National Cancer Institute Collaborative Workshop on Shaping the Landscape of Brain Metastases Research: challenges and recommended priorities

Brain metastases are an increasing global public health concern, even as survival rates improve for patients with metastatic disease. Both metastases and the sequelae of their treatment are key determinants of the inter-related priorities of patient survival, function, and quality of life, mandating a multidimensional approach to clinical care and research. At a virtual National Cancer Institute Workshop in September, 2022, key stakeholders convened to define research priorities to address the crucial areas of unmet need for patients with brain metastases to achieve meaningful advances in patient outcomes. This Policy Review outlines existing knowledge gaps, collaborative opportunities, and specific recommendations regarding consensus priorities and future directions in brain metastases research. Achieving major advances in research will require enhanced coordination between the ongoing efforts of individual organisations and consortia. Importantly, the continual and active engagement of patients and patient advocates will be necessary to ensure that the directionality of all efforts reflects what is most meaningful in the context of patient care.

Addressing resistance to PD-1/PD-(L)1 pathway inhibition: considerations for combinatorial clinical trial designs

With multiple PD-(L)1 inhibitors approved across dozens of indications by the US Food and Drug Administration, the number of patients exposed to these agents in adjuvant, first-line metastatic, second-line metastatic, and refractory treatment settings is increasing rapidly. Although some patients will experience durable benefit, many have either no clinical response or see their disease progress following an initial response to therapy. There is a significant need to identify therapeutic approaches to overcome resistance and confer clinical benefits for these patients. PD-1 pathway blockade has the longest history of use in melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma (RCC). Therefore, these settings also have the most extensive clinical experience with resistance. In 2021, six non-profit organizations representing patients with these diseases undertook a year-long effort, culminating in a 2-day workshop (including academic, industry, and regulatory participants) to understand the challenges associated with developing effective therapies for patients previously exposed to anti-PD-(L)1 agents and outline recommendations for designing clinical trials in this setting. This manuscript presents key discussion themes and positions reached through this effort, with a specific focus on the topics of eligibility criteria, comparators, and endpoints, as well as tumor-specific trial design options for combination therapies designed to treat patients with melanoma, NSCLC, or RCC after prior PD-(L)1 pathway blockade.

Abstract PD7-03: Translational Breast Cancer Research Consortium Trial 022: Neratinib and Trastuzumab-Emtansine for HER2+ Breast Cancer Brain Metastases (BCBM)

PURPOSE: Treatment options for patients (pts) with HER2+ BCBM remain limited. We previously reported that neratinib monotherapy is associated with a volumetric central nervous system objective response rate (CNS ORR) of 8%, whereas the combination of neratinib and capecitabine resulted in a volumetric CNS ORR of 49% (in lapatinib-naïve pts). Preclinical data suggest that neratinib may overcome resistance to trastuzumab-emtansine (T-DM1) and that the combination has potential CNS efficacy. Here, we report results of neratinib plus T-DM1 in pts with HER2+ BCBM. PATIENTS AND METHODS: In this prospective, multicenter, phase II study, pts with measurable HER2+ BCBM received neratinib 160 mg orally once daily plus T-DM1 3.6 mg/kg IV every 21 days in three parallel-enrolling cohorts. Cohort 4A enrolled pts with previously untreated brain metastases. Cohort 4B enrolled pts with BCBM progressing after prior local CNS-directed therapy without prior exposure to T-DM1. Cohort 4C enrolled pts with BCBM progressing after prior local CNS-directed therapy who had previous exposure to T-DM1. Diarrhea prophylaxis with colestipol and loperamide was required during cycle 1. Cohorts 4A and 4B were single-stage with a planned enrollment of 20 patients; cohort 4C had a two-stage design, with a requirement for at least 1 of the first 9 pts to achieve a response in order to enroll a total of 24 patients. The primary endpoint was Response Assessment in Neuro-Oncology-Brain Metastases (RANO BM) in each cohort separately. Correlative studies included patient-reported outcomes (PROs) for gastrointestinal toxicity. RESULTS: We enrolled 6, 17, and 21 patients to cohorts 4A, 4B, and 4C, during 11/07/2018 – 11/01/2021. Enrollment was stopped prematurely due to slow accrual. Across Cohorts 4A-4C, the median number of prior lines of chemotherapy prior to enrollment was 2 (range 1-10); 25% received prior lapatinib and no patients received prior tucatinib. In cohorts 4B and 4C (prior CNS-treated cohorts), 33% had prior CNS surgery and >94% had prior CNS radiation. Among evaluable patients, CNS ORR in cohorts 4A (n=6), 4B (n=16), and 4C (n=21) was 50.0% (95% CI 18.8- 81.2%), 25.0% (95% CI 8.3-52.6%), and 38.1% (95% CI 19.0-61.3%), respectively. Median (range) number of cycles completed for 4A, 4B, and 4C was 4.5 (1-15), 4 (range 0-49+), and 6 (0-23); three patients on Cohort 4B remain on protocol therapy (cycles 14, 45, and 49). The overall survival at 12-months for cohorts 4A, 4B, and 4C was 83.3% (95% CI, 58.3-100%), 86.2% (95% CI 70-100%), and 83.3% (95% CI 67.6-100%). Diarrhea was the most common grade 3 toxicity (19.0–33.3% across cohorts); one grade 4 liver function event occurred in cohort 4B. Updated efficacy results will be reported at the meeting; PRO analyses are ongoing. CONCLUSION: Intracranial activity was observed for the combination of neratinib plus T-DM1 across all three enrolled cohorts, including those with prior T-DM1 exposure, suggesting synergistic effects of this treatment combination. Our data provide additional evidence for consideration of neratinib-based combinations in pts with HER2+ BCBM.

Citation Format: Rachel Freedman, Siyang Ren, Nabihah Tayob, Rebecca Gelman, Karen L. Smith, Raechel Davis, Alyssa Pereslete, Victoria Attaya, Christine Cotter, Wendy Y. Chen, Cesar Augusto Santa-Maria, Catherine Van Poznak, Beverly Moy, Adam M. Brufsky, Michelle Melisko, Ciara C. O’Sullivan, Nadia Ashai, Yasmeen Rauf, Julie Nangia, Dario Trapani, Jennifer Savoie, Robyn Burns, Antonio C. Wolff, Eric Winer, Mothaffar Rimawi, Ian Krop, Nancy U. Lin. Translational Breast Cancer Research Consortium Trial 022: Neratinib and Trastuzumab-Emtansine for HER2+ Breast Cancer Brain Metastases (BCBM) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD7-03.

Modeling gait score of broiler chicken via production and behavioral data

Lameness in broilers may be associated with pain and is considered a major broiler production and welfare concern. Manual gait score assessment in commercial broiler houses is discrete, time-consuming, and laborious. As such, automatic methods for broiler gait score assessment are urgently needed. The objective of this study was to identify the relation of broiler gait score with several productions and behavioral metrics (bird BW, age, activity, and distribution), and establish three gait score prediction models for automatic gait score estimations in broiler farms with automatic weighing systems, camera systems, or both. Sixteen pens were used to rear Cobb 500 and Ross 708 broilers for eight and nine weeks, respectively (eight pens/strain, 12 birds/pen). The gait scores of all birds were assessed weekly by trained assessors following a six-point (0-5) scoring protocol from the third week. The pen's average BW was measured weekly. Top-view cameras were installed to continuously record videos of broilers in all 16 pens. Images were extracted from video clips (10 min/hour) during a 16-hour light period to determine the activity index and distribution index through image processing. The gait score was positively correlated with BW (R² = 0.97 for Cobb and R² = 0.96 for Ross), while negatively correlated with activity (R² = 0.78 for Cobb and R² = 0.73 for Ross). The three models showed high accuracies in predicting broiler gait score based on variables of BW, age, activity index, and distribution index (R² = 0.90-0.91, RMSE = 0.38-0.41). The findings of this study demonstrated the potential of estimating broiler gait score using bird BW, age, activity index, and distribution index. This information will assist in the development of automated gait score assessment systems in broiler production.

