Symptom severity and trajectories among adolescent and young adult patients with cancer

BACKGROUND

Patients with cancer experience significant symptom burden. We investigated symptom severity in adolescents and young adults (18- to 39-year-olds) during the year following a cancer diagnosis and made comparisons with older adult (those older than 40 years of age) patients with cancer.

METHODS

All Albertan residents diagnosed with a first primary neoplasm at 18 years of age or older between April 1, 2018, and December 31, 2019, and who completed at least 1 electronic patient-reported outcome questionnaire were included. Symptom severity was assessed using the Edmonton Symptom Assessment System-revised. Descriptive statistics, multivariable logistic modeling, and mixed logistic regression modeling were used to describe symptom severity, identify risk factors, and assess symptom trajectories, respectively.

RESULTS

In total, 473 and 322 adolescents and young adults completed a patient-reported outcomes questionnaire at diagnosis and 1 year after diagnosis, respectively. Adolescent and young adult patients with cancer reported high levels of tiredness, poor well-being, and anxiety. Important risk factors included metastatic disease, female sex, treatment types received, and age at diagnosis. Symptom severity varied by clinical tumor group, with those diagnosed with sarcoma having the worst scores for all symptoms at diagnosis and patients with intrathoracic or endocrine tumors having the worst scores for all symptoms at 1 year after diagnosis. Statistically significant differences in symptom severity over the 1-year period were observed between adolescents and young adults and older adults-specifically, the odds of having moderate to severe symptoms were statistically significantly greater among adolescents and young adults with respect to pain, tiredness, nausea, depression, anxiety, and poor well-being (all P < .01).

CONCLUSIONS

A substantial proportion of adolescents and young adults experience moderate to severe symptoms during the year following diagnosis. Modifying existing supportive services and developing interventions based on the needs of adolescent and young adult patients with cancer could aid symptom control.

GYY4137, a hydrogen sulfide donor, protects against endothelial dysfunction in porcine coronary arteries exposed to myeloperoxidase and hypochlorous acid

BACKGROUND AND AIMS

Myeloperoxidase (MPO) and its principal reaction product hypochlorous acid (HOCl) are part of the innate immune response but are also associated with endothelial dysfunction, thought to involve a reduction in nitric oxide (NO) bioavailability. We aimed to investigate the effect of MPO and HOCl on vasorelaxation of coronary arteries and to assess directly the involvement of NO. In addition, we hypothesised that the slow release hydrogen sulfide (H2S) donor GYY4137 would salvage coronary artery endothelial function in the presence of MPO and HOCl.

METHODS AND RESULTS

Contractility of porcine coronary artery segments was measured using isometric tension recording. Incubation with MPO (50 ng/ml) plus hydrogen peroxide (H2O2) (30 μM; substrate for MPO) impaired endothelium-dependent vasorelaxation to bradykinin in coronary arteries. HOCl (10-500 μM) also impaired endothelium-dependent relaxations. There was no effect of MPO plus H2O2, or HOCl, on endothelium-independent relaxations to 5'-N-ethylcarboxamidoadenosine and sodium nitroprusside. L-NAME (300 μM), a NO synthase inhibitor, attenuated bradykinin relaxations, leaving L-NAME-resistant relaxations to bradykinin mediated by endothelium-dependent hyperpolarization. In the presence of L-NAME, MPO plus H2O2 largely failed to impair endothelium-dependent relaxations to bradykinin. Similarly, HOCl failed to inhibit endothelium-dependent relaxations to bradykinin in the presence of L-NAME. GYY4137 (1-100 μM) protected endothelium-dependent relaxations to bradykinin from dysfunction caused by MPO plus H2O2, and HOCl, with no effect alone on bradykinin relaxation responses. The specific MPO inhibitor aminobenzoic acid hydrazide (ABAH) (1 and 10 μM) also protected against MPO plus H2O2-induced endothelial dysfunction (at 10 μM ABAH), but was less potent than GYY4137.

CONCLUSIONS

MPO plus H2O2, and HOCl, impair coronary artery endothelium-dependent vasorelaxation via inhibition of NO. GYY4137 protects against endothelial dysfunction in arteries exposed to MPO plus H2O2, and HOCl. H2S donors such as GYY4137 are possible therapeutic options to control excessive MPO activity in cardiovascular diseases.

The penetrance of rare variants in cardiomyopathy-associated genes: A cross-sectional approach to estimating penetrance for secondary findings

Understanding the penetrance of pathogenic variants identified as secondary findings (SFs) is of paramount importance with the growing availability of genetic testing. We estimated penetrance through large-scale analyses of individuals referred for diagnostic sequencing for hypertrophic cardiomyopathy (HCM; 10,400 affected individuals, 1,332 variants) and dilated cardiomyopathy (DCM; 2,564 affected individuals, 663 variants), using a cross-sectional approach comparing allele frequencies against reference populations (293,226 participants from UK Biobank and gnomAD). We generated updated prevalence estimates for HCM (1:543) and DCM (1:220). In aggregate, the penetrance by late adulthood of rare, pathogenic variants (23% for HCM, 35% for DCM) and likely pathogenic variants (7% for HCM, 10% for DCM) was substantial for dominant cardiomyopathy (CM). Penetrance was significantly higher for variant subgroups annotated as loss of function or ultra-rare and for males compared to females for variants in HCM-associated genes. We estimated variant-specific penetrance for 316 recurrent variants most likely to be identified as SFs (found in 51% of HCM- and 17% of DCM-affected individuals). 49 variants were observed at least ten times (14% of affected individuals) in HCM-associated genes. Median penetrance was 14.6% (±14.4% SD). We explore estimates of penetrance by age, sex, and ancestry and simulate the impact of including future cohorts. This dataset reports penetrance of individual variants at scale and will inform the management of individuals undergoing genetic screening for SFs. While most variants had low penetrance and the costs and harms of screening are unclear, some individuals with highly penetrant variants may benefit from SFs.

Alberta Childhood Cancer Survivorship Research Program

Adverse outcomes after childhood cancer have been assessed in a range of settings, but most existing studies are historical and ascertain outcomes only after 5-year survival. Here, we describe the Alberta Childhood Cancer Survivorship Research Program and its foundational retrospective, population-based cohort of Albertan residents diagnosed with a first primary neoplasm between the ages of 0 and 17 years from 1 January 2001 to 31 December 2018. The cohort was established in collaboration with the Alberta Cancer Registry and Cancer in Young People in Canada program and has been linked to existing administrative health databases and patient-reported outcome questionnaires. The cohort comprised 2580 survivors of childhood cancer, 1379 (53.4%) of whom were 5-year survivors. Approximately 48% of the cohort was female, 47% of the cohort was diagnosed between 0 and 4 years of age, and the most frequent diagnoses were leukemias (25.4%), central nervous system tumors (24.0%), and lymphomas (14.9%). Detailed treatment information was available for 1741 survivors (67.5%), with manual abstraction ongoing for those with missing data. By the study exit date, the median time since diagnosis was 5.5 years overall and 10.4 years for 5-year survivors. During the follow-up time, 82 subsequent primary cancers were diagnosed, 20,355 inpatient and 555,425 ambulatory/outpatient events occurred, 606,773 claims were reported, and 437 survivors died. The results from this research program seek to inform and improve clinical care and reduce cancer-related sequelae via tertiary prevention strategies.

