Rett syndrome in Ireland: a demographic study

BACKGROUND

Rett syndrome (RTT) is a rare neurodevelopmental condition associated with mutations in the gene coding for the methyl-CpG-binding protein 2 (MECP2). It is primarily observed in girls and affects individuals globally. The understanding of the neurobiology of RTT and patient management has been improved by studies that describe the demographic and clinical presentation of individuals with RTT. However, in Ireland, there is a scarcity of data regarding individuals with RTT, which impedes the ability to fully characterize the Irish RTT population. Together with the Rett Syndrome Association of Ireland (RSAI), we prepared a questionnaire to determine the characteristics of RTT individuals in Ireland. Twenty-five families have participated in the study to date, providing information about demographics, genetics, familial history, clinical features, and regression.

RESULTS

The results show that Irish individuals with RTT have comparable presentation with respect to individuals in other countries; however, they had a better response to anti-epileptic drugs, and fewer skeletal deformities were reported. Nonetheless, seizures, involuntary movements and regression were more frequently observed in Irish individuals. One of the main findings of this study is the limited genetic information available to individuals to support the clinical diagnosis of RTT.

CONCLUSIONS

Despite the limited sample size, this study is the first to characterize the RTT population in Ireland and highlights the importance of having a swift access to genetic testing to sharpen the characterization of the phenotype and increase the visibility of Irish individuals in the international RTT community.

Analysis of primary care electronic health record data of people living with hepatitis B virus: infection and hepatocellular carcinoma risk associated with socio-economic deprivation

OBJECTIVES

We set out to characterise chronic hepatitis B (CHB) in the primary care population in England and investigate risk factors for progression to hepatocellular carcinoma (HCC).

STUDY DESIGN

Retrospective cohort study.

METHODS

We identified 8039 individuals with CHB in individuals aged ≥18 years between 1999 and 2019 in the English primary care database QResearch. HCC risk factors were investigated using Cox proportional hazards modelling.

RESULTS

Most of those with a record of CHB were males (60%) of non-White ethnicity (>70%), and a high proportion were in the most deprived Townsend deprivation quintile (44%). Among 7029 individuals with longitudinal data, 161 HCC cases occurred. Increased HCC hazards were significantly associated with male sex (adjusted hazards ratio [aHR] 3.17, 95% confidence interval [95% CI] 1.92-5.23), in the fifth deprivation quintile as compared to the third quintile (aHR 1.69, 95% CI 1.01-2.84), with older age (for age groups 56-65 and ≥66 years, compared to 26-35 years, aHRs 2.82 [95% CI 1.45-5.46] and 3.76 [95% CI 1.79-7.9], respectively), Caribbean ethnicity (aHR 3.32, 95% CI 1.43-7.71, compared to White ethnicity), ascites (aHR 3.15, 95% CI 1.30-7.67), cirrhosis (aHR 6.55, 95% CI 4.57-9.38) and peptic ulcer disease (aHR 2.26, 95% CI 1.45-3.51).

CONCLUSIONS

Targeting interventions and HCC surveillance at vulnerable groups is essential to improve CHB outcomes and to support progress towards international goals for the elimination of hepatitis infection as a public health threat.

Creating resistance to avian influenza infection through genome editing of the ANP32 gene family

Chickens genetically resistant to avian influenza could prevent future outbreaks. In chickens, influenza A virus (IAV) relies on host protein ANP32A. Here we use CRISPR/Cas9 to generate homozygous gene edited (GE) chickens containing two ANP32A amino acid substitutions that prevent viral polymerase interaction. After IAV challenge, 9/10 edited chickens remain uninfected. Challenge with a higher dose, however, led to breakthrough infections. Breakthrough IAV virus contained IAV polymerase gene mutations that conferred adaptation to the edited chicken ANP32A. Unexpectedly, this virus also replicated in chicken embryos edited to remove the entire ANP32A gene and instead co-opted alternative ANP32 protein family members, chicken ANP32B and ANP32E. Additional genome editing for removal of ANP32B and ANP32E eliminated all viral growth in chicken cells. Our data illustrate a first proof of concept step to generate IAV-resistant chickens and show that multiple genetic modifications will be required to curtail viral escape.

Whole-genome sequencing to investigate transmission of SARS-CoV-2 in the acute healthcare setting: a systematic review

BACKGROUND

Whole-genome sequencing (WGS) has been used widely to elucidate transmission of SARS-CoV-2 in acute healthcare settings, and to guide infection, prevention, and control (IPC) responses.

AIM

To systematically appraise available literature, published between January 1st, 2020 and June 30th, 2022, describing the implementation of WGS in acute healthcare settings to characterize nosocomial SARS-CoV-2 transmission.

METHODS

Searches of the PubMed, Embase, Ovid MEDLINE, EBSCO MEDLINE, and Cochrane Library databases identified studies in English reporting the use of WGS to investigate SARS-CoV-2 transmission in acute healthcare environments. Publications involved data collected up to December 31st, 2021, and findings were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

FINDINGS

In all, 3088 non-duplicate records were retrieved; 97 met inclusion criteria, involving 62 outbreak analyses and 35 genomic surveillance studies. No publications from low-income countries were identified. In 87/97 (90%), WGS supported hypotheses for nosocomial transmission, while in 46 out of 97 (47%) suspected transmission events were excluded. An IPC intervention was attributed to the use of WGS in 18 out of 97 (18%); however, only three (3%) studies reported turnaround times ≤7 days facilitating near real-time IPC action, and none reported an impact on the incidence of nosocomial COVID-19 attributable to WGS.

