Identifying Perspectives on Physical Therapist Residency Program Goals: Hallmarks of Success and Excellence

OBJECTIVE

The purpose of this study was to describe common perspectives important to achieving excellence and success in physical therapist residency education programs.

METHODS

Individuals with direct responsibility for creating and revising physical therapist residency program goals participated in a mixed-methods study using Q-methodology. They sorted 31 goal topics based on the level of importance for achieving excellence and success in physical therapist residency education. By-participant factor analysis identified dominant perspectives, which were interpreted based on emergent themes from the topics identified as the most important. Participants' rationale for selecting goal topics as the most important were extracted from the post-survey.

RESULTS

Seventy-three individuals responded, representing 9 of the 11 clinical residency areas of practice. Three main perspectives emerged: resident behaviors, resident achievements, and program attributes. One shared perspective emerged across all 3 factors that emphasized the residents' ability to become self-regulated, lifelong learners who integrate learning into practice: preparation for future learning.

CONCLUSIONS

Variability in weighting the importance of program goals associated with each perspective may include a program's organization and mission, individual beliefs and experiences related to program leadership, and resource availability. Although respondent emphasis placed importance of some items over others, the findings do not suggest that items ranked lower were unnecessary or unimportant in achieving program excellence. The relative importance of items was weighted differently based on the perspective of program leadership and the individual completing the sorting activity.

IMPACT

The results of this study suggest that physical therapist residency programs should have at least 1 or 2 goals in each of the 3 distinct perspectives, as well as the 1 shared perspective identified in our findings. Some consistency in program goals based on the perspectives identified here may enable further research exploring excellence, value, and outcomes in physical therapist residency education.

Virtual Rehabilitation and COVID-19: Varied Adoption and Satisfaction Among Patients and Providers Participating in a Multi-Site Survey Study

The COVID-19 pandemic compelled rapid healthcare adaptations including increased use of telehealth (TH) and virtual care (VC) to provide rehabilitation services. This multi-site cross-sectional survey study examined rehabilitation patients' and providers' experiences with service delivery during the COVID-19 pandemic, including the use of TH/VC. Patients and providers who received or provided rehabilitation services were recruited from 1 of 3 large, post-acute rehabilitation systems located in the Southeastern and Midwestern United States during the COVID-19 pandemic. Participants rated personal satisfaction with rehabilitation services received or rendered during the pandemic and willingness to use TH/VC in the future. Questions also addressed accessibility, ease of use, and perceived barriers to TH/VC use. The adoption and personal satisfaction of TH/VC for rehabilitation care varied between patients and providers. Patients reported higher levels of satisfaction compared to providers (P < .001). Patients who did not use TH/VC had higher satisfaction than those who did (P < .05). Patients were less willing than providers to use TH/VC (P < .001). Those who used TH/VC prior to the pandemic were more willing to use post-pandemic (P < .001). Patients reported TH/VC was useful in increasing health services accessibility yet were neutral as to the ability of TH/VC to improve outcomes. Patients and providers agreed that TH/VC was easy to learn and use. Medical providers found TH/VC more useful than therapy providers. Participants who used TH/VC during the pandemic are more willing to use the service again in the future. Understanding patient and provider preferences and perspectives is key to the continued use of TH/VC in rehabilitation care.

Structural Equation Modeling: Effects of Master Adaptive Learner and Clinical Learning Environment Attributes on Career Satisfaction and Intention to Stay

OBJECTIVE

The objective of this observational study was to test a proposed conceptual model depicting the influence of personal and environmental attributes of clinical learning environments on rehabilitation professionals' career satisfaction and intention to stay with their current organization. The mediating effects of 2 loci of engagement were also assessed.

METHODS

Rehabilitation professionals (physical therapists, occupational therapists, speech-language pathologists, and registered nurses; n = 436) from 4 health care organizations in the Northeast, Southeast, and Midwest regions in the USA completed a battery of questionnaires related to personal attributes (resilience and orientation toward lifelong learning), environmental attributes (innovation support and basic psychological need satisfaction at work), loci of engagement (professional and organizational), career satisfaction, and intention to stay. Data were analyzed using structural equation modeling.

RESULTS

The measurement and structural model fit was acceptable. The greatest total effects on career satisfaction (r = .459) and intention to stay (r = .462) were observed through the influences of basic psychological need satisfaction, professional engagement, and organizational engagement. Orientation toward lifelong learning was negatively associated with career satisfaction (r = -.208) and intention to stay (r = -.154), but this was mitigated by organizational engagement (r = -.060 and - .134, respectively). Small but significant total effects were also observed between innovation support, professional and organizational engagement, and intention to stay (r = .144) and resilience, professional and organizational engagement, and career satisfaction (r = .110).

CONCLUSION

Clinical learning environments that support rehabilitation professionals' basic psychological needs (autonomy, competency, and relatedness) are associated with greater career satisfaction and intention to stay. This association is further enhanced by organizational engagement and innovation support.

IMPACT

Rehabilitation organizations interested in developing and retaining master adaptive learners should create clinical learning environments that reinforce rehabilitation professionals' sense of autonomy, competency, and relatedness, and are supportive on innovative behaviors.

Qualitative study exploring general dental practitioners' views of MIH and its management in the UK and Australia

BACKGROUND

Molar-incisor hypomineralisation (MIH) is a prevalent condition, and how it is managed varies greatly between professional groups.

AIM

To explore, and compare, the UK and Australian general dental practitioners' management of MIH in children.

DESIGN

Face-to-face (remote) semistructured interviews were undertaken, using country-specific topic guides. Participants were purposively sampled and recruited through national conferences and research networks (eviDent Foundation and Northern Dental Practice Based Research Network). Interviews (from each country) were audio-recorded, transcribed verbatim and independently analysed using thematic analysis.

RESULTS

Two major themes arose from the UK interviews: (i) decision-making complexities and understanding of treatment options and (ii) need for specialist input. The main Australian themes were (i) multidisciplinary approach to management supporting decision-making complexities and (ii) economic implications for care. Several difficulties, such as financial implications, multidisciplinary care and clinical decision-making, were identified as barriers to effectively managing MIH by GDPs in primary care.

CONCLUSION

There are similarities and differences in the knowledge and management of MIH amongst UK and Australian nonspecialists. The different healthcare systems played a significant role in shaping how GDPs manage MIH with barriers relating to affordability, multidisciplinary care and clinical decision-making.

What Determinants Affect Inpatient Satisfaction in a Post-Acute Care Rehabilitation Hospital?

OBJECTIVE

To examine how specific hospital service domains (personal issues domain, discharge domain, rehabilitation doctor domain, nursing domain, physical therapist domain, occupational therapist domain, and food domain) influence final patient satisfaction scores, the overall quality of care, and willingness to recommend the hospital to others among patients in an inpatient rehabilitation hospital.

