Perceived feasibility of a community pharmacy-based asthma intervention: a qualitative follow-up study

WHAT IS KNOWN AND OBJECTIVE

Asthma is a National Health Priority Area in Australia; however, recent evidence suggests that its management remains suboptimal. Community pharmacists are in a unique position to help patients manage asthma, and a number of community pharmacy-based asthma interventions have demonstrated effectiveness with improved patient outcomes. This study aimed to explore the views of general practitioners (GPs), community pharmacists and patients towards a pharmacy-based intervention that saw patients with poorly managed asthma supplied with educational material and referred to their GP for an asthma management review.

METHODS

A qualitative follow-up study of participants who had been involved in the intervention was conducted. A sample of six GPs, 10 community pharmacists and 10 patients participated in semi-structured face-to-face interviews. Data were analysed using interpretive phenomenology.

RESULTS AND DISCUSSION

General practitioners accepted the intervention process if they had positive relationships with pharmacists. There was also some hesitance of GPs towards the intervention, related to a perceived encroachment on their area of responsibility and a perceived conflict of interest of pharmacists in providing health care. GPs indicated the need to be more involved with the intervention process, and expressed that patients were rarely forthcoming about problems with their asthma. Community pharmacists felt that patients can be apathetic about asthma and often fail to seek medical advice. The intervention was implemented very easily, with minimal disruptions to the pharmacists' workflow, and pharmacists suggested that it would be better if GPs were more involved with the intervention process. Patients' general satisfaction with pharmacy services was high, but their expectations were quite low. Although there was an appreciation by patients of community pharmacists' interest in their health, this did not necessarily translate into appointments with GPs for an asthma management review. The reason for this related primarily to patients' under-estimation of their asthma severity.

WHAT IS NEW AND CONCLUSION

A wider rollout of the asthma intervention, with an improved process for involving GPs, would be feasible and well accepted. Further research should determine the best approach in influencing patients' perceptions of asthma control and whether these perceptions are amenable to a more intensive educational intervention. This could result in more efficient asthma interventions, translating to improved patient outcomes.

The sustainability of a community pharmacy intervention to improve the quality use of asthma medication

WHAT IS KNOWN AND OBJECTIVE

A previously published asthma intervention used a software application to data mine pharmacy dispensing records and generate a list of patients with potentially suboptimal management of their asthma; in particular, a high rate of provision of reliever medication. These patients were sent educational material from their community pharmacists and advised to seek a review of their asthma management from their general practitioner. The intervention resulted in a 3-fold improvement in the ratio of dispensed preventer medication (inhaled corticosteroids) to reliever medication (short-acting beta-2 agonists). This follow-up study aimed to determine the long-term effects of the intervention programme on the preventer-to-reliever (P:R) ratio.

METHODS

The same data mining software was modified so that it could re-identify patients who were originally targeted for the intervention. Community pharmacists who participated in the previous intervention installed the modified version of the software. The dispensing data were then de-identified, encrypted and transferred via the Internet to a secure server. The follow-up dispensing data for all patients were compared with their pre- and post-intervention data collected originally.

RESULTS AND DISCUSSION

Of the 1551 patients who were included in the original study, 718 (46·3%) were eligible to be included in the follow-up study. The improved P:R ratio was sustained for at least 12 months following the intervention (P < 0·01). The sustained increase in the P:R ratio was attributed to significant decreases in the average daily usage of reliever medication (P < 0·0001).

WHAT IS NEW AND CONCLUSION

The follow-up study demonstrated a sustained improvement in the ratio of dispensed preventer medication to reliever medication for asthma. The intervention has the potential to show long-lasting and widespread improvements in asthma management, improved health outcomes for patients, and ultimately, a reduced burden on the health system.

HIV seroprevalence among hospital inpatients with neuropsychiatric and other central nervous system disorders

OBJECTIVE

To determine the seroprevalence of HIV among inpatients with neuropsychiatric and other central nervous system (CNS) disorders at the University Hospital of the West Indies (UHWI).

METHODS

Sera and data of hospital inpatients with disorders of the CNS were prospectively investigated and reviewed at the Virology Laboratory, UHWI, over the period January 1 to December 31, 2007. The study population included inpatients with a principal diagnosis of a neuropsychiatric or other CNS disorder and for whom a serological analysis for HIV had been requested. The CNS disorders were categorized as follows: neuropsychiatric disorder (eg schizophrenia), CNS infection (eg viral, bacterial), motor and psychogenic dysfunction not included in other categories (eg seizures), gross structural brain lesion (eg tumours) and other HIV prevalence rates were calculated and compared according to age, gender and diagnostic category.

RESULTS

Eighty-two patients were included. Sixty-one per cent were males and 39% females. The mean age in years (+/- SD) was 37.6 (+/- 16.3). There were significant differences in prevalence rates according to diagnostic category (p = 0.026). All of the patients with psychiatric disorders (n = 40) were HIV-negative and 25% (3 out of 12) of patients with CNS infection were HIV-positive. There were no statistically significant associations demonstrated between HIV and age or gender (p > 0.05).

CONCLUSION

Clinicians should have a high index of suspicion for HIV infection when faced with patients with CNS infection. Further research is needed to clearly identify the reasons for the comparatively low prevalence of HIV among the psychiatric patients included in this study.

The association of fatty acid deficiency symptoms (FADS) with actual essential fatty acid status in cheek cells

Seven clinical symptoms have been utilised in several studies as a means of potentially identifying children with a deficiency in essential polyunsaturated fatty acids (PUFAs). The purpose of this study was to investigate whether there was any correlation between parental reports of the frequency of these seven 'fatty acid deficiency symptoms' (FADS) with actual levels of fatty acids in buccal cell samples of 450 children aged 8-10 years old. Additionally, the relationship between FADS and cognitive test performance, ratings of attention and behaviour and other somatic complaints were explored. The severity of reported FADS was not related to the levels of omega-6 or omega-3 in buccal cell samples. There was a relationship between parental reports of child behaviour and reported FADS; with high FADS being related to higher ratings of behaviour problems. Using FADS as a marker of PUFA deficiency may not be appropriate especially when assessing typically developing children.

