Discussion paper: implications for the further development of the successfully in emergency medicine implemented AUD2IT-algorithm

The AUD2IT-algorithm is a tool to structure the data, which is collected during an emergency treatment. The goal is on the one hand to structure the documentation of the data and on the other hand to give a standardised data structure for the report during handover of an emergency patient. AUD2IT-algorithm was developed to provide residents a documentation aid, which helps to structure the medical reports without getting lost in unimportant details or forgetting important information. The sequence of anamnesis, clinical examination, considering a differential diagnosis, technical diagnostics, interpretation and therapy is rather an academic classification than a description of the real workflow. In a real setting, most of these steps take place simultaneously. Therefore, the application of the AUD2IT-algorithm should also be carried out according to the real processes. A big advantage of the AUD2IT-algorithm is that it can be used as a structure for the entire treatment process and also is entirely usable as a handover protocol within this process to make sure, that the existing state of knowledge is ensured at each point of a team-timeout. PR-E-(AUD2IT)-algorithm makes it possible to document a treatment process that, in principle, does not have to be limited to the field of emergency medicine. Also, in the outpatient treatment the PR-E-(AUD2IT)-algorithm could be used and further developed. One example could be the preparation and allocation of needed resources at the general practitioner. The algorithm is a standardised tool that can be used by healthcare professionals of any level of training. It gives the user a sense of security in their daily work.

Notfall-Neuropädiatrie – Der arteriell ischämische Schlaganfall als einer der zeitkritischsten Notfälle bei Kindern und Jugendlichen

Der arteriell ischämische Schlaganfall im Kindes- und Jugendalter gehört zu den zeitkritischsten Notfällen in der Pädiatrie. Dennoch wird er häufig mit einer oft prognostisch relevanten Zeitverzögerung diagnostiziert. Gründe dafür liegen neben der geringen Awareness auch in der zuweilen unspezifischen klinischen Präsentation mit einer herausfordernden Breite kritischer Differenzialdiagnosen sowie in der Fläche noch wenig verzahnter Akutversorgungsstrukturen. Gleichwohl zeigen grundsätzlich die beim Erwachsenen etablierten Revaskularisationsstrategien auch beim Kind ihre möglichen, zum Teil spektakulären Erfolge. Es gilt also, diese nach Möglichkeit auch den betroffenen Kindern zur Verfügung zu stellen, auch wenn hier derzeit ein nicht annähernd vergleichbarer Grad an Evidenz erreicht ist. Postakut ist die ätiologische Aufarbeitung durch die größere Bandbreite zu bedenkender Risikofaktoren besonders komplex, muss aber in der Lage sein, das individuelle Risikoprofil mit Sekundärprophylaxe, Rezidivrisiko und Outcome präzise zu identifizieren. Die Langzeitbetreuung im multiprofessionellen, interdisziplinären Team muss die biopsychosozialen Aspekte des Kindes in seiner jeweiligen Entwicklungsphase berücksichtigen und damit eine bestmögliche Integration des Kindes in sein soziales und schulisches, später berufliches Umfeld realisieren.

Microcatheter-assisted stenting of the tortuous vertical ductus arteriosus via femoral access in a duct-dependent pulmonary circulation

BACKGROUND

Stenting of the patent ductus arteriosus (PDA) has been accepted as alternative option to surgical shunting to enable additional pulmonary blood flow or for palliation of patients with a truly duct-dependent pulmonary circulation. The procedure can be challenging given the variable and often tortuous anatomy of the PDA and various technical approaches are reported.

OBJECTIVE

To report an alternative technique to treat tortuous ducts with microcatheter assistance and by transfemoral approach.

METHODS

We applied this technique of PDA stenting in 5 consecutive patients (4/5 age < 1 week, weight 2,7-3,2 kg; 1/5 re-do PDA stenting at 6,5 month and 5,9 kg). A soft coronary guidewire was advanced by microcatheter assistance into the branch pulmonary arteries and thereafter replaced by an extrastiff guidewire to enable the placement of long coronary stents.

RESULTS

Successful PDA stenting with this stepwise approach and with femoral access only could be achieved in all patients (n = 5/5). A single stent was used in 2 patients (one with re-do stenting and previous stents). 3/5 patients had 2 stents implanted by telescopic technique. Stent sizes used were 4,5 × 15 mm (n = 2) and 4,5 × 18 mm (n = 6). No guide wire or stent dislodgement appeared through all procedures with microcatheter assistance.