DESIGN

Longitudinal study.

SETTING

Patient-level data from electronic medical records were joined with Press Ganey (www.pressganey.com) satisfaction data for a single post-acute care inpatient rehabilitation facility in northeast Florida.

PARTICIPANTS

Patients who participated in the inpatient rehabilitation survey (N=4,785).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Main outcome measures included final patient satisfaction scores, overall rating of care during the stay, and willingness to recommend the hospital to others.

RESULTS

This study found the personal issues domain to be the most important factor in determining the final patient satisfaction score, overall rating of care, and likelihood to recommend the hospital to others, followed by the physical therapist, nurse, discharge, and food domains (P<.0001). Within the personal issues domain score, staff promptness and explanation upon arrival were areas identified as opportunities to make improvements that would result in the greatest positive effect.

CONCLUSIONS

This work represents novel findings by investigating the major determinants of positive patient experience in a rehabilitation hospital setting. These findings provide actionable information to improve patient experience as well as where to focus improvement efforts using limited resources.

Addressing health literacy to reduce inequalities among migrants: which profiles need our attention?

 

Health literacy, the ability to access, understand, appraise, remember and use health information and services, has great potential to reduce inequalities in access to and outcomes of care. People may have different patterns of health literacy needs and strengths. Yet, the design of interventions is frequently not responsive to the specificities of different segments of the population, including migrant groups. We aimed to identify profiles of migrants to inform the co-design of interventions targeting people at risk of poor outcomes. A cross-sectional survey was conducted with 1126 adult migrants living in Portugal. Data were collected using the 9-dimension HLQ (Health Literacy Questionnaire), and a sociodemographic questionnaire. A cluster analysis of data was performed. Semi-structured interviews were conducted with 15 migrants, stratified by the clusters. The optimal cluster solution yielded 16 profiles revealing diversity in combinations of strengths and needs across the HLQ domains. While 29.8% of migrants scored moderate to high on all 9 domains (profiles 2, 6, 8, 16), 63.4% of participants struggled with 1 or several aspects of health literacy, namely ‘Feeling understood and supported by healthcare providers'. Notably, 36.8% (6 profiles) exhibited difficulty across most of health literacy domains. The interviews provided a tangible description of the health literacy needs and resources with five main themes (access, understand, appraise, retrieve and use). Regarding ‘access', migrants expressed different preferred learning styles and needed to access different sorts of information at distinct times. The ‘use’ of information was rarely a one-time decision but a decision that people needed to make repeatedly. Health literacy is a highly diverse concept where subgroups exhibited diverse patterns. The cluster analysis can be used to inform the co-design, prioritisation and implementation of locally designed, fit-for-purpose solutions to improve health literacy.

Key messages

• Health literacy profiles can inform interventions to mitigate health inequalities among vulnerable migrant groups.

• The identification of distinct profiles can contribute to minimise the disconnect between what people/communities need and what is developed to improve health and equity.

Health literacy and physical and mental health status in octogenarian patients with coronary artery disease - a prospective cohort multicentre study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): MTG Holding AS

Introduction

The number of octogenarians (≥80 years of age) receiving percutaneous coronary intervention (PCI) is rising. Evidence supports that PCI improves quality of life and functional status in this group. Optimal health-promoting behaviour is strongly influenced by health literacy. However, there is limited knowledge about the association between health literacy, physical and mental health status in octogenarians.

Purpose

To determine if octogenarians health literacy is associated with generic and disease-specific physical and mental health status after PCI.

Methods

A prospective cohort study recruited 3417 participants from seven Danish and Norwegian PCI centres, and was conducted from June 2017 until May 2019. Multiple linear regression analysis was used. Health literacy was assessed by four of the nine scales from the Health Literacy Questionnaire (HLQ) (were higher score are better); "Social support for health" (scale range 1-4) "Appraisal of health information", (scale range 1-4) "Ability to find good health information" (scale range 1-5) and "Understand health information well enough to know what to do" (scale range 1-5). Generic physical and mental health status was assessed with RAND-12 at baseline (scale range 0-100, were higher score are better). After two months, disease-specific physical and mental health status was assessed with Myocardial Infarction Dimensional Assessment Scale (scale range 0-100, were lower score are better). Socio-demographic (age, gender, cohabitation status, education) and clinical variables (number of comorbidities) were included as covariates.

Results

In all, 318 octogenarians with mean age 83.4 years (range 80-96) participated, of which 69% were males. Three aspects of health literacy, "Social support for health", "Ability to find good health information" and "Understand health information well enough to know what to do", were significantly associated with health status. Specifically, for a unit increase of "Social support for health", the generic mental health status increased by 3 units (B: 3.0 [0.2 to 5.8] P=0.034). Further, a unit increase of "Ability to find good health information" was associated with a significant 4.2 higher disease-specific physical health and significant 5.3 higher disease-specific mental health (B:-4.2 [-8.0 to -0.4] P=0.029, B:-5.3 [-9.0 to -1.6] P=0.005, respectively). Finally, for a unit increase of "Understand health information well enough to know what to do" the disease-specific physical health improved by 5.1 units (B:-5.1 [-9.7 to -0.5] P=0.029) and disease-specific mental health improved by 5.2 units (B:-5.2 [-9.7 to -0.7] P=0.025).

Conclusion

In this study, we found that elements of health literacy were associated with both physical and mental health status in octogenerians. These findings highlight the importance of adequate health literacy and the need to support those with lower health literacy following PCI.

Essential Components of Physical Therapist Management of Patients With Osteoporosis: A Delphi Study

BACKGROUND AND PURPOSE

Osteoporosis is a systemic, metabolic bone disease that affects bone quality, increases susceptibility to low-trauma bone fracture, and has downstream effects on falls and fragility fractures. Osteoporosis is a multifactorial disease process that requires management from multiple health care providers including physicians, nurses, and physical therapists. However, the paucity of information regarding comprehensive physical therapist management for patients with osteoporosis indicated the need for an evidence-based document. The purpose of this document was to provide the best available expert guidance for clinicians in the selection of screening tools, essential tests and measures, treatment goals, and interventions for patients with osteoporosis.

METHODS

A Delphi process was used. Thirty-one physical therapists with expertise in the care of patients with osteoporosis participated in a series of 3 sequential surveys designed to build and reach agreement on the management of patients with osteoporosis. The desired survey outcomes were to: (1) identify the range of examination and plan of care components considered important to physical therapists' care for patients with osteoporosis, (2) determine which components should be considered essential, and (3) achieve consensus on the final list of essential components and related operational definitions.

RESULTS

A clear consensus on the essential components of examination and interventions was achieved. In general, there were 4 to 6 items across each category of history, tests and measures, education/goals, and treatment.

CONCLUSIONS

The prioritization of these management items will better support clinicians working with adults who have osteoporosis.

