Tinkering with care: Implementing extended-release buprenorphine depot treatment for opioid dependence

We examine how extended-release buprenorphine depot (BUP-XR) is put to use and made to work in implementation practices, attending to how care practices are challenged and adapted as a long-acting technology is introduced into service in opioid agonist treatment (OAT) in Australia. Our approach is informed by ideas in science and technology studies (STS) emphasising the irreducible entanglement of care practices and technology, and in particular the concept of 'tinkering' as a practice of adaptation. To make our analysis, we draw on qualitative interview accounts (n = 19) of service providers involved in BUP-XR implementation across five sites. Our analysis considers the disruptive novelty of BUP-XR. Tinkering to make a novel technology work in practice slows down the expectation of implementation in relation to transformative innovation, despite the promise of dramatic or rapid change. Tinkering allowed for more open relations, for new care practices that departed from the routine and familiar, opening potential for how BUP-XR could be put to use and made to work in its new situation, and as its situation evolved along-with its implementation. Flexibility and openness of altering relations was, however, at times, held in tension with inflexibility and closure. This analysis identifies a concern for what is made present and what is made absent in the altered care network affected by BUP-XR, with the multiple effects of supervised daily dosing practices thrown into relief as they become absented. Tinkering to implement BUP-XR locally connects with a broader assemblage of trial and movement in the constitution of treatment. The introduction of long-acting technologies prompts new questions about embedded implementation practices, including supervised dosing, urinalysis, the time and place of psychosocial support, and how other social aspects of care might be recalibrated in drug treatment.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Extreme eutrophication and salinisation in the Coorong estuarine-lagoon ecosystem of Australia's largest river basin (Murray-Darling)

Estuaries in rainfall poor regions are highly susceptible to climatic and hydrological changes. The Coorong, a Ramsar-listed estuarine-coastal lagoon at the end of the Murray-Darling Basin (Australia), has experienced declining ecological health over recent decades. Twenty years of environmental data were analysed to assess patterns and drivers of water quality changes. Large areas of the Coorong are now persistently hyper-saline (salinity >80 psu) and hypereutrophic (total nitrogen, TN > 4 mg L^-1, total phosphorus, TP > 0.2 mg L^-1, chlorophyll a > 50 μg L^-1) which coincided with reduced flushing due to diminished freshwater inflows and increasing evapo-concentration. Sediment quality also was related to flushing, with higher concentrations of organic carbon, TN, TP and sulfides as salinity increased. While total nutrient levels are very high, dissolved inorganic nutrients are generally low. Increased lagoonal flushing would be beneficial to reduce the hypersalinisation and hypereutrophication and improve ecosystem health.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Warming and redistribution of nitrogen inputs drive an increase in terrestrial nitrous oxide emission factor

Anthropogenic nitrogen inputs cause major negative environmental impacts, including emissions of the important greenhouse gas N2O. Despite their importance, shifts in terrestrial N loss pathways driven by global change are highly uncertain. Here we present a coupled soil-atmosphere isotope model (IsoTONE) to quantify terrestrial N losses and N2O emission factors from 1850-2020. We find that N inputs from atmospheric deposition caused 51% of anthropogenic N2O emissions from soils in 2020. The mean effective global emission factor for N2O was 4.3 ± 0.3% in 2020 (weighted by N inputs), much higher than the surface area-weighted mean (1.1 ± 0.1%). Climate change and spatial redistribution of fertilisation N inputs have driven an increase in global emission factor over the past century, which accounts for 18% of the anthropogenic soil flux in 2020. Predicted increases in fertilisation in emerging economies will accelerate N2O-driven climate warming in coming decades, unless targeted mitigation measures are introduced.

Remote delivery of cardiac rehabilitation can achieve equivalent health-related quality of life outcomes to in-person methods in patients with coronary heart disease: a multi-site study

Funding Acknowledgements

Type of funding sources: None.

Background In-person exercise-based cardiac rehabilitation (CR) has well-established benefits for health-related quality of life (HRQL) for patients with coronary heart disease (CHD). During COVID-19 pandemic restrictions, remote delivery replaced in-person CR, but the impact on HRQL is unclear. This study addresses this gap.

