Randomised non-inferiority trial: 1600 mg versus 400 mg tablets of mesalazine for the treatment of mild-to-moderate ulcerative colitis

BACKGROUND

High concentration mesalazine formulations are more convenient than conventional low concentration formulations for the treatment of ulcerative colitis (UC).

AIM

To compare the efficacy and safety of 1600 mg and 400 mg tablet mesalazine formulations.

METHODS

Patients with mild-to-moderate active UC (Mayo Clinic Score >5; N=817) were randomised to 3.2 g of oral mesalazine, administered as two 1600 mg tablets once, or four 400 mg tablets twice daily. We hypothesised that treatment with the 1600 mg tablet was non-inferior (within a 10% margin) to the 400 mg tablet for induction of clinical and endoscopic remission at week 8. Open-label treatment with the 1600 mg tablet continued for 26-30 weeks based on induction response. Predictors of treatment response were also explored.

RESULTS

At week 8, remission occurred in 22.4% and 24.6% of patients receiving the 1600 mg and 400 mg tablets, respectively (absolute difference -2.2%, 95% CI: -8.1% to 3.8%, non-inferiority P=.005). Endoscopic and histopathologic disease activity, leucocyte concentration and age were significantly associated with clinical remission (P=.022, .042, .014 and .023, respectively). At week 38, 43.9% (296/675) of patients who continued treatment with the 1600 mg formulation were in remission, including 70.3% (142/202) of patients who received a reduced dose of mesalazine (1.6 g/d). The overall incidence of serious adverse events was low.

CONCLUSIONS

Induction therapy with 3.2 mg mesalazine using two 1600 mg tablets once-daily was statistically and clinically non-inferior to a twice-daily regimen using four 400 mg tablets (NCT01903252).

Pain expectations in neuropathic pain: Is it best to be optimistic?

BACKGROUND

Pain expectancy may be an important variable that has been found to influence the effectiveness of treatments for pain. Much of the literature supports a self-fulfilment perspective where expectations for pain relief predict the actual pain experienced. However, in conditions such as neuropathic pain (NeP) where pain relief is difficult to attain, expectations for pain relief could be unrealistic. The objective of this study was to investigate the relationship between realistic/unrealistic expectations and 6-month, post-treatment outcomes.

METHODS

We performed a retrospective analysis of a large cohort of patients with NeP (n = 789) attending tertiary care centres to determine the association between unrealistic (both positive and negative) and realistic expectations with outcomes after multidisciplinary treatment. An expectation variable with three categories was calculated: realistic expectations were those whose expected reduction in pain was similar to the observed mean group reduction in pain, while optimistic and pessimistic expectations were those who over- or under-estimated the expected response to treatment, respectively. The association between baseline realistic/unrealistic expectations and 6-month pain-related disability, catastrophizing and psychological distress was assessed.

RESULTS

Univariable analyses suggested that realistic expectations were associated with lower levels of disability, catastrophizing and psychological distress, compared to unrealistic expectations. However, after adjustment for baseline symptom severity, multivariable analysis revealed that patients with optimistic expectations had lower levels of disability, than those with realistic expectations. Those with pessimistic expectations had higher levels of catastrophizing and psychological distress at follow-up.

CONCLUSIONS

These findings are largely congruent with the self-fulfilment perspective to expectations.

SIGNIFICANCE

This study defined realistic pain expectations with patient data. Examining the relationship between expectations between pain and disability in a large cohort of patients with neuropathic pain.

Usefulness of Ki-67, Mitoses, and Tumor Size for Predicting Metastasis in Carcinoid Tumors of the Lung: A Study of 48 Cases at a Tertiary Care Centre in Canada

Background. Evaluation of Ki-67 index in lung carcinoid tumors (LCTs) has been of interest in order to identify high risk subsets. Our objectives are (1) to evaluate the usefulness of Ki-67 index, mitoses, and tumor size in predicting metastasis and (2) to compare the Manual Conventional Method (MCM) and the Computer Assisted Image Analysis Method (CIAM) for Ki-67 calculation. Methods. We studied 48 patients with LCTs from two academic centres in Canada. For Ki-67 calculation, digital images of 5000 cells were counted using an image processing software and 2000 cells by MCM. Mitoses/10 HPF was counted. Results. We had 37 typical carcinoids (TCs) and 11 atypical carcinoids (ACs). 7/48 patients developed metastasis. There was a positive relationship between metastasis and carcinoid type (P = 0.039) and metastasis and mitoses (≥2) (P = 0.017). Although not statistically significant, the mean Ki-67 index for ACs was higher than for TCs (0.95% versus 0.72%, CIAM, P = 0.299). Similarly, although not statistically significant, the mean Ki-67 index for metastatic group (MG) was higher than for nonmetastatic group (NMG) (1.01% versus 0.71% by CIAM, P = 0.281). However when Ki-67 index data was categorized at various levels, there is suggestion of a useful cutoff (≥0.50%) to predict metastasis (P = 0.106, CIAM). A significantly higher proportion of patients with mitosis ≥2 and Ki-67 index ≥0.50% had metastasis (P = 0.033) compared to other patients. Similarly patients with tumor size ≥3 cm and Ki-67 ≥0.50% had a greater percentage of metastases than others (P = 0.039). Although there was a strong correlation between two (MCM versus CIAM) counting methods (r = 0.929, P = 0.001), overall the calculated Ki-67 index was slightly higher by MCM (range 0 to 6.4, mean 1.5) compared to CIAM (range 0 to 2.9, mean 0.75). Conclusion. This study confirms that mitoses ≥2 is a powerful predictor of metastasis in LCTs. Although this is a small sample size, there is suggestion that analysis of Ki-67 index along with mitoses and tumor size may be a useful adjunct for predicting metastasis in LCTs.

