Teaching Social Determinants of Health in Nursing Programs: An Integrative Review of Strategies and Effectiveness

BACKGROUND

Incorporating social determinants of health (SDoH) into clinical decision-making can clarify disease causes, enhance care planning, and improve health outcomes. Nurse educators should know which strategies are most effective for teaching SDoH in bachelor of science in nursing (BSN) programs.

OBJECTIVE

This integrative review synthesizes the literature on familiarizing BSN students with SDoH and identifies effective teaching interventions for SDoH in these programs.

METHODS

The researchers searched CINAHL, PubMed, Web of Science, and ERIC databases, and 21 articles met the inclusion criteria. The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines were followed for reporting.

RESULTS

The curriculum method, service learning, and international outreach experiences were frequently used teaching strategies. Qualitative evaluation was used to evaluate student outcomes.

CONCLUSIONS

Nurse educators should be mindful of these strategies. Interdisciplinary teamwork can bolster students' understanding of disadvantaged populations while integrating SDoH in nursing curricula. Quantitative evaluations of learning outcomes are needed to determine teaching effectiveness.

Extraction vs nonextraction of premolars for orthodontic treatment: A scoping review examining the extent, range, and characteristics of the literature

INTRODUCTION

The debate about whether malocclusion can or should be treated with or without extraction of premolars continues. This scoping review quantifies the literature, summarizes the outcomes researched and methods, and proposes a way to reduce uncertainty in this area.

METHODS

Electronic and gray literature searches were undertaken without language restriction, but non-English language titles and abstracts were not translated. A minimum of 2 people independently screened the titles and abstracts.

RESULTS

Searches identified 9010 articles, of which 3851 were duplicates; 5159 were screened, and 4617 were excluded (1092 laboratory or animal studies, 1219 case reports or series, 2306 with no information). By consensus, 399 articles contained information concerning differences between orthodontic patients treated with or without premolar extractions (143 were unclear). The majority (n = 372) reported outcomes in 8 areas. Fifty-seven were review articles (32 systematic reviews and 25 nonsystematic reviews or opinions). The most common research design in the remainder was a cohort (n = 280, 82% of 342 articles reporting primary data), of which a very large majority were considered retrospective (n = 249, 89% of articles reported for subjects over ≥2 time points). Only 28 (8% of articles reporting primary data) were judged to involve prospective data collection (4 randomized controlled trials [RCTs], 23 cohorts, 1 unclear design). Excluding reviews and unclear articles, 99% (332 out of 336) were considered observational research and only 1% were interventional.

CONCLUSIONS

There was limited low-quality evidence that extracting premolars in orthodontic patients have a possible negative effect in 2 outcome areas and a positive effect in 1 outcome area. Most study reports were of low methodological quality, and further reviews are unlikely to provide new information. Investigators should concentrate on collecting primary data of outcomes important to patients. A protocol has been made available to help reduce methodological differences, assist future meta-analyses and increase the generalizability of findings: https://doi.org/10.17605/OSF.IO/CQ49Y.

Rethinking Oral Health in Aging: Ecosocial Theory and Intersectionality

Poor oral health affects the health and well-being of older adults in many ways. Despite years of international research investigating poor oral health among older adults, it has remained a largely unresolved problem. The aim of this article is to explore the combination of 2 key frameworks, ecosocial theory and intersectionality, to guide our exploration and understanding of oral health and aging and help inform research, education, policy, and services. Proposed by Krieger, ecosocial theory is concerned with the symbiotic relationship among embodied biological processes and social, historical, and political contexts. Building on the work of Crenshaw, intersectionality explores how social identities such as race, gender, socioeconomic status, and age interconnect in ways that can enhance privilege or compound discrimination and social disadvantage. Intersectionality offers a layered understanding of how power relations reflected in systems of privilege or oppression influence an individual's multiple intersecting social identities. Understanding this complexity and the symbiotic relationships offers an opportunity to reconsider how inequities in oral health for older adults can be addressed in research, education, and practice and increase the focus on equity, prevention, interdisciplinary care, and use of innovative technology.

Immune Activation following Irbesartan Treatment in a Colorectal Cancer Patient: A Case Study

Colorectal cancers are one of the most prevalent tumour types worldwide and, despite the emergence of targeted and biologic therapies, have among the highest mortality rates. The Personalized OncoGenomics (POG) program at BC Cancer performs whole genome and transcriptome analysis (WGTA) to identify specific alterations in an individual's cancer that may be most effectively targeted. Informed using WGTA, a patient with advanced mismatch repair-deficient colorectal cancer was treated with the antihypertensive drug irbesartan and experienced a profound and durable response. We describe the subsequent relapse of this patient and potential mechanisms of response using WGTA and multiplex immunohistochemistry (m-IHC) profiling of biopsies before and after treatment from the same metastatic site of the L3 spine. We did not observe marked differences in the genomic landscape before and after treatment. Analyses revealed an increase in immune signalling and infiltrating immune cells, particularly CD8+ T cells, in the relapsed tumour. These results indicate that the observed anti-tumour response to irbesartan may have been due to an activated immune response. Determining whether there may be other cancer contexts in which irbesartan may be similarly valuable will require additional studies.

