Oral hormonal contraception in special circumstances

BACKGROUND

Despite the general consensus that long-acting reversible contraceptives (LARCs) are the most appropriate choice of contraception for most women, there are special circumstances when the contraceptive and non-contraceptive needs of the patient are met by oral methods.

OBJECTIVE

By using case histories, we seek to demonstrate the medical and practical complexities in managing contraceptive needs that may result in oral contraception being the most appropriate choice. The cases also illustrate the resources available to enable evidence-based management.

DISCUSSION

Concurrent medical conditions and non-contraceptive benefits of oral contraceptive methods will see the continued use of these medications for a significant minority of women. A comprehensive knowledge of the rapidly developing evidence regarding medical eligibility and indications for usage is required. Reference to the already highly developed and easily accessible evidence bases ensures best practice for the women and families who seek advice.

Patient-reported outcome measure for neuromyelitis optica: pretesting of preliminary instrument and protocol for further development in accordance with international guidelines

OBJECTIVE

This study outlines the development of a patient-reported outcome measure (PROM), an instrument to obtain self-reported health status for neuromyeltis optica (NMO), a disabling neurological condition.

DESIGN

Development was conducted in accordance with international guidance for PROMs including systematic review of existing literature, item generation guided by qualitative interviews, health-related quality of life conceptual framework and clinical expert panel and cognitive interviews with NMO patients.

SETTING

Participants were identified through a national NMO clinic in a tertiary NHS neurosciences service.

PARTICIPANTS

15 individuals with NMO participated in cognitive interviews requiring review and ranking of proposed PROM items and qualitative feedback on content, layout and response options.

RESULTS

Participants endorsed the draft instrument as reflecting their experience of the condition and as being easy to understand. Rating and ranking of item relevance and importance reduced the draft instrument from 106 to 48 items. Participant feedback on overlapping items eliminated a further 2 items and resulted in a preliminary instrument of 46 items. As a direct result of participant feedback ordering of the 10 domains was revised, a 4 option Likert scale was employed and a 4-week recall period for impact of symptoms was selected.

CONCLUSIONS

A 46-item instrument developed in accordance with international PROM development guidelines through literature review, developed by subject matter experts and refined through pretesting examining content validity provides a preliminary measure for assessing patient-report of health status in NMO. Further evaluation is proposed including sensitivity to clinical change, and international contributions to evaluating the measure are encouraged.

An integrated model of comprehensive care for people with Alzheimer's disease and their caregivers in a primary care setting

Most people with Alzheimer's disease and their families receive care in primary care. This article describes an integrated model of Alzheimer's disease care in a primary care setting serving a predominantly ethnic minority population. This model included: a comprehensive screening and diagnosis process; a multidisciplinary team approach to care, coordinated by a geriatric advanced practice nurse; and a proactive, longitudinal tracking system. The psychosocial intervention included specific responses to the treatment and management of behavioral and psychological symptoms of dementia, including caregiver directed interventions and pharmacological treatment if needed. Results suggest that this type of model can be implemented in primary care, particularly with the involvement of geriatric advanced practice nurses who can effectively manage the complex nature of Alzheimer's disease.

ACCURACY ASSESSMENT OF A UAV-BASED LANDSLIDE MONITORING SYSTEM

Landslides are hazardous events with often disastrous consequences. Monitoring landslides with observations of high spatio-temporal resolution can help mitigate such hazards. Mini unmanned aerial vehicles (UAVs) complemented by structure-from-motion (SfM) photogrammetry and modern per-pixel image matching algorithms can deliver a time-series of landslide elevation models in an automated and inexpensive way. This research investigates the potential of a mini UAV, equipped with a Panasonic Lumix DMC-LX5 compact camera, to provide surface deformations at acceptable levels of accuracy for landslide assessment. The study adopts a self-calibrating bundle adjustment-SfM pipeline using ground control points (GCPs). It evaluates misalignment biases and unresolved systematic errors that are transferred through the SfM process into the derived elevation models. To cross-validate the research outputs, results are compared to benchmark observations obtained by standard surveying techniques. The data is collected with 6 cm ground sample distance (GSD) and is shown to achieve planimetric and vertical accuracy of a few centimetres at independent check points (ICPs). The co-registration error of the generated elevation models is also examined in areas of stable terrain. Through this error assessment, the study estimates that the vertical sensitivity to real terrain change of the tested landslide is equal to 9 cm.

Abstract PD2-06: Inhibition of 3-phosphoinositide dependent protein kinase 1 (PDK1) synergizes with CDK4/6 inhibitors against ER-positive breast cancer

Background: Dysregulation in cell cycle checkpoints is common in cancer. Small molecule inhibitors that target the CDK4/6/cyclinD1 pathway of the cell cycle are in clinical development. Recently the combination of the CDK4/6 inhibitor palbociclib and the aromatase inhibitor letrozole was approved for the treatment of post-menopausal women with ER+/HER2- advanced breast cancer. However, not all patients benefit from CDK4/6 inhibitors and a significant fraction of them eventually progress on these agents, underscoring the need to develop potent therapeutic strategies to circumvent drug resistance.

