IDEA tool: Establishing a prioritisation matrix for oral health improvement interventions

Initial impetus for action: Oral health is not equitably distributed. More deprived areas experience appreciably worse oral health outcomes. Oral health improvement programmes in Local Authorities (LA) seek to reduce these inequalities but have diminished in recent years following the COVID-19 pandemic. LAs have also endured funding cuts to public health budgets, placing a greater emphasis on the need for establishing a clear prioritisation matrix for oral health improvement interventions. Solution: A prioritisation matrix that considered both the importance and do-ability of oral health improvement interventions was developed. Both are composite measures. The importance comprised evidence of benefit, impact on inequalities, alignment with national/local priorities and cost-effectiveness of the intervention. The do-ability considered the available support from stakeholders, building/equipment requirements, workforce issues and investment funding. A working group was necessary to inform the do-ability aspect of the prioritisation matrix. Scores were assigned to each criterion, the sum of the scores informed whether the intervention was eliminated, aspirational or implemented based on predetermined thresholds. Outcome: The prioritisation matrix ensured a transparent and systematic approach for intervention selection, which reflected local resources and priorities. Moreover, this tool should help ensure the most effective, equitable, practical and sustainable interventions are chosen having the greatest impact on improving oral health outcomes.

The Thresholds of Caprini Score Associated With Increased Risk of Venous Thromboembolism Across Different Specialties: A Systematic Review

OBJECTIVE

Estimation of the specific thresholds of the Caprini risk score (CRS) that are associated with the increased incidence of venous thromboembolism (VTE) across different specialties, including identifying the highest level of risk.

BACKGROUND

Accurate risk assessment remains an important but often challenging aspect of VTE prophylaxis. One well-established risk assessment model is CRS, which has been validated in thousands of patients from many different medical and surgical specialties.

METHODS

A search of MEDLINE and the Cochrane Library was performed in March 2022. Manuscripts that reported on (1) patients admitted to medical or surgical departments and (2) had their VTE risk assessed by CRS and (3) reported on the correlation between the score and VTE incidence, were included in the analysis.

RESULTS

A total of 4562 references were identified, and the full text of 202 papers was assessed for eligibility. The correlation between CRS and VTE incidence was reported in 68 studies that enrolled 4,207,895 patients. In all specialties, a significant increase in VTE incidence was observed in patients with a CRS of ≥5. In most specialties thresholds of ≥7, ≥9, and ≥11 to 12 were associated with dramatically increased incidences of VTE. In COVID-19, cancer, trauma, vascular, general, head and neck, and thoracic surgery patients with ≥9 and ≥11 to 12 scores the VTE incidence was extremely high (ranging from 13% to 47%).

CONCLUSION

The Caprini score is being used increasingly to predict VTE in many medical and surgical specialties. In most cases, the VTE risk for individual patients increases dramatically at a threshold CRS of 7 to 11.

Detailed analysis of in-hospital transmission of SARS-CoV-2 using whole genome sequencing

BACKGROUND

Hospital transmission of SARS-CoV-2 has proved difficult to control, with healthcare-associated infections troublesome throughout.

AIM

To understand factors contributing to hospital transmission of infections, which is necessary for containing spread.

METHODS

An outbreak of 56 staff and patient cases of COVID-19 over a 31-day period in a tertiary referral unit is presented, with at least a further 29 cases identified outside of the unit and the hospital by whole genome sequencing (WGS).

FINDINGS

Transmission is documented from staff to staff, staff to patients, and patients to staff, showing disruption of a tertiary referral service, despite implementation of nationally recommended control measures, superior ventilation, and use of personal protective equipment. There was extensive spread from the index case, despite this patient spending only 10 h bed bound on the ward in strict cubicle isolation and with an initial single target low level (C_T = 32) polymerase chain reaction test.

CONCLUSION

This investigation highlights how effectively and rapidly SARS-CoV-2 can spread in certain circumstances. It raises questions about infection control measures in place at the time and calls into question the premise that transmissibility can be reliably detected by using lower sensitivity rapid antigen lateral flow tests. We also highlight the value of early intervention in reducing impact as well as the value of WGS in understanding outbreaks.

Resumption of Elective Orthopaedic Surgery in the US Epicenter of COVID-19: Overcoming the Continuous Challenges

On 1 March 2020, New York State confirmed its first case of COVID-19. An explosive progression of hospitalizations ensued, and all elective surgeries were cancelled between 23 March and 13 May 2020 per federal and state mandate. Upon return to elective surgery in May, 2020, the hospital found itself navigating uncharted territory. The unpredictability of the post-pandemic environment has required the healthcare team to constantly reassess and revise processes to ensure optimal patient outcomes, as well as safe practices for staff providing perioperative care. Health care professionals must continue to remain adaptable and amenable to constant change.

