Ageing-related considerations for medication used in supportive care in cancer

Both randomized controlled trials (RCTs) and retrospective studies have shown that a comprehensive geriatric assessment (CGA) prior to a patient commencing systemic anti-cancer therapy (SACT) results in improved quality of life outcomes and is associated with a decreased risk of grade 3-5 toxicity; however, data are lacking in relation to adverse drug events (ADE) associated with supportive care medications. Supportive care medications are prescribed as prophylactic agents in a SACT regimen, for management of treatment related toxicity and for symptoms caused by the disease itself. While necessary, the commencement of SACT and supportive medications may cause, or exacerbate, a significant drug burden in older patients, some of whom may have existing comorbidities. For many medications, older adults are underrepresented in pharmacokinetic and pharmacodynamic modelling studies. In this article we will review ageing-related changes in pharmacokinetics and pharmacodynamics, as well as how these changes may impact supportive care medications. Additional considerations for prescribing these medications in older adults with cancer, such as polypharmacy, potentially inappropriate medications, drug-drug interactions, and anticholinergic burden, as well as ageing-related considerations and recommendations for supportive care medications commonly used in older adults with cancer are also reviewed.

Comprehensive pharmacological geriatric assessment compared to usual care in an older adult with cancer in the absence of polypharmacy

INTRODUCTION

Medication reconciliation as part of a Comprehensive Geriatric Assessment by a specialist pharmacist is a process that has been shown to be beneficial in terms of medication adherence in patients taking oral anticancer medication and potentially cost-effective in cancer patients. Medication review guidelines in older adults with cancer suggest using polypharmacy (≥ 5 medications) as an indication for medication review in older adults with cancer.

CASE REPORT

We present a case where a medication review as part of a Comprehensive Geriatric Assessment in the absence of polypharmacy resulted in two pharmacist interventions when standard care resulted in no intervention. A 71-year-old male prescribed capecitabine for rectal cancer had a medication reconciliation done as standard care before starting an oral anticancer medication. He then proceeded to get a medication review as part of a Comprehensive Geriatric Assessment and was deemed to have a potentially excessive anticholinergic burden and underprescribed gastro protection. This case is interesting as it occurred in a patient who would not have met the current inclusion criteria for a medication review as part of a Comprehensive Geriatric Assessment.

MANAGEMENT AND OUTCOME

As a result of the Comprehensive Geriatric Assessment, a letter was written to the patient's general practitioner, recommending a change to anti-depressant therapy to optimise anticholinergic burden, as well as introducing a proton-pump inhibitor upon completion of the Capecitabine protocol concurrent with radiotherapy, to confer gastro-protection against the antidepressant medication, as per the START criteria. Upon discharge from medical oncology, neither of the changes had been adopted by the patient's general practitioner. This highlights one of the challenges facing clinical pharmacists in an outpatient setting, where evidence-based recommendations are not always implemented as care transitions from tertiary to primary care.

CONCLUSION

Comprehensive Geriatric Assessment is a process that identifies potential issues in older adults with cancer that aren't identified with standard medication review. This is also evident for medication reviews as part of a Comprehensive Geriatric Assessment, and where resources allow, and recommendations are likely to be accepted, it should be offered to all older adults with cancer. Pharmacists are still faced with challenges in implementing recommendations from medication reviews, particularly in healthcare systems where pharmacist prescribing has yet to be introduced.

Setting a Patient-Driven Agenda for Cancer Research Priorities in Geriatric Oncology: A Qualitative Study

OBJECTIVES

This study aims to explore older adults' perceptions of priorities for research in cancer and hematological malignancies and proposes an agenda of patient-driven priorities for cancer care research in the field of geriatric oncology.

DATA SOURCES

Sixteen older adults (≥65 years) living with or after a diagnosis of cancer participated in a descriptive qualitative study. Participants were purposively recruited via a regional cancer center and cancer advocacy organizations. Semistructured telephone interviews explored participants' experiences of cancer and perceptions of priorities for future cancer-related research.

CONCLUSION

Participants reported positive experiences of cancer care. However, positive and negative experiences of information, symptoms, and support both within and beyond the hospital setting were highlighted. Forty-two research priorities in six thematic areas were identified: 1) recognition of the signs and symptoms of cancer; 2) research about cancer treatment; 3) assessment and management of comorbidities; 4) unmet needs of older adults living with and after cancer; 5) impact of COVID-19; and 6) impact on caregivers and family members of people living with and after cancer.

IMPLICATIONS FOR NURSING PRACTICE

The results of this study provide a basis for future priority-setting activities that are culturally and contextually sensitive to health care systems, resources, and needs of older adults living with and after cancer. Based on the findings of this study, we make recommendations for the development of interventions that can build awareness, capacity, and competence in geriatric oncology among cancer care professionals and consideration of the diverse needs of older adults in the development of interventions to address unmet information and supportive care needs.

Hospitalization due to adverse drug events in older adults with cancer: A retrospective analysis

INTRODUCTION

Geriatric oncology is a rapidly evolving field of practice, where comprehensive geriatric assessments (CGA) and multidisciplinary team (MDT) input have the potential to improve patient outcomes. Polypharmacy and potential drug interactions (PDI) have been associated with an increased risk of adverse outcomes in older adults with cancer, receiving systemic anti-cancer therapy (SACT). Our aim was to assess the incidence of unplanned hospitalization in older adults with cancer attending medical oncology outpatient clinics and to determine whether an unplanned hospitalization was potentially due to an adverse drug event (ADE).

