Adverse Events from Fluoroscopic versus Portable Placement of PICCs and CVCs in Pediatric Patients

PURPOSE

To evaluate the outcomes of fluoroscopic versus portable placement of peripherally inserted central catheters (PICCs) and central venous catheters (CVCs) in pediatric patients.

MATERIALS AND METHODS

This is a single-center, retrospective review of 346 upper-extremity PICCs (286 fluoroscopic, 60 portable), mean age = 9.83 ± 5.58 years, 49.1% female; and 138 tunneled femoral CVCs (56 fluoroscopic, 82 portable), mean age = .23 ± .36 years, 57.0% female. Portable placements used mobile plain-film radiography. All lines were placed by board-certified interventional radiologists.

RESULTS

Fluoroscopic PICC versus portable PICC placements had a lower procedure time (43.9 vs. 57.9 minutes, P<.001); radiation dosage (342 vs. 590 mGy.cm2, P<.001); incidence of technical failure (0 vs. 3.3%, P=.029); incidence of catheter malfunction (1.7% vs. 12.1%, P<.001). Fluoroscopic CVC versus portable CVC placements had a lower procedure time (42.6 vs 54.8 minutes, P<.001); and radiation dosage (63.8 vs 405 mGy.cm2, P<.001). No technical failures were found in either CVC groups and the difference was non-significant for catheter malfunction (0 vs 7.3%, P=.081). Fluoroscopic placements of PICCs and CVCs had a lower incidence rate of central line-associated bloodstream infection (CLABSI) compared to portable placements (.71 vs 2.22 cases per 1000 line-day, P=.046). Overall, fluoroscopic placements of PICCs and CVCs had fewer adverse events compared to portable placements (3.2% vs 14.8%, P<.001). Portable procedure was the only significant factor associated with adverse events (OR, 33.77 (4.56-757.01)).

CONCLUSIONS

Fluoroscopic placements of PICCs and CVCs are associated with lower procedure time, radiation dose, and risk of adverse events compared to portable placements in pediatric patients.

A Quality Improvement Initiative to Increase Documentation of Preferences for Life-Sustaining Treatment in Hospitalized Adults

BACKGROUND

Portable Orders for Life-Sustaining Treatment (POLST) forms allow patients to codify their preferences for life-sustaining treatments across inpatient and outpatient settings. In 2019 only 29.5% of our hospitalized internal medicine patients with an inpatient do-not-resuscitate (DNR) order and no DNR POLST at admission discharged with a DNR POLST. This presented an opportunity to improve POLST completion and avoid undesired or inappropriate care after discharge.

METHODS

Using electronic health record (EHR) data, the authors identified hospitalized adults (age ≥ 50 years) admitted to an internal medicine service with a DNR order and discharged alive. Patient records were cross-referenced with the state's POLST registry for an active POLST form. Among patients with a missing or full-code POLST form at admission, the authors calculated the proportion with a DNR POLST form completed by discharge. These data were tracked over time with control charts to detect performance shifts following three Plan-Do-Study-Act (PDSA) cycles over 34 months, which included a single educational training on electronic POLST navigation, an EHR discharge navigator notification, and quarterly e-mailed individualized performance reports.

RESULTS

The study population (N = 387) was 55.0% male and predominately non-Hispanic white (80.9%). Patients discharging to a skilled nursing facility or hospice were three times more likely to discharge with a DNR POLST compared to patients discharging home. Overall, the proportion of DNR POLST forms completed by discharge increased from 0.36 to 0.60 after three PDSA cycles (p < 0.001).

CONCLUSION

This quality improvement initiative demonstrated improved POLST form completion rates in a target population of adults at elevated risk for readmission and death.

Survey of Vaccine Hesitancy in Patients Visiting Three Tertiary-care Emergency Departments in Southeast Louisiana

Objectives

Vaccine hesitancy has been a barrier to achieving herd immunity during the coronavirus 2019 (COVID-19) pandemic. Having low socioeconomic status and education levels, and being a person of color, are associated with higher COVID-19 infection risk and worse outcomes. These same groups are associated with higher vaccine hesitancy. The state of Louisiana has one of the lowest vaccination rates in the country. In this study we aimed to identify demographic, perspective, and health behavior factors associated with vaccine hesitancy in emergency departments (ED) in Southeast Louisiana.

Methods

A cross-sectional survey was distributed at three tertiary-care hospital EDs. Patients >18 years old and not in acute distress were recruited between April-July 2021. The 37-item questionnaire addressed socioeconomic demographics, social determinants of health, COVID-19 safety practices, thoughts and perceptions on COVID-19 and vaccines, sources of COVID-19 and vaccine information, and trust in the healthcare system.

Results

Overall, 247 patients completed our survey. Of those, 29.6% reported they were vaccine hesitant. These respondents were significantly more likely, when compared to vaccine-acceptant respondents, to never have married, to have some college education, make less than <$25,000 in household earnings yearly, be unsure whether vaccines prevent disease, not have discussed the COVID-19 vaccine with their primary care doctor, and to prefer to do their own research for COVID-19 vaccine information. We observed no statistically significant differences based on gender, race/ethnicity, parental status, area of living, or their perceived risk of needing hospitalization for treatment or dying from the virus.

