High-dimensional immune cell profiling of cerebrospinal fluid from patients with metastatic breast cancer and leptomeningeal disease

Leptomeningeal disease (LMD) is a devastating complication of metastatic breast cancer (MBC). In this non-therapeutic study, we enrolled 12 patients with MBC and known or suspected LMD who were undergoing a lumbar puncture as part of clinical care and collected extra cerebrospinal fluid (CSF) and a paired blood sample from each patient at a single time point. Of the 12 patients, 7 patients are confirmed to have LMD based on positive cytology and/or convincing MRI imaging (LMD^pos), and 5 patients are deemed not to have LMD based on similar criteria (LMD^neg). Using high-dimensional, multiplexed flow cytometry, we profile and compare the CSF and peripheral blood mononuclear cell (PBMCs) immune populations between patients with LMD and those without. Patients with LMD observe a lower overall frequency of CD45⁺ cells (29.51% vs. 51.12%, p < 0.05), lower frequencies of CD8⁺ T cells (12.03% vs. 30.40%, p < 0.01), and higher frequency of T_regs than patients without LMD. Interestingly, the frequency of partially exhausted CD8⁺ T cells (CD38^hiTIM3^lo) is ~6.5-fold higher among patients with LMD vs. those without (2.99% vs. 0.44%, p < 0.05). Taken together, these data suggest that patients with LMD may have lower overall immune infiltrates than patients without LMD, suggesting a more permissive CSF immune microenvironment but a higher frequency of partially exhausted CD8⁺ T cells, which may offer an important therapeutic target.

Do studies published in two leading reproduction journals between 2011 and 2020 demonstrate that they followed WHO5 recommendations for basic semen analysis?

STUDY QUESTION

Do publications that involve the interpretation of the results of a basic semen analysis, published in Human Reproduction and Fertility & Sterility between 2011 and 2020, give sufficient evidence in their methodology to demonstrate that they followed the technical methods recommended in the fifth edition of the World Health Organization (WHO) laboratory manual, entitled WHO Laboratory Manual for the Examination and Processing of Human Semen (WHO5)?

SUMMARY ANSWER

Evidence of methodological agreement of studies with the WHO5 recommendations was low, despite 70% of papers stating that they followed WHO5 recommendations.

WHAT IS KNOWN ALREADY

A basic semen analysis is currently an integral part of infertility investigations of the male, but method standardization in laboratories remains an issue. The different editions of the WHO manual for the basic semen analysis (WHO1-6) have attempted to address this by providing increasingly rigorous methodological protocols to reduce experimental error. However, to what extent these methods are followed by studies that involve the interpretation of the results of basic semen analysis remains unknown.

STUDY DESIGN, SIZE, DURATION

A survey of the technical methods used to perform a basic semen analysis was conducted on studies published in two leading reproduction journals (Human Reproduction and Fertility & Sterility) between 2011 and 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The literature search was performed on the electronic databases PUBMED and MEDLINE Ovid between January 2021 and March 2021. The MeSH terms included in the search were 'sperm concentration' OR 'sperm motility' OR 'sperm morphology' OR 'sperm vitality' OR 'male fertility' AND 'human spermatozoa' NOT 'animals'. A total of 122 studies were available for analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 70% of the studies cited WHO5 in their methods section. Of the remaining studies, 10% cited the fourth edition of the WHO laboratory manual (WHO4), 7% cited both WHO4 and WHO5, 1% cited the third edition of the WHO laboratory manual (WHO3), and 12% did not cite the WHO at all. Overall methodological agreement with WHO5 recommendations was poor, with the main reason for this lack of agreement being that the research studies did not disclose specific details of the technical methods and equipment used.

LIMITATIONS, REASONS FOR CAUTION

In the case of studies that did not disclose any specific technical methods that they used, we did not attempt to contact these authors and so were unable to confirm the agreement between their technical methods and WHO5 recommendations.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings suggest there is an urgent need to develop strategies to address standardization in reporting the results of a semen analysis for publication. This is particularly timely given the recent publication of WHO6 and ISO standard 23162 for the basic examination of human semen.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding for this project. C.L.R.B., as an employee of the University of Dundee, serves on the Scientific Advisory board of ExSeed Health (from October 2021, financial compensation to the University of Dundee) and is a scientific consultant for Exscientia (from September 2021, financial compensation to the University of Dundee). C.L.R.B. has previously received a fee from Cooper Surgical for lectures on scientific research methods outside the submitted work (2020) and Ferring for a lecture on male reproductive health (2021). C.L.R.B. is Editor for RBMO.

TRIAL REGISTRATION NUMBER

N/A.

Cardiac MRI risk factors predict atrial arrhythmia development in repaired tetralogy of Fallot patients

Background/Introduction

Tetralogy of Fallot (TOF) patients with atrial arrhythmias (AA) experience greater morbidity and mortality than do their arrhythmia-free counterparts. Cardiac MRI (cMRI) has proven useful in elucidating risk factors for arrhythmia development in this population, but more work needs to be done to assess the efficacy of predicting AA onset.

Purpose

To evaluate demographic and clinical metrics, including those routinely assessed on cMRI, that predict AA onset in repaired TOF.

Methods

175 repaired TOF patients ≥18 years of age and without prior AA undergoing initial cMRI between 2003 and 2020 were identified from a tertiary U.S. hospital database. Subsequent development of AA (specifically atrial fibrillation, atrial flutter, and atrial tachycardia) was evaluated by chart review and device checks (if present). Kaplan-Meier analysis was used to assess arrhythmia-free survival based on cMRI characteristics, and log-rank test used to compare differences in survival curves. Cutoff values for Kaplan-Meier analysis were the mean value (for the respective variable being measured) of our cohort at the time of their initial cMRI.

Results

Over a median follow-up of 3.3 years, 30 patients (17%) developed AA, including 16 with atrial fibrillation (53%), 20 with atrial flutter (67%), and 2 with atrial tachycardia (7%). Age at cMRI (p&lt;0.01), history of hypertension (p=0.01), and time from birth to complete TOF repair (p&lt;0.05) predicted AA. cMRI predictors included indexed right ventricular (RV) end diastolic and systolic volumes (both p&lt;0.01), as well as indexed right atrial (RA) volume (p&lt;0.05) and pulmonic regurgitation (PR) fraction (p&lt;0.05). Indexed RV and RA volumes but not left sided chamber volumes predicted the development of atrial fibrillation. All Kaplan-Meier survival distributions were significantly different with the exception of those for right atrial volumes.

Conclusions

Our study suggests that RA and RV volumes may play a valuable role in predicting atrial arrhythmia onset in the repaired TOF population. Disease progression in a predominantly right-sided heart disease may play a role in predicting the onset of both “right sided” arrhythmias such as atrial flutter, as well as “left sided” arrhythmias such as atrial fibrillation. Additionally, the increased AA burden in patients with mild RV dilation seen in our study may suggest a potential benefit to early pulmonic valve replacement in this patient group.

Funding Acknowledgement

Type of funding sources: None. Clinical and cMRI CharacteristicsKaplan-Meier Survival Analysis

Myeloperoxidase inhibitor AZD5904 enhances human sperm function in vitro

STUDY QUESTION

Does AZD5904, a myeloperoxidase inhibitor (MPOi), have any effect on human sperm function in vitro?

SUMMARY ANSWER

AZD5904 improves sperm function in an in vitro model of oxidative stress (OS) and potentially offers a novel treatment approach for male infertility.

WHAT IS KNOWN ALREADY

Male infertility is an underlying or contributory cause in half of all couples experiencing difficulties conceiving, yet there is currently no effective treatment or cure. OS is a common pathology in a significant proportion of infertile men. It can negatively affect sperm motility and the ability to fertilize a mature oocyte, as well as DNA integrity, and therefore represents an attractive target for therapeutic intervention.