CONCLUSIONS

This technique enables PDA stenting via transfemoral approach in complex and tortuous ducts and thereby offers an attractive addition to the interventional management of truly duct-dependent pulmonary circulation.

Breastfeeding and vitamin D supplementation reduce the risk of Kawasaki disease in a German population-based case-control study

Background

In Kawasaki disease (KD), a vasculitis of unknown etiology, the most serious complication is the development of coronary artery aneurysm (CAA). To date, the exact pathomechanism of KD is unknown. Both environmental and genetic factors seem to be associated with the development of the disease.

Methods

Data on KD patients recruited from the population-based German Pediatric Surveillance Study during 2012–2014 were used to evaluate the impact of various factors from the perinatal and infancy period on the development of KD. The study design was a matched case-control study with respect to age, sex and place of residence (n = 308 KD cases, n = 326 controls). All KD patients were individually re-evaluated; all fulfilled the international diagnostic KD criteria. A standardized questionnaire was used to review breastfeeding practices, vitamin D supplementation and birth characteristics. Logistic regression analyses were performed to obtain odds ratios (OR) for various risk factors among the case-control pairs. Simple measures of association were used to assess the impact of these factors on the clinical course.

Results

There was no difference in lengths of gestation, birth weight or parturition between KD patients and controls, but independently from each other vitamin D supplementation and breastfeeding were negatively associated with KD, even when adjusted for age, place of residence and sex. The duration of vitamin D was significantly shorter among children with KD than among children without KD (p = 0.039, OR = 0.964, 95% CI: 0.931–0.998), as was the duration of breastfeeding (p = 0.013, OR = 0.471, 95% CI: 0.260–0.853). Comparing KD patients with and without breastfeeding and/or vitamin D supplementation, there were no differences regarding developing CAA, being refractory to intravenous immunoglobulin treatment, age at onset of the disease and levels of inflammatory laboratory values.

Conclusion

Our findings indicate breastfeeding and vitamin D supplementation to have protective effects in association with KD in our study population; however, these seem not to influence the natural course of the disease. Although the overall effects were relatively small, they nevertheless underline the overall benefit of both interventions.

Trial registration

Clinical Trial Registration: German clinical trial registration, http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00010071. Date of registration was 26. February 2016. The trial was registered retrospectively.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1438-2) contains supplementary material, which is available to authorized users.

Heparin Coating of the Extracorporeal Circuit Combined with Leukocyte Filtration Reduces Coagulation Activity, Blood Loss and Blood Product Substitution

Background

Cardiopulmonary bypass is associated with activation of the coagulation cascade. Occasionally, this results in postoperative hemorrhage and consequently the need for blood products associated with increasing costs and risk of infection. Contact activation of the intrinsic coagulation pathway, and damage to cellular blood components with the release of proteolytic substances from neutrophil granulocytes have been linked to these coagulation disorders.

Methods

Eighteen routine CABG-patients were randomly assigned to totally heparin coated circuits (Bioline coating) combined with leukocyte filtration in a double blind protocol (group I), 34 patients served as controls (group II). Leukocyte filters were activated before release of the aortic crossclamp. Coagulation activity, postoperative blood loss, and substitution with blood products were assessed.

Results

Blood loss in the first 24h after surgery was significantly lower with combined application of heparin coating and leukocyte filters (group I) vs. controls (group II) (526±78ml vs. 786±88ml; p<0.05). Thrombin formation represented by prothrombin fragments 1+2 was significantly lower in group I vs. group II after declamping of the aorta (2.1±0.3nmol/L vs. 4.0±0.3nmol/L; p<0.05). Group I showed higher AT III plasma than group II (48.8±3.2% vs. 41.5±1.7%; p<0.05).

Conclusions

Leukocyte filtration during reperfusion in heparin coated cardiopulmonary bypass circuits is associated with lower coagulation activation, decreased blood loss and reduced transfusion of packed red cells in elective CABG patients.

