Serum LDH and LDH Isoenzymes in Chronic Renal Failure: Effect of Hemodialysis

Serum levels of several commonly measured enzymes are abnormal in patients with end-stage renal disease (ESRD). In the present study we measured serum total LDH activity and LDH isoenzymes in a group of 25 ESRD patients shortly before, during, and immediately after hemodialysis. Baseline serum total LDH activity in the ESRD group was midly but significantly higher than that found in the normal control group. The observed elevation was associated with an isomorphic pattern. Single passage of blood through the extracorporeal apparatus led to a rise in total LDH, LDH-3, LDH-2 and LDH-4, a pattern consistent with release from the platelets. A steady increase was noted in total LDH, LDH-5 and LDH-1 of arterial blood during hemodialysis. This was thought to be due to ultrafiltration-induced hemoconcentration, enzyme release from the formed elements within the extracorporeal circuit and complement-mediated leukocyte activation and pulmonary leukostasis. These observations should be taken into consideration with regards to interpretation of LDH and LDH isoenzyme values and proper time of blood sampling in ESRD patients.

Shortening of an existing generic online health-related quality of life instrument for dogs

OBJECTIVE

Development, initial validation and reliability testing of a shortened version of a web-based questionnaire instrument to measure generic health-related quality of life in companion dogs, to facilitate smartphone and online use.

MATERIALS AND METHODS

The original 46 items were reduced using expert judgment and factor analysis. Items were removed on the basis of item loadings and communalities on factors identified through factor analysis of responses from owners of healthy and unwell dogs, intrafactor item correlations, readability of items in the UK, USA and Australia and ability of individual items to discriminate between healthy and unwell dogs. Validity was assessed through factor analysis and a field trial using a "known groups" approach. Test-retest reliability was assessed using intraclass correlation coefficients.

RESULTS

The new instrument comprises 22 items, each of which was rated by dog owners using a 7-point Likert scale. Factor analysis revealed a structure with four health-related quality of life domains (energetic/enthusiastic, happy/content, active/comfortable, and calm/relaxed) accounting for 72% of the variability in the data compared with 64% for the original instrument. The field test involving 153 healthy and unwell dogs demonstrated good discriminative properties and high intraclass correlation coefficients.

CLINICAL SIGNIFICANCE

The 22-item shortened form is superior to the original instrument and can be accessed via a mobile phone app. This is likely to increase the acceptability to dog owners as a routine wellness measure in health care packages and as a therapeutic monitoring tool.

Cancer and serious mental illness: A qualitative exploration–findings

Introduction

Serious mental illness (SMI) is associated with poorer cancer outcomes. Reasons for such inequalities are unclear; those with this comorbidity receive fewer specialist interventions and die earlier than the general population. Further exploratory work is required.

Objectives

Exploring the experience of SMI and cancer from the perspective of those affected by this comorbidity and those caring for them professionally or informally.

Methods

Semi-structured interviews were conducted with ‘key patients’ living with SMI who had received a cancer diagnosis (n = 7), significant others who had supported key patients (n = 4) and healthcare professionals who had worked with at least one KP (n = 17). A panel of patients and professionals ratified interview guides. Interviews were analysed thematically.

Results

Mental health professionals were more confident in their knowledge of the needs of this population than oncology professionals, but were challenged by working with patients with major physical health needs. Key patients’ mental health appeared to remain stable after cancer diagnosis, and they expressed altruism towards others with comorbid cancer and SMI. Significant others and healthcare professionals were more likely to critique systemic aspects of care than were key patients.

Conclusions

Professionals feel challenged when working outside of their usual job role. Training needs include mental illness awareness in an oncology setting. Improved coordination and communication is required, encompassing significant others as well as professional groups. SMI may protect against the psychological impact of cancer. Key patients were keen to provide advice and support to others in similar situations. Further research is needed into these areas.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Abstract P1-09-02: Homologous repair deficiency (HRD) as measure to predict the effect of carboplatin on survival in the neoadjuvant phase II trial GeparSixto in triple-negative early breast cancer

Introduction

Addition of carboplatin to anthracycline/taxane-based neoadjuvant chemotherapy has shown to improve pathological complete response (pCR; ypT0 ypN0) rates in patients with triple-negative breast cancer (TNBC) in two large phase II studies (GeparSixto: von Minckwitz et al, Lancet Oncol 2014, CALGB 40603: Sikov WM, J Clin Oncol 2015). Participants of the GeparSixto study showed an improvement of pCR rate from 36.9 to 53.2% (p=0.005) and DFS by absolute 9% (HR 0.56 95% CI 0.33-0.96] p=0.035) with the addition of carboplatin in the TNBC subgroup. No effect was observed in the HER2-positive subgroup. We here report results on homologous repair deficiency (HRD) status in relation to pCR and DFS in the TNBC subgroup.

