Performance and usability testing of an automated tool for detection of peripheral artery disease using electronic health records

Peripheral artery disease (PAD) is a common cardiovascular disorder that is frequently underdiagnosed, which can lead to poorer outcomes due to lower rates of medical optimization. We aimed to develop an automated tool to identify undiagnosed PAD and evaluate physician acceptance of a dashboard representation of risk assessment. Data were derived from electronic health records (EHR). We developed and compared traditional risk score models to novel machine learning models. For usability testing, primary and specialty care physicians were recruited and interviewed until thematic saturation. Data from 3168 patients with PAD and 16,863 controls were utilized. Results showed a deep learning model that utilized time engineered features outperformed random forest and traditional logistic regression models (average AUCs 0.96, 0.91 and 0.81, respectively), P < 0.0001. Of interviewed physicians, 75% were receptive to an EHR-based automated PAD model. Feedback emphasized workflow optimization, including integrating risk assessments directly into the EHR, using dashboard designs that minimize clicks, and providing risk assessments for clinically complex patients. In conclusion, we demonstrate that EHR-based machine learning models can accurately detect risk of PAD and that physicians are receptive to automated risk detection for PAD. Future research aims to prospectively validate model performance and impact on patient outcomes.

An allied reprogramming, selection, expansion and differentiation platform for creating hiPSC on microcarriers

OBJECTIVES

Induced pluripotent stem cells (iPSCs) generated by monolayer cultures is plagued by low efficiencies, high levels of manipulation and operator unpredictability. We have developed a platform, reprogramming, expansion, and differentiation on Microcarriers, to solve these challenges.

MATERIALS AND METHODS

Five sources of human somatic cells were reprogrammed, selected, expanded and differentiated in microcarriers suspension cultures.

RESULTS

Improvement of transduction efficiencies up to 2 times was observed. Accelerated reprogramming in microcarrier cultures was 7 days faster than monolayer, providing between 30 and 50-fold more clones to choose from fibroblasts, peripheral blood mononuclear cells, T cells and CD34+ stem cells. This was observed to be due to an earlier induction of genes (β-catenin, E-cadherin and EpCAM) on day 4 versus monolayer cultures which occurred on days 14 or later. Following that, faster induction and earlier stabilization of pluripotency genes occurred during the maturation phase of reprogramming. Integrated expansion without trypsinization and efficient differentiation, without embryoid bodies formation, to the three germ-layers, cardiomyocytes and haematopoietic stem cells were further demonstrated.

CONCLUSIONS

Our method can solve the inherent problems of conventional monolayer cultures. It is highly efficient, cell dissociation free, can be operated with lower labor, and allows testing of differentiation efficiency without trypsinization and generation of embryoid bodies. It is also amenable to automation for processing more samples in a small footprint, alleviating many challenges of manual monolayer selection.

Selection of O-negative induced pluripotent stem cell clones for high-density red blood cell production in a scalable perfusion bioreactor system

Objectives

Large‐scale generation of universal red blood cells (RBCs) from O‐negative (O‐ve) human induced pluripotent stem cells (hiPSCs) holds the potential to alleviate worldwide shortages of blood and provide a safe and secure year‐round supply. Mature RBCs and reticulocytes, the immature counterparts of RBCs generated during erythropoiesis, could also find important applications in research, for example in malaria parasite infection studies. However, one major challenge is the lack of a high‐density culture platform for large‐scale generation of RBCs in vitro.

Materials and Methods

We generated 10 O‐ve hiPSC clones and evaluated their potential for mesoderm formation and erythroid differentiation. We then used a perfusion bioreactor system to perform studies with high‐density cultures of erythroblasts in vitro.

Results

Based on their tri‐lineage (and specifically mesoderm) differentiation potential, we isolated six hiPSC clones capable of producing functional erythroblasts. Using the best performing clone, we demonstrated the small‐scale generation of high‐density cultures of erythroblasts in a perfusion bioreactor system. After process optimization, we were able to achieve a peak cell density of 34.7 million cells/ml with 92.2% viability in the stirred bioreactor. The cells expressed high levels of erythroblast markers, showed oxygen carrying capacity, and were able to undergo enucleation.

Conclusions

This study demonstrated a scalable platform for the production of functional RBCs from hiPSCs. The perfusion culture platform we describe here could pave the way for large volume‐controlled bioreactor culture for the industrial generation of high cell density erythroblasts and RBCs.

Endocrine disruptors: Challenges and future directions in epidemiologic research

Public concern about the impact of endocrine disrupting chemicals (EDCs) on both humans and the environment is growing steadily. Epidemiologic research provides key information towards our understanding of the relationship between environmental exposures like EDCs and human health outcomes. Intended for researchers in disciplines complementary to epidemiology, this paper highlights the importance and challenges of epidemiologic research in order to present the key elements pertaining to the design and interpretation of an epidemiologic study on EDCs. The conduct of observational studies on EDCs derives from a thoughtful research question, which will help determine the subsequent methodological choices surrounding the careful selection of the study population (including the comparison group), the adequate ascertainment of exposure(s) and outcome(s) of interest, and the application of methodological and statistical concepts more specific to epidemiology. The interpretation of epidemiologic results may be arduous due to the latency occurring between EDC exposure and certain outcome(s), the complexity in capturing EDC exposure(s), and traditional methodological and statistical issues that also deserve consideration (e.g., confounding, effect modification, non-monotonic responses). Moving forward, we strongly advocate for an integrative approach of expertise in the fields of epidemiology, exposure science, risk assessment and toxicology to adequately study the health risks associated with EDCs while tackling their challenges.