STUDY DESIGN, SIZE, DURATION

This study included population-based samples from men (23-50 years) attending Ninewells Assisted Conception Unit, Dundee for diagnostic semen analysis, July 2017-September 2018. Semen samples (n = 47) from 45 patients were used.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Neutrophils activated using zymosan were incubated with prepared human spermatozoa for 2 h (T2) and 24 h (T24) to create an in vitro model of OS. Parallel samples were co-incubated with AZD5904, an MPOi, to examine its effects. Sperm motility was assessed by computer-assisted sperm analysis at T2 and T24. Functional motility was assessed by sperm penetration assay. Statistical analysis was performed using GraphPad Prism.

MAIN RESULTS AND THE ROLE OF CHANCE

There was no significant difference in total or progressive sperm motility between any treatment and control groups at T2 or T24. Nonetheless, significant positive effects on sperm function were observed with AZD5904, with 16/45 (35.6%) samples (with both normal and abnormal baseline semen analysis characteristics) displaying a ≥20% increase in sperm penetrated through viscous media (P < 0.003).

LIMITATIONS, REASONS FOR CAUTION

This was an in vitro study.

WIDER IMPLICATIONS OF THE FINDINGS

Treatment with AZD5904 resulted in significant increased sperm penetration in one of three samples treated, which is likely to represent improvement in sperm function required for fertilization. We are now planning a clinical trial to validate these results and hope that this could represent a new treatment for male infertility.

STUDY FUNDING/COMPETING INTEREST(S)

AZD5904 was shared through the AstraZeneca Open Innovation program. The study was funded by AstraZeneca and sponsored by the University of Dundee. Additional funding was provided by Chief Scientist Office/NHS Research Scotland (S.J.M.d.S.). A.W. and H.J.S. are both full time employees of AstraZeneca. A.W. and H.J.S. are inventors on a patent filed by AstraZeneca titled MPOi for use in medicine which includes MPOi for use in the treatment of male infertility (WO 2019/016074 Al). S.J.M.d.S. is Associate Editor of Human Reproduction and Editorial Board member of Reproduction & Fertility. C.L.R.B. is Editor of RBMO and has received lecturing fees from Merck and Ferring and is on the Scientific Advisory Panel for Ohana BioSciences. C.L.R.B. was chair of the World Health Organization Expert Synthesis Group on Diagnosis of Male infertility (2012-2016). C.L.R.B. has a patent WO2013054111 A1 issued. The other authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Cardiac arrhythmias and electrophysiologic responses during spontaneous hyperglycaemia in adults with type 1 diabetes mellitus

AIM

We examined the effect of spontaneous hyperglycaemia in adults with type 1 diabetes mellitus (T1DM) and without history of cardiovascular disease on heart rate variability (HRV), cardiac repolarisation and incidence of cardiac arrhythmias.

METHODS

Thirty-seven individuals with T1DM (age 17-50 years, 19 males, mean duration of diabetes 19.3 SD(9.6) years) underwent 96 h of simultaneous ambulatory 12-lead Holter ECG and blinded continuous interstitial glucose (IG) monitoring (CGM). HRV, QT interval and cardiac repolarisation were assessed during hyperglycaemia (IG ≥ 15 mmol/l) and compared with matched euglycaemia (IG 5-10 mmol/l) on a different day, separately during the day and night. Rates of arrhythmias were assessed by calculating incidence rate differences.

RESULTS

Simultaneous ECG and CGM data were recorded for 2395 hours. During daytime hyperglycaemia vs euglycaemia the mean QT_c interval duration was 404 SD(21)ms vs 407 SD(20)ms, P = 0.263. T-peak to T-end interval duration corrected for heart rate (T_pT_endc) shortened: 74.8 SD(16.1)ms vs 79.0 SD(14.8)ms, P = 0.033 and T-wave symmetry increased: 1.62 SD(0.33) vs 1.50 SD(0.39), P = 0.02. During night-time hyperglycaemia vs euglycaemia, the mean QT_c interval duration was 401 SD(26)ms vs 404 SD(27)ms, P = 0.13 and T_pT_end shortened: 62.4 SD(12.0)ms vs 67.1 SD(11.8)ms, P = 0.003. The number of cardiac arrhythmias was low and confined to bradycardia and isolated ectopic beats. A considerable inter-subject and diurnal variability was observed.

CONCLUSIONS

Hyperglycaemia in individuals with T1DM without known cardiovascular disease was not associated with clinically important cardiac arrhythmias.

Abstract P2-09-02: Modulation of the immune microenvironment in high risk DCIS by intralesional injection of anti-PD-1 (pembrolizumab)

Background. Ductal carcinoma in situ (DCIS) is a risk factor for the subsequent development of invasive breast cancer. Features of DCIS that are associated with a high risk of a subsequent event include large size (&gt; 5 cm), high grade, comedo necrosis, palpable mass, hormone receptor negativity, and HER2 positivity. We have previously shown that immune infiltrates are positively associated with these high-risk features, suggesting that manipulating the immune microenvironment in high-risk DCIS, for example via checkpoint blockade, could potentially alter disease progression.

Methods. In this phase 1 pilot study we investigated changes in the immune microenvironment of high risk DCIS after intralesional injection of anti-PD-1 (pembrolizumab). Study participants received 2 intralesional injections of pembrolizumab, 3 weeks apart, with surgery approximately 3 weeks after the 2nd dose. The study started with a dose of 2 mg/injection (1/100 of the standard 200 mg iv dose), then escalated to 4 mg and 8 mg, with 3 patients at each dose. Tissue samples from pre-treatment biopsies and post-treatment surgical resections were stained with two 6-plex immune panels using Opal immunofluorescence reagents (Perkin Elmer) on a fully automated Ventana Discovery platform, imaged with a Vectra 3 system and analyzed with inForm software (Perkin Elmer). An algorithm for tumor/stroma segmentation developed in inForm was used to randomly select 10 high power fields (hpfs) for imaging. Cell phenotype maps were generated for each of these hpfs for each sample. Cell densities were determined per area of stroma, DCIS, or total tissue and averaged across all hpfs for a given case. Spatial analyses were performed to quantitate co-localization of immune cells with DCIS cells.

Results. The intralesional injections were easily administered and well tolerated. No systemic toxicities were observed at any dose. MRI imaging demonstrated no change in the size of lesions after treatment. Multiplex immunofluorescence analyses demonstrated heterogeneous responses ranging from dramatic increases in T cells, in particular CD8+ T cells, in cases which had a T cell infiltrate prior to therapy, to no post-therapy T cell infiltrate in cases with a pre-therapy immune desert. We also observed increases in B cells and macrophages and a decrease in the ratio of FoxP3+ T cells to CD8+ T cells, the latter mainly due to a significant increase in CD8+ cells, as opposed to a decrease in FoxP3+ cells. Spatial analyses indicated that in some cases, despite a marked increase in T cells post therapy, these cells did not co-localize with DCIS cells, indicating a state of immune exclusion.

Conclusions. We have demonstrated the safety and feasibility of intralesional injection of an immune checkpoint inhibitor (pembrolizumab) in high risk DCIS. In some patients we observed a dramatic change in the immune microenvironment, with an increase in T cells, B cells, and macrophages, and a decrease in the FoxP3:CD8 ratio, even at a dose that is 1/100 of the standard intravenous clinical dose. An expansion study is underway in which patients will receive 4 injections of pembrolizumab at 3 week intervals prior to going to surgery to determine if more injections/time will increase response rate.

Citation Format: Campbell MJ, McCune E, Rothschild H, Bolen J, VandenBerg S, Chien J, Wong J, Esserman L. Modulation of the immune microenvironment in high risk DCIS by intralesional injection of anti-PD-1 (pembrolizumab) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-09-02.

