Budgetary Impact of Including the Urinary Genomic Marker Cxbladder Detect in the Evaluation of Microhematuria Patients

INTRODUCTION

Current AUA guidelines mandate a risk-stratified approach for the evaluation of microhematuria. Urine genomic tests with high negative predictive value could further reduce unnecessary diagnostic testing and morbidity, but the economic impact is unknown. This study modeled the financial impact of Cxbladder Detect on microhematuria evaluations.

METHODS

A decision tree analysis was constructed by Coreva Scientific comparing 1-year costs of the standard microhematuria evaluation using the AUA guidelines vs an algorithm incorporating Cxbladder Detect. Cxbladder Detect-positive patients had cystoscopy and imaging, whereas patients with negative tests were reevaluated in 6 months. Patients with positive diagnostic testing underwent cystoscopy, and positive cystoscopies led to transurethral resection of bladder tumor. Test performance was based on published literature, and costs were based on Medicare allowable fees.

RESULTS

Using the decision tree model, the average savings of using Cxbladder Detect was $559 compared with the standard of care, with an average reduction of 0.38 procedures per patient. Probabilistic analysis showed statistical significance with a median reduction in the total cost of $498 per patient (95% CrI [-1356, -2]) and a significant median reduction in diagnostic procedures per patient of 0.36 (95% CrI [-0.52, -0.16]) without impact on the number of cancers diagnosed.

CONCLUSIONS

This model-based study demonstrates the potential economic value of using a Cxbladder-driven protocol for microhematuria evaluations.

Fast In-House Next-Generation Sequencing in the Diagnosis of Metastatic Non-small Cell Lung Cancer: A Hospital Budget Impact Analysis

Background: Targeted therapy for cancer is becoming more frequent as the understanding of the molecular pathogenesis increases. Molecular testing must be done to use targeted therapy. Unfortunately, the testing turnaround time can delay the initiation of targeted therapy. Objective: To investigate the impact of a next-generation sequencing (NGS) machine in the hospital that would allow for in-house NGS testing of metastatic non-small cell lung cancer (mNSCLC) in a US setting. Methods: The differences between 2 hospital pathways were established with a cohort-level decision tree that feeds into a Markov model. A pathway that used in-house NGS (75%) and the use of external laboratories (so-called send-out NGS) (25%), was compared with the standard of exclusively send-out NGS. The model was from the perspective of a US hospital over a 5-year time horizon. All cost input data were in or inflated to 2021 USD. Scenario analysis was done on key variables. Results: In a hospital with 500 mNSCLC patients, the implementation of in-house NGS was estimated to increase the testing costs and the revenue of the hospital. The model predicted a $710 060 increase in testing costs, a $1 732 506 increase in revenue, and a $1 022 446 return on investment over 5 years. The payback period was 15 months with in-house NGS. The number of patients on targeted therapy increased by 3.38%, and the average turnaround time decreased by 10 days when in-house NGS was used. Discussion: Reducing testing turnaround time is a benefit of in-house NGS. It could contribute to fewer mNSCLC patients lost to second opinion and an increased number of patients on targeted therapy. The model outcomes predicted that, over a 5-year period, there would be a positive return on investment for a US hospital. The model reflects a proposed scenario. The heterogeneity of hospital inputs and the cost of send-out NGS means context-specific inputs are needed. Conclusion: Using in-house NGS testing could reduce the testing turnaround time and increase the number of patients on targeted therapy. Additional benefits for the hospital are that fewer patients will be lost to second opinion and that in-house NGS could generate additional revenue.

Time trade-off study to establish utility decrements in individuals with a spinal cord injury who perform intermittent catheterisation

AIMS

To generate utility decrements for three attributes associated with catheterisation for individuals with a spinal cord injury (SCI): the process of catheterisation, the physical impact of urinary tract infections (UTIs) and worry associated with hospitalisation.

