The effectiveness of structured physical activity on agitation in people with dementia: a rapid review

OBJECTIVES

Managing agitation and other behaviours that challenge is a significant dementia care challenge. The priority is to find effective non-pharmacological interventions as drug treatments can have significant side effects. This review evaluates the effectiveness of structured physical activity on agitation in dementia.

METHOD

Our rapid review searched four electronic databases, Cochrane CENTRAL, MEDLINE, CINAHL and Embase, for interventional studies using a structured physical activity programme in people with dementia and studied the effect of this activity on behaviours that challenge. Study quality was assessed using CASP criteria and data was narratively synthesised.

RESULTS

We included 13 studies in this review (four rated as high quality), involving a total of 1546 participants. Results were analysed according to exercise type, frequency and intensity of the intervention. Exercise is effective in reducing agitation and studies with higher adherence to exercise demonstrated more positive effects on agitation and behaviours that challenge.

CONCLUSION

Physical activity can be effective in reducing agitation in older adults with dementia. Further research is needed to clarify the type of intervention that is most beneficial. Strategies to make physical activity more acceptable and available to people with dementia need to be established.

Abstract ES8-1: Adjuvant endocrine therapy in 2020: It's complicated

Adjuvant endocrine therapy in 2020: It’s complicated Data regarding the use of adjuvant endocrine therapy in patients with hormone receptor-positive early breast cancer has grown over the past decades, and yet still uncertainty remains in management recommendations. In pre-menopausal women, treatment decisions are often driven by estimation of risk of recurrence, measured in terms of clinical and pathological parameters, algorithm-based prognostic modelling derived from breast cancer registries, molecular profiling and gene signature assays. Despite these significant advances, risk of distant disease recurrence is still over-estimated in a significant proportion of women. The addition of ovarian suppression to tamoxifen in pre-menopausal women has been shown to increase rates of both disease-free survival and overall survival than tamoxifen alone, with the use of the steroidal aromatase inhibitor exemestane producing further higher rates of freedom from recurrence. However, the addition of ovarian suppression in this generally low-risk population comes at the cost of increased adverse events and potential to interpose child-bearing years. Further to this, the SOFT/TEXT studies mandated five years of active treatment; little is known as to whether extended treatment beyond those five years would be comparatively equal, better or worse in terms of outcome endpoints.

In the post-menopausal population, the updated ASCO Clinical Practice Guideline suggests that all women with node-positive disease should be offered extended therapy including an aromatase inhibitor for a total of ten years, as well as women with node-negative disease possessing high-risk prognostic factors. The question of how best to identify those women who may fare equally well with de-escalated, shorter therapy remains open. The issue of adverse events and drug-related side effects, particularly in the setting of extended therapy, is relevant and may impact negatively on overall treatment compliance and quality of life. As such, the choice of endocrine therapy remains an important consideration, as is evidence that intermittent administration of aromatase inhibitors may be feasible in selected patients.

CDK4/6 inhibitors, administered in tandem with endocrine therapy, have radically changed the approach to managing metastatic endocrine receptor-positive disease. There is now much interest in moving these agents forward into the neoadjuvant and adjuvant setting, with a number of phase II and III trials ongoing. If positive data is consistently reported in adjuvant studies, this will undoubtedly create another layer of complexity to the clinical management of endocrine-sensitive disease.

Citation Format: A McCartney, A Di Leo. Adjuvant endocrine therapy in 2020: It's complicated [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr ES8-1.

Palbociclib as single agent or in combination with the endocrine therapy received before disease progression for estrogen receptor-positive, HER2-negative metastatic breast cancer: TREnd trial

Background

The activity of palbociclib as a single agent in advanced breast cancer has not been extensively studied, with the only available clinical data limited to heavily pretreated patients. Preclinical data suggests palbociclib may partially reverse endocrine resistance, though this hypothesis has not been evaluated in previous clinical studies. This phase II, open-label, multicenter study examined the activity of palbociclib monotherapy, as well as palbociclib given in combination with the same endocrine therapy (ET) that was received prior to disease progression, in postmenopausal women with moderately pretreated, estrogen receptor-positive, HER2 negative advanced breast cancer.

Patients and methods

Eligible women with advanced disease which had progressed on one or two prior ETs were randomized 1 : 1 to receive either palbociclib alone, or palbociclib in combination with the ET as previously received. Primary end point was clinical benefit rate (CBR); secondary end points included progression-free survival (PFS).

