The spectrum of COVID-19-associated chorioretinal vasculopathy

Purpose

Although conjunctivitis represents the most common ocular manifestation of COVID-19 infection, sight-threatening retinal involvement has been reported. Herein, we report and characterize with multimodal retinal imaging 5 cases of acute vision loss secondary to presumed chorioretinal vasculopathy temporally associated with COVID-19 infection with varying severity, visual morbidity, and treatment response, and review the available literature on the association between COVID-19 infection and retinal microvascular changes.

Design

Observational case series and literature review.

Methods

Multicenter case series of 5 patients who presented to academic centers and private offices with acute vision loss temporally associated with COVID-19 infection. A review of the literature was conducted using online databases.

Results

10 eyes of 5 patients, 3 men and 2 women, with a mean age of 30.8 years (median 33, range 16-44) were described. All patients had a recently preceding episode of COVID-19, with symptomatology ranging from mild infection to life-threatening encephalopathy. Treatment for their retinal disease included topical, oral, intravitreal, and intravenous steroids, steroid-sparing immunosuppression, retinal photocoagulation, antivirals, and antiplatelet and anticoagulant agents. Treatment response and visual recovery ranged from complete recovery of baseline acuity to permanent vision loss and need for chronic immunosuppression.

Conclusions and Importance

Clinicians should be mindful of the potential for vision-threatening retinal involvement after COVID-19 infection. If found, treatment with both anti-inflammatory therapy and anticoagulation should be considered, in addition to close monitoring, as some patients with this spectrum of disease may require chronic immune suppression and/or anti-VEGF therapy.

Clinical and Anatomic Outcomes of 3-Piece Poly(methyl methacrylate) Intraocular Lens Rescue and Needle-Assisted Transconjunctival Intrascleral Lens Fixation

Purpose: To report the clinical and anatomic outcomes of a single-stage rescue and sutureless 30-gauge needle-assisted transconjunctival intrascleral fixation of dislocated 3-piece rigid poly(methyl methacrylate) (PMMA) intraocular lenses (IOLs). Methods: This retrospective noncomparative single-surgeon interventional study comprised eyes that had concurrent 23- or 25-gauge pars plana vitrectomy and IOL rescue with sutureless transconjunctival needle-assisted flanged haptic intrascleral fixation. Lamellar scleral dissection for haptic fixation was performed 3 mm posterior to the surgical limbus with 30-gauge needles. Primary endpoints included visual acuity (VA), IOL tilt measured with ultrasound biomicroscopy (UBM), and postoperative complications. Results: The study evaluated 25 eyes of 24 patients. The IOL was successfully refixated in 24 of the 25 eyes. The mean preoperative logMAR VA of 1.21 ± 0.79 SD (median 1.3; Snellen equivalent 20/400) improved to 0.28 ± 0.35 (median 0.14; Snellen equivalent 20/30) postoperatively (P < .0001). The mean IOL tilt measured by UBM (n = 7) was 3.79 ± 3.60 degrees. The mean postoperative follow-up was 348 ± 284 days (range, 7-979 days). Postoperative complications included self-clearing vitreous hemorrhage (n = 9), retinal detachment (RD) (n = 1), cystoid macular edema (n = 3), and corneal edema (n = 3). Three eyes (13%) required additional surgery, 1 for RD and 2 for delayed haptic slippage and secondary IOL tilt causing irregular astigmatism. Conclusions: Intrascleral needle-assisted fixation of dislocated or mobile 3-piece PMMA IOLs is an effective, safe method to restore VA.

Ocrevus reduces TH40 cells, a biomarker of systemic inflammation, in relapsing multiple sclerosis (RMS) and in progressive multiple sclerosis (PMS)

Treating MS has been difficult. One successful drug is Ocrelizumab (anti-CD20), used for the chronic relapsing MS (RMS) and the progressive MS (PMS) forms. TH40 cells are pathogenic effector T cells that increase in percentage and numbers during chronic inflammation. Here we show that in the earliest MS course, clinically isolated syndrome (CIS), TH40 cells expand in number. In PMS TH40 cell numbers remain expanded demonstrating sustained chronic inflammation. In RMS TH40 cells were found in CSF and express CD20. Ocrelizumab reduced TH40 cells to healthy control levels in patients. During treatment inflammatory cytokine producing TH40 cells were decreased.

259 AN AUDIT OF DNACPR FORM USAGE IN A LEVEL 4 HOSPITAL FOLLOWING RE-DESIGN AND IMPLICATIONS FOR ITS FUTURE USE

Background

In 2020 during the Covid-19 pandemic our hospital introduced a new green DNACPR form with 2 significant changes. It now specifies if the patient is or is not for resuscitation (as a yes/no choice) and a Treatment Escalation Plan (TEP) has moved to the front of the page from the back. A subsequent audit found that 19% of inpatients had forms completed, of which 68% stated DNACPR and 29% for CPR. 76% of forms had a TEP (versus 56% on the old forms). We repeated the hospital wide audit in 2022 to assess if the improvement in TEP documentation was sustained, and if it was used on all patients or primarily to document DNACPR decisions.

Methods

The hospital-wide audit was performed on the 25.05.2022. Charts were reviewed on medical and surgical wards. ICU patients were excluded. The following data were recorded: Resuscitation status, form completion, presence of a TEP, if the date of admission and form completion were recorded, if the name of doctor and nature of discussion with patient and family were documented, and if the TEP was consistent with the most recent clinical notes. The data was compared to the 2020 audit and against the Hospital’s DNAR & TEP policy.

Results

634 inpatients were identified. 15.7% (100) had a form completed of which 92% stated DNAR. One of these did not have a TEP. The doctor’s name and grade were clearly documented on all forms.

