Exercise prehabilitation may lead to augmented tumor regression following neoadjuvant chemoradiotherapy in locally advanced rectal cancer

  Purpose: We evaluate the effect of an exercised prehabilitation programme on tumour response in rectal cancer patients following neoadjuvant chemoradiotherapy (NACRT). Patients and Methods: Rectal cancer patients with (MRI-defined) threatened resection margins who completed standardized NACRT were prospectively studied in a post hoc, explorative analysis of two previously reported clinical trials. MRI was performed at Weeks 9 and 14 post-NACRT, with surgery at Week 15. Patients undertook a 6-week preoperative exercise-training programme. Oxygen uptake (VO2) at anaerobic threshold (AT) wasmeasured at baseline (pre-NACRT), after completion of NACRT and at week 6 (post-NACRT). Tumour related outcome variables: MRI tumour regression grading (ymrTRG) at Week 9 and 14; histopathological T-stage (ypT); and tumour regression grading (ypTRG)) were compared. Results: 35 patients (26 males) were recruited. 26 patients undertook tailored exercise-training with 9 unmatched controls. NACRT resulted in a fall in VO2 at AT -2.0 ml/kg^-1/min^-1(-1.3,-2.6), p < 0.001. Exercise was shown to reverse this effect. VO2 at AT increased between groups, (post-NACRT vs. week 6) by +1.9 ml/kg^-1/min^-1(0.6, 3.2), p = 0.007. A significantly greater ypTRG in the exercise group at the time of surgery was found (p = 0.02). Conclusion: Following completion of NACRT, exercise resulted in significant improvements in fitness and augmented pathological tumour regression.

A systematic review of the safety and efficacy of aerobic exercise during cytotoxic chemotherapy treatment

PURPOSE

Aerobic exercise improves prognosis and quality of life (QoL) following completion of chemotherapy. However, the safety and efficacy of aerobic exercise during chemotherapy is less certain. A systematic review was performed of randomised trials of adult patients undergoing chemotherapy, comparing an exercise intervention with standard care.

METHOD

From 253 abstracts screened, 33 unique trials were appraised in accordance with PRISMA guidance, including 3257 patients. Interventions included walking, jogging or cycling, and 23 were of moderate intensity (50-80% maximum heart rate).

RESULTS

Aerobic exercise improved, or at least maintained fitness during chemotherapy. Moderately intense exercise, up to 70-80% of maximum heart rate, was safe. Any reported adverse effects of exercise were mild and self-limiting, but reporting was inconsistent. Adherence was good (median 72%). Exercise improved QoL and physical functioning, with earlier return to work. Two out of four studies reported improved chemotherapy completion rates. Four out of six studies reported reduced chemotherapy toxicity. There was no evidence that exercise reduced myelosuppression or improved response rate or survival.

CONCLUSIONS

Exercise during chemotherapy is safe and should be encouraged because of beneficial effects on QoL and physical functioning. More research is required to determine the impact on chemotherapy completion rates and prognosis.

Proactive multi-modality treatment of Pancreatic Neuroendocrine Tumours (PNETs): Potential survival benefits

BACKGROUND/OBJECTIVES

Primary and metastatic pancreatic neuroendocrine tumours (PNET) can be treated with combination of surgery, locoregional and systemic therapy. Survival benefits from individual treatments have been well reported, however, the combined outcome from multimodal treatments are not well described in the literature. We report outcomes in a cohort of PNET patients treated with proactive, multimodality therapy.

METHODS

106 patients were identified from a single tertiary referral centre prospective database. Outcomes of treatment were studied, with the primary end point being death from any cause.

RESULTS

Median follow-up was 71 months and overall 5-year survival of 62%. In patients with stage I-III disease (51 patients) estimated 5-year survival was 90%. Median survival in patients with stage IV disease was 51 months with an estimated 5-year survival of 40% in this group. A total of 80 patients (75%) had surgery of which 16% suffered complications requiring intervention. There was no perioperative mortality.

CONCLUSIONS

This study demonstrates that proactive multimodal treatment is safe and may confer a survival benefit to patients in this cohort compared to historical data.

