An assessment of the long-term health outcome of renal transplant recipients in Ireland

BACKGROUND

Renal transplantation remains the preferred method of renal replacement therapy in terms of patient survival, quality of life and cost. However, patients have a high risk of complications ranging from rejection episodes, infection and cancer, amongst others.

AIMS AND METHODS

In this study, we sought to determine the long-term health outcomes and preventive health measures undertaken for the 1,536 living renal transplant patients in Ireland using a self-reported questionnaire. Outcomes were divided into categories, namely, general health information, allograft-related information, immunosuppression-related complications and preventive health measures.

RESULTS

The results demonstrate a high rate of cardiovascular, neoplastic and infectious complications in our transplant patients. Moreover, preventive health measures are often not undertaken by patients and lifestyle choices can be poor.

CONCLUSIONS

This study highlights the work needed by the transplantation community to improve patient education, adjust immunosuppression where necessary and aggressively manage patient risk factors.

Non-invasive brain stimulation techniques for chronic pain. A report of a Cochrane systematic review and meta-analysis

BACKGROUND

Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES) and transcranial direct current stimulation (tDCS).

AIM

To evaluate the efficacy of non-invasive brain stimulation techniques in chronic pain.

DESIGN

A Cochrane systematic review with meta-analyses.

METHODS

We employed a comprehensive search strategy. Randomised and quasi-randomised studies of rTMS, CES or tDCS were included if they employed a sham stimulation control group, recruited patients over the age of 18 with pain of three months duration or more and measured pain as a primary outcome. Where possible we entered data into meta-analyses.

RESULTS

We included 33 trials in the review (19 rTMS, eight CES and six tDCS). Only one study was judged as being at low risk of bias. Studies of rTMS demonstrated significant heterogeneity. Pre-specified subgroup analyses suggest that low-frequency stimulation is ineffective. A short-term effect on pain of active high-frequency stimulation of the motor cortex in single-dose studies was suggested (standardised mean difference (SMD) -0.40, 95% confidence interval (CI) -0.26 to -0.54, P < 0.00001). This equates to a 15% (95% CI 10% to 20%) reduction in pain which does not clearly exceed the pre-established criteria for a minimally clinically important difference (> 15%). For CES (four studies, 133 participants) no statistically significant difference was found between active stimulation and sham. Analysis of tDCS studies (five studies, 83 people) demonstrated significant heterogeneity and did not find a significant difference between active and sham stimulation. Pre-specified subgroup analysis of tDCS applied to the motor cortex suggested superiority of active stimulation over sham (SMD -0.59, 95% CI -1.10 to -0.08). Non-invasive brain stimulation appears to be associated with minor and transient side effects.

CONCLUSION

Single doses of high-frequency rTMS of the motor cortex may have small short-term effects on chronic pain. The effects do not clearly exceed the predetermined threshold of minimal clinical significance. Low-frequency rTMS is not effective in the treatment of chronic pain. There is insufficient evidence from which to draw firm conclusions regarding the efficacy of CES or tDCS. The available evidence suggests that tDCS applied to the motor cortex may have short-term effects on chronic pain and that CES may be ineffective. There is a need for further, rigorously designed studies of all types of stimulation.

Abstract ES6-2: Cell to Cell Variability in the Responses of Tumor Cells to Death Ligands and Other Anti-Cancer Drugs

Cell to cell variability in phenotype and fate is important for tissue homeostasis, the emergence of drug resistance and the evolution of tumors. I will discuss cell to cell variability in the responses of clonal populations of human cells to TRAIL, a prototypical inducer of receptor-mediated (extrinsic) apoptosis and an investigational therapeutic, as well as to other pro-apoptotic drugs. Some TRAIL-treated human cells die within ∼40 min, others only after 12 hr and some live indefinitely. During this variable delay initiator caspases (ICs) are active in processing substrates such as Bid and downstream effector caspases (ECs) but mitochondrial membrane permeablization (MOMP) does not occur and (ECs are catalytically inactive. We have explored three explanations for cell to cell differences among members of a clonal and notionally uniform population: (i) genetic or epigenetic variation (ii) the involvement of one or more biochemical processes subject to stochastic fluctuation (iii) difference in cell state such as position in the cell cycle or protein concentrations. To distinguish these three possibilities we compared the fates of sister cells exposed to TRAIL and other drugs using live-cell microscopy. Genetic and epigenetic factors are transmitted with near-perfect fidelity; reaction rates dominated by stochastic fluctuations are no more similar in sisters than in any two cells chosen at random and variability arising from differences in mRNA or protein levels should be transiently heritable (because division is a binomial process in which sister cells inherit roughly equal numbers of abundant cytosolic and nuclear factors but drift towards the population average over time). The later explanation is correct — natural fluctuations in protein levels dominate phenotypic heterogeneity in extrinsic apoptosis and cause transient phenotypic heritablility. Variability can be manipulated by protein over-expression and drugs and I will describe analytic methods for modeling these perturbations mathematically. A key conclusion from this work is that variability in the responses of cells to drugs is inherent to the stochastic operation of the biochemical pathways that anti-cancer drugs target. Fractional killing is one inevitable consequence.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr ES6-2.

