Access to an Educational Video Preoperatively Has No Effect on Postoperative Opioid Use After Arthroscopic Partial Meniscectomy of the Knee: A Prospective Cohort Study

Purpose

To determine whether access to a website with an educational video would decrease postoperative opioid use in patients undergoing arthroscopic partial meniscectomy.

Methods

Enrolled patients who underwent arthroscopic partial meniscectomy at a single center were randomized to either the intervention or control group prior to surgery. The intervention group received a card with access to an online educational video regarding opioids with their postoperative instructions; the control group did not. The online video was just over 5 minutes long and contained general information about the dangers of opioid use, how to safely dispose of unused opioids, and local support contact information. Data were collected by telephone 10 to 14 days postoperatively and analyzed with GraphPad Prism version 9.5.0. Patient characteristics including age, sex, body mass index, allergies, smoking, depression, alcohol abuse, American Society of Anesthesiologists level, diagnosis of chronic obstructive pulmonary disease, hypertension, diabetes, substance abuse, employment status, workers' compensation, and sports participation were analyzed and correlated with postoperative opioid use.

Results

A total of 166 patients were included in this study, with 78 in the control group and 88 in the intervention group. Mean number of pills consumed was 3 in the control group and 2.2 in the intervention group. This difference did not reach statistical significance. Patients who were obese, smokers, or diagnosed with depression both consumed more opioids and were less likely to take no narcotics postoperatively. Patients who participated in sports consumed fewer total opioids on average than those who did not. Subgroup analysis of patients with higher risk factors did not show a difference between the control and intervention groups in the average amount of opioid used or the likelihood of using no narcotics. Among all patients, 82 (49%) used no narcotics postoperatively and 90% used 8 or fewer tablets.

Conclusions

Directing patients to an educational website and video is not an effective tool in decreasing opioid consumption. Patients undergoing arthroscopic meniscectomy who are obese, active smokers, and clinically depressed or do not participate in sports are likely to use more postoperative narcotics. Regardless of access to the online educational video, half of patients used no narcotics.

Level of Evidence

Level II, prospective cohort.

Implementation Mapping for Managing Patients at High Risk for Hereditary Cancer

INTRODUCTION

Currently, no standard workflow exists for managing patients with pathogenic variants that put them at higher risk for hereditary cancers. Therefore, follow-up care for individuals with pathogenic variants is logistically challenging and results in poor guideline adherence. To address this challenge, authors created clinical management strategies for individuals identified at high risk for hereditary cancers.

METHODS

An implementation mapping approach was used to develop and evaluate the establishment of a Hereditary Cancer Clinic at the Medical University of South Carolina throughout in 2022. This approach consisted of 5 steps: conduct a needs assessment, identify objectives, select implementation strategies, produce implementation protocols, and develop an evaluation plan. The needs assessment consisted of qualitative interviews with patients (n=11), specialists (n=9), and members of the implementation team (n=4). Interviews were coded using the Consolidated Framework for Implementation Research to identify barriers and facilitators to establishment of the Hereditary Cancer Clinic. Objectives were identified, and then the team selected implementation strategies and produced implementation protocols to address concerns identified during the needs assessment. Authors conducted a second round of patient interviews to assess patient education materials.

RESULTS

The research team developed a long-term evaluation plan to guide future assessment of implementation, service, and clinical/patient outcomes.

CONCLUSIONS

This approach provides the opportunity for real-time enhancements and impact, with strategies for care specialists, patients, and implementation teams. Findings support ongoing efforts to improve patient management and outcomes while providing an opportunity for long-term evaluation of implementation strategies and guidelines for patients at high risk for hereditary cancers.

Successful Development of a Natural Language Processing Algorithm for Pancreatic Neoplasms and Associated Histologic Features

OBJECTIVES

Natural language processing (NLP) algorithms can interpret unstructured text for commonly used terms and phrases. Pancreatic pathologies are diverse and include benign and malignant entities with associated histologic features. Creating a pancreas NLP algorithm can aid in electronic health record coding as well as large database creation and curation.

METHODS

Text-based pancreatic anatomic and cytopathologic reports for pancreatic cancer, pancreatic ductal adenocarcinoma, neuroendocrine tumor, intraductal papillary neoplasm, tumor dysplasia, and suspicious findings were collected. This dataset was split 80/20 for model training and development. A separate set was held out for testing purposes. We trained using convolutional neural network to predict each heading.

RESULTS

Over 14,000 reports were obtained from the Mass General Brigham Healthcare System electronic record. Of these, 1252 reports were used for algorithm development. Final accuracy and F1 scores relative to the test set ranged from 95% and 98% for each queried pathology. To understand the dependence of our results to training set size, we also generated learning curves. Scoring metrics improved as more reports were submitted for training; however, some queries had high index performance.

CONCLUSIONS

Natural language processing algorithms can be used for pancreatic pathologies. Increased training volume, nonoverlapping terminology, and conserved text structure improve NLP algorithm performance.

Access disparities and underutilization of germline genetic testing in Chilean breast cancer patients

PURPOSE

Latin American reports on genetic cancer risk assessments are scarce. In Chile, current breast cancer (BC) guidelines do not define strategies for germline genetic testing. Our study sought to quantify the disparities in access to genetic testing in Chilean BC patients, according to international standards and their clinical characteristics to explore improvement strategies.

METHODS

Retrospective analysis of invasive BC databases including patients treated in a Public Hospital (PH) and in an Academic Private Center (AC) in Santiago, Chile between 2012 and 2021.

RESULTS

Of 5438 BC patients, 3955 had enough data for National Comprehensive Cancer Network (NCCN) categorization. From these, 1911 (48.3%) fulfilled NCCN criteria for germline testing, of whom, 300 were tested for germline mutations and 268 with multigene panels. A total of 65 pathogenic variants were found in this subset. As expected, BRCA1/2 mutations were the most frequent (17.7%). Access to genetic testing was higher in AC versus PH (19.6% vs. 10.3%, p = 0.0001). Other variables associated with germline genetic testing were BC diagnosis after 2018, being 45 years old or younger at diagnosis, BC family history (FH), FH of ovarian cancer, non-metastatic disease, and triple-negative subtype.

CONCLUSION

In our cohort, 15% of BC patients who met NCCN criteria for germline testing were effectively tested. This percentage was even lower at the PH. Current recommendations encourage universal genetic testing for BC patients; however, our findings suggest that Chile is far from reaching such a goal and national guidelines in this regard are urgently needed. To our knowledge, this is the first study of its kind in Chile and Latin America.

Penetrance of Gastric Adenocarcinoma Susceptibility Genes: A Systematic Review

BACKGROUND

Gastric adenocarcinoma (GAC) is the fifth most common cancer in the world, and the presence of germline pathogenic variants has been linked with approximately 5% of gastric cancer diagnoses. Multiple GAC susceptibility genes have been identified, but information regarding the risk associated with pathogenic variants in these genes remains obscure. We conducted a systematic review of existing studies reporting the penetrance of GAC susceptibility genes.

METHODS

A structured search query was devised to identify GAC-related papers indexed in MEDLINE/PubMed. A semi-automated natural language processing algorithm was applied to identify penetrance papers for inclusion. Original studies reporting the penetrance of GAC were included and the full-text articles were independently reviewed. Summary statistics, effect estimates, and precision parameters from these studies were compiled into a table using a predetermined format to ensure consistency.

RESULTS

Forty-five studies were identified reporting the penetrance of GAC among patients harboring mutations in 13 different genes: APC, ATM, BRCA1, BRCA2, CDH1, CHEK2, MLH1, MSH2, MSH6, PMS2, MUTYH-Monoallelic, NBN, and STK11.

