Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data

PURPOSE

Health service use is most intensive in the final year of a person's life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients' use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage.

METHODS

Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017.

RESULTS

A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month.

CONCLUSION

This study identifies two important primary care processes-home visits and anticipatory medication-associated with reduced hospital usage and intervention at the end of life.

GABAB receptors induce phasic release from medial habenula terminals through activity-dependent recruitment of release-ready vesicles

GABAB receptor (GBR) activation inhibits neurotransmitter release in axon terminals in the brain, except in medial habenula (MHb) terminals, which show robust potentiation. However, mechanisms underlying this enigmatic potentiation remain elusive. Here, we report that GBR activation on MHb terminals induces an activity-dependent transition from a facilitating, tonic to a depressing, phasic neurotransmitter release mode. This transition is accompanied by a 4.1-fold increase in readily releasable vesicle pool (RRP) size and a 3.5-fold increase of docked synaptic vesicles (SVs) at the presynaptic active zone (AZ). Strikingly, the depressing phasic release exhibits looser coupling distance than the tonic release. Furthermore, the tonic and phasic release are selectively affected by deletion of synaptoporin (SPO) and Ca2+-dependent activator protein for secretion 2 (CAPS2), respectively. SPO modulates augmentation, the short-term plasticity associated with tonic release, and CAPS2 retains the increased RRP for initial responses in phasic response trains. The cytosolic protein CAPS2 showed a SV-associated distribution similar to the vesicular transmembrane protein SPO, and they were colocalized in the same terminals. We developed the "Flash and Freeze-fracture" method, and revealed the release of SPO-associated vesicles in both tonic and phasic modes and activity-dependent recruitment of CAPS2 to the AZ during phasic release, which lasted several minutes. Overall, these results indicate that GBR activation translocates CAPS2 to the AZ along with the fusion of CAPS2-associated SVs, contributing to persistency of the RRP increase. Thus, we identified structural and molecular mechanisms underlying tonic and phasic neurotransmitter release and their transition by GBR activation in MHb terminals.

Pre- and postsynaptic nanostructures increase in size and complexity after induction of long-term potentiation

Synapses, specialized contact sites between neurons, are the fundamental elements of neuronal information transfer. Synaptic plasticity involves changes in synaptic morphology and the number of neurotransmitter receptors, and is thought to underlie learning and memory. However, it is not clear how these structural and functional changes are connected. We utilized time-lapse super-resolution STED microscopy of organotypic hippocampal brain slices and cultured neurons to visualize structural changes of the synaptic nano-organization of the postsynaptic scaffolding protein PSD95, the presynaptic scaffolding protein Bassoon, and the GluA2 subunit of AMPA receptors by chemically induced long-term potentiation (cLTP) at the level of single synapses. We found that the nano-organization of all three proteins increased in complexity and size after cLTP induction. The increase was largely synchronous, peaking at ∼60 min after stimulation. Therefore, both the size and complexity of individual pre- and post-synaptic nanostructures serve as substrates for tuning and determining synaptic strength.

Nedd4-2-dependent regulation of astrocytic Kir4.1 and Connexin43 controls neuronal network activity

Nedd4-2 is an E3 ubiquitin ligase in which missense mutation is related to familial epilepsy, indicating its critical role in regulating neuronal network activity. However, Nedd4-2 substrates involved in neuronal network function have yet to be identified. Using mouse lines lacking Nedd4-1 and Nedd4-2, we identified astrocytic channel proteins inwardly rectifying K+ channel 4.1 (Kir4.1) and Connexin43 as Nedd4-2 substrates. We found that the expression of Kir4.1 and Connexin43 is increased upon conditional deletion of Nedd4-2 in astrocytes, leading to an elevation of astrocytic membrane ion permeability and gap junction activity, with a consequent reduction of γ-oscillatory neuronal network activity. Interestingly, our biochemical data demonstrate that missense mutations found in familial epileptic patients produce gain-of-function of the Nedd4-2 gene product. Our data reveal a process of coordinated astrocytic ion channel proteostasis that controls astrocyte function and astrocyte-dependent neuronal network activity and elucidate a potential mechanism by which aberrant Nedd4-2 function leads to epilepsy.

