Association of fall rate and functional status by APOE genotype in cancer survivors after exercise intervention

PURPOSE/OBJECTIVES

Cancer treatment survivors often report impaired functioning and increased falls. Not all survivors experience the same symptom burden, suggesting individual susceptibilities. APOE genotype is a potential genetic risk factor for cancer treatment related side effects. Lifestyle factors such as physical activity can mitigate the effect of APOE genotype on measures of clinical interest in individuals without a history of cancer. We tested the hypothesis that APOE genotype influences cancer treatment related side effects and symptoms as well as response to exercise intervention.

MATERIALS AND METHODS

Data from a subsample of a study of fall prevention exercise in post-treatment female cancer survivors aged 50-75 years old (https://clinicaltrials.gov NCT01635413) were used to conduct a secondary data analysis. ApoE genotype was determined by serum sampling. Physical functioning, frequency of falls, and symptom burden were assessed using survey instruments.

RESULTS

Data from 126 female cancer survivors a median of 49 months out from cancer diagnosis were analyzed. ApoE4 carriers trended toward a higher fall rate at baseline (p = 0.059), but after exercise intervention had a fall rate lower than E4 non-carriers both immediately after structured intervention (p = 0.013) and after 6 months of follow up (p = 0.002). E2 carriers did not show improved measures of depressive symptoms and self-report disability after exercise intervention. E3 homozygotes showed increased self report physical activity after the 6 month exercise intervention, but E4 and E2 carriers did not.

CONCLUSIONS

APOE genotype may modulate cancer treatment related side effects and symptoms and response to exercise intervention.

RONC-17. STEREOTACTIC RADIOSURGERY FOR SPINE METASTASES IN PEDIATRIC MALIGNANCIES

BACKGROUND

Spine stereotactic radiosurgery (SSRS) is a non-invasive technique that delivers ablative radiotherapy for optimal control of bony disease. While SSRS is known to provide excellent local control (LC) and minimal toxicity in adults, the role of SSRS in pediatrics is less clear.

PURPOSE

To evaluate SSRS in pediatric patients with spinal metastases.

METHODS

A retrospective review of patients (<18 yrs) treated with SSRS at MDACC was performed after IRB approval. Descriptive statistics were utilized for analysis.

RESULTS

From 2011–2019, 12 metastatic osseous sites (3 cervical, 4 thoracic, 5 lumbar-sacral) in 9 patients were treated. Median follow-up was 9 months (range 2–41). Six males (67%) and 3 females (33%) all KPS ≥70, received radiation to ≤3 contiguous vertebral bodies. Median age was 16 yrs (range 8–18). No patients required sedation. Histologies included 7 osteosarcomas, one rhabdomyosarcoma and one Ewing’s sarcoma. Metastatic epidural spinal cord compression scores ranged from 0 (6), 1b (3) and 3 (3). No sites had surgery prior to SSRS and one site received prior conventional radiation. SSRS doses included 24 Gy in 1 fraction (7), 24–27 Gy in 3 fractions (4) and 50 Gy in 5 fractions (1). Six-month LC was 83% with one local failure following 27 Gy. OS at 6 and 12 mo were 55% and 23%. There was no grade ≥3 acute toxicity, no radiation myelopathy or vertebral compression fractures.

CONCLUSION

In this initial report, SSRS represents a promising modality that is well tolerated and provides excellent LC. However, further follow-up is warranted in the pediatric setting.

Assessment of Radiation Doses Delivered to Organs at Risk Among Patients With Early-Stage Favorable Hodgkin Lymphoma Treated With Contemporary Radiation Therapy

IMPORTANCE

Response-adapted randomized trials have used positron emission tomography-computed tomography to attempt to identify patients with early-stage favorable Hodgkin lymphoma (ESFHL) who could be treated with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) without radiation therapy (RT). While maximal efficacy is demonstrated with combined modality therapy, RT is often omitted in fear of late adverse effects; however, the application of modern RT could limit these toxic effects.

OBJECTIVE

To determine the radiation doses delivered to organs at risk with modern involved-site RT among patients with ESFHL treated with 20 Gy after 2 cycles of ABVD.

