294 Stem Cell Enriched Fat Grafts Versus Autologous Fat Grafts for Facial Reconstruction: A Systematic Review and Meta-Analysis

Aim

To compare the results of stem cell-enhanced fat grafting to autologous fat grafting for face reconstruction.

Method

A systematic review and meta-analysis were carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines, and an electronic search was carried out to identify all Randomised Controlled Trials (RCTs), case control studies, and cohort studies comparing the outcomes of stem cell-enrichment fat grafting versus routine fat grafting for facial reconstruction. The primary outcome measures were volume retention and infection rate. Secondary outcome measures included post-surgery patient satisfaction, redness and swelling, fat necrosis, cysts, and operation time. For the analysis, fixed and random effects modelling were utilised.

Results

Eight studies with a total of 275 participants were assessed. In terms of mean volume retention, there was a significant difference between the stem cell-enrichment fat grafting and routine grafting groups (standardised Mean Difference [MD] = 2.49, P 0.00001). However, there was no significant difference in infection rates between the two groups (OR = 0.36, P = 0.30). Except for the operation duration, which was shorter in the latter, the intervention group had similar results to the control group for all secondary outcomes.

Conclusions

When compared to conventional fat grafting, stem cell-enriched fat grafting is a better alternative for facial reconstruction surgery since it enhances mean volume retention and does not worsen patient satisfaction or surgical complications.

Transcatheter aortic valve implantation outcomes compared between bicuspid aortic and tricuspid aortic valve stenosis: an updated systematic review and meta-analysis

Background

TAVI has emerged as an attractive treatment modality based on promising recent trial data. Patients with BAV, a commonly encountered clinical condition have largely been excluded from a majority of trials.

Purpose

Elderly patients with BAV and severe AS are increasingly encountered in clinical practice. This meta-analysis compares clinical outcomes between bicuspid and tricuspid AV patients to address the current knowledge-gap and identify optimal management strategies of these patients.

Methods

A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify the available observational studies comparing outcomes of TAVI in BAV and TAV patients. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints.

Results

16 Observational studies met inclusion criteria, comprising 10,053 patients with BAV and 173,307 patients with TAV that underwent TAVI. No significant differences in 30-day and long-term mortality rates were observed. Patients with BAV had an increased risk of stroke (OR 1.23; 95% CI [1.06–1.44], p=0.007), re-intervention (OR 1.90; 95% CI [1.15–3.15], p=0.01), paravalvular leak (OR 1.42; 95% CI [1.25–1.61], p<0.ehab724.22251), conversion to open surgery (OR 1.93; 95% CI [1.21–3.07], p=0.006), and new pacemaker implantation (1.57; 95% CI (1.06 - 2.33, p=0.02). Adverse event rates are lower with the use of newer generation of valves. No significant difference in major vascular complications, major bleeding, or incidence of AKI was noted.

Conclusions

Complication rates for BAV TAVI are higher, but mortality is similar to TAV TAVI indicating TAVI is an appropriate alternative for intermediate-high risk patients with BAV. A better understanding of valve anatomy, physician expertise, the use of newer-generation valves can help reduce these complications.

Funding Acknowledgement

Type of funding sources: None.

Abstract OT-16-01: A phase 1 study of abemaciclib and niraparib as neoadjuvant therapy in hormone receptor positive (HR+) HER2 negative (HER2-) breast cancer

Background: Achieving a pathologic complete response (pCR) to neoadjuvant therapy correlates with excellent outcome in early stage breast cancer, including HR+ breast cancer (HRBC). Unfortunately, less than 10% of HRBC patients achieve pCR to neoadjuvant therapy; indicating a need for novel HRBC therapies, especially in the neoadjuvant setting. This study evaluates the novel combination of the cyclin dependent kinase inhibitor (CDKi), abemaciclib, in combination with the poly-ADP ribose polymerase inhibitor (PARPi), niraparib, as a neoadjuvant therapy for HRBC.

Niraparib is an orally bioavailable PARPi indicated for the maintenance treatment of platinum-responsive, ovarian cancer, both 1st line and 2nd line. Abemaciclib is approved as a monotherapy or in combination with endocrine therapy in metastatic HRBC. In addition to targeting CDK4/6, abemaciclib also inhibits CDK1, CDK2, and Aurora A/B kinases, which are involved in DNA damage repair. Targeting kinases with abemaciclib sensitizes tumors to DNA-damaging agents, including PARPi. Preclinical data justifies the combination of abemaciclib and niraparib as a novel combination for the treatment of HRBC.

Trial Design: This is a phase I dose-finding study evaluating the combination of abemaciclib and niraparib as a neoadjuvant therapy in patients with early stage HRBC. All eligible participants with biopsy-proven HRBC will undergo a pre-treatment biopsy and start on-study treatment with the combination of abemaciclib and niraparib using a traditional 3+3 dose-escalation algorithm to determine maximum-tolerated dose (MTD). Dose levels are outlined in Table 1. Each cycle is 28 days. After 2 cycles, participants will undergo repeat imaging and biopsy: those with stable or responding disease will continue to receive an additional 2 cycles of abemaciclib and niraparib, followed by surgical resection. Participants with progressive disease will be switched to standard of care chemotherapy. Once the MTD is determined, additional participants up to a sample size maximum of 25 will be enrolled into an expansion cohort (including those from the dosing finding phase) and treated at the established MTD.

