An Overview of Treating People with Comorbid Dementia: Implications for Cancer Care

With increasing prevalence of both cancer and dementia in the UK, due to an ageing population, oncology healthcare professionals will experience higher numbers of people with both conditions. As dementia is highly heterogeneous and symptoms vary from individual to individual, it presents specific challenges for healthcare professionals, people with dementia and caregivers alike. This overview will describe current theories that explain the association between cancer and dementia, report prevalence rates and highlight the evidence on the impact of having a diagnosis of dementia on outcomes along the cancer pathway from cancer symptom detection to cancer treatment outcomes. It suggests that although prevalence rates of cancer and dementia are typically lower than other comorbidities, people with cancer and dementia have poorer cancer-related outcomes. This includes later stage cancer diagnoses, fewer cancer treatment options and an increased risk of death compared with people who have cancer alone or other comorbid conditions. Considerations for cancer treatment decision making and management are proposed to improve patient experience for this group.

A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care

OBJECTIVES

A comorbid diagnosis of cancer and dementia (cancer-dementia) may have unique implications for patient cancer-related experience. The objectives were to estimate prevalence of cancer-dementia and related experiences of people with dementia, their carers and cancer clinicians including cancer screening, diagnosis, treatment and palliative care.

METHOD

Databases were searched (CINAHL, Psychinfo, Medline, Embase, BNI) using key terms such as dementia, cancer and experience. Inclusion criteria were as follows: (a) English language, (b) published any time until early 2016, (c) diagnosis of cancer-dementia and (d) original articles that assessed prevalence and/or cancer-related experiences including screening, cancer treatment and survival. Due to variations in study design and outcomes, study data were synthesised narratively.

RESULTS

Forty-seven studies were included in the review with a mix of quantitative (n = 44) and qualitative (n = 3) methodologies. Thirty-four studies reported varied cancer-dementia prevalence rates (range 0.2%-45.6%); the others reported reduced likelihood of receiving: cancer screening, cancer staging information, cancer treatment with curative intent and pain management, compared to those with cancer only. The findings indicate poorer cancer-related clinical outcomes including late diagnosis and higher mortality rates in those with cancer-dementia despite greater health service use.

CONCLUSIONS

There is a dearth of good-quality evidence investigating the cancer-dementia prevalence and its implications for successful cancer treatment. Findings suggest that dementia is associated with poorer cancer outcomes although the reasons for this are not yet clear. Further research is needed to better understand the impact of cancer-dementia and enable patients, carers and clinicians to make informed cancer-related decisions.

Drug-induced toxicity and patient reported outcomes in rheumatoid arthritis patients following intensive treated-to-target strategy: does ceasing therapy due to toxicity worsen outcomes in long term?

AIM

While the introduction of the treat-to-target (T2T) strategy has been an important advance in the management of rheumatoid arthritis (RA), the potential for increased toxicity due to use of concurrent drugs could adversely affect patient reported outcomes (PROs). The objective was to determine whether the cessation of therapy due to toxicity affects long-term improvement in PROs in patients treated according to T2T strategy.

METHODS

A total of 149 patients from an inception cohort of early RA were included. The occurrence and severity of toxicity were monitored at each visit over 3 years. PROs studied were function (measured using health assessment questionnaire); pain, fatigue and patient global assessment (PtGA) all assessed using a 100 mm visual analogue scale; helplessness and health-related quality of life (HRQoL). For each PRO, effect of drug withdrawal was measured by comparing mean change in PROs among patients with no/temporary vs. permanent withdrawal. In addition, effects of frequency of drug withdrawals, weeks to withdrawal and number of drugs withdrawn were analysed using linear regression.

RESULT

After 3 years, 56 (37.4%) patients ceased at least one drug permanently due to toxicity. Patients with no/temporary withdrawal (n = 93) achieved significantly greater improvement in function (mean change = -0.54 vs. -0.31, p = 0.033), pain (mean change = -39.82 vs. -5.02, p = 0.018), fatigue (mean change = -29.14 vs. -14.76, p = 0.015) and PtGA (mean change = -29.64 vs. -17.00, p = 0.018) compared with their counterparts. Higher frequency of withdrawals was associated with lesser improvements in function, pain, fatigue and PtGA, while the number of drugs withdrawn and the weeks to withdrawal had lesser effects. However, the cessation of the drugs due to their toxicity did not have a significant association with HRQoL and helplessness.

CONCLUSION

Improvements in function, pain, fatigue and PtGA at 3 years were diminished for patients who ceased drugs due to toxicity while broader measures of HRQoL were not affected.