CONCLUSION

Our systematic review highlights the importance of testing for germline pathogenic variants in patients before the development of GAC. Management of patients who harbor a pathogenic mutation is multifactorial, and clinicians should consider cancer risk for each applicable gene-cancer association throughout the screening and management process. The scarcity of studies we found investigating the risk of GAC among patients with pathogenic variants in GAC susceptibility genes highlights the need for more investigations that focus on producing robust risk estimates for gene-cancer associations.

Combining Breast Cancer Risk Prediction Models

Accurate risk stratification is key to reducing cancer morbidity through targeted screening and preventative interventions. Multiple breast cancer risk prediction models are used in clinical practice, and often provide a range of different predictions for the same patient. Integrating information from different models may improve the accuracy of predictions, which would be valuable for both clinicians and patients. BRCAPRO is a widely used model that predicts breast cancer risk based on detailed family history information. A major limitation of this model is that it does not consider non-genetic risk factors. To address this limitation, we expand BRCAPRO by combining it with another popular existing model, BCRAT (i.e., Gail), which uses a largely complementary set of risk factors, most of them non-genetic. We consider two approaches for combining BRCAPRO and BCRAT: (1) modifying the penetrance (age-specific probability of developing cancer given genotype) functions in BRCAPRO using relative hazard estimates from BCRAT, and (2) training an ensemble model that takes BRCAPRO and BCRAT predictions as input. Using both simulated data and data from Newton-Wellesley Hospital and the Cancer Genetics Network, we show that the combination models are able to achieve performance gains over both BRCAPRO and BCRAT. In the Cancer Genetics Network cohort, we show that the proposed BRCAPRO + BCRAT penetrance modification model performs comparably to IBIS, an existing model that combines detailed family history with non-genetic risk factors.

Insulin expression in β cells is reduced within islets before islet loss in diabetic cats

OBJECTIVES

Diabetes mellitus is a common condition that requires intensive treatment and markedly impacts the welfare of affected cats. The aim of this study was to identify diabetes mellitus-associated perturbations in the feline pancreatic islet microenvironment. The utility of "clear, unobstructed brain/body imaging cocktails and computational analysis" (CUBIC) for three-dimensional pancreatic analysis was investigated.

METHODS

Formalin-fixed paraffin-embedded tissues from cats with diabetes mellitus, or control cats without pancreatic pathology, were retrospectively identified. Immunohistochemistry for synaptophysin and ionised calcium binding adaptor molecule 1, and immunofluorescence for insulin and synaptophysin, were used to assess changes in islets. An image analysis pipeline was developed to analyse images acquired from two-dimensional immunofluorescence. CUBIC was used to optically clear selected pancreas samples before immunofluorescence and deep three-dimensional confocal microscopy.

RESULTS

Diabetic cats have a significant reduction in synaptophysin-positive islet area. Whilst islets from diabetic patients have similar numbers of β cells to islets from control cats, significantly lower intensity of insulin expression can be observed in the former. CUBIC facilitates clear visualisation of pancreatic islets in three dimensions.

CLINICAL SIGNIFICANCE

The data presented support the theory that there is a decrease in function of β cells before their destruction, suggesting a potentially significant step in the pathogenesis of feline diabetes mellitus. In parallel, we demonstrate CUBIC as a valuable new tool to visualise the shape of feline pancreatic islets and to interrogate pathology occurring in the islets of diabetic pets.

Clinical Utility of Universal Germline Genetic Testing for Patients With Breast Cancer

IMPORTANCE

National Comprehensive Cancer Network guidelines currently recommend germline testing for high-risk genes in selected patients with breast cancer. The clinical utility of recommending testing all patients with breast cancer with multigene panels is currently under consideration.

OBJECTIVE

To examine the implications of universal testing of patients with breast cancer with respect to clinical decision-making.

DESIGN, SETTING, AND PARTICIPANTS

Patients from a previously reported cohort were assessed as in-criteria or out-of-criteria according to the 2017 guidelines and underwent testing with a multigene germline panel between 2017 to 2018. Patients were women and men aged 18 to 90 years, with a new and/or previous diagnosis of breast cancer who had not undergone either single or multigene testing. Clinicians from 20 community and academic sites documented patient clinical information and changes to clinical recommendations made according to test findings. Association between prevalence of pathogenic or likely pathogenic germline variants and previously unreported clinical features, including scores generated by the BRCAPRO statistical model, was determined. Data were analyzed from April 2020 to May 2022.

EXPOSURE

New and/or previous diagnosis of breast cancer.

MAIN OUTCOMES AND MEASURES

Disease management recommendations that were changed as a result of genetic testing results are reported.

RESULTS

Clinicians were asked to assess changes to clinical management as a result of germline genetic testing for 952 patients. Informative clinician-reported recommendations were provided for 939 (467 in-criteria and 472 out-of-criteria) of the patients with breast cancer (936 [99.7%] female; 702 [74.8%] White; mean [SD] age at initial diagnosis, 57.6 [11.5] years). One or more changes were reported for 31 of 37 (83.8%) in-criteria patients and 23 of 34 (67.6%) out-of-criteria patients with a pathogenic or likely pathogenic variant. Recommendations were changed as a result of testing results for 14 of 22 (63.6%) out-of-criteria patients who had a variant in a breast cancer predisposition gene. Clinicians considered testing beneficial for two-thirds of patients with pathogenic or likely pathogenic variants and for one-third of patients with either negative results or variants of uncertain significance. There was no difference in variant rate between patients meeting the BRCAPRO threshold (≥10%) and those who did not (P = .86, Fisher exact test). No changes to clinical recommendations were made for most patients with negative results (345 of 349 patients [98.9%]) or variants of uncertain significance (492 of 509 patients [96.7%]).

CONCLUSIONS AND RELEVANCE

In this cohort study, germline genetic testing was used by clinicians to direct treatment for most out-of-criteria patients with breast cancer with pathogenic or likely pathogenic germline variants, including those with moderate-risk variants. Universal germline testing informs clinical decision-making and provides access to targeted treatments and clinical trials for all patients with breast cancer.

Laryngopharyngeal reflux: is laparoscopic fundoplication an effective treatment?

INTRODUCTION

Laryngopharyngeal reflux (LPR) is difficult to diagnose and treat owing to uncertainty relating to the underlying pathology. The initial management of LPR includes lifestyle modifications and oral medications. In patients who have failed to respond to proton pump inhibitor (PPI) therapy, anti-reflux surgery is considered; laparoscopic fundoplication is the surgery of choice. The primary aim of this review is to identify whether fundoplication is effective in improving signs and symptoms of LPR. The secondary aim is to identify whether patients who have had a poor response to PPIs are likely to have symptom improvement with surgery. The objective of the study is to establish the effect of laparoscopic fundoplication on the reflux symptom index score (RSI).

METHODS

PubMed, Embase, Medline and Cochrane databases were used to search according to the PRISMA guidelines. Original articles assessing the efficacy of fundoplication in relieving symptoms of LPR were included. For each study, the efficacy endpoints and safety outcomes were recorded.

FINDINGS

Nine studies from 844 initial records met the inclusion criteria: one prospective case control study, one retrospective case-control study, four prospective case series and three retrospective case series involving 287 fundoplications. All nine studies found fundoplication to be effective in improving symptoms of LPR (p < 0.05).

CONCLUSION

Current evidence suggests laparoscopic fundoplication is an effective treatment for LPR and should be considered if medical management is unsuccessful.

