The multifaceted role of mast cells in joint inflammation and arthritis

OBJECTIVE

To review current knowledge surrounding the role of mast cells in joint inflammation and arthritis.

METHOD

Narrative review.

RESULTS

Mast cells (MCs) are commonly observed in the synovium of the joint, particularly surrounding blood vessels and nerve endings. Some studies have reported increased MC number and degranulation in patients with osteoarthritis (OA). In two studies, MCs were the only immune cell type found in higher concentrations in synovium of OA patients compared to rheumatoid arthritis patients. Activation of MCs in OA includes signaling pathways such as immunoglobulin E/Fc epsilon Receptor 1 (IgE/FcεR1), immunoglobulin G/Fc gamma receptor (IgG/FcγR), complement, and toll-like cell surface receptor-mediated signaling, resulting in context-dependent release of either pro-inflammatory and/or anti-inflammatory mediators within the joint. Activation of MCs results in the release of pro-inflammatory mediators that ultimately contribute to inflammation of the synovium, bone remodeling, and cartilage damage. However, some studies have proposed that MCs can also exhibit anti-inflammatory effects by secreting mediators that inactivate pro-inflammatory cytokines such as interleukin 6 (IL-6).

CONCLUSIONS

MCs may play a role in mediating synovial inflammation and OA progression. However, the mechanisms governing MC activation, the downstream pro- and/or anti-inflammatory effects, and their impact on osteoarthritis pathogenesis remains to be elucidated and requires extensive further study. Furthermore, it is important to establish the pathways of MC activation in OA to determine whether MCs exhibit varying phenotypes as a function of disease stage. Ultimately, such research is needed before understanding whether MCs could be targeted in OA treatments.

Role of the vulnerable elders survey-13 screening tool in predicting treatment plan modification for older adults with cancer

BACKGROUND

The Vulnerable Elders Survey (VES-13) is commonly used to identify older patients who may benefit from Comprehensive Geriatric Assessment (CGA) prior to cancer treatment. The optimal cut point of the VES-13 to identify those whose final oncologic treatment plan would change after CGA is unclear. We hypothesized that patients with high positive VES-13 scores (7-10)have a higher likelihood of a change in treatment compared to low positive scores (3-6).

METHODS

Retrospective review of a customized database of all patients seen for pre-treatment assessment in an academic geriatric oncology clinic from June 2015 to June 2019. Various VES-13 cut points were analyzed to identify those individuals whose treatment was modified after CGA. Area under the curve (AUC) was calculated and subgroups of patients treated locally or systemically were also examined to determine if performance varied by treatment modality.

RESULTS

We included 386 patients with mean age 81, 58% males. Gastrointestinal cancer was the most common site (31%) and 60% were planned to receive curative treatment. The final treatment plan was modified in 59% overall, with 52.7% modified with VES-13 scores 7-10, 50.8% with scores 3-6 and 28.1% with scores <3 (P = 0.002). VES-13 performance in predicting treatment modification was similar for cut points 3 (AUC 0.58), 4 (0.59), 5 (0.59), and 6 (0.59) and in those considering local treatment vs. chemotherapy.

CONCLUSIONS

A positive VES-13 score was associated with final oncologic treatment plan modification. A high positive score was not superior to the conventional cut point of ≥3.

Predictive role of Vulnerable Elders Survey-13 screen tool for elder cancer patients in final oncology treatment plan

