Does Perioperative Radiation Affect Implant Survivorship of Primary Total Hip Arthroplasty in the Setting of Metastatic Bone Disease?

Background

Metastatic bone disease (MBD) commonly affects the hip and surgical intervention including total hip arthroplasty (THA) is often indicated to treat the joint and improve function. Patients with metastatic cancer often receive radiotherapy, and orthopaedic oncologists must consider surgical risks with operating on irradiated bone and soft tissue. We evaluated surgical outcomes and implant survival (IS) of titanium acetabular components and femoral components in patients treated for MBD in the setting of perioperative radiation.

Methods

This was a retrospective review of patients who underwent THA for MBD at 3 institutions between 2017 and 2021. Outcomes included rates of reoperation, complications, IS, and overall survival.

Results

Forty-six patients who received primary THA for MBD were included in the study. Twenty patients (43.5%) received perioperative radiation for MBD. Six postoperative complications including one superficial wound infection, 2 dislocations, 2 pathologic fractures, and one aseptic acetabular component loosening led to 5 reoperations. There were no significant differences in postoperative outcomes, reoperation after THA, and IS based on radiotherapy status.

Conclusions

To our knowledge, this is the first paper evaluating primary THA outcomes and IS between patients who receive perioperative radiation for MBD to the hip and those who do not. As surgical management is a crucial part of the treatment in alleviating pain and disability in patients with MBD, we continue to recommend THA for patients who received radiation at the operative site.

Opiate use after total hip arthroplasty for metastatic bone disease

OBJECTIVES

To investigate post-operative opioid use following a total hip arthroplasty (THA) in metastatic bone disease (MBD) patients and identify factors associated with post-operative opioid use at 6 weeks and 90 days.

BACKGROUND

MBD commonly affects the hip, and surgical intervention including THA may be indicated for pain relief or to improve function. Following THA, patients are often prescribed short courses of opioids for post-operative pain relief. No study has evaluated opiate use following THA in patients for MBD.

METHODS

This was a retrospective review of patients using opioids preoperatively who underwent primary THA for MBD at two institutions between 2009 and 2022. Preoperative and post-operative opioid usages, respectively, at 6 weeks and 90 days were quantified through calculating daily morphine milligram equivalents (MMEs) and compared using the sign test. Factors associated with post-operative opioid use at 6 weeks and 90 days were compared using χ2 test or Fisher's exact test as appropriate.

RESULTS

Nineteen THA and 11 THA with complex acetabular reconstruction were included. At 6 weeks, 26 (86.7 percent) patients were utilizing opiates, and at 90 days, 23 (76.7 percent) patients were utilizing opiates. There was a statistically significant difference between median daily preoperative MME compared to daily MME at 90 days (p < 0.001). The only statistically significant association with opioid use at 90 days was opioid use at 6 weeks.

CONCLUSION

To our knowledge, this is the first paper evaluating post-operative opioid use following primary THA in MBD patients. After THA in the setting of MBD, patients exhibit decreased post-operative opioid use. Future studies with larger cohorts should be conducted to characterize post-operative opioid use following joint arthroplasty in MBD patients.

Identification, validation and biological characterisation of novel glioblastoma tumour microenvironment subtypes: implications for precision immunotherapy

BACKGROUND

New precision medicine therapies are urgently required for glioblastoma (GBM). However, to date, efforts to subtype patients based on molecular profiles have failed to direct treatment strategies. We hypothesised that interrogation of the GBM tumour microenvironment (TME) and identification of novel TME-specific subtypes could inform new precision immunotherapy treatment strategies.

MATERIALS AND METHODS

A refined and validated microenvironment cell population (MCP) counter method was applied to >800 GBM patient tumours (GBM-MCP-counter). Specifically, partition around medoids (PAM) clustering of GBM-MCP-counter scores in the GLIOTRAIN discovery cohort identified three novel patient clusters, uniquely characterised by TME composition, functional orientation markers and immune checkpoint proteins. Validation was carried out in three independent GBM-RNA-seq datasets. Neoantigen, mutational and gene ontology analysis identified mutations and uniquely altered pathways across subtypes. The longitudinal Glioma Longitudinal AnalySiS (GLASS) cohort and three immunotherapy clinical trial cohorts [treatment with neoadjuvant/adjuvant anti-programmed cell death protein 1 (PD-1) or PSVRIPO] were further interrogated to assess subtype alterations between primary and recurrent tumours and to assess the utility of TME classifiers as immunotherapy biomarkers.

RESULTS

TME^High tumours (30%) displayed elevated lymphocyte, myeloid cell immune checkpoint, programmed cell death protein 1 (PD-1) and cytotoxic T-lymphocyte-associated protein 4 transcripts. TME^High/mesenchymal+ patients featured tertiary lymphoid structures. TME^Med (46%) tumours were enriched for endothelial cell gene expression profiles and displayed heterogeneous immune populations. TME^Low (24%) tumours were manifest as an 'immune-desert' group. TME subtype transitions upon recurrence were identified in the longitudinal GLASS cohort. Assessment of GBM immunotherapy trial datasets revealed that TME^High patients receiving neoadjuvant anti-PD-1 had significantly increased overall survival (P = 0.04). Moreover, TME^High patients treated with adjuvant anti-PD-1 or oncolytic virus (PVSRIPO) showed a trend towards improved survival.

CONCLUSIONS

We have established a novel TME-based classification system for application in intracranial malignancies. TME subtypes represent canonical 'termini a quo' (starting points) to support an improved precision immunotherapy treatment approach.