Predictors and risk factors for admission to critical care in cervicofacial infections: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infections carry significant morbidity. Patients present on a broad spectrum of severity, with some requiring outpatient management and others admission to higher level care. Recognition of risk factors is helpful in decision making regarding the need for admission to higher level care. Prospective data were captured on 1002 patients in 25 centres across 17 regions of the United Kingdom (UK) by the Maxillofacial Trainee Research Collaborative (MTReC). Patients admitted to critical care were compared with those who received ward-level care. Multivariate and receiver operating characteristic curve analyses were used to identify predictors for critical care admission. Our results show that the best predictor for critical care admission is the presence of three or more features of airway compromise (AUC 0.779), followed by C-reactive protein (CRP) >100 mg/L (OR 2.70; 95% CI 1.59 to 4.58; p < 0.005), submandibular space involvement (OR 3.82; 95% CI 1.870 to 7.81; p = 0.003), white cell count (WCC) >12 × 10⁹/ dl (1.05; 95% CI 1.01 to 1.10; p = 0.03), and positive systemic inflammatory response syndrome criteria (OR 2.78; CI 1.35 to 5.80; p = 0.006). Admission to critical care is multifactorial, however, the presence of three or more features of airway compromise is the best predictor. Awareness of this alongside other key clinical findings in cervicofacial infections may allow for the early recognition of patients who may require escalation to critical care.

Osimertinib and anti-HER3 combination therapy engages immune dependent tumor toxicity via STING activation in trans

Over the past decade, immunotherapy delivered novel treatments for many cancer types. However, lung cancer still leads cancer mortality, and non-small-cell lung carcinoma patients with mutant EGFR cannot benefit from checkpoint inhibitors due to toxicity, relying only on palliative chemotherapy and the third-generation tyrosine kinase inhibitor (TKI) osimertinib. This new drug extends lifespan by 9-months vs. second-generation TKIs, but unfortunately, cancers relapse due to resistance mechanisms and the lack of antitumor immune responses. Here we explored the combination of osimertinib with anti-HER3 monoclonal antibodies and observed that the immune system contributed to eliminate tumor cells in mice and co-culture experiments using bone marrow-derived macrophages and human PBMCs. Osimertinib led to apoptosis of tumors but simultaneously, it triggered inositol-requiring-enzyme (IRE1α)-dependent HER3 upregulation, increased macrophage infiltration, and activated cGAS in cancer cells to produce cGAMP (detected by a lentivirally transduced STING activity biosensor), transactivating STING in macrophages. We sought to target osimertinib-induced HER3 upregulation with monoclonal antibodies, which engaged Fc receptor-dependent tumor elimination by macrophages, and STING agonists enhanced macrophage-mediated tumor elimination further. Thus, by engaging a tumor non-autonomous mechanism involving cGAS-STING and innate immunity, the combination of osimertinib and anti-HER3 antibodies could improve the limited therapeutic and stratification options for advanced stage lung cancer patients with mutant EGFR.

Intrinsic somatosensory feedback supports motor control and learning to operate artificial body parts

Objective.Considerable resources are being invested to enhance the control and usability of artificial limbs through the delivery of unnatural forms of somatosensory feedback. Here, we investigated whether intrinsic somatosensory information from the body part(s) remotely controlling an artificial limb can be leveraged by the motor system to support control and skill learning.Approach.We used local anaesthetic to attenuate somatosensory inputs to the big toes while participants learned to operate through pressure sensors a toe-controlled and hand-worn robotic extra finger. Motor learning outcomes were compared against a control group who received sham anaesthetic and quantified in three different task scenarios: while operating in isolation from, in synchronous coordination, and collaboration with, the biological fingers.Main results.Both groups were able to learn to operate the robotic extra finger, presumably due to abundance of visual feedback and other relevant sensory cues. Importantly, the availability of displaced somatosensory cues from the distal bodily controllers facilitated the acquisition of isolated robotic finger movements, the retention and transfer of synchronous hand-robot coordination skills, and performance under cognitive load. Motor performance was not impaired by toes anaesthesia when tasks involved close collaboration with the biological fingers, indicating that the motor system can close the sensory feedback gap by dynamically integrating task-intrinsic somatosensory signals from multiple, and even distal, body-parts.Significance.Together, our findings demonstrate that there are multiple natural avenues to provide intrinsic surrogate somatosensory information to support motor control of an artificial body part, beyond artificial stimulation.