Improvement in patient-reported pain among patients with metastatic cancer and its association with opioid prescribing

PURPOSE

Opioids are a mainstay of cancer pain management; however, patients with metastatic cancer are often excluded from studies, leading to a lack of evidence on whether increased prescribing (dosage and/or duration) results in improved outcomes for this population. This study aimed to investigate whether increased opioid prescribing is associated with an improvement in patient-reported pain among patients with metastatic cancer.

PATIENTS AND METHODS

A retrospective cohort of all adult patients diagnosed with stage IV cancers, who completed at least two patient-reported outcomes (PROs) within 30 days of each other, was identified from administrative data. Opioid prescriptions were categorized by dosage level and number of prescription days. Multivariable logistic regression was used to investigate the association between opioid prescribing and clinically important improvement in pain score (≥ 1 point change on the Edmonton Symptom Assessment System).

RESULTS

A total of 2169 patients were included, 770 (35.5%) of whom had active opioid prescription between PROs, with an average daily dosage of 86.1 mg of oral morphine equivalent. Active prescription was associated with improvement in pain (OR = 2.17, P < 0.001). However, among patients with active prescription, neither dosage nor number of prescription days was significantly associated with pain improvement.

CONCLUSION

Opioid prescription is important for treating cancer-related pain; however, increased dosage or duration may not be leading to greater improvements in pain. Patients with metastatic cancer who are receiving increased opioid prescribing may have difficult-to-treat pain and may benefit from multidisciplinary pain management strategies to supplement opioid prescription and improve outcomes.

Association between Presurgical Weight Status and Urinary and Sexual Function in Prostate Cancer Patients Treated by Radical Prostatectomy: A Prospective Cohort Study

OBJECTIVE

To prospectively examine the influence of weight status on urinary and sexual function in clinically localized prostate cancer patients treated by radical prostatectomy (RP).

METHODS

The Prostatectomy, Incontinence and Erectile dysfunction study recruited patients at 2 US institutions between 2011 and 2014. At baseline, height and weight were measured, and urinary and sexual function were collected by the modified Expanded Prostate Cancer Index Composite-50. This index was repeated at the 5-week, 6-month, and 12-month postsurgical assessments and compared to baseline using linear generalized estimating equations. Logistic equations were used to evaluate the likelihood of functional recovery at the 6- and 12-month assessments.

RESULT

Presurgery, nonobese patients (68.8% of 407 patients) had similar urinary function as those with obesity (P = .217), but better sexual function (P = .006). One year after surgery, 50.5% and 28.9% patients had recovered to baseline levels for urinary and sexual function, respectively. Recovery was not, however, uniform by obesity. Compared to those with obesity, nonobese patients had better urinary function at the 6- (P < .001) and 12-month postsurgical assessments (P = .011) and were more likely to recover their function by the 6-month assessment (OR = 2.55, 95% CI = 1.36-4.76). For sexual function, nonobese patients had better function at the 6- (P = .028) and 12-month (P = .051) assessments, but a similar likelihood of recovery 1-year postsurgery.

CONCLUSION

Nonobese prostate cancer patients had better and likely earlier recovery in urinary function postsurgery, and better sexual function both pre- and postsurgery. These findings support the potential for tailored presurgical counseling about RP side-effects and prehabilitation to improve these side-effects.

Plasma hPG80 (Circulating Progastrin) as a Novel Prognostic Biomarker for early-stage breast cancer in a breast cancer cohort

BACKGROUND

Recurrence and metastases are still frequent outcomes after initial tumour control in women diagnosed with breast cancer. Although therapies are selected based on tumour characteristics measured at baseline, prognostic biomarkers can identify those at risk of poor outcomes. Circulating progastrin or hPG₈₀ was found to be associated with survival outcomes in renal and hepatocellular carcinomas and was a plausible prognostic biomarker for breast cancer.

METHODS

Women with incident breast cancers from Calgary, Alberta, Canada enrolled in the Breast to Bone (B2B) study between 2010 to 2016 and provided blood samples prior to any treatment initiation. Plasma from these baseline samples were analysed for circulating progastrin or hPG₈₀. Participant characteristics as well as tumour ones were evaluated for their association with hPG₈₀ and survival outcomes (time to recurrence, recurrence - free survival, breast cancer specific survival and overall survival) in Cox proportional hazards regression models.

RESULTS

The 464 participants with measurable hPG₈₀ in this study had an average age of 57.03 years (standard deviation of 11.17 years) and were predominantly diagnosed with Stage I (52.2%) and Stage II (40.1%) disease. A total of 50 recurrences and 50 deaths were recorded as of June 2022. In Cox PH regression models adjusted for chemotherapy, radiation therapy, cancer stage and age at diagnosis, log hPG₈₀ (pmol/L) significantly increased the risks for recurrence (Hazard Ratio (HR) = 1.330, 95% Confidence Interval (CI) = (0.995 - 1.777, p = 0.054)), recurrence-free survival (HR = 1.399, 95% CI = (1.106 - 1.770), p = 0.005) and overall survival (HR = 1.385, 95% CI = (1.046 - 1.834), = 0.023) but not for breast cancer specific survival (HR = 1.015, 95% CI = (0.684 - 1.505), p = 0.942).

CONCLUSIONS

hPG₈₀ levels measured at diagnosis were significantly associated with the risk of recurrence or death from any cause in women with breast cancer. Since the recurrence rates of breast cancer are still relatively high amongst women diagnosed at an early stage, identifying women at high risk of recurrence at their time of diagnosis is important. hPG₈₀ is a promising new prognostic biomarker that could improve the identification of women at higher risk of poor outcomes.

036 A GWAS of LGI1-antibody encephalitis

Introduction

Patients with encephalitis with antibodies to leucine-rich glioma-inactivated 1 (LGI1-Ab-E) are typically elderly males with a distinct phenotype, and ~90% carry the class II major histocompatibility (MHC) allele, DRB1*07:01. This allele is found in ~25% of healthy controls, suggesting other genetic and environmental disease factors operate in patients with LGI1-Ab-E. Yet, a previous genome-wide associa- tion study did not find variants attaining genome-wide significance outside the MHC region.

Methods

LGI1-Ab-E patients were genome-wide genotyped with standard arrays. Missing variants were imputed using Minimac4 and the Haplotype Reference Consortium panel. Population-matched controls were selected from UK Biobank. Genetic association with LGI1-Ab-E was determined with PLINK, SNPTEST and GWAMA and processed using bespoke bioinformatics pipelines.

The discovery cohort of 131 French patients (92 men; 70%) was population-matched with 2613 controls (957 men; 36.6%): >6 million SNPs remained after quality control (lambda 1.04). The validation cohort comprises 97 US/UK cases (66 men; 68%) and 1940 matched controls (882 men; 45%), >5 million variants and lambda of 1.

Results

We replicated the MHC association (rs2858869, p=3.371e-52 in the discovery cohort;rs2858870, p=1.085e-54 in the validation cohort) and will report the extent of non-MHC associations currently under- going bioinformatic assessment and validation.

COVID-19 and Vitamin D Misinformation on YouTube: Content Analysis

Background

The “infodemic” accompanying the SARS-CoV-2 virus pandemic has the potential to increase avoidable spread as well as engagement in risky health behaviors. Although social media platforms, such as YouTube, can be an inexpensive and effective method of sharing accurate health information, inaccurate and misleading information shared on YouTube can be dangerous for viewers. The confusing nature of data and claims surrounding the benefits of vitamin D, particularly in the prevention or cure of COVID-19, influences both viewers and the general “immune boosting” commercial interest.

