Retention rates and reasons for non-retention in exercise oncology trials in the post-treatment phase-a systematic review

PURPOSE

Retention is a key marker of trial success. Poor retention can induce bias, reduce statistical power and minimise the validity of trials. This review examined retention rates in exercise trials in cancer survivors, reasons for non-retention and retention strategies utilised.

METHODS

A systematic review was conducted using a predefined search strategy in EMBASE RCTs, MEDLINE OVID, CINAHL, Web of Science-Core Collection and Cochrane Central Register of Controlled Trials (CENTRAL). The search was conducted on 27/03/2023. Title and abstract screening, full text review and data extraction were completed in duplicate.

RESULTS

Of 17,524 studies identified, 67 trials involving 6093 participants were included. The median overall retention rate immediately post-intervention was 89.85%, range (52.94-100%) and mean 87.36% (standard deviation 9.89%). Trials involving colorectal cancer survivors only had the highest median retention rate (94.61%), followed by breast (92.74%), prostate (86.00%) and haematological cancers (85.49%). Studies involving mixed cancer cohorts had the lowest retention rate (80.18%). The most common retention strategies were wait-list control groups, regular check-ins/reminders and free exercise equipment. Common reasons for non-retention were lost to follow-up, health problems, personal reasons including family/work commitments and travel burden, and disease progression.

CONCLUSIONS

Retention rates in exercise oncology trials are approximately 90% immediately post-interventions. Our previous work highlighted variable suboptimal recruitment rates of median 38% (range 0.52-100%). Recruitment rather than retention should be prioritised for methodology research in exercise oncology.

IMPLICATIONS FOR CANCER SURVIVORS

Optimising the quality of exercise oncology trials is critical to informing high quality survivorship care. PROSPERO registration number: CRD42023421359.

Effect of in-water administration of quorum system inhibitors in broilers' productive performance and intestinal microbiome in a mild necrotic enteritis challenge

The poultry industry has been facing the impact of necrotic enteritis (NE), a disease caused by the bacterium Clostridium perfringens producing the haemolytic toxin NetB. NE severity may vary from mild clinical to prominent enteric signs causing reduced growth rates and affecting feed conversion ratio. NetB production is controlled by the Agr-like quorum-sensing (QS) system, which coordinates virulence gene expression in response to bacterial cell density. In this study, the peptide-containing cell-free spent media (CFSM) from Enterococcus faecium was tested in NE challenged broilers in two battery cage and one floor pen studies. Results showed a significant reduction of NE mortality. Metagenomic sequencing of the jejunum microbiome revealed no impact of the CFSM on the microbial community, and growth of C. perfringens was unaffected by CFSM in vitro. The expression of QS-controlled virulence genes netB, plc and pfoA was found to be significantly repressed by CFSM during the mid-logarithmic stage of C. perfringens growth and this corresponded with a significant decrease in haemolytic activity. Purified fractions of CFSM containing bioactive peptides were found to cause reduced haemolysis. These results showed that bioactive peptides reduce NE mortality in broilers by interfering with the QS system of C. perfringens and reducing bacterial virulence. Furthermore, the microbiome of C. perfringens-challenged broilers is not affected by quorum sensing inhibitor containing CFSM.

[Interest of iDAScore (intelligent Data Analysis Score) for embryo selection in routine IVF laboratory practice: Results of a preliminary study]

INTRODUCTION

Embryo selection is a major challenge in ART, especially since the generalization of single embryo transfer, and its optimization could lead to the improvement of clinical results in IVF. Recently, several Artificial Intelligence (AI) models, based on deep-learning such as iDAScore, have been developed. These models, trained on time-lapse videos of embryos with known implantation data, can predict the probability of pregnancy for a given embryo, allowing automatization and standardization in embryo selection.

