Dose-Escalated Radiation Alone or in Combination With Short-Term Total Androgen Suppression for Intermediate-Risk Prostate Cancer: Patient-Reported Outcomes From NRG/Radiation Therapy Oncology Group 0815 Randomized Trial

PURPOSE

To report patient-reported outcomes (PROs) of a phase III trial evaluating total androgen suppression (TAS) combined with dose-escalated radiation therapy (RT) for patients with intermediate-risk prostate cancer.

METHODS

Patients with intermediate-risk prostate cancer were randomly assigned to dose-escalated RT alone (arm 1) or RT plus TAS (arm 2) consisting of luteinizing hormone-releasing hormone agonist/antagonist with oral antiandrogen for 6 months. The primary PRO was the validated Expanded Prostate Cancer Index Composite (EPIC-50). Secondary PROs included Patient-Reported Outcome Measurement Information System (PROMIS)-fatigue and EuroQOL five-dimensions scale questionnaire (EQ-5D). PRO change scores, calculated for each patient as the follow-up score minus baseline score (at the end of RT and at 6, 12, and 60 months), were compared between treatment arms using a two-sample t test. An effect size of 0.50 standard deviation was considered clinically meaningful.

RESULTS

For the primary PRO instrument (EPIC), the completion rates were ≥86% through the first year of follow-up and 70%-75% at 5 years. For the EPIC hormonal and sexual domains, there were clinically meaningful (P < .0001) deficits in the RT + TAS arm. However, there were no clinically meaningful differences by 1 year between arms. There were also no clinically meaningful differences at any time points between arms for PROMIS-fatigue, EQ-5D, and EPIC bowel/urinary scores.

CONCLUSION

Compared with dose-escalated RT alone, adding TAS demonstrated clinically meaningful declines only in EPIC hormonal and sexual domains. However, even these PRO differences were transient, and there were no clinically meaningful differences between arms by 1 year.

Chronic Pain in Children and Adolescents: Diagnosis and Treatment of Primary Pain Disorders in Head, Abdomen, Muscles and Joints

Primary pain disorders (formerly “functional pain syndromes”) are common, under-diagnosed and under-treated in children and teenagers. This manuscript reviews key aspects which support understanding the development of pediatric chronic pain, points to the current pediatric chronic pain terminology, addresses effective treatment strategies, and discusses the evidence-based use of pharmacology. Common symptoms of an underlying pain vulnerability present in the three most common chronic pain disorders in pediatrics: primary headaches, centrally mediated abdominal pain syndromes, and/or chronic/recurrent musculoskeletal and joint pain. A significant number of children with repeated acute nociceptive pain episodes develop chronic pain in addition to or as a result of their underlying medical condition “chronic-on-acute pain.” We provide description of the structure and process of our interdisciplinary, rehabilitative pain clinic in Minneapolis, Minnesota, USA with accompanying data in the treatment of chronic pain symptoms that persist beyond the expected time of healing. An interdisciplinary approach combining (1) rehabilitation; (2) integrative medicine/active mind-body techniques; (3) psychology; and (4) normalizing daily school attendance, sports, social life and sleep will be presented. As a result of restored function, pain improves and commonly resolves. Opioids are not indicated for primary pain disorders, and other medications, with few exceptions, are usually not first-line therapy.

Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: a trial with adaptive allocation

BACKGROUND

Back-related leg pain (BRLP) is often disabling and costly, and there is a paucity of research to guide its management.

OBJECTIVE

To determine whether spinal manipulative therapy (SMT) plus home exercise and advice (HEA) compared with HEA alone reduces leg pain in the short and long term in adults with BRLP.

DESIGN

Controlled pragmatic trial with allocation by minimization conducted from 2007 to 2011. (ClinicalTrials.gov: NCT00494065).

SETTING

2 research centers (Minnesota and Iowa).

PATIENTS

Persons aged 21 years or older with BRLP for least 4 weeks.

INTERVENTION

12 weeks of SMT plus HEA or HEA alone.

MEASUREMENTS

The primary outcome was patient-rated BRLP at 12 and 52 weeks. Secondary outcomes were self-reported low back pain, disability, global improvement, satisfaction, medication use, and general health status at 12 and 52 weeks. Blinded objective tests were done at 12 weeks.

