Improvement in Dysphagia Outcomes Following Clinical Target Volume Reduction in the De-ESCALaTE Study

AIMS

The De-ESCALaTE study showed an overall survival advantage for the administration of synchronous cisplatin chemotherapy with radiotherapy in low-risk oropharyngeal cancer when compared with synchronous cetuximab. During the trial, a radiotherapy quality assurance protocol amendment permitted centres to swap from the original radiotherapy contouring protocol (incorporating the whole oropharynx into the high-dose clinical target volume (CTV); anatomical protocol) to a protocol that incorporated the gross tumour volume with a 10 mm margin into the CTV (volumetric protocol). The purpose of this study was to examine both toxicity and tumour control related to this protocol amendment.

MATERIALS AND METHODS

Overall survival and recurrence at 2 years were used to compare tumour control in the two contouring cohorts. For toxicity, the cohorts were compared by both the number of severe (grades 3-5) and all grades acute and late toxicities. In addition, quality of life and swallowing were compared using EORTC-C30 and MD Anderson Dysphagia Inventory, respectively.

RESULTS

Of 327 patients included in this study, 185 were contoured according to the anatomical protocol and 142 by the volumetric protocol. The two cohorts were well balanced, with the exception of significantly more patients in the anatomical cohort undergoing prophylactic feeding tube insertion (P < 0.001). With a minimum of 2 years of follow-up there was no significant difference in overall survival or recurrence between the two contouring protocols. Similarly, there was no significant difference in the rate of reported severe or all grades acute or late toxicity and no sustained significant difference in quality of life. However, there was a significant difference in favour of volumetric contouring in several domains of the MD Anderson Dysphagia Inventory questionnaire at 1 year, which persisted to 2 years in the dysphagia functional (P = 0.002), dysphagia physical (P = 0.009) and dysphagia overall function (P = 0.008) domains.

CONCLUSION

In the context of the unplanned post-hoc analysis of a randomised trial, measurable improvement in long-term dysphagia has been shown following a reduction in the CTV. Further reductions in the CTV should be subject to similar scrutiny within the confines of a prospective study.

Research-intensive cancer care in the NHS in the UK

In the late 1990 s, in response to poor national cancer survival figures, government monies were invested to enhance recruitment to clinical cancer research. Commencing with England in 2001 and then rolling out across all four countries, a network of clinical cancer research infrastructure was created, the new staff being linked to existing clinical care structures including multi-disciplinary teams. In parallel, a UK-wide co-ordination of cancer research funders driven by the 'virtual' National Cancer Research Institute, combined to create a 'whole-system approach' linking research funders, researchers and NHS clinicians all working to the same ends. Over the next 10 years, recruitment to clinical trials and other well-designed studies, increased 4-fold, reaching 17% of the incident cancer population, the highest national rate world-wide. The additional resources led to more studies opened, and more patients recruited across the country, for all types of cancers and irrespective of additional clinical research staff in some hospitals. In 2006, a co-ordinated decision was made to increasingly focus on randomized trials, leading to increased recruitment, without any fall-off in accrual to non-randomized and observational studies. The National Cancer Research Network has supported large successful trials which are changing clinical practice in many cancers.

Strengthening clinical cancer research in the United Kingdom

BACKGROUND

In 1999, 270,000 cases of cancer were registered in the United Kingdom, placing a large burden on the NHS. Cancer outcome data in 1999 suggested that UK survival rates were poorer than most other European countries. In the same year, a Department of Health review noted that clinical trials accrual was poor (<3.5% of incident cases) and hypothesised that increasing research activity might improve outcomes and reduce the variability of outcomes across England. Thus, the National Cancer Research Network (NCRN) was established to increase participation in cancer clinical research.

METHODS

The NCRN was established in 2001 to provide a robust infrastructure for cancer clinical research and improvements in patient care. Remit of NCRN is to coordinate, support and deliver cancer clinical research through the provision of research support staff across England. The NCRN works closely with similar networks in Scotland, Wales and the Northern Ireland. A key aim of NCRN is to improve the speed of research and this was also assessed by comparing the speed of study delivery of a subset of cancer studies opening before and after NCRN was established.

