Systematically assessed symptoms as outcome predictors in emergency patients

INTRODUCTION

It is known that symptoms are predictive of mortality in "nonsurgical" emergency patients. It is unknown whether a prospective, systematic, and "unscreened" assessment of all symptoms is of any prognostic value. Therefore, we aimed to examine the association between symptoms and outcomes in an all-comer population.

METHODS

Data were acquired during 6weeks at the ED of the University Hospital Basel, a tertiary hospital. Consecutive patients presenting to the ED were included. Symptoms at presentation were systematically assessed using a comprehensive questionnaire.

RESULTS

A consecutive sample of 3960 emergency patients with a median age of 51years (51.7% male) was studied. The median number of symptoms was two. In the group of patients with the most prevalent symptoms, the median number of symptoms ranged between two and five. Overall, hospitalisation rate was 31.2%, referral to intensive care was 5.5%, in-hospital-mortality was 1.4%, and one-year mortality was 5.8%. In-hospital mortality ranged from 0% to 4.3%, and one-year mortality from 0% to 14.4% depending on the presenting symptoms. Dyspnoea and weakness were significant predictors of one-year mortality (14.4% and 9.2%, respectively).

DISCUSSION

Most emergency patients indicated two or more symptoms. Systematically assessed symptoms at presentation can be used for prediction of outcomes. While dyspnoea is a known predictor, weakness has not been identified as predictor of mortality before. This knowledge could be used to improve risk stratification- thereby reducing the risk of adverse outcomes.

Abstract OT3-07-01: A randomized trial evaluating bioimpedance spectroscopy vs. tape measurement in the prevention of lymphedema following breast cancer treatment

Background: Breast cancer related lymphedema (BCRL) represents a common treatment associated complication following surgery, radiation and/or chemotherapy. Increasing data has demonstrated the ability of new diagnostic modalities to detect BCRL in the subclinical phase of the process allowing for early intervention.

Trial Design: This 2-group stratified randomized clinical trial evaluates the effectiveness of bioimpedance spectroscopy (BIS) for early detection and prevention of BCRL compared to tape measurement (TM). Baseline assessments are made pre-operatively. Two-months post-op, patients are censored out if they have developed any of the exclusion conditions, did not have a mastectomy, axillary dissection, >6 sentinel nodes removed, radiation therapy, or taxane. Remaining patients are randomized within site to either BIS or TM; monitored at 3 to 6-month intervals up to 36-months post-op for a change over baseline specified to trigger a compression sleeve & gauntlet intervention. Cohort trigger thresholds are change of ≥10 L-Dex units or 5 to <10% volume. If the intervention is triggered, measurements by the other method are taken before initiating the 4-week intervention. Post intervention, patients are monitored only with TM. Volume change of ≥10% results in study removal and physician referral. At the 2 study endpoints (36 month visit or volume change of ≥10%) measurements are taken with each method.

Eligibility Criteria: Inclusion criteria: ≥ 18 with histologically confirmed stage I-III breast cancer (BC) or DCIS with planned surgery. Exclusion criteria include history of BC therapy or lymphedema.

Specific Aims: The primary hypothesis is that subclinical detection of BCRL with BIS and early intervention will reduce the rate of lymphedema progression (as measured by referral to complex decongestive physiotherapy) compared to TM. Secondary outcomes include BCRL risk factors, quality of life, and time to treatment.

Statistical Methods: Sample size and powering were based on the hypothesis that BIS would reduce progression rate by 20%. A rate of 50% progression in the TM group was used as the standard. 1100 patients will be enrolled to result in randomized groups of 100 (Total N=200) Statistics include relative risks with respective bootstrapped 95% C.I. and Cochran-Mantel-Haenszel tests.

Present Accrual and Target Accrual: Overall, the study target or expected enrollment as of the end of March 31, 2016 was 690 participants, 534 were actually enrolled (actual accrual 77% of target). Accrual at the study sites ranged from 15 to 104% of target.

Contact Information: Sheila Ridner: 615-322-0831, Sheila.ridner@vanderbilt.edu

Support: ImpediMed Limited, ImpediMed, Inc. and medi USA.

Citation Format: Ridner S, Shah C, Dietrich M, Vicini F. A randomized trial evaluating bioimpedance spectroscopy vs. tape measurement in the prevention of lymphedema following breast cancer treatment [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 OT3-07-01.