Results of a nationally implemented cardiac screening programme in elite cricket players in England and Wales

OBJECTIVES

We assessed the diagnostic yield and costs of an electrocardiogram-based national screening programme in elite cricket players and the incremental value of transthoracic echocardiography and periodic evaluation.

DESIGN

Cross-sectional study.

METHODS

Between 2008 and 2019, 1208 cricketers underwent screening with a health questionnaire, 12-lead electrocardiogram and cardiology consultation. Athletes with concerning findings underwent on-site transthoracic echocardiography and further investigations as necessary. In addition, despite a normal health questionnaire and electrocardiogram, 342 (28.3%) athletes had a transthoracic echocardiogram and 493 (40.8%) underwent repeat evaluations.

RESULTS

After initial evaluation, 47 (3.9%) athletes underwent on-site transthoracic echocardiography of whom 35 (2.8%) were referred for further evaluation. Four athletes (0.3%) were diagnosed with major cardiac conditions; hypertrophic cardiomyopathy (n = 1), arrhythmogenic cardiomyopathy (n = 1) and Wolff-Parkinson-White pattern (n = 2). Two athletes were identified with minor valvular abnormalities. Repeat evaluation of 493 athletes identified hypertrophic cardiomyopathy in a 22-year-old athlete, two years after his initial normal screening. During a follow-up of 5.8 ± 2.9 years no additional diagnoses or adverse cardiac events were reported. The cost of the electrocardiogram-based programme was £127,844, translating to £106 per athlete and £25,569 per major cardiac condition identified.Routine transthoracic echocardiography in 342 athletes identified two athletes with major cardiac conditions (bicuspid aortic valve with severe aortopathy and aortic regurgitation and an atrial septal defect associated with right ventricular volume overload) and 10 athletes with minor abnormalities.

CONCLUSIONS

An electrocardiogram-based national screening programme identified a major cardiac condition in 0.3% of athletes. Routine transthoracic echocardiography and periodic evaluation increased the diagnostic yield to 0.6%, at an incremental cost.

Evaluation of a Head-Tongue Controller for Power Wheelchair Driving By People With Quadriplegia

The head-tongue controller (HTC) is a multimodal alternative controller designed for people with quadriplegia to access complex control capabilities by combining tongue and head tracking to offer both discrete and proportional controls in a single controller. In this human study, 17 patients with quadriplegia and current users of alternative controllers were asked to perform four trials of either simple driving tasks or advanced maneuvers in a custom-designed course. Completion time and accuracy were compared between their personal alternative controller (PAC) and various combinations of driving modalities with the HTC. Out of 8 subjects assigned to simple driving, the best HTC trial of 3 subjects was completed faster than their PAC for the tasks of rolling forward and turning around cones, and 5 subjects in rolling backward. Across all these subjects, the average completion time of their best HTC modality is 23s for rolling forward, 15s for rolling backward, and 70s for turning around cones as compared to 19s, 17s, and 45s with their PAC. For advanced driving, the course was completed faster with the HTC by 1 out of 9 subjects, while the best HTC trials of all subjects are less than 1.3 times of their best PAC completion time with an average of 170s for the HTC and 140s for their PAC. The qualitative feedback provided by all subjects to a post-study questionnaire scored to an average of 7.5 out of 10 which shows their interests in the HTC and acknowledgement of its usefulness for this population.

POS0299 SOCIOECONOMIC BACKGROUND IS ASSOCIATED WITH DISCORDANCE BETWEEN HEALTH LITERACY OF PEOPLE WITH RMDs AND ASSESSMENT OF HEALTH LITERACY BY THEIR TREATING HEALTH PROFESSIONAL

Background:

Health literacy is increasingly recognised as a critical determinant of health. While care should be tailored to the health literacy needs of each patient [1], research in primary care shows that physicians often under- or overestimate their patients’ health literacy, with socioeconomic factors playing a role [2]. Evidence in a rheumatology setting is scarce.

Objectives:

-To investigate discordance between health literacy of patients with rheumatic and musculoskeletal diseases (RMDs) and assessment by their treating health professional, across the nine domains of the Health Literacy Questionnaire (HLQ).

-To explore whether discordance is associated with the patient’s socioeconomic background.

Methods:

Patients with rheumatoid arthritis (RA), spondyloarthritis (SpA), or gout from three Dutch outpatient rheumatology clinics completed the HLQ [3]. The treating health professional (rheumatologist, physician assistant, nurse (practitioner) or resident) assessed their patient’s level for each HLQ domain, or answered “I don’t know”. Discordance per domain was calculated as the patient’s score subtracted from the professional’s score (both on a 0-10 scale). Discordance was defined as a ≥2-point difference in either direction. Adjusted multilevel multinomial regression models (ref. = no discordance) with patients clustered by health professionals were computed to test the role of socioeconomic factors (age, gender, education level, immigration background, living alone and employment status) in negative (i.e. professional scored lower) and positive (i.e. professional scored higher) discordance.

Results:

Of 778 patients included, 41% had RA, 34% had SpA, and 25% had gout. We observed considerable discordance across all HLQ domains (Table 1). Professionals answered “I don’t know” most often for “Having social support for health” (19.4%, domain 4). Most discordance occurred for “Critically appraising information” (42.1%, domain 5). For all HLQ domains except “Having social support for health” (domain 4), discordance was associated with socioeconomic factors. In patients with a non-Western immigration background, professionals were likely to assign lower scores than patients’ HLQ scores in six domains. Education level was an important driver of discordance in seven domains, with the direction of the association being domain-dependent. Other factors associated with discordance in multiple domains were type of rheumatic disease, comorbidities, mastery, how well the professional knew the patient, type of professional, and disease impact.

Table 1.

Discordance per HLQ domain (n=778)

HLQ domainProfessional scored lowerNo discordanceProfessional scored higherProfessional did not known (%)1. Healthcare provider support128 (16)514 (66)126 (16)10 (1)2. Having sufficient information100 (13)528 (68)143 (18)7 (1)3. Actively managing health95 (12)461 (59)208 (27)14 (2)4. Having social support for health55 (7)397 (51)175 (22)151 (19)5. Critically appraising information78 (10)448 (58)250 (32)2 (0)6. Actively engaging with providers205 (26)500 (64)70 (9)3 (0)7. Navigating the health system115 (15)544 (70)107 (14)12 (2)8. Finding health information163 (21)492 (63)98 (13)25 (3)9. Understanding health information145 (19)511 (66)110 (14)12 (2)

Conclusion:

Considerable discordance between patients’ health literacy and their treating health professionals’ assessment exists across health literacy domains. In eight out of nine domains, discordance was associated with the patient’s socioeconomic background, particularly education and immigration background. Understanding and addressing the reasons for discordance between patient-reported and professional-perceived health literacy has potential to improve responsiveness to patients’ needs, promote better communication and ultimately improve care outcomes.