Introduction to the National Cancer Imaging Translational Accelerator (NCITA): a UK-wide infrastructure for multicentre clinical translation of cancer imaging biomarkers

The National Cancer Imaging Translational Accelerator (NCITA) is creating a UK national coordinated infrastructure for accelerated translation of imaging biomarkers for clinical use. Through the development of standardised protocols, data integration tools and ongoing training programmes, NCITA provides a unique scalable infrastructure for imaging biomarker qualification using multicentre clinical studies.

International Collaboration as an interdisciplinary approach for the development of a Cultural Competency online module

Introduction

Culture is a concept most people instinctively understand, but may struggle to fully articulate. Culture is not limited to ethnicity and religion, but encompasses age, gender, sexual orientation, occupation, socioeconomic status, ethnic origin or migrant experience, religious or spiritual belief, and dis/ability. Given the breadth and complexity of culture, healthcare professionals in particular are challenged to interact with an increasingly multicultural world and various cultural groups. There is a growing need for appropriate training models to enhance cultural awareness, and cultural competence, including in pharmacy schools.

“Interdisciplinary” can be defined as “relating to more than one branch of knowledge” [1], and international collaboration allows the connection of knowledge of different cultures. Developing a teaching intervention internationally, across three continents allows wider exposure to different cultures and can help students appreciate what culture may mean in different countries and how different ways of living are accepted and/or perceived in different societies.

Aim

To design and disseminate an online cultural communication module for use by pharmacy students across three countries and continents

Methods

A team from the Schools of Pharmacy at University College London (UCL), UK; Monash University, Australia and University of North Carolina (UNC), USA worked collaboratively to build an online module to help pharmacy students understand the importance of cultural awareness when communicating with patients. The Schools identified a range of cultural groups and scenarios in which pharmacist led communications could occur. Each School designed and filmed three scenarios, with two versions: one relatively good demonstration of communication and one poor. A range of actors, patients and pharmacists from different cultural groups (e.g. ethnic background, disability, LGBTQi, gender etc.) were involved in the design and filming. The module required students to reflect on the roleplays and provided feedback in the form of summary key points for each topic area. This module was embedded into the existing curricula for all Year 1 (Monash and UCL) and Year 2 (UNC) students in 2019. Students were informed as part of their regular course communication. A Likert style evaluation survey, including free text responses about the module was included, Questions were adapted from previous teaching evaluations. This data was recorded via each School’s Learning Management System. Descriptive statistics and a basic thematic analysis were conducted.

Results

Across the three Schools, a total of 525 students were offered the online module and 208 completed it. At UNC, 72.2% of students who completed would recommend the module to others, at UCL 83% and Monash 88%. Students’ feedback fell under three themes as seen in Table 1.

Conclusion

The innovation and strength of this learning intervention comes from the international collaboration. The online module allows students to identify and be culturally aware of a diverse group of people across three continents, allowing a unique and rich experience for all students through this collaboration and developing them not only as culturally competent healthcare professionals but also global citizens.

References

1. Oxford Dictionaries, Oxford University Press, Definition of Interdisciplinary in English, Oxford, 2020. [Accessed 11th October 2020]. Available from: https://premium-oxforddictionaries-com.libproxy.ucl.ac.uk/definition/english/interdisciplinary

A randomized trial of individualized versus standard of care antiemetic therapy for breast cancer patients at high risk for chemotherapy-induced nausea and vomiting

Purpose

Despite triple antiemetic therapy use for breast cancer patients receiving emetogenic chemotherapy, nausea remains a clinical challenge. We evaluated adding olanzapine (5 mg) to triple therapy on nausea control in patients at high personal risk of chemotherapy-induced nausea and vomiting (CINV).

Methods

This multi-centre, placebo-controlled, double-blind trial randomized breast cancer patients scheduled to receive neo/adjuvant chemotherapy with anthracycline-cyclophosphamide or platinum-based chemotherapy to olanzapine (5 mg, days 1–4) or placebo. Primary endpoint was frequency of self-reported significant nausea, repeated for all cycles of chemotherapy. Secondary endpoints included: duration of nausea, overall total control of CINV, Health Related Quality of Life (HRQoL) using FLIE questionnaire, use of rescue mediation and treatment-related adverse events.

Results

218 eligible patients were randomised to placebo (105) or olanzapine (113). From days 0–5 following each cycle of chemotherapy, 41.3% (95%CI: 36.1–46.7%) of patients in the placebo group reported significant nausea compared to 27.7% (95%CI: 23.2–32.4%) in the olanzapine group (p = 0.001). Across all cycles of chemotherapy, patients receiving olanzapine experienced a statistically significant improvement in HRQoL (p < 0.001). Grade 1/2 sedation was the most commonly side effect reported at 40.8% in the placebo group vs. 54.1% with olanzapine (p < 0.001).

