Proton therapy enables normal tissue sparing for curative-intent treatment of children with cancer who require radiation therapy. In the USA and elsewhere, proton therapy is being rapidly adopted, and many new proton centres are being established. Without a proton centre in Canada, children and their families must travel abroad for treatment at high cost and has raised the question whether a Canadian proton therapy facility is needed. METHODS: Canadian Pediatric Oncology centres were surveyed to assess current and future clinical practices. Needs were modeled by screening the Alberta Cancer Registry, ascertaining the number of children eligible for proton RT and comparing to the number who actually received this therapy. RESULTS: Most centres (63%) referred children, and 49 children were referred abroad between 2008 and 2013. Referrals were estimated to increase to 36 cases per annum across Canada. Most respondents (75%) supported that proton therapy will reduce late effects in most or selected cases compared to photon therapy. The registry search revealed 37,170 patients irradiated of which 379 children (1.0%) were potentially eligible for proton therapy, accounting for 15.9% of the new cases of childhood cancers diagnosed in Alberta over the interval. CONCLUSIONS: A strong perceived need for a pediatric proton therapy in Canada was identified. Proton therapy utilization was lower than modeled needs. Future referrals are anticipated to increase, with annual estimated cost of approximately $60 million spent outside of Canada that could be invested within the Canadian health care economy. These issues are worthy of further national discussion.

Gangliogliomas (GG) are low grade neuroepithelial tumours of the central nervous system (CNS) comprised of neoplastic glial and neuronal cells. There are no animal models or cell lines to study. Microarray data of a panel of low grade gliomas including GG revealed overexpression of the DLX2 homeobox gene required for tangential interneuronal migration and differentiation in the embryonic forebrain. We hypothesized that DLX2 regulates neural versus glial cell fate decisions in CNS progenitors and that GG are arrested in development. METHODS: DLX2 expression was examined along with glial fibrillary acidic protein (GFAP; glial marker) and synaptophysin and/or NeuN (neuronal markers) expression in a cohort of GG tumours using immunohistochemistry and dual immunofluorescence labelling of formalin fixed paraffin embedded (FFPE) tissue sections. BRAF mutational status was also assessed. RESULTS: In our discovery cohort (Genoa), 10/30 samples (33%) expressed DLX2. In our validation cohort (Edmonton), 22/36 (61%) expressed nuclear DLX2 and 12/22 DLX2+cases had BRAF mutations (55%; 11 V600E, 1 V600G). 12/18 cases with BRAF mutations were DLX2+(67%). One heavily pre-treated child with progressive cervicomedullary GG has had a very good partial response to BRAF inhibitor therapy. All 22 DLX2+tumours co-expressed GFAP (100%) and 21/22 (95%) also expressed synaptophysin or NeuN. CONCLUSIONS: Our results support GG as neurodevelopmental tumours arising from bipotential CNS progenitors that are arrested at the neural-glial cell fate "decision" point. Biological or differentiation-based treatments could be considered+/- BRAF inhibitors for those GG with/without the V600E mutation, respectively.

Background: The Saskatoon stroke program participated in the ESCAPE trial looking at rapid endovascular revascularization for large vessel occlusion. Improvements were necessary to meet the timelines mandates in ESCAPE and to comply with Canadian Best Practice Guidelines. Methods: Retrospective chart review and prospective gathering of key metrics was performed using REDCap (Research Electronic Data Capture) software. Changes adapted from Canadian Best Practice Recommendations for Stroke Care, the ESCAPE protocol, and the Calgary stroke program HASTE project were implemented. Results: Changes implemented included increasing ambulance bypass window to 12 hours, FAST stroke assessment, emergency department pre-notification and registration, stroke alert protocol, team swarm of the patient, administration of tPA in the computed tomography (CT) room, and rapid access to the endovascular suite. Total number of patients between the years 2012 and 2014 was 287, and of those, 93 received tPA. Door-to-CT times decreased from 40 minutes to 21 minutes from 2012 to 2014; and Door-to-Needle (tPA) decreased from 62 minutes to 46 minutes from 2012 to 2014. Conclusions: By following Canadian best practice recommendations for stroke care, the ESCAPE protocol, and adaptation of Calgary stroke program HASTE project, our stroke program implemented changes to reduce treatment times for patients experiencing stroke in our province.

