A community engagement training program for basic and translational cancer researchers

PURPOSE

There is an increasing awareness of the importance of patient engagement in cancer research, but many basic and translational researchers have never been trained to do so. To address this unmet need, a 1-year patient engagement training program for researchers was developed.

METHODS

Eleven researchers and eleven paired research advocates participated. This program, designed for virtual delivery, included 3 didactic modules focused on (1) Community Outreach and Engagement principles and methods, (2) Communication skills, and (3) Team Science. This was followed by longitudinal projects to be completed by the researcher/advocate pairs, including learning about the research project, and co-authoring abstracts, manuscripts and grant proposals. Monthly group meetings allowed pairs to share their experiences. The program culminated in the pairs creating and presenting oral abstracts for the University of Kansas Cancer Center's Annual Research Symposium.

RESULTS

All participants indicated that the modules had a positive impact on their ability to collaborate in research. Both researcher self-evaluations and patient advocate evaluations of their researcher partner showed an improvement in researcher communication competency. Results from the Patient Engagement in Research Scale showed that advocates were highly engaged. Within 1 year after program completion, participating pairs have completed four abstracts and 9 grant proposals.

CONCLUSION

The program will be modified based on participant feedback, and can be adapted for future cohorts if an increased number of sessions per month and shortened program duration are desired. The program's virtual format allows scalability across institutions to potentially benefit large cohorts of researchers.

EMBRACING GENDER DIVERSITY: REIMAGINING HEALTH AND HEALTH EQUITY FOR TRANSGENDER OLDER ADULTS

This presentation will share results of in-depth focus groups exploring eight transgender older adults’ (TOAs) experiences of health and healthcare and related themes, explain weathering and factors contributing to health and healthcare disparities, and apply the Sexual and Gender Minority Health Disparities Research Framework to explore strategies to address individual, interpersonal, community, and societal factors to foster health and health equity. TOAs represent an underserved population at elevated risk for lower socioeconomic status, higher rates of disability and chronic illness, and poorer overall physical and mental health compared to their non-transgender LGBQ and cisgender peers. Due to their unique life experiences including difficult decisions about “coming out” and transitioning, lack of acceptance of being transgender, and physiological impacts of hormonal and surgical treatments, transgender individuals experience long-term chronic stress and accumulate health-related risks as they age, contributing to significant health disparities. Higher levels of illness, disability, and premature death among historically disadvantaged groups can be explained by weathering, the accumulated impact of social disadvantages and socio-political inequalities over the life course producing premature biological aging. A 2019 systematic review of LGBTQ aging literature found that only 10% of studies included trans-identified participants and few addressed the needs of transgender older adults. Understanding the lived experiences of TOAs including healthcare access and receipt, and psychological, social, and financial experiences across the life course, is crucial to understanding current disparities in health and healthcare, developing strategies to improve care and reduce inequities, and fostering health and health equity of transgender older adults.

Strengths-Based Interprofessional Practice and Education: Transforming Care Through Disruption

In December 2020 we began conducting phone interviews with Veterans, and their caregivers, receiving care through the United Sates (US) Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) program. Our goal was to describe experiences of Veterans and caregivers managing changes in care delivery related to the COVID-19 pandemic and navigating increased social isolation due to social distancing. We interviewed 38 Veterans (average age 78) and caregivers (average age 62) across seven VA HBPC programs. Findings showed those living in their own homes found increased isolation more manageable than those living in assisted living facilities, which restricted visitors. Caregivers had a harder time managing isolation than Veterans, as Veterans were used to being primarily homebound. Veterans and caregivers relied on increased phone communication with their HBPC teams, with some began participating in virtual visits. Implications include insights into better supporting older, homebound adults and their caregivers during disasters.

Oral Health Status and Oral Health-Related Quality of Life of First Nations and Metis Children

Objectives:

To assess the oral health status and oral health–related quality of life (OHRQoL) of young First Nations and Metis children.

Methods:

This cross-sectional study assessed the oral health status of Indigenous children <72 mo of age while their parents/caregivers completed a questionnaire, including the Early Childhood Oral Health Impact Scale (ECOHIS), to assess OHRQoL. Analysis included descriptive statistics, bivariate analyses, and multiple regression. A P value ≤0.05 was considered significant.

