Consumer experiences of shame in clinical encounters for breast cancer treatment. "Who do you think you are- Angelina Jolie?"

BACKGROUND

Shame is a powerful negative emotion that has the potential to affect health. Due to the intimate nature of breast cancer treatment and its impact on body image, it is hypothesised that shame may be experienced during treatment. The aim of this study was to explore shame experiences related to clinical encounters for breast cancer treatment.

METHODS

People with a lived experience of breast cancer were invited to anonymously share their stories of shame through an online survey. Using qualitative methodology, the stories were examined, and themes identified.

PARTICIPANTS

Participants were members of the consumer organisation Breast Cancer Network Australia.

RESULTS

Stories were contributed by 38 participants. Most (n = 28, 73.7 %) were >5 years post-diagnosis. Shame was experienced in a range of clinical settings (consulting rooms, wards, operating theatres, radiotherapy departments). They involved a different health professionals (oncologists, surgeons, nurses, radiation therapists, psychologists.) Five themes were identified: (1) Body shame (sub-themes: Naked/vulnerable and Weight), (2) Communication (subthemes: Lack of compassion/impersonal manner and Not listening), (3) Being blamed (subthemes: diagnosis and complications), (4) Feeling unworthy (subthemes: Burden to staff and Unworthy of care), (5) Judgement for treatment choices.

CONCLUSIONS

Shame can be experienced in a range of situations, from scrutiny of the naked body to comments from health professionals. The impact of these experiences is profound, and the feelings of shame are carried for many years. These findings can inform strategies to support consumers and educate health professionals with the aim of reducing harm related to cancer treatment.

Hepatocellular carcinoma presentation and prognosis among Nigerian adults with and without HIV

INTRODUCTION

Hepatocellular carcinoma (HCC) is an increasing cause of mortality in Nigeria among persons with HIV (PLH), as access to antiretroviral therapy (ART) improves. In this study we describe clinical, radiological, and laboratory characteristics in Nigerian adults with HCC, with and without HIV, and examine how HIV impacts survival.

METHODS

This prospective observational study was conducted between August 2018 and November 2021 at two Nigerian hospitals [Jos University Teaching Hospital (JUTH) and Lagos University Teaching Hospital (LUTH)]. Subjects ≥18 years with HCC diagnosed according to American Association for the Study of Liver Diseases (AASLD) criteria were included. Baseline characteristics were compared, and Kaplan-Meier curves were generated to estimate survival.

RESULTS

213 subjects [177 (83%) without HIV and 36 (17%) with HIV (PLH)] were enrolled. Median age was 52 years (IQR 42,60) and most subjects were male (71%). 83% PLH were on antiretroviral therapy (ART). Hepatitis B surface antigen (HBsAg) positivity was similar between the two groups [91/177 (51%) without HIV vs. 18/36 (50%) with HIV; p = 0.86]. 46/213 (22%) subjects had active hepatitis C (anti-HCV+/HCV RNA>10 IU/mL). Cirrhosis was more common in PLH but there were no other significant differences in clinical and tumor characteristics between the groups. Overall, 99% subjects were symptomatic and 78% in late-stage HCC. Median overall survival was significantly shorter in PLH vs. without HIV (0.98 months vs 3.02 months, HR = 1.55, 95%CI 1.02, 2.37, p = 0.04). This association was not significant after adjusting for known risk factors including gender, current alcohol use, alpha-fetoprotein (AFP), albumin, and total bilirubin (HR = 1.38, 95%CI 0.84, 2.29, p = 0.21).

CONCLUSION

HCC presented late with an extremely poor overall prognosis, highlighting the urgent need for more intensive surveillance in Nigeria to diagnose HCC at earlier stages. Early diagnosis and management of viral hepatitis, and access to HCC therapies, could prevent early mortality among persons with HCC, especially among PLH.

A novel approach to interpret quasi-collimated beam results to support design and scale-up of vacuum UV based AOPs

UV-C at 254 nm and vacuum UV (VUV) at 185 nm are the two major emission lines of a low-pressure mercury lamp. Upon absorption of VUV photons, water molecules and selected inorganic anions generate hydroxyl (HO^.) and other redox radicals, both capable of degrading organic micropollutants (OMPs), thereby offering the opportunity to reduce H₂O₂ and energy consumption in UV-based advanced oxidation process (AOP). To be successfully scaled-up, the dual-wavelength VUV+UV/H₂O₂ AOP requires laboratory-scale experiments to establish design criteria. The figures of merit typically used for reporting and interpreting quasi-collimated beam results for UV-based AOPs (time, dose, absorbed energy and E_EO) are insufficient and inaccurate when employed for dual-wavelength AOP such as the VUV+UV/H₂O₂ AOP, and do not support system scale-up. In this study, we introduce a novel figure of merit, useful absorbed energy (uAE), defined as fraction of absorbed energy that results in the generation of oxidative radicals. Here, results of quasi-collimated beam VUV+UV/H₂O₂ AOP experiments on four different water matrices are used to introduce 2D plots that employ both uAE_UV and uAE_VUV as a novel method to represent laboratory-scale experiments of VUV+UV/H₂O₂ AOP and demonstrate how the 2D plots sufficiently support scale-up of the AOP.

