Multimodality therapy including surgical resection (SR) and intraoperative electron radiotherapy (IOERT) for locoregionally recurrent (LRR) or advanced primary malignancies of the urinary bladder (UB) or ureter

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Background: For patients (pts) with LRR or advanced primary tumors of the UB or ureter, limited therapeutic options exist. Outcomes of combined SR and IOERT are reported here.

Methods: From 1983 to 2009, a total of 17 pts with urothelial (16 pts) or squamous cell carcinoma (1 pt) of the UB (n=13) or ureter (n=4) were treated with SR and IOERT. Pts had LRR after radical cystoprostatectomy or nephroureterectomy (n=15) or advanced primary tumor (n=2). Extent of SR was R0 (microscopic negative margins), R1 (microscopic positive margins), and R2 (gross residual tumor) in 7, 1, and 9 pts, respectively. After maximal SR, IOERT was delivered to the tumor bed. Median IOERT dose and energy delivered were 12.5 Gy (range; 10-20) and 9 MeV (range; 6-18), respectively, with 1 (n=15), 2 (n=1), or 3 (n=1) IOERT fields. Sixteen pts also received perioperative external beam radiotherapy (EBRT) with a median dose of 50.4 Gy (range; 21.6- 60). Five pts received concurrent chemotherapy (CT) with perioperative EBRT. Overall (OS), disease-free survival (DFS) and relapse patterns were estimated from the date of SR and IOERT using the Kaplan-Meier method.

Results: The median pt age was 63 years (yrs) (range; 51-76). The median follow-up of surviving pts was 3.6 yrs (range; 1.1-10.0). OS and DFS at 1, 2, and 5 yrs were 53%, 31%, and 16%, and 24%, 18%, and 18%, respectively. Central (within the IOERT field), locoregional (tumor bed or first echelon draining lymphatics), and distant relapse at 2 yrs were 15%, 49%, and 67%, respectively. Seven pts received systemic CT after relapse. Mortality within 30 days of SR and IOERT was 0%. Two pts (12%) experienced grade 4-5 (NCI-CTCAE v. 4) toxicity potentially related to the multimodality therapy.

Conclusions: For pts with LRR or advanced primary tumor of the UB or ureter, this multimodality therapy including SR and IOERT resulted in durable OS and DFS in a small but significant number of pts. Both LRR and distant relapse were common, indicating a need for more effective systemic therapy along with more refined locoregional therapy.

No significant financial relationships to disclose.

Development and characterization of sub-100 ps photomultiplier tubes

We describe the evaluation of a microchannel plate (MCP) photomultiplier tube (PMT), incorporating a 3 μm pore MCP and constant voltage anode and cathode gaps. The use of the small pore size results in PMTs with response functions of the order of 85 ps full-width-half-maximum, while the constant electric field across the anode and cathode gaps produces a uniform response function over the entire operating range of the device. The PMT was characterized on a number of facilities and employed on gas Cherenkov detectors fielded on various deuterium tritium fuel (DT) implosions on the Omega Laser Facility at the University of Rochester. The Cherenkov detectors are part of diagnostic development to measure Gamma ray reaction history for DT implosions on the National Ignition Facility.

Modelling nutrient loads to Sydney estuary (Australia)

Sydney estuary (Australia) catchment is substantially urbanised (80%) and small (480 km2) with a large population (2.5 million) and is therefore highly sensitive to anthropogenic influence. The Model for Urban Stormwater Improvement Conceptualisation used to model nutrient export to the estuary determined an average annual load of 475 t total nitrogen, 63.5 t total phosphorus and 343,000 t total suspended solids. Model verification included intense, short-term water sampling and analysis undertaken in the current project and use of published data spanning 10 years. Under high-rainfall conditions (>50 mm day(-1)), the estuary becomes stratified and nutrients are either removed from the estuary directly in a plume or indirectly by advective/dispersive remobilisation. The majority of the nutrient load is delivered during moderate rainfall (5-50 mm day(-1)) conditions and accumulates close to discharge points and remains in the estuary. To significantly reduce nutrient load, management strategies should aim to minimise low and moderate rainfall pollutant loads.