Inter-rater reliability of occupational exposure assessment in a case-control study of female breast cancer

The objective of this paper was to estimate the inter-rater reliability of expert assessments of occupational exposures. An inter-rater reliability sub-study was conducted within a population-based case-control study of postmenopausal breast cancer. Detailed information on lifetime occupational histories was obtained from participants and two industrial hygienists assigned exposures to 185 jobs using a checklist of 293 agents. Experts rated exposure for each job-agent combination according to exposure status (unexposed/exposed), confidence that the exposure occurred (possible/probable/definite), intensity (low/medium/high), and frequency (% time per week). The statistical unit of observation was each job-agent assessment (185 jobs × 293 agents = 54,205 assessments per expert). Crude agreement, Gwet AC1/2 statistics, and Cohen's Kappa were used to estimate inter-rater agreement for confidence and intensity; for frequency, the intra-class correlation coefficient (ICC) was used. The majority of job-agent combinations were evaluated by the two experts to be not exposed (crude agreement >98% of decisions). The degree of agreement between the experts for the confidence of exposure status was Gwet AC1/2 = 0.99 (95% CI: 0.99-0.99), and for intensity, a Gwet AC2 = 0.99 (95% CI: 0.99-0.99). For frequency, an ICC of 0.31 (95% CI: 0.26-0.35) was found. A sub-analysis restricted to job-agent combinations for which the two experts agreed on exposure status revealed a moderate agreement for confidence of exposure (Gwet AC2 = 0.66) and high agreement for intensity (Gwet AC2 = 0.96). For frequency, the ICC was 0.52 (95% CI: 0.47-0.57). A high level of inter-rater agreement was found for identifying exposures and for coding intensity, but agreement was lower for the coding of frequency of exposure.

Integrating Human-Induced Pluripotent Stem Cell Expansion Capability and Cardiomyocyte Differentiation Potential in a Microcarrier Suspension Culture

Human-induced pluripotent stem cells are known for their high proliferation capacity as well as their ability to differentiate to different lineages (Ban et al., Theranostics 7(7):2067-2077, 2017; Chen et al., Stem Cell Res 15(2):365-375, 2015; Serra et al., Trends Biotechnol 30(6):350-359, 2012). For stem-cell-derived cardiomyocytes to evolve into a scalable therapeutic source, a large quantity of highly pure cardiomyocytes is needed. Thus, lies the challenge of defining an efficient cardiomyocyte differentiation process. This chapter describes a method to evaluate multiple human-induced pluripotent stem cell lines for their cardiac differentiation potentials before evaluating their integrated proliferation and differentiation abilities in microcarrier cultures in a spinner culture format.

O-233 Micronized progesterone plus dydrogesterone versus micronized progesterone alone for luteal phase support in frozen-thawed cycles: a prospective cohort study

Study question

Does the addition of oral dydrogesterone to vaginal progesterone as luteal phase support improve pregnancy outcomes during frozen embryo transfer (FET) cycles compared with vaginal progesterone alone?

Summary answer

Luteal phase support with oral dydrogesterone added to vaginal progesterone improves live birth rates and reduces miscarriage rates compared with vaginal progesterone alone.

What is known already

Progesterone is an important hormone that triggers secretory transformation of the endometrium to allow implantation of the embryo. During in vitro fertilization (IVF), exogenous progesterone is administered for luteal phase support. However, there is wide inter-individual variation in absorption of progesterone via the vaginal wall. Oral dydrogesterone is effective and well tolerated when used to provide luteal phase support after fresh embryo transfer. However, there are currently no data on the effectiveness of luteal phase support with the combination of dydrogesterone with vaginal micronized progesterone compared with vaginal micronized progesterone after FET.

Study design, size, duration

Prospective cohort study conducted at an academic infertility center in Vietnam from 26 June 2019 to 30 March 2020.

Participants/materials, setting, methods

We studied 1364 women undergoing IVF with FET. The luteal support regimen was either vaginal micronized progesterone 400 mg twice daily plus oral dydrogesterone 10 mg twice daily (second part of the study) or vaginal micronized progesterone 400 mg twice daily (first 4 months of the study). The primary endpoint was live birth after the first FET of the started cycle, with miscarriage &lt;12 weeks as one of the secondary endpoints.

Main results and the role of chance

The vaginal progesterone + dydrogesterone group and vaginal progesterone groups included 732 and 632 participants, respectively. Live birth rates were 46.3% versus 41.3%, respectively (rate ratio [RR] 1.12, 95% confidence interval [CI] 0.99–1.27, p = 0.06; multivariate analysis RR 1.30 (95% CI 1.01–1.68), p = 0.042), with a statistically significant lower rate of miscarriage at &lt; 12 weeks (3.4% vs 6.6%; RR 0.51, 95% CI 0.32–0.83; p = 0.009). Birth weight of both singletons (2971.0 ± 628.4 vs. 3118.8 ± 559.2 g; p = 0.004) and twins (2175.5 ± 494.8 vs. 2494.2 ± 584.7; p = 0.002) was significantly lower in the progesterone plus dydrogesterone versus progesterone group.

Limitations, reasons for caution

The study were the open-label design and the non-randomized nature of the sequential administration of study treatments. However, our systematic comparison of the two strategies was able to be performed much more rapidly than a conventional randomized controlled trial. In addition, the single ethnicity population limits external generalizability.

Wider implications of the findings

Oral dydrogesterone in addition to vaginal progesterone as luteal phase support in FET cycles can reduce the miscarriage rate and improve the live birth rate. Carefully planned prospective cohort studies with limited bias could be used as an alternative to randomized controlled clinical trials to inform clinical practice.