Optimal integration of vacuum UV with granular biofiltration for advanced wastewater treatment: Impact of process sequence on CECs removal and microbial ecology

This study explored process synergies attainable by integrating a vacuum ultraviolet-based advanced oxidation process with biofiltration. A comparison using granular activated carbon or granular zeolite as filtration media were examined in context of advanced wastewater treatment for potable reuse. Six biofiltration columns, three with granular activated carbon and three with granular zeolite, were operated in parallel and batch-fed daily with nitrified secondary effluent. After achieving a pseudo-steady state through the filter columns, vacuum ultraviolet treatment was applied as pre-treatment or as post-treatment, at two different applied energies (i.e., VUV-E1=1 kWh/m³ and VUV-E10=10 kWh/m³). Once granular activated carbon had transitioned to biologically activated carbon, as determined based on soluble chemical oxygen demand removal, adsorption was still observed as the main mechanism for contaminants of emerging concern and nitrate removal. Vacuum ultraviolet pre-treatment markedly improved contaminants of emerging concern removal through the integrated system, achieving 40% at VUV-E1 and 90% at VUV-E10. When applied as post-treatment to zeolite column effluents, VUV-E1 and VUV-E10 further increased contaminants of emerging concern removal by 20% and 90%, respectively. In the zeolite system, vacuum ultraviolet pre-treatment also increased soluble chemical oxygen demand removal efficiency, indicating that higher energy vacuum ultraviolet increased biodegradability. Total prokaryotes were two-fold more abundant in biologically activated carbon than in zeolite, with vacuum ultraviolet pretreatment markedly affecting microbial diversity, both in terms of richness and composition. Media type only marginally affected microbial richness in the biofilters but showed a marked impact on structural composition. No clear relationship between compositional structure and depth was observed.

A-07 Initial Symptoms, Pre-Existing Emotional Factors, and Symptoms of Stress During Recovery from Concussion

Purpose: Investigate the association of initial symptoms, mechanism of concussion, and emotional state with symptoms of stress reported during recovery from concussion in high school students. Methods: Concussed High School students (n = 183) aged 13–18 were evaluated within 30 days of injury at a North Texas Concussion Registry (ConTex) clinic with 71% (n = 130) sport-related. Subjects completed a medical history, the Sport Concussion Assessment Tool-5 Symptom Evaluation (PCSS), General Anxiety Disorder (GAD-7), and Patient Health Questionnaire-8 (PHQ-8) at initial visit. At three-month follow-up subjects completed the PTSD Checklist for DSM-5 (PCL-5). A linear regression was conducted predicting total scores on the follow up PCL-5. Predictors included initial Total PCSS Symptom Score, GAD-7, PHQ-8, sex, mechanism of injury (sport vs non-sport) and history of treatment for anxiety/depression. Results: A multiple regression model predicting participant’s total PCL-5 score at three month follow-up (R2 = 0.40, p < 0.001) included PHQ-8 (β = 0.34, p < 0.001), GAD-7 (β = 0.20, p = 0.016), history of treatment for depression (β = 0.17, p = 0.015), severity of initial symptoms (β = 0.15, p = 0.045) and mechanism of injury (β = −0.14, p = 0.018). There was no significant difference in PCL-5 scores between sport vs non-sport injury groups. Conclusions: Pre-existing depression and higher levels of self-reported anxiety and/or depression at time of injury may be associated with increased symptoms of stress during concussion recovery. Severity of initial symptoms and mechanism of injury may also be related to feelings of stress during recovery. Further investigations should include baseline measure of stress prior to injury.

Cardiac muscle activation; the role of length dependent activation and the novel myosin activator danicamtiv

 

B: Alterations in the length dependent activation (LDA) of left ventricular (LV) muscle fibres, the mechanistic driver of the Frank-Starling Law of the heart, are thought to mediate impaired LV function in heart failure (HF). However, little is known about LDA's role in the left atria (LA). Given the concomitant presence of LA dysfunction in HF, the purpose of this study was to compare/assess LDA on LA and LV muscle, as well to evaluate the effects of a novel small-molecule acto-myosin activator, danicamtiv (formerly known as MYK-491).

M: LA and LV myofibrils from healthy Yucatan mini-pigs were used to determine biomechanical function with ATPase assays, with and without danicamtiv. Skinned LA and LV muscle fibres from these same animals were prepared to study contractile force, Ca2+ sensitivity, active/passive stiffness, and responsiveness to increasing sarcomere length (2.0 and 2.3). These parameters were also evaluated in the presence of danicamtiv.

