Impact of Concurrent Targeted Therapy and Immunotherapy on the Incidence of Radiation Necrosis Following Stereotactic Radiosurgery for Brain Metastases

PURPOSE/OBJECTIVE(S)

The management of metastatic disease has evolved with the advent of immunotherapy (IT) and targeted therapies (TT). Yet, there is limited understanding of the toxicity associated with combining these agents with stereotactic radiosurgery (SRS). We retrospectively evaluated the impact of concurrent systemic therapy (ST) on the risk of radiation necrosis (RN) following LINAC-based SRS for brain metastases (BM).

MATERIALS/METHODS

A retrospective study was conducted within an integrated health care system from March 2017 to December 2021 of 313 patients who underwent SRS or fractionated SRS in 3 or 5 treatments to a total of 1,644 intact BM. Post-operative cavity SRS and re-irradiated lesions were excluded. RN was diagnosed using perfusion MRI, contrast clearance MRI, or serial standard MRI and graded using CTCAE (v.5). Concurrent ST was defined as administration within 1 month preceding or following SRS. Overall survival (OS) and risk of RN were estimated by the Kaplan-Meier method. Logistics regression analyses were performed to compare risk of RN in patients who received concurrent systemic therapy to those who did not, adjusted for PTV volume and receipt of whole brain radiotherapy (WBRT).

RESULTS

Median follow-up was 12.2 months. Median age was 64 years (range: 24-92). Primary sites per patient included lung (48.9%), breast (18.2%), melanoma (11.5%), kidney (6.1%), and other (15.3%). Median total lesions treated was 3 (range: 1-44); 65.9% of patients underwent 1 course of SRS, 23.4% underwent 2 courses, 6.2% underwent 3 courses, 4.5% underwent >4 courses. Seventy-six (24.2%) patients received WBRT. Overall, 70.6% of lesions received concurrent ST including chemotherapy (CT) (32.5%), IT (26.8%), and TT (27.6%); 16.4% received a combination of ST. Median OS was 12.9 months (95% CI: 10.4-15.5). RN was observed in 50 (3.0%) lesions in 42 (13.4%) patients. The 1-year risk of RN was 4.0% per lesion and 15.4% per patient. Symptomatic RN (SRN) was observed in 31 (1.9%) lesions in 24 (7.7%) patients. The 1-year risk of SRN was 2.7% per lesion and 10.1% per patient. When compared to lesions treated without concurrent systemic therapy, there was no increased risk of RN observed in lesions treated with concurrent CT (adjusted OR = 0.86 (95% CI: 0.43-1.73) p = 0.68), concurrent IT (adjusted OR = 0.84 (95% CI: 0.41-1.71) p = 0.84), or concurrent TT (adjusted OR = 0.57 (95% CI: 0.25-1.30) p = 0.18). Treatments of SRN included dexamethasone (96.8%), bevacizumab (22.6%), and laser interstitial thermal therapy (6.5%).

CONCLUSION

Concurrent IT and TT appears well-tolerated in patients who undergo SRS for treatment of BM. No increased risk of RN was observed in lesions treated with concurrent IT or TT compared to lesions treated in the absence of concurrent ST. Further prospective and agent-specific evaluation is necessary to confirm these findings.

Approach avoidance training versus Sham in veterans with alcohol use disorder: protocol for a randomized controlled trial

BACKGROUND

Alcohol use disorder (AUD) is highly prevalent and commonly co-occurs with other psychiatric disorders among Veterans. Provisional evidence supports the use of Approach Avoidance Training (AAT) - a form of computer-delivered cognitive bias modification designed to target implicit approach bias for alcohol-related cues - as an adjunctive program to treat AUD. However, the extent to which AAT is effective for improving AUD recovery outcomes in outpatient Veteran samples and those with psychiatric comorbidities has been understudied to date. Here we describe a double-blind randomized controlled trial of AAT versus a comparison condition (Sham) being conducted in Veterans with comorbid psychiatric conditions completing outpatient standard care.

METHODS

One hundred thirty-six Veterans currently receiving outpatient treatment for AUD will be recruited for this randomized controlled trial with parallel group assignment. Participants will be randomized to either 6 weeks of AAT (n = 68) or Sham (n = 68) training in conjunction with usual care. Assessments will occur at baseline and 6 weeks, 3 months, and 6 months post-baseline. Primary outcome variables will include functional consequences of drinking. Secondary outcome variables will include alcohol consumption, and behavioral indicators of alcohol approach bias. A subset of participants (n = 51) will also complete functional magnetic resonance imaging (fMRI) to assess neural response during an alcohol approach bias assessment.

DISCUSSION

This study is the first randomized controlled trial of AAT administered as an adjunctive treatment to standard care in Veterans with AUD and comorbid psychiatric disorders. Additionally, behavioral and neuroimaging data will be used to determine the extent to which AAT targets approach bias for alcohol cues. If effective, AAT may be a promising low-cost adjunctive treatment option for individuals with AUD.

REGISTRY NAME

AAT for Alcohol Use Disorder in Veterans.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05372029; Date of Registration: 5/9/2022.

Improvement in Dysphagia Outcomes Following Clinical Target Volume Reduction in the De-ESCALaTE Study

AIMS

The De-ESCALaTE study showed an overall survival advantage for the administration of synchronous cisplatin chemotherapy with radiotherapy in low-risk oropharyngeal cancer when compared with synchronous cetuximab. During the trial, a radiotherapy quality assurance protocol amendment permitted centres to swap from the original radiotherapy contouring protocol (incorporating the whole oropharynx into the high-dose clinical target volume (CTV); anatomical protocol) to a protocol that incorporated the gross tumour volume with a 10 mm margin into the CTV (volumetric protocol). The purpose of this study was to examine both toxicity and tumour control related to this protocol amendment.

MATERIALS AND METHODS

Overall survival and recurrence at 2 years were used to compare tumour control in the two contouring cohorts. For toxicity, the cohorts were compared by both the number of severe (grades 3-5) and all grades acute and late toxicities. In addition, quality of life and swallowing were compared using EORTC-C30 and MD Anderson Dysphagia Inventory, respectively.