MATERIAL AND METHODS

In this study, we have compared the hierarchical categorization of 311 D5 blastocysts of iDAScore v1.0 and the embryologists of our unit. These 311 D5 blastocysts have been classified as top (70.1%), good (Q+: 10.6%) and poor (Q-: 19.3%) quality by embryologists according to Gardner classification. Median iDAScores were [9.9-8.4],]8.4-7.5] and]7.5-2.1] for top, good and poor-quality blastocysts respectively.

RESULTS

We observed a significantly concordant categorization between iDAScore and embryologists for top, good and poor-quality blastocysts (respectively, 89.5, 36.4 and 48.3%, P < 10-4). Moreover, the hierarchical categorization of the three best blastocysts between iDAScore and the embryologists was as follow: 1st rank: 71.9%; 2nd rank: 61.6%; 3rd rank: 56.8% (P=0.07). One hundred and fifty-one blastocysts with known implantation data were analyzed. The iDAScore of blastocysts that implanted was significantly higher than those that did not implant (implantation+: 9.10±0.57; implantation-: 8.70±0.95, P=0.003).

CONCLUSION

This preliminary study shows that iDAScore is able to perform a reproducible, reliable and immediate hierarchical classification of blastocysts. Moreover, this tool can identify the blastocysts with the highest implantation potential. If these results confirmed on a larger scale of embryos and patients, IA could revolutionize IVF laboratories by standardizing embryo hierarchical selection.

Cardiopulmonary Exercise Testing in Oesophagogastric Surgery: a Systematic Review

BACKGROUND

Cardiopulmonary exercise testing (CPX) can objectively measure fitness and oxygen uptake at anaerobic threshold. The relationship between fitness and postoperative outcomes after upper gastro-intestinal surgery is unclear. The aim of the present review is to assess the prognostic ability of CPX in predicting postoperative outcome associated with oesophagogastric surgery.

METHODS

Relevant studies were identified through a systematic search of EMBASE, Medline, CINAHL, Cochrane Library, and Web of Science to July 2019. The eligibility criteria for studies included prognostic studies of upper gastro-intestinal surgery among adult populations using a preoperative CPX and measurement of postoperative outcome (mortality or morbidity or length of stay). Risk of bias was assessed using the QUIPS Quality in Prognostic Studies validated tool.

RESULTS

Thirteen papers with a total of 1735 participants were included in data extraction. A total of 7 studies examined the association between CPX variables and postoperative mortality. Patients undergoing gastro-intestinal surgery with lower anaerobic threshold values were found to have an increased risk of postoperative mortality. Similarly, a lower rate of oxygen consumption was found to be associated with higher mortality. There was conflicting evidence regarding the association between CPX variables and postoperative morbidity. The evidence did not demonstrate any association between preoperative CPX variables and hospital length of stay.

CONCLUSION

Studies report an association between CPX variables and postoperative mortality; however, there is conflicting evidence regarding the association between CPX variables and postoperative morbidity.

Measuring the impact of oesophagectomy on physical functioning and physical activity participation: a prospective study

BACKGROUND

Oesophagectomy remains the only curative intervention for oesophageal cancer, with defined nutritional and health-related quality of life (HR-QOL) consequences. It follows therefore that there is a significant risk of decline in physical wellbeing with oesophagectomy however this has been inadequately quantified. This study prospectively examines change in physical functioning and habitual physical activity participation, from pre-surgery through 6-months post-oesophagectomy.

METHODS

Patients scheduled for oesophagectomy with curative intent were recruited. Key domains of physical functioning including exercise tolerance (six-minute walk test (6MWT)) and muscle strength (hand-grip strength), and habitual physical activity participation, including sedentary behaviour (accelerometry) were measured pre-surgery (T0) and repeated at 1-month (T1) and 6-months (T2) post-surgery. HR-QOL was measured using the EORTC-QOL C30.

