Per-protocol investigation of a best practice exercise referral scheme

OBJECTIVES

To investigate the effects of an exercise referral scheme (ERS) aligned to the UK best practice guidelines on a range of outcomes including those associated with key health concerns of the Scottish population.

STUDY DESIGN

A longitudinal design with data collection at three time points (baseline, midway and post) during a 12-week ERS intervention was employed.

METHODS

Health-related physical fitness was assessed through measurement of resting heart rate, blood pressure, FEV1:FEV6 (ratio of forced expiratory volume over one [FEV1] and six [FEV6] seconds), body mass and peak oxygen uptake (VO₂ peak), whilst functional capacity was assessed through the five times sit to stand test. Psychosocial well-being and quality of life were measured using the World Health Organization Quality of Life questionnaire (WHOQOL-BREF) and the Profile of Mood State questionnaires. Growth curve analyses were used to model each outcome variable across the three time periods.

RESULTS

A range of effects were obtained with significant linear improvements in physical performance tests (P < 0.001) and psychosocial assessments (P ≤ 0.002). Additionally, significant quadratic effects of time were obtained for body composition variables and physical activity levels (P < 0.001) with the greatest improvements obtained between baseline and midway assessments.

CONCLUSIONS

An ERS aligned to the UK best practice guidelines can positively influence a range of health outcomes including those associated with lung function and cardiovascular fitness which are prevalent medical conditions in Scotland. In addition, results indicate that ERS can positively affect outcomes related to functional capacity as well as mental well-being and perceptions of health. The findings of the study identify the need for further investigation including consideration of the initial health status of referred clients.

Abstract B28: Tumor-associated macrophages and angiogenesis in prostate cancer

Introduction: Role of tumor associated macrophages (TAM) and angiogenesis is being extensively evaluated. Macrophages are subdivided in two phenotypes: M1 (classically activated: promote inflammation, act against cancer growth) and M2 (alternatively activated: promote healing, angiogenesis; could support tumor growth). Our preliminary study was intended to study number of macrophages (CD68 positive), M2 macrophages (CD163 positive) and microvessels (ERG positive) between non-neoplastic and neoplastic prostate tissue.

Methods: We evaluated 10 radical prostatectomy specimens (RP) with prostate cancer (PCA) (cases) and 10 cystoprostatectomy specimens (CP) negative for PCA (controls). Representative paraffin blocks were selected for analysis and stained by immunohistochemistry for CD68 PGM1, CD163 and ERG. For RP specimens, two distinct blocks were selected: one with tumor (RP-T) and one away from tumor (RP-NT). Macrophages count was done using two methods. Method 1: average manual count in 12 fields at 400X magnification in areas uninvolved by chronic inflammation (CI), away from hotspots. Method 2: average count in three hotspots (associated with CI) at 400X magnification with manual assistance on Aperio Image Spectrum Software. Vessels count was done using a Chalkley point counting technique at 100X magnification. Statistical analysis was done using t test and Pearson correlation.

Results: Different degree of CI was found in most CP and RP samples, ranging from focal mild to multifocal severe (hotspots). Mean age of CP and RP patients was 58 and 60 years, respectively. RP Gleason score ranged from 6 to 9. No significant difference in CD68, CD163 and ERG positive cells existed between the three groups by t-test. The CD68 count in RP-T was 104 by method 1 and 114 by method 2. The CD163 count in RP-T was 51 by method 1 and 54 by method 2. ERG count in RP-T was 6.9. A positive correlation of M2 macrophages (method 2) with microvessels in RP-T (p=0.046) was found. None of the counts correlated with Gleason score.

Conclusions: Our preliminary study found no significant difference in TAM between non-neoplastic and neoplastic prostate tissue, independently from the association with CI. The vessel count in prostate tumor positively correlated with M2 macrophages, suggesting a possible crosstalk between M2 macrophages and tumor cells promoting angiogenesis. These findings require further validation in additional studies including a larger sample size.

