Recurrent primary scrotal extramammary Paget disease: a case report and literature review

Extramammary Paget disease (EMPD) is a rare malignant neoplasm arising in apocrine gland-rich skin, which may be classified as either of primary or secondary origin. Management of this condition is predominantly surgical, and is often characterised by lengthy diagnostic delays. Complete surgical excision is challenging, and local recurrence is common. Herein, we discuss a subtle presentation of recurrent scrotal EMPD in a 77-year-old male and review the available literature. Although relatively rare, the indistinct nature of this pathology merits special attention from treating surgeons, who are frequently responsible for initial management and follow-up. The risk of distant metastasis and concomitant prognostic implications necessitate a high clinical index of suspicion, and low threshold for definitive biopsy in similar cases.

Di-valent siRNA-mediated silencing of MSH3 blocks somatic repeat expansion in mouse models of Huntington's disease

Huntington's disease (HD) is a severe neurodegenerative disorder caused by the expansion of the CAG trinucleotide repeat tract in the huntingtin gene. Inheritance of expanded CAG repeats is needed for HD manifestation, but further somatic expansion of the repeat tract in non-dividing cells, particularly striatal neurons, hastens disease onset. Called somatic repeat expansion, this process is mediated by the mismatch repair (MMR) pathway. Among MMR components identified as modifiers of HD onset, MutS homolog 3 (MSH3) has emerged as a potentially safe and effective target for therapeutic intervention. Here, we identify a fully chemically modified short interfering RNA (siRNA) that robustly silences Msh3 in vitro and in vivo. When synthesized in a di-valent scaffold, siRNA-mediated silencing of Msh3 effectively blocked CAG-repeat expansion in the striatum of two HD mouse models without affecting tumor-associated microsatellite instability or mRNA expression of other MMR genes. Our findings establish a promising treatment approach for patients with HD and other repeat expansion diseases.

Effects of color-enhancing glasses on color vision in congenital red-green color deficiencies

As commercially available glasses for color vision deficiency (CVD) are classified as low risk, they are not subject to stringent marketing regulations. We investigate how EnChroma and VINO glasses affect performance on the Colour Assessment and Diagnosis (CAD) test in individuals with CVD. Data were obtained from 51 individuals with red-green CVD. Blood or saliva samples were collected to examine the structure of the OPN1LW/OPN1MW array. Individuals completed the CAD test twice without glasses and once with each pair of glasses. Although there was a statistically significant effect of both glasses, only that of VINO could be considered functionally meaningful.

Theoretical versus empirical measures of retinal magnification for scaling AOSLO images

The adaptive optics scanning light ophthalmoscope (AOSLO) allows cellular resolution imaging of the living retina. The accuracy of many quantitative measurements made from these images requires accurate estimates of the lateral scale of the images. Here, we used trial lenses, which are known to affect the relative magnification of the retinal image, to compare empirical measures of image scale with theoretical estimates from a four-surface optical model. The theoretical optical model overestimated the empirically determined change in image scale in 70% of the subjects examined, albeit to varying degrees. While the origin for the differences between subjects is not known, residual accommodation during imaging likely contributes to this variability in retinal magnification. These data provide an opportunity to derive improved lateral scaling error estimates for structural metrics extracted from AOSLO retinal images.

Erratum: Azimuthal Anisotropy of K_{S}^{0} and Λ+Λ[over ¯] Production at Midrapidity from Au+Au Collisions at sqrt[s]_{NN}=130 GeV [Phys. Rev. Lett. 89, 132301 (2002)]

This corrects the article DOI: 10.1103/PhysRevLett.89.132301.

Erratum: Azimuthal Anisotropy at the Relativistic Heavy Ion Collider: The First and Fourth Harmonics [Phys. Rev. Lett. 92, 062301 (2004)]

This corrects the article DOI: 10.1103/PhysRevLett.92.062301.

Evaluation of a Hyperbaric Oxygen Therapy Intervention in Individuals with Fibromyalgia

OBJECTIVE

To evaluate the feasibility and safety of hyperbaric oxygen therapy (HBOT) in patients with fibromyalgia (FM).

DESIGN

A cohort study with a delayed treatment arm used as a comparator.

SETTING

Hyperbaric Medicine Unit, Toronto General Hospital, Ontario, Canada.