Conclusion

Vaccine hesitancy was associated with multiple socioeconomic factors, perspectives, and beliefs. Vaccine-hesitant individuals were more uncertain about the safety of the COVID-19 vaccine, the feasibility of obtaining the vaccine, and its efficacy. Public health interventions aimed at these findings and improving public trust in healthcare systems are needed to increase vaccine acceptance.

Pilot Study on Music in the Waiting Room of Outpatient Pain Clinics

BACKGROUND

This study explores live and recorded music listening in the outpatient pain clinic. There is evidence demonstrating the effectiveness of live and recorded music in a hospital setting but a comparison study of this kind has yet to be conducted.

METHODS

A multimethod survey study design was used. A questionnaire utilizing rating scales was self-administered across two outpatient pain clinic waiting rooms. Patients were included through convenience sampling. In one clinic, a playlist of recorded music curated by two of the authors was provided. In the second clinic, a music therapy student played live music using guitar, flute, and voice. The questionnaire gathered data on music's impact on pain and emotional states, as well as attitudes toward music in the waiting room. Quantitative data was analyzed using descriptive statistics and qualitative data, gathered in the questionnaires open ended question, was analyzed using thematic analysis.

RESULTS

The questionnaire was completed by 200 adult patients. Patients reported lowered levels of anxiety, stress, and pain in both clinics, as well as a shorter waiting time and more caring experience. Patients in the live music clinic reported that music lowered levels of stress, nervousness, agitation, and pain more than in the recorded music clinic.

CONCLUSIONS

Participants in this study identified that music is a useful tool in the pain clinic waiting room. This study contributes to evidence that music should be considered as a complimentary treatment for people living with pain and in the wider hospital setting. Additional research is warranted with a control group, pre- and posttesting, and studies of music in hospitals in a range of cultural contexts.

Pacemaker generator replacement as a key to the puzzle of dyspnoea in a community dwelling centenarian

A 104-year-old woman presented with dyspnoea. Workup revealed normal troponins, elevated D-dimer at 2285 with subsequent chest CT angiogram negative for pulmonary embolism. NT-pro BNP elevated to 5208 pg/mL. Chest X-ray revealed mild cardiac enlargement with bilateral pleural effusions. ECG revealed accelerated junctional rhythm. The initial plan was to obtain transthoracic echocardiogram and start diuresis for presumed heart failure. Given her specific cardiac history, pacemaker interrogation was ordered which revealed her pacemaker mode changed from DDDR to VVI. She underwent pacemaker battery exchange with complete resolution in her symptoms and ability to return to prior functional status. Overall, dyspnoea in centenarians could be multifactorial. Pacemaker elective replacement mode secondary to end of life battery can present as non-specific cardio respiratory symptoms. As the pacemaker population ages to the survival beyond the battery life, pacemaker aetiology behind heart failure symptoms needs to be highly considered by medical providers.

Comprehensive Health Evaluation of the Newly Adopted Child

Children who join families through the process of adoption, whether through a domestic or international route, often have multiple health care needs. Pediatricians and other health care personnel are in a unique position to guide families in achieving optimal health for the adopted children as families establish a medical home. Shortly after placement in an adoptive home, it is recommended that children have a timely comprehensive health evaluation to provide care for known medical needs and identify health issues that are unknown. It is important to begin this evaluation with a review of all available medical records and pertinent verbal history. A complete physical examination then follows. The evaluation should also include diagnostic testing based on findings from the history and physical examination as well as the risks presented by the child's previous living conditions. Age-appropriate screenings may include, but are not limited to, newborn screening panels and hearing, vision, dental, and formal behavioral and/or developmental screenings. The comprehensive assessment may occur at the time of the initial visit to the physician after adoptive placement or can take place over several visits. Adopted children can be referred to other medical specialists as deemed appropriate. The Council on Adoption, Foster Care, and Kinship Care is a resource within the American Academy of Pediatrics for physicians providing care for children who are being adopted.

Pulsed radiofrequency of the brachial plexus in the treatment of chemotherapy-induced peripheral neuropathy of the upper limb

We describe the treatment of chemotherapy-induced peripheral neuropathy in the upper limb of a patient via ultrasound-guided pulsed radiofrequency of the brachial plexus. A 54-year-old female, who underwent chemotherapy and mastectomy for left-sided breast cancer, presented to the pain clinic describing continuous and severe shock-like pain in the posterolateral aspect of the left upper limb, above the elbow. A diagnosis of chemotherapy-induced peripheral neuropathy was made. Pain management with multi-modal analgesia was not fully effective and pulsed radiofrequency was offered as an alternative. Ultrasonography of the supraclavicular region was used to identify the brachial plexus, followed by pulsed radiofrequency using an insulated-tip needle that produced paraesthesia in the affected area. Onset of pain relief occurred one week post-procedure and lasted approximately 10 weeks. An estimated 80% decrease in pain intensity was reported by the patient. We propose that pulsed radiofrequency can be offered as a pain management alternative in certain presentations of chemotherapy-induced peripheral neuropathy.

