Topical antibiotics prophylaxis for infections of indwelling pleural/peritoneal catheters (TAP-IPC): A pilot study

BACKGROUND AND OBJECTIVE

Indwelling pleural catheter (IPC) and indwelling peritoneal catheter (IPeC) have established roles in the management of malignant pleural and peritoneal effusions but catheter-related infections remain a major concern. Topical mupirocin prophylaxis has been shown to reduce peritoneal dialysis catheter infections. This study aimed to assess the (i) compatibility of IPC with mupirocin and (ii) feasibility, tolerability and compliance of topical mupirocin prophylaxis in patients with an IPC or IPeC.

METHODS

(i) Three preparations of mupirocin were applied onto segments of IPC thrice weekly and examined with scanning electron microscope (SEM) at different time intervals. (ii) Consecutive patients fitted with IPC or IPeC were given topical mupirocin prophylaxis to apply to the catheter exit-site following every drainage/dressing change (at least twice weekly) and followed up for 6 months.

RESULTS

(i) No detectable structural catheter damage was found with mupirocin applied for up to 6 months. (ii) Fifty indwelling catheters were inserted in 48 patients for malignant pleural (n = 41) and peritoneal (n = 9) effusions. Median follow-up was 121 [median, IQR 19-181] days. All patients tolerated mupirocin well; one patient reported short-term local tenderness. Compliance was excellent with 95.8% of the 989 scheduled doses delivered. Six patients developed catheter-related pleural (n = 3), concurrent peritoneal/local (n = 1) and skin/tract (n = 2) infections from Streptococcus mitis (with Bacillus species or anaerobes), Staphylococcus aureus, Klebsiella pneumoniae and Pseudomonas aeruginosa.

CONCLUSION

This first study of long-term prevention of IPC- or IPeC-related infections found topical mupirocin prophylaxis feasible and well tolerated. Its efficacy warrants future randomized studies.

Preferred health outcome states following treatment for pulmonary exacerbations of cystic fibrosis

BACKGROUND

Treatment for pulmonary exacerbations of cystic fibrosis (CF) can produce a range of positive and negative outcomes. Understanding which of these outcomes are achievable and desirable to people affected by disease is critical to agreeing to goals of therapy and determining endpoints for trials. The relative importance of outcomes resulting from treatment of these episodes are not reported. We aimed to (i) quantify the relative importance of outcomes resulting from treatment for pulmonary exacerbations and (ii) develop patient and proxy carer-reported weighted outcome measures for use in adults and children, respectively.

METHODS

A discrete choice experiment (DCE) survey was conducted. Participants were asked to make a series of hypothetical decisions about treatment for pulmonary exacerbations to assess how they make trade-offs between different attributes of health. Data were analysed using a conditional logistic regression model. The correlation coefficients from these data were rescaled to enable generation of a composite health outcome score between 0 and 100 (worst to best health state).

RESULTS

362 individuals participated (167 people with CF and 195 carers); of these, 206 completed the survey (56.9%). Most participants were female and resided in Australia. Difficult/painful breathing had the greatest impact on the preferred health state amongst people with CF and carers alike. Avoidance of gastrointestinal problems also heavily influenced decision-making.

CONCLUSIONS

These data should be considered when making treatment decisions and determining endpoints for trials. Further research is recommended to quantify the preferences of children and to determine whether these align with those of their carer(s).

Novel method to select meaningful outcomes for evaluation in clinical trials

Background

A standardised framework for selecting outcomes for evaluation in trials has been proposed by the Core Outcome Measures in Effectiveness Trials working group. However, this method does not specify how to ensure that the outcomes that are selected are causally related to the disease and the health intervention being studied. Causal network diagrams may help researchers identify outcomes that are both clinically meaningful and likely to be causally dependent on the intervention, and endpoints that are, in turn, causally dependent on those outcomes. We aimed to (1) develop a generalisable method for selecting outcomes and endpoints in trials and (2) apply this method to select outcomes for evaluation in a trial investigating treatment strategies for pulmonary exacerbations of cystic fibrosis (CF).