DESIGN, SETTING, AND PARTICIPANTS

This case series included 42 adult patients with ESFHL (according to the German Hodgkin Study Group criteria) who were treated between 2010 and 2019, achieved complete response by positron emission tomography-computed tomography (1-3 on 5-point scale) following 2 cycles of ABVD, and then received consolidative RT. The study was conducted at a single comprehensive cancer center.

EXPOSURES

2 cycles of chemotherapy followed by 20-Gy involved-site RT.

MAIN OUTCOMES AND MEASURES

The medical records of patients with ESFHL were examined. Organs at risk were contoured, and doses were calculated. Progression-free survival, defined from date of diagnosis to disease progression, relapse, or death, and overall survival were estimated using the Kaplan-Meier method.

RESULTS

The cohort comprised 42 patients with ESFHL (median [range] age at diagnosis, 35 [18-74] years; 18 [43%] women; 24 [57%] with stage II disease). At a median follow-up of 44.6 (95% CI, 27.6-61.6) months, the 3-year progression-free survival and overall survival rates were 91.2% (95% CI, 74.9%-97.1%) and 97.0% (95% CI, 80.4%-99.6%), respectively. The mean heart dose was less than 5 Gy (mean, 0.8 Gy; SD, 1.5 Gy; range, 0-4.8 Gy) in all patients. The mean (SD) breast dose for both breasts was 0.1 (0.2) Gy (left breast range, 0-1.0 Gy; right breast range, 0-0.9 Gy).

CONCLUSIONS AND RELEVANCE

In this study, combined modality therapy with 2 cycles of ABVD and 20 Gy for ESFHL was highly effective and avoided excess doses to organs at risk, which may limit long-term toxic effects.

ADVERSE EVENTS ASSOCIATED WITH THERAPEUTIC DRY NEEDLING

BACKGROUND

There is a paucity of literature about the adverse events associated with Therapeutic Dry Needling (TDN). Much of the literature surrounding adverse events associated with TDN has been extrapolated from the acupuncture literature. Given that acupuncture and TDN are distinctly different in their application and proposed mechanisms, adverse events associated with TDN should be examined specifically.

PURPOSE

To determine and report the type of adverse events associated with the utilization of TDN.

STUDY DESIGN

Prospective Questionnaire.

METHODS

Four hundred and twenty physical therapists participated in this study. Information related to minor and major adverse events that occurred during 20,464 TDN treatment sessions was collected. Each physical therapist respondent was asked to fill out two weekly self-reported electronic surveys over a six-week period. One survey was related to "minor adverse events" (i.e. pain, bleeding, bruising), while the other was related to "major adverse events" (i.e. pneumothorax, excessive bleeding, prolonged aggravation). Following the six-week period, descriptive statistics were used to describe the adverse events (AE) associated with TDN and calculate the frequencies of those events.

RESULTS

A total of 7,531 minor AE's were reported, indicating that 36.7% of the reported TDN treatments resulted in a minor AE. The top three minor AE's were bleeding (16%), bruising (7.7%), and pain during dry needling (5.9 %). The average ratio of minor AE's for all respondents across all weeks was 0.53 or approximately one event for every two patients. Twenty major AE's were reported out of the 20,494 treatments for a rate of <0.1% (1 per 1,024 TDN treatments). No associations were noted between the frequency of adverse events and the number of patients treated, practitioner age, level of education, years in practice, level of training or months experience with dry needling.

CONCLUSION

Expected minor AE's such as mild bleeding, bruising, and pain during TDN were common and major AE's were rare. Physical therapists and other medical practitioners need to be aware of the risks of TDN. Based on the findings of this study the overall risk of a major adverse event during TDN is small.

LEVEL OF EVIDENCE

3, survey research.