Abstract P4-06-02: Chemoimmunotherapy with cyclophosphamide plus a toll-like receptor 9 (TLR9) agonist eradicates triple negative breast cancer in a murine model

Background. Toll-like receptors (TLR) recognize conserved molecular patterns expressed by microbes and together with other molecular sensors serve as a first line of defense, inducing soluble and cellular mediators of innate immunity and initiating key steps of an adaptive immune response. The use of TLR agonists for therapeutic purposes relies on the ability of these compounds to induce, at least partially, some of the immune events that occur during natural infections. For example, synthetic CpG-containing oligodeoxynucleotides (ODN) act as TLR9 agonists, mimicking stimulation of the immune system by bacterial or viral DNA. CpG ODNs are being developed for cancer immunotherapy based on their capacity to stimulate innate and adaptive anti-tumor responses. In this study, we examined the efficacy of intratumorally administered CpG-ODN 1826 alone or in combination with immunomodulatory antibodies (anti-PD-1, anti-OX40, anti-CTLA4) or chemotherapy (cyclophosphamide, paclitaxel) in the syngeneic mouse 4T1 breast tumor model.

Methods. Tumors were implanted orthotopically in the mammary fat pads on the left and right flanks while only one tumor was injected with CpG-ODN 1826. Therapy began 12-14 days post tumor injection when tumors were 8-10 mm in diameter. CpG-ODN 1826 (100 ug) was administered intratumorally, while immunomodulatory antibodies (anti-PD-1 [200 ug], anti-CTLA4 [100 ug], anti-OX40 [400 ug]) and chemotherapies (cyclophosphamide [150 mg/kg], paclitaxel [10 mg/kg]) were administered intraperitoneally. Tumor volume was monitored on both flanks to assess direct and abscopal/systemic anti-tumor activity. Tumor tissue obtained during the treatment regimen was used to evaluate therapy-induced changes in the immune microenvironment.

Results. CpG-ODN 1826, administered intratumorally over 5 consecutive days induced complete regressions in ˜50% of the treated tumors, but only delayed growth in the distant lesions. The immunomodulatory antibodies had little effect on their own and did not add to the therapeutic efficacy of CpG-ODN 1826. The best therapeutic efficacy was obtained with a combination of weekly cyclophosphamide + CpG-ODN 1826 resulting in complete regression of both the CpG injected tumors and the contralateral tumors in 100% of the mice.

Conclusions. These data support the clinical investigation of the combination of a TLR9 agonist (CpG-ODN) with cyclophosphamide in women with breast cancer.

Citation Format: Campbell MJ, Tandon V, Senman B, Li J, Esserman L. Chemoimmunotherapy with cyclophosphamide plus a toll-like receptor 9 (TLR9) agonist eradicates triple negative breast cancer in a murine model [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-02.

A randomised controlled trial is not a pilot trial simply because it uses a surrogate endpoint

BACKGROUND

It has been argued that true endpoints (or 'hard' endpoints) for clinical trials, which are meaningful to clinicians, researchers and patients alike, are limited to those that measure health status, survival and cost. Other endpoints are termed 'surrogate' endpoints and are intended to substitute and predict the true endpoint.  A number of trials that describe using surrogate endpoints use the term 'pilot' in the title of the paper but the reason for this, as related by the authors, is the use of these surrogate endpoints in the trial. The conduct and reporting of such a trial may follow the traditional pattern for a conventional randomised controlled trial (RCT) as defined by the original CONSORT statement, with power-based sample size calculations, and significance tests of the results. However, this is contrary to the guidelines of the CONSORT extension for the reporting of pilot trials.

MAIN BODY

We review the definition of a surrogate endpoint and the use of surrogate endpoints in clinical trials. We consider to what extent a trial could be considered a pilot trial if it uses a surrogate endpoint and discuss two examples that illustrate current practice.

CONCLUSION

Trials which use surrogate endpoints should only be described as 'pilot' when a definitive trial is a distinct possibility and the authors consider conditions which would indicate whether the definitive main trial was worthwhile and feasible. Simply because a trial uses a surrogate endpoint is not justification for calling it a pilot trial.

Chronic obstructive pulmonary disease in Welsh slate miners

BACKGROUND

Exposure to respirable crystalline silica (RCS) causes emphysema, airflow limitation and chronic obstructive pulmonary disease (COPD). Slate miners are exposed to slate dust containing RCS but their COPD risk has not previously been studied.

AIMS

To study the cumulative effect of mining on lung function and risk of COPD in a cohort of Welsh slate miners and whether these were independent of smoking and pneumoconiosis.

METHODS

The study was based on a secondary analysis of Medical Research Council (MRC) survey data. COPD was defined as forced expiratory volume in 1 s/forced vital capacity (FEV₁/FVC) ratio <0.7. We created multivariable models to assess the association between mining and lung function after adjusting for age and smoking status. We used linear regression models for FEV₁ and FVC and logistic regression for COPD.

RESULTS

In the original MRC study, 1255 men participated (726 slate miners, 529 unexposed non-miners). COPD was significantly more common in miners (n = 213, 33%) than non-miners (n = 120, 26%), P < 0.05. There was no statistically significant difference in risk of COPD between miners and non-miners when analysis was limited to non-smokers or those without radiographic evidence of pneumoconiosis. After adjustment for smoking, slate mining was associated with a reduction in %predicted FEV₁ [β coefficient = -3.97, 95% confidence interval (CI) -6.65, -1.29] and FVC (β coefficient = -2.32, 95% CI -4.31, -0.33) and increased risk of COPD (odds ratio: 1.38, 95% CI 1.06, 1.81).

CONCLUSIONS

Slate mining may reduce lung function and increase the incidence of COPD independently of smoking and pneumoconiosis.

Tibialis anterior surface EMG parameters change before force output in multiple sclerosis patients

Neuromuscular function has been studied in multiple sclerosis patients with differing levels of disability. Force during maximal voluntary ankle dorsiflexion and surface EMG in tibialis anterior for weakest and strongest legs in 31 patients was compared with 16 control subjects. In the most mildly affected patients strength of dorsiflexion for the strongest leg was not significantly different from that of controls, but integrated mean EMG and median frequency of the power spectrum were significantly lower. In all other patient groups, all parameters measured were different from control values. Results indicate an important change in neuromuscular parameters which precedes loss of the ability to recruit normal force levels. Such changes may imply that the muscles of multiple sclerosis patients are affected even before there is significant evidence of neural motor dysfunction.

Stepped wedge cluster randomised trials: a review of the statistical methodology used and available

BACKGROUND

Previous reviews have focussed on the rationale for employing the stepped wedge design (SWD), the areas of research to which the design has been applied and the general characteristics of the design. However these did not focus on the statistical methods nor addressed the appropriateness of sample size methods used.This was a review of the literature of the statistical methodology used in stepped wedge cluster randomised trials.

METHODS

Literature Review. The Medline, Embase, PsycINFO, CINAHL and Cochrane databases were searched for methodological guides and RCTs which employed the stepped wedge design.

RESULTS

This review identified 102 trials which employed the stepped wedge design compared to 37 from the most recent review by Beard et al. 2015. Forty six trials were cohort designs and 45 % (n = 46) had fewer than 10 clusters. Of the 42 articles discussing the design methodology 10 covered analysis and seven covered sample size. For cohort stepped wedge designs there was only one paper considering analysis and one considering sample size methods. Most trials employed either a GEE or mixed model approach to analysis (n = 77) but only 22 trials (22 %) estimated sample size in a way which accounted for the stepped wedge design that was subsequently used.

CONCLUSIONS

Many studies which employ the stepped wedge design have few clusters but use methods of analysis which may require more clusters for unbiased and efficient intervention effect estimates. There is the need for research on the minimum number of clusters required for both types of stepped wedge design. Researchers should distinguish in the sample size calculation between cohort and cross sectional stepped wedge designs. Further research is needed on the effect of adjusting for the potential confounding of time on the study power.

Abstract P5-08-12: Co-expression modules identified from published immune signatures reveals five distinct immune subtypes in breast cancer

Introduction

Immune modulating therapies offer an attractive novel approach in the treatment of breast cancer. There is a growing body of literature demonstrating that immune-related expression signatures predict breast cancer prognosis and chemo- and/or targeted therapy responsiveness. However, it is unclear how these signatures relate to one another. Here we evaluated 58 immune signatures in breast cancer and generated co-expression modules to classify patients into immune subtypes.