A prospective cohort study to determine the relationship between serum infliximab concentration and efficacy in patients with luminal Crohn's disease

BACKGROUND

Patients with Crohn's disease (CD) may experience disease relapse on maintenance infliximab. Anti-drug antibodies likely contribute to loss of response, and serum infliximab levels likely correlate with efficacy.

AIM

To prospectively evaluate the relationship between trough serum infliximab concentration and disease activity.

METHODS

Adult patients (N = 327) with a diagnosis of CD who had received at least five consecutive infliximab infusions and who planned to receive at least two additional infusions were enrolled. The Crohn's Disease Activity Index (CDAI), serum infliximab, C-reactive protein (CRP) and antibodies-to-infliximab (ATI) were assessed at baseline, week 4 and week 8. Receiver operating characteristic (ROC) analysis examined the relationship between infliximab concentrations and disease activity.

RESULTS

The mean CDAI score, which decreased 1.05 points between infusions, did not correlate with the mean change in trough infliximab concentration (+0.39 μg/mL; r = 0.099, P = 0.083), but was associated with the mean change in CRP concentration (r = 0.19, P < 0.001). Trough infliximab concentrations below 2.8-4.6 μg/mL best predicted a ≥ 70 point increase in the CDAI between infusions, and those below 2.7-2.8 μg/mL best predicted CRP >5 mg/mL at the second infusion. ATI at either visit decreased the proportion of patients with therapeutic infliximab trough levels compared with patients who were ATI negative (17.5% vs. 77.3% at visit 1 and 13.8% vs. 75.6% at visit 3; P < 0.001 for both comparisons).

CONCLUSIONS

This prospective study confirms the relationship between trough infliximab concentrations, inflammation and antibodies-to-infliximab. Infliximab trough concentrations below 3 μg/mL may increase the likelihood of symptoms and inflammation (ClinicalTrials.gov identifier: NCT00676988).

Abstract P4-03-09: Time points to diagnosis and treatment of invasive breast cancer in southwestern Ontario

Background Delays in breast cancer diagnosis and treatment are associated with increased tumour size at presentation, higher incidence of lymph node metastasis, higher relapse rates and lower 5-year survival rates in some studies. Diagnosis and treatment of breast cancer is complex, involving many health care practitioners at multiple locations. New advances in diagnostic and prognostic indicators make the process ever more complex. We reviewed the timing of crucial events in breast cancer diagnosis and treatment in Southwestern Ontario. Methods: Two time periods (2001, 2011) were assessed. Patients with new early invasive breast cancer with specific TNM criteria (T1c or greater plus any N, or any T plus N1-3; M0) were included. Data collection and analysis explored significant time points from first suspicion of malignancy, to diagnosis and definitive treatment, as well as patient demographic information. Results: 300 and 451 eligible patients were identified in 2001 and 2011 cohorts. Distribution of T and N status by cohort was compared by Chi-square test and time from first suspicion to diagnosis by Wilcoxon testing. The proportion of patients in which the time from first suspicion (clinical by lay person or health professional or by imaging) to pathological diagnosis exceeded two months increased from 20.4% in 2001 to 42.1% in 2011. There were no differences in time from first suspicion to diagnosis when analyzed by age (p = 0.54) or location (p = 0.50). Pathological T2-4 status at diagnosis increased from 48.4% in 2001 to 56.8% in 2011, and N2-3 status increased from 7.3% to 12.6%. Patients who had mammograms increased from 52.7% to 59.4%. A positive or suspicious mammogram was the first sign in 36% and 39.1% of cases. There was a trend towards more pathological diagnoses and definitive surgeries at tertiary centers compared to community hospitals. Conclusions: There is a longer time interval from first suspicion of malignancy to pathological diagnosis in 2011 compared to 2001 for both urban and rural populations. The number of non-low risk, non-metastatic cancers at diagnosis increased by 50% over the time interval studied (300 v 451), but number of T2-T4 non-metastatic cancers increased by 77% (145 v 256) and N2,3 cancers by 136% (22 v 52). This is despite more patients receiving mammograms (52.7% v 59.4%). Delays in breast cancer treatment are multifactorial, including both system-, and patient-related factors. This is an under-researched area and more investigation is needed to understand the reasons for the diagnostic delays and more serious cancers at presentation in order to improve outcomes. Reasons for higher proportions of advanced cancers will be discussed.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-03-09.

Implant volume as a prognostic variable in brachytherapy decision-making for malignant gliomas stratified by the RTOG recursive partitioning analysis

PURPOSE

When an initial retrospective review of malignant glioma patients (MG) undergoing brachytherapy was carried out using the Radiation Therapy Oncology Group (RTOG) recursive partitioning analysis (RPA) criteria, it revealed that glioblastoma multiforme (GBM) cases benefit the most from implant. In the present study, we focused exclusively on these GBM patients stratified by RPA survival class and looked at the relationship between survival and implanted target volume, to distinguish the prognostic value of volume in general and for a given GBM class.

METHODS AND MATERIALS

Between 1991 and 1998, 75 MG patients were treated with surgery, external beam radiation, and stereotactic iodine-125 (I-125) implant. Of these, 53 patients (70.7%) had GBMs, with 52 (98%) having target volume (TV) data for analysis. Stratification by RPA criteria showed 12, 26, 13, and 1 patients in classes III to VI, respectively. For analysis purposes, classes V and VI were merged. There were 27 (51.9%) male and 25 (48.1%) female patients. Mean age was 57.5 years (range 14-79). Median Karnofsky performance status (KPS) was 90 (range 50-100). Median follow-up time was 11 months (range 2-79).