Background: Vasospasm causing delayed ischemic neurologic deficit (DIND) remains a leading cause of devastating outcome after aneurysmal subarachnoid hemorrhage (aSAH). Therapy using intravenous milrinone (IVM) and intra-arterial milrinone (IAM) has been described. We report our results using IAM in patients with refractory and super refractory vasospasm (RV and SRV respectively). Methods: Retrospective single center study of all adult patients treated with IAM between 2006 and 2016 inclusively. IAM was used as part of the Montreal Neurological Hospital Protocol when the patients’ symptoms failed to respond to initial and higher IVM doses. We report their clinical outcomes. Results: IAM was used in 19 patients. The median loading dose was 8 mg and average maintenance dose was 0.78 mcg/kg/min. Angiographic improvement was seen in 15 (79%) and clinical improvement - within the first 48 hours - was seen in all patients. The median mRS was 3 at time of discharge and 1 three months later. Five patients lost follow up. Conclusions: IAM appears to be safe and effective in this small retrospective series of RV and SRV complicating aSAH. Angiographic and clinical improvements were observed. Further prospective studies are warranted to confirm these findings.

Dianhydrogalactitol (VAL-083) is a unique bi-functional alkylating agent causing N7-guanine-methylation and inter-strand DNA crosslinks. VAL-083 readily crosses the blood-brain barrier, accumulates in brain tumor tissue and has shown activity in prior NCI-sponsored clinical trials against various cancers, including glioblastoma (GBM) and medulloblastoma. VAL-083 is also active against GBM cancer stem cells and acts as a radiosensitizer independent of O6-methylguanine-DNA methyltransferase activity (in contrast to e.g. temozolomide and BCNU). Here we report new insights into VAL-083 mechanism of action by showing that VAL-083 induces irreversible cell-cycle arrest and cell death caused by replication-dependent DNA damage. In lung (H2122, H1792, H23, A549) and prostate (PC3, LNCaP) cancer cell lines VAL-083 treatment caused irreversible S/G2 cell-cycle arrest and cell death (IC50 range 3.06-25.7 µM). VAL-083 pulse-treatment led to persistent phosphorylation of DNA double-strand breaks (DSB) sensors ATM, single-strand DNA-binding Replication Protein A (RPA32), and histone variant H2A.X, suggesting persistent DNA lesions. After 10 months in culture with increasing VAL-083 concentrations, H1792 and LNCaP cells survive at concentrations up to 9.4 µM and 7.4 µM, respectively, suggesting that efficient resistance mechanisms are not easily acquired by the cancer cells. Taken together with previous results showing that VAL-083 circumvents cisplatin-resistance and is less dependent on p53 activity than cisplatin, these results suggest a molecular mechanism for VAL-083 that differs from both TMZ, BCNU and cisplatin. They further suggest that irreparable DNA damage induced by VAL-083 is impervious to common strategies employed by cancer cells to escape effects of alkylating drugs used in GBM treatment.

Somatic mutations in the Capicua (CIC) gene were first identified in Type I low-grade gliomas (LGGs), which are characterized by 1p/19q co-deletions and IDH mutations. They are found at frequencies of ~50-70% in this glioma subtype, and have since been identified in ~40% of stomach adenocarcinomas (STADs) of the microsatellite instability (MSI) subtype; however, the role of these somatic mutations in malignancy has yet to be established. In Drosophila, CIC functions as a transcriptional repressor whose activity is inhibited upon activation of the mitogen-activated protein kinase (MAPK) signalling pathway. Though mammalian CIC appears to retain these functions, only three of its target genes have been established in human cells: ETV1, ETV4, and ETV5 (ETV1/4/5). To further probe CIC’s transcriptional network, we developed CIC knockout cell lines and performed transcriptomic and proteiomic analyses in these and in control cell lines expressing wild type CIC, identifying a total of 582 differentially expressed genes. We also used RNA-seq data from The Cancer Genome Atlas (TCGA) for Type I LGGs and STADs to perform additional differential expression analyses between CIC-deficient and CIC-expressing samples. Though gene-level overlap was limited between the three contexts, we found that CIC appears to regulate the expression of genes involved in cell-cell adhesion, metabolism, and developmental processes in all three contexts. These results shed light on the pathological role of CIC mutations and may help explain why these have been associated with poorer outcome within Type I LGGs.