Conclusion

99% of patients who were not for CPR had a TEP indicating sustained improvement since the introduction of the new form. Given 83.3% of patients did not have any documented resuscitation status the approach of documenting yes or no for resuscitation is not being utilised. A return to a dedicated form that indicates someone should not undergo attempts at resuscitation may offer more clarity.

154 SAFEGUARDING ADULTS AT RISK OF ABUSE—IDENTIFYING KNOWLEDGE GAPS AMONGST HOSPITAL STAFF TO GUIDE POLICY IMPLEMENTATION AND TRAINING

Background

Safeguarding is the protection of health, wellbeing and life free from abuse. Abuse is a a violation of a person’s human and civil rights; forms include psychological, financial, physical, sexual, neglect and self-neglect. Health Service Executive (HSE) drafted the 2019 ‘Adult Safeguarding Policy’ for adults at risk of abuse to replace the 2014 version. In preparation for implementation a tertiary hospital founded a Safeguarding Committee in 2021. A core objective was establishing staff understanding, experience of safeguarding and education needs to guide future training.

Methods

10-question survey of 223 staff; included doctors, nurses, allied health professionals, medical social workers, healthcare assistants, porters, psychologists.

Results

91% response rate.

184 (91%) staff were familiar with the term ‘safeguarding’; only 44% were aware of the HSE 2019 policy. 129 (64%) had experience with a case of suspected abuse. Most common forms were financial, psychological and self-neglect (n = 60, 47, 39 respectively). Sexual abuse was least common (n = 10).

47% felt ‘somewhat’ confident recognising possible abuse compared to 42% who felt ‘extremely’ or ‘very’ confident.

61% were ‘somewhat’ or ‘not so’ confident about the next steps for suspected abuse; only 11% were ‘extremely’ confident.

49% felt ‘extremely’ or ‘very’ confident in reporting a suspected abuse case; 50% felt ‘somewhat’ or ‘not so’ confident.

Most common reasons for lack of confidence were lack of training, unclear reporting process and lack of experience with cases of abuse. Medical social workers were most confident; doctors were the least.

170 (84%) wanted more safeguarding training—the most popular options were online or in-person training.

Conclusion

Gaps in knowledge and confidence were identified amongst staff for cases of suspected abuse. This will guide future training in the hospital in line with the HSE Adult Safeguarding policy.

An economic analysis comparing health care resource use and cost of dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin versus gemcitabine and cisplatin as neoadjuvant therapy for muscle invasive bladder cancer

PURPOSE

To compare healthcare resource utilization (HRU) and costs associated with dose-dense methotrexate, vinblastine, doxorubicin, cisplatin (ddMVAC) and gemcitabine, cisplatin (GC) as neoadjuvant chemotherapy for muscle-invasive bladder cancer (MIBC).

METHODS

Patient treated at Dana-Farber Cancer Institute from 2010 to 2019 were identified. HRU data on chemotherapy administered, supportive medications, patient monitoring, clinic, infusion, emergency department (ED) visits and hospitalization were collected retrospectively. Unit costs for HRU components were obtained from the Centers for Medicare and Medicaid Website and HRU was compared between groups using quantile regression analysis.

RESULTS

137 patients were included; 51 received ddMVAC and 86 GC. Baseline characteristics were similar, except lower mean age (P < 0.001) and higher proportion of ECOG-PS = 0 (P < 0.001) for ddMVAC. ddMVAC required more granulocyte-colony stimulating factor support (P < 0.001), central line placement (P = 0.017), cardiac imaging (P < 0.001), and infusion visits (P < 0.001), whereas GC required more clinic visits. ED visits were higher for ddMVAC (P = 0.048), while chemotherapy cycle delays and hospitalization days were higher for GC (P = 0.008). After adjusting for ECOG-PS and age, the cost per patient was approximately 41% lower (95%CI: 28% to 52%; P < 0.001) for GC vs. ddMVAC, which translated to a median adjusted cost savings of $7,410 (95%CI: $5,474-$9,347) per patient.

CONCLUSIONS

Although excess HRU did not clearly favor one regimen, adjusting for PS and age indicated lower costs with GC vs. ddMVAC. Given the similar cumulative cisplatin delivery with both regimens, the associated values and costs supports the preferential selection of GC in the neoadjuvant setting of MIBC.

Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium

BACKGROUND

Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies.

PATIENTS AND METHODS

Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients).

RESULTS

A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality.

CONCLUSIONS

Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies.

CLINICAL TRIAL IDENTIFIER

NCT04354701.

A3 THE LOSS OF THE CIRCADIAN CLOCK GENE BMAL1 INCREASES TUMOUR INITIATION IN APCMIN MICE

Background

Circadian rhythms are autonomously running 24h cycles in bodily processes. In animals these rhythms are driven by a molecular time keeper known as the circadian clock. The clock is a transcription-translation feedback loop composed of the transcription factors Bmal1 and Clock as well as their repressors Per and Cry. The circadian clock regulates over 40% of the genome rhythmically. Chronic circadian disruption, in the case of shift work, can lead to pathologies including cancer. Colorectal cancer is most frequently initiated through a mutation in the Wnt pathway regulator, Apc. Several studies have attempted to provide a mechanistic link between cancer and circadian clock disruption but the use of mice on mixed genetic backgrounds and poor circadian models have made this link unclear.

Aims

We aim to determine if the circadian clock plays a role in intestinal tumourigenesis.