MATERIALS AND METHODS

We identified patients who attended a medical oncology outpatient appointment from January 1 to March 31, 2018. Medical records were examined to identify any unplanned hospital admissions between the clinic visit date and three and six months after initial clinic visit. Incidences of unplanned hospitalization were assessed to determine if an ADE potentially occurred.

RESULTS

Data collected from 174 patients were analyzed. Over half (57%) were female, median age was 75 years and 53% had a favorable performance status. The most common malignancies were gastrointestinal (GI) at 31% (n = 54), breast 29% (n = 51), and genitourinary 22% (n = 37). Seventy-two percent had advanced disease (stage III/IV) and 61% had systemic therapy (SACT and hormonal therapy). Polypharmacy (≥5 medications) was observed in 77% of patients. The total number of admissions at six months was 99, with 55% of these potentially due to an ADE. On multivariate analysis breast cancer (p ≤0.001), lung cancer (p = 0.034), performance status (p ≤0.001), monochemotherapy (p = 0.012), polychemotherapy (p ≤0.001), and radiotherapy (p = 0.048) were independent predictors of unplanned hospitalization. Breast cancer (p = 0.008), GI cancer (p = 0.019), monochemotherapy (p = 0.039), and polychemotherapy (p ≤0.001) were independent predictors of unplanned hospitalization due to ADE on multivariate analysis.

DISCUSSION

We observed that older adults with cancer have a high risk of unplanned hospitalization due to ADE. Medication review as part of a CGA in newly diagnosed older adults with cancer by a clinical pharmacist is recommended. This may identify opportunities to avoid medications that could potentially lead to unplanned hospitalization.

Loneliness in older adults living with cancer: A scoping review of the quantitative and qualitative evidence on behalf of the International Society of Geriatric Oncology Nursing and Allied Health Interest Group

INTRODUCTION

Loneliness is common in older adults. Cancer and its treatments can heighten loneliness and result in poor outcomes. However, little is known about loneliness in older adults with cancer. Our objective was to provide an overview of the prevalence of loneliness, contributing factors, evolution during the cancer trajectory, impact on treatment, and interventions to reduce loneliness.

MATERIALS AND METHODS

We conducted a scoping review including studies on loneliness in adults with cancer aged ≥65. Original, published studies of any designs (excluding case reports) were included. A two-step screening process was performed.

RESULTS

Out of 8,720 references, 19 studies (11 quantitative, 6 qualitative, 2 mixed-methods), mostly from the United States, Netherlands, and/or Belgium, and most published from 2010, were included. Loneliness was assessed by the De Jong Gierveld Loneliness Scale, and the UCLA loneliness scale. Up to 50% of older adults felt lonely. Depression and anxiety were often correlated with loneliness. Loneliness may increase over the first 6-12 months during treatment. One study assessed the feasibility of an intervention aiming at reducing primarily depression and anxiety and secondarily, loneliness in patients with cancer aged ≥70 after five 45-min sessions with a mental health professional. No studies investigated the impact of loneliness on cancer care and health outcomes.

DISCUSSION

This review documents the scarcity of literature on loneliness in older adults with cancer. The negative impacts of loneliness on health in the general population are well known; a better understanding of the magnitude and impact of loneliness in older adults with cancer is urgently warranted.

Nutrition and quality status of dry-salted Hilsa (Tenualosa ilisha) in the retail market of Bangladesh

Hilsa (Tenualosa ilisha) is the national fish and geographical indication (GI) product of Bangladesh. Salting is the most suitable and oldest method of Hilsa preservation in Bangladesh. The quality of the traditionally salted dried fish in retail markets of Bangladesh is doubtful. This study aimed to assess the organoleptic, nutritional, biochemical, and safety attributes of dry-salted Hilsa. Organoleptic characteristics, nutritional (proximate composition, salt content), biochemical (pH, total volatile basenitrogen (TBV-N), thiobarbituric acid reactive substances (TBARS)), and safety attributes (total plate count, presence of coliform bacteria, Salmonella-Shigella, Staphylococcus, enteropathogenic Vibrio, and heavy metals: Hg, Cd, Cr, Pb, Ni, Cu, Zn) of dry-salted Hilsa was analyzed by standard methods. The product was organoleptically acceptable (defect point score: 2.65). Moisture (48.16%), protein (29.95%), lipid (4.36%), ash (17.53%), and salt (17.90%) content showed that the product was highly nutritious for human consumption. The pH, TVB-N, and TBARS values were 6.21, 83.25 mg N/100 g, and 4.18 mg MDA/Kg, respectively. Total plate count, coliform, Staphylococcus bacteria were 7.87×104 , 6.96×103 , and 2.70×103 CFU/g, respectively, indicating that the microbiological quality of the product was not satisfactory. However, Salmonella-Shigella and Enteropathogenic Vibrio were not found in the samples. Amounts of Hg, Cd, Cr, Pb, Ni, Cu, and Zn were 0.00005, 0.00004, 0.00112, 0.00102, 0.00134, 0.00167, and 0.00045 µg/g, respectively; which were within safety limit for human consumption. To improve the quality of dry-salted Hilsa, processors, sellers, and other stakeholders should be trained up properly.