RESULTS

Of 327 patients included in this study, 185 were contoured according to the anatomical protocol and 142 by the volumetric protocol. The two cohorts were well balanced, with the exception of significantly more patients in the anatomical cohort undergoing prophylactic feeding tube insertion (P < 0.001). With a minimum of 2 years of follow-up there was no significant difference in overall survival or recurrence between the two contouring protocols. Similarly, there was no significant difference in the rate of reported severe or all grades acute or late toxicity and no sustained significant difference in quality of life. However, there was a significant difference in favour of volumetric contouring in several domains of the MD Anderson Dysphagia Inventory questionnaire at 1 year, which persisted to 2 years in the dysphagia functional (P = 0.002), dysphagia physical (P = 0.009) and dysphagia overall function (P = 0.008) domains.

CONCLUSION

In the context of the unplanned post-hoc analysis of a randomised trial, measurable improvement in long-term dysphagia has been shown following a reduction in the CTV. Further reductions in the CTV should be subject to similar scrutiny within the confines of a prospective study.

Evaluation of Response to Stereotactic Radiosurgery in Brain Metastases Using Multiparametric Magnetic Resonance Imaging and a Review of the Literature

AIMS

Following stereotactic radiosurgery (SRS), brain metastases initially increase in size in up to a third of cases, suggesting treatment failure. Current imaging using structural magnetic resonance imaging (MRI) cannot differentiate between tumour recurrence and SRS-induced changes, creating difficulties with patient management. Combining multiparametric MRI techniques, which assess tissue physiological and metabolic information, has shown promise in answering this clinical question.

MATERIALS AND METHODS

Multiparametric MRI techniques, including spectroscopy, diffusion and perfusion imaging, were used for the differentiation of radiation-related changes and tumour recurrence after SRS for intracranial metastases in six cases. All patients presented with enlargement of the treated lesion, an increase in perilesional brain oedema and aggravation or appearance of neurological signs and symptoms from 7 to 29 weeks after primary treatment.

RESULTS

Multiparametric imaging helped to differentiate features of tumour progression (n = 4) from radiation-related changes (n = 2). A low apparent diffusion coefficient (ADC) <1000 × 10^-6 mm²/s, high relative cerebral blood volume (rCBV) ratio > 2.1, high choline:creatine (Cho:Cr) ratio > 1.8 suggested tumour recurrence. A high ADC > 1000 × 10^-6 mm²/s, low rCBV ratio < 2.1, Cho:Cr ratio < 1.8 suggested SRS-induced radiation changes. Multiparametric MRI diagnosis was confirmed by histology or radiological and clinical follow-up.

CONCLUSION

Multiparametric MRI was helpful in the early identification of radiation-related changes and tumour recurrence and may be useful for monitoring treatment changes in intracranial neoplasms after SRS treatment.

Abstract P4-15-05: The presence of one or multiple foci of microinvasion is not associated with an increased risk of local recurrence in women with ductal carcinoma in situ treated with breast conserving therapy

Background: Ductal Carcinoma in Situ (DCIS) is a non-invasive breast cancer often treated with breast-conserving surgery (BCS) with or without radiotherapy (RT). It is unclear if the presence of microinvasion (MI) (invasion ≤1mm) is associated with an increased risk of LR (DCIS or invasive) or invasive LR compared to women with pure DCIS. In addition, the impact of multiple foci (&gt;2) of MI compared to pure DCIS is also unknown; therefore, it is unclear if some women with MI require more aggressive treatment. We evaluated the impact of the presence of MI and the number of foci of MI on the risks of any LR and invasive LR in a population of women with DCIS with and without MI treated with BCS.

Methods: The cohort includes all women diagnosed with pure DCIS or DCIS with MI in Ontario from 1994-2003 treated with BCS +/- RT. All cases had systematic pathology review to confirm the presence and number of foci of MI. Treatment and outcomes were ascertained through administrative databases and validated by chart review. Cox proportional hazards model was used to evaluate the impact of MI and the number of foci of MI (1 vs &gt;2 foci) on the development of any LR and invasive LR compared to cases with pure DCIS. The 10-yr local recurrence-free survival (LRFS) and invasive LRFS rates were calculated using the Kaplan-Meier approach with differences compared using the log-rank test.

Results: The population cohort includes 2,988 women with DCIS treated by BCS (N=2,721 pure DCIS, N= 267 DCIS with MI). Median follow-up (12 years; p=.23) and median age at diagnosis (58 years; p=.17) were similar in both groups. RT was given in 58% of cases with MI and 51% of cases with pure DCIS (p=.03). Hormonal therapy was utilized in 7.1% of women with MI and 5.3% of women with pure DCIS (p=.22). LR developed in 59 (22.1%) cases with MI and 530 (19.6%) cases of pure DCIS. Women with MI were more likely to have high nuclear grade (p&lt;.001), and larger tumor size (p&lt;.001) compared to those without MI. On multivariable analyses adjusted for age, the presence of 1 focus of MI(HR=.92, 95% CI: .64-1.33) or ≥2 foci of MI (HR=1.26, 95% CI: .85-1.85) was not associated with an increased risk of any LR compared to cases with pure DCIS. Factors associated with any LR were age &lt;50 years at diagnosis, RT, multifocality and high nuclear grade. The presence of 1 focus of MI (HR=.86, 95% CI: .52-1.40) or &gt; 2 foci of MI (HR=1.45, 95% CI: .90-2.32) was also not associated with an increased risk of invasive LR compared to cases of pure DCIS. Among women treated with BCS alone, the 10 year LRFS rates were 80%, 75% and 73% for women with pure DCIS, 1 focus, &gt;2 foci of MI (p=.10). The invasive LRFS rates were 89%, 91% and 85% (p=.26). Among women treated with BCS+RT, the 10 year LRFS rates were 87%, 88% and 80% (p=0.32) for women with pure DCIS, 1 focus or ≥2 foci of MI. The invasive LRFS rates were 93%, 90% and 86% (p=.44). There was no interaction between the presence of MI and RT.

Conclusions: Women with DCIS with one or multiple foci of microinvasion (&lt;1mm) treated by breast conserving therapy do not have an increased risk of LR or invasive LR compared to women with pure DCIS.

