Outcomes from a proof-of-concept specialist lymphoedema clinic in the community

The Health and Safety Execultive lymphoedema model of care was published in 2018 highlighting the lack of dedicated lymphoedema services in Ireland. This led to the introduction of a proof-of-concept primary care specialist lymphoedema clinic. The clinic was responsible for all patients from their county. A comprehensive dataset was gathered which included the patient's history for 1 year prior to their presentation at clinic and then 6 monthly. A quality of life tool (LymQoL) and a patient satisfaction survey were completed. Completed 1-year data showed a significant reduction in GP and public health nurse visits as well as a reduction in the occurrence of cellulitis and associated hospital admissions. All areas of quality of life were improved and patient satisfaction was either excellent (89%) or very good (11%). The 1-year findings strongly support the roll-out of specialist clinics to all regional health areas.

115 BARRIERS AND FACILITATORS TO DOCTORS DEPRESCRIBING FALL-RISK INCREASING DRUGS IN OLDER ADULTS

Background

Some medicines are associated with falls in older adults and have been classified as Fall-Risk Increasing Drugs (FRIDs). Deprescribing FRIDs is one of several possible preventive measures to reduce falls risk [1]. The aim of this qualitative study was to explore the barriers and facilitators to doctors deprescribing FRIDs in hospitals.

Methods

Doctors, who were experienced in caring for older patients, were interviewed individually, directed by an interview guide, at a large teaching hospital. Thematic analysis of transcribed audio recordings was undertaken in NVivo 12.

Results

A total of eighteen doctors participated in the study. Barriers and facilitators were classified into three categories: factors related to the care setting, to doctors and to patients. Incomplete patient medical records, limited time during inpatient stay, poor communication between care providers, and difficulties following up patients after discharge were major barriers to deprescribing in hospital. Doctors’ barriers included concerns about consequences and reluctance changing medications initiated by other prescribers. Acute illness or resistance to change were patient-related barriers to deprescribing. Facilitators included doctors’ awareness of the importance of deprescribing FRIDs, the ability to monitor patients during their inpatient stay, the use of electronic medical records, and support from other healthcare professionals e.g. clinical pharmacists.

Conclusion

Deprescribing FRIDs in older adults is challenging. Interventions based on identified facilitators, such as improved communication between prescribers, enhanced documentation using electronic medical records, and the support of team members with expertise in medication review, might enhance the feasibility of deprescribing.

Reference

1. Seppala LJ et al. EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research. Drugs Aging. 2019; 36(4): 299–307.

237 POTENTIALLY INAPPROPRIATE PRESCRIBING IN HOSPITALISED FRAIL OLDER ADULTS: DEVELOPMENT OF THE OPTI-3S PRELIMINARY STATEMENTS

Background

Few assessment criteria exist for Potentially Inappropriate Medications (PIMs) in the hospital setting. This study aims to develop the preliminary statements of OPTI-3S, criteria for optimising medicines by stopping, stepping down or switching to safer alternatives. These are designed to be of value to clinical practitioners in the routine care of hospitalised, frail older adults.

Methods

A systematic literature review was conducted in the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, CINAHL, EMBASE and Scopus (2010-2021). Search terms included the concepts of inappropriate prescribing, deprescribing and the target population (e.g. older, frail, hospitalized). This was supplemented with a PubMed focused search (2010-2021) using key words pertaining to the index diseases/conditions or inappropriate medications. The structured reviews included clinical based guidelines, PIMs lists, systematic/non-systematic reviews, or clinical/observational trials that assessed safe and/or effective use of medications in older adults. The preliminary statements were then drafted based on the available relevant evidence.

