Developing Treatments for Stimulant Abuse: A Brief Overview

The abuse of stimulants such as cocaine, amphetamine, and methamphetamine is a huge problem in many parts of the world. Abuse of these drugs does not ruin just the user's life, but also adversely affects those around them. Despite many years of research, there are no approved medications for stimulant dependence, and treatment is focused on psychotherapy and abstinence. Over the last 10 to 20 years, there have been some major changes in approach to medication development for stimulant dependence. These include assessing ligands for non-dopaminergic sites, atypical dopamine transporter ligands, blocking long-term potentiation and / or memory reconsolidation, vaccines against the stimulant, and molecular approaches including pharmacogenomics and gene silencing. Also included in this overview are non-drug treatments such as deep brain stimulation and psychosurgery. This overview highlights recent preclinical and clinical studies of treatment development for stimulant dependence.

Autologous CD34+ Cell Therapy for Refractory Angina: 2-Year Outcomes From the ACT34-CMI Study

An increasing number of patients have refractory angina despite optimal medical therapy and are without further revascularization options. Preclinical studies indicate that human CD34⁺ stem cells can stimulate new blood vessel formation in ischemic myocardium, improving perfusion and function. In ACT34-CMI (N = 167), patients treated with autologous CD34⁺ stem cells had improvements in angina and exercise time at 6 and 12 months compared to placebo; however, the longer-term effects of this treatment are unknown. ACT34 was a phase II randomized, double-blind, placebo-controlled clinical trial comparing placebo, low dose (1 × 10⁵ CD34/kg body weight), and high dose (5 × 10⁵ CD34/kg) using intramyocardial delivery into the ischemic zone following NOGA^® mapping. To obtain longer-term safety and efficacy in these patients, we compiled data of major adverse cardiac events (MACE; death, myocardial infarction, acute coronary syndrome, or heart failure hospitalization) up to 24 months as well as angina and quality of life assessments in patients who consented for 24-month follow-up. A total of 167 patients with class III-IV refractory angina were randomized and completed the injection procedure. The low-dose-treated patients had a significant reduction in angina frequency (p = 0.02, 0.035) and improvements in exercise tolerance testing (ETT) time (p = 0.014, 0.017) compared to the placebo group at 6 and 12 months. At 24 months, patients treated with both low-and high-dose CD34⁺ cells had significant reduction in angina frequency (p = 0.03). At 24 months, there were a total of seven deaths (12.5%) in the control group versus one (1.8%) in the low-dose and two (3.6%) in the high-dose (p = 0.08) groups. At 2 years, MACE occurred at a rate of 33.9%, 21.8%, and 16.2% in control, low-, and high-dose patients, respectively (p = 0.08). Autologous CD34⁺ cell therapy was associated with persistent improvement in angina at 2 years and a trend for reduction in mortality in no-option patients with refractory angina.

Abstract 161: Heart Failure Care Transitions: A Queuing Theory Approach to Match Variable Hospital Discharge Rate With Outpatient Clinic Capacity

Background: Heart failure (HF) readmissions remain a major driver of cost and health care utilization. Timely follow-up of patients post-discharge represents an evidence-based intervention proven to reduce readmission rates. A previously unexplored characteristic of hospital discharges is variability in discharge caseload. This variability thwarts the timeliness of follow-up, negates the benefit of transition care planning and may lead to a higher risk of HF readmissions. Queuing theory is the mathematical study of waiting times. We opted to use queuing theory to determine if caseload can be determined more precisely in a manner that sufficiently accommodates HF discharge variability.

Objective: To analyze the impact of hospital discharge rate variability on outpatient clinic capacity needs using HF hospitalization discharge data and operations management approaches.

Methods: Higher risk hospitalizations requiring active transitional care heart failure management were detected using an enterprise data warehouse-supported process over the study period. Queuing theory approaches were used to model the impact of HF discharge clinic capacity on wait time to an appointment. Discharge clinic was modeled as a single 7-day follow-up appointment, with an acceptable scheduling window of 5 to 9 days post-discharge.