Irreducible posterior subtalar dislocation with incarceration of a fracture of the anterior process of the calcaneum

Subtalar dislocation is a significant injury characterised by late complications, including subtalar arthritis. We describe a rare case of irreducible posterior subtalar dislocation due to incarceration of a fracture of the anterior process of the calcaneum in the subtalar joint, and discuss appropriate management.

Determining Issues of Importance for Patients with Breast Cancer: Results of a Web-Based Study in 1072 Patients To Enhance the Content Validity for the Development of a New Health-Related Quality of Life (Ql) Instrument, the Breast Cancer Symptom Scale (BCSS)

Background:Identifying key issues for patients with malignancy is central to assessing QL and patient reported outcomes during all points of the illness trajectory. The involvement of patients in establishing content validity is crucial for instrument development. The conceptual model for the BCSS focuses on areas of importance for patients (Hollen, Supp Care Ca 1994).Methods:We used the established patient base of the web-based NexCura information resource to survey registered patients with breast cancer. Demographic stratifications included disease stage, age, menopausal status, time since diagnosis, prior/current treatment with surgery, RT, chemotherapy, hormonal, targeted, and CAM approaches. 1072 patients (median age 53, 65% stage I, 43% > 2 years since diagnosis) completed the anonymous web-conducted survey. Patients ranked 21 issues on a 5-point scale, assessing the importance of each item. Issues included general, physical, functional, psychosocial and summative items.Results:The 9 highest ranked items are seen below. Results are described by the percent of patients choosing the top category (very important) and the top 2 importance categories. The five lowest ranked items dealt with appetite, breast-specific issues, hot flashes and sexuality. Ratings by breast cancer subsets (newly diagnosed, on treatment, NED, hormonal or non-hormonal treatment, metastatic disease, survivors) showed some differences compared with the whole group.[table1]N=1072Very ImportantVery Important +ImportantGood QL82%99%Maintaning independence75%97%Able to sleep69%97%Able to concentrate65%97%Perfrom normal activities62%97%Being fatigued61%95%Having depression51%85%Being anxious47%85%Having pain46%80% Conclusions:These results represent one of the largest surveys of concerns expressed by patients with breast cancer and support using computer-assisted technology to assess such information for rapid input of large patient samples. This study gives strong support for content validity for the BCSS and provides data on which to base separate QL instruments for specific breast cancer settings.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5048.

A double-blind, multicentered study comparing the accuracy of diagnostic markers to predict short- and long-term clinical events and their utility in patients presenting with chest pain

BACKGROUND

Millions of patients present annually with chest pain, but only 10% have myocardial infarction (MI). We recently reported comparative sensitivity and specificity of available markers in the diagnosis of MI; however, optimum interpretation of marker results requires prognostic follow-up data.

HYPOTHESIS

The study was undertaken to study the accuracy of CK-MB subforms, troponin I and T, myoglobin, and CK-MB in predicting clinical events at 30 days and 6 months.

METHODS

In all, 955 consecutive patients with chest pain were enrolled in a prospective, multicenter, double-blind study to test the prognostic accuracy of these markers.

RESULTS

Myocardial infarction was diagnosed in 119 by CK-MB mass criteria and unstable angina (UA) in 203 patients by clinical criteria. Follow-up at 30 days and 6 months was available in 824 and 724 patients, respectively, with mortalities of 2.8 and 4.14%, respectively. Cumulative 6-month mortality was 5.6% in MI, 4.4% in UA, and 3.0% in others. Revascularization was reported in 9.3% of patients by 6 months. A positive test on each of the markers except myoglobin was predictive of revascularization. The composite endpoint of death or revascularization occurred in 107 patients by 6 months and a positive result on each of the markers was predictive of this composite endpoint (p < 0.05). The relative risk of death or revascularization for patients who did not have MI but tested positive on each of the markers was > 1.0 but did not reach statistical significance.

CONCLUSIONS

With the possible exception of myoglobin, each of the diagnostic markers displayed similar prognostic performance in patients with chest pain presenting to emergency departments. The most appropriate markers to triage patients with chest pain, which has both adequate early diagnostic sensitivity and prognostic accuracy, are the CK-MB subforms.