A multicentre, randomized, double-blind trial of the safety and efficacy of mannose-6-phosphate in patients having Zone II flexor tendon repairs

The safety, tolerability and preliminary efficacy of mannose 6-phosphate in enhancing the outcome in Zone II flexor tendon repair was studied in a multicentre parallel double-blinded randomized controlled trial. Eight UK teaching hospitals were involved in treating repaired flexor tendons with a single intraoperative intrathecal dose of 600 mM mannose 6-phosphate, with follow-up over 26 weeks. A total of 39 patients (mannose 6-phosphate, n = 20; standard care, n = 19) were randomized. Seven were excluded from the safety and tolerability analysis because of intraoperative findings and eight were excluded due to early dropout (n = 4) or tendon rupture (n = 4), leaving 24 (mannose 6-phosphate, n = 13; standard care, n = 11) for assessment of total active motion. The safety, tolerability and other side effects were comparable between the groups. There was no significant difference between the two groups in the total active motion at Week 26. We concluded that mannose 6-phosphate, although safe and tolerable, had no beneficial effect on finger range of motion after Zone II tendon division.Level of evidence 1b.

Outcomes of hospitalisation for right heart failure in pulmonary arterial hypertension

The aim of this study was to examine the causes and outcomes of hospitalisation in patients with pulmonary arterial hypertension (PAH). 205 consecutive hospitalisations occurring between 2000 and 2009 in 90 PAH patients were studied. The leading causes for hospitalisation were right heart failure (RHF; 56%), infection (16%) and bleeding disorders (8%). For patients with RHF, in-hospital mortality was 14% overall, 46% for patients receiving inotropes and 48% for those admitted to the intensive care unit. The predictors for in-hospital mortality were the presence of connective tissue disease (CTD) (OR 4.92), systolic blood pressure <100 mmHg (OR 4.32) and Na ≤ 136 mEq · L(-1) (OR 4.29). Mortality after discharge was 13, 26 and 35% at 3, 6 and 12 months, respectively. World Health Organization functional class prior to admission, renal dysfunction, Charlson comorbidity index, and the presence of CTD were all predictors of mortality after discharge. Hyponatraemia and low systolic blood pressure upon admission and underlying CTD are the main prognostic factors for in-hospital mortality in patients with PAH admitted for RHF. The short-term outcomes after discharge are poor and remarkably worse in patients with underlying CTD or renal impairment. Early recognition of these factors may guide decisions regarding more aggressive therapy, including consideration for lung transplantation.

Disproportionate elevation of N-terminal pro-brain natriuretic peptide in scleroderma-related pulmonary hypertension

N-terminal pro-brain natriuretic peptide (NT-proBNP) is a marker of neurohormonal activation that is useful in the diagnosis and prognosis of various forms of pulmonary arterial hypertension (PAH). We sought to characterise and compare NT-proBNP in a cohort of PAH related to systemic sclerosis (PAH-SSc) and idiopathic PAH (IPAH) patients. NT-proBNP levels, collected from PAH-SSc and IPAH patients followed prospectively, were compared and correlated with haemodynamic variables. Cox proportional hazard models were created to assess the predictive value of NT-proBNP. 98 patients (55 PAH-SSc, 43 IPAH) were included. Haemodynamics were similar, except for lower mean pulmonary arterial pressure in PAH-SSc. NT-proBNP levels were significantly higher in PAH-SSc (3,419+/-3,784 versus 1,393+/-1,633 pg x mL(-1); p<0.01) and were more closely related to haemodynamics in PAH-SSc than IPAH. 28 patients died. NT-proBNP predicted survival (hazard ratio (HR) 3.18; p<0.01) in the overall cohort; however, when stratified by group, predicted survival only in PAH-SSc (HR 3.07, p<0.01 versus 2.02, p = 0.29 in IPAH). This is the first description showing NT-proBNP levels are 1) significantly higher in PAH-SSc than IPAH despite less severe haemodynamic perturbations, and 2) stronger predictors of survival in PAH-SSc, suggesting that neurohormonal regulation may differ between PAH-SSc and IPAH. Future studies to define pertinent mechanisms are warranted.

Epidermal growth factor therapy and wound healing--past, present and future perspectives

The role ofepidermal growth factor (EGF) has been extensively investigated in normal and pathological wound healing. It is implicated in keratinocyte migration, fibroblast function and the formation of granulation tissue. Since the discovery of EGF, the first growth factor to be isolated, over 45 years ago, growth factor therapy has progressed into clinical practice in the treatment ofwounds. The investigation EGF in wound healing has progressed from the treatment of acute wounds, to its limited effect in chronic wounds. EGF is readily degraded in the chronic wound environment, but with the recent focus of research in new drug delivery systems that are able to protect and stabilise the protein, the potential healing effects of EGF are at the forefront of research. In this review, the history of EGF and wound healing research is considered, as are current and future therapeutic options.