The human fetal lymphocyte lineage: identification by CD27 and LIN28B expression in B cell progenitors

CD27, a member of the TNFR superfamily, is used to identify human memory B cells. Nonetheless, CD27(+) B cells are present in patients with HIGM1 syndrome who are unable to generate GCs or memory B cells. CD27(+)IgD(+) fetal B cells are present in umbilical cord blood, and CD27 may also be a marker of the human B1-like B cells. To define the origin of naïve CD27(+)IgD(+) human B cells, we studied B cell development in both fetal and adult tissues. In human FL, most CD19(+) cells coexpressed CD10, a marker of human developing B cells. Some CD19(+)CD10(+) B cells expressed CD27, and these fetal CD27(+) cells were present in the pro-B, pre-B, and immature/transitional B cell compartments. Lower frequencies of phenotypically identical cells were also identified in adult BM. CD27(+) pro-B, pre-B, and immature/transitional B cells expressed recombination activating gene-1, terminal deoxynucleotidyl transferase and Vpre-B mRNA comparably to their CD27(-) counterparts. CD27(+) and CD27(-) developing B cells showed similar Ig heavy chain gene usage with low levels of mutations, suggesting that CD27(+) developing B cells are distinct from mutated memory B cells. Despite these similarities, CD27(+) developing B cells differed from CD27(-) developing B cells by their increased expression of LIN28B, a transcription factor associated with the fetal lymphoid lineages of mice. Furthermore, CD27(+) pro-B cells efficiently generated IgM(+)IgD(+) immature/transitional B cells in vitro. Our observations suggest that CD27 expression during B cell development identifies a physiologic state or lineage for human B cell development distinct from the memory B cell compartment.

CD27 expression patterns on human developing B cells in fetal and adult tissues (111.27)

CD27 is an accepted marker for memory B cells in humans. However, CD27 expression was recently demonstrated on substantial populations of human B cells in cord blood and fetal liver (FL), tissues that contain few if any memory B lymphocytes. In addition, CD27 expression was recently proposed to identify natural B cells, the human counterpart of murine B-1 B cells. These observations led us to explore the characteristics of human, CD27+ B cells, and particularly developing B cells. Comparing B cells from FL, cord blood, and adult bone marrow (BM), we found CD27 expression as early as the pro-B cell stage. Moreover, the frequency of CD27+ pro-B cells was higher in FL than in BM. Expression of TdT, RAG1 and VpreB in CD27+ pro-B cells was similar to conventional, CD27- pro-B cells, confirming their identity as B-lineage progenitors. Developmentally immature CD27- and CD27+ B cells showed no significant differences in VH gene usage, VH mutation frequencies, or CDRH3 length, excluding the possibility of contamination by memory B cells. Interestingly, when placed in an in vitro culture system optimized to support the maturation of human fetal pro-B cells and murine B-1 B cells, CD27+ pro-B cells differentiated into IgM+ immature and transitional B cells significantly more efficiently than did autochthonous CD27- pro-B cells. In conclusion, we have demonstrated functional CD27+ pro-B cells in FL and BM that may identify a predominantly fetal, B-cell lineage in humans.

AID expression during B-cell development: searching for answers

Expression of activation-induced cytidine deaminase (AID) by germinal center (GC) B cells drives the processes of immunoglobulin (Ig) somatic hypermutation (SHM) and class switch recombination (CSR) necessary for the generation of high affinity IgG serum antibody and the memory B-cell compartment. Increasing evidence indicates that AID is also expressed at low levels in developing B cells but to date, this early, developmentally regulated AID expression has no known function. Does the timing and extent of AID expression in developmentally immature, non-GC B cells provide clues to reveal its physiologic role?

Treatment-induced stable, moderate reduction in blood cell counts correlate to disease control in early rheumatoid arthritis

BACKGROUND

Treatment of rheumatoid arthritis (RA) has become more intensive, thereby raising concerns regarding toxicities, including leucopenia. The objective was to analyse cell counts obtained as routine surveillance for adverse effects to assess the effect of intensive treatment and treatment dosage and to examine correlations to disease activity scores.

METHODS

Patients with early RA were treated with combinations of disease-modifying anti-inflammatory drugs according to pre-defined rules, with dose adjustments contingent on residual disease activity and tolerance.

RESULTS

Mean leucocyte, neutrophil and platelet counts fell with levels that correlated to disease activity scores. The strongest correlation was between platelets and disease activity scores. There was a modest, inverse correlation between methotrexate dose and monocyte and lymphocyte counts. No serious toxicity associated with the therapy was seen.

CONCLUSION

Moderate reductions in cell counts are well tolerated in RA and appear to contribute to disease control.

Influence of ionic strength, electrolyte type, and NOM on As(V) adsorption onto TiO2

As(V) adsorption onto a commercially available TiO2 (Degussa P25) in NaCl or NaClO4 at various concentrations (0.001-0.1 M) was investigated. The effect of natural organic matter (NOM) on As(V) removal through the adsorption by TiO2 was also examined. In either electrolyte, As(V) adsorption onto TiO2 increased with the increase of ionic strength under alkaline conditions (pH 7.0-11.0). Under acidic conditions (pH 4.0-6.0), the adsorption of As(V) onto TiO2 was insensitive to ionic strength in NaClO4 electrolyte but decreased with increasing ionic strength in NaCl electrolyte. The presence of 2-15 mg/L NOM as C significantly decreased the fraction of As(V) adsorbed onto TiO2 at pH 6.0 regardless of the initial As(V) concentration (1-15 microM). The measurement of zeta potential of TiO2 with and without As(V) suggests that the presence of As(V) can shift the point of zero charge (pH(pzc)) of TiO2 to a lower pH value. The overall data presented in this study suggest that As(V) can form both inner-sphere and outer-sphere complexes on TiO2 surface, and NOM is an important factor controlling As(V) adsorption onto TiO2.