Utilization of the Caprini Score for Risk Stratification of the Arthroplasty Patient in the Prevention of Postoperative Venous Thrombosis

Venous thromboembolism (VTE) is a serious and predictable complication following arthroplasty. It has been recognized that a strategy utilizing individualized anticoagulation choices based on patient risk stratification results in improved patient outcomes. A 2013 version of the Caprini Risk Score has previously been validated for use in total joint arthroplasty. A Caprini score of 10 or greater assesses the patient as "high risk" while 9 or less is considered "low risk." Patients scored as "low risk" for postoperative VTE receive enteric coated aspirin 81 mg twice a day for 6 weeks. Patients scored as "high risk" for VTE are prescribed apixaban. This retrospective cohort study was conducted to assess the safety and efficacy of the thromboprophylaxis treatment prescribed based on a standardized risk assessment protocol for the calendar year 2020. Patients having total hip arthroplasty, total knee arthroplasty, revision total hip arthroplasty, revision total knee arthroplasty, or bilateral arthroplasties by 13 surgeons (N = 873) were reviewed. Patients were risk assessed using the Caprini Risk Score and thromboprophylaxis was prescribed based on the score obtained. The annual rate of VTE was 0.2%. The Caprini Risk Score is an effective approach to individualize thromboprophylaxis choices after total joint arthroplasty.

Interaction Between Low-Dose Aspirin and Nonsteroidal Anti-Inflammatory Drugs Can Compromise Aspirin's Efficacy in Preventing Venous Thrombosis Following Total Joint Arthroplasty

Total joint arthroplasty is a rapid recovery procedure with patients optimized quickly in preparation for discharge. Two significant postoperative goals are effective pain management and prevention of postoperative venous thromboembolism (VTE). Low-risk patients receive aspirin 81 mg twice daily for VTE prophylaxis; this dosing regimen has been reduced over the past few years from 325 mg to 162 mg to 81 mg twice daily. Unless contraindications exist, all patients receive multimodal pain management that includes the use of celecoxib or meloxicam. Upon reduction of the aspirin dose to 81 mg twice daily, we rapidly identified 2 patients who developed a pulmonary embolus when celecoxib or meloxicam was administered concurrently with aspirin. The interaction between nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin varies among the different NSAIDs. It is also highly dependent on numerous factors, including time of administration, dose of aspirin, and both pharmacodynamics and dose of the NSAID. Real-world outcomes of concomitant administration of NSAIDs with low-dose aspirin led to increased incidence of VTE, possibly due to competitive inhibition of aspirin at platelet receptor sites. This interaction was mitigated by altering the administration times of both agents.

Resumption of Elective Orthopaedic Surgery in the US Epicenter of COVID-19

On March 1, 2020, New York State confirmed its first case of COVID-19. This state has had the largest initial mortality in the United States with more than 479,000 confirmed cases and over 25,000 deaths as of October 10, 2020. All elective surgeries in New York State were suspended on March 23, 2020, due to the national state of emergency. Syosset Hospital is a 75-bed community hospital dedicated primarily to elective surgery. During the COVID-19 surge, the hospital was converted to provide needed beds for the treatment of COVID-19 illness. In anticipation of the resumption of urgent elective procedures, this hospital became one of the two designated sites within the Northwell Health system to be “non-COVID.” Once the hospital was emptied of all inpatients, a complete and thorough cleaning and disinfection was performed on the entire building. All equipment was thoroughly decontaminated following Centers for Disease Control and Prevention (CDC) guidelines. In anticipation of the resumption of elective surgery, each surgeon evaluated their cancelled case list to determine patient priority, based on a scale of 1 (elective, non-urgent), 2 (semi-urgent), 3 (urgent), to 4 (highly urgent). Site-specific disaster credentialing was expedited so that emergent surgeries could be performed by surgeons located at other Northwell sites. To ensure a structured and informative onboarding process, each visiting surgeon received a “welcome” email which requested pertinent information to facilitate the surgical process. Presurgical, surgical, and postoperative protocols were revised based on federal and local guidance and regulations. Resumption of elective surgery post COVID-19 placed the hospital into uncharted territory.

