Variation in Rates of Post-Mastectomy Radiotherapy Among Women with Early Invasive Breast Cancer in England and Wales: A Population-Based Cohort Study

AIMS

This study examined whether patterns of post-mastectomy radiotherapy (PMRT) among women with early invasive breast cancer (EIBC) varied within England and Wales and explored the role of different patient factors in explaining any variation.

MATERIALS AND METHODS

The study used national cancer data on women aged ≥50 years diagnosed with EIBC (stage I-IIIa) in England and Wales between January 2014 and December 2018 who had a mastectomy within 12 months of diagnosis. A multilevel mixed-effects logistic regression model was used to calculate risk-adjusted rates of PMRT for geographical regions and National Health Service acute care organisations. The study examined the variation in these rates within subgroups of women with different risks of recurrence (low: T1-2N0; intermediate: T3N0/T1-2N1; high: T1-2N2/T3N1-2) and investigated whether the variation was linked to patient case-mix within regions and organisations.

RESULTS

Among 26 228 women, use of PMRT increased with greater recurrence risk (low: 15.0%; intermediate: 59.4%; high: 85.1%). In all risk groups, use of PMRT was more common among women who had received chemotherapy and decreased among women aged ≥80 years. There was weak or no evidence of an association between use of PMRT and comorbidity or frailty, for each risk group. In women with an intermediate risk, unadjusted rates of PMRT varied substantially between geographical regions (range 40.3-77.3%), but varied less for the high-risk (range 77.1-91.6%) and low-risk groups (range 4.1-32.9%). Adjusting for patient case-mix reduced the variation in regional and organisational PMRT rates to a small degree.

CONCLUSIONS

Rates of PMRT are consistently high across England and Wales among women with high-risk EIBC, but variation exists across regions and organisations for women with intermediate-risk EIBC. Effort is required to reduce unwarranted variation in practice for intermediate-risk EIBC.

The Association Between Survival and Receipt of Post-mastectomy Radiotherapy According to Age at Diagnosis Among Women With Early Invasive Breast Cancer: A Population-Based Cohort Study

AIMS

Clinical trials of post-mastectomy radiotherapy (PMRT) for early invasive breast cancer (EIBC) have included few older women. This study examined whether the association between overall survival or breast cancer-specific survival (BCSS) and receipt of PMRT for EIBC altered with age.

MATERIALS AND METHODS

The study used patient-level linked cancer registration, routine hospital and radiotherapy data for England and Wales. It included 31 243 women aged ≥50 years diagnosed between 2014 and 2018 with low- (T1-2N0), intermediate- (T3N0/T1-2N1) or high-risk (T1-2N2/T3N1-2) EIBC who received a mastectomy within 12 months from diagnosis. Patterns of survival were analysed using a landmark approach. Associations between overall survival/BCSS and PMRT in each risk group were analysed with flexible parametric survival models, which included patient and tumour factors; whether the association between PMRT and overall survival/BCSS varied by age was assessed using interaction terms.

RESULTS

Among 4711 women with high-risk EIBC, 86% had PMRT. Five-year overall survival was 70.5% and BCSS was 79.3%. Receipt of PMRT was associated with improved overall survival [adjusted hazard ratio (aHR) 0.75, 95% confidence interval 0.64-0.87] and BCSS (aHR 0.78, 95% confidence interval 0.65-0.95) compared with women who did not have PMRT; associations did not vary by age (overall survival, P-value for interaction term = 0.141; BCSS, P = 0.077). Among 10 814 women with intermediate-risk EIBC, 59% had PMRT; 5-year overall survival was 78.4% and BCSS was 88.0%. No association was found between overall survival (aHR 1.01, 95% confidence interval 0.92-1.11) or BCSS (aHR 1.16, 95% confidence interval 1.01-1.32) and PMRT. There was statistical evidence of a small change in the association with age for overall survival (P = 0.007), although differences in relative survival were minimal, but not for BCSS (P = 0.362).

CONCLUSIONS

The association between PMRT and overall survival/BCSS does not appear to be modified by age among women with high- or intermediate-risk EIBC and, thus, treatment recommendations should not be modified on the basis of age alone.

Full-Length SMN Transcript in Extracellular Vesicles as Biomarker in Individuals with Spinal Muscular Atrophy Type 2 Treated with Nusinersen

BACKGROUND

Three therapeutic strategies have radically changed the therapeutic scenario for spinal muscular atrophy (SMA). However, therapeutic response differs between individuals. There is a need to identify biomarkers to further assess therapeutic response and to better understand which variables determine the extent of response.

METHODS

We conducted a study using an optimized digital droplet PCR-based method for the ultra-sensitive detection of SMN transcript in serum EVs from SMA 2 individuals treated with nusinersen over 14 months. In parallel, we investigated levels of serum and CSF neurofilament heavy chain (pNF-H) in the same cohort.

RESULTS

Expression of flSMN transcript in EVs of SMA 2 individuals prior to nusinersen was lower than in controls (0.40 vs 2.79 copies/ul; p < 0.05) and increased after 14 months of nusinersen (0.40 vs 1.11 copies/ul; p < 0.05). The increase in flSMN with nusinersen was significantly higher in younger individuals (p < 0.05). Serum pNF-h was higher in non-treated individuals with SMA 2 than in controls (230.72 vs 22.88 pg/ml; p < 0.05) and decreased with nusinersen (45.72 pg/ml at 6 months, 39.02 pg/ml at 14 months). CSF pNF-h in SMA 2 individuals also decreased with nusinersen (248.04 pg/ml prior to treatment, 197.10 pg/dl at 2 months, 104.43 pg/dl at 6 months, 131.03 pg/dl at 14 months).

