The effectiveness and cost-effectiveness of acupressure for the control and management of chemotherapy-related acute and delayed nausea: Assessment of Nausea in Chemotherapy Research (ANCHoR), a randomised controlled trial

BACKGROUND

Chemotherapy-induced nausea and vomiting remain difficult symptoms to manage in clinical practice. As standard antiemetic drugs do not fully eliminate these symptoms, it is important to explore the adjuvant role of non-pharmacological and complementary therapies in antiemetic management approaches. Acupressure is one such treatment showing highly suggestive evidence so far of a positive effect, meriting further investigation.

OBJECTIVES

The primary objective was to assess the effectiveness and cost-effectiveness of self-acupressure using wristbands compared with sham acupressure wristbands and standard care alone in the management of chemotherapy-induced nausea. Secondary objectives included assessment of the effectiveness and cost-effectiveness of the wristbands in relation to vomiting and quality of life and exploration of any age, gender and emetogenic risk effects.

DESIGN

Randomised three-arm sham-controlled trial (Assessment of Nausea in Chemotherapy Research or ANCHoR) with an economic evaluation. Arms include the wristband arm, the sham wristband arm and the standard care only arm. Randomisation consisted of minimisation with a random element balancing for gender, age (16-24, > 24-50, >50 years) and three levels of emetogenic chemotherapy (low, moderate and high). Qualitative interviews were incorporated to shed more light on the quantitative findings.

SETTING

Outpatient chemotherapy clinics in three regions in the UK involving 14 different cancer units/centres.

PARTICIPANTS

Chemotherapy-naive cancer patients receiving chemotherapy of low, moderate and high emetogenic risk.

INTERVENTION

The intervention was acupressure wristbands pressing the P6 point (anterior surface of the forearm).

MAIN OUTCOME MEASURES

The Rhodes Index for Nausea/Vomiting, the Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool and the Functional Assessment of Cancer Therapy - General (FACT-G). At baseline participants completed measures of anxiety/depression, nausea/vomiting expectation and expectations from using the wristbands.

RESULTS

In total, 500 patients were randomised in the study arms (166 standard care, 166 sham acupressure and 168 acupressure) and data were available for 361 participants for the primary outcome. The primary outcome analysis (nausea in cycle 1) revealed no statistically significant differences between the three arms, although the median nausea experience in patients using wristbands (both real and sham ones) was somewhat lower than that in the antiemetics only group (median nausea experience scores for the four cycles: standard care arm 1.43, 1.71, 1.14, 1.14; sham acupressure arm 0.57, 0.71, 0.71, 0.43; acupressure arm 1.00, 0.93, 0.43, 0). A gender effect was evident (p= 0.002), with women responding more favourably to the use of sham acupressure wristbands than men (odds ratio 0.35 for men and 2.02 for women in the sham acupressure group; 1.27 for men and 1.17 for women in the acupressure group). This suggests a placebo effect. No significant differences were detected in relation to vomiting outcomes, anxiety and quality of life. Some transient adverse effects were reported, including tightness in the area of the wristbands, feeling uncomfortable when wearing them and minor swelling in the wristband area (n= 6).There were no statistically significant cost differences associated with the use of real acupressure bands (£70.66 for the acupressure group, £111.13 for the standard care group and £161.92 for the sham acupressure group). In total, 26 subjects took part in qualitative interviews. The qualitative data suggested that participants perceived the wristbands (both real and sham) as effective and helpful in managing their nausea during chemotherapy.

CONCLUSIONS

There were no statistically significant differences between the three arms in terms of nausea, vomiting and quality of life, although apparent resource use was less in both the real acupressure arm and the sham acupressure arm compared with standard care only; therefore; no clear conclusions can be drawn about the use of acupressure wristbands in the management of chemotherapy-related nausea and vomiting. However, the study provided encouraging evidence in relation to an improved nausea experience and some indications of possible cost savings to warrant further consideration of acupressure both in practice and in further clinical trials.

TRIAL REGISTRATION

ISRCTN87604299.

SOURCE OF FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 26. See the HTA programme website for further project information.

Psychological therapies for people with intellectual disabilities: comments on a matrix of evidence for interventions in challenging behaviour

BACKGROUND

Psychological therapies with a proven efficacy in the general population are being adapted for use with people who have intellectual disabilities in community settings.

METHODS

A systematic review of peer-reviewed literature published between 1980 and 2010 was carried out, to identify the evidence base for effective psychological interventions in challenging behaviour. Relevant databases were searched using applied key terms. Evidence was graded, according to the quality of the research. A best-evidence Matrix was produced to improve guidance for service providers and practitioners in the range, volume and quality of psychological interventions.

