Anaesthetic management of people with multiple sclerosis

There is a lack of published guidelines on the management of patients with multiple sclerosis (MS) undergoing procedures that require anaesthesia and respective advice is largely based on retrospective studies or case reports. The aim of this paper is to provide recommendations for anaesthetists and neurologists for the management of patients with MS requiring anaesthesia. This review covers issues related to the anaesthetic management of patients with MS, with a focus on preoperative assessment, choice of anaesthetic techniques and agents, side-effects of drugs used during anaesthesia and their potential impact on the disease evolution, drug interactions that may occur, and the need to use monitoring devices. A systematic PubMed research was performed to retrieve relevant articles.

Role of four-dimensional computer tomography (4D-CT) in non-localising and discordant first-line imaging in primary hyperparathyroidism

BACKGROUND

Accurate preoperative localisation of parathyroid adenoma is imperative for the success of minimally invasive parathyroidectomy (MIP).

OBJECTIVE

Our study aimed to evaluate the role of four-dimensional computer tomography (4D-CT) scan as an imaging modality in patients with failed and discordant localisation reported in the first-line imaging modalities (ultrasonography and 99mTc-MIBI-SPECT/CT).

METHODS

This is a prospective cohort study performed at a university teaching centre from March 2013 to July 2021. All patients with primary hyperparathyroidism who had failed localisation by ultrasonography and 99mTc-MIBI-SPECT/CT (SpCT), or discordance between them, had 4D-CT performed in this study.

RESULTS

One hundred and two sporadic cases of pHPT with failed/discordant first-line imaging had 4D-CT imaging prior to parathyroidectomy. In 102 patients, 105 parathyroid adenomas were reported on histopathology. 4D-CT was able to localise 78% of them to the correct side and 64% to the correct quadrant in 102 patients, as compared with US (correct side 21%, correct quadrant 16%) and 99mTc-MIBI-SPECT/CT (correct side 36%, correct quadrant 31%). 4D-CT had a sensitivity, precision, accuracy and F1 score for correct quadrant localisation as 79%, 81%, 66% and 80%; and for correct side localisation as 82%, 98%, 80% and 89%, respectively. 4D-CT was able to identify three ectopic adenomas (two in superior mediastinum and one in the oesophageal wall) which were not detected on US or SpCT.

CONCLUSION

4D-CT was found to be sensitive and accurate in preoperative localising of the diseased parathyroid glands after failed/discordant US and SpCT. This led to more patients being offered MIP as the primary surgery and improved operative outcomes.

Enhancing diabetes care for the most vulnerable in the 21st century: Interim findings of the National Advisory Panel on Care Home Diabetes (NAPCHD)

Older adults with diabetes may carry a substantial health burden in Western ageing societies, occupy more than one in four beds in care homes, and are a highly vulnerable group who often require complex nursing and medical care. The global pandemic (COVID-19) had its epicentre in care homes and revealed many shortfalls in diabetes care resulting in hospital admissions and considerable mortality and comorbid illness. The purpose of this work was to develop a national Strategic Document of Diabetes Care for Care Homes which would bring about worthwhile, sustainable and effective quality diabetes care improvements, and address the shortfalls in care provided. A large diverse and multidisciplinary group of stakeholders (NAPCHD) defined 11 areas of interest where recommendations were needed and using a subgroup allocation approach were set tasks to produce a set of primary recommendations. Each subgroup was given 5 starter questions to begin their work and a format to provide responses. During the initial phase, 16 key findings were identified. Overall, after a period of 18 months, 49 primary recommendations were made, and 7 major conclusions were drawn from these. A model of community and integrated diabetes care for care home residents with diabetes was proposed, and a series of 5 'quick-wins' were created to begin implementation of some of the recommendations that would not require significant funding. The work of the NAPCHD is ongoing but we hope that this current resource will help leaders to make these required changes happen.

349 Improving Surgical Teaching for Junior Trainees Internationally in Light of Covid-19

Aim

During the Covid-19 pandemic there has been a gross effect on surgical training at all grades. A cohort that has been affected but reported less frequently are medical students and foundation doctors (junior trainees), whose interest in the field and clinical skills may have been affected by reduced service provision.

Method

A survey of junior trainees was conducted to analyse their perceived adequacy of surgical teaching in light of the effect of Covid-19. An online teaching course was then designed to target areas of weakness identified in the survey. The content was designed with the Imperial College London surgery curriculum and was vetted by a consultant surgeon.

Results

Of the 713 people surveyed, 393 (55%) had received little or no surgical teaching and 496 (70%) respondents said they were “not” or “slightly” confident in managing common and emergency surgical presentations. A free text box highlighted that deteriorating patients, clinical decision-making, and initiating management were the greatest concerns. This was used to design an international online teaching course for junior trainees, that focused explicitly on clinical care. The sessions were run live on MindTheBleep via Facebook live, to answer questions in real time and examine cases with live audience participation, receiving feedback after every session. This model has reached trainees in >30 countries with >200 feedback responses and an average rating of 4.5/5.

Conclusions

Junior trainees are a key cohort whose interest and education in surgery has suffered due to the pandemic. An innovative, online, clinically orientated course is assisting to re-engage trainees internationally.

1113 Surgical Innovators or Spin Doctors: Reporting of Expectations for Robotic Gastrointestinal Surgery

Introduction

The use of robotics in gastrointestinal surgery is an increasingly popular area of surgical innovation. Despite uncertainty regarding clinical benefits, gastrointestinal surgery centres continue to introduce robotic services. This may be motivated by perceived benefits, in lieu of substantial empirical benefits. We aimed to summarise the expected advantages and disadvantages of robotic techniques in gastrointestinal surgery, as reported by study authors.

Method

A systematic review was undertaken by the trainee led RoboSurg Collaborative. Searches were conducted on of Embase, Medline, the Cochrane Library and Web of Science. Articles were double screened by abstract, then full text. All primary studies reporting outcomes following robotic cholecystectomy or oesophagectomy were included. Reports of expected benefits and disadvantages or robotic techniques were extracted verbatim, and summarised using descriptive statistics.