Methods

We evaluated 58 published expression signatures related to immune function in 5 breast cancer gene expression datasets (TCGA (n=817), METABRIC (n=1992), EMC344 (n=344), pooled triple negative: GSE31519 (n=579), pooled neoadjuvant chemotherapy treated: GSE25066 (n=508)). For each dataset, consensus clustering was used to subset the signatures based on their co-expression pattern. Signatures in the same consensus cluster across all 5 datasets were used to define immune modules. Module scores were computed as the average across their constituent signatures. Patients were classified into immune subtypes based on their module scores using consensus clustering. Overall survival (OS) differences between immune subtypes were assessed using Cox proportional hazard modeling in basal breast cancers from the METABRIC dataset (n=329).

Results

Consensus clustering of the 58 expression signatures consistently yields four distinct co-expression modules across the five datasets. These modules appear to represent distinct immune components and signals, with constituent signatures relating to: 1) T-cells and/or B-cells (T/B-cell), 2) interferon (IFN), 3) transforming growth factor beta (TGFB), 4) core serum response, dendritic cells and/or macrophages (CSR). Of note, the T/B-cell module contains 20 of the 58 signatures evaluated; and the CSR module is highly correlated to proliferation (r=0.81). Subtyping of patients based on these co-expression modules consistently yields subsets that fall into five major immune subtypes. The expression pattern of the four modules within each immune subtype is summarized below:

 T/B-cellIFNTGFBCSRT/B-cell/IFN HighHighHighIntermediateIntermediateIFN/CSR HighLowHighLowHighImmune LowLowLowLowLowCSR HighLowLowLowHighTGFB HighLowLowHighLowImmune Co-expression Modules (columns); Immune Subtypes (rows)

These immune subtypes are associated with differences in overall survival in the METABRIC basal breast cancer cases, where the CSR High subtype has the worst outcome (10-year OS: 23%). In comparison, the subsets corresponding to the T/B-cell/IFN High subtype have better outcomes (Hazard ratio: 0.43, p = 0.018). In contrast, no significant outcome differences were observed between the poor outcome CSR-High subtype and the remaining three immune subtypes (p&gt;0.05).

Conclusion

Our exploratory study identified four distinct immune co-expression modules (T/B-cell, IFN, TGFB, or CSR) from a collection of published immune signatures. Using these modules, we identified 5 immune subtypes with prognostic significance in basal breast cancers. We propose to test representative signatures from the 4 modules and the combined immune subtypes as predictive biomarkers of response to immunotherapies.

Citation Format: Amara D, Wolf D, van 't Veer L, Esserman LJ, Campbell MJ, Yau C. Co-expression modules identified from published immune signatures reveals five distinct immune subtypes in breast cancer. [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 P5-08-12.

A cluster randomized controlled non-inferiority trial of 5-day Dose Adjustment for Normal Eating (DAFNE) training delivered over 1 week versus 5-day DAFNE training delivered over 5 weeks: the DAFNE 5 × 1-day trial

AIMS

To compare, in a randomized controlled non-inferiority trial, the outcomes of the traditional format for Dose Adjustment for Normal Eating structured education courses; that is, one delivered over 5 consecutive days (1-week course) with a variant of this format delivered 1 day a week for 5 consecutive weeks (5-week course).

METHODS

Adults with Type 1 diabetes, from seven UK Dose Adjustment For Normal Eating training centres, were individually randomized, stratified by centre, to receive either a 1-week or 5-week course. A qualitative study was embedded within the trial to explore patients' experiences.

RESULTS

In total, 213 patients were randomized and 160 completed the study procedures. In the per-protocol analysis, the difference in HbA1c levels (95% CI) between the arms at 6 months was 0.4 mmol/mol (-2.4, 3.1) or 0.03% (-0.22, 0.28) and -0.9 mmol/mol (-3.9, 2.2) or -0.08% (-0.36, 0.20) at 12 months. All confidence limits were within the non-inferiority margin of ± 5.5 mmol/mol (0.5%) for HbA1c %. For those patients with a baseline HbA1c of ≥ 58 mmol/mol (≥ 7.5%) the mean change (95% CI) in HbA1c was -2.2 mmol/mol (-4.0, -0.4) or -0.20% (-0.37, -0.04) at 6 months (P = 0.016), and -2.0 mmol/mol (-4.1, 0.04) or -0.18% (-0.37 to 0.004) at 12 months (P = 0.055). Episodes of severe hypoglycaemia were decreased by 82% [relative risk 0.18 (95% CI 0.03-0.936); P = 0.042], psychosocial outcomes improved significantly, and the difference between arms was not significant. Qualitative interviews showed that patients overwhelmingly favoured the format of course that they attended.

CONCLUSIONS

In summary, 5-week and 1-week Dose Adjustment for Normal Eating courses are equivalent in terms of biomedical and psychosocial outcomes, and we were persuaded that both course formats should be made available in routine care.

Adjusting for treatment switching in randomised controlled trials – A simulation study and a simplified two-stage method

Estimates of the overall survival benefit of new cancer treatments are often confounded by treatment switching in randomised controlled trials (RCTs) – whereby patients randomised to the control group are permitted to switch onto the experimental treatment upon disease progression. In health technology assessment, estimates of the unconfounded overall survival benefit associated with the new treatment are needed. Several switching adjustment methods have been advocated in the literature, some of which have been used in health technology assessment. However, it is unclear which methods are likely to produce least bias in realistic RCT-based scenarios. We simulated RCTs in which switching, associated with patient prognosis, was permitted. Treatment effect size and time dependency, switching proportions and disease severity were varied across scenarios. We assessed the performance of alternative adjustment methods based upon bias, coverage and mean squared error, related to the estimation of true restricted mean survival in the absence of switching in the control group. We found that when the treatment effect was not time-dependent, rank preserving structural failure time models (RPSFTM) and iterative parameter estimation methods produced low levels of bias. However, in the presence of a time-dependent treatment effect, these methods produced higher levels of bias, similar to those produced by an inverse probability of censoring weights method. The inverse probability of censoring weights and structural nested models produced high levels of bias when switching proportions exceeded 85%. A simplified two-stage Weibull method produced low bias across all scenarios and provided the treatment switching mechanism is suitable, represents an appropriate adjustment method.

Substantial reductions in the number of diabetic ketoacidosis and severe hypoglycaemia episodes requiring emergency treatment lead to reduced costs after structured education in adults with Type 1 diabetes

AIMS

To determine the impact of structured education promoting flexible intensive insulin therapy on rates of diabetic ketoacidosis, and the costs associated with emergency treatment for severe hypoglycaemia and ketoacidosis in adults with Type 1 diabetes.

METHODS

Using the Dose Adjustment For Normal Eating research database we compared the rates of ketoacidosis and severe hypoglycaemia during the 12 months preceding Dose Adjustment For Normal Eating training with the rates during the 12-month follow-up after this training. Emergency treatment costs were calculated for associated paramedic assistance, Accident and Emergency department attendance and hospital admissions.

RESULTS

Complete baseline and 1-year data were available for 939/1651 participants (57%). The risk of ketoacidosis in the 12 months after Dose Adjustment For Normal Eating training, compared with that before training, was 0.39 (95% CI: 0.23 to 0.65, P < 0.001), reduced from 0.07 to 0.03 episodes/patient/year. For every 1 mmol/mol unit increase in HbA1c concentration, the risk of a ketoacidosis episode increased by 6% (95% CI: 5 to 7%; 88% for a 1% increase), and for each 5-year increase in diabetes duration, the relative risk reduced by 20% (95% CI: 19 to 22%). The number of emergency treatments decreased for ketoacidosis (P < 0.001), and also for severe hypoglycaemia, including paramedic assistance (P < 0.001), Accident and Emergency department attendance (P = 0.029) and hospital admission (P = 0.001). In the study cohort, the combined cost of emergency treatment for ketoacidosis and severe hypoglycaemia fell by 64%, from £119,470 to £42,948.

CONCLUSIONS

Structured training in flexible intensive insulin therapy is associated with a 61% reduction in the risk of ketoacidosis and with 64% lower emergency treatment costs for ketoacidosis and severe hypoglycaemia.