R: LA myofibrils had significantly faster ATPase and Pi release rates compared to LV, consistent with their respective alpha/beta myosin-isoform content. Despite increased metabolic rate, LA fibres generated less maximum isometric tension (12.3±1.96 vs 35.2±3.07 mN/mm2) and had a lower pCa50 than LV fibres (5.66±0.02 vs 5.82±0.02), demonstrating reduced force-generating capability and Ca2+ sensitivity. Stretch of LV fibres resulted in a gain in tension over a range of pCas (pCa6.4, 6.2, 6.0, and 5.8, all p<0.05). However, in LA, LDA-induced gain was not significant at submaximal pCas (pCa6.4, 6.2, 6.0, all p>0.05). Stretch had no effect on active stiffness, but increased passive stiffness in both muscle types. Stretched LA fibres showed grater passive stiffness compared to LV (196.7±21.5 vs. 138.5±22.3 kN/m3). A stiffer myofilament would in part explain the blunted ability of the LA to generate force in response to stretch. Danicamtiv activated both LA and LV myofibrils, increasing ATPase and Pi release rates, and increased Ca2+ sensitivity in fibres (ΔpCa; LV, 0.320±0.032; LA, 0.149±0.028, p<0.01). Unlike with stretch, danicamtiv had no effect on passive stiffness, yet altered the active stiffness/tension (S/T) relationship in both fiber types, but, differentially. In LV, danicamtiv increased the number of available heads (Y0; 129.9±26.3 vs 10.1±4.2 kN/m3, p<0.001) with no significant effect on slope. In the LA, Y0 was largely unchanged with a significant increase in the slope of the S/T relationship (slope: 34.0±2.9 vs. 20.0±1.9 au, p<0.01). Together, these data suggest an increased number of force producing cross-bridges, without altering passive stiffness.

C: These data confirm the functional differences between LA and LV muscle fibres and demonstrate a blunted ability of LA tissue to recruit force when stretched. The acto-myosin activator danicamtiv increased biochemical activity, Ca2+ sensitivity, and the active S/T relationship in LA and LV fibres without altering passive strain.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): MyoKardia Inc.

Menstrual Type, Pain and Psychological Distress in Adult Women with Sickle Cell Disease (SCD)

OBJECTIVE

We evaluated the effects of menstrual types inclusive of PMS on reports of chronic pain intensity and psychopathology in twenty-eight women (mean age 38.93 ± 13.51) with Sickle Cell disease (SCD).

METHODS

Using the Menstrual Symptoms Questionnaire, we compared women with PMS to those with less distressing spasmodic cycle types.

RESULTS

Thirty-four percent of the sample used oral contraception; there were no significant effects of birth control use on reports of pain. Women with PMS characterized the sensory (p = .04) and affective (p = .04) experiences of their SCD-related chronic pain, including their current pain intensity (p = .03), as significantly greater than women with primary spasmodic menstrual type. Further, there was a trend towards significance for women with PMS to report greater levels of overall pain intensity (p = .07) and average pain intensity over the past month (p = .08).

CONCLUSIONS

The authors interpret these results to suggest that there may be a complex interaction of neurohormonal, biological, and psychological factors associated with PMS that influence manifestation and experience of chronic pain in patients with SCD.

A-32 Acute Concussive Symptom Profiles in Adolescents and Young Adults with History of Depression and Anxiety

Objective

The aims of this study are (1) to examine the clinical symptom profiles of individuals with depression and/or anxiety history following a concussion and (2) to compare profile differences across groups.

Method

Participants aged 12-25 (n=129, mean=15.6) with premorbid diagnoses of depression (n=24), anxiety (n=50), or depression+anxiety (n=55) were evaluated within 21 days after sustaining a concussion as part of the North Texas Concussion Registry (ConTex) using the Post-Concussion Symptom Scale (PCSS). Following the model described by Kontos and Collins (2014), symptom clusters were derived from the PCSS to create six domains (cognitive/fatigue, vestibular, ocular, posttraumatic migraine, anxiety/mood, cervical). ANOVAs with Tukey’s post-hoc tests were conducted to compare domain symptom severity and total symptom severity across groups.

Results

There were no demographic differences between groups. A single symptom profile was prominent across each group, with the primary, secondary, and tertiary symptomatic domains being posttraumatic migraine, ocular, and cognitive/fatigue, respectively. Across each domain the depression+anxiety group was most symptomatic, followed in order by the depression and anxiety groups. The depression+anxiety group reported significantly higher anxiety/mood (M=2.0 vs. M=1.3) and cognitive/fatigue (M=2.9 vs M=2.1) symptom severity compared to the anxiety group. Group differences on total symptom severity approached significance (F=2.83, p=.06).

Conclusions

The observed symptom profiles suggest that the acute-concussive response is similar in adolescents and young adults with history of depression and/or anxiety. Multiple premorbid conditions, such as depression and anxiety, appear to magnify overall symptom severity. Further research is warranted to understand the relationship between symptom burden and premorbid mental health factors.

1136 Polysomnography Is Feasible During Inpatient TBI Rehabilitation

Introduction

A recent meta-analytic report highlighted that obstructive sleep apnea was 12 times more prevalent in TBI (mixed severity) than in community-based samples. Recent studies highlight prevalent obstructive sleep apnea during acute inpatient rehabilitation which is a time of critical neural repair. Acute sleep disturbances are associated with therapy cooperation due to effects on daytime sleepiness and are associated with key rehabilitation outcomes. Given the high rates of OSA and risk for negative morbidity, this analysis sought to examine the feasibility of administering polysomnography (PSG) with EEG to diagnose sleep apnea during inpatient rehabilitation in persons with moderate to severe TBI.

Methods

This is a secondary analysis from a prospective diagnostic comparative effectiveness clinical trial (NCT03033901) that took place at six NIDILRR and one VA TBI Model System Centers. Participants were included if they met the TBI Model System case definition and slept at least 2 hours per night prior to PSG. PSG was conducted following AASM procedures in the participant’s hospital bed on the inpatient rehabilitation unit. Studies were scored by RPSGT staff and interpreted by a board certified sleep medicine physician at a centralized sleep scoring center in Tampa, FL.

