Anti-cholinergic drug burden in patients with dementia increases after hospital admission: a multicentre cross-sectional study

Background

Anticholinergic medications are drugs that block cholinergic transmission, either as their primary therapeutic action or as a secondary effect. Patients with dementia may be particularly sensitive to the central effects of anticholinergic drugs. Anticholinergics also antagonise the effects of the main dementia treatment, cholinesterase inhibitors. Our study aimed to investigate anticholinergic prescribing for dementia patients in UK acute hospitals before and after admission.

Methods

We included 352 patients with dementia from 17 UK hospital sites in 2019. They were all inpatients on surgical, medical or Care of the Elderly wards. Information about each patient’s medications were collected using a standardised form, and the anticholinergic drug burden of each patient was calculated with an evidence-based online calculator. Wilcoxon’s rank test was used to look at the correlation between two subgroups upon admission and discharge.

Results

On admission to hospital, 37.8% of patients had an anticholinergic burden score ≥ 1 and 5.68% ≥3. On discharge, 43.2% of patients with an anticholinergic burden score ≥ 1 and 9.1% ≥3. The increase in scores was statistically significant (p = 0.001). Psychotropics were the most common group of anticholinergic medications prescribed at discharge. Of those patients taking cholinesterase inhibitors, 44.9% were also prescribed anticholinergic medications.

Conclusions

Our cross-sectional, multicentre study found that people with dementia are commonly prescribed anticholinergic medications, even if concurrently taking cholinesterase inhibitors, and are significantly more likely to be discharged from hospital with a higher anticholinergic burden than on admission.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03235-9.

Dementia patients have greater anti-cholinergic drug burden on discharge from hospital: A multicentre cross-sectional study

Introduction

Anticholinergic medications block cholinergic transmission. The central effects of anticholinergic drugs can be particularly marked in patients with dementia. Furthermore, anticholinergics antagonise the effects of cholinesterase inhibitors, the main dementia treatment.

Objectives

This study aimed to assess anticholinergic drug prescribing among dementia patients before and after admission to UK acute hospitals.

Methods

352 patients with dementia were included from 17 hospitals in the UK. All were admitted to surgical, medical or Care of the Elderly wards in 2019. Information about patients’ prescriptions were recorded on a standardised form. An evidence-based online calculator was used to calculate the anticholinergic drug burden of each patient. The correlation between two subgroups upon admission and discharge was tested with Spearman’s Rank Correlation.

Results

Table 1 shows patient demographics. On admission, 37.8% of patients had an anticholinergic burden score ≥1 and 5.68% ≥3. At discharge, 43.2% of patients had an anticholinergic burden score ≥1 and 9.1% ≥3. The increase was statistically significant (rho 0.688; p=2.2x10-16). The most common group of anticholinergic medications prescribed at discharge were psychotropics (see Figure 1). Among patients prescribed cholinesterase inhibitors, 44.9% were also taking anticholinergic medications.

Conclusions

This multicentre cross-sectional study found that people with dementia are frequently prescribed anticholinergic drugs, even if also taking cholinesterase inhibitors, and are significantly more likely to be discharged with a higher anticholinergic drug burden than on admission to hospital.

Conflict of interest

This project was planned and executed by the authors on behalf of SPARC (Student Psychiatry Audit and Research Collaborative). We thank the National Student Association of Medical Research for allowing us use of the Enketo platform. Judith Harrison was su

A multicentre, randomised trial comparing schedules of G-CSF (filgrastim) administration for primary prophylaxis of chemotherapy-induced febrile neutropenia in early stage breast cancer

BACKGROUND

The optimal duration of filgrastim as primary febrile neutropenia (FN) prophylaxis in early breast cancer patients is unknown, with 5, 7 or 10 days being commonly prescribed. This trial evaluates whether 5 days of filgrastim was non-inferior to 7/10 days.

PATIENTS AND METHODS

In this randomised, open-label trial, early breast cancer patients who were to receive filgrastim as primary FN prophylaxis were randomly allocated to 5 versus 7 versus 10 days of filgrastim for all chemotherapy cycles. A protocol amendment in November 2017 allowed subsequent patients (N = 324) to be randomised to either 5 or 7/10 days. The primary outcome was a composite of either FN or treatment-related hospitalisations. Secondary outcomes included chemotherapy dose reductions, delays and discontinuations. Analyses were carried out by per protocol (primary) and intention-to-treat, and the non-inferiority margin was set at 3% for the risk of having FN and/or hospitalisation per cycle of chemotherapy.