Molecular classification and biomarkers of clinical outcome in breast ductal carcinoma in situ: Analysis of TBCRC 038 and RAHBT cohorts

Ductal carcinoma in situ (DCIS) is the most common precursor of invasive breast cancer (IBC), with variable propensity for progression. We perform multiscale, integrated molecular profiling of DCIS with clinical outcomes by analyzing 774 DCIS samples from 542 patients with 7.3 years median follow-up from the Translational Breast Cancer Research Consortium 038 study and the Resource of Archival Breast Tissue cohorts. We identify 812 genes associated with ipsilateral recurrence within 5 years from treatment and develop a classifier that predicts DCIS or IBC recurrence in both cohorts. Pathways associated with recurrence include proliferation, immune response, and metabolism. Distinct stromal expression patterns and immune cell compositions are identified. Our multiscale approach employed in situ methods to generate a spatially resolved atlas of breast precancers, where complementary modalities can be directly compared and correlated with conventional pathology findings, disease states, and clinical outcome.

Intramedullary, periosteal, and extraskeletal Ewing sarcomas: retrospective study of a series of 126 cases in a reference center

OBJECTIVE

To evaluate the proportion of extraskeletal, periosteal, and intramedullary Ewing sarcomas among musculoskeletal Ewing sarcomas.

MATERIAL AND METHOD

Our single-center retrospective study included patients with musculoskeletal Ewing sarcoma diagnosed between 2005 and 2019 in our pathology center (cases from our adult bone tumor referral center and adult and pediatric cases referred for review). Recurrences, metastases, and visceral Ewing sarcomas were excluded. Intramedullary Ewing sarcomas were defined by involvement of the medullary cavity. Periosteal cases were defined by involvement of the subperiosteal area without extension to the medullary cavity. Extraskeletal cases were defined by the absence of involvement of the bone tissue and the subperiosteal area.

RESULTS

Our series included 126 patients with musculoskeletal Ewing sarcoma, including 118 skeletal Ewing sarcomas (93.7%) and 8 extraskeletal Ewing sarcomas (6.3%). Of the 118 skeletal Ewing sarcomas 112 were intramedullary (88.9%) and 6 were periosteal (4.8%). Extraskeletal Ewing sarcomas were more common in women and in patients older than 40 (p < 0.05).

DISCUSSION

The 6.3% proportion of extraskeletal Ewing sarcoma is lower than the median of 30% estimated from the literature. This difference could be explained by an overestimation of extraskeletal Ewing sarcomas of the chest wall (Askin tumors), an underestimation of periosteal cases confused with extraskeletal cases, and the presence of "Ewing-like" soft tissue sarcomas in previous series. Because of its prognostic and therapeutic impact, the distinction of morphologic subtypes requires the cooperation of experienced radiologists and pathologists.

POS0993 RADIOLOGICAL CERVICAL INVOLVMENT IN ANKYLOSING SPONDYLITIS

Background

Cervical involvement in ankylosing spondylitis (AS) is particularly disabling and has been poorly studied yet. Actual radiologic scoring design to assess disease progression does not provide a comprehensive picture of the cervical involvement in AS. [1] Association with clinical features such as psoriasis are discussed.

Objectives

We aimed to assess radiographic features of cervical involvement in AS and clinico-biological parameters associated with this specific radiographic location.

Methods

Cross-sectional study based on radiographic analysis of a subgroup of patients included in the French BambooSpine cohort, originally designed to study the genetic risk factors of AS structural severity. The analysis was based on patients included in Parisian hospitals to have access to images of the entire spine on the Picture Archiving and Communication System (PACS) shared by all University Hospitals in Paris. A double reading of the images was performed by a rheumatologist/radiologist pair until consensus was reached, to identify syndesmophytes, zygapophyseal joint (ZJ) involvement and posterior ligament structures (PLS) at each cervical level, syndesmophytes in the thoracic region, and ZJ and PLS involvement in the lumbar region.

Results

Of the 113 assessed patients, 101 were men, mean age 53 years (+/- 11 years) with 27 years (+/- 13 years) of disease duration (Table 1). Of those whose HLA B27 status was known, 85% (70/82) were carriers. Among 86 patients with radiological cervical involvement, 83% had syndesmophytes, 86% had ZJ involvement and 24% had PLS involvement. In the cervical region, 13 patients (15%) had zygapophyseal fusion without syndesmophytes. 26/113 patients were completely free of any cervical involvement while 30/113 had a maximal cervical involvement (anterior and posterior). In univariate analyses, HLA-B27 was significantly associated with ZJ involvement at the cervical and lumbar level (p=0.016). Cervical involvement of any type was not associated with psoriasis. Low educational level (not beyond secondary school) was significantly associated with syndesmophytic involvement (p=0.035). There was a non-significant trend for an association between arthritis and ZJ involvement.

Table 1.

Clinical features

Men (n,%)101/11389,4%Age at diagnosis (mean, SD)31,211,68Duration of evolution (mean, SD)27,013,0Smoking ever (n,%)65/11258,0 %Chronic Back Pain (for > 3 months) (n,%)109/11396,5%Chest pain45/11040,9%Buttock pain78/10971,6%Arthritis36/11132,4%Enthesitis38/11233,9%Dactylitis6/1115,4%HLA B2770/8285,4%CRP87/10384,5%X ray sacro-iliitis112/112100%Personnal history -Uveitis41/11336,3% -Inflammatory bowel disease13/11311,5% -Reactive arthritis2/1121,8% -Psoriasis19/11117,1%

Conclusion

Cervical involvement was very frequent (76% of this severe AS population) but not associated with psoriasis, as usually thought. Zygapophyseal involvement was present in 86 % of cases and exclusive in 15 % of cases. This latter radiological form of the disease, i.e. without syndesmophytes, is usually more difficult to diagnose, and should be systematically assessed among AS patients with cervical pain and/or patients with reduced cervical mobility.

References

[1]Wanders AJB, Landewé RBM, Spoorenberg A, et al. What is the most appropriate radiologic scoring method for ankylosing spondylitis? Arthritis & Rheumatism 2004

Disclosure of Interests

None declared

Trait-anger, hostility, and the risk of incident type 2 diabetes and diabetes-related complications: a systematic review of longitudinal studies

Introduction

There is a well-established association between anger, hostility, and an increased risk of cardiovascular disease. Emerging evidence also suggests associations between anger/hostility and type 2 diabetes (T2D), though evidence from longitudinal studies has not yet been synthesized.

Objectives

To systematically review findings from existing prospective cohort studies on trait anger/hostility and the risk of T2D and diabetes-related complications.