RESULTS

At analysis, 18 GBM patients (34.6%) were alive and 34 (65.4%) were dead. Two-year and 5-year survivals were 42% and 17.5%, respectively, with a median survival time (MST) of 16 months. Two-year survivals and MSTs for the implanted GBM patients compared to the RTOG database were as follows: 74% vs. 35% and 28 months vs. 17.9 months for class III; 32% vs. 15% and 16 months vs. 11.1 months for class IV; 29% vs. 6% and 11 months vs. 8.9 months for class V/VI. Mean implanted TV was 15.5 cc (range 0.8-78), which corresponds to a spherical implant diameter of 3.1 cm. Plotting survival as a function of 5-cc TV increments suggested a trend toward poorer survival as the implanted volume increases. The impact of incremental changes in TV on survival within a given RPA class of GBMs was compared to the RTOG database. Looking at absolute differences in MSTs: for classes III and IV, there was little effect of different TVs on survival; for class V/VI, a survival benefit to implantation was still seen at the target volume cutoff (TV > 25 cc). Within a given RPA class, no significant differences were found within class III; for class IV, the most significant difference was at 10 cc (p = 0.05); and for class V/VI, at 20 cc (p = 0.06).

CONCLUSION

For all GBM patients, an inverse relationship between implanted TV size and median survival is suggested by this study. However, when GBM patients are stratified using the RTOG's RPA criteria, the prognostic effect of implant volume disappears within each RPA survival class. At the critical volume of 25 cc, which approximates an implant of 5-cm diameter (upper implantation limit of many CNS brachytherapy protocols), the "poorest" prognosis GBM patients stratified by RPA still demonstrate a survival benefit with implant. We suggest that any GBM patient meeting brachytherapy recognized size criteria be considered for I-125 implant.

Metallothionein expression in patients with small cell carcinoma of the lung: correlation with other molecular markers and clinical outcome

BACKGROUND

Patients with small cell carcinoma of the lung (SCLC) are known to have an extremely poor prognosis, with a 5-year survivor rate of only 5%. Chemotherapeutic drug resistance is a major obstacle to curative therapy in patients with SCLC.

METHODS

The authors evaluated retrospectively the expression of metallothionen (MT), proliferating cell nuclear antigen (PCNA), p53, and retinoblastoma gene product (RBGP) in biopsy samples from 58 patients with SCLC prior to standard chemotherapy. The objective was to study the correlation between MT and other molecular markers in SCLC and correlate these data with the clinical outcome of patients. The authors studied 28 short-term survivors (STS; survival < 24 months) and 30 long-term survivors (LTS; survival > 24 months).

RESULTS

In line with expectations, the authors found a strong inverse association between stage and survival. Of 58 patients with SCLC, 26 patients (45%; 17 STS and 9 LTS) showed MT expression, 55 patients (94%; 28 STS and 27 LTS) were positive for PCNA, 28 patients (48%; 16 STS and 12 LTS) were positive for p53, and only 6 patients (10%; 1 STS and 5 LTS) showed positivity for RBGP. On comparing the percent positivity of various markers in the two survivor groups, there was greater frequency of expression of MT, PCNA, and p53 and lower RBGP expression in the STS group compared with the LTS group. However, only the difference in expression of MT between the two survivor groups was statistically significant (Fisher exact test; P = 0.034). Multivariable analysis using a logistic regression model showed a significant association between MT expression and patient survival after adjusting for disease stage (chi-square test; P = 0.022). There was also a statistically significant association between MT expression and p53 expression (chi-square test; P = 0.001).

CONCLUSIONS

In this study, of the molecular markers studied, the authors demonstrated that only MT overexpression was independently predictive of short-term survival in patients with SCLC undergoing chemotherapy.

Cumulative sum failure analysis of a policy change from on-pump to off-pump coronary artery bypass grafting

BACKGROUND

Use of the sequential probability cumulative sum (CUSUM) technique may be more sensitive than standard statistical analyses in detecting a cluster of surgical failures. We applied CUSUM methods to evaluate the learning curve after a policy change by a single surgeon from routine on-pump (cardiopulmonary bypass [CPB]) to off-pump coronary artery bypass grafting (OPCAB).

METHODS

Fifty-five consecutive first-time coronary artery bypass patients (CPB group) were compared with the next 55 patients undergoing an attempt at routine OPCAB using the same coronary stabilizer. The goal in OPCAB patients was to obtain complete revascularization, albeit with a low threshold for conversion to CPB to maximize patient safety during the learning curve. Preoperative patient risk was calculated using previously validated models of the Cardiac Care Network of Ontario. The occurrence of operative mortality and nine predefined major complications (myocardial infarction, bleeding, stroke, renal failure, balloon pump use, mediastinitis, respiratory failure, life-threatening arrhythmia, and sepsis) was compared between the CPB and OPCAB groups using Wilcoxon, Fisher exact, and two-tailed t tests, as well as CUSUM methodology. An intention to treat analysis was performed.

RESULTS

The CPB and OPCAB groups had similar predicted mortality and length of stays (2.2% +/- 2.5%, 8.1 +/- 2.5 days versus 2.4% +/- 3.5%, 8.1 +/- 2.4 days, respectively). The mean number of grafts per patient was 3.1 +/- 0.7 in the CPB group versus 3.0 +/- 0.7 in the OPCAB group (p = 0.45). Two of 55 (3.6%) CPB patients died, as opposed to 1 of 55 (1.8%) OPCAB patients (p = 0.99). Eight of 55 CPB patients (14.5%) incurred major complications, as opposed to 4 of 55 (7.3%) OPCAB patients (p = 0.36). Median hospital length of stay was 6.0 days in the CPB group versus 5.0 days in the OPCAB group (p = 0.28). On CUSUM analysis, the failure curve in CPB patients approached the upper 80% alert line after eight cases, whereas the curve in OPCAB patients reached below the lower 80% (reassurance) boundary 28 cases after the policy change, indicating superior results in the OPCAB group despite the learning curve.

CONCLUSIONS

A policy change from coronary artery bypass on CPB to routinely attempting OPCAB can be accomplished safely despite the learning curve. CUSUM analysis was more sensitive than standard statistical methods in detecting a cluster of surgical failures and successes.

