Team consultancy using cognitive analytic therapy: a controlled study in assertive outreach

The objective of this study was to evaluate the clinical and organizational efficacy of formulation-based consultancy to clinical teams using a randomized control trial methodology. Patients in an Assertive Outreach Team (AOT) were randomized into cognitive analytic consultancy (CAC; n = 10) or treatment as usual (TAU; n = 10). CAC consisted of three consultancy sessions with individual team members to formulate and map the dysfunctional roles and procedures adopted by both patient and team. Subsequent changes to practice were then supported via team supervision. Measures of patient and team functioning were taken across four discrete study phases; (1) baseline team training, (2) case consultation, (3) team supervision and (4) 3-month follow-up. Team members were additionally interviewed before and following the trial. No differences were evident between CAC and TAU in terms of patient outcomes. However, the climate of the AOT significantly improved longitudinally over the course of the trial, with CAC facilitating enhanced clinical and team practices. The results are discussed in terms of methodological limitations, the advantages/disadvantages of team consultation and the potential for the further development of the CAC model.

A first-in-human study of the anti-α5β1 integrin monoclonal antibody PF-04605412 administered intravenously to patients with advanced solid tumors

Purpose

A first-in-human clinical trial of a fully human, Fc-engineered IgG1 monoclonal antibody targeting integrin α5β1 was conducted to evaluate tolerability, maximum tolerated dose, pharmacokinetics, pharmacodynamics and preliminary anti-tumor activity.

Methods

Escalating doses of PF-04605412 were given IV on day 1, 28 and every 2 weeks thereafter to patients with advanced solid tumors until disease progression or unacceptable toxicity. Sequential dose cohorts were evaluated based on a modified 3 + 3 dose-escalation design. The starting dose was 7.5 mg based on preclinical data.

Results

Thirty-three patients were enrolled to six dose levels (7.5, 11.25, 16.9, 34, 68 and 136 mg). Twenty-three patients were evaluable for the primary endpoint (determination of the maximum tolerated dose). Five patients required permanent drug discontinuation due to acute infusion-related reactions, which occurred as grade 3 events in two patients. PK analysis indicated that the targeted drug exposure based on preclinical models was not achieved by the tolerated doses and PK modeling suggesting that doses at least fivefold higher would be necessary. No anti-tumor activity was observed.

Conclusion

Based on the safety data, the risks associated with the likelihood of significant cytokine-mediated infusion reactions at higher doses, the projected high dose necessary to affect on the biological target and the lack of anti-tumor activity at the doses explored, the trial was prematurely terminated without determining a formal maximum tolerated dose. Further clinical development of PF-04605412 has been discontinued.

Electronic supplementary material

The online version of this article (doi:10.1007/s00280-014-2576-8) contains supplementary material, which is available to authorized users.

The incidence of pelvic fractures with traumatic lower limb amputation in modern warfare due to improvised explosive devices

Aims

A frequently-seen injury pattern in current military experience is traumatic lower limb amputation as a result of improvised explosive devices (IEDs). This injury can coexist with fractures involving the pelvic ring. This study aims to assess the frequency of concomitant pelvic fracture in IED-related lower limb amputation.

Methods

A retrospective analysis of the trauma charts, medical notes, and digital imaging was undertaken for all patients arriving at the Emergency Department at the UK military field hospital in Camp Bastion, Afghanistan, with a traumatic lower limb amputation in the six months between September 2009 and April 2010, in order to determine the incidence of associated pelvic ring fractures.

Results

Of 77 consecutive patients with traumatic lower limb amputations, 17 (22%) had an associated pelvic fracture (eleven with displaced pelvic ring fractures, five undisplaced fractures and one acetabular fracture). Unilateral amputees (n=31) had a 10% incidence of associated pelvic fracture, whilst 30 % of bilateral amputees (n=46) had a concurrent pelvic fracture. However, in bilateral, trans-femoral amputations (n=28) the incidence of pelvic fracture was 39%.

Conclusions

The study demonstrates a high incidence of pelvic fractures in patients with traumatic lower limb amputations, supporting the routine pre-hospital application of pelvic binders in this patient group.