Impact of a GP-led walk-in centre on NHS emergency departments

OBJECTIVE

To determine the impact of the GP-led walk-in centre (WIC) in Sheffield (England) on the demand for emergency department (ED) care.

METHODS

A survey of patients visiting the Sheffield GP WIC was conducted over 3 weeks during September and October 2011. A short, postvisit questionnaire was also sent to those who agreed to determine if the patient had used another NHS service for the same problem. Routine data were obtained from the adult and children's EDs and minor injuries unit in Sheffield, 1 year before and 1 year after the opening of the GP WIC. A linear model of the number of minor daytime attendances (GP type) per month was used to estimate the impact of opening the GP WIC, after controlling for seasonal variation and a linear time trend.

RESULTS

A total of 529 patients responded to the survey (response rate 51%). Based on their self-reported intentions, 64 of these patients (53 adults and 11 children) were diverted from going to ED in the 3-week survey period as a result of the establishment of the GP WIC. From this we would have expected around a 26% monthly reduction in GP-type attendances at adult ED, and 7% reduction at children's ED. However, routine data only showed an 8% (95% CI 1% to 16%) reduction at the adult ED. Reductions in GP-type attendances at the children's ED and the minor injury unit at the time of the opening of the GP WIC were also found, but were not statistically significant. The estimated impact on children's ED was a 14% reduction (95% CI -38% to 8%), and for minor injuries unit (MIU) a 4% reduction (95% CI -18 to 9%).

CONCLUSIONS

There was a statistically significant reduction in GP-type daytime attendances at the adult ED after the opening of the GP WIC. Since this reduction was not mirrored in changes in night-time attendances (when the GP WIC was closed), and our survey responses suggested some people were diverted from going to the ED, it is possible that the opening of the GP WIC caused this reduction.

Abstract P5-01-06: Remodeling the tumor immune microenvironment via intratumoral administration of immunomodulatory agents

Background: Immune dysregulation has been implicated in the poor outcomes associated with high grade and/or triple negative (Tneg) breast cancers. This suggests that a multi-modal approach to stimulating the immune system could be an effective therapeutic strategy for Tneg breast cancer. However, many immunotherapeutic agents demonstrate significant toxicities when administered systemically at high doses. Therefore, we investigated the therapeutic efficacy of local, intratumoral administration of immunomodulators in a mouse model of Tneg breast cancer.

Methods: 4T1, an aggressive, Tneg mammary carcinoma, was implanted orthotopically into syngeneic BALB/c mice. Treatment was initiated when tumors were 0.5-1.0 cm in the largest dimension. We examined various combinations of Toll-like receptor agonists (CpG oligonucleotide [TLR9] and imiquimod [TLR7]) with immunomodulatory antibodies (anti-CD40, anti-CTLA-4, anti-OX40). These agents were administered intratumorally (i.t.), either in PBS or formulated in an in situ depot forming drug delivery system. Growth of the injected tumors was monitored over time. In some experiments, tumors and spleens were harvested 3-10 days post therapy and analyzed for the presence of CD4+ T cells, CD8+ T cells, immunoregulatory T cells (Treg), and myeloid derived suppressor cells (MDSC). To test whether local immunotherapy generates a systemic antitumor immune response, 4T1 tumors were implanted at 2 sites on opposite sides of the mice, with one (left) used as the site of in situ immunomodulation (i.t. injections) and the other (right) observed to assess the systemic antitumor immune response.

Results: Intratumoral administration of various combinations of immunomodulators resulted in complete regression of the injected tumor. These regressions were associated with a reduction in the number of MDSCs in the tumor as well as activation of both CD4+ and CD8+ T cells. Furthermore, local immunotherapy generated a systemic antitumor immune response that inhibited tumors growing at a distant site.

Conclusions: Our findings demonstrate that remodeling the tumor immune microenvironment via intratumoral administration of immunomodulatory agents elicits antitumor immunity that eradicates tumor cells locally as well as systemically at distant sites. The prospect of delivering immunotherapeutics only where it matters most, namely within the tumor microenvironment, is extremely attractive as this would likely be substantially less toxic and more specific than many of the current cancer treatments. Ongoing studies include identifying companion diagnostics that can indicate which patients would benefit most from such an immunotherapeutic approach.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-01-06.

Biology of breast cancer in Nigerian women: a pilot study

BACKGROUND

Compared to the developed world, there are relatively few studies that describe the tumor biology of breast cancer in African women. While little is known about the tumor biology, clinical and epidemiologic studies suggest that breast cancer in African women are characterized by presentation at late stage and poor clinical outcomes. Analysis of the biological features of breast cancers in Nigerian women was designed to bring additional insight to better understand the spectrum of disease, the phenotypes that present, and the types of interventions that might improve outcomes.

MATERIALS AND METHODS

We performed histological analyses for hormone receptors (estrogen and progesterone receptors), HER2, and tumor infiltrating macrophages (TAM) on 17 breast cancers, obtained from Abia State University Teaching Hospital (Aba, Nigeria), between November 2008 and October 2009. On a subset of these cases, we investigated the potential role of a virus in the etiology of these aggressive cancers.

RESULTS

The majority of cases in this cohort were characterized as high grade (100% were grade III), triple-negative (65%), and occur in young women (mean age 47 years). We observed high infiltration of TAMs in these tumors, but no evidence of a viral etiology.

CONCLUSION

Our findings indicate that breast cancers in Nigerian women have a highly aggressive phenotype (high grade, hormone receptor negative), which is similar to other studies from Africa and other developing nations, as well as from African American women, but is significantly different from Caucasian women in the developed world. The presence of high numbers of TAMs in these tumors raises the possibility of targeting the immune microenvironment for therapeutic interventions.

The development and validation of a clinical prediction model to determine the probability of MODY in patients with young-onset diabetes

AIMS/HYPOTHESIS

Diagnosing MODY is difficult. To date, selection for molecular genetic testing for MODY has used discrete cut-offs of limited clinical characteristics with varying sensitivity and specificity. We aimed to use multiple, weighted, clinical criteria to determine an individual's probability of having MODY, as a crucial tool for rational genetic testing.

METHODS

We developed prediction models using logistic regression on data from 1,191 patients with MODY (n = 594), type 1 diabetes (n = 278) and type 2 diabetes (n = 319). Model performance was assessed by receiver operating characteristic (ROC) curves, cross-validation and validation in a further 350 patients.

RESULTS

The models defined an overall probability of MODY using a weighted combination of the most discriminative characteristics. For MODY, compared with type 1 diabetes, these were: lower HbA(1c), parent with diabetes, female sex and older age at diagnosis. MODY was discriminated from type 2 diabetes by: lower BMI, younger age at diagnosis, female sex, lower HbA(1c), parent with diabetes, and not being treated with oral hypoglycaemic agents or insulin. Both models showed excellent discrimination (c-statistic = 0.95 and 0.98, respectively), low rates of cross-validated misclassification (9.2% and 5.3%), and good performance on the external test dataset (c-statistic = 0.95 and 0.94). Using the optimal cut-offs, the probability models improved the sensitivity (91% vs 72%) and specificity (94% vs 91%) for identifying MODY compared with standard criteria of diagnosis <25 years and an affected parent. The models are now available online at www.diabetesgenes.org .

CONCLUSIONS/INTERPRETATION

We have developed clinical prediction models that calculate an individual's probability of having MODY. This allows an improved and more rational approach to determine who should have molecular genetic testing.

P4-09-19: PCNA+ Tumor Associated Macrophages Are Associated with M1 and M2 Gene Expression, and Confer Poor Prognosis in the Absence of Anti-Tumor Immune Environment

Background

Tumor associated macrophages (TAMs) promote breast tumor progression through the production of angiogenic factors, stromal breakdown factors, and the suppression of adaptive immunity. TAMs are recruited from the circulation to the tumor site, and can undergo a spectrum of phenotypic changes, with two contrasting activation states described in the literature: the M1 anti-tumoral and M2 pro-tumoral phenotypes. We previously identified a population of PCNA+ TAMs associated with high grade, hormone receptor (HR) negative tumors with poor outcomes. We hypothesized that high PCNA+ TAMs would be associated with expression of M2 related genes.