Results

We included 192 studies. An expected benefit was reported in 161 (84%). Of those, 127 (79%) expected robotics to have an intra-operative advantage, such as reduced operative time, improved dexterity and improved visualisation. Post-operative benefits, such as reduced recovery time and shorter length of hospital stay, were expected in 72 (45%). Expected disadvantages were reported in 96 (50%) of the included studies. Of those, 74 (77%) expected robotics to have intra-operative disadvantages such as increased operative times and lack of tactile feedback. Increased cost was another commonly expected limitation.

Conclusions

Study authors reported perceived benefits more frequently than disadvantages. Perceived benefits were more commonly advantageous to the surgeon rather than the patient. There were directly conflicting perceptions of how robotic techniques affect operative times.

Neutron calorimeter design for pulsed neutron experiment diagnostics

Neutron calorimeter for diagnostic support of both fission- and fusion-based pulsed neutron experiments is described. The calorimeter generates a voltage signal output via a pair of thermocouples contacting a sample material, which experiences a temperature increase due to interactions with an incident neutron fluence. Advantages of the calorimeter include the versatility derived from its small size, modularity, and the variety of employable neutron absorber materials and sizes. These characteristics permit use with neutron energies between the thermal and fast (up to 14 MeV) spectra. Design overview and requirements, Monte Carlo particle transport simulation results, test data, and possibilities for calorimeter development are provided and discussed.

P11 A systematic review of the reporting of robotic cholecystectomy

Introduction

Robotic cholecystectomy (RC) is reported to be an innovative alternative to laparoscopic cholecystectomy for the surgical management of gallbladder disease. Perceived technical benefits of RC include enhanced ergonomic capabilities and visualisation. Whilst RC is becoming increasingly widespread, there is a paucity of high-quality data supporting its use, and conflicting evidence of outcomes in current literature. With accumulating reports citing complications associated with novel invasive procedures, experts have suggested that robust clinical evaluation is required. It is vital that techniques such as RC are evaluated consistently, in order for surgeons to fully educate patients about the treatment and obtain informed consent. This study aims to summarise and appraise the reporting of studies of RC.

Methods

Systematic searches identified all published studies reporting RC. Data collection was based on the IDEAL (Idea, Development, Exploration, Assessment, Long-term follow-up) framework. This will be used to identify key areas of reporting including; general study characteristics, patient selection, regulatory and governance arrangements, operator and centre expertise, technique description, and outcome reporting. Because the study will not aim to draw conclusions about the effectiveness of robotic surgery, meta-analyses will not be not performed.

Results

Systematic searches identified 1425 abstracts; 90 full-text papers were included. Results will be summarised in a narrative synthesis and further data will be analysed prior to presentation.

Conclusion

This in-depth analysis of the published literature on RC will provide evidence to understand how this innovative procedure has been introduced and evaluated in relation to the IDEAL recommendations.

Role of long-term supplementation of 25-hydroxyvitamin D3 on egg production and egg quality of laying hen

A study was conducted to evaluate the effect of dietary 25-hydroxyvitamin D₃ (25OHD) on pullet and egg-laying hen growth performance, egg production, and egg quality. Three hundred and ninety 1-day-old Hy-Line W36 pullets were randomly allocated to 3 treatments with 10 replicated cages and 13 birds per cage. Dietary treatments were vitamin D₃ at 2,760 IU/kg (D); vitamin D₃ at 5,520 IU/kg (DD), and vitamin D₃ at 2,760 IU/kg plus 25OHD at 2,760 IU (69 μg)/kg (25D). Body weight and feed intake were recorded at the end of each stage: starter 1 (0–3 wk), starter 2 (4–6 wk), grower (7–12 wk), developer (13–15 wk), prelay (15–17 wk), peaking (18–38 wk), layer 2 (39–48 wk), layer 3 (49–60 wk), layer 4 (61–75 wk), and layer 5 (76–95 wk). Egg production was recorded daily. Egg quality was evaluated every 8 wk starting from 25 wk. There was no difference in growth performance during the rearing period (0–17 wk). In the laying period (18–95 wk), DD showed lower feed intake at layer 2, but higher intake at layer 3 along with lower hen day production (HDP) from 22 to 48 wk compared to the other treatments. During the same period, the DD group laid smaller eggs with higher specific gravity and shell thickness compared with the other treatments or D alone at 40 wk, which may be partly due to the lower body weight. In contrast, 25D had better feed conversion ratio (feed intake per dozen of eggs) at layer 2, and higher overall (22–60 wk) HDP compared with DD. For the egg quality analysis, at 25 and 33 wk, both DD and 25D had higher Haugh unit compared with D. However, 25OHD has no effects on eggshell quality during the entire production period and no beneficial effects on egg production during the later laying period (after 60 wk). In summary, long-term and early supplementation of 25OHD has positive effects on egg production and egg quality, and the beneficial effects were mainly observed during the early laying stage.

Abstract P4-02-03: Impact of the 2018 ASCO/CAP HER2 focused update on human epidermal growth factor receptor-2 (HER2) testing in breast cancer: A retrospective review of a single institutional cohort

Background: In the 2013 ASCO/CAP HER2 update, new recommendations for HER2 diagnostic criteria in breast cancer organized in situ hybridization (ISH) results into five categories; group1 (amplified), group 2 (monosomy), group 3 (co-amplified), group 4 (equivocal) and group 5 (non-amplified). Patients falling into groups 2, 3 and 4 were potentially eligible for HER2 targeted therapy, however, there is uncertainty from limited prospective clinical trials that show patients in these uncommon groups would receive the same benefit as group 1. Concern over whether the interpretation criteria should be modified for these uncommon groups led to the recent publication of the 2018 HER2 focused update. This update has modified ISH criteria for groups 2, 3 and 4, recommending the final diagnosis take into consideration both immunohistochemistry (IHC) and ISH results. The publication of this new guideline has prompted us to investigate what impact this would have on our institution.

Materials & Methods: A retrospective review of the URMC pathology database revealed 2,281 cases that had undergone HER2 FISH analysis since the 2013 update. IHC for initial HER2 screening was used, followed by reflex testing of all 2+ results and cases with histopathologic discordance. All 2,281 FISH cases were sorted into their 5 HER2 categories based on the 2013 guidelines. The final HER2 diagnosis for groups 2, 3 and 4 were then re-determined after applying the new criteria presented in the 2018 focused update.