Evaluating factors affecting length of hospital stay in patients with metastatic bone tumors

BACKGROUND

Specific medical conditions known to increase LOS following orthopedic surgery including congestive heart failure, diabetes mellitus and COPD. It is also known that patient demographics such as increasing age and non-white race can negatively affect orthopedic surgical outcomes However, there is a lack of research examining the effect of these variables on patients with metastatic bone disease regarding length of hospital stay and ultimately economic burden following surgery. The aim of this study is to identify factors affecting LOS in patients following surgery for bone metastasis.

METHODS

A retrospective chart review was used to extract data from 93 patients with an underlying diagnosis of bony metastatic cancer who underwent an orthopedic surgical procedure. Data collected included: length of hospital stay, demographic information (age, sex, race, BMI, smoking status), complications (infection, DVT, PE, fractures), pre-operative lab values (WBC, Albumin, Creatinine, HbA1c), primary cancer type, and surgical procedure measures to understand which factors affected LOS.

RESULTS

Increased LOS in this specific patient population was found to be associated with pre-existing diabetes (P = 0.005), obesity (P = 0.025), multiple disease sites (P = 0.042), or disease at the femur (P = 0.035). Patients had a decreased LOS when undergoing a prophylactic procedure (3.53 days vs 5.51 days for non-prophylactic procedure).

DISCUSSION

These findings allow providers to better communicate expectations regarding the duration of admission and allows for a better estimation of cost burden for patients and health systems. The present study demonstrates increased LOS in patients undergoing orthopedic procedures for metastatic bone disease who had pre-existing diabetes, obesity, multiple disease sites, disease in the femur, or surgery for a pathologic fracture (as opposed to a prophylactic procedure). Understanding the factors affecting LOS in this patient population can optimize preoperative care, improve communication between the patient and provider, and ultimately decrease financial burden.

O78: SARCOPENIA IN LOCALLY ADVANCED BREAST CANCER: PREVALENCE, AND IMPACT ON CLINICAL AND ONCOLOGIC OUTCOMES

Introduction

Sarcopenia in cancer may confer negative outcomes, but its prevalence and impact in the modern multimodal management of locally advanced breast cancer have not been systematically studied.

Method

Patients undergoing neoadjuvant therapy and surgery for locally advanced breast cancer between 2010 and 2015 were studied. Skeletal muscle index (SMI) and lean body mass (LBM) were determined. Sarcopenia was defined by computed tomography (CT) at L3 as SMI&lt;38.5cm2/m2. Multivariable linear, logistic, and Cox regression analysis was undertaken to determine the independent impact of sarcopenia on clinical and oncologic outcome.

Result

258 patients were studied. Sarcopenia was present in 23.0%, 7.8% and 0.0% of patients with normal weight, overweight and obesity, respectively (P=0.001). Sarcopenia was not associated with baseline cT and cN stage, tumour grade, histologic type or receptor status. Patients with sarcopenia exhibited equivalent indices of neoadjuvant therapy response including ypT and ypN stage, pathologic complete response and Sataloff grade following surgical resection. Postoperatively, sarcopenia was not independently associated with comprehensive complications index (P=0.242), length of stay (P=0.716) or overall morbidity (P=0.365). However, on multivariable analysis, lower LBM independently predicted reduced invasive disease-free (P=0.049,HR0.93[95%CI0.87-1.00]) and overall (P=0.028,HR0.92[0.85-0.99]), but not disease-specific survival (P=0.070).

Conclusion

Consistent with a lack of association with baseline and post-treatment pathologic features, sarcopenia in locally advanced breast cancer is associated with reduced overall, but not disease-specific, survival. These data indicate that the prognostic impact of sarcopenia may be mediated by impaired performance status and increased non-cancer mortality.

Take-home message

Consistent with a lack of association with baseline and post-treatment pathologic features, sarcopenia in locally advanced breast cancer is associated with reduced overall, but not disease-specific, survival. These data indicate that the prognostic impact of sarcopenia may be mediated by impaired performance status and increased non-cancer mortality.

O39: THE HISTOPATHOLOGICAL AND MOLECULAR FEATURES OF BREAST CARCINOMA WITH HIGH-GRADE TUMOUR BUDDING

Background

Tumour budding (TB) is an adverse histological feature in many cancers. It is thought to represent epithelial-to-mesenchymal transition, a key step in the metastatic process. The role of TB in breast carcinoma (BC) remains unclear.

Aim

To investigate the relationship between TB and other histological and molecular features of BC.

Method

A systematic search was performed to identify studies that compared features of BC based on the presence or absence of high-grade TB. Dichotomous variables were pooled as odds ratios (OR) using the Cochran–Mantel–Haenszel method. Quality assessment of the included studies was performed using the Newcastle-Ottawa scale (NOS).

Result

Seven studies with a total of 1040 patients (high grade TB n=519, 49.9%; low grade TB n=521, 50.1%) were included. A moderate- to high-risk of bias was noted. The median NOS was 7 (range 6-8). High-grade TB was significantly associated with lymph node involvement (OR 2.28, 95% c.i. 1.74 to 2.98, P&lt;0.001) and lymphovascular invasion (OR 3.08, 95% c.i. 2.13 to 4.47, P&lt;0.001). Regarding molecular subtypes, there was an increased likelihood of high-grade TB in oestrogen- (OR 1.66, 95% c.i. 1.21 to 2.29, P=0.002) and progesterone-receptor positive (OR 1.68, 95% c.i. 1.10 to 2.59, P=0.02) tumours. In contrast triple negative breast cancer had a reduced incidence of high-grade TB (OR 0.46, 95% c.i. 0.30 to 0.72, P=0.0006).

Conclusion

High-grade TB is enriched in hormone-positive BC and is associated with known adverse prognostic variables. TB may offer new insights into the metastatic processes of luminal BC.

Take-home message

High-grade TB is enriched in hormone-positive BC and is associated with known adverse prognostic variables. TB may offer new insights into the metastatic processes of luminal BC.

