Impact of Testosterone Recovery on Clinical Outcomes of Patients Treated with Salvage Radiotherapy and Androgen Suppression: A Secondary Analysis of the NRG/RTOG 0534 Sport Phase 3 Trial

PURPOSE/OBJECTIVE(S)

Testosterone (T) kinetics and its relationship with clinical outcomes has not been studied in trials using salvage radiotherapy and androgen deprivation therapy (ADT). We performed a secondary analysis of the NRG Oncology/RTOG 0534 SPPORT trial, which compared prostate bed radiotherapy (PBRT) (arm 1), PBRT + short-term androgen deprivation therapy (ADT) (arm 2), or PBRT + pelvic lymph node radiotherapy (PLNRT) + short-term ADT (arm 3). We assessed longitudinal serum T levels and the impact of testosterone recovery (TR) on clinical outcomes.

MATERIALS/METHODS

ADT was given for 4-6 months in arms 2 and 3, starting 2 months prior to radiotherapy. The trial excluded patients with baseline T < 40% of the lower limit of normal. TR was defined in 3 ways: 1) return to non-castrate level (>50 ng/dL), 2) return to normal level (>300 ng/dL), and 3) return to baseline level. Time to TR was estimated using cumulative incidence and death without an event considered a competing risk. Unadjusted and adjusted hazard ratios and 95% confidence intervals (CIs) were calculated using Cox proportional hazards model. Freedom from progression (FFP) was defined as biochemical failure according to the Phoenix definition (PSA ≥2 ng/mL over the nadir PSA), clinical failure (local, regional, or distant), or death from any cause.

RESULTS

A total of 1699 patients with T at baseline and at least 1 follow-up assessment were included. The median age was 64 years (IQR 59 - 69), 12.8% were black, 14.9% had diabetes, and 54.1% were former or current smokers. Median baseline T in arms 1, 2 and 3 was 320 ng/dL (IQR 239 - 424), 319 ng/dL (IQR 237 - 438) and 330 ng/dL (IQR 252 - 446), respectively. At 6 months, median T in arms 1, 2 and 3 was 290 ng/dL (IQR 210 - 390), 190.4 ng/dL (IQR 66 - 296) and 191 ng/dL (IQR 40.5 - 313). At 2 years, in arms 2 and 3, TR to non-castrate, normal and baseline levels were 95%, 55% and 23%, respectively. At 5 years, in arms 2 and 3, TR to non-castrate, normal and baseline levels were 98%, 73% and 42%, respectively. FFP was superior in arms 2 and 3 vs. arm 1 in patients with TR by all three definitions. In patients with recovered T to normal levels by 2 years (n = 904), the 5-year FFP rates were 71.8% (95% CI 66.9-76.6) in arm 1, 77.2% (72.1-82.2) in arm 2, and 86.3% (82.3-90.3) in arm 3 (arm 2 vs arm 1: HR 0.74, 95% CI 0.56-0.98, p = 0.034; arm 3 vs arm 1: HR 0.54, 95% CI 0.40-0.72, p<.0001).

CONCLUSION

This work represents the largest study of T kinetics in patients treated with salvage radiation and ADT. Approximately half of patients did not normalize their T levels by 2 years. Our data validate an incremental and meaningful FFP benefit of adding short-term ADT and PLNRT to PBRT independent of T recovery.

Prognostic Significance of Pretreatment Immune Cell Infiltration in Muscle Invasive Bladder Cancer Treated with Definitive Chemoradiation: Analysis of NRG RTOG 0524 and 0712

PURPOSE/OBJECTIVE(S)

Chemoradiation therapy (CRT) is an organ conserving approach in the treatment of locally advanced bladder cancer. Chemoradiation is thought to potentially result in immunogenic stimulation, and bladder cancer is often a tumor with high immune cell infiltration. Thus, we aimed to profile the tumor immune microenvironment of bladder cancer and identify prognostic immune biomarkers for CRT response by profiling tumor samples from NRG/RTOG 0524 and 0712, two prospective trials of CRT in muscle invasive bladder cancer (MIBC).

MATERIALS/METHODS

Pretreatment tissue samples from both trials were profiled using Cofactor Genomics ImmunoPrism, an RNA sequencing assay that uses gene expression profiles to quantify immune cell populations in the tumor microenvironment (TME). Differential gene expression was estimated for different immune cell type proportions across samples. Kaplan-Meier survival analysis and log rank tests were performed to evaluate differences in overall survival (OS) stratified by genes influenced by immune cell proportions or genes associated with immune response signatures.

RESULTS

A total of 70 samples (43 from RTOG 0524 and 27 from RTOG 0712) underwent analysis using the ImmunoPrism assay. Immune cell proportions were as follows: CD8 T cells: median 1.2%, CD4 T cells: median 0.8%, Treg cells: median 9.2%, CD19 B cells: median 5.1%, M2 macrophages: median 0.8%, M1 macrophages: median 0%. Unbiased clustering based on gene expression profiles driven by immune cell proportions demonstrated two groups: cluster 1 with a low percentage of immune cells and shorter OS (median 31 months) and cluster 2 with a high percentage of immune cells and longer OS (median 101 months, p = 0.036). Higher expression of genes associated with T cell infiltration (CD8A and ICOS) was associated with improved OS (104 vs 35 months, p = 0.028, HR = 0.48 (0.25 - 0.94), p = 0.031) as was higher expression of IDO1, which is associated with the interferon gamma pathway (104 vs 35 months, p = 0.042, HR = 0.49 (0.24 - 0.99), p = 0.046).

CONCLUSION

Bladder tumors have a wide range of immune cell infiltration in the TME. Increased immune cell proportions are prognostic for OS following CRT, as well as a higher expression of genes associated with T cell infiltration interferon gamma signaling. These findings have implications for the integration of immunotherapy in the definitive management of MIBC; and can be explored further in the ongoing NRG/SWOG 1806 trial.

Quality of Life Results of Addition of Androgen Deprivation Therapy and Pelvic Lymph Node Treatment to Prostate Bed Salvage Radiotherapy: NRG Oncology/RTOG 0534 SPPORT

PURPOSE/OBJECTIVE(S)

Report the quality of life (QOL) analysis of the SPPORT trial of men with a detectable prostate specific antigen (PSA) after prostatectomy for prostate cancer randomized to (Arm 1) salvage prostate bed radiotherapy (PBRT), (Arm 2) 4-6 months of short-term androgen deprivation therapy (STADT) + PBRT, and (Arm 3) pelvic lymph node radiotherapy (PLNRT) + STADT + PBRT. Primary analysis established a benefit of adding PLNRT and STADT to PBRT. There was higher short term but no statistically significant difference in long term adverse events with the exception of blood or bone marrow events.

MATERIALS/METHODS

QOL endpoints were assessed at baseline, 6 weeks after RT start, 1 and 5 years, including Expanded Prostate Cancer Index Composite (EPIC) (bowel, urinary, sexual, and hormonal domains), Hopkins Symptom Checklist (HSCL-25) (depressive symptoms), and the EuroQol (EQ-5D) (health state weights used in quality adjusted life years (QALYs). In addition to statistical significance, differences in scores were assessed using 0.5 standard deviation (SD) as the criterion for clinical importance. Difference among arms was assessed using pairwise t-tests, Fisher's exact test, and mixed effects regression modeling. To control for multiplicity, the p-value required for statistical significance is p<0.025.

RESULTS

Six hundred forty-four patients consented to QOL, about 210 on each arm. Baseline characteristics were not significantly different among arms: 81% were white and 54% <65 years. For EPIC, bowel domain scores decreased at 6 weeks post-RT then increased by years 1 and 5, although not to baseline levels. One clinically significant difference in bowel scores was Arm 3 vs. Arm 1 at 6 weeks. For the urinary domain, scores decreased at 6 weeks post-RT and remained below baseline at 1 and 5 years, but there were no significant differences among arms. For the sexual domain, there were statistically significant differences between arms at 6 weeks and 1 year with patients receiving STADT exhibiting poorer sexual QOL scores. By year 5 the differences were no longer significant. A similar pattern was seen for the hormonal domain. For HSCL-25, differences at 6 weeks were statistically but not clinically significant, and there were no significant differences at the later time points. Comparisons of QALYs for overall survival over an 8-year horizon showed no significant group differences, with a mean of about 7.8 in each arm. Regarding freedom from progression, QALY means were 5.7, 6.5, and 7.4 years for Arms 1, 2, and 3, respectively, with a significant difference between Arms 3 and 1 (p = <.001) favoring the more intensive treatment.

CONCLUSION

While QOL generally declined among all arms at 6 weeks post RT, there were no clinically significant differences in QOL among arms at 5 years. QALYs for freedom from progression favored STADT + PLNRT + PBRT for salvage treatment of prostate cancer.