MATERIALS AND METHODS

Health state vignettes comprising various levels of the three attributes were developed. Two cohorts of respondents, corresponding to people with SCIs and a sample broadly representative of the UK population, were presented with nine vignettes (three vignettes for the mild, moderate and severe health states in addition to a random set of six vignettes). It was assumed no or a nominal decrement was associated with the mild health state. Utility decrements were derived from analysing the data obtained from the online time trade-off (TTO). A proportion of the SCI cohort (n = 57) also completed the EQ-5D-5L questionnaire.

RESULTS

Utility decrements were generated using statistical models for the general population (n = 358), the SCI population (n = 48) and the two populations combined (merged model, n = 406). Results from the two cohorts showed minimal differences. For the merged model, SCI status was not statistically significant. All interaction terms, excluding SCI and the severe level of the physical attribute, were not statistically significant. Compared to the mild level, the greatest utility decrement calculated was the severe level of the emotional (worry) attribute (0.09, p < 0.001) for the SCI population. A significant decrement of 0.02 (p <0.001) was calculated for the moderate level of the emotional attribute for all models. The mean utility score for those with SCI having completed the EQ-5D-5L was 0.371.

LIMITATIONS

Modest sample size of respondents from the SCI population (n = 48).

CONCLUSIONS

Worry associated with hospitalisation had the greatest impact on patients' health-related quality of life (HRQoL). The catheterisation process, such as the lubrication and repositioning of the catheter, also impacted on patients' HRQoL.

Treatment outcomes of patients with Atopic Dermatitis (AD) treated with dupilumab through the Early Access to Medicines Scheme (EAMS) in the UK

BACKGROUND

Dupilumab, a monoclonal antibody against interleukin (IL)-4 receptor alpha that inhibits IL-4/IL-13 signalling is indicated in dermatology for the treatment of moderate-to-severe atopic dermatitis (AD) in adult and adolescent patients 12 years and older and severe AD in children 6-11 years, who are candidates for systemic therapy. Dupilumab received Early Access to Medicines Scheme (EAMS) approval for adults in March 2017.

OBJECTIVES

The purpose of this study was to assess the efficacy outcomes of treatment with dupilumab in EAMS.

METHODS

A retrospective analysis of adult patients enrolled in the dupilumab EAMS in the UK. Scores were assessed at baseline and follow up, including the Eczema Area and Severity Index (EASI), Investigator's Global Assessment Score (IGA) and Dermatology Life Quality Index (DLQI).

RESULTS

Data were available for 57 adult patients treated with dupilumab for at least 12 weeks; 73.6% of patients had received prior treatment with 3 or 4 immunosuppressants. Baseline scores for the EASI and DLQI were 27.93 (standard deviation, SD 13.09) and 18.26 (SD 6.18) respectively. AD severity scores showed statistically significant improvement at week 16±4 weeks (p <0.001 for all). The mean change in EASI was 14.13 points with 66.7% and 36.7% achieving a 50% (EASI-50) and 75% (EASI-75) improvement in EASI, respectively at 16^+/- 4 weeks. IGA scores improved by at least two categories for 75% patients. DLQI scores decreased by a mean of 9.0 points, with 80% patients demonstrating a MCID 4-point improvement. For 85% patients, clinicians rated the treatment response as being either 'better' (19%) or 'much better' (65%).

CONCLUSIONS

Dupilumab is associated with a significant and clinically relevant improvements in AD as measured by patient- and physician-reported outcome measures. Importantly, the clinical efficacy, despite the refractory disease of this EAMS cohort, is comparable to that previously reported in clinical trials.

Cancer information overload and multiple prevention behaviors

Background

Many people feel overwhelmed by the increasing amount of cancer-related material available in the information environment. Our aims was to evaluate the psychometric properties of the brief version of the cancer information overload (CIO) scale and to examine the association between CIO and multiple cancer prevention behaviors.

Methods

A large survey using a self-administered online questionnaire was proposed to all adult members of the Seintinelles, a French national non-profit organization. The psychometric properties of the CIO scale were evaluated. Measurement invariance across French and English languages was studied using an additional sample of 224 Australian cancer survivors from Register4. We also collected functional, communicative, and critical health literacy (FCCHL), deprivation (EPICES index), current smoking, alcohol misuse, frequent sunburns, and rare skin self-examination.

