Nonsterile glove use in addition to hand hygiene to prevent late-onset infection in preterm infants: randomized clinical trial

IMPORTANCE

Late-onset infections commonly occur in extremely preterm infants and are associated with high rates of mortality and neurodevelopmental impairment. Hand hygiene alone does not always achieve the desired clean hands, as microorganisms are still present more than 50% of the time. We hypothesize that glove use after hand hygiene may further decrease these infections.

OBJECTIVE

To determine if nonsterile glove use after hand hygiene before all patient and intravenous catheter contact, compared with hand hygiene alone, prevents late-onset infections in preterm infants.

DESIGN, SETTINGS, AND PARTICIPANTS

A prospective, single-center, clinical, randomized trial was conducted in infants admitted to the neonatal intensive care unit who weighed less than 1000 g and/or had a gestational age of less than 29 weeks and were less than 8 days old. There were 175 eligible infants, of which 120 were enrolled during a 30-month period from December 8, 2008, to June 20, 2011.

INTERVENTIONS

Infants were randomly assigned to receive care with nonsterile gloves after hand hygiene (group A) or care after hand hygiene alone (group B) before all patient and intravenous line (central and peripheral) contact. Study intervention was continued while patients had central or peripheral venous access.

MAIN OUTCOMES AND MEASURES

One or more episodes of late-onset (>72 hours of age) infection in the bloodstream, urinary tract, or cerebrospinal fluid or necrotizing enterocolitis.

RESULTS

The 2 groups were similar in baseline demographic characteristics. Late-onset invasive infection or necrotizing enterocolitis occurred in 32% of infants (19 of 60) in group A compared with 45% of infants (27 of 60) in group B (difference, -12%; 95% CI, -28% to 6%; P = .13). In group A compared with group B, there were 53% fewer gram-positive bloodstream infections (15% [9 of 60] vs 32% [19 of 60]; difference, -17%; 95% CI, -31% to -1%; P = .03) and 64% fewer central line-associated bloodstream infections (3.4 vs 9.4 per 1000 central line days; ratio, 0.36; 95% CI, 0.16 to 0.81; P = .01).

CONCLUSIONS AND RELEVANCE

Glove use after hand hygiene prior to patient and line contact is associated with fewer gram-positive bloodstream infections and possible central line-associated bloodstream infections in preterm infants. This readily implementable infection control measure may result in decreased infections in high-risk preterm infants.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01729000.

Adolescents with cerebral palsy: transitioning to adult health care services

Data from the 2009-2010 US National Survey of Children with Special Health Care Needs were examined to determine the health, developmental and behavioral status of adolescents with cerebral palsy (CP) and to assess how well pediatric health care providers were preparing them for transition to adult health care services. Adolescents with CP had no higher rates of attention deficit hyperactivity disorder, depression, anxiety, oppositional or conduct disorders, or autism spectrum than a comparison group. However, those with CP participated less in sports, clubs, or other organized activities (P < .001). Neither group reported much help in coordinating health services or preparing for transition to adult health care services. Inadequate adult health care services have a direct and unsatisfactory impact on the adult life span. Physicians and other health care providers who include adolescents with CP in their practices should begin discussion and planning for transition to adult health care early in adolescence.

Phase I/II adaptive design for drug combination oncology trials

Existing statistical methodology on dose finding for combination chemotherapies has focused on toxicity considerations alone in finding a maximum tolerated dose combination to recommend for further testing of efficacy in a phase II setting. Recently, there has been increasing interest in integrating phase I and phase II trials in order to facilitate drug development. In this article, we propose a new adaptive phase I/II method for dual-agent combinations that takes into account both toxicity and efficacy after each cohort inclusion. The primary objective, both within and at the conclusion of the trial, becomes finding a single dose combination with an acceptable level of toxicity that maximizes efficacious response. We assume that there exist monotone dose-toxicity and dose-efficacy relationships among doses of one agent when the dose of other agent is fixed. We perform extensive simulation studies that demonstrate the operating characteristics of our proposed approach, and we compare simulated results to existing methodology in phase I/II design for combinations of agents.