Targeting programmed cell death ligand 1 by CRISPR/Cas9 in osteosarcoma cells

Programmed cell death ligand 1 (PD-L1) is a transmembrane protein that is expressed on tumor cells that suppresses the T cell-mediated immune response. Therapies targeting the PD-L1 pathway promote anti-tumor immunity and have shown promising results in some types of cancers. However, the functional and therapeutic roles of PD-L1 in osteosarcoma remain largely unknown. In this study, we found that PD-L1 protein was expressed in osteosarcoma cell lines and tissue microarray of patient tumors. Tissue microarray immunohistochemistry analysis showed that the overall and five-year survival rates of patients with high levels of PD-L1 expression were significantly shorter than patients with low levels. High levels of PD-L1 expression were also associated with metastasis in osteosarcoma patients. Furthermore, we applied the Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)/Cas9 system to target PD-L1 gene at the DNA level in osteosarcoma cell lines. We found that the expression of PD-L1 could be efficiently disrupted by CRISPR/Cas9 system and PD-L1 knockdown increased drug sensitivities for doxorubicin and paclitaxel. These results suggest that PD-L1 is an independent prognostic factor in osteosarcoma and that PD-L1 knockout by CRISPR/Cas9 may be a therapeutic approach for the treatment of osteosarcoma.

Extraskeletal osteosarcoma: A large series treated at a single institution

Purpose: This study is to present a large cohort of extraskeletal osteosarcoma (ESOS) and evaluate prognostic factors and treatment options. Methods: Medical records were reviewed retrospectively for 41 patients with extraskeletal osteosarcoma that was diagnosed by pathology, and treated at our institution between 1960 and 2016. Kaplan-Meier analysis and Cox proportional hazards regression were used to identify variables that affect survival outcomes. Results: 41 patients were identified from 952 osteosarcomas. 32 patients had non-metastatic disease. Prognostic factors were identified by univariate analysis and multi-variate analysis. Surgery (p<0.001), and surgery type (p<0.001) both were shown to significantly affect overall survival (OS). Chemotherapy and radiation therapy (RT) did not show any significant effect on OS, local recurrence, or progression free survival as a whole. However for patients who had incomplete resection with residual tumor RT improved OS (p=0.03). The survival curve for ESOS follows more closely that of non-rhabdomyosarcoma soft tissue sarcomas (NRSTS). Conclusions: ESOS is a very rare tumor. Attempt to achieve wide resection is the treatment of choice. However for patients who are not able to achieve complete resection, RT may improve OS. The behavior of ESOS more closely follows that of NRSTS than osteosarcoma of the bone.

Needs of Kinship Care Families and Pediatric Practice

As many as 3% of children in the United States live in kinship care arrangements with caregivers who are relatives but not the biological parents of the child. A growing body of evidence suggests that children who cannot live with their biological parents fare better, overall, when living with extended family than with nonrelated foster parents. Acknowledging this, federal laws and public policies increasingly favor kinship care over nonrelative foster care when children are unable to live with their biological parents. Despite overall better outcomes, families providing kinship care experience many hardships, and the children experience many of the same adversities of children in traditional foster care. This policy statement reviews both the strengths and vulnerabilities of kinship families and suggests strategies for pediatricians to use to address the needs of individual patients and families. Strategies are also outlined for community, state, and federal advocacy on behalf of these children and their families.

High-Dose Proton Beam-Based Radiation Therapy in the Management of Extracranial Chondrosarcomas

Purpose

Radiation therapy (RT) improves local tumor control in axial chondrosarcomas (CS). It is, however, often difficult to safely deliver the high doses (range, 70.2-77.4 Gy) required for achieving a high likelihood of local control, especially in the spine, using photons. This, however, can be achieved with proton beam therapy (PBT) due to its unique physical characteristics. The main goal of our study is to evaluate the outcomes of CS patients treated with passive scattered PBT.

Materials and Methods

Forty-four patients (N = 44) were identified who received PBT as part of their treatment from 1990 to 2012. A retrospective review of their medical and RT treatment records was conducted. Multivariate analyses were performed to identify patient- and tumor-related factors predicting for improved local control and overall survival.

Results

Median age was 45.5 years and 55% were female. Median tumor size was 13 cm. Most common anatomical location was the spine (80%). Median follow-up was 29.1 months. Median external beam RT dose was 70.2 Gy relative biological effectiveness (RBE) at 1.8 Gy (RBE) per fraction typically administered using a combination of photon RT + PBT (77%) or PBT alone (23%). Local control was 76% and 57%, and overall survival was 90% and 68% at 2 and 5 years, respectively. Toxicity was acceptable, with the most frequent being wound complications (16%). On multivariate analyses, grade III tumors were significantly associated with decreased local control (P = 0.019), while female sex (P = 0.037) and grade III tumors (P = 0.005) were associated with a poorer overall survival.

Conclusions

High-dose proton-based RT in combination with surgery resulted in local tumor control in most of these high-risk CS patients. Female sex was predictive for decreased survival, while higher tumor grade (grade III) was predictive of decreased local control and survival. Proton beam therapy is an attractive treatment modality for these challenging tumors.