RESULTS

Patient recruitment increased through NCRN, with almost 32,000 (12% of annual incident cases) cancer patients being recruited each year. Study delivery has improved, with more studies meeting the recruitment target - 74% compared with 39% before NCRN was established.

CONCLUSION

The coordinated approach to cancer clinical research has demonstrated increased accrual, wide participation and successful trial delivery, which should lead to improved outcomes and care.

Should we routinely offer a second admission for radioiodine to patients with high-risk differentiated thyroid cancer?

AIMS

To assess whether an elective second admission for radioiodine is useful for patients with high-risk differentiated thyroid cancer (DTC).

MATERIALS AND METHODS

A retrospective analysis was carried out on 47 high-risk DTC patients treated with a second admission for radioiodine at our centre during the 2007-2008 period.

RESULTS

In 21 patients (45%), the surgeon described an incomplete resection. Twenty-six (55%) had surgical macroscopic complete resection, but cancer cells at the margin of excision histologically. Overall, at the second admission for radioiodine, 27 patients (57%) had a normal post-treatment scan and undetectable thyroid-stimulating hormone (TSH) stimulated thyroglobulin. Twenty patients (43%) had raised stimulated thyroglobulin at second admission for radioiodine, of whom only six (13%) had abnormal uptake (>0.1%) on the post-treatment scan.

CONCLUSIONS

A second admission for radioiodine could have been avoided in most patients. Instead, information from stimulated thyroglobulin and a diagnostic radioiodine scan would have been sufficient to guide further management. This study also provides interesting outcome data on incompletely resected DTC.

An evaluation of the effects of Tai Chi Chuan and Chi Kung training in patients with symptomatic heart failure: a randomised controlled pilot study

OBJECTIVE

To study the effect of Tai Chi on exercise tolerance in patients with moderate heart failure.

DESIGN

Randomised parallel group study balanced for baseline variables.

SETTING

Cardiology Department, Royal Hallamshire Hospital.

PATIENTS AND METHODS

52 patients (42 men, mean age (68.9 years), range (46-90 years), and 10 women, mean age (70.0 years), range (58-82)) with chronic heart failure (New York Heart Association symptom class II-III) were studied. Patients were randomised to Tai Chi Chuan twice a week for 16 weeks or to standard medical care without exercise rehabilitation.

MAIN OUTCOME MEASURES

The primary outcome measure was the change in the distance walked in the shuttle walk test. Secondary outcome measures were changes in symptom scores and quality of life indices.

RESULTS

Objective measures of exercise tolerance did not improve significantly with Tai Chi, but patients having Tai Chi exercise had an improvement in symptom scores of heart failure measured by the Minnesota Living with Heart Failure Questionnaire (comparison of deltas, -2.4 control vs -14.9; p = 0.01), and depression scores measured by the SCL-90-R questionnaire (-2.9 vs -6.8; p = 0.12) compared with those patients in the control group.

CONCLUSION

In patients with chronic heart failure, 16 weeks of Tai Chi training was safe, with no adverse exercise related problems. It was enjoyed by all taking part and led to significant improvements in symptoms and quality of life.

Eyelid hypertrichosis associated with latanoprost is reversible

A 56-year-old woman with primary open-angle glaucoma in an only eye presented with hypertrichosis after using Latanoprost to lower IOP. After trabeculectomy with adjunctive Mitomycin C, IOP was well controlled and antiglaucoma medications could be discontinued. At eight-month follow-up the abnormal eyelashes had disappeared.