Results:

Overall, 146 children were recruited with a mean age of 40.1 ± 21.2 (SD) months, and 49% were male. Among First Nations children, 65.4% had early childhood caries (ECC) as compared with 45.2% among Metis children (P = 0.025). However, there was no statistically significant difference in the prevalence of severe ECC (S-ECC) between First Nations and Metis children (60.6% v. 42.9%, P = 0.051). The mean decayed, missing, and filled primary teeth (dmft) score was 4.9 ± 5.3 (range 0–20), and the mean decayed, missing, and filled surfaces (dmfs) score was 14.5 ± 20.4 (range 0–80). The total mean ECOHIS score was 4.4 ± 5.9 (range 0–25), while the mean Child Impact Section and Family Impact Section scores were 2.6 ± 4.0 (range 0–10) and 1.8 ± 2.8 (range 0–8), respectively. Multiple linear regression showed S-ECC was associated with total mean ECOHIS scores (P = 0.02). Higher total mean ECOHIS scores (which indicates poorer OHRQoL) were observed in children with ECC compared with caries-free children (5.8 v. 2.4, P = 0.0001).

Conclusion:

Oral health disparities such as ECC and reduced OHRQoL exist among many First Nations and Metis children in Manitoba. This is the first Canadian study exploring the OHRQoL of Indigenous children in addition to their oral health status.

Knowledge Transfer Statement:

This study is the first to report on the oral health–related quality of life and its relationship to early childhood caries (ECC) among young Canadian First Nations and Metis children. Metis children are just as likely to suffer from severe ECC than First Nations children. The findings of this study have informed community-based and community-developed oral health promotion and ECC prevention activities.

Why Arts Matter to People and Families Living With Dementia: Interprofessional Health Humanities Collaboration

This presentation will share examples of arts-based and creative interventions serving people and their families living with dementia representing evidence-based and promising practices in the United States. Such interventions offer effective non-pharmacological approaches to dementia care including use of the visual arts (e.g., drawings, paintings, sculpture) and performing arts (e.g., music, theatre); literature and writing including reminiscence, biographical approaches, and life story work; photography and Photovoice; and dance and movement as intervention modalities. Current evidence will be presented that demonstrates the effectiveness of arts-based interventions as a form of psycho-social and self-care to alleviate the effects of dementia and enhance the quality of life. Recommendations for future research will be discussed. Strategies will be proposed to develop interprofessional health humanities networks between universities, healthcare systems, libraries, museums, and the arts community to collaborate on the creation of arts-based programs in communities currently without the benefit of such programs.

Location and Setting of the Mars InSight Lander, Instruments, and Landing Site

Knowing precisely where a spacecraft lands on Mars is important for understanding the regional and local context, setting, and the offset between the inertial and cartographic frames. For the InSight spacecraft, the payload of geophysical and environmental sensors also particularly benefits from knowing exactly where the instruments are located. A ~30 cm/pixel image acquired from orbit after landing clearly resolves the lander and the large circular solar panels. This image was carefully georeferenced to a hierarchically generated and coregistered set of decreasing resolution orthoimages and digital elevation models to the established positive east, planetocentric coordinate system. The lander is located at 4.502384°N, 135.623447°E at an elevation of -2,613.426 m with respect to the geoid in Elysium Planitia. Instrument locations (and the magnetometer orientation) are derived by transforming from Instrument Deployment Arm, spacecraft mechanical, and site frames into the cartographic frame. A viewshed created from 1.5 m above the lander and the high-resolution orbital digital elevation model shows the lander is on a shallow regional slope down to the east that reveals crater rims on the east horizon ~400 m and 2.4 km away. A slope up to the north limits the horizon to about 50 m away where three rocks and an eolian bedform are visible on the rim of a degraded crater rim. Azimuths to rocks and craters identified in both surface panoramas and high-resolution orbital images reveal that north in the site frame and the cartographic frame are the same (within 1°).