'It's quite hard to grasp the enormity of it': perceived needs of people upon diagnosis of rheumatoid arthritis

OBJECTIVES

The diagnosis of rheumatoid arthritis (RA) brings rapid pharmacological and multidisciplinary team interventions to address inflammatory processes and symptom management. However, people may also need support on the journey to self-management. The aim of this study was to explore what professional support patients feel they receive upon diagnosis, and what support they feel would be most helpful.

METHODS

Two focus groups comprised patients with at least five years'; disease duration (n = 7), and patients more recently diagnosed (5-18 months, n = 5). The latter had attended at least two appointments in a rheumatology nurse specialist clinic during the previous year, aimed at providing support upon diagnosis. Transcripts were subjected to thematic analysis to identify common issues regarding support needs, which were then grouped into themes. Interviewing and analysis was performed by researchers not involved in clinical care.

RESULTS

Four overarching themes emerged. 'Information' was needed about the symptoms of RA, its management and personal outcome, while 'Support' related to emotional needs ('It's quite hard to grasp the enormity of it'). Information and Support overlapped, in that patients wanted someone to talk to, and to be listened to. These two themes were underpinned by issues of service delivery: 'Choice' (patient or professional to talk to, groups, one-to-one) and 'Involvement' (holistic care, partnership), which overlapped in terms of the opportunity to decide when and which interventions to access.

CONCLUSIONS

People with RA report not only informational, but also emotional support needs at diagnosis. The potential for delivering emotional support to patients around the time of diagnosis warrants further exploration.

The effect of IVX-0142, a heparin-derived hypersulfated disaccharide, on the allergic airway responses in asthma

BACKGROUND

IVX-0142 is a heparin-derived hypersulfated disaccharide devoid of anticoagulant activity while possessing anti-allergic and anti-inflammatory activity in preclinical studies. In a proof-of-concept study, the allergen inhalation challenge model was used to investigate the effect of IVX-0142 in mild atopic asthma.

METHODS

Nineteen subjects, not on controller medications, were randomized to an evaluator-blind, placebo-controlled, cross-over study. The effect of a single nebulized dose of IVX-0142 (80 mg) or placebo administered 30 min prior to allergen inhalation was evaluated on the allergic airway responses, airway responsiveness, and airway inflammation.

RESULTS

When compared with placebo, 14 and 13 subjects experienced a relatively smaller maximum fall in forced expiratory volume in 1 s (maxFEV(1)%) for the early airway response (EAR) and late airway response (LAR) with IVX-0142, respectively (P < 0.01). The degree of attenuation in the EAR [maxFEV(1)% (mean +/- SE) 26.5 +/- 2.8%vs placebo 31.0 +/- 2.8%, P = 0.059] and LAR (15.6 +/- 2.9%vs placebo 19.0 +/- 2.9%, P = 0.24) with IVX-0142, however, was small and did not reach statistical significance compared with placebo. Similarly, a trend in the attenuation of allergen-induced increase in the absolute sputum cell counts was also observed. No difference in the allergen-induced increase in airway hyper-responsiveness and exhaled nitric oxide was noticed.

CONCLUSIONS

The majority of mild atopic asthmatics demonstrated a reduction in the EAR and LAR to IVX-0142. However, the treatment effect observed with a single prechallenge dose of IVX-0142 was small and heterogeneous. The potential anti-allergic and anti-inflammatory effects using multiple higher doses need to be evaluated.

Nursing support at the onset of rheumatoid arthritis: Time and space for emotions, practicalities and self-management

BACKGROUND

Following a diagnosis of rheumatoid arthritis (RA), patients have to adapt to lifelong, unpredictable but repeated episodes of pain and disability, potentially leading to permanent loss of function and its consequences on their lives. We established nurse clinics with the aim of supporting newly diagnosed RA patients in adapting to and managing their long-term condition. The aim of this study was to explore the content of clinic discussions in this new clinical service, in order to ascertain patients' needs upon diagnosis.