Methods Consecutive patients commencing CR at four sites in one Local Health District in Sydney were recruited (n = 194), recruited from December 2019 to October 2020. Remote delivery from March 2020 created a natural comparison group to in-person CR. HRQL was measured at CR entry and completion using the SF-12v2 and linear regression was used for analyses.

Results Participants were aged mean 65.94 (SD 10.45) years, were 80.9% male and diagnoses included elective PCI (37.9%), CABG (26.7%), and MI (34.9%) either with PCI (23.6%) or alone (11.3%). Participants received remote (n = 103, 53.1%) or in-person (n = 91, 46.9%; ≥ assessment + 2 sessions) CR, with more completions for in-person (75.8% vs 63.1%, p=.03). Remote participants were more likely to be white than ethnic minority (35.2% vs 13.6% p<.001), however, there were no differences in baseline HRQL for delivery group after adjustment.

HRQL improved from CR entry to completion regardless of delivery mode (adjusted). Most improvements occurred in physical function (SMD 6.37, 95% CI 4.81,7.92), role physical (SMD 5.72, 95% CI 4.29. 7.16) and physical component (SMD 5.77 95% CI 4.43, 7.12) scores. Least improvement occurred in mental component scores (SMD 1.65, 95%CI .53, 2.78).

Conclusion Remotely delivered CR provides comparable HRQL outcomes to in-person delivery, thus providing a promising alternative. Data are needed on cost-effectiveness, as well as staff and patient preferences.

Developing "inverted-corona" fusion targets as high-fluence neutron sources

We present experimental studies of inverted-corona targets as neutron sources at the OMEGA Laser Facility and the National Ignition Facility (NIF). Laser beams are directed onto the inner walls of a capsule via laser-entrance holes (LEHs), heating the target interior to fusion conditions. The fusion fuel is provided either as a wall liner, e.g., deuterated plastic (CD), or as a gas fill, e.g., D₂ gas. Such targets are robust to low-mode drive asymmetries, allowing for single-sided laser drive. On OMEGA, 1.8-mm-diameter targets with either a 10-μm CD liner or up to 2 atm of D₂-gas fill were driven with up to 18 kJ of laser energy in a 1-ns square pulse. Neutron yields of up to 1.5 × 10¹⁰ generally followed expected trends with fill pressure or laser energy, although the data imply some mix of the CH wall into the fusion fuel for either design. Comparable performance was observed with single-sided (1x LEH) or double-sided (2x LEH) drive. NIF experiments tested the platform at scaled up dimensions and energies, combining a 15-μm CD liner and a 3-atm D₂-gas fill in a 4.5-mm diameter target, laser-driven with up to 330 kJ. Neutron yields up to 2.6 × 10¹² were measured, exceeding the scaled yield expectation from the OMEGA data. The observed energy scaling on the NIF implies that the neutron production is gas dominated, suggesting a performance boost from using deuterium-tritium (DT) gas. We estimate that neutron yields exceeding 10¹⁴ should be readily achievable using a modest laser drive of ∼300 kJ with a DT fill.

Direct-drive laser fusion: status, plans and future

Laser-direct drive (LDD), along with laser indirect (X-ray) drive (LID) and magnetic drive with pulsed power, is one of the three viable inertial confinement fusion approaches to achieving fusion ignition and gain in the laboratory. The LDD programme is primarily being executed at both the Omega Laser Facility at the Laboratory for Laser Energetics and at the National Ignition Facility (NIF) at Lawrence Livermore National Laboratory. LDD research at Omega includes cryogenic implosions, fundamental physics including material properties, hydrodynamics and laser-plasma interaction physics. LDD research on the NIF is focused on energy coupling and laser-plasma interactions physics at ignition-scale plasmas. Limited implosions on the NIF in the 'polar-drive' configuration, where the irradiation geometry is configured for LID, are also a feature of LDD research. The ability to conduct research over a large range of energy, power and scale size using both Omega and the NIF is a major positive aspect of LDD research that reduces the risk in scaling from OMEGA to megajoule-class lasers. The paper will summarize the present status of LDD research and plans for the future with the goal of ultimately achieving a burning plasma in the laboratory. This article is part of a discussion meeting issue 'Prospects for high gain inertial fusion energy (part 2)'.