Multi-Institutional Validation of a Mammography-Based Breast Cancer Risk Model

PURPOSE

Accurate risk assessment is essential for the success of population screening programs in breast cancer. Models with high sensitivity and specificity would enable programs to target more elaborate screening efforts to high-risk populations, while minimizing overtreatment for the rest. Artificial intelligence (AI)-based risk models have demonstrated a significant advance over risk models used today in clinical practice. However, the responsible deployment of novel AI requires careful validation across diverse populations. To this end, we validate our AI-based model, Mirai, across globally diverse screening populations.

METHODS

We collected screening mammograms and pathology-confirmed breast cancer outcomes from Massachusetts General Hospital, USA; Novant, USA; Emory, USA; Maccabi-Assuta, Israel; Karolinska, Sweden; Chang Gung Memorial Hospital, Taiwan; and Barretos, Brazil. We evaluated Uno's concordance-index for Mirai in predicting risk of breast cancer at one to five years from the mammogram.

RESULTS

A total of 128,793 mammograms from 62,185 patients were collected across the seven sites, of which 3,815 were followed by a cancer diagnosis within 5 years. Mirai obtained concordance indices of 0.75 (95% CI, 0.72 to 0.78), 0.75 (95% CI, 0.70 to 0.80), 0.77 (95% CI, 0.75 to 0.79), 0.77 (95% CI, 0.73 to 0.81), 0.81 (95% CI, 0.79 to 0.82), 0.79 (95% CI, 0.76 to 0.83), and 0.84 (95% CI, 0.81 to 0.88) at Massachusetts General Hospital, Novant, Emory, Maccabi-Assuta, Karolinska, Chang Gung Memorial Hospital, and Barretos, respectively.

CONCLUSION

Mirai, a mammography-based risk model, maintained its accuracy across globally diverse test sets from seven hospitals across five countries. This is the broadest validation to date of an AI-based breast cancer model and suggests that the technology can offer broad and equitable improvements in care.

COVID-19 impact on financial security: evidence from the National Public Engagement Survey in Wales

Background

A nationally representative COVID-19 Public Engagement Survey for Wales, led by the World Health Organization Collaborating Centre on Investment for Health and Well-being at Public Health Wales, has been ongoing from April 2020, helping to inform a sustainable recovery from the COVID-19 pandemic. A data analysis was performed as part of the Welsh Health Equity Status Report initiative focusing on income and job security, which influences living conditions and lifestyle behaviours.

Methods

A Generalized Linear Model was used to calculate the predicted probability of response for variables of interest, e.g. whether an individual reported being in a worse financial situation due to the pandemic, across the life course, socio-economic gradient and sex. Data collected via telephone between 03 April - 25 July 2020 produced a sample ranging between approx. 2,500 - 7,500 participants. The sample was weighted according to deprivation quintile (using the Welsh Index of Multiple Deprivation), age group and sex.

Results

A significantly higher proportion of survey respondents (18 - 24 years of age) reported being worried about losing their job or not being able to find one, than any other age group. A significantly higher proportion of survey respondents in the most deprived population fifth (33.7%) reported being in a worse financial situation as a result of the restrictions, compared to the least deprived fifth (21.7%).

Conclusions

COVID-19 has had a major impact on people's lives and livelihoods in Wales, hitting the most deprived and vulnerable the most. It has increased job insecurity, especially among younger/working age people. The government has taken unprecedented financial and other measures to address inequities; nevertheless, most are temporary and not specifically targeted to support specific (vulnerable) groups. Measures to promote sustainable economic recovery, job security and safeguarding due to the COVID-19 pandemic need continuity and consistency

Key messages

COVID-19 has had a significant impact on income and job security in Wales, disproportionately affecting the most deprived. To mitigate COVID-19 harms, a continuous and consistent focus on equity is essential to promote sustainable economic recovery.

799 Do Not Attempt Cardiopulmonary Resuscitation Decisions in Neck of Femur Fractures – Is Documentation Adequate?

Introduction

‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) documentation is essential to communicate decisions regarding ceilings of care for patients to the clinical team. Patients admitted to hospital with a fractured neck of femur (#NOF) are often elderly with multiple comorbidities, and so robust and clear anticipatory care plans are especially indicated.

Method

All patients admitted to a large district general hospital in Scotland with a #NOF over a three-week period between 23/10/2020 and 12/11/2020 were identified prospectively and included in this audit. Patients’ demographic information, DNACPR status and the quality of their DNACPR documentation was recorded.

Results

20 patients (85% Female, 15% Male) were identified and included. Median ASA grade was 3, with 77.8% of patients ASA grade 3 or 4. 63.2% of patients had DNACPR documentation in place, all of which were ASA grade 3 or above. Most DNACPR documentation had patient information clearly identifiable (91.7%), was completed preoperatively (90.9%), and involved either the patient or appropriate relative or power of attorney (91.6%). However, only 75% of patients’ documentation had the rationale for the DNACPR decision documented and only 25% of DNACPR decisions were reviewed by a senior clinician within 72 hours. No DNACPR decisions were documented as having been communicated to the wider healthcare team.

Conclusions

DNACPR documentation is a crucial for anticipatory care planning in #NOF patients. This audit shows improvement is needed in documenting whether decisions have been reviewed by senior clinicians, and if they have been communicated to the wider healthcare team.

742 Transurethral LASER Ablation (TULA): A Safe and Well Tolerated Procedure for The Treatment of Bladder Tumours Up To 4cm In Diameter in An Outpatient Setting

Aim

Traditionally the management of recurrent non-muscle invasive bladder cancer (NMIBC) involves rigid cystoscopy and bladder biopsies/tumour resection under general/regional anaesthesia. As a result, many frail patients endure frequent anaesthetics and therefore are at increased risk of adverse outcomes including cognitive decline. Discontinuation of anti-platelet/anti-coagulation is not required for TULA. An outpatient TULA service was recently started at our trust. We present a case series of our first 4 months data.

Method

All TULA cases (n = 39) performed between Aug-Dec 2020 were included. Data was gathered prospectively including patient demographics, co-morbidities, initial cancer diagnosis and number of subsequent recurrences, post-procedural complications, and patient procedural satisfaction.

Results

Median age was 82 years (range 34-96) and median number of co-morbidities were 4 (range 0-10). Previous bladder cancer diagnosis was present for 85% with the most common initial stage G2pTa (n = 11). Median number of recurrences was 1 (range 1-5). Median patient perceived pain score was 3 (range 1-7) with 100% of patients preferring TULA over TURBT. Reasons included reduced procedural time (n = 18) and enhanced recovery (n = 15). Only 1 patient was readmitted post-procedure due to haematuria, however urine was clear after catheterisation and the patient was discharged.

Conclusions

TULA is safe for all low risk NMIBC, particularly for frail patients. It is well tolerated and facilitates improved patient experience. It also alleviates demand on theatre capacity and inpatient beds which has a positive effect on surgical waiting lists. Further audit of clinical outcomes should continue as recommended by NICE.

Laryngopharyngeal reflux: is laparoscopic fundoplication an effective treatment?

INTRODUCTION

Laryngopharyngeal reflux (LPR) is difficult to diagnose and treat owing to uncertainty relating to the underlying pathology. The initial management of LPR includes lifestyle modifications and oral medications. In patients who have failed to respond to proton pump inhibitor (PPI) therapy, anti-reflux surgery is considered; laparoscopic fundoplication is the surgery of choice. The primary aim of this review is to identify whether fundoplication is effective in improving signs and symptoms of LPR. The secondary aim is to identify whether patients who have had a poor response to PPIs are likely to have symptom improvement with surgery. The objective of the study is to establish the effect of laparoscopic fundoplication on the reflux symptom index score (RSI).