SUBJECTS

Eighteen patients diagnosed with FM according to the American College of Rheumatology and a score ≥60 on the Revised Fibromyalgia Impact Questionnaire.

METHODS

Participants were randomized to receive immediate HBOT intervention (n = 9) or HBOT after a 12-week waiting period (n = 9). HBOT was delivered at 100% oxygen at 2.0 atmospheres per session, 5 days per week, for 8 weeks. Safety was evaluated by the frequency and severity of adverse effects reported by patients. Feasibility was assessed by recruitment, retention, and HBOT compliance rates. Both groups were assessed at baseline, after HBOT intervention, and at 3 months' follow-up. Validated assessment tools were used to evaluate pain, psychological variables, fatigue, and sleep quality.

RESULTS

A total of 17 patients completed the study. One patient withdrew after randomization. HBOT-related adverse events included mild middle-ear barotrauma in three patients and new-onset myopia in four patients. The efficacy of HBOT was evident in most of the outcomes in both groups. This improvement was sustained at 3-month follow-up assessment.

CONCLUSION

HBOT appears to be feasible and safe for individuals with FM. It is also associated with improved global functioning, reduced symptoms of anxiety and depression, and improved quality of sleep that was sustained at 3-month follow-up assessment.

Measurement of the Positive Muon Anomalous Magnetic Moment to 0.46 ppm

We present the first results of the Fermilab National Accelerator Laboratory (FNAL) Muon g-2 Experiment for the positive muon magnetic anomaly a_{μ}≡(g_{μ}-2)/2. The anomaly is determined from the precision measurements of two angular frequencies. Intensity variation of high-energy positrons from muon decays directly encodes the difference frequency ω_{a} between the spin-precession and cyclotron frequencies for polarized muons in a magnetic storage ring. The storage ring magnetic field is measured using nuclear magnetic resonance probes calibrated in terms of the equivalent proton spin precession frequency ω[over ˜]_{p}^{'} in a spherical water sample at 34.7 °C. The ratio ω_{a}/ω[over ˜]_{p}^{'}, together with known fundamental constants, determines a_{μ}(FNAL)=116 592 040(54)×10^{-11} (0.46 ppm). The result is 3.3 standard deviations greater than the standard model prediction and is in excellent agreement with the previous Brookhaven National Laboratory (BNL) E821 measurement. After combination with previous measurements of both μ^{+} and μ^{-}, the new experimental average of a_{μ}(Exp)=116 592 061(41)×10^{-11} (0.35 ppm) increases the tension between experiment and theory to 4.2 standard deviations.

137 Specialist Medication Review as Part of the Comprehensive Geriatric Assessment in the Day Hospital Setting

Introduction

Medication use in older people is complex. Consequently, regular medication reviews as an integral part of healthcare provision for older people are necessary. Patients attending consultant-led, multidisciplinary, day hospital clinics have specialist medication reviews undertaken by our senior clinical pharmacist. “Pharmacy Interventions” (PIs) are suggested and typed prior to physician-led patient review.

Method

Data collected by our senior clinical pharmacist were reviewed including patient demographics, clinical characteristics, types of prescribed drugs and PIs. Clinical severity of PIs was assessed using the NCC MERP Medication error index and American Journal Health-Syst Pharm Medication error index. Scores, ranging in clinical severity from A-I (A = capacity to cause error, I = may have contributed to death) and 0–10 (0 = no potential effect, 10 = death) were assigned by the pharmacist and two physicians.

Results

100 patients were included, mean age 82y (range 65-99y). 62% were female and 63% were first time attenders. Mean number of regularly prescribed medications was 7.2 (range 1–16), 10% reported compliance issues. The most commonly prescribed drugs belonged to the “Alimentary tract and metabolism” class (24%), including PPIs, laxatives and blood-glucose lowering medications. 16% and 15% were on regularly prescribed neuroactive and psychoactive medications, respectively. Of suggested PIs, 46% were acted upon during physician review, a further 4% were acknowledged in clinical notes. PIs covered many prescribing issues including drug–drug interactions, incorrect dosing, drug monitoring and administration timing. The average PI scores assigned by the pharmacist, physicians 1 and 2 differed, at 6.4, 3.2 and 4.8, respectively.

Conclusion

PIs suggested at senior pharmacy level are an important component of the comprehensive geriatric assessment, highlighting multiple complex prescribing issues. Clinical severity of PIs was scored lower by physicians, perhaps indicating an underestimation of prescribing errors. Senior pharmacy involvement in the care of frail older outpatients is an invaluable resource.