A comparison of depth of necrosis among adjuvant therapies used for the treatment of benign bone tumors

BACKGROUND AND OBJECTIVES

Benign bone tumors are often treated with extended curettage utilizing an adjuvant therapy to eliminate any remaining tumor cells. The purpose of this study was to explore and compare the histologic depth of necrosis created by various adjuvant therapies used in the treatment of benign bone tumors.

METHODS

A high-speed burr was utilized to create cortical defects within porcine humeri and femora. Phenol, polymethyl methacrylate (PMMA), argon beam coagulation (ABC), liquid nitrogen, and the Bipolar Hemostatic Sealer (BHS) were each applied to five defects, with an additional five defects left untreated as a control. The maximal depth of necrosis was determined under microscopic examination.

RESULTS

The phenol, PMMA, ABC, liquid nitrogen, and BHS demonstrated an average histologic depth of necrosis of 0.30, 0.78, 2.54, 2.54, and 0.92 mm, respectively, each of which was significantly increased compared to the control group (p = .001, .003, .003, .01, and  <.001). Their respective variances, a measure of reproducibility, were 0.01, 0.09, 0.96, 1.93, and 0.03 mm² .

CONCLUSION

This study confirms, through histologic analysis, adjuvant therapies create a rim of cellular necrosis beyond that of burring during extended curettage, supporting their use in the treatment of benign bone tumors. Furthermore, it provides a head-to-head comparison.

Characterization of sperm-associated antigen 6 expression in the reproductive tract of the domestic rooster (Gallus domesticus) and its impact on sperm mobility

Sperm mobility is a major determinant of sperm quality in the domesticated chicken (Gallus domesticus) and is therefore an area of interest for improving fertility. Sperm-associated antigen 6 (SPAG6) is an important flagellar protein implicated to be necessary for flagellar function but negatively associated with rooster fertility. This study was aimed to characterize the expression of SPAG6 and investigate its utility as a protein biomarker of sperm mobility. By western analysis, relative SPAG6 abundances were compared between the testicular, epididymal, and vasal tissues and in sequentially maturing sperm. Immunocytochemistry techniques were used to detect localization of SPAG6 in chicken sperm. Last, western analysis was used to compare relative SPAG6 abundances in sperm of differing mobility. SPAG6 was found in higher abundance in epididymal tissues and in highest abundance in vasal tissues, relative to that of the testis. SPAG6 was also found to sequentially increase in abundance in maturing sperm. SPAG6 localizes between the axonemal central pair of microtubules in the sperm flagella, but it is also found in lower concentration in the acrosomal region. SPAG6 was not a significant predictor of sperm mobility. SPAG6 abundance, alone, is not a strong predictor of sperm mobility. Its impact on rooster fertility is likely unrelated to its impact on sperm mobility.

Your role in early diagnosis & Tx of metastatic bone disease

This approach to the work-up and diagnosis will help you to ensure prompt treatment while maximizing your patient's quality of life.

A re-examination of the relationship between Steller sea lion (Eumetopias jubatus) diet and population trend using data from the Aleutian Islands

Prey diversity and energy density have been linked to each other and to population trends in many studies of bird and mammal diets. We re-examined these relationships in Steller sea lions (Eumetopias jubatus (Schreber, 1776)) using data collected from the Aleutian Islands, where there has been a strong longitudinal gradient in population trend. Diet diversity and energy density metrics were similar in the western Aleutians, where sea lion counts declined consistently, and in the easternmost Aleutian area, where population trends improved significantly. We compared traditional deterministic diet diversity metrics with diversity scores based on an occupancy model that accounts for differences in sample size and uncertainty in prey group detection. This analysis indicated that there was no significant change in diet diversity over the 23-year study period or any significant differences across the Aleutian Islands. These results are consistent with prey abundance data from nine groundfish bottom trawl surveys conducted over the same period. While diet studies detail what Steller sea lions eat and provide an estimate of their energy intake, they provide only limited information on the energy expended to obtain their food or the consequences of their diet and foraging ecology on individual or population fitness.

Synchronous renal and para-aortic metastasis in a uterine serous carcinoma: A case review and clinical considerations

•

Serous endometrial carcinomas rarely involve the renal system.

•

Stage IVB serous endometrial carcinoma with confirmed renal metastasis.

•

Paclitaxel/carboplatin treating serous endometrial carcinoma with renal metastasis.

Leopard (Panthera pardus) predation on a red-tailed monkey (Cercopithecus ascanius) in the Issa Valley, western Tanzania

Predation is predicted to be an important selection pressure for primates. Evidence for this hypothesis is rare, however, due to the scarcity of direct observations of primate predation. We describe an observation of leopard (Panthera pardus) predation on a red-tailed monkey (Cercopithecus ascanius schmidti) at the Issa Valley, a savanna-woodland mosaic landscape in western Tanzania. We compare rates of evidence of leopard presence between Issa and other primate study sites in sub-Saharan Africa. An increase in direct observations of leopards at Issa in recent years suggests that leopards may be habituating to researcher presence.

Natural cause mortality in persons with serious mental illness

OBJECTIVE

To identify the determinants of natural cause mortality in a cohort of individuals with serious mental illness assessed prospectively.

METHOD

Persons with schizophrenia (n = 789) and bipolar disorder (n = 498), mean age of 38 (s.d. 12.6) years, underwent an in-person clinical assessment. They also had a blood sample drawn from which infectious disease markers were measured. Mortality was subsequently determined utilizing data from the National Death Index following a period of up to 16.9 years.

