Enamel Caries Detection and Diagnosis: An Analysis of Systematic Reviews

Detection and diagnosis of caries-typically undertaken through a visual-tactile examination, often with supporting radiographic investigations-is commonly regarded as being broadly effective at detecting caries that has progressed into dentine and reached a threshold where restoration is necessary. With earlier detection comes an opportunity to stabilize disease or even remineralize the tooth surface, maximizing retention of tooth tissue and preventing a lifelong cycle of restoration. We undertook a formal comparative analysis of the diagnostic accuracy of different technologies to detect and inform the diagnosis of early caries using published Cochrane systematic reviews. Forming the basis of our comparative analysis were 5 Cochrane diagnostic test accuracy systematic reviews evaluating fluorescence, visual or visual-tactile classification systems, imaging, transillumination and optical coherence tomography, and electrical conductance or impedance technologies. Acceptable reference standards included histology, operative exploration, or enhanced visual assessment (with or without tooth separation) as appropriate. We conducted 2 analyses based on study design: a fully within-study, within-person analysis and a network meta-analysis based on direct and indirect comparisons. Nineteen studies provided data for the fully within-person analysis and 64 studies for the network meta-analysis. Of the 5 technologies evaluated, the greatest pairwise differences were observed in summary sensitivity points for imaging and all other technologies, but summary specificity points were broadly similar. For both analyses, the wide 95% prediction intervals indicated the uncertainty of future diagnostic accuracy across all technologies. The certainty of evidence was low, downgraded for study limitations, inconsistency, and indirectness. Summary estimates of diagnostic accuracy for most technologies indicate that the degree of certitude with which a decision is made regarding the presence or absence of disease may be enhanced with the use of such devices. However, given the broad prediction intervals, it is challenging to predict their accuracy in any future "real world" context.

The contribution of global aviation to anthropogenic climate forcing for 2000 to 2018

Global aviation operations contribute to anthropogenic climate change via a complex set of processes that lead to a net surface warming. Of importance are aviation emissions of carbon dioxide (CO₂), nitrogen oxides (NO_x), water vapor, soot and sulfate aerosols, and increased cloudiness due to contrail formation. Aviation grew strongly over the past decades (1960-2018) in terms of activity, with revenue passenger kilometers increasing from 109 to 8269 billion km yr^-1, and in terms of climate change impacts, with CO₂ emissions increasing by a factor of 6.8 to 1034 Tg CO₂ yr^-1. Over the period 2013-2018, the growth rates in both terms show a marked increase. Here, we present a new comprehensive and quantitative approach for evaluating aviation climate forcing terms. Both radiative forcing (RF) and effective radiative forcing (ERF) terms and their sums are calculated for the years 2000-2018. Contrail cirrus, consisting of linear contrails and the cirrus cloudiness arising from them, yields the largest positive net (warming) ERF term followed by CO₂ and NO_x emissions. The formation and emission of sulfate aerosol yields a negative (cooling) term. The mean contrail cirrus ERF/RF ratio of 0.42 indicates that contrail cirrus is less effective in surface warming than other terms. For 2018 the net aviation ERF is +100.9 milliwatts (mW) m^-2 (5-95% likelihood range of (55, 145)) with major contributions from contrail cirrus (57.4 mW m^-2), CO₂ (34.3 mW m^-2), and NO_x (17.5 mW m^-2). Non-CO₂ terms sum to yield a net positive (warming) ERF that accounts for more than half (66%) of the aviation net ERF in 2018. Using normalization to aviation fuel use, the contribution of global aviation in 2011 was calculated to be 3.5 (4.0, 3.4) % of the net anthropogenic ERF of 2290 (1130, 3330) mW m^-2. Uncertainty distributions (5%, 95%) show that non-CO₂ forcing terms contribute about 8 times more than CO₂ to the uncertainty in the aviation net ERF in 2018. The best estimates of the ERFs from aviation aerosol-cloud interactions for soot and sulfate remain undetermined. CO₂-warming-equivalent emissions based on global warming potentials (GWP* method) indicate that aviation emissions are currently warming the climate at approximately three times the rate of that associated with aviation CO₂ emissions alone. CO₂ and NO_x aviation emissions and cloud effects remain a continued focus of anthropogenic climate change research and policy discussions.

Influence of weaning strategy on behavior, humoral indicators of stress, growth, and carcass characteristics

Weaning is one of the most stressful events a calf experiences in our current beef production system. Its effects may include reduced feed intake, increased activity, slower growth, and increased susceptibility to disease. This study was designed to evaluate weaning after a 7-d placement of nose flaps at 7 mo (N, n = 40) and delaying weaning by 49 d relative to 7-mo weaning (D, n = 39) as alternatives to the industry standard; abrupt weaning at 7 mo of age (A, n = 39). The 4-yr trial utilized Angus and Angus X Senepol steer calves. Calves were randomly assigned to weaning strategy after being stratified by dam parity (heifer/cow), hair coat phenotype (normal/slick), and body weight. Behavioral observations were made on five steers per strategy group per year over the weeks surrounding weaning. Activity levels were determined by accelerometers worn on neck collars. Blood samples were obtained from the observed cattle during the last 2 yr to determine haptoglobin and cortisol concentration. Once weaned, the steers were followed through finishing and carcass characteristics obtained at harvest. Twelve of 38 steers in the N group had sores in their nostrils from the nose flaps when the flaps were removed at weaning of A/N (237 ± 3 d of age). The A and D calves were more active than N calves in the first 2 to 3 d after weaning but settled down to similar activity levels to N by the day 4. The A and D groups were more vocal than N during the same time frame. Cortisol and haptoglobin remained within normal reference ranges. Average daily body weight gain (ADG) was greater for D than A, who in turn had greater ADG than N during the first 42 d after A and N calves were weaned (0.69, 0.54, and 0.37 kg/d for D, A, and N, respectively; P < 0.01). All treatment groups graded Low Choice at harvest and exhibited similar efficiency of gain during growth and finishing (P > 0.2). Based on ADG during the 42 d after weaning, we recommend delaying weaning when available pasture and cow body condition support this strategy. When conditions do not permit delayed weaning, abrupt weaning may be the next viable option based on animal welfare concerns and increased handling to place and remove the flaps. Nose flaps reduced vocalization at weaning but resulted in less postweaning ADG. Based on our data, we suggest that abrupt weaning under the conditions of this study, is less stressful than we perceive it to be, based on calf behavior.