Zinc Source and Concentration Altered Physiological Responses of Beef Heifers during a Combined Viral-Bacterial Respiratory Challenge

Simple Summary

Bovine respiratory disease is one of the greatest health challenges cattle producers face and is most commonly treated with antibiotics. With the current push to reduce the use of antibiotics in livestock production, producers are looking at non-pharmaceutical alternatives such as nutritional supplements. This study aimed to determine if different forms of zinc supplementation could reduce some of the negative health effects associated with bovine respiratory disease. Overall, cattle supplemented with ZinMet (zinc methionine/organic zinc) responded better during the disease as evidenced by blood parameters, decreased lesion severity, and decreased fever. Conversely, cattle fed a large dose of zinc sulfate (inorganic zinc) displayed a higher fever and blood parameters that indicated a greater sickness response. Findings from this study suggest that the type and amount of zinc fed to cattle may influence their response to bovine respiratory disease.

Abstract

To determine the effects of zinc supplementation on the immune response to a combined viral-bacterial respiratory disease challenge, thirty-two beef heifers (255 ± 15 kg) were subjected to a 30-d period of Zn depletion, then randomly assigned to one of three treatment diets fed for 30 d before the challenge: (1) supplementation with 100 mg of Zn from Zn sulfate/kg of DM (Zn100), (2) supplementation with 200 mg of Zn from Zn sulfate/kg of DM (Zn200), and (3) supplementation with 80 mg of Zn/kg of DM from zinc methionine and 20 mg of Zn from Zn sulfate/kg of DM (ZinMet). After the 30-d supplementation period, all heifers were fitted with indwelling vaginal temperature (VT) devices and intra-nasally challenged with 1 × 10⁸ PFU bovine herpesvirus-1 on d -3, and then allowed to rest in outdoor pens for 3 d. On d 0, each heifer was challenged intra-tracheally with an average dose of 2.38 × 10⁷ CFU Mannheimia haemolytica (MH), fitted with an indwelling jugular catheter, and then moved into individual stalls in an environmentally-controlled enclosed barn. Whole blood samples were collected at 1-h (serum) and 2-h (complete blood counts) intervals from 0 to 8 h, and at 12, 24, 36, 48, 60, 72, 168, and 360 h relative to MH challenge. Data were analyzed using the MIXED procedure of SAS specific for repeated measures with fixed effects of treatment, time, and their interaction. There was a treatment effect (p < 0.01) for VT such that Zn200 heifers had greater VT than Zn100 and ZinMet heifers. There was a trend (p = 0.10) for a serum cortisol treatment effect with Zn100 heifers having greater cortisol than ZinMet heifers. Total leukocytes and lymphocytes were greater (p ≤ 0.01) in Zn100 heifers than Zn200 and ZinMet heifers, whereas monocytes were less (p = 0.05) in ZinMet heifers than Zn100 and Zn200 heifers. Concentrations of IL-6 were greater (p = 0.02) in ZinMet heifers than Zn100 and Zn200 heifers. Concentrations of IFN-γ were greater in Zn200 heifers than ZinMet heifers at 0 h, and Zn100 heifers from 0 to 12 h post-MH challenge (treatment x time p = 0.02). Serum haptoglobin was not affected by treatment or treatment x time (p ≥ 0.36) but increased over time (p < 0.01) in all groups. There was a trend (p = 0.11) for ZinMet heifers to have less severe nasal lesion scores than Zn100 heifers. The observed differential physiological responses in this study indicate that zinc source and concentration may alter the response to a bovine respiratory challenge in heifers.