CONCLUSION

WGS can elucidate transmission of SARS-CoV-2 in acute healthcare settings to enhance epidemiological investigations. However, evidence was not identified to support sequencing as an intervention to reduce the incidence of SARS-CoV-2 in hospital or to alter the trajectory of active outbreaks.

"Oh! How Modern! And... Are You Ok with That?": Consensually Non-Monogamous People's Experiences When Accessing Sexual Health Care

The current research explored consensually non-monogamous peoples' experiences accessing sexual healthcare. Using a mixed method approach, a sample of 67 consensually non-monogamous individuals (48% Polyamorous; 42% Relationship Anarchy/Solo polyamory; 6% Swingers; 4% Uncategorized) reported having significantly lower rates of trust in healthcare professionals compared to standardized scores. Sixty-three percent of participants reported disclosing their relationship status to a clinician when accessing sexual health services, whereas 37% sometimes or never disclosed. Qualitative responses identified that some participants reported a willingness to be open about their relationships, but many chose to "pass" as monogamous to both simplify and streamline their interactions as well as to avoid potential stigma. Participants reported a wide range of experiences with clinicians from those who were accepting and professional, to some who displayed prejudice and withheld treatment. This research outlines some of the experiences and challenges presented to consensual non-monogamists when accessing sexual healthcare as well as providing suggestions for clinicians to help remove some of the barriers to appropriate patient care.

Overall survival in the OlympiA phase III trial of adjuvant olaparib in patients with germline pathogenic variants in BRCA1/2 and high risk, early breast cancer

BACKGROUND

The randomized, double-blind OlympiA trial compared 1 year of the oral poly(adenosine diphosphate-ribose) polymerase inhibitor, olaparib, to matching placebo as adjuvant therapy for patients with pathogenic or likely pathogenic variants in germline BRCA1 or BRCA2 (gBRCA1/2pv) and high-risk, human epidermal growth factor receptor 2-negative, early breast cancer (EBC). The first pre-specified interim analysis (IA) previously demonstrated statistically significant improvement in invasive disease-free survival (IDFS) and distant disease-free survival (DDFS). The olaparib group had fewer deaths than the placebo group, but the difference did not reach statistical significance for overall survival (OS). We now report the pre-specified second IA of OS with updates of IDFS, DDFS, and safety.

PATIENTS AND METHODS

One thousand eight hundred and thirty-six patients were randomly assigned to olaparib or placebo following (neo)adjuvant chemotherapy, surgery, and radiation therapy if indicated. Endocrine therapy was given concurrently with study medication for hormone receptor-positive cancers. Statistical significance for OS at this IA required P < 0.015.

RESULTS

With a median follow-up of 3.5 years, the second IA of OS demonstrated significant improvement in the olaparib group relative to the placebo group [hazard ratio 0.68; 98.5% confidence interval (CI) 0.47-0.97; P = 0.009]. Four-year OS was 89.8% in the olaparib group and 86.4% in the placebo group (Δ 3.4%, 95% CI -0.1% to 6.8%). Four-year IDFS for the olaparib group versus placebo group was 82.7% versus 75.4% (Δ 7.3%, 95% CI 3.0% to 11.5%) and 4-year DDFS was 86.5% versus 79.1% (Δ 7.4%, 95% CI 3.6% to 11.3%), respectively. Subset analyses for OS, IDFS, and DDFS demonstrated benefit across major subgroups. No new safety signals were identified including no new cases of acute myeloid leukemia or myelodysplastic syndrome.

CONCLUSION

With 3.5 years of median follow-up, OlympiA demonstrates statistically significant improvement in OS with adjuvant olaparib compared with placebo for gBRCA1/2pv-associated EBC and maintained improvements in the previously reported, statistically significant endpoints of IDFS and DDFS with no new safety signals.

Cervical cancer screening utilization, and associated factors, in Nepal: a systematic review and meta-analysis

OBJECTIVE

To systematically appraise the existing published literature on cervical cancer screening utilization, and associated barriers and facilitators, in Nepal.

STUDY DESIGN

Systematic literature review and meta-analysis.

METHODS

PubMed/MEDLINE, CINAHL, Scopus, Embase, and, Google Scholar were systematically searched using Preferred Reporting Items for Systematic Review and Meta-Analysis guideline. All quantitative and qualitative studies reporting cervical cancer screening (using the Pap smear test or visual inspection with acetic acid or human papillomavirus test) utilization, barriers, and facilitators for screening were identified. A meta-analysis was performed to estimate Nepal's pooled cervical cancer screening utilization proportion.

RESULTS

The search yielded 97 records, of which 17 studies were included. Fifteen studies were quantitative and two were qualitative. Of the 17 studies, six were hospital-based and six were community-based. The pooled cervical cancer screening utilization proportion (using Pap smear test) among Nepalese women was 17% from the studies in the hospital settings, and 16% in the community. Six studies reported barriers to cervical cancer screening, of which four reported embarrassments related to the gynecological examination and a low level of knowledge on cervical cancer. Three (of four) studies reported health personnel, and two studies reported screening services-related facilitators for cervical cancer screening.