METHODS

All clinic letters from the nurse to the family doctor were analysed. Every topic mentioned was systematically coded independently by a researcher and a patient research partner, who compared and agreed codes. Codes were organized into categories, and, finally, into overarching themes.

RESULTS

Twenty-four patients had 74 appointment letters. A total of 79 codes were identified, from which ten categories emerged, and, finally, three overarching themes. The first theme related to 'Emotional support', which underpinned the other two themes and was discussed in almost all appointments. Issues included discussions about the emotional consequences of RA, needing time to adjust, frustration and fears for the future. The second theme 'Practicalities of the treatment of RA', included subordinate themes relating to the nature of RA, such as identity, cause, timeline, consequences and treatment. Medication issues were discussed and referrals to the multidisciplinary team were made. The final theme related to the 'Self-management of RA', and included discussions on physical symptoms and their management.

CONCLUSIONS

The offer to attend a nurse clinic soon after diagnosis allowed RA patients to discuss a wide range of practical and self-management issues. However, most patients also took the opportunity and time to discuss emotional reactions and adaptations to diagnosis. The data suggest an unmet need for emotional support that a nurse clinic might be able to provide.

Regulation of Na+ and Cl- transport and mucous gland secretion in airway epithelium

Ussing's short-circuit technique was applied to canine airway epithelium in vitrol and a net flux of Cl- towards the airway lumen was demonstrated, with a smaller net flux of Na+ in the opposite direction. Furosemide decreased and acetylcholine, terbutaline, and histamine increased net ion transport towards the airway lumen. Associated changes in water content in the airway lumen could affect mucociliary clearance, and therefore inhibition of ion transport may play a role in disease states. To study secretions from submucosal glands in vivo, two techniques were used to identify the duct openings in the exposed canine tracheal epithelium. (a) The exposed mucosal surface was coated with powdered tantalum; accumulated secretions produced elevations under which the duct openings were located. (b) A vital dye (0.1% Neutral red) was placed on the exposed mucosal surface; the dye stained the duct openings. With these techniques, the innervation of the submucosal glands and the autonomic regulation of their secretions were studied. Micropuncture techniques were used to sample the secretions from the glands and ducts.

Operative delay for fracture of the hip: a two-centre prospective study

We undertook a simultaneous prospective two-centre study to examine why patients with fractures of the proximal femur experience a delay in undergoing surgery. At centre 1, 23 of 105 patients (22%) suffered an avoidable delay, 18 (78%) because of a lack of theatre capacity while at centre 2, 71 of 130 patients (55%) had an avoidable delay, with 54 (76%) because of this cause. Miscellaneous reasons such as poor ward management, co-existing medical conditions, and lack of equipment were responsible for the remainder of the delays. Without a substantial increase in operating capacity for acute trauma, it will not be possible to comply with guidelines which recommend surgical treatment within 24 hours in elderly and vulnerable patients.

HSP60 in heart failure: abnormal distribution and role in cardiac myocyte apoptosis

Heat shock protein (HSP) 60 is a mitochondrial and cytosolic protein. Previously, we reported that HSP60 doubled in end-stage heart failure, even though levels of the protective HSP72 were unchanged. Furthermore, we observed that acute injury in adult cardiac myocytes resulted in movement of HSP60 to the plasma membrane. We hypothesized that the inflammatory state of heart failure would cause translocation of HSP60 to the plasma membrane and that this would provide a pathway for cardiac injury. Two models were used to test this hypothesis: 1) a rat model of heart failure and 2) human explanted failing hearts. We found that HSP60 localized to the plasma membrane and was also found in the plasma early in heart failure. Plasma membrane HSP60 localized to lipid rafts and was detectable on the cell surface with the use of both flow cytometry and confocal microscopy. Localization of HSP60 to the cell surface correlated with increased apoptosis. In heart failure, HSP60 is in the plasma membrane fraction, on the cell surface, and in the plasma. Membrane HSP60 correlated with increased apoptosis. Release of HSP60 may activate the innate immune system, promoting a proinflammatory state, including an increase in TNF-alpha. Thus abnormal trafficking of HSP60 to the cell surface may be an early trigger for myocyte loss and the progression of heart failure.