Eligibility Criteria: Key Inclusion Criteria: Age ≥ 18 years, biopsy-proven HR+ Her2 non-amplified breast cancer planned for neoadjuvant chemotherapy, ECOG PS ≤1, disease amenable to curative surgical resection. Key Exclusion Criteria: Evidence of metastatic disease, prior PARPi or CDK 4/6i exposure

Specific Aims: Primary Endpoints: Incidence of dose-limiting toxicities (DLTs), incidence of adverse events (AEs) and serious AEs (per CTCAE 5.0). Secondary Endpoints: overall objective response rate, clinical benefit rate, pCR rate, and rate of residual cancer burden 0-1

Statistical Methods: This phase I dose-escalation study for the proposed combination will follow traditional 3+3 escalation rules. The sample size maximum of 25 (including both those from the dosing finding and expansion portions) allows for a greater than 80% chance that the incidence of any AE as rare as 6.4% or greater will be observed in the cohort. For assessments of preliminary efficacy, the sample size provides a two-sided 95% confidence interval with a half width equal to 0.140 when the targeted pCR is 0.15.

Planned Activation Date: Target Accrual: n=25 participants

Contact: Zahi Mitri, MD, MS 3181 SW Sam Jackson Park Road, OC14HO, Portland, OR 97239 503-494-9160, mitri@ohsu.edu

Table 1. Study Regimen Dose LevelsDose Levels (DLAbemaciclib (PO)Niraparib (PO)DL -1100 mg BID100 mg QDDL 1 starting150 mg BID100 mg QDDL 2150 mg BID200 mg QD

Citation Format: Allen Li, Arpana Naik, Nathalie Johnson, Shaun Goodyear, Brett Johnson, Byung Park, Christopher Corless, Joe Gray, Gordon Mills, Zahi Mitri. A phase 1 study of abemaciclib and niraparib as neoadjuvant therapy in hormone receptor positive (HR+) HER2 negative (HER2-) breast cancer [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 OT-16-01.

Incidence and risk predictors analysis of adverse donor reactions in whole blood donation

OBJECTIVE

Adverse donor reactions in normal healthy blood donors is not unusual. However, these unpleasant effects have a negative impact on donor retention. Adverse event due to blood donation is multifactorial in origin. Therefore, the objective of this study was to determine the frequency and type of adverse donor reactions during or after blood donation. More importantly, this study also aimed at analyzing important risk predictors of adverse donor reaction.

MATERIAL AND METHODS

This was a retrospective study conducted from May 2017 to April 2019 in the department of Transfusion Medicine at a tertiary care center in eastern India. Data were stored in Microsoft excel 2016 by using a standardized format as per ISBT criteria and analyzed with software "R, version 3.5.3" to find out the various independent precipitating factor.

RESULTS

Overall, 107 donors (0.98%) experienced adverse events with 10,814 whole blood donations. The first time, females, younger age donors (18-30 years), and donors with a mean arterial blood pressure of less than 90mm of Hg were the most important independent risk factors predicting the possibility of adverse donor reaction. Donors' weight, hemoglobin, and the type of donation had not affected the frequency of adverse events.

CONCLUSION

Analysis of adverse donor reactions helps in selecting the blood donors who are at risk of donor reactions. Our study highlights the importance of proper predonation screening especially in terms of assessment of mean blood pressure, along with identification of first time and female blood donors in order to reduce untoward donor reaction.

Deep venous thrombosis manifestation of common femoral vein leiomyoma

Deep vein thrombosis is a common clinical condition, with well-known risk factors. An unusual case of venous leiomyoma manifesting as a deep vein thrombosis in the left femoral vein of a 55-year-old man was managed successfully at our institution with anticoagulation, en-bloc excision and reconstruction of the femoral vein with spiral vein graft.

Abstract P3-08-16: The impact of residual ductal carcinoma in situ on breast cancer recurrence in the neoadjuvant I-SPY2 TRIAL

Background: Patients who achieve a pathological complete response (pCR- defined as no invasive cancer) after neoadjuvant chemotherapy (NAC) for breast cancer (BC) have improved outcomes, but there is still controversy about the significance of residual ductal carcinoma in situ (DCIS) on local recurrence rate (LRR). The I-SPY 2 TRIAL is an adaptive neoadjuvant platform trial evaluating novel experimental regimens in comparison to standard chemotherapy in women with high-risk breast cancer. The purpose of this study is to determine if residual DCIS after NAC in early BC affects LRR in patients with or without residual invasive disease in the I-SPY 2 TRIAL.

Methods: 933 I-SPY 2 patients with residual cancer burden (RCB) and follow-up data were included in this analysis. Residual DCIS was defined as any carcinoma in situ > 0% on RCB evaluation. Local recurrence was defined as recurrence in breast, chest wall or locoregional nodes and/or skin and subcutaneous tissue. We stratified our cohort into four groups: those without residual invasive disease (defined as RCB0) ± residual DCIS, and those with residual invasive disease (RCB>0) ± residual DCIS. We estimated LRR within each group using the Kaplan Meier method; and used Cox proportional hazards models to assess LRR differences between groups, with: patients with no residual disease (invasive or in situ) as reference group.

Results: Among 933 patients assessed, median follow up time was 3.9 years. RCB 0 status was achieved in 337 patients (36%). Of these, 267 (29%) had no residual DCIS, which represents our reference group, and 70 (7%) had residual DCIS. Among 596 (64%) patients who had RCB>0, 296 (32%) had residual DCIS. For patients with RCB0 without DCIS and RCB0 with DCIS, the LRR at 3 years were similar: 2% vs 3% respectively (Hazard ratio: 1.29 [0.26-6.39]). Results were also similar in the RCB>0 group, with a LRR of 10% at 3 years in those without residual DCIS, and 11% in those with residual DCIS. Both RCB>0 groups had significantly higher LRR when compared to the patients with RCB0 without DCIS (Hazard ratio: 5.25 [2.20-12.5]) and HR 5.85 [2.47-13.9] respectively).