CONCLUSION

Our review reported that cervical cancer screening utilization (16%) is more than four times lower than the national target (70%) in Nepal. Multiple barriers such as low levels of knowledge and embarrassment are associated with cervical cancer screening utilization. Health personnel's gender, counseling, and privacy of screening services were commonly reported facilitators. These findings could help to inform future research, and policy efforts to increase cervical cancer screening utilization in Nepal.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Guillain-Barré Syndrome and Unilateral Optic Neuritis Following Vaccination for COVID-19: A Case Report and Literature Review

A 71-year-old woman presented 2 weeks after vaccination with the first dose of Vaxzevria (AstraZeneca, Oxford) for COVID-19 with a left lower motor neuron facial nerve palsy, which progressed to bilateral involvement. This was accompanied by bilateral proximal leg weakness. She was diagnosed with the 'facial diplegia with paraesthesia' variant of Guillain-Barré syndrome. Seven weeks post vaccination she developed painless loss of vision in the right eye. The visual acuity in that eye was light perception only with a right relative afferent pupillary defect and right optic disc swelling. A diagnosis of optic neuritis was made and she received pulsed intravenous methylprednisolone for 3 days, followed by oral prednisolone. The optic neuritis recurred following initial cessation of steroids requiring an extended course of steroids. Despite this, she made a good visual recovery to 6/6 in the affected eye. We present this case and a review of the literature surrounding vaccination and the development of these conditions.

P36: SOMATIC SYMPTOM DISORDER (SSD) AND ABDOMINAL PAIN: INCREASED OPIOID PRESCRIBING IN SURGICAL PATIENTS

Introduction

Undifferentiated pain, and pain out of proportion of diagnosed pathology are sources of frustration to clinician and patient. SSD is a DSM-V diagnosis that has consolidated the previous diagnoses of psychogenic pain. It is a health anxiety condition, where sufferers experience multiple somatic symptoms which cause anxiety and distress. This anxiety results in frequent ED and GP presentations, extensive investigations, and increased opioid prescription. However, opioids do little to alleviate symptoms. Treatment should focus on underlying anxiety and depression.

Population studies show SSD prevalence to be 15-20%, however SSD has never been studied in the surgical population. We hypothesized that the rates of SSD in the surgical population reflects that in primary care, and that SSD sufferers are more likely to be prescribed opioid analgesia.

Method

Adult patients admitted with abdominal pain of any non-traumatic aetiology to the Acute General Surgical Unit at a major tertiary hospital are being screened for SSD using the PHQ-15 questionnaire, and opioid prescription is being recorded.

Result

400 participants have been recruited with a total SSD prevalence of 20%. Opioid prescribing rises sharply with SSD diagnosis. The average opioid prescription appears to be 3 times higher in patients with SSD compared to those without.

Conclusion

Our data confirms an SSD prevalence of 20% in the surgical population. This is associated with increased opioid prescription. Early recognition of SSD and implementation of appropriate treatment could reduce hospital presentations, admissions and opioid prescription. We will continue recruitment to 800 participants by March 2020.

Take-home message

SSD is common in all populations, and results in increased hospital presentations, admissions and opioid prescription. Early recognition and implementation of appropriate treatment may reduce healthcare burden, improve patient outcomes, and reduce opioid prescription.

The Canadian Neuromuscular Disease Registry 2010-2019: A Decade of Facilitating Clinical Research Througha Nationwide, Pan-NeuromuscularDisease Registry

We report the recruitment activities and outcomes of a multi-disease neuromuscular patient registry in Canada. The Canadian Neuromuscular Disease Registry (CNDR) registers individuals across Canada with a confirmed diagnosis of a neuromuscular disease. Diagnosis and contact information are collected across all diseases and detailed prospective data is collected for 5 specific diseases: Amyotrophic Lateral Sclerosis (ALS), Duchenne Muscular Dystrophy (DMD), Myotonic Dystrophy (DM), Limb Girdle Muscular Dystrophy (LGMD), and Spinal Muscular Atrophy (SMA). Since 2010, the CNDR has registered 4306 patients (1154 pediatric and 3148 adult) with 91 different neuromuscular diagnoses and has facilitated 125 projects (73 academic, 3 not-for-profit, 3 government, and 46 commercial) using registry data. In conclusion, the CNDR is an effective and productive pan-neuromuscular registry that has successfully facilitated a substantial number of studies over the past 10 years.

Setting the research agenda for living with and beyond cancer with comorbid illness: reflections on a research prioritisation exercise

BACKGROUND

People living with and beyond cancer are more likely to have comorbid conditions and poorer mental and physical health, but there is a dearth of in-depth research exploring the psychosocial needs of people experiencing cancer and comorbid chronic conditions. A patient partnership approach to research prioritisation and planning can ensure outcomes meaningful to those affected and can inform policy and practice accordingly, but can be challenging.

METHODS

We aimed to inform priorities for qualitative inquiry into the experiences and support needs of people living with and beyond cancer with comorbid illness using a partnership approach. A three-step process including a patient workshop to develop a consultation document, online consultation with patients, and academic expert consultation was carried out. The research prioritisation process was also appraised and reflected upon.