Methods

Electronic searches of MEDLINE (PubMed), PsychINFO, Web of Science, and CINAHL were performed for articles/abstracts published up to December 15, 2020. Peer-reviewed longitudinal studies conducted with adult samples, with effect estimates reported for trait anger or hostility and incident T2D or diabetes-related complications, were eligible for inclusion. Risk of bias/study quality was assessed. The review protocol was published a priori in PROSPERO (CRD42020216356) and was in keeping with PRISMA guidelines. Screening for eligibility, data extraction, and quality assessment was conducted by two independent reviewers.

Results

Four studies with a total of 155,146 participants met the inclusion criteria. A narrative synthesis of extracted data was conducted according to the Synthesis Without Meta-Analysis guidelines. While results were mixed, our synthesis suggested a positive association between high trait-anger/hostility and increased risk of incident T2D. No longitudinal studies were identified relating to anger/hostility and incident diabetes-related complications. Geographical locations of the study samples were limited to the USA and Japan.

Conclusions

Further research is needed to investigate whether trait-anger/hostility predicts incident type 2 diabetes after adjustments for potential confounding factors. Longitudinal studies are needed to investigate trait-anger/hostility and the risk of diabetes-related vascular complications.

Disclosure

No significant relationships.

Abstract GS4-07: The Breast PreCancer Atlas DCIS genomic signatures define biology and correlate with clinical outcomes: An analysis of TBCRC 038 and RAHBT cohorts

Background. DCIS consists of a molecularly heterogeneous group of premalignant lesions, with variable risk of invasive progression. Understanding biomarkers for invasive progression could help individualize treatment recommendations based upon tumor biology. As part of the NCI Human Tumor Atlas Network (HTAN), we conducted comprehensive genomic analyses on two large DCIS case-control cohorts. Methods. We performed smart3-seq and low-pass whole genome sequencing on two independent, retrospective, longitudinally sampled DCIS case-control cohorts. TBCRC 038 was a multicenter cohort diagnosed with DCIS between 1998 and 2016 at one of the Translational Breast Cancer Research sites; the RAHBT (Resource of Archival Human Breast Tissue) cohort included women identified through the St. Louis Breast Tissue Repository, and the Women’s Health Repository diagnosed between 1997 and 2001. We studied the spectrum of molecular changes present and sought genomic predictors of subsequent ipsilateral breast events (iBEs: DCIS recurrence or invasive progression) in both DCIS epithelium and stroma in formalin fixed paraffin embedded tissue. We generated de novo tumor and stroma-centric subtypes for DCIS that represents fundamental transcriptomic organization. Copy number analysis was performed using low-pass DNA sequencing. Non-negative matrix factorization (NMF) was applied to the RNA expression of all coding genes to identify clusters. A negative-binomial regression model was used to identify differentially expressed genes. Results. We analyzed 677 DCIS samples from 481 patients with 7.1 years median follow-up. In TBCRC samples, we identified three clusters via NMF in TBCRC referred to as ER low, quiescent, and ER high. The ER-low cluster had significantly higher levels of ERBB2 and lower levels of ESR1 compared to quiescent and ER-high clusters. Quiescent cluster lesions were less proliferative and less metabolically active than ER high and ER low subtypes. These findings were replicated in the RAHBT cohort. Focusing on the stromal component of DCIS from laser capture microdissection in RAHBT samples, we identified four distinct DCIS-associated stromal clusters. A “normal-like” stromal cluster with ECM organization and PI3K-AKT signaling; a “collagen-rich” stromal cluster; a “desmoplastic” stromal cluster with high fibroblast and total myeloid abundance, mostly associated with macrophages and myeloid dendritic cells (mDC); and an “immune-dense” stromal cluster. Further, we compared differentially expressed genes in patients with or without subsequent iBEs within 5 years of diagnosis. Hypothesizing that the resulting 812 DE genes (DESeq2) represent multiple routes to subsequent iBEs, we leveraged NMF to identify paths to progression. In both TBCRC and RAHBT cohorts, poor outcome groups exhibited increased ER, MYC signaling, and oxidative phosphorylation, supporting that these pathways are important for DCIS recurrence and progression. Conclusion. Comprehensive genomic profiling in two independent DCIS cohorts with longitudinal outcomes shows distinct DCIS stromal expression patterns and immune cell composition. RNA expression profiles reveal underlying tumor biology that is associated with later iBEs in both cohorts. These studies provide new insight into DCIS biology and will guide the design of diagnostic strategies to prevent invasive progression.

Citation Format: Siri H Strand, Belén Rivero-Gutiérrez, Kathleen E Houlahan, Jose A Seoane, Lorraine M King, Tyler Risom, Lunden Simpson, Sujay Vennam, Aziz Khan, Timothy Hardman, Bryan E Harmon, Fergus J Couch, Kristalyn Gallagher, Mark Kilgore, Shi Wei, Angela DeMichele, Tari King, Priscilla F McAuliffe, Julie Nangia, Joanna Lee, Jennifer Tseng, Anna Maria Storniolo, Alastair Thompson, Gaorav Gupta, Robyn Burns, Deborah J Veis, Katherine DeSchryver, Chunfang Zhu, Magdalena Matusiak, Jason Wang, Shirley X Zhu, Jen Tappenden, Daisy Yi Ding, Dadong Zhang, Jingqin Luo, Shu Jiang, Sushama Varma, Cody Straub, Sucheta Srivastava, Christina Curtis, Rob Tibshirani, Robert Michael Angelo, Allison Hall, Kouros Owzar, Kornelia Polyak, Carlo Maley, Jeffrey R Marks, Graham A Colditz, E Shelley Hwang, Robert B West. The Breast PreCancer Atlas DCIS genomic signatures define biology and correlate with clinical outcomes: An analysis of TBCRC 038 and RAHBT cohorts [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr GS4-07.

Abstract PD5-08: The human tumor atlas network (HTAN) breast pre cancer atlas: A multi-omic integrative analysis of ductal carcinoma in situ (DCIS) and correlation with clinical outcomes

Introduction. As nonobligate precursors of invasive disease, pre-cancers provide a unique vantage point from which to study the molecular pathways and evolutionary dynamics that lead to the development of life-threatening cancers. Ductal carcinoma in situ (DCIS) is the most commonly diagnosed precursor of breast cancer, with variable propensity for invasive progression. In order to address the problems of over- and under-treatment, we performed a multimodal, integrated profile of DCIS with clinical outcomes with which to develop and validate predictors of invasive progression. Methods. We present observations on DNA, RNA, and protein expression on two independent patient cohorts of DCIS, diagnosed from 1981 to 2014, from the Translational Breast Cancer Research Consortium (TBCRC 038) and the Washington University Repository of Archival Human Breast Tissue (RAHBT). Patients initially diagnosed with DCIS, with either DCIS or invasive recurrence (cases; mean follow up 5.8 years) were matched to those without recurrence (controls; mean follow up 10.3 years), based upon age at diagnosis and year of diagnosis. Results. We present genomic and cellular changes that correlate with both disease states and patient outcomes in DCIS. DCIS can be clustered by classification systems developed for IBC. Specific immune cell types and pathways correlate with longitudinal outcome. Luminal cell adhesion and metabolism pathways are upregulated in controls and cases, respectively. Highly multiplexed ion beam imaging (MIBI) was used to validate RNA seq findings, and to provide single cell-level spatial context for molecular alterations.Conclusion. We have performed an integrated multi-omic analysis of DCIS and associated tumor micorenvironment. Our multi-scale approach employs in situ methods to generate a spatially resolved atlas of breast precancers where different modalities can be directly compared to each other, and correlated with conventional pathology findings and clinical outcome. The PreCancer Atlas represents a complex multi-modal database for DCIS study, whose design allows for future discovery and hypothesis generation.