RESULTS

Of the 192 enrolled patients, 191 (99%) provided follow-up data at 12 weeks and 179 (93%) at 52 weeks. For leg pain, SMT plus HEA had a clinically important advantage over HEA (difference, 10 percentage points [95% CI, 2 to 19]; P=0.008) at 12 weeks but not at 52 weeks (difference, 7 percentage points [CI, -2 to 15]; P=0.146). Nearly all secondary outcomes improved more with SMT plus HEA at 12 weeks, but only global improvement, satisfaction, and medication use had sustained improvements at 52 weeks. No serious treatment-related adverse events or deaths occurred.

LIMITATION

Patients and providers could not be blinded.

CONCLUSION

For patients with BRLP, SMT plus HEA was more effective than HEA alone after 12 weeks, but the benefit was sustained only for some secondary outcomes at 52 weeks.

PRIMARY FUNDING SOURCE

U.S. Department of Health and Human Services.

Instantaneous helical axis methodology to identify aberrant neck motion

BACKGROUND

Neck pain afflicts 30-50% of the U.S. population annually; however we currently have poor diagnostic differentiation techniques to inform individualized treatment. Planar neck kinematics has been shown to be correlated with neck pain, but neck motion is much more complex than pure planar activities. Our objective was to define a methodology for determining aberrant neck kinematics and assess it.

METHODS

We examined a complex neck kinematic activity of neck circumduction and computed the pathway of motion using the instantaneous helical axis approach in 81 patients with non-specific neck pain and in 20 non-matched symptom free subjects. Neck circumduction, or rolling of the head, represents a complex neck kinematic activity, investigating the innate coupled motion of the cervical spine at the end ranges of motion in all directions. Instance of discontinuities in the helical axis patterns, or folds, were identified and labeled as occurrences of aberrant motion.

FINDINGS

The instances of aberrant motion, or folds, which are nearly non-existent in the healthy sample group, are present in both the pre- and post-treatment neck pain patients. Following a treatment intervention of the symptomatic patients, pain and neck disability index decreased significantly (P<0.001) concomitant with a decrease in the number of folds (P=0.021).

INTERPRETATION

The present study highlights a new technique using an instantaneous helical axis approach to detect subtle abnormalities in the pathway of motion of the head about the trunk, during a neck circumduction exercise.

Supervised exercise, spinal manipulation, and home exercise for chronic low back pain: a randomized clinical trial

BACKGROUND CONTEXT

Several conservative therapies have been shown to be beneficial in the treatment of chronic low back pain (CLBP), including different forms of exercise and spinal manipulative therapy (SMT). The efficacy of less time-consuming and less costly self-care interventions, for example, home exercise, remains inconclusive in CLBP populations.

PURPOSE

The purpose of this study was to assess the relative efficacy of supervised exercise, spinal manipulation, and home exercise for the treatment of CLBP.

STUDY DESIGN/SETTING

An observer-blinded and mixed-method randomized clinical trial conducted in a university research clinic in Bloomington, MN, USA.

PATIENT SAMPLE

Individuals, 18 to 65 years of age, who had a primary complaint of mechanical LBP of at least 6-week duration with or without radiating pain to the lower extremity were included in this trial.

OUTCOME MEASURES

Patient-rated outcomes were pain, disability, general health status, medication use, global improvement, and satisfaction. Trunk muscle endurance and strength were assessed by blinded examiners, and qualitative interviews were performed at the end of the 12-week treatment phase.

METHODS

This prospective randomized clinical trial examined the short- (12 weeks) and long-term (52 weeks) relative efficacy of high-dose, supervised low-tech trunk exercise, chiropractic SMT, and a short course of home exercise and self-care advice for the treatment of LBP of at least 6-week duration. The study was approved by local institutional review boards.

RESULTS

A total of 301 individuals were included in this trial. For all three treatment groups, outcomes improved during the 12 weeks of treatment. Those who received supervised trunk exercise were most satisfied with care and experienced the greatest gains in trunk muscle endurance and strength, but they did not significantly differ from those receiving chiropractic spinal manipulation or home exercise in terms of pain and other patient-rated individual outcomes, in both the short- and long-term.

CONCLUSIONS

For CLBP, supervised exercise was significantly better than chiropractic spinal manipulation and home exercise in terms of satisfaction with treatment and trunk muscle endurance and strength. Although the short- and long-term differences between groups in patient-rated pain, disability, improvement, general health status, and medication use consistently favored the supervised exercise group, the differences were relatively small and not statistically significant for these individual outcomes.

