Conditioning with rabbit versus horse ATG dramatically alters clinical outcomes in identical twins with severe aplastic anemia transplanted with the same allogeneic donor

Severe aplastic anemia (SAA) is a rare disorder leading to bone marrow failure, which if left untreated, is invariably fatal. Conventional therapies with immunosuppressive therapy or allogeneic hematopoietic stem cell transplantation (HSCT) are highly effective. HSCT can offer a greater outcome in younger patients who have an available HLA match-related donor. Recent studies showing the addition of antithymocyte globulin (ATG) to the conditioning regimen improves engraftment and reduces the risk of graft-versus-host disease (GVHD).There are currently two ATG preparations in the USA, equine (or horse) and rabbit ATG. These agents are pharmacologically distinct, having significant differences in their pharmacokinetics and in vivo immunosuppressive effects [N Engl J Med 365(5):430–438, 2011]. Here, we report a case of two monozygotic twins with constitutional SAA that evolved to myelodysplastic syndrome (MDS) who both underwent allogeneic peripheral blood stem cell transplantation (PBSC) from the same single HLA antigen mismatched sibling donor with the only difference in the transplant regimen being the type of ATG used in the preparative regimen; one twin received horse ATG and the other received rabbit ATG during conditioning. This report emphasizes that dramatic differences in donor T cell chimerism and clinical outcomes including GVHD can occur as a consequence of the type of ATG that is utilized in the transplant conditioning regimen. These differences highlight that these agents should not be considered interchangeable drugs when used in this setting.

Clinical trial networks in orthopaedic surgery

The aim of this study was to review the role of clinical trial networks in orthopaedic surgery. A total of two electronic databases (MEDLINE and EMBASE) were searched from inception to September 2013 with no language restrictions. Articles related to randomised controlled trials (RCTs), research networks and orthopaedic research, were identified and reviewed. The usefulness of trainee-led research collaborations is reported and our knowledge of current clinical trial infrastructure further supplements the review. Searching yielded 818 titles and abstracts, of which 12 were suitable for this review. Results are summarised and presented narratively under the following headings: 1) identifying clinically relevant research questions; 2) education and training; 3) conduct of multicentre RCTs and 4) dissemination and adoption of trial results. This review confirms growing international awareness of the important role research networks play in supporting trials in orthopaedic surgery. Multidisciplinary collaboration and adequate investment in trial infrastructure are crucial for successful delivery of RCTs.

Cite this article: Bone Joint Res 2014;3:169–74.

Mindfulness-based interventions for obesity-related eating behaviours: a literature review

Mindfulness-based interventions (MBIs) targeting eating behaviours have gained popularity in recent years. A literature review was conducted to determine the effectiveness of MBIs for treating obesity-related eating behaviours, such as binge eating, emotional eating and external eating. A search protocol was conducted using the online databases Google Scholar, PubMed, PsycINFO and Ovid Healthstar. Papers were required to meet the following criteria to be included in this review: (i) describe a MBI or the use of mindfulness exercises as part of an intervention; (ii) include at least one obesity-related eating behaviour as an outcome; (iii) include quantitative outcomes; and (iv) be published in English in a peer-reviewed journal. A total of N = 21 papers were included in this review. Interventions used a variety of approaches to implement mindfulness training, including combined mindfulness and cognitive behavioural therapies, mindfulness-based stress reduction, acceptance-based therapies, mindful eating programmes, and combinations of mindfulness exercises. Targeted eating behaviour outcomes included binge eating, emotional eating, external eating and dietary intake. Eighteen (86%) of the reviewed studies reported improvements in the targeted eating behaviours. Overall, the results of this first review on the topic support the efficacy of MBIs for changing obesity-related eating behaviours, specifically binge eating, emotional eating and external eating.

Diagnosing autistic spectrum disorder in the age of austerity

BACKGROUND

Diagnosing autistic spectrum disorder is a challenge, typically involving myriad professionals. In the current climate we explore how diagnosis is managed in the real world by professionals.

METHODS

Using semi-structured interviews we thematically analyse data from psychiatrists, paediatricians and educational psychologists.

RESULTS

While there is some consistency across and within these groups there are also a number of variances, and several important issues are highlighted. These include the problem of time and resources, the issue of location for diagnosis, the value of diagnostic tools and schedules, the need for supporting information, the difficulty of multi-agency working, the relevance of a physical examination and the eventual diagnostic label.