Development and scale-up of a fed-batch process for the production of capsular polysaccharide from Haemophilus influenzae

The production of the capsular polysaccharide, polyribosylribitolphosphate, from Haemophilus influenzae type b is important for the production of effective conjugate vaccines. Factors limiting the production of this polysaccharide from H. influenzae type b in liquid culture were investigated. A fed-batch fermentation was developed that increased cell density and PRP titer approximately four fold when compared to the batch fermentation. This fed-batch process was successfully scaled from the 1.5 l development scale to the 500 l manufacturing scale. The maximum cell density in the 500 l fermentation was 6 g dry cell weight per liter and the PRP concentration was 1.3 g l(-1).

Effects of menstrual cycle and urinary tract instrumentation on uroflowmetry

We sought to compare bladder emptying function in normal women during the proliferative and secretory phases of the menstrual cycle and to evaluate whether urethral catheterization affected uroflowmetry parameters. Forty-nine normal volunteers (ages 19-42 years) were recruited and underwent uroflowmetry in the proliferative and secretory phases of the menstrual cycle. A serum progesterone level of <3.0 ng/mL defined the proliferative phase. During the proliferative phase, volunteers underwent uroflowmetry analysis when a sensation of fullness was appreciated. A post-void residual volume was determined, and the bladder was filled with 400 mL of normal saline. Repeat uroflowmetry analysis was then performed. This two-step procedure was repeated at a separate visit during the secretory phase. Voided volume, residual volume, maximum and average flow rates, time-to-maximum flow, and duration of flow were recorded. Wilcoxon signed-rank tests were used for statistical analysis. A two-tailed alpha value of <0.05 defined statistical significance. Our analysis was limited to the 33 patients whose predicted menstrual dating correlated with the obtained progesterone levels. During the follicular phase, we found significantly faster maximum (P < 0.0001) and average flow rates (P = 0.01), along with a shorter time-to-maximum flow (P < 0.0001) and shorter duration of flow (P < 0.0001), during the pre-catheterized void than the post-catheterized void. Similar results were observed in the secretory phase with the exception of a slightly higher residual volume (P = 0.05). No difference was seen in any measured uroflowmetry parameter when comparing similar voids between phases of the menstrual cycle. We conclude that when evaluating pre-menopausal patients, uroflowmetry may be scheduled and performed during either phase of the menstrual cycle. Neurourol. Urodynam. 19:147-152.

Effect of the insertion/deletion polymorphism of the angiotensin-converting enzyme gene on response to angiotensin-converting enzyme inhibitors in patients with heart failure

There is marked interindividual variation in serum and tissue angiotensin-converting enzyme (ACE) levels for which the insertion (I)/deletion (D) polymorphism in intron 16 of the ACE gene is a marker. ACE inhibitors have important effects on morbidity and mortality in heart failure. The influence of this polymorphism on the response to ACE inhibitors in patients with heart failure is not known. We studied response by ACE genotype of 34 subjects in a randomised, double-blind, crossover study comparing 6 weeks of lisinopril (10 mg, o.d.) or captopril (25 mg, t.d.s.) on 24-h blood pressure (BP) profile and on renal function in patients with symptomatic heart failure [mean left ventricular ejection fraction (LVEF), 24%]. Glomerular filtration rate (GFR), 99mTc diethylenetriaminepentaacetic acid (DTPA), and ambulatory 24-h mean arterial pressure (MAP; Spacelabs 90207) were assessed at the beginning and end of treatment periods. There was a significant relation between ACE genotype and change in MAP with captopril (mm Hg; DD group, -0.5; ID, -4.7; II, -7.4; p = 0.02) but not to lisinopril (mm Hg DD, -6.0; ID, -6.6; II, -7.4; p = 0.89) in these patients. There was no significant relation between genotype and change in GFR with captopril (percentage change from baseline: DD, +7.9; ID, +13.1; II, -0.6; p = 0.45) or lisinopril (percentage change from baseline: DD, -0.1; ID, -3.0; II, -13.3; p = 0.39), but the decline in renal function tended to be greatest in II subjects. Whereas the results are not conclusive, there may be a significant interaction between ACE genotype and response to ACE inhibitors in patients with heart failure.