S-SCAM is essential for synapse formation

Synapse formation is critical for the wiring of neural circuits in the developing brain. The synaptic scaffolding protein S-SCAM/MAGI-2 has important roles in the assembly of signaling complexes at post-synaptic densities. However, the role of S-SCAM in establishing the entire synapse is not known. Here, we report significant effects of RNAi-induced S-SCAM knockdown on the number of synapses in early stages of network development in vitro. In vivo knockdown during the first three postnatal weeks reduced the number of dendritic spines in the rat brain neocortex. Knockdown of S-SCAM in cultured hippocampal neurons severely reduced the clustering of both pre- and post-synaptic components. This included synaptic vesicle proteins, pre- and post-synaptic scaffolding proteins, and cell adhesion molecules, suggesting that entire synapses fail to form. Correspondingly, functional and morphological characteristics of developing neurons were affected by reducing S-SCAM protein levels; neurons displayed severely impaired synaptic transmission and reduced dendritic arborization. A next-generation sequencing approach showed normal expression of housekeeping genes but changes in expression levels in 39 synaptic signaling molecules in cultured neurons. These results indicate that S-SCAM mediates the recruitment of all key classes of synaptic molecules during synapse assembly and is critical for the development of neural circuits in the developing brain.

An intellectual-disability-associated mutation of the transcriptional regulator NACC1 impairs glutamatergic neurotransmission

Advances in genome sequencing technologies have favored the identification of rare de novo mutations linked to neurological disorders in humans. Recently, a de novo autosomal dominant mutation in NACC1 was identified (NM_052876.3: c.892C > T, NP_443108.1; p.Arg298Trp), associated with severe neurological symptoms including intellectual disability, microcephaly, and epilepsy. As NACC1 had never before been associated with neurological diseases, we investigated how this mutation might lead to altered brain function. We examined neurotransmission in autaptic glutamatergic mouse neurons expressing the murine homolog of the human mutant NACC1, i.e., Nacc1-R284W. We observed that expression of Nacc1-R284W impaired glutamatergic neurotransmission in a cell-autonomous manner, likely through a dominant negative mechanism. Furthermore, by screening for Nacc1 interaction targets in the brain, we identified SynGAP1, GluK2A, and several SUMO E3 ligases as novel Nacc1 interaction partners. At a biochemical level, Nacc1-R284W exhibited reduced binding to SynGAP1 and GluK2A, and also showed greatly increased SUMOylation. Ablating the SUMOylation of Nacc1-R284W partially restored its interaction with SynGAP1 but did not restore binding to GluK2A. Overall, these data indicate a role for Nacc1 in regulating glutamatergic neurotransmission, which is substantially impaired by the expression of a disease-associated Nacc1 mutant. This study provides the first functional insights into potential deficits in neuronal function in patients expressing the de novo mutant NACC1 protein.

CADPS functional mutations in patients with bipolar disorder increase the sensitivity to stress

Bipolar disorder is a severe and chronic psychiatric disease resulting from a combination of genetic and environmental risk factors. Here, we identified a significant higher mutation rate in a gene encoding the calcium-dependent activator protein for secretion (CADPS) in 132 individuals with bipolar disorder, when compared to 184 unaffected controls or to 21,070 non-psychiatric and non-Finnish European subjects from the Exome Aggregation Consortium. We found that most of these variants resulted either in a lower abundance or a partial impairment in one of the basic functions of CADPS in regulating neuronal exocytosis, synaptic plasticity and vesicular transporter-dependent uptake of catecholamines. Heterozygous mutant mice for Cadps^+/- revealed that a decreased level of CADPS leads to manic-like behaviours, changes in BDNF level and a hypersensitivity to stress. This was consistent with more childhood trauma reported in families with mutation in CADPS, and more specifically in mutated individuals. Furthermore, hyperactivity observed in mutant animals was rescued by the mood-stabilizing drug lithium. Overall, our results suggest that dysfunction in calcium-dependent vesicular exocytosis may increase the sensitivity to environmental stressors enhancing the risk of developing bipolar disorder.

A decision support tool for the detection of pancreatic cancer in general practice: A modified Delphi consensus

BACKGROUND/OBJECTIVES

Diagnosis of pancreatic cancer is often delayed, contributing to patient and family distress and leading to worse survival. We aimed to develop a decision support tool to support primary care providers to identify patients that should undergo investigations for pancreatic cancer, and to recommend initial diagnostic pathways.

METHODS

A modified Delphi process, including a series of three surveys, was undertaken to ascertain clinical expert opinion on which combinations of signs, symptoms and risk factors should be included in a tool for the early identification of pancreatic cancer. A group of clinical specialists finalised the development of the tool during a focus group meeting.

RESULTS

The tool presents individual or combinations of signs, symptoms, and risk factors in three tiers which direct the urgency of investigation. Tier 1 includes 5 clinical presentation and risk factors clusters that indicate the need for urgent investigation of the pancreas. A further five clusters are included as Tier 2 aiming to elimate other causes and reduce the time to investigating the pancreas. Tier 3 includes a list of non-specific signs, symptoms and risk factors that indicate the need to consider pancreatic cancer as a potential diagnosis, but without specific recommendations for investigation.