RESULTS

Patients (N = 466) were randomised to receive 5 (184, 39.5%), or 7/10 (282, 60.5%) days of filgrastim. In our primary analysis, the difference in risk of either FN or treatment-related hospitalisation per cycle was -1.52% [95% confidence interval (CI): -3.22% to 0.19%] suggesting non-inferiority of a 5-day filgrastim schedule compared with 7/10-days. The difference in events per cycle for FN was 0.11% (95% CI: -1.05 to 1.27) while for treatment-related hospitalisations it was -1.68% (95% CI: -2.73% to -0.63%). The overall proportions of patients having at least one occurrence of either FN or treatment-related hospitalisation were 11.8% and 14.96% for the 5- and 7/10-day groups, respectively (risk difference: -3.17%, 95% CI: -9.51% to 3.18%).

CONCLUSION

Five days of filgrastim was non-inferior to 7/10 days. Given the cost and toxicity of this agent, 5 days should be considered standard of care. CLINICALTRIALS.

GOV REGISTRATION

NCT02428114 and NCT02816164.

The personality disorder patient pathway: Service user and clinical perspectives

AIMS

There have been recent policy developments and research into care provision for service users with personality disorder. However, few studies have focused on service user and staff perspectives on how services could be improved.

METHODS

A qualitative study was undertaken in the UK between 2016 and 2017. We conducted six focus groups with clinicians in mental health services with experience of working with people with personality disorder. Using an online survey, we asked current and past service users with personality disorder to describe their experiences of mental health services and make recommendations for improvements. A thematic analysis was conducted.

RESULTS

Forty-five clinicians participated in the focus group and 131 service users contributed to the online survey. The main areas of concern identified by both staff and patients were the diagnosis of personality disorder, the absence of a coherent care pathway, access to psychological treatment and staff training.

CONCLUSIONS

The care pathway for individuals with personality disorder is unclear to clinicians and service users, and elements of the pathway are disjointed and not working as effectively as they could. Guidelines recommended by National Institute for Health and Care Excellence are not being followed. Specialist psychological interventions should be available to ensure consistent and stable care provision. © 2019 John Wiley & Sons, Ltd.

Abstract P1-07-34: Clinical outcomes of single versus double hormone receptor positive breast cancer patients treated with neoadjuvant chemotherapy

Purpose

This study aimed to evaluate and compare tumor response rates and survival outcomes between single and double hormone receptor (HR) positive (+) [Estrogen Receptor (ER+)/Progesterone Receptor (PR) negative (-) or ER-/PR+ versus ER+/PR+] breast cancer (BC) patients with any HER2 status treated with neoadjuvant chemotherapy at a single institution

Methods

A retrospective review was conducted using the Sunnybrook “Biomatrix” database to identify eligible patients. A multivariable logistic regression analysis (MLR) was performed to assess the association between HR status (single or double HR+) and pathologic complete response (pCR) rates at surgery. A Kaplan-Meier method was used to estimate Disease Free Survival (DFS) and a log-rank test was used to compare DFS between 3 subgroups of patients: single or double HR+ and HR negative patients

Results

Three hundred and four BC patients were identified and included in the analysis with a median follow up of 43.3months (Q1-Q3: 28.7-61.1) and a mean age of 49.7 years (Standard deviation 10.9). Forty seven percent (47/101), 31% (11/36) and 14% (24/167) of patients with HR negative, single HR+ and double HR+ disease achieved a pCR respectively (X2 test <0.0001). In a MLR analysis, HR status and HER2 status were associated with pCR rates. Compared to HR negative patients, patients with double HR+ disease were less likely to achieve pCR (Odd ratio (OR):0.14, 95%CI 0.06-0.31, p<0.0001) while single HR+ patients did not differ (OR:0.51, 95%CI 0.19-1.4). The association between HR+ status (single versus double HR+) and pCR rates compared to HR negative patients remained the same in subgroup analyses of HER2+ and HER2 negative patients separately. No difference in survival (DFS) was seen between the 3 subgroups of patients: HR negative, single and double HR+ patients.

Conclusion

BC patients with single HR+ disease behave differently than double HR+ patients in terms of likelihood of achieving pCR after neoadjuvant chemotherapy and do not differ from HR negative patients. This difference does not translate into a difference in DFS. Prospective studies are needed to validate these findings before considering different treatment strategies for these 2 subgroups of HR+ BC patients.