A double-blind, placebo-controlled study investigating the effects of omega-3 supplementation in children aged 8-10 years from a mainstream school population

Despite the increased interest in the effects of omega-3 supplementation on children's learning and behaviour, there are a lack of controlled studies of this kind that have utilised a typically developing population. This study investigated the effects of omega-3 supplementation in 450 children aged 8-10 years old from a mainstream school population, using a randomised, double-blind, placebo-controlled design. Participants were supplemented with either active supplements (containing docosahexaenoic acid, DHA and eicosapentaenoic acid, EPA) or a placebo for 16 weeks. Cheek cell fatty acid levels were recorded pre- and post-supplementation and a range of cognitive tests and parent and teacher questionnaires were used as outcome measures. After supplementation, changes in the relationship between omega-6 and omega-3 were significant in the active group. Despite the wide range of cognitive and behavioural outcome measures employed, only three significant differences between groups were found after 16 weeks, one of which was in favour of the placebo condition. Exploring the associations between changes in fatty acid levels and changes in test and questionnaire scores also produced equivocal results. These findings are discussed in relation to previous findings with clinical populations and future implications for research.

Childrens' learning and behaviour and the association with cheek cell polyunsaturated fatty acid levels

Increasing interest in the role of omega-3 fatty acids in relation to neurodevelopmental disorders (e.g. ADHD, dyslexia, autism) has occurred as a consequence of some international studies highlighting this link. In particular, some studies have shown that children with ADHD may have lower concentrations of polyunsaturated fatty acids (PUFAs), particularly omega-3, in their red blood cells and plasma, and that supplementation with omega-3 fatty acids may alleviate behavioural symptoms in this population. However, in order to compare levels it seems appropriate to establish fatty acid levels in a mainstream school aged population and if levels relate to learning and behaviour. To date no study has established this. For this study, cheek cell samples from 411 typically developing school children were collected and analysed for PUFA content, in order to establish the range in this population. In addition, measures of general classroom attention and behaviour were assessed in these children by teachers and parents. Cognitive performance tests were also administered in order to explore whether an association between behaviour and/or cognitive performance and PUFA levels exists. Relationships between PUFA levels and socio-economic status were also explored. Measures of reading, spelling and intelligence did not show any association with PUFA levels, but some associations were noted with the level of omega-3 fatty acids and teacher and parental reports of behaviour, with some evidence that higher omega-3 levels were associated with decreased levels of inattention, hyperactivity, emotional and conduct difficulties and increased levels of prosocial behaviour. These findings are discussed in relation to previous findings from omega-3 supplementation studies with children.

Circulating Tumor Cells and FDG-PET/CT for the Therapeutic Monitoring of Bone Metastases from Breast Cancer

Background: Circulating tumor cells (CTCs) and [18F]fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) are two promising new tools for monitoring therapy in patients with metastatic breast cancer. The two modalities showed high sensitivity in detection of bone relapse/progression from breast cancer (De Giorgi U et al. Ann Oncol 2009). In this study, we sought to evaluate the prognostic significance of two different modalities represented by the detection of CTC and FDG-PET/CT in patients with bone metastases from breast cancer treated with standard therapies. Our objective was to compare the two modalities to identify which technology could be more sensitive in prospectively monitoring such patients.Patients and Methods: This is a retrospective study of 54 patients with bone metastases from breast cancer without visceral metastases treated at The University of Texas M. D. Anderson Cancer Center from September 2004 to May 2008. CTC were detected and enumerated using the CellSearch system (Veridex LLC, Rariten NJ, USA). Patients were categorized according to first follow-up CTC counts as having a favorable (&lt; 5 CTC/7.5 mL of blood) or unfavorable (≥ 5 CTC) outcome. Reassessment of disease status by CTC count and FDG-PET/CT was performed approximately 2-3 months after initiation of the new treatment, depending on treatment type and schedule. Progression-free survival (PFS) and overall survival (OS) were estimated by Kaplan-Meier product limit method, and compared between groups with the log-rank test.Results: In 54 evaluable patients, the median overall survival time was 17 months (range, 3 to &gt;36). Follow-up CTC levels and FDG-PET/CT response predicted both PFS (p = 0.02 and p = 0.0001, respectively) and OS (p = 0.01 and p = 0.02, respectively), while baseline CTC predicted neither PFS (p = 0.8) nor OS (p = 0.76). In patients with either CTC or FDG-PET/CT response PFS has been 13 months, while in patients with discordant CTC and FDG-PET/CT response PFS has been 6 months and in patients with neither CTC nor FDG-PET/CT response PFS has been 5 months (p = &lt;0.00002). In patients with either CTC or FDG-PET/CT response, OS has not been reached (&gt;31 months); in patients with discordant CTC and FDG-PET/CT response, OS has been 24 months; and in patients with neither CTC nor FDG-PET/CT response, OS has been 18 months (p = 0.02).Conclusions: CTC and FDG-PET/CT are useful tools for therapeutic monitoring of bone metastases from breast cancer. Prospective studies in this specific clinical context are needed to assess the critical roles that CTC and FDG-PET/CT individually as well as collectively play in the prognostic and therapeutic monitoring of bone metastases from breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1109.

