Outcomes of Allogeneic Hematopoietic Cell Transplantation in Patients with Myelofibrosis with Prior Exposure to Janus Kinase 1/2 Inhibitors

The impact of Janus kinase (JAK) 1/2 inhibitor therapy before allogeneic hematopoietic cell transplantation (HCT) has not been studied in a large cohort in myelofibrosis (MF). In this retrospective multicenter study, we analyzed outcomes of patients who underwent HCT for MF with prior exposure to JAK1/2 inhibitors. One hundred consecutive patients from participating centers were analyzed, and based on clinical status and response to JAK1/2 inhibitors at the time of HCT, patients were stratified into 5 groups: (1) clinical improvement (n = 23), (2) stable disease (n = 31), (3) new cytopenia/increasing blasts/intolerance (n = 15), (4) progressive disease: splenomegaly (n = 18), and (5) progressive disease: leukemic transformation (LT) (n = 13). Overall survival (OS) at 2 years was 61% (95% confidence interval [CI], 49% to 71%). OS was 91% (95% CI, 69% to 98%) for those who experienced clinical improvement and 32% (95% CI, 8% to 59%) for those who developed LT on JAK1/2 inhibitors. In multivariable analysis, response to JAK1/2 inhibitors (P = .03), dynamic international prognostic scoring system score (P = .003), and donor type (P = .006) were independent predictors of survival. Among the 66 patients who remained on JAK1/2 inhibitors until stopped for HCT, 2 patients developed serious adverse events necessitating delay of HCT and another 8 patients had symptoms with lesser severity. Adverse events were more common in patients who started tapering or abruptly stopped their regular dose ≥6 days before conditioning therapy. We conclude that prior exposure to JAK1/2 inhibitors did not adversely affect post-transplantation outcomes. Our data suggest that JAK1/2 inhibitors should be continued near to the start of conditioning therapy. The favorable outcomes of patients who experienced clinical improvement with JAK1/2 inhibitor therapy before HCT were particularly encouraging, and need further prospective validation.

Cardio-respiratory fitness is independently associated with cardio-metabolic risk markers in severely obese women

INTRODUCTION

Many studies have shown an inverse relationship between cardio-respiratory fitness and cardio-metabolic risk markers in normal-weight to moderately obese subjects. However, whether such a relationship exists in severely obese subjects is not known.

MATERIALS AND METHODS

Cardio-respiratory fitness was measured by bicycle spiroergometry in 308 severely obese women (all BMI>35 kg/m(2)). The following cardio-metabolic risk markers were assessed: Glycolized hemoglobin levels (HbA1c), fasting glucose, insulin, calculated HOMA index, triglycerides (TG), total, low-, high-density cholesterol (Chol, LDL; HDL), Chol/HDL-Ratio, and uric acid. Computed multiple stepwise linear regression models generally included age, weight and height as independent variables.

RESULTS

Multiple stepwise linear regression models indicated that peak but not aerobic threshold related cardio-respiratory fitness indices were independently of age, weight and height associated with several cardio-metabolic risk markers. Specifically, maximally achieved load (Watt-peak) explained 1.4% of the variance in glucose levels (beta= -0.13; p=0.04) and 2.8% of the variance in HbA1c levels (beta= -0.18; p=0.01), while maximally achieved O2-uptake explained 3.9% of the variance in TG levels (beta= -0.20, p=0.001).

CONCLUSION

Our data for the first time indicate that cardio-respiratory fitness is independently associated with cardio-metabolic risk markers in severely obese women.

Toxicity testing of freshwater sediment collected near freshwater aquaculture facilities in the Maritimes, Canada

In the Atlantic region of Canada, there are close to 50 land-based freshwater aquaculture facilities, most of which discharge wastewater to freshwater receiving environments. This study was designed to assess the chemical and toxicological characteristics of sediments in those receiving environments. Thirty sediment samples were collected from 3 locations (upstream, outfall and downstream) at seven freshwater aquaculture facilities. Toxicity tests conducted included amphipod growth, amphipod survival and Microtox™. Sediments were also analysed for ammonia/porewater ammonia, redox and sulphide. Porewater ammonia concentration for the amphipod survival test ranged from 0.01 to 42 mg/L at the conclusion of the 14-day survival test. Ammonia concentration in sediment ranged from 0.3-202 μg/g, sulphide concentration ranged from 0.15 to 17.4 μg/g, yet redox ranged from 32 to 594 mV. Microtox™  IC50 values ranged from 108,00 to >164,000 mg/L, yet amphipod survival ranged from 0 to 100%, depending on sampling locations. Amphipod survival was significantly related (P < 0.05) to porewater ammonia (at time = 0 and 14 days) and Microtox™  IC50 was significantly related (P < 0.05) to ammonia, sulphide and redox levels. These results indicate that discharges from some the land-based aquaculture facilities are impacting sediment dwelling benthic invertebrates at the outfall but that impact largely disappears by 100 m downstream. Furthermore those impacts were rarely detected during the early winter season, when biomass production was at the lowest.