Methods: We performed a high-throughput RNA interference (RNAi) kinome screen targeting 720 kinases to identify targetable molecules whose inhibition, in combination with the CDK4/6 inhibitor LEE011 (ribociclib), induced synthetic lethality in MCF7 ER+ breast cancer cells. PDK1 RNAi oligonucleotides and the PDK1 inhibitor GSK2334470 in combination with each of the CDK4/6 inhibitors, palbociclib and LEE011, were tested against ER+ breast cancer cells. In vivo anti-tumor efficacy of LEE011 and GSK2334470 was assessed in ovariectomized athymic nude mice bearing MCF7 xenografts.

Results: A siRNA kinome screen identified PDK1 as the top RNA whose downregulation sensitized MCF7 cells to CDK4/6 inhibitors. This was confirmed with independent siRNAs in ER+ MCF7, T47D, HCC1428 and HCC1500 breast cancer cells. Pharmacological inhibition of PDK1 with the ATP-competitive, small molecule inhibitor GSK2334470 in combination with each of the CDK4/6 inhibitors, LEE011 and palbociclib, synergistically inhibited proliferation and increased apoptosis of MCF7 and T47D cells (combination index 0.19-0.89). LEE011-resistant MCF7 and T47D cells were generated by chronic treatment with doses of LEE011 up to 1 µM. Drug-resistant cells displayed increased levels of PDK1, phosphorylated Rb, and phosphorylated S6 ribosomal protein (pS6), an effector of the PDK1 substrate p70S6K, compared to parental drug-sensitive cells. Inhibition of PDK1 with siRNA or GSK2334470 re-sensitized the LEE011-resistant cells to the CDK4/6 inhibitors. Genetic (RNAi) and pharmacological inhibition of PDK1 (with GSK2334470) abrogated pS6 levels whereas inhibition of AKT with the small molecule inhibitor MK2206 did not affect pS6 levels, suggesting PDK1 can induce resistance to CDK4/6 inhibitors via p70S6K/pS6 signaling in an AKT-independent manner. The effects observed in cell lines in culture were recapitulated in vivo using MCF7 xenografts established in ovariectomized nude mice in the absence of estrogen supplementation. Treatment with GSK2334470 and LEE011 induced tumor regressions (8/8 tumors by RECIST criteria) more potently than either drug alone.

Conclusions: These data support a critical role of PDK1 in mediating acquired resistance to CDK4/6 inhibitors in ER+ breast cancer cells. Co-targeting of the PDK1 and CDK4/6 pathways may overcome resistance to CDK4/6 inhibitors and is worthy of further translational and clinical investigation in patients with ER+ breast cancer.

Citation Format: Jansen VM, Bhola NE, Bauer JA, Formisano L, Moore P, Koch J, Arteaga CL. Inhibition of 3-phosphoinositide dependent protein kinase 1 (PDK1) synergizes with CDK4/6 inhibitors against ER-positive breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD2-06.

Impact of Pratylenchus penetrans on Establishment of Red Raspberry

The plant-parasitic nematode, Pratylenchus penetrans, is a major constraint to red raspberry (Rubus idaeus) production. To determine the impact of P. penetrans on the establishment and productivity of eight raspberry cultivars, R. niveus, and R. leucodermis, plants were grown in fumigated and nonfumigated soil. Then, soil and root populations of P. penetrans and plant productivity (vigor, cane height, biomass, and yield) were monitored over 2 years. In a separate experiment, the role that soil type plays in mediating P. penetrans populations and raspberry establishment was investigated. At 6 and 12 months after planting, population densities of P. penetrans were lower in fumigated than in nonfumigated soil; this trend continued 18 months after planting. All cultivars and R. leucodermis were found to be extremely susceptible to damage caused by P. penetrans. By the end of the experiment, yield was the most sensitive indicator of plant productivity among cultivars, with losses in nonfumigated soil ranging from 63 to 100% of those observed in fumigated soil. However, there was no difference in the productivity of R. niveus plants grown in nonfumigated versus fumigated soils. Results also indicated that the damage potential of P. penetrans was greater on sandy loam versus silt loam soils. The total plant biomass of 'Meeker' raspberry was 46% lower in a sandy loam soil containing P. penetrans compared with soil without P. penetrans; this trend was not observed consistently in a silt loam soil. Despite the fact that soil fumigation is increasingly more limited by regulations, this study shows the utility of fumigation in reducing P. penetrans populations for a sufficient period of time to ensure that newly planted raspberry seedlings can become successfully established.

Exploring attitudes toward eating disorders among elite athlete support personnel

To date, little is known about the beliefs, attitudes, and experiences of athlete support personnel (ASP) working in elite sport toward disordered eating (DE) and eating disorders (EDs). This study seeks to explore this area of mental health, employing an attribution model of stigma as a conceptual lens. Interviews were undertaken with 14 service providers (seven males and seven females) working in high-performance sport in Ireland. In contrast to previous research in the general population, findings revealed that sport-based personnel, in the main, did not hold the individual responsible for the development of their eating disorder. The predominant emotional response of those who had worked with an athlete with a known or suspected eating disorder was anxiety and worry. In line with the findings of previous studies with other health professionals, negative views on the prognosis of those with EDs were expressed by the ASP. Furthermore, confidentiality was found to be a significant barrier to bringing athletes' disclosure of problematic eating or exercise behavior to the fore. The findings of this study add to the limited research exploring attitudes toward EDs in sport and highlights the importance of greater education and openness toward this particular mental health problem.

