Proton Based Stereotactic Radiotherapy for Skull Base Patients: Dosimetric Comparison to 4 Modern Radiation Treatment Modalities

PURPOSE/OBJECTIVE(S)

Re-irradiation with ablative doses to a smaller target volume and strict critical structure constraint is a challenge for modern radiation planning and delivery systems. Several advanced radiation treatment techniques can be used for fractionated stereotactic ablative radiosurgery (FSRS) in select patients with unresectable recurrent head and neck tumors. In this study, in order to better understand the dosimetry advantage of each technique, we compare the stereotactic treatment plans of our new small spot size Hitachi proton treatment unit to those of CyberKnife stereotactic radiosurgery (CK), Gamma Knife radiosurgery (GK), volumetric modulated arc therapy (VMAT), and MR Linac radiotherapy (MRL).

MATERIALS/METHODS

Ten FSRS skull base patients treated at our institution using VMAT (n = 5) or GK (n = 5) techniques. Intensity-modulated proton therapy (IMPT) plans were created in Raystation using Monte Carlo dose calculation algorithm. VMAT, CK, GK and MRL plans were generated in RayStation, Accuray Precision, Leksell Gamma Plan, and Monaco treatment planning systems, separately. Planning goals were to achieve the best target coverage of prescribed dose without compromising the critical organs at risk dose volume constraints of the clinical treatment plans. Plans were compared based on percent CTV coverage, Paddick conformity index (PCI), gradient index (GI, V50/V100), dose homogeneity index (HI, (D2-D98)/D50), low dose bath volume (LDBV, ratio of total volume irradiated between 20% and 50% prescription dose and the target volume), beam-on-time (BOT), and mean/maximum doses to brainstems.

RESULTS

The median target volume was 15.5 cm3 (range 1.0 - 36.23 cm3). The prescription was 45 Gy in 5 fractions for VMAT patients, and 21 - 27 Gy in 3 fractions for GK patients. The comparison of the treatment plans of these 5 delivery modalities was shown in table. All techniques achieved comparable CTV coverage. GI was superior for GK plans and outstanding in CK and IMPT plans. IMPT plans were also outstanding in regard to BOT and PCI. Significantly improved HI, LDBV and brainstem mean doses were achieved in IMPT plans. For adjacent brainstem and other OARs, maximum doses were comparable among all techniques.

CONCLUSION

In these five advanced radiation therapy modalities, proton therapy SBRT showed dosimetric advantage over other modalities to spare nearby OARs without sacrifice of target coverage. Further studies are needed to utilize this clinical benefit and investigate plan robustness.

Resistance to ATR Inhibitors Is Mediated by Loss of the Nonsense-Mediated Decay Factor UPF2

Significance:

Loss of NMD proteins promotes resistance to ATR inhibitors in gastric cancer cells, which may provide a combination of therapeutic targets and biomarkers to improve the clinical utility of these drugs.

How well do polygenic risk scores identify men at high risk for prostate cancer? Systematic review and meta-analysis

OBJECTIVES

Genome-wide association studies have revealed over 200 genetic susceptibility loci for prostate cancer (PCa). By combining them, polygenic risk scores (PRS) can be generated to predict risk of PCa. We summarize the published evidence and conduct meta-analyses of PRS as a predictor of PCa risk in Caucasian men.

PATIENTS AND METHODS

Data were extracted from 59 studies, with 16 studies including 17 separate analyses used in the main meta-analysis with a total of 20,786 cases and 69,106 controls identified through a systematic search of ten databases. Random effects meta-analysis was used to obtain pooled estimates of area under the receiver-operating characteristic curve (AUC). Meta-regression was used to assess the impact of number of single-nucleotide polymorphisms (SNPs) incorporated in PRS on AUC. Heterogeneity is expressed as I² scores. Publication bias was evaluated using funnel plots and Egger tests.

RESULTS

The ability of PRS to identify men with PCa was modest (pooled AUC 0.63, 95% CI 0.62-0.64) with moderate consistency (I² 64%). Combining PRS with clinical variables increased the pooled AUC to 0.74 (0.68-0.81). Meta-regression showed only negligible increase in AUC for adding incremental SNPs. Despite moderate heterogeneity, publication bias was not evident.

CONCLUSION

Typically, PRS accuracy is comparable to PSA or family history with a pooled AUC value 0.63 indicating mediocre performance for PRS alone.

799 Do Not Attempt Cardiopulmonary Resuscitation Decisions in Neck of Femur Fractures – Is Documentation Adequate?

Introduction

‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) documentation is essential to communicate decisions regarding ceilings of care for patients to the clinical team. Patients admitted to hospital with a fractured neck of femur (#NOF) are often elderly with multiple comorbidities, and so robust and clear anticipatory care plans are especially indicated.

Method

All patients admitted to a large district general hospital in Scotland with a #NOF over a three-week period between 23/10/2020 and 12/11/2020 were identified prospectively and included in this audit. Patients’ demographic information, DNACPR status and the quality of their DNACPR documentation was recorded.

Results

20 patients (85% Female, 15% Male) were identified and included. Median ASA grade was 3, with 77.8% of patients ASA grade 3 or 4. 63.2% of patients had DNACPR documentation in place, all of which were ASA grade 3 or above. Most DNACPR documentation had patient information clearly identifiable (91.7%), was completed preoperatively (90.9%), and involved either the patient or appropriate relative or power of attorney (91.6%). However, only 75% of patients’ documentation had the rationale for the DNACPR decision documented and only 25% of DNACPR decisions were reviewed by a senior clinician within 72 hours. No DNACPR decisions were documented as having been communicated to the wider healthcare team.