STRENGTH IN AGE-FRIENDLY HEALTH SYSTEMS: AN INNOVATIVE INTEGRATED INTERPROFESSIONAL MODEL

This paper presents an innovative conceptual approach to health care policy for older adults: the Age-Friendly Health Systems Integrated Interprofessional Model. In 2017, the John A. Hartford Foundation and Institute for Healthcare Improvement, in partnership with the American Hospital Association and Catholic Health Association of the United States, advanced the concept of an Age-Friendly Health System. This initiative is designed to respond to the needs of a burgeoning U.S. older adult population, expected to double from 2012 to 2050, largely due to the aging of Baby Boomers and increased life expectancy. These Baby Boomers will demand a well-coordinated, communicative health system responsive to their values and preferences. In an Age-Friendly Health System, all older adults receive the best possible care, without care-related harms, and with satisfaction of care received. Essential elements include what matters, mentation, mobility, and medications, with a focus on patient-directed, family-engaged care. While a solid framework for improving healthcare for older adults, this model is further strengthened by incorporating the essential elements of person-, family-, and community-centered approaches to care; interprofessional team-based competencies, and Quadruple Aim outcomes. This enhanced model, referred to as the Age-Friendly Health System Integrated Interprofessional Model, combines elements essential to quality healthcare within the framework of an Age-Friendly Health System. This paper will present the original Age-Friendly Health System framework, the proposed Age-Friendly Health System Integrated Interprofessional Model, then compare and contrast each model’s essential principles. Implications for adoption of this enhanced model for policy, education, and practice will be explored.

Two case reports of zoledronic acid-induced uveitis

Zoledronic acid (zoledronate) is a bisphosphonate used predominantly as a second-line treatment for post-menopausal osteoporosis. Its administration is associated with an acute phase reaction. Here, we present two cases of anterior uveitis following initial administration of zoledronate. In the first case, an 80-year-old lady presented with right eye pain and decreased visual acuity 24-hours post-infusion. Uveitis was diagnosed and sub-conjunctival injection of corticosteroids was required. In the second case, a 78-year-old lady presented with right eye pain, vomiting and decreased acuity 24-hours after infusion. She was treated with topical steroids and required cataract surgery to normalise visual acuity. Patients prescribed zoledronate should be warned of the risk of ocular side effects and asked to report promptly for treatment if they develop a red, painful eye or blurred vision.

Anaesthesia: what a surgeon needs to know

Surgeons and anaesthetists work closely together, sometimes in challenging circumstances. To help surgeons cooperate with anaesthetists to deliver high quality care for patients, a working knowledge of modern anaesthetic practice is useful. The specialty of anaesthetics is developing rapidly, and periodic updating of this knowledge is likely to be required. This article provides an update of anaesthetic practice for surgeons, covering the varied roles of anaesthetists, preoperative assessment, management on the day of surgery (induction, maintenance and reversal of anaesthetic), general anaesthesia, the role of regional blocks and sedation. It also discusses safety issues, the management of frail patients and future challenges.

Investigation of the efficacy and tolerability of Dr Michaels® (also branded as Eczitinex® and Itchinex Eczitinex®) topical products in the treatment of atopic dermatitis in children

Atopic eczema is a chronic relapsing inflammatory skin disorder, characterized clinically by intensely pruritic eczematous skin lesions and a defective epidermal barrier. It affects more than 15% of children and up to 10%of adults, which makes the disease a social health problem still without a challenging treatment. The aim of this study was to evaluate the efficacy and tolerability of Dr Michaels® (Eczitinex®) topical product family in the treatment of atopic dermatitis in children. We studied a group of 30 patients (17 female, 13 male), aged 5 to 13 (mean age: 9), affected by atopic dermatitis since they were newborn. All patients had been unsuccessfully treated with conventional anti-inflammatory therapies and ceased treatment 2 weeks before commencing research. The patients were treated with Dr Michaels® (Eczitinex® and Itchinex®) product family including a moisturising bar, topical ointment and PSC 900 oral herbal formulation. The treatment was evaluated clinically and photographically at 0, 1, 2, 4, 6, 8, 10, 12, and 14 weeks. Twenty-eight patients showed a significant improvement of cutaneous rashes and pruritus on the first week of treatment, with a complete remission at 10-12 weeks. Only two patients, brother and sister respectively, showed a slow response to treatment and reported an increasing itching. Following 14 weeks of treatment with the Dr Michaels® (Eczitinex® and Itchinex®) product family, patients demonstrated complete resolution of their AD. All patients showed a marked improvement in their condition within 3 days of treatment with most of the lesions and symptoms totally resolved within 10 to 12 weeks of treatment with Dr Michaels® (Eczitinex® and Itchinex®) family of products. This clinical report highlights that the Dr Michaels® (Eczitinex® and Itchinex®) product family is a safe and effective treatment option for AD.