Citation Format: Lalani N, Paszat L, Sutradhar R, Gu S, Fong C, Nofech-Mozes S, Hanna W, Tuck A, Youngson B, Miller N, Done SJ, Chang MC, Sengupta S, Elavathil L, Jani PA, Bonin M, Rakovitch E. The presence of one or multiple foci of microinvasion is not associated with an increased risk of local recurrence in women with ductal carcinoma in situ treated with breast conserving therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-15-05.

Abstract P2-12-02: Is breast-conserving therapy effective in women with large ductal carcinoma in situ (DCIS) lesions? A population-based analysis

Background: Most women diagnosed with DCIS will be treated by breast-conserving surgery (BCS) with or without radiotherapy (RT). Data on outcomes following breast-conserving therapy are predominantly based on women with small (&lt;25mm) lesions. The paucity of data on outcomes of women with larger (&gt;40mm) DCIS lesions leads to uncertainty of the appropriateness of breast-conserving therapy for women with larger lesions. Specifically, it is unclear if women with large tumors experience higher risks of local recurrence (LR) and invasive LR after BCS+/-RT that would preclude recommendations of breast-conserving therapy. We report the outcomes and evaluate the impact of large tumor size (&gt;40mm) on recurrence risk in a population of women with pure DCIS treated by BCS alone or with RT.

Methods: The cohort includes all women diagnosed with DCIS in Ontario from 1994-2003 treated with BCS +/- RT; 82% had pathology review. Treatment and outcomes were ascertained through administrative databases and validated by chart review. Cox proportional hazards model was used to evaluate the impact of tumor size (≤10mm,11-25mm, 26-39mm, ≥40mm) on the development of any LR (DCIS or invasive) and invasive LR. The 10 and 15-year LR-free survival (LRFS) and invasive LRFS rates were calculated using the Kaplan-Meier method with differences compared using the log-rank test.

Results: The cohort includes 3262 women with DCIS treated by BCS (N=1635 had RT). Median age at diagnosis was 59 years (IQR 50-68 years). Median follow-up was 13 years (IQR 8-15 years). Distribution of tumor size: 707 (22%) ≤10mm, 524 (16%) 11-25mm, 107 (3%) 26-39mm, 84 (3%) ≥40mm, unable to determine in 1840 (56%). Women with lesions ≥ 40mm were more likely to be ≤50 years of age at diagnosis (p=.02), have high nuclear grade (p&lt;.001), multifocality (p&lt;.001), and positive margins (p&lt;.001) compared to women with smaller lesions. On multivariable analyses adjusted for age and year of diagnosis, tumor size ≥40mm was significantly associated with an increased risk of LR compared to size ≤10mm (HR=2.5, 95%CI:1.64-3.81). Other factors associated with LR were age &lt;50 years (p&lt;.001), omission of RT (p&lt;.001), high nuclear grade (p=.002), and multifocality (p=.0008). Tumor size ≥40mm was not significantly associated with an increased risk of invasive LR (HR=1.68, 95%CI:.94-3.04). Women with tumour size ≥40mm treated with BCS alone had lower 10 and 15 year LRFS (53% and 41%) and invasive LRFS rates (78% and 75%) compared to women with smaller lesions. However, women with larger lesions treated with RT had significantly higher LRFS and invasive LRFS rates

Outcomes by tumour size for women with DCIS treated with BCS with or without RT  ≤10mm N=70711-25mm N=52426-39mm N=107≥40mm N=84p-valueBCS AloneLRFS (%)      10 yr85797053&lt;0.001 15 yr81746741  Invasive LRFS (%)      10 yr928786780.03 15 yr89838375 BCS + RTLRFS (%)      10 yr928874850.01 15 yr86847079  Invasive LRFS (%)      10 yr959492910.27 15 yr90918789 

. There was a significant interaction between tumor size ≥40mm and RT (p=.02).

Conclusions: Women with DCIS lesions ≥40mm treated by BCS alone experience significantly higher risks of LR and invasive LR compared to smaller lesions but this risk can be mitigated with the addition of RT.

Citation Format: Lalani N, Paszat L, Nofech-Mozes S, Sutradhar R, Gu S, Hanna W, Fong C, Miller N, Youngson B, Done SJ, Tuck A, Chang MC, Sengupta S, Jani PA, Bonin M, Rakovitch E. Is breast-conserving therapy effective in women with large ductal carcinoma in situ (DCIS) lesions? A population-based analysis [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-02.

A walking program for people with severe knee osteoarthritis did not reduce pain but may have benefits for cardiovascular health: a phase II randomised controlled trial

OBJECTIVE

The primary aim was to evaluate the effect of a dosed walking program on knee pain for patients with severe knee osteoarthritis (OA). Secondary aims evaluated the effects on cardiovascular health, function and quality of life.

DESIGN

Participants with severe knee OA and increased cardiovascular risk were randomly assigned to a 12-week walking program of 70 min/week of at least moderate intensity, or to usual care. The primary outcome was knee pain (0-10). Secondary outcomes were of cardiovascular risk including physical activity, blood pressure, blood lipid and glucose levels, body mass index and waist circumference; WOMAC Index scores; physical function; and quality of life.

RESULTS

Forty-six participants (23 each group) were recruited. Sixteen participants (70%) adhered to the walking program. Intention to treat analysis showed no between-group difference in knee pain. The walking group had increased odds of achieving a healthy systolic blood pressure (OR = 5.7, 95% CI 1.2-26.9), and a faster walking speed (Mean Difference (MD) = 0.12 m/s, 95% CI 0.02-0.23). Per protocol analysis based on participant adherence showed the walking group had more daily steps (MD = 1345 steps, 95% CI 365-2325); more time walking (MD = 18 min/day, 95% CI 5-31); reduced waist circumference (MD = -5.3 cm, 95% CI -10.5 to -0.03); and increased knee stiffness (MD = 0.9 units, 95% CI 0.07-1.8).

CONCLUSIONS

Patients with severe knee OA prescribed a 12-week walking program of 70 min/week may have had cardiovascular benefits without decreasing knee pain. Australian New Zealand Clinical Trials Registry ACTRN12615000015549.