Results: The results from the 2,281 HER2 FISH cases are shown in Tables 1 and 2. The results for group 1 and group 5 cases remained the same. However, for ISH cases in groups 2, 3 and 4, there were alterations in the final HER2 results. All 25 monosomy cases, originally interpreted as HER2 positive by the 2013 guidelines, were now considered HER2 negative. All group 3 (co-amplified) cases remained positive (due to IHC 2+ results). The largest change was that the original 199 equivocal cases, based on the 2013 guidelines, became split into 198 HER2 negative (99.5%) and 1 HER2 positive (0.5%).

Conclusion: Comparison of the HER2 FISH cases between 2013 and 2018 revealed differences in the final HER2 status. Using the 2018 guideline, 13.72% (313 cases) of the 2281 cases were HER2 positive in contrast to 14.77% (337 cases) from 2013. While that is only a difference of 1.05%, the reclassification of 198 of 199 equivocal cases to negative indicates that 9.82% of the final HER2 results for the entire patient cohort was affected. With 266,000 new cases of breast cancer annually, the final HER2 status of approximately 26,000 patients and their potential eligibility for targeted-therapy would change. Further study of the clinical significance of these changes is warranted.

Final ISH HER2 Status (2013)AmplifiedMonosomyCo-AmplifiedEquivocalNon-Amplified272 cases (11.93%)25 cases (1.10%)40 cases (1.75%)199 cases (8.72%)1,745 cases (76.50%)

Citation Format: Hicks DG, D'Aguiar M, Henry J, McMahon L, Buscaglia B, Turner B. Impact of the 2018 ASCO/CAP HER2 focused update on human epidermal growth factor receptor-2 (HER2) testing in breast cancer: A retrospective review of a single institutional cohort [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-02-03.

Abstract P1-03-02: ASCO/CAP human epidermal growth factor receptor-2 (HER2) in situ hybridization (ISH) categories evaluated by quantitative HER2 protein diagnostic methodologies: A comparative analysis

Background: In 2013, the ASCO/CAP consensus panel published updated guidelines for HER2 testing in breast cancer that modified the definition of HER2 amplification by in situ hybridization (ISH), creating five new prognostic categories (group 1: classic amplified, group 2: monosomy, group 3: co-amplified (polysomy), group 4: equivocal, and group 5: classic non-amplified). Patients determined to be ISH amplified, were considered eligible for HER2-directed therapy. Concern over whether patients from non-classic groups 2-4 would benefit from treatment has led to the recent publication of the 2018 HER2 focused update. This update has modified the criteria for interpreting these ISH categories, recommending that the final diagnosis take into consideration a combination of HER2 immunohistochemistry (IHC) and ISH results. With increased emphasis on the HER2 protein assessment, it has prompted us to quantitatively examine HER2 protein expression in the ISH categories, using two different novel technologies. Materials & Methods: A cohort of 170 cases (URMC) and 102 cases (PSHMC) of invasive breast cancers, which had previously undergone HER2 IHC and ISH testing, were selected for this study. Cases were sorted and categorized into the HER2 ISH categories defined by ASCO/CAP. HER2 protein expression was quantitatively measured in the URMC and PSHMC cohorts using a novel immunodetection methodology (streptavidin-coated Phosphor-Integrated Dot (PID) fluorescent nanoparticles), and a novel dual-antibody, proximity-binding immunoassay (HERmark® Breast Cancer Assay, Monogram Biosciences, South San Francisco, California), respectively. HER2 protein expression was compared to the HER2 FISH and IHC results by ASCO/CAP category. Results: Cases in group 1 had a significantly (p < 0.01) higher average PID/cell and HERmark compared to cases in groups 2-5 (Table 1). Cases in groups 2-4 showed lower quantitative levels of HER2 protein expression, similar to the classic non-amplified cases (group 5). Group 1 was further divided into three subgroups (Table 2): Group A - ISH high-level amplified (ratio > 2, HER2 > 6, CEP17 < 2.7), Group B - amplified with elevated CEP17 (ratio > 2, CEP17 > 2.7), and Group C - low-level amplified (ratio > 2, HER2 > 4 and < 6). Group A and B had a significantly (p < 0.01) higher average PID/cell and HERmark compared to Group C. Group C was more comparable to cases in groups 2-5 (Table 1). Conclusion: Our results suggest that quantitative assessment of HER2 protein expression may help to further classify cases for HER2 status for targeted therapy, supporting the 2018 ASCO/CAP recommendation that non-classic ISH results might be resolved by evaluating protein expression. Follow up studies with a larger patient cohort and dual quantitative assessment are warranted.

Average PID/cell and HERmark in ASCO category groupsASCO category groupN (URMC)PID/cell (URMC)*N (PSHMC)HERmark (PSHMC)*18888.07761.521011.20N/A32016.0213.84238.5315.95296.3208.3*averageTable 2:Average PID/cell and HERmark in subgroups of Group 1SubgroupN (URMC)PID/cell (URMC)*N (PSHMC)HERmark (PSHMC)*A24157.66465.7B34101.61044.1C3016.9329.8*average

Citation Format: Buscaglia B, Turner B, Goda H, Huang W, Leitzel K, Natori T, Nakano Y, Okada H, Sperinde J, Ali S, Vasekar M, D'Aguiar M, McMahon L, Henry J, Lipton A, Hicks D. ASCO/CAP human epidermal growth factor receptor-2 (HER2) in situ hybridization (ISH) categories evaluated by quantitative HER2 protein diagnostic methodologies: A comparative analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-03-02.

Protein hydration in living cells probed by Fourier transform infrared (FT-IR) spectroscopic imaging

FT-IR spectra of a HEK cell were analyzed with 2D disrelation mapping to reveal molecular states of water and protein hydration.

The new system of health accounts in Ireland: what does it all mean?

BACKGROUND

The Central Statistics Office released new figures on Ireland's health spending in December 2015, based on the System of Health Accounts (SHA2011). These figures differ from previous figures, by virtue of an expanded definition of what constitutes health care. The new figures also provide more detail on health expenditure than the previous figures allowed.

AIMS

This article examines the new figures, drawing out findings of note and discussing the implications of these for the Irish health care system. It also compares Ireland with international health systems, highlighting where Ireland is unusual or comparable to international norms.