Methods

We crossed the Apcmin mouse strain, a common intestinal tumour model, with Bmal1 mutant mice, which lack a functioning circadian clock. After creating an isogenic strain, we examined the number of tumours in control (Bmal1+/+) and clock dead (Bmal1-/-) animals. We derived organoids, a 3D cell culture method, from Apc+/+; Bmal1+/+ (healthy, clock-live), Apc+/+, Bmal1-/-(healthy, clock-dead), Apcmin; Bmal1+/+(adenoma, clock-live), Apcmin; Bmal1-/- (adenoma, clock-live) mouse ileum and collected every 2h from 24-48h after synchronizing their circadian clock. Collected samples were sent for RNA sequencing and assessed for circadian regulated transcripts. This experiment was followed up by in vitro organoid assays.

Results

The circadian clock controls 41 genes in the intestinal epithelium, including genes like Tead4 which are known to be important in intestinal biology. There are twofold more tumours in Bmal1-/- mice than their Bmal1+/+ littermates, and Bmal1-/- tumours upregulate Tead4 and Hippo pathway targets and downregulate Wnt pathway targets. Bmal1-/- adenoma organoids show increased self-renewal when compared to Bmal1+/+ adenoma organoids. However, this increase in self-renewal is lost when organoids are treated with inhibitors of the hippo pathway.

Conclusions

The circadian clock is important in maintaining the health of an organism, and disruption of the clock can lead to many health consequences including cancer. We show for the first time that the circadian clock controls the hippo signaling mediator Tead4. Additionally, we show that the loss of the clock leads to an increase in the number of tumours present in the epithelium which are characterized by an increase in hippo signaling. This research shows the important of considering time of day when studying stem cells during homeostasis and in cancer.

Funding Agencies

CIHRNSERC

Quantifying Argonaute 2 (Ago2) expression to stratify breast cancer

BACKGROUND

Argonaute-2 (Ago2) is an essential component of microRNA biogenesis implicated in tumourigenesis. However Ago2 expression and localisation in breast cancer remains undetermined. The aim was to define Ago2 expression (mRNA and protein) and localisation in breast cancer, and investigate associations with clinicopathological details.

METHODS

Ago2 protein was stained in breast cancer cell lines and tissue microarrays (TMAs), with intensity and localization assessed. Staining intensity was correlated with clinicopathological details. Using independent databases, Ago2 mRNA expression and gene alterations in breast cancer were investigated.

RESULTS

In the breast cancer TMAs, 4 distinct staining intensities were observed (Negative, Weak, Moderate, Strong), with 64.2% of samples stained weak or negatively for Ago2 protein. An association was found between strong Ago2 staining and, the Her2 positive or basal subtypes, and between Ago2 intensity and receptor status (Estrogen or Progesterone). In tumours Ago2 mRNA expression correlated with reduced relapse free survival. Conversely, Ago2 mRNA was expressed significantly lower in SK-BR-3 (HER2 positive) and BT-20 (Basal/Triple negative) cell lines. Interestingly, high levels of Ago2 gene amplification (10-27%) were observed in breast cancer across multiple patient datasets. Importantly, knowledge of Ago2 expression improves predictions of breast cancer subtype by 20%, ER status by 15.7% and PR status by 17.5%.

CONCLUSIONS

Quantification of Ago2 improves the stratification of breast cancer and suggests a differential role for Ago2 in breast cancer subtypes, based on levels and cellular localisation. Further investigation of the mechanisms affecting Ago2 dysregulation will reveal insights into the molecular differences underpinning breast cancer subtypes.

Breast cancer subtype discordance: impact on post-recurrence survival and potential treatment options

Background

Recent studies have shown that breast cancer subtype can change from the primary tumour to the recurrence. Discordance between primary and recurrent breast cancer has implications for further treatment and ultimately prognosis. The aim of the study was to determine the rate of change between primary and recurrence of breast cancer and to assess the impact of these changes on survival and potential treatment options.

Methods

Patient demographics were collected on those who underwent surgery for breast cancer between 2001 and 2014 and had a recurrence with biopsy results and pathology scoring of both the primary and recurrence.

Results

One hundred thirty two consecutive patients were included. There were 31 (23.5%) changes in subtype. Discordance occurred most frequently in luminal A breast cancer (n = 20), followed by triple negative (n = 4), luminal B (n = 3) and HER2 (n = 3). Patients who changed from luminal A to triple negative (n = 18) had a significantly worse post-recurrence survival (p < 0.05) with overall survival approaching significance (p = 0.064) compared to concordant luminal A cases (n = 46). Overall receptor discordance rates were: estrogen receptor 20.4% (n = 27), progesterone receptor 37.7% (n = 50) and HER2 3% (n = 4). Loss of estrogen receptor and progesterone receptor was more common than gain (21 vs. 6 (p = 0.04) and 44 vs. 6 (p = 0.01) respectively). Nine patients (6.8%) gained receptor status potentially impacting treatment options.

Conclusion

Discordance in subtype and receptor status occurs between primary and recurrent breast cancer, ultimately affecting survival and potentially impacting treatment options.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4101-7) contains supplementary material, which is available to authorized users.

Controlled comparison of two crisis resolution and home treatment teams

Aims and method

To compare an existing crisis resolution service with a new crisis resolution team (CRT) in Wales. The impact of the new team was measured by changes in bed days and admissions. A random sample of patients from each service was assessed for service satisfaction, social functioning and quality of life after first presentation.

Results

The total number of bed days was reduced following the introduction of the new CRT (27.3%). The frequency and duration of compulsory admissions increased by 31% in the CRT between the first and second years and by 7% in the control service, offset by a greater reduction in informal admissions in the CRT (23.5%) compared with the control group (13.3%); overall bed usage was unchanged. Service satisfaction, social functioning and quality of life showed no important differences between the services.

Clinical implications

Crisis resolution teams may reduce informal admissions in the short term but at the cost of more compulsory admissions later.