Evidence of Three-Dimensional Asymmetries Seeded by High-Density Carbon-Ablator Nonuniformity in Experiments at the National Ignition Facility

Inertial confinement fusion implosions must achieve high in-flight shell velocity, sufficient energy coupling between the hot spot and imploding shell, and high areal density (ρR=∫ρdr) at stagnation. Asymmetries in ρR degrade the coupling of shell kinetic energy to the hot spot and reduce the confinement of that energy. We present the first evidence that nonuniformity in the ablator shell thickness (∼0.5% of the total thickness) in high-density carbon experiments is a significant cause for observed 3D ρR asymmetries at the National Ignition Facility. These shell-thickness nonuniformities have significantly impacted some recent experiments leading to ρR asymmetries on the order of ∼25% of the average ρR and hot spot velocities of ∼100  km/s. This work reveals the origin of a significant implosion performance degradation in ignition experiments and places stringent new requirements on capsule thickness metrology and symmetry.

Long-term effects of copper exposure to agricultural soil function and microbial community structure at a controlled and experimental field site

The long-term effect of heavy metals on soil microbial communities and their function is relatively unknown and little work has been done in field settings. To address this gap, we revisited a field-based experiment, 12 years after the application of copper (Cu) to agricultural soils, with treatment concentrations ranging from 0 to 3310 mg Cu kg^-1 soil. We measured the long-term effects of Cu exposure to soils using multiple functionality assessments and environmental DNA-based community analyses. The assessment results revealed that soils that received moderate to high Cu doses had still not recovered functionality 12-years post exposure. However, plots that received doses of 200 mg kg^-1 Cu or less appeared to have a functionality index not dissimilar to control plots. Environmental DNA analyses of the microbial communities revealed a high level of beta diversity in low Cu treatment plots, whereas communities within high Cu treatment plots had similar community structures to one another (low beta diversity), indicating that specific Cu-tolerant or dormant taxa are selected for in high-Cu environments. Interestingly, high Cu plots had higher within-sample taxa counts (alpha diversity) compared with controls and low Cu plots. We hypothesise that taxa in high Cu plots activated dormancy mechanisms, such that their genetic signal remained present, whilst the functionality of the soil was reduced. Many species identified in high Cu plots are known to have associated dormancy mechanisms and survive in high stress environments. Understanding how these mechanisms collectively contribute to contaminant outcomes is of great importance for the goals of predicting and managing microbial communities and their function. As we found that Cu concentrations above 200 mg kg^-1 can cause significant functionality loss and a selective pressure on microbial communities, it is recommended that Cu concentrations above 200 mg kg^-1are avoided in agricultural soils.

Multi-centre retrospective study of the long-term outcome following suspected traumatic elbow luxation in 32 cats

OBJECTIVES

To describe reduction techniques and clinical outcome in a series of traumatic elbow luxations in cats.

MATERIALS AND METHODS

Retrospective review of unilateral elbow luxations treated at five specialist referral centres. Data included signalment, aetiology, concurrent injuries, luxation direction, time to reduction, primary reduction technique, surgical procedure and complications. Cases were excluded if reduction technique was unknown. Telephone owner questionnaire follow-up was completed using a Feline Musculoskeletal Pain Index.

RESULTS

Thirty-two cats were included. Lateral luxations were most common (n = 21). Time (hours) until attempted initial closed reduction was <24 (n = 12), 24-48 (n = 13), >48 (n = 3) or unrecorded (n = 4). Luxation was treated by closed reduction alone (n = 7) or by surgery (n = 25); 14 of 25 cases underwent primary surgical reduction and 11 of 25 were secondary procedures following failure of closed reduction. Transcondylar bone tunnels and circumferential suture (n = 19) was the most commonly used surgical technique. Catastrophic (n = 1), major (n = 11) and minor complications (n = 5) were recorded; reluxation occurred more frequently after closed reduction (n = 8) than after open reduction with fixation (n = 0). Feline Musculoskeletal Pain Index data were available for 12 cats; outcome was good-excellent in all 12, with a median function score of 64.5/68 (range: 55-68) and a median pain score of 0/15 (range: 0-5). Outcome was not associated with reduction technique.