Predictors of Persistent Micrometastatic Disease after Neoadjuvant Chemotherapy

Introduction: Patients who receive neoadjuvant chemotherapy (NAC) for breast cancer typically do not receive further cytotoxic chemotherapy after surgery. We hypothesized that some patients would have micrometastatic disease in the bone marrow (disseminated tumor cells, DTCs) or peripheral blood (circulating tumor cells, CTCs) after NAC. This study documented rates and factors predicting DTCs and CTCs after NAC.Methods: We prospectively evaluated patients undergoing surgery for stage I-III breast cancer. All patients had blood and bone marrow samples taken after completing systemic NAC. CTCs (per 7.5ml blood) were detected using the CellSearchTM system (Veridex). CTCs were defined as nucleated cells lacking CD45 but expressing cytokeratins (CK) 8, 18, or 19. DTCs were assessed using anti-CK antibody cocktail (AE1/AE3, CAM5.2, MNF116, CK8 and 18) following cytospin. The presence of ≥1 CK positive cells and ≥1 epithelial cells meeting morphologic criteria for malignancy was considered a positive result for DTCs and CTCs, respectively. Clinicopathologic factors correlated with DTCs and CTCs and response after NAC included: Her2/neu, estrogen receptor (ER), progesterone receptor (PR) and COX2 status as well as tumor size and grade. Complete pathologic response (pCR) was defined as lack of any residual invasive disease in primary tumor and regional lymph nodes after NAC. Statistical analyses used chi-square and Fischer's exact test.Results: Results were available for 53 patients who had bone marrow and blood collected after NAC. Median follow-up was 26 months. Mean age was 52 years. NAC included anthracyclines and taxanes +/- trastuzumab. Forty percent of patients had either DTCs or CTCs after NAC. Six patients had DTCs amongst 11 patients (55%) who received trastuzumab as compared to those who did not 6/33 (18%), P=0.019. DTCs and CTCs were found in 10/43 patients (23%) and 11/43 patients (27%), respectively. Factors predicting the presence of DTCs after NAC were Her2/neu positivity (P=0.001) and COX2 positivity determined in the primary tumor at diagnosis (P=0.04). No statistically significant correlations were found between CTCs after NAC and primary tumor characteristics. Thirty percent of patients with evidence of DTCs and 10% with CTCs had a pCR. Among the 7 patients with pCR after NAC, 2 (28%) had DTCs and 2 (28%) had CTCs. Factors predicting pCR following NAC were Her2/neu positivity (P=0.0003) and ER negativity (P=0.044). In our analysis, the best predictor of the presence of DTCs and the most likely reason for pCR following NAC was Her2/neu positivity.Conclusions: A significant number of patients have persistent DTCs and/or CTCs after NAC. Interestingly, HER2 positive patients were more likely to have pCR but were also more likely to show persistence of DTCs following NAC. Follow-up is needed to determine if these patients comprise groups at higher risk for recurrence, and therefore benefit from additional chemotherapy or targeted therapies.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3020.

Effect of Trastuzumab and Chemotherapy on Circulating Tumor Cells in Patients with Poor Prognosis Metastatic Breast Cancer

Background. Trastuzumab has significant activity in HER2 neu amplified metastatic breast cancer (MBC). We hypothesized that it may selectively act against circulating tumor cells (CTC) in HER2-positiveMBC. We assessed the effect of trastuzumab-based regimens on CTC in HER2-positive MBC with poor prognosis (≥ 5 CTC).Patients and Methods. We retrospectively evaluated patients with poor prognosis MBC (baseline ≥ 5 CTC) treated with a first-line regimen consisting of trastuzumab+antimitotic agents in 11 HER2-positive patients not previously pretreated with trastuzumab, chemotherapy with antimitotic agents in 24 HER2-normal patients, and other chemotherapeutic drugs (mainly capecitabine) in other 16 HER2-normal patients. CTC were detected and enumerated using the CellSearch system (Veridex LLC, Warren NJ, USA). We evaluated the effect on CTC counts and on progression-free survival (PFS) and overall survival (OS).Results. At a median follow-up of 16 months (range, 4 to 48), 24 patients (47%) died. All 11 HER2-positive patients treated with trastuzumab+antimitotic agents had &lt;5 CTC during the treatment. Only 16 (67%) with HER2-normal MBC had &lt;5 CTC with antimitotic agents (p = 0.037), and 28 (70%) with other chemotherapeutic regimens (p = 0.048). No statistically significant difference was observed between patients treated with antimitotic agents and those treated with other chemotherapeutic agents (p = 0.73). There was no difference between patients receiving polychemotherapy and monochemotherapy (p = 0.73). The median PFS was 12 months in HER2-positive patients treated with trastuzumab+antimitotic agents compared with 7 months for those with HER2-normal (p = 0.09). The median OS was not reached (&gt;20 months) and 19 months (p = 0.034), respectively. The median PFS was 8 months in HER2-normal patients with ≥5 CTC and 4 months in those with &lt;5 CTC (p = 0.01). The median OS was not reached (&gt;17 months) and 9 months (p = 0.01), respectively.Conclusions. Trastuzumab is highly effective in patients with HER2-positive MBC with poor prognosis (≥ 5 CTC). Antimitotic agents and other chemotherapy agents did not show a similar effect in HER2-normal MBC. CTC might be useful in the monitoring of poor prognosis MBC patients undergoing therapy with trastuzumab.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3014.