Conclusions

DNACPR documentation is a crucial for anticipatory care planning in #NOF patients. This audit shows improvement is needed in documenting whether decisions have been reviewed by senior clinicians, and if they have been communicated to the wider healthcare team.

Instrument flight to the inner ear

Surgical robot systems can work beyond the limits of human perception, dexterity and scale making them inherently suitable for use in microsurgical procedures. However, despite extensive research, image-guided robotics applications for microsurgery have seen limited introduction into clinical care to date. Among others, challenges are geometric scale and haptic resolution at which the surgeon cannot sufficiently control a device outside the range of human faculties. Mechanisms are required to ascertain redundant control on process variables that ensure safety of the device, much like instrument-flight in avionics. Cochlear implantation surgery is a microsurgical procedure, in which specific tasks are at sub-millimetric scale and exceed reliable visuo-tactile feedback. Cochlear implantation is subject to intra- and inter-operative variations, leading to potentially inconsistent clinical and audiological outcomes for patients. The concept of robotic cochlear implantation aims to increase consistency of surgical outcomes such as preservation of residual hearing and reduce invasiveness of the procedure. We report successful image-guided, robotic CI in human. The robotic treatment model encompasses: computer-assisted surgery planning, precision stereotactic image-guidance, in-situ assessment of tissue properties and multipolar neuromonitoring (NM), all based on in vitro, in vivo and pilot data. The model is expandable to integrate additional robotic functionalities such as cochlear access and electrode insertion. Our results demonstrate the feasibility and possibilities of using robotic technology for microsurgery on the lateral skull base. It has the potential for benefit in other microsurgical domains for which there is no task-oriented, robotic technology available at present.

Sporting participation following the operative management of chondral defects of the knee at mid-term follow up: a systematic review and meta-analysis

PURPOSE

The purpose of this study was to perform a systematic review of the reparticipation in sport at mid-term follow up in athletes who underwent biologic treatment of chondral defects in the knee and compare the rates amongst different biologic procedures.

METHODS

A search of PubMed/Medline and Embase was performed in May 2020 in keeping with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The criteria for inclusion were observational, published research articles studying the outcomes and rates of participation in sport following biologic treatments of the knee with a minimum mean/median follow up of 5 years. Interventions included microfracture, osteochondral autograft transfer (OAT), autologous chondrocyte implantation (ACI), matrix-induced autologous chondrocyte implantation (MACI), osteochondral allograft, or platelet rich plasma (PRP) and peripheral blood stem cells (PBSC). A random effects model of head-to-head evidence was used to determine rates of sporting participation following each intervention.

RESULTS

There were twenty-nine studies which met the inclusion criteria with a total of 1276 patients (67% male, 33% female). The mean age was 32.8 years (13-69, SD 5.7) and the mean follow up was 89 months (SD 42.4). The number of studies reporting OAT was 8 (27.6%), ACI was 6 (20.7%), MACI was 7 (24.1%), microfracture was 5 (17.2%), osteochondral allograft was 4 (13.8%), and one study (3.4%) reported on PRP and PBSC. The overall return to any level of sport was 80%, with 58.6% returning to preinjury levels. PRP and PBSC (100%) and OAT (84.4%) had the highest rates of sporting participation, followed by allograft (83.9%) and ACI (80.7%). The lowest rates of participation were seen following MACI (74%) and microfracture (64.2%).

CONCLUSIONS

High rates of re-participation in sport are sustained for at least 5 years following biologic intervention for chondral injuries in the knee. Where possible, OAT should be considered as the treatment of choice when prolonged participation in sport is a priority for patients. However, MACI may achieve the highest probability of returning to the same pre-injury sporting level.

LEVEL OF EVIDENCE

IV.

Developing a Data Integrated COVID-19 Tracking System for Decision-Making and Public Use

Introduction

The unprecedented COVID-19 pandemic unveiled a strong need for advanced and informative surveillance tools. The Centre for Health Informatics (CHI) at the University of Calgary took action to develop a surveillance dashboard, which would facilitate the education of the public, and answer critical questions posed by local and national government.

Objectives

The objective of this study was to create an interactive method of surveillance, or a “COVID-19 Tracker” for Canadian use. The Tracker offers user-friendly graphics characterizing various aspects of the current pandemic (e.g. case count, testing, hospitalizations, and policy interventions).

Methods

Six publicly available data sources were used, and were selected based on the frequency of updates, accuracy and types of data, and data presentation. The datasets have different levels of granularity for different provinces, which limits the information that we are able to show. Additionally, some datasets have missing entries, for which the “last observation carried forward” method was used. The website was created and hosted online, with a backend server, which is updated on a daily basis. The Tracker development followed an iterative process, as new figures were added to meet the changing needs of policy-makers.

Results

The resulting Tracker is a dashboard that visualizes real-time data, along with policy interventions from various countries, via user-friendly graphs with a hover option that reveals detailed information. The interactive features allow the user to customize the figures by jurisdiction, country/region, and the type of data shown. Data is displayed at the national and provincial level, as well as by health regions.

Conclusion

The COVID-19 Tracker offers real-time, detailed, and interactive visualizations that have the potential to shape crucial decision-making and inform Albertans and Canadians of the current pandemic.

