Fractured Knowledge: Making Sense of Exercise in Patients With Bone Metastases

PURPOSE

Traditional dogma suggests that individuals with cancer-related bone metastases should restrict their physical activity, potentially engaging cautiously in isometric exercises. However, occurrences of adverse skeletal events during supervised exercise in patients with known metastatic bone lesions are exceedingly rare, contrasting with the substantial risks of inactivity. Recent studies advocate for well-designed exercise regimens for individuals with bone metastases, highlighting the potential benefits of enhanced mental well-being, fatigue mitigation, enhanced physical function, and an overall improved quality of life. As cancer rehabilitation physicians, it falls within our scope of practice to diagnose, assess, and manage risk while emphasizing the role of exercise and rehabilitation therapies, accompanied by necessary precautions, for individuals with metastatic cancer. This review aims to explore the safety and feasibility of exercise interventions for individuals affected by metastatic bone disease.

Pragmatic Approaches to Scalable Prehabilitation

Patients with cancer should ideally undergo proactive screening for muscle wasting, dietary deficiencies, functional changes, and/or psychological needs. Alternatively, a cross-referral strategy may be useful. A multimodal prehabilitation approach can address impairments and optimize function before treatment. Urological prehabilitation has led to improvements in lean body mass, bone density, erectile function, and urinary continence.

Rehabilitation of Individuals With Cancer

The survival rate of cancer is increasing as treatment improves. As patients with cancer now live longer, impairments may arise that impact quality of life (QOL) and function. Therefore, a focus on QOL is often as important as survival. An interdisciplinary team can achieve goal-oriented and patient-centered rehabilitation, which can optimize function and QOL, and minimize impairments, restrictions, and activity limitations. In most cases, cancer patients must be active participants in therapy and exhibit carryover. Patients with cancer often have impairments that include fatigue, pain, brain fog, impaired cognition, paresis, mood disorders, difficulty with activities of daily living (ADL), bowel/bladder/sexual dysfunction, and bone and soft tissue involvement. Adaptive equipment, exercise, and ADL training can mitigate restrictions on activity. The trajectory and phase of the disease along the continuum of cancer care may influence the goals of rehabilitation in that time window. QOL is often influenced by participation in vocational, recreational, and home-based activities. A holistic perspective should include an analysis of distress, socioeconomic barriers, and transportation limitations when addressing issues.

Translating 2019 ACSM Cancer Exercise Recommendations for a Physiatric Practice: Derived Recommendations from an International Expert Panel

In 2018, the American College of Sports Medicine (ACSM) reconvened an international, multi-disciplinary group of professionals to review pertinent published literature on exercise for people with cancer. The 2018 roundtable resulted in the publication of three articles in 2019. The three articles serve as an important update to the original ACSM Roundtable on Cancer, which convened in 2010. Although the focus of the three 2019 articles is on exercise, which is only one part of comprehensive cancer rehabilitation, the evidence presented in the 2019 ACSM articles has direct implications for physiatrists and other rehabilitation professionals who care for people with cancer. As such, the narrative review presented here has two primary objectives. First, we summarize the evidence within the three ACSM articles and interpret it within a familiar rehabilitation framework, namely the Dietz model of Cancer Rehabilitation, in order to facilitate implementation broadly within rehabilitation practice. Second, via expert consensus, we have tabulated relevant exercise recommendations for specific cancer populations at different points in the cancer care continuum and translated them into text, tables, and figures for ease of reference. Notably, the authors of this article are members of the Cancer Rehabilitation Physician Consortium (CRPC), a group of physicians who subspecialize in cancer rehabilitation medicine (CRM).

Fine and Visual Motor Development Emerging Through Infant and Maternal Reciprocity

Date Presented 4/19/2018

A retrospective study exploring the bidirectionality of reciprocity in infants and mothers revealed changes occurring over 6 months in several domains. This retrospective analysis creates a novel process of assessing visual and fine motor development through the lens of reciprocity.

Primary Author and Speaker: Bryan Gee

Additional Authors and Speakers: Jessica Engle, Chelsee Parker, Matt Stanger, Kelly Thompson

Contributing Authors: Nancy Devine, Nicki Aubuchon-Endsley, Michele Brumley, Heather Ramsdell-Hudock

WE-C-217BCD-06: In Vivo Targeting and Imaging of Tumor Vasculature with Radiolabeled, Antibody-Conjugated Nano-Graphene

PURPOSE

Our goal was to explore nano-graphene for in vivo tumor targeting and quantitatively evaluate the pharmacokinetics and tumor targeting efficacy through PET imaging, using ^{6 4} Cu and ⁶⁶ Ga as the radiolabel.