Table 1. Breast Pre-cancer Atlas Multi-scale Characterization AssaysAssayScaleType of DataIntegration and validation with other assaysRNA-seq (Single duct, single cell, TME)Cell, duct, organ, normal tissue1. Whole transcriptome gene expression profiling per single duct (also enabling CNV and cell type prediction)2. Whole transcriptome gene expression profiling per single duct1. Prediction of CNV confirmed by DNA-seq (single duct) and FISH (single cell)2. Prediction of cell type composition (Cibersort) confirmed by multiplex IHC and multicolor flow cytometryLow-pass whole genome DNA-seqDuct and adjacent normalCNV profiling per single ductAnalysis of CNV supported by RNA-seq (single duct) and MIBI (single cell)Whole genome sequencingDuct and adjacent normalMutation status per single ductMutational analysis confirmed by RNA-seqMultiplex IHC (MIBI & Cyclic multicolor)Cell1. Cell type2. Proteomic analysisAnalysis of cell type supported by RNA-seq of ducts (Cibersort) and single cellsH&E MorphometricsCell, duct, organSpatial location of cell types, organization of ductsAnalysis of H&E images correlated with FISH data

Citation Format: Shelley Hwang, Siri H Strand, Belen Rivero, Lorraine King, Tyler Risom, Bryan Harmon, Fergus Couch, Kristalyn Gallagher, Mark Kilgore, Shi Wei, Angela DeMichele, Tari King, Priscilla McAuliffe, Julie Nangia, Ana Maria Storniolo, Alastair Thompson, Gaorav Gupta, Joanna Lee, Jennifer Tseng, Robyn Burns, ChunFang Zhu, Magda Matusiak, Shirley X Zhu, Jason Wang, Jose Seoane, Jen Tappenden, Daisy Ding, Dadong Zhang, Jingqin Luo, Sujay Vennam, Sushama Varma, Lunden Simpson, Luis Cisneros, Timmothy Hardman, Lauren Anderson, Cody Straub, Sucheta Srivastava, Deb J Veis, Christina Curtis, Rob Tibshirani, Robert Michael Angelo, Allison Hall, Kouros Owzar, Kornelia Polyak, Carlo Maley, Jeff Marks, Graham Colditz, Robert B West. The human tumor atlas network (HTAN) breast pre cancer atlas: A multi-omic integrative analysis of ductal carcinoma in situ (DCIS) and correlation with clinical outcomes [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD5-08.

Developing a smartphone app with UK migrants for UK migrants: lessons learned from focus group work

Background

In 2018, 14% of people living in the UK were born abroad, yet we have a limited understanding of the broader determinants of their health. To address this knowledge gap, the Health on the MovE (HOME) smartphone application (app) study was conceived. Through app-based surveys, the study will examine how risk factors for health and well-being are distributed among migrants and how these vary over time since migration to the UK. There is a lack of research addressing the development of apps for longitudinal data collection in the general population - and we did not find any in migrant groups.

Methods

To better inform the design of the HOME app study, three workshops were held in 2018 and 2019, involving both migrants and App development experts. We used a semi-structured interview schedule focused on five themes: smartphones, apps and research, HOME app wireframe (screen-by-screen review of the app), types of surveys and survey schedules, resource section content, and participant engagement strategies. The participants were purposively sampled to reflect the migrant population arriving in the UK from non-EU countries.

Results

Migrants reported high smartphone use and were positive about the app design and app-based research. Concerns around privacy and data protection were highlighted and limits were suggested for the frequency of surveys and the number of questions used. Mental health was identified as a key topic for research. Participants requested the inclusion of resources concerning asylum claim procedures and immigrant and labour laws. Migrants advised that study recruitment material should clearly state the purpose and scope of the research and requested regular feedback on study outcomes.

Conclusions

The workshops provided important feedback and facilitated the co-production of the HOME app. Overall findings suggest that the study would be both acceptable to the migrant population and feasible for real-time data collection.

Key messages

The process identified potential barriers to the acceptability and feasibility of an app-based study for real-time data collection in the UK migrant population. Organising workshops with migrants allowed for an iterative process of co-production of the HOME app. Their critical comments resulted in subsequent changes to the app design and study methodology.

Validity of UK electronic health records to study migrant health: a population-based cohort study

Background

An estimated 14.3% (9.4 million people) of people living in the UK in 2019 were international migrants. Despite this, little is known about how migrants access and use healthcare services. To use electronic healthcare records (EHRs) to study migration health, a valid migration phenotype is necessary: a transparent reproducible algorithm using clinical terminology codes to determine migration status. We have previously described the validity of a migration phenotype in CALIBER data using the Clinical Practice Research Datalink (CPRD), the largest UK primary care EHR. This study further evaluates the phenotype by examining certainty of migration status.

Methods

This is a population-based cohort study of individuals in CPRD Gold (1997-2018) with a Read term indicating migration to the UK. We describe completeness of recording of migration over time: percentage of individuals recorded as migrants. We also describe cohort size based on certainty of migration status: “definite” (country of birth or visa status terms), “probable” (non-English first/main language terms), and “possible” (non-UK origin terms).

Results

Overall, 2.5% (403,768/16,071,111) of CPRD had ≥1 of 434 terms indicating migration to the UK. The percentage of recorded migrants per year increased from 0.2% (4,417/2,210,551) in 1997 to 3.64% (100,626/2,761,397) in 2018, following a similar trend to national migration data. 44.27% (178,749/403,768) were “definite” migrants and 53.68% (216,731/403,768) were “probable” migrants. Only 2.05%(8,288/16,071,111) were “possible” migrants.

Conclusions

We have created a large cohort of international migrants in the UK and certainty of migration status is high. This cohort can be used to study migration health in UK primary care EHR. The large contribution of language terms make this phenotype particularly suitable for understanding healthcare access and use by non-English speaking migrants who may face additional barriers to care.

Key messages

We have developed a way to study migration health in UK primary care electronic health records. Our method is particularly useful to study healthcare for non-English speaking migrants who may face additional barriers to care.

Left behind: the state of universal health coverage in Europe

Background

Barriers to access healthcare and lack of data undermine Universal Health Coverage (UHC) in Europe, despite the region's clear commitment to the Sustainable Development Goals and UHC. Current indicators measuring unmet healthcare needs in the European Union (EU) often exclude more marginalised groups, further rendering their health needs invisible and the data to inform policy flawed. For effective evaluation of UHC, comprehensive data on the health of these groups is needed.

Methods

We conducted an evaluation of humanitarian healthcare provision of people attending Médecins du Monde (MdM) programmes in seven countries in Europe (Belgium, France, Germany, Luxembourg, Sweden, Switzerland, and the United Kingdom). MdM is a humanitarian organisation, providing care to those excluded from mainstream healthcare services. We describe the characteristics of MdM service users, their determinants of health and healthcare access.