Can Linked Electronic Medical Record and Administrative Data Help Us Identify Those Living with Frailty?

Introduction

Frailty is a complex condition that affects many aspects of patients’ wellbeing and health outcomes.

Objectives

We used available Electronic Medical Record (EMR) and administrative data to determine definitions of frailty. We also examined whether there were differences in demographics or health conditions among those identified as frail in either the EMR or administrative data.

Methods

EMR and administrative data were linked in British Columbia (BC) and Manitoba (MB) to identify those aged 65 years and older who were frail. The EMR data were obtained from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and the administrative data (e.g. billing, hospitalizations) was obtained from Population Data BC and the Manitoba Population Research Data Repository. Sociodemographic characteristics, risk factors, prescribed medications, use and costs of healthcare are described for those identified as frail.

Results

Sociodemographic and utilization differences were found among those identified as frail from the EMR compared to those in the administrative data. Among those who were >65 years, who had a record in both EMR and administrative data, 5%-8% (n=191 of 3,553, BC; n=2,396 of 29,382, MB) were identified as frail. There was a higher likelihood of being frail with increasing age and being a woman. In BC and MB, those identified as frail in both data sources have approximately twice the number of contacts with primary care (n=20 vs. n=10) and more days in hospital (n=7.2 vs. n=1.9 in BC; n=9.8 vs. n=2.8 in MB) compared to those who are not frail; 27% (BC) and 14% (MB) of those identified as frail in 2014 died in 2015.

Conclusions

Identifying frailty using EMR data is particularly challenging because many functional deficits are not routinely recorded in structured data fields. Our results suggest frailty can be captured along a continuum using both EMR and administrative data.

Acceptability of anal cancer screening tests for women living with HIV in the EVVA study

Background

Anal cancer is potentially preventable through screening. For screening to be implemented, the screening procedures must be acceptable to the affected population. The objective of the present study was to measure the acceptability of currently available anal cancer screening tests in a population of women living with hiv who had experienced the tests.

Methods

The evva study ("Evaluation of Human Immunodeficiency Virus, Human Papillomavirus, and Anal Intraepithelial Neoplasia in Women") is a prospective cohort study of adult women living with hiv in Montreal, Quebec. Participants were screened with cervical or anal hpv testing and cervical or anal cytology every 6 months for 2 years. High-resolution anoscopy (hra) and digital anal rectal examination (dare) were also performed systematically, with biopsies, at baseline and at 2 years. An acceptability questionnaire was administered at the final visit or at study withdrawal.

Results

Of 124 women who completed the acceptability questionnaire, most considered screening "an absolute necessity" in routine care for all women living with hiv [77%; 95% confidence interval (ci): 69% to 84%]. Yearly anal cytology or anal hpv testing was considered very acceptable by 81% (95% ci: 73% to 88%); hra every 2 years was considered very acceptable by 84% (95% ci: 77% to 90%); and yearly dare was considered very acceptable by 87% (95% ci: 79% to 92%). Acceptability increased to more than 95% with a longer proposed time interval. Pain was the main reason for lower acceptability.

Conclusions

Most participating women considered anal cancer screening necessary and very acceptable. Longer screening intervals and adequate pain management could further increase the acceptability of repeated screening.

Achieving quality primary care data: a description of the Canadian Primary Care Sentinel Surveillance Network data capture, extraction, and processing in Alberta

Introduction

Electronic medical record (EMR) databases have become increasingly popular for secondary purposes, such as health research. The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is the first and only pan-Canadian primary care EMR data repository, with de-identified health information for almost two million Canadians. Comprehensive and freely available documentation describing the data ‘lifecycle’ is important for assessing potential data quality issues and appropriate interpretation of research findings. Here, we describe the flow and transformation of CPCSSN data in the province of Alberta.

Approach

In Alberta, the data originate from 54 publicly-funded primary care settings, including one community pediatric clinic, with 318 providers contributing de-identified EMR data for 410,951 patients (as of December 2018). Data extraction methods have been developed for five different EMR systems, and include both backend and automated frontend extractions. The raw EMR data are transformed according to specific rules, including trimming implausible values, converting values and free text to standard terminologies or classification systems, and structuring the data into a common CPCSSN format. Following local data extraction and processing, the data are transferred to a central repository and made available for research and disease surveillance.

Conclusion

This paper aims to provide important contextual information to future CPCSSN data users.

When prevention is dangerous: perceptions of isoniazid preventive therapy in KwaZulu-Natal, South Africa

Setting

In 2011, the South African government began to offer isoniazid preventive therapy (IPT) through the public health system to presumptively treat latent tuberculous infection (LTBI) among people living with human immunodeficiency virus.

Objective

To describe IPT perceptions and experiences in three Zulu communities in KwaZulu-Natal Province, South Africa.

Design

Using a combination of community-based research and ethnographic methods, we undertook 17 individual and group interviews between October 2014 and May 2015. Interviews transcripts were analysed using qualitative content analysis and validated with grass-roots community advisors.

Results

Participants reported multiple ways in which IPT was perceived as dangerous: when costs related to pill collection or consumption were unsustainable, or when daily pill consumption resulted in stigma or was seen to introduce excess dirt or toxins, 'ukungcola', in the body. Theories on dirt are evoked to describe how IPT was perceived as 'matter out of place' when given to people who believed themselves to be healthy, suggesting that under the current TB aetiological model in Zulu culture, 'prevention as tablet' may not fit.

