Preliminary Studies on Bemitradine-Induced Cardiotoxicity in Female Rats

The mechanism of bemitradine (SC-33643) cardiotoxicity in female rats was investigated in the set of preliminary experiments reported here. Specifically, the involvement of bemitradine metabolites and the potential role of adrenal epinephrine release were examined. Desethylbemi-tradine (the primary metabolite of bemitradine) was shown to be cardiotoxic at oral dosages greater than 300 mg/kg for 7 days. In a separate experiment, a major metabolite (bemitradine glycol) unique to the rat was not cardiotoxic at dosages up to 600 mg/kg for 7 days. Treatment of rats with SKF 525-A enhanced the lethality and the cardiotoxicity of bemitradine. In contrast, prior treatments of rats with phenobarbital resulted in decreased cardiotoxicity of both bemitradine and desethylbemitradine (a bemitradine metabolite presumably further metabolized by the microsomal mixed function oxidases). In other independent experiments, bemitradine-induced cardiotoxicity was shown to be accompanied by adrenal damage and decreases in adrenal epinephrine. Propranolol (a β-antagonist) treatment protected rats against cardiotoxicity. Bemitradine also had a direct effect on the heart, as evidenced in an experiment in which bemitradine caused dose-related increases in the T-wave of the rat ECG complex. These data suggest that (1) both bemitradine and desethylbemitradine may be responsible for the cardiotoxicity, and the other downstream metabolites are not and (2) cardiotoxicity may be due to the combination of direct effects of bemitradine on the rat heart and the bemitradine-mediated release of adrenal epinephrine (a known cardiotoxin at high circulating levels).

Long-term outcome of HER2 positive metastatic breast cancer patients treated with first-line trastuzumab

BACKGROUND

Trastuzumab has changed the natural history of metastatic HER2 positive breast cancer. Some patients remain well and in remission for many years. There is currently no established duration after which trastuzumab in the advanced setting can be safely discontinued. This study aims to evaluate long-term efficacy and cardiac safety of trastuzumab when used as first-line treatment for patients with metastatic HER2 positive breast cancer.

PATIENT AND METHODS

We retrospectively identified 215 patients with HER2 positive, locally advanced or metastatic breast cancer who commenced first line trastuzumab-containing therapy for metastatic disease between 2001 and 2010 at The Royal Marsden Hospital.

RESULTS

The median progression free survival for all patients was 12 months (95%CI: 10.3-14.6 months); 103 (48%) patients remained in remission beyond one year, 59 (27%) beyond two years and 25 (12%) beyond five years. The median overall survival was 2.6 years (95% confidence interval (CI): 2.2-3.3). The objective response rate (ORR) was 65% with 17 (8%) complete responses and 120 (57%) partial responses. Trastuzumab was well tolerated. Twenty eight (13%) patients recorded any grade of left ventricular dysfunction. There was no significant difference in cardiac toxicity between those patients on less than or more than one year of trastuzumab.

CONCLUSION

Trastuzumab is associated with long-term remissions in a significant proportion of patients with metastatic HER2 positive disease when used in the first-line advanced setting.

Lessons from aviation - the role of checklists in minimally invasive cardiac surgery

We describe an adverse event during minimally invasive cardiac surgery that resulted in a multi-disciplinary review of intra-operative errors and the creation of a procedural checklist. This checklist aims to prevent errors of omission and communication failures that result in increased morbidity and mortality. We discuss the application of the aviation - led “threats and errors model” to medical practice and the role of checklists and other strategies aimed at reducing medical errors.

Meta-analysis of suicide rates among psychiatric in-patients

OBJECTIVE

To examine factors associated with the number of psychiatric admissions per in-patient suicide and the suicide rate per 100,000 in-patient years in psychiatric hospitals.

METHOD

Random-effects meta-analysis was used to calculate pooled estimates, and meta-regression was used to examine between-sample heterogeneity.

RESULTS

Forty-four studies published between 1945 and 2013 reported a total of 7552 in-patient suicides. The pooled estimate of the number of admissions per suicide calculated using 39 studies reporting 150 independent samples was 676 (95% CI: 604-755). Recent studies tended to report higher numbers of admissions per suicide than earlier studies. The pooled estimate of suicide rates per 100,000 in-patient years calculated using 27 studies reporting 95 independent samples was 147 (95% CI: 138-156). Rates of suicide per 100,000 in-patient years tended to be higher in more recent samples, in samples from regions with a higher whole of population suicide rate, in samples from settings with a shorter average length of hospital stay and in studies using coronial records to define suicide.