Conclusion: There was no association between residual DCIS and LRR after neoadjuvant chemotherapy, regardless of resolution of invasive disease. Further work is needed to determine whether residual DCIS should drive locoregional therapy decisions after neoadjuvant chemotherapy for invasive breast cancer.

Citation Format: Marie Osdoit, Christina Yau, W. Fraser Symmans, Judy C. Boughey, Smita M. Asare, Ron Balassanian, Jodi M. Carter, Yunn-Yi Chen, Kimberly Cole, Laila Khazai, Molly Klein, Dina Kokh, Gregor Krings, Sunati Sahoo, Gretchen Ahrendt, Akiko Chiba, Cheryl Ewing, Constantine Godellas, Nora Jaskowiak, Brigid Killelea, Helen Krontiras, Rachael Lancaster, Julie Lang, M. Catherine Lee, Arpana Naik, Roshni Rao, Julia Tchou, Shannon Tierney, Eleni Tousimis, Tod Tuttle, Anne Wallace, I-SPY 2 TRIAL Consortium, Bev Parker, Laura J. Esserman, Rita A. Mukhtar. The impact of residual ductal carcinoma in situ on breast cancer recurrence in the neoadjuvant I-SPY2 TRIAL [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-08-16.

Early Prediction of Breast Cancer Therapy Response using Multiresolution Fractal Analysis of DCE-MRI Parametric Maps

We aimed to determine whether multiresolution fractal analysis of voxel-based dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parametric maps can provide early prediction of breast cancer response to neoadjuvant chemotherapy (NACT). In total, 55 patients underwent 4 DCE-MRI examinations before, during, and after NACT. The shutter-speed model was used to analyze the DCE-MRI data and generate parametric maps within the tumor region of interest. The proposed multiresolution fractal method and the more conventional methods of single-resolution fractal, gray-level co-occurrence matrix, and run-length matrix were used to extract features from the parametric maps. Only the data obtained before and after the first NACT cycle were used to evaluate early prediction of response. With a training (N = 40) and testing (N = 15) data set, support vector machine was used to assess the predictive abilities of the features in classification of pathologic complete response versus non-pathologic complete response. Generally the multiresolution fractal features from individual maps and the concatenated features from all parametric maps showed better predictive performances than conventional features, with receiver operating curve area under the curve (AUC) values of 0.91 (all parameters) and 0.80 (K^trans), in the training and testing sets, respectively. The differences in AUC were statistically significant (P < .05) for several parametric maps. Thus, multiresolution analysis that decomposes the texture at various spatial-frequency scales may more accurately capture changes in tumor vascular heterogeneity as measured by DCE-MRI, and therefore provide better early prediction of NACT response.

Establishing scald prevention measures in UK maternity units from takeaway drinks

AIM

To identify policies on the consumption of hot drinks by patients and visitors on all perinatal and postnatal wards in the United Kingdom, and to seek the opinions of members of the wider burns MDT as to whether standardised patient education or regulation of hot drinks around newborn babies is required.

METHODS

All maternity units with postnatal wards across the United Kingdom were surveyed to establish availability of hot drinks on site and whether these were permitted on postnatal wards around infants. An online questionnaire was distributed to members of the British Burn Association to ascertain opinions on hot drinks policies.

RESULTS

Hot takeaway drinks were permitted around newborn infants in 194 of surveyed postnatal wards and were only banned by two units. The online survey received 49 responses from different members of the British Burn Association. Thirty responders (61%) supported a takeaway hot drink ban, while those against the policy would alternatively encourage patient education, dedicated drinking areas and introduction of safety measures.

CONCLUSIONS

Almost every postnatal unit in the UK has access to hot drink retailers on site allowing parents and visitors to bring them into close contact with babies. With varying local regulations, this poses potentially serious consequences during feeding or carrying. We propose a standardised antenatal education be made available, together with standardised designated areas on wards for parents and visitors to consume hot drinks away from infants.

Temperature dissociation of liquids in reusable thermoplastic containers-An eco-friendly scald risk?

Recent global concern regarding the impact of plastic waste on the environment has resulted in efforts to utilise reusable drink containers. Research is lacking regarding temperature dissociation of drinks in reusable thermoplastic cups. This study aimed to compare the cooling time of two common hot drinks sold at a UK retailer, in the three vessels they are sold; ceramic, disposable paper (with and without lid) and reusable thermoplastic cups (with and without lid). All temperatures were collated from 250 ml volumes of black Americano coffee or café latte in the three different containers. The cooling time was measured every sixty seconds using a standardised digital thermocouple thermometer until a threshold liquid temperature of 43 °C was reached. All experiments were performed in triplicate and temperatures converted to a dimensionless logarithmic scale prior to statistical analysis. Cooling time was significantly slower for lidded cups irrespective of material. Unlidded thermoplastic cups significantly slowed cooling times for both black Americano coffee and café latte compared to ceramic and unlidded disposable paper cups. The growing trend in reusable cups does not in itself pose an increased risk of scald injury. However, we consider that the potentially increased ambulatory behaviour associated with using a lidded rather than unlidded cup may increase scald risk. We propose that further consumer guidance should be disseminated regarding the use of any lidded takeaway container to prevent scalds in both adults and children.

Acquired diaphragmatic hernia in a preterm low birth weight neonate

Iatrogenic diaphragmatic hernia is rare in children and we report a preterm low birth weight neonate with a presumably acquired diaphragmatic hernia due to trauma caused by treatment following pneumothorax.

Outcomes of intraoperative radiotherapy for early-stage breast cancer: Experience from a multidisciplinary breast oncology program

BACKGROUND

Intraoperative radiotherapy (IORT) was implemented at our institution for early stage breast cancer patients including those with geographic or medical co-morbidity limitations to whole breast radiation therapy (WBRT).