RESULTS

There is a limited amount of efficacy research that meets the most stringent standards of empirical evidence.

CONCLUSIONS

It is important to broaden the evidence base and consider the context of psychological interventions, alongside the values underpinning care and treatment.

Abstract P6-06-21: A 5-gene predictor of triple negative breast cancer outcome that also correlates with immune checkpoint receptor expression

Background: It is becoming increasingly clear that immune responses play an important role in determining triple negative (Tneg) breast cancer prognosis. Thus, emerging immunotherapeutic strategies, such as targeting immune checkpoint co-receptors (e.g. CTLA4 or PD-1), offer an attractive novel approach. However, to date, there are no established predictive biomarkers to identify Tneg patients most likely to benefit from these immunotherapies. We recently identified a 5-gene prognostic signature (TNFRSF17, CLIC5, HLA-F, CXCL13, XCL2), referred to as the Integrated Cytokine Score (ICS). Interestingly, the ICS showed functional linkage through both type 1 (interferon-γ (IFNG)) and type 2 (IL-10) immune response pathways. Here, we hypothesized that the ICS would be associated with the expression of IFNG as well as immune checkpoint genes and may therefore serve as a surrogate biomarker for targeted immunotherapies.

Method: Transcriptome data from a set of 94 node negative chemotherapy naïve Tneg tumors were pooled from three independent microarray datasets (GSE2034, GSE5327 and GSE7930). The ICS was computed as the scaled sign-corrected average of the 5 signature genes, such that a high ICS is indicative of low immune function, which in turn translates to a higher recurrence risk. We explored the correlation between the ICS and the expression of IFNG, IL-10 and 3 different immune checkpoint co-receptor genes: CTLA4 (cytotoxic T-lymphocyte antigen 4), PD-1/PDCD1 (programmed cell death protein-1) and LAG3 (lymphocyte activation gene 3). In addition, Cox proportional hazard modeling was used to evaluate the association with distant metastasis free survival (DMFS).

Results: The ICS is significantly prognostic (hazard ratio associated with 1 standard deviation increase = 1.48 (1.04 - 2.10), p = 0.03). ICS strongly anti-correlated (p<0.05) with IFNG (r = -0.66), CTLA4 (r = -0.38), PD-1/PDCD1 (r = -0.25) and LAG3 (r = -0.60) expression. Interestingly, despite this strong correlation and the prognostic significance of the ICS, none of these four immune genes were significantly associated with Tneg DMFS (p = 0.31 - 0.86). IL-10 expression was not correlated with ICS (r = -0.04) or DMFS (p = 0.43).

Conclusion: Our current findings suggest that Tneg tumors with a low ICS have elicited a type-1 (IFNG pathway) antitumor immune response. However, since the tumor is essentially “self”, this results in the activation of negative immunoregulatory networks that prevent autoimmunity (checkpoint co-receptors). Thus, the prognostic 5-gene ICS may also be a useful biomarker for immune checkpoint blockade, which could become an alternative therapeutic strategy to traditional chemotherapy for low-ICS Tneg patients who are at reduced risk of metastatic recurrence. In contrast, we propose that high-ICS Tneg tumors do not elicit type-1 antitumor immune responses or subsequent immunoregulatory network activation. For these high-ICS patients at increased risk of metastatic recurrence, additional immunotherapeutic approaches capable of enhancing both recruitment and activation of immune effector cells, as well as checkpoint blockade, may be necessary.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-21.

Evaluation of the effect of intra-operative intravenous fluid on post-operative pain and pulmonary function: a randomized trial comparing 10 and 30 ml kg(-1) of crystalloid

BACKGROUND

Existing evidence suggests that administration of intravenous fluids has been shown to improve outcomes including pain in gynecological laparoscopic surgery but the optimum fluid dose has not been determined.

AIMS

To determine the effect of administration of intravenous fluids on post-operative pain and pulmonary function after gynecological laparoscopy.

METHODS

In a prospective randomized double-blinded study 100 ASA 1 and 2 elective patients undergoing gynecological laparoscopy were randomized to receive intravenous compound sodium lactate 10 ml kg(-1) (CSL10-restrictive) or 30 ml kg(-1) (CSL30-liberal) administered intra-operatively. The primary outcome measure was the post-operative pain score at 24, 48 and 72 h, assessed by 0-10 verbal rating scale (VRS). Pulmonary function (FEV1, FVC, PEFR) and oxygen saturation were also measured.