Using treatment interruptions to palliate the toxicity from concurrent chemoradiation for limited small cell lung cancer decreases survival and disease control

BACKGROUND AND PURPOSE

We analyzed the impact on survival outcomes of treatment interruptions due to toxicity arising during the concurrent phase of chemotherapy/radiotherapy (ChT/RT) for our limited-stage small-cell cancer (LSCLC) population over the past 10 years.

MATERIALS AND METHODS

From 1989 to 1999, 215 patients received treatment for LSCLC, consisting of six cycles of alternating cyclophosphamide/doxorubicin or epirubicin/vincristine (CAV; CEV) and etoposide/cisplatin (EP). Thoracic RT was started with EP at either the second or third cycle (85% of patients). RT dose was either 40 Gy in 15 fractions over 3 weeks or 50 Gy in 25 fractions over 5 weeks, delivered to a target volume encompassing gross disease and suspected microscopic disease with a 2 cm margin. Treatment breaks arising during concurrent ChT+RT were used to manage severe symptomatic or hematologic toxicities. We used the interruptions in thoracic RT as the 'marker' for any concurrent break and measured 'break duration' by the total length of time (in days) RT was interrupted, since that also signaled that ChT could be re-initiated. Patient results were analyzed for the impact of interruptions/treatment prolongation on overall and disease-free survival.

RESULTS

For all patients, 2-year and 5-year overall and disease-specific survivals were 22.7 and 7.2, 27.6 and 9.3%, respectively; overall and disease-specific median survivals were 14.7 months each. A total of 56 patients (26%) had treatment breaks due to toxicity. Hematologic depression caused the majority of breaks (88%). The median duration of breaks was 5 days (range 1-18). Patients with and without interruptions were compared for a range of prognostic factors and were not found to have any significant differences. Comparing interrupted/uninterrupted courses, median survivals were 13.8 versus 15.6 months, respectively, and 5-year overall survivals were 4.2 versus 8.3%, respectively. There was a statistical difference between overall survival curves which favored the uninterrupted group (P=0.01). When comparing a series of prognostic variables, multivariable analysis found that the most significant factor influencing survival in the present study was the presence of treatment breaks (P=0.006). There was a trend for development of any recurrence in the patients with breaks (P=0.08). When controlling for the use of prophylactic cranial irradiation (PCI) in the two groups, the rate of failure in the chest was higher in the patients with RT breaks (58 vs. 33%). The rate of failure in the brain was dependent on the use of PCI only.

CONCLUSIONS

Interruptions in treatment to palliate the toxicity from concurrent chemoradiation result in poorer local control and decreased survival.

Predictors of general surgical complications after heart transplantation

BACKGROUND

Several studies have reported the incidence, morbidity, and mortality of general surgical conditions (GSCs) in orthotopic heart transplant (OHT) patients. The following is the largest reported series of such patients and the first study with sufficient patient numbers to formally evaluate peritransplant variables as risk factors for GSC development.

STUDY DESIGN

A GSC was defined as a condition for which a general surgeon had been consulted or as a general surgical condition recognized at the time of autopsy. The records of 453 consecutive patients who underwent OHT between 1981 and 1999 were reviewed to identify patients who developed a GSC. Kaplan-Meier actuarial analysis on this cohort, and univariate and multivariate logistic regression models applied to a subpopulation of 324 consecutive OHT patients between 1987 and 1997 were used to determine factors associated with and predictive of GSC after OHT.

RESULTS

Of 453 OHT patients, 371 (81.9%) were men, and the average age was 44.5 +/- 15 (standard deviation) years. Median followup was 2,086 days (range 1 to 6,642 days). Ninety-three patients (20.5%) developed 111 GSCs. Of these, 78 were men, and the average age was 49.9+/-10.2 years. There were 83 general surgical interventions. Actuarial analyses revealed that age greater than 50 years, pretransplant diagnosis of ischemic (PTDxI) versus nonischemic heart disease, and previous general surgical history were factors associated (p < 0.05) with a higher GSC incidence. Gender, more urgent transplant priority status, cardiopulmonary bypass time, total graft ischemic time, and intensive care unit length of stay were not associated with GSC. Factors associated with GSC on univariate analysis, with odds ratios (ORs) and 95% confidence intervals (CIs) included: age analyzed as a continuous variable (OR 1.04 per year; CI 1.01, 1.06 per year; p = 0.0021), PTDxI (OR 2.40; CI 1.39, 4.15; p = 0.0016), and pretransplant general surgical history (OR 3.35; CI 1.65, 6.82; p = 0.0008). Multivariate analysis revealed that only pretransplant general surgical history (OR 3.27; CI 1.58, 6.76; p = 0.0004) and PTDxI (OR 2.37; CI 1.35, 4.16; p = 0.0023) were associated with subsequent development of GSC.

CONCLUSIONS

A pretransplant diagnosis of ischemic heart disease and previous history of a general surgical procedure are two independent risk factors that predispose OHT patients to development of GSC. Because GSC may arise insidiously in immunosuppressed patients, identification of OHT patients at higher risk for GSC will permit timely intervention decisions, decreasing morbidity and mortality in this challenging group of patients.

Low back pain: prevalence and risk factors in an industrial setting

OBJECTIVE

To examine various factors associated with low back pain (LBP) in an industrial setting.

METHODS

A cross sectional study was carried out among 1,562 employees of a large utilities corporation in Ontario using a self-administered questionnaire. Abdominal muscle strength was measured using a modified sphygmomanometer. Statistical analysis was carried out with Student's t test, chi-square test, and logistic regression analysis.

RESULTS

Among 1,302 male employees the lifetime and point prevalence of LBP were 60% and 11%, respectively. Low back pain was significantly more prevalent among married employees, with more physically demanding jobs, regular lifting, poor general health, and past major illness. Abdominal muscle weakness was associated with current LBP. The mean time lost from work due to LBP over 5 years was 17 days. Sedentary workers developing LBP were more likely to require hospital admission.