Mu-opioid antagonists for opioid-induced bowel dysfunction

BACKGROUND

Opioid-induced bowel dysfunction (OBD) is characterized by constipation, incomplete evacuation, bloating, and increased gastric reflux. OBD occurs both acutely and chronically, in multiple disease states, resulting in increased morbidity and reduced quality of life.

OBJECTIVES

To compare the efficacy and safety of traditional and peripherally active opioid antagonists versus conventional interventions for OBD.

SEARCH STRATEGY

We searched MEDLINE, the Cochrane Central Register of Controlled Trials and EMBASE in January 2007. Additional reports were identified from the reference lists of retrieved papers.

SELECTION CRITERIA

Studies were included if they were randomized controlled trials that investigated the efficacy of mu-opioid antagonists for OBD.

DATA COLLECTION AND ANALYSIS

Data were extracted by two independent review authors and included demographic variables, diagnoses, interventions, efficacy, and adverse events.

MAIN RESULTS

Twenty-three studies met inclusion criteria and provided data on 2871 opioid antagonist-treated patients. The opioid antagonists investigated were alvimopan (nine studies), methylnaltrexone (six), naloxone (seven), and nalbuphine (one). Meta-analysis demonstrated that methylnaltrexone and alvimopan were better than placebo in reversing opioid-induced increased gastrointestinal transit time and constipation, and that alvimopan appears to be safe and efficacious in treating postoperative ileus. The incidence of adverse events with opioid antagonists was similar to placebo and generally reported as mild-to-moderate.

AUTHORS' CONCLUSIONS

Insufficient evidence exists for the safety or efficacy of naloxone or nalbuphine in the treatment of OBD. Long-term efficacy and safety of any of the opioid antagonists is unknown, as is the incidence or nature of rare adverse events. Alvimopan and methylnaltrexone both show promise in treating OBD, but further data will be required to fully assess their place in therapy.

Data sharing - a case of shared databases and community use of on-line GIS support systems

Data management is becoming increasingly simple and complex at the same time. The challenge is to effectively use the increasing number of tools available to manage increasing amounts of environmental information for purposes of data capture, analysis, display, sharing and storage. Government is no longer the main collector and provider of data. Community groups possess vast amounts of data collected through daily work of monitoring the environment in their local community. The chief concerns are data access, sharing, integrity and comparability. The capacity of groups to sustain data management is the key to making the sharing possible. The Southeast Environmental Association has been working with Environment Canada to develop a community, on-line database that will be linked to other geo-spatial data sets to allow instant access to geo-referenced data.

A comparison between optimal and actuarial health care costs of adolescents with diabetes

OBJECTIVE

To assess actuarial cost and cost of optimal standards of care for adolescents with type 1 diabetes in a tertiary, hospital-based care setting. To also assess actuarial costs of diabetic adolescents in psychosocial crisis.

METHODS

Contact diaries were maintained over a 1-year period (June 1999-June 2000). Contacts recorded included both structured and non-structured clinical encounters with contact times recorded. In addition, optimal or 'ideal' hospital-based support and contact times for adolescents were estimated and recorded in minutes per year. Three illustrative cases of adolescents in psychosocial crisis were also assessed in terms of actuarial health care professional contact times. Costs were then calculated according to Victorian hospital pay structures per professional for 1999-2000.

RESULTS

The mean and median actuarial costs of caring for patients aged between 10 and 19 years were 1307 Australian dollars per year and 515 Australian dollars per year, respectively. The cost of optimal care for an adolescent was estimated at 2817 Australian dollars per year after the first year of diagnosis. The costs per year of the three adolescents in crisis ranged from 10,137 Australian dollars per year to 30,524 Australian dollars per year.

CONCLUSIONS

Cost benefits may be seen in the short term by reducing the number of adolescents who end up in psychosocial crisis. Current actuarial costs of diabetic care for adolescents falls short of an optimal standard of care. Diabetic adolescents who fall into psychosocial crisis consume a disproportionate share of a limited clinical resource.