Citation Format: Pallavi Patil, Paula Carver, Karen Streator Smith, Jeffrey Lin, Cristina Magi-Galluzzi. Tumor-associated macrophages and angiogenesis in prostate cancer. [abstract]. In: Proceedings of the AACR Special Conference: Tumor Angiogenesis and Vascular Normalization: Bench to Bedside to Biomarkers; Mar 5-8, 2015; Orlando, FL. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl):Abstract nr B28.

Gene expression profiling of serrated polyps identifies annexin A10 as a marker of a sessile serrated adenoma/polyp

Sessile serrated adenomas/polyps (SSA/Ps) are precursors of colon cancer, particularly those that exhibit microsatellite instability. Distinguishing SSA/Ps from the related, but innocuous, microvesicular hyperplastic polyp (MVHP) can be challenging. In this study seven gastrointestinal pathologists reviewed 109 serrated polyps and identified 60 polyps with histological consensus. Microarray analysis was performed on six distal consensus MVHPs < 9 mm, six proximal consensus SSA/Ps > 9 mm, and six normal colon biopsies (three proximal, three distal). Comparative gene expression analysis confirmed the close relationship between SSA/Ps and MVHPs as there was overlapping expression of many genes. However, the gene expression profile in SSA/Ps had stronger and more numerous associations with cancer-related genes compared with MVHPs. Three genes (TFF2, FABP6, and ANXA10) were identified as candidates whose expression can differentiate SSA/Ps from MVHPs, and the differences in expression were confirmed by quantitative RT-PCR. As ANXA10 showed the most promise in differentiating these polyps, the expression of ANXA10 was evaluated by immunohistochemistry in consensus SSA/Ps (n = 26), MVHPs (n = 21), and normal colon (n = 9). Immunohistochemical expression of ANXA10 was not identified in separate samples of normal colon or in the normal colonic epithelium adjacent to the serrated polyps. Consistent with the microarray and quantitative RT-PCR experiments, immunohistochemical expression of ANXA10 was markedly increased in SSA/Ps compared to MVHPs (p < 0.0001). An ANXA10 score ≥ 3 has a sensitivity of 73% and a specificity of 95% in the diagnosis of an SSA/P. In conclusion, we show that SSA/Ps and MVHPs have significant overlap in gene expression, but also important differences, particularly in cancer-related pathways. Expression of ANXA10 may be a potential marker of the serrated pathway to colon cancer.

Abstract 11: Arginine deprivation therapy using ADI-PEG20 as a novel therapeutic modality in the treatment of bladder cancer

Background: Argininosuccinate synthetase (ASS1) catalyzes the rate limiting step in the biosynthesis of arginine. ASS1-deficient tumors are therefore candidates for arginine deprivation therapy, utilizing ADI-PEG20 as it degrades circulating arginine. We therefore evaluated 187 patients with bladder cancer, who underwent radical cystectomy between 1988 and 2008 at our institution for ASS1 expression. ASS1 was evaluated as a predictor of disease outcome, while in-vitro studies were conducted to assess the therapeutic efficacy of ADI-PEG20 in representative cell lines.

Design: ASS-1 expression was assessed by immunostaining and stratified based on moderate to strong expression (2+, 3+) versus absent to weak expression (0 or 1+). Both univariate and multivariate statistical analysis of ASS1 expression, along with various clinical parameters, was carried out to determine the effect on overall (OS) and progression-free (PFS) survival. In addition, multiple bladder cancer cell-lines were screened for ASS1 expression and utilized as an in-vitro model. Downstream signaling changes in these cells, in response to arginine deprivation, were assessed by quantitative PCRs and immunoblotting and this was correlated with changes in cell viability, proliferation and cell death. The latter was assessed by a combination of clonogenic and MTT assays in addition to propidium iodide (PI) staining alone or PI /Annexin V double staining followed by flow cytometry.