CONCLUSIONS

We identified an increase of flSMN transcript in serum EVs of SMA 2 individuals treated with nusinersen that was more pronounced in the younger individuals. Our results indicate that flSMN transcript expression in serum EVs is a possible biomarker in SMA to predict or monitor the response to treatment.

Change in the Use of Fractionation in Radiotherapy Used for Early Breast Cancer at the Start of the COVID-19 Pandemic: A Population-Based Cohort Study of Older Women in England and Wales

Aims

Adjuvant radiotherapy is recommended for most patients with early breast cancer (EBC) receiving breast-conserving surgery and those at moderate/high risk of recurrence treated by mastectomy. During the first wave of COVID-19 in England and Wales, there was rapid dissemination of randomised controlled trial-based evidence showing non-inferiority for five-fraction ultra-hypofractionated radiotherapy (HFRT) regimens compared with standard moderate-HFRT, with guidance recommending the use of five-fraction HFRT for eligible patients. We evaluated the uptake of this recommendation in clinical practice as part of the National Audit of Breast Cancer in Older Patients (NABCOP).

Materials and methods

Women aged ≥50 years who underwent surgery for EBC from January 2019 to July 2020 were identified from the Rapid Cancer Registration Dataset for England and from Wales Cancer Network data. Radiotherapy details were from linked national Radiotherapy Datasets. Multivariate mixed-effects logistic regression models were used to assess characteristics influential in the use of ultra-HFRT.

Results

Among 35 561 women having surgery for EBC, 71% received postoperative radiotherapy. Receipt of 26 Gy in five fractions (26Gy5F) increased from <1% in February 2020 to 70% in April 2020. Regional variation in the use of 26Gy5F during April to July 2020 was similar by age, ranging from 49 to 87% among women aged ≥70 years. Use of 26Gy5F was characterised by no known nodal involvement, no comorbidities and initial breast-conserving surgery. Of those patients receiving radiotherapy to the breast/chest wall, 85% had 26Gy5F; 23% had 26Gy5F if radiotherapy included regional nodes. Among 5139 women receiving postoperative radiotherapy from April to July 2020, nodal involvement, overall stage, type of surgery, time from diagnosis to start of radiotherapy were independently associated with fractionation choice.

Conclusions

There was a striking increase in the use of 26Gy5F dose fractionation regimens for EBC, among women aged ≥50 years, within a month of guidance published at the start of the COVID-19 pandemic in England and Wales.

Range and Frequency of Congenital Malformations Among Children With Cleft Lip and/or Palate

To assess the range and frequency of additional congenital malformations identified among children born alive with CL/P.

Analysis of patient-level data from a national registry of cleft births linked to national administrative data of hospital admissions.

National Health Service, England.

Children born between 2000 and 2012 receiving cleft care in English NHS hospitals.

The proportion of children with ICD-10 codes for additional congenital malformations, according to cleft type.

The study included 9403 children. Of these 2114 (22.5%) had CL±A, 4509 (48.0%) had CP, 1896 (20.2%) had UCLP, and 884 (9.4%) had BCLP. A total of 3653 (38.8%) children had additional congenital malformations documented in their hospital admission records. The prevalence of additional congenital malformations was greatest among children with CP (53.0%), followed by those with BCLP (33.5%), UCLP (26.3%), and then CL±A (22.2%) (P < .001). Among those with UCLP, children with right-sided clefts were more likely to have additional malformations than those with left-sided clefts (31.6% vs 23.0%, P < .001). Malformations of the skeletal system and circulatory system were most common, affecting 10.5% and 10.2% of the included children, respectively. A total of 16.8% of children had additional congenital malformations affecting 2 or more structural systems.

Congenital malformations are common among children born alive with a cleft, affecting over half of some cleft subgroups. Given the frequency of certain structural malformations, clinicians should consider standardized screening for these children. Establishing good links with pediatric and genetic services is recommended.

Body representation among adults with phantom limb pain: Results from a foot identification task

BACKGROUND

Impaired body representation (i.e. disrupted body awareness or perception) may be a critical, but understudied, factor underlying phantom limb pain (PLP). This cross-sectional study investigated whether adults with lower-limb loss (LLL) and PLP demonstrate impaired body representation as compared to Pain-Free peers with and without LLL.

METHODS

Participants (n = 41 adults with PLP, n = 27 Pain-Free peers with LLL, n = 39 Controls with intact limbs) completed an online foot identification task. Participants judged whether randomized images depicted left or right feet (i.e. left-right discrimination) as quickly as possible without limb movement. Using two Generalized Estimating Equations, effects of group, image characteristics (i.e. side, foot type, view, angle) and trial block (i.e. 1-4) were evaluated, with task response time and accuracy as dependent variables (a ≤ 0.050).

RESULTS

Adults with PLP demonstrated slower and less accurate performance as compared to Controls with intact limbs (p = 0.018) but performed similarly to Pain-Free peers with LLL (p = 0.394). Significant three-way interactions of group, view and angle indicated between-group differences were greatest for dorsal-view images, but smaller and angle-dependent for plantar-view images. While all groups demonstrated significant response time improvements across blocks, improvements were greatest among adults with PLP, who also reported significant reductions in pain intensity.