A prospective comparison of common toxicity criteria adverse events Version 3 and 4 in assessing oral mucositis for oral and oropharyngeal carcinoma

BACKGROUND AND PURPOSE

Oral mucositis is an expected complication of radiotherapy in the management of carcinoma of the head and neck. The Common Terminology Criteria for Adverse Events (CTCAE) Version 3 (V3) and related systems based on mucosal appearance have been used in clinical trials historically. More recently, Version 4 (V4) which is based on patient symptoms has been employed. This study compares the use of V3 and V4 in the grading of mucositis in patients undergoing radiotherapy with or without concurrent systemic therapy for carcinoma of the oral cavity and oropharynx.

METHODS

Oral mucositis was graded prospectively in patients receiving radiotherapy with or without concurrent systemic therapy using both V3 and V4. Grading was recorded during and after completion of therapy.

RESULTS

Between November 2014 and November 2015, 555 measurements were taken from 73 patients. Mucositis scores were equal in both versions in 327 (59%) measurements. Significant differences between V3 and V4 were seen in patients receiving cetuximab-based concurrent therapy (p < 0.001) and beyond 8 weeks from the start of radiotherapy (p = 0.004).

CONCLUSION

Differences in grading of mucositis scored by V3 and V4 are frequent. Relationships between biologically effective dose and rates of grade 3 mucositis have historically been based on mucosal appearances. It is not known whether the same relationships apply when mucositis is graded based on symptomatic grading systems. Both V3 and V4 should be used in clinical trials to improve understanding of mucositis and its relationship to quality of life and late mucosal toxicity.

Abstract P3-17-01: Long-term rates of breast preservation after breast-conserving therapy for ductal carcinoma in situ

Background: Despite evidence that radiotherapy (RT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) halves the risk of recurrence, the benefit of RT in the management of DCIS continues to be a matter of controversy. One argument against the use of RT after BCS is that patients who develop ipsilateral local recurrence (LR) can be salvaged with further breast-conserving surgery such that the omission of RT will lead to high rates of breast preservation while minimizing exposure to RT. Breast preservation is an important determinant of quality of life for women with early stage breast cancer and DCIS. Yet the management of LR and the impact of RT on the resultant long-term risks of bilateral breast preservation in a population of women with DCIS are unclear. We assessed the treatment of LR, the impact of RT on the use of salvage mastectomy and the long-term risks of bilateral breast preservation achieved in a population of women with DCIS treated with BCS alone or BCS+RT.

Methods: A population-based analysis of women diagnosed with DCIS from 1994-2003 treated with BCS alone or BCS+RT with pathology review. Treatment and outcomes, including the development of LR and contralateral breast events, were determined by administrative databases with validation by review of operative or pathology reports. Median follow-up was 10.2 years for cases treated by BCS alone, 11.6 years for those treated by BCS+RT. We used a propensity-adjusted Cox proportional hazards model to evaluate factors associated with the use of salvage mastectomy for LR and to evaluate factors associated with any mastectomy. We assessed the risk of long-term breast preservation by calculating the KM 10-year risk of ipsilateral mastectomy and any mastectomy.

Results: The population cohort includes 3303 women with pure DCIS;1649 (50%) were treated by BCS alone, 1654 (50%) received BCS+RT. Women treated with RT had more high risk features of DCIS than those treated by BCS alone. LR developed in 343 (21%) women treated by BCS alone and in 257 (15.5%) women treated by BCS+RT (p&lt;0.01). Most women who developed LR received salvage mastectomy, irrespective of age at diagnosis and histology. Salvage mastectomy was used in 57.4% (197/343) of cases that recurred after BCS alone and in 67.6% (173/257) that recurred after BCS+RT. The likelihood of receiving salvage mastectomy for LR was similar in patients initially treated by BCS+RT vs. those initially treated BCS alone. Most (90%) of mastectomies were performed for a LR. Overall, individuals initially treated by BCS+RT had a 29% lower probability of having a mastectomy at 10 years compared to those treated by BCS alone (HR=0.71, 95%CI: 0.60,0.84,p&lt;0.0001). The 10 year mastectomy-free survival rates are 82.7% for women initially treated by BCS alone and 87.3% for those treated by BCS+RT (p=0.0096).

Conclusion: Women who received RT after BCS for DCIS experience a greater likelihood of long-term bilateral breast preservation. This is attributable to the lower risks of LR and that most local recurrences after breast-conserving therapy are treated by salvage mastectomy. Long-term breast preservation should be considered in discussions weighing the benefits and risks of RT after conservative surgery for DCIS.

Citation Format: Rakovitch E, Nofech-Mozes S, Hanna W, Gu S, Fong C, Tuck A, Sengupta S, Elavathil L, Jani P, Done S, Miller N, Youngson B, Bonin M, Chang M, Paszat L. Long-term rates of breast preservation after breast-conserving therapy for ductal carcinoma in situ [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-17-01.

The maximum tolerated dose of walking for people with severe osteoarthritis of the knee: a phase I trial

OBJECTIVE

To determine how much physical activity, in the form of walking, can be safely and feasibly tolerated for people with severe knee osteoarthritis (OA).

DESIGN

Phase I dose response trial with escalating walking doses of 10, 20, 35, 50, 70, and 95 min over 1 week, were prescribed non-randomly to people with severe knee OA. The primary stopping rule was a substantial increase in knee pain. The primary outcomes were an estimation of the maximum tolerated dose of walking; and the proportion of people who did not complete the dose for feasibility reasons. The secondary outcomes were pain, stiffness and activity limitation Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

Twenty-four participants (13 women) aged 53-83 years, and average body mass index (BMI) of 34 kg/m(2) (SD 9) were recruited. Three participants were assigned to each dose between 10 and 70 min, and nine participants assigned to the 95-min dose. The trial was stopped at 95 min due to the maximum number of adverse events occurring at this dose. Therefore, the maximum tolerated dose was 70 min. No participant stopped due to reasons related to feasibility. There was a moderate association between dose and increased activity (linear R(2) = 0.31, cubic R(2) = 0.69) and reduced stiffness (linear R(2) = 0.20, cubic R(2) = 0.52), with increased benefits at moderate to higher doses.