Conclusion

Implementing IPT without understanding the realities of community stakeholders can unintentionally undermine TB control efforts by worsening the situation for people who already encounter numerous daily problems.

Communication training interventions for family and professional carers of people living with dementia: a systematic review of effectiveness, acceptability and conceptual basis

OBJECTIVES

To update previous reviews and provide a more detailed overview of the effectiveness, acceptability and conceptual basis of communication training-interventions for carers of people living with dementia.

METHOD

We searched CINAHL Plus, MEDLINE and PsycINFO using a specific search and extraction protocol, and PRISMA guidelines. Two authors conducted searches and extracted studies that reported effectiveness, efficacy or acceptability data regarding a communication training-intervention for carers of people living with dementia. Risk of bias was assessed using the Cochrane Collaboration guidelines. Quality of qualitative studies was also systematically assessed.

RESULTS

Searches identified 450 studies (after de-duplication). Thirty-eight studies were identified for inclusion in the review. Twenty-two studies focused on professional carers; 16 studies focused mainly on family carers. Training-interventions were found to improve communication and knowledge. Overall training-interventions were not found to significantly improve behaviour that challenges and caregiver burden. Acceptability levels were high overall, but satisfaction ratings were found to be higher for family carers than professional carers. Although many interventions were not supported by a clear conceptual framework, person-centred care was the most common framework described.

CONCLUSION

This review indicated that training-interventions were effective in improving carer knowledge and communication skills. Effective interventions involved active participation by carers and were generally skills based (including practicing skills and discussion). However, improvements to quality of life and psychological wellbeing of carers and people living with dementia may require more targeted interventions.

Abstract P6-12-05: Metastatic breast cancer collateral damage project (MBCCD): Development and preliminary results of the survey of health, impact, needs, and experiences (SHINE)

Rationale: People living with metastatic breast cancer face unique challenges, which have not been well characterized. The aim of the MBCCD was to characterize the MBC patient experience in order to identify and address potential areas of need in this underserved population.

Method: We crowdsourced input and gathered free-text data from 353 people living with MBC to document the breadth of challenges affecting quality of life. From the responses, we developed a new measure (SHINE) with 79 patient-driven items regarding the experience of MBC, including verbatim statements from crowdsourcing data. Validated quality of life scales, clinical information, and demographic data were also collected. Participants were recruited from Dr. Susan Love Research Foundation's Army of Women® and other advocacy organizations; 515 completed the questionnaire. Confirmatory and exploratory factor analyses were conducted to assess model fit for SHINE and to identify subscales. Next, differences in MBC-specific concerns and experiences as a function of age, marital status, financial status, education, children, metastatic site location(s), and current medical treatment were examined with ANOVAs and t-tests.

Results: Factor analyses indicated good model fit (CFI=.96, RMSEA=.05, SRMR=.04) for a 36-item scale of MBC-specific concerns and experiences with nine subscales: 1) Employment/achievement, 2) Finances, 3) Insurance, 4) Mortality/uncertainty, 5) Activity disruption, 6) Concern for others, 7) Social isolation/withdrawal, 8) Self-concept disruption, 9) Benefit finding. A within-subjects ANOVA revealed that participants were most bothered by mortality/uncertainty concerns, followed by activity disruption, financial, employment/achievement, and insurance concerns, respectively (F(4,508)=111.38, p<0.01). Additionally, participants endorsed strongest agreement with benefit finding, followed by concern for others, self-concept disruption, and social isolation/withdrawal (F(4,508)=101.53, p<.01). Participants younger than 50 years and those with lower financial status reported higher concerns on all subscales (ps<0.01), except for benefit finding (ps>0.18). Participants with a child under 18 living at home, those on combination therapies, and those with metastases to multiple sites or bone only reported higher concerns on several subscales (ps<0.05). Being married was significantly associated with higher concern for others and lower concern about finances (ps<0.02). Education was not significantly related to any subscale.

Conclusions: Several important concerns and experiences related to MBC are not captured adequately in existing measures. This study developed a new measure (SHINE), which reliably assessed these disease-specific concerns and experiences in 515 adults living with MBC. Concerns regarding mortality and uncertainty were most prominent. Specific demographic and medical characteristics modified responses on eight subscales, but not on the benefit finding subscale. Findings can aid the development of supportive care efforts that address areas of need (e.g., concerns about mortality and uncertainty) in this understudied medical population.

Citation Format: Stanton A, Williamson T, Clague DeHart J, Jorge A, Eshraghi L, Cooper Ortner H, Love S. Metastatic breast cancer collateral damage project (MBCCD): Development and preliminary results of the survey of health, impact, needs, and experiences (SHINE) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-05.

Abstract P6-12-07: Metastatic breast cancer collateral damage project: Associations of disease-specific concerns and experiences with psychological health, illness management, and health behaviors

Rationale: Research has identified risk and protective factors that predict health and well-being in adults with breast cancer, but this work has been focused largely on women with early-stage disease. Metastatic breast cancer (MBC) patients report worse psychological health and poorer quality of life compared to those with early-stage breast cancer. We investigated whether a newly developed measure of MBC-specific concerns and experiences, the Survey of Health, Impact, Needs, and Experiences (SHINE), is associated with psychological health, illness management, and health behaviors in a sample of MBC patients.