CONCLUSION

Rates of in-patient suicide in psychiatric hospitals vary remarkably and are disturbingly high. Further research might clarify the extent to which patient factors and the characteristics of in-patient facilities contribute to the unacceptable mortality in psychiatric hospitals.

Online patient safety education programme for junior doctors: is it worthwhile?

BACKGROUND

Increasing demand exists for blended approaches to the development of professionalism. Trainees of the Royal College of Physicians of Ireland participated in an online patient safety programme.

AIMS

Study aims were: (1) to determine whether the programme improved junior doctors' knowledge, attitudes and skills relating to error reporting, open communication and care for the second victim and (2) to establish whether the methodology facilitated participants' learning.

METHODS

208 junior doctors who completed the programme completed a pre-online questionnaire. Measures were "patient safety knowledge and attitudes", "medical safety climate" and "experience of learning". Sixty-two completed the post-questionnaire, representing a 30 % matched response rate.

RESULTS

Participating in the programme resulted in immediate (p < 0.01) improvement in skills such as knowing when and how to complete incident forms and disclosing errors to patients, in self-rated knowledge (p < 0.01) and attitudes towards error reporting (p < 0.01). Sixty-three per cent disagreed that doctors routinely report medical errors and 42 % disagreed that doctors routinely share information about medical errors and what caused them. Participants rated interactive features as the most positive elements of the programme.

CONCLUSIONS

An online training programme on medical error improved self-rated knowledge, attitudes and skills in junior doctors and was deemed an effective learning tool. Perceptions of work issues such as a poor culture of error reporting among doctors may prevent improved attitudes being realised in practice. Online patient safety education has a role in practice-based initiatives aimed at developing professionalism and improving safety.

A phase II randomized trial of induction chemotherapy versus no induction chemotherapy followed by preoperative chemoradiation in patients with esophageal cancer

BACKGROUND

The contribution of induction chemotherapy (IC) before preoperative chemoradiation for esophageal cancer (EC) is not known. We hypothesized that IC would increase the rate of pathologic complete response (pathCR).

METHODS

Trimodality-eligibile patients were randomized to receive no IC (Arm A) or IC (oxaliplatin/FU; Arm B) before oxaliplatin/FU/radiation. Surgery was attempted ∼5-6 weeks after chemoradiation. The pathCR rate, post-surgery 30-day mortality, overall survival (OS), and toxic effects were assessed. Bayesian methods and Fisher's exact test were used.

RESULTS

One hundred twenty-six patients were randomized dynamically to balance the two arms for histology, baseline stage, gender, race, and age. Fifty-five patients in Arm A and 54 in Arm B underwent surgery. The median actuarial OS for all patients (54 deaths) was 45.62 months [95% confidence interval (CI), 27.63-NA], with median OS 45.62 months (95% CI 25.56-NA) in Arm A and 43.68 months (95% CI 27.63-NA) in Arm B (P = 0.69). The pathCR rate in Arm A was 13% (7 of 55) and 26% (14 of 54) in Arm B (two-sided Fisher's exact test, P = 0.094). Safety was similar in both arms.

CONCLUSIONS

These data suggest that IC produces non-significant increase in the pathCR rate and does not prolong OS. Further development of IC before chemoradiation may not be beneficial. Clinical trial no.: NCT 00525915 (www.clinicaltrials.gov).

Bridging the gap: an integrated paediatric to adult clinical service for young adults with kidney failure

PROBLEM

Transition from paediatric to adult care of young adults with chronic diseases is poorly coordinated, often delayed, and usually managed through a single referral letter. About 35% of young adults lose a successfully functioning kidney transplant within 36 months of transfer from paediatric to adult services.

DESIGN

Before and after study of the impact of a new integrated paediatric-adult clinical service for patients with kidney failure.

SETTING

Adult renal centre in Oxford and two paediatric renal centres in London.

STRATEGIES FOR CHANGE

An integrated paediatric-young adult joint transition clinic and care pathway was established in 2006, in conjunction with a young adult clinical service with regular community based clinics. Previously, young adult transplant recipients were transferred by a single referral letter to an adult renal consultant and managed in a conventional adult clinic.

KEY MEASURES FOR IMPROVEMENT

Rates of acute rejection and loss of kidney transplants five years before and five years after the introduction of the integrated young adult care pathway. EFFECTS OF THE CHANGE: Nine young adult kidney transplant recipients were transferred directly to adult care between 2000 and 2006 (group 1). From 2006 to 2010, 12 young adult transplant recipients underwent integrated transition into the new young adult service (group 2). Six transplants were lost in group 1 (67%) compared with no transplant losses in group 2.