Background: The cause of ICU delirium is unknown. We used near infrared spectroscopy (NIRS) to measure brain tissue oxygenation (BtO2) in critically ill patients, to test the hypothesis that poor cerebral oxygen delivery contributes to ICU delirium. Methods: Adult patients were enrolled if they required mechanical ventilation for >24 hours, and/or vasoactive agents. Patients were excluded if they had previous cognitive dysfunction, brain injury on admission, or a life expectancy <24 hours. BtO2 was measured for the first 24 hours of ICU admission. The confusion assessment method-ICU (CAM-ICU) was used to screen for delirium. Participants were designated to one of three groups on the basis of their predominant neurological status (comatose, delirious, or intact). Results: To date, 47 patients have been recruited. Both delirious and comatose patients’ had significantly lower BtO2 levels compared to intact patients (P<0.001). There was a significant correlation between hemoglobin and BtO2 (R2=0.347, P<0.01). However, when correlation analysis was conducted separately amongst the three groups, the delirious patients (R2=0.485, P<0.05) were the strongest contributors to this positive correlation. Conclusions: Delirious patients exhibited the lowest BtO2 recordings and demonstrated a significant association between Hb and BtO2. This study offers potential insight into the pathophysiology of ICU delirium.

Background: Graduating neurology residents require general palliative care skills. This study aims to develop an evidence-based palliative care curriculum to provide neurology residents with the general palliative care skills required for providing patient care along the continuum of life. Methods: A needs assessment of the palliative skills necessary for a neurology resident was performed. Focus groups were held with physicians, allied health care and senior residents. Semi-structured interviews were held with patients and their caregivers. Interviews analysed using qualitative thematic analysis techniques. The Kolb learning style inventory will determine the learning style of neurology residents and inform the curricular design. Results: Qualitative analysis identified 3 overarching challenges for neurology residents: 1) uncertainty regarding disease trajectory in neurology and timing of palliative care discussions; 2) cohesiveness of the health care team regarding end of life issues; 3) the role of the resident in initiating palliative care. Other principals identified for inclusion were: symptom management, communication, psychosocial aspects of care, care coordination and access, and myths and pitfalls in palliative care. Conclusions: This project will identify the current best evidence and expert opinion in palliative care neurology. The data will be used to develop a novel Canadian neurological palliative care curriculum.

Glioblastoma (GBM) is an aggressive brain tumor that is resistant to conventional radiation and cytotoxic chemotherapies. We hypothesize that brain tumor initiating cells (BTICs), a subpopulation of treatment-resistant cells with stem cell properties cause tumor relapse and a subset of neural stem cell genes regulate BTIC self-renewal, driving GBM recurrence. We adapted the existing treatment protocol for adults with primary GBM for in vivo treatment of immunocompromised mice engrafted with GBMs. Post-chemoradiotherapy, the recovered GFP+GBMs were profiled for self-renewal and expression of critical stem cell genes. Using invitro and invivo gain-of-function/loss-of-function experiments, we investigated the regulatory functions of Bmi1 in primary neural stem & progenitor cells (NSPCs) and GBM tumor formation. Finally, global RNA-Seq profiling was performed to understand the consequences of Bmi1 dysregulation on target gene expression. GBM cells showed an increase in Bmi1 levels post-chemoradiotherapy, suggesting the presence of a treatment-refractory BTICs. GFP+cells extracted from treated xenografts had higher self-renewal and BTIC marker expression. Although treated mice responded to therapy, we observed tumor relapse with increased Bmi1 expression. Knockdown of Bmi1 diminished self-renewal and proliferation of GBM cells and delayed tumorigenesis, highlighting a critical role for Bmi1 in tumor maintenance. Conversely, over-expressing Bmi1 in NSPCs failed to initiate tumor formation in vivo. Using high-throughput sequencing data, we generated a map of signaling pathways dysregulated in GBM that may lead to tumor recurrence. Our data confirms the existence of a rare treatment-refractory BTIC population with enhanced self-renewal capacity that escapes therapy and drives tumor relapse.