Objective

The aim of this study was to ascertain how information on vitamin D and COVID-19 was presented on YouTube in 2020.

Methods

YouTube video results for the search terms “COVID,” “coronavirus,” and “vitamin D” were collected and analyzed for content themes and deemed useful or misleading based on the accuracy or inaccuracy of the content. Qualitative content analysis and simple statistical analysis were used to determine the prevalence and frequency of concerning content, such as confusing correlation with causation regarding vitamin D benefits.

Results

In total, 77 videos with a combined 10,225,763 views (at the time of data collection) were included in the analysis, with over three-quarters of them containing misleading content about COVID-19 and vitamin D. In addition, 45 (58%) of the 77 videos confused the relationship between vitamin D and COVID-19, with 46 (85%) of 54 videos stating that vitamin D has preventative or curative abilities. The major contributors to these videos were medical professionals with YouTube accounts. Vitamin D recommendations that do not align with the current literature were frequently suggested, including taking supplementation higher than the recommended safe dosage or seeking intentional solar UV radiation exposure.

Conclusions

The spread of misinformation is particularly alarming when spread by medical professionals, and existing data suggesting vitamin D has immune-boosting abilities can add to viewer confusion or mistrust in health information. Further, the suggestions made in the videos may increase the risks of other poor health outcomes, such as skin cancer from solar UV radiation.

Data-driven modelling of mutational hotspots and in silico predictors in hypertrophic cardiomyopathy

BACKGROUND

Although rare missense variants in Mendelian disease genes often cluster in specific regions of proteins, it is unclear how to consider this when evaluating the pathogenicity of a gene or variant. Here we introduce methods for gene association and variant interpretation that use this powerful signal.

METHODS

We present statistical methods to detect missense variant clustering (BIN-test) combined with burden information (ClusterBurden). We introduce a flexible generalised additive modelling (GAM) framework to identify mutational hotspots using burden and clustering information (hotspot model) and supplemented by in silico predictors (hotspot+ model). The methods were applied to synthetic data and a case-control dataset, comprising 5338 hypertrophic cardiomyopathy patients and 125 748 population reference samples over 34 putative cardiomyopathy genes.

RESULTS

In simulations, the BIN-test was almost twice as powerful as the Anderson-Darling or Kolmogorov-Smirnov tests; ClusterBurden was computationally faster and more powerful than alternative position-informed methods. For 6/8 sarcomeric genes with strong clustering, Clusterburden showed enhanced power over burden-alone, equivalent to increasing the sample size by 50%. Hotspot+ models that combine burden, clustering and in silico predictors outperform generic pathogenicity predictors and effectively integrate ACMG criteria PM1 and PP3 to yield strong or moderate evidence of pathogenicity for 31.8% of examined variants of uncertain significance.

CONCLUSION

GAMs represent a unified statistical modelling framework to combine burden, clustering and functional information. Hotspot models can refine maps of regional burden and hotspot+ models can be powerful predictors of variant pathogenicity. The BIN-test is a fast powerful approach to detect missense variant clustering that when combined with burden information (ClusterBurden) may enhance disease-gene discovery.

460 THE IMPACT OF THE BONE MDT: EXPLORING CHANGES IN BONE PROTECTION DECISIONS BETWEEN 2015 AND 2018

Introduction

The Hip fracture Multidisciplinary metabolic bone Team (MDT) was developed in June 2016 as a collaboration between Orthogeriatricians and the Metabolic Bone Team. The objective was to improve the quality of bone protection treatment decisions. This audit aimed to assess the impact of the new MDT by reviewing treatment decisions prior to and post its introduction. Data collection and.

Methodology

Case notes were reviewed for admissions from September to October 2015 and from September to November 2018. For both time periods the inpatient list, discharge summary and blood tests were reviewed in order to collect data regarding demographics, type of surgery, co-morbidities, calcium and vitamin D levels, bone protection prior to admission and bone protection decisions at discharge.

Results

In 2015, 83% of patients were admitted with no form of bone protection. Around 6% of patients were admitted on a bisphosphonate and 36% were discharged on a bisphosphonate. Less than 2% of people received denosumab prior to their admission, with this number rising to 9.4% at discharge. In 2018, 77% of patients were admitted on no form of bone protection. 5.4% were admitted on a bisphosphonate rising to 16% on discharge. No patients were admitted on denosumab, but 27% were discharged having received it in hospital, or with a plan to receive it from their GP.

Conclusions

There was a fall in bisphosphonate use and a significant increase in the frequency of denosumab prescription after the introduction of the Bone MDT. This MDT facilitated better decision-making through access to the further specialist skills from the endocrinologist and specialist nurses. Individual case discussion enhanced the delivery of personalised medicine.

Sun Protection Use at Work and Leisure by Outdoor Workers in Alberta, Canada

OBJECTIVE

To assess the prevalence and determinants of sun protection behaviours among outdoors workers at work and leisure in Alberta, Canada.

METHODS

We collected outdoor workers' demographics, skin cancer risk factors, job information, and sun habits at work and leisure using self-completed questionnaires. For both settings, we compared use of specific behaviours and modelled determinants of sun protection behaviour scores.

RESULTS

At work, wearing a sleeved shirt (81% often/always) and hat (73%) were most prevalent, while seeking shade (12%) and applying sunscreen (36%) were least prevalent. Workers had higher sun protection scores at work than leisure. Hours spent outdoors was a strong determinant for both models. Additional leisure model predictors were eye colour, sex, skin type, and job group.

CONCLUSIONS

Differences in behaviours across settings were observed and should be considered when developing solar UVR exposure reduction initiatives.

Social Jetlag and Prostate Cancer Incidence in Alberta's Tomorrow Project: A Prospective Cohort Study

Simple Summary

Due to social obligations (e.g., school, work), people shift their sleep and activity time regardless of their sleep-wake preference. To compensate for the lack of sleep accumulated over the workdays, people tend to oversleep on a work-free day. This difference in sleep timing between workdays and free days resembles traveling across different time zones, which causes jetlag (a mild form of circadian disruption). Thus, it is named social jetlag. Social jetlag has been linked with obesity, metabolic disorders, and cardiovascular risk in previous research. This study assessed social jetlag in 7455 cancer-free men in Alberta’s Tomorrow Project and followed them for on average 9.6 years, 250 men were diagnosed with prostate cancer. The study found that the more social jetlag men experienced, the greater their prostate cancer risk was. This finding warrants future research to better understand the complex behavioral and biological pathways between social jetlag and prostate cancer risk.