Obstetric risk factors for urinary incontinence and preventative pelvic floor exercises: Cohort study and nested randomized controlled trial

We conducted a cohort study assessing risk factors for developing urinary incontinence following childbirth, and a pilot randomized controlled trial of a physiotherapist-led intervention to reduce incidence of incontinence. A total of 723 women were recruited to the cohort study, of which 234 entered the nested trial and were randomized to intensive training in pelvic floor exercises or standard information. At 6 months post-partum, 45% of women reported some incontinence problems. A pre-existing incontinence problem was the best predictor of future incontinence (odds ratio 4.49, 95% confidence interval (CI) 3.09-6.53). Chronic constipation (1.86, 1.03-3.34) and episiotomy in at least one delivery (1.96, 1.25-3.07) were also independent risk factors, while an epidural or spinal (0.62, 0.42-0.92) was protective. The intervention as designed did not help in preventing future incontinence (relative risk 1.28, 95% CI 0.98-1.67), but this may be due to the failure to persuade the women to return for the classes. Any intervention aimed at promoting postnatal pelvic floor exercises should be limited to women who have already been experiencing incontinence problems.

A qualitative study of exceptional survivors of cancer

e17522

Background: An exceptional survivor of cancer is an individual who has outlived actuarial predictions for his/her particular form of cancer or experienced a complete regression. This pilot study was designed to determine if there were any biological, psychosocial, cultural or lifestyle characteristics exceptional survivors of cancer that can be measured and transferred through interventions to other cancer patients. Methods: The sample consisted of 21 survivors of cancer who were identified by oncologists at UAB as exceptional survivors. The study gathered qualitative data through semi-structured interviews and two validated scales measuring resilience, sense of coherence. A new cancer ‘catastrophizing’ scale based on the pain catastrophizing scale (PCS) was tested for its concordance with the two validated scales. The diagnosis and treatment information on these patients was collected through a questionnaire completed by the patient's oncologist. Results: Eight oncologists referred twenty-five patients to the study. Twenty-one patients agreed to participate. A unifying theme across all patient interviews was a deep spiritual connection with a supreme being. Praying for healing, intercessory prayer, and seeking guidance through faith with respect to best treatment options were common. The patients verbalized faith in physicians and were willing to seek more experimental treatments largely due to their spirituality. In general, the survivors were highly resilient as measured by the resilience scale and had a high sense of coherence as measured by the sense of coherence scale. They were also unlikely to conceptualize the diagnosis as a ‘catastrophe’ as measured by the new cancer catastrophizing scale. Conclusions: This study provides preliminary evidence of a relationship between spirituality and exceptional survivorship. Findings suggest exceptional survivors may be more willing to participate in clinical trials than other populations of cancer patients. Future studies should prospectively follow cancer patients to ascertain the temporal nature of the association between spirituality and exceptional survivorship.

No significant financial relationships to disclose.

UAB 0210: A phase I/II trial of induction chemotherapy followed by concomitant docetaxel/radiotherapy with subcutaneous amifostine for advanced squamous cell carcinoma of the head and neck (SCCHN)

6061

Background: Attempts to improve the outcome of locally advanced SCCHN have generally added chemotherapy to radiation, though the optimal manner of integration has been controversial. To impact distant and local control, we utilized neoadjuvant chemotherapy followed by concomitant boost radiation (CBR) with docetaxel as a radiosensitizer. To improve cytoprotection, subcutaneous amifostine was added during radiotherapy. Methods: From April 2003-March 2007 46 patients with stage III or IV newly diagnosed SCCHN were enrolled (30 Caucasian, 16 African-American). Treatment consisted of 3 cycles of neoadjuvant chemotherapy with cisplatin 75 mg/m2 and docetaxel 75 mg/m2 intravenously at 21 day intervals followed by CBR and concurrent dose-escalated weekly docetaxel starting at 20 mg/m2. Standard 2D radiotherapy was used in the majority of patients. Subcutaneous amifostine was administered at 500 mg during each day of radiation. Results: 39 patients were evaluable. The neoadjuvant chemotherapy was well tolerated by the majority of patients and appeared effective; no patient had progressive disease while on therapy. Three patients required a change to carboplatin due to toxicity. Weekly docetaxel during all weeks of CBR was not tolerable due to severe mucositis and the phase I component defined the MTD of concurrent docetaxel as 20 mg/m2 for 4 cycles during CBR. 4 patients (10%) had persistent disease at completion of treatment. Amifostine administration was well tolerated though 4 patients required discontinuation of the drug. The majority of recurrences have been localized at the primary site (6 patients). 3 patients developed isolated pulmonary metastasis. Only 2 patients remain PEG dependent with median follow-up of 24 months. Conclusions: Induction chemotherapy using cisplatin and docetaxel is feasible and easy to administer in the outpatient setting; those patients who had a major radiographic and clinical response did particularly well in follow-up. Weekly docetaxel can be safely and effectively administered during CBR with good local control. Amifostine can be safely administered via the subcutaneous route; the benefit in locally advanced patients is difficult to assess.