Citation Format: Raphael J, Nofech-Mozes S, Trudeau ME. Clinical outcomes of single versus double hormone receptor positive breast cancer patients treated with neoadjuvant chemotherapy [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 P1-07-34.

Abstract P4-12-08: Palbociclib in hormone receptor positive advanced breast cancer: A cost-utility analysis

Introduction

The addition of palbociclib to letrozole improves progression free survival (PFS) and response rates compared to letrozole alone in the 1st line treatment of hormone receptor positive advanced breast cancer. However palbociclib increases toxicity (i.e. neutropenia) and costs more than $6,250 per month in Canada. This study assesses the cost-utility of palbociclib from the Canadian healthcare payer perspective.

Methods

To evaluate the cost-utility of palbociclib, a probabilistic discrete event simulation model was developed. The model was parameterized with data from the phase 2 and 3 PALOMA 1 and 2 trials and other sources. The incremental cost per quality-adjusted life-month (QALM) gained for palbociclib was calculated. A time horizon of 15 years was used in the base case with costs and effectiveness discounted 5% annually. The time to progression and death were derived from a Weibull and exponential distribution. Expected costs were based on Ontario fees and other sources. Probabilistic sensitivity analyses were conducted to account for parameter uncertainty.

Results

Compared to letrozole alone, the addition of palbociclib provided an additional 14.7 QALM at an incremental cost of $161,508. The resulting incremental cost-effectiveness ratio was $10,999 per QALM gained. Assuming a willingness to pay (WTP) of $4,167 per QALM, the addition of palbociclib was not cost-effective and the probability of palbociclib to be cost-effective was 0%. Cost-effectiveness acceptability curves derived from a probabilistic sensitivity analysis showed that at a WTP of $11,667 per QALM gained, the probability of palbociclib to be cost-effective was 50%.

Conclusion

Compared with letrozole alone, the addition of palbociclib is unlikely to be cost-effective for the treatment of advanced breast cancer from a Canadian healthcare perspective with its current price. While advanced breast cancer patients derive a meaningful clinical benefit from palbociclib, considerations should be given to increase the WTP threshold and reduce the drug pricing, to render this strategy more affordable.

Citation Format: Raphael J, Helou J, Naimark DM. Palbociclib in hormone receptor positive advanced breast cancer: A cost-utility analysis [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 P4-12-08.

Palbociclib in hormone receptor positive advanced breast cancer: A cost-utility analysis

INTRODUCTION

The addition of palbociclib to letrozole improves progression-free survival in the first-line treatment of hormone receptor positive advanced breast cancer (ABC). This study assesses the cost-utility of palbociclib from the Canadian healthcare payer perspective.

METHODS

A probabilistic discrete event simulation (DES) model was developed and parameterised with data from the PALOMA 1 and 2 trials and other sources. The incremental cost per quality-adjusted life-month (QALM) gained for palbociclib was calculated. A time horizon of 15 years was used in the base case with costs and effectiveness discounted at 5% annually. Time-to- progression and time-to-death were derived from a Weibull and exponential distribution. Expected costs were based on Ontario fees and other sources. Probabilistic sensitivity analyses were conducted to account for parameter uncertainty.

RESULTS

Compared to letrozole, the addition of palbociclib provided an additional 14.7 QALM at an incremental cost of $161,508. The resulting incremental cost-effectiveness ratio was $10,999/QALM gained. Assuming a willingness-to-pay (WTP) of $4167/QALM, the probability of palbociclib to be cost-effective was 0%. Cost-effectiveness acceptability curves derived from a probabilistic sensitivity analysis showed that at a WTP of $11,000/QALM gained, the probability of palbociclib to be cost-effective was 50%.

CONCLUSION

The addition of palbociclib to letrozole is unlikely to be cost-effective for the treatment of ABC from a Canadian healthcare perspective with its current price. While ABC patients derive a meaningful clinical benefit from palbociclib, considerations should be given to increase the WTP threshold and reduce the drug pricing, to render this strategy more affordable.

Stereotactic Body Radiotherapy versus Low Dose Rate Brachytherapy for Localised Prostate Cancer: a Cost-Utility Analysis

AIMS

To conduct a cost-utility analysis comparing stereotactic body radiotherapy (SBRT) with low dose rate brachytherapy (LDR-BT) for localised prostate cancer (PCa).