RESULTS

Six people attended the workshop, ten responded online and eight academic experts commented on the consultation document. Five key priorities were identified for exploration in subsequent qualitative studies, including the diagnostic journey, the burden of symptoms, managing medications, addressing the needs of informal carers, and service provision. Limitations of patient involvement and reflections on procedural ethics, and the challenge of making measurable differences to patient outcomes were discussed.

CONCLUSIONS

Findings from this research prioritisation exercise will inform planned qualitative work to explore patients' experiences of living with and beyond cancer with comorbid illness. Including patient partners in the research prioritisation process adds focus and relevance, and feeds into future work and recommendations to improve health and social care for this group of patients. Reflections on the consultation process contribute to a broadening of understanding the field of patient involvement.

Neonatal outcomes following previable prelabour rupture of membranes before 23 weeks of gestation - A retrospective cohort study

OBJECTIVE

To compare outcomes of hospitalized preterm infants following previable prelabour rupture of membranes (PPROM) at≤23 weeks of gestation.

METHODS

Retrospective cohort study of preterm infants admitted for intensive care, between January 2006 and December 2016 following PPROM, was conducted. Short term clinical outcomes included severity of respiratory morbidity, length of hospital stay and mortality. Neurodevelopment in survivors was assessed using Bayley's Scales of Infant Development (3rd edition) at 24 months corrected age.

RESULTS

A total of 82 preterm infants were admitted following PPROM at < 23 weeks and were grouped as: Group 1 (n = 28) with PPROM < 20 weeks and Group 2 (n = 54) with PPROM between 20-22 + 6 weeks. Median latency following PPROM was significantly longer in Group 1 infants [69(Interquartile range (IQR): 43-74; Range (R): 25-100 vs. 29(IQR: 10-53; R: 2-72) days, p < 0.001]. Median gestation at delivery was 27.4 weeks (Group 1) vs. 25.1 weeks (Group 2). Group 1 had a significantly higher incidence of oligohydramnios [13(46.4%) vs. 8(14.8%), p = 0.002], lower Apgar scores (<7) at 5 minutes [19(67.9%) vs. 24(44.4%), p = 0.044], increased pulmonary hypoplasia [13(46.4%) vs. 5(9.3%), p < 0.001], joint contractures [3(10.7%) vs. 0, p = 0.037] and mortality [10(35.7%) vs. 7(13.0%), p = 0.016]. Neurodevelopmental outcomes at 24 months corrected age were comparable in the 36 surviving infants (9/18 vs. 27/547).

CONCLUSION

Morbidity and mortality is high in infants born after previable PPROM; specifically, in those with PPROM < 20 weeks although early childhood neurodevelopmental outcomes were comparable. Larger prospective studies focussing on long term neonatal outcomes are needed to confirm these findings.

Comparison of the Reveal 20-Hour Method and the BAM Culture Method for the Detection of Escherichia coli O157:H7 in Selected Foods and Environmental Swabs: Collaborative Study

Four different food types along with environmental swabs were analyzed by the Reveal for E. coli O157:H7 test (Reveal) and the Bacteriological Analytical Manual (BAM) culture method for the presence of Escherichia coli O157:H7. Twenty-seven laboratories representing academia and private industry in the United States and Canada participated. Sample types were inoculated with E. coli O157:H7 at 2 different levels. Of the 1095 samples and controls analyzed and confirmed, 459 were positive and 557 were negative by both methods. No statistical differences (p &lt;0.05) were observed between the Reveal and BAM methods.

Reveal 8-Hour Test System for Detection of Escherichia coli O157:H7 in Raw Ground Beef, Raw Beef Cubes, and Iceberg Lettuce Rinse: Collaborative Study

Five different food types were analyzed by the Reveal for E. coli O157:H7 8-Hour Test System (Reveal 8) and either the U.S. Food and Drug Administration's Bacteriological Analytical Manual (BAM) culture method or the U.S. Department of Agriculture Food Safety Inspection Service (FSIS) culture method for the presence of E. coli O157:H7. A total of 27 laboratories representing academia and private industry in the United States and Canada participated. Food types were inoculated with E. coli O157:H7 at 2 different levels: a high level where predominantly positive results were expected, and a low level where fractional recovery was anticipated. During this study, 1110 samples and controls were analyzed by both the Reveal 8 and by BAM or FSIS by each of the collaborators (2220 samples in total). For each set of samples, 740 were artificially inoculated with E. coli O157:H7, and 370 were uninoculated controls. The Reveal 8 detected 528 presumptive positives of which 487 were confirmed positive by the BAM culture method. In comparison, BAM and FSIS detected 489 of the 740 artificially contaminated samples as positive. In an additional in-house study performed only on chilled and frozen raw ground beef, 240 artificially inoculated samples were analyzed by both the Reveal 8 and by FSIS. The Reveal 8 detected and confirmed 104 samples as positive compared to 79 confirmed positive by FSIS.

Frankel 2 appliance versus the Modified Twin Block appliance for Phase 1 treatment of Class II division 1 malocclusion in children and adolescents: A randomized clinical trial

OBJECTIVE

To compare Phase 1 treatment, using the Frankel 2 (FR2) or the modified Twin Block (MTB), for Class II division 1 malocclusion in children and adolescents with respect to: treatment duration, number of appliance breakages, occlusal outcome, and patient and parent perspectives.