Apparatus for skidding sensitivity testing of energetic materials

A remote-operated apparatus for testing the detonation sensitivity of energetic materials is detailed. Using an air ram and rotating disk, the normal force and transverse velocity of the impact plane are controlled independently, enabling the exploration of varying impact conditions over a wide parameter space. A microcontroller local to the apparatus is used to automate apparatus operation and ensure temporal alignment of the impacting ram head with the rotating disk. Calculation of the firing parameters and issuing of operational commands are handled by a remote computer and relayed to the local microcontroller for execution at the hardware level. Impact forces are taken from fast strain measurements obtained from gauges incorporated into the ram head. Infrared imaging of explosive samples provides insight into the peak thermal temperatures experienced at the sample surface during the impact event.

Longitudinal characterisation of haematological and biochemical parameters in cancer patients prior to and during COVID-19 reveals features associated with outcome

BACKGROUND

Cancer patients are at increased risk of death from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Cancer and its treatment affect many haematological and biochemical parameters, therefore we analysed these prior to and during coronavirus disease 2019 (COVID-19) and correlated them with outcome.

PATIENTS AND METHODS

Consecutive patients with cancer testing positive for SARS-CoV-2 in centres throughout the United Kingdom were identified and entered into a database following local governance approval. Clinical and longitudinal laboratory data were extracted from patient records. Data were analysed using Mann-Whitney U test, Fisher's exact test, Wilcoxon signed rank test, logistic regression, or linear regression for outcomes. Hierarchical clustering of heatmaps was performed using Ward's method.

RESULTS

In total, 302 patients were included in three cohorts: Manchester (n = 67), Liverpool (n = 62), and UK (n = 173). In the entire cohort (N = 302), median age was 69 (range 19-93 years), including 163 males and 139 females; of these, 216 were diagnosed with a solid tumour and 86 with a haematological cancer. Preinfection lymphopaenia, neutropaenia and lactate dehydrogenase (LDH) were not associated with oxygen requirement (O2) or death. Lymphocyte count (P < 0.001), platelet count (P = 0.03), LDH (P < 0.0001) and albumin (P < 0.0001) significantly changed from preinfection to during infection. High rather than low neutrophils at day 0 (P = 0.007), higher maximal neutrophils during COVID-19 (P = 0.026) and higher neutrophil-to-lymphocyte ratio (NLR; P = 0.01) were associated with death. In multivariable analysis, age (P = 0.002), haematological cancer (P = 0.034), C-reactive protein (P = 0.004), NLR (P = 0.036) and albumin (P = 0.02) at day 0 were significant predictors of death. In the Manchester/Liverpool cohort 30 patients have restarted therapy following COVID-19, with no additional complications requiring readmission.

CONCLUSION

Preinfection biochemical/haematological parameters were not associated with worse outcome in cancer patients. Restarting treatment following COVID-19 was not associated with additional complications. Neutropaenia due to cancer/treatment is not associated with COVID-19 mortality. Cancer therapy, particularly in patients with solid tumours, need not be delayed or omitted due to concerns that treatment itself increases COVID-19 severity.

Brain microenvironment-driven resistance to immune and targeted therapies in acral melanoma

BACKGROUND

Combination treatments targeting the MEK-ERK pathway and checkpoint inhibitors have improved overall survival in melanoma. Resistance to treatment especially in the brain remains challenging, and rare disease subtypes such as acral melanoma are not typically included in trials. Here we present analyses from longitudinal sampling of a patient with metastatic acral melanoma that became resistant to successive immune and targeted therapies.

METHODS

We performed whole-exome sequencing and RNA sequencing on an acral melanoma that progressed on successive immune (nivolumab) and targeted (dabrafenib) therapy in the brain to identify resistance mechanisms. In addition, we performed growth inhibition assays, reverse phase protein arrays and immunoblotting on patient-derived cell lines using dabrafenib in the presence or absence of cerebrospinal fluid (CSF) in vitro. Patient-derived xenografts were also developed to analyse response to dabrafenib.

RESULTS

Immune escape following checkpoint blockade was not due to loss of tumour cell recognition by the immune system or low neoantigen burden, but was associated with distinct changes in the microenvironment. Similarly, resistance to targeted therapy was not associated with acquired mutations but upregulation of the AKT/phospho-inositide 3-kinase pathway in the presence of CSF.

CONCLUSION

Heterogeneous tumour interactions within the brain microenvironment enable progression on immune and targeted therapies and should be targeted in salvage treatments.

P6296The role of extracellular matrix protein 1 (ECM1) - a novel link between inflammation and cardiac fibrosis

Introduction

Cardiac fibrosis is a severe consequence of cardiovascular disease and aging, in which we currently have no effective treatments. The mechanisms underpinning the development of cardiac fibrosis remains poorly understood. Our preliminary data suggested extracellular matrix protein 1 (ECM1) is involved in cardiac fibrosis. We therefore aimed to investigate the role of ECM1 in several fibrotic cardiac diseases.

Methods

Young and ageing (3m/18m) male C57BL/6 mice, and primary mouse cardiac fibroblast (cFB) cultures, commercial human cardiac fibroblasts (Hu-cFB), human coronary artery endothelial cell (HCAEC)/smooth muscle cell (HCASMC), and human cardiac myocyte (HCM) cell lines were used. Young mice were subject to myocardial infarction (MI, 3-day/28-day, n=6/6), or pressure overload (TAC, 3-day/13-week, n=4/4). Left ventricle (LV) was collected at all time-points, and at 18m (ageing; n=3). Spleen and bone marrow was extracted from young control mice. Hu-cFB cells were treated with recombinant ECM1 (20ng/ml) for either 10, 30 or 50 min, or 48h. Immunoblotting was conducted on all samples, qPCR on LV tissue only, density gradient centrifugation and multicolour flow cytometry coupled with fluorescent ECM1 mRNA in-situ hybridisation (FISH-Flow) on bone marrow cells.

Results

ECM1 expression was upregulated in ageing LV (mRNA 2.2±0.1-fold, p=0.0002; protein 2.0-fold, p=0.0006), day-3 post-MI (mRNA, 4.9±2.0-fold, p=0.004; protein, 3.0-fold, p=0.004), a trend of ECM1 upregulation was observed at day-28 post-MI (mRNA, 13.2±12.0-fold, p=0.003; protein, 1.8-fold, p=0.2), but no change post-TAC. Both ERK1/2 and AKT phosphorylation was upregulated 10 min post-ECM1 treatment of Hu-cFBs (ERK1/2, 2.0-fold, p<0.0001; AKT, 1.9-fold, p<0.0001), and Collagen-I protein expression was upregulated 48h post-ECM1 treatment (1.9-fold, p=0.004). ECM1 protein was not expressed in cFB, Hu-cFB, HCAEC, HCASMC or HCM, however ECM1 protein was highly expressed in spleen and bone marrow; to a greater extent in granulocytes compared to monocytes (p=0.004). tSNE analysis of ECM1 mRNA FISH-Flow revealed ECM1+ are highly granular, moderate to large in size, and express (to varying levels) CD45, CD11b, CD11c, F4/80, Ly6-C, Ly-6G, and FcεrI-α. However ECM1+ cells did not express markers indicative of smaller cells (CD3 or MHC II).

Conclusions

These data demonstrate that ECM1 plays a role in ageing and post-MI fibrosis. Although ECM1 was not produced by resident cardiac cells, it was highly expressed in spleen and bone marrow; specifically, large, granular bone marrow cell sub-types such as granulocytes and/or macrophages. Our data suggest ECM1 is expressed by cardiac infiltrating leukocytes to provoke fibroblast collagen expression in a disease specific manner; potentially via the ERK1/2 and/or AKT pathway activation. Therefore, ECM1 warrants further investigation, and may be a promising target for the treatment of fibrotic cardiac diseases.

Acknowledgement/Funding

John hunter hospital charitable trust, Hunter medical research institute (HMRI) grants

Prediction and monitoring of relapse in stage III melanoma using circulating tumor DNA

BACKGROUND

The advent of effective adjuvant therapies for patients with resected melanoma has highlighted the need to stratify patients based on risk of relapse given the cost and toxicities associated with treatment. Here we assessed circulating tumor DNA (ctDNA) to predict and monitor relapse in resected stage III melanoma.

PATIENTS AND METHODS

Somatic mutations were identified in 99/133 (74%) patients through tumor tissue sequencing. Personalized droplet digital PCR (ddPCR) assays were used to detect known mutations in 315 prospectively collected plasma samples from mutation-positive patients. External validation was performed in a prospective independent cohort (n = 29).