Chiropractic and self-care for back-related leg pain: design of a randomized clinical trial

Background

Back-related leg pain (BRLP) is a common variation of low back pain (LBP), with lifetime prevalence estimates as high as 40%. Often disabling, BRLP accounts for greater work loss, recurrences, and higher costs than uncomplicated LBP and more often leads to surgery with a lifetime incidence of 10% for those with severe BRLP, compared to 1-2% for those with LBP.

In the US, half of those with back-related conditions seek CAM treatments, the most common of which is chiropractic care. While there is preliminary evidence suggesting chiropractic spinal manipulative therapy is beneficial for patients with BRLP, there is insufficient evidence currently available to assess the effectiveness of this care.

Methods/Design

This study is a two-site, prospective, parallel group, observer-blinded randomized clinical trial (RCT). A total of 192 study patients will be recruited from the Twin Cities, MN (n = 122) and Quad Cities area in Iowa and Illinois (n = 70) to the research clinics at WHCCS and PCCR, respectively.

It compares two interventions: chiropractic spinal manipulative therapy (SMT) plus home exercise program (HEP) to HEP alone (minimal intervention comparison) for patients with subacute or chronic back-related leg pain.

Discussion

Back-related leg pain (BRLP) is a costly and often disabling variation of the ubiquitous back pain conditions. As health care costs continue to climb, the search for effective treatments with few side-effects is critical. While SMT is the most commonly sought CAM treatment for LBP sufferers, there is only a small, albeit promising, body of research to support its use for patients with BRLP.

This study seeks to fill a critical gap in the LBP literature by performing the first full scale RCT assessing chiropractic SMT for patients with sub-acute or chronic BRLP using important patient-oriented and objective biomechanical outcome measures.

Trial Registration

ClinicalTrials.gov NCT00494065

Continuous 28-day iododeoxyuridine infusion and hyperfractionated accelerated radiotherapy for malignant glioma: a phase I clinical study

PURPOSE

To investigate the maximal tolerated dose of a continuous 28-day iododeoxyuridine (IUdr) infusion combined with hyperfractionated accelerated radiotherapy (HART); to analyze the percentage of IUdr-thymidine replacement in peripheral granulocytes as a surrogate marker for IUdr incorporation into tumor cells; to measure the steady-state serum IUdr levels; and to assess the feasibility of continuous IUdr infusion and HART in the management of malignant glioma.

METHODS AND MATERIALS

Patients were required to have biopsy-proven malignant glioma. Patients received 100 (n = 4), 200 (n = 3), 300 (n = 3), 400 (n = 6), 500 (n = 4), 625 (n = 5), or 781 (n = 6) mg/m(2)/d of IUdr by continuous infusion for 28 days. HART was started 7 days after IUdr initiation. The total dose was 70 Gy (1.2 Gy b.i.d. for 25 days with a 10-Gy boost [2.0 Gy for 5 Saturdays]). Weekly assays were performed to determine the percentage of IUdr-DNA replacement in granulocytes and serum IUdr levels using standard high performance liquid chromatography methods. Standard Phase I toxicity methods were used.

RESULTS

Between June 1994 and August 1999, 31 patients were enrolled. No patient had Grade 3 or worse HART toxicity. Grade 3 or greater IUdr toxicity predominantly included neutropenia (n = 3), thrombocytopenia (n = 3), and elevated liver function studies (n = 3). The maximal tolerated dose was 625 mg/m(2)/d. Thymidine replacement in the peripheral granulocytes peaked at 3 weeks and increased with the dose (maximal thymidine replacement 4.9%). The steady-state plasma IUdr level increased with the dose (maximum, 1.5 microM).

CONCLUSION

In our study, continuous long-term IUdr i.v. infusion had a maximal tolerated dose of 625 mg/m(2)/d. Granulocyte incorporation data verified the concept that prolonged IUdr infusion results in IUdr-DNA replacement that corresponds to a high degree of cell labeling. IUdr steady-state plasma levels increased with increasing dose and attained levels needed for clinical radiosensitization. Continuous IUdr infusion and HART were both feasible and well tolerated.

Multiple daily fractionation radiotherapy schedules in lung cancer

Lung cancer is the number one worldwide cancer killer, and in spite of therapeutic advances, the overall impact on survival has remained very modest. For both small and non-small-cell lung cancer, treatment trends have shifted toward combined-modality approaches, chemotherapy for the control of systemic micrometastases, and radiotherapy for intrathoracic control. However, on both counts, rates of failure remain unacceptably high, and several novel strategies are currently being explored. The use of altered fractionation, including multiple daily fractions, reflects one approach for modifying radiotherapy. The two most common approaches are hyperfractionation and acceleration, the former designed to reduce late normal tissue toxicities and the latter to counteract accelerated tumor repopulation. Recent randomized trials suggest that such approaches may result not only in lowered rates of intrathoracic failure but also in improved survival.