Trial registration number

NCT03998761

An approach to classifying occupational exposures to endocrine disrupting chemicals by sex hormone function using an expert judgment process

Endocrine disrupting chemicals (EDCs) are exogenous substances that interfere with the endocrine system and cause adverse effects. We aimed to classify the effects of 24 known EDCs, prevalent in certain occupations, according to four modes of action (estrogenic, antiestrogenic, androgenic, and/or antiandrogenic). A literature search, stratified into four types of literature was conducted (namely: national and international agency reports; review articles; primary studies; ToxCast^TM). The state of the evidence of each EDC on sex hormone function was summarized and reviewed by an expert panel. For each mode of action, the experts evaluated the likelihood of endocrine disruption in five categories: "No", "Unlikely", "Possibly", "Probably", and "Yes". Seven agents were categorized as "Yes," or having strong evidence for their effects on sex hormone function (antiandrogenic: lead, arsenic, butylbenzyl phthalate, dibutyl phthalate, dicyclohexyl phthalate; estrogenic: nonylphenol, bisphenol A). Nine agents were categorized as "Probable," or having probable evidence (antiandrogenic: bis(2-ethylhexyl)phthalate, nonylphenol, toluene, bisphenol A, diisononyl phthalate; androgenic: cadmium; estrogenic: copper, cadmium and; anti-estrogenic: lead). Two agents (arsenic, polychlorinated biphenyls) had opposing conclusions supporting both "probably" estrogenic and antiestrogenic effects. This synthesis will allow researchers to evaluate the health effects of selected EDCs with an added level of precision related to the mode of action.

451 THE BEST MARKER FOR COGNITION—RELATIVE HANDGRIP STRENGTH, ASYMMETRY OR WEAKNESS?

Introduction

Handgrip strength (HGS) is increasingly used to estimate overall muscle strength. Association between low HGS and cognitive decline has been well documented. Recently, McGrath’s team elucidated a new dimension of HGS asymmetry with important implications on physical and cognitive limitations. It is unclear if these effects can be generalised. The Asian working group for sarcopenia (AWGS) has called for ‘special considerations’ due to ‘anthropometric and cultural or lifestyle-related differences’6. Hence, we aim to investigate if HGS asymmetry is associated with cognition in Asians.

Methodology

We defined sarcopenia by AWGS consensus: HGS &lt;28 kg for men; &lt;18 kg for women. Asymmetry was HGS &gt;10% stronger on either hand; relative HGS was HGS adjusted for BMI. Low cognitive function was defined as MMSE&lt;26. We compared weakness alone, any HGS asymmetry or relative HGS alone and combination of weakness and HGS asymmetry or relative HGS asymmetry. Each model was adjusted for demographic characteristics, hand dominance, obesity, frailty, physical activity, depression and perceived health status.

Results

738 Asian subjects participated. Mean age 70.8 ± 0.2 years, 45.1% males, 82.5% Chinese. More than 50% have multimorbidity. 5.4% were frail. Mean BMI 24.4 ± 0.1 kg/m2. Mean HGS 22.6 ± 0.3. 93 (12.7%) had symmetrical HGS and not weak, 59 (7.8%) asymmetrical and not weak, 321 (43.6%) symmetrical and weak, 265 (35.9%) asymmetrical and weak. Mean MMSE scores for weakness alone, asymmetry alone and combined weakness and asymmetry are 26.6 ± 0.1, 26.8 ± 0.2 and 26.5 ± 0.2 respectively. HGS asymmetry alone was not associated with better cognitive function OR 0.66 (95%CI: 0.30–1.44). Combined asymmetry and weakness was non-significantly linked to worse cognition OR 2.14 (95%CI: 0.79–5.82). We found relative HGS to be protective for cognitive decline, OR 0.31 (95%CI: 0.12–0.78, p = 0.012).

Conclusion

Our study highlights the impact of ethnicity in sarcopenia research. Our population shows association of relative HGS with cognition. Further longitudinal studies are needed.

Selection of human induced pluripotent stem cells lines optimization of cardiomyocytes differentiation in an integrated suspension microcarrier bioreactor

Background

The production of large quantities of cardiomyocyte is essential for the needs of cellular therapies. This study describes the selection of a human-induced pluripotent cell (hiPSC) line suitable for production of cardiomyocytes in a fully integrated bioprocess of stem cell expansion and differentiation in microcarrier stirred tank reactor.

Methods

Five hiPSC lines were evaluated first for their cardiac differentiation efficiency in monolayer cultures followed by their expansion and differentiation compatibility in microcarrier (MC) cultures under continuous stirring conditions.

Results

Three cell lines were highly cardiogenic but only one (FR202) of them was successfully expanded on continuous stirring MC cultures. FR202 was thus selected for cardiac differentiation in a 22-day integrated bioprocess under continuous stirring in a stirred tank bioreactor. In summary, we integrated a MC-based hiPSC expansion (phase 1), CHIR99021-induced cardiomyocyte differentiation step (phase 2), purification using the lactate-based treatment (phase 3) and cell recovery step (phase 4) into one process in one bioreactor, under restricted oxygen control (< 30% DO) and continuous stirring with periodic batch-type media exchanges. High density of undifferentiated hiPSC (2 ± 0.4 × 10⁶ cells/mL) was achieved in the expansion phase. By controlling the stirring speed and DO levels in the bioreactor cultures, 7.36 ± 1.2 × 10⁶ cells/mL cardiomyocytes with > 80% Troponin T were generated in the CHIR99021-induced differentiation phase. By adding lactate in glucose-free purification media, the purity of cardiomyocytes was enhanced (> 90% Troponin T), with minor cell loss as indicated by the increase in sub-G1 phase and the decrease of aggregate sizes. Lastly, we found that the recovery period is important for generating purer and functional cardiomyocytes (> 96% Troponin T). Three independent runs in a 300-ml working volume confirmed the robustness of this process.