RESULTS

ctDNA was detected in 37 of 99 (37%) individuals. In 81 patients who did not receive adjuvant therapy, 90% of patients with ctDNA detected at baseline and 100% of patients with ctDNA detected at the postoperative timepoint relapsed at a median follow up of 20 months. ctDNA detection predicted patients at high risk of relapse at baseline [relapse-free survival (RFS) hazard ratio (HR) 2.9; 95% confidence interval (CI) 1.5-5.6; P = 0.002] and postoperatively (HR 10; 95% CI 4.3-24; P < 0.001). ctDNA detection at baseline [HR 2.9; 95% CI 1.3-5.7; P = 0.003 and postoperatively (HR 11; 95% CI 4.3-27; P < 0.001] was also associated with inferior distant metastasis-free survival (DMFS). These findings were validated in the independent cohort. ctDNA detection remained an independent predictor of RFS and DMFS in multivariate analyses after adjustment for disease stage and BRAF mutation status.

CONCLUSION

Baseline and postoperative ctDNA detection in two independent prospective cohorts identified stage III melanoma patients at highest risk of relapse and has potential to inform adjuvant therapy decisions.

The evolution and understanding of skeletal complication endpoints in clinical trials of tumors with metastasis to the bone

Bone metastases are a frequent complication of solid tumors, leading to significant skeletal sequelae that negatively impact quality of life and survival. Prevention and management of skeletal-related complications are critical treatment goals in oncology. Endpoints used in clinical trials to evaluate skeletal-related complications have evolved. In contrast to single measures of bone health, contemporary clinical trial endpoints reflect composite measures of skeletal-related complications, and increasingly also survival. In addition, key symptomatic components, which are more reflective of quality of life and the patient experience, are being incorporated. Given the evolution and resulting diversity of the endpoints being used in pivotal trials, it is becoming increasingly relevant to clarify the utility and the potential clinical impact of these measures not only within the context of trials but also in the real-world setting. Here, we describe the development and evolution of skeletal endpoints used in trials, and discuss their clinical relevance.

Spatial and temporal variation of three biomarkers in Mytilus edulis

Environmental conditions and xenobiotic exposure can be sources of stress to living organisms. Biological markers are measurable indicator of changes which may happen at any biological level and which can be considered an early warning signal of some biological or environmental state or condition. A structured field study was undertaken to investigate the relationship between three biomarker assays and the spatial and temporal variation of each biomarker in samples of Mytilus edulis. The three biomarkers were the neutral red retention assay, micronucleus assay and comet assay, which indicate damage at different cellular/molecular levels. Three sites in Poole Harbour, an area on the South coast of the UK were sampled on six separate occasions at least three weeks apart. The results for the comet assay showed a significant difference between sites and between sampling dates whereas the results for the other two assays did not show a significant difference for either factor. There was no significant correlation between the results of any pair of the three biomarkers. The results of the micronucleus assay showed a significant correlation with water temperature. This temperature effect, as well as induced repair, may contribute to explain the lack of a strict correspondence between pollution gradients and biomarkers responses.

Circulating tumor DNA predicts survival in patients with resected high-risk stage II/III melanoma

Background

Patients with high-risk stage II/III resected melanoma commonly develop distant metastases. At present, we cannot differentiate between patients who will recur or those who are cured by surgery. We investigated if circulating tumor DNA (ctDNA) can predict relapse and survival in patients with resected melanoma.

Patients and methods

We carried out droplet digital polymerase chain reaction to detect BRAF and NRAS mutations in plasma taken after surgery from 161 stage II/III high-risk melanoma patients enrolled in the AVAST-M adjuvant trial.

Results

Mutant BRAF or NRAS ctDNA was detected (≥1 copy of mutant ctDNA) in 15/132 (11%) BRAF mutant patient samples and 4/29 (14%) NRAS mutant patient samples. Patients with detectable ctDNA had a decreased disease-free interval [DFI; hazard ratio (HR) 3.12; 95% confidence interval (CI) 1.79-5.47; P < 0.0001] and distant metastasis-free interval (DMFI; HR 3.22; 95% CI 1.80-5.79; P < 0.0001) versus those with undetectable ctDNA. Detectable ctDNA remained a significant predictor after adjustment for performance status and disease stage (DFI: HR 3.26, 95% CI 1.83-5.83, P < 0.0001; DMFI: HR 3.45, 95% CI 1.88-6.34, P < 0.0001). Five-year overall survival rate for patients with detectable ctDNA was 33% (95% CI 14%-55%) versus 65% (95% CI 56%-72%) for those with undetectable ctDNA. Overall survival was significantly worse for patients with detectable ctDNA (HR 2.63; 95% CI 1.40-4.96); P = 0.003) and remained significant after adjustment for performance status (HR 2.50, 95% CI 1.32-4.74, P = 0.005).

Conclusion

ctDNA predicts for relapse and survival in high-risk resected melanoma and could aid selection of patients for adjuvant therapy.

Clinical trial number

ISRCTN 81261306.

Plasma total cell-free DNA (cfDNA) is a surrogate biomarker for tumour burden and a prognostic biomarker for survival in metastatic melanoma patients

INTRODUCTION

Tumour burden is a prognostic biomarker in metastatic melanoma. However, tumour burden is difficult to measure and there are currently no reliable surrogate biomarkers to easily and reliably determine it. The aim of this study was to assess the potential of plasma total cell free DNA as biomarker of tumour burden and prognosis in metastatic melanoma patients.

MATERIALS AND METHODS

A prospective biomarker cohort study for total plasma circulating cell-free DNA (cfDNA) concentration was performed in 43 metastatic melanoma patients. For 38 patients, paired blood collections and scan assessments were available before treatment and at first response evaluation. Tumour burden was calculated as the sum of volumes from three-dimensional radiological measurements of all metastatic lesions in individual patients.

RESULTS

Baseline cfDNA concentration correlated with pre-treatment tumour burden (ρ = 0.52, P < 0.001). Baseline cfDNA levels correlated significantly with hazard of death and overall survival, and a cut off value of 89 pg/μl identified two distinct prognostic groups (HR = 2.22 for high cfDNA, P = 0.004). Patients with cfDNA ≥89 pg/μl had shorter OS (10.0 versus 22.7 months, P = 0.009; HR = 2.22 for high cfDNA, P = 0.004) and the significance was maintained when compared with lactic dehydrogenase (LDH) in a multivariate analysis. We also found a correlation between the changes of cfDNA and treatment-related changes in tumour burden (ρ = 0.49, P = 0.002). In addition, the ratio between baseline cfDNA and tumour burden was prognostic (HR = 2.7 for cfDNA/tumour volume ≥8 pg/(μl*cm3), P = 0.024).

CONCLUSIONS

We have demonstrated that cfDNA is a surrogate marker of tumour burden in metastatic melanoma patients, and that it is prognostic for overall survival.

Atrial natriuretic peptide and brain natriuretic peptide changes after epicardial percutaneous left atrial appendage suture ligation using LARIAT device

Percutaneous left atrial appendage closure is an alternative treatment for stroke and systemic thromboembolism risk reduction in non-valvular atrial fibrillation (AF). However, the neurohormonal impact of epicardial exclusion of the left atrial appendage (LAA) with the LARIAT procedure is unknown. Evaluation of changes in atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) levels in AF patients underwent percutaneous LAA suture ligation. Sixty six patients underwent successfully percutaneous LAA suture ligation using LARIAT device. The level of ANP and BNP was measured before and 3 months after procedure. Mean ANP level before procedure was 249 ± 77 pg/mL (range from 95 pg/mL to 503 pg/mL) and mean BNP level was 481 ± 517 pg/mL (range from 34 pg/mL to 2508 pg/mL). Three months after procedure mean ANP level was 249 ± 79 pg/mL (range from 98 pg/mL to 492 pg/mL) and mean BNP level was 495 ± 526 pg/mL (range from 52 pg/mL to 2420 pg/mL). At 3 months follow up after percutaneous LAA suture ligation there were no significant differences in ANP and BNP levels.

Attitudes of breast cancer professionals to conventional and telemedicine-delivered multidisciplinary breast meetings

We surveyed the attitudes of breast cancer professionals to standard face-to-face and future telemedicine-delivered breast multidisciplinary team (MDT) meetings. Interviews, which included the Group Behaviour Inventory, were conducted face-to-face (n = 19) or by telephone (n = 26). The mean total score on the Group Behaviour Inventory was 96 (SD 19) for 33 respondents, which indicated satisfaction with standard MDT meetings, irrespective of role and base hospital. Positive attitudes to videoconferencing were more common among participants with previous experience of telemedicine (Spearman's rank correlation 0.26, P = 0.91). Common themes emerging from the interviews about telemedicine-delivered MDTs included group leadership, meeting efficiency, group interaction, group atmosphere and technical quality of communication. Most participants were satisfied with standard breast MDTs. Nurses and allied health professionals were least supportive of telemedicine.

Endovascular Therapy Research in Lower Limb Peripheral Arterial Disease Published Over a 5-Year Period: Who is Publishing and Where?

INTRODUCTION

Peripheral arterial disease (PAD) is being increasingly managed by endovascular therapies. In this study, we identified the clinical services publishing research as well as the journals of publication over a 5-year period.