Androgen receptor is a potential novel prognostic marker and oncogenic target in osteosarcoma with dependence on CDK11

Osteosarcoma is the most common bone cancer in children and adolescents. Previously, we have found that cyclin-dependent kinase 11 (CDK11) signaling was essential for osteosarcoma cell growth and survival. Subsequently, CDK11 siRNA gene targeting, expression profiling, and network reconstruction of differentially expressed genes were performed between CDK11 knock down and wild type osteosarcoma cells. Reconstructed network of the differentially expressed genes pointed to the AR as key to CDK11 signaling in osteosarcoma. CDK11 increased transcriptional activation of AR gene in osteosarcoma cell lines. AR protein was highly expressed in various osteosarcoma cell lines and patient tumor tissues. Tissue microarray analysis showed that the disease-free survival rate for patients with high-expression of AR was significantly shorter than for patients with low-expression of AR. In addition, AR gene expression knockdown via siRNA greatly inhibited cell growth and viability. Similar results were found in osteosarcoma cells treated with AR inhibitor. These findings suggest that CDK11 is involved in the regulation of AR pathway and AR can be a potential novel prognostic marker and therapeutic target for osteosarcoma treatment.

miR-15b modulates multidrug resistance in human osteosarcoma in vitro and in vivo

The development of multidrug resistance (MDR) in cancer cells to chemotherapy drugs continues to be a major clinical problem. MicroRNAs (miRNA, miR) play an important role in regulating tumour cell growth and survival; however, the role of miRs in the development of drug resistance in osteosarcoma cells is largely uncharacterized. We sought to identify and characterize human miRs that act as key regulators of MDR in osteosarcoma. We utilized a miR microarray to screen for differentially expressed miRs in osteosarcoma MDR cell lines. We determined the mechanisms of the deregulation of expression of miR-15b in osteosarcoma MDR cell lines, and its association with clinically obtained tumour samples was examined in tissue microarray (TMA). The significance of miR-15b in reversing drug resistance was evaluated in a mouse xenograft model of MDR osteosarcoma. We identified miR-15b as being significantly (P < 0.01) downregulated in KHOS_MR and U-2OS_MR cell lines as compared with their parental cell lines. We found that Wee1 is a target gene of miR-15b and observed that transfection with miR-15b inhibits Wee1 expression and partially reverses MDR in osteosarcoma cell lines. Systemic in vivo administration of miR-15b mimics sensitizes resistant cells to doxorubicin and induces cell death in MDR models of osteosarcoma. Clinically, reduced miR-15b expression was associated with poor patient survival. Osteosarcoma patients with low miR-15b expression levels had significantly shorter survival times than patients with high expression levels of miR-15b. These results collectively indicate that MDR in osteosarcoma is associated with downregulation of miR-15b, and miR-15b reconstitution can reverse chemotherapy resistance in osteosarcoma.

Evaluation of P-glycoprotein (Pgp) expression in human osteosarcoma by high-throughput tissue microarray

Survival of osteosarcoma patients is currently limited by the development of metastases and multidrug resistance (MDR). A well-established cause of MDR involves overexpression of P-glycoprotein (Pgp) in tumor cells. However, some discrepancies still exist as to the clinical significance of Pgp in osteosarcoma. We sought to elucidate further whether the Pgp expression correlated with clinical behavior in a series of patients with osteosarcoma via high-throughput tissue microarray (TMA) analysis. Immunohistochemical analysis of Pgp expression in a TMA of 114 specimens with a retrospective review of 70 osteosarcoma patients admitted to the Massachusetts General Hospital (MGH) was performed. High Pgp expression was correlated with metastasis development and poor response to pre-operative chemotherapy in osteosarcoma patients. Eighteen of the fifty-seven patients initially admitted with primary osteosarcoma showed high Pgp expression. Among these 18 patients with high Pgp expression, 13 of 18 (72%) patients eventually developed metastases. There was no significant clinical relevance between Pgp expression and osteosarcoma survival. These results support that high expression of Pgp is important, but cannot be assigned as, an individual predictor in the development of human osteosarcoma. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1606-1612, 2016.

Who accompanies patients to the chronic pain clinic?

BACKGROUND

Patients may be accompanied to the pain clinic consultation and these accompanying persons are relevant in the communication process.

AIMS

We sought to characterize if patients were accompanied and by whom to the pain clinic. We also wished to determine the accompanying persons influence on the doctor-patient interaction. This has not been studied previously in this clinical setting.

METHODS

Local ethics committee approval followed by written informed consent was obtained. Patients attending the pain clinic for the first time and review patients were included (n = 219).

RESULTS

Twenty-one percent of patients (n = 46) were accompanied. Adult accompanied by spouse 19 (41.3 %) and adult child accompanied by parent 18 (39.1 %) were the most common dyads. The accompanying person's role was most frequently described by doctors as an advocate for the patient 30/46 (65.2 %) [for an adult accompanied by spouse (63.1 %)]. The influence of the main accompanying person on the patient doctor encounter was described as positive [adult accompanied by spouse (78.9 %)] [(adult accompanied by parent (94.4 %)].

CONCLUSIONS

Patients are accompanied to the pain clinic with a typically positive influence on doctor patient relationship and communication. Awareness of these issues is important in good communication in the pain clinic.

Clinical and biological significance of PIM1 kinase in osteosarcoma

Osteosarcoma is the most prevalent histological form of primary malignant bone tumor. The majority of osteosarcoma patients have limited alternative therapeutic options and metastatic patients generally have a poor prognosis. Proto-oncogene serine/threonine-protein kinase PIM1 is associated with growth and survival of many kinds of tumor cells. However, the role of PIM1 in osteosarcoma remains largely unknown. In this study, we investigated the functional and therapeutic relevance of PIM1 as a putative target in osteosarcoma. We found PIM1 was highly expressed in various osteosarcoma cell lines and in tumor tissues from osteosarcoma patients. Tissue microarray and immunohistochemistry analysis showed that the overall and disease-free survival rate of patients with high levels of PIM1 protein expression were significantly shorter than patients with low levels. High levels of PIM1 were also associated with present metastasis and can be considered as an independent prognostic factor in osteosarcoma patients. Knockdown of PIM1 expression by synthetic siRNA or shRNA greatly inhibited cell growth, migration, and invasion. Moreover, these changes accompanied with down-regulation of anti-apoptotic protein Bcl-2. The similar results were obtained in osteosarcoma cells treated with PIM1 specific inhibitor (SMI-4a). These results suggest that PIM1 kinase is critical for the growth and metastasis of osteosarcoma cells and can be a potential therapeutic target for osteosarcoma treatment. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1185-1194, 2016.