No significant financial relationships to disclose.

Evaluating the accuracy of perfusion/metabolism (SPET/PET) ratio in seizure localization

The uncoupling between brain perfusion and metabolism was evaluated as a potential tool for seizure localization by creating an interictal SPET divided by interictal PET functional ratio-image and by evaluating its sensitivity and specificity to areas subsequently surgically resected. The uncoupling between brain perfusion and metabolism was evaluated through the creation of a functional SPET/PET ratio-image relying on interictal single-photon emission computed tomography (SPET) and positron emission tomography (PET) scans in epilepsy patients. The uncoupling of these two physiological brain functions has been demonstrated to be a characteristic of epileptogenic tissue in temporal lobe epilepsy and could potentially serve as a diagnostic measure for localization of seizure onset areas in the brain. The accuracy of hemispheric localization, sensitivity, and specificity of perfusion to metabolism ratio-images were evaluated as compared to standard methods of PET reading.

METHODS

Interictal HMPAO-SPET and FDG-PET scans were obtained from 21 patients who then went on to remain seizure free for a minimum of 1 year post surgical resection. Using Statistical Parametric Mapping (SPM2), the SPET and PET scans were spatially registered and spatially normalized to a standard template (geometric warping). A functional image was created by calculating the ratio of perfusion to metabolism. Discrete areas of uncoupling in the ratio-images were selected, quantified, and compared to visually interpreted PET readings as well as the actual site of subsequent surgical resection. Localization was determined by comparing the hemispheric location of these areas to sites of surgical resection. Sensitivity and specificity of ratio-images and PET readings were calculated by dividing the brains into four sections per hemisphere.

RESULTS

When compared to known sites of successful surgical resection, the pre-surgical visually interpreted PET readings had a correct hemispheric localization in 69.6% of cases, while the regions of uncoupling selected in the pre-surgical ratio-images had a correct hemispheric localization of 82.6%. In addition, the regional sensitivity of visually interpreted PET readings was 63.0% with a specificity of 95.7%, while the sensitivity of the ratio-images was 68.0% with a specificity of 96.0%.

CONCLUSION

Compared to the PET readings, the ratio-images yielded similar sensitivity and specificity measures, but had an improved hemispheric localization. Hence, ratio-images may be a valuable diagnostic tool in the hemispheric localization, which could enhance the use of PET readings alone.

Phase II evaluation of cetuximab (C225) combined with induction paclitaxel and carboplatin followed by C225, paclitaxel, carboplatin, and radiation for stage III/IV operable squamous cancer of the head and neck (ECOG, E2303)

6015

Introduction: Neoadjuvant C225 with induction chemotherapy and chemo-radiation was studied in stage III/IV head and neck squamous cancer with primary and secondary objectives of 1year event- free survival, pathologic complete response rate at the primary site (PS) (determined by mandatory biopsy week 8) and toxicity. Protocol Design: Operable patients (pts) staged by triple endoscopy, CT/MRI, had gastrostomy, signed IRB approved consent and received induction chemotherapy with weekly C225 250 mg/m2, P 90 mg/m2, C (AUC=2). Restaging PS biopsy was done at week 8, if there was a clinical response. Pts with positive biopsy (or persistent tumor) at PS had restaging biopsy at week 14 after chemo radiation (C225 250 mg/m2, P 30 mg/m2, C(AUC=1) and 50 Gy). If PS Bx was negative patients had completion RT (68–72 Gy, plus continued C225, P,C). If PS Bx was positive at 14 weeks salvage surgery was required. Results: 74 patients were enrolled (67 are evaluable). T and N stage were T1/2 (11%/27%), T ¾ (47%/14%); N O/N1 (11%/23 %), N 2/3 (50%/16%). Site: tonsil 30%, oral cavity/tongue 24%, Post pharynx (BOT) 42%, Larynx 34%; performance status 0/1 (61% / 39%). PS re biopsy was done at week 8 in 40 patients; no residual tumor was detected in 26 (65%). Restaging biopsy after induction and chemo radiation was done at week 14 in 28 pts (14 with persistent tumor and 14 with previous positive biopsy) and was negative in all 28 patients. All 54 patients with negative PS biopsy had completion RT. Data on disease status are incomplete. Post treatment toxicity (Gr 3/4) included acneiform rash (12%), leukopenia/neutropenia 32%/24%, dysphagia (29%), and stomatitis (82%). One grade 5 AE occurred (death from encephalopathy). Conclusion: Neoadjuvant induction C225, plus chemotherapy followed by C225 plus chemo-radiation elicited a complete pathologic response at the primary site, by restaging biopsy (65%) with induction alone, and 100% among sampled patients after chemo RT 50Gy. These preliminary results suggest a high pathologic complete response rate to induction chemotherapy plus cetuximab followed by chemo radiation plus cetuximab. Progression and survival data are not yet mature.

No significant financial relationships to disclose.