MATERIALS AND METHODS

A decision-analytic Markov model was developed from the healthcare payer perspective to simulate the history of a 66-year-old man with low-risk PCa. The model followed patients yearly over their remaining lifetimes. Health states included 'recurrence-free', 'biochemical recurrence' (BR), 'metastatic' and 'death'. Transition probabilities were based on a retrospective cohort analysis undertaken at our institution. Utilities were derived from the literature. Costs were assigned in 2015 Canadian dollars ($) and reflected Ontario's health system and departmental costs. Outcomes included quality-adjusted life years (QALYs), costs and incremental cost-effectiveness ratios. A willingness-to-pay threshold of $50 000/QALY was used.

RESULTS

SBRT was the dominant strategy with 0.008LYs and 0.029QALYs gained and a reduction in cost of $2615. Under base case conditions, our results were sensitive to the BR probability associated with both strategies. LDR-BT becomes the preferred strategy if the BR with SBRT is 1.3*[baseline BR_SBRT] or if the BR with LDR-BT is 0.76*[baseline BR_LDR-BT]. When assuming the same BR for both strategies, LDR-BT becomes marginally more effective with 0.009QALYs gained at a cost of $272 848/QALY.

CONCLUSIONS

SBRT represents an economically attractive radiation strategy. Further research should be carried out to provide longer-term follow-up and high-quality evidence.

Abstract P6-09-39: The role of quantitative estrogen receptor status in predicting breast tumor response to neoadjuvant chemotherapy

Introduction:

Patients with Estrogen Receptor negative breast cancer (BC) are known to have higher tumor response rates than ER positive patients when treated with neoadjuvant chemotherapy (NCT). Few studies have assessed ER status as a quantitative continuous measure in predicting tumor response in this setting.

We aimed to study the association between quantitative ER status and tumor response at surgery in BC patients treated with NCT at our institution, and identify potential predictors of better survival outcomes.

Methods:

A retrospective review using a neoadjuvant BC database (The "Sunnybrook Biomatrix") identified 304 eligible patients that were included in the analyses. A univariate followed by a multivariable logistic regression analyses were conducted to assess the association between quantitative ER (expressed in percentage) and tumor response (good vs. poor response defined as < vs. ≥ 50% reduction in tumor size) while controlling for potential confounders.

For the secondary outcome, the Kaplan Meier method was used to estimate the recurrence free survival (RFS) in this cohort. Predictors of RFS were identified using a cox proportional hazards model (CPH) to adjust for clinically relevant variables. A log-rank test was used to compare RFS between groups for any significant binary predictor.

Results:

The median follow up of all patients was 43.3 months (Q1-Q3: 28.7-61.1). Quantitative ER was inversely associated with tumor response in a multivariable logistic regression model (Odds Ratio 0.99 95%CI: 0.99-1.00, p=0.027). A cut-off of 60% seemed to best predict the association based on the c-statistic (c=0.67) and the receiver operating characteristic curve.

However, quantitative ER was not associated with RFS; pathologic complete response (pCR) was shown to be an independent predictor of RFS in a CPH model (Hazard Ratio: 0.17, 95% CI: 0.07, 0.43, p=0.0002) in all patients, after controlling for potential confounders. At 5 years, 93% of patients with pCR and 72% of patients with residual tumor (no pCR) were recurrent-free respectively (log-rank test p=0.0012).

Conclusion:

This study suggests that BC patients with ER status < 60% are more likely to respond to NCT. Although ER status itself did not predict for relapse-free survival, patients with a pCR had better RFS, and this association was seen amongst all tumor phenotypes.

The role of quantitative ER in predicting and maximizing tumour response to NCT (including optimizing pCR rate) needs to be better defined in prospective studies.

Key words: Estrogen receptors, breast cancer, quantitative, tumor response, pathologic complete response.

Citation Format: Raphael J, Trudeau M, Paramsothy T, Lee N, Gandhi S. The role of quantitative estrogen receptor status in predicting breast tumor response to neoadjuvant chemotherapy [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 P6-09-39.

Abstract P6-10-17: Rates of prophylactic surgeries among BRCA 1 or 2 mutation carriers: A single institution experience

Background

Women with identified BRCA1/2 mutation have a substantially increased risk of developing several types of cancer, mainly breast and ovarian, during their lifetime. Management options included close surveillance, chemoprevention and prophylactic surgeries. The aim of this study is to assess the rate of prophylactic surgeries among BRCA1/2 carriers counseled and screened at a single institution in the last 2 decades.