Results

Of 896 potential TBI participants, 449 met initial eligibility and 345 consented for further screening; a final sample of 263 (76%) completed PSG during hospitalization. Primary reasons for not completing PSG included early discharge or medical instability (n=59) and last-minute withdrawal of consent for PSG (n=23). Of the 263 participants who completed PSG, 3 were excluded from analysis due to technical issues and 12 were excluded as the total sleep time (TST) was less than 120 minutes. Of the 248, 85.5% of the PSGs were rated as interpretable/scoreable by RPSGT and sleep physicians.

Conclusion

For a majority of participants, polysomnography is feasible during inpatient rehabilitation. Participants with shorter lengths of stay, medical instability, prolonged agitation may require polysomnography follow-up after discharge.

Support

Supported by PCORI (CER-1511-33005), VA TBIMS, DVBIC with subcontract from GDIT/GDHS (W91YTZ-13-C-0015, HT0014-19-C-0004), and NIDILRR (90DPTB00070, 90DPTB00130100, 90DPTB0008, 90DPT8000402, 90DPTB0001).

1124 Central Sleep Apnea and Traumatic Brain Injury: A NIDILRR and VA TBI Model System Study

Introduction

Sleep-related breathing disorders are common after TBI. To date, two single site studies have reported divergent findings in post-TBI patients with one reporting predominantly obstructive sleep apnea (OSA, Holcomb et al., 2016) and the other central sleep apnea (CSA, Webster and Bell, 1998). The purpose of this analysis is to explore prevalence, demographics, and injury characteristics of patients with a clinical diagnosis of CSA in a recently-completed multicenter comparative-effectiveness trial during inpatient rehabilitation following moderate to severe TBI.

Methods

Participants in a six-center diagnostic comparative effectiveness trial underwent Level-1 polysomnography (PSG) during inpatient rehabilitation for TBI. Studies were scored at a centralized scoring center by one of two certified PSG technicians with final interpretation by a board-certified sleep medicine physician.

Results

21 of 248 (8.5%) participants evidenced elevated CSA indices >5. Predominant CSA was rare (n=3 [1.2%], age range: 36-59; 100% male; 33-52 days post-TBI). One participant was on opioid, anti-depressant and antiepileptic drugs, one was on an antiepileptic, and another was on an opioid. PAP therapy was not initiated during PSG thus there was no treatment-emergent CSA. All had a central apnea-hypopnea index (AHI) in the moderate to severe range (29-49). Two out of the three had a GCS <8 and one participant had a GCS of 14.

Conclusion

In this multi-center clinical trial, predominant CSA was rare. The common practice of reducing polypharmacy in order to minimize sedation and optimize mental status in specialized inpatient brain-injury rehabilitation programs may contribute to the low CSA incidence in this cohort. Attention to medication side-effects and their influence on sleep-related breathing should be routinely considered.

Support

PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015) for DVBIC, NIDILRR (90DPTB0008-03-00; 90DPTB0013-01-00).

0606 Comparative Effectiveness of Sleep Apnea Screening Tools During Inpatient Rehabilitation for Moderate to Severe TBI

Introduction

Recent studies highlight prevalent obstructive sleep apnea after moderate to severe TBI during a time of critical neural repair. The purpose of this study is to determine the diagnostic sensitivity, specificity and comparative effectiveness of traditional sleep apnea screening tools in TBI neurorehabilitation admissions.

Methods

This is a prospective diagnostic comparative effectiveness trial of sleep apnea screening tools (STOPBANG, Berlin, MAPI [Multi-Apnea Prediction Index]) relative Level 1 polysomnography at six TBI Model System Inpatient Rehabilitation Centers. Between 05/2017 and 02/2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248. The primary outcome was the Area Under the Curve (AUC) of screening tools relative to total apnea hypopnea index ≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (IQR 29-47).

Results

Participants were primarily young to middle age (AGE IQR 28,40,59), male (81%), white (74%), and had primarily severe TBI (IQR GCS 3,6,14). A subset (26%) had a history of military service. Results revealed that the Berlin high risk score (ROC-AUC=0.63) was inferior to the MAPI (ROC-AUC = 0.7802) (p=.0211, CI: 0.0181, 0.2233) and STOPBANG (ROCAUC = 0.7852) (p=.0006, CI: 0.0629, 0.2302); both of which had comparable AUC (p=.7245, CI: -0.0472, 0.0678). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI>5. The pattern was similar across TBI severity subgroups except for delirium or post-traumatic amnesia status wherein the MAPI outperformed the Berlin and STOPBANG. Youden’s Index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples.

Conclusion

This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for moderate to severe TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome.

Support

PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

3M™ Petrifilm™ Enterobacteriaceae Count Plate Method for Enumeration of Enterobacteriaceae in Selected Foods: Collaborative Study

The practice of detecting and enumerating all oxidase-negative, glucose-fermenting-Gram-negative rods (i.e., the family Enterobacteriaceae) isused to indicate unsanitary or inadequate food processing conditions. The objective of this interlaboratory collaborative study was to evaluate and compare the methods described in Standard Methods for the Examination of Dairy Products (SMEDP) and the Compendium of Methods for the Microbiological Examination of Foods (Compendium) with a commercial product, the 3M™ Petrifilm™ Enterobacteriaceae Count Plate, for the recovery of Enterobacteriaceae in foods. Six foods—cheddar cheese, milk, flour, frozen prepared meals, frozen broccoli, and nut pieces—were analyzed for Enterobacteriaceae by 12 collaborating laboratories. For each food tested, the collaborators received 8 blind test portions consisting of a control test portion and 3 levels of inoculated test portion, each in duplicate. Each test portion was tested by the Petrifilm Enterobacteriaceae Count Plate method as well as the SMEDP or Compendium methods. The precision estimates (repeat-ability or within-laboratory variation, and reproducibility or between-laboratory variation) were calculated with standard statistical techniques.

