A rare case of an extra-oral plasmablastic lymphoma presenting through a scrotal abscess in a 42-year-old man

Plasmablastic lymphoma (PBL) is a rare lymphoid neoplasm frequently presenting in the oral cavity. It is an aggressive type of non-Hodgkin's lymphoma that shares pathological features with plasma cell myeloma. In addition to human immunodeficiency virus (HIV), it is also associated with Epstein-Bar virus (EBV) and immunosuppression in HIV-negative patients, for example, post transplantation. Extra-oral PBL is rare and only a few case reports involving the testis have been described. Here we describe the first reported case of PBL presenting with a scrotal abscess (not involving the testes) in a patient newly diagnosed with HIV. This case highlights the rare presentation of a rare disease, the difficulties in establishing a diagnosis and the importance of a timely multidisciplinary approach to its management.

Entrepreneurial mental health in the wake of COVID-19 in China with an emphasis on attention deficit hyperactivity disorder (ADHD) and dyslexia analysis

The COVID-19 pandemic has precipitated a global mental health crisis, with a particularly pronounced impact on the entrepreneurial sector. This paper presents a comparative analysis of mental health challenges among entrepreneurs in China during the pandemic, with a specific focus on attention deficit hyperactivity disorder (ADHD) and Dyslexia. The study assesses the prevalence of ADHD and dyslexia symptoms among established and emerging entrepreneurs in China, finding notable occurrences within this group. The research also examines the self-care practices of these entrepreneurs, shedding light on their approaches during the pandemic period. The findings highlight a complex interplay between mental health issues and entrepreneurial activities, suggesting that certain ADHD and dyslexia traits may offer unexpected benefits in the entrepreneurial realm. These insights are critical for developing supportive frameworks that leverage the strengths of neurodiverse entrepreneurs while mitigating associated challenges, especially in a post-pandemic economic landscape. The study concludes with policy and practice recommendations to bolster the wellbeing and resilience of entrepreneurs facing the multifaceted impacts of the pandemic.

Therapeutic effects of 7- to 14-day subanesthetic ketamine infusions for chronic pain on standardized psychiatric measures

Background: We have previously shown that subanesthetic ketamine infusions effectively reduce refractory pain. However, the effects of ketamine infusions on comorbid conditions of depression and anxiety have not been explored in this patient population. Methods: We investigated the effects of ketamine on mood and anxiety in patients with refractory chronic pain treated with 7-14 days of subanesthetic continuous intravenous ketamine infusions, using well-validated clinical scales. Results: There was a significant 52% reduction in pain severity and 33% reduction in pain interference scores following ketamine treatment. Ketamine treatment also reduced scores on the depression module of the Patient Health Questionnaire (PHQ-9) by 28% and scores on the Generalised Anxiety and Depression Assessment (GAD-7) by 36%. Conclusion: Multiday subanesthetic ketamine infusions effectively reduce pain, anxiety and depression in patients with complex chronic pain.

Social Frailty and Executive Function: Association with Geriatric Syndromes, Life Space and Quality of Life in Healthy Community-Dwelling Older Adults

BACKGROUND

Despite emerging evidence about the association between social frailty and cognitive impairment, little is known about the role of executive function in this interplay, and whether the co-existence of social frailty and cognitive impairment predisposes to adverse health outcomes in healthy community-dwelling older adults.

OBJECTIVES

We aim to examine independent associations between social frailty with the MMSE and FAB, and to determine if having both social frailty and cognitive impairment is associated with worse health outcomes than either or neither condition.

METHODS

We studied 229 cognitively intact and functionally independent community-dwelling older adults (mean age= 67.2±7.43). Outcome measures comprise physical activity; physical performance and frailty; geriatric syndromes; life space and quality of life. We compared Chinese Mini Mental State Examination (CMMSE) and Chinese Frontal Assessment Battery (FAB) scores across the socially non-frail, socially pre-frail and socially frail. Participants were further recategorized into three subgroups (neither, either or both) based on presence of social frailty and cognitive impairment. Cognitive impairment was defined as a score below the educational adjusted cut-offs in either CMMSE or FAB. We performed logistic regression adjusted for significant covariates and mood to examine association with outcomes across the three subgroups.

RESULTS

Compared with CMMSE, Chinese FAB scores significantly decreased across the social frailty spectrum (p<0.001), suggesting strong association between executive function with social frailty. We derived three subgroups relative to relationship with socially frailty and executive dysfunction: (i) Neither, N=140(61.1%), (ii) Either, N=79(34.5%), and (iii) Both, N=10(4.4%). Compared with neither or either subgroups, having both social frailty and executive dysfunction was associated with anorexia (OR=4.79, 95% CI= 1.04-22.02), near falls and falls (OR= 5.23, 95% CI= 1.10-24.90), lower life-space mobility (odds ratio, OR=9.80, 95% CI=2.07-46.31) and poorer quality of life (OR= 13.2, 95% CI= 2.38-73.4).