Abstract

We investigated the association of social jetlag (misalignment between the internal clock and socially required timing of activities) and prostate cancer incidence in a prospective cohort in Alberta, Canada. Data were collected from 7455 cancer-free men aged 35–69 years enrolled in Alberta’s Tomorrow Project (ATP) from 2001–2007. In the 2008 survey, participants reported usual bed- and wake-times on weekdays and weekend days. Social jetlag was defined as the absolute difference in waking time between weekday and weekend days, and was categorized into three groups: 0–<1 h (from 0 to anything smaller than 1), 1–<2 h (from 1 to anything smaller than 2), and 2+ h. ATP facilitated data linkage with the Alberta Cancer Registry in June 2018 to determine incident prostate cancer cases (n = 250). Hazard ratios (HR) were estimated using Cox proportional hazards regressions, adjusting for a range of covariates. Median follow-up was 9.57 years, yielding 68,499 person-years. Baseline presence of social jetlag of 1–<2 h (HR = 1.52, 95% CI: 1.10 to 2.01), and 2+ hours (HR = 1.69, 95% CI: 1.15 to 2.46) were associated with increased prostate cancer risk vs. those reporting no social jetlag (p for trend = 0.004). These associations remained after adjusting for sleep duration (p for trend = 0.006). With respect to chronotype, the association between social jetlag and prostate cancer risk remained significant in men with early chronotypes (p for trend = 0.003) but attenuated to null in men with intermediate (p for trend = 0.150) or late chronotype (p for trend = 0.381). Our findings suggest that greater than one hour of habitual social jetlag is associated with an increased risk of prostate cancer. Longitudinal studies with repeated measures of social jetlag and large samples with sufficient advanced prostate cancer cases are needed to confirm these findings.

Hospital memorial service bereavement support

BACKGROUND

Pastoral care in an acute hospital setting necessarily includes some bereavement support for families of patients who die. Termed universal bereavement support, an important component of such support is provision of educational information to assist bereaved people struggling with grief. This project aimed to understand, from the perspective of those attending, the value of providing a memorial service for remembering a loved one and whether the education provided at the service successfully met the requirement of a universal bereavement support strategy.

METHODS

A qualitative study, comprising a semistructured telephone interview with memorial service attendees was undertaken. Data were audio recorded, transcribed and analysed thematically.

RESULTS

Twenty-nine attendees participated. Three themes provided insights into attendees' perceptions. The first theme encapsulated the value of remembering and celebrating the life of the deceased; the second theme focused on 'finding our way through the grief process' including the value of the educational materials ; and the third theme identified appreciation for the hospital in providing care to those bereaved.

CONCLUSION

The memorial service provides a valued universal bereavement support strategy and such support strategies are an important part in the process of grieving for many attendees.

The Impact of Color Fidelity on Evaluation of Patients in the Outpatient Dermatologic Setting

BACKGROUND AND OBJECTIVES

To demonstrate that high color fidelity light-emitting diode (LED) sources are preferred by dermatologists for the evaluation of patients during standard-of-care, outpatient visits when compared to low color fidelity LED sources similar to fluorescent lighting.

STUDY DESIGN/MATERIALS AND METHODS

Three different LED sources were installed in exam rooms at a single, academic, medical institution (low color fidelity [82 color rendering index (CRI)] similar to fluorescent lighting, and high color fidelity [97 CRI and 96+red CRI]). A cross-sectional survey study was conducted in three parts. Naturalness (i.e. ability to reproduce natural, daylight conditions), effectiveness, color contrast, comfort, and overall performance of each LED source were rated on a 5-point scale from 0 to 4 with 0 being the worse, and 4 being the best. The first part included a survey of board-certified dermatologists (n = 3) assessing their visual experience while clinically evaluating a subset of patients during standard-of-care outpatient visits. The second survey was completed by dermatologic medical providers (n = 55) at three separate monthly departmental Grand Rounds sessions in which standardized patients were evaluated with the LED sources. Lastly, patients (n = 75) finished a survey assessing the comfort level of the LED sources.

RESULTS

In the first part of the study, all dermatologists significantly preferred the high color fidelity sources over low color fidelity sources based on all five evaluation criteria, with two preferring the 97 CRI LED source overall, while the third dermatologist favored 96+red CRI. Assessments provided by the 55 participants at Grand Rounds demonstrated that the 97 CRI was most "liked." Patients also preferred the high color fidelity LED source, reporting the 96+red CRI source was the "most comfortable."

CONCLUSION

Dermatologists, dermatologists-in-training and mid-level providers significantly prefer high color fidelity LED sources for outpatient evaluation of dermatologist patients in enclosed spaces, rating them the more natural, effective, comfortable, and providing superior color contrast than low color sources. Patients also favor high color fidelity LED sources as being the most comfortable in the clinic room. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

International Trends in the Incidence of Cancer Among Adolescents and Young Adults

BACKGROUND

Although adolescent and young adult (AYA) cancers represent a unique spectrum of malignancies, epidemiological studies of cancer incidence often group AYAs together with younger or older populations, obscuring patterns specific to this population.

METHODS

We examined AYA cancer incidence trends in 41 countries over a 15-year period using the CI5plus database. Truncated age-standardized incidence rates were calculated and the annual percentage change was assessed, with statistical significance corresponding to a 95% confidence interval that does not include zero.

RESULTS

From 1998 to 2012, the 41 included countries contributed a total of 1 846 588 cancer cases and 3.1 billion person-years among AYAs. Although statistically significant increases in the overall cancer burden were observed in 23 countries, the magnitude varied considerably, with the greatest increase in incidence observed in South Korea (annual percentage change2002-2012 = 8.5%, 95% confidence interval = 7.6% to 9.4%) due to thyroid cancer. Notable trends included sharp increases in the incidence of obesity-related malignancies among AYAs; indeed, statistically significant increases were observed among AYAs for 10 of 11 and 9 of 11 obesity-related cancer sites in the US and UK, respectively, with at least five obesity-related cancers statistically significantly increasing in Canada, Japan, South Korea, Australia, and the Netherlands. Other striking trends were noted for thyroid and testicular cancer, with statistically significantly increasing rates observed in 33 and 22 countries, respectively, whereas statistically significant declines in incidence were observed for smoking-related cancers, cervical cancer, and Kaposi sarcoma in many countries.

CONCLUSIONS

Our results highlight the future health-care needs related to treatment as well as the urgency for public health initiatives that can mitigate the increasing burden of cancer in AYAs.

Solar ultraviolet radiation exposure among outdoor workers in Alberta, Canada

BACKGROUND

Outdoor workers are at risk of prolonged and high solar ultraviolet radiation (UVR) exposure, which is known to cause skin cancer. The objectives of this study were to characterize the UVR exposure levels of outdoor workers in Alberta, Canada, and to investigate what factors may contribute to their exposure.

METHODS

This study collected objective solar UVR measurements from outdoor workers primarily in Alberta during the summer of 2019. Workers were recruited via the management or health and safety teams from building trade unions and employers. Calibrated, electronic UVR dosimeters were worn by workers on their hardhats, wrists, or lapels for five working days. Data on workers' demographics, jobs, sun protection behaviors, and personal risk factors were collected using questionnaires, and meteorological data for each sampling day were noted. Mean daily exposure measured as the standard erythemal dose (SED) was calculated and compared to the international occupational exposure limit guideline (1.3 SED). Marginal models were developed to evaluate potential determinants of occupational solar UVR exposure.

RESULTS

In total, 883 measurements were collected from 179 workers. On average, workerswere exposed to 1.93 SED (range: 0.03-16.63 SED) per day. Just under half of workers (45%) were exposed to levels exceeding the international exposure limit guideline. In the bivariate analyses, landscape and maintenance workers, as well as trade and recreation workers, had the highest levels of exposure (average: 2.64 and 1.84 SED, respectively). Regional variations were observed, with the "other" cities/regions (outside of Edmonton and Calgary) experiencing the highest average levels (2.60 SED). Workers who placed the dosimeters on their hardhats experienced higher levels compared to the other groups. Exposure was highest on sunny and mixed days. Education, trade, city, dosimeter placement, forecast, hair colour, and number of hours outside were included in the final exposure model, of which trade, dosimeter placement, forecast, and number of hours outside at work were statistically significant.