References:

[1]Bakker et al., Arthrit Care Res (2021)

[2]Storms et al., BMJ Open (2019)

[3]Osborne et al., BMC Public Health (2013)

Disclosure of Interests:

None declared

Covid-19 Impacts on Florida's Healthcare Professionals

This study described how COVID-19 impacted employment, telehealth usage, and interprofessional collaboration. A cross-sectional survey was deployed in June 2020 to healthcare professionals in Florida. Job status was uniquely separated by profession, with more nurses and medical doctors reported having no effect, and more mental health counselors transitioned to telehealth. Over a third of rehabilitation providers reported being furloughed. Over forty percent of providers had no training in telehealth, yet 33.1% reported an increase in usage. Interprofessional interactions are lower across professions during the pandemic, compared with before. This study shows the need for additional training on telehealth and interprofessional collaboration.

OP0257-PARE USING PATIENT HEALTH LITERACY PROFILES TO IDENTIFY SOLUTIONS TO CHALLENGES FACED IN RHEUMATOLOGY CARE

Background:

The prevalence of limited health literacy (i.e. cognitive and social resources of individuals to access, understand and apply health information to promote and maintain good health) in the Netherlands is estimated to be over 36% [1]. Access to and outcomes of rheumatological care may be compromised by limited patient health literacy, yet little is known about how to address this, thus action is required. As influencing individual patients’ health literacy in the rheumatology context is often unrealistic, it is paramount for the health system to be tailored to the health literacy needs of its patients. The OPtimising HEalth LIteracy and Access (Ophelia) process offers a method to inform system change [2].

Objectives:

Following the Ophelia approach:

Methods:

Patients with RA, SpA and gout attending outpatient clinics in three centres in the Netherlands completed the Health Literacy Questionnaire (HLQ) and questions on socio-demographic and health-related characteristics. Hierarchical cluster analysis using Ward’s method identified clusters based on the nine HLQ domains. Three researchers jointly examined 24 cluster solutions for meaningfulness by interpreting HLQ domain scores and patient characteristics. Meaningful clusters were translated into health literacy profiles using HLQ patterns and demographic data. A patient research partner confirmed the identified profiles. Patient vignettes were designed by combining cluster analyses results with qualitative patient interviews. The vignettes were used in two two-hour co-design workshops with rheumatologists and nurses to discuss their perspective on health literacy-related challenges for patients and professionals, and generate ideas on how to address these challenges.

Results:

In total, 895 patients participated: 49% female, mean age 61 years (±13.0), 25% lived alone, 18% had a migrant background, 6.6% did not speak Dutch at home and 51% had low levels of education. Figure 1 shows a heat map of identified health literacy profiles, displaying the score distribution per profile across nine health literacy domains. Figure 2 shows an excerpt of a patient vignette, describing challenges for a patient with profile number 9. The workshops were attended by 7 and 14 nurses and rheumatologists. Proposed solutions included health literacy communication training for professionals, developing and improving (visual) patient information materials, peer support for patients through patient associations or group consultations, a clear referral system for patients who need additional guidance by a nurse, social worker, lifestyle coach, pharmacist or family doctor, and more time with rheumatology nurses for target populations. Moreover, several system adaptations to the clinic, such as a central desk for all patient appointments, were proposed.

Conclusion:

This study identified several distinct health literacy profiles of patients with rheumatic conditions. Engaging with health professionals in co-design workshops led to numerous bottom-up ideas to improve care. Next steps include co-design workshops with patients, followed by prioritising and testing proposed interventions.

References:

[1]Heijmans M. et al. Health Literacy in the Netherlands. Utrecht: Nivel 2018

[2]Batterham R. et al. BMC Public Health 2014, 14:694

Disclosure of Interests:

Mark Bakker: None declared, Polina Putrik: None declared, Jany Rademakers Speakers bureau: In March 2017, Prof. Dr. Rademakers was invited to speak about health literacy at the “Heuvellanddagen” Conference, hosted by Janssen-Cilag., Mart van de Laar Consultant of: Sanofi Genzyme, Speakers bureau: Sanofi Genzyme, Harald Vonkeman: None declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Hanneke Voorneveld: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis, Maarten de Wit Grant/research support from: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Consultant of: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Speakers bureau: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Richard Osborne Consultant of: Prof. Osborne is a paid consultant for pharma in the field of influenza and related infectious diseases., Roy Batterham: None declared, Rachelle Buchbinder: None declared, Annelies Boonen Grant/research support from: AbbVie, Consultant of: Galapagos, Lilly (all paid to the department)

Motivations to Pursue Physical Therapy Residency Training: A Q-Methodology Study of Stakeholder Perspectives

BACKGROUND

Residency training is recognized as a valuable form of professional development and pathway to specialization. Currently residency is voluntary for physical therapists, with less than 12% of DPT students choosing to apply upon graduation. Motivations that drive the decision to pursue residency are currently unknown as is the extent of similarity and difference in perspective among various stakeholders.

OBJECTIVE

The purpose of this study was to identify the dominant perspectives on motivations to pursue residency held by various stakeholders.

DESIGN

This study was conducted using Q Methodology, which incorporates aspects of quantitative and qualitative techniques into the examination of human subjectivity.

METHODS

Program directors, faculty, and current residents from all accredited physical therapy residency programs were invited to complete a forced-choice sorting activity where potential motivations for residency were sorted by perceived level of importance. Principal component analysis was used to identify dominant perspectives, which were interpreted based on emergent themes in the cluster of motivations identified as most important.

RESULTS

Four dominant perspectives were identified: (1) desire to provide better patient care, (2) preparation for specialty practice, (3) fast track to expert practice, and (4) career advancement. These perspectives provided context and utility to 2 broad meta-motivations: improved clinical reasoning and receiving mentoring. Both within- and between-group differences among stakeholders were identified. However, subsets from each role-group population were found to share similar perspectives.

LIMITATIONS

Results from this study may not apply to potential residents in all specialty areas, and the implications of having a particular perspective are unknown.

CONCLUSIONS

Identification of the dominant perspective on motivations for pursuing residency may aid in promoting participation, program development, matching residents to programs and mentors, and future research.

Musculoskeletal pain stakeholder engagement and partnership development: determining patient-centered research priorities

BACKGROUND

Musculoskeletal (MSK) pain is a global public health problem with increased societal burden. Increased attention has focused toward patient and other stakeholder perspectives when determining future MSK pain research priorities, however infrastructure and capacity building within the community are needed for individuals and organizations to participate in patient-centered outcomes research. The purpose of this manuscript is to describe our collaborative experiences with several MSK pain stakeholders and processes to identify a top priority research topic.