CONCLUSION

Our results explicated the association of executive dysfunction with social frailty, and their synergistic relationship independent of mood with geriatric syndromes, decreased life space and poorer quality of life. In light of the current COVID-19 pandemic, the association between social frailty and executive dysfunction merits further study as a possible target for early intervention in relatively healthy older adults.

The effects of a multiday (10-14 days) subanesthetic dose IV ketamine infusion in the treatment of refractory chronic pain

Aim: Ketamine is an anesthetic agent that at lower doses can be a potent analgesic. There has been an interest in the use of low dose ketamine in treatment of chronic pain syndromes. Patients & methods: We report the results of a retrospective observational study for patients diagnosed with a chronic noncancer pain syndrome receiving a 2-week continuous subanesthetic IV ketamine infusion. Results & conclusion: We conclude that a 10-14 days of subanesthetic ketamine infusion in chronic patients results in clinically significant lowering of patients' numerical pain score. Further studies looking at subanesthetic ketamine infusion in a prospective trial of multi-day IV ketamine infusion in chronic refractory chronic neuropathic pain are needed to further assess the efficacy of ketamine.

Consensus-based recommendations for titrating cannabinoids and tapering opioids for chronic pain control

AIMS

Opioid misuse and overuse have contributed to a widespread overdose crisis and many patients and physicians are considering medical cannabis to support opioid tapering and chronic pain control. Using a five-step modified Delphi process, we aimed to develop consensus-based recommendations on: 1) when and how to safely initiate and titrate cannabinoids in the presence of opioids, 2) when and how to safely taper opioids in the presence of cannabinoids and 3) how to monitor patients and evaluate outcomes when treating with opioids and cannabinoids.

RESULTS

In patients with chronic pain taking opioids not reaching treatment goals, there was consensus that cannabinoids may be considered for patients experiencing or displaying opioid-related complications, despite psychological or physical interventions. There was consensus observed to initiate with a cannabidiol (CBD)-predominant oral extract in the daytime and consider adding tetrahydrocannabinol (THC). When adding THC, start with 0.5-3 mg, and increase by 1-2 mg once or twice weekly up to 30-40 mg/day. Initiate opioid tapering when the patient reports a minor/major improvement in function, seeks less as-needed medication to control pain and/or the cannabis dose has been optimised. The opioid tapering schedule may be 5%-10% of the morphine equivalent dose (MED) every 1 to 4 weeks. Clinical success could be defined by an improvement in function/quality of life, a ≥30% reduction in pain intensity, a ≥25% reduction in opioid dose, a reduction in opioid dose to <90 mg MED and/or reduction in opioid-related adverse events.

CONCLUSIONS

This five-stage modified Delphi process led to the development of consensus-based recommendations surrounding the safe introduction and titration of cannabinoids in concert with tapering opioids.

Cabazitaxel versus abiraterone or enzalutamide in poor prognosis metastatic castration-resistant prostate cancer: a multicentre, randomised, open-label, phase II trial

BACKGROUND

Treatment of poor prognosis metastatic castration-resistant prostate cancer (mCRPC) includes taxane chemotherapy and androgen receptor pathway inhibitors (ARPI). We sought to determine optimal treatment in this setting.

PATIENTS AND METHODS

This multicentre, randomised, open-label, phase II trial recruited patients with ARPI-naive mCRPC and poor prognosis features (presence of liver metastases, progression to mCRPC after <12 months of androgen deprivation therapy, or ≥4 of 6 clinical criteria). Patients were randomly assigned 1 : 1 to receive cabazitaxel plus prednisone (group A) or physician's choice of enzalutamide or abiraterone plus prednisone (group B) at standard doses. Patients could cross over at progression. The primary endpoint was clinical benefit rate for first-line treatment (defined as prostate-specific antigen response ≥50%, radiographic response, or stable disease ≥12 weeks).

RESULTS

Ninety-five patients were accrued (median follow-up 21.9 months). First-line clinical benefit rate was greater in group A versus group B (80% versus 62%, P = 0.039). Overall survival was not different between groups A and B (median 37.0 versus 15.5 months, hazard ratio (HR) = 0.58, P = 0.073) nor was time to progression (median 5.3 versus 2.8 months, HR = 0.87, P = 0.52). The most common first-line treatment-related grade ≥3 adverse events were neutropenia (cabazitaxel 32% versus ARPI 0%), diarrhoea (9% versus 0%), infection (9% versus 0%), and fatigue (7% versus 5%). Baseline circulating tumour DNA (ctDNA) fraction above the cohort median and on-treatment ctDNA increase were associated with shorter time to progression (HR = 2.38, P < 0.001; HR = 4.03, P < 0.001). Patients with >30% ctDNA fraction at baseline had markedly shorter overall survival than those with undetectable ctDNA (HR = 38.22, P < 0.001).