CONCLUSIONS

There is preliminary evidence that 70 min per week of moderate intensity supervised walking was safe and feasible for people with severe OA of the knee; for higher doses there was a risk of exacerbating knee pain levels.

Newborn screening for X-linked adrenoleukodystrophy in New York State: diagnostic protocol, surveillance protocol and treatment guidelines

PURPOSE

To describe a diagnostic protocol, surveillance and treatment guidelines, genetic counseling considerations and long-term follow-up data elements developed in preparation for X-linked adrenoleukodystrophy (X-ALD) newborn screening in New York State.

METHODS

A group including the director from each regional NYS inherited metabolic disorder center, personnel from the NYS Newborn Screening Program, and others prepared a follow-up plan for X-ALD NBS. Over the months preceding the start of screening, a series of conference calls took place to develop and refine a complete newborn screening system from initial positive screen results to long-term follow-up.

RESULTS

A diagnostic protocol was developed to determine for each newborn with a positive screen whether the final diagnosis is X-ALD, carrier of X-ALD, Zellweger spectrum disorder, acyl CoA oxidase deficiency or D-bifunctional protein deficiency. For asymptomatic males with X-ALD, surveillance protocols were developed for use at the time of diagnosis, during childhood and during adulthood. Considerations for timing of treatment of adrenal and cerebral disease were developed.

CONCLUSION

Because New York was the first newborn screening laboratory to include X-ALD on its panel, and symptoms may not develop for years, long-term follow-up is needed to evaluate the presented guidelines.

Differential cellular zinc levels in metastatic and primary nasopharyngeal carcinoma

Zinc levels are known to be elevated in certain cancer tissues. In this study, zinc content in metastatic and primary nasopharyngeal carcinoma (NPC) cells were quantitated by X-ray microanalysis at the ultrastructural level. Zinc levels of cancer cells derived from the cervical lymph node of a patient with metastatic carcinoma and that from the nasopharynx biopsy of another NPC patient with no clinical evidence of secondary spread, were analyzed. X-ray microanalysis revealed significantly higher cellular zinc levels in metastatic NPC cells. Zinc is a known anti-apoptotic agent and tumor response to radiotherapy is linked with apoptosis or programmed cell death. Raised zinc levels observed here could provide the biological basis for the observation of a higher percentage of distant metastasis in cervical node positive NPC patients treated by radiotherapy (the mainstay of treatment for NPC) as compared to those without regional nodal disease.

PGAT: a multistrain analysis resource for microbial genomes

Motivation: The Prokaryotic-genome Analysis Tool (PGAT) is a web-based database application for comparing gene content and sequence across multiple microbial genomes facilitating the discovery of genetic differences that may explain observed phenotypes. PGAT supports database queries to identify genes that are present or absent in user-selected genomes, comparison of sequence polymorphisms in sets of orthologous genes, multigenome display of regions surrounding a query gene, comparison of the distribution of genes in metabolic pathways and manual community annotation.

Availability and Implementation:The PGAT website may be accessed at http://nwrce.org/pgat.

Contact:mbrittna@uw.edu

Comparison of the MMSE and RUDAS cognitive screening tools in an elderly inpatient population in everyday clinical use

We compared test score and performance times of Folstein's Mini Mental State Examination (MMSE) and the Rowland Universal Dementia Assessment Scale (RUDAS). Forty-six patients were recruited. The mean score was 20.6 for the MMSE and 20.5 for the RUDAS. Linear regression analysis revealed an r value of 0.83 (P < 0.05). The mean performance time was 9.4 min for both the MMSE and the RUDAS. Patient satisfaction was similar for both tests. Surveyed clinicians preferred the MMSE because of greater familiarity. We concluded that the RUDAS correlates well with the MMSE and is no more time-consuming to perform. It has good clinical utility as a cognitive screening tool.

Obstetric performance of ethnic Kosovo Albanian asylum seekers in London: a case – control study

The most recent Confidential Enquiry into Maternal Deaths expressed concern that mortality in women from non-English-speaking ethnic groups was twice that of native-born women. There are very few published data on the obstetric performance of Kosovo Albanian refugees who have relocated to the United Kingdom and the aim of this study was to compare the obstetric performances of Kosovo Albanian women currently residing in the United Kingdom with their British-born Caucasian counterparts. Sixty-one index and 61 control cases were analysed; 63% of the Kosovo Albanian women spoke little or no English and 50% were on income support. Of the study group, 9.8% had caesarean sections, 8.2% had instrumental vaginal deliveries and 82% achieved normal deliveries. The Kosovo Albanian women were statistically younger and had shorter duration of labour compared to controls (P < 0.05, unpaired t-test). Epidural use was significantly lower in Kosovan women (P < 0.05, chi2 test). The rates of induction of labour (IOL), caesarean section, instrumental deliveries, premature delivery and low birth weight < 2.5 kg were not statistically different (P > 0.05 in all cases, chi2 test) between the two groups. This is the first study to examine the obstetric outcomes of Kosovo Albanian women who have resettled in a western European country. Most Kosovo Albanian refugees living in the United Kingdom are not socio-economic migrants but displaced due to civil unrest and many had reasonable socio-economic status prior to resettlement. The similarity in obstetric and fetal outcomes between the study and control groups could be attributed to the 'healthy immigrant effect', where immigrant groups appear to have better outcomes due to family support and relatively lower intake of alcohol and nicotine. It also suggests that obstetricians may be heeding the recommendations from recent Confidential Enquiry into Maternal Deaths, which highlight the need for increased vigilance in women from ethnic minorities.

Can an evidence-based guideline reduce unnecessary imaging of road trauma patients with cervical spine injury in the emergency department?