CONCLUSIONS

In the current economic climate and considering changes in guidelines there is a need to evaluate current service provision and enhance services. However, attention needs to be paid to the practical and realistic application of the suggested guidance.

Abstract P2-18-17: Breast cancer surgery for the elderly - Are we meeting a growing need?

Background≤br≥Between 2002 and 2011, in the UK, the number of people aged 90 increased by 26%. By 2034 the number of people aged 85 and over, is projected to be 2.5 times larger than in 2009. Life expectancy of 80 year old woman is now 9.4 years.

These population statistics bring challenges to the provision of healthcare in general and Breast Cancer Services will see a significant increase in the number of very elderly patients.

Prior to 2009 it was common place to treat patients aged over 80 with endocrine therapy alone, avoiding surgery, however as the general life expectancy for this age group has improved this is no longer recommended management.

NICE guidelines issued in February 2009 recommend surgery for breast cancer where possible over endocrine treatment

We aim to review the proportion of patients presenting with breast cancer aged over 80, assess their management and survival during a 12 year period and audit patients presenting after 2009 against NICE guideline to explore reasons for noncompliance.

Methods

We have conducted a retrospective audit of all patients presenting with breast cancer to a single high-volume center from 2000-2012.

Patients were identified from a comprehensive departmental database recording patient demographics as well as treatment modality.

For patients treated after 2009, case records were accessed to assess the reasons for omitting surgery.

One-tailed Fisher's Exact Test used throughout to calculate p-values.

Results≤br≥5446 patients were treated at our unit from 2000-2012 with the over 80's comprising 6.0-8.7% p.a.

This age group increased over time by 29% from 6.5% in 2000-2003 to 8.4% (p = 0.0001) in 2009-2012. The population aged 90 or over increased by around 50% from 1.7% to 2.6% (p = 0.06) in the same period.

The table below shows changes in the proportion of patients offered surgery before and after the 2009 guidelines.

Patients Undergoing Breast Cancer SurgeryPatients aged 80-89Patients aged 90 and over2000- 20082009-2012p-value2000-20082009-2012p-value267/396 (67%)172/230 (75%)0.0318/64 (28%)21/47 (44%)0.05

Following introduction of regional anaesthesia without General Anasthesia in 2011, the proportion of patients aged over 90 having surgery, increased further to 16/25 (64% p-0.0031).

In the 10 year period from 2001-2010 the mastectomy rate was 60% in the over 80's and 45% in the over 90 year old, however this difference was not statistically significant (p = 0.29).

We have accurate survival data for 396 patients who died during follow up. No patients died within 12 months of surgery. The median survival was 40 months following surgery and 27 months for patients treated with primary endocrine therapy.

16/218 patients aged 80-89 and 2/111 patients aged over 90 at diagnosis required resectional surgery after relapse on primary endocrine therapy.

Of patients not having surgery after 2009, 48 were deemed unfit and 36 declined surgery.

Conclusions≤br≥The elderly is a growing part of our population of breast cancer patients.

We have increased the proportion of elderly patient having surgery in line with NICE guidance, partly due regional anaesthesia for breast surgery and modification of care pathways. The relapse rate following primary endocrine therapy was very low in the most elderly patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-17.

The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients

BACKGROUND

Among trauma patients who survive to reach hospital, exsanguination is a common cause of death. A widely practicable treatment that reduces blood loss after trauma could prevent thousands of premature deaths each year. The CRASH-2 trial aimed to determine the effect of the early administration of tranexamic acid on death and transfusion requirement in bleeding trauma patients. In addition, the effort of tranexamic acid on the risk of vascular occlusive events was assessed.

OBJECTIVE

Tranexamic acid (TXA) reduces bleeding in patients undergoing elective surgery. We assessed the effects and cost-effectiveness of the early administration of a short course of TXA on death, vascular occlusive events and the receipt of blood transfusion in trauma patients.

DESIGN

Randomised placebo-controlled trial and economic evaluation. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial co-ordinating centre staff) were masked to treatment allocation. All analyses were by intention to treat. A Markov model was used to assess cost-effectiveness. The health outcome was the number of life-years (LYs) gained. Cost data were obtained from hospitals, the World Health Organization database and UK reference costs. Cost-effectiveness was measured in international dollars ($) per LY. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the results to model assumptions.