Current pharmacotherapy for hepatitis B infection

Chronic infection with the hepatitis B virus (HBV) affects 350 million people worldwide, or approximately 5% of the global population, and commonly results in cirrhosis and hepatocellular carcinoma. Until recently, the only available treatment was injectable interferon alpha and response rates were suboptimal. Moreover, this expensive and toxic therapy had little applicability in the endemic regions of the world, i.e., Asia and Africa. The realisation that orally available nucleoside and nucleotide agents may effectively control this infection opened a new era in the management of chronic hepatitis B. Oral lamivudine recently became approved for treatment of hepatitis B worldwide. It is free of significant toxicity, improves liver histology and rapidly diminishes HBV DNA levels; lamivudine is expected to become the first-line therapy of choice. Nevertheless, the consistent emergence of lamivudine-resistant variants mandates the need to develop additional therapeutic agents. Adefovir dipivoxil, a nucleotide, and entecavir, a nucleoside agent, are promising new drugs that might eventually be used in combination with lamivudine and therefore reduce the incidence of drug resistance. There is a critical need to advance the research of hepatitis B antiviral agents so that effective combination therapies can become widely available.

International nursing education: Istanbul, Turkey

To assist Turkish nurses in reaching educational standards and goals, an international neonatal program was developed that would incorporate a train-the-trainer module. The primary goal was to develop and teach a neonatal intensive care course while exposing identified trainers to content, theory, teaching strategies, and concepts. The expectations of the future trainers were to use the knowledge they obtained from the course to enable them to provide future neonatal intensive care courses and serve as experts in the field of neonatal nursing. The achievement of this program was a direct reflection of a collaborative effort between two diverse cultures with the same goal of improving quality of nursing care delivered to high-risk neonates. Striving for nursing care excellence means continuously learning and keeping pace with the newest technologies and trends. Turkish nurses now have one more way of maintaining current knowledge and professionalism.

Autonomic nerve function in adolescents with Type 1 diabetes mellitus: relationship to microalbuminuria

AIMS

Thirty adolescent patients with Type 1 diabetes mellitus and microalbuminuria were studied for evidence of early autonomic neuropathy.

METHODS

Using tests involving cardiovascular and pupillary reflexes, the adolescents were compared with a normoalbuminuric group of patients with diabetes, who were matched for age, sex, puberty and duration of diabetes.

RESULTS

There was an increased prevalence of autonomic nerve dysfunction in the patients with microalbuminuria. These patients had higher resting heart rates (86 beats/min in the microalbuminuric group vs. 77 beats/min in normoalbuminuric controls, P = 0.002), and impaired pupillary dilatation in darkness (pupillary diameter % 56.5% vs. 62.5%, P = 0.003). Patients with microalbuminuria also had poorer long term glycaemic control (mean HbA1C 8.7% vs. 7.8%, P = 0.002) and higher blood pressures (systolic 125 vs. 116 mmHg, P = 0.001; diastolic 69 vs. 62 mmHg, P = 0.0001; mean arterial pressure 90 vs. 83 mmHg, P = 0.002) than those with normal urinary albumin excretion.

CONCLUSIONS

Microalbuminuria and autonomic nerve dysfunction co-exist in patients with Type 1 DM. Longitudinal studies will determine whether these findings have implications for the identification of patients at higher risk of progression of early renal complications.

Progression of borderline increases in albuminuria in adolescents with insulin-dependent diabetes mellitus