Neuroaxonal dystrophy in Merino-Border Leicester × Polled Dorset lambs

CASE REPORT

The clinicopathological features of neuroaxonal dystrophy (NAD) in 2 lambs are described. Of 40 Merino-Border Leicester × Polled Dorset lambs on a property in north-eastern Victoria, 4 presented with marked ataxia and listlessness, and 2 affected animals (2 days and 2 weeks of age, respectively) of both sexes were necropsied. Numerous axonal swellings (spheroids) were found in the central nervous system, particularly in brainstem nuclei and spinal cord grey matter, and there was severe spinal cord demyelination.

CONCLUSIONS

This is the first report of NAD in such crossbred lambs; the affected animals were much younger than in previously described cases of ovine NAD and myelin loss was of much greater magnitude than previously reported.

Should we implement 'opt-out' HIV testing for patients with lymphoma?

Patients with HIV are dying due to late diagnosis and physicians are being encouraged to increase HIV testing. The uptake of opt-in HIV screening for 113 lymphoma patients was audited at University College London Hospital. Of the 113 patients, 46 were not tested (41%). Previous research in the antenatal setting suggests that adopting opt-out screening would increase testing rates.

Medical student teaching in the UK: how well are newly qualified doctors prepared for their role caring for patients with cancer in hospital?

A number of studies have identified problems with undergraduate oncology teaching. We have investigated how well prepared newly qualified doctors (first foundation year, or FY1 doctors) are for treating patients with cancer. Twenty-five FY1 doctors and 15 senior doctors participated in interviews. We turned the emergent themes into a questionnaire for all 5143 UK FY1 doctors in 2005. The response rate was 43% (2062 responses). Sixty-one percent of FY1 doctors had received oncology teaching at medical school, but 31% recalled seeing fewer than 10 patients with cancer. Forty percent of FY1 doctors felt prepared for looking after patients with cancer. Sixty-five percent felt prepared for diagnosing cancer, 15% felt they knew enough about chemotherapy and radiotherapy, and 11% felt prepared for dealing with oncological emergencies. Respondents believed medical students should learn about symptom control (71%) and communication skills (41%). Respondents who had received oncology teaching were more likely to feel prepared for looking after patients with cancer (OR 1.52; 95% CI 1.14–2.04). Preparedness also correlated with exposure to patients with cancer (OR 1.48; 95% CI 1.22–1.79). We have found worryingly low levels of exposure of medical students to patients with cancer. First foundation year doctors lack knowledge about cancer care and symptom control. Oncologists should maintain involvement in undergraduate teaching, and encourage greater involvement of patients in this teaching.

Should weaker study designs ever be preferred over randomised controlled trials

Randomised controlled trials are typically cited as the 'best' form of study design to be used when comparing the efficacy or effectiveness of different devices such as pressure-redistributing beds and mattresses. This article presents a RCT that compared two forms of alternating pressure air mattress. No statistically significant differences were found between the incidence of sores upon the two mattresses. However the study was under-powered, and so was unlikely to identify differences in efficacy should they have existed. In discussion it is suggested that randomised controlled trials may be less useful to those purchasing mattresses than 'weaker' study designs that capture the experience of the users of such devices.

Antibiotics for acute bacterial conjunctivitis

BACKGROUND

There are concerns regarding whether antibiotic therapy confers significant benefit in the treatment of acute bacterial conjunctivitis.

OBJECTIVES

The aim of this review is to assess the benefit and harm of antibiotic therapy in the management of acute bacterial conjunctivitis.

SEARCH STRATEGY

We searched the Cochrane Eyes and Vision Group specialised register, the Cochrane Controlled Trials Register - Central, MEDLINE and the reference lists of identified trial reports. We used the Science Citation Index to look for articles that cited the relevant studies, and we contacted investigators and pharmaceutical companies for information about additional trials. The most recent searches were carried out in September 1998.

SELECTION CRITERIA

We included double masked randomised controlled trials in which any form of antibiotic treatment had been compared with placebo in the management of acute bacterial conjunctivitis. This included topical, systemic and combination (for example, antibiotics and steroids) antibiotic usage.

DATA COLLECTION AND ANALYSIS

One reviewer extracted data and the accuracy was checked by a second reviewer. Relative risks were summarised. We tested for heterogeneity between studies.