Results

A total of 29,359 people were seen between January 2017 and December 2018. Nearly all were migrants (97.2%, 21,591/22,136), with 66.3% (11,690/17,629) of people reported not having a right or permission to reside in the country they presented in. A majority were living below the poverty line (92.6%, 7,660/8,268), residing in insecure housing (44.3%, 8,895/20,097) or living as street homeless or in emergency shelters (20.4%, 4,107/20,097). Most people reported having no healthcare coverage (81.7%, 14,848/18,164). When asked about barriers to accessing healthcare, 20.8% of responses reported economic barriers (3,960/19,020) and 14.3% reported a lack of knowledge of health system/entitlements (2,718/19,020).

Conclusions

This humanitarian service evaluation highlights the intersecting vulnerabilities and barriers to access healthcare for people excluded from mainstream healthcare systems across Europe. Our findings provide a unique insight into the extent of unmet healthcare needs of migrants and other marginalised populations.

Key messages

UHC requires comprehensive data on the population groups who are many times left without access to health services and who are often excluded from national data collection and research. A majority of MdM service users do not have healthcare coverage and experience multiple and intersecting barriers to access healthcare across Europe.

1 Review of the Identification and Management of Contractures in Inpatients with Dementia In A District General Hospital

Background

Patients with dementia are at risk of contractures which are associated with pain, pressure sores, increased carer burden and reduced function (1). It has been estimated up to 55% of residents in nursing homes have a contracture (2). Locally, patients are identified and treated in care homes. We questioned why comparatively few hospital inpatients were seen.

Methods

We audited acute elderly inpatients at a large district general hospital on two days. Patients with a diagnosis of dementia were identified and then checked for contractures. Information was collected on a proforma. Patients audited on day one were excluded from day two.

Results

410 patients were audited. 100 patients were identified with dementia. 21 individual contractures were identified with the hands been the most common site (47.6%). Only three contractures had been highlighted in the medical notes. Patients with contractures were more likely to be at home with carers or in a care facility (93.7% verse 64.3%). None of the patients with contractures were independently mobile. Higher proportions (31.2% vs 8.3%) with contractures were bedbound compared to those without. Complications were identified, with two patients reporting pain and three patients having pressure sores. Only one patient was receiving treatment for their contractures. Patients with contractures were more likely to have a higher frailty score, had a previous stroke (37.5% verse 13.1%) and have a vascular type dementia (31.3% verse 14.2%).

Conclusions

Contractures were a significant problem in our inpatient population in patients with a diagnosis of dementia. A large proportion were not identified by the clerking team, not receiving treatment and beginning to have complications. Subsequently a presentation highlighting this issue was carried out to junior doctors on the elderly wards, a coding proforma for contractures was produced and a guide to management of this issue is being put together for use in the inpatient setting.

References

1. Souren L, Franssen, Reisberg E. Contractures and loss of function in patients with Alzheimer's disease, J. Am. Geriatr. Soc. 1995; 43(6): 650–655.

2. Offenbacher M, Sauer S, Riess J, Muller M, et al. Disabil Rehabil 2013; 36(7): 529–538.

Dactylitis: A pictorial review of key symptoms

Dactylitis refers to a global swelling of a finger or a toe giving it a clinical sausage-shape presentation. It is an extremely suggestive symptom as it guides the rheumatologist towards a shortlist of diagnoses. However, radiologists are less familiar with dactylitis. The aim of this review is to detail and illustrate the main causes of dactylitis using standard X-ray imaging, ultrasound, computed tomography and magnetic resonance imaging in order to make radiologists more familiar with this symptom by illustrating the various conditions that are associated with dactylitis including infection, peripheral spondyloarthritis, sarcoidosis, microcrystalline deposition, osteoid osteoma, and sickle cell disease.

Pre- and Postoperative Neratinib for HER2-Positive Breast Cancer Brain Metastases: Translational Breast Cancer Research Consortium 022

PURPOSE

This pilot study was performed to test our ability to administer neratinib monotherapy before clinically recommended craniotomy in patients with HER2-positive metastatic breast cancer to the central nervous system, to examine neratinib's central nervous system penetration at craniotomy, and to examine postoperative neratinib maintenance.

PATIENTS AND METHODS

Patients with HER2-positive brain metastases undergoing clinically indicated cranial resection of a parenchymal tumor received neratinib 240 mg orally once a day for 7 to 21 days preoperatively, and resumed therapy postoperatively in 28-day cycles. Exploratory evaluations of time to disease progression, survival, and correlative tissue, cerebrospinal fluid (CSF), and blood-based analyses examining neratinib concentrations were planned. The study was registered at ClinicalTrials.gov under number NCT01494662.

RESULTS

We enrolled 5 patients between May 22, 2013, and October 18, 2016. As of March 1, 2019, patients had remained on the study protocol for 1 to 75+ postoperative cycles pf therapy. Two patients had grade 3 diarrhea. Evaluation of the CSF showed low concentrations of neratinib; nonetheless, 2 patients continued to receive therapy without disease progression for at least 13 cycles, with one on-study treatment lasting for nearly 6 years. Neratinib distribution in surgical tissue was variable for 1 patient, while specimens from 2 others did not produce conclusive results as a result of limited available samples.

CONCLUSION

Neratinib resulted in expected rates of diarrhea in this small cohort, with 2 of 5 patients receiving the study treatment for durable periods. Although logistically challenging, we were able to test a limited number of CSF- and parenchymal-based neratinib concentrations. Our findings from resected tumor tissue in one patient revealed heterogeneity in drug distribution and tumor histopathology.

TBCRC 022: A Phase II Trial of Neratinib and Capecitabine for Patients With Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer and Brain Metastases

PURPOSE

Evidence-based treatments for metastatic, human epidermal growth factor receptor 2 (HER2)-positive breast cancer to the CNS are limited. We previously reported modest activity of neratinib monotherapy for HER2-positive breast cancer brain metastases. Here we report the results from additional study cohorts.

PATIENTS AND METHODS

Patients with measurable, progressive, HER2-positive brain metastases (92% after receiving CNS surgery and/or radiotherapy) received neratinib 240 mg orally once per day plus capecitabine 750 mg/m² twice per day for 14 days, then 7 days off. Lapatinib-naïve (cohort 3A) and lapatinib-treated (cohort 3B) patients were enrolled. If nine or more of 35 (cohort 3A) or three or more of 25 (cohort 3B) had CNS objective response rates (ORR), the drug combination would be deemed promising. The primary end point was composite CNS ORR in each cohort separately, requiring a reduction of 50% or more in the sum of target CNS lesion volumes without progression of nontarget lesions, new lesions, escalating steroids, progressive neurologic signs or symptoms, or non-CNS progression.

RESULTS

Forty-nine patients enrolled in cohorts 3A (n = 37) and 3B (n = 12; cohort closed for slow accrual). In cohort 3A, the composite CNS ORR = 49% (95% CI, 32% to 66%), and the CNS ORR in cohort 3B = 33% (95% CI, 10% to 65%). Median progression-free survival was 5.5 and 3.1 months in cohorts 3A and 3B, respectively; median survival was 13.3 and 15.1 months. Diarrhea was the most common grade 3 toxicity (29% in cohorts 3A and 3B).