Results: 63% had conventional urothelial carcinoma (UCa), while the rest had rarer variants such as squamous cell carcinoma (SCC: 18%), the micropapillary variant (9%), adenocarcinoma (5%) and small cell carcinomas (4%). Micropapillary variants (71%) and adenocarcinomas (90%) tended to show moderate to strong ASS1 expression, while UCa (42%) and small cell carcinomas (38%) demonstrated intermediate ASS1 expression (2+, 3+). In contrast, patients with SCC tended to have weak ASS1 expression (91%, 0 or 1+). In univariate analysis, increased ASS1 expression was associated with poorer OS (p≤.10 in all cases for OS) and PFS (p=.03 for PFS (2+, 3+ vs 0, 1+)). In multivariate analysis, ASS1 expression (3+ vs 0, 1+ or 2+), p=.04, along with positive nodes (p=.0005), surgical margins (p=.007), and higher pT-stage (p=.02) were all seen to be independent predictors of poorer OS. In-vitro studies with UCa derived J82 cells (that were found to be ASS1 deficient) following ADI-PEG20 treatment revealed an activation of GCN2, a kinase known to be activated by amino acid deprivation. Downstream changes included induction of the pro-apoptotic gene CHOP. This was correlated with a reduction in cell viability (IC50=0.24ug/ml) that was attributed to increased apoptosis.

Conclusion: High ASS1 expression is an independent predictor of poor OS and PFS in bladder cancer. Furthermore, ADI-PEG20 represents a promising new therapy for ASS1-deficient bladder cancers.

Citation Format: Sounak Gupta, Mir Maria, John Bomalaski, Paul J. Elson, Kamini Singh, Jyoti Harwalkar, Paula Carver, Alex Almasan, Donna E. Hansel. Arginine deprivation therapy using ADI-PEG20 as a novel therapeutic modality in the treatment of bladder cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 11. doi:10.1158/1538-7445.AM2013-11

Expression of ERG protein, a prostate cancer specific marker, in high grade prostatic intraepithelial neoplasia (HGPIN): lack of utility to stratify cancer risks associated with HGPIN

What's known on the subject? and What does the study add? High grade prostatic intraepithelial neoplasia is a pre-malignant lesion to prostate cancer and is associated with 20%-25% risk of prostate cancer in subsequent repeat biopsies. ERG is a highly prostate-cancer-specific marker. Expression of ERG is rare in isolated high grade prostatic intraepithelial neoplasia diagnosed in prostate biopsy and is not associated with cancer risk in subsequent repeat biopsies.

OBJECTIVES

• To evaluate how often ERG, a highly prostate-cancer-specific marker, is expressed in isolated high grade prostatic intraepithelial neoplasia (HGPIN) by immunohistochemistry. • To study whether a positive ERG immunostain in HGPIN correlates with prostate cancer (PCa) detection in subsequent repeat biopsies.

PATIENTS AND METHODS

• Patients with initial HGPIN in biopsies and at least one follow-up prostate biopsy were included. • Biopsies with HGPIN were immunostained for ERG. • The ERG staining results were then correlated with the PCa risk in subsequent biopsies.

RESULTS

• The mean age of 94 patients was 63 years (range 48-78). A mean of 1.8 (range 1-5) repeat biopsy sessions were carried out at a mean interval of 27.4 months (range 1.5-140). The repeat biopsies showed PCa and non-cancer lesions (benign, HGPIN, atypical glands suspicious for cancer) in 36 patients (38%) and 58 patients (62%) respectively. • ERG immunostain was positive in five (5.3%) biopsies with HGPIN, in which PCa was found in two (40%) subsequent biopsies. Of 89 biopsies with negative ERG staining, PCa was found in 34 (38%) repeat biopsies. The cancer detection rate was not different between ERG positive and negative cases (P= 0.299).

CONCLUSIONS

• This is the first study to investigate the ERG protein expression in prostate biopsy containing HGPIN only and its use to stratify the cancer risk associated with HGPIN. We found that ERG expression is distinctly uncommon in isolated HGPIN (5.3%). • Positive ERG expression is not associated with increased cancer detection in subsequent repeat biopsies. The use of ERG immunostain in the evaluation and cancer risk stratification of HGPIN is of limited value.

Solitary fibrous tumor: is there a molecular relationship with cellular angiofibroma, spindle cell lipoma, and mammary-type myofibroblastoma?