Abstract P1-11-01: Effectiveness, safety and quality of life (QoL) results from the German multicenter AVANTI study of 1st-line bevacizumab (BEV)-containing therapy in &gt;2000 patients (pts) with advanced breast cancer (aBC)

Background: In Europe, BEV is approved with either paclitaxel (PAC) or capecitabine (CAP) as 1st-line therapy for HER2-negative aBC. These regimens are being evaluated in routine oncology practice in the German AVANTI (ML22452) observational study.

Methods: Eligible pts had received no prior chemotherapy (CT) for aBC and had no BEV contraindications. CT schedule, diagnostics and frequency of follow-up are at the physician's discretion. Data are collected for 1 y after starting BEV, with 6-monthly follow-up for 1.5 y thereafter. QoL is assessed using EORTC QLQ-C30. Data cutoff for the 3rd interim analysis was Dec 1, 2016.

Results: Between Oct 2009 and Feb 2015, 2056 eligible pts at &gt;300 centers began treatment with BEV+PAC (n=1658) or BEV+CAP (n=398). Median follow-up was 12.7 (range &lt;0.1–50.9) mo. Median treatment duration was 4.4 (95% CI 4.2–4.6) mo for CT and 6.0 (95% CI 5.8–6.5) mo for BEV. Table 1 summarizes PFS. In the overall population, grade 3/4 AEs were reported in 20% of pts (20% BEV+PAC; 22% BEV+CAP) and led to treatment discontinuation in 5% (5% and 5%, respectively). Mean QLQ-C30 scores were relatively stable over time both overall and in subgroups aged &lt;65 vs ≥65 y, indicating maintained QoL during therapy; no relevant QoL differences between age groups were seen (Table 2). To characterize 'long responders', we identified 459 pts with PFS ≥15 mo (410 BEV+PAC; 49 BEV+CAP). Of these, 33% were aged ≥65 y, 15% had triple-negative aBC (TNBC) and 25% had ≥3 metastatic sites. Median treatment duration was 5.1 mo for CT and 10.8 mo for BEV.

Table 1. PFS by subgroupPtsNo. of events/pts (%)Median PFS (95% CI), moAll1121/2042 (55)14.2 (13.5–15.3)BEV+PAC902/1646 (55)15.2 (14.0–16.2)BEV+CAP219/396 (55)10.9 (10.1–13.4)TNBC187/429 (44)12.6 (10.7–14.3)Non-TNBC677/1486 (46)14.7 (13.6–16.1)&lt;65 y577/1325 (44)15.1 (13.6–16.2)≥65 y344/717 (48)13.5 (12.5–14.9)&lt;3 metastatic sites678/1522 (45)14.4 (13.6–15.8)≥3 metastatic sites254/534 (48)13.5 (11.7–15.5)

Table 2. Mean QoL scores over time, selected scalesScaleTimepointAll pts&lt;65 y≥65 y  nMean scorenMean scorenMean scoreGlobal health statusaBL84046.555747.128345.4 Wk 986744.057044.229743.7 Wk 3352043.335543.716542.4 Wk 5434244.622845.111443.6Physical functioningaBL83668.555570.328164.7 Wk 986360.956864.329554.4 Wk 3351360.335263.316153.8 Wk 5434161.622862.411359.9Social functioningaBL82761.455559.727264.8 Wk 985654.456655.429052.5 Wk 3351455.435156.516353.2 Wk 5433758.122555.811262.8FatiguebBL83548.955548.128050.6 Wk 986059.156756.329364.6 Wk 3351656.135254.516459.7 Wk 5434055.822855.711255.9PainbBL83537.855638.027937.2 Wk 986438.556937.029541.3 Wk 3351746.935345.616449.8 Wk 5434046.922848.111244.5BL=baseline. aHigher score=better QoL/functioning. bHigher score=greater symptom burden.

Conclusions: More mature results from AVANTI show median PFS of 14.2 mo, favorable tolerability and maintained QoL, supporting 1st-line use of BEV for aBC. The subgroup with prolonged disease control (PFS &gt;15 mo) was heterogeneous; further analyses of these pts are ongoing.

Citation Format: Müller V, Jakob A, Aktas B, Grafe A, März W, Fett W, Bruch H-R, Klare P, Hoefflin S, Schneeweiss A. Effectiveness, safety and quality of life (QoL) results from the German multicenter AVANTI study of 1st-line bevacizumab (BEV)-containing therapy in &gt;2000 patients (pts) with advanced breast cancer (aBC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-11-01.