Open Reduction and Internal Fixation of Fractures of the Proximal Part of the Humerus

Introduction

We describe the surgical technique for open reduction and internal fixation (ORIF) of proximal humeral fractures with a locking plate.

Step 1 Preoperative Planning

To choose the right candidate, obtain a full understanding of the patient's fracture pattern, activity level and demands, and bone quality; be aware of predictors of complications and poor outcomes.

Step 2 Patient Positioning

Place the patient in the beach-chair position with the arm draped free or in a hydraulic device with good access for the image intensifier.

Step 3 Approach

The deltopectoral approach is generally preferred because of the exposure obtained, the possibility of distal extension, and the minimal risk of nerve injury.

Step 4 Reduction and Fixation of the Tuberosities the Key to Obtaining Marionette-Like Control

The control, reduction, and fixation of the tuberosities are crucial to restore the anterior-posterior force couple of the shoulder and must therefore be done properly no matter what the fracture pattern looks like.

Step 5 Fracture Reduction

After carrying out Steps 1 through 4, perform the reduction techniques for the specific fracture type as described below for types that we think suitable for ORIF with a locking plate.

Step 6 Fixation Implant-Specific Considerations

Plate length and positioning, humeral head screw placement, distal locking, confirming the screw tip position with the image intensifier, and securing the tuberosities.

Step 7 Tenotomy or Tenodesis of the Long Biceps Tendon

Perform a biceps tenotomy if the biceps is displaced out of the groove by the fracture pattern or if you have to open the rotator interval.

Step 8 Wound Closure

Do not close the deltopectoral interval.

Step 9 Rehabilitation

As the failure rate of ORIF of proximal humeral fractures is high, do not force an active rehabilitation protocol.

Results

In our analysis of 269 fractures followed for twelve months, we found that the Constant-Murley score (CMS) and Short Form-36 (SF-36) score improved continuously during the first six months postoperatively.IndicationsContraindicationsPitfalls & Challenges.

Clinical intuition ratings are associated with morbidity and hospitalisation

OBJECTIVE

To evaluate how the rating of the severity of sickness - as performed by the physician, nurse and patient - is associated with hospitalisation and acute morbidity.

METHODS

Prospective observational study, performed in the emergency department of a tertiary hospital. Patients, physicians and nurses were interviewed separately after the first contact from 21 October through to 11 November 2013.

RESULTS

Of 2426 presenting patients, 1861 were screened, and 1196 were included. A total of 299 (25%) were hospitalised, 504 (42%) suffered acute morbidity. In the univariate analysis, the physician's, nurse's and patient's rating of severity of sickness, expressed on a scale from 0 to 10, was significantly associated with hospitalisation (physicians: OR 1.61, 95% CI 1.50-1.73; nurses: OR 1.52, 1.41-1.64; patients: OR 1.16, 1.10-1.22), and with acute morbidity (OR 1.49, 1.40-1.59; OR 1.39, 1.30-1.48 and OR 1.05, 1.003-1.09 respectively). The area under the curve of the receiver operating characteristic curves was 0.77, 0.72 and 0.61 for hospitalisation, and 0.72, 0.68 and 0.54 for acute morbidity. The interrater reliability was estimated by the intraclass correlation, which was 0.49 for physician/nurse, 0.17 for nurse/patient and 0.07 for physician/patient. In a multivariable analysis model consisting of age, male sex, ethnic origin, ratings of severity of sickness, symptoms, ability to go home and hospitalisation during the preceding 12 months, only age, and the physician's and nurses' rating of severity of sickness remained significantly associated with both outcomes.

CONCLUSION

The first impression of severity of sickness was associated with hospitalisation and morbidity.

Reduced hepatic lipid content in Pten-haplodeficient mice because of enhanced AKT2/PKBβ activation in skeletal muscle

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) is a major health problem and occurs frequently in the context of metabolic syndrome and type 2 diabetes mellitus. Hepatocyte-specific Pten-deficiency in mice was shown previously to result in hepatic steatosis due to hyperactivated AKT2. However, the role of peripheral insulin-sensitive tissues on PTEN- and AKT2-dependent accumulation of hepatic lipids has not been addressed.