LESSONS LEARNT

Implementing an integrated transition clinic, coupled with improving young adults' healthcare experience through a young adult clinic, improved patient adherence to regular medication and engagement with healthcare providers, as judged by reduced transplant failure rates. This model may be applicable to other young adult populations with chronic disease transferring to adult healthcare.

Minimally invasive esophagectomy versus open esophagectomy, a symptom assessment study

Minimally invasive esophagectomy (MIE) is used with hope to decrease the morbidity associated with an open esophagectomy. Reflux and dumping syndromes are the most important functional complaints in patients after esophagectomy. This study compares the functional benefits of MIE with open esophagectomy. The study enrolled patients who underwent either minimally invasive or open esophagectomy for cancer between 2004 and 2009. No patients in the MIE group had a pyloroplasty or myotomy. Each patient in the MIE group was paired to a patient in the open esophagectomy group via propensity matching. Matching variables included age, race, gender, preoperative treatment, history of prior cancer, American Society of Anesthesiologists Risk Scale, performance status, clinical stage, body mass index, histology, level of anastomosis, and time elapsed since surgery. The patients were asked to answer 26 questions about their reflux and dumping using validated questionnaires. A total of 181 patients were included in the study. From this group, 44 pairs of patients were created and used for the analysis. The median follow-up was 12.1 months for the MIE group and 18.3 months for the open group. The reflux score was slightly worse in the MIE group (5.5 versus 3.5, P= 0.021). There was no difference in the dumping symptoms between the two groups. The most common complaints seen in the dumping questionnaire in almost one-third of all patients were early satiety, abdominal discomfort, nausea, and diarrhea. Of the patients, 77% were satisfied or very satisfied with their condition in the MIE group compared with 93% in the open group (P= 0.287). Reflux, dumping, and overall satisfaction after MIE without pyloroplasty are comparable with those obtained after open esophagectomy with a pyloric drainage procedure.

Different depth intermittent sand filters for laboratory treatment of synthetic wastewater with concentrations close to measured septic tank effluent

The objective of this study was to apply hydraulic and chemical oxygen demand (COD) loading rates at the upper limits of the design criteria for buried sand filters to test the sand filter depth design criteria. Over a 274-day study duration, synthetic effluent with a strength of domestic wastewater was intermittently dosed onto two sand filters of 0.2 m diameter, with depths of 0.3 and 0.4 m. Hydraulic and organic carbon loading rates of 105 L m(-2) d(-1) and 40 g COD m(-2) d(-1), respectively, were applied to the filters. The filters did not clog and had good effluent removal capabilities for 274 and 190 days, respectively. However, the 0.3 m-deep filter did experience a reduced performance towards the end of the study period. In the 0.3 and 0.4 m-deep filters, the effluent COD and SS concentrations were less than 86 and 31 mg L(-1), respectively, and nitrification was nearly complete in both these columns. Ortho-phosphorus (PO(4)-P) removal in fine sand and laterite 'upflow' filters, receiving effluent from the 0.3 m-deep filter, was 10% and 44%, respectively.

What is optimal flow using a mini-bypass system?

The purpose of this study is to determine the appropriate arterial pump flow /cardiac index (CI) utilizing a mini-bypass system. The unique feature of most mini-bypass systems is that the centrifugal pump combines the function of kinetic venous drainage with arterial pump flow. Therefore, if drainage is reduced, arterial pump flow is also reduced. Managing this system can present challenges to the clinical perfusionist. We reviewed fifteen cases, using the Medtronic Resting Heart System (RHS). This retrospective study examined the arterial pump flow, measured as cardiac index (CI), mean arterial pressure, inlet venous saturation, urine output, vasopressor use, and lactate production during routine cardiac surgery. The mean cardiac index for all patients was 1.90 +/- 0.14, range 1.63-2.08 L/min/m(2). The mean hemoglobin on cardiopulmonary bypass (CPB) was 10.6 +/- 1.2, with a range of 9.2-13.3 g/dL. The lactate produced on CPB was 2.03 +/-0.67 with a range of 1.5-3.5 mmol/L. The mean change in lactate measured from pre CPB to post CPB was 0.85 +/- 0.71 with a median lactate of 0.6 mmol/L. The venous saturation was 65.53 +/- 6.03% with a median of 65% and a range of 57-82%. The mean arterial pressure was 67.04 +/- 10.45 mmHg with a median of 62.5 mmHg. The median urine output was 125 mls. The vasopressor median was 2200 microg. All patients were maintained on CPB with a mean nasopharyngeal temperature of 35.43 degrees Celsius. Despite using lower than predicted flows, it would appear that adequate perfusion is provided. The higher hemoglobin content achieved through reduced hemodilution and reduced inflammation appears to enable this system to deliver adequate flow and perfusion at reduced cardiac indices. This research provides evidence which challenges longstanding beliefs that a cardiac index of 2.4 L/min/m(2) is required for all cases.