Abstract P6-13-02: Efficacy of first-line bevacizumab (BEV)-containing therapy for poor-prognosis advanced breast cancer (aBC): Subgroup analyses of the German AVANTI observational study

Background: The multicenter AVANTI observational study is evaluating the safety and effectiveness of EU-approved BEV-containing regimens (BEV + paclitaxel [PAC] or BEV + capecitabine [CAP]) as first-line therapy for HER2-negative aBC in German routine oncology practice.

Methods: Eligible patients (pts) had received no prior chemotherapy (CT) for aBC and had no BEV contraindications. CT schedule, diagnostics, and frequency of follow-up visits are at the physician's discretion. Data are collected for 1 year after starting BEV, with 6-monthly follow-up for 1.5 years thereafter. We explored treatment outcomes in pts with triple-negative aBC (TNBC), pts considered at high risk according to a simple prognostic index for OS in BEV-treated pts [Llombart, 2014], and subgroups defined by timing of BEV+CT initiation.

Results: Between Oct 2009 and Feb 2015, 2168 pts treated at 331 centers received BEV+PAC (n=1774) or BEV+CAP (n=394). Of these, 445 (21%) had TNBC and 306 (14%) met the high-risk criteria. Within the hormone receptor-positive (HR+) subgroup, pts receiving endocrine therapy (ET) before BEV+CT were older than pts starting BEV+CT immediately (median age 65 vs 60 years, respectively) and included a smaller proportion with ECOG performance status 0 (39% vs 47%), visceral metastases (70% vs 77%), or prior (neo)adjuvant CT exposure (46% vs 57%). In all subgroups, median BEV treatment duration was longer than median CT duration. At the data cutoff for this interim analysis (Mar 1, 2015), median duration of observation was 10.8 (range &lt;0.1–47.5) months. The table shows treatment exposure and efficacy overall and in selected subgroups.

table 1 All pts (n=2168)TNBC (n=445)aHR+ with immediate BEV+CT (n=1260)a,bHR+ with ET before BEV+CT (n=309)a,bHigh riskc (n=306)bBEV+PAC, n (%)1774 (82)352 (79)b1062 (84)238 (77)229 (75)Treated until PD, n (%)b,d640 (30)180 (40)314 (25)104 (34)125 (41)BEV+CT until PD449 (21)143 (32)210 (17)61 (20)99 (32)Single-agent BEV until PD191 (9)37 (8)104 (8)43 (14)26 (8)Median BEV duration, months (95% CI)5.9 (5.6–6.3)5.1 (4.9–5.6)6.4 (5.9–7.0)5.6 (5.1–6.5)5.1 (4.6–5.6)Median CT duration, months4.6 (4.4–4.9)3.9 (3.5–4.2)4.9 (4.6–5.1)4.6 (4.2–5.1)3.9 (3.3–4.4)No. of PFS events/pts (%)e1238/2154 (57)302/441 (68)667/1255 (53)187/307 (61)210/306 (69)Median PFS, months (95% CI)10.1 (9.7–10.7)7.2 (6.2–8.0)11.5 (10.8–12.3)9.0 (8.3–10.0)6.4 (5.9–7.4)a154 pts could not be classified as TNBC or HR+ because of missing HR status information. bPost hoc analysis. c≥3 of the 5 risk factors (disease-free interval ≤24 months; ECOG performance status ≥2; liver metastases and/or ≥3 metastatic organ sites; TNBC; prior (neo)adjuvant anthracycline and/or taxane). dData available only in pts with documented end of treatment. ePFS data missing in 14 pts.

Conclusions: Interim results from this large observational study indicate that first-line BEV+CT is an effective therapy in all risk subgroups of a general population of pts with HER2-negative aBC treated in routine oncology practice, including pts with a particularly poor prognosis. Results of these exploratory subgroup analyses suggest that BEV+CT could be considered irrespective of HR status.

Citation Format: Mueller V, Jakob A, Aktas B, Pott D, Grafe A, Jungberg P, Maerz W, Fett W, Bruch H-R, Klare P, Boller E, Hoefflin S, Schneeweiss A. Efficacy of first-line bevacizumab (BEV)-containing therapy for poor-prognosis advanced breast cancer (aBC): Subgroup analyses of the German AVANTI observational study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-13-02.

