Feasibility of abdominal fat quantification on MRI and impact on effectiveness of abdominal compression for radiotherapy motion management

The impact of fat on abdominal compression effectiveness in abdominal cancers was determined using magnetic resonance imaging (MRI). Visceral and subcutaneous fat were delineated on T2W 3D MRI, and motion change with compression was measured on 2D cine MRI. Results from 16 participants showed no correlation between fat percentage, body mass index (BMI), and motion change. Median BMI was 28.7 (SD, 4.9). Mean motion reduction was 7.8 mm (IQR, 5.0; p = 0.001) with compression. While no direct link was found between fat, BMI, and compression effectiveness, abdominal compression remains crucial for motion management in radiotherapy planning, providing dosimetric benefits.

The development and acceptability of an educational and training intervention for recruiters to neonatal trials: the TRAIN project

BACKGROUND

Suboptimal or slow recruitment affects 30-50% of trials. Education and training of trial recruiters has been identified as one strategy for potentially boosting recruitment to randomised controlled trials (hereafter referred to as trials). The Training tRial recruiters, An educational INtervention (TRAIN) project was established to develop and assess the acceptability of an education and training intervention for recruiters to neonatal trials. In this paper, we report the development and acceptability of TRAIN.

METHODS

TRAIN involved three sequential phases, with each phase contributing information to the subsequent phase(s). These phases were 1) evidence synthesis (systematic review of the effectiveness of training interventions and a content analysis of the format, content, and delivery of identified interventions), 2) intervention development using a Partnership (co-design/co-creation) approach, and 3) intervention acceptability assessments with recruiters to neonatal trials.

RESULTS

TRAIN, accompanied by a comprehensive intervention manual, has been designed for online or in-person delivery. TRAIN can be offered to recruiters before trial recruitment begins or as refresher sessions during a trial. The intervention consists of five core learning outcomes which are addressed across three core training units. These units are the trial protocol (Unit 1, 50 min, trial-specific), understanding randomisation (Unit 2, 5 min, trial-generic) and approaching and engaging with parents (Unit 3, 70 min, trial-generic). Eleven recruiters to neonatal trials registered to attend the acceptability assessment training workshops, although only four took part. All four positively valued the training Units and resources for increasing recruiter preparedness, knowledge, and confidence. More flexibility in how the training is facilitated, however, was noted (e.g., training divided across two workshops of shorter duration). Units 2 and 3 were considered beneficial to incorporate into Good Clinical Practice Training or as part of induction training for new staff joining neonatal units.

CONCLUSION

TRAIN offers a comprehensive co-produced training and education intervention for recruiters to neonatal trials. TRAIN was deemed acceptable, with minor modification, to neonatal trial recruiters. The small number of recruiters taking part in the acceptability assessment is a limitation. Scale-up of TRAIN with formal piloting and testing for effectiveness in a large cluster randomised trial is required.

3D Surface Imaging in Reducing Setup Error for Prone Whole Breast Radiotherapy

PURPOSE/OBJECTIVE(S)

For patients undergoing whole breast radiotherapy, treatment in the prone position allows for reduced dose to critical organs such as the heart and lungs. However, this treatment position comes with greater challenges in reproducibility and setup error given the unstable position. Our objective was to investigate the benefit of using 3D surface imaging to reduce daily setup errors for these patients.

MATERIALS/METHODS

We performed a retrospective review of consecutive breast patients receiving prone breast radiotherapy at our institution. All patients were positioned initially using setup tattoos and twice a week, the positioning was adjusted using the aid of a motion tracking system. Then, a daily kilovoltage (kV) cone beam computed tomography (CBCT) image was acquired and positioning was adjusted to setup the breast and chest wall. Shifts in each translational direction were recorded and the three-dimensional vector displacement was calculated. For each patient the average displacements on days where a motion tracking system was used were compared to days whereas motion tracking system was not used. Patients were classified into significant benefit (more than 4 mm improvement), small benefit (0-4 mm improvement) or increased error (increased shifts on days a motion tracking system was used). Patient demographics were collected including stage, BMI, weight, heigh, age, ethnicity. Comparisons were made using t-tests.

RESULTS

A total of 40 patients with stage T0-2N0 breast cancer were included. The median age was 64 and 60% of patients had left sided breast cancer. A total of 665 daily CBCT scans were analyzed, and the median daily vector displacement was 7.2 mm (1-21 mm). The median displacement on treatments where a motion tracking system was used (41% of treatments) was 6.1 mm versus 8.1 mm when not used (p<.0001). The use of a motion tracking system significantly reduced the occurrence of shifts more than 1 cm (12% vs. 33%, p < .0001) and 5 mm (65% vs. 83% p < .0001). For individual patients, 28% showed a significant improvement, 55% showed small improvement, 17% showed increased error. The median BMI was 27, weight was 71 kg, and neither was associated with an improvement in the use of Align RT (p > .05). However, patients in the small improvement group had a higher BMI than patients in the other two groups 29 vs. 25 (p = .01). A similar association was seen for weight (p < .05). No association was found for the benefit of a motion tracking system for height, age, stage or ethnicity.