Conclusion

In patients at high personal risk of CINV, the addition of olanzapine 5 mg daily to standard antiemetic therapy significantly improves the control of nausea, HRQoL, with no unexpected toxicities.

•

Double-blind trial evaluated the addition of olanzapine to triple therapy in patients at high personal risk of CINV.

•

Adding 5 mg olanzapine was associated with significantly improved nausea control with no unexpected toxicities.

•

Olanzapine plus triple therapy should be considered standard of care for breast cancer patients at high risk of CINV.

P4138Clinical differences between methamphetamine and non-methamphetamine associated non-ischemic dilated cardiomyopathy

Background

Methamphetamine associated cardiomyopathy (MACM) is an increasingly recognized form of dilated cardiomyopathy around the globe which remains poorly characterized.

Purpose

To compare the clinical characteristics of MACM to those of non-MA associated dilated CM (NMACM).

Methods

Consecutive patients with MACM presenting to our institution between Jun 2018 and Jan 2019 were prospectively studied and compared to an age and gender-matched cohort of dilated non-ischemic CM cases.

Results

Seventy patients were studied (35 MACM and 35 NMACM). Mean age was similar between groups (49±9 vs. 48±10 years, p=0.465) and 97% of patients were male. Median duration of MA use prior to cardiomyopathy diagnosis was 5 years (range 0–30). Patients were predominantly Hispanic in both groups (48% vs. 62%, p=0.229), but with a greater proportion of Caucasians in the MACM group compared to NMACM (26% vs 6%, p=0.045).MACM was characterized by lower left ventricular ejection fraction (LVEF) and greater left ventricular end diastolic volume (LVEDV) compared to NMACM. RV dilation was present more often in MACM cases (Table). Years of MA use was associated with greater LA volumes (R2= 0.13, p=0.048). Association with larger LVEDV and incidence of RV dilation were borderline significant (R2= 0.11, p=0.054 and p=0.058 respectively). The amount of MA used per week correlated with higher RVSP (R2=0.317, p=0.004). Polysubstance abuse was associated with greater LVEF (p=0.028), lower LVEDV (p=0.037) and lower LV mass (p=0.004).

Echocardiographic parameters MACM Non-MACM p-value LVEDV (ml) 215 (62) 181 (40) 0.009* LVESV (ml) 166 (63) 133 (41) 0.017* LVEF (%) 20 (8) 26 (10) 0.006* LV Mass (g) 311 (109) 285 (81) 0.286 LA Volume (ml) 88 (26) 85 (29) 0.670 RV Dilation (no.) 23 (65.7%) 14 (40.0%) 0.027* Reduced RV Function (no.) 21 (60.0%) 21 (60.0%) 0.596 RVSP (mmHg) 40 (14) 44 (12) 0.671 RAP (mmHg) 9 (5) 10 (5) 0.682 Intracardiac Thrombus (no.) 3 (8.6%) 2 (5.7%) 0.500 Mean values are reported with standard deviation. *p<0.05.

Conclusion

MACM is associated with higher degree of LV and RV dilatation as well as LV systolic dysfunction when compared to matched NMACM cases. Years of MA use and amount of MA consumed appear to influence severity of disease.

Acknowledgement/Funding

None

Outcomes of transperineal and transrectal ultrasound-guided prostate biopsy

OBJECTIVE

To compare the clinical outcomes and pathological findings of transperineal ultrasound-guided prostate biopsy (TPUSPB) and transrectal ultrasound-guided prostate biopsy (TRUSPB) in a secondary referral hospital.

METHODS

This was a retrospective study of 100 TPUSPBs and 100 TRUSPBs performed in our centre. Pre-biopsy patient parameters (eg, patient age, clinical staging, serum prostate-specific antigen [PSA] level, prostate size, and PSA density), as well as pathological results and 30-day complication and readmission rates, were retrieved from the patients' medical records and compared between the two groups.

RESULTS

One hundred TPUSPBs performed from January 2018 to May 2018 and 100 TRUSPBs performed from January 2016 to April 2016 were included for analysis. Mean age did not significantly differ between the groups. The TPUSPB group had a higher mean PSA level, smaller prostate size, and higher PSA density, compared with the TRUSPB group. The overall prostate cancer detection rate was similar between the TPUSPB and TRUSPB groups (35% vs 25%, P=0.123). There were no significant differences between the groups in prostate cancer detection rates after stratification according to PSA density and clinical staging. With respect to complications, no patients developed fever in the TPUSPB group, while 4% of patients in the TRUSPB group had fever and required at least 1-week admission for intravenous antibiotic administration.

CONCLUSION

For prostate biopsy, TPUSPB is safer, with no infection complications, and has similar prostate cancer detection rate compared with TRUSPB.

Infection control in residential care homes for the elderly in Hong Kong (2005-2014)

INTRODUCTION

This serial cross-sectional survey study aimed to review the trend in various infection control practices in residential care homes for the elderly (RCHEs) in Hong Kong from 2005 to 2014.