Impact of Reducing Water Fluoride on Dental Caries and Fluorosis

Guidance intended to reduce fluoride toothpaste ingestion in early childhood was introduced in Ireland in 2002. In 2007, water fluoride concentration was adjusted from 0.8-1.0 to 0.6-0.8 ppm. The objective of this study was to determine the difference in caries and fluorosis levels following introduction of these 2 policy measures. A before-and-after study compared caries and fluorosis in random samples of 8-y-olds in Dublin (n = 707) and Cork-Kerry (n = 1148) in 2017 with 8-y-olds in Dublin (n = 679) and Cork-Kerry (n = 565) in 2002. Dentinal caries experience (primary teeth, d_3vcmft(cde)) and fluorosis (permanent teeth, Dean's index of very mild or higher) were clinically measured. Lifetime exposure to community water fluoridation (CWF) was classified as "full CWF"/"no CWF." Effect of examination year on caries prevalence and severity and fluorosis prevalence was assessed using multivariate regression adjusting for other explanatory variables. There was little change in commencement of fluoride toothpaste use at ≤24 mo following introduction of toothbrushing guidance. Among children with full CWF, there was no statistically significant difference in caries prevalence or severity between 2017 and 2002. In 2017, caries prevalence was 55% in Dublin (full CWF) and 56% in Cork-Kerry (full CWF), and mean d_3vcmft(cde) among children with caries was 3.4 and 3.7, respectively. Caries severity was less in 2017 (mean 4.2) than 2002 (mean 4.9) among children with no CWF (P = 0.039). The difference in caries severity between children with full CWF and no CWF was less in 2017 than in 2002 (interaction P = 0.013), suggesting a reduced benefit for CWF in 2017. In 2017, fluorosis prevalence was 18% in Dublin (full CWF) and 12% in Cork-Kerry (full CWF). Fluorosis was predominantly "very mild" with no statistically significant difference between 2017 and 2002. CWF at 0.6 to 0.8 ppm is an effective caries-preventive measure. Results suggested low uptake of toothbrushing guidance, a reduced caries-preventive effect for CWF in primary teeth, and no reduction in fluorosis following introduction of the policy measures.

Malignant peripheral nerve sheath tumor of the sciatic nerve presenting with leg pain in the setting of lumbar scoliosis and spinal stenosis

STUDY DESIGN

Case report.

OBJECTIVE

We present a case of malignant peripheral nerve sheath tumor (MPNST) presenting as neuropathic pain in the setting of lumbar scoliosis and spinal stenosis. Most peripheral nerve sheath tumors are benign, and malignant cases are more commonly associated with neurofibromatosis type 1 or prior radiation exposure. MPNST is a rare tumor with a poor prognosis. We report a case of MPNST that presented as neuropathic pain following lumbar decompression and fusion surgery.

METHODS

A 60-year-old woman presented for management of lumbar scoliosis, stenosis, and left leg pain. After lumbar decompression and fusion surgery, the patient was readmitted to the hospital after falling 10 weeks post-op. She reported gradual recurrence of leg pain. Left foot drop was noted on exam. Imaging studies showed no spinal changes postoperatively or residual stenosis. Obesity limited electrodiagnostic studies. Hip MRI revealed a lobular soft tissue mass in the left sciatic notch. Surgical resection and pathology provided the diagnosis of MPNST. The patient declined wide resection and other interventions after seeking a second opinion. Palliative pain management was implemented.

RESULTS

The patient expired 15 months after her index spinal surgery.

CONCLUSIONS

MPNST is an extremely rare tumor that can present with symptoms similar to radiculitis. Clinical signs and symptoms of MPNST are vague and nonspecific due to compression of surrounding structures. Surgical wide resection is the first line of treatment for MPNST with chemotherapy and radiotherapy as adjuvant treatments. MPNST has a poor prognosis with reported 5-year survival ranging from 16 to 54%. This case demonstrates the need to pursue additional workup when diagnostic imaging and objective findings do not satisfactorily explain the clinical presentation.

LEVEL OF EVIDENCE

IV.

Lessons Learned: Using the Caprini Risk Assessment Model to Provide Safe and Efficacious Thromboprophylaxis Following Hip and Knee Arthroplasty

Two of the more common potential complications after arthroplasty are venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolus (PE), and excess bleeding. Appropriate chemoprophylaxis choices are essential to prevent some of these adverse events and from exacerbating others. Risk stratification to prescribe safe and effective medications in the prevention of postoperative VTE has shown benefit in this regard. The Department of Orthopaedic Surgery at Syosset Hospital/Northwell Health, which performs over 1200 arthroplasties annually, has validated and is using the 2013 version of the Caprini Risk Assessment Model (RAM) to stratify each patient for risk of postoperative VTE. This tool results in a culling of information, past and present, personal and familial, that provides a truly thorough evaluation of the patient's risk for postoperative VTE. The Caprini score then guides the medication choices for thromboprophylaxis. The Caprini score is only valuable if the data is properly collected, and we have learned numerous lessons after applying it for 18 months. Risk stratification requires practice and experience to achieve expertise in perioperative patient evaluation. Having access to pertinent patient information, while gaining proficiency in completing the Caprini RAM, is vital to its efficacy. Ongoing, real time analyses of patient outcomes, with subsequent change in process, is key to improving patient care.

Implementation and Validation of the 2013 Caprini Score for Risk Stratification of Arthroplasty Patients in the Prevention of Venous Thrombosis

Appropriate chemoprophylaxis choice following arthroplasty requires accurate patient risk assessment. We compared the results of our prospective department protocol to the Caprini risk assessment model (RAM) retrospectively in this study group. Our goal was to determine whether the department protocol or the Caprini score would identify venous thromboembolism (VTE) events after total joint replacement. A secondary purpose was to validate the 2013 Caprini RAM in joint arthroplasty and determine whether patients with VTE would be accurately identified using the Caprini score. A total of 1078 patients met inclusion criteria. A Caprini score of 10 or greater is considered high risk and a score of 9 or less is considered low risk. The 2013 version of the Caprini RAM retrospectively stratified 7 of the 8 VTE events correctly, while only 1 VTE was identified with the prospective department protocol. This tool provided a consistent, accurate, and efficacious method for risk stratification and selection of chemoprophylaxis.