Results

Searches yielded ~1500 articles. These were included in structured reviews, yielding a total of 109 initial statements across seven physiological systems, and one patient-centred point of care (perioperative care). In addition to detailed PIMs statements (n=98), 11 statements address clinically important Potential Prescribing Omissions (PPOs) (e.g. anticoagulant underdosing) and altered blood pressure and glycaemic targets. Uniquely for criteria of this kind, 23 statements suggest PIMs be considered based on the different frailty levels, according to the Clinical Frailty Scale. 11/98 PIMs statements concern prescribing cascades and suggest tapering regimens for six inappropriate medication classes (e.g. antipsychotics, benzodiazepines). Several statements address medication appropriateness in other frailty related circumstances (e.g. non-compliance, overlapping co-morbidities, feeding tube incompatibility, pill burden/ polypharmacy).

Conclusion

Literature provides a large body of evidence to support prescribing optimization. This has been distilled into consensus-based statements, which should guide hospital-based health care professionals caring for frail older adults.

A universal test for gravitational decoherence

Quantum mechanics and the theory of gravity are presently not compatible. A particular question is whether gravity causes decoherence. Several models for gravitational decoherence have been proposed, not all of which can be described quantum mechanically. Since quantum mechanics may need to be modified, one may question the use of quantum mechanics as a calculational tool to draw conclusions from the data of experiments concerning gravity. Here we propose a general method to estimate gravitational decoherence in an experiment that allows us to draw conclusions in any physical theory where the no-signalling principle holds, even if quantum mechanics needs to be modified. As an example, we propose a concrete experiment using optomechanics. Our work raises the interesting question whether other properties of nature could similarly be established from experimental observations alone—that is, without already having a rather well-formed theory of nature to make sense of experimental data.

Whether gravity causes decoherence is a natural question on the way of making quantum physics compatible with the theory of gravity. Here the authors devise a general method to estimate gravitational decoherence in any no-signalling physical theory, which holds even if quantum mechanics would be modified.

Comparison of non-invasive and invasive blood pressure in aeromedical care

Blood pressure measurement is an essential physiological measurement for all critically ill patients. Previous work has shown that non-invasive blood pressure is not an accurate reflection of invasive blood pressure measurement. In a transport environment, the effects of motion and vibration may make non-invasive blood pressure less accurate. Consecutive critically ill patients transported by a dedicated aeromedical retrieval and critical care transfer service with simultaneous invasive and non-invasive blood pressure measurements were analysed. Two sets of measurements were recorded, first in a hospital environment before departure (pre-flight) and a second during aeromedical transport (in-flight). A total of 56 complete sets of data were analysed. Bland-Altman plots showed limits of agreement (precision) for pre-flight systolic blood pressure were -37.3 mmHg to 30.0 mmHg, and for pre-flight mean arterial pressure -20.5 mmHg to 25.0 mmHg. The limits of agreement for in-flight systolic blood pressure were -40.6 mmHg to 33.1 mmHg, while those for in-flight mean blood pressure in-flight were -23.6 mmHg to 24.6 mmHg. The bias for the four conditions ranged from 0.5 to -3.8 mmHg. There were no significant differences in values between pre-flight and in-flight blood pressure measurements for all categories of blood pressure measurement. Thus, our data show that non-invasive blood pressure is not a precise reflection of invasive intra-arterial blood pressure. Mean blood pressure measured non-invasively may be a better marker of invasive blood pressure than systolic blood pressure. Our data show no evidence of non-invasive blood pressures being less accurate in an aeromedical transport environment.

How can we improve our understanding of cardiovascular safety liabilities to develop safer medicines?

Given that cardiovascular safety liabilities remain a major cause of drug attrition during preclinical and clinical development, adverse drug reactions, and post-approval withdrawal of medicines, the Medical Research Council Centre for Drug Safety Science hosted a workshop to discuss current challenges in determining, understanding and addressing 'Cardiovascular Toxicity of Medicines'. This article summarizes the key discussions from the workshop that aimed to address three major questions: (i) what are the key cardiovascular safety liabilities in drug discovery, drug development and clinical practice? (ii) how good are preclinical and clinical strategies for detecting cardiovascular liabilities? and (iii) do we have a mechanistic understanding of these liabilities? It was concluded that in order to understand, address and ultimately reduce cardiovascular safety liabilities of new therapeutic agents there is an urgent need to: • Fully characterize the incidence, prevalence and impact of drug-induced cardiovascular issues at all stages of the drug development process. • Ascertain the predictive value of existing non-clinical models and assays towards the clinical outcome. • Understand the mechanistic basis of cardiovascular liabilities; by addressing areas where it is currently not possible to predict clinical outcome based on preclinical safety data. • Provide scientists in all disciplines with additional skills to enable them to better integrate preclinical and clinical data and to better understand the biological and clinical significance of observed changes. • Develop more appropriate, highly relevant and predictive tools and assays to identify and wherever feasible to eliminate cardiovascular safety liabilities from molecules and wherever appropriate to develop clinically relevant and reliable safety biomarkers.