CLINICAL SIGNIFICANCE

Elbow reluxation occurred in 61% of cats following primary closed reduction but did not occur in any open reduction cases. Reluxation rate increased with duration from injury. Most cats had good-excellent owner-assessed outcome, regardless of reduction technique.

The natural history of canine occult Grade II medial patellar luxation: an observational study

OBJECTIVES

To determine the risk of lameness and the rate of subsequent medial patellar luxation surgery in dogs that present with occult Grade II medial patellar luxation.

MATERIALS AND METHODS

Retrospective owner survey and review of clinical records of adult dogs diagnosed with Grade II medial patellar luxation that were initially asymptomatic and managed non-surgically that had a minimum of 4-year follow-up. Clinical notes and owner questionnaires identified dogs that subsequently developed lameness and required surgery on the previously asymptomatic stifle.

RESULTS

Thirty-eight dogs were included with an average follow-up of 51 months. Seventeen dogs re-presented for unscheduled contralateral medial patellar luxation surgery at an average of 15 months after initial presentation. A further two dogs had chronic contralateral limb lameness after an average of 33 months after initial surgery and may have been potential surgical candidates.

CLINICAL SIGNIFICANCE

Fifty percent of adult dogs presenting with occult Grade II medial patellar luxation subsequently developed chronic lameness or required surgery.

Health care engagement behaviors of men who use performance- and image-enhancing drugs in Australia

Background: Although people who inject performance- and image-enhancing drugs (PIEDs) report fewer unsafe injecting practices, stigma and discrimination may negatively impact their access to help and information. Engagement with health care services, compared with social networks (friends, relatives, and gym associates) and the Internet and media (steroid user forums, information sites, and magazines), may be important for harm minimization. Methods: A cross-sectional Internet or in-person survey of men who use PIEDs in Australia in 2014-2015 examined differences in sources for PIEDs, injecting equipment, and anabolic-androgenic steroids (AAS) information and factors associated with having periodical medical checks related to PIEDs issues using multivariate logistic regression. Results: In total, 267 men (mean age: 25 years, SD: 8.7 years; 246 of 267 [92%] reported recent AAS injection) were recruited. Most participants sourced injecting equipment from health professionals, PIEDs from their social networks, and AAS information from the Internet and media. Self-reported AAS knowledge was high and frequent. Higher income (adjusted odds ratio [AOR]: 2.04, 95% confidence interval [CI]: 1.03, 4.00), ≥2 different PIEDs used in addition to AAS (AOR: 1.94, 95% CI: 1.08, 3.49), and sourcing AAS information from health care professionals (AOR: 3.14, 95% CI: 1.81, 5.46) were independently associated with periodical medical checks. Participants nominated preference for improved health services through needle-syringe programs, primary care services, and peer educator support groups. Conclusion: Men who use PIEDs in Australia consider themselves well informed but tend to use Internet and media sources, providing potentially misleading or inaccurate information. Increasing trust between men who use PIEDs and health care providers may enable delivery of PIEDs-specific information to those at greatest need.

Abstract P5-09-19: The complexity of germline panel testing: Cost, access and variant interpretation in an Irish context

Objectives

Diagnostic germline genetic testing of single or multiple cancer predisposition genes is increasingly central to the care of women with breast cancer. Testing for mutations in BRCA1/2 has therapeutic relevance in perioperative and metastatic settings. Variants of uncertain significance (VUS) are identified in approximately 5-20% of tests. Single gene testing in the Rep. of Ireland occurs through 3 clinics using laboratories in England. Panel testing is offered through Color Genomics and Myriad Genetics. Color genomics offers a less expansive panel test. Panels have made variant interpretation a common clinical challenge. We investigated interpretation of 10 VUS in 3 laboratories.

Methods

We selected 10 patients who had VUS reported in BRCA1/2 in NHS laboratories. Further diagnostic testing for mutations in BRCA1/2 was subsequently completed using BRACAnalysis on stored DNA from these individuals. Patients were re-contacted and offered Color panel testing for mutations in 30 genes. Previous test reports were not provided to either company. A review of all 10 BRCA1/2 VUS was performed on ClinVar database.