Results

Between June 16th and 30th 2016, 2 363 French participants answered the online questionnaire. The five-item CIO scale demonstrated the best balance between psychometric properties and number of items. It showed satisfactory internal consistency and adequate fit. No measurement invariance issue was found across age, gender, education level, and language groups.

CIO was increased among people with higher deprivation, lower education and a cancer information avoidant profile. In multivariate analyses, CIO was associated with tobacco use (OR = 1.05, 95%CI [1.00-1.10]), rare skin checks (OR = 1.05 [1.01-1.08]) and frequent sunburns (OR = 1.04 [1.01-1.07]), but not with alcohol misuse.

Conclusions

The 5-item CIO scale is ready to be used in French and English-speaking countries. The links observed between CIO and multiple prevention behaviors encourage further research in order to better characterize the psycho-cognitive and environmental phenomena at play. Efforts are needed to communicate adequately and empower citizens to limit the growing burden of cancer.

Key messages

The 5-item CIO scale is ready to be used in French and English-speaking countries. Efforts are needed to communicate adequately and empower citizens to limit the growing burden of cancer.

Psychological intervention (ConquerFear) for treating fear of cancer recurrence: mediators and moderators of treatment efficacy

PURPOSE

ConquerFear is an efficacious intervention for fear of cancer recurrence (FCR) that demonstrated greater improvements than an attention control (relaxation training) in a randomized controlled trial. This study aimed to determine mediators and moderators of the relative treatment efficacy of ConquerFear versus relaxation.

METHODS

One hundred and fifty-two cancer survivors completed 5 therapy sessions and outcome measures before and after intervention and at 6 months' follow-up. We examined theoretically relevant variables as potential mediators and moderators of treatment outcome. We hypothesized that metacognitions and intrusions would moderate and mediate the relationship between treatment group and FCR level at follow-up.

RESULTS

Only total FCR score at baseline moderated treatment outcome. Participants with higher levels of FCR benefited more from ConquerFear relative to relaxation on the primary outcome. Changes in metacognitions and intrusive thoughts about cancer during treatment partially mediated the relationship between treatment group and FCR.

CONCLUSIONS

These results show that ConquerFear is relatively more effective than relaxation for those with overall higher levels of FCR. The mediation analyses confirmed that the most likely mechanism of treatment efficacy was the reduction in unhelpful metacognitions and intrusive thoughts during treatment, consistent with the theoretical framework underpinning ConquerFear.

IMPLICATIONS FOR CANCER SURVIVORS

ConquerFear is a brief, effective treatment for FCR in cancer survivors with early-stage disease. The treatment works by reducing intrusive thoughts about cancer and changing beliefs about worry and is particularly helpful for people with moderate to severe FCR.

Margins and survival in oral cancer

In the surgical management of oral squamous cell carcinoma (SCC) we aim to resect the tumour with clear margins in all planes. The aim of this study was to identify and compare overall survival in a group of 591 patients who had resections, and to relate this to the clearance of margins at the tumour bed. We used life tables to calculate survival at one, two, three, five, and 10 years after diagnosis by margin (clear=5mm or more; close=2-5mm; and involved=less than 2mm). Kaplan-Meier curves were produced for the margins alone, which were defined as clear in 480 patients (81%), close in 63 (11%), and involved in 48 (8%). Five-year survival was 81%, 75%, and 54% for clear, close, and involved margins, respectively, which highlights the importance of clear margins for survival. There is a significant prognostic implication associated with close, and particularly with involved, margins.

Abstract P6-12-14: Quality of life and ability to work in patients at different disease stages of HER2+ breast cancer

OBJECTIVES: Health-related quality of life (HRQoL) and ability to work in patients treated for HER2+ early breast cancer (EBC) are poorly understood. This study compared HRQoL and ability to work in 3 HER2+ patient cohorts: EBC during adjuvant treatment, EBC after treatment, and metastatic disease (MBC).