CONCLUSIONS

Prospective validation studies are now required prior to implementation in the primary care setting. Implementation into primary care practice and as an educational resource may facilitate rapid diagnosis and improve outcomes such as distress and survival.

The murine ortholog of Kaufman oculocerebrofacial syndrome protein Ube3b regulates synapse number by ubiquitinating Ppp3cc

Kaufman oculocerebrofacial syndrome (KOS) is a severe autosomal recessive disorder characterized by intellectual disability, developmental delays, microcephaly, and characteristic dysmorphisms. Biallelic mutations of UBE3B, encoding for a ubiquitin ligase E3B are causative for KOS. In this report, we characterize neuronal functions of its murine ortholog Ube3b and show that Ube3b regulates dendritic branching in a cell-autonomous manner. Moreover, Ube3b knockout (KO) neurons exhibit increased density and aberrant morphology of dendritic spines, altered synaptic physiology, and changes in hippocampal circuit activity. Dorsal forebrain-specific Ube3b KO animals show impaired spatial learning, altered social interactions, and repetitive behaviors. We further demonstrate that Ube3b ubiquitinates the catalytic γ-subunit of calcineurin, Ppp3cc, the overexpression of which phenocopies Ube3b loss with regard to dendritic spine density. This work provides insights into the molecular pathologies underlying intellectual disability-like phenotypes in a genetically engineered mouse model.

418 The Management of Distal Radius Fractures in Adults with A Removable Soft Cast During the Peak Of The Covid-19 Pandemic: Patient Reported Outcomes And Experiences

Introduction

Immobilisation tools for non-operative management of distal radius fractures (DRFs) in adults, include plaster casts, orthotic splints, and recently removable soft cast as per the BOAST COVID-19 guidelines. Limited evidence exists on the effectiveness of removable soft casts in adults with DRFs. We assessed patient reported functional outcomes and experiences of adults with DRFs managed non-operatively in a removable soft cast during the COVID-19 pandemic.

Method

We retrospectively reviewed adults with DRFs, treated with a removable soft cast for 6 weeks between 9^th April 2020 and 18^th May 2020. Functional scores - Disabilities of the Arms, Shoulders and Hands (DASH) and a 7-question Patient Reported Experience Questionnaire (PREQ) were conducted at 6 weeks, along with a record of complications. A DASH score of < 25 was deemed a satisfactory functional score.

Results

34 patients formed our cohort, with a 65% (22patients) completion rate, mean age of 69years. 82% had a DASH score < 25 and 18% had a DASH score > 25 at 6 weeks. 86% reported satisfactory comfort in the PREQ with 14% reporting discomfort. Two patients re-attended hospital with soft cast related problems.

Conclusions

Most adults with DRFs managed in a removable soft cast reported good early functional outcomes, satisfactory experiences, and no clinic visits at 6weeks.

The α3 subunit of GABAA receptors promotes formation of inhibitory synapses in the absence of collybistin

Signaling at nerve cell synapses is a key determinant of proper brain function, and synaptic defects—or synaptopathies—are at the basis of many neurological and psychiatric disorders. Collybistin (CB), a brain-specific guanine nucleotide exchange factor, is essential for the formation of γ-aminobutyric acidergic (GABAergic) postsynapses in defined regions of the mammalian forebrain, including the hippocampus and basolateral amygdala. This process depends on a direct interaction of CB with the scaffolding protein gephyrin, which leads to the redistribution of gephyrin into submembranous clusters at nascent inhibitory synapses. Strikingly, synaptic clustering of gephyrin and GABA_A type A receptors (GABA_ARs) in several brain regions, including the cerebral cortex and certain thalamic areas, is unperturbed in CB-deficient mice, indicating that the formation of a substantial subset of inhibitory postsynapses must be controlled by gephyrin-interacting proteins other than CB. Previous studies indicated that the α3 subunit of GABA_ARs (GABA_AR-α3) binds directly and with high affinity to gephyrin. Here, we provide evidence (i) that a homooligomeric GABA_AR-α3^A343W mutant induces the formation of submembranous gephyrin clusters independently of CB in COS-7 cells, (ii) that gephyrin clustering is unaltered in the neuronal subpopulations endogenously expressing the GABA_AR-α3 in CB-deficient brains, and (iii) that exogenous expression of GABA_AR-α3 partially rescues impaired gephyrin clustering in CB-deficient hippocampal neurons. Our results identify an important role of GABA_AR-α3 in promoting gephyrin-mediated and CB-independent formation of inhibitory postsynapses.