METHODS

Lunch meetings and formalized workshops were used to develop infrastructure for engaging patients and other stakeholders with early capacity building for partners to identify MSK pain research ideas based on their personal experiences. Additional capacity building and engagement through literature searching further prepared partners to contribute informed decisions about MSK pain research topics and subsequent selection of an important research question.

RESULTS

Several key deliverables (e.g., Governance Document, Communication Plan) were developed and completed over the course of this project to provide partnership structure. Other key deliverables included a list of preliminary comparative effectiveness research ideas (n = 8) and selection of shared decision making for MSK pain as the top priority research topic with patient partners identifying pain self-efficacy as an important outcome domain.

CONCLUSIONS

Our patient partners provided the catalyst for identifying shared decision making as a high priority research topic based on a wide spectrum of stakeholder perspectives and unique experiences. Patient partners were primarily identified using a single rehabilitation health system and clinician partners were heavily weighted by physical therapists which may have introduced selection bias.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Laser testing for upper extremity proprioceptive deficits following rotator cuff injury: two case reports

Background: Rotator cuff (RTC) dysfunction incidence ranges from 7% to 25% in the general population with a high recurrence rate. RTC musculature plays a significant role in dynamic stability of the glenohumeral joint with damage to these structures associated with proprioceptive impairments. Impaired proprioception has been linked to increased injury risk in other body regions; however, similar relationships with the upper extremity have not been extensively evaluated. The purpose of this case report is to present a preliminary, yet clinically feasible approach for using a laser for proprioceptive assessment and treatment in patients with RTC dysfunction. Case description: Patient 1 was a 21-year-old female with right shoulder pain from injury at work as a waitress where she lifted a heavy tray of plates. Patient 2 was a 48-year-old male with gradual and insidious onset of right shoulder pain during recreational baseball. Examination findings indicated contractile tissue involvement in both patients. Reaching and throwing tasks requiring accurate proprioceptive function were essential for return of each patient to their functional tasks. Laser proprioception testing was performed every 2 weeks with proprioceptive training provided as a supplement to other interventions. Outcomes: Over 4 weeks, improvements in objective laser proprioceptive test results were observed for both patients (Patient 1 = 6.0 cm; Patient 2 = 5.5 cm) in conjunction with active range-of-motion and self-report measures for pain intensity and function. Discussion: This case report describes a clinically feasible approach to testing and treating upper extremity proprioceptive deficits after RTC injury. Future research is required to establish reliability and validity of these methods.

Sensitivity of the early-life stages of freshwater mollusks to neonicotinoid and butenolide insecticides

Neonicotinoid insecticides can be transported from agricultural fields, where they are used as foliar sprays or seed treatments, to surface waters by surface or sub-surface runoff. Few studies have investigated the toxicity of neonicotinoid or the related butenolide insecticides to freshwater mollusk species. The current study examined the effect of neonicotinoid and butenolide exposures to the early-life stages of the ramshorn snail, Planorbella pilsbryi, and the wavy-rayed lampmussel, Lampsilis fasciola. Juvenile P. pilsbryi were exposed to imidacloprid, clothianidin, or thiamethoxam for 7 or 28 d and mortality, growth, and biomass production were measured. The viability of larval (glochidia) L. fasciola was monitored during a 48 h exposure to six neonicotinoids (imidacloprid, thiamethoxam, clothianidin, acetamiprid, thiacloprid, or dinotefuran), or a butenolide (flupyradifurone). The 7-d LC50s of P. pilsbryi for imidacloprid, clothianidin, and thiamethoxam were ≥4000 μg/L and the 28-d LC50s were ≥182 μg/L. Growth and biomass production were considerably more sensitive endpoints than mortality with EC50s ranging from 33.2 to 122.0 μg/L. The 48-h LC50s for the viability of glochidia were ≥456 μg/L for all seven insecticides tested. Our data indicate that neonicotinoid and butenolide insecticides pose less of a hazard with respect to mortality of the two species of mollusk compared to the potential hazard to other non-target aquatic insects.

Recognition and management of BPPV for an elderly female patient referred for low back pain: a resident's case study

Benign paroxysmal positional vertigo (BPPV) is common among older adults and frequently misdiagnosed or unidentified. Undiagnosed BPPV has been associated with depression, falls and ADL limitations. This case study describes the diagnostic process and management of BPPV for a 65-year-old patient with a primary complaint of chronic low back pain (LBP) in an outpatient orthopedic physical therapy setting. Following routine screening performed on initial evaluation, the patient was educated about examination findings that indicated the potential for BPPV and given the option to proceed with further assessment or defer until LBP was under control. The patient attended 16 visits over the course of care and the complaint of vertigo, described as a true spinning sensation, was assessed further on the visit 5. Continued assessment confirmed BPPV and the canalith repositioning procedure was administered. Following positive response to this intervention, the maneuver was re-administered on visit 6. Complete resolution of symptoms was reported on visit 7 and for the remainder of physical therapy services over the following month. Physical therapists may play a vital role in reducing healthcare expenses associated with cost to arrive at the diagnosis of BPPV, as well as improving the quality of life and safety of the older adult population affected by BPPV.

Practical application of cellular bioenergetics to the care of aged skin

In human skin fibroblasts in vitro, procollagen-1 and NAD(+)/NADH were reduced in three strains of adult fibroblasts compared with neonatal fibroblasts. The levels of both procollagen-1 and NAD(+)/NADH were increased in the adult fibroblasts by treatment for 24 (NAD energy) or 48 h (procollagen-1) with a complex containing niacinamide, Pal-KTTKS peptide and an olive oil fatty acid derivative (Olivem(®)), especially in combination with a natural extract from dill (Lys'lastine V(®)). In one of the adult fibroblast strains evaluated, these changes in procollagen-1 and NAD(+)/NADH in response to the complex of bioactives were in parallel with increased expression of mRNA biomarkers related primarily to dermal matrix and basement membrane structure, including COL1A1, COL3A1, COL5A1, COL14A1, ELN and LOXL2, in addition to SOD2, NAMPT and TGFBR3; MMP1 was decreased in expression. In general, these mRNA biomarker effects were maintained or boosted by the addition of Lys'lastine V, particularly at 1%, and were similar to the fold changes in mRNA expression in neonatal compared with adult fibroblasts. These results indicate that the complex of niacinamide, Pal-KTTKS and Olivem, especially with addition of Lys'lastine V, increases the NAD(+)/NADH bioenergy level of adult skin fibroblasts in parallel with increased expression of skin structure biomarkers in vitro to levels similar to those in younger fibroblasts. Thus, niacinamide, Pal-KTTKS, Olivem and Lys'lastine V are promising bioactive candidates for inclusion in cosmetic formulations.