CONCLUSIONS

Cabazitaxel was associated with a higher clinical benefit rate in patients with ARPI-naive poor prognosis mCRPC. ctDNA abundance was prognostic independent of clinical features, and holds promise as a stratification biomarker.

Massive Perivillous Fibrin Deposition and Chronic Histiocytic Intervillositis of a Placenta: Rare co-existence

Introduction/Objective

Massive perivillous fibrin deposition (MPFD) and chronic histiocytic intervillositis (CHI) of the placenta are both very rare entities individually. They both are associated with reccurent loss of the fetus.

Methods

Here we report a placenta with coexisting MPFD and CHI. Patient is a 24-year-old African American female who has a history of spontaneous abortion at the 10th week when she was 18. Her latest pregnancy is complicated by intrauterine growth retardation and she eventually losses the fetus at 20th week of gestation.

Results

Histopathology reveals extensive fibrin deposition of the perivillous area and the histiocytic infiltration of the intervillous spaces which is highlighted by CD68 staining.

Conclusion

This is the second literature report of a co-occurrence of MPFD and CHI to our knowledge. Pathologists must be familiar with these entities and inform the obstetricians because these placental lesions often result with recurrent loss of fetus.

Genomic Analysis Identifies Rare ALK Positive Cases In The TCGA Database

Introduction/Objective

The anaplastic lymphoma kinase (ALK) gene is a receptor tyrosine kinase gene located in the 2p23.2 region. Normally, dimerization of ALK receptor by binding to its ligand activates the ALK receptor by autophosphorylation of c-termius and activates downstream PI3K, MAPK and JAK3 pathways. The ALK gene is abnormally hyperactivated by fusion of the 3’ half containing the kinase domain with 5’ portion of other genes, resulting in the ligand independent dimerization and activation of the ALK receptor. The tumors harboring these translocations are termed as ALK-positive tumors and can be treated with ALK inhibitors.

Methods

We analyzed the status of clinically relevant ALK fusion driver mutations in 230 different cancer studies, containing tumors from 79222 different individuals, in The Cancer Genome Atlas database (TCGA) using the cbioportal web browser.

Results

We observed that, as expected ALK-positive mutations are predominantly present in NSCLC, with EML4- ALK being the most common. In addition, we were able to identify ALK positive mutations in colorectal carcinomas, papillary thyroid carcinomas, papillary renal cell carcinomas, sarcomas and invasive ductal carcinomas of the breast. Most important, our analysis identified extremely rare ALK positive cases in salivary duct carcinomas, urothelial carcinomas, cutaneous melanomas and prostatic adenocarcinomas.

Conclusion

Our analysis identified ALK positive cases were predominant in adenocarcinoma of lung with EML4-ALK being the most common ALK positive mutation, which is also consistent with the literature. However, the ALK positive mutations were at a lower prevalence rate than that described in the literature. We attribute the lower prevalence rate to underrepresentation of the Asian population in the TCGA database. In addition, we identified extremely rare ALK positive cases in salivary duct carcinomas, melanomas and prostate cancers, thus highlighting the need for testing for these mutations in these cancers.

Establishing Adrenocortical Carcinoma Specific Prognostic Genes Signature

Introduction/Objective

Adrenal Cortical Carcinoma (ACC) is a rare malignant neoplasms originating from adrenal cortical tissue with an annual incidence rate of 1 to 2 cases per million individuals. These tumors have poor prognosis with 5-year disease free survival being 30% after complete resection in Stage I to Stage III patients. Hence, there is a need for identifying prognostic markers for effective management of disease in these patients.

Methods

We analyzed the data in The Cancer Genome Atlas of 1141 ACC individuals, using cbioportal.org, a web- based platform for analysis of large-scale cancer genomics data sets, and derived correlation between prognosis and genetic alterations in approximately 51,309 genes.

Results

We identified 15 signature genes (NOTCH1, TP53, ZNRF3, LRP1, KIF5A, MDM2, LETMD1, MTOR, NOTCH3, RERE, SMARCC2, LDLR, HRNR, AVPR1A and PCDH15), alterations in which indicated a poor prognosis for ACC individuals. Analysis of 15 signature genes demonstrated that disease specific median survival for the patients with ACC, was reduced to 39.5 months (p value &lt; 8 x 10 -9 and sensitivity of 93%) when any one or more of these genes was altered. Whereas, disease specific median survival was greater than 180 months (90% survival being 180 months) with no alteration in our signature genes. In addition, our analysis of our signature genes demonstrates reduced overall survival, disease free survival and progression free survival in individuals having alterations in our signature genes. Moreover, our set of 15 genes belonged mainly to MDM2-TP53, NOTCH and mTOR pathways, and small molecule modulators of these pathways are in process of development.