CONCLUSION

This study confirms the high prevalence of LBP in industry and identifies several risk factors.

The learning curve of an academic cardiac surgeon: use of the CUSUM method

BACKGROUND

Despite the sizeable volume of research on the determinants of outcome after cardiac operations, few articles have analyzed the learning curves of individual cardiac surgeons over time. The objective of our study was to analyze statistically the learning curve of an academic cardiac surgeon in reducing operative morbidity and mortality during a 10-year interval.

METHODS

The study cohort of 1347 consecutive and unselected patients undergoing cardiac surgical operations from October 1988 to September 1998 were grouped into five 2-year blocks (periods 1 to 5) according to the date of operation. The main outcome measures were operative mortality rate and standardized definitions of perioperative myocardial infarction, intra-aortic balloon pump use, reoperation for bleeding, stroke, sternal wound complications, sepsis, and respiratory insufficiency. Preoperative risk factors and operative results in periods 1 to 5 were compared statistically using a chi-square test for linear trend (categorical variables) or analysis of variance with linear contrast and lack of fit tests (continuous variables). In addition, the cumulative sum (CUSUM) method was used to determine the association among operative morbidity, mortality, and prespecified 80% alert and 95% alarm boundary lines in practice years 1, 5, and 9.

RESULTS

Of the preoperative risk factors, only patient age showed an important change during the 10 years of the study (61.3+/-0.7 to 64.3+/-0.6, p = 0.001). There were no statistically significant changes from periods 1 to 5 in overall operative mortality (4.0% to 2.2%, p = 0.56) or in the rates of perioperative stroke (1.8% to 3.8%, p = 0.33), sternal wound complications (0.4% to 0.8%, p = 0.97), sepsis (0.9% to 0.8%, p = 0.63), or respiratory failure (4.4% to 2.8%, p = 0.21). Decreases occurred in a linear fashion during periods 1 to 5 in mortality after coronary artery bypass grafting (5.1% to 1.3%, p = 0.012) and in the rates of perioperative myocardial infarction (7.0% to 2.2%, p = 0.005), intra-aortic balloon pump use (7.0% to 3.0%, p = 0.05), and reoperation for bleeding (8.4% to 2.2%, p = 0.001). The number of uneventful cases between a death or complication increased from 2.82+/-0.43 in period 1 to 6.44+/-1.10 in period 5 (p < 0.001). On CUSUM analysis, the cumulative failure rate in year 1 transgressed the upper 80% alert line after 56 cases and the upper 95% alarm line after 69 cases. During years 5 and 9 the failure rate gravitated around the 80% and 95% "reassurance" lines, respectively, indicating improved results as compared to year 1.

CONCLUSIONS

The mortality rate after coronary artery bypass grafting and select perioperative morbidity rates improved in a linear fashion from the onset of independent practice to year 10. The CUSUM method was helpful in identifying suboptimal results during the first year of practice and shows promise as a method of prospective quality control in cardiac surgery. These data support mentorship of new consultants by a senior surgeon during the first year or two of independent practice.

Tumour epidermal growth factor receptor, erbB-2 and cathepsin D in node-negative invasive breast cancer: their impact on the selection of patients for systemic adjuvant therapy

OBJECTIVE

To determine the feasibility and the economic impact of tumour EGFR, erbB-2 and cathepsin-D measurements in women with node-negative breast cancer.

DESIGN

Consecutive tumour samples received at a regional steroid receptor laboratory from patients with node-negative breast cancer were evaluated with commercially available kits to determine EGFR, erbB-2 and cathepsin-D levels.

SETTING

All node-negative patients whose tumours were submitted to the steroid receptor laboratory from November 1992 to March 1994 were included (n = 142). A control group of concurrent node-negative breast cancer patients from the London Regional Cancer Centre (LRCC) database were also evaluated to determine the representativeness of our sample.

MAIN OUTCOME MEASURE

To determine the proportion of patients who were positive for the 3 newer prognostic factors relative to their risk of relapse.

RESULTS

We found 75 positive values in 69 patients (48.6%). We demonstrated that each factor identified a different high-risk subgroup. Epidermal growth factor receptor (EGFR) positivity (> 10 fmol/mg protein) was found in 16.3% of patients, with 19.9% of patients positive for erbB-2 (> 250 units/mg protein) and 17.3% positive for cathepsin D (> 70 pmol/mg protein). Between 10% and 23.2% more node-negative patients currently seen in a regional cancer centre could be offered systemic adjuvant chemotherapy based on a single positive new factor.

CONCLUSIONS

These tumour evaluations are straightforward using material already available in a regional steroid receptor laboratory or on tumour tissue available to pathologists. The economic impact is minimal; the 1995 cost of performing all 3 evaluations is Can$425-616 (US$304-440) per patient treated depending on the number of assays per run. Prospective clinical trials incorporating tumour EGFR, erbB-2 and cathepsin D are feasible and economically viable.