Characterization of CD4 and CD8 T cell responses in MuSK myasthenia gravis

Muscle specific tyrosine kinase myasthenia gravis (MuSK MG) is a form of autoimmune MG that predominantly affects women and has unique clinical features, including prominent bulbar weakness, muscle atrophy, and excellent response to therapeutic plasma exchange. Patients with MuSK MG have predominantly IgG4 autoantibodies directed against MuSK on the postsynaptic muscle membrane. Lymphocyte functionality has not been reported in this condition. The goal of this study was to characterize T cell responses in patients with MuSK MG. Intracellular production of IFN-gamma, TNF-alpha, IL-2, IL-17, and IL-21 by CD4+ and CD8+ T cells was measured by polychromatic flow cytometry in peripheral blood samples from 11 Musk MG patients and 10 healthy controls. Only one MuSK MG patient was not receiving immunosuppressive therapy. Regulatory T cells (Treg) were also included in our analysis to determine if changes in T cell function were due to altered Treg frequencies. CD8+ T cells from MuSK MG patients had higher frequencies of polyfunctional responses than controls, and CD4+ T cells had higher IL-2, TNF-alpha, and IL-17. MuSK MG patients had a higher percentage of CD4+ T cells producing combinations of IFN-gamma/IL-2/TNF-gamma, TNF-alpha/IL-2, and IFN-gamma/TNF-alpha. Interestingly, Treg numbers and CD39 expression were not different from control values. MuSK MG patients had increased frequencies of Th1 and Th17 cytokines and were primed for polyfunctional proinflammatory responses that cannot be explained by a defect in CD39 expression or Treg number.

The Performance of the Tissue Equivalent Assay using the Skin(2)(TM) ZK1200 Model in the COLIPA International Validation Study on Alternatives to the Draize Eye Irritation Test

The tissue equivalent assay (TEA) (Osborne et al., 1995) was used to evaluate 55 mixed ingredients and formulations in the COLIPA International Validation Study on Alternatives to the Draize Rabbit Eye Irritation Test (Brantom et al., 1997). The TEA can be used to test all types of materials since it uses a topical application approach and is not limited to only testing liquid or soluble materials. A prediction model (PM) for the test was developed using historical eye irritation data from a total of 132 materials on which in vivo and in vitro data were available. A regression model was derived from these data and used to relate the in vitro endpoint (t(50)) obtained in the study to a Draize MMAS (modified maximum average score). This provided a measure of the predicted in vivo eye irritation scores. In the current study, two separate laboratories used the same protocol to test the same set of coded materials and the results of both laboratories were compared to the initial PM. The TEA met the reliability criteria of the validation study in reproducing the predefined PM in both laboratories, and a good relationship between predicted and observed Draize MMAS values was obtained (r=0.906 and r=0.850). Good correlations were maintained when separate analyses were made of the formulations and ingredients included in the test set. Good relationships between the in vitro endpoint and individual Draize tissue scores (r>0.8) were also exhibited. Although insufficient data were available to make an assessment of interlaboratory variation, some difference in the reproducibility of the assay was noted between the two laboratories, particularly for the highly irritating materials. However, the consistency of data was encouraging and the discrepancies seen between the laboratories suggested a sensitivity of the model to subtle differences in application techniques, and in handling and timing. Taken together, these results indicate the utility of the TEA test for these types of substances and the need to more fully address the issue of interlaboratory reproducibility.

Cancer of unknown primary: progress in the search for improved and rapid diagnosis leading toward superior patient outcomes

This paper explores the enigma of cancer of unknown primary (CUP) in relation to rapidly improving molecular diagnostic approaches. It is based on the first global collaboration meeting on improving research and clinical outcomes in CUP organized by the CUP Foundation. We review the difficulties of classifying this widely heterogeneous disease and the available diagnostic and pathological evaluative techniques, focusing on molecular profiling. Retrospective studies in CUP patients are shown to provide indirect validation of the accuracy of several platforms of gene expression profiling assays that may identify CUP subsets that respond favorably to active chemotherapy regimens. This review concludes that the recent major improvements in pathologic and molecular diagnostics, coupled with new improved therapies for several specific advanced solid tumors, need to be harmonized with more evidence from clinical-translational trials. All patients with CUP could thus be appropriately managed without the constant uncertainty that has previously severely hampered patient care and optimal outcomes. The longer-term objective is to understand the biology of highly metastatic disease, leading to the development of future global therapeutic programs. Current clinical studies, such as CUP-ONE, will address some of these issues.

Phase II trial of combretastatin A4 phosphate, carboplatin, and paclitaxel in patients with platinum-resistant ovarian cancer

BACKGROUND

A previous dose-escalation trial of the vascular disrupting agent combretastatin A4 phosphate (CA4P) given before carboplatin, paclitaxel, or both showed responses in 7 of 18 patients with relapsed ovarian cancer.

PATIENTS AND METHODS

Patients with ovarian cancer that had relapsed and who could start trial therapy within 6 months of their last platinum chemotherapy were given CA4P 63 mg/m(2) minimum 18 h before paclitaxel 175 mg/m(2) and carboplatin AUC (area under the concentration curve) 5, repeated every 3 weeks.

RESULTS

Five of the first 18 patients' disease responded, so the study was extended and closed after 44 patients were recruited. Grade ≥2 toxic effects were neutropenia in 75% and thrombocytopenia in 9% of patients (weekly blood counts), tumour pain, fatigue, and neuropathy, with one patient with rapidly reversible ataxia. Hypertension (23% of patients) was controlled by glyceryl trinitrate or prophylactic amlodipine. The response rate by RECIST was 13.5% and by Gynecologic Cancer InterGroup CA 125 criteria 34%.

CONCLUSIONS

The addition of CA4P to paclitaxel and carboplatin is well tolerated and appears to produce a higher response rate in this patient population than if the chemotherapy was given without CA4P. A planned randomised trial will test this hypothesis.

Gemcitabine alone or in combination with cisplatin in patients with advanced or metastatic cholangiocarcinomas or other biliary tract tumours: a multicentre randomised phase II study - The UK ABC-01 Study

BACKGROUND

We assessed the activity of gemcitabine (G) and cisplatin/gemcitabine (C/G) in patients with locally advanced (LA) or metastatic (M) (advanced) biliary cancers (ABC) for whom there is no standard chemotherapy.

METHODS

Patients, aged > or =18 years, with pathologically confirmed ABC, Karnofsky performance (KP) > or =60, and adequate haematological, hepatic and renal function were randomised to G 1000 mg m(-2) on D1, 8, 15 q28d (Arm A) or C 25 mg m(-2) followed by G 1000 mg m(-2) D1, 8 q21d (Arm B) for up to 6 months or disease progression.