Conclusion

Our 15 gene signature was not only able to predict poor prognosis in ACC, but also has the potential to serve as a molecular marker set for initiation of NOTCH and mTOR specific targeted therapies in these patients.

Understanding the microbial basis of body odor in pre-pubescent children and teenagers

BACKGROUND

Even though human sweat is odorless, bacterial growth and decomposition of specific odor precursors in it is believed to give rise to body odor in humans. While mechanisms of odor generation have been widely studied in adults, little is known for teenagers and pre-pubescent children who have distinct sweat composition from immature apocrine and sebaceous glands, but are arguably more susceptible to the social and psychological impact of malodor.

RESULTS

We integrated information from whole microbiome analysis of multiple skin sites (underarm, neck, and head) and multiple time points (1 h and 8 h after bath), analyzing 180 samples in total to perform the largest metagenome-wide association study to date on malodor. Significant positive correlations were observed between odor intensity and the relative abundance of Staphylococcus hominis, Staphylococcus epidermidis, and Cutibacterium avidum, as well as negative correlation with Acinetobacter schindleri and Cutibacterium species. Metabolic pathway analysis highlighted the association of isovaleric and acetic acid production (sour odor) from enriched S. epidermidis (teen underarm) and S. hominis (child neck) enzymes and sulfur production from Staphylococcus species (teen underarm) with odor intensity, in good agreement with observed odor characteristics in pre-pubescent children and teenagers. Experiments with cultures on human and artificial sweat confirmed the ability of S. hominis and S. epidermidis to independently produce malodor with distinct odor characteristics.

CONCLUSIONS

These results showcase the power of skin metagenomics to study host-microbial co-metabolic interactions, identifying distinct pathways for odor generation from sweat in pre-pubescent children and teenagers and highlighting key enzymatic targets for intervention.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Taxane acute pain syndrome (TAPS) in patients receiving chemotherapy for breast or prostate cancer: a prospective multi-center study

BACKGROUND

Taxane acute pain syndrome (TAPS) is characterized by myalgias and arthralgias starting 2-3 days after taxane-based chemotherapy and lasting up to 7 days. In the absence of validated tools, many studies use the presence of both the myalgia and arthralgia components of the Common Terminology Criteria for Adverse Events (CTCAE) to define TAPS. The present study prospectively evaluated the frequency, severity, and impact of TAPS in patients with breast or prostate cancer.

PATIENTS AND METHODS

In this prospective, non-randomized study, patients with breast or prostate cancer commencing taxane-based chemotherapy completed the CTCAE (version 4.03), the Functional Assessment of Cancer Therapy-Taxane (FACT-T), and Brief Pain Inventory (BPI) questionnaires at baseline and once between days 5 and 7 of each chemotherapy cycle.

RESULTS

From March 2015 to April 1, 2016, 75 patients (breast n = 66, prostate n = 9) were enrolled; 83% received docetaxel and 16% paclitaxel and 1% withdrew. After the first cycle of taxane, TAPS was reported by 25/69 (36.2%) patients; a further 8/69 (18.2%) reporting TAPS after a subsequent chemotherapy treatment. Overall incidence of TAPS was 33/75 (44%). While associated with detrimental scores on FACT-T and BPI as well as increased use of analgesics in 63% (21/33) of patients with TAPS, TAPS did not lead to alterations in chemotherapy dosing.

CONCLUSIONS

TAPS is common after taxane-based chemotherapy, and its presence is associated with reduced quality of life and increased analgesic requirements. Prospective patient-reported outcome assessments are crucial to help individualize treatment strategies and improve management of TAPS.

A SEVEN-YEAR-OLD MALE WITH CIRCULATING RED BLOOD CELLS SHOWING A THERMAL INJURY-LIKE MORPHOLOGY

A seven-year-old African-American male presented with a history of hematuria, proteinuria, jaundice, and anemia occasionally treated with transfusions since early childhood. The family history included a father and sister with similar symptoms of anemia, both of which had been diagnosed with hereditary pyropoikilocytosis. Due to the patient's family history and symptoms indicating a possible hematologic problem, a blood draw was performed. Laboratory studies showed an elevated alkaline phosphatase and bilirubin, and hemolytic anemia with unusual erythrocyte indices. The patient's vital signs and abdominal ultrasound were normal, and he had no known allergies. Examination of the patient's peripheral blood smear revealed extreme erythrocyte poikilocytosis with bizarre forms resembling the erythrocyte morphology sometimes seen in individuals with severe thermal burns.