RESULTS

A total of 6.8% (87 of 1287) of persons died of natural causes. Mortality was predicted in a multivariate model by baseline cigarette smoking (RR = 6.29, 95% CI 1.41, 3.72, P = 0.00076); divorced or widowed status (RR = 1.90, CI 1.21, 2.99); reduced cognitive score (RR = 0.73, CI 0.61, 0.87); receipt of antidepressant medication (RR = 1.74, CI 1.12, 2.71); elevated levels of antibodies to Epstein-Barr virus (EBV) (RR = 1.29, CI 1.01, 1.66); and a genitourinary (RR = 1.82, CI 1.16, 2.86), respiratory (RR = 1.82, CI 1.16, 2.86), or cardiac (RR = 2.09, CI 1.33, 3.29) condition. There was an additive effect of smoking and both a cardiac and a respiratory condition but not elevated EBV antibody levels.

CONCLUSION

Smoking is a modifiable behaviour which is associated with mortality in this population.

Abstract P6-12-10: The importance of a survivorship coordinator role in the creation of survivorship care plans and maintaining compliance with new accreditation standards

Background: Froedtert Hospital and the Medical College of Wisconsin's Breast Care Center (F&MCWBCC), is a Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC) accredited facility providing care to over 500 patients a year. The F&MCWBCC recognized the importance of following the IOM survivorship recommendations and in 2014 began providing a survivorship care plan (SCP) to patients completing radiation therapy. In 2015, SCP standards for both CoC and NAPBC were established. A redesign of the process was necessary to meet these new requirements.

Methods: A review of accreditation standards was conducted along with an examination of staff availability. A collaborative team of content experts was gathered who worked with an informatics nurse to design content and a template in the EHR that met the elements outlined by the accreditation standards. Initially, treating physicians and advanced practice nurses were responsible for creating the SCP. However, these providers found it to be increasingly difficult to manage on top of their other responsibilities.

In May 2015, an experienced breast cancer technician was identified for the survivorship data coordinator role. The coordinator used available sources, patient lists and clinic schedules, to case find. She developed spreadsheets to assist in tracking patients and measuring compliance. The coordinator communicated with providers to alert them to populate and review the SCP and coordinated the survivorship appointment with the nurse.

Once the SCP is completed, a dedicated RN position is utilized for a survivorship visit with patients. During this visit, the RN reviews the care plan and provides education on follow up care guidelines and overall health and wellness concepts. Assessments for further supportive services are performed, and appropriate referrals made. The RN shares the SCP with the primary care provider. Results are tracked and reported to Cancer Service Line Leadership and the Breast Steering and Cancer Committees.

Results: During the implementation phase, completion of SCPs by physicians and advance practice nurses was inconsistent. Once the survivorship coordinator role was created and implemented, compliance with NAPBC standards improved as SCP delivery numbers increased 141%.

The survivorship coordinator improved delivery of SCPs. In 2014, 130 plans were delivered, and 185 in 2015. In 2016, 314 were delivered, achieving 100% compliance to the NAPBC survivorship standard.

Conclusion:Compliance with NAPBC and CoC standards to deliver SCPs to patients and primary care providers is labor intensive and requires a large number of resources. Use of a survivorship data coordinator has proven successful in determining and tracking eligible patients and ensuring timely delivery of SCPs to patients. The monitoring of new patients through this process has enabled this center to go from estimates of analytic cases, to a current real-time numbers. This is necessary to provide a comprehensive review of care and survivorship guidelines to cancer survivors and meeting accreditation standards. Further work is needed to assess the impact of the SCPs on patient outcomes and satisfaction.

Citation Format: Blissitt J, Scalio R, Myers KB, Sweeney K, Kelly TR, Kong A, Chitambar C, Currey AD. The importance of a survivorship coordinator role in the creation of survivorship care plans and maintaining compliance with new accreditation standards [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-10.

Trends in breast reconstruction practices in a specialized breast tertiary referral centre

BACKGROUND

Breast reconstruction is an important component of multidisciplinary breast cancer management. The practice of breast reconstruction after mastectomy has evolved significantly in the past decade as a result of both increasing mastectomy rates and advances in reconstructive strategy. These changes have significantly influenced the contemporary surgical management of breast cancer. The aim of this study was to examine trends in breast reconstruction after mastectomy in an Irish population.

METHODS

Data were reviewed from a database of all patients who had mastectomy with or without breast reconstruction at Galway University Hospital, a tertiary breast cancer referral centre, between 2004 and 2014. Trends in breast reconstruction after mastectomy were explored with respect to patient demographics, clinicopathological features, and neoadjuvant and adjuvant therapy.

RESULTS

Of 1303 patients who underwent mastectomy during interval studied, 706 (54.2 per cent) had breast reconstruction after mastectomy. In 629 patients (89·1 per cent), breast reconstruction was performed in the immediate setting. Reconstruction rates increased over time from 20·5 per cent in 2004 to 44·7 per cent in 2014. Reconstruction was more commonly performed in younger patients and those with benign, in situ and early-stage disease. A negative relationship between radiotherapy and reconstruction was observed. A pedicled flap with or without an implant was the most commonly used reconstructive approach in patients receiving radiotherapy.

CONCLUSION

Breast reconstruction after mastectomy has become the standard of care in the surgical treatment of breast cancer. Recent trends show a transition favouring implant-based approaches.

Population Pharmacokinetics, Pharmacodynamics, and Exploratory Exposure-Response Analyses of Apixaban in Subjects Treated for Venous Thromboembolism

Apixaban is approved for treatment of venous thromboembolism (VTE) and prevention of recurrence. Population pharmacokinetics, pharmacokinetics-pharmacodynamics (anti-FXa activity), and exposure-response (binary bleeding and thromboembolic endpoints) of apixaban in VTE treatment subjects were characterized using data from phase I-III studies. Apixaban pharmacokinetics were adequately characterized by a two-compartment model with first-order absorption and elimination. Age, sex, and Asian race had less than 25% impact on exposure, while subjects with severe renal impairment were predicted to have 56% higher exposure than the reference subject (60-year-old non-Asian male weighing 85 kg with creatinine clearance of 100 mL/min). The relationship between apixaban concentration and anti-FXa activity was described by a linear model with a slope estimate of 0.0159 IU/ng. The number of subjects with either a bleeding or thromboembolic event was small, and no statistically significant relationship between apixaban exposure and clinical endpoints could be discerned with a logistic regression analysis.