Ultrastructural Correlates of Presynaptic Functional Heterogeneity in Hippocampal Synapses

Although similar in molecular composition, synapses can exhibit strikingly distinct functional transmitter release and plasticity characteristics. To determine whether ultrastructural differences co-define this functional heterogeneity, we combine hippocampal organotypic slice cultures, high-pressure freezing, freeze substitution, and 3D-electron tomography to compare two functionally distinct synapses: hippocampal Schaffer collateral and mossy fiber synapses. We find that mossy fiber synapses, which exhibit a lower release probability and stronger short-term facilitation than Schaffer collateral synapses, harbor lower numbers of docked synaptic vesicles at active zones and a second pool of possibly tethered vesicles in their vicinity. Our data indicate that differences in the ratio of docked versus tethered vesicles at active zones contribute to distinct functional characteristics of synapses.

•

Electron tomography enables the dissection of vesicle pools at synaptic active zones

•

Docked and primed vesicle availability contributes to initial release probability

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The ratio of docked and tethered vesicles may co-determine short-term plasticity

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Hippocampal mossy fibers contain three morphological types of docked vesicles

Association of blood mercury levels with nonmelanoma skin cancer in the U.S.A. using National Health and Nutrition Examination Survey data (2003-2016)

BACKGROUND

Some studies have reported increased incidence or mortality of lung and brain cancers associated with occupations involving potential mercury exposure. Epidemiological evidence related to skin cancer is also limited.

OBJECTIVES

To investigate the association between blood mercury (Hg) levels and nonmelanoma skin cancer (NMSC).

METHODS

We used National Health and Nutrition Examination Survey data from 2003 to 2016. The exposures were blood total (tHg), inorganic (iHg) and methylmercury (MeHg). The outcome was a self-reported diagnosis of NMSC. We included participants aged ≥ 20 years who had information on blood mercury and sociodemographic factors. We conducted a logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of NMSC associated with quartiles of blood Hg, after adjusting for the sociodemographic factors and survey year.

RESULTS

The number of participants was 29 413; mean age was 49 years and 52% were female. Compared with those with a tHg ≤ 0·47 μg L^-1 (Q1), those with a tHg > 1·74 μg L^-1 (Q4) had nearly double the odds of NMSC (OR 1·79, 95% CI 1·19-2·71; P_trend = 0·004). Similarly, those in the highest quartile of MeHg (> 1·44 μg L^-1 ) had 1·7 times greater odds of NMSC (OR 1·74, 95% CI 1·13-2·70; P_trend = 0·01) than those in the lowest quartile (≤ 0·21 μg L^-1 ). iHg levels were nonsignificantly positively associated with NMSC (P_trend = 0·08).

CONCLUSIONS

We found that higher blood tHg and MeHg levels were associated with a higher prevalence of NMSC. Linked Comment: Taylor. Br J Dermatol 2020; 183:413-414.

Molecular Mechanisms of Synaptic Vesicle Priming by Munc13 and Munc18

Munc13 catalyzes the transit of syntaxin from a closed complex with Munc18 into the ternary SNARE complex. Here we report a new function of Munc13, independent of Munc18: it promotes the proper syntaxin/synaptobrevin subconfiguration during assembly of the ternary SNARE complex. In cooperation with Munc18, Munc13 additionally ensures the proper syntaxin/SNAP-25 subconfiguration. In a reconstituted fusion assay with SNAREs, complexin, and synaptotagmin, inclusion of both Munc13 and Munc18 quadruples the Ca²⁺-triggered amplitude and achieves Ca²⁺ sensitivity at near-physiological concentrations. In Munc13-1/2 double-knockout neurons, expression of a constitutively open mutant of syntaxin could only minimally restore neurotransmitter release relative to Munc13-1 rescue. Together, the physiological functions of Munc13 may be related to regulation of proper SNARE complex assembly.

Upregulation of Atrogin-1/FBXO32 is not necessary for cartilage destruction in mouse models of osteoarthritis

OBJECTIVE

In a preliminary study, we found that recently identified catabolic regulators of osteoarthritis (OA), including hypoxia-inducible factor (HIF)-2α and members of the zinc-ZIP8-MTF1 axis, upregulate the E3 ubiquitin ligase, Atrogin-1 (encoded by Fbxo32), in chondrocytes. As the ubiquitination/proteasomal degradation pathways are tightly regulated to modulate the expression of catabolic factors in chondrocytes, we examined the in vivo functions of Atrogin-1 in mouse models of OA.

METHODS

The mRNA and protein levels of Atrogin-1 and other regulators of OA were determined in primary cultured mouse chondrocytes, OA human cartilage, and OA cartilage from wild-type (WT) and Fbxo32-knockout (KO) mice subjected to destabilization of the medial meniscus or intra-articular (IA) injection of adenoviruses expressing HIF-2α (Ad-Epas1), ZIP8 (Ad-Zip8), or Atrogin-1 (Ad-Fbxo32). The effect of Atrogin-1 overexpression on the cartilage of WT mice was examined by IA injection of Ad-Fbxo32.