Methods

We conducted a series of online surveys and workshops among people affected by CF. We used a modified Delphi approach to develop a consensus list of important outcomes. A workshop involving domain experts elicited how these outcomes were causally related to the underlying pathophysiological processes. Meaningful outcomes were prioritised based on the extent to which each outcome captured separate rather than common aspects of the underlying pathophysiological process.

Results

The 10 prioritised outcomes were: breathing difficulty/pain, sputum production/clearance, fatigue, appetite, pain (not related to breathing), motivation/demoralisation, fevers/night sweats, treatment burden, inability to meet personal goals and avoidance of gastrointestinal symptoms.

Conclusions

This proposed method for selecting meaningful outcomes for evaluation in clinical trials may improve the value of research as a basis for clinical decisions.

Mepolizumab use in cystic fibrosis-associated allergic bronchopulmonary aspergillosis

Allergic bronchopulmonary aspergillosis (ABPA) is common in cystic fibrosis (CF). Treatment is challenging and the relapse rate is high. Standard therapy is oral steroids and antifungals. However, long-term systemic steroid often results in adverse effects and drug interactions between azoles and CFTR modulators are a potential concern. Mepolizumab, an anti-interleukin (IL)-5 monoclonal antibody, can benefit patients with severe eosinophilic asthma and there are reports of mepolizumab use in ABPA but not in ABPA complicating CF. We present the case of an adult with CF who had recurrent ABPA and intolerable treatment side effects with steroid, azole, and omalizumab. Mepolizumab was well tolerated and led to significantly improved clinical stability and symptomatic improvement. To our knowledge, this is the first report of successful mepolizumab treatment for ABPA in CF. Mepolizumab may be an important adjunctive treatment for difficult to control ABPA in CF.

Distance to treatment as a factor for loss to follow up of hepatitis C patients in North East England

BACKGROUND

A large proportion of the 200 000 HCV-infected individuals in the UK are undiagnosed or lost to follow-up. Engaging known infected individuals in treatment is essential for elimination.

METHODS

Using PHE surveillance data and HCV treatment registers from North East of England (NE) treatment centres for 1997-2016, we estimated the number of HCV cases not linked to treatment and the proportion with active infection. We compared distances of treated and untreated cases to treatment services, and assessed the effect of expanding HCV treatment into existing drug and alcohol treatment centres in the NEE on treatment accessibility.

RESULTS

The odds of being treated was associated with distance to treatment services. Confirmatory results for ~50% were not reported to PHE NE. Overall, 3385 patients reported to PHE NE had no record of treatment; we estimated 1621 of these may have been lost to follow-up after confirmation of active infection.

CONCLUSIONS

Poor access to healthcare services may contribute to under-diagnosis or loss to follow-up. Expanding HCV treatment delivery into NEE drug and alcohol treatment centres would improve the accessibility of treatment services to people infected with/at risk of HCV. This may increase the proportion receiving treatment and support progress towards elimination.

A smartphone application for reporting symptoms in adults with cystic fibrosis improves the detection of exacerbations: Results of a randomised controlled trial

BACKGROUND

Respiratory exacerbations impair lung function and health-related quality of life in people with CF, with delayed identification of exacerbations often resulting in worse outcomes. We developed a smartphone application (app) for adults with CF to report symptoms to the CF team, and investigated its impact on antibiotic use and other outcomes.

METHODS

Participants were randomised to intervention (use of the app weekly or sooner if symptoms had worsened) or control (usual care). The app comprised questions relating to symptoms suggestive of an exacerbation. If worsening symptoms were reported, the participant was contacted by the nurse practitioner. The primary outcome measure was the number of courses and days of intravenous (IV) antibiotics.

RESULTS

Sixty participants (29 female, aged [mean ± SD] 31 ± 9 years, FEV₁ 60 ± 18% predicted) were recruited, with 29 (48%) allocated to the intervention group. Over the 12-month follow-up, there was no clear effect of the app on the number of courses of IV antibiotics (incidence rate ratio [IRR] 1; 95% confidence interval [CI] 0.6 to 1.7), however number of courses of oral antibiotics increased (IRR 1.5; 95% CI 1.0 to 2.2). The median [IQR] time to detection of exacerbation requiring oral or IV antibiotics was shorter in the intervention group compared with the control group (70 [123] vs. 141 [140] days; p = .02). No between-group differences were observed in other outcomes.