The aim of this study was to determine if an unvalidated imaging guideline can reduce the use of imaging in patients with cervical spine trauma. A non-randomized clinical trial using historical controls was conducted in the emergency department from October 2001 to September 2002. Following an education programme, which introduced the imaging guideline to clinicians, the use of guideline and imaging were measured. The guideline was also converted to decision-support software for use in the emergency department. Three hundred and fifty-three patients satisfied inclusion criteria during the study period and these were compared with 403 historical control subjects. No significant difference was found between the two groups for age, sex or fracture prevalence. A significant increase was observed during the study period in the proportion of patients who were managed without the use of any cervical spine imaging (21.25 vs 31.2%; P=0.03; 95% confidence interval, 3-13). There were no delayed diagnoses of cervical spine injury among those not imaged. It is feasible to disseminate and implement an evidence-based imaging guideline for patients with cervical spine trauma. The use of a computerized decision-support system can facilitate this and is associated with a safe reduction in the proportion of patients imaged.

Synthesis and Mesophases of Glycerate Surfactants

In the quest to rationally design novel mesophase systems the challenge remains to deconvolute the relationship between structure, composition, and function. In the current study, novel glycerol-derived surfactants with high negative interfacial areas and a preference for inverse phase behavior have been targeted and synthesized. This has been achieved by application of the rule-of-thumb afforded by the critical packing parameter (CPP), namely, that inverse phase behavior is favored by wedge-shaped molecules with relatively small head group versus chain volume. Highly splayed hydrophobes with exaggerated cross section such as oleyl (cis-octadec-9-enyl) hexahydrofarnesyl (3,7,11-trimethyl-dodecyl) and phytanyl (3,7,11,15-tetramethyl-hexadecyl) were particularly successful for this purpose across many variations of head group. The phase behavior of the binary system in water of many of these surfactants is relatively simple. Typically, cubic or inverse hexagonal phases exist at the interface with water with the inverse micellar phases present at lower hydration. The inverse liquid crystalline phases were present for a broad range of temperatures and compositions.

Using herbal medicine as a means of prevention experience during the SARS crisis

At the peak of the SARS epidemic in Hong Kong, hospital workers were under high risks of contraction of the infection. Herbal preparations had been used historically in China to treat influenza-like diseases. During the SARS outbreak, herbal preparations had been used jointly with standard modern treatment in China. As a means to protect the at-risk hospital workers, an innovative herbal formula was created and consumed by 3160 of them in two weeks. During the two weeks, symptoms and adverse effects were close monitored; 37 of them had their serum checked for immunological responses. The results showed that none of the herb consumers contracted the infection, compared to 0.4% among the non-consumers. Adverse effects had been infrequent and mild. There were hardly any influenza-like symptoms and the quality of life improved. In the group who volunteered to have their immunological state checked, significant boosting effects were found. It was concluded that there might be a good indication for using suitable herbal preparations as a means of preventing influenza-like infection. The mode of preventive effect could be treatment of the infection at its very early stage instead of producing a period of higher immunological ability, as in the case of vaccination.

The use of an herbal formula by hospital care workers during the severe acute respiratory syndrome epidemic in Hong Kong to prevent severe acute respiratory syndrome transmission, relieve influenza-related symptoms, and improve quality of life: a prospective cohort study

OBJECTIVES

To investigate the efficacy of an herbal formula in the prevention of severe acute respiratory syndrome (SARS) transmission among health care workers. The secondary objectives are to investigate quality of life (QOL) and symptomology changes among supplement users, and to evaluate the safety of this formula.

DESIGN

Controlled clinical trial.

SETTINGS

Hong Kong during epidemic of SARS.

SUBJECTS

Two cohorts of health care workers from 11 hospitals in Hong Kong, 1 using an herbal supplement for a 2-week period (n = 1063) and a control cohort comprising all other health care workers who did not receive the supplement (n = 36,111) were compared prospectively.

INTERVENTIONS

Taking an herbal supplement for a 2-week period.

OUTCOME MEASURES

SARS attack rates and changes in quality of life and influenza-like symptoms were also examined at three timepoints among herbal supplement users.

RESULTS

None of the health care workers who used the supplement subsequently contracted SARS compared to 0.4% of the health care workers who did not use the supplement (p = 0.014). Improvements in influenza-like symptoms and quality of life measurements were also observed among herbal supplement users. Less than 2% reported minor adverse events.

CONCLUSION

The results of this pilot study suggest that there is a good potential of using Traditional Chinese Medicine (TCM) supplements to prevent the spread of SARS.

Suppression of tumorigenicity in human ovarian carcinoma cell line SKOV-3 by microcell-mediated transfer of chromosome 11

To determine the pathogenic role of chromosomes 11 and 17 in the carcinogenesis of human ovarian cancers, neo(R)-tagged chromosome 11 or 17 was transferred from cell lines A9H11 or A9H17, respectively, into the ovarian carcinoma cell line SKOV-3 using microcell-mediated chromosome transfer. The chromosome transfer was verified by polymerase chain reaction detection of the neo(R) gene, fluorescence in situ hybridization detection of an extra chromosome 11, and microsatellite polymorphism detection of an exogeneous chromosome 11. Five SKOV-3/A9H11 hybrids and five SKOV-3/A9H17 hybrid clones were generated. For the chromosome 11 transfer, complete suppression of tumorigenicity was observed in four clones, (11)9-8 and 11(H)7-2, 11(H)8-3, and 11(H)7-2, 100 days post implantation. For the chromosome 17 transfer, no complete suppression of tumorigenicity was observed. However, an increased latency period ranging from 25 to 49 days in contrast to 7 days for the SKOV-3 parental line, and a significant reduction in tumor size was observed. There was no correlation between the in vitro growth rate and the tumorigenicity or length of latency period. Our results demonstrate functionally that chromosome 11 may carry a tumor suppressor gene(s) while chromosome 17 may carry a tumor growth-inhibitor gene(s) for the ovarian carcinoma cell line, SKOV-3.

Post-exposure prophylaxis for HIV infection after sexual assault: when is it indicated?

To date there are no published studies on the effectiveness of HIV post-exposure prophylaxis (PEP) after sexual exposure. However, as emergency physicians we are faced with the dilemma of assessing the risk of HIV transmission and providing appropriate care for patients who present to us after sexual assault. Current practice in UK emergency departments and genitourinary clinics varies from trust to trust. There is no direct evidence that HIV PEP after rape prevents transmission or is cost effective. However, there may be certain rape cases where HIV PEP should be prescribed or at least considered. While we wait for more definitive clinical studies, HIV PEP after rape should be considered on a case to case basis. This article aims to provide emergency physicians with current scientific evidence on HIV PEP enabling them to make an informed decision on when HIV PEP is indicated after rape.