METHODS

Annual cross-sectional surveys were conducted at all RCHEs in Hong Kong, including self-administered questionnaires, on-site interviews, inspections, and assessments conducted by trained nurses, from 2005 to 2014. In all, 98.5% to 100% of all RCHEs were surveyed each year based on the list of licensed RCHEs in Hong Kong.

RESULTS

There was a substantial increase in the proportion of RCHE residents aged ≥85 years, from 40.0% in 2005 to 50.2% in 2014 (P=0.002). The percentage of RCHE residents with special care needs also increased, from 22.3% in 2005 to 32.6% in 2014 for residents with dementia (P<0.001) and from 3.4% in 2005 to 5.0% in 2014 for residents with a long-term indwelling urinary catheter (P<0.001). The proportion of RCHEs with separate rooms for isolation areas ranged from 73.6% to 80% but did not show any significant trend over the study period. The proportion of RCHEs with alcohol hand rub available showed an increasing trend from 25.4% in 2006 to 99.2% in 2014 (P=0.008). The proportion of health or care workers (who were not the designated infection control officers) passing skills tests on hand washing techniques increased from 79.2% in 2006 to 91.5% in 2014 (P=0.02). An increasing trend was also observed for the proportion of infection control officers who were able to prepare properly diluted bleach solution, from 71.5% in 2005 to 92.2% in 2014 (P=0.002).

CONCLUSIONS

For infection control practice to continue improving, more effort should be made to enhance and maintain proper practice, and to mitigate the challenge posed by the high turnover rates of healthcare workers in RCHEs. Introduction of self-audits on infection control practices should be considered.

Successful targeting of the NRG1 pathway indicates novel treatment strategy for metastatic cancer

Background

NRG1 fusion-positive lung cancers have emerged as potentially actionable events in lung cancer, but clinical support is currently limited and no evidence of efficacy of this approach in cancers beyond lung has been shown.

Patients and methods

Here, we describe two patients with advanced cancers refractory to standard therapies. Patient 1 had lung adenocarcinoma and patient 2 cholangiocarcinoma. Whole-genome and transcriptome sequencing were carried out for these cases with select findings validated by fluorescence in situ hybridization.

Results

Both tumors were found to be positive for NRG1 gene fusions. In patient 1, an SDC4-NRG1 gene fusion was detected, similar gene fusions having been described in lung cancers previously. In patient 2, a novel ATP1B1-NRG1 gene fusion was detected. Cholangiocarcinoma is not a disease type in which NRG1 fusions had been described previously. Integrative genome analysis was used to assess the potential functional significance of the detected genomic events including the gene fusions, prioritizing therapeutic strategies targeting the HER-family of growth factor receptors. Both patients were treated with the pan HER-family kinase inhibitor afatinib and both displayed significant and durable response to treatment. Upon progression sites of disease were sequenced. The lack of obvious genomic events to describe the disease progression indicated that broad transcriptomic or epigenetic mechanisms could be attributed to the lack of prolonged response to afatinib.

Conclusion

These observations lend further support to the use of pan HER-tyrosine kinase inhibitors for the treatment of NRG1 fusion-positive in both cancers of lung and hepatocellular origin and indicate more broadly that cancers found to be NRG1 fusion-positive may benefit from such a clinical approach regardless of their site of origin.

Clinical trial information

Personalized Oncogenomics (POG) Program of British Columbia: Utilization of Genomic Analysis to Better Understand Tumour Heterogeneity and Evolution (NCT02155621).

Carcinoma ex pleomorphic adenoma: case report and options for systemic therapy

The most common benign salivary tumour is a pleomorphic adenoma. Transformation to malignancy, carcinoma ex pleomorphic adenoma (cxpa), occurs in 6% of cases. Management focuses on surgical resection and radiotherapy; however, rare cases require systemic management. We present the case of a 60-year-old woman with a cxpa of the left parotid gland who required systemic therapy for locally recurrent disease. Treatment options were guided by the literature concerning malignant salivary gland tumour and by whole-genome and transcriptome sequencing of the tumour. The patient received multiple systemic agents during the course of her disease, with cyclophosphamide-doxorubicin-cisplatin providing the best control (partial response). Genomeand transcriptome-directed therapy, including sorafenib and vismodegib, were utilized with limited clinical benefit. Malignant transformation in cxpa is a complex process, and therapy directed at a single tumour pathway might not be sufficient to control disease.