METHODS

PubMed, Embase, Medline and Cochrane databases were used to search according to the PRISMA guidelines. Original articles assessing the efficacy of fundoplication in relieving symptoms of LPR were included. For each study, the efficacy endpoints and safety outcomes were recorded.

FINDINGS

Nine studies from 844 initial records met the inclusion criteria: one prospective case control study, one retrospective case-control study, four prospective case series and three retrospective case series involving 287 fundoplications. All nine studies found fundoplication to be effective in improving symptoms of LPR (p < 0.05).

CONCLUSION

Current evidence suggests laparoscopic fundoplication is an effective treatment for LPR and should be considered if medical management is unsuccessful.

Relationship of established risk factors with breast cancer subtypes

Background

Breast cancer is a heterogeneous disease, divided into subtypes based on the expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Subtypes have different biology and prognosis, with accumulating evidence of different risk factors. The purpose of this study was to compare breast cancer risk factors across tumor subtypes in a large, diverse mammography population.

Methods

Women aged 40–84 without a history of breast cancer with a screening mammogram at three United States health systems from 2006 to 2015 were included. Risk factor questionnaires were completed at mammogram visit, supplemented by electronic health records. Invasive tumor subtype was defined by immunohistochemistry as ER/PR+HER2−, ER/PR+HER2+, ER, and PR−HER2+, or triple‐negative breast cancer (TNBC). Cox proportional hazards models were run for each subtype. Associations of race, reproductive history, prior breast problems, family history, breast density, and body mass index (BMI) were assessed. The association of tumor subtypes with screen detection and interval cancer was assessed using logistic regression among invasive cases.

Results

The study population included 198,278 women with a median of 6.5 years of follow‐up (IQR 4.2–9.0 years). There were 4002 invasive cancers, including 3077 (77%) ER/PR+HER2−, 300 (8%) TNBC, 342 (9%) ER/PR+HER2+, and 126 (3%) ER/PR−HER2+ subtype. In multivariate models, Black women had 2.7 times higher risk of TNBC than white women (HR = 2.67, 95% CI 1.99–3.58). Breast density was associated with increased risk of all subtypes. BMI was more strongly associated with ER/PR+HER2− and HER2+ subtypes among postmenopausal women than premenopausal women. Breast density was more strongly associated with ER/PR+HER2− and TNBC among premenopausal than postmenopausal women. TNBC was more likely to be interval cancer than other subtypes.

Conclusions

These results have implications for risk assessment and understanding of the etiology of breast cancer subtypes. More research is needed to determine what factors explain the higher risk of TNBC for Black women.

Exploiting Rules to Enhance Machine Learning in Extracting Information From Multi-Institutional Prostate Pathology Reports

PURPOSE

Literature on clinical note mining has highlighted the superiority of machine learning (ML) over hand-crafted rules. Nevertheless, most studies assume the availability of large training sets, which is rarely the case. For this reason, in the clinical setting, rules are still common. We suggest 2 methods to leverage the knowledge encoded in pre-existing rules to inform ML decisions and obtain high performance, even with scarce annotations.

METHODS

We collected 501 prostate pathology reports from 6 American hospitals. Reports were split into 2,711 core segments, annotated with 20 attributes describing the histology, grade, extension, and location of tumors. The data set was split by institutions to generate a cross-institutional evaluation setting. We assessed 4 systems, namely a rule-based approach, an ML model, and 2 hybrid systems integrating the previous methods: a Rule as Feature model and a Classifier Confidence model. Several ML algorithms were tested, including logistic regression (LR), support vector machine (SVM), and eXtreme gradient boosting (XGB).

RESULTS

When training on data from a single institution, LR lags behind the rules by 3.5% (F1 score: 92.2% v 95.7%). Hybrid models, instead, obtain competitive results, with Classifier Confidence outperforming the rules by +0.5% (96.2%). When a larger amount of data from multiple institutions is used, LR improves by +1.5% over the rules (97.2%), whereas hybrid systems obtain +2.2% for Rule as Feature (97.7%) and +2.6% for Classifier Confidence (98.3%). Replacing LR with SVM or XGB yielded similar performance gains.

CONCLUSION

We developed methods to use pre-existing handcrafted rules to inform ML algorithms. These hybrid systems obtain better performance than either rules or ML models alone, even when training data are limited.

How Protective are Nipple-Sparing Prophylactic Mastectomies in BRCA1 and BRCA2 Mutation Carriers?

BACKGROUND

Nipple-sparing mastectomy (NSM) is now routinely offered to BRCA mutation carriers for risk reduction. We assessed the rates of ipsilateral cancer events after prophylactic and therapeutic NSM in BRCA1 and BRCA2 mutation carriers.

METHODS

BRCA1 and BRCA2 mutation carriers undergoing NSM from October 2007 to June 2019 were identified in a single-institution prospective database, with variants of unknown significance being excluded. Patient, tumor, and outcomes data were collected. Follow-up analysis was by cumulative breast-years (total years of follow-up of each breast) and woman-years (total years of follow-up of each woman).

RESULTS

Overall, 307 BRCA1 and BRCA2 mutation carriers (160 BRCA1, mean age 41.4 years [range 21-65]; and 147 BRCA2, mean age 43.8 years [range 23-65]) underwent 607 NSMs, with a median follow-up of 42 months (range 1-143). 388 bilateral prophylactic NSMs had 744 cumulative woman-years of follow-up, with no new cancers seen (< 0.0013 new cancers per woman-years); 251 BRCA1 prophylactic NSMs had 1034 cumulative breast-years of follow-up, with no new ipsilateral cancers seen (< 0.0010 per breast-year); 66 BRCA1 therapeutic NSMs had 328 cumulative breast-years of follow-up, with one ipsilateral cancer recurrence not directly involving the nipple or areola (0.0030 per breast-year); 237 BRCA2 prophylactic NSMs had 926 cumulative breast-years of follow-up, with no new ipsilateral cancers seen (< 0.0011 per breast-year); and 53 BRCA2 therapeutic NSMs had 239 cumulative breast-years of follow-up, with two ipsilateral recurrent cancers, neither of which directly involved the nipple or areola (0.0084 per breast-year).

CONCLUSIONS

The risk of new ipsilateral breast cancers is extremely low after NSM in BRCA1 and BRCA2 mutation carriers. NSM is an effective risk-reducing strategy for BRCA gene mutations.

Toward robust mammography-based models for breast cancer risk

Improved breast cancer risk models enable targeted screening strategies that achieve earlier detection and less screening harm than existing guidelines. To bring deep learning risk models to clinical practice, we need to further refine their accuracy, validate them across diverse populations, and demonstrate their potential to improve clinical workflows. We developed Mirai, a mammography-based deep learning model designed to predict risk at multiple timepoints, leverage potentially missing risk factor information, and produce predictions that are consistent across mammography machines. Mirai was trained on a large dataset from Massachusetts General Hospital (MGH) in the United States and tested on held-out test sets from MGH, Karolinska University Hospital in Sweden, and Chang Gung Memorial Hospital (CGMH) in Taiwan, obtaining C-indices of 0.76 (95% confidence interval, 0.74 to 0.80), 0.81 (0.79 to 0.82), and 0.79 (0.79 to 0.83), respectively. Mirai obtained significantly higher 5-year ROC AUCs than the Tyrer-Cuzick model ( P < 0.001) and prior deep learning models Hybrid DL ( P < 0.001) and Image-Only DL ( P < 0.001), trained on the same dataset. Mirai more accurately identified high-risk patients than prior methods across all datasets. On the MGH test set, 41.5% (34.4 to 48.5) of patients who would develop cancer within 5 years were identified as high risk, compared with 36.1% (29.1 to 42.9) by Hybrid DL ( P = 0.02) and 22.9% (15.9 to 29.6) by the Tyrer-Cuzick model ( P < 0.001).