METHODS

Retrospective review of patients (n = 127) who underwent IORT from 2009 to 2016 for breast cancer. Demographics, pathology, toxicity, and recurrences were ascertained.

RESULTS

The median age was 67 years (interquartile range: 62-73). At median follow-up (49.6 months), 5 patients (4%) had ipsilateral breast tumor recurrence with median time to recurrence of 36.8 months. Acute and late grade ≥3 skin toxicities were observed in 3.1% and 4.7% of patients, respectively. A subset (n = 7) who received prior ipsilateral WBRT was found to have no subsequent local recurrence, one case of acute grade 3 skin toxicity, and no late toxicity.

CONCLUSIONS

IORT is a safe and effective alternative to whole breast radiotherapy, and serves as a suitable alternative to completion mastectomy in locally recurrent breast cancer.

Oral Ketamine or Midazolam or Low Dose Combination for Premedication in Children

This randomized controlled trial was designed to evaluate whether the combination of low dose oral midazolam (0.25 mg/kg) and low dose oral ketamine (3 mg/kg) provides better premedication than oral midazolam (0.5 mg/kg) or oral ketamine (6 mg/kg). Seventy-eight children of ASA physical status I or II scheduled for elective ophthalmic surgery were randomly divided into three groups and given premedication in the holding area 30 minutes before surgery. Two subjects from each group vomited the medication and were excluded, leaving 72 subjects for further analysis.

The onset of sedation was earlier in the combination group than the other two groups. At 10 minutes after premedication 12.5% in the combination group had an acceptable sedation score compared with none in the other two groups. After 20 minutes 54% in the combination group had an acceptable sedation score, 21% in the midazolam group and 16% in the ketamine group (P<0.05). There were no significant differences in the parental separation score, response to induction and emergence score. The mean time for best parental separation score was significantly less in the combination group (19±8 min) than either the midazolam (28±7) or ketamine (29±7 min) groups (P<0.05). Recovery was earlier in the combination group, as the time required to reach a modified Aldrete score of 10 was significantly less in the combination group (22±5 min) than in the oral midazolam (36±11 min) or ketamine (38±8 min) groups. The incidence of excessive salivation was significantly higher in the ketamine alone group (P<0.05). In conclusion, the combination of oral ketamine (3 mg/kg) and midazolam (0.25 mg/kg) has minimal side effects and gives a faster onset and more rapid recovery than ketamine 6 mg/kg or midazolam 0.5 mg/kg for premedication in children.

DCE-MRI Texture Features for Early Prediction of Breast Cancer Therapy Response

This study investigates the effectiveness of hundreds of texture features extracted from voxel-based dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) parametric maps for early prediction of breast cancer response to neoadjuvant chemotherapy (NAC). In total, 38 patients with breast cancer underwent DCE-MRI before (baseline) and after the first of the 6-8 NAC cycles. Quantitative pharmacokinetic (PK) parameters and semiquantitative metrics were estimated from DCE-MRI time-course data. The residual cancer burden (RCB) index value was computed based on pathological analysis of surgical specimens after NAC completion. In total, 1043 texture features were extracted from each of the 13 parametric maps of quantitative PK or semiquantitative metric, and their capabilities for early prediction of RCB were examined by correlating feature changes between the 2 MRI studies with RCB. There were 1069 pairs of feature-map combinations that showed effectiveness for response prediction with 4 correlation coefficients >0.7. The 3-dimensional gray-level cooccurrence matrix was the most effective feature extraction method for therapy response prediction, and, in general, the statistical features describing texture heterogeneity were the most effective features. Quantitative PK parameters, particularly those estimated with the shutter-speed model, were more likely to generate effective features for prediction response compared with the semiquantitative metrics. The best feature-map pair could predict pathologic complete response with 100% sensitivity and 100% specificity using our cohort. In conclusion, breast tumor heterogeneity in microvasculature as measured by texture features of voxel-based DCE-MRI parametric maps could be a useful biomarker for early prediction of NAC response.

Psychometric properties of the English version of the Oral Health Literacy Adults Questionnaire - OHL-AQ

Objective

To test the psychometric properties of the Oral Health Literacy Adult Questionnaire (OHL-AQ) in English. The OHL-AQ was designed to test functional oral health literacy in general populations and was initially validated in Iran.

Methods

The instrument was administered to 405 adult subjects (mean age 45 (SD 16) years and 67% female) attending the 2014 Minnesota State Fair. The OHL-AQ is composed of 17 items measuring four conceptual dimensions: reading comprehension, numeracy, listening, and decision-making. Participants selected the best answer for written or verbally administered items and entered answers on an electronic tablet. Item responses for each individual were combined into a summary score (range 0-17) with higher scores indicating better oral health literacy. Score dimensionality, reliability, and validity were investigated.

Results

For dimensionality, both exploratory factor analysis and a parallel analysis yielded evidence for scale unidimensionality. Reliability was sufficient indicated by a Cronbach's alpha ⟩0.74. Validity of scores was supported by "small" and "medium" effect sizes for construct validity. "Small" effect sizes were observed for global oral health self-report, OHIP-5 scores, treatment urgency, and having a regular dentist. "Medium" effect sizes were seen for presence of dentures, number of natural teeth present, and educational level.

Conclusions

Dimensionality, reliability and validity of the English version of the OHL-AQ in a general adult English-speaking population is supported, providing sufficient psychometric properties in an important target population of the instrument.