Prospective comparison of outcome after treatment for triple-negative and non-triple-negative breast cancer

INTRODUCTION

Triple-negative breast cancers (TNBC) are associated with a poor prognosis owing to an aggressive phenotype. We aimed to carry out a prospective study comparing management strategies and response to therapy in TNBC and non-TNBC patients.

METHODS

Data were obtained from a prospectively maintained database of patients treated for breast cancer.

RESULTS

A total of 142 TNBC and 142 age-, stage- and NPI-matched non-TNBC patients were treated. The difference in overall survival between the 2 groups was statistically significant (77% of TNBC patients alive at a mean follow-up of 32 months, versus 92% of non-TNBC patients at a mean follow-up of 38 months, P = 0.0 Log rank test). This survival difference was found to be independent of NPI (P = 0.0 Log rank test). Locoregional recurrence rates were similar between TNBC patients who were treated with wide local excision versus mastectomy (P = 0.449 Log rank test). A significant difference in survival was noted between TNBC patients who responded differentially to neoadjuvant chemotherapy (P = 0.035 Log rank test).

CONCLUSION

Patients with TNBC have adverse outcomes despite aggressive treatment. The development of effective targeted therapies is essential for this breast cancer subtype.

Relationship between CCL5 and transforming growth factor-β1 (TGFβ1) in breast cancer

PURPOSE

Investigate circulating CCL5 in breast cancer patients and healthy controls, along with gene expression levels in corresponding tumour tissue and isolated primary stromal cells. Hormonal control of CCL5, and a potential relationship with TGFβ1, was also investigated.

METHODS

Circulating levels of CCL5 and TGFβ1 were measured in 102 breast cancer patients and 66 controls using ELISA. Gene expression levels (CCL5, CCR5, TGFβ1, TGFβRII) were quantified in corresponding tumour tissue (n = 43), normal tissue (n = 16), and isolated tumour (n = 22) and normal (n = 3) stromal cells using RQ-PCR. CCL5 and circulating menstrual hormones (LH, FSH, Oestradiol, Progesterone) were analysed in serum samples from healthy, premenopausal volunteers (n = 60).

RESULTS

TGFβ1 was significantly higher in breast cancer patients (Mean(SEM) 27.4(0.9)ng/ml) compared to controls (14.9(0.9)ng/ml). CCL5 levels decreased in the transition from node negative (59.6(3.7)ng/ml) to node positive disease (40.5(6.3)ng/ml) and increased again as the number of positive lymph nodes increased (⩾3 positive 50.95(9.8)ng/ml). A significant positive correlation between circulating CCL5 and TGFβ1 (r = 0.423, p<0.0001) was observed, and mirrored at the gene expression level in tumour tissue from the same patients (r = 0.44, p<0.001). CCL5, CCR5 and TGFβ1 expression was significantly higher in tumour compared to normal breast tissue (p < 0.001). A significant negative correlation was observed between circulating CCL5, Oestradiol and Progesterone (r = -0.50, r = -0.39, respectively, p < 0.05).

CONCLUSION

CCL5 expression is elevated in the tumour microenvironment. The data support a role for hormonal control of circulating CCL5 and also highlight a potentially important relationship between CCL5 and TGFβ1 in breast cancer.

Epitaxial Ferroelectric Aurivillius-Type Phases on Metallic Oxides by Pulsed Laser Deposition

Bi-based layered perovskites, also called Aurivillius-type phases, are superior to simple perovskite materials with regard to their ferroelectric long-term stability. Another way to alleviate fatigue and aging problems in metal-ferroelectric-metal (MFM) heterostructures is to replace the bottom metallic electrode with a conductive oxide electrode. An attempt to combine the two approaches has been made to investigate whether a further improvement in stability can be achieved. To promote an oriented growth of the ferroelectric films, epitaxial buffer layers (YSZ, Ce02) and epitaxial electrodes of (La0.5Sr0.5 )Co03 (LSC) have been consecutively deposited onto Si (100). Finally a ferroelectric thin film of the layered perovskite Bi4Ti3012 (BiT) has been grown. Rocking curve measurements demonstrate good epitaxial growth of both the buffer and the electrode layers. The ferroelectric thin films show a preferred c-axis orientation. Cross-section TEM images reveal a twinned superstructure in the LSC layer with a tripling of the lattice parameter. EDX line-scans show that a Co-enriched and Bi-depleted layer had formed at the BiT/LSC interface. After deposition of Au electrodes on both the BiT and the LSC layer, a hysteretic behavior could be detected and the ferroelectric properties of the c-oriented BiT film be confirmed.

Predictors of early arrival at the emergency department in acute ischaemic stroke

BACKGROUND

A requirement of an effective acute stroke service is the early arrival of patients to the hospital emergency department (ED). This will allow the possible use of thrombolytic therapy or other acute interventions within a limited time window.

AIMS

We investigated the predictors of early arrival in a single hospital serving a mixed urban and rural catchment area.

METHODS

A retrospective review of all case notes for 1 year was performed.

RESULTS

Of 105 acute strokes, 91 were cerebral infarcts and a total of 71 cases presenting initially to the ED had timing available for analysis. 39.4% presented within 3 h, and 12.7% were potentially suitable for thrombolysis. Those living closer to the hospital were not more likely to arrive within 3 h (Z = -0.411, p = 0.68). Presenting directly to the hospital by emergency services (or private transport) was significantly associated with early arrival in a univariate comparison (p < 0.001), and in a multivariate model.

CONCLUSION

The only independent predictor of early arrival to the ED is direct presentation. Improved public education of the importance of recognition of stroke symptoms and rapid contact with the emergency services will improve the early attendance following acute stroke, allowing increased use of acute stroke treatments.