MATERIALS AND METHODS

Sixty participants with a Class II division 1 malocclusion were randomly assigned to either the FR2 or MTB appliance in a two-armed parallel randomized clinical trial with an allocation ratio of 1 to 1. Time to achieve a Class I incisor relationship was the primary outcome. The number of appliance breakages was recorded. The Peer Assessment Rating (PAR) index was used to evaluate pre- and post-treatment occlusal outcome on study models. Participants completed the child OHRQoL (oral health-related quality of life), Piers-Harris, Standard Continuum of Aesthetic Need (SCAN), and Oral Aesthetic Subjective Impact Score (OASIS) questionnaires pre- and post-treatment; parents completed a SCAN questionnaire.

RESULTS

Forty-two participants completed treatment (FR2: 20; MTB: 22). Multiple imputation was used to impute missing data for noncompleters. Mean treatment duration was similar for the two appliances (FR2: 376 days [SD 101]; MTB: 340 days [SD 102]; P = .41). There were no significant differences in mean number of appliance breakages (FR2: 0.3 SD 0.7; MTB: 0.4 SD 0.8; P = .67 or mean PAR score P = .48). Patient and parent perspectives did not differ between appliances (P > .05).

CONCLUSIONS

Phase 1 treatment duration, number of appliance breakages, occlusal outcome, and patient and parent perspectives were similar in 11-14 year olds with Class II division 1 malocclusion treated using the FR2 or MTB appliance.

Abstract P4-13-13: Meta-analyses of visceral versus non-visceral metastases treated by AI & SERD agents as 2nd line endocrine therapy (ET) for HR+ breast cancer (BC)

There is a prevailing belief that ET for HR+ advanced BC is not as effective in patients with visceral metastases (VM) compared to non-visceral metastases (nVM), particularly with later lines of ET. Recently fulvestrant 500mg (Ful 500), has been reported to have greater efficacy in nVM compared to i) VM treated by Ful 500 but also compared to ii) nVM treated by Ful 250 (2nd line) and iii) nVM treated by aromatase inhibitor (AI), anastrozole (1st Line) – implying both site and agent related efficacy. Absence of significant overall survival (OS) difference in PALOMA 3 (2nd line) has increased the debate regarding when to add CDK 4/6is to ET, especially given the OS advantage for Ful 500 monotherapy in the 1st & 2nd line settings.

Patients & Methods: Anonymised, individual patient level data was obtained from randomised controlled trials (RCTs) involving AI & SERD used as mono-theraphy in 2nd or 3rd Line setting in known HR+ BC. All the trials were Phase 3 double-blind, placebo RCTs. All were rigorously assessed for clinical benefit (CB), progression free survival (PFS), duration of CB (DoCB) and OS. Details of the studies, types of ET and patient numbers are shown in the Table.

Results: Outcome data is presented for each study and then summarised under AI, SERD (Ful 250 or 500) and 'all Ets combined'. Odds ratios (Ors) & hazard ratios (HRs) for VM versus nVM by endocrine agents are shown in the Table.

AgentStudyTotal Pats.HR+ Pats.CBRPFSOSDoCBAI(n)(n)OR (95%Cis)HR (95%Cis)HR (95%Cis)HR (95%Cis)Exe00202301831.181.441.271.50Exe00211931681.151.951.832.12AnaEFECT3403360.941.521.201.10AnaSOFEA2492491.291.181.051.41subtotal7636871.11 (0.84-1.48)1.47*** (1.22-1.79)1.21* (1.01-1.45)1.43** (1.10-1.86)SERDFul 25000202191601.791.701.401.23Ful 25000212041771.281.811.322.06Ful 250EFECT3513450.791.401.311.03Ful 250SOFEA2312310.701.171.242.22Ful 250CONFIRM1521521.131.071.510.84Subtotal9268341.05 (0.75-1.45)1.39*** (1.16-1.67)1.34*** (1.14-1.57)1.36 (0.93-1.98)SERDFul 500CONFIRM1441442.24 (1.12-4.48)1.30 (0.90-1.87)1.33 (1.14-1.57)0.97 (0.55-1.66)All ETsTotal183316651.13 (0.92-1.39)1.42*** (1.26-1.59)1.28*** (1.14-1.44)1.35** (1.09-1.66)

[Pats=Patients; (n)=number; CBR-Clinical Benefit Rate; p-values p&lt;0.05*, p&lt;0.01**, p&lt;0.001***]

Median PFS (months) for nVM for AI, SERD250, SERD500 & ‘all Ets combined’ were 5.4, 5.5, 11.0 & 5.5 respectively: for VM they were 2.9, 3.5, 5.5 & 3.2 respectively.

Median OS (months) for nVM for AI, SERD250, SERD500 & ‘all Ets combined’ was 24.2, 26.0, 35.4 & 25.4 respectively: for VM the figures were 22.8, 20.8, 26.4 & 22.0 respectively.Conclusions:1) In the 2nd line HR+ setting AI & Ful 250 both significantly increased PFS & OS in nVM versus VM. Longer PFS appears due to longer duration of control (DoCB) than increasing the number of patients responding (CBR).

2) Median OS for nVM ranged from 24 – 35 months versus 20.8-26.4 months for VM: for the majority of patients the 2nd line ET setting is not ‘immediately life threating’ and ET is therefore an option to consider.