Successful treatment of mild to moderate acne vulgaris with Dr Michaels® (also branded as Zitinex®) topical products family: a clinical trial

Acne vulgaris is an epidemic inflammatory skin disease of multi-factorial origin, frequently seen in adolescents and often persisting or occurring through to adulthood. Acne vulgaris is a nearly universal skin disease afflicting 79-95% of the adolescent population in westernized societies and is a significant cause of psychological morbidity in affected patients. Despite the various treatment options available for acne, there is still a need for a safe and effective option. The aim of the study was to investigate the efficacy and tolerability of Dr Michaels® (Zitinex®) product family in the treatment of papulo-pustular acne. 25 patients (17 female/8 male), aged 15-22, with a mild to moderate papulo-pustular acne, localized on the face and on the trunk, were included in this study. None of the patients had used any other kind of treatment in the 3 months prior to commencing this study. All of the patients were treated with Dr Michaels® (Zitinex®) facial exfoliating cleanser, activator formula, a cream, PSC 200 and PSC 900 oral supplements. Application time of Dr Michaels® (Zitinex®) products was 12 weeks. The treatment was been evaluated clinically at 0, 4, 8 and 12 weeks. All of the patients showed an improvement in all parameters of their acne (comedones, papules, pustules, hyperpigmentation and scars). The acne lesions and erythema had mostly resolved. The hyperpigmentation and pitted scarring had significantly reduced also, with the skin appearing smoother. The treatment was well tolerated and no side effects have been described. Our study demonstrates that the Dr Michaels® (Zitinex®) facial exfoliating cleanser, activator formula, cream and oral supplements PSC 200 and PSC 900 are an effective therapeutic option for the treatment of moderately severe acne vulgaris. Moreover, it highlights the safety profile of the Dr Michaels® (Zitinex®) product family in a case of acne compared to traditional first-line treatments.

Successful treatment of recalcitrant candidal intertrigo with Dr Michaels® (Fungatinex®) product family

Candidal intertrigo is an infection of the skin caused by Candida albicans that typically occurs in opposing cutaneous or muco-cutaneous surfaces. Because Candidiasis requires a damaged and moist environment for infection, it typically occurs in areas of friction such as the skin folds of the body. Candidal intertrigo is often difficult to treat and results are often unsatisfactory. In addition, there is a lack of evidence-based literature supporting prevention and treatments for candidal intertrigo. The aim of the study was to evaluate the efficacy of Dr Michaels® (also branded as Fungatinex®) products in the treatment of fungal intertrigo, in 20 women and 2 men with a mean age of 72. Five patients (3 female and 2 male) had type 2 diabetes and 16 (14 female and 2 male) were obese. The patients were treated with Dr Michaels® (Fungatinex®) moisturising bar, topical ointment (twice daily application) and oral herbal formulation, PSC 200 two tablets twice daily with food. After 2 weeks of treatment, the lesions had mostly resolved in all patients with only slight erythema evident. After six weeks of treatment using the moisturising bar, topical ointment and oral herbal formulations from the Dr Michaels® (Fungatinex®) product family, the lesions had totally resolved in 18 patients, while 4 patients had to continue the therapeutic protocol for another 2 weeks. Our results demonstrate that the Dr Michaels® (Fungatinex®) complementary product family is efficacious in the treatment of recalcitrant candidal intertrigo. Furthermore, this study highlights that the Dr Michaels® (Fungatinex®) product family is fast-acting and well tolerated with no serious adverse events reported. These data have important implications for resistant cases of candidal intertrigo where traditional therapies have failed.

The use of immunosuppressive agents in the management of recalcitrant lower limb ulcers

OBJECTIVE

Lower limb ulcers that are resistant to standard forms of treatment place a significant burden on both patients and health services. There is no widely agreed definition of a recalcitrant ulcer but failure to heal following 6-12 months of focused treatment would identify a small group of patients with highly resistant ulceration. We describe a series of patients with recalcitrant ulceration for which immunosuppressive agents have been used.

METHODS

This is a case series of 13 patients who underwent immunomodulation therapy for lower limb ulcers at a tertiary referral university hospital. Regimens of immunomodulation used mainly ciclosporin and/or cyclophosphamide, with concurrent antibiotic therapy. Case notes and computer systems were analysed by two reviewers. A patient was deemed to have a success if their ulcer fully healed while on immunomodulation therapy.

RESULTS

Over a period of eight years, from 2004-2012, 13 patients underwent immunomodulation therapy. Among these patients there were 18 ulcerated limbs. Ulcer healing occurred in 10 limbs out of 18 (55.6%) and full healing occurred in six patients (46.2%). Ulcers were present for a median of five years (range 2-40 years), with a median diameter of 7.5 cm (range 4-18 cm) before treatment.