Relationship between elemental carbon, total carbon, and diesel particulate matter in several underground metal/non-metal mines

Elemental carbon (EC) is currently used as a surrogate for diesel particulate matter (DPM) in underground mines since it can be accurately measured at low concentrations and diesels are the only source of submicrometer EC in underground mines. A disadvantage of using EC as a surrogate for DPM is that the fraction of EC in DPM is a function of various engine parameters and fuel formulations, etc. In order to evaluate how EC predicts DPM in the underground mining atmosphere, measurements of total carbon (TC; representing over 80% of the DPM) and EC were taken away from potential interferences in four underground metal/non-metal mines during actual production. In a controlled atmosphere, DPM mass, TC, and EC measurements were also collected while several different types of vehicles simulated production with and without different types of control technologies. When diesel particulate filters (DPFs) were not used, both studies showed that EC could be used to predict DPM mass or TC. The variability of the data started to increase at TC concentrations below 230 microg/m3 and was high (> +/- 20%) at TC concentrations below 160 microg/m3, probably due to the problem with sampling organic carbon (OC) at these concentrations. It was also discovered that when certain DPFs were used, the relationship between DPM and EC changed at lower DPM concentrations.

Adaptation of the RAQoL for use in Australia

Quality of life is an important patient-reported outcome of rheumatoid arthritis (RA) in addition to structural and functional outcomes. The RAQoL (Rheumatoid Arthritis Quality of Life questionnaire) was developed in the UK and the Netherlands as a disease-specific tool. It was adapted for use in the Australian social context and the reliability and validity was tested. A lay panel assessed the UK version and adapted the wording for use within Australia. Reliability and validity were assessed by a postal survey of the RAQoL and comparator questionnaires to 100 patients with RA. The RAQoL was easily adapted into Australian-English. Test-retest reliability was high with a Spearman rank correlation coefficient of 0.93. RAQoL scores correlated well with patient-perceived disease activity and severity--indicating good validity. The Australian version of the RAQoL is a valid and reliable tool for the assessment of quality of life. It is practical, easy to administer and has good potential for use in clinical settings and trials in Australia.

Teacher discipline and child misbehavior in day care: untangling causality with correlational data

Day-care centers provide an ideal, underused setting for studying the developmental processes of child psychopathology. The influence of day-care teachers' lax and overreactive discipline on children's behavior problems was examined, as was the influence of children's behavior problems on teachers' discipline. Participants were 145 children and 16 day-care teachers from 8 classrooms in a day-care center for children from low-income families. Two techniques are presented for estimating causal relations based on correlational data gathered from day-care centers: 2-stage least squares and simultaneous structural equation modeling. Across techniques, teachers' laxness strongly influenced child misbehavior, and child misbehavior influenced both teachers' overreactivity and laxness. Teachers' overreactivity did not influence child misbehavior

Teacher discipline and child misbehavior in day care: untangling causality with correlational data

Day-care centers provide an ideal, underused setting for studying the developmental processes of child psychopathology. The influence of day-care teachers' lax and overreactive discipline on children's behavior problems was examined, as was the influence of children's behavior problems on teachers' discipline. Participants were 145 children and 16 day-care teachers from 8 classrooms in a day-care center for children from low-income families. Two techniques are presented for estimating causal relations based on correlational data gathered from day-care centers: 2-stage least squares and simultaneous structural equation modeling. Across techniques, teachers' laxness strongly influenced child misbehavior, and child misbehavior influenced both teachers' overreactivity and laxness. Teachers' overreactivity did not influence child misbehavior

Serotonergic agents that activate 5HT2A receptors prevent NMDA antagonist neurotoxicity

Phencyclidine, ketamine, and other agents that block NMDA glutamate receptors trigger a schizophrenia-like psychosis in humans and induce pathomorphological changes in cerebrocortical neurons in rat brain. Accumulating evidence suggests that a complex network disturbance involving multiple transmitter receptor systems is responsible for the neuronal injury, and it is proposed that a similar network disturbance is responsible for the psychotomimetic effects of NMDA antagonists, and might also be involved in the pathophysiology of schizophrenia. In the present study we present evidence that serotonergic agents possessing 5HT2A agonist activity prevent NMDA antagonist neurotoxicity in rat brain. It is proposed that 5HT2A agonists may also prevent the psychotomimetic effects of NMDA antagonists. Among the 5HT2A agonists examined and found to be neuroprotective are LSD and related hallucinogens. The apparent contradiction in proposing that these agents might have antipsychotic properties is resolved by evidence linking their hallucinogenic activity to agonist action at 5HT2C receptors, whereas antipsychotic activity would be attributable to agonist action at 5HT2A receptors.