Methods

We used immunohistochemistry to measure PCNA+ TAM levels (double positive for PCNA and CD68) in 135 invasive breast cancer cases from the I-SPY 1 Trial, a prospective neoadjuvant trial with serial core biopsies and gene array data. We developed gene-sets representing M1 related, M2 related, and anti-tumoral immune response (represented by cytotoxic T cells and MHC Class II) genes based on literature review. We compared PCNA+ TAM levels, expression of these gene-sets, and outcomes.

Results

Higher than mean PCNA+ TAM counts were associated with increasing grade (p &lt; 0.001), HR negativity (p &lt; 0.001), and decreased recurrence free survival (RFS, p = 0.05). Among subjects who had a pathologic complete response (pCR), there was no difference in RFS between those with high versus low PCNA+ TAMs. Among subjects without pCR, those with high PCNA+ TAMs had significantly worse RFS than those with low PCNA+ TAMs (p = 0.0028). In the 95 subjects with both PCNA+ TAM results and gene expression arrays available, high PCNA+ TAM levels were associated with more M1 than M2 related genes. The gene-set representing anti-tumoral immune environment was not by itself associated with RFS. However, those subjects with both high PCNA+ TAMs and the absence of anti-tumoral immune response gene expression had significantly worse RFS than those with high PCNA+ TAMs but the presence of anti-tumoral immune related genes (p = 0.01).

Seasonality of medical contacts in school-aged children with asthma: association with school holidays

OBJECTIVES

To assess the seasonality of medical contacts in children with asthma, to compare England with Scotland, and to assess the impact of medication compliance on the frequency of medical contacts.

STUDY DESIGN

A retrospective study taken from the General Practice Research Database of daily medical contacts from 1999 to 2005 in a population of school-aged (5-16 years) children with a diagnosis of asthma, and age- and gender-matched controls.

PRIMARY OUTCOME MEASURE

All unscheduled medical contacts. Prescription frequency for inhaled corticosteroids over the same period was also assessed.

RESULTS

Data from 76,924 children were analyzed. There was an increase in unscheduled medical contacts for all children on return to school in September. Unscheduled medical contacts occurred almost twice as frequently in children with asthma compared with non-asthmatic children. The frequency of medical contacts in children with asthma could be predicted from the frequency of medical contacts in non-asthmatic children. In the 3 months from September to December, unscheduled medical contacts were disproportionately greater than would be predicted for children with asthma relative to non-asthmatic children in both England and Scotland. The rise in medical contacts in Scotland preceded that in England by approximately 14 days, reflecting the earlier date for returning to school. The number of prescriptions for inhaled corticosteroids decreased in August. A higher incidence of unscheduled medical contacts was noted during September in those not receiving a prescription in August.

CONCLUSIONS

Returning to school after the summer break is associated with a sharp increase in unscheduled medical contacts in school-aged children, particularly in those with asthma. This follows a decrease in the number of prescriptions for inhaled corticosteroids. It is suggested that at least part of the excess numbers of unscheduled contacts in children with asthma is because they do not maintain their inhaled corticosteroids over the summer holidays.

Epidemiology of scabies prevalence in the U.K. from general practice records

BACKGROUND

Scabies is a contagious parasitic infestation which causes an allergic reaction to just a few mites.

OBJECTIVES

To examine the epidemiology of scabies consultations in the U.K. by age, sex, region of the country and time.

METHODS

Data were obtained from the THIN (The Health Information Network) database provided by EPIC U.K. in which each consultation episode is coded according to a 'READ' code. Data were available for 1997-2005 inclusive (9 years) for approximately 8·5% of the U.K. population from 12 regions of the U.K. We used harmonic analysis to model the data over time and derived cycle amplitudes and phases for each region in the U.K.

RESULTS

There was a significantly greater infestation rate among females with a relative risk of 1·24 (P < 0·001) relative to males. The age group 10-19 years had the highest infestation rates (with rates of 4·55 per 1000 and 5·92 per 1000 for males and females, respectively). The middle age groups had the smallest infestation rates. A cycle with length of between 15 and 17 years was derived, and the phase times of the cycles for each region suggested a progression of the disease originating from the North East, spreading to Northern parts of the U.K. and then to the Midlands and the South.

CONCLUSIONS

The study confirms earlier studies with regard to the age/sex distribution of scabies. We suggest a contagious pattern of spread of scabies infestation in the U.K. with an epidemic cycle length of 15-17 years.

Abstract P5-04-01: Expression of Genes Associated with the Innate Immune System and Response to Neoadjuvant Chemotherapy in Breast Cancer

Background: The efficacy of cancer chemotherapy is generally assessed by the ability to directly kill or inhibit the growth of cancer cells. However, there is evidence suggesting that anticancer immune responses also contribute to the efficacy of conventional chemotherapy. Recent studies have shown that chemotherapeutic agents (anthracyclines in particular) can elicit innate immune responses via the release of proteins from dying tumor cells that interact with Toll-like receptors (TLR) on macrophages (mΦ) and dendritic cells (DC). The subsequent induction of cytotoxic T cell responses leads to the elimination of residual cancer cells not killed by the chemotherapy. To test this idea of chemotherapy-induced immunogenic cell death in breast cancer, we examined gene expression data for women with breast cancer treated neoadjuvantly, starting with adriamycin, on the I-SPY TRIAL (2003-2006), to see if genes that predict this type of immune response would also predict complete pathologic response (pCR) Methods: A panel of 47 genes were selected, including those expressed by the cancer cells as well as infiltrating immune cells: TLR/mΦ/DC activating proteins, TLR signaling genes, chemokines & chemokine receptors, cytokines & cytokine receptors, and mO, DC, & T cells markers. This gene set was then evaluated using expression array data from the I-SPY TRIAL, available on both Affymetrix (n=) and Agilent (n= 153) platforms. Initial analyses were performed using the UCSC Cancer Genomics Browser, a suite of web-based tools to integrate, visualize and analyze cancer genomics/expression data and clinical data. Differentially expressed genes were compared between patients who achieved a pathological complete response (pCR) following neoadjuvant chemotherapy vs. those who did not. A second independent data set available on the Cancer Genomics browser served as a validation set. These data, from MD Anderson, included 133 patients treated with neoadjuvant therapy (TFAC) with available Affymetrix array data.

Results: Of the 47 selected genes, 1 was not present on the Affymetrix array and 7 were absent from the Agilent array. Twelve of the 46 genes (26%) on the Affymetrix array and 20 of the 40 genes (50%) on the Agilent array were significantly differentially expressed comparing responders vs. non-responders. Overall, 25 of the 47 genes (53%) were differentially expressed on one or both arrays. Gene set enrichment and Paradigm pathway inference analyses confirmed that these genes are significantly enriched among responders. In the validation set, 20 of 46 genes (43%) were significantly differentially expressed.

Conclusion: We identified a panel of genes associated with immunogenic cell death and demonstrated their differential expression in patients who responded to neoadjuvant chemotherapy vs. non-responders. These results suggest a role for the host immune system in the response to chemotherapy. If the success of currently used chemotherapies depends on synergistic interactions with the immune system, then a better understanding of the mechanisms involved in chemotherapy-induced immunogenic cell death will provide a foundation for the design of novel chemo-immunotherapeutic strategies for breast cancer treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-04-01.

Delivering the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis

OBJECTIVES

To assess the long term clinical and cost effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) intervention compared with usual care in people with newly diagnosed type 2 diabetes.

DESIGN

We undertook a cost-utility analysis that used data from a 12 month, multicentre, cluster randomised controlled trial and, using the Sheffield type 2 diabetes model, modelled long term outcomes in terms of use of therapies, incidence of complications, mortality, and associated effect on costs and health related quality of life. A further cost-utility analysis was also conducted using current "real world" costs of delivering the intervention estimated for a hypothetical primary care trust.

SETTING

Primary care trusts in the United Kingdom.

PARTICIPANTS

Patients with newly diagnosed type 2 diabetes.