Completion of the Updated Caprini Risk Assessment Model (2013 Version)

The Caprini risk assessment model (RAM) has been validated in over 250 000 patients in more than 100 clinical trials worldwide. Ultimately, appropriate treatment options are dependent on precise completion of the Caprini RAM. As the numerical score increases, the clinical venous thromboembolism rate rises exponentially in every patient group where it has been properly tested. The 2013 Caprini RAM was completed by specially trained medical students via review of the presurgical assessment history, medical clearances, and medical consults. The Caprini RAM was completed for every participant both preoperatively and predischarge to ensure that any changes in the patient’s postoperative course were captured by the tool. This process led to the development of completion guidelines to ensure consistency and accuracy of scoring. The 2013 Caprini scoring system provides a consistent, thorough, and efficacious method for risk stratification and selection of prophylaxis for the prevention of venous thrombosis.

An RCT of atraumatic restorative treatment for older adults: 5 year results

OBJECTIVES

to compare the survival of ART and a conventional restorative technique (CT) for restoring carious lesions in older adults after 5 years.

METHODS

In this parallel randomised controlled clinical trial, 219 independently-living adults were recruited from a dental hospital/community and a geriatric day hospital. Ninety-nine patients who met the inclusion criteria and presented with carious lesions were randomly allocated to receive either ART or conventional restorations (anaesthesia, rotary instruments and resin-modified glass ionomer). The status of restorations was assessed 6 months, 1, 2 and 5 years after restoration placement. Estimates of cumulative survival were calculated for each interval between assessments and a Cox Proportional Hazards (PH) model was fitted to the interval-censored survival time.

RESULTS

Three hundred restorations (ART n=142; CT n=158) were placed on 99 patients, 46 males and 53 females, with a mean age of 73.2, SD: 6.8 (65-90 yrs). After 5 years, ART and CT presented cumulative probability of survival of 85% and 79% (p=0.8095), respectively.

CONCLUSIONS

ART presents survival rates comparable to a conventional technique, when treating older adults after 5 years. The ART approach could be a useful tool to provide dental care for older adults particularly in the nonclinical setting. (Trial Registration number: ISRCTN 76299321).

CLINICAL RELEVANCE

This study shows that ART presents survival rates comparable to conventional techniques to treat carious lesions in older patients after 5 years. It is well accepted by this age cohort, and therefore could be an alternative to treat the elderly, especially those who are homebound or cannot attend the dentist.

The Effect of BMI and Gender on Bleeding Events when Rivaroxaban Is Administered for Thromboprophylaxis Following Total Hip and Total Knee Arthroplasty

Rivaroxaban is approved in Europe and the United States for thromboprophylaxis following total joint arthroplasty. As the rate of obesity increases, confirming safety and efficacy in this patient population is paramount. This retrospective chart review assessed the efficacy and safety of rivaroxaban between two body mass index (BMI) groups: normal or overweight (< 30 kg/m2) and obese or morbidly obese (≥30 kg/m2). Safety outcome was a major bleeding event, defined as a decrease in hemoglobin of at least 2 g/dL from postoperative day 1(POD 1) to discharge or a blood transfusion of at least two units. Efficacy outcome was venous thromboembolism within 35 days postoperatively. There were 68 (68/1,241; 5.48%) major bleeding events. There was no significant association between major bleeding events and BMI in the univariable analysis (p < 0.36). However, after adjusting for other factors in the multivariable model, there was a significant interaction between BMI and gender (p < 0.001). Among males, the incidence of major bleeding events was three times greater in obese/morbidly obese subjects as compared with normal/overweight male subjects (odds ratio [OR]: 3.09, 95% confidence interval [CI]: 1.25, 7.62). Among females, incidence of having a major bleeding event was almost two times greater in normal/overweight subjects as compared with obese/morbidly obese female subjects (OR: 2.17, 95% CI: 1.10, 4.35). Incidence of venous thromboembolism was 0.4% in each group. The authors' study results highlight a previously unexplored association between BMI and gender-dependent differences in bleeding outcomes when rivaroxaban is used for thromboprophylaxis following total joint arthroplasty.

A Retrospective Audit of In-Hospital 30-day Mortality from Acute Myocardial Infarction in Connolly Hospital Blanchardstown

In 2015, The Department of Health published the first annual report of the "National Healthcare Quality Reporting System." Connolly Hospital was reported to a mortality rate within 30 days post-Acute Myocardial Infarction (AMI) of 9.87 per 100 cases which was statistically significantly higher than the national rate. We carried out a retrospective audit of patients who were HIPE-coded as having died within 30 days of AMI from 2011-2013 and identified 42 patients. On review, only 23 patients (54.8%) were confirmed as having had an AMI. We identified 12 patients who had AMI included on death certificate without any evidence for same. If the 22 patients incorrectly coded were excluded, the mortality rate within 30 days post-AMI in CHB would fall to 4.14 deaths per 100 cases, well below the national average. Inaccuracies of data collection can lead to erroneous conclusions when examining healthcare data.