SETTING

Two hundred and seventy-four hospitals in 40 countries.

PARTICIPANTS

Adult trauma patients (n = 20,211) with, or at risk of, significant bleeding who were within 8 hours of injury.

INTERVENTIONS

Tranexamic acid (loading dose 1 g over 10 minutes then infusion of 1 g over 8 hours) or matching placebo.

MAIN OUTCOME MEASURES

The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury and other.

RESULTS

Patients were allocated to TXA (n = 10,096) and to placebo (n = 10,115), of whom 10,060 and 10,067 patients, respectively, were analysed. All-cause mortality at 28 days was significantly reduced by TXA [1463 patients (14.5%) in the TXA group vs 1613 patients (16.0%) in the placebo group; relative risk (RR) 0.91; 95% confidence interval (CI) 0.85 to 0.97; p = 0.0035]. The risk of death due to bleeding was significantly reduced [489 patients (4.9%) died in the TXA group vs 574 patients (5.7%) in the placebo group; RR 0.85; 95% CI 0.76 to 0.96; p = 0.0077]. We recorded strong evidence that the effect of TXA on death due to bleeding varied according to the time from injury to treatment (test for interaction p < 0.0001). Early treatment (≤ 1 hour from injury) significantly reduced the risk of death due to bleeding [198 out of 3747 patients (5.3%) died in the TXA group vs 286 out of 3704 patients (7.7%) in the placebo group; RR 0.68; 95% CI 0.57 to 0.82; p < 0.0001]. Treatment given between 1 and 3 hours also reduced the risk of death due to bleeding [147 out of 3037 patients (4.8%) died in the TXA group vs 184 out of 2996 patients (6.1%) in the placebo group; RR 0.79; 95% CI 0.64 to 0.97; p = 0.03]. Treatment given after 3 hours seemed to increase the risk of death due to bleeding [144 out of 3272 patients (4.4%) died in the TXA group vs 103 out of 3362 patients (3.1%) in the placebo group; RR 1.44; 95% CI1.12 to 1.84; p = 0.004]. We recorded no evidence that the effect of TXA on death due to bleeding varied by systolic blood pressure, Glasgow Coma Scale score or type of injury. Administering TXA to bleeding trauma patients within 3 hours of injury saved an estimated 755 LYs per 1000 trauma patients in the UK. The cost of giving TXA to 1000 patients was estimated at $30,830. The incremental cost of giving TXA compared with not giving TXA was $48,002. The incremental cost per LY gained of administering TXA was $64.

CONCLUSIONS

Early administration of TXA safely reduced the risk of death in bleeding trauma patients and is highly cost-effective. Treatment beyond 3 hours of injury is unlikely to be effective. Future work [the Clinical Randomisation of an Antifibrinolytic in Significant Head injury-3 (CRASH-3) trial] will evaluate the effectiveness and safety of TXA in the treatments of isolated traumatic brain injury (http://crash3.lshtm.ac.uk/).

TRIAL REGISTRATION

Current Controlled Trials ISRCTN86750102, ClinicalTrials.gov NCT00375258 and South African Clinical Trial Register DOH-27-0607-1919.

FUNDING

The project was funded by the Bupa Foundation, the J P Moulton Charitable Foundation and the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 10. See HTA programme website for further project information.

A rapid automatic technique for generating operant key-press behavior in rats

Experimentally naive rats were trained to key press on a fixed-ratio 10 schedule of food reinforcement by a completely automatic procedure within a single, 1-hr session. Control procedures demonstrated that the resulting behavior was an operant, under control of the schedule of reinforcement and the specified reinforcing stimulus (food). A simple, combination food-tray operandum, also described, was used as the basis for the training technique.

Concurrent fixed-ratio and avoidance responding in the squirrel monkey

Squirrel monkeys maintained concurrent performances appropriate to a fixed-ratio schedule of food reinforcement on one lever and an avoidance schedule on a second lever. The overall rate of responding maintained by either schedule was not systematically affected when the other schedule was discontinued and its lever removed.