Results: During the study period of 100 days, 566 HF discharges were made, for a median of 5.66 discharges daily, or 39.6 discharges weekly. The distribution of daily discharges was skewed rightward (mode = 3, range = 0 to 18, standard deviation = 3.3, coefficient of variation = 0.58). Current clinic design: Providing one discharge slot for every hospital discharge (100% utilization) leads to an average wait of 18.3 days prior to an appointment, with only 31.9% of appointments scheduled within 7 days, and 38.9% of appointments scheduled within 9 days. Clinic re-design (queuing theory): Providing five extra discharge appointment slots per week (88% utilization or 13.6% excess capacity) reduces the expected waiting period to 1.1 days, with 99.8% of patients seen within 7 days, and virtually all patients seen within 9 days of discharge.

Conclusions: Deployment of queuing theory allows for a more precise quantification of needed clinical capacity to accomplish appropriate HF follow-up with a reasonable degree of certainty. Our simplified model demonstrates that variability in hospital discharge rates leads to excessive clinic wait times in the absence of a modest capacity buffer and consequently exposes patients to a higher risk of HF readmission. We show using single center HF discharge data that a 10-15% increase in capacity is needed to ensure an adequate follow-up service level. Ongoing process of care work will demonstrate if optimization of clinic load yields a significant reduction in HF readmissions.

Abstract 152: Enterprise Data Warehouse-Supported Early Identification of Acute Decompensated Heart Failure Admissions for Efficient and Multidisciplinary Transitional Care Team Interventions

Background: Multidisciplinary transitional care teams represent a model for reducing heart failure readmissions. Within this context, early identification of patients hospitalized with acute decompensated heart failure (ADHF) permits meaningful transitional care plan development. Improving the efficiency of early identification of the higher risk ADHF patient represents an area not well studied in hospitalized heart failure (HF).

Objective: To validate the sensitivity and specificity of an enterprise data warehouse (EDW)-based strategy for early identification of patients with ADHF.

Methods: An EDW query was constructed to identify patients with ADHF based on clinical and diagnosis-related parameters, including BNP level and administration of intravenous diuretics. The EDW query was run daily; expert clinicians verified the diagnosis of ADHF based on comprehensive chart review. This classification was used to determine specificity of the query for ADHF. We computed the sensitivity of the EDW-based approach by matching query results to heart failure diagnosis related group (DRG) data and primary discharge diagnosis data from separate hospital systems.

Results: During the study period of 70 days, a total of 2354 charts were screened (33.6 charts per day). A total of 410 patients were identified by chart review as having heart failure requiring active management, for a specificity of 17.4%. Sensitivity was computed using both heart failure DRG data and primary discharge diagnosis data. Of the 114 patients discharged with a heart failure DRG (291, 292, or 293), all 114 were detected a priori by the admission EDW screen, for a sensitivity of 100%. A similar analysis conducted using HF principal diagnoses, which includes cardiac surgery-related admissions, yielded a sensitivity of 97.2%.

Conclusions: EDW-based screening of patients based on simple clinical parameters early in the hospitalization is highly sensitive for detection of ADHF hospitalizations, but specificity is low. Brief chart review by expert clinicians is rapid, and identifies a specific cohort of patients that can be targeted for multidisciplinary HF transitional care. A better delineation of risk has broad outpatient workflow implications. Ongoing process improvements will demonstrate if early identification of at-risk patients yields significant reduction in HF readmissions.

A feasibility study of behavioural activation for depressive symptoms in adults with intellectual disabilities

BACKGROUND

Important work has been carried out adapting cognitive behavioural therapy for people with intellectual disabilities. However, there is a lack of alternative psychological therapies available for people with intellectual disabilities and emotional difficulties. Behavioural activation for depression is less reliant on verbal communication and focuses on increasing purposeful activity and reducing avoidance.

METHOD

This feasibility study involved the development and piloting of an adapted manual of behavioural activation for people with intellectual disabilities. The intervention consisted of 10-12 sessions and a key adaptation was that the therapist worked with the clients alongside a significant other in their life, either a paid carer or family member. Baseline, post-intervention (3 months after entering the study) and 6-month quantitative follow-up data were obtained. Primary outcome data were gathered, concerning depressive symptoms, participants' levels of activity and general well-being.