Solitary fibrous tumor (SFT) is a mesenchymal tumor characterized by ovoid cells, branching blood vessels, stromal hyalinization, and CD34 immunoreactivity. Studies have shown loss of 13q in a group of morphologically similar entities, including cellular angiofibroma, mammary-type myofibroblastoma, and spindle cell lipoma. The histologic and immunophenotypic overlap between SFT and the latter group of tumors suggests that these tumors may be genetically linked. We tested a group of 40 SFTs to assess for loss of RB1 (13q14) by fluorescence in situ hybridization (FISH). All 38 SFTs with evaluable signals failed to show loss of RB1 (13q14) by FISH. All cases of cellular angiofibroma (1/1), spindle cell lipoma (6/6), and mammary-type myofibroblastoma (4/4), which were used as a control group, showed monoallelic or biallelic loss of RB1. The absence of RB1 loss in SFTs suggests that they are not related to cellular angiofibroma, mammary-type myofibroblastoma, or spindle cell lipoma.

Effect of neoadjuvant docetaxel treatment for locally advanced prostate cancer on miRNA expression: A pilot study

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Background: Taxanes are microtubule-stabilizing drugs used investigationally in adjuvant and neoadjuvant settings of prostate cancer (PCA) treatment in an attempt to improve systemic control of high risk disease. Understanding mechanism of response to taxanes is an essential step in developing novel combination therapies to improve PCA response rates. MicroRNAs (miRNAs) are small noncoding RNA molecules that negatively regulate gene expression by binding target messenger RNAs and inhibiting their stability and/or translation. In cancer miRNAs can act as oncogenes and/or tumor suppressor genes. The objective of our study was to identify miRNAs that are affected by neoadjuvant docetaxel in high-risk PCA.

Methods: Whole cell RNA was extracted from formalin-fixed paraffin-embedded (FFPE) radical prostatectomy specimens from 8 patients with high grade PCA treated with neoadjuvant docetaxel, 8 high grade untreated PCA and their corresponding untreated non-neoplastic tissue. Tumors were matched by Gleason score, patient age and year of surgery. The expression of 88 cancer-associated miRNAs was then quantified using a PCR-based miRNA microarray assay.

Results: Thirty-eight (43%) of the 88 analyzed miRNAs (including miR-205, miR-222, and miR-1) were sgnificantly downregulated in untreated PCA compared with untreated non-neoplastic tissue, and one (miR-183) was upregulated. Twenty (23%) miRNAs (including miR-218, miR-124, and let-7b) were significantly upregulated in treated compared to untreated PCA. The expression levels of 16 of these miRNAs (including miR-9, miR-133b, and miR-27b) were reverted to values similar to untreated non-neoplastic prostatic tissue, as a result of docetaxel treatment.

Conclusions: Our results indicate a potential role of miRNAs in PCA response to taxanes. A subset of miRNAs are downregulated in untreated tumors but upregulated in treated PCA to the levels compared to untreated non-neoplastic tissue, suggesting a miRNA modulation towards a non-neoplastic expression profile with neoadjuvant docetaxel treatment. Further studies are underway to evaluate the miRNA-mediated effects of taxanes in PCA.

The expanded histologic spectrum of myxoid liposarcoma with an emphasis on newly described patterns: implications for diagnosis on small biopsy specimens

The variety of histologic patterns in myxoid liposarcoma is underappreciated. The diversity of these patterns can lead to diagnostic difficulty. We examined the morphologic spectrum of myxoid liposarcoma by cataloguing and describing different patterns identified in biopsy and resection specimens of 46 primary, recurrent, and metastatic myxoid liposarcomas. The patterns identified in the 46 cases included traditional myxoid (43 [93%]), traditional round cell (17 [37%]), pseudoacinar (24 [52%]), lipoblast-rich (13 [28%]), island (11 [24%]), lipomatous (10 [22%]), stromal hyalinization (7 [15%]), cord-like (5 [11%]), nested (3 [7%]), chondroid metaplasia (2 [4%]), and hemangiopericytoma (HPC)-like (1 [2%]). Island and nested patterns had not previously been described. The diagnosis of myxoid liposarcoma was confirmed by fluorescence in situ hybridization studies for DDIT3 (also known as CHOP) rearrangement. The morphologic spectrum of myxoid liposarcoma spans well beyond its typical appearance of spindle cells in a myxoid stroma with a prominent vascular pattern. Awareness of the variety of histologic patterns is critical to avoid misdiagnosis, especially in small biopsy specimens.