METHODS

Nano-graphene oxide (GO) sheets, with amino group- terminated PEG chains (10 kDa) covalently attached, were conjugated to NOTA (l,4,7-triazacyclononane-l,4,7-triacetic acid, a suitable chelator for ^{6 4} Cu and ^{6 6} Ga) and TRC105 (a mAb that binds to CD 105, overexpressed on neovasculature). FACS analyses, size measurements, and serum stability studies were performed to characterize the GO conjugates before in vivo investigation (PET, bio distribution, blocking studies, etc.) in 4T1 murine breast tumor-bearing mice. Findings from imaging studies were then validated by histology.

RESULTS

TRC105-conjugated GO, 20-30 nm in diameter, was specific for CD105 with little non-specific binding. Both ⁶⁴ Cu- and ⁶⁶ Ga- labled GO conjugates had excellent stability in mouse serum. Clearance of the GO conjugates in mice was via the hepatobiliary pathway. ^v Cu/^{6 6} Ga-NOTA-GO-TRC105 accumulated rapidly in the 4T1 tumor and tumor uptake remained stable over time (3.8±0.4, 4.5±0.4, 5.8±0.3, and 4.5±0.4 %ID/g at 0.5, 3, 7, and 24 h p.i. for⁶⁶ Ga; 5.8±0.6, 5.3±0.6, 4.0±0.4, and3.4±0.1 %ID/g at 0.5, 3,24, and 48 h p.i. for ^{6 4} Cu; n = 4). Blocking studies confirmed CD105 specificity of ^{6 4} Cu/^{6 6} Ga-NOTA- GOTRC105, which was corroborated by bio distribution studies. Furthermore, microscopy examination of GO in light view mode and immunofluorescence staining revealed that targeting of NOTA-GO-TRC105 is tumor vasculature CD105 specific with little extravasation.

CONCLUSIONS

For the first time, we demonstrated that GO can be specifically directed to the tumor neovasculature in vivo through targeting of CD105, a marker of tumor angiogenesis. The versatile chemistry of graphene-based nanomaterials makes them suitable nanoplatforms for future biomedical research, such as cancer theranostics.

WE-C-217BCD-04: Multimodality Imaging of Breast Cancer Experimental Lung Metastasis

PURPOSE

Metastatic breast cancer (MBC) is incurable. The clinical gold standard for assessing tumor microvessel density (MVD), an independent prognostic marker in MBC, is CD 105 staining. The goal of this study is to develop a positron emission tomography (PET)/near-infrared fluorescent (NIRF) probe for imaging of CD105 expression in MBC (i.e. non-invasive measurement of MVD), as well as other applications such as early detection of metastasis, intraoperative guidance, etc.

METHODS

TRC105, a chimeric anti-CD105 mAb, was dual-labeled with a NIRF dye and ⁸⁹ Zr to yield ^{8 9} Zr-Df-TRC105-800CW. Luciferase-transfected 4T1 murine breast cancer cells were injected intravenously into female BALB/c mice to establish a lung MBC model. Bio luminescence imaging (BLI) was carried out to non- invasively monitor the lung tumor burden. Comprehensive in vivo/ex vivo studies were performed to investigate ^{8 9} Zr-Df-TRC105-800CW in this MBC model. Cetuximab was used as an isotype-matched control.

RESULTS

Radiolabeled TRC105 has high tumor uptake in many tumor types in addition to MBC (e.g. pancreatic/prostate cancer and brain tumor), revealing broad clinical potential for TRC105-based agents. FACS analysis of HUVECs showed no difference in CD 105 binding between TRC105 and Df- TRC105-800CW. PET imaging revealed that 4T1 lung tumor uptake of ⁸⁹ Zr-Df-TRC105-800CW was 8.7±1.4,10.9±0.5, and 9.7±1.1 %ID/g at 4, 24, and 48 h post-injection (n = 4), with excellent tumor contrast. Bio distribution studies, blocking, control studies with ^{8 9} Zr-Df-cetuximab- 800CW, ex vivo BLI/PET/NIRF imaging, and histology all confirmed CD 105 specificity of the tracer. NIRF imaging-guided removal of 4T1 tumors with Df-TRC105-800CW in a subcutaneous model was also straightforward.

CONCLUSIONS

We report the first PET/NIRF imaging of CD105 expression in a MBC model. Broad clinical potential of TRC105- based agents was shown in many tumor types, which also enabled early detection of small metastases and provided intraoperative guidance for tumor removal.

The impact of diaphragm management on prolonged ventilator support after thoracoabdominal aortic repair

PURPOSE

The relationship of the division of the diaphragm during thoracoabdominal aortic repair to prolonged ventilator support has not been studied. The purpose of this study was (1) to determine whether preservation of diaphragm integrity has a significant effect on postoperative ventilator duration and (2) to elucidate other pulmonary risk factors related to thoracoabdominal aortic surgery and to study the relationship of these factors to the intact diaphragm technique.