Neratinib plus capecitabine is active against refractory, HER2-positive breast cancer brain metastases, adding additional evidence that the efficacy of HER2-directed therapy in the brain is enhanced by chemotherapy. For optimal tolerance, efforts to minimize diarrhea are warranted.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Iodine Status over Two Decades: Influence of Seaweed Exposure

Iodine deficiency is known to result in deficits in neuropsychological development in children born to iodine deficient mothers. However, a remedy in terms of iodisation of table salt as is the norm in most countries, has not been embraced by Ireland. The borderline iodine status of the Irish population persists unchanged over the past 20 years with the annual median urinary iodine (UI) varying from 62.9 to 105 μg/L; overall median 72.4 μg/L (WHO recommended 100 μg/L). Exposure to a seaweed rich environment allowing for intake by respiration of seaweed derived gaseous iodine, rather than simple proximity to the sea, confers advantages in terms of iodine intake with 21/46 (45.6%) of schoolchildren in seaweed rich coastal areas having UI values > 150 μg/L compared to 1/28 (3.6 %) and 2/93 (2.2%) in low seaweed abundant coastal and inland areas respectively. The corresponding values for adult females were 31/72 (43%), 7/60 (11.6%) and 21/132 (16.0%). The findings support introduction of iodine prophylaxis through Universal Salt Iodisation (USI), to ensure that women of child bearing age have access to sufficient dietary iodine.

Depressive symptoms and glycated hemoglobin A1c: a reciprocal relationship in a prospective cohort study

BACKGROUND

The aim of this study was to evaluate the dynamic association between depressive symptoms and glycated hemoglobin A1c (HbA1c) levels using data from the English Longitudinal Study of Ageing (ELSA).

METHOD

The sample was comprised of 2886 participants aged ⩾50 years who participated in three clinical assessments over an 8-year period (21% with prediabetes and 7% with diabetes at baseline). Structural equation models were used to address reciprocal associations between depressive symptoms and HbA1c levels and to evaluate the mediating effects of lifestyle-related behaviors and cardiometabolic factors.

RESULTS

We found a reciprocal association between depressive symptoms and HbA1c levels: depressive symptoms at one assessment point predicted HbA1c levels at the next assessment point (standardized β = 0.052) which in turn predicted depressive symptoms at the following assessment point (standardized β = 0.051). Mediation analysis suggested that both lifestyle-related behaviors and cardiometabolic factors might mediate the association between depressive symptoms and HbA1c levels: depressive symptoms at baseline predicted lifestyle-related behaviors and cardiometabolic factors at the next assessment, which in turn predicted HbA1c levels 4 years later. A similar association was observed for the other direction: HbA1c levels at baseline predicted lifestyle-related behaviors and cardiometabolic factors at the next assessment, which in turn predicted depressive symptoms 4 years later.

CONCLUSIONS

Our results suggest a dynamic relationship between depressive symptoms and HbA1c which might be mediated by both lifestyle and cardiometabolic factors. This has important implications for investigating the pathways which could link depressive symptoms and increased risk of diabetes.

The criterion-referenced validity of the FITNESSGRAM Trunk-Extension test

AIM

The purpose of this study was to test utility of different fitness field tests to predict self-reported low-back pain (LBP) in youth.

METHODS

A sample of 376 school aged (4th through 10th grade students) first completed a survey instrument designed to assess past events (and degree) of LBP. On subsequent days, participants completed a battery of different muscular fitness tests including the current FITNESSGRAM trunk extension test. Receiver operator characteristic curves (ROC) were used to test the utility of single and combined scores from various tests to predict self-reported LBP.

RESULTS

The results show that the trunk extension test used in FITNESSGRAM has poor utility for predicting self-reported LBP. In girls, the sit-and-reach, the static curl-up test, and a composite score using static and dynamic curl-up scores had the highest Area Under the Curve (AUC=0.80, 0.71, and 0.79, respectively). Sensitivity (Se) values ranged from 75.0-85.7 while Specificity (Sp) ranged from 59.1-81.4. In boys, the dynamic curl-up test alone was the best predictor of LBP in high-school boys (AUC=0.75, Sensitivity=75.0 and Specificity=74.1).

CONCLUSION

The reasonable Sensitivity values from the ROC analyses indicate that individual and aggregate indicators of musculoskeletal fitness can potentially identify girls that had LBP in the past. However, the low values for Specificity indicates that girls with "No LBP" can be misclassified as being at risk for LBP. The current FITNESSGRAM trunk extension test was not able to discriminate between students with and without LBP therefore, the utility of this test for fitness assessment in youth should be revisited.

Regulation of iodide uptake in placental primary cultures

BACKGROUND

Maintenance of adequate iodide supply to the developing fetus is dependent not only on maternal dietary iodine intake but also on placental iodide transport. The objective of this study was to examine the effects of different pregnancy-associated hormones on the uptake of radioiodide by the placenta and to determine if iodide transporter expression is affected by hormone incubation.

METHODS

Primary cultures of placental trophoblast cells were established from placentas obtained at term from pre-labor caesarean sections. They were pre-incubated with 17β-estradiol, prolactin, oxytocin, human chorionic gonadotropin (hCG) and progesterone either singly or in combination over 12 h with (125)I uptake being measured after 6 h. RNA was isolated from placental trophoblasts and real-time RT-PCR performed using sodium iodide symporter (NIS) and pendrin (PDS) probes.

RESULTS

Significant dose response increments in (125)I uptake by trophoblast cells (p < 0.01) were observed following incubation with hCG (60% increase), oxytocin (45% increase) and prolactin (32% increase). Although progesterone (50-200 ng/ml) and 17β-estradiol (1,000-15,000 pg/ml) alone produced no significant differences in uptake, they facilitated increased uptake when combined with prolactin or oxytocin, with a combination of all four hormones producing the greatest increase (82%). Increased (125)I uptake was accompanied by corresponding increments in NIS mRNA (ratio 1.52) compared to untreated control cells. No significantly increased expression levels of PDS were observed.

CONCLUSIONS

Pregnancy-associated hormones, particularly oxytocin and hCG, have a role in promoting placental iodide uptake which may protect the fetus against iodine deficiency.

P1-08-10: Invasive Lobular Breast Cancer – No Increased Risk of Contralateral Disease

Background: Invasive lobular carcinoma (ILC) is the second most common type of breast cancer accounting for up to 14% of invasive breast cancers. Worldwide the incidence of breast cancer is increasing each year. Large population based studies using the Surveillance, Epidemiology, and End results (SEER) data have shown that the incidence of ILC has increased from 1977 to 1995. ILC has historically been thought to be associated with an increased risk of developing contralateral breast cancer and this belief may, in part, be responsible for the increasing trend towards contralateral prophylactic mastectomy.

Methods: All female patients diagnosed with breast cancer during the time period 1998–2003 were identified from two large cancer registries, Northern and Yorkshire Cancer Registry and Information Service (NYCRIS) and West Midlands Cancer Intelligence Unit (WMCIU). All patients diagnosed with either Infiltrating duct(adeno) carcinoma, microinvasive ductal carcinoma, infiltrating ductular carcinoma (all classified as ‘ductal') or lobular (adeno)carcinoma were included. Patients with a mixed type of breast cancer were excluded from the analysis. Follow-up was complete until October 2010. Data were compiled for diagnosed contralateral breast cancer of any histological type.

Results: Of the 32,735 patients with invasive ductal cancer 898 (2.74%) developed a contralateral breast cancer. In comparison 166 (3.1%) of 5397 patients with lobular cancer developed a contralateral breast cancer. The median time to first contralateral event was equivalent for both morphologies (ductal 40 months and lobular 39 months).