Use of Intravenous Tranexamic Acid Improves Early Ambulation After Total Knee Arthroplasty and Anterior and Posterior Total Hip Arthroplasty

We conducted a retrospective cohort study (N = 477) to determine if use of intravenous tranexamic acid (TXA) improves early ambulation and reduces blood loss after total knee arthroplasty and anterior and posterior total hip arthroplasty. Mean (SD) patient age was 66.5 (10.1) years. For all 3 procedures, early ambulation was significantly better in the TXA group than in the no-TXA group at postoperative days 1 and 2, and, over time, reductions in hemoglobin and hematocrit were statistically significantly lower in the TXA group than in the no-TXA group. TXA groups required fewer postoperative transfusions. Incidence of postoperative venous thromboembolism was similar between all groups. TXA use improves early ambulation after total joint arthroplasty.

Spatial Overlap of Grey Seals and Fisheries in Irish Waters, Some New Insights Using Telemetry Technology and VMS

Seals and humans often target the same food resource, leading to competition. This is of mounting concern with fish stocks in global decline. Grey seals were tracked from southeast Ireland, an area of mixed demersal and pelagic fisheries, and overlap with fisheries on the Celtic Shelf and Irish Sea was assessed. Overall, there was low overlap between the tagged seals and fisheries. However, when we separate active (e.g. trawls) and passive gear (e.g. nets, lines) fisheries, a different picture emerged. Overlap with active fisheries was no different from that expected under a random distribution, but overlap with passive fisheries was significantly higher. This suggests that grey seals may be targeting the same areas as passive fisheries and/or specifically targeting passive gear. There was variation in foraging areas between individual seals suggesting habitat partitioning to reduce intra-specific competition or potential individual specialisation in foraging behaviour. Our findings support other recent assertions that seal/fisheries interactions in Irish waters are an issue in inshore passive fisheries, most likely at the operational and individual level. This suggests that seal population management measures would be unjustifiable, and mitigation is best focused on minimizing interactions at nets.

Acute Renal Infarction After Lateral Lumbar Interbody Spinal Fusion for Kyphoscoliosis

STUDY DESIGN

Case report.

OBJECTIVES

Case report of acute renal infarction following lateral interbody fusion with posterior instrumentation for adult lumbar kyphoscoliosis.

SUMMARY OF BACKGROUND DATA

This is the first reported renal infarction following minimally invasive lateral interbody fusion and posterior spinal instrumentation.

METHODS

We report a case of acute renal infarction in a 72-year-old woman following direct lateral interbody fusion (DLIF) with percutaneous pedicle screw and rod fixation from L1 to L5 for correction of kyphoscoliosis. She reported vague abdominal pain on postoperative day (POD) 7. Abdominal ultrasound findings revealed no abnormalities. The patient tolerated a regular diet, improved in rehabilitative modalities, and had stable vital signs. Abdominal computed tomographic (CT) scan on POD 9 for persistent abdominal pain revealed right renal infarction and right renal artery occlusion. The patient was transferred to the ICU for evaluation, where intravenous heparin was administered and no reperfusion was performed. Transesophageal echocardiography on POD 14 revealed moderate diffuse plaque in the descending aorta.

RESULTS

Surgical correction of kyphoscoliosis through DLIF and posterior spinal instrumentation was performed with improvement of deformity. Subsequent acute renal infarction was noted. The patient was discharged home on POD 21. There were no further adverse events up to the 1-year follow-up.

CONCLUSIONS

A lateral approach to the anterior lumbar spine may precipitate renal artery occlusion and renal infarction in patients with atherosclerosis. Diagnosis of renal infarction requires a high index of suspicion because the primary complaint may be vague back, flank, and abdominal pain. We emphasize the importance of recognizing potential symptoms early to prevent additional renal injury. Caution should be taken with deformities around the origin of the renal arteries and great vessels, especially in patients with atherosclerosis.

LEVEL OF EVIDENCE

Level IV.

Bacterial-mediated DNA delivery to tumour associated phagocytic cells

Phagocytic cells including macrophages, dendritic cells and neutrophils are now recognised as playing a negative role in many disease settings including cancer. In particular, macrophages are known to play a pathophysiological role in multiple diseases and present a valid and ubiquitous therapeutic target. The technology to target these phagocytic cells in situ, both selectively and efficiently, is required in order to translate novel therapeutic modalities into clinical reality. We present a novel delivery strategy using non-pathogenic bacteria to effect gene delivery specifically to tumour-associated phagocytic cells. Non-invasive bacteria lack the ability to actively enter host cells, except for phagocytic cells. We exploit this natural property to effect 'passive transfection' of tumour-associated phagocytic cells following direct administration of transgene-loaded bacteria to tumour regions. Using an in vitro-differentiated human monocyte cell line and two in vivo mouse models (an ovarian cancer ascites and a solid colon tumour model) proof of delivery is demonstrated with bacteria carrying reporter constructs. The results confirm that the delivery strategy is specific for phagocytic cells and that the bacterial vector itself recruits more phagocytic cells to the tumour. While proof of delivery to phagocytic cells is demonstrated in vivo for solid and ascites tumour models, this strategy may be applied to other settings, including non-cancer related disease.