CONCLUSIONS

Exposure to elevated solar UVR levels is common among outdoor workers in Alberta. The study findings can help inform future monitoring studies and exposure reduction initiatives aimed at protecting workers.

Abstract 4655: Social jetlag and lung cancer incidence in the Alberta's Tomorrow Project: A prospective cohort study

Objectives: Increased lung cancer risk has been associated with markers of circadian disruption (e.g., overly short or long sleep duration, shift work, circadian gene mutation) in both human and animal studies. However, no study to date has reported the association of social jetlag, the misalignment between the internal clock and the socially required timing of activities, with lung cancer risk. We, therefore, aim to investigate this association in the Alberta's Tomorrow Project (ATP), a population-based prospective cohort study in Alberta, Canada, and the potential effect modification of smoking behavior.

Methods: Data on sleep patterns were collected on 19,436 (37.6% male) Albertans aged 35-69 years recruited from 2001-2015. Social jetlag was defined as the absolute difference in waking time between free day and workday that accounted for sleep debt, and categorized into three levels, 0 hours (32.52%), &gt;0-1 hours (32.44%), and &gt;1-4 hours (35.04%). Incident lung cancer cases were determined through linkage with the Alberta Cancer Registry by June 2018. Smoking behavior was defined as never smokers, former smokers, and current smokers. Hazard ratios (HR) were estimated using a series of Cox proportional hazards regressions, adjusting for age, sex, recreational physical activity, sitting time, daily calorie consumption, body mass index, marital status, education, employment status, total household income, smoking and drinking behavior, family history of cancer and preexistence of medical condition.

Results: A total of 117 incident lung cancer cases were identified during a medium of 9.6 years of follow-up, yielded 179,028 person-years. In the multivariable-adjusted model, a suggestive significant association between social jetlag and lung cancer risk was observed (&gt;1-4 hours vs. 0: HR=1.67, 95% CI: 0.96-2.92, p for trend = 0.047). The increased lung cancer risk with social jetlag was retrained and heightened among daily smokers (&gt;1-4 hours vs. 0: HR=2.72, 95% CI: 1.26-5.84, p for trend = 0.010), and attended to null among never smokers (&gt;1-4 hours vs. 0: HR=0.98, 95% CI: 0.15-6.54, p for trend = 0.91) and former smokers (&gt;1-4 hours vs. 0: HR=0.76, 95% CI: 0.27-2.12, p for trend = 0.63). Latency multivariate-adjusted model excluding those diagnosed with cancer within 2 years of baseline assessment returned similar results.

Conclusion: Increased risk for lung cancer was observed among adults who reported social jetlag, particularly daily smokers. Our findings suggest a potential lung cancer risk associated with switching sleep patterns between work and free days among smokers. Further studies are necessary to confirm these findings and elucidate the biological mechanisms.

Citation Format: Benny Rana, Andrew Harper, Grace Shen-Tu, Cheryl Peters, Darren Brenner, Don G. Morris, Lin Yang. Social jetlag and lung cancer incidence in the Alberta's Tomorrow Project: A prospective cohort study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4655.

Global burden and trends in premenopausal and postmenopausal breast cancer: a population-based study

BACKGROUND

Breast cancer has distinct causes, prognoses, and outcomes and effects in patients at premenopausal and postmenopausal ages. We sought to assess the global burden and trends in breast cancer by menopausal status.

METHODS

We did a population-based analysis of global breast cancer incidence and mortality among premenopausal and postmenopausal women. Menopausal status was defined using age as a proxy, whereby breast cancer cases or deaths at age 50 years or older were regarded as postmenopausal. Age-standardised breast cancer incidence and mortality in 2018 were calculated using GLOBOCAN data. Incidence trends for 1998-2012 were assessed in 44 populations from 41 countries using the Cancer in Five Continents plus database, by calculating the annual average percent change.

FINDINGS

Approximately 645 000 premenopausal and 1·4 million postmenopausal breast cancer cases were diagnosed worldwide in 2018, with more than 130 000 and 490 000 deaths occurring in each menopausal group, respectively. Proportionally, countries with a low UNDP human development index (HDI) faced a greater burden of premenopausal breast cancer for both new cases and deaths compared with higher income countries. Countries with a very high HDI had the highest premenopausal and postmenopausal breast cancer incidence (30·6 and 253·6 cases per 100 000, respectively), whereas countries with low and medium HDI had the highest premenopausal and postmenopausal mortality, respectively (8·5 and 53·3 deaths per 100 000, respectively). When examining breast cancer trends, we noted significantly increasing age-standardised incidence rates (ASIRs) for premenopausal breast cancer in 20 of 44 populations and significantly increasing ASIRs for postmenopausal breast cancer in 24 of 44 populations. The growth exclusively at premenopausal ages largely occurred in high-income countries, whereas the increasing postmenopausal breast cancer burden was most notable in countries under transition.

INTERPRETATION

We provide evidence of a rising burden of both premenopausal and postmenopausal breast cancer worldwide. Although early diagnosis and access to treatment remain crucial in low-income and middle-income countries, primary prevention efforts seeking to decrease exposure to known breast cancer risk factors are warranted in all world regions to curb the future breast cancer burden.

FUNDING

None.

Associations between baseline symptom burden as assessed by patient-reported outcomes and overall survival of patients with metastatic cancer

BACKGROUND

Serial symptom assessments using patient-reported outcomes may be challenging to implement in routine clinical practices. We aimed to determine if a single measurement of symptom burden at the time of metastatic diagnosis is associated with survival.

METHODS

We examined baseline patient-reported outcomes (within 90 days of diagnosis) of patients newly diagnosed with metastatic breast, lung, colorectal, or prostate cancer using the revised Edmonton Symptom Assessment System (ESASr) questionnaire. The ESASr was categorized into physical, psychological, and total symptom domains whereby scores were classified as none to mild (0-3) or moderate to severe (4-10). Multivariable Cox proportional hazards models were constructed to evaluate the effect of baseline symptom scores on overall survival.

RESULTS

We identified 1316 patients eligible for analysis. There were 181, 601, 240, and 294 patients with breast, lung, colorectal, and prostate cancer, respectively. Approximately one-quarter of all patients reported moderate to severe physical, psychological, and total symptom subscores. On multivariable Cox regression analysis, older age (P < 0.001), male sex (P = 0.002), primary lung cancer (P < 0.001), and smoking in the previous month (P = 0.007) were predictive of inferior overall survival as were baseline moderate to severe physical (hazard ratio, 1.49; 95% confidence interval, 1.16-1.90; P = 0.002) and total symptom subscores (hazard ratio, 1.38; 95% confidence interval, 1.06-1.81; P = 0.017).

CONCLUSIONS

A single assessment of baseline symptom burden using the ESASr in patients with metastatic cancer has significant prognostic value. This may represent a feasible first step towards routine collection of patient-reported outcomes in real-world settings where serial symptom measurements can be challenging to implement.