Soluble Factors and Circulating Tumor Cells in Inflammatory Breast Cancer

Background: Inflammatory breast cancer (IBC) is an insidious form of breast cancer. Cytokines and chemokines direct the metastatic potential of disease and serve as biomarkers for disease progression. Circulating tumor cells (CTC) are an independent prognostic factor in metastatic disease. Further, TGF-β is involved in the induction of the epithelial-mesenchymal transition (EMT) which regulates the metastatic ability of IBC. As prognostic factors of aggressive disease, we measured serum cytokines and leukocyte phenotypes, and correlated the values with known CTC results of IBC and non-IBC patients.Methods: Peripheral blood (PB) from 35 IBC patients (18 non-metastatic and 17 metastatic) and 19 non-IBC patients (7 LABC, 12 MBC) was collected prior to starting a new therapy to measure a panel of 33 cytokines, chemokines, and growth factors in serum by Luminex; CTC by CellSearch™; and PB leukocyte immunophenotype by FACS. The Kruskal-Wallis and Mann-Whitney U tests determined the differences in cytokine levels between IBC, non-IBC and healthy donors (HD) and presence of CTCs.Results: There were no differences in serum cytokine, chemokine or growth factor levels between IBC and non-IBC patients. EGF, IP-10, MIG, Eotaxin, MCP-1 and TNF-RI were significantly elevated in breast cancer patients compared to HD. TNF-RI, EGF, HGF, IP-10, MIG, Eotaxin, MCP-1 and interleukin (IL)-10 were higher in IBC patients than in HD. Compared to IBC patients, non-IBC patients had fewer dysregulated cytokines relative to HD including higher EGF, Eotaxin, MCP-1 and IL-8.Perhaps counter-intuitively, non-metastatic IBC patients had higher plasma levels of IL-2, -2R, -4, -5, -10, -12p70, -15, -17, FGF-b, IFN-γ, GM-CSF, and MIP1-α than metastatic IBC patients. Moreover, these differences were not observed between LABC and MBC patients. Furthermore, compared to HD, metastatic IBC had lower IL-4, -7, -17, -12p70, IFN-γ, RANTES, but higher levels of IP-10, Eotaxin, MCP-1, and TNF-RI. These data suggest that non-metastatic IBC patients are more immune competent than metastatic IBC patients. Finally, there were differences in the immunophenotype as well as cytokine levels between IBC patients with and without CTCs. IBC patients with CTC had a lower %T-cells (p=0.003) and higher %B-cells (p=0.008) and TNF-RI (p=0.01) than IBC patients without CTCs which may lead to a decrease in cellular immunity. Cell-mediated immunity may be further compromised by the elevated levels of serum TGF-β (p= 0.064) that can also promote EMT and metastatic progression.Conclusion: We report a comprehensive analysis of the serum cytokine and chemokine profiles in IBC patients. More importantly, this is the first report of potential interactions between soluble factors, CTC, and immune parameters in IBC patients. Non-metastatic IBC patients are more immune competent than metastatic IBC patients as evidenced by the high levels of pro- and anti-inflammatory factors; however, the presence of CTC in IBC tends to shift the immune response to a TH2 polarization with a decrease in T-cells, and a concomitant increase in B-cells and serum TGF-β and TNF-RI levels. Additional studies are needed to determine the role of soluble factors in the pathogenesis and progression of IBC and the impact on clinical outcome.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2135.

Clinical Outcomes in Two Different Cohorts of Patients with Inflammatory Breast Cancer (IBC) Treated at the MD Anderson Cancer Center: The Experience of the Morgan Welch IBC Research Program and Clinic

BACKGROUND: Inflammatory Breast Cancer (IBC) is a rare but aggressive manifestation of primary breast cancer. Survival in patients with IBC is significantly lower than for non-IBC breast cancer patients. Appropriate diagnostic and treatment strategies provided by a specialized multidisciplinary team could impact the overall prognosis of the disease. We recently established an IBC research program and clinic including investigators from various disciplines solely dedicated to this disease. We sought to compare the characteristics and clinical outcomes of newly diagnosed IBC patients evaluated and treated using novel diagnostic and therapeutic approaches with an historical cohort of IBC patients treated at our institution.METHODS: We included 240 IBC patients treated at MD Anderson Cancer Center between January 1970 and August 2000. In this analysis we compared characteristics, 1 year progression free survival (PFS) and 1 year survival between the historic cohort and 47 patients diagnosed with IBC and seen at our IBC clinic between August 2007 and September 2008. The new patients are part of a prospective IBC registry. All of them had staging and monitoring with breast MRI and FDG-PET/CT. When indicated, they were treated with targeted therapies (e.g. trastuzumab and tipifarnib), that were not available for the patients in the old cohort. Descriptive statistics were used. Kaplan Meier product-limit method was used to calculate survival outcomes, groups were compare by log-rank test.RESULTS: Median age was similar in both cohorts (53 vs 51). In the new cohort 40% of the patients had evidence of distant metastasis at presentation. The most common sites were contralateral lymph nodes (26%), pleura (16%), bone (16%) and liver (11%). In the old cohort only 17% presented with stage IV. 38.7% of the new patients had Her2-neu amplified and 34%, triple receptor negative IBC. There was no difference in 1-year survival between the two groups (92.4% vs. 93.8%, p=0.637). For patients with stage III disease, the 1-year survival was 95% for both groups. The 1 year-PFS was 86.4% in the new cohort compared to 77.9% (p=0.43) in the old cohort. With a median follow up of 13 months, 51%of the patients in the new cohort are disease free and 87% are still alive.CONCLUSIONS: IBC is an aggressive but rare disease with poor prognosis. We have established a specialized IBC research program and clinic that introduces novel concepts and strategies in laboratory, imaging diagnostics and targeted therapies. This approach may accelerate our understanding of the biology, develop new therapeutic strategies and finally improve the outcome of IBC. Early results of this multidisciplinary approach show a modest, but not significant difference in outcome. We hope that with additional patients and longer follow-up a significant improvement in outcomes will become apparent.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5119.

