Enhancing Specialist Training in Radiation Oncology through the Implementation of Structured Radiotherapy Contouring Workshops

PURPOSE/OBJECTIVE(S)

Contouring tumor volumes and organs at risk is a key component of Radiation Oncology specialist training. As trainees rotate through different tumor sites, they are expected to develop proficiency in contouring skills relevant to their year of training. These skills have historically been acquired in an unstructured manner during supervised clinical work. However, trainees often struggle to learn these skills due to variability in practice and approach amongst senior colleagues. Research has shown that contouring workshops improve the standardization of contouring and can be an effective way of enhancing the learning experience through interaction, instant feedback and reflection. We present our experience of implementing structured contouring workshops and the feedback received from the trainees.

MATERIALS/METHODS

Eight contouring workshops were held in our institution over a period of 3 years between 2019 and 2022. These included Head & Neck (3), Prostate (1), SABR Lung (2), Breast (1), and Esophagus (1). Six were held in-person pre-COVID and two in a virtual format during the pandemic. Each workshop was 2 hours long and attended by trainees with varying levels of contouring experience. All the workshops were facilitated by a consultant radiation oncologist and a clinical tutor and followed a similar format consisting of a brief tutorial on the tumor site, followed by a contouring demonstration on an anonymized case on an Eclipse planning platform referencing published contouring atlases. Each of the trainees had access to a copy of the same case throughout the workshop and their contours were then reviewed both individually and collectively. A key component of the workshops was instant feedback, as trainees could compare their contours to that of the tutors and discuss any differences. Feedback on the contouring workshop was then collected through a post workshop questionnaire.

RESULTS

The workshops were attended by an average of 12 trainees (range 10 to 14). Regardless of their year of training, all trainees rated the content and format of the workshops highly and stated they were relevant to their daily practice. Their subjective level of confidence in contouring in that specific tumor site improved significantly, going from an average of 5.6 out of 10 (range of 4 to 7) before the workshop to 8.7 (range of 8 to 9) after the 8 workshops. All the workshops were conducted at no extra cost as they were held using our existing planning software.

CONCLUSION

The trainees indicated that the workshops were of definite educational benefit and strongly supported incorporating this approach to teaching contouring skills into the curriculum. Based on this feedback, these contouring workshops have been integrated into the recently revised higher specialist training curriculum on a more structured basis. This will ensure that trainees will continue to develop progressive expertise in contouring skills in keeping with best international practice as they advance through their training scheme.

Decolonising the commissioning of Indigenous health and wellbeing program evaluations in Australia

Background

Significant financial investments have been made to improve the life expectancy gap between Indigenous people and other Australians over the last 10 years. Despite the investment, few evaluations have been commissioned to assess program effectiveness. Indigenous leaders have been calling for a more active role in the commissioning of Indigenous program evaluations. This project aims to identify how government and non-government commissioning practices can better support Indigenous engagement and leadership in the evaluation of health and wellbeing programs in Australia. This presentation reports on the different commissioning models that support Indigenous program evaluations, from the perspectives of commissioners, evaluators and program providers.

Methods

Semi-structured interviews were conducted with 20 Indigenous and non-Indigenous commissioners, evaluators and program providers. A mixed coding procedure was used. Interviews were coded using deductively derived codes reflecting best practice principles in Indigenous evaluation and inductively derived codes from participant stories. Interviews were analysed using NVivo qualitative software. A collaborative group-based approach to data analysis was used guided by Indigenous Standpoint Theory.

Results

The commissioning of Indigenous-specific program evaluations in Australia reflects top-down, participatory, co-design and Indigenous-led approaches. Top-down approaches were considered 'extractive' and had limited or token Indigenous input. Indigenous models were more strongly aligned with best practice and reflected authentic Indigenous engagement. There was agreement across the stakeholder groups on the value of Indigenous engagement in the commissioning process. The presentation will elaborate on the different approaches, their characteristics, strengths/ limitations.

Conclusions

Diverse approaches to commissioning are used and reflect different levels of Indigenous engagement and leadership.