Long-term behavior of (90)Sr and (137)Cs in the environment: Case studies in Switzerland

We present long-term records of the (137)Cs and (90)Sr activity concentrations in soil, grass and milk from two lowland and two alpine pastures of Switzerland. The data is used for better understanding the long-term behavior of these radionuclides in the environment. Transfer factors between compartments are used as qualitative indicators of the magnitude of transfer and as a way to compare different elements (e.g. Cs and Sr) in similar conditions. The long-term behavior was quantified by means of the effective half-life which integrates all processes that cause a decrease of activity in a given medium such as leaching, fixation, erosion and radioactive decay. Our study shows that (90)Sr is more likely transferred from alpine soil to grass than (137)Cs. This is explained by a stronger fixation of Cs in the soils. We observed higher transfers of (90)Sr to grass in soils with lower Ca concentrations, and vice versa. In contrast, the transfer of (137)Cs to grass was not affected by the variations of the K content in the soil. We provide evidence that shows that (137)Cs, after intake by dairy cattle, is more likely transferred to milk than (90)Sr. However, as the (90)Sr and Ca transfers to milk are influenced by parameters/processes that were not taken into account in our study, our result cannot be entirely validated. The effective half-lives of (137)Cs and (90)Sr in soil, grass and milk corresponded with previous estimates in alpine soils. We have found that processes other than radioactive decay are responsible for a major decrease of the (90)Sr activity in soil. For (137)Cs, on the other hand, radioactive decay is among the most relevant process. Our data shows to be of interest in studying the trends of behavior of radionuclides in alpine regions.

Abstract P4-13-26: Efficacy, safety, and treatment decision-making in the AVANTI German observational study of first-line bevacizumab (BEV)-containing therapy for locally advanced, recurrent, or metastatic breast cancer (aBC)

Background: In Europe, BEV is approved as first-line therapy for metastatic breast cancer in combination with either paclitaxel (PAC) or capecitabine (CAP).

Methods: The ongoing multicenter non-interventional AVANTI study aims to determine the safety and efficacy of first-line BEV–PAC or BEV–CAP in the context of routine oncology practice in Germany and to assess selection criteria that influence therapy choice. Eligible patients (pts) have previously untreated aBC and no contraindications for BEV. Chemotherapy schedule, diagnostics, and frequency of follow-up visits are at the physician's discretion. Data are collected for 1 year after the start of BEV, with 6-monthly follow-up for 1.5 years after the end of documented observation or BEV discontinuation, whichever occurs first.

Results: Between Oct 2009 and Feb 2015, 2168 pts treated at 331 German centers received BEV–PAC (N=1774) or BEV–CAP (N=394). The most common reasons driving treatment choice were efficacy (66% BEV–PAC, 60% BEV–CAP), guidelines (55% BEV–PAC, 50% BEV–CAP), and tolerability (40% BEV–PAC, 45% BEV–CAP). Compared with pts receiving BEV–PAC, the BEV–CAP subgroup included relatively fewer pts with ≥3 metastatic sites, visceral metastases, and stage IV disease at diagnosis, and relatively more pts with triple-negative aBC (TNBC) and prior (neo)adjuvant chemotherapy. At the time of data cut-off for this interim analysis (Mar 1, 2015), median duration of observation was 10.8 months (range &lt;0.1–47.5). BEV was typically continued for longer than chemotherapy (median 5.9 months [95% CI 5.6–6.3] vs 4.6 months [95% CI 4.4–4.9], respectively). Among pts with hormone receptor-positive disease, only 9% received concurrent endocrine therapy with BEV. The most common reason for stopping treatment was disease progression (483 of 1529 [32%] who had stopped BEV–PAC; 157/345 [46%] who had stopped BEV–CAP). At data cut-off, 1245 pts (57%) had experienced a PFS event. Median PFS was 10.1 months (95% CI 9.6–10.7) overall, 10.7 months (95% CI 10.1–11.3) for BEV–PAC, and 8.1 months (95% CI 6.6–9.0) for BEV–CAP. Median PFS in clinically important subgroups was: TNBC 7.1 months (95% CI 6.2–8.0); ≥3 metastatic sites 9.7 months (8.7–11.2); anthracycline- and/or taxane-pretreated 9.2 months (8.5–9.9); ≥65 years old 9.9 months (9.1–10.7). Safety was consistent with the well-established safety profiles of the two regimens. Grade ≥3 adverse events occurred in 17% of pts (16% BEV–PAC, 18% BEV–CAP). There were no new safety signals.