Immune Profile of Inflammatory Breast Cancer Patients

Background: Inflammatory breast cancer (IBC) is characterized by an acute inflammation of the skin of the affected breast due to blockage of the dermal lymphatics by tumor emboli. Cytokines and chemokines affect the migration of tumor cells and immune cell function that regulates the pathogenesis of IBC. Preliminary data suggest that sera of IBC patients contain several inflammatory cytokines and chemokines capable of regulating innate and adaptive cellular immune responses. Since there is a paucity of data on the characteristics and function of immune cells of IBC patients, we determined the immunophenotype and cytokine production by T cells and dendritic cells.Methods: From October 2008 through May 2009, peripheral blood (PB) from 34 IBC patients (18 non-metastatic and 16 metastatic), 18 non-IBC patients and 24 healthy donors (HD) were analyzed to determine the immunophenotype of T-cell subsets, activated and regulatory T-cells, B-cells, natural killer cell subsets (NKC), and dendritic cell (DC) subsets. Additionally, we assessed the ability of T-cells and DCs to synthesize cytokines following activation through the T-cell receptor (TCR) and toll-like receptors (TLR), respectively. The Kruskal-Wallis and Mann-Whitney U tests determined the differences between IBC patients, non-IBC patients, and HD.Results: IBC and non-IBC patients were well-matched in terms of ER, PR, Her2, high-grade tumor, tumor size, and menopause status. Both IBC and non-IBC patients had significantly fewer lymphocytes, total T-cells (CD3+), T-helper (CD4+), T-cytotoxic/suppressor (CD8+), and B (CD19+) than HD (all p &lt; 0.01). Non-IBC patients had a significantly lower CD4/CD8 ratio than HD (p = 0.016) while IBC patients had significantly fewer T-regulatory (CD4+CD25hiCD127-) cells than HD (p = 0.02) and non-IBC patients (p &lt; 0.05). With respect to innate immunity markers, IBC patients also had significantly lower percentages of ADCC/NK (CD16+CD56+, p = 0.034) and non-exhaustive NK (CD56+CD57+, p = 0.02) than HD and a significantly higher percentage of non-ADCC/NK cells than non-IBC patients (p = 0.03). Non-IBC patients and HD had similar innate immunity markers. Even though all groups had similar percentages of myeloid (mDC) and plasmacytoid (pDC) dendritic cells, mDC of IBC patients displayed a higher level of constitutive activation than non-IBC with increased expression of CD40 and CD80, and decreased CCR5 expression. IBC patients had more mDC that constitutively produced TNF-a (p 0.041) and IL-10 (p = 0.029) than HD, and more mDC than non-IBC patients that produced IL-10 (p = 0.028).Conclusion: The immune profile of patients with breast cancer suggests multiple abnormalities involving T-, B-, NK- and dendritic cells. Furthermore, IBC patients exhibited constitutive immune activation as measured by increased expression of co-stimulatory receptors (CD80, CD40) and constitutive production of TNF-a and IL-10 by mDC as well as fewer T-regulatory cells. Taken together, these preliminary data suggest that IBC patients are more likely than non-IBC patients to have a dysregulated immune function. Additional studies on T-cell activation and function are warranted to better understand factors associated with host defense mechanisms of IBC patients and possible therapeutic strategies to restore immune function.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4129.

Surveillance of the first 205 confirmed hospitalised cases of pandemic H1N1 influenza in Ireland, 28 April - 3 October 2009

From 28 April 2009 to 3 October 2009, 205 cases of confirmed pandemic H1N1 influenza were hospitalised in Ireland. Detailed case-based epidemiological information was gathered on all hospitalised cases. Age-specific hospitalisation rates were highest in the age group of 15 to 19 year-olds and lowest in those aged 65 years and over. Nineteen hospitalised cases (9%) were admitted to intensive care units (ICU) where the median length of stay was 24 days. Four hospitalised cases (2%) died. Fifty-one percent of hospitalised cases and 42% of ICU cases were not in a recognised risk group. Asthma was the most common risk factor among cases; however, people with haemoglobinopathies and immunosuppression were the most over-represented groups.

Surveillance of the first 205 confirmed hospitalised cases of pandemic H1N1 influenza in Ireland, 28 April – 3 October 2009

From 28 April 2009 to 3 October 2009, 205 cases of confirmed pandemic H1N1 influenza were hospitalised in Ireland. Detailed case-based epidemiological information was gathered on all hospitalised cases. Age-specific hospitalisation rates were highest in the age group of 15 to 19 year-olds and lowest in those aged 65 years and over. Nineteen hospitalised cases (9%) were admitted to intensive care units (ICU) where the median length of stay was 24 days. Four hospitalised cases (2%) died. Fifty-one percent of hospitalised cases and 42% of ICU cases were not in a recognised risk group. Asthma was the most common risk factor among cases; however, people with haemoglobinopathies and immunosuppression were the most over-represented groups.

Circulating tumor cells and FDG-PET/CT: biological and functional methods for therapeutic monitoring in metastatic breast cancer

Abstract #6052

Introduction: The combination of Computed Tomography (CT) and [18F] Fluorodeoxyglucose - Positron Emission Tomography (FDG-PET) scanning technologies provides a more complete picture of disease activity than CT alone. Circulating tumor cell (CTC) levels were shown to be more predictive than standard imaging (CT) when used to monitor disease progression in women with metastatic breast cancer (MBC). We performed a retrospective study to compare the ability of combined FDG-PET/CT to CTC to predict clinical outcomes in patients treated for MBC.&#x2028; Methods: One hundred and two MBC patients with either measurable or evaluable disease starting a new line of therapy had CTC counts and FDG-PET/CT scans done at baseline (BL) and at mid-therapy. CTC: 7.5mL of blood collected in CellSave tubes at both time points was assayed for CTC using the FDA approved CellSearch® System. Patients were categorized as having a favorable (&lt;5CTC) or unfavorable (≥5CTC) outcome. Imaging: non-contrast-enhanced CT images were acquired first, then FDG-PET/CT scans were performed after administering a mean dose of 555 MBq FDG (range 444-740 MBq) to fasting patients. CT, PET, and co-registered CT-PET images were reviewed independently by 2 radiologists. The highest recorded FDG uptake was semi-quantitatively analyzed and maximum standardized uptake value (SUV) calculated with response = SUV of &lt;50% in target lesions and no response = SUV of &gt;50%. Changes in CTC and SUV at mid-therapy were compared to progression free survival (PFS) and overall survival (OS).&#x2028; Results: CTC: 50% (51/102) patients had ≥5 CTC at baseline (BL). At mid-therapy (median 2.5 months from BL), 21/102 progressed (≥5CTC) with a median PFS of 2.8 months vs. 7.8 months for those with no progression (&lt;5CTC) (p&lt;0.0001). OS was 10.0 months for patients with ≥5CTC at mid-therapy vs. 29.6 months for those with &lt;5CTC (p&lt;0.0001). PET/CT: 48% (49/102) patients showed no response at mid-therapy with median OS = 17.4 months vs. 29.6 months for those responding (p=0.0020). Overall, there was approximately 75% concordance in predicting outcomes between imaging and CTC assay changes [Table 1]. The majority of patients with discordant results had more advanced aggressive disease, i.e., &gt;2nd line chemotherapy and triple-negative disease.&#x2028; &#x2028; Conclusion: ≥5 CTC and/or no response at FDG-PET/CT at mid-therapy accurately predicted significantly shorter OS.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6052.