Background: Few evidence-based disease-modifying treatments exist for progressive multiple sclerosis (MS). How can neurologists best care for patients with advanced MS? Little is known about how patients with progressive MS view their relationship with their treating neurologist, and if the role of the neurologist matches their needs and preferences. Methods: A qualitative cross-sectional analysis of patient preferences regarding the role of the neurologist in their care. Patients with progressive MS and an EDSS score of 6 or more were invited to participate. Patients and caregivers completed separate written questionnaires and were then interviewed by one of the authors. Data were subjected to thematic coding to group common themes and the distribution of themes among different disability sub-groups was analyzed. Results: Full results will be available at the time of the conference. Preliminary results suggest that the neurologist has an important role in updating patients on the progress of their disease and responding to questions. Patients are fearful of becoming dependent on others for their care. The concept of palliative care is unfamiliar to most patients. Conclusions: Despite a lack of disease-modifying treatments for progressive multiple sclerosis, patients believe that the neurologist has an important role in their care.

Glioblastoma (GBM), an aggressive primary adult brain tumor, is feared for its near uniformly fatal prognosis. Despite the use of aggressive treatment including surgical resection, radiotherapy and chemotherapy, the outcome of patients with GBM has failed to improve significantly. Numerous studies have implicated CD133+GBM subpopulation as driver of chemo- and radio-resistance. CD133 expression correlates with disease progression, recurrence, and poor overall survival of GBM patients. Here, we describe the preclinical evaluation of a recombinant CD133xCD3 bispecific T-cell engager (BiTE) antibody that redirects human polyclonal T cells to CD133+GBM cells, inducing very potent anti-tumor response. CD133-specific BiTE was constructed; with one arm recognizing the tumor antigen (CD133) while the second is specific to CD3 antigen. Using CD133high and CD133low primary GBM lines, we validated the binding of BiTEs to CD133+GBMs and CD3+T cells. In order to test the ability of BiTEs to functionally elicit CD133-specific cytotoxic responses in vitro, we performed killing assays. We observed CD133-specific BiTE mediated T cell activation and redirection to kill CD133-expressing GBM cells in a co-culture of T cells and GBM cells. The killing was more efficient in CD133high GBMs compared to CD133low GBMs, validating its specificity to target CD133+BTICs. Treatment with BiTEs yielded significant reductions in brain tumor burden in vivo. These data offers compelling evidence that BiTE-mediated cytotoxicity against treatment-resistant CD133+GBMs could provide a very potent, specific and can be a novel therapeutic strategy for GBM patients.

Our ongoing work has demonstrated that hexokinase 2 (HK2) but not HK1 or HK3 is a critical mediator of tumour glycolysis and mitochondrial metabolism in Glioblastoma (GB). Furthermore, HK2 is highly expressed in GB but not in normal brain making it an attractive therapeutic target. Our current findings now support that loss of HK2 alters tumor vasculature, increases sensitivity to radiation, and confers a significant survival benefit in several GB xenograft-bearing mice. Using a genome wide transcript analysis, we identified that loss of HK2 attenuates several pro-growth signaling pathways in GB including ERK signaling. Mechanistically, ERK rescue experiments in HK2 depleted cells rescues cell sensitivity to radiation and reduces DNA damage. Furthermore using a systems biology approach and a rationale drug screen we identified several antifungal agents in the azole class as to inhibit tumor metabolism and growth in HK2 expressing GB cells. Loss of HK2 in GB cells dampened the effect of several azoles suggesting that the mechanism of action is mediated in part through HK2. Furthermore, we tested several azole compounds known to cross the blood brain barrier in vivo. Clinically achievable doses of azoles as single agents increased survival in several orthotopic xenograft GB mouse models. In summary, HK2 drives several oncogenic pathways associated with GB including ERK signaling and sensitizes tumour cells to the azole class of antifungals. Future work will determine whether azoles work synergistically with radiation and temozolomide and elucidate the mechanisms by which they inhibit GB growth in HK2 expressing cells.