Cross-talk between 1,25-dihydroxyvitamin D3 and transforming growth factor-beta signaling requires binding of VDR and Smad3 proteins to their cognate DNA recognition elements

1,25-Dihydroxyvitamin D(3) (vitamin D) and transforming growth factor-beta (TGF-beta) regulate diverse biological processes including cell proliferation and differentiation through modulation of the expression of target genes. Members of the Smad family of proteins function as effectors of TGF-beta signaling pathways whereas the vitamin D receptor (VDR) confers vitamin D signaling. We investigated the molecular mechanisms by which TGF-beta and vitamin D signaling pathways interact in the regulation of the human osteocalcin promoter. Synergistic activation of the osteocalcin gene promoter by TGF-beta and vitamin D was observed in transient transfection experiments. However, in contrast to a previous report by Yanagisawa, J., Yanagi, Y., Masuhiro, Y., Suzawa, M., Watanabe, M., Kashiwagi, K., Toriyabe, T., Kawabata, M., Miyazono, K., and Kato, S. (1999) Science, 283, 1317-1321, synergistic activation was not detectable when the osteocalcin vitamin D response element (VDRE) alone was linked to a heterologous promoter. Inclusion of the Smad binding elements (SBEs) with the VDRE in the heterologous promoter restored synergistic activation. Furthermore, this synergy was dependent on the spacing between VDRE and SBEs. The Smad3-Smad4 heterodimer was found to bind in gel shift assay to two distinct DNA segments of the osteocalcin promoter: -1030 to -989 (SBE3) and -418 to -349 (SBE1). Deletion of SBE1, which is proximal to the VDRE, but not the distal SBE3 in this promoter reporter abolished TGF-beta responsiveness and eliminated synergistic co-activation with vitamin D. Thus the molecular mechanism, whereby Smad3 and VDR mediate cross-talk between the TGF-beta and vitamin D signaling pathways, requires both a VDRE and a SBE located in close proximity to the target promoter.

Fracture site-specific deficits in bone size and volumetric density in men with spine or hip fractures

To study the structural basis of bone fragility in men, we compared bone size and volumetric bone mineral density (vBMD) of the third lumbar vertebra and femoral neck in 95 men with spine fractures, 127 men with hip fractures, and 395 healthy controls using dual-energy X-ray absorptiometry (DXA). The results were expressed in absolute terms and age-specific SD scores (mean +/- SEM). In controls, vertebral body and femoral neck width increased across age, being 0.46 +/- 0.11 SD and 0.91 +/- 0.08 SD higher in elderly men than in young men, respectively (both,p < 0.001). Men with spine fractures had reduced vertebral body width (-0.45 +/- 0.10 SD;p < 0.01) but not femoral neck width (-0.15 +/- 0.10 SD, NS). Men with hip fractures had reduced femoral neck width (-0.45 +/- 0.11 SD; p < 0.01) and vertebral body width (-0.25 +/- 0.10 SD; p < 0.05). The deficits in bone volume (BV) exaggerated the deficits in bone mineral content (BMC) by 40% at the vertebrae in men with spine fractures and by 9% at the femoral neck in men with hip fractures. vBMD deficits were greater at the vertebrae in men with spine fractures than in men with hip fractures (-1.37 +/- 0.08 SD vs.-0.70 +/- 0.10 SD, respectively; p < 0.01) but were similar at the femoral neck (-0.93 +/- 0.10 SD and -0.76 +/- 0.11 SD, respectively, NS), despite the men with spine fracture being 10 years younger. Bone fragility leading to spine or hip fractures in men may be the result of fracture site-specific deficits in bone size and vBMD that have their origins in growth, aging, or both.

Effects of a single and double commercial athletic mouthpiece on expiratory peak flow: a pilot study

Utilizing an Assess Peak Flow Meter, six healthy subjects with no lung disease volunteered to have their expiratory peak flow measured under the following five conditions: 1. Biting on the oral tube of the peak flow meter and lip-sealing the tube; 2. Using a custom built diaphragm allowing the subject to lip-seal the tube of the peak flow meter without biting on it; 3. Using orange wood blocks of known dimension bilaterally on the posterior occlusion, and a custom built diaphragm allowing the subject to lip-seal the oral tube of the peak flow meter without biting on it; 4. Using a commercial single (maxillary) athletic mouthpiece and a custom built diaphragm allowing the subject to lip-seal the oral tube of the peak flow meter without biting on it; and 5. Using a commercial double (maxillary and mandibular) athletic mouthpiece and a custom built diaphragm allowing the subject to lip-seal the oral tube of the peak flow meter without biting on it. Expiratory peak flow measurements were virtually the same whether the subjects bit and lip-sealed on the oral tube of the peak flow meter, used the custom diaphragm and lip-sealed without biting on the oral tube of the peak flow meter, or bit on the orange wood blocks while using the custom diaphragm and lip-sealing without biting on the oral tube. There was significant deterioration (p < .0001) in expiratory peak flow volume when either the single or double commercial athletic mouthpieces were employed.

Are decisions under risk malleable?

Human decision making under risk and uncertainty may depend on individual involvement in the outcome-generating process. Expected utility theory is silent on this issue. Prospect theory in its current form offers little, if any, prediction of how or why involvement in a process should matter, although it may offer ex post interpretations of empirical findings. Well-known findings in psychology demonstrate that when subjects exercise more involvement or choice in lottery procedures, they value their lottery tickets more highly. This often is interpreted as an "illusion of control," meaning that when subjects are more involved in a lottery, they may believe they are more likely to win, perhaps because they perceive that they have more control over the outcome. Our experimental design eliminates several possible alternative explanations for the results of previous studies in an experiment that varies the degree and type of involvement in lottery procedures. We find that in treatments with more involvement subjects on average place less rather than more value on their lottery tickets. One possible explanation for this is that involvement interacts with loss aversion by causing subjects to weigh losses more heavily than they would otherwise. One implication of our study is that involvement, either independently or in interaction with myopic loss aversion, may help explain the extreme risk aversion of bond investors.