RESULTS

Patients who received CSL 30 had lower post-operative pain scores than CSL 10 (ANCOVA-mean difference = 0.47, 95 % CI 0.11-0.83, P = 0.01). Post-operative pain VRS was lower in CSL30 than CSL10 at 48 h (mean difference 0.56, 95 % CI 0.04-1.09, P = 0.036). Patients in CSL30 reported shoulder tip pain less frequently than those in CSL10 (30.4 vs. 43.9 % of assessments, P = 0.03, OR 0.58) but reported wound pain more frequently 39.0 vs. 24.2 %, P = 0.01, OR 2.0). Indices of pulmonary function did not differ between groups at any time.

CONCLUSIONS

Liberal compared to restrictive administration of i.v. crystalloid is associated with a clinical modest reduction in pain. Pulmonary dysfunction was not increased with liberal fluid administration.

Predictors of outcomes of recovery following total hip replacement surgery: A prospective study

Objectives

To investigate psychosocial and biomedical outcomes following total hip replacement (THR) and to identify predictors of recovery from THR.

Methods

Patients with osteoarthritis (OA) on the waiting list for primary THR in North West England were assessed pre-operatively and at six and 12 months post-operatively to investigate psychosocial and biomedical outcomes. Psychosocial outcomes were anxiety and depression, social support and health-related quality of life (HRQoL). Biomedical outcomes were pain, physical function and stiffness. The primary outcome was the Short-Form 36 (SF-36) Health Survey Total Physical Function. Potential predictors of outcome were age, sex, body mass index, previous joint replacement, involvement in the decision for THR, any comorbidities, any complications, type of medication, and pre-operative ENRICHD Social Support Instrument score, Hospital Anxiety and Depression scores and Western Ontario and McMaster Universities osteoarthritis index score.

Results

The study included 206 patients undergoing THR. There were 88 men and 118 women with a mean age of 66.3 years (sd 10.4;36 to 89). Pain, stiffness and physical function, severity of OA, HRQoL, anxiety and depression all improved significantly from pre-operative to 12-month assessment (all p < 0.001), with the greatest improvement occurring in the first six months (all p < 0.001). The predictors that were found to influence recovery six months after THR were: pain (p < 0.001), anxiety (p = 0.034), depression (p = 0.001), previous joint replacement (p = 0.006) and anti-inflammatory drugs (p = 0.012).

Conclusions

The study identified the key psychosocial and biomedical predictors of recovery following THR. By identifying these predictors, we are able to identify and provide more support for patients at risk of poor recovery following THR.

Cite this article: Bone Joint Res 2013;2:248–54.

Autism in Glasgow: cumulative incidence and the effects of referral age, deprivation and geographical location

BACKGROUND

Referrals to the Greater Glasgow Community Autism Team (CAT) made before the child's sixth birthday were analysed to obtain an estimation of the proportion of children in Greater Glasgow with childhood autism and investigate whether there were any variations in diagnosis rates, or in age at referral and diagnosis, depending on deprivation or geographical location.

METHODS

An analysis was made of the database recording referrals to Greater Glasgow CAT, between 2004 and 2007 inclusive, of children referred by age 6 years, comprising 584 cases. Cumulative incidence was calculated for childhood autism. Ages at referral and diagnosis were also analysed.

RESULTS

For this subset of children, there were 246 diagnosed cases of childhood autism, a cumulative incidence from 2004 until 2007 of 11.1 per year per 10,000 children aged 0-6 years. Of children with an eventual diagnosis of autism by age 6, 72% were referred by the age of 4 years. Deprivation was found to have an association with referral and diagnostic rates, with higher rates seen in the most deprived. There was geographical variation in the cumulative incidence of autism.

CONCLUSION

Given that the populations were not known to differ in any manner that would lead to a true variation, the geographical variation in the cumulative incidence of autism in children up to 6 years in Greater Glasgow observed in this study is likely to represent differences in the care pathway between areas. Such differences may also explain the observed association with deprivation. Reasons for the variation are being explored.

How young is too young to be a living donor?