FINDINGS

Healthcare spending in Ireland as a percentage of GDP is higher than in many other countries, having increased during the economic downturn, although this was due more to the contraction in GDP than an increase in spending. While the majority of healthcare expenditure in Ireland comes from the Government, the share of private expenditure on healthcare in Ireland has increased, with implications for equity in the system. Over half of the expenditure is on curative and rehabilitative services, broadly in line with other countries. The proportion of spending going to long-term care facilities is relatively high by international standards.

CONCLUSION

Suggestions that Ireland is over-spending on health need to be tempered by cognisance that the Irish health system is under-resourced in a number of areas (particularly the number of doctors and the number of hospital beds) and has not fully recovered from cutbacks in the late 1980s and early 1990s.

Breast Cancer in the Bahamas in 2009-2011

BACKGROUND

Breast cancer is the most common form of cancer affecting women in the Bahamas, which consists of many islands. This is the first attempt to identify which island has the highest occurrence of breast cancer.

OBJECTIVE

The aim of this study was to describe the sociodemographical and spatial features of breast cancer in the Bahamas in 2009-2011.

METHODS

A review of the medical records of all women with a confirmed diagnosis of breast cancer during the period January 1, 2009-December 31, 2011, was undertaken. Data were first obtained from the National Oncology Board of the Bahamas and validated by a review of the medical records. The patient address was geocoded and mapped using ArcGIS 10.0 Environmental Systems Research Institute (ESRI) to satellite images obtained from The Nature Conservancy in the Bahamas.

RESULTS

We recruited 270 patients who satisfied the entry criteria. The cumulative incidences of breast cancer for the years 2009-2011 were 51.4, 45.4, and 51.4, respectively. Breast cancer occurred most often in women of African origin with a mean age at diagnosis of 56.6 ± 13.8 years. Ductal carcinoma was the most common histological type observed with most cancers occurring in Grade II or higher and presenting as late stage (≥ Stage II). Surgery was the preferred method of treatment with modified radical mastectomy being the procedure of choice. Spatial distribution of cases across the Bahamas revealed one cluster, which is present on the island of New Providence. Further analysis of New Providence showed a consistently skewed kernel density in the central and eastern regions, compared with a scattered distribution in the southern and western regions.

CONCLUSION

The island of New Providence had the highest occurrence of breast cancer among all the islands of the Bahamas. The increasing incidence of breast cancer in young women is likely to impose a significant burden on the future of Bahamian health care.

Meta-analysis of vagus nerve stimulation treatment for epilepsy: correlation between device setting parameters and acute response

BACKGROUND

Vagus nerve stimulation (VNS) is an adjunctive neurophysiological treatment for those patients who have pharmacoresistant or surgically resistant partial onset epilepsy.

OBJECTIVE

The aim of this study is to determine the effects of high and low stimulation paradigms on a responder rate of ≥50 and ≥75% reduction in seizure frequency and associated adverse effects in adults and children.

METHOD

A literature search was performed using Medline, PubMed, EMBASE, and Cochrane library for studies using vagus nerve stimulation published from January 1980 until July 2014 for medically or surgically resistant partial onset seizures, in children and adults. No restrictions on languages were imposed.

DATA COLLECTION AND ANALYSIS

Four authors reviewed and selected studies for inclusion and exclusion. The search identified five randomized control trials that fit with our inclusion criteria. The following outcomes were evaluated: 50% or greater reduction in total seizure frequency, 75% or greater reduction in total seizure frequency, and adverse effects.

RESULTS

Four randomized controlled trials were analyzed in this meta-analysis. Results indicate high stimulation is more effective in adult patients who experienced ≥50 and ≥75% reduction in seizure frequency with a significant difference within both high and low stimulation groups. In children, there was no significant difference between the two groups and patients with ≥50 % reduction in seizures. Adverse effects such as hoarseness and dyspnea were more common in the high stimulation group where the remaining side effects were not statistically different among both groups.

CONCLUSION

High stimulation is more effective than low stimulation in producing a greater reduction in seizure frequency in patients with medically and surgically resistant epilepsy.

A decade in diabetes specialist services, 2000 to 2011, in England: the views of consultant diabetologists and diabetes specialist nurses amidst persistent healthcare delivery change

AIMS

To assess the impact of continual major National Health Service reorganization on commissioning, organizational and delivery arrangements for secondary care diabetes services. To explore how consultant diabetologists and diabetes specialist nurses perceive the issues facing diabetes specialist services in 2011 and how these have changed in the preceding decade.

METHODS

We used a longitudinal case study approach that combined quantitative and qualitative methods. Five locations in England were purposively selected to represent the wider diabetes specialist community, and seven semi-structured interviews were conducted. Interviews were recorded, transcribed verbatim and analysed using Framework analysis. Findings were compared with and contrasted to results from national quantitative surveys of diabetes specialist services undertaken in 2000 and 2006.

RESULTS

Clinicians viewed positively the expertise and commitment of multidisciplinary teams and their ability to adapt to new situations. Negative perceptions persisted throughout the decade, relating to the continual change that threatens to dismantle relationships and services which had taken many years to establish. Lack of resources, inadequate manpower planning and poor access to psychological support for people with diabetes remained constant themes from 2000 to 2011.

CONCLUSIONS

A willingness to innovate and work differently to improve services was identified; however, clinicians must be supported through organizational changes to ensure people with diabetes receive high-quality care. The disruptive nature of organizational change was a recurrent theme throughout the decade. Periods of stability must exist within commissioning to allow relationships, which are key to integration, to be maintained and permit service improvements to develop.

Diabetes UK Position Statement. Competency frameworks in diabetes

The quality, skills and attitudes of staff working in the healthcare system are central to multidisciplinary learning and working, and to the delivery of the quality of care patients expect. Patients want to know that the staff supporting them have the right knowledge and attitudes to work in partnership, particularly for conditions such as diabetes where 95% of all care is delivered by the person with diabetes themselves. With the current changes in the NHS structures in England, and the potential for greater variation in the types of 'qualified provider', along with the recent scandal at Mid-Staffordshire Hospital, staff need to be shown to be competent and named/accredited or recognized as such. This will help to restore faith in an increasingly devolved delivery structure. The education and validation of competency needs to be consistently delivered and assured to ensure standards are maintained for different roles and disciplines across each UK nation. Diabetes UK recommends that all NHS organizations prioritize healthcare professional education, training and competency through the implementation of a National Diabetes Competency Framework and the phased approach to delivery to address this need.