Effects of race, ethnicity, and gender on surgical mortality in hypoplastic left heart syndrome

Information is limited regarding the effect of race, ethnicity, and gender on the outcomes of the three palliative procedures for hypoplastic left heart syndrome (HLHS). This study examined the effects of race, ethnicity, gender, type of admission, and surgical volume on in-hospital mortality associated with palliative procedures for HLHS between 1998 and 2007 using data from the University HealthSystem Consortium. According to the data, 1,949 patients underwent stage 1 palliation (S1P) with a mortality rate of 29 %, 1,279 patients underwent stage 2 palliations (S2P) with a mortality rate of 5.4 %, and 1,084 patients underwent stage 3 palliation (S3P) with a mortality rate of 4.1 %. The risk factors for increased mortality with S1P were black and "other" race, smaller surgical volume, and early surgical era. The only risk factors for increased mortality with S2P were black race (11 % mortality; odds ratio [OR], 3.19; 95 % confidence interval [CI] 1.69-6.02) and Hispanic ethnicity (11 % mortality; OR 3.30; 95 % CI 1.64-6.64). For S2P, no racial differences were seen in the top five surgical volume institutions, but racial differences were seen in the non-top-five surgical volume institutions. Mortality with S1P was significantly higher for patients discharged after birth (37 vs 24 %; p = 0.004), and blacks were more likely to be discharged after birth (12 vs 5 % for all other races; p < 0.001). No racial differences with S3P were observed. The risk factors for increased mortality at S1P were black and "other" race, smaller surgical volume, and early surgical era. The risk factors for increased in-hospital mortality with S2P were black race and Hispanic ethnicity.

Abstract A62: Imaging the tumor micro-environment to monitor ovarian cancer metastasis

The inability to successfully treat women with ovarian cancer is due in large part to the advanced stage of disease at diagnosis, the development of platinum resistance, and the lack of sensitive methods to monitor tumor progression and response to treatment. Vascular cell adhesion molecule-1 (VCAM-1) is expressed on the mesothelium of ovarian cancer patients. We investigated VCAM-1 expression as a marker of peritoneal metastasis and tumor response to platinum-based chemotherapy. Immunohistochemical staining of peritoneal or omental biopsies obtained from women diagnosed with Stage I, Stage II or Stage III/IV ovarian cancer demonstrated that VCAM-1 expression correlated with tumor stage. All specimens from Stage I patients were negative, while 29% of Stage II patients and the 73% of Stage III/IV patients were positive. While the majority of women with advanced stage disease expressed VCAM-1, the incidence of expression was reduced among women who received neoadjuvant chemotherapy, suggesting a role for chemotherapy in regulating VCAM-1 expression. The effects of carboplatin on mesothelial VCAM-1 expression were determined in a mouse model of ovarian cancer peritoneal metastasis using radiolabeled VCAM-1-specific peptide imaging probes and single photon emission computed tomography (SPECT). This approach showed that 1) VCAM-1 is a viable imaging target in ovarian cancer metastasis, 2) maximal expression was detected with microscopic tumor burden, and 3) VCAM-1 expression reflected the effect of platinum-based treatment on tumor burden. Specifically, carboplatin treatment of mice with platinum-sensitive tumors showed reduced VCAM-1 expression, which correlated with reduced tumor burden; mice with platinum-resistant tumors retained elevated VCAM-1 expression and tumor burden following treatment. These observations support testing the utility of VCAM-1 imaging probes to monitor treatment response in ovarian cancer patients, thus providing the potential to improve management of women with this disease.

Citation Format: Jill K. Slack-Davis, Jennifer M. Scalici, Stephanie Thomas, Christine Harrer, Timothy A. Raines, Joanna Curran, Kristen A. Atkins, Mark R. Conaway, Linda Duska, Kimberly A. Kelly. Imaging the tumor micro-environment to monitor ovarian cancer metastasis. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research: From Concept to Clinic; Sep 18-21, 2013; Miami, FL. Philadelphia (PA): AACR; Clin Cancer Res 2013;19(19 Suppl):Abstract nr A62.