RESULTS

Atrogin-1 mRNA levels in chondrocytes were markedly increased by treatment with interleukin-1β, HIF-2α, and members of the zinc-ZIP8-MTF1 axis. Atrogin-1 protein levels were also increased in OA cartilage from humans and various mouse OA models. However, the forced overexpression of Atrogin-1 in chondrocytes did not modulate the expression of cartilage matrix molecules or matrix-degrading enzymes. Moreover, overexpression of Atrogin-1 in the mouse joint tissues failed to cause OA pathogenesis, and Fbxo32 knockout failed to affect post-traumatic OA cartilage destruction in mice.

CONCLUSIONS

Although Atrogin-1 is upregulated in OA cartilage, overexpression of Atrogin-1 in the joint tissues or knockout of Fbxo32 does not affect OA cartilage destruction in mice.

Transient oxytocin signaling primes the development and function of excitatory hippocampal neurons

Beyond its role in parturition and lactation, oxytocin influences higher brain processes that control social behavior of mammals, and perturbed oxytocin signaling has been linked to the pathogenesis of several psychiatric disorders. However, it is still largely unknown how oxytocin exactly regulates neuronal function. We show that early, transient oxytocin exposure in vitro inhibits the development of hippocampal glutamatergic neurons, leading to reduced dendrite complexity, synapse density, and excitatory transmission, while sparing GABAergic neurons. Conversely, genetic elimination of oxytocin receptors increases the expression of protein components of excitatory synapses and excitatory synaptic transmission in vitro. In vivo, oxytocin-receptor-deficient hippocampal pyramidal neurons develop more complex dendrites, which leads to increased spine number and reduced γ-oscillations. These results indicate that oxytocin controls the development of hippocampal excitatory neurons and contributes to the maintenance of a physiological excitation/inhibition balance, whose disruption can cause neurobehavioral disturbances.

DOI:http://dx.doi.org/10.7554/eLife.22466.001

Abstract OT1-03-18: COLET: A multistage, phase 2 study evaluating the safety and efficacy of cobimetinib in combination with paclitaxel as first-line treatment for patients with metastatic triple-negative breast cancer

Background: Cobimetinib (cobi) is a potent, highly selective inhibitor of MEK that has shown benefit when administered in combination with the BRAF inhibitor vemurafenib in BRAFV600-mutated metastatic melanoma. Preclinical data suggest that up-regulation of the MAPK pathway is a potential resistance mechanism against taxane chemotherapy. Clinically, the combination of MEK inhibition and taxane chemotherapy in non–small cell lung cancer patients (pts) has improved response rate (RR) and progression-free survival (PFS). Because most triple-negative breast cancer (TNBC) pts develop resistance to taxane chemotherapy and because genetic alterations (including mutations and gene amplifications) in the MAPK pathway are present in many TNBC tumors, the combination of taxane chemotherapy and MEK inhibition could be an effective treatment option.

Study design: COLET (WO29497) is a multistage study designed to evaluate the safety of and to estimate the efficacy of cobi  paclitaxel in pts with metastatic or locally advanced TNBC who have not previously received systemic therapy for metastatic disease. The study will be conducted in 2 stages: an initial safety run-in stage of approximately 12 pts, followed by a randomized stage in which approximately 100 pts will be randomly assigned in a 1:1 ratio to receive either cobi + paclitaxel or placebo + paclitaxel. Pts will receive paclitaxel 80 mg/m2 on Days 1, 8, and 15 of each 28-day cycle and cobi/placebo 60 mg/day on Days 3-23 of each 28-day cycle until progression of disease or toxicity occurs.

Key eligibility criteria:

• Metastatic or locally advanced (not amenable to curative resection) TNBC

• No prior systemic therapy for metastatic or unresectable locally advanced TNBC

• Neoadjuvant or adjuvant chemotherapy or radiation therapy is allowed if completed &gt;6 months before the start of study treatment

• Measureable disease using Response Evaluation Criteria In Solid Tumors, version 1.1 (RECIST v1.1)

• History of or active untreated or unstable brain metastases or requiring corticosteroids for brain metastases precludes eligibility

• Left ventricular ejection fraction (LVEF) greater than the institutional lower limit of normal or above 50%

Specific aims of the safety run-in stage: Determine the safety and tolerability of cobi when administered in combination with paclitaxel.

Specific aims of the randomized stage: Investigator-assessed PFS (primary end point); safety; pharmacokinetics; the effect of intrinsic subtypes and genetic alterations in PFS; mechanisms of resistance; and health-related quality of life.

Accrual: Approximately 112 pts from sites across Europe, North America, and the Asia-Pacific region.