CONCLUSION

The use of 3D surface imaging for breast cancer patients receiving prone whole breast radiotherapy on average significantly reduced setup errors. For patients with higher BMI there was a consistent small reduction in setup error when compared to using setup marks alone. For patients with lower BMI, caution should be exercised as there was more variation with some patients demonstrating a large benefit and other patients having an increased setup error with the use of surface imaging. Further research is needed to investigate on the optimal use of this technology.

Distinct and shared genetic architectures of Gestational diabetes mellitus and Type 2 Diabetes Mellitus

Gestational diabetes mellitus (GDM) affects more than 16 million pregnancies annually worldwide and is related to an increased lifetime risk of Type 2 diabetes (T2D). The diseases are hypothesized to share a genetic predisposition, but there are few GWAS studies of GDM and none of them is sufficiently powered to assess whether any variants or biological pathways are specific to GDM. We conducted the largest genome-wide association study of GDM to date in 12,332 cases and 131,109 parous female controls in the FinnGen Study and identified 13 GDM-associated loci including 8 novel loci. Genetic features distinct from T2D were identified both at the locus and genomic scale. Our results suggest that the genetics of GDM risk falls into two distinct categories - one part conventional T2D polygenic risk and one part predominantly influencing mechanisms disrupted in pregnancy. Loci with GDM-predominant effects map to genes related to islet cells, central glucose homeostasis, steroidogenesis, and placental expression. These results pave the way for an improved biological understanding of GDM pathophysiology and its role in the development and course of T2D.

SARS-CoV-2 vaccination and myocarditis in a highly vaccinated New Zealand population

Background

A higher incidence of myocarditis has been reported in those who have recently received mRNA SARS – CoV-2 vaccination.1 Canterbury District Health Board (CDHB) serves 578,290 people, including 441,852 adults, with one large tertiary referral hospital offering specialist cardiology services. In 2021 97% of eligible adults received at least one dose and 92% two doses of the BNT162b2 mRNA vaccine (Pfizer-BioNTech). During this time only 21 community cases of COVID-19 infection were reported. We investigated the incidence of myocarditis during the BNT162b2 mRNA vaccine rollout in comparison to the preceding 5 years assuming a stable population size.

Methods

All adult patients admitted to our hospital who received a diagnostic code of acute myocarditis (ICD10 codes I40, I41 and I51.4) during admission between 2016 and 2021 were included. Demographics and peak troponin concentration (hsTnI) were recorded. Vaccine-associated myocarditis was defined as that leading to admitted within 28 days of BNT162b2 vaccination. Myocarditis-associated mortality was defined as death occurring within 28 days of hospital admission. Incidence of myocarditis before and during COVID-19 vaccination was tested using ANOVA.

Results

Between 2016 and 2020 there were 178 total hospital admissions (annualised mean 35.6 [SD6.3] range 28–44) with myocarditis. The mean age was 47.8 [SD15.9] years, 38% were women, and median peak hsTnI 641 (IQR 95.25–8526) ng/L. One patient died within 28 days of admission. In 2021 there were 43 myocarditis admissions, mean age 49.7 [SD18] years, 42% women, with a median hsTnI 355 (IQR 106.5–1876.5) ng/L. Nine of these admissions were within 28 days of vaccination. They were 78% female, mean age 52.6 [SD24.8] years, median peak hsTnI 179 (IQR 52–528) ng/L. One patient died during admission. There was no variance in annual incidence of myocarditis during vaccine rollout (p=0.342).

Conclusion

In a highly vaccinated adult population largely free of COVID-19 infection there were few cases of myocarditis within 28 days of vaccination and no increase in incidence overall compared to the preceding 5 years.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Heart Foundation of New Zealand grant to C Greer

Standardization in Quantitative Imaging: A Multicenter Comparison of Radiomic Features from Different Software Packages on Digital Reference Objects and Patient Data Sets

Radiomic features are being increasingly studied for clinical applications. We aimed to assess the agreement among radiomic features when computed by several groups by using different software packages under very tightly controlled conditions, which included standardized feature definitions and common image data sets. Ten sites (9 from the NCI's Quantitative Imaging Network] positron emission tomography–computed tomography working group plus one site from outside that group) participated in this project. Nine common quantitative imaging features were selected for comparison including features that describe morphology, intensity, shape, and texture. The common image data sets were: three 3D digital reference objects (DROs) and 10 patient image scans from the Lung Image Database Consortium data set using a specific lesion in each scan. Each object (DRO or lesion) was accompanied by an already-defined volume of interest, from which the features were calculated. Feature values for each object (DRO or lesion) were reported. The coefficient of variation (CV), expressed as a percentage, was calculated across software packages for each feature on each object. Thirteen sets of results were obtained for the DROs and patient data sets. Five of the 9 features showed excellent agreement with CV < 1%; 1 feature had moderate agreement (CV < 10%), and 3 features had larger variations (CV ≥ 10%) even after attempts at harmonization of feature calculations. This work highlights the value of feature definition standardization as well as the need to further clarify definitions for some features.