Method: SHINE includes 36 items capturing the experience of MBC, including verbatim statements from previously collected crowdsourcing data. Participants (N=515) were recruited from Dr. Susan Love Research Foundation's Army of Women® and other advocacy organizations. Participants also completed measures of psychological health (i.e., depression, anxiety), illness management (i.e., self-efficacy for managing medications/treatments and symptoms), and health behaviors (i.e., sleep, degree of moderate physical activity). The nine SHINE subscales, along with age, marital status, financial status, children, metastatic site location(s), and current medical treatment(s), were entered as simultaneous predictors in a multivariate regression. Psychological health, illness management, and health behaviors were entered as dependent variables in separate models.

Results: With demographic and medical variables controlled, MBC-specific concerns were associated significantly with depressive symptoms (ΔR2=.38), anxiety (ΔR2=.37), efficacy for medication/treatment management (ΔR2=.08), efficacy for symptom management (ΔR2=.32), sleep disruption (ΔR2 =.10), and physical activity (ΔR2=.17), with all ps<.01. Specifically, higher depressive symptoms and anxiety were associated greater mortality/uncertainty concerns (ps<.01), greater social isolation/withdrawal (ps<.01), and higher self-concept disruption (ps<.02). Anxiety was uniquely associated with greater financial concerns (p<.02), whereas depression was uniquely associated with fewer positive experiences (p<.05). Higher self-efficacy for managing symptoms was related to more positive experiences, higher mortality concerns, and more self-concept and activity disruption (ps<.01), whereas higher efficacy for managing medications/treatments was associated with lower social isolation/withdrawal (p<.03). More sleep disruption was associated with higher concern for others (p<.05), and less physical activity was associated with more activity disruption (p<.01).

Conclusions: After controlling for demographic and medical characteristics, MBC-specific concerns were related significantly to psychological health, self-efficacy for illness management, and health behaviors. Mortality/uncertainty concerns, social isolation/withdrawal, and self-concept disruption were especially important correlates of depressive symptoms, anxiety, and MBC-related self-efficacy. Higher concern for others was related to more sleep disruption. Approaches that address these MBC-specific concerns and promote positive experiences may be beneficial for patients.

Citation Format: Williamson T, Stanton A, Clague DeHart J, Jorge A, Eshraghi L, Cooper Ortner H, Love S. Metastatic breast cancer collateral damage project: Associations of disease-specific concerns and experiences with psychological health, illness management, and health behaviors [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-07.

Twelve-month outcomes following midurethral sling procedures for stress incontinence: impact of obesity

OBJECTIVE

To evaluate impact of body mass index (BMI) ≥30 on objective and subjective cure rates 12 months after midurethral sling surgery.

DESIGN

Secondary analysis.

SETTING

Three hospitals in Calgary, Canada, 2005-07.

POPULATION

A total of 182 women enrolled in a randomised control trial of tension-free vaginal tape versus transobturator tape.

METHODS

Women were classified as obese or nonobese from height and weight on day of surgery. Women underwent postoperative standardised pad tests, self-reporting of urinary incontinence, and quality of life scores. Categorical data compared with chi-square or Fisher's exact, continuous data compared with Mann-Whitney U test.

MAIN OUTCOME MEASURES

Primary outcome was objective cure, defined as <1 g urine loss on postoperative 1-hour pad test. Secondary outcomes were subjective cure of incontinence (no stress incontinence in previous 7 days), presence of urinary urgency in previous 7 days, Urogenital Distress Inventory (UDI-6) scores, Incontinence Impact Questionnaire (IIQ-7) scores, and surgical complication rates.

RESULTS

Objective cure differed, with 85.6% of nonobese women leaking <1 g on 1-hour pad test, versus 67.8% of obese women (P = 0.006, risk difference [RD] 17.8%, 95% confidence interval [95% CI] 4.2-31.4%). Subjective cure was 85.8% for nonobese women versus 70.7% for obese women (P = 0.016, RD 15.1%, 95% CI 1.9-28.4%). For both groups, improvement was seen for postoperative UDI-6 (median -33.3 [-44.4 to -22.2] and -27.2 [-44.4 to -16.7]) and IIQ-7 scores (median -26.2 [-45.2 to -14.3] and -23.8 [-42.9 to -14.3]). No differences existed in rates of operative complications between the two groups.

CONCLUSION

Twelve months after midurethral sling surgery, obese women experience lower rates of cure than those who are nonobese.

Macitentan for the treatment of pulmonary arterial hypertension

Macitentan is a novel, dual endothelin receptor antagonist recently approved for the treatment of WHO Group I pulmonary arterial hypertension. Its pharmacologic mechanism of action as well as the pharmacokinetics, pharmacodynamics and potential drug-drug interactions have been demonstrated in multiple phase I and II trials. The pivotal randomized, placebo-controlled, event-driven clinical trial revealed a significant reduction in morbidity. The most common adverse events were rarely clinically significant, nor did they result in a high rate of discontinuation. Of note, macitentan is contraindicated in pregnant women due to embryo-fetal toxicity.

Interventions for ear discharge associated with grommets (ventilation tubes)

BACKGROUND

The insertion of grommets (also known as ventilation or tympanostomy tubes) is one of the most common surgical procedures performed on children. Postoperative otorrhoea (discharge) is the most common complication with a reported incidence ranging from 10% to 50%. In the UK, many ENT surgeons treat with topical antibiotics/steroid combinations, but general practitioners, mainly through fears of ototoxicity, are unlikely to prescribe these and choose systemic broad-spectrum antibiotics.