Statistical methods: In the randomized stage, pts will be followed up until a total of 60 PFS events occur across the 2 arms. This provides 77% power to detect a hazard ratio of 0.5 at a two-sided significance level of 0.05.

Contact information: Registered with ClinicalTrials.gov, identifier NCT02322814. For more information, please contact Roche/Genentech trials, 888-662-6728 (US only) or reference study ID WO29479 at www.roche.com/about_roche/roche_worldwide.htm.

Citation Format: Kim S-B, Miles D, Rhee J, Yan Y, Hsu J, Brufsky A. COLET: A multistage, phase 2 study evaluating the safety and efficacy of cobimetinib in combination with paclitaxel as first-line treatment for patients with metastatic triple-negative breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT1-03-18.

A Spanish version of the Skin Cancer Index: a questionnaire for measuring quality of life in patients with cervicofacial nonmelanoma skin cancer

INTRODUCTION

The Skin Cancer Index (SCI) is the first specific patient-reported outcome measure for patients with cervicofacial nonmelanoma skin cancer. To date, only the original English version has been published.

OBJECTIVES

To develop a Spanish version of the SCI that is semantically and linguistically equivalent to the original, and to evaluate its measurement properties in this different cultural environment.

MATERIAL AND METHODS

A cross-sectional study was conducted of the cultural adaptation and empirical validation of the questionnaire, analysing the psychometric properties of the new index at different stages.

RESULTS

Of 440 patients recruited to the study, 431 (95%) completed the Spanish version of the SCI questionnaire, in a mean time of 6·3 min (SD 2·9). Factor analysis of the scale revealed commonality and loading values of < 0·5 for three of the 15 items. The remaining 12 items converged into two components: appearance/social aspects (seven items) and emotional aspects (five items). Both domains presented a high level of internal consistency, with Cronbach's alpha values above 0·8. The convergent-discriminant validity analysis produced correlations higher than 0·3 for the mental component of the Short Form Health Survey-12v2 Health Questionnaire (correlation coefficient 0·39) and the Dermatology Quality of Life Index (correlation coefficient -0·30). In the test-retest, nine of the 12 items produced a weighted kappa value exceeding 0·4, and for the remaining three items, the absolute agreement percentage exceeded 60%.

CONCLUSIONS

The Spanish version of the SCI quality of life scale has been satisfactorily adapted and validated for use in Spanish-speaking countries and populations.

Secretory vesicle priming by CAPS is independent of its SNARE-binding MUN domain

Priming of secretory vesicles is a prerequisite for their Ca(2+)-dependent fusion with the plasma membrane. The key vesicle priming proteins, Munc13s and CAPSs, are thought to mediate vesicle priming by regulating the conformation of the t-SNARE syntaxin, thereby facilitating SNARE complex assembly. Munc13s execute their priming function through their MUN domain. Given that the MUN domain of Ca(2+)-dependent activator protein for secretion (CAPS) also binds syntaxin, it was assumed that CAPSs prime vesicles through the same mechanism as Munc13s. We studied naturally occurring splice variants of CAPS2 in CAPS1/CAPS2-deficient cells and found that CAPS2 primes vesicles independently of its MUN domain. Instead, the pleckstrin homology domain of CAPS2 seemingly is essential for its priming function. Our findings indicate a priming mode for secretory vesicles. This process apparently requires membrane phospholipids, does not involve the binding or direct conformational regulation of syntaxin by MUN domains of CAPSs, and is therefore not redundant with Munc13 action.

The morphological and molecular nature of synaptic vesicle priming at presynaptic active zones

Synaptic vesicle docking, priming, and fusion at active zones are orchestrated by a complex molecular machinery. We employed hippocampal organotypic slice cultures from mice lacking key presynaptic proteins, cryofixation, and three-dimensional electron tomography to study the mechanism of synaptic vesicle docking in the same experimental setting, with high precision, and in a near-native state. We dissected previously indistinguishable, sequential steps in synaptic vesicle active zone recruitment (tethering) and membrane attachment (docking) and found that vesicle docking requires Munc13/CAPS family priming proteins and all three neuronal SNAREs, but not Synaptotagmin-1 or Complexins. Our data indicate that membrane-attached vesicles comprise the readily releasable pool of fusion-competent vesicles and that synaptic vesicle docking, priming, and trans-SNARE complex assembly are the respective morphological, functional, and molecular manifestations of the same process, which operates downstream of vesicle tethering by active zone components.