Conclusion

A streamlined and controllable platform for large quantity manufacturing of pure functional atrial, ventricular and nodal cardiomyocytes on MCs in conventional-type stirred tank bioreactors was established, which can be further scaled up and translated to a good manufacturing practice-compliant production process, to fulfill the quantity requirements of the cellular therapeutic industry.

Supplementary information

The online version of this article (10.1186/s13287-020-01618-6) contains supplementary material, which is available to authorized users.

Socioeconomic status and lifestyle behaviours in cancer survivors: smoking and physical activity

PURPOSE

Smoking cessation and increased physical activity (pa) have been linked to better outcomes in cancer survivors. We assessed whether socioeconomic factors influence changes in those behaviours after a cancer diagnosis.

METHODS

As part of a cross-sectional study, a diverse group of cancer survivors at the Princess Margaret Cancer Centre (Toronto, ON), completed a questionnaire about past and current lifestyle behaviours and perceptions about the importance of those behaviours with respect to their health. The influence of socioeconomic indicators on smoking status and physical inactivity at 1 year before and after diagnosis were assessed using multivariable logistic regression with adjustment for clinico-demographic factors.

RESULTS

Of 1222 participants, 1192 completed the smoking component. Of those respondents, 15% smoked before diagnosis, and 43% of those smokers continued to smoke after. The proportion of survivors who continued to smoke increased with lower education level (p = 0.03). Of the 1106 participants answering pa questions, 39% reported being physically inactive before diagnosis, of whom 82% remained inactive afterward. Survivors with a lower education level were most likely to remain inactive after diagnosis (p = 0.003). Lower education level, household income, and occupation were associated with the perception that pa had no effect or could worsen fatigue and quality of life (p ≤ 0.0001).

CONCLUSIONS

In cancer survivors, education level was a major modifier of smoking and pa behaviours. Lower socioeconomic status was associated with incorrect perceptions about pa. Targeting at-risk survivors by education level should be evaluated as a strategy in cancer survivorship programs.

Cancer Patients? Willingness to Routinely Complete the EQ-5D Instrument at Clinic Visits

BACKGROUND

Health utility (HU) scores play an essential role in pharmacoeconomic analyses. Routine clinical administration of the EuroQol-5 Dimensions (EQ-5D) can allow for HU and health related quality of life (HRQOL) assessments in the real-world setting.

OBJECTIVES

The primary goals of this study were to evaluate whether patients were willing to complete the EQ-5D instrument on a routine basis and which clinical or demographic factors influence this willingness.

METHODS

618 adult cancer survivors across multiple cancer disease sites at the Princess Margaret Cancer Centre completed an acceptability survey after completing the EQ-5D instrument.

RESULTS

The mean (SD) EQ-5D score was 0.81 (0.15). Among those surveyed, 88% reported that the EQ-5D was easy to complete. 91% took under 5 minutes and 88% were satisfied with its length. 85% were satisfied with the types of questions asked on the EQ-5D. Importantly, 92% reported that they would complete the EQ-5D, even if it were used solely for research purposes; 73% agreed with the notion of completing it regularly at their clinic visits. Patients with lower EQ-5D scores (p=0.0006), and non-Caucasians (p=0.0024; 60% willing) were less willing to complete the instrument on a regular basis. Curability of tumour, disease site, age, and gender did not influence willingness.

CONCLUSIONS

The majority of cancer patients across disease sites are willing to complete the EQ-5D instrument regularly, even if it were solely for research purposes, but up to 39% declined participation in the first place.

Platelet Activation and Clopidogrel Effects on ADP-Induced Platelet Activation in Cats with or without the A31P Mutation in MYBPC3

Background

Clopidogrel is commonly prescribed to cats with perceived increased risk of thromboembolic events, but little information exists regarding its antiplatelet effects.

Objective

To determine effects of clopidogrel on platelet responsiveness in cats with or without the A31P mutation in the MYBPC3 gene. A secondary aim was to characterize variability in feline platelet responses to clopidogrel.

Animals

Fourteen healthy cats from a Maine Coon/outbred mixed Domestic cat colony: 8 cats homozygous for A31P mutation in the MYPBC3 gene and 6 wild‐type cats without the A31P mutation.

Methods

Ex vivo study. All cats received clopidogrel (18.75 mg PO q24h) for 14 days. Before and after clopidogrel treatment, adenosine diphosphate (ADP)‐induced P‐selectin expression was evaluated. ADP‐ and thrombin‐induced platelet aggregation was measured by optical aggregometry (OA). Platelet pVASP and ADP receptor response index (ARRI) were measured by Western blot analysis.

Results

Platelet activation from cats with the A31P mutation was significantly (P = .0095) increased [35.55% (18.58–48.55) to 58.90% (24.85–69.90)], in response to ADP. Clopidogrel treatment attenuated ADP‐induced P‐selectin expression and platelet aggregation. ADP‐ and PGE₁‐treated platelets had a similar level of pVASP as PGE₁‐treated platelets after clopidogrel treatment. Clopidogrel administration resulted in significantly lower ARRI [24.13% (12.46–35.50) to 11.30% (−7.383 to 23.27)] (P = .017). Two of 13 cats were nonresponders based on OA and flow cytometry.

Conclusion and Clinical Importance

Clopidogrel is effective at attenuating platelet activation and aggregation in some cats. Cats with A31P mutation had increased platelet activation relative to the variable response seen in wild‐type cats.

Abstract B15: Second-hand smoke (SHS) and smoking cessation in non-tobacco related cancers

Introduction: Continued smoking after a diagnosis of cancer has been found to lead to poorer treatment response, reduced survival and quality of life and increased risk of second primary cancers. We have previously demonstrated that SHS (exposure at home, with spouses and peers) is a significant barrier to smoking cessation in tobacco-related (lung and head and neck) cancers with adjust odds ratios of 6-9 (PMID: 24419133, 23765604) for quitting 1 year after diagnosis and quitting at any time after diagnosis; relationships stronger than in non-cancer populations. Here, we examined whether this relationship exists in cancers that are not traditionally associated with smoking.