OBJECTIVES

1. To identify the most effective non-surgical management of discharge from ears with grommets in place.2. To identify the risks of non-surgical management for this condition (e.g. ototoxicity), and to set benefits of treatment against these risks.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2005), MEDLINE (1966 to 2005) and EMBASE (1974 to 2005). We also searched the CINAHL, AMED, LILACS, ISI WEB OF KNOWLEDGE, ISI PROCEEDINGS, mRCT, NNR, ZETOC, KOREAMED, CSA, MEDCARIB, INDMED and SAMED databases. The date of the last search was February 2005.

SELECTION CRITERIA

Randomised controlled trials of adults or children, with any type of grommet and an ear with discharge were included. The trials compared treatment with placebo or one treatment with another. The primary outcome measure was the duration of the discharge.

DATA COLLECTION AND ANALYSIS

The trials were selected independently according to the above criteria by the four reviewers. Differences in opinion over the inclusion of studies were resolved by discussion. The studies were graded using the CASP critical appraisal tool. Analyses were based on the presence of discharge seven days from the onset of treatment.

MAIN RESULTS

There was very little good quality evidence. Four studies were included, all of them investigating different interventions and therefore a meta-analysis was not possible. Only one study demonstrated a significant difference. Oral amoxicillin clavulanate was compared to placebo in 79 patients. The odds of having a discharge persisting eight days after starting treatment was 0.19 (95% CI 0.07 to 0.49) . The number needed to treat to achieve that benefit is 2.5. Participants in both arms of this study also received daily aural toilet. The results will therefore not be applicable to most settings including primary care. No significant benefit was shown in the two studies investigating steroids (oral prednisolone with oral amoxicillin clavulanate and topical dexamethasone with topical ciprofloxacin ear drops), or the one study comparing an antibiotic-steroid combination (Otosporin(R)) drops versus spray (Otomize(R)) (although more patients preferred the spray form).

AUTHORS' CONCLUSIONS

The authors of this review have been unable to identify the most effective intervention or to assess the associated risks. Research is urgently needed into the effectiveness of oral versus topical antibiotics in this group of patients. Clinicians considering antibiotic treatment need to balance any potential benefit against the risks of side effects and antibiotic resistance.

Cost-Effectiveness of tolterodine for patients with urge incontinence who discontinue initial therapy with oxybutynin: a Canadian perspective

BACKGROUND

Tolterodine is a novel muscarinic receptor antagonist for the treatment of overactive bladder.

OBJECTIVE

The purpose of this study was to examine the cost-effectiveness of tolterodine for patients with urge incontinence (UI) who discontinue initial therapy with oxybutynin in a Canadian setting.

METHODS

We compared 2 treatment strategies for the management of adult patients with UI: (1) generic oxybutynin with no further treatment for patients who discontinue and (2) generic oxybutynin with switch to tolterodine (2 mg BID) for patients who discontinue. We developed a 1-year Markov model (4-week cycle length) with transitions between disease states of normal, mild, moderate, and severe. Transition probabilities over 12 weeks were obtained from randomized trial data, and drug discontinuation rates were obtained from Quebec prescription claims data. Outcome measures were time in "normal" health state and quality-adjusted life-years (QALYs) using EuroQol-5D utility scores from a survey of Swedish patients with overactive bladder. Costs to the health care payer and patient out-of-pocket costs (in Canadian dollars) were included.

RESULTS

For patients who discontinue oxybutynin, the use of tolterodine is associated with approximately 6 months per year in a normal health or mild disease state, compared with approximately 3 months for those who do not receive further drug therapy after discontinuation. Tolterodine use resulted in an annual additional cost per patient of Can $163. The incremental cost per QALY was Can $9,982 and appeared to be robust to alternative model parameter assumptions.

CONCLUSION

Use of tolterodine in patients with UI who discontinue initial therapy with generic oxybutynin lies within currently accepted benchmarks for cost-effectiveness.

Costs and resources associated with the treatment of overactive bladder using retrospective medical care claims data

The objectives of this study were to determine age- and gender-specific drug treatment prevalence rates for overactive bladder (OAB), and to compare resource use and costs among MCO members receiving drug treatment for OAB. Administrative claims data from seven affiliated health plans were analyzed for 8,661 members with a diagnosis or treatment indicative of OAB during 1998. Resource use and associated costs were analyzed over a four-month follow-up. In 1998, the prevalence of OAB among plan members was 1.1%. Of the patients with OAB, 71% did not receive pharmacotherapy. After multivariate analysis, treatment with tolterodine, oxybutynin, or other OAB treatment did not significantly affect the percent change in total per patient per month (PPPM) costs compared with the group not receiving a pharmacologic agent. Although the adjusted percent change in PPPM pharmacy costs was significantly higher within the tolterodine group, medical and total PPPM costs were not.

Economic evaluation of systemic treatments for cytomegalovirus retinitis in patients with AIDS

OBJECTIVE

To determine the cost of using systemic therapy to treat newly diagnosed cytomegalovirus (CMV) retinitis in persons with AIDS.

DESIGN

Incidence-based simulation model of CMV treatment from a government payer perspective.

SETTING

Swiss healthcare system.

PATIENTS AND PARTICIPANTS

Patients with AIDS and newly diagnosed CMV retinitis.