Methods

We retrospectively captured all women with a BRCA1/2 mutation that were identified in our genetic clinic between 2000 and 2015. The incidence of breast and ovarian cancer among all BRCA carriers was reported. The rates of prophylactic surgeries were calculated and analyzed in all identified carriers.

Results

Six hundred and eighty four women were identified to carry a deleterious BRCA mutation, among them 364 BRCA1 (53%) and 320 BRCA2 (47%). Three hundred and twenty seven (48%) were diagnosed with breast cancer and 80 (12%) had either ovarian or fallopian tumor. Forty percent (N=271) of the women assessed were healthy carriers. Prophylactic bilateral salpingo-oophorectomies (BSO) were performed in 342 women (50%) and prophylactic mastectomies (PM) (bilateral or unilateral) in 190 (28%). Furthermore, 154 women (23%) had both BSO and PM. Of note, 79 women (12%) were less than 35 years old and 122 were less than 40 years old (18%), the majority of those were waiting to have BSO later on. If we remove the young women from the analysis, 57 and 61% of the women would have had BSO (less than 35 and 40 years excluded respectively). If we only analyze the women who had a recent follow up in our clinic (2014-2015), 422 women would be eligible. Among those, 58 and 84 were less than 35 and 40 years old (y) respectively. For this cohort, the rates of BSO would be 61% (257/422)(whole cohort), 71% (excluding women less than 35y) and 76% (excluding women less than 40y).

Conclusion

A promising rate of BSO was reported in our cohort of BRCA carriers as compared to the literature. This rate was even higher (from 50 to over 70%) when we only analyzed patients with recent follow up in clinic and when we excluded young women waiting to have BSO. More efforts are needed to determine why the rates of PM are lower, for example limited breast reconstruction resources, in order to reduce the incidence of subsequent invasive breast cancer in this high-risk population.

Citation Format: Raphael J, Hewitt P, Graham T, Ott K, Mancuso T, Lorentz J, Emmerson M, Eisen A. Rates of prophylactic surgeries among BRCA 1 or 2 mutation carriers: A single institution experience. [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 P6-10-17.

Outcome of patients with pregnancy during or after breast cancer: a review of the recent literature

BACKGROUND

An increasing number of young women are delaying childbearing; hence, more are diagnosed with breast cancer (bca) before having a family. No clear recommendations are currently available for counselling such a population on the safety of carrying a pregnancy during bca or becoming pregnant after treatment for bca.

METHODS

Using a Web-based search of PubMed we reviewed the recent literature about bca and pregnancy. Our objective was to report outcomes for patients diagnosed with bca during pregnancy, comparing them with outcomes for non-pregnant women, and to evaluate prognosis in women diagnosed with and treated for bca who subsequently became pregnant.

RESULTS

"Pregnancy and bca" should be divided into two entities. Pregnancy-associated bca tends to be more aggressive and advanced in stage at diagnosis than bca in control groups; hence, it has a poorer prognosis. With respect to pregnancy after bca, there is, despite the bias in reported studies and meta-analyses, no clear evidence for a different or worse disease outcome in bca patients who become pregnant after treatment compared with those who do not.

CONCLUSIONS

Pregnancy-associated bca should be treated as aggressively as and according to the standards applicable in nonpregnant women; pregnancy after bca does not jeopardize outcome. The guidelines addressing risks connected to pregnancy and bca lack a high level of evidence for better counselling young women about pregnancy considerations and preventing unnecessary abortions. Ideally, evidence from large prospective randomized trials would set better guidelines, and yet the complexity of such studies limits their feasibility.

[Helical tomotherapy in the treatment of malignant pleural mesothelioma: The impact of low doses on pulmonary and oesophageal toxicity]

PURPOSE

To evaluate the adjuvant treatment of malignant pleural mesothelioma by helical tomotherapy and the impact of low doses on esophageal and pulmonary toxicity.

PATIENTS AND METHODS

Between June 2007 and May 2011, 29 patients diagnosed with malignant pleural mesothelioma received adjuvant radiotherapy by helical tomotherapy. The median age was 63 years (34-72). Histologically, 83 % of patients had epithelioid malignant pleural mesothelioma. Clinically, 45 % of patients were T3 and 55 % N0. Eighty six percent of the patients were treated by extrapleural pneumonectomy and 35 % received neoadjuvant chemotherapy with platinum and pemetrexed. The median dose in the pneumonectomy cavity was 50Gy at 2Gy/fraction.