Results

Two VUS in BRCA1 and 8 VUS in BRCA2 were included in the study. Retesting was completed at a median time of 20mths (14-70mths) after the original testing. All 10 individuals underwent BRCAnalysis testing, only 7 had panel testing (2 did not make contact following calls/ letters, 1 had left Ireland). ClinVar classified 3 variants as benign, 2 likely benign, 2 VUS and 2 pathogenic (1not on ClinVar). All 10 VUS were re-classified by Myriad and Color. One result was deemed 'pathogenic' by Color and 'suspected deleterious' by Myriad (pt 9, table 1). Panel testing identified two additional VUS: an MSH6 and a RAD51.

Interpretation of testing CliniVarNHS laboratory testingMyriadColor GenomicsPtDatabase ReviewGeneexon BRACAnalysis30 gene panel test1Benign (2018)BRCA111c.3708T&gt;G, p.(Asn1236Lys)No deleterious mutationMSH6 VUS c.2585T&gt;A (p.Leu862Gln)2Benign (2015)BRCA111c.4910C&gt;T, p.(Pro1637Leu)No deleterious mutationNo mutations identified3Not on ClinVarBRCA211c.3037A&gt;G, p.(Lys1025Glu)No deleterious mutationNo mutations identified4Pathogenic (2016)BRCA23c.316+5G&gt;CDeleterious MutationNo sample submitted5VUS (2016)BRCA24c.343A&gt;G , p.(Lys115Glu)No deleterious mutationNo mutations identified6Likely benign (2016)BRCA211c.5635G&gt;A, p.(Glu1879Lys)No deleterious mutationRAD51D VUS c.26G&gt;C (p.Cys9Ser)7Benign (2017)BRCA211c.6821G&gt;T, p.(Gly2274Val)No deleterious mutationNo sample submitted8Likely Benign (2018)BRCA215c.7601C&gt;T, p.(Ala2534Val)No deleterious mutationvNo mutations identified9Pathogenic (2017)BRCA217c.7958T&gt;C, p.(Leu2653Pro)Suspected deleterious mutationBRCA2, c.7958T&gt;C, p.(Leu2653Pro) PATHOGENIC10VUS (2016)BRCA219c.8351G&gt;A, p.(Arg2784Gln)No deleterious mutationNo sample submitted

Conclusions

All 10 VUS in BRCA1/2 were reclassified with additional testing by two commercial laboratories at a later date. The results of this testing by two different companies are clinically concordant. Panel testing identified 2 additional VUS in potentially clinically relevant genes. Less expansive testing increases access to germline genetic testing but requires responsible interpretation.

Citation Format: O'Donovan EM, Farrell M, Gallagher D. The complexity of germline panel testing: Cost, access and variant interpretation in an Irish context [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 P5-09-19.

Pituitary Apoplexy in an Ectopic Pituitary Tumour

A case report of a patient with unilateral visual loss, due to infarction in an ectopic pituitary tumour, is presented. Good return of vision followed surgical removal of the tumour.

Pituitary tuberculoma: a rare cause of sellar mass

INTRODUCTION

Pituitary tuberculosis is an uncommon cause of sellar mass [1]; the estimated prevalence worldwide is not known, and there have been no reports of the condition occurring in Ireland. Tuberculosis of the pituitary gland may present as a sellar mass or with symptoms of hypopituitarism.

CASE PRESENTATION

A 41-year-old woman, with a short prodromal history without endocrine symptoms, was found to have pituitary tuberculosis after the demonstration of a sellar mass on MRI, and lumbar puncture findings consistent with lymphocytic meningitis.

CONCLUSION

To our knowledge, this is the first published case of pituitary tuberculoma in Ireland.

Growth of a progesterone receptor-positive meningioma in a female patient with congenital adrenal hyperplasia