Background: Background: High-dose intravenous immunoglobulin (IV-Ig) is an evidence-based treatment for chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN). Recently, subcutaneous Ig (SC-Ig) has received increasing attention. We performed a meta-analysis to assess the efficacy of SC-Ig versus IV-Ig. Methods: Methods: We searched PubMed, Embase, and Scopus from January, 1990 to December, 2015 for publications comparing IV-Ig vs. SC-Ig in patients with CIDP or MMN. We performed fixed-effects meta-analyses for strength changes as measured by the Medical Research Council sum score changes (MRC-SS). Results: Results: A total of 8 studies comprising 138 patients (88 with CIDP and 50 with MMN) were included in the meta-analysis. Considering the total population the use of SC-Ig showed slightly better results for MRC-SS (ES=-1.78, 95%CI=-3.45 to -0.11, I2<0.001%). However, when CIDP and MMN were compared separately, there were no differences between treatments (CIDP: ES=-0.28, 95%CI=-0.57 to 0.02, I2<0.001%; MMN: ES=-0.34, 95%CI=-3.99 to 3.31, I2<0.001%). Conclusions: Conclusions: We found comparable efficacy between SC and IV-Ig administrations for CIDP and MMN. These results suggest that SC-Ig is a suitable alternative treatment method, especially when other situations (e.g. convenience, safety profile) warrant its use. Further studies are needed to explore the efficacy of SC-Ig for CIDP and MMN.

Background: Several studies have demonstrated the safety and efficacy of endovascular therapy for patients with acute ischemic stroke. However, patient, imaging and treatment factors associated with the optimal functional outcome require better definition. Methods: We pooled data from 8 randomized controlled trials (SYNTHESIS, MR RESCUE, IMS III, MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME, and REVASCAT). We conducted subgroup and sensitivity analyses to evaluate predictors of optimal functional results (modified Rankin scale, mRS) at 90 days. Results: Meta-analysis of 8 trials including 2,423 patients yielded that endovascular therapy resulted in 44.6% functional independence (mRS 0-2) versus 31.8% in the usual care group (OR 1.71, 95% CI 1.18-2.49, P=0.005). This treatment effect was significantly greater among patients with confirmed angiographic imaging of proximal arterial occlusion (OR 2.24, 95% CI 1.72-2.90, P<0.001), in patients who received the combined therapy of intravenous tPA and endovascular intervention (OR 2.07, 95% CI 1.46-2.92, P<0.001), and when using stent retriever for mechanical thrombectomy (OR 2.39, 95% CI 1.88-3.04, P<0.001). Conclusions: The relative functional benefit associated with endovascular therapy among patients with acute ischemic stroke was increased when combined with intravenous tPA, with confirmed proximal arterial occlusion on angiographic imaging, and with use of stent retrievers for mechanical thrombectomy.

High-grade gliomas are deadly cancers, and current standard-of-care has demonstrated limited success. The ability to specifically target glioma cells can allow for the development of improved theranostic agents leading to better detection methods, as well as safer anti-cancer therapies. Brevican (Bcan), a CNS-specific protein is upregulated in glioma cells and correlates with tumor progression. Particularly, a Bcan isoform lacking normal glycosylation, called B/bDg is a unique glioma marker and is not expressed in non-cancerous tissues. Therefore, B/bDg represents a valuable target for anti-cancer strategies. We describe here the discovery of novel high-affinity B/bDg-targeted peptides using rapid combinatorial library screening approaches and a microfluidic sorting device of our own design. Briefly, a one-bead-one-compound (OBOC) peptide library was screened against small magnetic particles decorated with B/bDg. Positive “hit” beads labeled with magnetic particles were isolated using an inexpensive but yet, accurate and high-throughput in-house microfluidic magnetic-activated sorter. These hits were exposed to cells expressing B/bDg, and beads with the highest cell association were isolated and sequenced. Seven novel peptides were identified. Cell uptake analyses and blocking studies revealed that 5 of these peptides displayed specific uptake in B/bDg-overexpressing cells. These candidates displayed nano-/micromolar binding affinity for recombinant B/bDg protein. Further analyses of these candidates using confocal microscopy revealed increased peptide binding/uptake in patient-derived glioma stem cells (GSCs) compared with primary human astrocytes. We plan to incorporate these onto multi-functional BBB-penetrating nanoparticles loaded with imaging agents or a drug payload to translate them into highly selective and efficacious brain cancer theranostic agents.