Systemic anti-cancer therapy in older patients with gastrointestinal malignancies following comprehensive geriatric assessment: An age-based subgroup analysis

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Background: Comprehensive geriatric assessment (CGA) is recommended to inform treatment decisions in older patients with cancer. Patients ≥ 70 years are referred to the Geriatric Oncology and Liaison (GOAL) clinic in University Hospital Waterford, for a pre-treatment CGA, which includes assessment of mobility, cognitive, nutritional, functional, and psychological status, along with comprehensive geriatric pharmacological assessment. Informed treatment recommendations are made using CGA outcomes and risk assessed using the Cancer and Aging Research Group toxicity calculator. Limited information exists on treatment decisions based on age subgroups within the geriatric oncology population. Methods: Data from patients with gastrointestinal (GI) malignancies attending the GOAL clinic over a 3-year period to September 2022 were included. Patients ≥ 70 years with a G-8 (screening tool) score ≤14, and all patients aged ≥ 80 underwent CGA. An age-based subgroup analysis (< 80 vs ≥ 80) of systemic anti-cancer therapy (SACT) decisions was performed using the Chi-square test. Results: In total, 206 patients with GI malignancies were assessed, comprising 67 (33%) patients with gastroesophageal cancer, 40 (19%) with pancreaticobiliary and 92 (45%) with colorectal cancer. 40% of patients were ≥ 80 years (n = 83). The majority of patients had stage III/IV disease (82%, n = 168). Across all groups, 58% (n = 120) of patients were treated with SACT, comprising 70% of those < 80 (n = 86) and 41% (n= 34) of those ≥ 80. Across all stages (I-IV), patients ≥ 80 years were less likely to be treated with SACT compared to patients < 80 years (p < 0.01). There was no significant difference between age groups when comparing treatment intent (curative vs palliative) (p = 0.15). There was no significant difference between age groups for baseline dose reductions vs full dose (p = 0.18). Patients ≥ 80 years were less likely to receive polychemotherapy regimens in comparison with the < 80 subgroup (p < 0.01). Conclusions: Older patients with GI malignancies are a heterogeneous population. In the setting of a CGA, patients ≥ 80 years are less likely to receive SACT across any stage group, and are more likely to receive monochemotherapy regimens. The use of CGA ensures a considered and personalised approach to identify older adults most likely to benefit from active treatment and those where best supportive care alone is more appropriate.

Prevalence of abnormalities on cardiac MRI in unselected patients after recovery from acute SARS-CoV-2 infection and correlation with markers of immunity and coagulation: the SETANTA study

Background

Previous studies have reported ongoing cardiac inflammation as assessed by cardiac magnetic resonance imaging (CMR) in a significant proportion of patients several months after recovery from SARS-CoV-2 infection, many of whom had no or minimal symptoms at the time of infection.

Purpose

The aim of SETANTA was to investigate the prevalence of cardiac abnormalities by CMR in unselected patients in Ireland after acute SARS-CoV-2 infection and the correlation with immunological response and biomarkers of coagulation.

Methods

This was a prospective, observational, community-based study (clinicaltrials.gov identifier NCT04823182). Consecutive patients recovered from recent SARS-CoV-2 infection at 3 primary care sites were invited to participate. Key inclusion/exclusion criteria and outcomes of interest are shown in Figure 1.

Results

100 participants were enrolled (Feb-Sept 2021) at a median of 188 (IQR, 125, 246) days after positive SARS-CoV-2 swab. At index infection, 18% and 35% reported severe and moderate symptoms, respectively; 14% were hospitalized; 3% were admitted to intensive care for ventilatory support. At enrolment, 83% had ongoing symptoms. 85% had detectable SARS-CoV-2 antigens. CMR and laboratory findings are shown in Figure 1.

Conclusion

Among an unselected cohort of patients recovered from acute SARS-CoV2 infection, we report a low prevalence of cardiac abnormalities by CMR, despite a high prevalence of moderate/severe symptoms at presentation and a high prevalence of persistent symptoms. Correlation with biomarkers of immunity and coagulation will be available at ESC 2022.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): WomenAsOne

International trends in cancer incidence in middle-aged and older adults in 44 countries

OBJECTIVE

We examine international incidence trends of lung, colorectal, prostate, and breast cancers, as well as all cancers combined excluding non-melanoma skin cancer (NMSC) in adults aged 50 and older, over a fifteen-year period using data from 113 high quality population-based cancer registries included in the Cancer in Five Continents (CI5) series and NORDCAN.

MATERIALS AND METHODS

We calculated annual incidence rates between 1998 and 2012 for ages 50-64, 65-74, and 75+, by sex and both sexes combined. We estimated average annual percentage change (AAPC) in rates using quasi-Poisson regression models.

RESULTS

From 1998 to 2012, incidence trends for all cancers (excluding NMSC) have increased in most countries across all age groups, with the greatest increase observed in adults aged 75+ in Ecuador (AAPC = +3%). Colorectal cancer incidence rates increased in the majority of countries, across all age groups. Lung cancer rates among females have increased but decreased for males. Prostate cancer rates have sharply increased in men aged 50-64 with AAPC between 5% and 15% in 24 countries, while decreasing in the 75+ age group in 21 countries, by up to -7% in Bahrain. Female breast cancer rates have increased across all age groups in most countries, especially in the 65-74 age group and in Asia with AAPC increasing to 7% in the Republic of Korea.

CONCLUSIONS

These findings assist with anticipating changing patterns and needs internationally. Due to the specific needs of older patients, it is urgent that cancer systems adapt to address their growing number.