Dysfunction of complement receptors CR3 (CD11b/18) and CR4 (CD11c/18) in pre-eclampsia: a genetic and functional study

OBJECTIVE

To study genetic variants and their function within genes coding for complement receptors in pre-eclampsia.

DESIGN

A case-control study.

SETTING

Pre-eclampsia is a common vascular disease of pregnancy. The clearance of placenta-derived material is one of the functions of the complement system in pregnancy.

POPULATION

We genotyped 500 women with pre-eclamptic pregnancies and 190 pregnant women without pre-eclampsia, as controls, from the FINNPEC cohort, and 122 women with pre-eclamptic pregnancies and 1905 controls from the national FINRISK cohort.

METHODS

The functional consequences of genotypes discovered by targeted exomic sequencing were explored by analysing the binding of the main ligand iC3b to mutated CR3 or CR4, which were transiently expressed on the surface of COS-1 cells.

MAIN OUTCOME MEASURES

Allele frequencies were compared between pre-eclamptic pregnancies and controls in genetic studies. The functional consequences of selected variants were measured by binding assays.

RESULTS

The most significantly pre-eclampsia-linked CR3 variant M441K (P = 4.27E-4, OR = 1.401, 95% CI = 1.167-1.682) displayed a trend of increased adhesion to iC3b (P = 0.051). The CR4 variant A251T was found to enhance the adhesion of CR4 to iC3b, whereas W48R resulted in a decrease of the binding of CR4 to iC3b.

CONCLUSIONS

Results suggest that changes in complement-facilitated phagocytosis are associated with pre-eclampsia. Further studies are needed to ascertain whether aberrant CR3 and CR4 activity leads to altered pro- and anti-inflammatory cytokine responses in individuals carrying the associated variants, and the role of these receptors in pre-eclampsia pathogenesis.

TWEETABLE ABSTRACT

Genetic variants of complement receptors CR3 and CR4 have functional consequences that are associated with pre-eclampsia.

A micro-Raman and X-ray study of erupted submarine pyroclasts from El Hierro (Spain) and its' astrobiological implications

The pumice volcanic samples could have possible connections to the evolution of life and give us insight about their bio-geochemical processes related. In this regard, the samples from the volcanic eruption from La Restinga (El Hierro, Spain) in 2011 have been mainly studied by means of Raman spectroscopy. The research also includes analysis of XRD, Scanning Electron Microscopy and Optical Microscopy to support the Raman analysis. The results show that the Raman methods and mineral analyses are in strong agreement with the results obtained from other authors and techniques. The internal white foamy core (WFC) of the studied pumice samples shows amorphous silica, Fe-oxides, Ti-oxides, quartz, certain sulfates, carbonates, zeolites and organics. On the other hand, the external part (dark crust - DC) of these samples mainly presents primary-sequence mineralogy combined with some secondary alteration minerals such as olivine, feldspar, pyroxene, amorphous silica, and Fe-oxide. Raman spectroscopy detected other minerals not yet reported on these samples like barite, celestine and lepidocrocite. Also, the different chemometric and calibration methods for Raman spectroscopy in elemental composition, mineral classification and structural characterization has been successfully applied. From the astrobiological perspective, the research was also complemented with comparisons to other similar samples from terrestrial analogs. The main consideration was taking into account the proposed hypothesis regarding the potential behavior of the pumice as a substrate for the evolution of life. Furthermore, the detailed analysis from La Restinga eruption is coherent with the mineral phases and processes discussed from previous literature. The white internal part fulfills the conditions to work as an organic reservoir, confirmed by the detection of organic matter and selected minerals that could be used as energy sources for bacterial communities. The external layers of the samples work as a shielding layer to protect the organics from decay in extreme conditions. Finally, here we have demonstrated that the characteristics and advantages of Raman spectroscopy could help to assess and understand the possible biogenicity and alteration processes of any geological sample to be found on Mars.

Variation in outcome reporting in randomized controlled trials of interventions for prevention and treatment of fetal growth restriction

OBJECTIVE

Although fetal growth restriction (FGR) is well known to be associated with adverse outcomes for the mother and offspring, effective interventions for the management of FGR are yet to be established. Trials reporting interventions for the prevention and treatment of FGR may be limited by heterogeneity in the underlying pathophysiology. The aim of this study was to conduct a systematic review of outcomes reported in randomized controlled trials (RCTs) assessing interventions for the prevention or treatment of FGR, in order to identify and categorize the variation in outcome reporting.

METHODS

MEDLINE, EMBASE and The Cochrane Library were searched from inception until August 2018 for RCTs investigating therapies for the prevention and treatment of FGR. Studies were assessed systematically and data on outcomes that were reported in the included studies were extracted and categorized. The methodological quality of the included studies was assessed using the Jadad score.

RESULTS

The search identified 2609 citations, of which 153 were selected for full-text review and 72 studies (68 trials) were included in the final analysis. There were 44 trials relating to the prevention of FGR and 24 trials investigating interventions for the treatment of FGR. The mean Jadad score of all studies was 3.07, and only nine of them received a score of 5. We identified 238 outcomes across the included studies. The most commonly reported were birth weight (88.2%), gestational age at birth (72.1%) and small-for-gestational age (67.6%). Few studies reported on any measure of neonatal morbidity (27.9%), while adverse effects of the interventions were reported in only 17.6% of trials.