Key messages

In the commissioning of Indigenous evaluations there needs to be governance structures to support Indigenous engagement. In the commissioning of Indigenous evaluations there needs to be greater input by Indigenous people.

Physical illnesses associated with childhood homelessness - a literature review

Background and aims

Childhood homelessness is a growing concern in Ireland creating a Pediatric subpopulation at increased risk of physical illnesses, many with life-long consequences. Our aim was to identify and categorize the physical morbidities prevalent in homeless children.

Methods

A review of the English-language literature on physical morbidities affecting homeless children (defined as < 18 years of age), published from 1999-2019 was conducted. A total of 1194 articles were identified, 33 articles of which met our inclusion criteria.

Results

Respiratory issues were the most commonly cited illnesses affecting homeless children; including asthma, upper respiratory tract infections, and chronic cough. Homeless children were described as being at increased risk of contracting infectious diseases, many studies placing emphasis on STI and HIV/AIDS transmission. Dermatologic concerns comprised of scabies and head lice infestation, dermatitis, and abrasions. Malnutrition manifested as a range of physical morbidities; including childhood obesity, iron deficiency anemia, and stunted growth. Studies found a higher prevalence of poor dental and ocular health in this population as well. Many articles also commented on the risk factors predisposing homeless children to these physical health concerns, which can broadly be categorized as limited access to health care, poor living conditions, and lack of education.

Conclusions

This literature review summarized the physical illnesses prevalent among homeless children and the contributing factors leading to them. Gaps in the literature were also identified, and included a dearth of studies focusing on younger children compared to adolescents. We believe that the current issue of child homelessness is socially and medically unacceptable and that homelessness occurring today will be one of the scandals of the next generation. Further research into prevention and intervention programs for this vulnerable population is urgently needed.

Key messages

This literature review shows that homeless children are at an increased risk of several physical morbidities and identified the common themes among them. Based on this literature review, it is recommended that more research be done into developing appropriate intervention and prevention strategies to help this vulnerable population.

Trends in Mental Health Presentations to a Paediatric Emergency Department

Aims This study aimed to analyse trends in mental health presentations to the Emergency Department (ED), which anecdotally had increased over the past decade. Methods The ED's electronic 'Symphony' system was used to identify the annual number of presentations categorised as having a mental health complaint from 2006-2017. A detailed analysis was performed on presentations over a one-year period. Results The number of presentations increased from 69 in 2006 to a peak of 432 in 2016 (526% increase). The overall admission rate was 33.3%(n=99), while 52.5%(n=156) of presentations occurred outside of standard working hours. Similar increases were documented by other ED's worldwide, and the WHO estimate that neuropsychiatric disorders will become one of the top five causes of morbidity, mortality and disability among children by 2020. Conclusion With the number of mental health presentations dramatically increasing, carefully designed and integrated strategies are required to pro-actively tackle this growing epidemic.

Post-traumatic pelvic extramedullary haemopoetic tissue causing lower urinary tract symptoms

Extramedullary haemopoiesis (EMH) is the abnormal development and growth of haemopoietic tissue outside the bone marrow. It is usually asymptomatic and occurs in the presence of myelodysplastic syndromes. In this report, we describe the first post-traumatic EMH presenting with lower urinary tract symptoms.

Has the “Equal Environments” Assumption Been Tested in Twin Studies?

Arecurring criticism of the twin method for quantifying genetic and environmental components of human differences is the necessity of the so-called “equal environments assumption” (EEA) (i.e., that monozygotic and dizygotic twins experience equally correlated environments). It has been proposed to test the EEA by stratifying twin correlations by indices of the amount of shared environment. However, relevant environments may also be influenced by genetic differences. We present a model for the role of genetic factors in niche selection by twins that may account for variation in indices of the shared twin environment (e.g., contact between members of twin pairs). Simulations reveal that stratification of twin correlations by amount of contact can yield spurious evidence of large shared environmental effects in some strata and even give false indications of genotype x environment interaction. The stratification approach to testing the equal environments assumption may be misleading and the results of such tests may actually be consistent with a simpler theory of the role of genetic factors in niche selection.

