Review article: the practical management of acute severe ulcerative colitis

BACKGROUND

Acute severe ulcerative colitis (ASUC) is a life-threatening condition for which optimal management strategies remain ill-defined.

AIM

To review the evidence regarding the natural history, diagnosis, monitoring and treatment of ASUC to inform an evidence-based approach to management.

METHODS

Relevant articles addressing the management of ASUC were identified from a search of MEDLINE, the Cochrane Library and conference proceedings.

RESULTS

Of ASUC, 31-35% is steroid-refractory. Infliximab and ciclosporin salvage therapies have improved patient outcomes in randomised controlled trials. Short-term response rates (within 3 months) have ranged from 40% - 54% for ciclosporin and 46-83% for infliximab. Long-term clinical response rates (≥1 year) have ranged from 42%-50% for ciclosporin and 50-65% for infliximab. Short-term and long-term colectomy rates have been respectively: 26-47% and 36-58% for ciclosporin, and 0-50% and 35-50% for infliximab. Mortality rates for ciclosporin and infliximab-treated patients have been: 0-5% and 0-2%, respectively. At present, management challenges include the selection, timing and assessment of response to salvage therapy, utilisation of therapeutic drug monitoring and long-term maintenance of remission.

CONCLUSIONS

Optimal management of acute severe ulcerative colitis should be guided by risk stratification using predictive indices of corticosteroid response. Timely commencement and assessment of response to salvage therapy is critical to reducing morbidity and mortality. Emerging pharmacokinetic models and therapeutic drug monitoring may assist clinical decision-making and facilitate a shift towards individualised acute severe ulcerative colitis therapies.

Stroke survivors' preferences for post-stroke self-management programs: A discrete choice experiment

BACKGROUND AND PURPOSE

Self-management programs enhance survival in stroke patients. However, they require patient-centered designs to be effective. The aim of this study was therefore to investigate the type of post-stroke self-management programs that appeal to stroke survivors, and to estimate their willingness to participate in such programs.

METHODS

A Discrete Choice Experiment was administered to patients who had either a transient ischemic attack (TIA) or stroke within the past 3 years and were cognitively intact (i.e., stroke survivors). Stroke survivors were presented with eight choice tasks and asked to choose between 'No Program' and two hypothetical post-stroke management programs that varied by six attributes: Topics covered by the program; schedule of the program; frequency and duration of the sessions; number of participants; out-of-pocket registration fee for the whole program; and rewards for completing the program.

RESULTS

The analysis involved 146 stroke survivors. Based on the mixed logit model, the predicted willingness to participate ranged from 53% to 76%. The most popular characteristics in a program were topics on health education and risk management, being scheduled during weekends as four sessions that are each 2 hours long and involve four participants, a registration fee of SGD50 (∼USD36), and SGD500 (∼USD359) reward for program completion.

CONCLUSIONS

Interest in post-stroke self-management programs was high, with at least half of the sample showing interest in participating in these programs. Program features such as focusing on health education and risk management, charging a low registration fee, and offering incentives helped to increase the demand.

Exploring the Use of Virtual Reality for the Delivery and Practice of Stress-Management Exercises

Background

Mindfulness-based interventions may benefit healthcare professionals with burnout symptoms. Virtual reality (VR) may reduce initial difficulty of engaging in mindfulness exercises and increase participants’ engagement through immersion and presence.

Aim

The aim was to investigate how VR affects participants’ experience of engagement with mindfulness practice, and its impact on quality of practice and negative mood states.

Methods

Fifty-one healthcare professionals were randomized to receive either a visualization or non-visualization mindfulness practice, to compare the quality of practice through the use of audio only vs. with a virtual reality interface. Selected self-reported measures were collected during the session (immersion, quality and difficulty of practice, mood states and likelihood for future practice).

Results

Results showed that order instead of type of modality administered made a difference in quality of mindfulness practice. A greater sense of presence was reported with VR if administered after audio (F = 4.810, p = 0.033, Partial η² = 0.093). Further, participants described difficulty practicing with audio if administered after VR (F = 4.136, p = 0.048, Partial η² = 0.081). Additionally, lower mood disturbance was reported with VR if administered after audio (F = 8.116, p = 0.006, Partial η² = 0.147). Qualitative responses echoed a preference for VR to engage better, in addition to improved mood states after practice.

Conclusion

Findings suggest that VR has the potential to provide healthcare professionals with an alternative or a supplement to conventional mindfulness practice.

Abstract P6-11-09: Impact of tumor subtype on clinical features, treatment, and clinical outcomes among breast cancer patients with central nervous system disease

Background: Breast cancer is the second most common cancer associated with brain metastases. For some patients, central nervous system (CNS) progression is the primary clinical problem, and the optimal management of these patients remains a challenge. In this study we examined the differences in clinical characteristics, the features of CNS-directed therapy, and outcomes among breast cancer patients with brain metastases according to tumor subtype.