CONCLUSIONS

Adults with PLP demonstrate body representation impairments as compared to Controls with intact limbs. Body representation impairments, however, may not be unique to PLP, given similar performance between adults with and without PLP following LLL.

SIGNIFICANCE

Following lower-limb loss, adults with phantom limb pain (PLP) demonstrate impaired body representation as compared to Controls with intact limbs, evidenced by slower response times and reduced accuracy when completing a task requiring mental rotation. Importantly, 80% of participants with pre-task PLP reported reduced pain intensity during the task, providing compelling evidence for future investigations into whether imagery-based, mind-body interventions have positive effects on PLP.

Usefulness of carotid and femoral plaque burden quantification by 3-dimensional vascular ultrasound for cardiovascular risk assessment in the cardiovascular disease prevention unit

Introduction

Subclinical atherosclerosis improves cardiovascular risk assessment and is considered a risk modifier in individuals at borderline-to-intermediate estimated risk by clinical risk scores.

Purpose

We seek to propose a new decision algorithm for statin allocation based on the quantification of carotid and/or femoral atherosclerosis burden by novel 3-dimensional vascular ultrasound (3DVUS) and to explore its potential additive value when used in combination with conventional risk evaluation.

Methods

We conducted an observational study in all outpatients without previous history of cardiovascular events assessed in the Cardiovascular Disease Prevention Unit during 2017–2020. Cardiovascular risk was assessed with the ACC/AHA 10-year atherosclerotic cardiovascular disease (ASCVD) risk algorithm to establish the indication for initiating statin therapy following current clinical guidelines. All patients underwent 3DVUS evaluation for carotid plaque burden (CPB) calculated as the sum of all plaque volumes present in bilateral carotid arteries. Femoral 3DVUS evaluation was included later in the study protocol. Global plaque burden (GPB) was calculated in patients with both carotid and femoral 3DVUS as the sum of all plaque volumes present in bilateral carotid and femoral arteries. Carotid and global plaque burden was classified as high, moderate and low if a patient presented a percentile (p) &gt;75, p50–75 and p&lt;50, respectively, based on the age and sex-adjusted reference values reported by PESA study (1). We determined the percentage of patients reclassified for considering (p&gt;75) or discouraging (p&lt;50) statin therapy over clinical recommendation.

Results

One hundred sixty-three patients (age 51±8 years; 72,4% men; 10y-ASCVD 5,9%±4,8%) were included, being the most frequent reason for referral the presence of metabolic syndrome (37%), followed by intermediate or indeterminate estimated CV risk (33%), one markedly elevated single risk factor (15%) and family history of early CVD (13%). 10y-ASCVD score classified 80 (49%) patients as low-risk without recommendation for initiating statins, 18 (11%) as high-risk indicating statin therapy and 65 (40%) patients that needed clinical-patient risk discussion. Among patients under risk discussion, the CPB percentile re-stratified 51 (78%) of them, recommending statins in 26 (40%) and discouraging statins in 25 (38%). In addition, CPB re-stratified 24 (30%) low-risk patients to recommend statins. A sub-group of 114 patients additionally underwent femoral 3DVUS, and calculated GPB led to similar results of patient re-stratification (Figure).

Conclusions

Quantification of 3D atherosclerosis burden and its percentile would re-stratify a significant number of patients with intermediate risk, becoming a potentially useful tool for clinical decision making. In addition, it possibly improves the detection of low-risk patients who would benefit from statin therapy.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dr. Lόpez-Melgar has received a grant from the Spanish Society of Cardiology “Proyecto de investigaciόn traslacional en Cardiología 2020” Patient re-stratification with CPB/GPB

Out-of-sheath corticosteroid injections through the dorsal webspace for trigger finger and trigger thumb. A prospective cohort study

BACKGROUND AND OBJECTIVE

Steroid injections are effective in the treatment of trigger digits but the pain during the injection is an always-present accompanying effect. The aim of this study was to assess the effectiveness and perceived pain during an out-of-sheath corticosteroid injection through the dorsal webspace in the treatment of trigger digits.

MATERIAL AND METHOD

A total of 126 consecutive patients were included. A subcutaneous (out-of-sheath) corticosteroid injection was performed through the dorsal webspace in all digits. In cases where signs or symptoms persisted, a second injection was offered. Visual analog scale for pain during the injection, DASH questionnaire, success rate and complications were collected.

RESULTS

There were 86 women and 40 men with a mean age of 61 years. The mean visual analog scale for pain during the injection was 3.8. Twelve patients were lost to follow-up. The overall success was 68% and success after a single injection was 54%. The best result was achieved on the ring finger. Patients who were not previously operated on carpal tunnel syndrome responded better. No complications were noted.

CONCLUSIONS

The extra-sheath corticosteroid injection through the dorsal webspace is effective and safe. It seems to be less painful than the reported scores for the palmar midline technique although it should be assessed in a comparative study.

Surgical decisions in older women with early breast cancer: patient and disease factors

BACKGROUND

Studies reporting lower rates of surgery for older women with early invasive breast cancer have focused on women with oestrogen receptor (ER)-positive tumours. This study examined the factors that influence receipt of breast surgery in older women with ER-positive and ER-negative early invasive breast cancer .

METHODS

Women aged 50 years or above with unilateral stage 1-3A early invasive breast cancer diagnosed in 2014-2017 were identified from linked English and Welsh cancer registration and routine hospital data sets. Logistic regression analysis was used to evaluate the influence of tumour and patient factors on receipt of surgery.