Ryanodine receptor inhibition prevents ventricular arrhythmia in a murine model of hypokalaemia

Background

Hypokalaemia-induced arrhythmia is a major cause of morbidity and mortality, affecting approximately 14% of outpatients and 20% of inpatients. Hypokalaemic inpatients have a mortality 10 times higher than their counterparts. This is due to ventricular arrhythmias initiated by early afterdepolarisations (EADs) and triggered activity. There is no antiarrhythmic drug approved for the prevention of hypokalaemia-induced ventricular arrhythmia. Recent evidence suggests that EADs can arise because of the synchronised release of Ca2+ from the sarcoplasmic reticulum, rather than the reactivation of L-type Ca2+ channels during action potential prolongation. Therefore, ryanodine receptor inhibition should prevent hypokalaemia-induced ventricular arrhythmia.

Purpose

To test the hypothesis that the ryanodine receptor inhibitors dantrolene and VKII-86 (a carvedilol analogue) are effective in preventing hypokalaemia-induced ventricular arrhythmia.

Methods

Whole heart Langendorff preparations isolated from C57BL/J6 mice were perfused with Krebs-Henseleit solution containing normal (4mM) or low (2mM) concentrations of [K+]. Surface ECG and subepicardial ventricular action potentials were simultaneously recorded. After establishing that the model reproduces EAD-mediated triggered arrhythmias in low extracellular [K+], hearts in the treatment groups were pre-treated with dantrolene or VKII-86 for 30 minutes prior to being exposed to low extracellular [K+]. The frequency of non-sustained and sustained ventricular arrhythmias occurring during a 30-minute period of exposure to low extracellular [K+] were compared between the treatment groups and controls treated with the solvent DMSO (0.1% v/v) (n=6 in each group).

Results

The mean number of non-sustained arrhythmias was 29.3±9.6 (Mean±SEM) in the control group, 3.2±1.2 in the dantrolene group and 0 in the VKII-86 group; p&lt;0.05 for both treatments vs. control. The mean number of sustained arrhythmias was 1.7±0.4 in the control group, 0.17±0.17 in the dantrolene group and 0 in the VKII-86 group; p&lt;0.05 for both treatments vs. control. Thus, dantrolene significantly reduced arrhythmia frequency by approximately 90%, whereas VKII-86 prevented all hypokalaemia-induced ventricular arrhythmias.

Conclusions

These results provide the first demonstration of ryanodine receptor inhibition as an effective treatment for the prevention of ventricular arrhythmia in a murine model of hypokalaemia. This study is consistent with recent studies indicating that intracellular Ca2+ load is an important mechanism underlying the development of EAD-mediated triggered arrythmia. Further studies are needed to determine whether these drugs could be re-purposed as antiarrhythmics in the setting of hypokalemia. Further development of the carvedilol analogue VKII-86 should also be considered.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The British Heart Foundation, The Lankenau Institute for Medical Research.

Enhancing the adoption of stockpiling tall fescue and managed grazing

One of the primary goals of extension is to encourage and support adoption of improved technologies. Managed grazing and stockpiling forage are two such technologies. The goal of this project was to encourage adoption of these practices by providing on-farm demonstrations of the technologies. We also collected forage and soil data and held workshops at each of the demonstration sites. Host producers were selected, given a basic kit of temporary fencing supplies for use during the demonstration, and instructed on their proper use during the winter stockpiling season. Forage yield and quality data were collected and soil tests made to show the economic advantages of proper fertilization and grazing fresh forage in contrast to feeding stored forage and concentrate. The nutritive value of the forage stockpiled in September through November (67% total digestible nutrients [TDN] and 14% crude protein, CP) exceeded the needs of the cattle and was greater than the nutrient content of hay present on the farms (59% TDN and 11% CP, P < 0.01). The mean quantity of available forage (2,856 ± 164 kg dry matter per hectare) provided an average of 260 (±81.8) standard cow (545 kg) grazing days per hectare of stockpiled forage. Taking into account the higher nutritive value of the fresh forage when compared with hay and the savings of time and equipment costs by grazing, we estimated that grazing stockpiled forage saved $1.28 per standard cow per day. The grazing management skills gained during this project and the temporary fencing technology were adopted by 93% of the demonstration farms that responded to our follow-up survey (78% of demonstration sites), and the area managed with these technologies increased on these sites more than 350%. Having the hosts share personal experiences played an important role in encouraging their peers to adopt the technologies.