METHODS

Effects of systemically perturbed PTEN/AKT2 signalling on hepatic lipid content were studied in Pten-haplodeficient (Pten(+/-) /Akt2(+/+) ) mice and Pten-haplodeficient mice lacking Akt2 (Pten(+/-) /Akt2(-/-) ). The liver and skeletal muscle were characterized by histology and/or analysis of insulin signalling. To assess the effects of AKT2 activity in skeletal muscle on hepatic lipid content, AKT2 mutants were expressed in skeletal muscle of Pten(+/+) /Akt2(+/+) and Pten(+/-) /Akt2(+/+) mice using adeno-associated virus 8.

RESULTS

Pten(+/-) /Akt2(+/+) mice were found to have a more than 2-fold reduction in hepatic lipid content, at a level similar to that observed in Pten(+/-) /Akt2(-/-) mice. Insulin signalling in the livers of Pten(+/-) /Akt2(+/+) mice was enhanced, indicating that extrahepatic factors prevent lipid accumulation. The skeletal muscle of Pten(+/-) /Akt2(+/+) mice also showed enhanced insulin signalling. Skeletal muscle-specific expression of constitutively active AKT2 reduced hepatic lipid content in Pten(+/+) /Akt2(+/+) mice, and dominant negative AKT2 led to an increase in accumulation of hepatic lipids in both Pten(+/+) /Akt2(+/+) and Pten(+/-) /Akt2(+/+) mice.

CONCLUSION

Our results demonstrate that AKT2 activity in skeletal muscle critically affects lipid accumulation in the livers of Pten(+/+) /Akt2(+/+) and Pten(+/-) /Akt2(+/+) mice, and emphasize the role of skeletal muscle in the pathology of NAFLD.

Survival after neoadjuvant chemotherapy with or without bevacizumab or everolimus for HER2-negative primary breast cancer (GBG 44-GeparQuinto)†

BACKGROUND

The GeparQuinto study showed that adding bevacizumab to 24 weeks of anthracycline-taxane-based neoadjuvant chemotherapy increases pathological complete response (pCR) rates overall and specifically in patients with triple-negative breast cancer (TNBC). No difference in pCR rate was observed for adding everolimus to paclitaxel in nonearly responding patients. Here, we present disease-free (DFS) and overall survival (OS) analyses.

PATIENTS AND METHODS

Patients (n = 1948) with HER2-negative tumors of a median tumor size of 4 cm were randomly assigned to neoadjuvant treatment with epirubicin/cyclophosphamide followed by docetaxel (EC-T) with or without eight infusions of bevacizumab every 3 weeks before surgery. Patients without clinical response to EC ± Bevacizumab were randomized to 12 weekly cycles paclitaxel with or without everolimus 5 mg/day. To detect a hazard ratio (HR) of 0.75 (α = 0.05, β = 0.8) 379 events had to be observed in the bevacizumab arms.

RESULTS

With a median follow-up of 3.8 years, 3-year DFS was 80.8% and 3-year OS was 89.7%. Outcome was not different for patients receiving bevacizumab (HR 1.03; P = 0.784 for DFS and HR 0.974; P = 0.842 for OS) compared with patients receiving chemotherapy alone. Patients with TNBC similarly showed no improvement in DFS (HR = 0.99; P = 0.941) and OS (HR = 1.02; P = 0.891) when treated with bevacizumab. No other predefined subgroup (HR+/HER2-; locally advanced (cT4 or cN3) or not; cT1-3 or cT4; pCR or not) showed a significant benefit. No difference in DFS (HR 0.997; P = 0.987) and OS (HR 1.11; P = 0.658) was observed for nonearly responding patients receiving paclitaxel with or without everolimus overall as well as in subgroups.

CONCLUSIONS

Long-term results, in opposite to the results of pCR, do not support the neoadjuvant use of bevacizumab in addition to an anthracycline-taxane-based chemotherapy or everolimus in addition to paclitaxel for nonearly responding patients.

CLINICAL TRIAL NUMBER

NCT 00567554, www.clinicaltrials.gov.

The Nuclear Quadrupole Interaction of 204mPb in Cadmium Monitored by γ–γ –Perturbed Angular Correlations

For the first time the nuclear probe 204mPb was produced at the on-line isotope separator ISOLDE at CERN and used for time differential perturbed angular correlation experiments. The electric field gradient of 204mPb at room temperature in Cd metal was determined to be = 19(1) 1021 V/m2. Ab initio-calculations of the electric field gradient for the impurities Pt to Bi in cadmium were performed with the full-potential linearized augmented plane waves code WIEN97 to interpret this result. For Au, Hg and Pb, where experimental results are now available, these agree with the calculations within 10 %.