Abstract PD02-07: Next-generation sequencing of FFPE breast cancers demonstrates high concordance with FISH in calling HER2 amplifications and commonly detects other clinically relevant genomic alterations

Background: As more therapies targeting genomic alterations become available, next-generation sequencing (NGS) is increasingly performed in tumor types where mutational status may drive treatment choice. In addition to its ability to identify base substitutions, insertions and deletions across entire exons, NGS can detect relevant copy number changes such as amplification of HER2 in breast tumors. However, for NGS to be clinically applicable, it must reliably analyze FFPE tumor samples and show concordance with the best current diagnostic methods.

Methods: To confirm a clinical role for NGS in detecting copy number alterations, we identified 35 FFPE invasive breast carcinomas previously tested for HER2 status by FISH, including 15 HER2 positives (≥7 copies) and 20 HER2 negatives (&lt;4 copies) and sequenced 3,230 exons of 182 cancer genes including HER2, in a CLIA certified lab (Foundation Medicine). Average coverage depth of &gt;900X uniquely-mapping reads was obtained. Sequence data were analyzed for HER2 copy number (blinded to FISH results) based on a statistical model using allele frequencies and coverage depth of HER2 exons versus a process-matched normal control, classifying cases as HER2 positive (≥6 average copies), HER2 negative (&lt;4 copies), intermediate (4–5 copies) or unknown (&lt;20% tumor purity). The data were also analyzed for additional clinically relevant genomic alterations.

Results: High concordance was noted between HER2 copy number status determined by FISH and NGS: 30 of the 35 samples were classified as positive or negative by NGS, 1 was classified as intermediate and 4 as unknown due to low purity. Using FISH as a gold standard, NGS HER2 calls demonstrated an accuracy of 97% (29/30, 95% CI 83–99%), 93% sensitivity (13/14, 95% CI 69–99%) and 100% specificity (16/16, 95% CI 81–100%). One discordant case was noted (FISH positive, NGS negative). Furthermore, NGS revealed 70 additional alterations (38 base substitutions, 10 insertions/deletions, 22 copy number alterations) in 23 cancer genes (an average of 2.0 alterations per sample). Genomic alterations that predict sensitivity or resistance to approved or experimental targeted therapies and thus plausibly guide treatment decisions were found in 69% of patients. These include PIK3CA (16 cases, PI3 kinase/mTOR inhibitors), PTEN (3 cases, PI3K/AKT/mTOR inhibitors), KRAS (1 case, resistance to cetuximab and panitumumab), and NF1 (1 case, mTOR/MAPK inhibitors) plus amplifications of CCND1 (4 cases, CDK4 inhibitors), FGFR1 (3 cases, FGF inhibitors) and MCL1 (3 cases, BCL-2 inhibitors, resistance to anti-tubulin therapies). Four cases included co-amplification of RARA with HER2.

Conclusions: We conclude that HER2 status can be reliably determined by NGS on FFPE breast cancers and that NGS uncovers additional actionable genomic alterations that could impact disease management in a high proportion of patients. Further evaluation of NGS as a guide to therapy in breast cancer is warranted.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD02-07.

Bacterial vectors for imaging and cancer gene therapy: a review

The significant burden of resistance to conventional anticancer treatments in patients with advanced disease has prompted the need to explore alternative therapeutic strategies. The challenge for oncology researchers is to identify a therapy which is selective for tumors with limited toxicity to normal tissue. Engineered bacteria have the unique potential to overcome traditional therapies' limitations by specifically targeting tumors. It has been shown that bacteria are naturally capable of homing to tumors when systemically administered resulting in high levels of replication locally, either external to (non-invasive species) or within tumor cells (pathogens). Pre-clinical and clinical investigations involving bacterial vectors require relevant means of monitoring vector trafficking and levels over time, and development of bacterial-specific real-time imaging modalities are key for successful development of clinical bacterial gene delivery. This review discusses the currently available imaging technologies and the progress to date exploiting these for monitoring of bacterial gene delivery in vivo.