Hyperbaric oxygen and focused rehabilitation program: a feasibility study in improving upper limb motor function after stroke

Neuroplasticity and recovery after stroke can be enhanced by a rehabilitation program pertinent to upper limb motor function exercise and mental imagery (EMI) as well as hyperbaric oxygen therapy (HBOT). We assessed feasibility and safety of the combined approach utilizing both HBOT and EMI, and to derive preliminary estimates of its efficacy. In this randomized controlled trial, 27 patients with upper extremity hemiparesis at 3-48 months after stroke were randomized to receive either a complementary rehabilitation program of HBOT-EMI (intervention group), or EMI alone (control group). Feasibility and safety were assessed as total session attendance, duration of sessions, attrition rates, missing data, and intervention-related adverse events. Secondary clinical outcomes were assessed with both objective tools and self-reported measures at baseline, 8 weeks (end of treatment), and 12-weeks follow-up. Session attendance, duration, and attrition rate did not differ between the groups; there were no serious adverse events. Compared with baseline, there were significant sustained improvements of objective and subjective outcomes' measures in the intervention group, and a single improvement in an objective measure in the control group. Between-group outcome comparisons were not statistically significant. This study demonstrated that the combination HBOT-EMI was a safe and feasible approach in patients recovering from chronic stroke. There were also trends for improved motor function of the affected upper limb after the treatments. ClinicalTrials.gov registration no.: NCT02666469. Novelty HBOT combined with an upper limb exercise and mental imagery rehabilitation program is feasible and safe in chronic stroke patients. This combined approach showed trends for improved functional recovery.

Abstract P5-05-03: Estrogen receptor beta elicits anti-cancer effects in triple negative breast cancer through suppression of NFκB signaling

Background: Triple Negative Breast Cancer (TNBC) affects approximately 15-20% of BC patients, yet accounts for a disproportionately higher rate of BC morbidity and mortality, in part due to lack of targeted therapies. Using well-validated antibodies, Estrogen Receptor Beta (ERβ) protein has been shown to be expressed in approximately 25% of TNBCs and is associated with improved patient outcomes. Using multiple ERβ +/- TNBC cell lines and PDX models, we have demonstrated that ligand-mediated activation of ERβ by estradiol (E2) decreases cell proliferation, invasion, and migration in vitro, as well as primary tumor growth and metastatic spread in vivo.

Methods: To determine the mechanisms by which ERβ elicits these anti-cancer effects, we elucidated the ERβ transcriptome and cistrome via Microarray and ChIPseq, respectively, in TNBC cells stably expressing ERβ in a doxycycline-inducible manner. We also performed gene expression and luciferase assays to assess the impact of ERβ on NFκB signaling, followed by ChIP-PCR and ChIPseq to assess how ERβ modifies chromatin architecture near NFκB target genes.

Results: Pathway analysis of ERβ-regulated genes identified NFκB signaling as one of the most suppressed pathways in response to E2 treatment. Indeed, numerous NFκB target genes were among the most down-regulated genes following E2 treatment but only in the presence of ERβ expression. Chromatin Immunoprecipitation followed by sequencing (ChIPseq) revealed that ERβ primarily associated with estrogen response elements (EREs), but was also enriched around NFκB binding sites following E2 treatment. In fact, 12% of all ERβ binding sites were enriched for NFκB response elements and ERβ was shown to physically associate with NFκB protein. Using an NFκB reporter construct and qPCR, ERβ was shown to block TNFα-mediated induction of NFκB signaling and NFκB target gene expression. Globally, RNAseq identified 200 genes to be significantly regulated by TNFα in TNBC cells, of which 81 were significantly altered in the presence of E2+TNFα. ChIPseq demonstrated that ligand-mediated activation of ERβ significantly diminished an activating histone mark (H3K27Ac) at many of these NFκB target genes while enhancing a repressive mark (H3K27Me3). These modifications are also associated with recruitment of the histone methyltransferase, EZH2, to enhancer elements of these NFκB target genes. Drug-mediated blockade of HDAC and EZH2 activity reversed suppression of NFκB target gene expression by ERβ.

Conclusions: Our data suggest that ERβ may elicit its anti-cancer effects in part via formation of a novel co-repressor complex consisting of ERβ, NFκB, and EZH2. These data are in keeping with prior observations of the importance of NFκB signaling as it relates to TNBC cell proliferation and invasion, and that decreased expression of NFκB target genes is associated with improved outcomes in TNBC patients. Currently, a Mayo Breast SPORE prospective study is underway to investigate the role of estradiol in ERβ expressing TNBC and to further evaluate the cross-talk between ERβ and NFκB signaling in TNBC.

Citation Format: Aspros K, Nelson A, Ye Z, Sun Z, Chernukhin I, Carroll J, Ingle J, Goetz M, Hawse J. Estrogen receptor beta elicits anti-cancer effects in triple negative breast cancer through suppression of NFκB signaling [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 P5-05-03.