Abstract P5-02-06: The impact of the introduction of breast cancer screening on a symptomatic breast cancer unit

This abstract was not presented at the symposium.

Establishing best practices and guidance in population modeling: an experience with an internal population pharmacokinetic analysis guidance

This tutorial describes the development of a population pharmacokinetic (Pop PK) analysis guidance within Pfizer, which strives for improved consistency and efficiency, and a more systematic approach to model building. General recommendations from the Pfizer internal guidance and a suggested workflow for Pop PK model building are discussed. A description is also provided for mechanisms by which conflicting opinions were captured and resolved across the organization to arrive at the final guidance.

CPT: Pharmacometrics & Systems Pharmacology (2013) 2, e51; doi:10.1038/psp.2013.26; advance online publication 3 July 2013

Abstract 1457: Valproic acid enhances radiation therapy by protecting normal hippocampal neurons and sensitizing malignant glioblastoma cells

Neurocognitive deficits are devastating sequelae that follow cranial irradiation in patients with medulloblastoma and leukemia. Valproic acid (VPA) has been used effectively as a neuroprotector in various neurological insults. In the present study we demonstrate that VPA could be used to protect hippocampal neurons from the damaging effects of radiation. The effect of VPA pretreatment on cell death was examined using clonogenic survival assays. Mouse hippocampal neurons, HT-22 were treated with 0.6 mM VPA for 7 days prior to irradiation. A significant increase in survival was seen in HT-22 cells treated with VPA compared to cells treated with radiation alone. In contrast, VPA treatment decreased the survival of irradiated cancer cells, D54 and GL-261 compared to radiation alone. To elucidate the mechanism of this selective increased survival in normal hippocampal cells we monitored for program cell death by Annexin V-FITC or DAPI staining. Irradiated HT-22 cells which were pretreated with VPA demonstrated 2 fold decrease in apoptosis than irradiated cells. Similar results were obtained using irradiated mice. Seven-days old C57BL6J pups were either irradiated with the single dose of 7 Gy or treated with VPA (200mg/Kg) followed by 7Gy irradiation. VPA pretreatment protected hippocampal neurons from radiation-induced apoptosis as demonstrated by counting the pyknotic nuclei in the subgranular zone of the hippocampal region. Western immunoblotting of HT-22 cells revealed that VPA not only inhibited HDAC, but also inhibited glycogen synthase kinase-3β (GSK-3β), an enzyme required for apoptosis. A heterotopic glioma model of GL-261 was used to evaluate the tumor growth delay following treatment with VPA (200 mM) and radiation (five fractions of 2Gy). VPA alone delayed the tumor growth; however VPA in combination with radiation significantly delayed tumor growth. In conclusion, VPA protected hippocampal neurons from radiation-induced damage in vitro and in vivo. This protection is specific to hippocampal neuronal cells and not to cancer cells. The molecular mechanism could involve enzymatic inhibition of both HDAC and GSK-3β. VPA could be used as a novel therapy for the prevention of neurocognitive deficits resulting from cranial irradiation.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1457. doi:1538-7445.AM2012-1457

The Relationship between Breast Cancer and Research; a Bibliometric Study

Background: Thousands of articles are published every year in the medical literature relating to the diagnosis and treatment of cancer patients. An area of contention of late has been the amount of research time and money being devoted to breast cancer, to what some believe is to the detriment of research into other forms of malignancy. The aims of this study were to further investigate the relationship between malignancy and research, in order to better quantify the degree to which breast cancer is being over- or under-represented in the research world.Methods: Bibliometrics is the science of studying written communication by systematic measurement and analysis of research publications. In this study, we examined research output over a one-year period for the 26 most commonly diagnosed cancers in the UK. Our strategy was based on that employed by a group in Edinburgh in 2001, and involved correlating research output with incidence and mortality statistics. In addition, we sought to elucidate changes in research output over time and then to correlate these changes with improvements in survival. The survival data used was that published by Coleman et al in 2004, and represents changes in survival over 5 year periods between 1986 and 1999 in England and Wales.Results: A total of 73,798 publications were included in this study. Breast cancer received more research attention than any other malignancy in the time period of this study. Proportional to its incidence and associated mortality, however, breast cancer was markedly underrepresented. This relationship was consistent across publication and study types, and in the higher impact journals. There was a strong positive correlation between improvement in 5-year survival and research output (p = 0.003). Those malignancies enjoying the greatest increases in output included those involving the prostate, non-hodgkins lymphoma, breast and vaginal cancer.Conclusions: This study was intended to provide a snapshot-in-time of research output in malignancy. It has shown that, on the basis of both incidence and mortality, breast cancer is not receiving disproportionate attention by the research community, contrary to popular opinion. Whilst the absolute figures clearly reflect the success of the breast cancer advocacy community in raising and maintaining the profile of the disease, the evidence suggests that, if anything, breast cancer is not receiving the interest it deserves, based on its burden to society.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1080.