CONCLUSIONS

There is significant variation in outcome reporting across RCTs of therapies for the prevention and treatment of FGR. The clinical applicability of future research would be enhanced by the development of a core outcome set for use in future trials. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Abstract P6-19-03: The role of lumpectomy and radiation therapy in men 70 years of age and older with early breast cancer on hormone therapy: A NCDB analysis

Background: Current consensus guidelines for the treatment of male breast cancer are driven by female-only clinical trials despite data suggesting distinct biologic, clinicopathologic, and prognostic differences between male and female breast cancer patients. This includes a recent retrospective multicenter analysis showing greater overall survival among male breast cancer patients who underwent lumpectomy with radiation therapy (RT), compared to total mastectomy or lumpectomy alone. In light of these findings and the CALGB 9343 trial performed in women, we sought to evaluate if survival was also equivalent in men ≥70 years old with early stage breast cancer treated with hormone therapy and lumpectomy with or without radiation therapy (RT), as shown in women.

Methods: We performed a retrospective analysis of 752 stage I (T1N0M0), estrogen receptor (ER) positive male breast cancer patients ≥70 years of age who were treated with hormone therapy and underwent lumpectomy with or without RT or total mastectomy (without RT) from the National Cancer Database (NCDB) between the years 2004 to 2014. Chi-squared, Kruskal-Wallis, and analysis of variance tests were used to compare demographic and clinicopathologic differences between groups. Multivariable Cox proportional hazards regression analysis was used to compare overall survival between treatment groups, controlling for demographic and clinicopathologic differences.

Results: Most patients underwent total mastectomy (67.4%), with only 32.6% treated with lumpectomy. Of those who underwent lumpectomy, 72.6% (n=178) underwent adjuvant RT. There were significant differences in age, tumor size, histology, grade, surgical margins, nodal surgery, and chemotherapy between patients who underwent lumpectomy without RT, lumpectomy with RT, and total mastectomy (p&lt;0.05). Lumpectomy without RT patients were older (78.9 vs. 76.0 & 76.9 years, p&lt;0.01), more frequently presented with invasive ductal carcinoma (77.6% vs. 71.3% & 85.4%, p&lt;0.0001), and less frequently underwent axillary nodal surgery including sentinel lymph node biopsy (71.7% vs. 91.6% & 94.9%, p&lt;0.0001) compared to lumpectomy with RT and total mastectomy patients. In multivariate analysis, there were no significant differences in overall survival for lumpectomy without RT, lumpectomy with RT (HR 0.71, 95%CI 0.39-1.27, p=0.25), and total mastectomy alone (HR 0.92, 95%CI 0.55-1.56, p=0.76). Older age, higher Charlson-Deyo comorbidity scores, and poorly differentiated tumors were associated with poorer overall survival, while treatment at an academic/research center was associated with improved overall survival (p&lt;0.05).

Conclusion: In this national sample of elderly ER positive male breast cancer patients with early disease on hormone therapy, lumpectomy alone was associated with equivalent survival compared to lumpectomy with RT and total mastectomy alone. These results suggest that breast conserving surgery without radiation therapy is appropriate for this subset of male breast cancer patients and greater adoption by breast surgeons should be considered.

Citation Format: Bateni SB, Arora M, Daly ME, Bold RJ, Canter RJ, Sauder CA. The role of lumpectomy and radiation therapy in men 70 years of age and older with early breast cancer on hormone therapy: A NCDB analysis [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-19-03.

Abstract P3-12-25: Dosimetric impact of patient rotation during prone breast radiotherapy

Purpose

Prone positioning has been used as a viable alternative to conventional supine position for patients receiving breast radiation therapy. However, little research has been done exploring the axial rotation of patients toward the treated breast when “sinking” into the opening of the breast board and its potentially negative effects on dosimetric outcomes, which may include increased heart and lung dose. The physician may need to move the posterior border away from the chest wall to reduce heart and lung dose.

Methodology

49 consecutive female patients with left sided early stage breast cancer treated at University of California Davis Medical Center were assessed from 2015 to 2018 (age range: 42-84 years, median age: 62 years). All patients underwent prone whole breast therapy with conventional external beam radiation therapy (EBRT) at doses of 50 Gy (n = 12) or hypofractionated at 42.56 Gy (n = 37). Treatment plans and dose volumes were retrospectively analyzed for each patient. Standard tangents were designed for each patient using clinical landmarks of the midaxillary line and midsternal line, which were then compared to the delivered tangent beams. The angle created between a vertical line centered on center sternum and a line drawn from center sternum to center spinal cord served to define degree of axial rotation. Breast depth was defined by the longest horizontal length from outer rib to edge of breast on sagittal view. Patients were divided into subgroups by degree of rotation and absolute breast depth. A two tailed paired Student's t-test was used for analysis.