Detecting intratumoral heterogeneity of EGFR activity by liposome-based in vivo transfection of a fluorescent biosensor

Despite decades of research in the epidermal growth factor receptor (EGFR) signalling field, and many targeted anti-cancer drugs that have been tested clinically, the success rate for these agents in the clinic is low, particularly in terms of the improvement of overall survival. Intratumoral heterogeneity is proposed as a major mechanism underlying treatment failure of these molecule-targeted agents. Here we highlight the application of fluorescence lifetime microscopy (FLIM)-based biosensing to demonstrate intratumoral heterogeneity of EGFR activity. For sensing EGFR activity in cells, we used a genetically encoded CrkII-based biosensor which undergoes conformational changes upon tyrosine-221 phosphorylation by EGFR. We transfected this biosensor into EGFR-positive tumour cells using targeted lipopolyplexes bearing EGFR-binding peptides at their surfaces. In a murine model of basal-like breast cancer, we demonstrated a significant degree of intratumoral heterogeneity in EGFR activity, as well as the pharmacodynamic effect of a radionuclide-labeled EGFR inhibitor in situ. Furthermore, a significant correlation between high EGFR activity in tumour cells and macrophage-tumour cell proximity was found to in part account for the intratumoral heterogeneity in EGFR activity observed. The same effect of macrophage infiltrate on EGFR activation was also seen in a colorectal cancer xenograft. In contrast, a non-small cell lung cancer xenograft expressing a constitutively active EGFR conformational mutant exhibited macrophage proximity-independent EGFR activity. Our study validates the use of this methodology to monitor therapeutic response in terms of EGFR activity. In addition, we found iNOS gene induction in macrophages that are cultured in tumour cell-conditioned media as well as an iNOS activity-dependent increase in EGFR activity in tumour cells. These findings point towards an immune microenvironment-mediated regulation that gives rise to the observed intratumoral heterogeneity of EGFR signalling activity in tumour cells in vivo.

[18F]tetrafluoroborate-PET/CT enables sensitive tumor and metastasis in vivo imaging in a sodium iodide symporter-expressing tumor model

Cancer cell metastasis is responsible for most cancer deaths. Non-invasive in vivo cancer cell tracking in spontaneously metastasizing tumor models still poses a challenge requiring highest sensitivity and excellent contrast. The goal of this study was to evaluate if the recently introduced PET radiotracer [18F]tetrafluoroborate ([18F]BF4-) is useful for sensitive and specific metastasis detection in an orthotopic xenograft breast cancer model expressing the human sodium iodide symporter (NIS) as a reporter. In vivo imaging was complemented by ex vivo fluorescence microscopy and γ-counting of harvested tissues. Radionuclide imaging with [18F]BF4- (PET/CT) was compared to the conventional tracer [123I]iodide (sequential SPECT/CT). We found that [18F]BF4- was superior due to better pharmacokinetics, i.e. faster tumor uptake and faster and more complete clearance from circulation. [18F]BF4--PET was also highly specific as in all detected tissues cancer cell presence was confirmed microscopically. Undetected comparable tissues were similarly found to be free of metastasis. Metastasis detection by routine metabolic imaging with [18F]FDG-PET failed due to low standard uptake values and low contrast caused by adjacent metabolically active organs in this model. [18F]BF4--PET combined with NIS expressing disease models is particularly useful whenever preclinical in vivo cell tracking is of interest.

Eastern Canadian Gastrointestinal Cancer Consensus Conference 2016

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference 2016 was held in Montreal, Quebec, 5-7 February. Experts in radiation oncology, medical oncology, surgical oncology, and infectious diseases involved in the management of patients with gastrointestinal malignancies participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses multiple topics: ■ Follow-up and survivorship of patients with resected colorectal cancer■ Indications for liver metastasectomy■ Treatment of oligometastases by stereotactic body radiation therapy■ Treatment of borderline resectable and unresectable pancreatic cancer■ Transarterial chemoembolization in hepatocellular carcinoma■ Infectious complications of antineoplastic agents.

T Cell Costimulation by Derivatives of Benzoic Acid

A number of analogues of benzoic acid were evaluated in a T cell costimulation assay. One compound, the sodium salt of 2-chloro-5-nitrobenzoic acid (CNBA-Na) was chosen for further study and was found to be a potent costimulator of anti-CD3-induced proliferation of both H9 lymphoblastoid cells ( P<0.001) and human peripheral blood mononuclear cells ( P=0.001) in a dose-dependent manner. The costimulatory effect of CNBA-Na on CD3-triggered DNA synthesis did not enhance human immunodeficiency virus replication in infected cells. Studies with blocking monoclonal antibodies against B7-1 or B7-2 indicated that the immunopotentiatory effect of CNBA-Na required a macromolecular interaction between CD28 (a costimulatory receptor on T cells) and its counter receptor B7 expressed on antigen-presenting cells. The discovery that this low molecular weight compound causes T cell proliferation highlights a potentially novel therapeutic approach to immunodeficiency diseases.