We aimed to determine the natural history of borderline increases in albuminuria in adolescents with insulin-dependent (Type 1) diabetes mellitus (IDDM) and factors which are associated with progression to persistent microalbuminura. Fifty-five normotensive adolescents with IDDM and intermittent microalbuminura (overnight albumin excretion ratte of 20-200 micrograms min-1 on one of three consecutive timed collections, n = 29) or borderline albuminura (mean overnight albumin excretion rate of 7.2-20 micrograms min-1 on one of three consecutive timed collections, n = 30) were followed prospectively at 3 monthly intervals. The endpoint was persistent microalbuminuria defined as a minimum of three of four consecutive overnight albumin excretion rates of greater than 20 micrograms min-1. One hundred and forty-two adolescents with IDDM and normoalbuminura were also followed prospectively. Fifteen of the 59 patients (25.4%) with intermittent (9/29) or borderline (6/30) albuminura progressed to persistent microalbuminura (progressors) over 28 (15-50) months [median (range)] in comparison with two of the 142 patients with normoalbuminuria at entry (relative risk = 12.6; p = 0.001). Progressors to persistent microalbuminura were pubertal and had higher systolic (p = 0.02) and diastolic (p = 0.02) blood pressure, and HbA1c (p = 0.004) than non-progressors. All patients remained normotensive. Glomerular filtration rate, apolipoproteins, dietary phosphorus, protein and sodium intakes, and prevalence of smoking did not differ between progressors and non-progressors. Total renin was higher in the diabetic patients without a difference between progressors and non-progressors. In conclusion there is a relatively high rate of progression to persistent microalbuminuria in pubertal adolescents with borderline increases in albuminura and duration greater than 3 years. These patients require attention to minimize associated factors of poor metabolic control and higher blood pressure in the development of incipient nephropathy.

From the Journals

VENOUS LEG ULCERS AND SQUAMOUS CELL CARCINOMA LEG ULCER MANAGEMENT IN THE COMMUNITY A REAWAKENING OF TRACE-ELEMENT WOUND RESEARCH.

MR image texture analysis--an approach to tissue characterization

The role and value of texture analysis in the quantification of medical images is reviewed and the various methods described. The promise in magnetic resonance imaging is discussed and the coordinated research programme being carried out within the framework of the European Economic Community Concerted Action on Tissue Characterization by MRS and MRI is outlined. Tissue characterization of the human brain has been performed by texture analysis of proton relaxation time images using a standard MR whole body imager operating at 1.5 T and the results are presented.

Containing medicines costs in the private sector--the example of a medical benefit scheme

Despite a pre-existing cost-containment programme, expenditure on medicines was identified as a source of further cost savings in a medical benefit scheme faced with increasing divergence between income and benefit expenditure. Analysis of medicines utilisation trends showed that a relatively small number of pharmaceutical products accounted for a high percentage of total medicines expenditure, and that a small number of pharmacies were dispensing a very high proportion of prescriptions. On the basis of these findings, a revised cost-containment programme for medicines was implemented. It consisted of a recommended medicines list, designed to rationalise selection and utilisation of medicines, and a 'preferred provider pharmacy' network that allowed further savings to be achieved. In its first 12 months, the programme allowed for savings of R305,000, or 37% of anticipated expenditure on medicines for that year. This represents a decrease over 1988 expenditure notwithstanding an increase in membership and medicine prices over the same period. There are therefore significant savings to be obtained by medical schemes through implementation of cost-containment programmes for medicines.

The maximum medical aid price programme. A review of the concept and of its ability to reduce expenditure on medicines

Medicine prices in South Africa have increased significantly in recent years. Furthermore, a consideration of expenditure on medicines by medical schemes shows that this component of health care costs had grown to 26.1% in 1988, which is high by comparison with other Western economies. The use of generic medicines offers one possible solution to rising expenditure. For savings to be optimised, however, generics need to be used on a planned and structured basis. The maximum medical aid price (MMAP) system of the Pharmaceutical Society of South Africa provides such a programme. MMAP is a programme through which certain medical schemes elect to pay only a specified maximum price for off-patent products that have generic equivalents. Although MMAP does not require substitution by generic medicines, it does have the effect of encouraging their use. Two case studies measuring the savings that can be achieved through adoption of MMAP by medical schemes are reviewed. Although they differ in their respective methodologies, their results are consistent and show that savings of about 9.3% were possible in 1989. Medical schemes with higher proportions of older members tend to show greater savings. The studies also show that the potential for achieving savings through the use of MMAP increases with the passage of time.

Intrauterine fetal tachypnea

In a previous case report, intrauterine fetal tachypnea was associated with sudden fetal death. The authors have observed a similar case of fetal tachypnea. Early intervention occurred and a normal fetus was delivered. Pathophysiologic mechanisms for the phenomenon are discussed.