Results

Overall mean heart and lung dose were 82.2 cGy and 50.43 cGy for the entire cohort, respectively. For standard tangents, patients with degree of rotation &lt; 5 degrees in the prone position (n = 23) had significant lung sparing as compared to patients with degree of rotation &gt; 5 cm (n = 26) (mean lung dose: 61.8 cGy vs 129.6 cGy, p = 0.00329). This was also seen for cardiac sparing (mean heart dose: 105.9 cGy vs 183.9 cGy, p = 0.000235). Even with reduction of posterior border for treatment delivery, there remained a significant increase in mean heart and lung dose with increased rotation (p = 0.038, p = 0.046). Although not statistically significant, for patients with &gt; 5 degrees of rotation there was a trend toward increased reduction of the posterior border of the tangent (13 mm vs. 7.5 mm, p = 0.13). A significant predictor of increased rotation was breast depth &gt; 10 cm (p = 0.01). Patients with absolute breast depth &gt; 10 cm (n = 23) in the prone position had significant lung sparing as compared to patients with absolute breast depth &lt; 10 cm (n = 26) (mean lung dose: 58.6 cGy vs 40.8 cGy, p = 0.042).

Conclusion

To our knowledge, this is the first dosimetric comparison of prone breast therapy exploring the degree of patient roll into the prone-breast setup cavity. This study demonstrates a significant increase in mean lung and heart dose when patient rotation is greater than 5 degrees. Given this, the posterior border may have to be reduced to prevent a higher than intended dose to the heart and lung. Proper attention during simulation is important to allow for optimal dose distribution and special attention should be paid to women with smaller breast size.

Citation Format: Cheng K, Hoopingarner S, Wright C, Daly M, Fragoso R, Zhao X. Dosimetric impact of patient rotation during prone breast radiotherapy [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 P3-12-25.

Supporting prescribing in Irish primary care: protocol for a non-randomised pilot study of a general practice pharmacist (GPP) intervention to optimise prescribing in primary care

Background

Prescribing for patients taking multiple medicines (i.e. polypharmacy) is challenging for general practitioners (GPs). Limited evidence suggests that the integration of pharmacists into the general practice team could improve the management of these patients. The aim of this study is to develop and test an intervention involving pharmacists, working within GP practices, to optimise prescribing in Ireland, which has a mixed public and private primary healthcare system.

Methods

This non-randomised pilot study will use a mixed-methods approach. Four general practices will be purposively sampled and recruited. A pharmacist will join the practice team for 6 months. They will participate in the management of repeat prescribing and undertake medication reviews (which will address high-risk prescribing and potentially inappropriate prescribing, deprescribing and cost-effective and generic prescribing) with adult patients. Pharmacists will also provide prescribing advice regarding the use of preferred drugs, undertake clinical audits, join practice team meetings and facilitate practice-based education. Throughout the 6-month intervention period, anonymised practice-level medication (e.g. medication changes) and cost data will be collected. A nested Patient Reported Outcome Measure (PROM) study will be undertaken during months 4 and 5 of the 6-month intervention period to explore the impact of the intervention in older adults (aged ≥ 65 years). For this, a sub-set of 50 patients aged ≥ 65 years with significant polypharmacy (≥ 10 repeat medicines) will be recruited from each practice and invited to a medication review with the pharmacist. PROMs and healthcare utilisation data will be collected using patient questionnaires, and a 6-week follow-up review conducted. Acceptability of the intervention will be explored using pre- and post-intervention semi-structured interviews with key stakeholders. Quantitative and qualitative data analysis will be undertaken and an economic evaluation conducted.

Discussion

This non-randomised pilot study will provide evidence regarding the feasibility and potential effectiveness of general practice-based pharmacists in Ireland and provide data on whether a randomised controlled trial of this intervention is indicated. It will also provide a deeper understanding as to how a pharmacist working as part of the general practice team will affect organisational processes and professional relationships in a mixed public and private primary healthcare system.

A systematic review of the relationship between weight status perceptions and weight loss attempts, strategies, behaviours and outcomes

It is commonly assumed that a person identifying that they are 'overweight' is an important prerequisite to successful weight management. However, there has been no systematic evaluation of evidence supporting this proposition. The aim of the present research was to systematically review evidence on the relationship between perceived overweight and (i) weight loss attempts, (ii) weight control strategies (healthy and unhealthy), (iii) weight-related behaviours (physical activity and eating habits), (iv) disordered eating and (v) weight change. We synthesized evidence from 78 eligible studies and evaluated evidence linking perceived overweight with outcome variables separately according to the gender, age and objective weight status of study participants. Results indicated that perceived overweight was associated with an increased likelihood of attempting weight loss and with healthy and unhealthy weight control strategies in some participant groups. However, perceived overweight was not reliably associated with physical activity or healthy eating and was associated with greater disordered eating in some groups. Rather than being associated with improved weight management, there was consistent evidence that perceived overweight was predictive of increased weight gain over time. Individuals who perceive their weight status as overweight are more likely to report attempting weight loss but over time gain more weight.

Phenotypic approaches to gene mapping in platelet function disorders

Platelet number or function disorders cause a range of bleeding symptoms from mild to severe. Patients with platelet dysfunction but normal platelet number are the most prevalent and typically have mild bleeding symptoms. The study of this group of patients is particularly difficult because of the lack of a gold-standard test of platelet function and the variable penetrance of the bleeding phenotype among affected individuals.