Aeromedical retrieval diagnostic trends during a period of Coronavirus 2019 lockdown

Background

Little is known on the trends of aeromedical retrieval (AR) during social isolation.

Aim

To compare the pre, lockdown, and post‐lockdown AR patient characteristics during a period of Coronavirus 2019 (COVID‐19) social isolation.

Methods

An observational study with retrospective data collection, consisting of AR between 26 January and 23 June 2020.

Results

There were 16 981 AR consisting of 1983 (11.7%) primary evacuations and 14 998 (88.3%) inter‐hospital transfers, with a population median age of 52 years (interquartile range 29.0–69.0), with 49.0% (n = 8283) of the cohort being male and 38.0% (n = 6399) being female. There were six confirmed and 230 suspected cases of COVID‐19, with the majority of cases (n = 134; 58.3%) in the social isolation period. As compared to pre‐restriction, the odds of retrieval for the restriction and post‐restriction period differed across time between the major diagnostic groups. This included, an increase in cardiovascular retrieval for both restriction and post‐restriction periods (odds ratio (OR) 1.12, 95% confidence interval (CI) 1.02–1.24 and OR 1.18 95%, CI 1.08–1.30 respectively), increases in neoplasm in the post restriction period (OR 1.31, 95% CI 1.04–1.64) and increases for congenital conditions in the restriction period (OR 2.56, 95% CI 1.39–4.71). Cardiovascular and congenital conditions had increased rates of priority 1 patients in the restriction and post restriction periods. There was a decrease in endocrine and metabolic disease retrievals in the restriction period (OR 0.72, 95% CI 0.53–0.98). There were lower odds during the post‐restriction period for retrievals of the respiratory system (OR 0.78, 95% CI 0.67–0.93), and disease of the skin (OR 0.78, 95% CI 0.6–1.0). Distribution between the 2019 and 2020 time periods differed (P < 0.05), with the lockdown period resulting in a significant reduction in activity.

Conclusion

The lockdown period resulted in increased AR rates of circulatory and congenital conditions.

Botulism in injecting drug users, Dublin, Ireland, November-December 2008

In November and December 2008, six cases of suspect wound botulism were reported in heroin injecting drug users, all residents in Dublin, Ireland. Patients were aged between 23-42 years of age; four cases were male; one patient died shortly after admission. The patients presented to four different hospitals across the city. Botulism in injecting drug users in Ireland was last reported in 2002.

Botulism in injecting drug users, Dublin, Ireland, November-December 2008

In November and December 2008, six cases of suspect wound botulism were reported in heroin injecting drug users, all residents in Dublin, Ireland. Patients were aged between 23-42 years of age; four cases were male; one patient died shortly after admission. The patients presented to four different hospitals across the city. Botulism in injecting drug users in Ireland was last reported in 2002.

First isolation and report of clusters of Clostridium difficile PCR 027 cases in Ireland

We report the first documentation of C. difficile 027 in Ireland from a patient with diarrhoea transferred from a hospital in the United Kingdom (UK). In addition, we report two clusters of C. difficile ribotype 027 in two hospitals in Ireland.

P53 expression is associated with malignant potential in xenograft tissues of a fibrosarcoma mouse model

BACKGROUND

The expression of wild-type and mutant p53 was studied in two fibrosarcoma cell lines in a mouse xenograft model.

MATERIALS AND METHODS

Human cell lines HT1080 and Hs913(D)T were implanted in athymic mice via intramuscular (i.m.) or subcutaneous (s.c.) routes. After eight weeks, liver, lung and primary inoculation sites were harvested. Sections were stained using two methods: a) haematoxylin and eosin to detect tumour at implantation site, liver and lung; b) immunohistochemistry using monoclonal antibodies to detect expression of wild-type (wt) and mutant p53.

RESULTS

Both cell lines had similar implantation rates via either route but Hs913(D)T had a higher metastatic rate than HT1080. The Hs913(D)T cells exhibited greater expression of mutant and wild-type p53 than the HT1080 cells.

CONCLUSION

The expression of wild-type and mutant p53 is associated with a cell line of greater malignant potential. The inoculation route does not affect primary tumour uptake or metastatic rate.

Molecular epidemiologic investigation of tuberculosis in an area of increasing incidence in inner-city Dublin

In 2002 the tuberculosis (TB) incidence in Dublin was 13.1 cases per 100,000 persons. In inner city Dublin, the TB incidence was > 20 per 100,000 persons. TB notification rates have remained elevated. The objective of the study is to characterize the population affected in this inner city area and to investigate transmission patterns and potential risk factors for TB disease. This hospital-based molecular epidemiologic study included all culture positive cases of TB between January 1, 1998 and December 31, 2002 from the Mater Misericordiae University Hospital. 142 cases were analyzed. 84 (59%) had clustered Mycobacterium tuberculosis (Mtb) isolates, 58 (41%) had unique isolates by molecular typing. There were 13 clusters; the largest two clusters had 26 cases each, one linked to pubs, the other linked through family contact. In multivariate logistic regression analysis, birth in Ireland, pulmonary TB, and younger age were significantly associated with recent transmission. Dublin is a developed city with persistent areas of high rates of TB in the native population. Despite a functioning public health system and lack of predisposing risk factors such as HIV, immigration, and extreme poverty, TB can persist in pockets of the younger, native population.