Pathologic diagnosis, immunohistochemistry, multigene assays and breast cancer treatment: progress toward "precision" cancer therapy

Clinical decisions regarding the suitability of adjuvant systemic therapy for individual patients with breast cancer depends on comprehensive assessment of the underlying biology of each patient's tumor. The previous clinical-pathologic paradigm for treatment, which had been used for decades, now has been augmented by significant advances in molecular analysis of breast tumor tissue samples. Molecular testing has the potential to understand better both tumor biology and clinical behavior, which enables more appropriate therapy choices to be made. We review the rapid evolution in profiling breast cancer tissues, and discuss the current evidence for clinical use of this information and how the emerging molecular paradigm can be integrated into the clinical-pathologic context as we progress toward "precision" therapy for patients with breast cancer and other solid tumors.

Pharmacological treatment of patients with advanced prostate cancer

Prostate cancer is linked to the male sex hormone testosterone. In advanced disease, blocking the production of testosterone using androgen deprivation therapy causes regression of prostate cancer and minimises or prevents symptoms associated with the disease. Luteinising hormone-releasing hormone agonists are commonly used in the management of prostate cancer, however less is known about the role of the newer gonadotrophin-releasing hormone (GnRH) antagonists. This article focuses on the differences between the two treatments and provides nurses with the knowledge to explain the use of GnRH antagonists to patients and administer this therapy effectively.

Abstract P4-15-12: Rebastinib in combination with eribulin ablates TIE2-expressing macrophages, reduces metastasis, and increases survival in the PyMT metastatic breast cancer model

In cancer models, TIE2 kinase plays an important role in angiogenesis, vasculogenesis, and tumor metastasis. TIE2 expression is largely restricted to vascular endothelial cells, tissue macrophages, and bone marrow derived TIE2-expressing monocytes (TEMs), which are proangiogenic, provasculogenic and enhance invasiveness. The hypoxic tumor environment engendered by damaging the vasculature with chemotherapy, radiation, or anti-angiogenic treatments leads to rebound tumor vascularization by an angiogenic switch from the VEGF pathway to the angiopoietin/TIE2 pathway. This leads to recruitment of provasculogenic TEMs from the bone marrow, leading to the growth of residual tumor cells and disease progression. Significantly, a subset of TIE2-expressing macrophages are located within specialized vascular structures known as tumor microenvironment for metastases (TMEMs). Recent observations have linked TIE2-expressing macrophages within TMEM structures to intravasation of cancer cells into circulation and subsequent dissemination to metastatic sites. We hypothesized that TIE2 inhibition should decrease migration and association of TEMs with blood vessels in the tumor stroma, therefore blocking their proangiogenic activity and leading to reduced tumor growth. TIE2 inhibition may also alter TMEM function, leading directly to a blockade of metastasis.

Rebastinib is a picomolar inhibitor of TIE2 kinase, and exhibits an extraordinarily long off-rate from TIE2, measured to be over 24 hours in a cell-based assay. Herein, we examine the efficacy of rebastinib in the polyoma middle-T antigen (PyMT) syngeneic mouse breast cancer model. In this model, PyMT breast cancer cells are implanted in the mammary fat pad, and primary tumor growth leads to metastasis, which is known to be modulated by TEMs and TMEM vascular structures. We examined dosing rebastinib in combination with eribulin, an inhibitor of microtubule dynamics that recently was FDA-approved for treatment-refractory metastatic breast cancer. Rebastinib treatment in this model significantly ablated TEMs in the primary tumor stroma and caused a significant decrease in lung metastases. Furthermore, the combination of rebastinib and eribulin led to a significant further decrease in lung metastases compared to treatment with eribulin alone (Table 1). Rebastinib also enhanced the activity of eribulin in reducing primary tumor growth and regrowth of tumor post-resection.

TIE2 inhibition represents a novel treatment approach for metastatic breast cancer and other cancers that rely on TEMs and TMEMs for growth and metastasis. As such, rebastinib has been selected for further clinical development in combination with eribulin for treatment-refractory metastatic breast cancer, with a Phase 1b trial being planned for late 2013.

Rebastinib reduces lung metastases in the PyMT breast cancer modelTreatmentLung Metastases (% of Control)Vehicle100%Eribulin 1 mg/kg three times/week71%Rebastinib 10 mg/kg twice/week + Eribulin 1 mg/kg23%Eribulin 0.3 mg/kg three times/week71%Rebastinib 10 mg/kg twice/week + Eribulin 0.3 mg/kg51%Eribulin 0.1 mg/kg three times/week72%Rebastinib 10 mg/kg twice/week + Eribulin 0.1 mg/kg43%

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-15-12.

Abstract P4-15-13: Rebastinib in combination with paclitaxel ablates TIE2-expressing macrophages, reduces metastasis, and increases survival in the PyMT metastatic breast cancer model

In cancer models, TIE2 kinase plays an important role in angiogenesis, vasculogenesis, and tumor metastasis. TIE2 expression is largely restricted to vascular endothelial cells, tissue macrophages, and bone marrow derived TIE2-expressing monocytes (TEMs), which are proangiogenic, provasculogenic and enhance invasiveness. The hypoxic tumor environment engendered by damaging the vasculature with chemotherapy, radiation, or anti-angiogenic treatments leads to rebound tumor vascularization by an angiogenic switch from the VEGF pathway to the angiopoietin/TIE2 pathway. This leads to recruitment of provasculogenic TEMs from the bone marrow, leading to the growth of residual tumor cells and disease progression. Significantly, a subset of TIE2-expressing macrophages are located within specialized vascular structures known as tumor microenvironment for metastases (TMEMs). Recent observations have linked TIE2-expressing macrophages within TMEM structures to intravasation of cancer cells into circulation and subsequent dissemination to metastatic sites. We hypothesized that TIE2 inhibition should decrease migration and association of TEMs with blood vessels in the tumor stroma, therefore blocking their proangiogenic activity and leading to reduced tumor growth. TIE2 inhibition may also alter TMEM function, leading directly to a blockade of metastasis.