Fluoxetine- and norfluoxetine-mediated complex drug-drug interactions: in vitro to in vivo correlation of effects on CYP2D6, CYP2C19, and CYP3A4

Fluoxetine and its circulating metabolite norfluoxetine comprise a complex multiple-inhibitor system that causes reversible or time-dependent inhibition of the cytochrome P450 (CYP) family members CYP2D6, CYP3A4, and CYP2C19 in vitro. Although significant inhibition of all three enzymes in vivo was predicted, the areas under the concentration-time curve (AUCs) for midazolam and lovastatin were unaffected by 2-week dosing of fluoxetine, whereas the AUCs of dextromethorphan and omeprazole were increased by 27- and 7.1-fold, respectively. This observed discrepancy between in vitro risk assessment and in vivo drug-drug interaction (DDI) profile was rationalized by time-varying dynamic pharmacokinetic models that incorporated circulating concentrations of fluoxetine and norfluoxetine enantiomers, mutual inhibitor-inhibitor interactions, and CYP3A4 induction. The dynamic models predicted all DDIs with less than twofold error. This study demonstrates that complex DDIs that involve multiple mechanisms, pathways, and inhibitors with their metabolites can be predicted and rationalized via characterization of all the inhibitory species in vitro.

The effects of plastic spectacles on the condition and behaviour of pheasants

Plastic spectacles are often fitted to pheasants in laying pens to reduce feather pecking and egg eating. This study examined the effects of spectacles on the physiological condition and behaviour of pheasants in harem and flock laying pens. In 2006 and 2007, data were collected from 21 game farms across England. On each site, two identical pens were randomly allocated a treatment, with or without spectacles. The physiological condition of pheasants in each treatment pen was assessed before and after the laying season. In flock pens, the behaviour of spectacled and non-spectacled pheasants was also assessed weekly. Detailed records of egg collections and mortality were also kept. Spectacles had no effect on the behaviour of male pheasants but affected the behaviour of females by reducing pecking and increasing head shaking/scratching. Although spectacles halved feather damage in females, and at least halved incidences of skin damage in both sexes, they increased bill and nostril damage in females while causing no detectable damage in males. Egg collections and mortality rates did not differ between spectacled and non-spectacled pens.

The incidence of pelvic fractures with traumatic lower limb amputation in modern warfare due to improvised explosive devices

AIMS

A frequently-seen injury pattern in current military experience is traumatic lower limb amputation as a result of improvised explosive devices (IEDs). This injury can coexist with fractures involving the pelvic ring. This study aims to assess the frequency of concomitant pelvic fracture in IED-related lower limb amputation.

METHODS

A retrospective analysis of the trauma charts, medical notes, and digital imaging was undertaken for all patients arriving at the Emergency Department at the UK military field hospital in Camp Bastion, Afghanistan, with a traumatic lower limb amputation in the six months between September 2009 and April 2010, in order to determine the incidence of associated pelvic ring fractures.

RESULTS

Of 77 consecutive patients with traumatic lower limb amputations, 17 (22%) had an associated pelvic fracture (eleven with displaced pelvic ring fractures, five undisplaced fractures and one acetabular fracture). Unilateral amputees (n = 31) had a 10% incidence of associated pelvic fracture, whilst 30 % of bilateral amputees (n = 46) had a concurrent pelvic fracture. However, in bilateral, trans-femoral amputations (n = 28) the incidence of pelvic fracture was 39%.

CONCLUSIONS

The study demonstrates a high incidence of pelvic fractures in patients with traumatic lower limb amputations, supporting the routine pre-hospital application of pelvic binders in this patient group.

Uncertainty and anxiety in the cancer of unknown primary patient journey: a multiperspective qualitative study

BACKGROUND

Patients with cancer of unknown primary (CUP) have metastatic malignant disease without an identifiable primary site; it is the fourth most common cause of cancer death.

OBJECTIVES

To explore patients' informal and professional carers' experiences of CUP to inform development of evidence-based, patient-centred care.

METHODS

Qualitative study involving development of multiple exploratory case studies, each comprising a patient and nominated informal and professional carers, with contextual data extracted from medical records.