Comparison of the response of pelvic and proximal tibial cancellous bone in rat to ovariectomy with estrogen replacement

In this study, we found that the trabecular architecture of the rat pelvis has similarities to that of human iliac crest. Although we made no direct comparisons between the estrogen deficiency-induced rat osteopenia model and postmenopausal histomorphometry of iliac crest, we attempted to determine whether the rat pelvis might be appropriate to study changes in bone modeling and in situ changes in osteoblast protein expression. Three groups of young, sexually mature rats (12 weeks of age, each group comprising six animals) were either ovariectomized (ovx) and treated with 17beta-estradiol (ovx + E), vehicle (ovx), or sham-operated (sham). Histomorphometric variables were quantitated in the pelvis and compared with proximal tibial metaphysis in the three groups. Immunocytochemical localization of osteocalcin was also evaluated in the two skeletal sites. There was a greater reduction in bone volume of the proximal tibial metaphysis of ovx rats than in the pelvis of ovx rats when compared with sham-operated animals (p < 0.01), although bone formation rates were significantly higher at the pelvic site than tibial metaphysis (p < 0.01). The more rapid loss of bone between the tibia and pelvis may reflect differences in longitudinal growth in young rats, but the other intersite differences in bone remodeling consequent to ovx were at least as well demonstrated in the pelvic trabecular structure. Because ex vivo removal of the rat pelvis is simple, and provides a larger histomorphometric section with which to evaluate dynamic changes in metabolic bone disease, we suggest that this site may be useful in studies of osteopenia in the sexually mature female rat. Immunocytochemical demonstration of osteocalcin in trabecular surface osteoblasts was excellent in both sites. These results suggest that the rat pelvis is as accessible for histological study as the more conventional appendicular sites. When compared with the proximal tibial metaphysis, the rat pelvis (1) has a more homogeneous trabecular structure; (2) has more than twice as much trabecular bone area to sample; (3) has no open epiphyseal growth cartilages; (4) loses trabecular bone half as rapidly after ovx; (5) displays a greater increase in bone turnover after ovx; and (6) is the same anatomic site that is sampled in humans. We have also shown that the pelvis is a suitable site to demonstrate immunocytochemistry for osteoblast-derived proteins.

Preoperative radiation with concurrent 5-fluorouracil continuous infusion for locally advanced unresectable rectal cancer

BACKGROUND AND PURPOSE

To determine the percentage of complete responders and the resectability rate for patients with locally advanced carcinoma of the rectum treated by 5-fluorouracil (5-FU) infusional chemotherapy and pelvic radiation.

MATERIALS AND METHODS

Between October 1992 and June 1996, 29 patients with a diagnosis of locally advanced unresectable rectal cancer received preoperative 5 FU by continuous intravenous infusion at a dose of 225 mg/m2/day concurrent with pelvic radiation (median 54 Gy/28 fractions). All patients were clinical stage T4 on the bases of organ invasion or tumor fixation. Median time for surgical resection was 6 weeks.

RESULTS

Median follow-up for the group was 28 months (range 5-57 months). Six patients were felt to be persistently unresectable or developed distant metastases and did not undergo surgical resection. Of the 29 patients, 23 proceeded to surgery, 18 were resectable for cure, 13 by abdominoperineal resection, 3 by anterior resection and 2 by local excision. Of the 29 patients, 4 (13%) had a complete response, and 90% were clinically downstaged. Of the 18 resected patients, 1 has died of his disease, 17 are alive, and 15 disease-free. The regimen was well tolerated; there was only one treatment-related complication, a wound dehiscence.

CONCLUSION

The combination of 5 FU infusion and pelvic radiation in the management of locally advanced rectal cancer is well tolerated and provides a baseline for comparison purposes with future combinations of newer systemic agents and radiation.

Pulmonary retransplantation: predictors of graft function and survival in 230 patients. Pulmonary Retransplant Registry

BACKGROUND

Despite improving results in lung transplantation, a significant number of grafts fail early or late postoperatively. The pulmonary retransplant registry was founded in 1991 to determine the predictors of outcome after retransplantation. We hypothesized that ambulatory status of the recipient and center retransplant volume, which had been previously shown to predict survival after retransplantation, would also be associated with improved graft function postoperatively.

METHODS

Two hundred thirty patients underwent retransplantation in 47 centers from 1985 to 1996. Logistic regression methods were used to determine variables associated with, and predictive of, survival and lung function after retransplantation.

RESULTS

Kaplan-Meier survival was 47% +/- 3%, 40% +/- 3%, and 33% +/- 4% at 1, 2, and 3 years, respectively. On multivariable analysis, the predictors of survival included ambulatory status or lack of ventilator support preoperatively (p = 0.005; odds ratio, 1.62; 95% confidence interval, 1.15 to 2.27), followed by retransplantation after 1991 (p = 0.048; odds ratio, 1.41; 95% confidence interval, 1.003 to 1.99). Ambulatory, nonventilated patients undergoing retransplantation after 1991 had a 1-year survival of 64% +/- 5% versus 33% +/- 4% for nonambulatory, ventilated recipients. Eighty-one percent, 70%, 62%, and 56% of survivors were free of bronchiolitis obliterans syndrome at 1, 2, 3, and 4 years after retransplantation, respectively. Factors associated with freedom from stage 3 (severe) bronchiolitis obliterans syndrome at 2 years after retransplantation included an interval between transplants greater than 2 years (p = 0.01), the lack of ventilatory support before retransplantation (p = 0.03), increasing retransplant experience within each center (fifth and higher retransplant patient, p = 0.04), and total center volume of five or more retransplant operations (p = 0.05).

CONCLUSIONS

Nonambulatory, ventilated patients should not be considered for retransplantation with the same priority as other candidates. The best intermediate-term functional results occurred in more experienced centers, in nonventilated patients, and in patients undergoing retransplantation more than 2 years after their first transplant. In view of the scarcity of lung donors, patient selection for retransplantation should remain strict and should be guided by the outcome data reviewed in this article.

Superior vena cava obstruction in small-cell lung cancer

PURPOSE

To identify prognostic or treatment factors influencing the response of superior vena cava obstruction (SVCO), time to SVCO recurrence, and overall survival of SCLC patients with SVCO at presentation; and to assess the role of retreatment in patients with SVCO at recurrent or persistent disease.

METHODS AND MATERIALS

Between January 1983 and November 1993, 76 consecutive patients who had small-cell lung cancer (SCLC) with SVCO were treated in our institution. Analysis was done according to the disease status at diagnosis of SVCO. The first analysis concerned a group of 50 patients who had SVCO at initial presentation. The second analysis concerned a group who had SVCO as a manifestation of persistent or recurrent disease.