Bilateral Breast Cancer: Analysis of Incidence, Characteristics and Outcome of the Disease

Background: Despite the widespread adoption of breast conservation therapy in breast cancer, there is a dramatic increase in the rate of bilateral mastectomy in USA. The aim of this study was to address the incidence of bilateral breast cancer (BBC) and to investigate its characteristics, survival and outcome compared to unilateral breast cancer.Methods: Data was acquired from the prospectively maintained NUI Galway breast cancer database between 1988 and 2008. BBC were then categorized as synchronous (within 12 months) or metachronous cancer (after 12 months of first tumour). SPSS was used for data analysis.Results: The incidence of bilateral breast cancer in our population was 4.4% (112 of 2524). Of those 2.1% were synchronous while 2.3% were metachronous. Compared to unilateral cases, bilateral cancer patients were younger (0=0.021) and had smaller size (p=0.001) and earlier stage (p&lt;0.001) tumours at diagnosis. There were no differences in histological type (p=0.630) and grade (p=0.054)). While there was no significant difference in survival for patients with bilateral compared to unilateral tumour (p&gt;0.05), the synchronous bilateral tumour was associated with poor overall survival (p=0.010) and disease free survival (p=0.013) in comparison to metachronous bilateral tumour.Conclusion: We observed significant differences in bilateral tumour characteristics compared to unilateral disease. Although bilateral synchronous tumour was associated with poor outcome and overall survival, patients with metachronous disease do as well as patients with unilateral tumour. The increasing practice of bilateral mastectomy is not supported by this large single centre experience.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5033.

Age-structured modeling reveals long-term declines in the natality of western Steller sea lions

Since the mid-1970s, the western Steller sea lion (Eumetopias jubatus), inhabiting Alaskan waters from Prince William Sound west through the Aleutian Islands, has declined by over 80%. Changing oceanographic conditions, competition from fishing operations, direct human-related mortality, and predators have been suggested as factors driving the decline, but the indirect and interactive nature of their effects on sea lions have made it difficult to attribute changes in abundance to specific factors. In part, this is because only changes in abundance, not changes in vital rates, are known. To determine how vital rates of the western Steller sea lion have changed during its 28-year decline, we first estimated the changes in Steller sea lion age structure using measurements of animals in aerial photographs taken during population surveys since 1985 in the central Gulf of Alaska (CGOA). We then fit an age-structured model with temporally varying vital rates to the age-structure data and to total population and pup counts. The model fits indicate that birth rate in the CGOA steadily declined from 1976 to 2004. Over the same period, survivorship first dropped severely in the early 1980s, when the population collapsed, and then survivorship steadily recovered. The best-fitting model indicates that in 2004, the birth rate in the central Gulf of Alaska was 36% lower than in the 1970s, while adult and juvenile survivorship were close to or slightly above 1970s levels. These predictions and other model predictions concerning population structure match independent field data from mark-recapture studies and photometric analyses. The dominant eigenvalue for the estimated 2004 Leslie matrix is 1.0014, indicating a stable population. The stability, however, depends on very high adult survival, and the shift in vital rates results in a population that is more sensitive to changes in adult survivorship. Although our modeling analysis focused exclusively on the central Gulf of Alaska, the western Gulf of Alaska and eastern Aleutians show a similar pattern of declining pup fraction with no increase in the juvenile, or pre-breeding, fraction. This suggests that declining birth rate may be a problem for western Steller sea lions across the Gulf of Alaska and into the Aleutian Islands.

E1A-expressing adenoviral E3B mutants act synergistically with chemotherapeutics in immunocompetent tumor models

The majority of clinical trials evaluating replication-selective oncolytic adenoviruses utilized mutants with immunomodulatory E3B genes deleted, likely contributing to the attenuated efficacy. We investigated whether an intact immune response could contribute to the observed improved efficacy in response to combinations with chemotherapeutics. Seven carcinoma cell lines were evaluated by combining viral mutants; dl309 (DeltaE3B), dl704 (DeltaE3gp19K), dl312 (DeltaE1A) or wild-type Ad5 with the commonly used clinical drugs cisplatin and paclitaxel. Synergistic effects on cell death were determined by generation of combination indexes in cultured cells. In vivo tumor growth inhibition was achieved by virotherapy alone and was most efficacious with wild-type virus and least with the DeltaE3B mutant. Significantly higher efficacy was observed when the viruses were combined with drugs. The greatest enhancement of tumor inhibition was in combination with the DeltaE3B mutant restoring potency to that of Ad5 wild-type levels, observed only in animals with intact immune response. Increases in infectivity, viral gene expression and replication were identified as potential mechanisms contributing to the synergistic effects. Our results suggest that the attenuation of DeltaE3B mutants can be overcome by low doses of chemotherapeutics only in the presence of an intact immune response indicating a role for T-cell-mediated functions.

Thorough QT Study with Recommended and Supratherapeutic Doses of Tolterodine

The objective of our study was to determine the QTc effects of tolterodine. A crossover-design thorough QT study of recommended (2 mg twice daily) and supratherapeutic (4 mg twice daily) doses of tolterodine, moxifloxacin (400 mg once daily), and placebo was performed. Electrocardiograms (ECGs) and pharmacokinetic samples were obtained on days 1-4; time-matched baseline ECGs were taken on day 0. Mean placebo-subtracted change from baseline Fridericia-corrected QT (QTcF) during peak drug exposure on day 4 was the primary end point. Mean QTcF prolongation of moxifloxacin was 8.9 ms (machine-read) and 19.3 ms (manual-read). At recommended and supratherapeutic tolterodine doses, mean QTcF prolongation was 1.2 and 5.6 ms (machine-read), respectively, and 5.0 and 11.8 ms (manual-read), respectively. The QTc effect of tolterodine was lower than moxifloxacin. No subject receiving tolterodine exceeded the clinically relevant thresholds of 500 ms absolute QTc or 60 ms change from baseline. In conclusion, tolterodine does not have a clinically significant effect on QT interval.

Why general practitioners do not implement evidence: qualitative study

OBJECTIVES

To explore the reasons why general practitioners do not always implement best evidence.