Evaluation of adherence to highly active antiretroviral therapy in adults in Jamaica

BACKGROUND AND PURPOSE

Highly active antiretroviral therapy (HAART) has improved morbidity and mortality and quality of life, revitalized communities and transformed the perception of HIV/AIDS from being a "death sentence" to a chronic illness. Strict and sustained adherence to medication is essential long-term viral suppression. In April 2005, an Adherence Support Programme was introduced to Jamaica's HIV Programme, whereby Persons Living with HIV/AIDS (PLWHA) who had achieved high levels of adherence were trained to provide support to other PLWHA in order to increase their adherence to HAART regimens.

METHODS

A cross-sectional survey of 116 individuals with advanced HIV and on HAART was performed in June and July 2006.

RESULTS

Many participants were unemployed, poor persons with limited education. Based on self-report of seven-day adherence, 54.8% of persons were 95-100% adherent, 37.5% were 80-94% adherent and 7.7% were < 80% adherent. Having interacted with an adherence counsellor was not associated with adherence levels. Factors associated with nonadherence were: being away from home (38%), sleeping through dose-time (37%), forgetfulness (37%) and running out of pills (31%). Having no food (26.9%), not wanting to be seen taking medication (200%) and intolerable side effects (18.8%) were also reasons given. Only 44% of persons used aids to remind them of dose times.

CONCLUSION

Adherence in this study group is low and may have worsened since 2005. More emphasis must be placed on preparing adults to start HAART The use of pillboxes and other reminders such as alarm clocks and cell phones must be reinforced.

Nature and control of peptide release from the pars intermedia

Pro-opiocortin, the precursor of ACTH, LPH and gamma-MSH, is biosynthesized in both the cells of the pars intermedia and the corticotrophs of the pars distalis. In the pars distalis its processing does not vary significantly from species to species whereas in the pars intermedia large differences occur. The release of ACTH, beta-LPH and pro-gamma-MSH from the corticotrophs is under common positive control by hypothalamic corticotropin-releasing factor (CRF) and the nature of the peptides remains unchanged when they are secreted. The release of all five pars intermedia peptides that we have measured in vitro appears to be under tonic dopaminergic inhibition. The secreted peptides have also been identified chromatographically. The lack of unequivocal physiological function in the periphery, the diversity of the pars intermedia peptides and this common control mechanism tend to preclude a simple endocrine role for the pars intermedia. The neural effects of MSH and endorphin are well documented and specific neuronal uptake therefore cannot by dismissed. The absence of pars intermedia in the adult human pituitary suggests that such a site of synthesis of these peptides plays a minor role in learning and behaviour in a species (such as Homo sapiens) that has a highly evolved intelligence and may, instead, need to synthesize the peptides only in the brain.

Surveillance of cirrhosis for hepatocellular carcinoma: a cost-utility analysis

Using a decision-analytic model, we evaluated the effectiveness and cost-effectiveness of surveillance for hepatocellular carcinoma (HCC) in individuals with cirrhosis. Separate cohorts with cirrhosis due to alcoholic liver disease, hepatitis B and hepatitis C were simulated. Results were also combined to approximate a mixed aetiology population. Comparisons were made between a variety of surveillance algorithms using α-foetoprotein (AFP) assay and/or ultrasound at 6- and 12-monthly intervals. Parameter estimates were obtained from comprehensive literature reviews. Uncertainty was explored using one-way and probabilistic sensitivity analyses. In the mixed aetiology cohort, 6-monthly AFP+ultrasound was predicted to be the most effective strategy. The model estimates that, compared with no surveillance, this strategy may triple the number of people with operable tumours at diagnosis and almost halve the number of people who die from HCC. The cheapest strategy employed triage with annual AFP (incremental cost-effectiveness ratio (ICER): £20 700 per quality-adjusted life-year (QALY) gained). At a willingness-to-pay threshold of £30 000 per QALY the most cost-effective strategy used triage with 6-monthly AFP (ICER: £27 600 per QALY gained). The addition of ultrasound to this strategy increased the ICER to £60 100 per QALY gained. Surveillance appears most cost-effective in individuals with hepatitis B-related cirrhosis, potentially due to younger age at diagnosis of cirrhosis. Our results suggest that, in a UK NHS context, surveillance of individuals with cirrhosis for HCC should be considered effective and cost-effective. The economic efficiency of different surveillance strategies is predicted to vary markedly according to cirrhosis aetiology.

Adaptation of the Manchester-Minneapolis Quality of Life instrument for use in the UK population

INTRODUCTION

The availability of health-related quality of life (HRQL) measures that are reliable, valid, brief and comprehensible and appropriate for use with UK children is limited. We report the validation of a HRQL measure suitable for UK use in healthy children, children with chronic disease conditions and socially disadvantaged children.

PATIENTS

A total of 1238 children took part in the study, including healthy children as controls (n = 824) and five exemplar groups: children diagnosed with asthma (n = 87), diabetes (n = 103) or inflammatory bowel disease (IBD; n = 69), children in remission from cancer (n = 68) and children in public care (n = 87).

METHODS

In phase I, the Manchester-Minneapolis Quality of Life instrument (MMQL) Child Form was translated into UK English. In phases II and III, the questionnaire was shortened and validated.

RESULTS

MMQL was anglicised and shortened to five components comprising 29 items. Good internal reliability was found with alpha reaching at least 0.69 for all subscales. Construct validity was established through moderate correlations with comparable PedsQL subscales (Pearson's r ranged from 0.38 to 0.58, p<0.01). Discriminant validity was also demonstrated in children with asthma and IBD, children in remission from cancer and children in public care, all of whom reported significantly lower HRQL than healthy children. Children with diabetes showed similar HRQL to their healthy peers. Good reproducibility and moderate responsiveness were demonstrated for the new measure.

CONCLUSIONS

The anglicised and shortened MMQL was shown to be valid and reliable and could be a valuable new tool for the assessment of HRQL in children.