A phase I study of systemic sorafenib in combination with isolated limb infusion with melphalan (ILI-M) in patients (pts) with locally advanced in-transit melanoma

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Background: Sorafenib is a multi-kinase inhibitor that may also enhance the cytotoxicity of concurrently administered chemotherapy. In a preclinical model of regionally advanced melanoma, the combination of systemic Sorafenib and regional melphalan led to augmented tumor responses. Methods: A Phase I multicenter study was performed to evaluate the safety and pharmacokinetics (PK) of systemic Sorafenib in combination with ILI-M in patients with measurable in-transit melanoma of the extremity. Sorafenib dose escalation cohorts consisted of 200mg, 300mg, and 400mg administered systemically twice daily for one week prior and one week after a standard dose ILI-M corrected for ideal body weight. Tumor biopsies pre-therapy and pre-ILI were obtained to assess molecular changes associated with Sorafenib pretreatment. Response was defined at 3 months using RECIST. Results: Nine pts with high disease burden, including 7 previous ILI-M alone failures, have been treated; 3 in the first cohort and 6 in the second cohort. There were no grade 5 toxicities. Four patients had CTCAE Grade 4 toxicities including neutropenia (2), CPK elevation (1), and skin ulceration (1). In the remaining 5 patients, there were no >grade 3 toxicities. The maximally tolerated dose (MTD) has not yet been defined. Initial in field response determination in 6 of the 9 patients out at least 3 months includes 2 partial responses and 4 disease progressions. Conclusions: Systemic Sorafenib administered pre and post ILI-M is a well tolerated, novel targeted therapy approach to regionally advanced melanoma. An additional 10 patients will be enrolled to define the MTD. Correlation of response with drug PK, Sorafenib downregulation of pErk and Mcl1, and a melphalan resistance signature is in progress.

No significant financial relationships to disclose.

Optimizing melphalan pharmacokinetics in regional melanoma therapy: does correcting for ideal body weight alter regional response or toxicity?

BACKGROUND

This study aims to determine what effect correcting melphalan dosing for ideal body weight (IBW) has on toxicity and response in isolated limb infusion (ILI) in patients with advanced extremity melanoma.

METHODS

This was an open observational study examining whether correcting the melphalan dose for IBW will influence response and toxicity in patients undergoing ILI for advanced extremity melanoma in 41 patients undergoing 42 procedures (13 without correction for IBW; and 29 with correction for IBW). Melphalan pharmacokinetics, limb toxicity, serologic toxicity, and response at 3 months were compared.

RESULTS

The corrected group had a lower estimated limb volume (V (esti)) to melphalan volume at steady state (V (ss)) (P < .0001) ratio as well as lower incidence of grade > or =3 regional toxicity, serologic toxicity, and compartment syndrome (P = .0249, P = .027, P = .02). There was a positive correlation of V (esti)/V (ss) to toxicity (P = .0127, r = .382). No significant difference in response (P = .3609) between the groups was found, although there was a trend of association between V (esti)/V (ss) and response (P = .051, r = .3383).

CONCLUSIONS

Correcting for IBW in ILI lowers toxicity without significantly altering response rates.