ERG gene rearrangement status in prostate cancer detected by immunohistochemistry

TMPRSS2-ERG, the most common gene fusion in prostate cancer, is associated with expression of a truncated protein product of the oncogene ERG. A novel anti-ERG monoclonal antibody has been recently characterized. We investigated the correlation between ERG rearrangement assessed by fluorescence in situ hybridization (FISH) and ERG expression detected by immunohistochemistry in a large cohort of patients treated with radical prostatectomy for clinically localized prostate cancer. Thirteen tissue microarrays comprising 305 tumors and a subset of 112 samples of nonneoplastic prostatic tissue were assessed for ERG rearrangement status by FISH and for ERG expression by immunohistochemistry. Accuracy of ERG detection by immunohistochemistry in predicting ERG status as assessed by FISH (criterion standard) was calculated in terms of sensitivity, specificity, positive and negative predictive values. Of 305 tumor foci, 103 (34%) showed ERG rearrangement by FISH. ERG was detected by immunohistochemistry in 100 (33%) cases, 99 of which were FISH positive. ERG detection by immunohistochemistry demonstrated a sensitivity and specificity of 96% and 99%, respectively, with positive and negative predictive values of 99% and 98%, respectively. None of the 112 samples of nonneoplastic prostatic tissue was rearranged by FISH or showed any ERG expression. In conclusion, ERG detection by immunohistochemistry in prostate cancer was highly predictive of ERG rearrangement as assessed by FISH in a large cohort of prostatectomy patients. Given the high yield and the easier task of performing immunohistochemistry vs. FISH, ERG assessment by immunohistochemistry may be useful for characterizing ERG status in prostate cancer.

Quality improvement in chronic illness care: a collaborative approach

BACKGROUND

Despite rapid advances in the clinical and psycho-educational management of diabetes, the quality of care received by the average patient with diabetes remains lackluster. The "collaborative" approach--the Breakthrough Series (BTS; Institute for Healthcare Improvement [IHI]; Boston)--coupled with a Chronic Care Model was used in an effort to improve clinical care of diabetes in 26 health care organizations.

METHODS

Descriptive and pre-post data are presented from 23 health care organizations participating in the 13-month (August 1998-September 1999) BTS to improve diabetes care. The BTS combined the system changes suggested by the chronic care model, rapid cycle improvement, and evidence-based clinical content to assist teams with change efforts. The characteristics of organizations participating in the diabetes BTS, the collaborative process and content, and results of system-level changes are described.

RESULTS

Twenty-three of 26 teams completed participation. Both chart review and self-report data on care processes and clinical outcomes suggested improvement based on changes teams made in the collaborative. Many of the organizations evidencing the largest improvements were community health centers, which had the fewest resources and the most challenged populations.

DISCUSSION

The initial Chronic Illness BTS was sufficiently encouraging that replication and evaluation of the BTS collaborative model is being conducted in more than 50 health care systems for diabetes, congestive heart failure, depression, and asthma. This model represents a feasible method of improving the quality of care across different health care organizations and across multiple chronic illnesses.