CONCLUSION

The use of an app reduced time to detect respiratory exacerbations that required antibiotics, however did not demonstrate a clear effect on the number of courses of IV antibiotics.

A smartphone application for reporting symptoms in adults with cystic fibrosis: protocol of a randomised controlled trial

INTRODUCTION

In people with cystic fibrosis (CF), exacerbations have been shown to have profound and prolonged negative effects such as reducing physical activity and health-related quality of life, increasing the rate of decline of lung function and healthcare costs, and ultimately increasing the risk of mortality. Delayed initiation of treatment following the signs of an exacerbation has been shown to be associated with failure to recover to baseline. Therefore, the late identification and treatment of an exacerbation due to delayed presentation will potentially worsen short-term and long-term outcomes. We have developed a smartphone application, containing questions which require yes or no responses relating to symptoms suggestive of a respiratory exacerbation. Its use is intended to facilitate the early identification of symptoms suggestive of a respiratory exacerbation, and allow the CF team to initiate treatment sooner, thereby potentially reducing the risk of severe exacerbations which require intravenous antibiotics (IVAB) and often a hospital admission.

METHODS

We will undertake a randomised controlled trial. 60 adults with CF will be recruited and randomised to either the intervention or control group. The intervention group will use the smartphone application weekly for 12 months, or earlier than the next weekly reporting time if they feel their symptoms have worsened. The control group will continue to receive usual care, involving regular (approximately 3 monthly) CF outpatient clinic appointments. The primary outcome measure will be courses and days of IVAB.

ETHICS AND DISSEMINATION

Approval was obtained from the Sir Charles Gairdner Group Human Research Ethics Committee for WA Health (2015-030) and Curtin University Human Research Ethics Committee (HR212/2015), and has been registered with the Australian and New Zealand Clinical Trials Registry. Results of this study will be presented at international conferences and published in peer-reviewed journals in accordance with the Consolidated Standards of Reporting Trials statement.

TRIAL REGISTRATION NUMBER

ACTRN12615000599572.

High usability of a smartphone application for reporting symptoms in adults with cystic fibrosis

Introduction In cystic fibrosis, exacerbations impair lung function and health-related quality of life, increase healthcare costs and reduce survival. Delayed reporting of worsening symptoms can result in more severe exacerbations and worse clinical outcomes; therefore there is a need for a novel approach to facilitate the early identification and treatment of exacerbations in this population. This study investigated the usability of a smartphone application to report symptoms in adults with cystic fibrosis, and the observer agreement in clinical decision-making between senior clinicians interpreting smartphone application responses. Methods Adults with cystic fibrosis used the smartphone application weekly for four weeks. The application comprised 10 yes/no questions regarding respiratory symptoms and two regarding emotional well-being. Usability was measured with the System Usability Scale; Observer agreement was tested by providing a cystic fibrosis physician and a nurse practitioner with 45 clinical scenarios. For each scenario the clinicians, who were blinded to each other's responses, were asked to indicate whether or not they would: (i) initiate telephone contact, and/or (ii) request a clinic visit for the individual. Results Ten participants (five female), aged mean (SD) 33 (11) years, FEV1 49 (27)% predicted completed the study. The mean (SD) System Usability Scale score was 94 (6). There was perfect agreement between clinicians for initiating contact with the participant ( κ = 1.0, p < 0.001), and near-perfect for requesting a clinic visit ( κ = 0.86, p < 0.001). Discussion The use of a smartphone application for reporting symptoms in adults with cystic fibrosis has excellent usability and near-perfect agreement between senior clinicians when interpreting the application responses.