RESULTS

Twenty-three adults with intellectual disabilities with symptoms of depression were recruited from specialist health services. In terms of acceptability, the behavioural activation intervention was well received and only two individuals dropped out, with a further two lost to follow-up. The main measures of depression appeared to be sensitive to change. Pre- to post-intervention data showed a significant reduction in self-report of depressive symptoms with a strong effect size (r = 0.78), that was maintained at follow-up (r = 0.86). Positive change was also obtained for informant reports of depressive symptoms from pre- to post-intervention, with a strong effect size (r = 0.7). Once again, this positive change was maintained at follow-up (r = 0.72).

CONCLUSIONS

The study suggested that behavioural activation may be a feasible and worthwhile approach to tackling depression in people with intellectual disabilities. However, a randomised controlled trial would be required to establish its effectiveness, with more sensitive measurement of change in activity.

Targeting clinical outcomes: Endovascular simulation improves diagnostic coronary angiography skills

OBJECTIVE

The purpose of this study is to determine the effects of simulation-based medical education (SBME) on the skills required to perform coronary angiography in the cardiac catheterization laboratory.

BACKGROUND

Cardiovascular fellows commonly learn invasive procedures on patients. Because this approach is not standardized, it can result in inconsistent skill acquisition through exclusion of concepts and skills. Also, the learning curve varies between trainees yielding variability in skill acquisition. Therefore, coronary angiography skills are an excellent target for SBME in an environment in which direct patient care is not jeopardized.

METHODS

From January 2013 to June 2013, 14 cardiovascular fellows entering the cardiac catheterization laboratory at a tertiary care teaching hospital were tested on an endovascular simulator to assess baseline skills. All fellows subsequently underwent didactic teaching and preceptor-lead training on the endovascular simulator. Topics included basic catheterization skills and a review of catheterization laboratory systems. Following training, all fellows underwent a post-training assessment on the endovascular simulator. Paired t tests were used to compare items on the skills checklist and simulator defined variables.

RESULTS

Cardiovascular fellows scored significantly higher on a diagnostic coronary angiography skills checklist following SBME using an endovascular simulator. The mean pretest score was 66.6% (SD = 9.7%) compared to 86.0% (SD = 6.3%) following simulator training (P < 0.001). Additional findings include significant reduction in procedure time and use of cine-fluoroscopy at posttest.

CONCLUSIONS

SBME significantly improved cardiovascular fellows' performance of simulated coronary angiography skills. Standardized simulation-based education is a valuable adjunct to traditional clinical education for cardiovascular fellows.

Lenses and Lessons: Using three different research perspectives in early childhood education research

In contemporary Western research, collaboration is held in high esteem. This developing practice is chal¬lenging particularly for researchers who follow varying theoretical approaches. However although a challeng¬ing endeavour, when viewing the one data set with different lenses, there are various lessons that can be shared. A key aspect of this paper is involved researchers' different analytical perspectives in one data set to learn more about each other's research insights, rather than become instant expert in other's approaches. The interview data reported in this paper originates from a larger study researching parents' experience of using early child¬hood education and care (ECEC) in Australia. Here we analyse and report on two shared interview excerpts and use three different research lenses for analysis; phenomenographic study, conversational analysis and cul¬tural-historical theory. The finding of this paper demonstrates that applying different lenses provide different interpretations, including strengths, limitations and opportunities. In this paper we argue that collaborative research practices enhance our understanding of varying research approaches and the scope, quality, transla¬tion of research and the researchers' capacity are enhanced.

A phase I/II study of decitabine in combination with panitumumab in patients with wild-type (wt) KRAS metastatic colorectal cancer

PURPOSE

KRAS mutations are predictive of lack of response to monoclonal antibodies (mAb) against EGFR in metastatic colorectal cancer (mCRC). Most wild-type KRAS patients, however, are also resistant. Retrospective data suggest that EGFR silencing play a role in resistance to therapy. We conducted a study to evaluate the safety and efficacy of decitabine (a hypomethylating agent) in combination with panitumumab (mAb against EGFR) in mCRC patients.