Reducing achievement gaps in undergraduate general chemistry could lift underrepresented students into a "hyperpersistent zone"

Students from underrepresented groups start college with the same level of interest in STEM majors as their peers, but leave STEM at higher rates. We tested the hypothesis that low grades in general chemistry contribute to this "weeding," using records from 25,768 students. In the first course of a general chemistry series, grade gaps based on binary gender, race/ethnicity, socioeconomic status, and family education background ranged from 0.12 to 0.54 on a four-point scale. Gaps persisted when the analysis controlled for academic preparation, indicating that students from underrepresented groups underperformed relative to their capability. Underrepresented students were less likely than well-represented peers to persist in chemistry if they performed below a C-, but more likely to persist if they got a C or better. This "hyperpersistent zone" suggests that reducing achievement gaps could have a disproportionately large impact on efforts to achieve equity in STEM majors and professions.

Correction: Safety and utility of image-guided research biopsies in relapsed high-grade serous ovarian carcinoma-experience of the BriTROC consortium

This article was originally published under a CC BY NC SA License, but has now been made available under a CC BY 4.0 License.

Abstract PD9-02: Evolutionary analysis of 462 serial metastatic biopsies from 208 patients with estrogen receptor-positive (ER+) metastatic breast cancer (MBC) using whole exome sequencing (WES)

Background: While great strides have been made in the treatment of ER+ MBC, therapeutic resistance is nearly universal. The genomic evolution of ER+ breast cancer in the metastatic setting under the selective pressure of multiple lines of therapies is not well understood. To address this, we analyzed the clonal dynamics of serial metastatic samples (mets) to evaluate how tumors evolve and to identify acquired resistance mechanisms.

Methods: We performed WES on 462 clinically annotated samples from 208 patients (pts) with ER+ MBC, including 67 primary tumor biopsies, 229 metastatic biopsies and 160 blood samples (cfDNA). Pts with multiple mets included cases with temporally concordant metastatic tumor and blood samples (48 pts) and cases with serial mets obtained over the course of treatment in the metastatic setting (69 pts). Treatments given between the serial mets included CDK4/6 inhibitors (23 pts), and selective estrogen receptor degraders (19 pts), among others.

Results: In the temporally-concordant mets, we found that cfDNA mutations (muts) largely overlap with muts found in tumor biopsies, capturing &gt;85% of clonal tumor muts. However, we observed a higher level of heterogeneity in cfDNA compared to biopsies (p.value&lt; 1.05e-19, Welch test) and a subset of high-confidence muts that were only detected in cfDNA, including in clinically important genes such as ESR1, PIK3CA, KRAS, and ERBB2. Analysis of serial mets was used to elucidate the evolutionary dynamics within the metastatic setting under the selective pressure of treatment. The median duration between mets was 112 days and the median number of inter-biopsy unique treatments was two. Most tumors continued to evolve within the metastatic setting, with 50 out of 69 pts (72%) acquiring a meaningful sub-clone (50% increase in relative cancer cell fraction) and 31 out of 69 (45%) acquiring muts in known cancer genes, including a subset acquiring a plausible resistance alteration such as alterations that dysregulate ER (5 out of 69 pts, 7%; ESR1 mut, FOXA1 amplification (amp), NCOR1 bi-allelic deletion (del)), ERBB (4%; ERBB2 amp, ERBB3 mut), RAS (4%; KRAS mut, NRAS amp, NF1 del), FGF/FGFR (12%; FGFR2 mut, FGFR1/2 amp, FGF3 amp), and cell cycle (13%; RB1 del, CDK4 amp, AURKA amp, CDKN2A del). Finally, in pts who had multiple mets, we observed several cases of evolutionary convergence toward equivalent resistance mechanisms including convergent RB1 loss as a mechanism of resistance to a CDK4/6 inhibitor and convergent BRCA2 reversion following resistance to a PARP inhibitor.

Conclusions: This study demonstrates that ER+ MBC continues to evolve under the selective pressure of treatments in the metastatic setting. These findings elucidate the challenge of studying high complexity and heavily treated tumors, while also highlighting some commonalities in the evolutionary trajectories selected by these treatments. The multiplicity of clinically relevant genomic alterations acquired in these advanced stages highlights the need for serial biopsies and the potential to inform post-progression therapeutic choices through targeting the acquired dependencies in post-progression tumors.

Citation Format: Cohen O, Buendia-Buendia J, Wander S, Nayar U, Mao P, Waks A, Kim D, Freeman S, Adalsteinsson V, Helvie K, Livitz D, Rosebrock D, Leshchiner I, Dellostritto L, Garrido-Castro A, Jain E, Periyasamy S, Mackichan C, Lloyd M, Marini L, Krop I, Garraway L, Getz G, Winer E, Lin N, Wagle N. Evolutionary analysis of 462 serial metastatic biopsies from 208 patients with estrogen receptor-positive (ER+) metastatic breast cancer (MBC) using whole exome sequencing (WES) [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 PD9-02.

Fusarium oligoseptatum sp. nov., a mycosymbiont of the ambrosia beetle Euwallacea validus in the Eastern U.S. and typification of F. ambrosium

Fusarium oligoseptatum sp. nov. was isolated from the invasive Asian ambrosia beetle Euwallacea validis (Coleoptera, Scolytinae, Xyleborini) and from the galleries that females had constructed in dying Ailanthus altissima (tree-of-heaven) symptomatic for Verticillium wilt in south-central Pennsylvania, USA. This ambrosia fungus was cultivated by Euwallacea validis as the primary source of nutrition together with a second symbiont, Raffaelea subfusca . Female beetles transport their fungal symbionts within and from their natal galleries in paired pre-oral mycangia. Fusarium oligoseptatum was distinguished phenotypically from the 11 other known members of the Ambrosia Fusarium Clade (AFC) by uniquely producing mostly 1–2 septate clavate sporodochial conidia that were swollen apically. Phylogenetic analysis of multilocus DNA sequence data resolved F. oligoseptatum as a genealogically exclusive species-level lineage but evolutionary relationships with other members of the AFC were unresolved. Published studies have shown that F. oligoseptatum can be identified via phylogenetic analysis of multilocus DNA sequence data or a PCR multiplex assay employing species-specific oligonucleotide primers. In addition, to provide nomenclatural stability, an epitype was prepared from an authentic strain of F. ambrosium that was originally isolated from a gallery constructed in Chinese tea (Camellia sinensis ) by E. fornicatus in India, together with its lectotypification based on a published illustration.