Phenotypic and Genetic Analyses of a Short Measure of Psychosis-proneness in a Large-scale Australian Twin Study

Previous genetic analyses of psychosis proneness have been limited by their small sample size. For the purposes of large-scale screening, a 12-item questionnaire was developed through a two-stage process of reduction from the full Chapman and Chapman scales. 3685 individuals (including 1438 complete twin pairs) aged 18–25 years and enrolled in the volunteer Australian Twin Registry returned a mail questionnaire which included this psychosis proneness scale and the Eysenck Personality Questionnaire. Despite the brevity of the questionnaire, item and factor analysis identified four unambiguous and essentially uncorrelated scales. There were (1) Perceptual Aberration – Magical Ideation; (2) Hypomania – Impulsivity/Nonconformity; (3) Social Anhedonia and (4) Physical Anhedonia. Model-fitting analyses showed additive genetic and specific environmental factors were sufficient for three of the four scales, with the Social Anhedonia scale requiring also a parameter for genetic dominance. There was no evidence for the previously hypothesised sex differences in the genetic determination of psychosis-proneness. The potential value of multivariate genetic analysis to examine the relationship between these four scales and dimensions of personality is discussed. The growing body of longitudinal evidence on psychosis-proneness suggests the value of incorporating this brief measure into developmental twin studies.

Not for resuscitation: more harm than good?

Advance directives such as do not resuscitation orders are becoming more common place in Irish Hospitals. A questionnaire was completed by all 44 interns working in St James' Hospital in January 2010 and by 49/50 Senior House Officers in June 2010.3/44 of interns (6%) and 5/49 (10%) SHO believe that there is no difference between palliative patients and NFR patients. 41/44 interns (93%) and 40/49 of SHOs (81%) believe that attitudes of treating staff change once a patient is listed as NFR. 14/44 of Interns (32%) and 15/49 SHOs (31%) think that nursing staff are reluctant to request a review when these patients become unwell. They were asked if someone listed as NFR became unwell, what would be an appropriate intervention using a grading system. Interns and SHOs appeared to be reluctant to make basic interventions such as blood tests, blood cultures or even oral antibiotics in this sub group of patients. This questionnaire demonstrates that NFR patients are potentially treated differently and possibly under treated by Junior Doctors. The question remains how to balance the best interests of the patient. If NFR status results in under treatment does it cause more harm than good.

Chest pain and hypertension in an 18 year old girl

We describe the case of an 18 year old lady who presented with chest pain, breathlessness and hypertension. The initial diagnosis of renal artery stenosis, while correct, was incomplete. The finding of a reduced right radial pulse suggested the possibility of a large vessel vasculitis. She was also found to have critical coronary artery disease that required stenting and aortic incompetence. Renal artery stenting was also performed. Additional investigations confirmed Takayasu's arteritis. With immunosuppressive therapy and stenting she is now well and normotensive but may require aortic valve replacement in the future.

Exploring spatiotemporal organization of SCN circuits

Suprachiasmatic nucleus (SCN) neuroanatomy has been a subject of intense interest since the discovery of the SCN's function as a brain clock and subsequent studies revealing substantial heterogeneity of its component neurons. Understanding the network organization of the SCN has become increasingly relevant in the context of studies showing that its functional circuitry, evident in the spatial and temporal expression of clock genes, can be reorganized by inputs from the internal and external environment. Although multiple mechanisms have been proposed for coupling among SCN neurons, relatively little is known of the precise pattern of SCN circuitry. To explore SCN networks, we examine responses of the SCN to various photic conditions, using in vivo and in vitro studies with associated mathematical modeling to study spatiotemporal changes in SCN activity. We find an orderly and reproducible spatiotemporal pattern of oscillatory gene expression in the SCN, which requires the presence of the ventrolateral core region. Without the SCN core region, behavioral rhythmicity is abolished in vivo, whereas low-amplitude rhythmicity can be detected in SCN slices in vitro, but with loss of normal topographic organization. These studies reveal SCN circuit properties required to signal daily time.