Results

Between October 2012 and July 2016, a total of 115 patients were randomized. The CBR was 54% [95% confidence interval (CI): 41.5-63.7] for combination therapy, and 60% (95% CI: 47.8-72.9) for monotherapy. Median PFS was 10.8 months (95% CI: 5.6-12.7) for combination therapy, and 6.5 months (95% CI: 5.4-8.5) for monotherapy [hazard ratio (HR) 0.69; 95% CI: 0.4-1.1, exploratory P-value = 0.12]. Exploratory analyses revealed the PFS advantage for combination therapy was seen in the subgroup of patients who received prior ET for >6 months (HR 0.53; 95% CI: 0.3-0.9, exploratory P-value = 0.02), but not in those who received prior ET for ≤6 months.

Conclusion

Palbociclib has clinical activity as a single agent in women with moderately pretreated, oestrogen receptor-positive, HER2-negative advanced breast cancer. Palbociclib may have potential to reverse endocrine resistance in patients with a history of previous durable response to ET.

Clinical trial information

NCT02549430.

Abstract P6-09-02: Effects of palbociclib on thymidine kinase-1 (TK1) in hormone receptor positive (HR+) breast cancer cell lines

Introduction: TK1 plays a crucial role in DNA synthesis and is a well-established marker of cell proliferation. We and others have previously described the potential role of TK1 activity (TKa) as predictive biomarker of response to endocrine therapy in HR+/HER2 negative metastatic breast cancer patients. TK1 synthesis is regulated by the E2F pathway, the target pathway of CDK4/6 inhibitors, and TKa has recently been reported as a potential circulating pharmacodynamic marker of CDK4/6 inhibition in breast cancer. However, modulations of TK1 levels and activity during palbociclib treatment and in the development of treatment resistance are unknown. Here, we report how TK1 expression and TKa are modulated in response to palbociclib in a panel of HR+ breast cancer cell lines: both palbociclib-sensitive (PDS) and with acquired resistance to (PDR).

Material and methods: We used a panel of 7 PDR HR+ breast cancer models previously developed in our lab via chronic exposure of parental cells (MCF7, T47D, ZR75-1, BT474, MDAMB361 and two MCF7 endocrine resistant derivatives) to escalating doses of palbociclib, from a Starting Treatment Concentration (STC) of 50 nM or 350 nM according to the cell line, up to 1 μM. We analyzed gene expression profiles of PDS cells treated with drug vehicle (DMSO) as a control or palbociclib at STC for 3 days, and PDR cells grown with palbociclib 1 μM. Cell proliferation was assessed by methylene blue assay in MCF7 and BT474 PDS and PDR treated for 3, 6 and 9 days with DMSO, palbociclib STC and 1 μM. In parallel, TKa was measured in cell lysates at 3 days of treatment using the DiviTumTM assay (Biovica, Sweden).

Results: Among E2F target genes, gene expression data demonstrated that TK1 was one of the most differentially expressed genes between PDR and PDS treated cells. In PDS cells compared to control, treatment with palbociclib resulted in reduced TK1 expression, with the HER2 positive models (BT474 and MDAMB361) showing the highest reduction. In PDR cells, TK1 expression was higher, but remained slightly inhibited compared to untreated PDS cells. TKa was significantly reduced in PDS cells treated with palbociclib for 3 days compared to vehicle (p<0.05). TKa response to palbociclib was more dramatic in BT474 cells as compared to MCF7. As expected, palbociclib inhibited cell proliferation in PDS models, with a significant reduction observed only after 6 days of treatment, suggesting that TKa may be an early marker of growth inhibition in response to palbociclib. No significant alterations in TKa were observed in PDR cells, at any dose of palbociclib. Similarly, proliferation rate was not affected by palbociclib in PDR cells.

Conclusions: TK1 expression and activity are regulated by palbociclib in HR+ breast cancer cell lines, particularly in HER2 positive models. Ongoing studies of TKa in patients treated with palbociclib will assess the role of TKa as a circulating biomarker for predicting and monitoring response to CDK4/6 inhibitors.

Citation Format: Bonechi M, Migliaccio I, Benelli M, Romagnoli D, Bergqvist M, Mattsson K, Boccalini G, Capaccioli G, De Luca F, Galardi F, Biagioni C, Risi E, McCartney A, Rossi L, Osborne CK, Schiff R, De Angelis C, Guarducci C, Di Leo A, Malorni L. Effects of palbociclib on thymidine kinase-1 (TK1) in hormone receptor positive (HR+) breast cancer cell lines [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-09-02.

