Challenging symptoms in children with rare life-limiting conditions: findings from a prospective diary and interview study with families

AIM

The aim was to describe the nature, frequency, severity and management challenges of symptoms in children with two rare life-limiting conditions [Mucopolysaccharide (MPS) and Batten disease].

METHODS

This was an embedded mixed-method study set in the UK between 2009 and 2011. Twenty-six children from 23 families took part. Seventeen children had an MPS condition [MPS III (Sanfilippo) n = 15; MPS I (Hurler) n = 1; MPS IVA (Morquio); n = 1]. Nine children had Batten disease. Prospective data relating to symptoms were collected over 8 weeks using a symptom diary, and qualitative retrospective interviews with families were conducted. Main outcome measures included frequency, severity rating and identification of most challenging symptoms to manage.

RESULTS

The most common and severe symptoms in MPS III were agitation, repetitive behaviours, hyperactivity and disturbed sleep, and in Batten disease were agitation, joint stiffness, secretions, and disturbed sleep. The data highlighted the high prevalence of behavioural symptoms. Distress caused to families by symptoms was not related simply to their occurrence, but to difficulty in management, likelihood of control and extent to which they signalled disease progression and decline.

CONCLUSION

In challenging contrast to the dominant biomedical framing of these rare conditions it was behavioural symptoms, rather than the physical ones, that families documented as most frequent, severe and challenging to manage. The diary developed for this study has potential use in aiding parents and clinicians to document and communicate concerns about symptoms.

Structure property correlation in lithium borophosphate glasses

To investigate the influence of cation mobility variation due to the mixed glass former effect, 0.45Li(2)O-(0.55-x)P(2)O(5)-xB(2)O(3) glasses (0≤x≤0.55) are studied keeping the molar ratio of Li(2)O/(P(2)O(5)+B(2)O(3)) constant. Addition of B(2)O(3) into lithium phosphate glasses increases the glass transition temperature (T(g)) and number density, decreases the molar volume, and generally renders the glasses more fragile. The glass system has been characterised experimentally by XRD, XPS and impedance studies and studied computationally by constant volume molecular dynamics (MD) simulations and bond valence (BV) method to identify the structural variation with increasing the B(2)O(3) content, its consequence for Li(+) ion mobility, as well as the distribution of bridging and non-bridging oxygen atoms. These studies indicate the increase of P-O-B bonds (up to Y=[B(2)O(3)]/([B(2)O(3)]+[P(2)O(5)])≈0.5 and B-O-B bonds, as well as the decrease of P-O-P bonds and non-bridging oxygens (NBOs) with rising B(2)O(3) content. The system with Y≈0.5 exhibits maximum ionic conductivity, 1.0×10(-7) S cm(-1), with activation energy 0.63 V. Findings are rationalised by a model of structure evolution with varying B(2)O(3) content Y and an empirical model quantifying the effect of the various structural building blocks on the ionic conductivity in this mixed glass former system.

P1-17-07: Phase II Trial of RAD001 Plus Carboplatin in Patients with Triple-Negative Metastatic Breast Cancer

Background: RAD001 is an oral mTOR inhibitor that has exhibited activity in breast cancer. Triple negative breast cancer cells are unable to repair double stranded DNA breaks and hence have sensitivity to platinum agents that cause interstrand cross-links. Rapamycin acts synergistically with platinum agents to induce apoptosis and inhibit proliferation in at least two different breast cancer cell lines (including ER/PR negative cell lines). We propose that combination RAD001 and carboplatin may have activity in triple-negative breast cancer.

Methods: The primary objective of the study is to determine clinical benefit (complete remission (CR) + partial remission (PR) + stable disease (SD)) and the toxicity of this combination in women with triple negative metastatic breast cancer who have had 0–3 prior chemotherapy regimens for metastatic disease. Secondary objectives are to determine progression free survival as well as investigating the relationship between pretreatment sensitivity (biopsy at baseline) and clinical response (biopsy post 2 cycles) using IHC staining for abundance of key proteins in the Akt-mTOR pathway and their activity using surrogate phosphorylation site-specific antibodies (Akt and phospho-serine 473, phospho-threonine and phospho-threonine 308 Akt; mTOR and phospho-serine 2448 mTOR; ribosome protein S6 kinase (S6K) and phospho-threonine 378 S6K; 4E-BP1 and phospho-serine 65 4E-BP1). Prior carboplatin is allowed. Women with treated brain metastasis are eligible. According to the original study plan, carboplatin AUC 6, was to be given intravenously every three weeks. Five mg of RAD001 was to be given daily with a 3 patient run-in and then 10 mg daily if there were no dose-limiting toxicities. Due to a unexpected amount of thrombocytopenia with this combination the dose of carboplatin was first amended to AUC 5 and most recently to AUC 4 with 5 mg of RAD001 (and no plan to escalate to 10 mg).