DESIGN

Qualitative study using Balint-style groups.

SETTING

Primary care.

PARTICIPANTS

19 general practitioners.

MAIN OUTCOME MEASURES

Identifiable themes that indicate barriers to implementation.

RESULTS

Six main themes were identified that affected the implementation process: the personal and professional experiences of the general practitioners; the patient-doctor relationship; a perceived tension between primary and secondary care; general practitioners' feelings about their patients and the evidence; and logistical problems. Doctors are aware that their choice of words with patients can affect patients' decisions and whether evidence is implemented.

CONCLUSIONS

General practitioner participants seem to act as a conduit within the consultation and regard clinical evidence as a square peg to fit in the round hole of the patient's life. The process of implementation is complex, fluid, and adaptive.

The practice accreditation and improvement survey (PAIS). What patients think

BACKGROUND

The Practice Accreditation and Improvement Survey (PAIS) is an endorsed instrument by the Australian General Practice Accreditation Limited (AGPAL) for seeking patient views as part of the accreditation of Australian general practices.

METHOD

From September 1998 to August 2000, a total of 53,055 patients completed the PAIS within 449 general practices across Australia, which is about 8% of all Australian general practices. The validity and reliability of the PAIS instrument was assessed during the study. Patient views were also analysed via 27 items relating to doctors' interpersonal skills, access, availability and patient information.

RESULTS

PAIS was found to have sound validity and reliability measures. Patient evaluations showed a range of scores for the 27 items (69-91%). Lower scoring areas were issues about access, availability and availability of information for patients.

DISCUSSION

Users of general practice rate the doctors' interpersonal skills (capability) more highly than other practice service issues (capacity). There is, in patients' views, much more room for improving these capacity aspects of general practice.

CONCLUSION

Future research should explore how practices act on the results of patient feedback, and which practice based strategies are more effective in raising standards of care from a patient's perspective.

Non-LTR retrotransposons encoding a restriction enzyme-like endonuclease in vertebrates

All autonomous non-long terminal repeat (non-LTR) retrotransposons reported to date in vertebrates encode an apurinic/apyrimidinic endonuclease-like enzyme necessary for target sequence cleavage and subsequent target-primed reverse transcription. We describe here vertebrate non-LTR retrotransposons encoding another type of endonuclease more related to type IIS restriction enzymes. Such retrotransposons have been detected until now only in trypanosomes, nematodes, and arthropods. The retrotransposon Rex6 was identified in the genome of several teleost fish including Xiphophorus maculatus (platyfish), Oryzias latipes (medakafish), Oreochromis niloticus (Nile tilapia), and Fugu rubripes (Japanese pufferfish). Rex6 encodes a reverse transcriptase and a putative restriction enzyme-like endonuclease and is a member of the R4 family of non-LTR retrotransposons containing the Dong and R4 elements found in nematodes and insects. Rex6 was active in many species during teleost evolution and underwent several bursts of retrotransposition (some of them being relatively recent) leading to a high copy number of Rex6 in the genome of numerous fish. Extremely truncated Rex6-related sequences were detected by database screening in reptiles, including the snake Trimeresus flavoviridis and the lizard Anolis carolinensis, but not in sequences from the human genome project, suggesting that this element might have been lost from certain vertebrate lineages.

Jule from the fish Xiphophorus is the first complete vertebrate Ty3/Gypsy retrotransposon from the Mag family

Jule is the second complete long-terminal-repeat (LTR) Ty3/Gypsy retrotransposon identified to date in vertebrates. Jule, first isolated from the poeciliid fish Xiphophorus maculatus, is 4.8 kb in length, is flanked by two 202-bp LTRs, and encodes Gag (structural core protein) and Pol (protease, reverse transcriptase, RNase H, and integrase, in that order) but no envelope. There are three to four copies of Jule per haploid genome in X. maculatus. Two of them are located in a subtelomeric region of the sex chromosomes, where they are associated with the Xmrk receptor tyrosine kinase genes, of which oncogenic versions are responsible for the formation of hereditary melanoma in Xiphophorus. One almost intact copy of Jule was found in the first intron of the X-chromosomal allele of the Xmrk proto-oncogene, and a second, more corrupted copy is present only 56 nt downstream of the polyadenylation signal of the Xmrk oncogene. Jule-related elements were detected by Southern blot hybridization with less than 10 copies per haploid genome in numerous other poeciliids, as well as in more divergent fishes, including the medakafish Oryzias latipes and the tilapia Oreochromis niloticus. Database searches also identified Jule-related sequences in the zebrafish Danio rerio and in both genome project pufferfishes, Fugu rubripes and Tetraodon nigroviridis. Phylogenetic analysis revealed that Jule is the first member of the Mag family of Ty3/Gypsy retrotransposons described to date in vertebrates. This family includes the silkworm Mag and sea urchin SURL retrotransposons, as well as sequences from the nematode Caenorhabditis elegans. Additional related elements were identified in the genomes of the malaria mosquito Anopheles gambiae and the nematode Ascaris lumbricoides. Phylogeny of Mag-related elements suggested that the Mag family of retrotransposons is polyphyletic and is constituted of several ancient lineages that diverged before their host genomes more than 600 MYA.

A preliminary study of the decision-making process within general practice

OBJECTIVE

The aim of the present study was to explore the factors that contribute to the process of decision making within general practice, over and above evidence-based information.

METHODS

A qualitative study was conducted using semi-structured interviews on a purposeful sample of GPs, based in the South West of England. Each interview was tape-recorded and transcribed verbatim.

RESULTS

Five broad categories emerged from the data: practitioner; patient; practitioner-patient relationship; verbal and non-verbal communication; evidence-based medicine; and external factors.