RESULTS

In the first analysis, 93% had significant improvement in symptoms of SVCO after chemotherapy and 94% after mediastinal radiation. Response is almost universal despite a wide range of radiation fractionation and total dose used. Seventy percent remained SVCO-free before death. Thirty percent developed recurrence of SVCO symptoms 1-16 months (median 8) after the start of initial treatment. Those who received combined chemotherapy and radiation had a longer time to SVCO recurrence (p = 0.018) compared to those who received chemotherapy alone. This effect is mainly seen in limited-stage patients. The presence of SVCO recurrence tends to have an adverse effect on the overall survival (p = 0.077) irrespective of the time when the recurrences occurred (p = 0.296). The median survival of this whole group of 50 patients in the first analysis was 9.5 months, and the 2-year survival was 10%. Stage was strongly predictive of survival (p < 0.001). Sixteen percent (3 of 19) of the patients with limited-stage diseases were long-term survivors (two patients survived 35 months and one survived 70 months). The early mortality from SVCO was 2%. In the second analysis, 85% had previously been treated with chemotherapy alone. The response rate of SVCO in the analysable patients (n = 39) was 77%. There was no significant difference in the response rate of SVCO to treatment comparing patients treated by chemotherapy first or mediastinal radiation first (p = 0.653), but most patients [82% (32 of 39)] received radiation as the initially treatment of SVCO. Ninety-three percent (38 of 41) received mediastinal radiation as a part of their ultimate retreatment regimen, and 68% (28 of 41) received mediastinal radiation as their sole retreatment regimen. Thirty-two percent (13 of 41) received chemotherapy as a part of their ultimate retreatment regimen, and only 7% received chemotherapy alone as their sole retreatment regimen. Eighty-three percent (25 of 30) of those whose SVCO responded remained free of SVCO before death, with a median survival of 3 months after recurrent or persistent disease documented.

CONCLUSION

Chemotherapy or mediastinal radiation is very effective as an initial treatment in SCLC patients with SVCO at presentation and at recurrent or persistent disease. There is no obvious need to use big radiation fraction sizes for the first few radiation treatment as was previously believed. In patients with recurrent or persistent SCLC with SVCO, especially in those who previously received chemotherapy only, we have more experience in incorporating mediastinal radiation as a major component of the palliative regimen with highly effective and durable palliation achieved.

A randomized controlled trial to compare the efficacy of cyclical parathyroid hormone versus cyclical parathyroid hormone and sequential calcitonin to improve bone mass in postmenopausal women with osteoporosis

Short cycles of human (h) PTH-(1-34) may have an anabolic effect to increase bone mass in patients with osteoporosis. As PTH also stimulates bone resorption, it is theoretically possible to enhance the anabolic effects of PTH by using a sequential antiresorptive agent in the treatment cycle. To test this hypothesis, 30 women with osteoporosis, aged 67 +/- 8 yr, completed a 2-yr protocol that comprised 28-day courses of hPTH-(1-34) (800 U) given by daily sc injections; each course was repeated at 3-month intervals. By random allocation, patients either received sequential calcitonin (CT) immediately following the cycle of hPTH-(1-34) (75 U/day, sc; PTH + CT; n = 16) or placebo CT (PTH alone; n = 14) for 42 days. Baseline bone mineral density (BMD) at the lumbar spine site revealed t scores of -3.7 +/- 1.2 (+/-SD) for the PTH alone group and -3.0 +/- 1.4 for the PTH + CT groups, who had 2.0 +/- 2.3 and 1.8 +/- 2.4 vertebral fractures, respectively, at entry to the study. At the end of the 2 yr, the lumbar spine BMD increased from 0.720 +/- 0.130 to 0.793 +/- 0.177 g/cm2 (10.2%) in the PTH group and from 0.760 +/- 0.168 to 0.820 +/- 0.149 g/cm2 (7.9%) in the PTH + CT group. These changes were significant over time in both groups (P < 0.001). Although the final 2-yr lumbar spine BMD was not significantly different between the two treatment groups, those patients receiving sequential CT injections gained bone mass at a consistently slower rate. Changes in BMD at the femoral neck averaged +2.4% and -1.8% in the PTH and PTH + CT groups, respectively, neither of which was significant. In the group receiving only cyclical hPTH-(1-34), the observed 2-yr vertebral fracture incidence was 4.5 compared to 23.0/100 patient yr in the PTH + CT group (P = 0.078). During the first two cycles, changes in biochemical markers of bone formation (serum total alkaline phosphatase, bone-specific alkaline phosphatase, and osteocalcin) and bone resorption (fasting urinary hydroxyproline and N-telopeptide excretion) were significantly increased over pretreatment values after 28 days of hPTH-(1-34) injections (P < 0.05 to P < 0.01 for both groups). Even end of cycle values remained elevated over the study baseline across time (P < 0.01). There were no significant differences for any outcome parameter between the two treatment groups. We conclude that short cycles (28 days) of daily hPTH-(1-34) injections result in significant increases in lumbar spine BMD, without significant changes in cortical bone mass at the femoral neck. Very low incident vertebral fracture rates were documented over 2 yr. However, there is no evidence that sequential antiresorptive therapy with CT is of any benefit over that conferred by cyclical PTH alone.

The effect of socioeconomic status on the long-term outcome of cancer

This study reports the 8- to 10-year follow-up of male and female patients between the ages of 25 and 70, admitted to two Ontario Regional Cancer Centres with newly diagnosed cancers of a number of common sites. Information was gathered by interview on education, occupation, and chronic illnesses other than cancer. Stage of disease at diagnosis, exact pathologic diagnosis, date of diagnosis, treatment before and after clinic admission, and status of each patient on the last date for which information was available were obtained from clinic charts. Cox's proportional hazards model was used to examine the relationship between socioeconomic status (SES) and duration of survival, with adjustment for other significant prognostic factors. For breast and prostate, there is weak evidence that high SES is associated with improved survival; for other sites, there is no evidence that SES affected survival.