RESULTS

Thirty-six participants were studied (mean age 62.4 (8.8) years, n = 26 male, n = 26 transthoracic oesophagectomy). Mean 6MWT distance decreased significantly from T0 to T1 (p = 0.006) and returned to T0 levels between T1 and T2 (p < 0.001). Percentage time spent sedentary increased throughout recovery (p < 0.001) and remained significantly higher at T2 in comparison to T0 (p = 0.003). In contrast, percentage time spent engaged in either light or moderate-to-vigorous intensity activity, all reduced significantly (p < 0.001 for both) and remained significantly lower at T2 in comparison to T0 (p = 0.009 and p = 0.01 respectively). Patients reported deficits in multiple domains of HR-QOL during recovery including global health status (p = 0.04), physical functioning (p < 0.001) and role functioning (p < 0.001). Role functioning remained a clinically important 33-points lower than pre-operative values at T2.

CONCLUSION

Habitual physical activity participation remains significantly impaired at 6-months post-oesophagectomy. Physical activity is a measurable and modifiable target for physical rehabilitation, which is closely aligned with patient-reported deficits in role functioning. Rehabilitation aimed at optimising physical health in oesophageal cancer survivorship is warranted.

A randomized controlled trial protocol assessing the effectiveness, safety and cost-effectiveness of methotrexate vs. ciclosporin in the treatment of severe atopic eczema in children: the TREatment of severe Atopic eczema Trial (TREAT)

BACKGROUND

Oral systemic immunomodulatory medication is regularly used off-licence in children with severe atopic eczema. However, there is no firm evidence regarding the effectiveness, safety, cost-effectiveness and impact on quality of life from an adequately powered randomized controlled trial (RCT) using systemic medication in children.

OBJECTIVES

To assess whether there is a difference in the speed of onset, effectiveness, side-effect profile and reduction in flares post-treatment between ciclosporin (CyA) and methotrexate (MTX), and also the cost-effectiveness of the drugs. Treatment impact on quality of life will also be examined in addition to whether FLG genotype influences treatment response. In addition, the trial studies the immune-metabolic effects of CyA and MTX.

METHODS

Multicentre, parallel group, assessor-blind, pragmatic RCT of 36 weeks' duration with a 24-week follow-up period. In total, 102 children aged 2-16 years with moderate-to-severe atopic eczema, unresponsive to topical treatment will be randomized (1 : 1) to receive MTX (0·4 mg kg^-1 per week) or CyA (4 mg kg^-1 per day).

RESULTS

The trial has two primary outcomes: change from baseline to 12 weeks in Objective Severity Scoring of Atopic Dermatitis (o-SCORAD) and time to first significant flare following treatment cessation.

CONCLUSIONS

This trial addresses important therapeutic questions, highlighted in systematic reviews and treatment guidelines for atopic eczema. The trial design is pragmatic to reflect current clinical practice.

Cellular discrimination using in vitro Raman micro spectroscopy: the role of the nucleolus

Raman micro spectroscopy is employed to discriminate between cell lines. Results show the importance of the nuclear sub-cellular organelle, the nucleoli, to differentiate between cancer cell lines with high specificity and sensitivity.

Optimisation of vasculitis disease assessments in clinical trials, clinical care and long-term databases

The systemic vasculitides are a group of rare, chronic, relapsing, but often progressive inflammatory conditions. They are associated with a significant burden of morbidity both due to scarring from the disease itself and as a consequence of treatment with glucocorticoids and other potent immunosuppressive agents. Careful assessment of disease activity is critical to guide appropriate use of these potentially toxic therapies. It is also important to differentiate features of active disease from those attributable to damage, which will not respond to immunosuppression. As these are chronic complex conditions, the impact on a patient's functional ability and quality of life are also important considerations. Given the lack of a reliable biomarker for assessment of disease activity or damage in systemic vasculitis, clinical tools developed and validated for use initially in clinically trials are key outcome measures in the evaluation of these patients. While the conduct of randomised clinical trials in vasculitis has been significantly enhanced by the development and use of validated outcome measures, regular use of validated disease activity and damage measurements as part of routine care offers a structured approach, which can serve as the basis of justifying treatment decisions. The authors review the concepts of clinical assessment tools used in the evaluation of patients with systemic vasculitis in the setting of clinical practice, clinical trials and long term databases with particular emphasis on disease activity, damage, prognosis and function.

