Canadian pattern of care for anemia: comparison of chemotherapies in adjuvant breast cancer setting

Abstract #2118

Background: Anemia is a common side effect of chemotherapy in adjuvant breast cancer patients (pts) but its treatment may be inconsistent. Erythropoiesis-stimulating agents (ESAs) are the only alternative to blood transfusion in the treatment of chemotherapy-induced anemia, yet their appropriate use continues to be defined. The purpose of this study was to determine the frequency of anemia associated with adjuvant chemotherapy in Canadian breast cancer pts and to explore the corrective interventions which were undertaken.
 Methods: A retrospective chart review was conducted at 11 cancer centres in Ontario, Canada. Beginning on September 1, 2004 data were collected for 60 consecutive cases of adjuvant breast cancer at each centre, giving a total of 620 patients. Chemotherapy consisted mainly of FEC100, AC-T, AC, CEF, FEC50, and AC-T Dose Dense. Overall, 8% of pts were enrolled in a clinical trial and 76% received adjuvant radiotherapy. Hemoglobin level (Hb), supportive therapy (antibiotics, GCSF, ESA, and transfusion) and type of chemotherapy were recorded at each cycle.
 Results: The median pt age was 53. The mean baseline Hb was 132.8 (92.0-163) g/L, 11.6% of pts had Hb<120g/L. During the course of chemotherapy, the percentage of subjects with Hb<120 at least once was 55.8%, Hb<110 was 37.8%, Hb<100 was 21.2 % and Hb<90 was 11.5%, with a median of 36.0, 52.5, 71.0, and 75.0 days to develop anemia respectively. For pts whose Hb dropped below 100 g/L, 45.4% occurred after the 1st cycle, 68.8% after the 2nd, 83.7% after the 3rd, and 92.2% after the 4th chemotherapy cycle. Overall, 13.2% of subjects received prophylactic antibiotics, 26.3% were supported by G-CSF, 9.0% received an ESA (epoetin alfa) during their chemotherapy and 7.4% were transfused. The rates of anemia as well as means of intervention are summarized in Figure 1. ESAs were not used prophylactically in this setting.
 Conclusions: In Canada, breast cancer patients receiving adjuvant chemotherapy commonly become anemic during their course of treatment. This retrospective study demonstrated that ESAs play an important role in the management of anemia in the adjuvant setting. Canadian treatment guidelines recommend that ESA therapy be initiated when Hb <100 g/L. Our finding shows that ∼42% of patients whose Hb dropped below 100g/L were treated with ESAs, suggesting that ESAs were not overused in Canadian practice.
 


Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2118.

Surgical repair of pectus excavatum markedly improves body image and perceived ability for physical activity: multicenter study

OBJECTIVE

This study evaluated changes in both physical and psychosocial quality of life reported by the parent and child after surgical repair of pectus excavatum.

METHODS

As part of a multicenter study of pectus excavatum, a previously validated tool called the Pectus Excavatum Evaluation Questionnaire was administered by the research coordinator, via telephone, to parents and patients (8-21 years of age) before and 1 year after surgery. Eleven North American children's hospitals participated. From 2001 to 2006, 264 patients and 291 parents completed the initial questionnaire, and 247 patients and 274 parents completed the postoperative questionnaire. Responses used a Likert-type scale of 1 to 4, reflecting the extent or frequency of a particular experience, with higher values conveying less-desirable experience.

RESULTS

Preoperative psychosocial functioning was unrelated to objective pectus excavatum severity (computed tomographic index). Patients and their parents reported significant positive postoperative changes. Improvements occurred in both physical and psychosocial functioning, including less social self-consciousness and a more-favorable body image. For children, the body image component improved from 2.30+/-0.62 (mean+/-SD) to 1.40+/-0.42 after surgery and the physical difficulties component improved from 2.11+/-0.82 to 1.37+/-0.44. For the parent questionnaire, the child's emotional difficulties improved from 1.81+/-0.70 to 1.24+/-0.36, social self-consciousness improved from 2.86+/-1.03 to 1.33+/-0.68, and physical difficulties improved from 2.14+/-0.75 to 1.32+/-0.39. Ninety-seven percent of patients thought that surgery improved how their chest looked.