NVP-TAE684 reverses multidrug resistance (MDR) in human osteosarcoma by inhibiting P-glycoprotein (PGP1) function

BACKGROUND AND PURPOSE

Increased expression of P-glycoprotein (PGP1) is one of the major causes of multidrug resistance (MDR) in cancer, including in osteosarcoma, which eventually leads to the failure of cancer chemotherapy. Thus, there is an urgent need to develop effective therapeutic strategies to override the expression and function of PGP1 to counter MDR in cancer patients.

EXPERIMENTAL APPROACH

In an effort to search for new chemical entities targeting PGP1-associated MDR in osteosarcoma, we screened a 500+ compound library of known kinase inhibitors with established kinase selectivity profiles. We aimed to discover potential drug synergistic effects among kinase inhibitors and general chemotherapeutics by combining inhibitors with chemotherapy drugs such as doxorubicin and paclitaxel. The human osteosarcoma MDR cell lines U2OSR2 and KHOSR2 were used for the initial screen and secondary mechanistic studies.

KEY RESULTS

After screening 500+ kinase inhibitors, we identified NVP-TAE684 as the most effective MDR reversing agent. NVP-TAE684 significantly reversed chemoresistance when used in combination with doxorubicin, paclitaxel, docetaxel, vincristine, ET-743 or mitoxantrone. NVP-TAE684 itself is not a PGP1 substrate competitive inhibitor, but it can increase the intracellular accumulation of PGP1 substrates in PGP1-overexpressing cell lines. NVP-TAE684 was found to inhibit the function of PGP1 by stimulating PGP1 ATPase activity, a phenomenon reported for other PGP1 inhibitors.

CONCLUSIONS AND IMPLICATIONS

The application of NVP-TAE684 to restore sensitivity of osteosarcoma MDR cells to the cytotoxic effects of chemotherapeutics will be useful for further study of PGP1-mediated MDR in human cancer and may ultimately benefit cancer patients.

NSC23925 prevents the emergence of multidrug resistance in ovarian cancer in vitro and in vivo

OBJECTIVE

The development of multidrug resistance (MDR) remains the significant clinical challenge in ovarian cancer therapy; however, relatively little is known about how to prevent the emergence of MDR during chemotherapy treatment. NSC23925 previously has been shown to prevent the development of MDR in osteosarcoma cells in vitro. The purpose of this study was to evaluate the effects of NSC23925 on the prevention of MDR in ovarian cancer, especially in vivo.

METHODS

Human ovarian cancer cells were treated with paclitaxel alone or in combination with NSC23925 in vitro and in vivo. MDR ovarian cancer cells were established both in cultured cells and mouse models. The expression levels of Pgp and MDR1 were evaluated in various selected cell sublines by Western blot and real-time PCR. Pgp activity was also determined.

RESULTS

Paclitaxel treated cells eventually developed MDR with overexpression of Pgp and MDR1, and with high activity of Pgp, while paclitaxel-NSC23925 co-treated cells remained sensitive to chemotherapeutic agents in both in vitro and in vivo models. There was no observed increase in expression level and activity of Pgp in paclitaxel-NSC23925 co-treated cells. Additionally, there were no changes in the sensitivity to chemotherapeutic agents, nor expression of Pgp, in cells cultured with NSC23925.

CONCLUSION

Our findings suggest that NSC23925 can prevent the emergence of MDR in ovarian cancer both in vitro and in vivo. The clinical use of NSC2395 at the onset of chemotherapy may prevent the development of MDR and improve the clinical outcome of patients with ovarian cancer.

Transitioning Toward Competency: A Resident-Faculty Collaborative Approach to Developing a Transitions of Care EPA in an Internal Medicine Residency Program

BACKGROUND

Residency training and evaluation are moving toward competency-based models. Managing transitions of care is 1 of 16 entrustable professional activities (EPAs) that signal readiness for independent internal medicine practice. Methods for developing EPAs are evolving within the medical education community.

OBJECTIVE

We describe a process for developing a transitions-of-care EPA for internal medicine inpatient and ambulatory settings using an iterative, consensus-building, resident-faculty collaborative approach.

METHODS

We used an independent rank-ordering process and successive consensus group meetings to cull an initial list of 142 developmental Milestones to the 15 most relevant to transitions of care for internal medicine patients in an academic medical center and affiliated Veterans Administration hospital. Four senior internal medicine residents and 4 internal medicine faculty members representing inpatient and ambulatory practice settings identified examples of specific tasks and evaluative techniques for each Milestone.

RESULTS

We demonstrate a feasible resident-faculty collaboration to develop transitions of care as an EPA for an internal medicine training program. Inclusion of residents along with faculty provided broader insights as well as an important learning opportunity for trainees.

CONCLUSIONS

Our process demonstrated the feasibility of designing an EPA, but questions remain about how entrustment-based evaluation can be implemented in clinical settings. Our framework may serve as a foundation for EPA development in other areas of clinical practice.