Genetic study of oxygen resistance and melanization in Cryptococcus neoformans

Genetic analysis of oxygen-sensitive mutants of Cryptococcus neoformans revealed two loci (oxy1 and oxy2) linking hyperoxia sensitivity to production of melanin, a known virulence factor. Hyperoxia-sensitive strain 562 (oxy1 oxy2) is albino and avirulent. oxy2-defective strains lacking the oxy1 defect are melanin deficient but show normal hyperoxia resistance. Mutants defective at three additional mapped melanin loci fail to show hyperoxia sensitivity in the oxy1 background. Revertants of strain 562, which regain the ability to synthesize melanin by mutation at suppressor sites unlinked to oxy2, retain the oxygen sensitivity conferred by their oxy1 and oxy2 defects. These data identify the melanin gene oxy2 as unique in its association of hyperoxia resistance and melanization.

Responses to cAMP depend on stage of neuronal differentiation of NGF-treated adrenal chromaffin cells

The nerve growth factor (NGF)-dependent transdifferentiation of adrenal chromaffin cells into sympathetic neurons occurs in two sequential phases: The first phase, in which cells extend neurites and increase proliferation, is mimicked by phorbol myristate acetate (PMA), an activator of protein kinase C. Analogs of cAMP, and forskolin, an activator of adenylate cyclase, antagonize the early effects of both NGF and PMA. The second phase of transdifferentiation, in which cells withdraw from the mitotic cycle and express a true neuronal phenotype, occurs after about 2 weeks of exposure to NGF and is neither mimicked by PMA alone nor antagonized by cAMP. Rather, cAMP promotes the neuronal phenotype of cells previously exposed to NGF or PMA. Thus NGF appears to activate different second messenger systems depending on the stage of differentiation of its target cells.

A primary cell culture system of luteinizing hormone releasing hormone neurons derived from embryonic olfactory placode in the rhesus monkey

The purpose of this study is to establish a primary LHRH cell culture system using embryonic olfactory placode and to examine whether LHRH cells derived from olfactory placode and the migratory pathway of LHRH neurons mature in vitro. Six monkey fetuses at the ages of E34-E36 were delivered surgically and the area including the olfactory placode (PL) and the areas that encompass the migratory pathway (MP) were dissected out. The tissues were cut into small pieces and plated on collagen- or poly-L-lysine-coated glass coverslips in medium M199. Cultures were maintained for up to 33 days and immunostained for LHRH, GnRH-associated peptide, neurofilament protein, neuron-specific enolase, and glial fibrillary acidic protein. LHRH positive cells were also positive for neurofilament proteins neuron-specific enolase, and GnRH-associated peptides, but negative for glial fibrillary acidic protein. In the first week of culture, LHRH cells remained within the explants of PL, were rounded (average dimensions: 13.0 x 11.3 microns) and stained lightly. By the second week a number of LHRH cells (15.7 x 13.6 microns) with neurites started to migrate out from PL explants, whereas some still remained in the PL. By the third week a large number of LHRH cells (19.3 x 9.4 microns) had migrated out from the PL. They were fusiform in shape with clear nuclei and extended long varicose neurites up to 500 microns in length. A few "pioneer" LHRH cells appeared to lead the migration of 100-400 LHRH cells forming 1-3 major migratory paths. In contrast, LHRH cells from MP explants migrated out sooner than those from PL explants. LHRH cells from the ventral part of the MP, which is close to the PL, migrated out by 1-2 weeks and formed several migratory paths, whereas LHRH cells from the dorsal part of the MP, which is farther from the PL, were scattered widely around explants and their neurites were extended tortuously. Cultured LHRH cells released LHRH into the media and responded to challenge with high K+. The results indicate that 1) primary LHRH neurons can be obtained from the embryonic PL and their migratory pathway, 2) these neurons migrate and mature in culture and 3) they are accessible for cellular and molecular studies.