Under-utilization of pacemaker therapy for sinus node dysfunction - Real world data from South Asia

OBJECTIVE

Chronic symptomatic sinus node dysfunction (SND), the most common bradyarrhythmia, can be effectively managed by permanent cardiac pacing. Yet the care pathway and barriers to adoption of pacing therapy are not well understood - particularly in low volume implanting countries. The IMPROVE Brady study is a quality improvement initiative being conducted at centers in South Asia, Latin America, and Russia. We assessed the rates of SND diagnosis and pacemaker treatment for SND in the South Asia cohort.

METHODS

The prospective study enrolled patients with heart rate of  ≤50 beats per minute presenting with symptoms including syncope, dizziness, and/or dyspnea from ten centers in India and Bangladesh. Patients were followed to identify the proportion diagnosed with SND and subsequently treated with pacemaker therapy.

RESULTS

A total of 508 patients meeting criteria were enrolled and followed on average for 8.3±8.0months. Patients were on average 58 years of age, 77% were male, and 91% had completed at least primary education. An SND diagnosis was made in 368 (72%) of patients, with the majority (80%) of diagnoses occurring within 1 month of enrollment. Of the patients with an SND diagnosis, 63 (17%) were treated with a pacemaker. Reasons for not receiving treatment were: subject refusal or deferred decision (45%), unaffordability (34%), physician determined - not-indicated (20%), and other (1%). Older age, female gender, history of hypertension, lower resting heart rate, and syncopal or pre-syncopal symptoms were associated with a higher probability of implant.

CONCLUSIONS

In a care pathway assessment for the diagnosis and treatment of symptomatic SND in South Asia only 1 in 6 patients received pacemaker indicated therapy, largely due to patient refusal and physician decision. Phase II of the study will be aimed to improve this treatment rate.

Summer Temperature and Spatial Variability of all-Cause Mortality in Surat City, India

Background:

Ample information is available on extreme heat associated mortality for few Indian cities, but scant literature is available on effect of temperature on spatial variability of all-cause mortality for coastal cities.

Objective:

To assess the effect of daily maximum temperature, relative humidity and heat index on spatial variability of all-cause mortality for summer months (March to May) from 2014 to 2015 for the urban population of Surat (coastal) city.

Materials and Methods:

Retrospective analysis of the all-cause mortality data with temperature and humidity was performed on a total of 9,237 deaths for 184 summer days (2014-2015). Climatic and all-cause mortality data were obtained through Tutiempo website and Surat Municipal Corporation respectively. Bivariate analysis performed through SPSS.

Observations:

Mean daily mortality was estimated at 50.2 ± 8.5 for the study period with a rise of 20% all-cause mortality at temperature ≥ 40°C and rise of 10% deaths per day during extreme danger level (HI: > 54°C) days. Spatial (Zone wise) analysis revealed rise of 61% all-cause mortality for Southeast and 30% for East zones at temperature ≥ 40°C.

Conclusions:

All-cause mortality increased on high summer temperature days. Presence of spatial variation in all-cause mortality provided the evidence for high risk zones. Findings may be helpful in designing the interventions at micro level.

Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry

Aim

A national atrial fibrillation (AF) registry was conducted under the aegis of the Indian Heart Rhythm Society (IHRS), to capture epidemiological data-type of AF, clinical presentation and comorbidities, current treatment practices, and 1-year follow-up outcomes.

Methods

A total of 1537 patients were enrolled from 24 sites in India in the IHRS-AF registry from July 2011 to August 2012. Their baseline characteristics and follow-up data were recorded in case report forms and subsequently analyzed.

Results

The average age of Indian AF patients was 54.7 years. There was a marginal female preponderance – 51.5% females and 48.5% males. At baseline, 20.4% had paroxysmal AF; 33% had persistent AF; 35.1% had permanent AF and 11% had first AF episode. At one-year follow-up, 45.6% patients had permanent AF.

Rheumatic valvular heart disease (RHD) was present in 47.6% of patients. Hypertension, heart failure, coronary artery disease, and diabetes were seen in 31.4%, 18.7%, 16.2%, and 16.1%, respectively.

Rate control was the strategy used in 75.2% patients, digoxin and beta-blockers being the most frequently prescribed rate-control drugs. Oral anticoagulation (OAC) drugs were used in 70% of patients. The annual mortality was 6.5%, hospitalization 8%, and incidence of stroke 1%.

Conclusions

In India, AF patients are younger and RHD is still the most frequent etiology. Almost two-third of the patients have persistent/permanent AF. At one-year follow-up, there is a significant mortality and morbidity in AF patients in India.

Underutilization of Timely Kidney Transplants in Those With Living Donors

Preemptive kidney transplant (PKTx) and kidney transplant (KTx) within 1 year of dialysis initiation have been associated with superior outcomes. Wait times should be minimal for transplants with living donors; however, there is lack of literature studying utilization of timely KTx in this population. We designed this retrospective study using data from United Network for Organ Sharing Standard Transplant Analysis and Research files from 2000 to 2012 to assess the trends in utilization of PKTx and Early KTx (combination of PKTx or transplant within 1 year of dialysis initiation) in recipients of living donor KTx. Only 32.6% transplants were PKTx, and 61.9% were Early KTx. A significant improvement in proportion of PKTx was seen from 27.5% in 2000 to 35.4% in 2006, with no change since. Similarly, the proportion of Early KTx increased from 61.4% in 2000 to 63.6% in 2006, with no increase since. Similar results were seen after adjusted analysis and were independent of living donor type. Although there was some improvement in utilization of timely transplants in the early part of the last decade, there has been no improvement since. Considering the benefits of timely kidney transplant, it is important to understand the reasons behind the same and to improve utilization.