Mcl-1 is an anti-apoptotic Bcl-2 family member that is often over-expressed in the malignant brain tumour glioblastoma (GBM). It has been previously shown that epidermal growth factor receptors (EGFR) up-regulate Mcl-1 expression contributing to a cell survival response. Hypoxia is a poor prognostic marker in glioblastoma despite the fact that hypoxic regions have areas of necrosis. Hypoxic regions of GBM also highly express the pro-cell death Bcl-2 family member BNIP3, yet when BNIP3 is over-expressed in glioma cells, it induces cell death. The reasons for this discrepancy are unclear. METHODS: Using malignant glioma cell lines +/- hypoxia, gain and/or loss of function assays of BNIP3 or Mcl-1 were performed. BNIP3 and MCL-1 expression was assessed in GBM tumours from adult patients and human gliomas grown as xenografts in immunocompromised mice. RESULTS: Mcl-1 expression is reduced under hypoxia due to degradation by the E3 ligase FBW7 leading to increased hypoxia-induced cell death. This cell death is augmented by EGFR activation leading to increased Mcl-1 expression under hypoxia. Conversely, BNIP3 is over-expressed in hypoxia at times when Mcl-1 expression is decreased. Knocking down BNIP3 expression reduces hypoxia cell death and Mcl-1 expression effectively blocks BNIP3-induced cell death. Of significance, BNIP3 and Mcl-1 are co-localized under hypoxia in glioma cells, GBM tumours and in xenograft glioma tumours expressing mutant EGFR (EGFRvIII). CONCLUSION: These results support that Mcl-1 can block the ability of BNIP3 to induce cell death under hypoxia in GBM tumours

Background: The purpose of this study was to: 1) describe current non-invasive ventilation (NIV) usage patterns amongst Canadian ALS healthcare providers; 2) compare/contrast with previous practice patterns; and 3) explore barriers to NIV access encountered by current practitioners. Methods: Healthcare professionals (including physicians, respiratory therapists, and nurses) at major Canadian ALS care centres were sent a web-based survey. Participants were asked to provide input on practice demographics, access and initiation of NIV, and follow-up of NIV. Quantitative data were analyzed with descriptive and comparative statistics, while qualitative data were analyzed using interpretative phenomenological analysis method to identify emergent themes. Results: 26 participants responded. Median NIV usage was 39% (range 10-100%), about double of what was previously reported (18%). Mean times from referral to routine and urgent NIV initiation were 13 (95% CI 9-17) and 5 (95% CI 3-7) days respectively. NIV was most commonly initiated in clinic (68%), while 38% report having access to home-NIV initiation. Lack of social support (62%) and cognitive impairment (46%) were the most common deterrents to initiating NIV. Similar to what is previously reported, barriers to access can be stratified to patient, clinical, institutional, and regional levels. Conclusions: Despite increased usage and improved access, there remain considerable barriers for ALS patients to receive NIV.

Background: Spinal Cord Injury Without Radiological Abnormality (SCIWORA) is underreported and poorly recognized in adults. This entity is an important subtype of spinal cord injury (SCI) with relatively good outcomes. Despite this, few studies have been performed to determine specific imaging-related prognostic factors. Methods: A retrospective review of adult patients with cervical SCI admitted to two University hospitals from January 2000 to December 2010 was performed. Only patients with an MRI performed within 72 hours after trauma were included. All patients with bony injury or traumatic malalignment were excluded. Data gathered on the remaining patients included demographics, mechanism of injury, severity of SCI, long-term patient outcome, improvement in neurological condition and MRI results. Results: 49 patients selected. Patients with extramedullary hemorrhage showed worse neurological status at initial examination. Disruption of either the anterior longitudinal ligament or ligamentum flavum was associated with worse outcomes at initial examination and at 1-year follow up. Lesion length was also significantly associated with outcomes at 1 year evaluation and initial evaluation. Conclusions: Early MRI has an important prognostic value in patients suffering SCIWORA. Lesion length is a powerful predictor of outcome. Soft tissue injury and spinal cord changes play a role in the severity of injury as well as the ability to recover.