3) These data on site of disease (nVM vs VM) contribute to the selection of which patients should receive endocrine mono- and which endocrine combination therapy (ie plus mTORi or CDK4/6i) in the second line setting.

Citation Format: Robertson JFR, Di Leo A, Johnston S, Chia S, Bliss J, Bradbury I, Campbell C. Meta-analyses of visceral versus non-visceral metastases treated by AI & SERD agents as 2nd line endocrine therapy (ET) for HR+ breast cancer (BC) [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 P4-13-13.

Abstract P4-13-11: Meta-analyses of visceral versus non-visceral metastases treated by SERM, AI & SERD agents as 1st line endocrine therapy (ET) for HR+ breast cancer (BC)

Introduction: There is continuing debate whether efficacy of ET is different in non-visceral metastases (nVM) than VM. Recently fulvestrant 500mg, has been reported to have greater efficacy than an aromatase inhibitor (AI), anastrozole, particularly in nVM – implying efficacy may be both site and agent dependent. Absence of significant overall survival (OS) difference in PALOMA 1 & 3 has increased interest in site of disease, especially given the OS advantage for fulvestrant 500mg monotherapy.

Patients & Methods: Individual patient level data was obtained from 7 randomised controlled trials (RCTs) involving SERM, AI & SERD used as 1st Line ET in known HR+ BC were used in this meta-analysis (MA). Five were Phase 3 double-blind, placebo controlled RCTs. Details of the studies, type of ET and patient numbers are shown in Table. All were rigorously assessed for clinical benefit rate (CBR), progression free survival (PFS), duration of clinical benefit (DoCB) and OS.: Details of the studies, types of ET and patient numbers are shown in the Table. Aa two stage MA IPD meta-analysis was used to analyse these outcomesCBR, PFS, OS & DoCB. Peto method for pooled odds ratios was used to calculate p values and CI for CBR, yYusef pPeto method was used to calculate p-values and CI for PFS, OS, and DoCB. Random effect for trial was included when Tarone's test for heterogeneity was significant, otherwise fixed effect models were generated.

Results:

Outcome data is present for each study and then summarised under SERM, AI, SERD and 'all Ets combined'. Odds Ratios (Ors) & Hazard Ratios (HRs) for VM versus nVM by endocrine agent are shown in the Table

ETStudyNo. of Pats.HR+ Pats.CBRPFSOSDoCBSERM(n)(n)OR (95%CIs)HR (95%CIs)HR (95%CIs)HR (95%CIs)TamEORTC1891781.410.850.770.95Tam00273281441.330.981.051.26Tam00301821622.800.590.440.79Tam00252742091.100.780.730.78subtotal9736931.53** (1.11-2.10)0.79** (0.67-0.94)0.70* (0.52-0.94)0.92 (0.72-1.18)AIExeEORTC1821680.841.110.731.02Ana00273401543.850.550.361.06Ana00301711510.970.881.140.82AnaFALCON2322321.070.980.831.05AnaFIRST1031030.970.540.510.53Subtotal10288081.28 (0.73-2.22)0.80 (0.60-1.06)0.66* (0.45-0.95)0.92 (0.74-1.14)SERDFul 500CONFIRM1621622.940.630.561.15Ful 500FALCON2302302.710.410.450.61Ful 500FIRST1021024.110.580.440.55Subtotal4944943.06*** (2.00-4.06)0.56*** (0.45-0.70)0.50*** (0.39-0.65)0.71* (0.53-0.91)Total249519981.66*** (1.37-2.02)0.73*** (0.62-0.86)0.61*** (0.53-0.71)0.87* (0.75-1.00)CBR-Clinical Benefit Rate (n)= number of patients, pvalues p&lt;0.05*, p&lt;0.01**, p&lt;0.001***

Conclusions: This is the largest reported individual patient MA for nVM versus VM in patients with known HR+ advanced BC and clinical outcomes (CBR, DoCB, PFS & OS) approved to regulatory standards.

1) nVM had significantly better clinical outcomes compared to VM when treated by anti-estrogen receptor blocking agents (SERM & SERD) but not when treated by Ais, which have a fundamentally different mechanism of action.

2) SERD (Fulvestrant 500mg) significantly increased all four clinical outcomes. For nVM compared to VM, fulvestrant put more patients into CB, kept them in remission (DoCB) for longer, resulting in 44% reduction in disease progression and a 50% reduction in death.

3) Site of metastases (ie nVM or VM) is one of the factors to consider when selecting patients for endocrine mono or combination ET (plus CDK4/6i) in the 1st Line setting.

Citation Format: Robertson JFR, Paridaens R, Bogaerts J, Lichfield J, Bradbury I, Campbell C. Meta-analyses of visceral versus non-visceral metastases treated by SERM, AI & SERD agents as 1st line endocrine therapy (ET) for HR+ breast cancer (BC) [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 P4-13-11.

Resin-modified glass ionomer cement vs composite for orthodontic bonding: A multicenter, single-blind, randomized controlled trial

INTRODUCTION

In this study, we aimed to compare the incidence of new demineralized lesions and bond failures between 2 groups of participants wearing fixed orthodontic appliances bonded with either light-cured resin-modified glass ionomer cement or light-cured composite.