Assessing people in adolescence and early adulthood who wish to become living organ donors (LDs) provides unique challenges. In several Canadian provinces, 16-year-old can legally consent to living organ donation. While the World Health Organization states that adolescence corresponds roughly to the ages of 10-19 years, parts of the brain associated with judgment continue to develop into the mid-20s. Therefore, it is legally possible for some young people to donate organs before their capacity to judge the benefits and risks of surgery has fully matured. Potential young living donors (YLDs) may be financially and/or psychologically dependent on their recipients (e.g. parents), which can make it difficult to determine if the YLD's donation is voluntary. This paper suggests ways to manage three ethical challenges in the use of young people as LDs: (1) determining the YLD's ability to appreciate the consequences of living organ donation, (2) determining whether the YLD's donation is voluntary and (3) evaluating the unique risks and benefits to the YLD. We conclude that there are compelling ethical reasons to offer the opportunity of living donation to selected young people. A thorough and fair evaluation process can address social, emotional and developmental issues associated with YLDs.

Clinical outcomes of women with metastatic breast cancer treated with nab-paclitaxel: experience from a single academic cancer centre

BACKGROUND

Nab-paclitaxel is a solvent-free, taxane-based chemotherapy approved for the treatment of metastatic breast cancer (mbc). This study reports clinical benefit and toxicities experienced by women with mbc treated with nab-paclitaxel at the Ottawa Hospital Cancer Centre.

METHODS

Women with mbc treated with single-agent nab-paclitaxel between June 2006 and December 2010 were included in this analysis. Retrospective data obtained included demographics, disease characteristics, prior chemotherapy, nab-paclitaxel treatment, toxicity, and survival. Clinical benefit was defined as partial or complete response or stable disease (by clinical or radiologic evaluation, or both) at 6 months or more.

RESULTS

Of 43 women (mean age: 57.0 years; range: 34-74 years), most had disease positive for estrogen or progesterone receptor (72.1%, 58.1%), or both. Nab-paclitaxel was administered weekly (qw: 44.2%), every 3 weeks (q3w: 46.5%), q3w switched to qw (7.0%), or qw switched to q3w (2.3%). Median duration of therapy was 5.1 months (qw) and 3.0 months (q3w). Sensory neuropathy was the primary toxicity (45.4% qw, 38.1% q3w; p = 0.62). Clinical benefit was observed in most women (76.2% qw, 57.1% q3w; p = 0.20). Women receiving nab-paclitaxel had a median overall survival of 13.6 months qw (range: 8.1-28.3 months) and 10.8 months q3w (range: 5.9-17.9 months; p = 0.03). Regardless of dosing schedule, women experiencing clinical benefit lived significantly longer than those not experiencing a benefit (17.3 months vs. 7.7 months; hazard ratio: 0.14; 95% confidence interval: 0.06 to 0.33).

CONCLUSIONS

Our clinical experience demonstrates that most women treated with nab-paclitaxel experienced some clinical benefit. Patients achieving clinical benefit lived significantly longer than those who did not. Nab-paclitaxel was well tolerated, with the primary toxicity being mild sensory neuropathy. Nab-paclitaxel represents another treatment option, with a favourable toxicity profile, for women with mbc.

Search for a two-Higgs-boson doublet using a simplified model in pp collisions at sqrt[s] = 1.96 TeV

We present a search for new particles in an extension to the standard model that includes a heavy Higgs boson (H(0)), a lighter charged Higgs boson (H(±)), and an even lighter Higgs boson h(0), with decays leading to a W-boson pair and a bottom-antibottom quark pair in the final state. We use events with exactly one lepton, missing transverse momentum, and at least four jets in data corresponding to an integrated luminosity of 8.7 fb(-1) collected by the CDF II detector in proton-antiproton collisions at sqrt[s]= 1.96 TeV. We find the data to be consistent with standard model predictions and report the results in terms of a simplified Higgs-cascade-decay model, setting 95% confidence level upper limits on the product of cross section and branching fraction from 1.3 pb to 15 fb as a function of H(0) and H(±) masses for m(h)(0) = 126 GeV/c(2).

Home ovulation tests and stress in women trying to conceive: a randomized controlled trial

STUDY QUESTION

Does the use of a digital home ovulation test have any effect on the level of stress in women seeking to conceive?

SUMMARY ANSWER

No difference was found in levels of stress between women using digital ovulation tests to time intercourse compared with women who were trying to conceive without any additional aids: in addition, their use did not negatively impact time to conception in users but may provide additional benefits, including an increased understanding of the menstrual cycle, reassurance and confidence in focusing conception attempts to the correct time in the cycle.

WHAT IS KNOWN ALREADY

It has been suggested that timing of intercourse in such a way that it coincides with ovulation by using ovulation tests can lead to emotional distress; however, no study has been conducted to investigate this hypothesis specifically, until now.