Resiliency and Post-Concussion Symptoms in Adolescents with Sport-Related Concussions

Purpose

Resiliency is a factor affecting an individual’s ability to “bounce back” from stressful events, including injury. A Sport-Related Concussion (SRC) may constitute a stressful event for athletes, yet the association of resiliency with symptoms following SRC is not well known. Thus, we sought to determine if a brief measure of resiliency was related to initial symptoms following SRC in adolescent athletes.

Methods

Subjects (n=458, 199 female, 259 male) aged 12–25 with SRC were evaluated within 30 days of injury (M= 8.35 days, SD=6.98) at a North Texas Concussion Registry (ConTex) clinic. Subjects completed the Sport Concussion Assessment Tool-5 symptom evaluation and the Brief Resiliency Scale (BRS). Subjects were grouped into low (n=56,) average (n= 280), and high (n=122) resiliency groups according to the BRS. ANOVA was conducted to compare initial concussion symptoms across resiliency groups.

Results

Subjects with low resiliency reported a greater number of symptoms (M=12.96, SD=6.79) than those with high resiliency (M=9.47, SD=6.52; p<.005) and a higher level of symptoms (M=34.73, SD=25.90 vs M=25.11 SD=24.72; p<.02). Subjects with low resiliency also reported higher levels of emotional symptoms (Irritability, Sadness, Nervousness, and Feeling More Emotional) than those with average and high resiliency.

Conclusion

Our findings suggest that low resiliency may be associated with greater symptoms following SRC. For emotional symptoms, resiliency level (low, average, high) showed a linear relationship with symptom level. However, the potential relationship between resiliency and recovery or persistence of symptoms over time remains a question.

The Role of Premorbid Psychiatric History and Current Mood Ratings on Self-Reported Concussion Symptom Severity

Purpose

Psychiatric history is known to be relevant to concussion outcomes, although less is known about the role of such factors or current mood ratings in adolescents. The aim of this study was to assess the role of premorbid psychiatric history (PPH) and current mood ratings (CMR) on overall sports-related concussion (SRC) symptomology and cognitive outcomes in adolescent and young adult athletes.

Methods

Participants age 12–25 years (M=14.8) diagnosed with SRC (n=560) were evaluated within 14 days of injury as part of the North Texas Concussion Registry (ConTex) using the Patient Health Questionnaire-8 Items (PHQ-8), General Anxiety Disorder-7 Item Scale (GAD-7), and ImPACT. Subjects were dichotomized into those with (PPH+) and without (PPH-) pre-existing reported psychiatric diagnoses, and CMR groups were determined by normal vs. elevated scores on the GAD-7 and PHQ-8. T-tests were used to compare groups.

Results

Significant differences in total symptom severity scores were found between both PPH (p=.01) and CMR (p<.001) groupings. PPH+ (n=27) reported significantly higher symptom scores (M=31.6) than PPH- subjects (n=316, M=20.9). Additionally, those reporting elevated CMR endorsed 2.3x higher symptom severity scores (n=48, M=42.1 vs. n=276, M=18.2). Among ImPACT cognitive scores, only Visual Memory differed between CMR groups (p=.047).

Conclusion

Findings suggest that PPH and elevated CMR are associated with greater self-reported symptom severity in adolescent SRC, but have little relationship to cognitive outcomes as assessed by ImPACT. Further research is needed to understand the interaction between PPH, CMR, and SRC recovery across the age spectrum.

[Autoimmunity and glaucoma]

In addition to the clinically most relevant risk factor for glaucoma, i.e., elevated intraocular pressure (IOP), there are other factors with high relevance for the disease. Changes in the autoimmune component of the immune system are of particular importance. Clinical studies have demonstrated alterations in different autoantibodies in glaucoma patients compared to healthy controls, some of which increase in abundance/have a raised titer, but also some which have a reduced titer. These changes have a distinct potential-not only as a tool for early glaucoma detection, but also as a therapeutic option due to the documented neuroprotective effects of some of these antibodies. Several antibodies displaying lower abundance in glaucoma patients, e.g., antibodies against 14-3-3 proteins, γ‑/α-synuclein, or also against glial fibrillary acidic protein (GFAP), show neuroprotective effects on retinal ganglion cells in vivo and in vitro. To assess the relevance of changes detected in the immune system of glaucoma patients, "‑omics-based" analyses of different ocular tissues are of particular importance alongside cell culture studies. In this manner, not only samples derived from experimental studies but also samples derived from glaucoma patients in even very small amounts (e. g., tears, aqueous humor, serum, or post-mortem retina) can be analyzed in detail in terms of protein and, in particular, antibody changes. Modern mass spectrometric proteomic characterization of relevant samples will deliver valuable information concerning the understanding of molecular disease mechanisms in the coming years, thus also improving diagnosis and treatment of glaucoma.