RESULTS

Among 83 188 women, 86.8 per cent had ER-positive and 13.2 per cent had ER-negative early invasive breast cancer. These proportions were unaffected by age at diagnosis. Compared with women with ER-negative breast cancer, a higher proportion of women with ER-positive breast cancer presented with low risk tumour characteristics: G1 (20.0 versus 1.5 per cent), T1 (60.8 versus 44.2 per cent) and N0 (73.9 versus 68.8 per cent). The proportions of women with any recorded co-morbidity (13.7 versus 14.3 per cent) or degree of frailty (25 versus 25.8 per cent) were similar among women with ER-positive and ER-negative disease respectively. In women with ER-positive early invasive breast cancer aged 70-74, 75-79 and 80 years or above, the rate of no surgery was 5.6, 11.0 and 41.9 per cent respectively. Among women with ER-negative early invasive breast cancer, the corresponding rates were 3.8, 3.7 and 12.3 per cent. The relatively lower rate of surgery for ER-positive breast cancer persisted in women with good fitness.

CONCLUSION

The reasons for the observer differences should be further explored to ensure consistency in treatment decisions.

Association of Initial Maximal Motor Ability With Long-term Functional Outcome in Patients With COL6-Related Dystrophies

OBJECTIVE

To accurately categorize the phenotypes of individuals with collagen VI-related dystrophies (COL6-RDs) during the first years of life to predict long-term motor function and pulmonary function, to provide phenotype-specific anticipatory care, and to improve clinical trial readiness.

METHODS

This retrospective, multicenter, international study analyzed the relationship of long-term motor and pulmonary function with the initial maximal motor ability achieved in individuals with COL6-RD.

RESULTS

We studied 119 patients with COL6-RD from Spain (n = 54) and the United States (n = 65). The early maximal motor milestones of ability to rise from the floor unassisted and ability to climb 4 steps without holding onto a railing demonstrated reliability in distinguishing between 3 COL6-RD phenotypic subgroups: (1) Ullrich congenital muscular dystrophy, (2) intermediate COL6-RD, and (3) Bethlem myopathy. Long-term motor function and pulmonary function are strongly correlated with the maximal motor ability achieved during the first years of life. Maximal motor capacity can predict other disease-relevant events such as the age at loss of ambulation and the need for the initiation of nocturnal noninvasive ventilation.

CONCLUSION

This work proposes a prospective phenotypic classification for COL6-RDs that will enable an accurate prediction of a patient's COL6-RD phenotype during the first years of life. The ability to establish a patient's COL6-RD phenotypic classification early will enable a more accurate prognosis of future motor and pulmonary function, thus improving anticipatory clinical care, and it will be instrumental in aiding the design of future clinical trials by allowing early stratification of trial cohorts.

Early and long-term effect of the treatment with pyridostigmine in patients with GMPPB-related congenital myasthenic syndrome

GMPPB mutations cause congenital myasthenic syndromes (CMS) overlapping with muscular dystrophy. Treatment with pyridostigmine has been reported to be effective in those patients. Nevertheless, results of functional motor assessments to determine its precise impact on the short and long term were not available. We describe the response to treatment with pyridostigmine in three siblings with GMPPB-related CMS using functional motor scales performed regularly over a period of 40 months. The beneficial effect of the treatment was outstanding within the first hours, with all the scales showing a dramatic increase in only two days. This remarkable improvement remained steady during 12 months but a moderate decrease was subsequently detected in two of the three patients. Despite this decline in the scores of the scales at the end of follow up, the functional motor status of the patients was still significantly better than it was before starting treatment. The introduction of pyridostigmine at an early age of the disease in one of the patients, before the onset of scoliosis, may have had a protective effect on it.

OP0122 SUBCLINICAL ATHEROSCLEROSIS OF FEMORAL ARTERIES IN RHEUMATOID ARTHRITIS. AN ULTRASOUND STUDY

Background:

Cardiovascular morbidity and mortality is increased in patients with rheumatoid arthritis (RA). This cannot be entirely explained by traditional risk factors. Inflammation and autoimmunity may play a role in the cardiovascular risk excess. Subclinical atherosclerosis is associated with a risk comparable to established coronary heart disease. In RA it has been investigated by carotid artery ultrasound and carotid atherosclerotic plaques are more prevalent in RA patients than controls. EULAR recommendations for cardiovascular disease risk management consider that carotid ultrasound may be part of the risk evaluation in patients with RA. Recent studies in general population have shown that plaques in femoral arteries are more common and are associated with higher cardiovascular risk.

Objectives:

To study the usefulness of femoral artery ultrasound for the detection of subclinical atherosclerosis and its ability to improve cardiovascular risk assessment in RA patients.

Methods:

Cross-sectional observational study of prevalence in 140 RA patients aged 40 to 65 years. Subclinical atherosclerosis was evaluated by carotid and femoral artery ultrasound.

Results:

Atherosclerotic plaques were found in 86.4% of RA patients (60.7% in carotid arteries and 78.6% in femoral arteries). Patients with plaques were older and more frequently past or present tobacco users. Femoral plaques were larger and more numerous than the carotid plaques and people with plaques in both locations had more extensive subclinical atherosclerotic disease (table). Only 7.9% of RA patients were considered as having very high cardiovascular risk by clinical factors, after carotid ultrasound this increased to 57.1% and after femoral ultrasound to 86.4%.