Preemptive retransplantation for BK virus nephropathy: successful outcome despite active viremia

BK virus nephropathy (BKVN) is now recognized as a major cause of renal allograft loss. Recent reports suggest that retransplantation in patients with graft loss due to BKVN is safe after return to dialysis. Since early transplantation is associated with improved outcomes, it would be advantageous if this procedure could be performed prior to ultimate graft loss. However, little data are available regarding the safety of this approach during active viremia. In this report, we describe successful preemptive retransplantation with simultaneous allograft nephrectomy in two patients with active BKVN and viremia at the time of surgery. With 21- and 12-month follow-up, respectively, both patients have stable allograft function and no evidence for active viral replication. We conclude that preemptive retransplantation can be considered in patients with failing allografts due to BKVN.

Application of Bayesian Inference using Gibbs Sampling to Item-Response Theory Modeling of Multi-Symptom Genetic Data

Several "genetic" item-response theory (IRT) models are fitted to the responses of 1086 adolescent female twins to the 33 multi-category item Mood and Feeling Questionnaire relating to depressive symptomatology in adolescence. A Markov-chain Monte Carlo (MCMC) algorithm is used within a Bayesian framework for inference using Gibbs sampling, implemented in the program WinBUGS 1.4. The final model incorporated separate genetic and non-shared environmental traits ("A and E") and item-specific genetic effects. Simpler models gave markedly poorer fit to the observations judged by the deviance information criterion (DIC). The common genetic factor showed major loadings on melancholic items, while the environmental factor loaded most highly on items relating to self-deprecation. The MCMC approach provides a convenient and flexible alternative to Maximum Likelihood for estimating the parameters of IRT models for relatively large numbers of items in a genetic context. Additional benefits of the IRT approach are discussed including the estimation of latent trait scores, including genetic factor scores, and their sampling errors.

Genetic and Environmental Influences on the Relative Timing of Pubertal Change

A multicategory item-response theory model was developed to characterize developmental changes in three items relating to the assessment of puberty in adolescent twin girls and boys. The model allowed for the fixed effects of age on probability of endorsing the responses and for the random effects of individual differences on the timing of pubertal changes relative to chronological age. In girls, the model was applied three-wave data on twin pairs (N = 414 female monozygotic [MZ] and 197 female dizygotic [DZ] pairs) and female twins from boy-girl pairs (N = 300 twins) from the Virginia Twin Study of Adolescent Behavioral Development. In boys, the data comprised 318 MZ and 185 DZ pairs and 297 male twins from boy-girl pairs. A total of 3172 and 2790 individual twin assessments were available in girls and boys, respectively, spanning ages 8-17 years. The availability of twin data allows the contributions of genes, the shared environment and individual unique environmental experiences to be resolved in the relative timing of pubertal changes. Parameters of the mixed model including fixed effects of age and random effects of genes and environment were estimated by Markov Chain Monte Carlo simulations using the BUGS algorithm for Gibbs sampling. The estimated standard deviation of random differences in the timing of puberty relative to age was 0.96 years in girls and 1.01 years in boys. The estimated intraclass correlations for the relative timing of pubertal changes were 0.99 +/-0.01 in MZ girls, 0.52 +/-0.02 in DZ girls, 0.88 +/-0.04 in MZ boys and 0.44+/-0.02 in DZ boys, indicating a very large contribution of genetic factors to the relative timing of pubertal change in both sexes. Additive genetic factors account for an estimated 96.3+/-3.3% of the total variance in random effects in girls and 88.0+/-3.6% in boys. Shared environmental influences account for 3.6+/-3.4% in girls and 0% in boys. In girls, nonshared environmental effects explain 0.1+/-0.1% of the total residual variance. The comparable figure in boys is 12.0+/-3.6%.

Informant disagreement for separation anxiety disorder

OBJECTIVE

To characterize informant disagreement for separation anxiety disorder (SAD).