RESULTS

In total, 86 patients (A/B, n=44/42) were randomised between February 2002 and May 2004. Median age (64/62.5 years), KP, primary tumour site, earlier surgery, indwelling biliary stent and disease stage (LA: 25/38%) are comparable between treatment arms. Grade 3-4 toxicity included (A/B, % patients) anaemia (4.5/2.4), leukopenia (6.8/4.8), neutropenia (13.6/14.3), thrombocytopenia (9.1/11.9), lethargy (9.1/28.6), nausea/vomiting (0/7.1) and anorexia (2.3/4.8). Responses (WHO criteria, % of evaluable patients: A n=31 vs B n=36): no CRs; PR 22.6 vs 27.8%; SD 35.5 vs 47.1% for a tumour control rate (CR+PR+SD) of 58.0 vs 75.0%. The median TTP and 6-month progression-free survival (PFS) (the primary end point) were greater in the C/G arm (4.0 vs 8.0 months and 45.5 vs 57.1% in arms A and B, respectively).

CONCLUSION

Both regimens seem active in ABC. C/G is associated with an improved tumour control rate, TTP and 6-month PFS. The study has been extended (ABC-02 study) and powered to determine the effect on overall survival and the quality of life.

Combretastatin A-4 phosphate (CA4P) carboplatin and paclitaxel in patients with platinum-resistant ovarian cancer: Final phase II trial results

5502

Background: CA4P is a vascular disrupting agent that in pre-clinical models can increase the efficacy of a variety of therapies. A dose escalation trial of CA4P given prior to carboplatin, paclitaxel or both showed the combination was well tolerated and responses were seen in several tumor types including 6/17 with relapsed ovarian cancer. The trial was therefore extended into a phase II trial in patients with platinum resistant ovarian cancer. Methods: Patients with ovarian cancer that had relapsed and could start trial therapy within 6 months of their last platinum chemotherapy were given CA4P 63mg/m2 18–20 hours prior to paclitaxel 175mg/m2 and carboplatin AUC 5 repeated 3 weekly. If > 2 responses were seen in first 18 patients 43 patients were to be treated to confirm response rate>19%. Results: Five of the first 18 patients responded so the study was extended and closed after 44 patients were recruited, with full data available to date on 34. Weekly blood counts have demonstrated grade 3/4 neutropenia in 11 and thrombocytopenia in only 1 patient. Other grade > 2 toxicity seen in > 1 patient was fatigue, nausea / vomiting, pain, alopecia, rapidly reversible ataxia, diarrhoea, neuropathy and was little different to what would be expected with paclitaxel and carboplatin. Hypertension is the commonest CA4P related toxicity and was easily controlled by GTN, then prophylactic amlodipine. Responses according to GCIG criteria, have been seen in 11/34 (32%) patients with an additional unconfirmed PR. Conclusions: The addition of CA4P to paclitaxel and carboplatin is well tolerated and appears to produce a higher response rate in this patient population than if the chemotherapy was given without CA4P. A planned randomised trial will hopefully confirm this.

[Table: see text]

‘Getting your Life Back on Track after Stroke’: A Phase II Multi-Centered, Single-Blind, Randomized, Controlled Trial of the Stroke Self-Management Program Vs. the Stanford Chronic Condition Self-Management Program or Standard Care in Stroke Survivors

Background

Self-management is seen as a primary mechanism to support the optimization of care for people with chronic diseases such as symptomatic vascular disease. There are no established and evidence-based stroke-specific chronic disease self-management programs. Our aim is to evaluate whether a stroke-specific program is safe and feasible as part of a Phase II randomized-controlled clinical trial.

Methods

Stroke survivors are recruited from a variety of sources including: hospital stroke services, local paper advertisements. Stroke South Australia newsletter (volunteer peer support organization), Divisions of General Practice, and community service providers across Adelaide, South Australia. Subjects are invited to participate in a multi-center, single-blind, randomized, controlled trial. Eligible participants are randomized to either; standard care, standard care plus a six week generic chronic condition self-management group education program, or, standard care plus an eight week stroke specific self-management education group program. Interventions are conducted after discharge from hospital. Participants are assessed at baseline, immediate post intervention and six months.

Study Outcomes

The primary outcome measures determine study feasibility and safety, measuring, recruitment, participation, compliance and adverse events. Secondary outcomes include: positive and active engagement in life measured by the Health Education Impact Questionnaire, improvements in quality of life measured by the Assessment of Quality of Life instrument, improvements in mood measured by the Irritability, Depression and Anxiety Scale, health resource utilization measured by a participant held diary and safety.

Conclusion

The results of this study will determine whether a definitive Phase III efficacy trial is justified.

Who attends primary care services prior to attendance at genitourinary services and what level of care have they received?

OBJECTIVE

To determine the proportion of patients initially attending primary care services and describe the care received prior to attending genitourinary medicine (GUM) clinics.

METHOD

A cross-sectional survey of 1000 new patients attending GUM services in Cornwall between June and December 2006. Patients were asked during consultation whether they had attended primary care before coming and what examination, investigation and management had been carried out there.

RESULTS

35% (348/1000) of patients had attended primary care initially. Genital examination had been carried out in primary care on 60% (111/185) female and 58% (93/159) male patients (p = 0.78). Chlamydia testing had been carried out in 27% (46/171) female and 6% (8/139) male patients (p<0.005). 33% (100/301) patients seen in primary care had been offered treatment. 74% (68/92) patients with genital warts had been correctly diagnosed in primary care and 9% (8/92) of these offered treatment.

CONCLUSIONS

The majority of these patients, including those given a diagnosis and/or offered treatment in primary care, had not had a chlamydia test or any other investigations. With the potential "fall out" of patients between primary care and GUM services, this may represent a missed opportunity to detect and appropriately manage sexually transmitted infections.

Gefitinib and irinotecan in patients with fluoropyrimidine-refractory, irinotecan-naive advanced colorectal cancer: a phase I-II study

BACKGROUND

To establish the recommended dose level (RDL) and to evaluate the efficacy and safety of gefitinib plus irinotecan in patients with advanced fluoropyrimidine-refractory colorectal cancer (CRC).

PATIENTS AND METHODS

Patients with advanced CRC progressing on or within 12 weeks of fluoropyrimidine-based chemotherapy, irinotecan naive and performance status of two or less were recruited. During dose-finding phase, dose-limiting toxicity (DLT) was encountered at dose level 1, therefore subsequent dose de-escalation and pharmacokinetic (PK) studies were carried out. The RDL was then expanded in a multicentre setting to further evaluate safety and efficacy.

RESULTS

From June 2002 to February 2005, 39 patients were treated in total with 27 at the RDL. The RDL was established at irinotecan 225 mg/m(2) every 3 weeks and gefitinib 250 mg daily. The DLTs were neutropenia and diarrhoea. For the patients treated at RDL, the objective tumour response rate was 11.1% (95% confidence interval 2.4% to 29.2%) and median survival was 9.3 months. PK studies indicated that the addition of irinotecan to gefitinib resulted in an average of 50% increase in exposure to gefitinib (P < 0.05), but gefitinib did not alter the PK profiles of irinotecan or SN-38. Grade 3-4 toxic effects in all patients included diarrhoea (35.9%), lethargy (15.4%), neutropenia (15.4%), febrile neutropenia (10.3%) and skin rash (7.7%).