MAIN RESULTS

Six published trials were identified of which three fulfilled the eligibility criteria for inclusion in this review. One trial was single masked and therefore excluded. A second report, when translated, was found to have no placebo group and was therefore excluded. One trial is currently 'awaiting assessment'. This has been published in abstract form and has yet to be fully reported. All the trials thus far identified appear to have been conducted on a selected specialist care patient population. The trials were heterogeneous in terms of their inclusion and exclusion criteria, the nature of the intervention, and the outcome measures assessed. Meta-analysis indicates that acute bacterial conjunctivitis is frequently a self-limiting condition, as clinical remission (cure or significant improvement) occurred by days two to five in 64% (95% confidence interval (CI) 57% to 71%) of those treated with placebo. Treatment with antibiotics was, however, associated with significantly better rates of clinical remission (days two to five: relative risk (RR) 1.31 95% CI 1.11 to 1.55, NNT=5) with a suggestion that this benefit was maintained for late clinical remission (days six to 10: RR 1.27 95% CI 1.00 to 1.61, NNT=5). Antibiotic treatment was associated with rates of microbiological remission (pathogen eradication or reduction). No serious outcomes were reported in either the active or placebo arms of these trials, indicating that important sight-threatening complications are an infrequent occurrence.

REVIEWER'S CONCLUSIONS

Acute bacterial conjunctivitis is frequently a self-limiting condition but the use of antibiotics is associated with significantly improved rates of early clinical remission and early and late microbiological remission. Since trials to-date have been conducted in selected specialist care patient populations these results may not necessarily be generalisable to a primary care based population. A trial based in primary care designed to assess the cost-effectiveness of commonly prescribed antibiotic(s) versus placebo in acute bacterial conjunctivitis is warranted.

A narrow window of intracellular calcium concentration is optimal for neurite outgrowth in rat sensory neurones

We have examined neurite outgrowth in rat sensory neurones when cytosolic free calcium concentration ([Ca2+]i) was varied in the range 0-60 nM. Neurite outgrowth was maximal at 35 nM [Ca2+]i and was reduced at higher and lower values of [Ca2+]i. These results provide direct evidence for Mattson and Kater's suggestion of an optimal calcium range for growth cone function.

Nosocomial enterococcal infections: association with use of third-generation cephalosporin antibiotics

Enterococcal infections consistently account for approximately 10% of all nosocomial infections reported to the Centers for Disease Control. There is concern that an increase in nosocomial enterococcal infection is due to the increased severity of inpatient illnesses and to the widespread use of broad-spectrum beta-lactam antibiotics. Nosocomial enterococcal infections were analyzed at our medium-sized community hospital over a time period spanning 9 years. A significant increase in the infection rate was detected during the latter half of 1986. This increase was due primarily to a disproportionate rise in the incidence of the urinary tract as a site of infection. There were no associated clusters of infection, no predilection for certain patient care areas, and no preceding change in the hospital infection control policies and procedures. Total hospital use of cephalosporins remained stable during the period of increased enterococcal infections, but use of third-generation cephalosporins almost doubled in 1986 compared with the 4 preceding years. Selective pressure of third-generation cephalosporin use appeared to be a factor in the increased incidence of nosocomial enterococcal urinary tract infection.

Characterization of cells with high alkaline phosphatase activity derived from human bone and marrow: preliminary assessment of their osteogenicity

Confluent cellular layers are reproducibly obtained (from 21 of 24 specimens) by outgrowth from composite pieces of human trabecular bone and marrow. The cells resemble fibroblasts in terms of morphology, esterase profile, and production of collagen type 1. However, the cells displayed some osteoblastlike features. Both the primary outgrowths and passaged cultures had high alkaline phosphatase activities (37 nmols min-1 X microgram DNA-1) in the range displayed by embryonic osteoblastlike cells. The cellular alkaline phosphatase activity, which showed similarity to the bone isoenzyme on kinetic criteria, was stimulated by 1,25-dihydroxyvitamin D3 but decreased by PTH (1-34). In addition, the cell preparations were shown to increase osteocalcin (bone Gla protein) production in response to 1,25-dihydroxyvitamin D3. The osteogenic potential of the bone and marrow-derived cells has been assessed in an in vivo diffusion chamber assay in which congenitally athymic (nude) mice were used as hosts. None of the 25 chambers examined showed evidence of osteogenesis, although the cells remained viable and fibroblastlike. The alkaline phosphatase activities decreased to less than 1% of the original, high in vitro values. The findings question the hypothesis that bone and marrow-derived cells are osteoblasts or osteoblastlike cells, rather than a mixture of cell lines of the bone and marrow stromal system.