Patient-Reported Symptom Burden Near the End of Life in Patients With Gynaecologic Cancers

OBJECTIVE

There are limited data on patient-reported outcomes near the end of life in patients with gynaecologic cancers. This study aimed to assess the symptom burden in the last 6 months of life in a real-world cohort.

METHODS

Patients diagnosed with metastatic gynaecologic malignancies from 2016 to 2019 who completed the revised Edmonton Symptom Assessment System (ESASr) questionnaire within 6 months of death in a large Canadian province were identified. Patient-reported symptom scores were categorized as none to mild (0-3) and moderate to severe (4-10). Individual symptoms were subsequently grouped into physical, psychological, and total subscores. The severity of symptoms was further analyzed for any associations with age, time to death, and primary tumour site (ovarian vs. uterocervical and vulvovaginal).

RESULTS

We identified 107 patients with gynaecologic malignancies including 59 ovarian, 29 uterocervical, and 19 vulvovaginal cancers. The median ages at diagnosis and questionnaire completion were 64 and 65 years, respectively. The median time from completing the ESASr questionnaire to death was 65 days. Overall, physical and psychological symptoms were moderate to severe in 57.9% and 40.2% of patients, respectively. Among the individual symptoms, tiredness was the most commonly reported moderate to severe symptom (74.9%), while shortness of breath was least commonly reported (31.6%). While physical (P < 0.001) and total symptom (P = 0.009) subscores were more likely to be moderate to severe in intensity as death approached, the psychological subscore (P = 0.744) had no relationship with time to death. Longer time to death was predictive of lower physical (P = 0.002) and total symptom (P = 0.002) subscores, while a primary uterocervical cancer site was associated with a lower psychological symptom subscore (P = 0.042).

CONCLUSIONS

In the real-world setting, unique symptom trajectories can emerge for patients with gynaecologic cancer near the end of life. Knowledge of these specific symptom patterns can help inform the development and delivery of targeted palliative interventions to improve quality of life for these patients.

Atrial fibrillation and non-ischaemic cardiomyopathy in the peripartum period

A 31-year-old primiparous woman with a history of bigeminy as a teenager developed atrial fibrillation with rapid ventricular response during elective caesarean section. Initial postoperative medical management was undertaken on the maternal high dependency unit and involved the administration of beta-blockers and digoxin. On postoperative day 1 the patient was transferred to the coronary care unit where she subsequently required synchronised direct current cardioversion to restore sinus rhythm. The patient remained on the coronary care unit for 5 days before discharge. Magnetic resonance imaging undertaken 6 weeks postpartum showed non-ischaemic cardiomyopathy. In this report, we discuss tachycardia-induced and peripartum cardiomyopathies, along with their potential underlying pathologies, incidence and associated morbidity. We describe potential pharmacological therapies including beta-blockers and angiotensin-converting enzyme inhibitors, as well as the implications of such medications for breastfeeding mothers. Patients presenting with palpitations in the antenatal period should receive prompt investigation including electrocardiography with ambulatory monitoring considered for those with persistent symptoms. Anyone with a proven cardiac arrhythmia should undergo echocardiography. This report illustrates the importance of the investigation of the symptoms of arrhythmia during pregnancy and emphasises the role of multidisciplinary working in the management of obstetric patients with complex medical comorbidity.

Impact of baseline symptom burden as assessed by patient-reported outcomes (PROs) on overall survival (OS) of patients with metastatic cancer

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Background: Patients with metastatic cancer experience variable symptom burden, but serial symptom assessments using PROs may be challenging to implement in routine clinical practices. We aimed to determine if a single measurement of symptom burden at the time of metastatic diagnosis is associated with survival. Methods: We examined prospectively collected baseline PROs of patients newly diagnosed with metastatic breast, lung, colorectal, or prostate cancer using the revised Edmonton Symptom Assessment System (ESASr) questionnaire from a large province (Alberta, Canada) between 2016 and 2019. The ESASr was categorized into physical (PH), psychosocial (PS), and total symptom (TS) domains whereby scores were classified as mild (0-3), moderate (4-6), or severe (7-10). Multivariable Cox proportional hazards models were constructed to evaluate the effect of baseline symptom scores on OS. Results: We identified 1,315 patients, of whom 57% were men and median age was 66 (IQR, 27-93) years. There were 180, 601, 240, and 294 patients with breast, lung, colorectal, and prostate cancer, respectively. Approximately one-quarter of all patients reported moderate to severe PH, PS, and TS scores, with lung cancer patients experiencing the highest symptom intensity across all domains ( P<0.0001). While age did not affect symptom scores, women were more likely to report severe PH, PS, and TS scores as compared to men ( P=0.02, 0.002, and 0.007, respectively). On multivariable Cox regression analysis, older age (HR 1.02, 95% CI, 1.02-1.03, P<0.0001) and female sex (HR 1.67, 95% CI, 1.39-1.99, P<0.0001) were predictive of worse OS as were severe baseline PH and TS scores (see Table) . However, baseline PS scores were not related to OS. Conclusions: A single assessment of baseline symptom burden using the ESASr in patients with metastatic cancer has significant prognostic value. This may represent a feasible first step toward routine collection of PROs in real-world settings where serial symptom measurements can be challenging to implement. [Table: see text]

MSTO1 mutations cause mtDNA depletion, manifesting as muscular dystrophy with cerebellar involvement

MSTO1 encodes a cytosolic mitochondrial fusion protein, misato homolog 1 or MSTO1. While the full genotype–phenotype spectrum remains to be explored, pathogenic variants in MSTO1 have recently been reported in a small number of patients presenting with a phenotype of cerebellar ataxia, congenital muscle involvement with histologic findings ranging from myopathic to dystrophic and pigmentary retinopathy. The proposed underlying pathogenic mechanism of MSTO1-related disease is suggestive of impaired mitochondrial fusion secondary to a loss of function of MSTO1. Disorders of mitochondrial fusion and fission have been shown to also lead to mitochondrial DNA (mtDNA) depletion, linking them to the mtDNA depletion syndromes, a clinically and genetically diverse class of mitochondrial diseases characterized by a reduction of cellular mtDNA content. However, the consequences of pathogenic variants in MSTO1 on mtDNA maintenance remain poorly understood. We present extensive phenotypic and genetic data from 12 independent families, including 15 new patients harbouring a broad array of bi-allelic MSTO1 pathogenic variants, and we provide functional characterization from seven MSTO1-related disease patient fibroblasts. Bi-allelic loss-of-function variants in MSTO1 manifest clinically with a remarkably consistent phenotype of childhood-onset muscular dystrophy, corticospinal tract dysfunction and early-onset non-progressive cerebellar atrophy. MSTO1 protein was not detectable in the cultured fibroblasts of all seven patients evaluated, suggesting that pathogenic variants result in a loss of protein expression and/or affect protein stability. Consistent with impaired mitochondrial fusion, mitochondrial networks in fibroblasts were found to be fragmented. Furthermore, all fibroblasts were found to have depletion of mtDNA ranging from 30 to 70% along with alterations to mtDNA nucleoids. Our data corroborate the role of MSTO1 as a mitochondrial fusion protein and highlight a previously unrecognized link to mtDNA regulation. As impaired mitochondrial fusion is a recognized cause of mtDNA depletion syndromes, this novel link to mtDNA depletion in patient fibroblasts suggests that MSTO1-deficiency should also be considered a mtDNA depletion syndrome. Thus, we provide mechanistic insight into the disease pathogenesis associated with MSTO1 mutations and further define the clinical spectrum and the natural history of MSTO1-related disease.