The impact of medical comorbidities on the quality of care for patients with head and neck cancer

e16030

Background: Objectively assessing the treatment of patients with cancer offers a basis for raising the standard of care. Quality indicators provide criteria by which the safety of care can be measured and compared to defined benchmarks. However, variables influencing the metrics in quality can limit generalizability and applicability. Medical comorbidities pose significant threats to the care of patients with head and neck cancer. We sought to investigate the impact of medical comorbidities on quality indicators for patients undergoing management by the multidisciplinary team. Methods: Comorbidities were assessed in relation to quality indicators in 49 patients treated for squamous cell carcinoma of the head and neck over a 16-month period. Treatment with surgery, radiation, and chemotherapy was classified by the number and type of modalities delivered. Surgical procedures were stratified by high and low acuity as defined by extent. By univariate and multivariate analysis, medical comorbidities were correlated with length of hospital stay, readmission within 30 days, return to the operating room within 7 days, 30-day mortality, use of blood products, and surgical site infection. Results: Cardiovascular disease was present in 49% of patients, diabetes mellitus in 12%, liver disease in 8%, previous congestive heart failure in 4%, and chronic obstructive pulmonary disease in 17%. The presence of any single comorbidity was correlated with each of the negative indicators (p<0.05), and with multiple negative indicators (p<0.05). Comorbidities occurred more frequently in patients undergoing high acuity surgery (p<0.05) and combined modality therapy (p<0.05). Decreasing performance status and major clinical predictors were the factors most strongly associated with negative quality indicators. Conclusions: Approaches to adjust for comorbid status are critical to accurate assessment of quality indicators. Risk stratification of patients at initial evaluation can offer valuable criteria for selecting treatment. Evaluation and management of comorbidities by evidence-based guidelines may improve care.

Whole body vibration added to endurance training in obese women - a pilot study

Whole body vibration (WBV) training is an increasingly popular training method that is strongly promoted for weight loss, but scientific data on its effectiveness, particularly in obese subjects, are sparse. 14 obese women (BMI: 37.4 ± 1.3 kg/m2) randomized to 2 different groups (each n=7) participated in a 6-week endurance training program that was either combined or not combined with additional WBV training. Anthropometric measures, phase angle and body composition (assessed by bioelectrical impedance analysis; BIA), and resting energy expenditure (REE) were obtained before and after the training program. Body weight did not change during the training period (P=0.87), but waist circumference decreased in both groups (P=0.007; WBV: -3.4 ± 1.4 cm; no-WBV: -1.7 ± 0.7 cm) independent of WBV training (P=0.29 for group×time interaction). BIA revealed an enhancing effect of WBV training in comparison to no-WBV training on the phase angle (+0.20 ± 0.12° vs. -0.19 ± 0.12°; P=0.04) and calculated body cell mass (+0.8 ± 0.2 vs. -0.3 ± 0.4 kg; P=0.02), while calculated percentage fat mass decreased in both conditions (P=0.05) to similar extent (P=0.59; WBV: -0.8 ± 0.2%; no-WBV: -0.4 ± 0.5%). REE increased across the training (P=0.01; WBV: +77 ± 33 kcal/24 h; no-WBV: +68 ± 34 kcal/24 h), with this increase again not depending on WBV condition (P=0.85). Results of our pilot study in obese women provide preliminary evidence for a beneficial effect of WBV, when added to endurance training, on the bioelectrical phase angle, an increasingly recognized marker of individual's health status.

Direct improvement of quality of life using a tailored quality of life diagnosis and therapy pathway: randomised trial in 200 women with breast cancer

BACKGROUND

Despite thousands of papers, the value of quality of life (QoL) in curing disease remains uncertain. Until now, we lacked tools for the diagnosis and specific treatment of diseased QoL. We approached this problem stepwise by theory building, modelling, an exploratory trial and now a definitive randomised controlled trial (RCT) in breast cancer, whose results we report here.

METHODS

In all, 200 representative Bavarian primary breast cancer patients were recruited by five hospitals and treated by 146 care professionals. Patients were randomised to either (1) a novel care pathway including diagnosis of 'diseased' QoL (any QoL measure below 50 points) using a QoL profile and expert report sent to the patient's coordinating practitioner, who arranged QoL therapy consisting of up to five standardised treatments for specific QoL defects or (2) standard postoperative care adhering to the German national guideline for breast cancer. The primary end point was the proportion of patients in each group with diseased QoL 6 months after surgery. Patients were blinded to their allocated group.