Dimerization and N-terminal domain proximity underlie the function of the molecular chaperone heat shock protein 90

Heat shock protein (hsp)90 functions in a complex chaperoning pathway where its activity is modulated by ATP and by interaction with several co-chaperones. One co-chaperone, p23, binds selectively to the ATP-bound state of hsp90. However, the isolated ATP-binding domain of hsp90 does not bind p23. In an effort to identify the p23-binding domain, we have constructed a series of hsp90 deletion mutants fused with glutathione-S-transferase (GST). Full-length GST-hsp90 is able to bind p23, and also, to chaperone assembly of progesterone receptor complexes. Truncations from the C terminus of GST-hsp90 reveal a C-terminal boundary for the p23-binding domain at approximately residue 490. This fragment contains, in order, the ATP-binding domain, a highly charged region, and 203 residues beyond the charged region. p23 binding is unaffected by deletion of the charged region, indicating that two noncontiguous regions of hsp90 are involved in p23 binding. These regions are only effective when hsp90 is in a dimeric state as shown by loss of p23 binding upon removal of GST or as shown by use of FK506-binding protein12-hsp90 constructs that form dimers and bind p23 only in the presence of a bivalent drug. Thus, p23 binding requires an hsp90 dimer with close proximity between N-terminal regions of hsp90 and a conformation specified by ATP.

The assembly of progesterone receptor-hsp90 complexes using purified proteins

The progesterone receptor can be reconstituted into hsp90-containing complexes in vitro, and the resulting complexes are needed to maintain hormone binding activity. This process requires ATP/Mg2+, K+, and several axillary proteins. We have developed a defined system for the assembly of progesterone receptor complexes using purified proteins. Five proteins are needed to form complexes that are capable of maintaining hormone binding activity. These include hsp70 and its co-chaperone, hsp40, the hsp70/hsp90-binding protein, Hop, hsp90, and the hsp90-binding protein, p23. The proteins Hip and FKBP52 were not required for this in vitro process even though they have been observed in receptor complexes. Each of the five proteins showed a characteristic concentration dependence. Similar concentrations of hsp70, hsp90, and p23 were needed for optimal assembly, but hsp40 and Hop were effective at about 1/10 the concentration of the other proteins, suggesting that these two proteins act catalytically or are needed at levels similar to the receptor concentration. ATP was required for the functioning of both hsp70 and hsp90. The binding of hsp70 to the receptor requires hsp40 and about 10 microM ATP; however, hsp90 binding appears to occur subsequent to hsp70 binding and is optimal with 1 mM ATP. A three-step model is presented to describe the assembly process.

Reflex vascular responses in the anesthetized dog to large rapid changes in carotid sinus pressure

This study examined reflex vascular responses to large rapid increases and decreases in carotid sinus pressure to determine whether delayed or inappropriate vascular responses might be obtained that, if they occurred in people, could lead to hypotension during exposure to rapidly alternating gravitational forces. In chloralose-anesthetized open-chest dogs, a perfusion circuit controlled carotid sinus and thoracic aortic pressures and blood flows to both the vascularly isolated abdominal circulation and a hindlimb (perfusion pressure changes denoted resistance). When carotid pressure was increased and decreased over the range of 60-180 mmHg, the resulting reflex vasodilatation occurred significantly more rapidly than the vasoconstriction (P < 0.001). In the abdominal vascular bed, time constants for vasodilatation and vasoconstriction were 4.2 +/- 0.5 and 7.5 +/- 1.0 s, respectively. Decreases in carotid pressure in pulses of 10-s duration or less failed to elicit maximal vasoconstriction, whereas increases in carotid pressure lasting as little as 5 s did elicit maximal vasodilatation. "Square-wave" alternations in carotid pressure with periods of 10 s or less (5 s high, 5 s low) resulted in attenuation of the vasoconstriction, and at a 4-s period, both vascular beds remained almost maximally vasodilated throughout. The failure of vascular resistance to follow carotid pressure changes was not due to a failure of the response of sympathetic efferent activity, since the time constants for the reduction and increase in discharge were much shorter at 0.56 +/- 0.13 and 0.43 +/- 0.10 s, respectively. These results indicate that rapid changes in carotid pressure could result in inappropriate vasodilatation and hypotension and might, in some circumstances, such as in pilots flying high-performance aircraft, predispose to syncope.