METHOD

The sample comprised 2,779 8- to 17-year-old twins from a community-based registry. Children and their parents completed a personal interview about the child's psychiatric history. Parents completed a personal interview about their own psychiatric history and a questionnaire about their marital relationship.

RESULTS

Informant agreement for SAD ranged between chance and extremely poor. Most cases of SAD were diagnosed by interview with only one informant. SAD diagnosed only by child interview was associated with an increased odds of father-rated oppositional defiant disorder, and vice versa. SAD diagnosed only by parent interview was predicted by the parental informant's history of antisocial personality disorder. SAD diagnosed only by paternal interview was also predicted by mother-rated marital conflict and dissatisfaction.

CONCLUSIONS

Parents and children rarely agree about the presence of any level of child separation anxiety. A symptom "or-rule" mostly indexes diagnoses based on interview with only one informant, but the relative validity of such diagnoses remains unclear.

Improvement in efficacy of chemoradiotherapy by addition of an antiangiogenic agent in a murine tumor model

BACKGROUND

Chemoradiotherapy improves survival for some cancer patients. Methods of enhancing treatment response would further enhance survival rates. The effect of the addition of an antiangiogenic agent to a chemoradiotherapy regime has not previously been examined.

MATERIALS AND METHODS

C57B16 mice were inoculated with 1 x 10(6) Lewis lung carcinoma cells into the flank and randomized to 1 of 10 treatment groups when tumor volume approached 1000 mm(3). Animals received combinations of standard doses of intraperitoneal cisplatin, 5-fluorouracil, and the antiangiogenic agent genistein, together with 10 or 20 Gy of external beam radiotherapy. Animals were sacrificed at day 6 when tumor volume, microvessel density, and serum VEGF were determined.

RESULTS

Mean (SEM) tumor volume in the chemoradiotherapy group was 762 (212) mm(3) versus 565 (79) mm(3) in the chemoradiotherapy plus genistein group (P = 0.04, unpaired t-test). The addition of genistein produced a significant reduction in tumor microvessel density (P = 0.01) as well as serum VEGF levels (P < 0.05) compared to those animals receiving chemoradiation alone.

CONCLUSIONS

This study provides proof of principle that chemoradiation can be enhanced by the addition of an antiangiogenic agent to the regime and suggests that further examination of such regimes is warranted.

Has the "Equal Environments" Assumption Been Tested in Twin Studies?

A recurring criticism of the twin method for quantifying genetic and environmental components of human differences is the necessity of the so-called "equal environments assumption" (EEA) (i.e., that monozygotic and dizygotic twins experience equally correlated environments). It has been proposed to test the EEA by stratifying twin correlations by indices of the amount of shared environment. However, relevant environments may also be influenced by genetic differences. We present a model for the role of genetic factors in niche selection by twins that may account for variation in indices of the shared twin environment (e.g., contact between members of twin pairs). Simulations reveal that stratification of twin correlations by amount of contact can yield spurious evidence of large shared environmental effects in some strata and even give false indications of genotype x environment interaction. The stratification approach to testing the equal environments assumption may be misleading and the results of such tests may actually be consistent with a simpler theory of the role of genetic factors in niche selection.

Effect of neoadjuvant chemoradiotherapy on angiogenesis in oesophageal cancer

Background

Vascular endothelial growth factor (VEGF) levels are raised in the serum of patients with oesophageal carcinoma. The aim of this study was to evaluate the tumour microvasculature and the role of tumour-associated macrophages in VEGF production after neoadjuvant chemoradiotherapy and surgery for oesophageal cancer.

Methods

Sections from 92 consecutively resected oesophageal tumours were stained for VEGF, von Willebrand factor and CD68. Twenty-seven patients received preoperative chemoradiation and 65 underwent surgical excision alone. The cellular source of VEGF was determined by parallel-section staining. Microvessel density and macrophage count were determined for each tumour by means of image analysis software.