Procalcitonin: A Marker of Bacteraemia in SIRS

A number of European studies have documented the ability of procalcitonin (PCT), a novel inflammatory marker, to discriminate patients with sepsis from those with other causes of systemic inflammatory response syndrome (SIRS). The aim of this study was to assess procalcitonin's performance in an Australian intensive care unit (ICU) setting to examine whether it could discriminate between these two conditions.

One hundred and twenty-three consecutive adult ICU patients fulfilling criteria for SIRS were enlisted in the study. Over a period of five days, daily serum PCT and C-reactive protein (CRP) levels were measured. At least two sets of cultures were taken of blood, sputum/broncho-alveolar lavage (BAL) and urine. Other cultures were taken as clinically indicated. Questionnaires to ascertain clinical suspicion of sepsis were prospectively answered by the ICU senior registrars.

PCT values were ten times higher in patients with positive blood cultures; CRP values were also significantly higher in the bacteraemic patients. Both PCT and CRP had a good ability to discriminate bacteraemia from non-infectious SIRS, with the area under receiver operating characteristics (ROC) curves for PCT being 0.8 and for CRP being 0.82. However neither PCT or CRP was able to discriminate patients with localized sepsis from those without. Utilizing both tests resulted in a more sensitive screen than either one alone, while PCT was a more accurate diagnostic test for bacteraemia than CRP. The PCT value also differed between those who died in hospital and those who survived.

Measurement of PCT alone or in combination with CRP can aid discrimination of septicaemia/bacteraemia with associated SIRS from non-infectious SIRS in an Australian ICU setting.

A randomized comparison of three prandial insulin dosing algorithms for children and adolescents with Type 1 diabetes

AIM

To compare systematically the impact of two novel insulin-dosing algorithms (the Pankowska Equation and the Food Insulin Index) with carbohydrate counting on postprandial glucose excursions following a high fat and a high protein meal.

METHODS

A randomized, crossover trial at two Paediatric Diabetes centres was conducted. On each day, participants consumed a high protein or high fat meal with similar carbohydrate amounts. Insulin was delivered according to carbohydrate counting, the Pankowska Equation or the Food Insulin Index. Subjects fasted for 5 h following the test meal and physical activity was standardized. Postprandial glycaemia was measured for 300 min using continuous glucose monitoring.

RESULTS

33 children participated in the study. When compared to carbohydrate counting, the Pankowska Equation resulted in lower glycaemic excursion for 90-240 min after the high protein meal (p < 0.05) and lower peak glycaemic excursion (p < 0.05). The risk of hypoglycaemia was significantly lower for carbohydrate counting and the Food Insulin Index compared to the Pankowska Equation (OR 0.76 carbohydrate counting vs. the Pankowska Equation and 0.81 the Food Insulin Index vs. the Pankowska Equation). There was no significant difference in glycaemic excursions when carbohydrate counting was compared to the Food Insulin Index.

CONCLUSION

The Pankowska Equation resulted in reduced postprandial hyperglycaemia at the expense of an increase in hypoglycaemia. There were no significant differences when carbohydrate counting was compared to the Food Insulin Index. Further research is required to optimize prandial insulin dosing.

Systematic review with meta-analysis: online psychological interventions for mental and physical health outcomes in gastrointestinal disorders including irritable bowel syndrome and inflammatory bowel disease

BACKGROUND

Online psychotherapy has been successfully used as supportive treatment in many chronic illnesses. However, there is a lack of evidence on its role in the management of gastrointestinal (GI) diseases.

AIMS

To examine whether online psychological interventions improve mental and physical outcomes in gastrointestinal diseases.

METHODS

We searched CINAHL Plus, MEDLINE, EMBASE, Health Management Information Consortium, PsycINFO, British Nursing Index, Cochrane Library, a specialised register of the IBD/FBD Cochrane Group, MEDLINE (PubMed) WHO International Clinical Trial Registry, ClinicalTrials.gov, and reference lists of all papers included in the review. The Cochrane Risk of Bias Tool was used to assess internal validity. Where possible, data were pooled using random-effects meta-analysis.

RESULTS

We identified 11 publications (encompassing nine studies) meeting inclusion criteria. One study had a high risk of selection bias (allocation concealment), all studies had a high risk of performance and detection bias. Eight studies were included in the meta-analyses (6 on irritable bowel syndrome [IBS] and two on inflammatory bowel disease [IBD]). Online cognitive behavioural therapy (CBT) was shown to significantly improve gastrointestinal symptom-specific anxiety (MD: -8.51, 95% CI -12.99 to -4.04, P = 0.0002) and lessen symptom-induced disability (MD: -2.78, 95% CI -5.43 to -0.12, P = 0.04) in IBS post intervention. There was no significant effect of online CBT on any other outcomes in IBS. No significant effect of online psychotherapy was demonstrated in IBD.

CONCLUSION

There is insufficient evidence to demonstrate the effectiveness of online CBT to manage mental and physical outcomes in gastrointestinal diseases.