Early Prediction and Evaluation of Breast Cancer Response to Neoadjuvant Chemotherapy Using Quantitative DCE-MRI

The purpose is to compare quantitative dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) metrics with imaging tumor size for early prediction of breast cancer response to neoadjuvant chemotherapy (NACT) and evaluation of residual cancer burden (RCB). Twenty-eight patients with 29 primary breast tumors underwent DCE-MRI exams before, after one cycle of, at midpoint of, and after NACT. MRI tumor size in the longest diameter (LD) was measured according to the RECIST (Response Evaluation Criteria In Solid Tumors) guidelines. Pharmacokinetic analyses of DCE-MRI data were performed with the standard Tofts and Shutter-Speed models (TM and SSM). After one NACT cycle the percent changes of DCE-MRI parameters K^trans (contrast agent plasma/interstitium transfer rate constant), v_e (extravascular and extracellular volume fraction), k_ep (intravasation rate constant)_, and SSM-unique τ_i (mean intracellular water lifetime) are good to excellent early predictors of pathologic complete response (pCR) vs. non-pCR, with univariate logistic regression C statistics value in the range of 0.804 to 0.967. v_e values after one cycle and at NACT midpoint are also good predictors of response, with C ranging 0.845 to 0.897. However, RECIST LD changes are poor predictors with C = 0.609 and 0.673, respectively. Post-NACT K^trans, τ_i, and RECIST LD show statistically significant (P < .05) correlations with RCB. The performances of TM and SSM analyses for early prediction of response and RCB evaluation are comparable. In conclusion, quantitative DCE-MRI parameters are superior to imaging tumor size for early prediction of therapy response. Both TM and SSM analyses are effective for therapy response evaluation. However, the τ_i parameter derived only with SSM analysis allows the unique opportunity to potentially quantify therapy-induced changes in tumor energetic metabolism.

Gene expression signatures of breast cancer stem and progenitor cells do not exhibit features of Warburg metabolism

INTRODUCTION

Cancers are believed to adapt to continual changes in glucose and oxygen availability by relying almost exclusively on glycolytic metabolism for energy (i.e. the Warburg effect). The process by which breast cancers sustain growth in avascular tissue is thought to be mediated via aberrant hypoxia response with ensuing shifts in glycolytic metabolism. Given their role in initiating and perpetuating tumors, we sought to determine whether breast cancer stem and progenitor cells play an instrumental role in this adaptive metabolic response.

METHODS

Breast cancer stem/progenitor cells were isolated from invasive ductal carcinomas, and benign stem cells (SC) were isolated from reduction mammoplasty tissues. Relative expression of 33 genes involved in hypoxia and glucose metabolism was evaluated in flow cytometrically isolated stem and progenitor cell populations. Significance between cohorts and cell populations was determined using Student's 2-tailed t test.

RESULTS

While benign stem/progenitor cells exhibited few significant inter-group differences in expression of genes involved in hypoxia regulation or glucose metabolism, breast cancer stem/progenitor cells demonstrated significant inter-group variability. Breast cancer stem/progenitor cells adapted to microenvironments through changes in stem cell numbers and transcription of glycolytic genes. One of four breast cancer stem/progenitor cells subpopulations exhibited an aerobic glycolysis gene expression signature. This subpopulation comprises the majority of the tumor and therefore best reflects invasive ductal carcinoma tumor biology. Although PI3K/AKT mutations are associated with increased proliferation of breast cancer cells, mutations in breast cancer stem/progenitor cells subpopulations did not correlate with changes in metabolic gene expression.

CONCLUSIONS

The adaptive capacity of breast cancer stem/progenitor cells may enable tumors to survive variable conditions encountered during progressive stages of cancer growth.

When the living and the deceased cannot agree on organ donation: a survey of US organ procurement organizations (OPOs)

The legal concept of first person authorization (FPA) is based on the principle that a decision by a person with decision-making capacity should be respected even after he or she dies. Although the transplant community largely supports this concept, its implementation has not been universal. We conducted a web-based survey of all 58 Organ Procurement Organization (OPO)executive directors in the United States to assess OPOs' procurement policies and practices in the context of family objections. All 58 respondents(100%) responded to our survey. All OPOs except one have an online donor registration website. Most OPOs(89%) (51 of 57 respondents) estimated that the frequency of family objecting to organ donation in cases of registered donors was <10%. No OPOs reported the frequency to be higher than 25%. Only 50% (27 of 54) of the OPOs have a written policy on handling family objections. Approximately 80% of the OPOs reported honoring FPA. However, in the past 5 years, 20 OPOs (35%) have not yet participated in organ procurement from a registered deceased donor over family objection. Further research to identify the barriers and possible solutions to implementing FPA is warranted.

Breast cancer stem cells mutations: A new understanding of intratumoral heterogeneity

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Background: Breast cancer has long been recognized as a heterogeneous disease. This has profound implications for diagnosis, treatment and disease recurrence. Oncogenic mutations have been identified in breast cancer cells with stem-like and progenitor properties (BCSC). We have previously reported that BCSC mutations correlated with axillary lymph node metastases. This was even more significant when micrometastatic disease was included. Our hypothesis is that tumor heterogeneity extends to the genetics of BCSC, and that BCSC mutations are better predictors of lymph node status than whole tumor genetics. Methods: BCSC from fresh tissue specimens were matched to their whole tumor specimens. BCSC and whole tumor DNA were sent for PCR-based mutation analysis. Patient data was collected by chart review. Results: Twenty-eight matched BCSC and whole tumor samples were analyzed. PI3K/Akt signaling mutations in PIK3CA, AKT1, HRAS, and MET were identified in BCSC from 10 tumors. In 4 of these, mutations were also identified in the corresponding whole tumor specimens. In 4 patients, mutations were identified in whole tumor samples only. Fourteen tumors had no mutations. Tumor stage, grade, receptor status, and age did not correlate with tumor or BCSC mutation status. In contrast to BCSC mutations, mutation status of the whole tumor did not correlate with micro or macro metastatic disease in the lymph node (p = 0.92). Conclusions: Mutations in BCSC are more predictive of lymph node metastases than mutations identified in the tumors. Thus, PI3K/Akt pathway mutations in tumor precursor cells may have a stronger influence on tumor metastatic potential than mutations identified in whole tumor samples. Whole tumors and BCSC populations demonstrate significant heterogeneity, as mutations identified in BCSC and tumors were not always concordant. Rare BCSC populations must be tested separately as they provide crucial prognostic and treatment information in conjunction with whole tumor genetic analyses.