Results

There were no significant differences between the two groups in age, sex or tumour type. Local downstaging of disease was evident in most specimens of tumours that had received preoperative chemoradiation. All tumours stained positive for VEGF, including those demonstrating a complete pathological response. Staining of parallel sections confirmed macrophages as the principal source of VEGF. Mean microvessel density was 6·4 per high-power field (h.p.f.) in tumours that received preoperative chemoradiation compared with 5·3 per h.p.f. in those treated by surgery alone (P = 0·130). A significant increase in tumour-associated macrophage infiltration was noted in tumours treated with neoadjuvant chemoradiation (22·1 per h.p.f.) compared with those treated by surgery alone (14·3 per h.p.f.) (P = 0·042).

Conclusion

Preoperative chemoradiation had little effect on the local angiogenic profile of the tumour in patients with oesophageal cancer. Tumour-infiltrating macrophages seem to be the source of persistent VEGF production after chemoradiotherapy and might explain the raised serum levels. Addition of an antiangiogenic agent to this regimen may be worthwhile in patients with oesophageal carcinoma.

Serotonergic system and attention deficit hyperactivity disorder (ADHD): a potential susceptibility locus at the 5-HT(1B) receptor gene in 273 nuclear families from a multi-centre sample

Attention deficit hyperactivity disorder (ADHD) is a highly heritable and heterogeneous disorder, which usually becomes apparent during the first few years of childhood. Imbalance in dopamine neurotransmission has been suggested as a factor predisposing to ADHD. However, evidence has suggested an interaction between dopamine and serotonin systems in the pathophysiology of the disorder. Studies using selective agonists of the different 5-HT receptors microinjected into selected brain structures have shown a positive modulating effect on the functional activities of the mesotelencephalic dopaminergic system. This suggests that some of the genetic predisposition to ADHD might be due to DNA variation at serotonin system genes. In this study, we investigated polymorphisms in HTR(1B) and HTR(2A) (which encode the serotonin receptors 5-HT(1B) and 5-HT(2A) respectively) in a European ADHD sample. Using haplotype based haplotype relative risk (HHRR) and transmission disequilibrium test (TDT) analyses, we observed significant preferential transmission of the allele 861G of the HTR(1B) in the total sample (for HHRR; chi(2) = 7.4, P = 0.0065 and TDT; (chi(2) = 6.4, P = 0.014). Analysis of HTR(2A) failed to reveal evidence of association or linkage between the His452Tyr polymorphism and ADHD in the total sample. However, a significantly increased transmission of the allele 452His was observed in the Irish sample alone (chi(2) = 4.9, P = 0.026). These preliminary data suggest an important role for the serotonin system in the development of ADHD. Further studies, preferentially including different ethnic groups are required to substantiate these findings.

Value of coronary stenotic flow velocity acceleration in prediction of angiographic restenosis following balloon angioplasty

INTRODUCTION

Quantitative angiographic assessment after balloon angioplasty is a poor predictor of immediate and long-term outcome. However, the measurement of blood flow velocity during angioplasty has been proved clinically useful.

AIMS

To analyse the value of the maximal stenotic flow velocity and the presence of stenotic flow velocity acceleration (aSV) for the long-term outcome after balloon angioplasty.

METHODS AND RESULTS

Patients undergoing single lesion angioplasty within the DEBATE trial were included. aSV was defined as acceleration in the stenotic coronary flow velocity >50% baseline velocity assessed at a reference site of the target vessel. After balloon angioplasty diameter stenosis, minimal lumen diameter (MLD) and coronary flow velocity reserve were similar between the aSV (n=54) and non-aSV group (n=125). At follow-up, the aSV group had a higher restenosis rate (52% vs 30%, P=0.006) The presence of aSV was the strongest independent predictor of restenosis (OR 3.08, 95% CI 1.35 to 7.05, P=0.008). The best predictive cut-off value of SV was 101cm.s(-1) (sensitivity of 46%, specificity of 81%, positive predictive value of 85% and a negative predictive value of 58%).