A-770041 reverses paclitaxel and doxorubicin resistance in osteosarcoma cells

Background

Reversing multidrug resistance (MDR) has been an important goal for clinical and investigational oncologists. In the last few decades, significant effort has been made to search for inhibitors to reverse MDR by targeting ATP-binding cassette (ABC) transporters (Pgp, MRP) directly, but these efforts have achieved little clinical success. Protein kinases play important roles in many aspects of tumor cell growth and survival. Combinations of kinase inhibitors and chemotherapeutics have been observed to overcome cancer drug resistance in certain circumstances.

Methods

We screened a kinase specific inhibitor compound library in human osteosarcoma MDR cell lines to identify inhibitors that were capable of reversing chemoresistance to doxorubicin and paclitaxel.

Results

We identified 18 small molecules that significantly increase chemotherapy drug-induced cell death in human osteosarcoma MDR cell lines U-2OS_MR and KHOSR_2. We identified A-770041 as one of the most effective MDR reversing agents when combined with doxorubicin or paclitaxel. A-770041 is a potent Src family kinase (Lck and Src) inhibitor. Western blot analysis revealed A-770041 inhibits both Src and Lck activation and expression. Inhibition of Src expression in U-2OS_MR and KHOSR₂ cell lines using lentiviral shRNA also resulted in increased doxorubicin and paclitaxel drug sensitivity. A-770041 increases the intracellular drug accumulation as demonstrated by calcein AM assay.

Conclusions

These results indicate that small molecule inhibitor A-770041 may function to reverse ABCB1/Pgp-mediated chemotherapy drug resistance. Combination of Src family kinase inhibitor with regular chemotherapy drug could be clinically effective in MDR osteosarcoma.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2407-14-681) contains supplementary material, which is available to authorized users.

Informed consent for epidural analgesia in labour: a survey of Irish practice

Currently, we do not have a national standard regarding epidural consent in Ireland. The aim of this survey was to assess practice in obstetric units in Ireland with regard to obtaining informed consent prior to epidural insertion, and whether the risks discussed with women are being documented. A postal survey of anaesthetists in Irish obstetric units was performed in January 2012 to assess practice regarding obtaining informed consent prior to epidural insertion, and documentation of the risks discussed. The response rate was 16/18 (88%). There was major variation both in which risks are discussed with women in labour and what risks are quoted. The most frequently quoted risks were headache--15/16 (93.8% of the respondents), partially/not working epidural--15/16 (93.8%), drop in blood pressure--14/16 (87.5%) and temporary backache/local tenderness--12/16 (75%). The more serious risks were not discussed as frequently: permanent nerve damage--8/16 (50%), paralysis--8/16 (50%), epidural abscess/haematoma--6/16 (37.5%), meningitis--3/16 (18.7%). The vast majority of respondents supported introduction of a national standardised information leaflet, detailing all the benefits and risks of epidural analgesia, to be shown to all women before consenting to epidural insertion.

Prognostic significance of miRNA-1 (miR-1) expression in patients with chordoma

Reliable prognostic biomarkers for chordoma have not yet been established. Recent studies revealed that expression of miRNA-1 (miR-1) is frequently downregulated in several cancer types including chordoma. The goal of this follow-up study is to investigate the expression of miR-1 as a prognostic biomarker and further confirm the functional role of miR-1 in chordoma cell growth and proliferation. We determined the relative expression levels of miR-1 and Met in chordoma tissue samples and correlated those to clinical variables. The results showed that miR-1 was downregulated in 93.7% of chordoma tissues and expression was inversely correlated with Met expression. miR-1 expression levels also correlated with clinical prognosis. To characterize and confirm the functional role of miR-1 in the growth and proliferation of chordoma cells, miR-1 precursors were stably transfected into chordoma cell lines UCH-1 and CH-22. Cell Proliferation Assay and MTT were used to evaluate cell growth and proliferation. Restoring expression of miR-1 precursor decreased cell growth and proliferation in UCH-1 and CH-22 cells. These results indicate that suppressed miR-1 expression in chordoma may in part be a driver for tumor growth, and that miR-1 has potential to serve as prognostic biomarker and therapeutic target for chordoma patients.

Programmed cell death ligand 1 expression in osteosarcoma

Programmed cell death ligand 1 (PDL1, also known as B7H1) is a cell-surface protein that suppresses the cytotoxic CD8(+) T-cell-mediated immune response. PDL1 expression and its clinical relevance in sarcomas are not well understood. Therefore, we sought to measure RNA expression levels for PDL1 in 38 clinically annotated osteosarcoma tumor samples and aimed to determine if PDL1 expression correlates with clinical features and tumor-infiltrating lymphocytes (TIL). Quantitative real-time RT-PCR for PDL1 was optimized in 18 cell lines, of which 5 were osteosarcoma derived. qRT-PCR results were validated via flow cytometry and immunohistochemistry (IHC) in select cell lines. Total RNA was isolated from 38 human osteosarcoma samples for qRT-PCR analysis. Clinical data were sorted, and significance was determined by the Student t test. TILs were examined in patient samples by tissue microarray hematoxylin-eosin staining. We confirmed the constitutive PDL1 mRNA expression in cell lines by qRT-PCR, flow cytometry, and IHC. Across human osteosarcoma samples, PDL1 mRNA gene expression ranged over 4 log (>5,000-fold difference). Relative expression levels were evaluated against clinical factors such as age/gender, metastasis, recurrence, chemotherapy, percentage of necrosis, and survival; no significant associations were identified. The presence of TILs was associated with high PDL1 expression (R(2) = 0.37; P = 0.01). In summary, we developed an RNA-based assay to determine PDL1 expression levels, and we show, for the first time, that high levels of PDL1 are expressed in a subset of osteosarcoma, and PDL1 expression is positively correlated with TILs. Multiple agents targeting PD1/PDL1 are in clinical development, and this may be a novel immunotherapeutic strategy for osteosarcoma clinical trials.