Voriconazole in the treatment of fungal osteomyelitis of the orbit in the immunocompromised host

Scedosporium apiospermum is an uncommon cause of fungal infection in the orbit and sinus. Morbidity and mortality rates in immunocompromised patients are high. We review the first case of Scedosporium apiospermum orbito-sinus infection that was successfully treated with the new antifungal agent voriconazole. We highlight the efficacy of this drug, particularly in the treatment of osteomyelitis of the orbit and sinus, which may lead to an improvement in survival rates after Scedosporium infection.

Intermittent intravenous administration of the bisphosphonate ibandronate prevents bone loss and maintains bone strength and quality in ovariectomized cynomolgus monkeys

Using a clinically relevant regimen, this study investigated the effects of treatment with ibandronate, a highly potent nitrogen-containing bisphosphonate, on bone loss, biochemical markers of bone turnover, densitometry, histomorphometry, biomechanical properties, and bone concentration in aged ovariectomized monkeys. Sixty-six female cynomolgus monkeys, aged 9 years and older, were ovariectomized (OVX) or sham operated. Intravenous (iv) bolus injections of ibandronate at 10, 30, or 150 microg/kg or placebo were administered at 30-day intervals (corresponding to intervals of 3 months in humans), starting at OVX, for 16 months. OVX significantly decreased bone mass at the lumbar spine, proximal femur, femoral neck, and radius and increased bone turnover in a time-dependent manner, as assessed by dual energy X-ray absorptiometry, peripheral quantitative computed tomography, or histomorphometry. Ibandronate iv bolus injections administered at 30 microg/kg every 30 days prevented osteopenia induced by estrogen depletion. OVX-induced increases in bone turnover (as determined by activation frequency, bone formation rate, and biochemical markers of bone turnover, including urinary N-telopeptide and deoxypyridinoline excretion and serum values for osteocalcin and bone-specific alkaline phosphatase) were suppressed on treatment, and bone mass, architecture, and strength were preserved at clinically relevant sites. Treatment with high-dose (150 microg/kg/dose) iv bolus injections of ibandronate further increased bone mass and improved bone strength at both the spine and femoral neck, without adversely affecting bone quality. In contrast, treatment with a 10 microg/kg/dose only partially prevented the OVX-induced effects. These data support the potential for the long-term administration of ibandronate by intermittent iv bolus injections in humans to prevent osteoporosis and improve bone quality at clinically relevant sites.

Abdominal aortic calcific deposits are an important predictor of vascular morbidity and mortality

BACKGROUND

The impact of abdominal arterial calcific deposits on the prediction of cardiovascular disease (CVD) over a long follow-up interval deserves greater scrutiny.

METHODS AND RESULTS

Lateral lumbar radiographs were studied as a predictor of incident coronary heart disease (CHD), CVD, and CVD mortality in 1049 men and 1466 women (mean age, 61 years) who were followed from 1967 to 1989. Anterior and posterior wall calcific deposits in the aorta at the level of the first through fourth lumbar vertebrae were graded according to increasing severity using a previously validated rating scale for abdominal aortic calcium (AAC) that ranges from 0 to 24 points. There were 454 cases of CHD, 709 cases of CVD, and 365 CVD deaths. Proportional hazards logistic regression was used to test for associations between AAC and later events after adjustment for age, cigarette use, diabetes mellitus, systolic blood pressure, left ventricular hypertrophy, body mass index, cholesterol, and HDL cholesterol. In comparisons with the lowest AAC tertile, the multivariate age-adjusted relative risks (RR) for CVD were increased in tertile 2 (men: RR, 1.33; 95% confidence interval [CI], 1.02 to 1.74; women: RR, 1.25; 95% CI, 0.95 to 1.65) and tertile 3 (men: RR, 1.68; 95% CI, 1.25 to 2.27; women: RR, 1.78; 95% CI, 1.33 to 2.38). Similar results were obtained with CHD and CVD mortality.

CONCLUSIONS

AAC deposits, detected by lateral lumbar radiograms, are a marker of subclinical atherosclerotic disease and an independent predictor of subsequent vascular morbidity and mortality.

Central venous blood culture: a useful test for catheter colonisation?

OBJECTIVE

To evaluate the widespread practice of using qualitative culture of venous blood taken through central venous catheters (CVCs) as a means of diagnosing catheter colonisation in situ.

DESIGN

A prospective clinical study.

PATIENTS

Three hundred fifty-one CVCs were inserted into 228 critically ill patients.

INTERVENTIONS

Prior to CVC removal, blood was taken for qualitative culture from the CVC and a peripheral site. All catheter tips underwent semi-quantitative analysis of bacterial colony count [1].

MEASUREMENTS AND RESULTS

One hundred eighteen (33.6%) CVCs were found to be colonised on removal. A positive central blood culture had a sensitivity and specificity of 50.8% and 78.9% when compared with the 'gold standard' of catheter tip culture. This gives a positive predictive value of 47.7% and a negative predictive value of 76.5%. The sensitivity and specificity of a positive peripheral blood culture were 41.5% and 77.7% with positive and negative predictive values of 48.8% and 72.9%, respectively. When only those catheters removed because of systemic sepsis (n = 139) were considered, a positive central blood culture had a sensitivity of 58.8% and a specificity of 69.3%.