CONCLUSIONS

Surgical repair of pectus excavatum can significantly improve the body image difficulties and limitations on physical activity experienced by patients. These results should prompt physicians to consider the physiologic and psychological implications of pectus excavatum just as they would any other physical deformity known to have such consequences.

EuPA achieves visibility - an activity report on the first three years

Plans for the European Proteomics Association (EuPA) were conceived and established during 2004 and 2005, and culminated in the formal inception of the organisation during the 4th HUPO World Congress held in Munich in 2005. The mission from the outset has been three-tiered and is to: i) strengthen the national Proteomics organizations in their efforts; ii) to co-ordinate and provide educational programs, and iii) to advance the networking of scientists through meetings, workshops and student exchange. Linked to the mission were objectives to emphasise the benefits and contributions of Proteomics to biological and industrial researchers, the general public and science policy makers in Europe. In addition, the EuPA set out to promote scientific exchange for all applications and technology development related to Proteomics, and coordinate joint activities of national Proteomics societies at the European level. To achieve these tasks an organisational structure was conceived whereby four Activity Committees (Conferences/Communications, Education, EuPA-HUPO-Interactions and Funding) were implemented and a General Council consisting of all member countries. The remarkable rise and progress the EuPA has achieved in this small time frame is reported here.

Comparison of 4% articaine and 0.5% levobupivacaine/2% lidocaine mixture for sub-Tenon's anaesthesia in phacoemulsification cataract surgery: a randomised controlled trial

BACKGROUND/AIMS

[corrected] The aim of this study was to compare the efficacy and safety of 4% articaine with a mixture containing equal volumes of 2% lidocaine and 0.5% levobupivacaine without hyaluronidase for sub-Tenon's anaesthesia in phacoemulsification cataract surgery.

METHODS

The study was a prospective, randomised double-masked clinical trial of 65 patients allocated to receive either 4% articaine or a mixture containing equal parts of 2% lidocaine and 0.5% levobupivacaine. All patients had pre- and postoperative Hess charting to document ocular motility dysfunction. Ocular and eyelid movements were scored at 2 min intervals from 2 to 10 min after injection of the anaesthetic agent, and at the end of surgery. Complications related to injection, including pain, chemosis and subconjunctival haemorrhage, were recorded. Patients rated pain (none/mild/moderate/severe) during surgery. The operating surgeon masked to the anaesthetic agent assessed proptosis/chemosis at the start of the operation and the degree of ocular akinesia and analgesia at the end of surgery.

RESULTS

The articaine group demonstrated a rapid onset of ocular akinesia with a mean time to readiness for surgery (achieving a score of </=5) of 4.0 min compared with 10 min for the lidocaine/levobupivacaine group (p = 0.001). The effectiveness of block was significantly greater in the articaine group at all points (p<0.01). Surgeons rated ocular akinesia to be superior in the articaine group (p<0.001). Patients and surgeons rated the analgesic effect as comparable in either group. Eyelid scores, subconjunctival haemorrhage and chemosis were comparable in either group. Hess chart was performed on all patients pre- and postoperatively. There was no clinically significant motility disturbance in the articaine group, whereas one patient in the lidocaine/levobupivacaine group developed diplopia with abnormal ocular motility on the Hess chart.

CONCLUSION

Articaine (4%) is a safer and a superior anaesthetic agent than a mixture of 2% lidocaine and 0.5% levobupicaine in achieving ocular akinesia for sub-Tenon's block in phacoemulsification cataract surgery.

The Sony Ericsson WTA Tour 10 year age eligibility and professional development review

Concerns have long existed over the participation of adolescent athletes in professional sports. In 2004, the Sony Ericsson WTA Tour (WTA Tour) commissioned a Professional Development Advisory Panel (PDAP) to evaluate the WTA Tour's age eligibility rule (AER) and professional development programmes (PDPs) for female tennis players since their inception in 1995. More than 75% of the 628 respondents supported the principles of the AER, and 90% indicated a need for PDPs. Statistical analysis of WTA Tour players' careers found that premature retirements (players leaving the Tour at or before age 21) decreased significantly from 7% before the AER to less than 1% afterward, and median career length increased by 43%. The PDAP recommends that the WTA Tour continues a phased-in, developmentally appropriate AER, enhances the PDPs, and works with other sport governing bodies to coordinate rules and programmes at earlier ages to aid the transition of adolescents into adult sports.