Telehealth clinics increase access to care for adults with cystic fibrosis living in rural and remote Western Australia

Introduction A significant proportion (15%, n = 28) of the adults with cystic fibrosis (CF) in Western Australia (WA) live in rural and remote areas and have difficulty accessing specialist care at the state adult CF centre, located in Perth. We aimed to increase access by offering telehealth clinics, and evaluate the impact on health outcomes. Methods Telehealth clinics were offered via videoconference over a 12-month period, with uptake and satisfaction measured at the end of the intervention. Participants could still attend in person clinics at the CF centre if requested. Other outcomes comprised healthcare utilisation (HCU), spirometry, weight and health-related quality of life. Results In 21 participants, total clinic visits increased from 46 (median (range) per participant 2 (0-6)) in the 12-month period preceding the study to 100 (5 (2-8), p < 0.001) during the intervention. Of the 100 clinics in total, 66 were delivered via telehealth. Satisfaction with telehealth was high and most (94%) participants agreed that telehealth is a good way to deliver CF care. An increase in intravenous antibiotic days (incident rate ratio (IRR) 2.3, p = 0.03) and hospital admission days (IRR 3.7, p = 0.01) was observed. There was an improvement in the vitality domain of the Cystic Fibrosis Questionnaire - Revised ( p < 0.05). Discussion Telehealth had good uptake and increased clinic attendance in adults with CF living in rural and remote WA, and had high satisfaction amongst participants. The increase in HCU, resulting from increased detection and treatment of exacerbations, may improve long-term outcomes in this population.

Pleuroscopic cryoprobe biopsies of the pleura: a feasibility and safety study

BACKGROUND AND OBJECTIVE

Flexi-rigid pleuroscopy is a useful tool in the work-up of pleural effusions, but pleural biopsy using flexible forceps can be difficult in some patients. This study evaluated the feasibility, safety and diagnostic value of using a flexible cryoprobe to obtain parietal pleural biopsies during pleuroscopy.

METHODS

This was a single-centre retrospective study. In patients undergoing diagnostic pleuroscopy, pleural biopsy using flexible forceps, followed by a flexible cryoprobe introduced through the pleuroscope, were performed. A pathologist independently reviewed all biopsies. Any complications, particularly bleeding, were recorded. All patients were followed up for ≥ 6 months (median 12 months (range 7-26)).

RESULTS

Twenty-two patients (21 males; median age 72 years; 14 right-sided effusions) were included. All underwent flexible forceps biopsies (FFB) and cryoprobe biopsies (CB) of pleura. FFB and CB established a definitive diagnosis in 20/22 (90%). CB successfully obtained pleural tissue suitable for histopathological analysis in all patients. CB was larger than FFB (median, 25-75 IQR of 10, 7-15.8mm vs 4, 3-8mm), and had better preserved cellular architecture and tissue integrity. Crush artefacts were less common with CB (2/22) compared with FFB (21/22). No significant bleeding was reported.

CONCLUSIONS

CB during flexi-rigid pleuroscopy is feasible, safe and effective. Its routine use during flexi-rigid pleuroscopy requires further evaluation.

Indwelling pleural catheters reduce inpatient days over pleurodesis for malignant pleural effusion

BACKGROUND

Patients with malignant pleural effusion (MPE) have limited prognoses. They require long-lasting symptom relief with minimal hospitalization. Indwelling pleural catheters (IPCs) and talc pleurodesis are approved treatments for MPE. Establishing the implications of IPC and talc pleurodesis on subsequent hospital stay will influence patient choice of treatment. Therefore, our objective was to compare patients with MPE treated with IPC vs pleurodesis in terms of hospital bed days (from procedure to death or end of follow-up) and safety.

METHODS

In this prospective, 12-month, multicenter study, patients with MPE were treated with IPC or talc pleurodesis, based on patient choice. Key end points were hospital bed days from procedure to death (total and effusion-related). Complications, including infection and protein depletion, were monitored longitudinally.

RESULTS

One hundred sixty patients with MPE were recruited, and 65 required definitive fluid control; 34 chose IPCs and 31 pleurodesis. Total hospital bed days (from any causes) were significantly fewer in patients with IPCs (median, 6.5 days; interquartile range [IQR] = 3.75-13.0 vs pleurodesis, mean, 18.0; IQR, 8.0-26.0; P = .002). Effusion-related hospital bed days were significantly fewer with IPCs (median, 3.0 days; IQR, 1.8-8.3 vs pleurodesis, median, 10.0 days; IQR, 6.0-18.0; P < .001). Patients with IPCs spent significantly fewer of their remaining days of life in hospital (8.0% vs 11.2%, P < .001, χ(2) = 28.25). Fewer patients with IPCs required further pleural procedures (13.5% vs 32.3% in pleurodesis group). There was no difference in rates of pleural infection (P = .68) and protein (P = .65) or albumin loss (P = .22). More patients treated with IPC reported immediate (within 7 days) improvements in quality of life and dyspnea.