CONCLUSION

Our results indicate that the use of central blood culture confers a small advantage in sensitivity compared with peripheral blood culture. This advantage was further improved by only considering the catheters removed because of systemic sepsis but at the cost of a loss of specificity. Qualitative blood culture is a poor tool for the diagnosis of in-situ CVC colonisation.

HIV associated culture proved tuberculosis has increased in north central London from 1990 to 1996

OBJECTIVES

To examine rates of culture proved tuberculosis in HIV infected patients in three specialist centres in north central London.

METHODS

Cases of tuberculosis in patients with previously documented HIV infection from 1990 to 1996 were identified retrospectively from microbiological/clinical records at Chelsea and Westminster, St Mary's, and University College London Hospitals.

RESULTS

Between 1990 and 1996 202 cases of culture proved tuberculosis were identified at the three centres. Of these, 132/202 (65.3%) occurred in homosexual/bisexual men, 41/202 (20.3%) were in patients with heterosexual contact in sub-Saharan Africa, and 29/202 (14.4%) were in "others." Overall 148/202 (73.3%) had pulmonary tuberculosis. The total number of HIV infected individuals seen at the three centres increased from 4298 in 1990 to 5048 in 1996. Rates of tuberculosis in the three centres increased from 0.46% in 1990 to 0.83% in 1996. Part of this increase was due to an increase in tuberculosis among Africans from 1993 to 1996.

CONCLUSIONS

Rates of HIV associated tuberculosis increased in these three centres in north central London between 1990 and 1996. In part this was due to an increase in the number of African patients with HIV infection attending the three centres. In addition, there was circumstantial evidence of recent transmission among homosexual men with HIV infection. Prospective "real time" surveillance of tuberculosis in HIV infected patients is needed in order to detect case clustering and to improve tuberculosis control.

Antiseptic-bonded central venous catheters and bacterial colonisation

This study was undertaken to evaluate the impact of chlorhexidine/silver sulphadiazine-bonded catheters on the incidence of colonisation and catheter-related sepsis in critically ill patients. Threehundred and fifty-one catheters were inserted into 228 patients during the study period, 174chlorhexidine/silver sulphadiazine-bonded catheters and 177 standard catheters. Indications for catheter removal were: death, clinical redundancy and clinical evidence of local or systemic infection. All catheter tips were sent to the microbiology laboratory for semiquantitative analysis of bacterial colony count. Seventy-one (40.2%) of the standard catheters and 47 (27.2%) of the antiseptic-bonded catheters were found to be colonised on removal (p < 0.01). Eight cases (4.7%) of catheter-related sepsis were associated with standard catheters and three cases (1.7%) with antiseptic-bonded catheters, however, this reduction was not statistically significant. Our results indicate that the use of antiseptic-bonded catheters in critically ill patients significantly reduces the incidence of bacterial colonisation.

Critically sized osteo-periosteal femoral defects: a dog model

A 21-mm defect was created in 1 femoral diaphysis each of 15 dogs. Periosteum as well as a cylinder of bone was removed, and the defect was stabilized with a bone plate. Twelve of the defects were filled with an equal volume of autogenous cancellous bone harvested from the ipsilateral ilium. Three defects were left untreated. Cranial to caudal radiographs were taken postoperatively and every 4 weeks for 16 weeks. The radiographs were evaluated for healing using two ordinal scales. At 16 weeks, the dogs were euthanized and the femurs harvested for biomechanical testing and histologic evaluation. Both operated and contralateral not operated femurs were mechanically tested to failure in torsion, and load at failure and stiffness were calculated. All dogs tolerated the procedure well, and were using the operated limb within 1 or 2 days postoperatively. There were no complications noted during the 16 weeks of the study. Unfilled defects did not heal and became atrophic nonunions. The defects filled with autogenous cancellous bone healed in a consistent pattern of consolidation, incorporation, and remodeling, with uniform increases of both ordinal scales used. The femoral cortex opposite the bone plate demonstrated most mature remodeling, evident both radiographically as well as histologically. Unoperated femurs failed at 13.61 +/- 3.88 N-m and grafted femurs failed at 2.96 +/- 1.3 N-m, which was 23% of the measurement of the unoperated femur. Relative stiffness of the unoperated femurs was 5974 +/- 4316 N-m2/radian, and grafted femurs had a relative stiffness of 642 +/- 561 N-m2/radian, which was 10.4% of the measurement of unoperated femur. This model proved to be a critically sized defect, which when left unfilled resulted in an atrophic nonunion, and when filled with cancellous bone resulted in a consistent healing pattern.

Nasopharyngeal flora in HIV seropositive men who have sex with men

OBJECTIVES

To assess, in men who were infected with the human immunodeficiency virus (HIV) and who identified themselves as having had sex with men; the nasopharyngeal prevalence of Neisseria gonorrhoeae, N meningitidis, Corynebacterium diphtheriae, and candida species; oral sexual behaviour; the relation between oral flora and oral sexual behavior.

METHOD

Nasopharyngeal swabs were taken from HIV seropositive men for culture. The men were also asked to complete a self administered questionnaire.