CONCLUSION

Treatment of truly recalcitrant ulceration can be very frustrating for both the patient and physician, with poor success from more standard forms of treatment. We report experience with immunomodulation therapy that suggests there may be benefit from using this treatment in a subset of patients with this debilitating disease.

The application of humane slaughterhouse practices to large-scale culling

Mass culling is a strategy used inthe management of infectious disease outbreaks. The risk of disease spread due to animal transportation often precludes the use of slaughterhouses for this purpose, though they have been used on occasion. Consequently, culling takes place in the less-than-standardised environment on the farm. Regardless of where the cull occurs, the methods chosen to handle and kill the animals must preserve their welfare. This paper attempts to apply the best welfare practices from the controlled environment of the slaughterhouse to the mass culling of ruminants, pigs and poultry. It investigates the key welfare challenges and identifies astute planning executed by competent personnel as a crucial success factor. The urgency; capacity; species, type and age of the animal; personnel; and availability of equipment determine the restraint and killing methods used. The use of good on-farm restraining facilities and mobile killing devices can reasonably be expected to maintain welfare standards for ruminants and poultry. The pig's anatomy, natural behaviour, wide age range and housing types present additional challenges. Objective monitoring throughout the operation is vital for implementing immediate corrective measures whilst also informing procedural reviews. The authors suggest a monitoring tool based on a system currently used in abattoirs, but its limitations must first be validated.

DNA methylation of membrane-bound tyrosine phosphatase genes in acute lymphoblastic leukaemia

Aberrant DNA promoter methylation with associated gene silencing is a common epigenetic abnormality in acute lymphoblastic leukaemia (ALL) and is associated with poor survival. We have identified a family of transmembrane tyrosine phosphatase proteins as targets of hypermethylation in ALL and high-grade B cell lymphoma and demonstrated that this abnormal methylation correlates with transcript expression. PTPRG was methylated in 63% of ALL samples, PTPRK in 47%, PTPRM in 64% and PTPRO in 54% of cases, with most ALL samples containing methylation at multiple phosphatase loci. PTPRK promoter methylation was associated with a decreased overall survival in the cohort. Restoration of PTPRK transcript levels in leukaemia cells, where phosphatase transcript was silenced, reduced cell proliferation, inhibited colony formation and increased sensitivity to cytotoxic chemotherapy. These biological changes were associated with a reduction in levels of phosphorylated Erk1/2, Akt, STAT3 and STAT5 suggesting functional phosphatase activity after transcript re-expression. Methylation of the phosphatase promoters was reversible with decitabine and a histone deacetylase inhibitor, suggesting that PTPRK-mediated cell signalling pathways may be targeted with epigenetic therapies in lymphoid malignancy.

Instrumental activity of daily living limitations and supports in a clinic population of low-income Puerto Rican elderly adults with chronic diseases

Latino older adults in the United States have disproportionately high rates of chronic and disabling medical conditions. Puerto Ricans have a higher prevalence of several chronic medical conditions and higher rates of functional disability than other Latinos. Earlier studies have documented that Puerto Rican older adults traditionally have relied mostly on family members for assistance with their functional needs, with low use of formal support services, but little is known about their functional help needs and caregiving practices. This study examined independent living and caregiving practices of community-dwelling Puerto Rican older adults in western New York using a mixed-methods approach with a sample of 49 individuals attending an inner-city primary care clinic. Standard instruments were used to obtain information on socioeconomic and health status and functional ability. Forty participants who needed help with any instrumental activities of daily living (IADLs) were probed qualitatively for how their needs were addressed. Participants averaged six chronic medical conditions, mean age was 76.2 ± 5.3, most reported annual household income of $15,000 or less and had low fluency in English, and all had healthcare insurance. For the most part, participants' children and spouses were primary caregivers, and few used formal support services. Nearly one-third reported having insufficient help. Qualitative findings elucidated how IADL needs were addressed. In this sample of indigent Puerto Rican older adults, most needed help with IADLs. Although family members most often helped, one-third had unmet or undermet needs. Linguistically and culturally congruent formal support services are still needed for Puerto Rican older adults and their family caregivers.

