Achieving Self-Directed Integrated Cancer Aftercare (ASICA) in melanoma: protocol for a randomised patient-focused pilot trial of delivering the ASICA intervention as a means to earlier detection of recurrent and second primary melanoma

BACKGROUND

Melanoma is common; 15,906 people in the UK were diagnosed with melanoma in 2015 and incidence has increased fivefold in 30 years. Melanoma affects old and young people, with poor prognosis once metastatic. UK guidelines recommend people treated for cutaneous melanoma receive extended outpatient, hospital follow up to detect recurrence or new primaries. Such follow up of the growing population of melanoma survivors is burdensome for both individuals and health services. Follow up is important since approximately 20% of patients with early-stage melanoma experience a recurrence and 4-8% develop a new primary; the risk of either is highest in the first 5 years. Achieving Self-directed Integrated Cancer Aftercare (ASICA) is a digital intervention to increase total-skin-self-examination (TSSE) by people treated for melanoma, with usual follow up.

METHODS

We aim to recruit 240 adults with a previous first-stage 0-2C primary cutaneous melanoma, from secondary care in North-East Scotland and the East of England. Participants will be randomised to receive the ASICA intervention (a tablet-based digital intervention to prompt and support TSSE) or control group (treatment as usual). Patient-reported and clinical data will be collected at baseline, including the modified Melanoma Worry Scale (MWS), the Hospital Anxiety and Depression Scale (HADs), the EuroQoL 5-dimension 5-level questionnaire (EQ-5D-5 L), and questions about TSSE practice, intentions, self-efficacy and planning. Participants will be followed up by postal questionnaire at 3, 6 and 12 months following randomization, along with a 12-month review of clinical data. The primary timepoint for outcome analyses will be12 months after randomisation.

DISCUSSION

If the ASICA intervention improves the practice of TSSE in those affected by melanoma, this may lead to improved psychological well-being and earlier detection of recurrent and new primary melanoma. This could impact both patients and National Health Service (NHS) resources. This study will determine if a full-scale randomised controlled trial can be undertaken in the UK NHS to provide the high-quality evidence needed to determine the effectiveness of the intervention. ASICA is a pilot study evaluating the effectiveness of the practice of digitally supported TSSE in those affected by melanoma.

TRIAL REGISTRATION

Clinical Trials.gov, NCT03328247 . Registered on 1 November 2017.

Outcome of the Lima periurethral constrictor in children and adolescents: a European perspective

PURPOSE

The Lima constrictor was described in 1996 as a less complex and less expensive alternative to the artificial urinary sphincter for use in cases of pediatric neuropathic sphincter incontinence. The device provides a fixed periurethral resistance which creates continence, yet allows urethral catheterization without the need to deflate the cuff. We report our multicenter experience, and continence, revision and erosion rates.

MATERIALS AND METHODS

We performed a retrospective review of 14 consecutive patients who underwent insertion of the periurethral constrictor (Silimed, Rio de Janeiro, Brazil) between 2005 and 2011. Data are presented as medians (range).

RESULTS

A total of 14 patients (13 male, 1 female) with spina bifida (10), sacral agenesis (3) and Hirschsprung disease (1) underwent insertion of the constrictor at a median age of 12 years (range 8 to 20). All patients were wet despite clean intermittent catheterization, medical therapy and/or previous surgery. Eleven patients underwent simultaneous bladder augmentation and/or Mitrofanoff formation. The constrictor was activated a median of 8 weeks (range 2 to 99) after the procedure in 11 patients whereas 3 became dry without activation. Complications occurred in 4 patients (29%), including spontaneous bladder perforation and constrictor erosion (1), tubing disconnection requiring revision (2) and wound infection (1). At a median of 23 months of followup (range 7 to 77) 13 patients were dry and 1 was damp. All patients performed urethral or Mitrofanoff clean intermittent catheterization. The continence rate with the device in situ was 92%.

CONCLUSIONS

At a median followup of 23 months the Lima constrictor provided a 92% continence rate with erosion and revision rates of 7% and 14%, respectively. Interim results suggest that the constrictor provides a safe and effective surgical option, particularly in patients who are unable to void to completion.

Improving the sensitivity of the time trade-off method: results of an experiment using chained TTO questions

We test a chained time trade-off (TTO) approach to estimating health gains from interventions by asking respondents to directly compare the "before" and "after" intervention health states in the TTO framework. Respondents with experience of both health states were used, thus minimising biases stemming from confusion surrounding health descriptions. We found that responses to these direct comparisons were much more likely to capture a perceived change in health status than the conventional approach to TTO estimation. This is an important finding because the TTO method is preferred by practitioners to many other direct generic methods of health status valuation both on empirical grounds and because it is based on the notion of opportunity cost, which is central to consumer theory, requiring respondents to express their preferences in terms of foregoing some of one good in exchange for more of another (unlike a rating scale).