Surveillance of cirrhosis for hepatocellular carcinoma: systematic review and economic analysis

OBJECTIVES

To evaluate the effectiveness, cost-effectiveness and cost-utility of surveillance of patients with cirrhosis [alcoholic liver disease (ALD)-, hepatitis B (HBV)- and C virus (HCV)-related], using periodic serum alpha-fetoprotein (AFP) testing and/or liver ultrasound examination, to detect hepatocellular carcinoma (HCC), followed by treatment with liver transplantation or resection, where appropriate.

DATA SOURCES

Electronic databases were searched up to March 2006.

REVIEW METHODS

A systematic review was carried out using standard methodological guidelines. A computerised decision-analytic model was then developed to compare various surveillance strategies.

RESULTS

No studies were identified that met the criteria of the systematic review. Based on the assumptions used in the model, the most effective surveillance strategy uses a combination of AFP testing and ultrasound at 6-monthly intervals. Compared with no surveillance, this strategy is estimated to more than triple the number of people with operable HCC tumours at time of diagnosis, and almost halves the number of deaths from HCC. On all effectiveness measures and at both testing frequencies, AFP- and ultrasound-led surveillance strategies are very similar. This may be because test sensitivity was varied according to tumour size, which means that AFP testing is capable of identifying many more small tumours than ultrasound. The best available evidence suggests that AFP tests will detect approximately six times as many small tumours as ultrasound. Increasing the frequency of either test to 6-monthly intervals is more effective than performing combined testing on an annual basis. The undiscounted lifetime cost of the surveillance strategies, including all care and treatment costs, ranges from 40,300 pounds (annual AFP triage) to 42,900 pounds (6-monthly AFP and ultrasound). The equivalent discounted costs are 28,400 pounds and 30,400 pounds. Only a small proportion of these total costs results from the cost of the screening tests. However, screening test costs, and the cost of liver transplants and caring for people post-transplant, accounted for most of the incremental cost differences between alternative surveillance strategies. The results suggest that different surveillance strategies may provide the best value for money in patient groups of different cirrhosis aetiologies. The surveillance of people with HBV-related cirrhosis for HCC provides the best value for money, while surveillance in people with ALD-related cirrhosis provides the poorest value for money. In people with HBV-related cirrhosis, at an assumed maximum willingness to pay (WTP) for a quality-adjusted life-year (QALY) of 30,000 pounds, both the deterministic and probabilistic cost-utility analyses suggest the optimal surveillance strategy would be 6-monthly surveillance with the combination of AFP testing and ultrasound. In contrast, for those with ALD-related cirrhosis, annual screening with AFP as a triage test is the only surveillance strategy that is likely to be considered cost-effective at this WTP. The probabilistic analysis implies that the estimated benefits of a 6-monthly AFP triage strategy will only be worth the cost in those with ALD when society's WTP for a QALY exceeds around 40,000 pounds. For people with HCV-related cirrhosis, the model suggests that the most cost-effective surveillance strategy at a WTP threshold of 30,000 pounds/QALY would be surveillance with a 6-monthly AFP triage strategy.

CONCLUSIONS

In a mixed-aetiology cohort, the most effective surveillance strategy is to screen each patient with AFP assay and ultrasound imaging on a 6-monthly basis. However, when costs are taken into account it is doubtful whether ultrasound should be routinely offered to those with blood AFP of less than 20 ng/ml, unless policy-makers are prepared to pay over 60,000 pounds per QALY for the benefits achieved. Furthermore, the cost-effectiveness of surveillance for HCC varies considerably depending on the aetiology of cirrhosis; it is much more likely to be cost-effective in those with HBV-related cirrhosis, and much less likely to be cost-effective in those with ALD-related cirrhosis. Further development of the model would help to enable refinement of an optimal screening strategy. Research into the use of contrast-enhanced ultrasound technology for HCC detection would also be valuable, as would research into the epidemiology and natural history of ALD-related cirrhosis. Studies are also needed to investigate the influence of cirrhosis aetiology on tumour AFP expression.

Genomic of circulating tumor cells in metastatic breast cancer

1002

Background: Metastatic breast cancer (MBC) is an incurable condition and palliative treatments are selected by considering pre-treatment prognostic and predictive factors. Recently, we reported the detection of CTCs to be predictive of prognosis and treatment efficacy and reasoned they might also be used to assess biological characteristics of the patient’s tumor to improve on treatment selection. Methods: Twenty patients with newly diagnosed MBC were enrolled in a prospective clinical trial designed to assess the baseline value of CTCs, evaluate the expression of selected genes in CTCs, and compare the expression of same biomarkers in the primary tumor (PT) and/or metastatic site (MS), as determined by standard IHC and FISH. CTCs were assessed by CellSearch, and subjected to real-time PCR (qPCR) for the expression of transcripts for estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor (HER-2), notch-1, and mammaglobin (MGB) using commercial primers. Results: Sixteen of patients had =1CTCs. With respect to biomarkers of PT, 17 were ER+, 11 PR+, and 3 HER-2 amplified. Among the 15 patients with MS, the biomarkers were as follows: 9 ER+, 7 PR+, and 2 HER-2 amplified. There were significant associations between the primary and metastatic tumors with respect to the presence of ER (χ2 = 6.516, P = 0.0107), PR (χ2 = 5.529, P = 0.0187), and HER-2 (χ2 = 3.938, P = 0.0472). The qPCR of CTCs detected transcripts: ER in 3 patients (15%); PR in none (0%); MGB and HER-2 in 2 (10%) and 11 patients (55%), respectively. Notch-1 transcripts were detected in 13 patients (65%). CTCs with detectable transcripts of HER-2 were more likely to co-express notch-1 transcripts (χ2 = 4.295, P = 0.038). Of the 4 samples without detectable CTCs, one was HER-2 positive, and three had notch- 1 transcripts. Conclusions: This study demonstrated a significant concordance in biomarkers expression between the tumor cells of the primary tumors and the metastatic site. Furthermore, it suggests that CTCs differ significantly from those tumor cells with regards to the expression of hormone-receptor and HER-2 status. Thus, CTCs may represent a unique and heterogeneous cell population which phenotype and “homing” properties should be further investigated.