Rebastinib is a picomolar inhibitor of TIE2 kinase, and exhibits an extraordinarily long off-rate from TIE2, measured to be over 24 hours in a cell-based assay. Herein, we examine the efficacy of rebastinib in the polyoma middle-T antigen (PyMT) syngeneic mouse breast cancer model. In this model, PyMT breast cancer cells are implanted in the mammary fat pad, and primary tumor growth leads to metastasis, which is known to be modulated by TEMs and TMEM vascular structures. We examined multiple dosing schedules of rebastinib in combination with paclitaxel. Rebastinib treatment in this model significantly ablated TEMs in the primary tumor stroma and caused a significant decrease in lung metastases (Table 1). Furthermore, the combination of rebastinib and paclitaxel led to a significant further decrease in lung metastases compared to treatment with paclitaxel or rebastinib alone. Rebastinib also enhanced the activity of paclitaxel in reducing primary tumor growth and regrowth of tumor post-resection.

TIE2 inhibition with targeted therapy represents a novel treatment approach for metastatic breast cancer and other cancers that rely on TEMs and TMEMs for growth and metastasis. As such, rebastinib has been selected for further clinical development for treatment-refractory metastatic breast cancer, with a Phase 1b trial being planned for late 2013.

Rebastinib reduces lung metastases in the PyMT breast cancer modelStudynTreatmentLung Metastases (% of Control)110Vehicle100%110Paclitaxel 10 mg/kg Q5D36%110Rebastinib 10 mg/kg BID28%110Rebastinib 10 mg/kg BID + Paclitaxel7%210Vehicle100%210Paclitaxel 10 mg/kg Q5D51%210Rebastinib 10 mg/kg QD + Paclitaxel21%33Vehicle100%33Paclitaxel 10 mg/kg Q5D58%33Rebastinib 10 mg/kg twice/week + Paclitaxel28%

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-15-13.

Oxidative burst intensity of peripheral phagocytic cells and periodontitis in Down syndrome

BACKGROUND

This study investigated the oxidative burst function of peripheral phagocytic cells (granulocytes and monocytes) and assessed the relation between oxidative burst and periodontal status in adult individuals with Down syndrome (DS) vs. other groups.

METHODS

Of 55 DS individuals (18-56 years old), 74 individuals with mental retardation (MR) and 88 medically healthy controls (HC) participated in the study. The MR and HC groups were age, race and gender matched with the DS group. Gingival index, plaque index, probing depth, attachment level and bleeding on probing were recorded for each subject. Whole blood was collected for granulocyte/monocyte oxidative burst tests. Oxidative burst was determined by flow cytometry in terms of percentage of cells actively involved in oxidative burst, and oxidative intensity (magnitude of ROIs per cell).

RESULTS

The basal oxidative burst intensity of DS granulocytes was higher than that of HC and MR granulocytes (p = 0.05). The Escherichia coli stimulated oxidative burst intensity of DS monocytes was higher than that of HC and MR monocytes (p = 0.05). Regression analysis controlling for age, sex, race and plaque levels showed a significant association between monocyte oxidative burst intensity and loss of periodontal attachment in DS subjects (p < 0.01). Regression analysis also showed a significant association between granulocyte oxidative burst intensity and bleeding on probing in all subjects (p < 0.05).

CONCLUSIONS

Oxidative burst activity of peripheral monocytes and granulocytes is elevated in DS affected individuals and may contribute to periodontal tissue inflammation and loss of periodontal attachment in this susceptible group.

Abstract OT3-4-04: InVite: an observational pilot study evaluating the feasibility of genome-wide association studies using self-reported data from patients with metastatic breast cancer treated with bevacizumab

Background: Personalized healthcare tailors treatments to patients and their disease characteristics through the use of genetics and other biomarkers. Genetic differences among individuals may explain variations in drug treatment response, including side effects. With such information physicians could make more informed decisions about drugs and dosing for a given individual, thereby improving patient care. Although there has been some success, to a large extent genetic variation related to drug response remains unexplained.

Bevacizumab, a humanized monoclonal antibody against the angiogenic factor VEGF, has demonstrated activity in patients with metastatic breast cancer (MBC). The InVite study will evaluate the feasibility of performing genomewide association studies using self-reported information collected via an online platform from patients with MBC who have been treated with bevacizumab. Using novel methodology in a convenient, user-friendly, and scientifically rigorous format, InVite ultimately aims to identify potential pharmacogenetic associations in this patient population.

Trial design: InVite is a pilot, non-interventional, observational, web-based, prospective cohort study designed to collect patient-reported safety, efficacy, and genetic data from patients with MBC treated with bevacizumab. Data on demographics, breast cancer disease status, cancer treatment history, bevacizumab-related outcomes, and certain safety events will be collected directly from patients entirely via online surveys. Patients will be asked to complete surveys at the time of enrollment and then every 3 months for 1 year after enrollment. A saliva sample for DNA collection will be gathered using an at-home kit. Evaluations of data quality and collection feasibility will be conducted intermittently. There will be an optional substudy to allow for blood sample collection for DNA analysis.

Eligibility criteria: ≥18 years of age, residing in the US, locally recurrent breast cancer or MBC, currently being or having been treated with bevacizumab starting on or before Dec 31, 2011, fluent in English, and access to a computer with an internet connection.

Specific aims: The primary objective is to assess the feasibility of recruiting subjects and collecting biospecimens and self-reported data online. The secondary objective is to characterize the patient population. Exploratory objectives include analyzing potential associations between genetic polymorphisms and 1) bevacizumab-induced hypertension, the most common bevacizumab-related adverse event, and 2) patient-reported time-to-progression.

Statistical methods: Baseline demographics, clinical and treatment characteristics of enrolled patients will be summarized. Each polymorphism genotyped will be tested for association with the defined endpoint using appropriate statistical modeling.

Present and target accrual: Accrual as of May 23, 2012 is 82 patients. Target accrual is 1000 patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT3-4-04.

Evaluation of serovar-independent ELISA antigens of Actinobacillus pleuropneumoniae in pigs, following experimental challenge with A. pleuropneumoniae, Mycoplasma hyopneumoniae and Pasteurella multocida

OBJECTIVE

To compare the sensitivity and specificity of six serological enzyme-linked immunosorbent assays (ELISAs) based on serovar-independent antigens of Actinobacillus pleuropneumoniae (App) and investigate cross-reactivity in disease-free pigs challenged with Mycoplasma hyopneumoniae and Pasteurella multocida.