AZD3514, an oral selective androgen receptor down-regulator in patients with castration-resistant prostate cancer - results of two parallel first-in-human phase I studies

BACKGROUND

AZD3514 is a first-in-class, orally bio-available, androgen-dependent and -independent androgen receptor inhibitor and selective androgen-receptor down-regulator (SARD).

METHODS

In study 1 and 2, castration-resistant prostate cancer (CRPC) patients (pts) were initially recruited into a once daily (QD) oral schedule (A). In study 1, pharmacokinetic assessments led to twice daily (BID) dosing (schedule B) to increase exposure. Study 2 explored a once daily schedule.

RESULTS

In study 1, 49 pts were treated with escalating doses of AZD3514 (A 35 pts, B 14 pts). Starting doses were 100 mg (A) and 1000 mg (B). The AZD3514 formulation was switched from capsules to tablets at 1000 mg QD. 2000 mg BID was considered non-tolerable due to grade (G) 2 toxicities (nausea [N], vomiting [V]). No adverse events (AEs) met the dose-limiting toxicity (DLT) definition. Thirteen pts received AZD3514 in study 2, with starting doses of 250 mg QD. The most frequent drug-related AEs were N: G1/2 in 55/70 pts (79 %); G3 in 1 pt (1.4 %); & V: G1/2 in 34/70 pts (49 %) & G3 in 1 pt (1.4 %). PSA declines (≥50 %) were documented in 9/70 patients (13 %). Objective soft tissue responses per RECIST1.1 were observed in 4/24 (17 %) pts in study 1.

CONCLUSION

AZD3514 has moderate anti-tumour activity in pts with advanced CRPC but with significant levels of nausea and vomiting. However, anti-tumour activity as judged by significant PSA declines, objective responses and durable disease stabilisations, provides the rationale for future development of SARD compounds.

Validation and utilisation of high-coverage next-generation sequencing to deliver the pharmacological audit trail

Background:

Predictive biomarker development is a key challenge for novel cancer therapeutics. We explored the feasibility of next-generation sequencing (NGS) to validate exploratory genomic biomarkers that impact phase I trial selection.

Methods:

We prospectively enrolled 158 patients with advanced solid tumours referred for phase I clinical trials at the Royal Marsden Hospital (October 2012 to March 2013). After fresh and/or archived tumour tissue were obtained, 93 patients remained candidates for phase I trials. Results from tumour sequencing on the Illumina MiSeq were cross-validated in 27 out of 93 patients on the Ion Torrent Personal Genome Machine (IT-PGM) blinded to results. MiSeq validation with Sequenom MassARRAY OncoCarta 1.0 (Sequenom Inc., San Diego, CA, USA) was performed in a separate cohort.

Results:

We found 97% concordance of mutation calls by MiSeq and IT-PGM at a variant allele frequency ⩾13% and ⩾500 × depth coverage, and 91% concordance between MiSeq and Sequenom. Common ‘actionable' mutations involved deoxyribonucleic acid (DNA) repair (51%), RAS-RAF-MEK (35%), Wnt (26%), and PI3K-AKT-mTOR (24%) signalling. Out of 53, 29 (55%) patients participating in phase I trials were recommended based on identified actionable mutations.

Conclusions:

Targeted high-coverage NGS panels are a highly feasible single-centre technology well-suited to cross-platform validation, enrichment of trials with molecularly defined populations and hypothesis testing early in drug development.

Spontaneous coronary artery dissection in pregnancy requiring emergency caesarean delivery followed by coronary artery bypass grafting

Spontaneous coronary artery dissection is a rare and often fatal condition of pregnancy. The long-term morbidity is unknown, but a small cohort of patients develop severe ventricular dysfunction as a consequence. We describe a 37-week gestation parturient who presented with cardiogenic shock secondary to spontaneous left main coronary artery dissection. Despite rapid diagnosis, stabilisation with an intra-aortic balloon pump and prompt transfer to a tertiary centre for emergency caesarean delivery and coronary artery bypass grafting, the patient developed a severe postoperative dilated ischaemic cardiomyopathy. There is little information about the long-term outcomes and the specific anaesthesia management of combined emergency caesarean delivery and cardiac surgery in pregnancy for spontaneous coronary artery dissection. Therefore, we outline our multidisciplinary management of this critically ill pregnant woman.

Learning from incident reports in the Australian medical imaging setting: handover and communication errors

OBJECTIVE

To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence.

METHODS

71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n=298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging.

RESULTS

Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%).

CONCLUSION

The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings.

ADVANCES IN KNOWLEDGE

Handover and communication errors are prevalent in medical imaging. System-wide changes that facilitate effective communication are required.

