Team consultancy using cognitive analytic therapy: a controlled study in assertive outreach

The objective of this study was to evaluate the clinical and organizational efficacy of formulation-based consultancy to clinical teams using a randomized control trial methodology. Patients in an Assertive Outreach Team (AOT) were randomized into cognitive analytic consultancy (CAC; n = 10) or treatment as usual (TAU; n = 10). CAC consisted of three consultancy sessions with individual team members to formulate and map the dysfunctional roles and procedures adopted by both patient and team. Subsequent changes to practice were then supported via team supervision. Measures of patient and team functioning were taken across four discrete study phases; (1) baseline team training, (2) case consultation, (3) team supervision and (4) 3-month follow-up. Team members were additionally interviewed before and following the trial. No differences were evident between CAC and TAU in terms of patient outcomes. However, the climate of the AOT significantly improved longitudinally over the course of the trial, with CAC facilitating enhanced clinical and team practices. The results are discussed in terms of methodological limitations, the advantages/disadvantages of team consultation and the potential for the further development of the CAC model.

A first-in-human study of the anti-α5β1 integrin monoclonal antibody PF-04605412 administered intravenously to patients with advanced solid tumors

Purpose

A first-in-human clinical trial of a fully human, Fc-engineered IgG1 monoclonal antibody targeting integrin α5β1 was conducted to evaluate tolerability, maximum tolerated dose, pharmacokinetics, pharmacodynamics and preliminary anti-tumor activity.

Methods

Escalating doses of PF-04605412 were given IV on day 1, 28 and every 2 weeks thereafter to patients with advanced solid tumors until disease progression or unacceptable toxicity. Sequential dose cohorts were evaluated based on a modified 3 + 3 dose-escalation design. The starting dose was 7.5 mg based on preclinical data.

Results

Thirty-three patients were enrolled to six dose levels (7.5, 11.25, 16.9, 34, 68 and 136 mg). Twenty-three patients were evaluable for the primary endpoint (determination of the maximum tolerated dose). Five patients required permanent drug discontinuation due to acute infusion-related reactions, which occurred as grade 3 events in two patients. PK analysis indicated that the targeted drug exposure based on preclinical models was not achieved by the tolerated doses and PK modeling suggesting that doses at least fivefold higher would be necessary. No anti-tumor activity was observed.

Conclusion

Based on the safety data, the risks associated with the likelihood of significant cytokine-mediated infusion reactions at higher doses, the projected high dose necessary to affect on the biological target and the lack of anti-tumor activity at the doses explored, the trial was prematurely terminated without determining a formal maximum tolerated dose. Further clinical development of PF-04605412 has been discontinued.

Electronic supplementary material

The online version of this article (doi:10.1007/s00280-014-2576-8) contains supplementary material, which is available to authorized users.

The incidence of pelvic fractures with traumatic lower limb amputation in modern warfare due to improvised explosive devices

Aims

A frequently-seen injury pattern in current military experience is traumatic lower limb amputation as a result of improvised explosive devices (IEDs). This injury can coexist with fractures involving the pelvic ring. This study aims to assess the frequency of concomitant pelvic fracture in IED-related lower limb amputation.

Methods

A retrospective analysis of the trauma charts, medical notes, and digital imaging was undertaken for all patients arriving at the Emergency Department at the UK military field hospital in Camp Bastion, Afghanistan, with a traumatic lower limb amputation in the six months between September 2009 and April 2010, in order to determine the incidence of associated pelvic ring fractures.

Results

Of 77 consecutive patients with traumatic lower limb amputations, 17 (22%) had an associated pelvic fracture (eleven with displaced pelvic ring fractures, five undisplaced fractures and one acetabular fracture). Unilateral amputees (n=31) had a 10% incidence of associated pelvic fracture, whilst 30 % of bilateral amputees (n=46) had a concurrent pelvic fracture. However, in bilateral, trans-femoral amputations (n=28) the incidence of pelvic fracture was 39%.

Conclusions

The study demonstrates a high incidence of pelvic fractures in patients with traumatic lower limb amputations, supporting the routine pre-hospital application of pelvic binders in this patient group.

