype but rather as a binary feature of one of the other subtypes (e.g. BL1/IM+, LAR/IM-); second, when tumors—by a predefined correlation coefficient—showed traits of more than one subtype, both subtypes were reported as “dual subtypes.”

Aim: Our aim was to apply the 101-gene algorithm for TNBC subtyping and to establish the relation of TNBC subtypes with their IM-status across several independent data sets.

Methods: 951 patients from four independent TNBC cohorts with available gene expression data were analyzed by the 101-gene algorithm. Of these 848 were classified with at least one subtype.

Results: The distribution of the 5 TNBC subtypes in both single and dual subtypes was 47%,10%,15%,18%,11%, for BL1, BL2, LAR, M, and MSL respectively. The majority of cases gave only one subtype (572, 67%) with M (Mesenchymal) being 9% (n=54) of these. Given this frequency of 9% of M as a baseline, in the remaining 276 (33%) cases with dual subtypes, the expectation that M would be one of the two is 11% (64 subtype calls). However, M is one of the two of the dual subtypes at a much higher frequency of 40% (222 subtype calls, Chi-Squared, P&lt;0.0001). IM+ is a common feature across these cohorts (n=310 or 37%). When examining the IM feature within the patients exhibiting the M subtype as either a single subtype or one of the two dual subtypes (n=276, 33%), IM positive tumors are never of the M phenotype (Chi-Squared, p&lt;0.0001).

Conclusions: We further have confirmed with the 101-gene algorithm that the IM signature inversely associates with the M subtype as it has been observed with the 2188 gene algorithm (Lehmann et al., 2016). Moreover, the M signature is occasionally a confounder of other subtypes however still identifies those tumors negative for immune infiltrates. This raises important opportunities to understand the relationships between intrinsic tumor biology reflected in TNBC subtypes and their interaction with variable immune cell stroma which are the subject of ongoing analyses.

Citation Format: Grigoriadis A, Quist J, Mirza H, Cheang MC, Ring BZ, Hout DR, Bailey DB, Seitz RS, Tutt AN. Mesenchymal subtype negatively associates with the presence of immune infiltrates within a triple negative breast cancer classifier [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-07-03.

Abstract P1-05-14: Copy number aberration-induced gene breakage analysis identifies recurrent FOXP1 fusions in breast cancer

Background: Genomic instability is a critical feature of breast cancers, which manifests in genome-wide copy number aberrations (CNA), often causing “gene breakage” and the generation of fusion genes. We aimed to identify aborted transcripts with underlying CNAs and to investigate the molecular landscape of breast cancers harbouring such events.

Methods: A walking student's t-test algorithm was applied to Affymetrix Exon 1.0ST array data of 123 breast cancers to identify regions of aborted transcription and overlaid with DNA breakpoints derived from matched Affymetrix SNP6 ASCAT-segmented copy number. Aborted transcripts were investigated as potential fusion gene partners through RNA-seq analysis of 151 breast cancer samples (TCGA) and 51 breast cancer cell lines (BCCL) using ChimeraScan. Clinical correlates were established for clinicopathological features, genomic instability measures, and gene expression-based molecular classifiers including PAM50, TNBCtype, IntClust subtypes and immune signatures.

Results: One hundred and six genes with recurrent CNA-induced aborted transcription were identified. Aborted transcription showed hormone receptor subtype-specificity for 7 genes (nTNBC=1, nNon-TNBC=6) and was less prevalent in samples of IntClust 2 and IntClust 4 subtypes (p: 0.0043, 0.0011). Aborted transcripts were more frequently observed in samples with greater copy-neutral loss of heterozygosity (p=0.012), while aborted transcription of 54/106 genes significantly affected enrichment of 27 tumor-infiltrating lymphocyte subpopulations.14 aborted transcripts were found as a fusion gene with one partner in RNA-seq of TCGA and BCCL, while 19 were involved in multiple fusion events (range=1-6, median=2). Nine of 106 genes displayed gene breakage and fusion events exclusively in samples with an enriched tandem duplication phenotype. Notably, FOXP1, localised to a tumour suppressor locus at 3p14.1, reported the highest number of fusion configurations (n=6) with concurrent aborted transcription across all RNA-seq datasets (nPRADA=9, nTCGA=38, nBCCL=6).