Interaction of obesity with smoking and inflammatory arthropathies increases the risk of periprosthetic joint infection: a propensity score matched study in a Chinese Han population

BACKGROUND

Although a large number of studies have identified obesity as an independent risk factor for the development of periprosthetic joint infection (PJI), the synergistic impacts of obesity with other factors on PJI remain unknown. Additionally, few studies have specifically explored the risk factors of PJI within a Chinese population.

AIMS

To investigate the association between obesity and PJI in a Chinese population, and identify synergistic impacts of obesity with other risk factors on the development of PJI.

METHODS

Three hundred and seven patients at a single institution with a diagnosis of PJI following primary total hip or knee arthroplasty, treated from 2008 to 2015, were identified. Each case was matched with two controls who did not develop PJI after primary total hip or knee arthroplasty in the study period using propensity score matching for several important parameters. Multi-variable logistic regression models were used to estimate the association between body mass index (BMI) and the risk of developing PJI. Interaction and stratified analyses were conducted according to age, sex, type of surgery, smoking status, alcohol use, diabetes, inflammatory arthritis, liver disease and renal disease.

FINDINGS

The multiple logistic analyses showed that obesity was associated with increased risk of PJI [odds ratio (OR) 2.48; 95% confidence interval (CI) 1.66-3.69]. When analysed as a continuous variable, BMI was also associated with increased risk of PJI (OR per 1 kg/m² increase in BMI 1.08; 95% CI 1.02-1.14). In the interaction analysis, patients who were obese and smoked had a higher OR of developing PJI than non-smokers who were obese (OR 3.54 vs 1.55, P-value for interaction=0.031). Similarly, the OR was much higher for patients with both obesity and inflammatory arthritis than for patients who were obese with no history of inflammatory arthritis (OR 3.9 vs 1.55, P-value for interaction=0.029). No other significant interactions were found in the association between obesity and PJI.

CONCLUSION

Obesity is an independent risk factor for the development of PJI in the Chinese Han population. Surgeons should be aware that obese patients who smoke or have inflammatory arthritis are at additional increased risk of PJI.

Our Ethical Obligation to Treat Opioid Use Disorder in Prisons: A Patient and Physician's Perspective

The opioid epidemic has claimed the lives of more than 183,000 individuals since 1999 and is now the leading cause of accidental death in the United States. Meanwhile, rates of incarceration have quadrupled in recent decades, and drug use is the leading cause of incarceration. Medication-assisted treatment or MAT (i.e. methadone, buprenorphine) is the gold standard for treatment of opioid use disorder. Incarcerated individuals with opioid use disorder treated with methadone or buprenorphine have a lower risk of overdose, lower rates of hepatitis C transmission, and lower rates of re-incarceration. Despite evidence of improved outcomes, many jails and prisons do not offer MAT to individuals with opioid use disorder. This seems partly due to a scientifically unjustified preference for an abstinence-only treatment approach. The absence of MAT in prisons and jails results in poor outcomes for individuals and poses a public health threat to communities. Furthermore, it disproportionately harms poor communities and communities of color. Health care providers in prisons and jails have an ethical obligation to offer MAT to individuals with opioid use disorder to mitigate risk of infectious diseases, opioid overdose and health disparities associated with incarceration.

Prisoners as Patients: The Opioid Epidemic, Medication-Assisted Treatment, and the Eighth Amendment

This article argues that correctional institutions violate the Eighth Amendment when they refuse to establish MAT programs and prevent doctors from exercising medical judgment to properly treat incarcerated people with OUD.

Cyprinid herpesvirus 3 as a potential biological control agent for carp (Cyprinus carpio) in Australia: susceptibility of non-target species

Carp (Cyprinus carpio L.) is a pest species in Australian waterways, and cyprinid herpesvirus 3 (CyHV-3) is being considered as a potential biological control (biocontrol) agent. An important consideration for any such agent is its target specificity. In this study, the susceptibility to CyHV-3 of a range of non-target species (NTS) was tested. The NTS were as follows: 13 native Australian, and one introduced, fish species; a lamprey species; a crustacean; two native amphibian species (tadpole and mature stages); two native reptilian species; chickens; and laboratory mice. Animals were exposed to 100-1000 times the approximate minimum amount of CyHV-3 required to cause disease in carp by intraperitoneal and/or bath challenge, and then examined clinically each day over the course of 28 days post-challenge. There were no clinical signs, mortalities or histological evidence consistent with a viral infection in a wide taxonomic range of NTS. Furthermore, there was no molecular evidence of infection with CyHV-3, and, in particular, all RT-PCRs for viral mRNA were negative. As a consequence, the results encourage further investigation of CyHV-3 as a potential biocontrol agent that is specific for carp.