Conclusions: Interim results of this large non-interventional study indicate that first-line BEV-containing regimens represent an active and well-tolerated therapy option for aBC. Data collection in non-inferiority studies based on routine clinical practice typically differs from that in prospective clinical trials. Nevertheless, these results from AVANTI suggest that the efficacy and tolerability of BEV–PAC and BEV–CAP seen in the E2100, RIBBON-1, and TURANDOT trials can be replicated in routine oncology practice. Further analyses focusing on the incidence, management, and potential risk factors for elevation of blood pressure are ongoing.

Citation Format: Müller V, Jakob A, Aktas B, Grafe A, Fett W, März W, Bruch H, Pott D, Klare P, Boller E, Kiewitz C, Schneeweiss A. Efficacy, safety, and treatment decision-making in the AVANTI German observational study of first-line bevacizumab (BEV)-containing therapy for locally advanced, recurrent, or metastatic breast cancer (aBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-26.

Bis(β-diketonato)- and allyl-(β-diketonato)-palladium(ii) complexes: synthesis, characterization and MOCVD application

Halogen-free allyl- and β-diketonate-functionalized Pd(ii) compounds were synthesized and successfully applied as MOVCD precursors for Pd and PdO thin film formation.

Radioactive and chemical contamination of the water resources in the former uranium mining and milling sites of Mailuu Suu (Kyrgyzstan)

An assessment of the radioactive and chemical contamination of the water resources at the former uranium mines and processing sites of Mailuu-Suu, in Kyrgyzstan, was carried out. A large number of water samples were collected from the drinking water distribution system (DWDS), rivers, shallow aquifers and drainage water from the mine tailings. Radionuclides and trace metal contents in water from the DWDS were low in general, but were extremely high for Fe, Al and Mn. These elements were associated with the particle fractions in the water and strongly correlated with high turbidity levels. Overall, these results suggest that water from the DWDS does not represent a serious radiological hazard to the Mailuu Suu population. However, due to the high turbidities and contents of some elements, this water is not good quality drinking water. Water from artesian and dug wells were characterized by elevated levels of U (up to 10 μg/L) and some trace elements (e.g. As, Se, Cr, V and F) and anions (e.g. Cl(-), NO3(-), SO4(2-)). In two artesian wells, the WHO guideline value of 10 μg/L for As in water was exceeded. As the artesian wells are used as a source of drinking water by a large number of households, special care should be taken in order to stay within the WHO recommended guidelines. Drainage water from the mine tailings was as expected highly contaminated with many chemicals (e.g. As) and radioactive contaminants (e.g. U). The concentrations of U were more than 200 times the WHO guideline value of 30 μg/L for U in drinking water. A large variation in (234)U/(238)U isotopic ratios in water was observed, with values near equilibrium at the mine tailings and far from equilibrium outside this area (reaching ratios of 2.3 in the artesian well). This result highlights the potential use of this ratio as an indicator of the origin of U contamination in Mailuu Suu.

Abstract P4-14-04: AVANTI: A non-interventional study examining the combination of bevacizumab with paclitaxel or capecitabine in metastatic breast cancer

Background: We initiated a large, multicentre, non-interventional study (NIS) to determine the safety and efficacy of treatment, as well as the selection criteria that influence choice of therapy (bevacizumab plus paclitaxel or capecitabine), for patients with metastatic breast cancer (MBC) treated in the context of routine oncology practice in Germany. The study also aimed to gather information on patient-reported quality of life and treatment satisfaction. Here we present an interim analysis of the safety and efficacy data.

Methods: Pre- or postmenopausal female patients aged ≥18 years with previously untreated locally advanced, recurrent, or MBC were enrolled if they were considered eligible for treatment with a combination of bevacizumab and either paclitaxel or capecitabine. Endocrine pretreatment was allowed. Patients with contraindications to bevacizumab were excluded. Kaplan-Meier estimates and Cox-regression were used to model survival data.