Performance of two-stage continual reassessment method relative to an optimal benchmark

BACKGROUND

The two-stage, likelihood-based continual reassessment method (CRM-L) entails the specification of a set of design parameters prior to the beginning of its use in a study. The impression of clinicians is that the success of model-based designs, such as CRM-L, depends upon some of the choices made with regard to these specifications, such as the choice of parametric dose-toxicity model and the initial guess of toxicity probabilities.

PURPOSE

In studying the efficiency and comparative performance of competing dose-finding designs for finite (typically small) samples, the nonparametric optimal benchmark is a useful tool. When comparing a dose-finding design to the optimal design, we are able to assess how much room there is for potential improvement.

METHODS

The optimal method, based only on an assumption of monotonicity of the dose-toxicity function, is a valuable theoretical construct serving as a benchmark in theoretical studies, similar to that of a Cramér-Rao bound. We consider the performance of CRM-L under various design specifications and how it compares to the optimal design across a range of practical situations.

RESULTS

Using simple recommendations for design specifications, the CRM-L will produce performances, in terms of identifying doses at and around the maximum tolerated dose (MTD), that are close to the optimal method on average over a broad group of dose-toxicity scenarios.

LIMITATIONS

Although the simulation settings vary in the number of doses considered, the target toxicity rate, and the sample size, the results here are presented for a small, though widely used, set of two-stage CRM designs.

CONCLUSIONS

Based on simulations here, and many others not shown, CRM-L is almost as accurate, in many scenarios, as the nonparametric optimal design. On average, there appears to be very little margin for improvement. Even if a finely tuned skeleton offers some improvement over a simple skeleton, the improvement is necessarily very small.

Phase I design for completely or partially ordered treatment schedules

The majority of methods for the design of phase I trials in oncology are based upon a single course of therapy, yet in actual practice, it may be the case that there is more than one treatment schedule for any given dose. Therefore, the probability of observing a dose-limiting toxicity may depend upon both the total amount of the dose given, as well as the frequency with which it is administered. The objective of the study then becomes to find an acceptable combination of both dose and schedule. Past literature on designing these trials has entailed the assumption that toxicity increases monotonically with both dose and schedule. In this article, we relax this assumption for schedules and present a dose-schedule finding design that can be generalized to situations in which we know the ordering between all schedules and those in which we do not. We present simulation results that compare our method with other suggested dose-schedule finding methodology.

Imaging VCAM-1 as an indicator of treatment efficacy in metastatic ovarian cancer

The inability to successfully treat women with ovarian cancer is due in large part to the advanced stage of disease at diagnosis, the development of platinum resistance, and the lack of sensitive methods to monitor tumor progression and response to treatment. Vascular cell adhesion molecule-1 (VCAM-1) is expressed on the mesothelium of ovarian cancer patients. We investigated VCAM-1 expression as a marker of peritoneal metastasis and tumor response to platinum-based chemotherapy.

METHODS

Peritoneal or omental biopsies obtained from women diagnosed with stage I, stage II, or stage III/IV ovarian cancer were evaluated by immunohistochemistry. The effects of carboplatin on mesothelial VCAM-1 expression were determined in cultured cells by Western blot. Radiolabeled VCAM-1-specific peptide imaging probes and SPECT were used in a mouse model of ovarian cancer peritoneal metastasis to identify VCAM-1 as a viable imaging target.