Pressor and hormonal responses to angiotensin I infusion in healthy subjects of different angiotensin-converting enzyme genotypes

The effects of incremental infusion of angiotensin I on pressor and hormonal responses in relation to the angiotensin-converting enzyme (ACE) genotype were compared in healthy men of genotype DD (n = 8) and II (n = 8). The R(d)25 was the rate of angiotensin I infusion required to achieve a 25-mm Hg increase in diastolic pressure, and the R(s)25, that which caused a 25-mm Hg increase in systolic pressure. Changes in heart rate (HR25) were analysed at the time the R(d)25 was achieved. Serum ACE activity and plasma renin, angiotensin II, and aldosterone concentrations were measured at the start and end of the angiotensin I infusion. Serum ACE activity differed significantly between the genotypes with significantly higher mean values in DD subjects (46.3 +/- SEM 5.2 U/L) than II subjects (12.3 +/- 1.4 U/L; p < 0.001). Age, weight, and baseline blood pressure, heart rate, urinary sodium excretion, plasma renin, angiotensin II, and aldosterone concentrations did not differ between genotypes. The geometric mean infusion rates of angiotensin I required to achieve R(d)25 were 2.53 micrograms/min in II subjects and 2.67 micrograms/min in DD subjects (ratio of infusion rates, 0.95; 95% CI, 0.44-2.02; p > 0.05). The corresponding infusion rates for systolic blood pressure (R(s)25) were 4.47 micrograms/min in II subjects and 3.39 micrograms/min in DD subjects (ratio, 1.32; 95% CI, 0.49-3.55; p > 0.05). At the time of R(d)25, changes in heart rate from baseline were +1.2 beats/min for DD subjects and -9.5 beats/min for II subjects (diff II-DD = 10.7 beats/min; 95% CI, 6.7-14.8; p = 0.01). There were no differences in plasma renin, angiotensin, and aldosterone responses to angiotensin I infusion between the DD and II genotypes. We showed no difference in blood pressure or renin-angiotensin-aldosterone system responses to infusion of angiotensin I related to the deletion or insertion allele of the ACE gene polymorphism, but the study has insufficient power to exclude with certainty such differences. There was a significant difference between II and DD subjects in the chronotropic response to angiotensin I infusion.

A meta-analysis of the association of the deletion allele of the angiotensin-converting enzyme gene with myocardial infarction

BACKGROUND

The ACE gene is characterized by a polymorphism based on the presence (insertion [I]) or absence (deletion [D]) within intron 16 of a 287-basepair alu repeat sequence, resulting in three genotypes (DD and II homozygotes and ID heterozygotes). In 1992, the DD genotype was reported to be associated with an increased risk of myocardial infarction (MI). Subsequent studies have produced conflicting findings. To further evaluate the association of the ACE I/D genotype with MI risk, we carried out a meta-analysis of all the published studies.

METHODS AND RESULTS

In total, 15 studies containing 3394 MI cases and 5479 control subjects were analyzed. The overall distribution of genotypes in the control subjects was 22.7% II, 49.0% ID, and 28.3% DD. The mean odds ratio for MI for DD versus ID/II genotypes across all studies was 1.26 (95% CI, 1.15, 1.39; P < .0001). Pairwise odds ratios were 1.36 (95% CI, 1.19, 1.55) for DD and II, 1.24 (95% CI, 1.11, 1.38) for DD and ID, and 1.09 (95% CI, 0.96, 1.23) for ID and II. The relative risk appeared to be increased in Japanese populations (2.55; 95% CI, 1.75, 3.70).

CONCLUSIONS

Within the limitations of the available data, the meta-analysis therefore supports an association of the ACE D allele with MI risk and strengthens the justification for further evaluation in appropriately powered studies.

Insertion/deletion polymorphism in the angiotensin-converting enzyme gene and risk of and prognosis after myocardial infarction

OBJECTIVES

We sought to prospectively investigate whether genetic variation at the angiotensin-converting enzyme gene locus defined by an insertion (I)/deletion (D) polymorphism influences the risk of myocardial infarction or prognosis after infarction, or both.