Conclusion: CNA-induced gene breakage affects the molecular landscape of breast cancers and is linked with many genomic configurations of interest including copy-neutral loss of heterozygosity and tandem duplications. In particular, the role of recurrent gene fusions of the tumour suppressor, FOXP1, in tumourigenesis warrants further investigation.

Citation Format: Mohd Noor A, Maguire S, Watkins J, Quist J, Mirza H, Tutt A, Gillett C, Natrajan R, Grigoriadis A. Copy number aberration-induced gene breakage analysis identifies recurrent FOXP1 fusions in breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-05-14.

Spontaneous pneumomediastinum, pneumoretroperitoneum, and cervicofacial subcutaneous emphysema after repeatedly and forcefully blowing into a bottle

Spontaneous pneumomediastinum (SPM) is an uncommon, self-limiting condition associated with increased intra-thoracic pressure resulting in alveolar rupture. Search of the literature revealed no detailed case report about a 26-year-old psychiatric patient who repeatedly and forcefully blew air into a bottle for 5 days resulting in a combined condition of spontaneous pneumoretroperitoneum, pneumomediastinum, and cervicofacial subcutaneous emphysema. It is crucial to find a primary source and treat appropriately. Psychiatric patients may have psychotic behaviors mimicking Valsalva's maneuver that increases intra-thoracic pressure and causing SPM. Optimal medications should be given to control psychotic behaviors. Family members and caregivers should be explained about this unusual behavior so that they can prevent this rare condition.

Relationship of symptoms with sleep-stage abnormalities in obstructive sleep apnea-hypopnea syndrome

BACKGROUND

Patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) present with a variety of sleep-related symptoms. In polysomnography, sleep architecture is almost always abnormal, but it is not known which of the sleep-stage abnormalities are related to symptoms. Finding key sleep-stage abnormality that cause symptoms may be of therapeutic importance to alleviate symptoms. So far the mainstay of treatment is continuous positive airway pressure (CPAP)/bi-level positive airway pressure (BIPAP) therapy, but many patients are non-compliant to it. Correcting the sleep-stage abnormality that cause symptoms by pharmacotherapy may become an important adjunct to CPAP/BIPAP therapy.

METHODS

A cross-sectional study. Adult subjects who attended a sleep laboratory for diagnostic polysomnography for a period of 1 month were recruited consecutively. OSAHS was diagnosed using American Academy of Sleep Medicine criteria. Subjects filled a questionnaire for symptoms prior to polysomnography.

RESULTS

Thirty subjects, of whom 83.3% were obese, met diagnostic criteria, with males constituting 46.7% and females constituting 53%. Mean age was 53.40±11.60 years. Sleep architecture comprised N1 19.50±19.00%, N2 53.93±13.39%, N3 3.90±19.50%, and rapid eye movement 8.92±6.21%. Excessive fatigue or sleepiness, waking up tired, falling asleep during the day, trouble paying attention, snoring and insomnia were significantly related to decreased N3 sleep.

CONCLUSIONS

Most of the symptoms in OSAHS in adults are related to decreased stage N3 sleep. If confirmed by larger controlled studies, correcting N3 sleep deficiency by pharmacotherapy may become an important adjunct to CPAP/BIPAP therapy to alleviate symptoms.

Pharmacokinetic profile of methotrexate in psoriatic skin via the oral or subcutaneous route using dermal microdialysis showing higher methotrexate bioavailability in psoriasis plaques than in non-lesional skin

AIMS

The aim of this pilot study was to use microdialysis to evaluate levels of Methotrexate (MTX) directly in psoriatic skin following oral or subcutaneous administration of MTX to elaborate a complete pharmacokinetic profile within the dermal skin.