Conclusion: This study suggests that there is no increased risk for developing a contralateral breast cancer in patients diagnosed with an invasive lobular breast cancer.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-10.

Kr-PLIF for scalar imaging in supersonic flows

Experiments were performed to explore the use of two-photon planar laser-induced fluorescence (PLIF) of krypton gas for applications of scalar imaging in supersonic flows. Experiments were performed in an underexpanded jet of krypton, which exhibited a wide range of conditions, from subsonic to hypersonic. Excellent signal-to-noise ratios were obtained, showing the technique is suitable for single-shot imaging. The data were used to infer the distribution of gas density and temperature by correcting the fluorescence signal for quenching effects and using isentropic relations. The centerline variation of the density and temperature from the experiments agree very well with those predicted with an empirical correlation and a CFD simulation (FLUENT). Overall, the high signal levels and quantifiable measurements indicate that Kr-PLIF could be an effective scalar marker for use in supersonic and hypersonic flow applications.

Is placental iodine content related to dietary iodine intake?

OBJECTIVE

Delivery of iodine to the foetus depends not only on maternal dietary iodine intake but also on the presence of a functioning placental transport system. A role for the placenta as an iodine storage organ has been suggested, and this study compares the iodine content of placentas from women giving birth at term in Ireland and Iran, areas with median urinary iodine of 79 and 206 μg/l respectively.

DESIGN

Placental cotyledon iodine was measured using an alkaline ashing technique with Sandell-Kolthoff kinetic colorimetry. Samples were taken from six sites from the centre and periphery of each cotyledon. Placentas (Ireland n = 58; Iran n = 45) were obtained from consecutive euthyroid women delivering at term.

RESULTS

The median placental iodine (μg/g wet weight) was significantly higher in Iranian than in Irish women (187·2 μg/g vs 34·3 μg/g; P < 0·001). The distribution of individual placental iodine values showed that values >50μg/g were found in 71·0% of Iranian and in only 21·0% of Irish samples. In Irish subjects, the relationship of placental iodine to pregnant population urinary iodine (UI) (ng/g:μg/l) was 1:2 (40:79), while in Iranians this ratio is closer to 1:1 (211:206).

CONCLUSIONS

These findings, by demonstrating an apparent ability of the placenta to store iodine in a concentration-dependent manner, suggest a hitherto undetected role for the placenta. Whether placental iodine has a role in protecting the foetus from inadequacies in maternal dietary iodine intake is as yet unknown.

Does iodine gas released from seaweed contribute to dietary iodine intake?

Thyroid hormone levels sufficient for brain development and normal metabolism require a minimal supply of iodine, mainly dietary. Living near the sea may confer advantages for iodine intake. Iodine (I(2)) gas released from seaweeds may, through respiration, supply a significant fraction of daily iodine requirements. Gaseous iodine released over seaweed beds was measured by a new gas chromatography-mass spectrometry (GC-MS)-based method and iodine intake assessed by measuring urinary iodine (UI) excretion. Urine samples were obtained from female schoolchildren living in coastal seaweed rich and low seaweed abundance and inland areas of Ireland. Median I(2) ranged 154-905 pg/L (daytime downwind), with higher values (~1,287 pg/L) on still nights, 1,145-3,132 pg/L (over seaweed). A rough estimate of daily gaseous iodine intake in coastal areas, based upon an arbitrary respiration of 10,000L, ranged from 1 to 20 μg/day. Despite this relatively low potential I(2) intake, UI in populations living near a seaweed hotspot were much higher than in lower abundance seaweed coastal or inland areas (158, 71 and 58 μg/L, respectively). Higher values >150 μg/L were observed in 45.6% of (seaweed rich), 3.6% (lower seaweed), 2.3% (inland)) supporting the hypothesis that iodine intake in coastal regions may be dependent on seaweed abundance rather than proximity to the sea. The findings do not exclude the possibility of a significant role for iodine inhalation in influencing iodine status. Despite lacking iodized salt, coastal communities in seaweed-rich areas can maintain an adequate iodine supply. This observation brings new meaning to the expression "Sea air is good for you!"

Penetrating skull and brain injury due to a dog bite: a cautionary tale for the unwary

We describe a rare case of depressed skull fracture after a dog bite. To our knowledge only three such cases have been reported.

High crystalline quality single crystal chemical vapour deposition diamond

Homoepitaxial chemical vapour deposition (CVD) on high pressure, high temperature (HPHT) synthetic diamond substrates allows the production of diamond material with controlled point defect content. In order to minimize the extended defect content, however, it is necessary to minimize the number of substrate extended defects that reach the initial growth surface and the nucleation of dislocations at the interface between the CVD layer and its substrate. X-ray topography has indicated that when type IIa HPHT synthetic substrates are used, the density of dislocations nucleating at the interface can be less than 400  cm(-2). X-ray topography, photoluminescence imaging and birefringence microscopy of HPHT grown synthetic type IIa diamond clearly show that the extended defect content is growth sector dependent. ⟨111⟩ sectors contain the highest concentration of both stacking faults and dislocations but ⟨100⟩ sectors are relatively free of both. It has been shown that HPHT treatment of such material can significantly reduce the area of stacking faults and cause dislocations to move. This knowledge, coupled with an understanding of how growth sectors develop during HPHT synthesis, has been used to guide selection and processing of substrates suitable for CVD synthesis of material with high crystalline perfection and controlled point defect content.

A comparison of patient-reported outcomes (PROs) in National Cancer Institute-sponsored cancer treatment trials conducted during two time periods: 1999–2003 and 2003–2008

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Background: Over the past decade, the U.S. National Cancer Institute (NCI) support for incorporating Patient-Reported Outcomes (PROs) into disease treatment clinical trials has grown considerably, both in the number of trials, as well as the types of research questions being addressed and the measures used to answer the questions. This presentation will compare the breadth of NCI supported Phase III treatment trials in breast, colo-rectal, lung, and prostate cancers that include PRO secondary endpoints activated during two time periods: 1999–2003 and 2003–2008. Both time periods will be compared to identify the number and type of PRO measures; in addition the targeted PRO domain will be examined by cancer site. Methods: For this study, PRO was broadly defined to include any self-report questionnaire that gathered data on the potential impact that disease treatment might have on patient functioning, quality of life, or symptoms. Using the terms, 'protocol title, lead disease, phase III, quality of life, and instrument name,’ a search was conducted of the NCI database containing breast, colo-rectal, lung, and prostate Phase III treatment trials activated during the two time periods. If a scale was used more than once or if different versions of the scale were used, i.e., FACT-G and FACT-BR, it was only counted once. Results: Between 1999 and 2003, 42 phase III trials in the four major cancers were activated, with 15 trials having one or more PROs as secondary endpoints. Between 2003 and 2008, 50 phase III trials in the four major cancers were activated, with 28 trials having one or more PROs as secondary endpoints. Although the data reveal a 20% increase in the number of phase III trials in the 4 diseases between the two time periods, the number of trials with PRO endpoints has doubled. Conclusions: This significant increase in the use of PROs in phase III trials gives investigators additional data to fully analyze the impact of new treatments. These PRO data will provide researchers, clinicians, and future patients with a more in-depth understanding of the potential for new cancer therapies and technologies to extend both the quantity and quality of life.