INTERVENTIONS

Patients were assigned to 1 of 4 treatment regimens for induction and maintenance therapy: (i) intravenous (IV) cidofovir induction and maintenance (cidofovir IV/IV); (ii) IV foscarnet induction and maintenance (foscarnet IV/IV); (iii) IV ganciclovir induction and maintenance (ganciclovir IV/IV); and (iv) IV ganciclovir induction and oral (PO) ganciclovir maintenance (ganciclovir IV/PO). Following a second relapse, patients were assigned to one of the other regimens.

MAIN OUTCOME MEASURES

Time to first and subsequent progression, duration of maintenance treatment and direct medical expenditures [1998 Swiss francs (SwF)] .

RESULTS

The median time to first progression was longest for cidofovir IV/IV, followed by foscarnet IV/IV, ganciclovir IV/IV and ganciclovir IV/PO. Mean survival was 13 months and mean costs for this period in the base case were lowest in those initially treated with cidofovir (SwF146,742), followed by initial treatment with foscarnet IV/IV (SwF194,809), ganciclovir IV/PO (SwF195,190) and ganciclovir IV/IV (SwF243,964). Costs were most sensitive to changes in efficacy estimates.

CONCLUSIONS

Of the regimens studied, initiation of treatment with systemic cidofovir appears least costly over a 13-month period.

Community-based validation of the McCormick Toy Test

The aim of the present study was to investigate the validity of a community-based hearing test to detect conductive hearing loss in 3-year-old children. Sixty-five children had their hearing tested using standard audiological tests at the same time as they underwent their 3-year-old health checks. The checks were performed by health visitors at community health clinics, and included the McCormick Toy Test (MCTT) for hearing. Fourteen children failed both tests and none passed the MCTT and failed the standard tests, giving a sensitivity of 100%. Forty-eight children passed both tests and three children failed the MCTT but passed the standard tests, giving a specificity of 94%. Positive predictive value was 82%. The results from this sample indicate that the MCTT may be used as a valid test for conductive hearing loss for 3-year-old children in the community setting.

The impact of antidepressant use on social functioning: reboxetine versus fluoxetine

Depression compromises affected individuals' functional well-being and impairs their level of social and workplace performance. Improved social functioning in depressed patients may improve their work productivity. This study evaluated the differential effects of two antidepressants on social functioning outcomes for patients with major depression comparing reboxetine, a non-tricyclic, selective noradrenaline reuptake inhibitor and fluoxetine, a commonly prescribed selective serotonin reuptake inhibitor. A model using data from 284 depressed patients (138 reboxetine, 146 fluoxetine) in two 8-week clinical trials was developed to predict the percentage change over time in continuous outcome assessments as measured by a 21-item self-rating scale called the Social Adaptation Self-evaluation Scale (SASS). The percentage change from baseline SASS score was modelled as a function of both time-invariant and time-varying covariates. Results suggest that, by mid-study, the more severely ill subjects benefitted more from reboxetine treatment in terms of the outcome improvement rate and, by study-end, this effect also extended into the less severely ill population. In addition, a significant relationship was identified between the change in depression symptom severity as measured by the standard Hamilton Depression Rating Scale score and the change in social functioning per the SASS.

A pharmacoeconomic evaluation of the use of dexrazoxane in preventing anthracycline-induced cardiotoxicity in patients with stage IIIB or IV metastatic breast cancer

A Markov model was developed to determine the cost of treating patients with stage IIIB or IV metastatic breast cancer with 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC) and dexrazoxane (administered after six courses of FAC) versus FAC alone. The primary end point in our economic study was cost per cardiac event avoided. Cost per life-year saved was also calculated, even though the survival advantage needs to be confirmed in follow-up studies. The model incorporated the direct medical costs of treating patients with chemotherapy, as well as the costs associated with treatment of any cardiac events that occurred. Data were collected for this analysis from several sources, including completed clinical trials on FAC plus dexrazoxane versus FAC plus placebo (obtained from two patient groups randomized at different time points), a panel of three oncologists, and a panel of three cardiologists. Analyses showed that therapy with dexrazoxane costs $5661.77 per cardiac event prevented. Sensitivity analyses on model variables were performed and showed that the basic results of the model did not change when parameters were varied. The clinical efficacy and cost-effectiveness of dexrazoxane as shown by the results of the current study encourage further investigation of the uses of dexrazoxane in other populations and against other comparators.

Microtubule reorganization is obligatory for growth cone turning

To examine the role of microtubules in growth cone turning, we have compared the microtubule organization in growth cones advancing on uniform laminin substrates with their organization in growth cones turning at a laminin-tenascin border. The majority (82%) of growth cones on laminin had a symmetrical microtubule organization, in which the microtubules entering the growth cone splay out toward the periphery of the growth cone. Growth cones at tenascin borders had symmetrically arranged microtubules in only 34% of cases, whereas in the majority of cases the microtubules were displaced toward one-half of the growth cone, presumably stabilizing in the direction of the turn along the tenascin border. These results suggest that reorganization of microtubules could underlie growth cone turning. Further evidence for the involvement of microtubule rearrangement in growth cone turning was provided by experiments in which growth cones approached tenascin borders in the presence of nanomolar concentrations of the microtubule stabilizing compound, Taxol. Taxol altered the organization of microtubules in growth cones growing on laminin by restricting their distribution to the proximal regions of the growth cone and increasing their bundling. Taxol did not stop growth cone advance on laminin. When growing in the presence of Taxol, growth cones at tenascin borders were not able to turn and grow along the laminin-tenascin border, and consequently stopped at the border. Growth cones were arrested at borders for as long as Taxol was present (up to 6 h) without showing any signs of drug toxicity. These effects of Taxol were reversible. Together, these results suggest that microtubule reorganization in growth cones is a necessary event in growth cone turning.