Does the number of surgical excisions before delivering intraoperative radiotherapy (IORT) affect skin toxicity?

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Background: The TARGIT-A trial allowed administration of IORT both pre- and post-pathology. The advantage of post-pathology is the ability to determine eligibility based on margins, pathologic tumor size and nodal status, prior to delivering radiation. However, it is unclear whether having more than one operation before IORT is associated with worse skin toxicity. In this study, we aimed to examine the relationship of the number of operations and skin toxicities in women receiving IORT. Methods: We conducted a retrospective analysis of 57 consecutive patients who underwent IORT from 2009-2013. All patients received 20 Gy in 1 fraction prescribed to the applicator surface using the Carl Zeiss Intrabeam System. Skin toxicities were determined using CTCAE 4.0 and RTOG criteria. In addition, infection, skin erythema, desquamation, symptomatic seroma, and necrosis were scored individually and used as outcome measures. Pearson’s Chi-squared test was used to assess the association of the number of operations and skin toxicities. A multivariate analysis was performed and included age, applicator size, max skin dose, number of operations, DM, HTN, BMI, co-morbidity, and depth from skin on mammogram as variables. Results: The median follow-up was 11 months (range 1-33). The median age and applicator size were 68 yrs (range 49-85) and 4 cm (range 2.5-5). 20 (35%) patients had 1 operation (lumpectomy, SLNB and Intrabeam all in 1 setting). 36 (63%) patients had 2 operations (initial surgery, followed by Intrabeam +/- margin re-excision). One (2%) patient had 3 operations (initial surgery, re-excision, followed by Intrabeam). On univariate analysis, the number of operations was associated with increased infection (p = 0.044), but not other skin toxicities. On multivariate analysis, the association was no longer significant (p = 0.97). Conclusions: Our study suggests that delivering IORT post-pathology was not associated with worse acute or late skin complications. Delivering IORT after the initial operation decreases the uncertainty of margin status and avoids the controversy of excising an irradiated positive margin and/or the need for additional whole breast radiation.

Lack of evidence of hepatitis E virus infection among renal transplant recipients in a disease-endemic area

Persistent hepatitis E virus (HEV) infection has been reported among solid-organ transplant recipients in nonendemic areas. Such chronic infections have all been related to genotype 3 HEV, which is prevalent in these areas. Whether persistent infection occurs with genotype 1 HEV, prevalent in areas where the infection is hyperendemic, is unclear. We therefore tested sera from renal transplant recipients receiving immunosuppressive agents in India, where genotype 1 HEV infection is endemic, for alanine aminotransferase levels, and presence of IgM and IgG anti-HEV antibodies and HEV RNA. Of the 205 subjects studied [aged 16-65 (median, 38) years, 182 male], 46 (22.4%) had abnormal ALT levels (>40 IU/mL). IgG anti-HEV was detected in 52 (20.5%) and IgM anti-HEV was detected in 14 (6.8%) subjects, including four who had IgG anti-HEV; antibody positivity had no relation with serum ALT or serum creatinine. All the sera tested were negative for HEV RNA. These findings suggest that chronic infection with genotype 1 HEV is infrequent.

Pharmaceutical care: need of the hour in India

Pharmaceutical care signifies a shift of practice in pharmacy from being drug product-oriented to the one that is patient-oriented to achieve definite outcomes that improves patients’ quality of life. In order to achieve pharmaceutical care, pharmacists have to assume the role of caregiver, communicator, decision-maker, teacher, researcher, life-long learner, leader, and manager, which will help him to provide individualized care. As the patients visit community pharmacists more often, they can play a major role in providing individual care to the patients especially in the management of chronic noncommunicable diseases (NCDs). Community pharmacists have to upgrade their expertise in drug product orientation to that of clinical orientation to provide patient oriented care. Hence pharmacists have a larger role to play in managing NCDs which are rapidly increasing in India.

Determination of site of absorption of propranolol in rat gut using in situ single-pass intestinal perfusion

Previously, permeability and site of intestinal absorption of propranolol have been reported using the Ussing chamber. In the present study, the utility of Single-Pass Intestinal Perfusion to study permeability and site of intestinal absorption of propranolol was evaluated in rats. Drug permeability in different regions of rat intestine viz. duodenum, jejunum, ileum and colon was measured. Propranolol (30 μg/ml) solution was perfused in situ in each intestinal segment of rats. Effective permeability (Peff) of propranolol in each segment was calculated and site of absorption was determined. The Peff of propranolol in rat duodenum, jejunum, ileum and colon was calculated to be 0.3316×10(-4) cm/s, 0.4035×10(-4)cm/s, 0.5092×10(-4) cm/s and 0.7167×10(-4) cm/s, respectively. The above results suggest that permeability of propranolol was highest through colon compared to other intestinal sites, which is in close agreement to that reported previously. In conclusion, in situ single pass intestinal perfusion can be used effectively to study intestinal permeability as well as site of intestinal absorption of compounds in rats.