Women's lay knowledge of cervical cancer/cervical screening: accounting for non-attendance at cervical screening clinics

An assessment of women's knowledge of cervical screening and cervical cancer was considered important as up to 92% of those dying from this form of cancer had never been tested. What were the reasons which determined their non-attendance? Issues to be addressed were reactions to invitation, women's knowledge of screening, and the possible factors which they envisaged as being associated with cervical cancer. Other issues to be considered were practical problems associated with attendance, and preference for the sex and professional status of the health professionals involved; 187 women in a general practitioner practice in Lothian, Scotland were targeted by questionnaire. As with other studies in this field 50% of those contacted were ineligible for a variety of reasons. Seventy-two women completed the questionnaire, providing a mix of qualitative and quantitative data. Although the majority of women felt the invitation to attend screening was clear and easy to understand, there was a lack of knowledge with regard to both the screening itself and the possible causes of cervical cancer. The main 'causes' were seen as higher sexual activity among those aged under 37 and smoking and a virus by those over 37. The majority of women showed preference for a female professional to take the smear. Practical problems of time and venue were not considered insurmountable. The main reasons cited for non-compliance were the fear and dislike of the test itself.

Mimosine arrests DNA synthesis at replication forks by inhibiting deoxyribonucleotide metabolism

Mimosine has been reported to specifically prevent initiation of DNA replication in the chromosomes of mammalian nuclei. To test this hypothesis, the effects of mimosine were examined in several DNA replication systems and compared with the effects of aphidicolin, a specific inhibitor of replicative DNA polymerases. Our results demonstrated that mimosine inhibits DNA synthesis in mitochondrial, nuclear, and simian virus 40 (SV40) genomes to a similar extent. Furthermore, mimosine and aphidicolin were indistinguishable in their ability to arrest SV40 replication forks and mammalian nuclear chromosomal replication forks. In contrast to aphidicolin, mimosine did not inhibit DNA replication in lysates of mammalian cells supplied with exogenous deoxyribonucleotide triphosphate precursors for DNA synthesis. Mimosine also had no effect on initiation or elongation of DNA replication in Xenopus eggs or egg extracts containing high levels of deoxyribonucleotide triphosphates. In parallel with its inhibitory effect on DNA synthesis in mammalian cells, mimosine altered deoxyribonucleotide triphosphate pools in a manner similar to that reported for another DNA replication inhibitor that affects deoxyribonucleotide metabolism, hydroxyurea. Taken together, these results show that mimosine inhibits DNA synthesis at the level of elongation of nascent chains by altering deoxyribonucleotide metabolism.

Development and application of a quantitative method of monitoring macroscopic cavitation in smooth surface carious lesions in vivo

Replica techniques have been widely used in dental research, but not previously applied to the in vivo study of carious cavities on free smooth surfaces. A replica method was developed using an epimine resin as the impression material, and a silicone elastomer as the casting material. Cavity areas were measured on the replicas using the Reflex microscope. The sources of method error were identified and quantified. The method was successfully incorporated into a conventional clinical trial and changes in cavity size with time were investigated.

The clinical behaviour of free smooth surface carious lesions monitored over 2 years in a group of Scottish children

As far as the authors are aware, no large-scale clinical studies of free smooth surface caries have been carried out in the past, although carious lesions on these surfaces can be diagnosed at an 'early' stage. In this study on a group of 2854 13-year-old children, caries affecting the free smooth surfaces (buccal and lingual) was found to be a common problem, with a total of 2917 lesions observed on molar teeth at the first examination. Most of the lesions involved no macroscopic loss of tooth contour. When the children were examined 2 years later, three-quarters of the lesions had either remained static or regressed. Free smooth surface lesions were more likely to develop initially, and more likely to progress, in individuals with poor oral hygiene. Free smooth surface caries experience showed a positive correlation with occlusal and approximal decay experience. The number of free smooth surface carious lesions can be used as a predictor of caries risk. Strategies for diagnosis and prevention are suggested for patients presenting with free smooth surface caries on molar teeth.

An evaluation of transcutaneous electrical nerve stimulation for pain relief in labour

The effectiveness of transcutaneous nerve stimulation (TENS) for pain relief in labour was evaluated by randomizing 280 patients in early labour into 2 groups. Inoperative sham machines were applied to patients in the control group and active units to those in the test group. Neither patients nor attending labour ward staff were aware of which group the patient was in. The intensity of low back pain and abdominal pain was assessed by the patient each hour on a visual analogue pain scale. Each patient served as her own control by switching off the machine for 2 contractions every hour and then recording the intensity of pain. The amount of conventional analgesia each patient received was recorded by labour ward staff. There was no difference in the intensity of pain recorded by each group. Nor was there any difference between the 2 groups in the change of pain experienced when the machine was switched off. Moreover there was no difference in the amount of other analgesia required. Some differences were found when those with little low back pain were excluded from the study. We conclude that TENS is ineffective as a routine method of pain relief in labour. It is likely to benefit only those with severe back pain and then only to a modest degree.