Innovative Virtual Role Play Simulations for Managing Substance Use Conversations: Pilot Study Results and Relevance During and After COVID-19

BACKGROUND

Substance use places a substantial burden on our communities, both economically and socially. In light of COVID-19, it is predicted that as many as 75,000 more people will die from alcohol and other substance use and suicide as a result of isolation, new mental health concerns, and various other stressors related to the pandemic. Public awareness campaigns that aim to destigmatize substance use and help individuals have meaningful conversations with friends, coworkers, or family members to address substance use concerns are a timely and cost-effective means of augmenting existing behavioral health efforts related to substance use. These types of interventions can supplement the work being done by existing public health initiatives.

OBJECTIVE

This pilot study examines the impact of the One Degree: Shift the Influence role play simulation, designed to teach family, friends, and coworkers to effectively manage problem-solving conversations with individuals that they are concerned about regarding substance use.

METHODS

Participants recruited for this mixed methods study completed a presurvey, the simulation, and a postsurvey, and were sent a 6-week follow-up survey. The simulation involves practicing a role play conversation with a virtual human coded with emotions, a memory, and a personality. A virtual coach provides feedback in using evidence-based communication strategies such as motivational interviewing.

RESULTS

A matched sample analysis of variance revealed significant increases at follow-up in composite attitudinal constructs of preparedness (P<.001) and self-efficacy (P=.01), including starting a conversation with someone regarding substance use, avoiding upsetting someone while bringing up concerns, focusing on observable facts, and problem solving. Qualitative data provided further evidence of the simulation's positive impact on the ability to have meaningful conversations about substance use.

CONCLUSIONS

This study provides preliminary evidence that conversation-based simulations like One Degree: Shift the Influence that use role play practice can teach individuals to use evidence-based communication strategies and can cost-effectively reach geographically dispersed populations to support public health initiatives for primary prevention.

Artificial Intelligence-Aided Precision Medicine for COVID-19: Strategic Areas of Research and Development

Artificial intelligence (AI) technologies can play a key role in preventing, detecting, and monitoring epidemics. In this paper, we provide an overview of the recently published literature on the COVID-19 pandemic in four strategic areas: (1) triage, diagnosis, and risk prediction; (2) drug repurposing and development; (3) pharmacogenomics and vaccines; and (4) mining of the medical literature. We highlight how AI-powered health care can enable public health systems to efficiently handle future outbreaks and improve patient outcomes.

Unusual Near-Horizon Cosmic-Ray-like Events Observed by ANITA-IV

ANITA's fourth long-duration balloon flight in 2016 detected 29 cosmic-ray (CR)-like events on a background of 0.37_{-0.17}^{+0.27} anthropogenic events. CRs are mainly seen in reflection off the Antarctic ice sheets, creating a phase-inverted waveform polarity. However, four of the below-horizon CR-like events show anomalous noninverted polarity, a p=5.3×10^{-4} chance if due to background. All anomalous events are from locations near the horizon; ANITA-IV observed no steeply upcoming anomalous events similar to the two such events seen in prior flights.

Abstract PS7-02: The relationship of established breast cancer risk factors with breast cancer subtypes

Background: Molecular characterization of breast tumors has revealed four subtypes which differ in expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Breast cancer subtypes have different prognosis and unique risk factors. Breast cancer risk assessment models mainly reflect risk of ER/PR+ HER2- tumors, the most common subtype, and may not reflect risk of other subtypes. The study objective was to compare associations of established breast cancer risk factors across invasive breast cancer subtypes.

Methods: The study population included women aged 40-84 years who had a screening mammogram at Massachusetts General Hospital, Newton Wellesley Hospital, or the University of Pennsylvania from 2006-2015. Patients completed a risk factor questionnaire and additional risk factors were ascertained from clinical records. Women with prior breast cancer, breast implants, or BRCA1/2 mutations were excluded. Women diagnosed with breast cancer within 6 months were excluded to remove those with cancer at the time of risk assessment. Tumor characteristics were obtained from linkage with hospital and state cancer registries. For invasive tumors, subtype was defined based on immunohistochemistry as ER and/or PR+ HER2-, ER and/or PR+HER2+, ER and PR- HER2+, or ER and PR and HER2- (triple negative breast cancer, TNBC). Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for breast cancer using time from mammogram to cancer diagnosis or censoring. Separate Cox models were fit for each subtype, and patients who developed DCIS or another subtype, died, or were alive and cancer free on December 31, 2017 were censored. Age, biopsy history, atypical hyperplasia, age at menarche, age at first live birth, family history, race, BMI, and breast density at the time of screening were included in the models.

Results: The study population (N=197,836) had a mean age of 54 years and 74% of patients were white, 15% were Black, and 11% were other races. During a mean follow-up of 6.3 years, 4,510 (2.3%) women developed breast cancer. Of these cancers, 1068 (24%) were DCIS. Of the invasive cancers, 2675 (77%) were ER/PR+HER2-, 290 (8%) were ER/PR+HER2+, 108 (3%) were ER/PR-HER2+, 264 (8%) were TNBC and 105 (3%) had missing subtype. For ER/PR+HER2- cancers, all risk factors were consistent with the literature and statistically significant. Breast density was associated with increased risk of all four subtypes compared to women with less dense breasts. Atypical hyperplasia was strongly associated with HER2+ cancers (HR=2.97 CI 1.63-5.40 p&lt;0.01), less strongly associated with ER/PR+HER2- cancers, and not significantly associated with TNBC. Black women had higher risk of TNBC than white women (HR=2.61 CI 1.91-3.57 p&lt;0.01).

Conclusion Our results highlight both similarities and heterogeneity in risk factors across breast cancer subtypes. Prior diagnosis of atypical hyperplasia was more strongly associated with HER2+ compared to HER2- tumors. While it is well known that Black women have higher risk of TNBC, it is striking that the more than two-and-a-half-fold increased risk persisted even with comprehensive adjustment for breast cancer risk factors in a screened population. These results suggest that additional factors, such as genetics, biomarkers, and environmental exposures should be included in risk assessment to better capture risk of less common breast cancer subtypes such as TNBC.

Risk factors for breast cancer subtypes among 197,836 women undergoing screening mammography*ER/PR+ HER2- N=2674ER/PR+ HER2+ N=290ER/PR-HER2+ N=108ER/PR/HER2- N=264HR,95% CIpHR,95% CIpHR,95% CIpHR,95% CIpBlack vs. white unadjusted0.67,0.58-0.77&lt;0.010.73,0.48-1.090.120.91,0.49-1.680.772.61,1.96-3.46&lt;0.01Black vs. white multivariate*0.72,0.63-0.83&lt;0.010.75,0.49-1.150.191.23,0.65-2.330.532.61,1.91-3.57&lt;0.01Atypical Hyperplasia*1.38,1.02-1.870.042.77,1.42-5.42&lt;0.013.89,1.03-14.70.040.43,0.06-3.140.401 FDR** vs. none1.46,1.32-1.63&lt;0.011.16,0.82-1.650.391.93,1.18-3.160.011.11,0.75-1.630.602 FDR** vs. none2.12,1.67-2.71&lt;0.011.17,0.44-3.150.751.90,0.47-7.760.372.81,1.44-5.49&lt;0.01BMI ≥25 vs. &lt;25 kg/m2*1.37,1.25-1.50&lt;0.011.35,1.04-1.750.031.07,0.71-1.640.741.29,0.97-1.730.08Dense vs. non-dense breasts1.55,1.42-1.69&lt;0.011.75,1.34-2.29&lt;0.011.97,1.25-3.10&lt;0.011.65,1.26-2.17&lt;0.01*Adjusted for all factors in the table and additionally age, biopsy, age at menarche, age at first live birth**FDR= first degree relative with breast cancer

Citation Format: Anne Marie McCarthy, Tara Friebel, Wei He, Michaela Welch, Sarah Ehsan, Kevin Hughes, Alan Semine, Jinbo Chen, Despina Kontos, Susan Domchek, Emily Conant, Aditya Bardia, Constance Lehman, Katrina Armstrong. The relationship of established breast cancer risk factors with breast cancer subtypes [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-02.