Meningioma growth has been previously described in patients receiving oestrogen/progestogen therapy. We describe the clinical, radiological, biochemical and pathologic findings in a 45-year-old woman with congenital adrenal hyperplasia secondary to a defect in the 21-hydroxylase enzyme who had chronic poor adherence to glucocorticoid therapy with consequent virilisation. The patient presented with a frontal headache and marked right-sided proptosis. Laboratory findings demonstrated androgen excess with a testosterone of 18.1 nmol/L (0-1.5 nmol) and 17-Hydroxyprogesterone >180 nmol/L (<6.5 nmol/L). CT abdomen was performed as the patient complained of rapid-onset increasing abdominal girth and revealed bilateral large adrenal myelolipomata. MRI brain revealed a large meningioma involving the right sphenoid wing with anterior displacement of the right eye and associated bony destruction. Surgical debulking of the meningioma was performed and histology demonstrated a meningioma, which stained positive for the progesterone receptor. Growth of meningioma has been described in postmenopausal women receiving hormone replacement therapy, in women receiving contraceptive therapy and in transsexual patients undergoing therapy with high-dose oestrogen and progestogens. Progesterone receptor positivity has been described previously in meningiomas. 17-Hydroxyprogesterone is elevated in CAH and has affinity and biological activity at the progesterone receptor. Therefore, we hypothesise that patients who have long-standing increased adrenal androgen precursor concentrations may be at risk of meningioma growth.

LEARNING POINTS

Patients with long-standing CAH (particularly if not optimally controlled) may present with other complications, which may be related to long-standing elevated androgen or decreased glucocorticoid levels.Chronic poor control of CAH is associated with adrenal myelolipoma and adrenal rest tissue tumours.Meningiomas are sensitive to endocrine stimuli including progesterone, oestrogen and androgens as they express the relevant receptors.

Abstract P2-05-03: Whole genome transcriptome analysis of sequential breast to brain metastasis uncovers new signalling pathways and druggable targets

The occurrence of brain metastasis (BM) in breast cancer (BC) is currently on the rise across all molecular subtypes with 10-30% reported incidence. The need to uncover the mechanisms underlying this clinically devastating complication is apparent, and in the current study we sought to identify BC cell mediators of BM.

In our cohort of metastatic patients (n=196) we found that BM developed in 13% of the cases. Despite the previous reports of negative ER status being a risk factor for BM, the ER+ve patients accounted for 42% of all diagnosed BM. To elucidate the gene alterations required for successful colonisation of the brain we undertook RNA sequencing (RNA-seq) of sequential breast to brain metastasis of known receptor status (n=7).This study presents the first whole transcriptome next-generation RNA-seq analysis of resected BM and their matching primary breast tumours.

We identified 500 differentially expressed genes (DEGs) (&lt; 0.05, fcThreshold &gt;±1.5), accounting for those that were both upregulated and downregulated in BM compared to the primary. Analysis of protein-coding genes identified collective ER-specific metastatic pathways. Additionally, common functional pathways altered included ECM, cell adhesion and neuronal differentiation. Our analysis of the BM transcriptomic landscape and verification in cell line models that preferentially metastasise to the brain has unravelled a complex network of driver genes, cooperating with stromal derived factors, responsible for the organ-specific behaviour of the metastatic cells. Genes such as ANTRX1, THBS2, FAP, VCAN and TIMP2 were found to be part of the invasion and migration network that drives the extravasation of the BM cells. Furthermore, an EMT stemness signalling network driven by ANTRX1and WNT pathway driven RUNX was prominent in the cells acquiring the ability to migrate to the brain. Additional work is being carried out on uncovering the adaptations that re-activate the dormant brain metastatic cells and the contribution of the neuronal niche in the facilitating the colonisation by the MBC.

This study highlights the requirement of unique gene sets for the invasion, migration and colonisation to the brain and that functional characterisation of the DEGs will enable the identification of novel molecular targets for prevention and treatment of breast cancer BM.

Citation Format: Varešlija D, Fagan A, Buckley P, Farrell M, Hill A, Young L. Whole genome transcriptome analysis of sequential breast to brain metastasis uncovers new signalling pathways and druggable targets. [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 P2-05-03.

Chronic traumatic encephalopathy: a potential late and under recognized consequence of rugby union?

The association between exposure to head injury and increased risk of neurodegenerative disease, specifically chronic traumatic encephalopathy (CTE), is widely recognized. Historically, this was largely considered a phenomenon restricted to boxers, with more recent case series identifying further 'high risk' individuals, such as former American footballers, or military personnel. However, in all cases thus far reported, it is clear that it is the exposure to head injury which is associated with increased dementia risk, and not the circumstances or environment of exposure. As such, there is considerable potential for under-recognition of CTE in patients presenting with neurodegenerative disease, particularly where head injury exposure might have been historical and through sport. This article reviews current understanding of CTE and, via an illustrative case in rugby union, highlights the value of a detailed history on head injury and also draws attention to imaging studies in assessing patients with neurodegenerative disease.