Combined tumor necrosis factor-α (TNF–α) and interleukin-2 (IL-2) blockade in acute steroid refractory graft-versus-host disease (SR-GVHD) following allogeneic hematopoietic stem cell transplantation (HCT)

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Background: SR-GVHD is a frequent and often fatal complication of HCT. A variety of inflammatory cytokines have been implicated in the pathogenesis of GVHD; single agent therapy against targets such as the IL-2 receptor α chain (daclizumab) or TNF-α (infliximab) has modest activity in SR-GVHD. We hypothesized that concomitant blockade of both TNF-α and IL-2 pathways would be more effective in controlling SR-GVHD than inhibition of either cytokine alone. Methods: The incidence of and outcome following SR-GVHD in 141 pts undergoing nonmyeloablative HCT from an HLA-matched family donor at our institution between February 2001 and November 2008 were analyzed. All SR-GVHD pts were treated with a combination of daclizumab (1 mg/kg, days1, 4, 8, 15, 22) and infliximab (10 mg/kg, days1, 8, 15, 22); in addition, aspergillus prophylaxis, empiric broad-spectrum antibiotics, and a rapid reduction in the dose of corticosteroids was initiated in order to minimize the risk of opportunistic infections associated with immunosuppression. Results: Twenty-three pts (23/141, 16%) developed SR-GVHD (median age 35 y, range 17–65 y); involved organs included the GI tract (n = 23), liver (n = 3), and skin (n = 8). We observed a remarkably high response rate following therapy, with 20/23 (87%) pts experiencing complete resolution of GVHD. Responses were usually delayed (median onset 2 weeks) but durable. The most notable complication associated with therapy was the development of opportunistic infections (invasive fungal infections in 3 pts); in 2/3 of these cases, prophylactic antifungal therapy had been discontinued prematurely due to drug toxicity. The median survival for the SR-GVHD cohort was 255 days (range 67–2,148 days), with 10/23 pts surviving at the time of this analysis. Causes of death included underlying cancer (5 pts), CMV disease (2 pts), and infectious complications (5 pts). Conclusions: These data suggest combined TNF-α /IL-2 blockade is a highly effective therapeutic option for pts with SR-GVHD and highlight the need for aggressive antimicrobial prophylaxis in the management of this condition.

No significant financial relationships to disclose.

Efficacy and safety of gefitinib and potential prognostic value of soluble EGFR, EGFR mutations, and tumor markers in a Gynecologic Oncology Group phase II trial of persistent or recurrent endometrial cancer

e16542

Background: A phase II trial was performed to evaluate the efficacy and safety of gefitinib and to explore epidermal growth factor receptor (EGFR, sEGFR), estrogen receptor (ER) and progesterone receptor (PRA, PRB) expression in persistent/recurrent endometrial cancer (EC). Methods: Women with histologically-confirmed, measurable, persistent/recurrent EC following one or two prior regimens were eligible and treated with 500 mg oral gefitinib daily until progression or severe toxicity. A 2-stage group sequential design was used to evaluate the regimen with PFS at 6 months as the primary endpoint. The trial had a 10% type I error rate with 90% power. sEGFR was quantified in serum and categorized at the median (1960 fmol/ml). Mutations in exons 18–21 of EGFR and IHC-expression of EGFR, pEGFR, ER, PRA, PRB, pERK, or Ki67 were examined in tumors. Results: Of the 29 enrolled, 26 were evaluable for efficacy and toxicity. Four had PFS ≥6 months, 1 had a complete response, 7 had stable disease, 16 had progressive disease and 2 were indeterminate. High pre-cycle 1 sEGFR level was favorably associated with OS (hazard ratio = 0.33, 95% confidence interval = 0.13–0.84). A mutation in exon 18 of EGFR (E709K) was observed but was not associated with clinical outcome. None of the tumor markers was associated with response, PFS, or OS. Among some of the notable correlations observed in primary tumor expression were ER with PRA (r = 0.504), EGFR with pERK (r = 0.802), and pEGFR with pERK (r = 0.728). Changes in expression were notable for pEGFR (increasing) and pERK (increasing) in primary versus pre-treatment persistent/recurrent tumor. Conclusions: The regimen was tolerable but lacked sufficient efficacy to warrant further evaluation in this setting, however, the association between serum sEGFR and OS, correlations between tumor markers, and changes in expression of pEGFR and pERK are interesting and should be validated in future investigations. This study was supported by NIH grant R01CA099908 and NCI grants CA27469, CA11479 and CA37517.