The effect of increased overjet on the magnitude and reproducibility of smiling in adult females

The objective of this study was to determine if increased overjet (greater than 6 mm) influences the magnitude and reproducibility of natural smile and maximal smile in Caucasian adult females. Twenty adult females with an increased overjet (6-10 mm) and 20 control adult females (overjet 2-4 mm) with no history of orthodontic treatment volunteered to participate. The mean age in the control group was 30.1 ± 6.4 years and the mean age in the test group was 31.9 ± 10.8 years. Three-dimensional stereophotogrammetric images were captured of each subject for three expressions: at rest, natural smile, and maximal smile. The images were recorded twice on two separate occasions, 6 weeks apart. Images were landmarked and a partial ordinary Procrustes superimposition was used to adjust for the differences in head posture between the same expressions. The magnitude of movement relative to the rest position, averaged over all the landmarks, was calculated and compared between the groups using analysis of variance (linear mixed-effects model); the intra- and inter-session reproducibility of both expressions was assessed. There was greater mean movement, averaged over all the landmarks, in the control group than in the increased overjet group for both natural smile and maximal smile (P = 0.0068). For these expressions, there were no statistically significant differences in reproducibility within sessions (P = 0.5403) or between sessions (P = 0.3665). Increased overjet had a statistically significant effect on the magnitude of smiling but did not influence the reproducibility of natural or maximal smile relative to controls.

Safety implications of the Boyle-Davis mouth gag and tracheal tube position in tonsillectomy

BACKGROUND

The risk of death after tonsillectomy is extremely small, and is mostly caused by the direct or indirect effects of haemorrhage or anaesthetic complications. These complications include aspiration, accidental dislodgement of the tracheal tube (TT), and pneumothorax or pneumomediastinum. The Boyle-Davis mouth gag (BDG) is a device used to visualize the oropharynx and stabilize the TT during tonsillectomy. We postulate that a deployed BDG may influence the position of the TT, and potentially result in silent aspiration, accidental extubation, and unilateral pulmonary ventilation. This has not, to our knowledge, been evaluated before. The aim of this prospective, pilot study was to evaluate the displacement of the TT upon opening and closing the BDG, in an objective manner.

METHODS

Patients undergoing tonsillectomy with/without adenoidectomy at a regional department underwent flexible bronchoscopy to evaluate the changes in position of the TT tip with the BDG in an open and closed position, relative to the position of the carina.

RESULTS

Twenty-three patients were enrolled into the study. Deploying the BDG resulted in TT displacement in 96% of patients. The mean displacement was 9.5 mm (range -10 to +27 mm).

CONCLUSIONS

We believe that this study raises concerns not previously highlighted, on how manipulating a BDG may influence the TT position. It may serve to explain additional mechanisms of potentially fatal anaesthetic complications such as TT dislodgement, unilateral ventilation, and pneumothorax, particularly in paediatric patients, after tonsillectomy.

An open-label phase II study evaluating the safety and efficacy of PTK787 in patients with progressive metastatic neuroendocrine cancer

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Background: PTK787, an aminophthalazine, is an orally active angiogenesis inhibitor blocking all known vascular endothelial growth factor receptors (VEGFR)- and platelet-derived growth factor receptor (PDGFR)-tyrosine kinases . The majority of metastatic neuroendocrine malignancies express VEGF and PDGF receptors. Since both growth factors have been implicated in tumor-induced angiogenesis, PTK787 offers a novel approach for inhibiting tumor growth. Methods: In a phase II trial, we investigated the safety and antitumor activity of PTK787 in patients who had biopsy-proven metastatic neuroendocrine cancer, such as carcinoid, and had shown evidence of progression on somatosatin analog therapy. Eligible patients had measurable lesions other than bone, a Karnofsky performance status >60 and normal hematologic, renal and hepatic functions. Patients on octreotide therapy were required to be on a stable dose not exceeding 30 mg monthly of the LAR formulation. Initial dosing of PTK787 was 1,250 mg daily. Results: Six patients (4 males) were enrolled between 5/20/05 to 8/09/05. Median age was 61 years (range, 48 to 65). There was 1 withdrawal of consent. The remaining 5 patients continue on treatment as of January 2006. One patient required a 10 day discontinuation for rising SGOT/SGPT and alkaline phosphatase. Resumption of PTK787 at 1,000 mg daily was well tolerated in this patient. Radiographically and scintigraphically, all 5 patients have demonstrated stable disease by CT and OctreoScan, respectively. Recruitment to this trial continues. Conclusions: PTK787 is generally well tolerated in patients with metastatic neuroendocrine cancer and may be effective in controlling somatostatin analog resistant disease though partial radiographic responses have not been observed.

No significant financial relationships to disclose.

Validation of counter propagation neural network models for predictive toxicology according to the OECD principles: a case study

The OECD has proposed five principles for validation of QSAR models used for regulatory purposes. Here we present a case study investigating how these principles can be applied to models based on Kohonen and counter propagation neural networks. The study is based on a counter propagation network model that has been built using toxicity data in fish fathead minnow for 541 compounds. The study demonstrates that most, if not all, of the OECD criteria may be met when modeling using this neural network approach.

Dental caries and enamel fluorosis among the fluoridated population in the Republic of Ireland and non fluoridated population in Northern Ireland in 2002

BACKGROUND

An all Ireland/North South survey of Oral Health was carried out in 2001/2002.