INTERVENTION

A six hour structured group education programme delivered in the community by two professional healthcare educators.

MAIN OUTCOME MEASURES

Incremental costs and quality adjusted life years (QALYs) gained.

RESULTS

On the basis of the data in the trial, the estimated mean incremental lifetime cost per person receiving the DESMOND intervention is pound209 (95% confidence interval - pound704 to pound1137; euro251, -euro844 to euro1363; $326, -$1098 to $1773), the incremental gain in QALYs per person is 0.0392 (-0.0813 to 0.1786), and the mean incremental cost per QALY is pound5387. Using "real world" intervention costs, the lifetime incremental cost of the DESMOND intervention is pound82 (- pound831 to pound1010) and the mean incremental cost per QALY gained is pound2092. A probabilistic sensitivity analysis indicated that the likelihood that the DESMOND programme is cost effective at a threshold of pound20 000 per QALY is 66% using trial based intervention costs and 70% using "real world" costs. Results from a one way sensitivity analysis suggest that the DESMOND intervention is cost effective even under more modest assumptions that include the effects of the intervention being lost after one year.

CONCLUSION

Our results suggest that the DESMOND intervention is likely to be cost effective compared with usual care, especially with respect to the real world cost of the intervention to primary care trusts, with reductions in weight and smoking being the main benefits delivered.

Assessing quality of care from hospital case notes: comparison of reliability of two methods

OBJECTIVES

To determine which of the two methods of case note review provide the most useful and reliable information for reviewing quality of care.

DESIGN

Retrospective, multiple reviews of 692 case notes were undertaken using both holistic (implicit) and criterion-based (explicit) review methods. Quality measures were evidence-based review criteria and a quality of care rating scale.

SETTING

Nine randomly selected acute hospitals in England.

PARTICIPANTS

Sixteen doctors, 11 specialist nurses and three clinically trained audit staff, and eight non-clinical audit staff. ANALYSIS METHODS: Intrarater consistency, inter-rater reliability between pairs of staff using intraclass correlation coefficients (ICCs), completeness of criterion data capture and between-staff group comparison.

RESULTS

A total of 1473 holistic reviews and 1389 criterion-based reviews were undertaken. When the three same staff types reviewed the same record, holistic scale score inter-rater reliability was moderate within each group (ICC 0.46 to 0.52). Inter-rater reliability for criterion-based scores was moderate to good (ICC 0.61 to 0.88). Comparison of holistic review score and criterion-based score of case notes reviewed by doctors and by non-clinical audit staff showed a reasonable level of agreement between the two methods.

CONCLUSIONS

Using a holistic approach to review case notes, same staff groups can achieve reasonable repeatability within their professional groups. When the same clinical record was reviewed twice by the doctors, and by the non-clinical audit staff, using both holistic and criterion-based methods, there are close similarities between the quality of care scores generated by the two methods. When using retrospective review of case notes to examine quality of care, a clear view is required of the purpose and the expected outputs of the project.

Trials in primary care: statistical issues in the design, conduct and evaluation of complex interventions

Trials carried out in primary care typically involve complex interventions that require considerable planning if they are to be implemented successfully. The role of the statistician in promoting both robust study design and appropriate statistical analysis is an important contribution to a multi-disciplinary primary care research group. Issues in the design of complex interventions have been addressed in the Medical Research Council's new guidance document and over the past 7 years by the Royal Statistical Society's Primary Health Care Study Group. With the aim of raising the profile of statistics and building research capability in this area, particularly with respect to methodological issues, the study group meetings have covered a wide range of topics that have been of interest to statisticians and non-statisticians alike. The aim of this article is to provide an overview of the statistical issues that have arisen over the years related to the design and evaluation of trials in primary care, to provide useful examples and references for further study and ultimately to promote good practice in the conduct of complex interventions carried out in primary care and other health care settings. Throughout we have given particular emphasis to statistical issues related to the design of cluster randomised trials.

A phase I study of the nitroimidazole hypoxia marker SR4554 using 19F magnetic resonance spectroscopy

Background:

SR4554 is a fluorine-containing 2-nitroimidazole, designed as a hypoxia marker detectable with ¹⁹F magnetic resonance spectroscopy (MRS). In an initial phase I study of SR4554, nausea/vomiting was found to be dose-limiting, and 1400 mg m⁻² was established as MTD. Preliminary MRS studies demonstrated some evidence of ¹⁹F retention in tumour. In this study we investigated higher doses of SR4554 and intratumoral localisation of the ¹⁹F MRS signal.

Methods:

Patients had tumours ⩾3 cm in diameter and ⩽4 cm deep. Measurements were performed using ¹H/¹⁹F surface coils and localised ¹⁹F MRS acquisition. SR4554 was administered at 1400 mg m⁻², with subsequent increase to 2600 mg m⁻² using prophylactic metoclopramide. Spectra were obtained immediately post infusion (MRS no. 1), at 16 h (MRS no. 2) and 20 h (MRS no. 3), based on the SR4554 half-life of 3.5 h determined from a previous study. ¹⁹Fluorine retention index (%) was defined as (MRS no. 2/MRS no. 1)*100.

Results:

A total of 26 patients enrolled at: 1400 (n=16), 1800 (n=1), 2200 (n=1) and 2600 mg m⁻² (n=8). SR4554 was well tolerated and toxicities were all ⩽grade 1; mean plasma elimination half-life was 3.7±0.9 h. SR4554 signal was seen on both unlocalised and localised MRS no. 1 in all patients. Localised ¹⁹F signals were detected at MRS no. 2 in 5 out of 9 patients and 4 out of 5 patients at MRS no. 3. The mean retention index in tumour was 13.6 (range 0.6–43.7) compared with 4.1 (range 0.6–7.3) for plasma samples taken at the same times (P=0.001) suggesting ¹⁹F retention in tumour and, therefore, the presence of hypoxia.

Conclusion:

We have demonstrated the feasibility of using ¹⁹F MRS with SR4554 as a potential method of detecting hypoxia. Certain patients showed evidence of ¹⁹F retention in tumour, supporting further development of this technique for detection of tumour hypoxia.

Recurrence rates for sudden infant death syndrome (SIDS): the importance of risk stratification

OBJECTIVE

To investigate the importance of stratification by risk factors in computing the probability of a second death from sudden infant death syndrome (SIDS) in a family.

DESIGN

Simulation study.

BACKGROUND

The fact that a baby dies suddenly and unexpectedly means that there is a raised probability that the baby's family have risk factors associated with SIDS. Thus one cannot consider the risk of a subsequent death to be that of the general population. The Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) identified three major social risk factors: smoking, age<27 and parity>1, and unemployed/unwaged as major risk factors. It gave estimates of risk for families with different numbers of these risk factors. We investigate whether it is reasonable to assume that, conditional on these risk factors, the risk of a second event is independent of the risk of the first and as a consequence one can square the risks to get the risk of two SIDS in a family. We have used CESDI data to estimate the probability of a second SID in a family under different plausible scenarios of the prevalence of the risk factors. We have applied the model to make predictions in the Care of Next Infant (CONI) study.

RESULTS

The model gave plausible predictions. The CONI study observed 18 second SIDS. Our model predicted 14 deaths (95% prediction interval 7 to 21).

CONCLUSION

When considering the risk of a subsequent SIDS in a family one should always take into account the known risk factors. If all risks have been identified, then conditional on these risks, the risk of two events is the product of the individual risks. However, for a given family we cannot quantify the magnitude of the increased risk because of other possible risk factors not accounted for in the model.

Evaluating the efficacy of acupuncture in defined aspects of stroke recovery: a randomised, placebo controlled single blind study

OBJECTIVE

To investigate the efficacy of acupuncture on stroke recovery compared to an inert placebo.

DESIGN

Placebo-controlled, randomised, clinical trial.

SETTING

Post-stroke rehabilitation wards in five NHS hospitals in the UK.

SUBJECTS

Patients between 4 and 10 days after their first stroke.