Continuous quality improvement for patients with back pain

Recent evidence has changed traditional approaches to low back pain, suggesting minimal bed rest, highly selective imaging, and early return to normal activities. However, there are wide geographical variations in care, and substantial gaps between practice and evidence. This project sought to merge scientific evidence about back pain and knowledge about behavior change to help organizations improve care for back pain. Participating insurance plans, HMOs, and group practices focused on problems they themselves identified. The year-long program included quarterly meetings, coaching for rapid cycles of change, a menu of potential interventions, and recommendations for monitoring outcomes. Participants interacted through meetings, e-mail, and conference calls. Of the 22 participating organizations, 6 (27%) made major progress. Typical changes were reduced imaging, bed rest, and work loss, and increased patient education and satisfaction. Specific examples were a 30% decrease in plain x-rays, a 100% increase in use of patient education materials, and an 81% drop in prescribed bed rest. Despite the complexity of care for back pain, rapid improvements appear feasible. Several organizations had major improvements, and most experienced at least modest improvements. Key elements of successful programs included focus on a small number of clinical goals, frequent measurement of outcomes among small samples of patients, vigilance in maintaining gains; involvement of office staffs as well as physicians, and changes in standard protocols for imaging, physical therapy, and referral.

Reducing adverse drug events: lessons from a breakthrough series collaborative

BACKGROUND

In January 1996, 38 hospitals and health care organizations (for a total of 40 hospitals) in the United States came together in an Institute for Healthcare Improvement (IHI; Boston) Breakthrough Series collaborative to reduce adverse drug events-injuries related to the use or nonuse of medications.

METHODS

The participants were taught the Model for Improvement, a method for rapid-cycle change and evaluation, and were then coached on how to identify their own problem areas and develop changes in practice for rapid-cycle testing. These changes could be implementation of one or more known medication error prevention practices or new practices developed.

RESULTS

During a 15-month period the 40 hospitals conducted a total of 739 tests of changes. Process changes accounted for 63% of the cycles; the remainder consisted of preliminary data gathering, consensus-building, or education cycles. Eight types of changes were implemented by seven or more hospitals, with a success rate of 70%. These changes included non-punitive reporting, ensuring documentation of allergy information, standardizing medication administration times, and implementing chemotherapy protocols.

DISCUSSION

Success in making significant changes was associated with strong leadership, effective processes, and appropriate choice of intervention. Successful teams were able to define, clearly state, and relentlessly pursue their aims, and then chose practical interventions and moved early into changing a process. They did not spend months collecting data before beginning a change. Changes that were most successful were those that attempted to change processes, not people. Health care organizations committed to patient safety need not regard current performance limits as inevitable.

Antibacterial activity of sucralfate versus aluminum chloride in simulated gastric fluid

Studies have previously demonstrated that sucralfate possesses intrinsic antibacterial activity. This study was designed to indirectly assess whether aluminum is the active antibacterial component of sucralfate and to further evaluate factors that may influence this agent's antibacterial activity. Utilizing an in vitro model, the antibacterial activity of sucralfate, an equivalent quantity of aluminum in the form of aluminum chloride, and a control were compared. In addition, the influences of bacterial species (Enterobacter cloacae and Pseudomonas aeruginosa), time (0-24 h) and environmental pH (3,5,7) on the agents' antibacterial activities were evaluated. Equivalent quantities of aluminum, as either sucralfate or aluminum chloride, were added to two of three flasks containing approximately 10(5) cfu/ml of bacteria in pH-adjusted simulated gastric fluid. The third flask served as a control. Samples were obtained over 24 h, diluted and subcultured onto agar plates. The experiments demonstrated that bacterial growth was influenced by pH, time and treatment (aluminum chloride or sucralfate). Regardless of pH or bacterial species, bacterial death occurred within 20 min following the addition of aluminum chloride. In contrast, bacterial death following the addition of sucralfate was more variable and appeared to be pH dependent. In conclusion, sucralfate and aluminum chloride both possess antibacterial activity, even at pH values that normally support bacterial growth in gastric fluid. Although differences in the antibacterial activity of the two agents may in part be related to drug-induced changes in pH, these differences also support data suggesting that aluminum release from sucralfate is incomplete and is dependent on pH.

Basic principles of pharmacokinetics

Pharmacokinetics can be used clinically to empirically describe the serum concentrations of drugs in the body. With a good understanding of the general principles utilized in predicting drug levels, the practitioner can understand the drugs and specific patient populations most likely to benefit from or need careful adjustment in therapeutic drug monitoring.