Effect of 12-O-tetradecanoyl-phorbol-13-acetate and 3-methylcholanthrene on the toxicity of nicotine applied to mouse skin

The effect of the tumor promoter, 12-O-tetradecanoyl-phorbol-13-acetate (TPA) and 3-methylcholanthrene (MCA) on the toxicity of nicotine and the content of this alkaloid in mouse skin has been determined following the application of these reagents to the skin. TPA or MCA was applied to mouse skin at time 0, and then at various time intervals thereafter, nicotine was applied to the skin. The content of this alkaloid (nicotine DNA ratio) remaining in the skin was then determined 1/2 h after its application. After the application of TPA, the nicotine DNA ratio of the skin decreased from 120 at 1.8 h to 80 at 18 h, increased sharply from 24 h, reaching a maximum of 165 at 72 h, and then decreased gradually. As the nicotine DNA ratio of the skin increased, the mortality rate of the mice also increased, reaching a maximum of over 40% at 48 and 72 h following the application of TPA. When MCA was applied to mouse skin in the same fashion and then nicotine, there was a decrease in the nicotine DNA ratio similar to that induced by TPA and nicotine followed by an average increase in the nicotine DNA ratio of 130 at 72, 96 and 120 h. The mortality rate of these mice was low. Finally, ethyl phenyl propiolate (EPP) was applied to mouse skin at time 0, and nicotine was applied 24, 48, 72, 96 and 120 h later. The mortality rate was also quite low at these times 1/2 h after application of nicotine (nicotine was not determined in the skin). TPA has induced some change in the skin 24, 48, 72 and 96 h after its application which resulted in an increase in the toxicity of nicotine to mice. Nicotine was not detected by the gas chromatographic method employed in the serum or plasma of nicotine-treated and TPA and nicotine-treated mice even though the mice showed acute reactions of nicotine toxicity and the skin surface contained ample amounts of this alkaloid.

Effect of the tumor promotor 12-O-tetradecanoylphorbol-13-acetate on the rate of disappearance of nicotine from mouse skin

The rate of disappearance of nicotine from mouse skin was increased by the presence of 12-O-tetradecanoylphorbol-13-acetate (TPA) during the first 2-hour period following the application of nicotine to mouse skin. The biological half-life (t1/2) for nicotine alone was 1.2-1.3 h whereas in the presence of TPA, t1/2 was 0.8 to 0.9 h. The disappearance of nicotine from mouse skin followed first-order kinetics over a period of 6 h whereas the loss of nicotine in the presence of TPA from mouse skin followed first-order kinetics for the first 2 h, then the nicotine level became fairly constant for the time period of 2-5 h. Benzo (alpha) pyrene did not affect the rate of disappearance of nicotine from mouse skin. Neither cotinine nor nicotine 1'-N oxide, metabolites of nicotine, was detected in mouse skin following the topical application of this alkaloid.

A distinctive antigen present in liver carcinomas induced by 3'-methyl-p-dimethylaminoazobenzene

Hepatocellular carcinomas and cholangiocarcinomas induced in rat liver by the administration of 3'-methyl-p-dimethyl-aminoazobenzene (3'-Me-DAB) were found to contain a carcinoma distinctive antigen by immunofluorescence, immunoelectrophoresis and immunodiffusion. This carcinoma distinctive antigen does not appear to be alpha-fetoprotein (AFP) or the preneoplastic antigen.

Detection of liver-bound metabolites of azocarcinogens by the use of anti-hapten antibodies

The presence of the azocompounds, p-dimethylaminoazobenzene and 3'-methyl-p-dimethylaminoazobenzene, and p-amino-N-acetyl-N-methylaniline (or their metabolites) bound to components of the liver cells of rats fed a single large dose of each compound has been detected using rabbit antibodies raised against the p-azo-N-acetyl-N-methylaniline hapten in the indirect fluorescent antibody technique. Binding of these antibodies was seen on liver sections from rats fed any one of these compounds. When the anti-p-azo-N-acetyl-N-methylaniline antiserum was absorbed with either liver sediments or cytosol fractions from rats fed p-amino-N-acetyl-N-methylaniline, the antibodies reacting with the liver-bound compounds were removed from the antiserum. Also, absorption of the antiserum with liver sediments or cytosol fractions of rats fed either one of the azocompounds selectively removed all of the antibodies reacting with the livers of rats fed that compound but did not remove other antibodies that were still capable of reacting with liver cells of rats fed the other azocompound or p-amino-N-acetyl-N-methylaniline. Thus this antiserum appears to contain several different anti-p-azo-N-acetyl-N-methylaniline antibodies with different structural requirements for reaction. Some can react with the azocompounds or certain of their metabolites, while others require more of the p-azo-N-acetyl-N-methylaniline structure for reaction. Some of the antibodies appear to react with liver-bound p-dimethylaminoazobenzene but not with liver-bound 3'-methyl-p-dimethylaminoazobenzene, while still others react with 3'-methyl-p-dimethylaminoazobenzene but not with p-dimethylaminoazobenzene.