Potential role of mesenchymal stem cells (MSCs) in the breast tumour microenvironment: stimulation of epithelial to mesenchymal transition (EMT)

Bone marrow-derived mesenchymal stem cells (MSCs) are known to specifically migrate to and engraft at tumour sites. Understanding interactions between cancer cells and MSCs has become fundamental to determining whether MSC-tumour interactions should be harnessed for delivery of therapeutic agents or considered a target for intervention. Breast Cancer Cell lines (MDA-MB-231, T47D & SK-Br3) were cultured alone or on a monolayer of MSCs, and retrieved using epithelial specific magnetic beads. Alterations in expression of 90 genes associated with breast tumourigenicity were analysed using low-density array. Expression of markers of epithelial-mesenchymal transition (EMT) and array results were validated using RQ-PCR. Co-cultured cells were analysed for changes in protein expression, growth pattern and morphology. Gene expression and proliferation assays were also performed on indirect co-cultures. Following direct co-culture with MSCs, breast cancer cells expressed elevated levels of oncogenes (NCOA4, FOS), proto-oncogenes (FYN, JUN), genes associated with invasion (MMP11), angiogenesis (VEGF) and anti-apoptosis (IGF1R, BCL2). However, universal downregulation of genes associated with proliferation was observed (Ki67, MYBL2), and reflected in reduced ATP production in response to MSC-secreted factors. Significant upregulation of EMT specific markers (N-cadherin, Vimentin, Twist and Snail) was also observed following co-culture with MSCs, with a reciprocal downregulation in E-cadherin protein expression. These changes were predominantly cell contact mediated and appeared to be MSC specific. Breast cancer cell morphology and growth pattern also altered in response to MSCs. MSCs may promote breast cancer metastasis through facilitation of EMT.

Bilateral Breast Cancer: Analysis of Incidence, Characteristics and Outcome of the Disease

Background: Despite the widespread adoption of breast conservation therapy in breast cancer, there is a dramatic increase in the rate of bilateral mastectomy in USA. The aim of this study was to address the incidence of bilateral breast cancer (BBC) and to investigate its characteristics, survival and outcome compared to unilateral breast cancer.Methods: Data was acquired from the prospectively maintained NUI Galway breast cancer database between 1988 and 2008. BBC were then categorized as synchronous (within 12 months) or metachronous cancer (after 12 months of first tumour). SPSS was used for data analysis.Results: The incidence of bilateral breast cancer in our population was 4.4% (112 of 2524). Of those 2.1% were synchronous while 2.3% were metachronous. Compared to unilateral cases, bilateral cancer patients were younger (0=0.021) and had smaller size (p=0.001) and earlier stage (p&lt;0.001) tumours at diagnosis. There were no differences in histological type (p=0.630) and grade (p=0.054)). While there was no significant difference in survival for patients with bilateral compared to unilateral tumour (p&gt;0.05), the synchronous bilateral tumour was associated with poor overall survival (p=0.010) and disease free survival (p=0.013) in comparison to metachronous bilateral tumour.Conclusion: We observed significant differences in bilateral tumour characteristics compared to unilateral disease. Although bilateral synchronous tumour was associated with poor outcome and overall survival, patients with metachronous disease do as well as patients with unilateral tumour. The increasing practice of bilateral mastectomy is not supported by this large single centre experience.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5033.

Evaluation of variants in BRIP1, PALB2 and CHEK2 in a west of Ireland breast cancer cohort

Abstract #3092

Introduction&#x2028; Positive family history is the most important risk factor in breast cancer predisposition. Recent studies have identified variants in BRIP1, PALB2 and CHEK2, which have been proposed as breast cancer susceptibility genes conferring an increased relative risk of 2-4%.&#x2028; Aims&#x2028; To evaluate the role of the above variants in the West of Ireland population and to examine their potential clinical relevance.&#x2028; Methods&#x2028; Proposed candidate genetics variants in BRIP1, PALB2 and CHEK2 were interrogated in 192 patients with a high risk of familial breast cancer. Genescan analysis and direct sequencing were used to evaluate these variants. Where a variant was exhibited, it was then examined further in 990 sporadic breast cancer patients and 1016 matched non-cancer controls using KASPar genotyping technology.&#x2028; Results&#x2028; We demonstated mutations in BRIP1 and CHEK2 genes. 1 mutation was found in BRIP1 2392C→T in our 192 patients with a high risk of familial breast cancer. 5 breast cancer patients and 1 control exhibited a CHEK2110delC mutation within 990 breast cancer patients and 1016 matched non-cancer controls. Mutations previously demonstrated in PALB2 were not evident in 192 high risk patients.&#x2028; Conclusions&#x2028; We have confirmed the presence of variants in BRIP1 and CHEK2, candidate moderate penetrance genes, in breast cancer patients with a strong family history of breast cancer. This may have implications in clinical practice as our knowledge of these variants expands. The absense of PALB2 variants in patients at high genetic risk points to a low clinical significance. Our findings contribute to a better understanding of inherited breast cancer risk while helping to optimize future screening, therapeutic and prophylactic programs.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3092.

Crohn's disease: factors associated with exposure to high levels of diagnostic radiation

AIMS

Exposure to diagnostic radiation may be associated with increased risk of malignancy. The aims of this study were to (1) examine patterns of use of imaging in Crohn's disease; (2) quantify the cumulative effective dose (CED) of diagnostic radiation received by patients; and (3) identify patients at greatest risk of exposure to high levels of diagnostic radiation.

METHODS

409 patients with Crohn's disease were identified at a tertiary centre. CED was calculated retrospectively from imaging performed between July 1992 and June 2007. High exposure was defined as CED>75 mSv, an exposure level which has been reported to increase cancer mortality by 7.3%. Complete data were available for 399 patients. 45 were excluded (20 attended outside the study period, 25 were primarily managed at other centres).