Epitaxial growth of visible to infra-red transparent conducting In2O3 nanodot dispersions and reversible charge storage as a Li-ion battery anode

Unique bimodal distributions of single crystal epitaxially grown In2O3 nanodots on silicon are shown to have excellent IR transparency greater than 87% at IR wavelengths up to 4 μm without sacrificing transparency in the visible region. These broadband antireflective nanodot dispersions are grown using a two-step metal deposition and oxidation by molecular beam epitaxy, and backscattered diffraction confirms a dominant (111) surface orientation. We detail the growth of a bimodal size distribution that facilitates good surface coverage (80%) while allowing a significant reduction in In2O3 refractive index. This unique dispersion offers excellent surface coverage and three-dimensional volumetric expansion compared to a thin film, and a step reduction in refractive index compared to bulk active materials or randomly porous composites, to more closely match the refractive index of an electrolyte, improving transparency. The (111) surface orientation of the nanodots, when fully ripened, allows minimum lattice mismatch strain between the In2O3 and the Si surface. This helps to circumvent potential interfacial weakening caused by volume contraction due to electrochemical reduction to lithium, or expansion during lithiation. Cycling under potentiodynamic conditions shows that the transparent anode of nanodots reversibly alloys lithium with good Coulombic efficiency, buffered by co-insertion into the silicon substrate. These properties could potentially lead to further development of similarly controlled dispersions of a range of other active materials to give transparent battery electrodes or materials capable of non-destructive in situ spectroscopic characterization during charging and discharging.

Mediators of change in cognitive behaviour therapy and mebeverine for irritable bowel syndrome

BACKGROUND

Cognitive behaviour therapies (CBTs) have through several trials been demonstrated to reduce symptoms and disability in irritable bowel syndrome (IBS) patients, but the mechanisms responsible for the changes are still unknown. The aim of this study was to test a theoretical model of CBT and investigate if cognitions and/or behaviour mediated the changes seen in CBT for IBS.

METHOD

To assess for possible mediating effects, we applied path analysis to the dataset of 149 diagnosed participants randomized to mebeverine hydrochloride plus CBT or mebeverine hydrochloride alone. Primary outcome was symptom severity, while secondary outcomes were work and social adjustment and anxiety.

RESULTS

The path analyses supported mediational paths for all outcomes. Changes in behaviour and cognitions mediated all three outcomes, with models placing behaviour change 'upstream' of cognition change having best fit. The analyses of model fits revealed best fit for the anxiety model and hence provide increased confidence in the causal model of anxiety.

CONCLUSIONS

Changes in behaviour and cognitions mediate the change in CBT given to IBS patients. The results strengthen the validity of a theoretical model of CBT by confirming the interaction of cognitive, emotional and behavioural factors in IBS.

Rituximab for the treatment of rheumatoid arthritis

This paper presents a summary of the evidence review group's critical review of the evidence for the clinical effectiveness and cost-effectiveness of rituximab for the treatment of severe rheumatoid arthritis (RA) following failure of previous therapy, including one or more tumour necrosis factor-alpha inhibitors (TNFi), compared with current standards of care, based upon the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submission's clinical evidence came from one randomised, placebo-controlled, double-blind trial (REFLEX--Random Evaluation of Long-term Efficacy of Rituximab in Rheumatoid Arthritis) comparing rituximab plus methotrexate (MTX) with placebo plus MTX in 517 patients with long-standing refractory RA. Rituximab plus MTX was more effective than placebo plus MTX across a range of primary and secondary outcome measures, e.g. American College of Rheumatology (ACR) responses, Health Assessment Questionnaire (HAQ). However, this evidence cannot be used directly to address the manufacturer's analysis of the decision problem because, in the REFLEX trial, rituximab was not compared with a relevant comparator (e.g. leflunomide or second or third TNFi). Long-term efficacy data for retreatment with rituximab are favourable, with an estimated mean time to retreatment of 307 days (n = 164). Evidence from a further five trials is presented as the basis for indirect comparisons with other disease-modifying antirheumatic drugs (DMARDs); however, it is not clear that all relevant clinical studies have been included in the indirect comparison exercise, the rationale for the choice of indirect comparison method adopted is unclear and the indirect comparison method used to adjust the ACR responses only uses a single value for the reference placebo. The submitted microsimulation Markov model was based upon the REFLEX trial. For the 'NICE-recommended' scenario and the 'sequential TNFi' scenario, the original submission reports incremental cost-effectiveness ratios (ICERs) of 14,690 pounds and 11,601 pounds per quality-adjusted life-year (QALY) gained respectively. After model assumptions were adjusted to more realistic estimates by the ERG, the ICERs for the NICE-recommended scenario and the sequential use of TNFi range from 37,002 pounds to 80,198 pounds per QALY gained and from 28,553 pounds to 65,558 pounds per QALY gained respectively. The guidance issued by NICE in August 2007 states that rituximab in combination with methotrexate is recommended as an option for the treatment of adults with severe active rheumatoid arthritis who have had an inadequate response to or intolerance of other DMARDs including treatment with at least one TNFi therapy.