RESULTS

At 0 and 3 months after surgery, diseased QoL was diagnosed in 70% of patients. The QoL pathway reduced rates of diseased QoL to 56% at 6 months, especially in emotion and coping, compared with 71% in controls (P=0.048). Relative risk reduction was 21% (95% confidence interval (CI): 0-37), absolute risk reduction 15% (95% CI: 0.3-29), number needed to treat (NNT)=7 (95% CI: 3-37). When QoL therapy finished after successful treatment, diseased QoL often returned again, indicating good responsiveness of the QoL pathway.

CONCLUSION

A three-component outcome system including clinician-derived objective, patient-reported subjective end points and qualitative analysis of clinical relevance was developed in the last 10 years for cancer as a complex intervention. A separate QoL pathway was implemented for the diagnosis and treatment of diseased QoL and its effectiveness tested in a community-based, pragmatic, definitive RCT. While the pathway was active, it was effective with an NNT of 7.

The effect of 6-weeks of aerobic exercise training on serum fetuin-A levels in non-diabetic obese women

Emerging evidence suggests that fetuin-A, a liver-derived glycoprotein, represents an important factor in the pathophysiology of the metabolic syndrome, type 2 diabetes and cardiovascular disease. So far circulating fetuin-A was found to be increased in fatty liver disease, however, the precise mechanisms regulating fetuin-A expression and secretion are largely unknown. Here we assessed serum fetuin-A levels in 14 non-diabetic, obese women (BMI 36.5 ± 1.5 kg/m (2)) before and after a 6-week aerobic exercise program. Despite decreasing waist circumference (from 114.9 ± 3.5 to 112.3 ± 3.2 cm; P = 0.006) and body fat content (from 44.1 ± 1.5% to 43.4 ± 1.5%; P = 0.022) regular exercise 3-times per week over a 6-week period did not affect serum fetuin-A levels (before vs. after: 0.440 ± 0.018 vs. 0.440 ± 0.014 μg/ml; P = 0.767). Thus, our data provide evidence against a major role of exercise in the regulation of serum fetuin-A levels in non-diabetic obese women.

Implementing a system of quality-of-life diagnosis and therapy for breast cancer patients: results of an exploratory trial as a prerequisite for a subsequent RCT

A system for quality-of-life diagnosis and therapy (QoL system) was implemented for breast cancer patients. The system fulfilled the criteria for complex interventions (Medical Research Council). Following theory and modeling, this study contains the exploratory trial as a next step before the randomised clinical trial (RCT) answering three questions: (1) Are there differences between implementation sample and general population? (2) Which amount and type of disagreement exist between patient and coordinating practitioners (CPs) in assessed global QoL? (3) Are there empirical reasons for a cutoff of 50 points discriminating between healthy and diseased QoL? Implementation was successful: 74% of CPs worked along the care pathway. However, CPs showed preferences for selecting patients with lower age and UICC prognostic staging. Patients and CPs disagreed considerably in values of global QoL, despite education in QoL assessment by outreach visits, opinion leaders and CME: Zero values of QoL were only expressed by patients. Finally, the cutoff of 50 points was supported by the relationship between QoL in single items and global QoL: no patients with values above 50 dropped global QoL below 50, but values below 50 and especially at 0 points in single items, induced a dramatic fall of global QoL down to below 50. The exploratory trial was important for defining the complex intervention in the definitive RCT: control for age and prognostic stage grading, support for a QoL unit combining patient's and CP's assessment of QoL and support for the 50-point cutoff criterion between healthy and diseased QoL.

Analytical and functional characterization of microcystins [Asp3]MC-RR and [Asp3,Dhb7]MC-RR: consequences for risk assessment?