METHODS

Twenty keywords and phrases related to endovascular intervention were identified, and a literature search was performed through the PubMed database from January 2009 to January 2014. Inclusion criteria were English language, study population more than five patients, and matching the keyword search. Eligible studies were collated into a database and classified by journal of publication, PubMed number, article title, publishing clinical service, type of publication, country of origin, and authors.

RESULTS

825 studies from 114 different journals were identified. 297 papers were excluded. Of the 528 included papers, 204 (39%) were published by Vascular Surgery (VS), 157 (30%) by Interventional Radiology (IR), 101 (19%) by Cardiology, 43 (8%) by Angiology, 6 (1%) by Vascular Medicine, and 17 (3%) from miscellaneous services. 283 (54%) studies originated from Europe, 157 (30%) from North America, 76 (14%) from Asia, 6 from Australia, 3 each from South America and Africa. IR published the most papers on PAD endovascular intervention in Europe with VS second while this trend was reversed in the USA. The 528 papers were published in 98 different journals with retrospective case series (72%), the majority.

CONCLUSION

IR continues to play a significant research role in endovascular intervention in PAD, particularly in Europe, and specifically in below the knee intervention, pedal intervention, and drug-eluting technologies.

Distinct subclonal tumour responses to therapy revealed by circulating cell-free DNA

BACKGROUND

The application of precision medicine in oncology requires in-depth characterisation of a patient's tumours and the dynamics of their responses to treatment.

PATIENTS AND METHODS

We used next-generation sequencing of circulating cell-free DNA (cfDNA) to monitor the response of a KIT p.L576P-mutant metastatic vaginal mucosal melanoma to sequential targeted, immuno- and chemotherapy.

RESULTS

Despite a KIT mutation, the response to imatinib was mixed. Unfortunately, tumours were not accessible for molecular analysis. To study the mechanism underlying the mixed clinical response, we carried out whole-exome sequencing and targeted longitudinal analysis of cfDNA. This revealed two tumour subclones; one with a KIT mutation that responded to imatinib and a second KIT-wild-type subclone that did not respond to imatinib. Notably, the subclones also responded differently to immunotherapy. However, both subclones responded to carboplatin/paclitaxel, and although the KIT-wild-type subclone progressed after chemotherapy, it responded to subsequent re-administration of paclitaxel.

CONCLUSION

We show that cfDNA can reveal tumour evolution and subclonal responses to therapy even when biopsies are not available.

Development of a Fluorescence Detection System Using Optical Parametric Oscillator (OPO) Laser Excitation for in Vivo Diagnosis

In this work, the development and applications of a fluorescence detection system using optical parametric oscillator (OPO) laser excitation for in vivo disease diagnosis including oral carcinoma are described. The optical diagnosis system was based on an OPO laser for multi-wavelength excitation and time-resolved detection. The pulsed Nd-YAG-pumped OPO laser system (6 ns, 20 Hz) is compact and has a rapid, broad, and uniform tuning range. Time-gated detection of intensified charge-coupled device (ICCD) making use of external triggering was used to effectively eliminate the laser scattering and contribute to the highly sensitive in vivo measurements. Artificial tissue-simulating phantoms consisting of polystyrene microspheres and tissue fluorophores were tested to optimize the gating parameters. 51-ns gate width and 39-ns gate delays were determined to be the optimal parameters for sensitive detection. in vivo measurements with the optical diagnosis system were applied to esophagus, stomach, and small intestine using an endoscope in canine animal studies. The rapid tuning capability of the optical diagnosis system contributed greatly to the optimization of wavelength for the observation of porphyrin in the small intestine. When the small intestine was thoroughly washed with water, the emission band which corresponds to porphyrin disappeared. Based on this observation, it was concluded that the detected signal was yielded by porphyrin-containing bile secretion. Also, multispectral analyses using multiple excitations from 415 to 480 nm at 5 nm intervals confirmed the porphyrin detection in the small intestine. The optical diagnosis system was also applied to the detection of human xenograft of oral carcinoma in mice using 5-aminolevulinic acid (5-ALA) which is a photodynamic therapy (PDT) drug. Significant differences in protoporphyrin IX fluorescence intensity between normal and tumor tissue could be obtained 2 hours after the injection of 5-ALA into mice due to the preferential accumulation of 5-ALA in tumors. Results reported herein demonstrate potential capabilities of the LIF-OPO system for in vivo disease diagnosis.

Impact of muffle furnace preparation on the results of crystalline silica analysis

A prior report demonstrated an unacceptably low level of accuracy in silica analytical testing, with a general negative bias (i.e., underreporting) although other inaccuracies included false-positive results when analyzing blank filters. The possible bias may have been due to the loss of sample during shipping and or sample preparation. We report on a follow-up study that was designed to mimic the original study, but in which sources of variability were evaluated. We found no effect on silica recoveries due to shipping and confirmed the prior study results that the muffle furnace ashing process led to low overall recoveries (49-104%), depending on the adherence to the recommended preparation method. Plasma ashing recoveries ranged from 89 to 108%. Our results suggest that muffle-furnace ashing using a crucible should be restricted. More broadly, however, muffle-furnace ashing is only one source of analytical error that contributes to the relatively poor overall performance revealed by Cox et al. Whatever the case, OSHA should ensure that its proposed requirements to improve laboratory performance will actually lead to the discovery and correction of all major sources of error by participating laboratories. This is particularly important in light of OSHA's proposed reduction in the PEL and action level proposed by OSHA.

Geographical and temporal variation of E. coli and norovirus in mussels

Bivalve shellfish may accumulate contaminants of public health concern including pathogenic bacteria and viruses. Microbiological monitoring of production areas is based on faecal coliforms in water in the USA and Escherichia coli in bivalve molluscs in the European Union. E. coli is known to reflect contamination with Salmonella enterica but not necessarily with other human pathogens such as enteric viruses. A structured field study was undertaken at three locations in order to investigate the geographical and temporal variability of E. coli and norovirus (NoV). Total norovirus concentration differed significantly by both sampling site and sampling date. A significant correlation was found between total NoV concentration and E. coli concentration by sample, but not with E. coli in seawater. The results have implications for the establishment of sampling plans for NoV in harvesting areas and potentially also for the approach taken to classification based on faecal indicator bacteria.

Patient characteristics associated with risk of first hospital admission and readmission for acute exacerbation of chronic obstructive pulmonary disease (COPD) following primary care COPD diagnosis: a cohort study using linked electronic patient records

OBJECTIVES

To investigate patient characteristics of an unselected primary care population associated with risk of first hospital admission and readmission for acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

DESIGN

Retrospective open cohort using pseudonymised electronic primary care data linked to secondary care data.

SETTING

Primary care; Lothian (population approximately 800,000), Scotland.

PARTICIPANTS

Data from 7002 patients from 72 general practices with a COPD diagnosis date between 2000 and 2008 recorded in their primary care record. Patients were followed up until 2010, death or they left a participating practice.

MAIN OUTCOME MEASURES

First and subsequent admissions for AECOPD (International Classification of Diseases (ICD) 10 codes J44.0, J44.1 in any diagnostic position) after COPD diagnosis in primary care.

RESULTS

1756 (25%) patients had at least 1 AECOPD admission; 794 (11%) had at least 1 readmission and the risk of readmission increased with each admission. Older age at diagnosis, more severe COPD, low body mass index (BMI), current smoking, increasing deprivation, COPD admissions and interventions for COPD prior to diagnosis in primary care, and comorbidities were associated with higher risk of first AECOPD admission in an adjusted Cox proportional hazards regression model. More severe COPD and COPD admission prior to primary care diagnosis were associated with increased risk of AECOPD readmission in an adjusted Prentice-Williams-Peterson model. High BMI was associated with a lower risk of first AECOPD admission and readmission.

CONCLUSIONS

Several patient characteristics were associated with first AECOPD admission in a primary care cohort of people with COPD but fewer were associated with readmission. Prompt diagnosis in primary care may reduce the risk of AECOPD admission and readmission. The study highlights the important role of primary care in preventing or delaying a first AECOPD admission.

Targeting leukemia stem cells in vivo with antagomiR-126 nanoparticles in acute myeloid leukemia

Current treatments for acute myeloid leukemia (AML) are designed to target rapidly dividing blast populations with limited success in eradicating the functionally distinct leukemia stem cell (LSC) population, which is postulated to be responsible for disease resistance and relapse. We have previously reported high miR-126 expression levels to be associated with a LSC-gene expression profile. Therefore, we hypothesized that miR-126 contributes to “stemness” and is a viable target for eliminating the LSC in AML. Here we first validate the clinical relevance of miR-126 expression in AML by showing that higher expression of this microRNA (miR) is associated with worse outcome in a large cohort of older (≥60 years) cytogenetically normal AML patients treated with conventional chemotherapy. We then show that miR-126 overexpression characterizes AML LSC-enriched cell subpopulations and contributes to LSC long-term maintenance and self-renewal. Finally, we demonstrate the feasibility of therapeutic targeting of miR-126 in LSCs with novel targeting nanoparticles (NP) containing antagomiR-126 resulting in in vivo reduction of LSCs likely by depletion of the quiescent cell subpopulation. Our findings suggest that by targeting a single miR, i.e., miR-126, it is possible to interfere with LSC activity, thereby opening potentially novel therapeutic approaches to treat AML patients.