Rituximab for the treatment of rheumatoid arthritis

This paper presents a summary of the evidence review group’s critical review of the evidence for the clinical effectiveness and cost-effectiveness of rituximab for the treatment of severe rheumatoid arthritis (RA) following failure of previous therapy, including one or more tumour necrosis factor-α inhibitors (TNFi), compared with current standards of care, based upon the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submission’s clinical evidence came from one randomised, placebo-controlled, double-blind trial (REFLEX – Random Evaluation of Long-term Efficacy of Rituximab in Rheumatoid Arthritis) comparing rituximab plus methotrexate (MTX) with placebo plus MTX in 517 patients with long-standing refractory RA. Rituximab plus MTX was more effective than placebo plus MTX across a range of primary and secondary outcome measures, e.g. American College of Rheumatology (ACR) responses, Health Assessment Questionnaire (HAQ). However, this evidence cannot be used directly to address the manufacturer’s analysis of the decision problem because, in the REFLEX trial, rituximab was not compared with a relevant comparator (e.g. leflunomide or second or third TNFi). Long-term efficacy data for retreatment with rituximab are favourable, with an estimated mean time to retreatment of 307 days (n = 164). Evidence from a further five trials is presented as the basis for indirect comparisons with other disease-modifying antirheumatic drugs (DMARDs); however, it is not clear that all relevant clinical studies have been included in the indirect comparison exercise, the rationale for the choice of indirect comparison method adopted is unclear and the indirect comparison method used to adjust the ACR responses only uses a single value for the reference placebo. The submitted microsimulation Markov model was based upon the REFLEX trial. For the ‘NICE-recommended’ scenario and the ‘sequential TNFi’ scenario, the original submission reports incremental cost-effectiveness ratios (ICERs) of £14,690 and £11,601 per quality-adjusted life-year (QALY) gained respectively. After model assumptions were adjusted to more realistic estimates by the ERG, the ICERs for the NICE-recommended scenario and the sequential use of TNFi range from £37,002 to £80,198 per QALY gained and from £28,553 to £65,558 per QALY gained respectively. The guidance issued by NICE in August 2007 states that rituximab in combination with methotrexate is recommended as an option for the treatment of adults with severe active rheumatoid arthritis who have had an inadequate response to or intolerance of other DMARDs including treatment with at least one TNFi therapy.

Induction cetuximab (C) followed by C, paclitaxel (P), carboplatin (CP) and concurrent radiation (RT) for locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN)

16504

Background: C is an IgG1 chimerized, monoclonal antibody that binds specifically to the epidermal growth factor receptor, which is expressed in 90–100% of HNC. We conducted a phase II study to evaluate the toxicity and efficacy of induction C followed by concurrent C with chemoRT for patients (pts) with SCCHN. Methods: Eligible pts had untreated stage III or IV, SCCHN. All pts received induction, single agent, C, 400 mg/m2 week 1, followed by 250 mg/m2 weeks 2, 3, and 4. Potentially operable pts then received C, 250 mg/m2, P 40 mg/m2 and CP AUC=1, weekly x 5 wks, with 45 Gy RT then underwent endoscopic biopsy. If the biopsy was negative, pts received 3 additional weekly doses of C, P, CP and 22–27 Gy boost RT. Inoperable pts received 8 weeks of C, P and CP and 66.6–72 Gy RT. All pts then received maintenance C 250 mg/m2/week x 24 weeks. Results: 29 pts have been enrolled. Male:Female 18:11. Median age = 55 (38–75). Primary sites included oral cavity (10 pts), oropharynx (1), larynx (12), hypopharynx (2), and glottis (4). The tumor stages were III (10 pts), IV (19). Toxicity data are available for 23 pts. 2 of 23 (9%) had grade (G) 4 toxicities (hypokalemia =1, ischemic colitis=1) however there were no treatment related deaths. G 2 toxicities included rash (52%), dysphagia (35%), mucositis (43.5%) and hypomagnesemia (9%). G 3 toxicities included rash (9%), dysphagia (44%), mucositis (26%) and XRT dermatitis (18%). Induction C responses by RECIST criteria were SD (14 pts) 61%, PR (7) 30%, and CR (1) 4%. Conclusion: C can be safely administered with chemoRT (CRT) for pts with HNC. C increases cutaneous toxicity but does not increase in-field CRT side effects. There were no unexpected high-grade adverse events. Preliminary single agent activity of C in untreated SCCHN is promising.