Weekend operating room on call staffing requirements

This article describes a statistical method used to determine the minimum number of OR teams that should be on call for urgent procedures, in-house versus on standby from home, to minimize labor costs. The OR manager obtains the number of ORs staffed at each hour of the 24-hour period of interest (e.g., 7 AM Saturday to 7 AM Sunday) from the surgical suite's information system. The minimum number of total staffed hours needed to care for patients is calculated for a prespecified level of the acceptable risk of inadequate staffing. A method used to determine whether each staff member should work in-house or on standby from home then is introduced. This method enumerates all possible combinations of shifts to find the one with the lowest cost, and it ensures a prespecified service level. An example based on 248 weeks of data collected from a large surgical suite is presented, and staffing for emergency procedures is reviewed.

Complications of treatment with local field external beam radiotherapy for localized prostate cancer

We performed this analysis to document the rate and severity of complications both during and after local field irradiation for localized prostate cancer and to assess the influence of three-dimensional conformal radiation therapy (3DCRT) on these complications. Bowel, urinary and cutaneous toxicities were noted in all patients treated with primary radiotherapy (RT) for prostate cancer using Radiation Therapy Oncology Group/European Organization for Research on Treatment of Cancer scores. Evaluations were performed weekly during RT, 6 weeks after RT and 3 monthly thereafter. Data on 111 were analysed. We also compared the complications of conventional and 3DCRT. The serious complication rates identified in this study compare favourably with those reported in the literature. Only 3.6%, 0.8% and 0% had acute grade 3 or 4 urinary, bowel or skin reactions respectively. Only two patients had chronic grade 3 or 4 urinary complications. Thus far no patients have developed chronic bowel or skin complications greater than grade 2. Despite dose escalation from 66 Gy to 70 Gy (with 3DCRT), there was a trend towards reduced toxicity when 3DCRT was compared with conventional radiation. RT is a well-tolerated treatment for early stage carcinoma of the prostate and our complication rates are compatible with international experiences. Further follow-up is required to determine the efficacy of treatment, the incidence of impotence and the final number of late complications.

An MRP system for surgical linen management at a large hospital

Materials Requirements Planning (MRP) has been used extensively in manufacturing and other industries to improve on-time delivery and to reduce costs. In this paper, we illustrate how an MRP-type system was developed to monitor surgical linen at a large teaching hospital. We also describe a bar-code scanning 'tag and recapture' study to estimate total inventory. The hospital implemented several changes based upon our recommendations that resulted in time savings and a smoother flow of materials throughout the surgical linen supply chain.

Relationship between DNA methylation, histone H4 acetylation and gene expression in the mouse imprinted Igf2-H19 domain

DNA methylation and histone H4 acetylation play a role in gene regulation by modulating the structure of the chromatin. Recently, these two epigenetic modifications have dynamically and physically been linked. Evidence suggests that both modifications are involved in regulating imprinted genes - a subset of genes whose expression depends on their parental origin. Using immunoprecipitation assays, we investigate the relationship between DNA methylation, histone H4 acetylation and gene expression in the well-characterised imprinted Igf2-H19 domain on mouse chromosome 7. A systematic regional analysis of the acetylation status of the domain shows that parental-specific differences in acetylation of the core histone H4 are present in the promoter regions of both Igf2 and H19 genes, with the expressed alleles being more acetylated than the silent alleles. A correlation between DNA methylation, histone hypoacetylation and gene repression is evident only at the promoter region of the H19 gene. Treatment with trichostatin A, a specific inhibitor of histone deacetylase, reduces the expression of the active maternal H19 allele and this can be correlated with regional changes in acetylation within the upstream regulatory domain. The data suggest that histone H4 acetylation and DNA methylation have distinct functions on the maternal and paternal Igf2-H19 domains.