Vitamin D receptor gene polymorphisms and prognosis of breast cancer among African-American and Hispanic women

BACKGROUND

Vitamin D plays a role in cancer development and acts through the vitamin D receptor (VDR). Although African-Americans have the lowest levels of serum vitamin D, there is a dearth of information on VDR gene polymorphisms and breast cancer among African-Americans and Hispanics. This study examines whether VDR gene polymorphisms are associated with breast cancer in these cohorts.

METHODS

Blood was collected from 232 breast cancer patients (Cases) and 349 non-cancer subjects (Controls). Genotyping for four polymorphic variants of VDR (FokI, BsmI, TaqI and ApaI) was performed using the PCR-RFLP method.

RESULTS

An increased association of the VDR-Fok1 f allele with breast cancer was observed in African-Americans (OR = 1.9, p = 0.07). Furthermore, the FbTA, FbtA and fbtA haplotypes were associated with breast cancer among African-Americans (p<0.05). Latinas were more likely to have the VDR-ApaI alleles (Aa or aa) (p = 0.008). The VDR-ApaI aa genotype was significantly associated with poorly-differentiated breast tumors (p = 0.04) in combined Cases. Kaplan-Meier survival analysis showed decreased 5-year disease-free-survival (DFS) in breast cancer patients who had the VDR-Fok1 FF genotype (p<0.05). The Cox regression with multivariate analysis revealed the independent predictor value of the VDR-FokI polymorphism for DFS. The other three variants of VDR (BsmI, TaqI and ApaI) were not associated with disease outcome.

CONCLUSIONS

VDR haplotypes are associated with breast cancer in African-Americans, but not in Hispanic/Latinas. The VDR-FokI FF genotype is linked with poor prognosis in African-American women with breast cancer.

Abstract B26: CDU/UCLA U54 Cancer Center Partnership's Education and Training Program: Methods, measures, and outcomes

Background: The U54 CDU/UCLA Cancer Center Partnership has an Education and Training Program that provides cancer education and research training for students at the undergraduate, graduate/medical, and postdoctoral level. The Specific Aims of the Education and Training program are to facilitate training opportunities between CDU and UCLA for target student populations and to standardize and develop training/mentoring practices. The focus of the present abstract is on the methods, measures, and outcomes specifically developed by the program for the undergraduate student population (Undergraduate Cancer Research Training Program – UCRTP).

Methods: A logic model was developed to reveal the formal framework for an established Education and Training Program. The Logic Model reveals four central components of the Education and Training experience: 1) Research Methods and Theory; 2) Advanced Education; 3) Mentorship/Networking; 4) Career Development. All the components and student activities (before, during, and after participation in the program) are tied to an Evaluation component which statistically assesses recruitment, student/mentor experience, and student output on multiple levels (short-term, mid-term, and long-term). Evaluation allows for the program to self-monitor identifying key points of success and areas for improvement. Statistics are computed with SPSS 17.0 and Excel, P&gt;0.05 is significant.

Results: Highlights of the results of implementing recruitment, training, and evaluation methods are as follows. Recruitment - By strategically targeting counselors and utilizing the social media/internet, the program has increased: the applicant number by almost double every year (N= 27 in Year 1 to N = 99 in Year 3), the competitiveness of student applicants (80% with GPA &gt;3.5-4.0 GPA), and diversity of the student applicants (&gt;80% are underrepresented/underprivileged). Training and Scientific Output- A summary of the scientific output by students include over N = 8 peer reviewed publications resulting from student project participation, over N = 25 abstracts from student projects, and N = 9 manuscripts in preparation with students as co-authors. Education and Career Tracking- To date, we have a compiled tracking data on over N = 50 students. Among the U54 UCRTP (2010-2011 - N = 22), 18% have indicated they intend to pursue an MD/PHD Program, 36% to pursue an MD Program, and 45% to pursue a Graduate Program. The follow-ups of the Pre-U54 Students 2004 - Present (N = 28), reveal that 29% of former students have matriculated into Medical School, 25% have matriculated into Graduate School, 4% matriculated into Nursing School, 33% who have intentions of pursing higher degrees, and 11% who are employed, surprisingly all as research staff in academia.

Conclusion: The Education and Training program has crystallized its components into a logic model that has facilitated the systematic implementation of measures for successful recruitment, training, and tracking of students and concurrent program evaluation. The results indicate that we have contributed towards increasing the number of underrepresented students pursuing careers in health and research. Future plans include formal program assessment and pursuing accreditation for credits for participating students.

Acknowledgements: Thank you to all the students and mentors for their hard work. These activities were supported in part by grants from NIH/National Cancer Institute 1U54CA14393-01; U56 CA101599-01; CA15083-25S3; R25DK067015-01; to J.V. Vadgama.