No significant financial relationships to disclose.

Evaluation of diabetes determinants in woolly monkeys (Lagothrix lagotricha)

Woolly monkeys (Lagothrix lagotricha) are a threatened specie in the wild with limited successful management in captivity due to diagnosed hypertension and suspected diabetic conditions. Six woolly monkeys with known hypertension problems were tested to determine if diabetes mellitus and current daily diet are underlying links to health problems for the captive population of this species. Blood and urine were collected and serum was analysed for fructosamine, glucose, glycated haemoglobin, insulin, triacylglycerides, total cholesterol, high-density lipoprotein cholesterol (HDL-Chol) and low-density lipoprotein cholesterol (LDL-Chol) while urine was tested for glucose concentrations. Diet disappearance was determined for 3 days prior to blood collection and nutrient content was calculated using Zoo Diet Analysis computer program. Serum analyses were within normal ranges (fructosamine (139-242 micromol/l), glucose (2.22-4.78 mmol/l), glycated haemoglobin (3.52-4.73%), insulin (6.2-13.0 microU/ml), triacylglycerides (0.38-3.4 mmol/l), total cholesterol (2.5-5.1 mmol/l), HDL-Chol (0.4-1.6 mmol/l) and LDL-Chol (1.8-3.4 mmol/l)). Urine glucose concentrations were below the detection limit. Diets were not limiting in starch and total sugars and were similar in non-starch polysaccharides. Potential dietary deficiencies were noted for vitamin A, vitamin D, calcium, phosphorus and selenium. When compared with the available primate reference ranges, the results do not indicate problems with diabetes mellitus or with glucose metabolism and therefore they are not causes of the diagnosed hypertension. Further research to ascertain the true cause of health related problems and the role of dietary factors is needed.

Short-term changes in maternal and neonatal urinary iodine excretion

Investigation of maternal urinary iodine (UI) excretion in the immediate antenatal and early postpartum periods showed a precipitous fall in median values from 93 microg/L antenatally to 36 microg/L at delivery subsequently rising to 49 microg/L and 63 microg/L at days 3 and 10 postpartum respectively. The fate of ingested iodine not appearing in the maternal urine is unknown but measurement of UI in babies born to nursing mothers suggested transfer from the mother with median neonatal values of 117 and 159 microg/L being recorded at days 3 and 10. While maternal UI seemed to relatively unaffected by breast feeding, median UI from breast feeding babies (148 microg/L) was significantly greater than in those bottle feeding (50 microg/L). This was also reflected by the finding that no breast feeding baby had a UI values < 50 microg/L in comparison to 50% of bottle feeders. The depressed values in mothers and relatively high values in their infants could present a false picture and suggest the need to defer any investigations of iodine status at this time. The findings do however suggest a need for further investigations aimed at determining the fate of iodine ingested perinatally and its possible physiological significance in maintaining thyroid status in the mother and neonate.

Reducing transfer times for coronary angiography in patients with acute coronary syndromes: one solution to a national problem

BACKGROUND

Patients with acute coronary syndrome (ACS) are at high risk of further cardiac events and benefit from early intervention, as reflected by international guidelines recommending early transfer to interventional centres. The current average waiting time of up to 21 days contravenes evidence based early intervention, creates geographical inequity of access, wastes bed days, and is unsatisfactory for patients.

METHODS

A regional transfer unit (RTU) was created to expatriate access of ACS patients referred from other centres to the revascularisation service. By redesigning the care pathway patients arriving on the RTU undergo angiography within 24 hours, and then leave the RTU the following day, allowing other ACS patients to be treated.

RESULTS

During the first six months of the RTU, the mean waiting time from referral to procedure decreased from 20 (SD 15) days (range 0-51) to 8 (SD 3) days (range 0-21) for 365 patients transferred from a district general hospital. Ninety seven per cent of patients underwent angiography within 24 hours, 61% having undergone percutaneous coronary intervention at the same sitting, and 78% were discharged home within 24 hours.

CONCLUSIONS

Delivering standards laid out in the National Service Framework, reducing inequalities of care across the region, and facilitating evidence based strategies of care represents a challenging and complex issue. For high risk patients suffering ACS who need early invasive investigation, a coordinated network wide approach together with the creation of an RTU resulted in a 62% reduction in waiting times for no extra resources. Further improvements can be expected through increased capacity of this verified strategy.

Iodine intake in pregnancy in Ireland — A cause for concern?

BACKGROUND

Adequate dietary iodine intake is necessary to maintain maternal thyroid function at a level permitting normal neuropsychological development of the foetus.

AIMS AND METHODS

To determine dietary iodine status by measuring urinary iodine excretion (UIE), proportional to dietary intake, in Irish mothers during the first trimester of pregnancy.

RESULTS

Median UIE showed seasonal variations, being lower in summer than in winter. The median values in pregnant women were, summer 45microg/l, winter 68microg/l. Equivalent values for controls were 43 and 91microg/l respectively. UIE required to achieve WHO recommended daily iodine intakes would be 120-180microg/l. In the Irish subjects UIE values suggestive of iodine deficiency (<50microg/l) were observed in 55% of pregnant women tested in summer and 23% in winter. Dairy milk iodine, a major dietary iodine source, showed similar variation.

CONCLUSIONS

While there is as yet no available evidence of widespread thyroid hypofunction in the Irish obstetric population, the findings are a cause of concern, which if confirmed by a more comprehensive investigation, may indicate the need for iodine prophylaxis.

Anterior hypothalamic vasopressin modulates the aggression-stimulating effects of adolescent cocaine exposure in Syrian hamsters

Repeated low-dose cocaine treatment (0.5 mg/kg/day) during adolescence induces offensive aggression in male Syrian hamsters (Mesocricetus auratus). This study examines the hypothesis that adolescent cocaine exposure predisposes hamsters to heightened levels of aggressive behavior by increasing the activity of the anterior hypothalamic-vasopressinergic neural system. In a first experiment, adolescent male hamsters were treated with low-dose cocaine and then scored for offensive aggression in the absence or presence of vasopressin receptor antagonists applied directly to the anterior hypothalamus. Adolescent cocaine-treated hamsters displayed highly escalated offensive aggression that could be reversed by blocking the activity of vasopressin receptors within the anterior hypothalamus. In a second set of experiments, adolescent hamsters were administered low-dose cocaine or vehicle, tested for offensive aggression, and then examined for differences in vasopressin innervation patterns and expression levels in the anterior hypothalamus, as well as the basal- and stimulated-release of vasopressin in this same brain region. Aggressive, adolescent cocaine-treated hamsters showed no differences in vasopressin afferent innervation and/or peptide levels in the anterior hypothalamus compared with non-aggressive, saline-treated littermates. Conversely, significant increases in stimulated, but not basal, vasopressin release were detected from the anterior hypothalamus of aggressive, cocaine-treated animals compared with non-aggressive, saline-treated controls. Together, these data suggest that adolescent cocaine exposure increases aggression by increasing stimulated release of vasopressin in the anterior hypothalamus, providing direct evidence for a causal role of anterior hypothalamic-vasopressin activity in adolescent cocaine-induced offensive aggression. A model for how alterations in anterior hypothalamic-vasopressin neural functioning may facilitate the development of the aggressive phenotype in adolescent-cocaine exposed animals is presented.