HIPIN--a generic HIS/RIS-PACS interface based on clinical radiodiagnostic procedures

Within the EurIPACS HIPIN topic a generic HIS/RIS-PACS interface will be designed, implemented and evaluated. It is generally agreed that integration with the HIS/RIS is essential for the acceptance of PACS in a clinical environment. An interface between HIS/RIS and PACS allows more efficient usage of both systems, better integration of data, better consistency checking on shared data and better security and error handling. Also the PACS performance is improved by using HIS/RIS information to steer the image migration within the PACS. In this paper the functional specifications of the interface are described. These specifications are based on descriptions of clinical radiodiagnostic procedures. The generic interface consists of a common part, and of site specific adapters. The common part is identical for all incarnations and performs message scheduling, processing and logging. The adapters are specific for each communication standard, e.g. ACR-NEMA or HL7, and for each hospital. The interface will be implemented at the radiology department of the Philipps University Hospital in Marburg (Germany) and at the orthopaedic and neuroradiology departments of the hospital of the Free University in Brussels (Belgium).

Effects of NGF and glucocorticoid on NGF receptor immunolabeling of cultured rhesus adrenal chromaffin cells

Nerve growth factor (NGF) promotes the outgrowth of neurites from cultured adrenal chromaffin cells from adult rhesus monkeys, but little is known about the distribution, at the cellular level, of the NGF receptors (NGFR) responsible for this response. We examined changes in immunostaining for NGFR in chromaffin cells cultured for 4 weeks in the presence or absence of NGF, with or without dexamethasone (DEX), which inhibits neuritic outgrowth from these cells. Purified cultures of adrenal chromaffin cells from adult rhesus monkeys were grown for up to 9 weeks in NGF, DEX, NGF plus DEX, or control medium. Cells were immunolabeled with three different monoclonal antibodies directed against different epitopes of the human NGFR. Although the distribution of immunolabeling was not uniform from cell to cell, the overall intensity of NGFR immunolabeling varied dramatically between different growth conditions. Of greatest interest, DEX-treated cells stained the most intensely at all time points, while the intensity of immunolabeling was much fainter in NGF-treated cells and decreased with time in culture. In contrast to the intensity of labeling, the proportion of chromaffin cells with immunoreactivity increased with time in all treatment groups. Thus, GCs do not appear to antagonize the effects of NGF merely by decreasing the total number of immunoreactive NGFR on the surface of these cells.

Early and late effects of NGF may be mediated by different pathways in transdifferentiating chromaffin cells

Nerve growth factor (NGF) causes cultured adrenal chromaffin cells to extend neurites and, after about two weeks of exposure, to 'transdifferentiate' into mature sympathetic neurons. The molecular events leading to these responses are not fully understood, but one possible mediator of NGF's actions is protein kinase C (PKC), which can be directly activated by phorbol esters, including phorbol myristate acetate (PMA). Chronic exposure to PMA mimics the early effects of NGF, that is, it elicits the outgrowth of neurites and an enhanced rate of proliferation. However, while the initial responses to NGF and PMA are similar, after 10 days in culture striking differences become apparent: (1) cells in PMA fail to differentiate into sympathetic neuron-like cells and appear to remain in a transitional state. Even after more than 5 weeks in PMA, cells appear morphologically the same as those grown in PMA for only one week; cells fail to form a dense neuritic network or to exhibit the somatic hypertrophy characteristic of sympathetic neurons. (2) Cells continue to proliferate for at least 4 weeks in PMA, while cells in NGF become postmitotic after about two weeks. (3) While NGF supports and causes the further neuronal differentiation of cells grown in PMA, PMA cannot support NGF-dependent cells. These results suggest that different second messenger systems may be operating in the early and late effects of NGF.

Chronic exposure to an activator of protein kinase C mimics early effects of NGF in chromaffin cells

Adrenal chromaffin cells respond to nerve growth factor (NGF) in vitro by expressing neuronal characteristics and, over a period of 2 to 4 weeks, transdifferentiating into postmitotic sympathetic neurons. Phorbol myristate acetate (PMA) is a potent activator of protein kinase C (PKC); chronic exposure to PMA mimics the initial actions of NGF by promoting the outgrowth of neurites and increasing the incorporation of [3H] thymidine in primary cultures of adrenal chromaffin cells from young rats. PMA and NGF affect the same populations of cells and even individual neurites. These effects are specific for active phorbol ester and do not result from the release of NGF or FGF in the cultures. As in the case of NGF, the effects are inhibited by glucocorticoids. The PKC inhibitor staurosporine inhibits the effects of PMA, as well as those of NGF, in a dose-dependent manner. These results suggest that a modulation in activity of PKC is important in the neuritogenic and proliferative effects of NGF, at least for an initial period of approximately 1 week.