No significant financial relationships to disclose.

Vascular factors predict rate of progression in Alzheimer disease

BACKGROUND

While there is considerable epidemiologic evidence that cardiovascular risk factors increase risk of incident Alzheimer disease (AD), few studies have examined their effect on progression after an established AD diagnosis.

OBJECTIVE

To examine the effect of vascular factors, and potential age modification, on rate of progression in a longitudinal study of incident dementia.

METHODS

A total of 135 individuals with incident AD, identified in a population-based sample of elderly persons in Cache County, UT, were followed with in-home visits for a mean of 3.0 years (range: 0.8 to 9.5) and 2.1 follow-up visits (range: 1 to 5). The Clinical Dementia Rating (CDR) Scale and Mini-Mental State Examination (MMSE) were administered at each visit. Baseline vascular factors were determined by interview and physical examination. Generalized least-squares random-effects regression was performed with CDR Sum of Boxes (CDR-Sum) or MMSE as the outcome, and vascular index or individual vascular factors as independent variables.

RESULTS

Atrial fibrillation, systolic hypertension, and angina were associated with more rapid decline on both the CDR-Sum and MMSE, while history of coronary artery bypass graft surgery, diabetes, and antihypertensive medications were associated with a slower rate of decline. There was an age interaction such that systolic hypertension, angina, and myocardial infarction were associated with greater decline with increasing baseline age.

CONCLUSION

Atrial fibrillation, hypertension, and angina were associated with a greater rate of decline and may represent modifiable risk factors for secondary prevention in Alzheimer disease. The attenuated decline for diabetes and coronary artery bypass graft surgery may be due to selective survival. Some of these effects appear to vary with age.

Limited ileo-caecal resection for localised Crohn's disease in childhood: Clinical outcome and predictors of further surgery

OBJECTIVES

To investigate the outcome of limited ileo-caecal resection in children with localised Crohn's disease (CD) and determine predictors of further surgery.

METHODS

Review of children diagnosed with CD and operated on for ileo-caecal disease from 1995 to 2005. Age at diagnosis, endoscopic disease distribution, indication for surgery, site of recurrence and date of last follow-up were recorded. Surgery required removal of only the ileo-caecal junction and caecal pole with removal of the minimum terminal ileal length.

RESULTS

Thirty seven children underwent intestinal resection. Time between primary operation and most recent follow-up was 3.8 years (range 1 month-8.8 years). Indications for surgery were obstruction/stricture (20), treatment-resistant disease (13) and abscess/perforation peritonitis (4). Follow-up was available in 32. Nine (28%) required re-laparotomy. Median time to second laparotomy was 12 months (range 4-58 months). Eighteen children required no endoscopies after surgery (median follow-up 3.4 years).

CONCLUSION

Most conservative surgery occurs about 2 years after diagnosis. About 1 in 4 children have a further laparotomy within 12 months. Over half of these require division of adhesions. Limited ileo-caecal resection for localized Crohn's disease is not associated with early peri-anastomotic recurrence. Developments in laparoscopic surgery are likely to further reduce complications from adhesions.

Peripartum myocardial ischemia: a review of Canadian deliveries from 1970 to 1998

OBJECTIVE

The purpose of this study was to evaluate the incidence of peripartum myocardial ischemia in Canada.

STUDY DESIGN

We identified the cohort of women who were admitted to Canadian hospitals for delivery between 1970 and 1998 to calculate the incidence rate and to evaluate potential risk factors.

RESULTS

One hundred fourteen of 10,032,375 women delivered in Canadian hospitals between 1970 and 1998 had peripartum myocardial ischemia recorded as a discharge diagnosis. The overall crude incidence rate was 1.1 (95% confidence interval 0.93, 1.37) women with peripartum myocardial ischemia per 100,000 women delivering per year as noted in the Canadian Hospital Morbidity database. Rates did not increase over time but increased with maternal age. Identified risk factors were diabetes mellitus, hyperlipidemia, and chronic heart disease. The case fatality rate among women with the disease was 1.8%.

CONCLUSION

The incidence of peripartum myocardial ischemia did not increase between 1970 and 1998 in Canada, despite an aging cohort with more prevalent medical comorbidities. Maternal mortality from this event is lower than previously described.