RESULTS

390 men were recruited; 286 (73.3%) provided nasopharyngeal samples and questionnaires; 41 (10.5%) provided nasopharyngeal samples only; 63 (16.2%) provided questionnaires only. From the 327 nasopharyngeal samples N meningitidis was cultured in 49 (15%) and candida species in 165 (50.5%). Cultures for N gonorrhoeae and C diphtheriae were all negative. Data from the 349 completed questionnaires indicated that 285 men were practising oro-penile sex, over 90% did not consistently use condoms; 150 men were practising oro-anal sex, one used dental dams. In those providing both nasopharyngeal samples and sexual behaviour data meningococcal carriage was identified in 40 (17.5%) of the 228 men practising receptive oro-penile sex, compared with one (2.3%) of the 43 non-practisers (p < 0.025); in 21 (20%) of the 105 men practising insertive oro-anal sex, compared with 17 (12.5%) of the 136 non-practisers (p = 0.12). No correlation was identified between yeast carriage and oro-genital sex.

CONCLUSION

Oro-genital sex, usually without barrier protection, is common among HIV infected men who have sex with men. It appears to be associated with increased meningococcal carriage but is autonomous to candida species isolation. Routine screening for nasopharyngeal N gonorrhoeae is not deemed necessary.

Von Willebrand disease: a nursing perspective

Von Willebrand disease, caused by a deficiency or abnormality of von Willebrand factor, is the most common hereditary bleeding disorder, occurring in approximately 1% of the population. This article is intended to raise the level of awareness in the health care community and define the nurse's role in recognizing the clinical presentation of this underdiagnosed bleeding disorder.

Association of insulin-like growth factor-I with body composition, weight history, and past health behaviors in the very old: the Framingham Heart Study

OBJECTIVES

We examined correlates of insulin-like growth factor-I (IGF-I), an indicator of growth hormone levels, to identify factors associated with higher levels of IGF-I in old age.

DESIGN

Nested study of cross-sectional correlates and early-life predictors of IGF-I level.

SETTING

A longitudinal cohort study, the Framingham Heart Study.

PARTICIPANTS

A total of 790 men and women (mean age 78.5, range 72-94), who had weight, waist and hip circumferences measured at the time of IGF-I measurement.

MEASUREMENTS

Association of IGF-I with weight, fat distribution, functional status, nutritional indicators, and past health behaviors was assessed. We also examined IGF-I in relation to body composition derived from dual energy X-ray absorptiometry.

RESULTS

IGF-I levels declined with age in both men and women. However, low IGF-I did not show expected associations with low lean mass and increased body fat. Current functional status and grip strength were not associated with IGF-I Low IGF-I was associated with weight loss in men; the strongest associations were with indicators of poorer nutritional status in both men and women. Levels of IGF-I in old age did not vary by past health behaviors.

CONCLUSION

Although IGF-I declined with age, these data from the Framingham Heart Study did not show expected cross-sectional associations of weight, body fat, and lean mass. The strongest associations were between IGF-I and nutritional indicators. These results suggest caution may be warranted with regard to use of IGF-I as an indicator of growth hormone.

Are risk factors for patellofemoral and tibiofemoral knee osteoarthritis different?

OBJECTIVE

To determine whether patellofemoral (PF), tibiofemoral (TF), and combined patterns of knee osteoarthritis (OA) differ in their strengths of associations with any of the known risk factors for knee OA, and especially to evaluate whether body mass index (BMI) correlates with all 3 patterns, or only with tibiofemoral disease, as previously suggested.

METHODS

We obtained anteroposterior and lateral knee radiographs on 608 participants at the 22nd biennial examination of the Framingham cohort study (1992-3). The presence or absence of OA in the TF and PF compartments of each knee was scored, and subjects were classified on the basis of the pattern of compartmental involvement in their 2 knees. The strength of association of age, sex, BMI, chondrocalcinosis, and knee injury was computed for PF, TF, and combined pattern of knee OA using multiple logistic regression.

RESULTS

The mean age and BMI of the sample were 80.7 yrs (SD 5.0) and 25.4.kg-2 (SD 3.7), respectively. PF, TF, and combined patterns of knee OA were present in 5.3, 23.0 and 19.7%, respectively. Elevated BMI was a risk factor for all 3 patterns of disease (adjusted OR for highest vs lowest tertile of BMI 3.7, 1.9, and 7.0 for PF, TF, and combined pattern, respectively). Risk factor profiles were broadly similar for TF and PF OA, with the possible exception of knee injury in men (adjusted OR = 2.0 for PF, 3.7 for TF OA). Risk factors were generally more strongly associated with the combined pattern of OA.

CONCLUSION

Obesity is an important risk factor for PF, TF, and combined patterns of knee OA. The relationships of these patterns with the risk factors investigated here appear similar and are strongest for the combined pattern.

Apoliprotein B polymorphism: Application to monitoring early bone marrow transplantation in Saudi population

Seventy-three unrelated Saudi individuals and seven consecutive bone marrow transplant donor-recipient pairs were studied to characterize and determine the frequency of 3' apolipoprotein B alleles by polymerase chain reaction. The samples analyzed were either peripheral blood or bone marrow aspirates. Eleven different alleles were detected. The index of heterozygosity was 0.66. Apolipoprotein B analysis was informative in 57% of the studied donor-recipient pairs. Engraftment was detected as early as day three post-transplantation. The threshold of detection of this allele was up to 0.01x106/ml. Mixed chimerism of the order of 1% could be detected. We concluded that apolipoprotein B is a highly polymorphic allele among the Saudi population and this makes the region a useful marker for monitoring engraftment following allogeneic bone marrow transplantation.