BACKGROUND

It has been suggested that the deletion allele of the angiotensin-converting enzyme gene, and specifically the DD genotype, may increase the risk of myocardial infarction, although previous studies have produced conflicting reports. No studies have yet examined the effect of I/D polymorphism on survival after infarction.

METHODS

Angiotensin-converting enzyme genotypes in 684 patients with myocardial infarction recruited at the time of the acute event through coronary care units in two centers were compared with those of 537 control subjects recruited from the base populations. All patients were followed up to assess the impact of the angiotensin-converting enzyme genotype on prognosis.

RESULTS

We found no difference (p = 0.89) in the genotype distribution between patients and control subjects (patients DD 31%, ID 47%, II 22%; control subjects DD 30%, ID 48%, II 22%). The odds ratio for myocardial infarction for DD compared with II/ID genotype adjusted for age, gender and center was 1.16 (95% confidence interval [CI] 0.82 to 1.65, p = 0.44). The study had 90% power to detect a 1.5-fold increase in risk of myocardial infarction associated with the DD genotype. For one center, data were available for other risk factors (hypertension, diabetes, angina, previous myocardial infarction, smoking, body mass index, total and high density lipoprotein cholesterol) in both patients and control subjects. In a stepwise logistic regression analysis the odds ratio for DD versus ID/II genotypes remained nonsignificant (1.44, 95% CI 0.84 to 2.46, p = 0.20) for these subjects. Over a median follow-up period of 15 months (range 3 to 22), 155 patients (22.7%) died. There was no difference in mortality between subjects with the DD genotype and those with ID/II genotypes. (21.8% vs. 23.1%, p = 0.25). Likewise, there was no difference in the distribution of survival times in the two groups (p = 0.62). The study had 70% power to detect a 1.5-fold increase in mortality during follow-up associated with the DD genotype.

CONCLUSIONS

We conclude that in the groups studied, genetic variation at the angiotensin-converting enzyme gene locus defined by I/D polymorphism does not significantly influence either the risk of or the short- to medium-term prognosis after myocardial infarction.

Acute pulmonary vasodilatory properties of amlodipine in humans with pulmonary hypertension

OBJECTIVE

Calcium antagonists are the only oral vasodilators shown to influence mortality in primary pulmonary hypertension, but the high doses required are often poorly tolerated. Amlodipine is a novel, relatively well tolerated, calcium antagonist. It has not been previously tested in humans with pulmonary hypertension.

DESIGN

Calcium antagonists are claimed to be of benefit in the 20-30% of patients who respond--that is, whose mean pulmonary artery pressure and pulmonary vascular resistance decreased by 20% after acute administration. Increasing oral doses of amlodipine (up to 40 mg) were given and haemodynamic measurements were obtained by the use of indwelling pulmonary artery catheters 12 h after each dose.

SETTING

Large teaching hospital, primary referral centre.

PATIENTS

Six patients (four women; age range 37-78 years) with pulmonary hypertension (one with primary pulmonary hypertension, five with thromboembolic disease.

MAIN OUTCOME MEASURES

Mean pulmonary artery pressure and pulmonary vascular resistance decreased by greater than 20% in two patients, mean pulmonary artery pressure decreased by greater than 20% in one patient with a pulmonary vascular resistance reduction of 19%. Thus, two of six patients responded to amlodipine and one partially responded.

RESULTS

The whole group mean (SEM) pulmonary artery pressure decreased from 47.7 (4.2) to 41.7 (4.4) mm Hg and mean pulmonary vascular resistance from 8.6 (2.1) to 7.1 (1.8) Wood units. Cardiac output rose by a mean (range) of 4% (-20.8 to+20.8), heart rate by 8.8% (-10 to +33), and systemic systolic blood pressure decreased by 12% (-29.2 to -5.8) and diastolic blood pressure by 6.8% (-28.2 to+20.0). There were no symptoms of systemic hypotension.