METHODS

Between February 1991 and January 1997, we repaired 397 descending and thoracoabdominal aortic aneurysms. Descending thoracic aneurysms were not included in the study because their repair does not include the diaphragm. A total of 256 patients participated in this study. The diaphragm was divided in 150 patients and left intact in 106 patients. Examined as potential risk factors were patient demographics, history and physical findings, aneurysm extent, urgency of the procedure, acute dissection, cross-clamp time, homologous and autologous blood product consumption, and adjunctive operative techniques. FEV1 also was considered in the 197 patients for whom preoperative spirometry was available. Prolonged mechanical ventilation was defined as ventilator support for >72 hours. Data were analyzed by univariate contingency table and multiple logistic regression methods.

RESULTS

Increasing age (odds ratio [OR], 1.02/y; P <.02), current smoking (OR, 2.6; P <.0008), total cross-clamp time (OR, 1.0/min; P <.008), units packed red blood cells transfused (OR, 1.06/unit; P <.008), and division of the diaphragm (OR, 2.03; P <.02) were significant, independent predictors of prolonged ventilation. Sixty-seven percent of patients (71 of 106) whose diaphragms were preserved were extubated in <72 hours compared with 52% of patients (78 of 150) who underwent diaphragm division (OR, 0.53; P <.02).

CONCLUSION

Independently of well known pulmonary risk factors, an intact diaphragm during thoracoabdominal aortic repair results in a higher probability of early ventilator weaning.

Effect of gliotoxin on human polymorphonuclear neutrophils

OBJECTIVES

Candida albicans is known to produce gliotoxin, which has several prominent biological effects, including immunosuppression. Interference with host defenses may arise from the effects of this toxin on leukocyte structure and function.

METHODS

Flow cytometric analysis revealed that polymorphonuclear leukocytes (PMN) were more sensitive to gliotoxin than were mononuclear cells. Structural and various functional aspects of PMN exposed to gliotoxin were studied.

RESULTS

Gliotoxin at (1 microgram/mL) did not affect the viability but did diminish PMN chemotaxis and reduced their ability to ingest particles. Other functional aberrations included decreased nitroblue tetrazolium dye reduction, decreased superoxide production, and release of lactoferrin suggesting by degranulation. Gliotoxin also affected the ability of PMN to kill Escherichia coli.

CONCLUSIONS

This study suggests a previously unrecognized potential virulence factor of C. albicans that could contribute to persistence of yeast colonization or recurrence of symptomatic infection through diminished host resistance.

Effect of gliotoxin on human polymorphonuclear neutrophils

OBJECTIVES

Candida albicans is known to produce gliotoxin, which has several prominent biological effects, including immunosuppression. Interference with host defenses may arise from the effects of this toxin on leukocyte structure and function.

METHODS

Flow cytometric analysis revealed that polymorphonuclear leukocytes (PMN) were more sensitive to gliotoxin than were mononuclear cells. Structural and various functional aspects of PMN exposed to gliotoxin were studied.

RESULTS

Gliotoxin at (1 microgram/mL) did not affect the viability but did diminish PMN chemotaxis and reduced their ability to ingest particles. Other functional aberrations included decreased nitroblue tetrazolium dye reduction, decreased superoxide production, and release of lactoferrin suggesting by degranulation. Gliotoxin also affected the ability of PMN to kill Escherichia coli.

CONCLUSIONS

This study suggests a previously unrecognized potential virulence factor of C. albicans that could contribute to persistence of yeast colonization or recurrence of symptomatic infection through diminished host resistance.

Mucopolysaccharidosis presenting as pediatric multiple aortic aneurysm: first reported case

Within the pediatric population, the rare aortic aneurysm is most often brought on by congenital cardiovascular malformation or connective tissue disorder, trauma, inflammatory disease, or infection. Thus our 8-year-old patient who had multiple aortic aneurysms and evidence of mucopolysaccharidosis presented a doubly unique case. Three and one-half months after the patient underwent emergency aortic valve replacement, we performed resection and graft replacement of both her descending thoracic aorta and thoracoabdominal aorta. Histologic analysis of the aneurysm wall displayed severe medial degeneration with large deposits of acid mucopolysaccharides. Subsequent evaluation, although negative for connective tissue disorders, showed glycosaminoglycans, chondroitin sulfate, and heparan sulfate in the patient's urine. These findings are diagnostic for a heterogeneous group of storage diseases termed mucopolysaccharidoses, although testing of the patient's cultured fibroblasts failed to reveal any specific previously described enzymatic defect. After reviewing the literature, we believe that this is the first known successfully treated pediatric aortic aneurysm associated with mucopolysaccharidosis.