Response to angiotensin blockade with irbesartan in a patient with metastatic colorectal cancer

BACKGROUND

A patient suffering from metastatic colorectal cancer, treatment-related toxicity and resistance to standard chemotherapy and radiation was assessed as part of a personalized oncogenomics initiative to derive potential alternative therapeutic strategies.

PATIENTS AND METHODS

Whole-genome and transcriptome sequencing was used to interrogate a metastatic tumor refractory to standard treatments of a patient with mismatch repair-deficient metastatic colorectal cancer.

RESULTS

Integrative genomic analysis indicated overexpression of the AP-1 transcriptional complex suggesting experimental therapeutic rationales, including blockade of the renin-angiotensin system. This led to the repurposing of the angiotensin II receptor antagonist, irbesartan, as an anticancer therapy, resulting in the patient experiencing a dramatic and durable response.

CONCLUSIONS

This case highlights the utility of comprehensive integrative genomic profiling and bioinformatics analysis to provide hypothetical rationales for personalized treatment options.

Association of proinflammatory cytokines and chemotherapy-associated cognitive impairment in breast cancer patients: a multi-centered, prospective, cohort study

BACKGROUND

Existing evidence suggests that proinflammatory cytokines play an intermediary role in postchemotherapy cognitive impairment. This is one of the largest multicentered, cohort studies conducted in Singapore to evaluate the prevalence and proinflammatory biomarkers associated with cognitive impairment in breast cancer patients.

PATIENTS AND METHODS

Chemotherapy-receiving breast cancer patients (stages I-III) were recruited. Proinflammatory plasma cytokines concentrations [interleukin (IL)-1β, IL-2, IL-4, IL-6, IL-8, IL-10, granulocyte-macrophage colony-stimulating factor, interferon-γ and tumor necrosis factor-α] were evaluated at 3 time points (before chemotherapy, 6 and 12 weeks after chemotherapy initiation). The FACT-Cog (version 3) was utilized to evaluate patients' self-perceived cognitive disturbances and a computerized neuropsychological assessment (Headminder) was administered to evaluate patients' memory, attention, response speed and processing speed. Changes of cognition throughout chemotherapy treatment were compared against the baseline. Linear mixed-effects models were applied to test the relationships of clinical variables and cytokine concentrations on self-perceived cognitive disturbances and each objective cognitive domain.

RESULTS

Ninety-nine patients were included (age 50.5 ± 8.4 years; 81.8% Chinese; mean duration of education = 10.8 ± 3.3 years). Higher plasma IL-1β was associated with poorer response speed performance (estimate: -0.78; 95% confidence interval (CI) -1.34 to -0.03; P = 0.023), and a higher concentration of IL-4 was associated with better response speed performance (P = 0.022). Higher concentrations of IL-1β and IL-6 were associated with more severe self-perceived cognitive disturbances (P = 0.018 and 0.001, respectively). Patients with higher concentrations of IL-4 also reported less severe cognitive disturbances (P = 0.022).

CONCLUSIONS

While elevated concentrations of IL-6 and IL-1β were observed in patients with poorer response speed performance and perceived cognitive disturbances, IL-4 may be protective against chemotherapy-associated cognitive impairment. This study is important because cytokines would potentially be mechanistic mediators of chemotherapy-associated cognitive changes.

Discrete event simulation of patient admissions to a neurovascular unit

Evidence exists that clinical outcomes improve for stroke patients admitted to specialized Stroke Units. The Toronto Western Hospital created a Neurovascular Unit (NVU) using beds from general internal medicine, Neurology and Neurosurgery to care for patients with stroke and acute neurovascular conditions. Using patient-level data for NVU-eligible patients, a discrete event simulation was created to study changes in patient flow and length of stay pre- and post-NVU implementation. Varying patient volumes and resources were tested to determine the ideal number of beds under various conditions. In the first year of operation, the NVU admitted 507 patients, over 66% of NVU-eligible patient volumes. With the introduction of the NVU, length of stay decreased by around 8%. Scenario testing showed that the current level of 20 beds is sufficient for accommodating the current demand and would continue to be sufficient with an increase in demand of up to 20%.

The use of molecular imaging combined with genomic techniques to understand the heterogeneity in cancer metastasis

Tumour heterogeneity has, in recent times, come to play a vital role in how we understand and treat cancers; however, the clinical translation of this has lagged behind advances in research. Although significant advancements in oncological management have been made, personalized care remains an elusive goal. Inter- and intratumour heterogeneity, particularly in the clinical setting, has been difficult to quantify and therefore to treat. The histological quantification of heterogeneity of tumours can be a logistical and clinical challenge. The ability to examine not just the whole tumour but also all the molecular variations of metastatic disease in a patient is obviously difficult with current histological techniques. Advances in imaging techniques and novel applications, alongside our understanding of tumour heterogeneity, have opened up a plethora of non-invasive biomarker potential to examine tumours, their heterogeneity and the clinical translation. This review will focus on how various imaging methods that allow for quantification of metastatic tumour heterogeneity, along with the potential of developing imaging, integrated with other in vitro diagnostic approaches such as genomics and exosome analyses, have the potential role as a non-invasive biomarker for guiding the treatment algorithm.