Toxicity of cytarabine constant rate infusion in dogs with high-grade non-Hodgkin lymphoma with bone marrow or central nervous system involvement

OBJECTIVE

Cytarabine, a cell-cycle phase-specific antimetabolite, has been reported to improve outcomes in dogs with bone marrow (BM) or central nervous system (CNS) lymphoma involvement receiving combination chemotherapy. The objective of this study was to evaluate the incidence and severity of toxicity of cytarabine constant rate infusion (CRI) in dogs with high-grade non-Hodgkin lymphoma.

METHODS

Medical records of canine lymphoma patients with confirmed or suspected BM (group 1) or CNS (group 2) involvement, treated with a modified cyclophosphamide, epirubicin, vincristine and prednisolone protocol, including a single dose of cytarabine given as CRI, were reviewed and adverse events graded.

RESULTS

Twenty-six dogs were included. Gastrointestinal toxicity occurred in 17 dogs (65.3%), with 5 (19.2%) experiencing grade III or IV toxicity. Neutropenia occurred in nine dogs (34.6%), but was grade I or II in most cases. Three dogs (11.5%) had thrombocytopenia: one grade III and two grade IV. Four dogs (15.3%) experienced increases in alanine amino transferase: one each grade I and II and two grade III. Five dogs (19.2%) required hospitalisation to manage toxicity after completing cytarabine CRI, and haematological toxicity resulted in treatment delays in five dogs (median delay of 4 days, range: 3-7 days).

CONCLUSION

Our findings suggest that gastrointestinal toxicity should be expected in lymphoma patients undergoing cytarabine CRI.

Outcome following heart transplant assessment in adults with congenital heart disease

Objectives

Adults with congenital heart disease (ACHD) are a growing group with end-stage heart failure. We aim to describe the outcomes of ACHD patients undergoing assessment for orthotopic heart transplant (OHT).

Methods

Case notes of consecutive ACHD patients (>16 years) assessed for OHT between 2000 and 2016 at our centre were reviewed. Decision and outcome were reported as of 2017. Data were analysed in three groups: systemic left ventricle (LV), systemic right ventricle (RV) and single ventricle (SV).

Results

196 patients were assessed (31.8 years, 27% LV, 29% RV, 44% SV). 89 (45%) patients were listed for OHT and 67 (34%) were transplanted. 41 (21%) were unsuitable or too high risk and 36 (18%) were too well for listing. Conventional surgery was undertaken in 13 (7%) and ventricular assist device in 17 (9%) with 7 (4%) bridged to candidacy. Survival from assessment was 84.2% at 1 year and 69.7% at 5 years, with no difference between groups. Patients who were considered unsuitable for OHT (HR 11.199, p<0.001) and listed (HR 3.792, p=0.030) were more likely to die than those who were considered too well. Assessments increased over the study period.

Conclusions

The number of ACHD patients assessed for OHT is increasing. A third are transplanted with a small number receiving conventional surgery. Those who are unsuitable have a poor prognosis.

Association of Titin-Truncating Genetic Variants With Life-threatening Cardiac Arrhythmias in Patients With Dilated Cardiomyopathy and Implanted Defibrillators

Importance

There is a need for better arrhythmic risk stratification in nonischemic dilated cardiomyopathy (DCM). Titin-truncating variants (TTNtvs) in the TTN gene are the most common genetic cause of DCM and may be associated with higher risk of arrhythmias in patients with DCM.

Objective

To determine if TTNtv status is associated with the development of life-threatening ventricular arrhythmia and new persistent atrial fibrillation in patients with DCM and implanted cardioverter defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D) devices.

Design, Setting, and Participants

This retrospective, multicenter cohort study recruited 148 patients with or without TTNtvs who had nonischemic DCM and ICD or CRT-D devices from secondary and tertiary cardiology clinics in the United Kingdom from February 1, 2011, to June 30, 2016, with a median (interquartile range) follow-up of 4.2 (2.1-6.5) years. Exclusion criteria were ischemic cardiomyopathy, primary valve disease, congenital heart disease, or a known or likely pathogenic variant in the lamin A/C gene. Analyses were performed February 1, 2017, to May 31, 2017.

Main Outcome and Measures

The primary outcome was time to first device-treated ventricular tachycardia of more than 200 beats/min or first device-treated ventricular fibrillation. Secondary outcome measures included time to first development of persistent atrial fibrillation.

Results

Of 148 patients recruited, 117 adult patients with nonischemic DCM and an ICD or CRT-D device (mean [SD] age, 56.9 [12.5] years; 76 [65.0%] men; 106 patients [90.6%] with primary prevention indications) were included. Having a TTNtv was associated with a higher risk of receiving appropriate ICD therapy (shock or antitachycardia pacing) for ventricular tachycardia or fibrillation (hazard ratio [HR], 4.9; 95% CI, 2.2-10.7; P < .001). This association was independent of all covariates, including midwall fibrosis measured by late gadolinium enhancement on cardiac magnetic resonance images (adjusted HR, 8.3; 95% CI, 1.8-37.6; P = .006). Having a TTNtv was also associated with the risk of receiving a shock (HR, 3.6; 95% CI, 1.1-11.6; P = .03). Individuals with a TTNtv and fibrosis had a greater rate of receiving appropriate device therapy than those with neither (HR, 16.6; 95% CI, 3.5-79.3; P < .001). Having a TTNtv was also a risk factor for developing new persistent atrial fibrillation (HR, 3.9; 95% CI, 1.3-12.0; P = .01).

Conclusions and Relevance

Having a TTNtv was an important risk factor for clinically significant arrhythmia in patients with DCM and ICD or CRT-D devices. Having a TTNtv, especially in combination with midwall fibrosis confirmed with cardiovascular magnetic resonance imaging, may provide a risk stratification approach for evaluating the need for ICD therapy in patients with DCM. This hypothesis should be tested in larger studies.

Biogenic Amine Production by and Phylogenetic Analysis of 23 Photobacterium Species

Photobacterium species are members of the bacterial communities typically associated with scombrotoxin-forming fish. Reclassification and discovery of new Photobacterium species has caused confusion as to which species are capable of biogenic amine production. We analyzed histamine, cadaverine, and putrescine production by 104 Photobacterium strains representing 23 species. The presence of the genes for histidine decarboxylase ( hdc), lysine decarboxylase ( ldc), and ornithine decarboxylase ( odc) was determined by real-time or conventional PCR and whole genome sequencing. Significant histamine production (>200 ppm) was detected in five Photobacterium species: P. angustum, P. aquimaris, P. kishitanii, P. damselae, and P. phosphoreum. The hdc gene was detected in all of these histamine-producing species except P. phosphoreum. Cadaverine was produced by eight Photobacterium species: P. angustum, P. aquimaris, P. damselae, P. iliopiscarium, P. kishitanii, P. leiognathi, P. mandapamensis, and P. phosphoreum. Putrescine was produced by six Photobacterium species: P. angustum, P. aquimaris, P. kishitanii, P. leiognathi, P. mandapamensis, and Photobacterium sp. Cadaverine production correlated closely with the presence of the ldc gene, but putrescine production did not correlate closely with the presence of the odc gene. Characterization of the biogenic amine production by Photobacterium species will allow identification of these marine bacteria and help ensure that current guidelines account for mitigation of these bacteria.