Results: Fourteen patients of a planned 25 have been recruited thus far. Median age is 58.5. Median number of prior regimens is 2 (0-3). Of the 7 patients assessable for response at this time, there have been 2 PR's and 5 patients with SD. One SD was achieved in a patient progressing on single agent carboplatin at study entry. Median duration of SD + PR is 28.5 weeks (5 patients have ongoing response ranging from 8–46.5 weeks). Five of 8 patients assessable for toxicity had grade 3 or 4 thrombocytopenia and 2 patients had grade 3 neutropenia. No cases of febrile neutropenia were observed. Four patients have required blood transfusion and one patient has required platelet transfusion. All patients have had treatment held and/or dose reductions secondary to hematological toxicity, however, since amended carboplatin dose the regimen has been very well tolerated with only one out of six patients) with grade 3 neutropenia and grade 3 thrombocytopenia. There have been no non-hematological grade 3 or 4 toxicities.

Conclusions: Clinical benefit was observed in all 7 assessable patients. Dose limiting thrombocytopenia was an unexpected side effect requiring protocol amendment. We continue to accrue study subjects at the amended dosing.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-17-07.

Phase II trial of RAD001 plus carboplatin in patients with triple-negative metastatic breast cancer

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Background: RAD001 is an oral mTOR inhibitor that has exhibited activity in breast cancer. Triple negative breast cancer cells are unable to repair double stranded DNA breaks and hence have sensitivity to platinum agents that cause interstrand cross-links. Rapamycin acts synergistically with platinum agents to induce apoptosis and inhibit proliferation in at least two different breast cancer cell lines (including ER/PR negative cell lines). We propose that combination RAD001 and carboplatin may have activity in triple-negative breast cancer.

Methods: The primary objective of the study is to determine clinical benefit (complete remission; CR, partial remission; PR and stable disease; SD) and the toxicity of this combination in women with triple negative metastatic breast cancer who had received 0-3 prior chemotherapy regimens for metastatic disease. Prior carboplatin was allowed. Women with treated brain metastasis were eligible. Secondary objectives were to determine progression free survival. According to the original study plan, carboplatin AUC 6, was to be given intravenously every three weeks. 5 mg of RAD001 was to be given daily with a 3 patient run-in and then 10 mg daily if there were no dose-limiting toxicities. Due to a surprising amount of thrombocytopenia with this combination the dose of carboplatin was first amended to AUC 5 and most recently to AUC 4 with 5 mg of RAD001 (and no plan to escalate to 10 mg).

Results: Eleven patients of a planned 25 have been recruited thus far. Median age is 62. Median number of prior regimens is 1. Of the 6 patients assessable for response at this time, four have SD and two have had a PR. 1 SD was achieved in a patient progressing on prior carboplatin at study entry. Five of 7 patients assessable for toxicity had grade 3 or 4 thrombocytopenia and 2 patients had grade 3 neutropenia. All patients have had treatment held and/or dose reductions secondary to hematological toxicity. There have been no non-hematological grade 3 or 4 toxicities.

Conclusions: Clinical benefit was observed in all 6 evaluable patients. Dose limiting thrombocytopenia was an unexpected side effect requiring protocol amendment. We continue to accrue study subjects at the amended dosing.

Pathways to immunity: temporal dynamics of the bumblebee (Bombus terrestris) immune response against a trypanosomal gut parasite

Immune response dynamics in insects from natural host-parasite associations are poorly understood, despite accumulating evidence of ecological immune phenomena in these systems. Using a gene discovery approach, we have identified genes relating to signalling, enzymatic processes and respiration that were up-regulated in the bumblebee, Bombus terrestris, during infection with the trypanosomatid parasite, Crithidia bombi. In addition, we have mapped dynamic changes in the temporal expression of these genes and three candidate antimicrobial peptide (AMP) immune genes, Abaecin, Defensin and Hymenoptaecin, from 1 to 24 h after C. bombi infection. We show that dynamic changes in expression occur for individual genes at distinct phases of the immune response to C. bombi that correspond to early, intermediate and late stages of infection.