A Phase II Study of Pembrolizumab in EGFR-Mutant, PD-L1+, Tyrosine Kinase Inhibitor Naïve Patients With Advanced NSCLC

BACKGROUND

Despite the significant antitumor activity of pembrolizumab in NSCLC, clinical benefit has been less frequently observed in patients whose tumors harbor EGFR mutations compared to EGFR wild-type patients. Our single-center experience on the KEYNOTE-001 trial suggested that pembrolizumab-treated EGFR-mutant patients, who were tyrosine kinase inhibitor (TKI) naïve, had superior clinical outcomes to those previously treated with a TKI. As TKI naïve EGFR-mutants have generally been excluded from pembrolizumab studies, data to guide treatment decisions in this patient population is lacking, particularly in patients with programmed death ligand 1 (PD-L1) expression ≥50%.

METHODS

We conducted a phase II trial (NCT02879994) of pembrolizumab in TKI naive patients with EGFR mutation-positive, advanced NSCLC and PD-L1-positive (≥1%, 22C3 antibody) tumors. Pembrolizumab was administered 200 mg every 3 weeks. The primary endpoint was objective response rate. Secondary endpoints included safety of pembrolizumab, additional pembrolizumab efficacy endpoints, and efficacy and safety of an EGFR TKI after pembrolizumab.

RESULTS

Enrollment was ceased due to lack of efficacy after 11 of 25 planned patients were treated. Eighty-two percent of trial patients were treatment naïve, 64% had sensitizing EGFR mutations, and 73% had PD-L1 expression ≥50%. Only 1 patient had an objective response (9%), but repeat analysis of this patient's tumor definitively showed the original report of an EGFR mutation to be erroneous. Observed treatment-related adverse events were similar to prior experience with pembrolizumab, but two deaths within 6 months of enrollment, including one attributed to pneumonitis, were of concern.

CONCLUSIONS

Pembrolizumab's lack of efficacy in TKI naïve, PD-L1+, EGFR-mutant patients with advanced NSCLC, including those with PD-L1 expression ≥50%, suggests that it is not an appropriate therapeutic choice in this setting.

Abstract PD4-04: Combined inhibition of mTOR and CDK4/6 is required for optimal blockade of E2F function and long term growth inhibition in estrogen receptor positive breast cancer

The cyclin dependent kinase (CDK) –retinoblastoma (RB) -E2F pathway plays a critical role in the control of cell cycle in estrogen receptor positive (ER+) breast cancer. Small molecule inhibitors of CDK4/6 have shown promise in this tumour type in combination with hormonal therapies, reflecting the particular dependence of this subtype of cancer on cyclin D1 and E2F transcription factors. mTOR inhibitors have also shown potential in clinical trials in this disease setting. Recent data has suggested cooperation between the phosphatidylinositol 3-kinase (PI3K) pathway and CDK4/6 inhibition in preventing early adaptation and eliciting growth arrest, but the mechanisms of the interplay between these pathways have not been fully elucidated. Here we show that profound and durable inhibition of ER+ breast cancer growth is likely to require multiple hits on E2F mediated transcription. We demonstrate that inhibition of mTOR using the mTORC1/2 inhibitor vistusertib at 300nM causes a &gt;50% decrease in cyclin D1 protein levels and RB phosphorylation in three cell lines. At these concentrations, vistusertib treatment also elicits marked effects on E2F mediated transcription, causing changes in the mRNA levels of 28 out of 43 (65%) of a selected set of E2F target genes.Combined inhibition of mTOR, CDK4/6 and ER delivers profound and durable regressions in breast cancer cell lines and xenografts (110.2% tumour growth inhibition at day 48). In vivo data show, that over a period of 58 days, tumours failed to re-grow in the presence of the triplet combination compared to either agent alone, suggesting, that the triplet is necessary to maintain growth inhibition. Furthermore, we show that CDK4/6 inhibitor resistant cell lines re-activate the CDK-RB-E2F pathway, but remain sensitive to mTOR inhibition (EC50 52.7 nM in parental cells vs 39.6-73.3 nM in a number of palbociclib resistant cell populations), suggesting that mTORC1/2 inhibitors may represent an option for patients that have relapsed on CDK4/6 therapy. A Phase I study (PASTOR) combining the dual TOR kinase inhibitor Vistusertib with Palbociclib, and Fulvestrant is underway to explore safety and efficacy of the triplet combination in patients with metastatic breast cancer.