Pharmacological targeting of miR-155 via the NEDD8-activating enzyme inhibitor MLN4924 (Pevonedistat) in FLT3-ITD acute myeloid leukemia

High levels of microRNA-155 (miR-155) are associated with poor outcome in acute myeloid leukemia (AML). In AML, miR-155 is regulated by NF-κB, the activity of which is, in part, controlled by the NEDD8-dependent ubiquitin ligases. We demonstrate that MLN4924, an inhibitor of NEDD8-activating enzyme presently being evaluated in clinical trials, decreases binding of NF-κB to the miR-155 promoter and downregulates miR-155 in AML cells. This results in the upregulation of the miR-155 targets SHIP1, an inhibitor of the PI3K/Akt pathway, and PU.1, a transcription factor important for myeloid differentiation, leading to monocytic differentiation and apoptosis. Consistent with these results, overexpression of miR-155 diminishes MLN4924-induced antileukemic effects. In vivo, MLN4924 reduces miR-155 expression and prolongs the survival of mice engrafted with leukemic cells. Our study demonstrates the potential of miR-155 as a novel therapeutic target in AML via pharmacologic interference with NF-κB-dependent regulatory mechanisms. We show the targeting of this oncogenic microRNA with MLN4924, a compound presently being evaluated in clinical trials in AML. As high miR-155 levels have been consistently associated with aggressive clinical phenotypes, our work opens new avenues for microRNA-targeting therapeutic approaches to leukemia and cancer patients.

The role of chemotherapy in the modern management of melanoma

The last 4 years have seen dramatic changes in the treatment of advanced melanoma, largely based on advances in targeted therapy and immunotherapy. This article examines the role of chemotherapy in the modern management of melanoma. We examine the evidence for promising new agents and discuss their position in the sequencing of treatment options for patients with advanced disease. In addition, we discuss the combination of chemotherapy with targeted treatments and immune therapies. Finally, we discuss future areas of research for ensuring that we maximize the potential of all agents available to us and identify new, effective treatments.

Evaluation of take-home exposure and risk associated with the handling of clothing contaminated with chrysotile asbestos

The potential for para-occupational (or take-home) exposures from contaminated clothing has been recognized for the past 60 years. To better characterize the take-home asbestos exposure pathway, a study was performed to measure the relationship between airborne chrysotile concentrations in the workplace, the contamination of work clothing, and take-home exposures and risks. The study included air sampling during two activities: (1) contamination of work clothing by airborne chrysotile (i.e., loading the clothing), and (2) handling and shaking out of the clothes. The clothes were contaminated at three different target airborne chrysotile concentrations (0-0.1 fibers per cubic centimeter [f/cc], 1-2 f/cc, and 2-4 f/cc; two events each for 31-43 minutes; six events total). Arithmetic mean concentrations for the three target loading levels were 0.01 f/cc, 1.65 f/cc, and 2.84 f/cc (National Institute of Occupational Health and Safety [NIOSH] 7402). Following the loading events, six matched 30-minute clothes-handling and shake-out events were conducted, each including 15 minutes of active handling (15-minute means; 0.014-0.097 f/cc) and 15 additional minutes of no handling (30-minute means; 0.006-0.063 f/cc). Percentages of personal clothes-handling TWAs relative to clothes-loading TWAs were calculated for event pairs to characterize exposure potential during daily versus weekly clothes-handling activity. Airborne concentrations for the clothes handler were 0.2-1.4% (eight-hour TWA or daily ratio) and 0.03-0.27% (40-hour TWA or weekly ratio) of loading TWAs. Cumulative chrysotile doses for clothes handling at airborne concentrations tested were estimated to be consistent with lifetime cumulative chrysotile doses associated with ambient air exposure (range for take-home or ambient doses: 0.00044-0.105 f/cc year).

Tumor antigen ROR1 targeted drug delivery mediated selective leukemic but not normal B-cell cytotoxicity in chronic lymphocytic leukemia

Selective cytotoxicity to cancer cells without compromising their normal counterparts pose a huge challenge for traditional drug design. Here we developed a tumor antigen targeted delivery of immunonanoparticle carrying a novel non-immunosuppressive FTY720 derivative OSU-2S with potent cytotoxicity against leukemic B cells. OSU-2S induces activation of protein phosphatase 2A, phosphorylation and nuclear translocation of SHP1^S591 and deregulation of multiple cellular processes in chronic lymphocytic leukemia (CLL) resulting in potent cytotoxicity. To preclude OSU-2S mediated effects on these ubiquitous phosphatases in unintended cells and avoid potential adverse effects we developed a OSU-2S targeted delivery immunonanoparticles (2A2-OSU-2S-ILP), that mediated selective cytotoxicity of CLL but not normal B cells through targeting receptor tyrosine kinase ROR1 expressed in leukemic but not normal B cells. Developing a novel spontaneous CLL mouse model expressing human ROR1 (hROR1) in all leukemic B cells, we demonstrate the therapeutic benefit of enhanced survival with 2A2-OSU-2S-ILP in-vivo. The newly developed non-immunosuppressive OSU-2S, its delivery using human CLL directed immunonanoparticles and the novel transgenic mouse model of CLL that expresses hROR1 exclusively in leukemic B cell surface are highly innovative and can be applied to CLL and other ROR1+ malignancies including mantle cell lymphoma and acute lymphoblastic leukemia.

Relating the bivalve shellfish harvesting area classification criteria in the United States and European Union programmes

Estimation of the level of risk of faecal contamination of shellfish harvesting areas is undertaken by monitoring faecal indicator bacteria in seawater samples under the United States programme and shellfish flesh samples under the European Union (EU) programme. Determining the relationship between the two approaches is important for assessing the relative level of public health protection and regulating international trade. The relationship was investigated using both statistical modelling and simple compliance assessment on large international data sets of paired seawater and shellfish samples. The two approaches yielded the same conclusions: EU class A is more stringent than the US Approved category for all species; the US Restrictive standard is more restrictive than EU class B for some bivalve species. Therefore, the classifications under the two programmes are not exactly equivalent.

Sources of variation of Escherichia coli concentrations in bivalve molluscs

Bivalve molluscs can concentrate contaminants, including pathogenic microorganisms, from the water column during their normal filter-feeding activity. In the European Union, the risk of human and animal faecal contamination in bivalves is estimated by determining the concentration of Escherichia coli in time-series samples from production areas. A structured field study was undertaken to determine the extent to which such concentrations varied between sites, sampling occasions and shellfish species and to determine the residual variability of the method. E. coli was enumerated in three species of bivalve mollusc (Crassostrea gigas, Mytilus spp. and Pecten maximus) co-located in each of three geographically separate commercial shellfisheries. The data were subjected to analysis of variance (ANOVA). This showed that the effects of site, sampling occasion, species and site/sampling occasion interaction were all significant. The proportion of variation due to site was markedly greater than that due to other factors. Post-ANOVA analysis showed that the concentration of E. coli in P. maximus was significantly higher than in the other two species. Mytilus spp. and C. gigas exhibited comparable levels of E. coli. The observed standard deviation of the most probable number method in the study was 0.33 log(10).

Penile cancer: current therapy and future directions

Background Penile cancer (PC) is a rare cancer in western countries, but is more common in parts of the developing world. Due to its rarity and the consequent lack of randomized trials, current therapy is based on retrospective studies and small prospective trials. Design Studies of PC therapy were searched in PubMed and abstracts at major conferences. Results PC is generally an aggressive malignancy characterized by early locoregional lymph node (LN) spread and later metastases in distant sites. Given the strong predictive value of LN involvement for overall survival, evaluating regional LNs is critical. Advanced LN involvement is increasingly being treated with multimodality therapy incorporating chemotherapy and/or radiation. A single superior cisplatin-based regimen has not been defined. Further advances may occur with a better collaboration on an international scale and comprehensive understanding of tumor biology. To this end, the preventive role of circumcision and understanding of the oncogenic roles of Human Papilloma Virus-16, and smoking may yield advances. Preliminary data suggest a role for agents targeting epidermal growth factor receptor and angiogenesis. Conclusion Advances in therapy for PC will require efficient trial designs, synergistic collaboration, incentives to industry and the efforts of patient advocacy groups and venture philanthropists.

Multicenter phase II study of trabectedin in patients with metastatic castration-resistant prostate cancer

BACKGROUND

This multicenter phase II trial evaluated the efficacy and safety of trabectedin in metastatic castration-resistant prostate cancer (CRPC).