Dexrazoxane cardioprotection for patients receiving FAC chemotherapy: a pharmacoeconomic evaluation

Anthracyclines are among the most effective and commonly-prescribed antitumor agents but have dose-limiting cumulative cardiotoxicity. We performed a pharmacoeconomic evaluation of the ability of dexrazoxane to prevent cardiac-related adverse events in patients with Stage IIIB or IV metastatic breast cancer who were treated with a median of 10 cycles of intravenous FAC (5-fluorouracil, doxorubicin and cyclophosphamide) at doses of 500/50/500 mg/m2 respectively. Dexrazoxane was given at 500 mg/m2 commencing at the seventh cycle of treatment. We determined the cost of each cardiac event prevented and the cost of each additional life-year saved by dexrazoxane use. The cost per cardiac event prevented was CDN $5745 and the cost per additional life-year saved was CDN $2856. With the increasing use of anthracyclines in Stages I and II breast cancer, these favorable clinical and economic results may broaden the range of therapeutic possibilities for anthracyclines in adjuvant and metastatic therapy of breast cancer.

The role of heparan sulfate proteoglycans in the pathogenesis of Alzheimer's disease

The hallmark of Alzheimer's disease (AD) is the deposition of amyloid plaques and neurofibrillary tangles in the brain. The relationship between amyloid deposition and the cognitive deficit is still unclear. The amyloid beta A4 protein is produced by proteolytic cleavage of the amyloid protein precursor (APP). Very little is known about the normal function of APP and the role the protein may play in pathogenesis. Several studies have shown that APP is important for the regulation of neurite outgrowth. Our studies support these findings and indicate that the neurite outgrowth-promoting effects of APP are stimulated by an interaction between APP and specific proteoglycans. Using site-directed mutagenesis, a heparan sulfate binding site which mediates this effect has been mapped to the N-terminus of APP (residues 96-110, HBD-1). A peptide homologous to HBD-1 blocks the trophic effects of APP in cell culture. To purify specific proteoglycans which stimulate the action of APP, an affinity column was constructed using a biotinylated peptide homologous to HBD-1 coupled to streptavidin-agarose. Two proteoglycans were isolated from a crude brain cell conditioned medium by affinity chromatography. The purified proteoglycans bound APP saturably with high affinity and stimulated the action of APP on neurite outgrowth from chick sympathetic neurons. Digestion of the proteoglycan fraction with heparitinase I or chondroitinase ABC demonstrated the presence of two major proteins, a heparan sulfate proteoglycan with a core protein of 63-67 kD molecular mass and a chondroitin sulfate proteoglycan with a core protein of 100-110 kD molecular mass. The results demonstrate that APP binds to at least two proteoglycans and that this interaction may regulate the trophic effects of the protein. The interaction of specific APP-binding proteoglycans with amyloid plaques may disturb the normal function of APP and contribute to the neuritic degeneration that is commonly seen around the amyloid plaque cores.

Characterization of 4-nitro-o-phenylenediamine activation by plant systems

4-Nitro-o-phenylenediamine (NOP) is a powerful direct-acting mutagen which demonstrates significant enhancement in mutagenicity when exposed to plant enzymatic systems. Evidence implicating the involvement of peroxidactic oxidation in NOP activation has been obtained from plant-cell suspension and isolated enzyme experiments. Using selected cytochrome P450 and peroxidase enzyme inhibitors in conjunction with Salmonella typhimurium strain TA98 and intact plant-cell activating systems as well as isolated horseradish peroxidase enzyme we have further investigated NOP activation by plant systems. The activation of NOP by both plant cells and by horseradish peroxidase was suppressed by the P450 inhibitors methimazole and (+)-catechin and by the peroxidase inhibitors diethyldithiocarbamate and potassium cyanide, but was not suppressed by the P450 inhibitors metyrapone and 7,8-benzoflavone. In addition, peroxidase enzymatic activity was measured and found to be inhibited by methimazole, diethyldithiocarbamate and potassium cyanide but not by (+)-catechin. The data strongly support the involvement of exogenous peroxidase in the plant activation of NOP, but point to a complex metabolic system that requires multistep processing before full mutagenic potential of the plant-activated component of NOP is expressed.

Wegener granulomatosis with meningeal involvement

The clinical, radiographic, and neuropathologic features of the case of a 41-year-old man with Wegener granulomatosis presenting with neurologic symptoms are correlated. CT and MR scans of the head demonstrated extensive meningeal thickening and enhancement. The importance of considering this diagnosis, confirmed by antineutrophil cytoplasmic autoantibodies, is emphasized.

Health care interviews by school nurses

A health care interview (HCI) carried out by school nurses was piloted in Bath health authority for pupils entering secondary school. Tim Williamson reports the results of an evaluation study involving 99 pupils who had previously had a check with the school doctor at the age of ten. The HCI significantly improved the children's knowledge of who the school nurse was and how to contact her, but failed to improve knowledge of what the school nurse did. A total of 39 problems requiring some action were identified.