The microcystin (MC) producing P. rubescens occurs in pre-alpine lakes and may impact fishery success, bathing, and raw water quality. P. rubescens extracts, characterized via LC-MS, contained the two MC-RR variants [Asp3]MC-RR and [Asp3,Dhb7]MC-RR. The protein-phosphatase-inhibition assay (cPPIA with phosphatases 1 and 2A) in its capability to quantify [Asp3]MC-RR, [Asp3,Dhb7]MC-RR, and MC-RR was compared to HPLC-DAD and anti-Adda-ELISA. The IC50 values (PP1 and PP2A) determined for MC-LR, MC-RR, and [Asp3]MC-RR were in the same range (1.9-3.8 and 0.45-0.75 nM). A 50-fold higher concentration of [Asp3,Dhb7]MC-RR (29.8 nM) was necessary to inhibit the PP2A by 50%. The PP1-IC50 of [Asp3,Dhb7]MC-RR was 22-fold higher (56.4 nM) than those of the other MCs, suggesting that specific structural characteristics are responsible for its weaker PPI capacity. Western blots demonstrated that [Asp3,Dhb7]MC-RR does not covalently bind to PP1. [Asp3,Dhb7]MC-RR has comparable in vivo LD50 values to MC-RR, despite a far lower PP-inhibiting capacity, suggesting that toxicodynamic and toxicokinetic characteristics of [Asp3,Dhb7]MC-RR are responsible for its high in vivo toxicity. The data demonstrate that cPPIA analysis of [Asp3,Dhb7]MC-RR-containing samples prevent reliable MC determination and lead to underestimation of potential toxicity.

Necessity for including quality of life diagnostics and therapy in routine oncological care: Evaluation by methods of clinical guideline implementation

18594

Background: Application of quality of life assessment has become an important topic in oncology. Current approaches, however, have focused on technical issues within single center settings overlooking the requirements of routine care. We report on implementing of structural elements of a quality of life diagnostics and therapy system (QoL system). It was designed as integral part of the health care program for breast cancer patients in a regional tumor center. Methods: The QoL system was implemented by a systematic approach (Med. Care, 39, Suppl.2, 2(2001). Its elements comprised (a) coordinating practitioners (CPs) who functioned as gate keepers for QoL related therapies, (b) experts in the QoL unit who provided QoL reports and specific therapeutic recommendations based on patients’ responses to the EORTC questionnaire, (c) professional health care providers in psychotherapy, pain therapy, social support, physiotherapy/lymph drainage, and fitness (nutrition, sports), (d) clinicians (gynecologists) for patient recruitment and (e) opinion leaders for educational influence on the CPs to keep the QoL system in daily practice. Success of implementation (as indicated by CPs’ QoL-related changes in knowledge, attitude and behavior) was evaluated in a prospective study with breast cancer patients. Results: The QoL system was applicable in all of 170 patients recruited between Dec. 2002-June 2004 (age 34–86yrs, UICC 0–4, breast conserving surgery 67%). From 75 CPs (mostly gynecologists) in the area only 39 fulfilled criteria for the QoL system, 1 refused to participate. 38 CPs showed knowledge about QoL following educational outreach visits. Concerning attitudes and behavior, 64% of CPs found the experts’ reports comprehensible, 56% followed their recommendations, 20% made additional actions. Follow-up 4 months after first QoL measurement revealed improvements in pain, body image and social life (p < .05). Conclusion: The study—in combining doctor’s approach and patient’s demands—showed success using methods of guideline implementation by improving QoL deficits within a routine oncological care. Effectiveness will be analyzed in an ongoing randomized trial.

No significant financial relationships to disclose.

Relevance of mandibular helical axis analysis in functional and dysfunctional TMJs

The helical axis (HA), or motion screw, yields a comprehensive description of joint motion. The perspective representation of this axis clearly visualizes the regularity of mandibular functional movements (Yatabe et al. 1997. Journal of Dentist Research 76, 714-719 and Gallo et al. 2000. Journal of Dental Research 79, 1566-1572). In this study, the sensitivity of the HA representation was investigated relative to (a) irregularities in pathologic motion of clicking temporomandibular joints (TMJs) for jaw opening/closing and (b) differences in food bolus size and consistency for unilateral mastication in subjects with normal TMJs. Mandibular motion relative to the head was acquired using a jaw tracker with six degrees-of-freedom with a sampling frequency of 70 Hz. The HA was calculated according to an eigenvalue method (Spoor and Veldpaus 1980. Journal of Biomechanics 13, 391-393) and parameters were defined describing its position and orientation relative to the anatomy. We analyzed 39 subjects with unilateral or bilateral reciprocal TMJ clicking during jaw opening/closing and seven asymptomatic subjects during unilateral mastication of five different types of soft and hard food in two different bolus sizes. The results showed a greater variability of the HA parameters in the group of clicking joints than in the asymptomatic group: in particular, the area in which the HA moved was wider in clicking joints than in normal ones and the HA in clicking TMJs had a much greater fluctuation than in normal ones. During unilateral mastication, for more consistent food or a bigger bolus the HA showed a significantly greater excursion of the orientation parameters. Furthermore a significantly greater excursion of the dorsoventral and of the craniocaudal component of the distance vector from the HA to the condyle were found. The helical axis analysis of mandibular movements was sensitive to kinematic irregularities of the mandible due to an internal joint derangement as well as to differences in food bolus size and consistency.