PATIENTS AND METHODS

Two schedules were evaluated in three cohorts: weekly as 3-h i.v. infusion at 0.58 mg/m(2) for 3 out of 4 weeks (Cohort A, n = 33), and every 3 weeks (q3wk) as 24-h infusion at 1.5 mg/m(2) (Cohort B1, n = 5) and 1.2 mg/m(2) (Cohort B2, n = 20). The primary end point was prostate-specific antigen (PSA) response; secondary end points included safety, tolerability and time to progression (TTP).

RESULTS

Trabectedin resulted in PSA declines ≥ 50% in 12.5% (Cohort A) and 10.5% (Cohort B2) of patients. Among men pretreated with taxane-based chemotherapy, PSA response was 13.6% (Cohort A) and 15.4% (Cohort B2). PSA responses lasted 4.1-8.6 months, and median TTP was 1.5 months (Cohort A) and 1.9 months (Cohort B2). The dose of 1.5 mg/m(2) (approved for soft tissue sarcoma) given as 24-h infusion q3wk was not tolerable in these patients. At 1.2 mg/m(2) q3wk and 0.58 mg/m(2) weekly, the most common adverse events were nausea, fatigue and transient neutropenia and transaminase increase.

CONCLUSIONS

Two different trabectedin schedules showed modest activity in metastatic CRPC. Further studies may require identification of predictive factors of response in prostate cancer.

Physiological sex steroid replacement in premature ovarian failure: randomized crossover trial of effect on uterine volume, endometrial thickness and blood flow, compared with a standard regimen

BACKGROUND

Premature ovarian failure (POF) is currently managed by non-physiological sex steroid regimens which are inadequate at optimizing uterine characteristics. Previous short-term studies have demonstrated some benefits of a sex steroid replacement (SSR) regimen devised to replicate the physiological cycle. This study aimed to directly compare the effects of longer-term administration of physiological SSR (pSSR) and standard SSR (sSSR) regimens on the uterine volume, blood flow and endometrial thickness (ET) in women with POF.

METHODS

In a controlled crossover trial, 34 women with POF were randomized to receive 12 months of 4-week cycles of transdermal estradiol and vaginal progesterone (pSSR) followed by 12 months of 4-week cycles of oral ethinylestradiol and norethisterone (sSSR), or vice versa. Each treatment period was preceded by a 2-month washout period. At 0, 3, 6 and 12 months of each treatment period, transvaginal ultrasound examined the uterine volume and ET, as primary end-points, and uterine artery resistance (UARI) and pulsatility indices (UAPI), as secondary end-points. Serum estradiol, progesterone and gonadotrophins were also measured.

RESULTS

Of the 29 women eligible for the uterine analysis, 17 completed the entire study protocol, but 25 women contributed data to statistical analysis of treatment effect. There was a greater estimated mean ET with the use of pSSR (4.8 mm) compared to that with standard therapy (3.0 mm), with an estimated difference of 1.8 mm [95% confidence interval (CI), 0.7 to 2.8, P=0.002]. The estimated mean uterine volume was also greater during physiological treatment (24.8 cm(3)) than during standard treatment (20.6 cm(3)), but the estimated difference of 4.2 cm(3) (95% CI -0.4 to 8.7) was not statitsically significant, P=0.070. The small differences between the two treatments in the mean UARI and mean UAPI were not statistically significant. The estimated treatment differences were fairly constant across the treatment periods, suggesting that prolonged treatment does not increase response.

CONCLUSIONS

pSSR has a greater beneficial effect upon ET in women with POF in comparison with standard therapy. A similar trend was seen for uterine volume. Further studies are required to optimize treatment and to assess pregnancy rate and outcome. Trial Registration www.ClinicalTrials.gov, NCR00732693.

Context-dependent judgments of color that might allow color constancy in scenes with multiple regions of illumination

For a color-constant observer, a change in the spectral composition of the illumination is accompanied by a corresponding change in the chromaticity associated with an achromatic percept. However, maintaining color constancy for different regions of illumination within a scene implies the maintenance of multiple perceptual references. We investigated the features of a scene that enable the maintenance of separate perceptual references for two displaced but overlapping chromaticity distributions. The time-averaged, retinotopically localized stimulus was the primary determinant of color appearance judgments. However, spatial separation of test samples additionally served as a symbolic cue that allowed observers to maintain two separate perceptual references.

Randomized placebo-controlled trial of CDB-2914 in new users of a levonorgestrel-releasing intrauterine system shows only short-lived amelioration of unscheduled bleeding

BACKGROUND

The levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective contraceptive. However, during early months of use unscheduled vaginal bleeding is common, sometimes leading to discontinuation. This study aimed to determine whether intermittent administration of progesterone receptor modulator CDB-2914 would suppress unscheduled bleeding during the first 4 months after insertion of the LNG-IUS.

METHODS

CDB-2914 150 mg, in divided doses, or placebo tablets, were administered over three consecutive days starting on Days 21, 49 and 77 after LNG-IUS insertion, in a double-blind randomized controlled trial of women aged 19-49 years, newly starting use of LNG-IUS. Daily bleeding diaries were completed for 6 months, and summarized across blocks as percentage days bleeding/spotting (BS%).

RESULTS

Of 69 women randomized to receive CDB-2914, and 67 placebo, 61 and 55, respectively, completed the trial. BS% decreased with time in both arms, but showed a much steeper treatment-phase gradient in the placebo arm (P < 0.0001), so that a benefit of CDB-2914 in the 28 days after first treatment (-11% points, 95% CI -19 to -2), converted to a disadvantage by 64 days after the third treatment (+10% points, 95% CI 1-18).

CONCLUSIONS

The effect of CDB-2914 on BS% was initially beneficial but then by third treatment was disadvantageous. Nevertheless, only 3% (4/136) of all women discontinued LNG-IUS. These findings give insight into possible mechanisms and suggest future research directions. ISRCTN Trial no. ISRCTN58283041; EudraCT no. 2006-006511-72.

Latency characteristics of the short-wavelength-sensitive cones and their associated pathways

There are many distinct types of retinal ganglion and LGN cells that have opponent cone inputs and which may carry chromatic information. Of interest are the asymmetries in those LGN cells that carry S-cone signals: in S-ON cells, S+ signals are opposed by (L + M) whereas, in many S-OFF cells, L+ signals are opposed by (S + M), giving -S + L - M (C. Tailby, S. G. Solomon, & P. Lennie, 2008). However, the S-opponent pathway is traditionally modeled as +/-[S - (L + M)]. A phase lag of the S-cone signal has been inferred from psychophysical thresholds for discriminating combinations of simultaneous sinusoidal modulations along +/-[L - M] and +/-[S - (L + M)] directions (C. F. Stromeyer, R. T. Eskew, R. E. Kronauer, & L. Spillmann, 1991). We extend this experiment, measuring discrimination thresholds as a function of the phase delay between pairs of orthogonal component modulations. When one of the components isolates the tritan axis, there are phase delays at which discrimination is impossible; when neither component is aligned with the tritan axis, discrimination is possible at all delays. The data imply that the S-cone signal is delayed by approximately 12 ms relative to (L - M) responses. Given that post-receptoral mechanisms show diverse tuning around the tritan axis, we suggest that the delay arises before the S-opponent channels are constructed, possibly in the S-cones themselves.

Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis

CONTEXT

Prediction models to identify healthy individuals at high risk of cardiovascular disease have limited accuracy. A low ankle brachial index (ABI) is an indicator of atherosclerosis and has the potential to improve prediction.

OBJECTIVE

To determine if the ABI provides information on the risk of cardiovascular events and mortality independently of the Framingham risk score (FRS) and can improve risk prediction.

DATA SOURCES

Relevant studies were identified. A search of MEDLINE (1950 to February 2008) and EMBASE (1980 to February 2008) was conducted using common text words for the term ankle brachial index combined with text words and Medical Subject Headings to capture prospective cohort designs. Review of reference lists and conference proceedings, and correspondence with experts was conducted to identify additional published and unpublished studies.

STUDY SELECTION

Studies were included if participants were derived from a general population, ABI was measured at baseline, and individuals were followed up to detect total and cardiovascular mortality.

DATA EXTRACTION

Prespecified data on individuals in each selected study were extracted into a combined data set and an individual participant data meta-analysis was conducted on individuals who had no previous history of coronary heart disease.