The use of paracetamol (acetaminophen) among a community sample of people with chronic non-cancer pain prescribed opioids

BACKGROUND

The regular use of simple analgesics in addition to opioids such as paracetamol (or acetaminophen) is recommended for persistent pain to enhance analgesia. Few studies have examined the frequency and doses of paracetamol among people with chronic non-cancer pain including use above the recommended maximum daily dose.

AIMS

To assess (i) the prevalence of paracetamol use among people with chronic non-cancer pain prescribed opioids, (ii) assess the prevalence of paracetamol use above the recommended maximum daily dose and (iii) assess correlates of people who used paracetamol above the recommended maximum daily dose including: age, gender, income, education, pain severity and interference, use of paracetamol/opioid combination analgesics, total opioid dose, depression, anxiety, pain self-efficacy or comorbid substance use, among people prescribed opioids for chronic non-cancer pain.

METHODS

This study draws on baseline data collected for the Pain and Opioids IN Treatment (POINT) study and utilises data from 962 interviews and medication diaries. The POINT study is national prospective cohort of people with chronic non-cancer pain prescribed opioids. Participants were recruited from randomly selected pharmacies across Australia.

RESULTS

Sixty-three per cent of the participants had used paracetamol in the past week (95% CI = 59.7-65.8). Among the paracetamol users 22% (95% CI = 19.3-24.6) had used paracetamol/opioid combination analgesics and 4.8% (95% CI = 3.6-6.3) had used paracetamol above the recommended maximum daily dose (i.e. > 4000 mg/day). Following binomial logistic regression (χ(2) = 25.98, df = 10, p = 0.004), people who had taken above the recommended maximum daily dose were less likely to have low income (AOR = 0.52, 95% CI = 0.27-0.99), more likely to use paracetamol/opioid combination analgesics (AOR = 2.01, 95% CI = 1.02-3.98) and more likely to take a higher opioid dose (AOR = 1.00, 95% CI = 1.00-1.01).

CONCLUSION

The majority of people with chronic non-cancer pain prescribed opioids report using paracetamol appropriately. High income, use of paracetamol/opioid combination analgesics and higher opioid dose were independently associated with paracetamol use above the recommended maximum daily dose.

Haemangioma, an uncommon cause of an extradural or intradural extramedullary mass: case series with radiological pathological correlation

Abstract

Haemangiomas of the vertebrae, usually regarded as having little or no consequence, may display aggressive features, including extension into the extradural space, and cause significant neurological symptoms and signs necessitating treatment. Extraosseous haemangiomas in an extradural or intradural extramedullary location are a rare entity. Here we review our radiologic and pathologic experience of osseous haemangiomas with extradural extension and primary extradural and intradural extramedullary haemangiomas. Magnetic resonance imaging plays a pivotal role in the characterisation of spinal haemangiomas, with typical imaging features including T1 and T2 signal hyperintensity. Atypical and aggressive imaging features are also described. Spinal angiography may be required to differentiate haemangiomas from non-vascular lesions. This is a rare and unusual entity, and should be considered as a differential diagnosis for some extramedullary masses.

Teaching points

• Osseous haemangiomas can display aggressive features and cause neurologic symptoms needing treatment.

• Haemangioma extension into the extradural space is an imaging feature of aggressiveness.

• Extraosseous haemangiomas are a rare but important differential diagnosis for extramedullary masses.

• Extraosseous extramedullary haemangiomas most frequently present with progressive myelopathy.

• MRI is pivitol in characterising spinal haemangiomas; imaging characteristics can vary.

Paediatric cyclical Cushing's disease due to corticotroph cell hyperplasia

BACKGROUND

Cushing's disease is very rare in the paediatric population. Although uncommon, corticotroph hyperplasia causing Cushing's syndrome has been described in the adult population, but appears to be extremely rare in children. Likewise, cyclical cortisol hypersecretion, while accounting for 15 % of adult cases of Cushing's disease, has only rarely been described in the paediatric population. Here, we describe a very rare case of a 13-year old boy with cyclical cortisol hypersecretion secondary to corticotroph cell hyperplasia.