Fluoxetine- and norfluoxetine-mediated complex drug-drug interactions: in vitro to in vivo correlation of effects on CYP2D6, CYP2C19, and CYP3A4

Fluoxetine and its circulating metabolite norfluoxetine comprise a complex multiple-inhibitor system that causes reversible or time-dependent inhibition of the cytochrome P450 (CYP) family members CYP2D6, CYP3A4, and CYP2C19 in vitro. Although significant inhibition of all three enzymes in vivo was predicted, the areas under the concentration-time curve (AUCs) for midazolam and lovastatin were unaffected by 2-week dosing of fluoxetine, whereas the AUCs of dextromethorphan and omeprazole were increased by 27- and 7.1-fold, respectively. This observed discrepancy between in vitro risk assessment and in vivo drug-drug interaction (DDI) profile was rationalized by time-varying dynamic pharmacokinetic models that incorporated circulating concentrations of fluoxetine and norfluoxetine enantiomers, mutual inhibitor-inhibitor interactions, and CYP3A4 induction. The dynamic models predicted all DDIs with less than twofold error. This study demonstrates that complex DDIs that involve multiple mechanisms, pathways, and inhibitors with their metabolites can be predicted and rationalized via characterization of all the inhibitory species in vitro.

The effects of plastic spectacles on the condition and behaviour of pheasants

Plastic spectacles are often fitted to pheasants in laying pens to reduce feather pecking and egg eating. This study examined the effects of spectacles on the physiological condition and behaviour of pheasants in harem and flock laying pens. In 2006 and 2007, data were collected from 21 game farms across England. On each site, two identical pens were randomly allocated a treatment, with or without spectacles. The physiological condition of pheasants in each treatment pen was assessed before and after the laying season. In flock pens, the behaviour of spectacled and non-spectacled pheasants was also assessed weekly. Detailed records of egg collections and mortality were also kept. Spectacles had no effect on the behaviour of male pheasants but affected the behaviour of females by reducing pecking and increasing head shaking/scratching. Although spectacles halved feather damage in females, and at least halved incidences of skin damage in both sexes, they increased bill and nostril damage in females while causing no detectable damage in males. Egg collections and mortality rates did not differ between spectacled and non-spectacled pens.

The roles of occipitotemporal cortex in reading, spelling, and naming

We evaluated the hypothesis that Brodmann's area (BA) 37 within left occipitotemporal cortex has at least two important functions in lexical processing. One role is the computation of case-, font-, location-, and orientation-independent grapheme descriptions for written word recognition and production (reading and spelling). This role may depend on the medial part of BA 37, in left midfusiform gyrus. The second role is in accessing modality-independent lexical representations for output, for naming and for reading and spelling of irregular or exception words. This role may depend on the lateral part of BA 37 in inferior temporal cortex. We tested these hypotheses in 234 participants with acute left hemisphere ischaemic stroke who underwent magnetic resonance imaging (MRI) and language testing within 48 hours of onset of stroke symptoms.

Distinct mechanisms and timing of language recovery after stroke

The "language network" is remarkably stable across language tasks but changes in response to injury to specific components or in response to "disconnection" of input to one component. We investigated network changes during language recovery, hypothesizing that language recovery takes place through distinct mechanisms: (a) reperfusion; (b) recovery from diaschisis; (c) recovery from structural disconnection; and (d) "reorganization" of language, whereby various components assume function of a damaged component. We also tested the hypothesis that "reorganization" depends on: the language task, level of performance, size and site of stroke, and time post onset. We tested these hypotheses in five participants who had structural, perfusion, and functional imaging utilizing spelling, reading, word generation, and picture naming tasks at acute and subsequent stages after ischaemic stroke. These cases illustrate different mechanisms of aphasia recovery or illustrate that reorganization of language acutely depends on individual variables in addition to size and site of stroke.

Augmentation of spelling therapy with transcranial direct current stimulation in primary progressive aphasia: Preliminary results and challenges

BACKGROUND

Primary progressive aphasia (PPA) is a neurodegenerative disease that primarily affects language functions and often begins in the fifth or sixth decade of life. The devastating effects on work and family life call for the investigation of treatment alternatives. In this article, we present new data indicating that neuromodulatory treatment, using transcranial direct current stimulation (tDCS) combined with a spelling intervention, shows some promise for maintaining or even improving language, at least temporarily, in PPA.

AIMS

The main aim of the present article is to determine whether tDCS plus spelling intervention is more effective than spelling intervention alone in treating written language in PPA. We also asked whether the effects of tDCS are sustained longer than the effects of spelling intervention alone.

METHODS & PROCEDURES

We present data from six PPA participants who underwent anodal tDCS or sham plus spelling intervention in a within-subject crossover design. Each stimulation condition lasted 3 weeks or a total of 15 sessions with a 2-month interval in between. Participants were evaluated on treatment tasks as well as on other language and cognitive tasks at 2-week and 2-month follow-up intervals after each stimulation condition.