Patients and Methods: Cancer survivors from a single tertiary cancer centre, Princess Margaret Cancer Centre (Toronto, Canada) completed a one-time cross-sectional questionnaire assessing their socio-demographics, functional status, smoking history and SHS exposure. Clinico-pathological variables were obtained through review of patient charts. Multivariate logistic regression and Cox-proportional hazard models evaluated the association of SHS with smoking cessation at 1 year after diagnosis and any time after diagnosis, and time-to-quitting respectively, adjusted for significant co-variates.

Results: A total of 1011 non-tobacco related cancer survivors were surveyed between 2012 and 2014: 19% breast, 15% gastrointestinal, 16% genitourinary, 12% gynecological, 23% hematologic, 15% other. Median follow-up time after diagnosis was 26 months. Among the 162 patients currently smoking at diagnosis, 35% quit 1 year after diagnosis and 48% quit at any time after diagnosis. None of the 306 ex-smokers and 543 never smokers (re-)started smoking after diagnosis. Home exposure to SHS was found to be strongly associated with reduced smoking cessation in cancer patients at any time after diagnosis (aOR=4.28, 95% CI (1.56-11.78), P=4.8E-3), while there was a less strong and non-significant trend for home exposure to SHS and reduced smoking cessation at 1 year after diagnosis (aOR=2.56, 95% CI (0.91-7.22), P=0.08)). Time-to-quitting analysis for home exposure to SHS were consistent with these results (aHR=2.76, 95% CI (1.15-6.59), P=0.02)). Unlike lung and head and neck cancer patients, spousal and peer smoking were not found significantly associated with smoking cessation at either time-point (P&gt;0.05). Kaplan-Meier analysis found that 72% of patients who quit, did so within 1 year of their cancer diagnosis. When comparing factors between patients quitting one year after diagnosis versus quitting more than one year after diagnosis, those quitting at one year were more likely older (P&lt;0.05) and have received surgery as part of their cancer care (P=0.06).

Conclusions: Home exposure to SHS is a significant barrier to quitting smoking after a diagnosis of cancer in both tobacco-related and non-tobacco related cancers; while spousal and peer smoking were not found significantly associated with smoking cessation in non-tobacco related cancers. Unlike in tobacco-related cancers, home exposure to SHS had a weaker association with quitting at 1 year after diagnosis than quitting at any time after diagnosis; suggesting the effect of the “teachable moment” with SHS and cancer may not be as strong in these cancers. Survivorship programs focusing on secondary prevention and smoking cessation in cancer patients should focus on incorporating SHS exposure.

Citation Format: Lawson Eng, Xin Qiu, Jie Su, M Catherine Brown, Margaret Irwin, Dan Pringle, Hiten Naik, Chongya Niu, Mary Mahler, Henrique Hon, Kyoko Tiessen, Rebecca Charow, Henry Thai, Valerie Ho, Vivien Pat, Lindsay Herzog, Anthea Ho, Jennifer M. Jones, Doris Howell, David P. Goldstein, Meredith E. Giuliani, Wei Xu, Peter Selby, Geoffrey Liu. Second-hand smoke (SHS) and smoking cessation in non-tobacco related cancers. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr B15.

Gold nanocrystal arrays as a macroscopic platform for molecular junction thermoelectrics

The thermoelectric properties of gold nanocrystal arrays with thiol-terminated ligands are compared to molecular junction experiments.

Improving quality of care by obtaining patient-reported outcomes (PRO)-CTCAE chemotoxicities using tablet technology in daycare (DC) waiting rooms

165

Background: In a busy chemo DC, any efficient means of tracking important chemotoxicities can improve quality of care. The study goal was to evaluate whether tablet technology available in a DC waiting room is able to capture prevalent and severe toxicities associated with chemotherapy using the patient reported outcome (PRO) - common toxicity criteria for adverse events (CTCAE). Methods: This cross-sectional PRO-CTCAE study of 160 adult solid/hematologic cancer outpatients of all stages, who were undergoing chemotherapy (CT), focused on common chemotoxicities captured using touchscreen tablets in the DC waiting room of Princess Margaret Cancer Centre (Toronto, CA). Individual health scores from the EQ-5D VAS tool and the prevalence of AEs experienced by cancer patients within the past seven days were captured. Symptoms that were listed as moderate to very severe were considered significant. Results: Across a wide range of tumours and patients on intravenous CT, the median age (range) was 56 (19-88) years; 38% were males.Patients reported a median (range) health score (100 = best health possible, 0 = worst) of 70 (4-100). The severity offiveprevalent, key side-effects of CT were tabulated (Table). 59% of patients felt their fatigue interfered significantly with their daily activities, and 30% felt decreased appetite interfered significantly. 32% experienced nausea occasionally to almost constantly. Conclusions: The common symptoms of CT were captured FEASIBLY, and found to be highly prevalent in this CT-treated population. Capturing additional symptom prevalence outside of the 7-day time frame may be important from a clinical standpoint. Administration of PRO-CTCAE instrument through tablet technology may be an excellent method to help collect such data systematically and reliably. Updated data on 300 patients will be presented at the meeting. [Table: see text]

Assessing the utility of a patient-reported screener question to detect fatigue symptoms: Improving the quality of systematic symptom measurement in clinical practice