Results: Since October 2009, 1,807 patients have been recruited; this analysis includes data for 1,464 patients with a median age of 60.4 years (range: 23.6–86.4). Most patients had a performance status of 1 (43.1%) and HER2-negative (83.5%), hormone receptor-positive (70.2%) disease. The most common sites of metastasis were bone (52.3%), liver (39.3%) and lungs (33.4%); 736 patients (50.3%) had at least two documented metastatic sites. Bevacizumab plus paclitaxel (68.5% of patients) and bevacizumab plus capecitabine (12.0%) were the most frequently prescribed therapies. Other bevacizumab-containing combination regimens were prescribed to the remaining 19.5% of patients. The treatment decision factors cited most often were efficacy of therapy (62.4%), therapy guidelines (49.7%), tolerability of therapy (40.6%) and HER2 status (38.1%). The overall response rate (complete response [CR] + partial response [PR]) was 48.5% with 5.9% of patients achieving a CR. The disease control rate (CR + PR + stable disease) was 72.7%. At the time of data cut-off, 414 patients (28.3%) had experienced a progression-free survival (PFS) event. Median PFS was 9.5 months (95% CI: 8.8–10.1). Adverse events (AEs) and serious AEs were reported in 457 (31.2%) and 109 patients (7.4%), respectively. The most frequently reported AEs were hypertension (6.1% of patients), fatigue (5.5%), sensory neuropathy (4.6%), leukopenia (4.0%), nausea (4.2%) and diarrhoea (3.6%). Treatment was discontinued due to AEs in 72 patients (4.9%).

Conclusions: Interim results of this large NIS demonstrate that bevacizumab plus either paclitaxel or capecitabine combination therapy is well tolerated and active in patients with MBC representative of those treated in routine oncology practice. Follow-up is ongoing and final results of this interim analysis, as well as subgroup analyses, will be reported at the meeting.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-14-04.

Abstract P5-13-04: Use of Bisphosphonates in the Adjuvant Setting for Breast Cancer — A More Than 10 Years Single Centre Experience

Background: Adjuvant therapies for early breast cancer are associated with substantial decrease in bone mineral density. Bisphosphonates are antiresorptive agents that have an established role in preventing skeletal morbitity in patients with bone metastases and in the treatment of osteoporosis. It has also been shown that these agents are active in preventing cancer treatment induced bone loss in women with early stage breast cancer. Recently, several trials have demonstrated that bisphosphonates may exert anticancer effects in the adjuvant setting. Patients and methods: Since 1997 we treated an increasing number of unselected patients with early breast cancer with bisphosphonates (up to 2009: 1144 out of 1876 patients). There was no significant difference in the two patient groups concerning tumour size, nodal status, hormone receptor (HR) expression, HER-2 expression and adjuvant treatment modalities. In most cases we used zoledronic acid, but also clodronate ibandronate or alendronate.

Results: Disease-free survival (DFS) was significant better in patients treated with bisphosphonates (p = 0.009). This was also true in the subgroup of patients with hormone receptor positive disease (p=0.0011) and even more striking in patients with N+ disease (p=0.00003). There was no significant difference in DFS in patients with hormone receptor negative disease. In our analyses especially patients with N+ and ER/PR+ disease showed a significant advantage from treatment with bisphosphonates. Conclusion: This large single centre experience demonstrates a significant improvement of disease-free survival in patients with breast cancer treated with bisphosphonates in the adjuvant setting. The benefit was more pronounced in the subgroup of nodal positive and hormone receptor positive disease.

Lymphocyte reconstitution following allogeneic hematopoietic stem cell transplantation: a retrospective study including 148 patients