Reduced induction of P53 protein by gamma-irradiation in ataxia telangiectasia cells without constitutional mutations in exons 5, 6, 7, and 8 of the p53 gene

Ataxia telangiectasia (AT) is an autosomal recessive disease of childhood with several phenotypic characteristics. One of the hallmarks of this syndrome is its hypersensitivity to ionizing radiation, which is believed to be due to defects in DNA repair/processing. In addition to radio-resistant DNA synthesis, both fibroblasts and lymphoblastoid cell lines derived from these patients have been shown to have an impaired G1 arrest and prolonged G2 accumulation of cells indicating a defect in the regulation of cell cycle after irradiation. Since the (tumor suppressor) p53 protein has been reported to participate in the regulation of G1 arrest after irradiation, the possibility of p53 gene mutation and deregulating cell cycle in AT needed to be examined. We used the PCR amplification and DNA sequencing methods to detect mutations in the hypermutable exons (5-8) of germline p53 in fibroblast cells from 3 AT homozygotes. No mutation was found in any of these exons. In order to determine the role of the p53 protein in G1 arrest, its levels were measured before and after gamma-irradiation by flow cytometry in both AT and normal cells. Radiation-induced p53 protein levels in the AT cells varied from 6 to 60% compared to the normal cells, indicating a reduced induction of the protein in AT. These results suggest that mutation in the AT gene affects the p53 induction by irradiation and may, thus, alter the cell cycle regulation in the AT patients.

A PCR analysis of bcl-2 gene rearrangement in nodal and extranodal non-hodgkins-lymphoma (nhl) - some unusual observations in saudi patients

Non-Hodgkin's lymphoma (NHL) is the most common malignancy referred to our institute which is the largest tertiary referral cancer centre in Saudi Arabia, The proportion of follicular low grade NHL appears to be extremely small in this population (<5% of all NHL). To date, there is no data available regarding any correlation between bcl-2 gene rearrangement and different cell types of nodal and extranodal NHLs in Saudi patients. We used a sequential polymerase chain reaction (PCR) technique to determine the frequency of bcl-2/J(H) recombination occurring via the major breakpoint region (mbr) in 16 GI tract NHLs including 4 MALT lymphomas and 13 follicular (nodal) NHLs. The results showed only 2/13 (15%) nodal follicular NHLs with bcl-2/J(H) fusion DNA whereas 9/16 (56%) of the extranodal NHLs with at least 2 of them exhibiting MALT characteristics were positive for the bcl-2 gene rearrangement. A breakdown of the proportion of extranodal NHLs of different cell types showing bcl-2 rearrangement via mbr was as follows: 5/8 diffuse large non-cleaved cell (DLNCC), 1/3 diffuse small cleaved cell (DSCC), 1/1 follicular small cleaved cell (FSCC) and 2/4 MALTs. The PCR amplified bcl-2/J(H) fusion DNA from 5 randomly selected tumors (2 MALTs, 1 DLNCC, 1 DSCC and 1 nodal follicular lymphoma) were cloned and sequenced. All 5 of them showed different bcl-2/J(H) N-regions confirming the clonality of each tumor sample. The data indicating a very low incidence of bcl-2 translocation in nodal follicular NHLs and a surprisingly high incidence of it in extranodal NHLs are intriguing, and quite contrary to the findings in Western patients. These unusual observations warrant further studies and may suggest that different genetic events are involved in the development of extranodal NHLs including MALT and follicular center-cell NHLs in Saudi patients.

A molecular study of EBV DNA and p53 mutations in nasopharyngeal carcinoma of Saudi Arab patients

Tumor biopsies obtained from 25 Saudi Arab patients with nasopharyngeal carcinoma (NPC) were examined for the presence of Epstein-Barr virus (EBV) DNA detected by the polymerase chain reaction (PCR) and for the incidence of p53 mutations screened by a combination of PCR, single strand conformation polymorphism (SSCP) and PCR-restriction fragment length polymorphism (PCR-RFLP). DNA sequencing was carried out to confirm the occurrence of p53 mutation. While 92% of the tumor specimens were found to carry EBV DNA, only 1/25 showed the incidence of a homozygous mutation at codon 248 of the p53 gene. The data showed that despite a high association of EBV infection with Saudi NPC, the frequency of p53 mutations was very low. Our results are consistent with the worldwide observation of infrequent p53 mutations in NPC.

A comparison of antimicrobial sensitivities of urinary pathogens for the years 1980 and 1990

Urinary tract infection is a major cause of morbidity in both the hospital and community which often requires empirical therapy. We have retrospectively studied laboratory diagnosed urinary tract infections for the years 1980 and 1990 to document the common pathogens and antimicrobial susceptibility patterns. In 1990 a significantly lower proportion of specimens yielded Proteus sp. or Klebsiella sp. than was the case in 1980. This was true of specimens from both the hospital and the community. There was an increase in the proportion of specimens yielding Pseudomonas sp. and coagulase negative Staphylococci (CNS). Significant changes in the antimicrobial susceptibility of urinary pathogens are also noted. In particular a greater proportion of isolates from the community were sensitive to cephalothin in 1990, while fewer isolates were sensitive to nalidixic acid and gentamicin. A greater proportion of isolated from hospital practice were sensitive to ampicillin, to cephalothin and to trimethoprim in 1990 while fewer isolates were sensitive to gentamicin. In relation to nitrofurantoin no significant change was noted. In respect of isolates from both community and hospital practice the agents ofloxacin, co-amoxiclav (not available in 1980) and gentamicin are those which are most consistently active.