Abstract GS3-07: Genome-wide copy number analysis of chemotherapy-resistant metastatic triple-negative breast cancer from cell-free DNA

Introduction:

Triple-negative breast cancer (TNBC) is a poor prognosis breast cancer subset characterized by relatively few mutations but extensive copy number alterations (CNAs). Cell-free DNA (cfDNA) offers the potential to overcome infrequent tumor biopsies in metastatic TNBC (mTNBC) and interrogate the genomics of chemotherapy resistance.

Methods:

506 archival or fresh plasma samples were identified from 164 patients with mTNBC who had previously received chemotherapy. We performed low coverage whole genome sequencing to determine genome-wide copy number and estimate 'tumor fraction' of cfDNA (TFx) using our recently-developed approach, ichorCNA. In patient samples with TFx &gt;10%, we identified regions that were significantly gained or lost using GISTIC2.0. We compared CNAs of 20 paired primary-metastatic samples and also mTNBCs from cfDNA versus primary TNBCs from TCGA and METABRIC.

Results:

We successfully obtained high quality, low coverage whole genome sequencing data for 478 (94.5%) plasma samples from 158 patients, with 1 to 14 samples per patient. TFx and copy number profiles were highly concordant with paired metastatic biopsy (n=10, range 0-7 days from biopsy to blood draw) with sensitivity of 0.86 and specificity of 0.90 and reproducible in independently-processed blood draws (TFx intraclass correlation coefficient 0.984). Median overall survival from time of first blood draw was 8 months, and TFx was highly correlated independent of primary stage, primary receptor status, age at primary diagnosis, BRCA status, and metastatic line of therapy: adjusted hazard ratio between 4th and 1st quartiles = 2.14 (95% CI 1.40-3.28; p=0.00049). 101/158 patients (63.9%) had at least one sample with TFx &gt;10%, our threshold for high confidence CNA calls. Copy number profiles and percent genome altered were remarkably similar between mTNBCs and primary TNBCs in TCGA and METABRIC (n=433), suggesting that large-scale chromosomal events are infrequent in TNBC metastatic progression. We identified chromosomal gains that demonstrated significant enrichment in mTNBCs relative to paired primary TNBCs (n=20) and also TCGA/METABRIC, including driver genes (NOTCH2, AKT2, AKT3) and putative antibody-drug conjugate targets. Finally, we identify a novel association of gains of 18q11 and/or 19p13 with poor metastatic prognosis, independent of clinicopathologic factors and TFx.

Conclusions:

Here, we present the first large-scale genomic characterization of metastatic TNBC to our knowledge, derived exclusively from cfDNA. 'Tumor fraction' of cfDNA is an independent prognostic marker in mTNBC. Primary and metastatic TNBC have remarkably similar copy number profiles yet we identify alterations enriched and prognostic in mTNBC. Collectively, these data have potential implications in the understanding of metastasis, therapeutic resistance, and novel therapeutic targets.

Citation Format: Stover DG, Parsons HA, Ha G, Freeman S, Barry B, Guo H, Choudhury A, Gydush G, Reed S, Rhoades J, Rotem D, Hughes ME, Dillon DA, Partridge AH, Wagle N, Krop IE, Getz G, Golub TA, Love JC, Winer EP, Tolaney SM, Lin NU, Adalsteinsson VA. Genome-wide copy number analysis of chemotherapy-resistant metastatic triple-negative breast cancer from cell-free DNA [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr GS3-07.

Diffusion-weighted imaging in gynaecological malignancy

Diffusion weighted imaging (DWI) has become an essential part of the gynaecological magnetic resonance imaging (MRI) protocol. DWI is used as an adjunct to conventional MRI sequences and has been shown to improve reporting accuracy in the imaging of gynaecological malignancy. In this review, we discuss the role of DWI in the diagnosis, staging, and assessment of treatment response of endometrial, cervical, and ovarian cancer. We also review the role of DWI in the assessment of the sonographically indeterminate ovarian lesion. Further, we highlight potential pitfalls that can beset the accurate interpretation of DWI in patients with gynaecological malignancy.

Furosemide Administered before Noise Exposure can Protect the Ear

Objectives

We assessed the effect of furosemide administration on noise-induced hearing loss. This drug reversibly elevates the auditory threshold by inducing a temporary reduction of the endocochlear potential and thereby suppresses the cochlear amplifier and active cochlear mechanics.

Methods

Mice were given a single injection of furosemide 30 minutes before exposure to 113 dB sound pressure level broadband noise. Control animals received saline solution. Furosemide was administered in other mice after the noise exposure. Auditory threshold shifts were assessed by recording auditory nerve brain stem evoked response (ABR) thresholds to broadband clicks.

Results

The mean ABR threshold in the group injected with furosemide and exposed to temporary threshold shift (TTS)-producing noise was elevated by 20.4 ± 12.3 dB, and that in the saline control group was elevated by 35.4 ± 18.3 dB (p < 0.02). The mean threshold elevations in the group injected with furosemide and exposed to permanent threshold shift (PTS)-producing noise and in the PTS saline control group were 15.0 ± 10.3 dB and 27.0 ± 12.7 dB, respectively (p < 0.01). Similar results were obtained when the PTS was assessed with an 8-kHz tone burst ABR. There was no significant difference in the PTS between mice given a single injection of furosemide and those given saline solution after the noise; this finding shows that furosemide is not acting as an antioxidant.