CONCLUSION

These results show that oral amlodipine can produce acute pulmonary vasodilatation in patients with pulmonary hypertension. Further studies are required, but amlodipine may prove to be of value in the treatment of primary pulmonary hypertension.

Myocardial infarction

A conference on myocardial infarction (MI) was held at the Royal College of Physicians on 6 June 1994, organised by Dr K S Channer. The management of myocardial infarction has changed dramatically in the last few years with the introduction of effective measures to reduce early mortality and improve longterm prognosis. The purpose of this conference was to review these approaches and determine how they may be introduced into practice. The conference was divided into three sections: preventing myocardial infarction, acute intervention at the time of infarction, and preventing reinfarction.

Effects of dopamine on T-lymphocyte proliferative responses and serum prolactin concentrations in critically ill patients

OBJECTIVES

Dopamine is currently used in the ICU for its vasopressor, renal vasodilating, and cardiac inotropic properties. Animal studies have shown both endocrine and T-lymphocyte alterations with dopamine agonist administration. The relationships between exogenous dopamine and patient hormonal and lymphocyte proliferative responses have not been evaluated in the critically ill patient. These findings furnished the impetus for the present study.

DESIGN

Prospective, controlled, clinical study.

PATIENTS AND METHODS

All patients admitted to the ICU at Truman Medical Center were evaluated for admission into the protocol, excluding patients whose medications or diseases produced effects in the study-dependent variables. Before institution of dopamine therapy, blood samples were taken for T-cell analysis and prolactin measurement. Daily, early morning blood samples were taken if the dopamine infusion was > 5 micrograms/kg/min for 4 hrs during that 24-hr period. An early morning postdopamine sample was taken on the first day after dosage discontinuation. Control blood samples for determination of T-cell and prolactin responses were drawn from ICU patients who did not receive dopamine. A severity-of-disease score (Acute Physiology and Chronic Health Evaluation [APACHE II] score) was recorded for all patients.

MAIN RESULTS

Serum prolactin concentrations decreased > 90% (p < .001) within hours in all patients receiving dopamine infusions at study dose limit or above. The in vitro T-cell proliferative response to concanavalin A decreased (a transitory response) in patients receiving a dopamine infusion (p < .001). Dopamine infusions in medical ICU patients produced an immediate and profound reduction in serum prolactin concentrations in both males and females. An immediate transitory decrease in patient T-cell response to concanavalin A stimulation in vitro was seen in patients receiving dopamine.

CONCLUSIONS

The data suggest the possibility of altered endocrine and immune function as a corollary of therapeutic concentrations of dopamine in critically ill patients.

Relapses after multidrug therapy for leprosy: a preliminary report of 22 cases in west Nepal

The WHO recommended multidrug therapy regimens for leprosy patients were implemented in Nepal from 1982. Therefore a considerable number of both paucibacillary (PB) and multibacillary (MB) patients have been on observation after release from MDT, for as long as 4-5 years. A retrospective study was done considering the patients who relapsed during this period and who were registered at the Out-patients Department of Green Pastures Hospital in Pokhara, Nepal. A total of 22 patients relapsed out of 927 who were released from MDT.

Primary structure of glucagon from the gut of the common dogfish (Scyliorhinus canicula)

The primary structure of glucagon isolated from the intestine of the common dogfish, Scyliorhinus canicula, was established as H S E G T F T S D Y S K Y M D N R R A K D F V Q W L M N T. The peptide shows four substitutions compared with human glucagon: Glu-3 for Gln, Met-14 for Leu, Asn-16 for Ser and Lys-20 for Gln. Glucagon represented the predominant molecular form of the glucagon-like immunoreactivity in the dogfish gut extracts demonstrating that the pathway of posttranslational processing of proglucagon in the gut of this fish differs markedly from the pathway in the mammalian gut.