Validation of dental radiographs for human identification

Visual comparison of dental bitewing radiographs in simulated forensic identification, using observers of varying degrees of experience and radiographs with a range of time intervals from one to fifteen years showed an accuracy of 93%.

Pituitary adenoma in adolescents: a biologically more aggressive disease?

PURPOSE

To determine whether pituitary adenomas behave more aggressively in patients aged 20 years or younger.

MATERIALS AND METHODS

Of 178 patients with pituitary adenoma considered for radiation therapy, 18 (10.1%) were aged 20 years or younger at the time of diagnosis. Initial treatment was surgery in four of these patients, radiation therapy in one, and surgery and postoperative radiation therapy in 13. Median follow-up was 96 months.

RESULTS

Five of the adolescent patients (28%) failed to benefit from initial treatment (four after surgery alone, one after surgery and radiation therapy). The younger patients tended to have larger tumors and a shorter mean time to progression (18 vs 75 months [P = .040]). Control with surgery plus postoperative radiation was very high (94% at 5 years).

CONCLUSION

Adolescents with pituitary adenoma who do not receive postoperative radiation should be followed up closely and undergo imaging at more frequent intervals than do adult patients.

Surveillance and prophylactic intervention of Staphylococcus aureus nasal colonization in a hemodialysis unit

Surveillance of 101 hemodialysis patients for Staphylococcus aureus positive nasal cultures was performed by monthly nasal swabs over a 27-month period. All positive cultures were treated with a prophylactic antibiotic regimen. Forty-seven (46.5%) patients had one or more positive cultures. The surveillance period was longer in the S. aureus nasal carriers (p = 0.004). The frequency of positive cultures correlated with the duration of surveillance (p = 0.029). The incidence of S. aureus bacteremia was greater in patients with two or more positive cultures (p = 0.030). This study suggests that continuous surveillance for S. aureus nasal colonization is essential to properly identify all patients at risk of developing S. aureus bacteremias.

Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee

Within the context of a double blind randomized controlled parallel trial of 2 nonsteroidal antiinflammatory drugs, we validated WOMAC, a new multidimensional, self-administered health status instrument for patients with osteoarthritis of the hip or knee. The pain, stiffness and physical function subscales fulfil conventional criteria for face, content and construct validity, reliability, responsiveness and relative efficiency. WOMAC is a disease-specific purpose built high performance instrument for evaluative research in osteoarthritis clinical trials.

A comparison of physician and patient reports of Pap smear histories

We describe the level of agreement between patients and their physicians with respect to their use of the Pap smear, the symptoms present, and the smear results. The data derived from a case-control interview study of 181 newly diagnosed invasive squamous cell cervical cancer cases and 905 age-matched controls, a second case-control interview study of 250 cases of cervical dysplasia and 500 age-matched controls, and the medical records of attending physicians for all patients. Cases and controls in both studies reported more smears over the previous 5 years than their medical records indicated; also patients reported their last smear as more recent than noted in physician files. Cancer cases were somewhat more accurate on frequency and timing of smears than the other patient groups. Patients tend to report more symptoms at interview than recorded in their files. Disagreements on smear results were probably because of differences in terminology, especially in distinguishing invasive from pre-cancerous conditions; cancer cases tended to report some dysplasias as cancer, but the controls in both studies under-reported dysplasia. If high physician response rates can be obtained, we would prefer to use physician records as the basis of evaluation of screening programs, especially when accurate dating of screening events is required. However it is less clear whether physician records are to be preferred, if the evaluation is to take symptoms into account.

Evaluating the survival of cancer cases detected by screening

Early detection of cancer by screening advances the date of diagnosis, but may or may not affect survival. To assess the survival benefit associated with early detection, one must estimate the distribution of time survived post lead-time, that is, after the unknown date when clinical diagnosis would have occurred in the absence of screening. One can then compare the adjusted survival of screen-detected cancer cases to other groups of cases not diagnosed by screening. This paper describes a model for the survival of screen-detected cases, with a hazard function that depends on an individual's lead time, the duration of preclinical disease, and the time since diagnosis. The model is fitted to the ten year survival data from the 132 screen-detected cases of breast cancer in the well-known HIP (Health Insurance Plan of Greater New York) study. Comparison with the survival of several groups of cancer cases not detected by screening (interval cases arising clinically in persons previously screened, cases among persons who refuse screening, and cases among randomized controls not offered screening) yields various estimates of benefit. Use of the interval cases for comparison gives an estimate of about 21 breast cancer deaths prevented among 20,166 women screened in the HIP study; use of the data from the randomized controls gives an estimate of about 25 prevented deaths. The former estimate derives from the screened group of women only, and so the same method of evaluation may also be applied to community screening programmes and other situations that do not entail randomization.

Personal and job-related factors as determinants of incidence of back injuries among nursing personnel

The purpose of this multicenter prospective cohort study was to assess personal and job-related factors as determinants of incidence of reported back injuries among nurses. The study population included 5,649 nurses who were surveyed by questionnaire and then observed for a 12-month study period. An annual injury rate of 4.9% was observed. Four factors were found to be significant (P less than .01) predictors of back injury. All four factors--service area, lifting, job category, and previously reported back injury--maintain significance when a forward stepping model of logistic regression is applied. The adjusted odds ratios observed are 4.26 for service areas where lifting occurs most as compared with areas where lifting occurs least; 2.19 for daily lifters v light, occasional, and nonlifters; 1.77 for nursing aides v registered nurses and supervisory personnel; and 1.73 for individuals who have previously reported back injury v those who have not reported previous injury. These findings strongly suggest that job-related rather than personal characteristics are the major predictors of back injury in nurses.