RESULTS

The mean follow-up was 2.3 years after diagnosis. Overall survival at 1 and 2 years was 65 and 36 % respectively. The median survival from diagnosis was 18 months. Median lung volumes receiving 2, 5, 10, 13, 15 and 20Gy (V2, V5, V10, V13, V15 and V20) were 100, 98, 52, 36, 19 and 5 %. The median of the mean remaining lung dose was 11Gy. Two patients died of pulmonary complications, three patients had grade 3 lung toxicity, while esophageal grade 3-4 toxicity was observed in three other patients. No significant impact of clinical characteristics and dosimetric parameters were found on pulmonary toxicity, however a V10≥50 %, a V15≥15 % and mean lung dose of 10Gy or more had a tendency to be predictive of pulmonary toxicity (P<0.1). Moreover, in our analysis, the mean lung dose seems to have a significant impact on esophageal toxicity (P=0.03) as well as low doses to the controlateral lung: V5, V10 and V13 (P<0.05).

CONCLUSION

Helical tomotherapy is a promising technique in the multimodality treatment of malignant pleural mesothelioma. Low doses received by the contralateral lung appear to be the limiting factor. A dosimetric comparison with volumetric modulated arctherapy techniques would be interesting in this setting.

Using custom protein microarrays to identify autoantibody biomarkers for the early detection of breast cancer

Abstract #2003

Background: Cancer patients make antibodies to tumor-derived proteins that are potential biomarkers for early detection. To detect autoantibodies to tumor antigens in patient sera, we have adapted novel high-density custom protein microarrays (NAPPA) expressing 6,500 candidate tumor antigens for biomarker detection. These arrays are probed with sera from patients with early stage breast cancer and healthy women. Using this approach, we identified antibodies in the sera of breast cancer patients.&#x2028; Methods: 6,500 full-length human antigens were expressed using mammalian reticulocyte lysate and captured onto NAPPA protein microarrays. Protein expression (&gt;90%) was confirmed with anti-GST antibodies. Patient sera were added, and bound IgG detected with secondary antibodies. Serum samples were obtained from 103 patients with stages I-III breast cancer, and 103 age-matched control women, all undergoing routine mammography.&#x2028; Results: Using high-density protein microarrays, sera from breast cancer patients (n=53) and healthy donor sera (n=53) were screened for autoantibodies to 6,500 protein antigens. Antigens were selected for further analysis if the 95th percentile of signal of cases and controls were significantly different (p&lt;0.05) and if the number of cases with signals above the 95th percentile of controls was larger than the number expected due to random chance (p&lt;0.05). Known tumor antigens, such as p53, were detected, as well as novel antigens such as DCC1, Rab7L and USP44. In total, 768 unique antigens were selected for further analysis with an independent set of breast cancer patient (n=50) and healthy donor sera (n=50).&#x2028; Conclusions: Custom in-situ protein microarrays can be used to detect serum tumor antigen-specific antibodies and enables the rapid, simultaneous detection of immunogenic tumor antigens from patient sera. These autoantibodies are being evaluated as potential biomarkers for the early diagnosis of breast cancer.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2003.

Trends in the prevalence of adolescent births in Antigua and Barbuda over 35 years

A retrospective study was undertaken to determine trends in teenage births in Antigua and Barbuda from 1969 to 2003. Maternity Ward records were reviewed at Holberton Hospital, site of over 90% of deliveries in Antigua and Barbuda. Maternal age for all births were included. The estimated population in Antigua and Barbuda increased from 60,159 in 1969 to 69,866 in 1998, with no suspected change in age-group or gender distribution. Births to mothers 12-13, 14-15, 16-17 and 18-19 years old were analyzed separately. Yearly birth totals for the 10-year period from 1969 to 1973 and 1999 to 2003 were compared using student t test analysis. The total number of births averaged 1075 per year with no change in trend. For females aged 12 and 13 years, there was no change in births from 1969 to 1978 compared with 1994 to 2003. For females aged 14 years, there was a 54% drop; for females aged 15 years, a 59% drop; for females aged 16 years, a 53% drop; for females aged 17 years, a 51% drop; for females 18 years, a 37% drop and for females aged 19 years, a 30% drop, while births to mothers > or = 20 years increased 25%. The decrease for all teen births was 42% from 1969-1978 to 1994-2003. Teen births accounted for 29% of all births at Holberton in 1969 to 1973 but only 16% of births in 1999 to 2003. In conclusion, Antigua and Barbuda has seen a marked drop of 42% in teenage deliveries, including a 53% drop in school-aged teens from 1969 to 2003. Explanations include factors such as economic, social, educational and medical developments.