Best practices for selection of excipients for paediatrics - Workshop reflection

The development of age appropriate formulations for the paediatric population has become one of the key areas of focus for the pharmaceutical industry - with a subsequent influence on excipient use. Selection of excipients with appropriate safety and tolerability is a major hurdle in paediatric formulation development. Various factors influence selection of excipients, including target age group, route of administration and dosage form. Evaluation of these factors and a clear rationale and justification is expected by the regulators when it comes to selecting excipients for paediatric formulation. Scientists are encouraged to apply the principle of benefit to risk balance to assess the suitability of excipients to the specific paediatric population for whom the formulation is intended. In order to understand how scientists approach the task of establishing the risk to benefit analysis, a workshop was organised by the European Paediatric Formulation Initiative (EuPFI) to reflect on the current scenario and the different practices employed by formulation scientists in the selection of excipients for paediatric formulations. Aspects assessed by regulators were also canvassed. Finally, the participants were asked to comment on how selecting excipients for use in paediatric formulations may differ from the considerations applied in selecting excipients for formulations for other age groups. Based on the workshop discussion, some recommendations and questions to consider emerged regarding the selection of excipients in paediatric drug development. These best practice recommendations provided a good starting point for a more systematic strategy for selecting excipients for paediatric formulation development.

The utility of Amies charcoal bacteriology swabs for storage of canine urine prior to culture

OBJECTIVE

To determine the usefulness of bacteriology swabs as a storage method of canine urine samples and the effect on quantitative bacterial culture.

MATERIALS AND METHODS

Two hundred fourteen canine urine samples were collected by cystocentesis. The reference aliquot was placed in a sterile tube and processed for quantitative bacterial culture within 6 hours. A bacteriology swab was then immersed in the urine for 5 seconds and returned to the charcoal Amies media container. The urine samples in the sterile tube and bacteriology swab were stored at room temperature for 48 hours and processed for quantitative bacterial culture.

RESULTS

Thirty-seven of the samples were positive on reference culture with a total of 42 bacterial isolates. Samples stored in sterile tube and bacteriology swab had identical sensitivity and specificity for detection of bacteriuria (94.7% and 100%, respectively) with very good agreement (κ = 0.92; 95% CI 0.81 to 1.00). Agreement between the bacterial species of the reference sample and the bacteriology swab was higher (κ = 0.85; 95% CI 0.71 to 0.99) than compared to the sterile tube (κ = 0.78; 95% CI 0.62 to 0.94), but the overlapping confidence intervals mean improved agreement cannot be inferred.

CLINICAL SIGNIFICANCE

Bacteriology swabs stored in Amies charcoal transport media should be considered an alternative method to preserve canine urine sample when immediate processing for quantitative bacterial culture is not possible. The sensitivity of culturing plain urine, stored for 48 hours in a sterile tube, for detection of bacteriuria, was higher than previously reported.

The Bacterial Ro60 Protein and Its Noncoding Y RNA Regulators

Ro60 ribonucleoproteins (RNPs), composed of the ring-shaped Ro 60-kDa (Ro60) protein and noncoding RNAs called Y RNAs, are present in all three domains of life. Ro60 was first described as an autoantigen in patients with rheumatic disease, and Ro60 orthologs have been identified in 3% to 5% of bacterial genomes, spanning the majority of phyla. Their functions have been characterized primarily in Deinococcus radiodurans, the first sequenced bacterium with a recognizable ortholog. In D. radiodurans, the Ro60 ortholog enhances the ability of 3'-to-5' exoribonucleases to degrade structured RNA during several forms of environmental stress. Y RNAs are regulators that inhibit or allow the interactions of Ro60 with other proteins and RNAs. Studies of Ro60 RNPs in other bacteria hint at additional functions, since the most conserved Y RNA contains a domain that is a close tRNA mimic and Ro60 RNPs are often encoded adjacent to components of RNA repair systems.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Do Neural Information Extraction Algorithms Generalize Across Institutions?

PURPOSE

Natural language processing (NLP) techniques have been adopted to reduce the curation costs of electronic health records. However, studies have questioned whether such techniques can be applied to data from previously unseen institutions. We investigated the performance of a common neural NLP algorithm on data from both known and heldout (ie, institutions whose data were withheld from the training set and only used for testing) hospitals. We also explored how diversity in the training data affects the system's generalization ability.

METHODS

We collected 24,881 breast pathology reports from seven hospitals and manually annotated them with nine key attributes that describe types of atypia and cancer. We trained a convolutional neural network (CNN) on annotations from either only one (CNN1), only two (CNN2), or only four (CNN4) hospitals. The trained systems were tested on data from five organizations, including both known and heldout ones. For every setting, we provide the accuracy scores as well as the learning curves that show how much data are necessary to achieve good performance and generalizability.

RESULTS

The system achieved a cross-institutional accuracy of 93.87% when trained on reports from only one hospital (CNN1). Performance improved to 95.7% and 96%, respectively, when the system was trained on reports from two (CNN2) and four (CNN4) hospitals. The introduction of diversity during training did not lead to improvements on the known institutions, but it boosted performance on the heldout institutions. When tested on reports from heldout hospitals, CNN4 outperformed CNN1 and CNN2 by 2.13% and 0.3%, respectively.

CONCLUSION

Real-world scenarios require that neural NLP approaches scale to data from previously unseen institutions. We show that a common neural NLP algorithm for information extraction can achieve this goal, especially when diverse data are used during training.

Penetrance of Breast and Ovarian Cancer in Women Who Carry a BRCA1/2 Mutation and Do Not Use Risk-Reducing Salpingo-Oophorectomy: An Updated Meta-Analysis

Background

Use of risk-reducing Salpingo-oophorectomy (RRSO) substantially reduces the risk of ovarian and breast cancer for women who carry a BRCA1/2 mutation. It is important to adjust for RRSO use in the estimation of BRCA1/2 penetrance of breast and ovarian cancer.

Methods

We searched PubMed for penetrance estimates of breast and ovarian cancer from studies that genotyped individual patients and explicitly adjusted for RRSO use by censoring follow-up at the age of RRSO. We meta-analyzed penetrance estimates from 7 identified studies. We implemented the resulting penetrance estimates in a Mendelian risk prediction model as iplemented in the software package BRCAPRO, which we applied to estimate carrier probabilities in 2 BRCA cohorts.

Results

Penetrance estimates by age 70 years for breast cancer were 64.6% (95% confidence interval [CI] = 59.5% to 69.4%) for BRCA1 mutation carriers and 61.0% (95% CI = 48.1% to 72.5%) for BRCA2 mutation carriers, and for ovarian cancer they were 48.3% (95% CI = 38.8% to 57.9%) and 20.0% (95% CI = 13.3% to 29.0%), respectively. When integrated into BRCAPRO, our estimates led to good calibration and different estimates of carrier probabilities for some individuals when evaluating the models in 2 cohorts.