DESIGN

Five experimental pig trials using direct challenge with App serovars 1, 7 or 15 or direct challenge with M. hyopneumoniae and/or various dose rates of P. multocida.

PROCEDURE

A 39-kDa outer membrane protein antigen and five recombinant antigens from the apxIVA gene of App were evaluated. The latter were derived from the ApxIVA N-terminus (ApxIVA-N, ApxIVA-NP, ApxIVA-NPS) or C-terminus (ApxIVA-C, ApxIVA-CP). Pigs were sampled after challenge and clinical and necropsy findings evaluated.

RESULTS

The 39-kDa ELISA had high sensitivity but lacked specificity, with significantly increased cross-reactivity following P. multocida challenge. ELISAs based on ApxIVA N-terminus antigens were significantly more sensitive than C-terminus antigens for the detection of App-induced disease. Although ApxIVA-N and ApxIVA-NP ELISAs had increased reactivity following P. multocida challenge, they retained high specificity for App-induced disease (90-93%). Affinity purified ApxIVA-NP antigen had marginally better specificity than ApxIVA-N, without reduced sensitivity. Mycoplasma hyopneumoniae did not affect serological cross-reactivity. In disease-free pigs, the specificity of the ApxIVA-NPS ELISA may be adversely affected by nasal carriage of apparently low-virulence App strains.

CONCLUSIONS

ApxIVA-N-based ELISAs can be used for evaluating App status in commercial herds, but some appear limited by high carriage rates of low-virulence App. The 39-kDa antigen is only of merit in exclusion of App disease by negative serology.

Commissioning specialist diabetes services for adults with diabetes: summary of a Diabetes UK Task and Finish group report

The increasing prevalence of diabetes, the drive to develop community services for diabetes and the Quality and Outcomes Framework for diabetes have led to improvements in the management of diabetes in primary care settings, with services traditionally provided only in specialist care now provided for many patients with diabetes by non-specialists. Consequently, there is a need to redefine roles, responsibilities and components of a specialist diabetes service to provide for the needs of patients in the National Health Service (NHS) today. The delivery of diabetes care is complex and touches on almost every aspect of the health service. It is the responsibility of those working within commissioning and specialist provider roles to work together with people with diabetes to develop, organize and deliver a full range of integrated diabetes care services. The local delivery model agreed within the local diabetes network, comprising specialist teams, primary care teams, commissioners and people with diabetes, should determine how the diabetes specialist services are organizsed. It should identify the roles and responsibilities of provider organizations to ensure that the right person provides the right care, at the right time, and in the right place. We summarize a report entitled 'Commissioning Diabetes Specialist Services for Adults with Diabetes', which has been produced, as a 'Task and Finish' group activity within Diabetes UK, to assist managers, commissioners and healthcare professionals to provide advice on the structure, roles and components of specialist diabetes services for adults.

Phagocytic cell activity and periodontitis in Down syndrome

BACKGROUND

This study investigated the phagocytic function of peripheral granulocytes and monocytes from adult individuals with Down syndrome (DS) and assessed the relation between phagocytic function and periodontal status.

METHODS

Fifty-five DS individuals (18-56 years old), 74 mentally retarded individuals, and 88 medically healthy controls (HC) participated in the study. Gingival inflammation index, plaque index, probing depth, periodontal attachment level (AL), and bleeding on probing were taken for each subject. Whole blood was collected for granulocyte/monocyte phagocytosis tests. Phagocytic function was determined by flow cytometry in terms of percentage of cells actively involved in phagocytosis, and phagocytic intensity (magnitude of the bacterial staining per cell).

RESULTS

Phagocytic intensity of both granulocytes and monocytes was comparable in HC and DS subjects. While AL was directly related to phagocytic intensity of both granulocytes (r = 0.14, P = 0.03) and monocytes (r = 0.2, P = 0.003) in all subjects, this relationship was stronger in DS than in other subjects, even after controlling for known risk factors for periodontitis (P < 0.05). Monocyte phagocytic intensity was the only necessary predictor of AL (P = 0.003), indicating a similar relationship between AL and phagocytic activity in either cell type.

CONCLUSIONS

While granulocyte and monocyte phagocytic intensities are similar in Down and non-DS individuals, phagocytic intensity was associated with more AL in DS than non-DS individuals.

Neurosurgery and elderly: analysis through the years

The aging of the population in westernized countries constitutes an important issue for the health systems struggling with limited resources and increasing costs. Morbidity and mortality rates reported for neurosurgical procedures in the elderly vary widely. The lack of data on risk benefit ratios may result in challenging clinical decisions in this expanding group of patients. The aim of this paper is to analyze the elderly patients cohort undergoing neurosurgical procedures and any trend variations over time. The medical records of elderly patients (defined as an individual of 70 years of age and over) admitted to the Neurosurgical and Neuro-ICU Departments of a major University Hospital in Paris over a 25-year period were retrospectively reviewed. The analysis included: (1) number of admissions, (2) percentage of surgically treated patients, (3) type of procedures performed, (4) length of hospital stay, and (5) mortality. The analysis showed a progressive and significant increase in the proportion of elderly presenting for neurosurgical elective and/or emergency procedures over the last 25 years. The number of procedures on patients over 70 years of age increased significantly whereas the mortality dropped. Though the length of hospital stay was reduced, it remained significantly higher than the average stay. The types of procedures also changed over time with more craniotomies and endovascular procedures being performed. Age should not be considered as a contraindication for complex procedures in neurosurgery. However, downstream structures for postoperative elderly patients must be further developed to reduce the mean hospital stay in neurosurgical departments because this trend is likely to continue to grow.