Methods: A retrospective series of 214 breast cancer patients with brain metastases treated at the Dana-Farber Cancer Institute from 1999-2011 was identified. Tumor subtype was classified as hormone receptor (HR)+ (ER+/PR+/HER2-), triple negative (ER-/PR-/HER2-) or HER2+ (HER2+, any HR). Descriptive analysis was performed; Chi-square, Kruskal-Wallis, and Kaplan-Meier methods were used to compare clinical characteristics, CNS-directed therapy features, and outcomes between groups.

Results: Median follow-up time since CNS progression was 8 months (0-117). Median age at CNS diagnosis was 52 years (30-82). Tumor subtype distribution was as following: 35% HR+, 36% HER2+, and 29% triple negative. Table 1 represents the clinical characteristics, CNS-directed therapy features, and outcomes according to tumor subtypes. More patients with triple negative disease (32%) had CNS involvement at presentation of metastatic disease. 8% of HER2+ patients had CNS as the only site of disease. A higher proportion of patients with HER2+ disease received more than one modality of CNS directed treatment as initial therapy. These patients also received more lines of CNS-directed therapy during the entire course of their disease. The median survival time after CNS progression differed by subtype; patients with HER2+ disease had the longest median survival times.

Conclusions: Tumor subtype appears to impact clinical presentation, type and number of CNS-directed therapies, and survival among patients with breast cancer with brain metastases.

Table 1 Tumor subtype HR+ (n = 74, 35%)HER2+ (n = 78, 36%)Triple negative (n = 62, 29%)P-valueBreakdown of treatment periods 0.2011999-200334%45%29% 2004-200628%17%31% 2007-201138%38%40% Clinical features at CNS disease presentationCNS disease at presentation of metastatic disease,%1522320.052Only site of metastatic disease,%181 Time from metastatic disease until CNS disease (median, min-max; months)16 (0-113)12 (0-65)6 (0-60)<0.001Type of CNS disease,%   0.004Brain only849589 Leptomeningeal disease only040 Brain and leptomeningeal disease16111 Number of CNS lesions,%   0.4141202921 2-3151413 4+625666 Unknown300 CNS-directed therapy1st CNS-directed therapy,% 0.126Surgery553 Whole brain radiotherapy725660 SRS896 Experimental drug135 More than one modality directed to CNS82721 Never received a CNS-directed therapy505 CNS-directed therapy (first and subsequent treatments combined),%    Surgery113360.003SRS154421<0.001Whole brain radiotherapy8788850.866Intrathecal therapy114150.085Systemic therapy3215<0.001Number of CNS-directed treatments (median, min-max)1 (0-6)2 (1-9)1 (0-5)<0.001Clinical outcomesSurvival times (median, min-max; months)6 (0-83)22 (1-117)4 (0-110)<0.001Events,%9697980.016

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-11-09.

Abstract P5-18-03: Clinicopathological features among patients with HER2-positive breast cancer with prolonged response to trastuzumab based therapy

Background: HER2-positivity is a predictor of benefit from trastuzumab (TRZ), but fails to depict the observed interpatient variability in terms of treatment (tx) duration. In this study we described the relationship between clinicopathological features and TRZ tx duration.

Methods: A retrospective consecutive series of 343 HER2+ breast cancer (BC) patients (pts) treated with TRZ at the Dana-Farber Cancer Institute from 1999–2008 was identified. 139 pts treated with 1st line TRZ-based tx were selected for analysis. Pts who received any non-TRZ prior tx for metastatic disease were excluded. TRZ tx duration was defined as time from start of 1st line therapy to the 1st day of 2nd line therapy or death. Central nervous system (CNS) progression with TRZ maintenance was not considered change of tx. Pts were divided equally into 3 groups based on the duration of 1st line tx distribution. Short-term responders (STR) were on the 1st line tx for <7 months (m), intermediate responders (IR) 7–15m and long responders (LTR) for >15m. An additional group of extremely LTR (ELTR) was defined as being in the 90th percentile of tx duration (>37m). Descriptive analysis was performed; fisher exact test, Kruskal-Wallis and logistic regression methods were used to compare groups.

Results: Median follow-up time since metastatic diagnosis was 4 years (y) (range 0–11). Median age at diagnosis was 47y (22–83), 25% of stage I-III pts at diagnosis received adjuvant/neoadjuvant TRZ. The median disease free interval (DFI) was 20m (0–172), median number of metastatic sites was 2(1–5), 68% of pts had visceral disease. Median duration of 1st line tx was 10m (2–105). TRZ was given with CT in 86%, hormone tx in 6% and as monotherapy in 9%. 25% of pts developed CNS progression and continued tx. There were only small absolute differences for clinicopathological characteristics among STR, IR and LTR.