Acute radiotherapy toxicity in 57 dogs with gross and microscopic mast cell tumours

Mast cell tumours (MCTs) are commonly treated with radiation therapy, most often in a microscopic disease setting. Poorer outcomes are expected in patients with gross disease, and irradiation of gross disease may be associated with greater toxicity. The aim of this study was to compare acute radiation adverse events (AE) in dogs with gross and microscopic MCTs receiving radiotherapy. Fifty-seven dogs were included, 28 with gross disease and 29 with microscopic. In order to assess mucosal and skin toxicity, patients were assigned to 2 groups: head (29 patients, 14 patients with gross and 15 microscopic) and other sites (28 patients, 14 each). All were treated with external beam radiotherapy, and toxicity assessed at the end of treatment and 10 to 14 days later (first recheck). All patients developed some acute radiation toxicity by the end of the course. However, there was no difference in the severity of toxicity between gross and microscopic disease in either site group at either time point. The only variable associated with an increased frequency of grade 2 or 3 toxicity at the first recheck was the use of prednisolone prior to radiotherapy (P = .05). No other factors were identified which were associated with increased toxicity. For the head group, the site of highest grade toxicity was mucosa or, if included in the field, nasal planum, which was often more severely affected than the mucosa. No significant late toxicity was identified. Two dogs developed acute haematemesis during the radiotherapy course, but both completed the course without further events.

Evaluation of a multi-agent chemotherapy protocol combining lomustine, procarbazine and prednisolone (LPP) for the treatment of relapsed canine non-Hodgkin high-grade lymphomas

The standard of care treatment for canine lymphoma is multi-agent chemotherapy containing prednisolone, cyclophosphamide, vincristine and an anthracycline such as doxorubicin (CHOP) or epirubicin (CEOP). Lomustine, vincristine, procarbazine, and prednisone (LOPP) has been evaluated as a rescue, with encouraging results; however, resistance to vincristine is likely in patients relapsing on CHOP/CEOP, and this agent may enhance LOPP toxicity without improving efficacy. The aim of this study was to evaluate responses to a modified-LOPP protocol that does not include vincristine (LPP) and is administered on a 21-day cycle. Medical records of dogs with high-grade multicentric lymphoma from 2012 to 2017 were reviewed. Dogs with relapsed lymphoma that received LPP as a rescue protocol were enrolled. Response, time from initiation to discontinuation (TTD) and toxicity of LPP were assessed. Forty-one dogs were included. Twenty-five dogs (61%) responded to LPP including 12 complete responses (CR) and 13 partial responses (PR). Responders had a significantly longer TTD (P < .001) compared to non-responders with 84 days for CR and 58 days for PR. Neutropenia was documented in 20 dogs (57%): 12 grade I to II, 8 grade III to IV. Thrombocytopenia was infrequent (20%): 5 grade I to II, 2 grade III to IV. Twelve dogs developed gastrointestinal toxicity (30%): 10 grade I to II and 2 grade III. Nineteen dogs had elevated ALT (59%): 9 grade I to II, 10 grade III to IV. Treatment was discontinued due to toxicity in 8 dogs (19%). The LPP protocol shows acceptable efficacy and toxicity-profile and minimizes in-hospital procedures.

Base-Induced Cyclisation of ortho-Substituted 2-Phenyloxazolines to Give 3-Aminobenzofurans and Related Heterocycles

Treatment of ortho-benzyloxyphenyloxazolines with butyllithium and potassium tert-butoxide results in cyclisation with ring opening of the oxazoline to give 2-aryl-3-aminobenzofurans. The reaction also occurs with the corresponding benzylthio and benzylamino compounds to give benzothiophenes and indoles, respectively. Use of an ortho-allyloxyphenyloxazoline gives the corresponding 2-vinylbenzofuran, while both α-methylbenzyloxy and benzylsulfonyl compounds form stable spirooxazolidine products. The X-ray structure of an aminobenzothiophene product has been determined.

Two-year outcomes of "treat and extend" intravitreal therapy for neovascular age-related macular degeneration

PURPOSE

To report 24-month outcomes of anti-vascular endothelial growth factor (VEGF) therapy for treatment-naïve eyes with neovascular age-related macular degeneration (nAMD) using a treat and extend treatment regimen in routine clinical practice.

DESIGN

Database observational study.

PARTICIPANTS

We included treatment-naïve eyes receiving predominantly ranibizumab for nAMD in routine clinical practice treated using a treat and extend regimen that were tracked in the Fight Retinal Blindness observational registry.

METHODS

A cohort of eyes treated by practitioners using exclusively a treat and extend regimen was extracted from the Fight Retinal Blindness observational registry.

MAIN OUTCOME MEASURES

Change in visual acuity (VA) over 2 years and number of injections and visits.

RESULTS

Data from 1198 eyes from 1011 patients receiving anti-VEGF therapy using a treat and extend regimen for treatment-naïve nAMD between January 2007 and December 2012 and with 24-month follow-up were included in the analysis. Mean VA increased by +5.3 logarithm of the minimum angle of resolution letters from 56.5 letters (20/80+1) at initial visit to 61.8 (20/60+2) letters at 24 months. Mean VA gains improved and number of injections increased with successive years from +2.7 letters for eyes commencing in 2007 after a mean of 9.7 injections in 2 years, to +7.8 letters for eyes commencing in 2012 after a mean of 14.2 injections over 2 years. The proportion of eyes with VA >20/40 increased from 27% when starting treatment to 45% after 24 months; the proportion with vision of <20/200 remained unchanged (13% initial, 11% at 24 months). Of the included eyes, 90.5% avoided a vision loss of ≥15 letters. There was an overall mean of 13.0 injections over the 24 months, 7.5 injections in the first year and 5.5 in the second year, with a mean of 14.8 clinic visits.

CONCLUSIONS

These data indicate that eyes managed in routine clinical practice with a treat and extend regimen can achieve good visual outcomes while decreasing the burden of treatments and clinic visits.

Dose-response associations between cycling activity and risk of hypertension in regular cyclists: The UK Cycling for Health Study

Most population studies on physical activity and health have involved largely inactive men and women, thus making it difficult to infer if health benefits occur at exercise levels above the current minimum guidelines. The aim was to examine associations between cycling volume and classical cardiovascular risk markers, including hypertension and hypercholesterolemia, in a population sample of habitual cyclists. A nationwide sample comprising 6949 men and women (aged 47.6 years on average) completed questions about their cycling levels, demographics and health. Nearly the entire sample (96.3%) achieved the current minimum physical activity recommendation through cycling alone. There was a dose–response association between cycling volume and risk of diagnosed hypertension (P-trend =0.001), with odds ratios of 0.98 (95% confidence interval (CI), 0.80–1.21), 0.86 (0.70, 1.06), 0.67 (95% CI, 0.53–0.83) across categories of 23–40, 40–61 and >61 metabolic equivalent hours/week (MET-h/week) compared with <23 MET-h/week. These associations persisted in models adjusted for age, sex, smoking, alcohol, body mass index (BMI) and other moderatevigorous physical activities. We also observed inverse associations between cycling volume and other risk factors including BMI and hypercholesterolemia. In summary, results from a population sample of cyclists suggest that additional cardiovascular health benefits can be achieved beyond the current minimum physical activity recommendation.