Conclusion:

Ultrasound examinations of the femoral artery in addition to the carotid artery increased the detection of subclinical atherosclerosis and determine a group of patients with higher intensity of atherosclerotic disease. Examinations of both arteries allowed a greater number of RA patients previously considered to have low to moderate cardiovascular risk to be classified as very high cardiovascular risk.

References:

[1]Agca R, Heslinga SC, Rollefstad S, Heslinga M, McInnes IB, Peters MJL, et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis. 2017 Jan;76(1):17–28.

[2]Ambrosino P, Lupoli R, Di Minno A, Tasso M, Peluso R, Di Minno MND. Subclinical atherosclerosis in patients with rheumatoid arthritis. A meta-analysis of literature studies. Thromb Haemost. 2015 May;113(5):916–30.

[3]Laclaustra M, Casasnovas JA, Fernández-Ortiz A, Fuster V, León-Latre M, Jiménez-Borreguero LJ, et al. Femoral and Carotid Subclinical Atherosclerosis Association With Risk Factors and Coronary Calcium: The AWHS Study. J Am Coll Cardiol. 2016 Mar 22;67(11):1263–74.

TableOnly carotid plaquesn= 11Only femoral plaquesn= 36Femoral and carotid plaquesn= 74Number of carotid plaques per patient1,3 ± 0,5-2,5 ±2,0*Carotid plaques size (mm)1,63 ±0,20-2,08 ±0,69*Number of femoral plaques per patient-2,3 ±1,73,7 ± 2,9**Femoral plaque size (mm)-2,20 ± 0,593,10 ± 1,10**Total number of plaques per patient1,3 ± 0,52,3 ± 1,7*6,2 ± 4,3***

†Results in mean ± sd. *p<0,05 vs only carotid plaques. **p<0,05 vs only femoral plaques. ***p<0,05 vs only carotid plaques and only femoral plaques.

Disclosure of Interests:

Julio Medina: None declared, Francisco Aramburu: None declared, Carmen González Montagut: None declared, Dolores Sánchez: None declared, Estíbaliz Loza Grant/research support from: Roche, Pfizer, Abbvie, MSD, Novartis, Gebro, Adacap, Astellas, BMS, Lylly, Sanofi, Eisai, Leo, Sobi

Longitudinal Study of Three microRNAs in Duchenne Muscular Dystrophy and Becker Muscular Dystrophy

Our objective was to investigate the potential of three microRNAs, miR-181a-5p, miR-30c-5p, and miR-206 as prognostic biomarkers for long-term follow up of Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) patients. We analyzed the expression of three microRNAs in serum of 18 patients (DMD 13, BMD 5) and 13 controls using droplet digital PCR. Over 4 years a minimum of two and a maximum of three measurements were performed at different time points in the same patient. Correlations between microRNA serum levels, age, and functional outcome measures were analyzed. We show the individual evolution of the levels of the three microRNAs in 12 patients and also the effect of corticosteroid treatment on microRNAs expression. We measure the expression of three microRNAs in the muscle of six DMD patients and also the expression of target genes for miR-30c. We found that levels of miR-30c and miR-206 remained significantly elevated in DMD patients relative to controls over the entire study length. The introduction of the corticosteroid treatment did not significantly influence the levels of these microRNAs. We report a trend for microRNA levels to decrease with age. Moreover, miR-206 expression levels are capable to distinguish DMD from BMD patients according to ROC analysis. We found miR-30c expression decreased in the muscle of DMD patients and marked upregulation of the target genes for this microRNA. MiR-30c and miR-206 represent sensitive biomarkers for DMD, while miR-206 may have an additional value to distinguish the DMD and BMD phenotype. This may be particularly relevant to assess the effectiveness of treatments aimed at converting the DMD to the less-severe BMD like phenotype.

Dorsal web injection technique in the treatment of trigger finger and trigger thumb. Anatomical study

BACKGROUND AND OBJECTIVE

Corticosteroid injection is an effective treatment for trigger digits but the pain during the injection is an ever-present side effect. Since the palmar skin has a high density of sensitive receptors, injecting through dorsal skin could be less painful. Our aim was to assess whether a dorsal technique through the dorsal web is safe for extra-sheath injection of trigger fingers and thumb.

MATERIAL AND METHOD

This is an anatomical study in sixteen cadaveric hands. An injection through the dorsal web was performed on each digit. After careful resection of the palmar skin, the distance between the needle and the main anatomical structures was measured. The risk of major injury was considered high when the mean distance from the needle to the neurovascular bundle was below 1mm.

RESULTS

The mean distance from the needle to the neurovascular bundle was 1.77mm. Two neurovascular injuries in 112 injections were observed, one nerve and one artery. The safest digit was the thumb while the most dangerous was the index finger. At the ring finger, the technique was safer when it was carried out from the dorso-radial.

CONCLUSIONS

A subcutaneous injection near the flexor tendon sheath can be carried out through the dorsal web with a low, but present, risk of neurovascular injury. It could be useful for injection in the treatment of trigger finger and trigger thumb but it should be assessed in a clinical study.