The purpose of this short review is to discuss the way in which this group of patients can be investigated through platelet phenotyping in combination with targeted gene sequencing. This approach has been used recently to identify patients with mutations in key platelet activation receptors, namely those for ADP, collagen and thromboxane A2 (TxA2). One interesting finding from this work is that for some patients, mild bleeding is associated with heterozygous mutations in platelet proteins that are co-inherited with other genetic disorders of haemostasis such as type 1 von Willebrand‘s disease. Thus, the phenotype of mild bleeding may be multifactorial in some patients and may be considered to be a complex trait.

Does pride really come before a fall? Longitudinal analysis of older English adults

OBJECTIVE

To test whether high levels of reported pride are associated with subsequent falls.

DESIGN

Secondary analysis of the English Longitudinal Study of Ageing (ELSA) dataset.

SETTING

Multi-wave longitudinal sample of non-institutionalised older English adults.

PARTICIPANTS

ELSA cohort of 6415 participants at wave 5 (baseline, 2010/11), of whom 4964 were available for follow-up at wave 7 (follow-up, 2014/15).

MAIN OUTCOME MEASURES

Self reported pride at baseline (low/moderate/high) and whether the participant had reported having fallen during the two years before follow-up.

RESULTS

The findings did not support the contention that "pride comes before a fall." Unadjusted estimates indicate that the odds of reported falls were significantly lower for people with high pride levels compared with those who had low pride (odds ratio 0.69, 95% confidence interval 0.58 to 0.81, P<0.001). This association remained after adjustment for age, sex, household wealth, and history of falls (odds ratio 0.81, 0.68 to 0.97, P<0.05). It was partially attenuated after further adjustment for mobility problems, eyesight problems, the presence of a limiting long term illness, a diagnosis of arthritis or osteoporosis, medication use, cognitive function, and pain and depression (odds ratio 0.86, 0.72 to 1.03, P<0.1). Because the confidence interval exceeded 1 in the final model, it remains possible that pride may not be an independent predictor of falls when known risk factors are considered. People with moderate pride did not have lower odds of having fallen than those with low pride in adjusted models. Participants lost to follow-up did not differ from those retained in terms of key variables, and weighting the analyses to account for selective attrition did not produce different results.

CONCLUSIONS

Contrary to the well known saying "pride comes before a fall," these findings suggest that pride may actually be a protective factor against falling in older adults. Future studies may seek to investigate the mechanisms underpinning this relation.

The RSNA Image Sharing Network

In the era of health information exchanges, there are trade-offs to consider when sharing a patient's medical record among all providers that a patient might choose. Exchange among in-network partners on the same electronic medical records (EMR) and other integrated information systems is trivial. The patient identifier is common, as are the relevant departmental systems, to all providers. Difficulties arise when patient records including images (and reports) must be shared among different networks and even with the patients themselves. The National Institutes of Health (NIH) challenged Radiological Society of North America (RSNA) to develop a transport method that could supersede the need for physical media (for patients or other providers), replace point-to-point private networks among providers, and enable image exchange on an ad hoc basis between arbitrary health networks without long legal delays. In concert with the evolving US health care paradigm, patient engagement was to be fundamental. With Integrating Healthcare Enterprise's (IHE's) help, the challenge has been met with an operational system.

Perceived weight status and risk of weight gain across life in US and UK adults

BACKGROUND

Correctly identifying oneself as being overweight is presumed to be a prerequisite to successful weight management. The present research examined the effect that perceiving oneself as being 'overweight' has on risk of future weight gain in US and UK adults.

METHODS

Data from three longitudinal studies; US National Longitudinal Study of Adolescent Health (Add Health) 2001/2002-2008/2009, UK National Child Development Study (NCDS) 1981-2002/2004, and Midlife in the United States (MIDUS) 1995/1996-2004/2005, were used to examine the impact of perceiving oneself as being overweight on weight gain across adulthood in over 14 000 US and UK adults.

RESULTS

Participants who perceived their weight status as being overweight were at an increased risk of subsequent weight gain. This effect was observed irrespective of weight status at baseline and whether weight status perceptions were accurate or inaccurate. In the MIDUS sample, perceiving oneself as being overweight was associated with overeating in response to stress and this mediated the relationship between perceived overweight and weight gain.

CONCLUSIONS

Perceiving oneself as being 'overweight' is counter-intuitively associated with an increased risk of future weight gain among US and UK adults.

Use of next-generation sequencing and candidate gene analysis to identify underlying defects in patients with inherited platelet function disorders

BACKGROUND

Inherited platelet function disorders (PFDs) are heterogeneous, and identification of the underlying genetic defects is difficult when based solely on phenotypic and clinical features of the patient.

OBJECTIVE

To analyze 329 genes regulating platelet function, number, and size in order to identify candidate gene defects in patients with PFDs.

PATIENTS/METHODS

Targeted analysis of candidate PFD genes was undertaken after next-generation sequencing of exomic DNA from 18 unrelated index cases with PFDs who were recruited into the UK Genotyping and Phenotyping of Platelets (GAPP) study and diagnosed with platelet abnormalities affecting either Gi signaling (n = 12) or secretion (n = 6). The potential pathogenicity of candidate gene defects was assessed using computational predictive algorithms.