METHODS: A cross-sectional observational cohort study of 299 female consenting patients with HER2+BC, from 14 UK secondary care centres. Group1 (n=89): receiving targeted HER2 therapy±chemotherapy for EBC; Group2 (n=108): in follow up post-targeted treatment for eBC; Group3 (n=102): MBC on treatment. Data collected between Dec 2016-Mar 2017: HRQoL, demographic and employment status data collected via patient-reported questionnaires (including EQ-5D-5L and Functional Assessment of Cancer Therapy [FACT-B]); clinical data collected from medical records. Inter-group differences were assessed using univariate Analysis of variance (ANOVA) and chi-square tests as appropriate. [NCT03099200].

RESULTS: Table1 shows patient demographics, disease characteristics, employment status, and EQ-5D-5L scores. Group1 and Group2 patients did not differ in overall health utility or visual analogue scale (VAS) scores. However, Group3 patients reported significantly poorer health utility than Group1 (p&lt;0.02) and Group2 (p&lt;0.001), and significantly worse VAS scores than Group2 (p&lt;0.001). Significantly fewer Group2 patients and more Group3 patients were unable to work (p&lt;0.003), and fewer Group3 patients were employed than expected (by chi-square, p&lt;0.003).

CONCLUSIONS: HRQoL in patients with EBC was similar whether on or off treatment, and better than those with MBC. HRQoL scores reported on the generic EQ-5D will be compared with those from the disease-specific FACT-B. A smaller proportion of patients with MBC were employed compared to the EBC groups, reflecting the impact of advanced disease. Fewer patients with EBC reported being unable to work than we expected, suggesting these patients maintain function.

Table1

 Group1 (n=89)Group2 (n=108)Group3 (n=102)Age (years)↑55 (11)58 (11)55 (11)Hormone receptor status¥Positive64 (72%)84 (78%)74 (73%)Negative25 (28%)24 (22%)26 (26%)Unknown0 (0%)0 (0%)2 (2%)Time since diagnosis (months)+EBC9 (6)45 (32) (n=103)80 (82) (n=71*)MBC--39 (36) (n=101)Employment status¥Employed45 (51%)55 (51%)28 (28%)§Not employed41 (46%)52 (48%)69 (68%)Retired22 (25%)39 (36%)33 (32%)Unable to work7 (8%)5 (5%)§27 (27%)§Other12 (14%)8 (7%)9 (9%)Unknown3 (3%)1 (1%)5 (5%)EQ-5D summary scoresVisual analogue scale72.7 (18.4)†77.0 (17.5)†65.8 (22.9)† (n=99)Utility value0.809 (0.170)† (n=86)0.818 (0.181)†0.695 (0.262)† (n=97)↑mean (standard deviation); ¥n (%); +median (interquartile range); *excludes 27/102 patients (27%) with de novo MBC. Bold text: observed differences between three groups at significance thresholds of ‡p&lt;0.05, §p&lt;0.003 or †p&lt;0.001. EBC/MBC: early/metastatic breast cancer. %s have been rounded so may not total 100%

Citation Format: Verrill M, Wardley A, Retzler J, Smith AB, McNicol D, Dando S, Tran I, Leslie I, Schmid P. Quality of life and ability to work in patients at different disease stages of HER2+ breast cancer [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 P6-12-14.

e-TC: Development and pilot testing of a web-based intervention to reduce anxiety and depression in survivors of testicular cancer

e-TC is an online intervention designed to address common psychosocial concerns of testicular cancer survivors. It aims to reduce anxiety, depression and fear of cancer recurrence by providing evidence-based information and psychological intervention. This paper details the development and pilot testing of e-TC. During pilot testing, 25 men (with varying psychological profiles) who had completed treatment for testicular cancer, 6 months to 5 years ago (which had not recurred), used e-TC over a 10-week period and provided quantitative and qualitative feedback on the feasibility and acceptability of the programme. Six men also completed a qualitative interview to provide detailed feedback on their experiences using e-TC. Fourteen men (56%) completed at least 80% of the programme. Participants reported a high level of satisfaction with the programme. Men's limited time was a barrier to programme use and completion, and participants suggested that men with a more recent diagnosis and a higher level of distress may be more likely to engage with the programme. e-TC appears to be a feasible and acceptable online intervention for survivors of testicular cancer. Findings from this study are currently being used to refine e-TC and guide the design of a larger efficacy study.