SuperCam Calibration Targets: Design and Development

SuperCam is a highly integrated remote-sensing instrumental suite for NASA's Mars 2020 mission. It consists of a co-aligned combination of Laser-Induced Breakdown Spectroscopy (LIBS), Time-Resolved Raman and Luminescence (TRR/L), Visible and Infrared Spectroscopy (VISIR), together with sound recording (MIC) and high-magnification imaging techniques (RMI). They provide information on the mineralogy, geochemistry and mineral context around the Perseverance Rover. The calibration of this complex suite is a major challenge. Not only does each technique require its own standards or references, their combination also introduces new requirements to obtain optimal scientific output. Elemental composition, molecular vibrational features, fluorescence, morphology and texture provide a full picture of the sample with spectral information that needs to be co-aligned, correlated, and individually calibrated. The resulting hardware includes different kinds of targets, each one covering different needs of the instrument. Standards for imaging calibration, geological samples for mineral identification and chemometric calculations or spectral references to calibrate and evaluate the health of the instrument, are all included in the SuperCam Calibration Target (SCCT). The system also includes a specifically designed assembly in which the samples are mounted. This hardware allows the targets to survive the harsh environmental conditions of the launch, cruise, landing and operation on Mars during the whole mission. Here we summarize the design, development, integration, verification and functional testing of the SCCT. This work includes some key results obtained to verify the scientific outcome of the SuperCam system.

First Measurement of the Total Neutron Cross Section on Argon between 100 and 800 MeV

We report the first measurement of the neutron cross section on argon in the energy range of 100-800 MeV. The measurement was obtained with a 4.3-h exposure of the Mini-CAPTAIN detector to the WNR/LANSCE beam at LANL. The total cross section is measured from the attenuation coefficient of the neutron flux as it traverses the liquid argon volume. A set of 2631 candidate interactions is divided in bins of the neutron kinetic energy calculated from time-of-flight measurements. These interactions are reconstructed with custom-made algorithms specifically designed for the data in a time projection chamber the size of the Mini-CAPTAIN detector. The energy averaged cross section is 0.91±0.10(stat)±0.09(syst)  b. A comparison of the measured cross section is made to the GEANT4 and FLUKA event generator packages, where the energy averaged cross sections in this range are 0.60 and 0.68 b, respectively.

A micro-Raman and X-ray study of erupted submarine pyroclasts from El Hierro (Spain) and its' astrobiological implications

The pumice volcanic samples could have possible connections to the evolution of life and give us insight about their bio-geochemical processes related. In this regard, the samples from the volcanic eruption from La Restinga (El Hierro, Spain) in 2011 have been mainly studied by means of Raman spectroscopy. The research also includes analysis of XRD, Scanning Electron Microscopy and Optical Microscopy to support the Raman analysis. The results show that the Raman methods and mineral analyses are in strong agreement with the results obtained from other authors and techniques. The internal white foamy core (WFC) of the studied pumice samples shows amorphous silica, Fe-oxides, Ti-oxides, quartz, certain sulfates, carbonates, zeolites and organics. On the other hand, the external part (dark crust - DC) of these samples mainly presents primary-sequence mineralogy combined with some secondary alteration minerals such as olivine, feldspar, pyroxene, amorphous silica, and Fe-oxide. Raman spectroscopy detected other minerals not yet reported on these samples like barite, celestine and lepidocrocite. Also, the different chemometric and calibration methods for Raman spectroscopy in elemental composition, mineral classification and structural characterization has been successfully applied. From the astrobiological perspective, the research was also complemented with comparisons to other similar samples from terrestrial analogs. The main consideration was taking into account the proposed hypothesis regarding the potential behavior of the pumice as a substrate for the evolution of life. Furthermore, the detailed analysis from La Restinga eruption is coherent with the mineral phases and processes discussed from previous literature. The white internal part fulfills the conditions to work as an organic reservoir, confirmed by the detection of organic matter and selected minerals that could be used as energy sources for bacterial communities. The external layers of the samples work as a shielding layer to protect the organics from decay in extreme conditions. Finally, here we have demonstrated that the characteristics and advantages of Raman spectroscopy could help to assess and understand the possible biogenicity and alteration processes of any geological sample to be found on Mars.

Salbutamol tolerability and efficacy in patients with spinal muscular atrophy type II

Spinal muscular atrophy (SMA) is an autosomal recessive disease caused by homozygous deletions or loss-of-function mutations in SMN1, which result in a degeneration of motor neurons in the spinal cord and brain stem. Even without a randomized placebo-controlled trial, salbutamol has been offered to patients with SMA in the neuromuscular clinics of most of hospitals for many years. We describe the response to salbutamol in 48 patients with SMA type II who were not taking any other medication. We investigate the changes over an eighteen-month period in motor functional scales and we analyze side effects and subjective response to treatment. Our results suggest that oral administration of salbutamol might be helpful in the maintenance of motor function in patients with SMA type II. An apparent beneficial effect was observed in functional scales of children under the age of 6, especially during the first 6 months of therapy. The majority of patients of all ages referred some kind of subjective positive effect associated with therapy intake. Salbutamol seemed safe and was well tolerated without serious side effects.

Abstract P1-08-16: The influence of patient fitness on the likelihood of receiving primary surgery in older women with breast cancer: A population based cohort study

Introduction: There is evidence of variation in the patterns of treatment of older women with breast cancer (BC). As women age, there are less similarities in terms of their functional ability, physiology and social wellbeing. This multifaceted relationship between disease and ageing makes the interpretation of age-related differences in BC management and outcomes at a population level complex. Measuring frailty is as an emerging concept and offers a way to standardise how characteristics of ageing are used in BC.