RESULTS

Analysis of the 329 candidate PFD genes identified 63 candidate defects, affecting 40 genes, among index cases with Gi signaling abnormalities, while 53 defects, within 49 genes, were identified among patients with secretion abnormalities. Homozygous gene defects were more commonly associated with secretion abnormalities. Functional annotation analysis identified distinct gene clusters in the two patient subgroups. Thirteen genes with significant annotation enrichment for 'intracellular signaling' harbored 16 of the candidate gene defects identified in nine index cases with Gi signaling abnormalities. Four gene clusters, representing 14 genes, with significantly associated gene ontology annotations were identified among the cases with secretion abnormalities, the most significant association being with 'establishment of protein localization.'

CONCLUSION

Our findings demonstrate the genetic complexity of PFDs and highlight plausible candidate genes for targeted analysis in patients with platelet secretion and Gi signaling abnormalities.

Helical tomotherapy with simultaneous integrated boost dose painting for the treatment of synchronous primary cancers involving the head and neck

OBJECTIVE

To demonstrate the feasibility of helical tomotherapy (HT)-based intensity-modulated radiotherapy (IMRT) for the treatment of synchronous primary cancers arising from the head and neck.

METHODS

14 consecutive patients with histologically proven squamous cell carcinoma of the head and neck were determined to have a second primary cancer in the upper aerodigestive tract on further evaluation and were treated with HT using simultaneous integrated boost IMRT. Megavoltage CT scans were acquired daily as part of an image-guided registration protocol. Concurrent platinum-based systemic therapy was given to nine patients (64%).

RESULTS

HT resulted in durable local control in 21 of the 28 primary disease sites irradiated, including a complete clinical and radiographic response initially observed at 17 of the 20 sites with gross tumour. The mean displacements to account for interfraction motion were 2.44 ± 1.25, 2.92 ± 1.09 and 2.31 ± 1.70 mm for the medial-lateral (ML), superior-inferior (SI) and anteroposterior (AP) directions, respectively. Table shifts of >3 mm occurred in 19%, 20% and 22% of the ML, SI and AP directions, respectively. The 2-year estimates of overall survival, local-regional control and progression-free survival were 58%, 73% and 60%, respectively.

CONCLUSION

The effectiveness of HT for the treatment of synchronous primary cancers of the head and neck was demonstrated.

ADVANCES IN KNOWLEDGE

HT is a feasible option for synchronous primary cancers of the head and neck and can result in long-term disease control with acceptable toxicity in appropriately selected patients.

A novel mutation in the P2Y12 receptor and a function-reducing polymorphism in protease-activated receptor 1 in a patient with chronic bleeding

BACKGROUND

The study of patients with bleeding problems is a powerful approach in determining the function and regulation of important proteins in human platelets. We have identified a patient with a chronic bleeding disorder expressing a homozygous P2RY(12) mutation, predicting an arginine to cysteine (R122C) substitution in the G-protein-coupled P2Y(12) receptor. This mutation is found within the DRY motif, which is a highly conserved region in G-protein-coupled receptors (GPCRs) that is speculated to play a critical role in regulating receptor conformational states.

OBJECTIVES

To determine the functional consequences of the R122C substitution for P2Y(12) function.

PATIENT/METHODS

We performed a detailed phenotypic analysis of an index case and affected family members. An analysis of the variant R122C P2Y(12) stably expressed in cells was also performed.

RESULTS

ADP-stimulated platelet aggregation was reduced as a result of a significant impairment of P2Y(12) activity in the patient and family members. Cell surface R122C P2Y(12) expression was reduced both in cell lines and in platelets; in cell lines, this was as a consequence of agonist-independent internalization followed by subsequent receptor trafficking to lysosomes. Strikingly, members of this family also showed reduced thrombin-induced platelet activation, owing to an intronic polymorphism in the F2R gene, which encodes protease-activated receptor 1 (PAR-1), that has been shown to be associated with reduced PAR-1 receptor activity.

CONCLUSIONS

Our study is the first to demonstrate a patient with deficits in two stimulatory GPCR pathways that regulate platelet activity, further indicating that bleeding disorders constitute a complex trait.

Abstract P2-12-05: Exploring the experience of relatives with whom genetic test results are communicated