An educational initiative in anaesthetic nursing practice

The National Board for Nurses, Midwives and Health Visitors in Northern Ireland (NBNI) has adopted the principles of the UKCC's recommendations for specialist nursing practice and Incorporated these within their continuing education framework. Stage two of this framework decrees the standard required for specialist nursing practice (NBNI, 1995) and, as a result, a specialist anaesthetic nursing course has been instigated. The course extends over 44 weeks and includes 8 weeks of consolidation practice, comprising seven modules at degree and diploma level. The course gives the students an opportunity to deepen their knowledge, skills and attitudes in the field of anaesthetic nursing. Nurses were taught the necessary skills to work in collaboration with other professionals, patients and families in order to coordinate a patient-centred approach to perianaesthetic care. The role of the anaesthetic nurse specialist should be viewed as complementary to that of the anaesthetist. This course facilitates and encourages practitioners to move beyond registered practice on qualifying to a more specialized role where care is delivered in an innovative and creative manner.

Characterization of cellular infiltration in choroidal melanoma

An immunohistochemical double staining technique was used to examine the characteristics of cellular infiltration in choroidal melanoma. Seven of 16 melanomas examined demonstrated high levels of cellular infiltration, mainly with T-cells and macrophages, and little infiltration with B-cells and NK cells. The majority of T-cells were of the CD8+ type and were activated, as shown by the expression of histocompatibility antigens, HLA-DR and IL2-R. Most of the infiltrating macrophages also expressed HLA-DR antigen. We also detected malignant melanocytes expressing the HLA-DR antigen. This technique could be used to study in detail cellular infiltration in a large number of archival choroidal melanomas with known clinical history, which would enable detection of markers that correlate with the prognosis of the disease.

Increased expression and mutation of p53 in choroidal melanoma

Using CM-1 antibody directed against the human p53 protein, high levels of mutant p53 protein expression were found in 12 out of 18 malignant choroidal melanomas. In contrast, we failed to observe elevated p53 expression, indicating the absence of p53 mutation in seven choroidal naevi, a potentially premalignant condition that can progress to form malignant melanoma. For two choroidal melanomas, we demonstrated that high levels of p53 protein were accompanied by exon 7 mutations. The mutations were found at codon 238, TGT-->TTT and codon 253, ACC-->AGC. These observations suggest that acquisition of abnormalities of the p53 gene may be an important step in the development of malignant melanoma.

Familial aggressive nevi of the iris in childhood

We report the occurrence of amelanotic melanocytic tumors of the iris arising in the second decade of life in two successive generations. Clinically, both tumors enlarged rapidly, with subsequent enucleation of the eye in one patient. In both cases, histologic examination revealed an aggressive iris nevus composed of spindle A cells. Both lesions had similar argyrophilic nucleolar organizing region counts, which may be of prognostic significance. A possible autosomal-dominant pattern of inheritance for this rare tumor is discussed.

Microbial keratitis--the false negative

The investigation of presumed microbial keratitis includes microscopy and culture of corneal specimens obtained by scraping the infiltrated cornea. Routine microscopy fails to identify the infecting organism in about 15% of cases. We discuss the problems presented by 20 such eyes which required further investigation. We present a diagnostic algorithm aimed at reducing the delay in identifying the pathogen and increasing the rate of positive culture. This is important since unusual pathogens may require treatment with drugs other than the 'first line' broad spectrum combination of an aminoglycoside and a cephalosporin. The algorithm allows sequential restaining and reculturing of specimens for more thorough investigation. In addition to the use of special stains and culture conditions, it presents indications for further corneal scrapes and biopsies. Uncontrolled infection resulted in five perforations and penetrating keratoplasty was indicated in 11 cases. The visual outcome for these patients was poor with fewer than 30% achieving 6/12 acuity. The delay in diagnosis increases morbidity and this should be significantly reduced by adopting the algorithm we propose.

Nucleolar organiser regions in iris melanocytic tumours: an accurate predictor?

A silver staining technique which demonstrates the nucleolar organiser region (NOR) was used in paraffin sections of iris naevi and melanomas. The technique shows argyrophilic NOR associated proteins (AgNORs) which are seen in nuclei as black dots. In nine iris naevi the AgNOR count ranged from 1.54 to 3.82 (mean 2.73), in 21 melanomas from 1.89 to 8.31 (mean 4.67). Mean AgNOR counts greater than four dots per nucleus were only seen in malignant lesions, thereby differentiating between benign and malignant tumours, whenever high AgNOR counts were found. We subsequently examined three tumours in the intermediate group of aggressive naevi, Jakobiec group 6: there were counts averaging 4.08 but with a wide standard deviation of counts indicating that the behaviour of this group of aggressive tumours is likely to depend on the percentage of cells bearing the higher numbers of NORs, which may represent mitotic potential or increased metabolic rate.