RESULTS

VCAM-1 expression correlated with tumor stage. All specimens from stage I patients were negative, whereas 29% of stage II patients and 73% of stage III/IV patients were positive. Although most women with advanced stage disease expressed VCAM-1, the incidence of expression was reduced among women who received neoadjuvant chemotherapy, suggesting a role for chemotherapy in regulating VCAM-1 expression. Treatment of mesothelial cells in culture with carboplatin resulted in a transient decrease in VCAM-1 expression 4 h after treatment that returned to baseline within 16-24 h. In vivo imaging of VCAM-1 also demonstrated an acute decrease in expression 4 h after carboplatin administration that recovered within 48 h in mice harboring platinum-resistant tumors. Chronic VCAM-1 expression reflected the effect of platinum-based treatment on tumor burden. Specifically, carboplatin treatment of mice with platinum-sensitive tumors showed reduced VCAM-1 expression, which correlated with reduced tumor burden; mice with platinum-resistant tumors retained elevated VCAM-1 expression and tumor burden after treatment.

CONCLUSION

Clinically relevant VCAM-1-specific imaging probes identify VCAM-1 expression as an indicator of ovarian cancer peritoneal metastasis and therapeutic response to platinum-based agents. These observations support testing the utility of VCAM-1 imaging probes to monitor treatment response in ovarian cancer patients, thus providing the potential to improve management of women with this disease.

Overcoming platinum resistance in preclinical models of ovarian cancer using the neddylation inhibitor MLN4924

The nearly ubiquitous development of chemoresistant disease remains a major obstacle against improving outcomes for patients with ovarian cancer. In this investigation, we evaluated the preclinical activity of MLN4924, an investigational inhibitor of the NEDD8-activating enzyme, in ovarian cancer cells. Efficacy of MLN4924 both alone and in combination with platinum was assessed. Overall, single-agent MLN4924 exhibited moderate activity in ovarian cancer cell lines. However, the combination of MLN4924 with cisplatin or carboplatin produced synergistic effects in SKOV3 and ES2 cells, as well as in primary ovarian cancer cell lines established from high-grade serous, clear cell, and serous borderline ovarian tumors. The efficacy of cisplatin plus MLN4924 was also evident in several in vitro models of platinum-resistant ovarian cancer. Mechanistically, the combination of cisplatin and MLN4924 was not associated with DNA re-replication, altered platinum-DNA adduct formation, abrogation of FANCD2 monoubiquitination, or CHK1 phosphorylation. An siRNA screen was used to investigate the contribution of each member of the cullin RING ligase (CRL) family of E3 ubiquitin ligases, the best-characterized downstream mediators of MLN4924's biologic effects. Cisplatin-induced cytotoxicity was augmented by depletion of CUL3, and antagonized by siCUL1 in both ES2 and SKOV3 ovarian cancer cells. This investigation identifies inhibition of neddylation as a novel mechanism for overcoming platinum resistance in vitro, and provides a strong rationale for clinical investigations of platinum and MLN4924 combinations in ovarian cancer.

Specifications of a continual reassessment method design for phase I trials of combined drugs

In studies of combinations of agents in phase I oncology trials, the dose-toxicity relationship may not be monotone for all combinations, in which case the toxicity probabilities follow a partial order. The continual reassessment method for partial orders (PO-CRM) is a design for phase I trials of combinations that leans upon identifying possible complete orders associated with the partial order. This article addresses some practical design considerations not previously undertaken when describing the PO-CRM. We describe an approach in choosing a proper subset of possible orderings, formulated according to the known toxicity relationships within a matrix of combination therapies. Other design issues, such as working model selection and stopping rules, are also discussed. We demonstrate the practical ability of PO-CRM as a phase I design for combinations through its use in a recent trial designed at the University of Virginia Cancer Center.

Relationship of glucose values to sliding scale insulin (correctional insulin) dose delivery and meal time in acute care patients with diabetes mellitus

Findings of this study suggest the traditional sliding scale insulin (SSI) method does not improve target glucose values among adult medical inpatients. Timing of blood glucose (BC) measurement does affect the required SSI dose. BC measurement and insulin dose administration should be accomplished immediately prior to mealtime.

Methods of standing from supine and percentiles for time to stand and to run 10 meters in young children

OBJECTIVE

To assess the method and time to stand from supine and the time to run 10 m for normal young children.