Conclusions

It appears that reversible hearing threshold elevation as a result of furosemide administration before noise exposure can reduce the TTS and PTS. This finding provides insight into the mechanism of noise-induced hearing loss.

Safety and utility of image-guided research biopsies in relapsed high-grade serous ovarian carcinoma-experience of the BriTROC consortium

BACKGROUND

Investigating tumour evolution and acquired chemotherapy resistance requires analysis of sequential tumour material. We describe the feasibility of obtaining research biopsies in women with relapsed ovarian high-grade serous carcinoma (HGSC).

METHODS

Women with relapsed ovarian HGSC underwent either image-guided biopsy or intra-operative biopsy during secondary debulking, and samples were fixed in methanol-based fixative. Tagged-amplicon sequencing was performed on biopsy DNA.

RESULTS

We screened 519 patients in order to enrol 220. Two hundred and two patients underwent successful biopsy, 118 of which were image-guided. There were 22 study-related adverse events (AE) in the image-guided biopsies, all grades 1 and 2; pain was the commonest AE. There were pre-specified significant AE in 3/118 biopsies (2.5%). 87% biopsies were fit-for-purpose for genomic analyses. Median DNA yield was 2.87 μg, and was higher in biopsies utilising 14 G or 16 G needles compared to 18 G. TP53 mutations were identified in 94.4% patients.

CONCLUSIONS

Obtaining tumour biopsies for research in relapsed HGSC is safe and feasible. Adverse events are rare. The large majority of biopsies yield sufficient DNA for genomic analyses-we recommend use of larger gauge needles and methanol fixation for such biopsies, as DNA yields are higher but with no increase in AEs.

Abstract S1-01: Whole exome and transcriptome sequencing of resistant ER+ metastatic breast cancer

Background: While great strides have been made in the treatment of estrogen receptor-positive (ER+) metastatic breast cancer (MBC), therapeutic resistance invariably occurs. A better understanding of the underlying resistance mechanisms is critical to enable durable control of this disease.

Methods: We performed whole exome sequencing (WES) and transcriptome sequencing (RNA-seq) on metastatic tumor biopsies from 88 patients with ER+ MBC who had developed resistance to one or more ER-directed therapies. For 27 of these patients, we sequenced the treatment-naïve primary tumors for comparison to the resistant specimens. Tumors were analyzed for point mutations, insertions/deletions, copy number alterations, translocations, and gene expression. Detailed clinicopathologic data was collected for each patient and linked to the genomic information.

Results: WES of all metastatic samples demonstrated several recurrently altered genes whose incidence differed significantly from primary, treatment-naïve ER+ breast cancers sequenced in the TCGA study (TCGA). These include ESR1 mutations (n=17, 19.3%; 32.86 fold enrichment, q.value&lt;7.5e-12), CCND1 amplification (n=52, 59.1%; 2.3 fold enrichment, q.value&lt;0.0073), and MAP2K4 biallelic inactivation (n=14, 15.9%; 3.04 fold enrichment, q.value&lt; 0.054).

Comparing to matched primary samples from the same patient, many alterations were found to be acquired in several cases, including for ESR1, ERBB2, PIK3CA, PTEN, RB1, AKT1, and others. Initial analysis of RNA-seq data from metastatic samples (n=59) allowed classification of individual resistance mechanisms into broader resistance modes based on the observed transcriptional state.

Conclusions: We present a genomic landscape of resistant ER+ MBC using WES and RNA-seq. Multiple genes were recurrently altered in these tumors at significantly higher rates than in ER+ primary breast cancer. When compared with matched primary tumors from the same patient, alterations in these and other genes were often found to be acquired after treatment, suggesting a role in resistance to ER-directed therapies and/or metastasis. Potential resistance mechanisms appear to fall into several categories; integrating RNA-seq data may enhance the ability to identify these categories even when genomic alterations are not identified. Multiple clinically relevant genomic and molecular alterations are identified in metastatic biopsies– with implications for choice of next therapy, clinical trial eligibility, and novel drug targets.

Citation Format: Cohen O, Kim D, Oh C, Waks A, Oliver N, Helvie K, Marini L, Rotem A, Lloyd M, Stover D, Adalsteinsson V, Freeman S, Ha G, Cibulskis C, Anderka K, Tamayo P, Johannessen C, Krop I, Garraway L, Winer E, Lin N, Wagle N. Whole exome and transcriptome sequencing of resistant ER+ metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S1-01.

A comparison of clofarabine with ara-C, each in combination with daunorubicin as induction treatment in older patients with acute myeloid leukaemia

The study was designed to compare clofarabine plus daunorubicin vs daunorubicin/ara-C in older patients with acute myeloid leukaemia (AML) or high-risk myelodysplastic syndrome (MDS). Eight hundred and six untreated patients in the UK NCRI AML16 trial with AML/high-risk MDS (median age, 67 years; range 56-84) and normal serum creatinine were randomised to two courses of induction chemotherapy with either daunorubicin/ara-C (DA) or daunorubicin/clofarabine (DClo). Patients were also included in additional randomisations; ± one dose of gemtuzumab ozogamicin in course 1; 2v3 courses and ± azacitidine maintenance. The primary end point was overall survival. The overall response rate was 69% (complete remission (CR) 60%; CRi 9%), with no difference between DA (71%) and DClo (66%). There was no difference in 30-/60-day mortality or toxicity: significantly more supportive care was required in the DA arm even though platelet and neutrophil recovery was significantly slower with DClo. There were no differences in cumulative incidence of relapse (74% vs 68%; hazard ratio (HR) 0.93 (0.77-1.14), P=0.5); survival from relapse (7% vs 9%; HR 0.96 (0.77-1.19), P=0.7); relapse-free (31% vs 32%; HR 1.02 (0.83-1.24), P=0.9) or overall survival (23% vs 22%; HR 1.08 (0.93-1.26), P=0.3). Clofarabine 20 mg/m2 given for 5 days with daunorubicin is not superior to ara-C+daunorubicin as induction for older patients with AML/high-risk MDS.