CASE PRESENTATION

The case is that of a 13-year old boy, presenting with a long history of symptoms and signs suggestive of hypercortisolism, who was found to have cyclical ACTH-dependent hypercortisolism following dynamic pituitary testing and serial late-night salivary cortisol measurements. The patient underwent endoscopic transsphenoidal resection of the pituitary. Early surgical remission was confirmed by undetectable post-operative morning plasma cortisol levels. Histology and immunocytochemistry of the resected pituitary tissue showed extensive corticotroph cell hyperplasia.

CONCLUSION

This report describes a rare case of cyclical Cushing's disease secondary to corticotroph hyperplasia in a paediatric patient. This highlights the challenging and varied nature of Cushing's disease and its diagnosis, and the need to keep a differential diagnosis in mind during the diagnostic process.

Use of biosimilar filgrastim compared with lenograstim in autologous haematopoietic stem-cell transplant and in sibling allogeneic transplant

OBJECTIVES

Biosimilar filgrastim was compared with lenograstim for autologous haematopoietic stem-cell transplant (HSCT) in patients with haematological malignancies. Data from a separate group of sibling donors who underwent allogeneic HSCT are also reported.

METHODS

Patients with lymphoma or multiple myeloma (MM) who underwent autologous HSCT with biosimilar filgrastim were compared with a historical control group of patients who received lenograstim. Peripheral blood (PB) cells counts were monitored after 7-8 consecutive days of granulocyte-colony stimulating factor (G-CSF) injection and apheresis was performed on day 8 if PB CD34+ cell count was ⩾10 cells/µl. The target PB CD34+ cell doses were ⩾2.0 × 10(6)/kg (lymphoma), ⩾4.0 × 10(6)/kg (MM ⩾60 years old) or ⩾8.0 × 10(6)/kg (MM <60 years old).

RESULTS

A total of 259 patients were included in the autologous HSCT comparison (biosimilar filgrastim, n = 104; lenograstim, n = 155). In patients with lymphoma and older MM patients (⩾60 years old), no significant differences were observed between groups with regard to stem-cell mobilization parameters. However, in MM patients <60 years old, all parameters were significantly superior in the biosimilar filgrastim group, including the need for 1 rather than 2 apheresis procedures. No significant differences were observed between groups in median number of days to absolute neutrophil count (ANC) or platelet recovery. In the allogeneic setting, 47 sibling donors received biosimilar filgrastim. Mean CD34+ count at the first apheresis was 6.1 × 10(6)/kg. A total of 13 donors needed a second apheresis and 4 required a third. Among recipients, median days to ANC recovery was 16 (10-28) and to platelet recovery was 13 (9-54).

CONCLUSIONS

Biosimilar filgrastim is as effective as lenograstim for autologous HSCT in patients with lymphoma or MM patients ⩾60 years old. However, mobilization with biosimilar filgrastim appeared to be superior to that with lenograstim in younger MM patients.

In vitro assessment of aiming bias in the frontal plane during orthopaedic drilling procedures

Drilling trials were performed using drilling boards incorporating pairs of 22 mm polyethylene tubes mounted horizontally. The tubes were premarked with 20, 0.5 mm deep notches along the centre of their upper surface representing the starting point for each drilling trial. Volunteers were instructed to drill 20 straight holes across the tube until they penetrated both walls. Kirschner wires were inserted through each of the drill holes until they made indentations into the base board. Deviation of each mark from mid-line was measured using digital callipers. The measured values were used to calculate deviation angles to the left (negative values) or right (positive values). Trials were performed with the drill and guide held in the surgeon's line-of-sight (LOS) and with 300 mm offset (OFF). A systematic error (aiming bias) was identified in all individuals. Overall, left-hander's drilling action was skewed to the left and right-hander's drilling action was skewed to the right. Using LOS technique, mean overall bias was 2.3° (range 0°-7.7°) to the left for left-handers and 1.5(o) (range 0.3°-3.1°) to the right for right-handers. Surprisingly, aiming bias was greater for LOS than for OFF, although the difference for this comparison was not statistically significant.