The hip trial: psychosocial consequences for mothers of using ultrasound to manage infants with developmental hip dysplasia

BACKGROUND

The hip trial aimed to assess clinical effectiveness, economic and psychosocial costs, and benefits of ultrasound imaging (US) compared with conventional clinical assessment alone to guide the management of infants with neonatal hip instability.

OBJECTIVE

To report on psychosocial consequences for mothers and the developing mother-child relationship of US, and associations between abduction splinting and maternal psychosocial distress.

DESIGN

Multicentre randomised controlled trial.

SETTING

Thirty three hospitals in the United Kingdom and Ireland. PARTICIPANTS, INTERVENTIONS: A total of 629 infants with neonatal hip instability randomised to US examination or clinical assessment alone before treatment decision. Questionnaires were completed by 561 (89%) mothers at 8 weeks and 494 (79%) at 1 year.

MAIN OUTCOME MEASURES

Anxiety, postnatal depression, parenting stress assessed by standardised questionnaires. Maternal concerns about hip problems were assessed using the Infant hip worries inventory.

RESULTS

At 8 weeks, there were no differences between US and non-US groups of the trial in maternal anxiety (mean difference (MD) -1.2, 95% confidence interval (CI) -3.2 to 0.8), depression (MD 0.0, 95% CI -0.7 to 0.8), parenting stress (MD -1.2, 95% CI -2.8 to 0.4), or other measures. The same pattern was evident at 1 year. In an explanatory analysis, early splinting was associated with increased anxiety at 8 weeks (MD 3.8, 95% CI 1.7 to 5.9) and increased level of hip worries at 8 weeks (MD 6.8, 95% CI 5.6 to 7.9) and 1 year (MD 1.3, 95% CI 0.3 to 2.4).

CONCLUSIONS

Although early splinting is associated with maternal anxieties, US is not associated with any increase or reduction in psychosocial effects on mothers. Together with the clinical findings, this suggests that the use of US allows reduction in splinting rates without increased risk of adverse clinical or psychosocial outcomes.

Occupational nursing service in a small manufacturing plant: interventions and outcomes

PURPOSE

To describe the health needs presented by workers in a small industrial setting, describe the occupational health nursing (OHN) services provided, and examine the effectiveness of these services.

METHODS

Data were abstracted from 491 employee records accumulated over a 7-year service period. Standardized nursing languages were used to describe employee needs and nursing interventions.

FINDINGS

Data revealed 1,368 needs were identified and 3,193 nursing interventions were administered. Health-seeking behaviors, knowledge deficit, collaborative problems, risk of infection, and impaired tissue integrity seemed most amenable to change in the context of OHN services. Altered health maintenance was the problem that seemed least amenable to change.

CONCLUSIONS

Findings present a dynamic picture of OHN services provided in an OHN program and their effectiveness. Standardized nursing languages were effective and appropriate in describing the health issues managed and interventions applied.

PRACTICE IMPLICATIONS

Further use of standardized nursing languages in occupation health can establish core functions and knowledge base.

Report from the 1st International NOD Mouse T-Cell Workshop and the follow-up mini-workshop

A workshop on autoreactive T-cell responses in NOD mice was held to optimize autoreactive T-cell detection methodologies. Using different proliferation assay protocols, 1 of the 11 participating laboratories detected spontaneous T-cell responses to GAD(524-543) and insulin(9-23) in their NOD mice. Two other laboratories were able to detect autoreactive responses when using enzyme-linked immunospot assay (ELISPOT) and enzyme-linked immunosorbent assay (ELISA) analysis of cytokines in culture supernatants, suggesting that these assays provided greater sensitivity. To address the divergent findings, a follow-up mini-workshop tested NOD mice from four different colonies side-by-side for T-cell proliferative responses to an expanded panel of autoantigens, using the protocol that had enabled detection of responses in the 1st International NOD Mouse T-Cell Workshop. Under these assay conditions, 16 of 16 NOD mice displayed proliferative responses to whole GAD65, 13 of 16 to GAD(524-543), 9 of 16 to GAD(217-236), 7 of 16 to insulin(9-23), and 5 of 16 to HSP277. Thus, spontaneous proliferative T-cell responses can be consistently detected to some beta-cell autoantigens and peptides thereof. Overall, the results suggest that more sensitive assays (e.g., ELISPOT, ELISA analysis of cytokines in supernatants, or tetramer staining) may be preferred for the detection of autoreactive T-cells.