The influence of insurance status on nonurgent pediatric visits to the emergency department

OBJECTIVE

To compare the effects of HMOs with the effects of other types of private health insurance on nonurgent ED visits in the pediatric population.

METHODS

Secondary analysis of the emergency component of the 1994 National Hospital Ambulatory Medical Care Survey (NHAMCS) on patients aged 15 years or less. Variables of interest included urgency of visit, age, sex, race, ethnicity, method of payment (HMO, private insurance/non-HMO, and others), and chief complaint. A p-value of 0.01 was used as the threshold for significance to offset the effects of increases in variability and significance of p-values and narrow confidence intervals.

RESULTS

There were 6,744 observations. The overall rate of nonurgent ED visits was 58%. The rate of nonurgent visits for HMO patients was 51%, for private non-HMO insurance 56%, and for other types of payment (Medicare, Medicaid, patient paid, no charge, and other government) 60%. Chief complaints for nonurgent visits were general symptoms, EENT (ear, eyes, nose, and throat) symptoms, and dermatologic symptoms. After multivariate analysis, the odds ratio for patients with private insurance for a nonurgent visit compared with HMO patients was 1.27, with a 95% CI = 1.07 to 1.51, after adjusting for age, sex, and chief complaint.

CONCLUSION

Pediatric patients with private insurance were more likely to present for emergency care for nonurgent reasons when compared with HMO patients after adjusting for the above listed variables. The reasons for this disparity should be further explored.

Structural Studies of Rutile-Type Metal Dioxides

The structures of the four metal dioxides GeO2, SnO2, RuO2 and IrO2 (germanium, tin, ruthenium and iridium dioxides, respectively) have been redetermined by Rietveld refinement from neutron diffraction powder data. The four dioxides all adopt the rutile-type structure, space group P42/mnm (no. 136), with a = 4.4066 (1), 4.7374 (1), 4.4968 (2) and 4.5051 (3), c = 2.8619 (1), 3.1864 (1), 3.1049 (1) and 3.1586 (2) Å, and x = 0.3060 (1), 0.3056 (1), 0.3053 (1) and 0.3077 (3), respectively. These results are compared with those for other metal dioxides that adopt the rutile structure and trends in structural and thermal vibrations for a series of 11 metal dioxides which adopt the rutile-type structure are described.

The Spanish version of the Parental Stressor Scale: Pediatric Intensive Care Unit

The Spanish Parental Stressor Scale: Pediatric Intensive Care Unit (SPSS:PICU) was developed to assess Hispanic parents' perceptions of stressful stimuli in the PICU. Twenty parents completed a personal data sheet and the SPSS:PICU. Alpha coefficients were 0.91 for the total scale and ranged from 0.47 to 0.94 for the subscales. The Sights and Sounds and Procedures subscales were the most stressful to Hispanic parents. Significant positive correlations were found between SPSS:PICU scores and parents' level of education. Although further instrument validation is suggested, this pilot study of the SPSS:PICU instrument proved to be reliable in assessing Hispanic parents' perceptions of stress.

Pulmonary edema during IL-2 therapy: combined effect of increased permeability and hydrostatic pressure

Systemic administration of recombinant interleukin-2 (rIL-2) has been shown to be promising against certain metastatic cancers. However, major side effects, such as pulmonary edema, have limited its widespread use. Although this pulmonary edema has been attributed to a vascular leak syndrome, this hypothesis has not been verified in humans. The purpose of our study was to determine both the severity and mechanism of pulmonary edema in seven patients treated with rIL-2. The severity of edema was assessed by daily evaluation of chest radiographs, using a semiquantitative scale, as well as by repeated measurements of the alveolar-to-arterial oxygen gradient (A-aDO2) in each patient. To determine the mechanism of pulmonary edema, we serially measured in each patient the lung clearance of technetium 99m-diethylenetriamine pentaacetic acid (DTPA) 99mTc-DTPA), the plasma levels of Von Willebrand factor antigen, and the pulmonary capillary wedge pressure (PCWP). Our results show that there was a gradual increase in the chest radiography edema score that was paralleled by a significant increase in A-aDO2 over its baseline value. During rIL-2 treatment, 99mTc-DTPA clearance was augmented, and the plasma concentration of Von Willebrand factor antigen was elevated. PCWP climbed from 7 to 14 mm Hg and serum total protein fell from 66.1 to 42.1 gm/L. The results obtained indicate that although pulmonary edema associated with rIL-2 treatment is partially dependent on increased permeability of the lung, changes in hydrostatic and oncotic forces may be the principal determinants of edema development.

Cloning and analysis of the human myocardial Na+/H+ exchanger

The Na+/H+ exchanger is an integral membrane protein that is universally distribute in mammalian tissues and is responsible for intracellular pH regulation. Several isoforms of the Na+/H+ exchanger exist (NHE-1-NHE-4). The first that was cloned is the amiloride sensitive isoform (NHE-1). Using a fragment of the rabbit cardiac Na+/H+ exchanger cDNA clone we isolated and sequenced Na+/H+ exchanger cDNA from a human heart coding for the complete human Na+/H+ exchanger (NHE-1 isoform). Two overlapping cDNA clones were obtained, giving a combined sequence that contained both 3' and 5' untranslated regions. The 5' and 3' untranslated regions proved to be highly homologous to human sequences described earlier but contained some variations that could affect the mRNA stability and/or the efficiency of translation of the Na+/H+ exchanger. Northern blot analysis and reverse transcriptase polymerase chain reaction confirmed the presence of the 5 kb NHE-1 message in primary cultures of isolated myocytes.

Powder Neutron Diffraction Study of Pyrolusite, β-MnO2

The powder neutron diffraction pattern of pyrolusite, β-MnO2 [P42/mnm, No. 136, a = 4.4041(1), c = 2.8765(1)Ǻ], has been refined by the Rietveld method to give values for both the oxygen position parameter u=0.3046(1) and the anisotropic thermal parameters. The data confirm the MnO6 octahedra to be elongated with two long [1.894(1)Ǻ] and four short [1.882(2)Ǻ] Mn-O bond distances. The effect of the stereochemistry on the thermal vibrations is discussed.