A national survey of the current state of screening services for diabetic retinopathy: ABCD-diabetes UK survey of specialist diabetes services 2006

The main aims were to ascertain the progress made in the implementation of retinal screening services and to explore any barriers or difficulties faced by the programmes. The survey focused on all the essential elements for retinal screening, including assessment and treatment of screen-positive cases. Eighty-five per cent of screening programmes have a coordinated screening service and 73% of these felt that they have made significant progress. Eighty-five per cent of screening units use 'call and recall' for appointments and 73.5% of programmes follow the National Screening Committee (NSC) guidance. Although many units worked closely with ophthalmology, further assessment and management of screen-positive patients was a cause for concern. The fast-track referral system, to ensure timely and appropriate care, has been difficult to engineer by several programmes. This is demonstrated by 48% of programmes having waiting lists for patients identified as needing further assessment and treatment for retinopathy. Ophthalmology service for people with diabetic retinopathy was provided by a dedicated ophthalmologist in 89.4% of the programmes. Sixty-six per cent of the programmes reported inadequate resources to sustain a high-quality service, while 26% highlighted the lack of infrastructure and 49% lacked information technology (IT) support. In conclusion, progress has been made towards establishing a national screening programme for diabetic retinopathy by individual screening units, with a number of programmes providing a structured retinal screening service. However, programmes face difficulties with resource allocation and compliance with Quality Assurance (QA) standards, especially those which apply to ophthalmology and IT support. Screening programmes need to be resourced adequately to ensure comprehensive coverage and compliance with QA.

Nursing care and treatment of patients with bladder cancer

Bladder cancer is the second most common urological cancer after prostate cancer in the UK. This article aims to update nurses knowledge about the disease, focusing on diagnosis, treatment and nursing care.

Diabetes specialist nurses and role evolvement: a survey by Diabetes UK and ABCD of specialist diabetes services 2007

AIMS

To review the working practices of UK diabetes specialist nurses (DSNs), specific clinical roles, and to examine changes since 2000.

METHODS

Postal questionnaires were sent to lead DSNs from all identifiable UK diabetes centres (n = 361). Quantitative and qualitative data were collected on the specific clinical roles, employment, and continual professional development of hospital and community DSNs, Nurse Consultants and Diabetes Healthcare Assistants.

RESULTS

159 centres (44%) returned questionnaires. 78% and 76% of DSNs plan and deliver education sessions compared with 13% in 2000 with a wider range of topics and with less input from medical staff. 22% of DSNs have a formal role in diabetes research compared with 48% in 2000. 49% of Hospital DSNs, 56% of Community DSNs and 66% of Nurse Consultants are involved in prescribing. 55% of DSNs carry out pump training, 72% participate in ante-natal and 27% renal clinics. 90% of services have independent diabetes nurse-led clinics. 93% of services have a dedicated Paediatric DSN. The mean number of children under the care of each PDSN is 109 (mode 120), which exceeds Royal College of Nursing recommendations. 48% of DSNs have protected time for continuing professional development of staff and 15% have a protected budget. One third of DSNs are on short-term contracts funded by external sources.

CONCLUSIONS

The DSN role has evolved since 2000 to include complex service provision and responsibilities including specialist clinics, education of healthcare professionals and patients. The lack of substantive contracts and protected study leave may compromise these roles in the future.

Association of British Clinical Diabetologists (ABCD) and Diabetes-UK survey of specialist diabetes services in the UK, 2006. 1. The consultant physician perspective

AIMS

To identify the views and working practices of consultant diabetologists in the UK in 2006-2007, the current provision of specialist services, and to examine changes since 2000.

METHODS

All 592 UK consultant diabetologists were invited to participate in an on-line survey. Quantitative and qualitative analyses of responses were undertaken. A composite 'well-resourced service score' was calculated. In addition to an analysis of all respondents, a sub-analysis was undertaken, comparing localities represented both in 2006/2007 and in 2000.

RESULTS

In 2006/2007, a 49% response rate was achieved, representing 50% of acute National Health Service Trusts. Staffing levels had improved, but remained below recommendations made in 2000. Ten percent of specialist services were still provided by single-handed consultants, especially in Northern Ireland (in 50% of responses, P = 0.001 vs. other nations). Antenatal, joint adult-paediatric and ophthalmology sub-specialist diabetes services and availability of biochemical tests had improved since 2000, but access to psychology services had declined. Almost 90% of consultants had no clinical engagement in providing community diabetes services. The 'well-resourced service score' had not improved since 2000. There was continued evidence of disparity in resources between the nations (lowest in Wales and Northern Ireland, P = 0.007), between regions in England (lowest in the East Midlands and the Eastern regions, P = 0.028), and in centres with a single-handed consultant service (P = 0.001). Job satisfaction correlated with well-resourced service score (P = 0.001). The main concerns and threats to specialist services were deficiencies in psychology access, inadequate staffing, lack of progress in commissioning, and the detrimental impact of central policy on specialist services.

CONCLUSIONS

There are continued disparities in specialist service provision. Without effective commissioning and adequate specialist team staffing, integrated diabetes care will remain unattainable in many regions, regardless of reconfigurations and alternative service models.

Evaluation of Erysipelothrix rhusiopathiae vaccines in pigs by intradermal challenge and immune responses

In a vaccine trial, pigs were challenged intradermally with eight E. rhusiopathiae strains of serovars 1a, 1b or 2 given concurrently. The strains were derived from six herds affected with vaccine breakdowns in 1997-1999, one herd without vaccine breakdown and a serovar 2 reference strain. Responses to two commercial bacterins (one implicated in the vaccine breakdowns), and two experimental bacterins (based on field isolates from affected herds) showed distinct differences in protection, particularly in clinical responses measured at 72 h. Less protection was afforded against serovar 1 challenge by the vaccine implicated in the vaccine breakdowns. Antibody and cell-mediated immune (CMI) responses were significantly different between treatments, and highlighted a similar post-vaccinal antibody response was produced against serovar 2 lysate by all vaccines, but only those providing significant protection against serovar 1 [corrected] produced significantly elevated antiserovar I lysate [corrected] antibodies. Vaccination in general significantly reduced CMI responses to the mitogens concanavalin A and phytohaemagglutinin. This experimental pig challenge system was readily able to confirm suboptimal performance of a commercial bacterin that had passed potency tests in mice but was associated with vaccine failure in commercial herds. This vaccine was also the most immunosuppressive to CMI responses associated with E. rhusiopathiae-specific and non-specific stimulation. The best vaccine response was associated with the highest mean serovar 1 antibody response and the highest CMI response (by lymphoproliferation assay) to serovar 2.