CONCLUSION

Following angioplasty, SV appears to be exquisitely sensitive to the changes experienced at the treated area without depending on the status of the microcirculation.

Left main coronary artery dissection during percutaneous coronary intervention treated by stenting

AIM

Outcome after stenting for iatrogenic left main coronary artery (LMCA) dissection during percutaneous coronary intervention (PCI).

METHODS

From our database all patients with a PCI complicated by an LMCA dissection, between 1996 and 2001, were selected and medical records were reviewed.

RESULTS

Eighteen patients out of 7199 (0.25%) were found with an LMCA dissection during a PCI for unstable (n=14) and stable angina (n=4). Antegrade dissections were caused by guiding catheters (n=6). Retrograde dissections were caused by stent implantation (n=7) and balloon angioplasty (n=5). All patients were treated by stent implantation in the LMCA. Three patients died (17%) within ten days of the procedure. Emergency surgery was performed in four patients (22%) because of persistent ischaemia due to low coronary flow. One patient was operated one day later because of unstable angina and a failed attempt to recanalise the left descending coronary artery. The other ten patients (56%) with a stent in the LMCA were free of cardiac complaints after a follow-up period of 3.0 years (range 1.9-5.0). Cardiac catheterisation in six patients between three and eight months did not show stenosis of the LMCA stent.

CONCLUSION

LMCA dissection during a PCI can be treated by stent implantation, especially when the dissection is limited to the LMCA. When flow cannot be restored adequately, resulting in ischaemia and haemodynamic instability, LMCA stenting may serve as a bridge to emergency CABG.

Cyclo-oxygenase inhibition reduces tumour growth and metastasis in an orthotopic model of breast cancer

The effect of selective and non-selective cyclo-oxygenase inhibition on tumour growth and metastasis in an orthotopic model of breast cancer was investigated. 4T1 mammary adenocarcinoma cells were injected into the mammary fat pad of female BALB/c mice. When tumours reached a mean tumour diameter of 8.4+/-0.4 mm, mice were randomised into three groups (n=6 per group) and received daily intraperitoneal injections of the selective cyclo-oxygenase-2 inhibitor, SC-236, the non selective cyclo-oxygenase inhibitor, Indomethacin, or drug vehicle. Tumour diameter was recorded on alternate days. From 8 days after initiation of treatment, tumour diameter in animals treated with either SC-236 or indomethacin was significantly reduced relative to controls. Both primary tumour weight and the number of lung metastases were significantly reduced in the SC-236 and indomethacin treated mice. Microvessel density was reduced and tumor cell apoptosis increased in the primary tumour of mice treated with either the selective or non-selective cyclo-oxygenase inhibitor. In vitro, cyclo-oxygenase inhibition decreased vascular endothelial growth factor production and increased apoptosis of tumour cells. Our results suggest that cyclo-oxygenase inhibitors will be of value in the treatment of both primary and metastatic breast cancer.

Routine intracoronary beta-irradiation. Acute and one year outcome in patients at high risk for recurrence of stenosis

AIMS

Intracoronary radiation is a promising therapy potentially reducing restenosis following catheter-based interventions. Currently, only limited data on this treatment are available. The feasibility and outcome in daily routine practice, however, is unknown.

METHODS AND RESULTS

In 100 consecutive patients, intracoronary beta-radiation was performed with a (90)Strontium system (Novoste Beta-Cathtrade mark) following angioplasty. Predominantly complex (73% type B2 and C) and long lesions (length 24.3+/-15.3 mm) were included (37% de novo, 19% restenotic and 44% in-stent restenotic lesions). Radiation success was 100%. Mean prescribed dose was 19.8+/-2.5 Gy. A pullback procedure was performed in 19% lesions. Geographic miss occurred in 8% lesions. Periprocedural thrombus formation occurred in four lesions, dissection in nine lesions. During hospital stay, no death, acute myocardial infarction, or repeat revascularization was observed. Major adverse cardiac events occurred predominantly between 6 and 12 months after the index procedure with major adverse cardiac event-free survival of 66% at 12 months (one death, 10 Q-wave myocardial infarctions, 23 target vessel revascularizations; ranked for worst event).