Objective: We compared the primary treatment patterns of women aged ≥70yrs compared to those aged 50–69yrs, with early invasive BC (EIBC; stage 1-3A); using a novel measure of frailty in addition to commonly used patient fitness measures.

Methods: Women aged ≥50yrs, diagnosed with unilateral EIBC in England and Wales between 01/01/2014 and 31/12/2016; were identified by linkage of several national datasets. Patient fitness was measured by the reported WHO performance status (WHO PS), a calculated Charlson comorbidity score (CCS) and a developed frailty measure based on the electronic Frailty Index (eFI). Multilevel logistic regression was used to account for clustering in the data.

Results: Among 126,111 women aged ≥50yrs with BC, 88,028 had EIBC: 88% in women aged 50-69yrs and 75% in women aged ≥70yrs. Table 1 describes the proportion of women who received surgery by age and measures of fitness. Overall, older women were less likely to undergo primary surgery, regardless of fitness. For each measure of fitness, fewer women in both age groups underwent surgery as their levels of fitness decreased; the magnitude of this change was greater for women aged ≥70yrs. Older women were also less likely to receive BCS for tumours &lt;5cm, compared to women aged 50-69yrs.

Receipt of surgery in women aged ≥50years with EIBC according to CCS, eFi and WHO PS status, by age at diagnosisMeasure of fitness50-69 years70+years No. of patients% having surgeryNo. of patients% having surgeryNumber of women5481796%2343687%Charlson comorbidity score04861697%2343687%1345495%439067%1+106389%309645%Unknown168462%228914%eFIFit5250697%570789%Mild frailty56489%236947%Moderate to severe frailty6362%66921%Unknown168462%228914%WHO performance status01507397%570788%1137293%226474%219885%91146%3-411652%79517%Unknown3805896%2353476%

The association between independent factors of ageing and fitness, and 'no surgery' remained after accounting for case-mix differences and clustering within geographical region. Compared to women aged 50–69yrs, there was strong regional variation in the adjusted rate of surgical treatment for EIBC in women aged ≥70yrs.

Discussion: Older women are less likely to undergo surgery for EIBC. Even a minor decrease in fitness levels significantly impacts the likelihood of receiving surgery in women ≥70yrs; such a pattern is not observed in women aged 50–69yrs. Long-term follow up of these women will enable further understanding of the implications of this variability in practice on outcomes. We also acknowledge poor data completion for the WHO PS, and propose that eFI is suitable replacement measure of fitness in older patients with BC.

Citation Format: Jauhari Y, Gannon M, Medina J, Horgan K, Dodwell D, Cromwell D. The influence of patient fitness on the likelihood of receiving primary surgery in older women with breast cancer: A population based cohort study [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 P1-08-16.

Status of the UCN experiment

The neutron is the simplest nuclear system that can be used to probe the structure of the weak interaction and search for physics beyond the standard model. Measurements of neutron lifetime and β-decay correlation coefficients with precisions of 0.02% and 0.1%, respectively, would allow for stringent constraints on new physics. The UCNτ experiment uses an asymmetric magneto-gravitational UCN trap with in situ counting of surviving neutrons to measure the neutron lifetime, τn = 877.7s (0.7s)stat (+0.4/−0.2s)sys. We discuss the recent result from UCNτ, the status of ongoing data collection and analysis, and the path toward a 0.25 s measurement of the neutron lifetime with UCNτ.

[Proximal humeral resurfacing. Whats today indication?]

INTRODUCTION

Data published in the literature about humeral resurfacing prostheses are not conclusive with good functional results but with large differences in the revision rate. The aim of our study was to evaluate the clinical and functional outcomes in patients operated at our center.

MATERIAL AND METHODS

Retrospective study of 19 cases in 18 patients. Follow-up of 31 (12-61) months. Surgery was indicated in cases of primary or secondary osteoarthritis. Demographic data, Constant scale, DASH questionnaire, complications and satisfaction were analyzed. Three patients were lost to follow-up due to death unrelated to surgery.

RESULTS

Mean age of 56 (25-80) years. Constant normalized of 73 (23-104) points. DASH questionnaire of 31 (7-84) points. Ninety four percent of the patients resumed their recreational activities and 81% sports activities. In seven cases, inferior conflict in the glenoid with varus implant was observed radiologically. There were five complications; a conservatively resolved capsulitis, three reinterventions due to symptomatic inferior glenoid usury and another to uncontrollable pain in a conservative way. Patients without rotator cuff lesion presented better scores on the functional questionnaires. All patients were satisfied with the symptomatic improvement over the previous situation and would be operated again if necessary.

CONCLUSIONS

The functional outcomes reported are similar to those previously published and, based on them, we believe that the resurfacing prosthesis is an option to be considered in cases of primary or secondary osteoarthritis when there is no rotator cuff injury, regardless of age.

Risk Factors of Mortality After Liver Transplantation in Uruguay

INTRODUCTION

Identification of predictive factors of mortality in a liver transplant (LT) program optimizes patient selection and allocation of organs.

OBJECTIVE

To determine survival rates and predictive factors of mortality after LT in the National Liver Transplant Program of Uruguay.

METHODS

A retrospective study was conducted analyzing data prospectively collected into a multidisciplinary database. All patients transplanted since the beginning of the program on July 2009 to April 2017 were included (n = 148). Twenty-nine factors were analyzed through the univariate Kaplan-Meier model. A Cox regression model was used in the multivariate analysis to identify the independent prognostic factors for survival.