AIMS

To compare levels of dental caries and enamel fluorosis among children and adolescents in the fluoridated Republic of Ireland (RoI) with those in the non fluoridated North of Ireland (NI).

METHODOLOGY

Cross sectional oral health survey of a representative, random, stratified sample of 5-, 8-, 12- and 15-year-olds in Rol and in NI (N = 19,950). WHO examination criteria with the addition of visible, non cavitated dentine caries were used for recording caries. Fluorosis was measured using Dean's Index.

RESULTS

In the RoI, the mean d(3c)mft / D(3c)MFT for 5-, 8-, 12-, and 15-year-olds with full domestic water fluoridation (n = 9,975), was 1.0, 0.3, 1.1 and 2.1 respectively. The corresponding means in non fluoridated NI (n = 1,475) were 1.8, 0.3, 1.5 and 3.6 respectively. (p < 0.0001, NS, p < 0.0005 and p < 0.0001). The prevalence of enamel fluorosis has increased in RoI since 1984, 23% and 36% of 8- and 15-year olds respectively in fluoridated areas had Dean's Index scores at the questionable or greater level in 2002 compared with 6% and 5% respectively in 1984.

CONCLUSIONS

In 2002 apart from 8-year-olds, caries levels were lower amongst children resident in fluoridated communities in RoI than amongst corresponding age groups in non-fluoridated NI. Caries has declined in fluoridated and non fluoridated groups in both jurisdictions since the early 1960s. In RoI fluorosis levels were higher amongst lifetime residents of fluoridated communities and have increased since 1984.

Use of Dental Service Data to Inform Research and Policy

Data collected routinely in dental care delivery systems could be used to inform research and policy. Projects in which data were collected with the help of general dental practitioners are outlined. In an EU-funded project, six partners collaborated to develop a methodology designed to establish links between characteristics of a health care system and health outcome, and to determine the characteristics of oral health care systems which promote oral health and those which are detrimental to oral health. The results indicated that the data collected in the different systems investigated varied enormously, and they could not be easily adapted to help in developing policy. A theoretical model was developed in which the production of oral health care was considered separately from the production of oral health. In the second example, the longevity of the restorations in a dental care delivery system in Ireland was investigated by routine service data.

Primary tooth fluorosis in 5-year-old schoolchildren in Ireland

AIM

This was to determine the prevalence of primary tooth fluorosis in the dentitions of 5-year-old schoolchildren. A subsidiary aim was to investigate whether an association existed between the presence of primary tooth fluorosis, fluoridation status, infant feeding practices or the oral hygiene practices of the child.

STUDY DESIGN

A cross-sectional and stratified by fluoridation status study.

METHODS

Fluorosis was recorded using a modification of the Tooth Surface Index of Fluorosis (TSIF). Demographic data, information on infant feeding practices and oral hygiene practices were collected via a parental questionnaire.

STATISTICS

Stepwise logistic regression analysis.

RESULTS

Fluorosis prevalence in the fluoridated group (n=208) was 32%; 29.3% (n=61) had a modified TSIF score of 1; 2.4% (n=5) had a modified TSIF score of 2; and 1% (n=1) had a modified TSIF score of 5. In the non-fluoridated group (n=86) one child had a modified TSIF score of 1. Primary tooth prevalence of fluorosis in the entire sample (n=294) was 23%. Factors that were associated with primary tooth fluorosis were: fluoridation status (p= 0.0003, 95% CI = 5-281) and the age at which toothbrushing with toothpaste commenced (p = 0.016, 95% C.I. 1.1 - 3.8). No association with infant feeding practices was identified.

CONCLUSION

The overall prevalence of primary tooth fluorosis was 23%. Lifetime residence in a fluoridated area and commencement of toothbrushing with toothpaste between 12 and 18 months of age were associated with primary tooth fluorosis. No association with infant feeding practices was identified.

Parents' preference as to whether they would like to accompany their child when receiving dental treatment--results from a national survey

BACKGROUND AND DESIGN

parental accompaniment of children during dental treatment has always been a contentious issue. One of the factors that should be considered is the preference of the parents. The aim of this paper is to report the preference of parents of eight-year-old schoolchildren in Ireland in relation to accompanying their child during dental procedures and is part of the National Survey of Children's Dental Health in Ireland, which was conducted between October 2001 and June 2002. The survey had a cross sectional design and parents of children (average age 8.4 years) selected for dental examination were asked to complete a questionnaire.

RESULTS

3629 completed questionnaires were obtained from parents of eight-year-old children giving a response rate of 68 per cent. Sixty-seven per cent of parents expressed a preference to accompany their child during dental treatment, while nine per cent expressed a preference not to accompany their child. The sex of the child (p = 0.33) or the fact that the parents were holders of a medical card (surrogate for disadvantage) (p = 0.08) did not affect parents' preference. However, parents of a single child had a higher preference (78 per cent) for accompanying their child than did parents with greater than one child in the family unit (66 per cent) (p = 0.0009).

CONCLUSION

If given the choice, the majority of parents would prefer to accompany their child when receiving dental treatment.