Binding of the azocarcinogen 3'-methyl-p-dimethylaminoazobenzene to cellular components of normal rat liver and azocarcinogen-induced hepatomas

The location of binding sites for 3'-methyl-p-dimethylaminoazobenzene (3'-Me-DAB) or metabolites on components of rat liver cells and hepatoma cells in tumors induced by this carcinogen was determined at 2 stages during the induction of tumors in rats: (a) in normal liver immediately following the application of a massive dose of the azocarcinogen by intragastric feeding, and (b) in liver and tumor after hepatomas had developed following repeated exposures to the carcinogen by s.c. injections. Bound 3'-Me-DAB or metabolites were detected by the use of rabbit antisera directed against either p-azoazobenzene or p'-azo-p-dimethylaminoazobenzene in an indirect fluorescent antibody technique. Soon after massive intragastric doses of 3'-Me-DAB, the staining observed when the anti-p-azoazobenzene antiserum was used was principally on cytoplasmic components of liver cells with some staining of the intranuclear components. When the second antiserum, anti-p'-azo-p-dimethylaminoazobenzene antiserum, was used, the most intense fluorescent staining was on the nuclear membranes, although there was some cytoplasmic and intranuclear staining as well.

Respiratory effects in toluene diisocyanate manufacture: a multidisciplinary approach

A new plant manufacturing toluene diisocyanate (TDI) has provided a unique opportunity to investigate the effects of TDI vapor inhalation on respiratory health in a group of exposed workers who have been studied prior to the start of plant operation. In order to establish dose-response relationships and determine host factors, complete biologic monitoring, including pulmonary function and immunologic studies, has been performed concurrently with a comprehensive environmental monitoring program including continuous sampling for atmospheric concentrations of TDI. Study groups include workers with regular exposure to TDI in production jobs (83), workers with intermittent contact with this vapor, usually in maintenance (28), and a control group of workers employed outside the TDI area (55). This population is being followed for a period of 5 yr. The plant began operations in August 1973 with start-up procedures completed by the end of October. TDI spills occurred for numerous reasons, usually attributed to pump failure and resultant line blockage. Significant exposures also occurred in the drumming operation. The influence of these malfunctions is noted in the continuous monitoring data on atmospheric TDI concentrations which continue to reveal frequent excursions above the threshold limit value (TLV) of 0.02 ppm ceiling. These data are presented in relation to time and plant location. Although the first full year follow-up following initial exposure was not complete, certain preliminary clinical observations were made. A number of workers had episodes of acute respiratory symptoms related to single exposure to an irritant gas at work, usually either TDI or phosgene. It appears that two or three workers in the study population have become "clinically sensitized" to TDI and have been removed from regular TDI exposure. To date, the total number of workers who report the presence of recurring respiratory symptoms has not increased in comparison with the pre-exposure survey. Pulmonary function data after one full year of TDI exposure are not yet available. Pre- and post-shift ventilatory function studies do not indicate significant differences between the exposed and control groups. Selected individuals had carefully controlled inhalation challenge tests to monitored concentrations of TDI vapor under laboratory conditions. In workers suspected of having become "sensitized", immediate and/or late air flow obstruction was demonstrated and could be related to dose of inhaled TDI.

A technique for dynamic calibration of a continuous toluene diisocyanate monitor

A method was developed for generation of atmospheric concentrations of toluene dissocyanate at 0.005 to 0.08 parts per million. This paper describes an analytical methods for the calibration of a continuous 701 Monitor using a diffusion cell to generate constant concentrations of TDI.

The efficiency of protective hoods used by sandblasters to reduce silica dust exposure

Several types of respiratory protective hoods used by sandblasters were investigated in two steel fabrication yards. MSA Gravimetric Dust Samplers were used to collect respirable dust samples outside and inside hoods during sandblasting. Colorimetric and x-ray diffraction techniques were applied to the samples for free-silica determination. The majority of the sandblasters, who wore various types of air-supplied hoods, were exposed to an average level of silica dust several times higher than the TLV. Sandblasters wearing non-air-supplied hoods were at the greatest risk. Modern well maintained and properly worn air-supplied hoods offered fair protection during sandblasting periods, but the concentration of suspended respirable dust in ambient air during non-blasting intervals exceeded the TLV by several times.