CONCLUSIONS

Irinotecan and gefitinib at this dose schedule was tolerable, but gefitinib did not appear to add substantial efficacy to irinotecan.

Apo2L/TRAIL pharmacokinetics in a phase 1a trial in advanced cancer and lymphoma

3047

Background: Apo2L/TRAIL (Apo2L ligand/tumor necrosis factor-related apoptosis-inducing ligand) is the first recombinant human protein that selectively induces apoptosis or programmed cell death in cancer cells while sparing normal cells. The molecule used in this joint clinical development between Genentech, Inc. and Amgen, Inc., is an optimized recombinant human Apo2L/TRAIL protein produced in E. coli. It displays broad activity in preclinical models of a variety of solid and hematologic cancers. This is the first report of the pharmacokinetics of Apo2L/TRAIL in humans. Methods: Thirty-nine patients enrolled in a phase 1a study had PK assessments at dose levels ranging from 0.5–15 mg/kg in two cohorts, those with and those without liver metastases. Recombinant human Apo2L/TRAIL was administered as a 1-hr IV infusion for 5 consecutive days over a 21-day cycle. Serum concentrations were determined using a sensitive ELISA assay. PK calculations were performed using Non-compartmental analyses. Results: Currently Apo2L/TRAIL PK data are available for 27 patients, 15 in cohort 1 (no liver metastases) and 12 in cohort 2 (liver metastases). Mean (± SD) PK data for patients in cohort 1 and cohort 2 did not differ. PK data for cohort 1 are outlined in the table below. Apo2L/TRAIL clearance appeared proportional to dose and consistent with that predicted from nonclinical models. Cmax achieved at doses ≥ 4 mg/kg are equivalent to or greater than those displaying activity in preclinical models. There was no evidence of drug accumulation between day 1 and day 5 of treatment. Conclusions: Apo2L/TRAIL at doses which can be safely administered in humans produces serum concentrations consistent with those demonstrating efficacy in tumor xenograft models. Hepatic metastases with or without mild liver dysfunction do not appear to influence the PK of Apo2L/TRAIL.

[Table: see text]

[Table: see text]

Gefitinib and irinotecan in patients with fluoropyrimidine-refractory irinotecan-naïve advanced colorectal cancer (CRC): dose-finding, pharmacokinetics, safety and efficacy

13520

Background: Gefitinib (IRESSA) is an oral epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor that has shown supra-additive activity in human CRC xenografts when combined with irinotecan. We have previously established that the recommended dose level (RDL) to be irinotecan 225mg/m2 q3 weeks and gefitinib 250mg daily (Chau et al ASCO 2004). The dose limiting toxicities were neutropenia and diarrhoea. The continuation phase of this study aimed to evaluate the efficacy and safety of this combination. Patients and Methods: Between Jun 2002 and Feb 2005, patients (pts) with advanced CRC progressing on or within 12 weeks of fluoropyrimidines-based chemotherapy, irinotecan-naïve and performance status ≤2 were recruited. Thirty-nine pts were treated with irinotecan and gefitinib in total with 27 treated at the RDL. Results: Median age was 61 years (range: 31–79) and 13 (33.3%) pts were females. All pts were Caucasians (94.9%) and non-oriental Asians (5.1%). Thirteen (33.3%) pts had received (neo)adjuvant chemotherapy and 16 (41.0%) pts had prior oxaliplatin-based chemotherapy for metastatic disease. Grades 3–4 toxicities were anaemia 2.6%, neutropenia 15.4%, febrile neutropenia 10.3%, diarrhoea 35.9%, nausea 2.6%, vomiting 5.1%, lethargy 15.4% and skin rash 7.7%. For the pts treated at RDL, the objective tumour response rate was 11.1% (3 partial responses [PRs]; 95% confidence interval [CI]: 2.4–29.2%) and the disease control rate was 40.7% (3PRs, 8 stable diseases lasting for ≥12 weeks). The median time to progression was 4.2 months and median survival was 9.3 months. Six-month progression free survival was 22.2% (95% CI: 6.5–37.9%) and 6-month overall survival was 73.4% (95% CI: 56.5–90.3%). Preliminary pharmacokinetic data suggested that the addition of irinotecan to gefitinib resulted in an average of 14–33% increase in exposure to gefitinib (p<0.05). Conclusions: Irinotecan and gefitinib at this dose schedule was tolerable. Gefitinib did not appear to add substantial efficacy to irinotecan. The relative low dose of irinotecan at the RDL and the rarity of EGFR somatic mutation in CRC may be contributory to the modest activity of irinotecan and gefitinib combination.

[Table: see text]

SCOTROC 2A: carboplatin followed by docetaxel or docetaxel-gemcitabine as first-line chemotherapy for ovarian cancer

The feasibility of sequential carboplatin followed by docetaxel-based therapy for untreated ovarian cancer was determined. Patients received four q3w cycles of carboplatin AUC 7, then four q3w cycles of either docetaxel 100 mg m(-2) (day 1) (arm A); docetaxel 75 mg m(-2) (day 8) and gemcitabine 1250 mg m(-2) (days 1,8) (arm B) or docetaxel 25 mg m(-2) and gemcitabine 800 mg m(-2) (both given weekly (days 1,8,15)) (arm C). A total of 44 patients were randomised to each treatment arm. None of the arms demonstrated an eight cycle completion rate (70.5/72.7/45.5% in arms A/B/C, respectively), which was statistically greater than 60% (P=0.102, P=0.056, P=0.982) which was our formal feasibility criteria, although only the completion rate in arm C was clearly worse than this level. The overall response rate (ORR) after carboplatin was 65.7% in 70 evaluable patients. In evaluable patients, ORRs after docetaxel-based cycles were: arm A 84.0% (21 out of 25); arm B 77.3% (17 out of 22); arm C 69.6% (16 out of 23). At follow-up (median 30 months), median progression-free survival times were: arm A 15.5 months (95% CI: 10.5-20.6); arm B 18.1 months (95% CI: 15.9-20.3); arm C, 13.7 months (95% CI: 12.8-14.6). Neutropenia was the predominant grade 3-4 haematological toxicity: 77.8/85.7/54.4% in arms A/B/C, respectively. Dyspnoea was markedly increased in both gemcitabine-containing arms (P=0.001) but was worse in arm C. Although just failing to rule out eight cycle completion rates less than 60%, within the statistical limitations of these small cohorts, the overall results for arms A and B are encouraging. Larger phase III studies are required to test these combinations.