Fibronectin coating of oxygenator membranes enhances endothelial cell attachment

Background

Extracorporeal membrane oxygenation (ECMO) can replace the lungs’ gas exchange capacity in refractory lung failure. However, its limited hemocompatibility, the activation of the coagulation and complement system as well as plasma leakage and protein deposition hamper mid- to long-term use and have constrained the development of an implantable lung assist device. In a tissue engineering approach, lining the blood contact surfaces of the ECMO device with endothelial cells might overcome these limitations. As a first step towards this aim, we hypothesized that coating the oxygenator’s gas exchange membrane with proteins might positively influence the attachment and proliferation of arterial endothelial cells.

Methods

Sheets of polypropylene (PP), polyoxymethylpentene (TPX) and polydimethylsiloxane (PDMS), typical material used for oxygenator gas exchange membranes, were coated with collagen, fibrinogen, gelatin or fibronectin. Tissue culture treated well plates served as controls. Endothelial cell attachment and proliferation were analyzed for a period of 4 days by microscopic examination and computer assisted cell counting.

Results

Endothelial cell seeding efficiency is within range of tissue culture treated controls for fibronectin treated surfaces only. Uncoated membranes as well as all other coatings lead to lower cell attachment. A confluent endothelial cell layer develops on fibronectin coated PDMS and the control surface only.

Conclusions

Fibronectin increases endothelial cells’ seeding efficiency on different oxygenator membrane material. PDMS coated with fibronectin shows sustained cell attachment for a period of four days in static culture conditions.

Fibrin-based tissue engineering: comparison of different methods of autologous fibrinogen isolation

OBJECTIVE

This study is focussed on the optimal method of autologous fibrinogen isolation with regard to the yield and the use as a scaffold material. This is particularly relevant for pediatric patients with strictly limited volumes of blood.

MATERIALS AND METHODS

The following isolation methods were evaluated: cryoprecipitation, ethanol (EtOH) precipitation, ammonium sulfate [(NH(4))(2)SO(4))] precipitation, ammonium sulfate precipitation combined with cryoprecipitation, and polyethylene glycol precipitation combined with cryoprecipitation. Fibrinogen yields were quantified spectrophotometrically and by electrophoretic analyses. To test the influence of the different isolation methods on the microstructure of the fibrin gels, scanning electron microscopy (SEM) was used and the mechanical strength of the cell-free and cell-seeded fibrin gels was tested by burst strength measurements. Cytotoxicity assays were performed to analyze the effect of various fibrinogen isolation methods on proliferation, apoptosis, and necrosis. Tissue development and cell migration were analyzed in all samples using immunohistochemical techniques. The synthesis of collagen as an extracellular matrix component by human umbilical cord artery smooth muscle cells in fibrin gels was measured using hydroxyproline assay.

RESULTS

Compared to cryoprecipitation, all other considered methods were superior in quantitative analyses, with maximum fibrinogen yields of ∼80% of total plasma fibrinogen concentration using ethanol precipitation. SEM imaging demonstrated minor differences in the gel microstructure. Ethanol-precipitated fibrin gels exhibited the best mechanical properties. None of the isolation methods had a cytotoxic effect on the cells. Collagen production was similar in all gels except those from ammonium sulfate precipitation. Histological analysis showed good cell compatibility for ethanol-precipitated gels.

CONCLUSION

The results of the present study demonstrated that ethanol precipitation is a simple and effective method for isolation of fibrinogen and a suitable alternative to cryoprecipitation. This technique allows minimization of the necessary blood volume for fibrinogen isolation, particularly important for pediatric applications, and also has no negative influence on microstructure, mechanical properties, cell proliferation, or tissue development.