METHODS

This trial was a multicenter (6 centers: 2 teaching hospitals, 4 specialist orthodontic practices), single-blinded, randomized controlled trial with 2 parallel groups. Patients aged 11 years or older, in the permanent dentition, and about to start fixed orthodontic treatment in these 6 centers were randomly allocated to have either resin-modified glass ionomer cement or light-cured composite for bonding brackets, forward of the first molars. Pretreatment and day-of-debond digital photographic images were taken of the teeth and assessed by up to 5 clinical and 3 lay assessors for the presence or absence of new demineralized lesions and the esthetic impact. The assessors were masked as to group allocation.

RESULTS

We randomized 210 participants, and 197 completed the trial. There were 173 with complete before-and after-digital images of the teeth. The incidence of new demineralized lesions was 24%; but when the esthetic impact was taken into account, this was considerably lower (9%). There was no statistically significant difference between the bracket adhesives in the numbers with at least 1 new demineralized lesion (risk ratio,1.25; 95% confidence interval, 0.74-2.13; P = 0.403) or first-time bracket failure (risk ratio,0.88; 95% confidence interval, 0.67-1.16; P = 0.35). There were no adverse effects.

CONCLUSIONS

There is no evidence that the use of resin modified glass ionomer cement over light-cured composite for bonding brackets reduces the incidence of new demineralized lesions or bond failures. There might be other reasons for using resin modified glass ionomer cement.

REGISTRATION

This trial was registered at ClinicalTrials.govNCT01925924.

PROTOCOL

The protocol is available from the corresponding author on request.

A Systematic Review of Health System Level Initiatives Promoting the Earlier Diagnosis of Cancer Among the Adult Population in High-Income Countries

Background: The increased burden of cancer has driven the development of health system level initiatives worldwide promoting early diagnosis. Although it is challenging to synthesize results of such complex, diverse initiatives, it is crucial to review the evidence to inform future programs and enhance transparency and accountability. Aim: We aimed to systematically review the literature on health system level initiatives promoting early diagnosis among the adult population, describing and categorizing their components, stakeholders, target populations, and outcomes. Methods: We have searched databases (including Embase, PsycInfo, Medline and ASSIA), Web sites (including charities, governmental and nongovernmental agencies) and reference lists of included studies and relevant systematic reviews for peer-reviewed publications and gray literature. We included quantitative, qualitative, mixed-methods studies and reviews/overviews about a single initiative in high-income countries as defined by the World Bank. We included initiatives: 1) targeting adults aged 18 or older; 2) aiming to promote early diagnosis; 3) addressing the patient/public and at least two more levels of contextual influence (according to a model of multilevel influences on cancer care); 4) implemented at a national level or equivalent. Study selection, quality assessment and data extraction were carried out independently by two reviewers. Narrative synthesis was used to analyze the findings. The review protocol has been published by BMJ Open and registered at PROSPERO (CRD42016047233). Results: Twenty initiatives from 10 countries were identified in 263 publications. Data were extracted from 104 core publications about 19 initiatives. It was possible to assess the quality of 35 core publications. Initiatives focused on fast-track for patients with alarm symptoms or other referral pathways for those with other symptoms or abnormal test results (n=11), national awareness campaigns for the public (n=4), and strategies with multiple components (n=4). Tools developed for professionals included referral guidelines and online referral systems. Initiatives focusing on referral pathways showed some improvements in diagnostic intervals, and limited evidence on the impact on staging. Performance targets were often not met. Results from awareness campaigns indicated improvement in awareness, but evidence about changes in health-seeking behavior was limited. Barriers and facilitators were described, including availability of specialist staff. Conclusion: Robustness of methods/outcomes could not always be assessed as several publications were reports or government documents. Evidence on the impact of initiatives regarding longer-term outcomes is limited. Described barriers and facilitators may help to inform future initiatives. Findings may be useful to researchers, policy makers, and governments developing early diagnosis programs and assessing cancer outcomes.

Use of Thermocoagulation Within a 'Screen and Treat' Cervical Cancer Screening Programme in Malawi: Outcomes at One Year, Professional Perspectives, and Client Experience

Background: Thermocoagulation (also known as thermoablation, previously as cold coagulation) is increasingly being adopted as an alternative treatment to cryotherapy within 'screen and treat' cervical screening services using visual inspection with acetic acid (VIA) in resource-constrained settings. This ablative treatment is suitable for low-grade squamous epithelial lesions. Given that much of the current systematic review evidence is drawn from high-income settings, it is critical that the evidence base for use within LMICs is strengthened. Aim: To evaluate the effectiveness of thermo-coagulation in the treatment of VIA-positive lesions within a 'screen and treat' program in Malawi, and its acceptability to clients and providers. Methods: Over the last four years, the Nkhoma Cervical Cancer Screening Program has implemented a 'screen and treat' approach using VIA and treatment using thermocoagulation in a rural district general hospital and associated health centers. Women with VIA-positive lesions are offered treatment with thermocoagulation; treated women are requested to return for review at three- six months, and at one year. Mechanisms to ensure monthly data collection and collation are in place. Semistructured qualitative face-to-face interviews were carried out in English with nineteen providers in nine health centers associated with Nkhoma Hospital: a range of issues were explored, including their experience with use of thermocoagulation. A patient experience questionnaire using validated facial pain scales was developed and translated into Chichewa: women complete this following treatment together with a patient attendant. Results: Between October 2013 and July 2017, over 1650 women have received treatment with thermocoagulation. Of a cohort of 446 treated women who had returned for a 1-year review visit by July 2017, 426 (95.5%) were VIA-negative, i.e., a treatment failure rate of < 5%, comparable with the international literature. Relationship between HIV status, initial VIA positivity, and treatment outcomes, will be presented. Staff reported professional satisfaction in being able to offer treatment consistently to VIA-positive clients, closer to their communities. For some, this was contrasted with previous experience of unavailable cryotherapy resulting in loss to treatment of patients. Over 120 women have completed pain scales questionnaires following treatment with the traditional machine, or with one of the two new hand-held models: their experiences (facial pain scales, and free-text comments) will be reported. Conclusion: In many low-resource settings, VIA-based screening with robust treatment protocols will remain central to cervical cancer control until the promise of HPV vaccination is fully realized. Thermocoagulation is an effective treatment modality, acceptable to clients and patients. Ongoing review of outcomes within and across treatment facilities is critical.