Citation Format: Marianna Sarkissyan, May Ong, Yanyuan Wu, Judith Gasson, Robin Farias-Eisner, Jaydutt V. Vadgama. CDU/UCLA U54 Cancer Center Partnership's Education and Training Program: Methods, measures, and outcomes. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr B26.

Neoadjuvant erlotinib and surgical resection of a stage iiia papillary adenocarcinoma of the lung with an L861Q activating EGFR mutation

The use of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) is evolving, as is an understanding of predictive biomarkers for tumour response in non-small-cell lung cancer (NSCLC). In this report, we describe a case of rapidly progressing, borderline-resectable, clinical stage IIIA (micro) papillary adenocarcinoma in a 78-year-old woman who experienced a profound response to neoadjuvant erlotinib without short-term toxicity. On EGFR mutation testing, this patient had an uncommon activating point mutation at L861Q in exon 21. Her response permitted successful surgical resection with negative margins and avoidance of chemoradiation, which she was deemed too frail to tolerate. Our case addresses unique management issues such as preoperative testing for EGFR mutation, utility of histology in predicting EGFR mutations, and use of EGFR-TKIs pre- and postoperatively for potentially resectable NSCLC.

P3-16-11: Prospective Evaluation of Radiation Pneumonitis in Neoadjuvant Concurrent Docetaxel and Radiation Therapy for Locally Advanced Breast Cancer

Background: Taxanes are known to have radiosensitizing properties, by causing cell arrest in the G2 and M phases of the cell cycle. As taxanes have become integrated into routine oncologic use, concerns have arisen over the association between taxanes and radiation toxicities such as pneumonitis. Pneumonitis has been reported to occur both with taxane administration alone or, more commonly, with concurrent or sequential radiation. The purpose of this study is to evaluate radiation pneumonitis from our institutional phase I/II protocol of neoadjuvant FEC chemotherapy followed by weekly docetaxel concurrent with radiotherapy in the treatment of locally advanced breast cancer (LABC).

Materials and Methods: Since August 2009, thirty-two LABC patients with stage IIB, IIIA, IIIB, or IIIC invasive breast cancer were enrolled to receive protocol based treatment consisting of 3 cycles of intravenous (IV) fluorouracil 500 mg/m2, epirubicin 100 mg/m2, and cyclophosphamide 500 mg/m2 (FEC) every 3 weeks. Following this, weekly IV docetaxel 35 mg/m2 was administered concurrently with locoregional external beam radiotherapy to a total dose of 45 Gy in 25 fractions followed by a boost of 5.4-9 Gy in 3–5 fractions to gross residual disease. Adverse events were scored using the National Cancer Institute Common Terminology Criteria for Adverse Events v3.0. A linear regression model was built used to evaluate potential parameters predictive of clinical pneumonitis (grade ≥2).

Results: Of the 32 patients enrolled on this prospective protocol, 7 were excluded from analysis (n = 6, follow-up &lt; 4 weeks; n = 1, converted to palliative radiotherapy due to metastatic disease). Twenty-five patients remained for analysis. The median age was 48 years (range 26 to 64). Thirteen patients were treated with intensity modulated radiation therapy while 12 were treated using 3D conformal radiotherapy. In total 13 patients (52%) experienced clinical pneumonitis with 6 of these patients (24%) transiently requiring supportive oxygen (grade 3). On linear regression modeling, the use of IMRT (p = 0.08), grade 3 skin toxicity (p = 0.08), and baseline left ventricular ejection fraction (LVEF, p = 0.05) were potentially predictive of symptomatic pneumonitis. Conversely, various heart and lung dose-volume histogram parameters, trastuzumab use, bolus use, disease laterality, total docetaxel dose, were not predictive of symptomatic pneumonitis (p &gt; 0.10). In multivariable modeling, the use of IMRT (p = 0.05) and baseline LVEF (0 = 0.03) remained predictive of symptomatic pneumonitis.

Conclusion: The use of concurrent weekly docetaxel-based chemoradiotherapy in LABC is associated with significant symptomatic pneumonitis and may be related to low baseline LVEF and the use of IMRT. However, conventional parameters of low dose volumes of lung and heart irradiated were not predictive of pneumonitis. The relationship of the use of IMRT and taxanes in the development of pnemonitis is likely complex and warrants further investigation.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-16-11.

Real-time tissue elastography versus FibroScan for noninvasive assessment of liver fibrosis in chronic liver disease

PURPOSE

Transient elastography (FibroScan, [TE]) and serum fibrosis markers such as the FibroTest (FT) are established methods for the noninvasive staging of liver fibrosis. A study using real-time elastography (HI-RTE), which is integrated in a conventional ultrasound system, was recently published with comparable results to transient elastography. The aim of the present study was to validate real-time elastography using the formulas calculated in previous studies and to compare the results to transient elastography and FibroTest for the noninvasive assessment of liver fibrosis.