Here we investigated the influence of parameters known before hematopoietic stem cell transplantation (HSCT) as well as the relevance of graft-versus-host disease (GvHD) and cytomegalovirus (CMV) reactivation on post transplant lymphocyte reconstitution in 148 patients treated in our institution between 1996 and 2003. Median patient age was 42 (19-68) years, HSCT followed standard high dose (n=91) or reduced-intensity conditioning regimens (n=57) with bone marrow (BM, n=67) or peripheral blood stem cells (PBSC, n=81) from related (n=71) or unrelated (n=77) donors. In the first months, we observed a partially faster reconstitution of CD3+4+, CD3+8+ and CD4+45RA+ T cells in patients following peripheral blood stem cell transplantation when compared to bone marrow transplantation. Prolonged CD3+4+ and CD4+45RA+ lymphopenia was noted after unrelated donor HSCT and GvHD prophylaxis containing anti-T-lymphocyte globulin. Lymphocyte subset counts in patients older than the median age were comparable to those in patients transplanted at a younger age and not influenced by the conditioning regimen. CD3+8+ T cell reconstitution was strongly correlated with CMV reactivation, but not significantly affected by CMV serostatus before HSCT. Incidence or extent of GvHD did not significantly influence lymphocyte reconstitution. Therefore, the source of graft is the most predictive parameter in early lymphocyte reconstitution, but the differences in lymphocyte recovery completely resolved within the first year after HSCT.

An open label, non-comparative phase II study of gemcitabine as salvage treatment for patients with pretreated adult type soft tissue sarcoma

BACKGROUND

The number of effective cytotoxic agents for the treatment of patients with metastatic adult type soft tissue sarcoma (STS) is limited, when patients have failed anthracyline-based chemotherapy. The aim of this trial was to evaluate the efficacy of gemcitabine in this setting.

METHODS

Between August 2001 and March 2003 19 patients were eligible to enter. Gemcitabine was administered as a 30-minutes infusion at a dosage of 1 g/m2 on day 1, 8 and 15 every 4 weeks. All patients had progressive disease during (n = 12) or shortly after an anthracycline-based regimen (n = 3).

RESULTS

Four of 19 patients did not start study treatment because of fulminant progression. Fifteen patients with a median age 47 years (32-72) were assessable. All patients had received at least one prior treatment regimen (range, 1-6) for metastatic disease containing anthracyclines (n = 15) and ifosfamide (n = 11). To date, a total of 72+ cycles have been applied (median; 3, 1-28+). Seven patients (47%) had progressive disease after completion of two cycles at the first response assessment. One patient (6%) attained a partial remission, and 7 patients (47%) achieved disease stabilisations. One patient is still on treatment after more than 2.5 years. The calculated progression-free rate at 3 and 6 months was 46.7% (CI(95%), 21.4-71.9) and 13.3% (CI(95%), (0-30.5). 95% of the cycles have been applied without any dose modification or treatment delay.

CONCLUSIONS

Considering response and progression-free rate as the primary endpoints for phase II trials in pretreated STS, gemcitabine has moderate efficacy.

Snoring noise pollution—the need for objective quantification of annoyance, regulatory guidelines and mandatory therapy for snoring

Habitual snoring without episodes of apnea or hypoventilation and without respiratory related arousals is considered to be annoying and without any need for treatment. However, studies seem to suggest an enormous psychosocial impact of annoyance for the bed partner. Apart from subjective questionnaires there still exists no generally accepted mode of measurement that can describe snoring objectively. We therefore adapted methods developed for environmental medicine and established a new snore score using psycho-acoustic parameters. For quantification of snoring noise we conducted nocturnal measurements in 19 habitual snorers. Free-field snore sounds were acquired with two low-cost non-contact microphones and transferred to a PC (sampling frequency 11 kHz). The data were recorded, analysed and stored automatically using a MATLAB script. Following the analysis of sound characteristics and levels, the score was computed from relevant parameters containing the rating level (L(R)), maximum level, two percentile levels for frequent maxima (L(5)S; L(1)) and snoring time. The determined values substantially exceeded the prescribed limits defined by WHO noise guidelines, and mainly affected the equivalent continuous sound exposure level, rating level and the immission standard values of brief noise peaks, whose maximum was exceeded by up to 32 dB(A). The Berlin snore score illustrated the objective acoustic annoyance on a scale from 0 to 100. It allows inter-individual comparison and objectifies the need for therapy. The clinical applicability of evaluating the reduction of snoring after surgical therapy is discussed exemplarily. The presented measuring method was found to be suitable for quantifying snoring noise and can be easily integrated into existing polysomnographic applications. In the case of habitual snoring with objective evidence of psychosocially disturbing acoustic annoyance, health fund providers should assume the costs of mandatory medical therapy.