Citation Format: Oelmann E, Michaloglou C, Crafter C, Siersbaek R, Delpuech O, Curven J, Carnevalli L, Staniszweska A, Polanska U, Cheraghchi-Bashi A, Lawson M, Chernukhin I, McEwen R, Carroll J, Cosulich S. Combined inhibition of mTOR and CDK4/6 is required for optimal blockade of E2F function and long term growth inhibition in estrogen receptor positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD4-04.

Intracerebral Xenotransplantation of GFP Mouse Bone Marrow Stromal Cells in Intact and Stroke Rat Brain: Graft Survival and Immunologic Response

The present study characterized survival and immunologic response of bone marrow stromal cells (BMSCs) following transplantation into intact and stroke brains. In the first study, intrastriatal transplantation of BMSC (60,000 in 3 μl) or vehicle was performed in normal adult Sprague-Dawley male rats that subsequently received daily cyclosporin A (CsA, 10 mg/kg, IP in 3 ml) or vehicle (olive oil, similar volume) starting on day of surgery up to 3 days posttransplantation. Animals were euthanized at 3 or 30 days posttransplantation and brains were processed either for green fluorescent protein (GFP) microscopy or flow cytometry (FACS). Both GFP epifluorescence and FACS scanning revealed GFP+ BMSCs in both groups of transplanted rats with or without CsA, although significantly increased (1.6- to 3-fold more) survival of GFP+ BMSCs was observed in the immunosuppressed animals. Further histologic examination revealed widespread dispersal of BMSCs away from the graft core accompanied by many long outgrowth processes in non-CsA-transplanted animals, whereas a very dense graft core, with cells expressing only sporadic short outgrowth processes, was observed in CsA-transplanted animals. There were no detectable GFP+ BMSCs in nontrans-planted rats that received CsA or vehicle. Immunologic response via FACS analysis revealed a decreased presence of cytotoxic cells, characterized by near complete absence of CD8+ cells, and lack of activation depicted by low CD69 expression in CsA-treated transplanted animals. In contrast, elevated levels of CD8+ cells and increased activation of CD69 expression were observed in transplanted animals that received vehicle alone. CD4+ helper cells were almost nondetectable in transplanted rats that received CsA, but also only minimally elevated in transplanted rats that received vehicle. Nontransplanted rats that received either CsA or vehicle displayed very minimal detectable levels of all three lymphocyte markers. In the second study, a new set of male Sprague-Dawley rats initially received bilateral stereotaxic intrastriatal transplantation of BMSCs and 3 days after were subjected to unilateral transient occlusion of middle cerebral artery. The animals were allowed to survive for 3 days after stroke without CsA immunosuppression. Epifluorescence microscopy revealed significantly higher (5-fold more) survival of transplanted GFP+ BMSCs in the stroke striatum compared with the intact striatum. The majority of the grafts remained within the original dorsal striatal transplant site, characterized by no obvious migration in intact striatum, but with long-distance migration along the ischemic penumbra in the stroke striatum. Moreover, FACS scanning analyses revealed low levels of immunologic response of grafted BMSCs in both stroke and intact striata. These results, taken together, suggest that xenotransplantation of mouse BMSCs into adult rats is feasible. Immunosuppression therapy can enhance xenograft survival and reduce graft-induced immunologic response; however, in the acute phase posttransplantation, BMSCs can survive in intact and stroke brain, and may even exhibit long-distance migration and increased outgrowth processes without immunosuppression.

The role of family physicians in cancer care: perspectives of primary and specialty care providers

BACKGROUND

Currently, the specific role of family physicians (fps) in the care of people with cancer is not well defined. Our goal was to explore physician perspectives and contextual factors related to the coordination of cancer care and the role of fps.

METHODS

Using a constructivist grounded theory approach, we conducted telephone interviews with 58 primary and cancer specialist health care providers from across Canada.

RESULTS

The participants-21 fps, 15 surgeons, 12 medical oncologists, 6 radiation oncologists, and 4 general practitioners in oncology-were asked to describe both the role that fps currently play and the role that, in their opinion, fps should play in the future care of cancer patients across the cancer continuum. Participants identified 3 key roles: coordinating cancer care, managing comorbidities, and providing psychosocial care to patients and their families. However, fps and specialists discussed many challenges that prevent fps from fully performing those roles: ■ The fps described communication problems resulting from not being kept "in the loop" because they weren't copied on patient reports and also the lack of clearly defined roles for all the various health care providers involved in providing care to cancer patients.■ The specialists expressed concerns about a lack of patient access to fp care, leaving specialists to fill the care gaps. The fps and specialists both recommended additional training and education for fps in survivorship care, cancer screening, genetic testing, and new cancer treatments.