Chronic airflow obstruction and respiratory symptoms following tuberculosis: a review of South African studies

BACKGROUND

There is renewed interest in the chronic respiratory sequelae of pulmonary tuberculosis (PTB), particularly chronic airflow limitation. A number of South African epidemiological studies have been published, which, although not specifically designed to examine this association, provide useful data on the nature of the relationship.

OBJECTIVE

To review population-based and occupational studies conducted in South Africa that provide estimates of the association between PTB, chronic symptoms and lung function loss.

RESULTS

Two general population and a number of occupational studies were included. Most were able to control for likely confounders. Chronic chest symptoms and lung function loss were consistently associated with PTB, whether measured by self-report or prospectively in cohort studies. Odds ratios (ORs) were higher for chronic bronchitis (range 1.5-7.2) than for asthma (range 0.7-2.2). For spirometrically defined chronic obstructive pulmonary disease, the OR range was 2.6-8.9, depending on definition. Combined obstructive/restrictive lung function loss was the most common functional outcome, with a net obstructive effect. The association of past TB with non-specific bronchial hyperresponsiveness was equivocal.

CONCLUSION

These studies add to the evidence of a strong association between PTB, even if treated, and subsequent airflow obstruction as well as restrictive loss. Unanswered questions include extent of recovery over time, effect modification by smoking and other cofactors, and degree of reversibility by treatment.

Colonic perforation in collagenous colitis: a systematic review of a rare complication and guidance on management

OBJECTIVE

Collagenous colitis is an increasingly diagnosed clinical and pathological variant of microscopic colitis, mainly affecting middle-aged and elderly women; herein we review the literature for a rare complication (colonic perforation) and the most appropriate management.

METHODS

EMBASE, MEDLINE and abstracts from major gastroenterological congresses were searched in addition to hand-searching of electronic journals. Ten case reports and short series were identified as relevant to this study, and full papers of all these articles were obtained.

RESULTS

A total of 30 cases were recorded (28 female; age range 37-86 years, median 66 years). Colonic perforation was reported in 21 cases, mainly following colonoscopy (15 cases) or barium enema (4 cases). The site of colonic perforation/tears was predominantly right sided (17 cases). These cases were managed differently in different series, and none of the collagenous colitis-related colonic perforations that were treated conservatively (n = 5), or with diagnostic laparotomy but no colonic resection (n = 2), required further surgical intervention.

CONCLUSIONS

Conservative management of collagenous colitis-related perforation seems to be an appropriate initial approach. However, diagnosis of collagenous colitis is usually retrospective in colonic perforations related to endoscopy or barium enema, i.e. when the histology results are available, and it seems difficult to provide a management plan specific to these patients in the clinical setting. Therefore general guidelines for management of all colonoscopy- and barium enema-related perforation are required. When perforation occurs in an otherwise intact colon, diagnostic laparoscopy can be considered as appropriate initial management.

The impact of a complex care clinic in a children's hospital

BACKGROUND

The number of medically complex and fragile children (MCFC) cared for in children's hospitals is growing, necessitating the need for optimal care co-ordination. The purpose of this study was to describe the impact of a nurse practitioner/paediatrician-run complex care clinic in a tertiary care hospital on healthcare utilization, parental and primary care provider (PCP) perceptions of care and parental quality of life.

METHODS

MCFC and their parents were recruited for ambulatory follow-up by the hospital team to complement care provided by the PCP in this mixed methods single centre pre- or post-evaluative study. Parents participated in semi-structured interviews within 48 h of discharge; further data were collected at 6 and 12 months. Healthcare utilization was compared with equal time periods pre-enrolment. Parental health was assessed with the SF-36; parental perceptions of care were assessed using the Larsen's Client Satisfaction Questionnaire and the Measure of Processes of Care; PCPs completed a questionnaire at 12 months. Parental and PCP comments were elicited. Comparisons were made with baseline data.

RESULTS

Twenty-six children and their parental caregivers attended the complex care clinic. The number of days that children were admitted to hospital decreased from a median of 43 to 15 days, and outpatient visits increased from 2 to 8. Mean standardized scores on the SF-36 increased (improved) for three domains related to mental health. A total of 24 PCPs responded to the questionnaire (92% response); most found the clinic helpful for MCFC and their families. Parents reported improvements in continuity of care, family-centredness of care, comprehensiveness and thoroughness of care, but still experienced frustrations with access to services and miscommunication with the team.

CONCLUSION

A collaborative medical home focused on integrating community- and hospital-based services for MCFC is a promising service delivery model for future controlled evaluative studies.