Validated questionnaires on intimacy in patients who have had cancer

Problems with intimacy in patients with cancer of the head and neck may not be recognised. Our aim was to review published papers on patient-reported outcomes that record concerns about intimacy, sex, and function, to help develop a tool for use in head and neck cancer. We specifically looked for instruments with evidence of validation in patients with cancer, which could be used to identify problems with intimacy and sexuality. After evaluating 2563 papers, we identified 20 that satisfied our inclusion criteria, and these have been presented in a tabulated form. This review has shown the need to develop a questionnaire on intimacy that is specific to patients with cancer of the head and neck. It is an important issue that must be addressed by clinical and research teams, and will be done most effectively if it is linked to specific interventions.

Improving decision making about clinical trial participation - a randomised controlled trial of a decision aid for women considering participation in the IBIS-II breast cancer prevention trial

BACKGROUND

Decision aids may improve informed consent in clinical trial recruitment, but have not been evaluated in this context. This study investigated whether decision aids (DAs) can reduce decisional difficulties among women considering participation in the International Breast Cancer Intervention Study-II (IBIS-II) trial.

METHODS

The IBIS-II trial investigated breast cancer prevention with anastrazole in two cohorts: women with increased risk (Prevention), and women treated for ductal carcinoma in situ (DCIS). Australia, New Zealand and United Kingdom participants were randomised to receive a DA (DA group) or standard trial consent materials (control group). Questionnaires were completed after deciding about participation in IBIS-II (post decision) and 3 months later (follow-up).

RESULTS

Data from 112 Prevention and 34 DCIS participants were analysed post decision (73 DA; 73 control); 95 Prevention and 24 DCIS participants were analysed at follow-up (58 DA; 61 control). There was no effect on the primary outcome of decisional conflict. The DCIS-DA group had higher knowledge post decision, and the Prevention-DA group had lower decisional regret at follow-up.

CONCLUSIONS

This was the first study to evaluate a DA in the clinical trial setting. The results suggest DAs can potentially increase knowledge and reduce decisional regret about clinical trial participation.

Drug-specific laterality effects on frontal lobe activation of atomoxetine and methylphenidate in attention deficit hyperactivity disorder boys during working memory

BACKGROUND

The catecholamine reuptake inhibitors methylphenidate (MPH) and atomoxetine (ATX) are the most common treatments for attention deficit hyperactivity disorder (ADHD). This study compares the neurofunctional modulation and normalization effects of acute doses of MPH and ATX within medication-naive ADHD boys during working memory (WM).

METHOD

A total of 20 medication-naive ADHD boys underwent functional magnetic resonance imaging during a parametric WM n-back task three times, under a single clinical dose of either MPH, ATX or placebo in a randomized, double-blind, placebo-controlled, cross-over design. To test for normalization effects, brain activations in ADHD under each drug condition were compared with that of 20 age-matched healthy control boys.

RESULTS

Relative to healthy boys, ADHD boys under placebo showed impaired performance only under high WM load together with significant underactivation in the bilateral dorsolateral prefrontal cortex (DLPFC). Both drugs normalized the performance deficits relative to controls. ATX significantly enhanced right DLPFC activation relative to MPH within patients, and significantly normalized its underactivation relative to controls. MPH, by contrast, both relative to placebo and ATX, as well as relative to controls, upregulated the left inferior frontal cortex (IFC), but only during 2-back. Both drugs enhanced fronto-temporo-striatal activation in ADHD relative to control boys and deactivated the default-mode network, which were negatively associated with the reduced DLPFC activation and performance deficits, suggesting compensation effects.