STUDY DESIGN

Three hundred twenty-one normal children aged 2.8-7.8 years were recruited from primary schools. After standardization, each test was carried out twice, timed, and videoed. The influence of age, sex, height, weight, body mass index (BMI), and method of standing were analyzed. Charts for time to stand and running time were produced and assessment of reproducibility performed.

RESULTS

For the time to stand from supine and the method used, there was a significant correlation with age. More than 50% of young children took >2 seconds. There was no significant association with BMI. Method of standing was associated with standing time in boys but not in girls. A Bland-Altman plot of standing times by 2 observers showed good reproducibility with no clinically significant difference. For the 10-m running test, there was a significant negative correlation with age, height, weight, and BMI.

CONCLUSION

There is considerable variability in the method used and time taken to stand from supine in young children. These change with age, permitting the creation of charts showing age-related normal values.

Developmental, emotional and behavioral co-morbidities across the chronic health condition spectrum

AIMS

Estimate the prevalence of specific developmental, emotional, and behavioral (DEB) problems across selected chronic health conditions; examine the relationship of chronic health conditions to functional activities and participation; determine the potential confounding effect of sociodemographic factors on the prevalence of DEB problems.

METHODS

The 2007 National Survey of Children's Health, conducted by the Centers for Disease Control and Prevention, served as the primary data source for this study. A total of 91.642 interviews (66.6% response rate for identified households with children) were performed. Population-based estimates were obtained for variables of interest by assigning sampling weights to each child for whom an interview was completed.

RESULTS

Parents were two to 30 times more likely to report DEB problems, such as Attention Deficit/Hyperactivity Disorder, depression, learning problems, and challenging behaviors, for children with chronic health conditions. These children had a greater number and range of difficulties with social interaction and school functioning as well as a lower rate of participation in community activities. Although highest rates of DEB problems were reported for those conditions involving the nervous or sensory systems, children with asthma, diabetes, and musculoskeletal conditions also had a higher rate of problems than children without the conditions. The higher prevalence of DEB problems remained after statistical adjustment for socio-demographic factors.

CONCLUSIONS

Children with a spectrum of chronic health conditions are at high risk for DEB problems that affect learning, behavior, and emotional well-being. As part of a comprehensive approach to the management of chronic health conditions, children should be screened for these problems and referred for appropriate further evaluation and remediation. Attention to these common co-morbidities will not only result in enhanced quality of life but will also promote better adherence to medical recommendations and, thereby, optimal disease control.

The aching feet of nurses: an exploratory study

Results of a survey designed to determine the incidence of work-related foot pain/discomfort among RNs are described, along with factors associated with the foot problems.

A mechanistic study of the effect of doxorubicin/adriamycin on the estrogen response in a breast cancer model

OBJECTIVE

Estrogen treatment limits the cytotoxic effects of chemotherapy in estrogen receptor-positive (ER+) breast cancer cell lines, suggesting that estrogen pathway signaling may confer chemotherapeutic resistance. This study investigates the molecular responses of ER+ breast cancer cell lines to the chemotherapeutic agent, doxorubicin, in the presence or absence of estrogen.

METHODS

ER+ MCF-7 and T47-D cells were cultured in hormone-starved or estrogen-containing media with or without doxorubicin at concentrations mimicking the low concentrations seen in plasma and tumor microenvironments in humans following typical bolus administration. Protein levels, phosphorylations, and interactions of estrogen-signaling molecules were assessed following these treatments, as well the effects of ER signaling inhibitors on cell proliferation.

RESULTS

Surprisingly, estrogen and doxorubicin co-treatment markedly induced pro-growth alterations compared to doxorubicin alone and modestly enhanced estrogen alone-induced changes. Several inhibitors suppressed cell proliferation in the presence of doxorubicin and estrogen.

CONCLUSIONS

These findings demonstrate that molecular changes caused by doxorubicin in ER+ breast cancer cells can be reversed by estrogen, providing molecular evidence for the poorer responses of ER+ tumors to doxorubicin in the presence of physiologic estrogen levels. Our results also suggest that the addition of drugs targeting the ER, EGFR, the SFKs, MEK, PI3K, and/or the MMP proteins to a conventional chemotherapy regimen may improve chemosensitivity.