New Approach for Implantable Hearing Aids: A Feasibility Study

The objective of this study was to test the feasibility of a new kind of implantable hearing device based on a cerebrospinal fluid hydroacoustic pathway by which sound waves are conducted from the dura mater to the inner ear by cerebrospinal fluid. In this prospective animal study, a piezoelectric bimorph was implanted into 2 guinea pigs and 1 dog between the skull bone and the dura at the parietal area. The bimorph was connected transdermally by wires to a click generator. The auditory brain stem response was recorded after stimulation of the piezoelectric device by the click generator. In the 3 animals, the auditory brain stem response could be recorded in response to a stimulus intensity of 135 dB peak equivalent (pe) sound pressure level (SPL; instrument setting), corresponding to 3.8 V activating the device. The auditory brain stem response disappeared during white noise masking, proving that the origin of the response was in the inner ear. The threshold was 125 and 115 dB pe SPL in the 2 guinea pigs and 135 dB pe SPL in the dog (instrument setting). We conclude that transmission of sound waves by a cerebrospinal fluid hydroacoustic pathway to the inner ear is possible. Such a device would have advantages over more traditional implantable hearing devices: it would not be necessary to couple it to the ossicular chain, and it could be used in patients with infected middle ears.

Sternocleidomastoid pyomyositis

INTRODUCTION

Pyogenic myositis (pyomyositis) represents a bacterial infection of striated muscle. Predominantly associated with tropical regions and commonly caused by Staphylococcus aureus, the incidence of cervical pyomyositis is rare. To our knowledge, we report the first case of group A streptococcal cervical pyomyositis in an immunocompetent British Caucasian patient.

CASE PRESENTATION

A previously well 48-year-old Caucasian male presented with sore throat, left sided neck pain and swelling. He was a lifelong non-smoker with no recent travel or animal exposure. On admission, he was febrile with unilateral neck swelling. Random blood glucose was normal and an HIV test negative. CT imaging confirmed a large heterogeneous mass extending throughout the entirety of the left sternocleidomastoid muscle. The patient underwent exploration and drainage of a large intra-sternocleidomastoid neck abscess. Microbiology identified group A - streptococcus. Histology confirmed abscess formation in muscle with no acid-fast bacilli. The patient recovered well postoperatively and continues to do well.

DISCUSSION

Cervical pyomyositis is a rare condition that if not treated appropriately may cause internal jugular vein thrombosis, sepsis and death. Pyomyositis requires a high index of suspicion and should be considered a differential diagnosis in any painful swelling in the head and neck region.

Analysis of Genetic Diversity of Fusarium tupiense, the Main Causal Agent of Mango Malformation Disease in Southern Spain

Mango malformation disease (MMD) has become an important global disease affecting this crop. The aim of this study was to identify the main causal agents of MMD in the Axarquía region of southern Spain and determine their genetic diversity. Fusarium mangiferae was previously described in the Axarquía region but it represented only one-third of the fusaria recovered from malformed trees. In the present work, fusaria associated with MMD were analyzed by arbitrary primed polymerase chain reaction (ap-PCR), random amplified polymorphic DNA (RAPD), vegetative compatibility grouping (VCG), a PCR screen for mating type idiomorph, and phylogenetic analyses of multilocus DNA sequence data to identify and characterize the genetic diversity of the MMD pathogens. These analyses confirmed that 92 of the isolates were F. tupiense, which was previously only known from Brazil and Senegal. In addition, two isolates of a putatively novel MMD pathogen were discovered, nested within the African clade of the Fusarium fujikuroi species complex. The F. tupiense isolates all belonged to VCG I, which was first described in Brazil, and the 11 isolates tested showed pathogenicity on mango seedlings. Including the prior discovery of F. mangiferae, three exotic MMD pathogenic species have been found in southern Spain, which suggests multiple independent introductions of MMD pathogens in the Axarquía region.

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Long Version)

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Short Version)

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version/ short version; the long version is published online).

Rapid Increase in Neural Conduction Time in the Adult Human Auditory Brainstem Following Sudden Unilateral Deafness

Individuals with sudden unilateral deafness offer a unique opportunity to study plasticity of the binaural auditory system in adult humans. Stimulation of the intact ear results in increased activity in the auditory cortex. However, there are no reports of changes at sub-cortical levels in humans. Therefore, the aim of the present study was to investigate changes in sub-cortical activity immediately before and after the onset of surgically induced unilateral deafness in adult humans. Click-evoked auditory brainstem responses (ABRs) to stimulation of the healthy ear were recorded from ten adults during the course of translabyrinthine surgery for the removal of a unilateral acoustic neuroma. This surgical technique always results in abrupt deafferentation of the affected ear. The results revealed a rapid (within minutes) reduction in latency of wave V (mean pre = 6.55 ms; mean post = 6.15 ms; p < 0.001). A latency reduction was also observed for wave III (mean pre = 4.40 ms; mean post = 4.13 ms; p < 0.001). These reductions in response latency are consistent with functional changes including disinhibition or/and more rapid intra-cellular signalling affecting binaurally sensitive neurons in the central auditory system. The results are highly relevant for improved understanding of putative physiological mechanisms underlying perceptual disorders such as tinnitus and hyperacusis.