e24020

Background: The Vulnerable Elders Survey (VES-13) is one of several tools that can identify older patients who are vulnerable (if the score is ≥ 3 out of 10) and more likely to benefit from Comprehensive Geriatric Assessment (CGA) prior to cancer treatment. The optimal cutpoint of the VES-13 to identify those whose final oncologic treatment plan would change after CGA is unclear. We hypothesized that patients with high positive scores (7-10) will have a higher likelihood of a change in the final oncologic treatment plan compared to low positive patients (score 3-6). Methods: Retrospective review of a customized database of all patients seen for pre-treatment assessment (solid tumor and lymphoma) in the geriatric oncology clinic at the Princess Margaret Cancer Centre from June 2015 to June 2019. Various VES-13 score cutpoints were compared with the final treatment plan to identify those individuals whose treatment was modified after CGA. Area under the curve was calculated and subgroups of patients treated locally or systemically were also examined to determine if performance varied by type of patient. Results: 386 patients with mean age 81, 58% males were included. Gastrointestinal cancer was the most common site 31% and 60% were planned to receive curative treatment. The final treatment plan was modified in 50% with VES-13 scores 7-10, 46.7% with scores 3-6 and 26.8 % for scores < 3 (P = 0.002; Table). The optimal VES-13 cutoff was between 3-6 (C-statistics 0.57-0.59).The VES-13 performed similarly in those considering local treatment (surgery with/without radiation) vs. chemotherapy. Modified final treatment for local therapy with VES-13 scores < 3 was 11.4 % compared to 42.9% with scores ≥ 3 was 42.9% (p-value < 0.001), whereas for systemic therapy it was 32.4% and 62.5%, respectively (p-value = 0.002). Conclusions: Although high positive VES-13 scores (7-10) had slightly higher likelihood of having the final oncologic treatment plan modified, there was no strong advantage compared to the conventional cutpoint of 3 or higher. The VES-13 performed similarly in predicting treatment change after CGA for local and systemic treatment plans. Further studies are required to identify the optimal frailty screening tool and cutpoint. [Table: see text]

Does screening for frailty with the vulnerable elders survey (VES-13) identify older adults with GU malignancy who benefit most from a consultation in a geriatric oncology clinic?

209

Background: The VES-13 is a well-studied brief frailty screening tool for ≥ 65 older adults (OAs) in the oncology setting. Vulnerable patients (scoring ≥ 3) are at higher risk for adverse outcomes and will benefit from a Comprehensive Geriatric assessment (CGA) and cancer treatment decision optimization. Whether the VES-13 is effective specifically in patients with Genitourinary (GU) malignancies remains to be established. Primary objective: to determine if the VES-13 can predict which OAs with GU cancer (Bladder, Prostate, Kidney) had subsequent treatment modification after CGA. Secondary objective: to investigate if there is any association between VES-13 score with comorbidity and chemotherapy toxicity prediction tool (CARG). Methods: The VES-13 was administered to consecutive patients referred to the geriatric oncology (GO) clinic from GU site at the Princess Margaret Cancer Centre, Canada. All patients underwent CGA. CGA assess 8 domains including cognition, comorbidities, function, falls risk. Among patients referred for pre-treatment assessment, we examined whether the VES-13 predicted changes in the final treatment plan after CGA. Descriptive statistics were used to describe the VES-13 scores and final treatment impact. Results: From July 2015-October 2019, 77 were included in this analysis. The VES-13 ≥ 3 group were 52/77 (67.5%), and significantly associated with higher comorbidities (P = 0.003) and worse CARG scores (P = 0.005). The final treatment plan was modified in 36/77 (47%). In univariate analysis, the odds ratio (OR) for VES-13 ≥3 was 1.92 (95% CI 0.72-5.12) for change in final treatment, which was not statistically significant likely due to modest sample size. Interestingly in the same univariate analysis, there was a strong association between final treatment plan with falls risk (OR 2.63, 95% CI 1.03-6.72), physical performance (OR 2.51, 95% CI 0.98-6.45) and cognition (OR 3.95, 95% CI 1.19-13.19). Conclusions: The VES-13 identified vulnerable GU patients who will benefit from CGA and may predict treatment optimization by identifying patients at higher risk of chemotherapy toxicity and higher comorbidity.