OUTCOMES & RESULTS

All participants showed improvement in spelling (with sham or tDCS). There was no difference in the treated items between the two conditions. There was, however, consistent and significant improvement for untrained items only in the tDCS plus spelling intervention condition. Furthermore, the improvement lasted longer in the tDCS plus spelling intervention condition compared to sham plus spelling intervention condition.

CONCLUSIONS

Neuromodulation with tDCS offers promise as a means of augmenting language therapy to improve written language function at least temporarily in PPA. The consistent finding of generalisation of treatment benefits to untreated items and the superior sustainability of treatment effects with tDCS justifies further investigations. However, the small sample size still requires caution in interpretation. Present interventions need to be optimised, and particular challenges, such as ways to account for the variable effect of degeneration in each individual, are discussed.

The incidence of pelvic fractures with traumatic lower limb amputation in modern warfare due to improvised explosive devices

AIMS

A frequently-seen injury pattern in current military experience is traumatic lower limb amputation as a result of improvised explosive devices (IEDs). This injury can coexist with fractures involving the pelvic ring. This study aims to assess the frequency of concomitant pelvic fracture in IED-related lower limb amputation.

METHODS

A retrospective analysis of the trauma charts, medical notes, and digital imaging was undertaken for all patients arriving at the Emergency Department at the UK military field hospital in Camp Bastion, Afghanistan, with a traumatic lower limb amputation in the six months between September 2009 and April 2010, in order to determine the incidence of associated pelvic ring fractures.

RESULTS

Of 77 consecutive patients with traumatic lower limb amputations, 17 (22%) had an associated pelvic fracture (eleven with displaced pelvic ring fractures, five undisplaced fractures and one acetabular fracture). Unilateral amputees (n = 31) had a 10% incidence of associated pelvic fracture, whilst 30 % of bilateral amputees (n = 46) had a concurrent pelvic fracture. However, in bilateral, trans-femoral amputations (n = 28) the incidence of pelvic fracture was 39%.

CONCLUSIONS

The study demonstrates a high incidence of pelvic fractures in patients with traumatic lower limb amputations, supporting the routine pre-hospital application of pelvic binders in this patient group.

Uncertainty and anxiety in the cancer of unknown primary patient journey: a multiperspective qualitative study

BACKGROUND

Patients with cancer of unknown primary (CUP) have metastatic malignant disease without an identifiable primary site; it is the fourth most common cause of cancer death.

OBJECTIVES

To explore patients' informal and professional carers' experiences of CUP to inform development of evidence-based, patient-centred care.

METHODS

Qualitative study involving development of multiple exploratory case studies, each comprising a patient and nominated informal and professional carers, with contextual data extracted from medical records.

RESULTS

17 CUP patients, 14 informal and 13 professional carers participated in the study. Two inter-related themes distinct to CUP emerged: uncertainty and continuity of care. In the absence of a primary diagnosis, patients and informal carers experienced uncertainty regarding prognosis, possible recurrence and the primary's hereditary potential. Professional carers experienced difficulty communicating uncertainty to patients, ambiguity in deciding optimal treatment plans in the absence of trial data and a test or treat dilemma: when to discontinue seeking the primary and start treatment. Common problems with care continuity were amplified for CUP patients relating to coordination, accountability and timeliness of care. The remit of multidisciplinary teams (MDTs) often excluded CUP, leading to "MDT tennis" where patients were "bounced" between MDTs.

CONCLUSIONS

The experience of those with CUP is distinctive and it can serve to amplify some of the issues encountered by people with cancer. The clinical uncertainties related to CUP compound existing shortcomings in continuity of care, increasing the likelihood of a disrupted patient journey. However, while little can be done to overcome uncertainty, more could be done to address issues regarding continuity of care.

An area essential for linking word meanings to word forms: evidence from primary progressive aphasia

We investigated the relationship between deficits in naming and areas of focal atrophy in primary progressive aphasia (a neurodegenerative disease that specifically affects language processing). We tested patients, across multiple input modalities, on traditional naming tasks (picture naming) and more complex tasks (sentence completion with a name, naming in response to a question) and obtained high resolution MRI. Across most tasks, error rates were correlated with atrophy in the left middle and posterior inferior temporal gyrus. Overall, this result converges with prior literature suggesting that this region plays a major role in modality independent lexical processing.