RESULTS

Sixteen population cohort studies fulfilling the inclusion criteria were included. During 480,325 person-years of follow-up of 24,955 men and 23,339 women, the risk of death by ABI had a reverse J-shaped distribution with a normal (low risk) ABI of 1.11 to 1.40. The 10-year cardiovascular mortality in men with a low ABI (< or = 0.90) was 18.7% (95% confidence interval [CI], 13.3%-24.1%) and with normal ABI (1.11-1.40) was 4.4% (95% CI, 3.2%-5.7%) (hazard ratio [HR], 4.2; 95% CI, 3.3-5.4). Corresponding mortalities in women were 12.6% (95% CI, 6.2%-19.0%) and 4.1% (95% CI, 2.2%-6.1%) (HR, 3.5; 95% CI, 2.4-5.1). The HRs remained elevated after adjusting for FRS (2.9 [95% CI, 2.3-3.7] for men vs 3.0 [95% CI, 2.0-4.4] for women). A low ABI (< or = 0.90) was associated with approximately twice the 10-year total mortality, cardiovascular mortality, and major coronary event rate compared with the overall rate in each FRS category. Inclusion of the ABI in cardiovascular risk stratification using the FRS would result in reclassification of the risk category and modification of treatment recommendations in approximately 19% of men and 36% of women.

CONCLUSION

Measurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS.

Naturally occurring asbestos: a recurring public policy challenge

The potential environmental hazards and associated public health issues related to exposure to respirable dusts from the vicinity of natural in-place asbestos deposits (commonly referred to as naturally occurring asbestos, NOA) have gained the regulatory and media spotlight in many areas around the United States, such as Libby, MT, Fairfax County, VA, and El Dorado Hills, CA, among others. NOA deposits may be present in a variety of geologic formations. It has been suggested that airborne asbestos may be released from NOA deposits, and absent appropriate engineering controls, may pose a potential health hazard if these rocks are crushed or exposed to natural weathering and erosion or to human activities that create dust. The issue that needs to be addressed at a policy level is the method of assessing exposures to elongated rock fragments ubiquitous in dust clouds in these same environments and the associated risk. Elongated rock fragments and single crystal minerals present in NOA have been construed by some as having attributes, including the health effects, of asbestos fibers. However, the Occupational Safety and Health Administration (OSHA), Mine Safety and Health Administration (MSHA), and the Consumer Products Safety Commission (CPSC) found that the scientific evidence did not support this assumption. As in many environmental fields of study, the evidence is often disputed. Regulatory policy is not uniform on the subject of rock fragments, even within single agencies. The core of the issue is whether the risk parameters associated with exposures to commercial asbestos can or should be applied to rock fragments meeting an arbitrary set of particle dimensions used for counting asbestos fibers. Inappropriate inclusion of particles or fragments results in dilution of risk and needless expenditure of resources. On the other hand, inappropriate exclusion of particles or fragments may result in increased and unnecessary risk. Some of the fastest growing counties in the United States are in areas where NOA is known to exist and therefore this issue takes on national significance. This ongoing national dilemma has raised public and business concerns. There has been continuing political and scientific debate and widespread miscommunication over perceived versus actual health risks, the validity of various analytical sampling and testing methods, the questionable necessity and escalating costs of remediation procedures, and the combined negative impact on numerous commercial and public interests. Thus, conflicting research and regulatory positions on the distinctions between and hazards of true asbestos and ordinary rock fragments is all that is presently available to the public until the differing scientific communities and government agencies arrive at a consensus on these issues. The risk assessment methodology and the analytical technology needed to support inferences drawn from existing research are available, but have not been organized and implemented in the manner needed to resolve the NOA controversy. There should exist nationally adopted and peer-reviewed NOA standards (developed jointly by the scientific community, health risk professionals, and government regulators) that establish: (1) a scientific basis for risk evaluation and assessment of NOA and rock fragments; (2) accepted analytical protocols for determining if NOA actually exists in a given area and for separating NOA from related non-asbestos rock fragments and single crystal minerals; and (3) effective public policies for managing NOA, minimizing potential hazards, and protecting public health. This article will review some of the key issues involved with the current NOA debate, propose improved analytical methodologies, describe potential solutions for dealing with NOA, and outline the benefits to be gained by creating a practical national NOA public policy.

Airborne asbestos in buildings

The concentration of airborne asbestos in buildings nationwide is reported in this study. A total of 3978 indoor samples from 752 buildings, representing nearly 32 man-years of sampling, have been analyzed by transmission electron microscopy. The buildings that were surveyed were the subject of litigation related to suits alleging the general building occupants were exposed to a potential health hazard as a result the presence of asbestos-containing materials (ACM). The average concentration of all airborne asbestos structures was 0.01structures/ml (s/ml) and the average concentration of airborne asbestos > or = 5microm long was 0.00012fibers/ml (f/ml). For all samples, 99.9% of the samples were <0.01 f/ml for fibers longer than 5microm; no building averaged above 0.004f/ml for fibers longer than 5microm. No asbestos was detected in 27% of the buildings and in 90% of the buildings no asbestos was detected that would have been seen optically (> or = 5microm long and > or = 0.25microm wide). Background outdoor concentrations have been reported at 0.0003f/ml > or = 5microm. These results indicate that in-place ACM does not result in elevated airborne asbestos in building atmospheres approaching regulatory levels and that it does not result in a significantly increased risk to building occupants.

Cancer, cardiovascular disease and diabetes mortality among women with a history of endometrial cancer

Among 7182 women with endometrial cancer in Scotland, standardised mortality ratios (and 95% confidence intervals (CI)) were 6.38 (5.74-7.15) for all cancers and 1.10 (1.00-1.22) for circulatory diseases as underlying cause of death and 2.81 (2.19-3.70) for diabetes as underlying/contributory cause of death.

Factors predicting loss and gain of red cell volume in cardiac surgery patients

Haemoglobin may be a poor indicator of changes in red cell volume (RCV) because of factors such as haemodilution. This study has been designed to analyse what peri-operative variables may be associated with loss or gain in RCV due to bleeding or transfusion. Prospective observational study. Single centre study based in a regional cardiac surgery centre. Twenty-nine elective adult cardiac surgery patients. Loss and gain of RCV were measured in theatre and for the first 24 h post-operatively. Patient and operative factors analysed were age, sex, height, weight, body surface area (BSA), induction haematocrit (Hct), estimated pre-operative RCV and antiplatelet therapy taken less than 7 days before operation, cardiopulmonary bypass (CPB) time, aortic occlusion time, minimum and maximum CPB temperatures and fluid administered. Age, sex, height, weight, BSA and induction Hct were found to predict red cell transfusion but not RCV loss. The total number of red cells transfused was significantly associated with RCV lost when expressed as a percentage reduction in the estimated pre-operative RCV but not the absolute RCV lost. Pre-operative RCV, as predicted by the variables outlined above, is more important than RCV lost in triggering red cell transfusion.

How much time is needed for hand hygiene in intensive care? A prospective trained observer study of rates of contact between healthcare workers and intensive care patients

There are few data measuring rates of contact by healthcare workers (HCWs) with intensive care unit (ICU) patients (direct contacts) and their immediate environment (indirect contacts), or estimates of the time needed for 100% hand hygiene compliance. We measured this using a prospective trained observer study in a 12-bedded UK adult general ICU admitting > 600 mixed medical/surgical patients annually. HCWs were observed in ICU bed spaces for 1-h periods by a single researcher using a pre-determined plan, such that all 12 beds were observed for similar times and throughout the day. Mean daily rates of direct and indirect contact between HCWs and ICU patients were calculated. Observed post-contact hand hygiene compliance was also measured. Numbers of contacts/day that were or were not followed by hand hygiene, and estimates of the time needed daily for 100% compliance were calculated. On average, each patient was contacted directly 159 [95% confidence intervals (CI) 144-178] times and contacted indirectly 191 (95% CI 174-210) times/day. Observed post-contact hand hygiene rates were 43% for direct contacts and 12% for indirect contacts. Staff contacting more than one patient during routine care, who carry the highest risk of transmitting infection between patients, made, on average, 22 direct and 107 indirect contacts without adequate hand hygiene/patient/day. One hundred percent hand hygiene compliance by all healthcare workers would require about 230 min/patient/day (100 min for direct and 130 min for indirect contacts).

Occupational exposure to airborne asbestos from phenolic molding material (Bakelite) during sanding, drilling, and related activities

In this study, a historical phenolic (Bakelite) molding material, BMMA-5353, was tested to determine the airborne concentrations of asbestos fibers released during four different activities (sawing, sanding, drilling, and cleanup of dust generated from these activities). Each activity was performed for 30 min, often in triplicate. The primary objective for testing BMMA-5353 was to quantitatively determine the airborne concentration of asbestos fibers, if any, in the breathing zone of workers. Uses of this product typically did not include sawing or sanding, but it may have been drilled occasionally. For this reason, only small quantities were sawed, sanded, and drilled in this simulation study. Personal (n = 40), area (n = 80), and background/clearance (n = 88) air samples were collected during each activity and analyzed for total fiber concentrations using phase contrast microscopy (PCM) and, for asbestos fiber counts, transmission electron microscopy (TEM). The raw PCM-total fiber concentrations were adjusted based on TEM analyses that reported the fraction of asbestos fibers, to derive a PCM-asbestos concentration that would enable calculation of an 8-hour time-weighted average (TWA). The estimated 8-hour TWAs ranged from 0.006 to 0.08 fibers per cubic centimeter using a variety of worker exposure scenarios. Therefore, assuming an exposure scenario in which a worker uses power tools to cut and sand products molded from BMMA-5353 and similar products in the manner evaluated in this study, airborne asbestos concentrations should not exceed current or historical occupational exposure limits.