Conclusions

The report updates penetrance estimates for BRCA1/2-associated cancer. We report higher estimates than previously reported, which did not adjust for RRSO. Differential use of RRSO may partially explain heterogeneity in the currently available penetrance estimates. For some individuals, using our estimates in BRCAPRO may result in changes in estimated carrier probabilities, which warrants validation in future studies.

Scrubs contamination, domestic laundry effect and workwear habits of clinical staff at a referral hospital

OBJECTIVE

To determine contamination rates of scrub suits worn by veterinary surgeons and nurses following a single shift.

MATERIALS AND METHODS

Cross-sectional preliminary study at a UK small animal referral centre. Sterilised scrub suits were distributed to veterinary surgeons (n = 9) and nurses (n = 9) at the beginning of their clinical shift and worn for at least 8 hours. They were then analysed for bacterial contamination before and after home laundry at 30°C. A questionnaire was distributed to hospital clinical staff regarding workwear habits.

RESULTS

Median bacterial counts were 47 (interquartile range: 14 to 162) and 7 (interquartile range: 0 to 27) colony forming units per cm² before and after laundering scrub suits. Bacteria identified included Staphylococcus sp., Enterococcus sp., Escherichia coli , Bacillus sp., Pseudomonas aeruginosa , Micrococcus sp., β-haemolytic Streptococci and a Group G Streptococcus. From 101 staff surveyed, 64.0% reported wearing fresh, clean scrub tops and 58.4% fresh, clean trousers each day, while 64.4% left the workplace wearing the same clothing in which they undertook clinical work.

CLINICAL SIGNIFICANCE

Workwear contamination risks spread of pathogens into the community and personnel compliance with workplace guidelines warrants further attention. Home laundry at 30°C significantly decreases, but does not eliminate, the bacterial burden after a single shift.

Abstract P6-08-28: Comprehensive germline multigene panel testing changes clinical care for patients with breast cancer

Background: HBOC testing guidelines were established to identify patients with clinically actionable variants and limit economic burden. We report the impact of germline results on health outcome based on clinical decision making and treatment interventions, regardless of guidelines, in a multi-center registry.

Methods: 20 community-based and academic sites participated in an IRB approved registry. Patients with breast cancer were tested with an 80-gene panel and clinical information was collected.

Results: Data on 912 patients has been analyzed to date. 68% were recently diagnosed and the remaining were diagnosed in the past. 50.5% met NCCN criteria; 49.5% did not. Pathogenic/likely pathogenic (P/LP) germline mutations were found in 8.65% of patients. Of all patients with P/LP findings, 85% had variants in cancer-risk genes with established management recommendations and 80% had germline variants conferring eligibility for clinical trials and precision medicine-based cancer treatments, such as PARP inhibitors. When results were evaluated based on an 11 gene panel of genes most commonly associated with breast cancer, 4.9% (or X) were found to have variants and X percent of these had variants conferring eligibility for clinical trials and precision medicine. X Patients with variants outside of the 11 gene panel had eligibility for clinical trials and precision medicine.

There was no significant association between BRCAPRO scores and patients having a P/LP finding, whether in BRCA1/2 alone (p=0.42) or for any cancer gene (p=0.57). For 62% of patients with P/LP germline mutations, clinicians reported results impacted patients’ health outcome; and for 69%, results impacted the health outcome of patients’ relatives.

Physician reported impact on patient outcome associated significantly with the presence of P/LP germline findings (p&lt;0.00001). There was no significant difference in the clinician reported clinical utility of variants of uncertain significance (VUS) compared to negative results (p=0.467).

Conclusions: Comprehensive panel testing of breast cancer patients impacts physician assessed patient outcomes and informs changes in surgical treatment strategy, medical therapies and proactive screening. The data suggest that BRCAPRO calculators are poor predictors of germline presence of P/LP findings. Physicians in this study demonstrate the ability to discern the clinically actionable value of P/LP mutations from non-actionable VUS. Multigene panels impact breast cancer patient care by identifying precision medicine treatment interventions and guiding long-term medical management and preventive surveillance for patients and family members. More patients are provided opportunities for precision medicine when a larger panel is used.

Table 1. Comprehensive panel clinical management and treatment implications. Germline variants with implications for patient management and treatment. *P/LP variants in these genes confer potential clinical trial eligibility, e.g. NCT02401347.Table 1PatientsVariantsWith breast cancer management guidelines45 (56%)46 (55%)(ATM*, BRCA1*, BRCA2*, CHEK2*, NBN*, NF1, PALB2*, TP53*)With cancer management implications31 (38%)33 (39%)(BARD1*, FH, MITF, MSH6*, MUTYH*, PTCH1, RAD50*, RAD51C*, RAD51D*, RB1, RET, VHL)Evidence of actionability accruing5 (6%)5 (6%)(BLM, DIS3L2, RECQL4)Total8184

Citation Format: Peter Beitsch, Pat Whitworth, Kevin Hughes, Ian Grady, Karen Barbosa, Rakesh Patel, Michael Kinney, Paul Baron, Barry Rosen, Gia Compagnoni, Linda ann Smith, Rache Simmons, Cynara Coomer, Dennis Holmes, Eric Brown, Linsey Gold, Lisa Curcio, Patricia Clark, Tony Ruiz, Heather MacDonald, Sadia Khan, Lee Riley, Sam Lyons, Shan Yang, Mary K Hardwick, Edward D Esplin, Robert L Nussbaum. Comprehensive germline multigene panel testing changes clinical care for patients with breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-08-28.

The role of Micro-CT in imaging breast cancer specimens

PURPOSE

The goal of breast cancer surgery is to remove all of the cancer with a minimum of normal tissue, but absence of full 3-dimensional information on the specimen makes this difficult to achieve.

METHOD

Micro-CT is a high resolution, X-ray, 3D imaging method, widely used in industry but rarely in medicine.

RESULTS

We imaged and analyzed 173 partial mastectomies (129 ductal carcinomas, 14 lobular carcinomas, 28 DCIS). Imaging was simple and rapid. The size and shape of the cancers seen on Micro-CT closely matched the size and shape of the cancers seen at specimen dissection. Micro-CT images of multicentric/multifocal cancers revealed multiple non-contiguous masses. Micro-CT revealed cancer touching the specimen edge for 93% of the 114 cases judged margin positive by the pathologist, and 28 of the cases not seen as margin positive on pathological analysis; cancer occupied 1.55% of surface area when both the pathologist and Micro-CT suggested cancer at the edge, but only 0.45% of surface area for the "Micro-CT-Only-Positive Cases". Thus, Micro-CT detects cancers that touch a very small region of the specimen surface, which is likely to be missed on sectioning.

CONCLUSIONS

Micro-CT provides full 3D images of breast cancer specimens, allowing one to identify, in minutes rather than hours, while the patient is in OR, margin-positive cancers together with information on where the cancer touches the edge, in a fashion more accurate than possible from the histology slides alone.

Renewable energy production and demand dataset for the energy system of Colombia

During the last decades, an increasing number of studies have focused their attention on the development of energy system models in order to facilitate sustainable energy planning strategies and understand the technical challenges associated with the integration of renewable energy sources. However, these models usually require detailed and large amount of data as inputs. The data presented in this article provides key inputs and modelling assumptions adopted in the research paper titled "Large scale integration of renewable energy sources (RES) in the future Colombian energy system" [1]. These datasets can be used by researchers and policymakers in order to analyse different pathways oriented to the development of low carbon strategies for Colombia and countries with similar energy systems.