Modulation of innate and acquired immune responses by Escherichia coli heat-labile toxin: distinct pro- and anti-inflammatory effects of the nontoxic AB complex and the enzyme activity

We have examined the roles of enzyme activity and the nontoxic AB complex of heat-labile toxin (LT) from Escherichia coli on its adjuvant and immunomodulatory properties. LTK63, an LT mutant that is completely devoid of enzyme activity, enhanced Th1 responses to coinjected Ags at low adjuvant dose. In contrast, LTR72, a partially detoxified mutant, enhanced Th2 responses and when administered intranasally to mice before infection with Bordetella pertussis suppressed Th1 responses and delayed bacterial clearance from the lungs. LTR72 or wild-type LT inhibited Ag-induced IFN-gamma production by Th1 cells, and LT enhanced IL-5 production by Th2 cells in vitro. Each of the toxins enhanced B7-1 expression on macrophages, but enhancement of B7-2 expression was dependent on enzyme activity. We also observed distinct effects of the nontoxic AB complex and enzyme activity on inflammatory cytokine production. LT and LTR72 suppressed LPS and IFN-gamma induced TNF-alpha and IL-12 production, but enhanced IL-10 secretion by macrophages in vitro and suppressed IL-12 production in vivo in a murine model of LPS-induced shock. In contrast, LTK63 augmented the production of IL-12 and TNF-alpha. Furthermore, LTK63 enhanced NF-kappaB translocation, whereas low doses of LTR72 or LT failed to activate NF-kappaB, but stimulated cAMP production. Thus, E. coli LT appears to be capable of suppressing Th1 responses and enhancing Th2 responses through the modulatory effects of enzyme activity on NF-kappaB activation and IL-12 production. In contrast, the nontoxic AB complex can stimulate acquired immune responses by activating components of the innate immune system.

The Toll/interleukin-1 receptor domain: a molecular switch for inflammation and host defence

The pro-inflammatory cytokine interleukin-1 (IL-1) signals via the Type-I IL-1 receptor (IL-1RI), inducing an increase in the expression of many genes with roles in immunity and inflammation. The signalling pathways involve two adapter proteins, MyD88 and Tollip, which via two IL-1 receptor-associated kinases (IRAK and IRAK-2) activate transcription factors such as nuclear factor-kappa B and protein kinases such as p38 mitogen-activated protein kinase. A role for the low-molecular-mass G-proteins Rac, Ras and Rap in these processes has also been indicated. IL-1RI is the founder of a diverse superfamily of receptors, which all share a cytosolic domain, termed the Toll/IL-1 receptor (TIR) domain. The superfamily can be divided broadly into three subgroups. The first of these is most similar to IL-1RI and includes the receptor for IL-18 and the Th2 cell regulator T1/ST2. The second subgroup is most similar to the Drosophila melanagaster protein Toll and includes Toll-like receptor 2 (TLR2), which is required for host defence against Gram-positive bacteria and fungi, and TLR4, which is required for lipopolysaccharide responsiveness, and thus is involved in host defence against Gram-negative bacteria. There are also a number of TLRs in plants and insects, all involved in host defence. The third subgroup contains non-receptor proteins which possess a TIR domain and are cytosolic. MyD88 is a member, and it presumably complexes with IL-1RI via a TIR-TIR interaction. The other two members are proteins encoded by the vaccinia virus, A46R and A52R, which block TIR-dependent signalling. This receptor superfamily therefore appears to play a central role in inflammation and host defence against infection, pointing to the TIR domain as a critical molecular player in the innate immune response.

Surgeon characteristics associated with mortality and morbidity following carotid endarterectomy

PURPOSE

To identify surgeon characteristics associated with mortality or morbidity, following carotid endarterectomy (CEA).