CONCLUSIONS

Patients treated with IPCs required significantly fewer days in hospital and fewer additional pleural procedures than those who received pleurodesis. Safety profiles and symptom control were comparable.

Variation in levels of uptake of enhanced primary care item numbers between rural and urban settings, November 1999 to October 2001

We aimed to report on variation in levels of uptake of enhanced primary care item numbers between rural and urban Divisions of General Practice between November 1999 and October 2001. Most providers of EPC services and most services (close to 70%) are located in capital cities and other metropolitan centres. The average number of health assessments done per provider was slightly lower (8-14) in remote than urban and rural (20-30) areas. A similar pattern was observed for care plans, but rates of case conferences were similar in rural and urban areas. However, adjusted for population aged 75 years and over, in all jurisdictions except South Australia, between 30% and 144% more health assessments were done per full time equivalent general practitioner (FTE GP) in rural divisions. For rural and urban Divisions of General Practice, there is a wide range in the rate of services provided, between and within Divisions. However, overall, more services are provided per FTE GP in rural Divisions.

Uptake of health assessments, care plans and case conferences by general practitioners through the Enhanced Primary Care program between November 1999 and October 2001

We aimed to describe the uptake of the Enhanced Primary Care (EPC) item numbers listed on the Medicare Benefits Schedule for health assessment (HA), care plan (CP) and case conference (CC) between November 1999 (when these items first became available) and October 2001. We used data provided by the Commonwealth Department of Health and Ageing. General practitioners rendered 371,409 EPC services in all. Most services were HA (225,353; 61%), most of the remainder were CP (134,688; 36%), and CC comprised the rest (11,368; 3%). The number of HA done increased steadily and has stabilised at around 13,000 HA per month. Most CP done (80%) were in the community and with the GP preparing the plan. From a slow start, the number of CP done increased rapidly in 2001 to about 15,000 per month. There has been a slow and steady increase in the number of CC done each month, reaching 8-900 per month. Uptake of the EPC item numbers in the first two years of their availability has been rapid and has reached substantial levels, especially for HA and CP. The uptake of CC has been slower.

Are socio-economically disadvantaged Australians making more or less use of the Enhanced Primary Care Medicare Benefit Schedule item numbers?

We aimed to examine the relationship between levels of socio-economic disadvantage (measured by the Socio EconomicIndexes for Areas [SEIFA] used by the Australian Bureau of Statistics) and uptake of the Enhanced Primary Care(EPC) item numbers on the Medicare Benefits Schedule. Health services are often less likely to reach those that mostneed them and so it is important to monitor whether disadvantaged communities are accessing EPC. The rates ofhealth assessments, care plans and case conferences are similar in each SEIFA quartile (from advantaged todisadvantaged populations), favouring the more disadvantaged quartiles in some cases. These national trends are notobserved in each state and territory. For all EPC services combined, the lowest number of doctors that provide EPCservices are found in the 2 most disadvantaged quartiles, yet more EPC services are provided in these quartiles, due tothe higher mean and median number of services provided by general practitioners in these quartiles. Overall,populations living in the most disadvantaged quartiles have similar or higher levels of EPC uptake, apparently due,at least in part, to greater than average use of EPC services by general practitioners in these areas.

Variation in levels of uptake of Enhanced Primary Care item numbers between medical practices, within Divisions of General Practice and jurisdictions

We aimed to report on variation in levels of uptake of services between medical practices across Divisions of General Practice, and jurisdictions, through the Enhanced Primary Care (EPC) program between November 1999 and October 2001.No Divisions had levels of EPC uptake outside upper control limits plus/minus three standard deviations the national level, suggesting limited substantial systematic variation relating to high uptake. Four Divisions had rates of practices providing EPC services (33.3%-67.7%)substantially lower than the national rate (81.2%). For all EPC services combined and for health assessments (HAs) there is substantial variation between practices in almost all Divisions of General Practice, and in some this is extreme. For care plans (CPs), while several Divisions show wide variation in rates across practices (and in a few there is extreme variation), in other Divisions there are very low rates of CP across all practices. For case conferences (CCs) the picture is even more extreme, and these patterns are expressed across all jurisdictions. There is substantial variation in the level of uptake of EPC services across medical practices in Australia.