Bilateral vestibular schwannomas in older patients: NF2 or chance?

BACKGROUND

Neurofibromatosis type 2 (NF2) is an autosomal dominant condition with high spontaneous mutation rate which predisposes to the development of multiple nerve sheath tumours (schwannomas), meningiomas and ependymoma. The cardinal feature and main diagnostic criterion for the diagnosis of NF2 remains the development of bilateral vestibular schwannoma (BVS). With increasing use of MRI screening the possibility of a 'chance' diagnosis of BVS has been mooted with a potential frequency of one in two million people in their lifetime. Until now, however, no evidence for such an event has been published. We aimed to demonstrate that chance occurrence can occur and to estimate its frequency among those with just BVS late in life.

METHODS

Two vestibular schwannomas from the same patient were DNA sequenced and underwent loss of heterozygosity analysis.

RESULTS

We show that a man who developed BVS, at ages 52 and 67 years developed these tumours sporadically by demonstrating that there were no molecular events in common between the two tumours. Furthermore from a database of over 1200 patients with NF2, we have estimated that ~25% of cases of BVS over 50 years and 50% over 70 years of age where no other features of NF2 are present represent a chance occurrence rather than due to an underlying mosaic or constitutional NF2 mutation.

CONCLUSIONS

Patients presenting with BVS later in life should be appraised of the potential likelihood they may not have NF2 and the resultant further reduction in risks of transmission to offspring.

First Report of Mango Malformation Disease Caused by Fusarium pseudocircinatum in Mexico

Mango (Mangifera indica L.) malformation disease (MMD) is one of the most important diseases affecting this crop worldwide, causing severe economic loss due to reduction of yield. After the first report in India in 1891 (3), MMD has spread worldwide to most mango-growing regions. Several species of Fusarium cause the disease, including F. mangiferae in India, Israel, the USA (Florida), Egypt, South Africa, Oman, and elsewhere; F. sterilihyphosum in South Africa and Brazil; F. proliferatum in China; F. mexicanum in Mexico; and recently, F. tupiense in Brazil (1,2,3,4). Besides F. mexicanum, F. pseudocircinatum, not yet reported as a causal agent of MMD, was isolated in Mexico from affected inflorescences and vegetative malformed tissues (4). Symptoms of vegetative malformation caused by F. pseudocircinatum included hypertrophied, tightly bunched young shoots, with swollen apical and lateral buds producing misshapen terminals with shortened internodes and dwarfed leaves. Infected inflorescences of primary or secondary axes on affected panicles were shortened, thickened, and highly branched, while the peduncles became thick, remained green and fleshy, and branches profusely resembled a cauliflower in shape and size (3). Ten isolates of F. pseudocircinatum were recovered from cultivars Ataulfo, Criollo, Haden, and Tommy Atkins in Guerrero, Campeche, and Chiapas states and characterized. Isolates produced mostly 0-septate but occasionally 1- to 3-septate oval, obovoid, or elliptical aerial conidia (0-septate: 4 to 19 [avg. 8.7] × 1.5 to 4 [avg. 2.6] μm) in false heads in the dark and in short false chains under black light, unbranched or sympodially branched prostrate aerial conidiophores producing mono- and polyphialides, and sporodochia with straight or falcate conidia that were mostly 3- to 5-septate, but sometimes up to 7-septate (3-septate: 25 to 58 [avg. 41] × 2 to 3.3 [avg. 2.9] μm; 5-septate: 33.5 to 76.5 [avg. 56.7] × 2.5 to 6 [avg. 3.5] μm). Circinate sterile hyphae were rarely formed. Two representative isolates, NRRL 53570 and 53573, were subjected to multilocus molecular phylogenetic analyses of portions of five genes: nuclear large subunit 28S ribosomal RNA, β-tubulin, calmodulin, histone H3, and translation elongation factor (TEF)-1α (GenBank GU737456, GU737457, GU737290, GU737291, GU737371, GU737372, GU737425, GU737426, GU737398, and GU737399). Two pathogenicity tests were conducted with NRRL 53570 and 53573 on healthy 2-year-old nucellar seedlings of polyembryonic Criollo; 20 μl conidial suspensions (5 × 10⁶ conidia/ml) of each isolate and water controls were inoculated separately on 15 buds on 3 different trees, as described previously (1). The following conditions were used in experiment 1: 24 to 27°C with light intensity of 16.2 to 19.8 •Mol m^-2s^-1 in the range of 400 to 700 nm, and photoperiods of 14 h light and 10 h dark. Typical vegetative disease symptoms were discernible in plants inoculated with NRRL 53570 (20%) and 53573 (7%) after 8 months. In experiment 2, after 3 months growth under the above conditions, seedlings were transferred to an outdoor nursery in Iguala, Guerrero. Typical vegetative symptoms of MMD were observed in 86.7 and 13.3% of the buds inoculated with F. pseudocircinatum NRRL 53570 and 53573, respectively, after 9 months. Isolates from typical symptomatic vegetative buds were confirmed as F. pseudocircinatum by sequencing a portion of their TEF-1α gene, thus fulfilling Koch's postulates. This is the first report of F. pseudocircinatum as a causal agent of MMD. References: (1) S. Freeman et al. Phytopathology 89:456, 1999. (2) C. S. Lima et al. Mycologia 104:1408, 2012. (3) W. F. O. Marasas et al. Phytopathology 96:667, 2006. (4) G. Otero-Colina et al. Phytopathology 100:1176, 2010.