METHODS

Data on all inpatient discharges from the 284 nonfederal Pennsylvania hospitals were obtained from the Pennsylvania Health Care Cost Containment Council for the period from 1994 to 1995. Physician data were obtained from the Physicians List of the American Medical Association, including name, gender, specialty, year of birth, board certified, and year of licensure. Cases were selected if any of six procedures codes were ICD-9-CM rubric 38.12, indicating CEA.

RESULTS

Among the 12,725 cases studied, in-hospital mortality was 0.7%, nonfatal morbidity was 3.0%, and the total bad outcome rate was 3.7%. Surgeons who performed 1 to 2 CEAs over 2 years had the highest mortality (2.0%) and total bad outcome (9.2%) rates. For surgeons performing three or more cases in 2 years, increased volume was not associated with better outcomes. A greater number of years since the surgeon was licensed was associated with greater mortality (p = 0.001), but not with morbidity or bad outcome rates. In regression analyses that adjusted for patient risk, both years since licensure and specialty predicted surgical mortality rate, but only volume predicted surgical bad outcome rate.

CONCLUSIONS

More years since licensure and very low patient volume are associated with worse patient outcomes following CEA.

Change in cervical length after cerclage as a predictor of preterm delivery

OBJECTIVE

To determine whether the degree of cervical lengthening after cerclage and whether serial follow-up measurements of cervical length after cerclage are predictive of pregnancy outcome.

METHODS

Eighty women whose primary physician determined that a prophylactic (n = 50) or urgent cerclage (n = 30) was indicated had transvaginal ultrasonographic evaluation before and after cerclage. Thereafter, most women had three additional transvaginal ultrasound examinations until 32 weeks' gestation. At each examination, the mean of three measurements was calculated. Statistical analyses were done by t test, analysis of variance, and logistic regression, with significance set at P <.05.

RESULTS

The mean +/- standard deviation precerclage cervical length was 27.2 +/- 10.3 mm and after cerclage was 34.1 +/- 9.9 mm (n = 80, P <.001, paired t test). No significant association was found (r = -0.26) between the difference in cervical length (postcerclage - precerclage lengths) and pregnancy outcome. Patients with a prophylactic cerclage had a mean cervical length that was consistently longer in patients delivering at term compared with those who delivered preterm at 20 to 32 weeks' gestation. In the urgent cerclage group a significant difference in cervical length between those who delivered at term compared with preterm was evident only at 28 to 32 weeks.

CONCLUSION

The increase in cervical length after cerclage is not predictive of term delivery. Serial cervical length measurements in the late second or early third trimester predict preterm birth but could provide earlier warning in patients with a prophylactic cerclage than in patients with urgent cerclage.

Activated protein C inhibits lipopolysaccharide-induced nuclear translocation of nuclear factor kappaB (NF-kappaB) and tumour necrosis factor alpha (TNF-alpha) production in the THP-1 monocytic cell line

Activated protein C (APC) protects against sepsis in animal models and inhibits the lipopolysacharide (LPS)-induced elaboration of proinflammatory cytokines from monocytes. The molecular mechanism responsible for this property is unknown. We assessed the effect of APC on LPS-induced tumour necrosis factor alpha (TNF-alpha) production and on the activation of the central proinflammatory transcription factor nuclear factor-kappaB (NF-kappaB) in a THP-1 cell line. Cells were preincubated with varying concentrations of APC (200 microg/ml, 100 microg/ml and 20 microg/ml) before addition of LPS (100 ng/ml and 10 microg/ml). APC inhibited LPS-induced production of TNF-alpha both in the presence and absence of fetal calf serum (FCS), although the effect was less marked with 10% FCS. APC also inhibited LPS-induced activation of NF-kappaB, with APC (200 microg/ml) abolishing the effect of LPS (100 ng/ml). The ability of APC to inhibit LPS-induced translocation of NF-kappaB is likely to be a significant event given the critical role of the latter in the host inflammatory response.