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Background: In Ontario, there is a concerted effort to screen all cancer outpatients for clinically significant symptoms at every visit, without causing undue burden on the patient. Although fatigue symptoms are common in cancer patients, severe fatigue may require clinical intervention. To reduce reporting fatigue, we evaluated the use of a single item screener question to detect severe fatigue, as defined through the FACT-Fatigue Scale (FACT-F), with the goal of reducing patient reporting burden. Methods: 316 Princess Margaret Cancer Centre outpatients across a wide range of cancers at all phases of therapies and disease stages were asked to report fatigue symptoms using the FACT-F. The ability of one screener question “I feel fatigued” to detect severe fatigue symptoms in any of the six other fatigue-related questions was evaluated. Using the presence of any severe fatigue symptom as the reference, sensitivity (Se) and specificity (Sp) of the screener question was determined. Results: Median age was 59 (19-91) years; 45% were male. The prevalence of significant, severe fatigue-related symptoms for the six individual questions covering various fatigue domains ranged from 4% to 7%. 12% of patients exhibited at least one severe symptom on FACT-F (prevalence). Defining a positive screen as “quite a bit” or “very much” fatigued, with 16% prevalence, the screener question was able to correctly identify any severe symptom 81% of the time (Se) and was able to rule out any severe symptoms 92% of the time (Sp). Conclusions: The use of a screener question to accurately detect patient symptoms provide patients with the ability to be involved in their care without being overly burdened in the process. At the meeting we will provide updated results on 500 patients, the potential modifying role of clinico-demographic factors, and results of the performance two additional screener questions on fatigue. While patient-reported outcomes are widely used in research, they may also be a practical and acceptable means to accurately detect clinically important symptoms in the clinic.

Canadian cancer site-specific health utility values: Creating the basis for measuring value and costs of therapy

7

Background: Health utility values (HUVs) play an integral role when conducting health economic analyses, but a paucity of reference HUVs exists for cancer patients. Using EQ-5D, we generated reference HUVs for multiple malignancies. We further assessed patient willingness to compete the instrument on a regular basis by adding the EQ-5D to an Ontario-wide patient-reported symptom tool mandated by Cancer Care Ontario, the provincial cancer government agency. Methods: 1,831 cancer patients across all non-CNS solid and hematologic cancer sites at the Princess Margaret Cancer Centre completed the EQ-5D instrument; a subset (n=618) were asked about the acceptability of regularly completing the EQ-5D. HUVs were calculated using Canadian valuations. Results: The mean±SD HUV for all patients was 0.81±0.15, but were significantly different across different disease sites (p<0.0001): Testicular cancer, 0.87±0.13; prostate, 0.87±0.15; colorectal, 0.83±0.12; head/neck, 0.82±0.15; lymphoma, 0.82±0.15; breast, 0.81±0.17; esophageal, 0.81±0.16; ovarian, 0.79±0.15; leukemia, 0.78±0.15; lung, 0.78±0.13 and myeloma, 0.77±0.14. Confirming the validity of these HUVs, patients with PRO-ECOG scores of 0, 1, 2 and 3 had HUVs of 0.90±0.14, 0.77±0.11, 0.65±0.14 and 0.59±0.19, respectively (p<0.0001). In patients with solid tumors, those with local disease had HUVs of 0.82±0.15; metastatic disease, 0.80±0.15; p=0.015. 88% of patients reported that the EQ-5D was easy to complete, 92% took less than 5 minutes, 89% were satisfied with its length and 86% were satisfied with the types of questions asked. Importantly, 92% reported that they would complete the EQ-5D, even if it was used solely for research purposes and 73% agreed with the notion of completing it regularly at their clinic visits. Conclusions: We present the first Canadian reference dataset of HUVs for common cancers; stage-and site-specific reference values will be presented at the meeting. Mean HUVs varied by disease site, performance status, and disease severity. Furthermore, a majority of patients surveyed were willing to complete the EQ-5D on a regular basis, suggesting that routine administration is feasible across Ontario.

Using tablet technology in routine patient-reported outcome measure surveys to improve cancer quality care: A patient acceptability assessment

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Background: Patient-reported outcome measure (PROM) surveys are a tool used to collect information about clinically-relevant symptoms in patients. Touch-screen technology has been previously identified as a feasible and effective method of routinely capturing PROMs.Our aim was to evaluate cancer patients’ acceptance and perception of usefulness of tablet technology as a means of communicating PROMs to healthcare providers during delivery of quality care. Methods: 337 adult cancer patients across all outpatient clinics and disease sites at Toronto’s Princess Margaret Cancer Centre (PMCC) completed PROMs surveys using touch-screen technology. Acceptance and feasibility of completing the tablet-based PROMs data on a routine basis were also assessed. Results: The study population consisted of 45% males; median age 59 (19-91) years; 75% Caucasian, and 48% had a post-secondary degree.20% had lung cancer, 20% genitourinary, 16% breast, 16% lymphoma, 11% gastrointestinal, 7% gynecologic, and 7% head/neck. 88% were happy to complete the survey on a touch-screen tablet and 65% of these were willing to complete such surveys routinely. 86% did not find it time-consuming. Only 2% found that the completion of surveys made their clinic visit more difficult. Of the 72% that thought the survey was a useful means to inform the clinician of how they felt physically and emotionally, only 81% were willing to complete the survey at every visit. Conclusions: Tablet-technology was found to be an acceptable tool for survey administration, however, not on a routine basis. While the majority of patients found PROMs to be clinically important, almost 20% did not want to fill it in regularly at every visit. Current mixed-methods analysis is being utilized to help discern whether this discrepancy is related to the tablet technology or survey burden.