Abstract 979: Discovery of the JAK1 selective kinase inhibitor AZD4205

Janus kinases are a family of four enzymes; JAK1, JAK2, JAK3 and tyrosine kinase 2 (TYK2) that are critical in cytokine signalling, with constitutive activation of JAK/STAT pathways associated with a wide variety of malignancies. Elevated JAK/STAT signalling leading to increased activation of STAT3 is reported in a wide variety of cancers, including breast, liver, prostate, colorectal, head and neck, oesophageal, pancreatic, bladder, and non-small cell lung, and is implicated in the pathogenesis of diffuse large B-cell lymphoma and nasopharyngeal carcinomas. Overall, up to 70% of human tumours are linked to persistent elevated STAT3 activity which can be associated with poorer prognosis in many of these settings. In addition, elevated pSTAT3 is observed in response to chemotherapy treatment, and also in response to treatment with inhibitors of oncogenic signalling pathways such as EGFR, MAPK and AKT, and is associated with resistance or poorer response to agents targeting these pathways. In many of these cases, JAK1 is believed to be a primary driver of STAT3 phosphorylation and signalling, suggesting inhibition of JAKs as a therapeutic approach to treat these potential resistance mechanisms. The mixed JAK1/2 kinase inhibitor ruxolitinib is approved for the treatment of myeloproliferative neoplasms including intermediate or high risk myelofibrosis and polycythemia vera and has been tested in a variety of tumor settings. Since JAK2 is essential for the signal transduction downstream of erythropoietin, thrombopoietin and related receptors that control erythrocyte and megakaryocyte expansion, dosing of inhibitors that target JAK2 can be limited by toxicities such as thrombocytopenia and anaemia.

Starting from a non-kinome selective screening hit, structure-based design was used to optimise a series of aminopyrimidines that led to JAK1-selective candidate drug AZD4205. This compound demonstrates ATP competitive binding with IC50’s in a high ATP concentration enzyme assay against JAK1 of 73 nM (Ki = 2.8 nM), with high selectivity against JAK2 and JAK3 with IC50’s of 13,233 nM and &gt;30,000 nM respectively. In addition it showed potent inhibition of p-STAT3 in a cell based assay of JAK1 activity with an IC50 of 128 nM and excellent selectivity across the kinome. In summary, AZD4205 is a highly potent JAK1-selective kinase inhibitor with excellent preclinical pharmacokinetics with potential for further clinical development. The optimization from screening hit to first disclosure of this candidate drug will be presented.

Citation Format: Jason G. Kettle, Qibin Su, Neil Grimster, Sameer Kawatkar, Scott Throner, Richard Woessner, Huawei Chen, Geraldine Bebernitz, Kristen Bell, Erica Anderson, Linette Ruston, Jon Winter-Holt, Paul Lyne, Melissa Vasbinder, Claudio Chuaqui. Discovery of the JAK1 selective kinase inhibitor AZD4205 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 979. doi:10.1158/1538-7445.AM2017-979

Gender Differences in HIV-Related Neurological Progression in a Cohort of Injecting Drug Users Followed for 3.5 Years

We evaluated potential gender differences in the development of HIV related neurologic impairment, by matching 38 pairs of HIV positive male and female injecting drug users on their baseline age, education, disease stage and CD4 counts, and following them for 3.5 years. Adjusting for age, education, drug use, history of head injury and baseline CD4 count, more women had sensory abnormalities and symptoms than men at baseline, but the odds of having neurological impairment, particularly extrapyramidal signs and sensory abnormalities were increased over time in men but not in women. Men with ARC or AIDS had more neurological impairment than women in similar stages of illness. This study suggests further investigations of gender differences in HIV disease progression.

Abstract P6-12-08: Healthcare barrier profiles in patients navigated for cancer screening and treatment and the impact of the affordable care act

Background: The underserved community experiences barriers to cancer screening that result in overall greater mortality rates across all cancers. Insurance coverage brought forth by the Affordable Care Act has the potential to significantly impact these barriers through reducing the burden of health care cost on the patient. In this study the authors observe the impact of the Affordable Care Act on the barrier profiles presented by the patients navigated for cancer screening and treatment.

Methods: Patient navigation encounters were recorded for a total of 1146 patients navigated for cancer screening and treatment at the Cleveland Clinic Foundation from the years 2012 through 2015. A total of 3259 encounters were classified into barrier types. Health care billed encounters were retrieved from EPIC for this group of patients from the time they entered patient navigation and classified in terms of insurance coverage. Patients were categorized according to their barrier profile. Appropriate generalized linear regression models were used to test for association of these profiles to number and types of navigation and health care encounters and cost, and to test for change in types of encounters and patient barrier profiles through time.

Results: The insurance barrier is present in 23% of all navigation encounters. Patients presenting with an insurance barrier had a greater mean number of navigation (p&lt;0.001) and health care encounters (p&lt;0.006), had a greater proportion of self-paid health care encounters (p&lt;0.001) and a lower total cost billed for health care encounters after controlling for number of encounters (p&lt;0.001) . The access barrier is present in 53% of navigation encounters while patients that present with only the access barrier account for 42% of the entire sample. Patients that present with only the access barrier have doubled every year (OR 2.2 per year, 95% CI [1.8 2.6]) from 2012 to 2015, while the proportion of self-paid health care encounters (OR 0.26 per year, 95% CI [0.25 0.28]) and the presence of the insurance barrier (OR 0.55 per year, 95% CI [ 0.49 0.62]) have more than halved during this time period.

Conclusion: Although the Affordable Care Act has clearly had an impact by lowering the number of insurance barrier navigation encounters through time, it has uncovered access as the predominant remaining barrier. Understanding and targeting the access barrier will be the most effective way to potentiate the effects of the ACA on patients being navigated for cancer screening and treatment.

Citation Format: Raska P, Ott MA, Steele A, Bailey A, Hickman D, Allen D, Urbanek D, Glass K, Bailey J, Bell K, Montero A, Abraham J. Healthcare barrier profiles in patients navigated for cancer screening and treatment and the impact of the affordable care act. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-08.