Fresh surgical specimens yield breast stem/progenitor cells and reveal their oncogenic abnormalities

Background

The process by which breast cancer stem cells arise is unknown. It may be that the benign stem cells in breast tissue are transformed into malignant stem cells through the acquisition of genetic abnormalities. In this study, we collected and compared benign and malignant breast stem/progenitor cells to determine whether specific genetic abnormalities occur in breast cancer stem/progenitor cells within the human body.

Methods

Fresh surgical specimens from benign and malignant breast tissues were obtained directly from the operating room and examined. Cells variably expressing stem cell-associated surface markers CD49f and CD24 were collected by fluorescence-activated cell sorting. The frequencies of these cells in benign and malignant breast tissues were ascertained. Oncogenetic mutation analyses were performed and expression of stem cell-associated genes was measured.

Results

The frequencies of stem/progenitor cells were similar between benign and malignant tissues. Stem cell-associated gene expression also was similar between benign and malignant stem cells. Genetic mutations in the PIK/AKT pathway were found in 73% of the tumors’ stem cells, specifically within two subpopulations. No mutations were found in stem/progenitor cell subpopulations from benign breast tissue.

Conclusions

The results of this study suggest that, following malignant transformation, breast cancer stem/progenitor cells retain their stem cell functions and relative frequencies. In addition, they develop malignant capabilities by acquiring mutations in genes critical for maintaining normal cellular metabolism and proliferation.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-011-1892-z) contains supplementary material, which is available to authorized users.

Strength training stops bone loss and builds muscle in postmenopausal breast cancer survivors: a randomized, controlled trial

Targeted exercise training could reduce risk factors for fracture and obesity-related diseases that increase from breast cancer treatment, but has not been sufficiently tested. We hypothesized that progressive, moderate-intensity resistance + impact training would increase or maintain hip and spine bone mass, lean mass and fat mass and reduce bone turnover compared to controls who participated in a low-intensity, non-weight bearing stretching program. We conducted a randomized, controlled trial in 106 women with early stage breast cancer who were >1 year post-radiation and/or chemotherapy, ≥ 50 years of age at diagnosis and postmenopausal, free from osteoporosis and medications for bone loss, resistance and impact exercise naïve, and cleared to exercise by a physician. Women were randomly assigned to participate in 1 year of thrice-weekly progressive, moderate-intensity resistance + impact (jump) exercise or in a similar frequency and length control program of progressive, low-intensity stretching. Primary endpoints were bone mineral density (BMD; g/cm²) of the hip and spine and whole body bone-free lean and fat mass (kg) determined by DXA and biomarkers of bone turnover-serum osteocalcin (ng/ml) and urinary deoxypyrodiniline cross-links (nmol/mmolCr). Women in the resistance + impact training program preserved BMD at the lumbar spine (0.47 vs. -2.13%; P = 0.001) compared to controls. The resistance + impact group had a smaller increase in osteocalcin (7.0 vs. 27%, P = 0.03) and a larger decrease in deoxypyrodinoline (-49.9 vs. -32.6%, P = 0.06) than controls. Increases in lean mass from resistance + impact training were greatest among women currently taking aromatase inhibitors compared to controls not on this therapy (P = 0.01). Our combined program of resistance + impact exercise reduced risk factors for fracture among postmenopausal breast cancer survivors (BCS) and may be particularly relevant for BCS on aromatase inhibitors (AIs) because of the additional benefit of exercise on muscle mass that could reduce falls.

Screening for breast cancer: an update for the U.S. Preventive Services Task Force

BACKGROUND

This systematic review is an update of evidence since the 2002 U.S. Preventive Services Task Force recommendation on breast cancer screening.

PURPOSE

To determine the effectiveness of mammography screening in decreasing breast cancer mortality among average-risk women aged 40 to 49 years and 70 years or older, the effectiveness of clinical breast examination and breast self-examination, and the harms of screening.

DATA SOURCES

Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the fourth quarter of 2008), MEDLINE (January 2001 to December 2008), reference lists, and Web of Science searches for published studies and Breast Cancer Surveillance Consortium for screening mammography data.

STUDY SELECTION

Randomized, controlled trials with breast cancer mortality outcomes for screening effectiveness, and studies of various designs and multiple data sources for harms.

DATA EXTRACTION

Relevant data were abstracted, and study quality was rated by using established criteria.

DATA SYNTHESIS

Mammography screening reduces breast cancer mortality by 15% for women aged 39 to 49 years (relative risk, 0.85 [95% credible interval, 0.75 to 0.96]; 8 trials). Data are lacking for women aged 70 years or older. Radiation exposure from mammography is low. Patient adverse experiences are common and transient and do not affect screening practices. Estimates of overdiagnosis vary from 1% to 10%. Younger women have more false-positive mammography results and additional imaging but fewer biopsies than older women. Trials of clinical breast examination are ongoing; trials for breast self-examination showed no reductions in mortality but increases in benign biopsy results.

LIMITATION

Studies of older women, digital mammography, and magnetic resonance imaging are lacking.

CONCLUSION

Mammography screening reduces breast cancer mortality for women aged 39 to 69 years; data are insufficient for older women. False-positive mammography results and additional imaging are common. No benefit has been shown for clinical breast examination or breast self-examination.

Primary Hypothyroidism Presenting as a Sellar Mass Which Regressed with Thyroid Hormone Therapy

We describe a15-year-old girl presenting with compensatory pituitary enlargement due to primary hypothyroidism. The hyperplasia regressed following thyroxine administration. The clinical, laboratory and MRI features of the patients are described and the mechanisms of pituitary gland enlargement are discussed.