RESULTS

Overall survival was 92%, 87%, and 78% at discharge, 1 year, and 3 years, respectively. The Kaplan-Meier survival curves were significantly lower in: recipients aged >60 years, Model for End-Stage Liver Disease score >21, LT due to hepatocellular carcinoma (HCC) and acute liver failure (ALF), donors with comorbidities, intraoperative blood loss beyond the median (>2350 mL), red blood cell transfusion requirement beyond the median (>1254 mL), intraoperative complications, delay of extubation, invasive bacterial, and fungal infection after LT and stay in critical care unit >4 days. The Cox regression model (likelihood ratio test, P = 1.976 e^-06) identified the following independent prognostic factors for survival: LT for HCC (hazard ratio [HR] 4.511; P = .001) and ALF (HR 6.346; P = .004), donors with comorbidities (HR 2.354; P = .041), intraoperative complications (HR 2.707; P = .027), and invasive fungal infections (HR 3.281; P = .025).

CONCLUSION

The survival rates of LT patients as well as the mortality-associated factors are similar to those reported in the international literature.

[Subacromial sodium hyaluronate injection for the treatment of chronic shoulder pain: A prospective series of eighty patients]

OBJECTIVE

Our purpose was to assess the effectiveness of hyaluronic acid infiltrations for chronic shoulder pain as an alternative to the non-surgical and surgical treatments that are currently available.

MATERIAL AND METHODS

This is a prospective study of 80 consecutive patients suffering from chronic shoulder pain followed for twelve months. Five subacromial hyaluronic acid injections on five consecutive weeks were administrated to all patients.

RESULTS

A significant improvement within the whole group after six months was observed. Constant score improved by 7.7 points, DASH questionnaire decreased by 5 points and Visual Analog Scale for pain decreased by 1.6 points. Patients with history of less than 24 months of pain responded better to treatment. Females responded better. Patients with decreased subacromial space or cuff tear in the MRI improved but patients diagnosed by the MRI of acromioclavicular osteoarthritis worsened in all scales assessed.

DISCUSSION

Subacromial hyaluronic acid injections are specially effective in patients with history of less than 24 months of pain, a decreased subacromial space or partial or total cuff tear but, in our experience, its result is not good in patients with acromioclavicular osteoarthritis.

Acceso lateroungueal en los tumores glómicos periungueales. Revisión de 75 casos

Introducción: Los tumores glómicos son tumores benignos, poco frecuentes, localizados preferentemente en la mano, que presentan una clínica muy característica y cuyo tratamiento es quirúrgico.

Material y métodos: Se han revisado retrospectivamente 75 tumores glómicos periungueales, diagnosticados clínicamente y confirmados por estudio anatomopatológico que fueron extirpados quirúrgicamente por vía lateroungueal.

Resultados: El empleo de la vía lateroungueal para la exéresis de los tumores glómicos periungueales fue efectiva en todos los casos, sin originar distrofias ungueales y con un porcentaje de recidivas bajo (11,9%).

Discusión: El diagnóstico de los tumores glómicos es fundamentalmente clínico, aunque se apoya en las pruebas de imagen (radiografía, ecografía y resonancia magnética). Su tratamiento es quirúrgico, existiendo múltiples vías de abordaje. Existe un riesgo de recidiva, que debe ser conocido por el paciente previamente a la cirugía.

Conclusiones: El acceso lateroungueal en los tumores glómicos es un método seguro, que permite su exéresis completa.

Differences in Adipose Tissue and Lean Mass Distribution in Patients with Collagen VI Related Myopathies Are Associated with Disease Severity and Physical Ability

Mutations in human collagen VI genes cause a spectrum of musculoskeletal conditions in children and adults collectively termed collagen VI-related myopathies (COL6-RM) characterized by a varying degree of muscle weakness and joint contractures and which include Ullrich Congenital Muscular Dystrophy (UCMD) and Bethlem Myopathy (BM). Given that collagen VI is one of the most abundant extracellular matrix proteins in adipose tissue and its emerging role in energy metabolism we hypothesized that collagen VI deficiency might be associated with alterations in adipose tissue distribution and adipokines serum profile. We analyzed body composition by means of dual-energy X-ray absorptiometry in 30 pediatric and adult COL6-RM myopathy patients representing a range of severities (UCMD, intermediate-COL6-RM, and BM). We found a distinctive pattern of regional adipose tissue accumulation which was more evident in children at the most severe end of the spectrum. In particular, the accumulation of fat in the android region was a distinguishing feature of UCMD patients. In parallel, there was a decrease in lean mass compatible with a state of sarcopenia, particularly in ambulant children with an intermediate phenotype. All children and adult patients that were sarcopenic were also obese. These changes were significantly more pronounced in children with collagen VI deficiency than in children with Duchenne Muscular Dystrophy of the same ambulatory status. High molecular weight adiponectin and leptin were significantly increased in sera from children in the intermediate and BM group. Correlation analysis showed that the parameters of fat mass were negatively associated with motor function according to several validated outcome measures. In contrast, lean mass parameters correlated positively with physical performance and quality of life. Leptin and adiponectin circulating levels correlated positively with fat mass parameters and negatively with lean mass and thus may be relevant to the disease pathogenesis and as circulating markers. Taken together our results indicate that COL6-RM are characterized by specific changes in total fat mass and distribution which associate with disease severity, motor function, and quality of life and which are clinically meaningful and thus should be taken into consideration in the management of these patients.