RESULTS

Use of computed tomography increased significantly and accounted for 77.2% of diagnostic radiation. Mean CED was 36.1 mSv and exceeded 75 mSv in 15.5% of patients. Factors associated with high cumulative exposure were: age <17 years at diagnosis (hazard ratio 2.1, confidence interval (CI) 1.1 to 4.1), upper gastrointestinal tract disease (odds ratio (OR) 2.4, CI 1.2 to 4.9), penetrating disease (OR 2.0, CI 1.0 to 3.9) and requirement for intravenous steroids (OR 3.7, CI 2.0 to 6.6); infliximab (OR 2.3, CI 1.2 to 4.4); or multiple (>1) surgeries (OR 2.7, CI 1.4 to 5.4).

CONCLUSIONS

Identifiable subsets of patients with Crohn's disease are at risk of exposure to significant amounts of diagnostic radiation. Given the background risk of neoplasia and exposure to potentially synergistic agents such as purine analogues and other immune modulators, specialist centres should develop low-radiation imaging protocols.

Prospective matched-pair comparison of outcome after treatment for lobular and ductal breast carcinoma

Background

Whether the prognosis of invasive lobular carcinoma is different from that of other invasive breast cancers is controversial. The aim of this study was to compare the outcome in age- and stage-matched patients with lobular carcinoma and those with invasive breast cancer, and in particular to compare predictors of outcome.

Methods

Data were obtained from a prospectively maintained database that included patients who had breast surgery for invasive cancer. Patients were matched for International Union Against Cancer stage and age at diagnosis within 5 years. Two patients with invasive ductal carcinoma were matched to each patient with invasive lobular carcinoma.

Results

There was no significant difference between invasive ductal and lobular carcinomas in terms of overall survival. Oestrogen receptor (ER)-positive invasive ductal carcinoma had a better prognosis than ER-positive invasive lobular carcinoma (P = 0·011). Similarly, ER-negative invasive ductal carcinoma was associated with worse survival than ER-negative invasive lobular carcinoma (P = 0·054).

Conclusion

These results suggested that the differences in outcome between invasive ductal and lobular carcinomas may be determined by ER status.

Promoting mental well-being in the workplace: a European policy perspective

The nature of the workplace continues to change as Europe adapts to the challenges of competing in a global marketplace. Across the European Union there is a trend of increasing absenteeism and early retirement due to mental health problems, particularly stress and depression. The social and economic costs of lost productivity in Europe are substantial. Moreover, the sustainability of social protection systems may be challenged further by increases in the levels of disability benefits paid to people who have left work on grounds of poor mental health. Yet despite these significant consequences, at both national and pan-European levels, decision-makers have been slow to recognise the importance of promoting mental health within the workplace, although recently there have been some positive developments. This paper outlines some of the socio-economic arguments for the promotion of good mental well-being in the labour force and identifies how they link with different national and European policy agendas around four key issues: economic growth and development, the promotion of a high level of public health, sustainability of social welfare systems and social inclusion. The role and activities to promote mental well-being in the workplace undertaken by both national and international organizations in Europe are outlined along with important gaps and challenges that need to be addressed.

Identification in 2 Independent Samples of a Novel Schizophrenia RiskHaplotype of the Dystrobrevin Binding Protein Gene (DTNBP1)

CONTEXT

Recent research suggests that variation in the gene encoding dystrobrevin binding protein (DTNBP1) confers susceptibility to schizophrenia. Thus far, no specific risk haplotype has been identified in more than 1 study.

OBJECTIVES

To confirm DTNBP1 as a schizophrenia susceptibility gene, to identify and replicate specific risk and protective haplotypes, and to explore relationships between DTNBP1 and the phenotype.

DESIGN

Genetic association study based on mutation detection and case-control analysis.

SETTING

All subjects were unrelated and ascertained from general (secondary care) psychiatric inpatient and outpatient services.

PARTICIPANTS

The Cardiff, Wales, sample included 708 white subjects from the United Kingdom and Ireland (221 females) who met DSM-IV criteria for schizophrenia and were individually matched for age, sex, and ethnicity to 711 blood donor controls (233 females). Mean +/- SD age at first psychiatric contact for cases was 23.6 +/- 7.7 years; mean age at ascertainment was 41.8 +/- 13.5 years. The Dublin, Ireland, sample included 219 white subjects from the Republic of Ireland who met DSM-III-R criteria for schizophrenia or schizoaffective disorder and 231 controls. The mean age of the Irish cases was 46.0 +/- 8.5 years; mean age at first psychiatric contact was 25.2 +/- 12.4 years.

MAIN OUTCOME MEASURE

Evidence for association between the DTNBP1 locus and schizophrenia.

RESULTS

In the Cardiff sample, there was no evidence for association with previously implicated haplotypes but strong evidence for association with multiple novel haplotypes. Maximum evidence was found for a novel 3-marker haplotype (global P<.001), composed of 1 risk haplotype (P =.01) and 2 protective haplotypes, 1 common (P =.006) and 1 rare (P<.001). Specific risk and protective haplotypes were replicated in the Dublin sample (P =.02,.047, and.006, respectively). The only phenotypic variable associated with any haplotype was between the common protective haplotype and higher educational achievement (P =.02, corrected for multiple tests).

CONCLUSIONS

DTNBP1 is a susceptibility gene for schizophrenia. Specific risk and protective haplotypes were identified and replicated. Association with educational achievement may suggest protection mediated by IQ, although this needs to be confirmed in an independent data set.

Impact of early intervention on outcome following mild head injury in adults

BACKGROUND

The impact of mild head injury is variable and determinants of outcome remain poorly understood. Results of previous intervention studies have been mixed.