No significant financial relationships to disclose.

Correlation of statin use with breast random periareolar fine needle aspiration (RPFNA) cytomorphology in high risk postmenopausal women

1031

Background: In vitro studies have demonstrated that statins (HMG CoA reductase inhibitors) suppress tumor growth and proliferation in breast cancer cell lines. Published clinical data on the chemoprotective role of statins in breast cancer are conflicting. Moreover, there are no published studies specifically examining the impact of statin use on breast cancer risk biomarkers in high risk women. We have previously demonstrated that cytologic atypia detected by RPFNA is associated with a 5 fold increase in short term risk of breast cancer in high risk women. The aim of this study was to explore the effect of statin use on breast RPFNA cytomorphology in postmenopausal women at high risk of developing breast cancer (based on personal and family history). Methods: Thehigh risk breast clinic database at the University of Kansas Medical Center was queried from April 2002 to September 2005 for statin use in postmenopausal women. We first identified postmenopausal women who underwent RPFNA while on a statin (cases). Postmenopausal women who underwent RPFNA while not on a statin (controls) were then identified and matched with statin users for known breast cancer risk factors (age, 5 year Gail risk and BMI). Frequencies of categorical variables were assessed using chi-square analysis. Continuous variables were assessed using Mann-Whitney non parametric test. Results: 504 postmenopausal women were identified. Thirty five of these 504 women underwent RPFNA while on statin therapy. For statin users (cases), the median age was 56 years, median 5 year Gail risk was 3.6%, median BMI was 28 and the median duration of statin use was 1.4 years (range 0.3 to 13 yrs). Sixty nine controls were identified. There was no difference between cases and controls with respect to HRT use (54% vs 40%, p=0.22), duration of HRT use (p=0.30) and visual breast density (p=0.80). RPFNA atypia was detected in 11% of cases and 26% of controls (p=0.13). Conclusion: Although prevalence of RPFNA atypia was less frequent among statin users, this difference was not statistically significant in this small cohort of high risk women with relatively short duration of statin use. Larger studies are warranted to investigate this further.

No significant financial relationships to disclose.

Cetuximab, paclitaxel, carboplatin and radiation for esophageal and gastric cancer

4029

Background: Cetuximab is an IgG1, chimerized, monoclonal antibody that binds specifically to the epidermal growth factor receptor. Cetuximab improves survival when combined with radiation for patients with locally advanced head and neck cancer. We evaluated the safety and efficacy of the addition of cetuximab to concurrent chemoradiation for patients with esophageal and gastric cancer. Methods: Patients with adenocarcinoma or squamous cell cancer of the esophagus or stomach without distant organ metastases were eligible. Patients with locally advanced disease from mediastinal, celiac, portal and gastric lymphadenopathy were eligible. Surgical resection was not required. Clinical complete response was defined as no tumor on postreatment endoscopic biopsy. Patients received cetuximab, 400mg/m2 week #1 then 250 mg/m2/week for 5 weeks, paclitaxel, 50 mg/m2/week, and carboplatin, AUC =2 weekly for 6 weeks, with concurrent 50.4 Gy radiation. Results: Thirty-seven patients have been entered. The median age was 61 (range of 30–87). Thirty-four have esophageal cancer and 3 have gastric cancer. Of the patients with esophageal cancer, twenty-five have adenocarcinoma and nine have squamous cell cancer. Thus far, 30 patients have completed treatment and are evaluable for toxicity. There have been no grade 4 non-hematologic toxicities and 1 pt had grade 4 neutropenia (3%). Six patients (20%) had grade 3 esophagitis. Other grade 3 toxicities included dehydration (n=5), rash (n=9), and paclitaxel/cetuximab hypersensitivity reactions (n=2). Eighteen of 27 patients (67%) have had clinical complete response. Seven pts out of 16 (43%) who have gone to surgery have had a pathologic CR. Conclusions: Cetuximab can be safely administered with chemoradiation for patients with esophageal cancer. Consistent with the data in head and neck cancer, cetuximab increases cutaneous toxicity but does not increase mucositis/esophagitis when combined with chemoradiation. Further evaluation is ongoing.

[Table: see text]