EXPERIMENTAL DESIGN

20 patients with wild-type KRAS mCRC were included in this phase I/II study. Patients were treated with decitabine at 45 mg/m(2) IV over 2 h on day 1 and 15 and panitumumab 6 mg/kg IV over 1 h on day 8 and 22 every 28 days. Blood samples were collected at baseline, day 8, 15 and 22. Quantitative polymerase chain reaction was used to measure promoter-specific methylation in peripheral-blood cells (PBMCs).

RESULTS

The most common adverse events were grade 1-2 (rash and hypomagnesemia); 3 (16 %) patients had grade III-IV neutropenia including one patient with neutropenic fever. Two of 20 patients (10 %) had a partial response. Both had previously received cetuximab. Ten patients had stable disease (3 of them longer than 16 weeks). Decreased methylation of the MAGE promoter was not evidenced in PBMCs.

CONCLUSIONS

The combination of decitabine and panitumumab was well tolerated and showed activity in wild-type KRAS mCRC patients previously treated with cetuximab. Target modulation in surrogate tissues was not achieved and tumor biopsies were not available. Future studies evaluating hypomethylating agents in combination with EGFR mAb in patients with mCRC are warranted.

Abstract P6-07-24: Prognostic Tools in Early Breast Cancer: Predicting benefit of adjuvant chemotherapy

Introduction: Adjuvant chemotherapy (CT) in early breast cancer reduces the risk of mortality. However, absolute reductions in mortality can be small. For patient with low risk disease, prognostic tools such as ‘Adjuvant! Online’ and ‘Predict’ can be used to estimate the benefit of adjuvant chemotherapy. We compare the survival gains estimated using ‘Adjuvant! Online’ and ‘Predict’ in routine clinical practice, assessing the characteristics of patients in which ‘Adjuvant! Online’ and ‘Predict’ disagree.

Methods: In a retrospective study using the hospital electronic database, the clinical and pathological details of all patients with early breast cancer referred for adjuvant therapy at the Northern Ireland Cancer Centre in a 3 month period in 2011 were collected and were entered in to ‘Adjuvant! Online’ and ‘Predict’ to assess percentage benefit (absolute reduction in mortality at 10 years) from CT. We categorised patients into three prognostic groups: those where risk from CT outweighs benefit (&lt;2% predicted benefit), marginal benefit (2 to 5%) and significant benefit from CT (&gt;5%) We excluded patients with metastatic disease at presentation, DCIS, a second primary breast cancer or receiving neo-adjuvant treatment.

Results: Of the 250 patients identified, 61 (24.4%) fell in to different prognostic groups depending on whether ‘Adjuvant! Online’ or ‘Predict’ was used to calculate benefit from CT. In those in whom there was disagreement, ‘Adjuvant! Online’ suggested marginal or significant benefit in 75.4% of patients, compared to 55.7% using ‘Predict’. Nine patients had “major” comorbidities, which is weighted only in ‘Adjuvant! Online’, and were excluded in subsequent analysis. Of those without major comorbidities, ‘Adjuvant! Online’ offered at least 2% benefit in 85% of cases, and ‘Predict’ in only 58.3%. The majority (93.3%) of cases were ER positive, and node negative (85.0%). This difference was notable in women aged 65 or less, with 86.2% with &gt;2% benefit using ‘Adjuvant! Online’, compared to 55.1% using ‘Predict’. ‘Adjuvant! Online’ estimates of benefit were on average 3.7% higher for this age group. HER2 status had little impact, with similar recommendations using either ‘Adjuvant! Online’ or ‘Predict’.

Conclusions: This study highlights lack of concordance between two available online prognostic tools, notably in ER positive, node negative patients. For patients with a marginal benefit from adjuvant chemotherapy, care must be used when making adjuvant treatment decisions as other prognostic tools may be of help in this group of patients.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-07-24.