CONCLUSION

The nature of general practice is such that the process of making clinical decisions is complex. In an era when GPs are being overwhelmed by evidence-based information, consideration needs to be given to the implications that the nature of the decision-making process has upon the way 'evidence' is constructed and promoted within general practice.

Improving foot care for people with diabetes mellitus--a randomized controlled trial of an integrated care approach

AIMS

To evaluate a model of integrated diabetic footcare, for identification and clinical management of the high risk diabetic foot, centred on the primary care-based diabetic annual review.

METHODS

A pragmatic randomized controlled study was undertaken with matched cluster randomization of practices from 10 towns drawn from mid and east Devon responsible for the care of 1,939 people with diabetes (age > or =18 years). Outcome measures were patients' attitudes regarding the value and importance of footcare, patients' footcare knowledge, healthcare professionals' footcare knowledge and pattern of service utilization.

RESULTS

Attitudes towards footcare improved in both intervention and control groups (mean percentage change 3.91, 0.68) with a significant difference in change of 3.18 (95% confidence interval (CI) 1.29-5.07) between the groups. Patients' knowledge about diabetic foot problems improved significantly in both groups (mean percentage change 1.09, 1.32) but with no significant difference in change: -0.09 (95% CI -1.81-1.63) between groups. Health professionals' knowledge scores improved in the intervention group (mean percentage change 13.2; P < 0.001). No improvement was seen in the control group (mean percentage change -0.2; P = 0.1) with a significant difference in change of 13.46 (95% CI 8.30-18.62) between groups. Appropriate referrals from intervention practices to the specialized foot clinic rose significantly (P = 0.05) compared with control practices (P = 0.14).

CONCLUSIONS

Provision of integrated care arrangements for the diabetic foot has a positive impact on primary care staffs' knowledge and patients' attitudes resulting in an increased number of appropriate referrals to acute specialist services.

The non-LTR retrotransposon Rex3 from the fish Xiphophorus is widespread among teleosts

Rex3, the first reverse transcriptase (RT)-encoding retrotransposon isolated from the melanoma fish model Xiphophorus, is a non-long-terminal-repeat element related to the RTE family. The essential features of Rex3 are (1) an endonuclease and a reverse transcriptase, (2) 5' truncations of most of the copies, (3) a 3' tail consisting of tandem repeats of the sequence GATG, and (4) short target site sequence duplications of variable length. Compilation of Rex3 sequences from the pufferfish genome project suggested that, as observed for other members of the RTE family, no additional large open reading frame was present upstream of the endonuclease/reverse transcriptase open reading frame. There are about a thousand copies of Rex3 in the haploid genome of Xiphophorus, some of them probably resulting from recent retrotransposition events. Rex3 RNA was detected by RT-PCR in melanoma and in nontumorous tissues, as well as in melanoma-derived and embryonic cell lines. Rex3 is present in a broad panel of teleost species and was found in the promoter region and in introns of various genes. To our knowledge, Rex3 is the first autonomous retrotransposon described to date which is widespread in teleosts. This wide distribution and occasional association with coding sequences may confer on Rex3 a predisposition to play a role in genome evolution in teleosts.

The health of their nation: how would citizens develop England's health strategy?

BACKGROUND

England's first health strategy, The Health of the Nation, was formulated without systematic input from the citizens whose health it targeted. Several studies indicate that citizens, when asked to prioritize services, rank interventions for acute and life-threatening conditions highest. But how they view and what they want in the areas of prevention, public health, or care for the chronically and mentally ill is not known.

AIM

To explore citizens' attitudes towards England's health strategy as set out in The Health of the Nation and to elicit their ideas for developing it further.

METHOD

The study was conducted in four general practices and a secondary school in southwest England. The design was a qualitative analysis of testimony from 24 audiotaped focus groups. Twenty-three groups were drawn from lists of National Health Service registered patients, stratified by The Health of the Nation target category, and one group was drawn from 13 to 15 year-old girls at a mixed secondary school. In all, 173 citizens took part in the 24 focus group meetings.

RESULTS

In group discussions, these citizens demonstrated an understanding of The Health of the Nation strategy, which enabled them to form views and develop relevant arguments. They produced 26 specific ideas for developing the strategy across its five key areas. There was congruence with the action plans of a national expert group convened by the Department of Health and charged with reviewing the strategy's progress. The focus groups went beyond the experts' proposals, with further practical ideas to achieve The Health of the Nation targets.

CONCLUSION

Citizens in this study contributed a broad range of relevant, appropriate, and innovative ideas on how to develop health strategy. The use of focus groups to achieve this is practical and efficient.

Levels of physical activity, physical fitness and their relationship in the Northern Ireland Health and Activity Survey

The aim of the study was to describe the physical activity and physical fitness profile of the population of Northern Ireland and to explore the relationship between physical activity and physical fitness. This was a cross sectional population study using a two stage probability sample of the adult population of Northern Ireland (aged 16+). The main outcome measures were physical activity profile based on computer assisted interview. Physical fitness using estimation of VO2max by extrapolation from submaximal oxygen uptake while walking on a motor driven treadmill. We found that males were more vigorously active than females (M 21%:F 6%) with a steep gradient of decreasing activity with age: 49% (M 52%:F 46%) were regularly active up to at least moderate intensity. Males (mean predicted VO2max 44.4 mls/kg/min; 16-74 years) were fitter than females (mean predicted VO2max 34.0 mls/kg/min; 16-74 years) and while there was a decline in predicted VO2max with age, there was wide variation within each age category. There was no statistically significant relationship between current or past activity and fitness after adjustment for possible confounding factors, with the exception of a relationship between fitness and activity in males so that the difference between no activity and habitual vigorous activity in predicted VO2max was 4.4mls/kg/min (10.1%).