CONCLUSION

Routine catheter-based intracoronary beta-radiation therapy after angioplasty is safe and feasible with a high acute procedural success. The clinical 1-year follow-up showed delayed occurrence of major adverse cardiac events between 6 and 12 months after the index procedure.

Immune function, telomerase, and angiogenesis in patients with primary, operable nonsmall cell lung carcinoma: tumor size and lymph node status remain the most important prognostic features

BACKGROUND

Lung carcinoma usually is advanced at the time of presentation and frequently shows metastatic spread. In recent times, prognostic factors such as c-erbB-2 in patients with breast carcinoma have provided useful information and beneficial therapeutic targets. The objective of this study was to evaluate angiogenesis, immune function, and telomerase expression in patients with nonsmall cell lung carcinoma (NSCLC) to determine their prognostic significance.

METHODS

Immunohistochemistry was used to evaluate the expression of human telomerase reverse transcriptase (hTERT; n = 115 patients), interleukin-2r (IL-2r; n = 40 patients), microvessel density (MVD; n = 81 patients), and vascular endothelial growth factor (VEGF; n = 61 patients). Three-year survival follow-up information was available for most patients, and a comprehensive review of clinicopathologic features was carried out.

RESULTS

Fifty percent of tumors showed nuclear staining for hTERT, 55% of tumors showed some degree of lymphocyte IL-2r expression, 33% of tumors were recorded with an MVD that was higher than average, and VEGF staining was detected in 85% of tumors. None of the parameters measured had an impact on survival. hTERT expression was correlated with lymph node status. Lymph node status and tumor size were identified as independent prognostic factors.

CONCLUSIONS

This study failed to identify a marker of prognosis for patients with NSCLC other than tumor size and lymph node status in this population. Telomerase expression was associated with metastases, raising the possibility that this enzyme is involved in the metastatic process. Tumor cell VEGF expression was identified frequently: This growth factor may have potential as a target for antiangiogenic therapy. Lung carcinoma typically is the result of large numbers of mutations. Further understanding of the biologic implications of these mutations will lead to the development of effective prognostic markers and treatments for patients with NSCLC.

Daytime sleepiness is associated with 3-year incident dementia and cognitive decline in older Japanese-American men

OBJECTIVES

To assess the longitudinal association between sleep disturbances (insomnia and daytime sleepiness) and incidence of dementia and cognitive decline in older men.

DESIGN

Community-based longitudinal cohort study.

SETTING

The Honolulu-Asia Aging Study of dementia that is linked to the Honolulu Heart Program's fourth examination, conducted 1991-1993, and the 3-year follow-up fifth examination, conducted 1994-1996.

PARTICIPANTS

Two thousand three hundred forty-six Japanese-American men age 71 to 93 years who screened negative for prevalent dementia at baseline and were screened again for dementia incidence in a 3-year follow-up examination.

MEASUREMENTS

Baseline self-reports of trouble falling asleep or early morning awakening (insomnia) and being sleepy during the day (daytime sleepiness); Cognitive Abilities Screening Instrument (CASI) scores from baseline and followup; clinical diagnosis of incident dementia; and other baseline measures including age, years of education, body mass index, depressive symptoms, and history of hypertension, heart disease, diabetes mellitus, asthma, and use of benzodiazepines.

RESULTS

After adjusting for age and other factors, persons reporting excessive daytime sleepiness at baseline (8%) were twice as likely to be diagnosed with incident dementia than were those not reporting daytime sleepiness (odds ratio (OR)=2.19, 95% confidence interval (CI)=1.37-3.50) and about 40% more likely to have >or=9 point drop in their CASI score between examinations (OR=1.44, 95% CI=1.01-2.08). In contrast, insomnia was not associated with cognitive decline or incidence of dementia.

CONCLUSIONS

Daytime sleepiness in older adults may be an early indicator of decline in cognitive functioning and onset of dementia.