INTERVENTIONS AND OUTCOME MEASURES

The patients received 12 acupuncture or placebo treatments over four weeks. Acupuncture with electrical stimulation was compared with mock TENS, and assessments continued for 12 months after entry. Primary outcome was the Barthel Index (BI). Secondary outcomes were muscle power, Motricity Index (MI), mood, Nottingham Health Profile (NHP) and treatment credibility.

RESULTS

92 patients completed data sets. Data were analysed using both t tests and a structural equation based on longitudinal analysis of both BI and MI, using generalised estimating equations with an exchangeable correlation structure. While both acupuncture and placebo (mock TENS) appeared to have had an equal effect on stroke recovery, there is no significant difference between the two interventions at 12 (p = 0.737, 95 % CI -2.00 to 2.81) and 52 weeks (p = 0.371, 95 % CI -3.48 to 1.32). An apparently accelerated improvement in the MI scores in the acupuncture group at 3 weeks (p = 0.009, 95 % CI 1.55 to 10.77) is interesting.

CONCLUSIONS

Acupuncture did not demonstrate specific efficacy over placebo and both groups did as well as normally expected with this condition.

How common is repeat sudden infant death syndrome?

Recurrence of sudden infant death syndrome (SIDS) is rare but may give rise to confusion and controversy because of the differential diagnoses of familial disease or covert homicide. We examine eight studies of recurrent SIDS published in English since 1970. These studies reported relative risks of recurrence, as compared with the population or with controls, ranging from 1.7 to 10.1. We assess the validity of the studies by three main criteria: accuracy of ascertainment, adequacy of investigation and matching of controls. We found that all the studies failed to meet these criteria, and we think that their flaws would have resulted mainly in overestimation of recurrence risk. We conclude that, although an increase in risk is probable on theoretical grounds, this risk cannot be quantified from the available evidence. We suggest that professionals should be cautious in their pronouncements on the chances of recurrence, and that parents who have lost a baby to SIDS can, with the exception of particularly vulnerable families, be reassured that the risk of recurrence is small.

Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes.

DESIGN

Multicentre cluster randomised controlled trial in primary care with randomisation at practice level.

SETTING

207 general practices in 13 primary care sites in the United Kingdom.

PARTICIPANTS

824 adults (55% men, mean age 59.5 years).

INTERVENTION

A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care.

MAIN OUTCOME MEASURES

Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months.

MAIN RESULTS

Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008).

CONCLUSION

A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes.

DESIGN

Multicentre cluster randomised controlled trial in primary care with randomisation at practice level.

SETTING

207 general practices in 13 primary care sites in the United Kingdom.

PARTICIPANTS

824 adults (55% men, mean age 59.5 years).

INTERVENTION

A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care.

MAIN OUTCOME MEASURES

Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months.

MAIN RESULTS

Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008).

CONCLUSION

A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes.

DESIGN

Multicentre cluster randomised controlled trial in primary care with randomisation at practice level.

SETTING

207 general practices in 13 primary care sites in the United Kingdom.

PARTICIPANTS

824 adults (55% men, mean age 59.5 years).

INTERVENTION

A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care.

MAIN OUTCOME MEASURES

Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months.

MAIN RESULTS

Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008).

CONCLUSION

A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

Developments in cluster randomized trials and Statistics in Medicine

The design and analysis of cluster randomized trials has been a recurrent theme in Statistics in Medicine since the early volumes. In celebration of 25 years of Statistics in Medicine, this paper reviews recent developments, particularly those that featured in the journal. Issues in design such as sample size calculations, matched paired designs, cohort versus cross-sectional designs, and practical design problems are covered. Developments in analysis include modification of robust methods to cope with small numbers of clusters, generalized estimation equations, population averaged and cluster specific models. Finally, issues on presenting data, some other clustering issues and the general problem of evaluating complex interventions are briefly mentioned.

Combining growth hormone releasing hormone-arginine and synacthen testing diminishes the cortisol response

OBJECTIVES

The GHRH/arginine test and short synacthen test (SST) have been validated as safe alternatives to the insulin tolerance test for the assessment of the GH reserve and hypothalamic-pituitary-adrenal axis integrity, respectively. However, these two tests are usually performed separately. The objective was to see whether the synacthen and GHRH/arginine tests could be combined to save time and blood samples and minimize inconvenience to patients.

PATIENTS/METHODS

Twenty-four consecutive patients with adult onset pituitary disease requiring pituitary function testing were randomized to receive sequentially and in random order a SST, a GHRH/arginine test, and a combined SST and GHRH/arginine test on three different visits separated by at least 1 wk.

RESULTS

There was no difference in basal cortisol or ACTH values for the SST done alone or during the combined test. However, when GHRH/arginine was given with synacthen, patients had a lower peak cortisol response with a mean difference of 116 nmol/liter (95% confidence interval, 52.54 to 179.37; P < 0.001), and one patient with a normal response on the SST had a subnormal cortisol response in the combined test. Similar lower peak cortisol responses were observed in males and females with combined test. The difference between the peak cortisol responses showed no significant correlation with age (r = 0.123; P = 0.58) or with the body mass index (r = -0.376; P = 0.09). There was no difference in GH measurements between the GHRH/arginine test done alone or in combination with the SST.

CONCLUSIONS

Combining the SST and GHRH/arginine test results in a lower cortisol response to synacthen. For this reason, the combined test cannot be recommended to assess the integrity of cortisol and GH reserve using current diagnostic criteria.

Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain

OBJECTIVE

To determine whether a short course of traditional acupuncture improves longer term outcomes for patients with persistent non-specific low back pain in primary care.

DESIGN

Pragmatic, open, randomised controlled trial.

SETTING

Three private acupuncture clinics and 18 general practices in York, England.

PARTICIPANTS

241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration.

INTERVENTIONS

10 individualised acupuncture treatments from one of six qualified acupuncturists (160 patients) or usual care only (81 patients).

MAIN OUTCOME MEASURES

The primary outcome was SF-36 bodily pain, measured at 12 and 24 months. Other outcomes included reported use of analgesics, scores on the Oswestry pain disability index, safety, and patient satisfaction.

RESULTS

39 general practitioners referred 289 patients of whom 241 were randomised. At 12 months average SF-36 pain scores increased by 33.2 to 64.0 in the acupuncture group and by 27.9 to 58.3 in the control group. Adjusting for baseline score and for any clustering by acupuncturist, the estimated intervention effect was 5.6 points (95% confidence interval -0.2 to 11.4) at 12 months (n = 213) and 8.0 points (2.8 to 13.2) at 24 months (n = 182). The magnitude of the difference between the groups was about 10%-15% of the final pain score in the control group. Functional disability was not improved. No serious or life threatening events were reported.

CONCLUSIONS

Weak evidence was found of an effect of acupuncture on persistent non-specific low back pain at 12 months, but stronger evidence of a small benefit at 24 months. Referral to a qualified traditional acupuncturist for a short course of treatment seems safe and acceptable to patients with low back pain.

TRIAL REGISTRATION

ISRCTN80764175 [controlled-trials.com].

Challenge with mammary tumor cells expressing MHC class II and CD80 prevents the development of spontaneously arising tumors in MMTV-neu transgenic mice

The HER-2/Neu oncogene has been implicated in human and mouse breast cancer. Indeed, transgenic MMTV-neu mice expressing this oncogene from the mammary tumor virus long terminal repeat develop spontaneous mammary tumors and die within 1 year of life. We have expressed the class II transactivator (CIITA) and/or the costimulatory molecule CD80 (B7.1) in a mammary carcinoma cell line (MCNeuA) derived from these mice. Class II transactivator directs the expression of MHC class II and the machinery for antigen processing and presentation by this pathway. When injected into MMTV-neu mice, tumor cells expressing CD80 or CD80 and CIITA, were rejected completely. In addition, following the rejection of dual expressing cells, 75% of the mice were protected against the development of subsequent spontaneous tumors. Cells expressing only CD80 or CIITA were not as effective as antitumor vaccines in preventing the development of spontaneous tumors. Thus, converting cancer cells into antigen presenting cells could represent an effective immunotherapy for breast cancer.