Immune-based therapy for HIV

Even if there were antiretrovirals developed that could completely eliminate HIV from the body, it is thought that immune-based therapy would still be necessary. Pervasive damage occurs in the immune system even in early stages of the disease, and this damage would not be corrected by antiretrovirals. Several different types of immune-based therapies are presented in this article; some have been successful, and some have not been successful. All have been important, however, in increasing the knowledge base of HIV pathogenesis and in narrowing the options that might rebuild the immune system and, thereby, reverse this pathology.

Evaluation of five in-line hematocrit monitors

Monitoring the hematocrit is essential during cardiopulmonary bypass for efficacious administration of blood products. The purpose of this study was to evaluate five cardiopulmonary bypass in-line monitors designed to display continuous hematocrit or hemoglobin values. The devices were evaluated for accuracy using an in vitro circuit primed with human blood while randomizing hematocrit, blood flow rate, and temperature. Hematocrits correlated significantly with the error in all the devices (p < 0.01). Over evaluation time, the error of the CDI, Gish, IBC, and MX2 increased significantly (p < 0.05). Temperature correlated significantly with the error of the Gish device (r = -0.49, p < 0.01). Blood flow correlated significantly with the Gish error (r = -0.24, p < 0.01). The Cobe device had a significantly smaller overall error than the other devices (p < 0.001). Device evaluation, based on a low mean error, a low percent error, a high correlation with the actual hematocrit, low correlations between mean error, blood flow, and temperature, and insignificant correlation between time and error, suggests that the Cobe device is more accurate for the continuous monitoring of hematocrit during cardiopulmonary bypass.

Occlusive vascular stapling in a canine inferior vena cava model

A canine model for inferior vena cava resection was devised to study the biomechanical and clinical applications of the cartridge stapler, which applies a triple staggered staple line. Eighteen mongrel dogs were subjected to subhepatic, suprarenal inferior vena cava occlusion with excision of the excluded segment. At 1 hour, six dogs were killed and inferior vena cava sizes and pressures were measured. All staple lines were intact. The inferior vena cava bursting pressure was 150 to 300 mm Hg. Ten dogs survived to 6 weeks and underwent repeat laparotomy with excision and measurement of the remaining inferior vena cava. Mean diameter was 1.9 cm. No evidence of staple line leakage was found despite chronic pressures to 39 cm H2O: median static bursting pressures were 250 mm Hg. Vein wall thickness of greater than 0.24 mm were all satisfactorily stapled. Histologic examination revealed normal reendothelialization, with improved healing at higher chronic pressures. No evidence of inflammation at the staple line or foreign body reaction was found. We conclude that a triple staple line provides secure, rapid venous occlusion that can withstand supraphysiologic stresses immediately and at 6 weeks.

Neuromagnetic evidence of spatially distributed sources underlying epileptiform spikes in the human brain

Neuromagnetic measurements were performed on 17 subjects with focal seizure disorders. In all of the subjects, the interictal spike in the scalp electroencephalogram was associated with an orderly extracranial magnetic field pattern. In eight of these subjects, multiple current sources underlay the magnetic spike complex. The multiple sources within a given subject displayed a fixed chronological sequence of discharge, demonstrating a high degree of spatial and temporal organization within the interictal focus.

Ultrasound detection of a carcinoid tumor

The intraluminal component of symptomatic malignant carcinoid tumors of the small bowel is typically small relative to the extension in the mesentery, and barium examinations are occasionally normal. This case report illustrates the diagnostic value of abdominal ultrasonography in the detection of extraluminal component of a carcinoid tumor.

The evolution of a public health nursing performance evaluation tool

A tool was developed to evaluate the performance of nurses in a large public health department. Nursing staff were involved in the development process and received inservice education in some aspects of performance that would be measured by the tool. The evaluation tool is used to assess performance in four areas: clinical practice, supervision and management, professional growth and research. The authors wish to express their appreciation to the following individuals in the Chicago Department of Health who worked so diligently in the development of the Performance Evaluation Tool and the inservice education program described in this paper: Elizabeth Velten, Lee Gross, JoAnn Macon, Mitchi Oki, Carol Corcoran, Hazel Barclay, Carrie Manley, Evelyn Ribic, Etherlene Palmer, Zettie Richardson. The authors also acknowledge the guidance of Ms. Claudie Leckeisik during the preparation of this manuscript.

Acute interstitial nephritis

Acute allergic interstitial nephritis is manifested clinically by rash, fever, eosinophilia, hematuria, oliguria and azotemia. Histologically a monocytic inflammatory process in the renal interstitium is seen. The clinical course of a patient after excessive sodium cephalothin administration suggested allergic interstitial nephritis and implicates this drug as an etiologic agent.