OBJECTIVES

To evaluate the impact on outcome of the provision of information, measured in terms of reported symptoms, cognitive performance, and psychological adjustment three months postinjury.

METHODS

202 adults with mild head injury were studied: 79 were assigned to an intervention group and were assessed one week and three months after injury; 123 were assigned to a non-intervention control group and were seen at three months only. Participants completed measures of preinjury psychological adjustment, concurrent life stresses, post-concussion symptoms, and tests of attention, speed of information processing, and memory. Subjects seen at one week were given an information booklet outlining the symptoms associated with mild head injury and suggested coping strategies. Those seen only at three months after injury did not receive this booklet.

RESULTS

Patients in the intervention group who were seen at one week and given the information booklet reported fewer symptoms overall and were significantly less stressed at three months after the injury.

CONCLUSIONS

The provision of an information booklet reduces anxiety and reporting of ongoing problems.

Impact of early intervention on outcome after mild traumatic brain injury in children

OBJECTIVE

The impact of mild head injury or mild traumatic brain injury (TBI) in children is variable, and determinants of outcome remain poorly understood. There have been no previous attempts to evaluate the impact of interventions to improve outcome. Results of previous intervention studies in adults have been mixed. This study aimed to evaluate the impact of providing information on outcome measured in terms of reported symptoms, cognitive performance, and psychological adjustment in children 3 months after injury.

METHODS

A total of 61 children with mild TBI were assessed 1 week and 3 months after injury, and 58 children with mild TBI were assessed 3 months after injury only. They were compared with 2 control groups (N = 45 and 47) of children with minor injuries not involving the head. Participants completed measures of preinjury behavior and psychological adjustment, postconcussion symptoms, and tests of attention, speed of information processing, and memory. Children with mild TBI seen at 1 week were also given an information booklet outlining symptoms associated with mild TBI and suggested coping strategies. Those seen 3 months after injury only did not receive this booklet.

RESULTS

Children with mild TBI reported more symptoms than controls at 1 week but demonstrated no impairment on neuropsychological measures. Initial symptoms had resolved for most children by 3 months after injury, but a small group of children who had previous head injury or a history of learning or behavioral difficulties reported ongoing problems. The group not seen at 1 week and not given the information booklet reported more symptoms overall and was more stressed 3 months after injury.

CONCLUSIONS

Providing an information booklet reduces anxiety and thereby lowers the incidence of ongoing problems.

Informatics Competencies for Nurses at Four Levels of Practice

Valid and comprehensive nursing informatics (NI) competencies currently are lacking. Meanwhile, nursing leaders are emphasizing the need to include NI in nursing curricula, as well as within the roles of practicing nurses in all settings. This article presents the initial work of a team of NI experts toward development of a valid and reliable set of NI competencies. Previous work primarily has focused on computer-related skills, rather than examining a broad definition of informatics competencies. For this current work, NI competencies encompass all skills, not only computer-related skills, as well as knowledge and attitudes needed by nurses. The first two authors created a database of NI competencies from the existing literature. A larger panel of NI experts then affirmed, modified, added, or deleted competencies from this database. Competencies were placed into four distinct skill levels. Definitions of each skill level and an initial master list of competencies are provided.

Perceived information needs and communication difficulties of inpatient physicians and nurses

In order to understand the differing perceptions of information needs and communication patterns of healthcare professionals as they relate to medical errors, we conducted a survey and 5 focus group sessions of inpatient physicians and nurses. Although nurses and physicians stated differing information needs, both groups expressed significant problems with obtaining patient, domain and institution-specific information in a timely manner. Identification of appropriate providers and establishing contact with those people was perceived as the most pressing communication need. All focus group participants felt that communication difficulties were common and could give examples in which such difficulties led to adverse events. Our studies suggest that information needs and communication difficulties are common and can lead to medical errors or near misses. Many of these problems may be amenable to information technology solutions.

Development of an ontology to model medical errors, information needs, and the clinical communication space

Medical errors are common, costly and often preventable. Work in understanding the proximal causes of medical errors demonstrates that systems failures predispose to adverse clinical events. Most of these systems failures are due to lack of appropriate information at the appropriate time during the course of clinical care. Problems with clinical communication are common proximal causes of medical errors. We have begun a project designed to measure the impact of wireless computing on medical errors. We report here on our efforts to develop an ontology representing the intersection of medical errors, information needs and the communication space. We will use this ontology to support the collection, storage and interpretation of project data. The ontology's formal representation of the concepts in this novel domain will help guide the rational deployment of our informatics interventions. A real-life scenario is evaluated using the ontology in order to demonstrate its utility.

The effects of community health nurse monitoring on hypertension identification and control

Identification and control of hypertension are important public health concerns. Lack of regular health care makes diagnosis and control difficult in some populations. Community health nursing services in settings where clients regularly congregate promote identification and control of hypertension. This study focused on the effects of community health nursing screening and monitoring services for hypertension provided to participants in a breadline, a senior nutrition program, an English as Second Language (ESL) class, and employees providing these services. Community health nurses (CHNs) provided 2,407 blood pressure-related service encounters. Blood pressures were elevated in 19% of encounters, and 10% of clients had elevations that warranted referral for medical assistance. At the end of the 18-month study period, 67% of all clients with elevations and 71% of those referred for medical assistance had achieved normal blood pressures. One-way analysis of variance indicated a significant relationship between the number of encounters with the nurses and a positive outcome for all clients with elevations. This relationship was not supported for those clients referred to medical assistance. The effectiveness of intervention appeared to vary somewhat among subgroups with some groups more likely than others to achieve a positive outcome. Group differences in outcome were not statistically significant.