Parameters affecting the formation of perfluoroalkyl acids during wastewater treatment

This study examined the fate and behaviour of perfluoroalkyl acids (PFAAs) in liquid and solid samples from five different wastewater treatment types: facultative and aerated lagoons, chemically assisted primary treatment, secondary aerobic biological treatment, and advanced biological nutrient removal treatment. To the best of our knowledge, this is the largest data set from a single study available in the literature to date for PFAAs monitoring study in wastewater treatment. Perfluorooctanoic acid (PFOA) was the predominant PFAA in wastewater with levels from 2.2 to 150ng/L (influent) and 1.9 to 140ng/L (effluent). Perfluorooctanesulfonic acid (PFOS) was the predominant compound in primary sludge, waste biological sludge, and treated biosolids with concentrations from 6.4 to 2900ng/g dry weight (dw), 9.7 to 8200ng/gdw, and 2.1 to 17,000ng/gdw, respectively. PFAAs were formed during wastewater treatment and it was dependant on both process temperature and treatment type; with higher rates of formation in biological wastewater treatment plants (WWTPs) operating at longer hydraulic retention times and higher temperatures. PFAA removal by sorption was influenced by different sorption tendencies; median log values of the solid-liquid distribution coefficient estimated from wastewater biological sludge and final effluent were: PFOS (3.73)>PFDA (3.68)>PFNA (3.25)>PFOA (2.49)>PFHxA (1.93). Mass balances confirmed the formation of PFAAs, low PFAA removal by sorption, and high PFAA levels in effluents.

Abstract P5-01-01: Lymphoid tissue inducer cells: Identification of a novel immune cell within the breast tumour microenvironment and its role in promoting tumour cell invasion

Within breast cancers, trans-endothelial migration of tumour cells through lymphatic vessels is the first step to tumour dissemination and lympho-vascular invasion has been shown to stratify breast cancer phenotypes into distinct prognostic groups. The exact molecular mechanisms mediating tumor cell entry and persistence within the lymphatic system remain unclear. Lymphoid tissue inducer (LTi) cells are members of the emerging family of retinoic acid related orphan receptor (ROR)gt+ innate lymphoid cells (ILCs), and their interaction with stromal cells induces production by the stromal cells of VEGF-C and “lymphoid” chemokines, essential for lymphoid organogenesis. We hypothesized that tumour cells manipulate the normal processes that govern chemokine-dependent, trans-lymphatic migration of immune cells, including LTi cells; shaping its microenvironment. Results: We analyzed the expression of lymphoid chemokines genes (CXCL12, CXCL13, CCL19, CCL20 and CCL21) and their corresponding receptors (CXCR4, CXCR5, CCR6 and CCR7) within the METABRIC (Molecular Taxonomy of Breast Cancer International Consortium) Tissue Bank. An unsupervised hierarchical cluster analysis revealed co-expression of these genes, categorizing breast tumors as relatively high/low expressors. Tumors exhibiting relatively high expression of these genes were found to be enriched for “basal-like” breast cancers according to PAM50 intrinsic subtype assignments. Immunofluorescence of the primary tumour sections identified cells that were comparable in phenotype to LTi cells. In a blinded study, we observed that patients with high LTi counts within the tumour microenvironment were also likely to have a gene expression corresponding to high expression for the lymphoid chemokines. IHC for the lymphatic marker, podoplanin found that the LTi count correlated with both an increased lymphatic vessel density and tumor invasion into lymphatic vessels. Within the basal and HER2+ve subtypes, patients with more than 4 lymph nodes were found to exhibit higher numbers of intratumoural LTi cells. In vitro studies, alongside multi-photon in vivo imaging were performed to investigate the interaction between intra-tumoural LTi and mesenchymal stromal cells. CXCL13 was shown to be essential for LTi clustering around stromal cells in vitro, and, the administration of a blocking antibody in vivo delayed the onset of lymph node metastasis in a murine mammary tumour (4T1.2) model. CXCLl3 has been identified as having independent prognostic significance in breast cancer, but we and others report that breast cancer cell lines are not the source of CXCL13. We show that an increase in stromal CXCL13 concentration within the tumour microenvironment following LTi recruitment promotes an EMT phenotype in the 4T1.2 cancer cell line, possibly via activation of the RANKL/RANK axis promoting tumorigenesis. We report for the first time, the identification of LTi cells within the human breast cancer tumour microenvironment and propose a pivotal role for these cells, through stromal cell interactions in the tumour microenvironment, in facilitating lymphatic invasion of tumour cells by modulation of the local lymphoid chemokine profile.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-01-01.