Impact of a geriatric oncology (GO) clinic on cancer treatment plans and supportive care for older adults with genitourinary (GU) cancer

238

Background: Older adults with cancer are complex due to multiple comorbidities, polypharmacy, and functional/cognitive impairments, leading to over-treatment and undertreatment. Studies examining the impact of geriatric assessment (GA) in older adults with various cancers found a median of 39% of treatment plans were revised after the GA ( Ann Oncol 2014; 25:307). Although these findings support the need for a GO clinic, whether such a clinic leads to changes in treatment in patients with GU malignancies is not clear. We examined the impact on the treatment plan of a GO assessment in GU patients, along with other enhancements to patient care for consecutive patients referred to the GO clinic in a tertiary care hospital. Methods: All referred older adults (age 65+) with a GU malignancy seen in the GO clinic at the Princess Margaret Cancer Centre, Toronto, Canada between July 2015 and June 2017 were included. Patients were seen by a geriatric oncologist and GO nurse and treatment recommendations were provided to the referring oncologist. Pre- and post-GO clinic treatment plans and enhancements to supportive care were recorded prospectively. Analyses were descriptive. Results: 98 patients (mean age 80) were seen in the GO clinic, of whom 35 were seen pre-treatment (25 prostate, 5 kidney, 5 bladder). 31 of 35 were referred for input on the treatment plan. The initial treatment plan included surgery (n = 6), radiation (n = 14), systemic therapy (n = 8), and hormonal therapy (n = 11). The final treatment plan was intensified in 1 patient, reduced in 6 patients, changed to best supportive care in 8 patients, and unchanged in 15 patients. Overall, GO resulted in a treatment modification in 52% of patients. Enhancements to care included comorbidity management (87%), educational support (94%), disease-related symptoms (39%), and peri-operative management (19%). Conclusions: The GO clinic results in modifications to the proposed treatment plan in over half of referred patients (predominantly a reduction in treatment intensity), and enhancements to care in the vast majority of patients. GO clinics have the potential to avoid overtreatment and improve care for older adults with GU malignancies.

American College of Sports Medicine position stand. The Female Athlete Triad

The Female Athlete Triad is a syndrome occurring in physically active girls and women. Its interrelated components are disordered eating, amenorrhea, and osteoporosis. Pressure placed on young women to achieve or maintain unrealistically low body weight underlies development of the Triad. Adolescents and women training in sports in which low body weight is emphasized for athletic activity or appearance are at greatest risk. Girls and women with one component of the Triad should be screened for the others. Alone or in combination, Female Athlete Triad disorders can decrease physical performance and cause morbidity and mortality. More research is needed on its causes, prevalence, treatment, and consequences. All individuals working with physically active girls and women should be educated about the Female Athlete Triad and develop plans to prevent, recognize, treat, and reduce its risks.

A comparison of satisfaction with types of diaphragms among women in a college population

Since the 1940s diaphragms have been a popular contraceptive device used by women in the United States. This study compared three popular diaphragms and women's subjective comparisons of comfort, ease of insertion, and overall satisfaction. None of the three types, the wideseal, coil spring, or arcing spring, was found to be statistically more comfortable or easier to insert. For overall satisfaction, women were more pleased with the coil spring than the wideseal (p = .0416 at two to four weeks, p = .0759 at four to six months, and p = .0049 at one year). Women who used the arcing spring and wideseal were more pleased with the wideseal at two to four weeks (p = .0571). No significant difference was found at one year. The study results demonstrate that certain diaphragm styles may improve women's use of and satisfaction with the diaphragm.

Pelvic inflammatory disease: a review of therapy

Pelvic inflammatory disease (PID) is a serious health problem that affects the reproductive capacity and the sexual activities of women. Approximately 50,000 cases are reported annually resulting in severe pain, reduced fertility and costly health care. Diagnosis of PID requires a complex analysis of the history, a thorough physical examination and diagnostic testing. Goals of care include accurate diagnosis with particular emphasis on differential diagnosis, antibiotic therapy, close follow-up and counseling. Antibiotic therapy is directed against the pathogenic organism, either gonococcal or nongonococcal. Careful counseling and follow-up aids successful treatment and decreases the likelihood of infertility.

Genital herpes infections: diagnosis and management

Herpes genitalia is a common and serious sexually transmitted disease currently affecting five million people. Herpes simplex I and II are two of the five herpes viruses that affect humans. This article discusses the diagnosis and care of clients with genital herpes. The major focus of this article delineates the nurse practitioner's role in providing care for these clients. Special emphasis is placed on education, counseling and preventive care.