Complication rates associated with levonorgestrel intrauterine system use in adolescents with developmental disabilities

STUDY OBJECTIVE

To assess the complication rates with the use of the levonorgestrel intrauterine system (LNG IUS) in adolescents with developmental disabilities.

DESIGN

Retrospective chart review of all adolescents with developmental disabilities taken to the operating room for LNG IUS insertion between January 2000 and July 2009 at the Royal Children's Hospital, Melbourne, Australia. Cases identified from the surgical database, and medical records reviewed.

MAIN OUTCOME MEASURES

Complication rates with LNG IUS use in adolescents with development disabilities: non-insertion, uterine perforation, infection, and expulsion.

RESULTS

Fifty-six adolescents with developmental disabilities had an attempted LNG IUS insertion. The average age at insertion was 15.6 years (range 10.5-21.5 y). The LNG IUS was used as first line therapy in 14 cases (25%). Pre-insertion ultrasonography was ordered in 48% of cases, out of which 5 cases had uterine lengths <6 cm. Despite this, 4 of these cases had successful insertions. Two insertion attempts were abandoned intra-operatively (3.6%); one due to inadequate uterine length of 4 cm, and the other due to anatomic distortion. One spontaneous expulsion occurred at approximately 5 months (1.9%). Four IUDs were removed prematurely (7.4% withdrawal rate); 1 for persistent abdominal pain, 1 for irregular bleeding, and 2 for suspected malpositions. There were no documented cases of infection, perforation, or pregnancy.

CONCLUSION

Our experience in this population has been very positive and confirms that complication rates are comparable to that in adults.

Abstract P6-07-02: Pharmacoeconomic evaluation of denosumab for the treatment of bone metastases in patients with advanced breast cancer in Canada

Background: Skeletal-related events (SREs) occur in 80% of patients with advanced breast cancer (BC) and bone metastases. SREs are costly and can be painful and debilitating, impacting patients’ quality of life and morbidity. While intravenous bisphosphonates such as pamidronate (PAM) and zoledronic acid (ZA) have demonstrated clinical benefit in reducing SREs, skeletal metastases remain a problem as treatments that are more efficacious, well tolerated, more convenient and less costly to administer are needed. Denosumab (XGEVA™) is a novel subcutaneous human monoclonal antibody therapy that significantly reduces the risk of developing SREs in patients with bone metastases from BC.

Objective: The objective of this project is to estimate the incremental cost-effectiveness of denosumab relative to ZA and PAM in the treatment of advanced BC patients with bone metastases.

Methods: A lifetime Markov model with four-week cycle lengths was developed with three health states: on treatment; off treatment; and death. The model included the risk of an SRE for patients on and off treatment and adverse events during treatment. Efficacy was measured as reduction in SREs. Head-to-head efficacy data, transition probabilities, and risk of adverse events were obtained from the clinical trial of denosumab versus ZA. (Stopeck AT et al JCO 2010) Efficacy data compared to PAM was determined from a published network meta-analysis. (Ford JA et al Eur J Cancer 2012) The baseline SRE risk was derived from clinical trial data due to the absence of real-world Canadian data. Analyses were conducted from the Canadian healthcare system perspective and reported in 2011 $CAD. Resource use was determined from a Canadian retrospective chart review of oncology patients with SREs. Costs were based on the published literature, the Ontario Case Costing Initiative, and input from a physician panel. Utility inputs were based on a time trade-off study. (Matza LS et al. Eur J Health Econ 2013) Bisphosphonate administration costs were derived from a published time and motion study. (Dranitsaris G et al. J Oncol Pharm Pract 2001) Outcomes were measured as both SREs avoided and quality-adjusted life years (QALYs) gained. Dominance was assessed or incremental cost-effectiveness ratios calculated per SRE avoided and per QALY gained, for denosumab compared to ZA and PAM. Future costs and QALYs were discounted at 5% per annum. Sensitivity analyses were conducted to test the robustness of the results.

Results: Denosumab was dominant and resulted in $5,733 in cost savings compared to ZA and $2,566 in cost savings compared to PAM based on a probabilistic analysis. Cost savings was driven by differences in drug administration costs and reduction in SREs. SREs avoided were 0.27 and 0.57 compared to ZA and PAM respectively. Denosumab resulted in 0.012 QALYs gained and 0.025 QALYs gained per patient compared to ZA and PAM, respectively. Sensitivity analyses showed the results were robust but most sensitive to drug administration costs and the relative risk of SREs.

Conclusion: Compared to both ZA and PAM, denosumab is more efficacious and offers better value for money (i.e. dominant) in Canada for managing SREs in patients with advanced BC and bone metastases.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-07-02.