Effect of physical activity (PA) perceptions in cancer survivors on PA behaviors: Helping health care providers improve patient communication

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Background: While engagement in PA can lessen fatigue, improve quality of life (QOL) and/or improve survival in cancer survivors, to what extent patients are aware of this and how it affects their behavior is unclear. Methods: 1,244 adult cancer survivors across disease sites and stages (mostly curative) at the Princess Margaret Cancer Centre (PMCC) were surveyed about their perceptions of PA, the barriers that prevent them from being physically active, and their level of PA currently. Multivariable logistic regression evaluated the associations between clinical and socio-demographic factors on these perceptions and current activity levels. Analyses were adjusted for performance status and important covariates. Results: Cancer survivors were surveyed at a median of 26 months after diagnosis. 16% had breast, 12% GI, 26% gyne/GU, 14% head and neck, 6% lung and 19% hematologic cancers. 55% of survivors reported being physically active. Overall, 76% believed PA could lessen their fatigue, 91% reported PA could improve their QOL, and 89% felt PA could improve their 5-year survival. Common barriers to PA were: being too ill (41%), too tired (33%), too busy (29%) and having too many home responsibilities (28%). Older patients were more likely to believe that PA would not improve their fatigue (p=0.005) and not improve their 5-year survival (p=0.001). Lower household income was associated with belief in lack of benefit of PA on fatigue (p=0.0001) or QOL (p=0.02). Not perceiving benefit of PA on fatigue, QOL, or survival was associated with substantially lower levels of PA (p<0.01; each comparison), as was being older and having a lower income (p=<0.01, each comparison). Conclusions: Older patients (even those with good performance status) and those coming from a lower socioeconomic status were more likely to have negative perceptions of the effect of PA on major cancer outcomes, resulting in lower PA levels. At PMCC, we are using this information to shape how we communicate with our patients in our survivorship program to help them with their decision-making on PA.

Involving clinic patients in systematic symptom reporting to improve cancer care: Exploring prevalence of sleep disturbances (SD) and fatigue (FAT)

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Background: SD and FAT occur in 30-50% of cancer patients. Patient-reported outcome measure surveys are avenues through which healthcare providers (HCP) can receive symptom-related clinically relevant information directly from patients, and engage them in their own care plan. By asking patients to report symptoms rapidly through tablet/computer-based technology, HCPs can involve patients in the delivery of care. Methods: In a pilot study evaluating utility of systematic symptom reporting, 336 adult cancer patients across all stages and disease sites who were attending outpatient cancer clinics at Princess Margaret Cancer Centre (PMCC) (Toronto, Canada) completed electronic tablet-administered secure surveys on SD (Insomnia Severity Index) and FAT patterns (FACT-fatigue). These tools measured both symptom severity and interference with function. Results: With a median age of 59 (19-91) years, 55% female, across a broad distribution of cancer sites, 56% of our sample reported moderate to very severe (MTVS) SD over the last 7 days: 31% had MTVS difficulty falling asleep; 43% had MTVS difficulties staying asleep; 36% had MTVS problems waking up too early. While 62% who had MTVS SD were not distressed by their SD, 95% who were distressed by their SD met the criteria of MTVS SD. 78% of patients had any level of FAT over the last 7 days, with 40% reporting MTVS FAT. While 40% who had MTVS FAT were still able to perform their usual activities, 67% of patients who were not able to do their usual activities had MTVS FAT. Conclusions: Across all stages and disease sites of cancer patients at PMCC, the prevalence of SD and FAT was both high. Severity and interference with function by FAT and SD were often distinct and non-overlapping. Involving patients in the systematic evaluation of symptoms, particularly using newer tablet-based technology within the clinic, was feasible. Through the use of patient reported electronic applications, patients could easily and systemically report their symptoms in real-time. FAT management has always been a high priority at our institution. However, based on our results, a cancer center-wide self-management plan is being considered for SD.

Risk factors for development of dementia in a unique six-year cohort study. I. An exploratory, pilot study of involvement of the E4 allele of apolipoprotein E, mutations of the hemochromatosis-HFE gene, type 2 diabetes, and stroke

Risk factors for dementia development are not well-defined. We evaluated several factors alone and in combination in a unique cohort of Caucasian volunteers over an approximately 6-year observation window using a nested case/control design. Factors included: apolipoprotein E (ApoE) gene variants (the E4 allele is the strongest confirmed genetic predisposing factor for Alzheimer's disease), the hemochromatosis-HFE gene mutations (H63D and C282Y), diabetes, and stroke. At study entry, subjects were ≥65 years of age (M ± SD = 73.0 ± 4.9), had an MMSE score ≥24, and no evidence of cerebrovascular disease or current depression. Genotyping was completed on 163 available DNA samples from three different groups at the study end: those who still had normal cognitive function; those who had developed dementia; and those with Mild Cognitive Impairment (MCI). Analyses were interpreted at the 95% confidence level without Bonferroni corrections. In the subgroup with dementia, all cases of diabetes were type 2 and present at study entry, whereas all strokes occurred during the study. The results highlight apparently synergistic interactions between genetic and medical risk factors for dementia development, gender differences in risk factors, and involvement of HFE mutations. Having E4 (i.e., either of E3/4 or E4/4), C282Y, H63D, diabetes, or stroke alone did not attain significance. Significant predisposing factors with post-hoc power ≥80% were: E4 homozygosity (E4/4)males+females, odds ratio (OR) = 56.0); E4+diabetes (males+females, OR = 13.7; E4+H63D+diabetes (females, OR = 52.0); E4+stroke (males, OR = 46.5). The importance of preventing diabetes and stroke to ward off dementia and the possible role of iron dysmetabolism in dementia are discussed.

Disease progression and patient survival are significantly influenced by BRAF protein expression in primary melanoma

BACKGROUND

Mutation of BRAF is a prevalent event in melanoma. Despite much attention to the role of BRAF mutation in melanoma, the status of BRAF protein expression and its significance in melanoma progression are unknown.

OBJECTIVES

We investigated the BRAF expression level in different stages of melanocytic lesions and evaluated its correlation with clinicopathological features and patient survival.