Demographic and serological characteristics of Asian Americans with hepatitis B infection diagnosed at community screenings

There is limited information regarding follow-up and hepatitis B serological status of Asian Americans diagnosed with chronic hepatitis B (CHB) through community screening. The aims of this study were to evaluate the prevalence and characterize CHB among Asians living in Los Angeles, assess follow-up of individuals with CHB diagnosed at screening and compare with patients with CHB followed by community gastroenterologists. Between October 2007 and May 2010, 7387 Asians were tested for HBV. HBsAg positive individuals (CHB) underwent additional testing for ALT, HBeAg/anti-HBe and HBV DNA. Patients with CHB were contacted 6 months later to determine whether they received follow-up care. We compared serological patterns of these individuals with CHB to patients with CHB who were seen for the first time (treatment naïve) by community gastroenterologists during the study period. Prevalence of CHB was 5.2%. About 99% patients with CHB were foreign-born, and only 27% could read/write English. 297 (77%) patients with CHB could be reached 6 months after diagnosis; 43% did not receive follow-up care, mostly because of lack of medical insurance. Patients with CHB followed by gastroenterologists were more likely to have insurance (69% vs 26%, P < 0.0001). 90% patients with CHB at screening were HBeAg negative/anti-HBe positive with 62% having inactive disease compared to only 30% of patients seen by gastroenterologists (P < 0.0001). Among CHB participants, 13% met criteria for treatment compared to 51% of patients with CHB (P < 0.0001). Only a small number of CHB screening participants require antiviral therapy. Lack of medical insurance is the main reason for most patients with CHB not seeking follow-up care after screening.

Neurobeachin regulates neurotransmitter receptor trafficking to synapses

The surface density of neurotransmitter receptors at synapses is a key determinant of synaptic efficacy. Synaptic receptor accumulation is regulated by the transport, postsynaptic anchoring, and turnover of receptors, involving multiple trafficking, sorting, motor, and scaffold proteins. We found that neurons lacking the BEACH (beige-Chediak/Higashi) domain protein Neurobeachin (Nbea) had strongly reduced synaptic responses caused by a reduction in surface levels of glutamate and GABA(A) receptors. In the absence of Nbea, immature AMPA receptors accumulated early in the biosynthetic pathway, and mature N-methyl-d-aspartate, kainate, and GABA(A) receptors did not reach the synapse, whereas maturation and surface expression of other membrane proteins, synapse formation, and presynaptic function were unaffected. These data show that Nbea regulates synaptic transmission under basal conditions by targeting neurotransmitter receptors to synapses.

OS094. Subclinical left ventricular dysfunction in preeclamptic women with preserved left ventricular ejection fraction: A 2D speckle tracking imaging study

INTRODUCTION

Patients with preeclampsia are at risk for cardiovascular disease [1,2]. Changes in cardiac function are subtle in preeclampsia and are quantitatively difficult with conventional imaging. Strain measurements using speckle-tracking echocardiography have been used to sensitively quantifyabnormalities in other disease settings [3].

OBJECTIVES

The objective of this study was to evaluate changes in myocardial strain using speckle tracking echocardiography in women with and without preeclampsia. We hypothesized that global left systolic strain measures would prove more sensitive than conventional left ventricular ejection fraction in detecting early changes in systolic LV function manifesting as subclinical disease prior to overt progression.

METHODS

We evaluated the feasibility and sensitivity of strain imaging using speckle tracking echocardiography. Thirty-six women were enrolled in this pilot study; 28 were analyzed: 11 with preeclampsia and 17 without preeclampsia. Echocardiographic Ejection fraction and global peak longitudinal ,radial and circumferential strain were measured.

RESULTS

Global Median longitudinal strain was significantly worsened in women with preeclampsia compared to women without preeclampsia (P<0.0001). Similar results were observed for global radial strain (P=0.006) and circumferential strain (P=0.03). There was no significant difference in ejection fraction between the groups (P=0.52) (Table 1). Data are presented as median (interquartile range).

CONCLUSION

Myocardial strain imaging using speckle tracking is more sensitive than left ventricular ejection fraction to detect differences in left ventricular systolic function in women with and without preeclampsia.

Endoscopic versus direct vision for saphenous vein graft harvesting in coronary artery bypass surgery

AIM

Recent reports have suggested harvesting of the greater saphenous vein for coronary artery bypass (CABG) using endoscopic techniques (endoscopic) results in early graft closure, higher rates of myocardial infarction (MI) and death. We explored the impact of this technique performed by experienced operators on postoperative morbidities, MI and death in our CABG patients.

METHODS

All non-emergent patients presenting for first time CABG surgery from 2006 to June 2009 were included. Data pertaining to surgery, readmissions, cardiac catheterization and interventions during long term follow-up were extracted from our local STS and ACC registries. Linear and logistic regressions with clinical covariates were conducted to determine if vein harvest technique group predicted the major outcomes. Propensity score matching (PSM) was completed to simulate randomization and improve covariate balance across the endoscopic and direct vision groups.