Random variation in rectal position during radiotherapy for prostate cancer is two to three times greater than that predicted from prostate motion

Objective:

Radiotherapy for prostate cancer does not explicitly take into account daily variation in the position of the rectum. It is important to accurately assess accumulated dose (D_A) to the rectum in order to understand the relationship between dose and toxicity. The primary objective of this work was to quantify systematic (Σ) and random (σ) variation in the position of the rectum during a course of prostate radiotherapy.

Methods:

The rectum was manually outlined on the kilo-voltage planning scan and 37 daily mega-voltage image guidance scans for 10 participants recruited to the VoxTox study. The femoral heads were used to produce a fixed point to which all rectal contours were referenced.

Results:

Σ [standard deviation (SD) of means] between planning and treatment was 4.2 mm in the anteroposterior (AP) direction and 1.3 mm left–right (LR). σ (root mean square of SDs) was 5.2 mm AP and 2.7 mm LR. Superior–inferior variation was less than one slice above and below the planning position.

Conclusion:

Our results for Σ are in line with published data for prostate motion. σ, however, was approximately twice as great as that seen for prostate motion. This suggests that D_A may differ from planned dose in some patients treated with radiotherapy for prostate cancer.

Advances in knowledge:

This work is the first to use daily imaging to quantify Σ and σ of the rectum in prostate cancer. σ was found to be greater than published data, providing strong rationale for further investigation of individual D_A.

Fusarium euwallaceae sp. nov.--a symbiotic fungus of Euwallacea sp., an invasive ambrosia beetle in Israel and California

The invasive Asian ambrosia beetle Euwallacea sp. (Coleoptera, Scolytinae, Xyleborini) and a novel Fusarium sp. that it farms in its galleries as a source of nutrition causes serious damage to more than 20 species of live trees and pose a serious threat to avocado production (Persea americana) in Israel and California. Adult female beetles are equipped with mandibular mycangia in which its fungal symbiont is transported within and from the natal galleries. Damage caused to the xylem is associated with disease symptoms that include sugar or gum exudates, dieback, wilt and ultimately host tree mortality. In 2012 the beetle was recorded on more than 200 and 20 different urban landscape species in southern California and Israel respectively. Euwallacea sp. and its symbiont are closely related to the tea shot-hole borer (E. fornicatus) and its obligate symbiont, F. ambrosium occurring in Sri Lanka and India. To distinguish these beetles, hereafter the unnamed xyleborine in Israel and California will be referred to as Euwallacea sp. IS/CA. Both fusaria exhibit distinctive ecologies and produce clavate macroconidia, which we think might represent an adaption to the species-specific beetle partner. Both fusaria comprise a genealogically exclusive lineage within Clade 3 of the Fusarium solani species complex (FSSC) that can be differentiated with arbitrarily primed PCR. Currently these fusaria can be distinguished only phenotypically by the abundant production of blue to brownish macroconidia in the symbiont of Euwallacea sp. IS/CA and their rarity or absence in F. ambrosium. We speculate that obligate symbiosis of Euwallacea and Fusarium, might have driven ecological speciation in these mutualists. Thus, the purpose of this paper is to describe and illustrate the novel, economically destructive avocado pathogen as Fusarium euwallaceae sp. nov. S. Freeman et al.

Outcome of translabyrinthine surgery for vestibular schwannoma in neurofibromatosis type 2

OBJECTIVES

To analyse the long-term outcome of translabyrinthine surgery for vestibular schwannoma (VS) in neurofibromatosis type 2 (NF2). RESEARCH TYPE: Retrospective cohort study.

SETTING

Two tertiary referral NF2 units.

PATIENTS

One hundred and forty eight translabyrinthine operations for patients with VS were performed. Preoperative stereotactic radiotherapy had been performed on 12(9.4%) patients.

RESULTS

Mean tumour size was 3.1 cm. Total tumour excision was achieved in 66% of cases, capsular remnants were left in 24% of cases, and subtotal excision was achieved in 5% and partial removal was achieved in 5%. The radiological residual/recurrence rate was 13.9%. The perioperative mortality was 1.6%. At 2 years postoperatively, facial function was expressed in terms of House-Brackmann score (HB): HB 1 in 53.4%, HB 1/2 in 61.3%, HB 1-3 in 83.2% and HB 4-6 in 16.8%. All nine patients who underwent surgery following failed stereotactic radiotherapy had HB 3 function or better. Among 9.5% of the cases, 14 facial nerves were lost during surgery and repaired using direct anastomosis or grafting. There was no tinnitus present preoperatively in 27% of the cases, and 22% of patients developed tinnitus postoperatively. In patients with preoperative tinnitus, 61% remained the same, 17% got it resolved and only in 21% it worsened. The preoperative hydrocephalus rate was 26%, and among 15% of the cases five ventriculo-peritoneal (VP) shunts were performed. The cerebrospinal fluid leak rate was 2.5%. Fifty-six patients underwent auditory brainstem implantation (ABI) and two patients had cochlear implant (CI) sleepers inserted.

CONCLUSIONS

The management of patients with NF2 presents the clinician with a formidable challenge with many patients still presenting themselves late with the neurological compromise and a large tumour load. There is still an argument for the management by observation until the neurological compromise dictates interventional treatment particularly with the option of hearing rehabilitation with ABI or CI. The translabyrinthine approach provides a very satisfactory means of reducing the overall tumour volume.