[Table: see text]

DNA damage response mediators MDC1 and 53BP1: constitutive activation and aberrant loss in breast and lung cancer, but not in testicular germ cell tumours

MDC1 and 53BP1 are critical components of the DNA damage response (DDR) machinery that protects genome integrity and guards against cancer, yet the tissue expression patterns and involvement of these two DDR adaptors/mediators in human tumours remain largely unknown. Here we optimized immunohistochemical analyses of human 53BP1 and MDC1 proteins in situ and identified their virtually ubiquitous expression, both in proliferating and quiescent, differentiated tissues. Focus formation by 53BP1 and/or MDC1 in human spermatogenesis and subsets of breast and lung carcinomas indicated physiological and 'pathological' activation of the DDR, respectively. Furthermore, aberrant reduction or lack of either protein in significant proportions of carcinomas supported the candidacy of 53BP1 and MDC1 for tumour suppressors. Contrary to carcinomas, almost no activation or loss of MDC1 or 53BP1 were found among testicular germ-cell tumours (TGCTs), a tumour type with unique biology and exceptionally low incidence of p53 mutations. Such concomitant presence (in carcinomas) or absence (in TGCTs) of DDR activation and DDR aberrations supports the roles of MDC1 and 53BP1 within the ATM/ATR-regulated checkpoint network which, when activated, provides an early anti-cancer barrier the pressure of which selects for DDR defects such as p53 mutations or loss of 53BP1/MDC1 during cancer progression.

The effect of suction during die fill on a rotary tablet press

Die fill on a rotary tablet press involves complex powder flow phenomena. Conventional techniques for measuring flowability do not normally provide information that is directly relevant to the design of powder feed systems or to the selection of press parameters for the die filling process. Sinka et al. [I.C. Sinka, L.C.R. Schneider, A.C.F. Cocks, Measurement of the flow properties of powders with special reference to die fill, in: International Journal of Pharmaceutics 280 (1-2) (2004) 27-38] used an experimental shoe-die system to characterise the flow behaviour of pharmaceutical powders. A rigorous data analysis procedure was developed by Schneider et al. [L.C.R. Schneider, I.C. Sinka, A.C.F. Cocks, Characterisation of the flow behaviour of pharmaceutical powders using a model die-shoe filling system, in: Powder Technology (in press)] to evaluate the experimental results, however, when scaling the results to a rotary tablet press, the die fill efficiency was underpredicted by a factor of approximately 2, because the experimental system did not capture major features of the rotary press flow process. The suction effect, whereby the lower punch is moved downwards while the top of the die is exposed to powder in the feed system, is a key element of the process. In this note we describe the development of a model shoe-die system that allows the effect of suction to be investigated. The results demonstrate the improvement offered by suction and illustrate how a fundamental understanding of die fill phenomena could assist the selection of process parameters to maximise the operational speed of a rotary press.

A look at important issues regarding safe orthokeratology

No abstract available

A review of fixation disparity

No abstract available

Questionnaires to Assess Urinary and Anal Incontinence: Review and Recommendations

PURPOSE

We reviewed and provide recommendations about the most scientifically robust and appropriate questionnaires for evaluating symptoms and the quality of life impact of urinary and/or anal incontinence, and vaginal and pelvic floor problems. We also investigated the use of these questionnaires in randomized, controlled trials of treatment strategies.

MATERIALS AND METHODS

The Symptom and Quality of Life Committee of the International Consultation on Incontinence performed a systematic review of questionnaires related to urinary and anal incontinence, and vaginal and pelvic floor problems, searching MEDLINE, The Cochrane Library and other electronic databases between 2001 and 2004.

RESULTS

A total of 23 robust and relevant questionnaires could be recommended in clinical practice and research. The development of questionnaires to assess anal incontinence, and pelvic floor and vaginal problems has been limited with some promising measures but with none achieving the highest level of rigor. From 2001 to 2004 there were 150 published randomized trials of treatments for incontinence. Increasingly trials of incontinence are using recommended measures (38% of those for urinary incontinence and 22% of those for anal incontinence used the highest quality questionnaires in 2001 to 2004) but none of vaginal and pelvic floor problems used recommended questionnaires.

CONCLUSIONS

With increasing acknowledgment of the value of patient based assessment much attention has been given to the development of questionnaires to assess symptoms and quality of life. Sufficient measures are now available for urinary incontinence, and researchers and clinicians are encouraged to use the 18 achieving the highest level of rigor and their validated translations. In contrast, the development of questionnaires for anal incontinence and pelvic/vaginal problems is in its infancy and further study in this area is needed. Randomized trials of treatments for incontinence should use only questionnaires achieving the highest level of scientific rigor.

Light-induced flocculation of gold nanoparticles

Gold particles have been formed in water-in-oil microemulsions doped with a photodestructible surfactant. UV light-induced nanoparticle flocculation has been achieved after photolysis of the photosurfactant, leading to a reduction in the steric stabilization provided by the surfactant layer.

Poverty and the economic effects of TB in rural China

OBJECTIVE

To investigate the economic effects of illness on individual tuberculosis (TB) cases in rural China and to use a case-control study to show a strong TB-poverty link.

SETTING

In 2002-2004 we studied 160 new smear-positive pulmonary tuberculosis (PTB) cases and 320 age- and sex-matched controls living in neighbouring houses in four rural counties of Henan Province.

DESIGN

Cases and controls were interviewed 1-3 months after patients were diagnosed. We used matched multivariate logistic regression to compare cases with controls for poverty status using household income, household assets and relative wealth within the village. We conducted follow-up interviews of patients 10-12 months later to assess economic effects by collecting data on treatment costs, income losses, coping strategies and treatment completion.

RESULTS

Poverty is strongly associated with TB incidence even after controlling for smoking and other risk factors. Excluding income losses, direct out-of-pocket treatment costs (medical and non-medical) accounted for 55.5% of average annual household income, and most TB cases fell into heavy debt. The DOTS cure rate was 91%. When DOTS was incomplete or not done, mortality was high.

CONCLUSIONS

Poverty is both a cause and a devastating outcome of TB. Ongoing poverty reduction schemes in China must also include reducing TB.