There is increasing interest in the psychosocial impact of genetic testing, both on the individual who has been tested and on family members who could benefit from knowing the test results. The responsibility for informing relatives of genetic test results falls on the proband, the first family member being tested. While there is limited data about the reaction of relatives with whom genetic test results are shared, there is some evidence that open, positive family relationships increase the likelihood of disclosure of test results while emotional distance, family conflict, and loss of contact decrease the likelihood of disclosure. We explored the communication process between probands undergoing genetic testing for BRCA1/2 and their first degree relatives with whom they shared results. Four hundred twenty two women were randomized to a communication skills-building intervention or a wellness control session. Overall, probands shared their test result with 80% of eligible relatives. As part of this study, relatives were surveyed by phone regarding factors associated with the communication process, and their ability to understand and cope with the information provided to them by the proband. This study focuses on 438 relatives (of 253 probands) who reported that test results were shared. The percent of relatives with whom genetic test results were shared did not differ by study group. However, there were significant differences across gender and generation. Female relatives were more likely to receive genetic test results (p = 0.0001), and adult children were more likely to receive genetic test results than either parents or siblings (p = 0.0006). Both positive and true negative test results were more likely to be communicated to relatives than indeterminate or inconclusive results. Comparing the actual test result of the proband with that reported by the relative, we found that 26% of relatives cited an incorrect test result, and this number did not differ by study group. Positive test results were the most likely to be correctly understood by the relatives (90%), while inconclusive test results were the least likely to be correctly understood (60%) (p = 0.005). When asked about their reaction to receipt of test results, 32% of relatives reported difficulty in understanding the test result, and 27% were upset with the information they received. Of those relatives whose proband received a positive test result, only 52% reported intention to pursue testing for themselves. Similarly, only 36% of relatives whose proband received true negative test results intended to pursue testing, implying the relatives did not fully understand the significance of these informative results for their own risk These findings indicate that sharing of genetic test results by probands to their adult first degree relatives is variable, that the information shared is often not well understood, and that there is significant distress associated with the sharing of test results on the part of the relatives. These findings suggest that relying on the probands to share their test results with their relatives is fraught with limitations which may compromise the value of the information for the relatives.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-12-05.

Clinical-dosimetric relationship between lacrimal gland dose and ocular toxicity after intensity-modulated radiotherapy for sinonasal tumours

OBJECTIVE

To characterise the relationship between lacrimal gland dose and ocular toxicity among patients treated by intensity-modulated radiotherapy (IMRT) for sinonasal tumours.

METHODS

40 patients with cancers involving the nasal cavity and paranasal sinuses were treated with IMRT to a median dose of 66.0 Gy. Toxicity was scored using the Radiation Therapy Oncology Group morbidity criteria based on conjunctivitis, corneal ulceration and keratitis. The paired lacrimal glands were contoured as organs at risk, and the mean dose, maximum dose, V10, V20 and V30 were determined. Statistical analysis was performed using logistic regression and the Akaike information criterion (AIC).

RESULTS

The maximum and mean dose to the ipsilateral lacrimal gland were 19.2 Gy (range, 1.4-75.4 Gy) and 14.5 Gy (range, 11.1-67.8 Gy), respectively. The mean V10, V20 and V30 values were 50%, 25% and 17%, respectively. The incidence of acute and late Grade 3+ toxicities was 23% and 19%, respectively. Based on logistic regression and AIC, the maximum dose to the ipsilateral lacrimal gland was identified as a more significant predictor of acute toxicity (AIC, 53.89) and late toxicity (AIC, 32.94) than the mean dose (AIC, 56.13 and 33.83, respectively). The V20 was identified as the most significant predictor of late toxicity (AIC, 26.81).

CONCLUSION

A dose-response relationship between maximum dose to the lacrimal gland and ocular toxicity was established. Our data suggesting a threshold relationship may be useful in establishing dosimetric guidelines for IMRT planning that may decrease the risk of acute and late lacrimal toxicities in the future.

ADVANCES IN KNOWLEDGE

A threshold relationship between radiation dose to the lacrimal gland and ocular toxicity was demonstrated, which may aid in treatment planning and reducing the morbidity of radiotherapy for sinonasal tumours.

Smart consultation for musculoskeletal trauma: accuracy of using smart phones for fracture diagnosis

INTRODUCTION

Musculoskeletal trauma occupies a significant proportion of the daily workload of most Emergency and Radiology departments. The diagnosis and management of patients with musculoskeletal trauma often require assessment of radiographs along with clinical assessment. With the advent of smart phones we hypothesised that they could be used as a means of smarter communication, particularly for the transfer of radiographic images between healthcare professionals.

PATIENTS AND METHOD

We performed a cross sectional study using thirty radiographs each of the distal radius, ankle and hip. The study was approved by Ethics Committee and all data were anonymized in accordance to Caldicott guidelines and data protection act 1998. Photographs of radiographs were taken using an iphone camera and sent to three independent Orthopaedic Registrars via Multimedia messaging service (MMS). Each Registrar independently assessed these images on their smart phone display in their own time and recorded the specific diagnosis along with the classification of fractures and specific treatment plan. The accuracy of diagnosis on smart phone was measured against the radiology report; and inter observer agreement was assessed among registrars for classification and treatment plan.

RESULTS

The overall accuracy of fracture diagnosis was 97.7% with sensitivity of 100% and specificity of 94.4%. The inter observer agreement analysis showed kappa (k) values of 0.67, 0.67 and 0.71 for classification of wrist, ankle and hip fractures respectively showing substantial agreement while kappa values for management plan were 0.65, 0.88 and 0.65 for the three fractures respectively showing substantial to near perfect agreement.

CONCLUSION

This study suggests that smart phone can be used as a safe and accurate tool for skeletal trauma consultation among oncall doctors and can help reduce the waiting time in emergency departments.