RESULTS

17 CUP patients, 14 informal and 13 professional carers participated in the study. Two inter-related themes distinct to CUP emerged: uncertainty and continuity of care. In the absence of a primary diagnosis, patients and informal carers experienced uncertainty regarding prognosis, possible recurrence and the primary's hereditary potential. Professional carers experienced difficulty communicating uncertainty to patients, ambiguity in deciding optimal treatment plans in the absence of trial data and a test or treat dilemma: when to discontinue seeking the primary and start treatment. Common problems with care continuity were amplified for CUP patients relating to coordination, accountability and timeliness of care. The remit of multidisciplinary teams (MDTs) often excluded CUP, leading to "MDT tennis" where patients were "bounced" between MDTs.

CONCLUSIONS

The experience of those with CUP is distinctive and it can serve to amplify some of the issues encountered by people with cancer. The clinical uncertainties related to CUP compound existing shortcomings in continuity of care, increasing the likelihood of a disrupted patient journey. However, while little can be done to overcome uncertainty, more could be done to address issues regarding continuity of care.

An area essential for linking word meanings to word forms: evidence from primary progressive aphasia

We investigated the relationship between deficits in naming and areas of focal atrophy in primary progressive aphasia (a neurodegenerative disease that specifically affects language processing). We tested patients, across multiple input modalities, on traditional naming tasks (picture naming) and more complex tasks (sentence completion with a name, naming in response to a question) and obtained high resolution MRI. Across most tasks, error rates were correlated with atrophy in the left middle and posterior inferior temporal gyrus. Overall, this result converges with prior literature suggesting that this region plays a major role in modality independent lexical processing.

Assessing natural and anthropogenic variability in wetland structure for two hydrogeomorphic riverine wetland subclasses

The hydrogeomorphic approach (HGM) to wetland classification and functional assessment has been applied regionally throughout the United States, but the ability of HGM functional assessment models to reflect wetland condition has limited verification. Our objective was to determine how variability derived from anthropogenic effects and natural variability impacted site assessment variables within regional wetland subclasses in central Oklahoma. We collected data for nine potential assessment variables including vegetation physiognomy (e.g., tree basal area, herbaceous cover, canopy cover, etc.) and soil organic matter at wetlands of two HGM riverine subclasses (oxbow and riparian) in May and June, 2010. Using Akaike Information Criteria, we identified limited relationships between landscape disturbance metrics and assessment variables within subclasses. The high degree of natural variability from climatic and hydrologic factors within both subclasses may be masking the impact of landscape disturbance on the other measured assessment variables. Precipitation had significant effects on assessment variables within each of the subclasses. To reduce natural climatic variability, the reference domain may need to be further subdivided. The approach used in this study provides fairly rapid and quantitative methods for evaluating the effectiveness of using HGM assessment variables in assessing wetland condition regionally.

Retracing the routes of introduction of invasive species: the case of the Sirex noctilio woodwasp

Understanding the evolutionary histories of invasive species is critical to adopt appropriate management strategies, but this process can be exceedingly complex to unravel. As illustrated in this study of the worldwide invasion of the woodwasp Sirex noctilio, population genetic analyses using coalescent-based scenario testing together with Bayesian clustering and historical records provide opportunities to address this problem. The pest spread from its native Eurasian range to the Southern Hemisphere in the 1900s and recently to Northern America, where it poses economic and potentially ecological threats to planted and native Pinus spp. To investigate the origins and pathways of invasion, samples from five continents were analysed using microsatellite and sequence data. The results of clustering analysis and scenario testing suggest that the invasion history is much more complex than previously believed, with most of the populations being admixtures resulting from independent introductions from Europe and subsequent spread among the invaded areas. Clustering analyses revealed two major source gene pools, one of which the scenario testing suggests is an as yet unsampled source. Results also shed light on the microevolutionary processes occurring during introductions, and showed that only few specimens gave rise to some of the populations. Analyses of microsatellites using clustering and scenario testing considered against historical data drastically altered our understanding of the invasion history of S. noctilio and will have important implications for the strategies employed to fight its spread. This study illustrates the value of combining clustering and ABC methods in a comprehensive framework to dissect the complex patterns of spread of global invaders.