Prevalence of ischaemic heart disease at admission to intensive care and its influence on red cell transfusion thresholds: multicentre Scottish Study

BACKGROUND

Restrictive transfusion triggers are safe for most critically ill patients, but doubts exist for patients with ischaemic heart disease (IHD). We investigated the prevalence of reported IHD at admission to the intensive care unit (ICU) and investigated how this influenced red cell transfusion triggers. We also compared observed practice with the clinicians' responses to clinical scenarios.

METHODS

We studied 1023 sequential ICU admissions over 100 days to 10 Scottish ICUs. Daily haemoglobin, red cell transfusion, and haemorrhage data were available for 99.4% of 5638 ICU patient days. We recorded if IHD was recorded in clinical records at ICU admission. We grouped admissions as having a non-cardiac primary ICU diagnosis and no documentary evidence of IHD (Group 1, n=697), a non-cardiac primary ICU diagnosis with evidence of IHD (Group 2, n=213), or a cardiac primary ICU admission diagnosis (Group 3, n=113). We examined pre-transfusion haemoglobin concentration (Hb) for transfusion episodes not associated with haemorrhage. Clinical transfusion scenarios were sent to intensivists in the ICUs after data collection, which were designed to explore the clinicians' attitude to transfusion triggers in patients with IHD.

RESULTS

Previous myocardial infarction was documented in 159 (16%), cardiac failure in 142 (14%), and angina in 167 (16%). Overall, 28.8% of admissions had >/=1 of these documented. The adjusted mean (se) pre-transfusion Hb concentrations varied across the groups. These were 74 (2.2) g litre(-1) in Group 1, 77 (2.3) g litre(-1) in Group 2, and 79 (3.1) g litre(-1) in Group 3 (P=0.003 across the groups). There was concordance between observed practice and responses to the scenario similar to Group 1, but discordance for patients with IHD (Groups 2 and 3). In scenario responses, intensivists stated these patients should have significantly higher transfusion triggers than were actually observed (median [IQR] response for both groups: 90 [80-100] g litre(-1)).

CONCLUSIONS

About 29% of patients admitted to Scottish ICUs had documented IHD, which was associated with small adjustments to Hb transfusion triggers. In response to scenarios, clinicians believe that patients with IHD require higher transfusion triggers than are observed in practice.

A comparison of dermatologists', surgeons' and general practitioners' surgical management of cutaneous melanoma

BACKGROUND

Current guidelines for the surgical management of melanoma aim to bring a combined consensus approach to the surgery of melanoma. Whether different outcomes for melanoma are related to the specialist who treats the patient is unknown.

OBJECTIVES

To examine the clinicopathological features and surgical management of patients with primary cutaneous malignant melanoma treated by dermatologists, general surgeons, plastic surgeons and general practitioners (GPs). We also examined if the category of specialist had an effect on the survival outcome for the patient.

METHODS

A retrospective, observational study of patients registered on a specialist database that records the clinicopathological features, surgical treatment and follow-up information of patients with malignant melanoma in Scotland. The patients had invasive primary cutaneous malignant melanoma without evidence of metastasis at the time of surgery, diagnosed between 1979 and 1997, with follow-up to the end of December 1999. Clinicopathological characteristics and surgical treatment of patients were compared for the four groups of specialist, as were overall survival (OS), disease-free survival (DFS) and recurrence-free interval (RF).

RESULTS

Of 1536 patients, 663 (43%) were treated initially by a dermatologist, 486 (32%) by a general surgeon, 257 (17%) by a plastic surgeon and 130 (8%) by a GP. The proportion of patients managed by dermatologists rose over the lifetime of the study. Compared with the other specialists, the patients treated by general and plastic surgeons were older; a higher proportion of female patients was managed by dermatologists; median tumour thickness, lesion diameter and frequency of ulceration were all greater in the general surgeon-treated group; plastic surgeons treated a higher proportion of lentigo maligna melanomas; and general surgeons and GPs saw a higher proportion of nodular melanomas. Over 90% of patients managed by a dermatologist or GP underwent wider local excision following initial excision, compared with 43% and 25%, respectively, in the general and plastic surgery groups. General surgeons used wider excision margins than the other specialists. OS, DFS and RF were significantly better in the dermatology group compared with the general and plastic surgery groups.

CONCLUSIONS

This study showed that dermatologists manage an increasing majority of melanoma patients and that there were significant differences in the surgical treatment of melanoma between dermatologists and surgeons. Survival was significantly better in the dermatology-treated group, suggesting that dermatologists should have a central role in melanoma management.

Posterior pericallosal lipoma extending through the interhemispheric fissure into the scalp via the anterior fontanelle

We report an unusual pericallosal lipoma presenting as scalp mass at birth. The patient had no obvious neurological deficit, but CT and MRI revealed a striking lipoma extending extracranially into the scalp from the interhemispheric fissure via the anterior fontanelle. The corpus callosum was distorted but not dysplastic.

A retrospective observational study of primary cutaneous malignant melanoma patients treated with excision only compared with excision biopsy followed by wider local excision

BACKGROUND

For primary cutaneous malignant melanoma the guidelines recommend an excision biopsy of the suspected lesion followed by wider local excision; the diagnosis can then be confirmed and excision margins planned.

OBJECTIVES

To compare retrospectively the clinicopathological features, surgical margins and survival of patients from the Scottish Melanoma Group database whose tumour was removed by excision only (one-stage) or excision biopsy followed by wider local excision (two-stage) surgery.

METHODS

The Scottish Melanoma Group database records the clinicopathological features, surgical treatment and follow-up information of all patients with malignant melanoma in Scotland. From this 1595 patients were identified over a 19-year interval from 1979 to 1997 with follow-up until the end of December 1999. Overall survival, disease-free survival and recurrence-free interval were examined with univariate and multivariate statistical methods.

RESULTS

The patients in the one-stage excision group (n = 547) were statistically significantly older (P < 0.001), had thicker melanomas (P < 0.001), a higher proportion of lentigo maligna melanomas (P < 0.001), head and neck (P < 0.001), and ulcerated lesions (P < 0.003) compared with the two-stage group (n = 1048). The margins of excision were significantly narrower in the one-stage compared with the two-stage group (P < 1 x 10(-5)). Fifty-two percent of all one-stage excisions were performed with a margin < 1 cm compared with 20% of the two-stage group. The excision margin was more positively correlated with the Breslow thickness for the two-stage over the one-stage group (Spearman rho = 0.38, P < 0.001; and 0.27, P < 0.001, respectively). Overall survival (OS), disease-free survival (DFS), and recurrence-free survival (RF) were all statistically significantly better in the two-stage compared with the one-stage excision group, P < 1 x 10(-5), P < 1 x 10(-5) and P = 0.001, respectively (log rank test). After adjusting for the prognostic factors of age, sex, tumour thickness, site, histology and ulceration, OS, DFS and RF were still significantly better in the two-stage compared with the one-stage group [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.61-0.92, P = 0.006; HR 0.75, CI 0.62-0.90, P = 0.002; and HR 0.78, CI 0.62-0.99, P = 0.04, respectively].

CONCLUSIONS

This study showed that one-stage excisions were more common in patients with poorer prognostic features and that excision with margins narrower than those suggested by current guidelines was more likely. Patient survival was statistically significantly better with the two-stage procedure, although the reasons for this were unclear.

Design and characterization of an intracavitary ultrasound hyperthermia applicator for recurrent or residual lesions in the vaginal cuff

For evaluating the feasibility of treating recurrent lesions in the vaginal cuff by hyperthermia, a 2-element ultrasound applicator was designed, constructed and characterized. A half-cylindrical transducer (d=1 cm, length=1 cm) was used to construct the 2-element ultrasound applicator. Each element of this applicator was operated at 1.5 MHz and characterized by measuring transducer efficiency and acoustic power distribution. Thermocouple probes were used to measure the temperature rise in the phantom. The element sizes used in this study were selected to be comparable to a high dose rate brachytherapy colpostat applicator. Each element was powered separately to achieve a desired temperature pattern in a target. The acoustic output power as a function of applied electric power of elements 1 and 2 were linear over this 1-40 W range and efficiencies were 32.2 +/- 3.4% and 46.2 +/- 0.8%, respectively. The temperature measurements in the phantom showed that a 6 degrees C temperature rise was achieved 2 cm from the applicator surface. As a conclusion, the ability of the ultrasound colpostat applicator to be used for hyperthermia was demonstrated by measuring acoustic output power, ultrasound field distribution and temperature rise in the phantom. Based on the characteristics of this applicator, it has the potential to be useful for inducing hyperthermia to the vaginal cuff in the clinic.