Influence of platelet-derived growth factor-AB on tissue development in autologous platelet-rich plasma gels

Fibrin-based scaffolds are widely used in tissue engineering. We postulated that the use of platelet-rich plasma (PRP) in contrast to platelet-poor plasma and pure fibrinogen as the basic material leads to an increased release of autologous platelet-derived growth factor (PDGF)-AB, which may have a consequent positive effect on tissue development. Therefore, we evaluated the release of PDGF-AB during the production process and the course of PDGF release during cultivation of plasma gels with and w/o platelets. The influence of PDGF-AB on the proliferation rate of human umbilical cord artery smooth muscle cells (HUASMCs) was studied using XTT assay. The synthesis of extracellular matrix by HUASMCs in plasma- and fibrin gels was measured using hydroxyproline assay. The use of PRP led to an increase in autologous PDGF-AB release. Further, the platelet-containing plasma gels showed a prolonged release of growth factor during cultivation. Both PRP and platelet-poor plasma gels had a positive effect on the production of collagen. However, PDGF-AB as a supplement in medium and in pure fibrin gel had neither an effect on cell proliferation nor on the collagen synthesis rate. This observation may be due to an absence of PDGF receptors in HUASMCs as determined by flow cytometry. In conclusion, although the prolonged autologous production of PDGF-AB in PRP gels is possible, the enhanced tissue development by HUASMCs within such gels is not PDGF related.

Primary anastomosis vs Hartmann's procedure in patients undergoing emergency left colectomy for perforated diverticulitis

OBJECTIVE

Comparison of primary anastomosis (PA) and Hartmann's procedure (HP) in perforated diverticulitis is biased as the patient groups are different in age, comorbidity and severity of disease. Still, PA has been advocated as the procedure of choice. The aim of this study was to compare the two surgical procedures after eliminating this selection bias using a propensity score model.

METHOD

Sixty-five HP and 46 PA patients who underwent emergency laparotomy for perforated diverticulitis were analysed. Multivariate logistic regression using the Mannheim peritonitis index, Colorectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity, Charlson comorbidity index and Hinchey score was performed to determine the propensity score.

RESULTS

Patients with HP had significantly higher scores, median age and were more often on immunosuppressive medication. Unadjusted logistic regression for outcome showed a significant risk of HP vs PA for nonsurgical morbidity (odds ratio 3.25, 95% CI: 1.26-8.43; P = 0.015), but not for mortality and surgical morbidity. After adjusting for the propensity score, outcome was not significantly different. Patients with PA had a clinical leak rate of 28% and none of the patients with leakage had a protective ileostomy. Patients with PA and leak had higher Charlson scores whereas all other scores were similar to nonleak patients.

CONCLUSION

The theory that PA is generally superior to HP cannot be supported. HP remains a safe technique for emergency colectomy in perforated diverticulitis, especially in elderly patients with multiple comorbidities. If PA is performed, a protective ileostomy must be considered.

A sense of urgency: Evaluating the link between clinical trial development time and the accrual performance of CTEP-sponsored studies

CRA6509

Background: Post-activation barriers to oncology clinical trial accruals are well documented; however, potential barriers prior to trial opening are not. We investigate one such barrier: trial development time. Methods: National Cancer Institute Cancer Therapy Evaluation Program (NCI-CTEP) sponsored trials for all therapeutic, non-pediatric phase I,I/II, II, and III studies activated in an eight year period (2000–2007) were investigated (n=553). Successful trials were those achieving 100% of minimum accrual goal. Time to open a study was the calendar time from initial CTEP submission to trialactivation. Multivariable logistic regression analysis was used tocalculate unadjusted and adjusted odds ratios, controlling for study phase and size of expected accruals. Results: 40.0 percent (n=221) of CTEP-approved oncology trials failed to achieve minimum accrual goals, with 49.2 percent (n=30) of phase III trials failing to achieve at least 25 percent of accrual goals. A total of 8,723 patients (17.0% of accruals) accrued to those studies that were unable to achieve the projected minimum accrual goal. Trials requiring 9–12 months development were significantly more likely to achieve accrual goals (odds ratio, 1.94; 95% CI, 1.06 to 3.52, P=0.031) than trials requiring the median time (15–18 months); trials that exceeded 27 months of development time were significantly less likely of achieving accrual goals (odds ratio, 0.14; 95% CI, 0.04 to 0.54, P=0.004). Conclusions: A large percentage of oncology clinical trials do not achieve minimum projected accruals. Trial development time appears to be one important predictor of the likelihood of successfully achieving the minimum accrual goals.

[Table: see text]

No significant financial relationships to disclose.

A sense of urgency: Evaluating the link between clinical trial development time and the accrual performance of CTEP-sponsored studies

CRA6509

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

No significant financial relationships to disclose.