RESULTS

One thousand nine hundred and eighty-eight (N.=1988) patients were evaluated in this study (N.=1734 endoscopic group and N.=254 direct vision group). The perioperative major adverse outcomes (mortality within 30 days, stroke, reoperation for bleeding, prolonged ventilation and readmission within 30 days) were 17.8% in the endoscopic group and 25.2% in the direct vision group. The rate of leg infections was 0.3% for the endoscopic group and 1.6% for the direct vision group. After adjustment for covariates, the direct vision group had significantly greater risk for prolonged ventilation (P=0.03), MACE (P=0.02) and mortality within 30 days (P=0.01), but only marginally greater risk for leg infections (P=0.052). In the isolated CABG patients, operative death was 1% for the endoscopic group and 1.7% in the direct vision group (P=0.62). After PSM the endoscopic group was similar on all outcomes except for having fewer MACE (P=0.04). In a mean follow-up of 22.1±10.5 months, there were no significant differences in the overall rate and time to event for repeat revascularization, death and myocardial infarction. With maximum follow up of 39.6 months, 84 deaths were documented (N.=67 endoscopic and N.=17 direct vision).

CONCLUSION

The outcomes captured by the number of postoperative morbidities, incidence of myocardial infarction and/or the rate of death for the endoscopic technique were comparable to patients in whom the open techniques was used. There was a trend towards a decrease in leg infections with the use of the endoscopic device. Based on this study we consider the device safe and effective with experienced operators.

CYP2A6 and ERCC1 polymorphisms correlate with efficacy of S-1 plus cisplatin in metastatic gastric cancer patients

Background:

We evaluated the association between polymorphisms of cytochrome P450 2A6 (CYP2A6)/excision repair cross-complementation group 1 (ERCC1)/X-ray repair cross-complementing group 1(XRCC1) and treatment outcomes of metastatic gastric cancer (MGC) patients treated with S-1/cisplatin.

Methods:

Among MGC patients (n=108), who received S-1 (40 mg m⁻² b.i.d., days 1–14) and cisplatin (60 mg m⁻², day 1) every 3 weeks, we analysed the wild-type allele (W) and variants (V) of CYP2A6 (*4, *7, *9, *10), and the polymorphisms of ERCC1 (rs11615, rs3212986) and XRCC1 (rs25487).

Results:

Patients having fewer CYP2A6 variants had better response rates (W/W vs W/V other than *1/*4 vs V/V or *1/*4=66.7 vs 58.3 vs 32.3% P=0.008), time to progression (TTP) (7.2 vs 6.1 vs 3.5 months, P=0.021), and overall survival (23.2 vs 15.4 vs 12.0 months, P=0.004). ERCC1 19442C>A (rs3212986) was also associated with response rate (C/C, 46.7% vs C/A, 55.3% vs A/A, 87.5%) (P=0.048) and TTP (4.4 vs 7.6 vs 7.9 months) (P=0.012). Patients carrying both risk genotypes of CYP2A6 (V/V or 1/*4) and ERCC1 19442C>A (C/C) vs those carrying none showed an adjusted odds ratio of 0.113 (P=0.004) for response, and adjusted hazard ratios of 3.748 (P=0.0001) for TTP and 2.961 (P=0.006) for death.

Conclusion:

Polymorphisms of CYP2A6 and ERCC1 19442C>A correlated with the efficacy of S-1/cisplatin.

Two distinct secretory vesicle-priming steps in adrenal chromaffin cells

The calcium-dependent activator proteins for secretion, CAPS1 and CAPS2, facilitate syntaxin opening during synaptic vesicle priming.

Priming of large dense-core vesicles (LDCVs) is a Ca²⁺-dependent step by which LDCVs enter a release-ready pool, involving the formation of the soluble N-ethyl-maleimide sensitive fusion protein attachment protein (SNAP) receptor complex consisting of syntaxin, SNAP-25, and synaptobrevin. Using mice lacking both isoforms of the calcium-dependent activator protein for secretion (CAPS), we show that LDCV priming in adrenal chromaffin cells entails two distinct steps. CAPS is required for priming of the readily releasable LDCV pool and sustained secretion in the continued presence of high Ca²⁺ concentrations. Either CAPS1 or CAPS2 can rescue secretion in cells lacking both CAPS isoforms. Furthermore, the deficit in the readily releasable LDCV pool resulting from CAPS deletion is reversed by a constitutively open form of syntaxin but not by Munc13-1, a priming protein that facilitates the conversion of syntaxin to the open conformation. Our data indicate that CAPS functions downstream of Munc13s but also interacts functionally with Munc13s in the LDCV-priming process.