Phase 2 trial of aromatase inhibition with letrozole in patients with uterine leiomyosarcomas expressing estrogen and/or progesterone receptors

BACKGROUND

Advanced uterine leiomyosarcoma (ULMS) is an incurable disease. A significant percentage of cases of ULMS express estrogen and/or progesterone receptors (ER and/or PR). To the authors' knowledge, the role of estrogen suppression in disease management is not known.

METHODS

The authors performed a single-arm phase 2 study of the aromatase inhibitor letrozole at a dose of 2.5 mg daily in patients with unresectable ULMS with ER and/or PR expression confirmed by immunohistochemistry. Tumor assessments were performed at baseline, 6 weeks, 12 weeks, and every 8 weeks thereafter. Toxicity was monitored throughout treatment. The primary endpoint was the progression-free survival at 12 weeks.

RESULTS

A total of 27 patients was accrued, with a median of 2 prior treatment regimens (range, 0-9 treatment regimens). The median duration of protocol treatment was 2.2 months (range, 0.4 months-9.9 months). The 12-week progression-free survival rate was 50% (90% confidence interval, 30%-67%). The best response was stable disease in 14 patients (54%; 90% CI, 36%-71%). Three patients, all of whom had tumors expressing ER and PR in > 90% of tumor cells, continued to receive letrozole for > 24 weeks. The most common reason for treatment discontinuation was disease progression (85%). Letrozole was found to be well tolerated.

CONCLUSIONS

Letrozole met protocol-defined criteria as an agent with activity in patients with advanced ULMS. Patients with the longest progression-free survival rate were those whose tumors strongly and diffusely expressed ER and PR.

Cyclin-dependent kinase 11 (CDK11) is crucial in the growth of liposarcoma cells

Liposarcoma is the second most common soft tissue sarcoma in adults, but treatment options have been quite limited thus far. In this study, we investigated the functional and therapeutic relevance of cyclin-dependent kinase 11 (CDK11) as a putative target in liposarcoma. CDK11 knockdown by synthetic siRNA or lentiviral shRNA decreased cell proliferation, and induced apoptosis in liposarcoma cells. Moreover, CDK11 knockdown enhances the cytotoxic effect of doxorubicin to inhibit cell growth in liposarcoma cells. These findings suggest that CDK11 is critical for the growth and proliferation of liposarcoma cells. CDK11 may be a promising therapeutic target for the treatment of liposarcoma patients.

Abstract LB-174: Translation of preclinical predictive sensitivity of Ewing sarcoma to PARP inhibition: Phase II study of olaparib in adult patients with recurrent/metastatic Ewing sarcoma following failure of prior chemotherapy

Based on preclinical biology (1, 2), this translational trial aimed to assess the efficacy and tolerability of the PARP inhibitor, olaparib, in patients with advanced Ewing sarcoma progressing after prior chemotherapy.

In this uncontrolled phase II pilot, adult participants with radiographically measureable disease received 400 mg of olaparib capsules, twice daily, until disease progression or drug intolerance. Tumor measurements were determined by CT or MRI, at 6 and 12 weeks after starting olaparib administration, and then every 8 weeks thereafter. Tumor response determinations were made according to RECIST 1.1, and adverse event determinations were made according to CTCAE, version 4.0. A total of 22 participants were planned to be enrolled using a conventional 2-step phase II study design. If no objective responses were observed after 12 participants had been followed for at least 3 months, further accrual would be stopped.

12 participants were enrolled, and all were evaluable. A single case each of grade 3 anemia and grade 3 thrombocytopenia was observed (see Table One). Otherwise, no significant or unexpected toxicities were observed while participants were receiving study drugs. There were 0 PR/CR, 4 SD (duration 10.9, 11.4, 11.9, and 18.4 wks), and 8 PD as best response. Of the SD, 2 had minor responses (-16.7% and -11.7% by RECIST 1.1). The median time to disease progression was 5.7 weeks. Further enrollment was therefore discontinued.

This study is the first report of a prospective phase II trial to evaluate the safety and efficacy of a PARP inhibitor in patients with Ewing sarcoma. Olaparib tablets were safe and well tolerated when administered to this small cohort at the 400 mg BID dose, although the median duration of dosing was for only 5.7 weeks. However, no significant responses were seen, and the short average interval to disease progression underscores the aggressiveness of this disease. Preclinical modeling supports exquisite in vivo sensitivity of this pathway in combination with chemotherapy, and such a trial of olaparib with temozolomide will begin shortly at our Center.