STUDY DESIGN, SIZE AND DURATION

The study was performed over two complete menstrual cycles as a prospective, randomized, controlled trial including quantitative and qualitative methods. The intervention (test) group were given digital ovulation tests to time intercourse to the most fertile time of the cycle and the control group were provided with the current National Institute for Health and Clinical Excellence guidelines for increasing the chances of conception (intercourse every 2-3 days) and asked not to use any additional methods to time when ovulation occurs.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

A total of 210 women who were seeking to conceive were recruited from the general UK population. A total of 115 women were randomized to the test group and 95 to the control group through block randomization. The positive and negative affect schedule (PANAS) and the Perceived Stress Scale (PSS) were used to measure subjective stress levels, the Short-Form 12 health survey was used as a measure of general health and well-being and urine samples were measured for biochemical markers of stress including urinary cortisol. Qualitative data were collected in the form of a telephone interview upon study completion.

MAIN RESULTS AND THE ROLE OF CHANCE

There was no evidence for a difference either in total stress as measured using the PSS or in total positive or negative affect using the PANAS questionnaire between the test and control groups at any time point for the duration of the study. During cycle 1, for example, on Day 6, the difference in total stress score (test-control) was -0.62 [95% confidence interval (CI) -2.47 to 1.24] and on the day of the LH surge, it was 0.53 (95% CI -1.38 to 2.44). In addition, no correlation was observed between time trying to conceive and levels of stress, or between age and levels of stress, and no evidence was found to show that stress affected whether or not a pregnancy was achieved. There is also no evidence that the biochemistry measurements are related to whether a pregnancy was achieved or of a difference in biochemistry between the treatment groups. The use of digital ovulation tests did not negatively affect time to conception and with an adequately sized study, could potentially show improvement. To ensure that the results of this study were not affected by chance, we used a number of different methods for measuring stress, each of which had been independently validated.

LIMITATIONS AND REASONS FOR CAUTION

Randomization occurred before the start of the study because of the need to provide the ovulation tests in readiness for Day 6 of the first cycle. As a consequence, a number of women fell pregnant during this period (22 and 13 in the test and control groups, respectively). A further 15 women were either lost to follow-up or withdrew consent prior to study start. Pregnancy rate was higher overall in the test group, so to ensure that there were sufficient data from women who failed to become pregnant in the test group, we implemented an additional biased recruitment. This second cohort may have been different from the first, although no significant differences were observed between the two phases of recruitment for any of the information collected upon admission to the study.

WIDER IMPLICATIONS OF THE FINDINGS

Women who seek medical advice while trying to conceive should not be discouraged by health care professionals from using digital ovulation tests in order to time intercourse. The cohort of women recruited to this study initially had no evidence of infertility and were looking to conceive in a non-medical setting. A separate study to assess the impact of home ovulation tests in a subfertile population would be of interest and complementary to the present study.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by SPD Swiss Precision Diagnostics, GmbH, manufacturer of Clearblue(®) pregnancy and ovulation tests. SPD Development Company Ltd is a wholly owned subsidiary of SPD Swiss Precision Diagnostics GmbH; together referred to as SPD.

TRIAL REGISTRATION NUMBER

NCT01084304 (www.clinicaltrials.gov).

Measurements of the top-quark mass and the tt cross section in the hadronic τ+jets decay channel at sqrt[s] = 1.96 TeV

We present the first direct measurement of the top-quark mass using tt events decaying in the hadronic τ+jets decay channel. Using data corresponding to an integrated luminosity of 2.2 fb(-1) collected by the CDF II detector in pp collisions at sqrt[s] = 1.96 TeV at the Fermilab Tevatron, we measure the tt cross section, σ(tt), and the top-quark mass, M(top). We extract M(top) from a likelihood based on per-event probabilities calculated with leading-order signal and background matrix elements. We measure σ(tt) = 8.8 ± 3.3(stat) ± 2.2(syst) pb and M(top) = 172.7 ± 9.3(stat) ± 3.7(syst) GeV/c(2).

Search for the standard model Higgs Boson produced in association with top quarks using the full CDF data set

A search is presented for the standard model Higgs boson produced in association with top quarks using the full Run II proton-antiproton collision data set, corresponding to 9.45 fb(-1), collected by the Collider Detector at Fermilab. No significant excess over the expected background is observed, and 95% credibility-level upper bounds are placed on the cross section σ(ttH → lepton + missing transverse energy+jets). For a Higgs boson mass of 125 GeV/c(2), we expect to set a limit of 12.6 and observe a limit of 20.5 times the standard model rate. This represents the most sensitive search for a standard model Higgs boson in this channel to date.