METHODS

Six patients with chronic plaque psoriasis on the arm undergoing treatment with MTX were included in a mono-centre clinical trial. Patients were under treatment with p.o. or s.c. MTX (7.5 and 15 mg) for at least 3 months. Interstitial fluid was collected ex vivo via dermal microdialysis from lesional or non-lesional skin and via intravenous microdialysis as well as blood serum every hour up to 10 h after methotrexate administration every hour. MTX was analysed via liquid chromatography.

RESULTS

The area under the curve (AUC) of methotrexate from peripheral blood was up to four times higher than from microdiaylsis, which detection of free unbound MTX. The AUC from dialysates in psoriatic lesional skin was higher than in non-lesional psoriatic skin, and the AUC levels from i.v. microdialysis were non-significantly higher than those from lesional psoriatic skin. Pharmacokinetic profiles were individually quite different and did not primarily depend on the dose or the means (p.o. vs. s.c.) in which it was administered.

CONCLUSION

Dermal microdialysis is a valid tool to evaluate levels of methotrexate in the skin of psoriasis patients. Drug levels and bioavailability of methotrexate were higher in lesional than non-lesional psoriatic skin. The individual AUC of MTX was not primarily dependent on the route or dose of administration.

Use of flexible bronchoscopy in an adult for removal of an aspirated foreign body at a community hospital

Foreign body aspiration (FBA) is more common in children than adults with about 80% occurring in children aged less than 15 years. FBA in adults is often overlooked as a potential cause of airway obstruction especially if there is no asphyxiation. We present a case of a 45-year-old male with alcohol abuse who presented with post-obstructive pneumonia secondary to aspiration of tooth of unknown duration. The tooth was removed via flexible bronchoscopy (FBr) and we will discuss the use of FBr for foreign body (FB) removal, which FB can be easily removed by FBr, and the different techniques and devices used for FB removal via FBr.

Unrecognized clozapine-related constipation leading to fatal intra-abdominal sepsis - a case report

Clozapine is the preferred antipsychotic used for the treatment of resistant schizophrenia with suicidal ideation. The drug is started at a low dose and gradually increased to a target dose of 300–450 mg/day. It is well known to cause agranulocytosis and neutropenia. Several cases of fatal sepsis have been reported in neutropenic patients and emphasis is placed on monitoring for agranulocytosis; however, clozapine also causes intestinal hypomotility and constipation, which if unrecognized can lead to intestinal obstruction, bowel necrosis, and intra-abdominal sepsis. Reduced behavioral pain reactivity in schizophrenics may alter the ability to express pain, potentially leading to a delay in the presentation for medical attention. We report a case of fatal intra-abdominal sepsis secondary to an unrecognized case of clozapine-related constipation.

A case of chylothorax in a patient with sarcoidosis: a rare and potentially fatal complication

Obstruction of the thoracic duct may lead to accumulation of a lymphatic fluid rich in triglycerides named chyle. When chyle accumulates in the pleural cavity, it becomes a chylothorax. Malignancy, particularly lymphoma, is the most common cause of chylothorax; however, any pathology leading to obstruction or destruction of the thoracic duct can lead to a chylothorax. This particular case investigates an incidence of chylothorax in sarcoidosis. A 54-year-old African American woman with a medical history of sarcoidosis, congestive heart failure, and smoking presented to the emergency department with complaints of bilateral foot swelling and exertional shortness of breath 3 days in duration. Physical examination was positive for bilateral crepitations with decreased air entry, abdominal ascites, and bilateral 2+ pitting edema. Both chest X-ray and chest CT were positive for stable bilateral pleural effusions (when compared to imaging done 3 years previously), and thoracocentesis and paracentesis were positive for chylous fluid accumulation. Chylothorax was diagnosed, and based on the previous medical history, the lymphadenopathy of sarcoidosis was determined to cause the occlusion of the thoracic duct. Lymphoscintigraphy and surgical intervention were advised; however, the family decided on conservative management and the patient expired intubated in the ICU. Chylothorax is a rare manifestation of sarcoidosis and high index of suspicion should be there to diagnose this, as there is high morbidity and mortality associated with it.