Relative resistance to nasally induced tolerance in non-obese diabetic mice but not other I-A(g7)-expressing mouse strains

I-A(g7) is a unique class II MHC molecule that is clearly associated with autoimmune diabetes in non-obese diabetic (NOD) mice. To determine if I-A(g7) is defective in its ability to deliver tolerogenic signals in vivo, H-2(g7) mice were nasally pretreated with antigen, prior to immunization, to induce antigen-specific regulation. Nasally pretreated NOR (H-2(g7)) and (NON).NOD (H-2(g7)) congenic mice showed responses similar to those of NON (H-2(nb1)), BALB/c (H-2(d)) and B10.PL (H-2(u)) mice-a reduced recall response and a deviated T(h) cytokine profile. However, we found that NOD (H-2(g7)) mice are comparatively resistant to immunological tolerance induced by nasal pretreatment, such that at the usually effective dose no significant reduction was seen in the proliferative recall responses to nominal antigen after immunization. (NOD x BALB/c)F(1) (H-2(g7/d)) and (NOD x NOR)F(1) (H-2(g7)) mice were similarly resistant to nasal-induced tolerance, although significantly higher nasal doses of antigen were able to overcome the resistance in NOD and F(1) mice. Interestingly, activated NOD T cells were resistant to cell death induced by re-stimulation with plate-bound anti-CD3. These results demonstrate that activated T cells in NOD mice are defective in their ability to respond to regulatory signals delivered in vivo or in vitro. Furthermore, NOD T cells have an increased resistance to tolerance induced by I-A(g7)-dependent (antigen) or I-A(g7)-independent (anti-CD3) mechanisms. Thus, while I-A(g7) may contribute to insulin-dependent diabetes mellitus by selecting a particular repertoire of self-reactive T cell clones, additional defects in the peripheral T cells themselves are required to allow the expansion of diabetogenic clones and the development of autoimmune disease.

MHC class I-restricted determinants on the glutamic acid decarboxylase 65 molecule induce spontaneous CTL activity

CD4(+) T cell responses to glutamic acid decarboxylase (GAD65) spontaneously arise in nonobese diabetic (NOD) mice before the onset of insulin-dependent diabetes mellitus (IDDM) and may be critical to the pathogenic process. However, since both CD4(+) and CD8(+) T cells are involved in autoimmune diabetes, we sought to determine whether GAD65-specific CD8(+) T cells were also present in prediabetic NOD mice and contribute to IDDM. To refine the analysis, putative K(d)-binding determinants that were proximal to previously described dominant Th determinants (206-220 and 524-543) were examined for their ability to elicit cytolytic activity in young NOD mice. Naive NOD spleen cells stimulated with GAD65 peptides 206-214 (p206) and 546-554 (p546) produced IFN-gamma and showed Ag-specific CTL responses against targets pulsed with homologous peptide. Conversely, several GAD peptides distal to the Th determinants, and control K(d)-binding peptides did not induce similar responses. Spontaneous CTL responses to p206 and p546 were mediated by CD8(+) T cells that are capable of lysing GAD65-expressing target cells, and p546-specific T cells transferred insulitis to NOD.scid mice. Young NOD mice pretreated with p206 and p546 showed reduced CTL responses to homologous peptides and a delay in the onset of IDDM. Thus, MHC class I-restricted responses to GAD65 may provide an inflammatory focus for the generation of islet-specific pathogenesis and beta cell destruction. This report reveals a potential therapeutic role for MHC class I-restricted peptides in treating autoimmune disease and revisits the notion that the CD4- and CD8-inducing determinants on some molecules may benefit from a proximal relationship.