A randomised pilot Phase II study of doxorubicin and cyclophosphamide (AC) or epirubicin and cyclophosphamide (EC) given 2 weekly with pegfilgrastim (accelerated) vs 3 weekly (standard) for women with early breast cancer

Accelerated (dose-dense) chemotherapy, in which the frequency of administration is increased without changing total dose or duration, may increase the efficacy of cancer chemotherapy. We performed a randomised Phase II study to assess the safety and relative toxicity of AC (doxorubicin; cyclophosphamide) vs E(epirubicin)C given by conventional or accelerated schedules as neoadjuvant or adjuvant chemotherapy for early breast cancer. Furthermore, the relative toxicity of doxorubicin and epirubicin remains uncertain. Patients were randomised to one of four arms; four courses of standard 3 weekly cyclophosphamide 600 mg m⁻² in combination with doxorubicin 60 mg m⁻² (AC) vs epirubicin 90 mg m⁻² (EC) 3 weekly vs the same regimens administered every 2 weeks with pegfilgrastim (G-CSF). A total of 126 patients were treated, 42 with standard AC, 42 with accelerated AC, 19 with standard EC and 23 with accelerated EC. Significantly more grade 3/4 day one neutropenia was seen with standard (6/61, 10%) compared to accelerated (0/65,) regimens (P=0.01). A trend towards more neutropenic sepsis was seen in the combined standard and accelerated AC arms (12/84, 14%) compared to the combined EC arms (1/42, 2%), P=0.06. Falls in left ventricular ejection fraction were not increased with accelerated treatment. Accelerated AC and EC with pegfilgrastim are safe and feasible regimens in the treatment of early breast cancer with less neutropenia than conventional 3 weekly schedules.

Difficult Peripheral Venous Access: Recognizing and Managing the Patient at Risk

Nurses commonly face challenges placing peripheral intravenous (IV) lines in adults and children, a situation described as difficult venous access (DVA). Multiple venipuncture attempts can heighten patient anxiety and suffering, delay vital treatment, and increase costs. Numerous factors such as small, fragile or hidden veins can predispose patients to DVA, and collapsed veins due to dehydration are especially problematic. Several techniques can improve venous prominence, but when IV access cannot be achieved promptly, other routes of administration can be valuable. For rehydration fluids and certain drugs, subcutaneous administration may be a safe and effective alternative, providing cost and ease-of-use advantages.

Platinum-based chemotherapy in triple-negative breast cancer

BACKGROUND

Experimental data suggest that triple-negative (TN) breast cancer may have increased sensitivity to platinum-based chemotherapy but clinical data are limited. We present our long-term results with platinum-based chemotherapy for TN breast cancer.

PATIENTS AND METHODS

In all, 94 (17 TN), 79 (11 TN) and 155 (34 TN) patients receiving platinum-based chemotherapy in neo-adjuvant/adjuvant and advanced setting were included. Response rates and outcome were compared for TN tumours versus others.

RESULTS

Neo-adjuvant complete response rates were significantly higher for TN tumours (88%) than others (51%; P = 0.005). The 5-year overall survival (OS) for TN tumours following adjuvant/neo-adjuvant chemotherapy was 64% [95% confidence interval (CI) 44% to 79%] compared with 85% (95% CI 79% to 90%) for others. Five-year disease-free survival for TN tumours was 57% (95% CI 37% to 73%) compared with 72% (95% CI 64% to 78%) for others. For patients with advanced breast cancer, overall response rates were 41% for TN tumours and 31% for others (P = 0.3). Patients with TN tumours had a significantly prolonged progression-free survival of 6 months compared with 4 months for others (P = 0.05), though the OS was not significantly different between the two groups (11 versus 7 months).

CONCLUSION

Platinum-based chemotherapy achieves increased response rates for TN tumours, with a trend towards worse survival in early breast cancer through an improved survival in advanced disease. Prospective randomised trials are warranted.