The Experience of Living With and Beyond Cancer With Comorbid Illness: A Qualitative Systematic Review

Background: There is a need to explore the needs of the growing number of people living with and beyond cancer with additional long term chronic conditions, with implications for cancer survivorship management and support. Aim: This review aims to identify the qualitative evidence on the experience of cancer and comorbid illness from the perspective of patients, carers and health care professionals to identify psycho-social support needs, experience of health care, and to highlight areas where more research is needed. Methods: PRISMA guidance was used to review the evidence. Relevant research databases were searched using an exhaustive list of search terms. Two reviewers independently screened titles and abstracts and discussed variations. Included articles were subject to quality appraisal before data extraction of article characteristics and findings. Thematic synthesis of extracted findings was undertaken following Thomas and Harden's prescribed method. Results: 29 articles were included in the review covering a range of cancer types and comorbid conditions; with varying time since cancer diagnosis and apparent severity of disease for both cancer and other conditions. Studies are set in developed countries and include the views of patients and professionals but not carers. Few studies focused exclusively on the experience of living with comorbid conditions alongside cancer. Key themes identified included: the interaction between cancer and comorbid conditions; the added symptom burden; illness identities and ageing; self-management; prioritizing conditions, and treatment decision-making. Conclusion: In addition to a better understanding of the complex experience of such illness to illuminate developing models of patient-centered care, the review will combine with patient engagement work to inform an interview study with the defined patient group.

Second Primary Cancers (SPC): A Mixed-Methods Systematic Review of Pathways to Diagnosis and a National Linkage Study in Scotland to Understand Survival Outcomes Following an SPC Diagnosis

Background: As an increasing proportion of patients survive an initial cancer, the number who develop a second primary cancer (SPC) is also increasing. Aim: To examine the pathways to diagnosis of an SPC and the associated patients' and health practitioners' experiences, and survival outcomes following an SPC diagnosis. Methods: We conducted a systematic review to examine the pathways to diagnosis and associated patient and healthcare practitioners' experiences. Ten electronic databases were searched with no date or language restrictions. Two reviewers independently screened titles, abstracts and full-texts, and did the data extraction and quality assessment of the included studies. Secondary data analysis examined the survival outcomes following an SPC diagnosis. This involved three linked databases: the Scottish Cancer Registry, episode level data on hospital inpatient and day case discharges, and the National Register of Scotland death records. We included patients aged 18+, diagnosed with a first primary cancer (FPC) between 01.01.1980 and 31.12.2010 and subsequently diagnosed with an SPC (> 60 days following a FPC). The cases were matched for age, gender and cancer type to controls (individuals diagnosed with an FPC only within the same 5-year period). Descriptive statistics, survival analysis and Cox proportional hazard model were done. Results: Forty-nine articles were included in the review. The most commonly reported SPCs were breast, lung, colorectal, and melanoma. All included studies reported on the mode of detection of the SPC (30 symptomatic presentation, 18 screen detected, 34 other modes). The routes to detection (whether the SPC was diagnosed during routine follow-up/surveillance, or self-referral) varied by cancer type. Only two studies described provider experiences of diagnosis of an SPC; no study reported on the patients' experiences. The secondary data analysis included 37,193 people diagnosed with an SPC (51.6% females and 48.3% male). The proportion of SPC among people diagnosed with a FPC within a 5-year period ranged between 2.3% (1980-1985) and 31.2% (2006-2010). Trachea, bronchus and lung cancer (21.3%), colorectal cancer (13.9%), breast (12.9%) and prostate (7.3%) were the most frequently diagnosed SPCs in this population. These four cancers also accounted for the highest number of deaths in both sexes. Compared with people diagnosed with FPC (390 days: IQR 14-1825 days), those diagnosed with SPC had shorter median survival days (379 days: IQR 17-1825 days), which was statistically significant ( P = 0.001, X24df=163.2). Conclusion: The review provides early insights into diagnosis of an SPC. While it has identified that there is a dearth of quantitative and qualitative evidence on the pathways to diagnosis of an SPC, the secondary data analysis partly fills the gap, and has important implications for surveillance in both primary and secondary care, and secondary prevention and early detection.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.