Patients and Methods

In the GeparSixto trial (NCT01426880), patients were treated for 18 weeks with paclitaxel 80mg/m2 q1w and non-pegylated-liposomal doxorubicin (NPLD) 20mg/m2 q1w. Patients with TNBC (N=315) received concurrently bevacizumab 15mg/kg i.v. q2w until surgery. All patients were randomized 1:1 to receive concurrently carboplatin AUC 1.5-2 q1w vs no carboplatin. Carboplatin dose was reduced from AUC 2.0 to 1.5 by an amendment after 330 patients. Primary objective is pCR rate (ypT0 ypN0). Event free survival (EFS), and overall survival (OS) were secondary objectives. HR Deficiency status was assessed on FFPE material from pretherapeutic core biopsies. HR Deficiency was defined as either HRD score high or a BRCA mutation.

Results

HRD status was measurable in 193 of 315 TNBC patients. 101 patients of them were randomly assigned to receive carboplatin and 92 to no additional carboplatin. After median follow-up of 34.3 months 43 event free survival (EFS) events have been reported.

HR deficiency was detected in 136 (70.5%) tumors of which 79 (58.1%) showed high HRD score with intact tBRCA. HR deficiency independently predicted pCR (ypT0is ypN0) (odds ratio (OR) 2.506, CI 1.243-5.051, p=0.009). Adding carboplatin to PM significantly increased the pCR rate from 36.6% to 63.2% in HR deficient tumors with intact tBRCA (p=0.018), only marginally from 61.9% to 72.7% in BRCA mutated tumors (p=0.406), and moderately from 20.0% to 40.7% in HR non-deficient tumors (p=0.086). In general, patients with HRD deficient tumors had a better ESF than non HRD deficient ones (HR 1.805 (0.985-3.309); p=0.0526). Patients with high HRD score had an insignificant trend towards an improved EFS compared to those with low HRD score (HR 1.546 (0.764-3.127) p=0.2223). HRD deficiency did not predict carboplatin effect in patients without BRCA mutation (HR 0.8617). In multivariable analysis, only therapy, clinical nodal status before treatment, and lymphocyte predominant breast cancer were significant prognostic on EFS.

Conclusion

Within the GeparSixto study HR deficiency (either HRD score high or BRCA mutation) was associated with a higher pCR in general and an improved EFS. The effect of carboplatin could not be predicted by HR deficiency in this relatively small study. However, the results will help to understand the role of HR deficiency and the value of the HRD score in TNBC especially in patients without BRCA mutation.

Citation Format: von Minckwitz G, Timms K, Untch M, Elkin EP, Hahnen E, Fasching PA, Schneeweiss A, Salat CT, Rezai M, Blohmer J-U, Zahm D-M, Jackisch C, Gerber B, Klare P, Kümmel S, Paepke S, Schmutzler R, Chau S, Reid J, Hartman A-R, Nekljudova V, Weber KE, Loibl S. Homologous repair deficiency (HRD) as measure to predict the effect of carboplatin on survival in the neoadjuvant phase II trial GeparSixto in triple-negative early breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-09-02.

Timing of Aspirin and Secondary Preventative Therapies in Acute Stroke: Support for Use of Stroke Units

Background: We aimed to study the timing of aspirin prescription in ischaemic stroke comparing patients admitted to an acute stroke unit (ASU) directly or via a general medical ward. We also analysed prescription of secondary preventive therapies in stroke patients in an ASU. Methods: Retrospective analysis was made of medical notes and prescription records of 69 patients admitted to an ASU over a three month period to establish timing of aspirin prescription with respect to onset of stroke symptoms, CT brain scan and route of admission to the ASU. Results: CT brain scans were obtained at a median of 2.1 days post stroke (IQ range 1.3–4.3). Patients directly admitted to the ASU received aspirin earlier post admission compared to those admitted via a medical ward (0.7 vs 2.2 days, p<0.01) and were also more likely to receive aspirin prior to CT scan being performed (57% vs 19%, p=0.02). 86% of stroke patients were discharged on an antiplatelet therapy, 79% on a statin, 37% on a thiazide diuretic and 32% on an ACE inhibitor or angiotensin II antagonist. Conclusion: Aspirin was given more promptly in acute stroke and more commonly prior to CT scanning in an ASU compared to a medical ward. Statin therapy is used extensively in stroke but there is a much lower rate of initiation of other secondary preventive therapies (e.g. anti-hypertensive therapy) in hospital. These findings demonstrate a hesitancy in early use of aspirin amongst general physicians and lends support for the use of stroke units.