Characteristics of general practitioners that provided health assessments, care plans or case conferences, as part of the Enhanced Primary Care program

We aimed to describe the characteristics of general practitioners (GPs) who provided health assessments (HA), care plans (CP) or case conferences (CC) as part of the Enhanced Primary Care (EPC) program between November 1999 and October 2001.While the gender distribution of EPC-active GPs is similar to that of non-EPC-active GPs, EPC-active GPs tend to be younger (72% vs 58% aged 35-54 years). Among EPC-active GPs, males account for about 66% of providers and about 80%of services. There is a very wide range in the number of EPC services provided per GP. In all, 1591 (14%)have rendered a single service while 919 (8.1%)have rendered over 100 services each (accounting for almost half of all EPC activity in Australia). The number of GPs providing any EPC service each month gradually increased to around 5000 in October 2001.Most patients (80-90%)that received multiple EPC services did so from the same GP. Across Divisions of General Practice the proportion of practices registered for the Practice Incentive Program (PIP) that have provided EPC services ranges from 100 to 0%. In the first year at least 50% of all practices in 84 Divisions rendered at least one EPC service while in the second year 108 did. Across Australia 58% of PIP practices rendered at least one service in the first year and 76% did in the second year. A little over half the GP workforce rendered at least one EPC service in the first year of the program, but there was a very wide range in the number of services provided per GP. Most GPs provide very few and a small number provide very many. There is wide variation in the proportion of practices providing EPC services, but this is increasing.

Characteristics of patients receiving health assessments, care plans or case conferences by general practitioners, as part of the Enhanced Primary Care program between November 1999 and October 2001

We aimed to describe the characteristics of patients receiving health assessments (HA), care plans (CP) or case conferences (CC) through the Enhanced Primary Care (EPC) program between November 1999 and October 2001. The Commonwealth Department of Health and Ageing provided data. In all, 43%of non-Indigenous people who had a HA were aged 75-79 years and 32%were aged 80-84 years. Those having a HA at home were older (30.3% aged 85 years and above) than those having a HA in GP's rooms (20.2%85 years and above). For Indigenous people, between 12 and 17%of all HAs were done among each five-year age group between 55 and 84 years. As a group, CPs were mostly done among older people, with a higher proportion done among older women (74.2%among those 55 years and above) than older men (66.4%). Most CCs were also done among older people (60.4%55 years and above). Of the 286,250 people that had at least one EPC service, most (219,210; 76.6%)had only one. Of these, 153,624 (70.1%)had a HA. Of those having at least one EPC service, 95.7%had two services (most often a HA plus a CP). To date EPC activity has been concentrated among the elderly, gender patterns are similar, and few patients have received more than a single EPC service, which is usually a HA.

Variation between Divisions of General Practice in the uptake of health assessments, care plans and case conferences through the Enhanced Primary Care program

We aimed to describe the variation in rates of uptake of the enhanced primary care (EPC) Medicare Benefits Schedule items for health assessments (HA), care plans (CP) and case conferences (CC), between Divisions of General Practice from November 1999 (when these items first became available) to October 2001.There was substantial variation in uptake of the various EPC services between Divisions of General Practice, ranging from very low to high. For HA the rate in the highest uptake Division was 496 per 1000 eligible population, and the lowest was zero. There are seven Divisions with high and six with very low uptake, with the rest ranging between 100 and 400/1000.Five Divisions had CP rates over 15/1000 total population; most Divisions had fewer than 10/1000,and many had less than 5/1000.A similar pattern is observed for CC. The levels of uptake for HA increased in the second year of the program for all but eight Divisions of General Practice, and the levels of uptake for CP increased in all but two Divisions. In the first two years of availability, uptake has been highly variable across Divisions of General Practice. Uptake has however increased substantially and consistently in the second year of the program.