Toxicity Type # of Patients Grade 1 2 3 4 Anemia 1 0 0 0 0 Blood and lymphatic systems disorders: other 1 1 0 0 0 Fatigue 1 1 0 0 0 Fever 1 1 0 0 0 Pain 2 1 0 1 0 Rash maculo-papular 1 1 0 0 0 Nausea 1 1 1 0 0 Vomiting 1 1 0 0 0 Urinary tract infection 1 1 0 0 0 Platelet count decreased 2 1 1 0 Hypoglycemia 1 1 0 0 0 Metabolism and nutrition disorders: other 1 1 0 0 0 Arthritis 1 1 0 0 0 Musculoskeletal and connective tissue disorder: other 1 1 0 0 0 Dizziness 1 1 0 0 0 Nervous system disorders: other 1 1 1 0 0 Cough 3 3 0 0 0 Postnasal drip 1 1 0 0 0 Respiratory, thoracic and mediastinal disorders: other 1 1 0 0 0 Hypertension 1 1 0 0 0 Total 25 19 3 0 0

Citation Format: Edwin Choy, James Butrynski, David Harmon, Jeffrey Morgan, Suzanne George, Andrew Wagner, David D'Adamo, Greg Cote, Yael Rubinstein, Cyril Benes, Daniel Haber, Jose Baselga, George Demetri. Translation of preclinical predictive sensitivity of Ewing sarcoma to PARP inhibition: Phase II study of olaparib in adult patients with recurrent/metastatic Ewing sarcoma following failure of prior chemotherapy. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr LB-174. doi:10.1158/1538-7445.AM2013-LB-174

Abstract LB-167: Phase I dose escalation study of abexinostat and doxorubicin in patients with metastatic sarcomas

Intro/Objective: Several inhibitors of histone deacetylase have been shown to enhance chemotherapy induced apoptosis and reduce sarcoma tumor burden in preclinical models. We sought to determine the MTD, PK/PD, safety and toxicity of the histone deacetylase inhibitor (HDACi) abexinostat when administered with doxorubicin in patients with metastatic sarcomas.

Methods: Participants were enrolled in a standard 3x3 dose escalation phase I study design. Abexinostat was administered on days 1-5 with 75 mg/m2 of doxorubicin administered on day 4 of every 21 day cycle until disease progression, drug intolerance, or a cumulative lifetime dose of 450 mg/m2 of doxorubicin was reached. GCSF support was provided at physician discretion on Arm A or provided to all participants in Arm B. 3-6 subjects were administered abexinostat at doses of 15, 30, 45, and 60 mg/m2 BID. All patients without progressive disease after receiving a cumulative lifetime dose of 450 mg/m2 of doxorubicin continued with abexinostat as a single agent until disease progression. Results: 22 participants (10 with prior doxorubicin therapy) were enrolled (6 in Arm A, 14 in Arm B), 20 were evaluable for DLT, and 17 were evaluable for radiologic response. In Arm A, participants were administered abexinostat at 30 or 15 mg/m2 BID. DLTs of grade 3 and 4 ANC were observed in two out of three participants dosed at 30 mg/m2 BID. Neither of these patients received GCSF prophylaxis. In Arm B, participants were administered abexinostat at 30, 45, or 60 mg/m2 BID, all with mandated GCSF support. Two DLTs were observed on the 60 mg/m2 BID dose (grade 3 infection and grade 4 thrombocytopenia). The pharmacokinetics of abexinostat was not affected by doxorubicin. HDAC activity, as measured by histone acetylation in PBMC, was maximally inhibited at 30mg/m2 BID. In the 17 participants evaluable for radiologic response there was 1 PR, 11 SD, and 5 PD as best response, with 7 participants completing 5 cycles or more. 3 of those participants remain in SD as their last disease status when this abstract was submitted. 4 participants who continued on monotherapy remained in SD for a median of 9.8 weeks after completing doxorubicin. The most common toxicities were fatigue, thrombocytopenia, and anemia (see Table 1). No study related deaths were observed. Conclusion: The MTD for abexinostat is 45 mg/m2 BID when administered on days 1-5 when doxorubicin is given at 75 mg/m2 on day 4 of a 3-week cycle and GCSF support is provided. Toxicities were manageable and tumor responses were seen. Additional studies are needed to further define the specific contributions of HDAC inhibition for patients receiving doxorubicin to treat metastatic sarcoma.

Grade Type 1 2 3 4 Totals Fatigue 13 6 0 0 19 Platelets 10 3 1 2 16 Hemoglobin 11 4 1 0 16 Nausea 13 1 0 0 14 Neutrophils 4 1 4 3 12 Leukocytes 6 3 3 0 12 Diarrhea w/o prior colostomy 7 3 1 0 11 Hyperglycemia 7 1 1 0 9 QTc interval 7 2 0 0 9 Alopecia 1 5 1 0 7 Hypophosphatemia 3 4 0 0 7 Constipation 5 2 0 0 7 Extremity/limb pain 6 1 0 0 7 Anorexia 7 0 0 0 7 Lymphopenia 0 2 4 0 6 Pain: other 5 1 0 0 6 Hypomagnesemia 4 1 0 0 5 Hyponatremia 5 0 0 0 5 Taste disturbance 5 0 0 0 5

Citation Format: Edwin Choy, Sriram Balasubramanian, James Butrynski, Jeffrey Morgan, Mint Sirisawad, Chitra Mani, Suzanne George, Andrew Wagner, David Harmon, Yael Rubinstein, Zhenfeng Duan, Francis Hornicek, George Demetri. Phase I dose escalation study of abexinostat and doxorubicin in patients with metastatic sarcomas. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr LB-167. doi:10.1158/1538-7445.AM2013-LB-167