The single nucleotide polymorphism CRTh2 rs533116 is associated with allergic asthma and increased expression of CRTh2

BACKGROUND

CRTh2 (chemoattractant-receptor homologous molecule expressed on Th2 cells) is expressed by Th2 cells and other cells involved in allergic inflammation. Single nucleotide polymorphisms (SNPs) in CRTh2 (rs11571288, rs545659, rs634681) have been associated with various phenotypes of allergy in ethnically distinct populations. Here, we assessed the association between CRTh2 rs533116 and allergic asthma, expression of CRTh2 and Th2 cytokine production.

METHODS

CRTh2 rs533116 was genotyped in an ethnically diverse population (n = 1282). The proportion of cells expressing CRTh2 was determined in peripheral blood from subjects with allergic airways disease and controls as well as with in vitro differentiated Th2 cells. Receptor function was assessed by stimulating Th2 cells with the CRTh2-specific agonist 13,14-dihydro-15-keto-PGD(2) (DK-PGD(2) ) and measuring IL-4 and IL-13 by intracellular staining and ELISA.

RESULTS

CRTh2 rs533116 was associated with allergic asthma in White people (2.67 [1.09-6.55], P < 0.05), and expression of CRTh2 was higher in subjects with allergic airways disease compared to controls (P < 0.05). Among allergic individuals, the AA genotype was significantly associated with more eosinophils and higher expression of CRTh2 by both CD4(+) T cells and eosinophils (P < 0.05). In vitro, the AA genotype was associated with a higher proportion of CRTh2(+) cells during Th2 differentiation as well as more IL-4 and IL-13 expression following DK-PGD(2) stimulation (P < 0.05).

CONCLUSIONS

These findings show an association between CRTh2 rs533116 and allergic asthma and suggest this may be mediated by elevated expression of CRTh2, leading to higher numbers of circulating eosinophils and Th2 cytokine production.

The role of natural history collections in documenting species declines

Efforts to document the decline of extant populations require a historical record of previous occurrences. Natural history museums contain such information for most regions of the world, at least at a coarse spatial scale. Museum collections have been successfully used to analyse declines in a wide range of plants and animals, at spatial scales ranging from single localities to large biotic and political regions. Natural history museum collections, when properly analysed, can be an invaluable tool in documenting changes in biodiversity during the past century.

Allopregnanolone protects against dopamine-induced striatal damage after in vitro ischaemia via interaction at GABA A receptors

Sex steroid hormones, such as progesterone, have been shown to display neuroprotective properties after various models of central nervous system injury, including cerebral ischaemia, although the mechanism(s) of action remain largely undetermined. Allopregnanolone, an active progesterone metabolite, may explain some of the protective actions of progesterone. We utilised an in vitro model of ischaemia to evaluate the neuroprotective potential of allopregnanolone and examine its interaction at the GABA(A) receptor, which is hypothesised to be its main neuroprotective mechanism. In adult male mouse coronal caudate slices exposed to oxygen glucose deprivation (OGD), we measured aspects of OGD-induced dopamine release, which is neurotoxic during ischaemia, using fast cyclic voltammetry and also assessed tissue viability. The GABA(A) agonist, muscimol, displayed a neuroprotective profile in terms of delaying the OGD-evoked dopamine efflux (P < 0.05) and reducing the amount of dopamine released after OGD (P < 0.05). Allopregnanolone, at a concentration of 10(-6)  m, also displayed a neuroprotective profile because it significantly reduced the amount of dopamine efflux (P < 0.05) and reduced the loss of viable tissue after OGD compared to slices exposed to vehicle during OGD (P < 0.05). However, the effect of 10(-6)  m allopregnanolone on dopamine efflux was prevented in the presence of bicuculline, a competitive GABA(A) receptor antagonist. These results describe the use of an in vitro model of ischaemia with respect to determining that allopregnanolone is neuroprotective during the acute phase of ischaemia, and also demonstrate that such actions are dependent, at least in part, upon interaction at the GABA(A) receptor.