Induction of autoimmune valvular heart disease by recombinant streptococcal m protein

Rheumatic heart disease is an autoimmune sequela of group A streptococcal infection. Previous studies have established that streptococcal M protein is structurally and immunologically similar to cardiac myosin, a well-known mediator of inflammatory heart disease. In this study, we investigated the hypothesis that streptococcal M protein could produce inflammatory valvular heart lesions similar to those seen in rheumatic fever (RF). Fifty percent (3 of 6) of Lewis rats immunized with recombinant type 6 streptococcal M protein (rM6) developed valvulitis as well as focal lesions of myocarditis. Valvular lesions initiated at the valve surface endothelium spread into the valve. Anitschkow cells and verruca-like lesions were present. T cells from rM6-immunized rats proliferated in the presence of purified cardiac myosin, but not skeletal myosin. A T-cell line produced from rM6-treated rats proliferated in the presence of cardiac myosin and rM6 protein. The study demonstrates that the Lewis rat is a model of valvular heart disease and that streptococcal M protein can induce an autoimmune cell-mediated immune attack on the heart valve in an animal model. The data support the hypothesis that a bacterial antigen can break immune tolerance in vivo, an important concept in autoimmunity.

Regulatory and effector CD4 T cells in nonobese diabetic mice recognize overlapping determinants on glutamic acid decarboxylase and use distinct V beta genes

The 524--543 region of glutamic acid decarboxylase (GAD65), GAD65(524--543), is one of the first fragments of this islet Ag to induce proliferative T cell responses in the nonobese diabetic (NOD) mouse model of spontaneous autoimmune diabetes. Furthermore, NOD mice given tolerogenic doses of GAD65(524--543) are protected from spontaneous and cyclophosphamide-induced diabetes. In this study, we report that there are at least two I-A(g7)-restricted determinants present in the GAD65(524--543) sequence, each capable of recruiting unique T cell repertoires characterized by distinct TCR V beta gene use. CD4(+) T cells arise spontaneously in young NOD mice to an apparently dominant determinant found within the GAD65 peptide 530--543 (p530); however, T cells to the overlapping determinant 524-538 (p524) dominate the response only after immunization with GAD65(524--543). All p530-responsive T cells used the V beta 4 gene, whereas the V beta 12 gene is preferentially used to encode the TCR of p524-responsive T cell populations. T cell clones and hybridomas from both of these T cell groups were responsive to APC pulsed with GAD65(524--543) or whole rGAD65. p524-reactive cells appeared to be regulatory upon adoptive transfer into young NOD mice and could inhibit insulin-dependent diabetes mellitus development, although they were unable to produce IL-4, IL-10, or TGF beta upon antigenic challenge. Furthermore, we found that i.p. injection with p524/IFA was very effective in providing protection from cyclophosphamide-induced insulin-dependent diabetes mellitus. These data demonstrate that the regulatory T cells elicited by immunizing with GAD65(524--543) are unique and distinct from those that arise from spontaneous endogenous priming, and that T cells to this limited region of GAD65 may be either regulatory or pathogenic.

Ropivacaine 0.2% versus bupivacaine 0.1% with fentanyl: a double blind comparison for analgesia during labour

We have performed a randomized, double-blind comparison of two epidural drug regimens for analgesia in labour. In the bupivacaine group (BUPIV), 101 healthy parturients received 0.1% bupivacaine with fentanyl 2 microg ml(-1). In the ropivacaine group (ROPIV), 102 women received 0.2% ropivacaine. Both groups received an initial loading dose of 15 ml, a continuous infusion of 8 ml h(-1), and top-ups of 10 ml. Breakthrough pain not responding to a routine top-up was treated with an 'escape' top-up of 10 ml 0.25% bupivacaine. The two groups were compared for complete analgesia at 30 min, routine and 'escape' top-up requirements, midwife assessment of analgesic efficacy, delivery mode, patient visual analogue scores (VAS) for first and second stage analgesia, overall satisfaction, and patient assessment of motor blockade. Patients receiving ropivacaine received fewer routine top-ups (median 1.0 vs. 2.0, P=0.001) and fewer escape top-ups (9.8% vs. 21.8%, P=0.02). The ropivacaine group was more likely to be pain free in the first stage (51% vs. 33.7%, P=0.01). There were no significant differences in patients' assessment of motor block or mode of delivery between the groups. Pain relief and satisfaction scores from midwives and patients were consistently better in the ropivacaine group, but did not reach statistical significance.