Nucleotides and two functional states of hsp90

Previous studies have demonstrated the ATP-dependent formation of a complex containing the heat shock protein hsp90, the unique hsp90 binding protein p23, and one of three high molecular weight immunophilins. In the present study, hsp90 and p23 are shown to form a complex that requires elevated temperature and ATP/Mg2+. Complex formation is strongly promoted by molybdate and by the nonionic detergent Nonidet P-40. ADP and the benzoquinone ansamycin, geldanamycin, are potent inhibitors of complex formation. The ATP-dependent process alters the state of hsp90, not p23, and influences the ability of hsp90 to bind to phenyl-Sepharose. Conversion of hsp90 to the ATP-bound state lowers its affinity for phenyl-Sepharose. These results show that hsp90 can exist in at least two functional states, one able to bind p23 and the other with a high affinity for hydrophobic resins. A model is presented where these states are dictated by the binding of either ATP or ADP.

Repressive coping and blood lipids in men and women

Studies have suggested that a repressive coping style, characterized by defensiveness against negative emotions, may be related to several adverse health outcomes. This study examined whether repressive coping is associated with blood lipids, and whether this association is influenced by age or sex. One hundred fourteen healthy adults completed the Marlowe-Crowne scale (MC) and the Bendig version of the Taylor Manifest Anxiety scale (TMAS) prior to having their blood drawn after an overnight fast. Hierarchical regression analyses showed a significant interaction of sex, MC, and TMAS on total cholesterol (F(1, 104) = 4.41, p < 0.05), after controlling for the influence of age, body mass index, and other main effects and interactions. Results showed that male repressors (high MC; low TMAS) had the highest cholesterol levels, while truly low anxious males (low MC; low TMAS) had the lowest levels. The opposite pattern was noted for women. There were no interactive effects of age and coping style on lipids. The results suggest that males who repress negative emotions may be at greater risk for atherosclerotic diseases.

Single step selection of cis-diamminedichloroplatinum(II) resistant mutants from a human ovarian carcinoma cell line

We have shown that cis diamminedichloroplatinum-(II) (DDP) resistant mutants can be isolated from the human ovarian carcinoma cell line A2780 using a single-step selection protocol with DDP. DDP resistant colonies were calculated to be present at a frequency of 1.7 x 10(-6)/viable cell using a fluctuation analysis. The mutational origin of these surviving colonies is inferred by the fact that their frequency is increased by treatment of the A2780 cells with the chemical mutagen ethyl methane-sulfonate, with a maximum frequency observed after a 3-day expression time. Independently isolated clones maintain, in the absence of selection, a DDP resistant phenotype up to 7-fold more resistant than the parental A2780 cells. The resistance modifiers aphidicolin and buthionine sulfoximine have no effect on the frequency of DDP resistant mutants. Therefore neither of these drugs appears to have an effect on increasing the sensitivity of DDP resistant mutants existing in a cell population prior to DDP exposure.

Cotherapy: the need for positive pairing

Therapists who are of the opinion that the cotherapy relationship has minimal therapeutic value, fail to understand the potential of this type of therapy. Cotherapy, in group psychotherapy, is a unique form of therapy with specific implications for therapeutic intervention. This paper will present three hypotheses developed from clinical observations which encourage a re-examination of traditional group perspectives. First, the authors believe that the development of the cotherapy relationship effects the development of group process. Second, the authors hypothesize that the pairing of the cotherapy relationship is paralleled by the pairing of group participants and finally that pairing in group psychotherapy is positive and can be utilized as an intervention technique. Although, traditionally, pairing has been viewed as an obstacle to group process, this paper presents the premise that pairing in group psychotherapy should be considered as a positive and necessary occurrence for cotherapy intervention. Six phases of cotherapy development are illustrated to show how the complex aspects of the cotherapy relationship impacts upon the developmental stages of group process. The clinical implications of this perspective may be the beginnings of new therapeutic horizons for cotherapists.