Impact of canine overweight and obesity on health-related quality of life

Canine obesity is increasing in prevalence in the UK and raises concerns about dog welfare. This study compares the health-related quality of life (HRQL) of dogs of varying body condition: overweight and obese (BCS 4 and 5) versus non-overweight dogs (BCS 2 and 3), obese (BCS 5) versus non-overweight (BCS 2 and 3) and an overall comparison between all four BCS (BCS 2, 3, 4 and 5) using a novel, validated HRQL instrument which is both web and mobile tablet/phone app based. Of 271 dog owners who were approached, 174 completed a web-based instrument (2013) or a mobile tablet app instrument (2014) during the summers of 2013 and 2014. Automatically generated scores in four domains of HRQL (energetic/enthusiastic, happy/content, active/comfortable, calm/relaxed) were compared for dogs with each of the body condition scores (BCS 2-5). For all body condition scores a statistically significant difference was found between the HRQL scores in two of the domains: energetic/enthusiastic (p=0.02) and active comfortable (p=0.004). When BCS 2 and 3 were compared to BCS 4 and 5, statistical significance was found in the same two domains - energetic/enthusiastic (p=0.01) and active comfortable (p=0.001) - as it was in comparison of non-overweight (BCS 2 and 3) compared to obese dogs (BCS 5): energetic/enthusiastic (p=0.012) and active comfortable (p=0.004). These results suggest that overweight and obese dogs have a reduced HRQL in two of the domains compared to non-overweight dogs, and that differences in HRQL are detectable between BCS scores 2, 3, 4 and 5.

Popliteal artery entrapment syndrome: an important differential diagnosis to consider in young military personnel presenting with calf claudication

Popliteal artery entrapment syndrome is a rare but important condition, which all military health practitioners should be aware of. It should be considered in all young military personnel presenting with symptoms of calf claudication. This article explains the condition, its classification and the key examination findings, allowing differentiation from other diagnoses, as well as advice on management, definitive treatment and prognosis.

Older inpatients' room preference: single versus shared accommodation

INTRODUCTION

The Royal Victoria Hospital, a geriatric medicine assessment and rehabilitation hospital in Edinburgh, was re-provided into a new 130 bed purpose-built unit on the Western General Hospital site in June 2012. All patient rooms in the new unit are single occupancy with en-suite facilities.

METHODS

We surveyed inpatients on their room preference in 2008 and repeated the survey with inpatients in the new unit in 2013. Patients were asked whether they would prefer to be in a shared room or a single room and to explain the reason behind their choice. They were also asked whether they would prefer to eat their meals in a day/dining room or by their bed. The patients in the 2013 survey were also questioned as to whether they felt lonely in their single room. Forty-three inpatients agreed to participate in the 2008 survey and 46 in the 2013 survey. All had an abbreviated mental test score≥8/10. In 2008, those surveyed had a mean age of 78. In 2013, the mean age was 83.

RESULTS

In 2008, 37.2% of patients expressed a preference for single room accommodation, whereas in 2013, 84.8% said that they preferred a single room. The majority of patients, 60.5% in 2008 and 76.1% in 2013, preferred to eat their meal at their bedside. Only 8.7% of patients in 2013 would consider eating in a day/dining room compared with 34.9% in 2008. In the 2013 survey, 60.9% of patients reported that they never felt lonely in a single room.

DISCUSSION

The benefits of single room versus multi-occupancy room hospital accommodation has been recently debated. The results from our survey indicate a marked difference in the preference for a single room between 2008 and 2013. The introduction of open visiting and care rounding has reduced the risk of isolation in single rooms. Our survey introduces new discussion about social isolation, privacy, noise levels and patient well-being and recovery.

Impact of analgesic modality on stress response following laparoscopic colorectal surgery: a post-hoc analysis of a randomised controlled trial

BACKGROUND

Epidural analgesia is perceived to modulate the stress response after open surgery. This study aimed to explore the feasibility and impact of measuring the stress response attenuation by post-operative analgesic modalities following laparoscopic colorectal surgery within an enhanced recovery after surgery (ERAS) protocol.

METHODS

Data were collected as part of a double-blinded randomised controlled pilot trial at two UK sites. Patients undergoing elective laparoscopic colorectal resection were randomised to receive either thoracic epidural analgesia (TEA) or continuous local anaesthetic infusion to the extraction site via wound infusion catheter (WIC) post-operatively. The aim of this study was to measure the stress response to the analgesic modality by measuring peripheral venous blood samples analysed for serum concentrations of insulin, cortisol, epinephrine and interleukin-6 at induction of anaesthesia, at 3, 6, 12 and 24 h after the start of operation. Secondary endpoints included mean pain score in the first 48 h, length of hospital stay, post-operative complications and 30-day re-admission rates.

RESULTS

There was a difference between the TEA and WIC groups that varies across time. In the TEA group, there was significant but transient reduced level of serum epinephrine and a higher level of insulin at 3 and 6 h. In the WIC, there was a significant reduction of interleukin-6 values, especially at 12 h. There was no significant difference observed in the other endpoints.

CONCLUSIONS

There is a significant transient attenuating effect of TEA on stress response following laparoscopic colorectal surgery and within ERAS as expressed by serum epinephrine and insulin levels. Continuous wound infusion with local anaesthetic, however, attenuates cytokine response as expressed by interleukin-6.