MATERIALS AND METHODS

One hundred and thirty-four patients with chronic liver disease and either histological assessment of liver fibrosis (n = 112) or proven liver cirrhosis (n = 22) were included in the study. All patients received TE, HI-RTE, and biochemical evaluation on the same day as presentation. The calculation of the elasticity score of real-time elastography was performed in accordance with the two previously published studies.

RESULTS

The Spearman correlation coefficient between transient elastography, real-time elastography and FibroTest with the histological Chevallier score was statistically significant with 0.78, 0.34, and 0.67, respectively (p < 0.01). The diagnostic accuracy expressed as areas under ROC curves was 0.84, 0.69 and 0.85 for the diagnosis of significant fibrosis (F > or = 2), and 0.97, 0.65, and 0.83 for the diagnosis of cirrhosis, respectively.

CONCLUSION

Real-time elastography in its present form cannot replace transient elastography for noninvasive assessment of liver fibrosis.

Distribution of aflatoxin in non-irrigated peanuts

The aflatoxin B1 and total aflatoxin distribution in Georgia Green peanuts has been measured. Sample distributions were measured in approximately 400 small samples each of jumbo, medium and small other kernels sublots, containing 20, 10, and 5 kernels, respectively. Results were converted to single kernel probability density distributions, p(c), using methods previously published. This constitutes the first direct small sample experimental establishment of p(c) in USA peanuts. All three sublots show evidence in the single kernel probability density of peaks at about concentrations of 105 and 5×103 ng/g, and a partial peak at a concentration <5×102 ng/g. The first and last of these are similar to peaks seen in tree nuts.

Challenges in accessing multidisciplinary pain treatment facilities in Canada

PURPOSE

The objective of this survey was to examine the services offered by multidisciplinary pain treatment facilities (MPTFs) across Canada and to compare access to care at these MPTFs.

METHODS

A MPTF was defined as a clinic that advertised specialized multidisciplinary services for the diagnosis and management of patients with chronic pain, having a minimum of three different health care disciplines (including at least one medical speciality) available and integrated within the facility. The search method included approaching all hospital and rehabilitation centre administrators in Canada, the Insurance Bureau of Canada, the Workplace Safety and Insurance Board or similar body in each province. Designated investigators were responsible for confirming and supplementing MPTFs from the preliminary list for each province. Administrative leads at each eligible MPTF were asked to complete a detailed questionnaire regarding their MPTF infrastructure, clinical, research, teaching and administrative activities.

RESULTS

Completed survey forms were received from 102 MPTFs (response rate 85%) with 80% concentrated in major cities, and none in Prince Edward Island and the Territories. The MPTFs offer a wide variety of treatments including non-pharmacological modalities such as interventional, physical and psychological therapy. The median wait time for a first appointment in public MPTFs is six months, which is approximately 12 times longer than non-public MPTFs. Eighteen pain fellowship programs exist in Canadian MPTFs and 64% engage in some form of research activities

CONCLUSION

Canadian MPTFs are unable to meet clinical demands of patients suffering from chronic pain, both in terms of regional accessibility and reasonable wait time for patients' first appointment.

Hyperbaric oxygen therapy in the management of diabetic lower limb wounds

INTRODUCTION

Hyperbaric oxygen therapy (HBOT) involves the inhalation of 100 percent oxygen at pressures greater than at sea level. One of the most common indications for HBOT is to aid healing of diabetic foot wounds.

METHODS

All cases of diabetic foot wounds that were seen by the Hyperbaric Medicine Centre in Tan Tock Seng Hospital from May 2005 to March 2006 were analysed in terms of outcome (wound healing) after HBOT.

RESULTS

A total of 45 cases of foot ulcers/wounds were analysed. 32 patients had a favourable outcome, giving a success rate of 71 percent. The remaining 13 (28 percent) did not have a favourable outcome to HBOT. The success rate was even more significant as a large number of these patients (34 [77 percent]) were told by their specialist that they were at high risk of a further amputation. No major complications were noted.

CONCLUSION

The experience of the Hyperbaric Medicine Centre in Singapore is consistent with that reported in other centres. With proper patient selection, HBOT, together with a multidisciplinary team of vascular and orthopaedic surgeons, podiatrists, infection disease physicians and endocrinologists, can help reduce the numbers and severity of amputations as well as downtime due to increased wound healing.

Intracranial syphilitic gumma resembling malignant brain tumour

We report a patient with a temporal lobe syphilitic gumma mimicking a malignant brain tumour in a 43-year-old immunocompetent man. The diagnosis was confirmed histologically and using polymerase chain reaction. Syphilitic gummatous involvement of the central nervous system is rare, with only a few cases having been reported. The unique feature of this case was the extensive oedema surrounding the lesion, suggestive of an active process.