Replication-restricted vaccinia as a cytokine gene therapy vector in cancer: persistent transgene expression despite antibody generation

BACKGROUND

As antitumoral immunity requires the generation of local immunity directed against tissue proteins, we attempted to recreate within tumors the same environment found within tissues affected by autoimmune diseases (i.e., prolonged cytokine expression). Vaccinia virus (VV) has not been widely used as a cytokine gene therapy vector because of presumed high immunogenicity that would likely make repeated injections impossible; therefore, we modified it by inserting the cytokine gene into the thymidine kinase region, rendering it replication-restricted. The cytokine chosen was human interleukin-2 (IL-2); a molecule with powerful antitumoral effects.

METHODS

Six patients with the treatment-resistant tumor malignant mesothelioma received intratumoral (i.t.) VV-IL-2 therapy for 12 weeks by injection of 10(7) plaque-forming units of VV-IL-2 per dose. Serial tumor biopsies, sputum, urine, and blood samples were tested for VV-IL-2 mRNA expression; VV culture and T-cell infiltrates were evaluated by immunohistochemistry. Patients and contacts of patients were monitored for changes in VV immunoglobulin G (IgG) levels and clinical evidence of VV infection.

RESULTS

VV-IL-2 was not excreted and was only cultured in one patient from tumor biopsies. A T-cell infiltrate was detected in 50% of tumor biopsies. VV-IL-2 mRNA expression was highest on days 1-3 postinjection and was detected for up to 3 weeks after each injection even though VV IgG levels rose in all patients. No significant toxicities, infection of patient contacts, or tumor regressions were observed.

CONCLUSIONS

I.t. VV-IL-2 administration is safe, is associated with minimal toxicity, and results in i.t. expression of VV-IL-2 for up to 3 weeks postinjection regardless of the level of anti-VV IgG titers generated. This suggests that VV may be a good vector for repeated cytokine gene therapy of solid human cancer.

Intralesional cytokine therapy in cancer: a pilot study of GM-CSF infusion in mesothelioma

Systemic cytokine therapy in cancer has major side effects, and we reasoned that the local infusion of cytokines into tumors could induce local immunologic responses with minimal toxicity and potentially strong systemic anticancer effects. This study investigated the toxicity and effectiveness of intralesional granulocyte/macrophage-colony-stimulating factor (GM-CSF) infusion in solid-tumor masses. We studied 14 patients (12 men, two women) with malignant mesothelioma (MM), aged 60 years (range, 46-70 years), with stage 2 disease, in whom the tumor was of sufficient size and accessibility for an intralesional catheter to be inserted. Recombinant human GM-CSF (Molgramostim; Schering Plough) was infused intralesionally for 8 weeks, by using a portable pump, at a dose of 2.5-10 micrograms/kg/day. One patient using GM-CSF developed histologically confirmed necrosis of tumor surrounding the distal catheter, one developed a marked lymphocytic infiltrate in the tumor and had a partial response measured by chest computed tomography (CT) scan, 10 progressed, and three had no response. Neutrophilia with morphologic evidence of neutrophil activation and clinical features suggestive of neutrophil plugging of blood vessels occurred at doses > 5 micrograms/kg/day. In vitro, GM-CSF doubled human neutrophil/CD11b/CD18 expression, suggesting that neutrophil clumping as seen in vivo might be due to integrin upregulation. Intralesional infusion of cytokines is feasible but can be associated with systemic toxicity and has considerable technical problems. It produces a localized immune reaction with tumor regression in a minority of patients.

Cytokine gene therapy or infusion as treatment for solid human cancer

In the induction of tissue-directed immune responses, cytokines tend to be released within the affected tissues. We used two strategies to expose tumor tissues to continuous high levels of cytokines: First, a vaccinia interleukin (IL)2 recombinant was injected directly intratumorally 3-weekly at 10(7) pfus/dose in six patients with the solid tumor malignant mesothelioma (MM). No virus excretion was detectable. At each cycle vaccinia-IL-2 mRNA (SQ [semi-quantitative] reverse transcription polymerase chain reaction) was maximal 24-72 h following injection reduced at 8 days and faded by 21 days. No tumor regression occurred. Second, based on the success of granulocyte macrophage colony-stimulating factor (GM-CSF) in gene transfer experiments, we conducted a study using continuous intratumoral GM-CSF infusion in eight patients with MM using a portable pump at doses of 10 micro/cg/24 h over 8 weeks. Systemic neutrophil agglutination and local catheter-related difficulties occurred. Two patients demonstrated tumor necrosis, one of whom had a marked progressive mononuclear cell infiltration of the tumor associated with a partial response (>50% reduction in tumor area). Murine studies using our MM model in CBA and BALB/C mice have demonstrated that B7-1 and allo-class I transfections induce strong tumor-specific cytotoxic T lymphocyte responses: GM-CSF, IL-12, and IL-2 induced mixed nonspecific plus specific responses, whereas B7-2 and class II transfections were not effective. We conclude that increased intratumoral cytokine concentrations can be generated using both gene transfer and cytokine infusion approaches; however, both have their limitations and, at this stage, have not produced dramatic antitumor effects in humans.