CONCLUSIONS

Better communication, more collaboration, and further education are needed to enhance the role of fps in the care of cancer patients.

Family History-Taking in Paediatrics: It’s Much More Than Just A Checklist

BACKGROUND: Family history (FH) is a risk factor for many conditions in pediatric practice; interest has increased in supporting systematic FH taking in this area by identifying core conditions for enquiry and developing point of care tools. There is little published about current practice to inform implementing such changes.

OBJECTIVES: To inform future FH taking interventions by identifying pediatricians' perceptions, attitudes, beliefs, and current practices.

DESIGN/METHODS: The Theoretical Domains Framework (TDF) was used to develop a comprehensive interview scheme. Semi-structured interviews were conducted with community and hospital-based pediatricians Analysis was by the constant comparison method, using a thematic approach. This study was funded by the Canadian Institutes of Health Research.

RESULTS: The data revealed FH taking to be a firmly embedded, but complex aspect of pediatric practice. Participants described FH as part of regular, holistic care, extending to social and interpersonal, as well as clinical purposes; in addition to disease risk assessment, FH information helped clarify diagnosis, and select medication; tailor the overall patient management based on family circumstances; and provide psychosocial support for parents. It was also used as a method to build a relationship with parents/carers. FH and social history information were inextricably linked and often appeared to be the same concept in participants’ minds. Participating pediatricians generally expressed confidence in their FH skills and reported tailoring their approach according to experience, after initial training early in their career. While acknowledging some challenges in ensuring accuracy, they were attuned to nuances in their interactions with parents and children which would affect whether, and what, they were told about illness in the family. Most were not concerned about formal evidence, and would not change their practice except for “good reason”.

CONCLUSION: The use of the TDF helped ensure a comprehensive approach to FH taking in pediatric practice. The findings suggest that FH taking in this setting is a complex activity, embedded in routine care. Recommendations for systematic enquiry about specific conditions cannot be seen as a simple additional activity to current practice. Efforts to make FH taking more systematic may founder if they fail to take into account pediatricians’ attitudes, perspectives, and practices. Further studies should explore and seek to confirm and expand our observations.

Effectiveness of platelet inhibition on major adverse cardiac events in non-cardiac surgery after percutaneous coronary intervention: a prospective cohort study

BACKGROUND

Platelet inhibition is mandatory therapy after percutaneous coronary intervention (PCI). Withdrawal of oral antiplatelet agents has been linked to increased incidence of postoperative adverse cardiac events in post-PCI patients having non-cardiac surgery (NCS). There is limited knowledge of temporal changes in platelet inhibition in this high-risk surgical population. We therefore performed a multicentre prospective cohort study evaluating perioperative platelet function and its association with postoperative major adverse cardiac events (MACE).

METHODS

In 201 post-PCI patients having NCS, we assessed the association between platelet function and postoperative MACE. We performed perioperative platelet function testing using a platelet mapping assay (PMA). Troponin-I was measured every 8 h for 2 days, then daily until day 5. Myocardial infarction was assessed using the third universal definition. We used multivariable logistic regression to assess the association between platelet inhibition and MACE.

RESULTS

Major adverse cardiac events occurred in 40 patients within 30 days of surgery. Thirty-two of these events were non-ST-elevation myocardial infarction, four ST-elevation myocardial infarction, and four exacerbation of congestive heart failure. We were unable to show an association between platelet inhibition and MACE. The PMA showed declining levels of platelet inhibition the longer the antiplatelet therapy was withheld before surgery. Logistic regression did not show an association between preoperative platelet function or the type of stent and MACE. We found an increased cardiac risk of MACE after surgery within 6 weeks of PCI.

CONCLUSIONS

The incidence of MACE in patients undergoing NCS after previous PCI is high in spite of adequate perioperative antiplatelet therapy.

CLINICAL TRIAL REGISTRATION

NCT 01707459 (registered at http://www.clinicaltrials.gov).