Using the time-to-event continual reassessment method in the presence of partial orders

The time-to-event continual reassessment method (TITE-CRM) was proposed to handle the problem of long trial duration in Phase 1 trials as a result of late-onset toxicities. Here, we implement the TITE-CRM in dose-finding trials of combinations of agents. When studying multiple agents, monotonicity of the dose-toxicity curve is not clearly defined. Therefore, the toxicity probabilities follow a partial order, meaning that there are pairs of treatments for which the ordering of the toxicity probabilities is not known at the start of the trial. A CRM design for partially ordered trials (PO-CRM) was recently proposed. Simulation studies show that extending the TITE-CRM to the partial order setting produces results similar to those of the PO-CRM in terms of maximum tolerated dose recommendation yet reduces the duration of the trial.

Abstract 4200: Translation initiation factor eIF3b expression and its role in cancer cell growth and metastases

The initiation of translation in eukaryotes is promoted by multi-protein eukaryotic initiation factor complexes (eIFs). While several eIF subunits are overexpressed in cancer, very few have been conclusively implicated as drivers of human cancer phenotypes. Through a transcriptomic analysis of human bladder cancer our studies suggested that eIF3b, considered to be the major scaffolding subunit within the eIF3 complex, is elevated compared to normal urothelium. We went on to functionally evaluate eIF3b in human bladder cancer by siRNA depletion in UMUC3 and lul2 human bladder cancer lines. This reveled that expression of eIF3b was important for anchorage dependent and independent cell growth and G1 to S cell cycle transition. Depletion of eIF3b also inhibited cell migration in vitro and this was associated with disruption of actin cytoskeleton organization and focal adhesion formation through integrin [[Unsupported Character - Symbol Font &#61537;]]5, which in turn decreased FAK phosphorylation and downstream Akt phosphorylation. We also observed the similar results from PC3 prostate cancer cells. In vivo, UMUC3 and lul2 cells depleted of eIF3b formed smaller tumors that grew more slowly following subcutaneous inoculation and these cells formed fewer lung metastases following intravenous inoculation. This data provides the first demonstration of a causal role of eIF3b in human cancer cell phenotypes in vitro and in vivo.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4200. doi:1538-7445.AM2012-4200

The relationship of 26 clinical factors to weaning outcome

BACKGROUND

The Burns Wean Assessment Program (BWAP) assessment checklist is designed to assist clinicians in the systematic evaluation of 26 clinical factors important to weaning. The authors recently described the relationship of the BWAP score (derived from the checklist) to weaning trial outcomes (weaning success or failure) in patients receiving mechanical ventilation for 3 days or longer in 5 adult critical care units. A BWAP score of 50 or higher was significantly associated with weaning success regardless of the specific category of patient (surgical, medical, cardiovascular, etc). This secondary analysis extends the evaluation of the BWAP checklist as it focuses on the importance of each individual BWAP factor to weaning outcomes in 5 different populations of patients.

OBJECTIVES

To identify the relative importance of the 26 BWAP factors to weaning success in patients undergoing mechanical ventilation for 3 days or longer in 5 adult critical care units.

METHODS

BWAP checklists were completed within 24 hours of a weaning attempt in surgical-trauma, medical, neurological, thoracic-cardiovascular, and coronary care units in a 5-year period. Advanced practice nurses using a multidisciplinary pathway, the BWAP checklist, protocols for weaning trials, and sedation guidelines managed the patients similarly.

RESULTS

A total of 20 BWAP factors were significantly associated with successful weaning in all units combined (P ≤ .02). However, some differences in the importance of the BWAP factors to weaning outcome exist between units, with the neuroscience intensive care unit deviating the most from the other units.

CONCLUSIONS

Although not all BWAP factors are significantly associated with weaning success, most are predictive. Restructuring the BWAP as a unit-specific weaning checklist and potential predictor may assist clinicians to address factors that may impede weaning more efficiently and effectively.