CONCLUSIONS

The study shows both shared and drug-specific effects. ATX upregulated and normalized right DLPFC underactivation, while MPH upregulated left IFC activation, suggesting drug-specific laterality effects on prefrontal regions mediating WM.

Volatile components of scent material from cotton-top tamarin (Saguinus o. oedipus) : A chemical and behavioral study

The first chemical analysis of the volatile components of scent material from the cotton-top tamarin,Saguinus o. oedipus is presented. In contrast to our previous findings in saddle-back tamarins (Saguinus fuscicollis), the chemical composition of the scent marks is quite variable. Analysis of secretion expressed manually from different areas of the scent pads of sedated animals shows individual and regional variability. Only three components (squalene, cholesterol, andp-methoxybenzaldehyde) were found in all scent mark samples analyzed. However, suprapubic secretions obtained from one sedated female contained, in addition, 12 butyrate esters as well as five acetate esters which were homologous to the butyrates. The butyrate esters have been previously identified in scent material fromSaguinus fuscicollis. The variability of the composition of the scent material is discussed in relation to the scent-marking behavior of the cotton-top tamarins. Behavioral studies tested the ability of the cotton-top tamarins to discriminate between scent marks from conspecifics and scent marks from saddle-back tamarins. The group of 12 subjects discriminated between the scent marks from both species in choice tests during which they could freely contact the scent samples. However, when scent marks were presented under a screen, so that the subjects could smell but not contact the stimuli, no discrimination was shown. Four individuals displayed more interest in the screened scent stimuli than all other subjects. When these animals were tested in a second experiment for their ability to discriminate between material from the two species on the basis of only volatile cues, it became evident that they were able to do so. These results indicate that volatile cues alone enable the tamarins to recognize scent marks from conspecifics, but that additional cues perceived during contact with the scent are important for its full attractiveness and/or informational content.

Oleocanthal inhibits proliferation and MIP-1α expression in human multiple myeloma cells

Multiple myeloma (MM) is a plasma cell malignancy that causes devastating bone destruction by activating osteoclasts in the bone marrow milieu. MM is the second of all hematological malignancies. Thus, the search for new pharmacological weapons is under intensive investigation being MM a critically important public health goal. Recently, it has been demonstrated that macrophage inflammatory protein 1- alpha (MIP-1 α) is crucially involved in the development of osteolytic bone lesions in MM. Phenolic components of extra virgin olive oil are reported to have anti tumor activity. However, the underlying mechanisms and specific targets of extra virgin olive oil remain to be elucidated. In the present study, we investigated the effects of a recently isolated novel extra virgin olive oil polyphenol, oleocanthal, on the human multiple myeloma cell line ARH-77. Here we report that this natural compound has a remarkable in vitro activity by inhibiting MIP-1 α expression and secretion in MM cells. In addition, we also demonstrated that oleocanthal inhibits MM cells proliferation by inducing the activation of apoptosis mechanisms and by down-regulating ERK1/2 and AKT signal transduction pathways. This in vitro study suggests a therapeutic potential of oleocanthal in treating multiple myeloma.

Disorder-specific functional abnormalities during sustained attention in youth with Attention Deficit Hyperactivity Disorder (ADHD) and with autism

Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) are often comorbid and share behavioural-cognitive abnormalities in sustained attention. A key question is whether this shared cognitive phenotype is based on common or different underlying pathophysiologies. To elucidate this question, we compared 20 boys with ADHD to 20 age and IQ matched ASD and 20 healthy boys using functional magnetic resonance imaging (fMRI) during a parametrically modulated vigilance task with a progressively increasing load of sustained attention. ADHD and ASD boys had significantly reduced activation relative to controls in bilateral striato-thalamic regions, left dorsolateral prefrontal cortex (DLPFC) and superior parietal cortex. Both groups also displayed significantly increased precuneus activation relative to controls. Precuneus was negatively correlated with the DLPFC activation, and progressively more deactivated with increasing attention load in controls, but not patients, suggesting problems with deactivation of a task-related default mode network in both disorders. However, left DLPFC underactivation was significantly more pronounced in ADHD relative to ASD boys, which furthermore was associated with sustained performance measures that were only impaired in ADHD patients. ASD boys, on the other hand, had disorder-specific enhanced cerebellar activation relative to both ADHD and control boys, presumably reflecting compensation. The findings show that ADHD and ASD boys have both shared and disorder-specific abnormalities in brain function during sustained attention. Shared deficits were in fronto-striato-parietal activation and default mode suppression. Differences were a more severe DLPFC dysfunction in ADHD and a disorder-specific fronto-striato-cerebellar dysregulation in ASD.

Common and expected postmortem CT observations involving the brain: mimics of antemortem pathology

BACKGROUND AND PURPOSE

Postmortem imaging with CT or MR is emerging as an effective technique to augment forensic autopsy. Expected findings on postmortem imaging of the brain may mimic pathologic processes in the living brain, leading to potential misdiagnosis. The purpose of this study is to describe the array of CT findings that can be expected to be present within the brain after death.

MATERIALS AND METHODS

A retrospective review was performed using an anonymized data base of 33 postmortem head CTs with no evidence of trauma to the face or scalp. Head CTs were assessed for 1) loss of gray-white differentiation, 2) effacement of the ventricles and cisterns, 3) postmortem intravascular blood distribution, 4) presence of intracranial or intravascular air, and 5) an irregular appearance of the falx. Imaging findings were correlated with autopsy findings.

RESULTS

Visualization of the basal ganglia was noted in 30 (91%) subjects, and the cortical ribbon was appreciated in 14 (42%). The ventricles and cisterns were effaced in 19 (58%) cases. An "expected postmortem blood distribution" was seen in 27 (82%) instances. Intravascular air was present in 14 cases (42%). A "lumpy" falx was present in 20 cases (61%). In 4 cases of subdural or subarachnoid hemorrhage noted on autopsy, but not on CT, retrospective review confirmed that a true discrepancy between the radiology and pathology findings persisted.

CONCLUSIONS

Recognition of expected postmortem patterns is required before pathology can be accurately diagnosed. A limitation of CT virtual autopsy is the possibility of missing small blood collections.

A Clinical Study Comparing the Efficacy and Sensitivity of Home vs Combined Whitening

This randomized clinical study assessed efficacy in terms of color change and production of sensitivity after home whitening alone and home whitening supplemented with in-office bleaching. Thirty-six subjects (aged 19 to 58 years) were randomly assigned to one of three different treatment groups: (A) home whitening for two weeks, with 16% carbamide peroxide in custom-made trays; (B) home whitening for two weeks, with 16% carbamide peroxide in custom-made trays supplemented with in-office bleaching with 9% hydrogen peroxide (in the same trays); or (C) home whitening for two weeks, with 16% carbamide peroxide in custom-made trays supplemented with in-office bleaching with 27% hydrogen peroxide (in the same trays). The efficacy of tooth whitening was assessed by determining the color change associated with the six upper anterior teeth using a value-ordered shade guide. Sensitivity was self-assessed with the use of a visual analog scale (VAS). Tooth shade and sensitivity were assessed at the following points: pretreatment; immediately after the home whitening phase; immediately after the in-office phase (groups B and C); and one week post active treatment. At the one week follow-up visit, subjects in group A had a mean (SD) color change of 5.9 (1.83) (teeth were lighter) immediately after cessation of treatment (p&lt;0.01). Subjects in groups B and C experienced a greater change in mean (SD) shade immediately following their respective in-office treatments of 5.1 (1.53) and 5.4 (1.55). However, within one week, the shade of these teeth regressed to a similar degree to that achieved by subjects treated in group A. Overall, no significant difference in shade change or sensitivity was produced between the three groups. Investigators concluded that the in-office element of combined whitening produced no significant difference in tooth color or sensitivity when compared with home whitening alone.