Development and characterization of monoclonal antibody to T-antigen: (gal beta1-3GalNAc-alpha-O)

The saccharide antigen, Gal beta1-3GalNAc or T antigen, is of biologic importance in many systems. It is a tumor-associated carbohydrate antigen, a temporally expressed antigen in germinal center B cells and cortical T cells, a parasite-associated antigen, a spermatozoa vitality marker and an antigen on aged red blood cells. It may play a role in normal cellular adhesion and in tumor cell metastasis. Well characterized monoclonal antibodies (MAb) to Gal beta1-3GalNAc will be useful for further studies in these areas. We developed an IgG3 MAb to Gal beta1-3GalNAc by immunizing the mice with a synthetic Gal beta1-3GalNAc-BSA conjugate. The MAb was analyzed using inhibition enzyme immunoassays with related synthetically prepared sugars to determine the restrictions involved in the antibody binding. Use of synthetic sugars as competitors enabled us to delineate the epitope restrictions on the binding activity of this monoclonal and will enable use of this MAb in studies concerning the biologic importance of this disaccharide.

Health screening at school entry--what is achieved?

Evaluative research on screening in school children is needed because of a lack of studies about its effectiveness. This paper reports a study of the school medical records of 790 children, aged 5-6 years, first screened in 1980. Sixty-six per cent of the parents of children who were notified of an abnormality in their child were followed up to determine subsequent action. Although a complete physical examination had been performed, 87% of all notified abnormalities involved vision (including squint), hearing and dental problems. The prevalence rate of previously unknown health problems (excluding dental problems) confirmed by another health professional was 5%. This rate was lowered to 2% when only children with moderate or severe problems presently receiving treatment were included. Some of the practical problems and importance of screening are discussed.

Evaluation of the Australian Medical Association drink-driving campaign in Wollongong

A pilot public education campaign against drink-driving directed towards 18-24-year-old men in Wollongong in 1982 is described. Analysis suggested significant behavioural change in the target group. This was shown by a reduction in traffic accidents and by some reduction in drink-driving convictions. While a comparative assessment of the knowledge and attitudes of the community before and after the campaign showed a marked awareness of the campaign, attitudinal changes to drink-driving were equivocal.

Inner-city community health centre: six years' experience

Some aspects of the work of an inner-city community health centre administered by a large teaching hospital are described. Some sociodemographic characteristics and patterns of morbidity of persons attending the centre over the past six years are presented. Initial attempts of evaluation of clinical services provided by the centre are described.

Prevalence of alcoholism in a Sydney Teaching Hospital: some aspects

This paper presents some preliminary findings from an epidemiological study of inpatients in Royal Prince Alfred Hospital in 1977. The sample included 457 patients. Of these, 15% were found to have alcohol-related reasons for admission to hospital, and 33% had concomitant alcohol problems. The drinking habits of 30% of males and 9% of females placed them at risk. Some commonly used laboratory tests are evaluated.

Health centre x-ray unit

An analysis of the types and numbers of x-ray films requested in the first year of a health centre x-ray unit showed that chest films represented the largest proportion of these. The unit is most valuable when it is inmediately available to the patient and general practitioner at the time of consultation, and thus it should be open for at least five sessions per week. The likely referral rate for the health centre x-ray unit is 84 patients per 1,000 at risk, and a unit functioning for five sessions a week can examine 60 patients during that time. This minimum of five sessions would be fully used by a population of 30,000 patients. The running costs were found to be about the same as those of a hospital x-ray unit.