METHODS

Using tissue microarray, BRAF expression and its correlation with patient outcome was evaluated in 49 naevi samples and 370 patients with melanoma. We also evaluated the correlation of BRAF protein expression and V600E mutation using direct sequencing.

RESULTS

Compared with naevi samples, BRAF expression was remarkably increased in primary melanomas and further increased in metastatic melanomas (P = 1·8 × 10(-11) ). High BRAF expression was significantly correlated with thicker tumours, ulceration and higher American Joint Committee on Cancer stages (P = 1·5 × 10(-7) , 1·5 × 10(-5) and 3·6 × 10(-13) , respectively). In cases of primary melanoma, patients with high BRAF expression had significantly worse overall (P = 0·009) and disease-specific 5-year survival (P = 0·007). While there was a trend for higher prevalence of BRAF V600E mutation in patients with high BRAF protein expression, no significant correlation was observed between protein expression and BRAF mutation. Furthermore, univariate Cox regression analysis confirmed high BRAF protein expression as a strong risk factor for poor patient survival in primary melanoma [hazard ratio (HR) 2·08 for overall survival; HR 2·39 for disease-specific survival].

CONCLUSIONS

Our data demonstrate that BRAF protein expression is significantly increased during melanoma progression. In addition, we revealed a novel prognostic value for BRAF protein expression in primary melanoma as it is significantly correlated with poor patient survival.

Long-term safety of ustekinumab in patients with moderate-to-severe psoriasis: final results from 5 years of follow-up

BACKGROUND

Long-term safety evaluations of biologics are needed to inform patient management decisions.

OBJECTIVES

To evaluate the safety of ustekinumab in patients with moderate-to-severe psoriasis treated for up to 5 years.

METHODS

Safety data were pooled from four studies of ustekinumab for psoriasis. Rates of adverse events (AEs), serious AEs (SAEs) and AEs of interest [infections, nonmelanoma skin cancers (NMSCs), other malignancies and major adverse cardiovascular events (MACE)] per 100 patient-years (PY) of follow-up were analysed by ustekinumab dose (45 or 90 mg) and by year of follow-up (years 1-5) to evaluate the dose response and impact of cumulative exposure. Observed rates of overall mortality and other malignancies were compared with those expected in the general U.S. population.

RESULTS

Analyses included 3117 patients (8998 PY) who received one or more doses of ustekinumab, with 1482 patients treated for ≥4 years (including 838 patients ≥5 years). At year 5, event rates (45 mg, 90 mg, respectively) for overall AEs (242·6, 225·3), SAEs (7·0, 7·2), serious infections (0·98, 1·19), NMSCs (0·64, 0·44), other malignancies (0·59, 0·61) and MACE (0·56, 0·36) were comparable between dose groups. Year-to-year variability was observed, but no increasing trend was evident. Rates of overall mortality and other malignancies were comparable with those expected in the general U.S. population.

CONCLUSIONS

No dose-related or cumulative toxicity was observed with increasing duration of ustekinumab exposure for up to 5 years. Rates of AEs reported in ustekinumab psoriasis trials are generally comparable with those reported for other biologics approved for the treatment of moderate-to-severe psoriasis.

Screening for cystic fibrosis-related diabetes: a systematic review

BACKGROUND

Cystic fibrosis (CF) is an inherited disease that leads to damage to lungs, pancreas and other organs. Most people with CF die prematurely from lung disease, but survival has improved markedly over the decades and it is estimated that children born with CF now will live to an average age of 50 years. CF-related diabetes (CFRD) is due to damage to the pancreas, which, over time, loses its capacity to produce sufficient insulin. CFRD is becoming more common owing to the improved survival of people with CF.

OBJECTIVES

The initial aim was to review the methods for screening for CFRD, which can be symptomless but still be causing harm. As the aim of screening and early detection is to allow earlier treatment, a second aim was to assess the effectiveness of treatments. However, during the review it became clear that there were problems with how CFRD is defined, uncertainty about when hyperglycaemia should be treated.

DATA SOURCES

Details of relevant studies were obtained from the usual bibliometric databases - MEDLINE (1950-2008), EMBASE (1980-2008), The Cochrane Library (all sections), Web of Science (1970-2008). Websites of relevant bodies were searched for guidelines and reports. Conference abstracts were searched. Expert co-authors identified key papers.

REVIEW METHODS

Systematic reviews of treatments and screening tests. Screening studies were data extracted if they provided sufficient data to construct 2 × 2 tables. Other screening studies were described in narrative manner. The background to CF and CFRD were described in a narrative manner, as was Chapter 2 on problems with defining CFRD. A model was constructed for cost-effectiveness analysis, but was not used because of lack of data.

RESULTS

Diabetes is usually defined based on the level of blood glucose (BG) at which the risk of retinopathy occurs. For CFRD, it would be better to define it on the level at which the risk of lung disease (pulmonopathy) rises. There seems little place for treatments other than insulin, but the best insulin regimen remains to be confirmed. The best screening test may be by continuous glucose monitoring systems but further evidence is required. Screening may need to detect BG levels of > 8 mmol/l because that may be the level above which pulmonopathy starts in people with CF.

LIMITATIONS

The evidence base for treatment is disappointing with few large randomised controlled trials. The key question is when treatment should start, perhaps at the post-prandial hyperglycaemia stage. Research is needed. Until that is done, we cannot be sure what we are screening for, and, therefore, which screening strategy should be used.

CONCLUSIONS

The definition of CFRD should probably be based on pulmonopathy risk, rather than using the classical definition of diabetes. That implies that we should be screening for a wider range of hyperglycaemia than in other forms of diabetes, perhaps to detect BG excursions of > 8 mmol/l. Insulin treatment may need to start at lower levels than formerly accepted.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.