Two 46,XX,t(X;Y) females with linear skin defects and congenital microphthalmia: a new syndrome at Xp22.3

We describe two females with de novo X;Y translocations, who presented at birth with irregular linear areas of erythematous skin hypoplasia involving the head and neck, along with eye findings that included microphthalmia, corneal opacities, and orbital cysts. The features in these children are similar to but distinct from those seen in females with Goltz syndrome and incontinentia pigmenti. Cytogenetic analysis has shown the X chromosome breakpoint in both females to be at Xp22.3. We suggest that this syndrome is the result of a deletion or disruption of DNA sequences in the region of Xp22.3.

Pigmentation of the eyelid margin accompanying conjunctival melanoma

In a review of patients with histologically verified malignant melanoma of the conjunctiva, we found 17 patients who had heavy pigmentation of the ipsilateral eyelid margin that was visible on external examination. Among nine patients in whom the histologic characteristics of the skin pigmentation could be studied, the features ranged from an increase in pigmentation of melanocytes within the basal layer to invasive malignant melanoma. The presence of heavy skin pigmentation in association with conjunctival melanoma appeared to be an ominous sign, even when the eyelid did not show histologic features of malignancy. Twelve of the 17 patients (70%) died of metastases after histologic verification of the conjunctival melanoma.

Malignant melanomas of the conjunctiva, nasal cavity, and paranasal sinuses

Four patients had malignant melanoma involving the conjunctiva, nasal cavity, and paranasal sinuses. In each patient, the conjunctival melanoma preceded recognition of the lesion in the nasal cavity by months or years. Each patient had one or more conjunctival biopsy specimens that documented melanoma, and in each patient the melanomas evolved in primary acquired melanosis of the conjunctiva. Histologic examination of the epithelium adjacent to the tumor in the nasal cavity failed to show either atypia or diffuse melanosis. We believe that these melanomas in the nasal cavity and paranasal sinuses are most likely to evolve as regional metastases, although it is possible that they arise de novo or as related foci in accordance with the multicentric characteristics of conjunctival melanoma. If a patient with a conjunctival melanoma has symptoms referable to the nasal cavity or paranasal sinuses, ophthalmologists should refer the patient to an otolaryngologist.

Ocular injuries associated with the use of airguns

Sixty patients with eye injuries resulting from the use of airguns were admitted to a large eye hospital over an 11-year period. The typical patient was a young male teenager; 70 per cent of patients were under the age of 17, the age at which it is legally permissible to own an air weapon. In 4 cases the missile lodged in the ocular adnexae, in 18 cases there was a penetrating eye injury and in 38 patients blunt nonpenetrating eye injury. The prognosis for visual recovery was poor especially following penetration of the globe; visual acuity was reduced to 6/60 or less in 40 per cent of all eyes and in 18 per cent the injured eye was excised.

Congenital hereditary corneal oedema of Maumenee: its clinical features, management, and pathology

The clinical and histological features of congenital hereditary corneal oedema in 23 patients are presented. The series includes cases of both recessive and dominant inheritance. Although the condition is present at birth or in early childhood, visual development appears to be little impaired, if at all. Penetrating keratoplasty carries a relatively good surgical prognosis and can produce a substantial visual gain even when carried out late in life.

Postcholecystectomy syndrome and its association with ampullary stenosis

Fifty-six consecutive patients returning with recurrent or persistent upper abdominal pain after cholecystectomy were studied by endoscopic retrograde cholangiopancreatography, abdominal ultrasound and morphine neostigmine test. In 44 patients, pain recurred within 6 months after cholecystectomy. Forty patients were demonstrated on endoscopic retrograde cholangiopancreatography to have moderate to marked ampullary stenosis, which occurred as an isolated abnormality in 32 patients and in association with pancreatitis in 8. Thirteen patients were found to have pancreatitis, and 6 had retained common duct stones. In five patients no definite abnormality was demonstrated. The morphine neostigmine test was positive in 16 of 17 patients with isolated ampullary stenosis and in only 1 of 8 with pancreatitis. This test may be helpful in patients who are to undergo cholecystectomy. In those with positive results, endoscopic retrograde cholangiopancreatography would help assess the size of the ampullary sphincter so that sphincteroplasty could be done at the time of cholecystectomy in appropriate patients.