Spinal cord stimulation for relief of abdominal pain in two patients with familial Mediterranean fever

Familial Mediterranean fever is a hereditary disease characterized by recurrent attacks of fever and serosal inflammation that commonly presents as severe abdominal pain. Though colchicine remains the mainstay of treatment, a significant proportion of patients are partially responsive, unresponsive or intolerant to it. We present two such cases where spinal cord stimulation (SCS) was used to manage the paroxysmal abdominal pain associated with this disease. Abdominal visceral pain pathways and the application of SCS techniques in its management are discussed.

Isoflurane-induced myocardial preconditioning is dependent on phosphatidylinositol-3-kinase/Akt signalling

BACKGROUND

Isoflurane and other volatile anaesthetics have a cardioprotective effect and limit myocardial infarct size to the same extent as ischaemic preconditioning. Phosphatidylinositol-3-kinase (PI3K) was found to play a key role in myocardial protection by ischaemic preconditioning. The aim of the present investigation was to evaluate whether isoflurane-induced myocardial preconditioning is dependent on PI3K signalling.

METHODS

Using a model of regional myocardial ischaemia and reperfusion, New Zealand White rabbits were subjected to 40 min of regional myocardial ischaemia followed by 120 min of reperfusion. The rabbits were randomly assigned to one of the following six experimental groups: sham-operated controls (n=5); ischaemia and reperfusion controls (n=8); isoflurane preconditioning (n=8); a PI3K inhibitor, wortmannin (0.6 mg kg(-1) i.v.) + isoflurane (n=8); and wortmannin+ischaemia and reperfusion (n=8). An additional control group of sham operation+ wortmannin (n=5) was also included. Myocardial injury was assessed by measuring the serum concentration of the MB fraction of creatine kinase (CK-MB) and infarct size was assessed by 2,3,5-triphenyl tetrazolium chloride staining. Phosphorylation of Akt, a downstream target of PI3K, was assessed by western blotting.

RESULTS

Isoflurane preconditioning was seen as reduced infarct size compared with control animals: 24 (4) and 41 (5)% respectively (P<0.05). Wortmannin inhibited this cardioprotective effect with myocardial infarct size at 44 (3)% (not significant). Akt phosphorylation was increased after isoflurane preconditioning, but administration of wortmannin blocked this effect.

CONCLUSIONS

Our data demonstrate that isoflurane protects the heart against ischaemia and decreases myocardial infarction by activation of PI3K.

Isoflurane does not mimic ischaemic preconditioning in decreasing hydroxyl radical production in the rabbit

BACKGROUND

Reactive oxygen species are an important mediator in isoflurane-induced myocardial preconditioning. However, hydroxyl radicals are also released during reperfusion after regional ischaemia. The purpose of the present study was to test whether ischaemic preconditioning and isoflurane would influence the production of hydroxyl radicals during reperfusion.

METHODS

After i.v. administration of salicylate 100 mg kg(-1) and a 30 min stabilization period, New Zealand White rabbits were subjected to 40 min of regional myocardial ischaemia and 2 h of reperfusion. Ischaemic preconditioning was elicited by 5 min ischaemia followed by 10 min reperfusion (before the 40 min ischaemia). In another group, isoflurane (2.1%) was administered for 30 min, followed by 15 min washout, before the long ischaemia. Area at risk and infarct size were assessed by blue dye injection and tetrazolium chloride staining. We quantified the level of OH-mediated conversion of salicylate to its dihydrobenzoate derivatives (2,3- and 2,5-DHBAs). Normalized values of the DHBAs (ng DHBA per mg salicylate) were calculated.

RESULTS

Mean (se) infarct size was 57 (6)% of the risk area in the untreated controls. This was significantly smaller in the ischaemic preconditioning and isoflurane groups: 22 (5) and 23 (6)% respectively. At 10 min of reperfusion, ischaemic preconditioning limited the mean increase in 2,3-DHBA to 24% from baseline, compared with 81% in control and 74% in the isoflurane group. Normalized 2,5-DHBA was maximally increased by 75% in the untreated group, 4 min after reperfusion. Ischaemic preconditioning significantly inhibited this increase (24% increase from baseline, P<0.01). However, the increase observed in the isoflurane group was not different from control (71%).