Commensal orthologs of the human autoantigen Ro60 as triggers of autoimmunity in lupus

The earliest autoantibodies in lupus are directed against the RNA binding autoantigen Ro60, but the triggers against this evolutionarily conserved antigen remain elusive. We identified Ro60 orthologs in a subset of human skin, oral, and gut commensal bacterial species and confirmed the presence of these orthologs in patients with lupus and healthy controls. Thus, we hypothesized that commensal Ro60 orthologs may trigger autoimmunity via cross-reactivity in genetically susceptible individuals. Sera from human anti-Ro60-positive lupus patients immunoprecipitated commensal Ro60 ribonucleoproteins. Human Ro60 autoantigen-specific CD4 memory T cell clones from lupus patients were activated by skin and mucosal Ro60-containing bacteria, supporting T cell cross-reactivity in humans. Further, germ-free mice spontaneously initiated anti-human Ro60 T and B cell responses and developed glomerular immune complex deposits after monocolonization with a Ro60 ortholog-containing gut commensal, linking anti-Ro60 commensal responses in vivo with the production of human Ro60 autoantibodies and signs of autoimmunity. Together, these data support that colonization with autoantigen ortholog-producing commensal species may initiate and sustain chronic autoimmunity in genetically predisposed individuals. The concept of commensal ortholog cross-reactivity may apply more broadly to autoimmune diseases and lead to novel treatment approaches aimed at defined commensal species.

Does idiopathic congenital talipes equinovarus have an impact on attainment of developmental milestones? A multicentre international study

PURPOSE

The Ponseti method is a well-established approach to treating clubfoot. Potentially, both the underlying pathology and adherence to post-correction bracing can affect lower limb function and age of independent standing and walking. This cohort study investigates the age at which infants with idiopathic clubfoot treated using the Ponseti method achieved three selected developmental milestones and whether or not this correlated with treatment compliance.

METHODS

A prospectively collected database from four centres was visited. Inclusion criteria were patients with idiopathic clubfoot with no comorbidities or prior treatment. Age at attainment of independent standing, walking, nocturnal continence was compared across three groups: I) congenital talipes equinovarus (CTEV) children compliant with treatment; II) CTEV children non-compliant with treatment; and III) typically-developed siblings. Minimum follow-up was five years.

RESULTS

In all, 130 patients (198 feet) fitted the inclusion criteria: 43:87 (F:M). Standing was achieved by a mean 12.0 months in group I (sd 2.50); 12.0 months (sd 2.0) in II and ten months (sd 3.0) in III. Walking was achieved by a mean 15 months (sd 4.0) in group I, 14 months (sd 1.75) in II and 12 months (sd 3) in III, respectively. Both the compliant and non-compliant CTEV children were significantly slower at achieving standing and walking compared to sibling controls (p < 0.0001). There was no significant difference between age of nocturnal continence between the three groups.

CONCLUSION

Infants with idiopathic clubfoot treated according to the Ponseti method achieve independent standing and walking approximately two months later than their typically-developed siblings. The delay is not related to the use of the foot abduction brace.

LEVEL OF EVIDENCE

III.

Congenital talipes equinovarus

Aims

The Ponseti method is the benchmark treatment for the correction of clubfoot. The primary rate of correction is very high, but outcome further down the treatment pathway is less predictable. Several methods of assessing severity at presentation have been reported. Classification later in the course of treatment is more challenging. This systematic review considers the outcome of the Ponseti method in terms of relapse and determines how clubfoot is assessed at presentation, correction, and relapse.

Patients and Methods

A prospectively registered systematic review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that reported idiopathic clubfoot treated by the Ponseti method between 1 January 2012 and 31 May 2017 were included. The data extracted included demographics, Ponseti methodology, assessment methods, and rates of relapse and surgery.

Results

A total of 84 studies were included (7335 patients, 10 535 clubfeet). The relapse rate varied between 1.9% and 45%. The rates of relapse and major surgery (1.4% to 53.3%) and minor surgery (0.6% to 48.8%) both increased with follow-up time. There was high variability in the assessment methods used across timepoints; only 57% of the studies defined relapse. Pirani scoring was the method most often used.

Conclusion

Recurrence and further surgical intervention in idiopathic clubfoot increases with the duration of follow-up. The corrected and the relapsed foot are poorly defined, which contributes to variability in outcome. The results suggest that a consensus for a definition of relapse is needed. Cite this article: Bone Joint J 2019;101-B:639–645.

Underdiagnosis of Hereditary Breast Cancer: Are Genetic Testing Guidelines a Tool or an Obstacle?

PURPOSE

An estimated 10% of breast and ovarian cancers result from hereditary causes. Current testing guidelines for germ line susceptibility genes in patients with breast carcinoma were developed to identify carriers of BRCA1/ 2 variants and have evolved in the panel-testing era. We evaluated the capability of the National Comprehensive Cancer Network (NCCN) guidelines to identify patients with breast cancer with pathogenic variants in expanded panel testing.

METHODS

An institutional review board-approved multicenter prospective registry was initiated with 20 community and academic sites experienced in cancer genetic testing and counseling. Eligibility criteria included patients with a previously or newly diagnosed breast cancer who had not undergone either single- or multigene testing. Consecutive patients 18 to 90 years of age were consented and underwent an 80-gene panel test. Health Insurance Portability and Accountability Act-compliant electronic case report forms collected information on patient demographics, diagnoses, phenotypes, and test results.

RESULTS

More than 1,000 patients were enrolled, and data records for 959 patients were analyzed; 49.95% met NCCN criteria, and 50.05% did not. Overall, 8.65% of patients had a pathogenic/likely pathogenic (P/LP) variant. Of patients who met NCCN guidelines with test results, 9.39% had a P/LP variant. Of patients who did not meet guidelines, 7.9% had a P/LP variant. The difference in positive results between these groups was not statistically significant (Fisher's exact test P = .4241).

CONCLUSION

Our results indicate that nearly half of patients with breast cancer with a P/LP variant with clinically actionable and/or management guidelines in development are missed by current testing guidelines. We recommend that all patients with a diagnosis of breast cancer undergo expanded panel testing.

The challenge of differentiating vaso-occlusive crises from osteomyelitis in children with sickle cell disease and bone pain: A 15-year retrospective review

PURPOSE

The paediatric sickle cell disease (SCD) osteomyelitis (OM) incidence is 0.3% to 12%. Differentiating vaso-occlusive crises (VOC) from OM is a diagnostic challenge, with limited evidence guiding management. We present a 15-year review of a paediatric sickle cell cohort. We aim to identify OM incidence and provide a management protocol for these children presenting with bone pain.

METHODS

A prospective database of children with haemoglobinopathies (2002 to 2017) was analyzed for temperature, C-reactive protein (CRP) and white cell count (WCC) on admission as well as imaging, treatment and cultures. OM diagnosis was supported by imaging and blood cultures. VOC was defined as bone pain that improved without antibiotics.

RESULTS

Over 15 years, 96 children with SCD presented 358 times to hospital. Empirical antibiotics were given in 308 presentations. There were five cases of OM (1.4%); two acute and three chronic. In all, 50 presentations of VOC were identified. No significant differences in age were noted between the OM and VOC group. Temperature and CRP were significantly elevated in the OM group with no significant difference in WCC. Cultures were only positive in the chronic OM admissions. There were no cases of septic arthritis. No surgical intervention was required.

CONCLUSION

In children with SCD presenting with persistent bone pain, fever, elevated CRP and WCC, OM should be suspected and prompt antibiotic treatment started. Our treatment pathway was successful avoiding OM in 98.6% and septic arthritis in 100%. Further research on novel biological markers distinguishing OM from VOC should be investigated.

LEVEL OF EVIDENCE

III.