Patterns of dysgraphia in primary progressive aphasia compared to post-stroke aphasia

We report patterns of dysgraphia in participants with primary progressive aphasia that can be explained by assuming disruption of one or more cognitive processes or representations in the complex process of spelling. These patterns are compared to those described in participants with focal lesions (stroke). Using structural imaging techniques, we found that damage to the left extrasylvian regions, including the uncinate, inferior fronto-occipital fasciculus, and sagittal stratum (including geniculostriate pathway and inferior longitudinal fasciculus), as well as other deep white and grey matter structures, was significantly associated with impairments in access to orthographic word forms and semantics (with reliance on phonology-to-orthography to produce a plausible spelling in the spelling to dictation task). These results contribute not only to our understanding of the patterns of dysgraphia following acquired brain damage but also the neural substrates underlying spelling.

Abstract WP449: Right Hemisphere Dysfunction is more Accurately Detected by Prosody Impairment than by Hemispatial Neglect

Introduction It is well known that right hemisphere ischemic stroke often results in hemispatial neglect. Recent studies have also shown that right hemisphere stroke may cause impairment in processing emotional prosody (tone of voice) as well. We tested the hypothesis that stroke patients are more accurately distinguished from neurologically intact controls by tests of emotional prosody comprehension than by tests of hemispatial neglect.

Methods We tested a series of 29 patients (mean age - 55 years old and mean education - 14 years)within 48 hours of onset of first right hemisphere ischemic stroke and 23 hospitalized age- and education- matched controls with MRI, a prosody comprehension battery and a battery of hemispatial neglect tests (line cancellation, copying a scene, gap detection, line bisection) . Emotion categorization tasks assessed recognition of 6 emotion categories (happy, sad, angry, surprise, disinterest, neutral) from prosodic cues in 2 conditions with varying verbal demands (neutral sentences and monosyllables). We used Receiver Operating Characteristic curves to identify the scores that most accurately classified stroke patients versus controls, using summary scores for Prosody and Neglect based on all of subtests for each.

Results The Prosody Score was more effective than the Neglect Score in distinguishing stroke patients from controls, as measured by a Receiver Operating Characteristic (AUC for Prosody Score = 0.86). An overall error rate of > 27% on the prosody comprehension battery had a sensitivity of 89.74% and specificity of 68.18% (correctly classifying 82.0% of participants as patients vs controls). In contrast, the AUC for Neglect Summary Score was 0.55. At most, the Neglect Score could classify 55.8% of patients vs. controls. Of 25 patients who made >27% errors on Prosody Comprehension, 22 (88%) made 0% errors on the Neglect battery.

Conclusion Prosody impairment may be a better indicator of right cortical dysfunction than hemispatial neglect in acute stroke and may therefore be a better measure of effectiveness of interventions to salvage cortical function, such as reperfusion therapies.

Role of aphasia in discharge location after stroke

OBJECTIVE

To evaluate language deficits after acute stroke and their association with post-acute care at a setting other than home. We hypothesized that deficits in language comprehension would be associated with discharge to a setting other than home after adjustment for physical/occupational therapy (PT/OT) needs.

DESIGN

Secondary analysis of prospectively collected data. Discharge location, demographic characteristics (age, sex, race), and the presence of PT/OT recommendations were abstracted from the medical record.

SETTING

Acute stroke unit at a tertiary medical center.

PARTICIPANTS

Left hemispheric stroke patients (N=152) within 24 hours of event.

INTERVENTIONS

The following tasks were administered: (a-b) oral and written naming of pictured objects, (c) oral naming with tactile input (tactile naming), (d-f) oral reading, oral spelling, and repetition of words and pseudowords, (g) written spelling to dictation, (h) spoken word-picture verification (ie, auditory comprehension), and (i) written word-picture verification (ie, written word comprehension).

MAIN OUTCOME MEASURE

Discharge to a setting other than home.

RESULTS

Of 152 cases, 88 were discharged home and 64 to another setting. Among stroke subjects discharged to a setting other than home, 63.6% had auditory comprehension deficits compared with 42.9% of those discharged home (P=.03). Deficits in auditory and reading comprehension and oral spelling to dictation were significantly associated with increased odds of discharge to a setting other than home after adjustment for age and PT/OT recommendations.

CONCLUSIONS

Cases with deficits in auditory comprehension, reading comprehension, and oral spelling to dictation had increased odds of being discharged to settings other than home. Early evaluation of these language deficits and prompt treatment may allow patients who would otherwise be discharged to an institution to go home. Further research is needed to design and evaluate individualized treatment protocols and their effect on discharge recommendations.