CONCLUSIONS

As already known, ischaemic preconditioning and isoflurane markedly reduced infarct size. However, only ischaemic preconditioning decreased postischaemic production of hydroxyl radicals. These different effects suggest different protective mechanisms at the cellular level.

Halofuginone--an inhibitor of collagen type I synthesis--prevents postoperative formation of abdominal adhesions

OBJECTIVE

To evaluate the effects of halofuginone, a specific inhibitor of collagen type I synthesis, on the postoperative formation of abdominal adhesions in rats.

SUMMARY BACKGROUND DATA

Postoperative adhesions remain the leading cause of small bowel obstruction in the Western world. Surgical trauma causes the release of a serosanguineous exudate that forms a fibrinous bridge between two organs. This becomes ingrown with fibroblasts, and subsequent collagen deposition leads to the formation of a permanent adhesion. Most of the drugs used have been clinically ineffective, and none has been specific to a particular extracellular matrix molecule. Therefore, there are serious concerns about the toxic consequences of interfering with the biosynthesis of other collagens, other matrix proteins, or vital collagen-like molecules.

METHODS

Adhesions were induced by scraping the cecum until capillary bleeding occurred. The adhesions were scored 21 days later. Halofuginone was either injected intraperitoneally (1 microg/25 g body weight) every day, starting on the day of operation, or added orally at concentrations of 5 or 10 mg/kg, starting 4 days before the operation. Collagen alpha1(I) gene expression was evaluated by in situ hybridization, total collagen was estimated by Sirius red staining, and collagen type III was detected by immunohistochemistry.

RESULTS

The adhesions formed between the intestinal walls were composed of collagen and were populated with cells expressing the collagen alpha1(I) gene. Regardless of the administration procedure, halofuginone significantly reduced the number and severity of the adhesions. Halofuginone prevented the increase in collagen alpha1(I) gene expression observed in the operated rats, thus reducing collagen content to the control level. In fibroblasts derived from abdominal adhesions, halofuginone induced dose-dependent inhibition of collagen alpha1(I) gene expression and collagen synthesis. Collagen type III levels were not altered by adhesion induction or by halofuginone treatment.

CONCLUSIONS

Upregulation of collagen synthesis appears to have a critical role in the pathophysiology of postoperative adhesions. Halofuginone, an inhibitor of collagen type I synthesis, could be used as an important tool in understanding the role of collagen in adhesion formation, and it may become a novel and promising antifibrotic agent for preventing postoperative adhesion formation.

Metaphyseal dissociation fractures of the proximal tibia. An analysis of treatment and complications

A study was done of 44 metaphyseal dissociation fractures of the proximal tibia in 42 patients (27 men and 15 women, aged 22 to 77 years; mean, 42 years). Follow-up ranged from 6 months to 4 years. There were 2 study groups: a retrospective group (group 1, 22 fractures) given a variety of treatments ranging from casts to dual plates, and a prospective group (group 2, 22 fractures) treated by combining external fixation and optional minimal internal fixation. There were 12 comminuted fractures in group 1 and 20 in group 2 (P < 0.01). All fractures eventually healed, with an average healing time in group 1 of 3.8 months, and 5.3 months in group 2. There was one delayed union in group 2. Results were graded from poor to excellent, based on pain, range-of-motion, and malunion. There were 6 poor and 4 fair results in group 1, and no poor and 3 fair results in group 2. Complications included 6 deep infections, 5 in group 1 (1 requiring a free-flap procedure); and 1 pin-tract infection resulting in septic arthritis in group 2. There were 7 gastrocnemius flaps required in group 1, and 1 in group 2. The results of this study suggest that patients treated with external fixation had better results with less infection and soft-tissue complications than those treated with conventional internal fixation.

Arthroscopic resection of dorsal ganglion of the wrist

In summary, arthroscopic resection is a reasonable approach for operative treatment of the dorsal ganglion. Arthroscopy is safe and addresses the key anatomic pathology. Recurrences to date have been equal to or less than with the open technique. Arthroscopic resection minimizes the surgical scar. Arthroscopy also permits evaluation of any intra-articular pathologic condition of either midcarpal or radiocarpal joints. In our series, 42% of patients had intra-articular pathologic conditions. In this study, these findings were recorded but not treated. Symptom resolution, therefore, correlated with ganglion resection and not with intra-articular pathologic conditions. We look forward to publishing our data in full at the completion of our study.