Factors influencing outcome following mild traumatic brain injury in adults

This study aimed to investigate outcome in adults with mild traumatic brain injury (TBI) at 1 week and 3 months postinjury and to identify factors associated with persisting problems. A total of 84 adults with mild TBI were compared with 53 adults with other minor injuries as controls in terms of postconcussional symptomatology, behavior, and cognitive performance at 1 week and 3 months postinjury. At 1 week postinjury, adults with mild TBI were reporting symptoms, particularly headaches, dizziness, fatigue, visual disturbance, and memory difficulties. They exhibited slowing of information processing on neuropsychological measures, namely the WAIS-R Digit Symbol subtest and the Speed of Comprehension Test. By 3 months postinjury, the symptoms reported at 1 week had largely resolved, and no impairments were evident on neuropsychological measures. However, there was a subgroup of 24% of participants who were still suffering many symptoms, who were highly distressed, and whose lives were still significantly disrupted. These individuals did not have longer posttraumatic amnesia (PTA) duration. They were more likely to have a history of previous head injury, neurological or psychiatric problems, to be students, females, and to have been injured in a motor vehicle accident. The majority were showing significant levels of psychopathology. A range of factors, other than those directly reflecting the severity of injury, appear to be associated with outcome following mild TBI.

The androgen receptor exon 1 trinucleotide repeat does not act as a modifier of the age of presentation in breast cancer

The CAG repeat in exon 1 of the androgen receptor (AR) genes has been postulated as both a susceptibility allele and phenotypic modifier in BRCA1-associated breast cancers. We have analysed this repeat in a set of 178 breast cancer cases who have been selected only for age of presentation at 65 years or less. No effect of repeat length on age of presentation was found and there was no association between repeat length and family history. In combination with the data from other workers, our findings suggest that the androgen receptor repeat does not act as a modifier gene or susceptibility locus outside the context of the hereditary breast/ovarian cancer syndrome.

Advising on a thermometer for family use

Families will find it useful to have a clinical thermometer, but parents should be taught that children's illnesses can present in a range of different ways and that a young baby can be ill despite having a normal temperature. For people who find mercury thermometers difficult to use and read, alternatives are digital, strip or ear thermometers. Digital thermometers are safe, accurate and very easy to read. Colour-strip thermometers are placed on the skin and change colour at certain temperatures. As well as forehead strips there is a newer kind which can be used under the tongue. Ear thermometers are increasingly popular for young children, being safe, easy to read and accurate.

Cognitive and behavioral outcome following mild traumatic head injury in children

OBJECTIVES

To investigate outcome in children with mild traumatic head injury (THI) at 1 week and 3 months postinjury and to identify factors associated with persisting problems.

DESIGN

Postconcussional symptomatology, behavior ratings, and neuropsychological test performance were examined at 1 week and 3 months postinjury.

SETTING

Participants were recruited from successive presentations to emergency departments of two major hospitals.

PARTICIPANTS

130 Children with mild THI were compared with 96 children having other minor injuries as controls.

RESULTS

Children with mild THI experienced headaches, dizziness, and fatigue but exhibited no cognitive impairments, relative to controls, at 1 week postinjury. By 3 months, symptoms had resolved. However, 17% of children showed significant ongoing problems. They were more likely to have a history of previous head injury, learning difficulties, neurological or psychiatric problems, or family stressors.

CONCLUSIONS

Persisting problems following mild head injury in children are more common in those with previous head injury, preexisting learning difficulties, or neurological, psychiatric, or family problems. These "at-risk" children should be identified in the emergency department and monitored.

Reduced coronary NO production in conscious dogs after the development of alloxan-induced diabetes

The role of nitric oxide (NO) in the control of coronary blood flow (CBF) during the development of diabetes is unknown. To study this, mongrel dogs were chronically instrumented using sterile techniques for measurements of systemic hemodynamics and CBF. With heart rate controlled (150 beats/min), veratrine (1-10 micrograms/kg) caused dose-dependent increases in CBF; e.g., 5 mirograms/kg of veratrine increased CBF by 57 +/- 7% from 41 +/- 1.3 ml/min (P < 0.05). The dogs developed diabetes 4-5 wk after injection of alloxan (40-60 mg/kg iv, blood glucose levels were 384 +/- 18 mg/dl). After diabetes the same doses of veratrine caused smaller increases in CBF; i.e., 5 micrograms/kg of veratrine increased CBF by 32 +/- 2% (P < 0.05 compared with control) from 28 +/- 4 ml/min. ACh- and adenosine-induced coronary vasodilation were reduced after diabetes as well. In anesthetized dogs after diabetes, vagal stimulation caused smaller increases in CBF. ACh and bradykinin caused smaller increases in NO(-)(2) production in coronary microvessels from diabetic dogs. Furthermore, despite the fact that mRNA for endothelial cell NO synthase from the aorta was increased twofold with the use of Northern blotting, the protein for aortic endothelial constitutive NO synthase was reduced by 66% after diabetes, as determined by Western blotting. Our results indicate that the NO-dependent coronary vasodilation by the Bezold-Jarisch reflex is impaired in conscious dogs after diabetes. The mechanism responsible for the impaired endothelium-dependent coronary vasodilation is most likely the decreased release of NO from the endothelium.

Hay fever: an update on current treatments

Most hay fever sufferers can help themselves by taking steps to avoid high levels of pollen. Where eye symptoms are severe, sodium cromoglycate eye drops are recommended. Oral antihistamines are suitable for mild to moderate symptoms. For severe nasal symptoms, corticosteroid nasal sprays are useful. As with many medicines, use by expectant and breast-feeding mothers is best avoided. If symptoms are particularly troublesome, referral to a doctor is advisable.