A randomized, observer-blinded trial of twice vs. three times weekly narrowband ultraviolet B phototherapy for chronic plaque psoriasis

BACKGROUND

The optimum treatment frequency for narrowband (TL-01) ultraviolet B (NB-UVB) in psoriasis is not yet known. We have previously found three times weekly to be preferable to five times weekly treatment in our population.

OBJECTIVES

To compare twice weekly with three times weekly NB-UVB phototherapy in chronic plaque psoriasis.

METHODS

In an observer-blinded, randomized comparison, patients with chronic plaque psoriasis referred from dermatology out-patient clinics in Tayside for NB-UVB phototherapy received either twice weekly (Monday and Friday) or three times weekly (Monday, Wednesday and Friday) whole-body NB-UVB phototherapy following our standard departmental treatment protocol. Treatment was continued to clearance or until the fourth treatment after minimal residual activity (MRA) was first documented. Number of days in treatment, number of treatments, total dose and time to relapse were recorded.

RESULTS

In total, 113 patients were recruited, skin phototypes I-III: 58 in the twice weekly and 55 in the three times weekly group. Forty patients in the twice weekly group reached clearance/MRA, as did 44 in the three times weekly group. It took 1.5 (95% confidence interval 1.3-1.7) times longer to reach clearance/MRA with twice weekly therapy, a geometric mean of 88 vs. 58 days (P < 0.0001). Small differences in numbers of treatments and total dose to reach clearance tended to favour three times weekly therapy, but these were not significant.

CONCLUSIONS

Three times weekly NB-UVB clears psoriasis significantly faster than twice weekly treatment, and therefore is preferable for most patients.

A brief overview of the initial location decisions of immigrants

"The current longitudinal survey of recent migrants has provided information on the factors shaping their locational choices within Australia. The main finding is that family and friends are the dominant influence. Job opportunities are much less influential, even amongst Independent migrants."

Testing control of radiation-induced diarrhea with a psyllium bulking agent: a pilot study

Sixty cancer patients who were undergoing radiation therapy to the pelvis of at least 4,000 cGy in 20 fractions over four weeks were randomized to take or not take Metamucil. Results were analyzed for the presence of radiation-induced diarrhea in two groups: patients taking Metamucil (n = 30) or not taking Metamucil (n = 30). The Murphy Diarrhea Scale was developed to assist in the synthesis of data collected in daily patient-reported diaries. Results were analyzed using ANOVA F-tests. Metamucil significantly decreased the incidence (p = 0.049) and severity (p = 0.030) of diarrhea and showed a strong trend in reducing the use of anti-diarrhea medication (p = 0.062). According to this pilot study, Metamucil was an effective method of controlling radiation-induced diarrhea. Results of this pilot study have implications for clinical practice and nursing research.

Selenium intakes in 18-64-y-old Irish adults

OBJECTIVE

To measure the intake of selenium (Se) and the contribution of different food groups to Se intake in adults aged 18-64 y in Ireland. The adequacy of Se intake in the population is also assessed.

DESIGN

Food consumption was estimated using a 7 day food diary for a representative sample (n=1379; men=662, women=717) of 18-64-y-old Irish adults selected randomly from the electoral register. Se intake was estimated using updated tables of food composition.

RESULTS

Mean daily Se intakes (+/-s.d.) from all sources (ie food plus supplements), and from food sources alone, for the group of Irish adults aged 18-64 y were 52 (+/-23) and 50 (+/-21) microg, respectively. Mean daily Se intake (from all sources) was significantly higher in men of all ages than women of all ages at levels of 60 and 44 microg, respectively (P<0.001). Meat/meat products (30%), bread and rolls (24%), fish/fish products (approximately 11%), and milk and yoghurt (9%) were the main contributors to mean daily Se intake. Adequacy of Se intake in population groups was estimated as the percentage of the population with mean daily Se intakes that were lower than the average requirement of 40 microg. Using this measure, 45.6% of women and 17.1% of men had inadequate Se intakes.

CONCLUSION

A significant prevalence of inadequate Se intakes was observed in Irish adults. Therefore, it would seem prudent that the Se status of the Irish population be investigated at this time.

Selenium status of Irish adults: evidence of insufficiency

BACKGROUND

Sub-optimal selenium status may have a role in the aetiology of various pathologies. Selenium status depends on adequate selenium in the diet. A relatively high proportion of Irish adults (17% men; 46% women) have an inadequate dietary intake.

AIM

A study was designed to examine the selenium status of healthy Irish adults.

METHODS

Ninety-one healthy Irish adults, aged 18-67 years, were recruited from the Cork City area. A fasting blood sample was collected from each subject and each was assayed for serum selenium an index of serum selenium.

RESULTS

Mean (+/- SD) serum selenium concentration in healthy Irish adults was 76 (+/- 21)microg/l. There was no significant difference in values between males and females or between postmenopausal and premenopausal women or between the three main age categories.

CONCLUSION

Current serum selenium values of Irish adults would not appear to be sufficient to achieve optimal activity of glutathione peroxidase, which occurs at serum selenium concentration around 95microg/l. Sub-optimal selenium status may increase susceptibility to various chronic disorders.

Foreign body reaction to calcium alginate fibre mimicking recurrent tumour of the submandibular salivary gland

A 50-year-old woman was referred after the discovery of adenoid cystic carcinoma in an excised left submandibular gland. Treatment involved clearance of the left submandibular fossa, and bilateral levels II and III selective neck dissections. A left-sided submandibular haematoma developed during the immediate postoperative period. After removal of the clot, there was a persistent, low volume capillary ooze from the left submandibular fossa and a calcium alginate fibre pack (Kaltostat) was left in place to control the bleeding. After an extended period of time the pack excited a foreign body reaction which, on a computed tomogram, mimicked a recurrence of the tumour. We review the role of Kaltostat in this setting and its potential for foreign body reaction, which may mimic serious disease.

Alcohol consumption alters insulin secretion and cardiac autonomic activity

BACKGROUND

Alcohol may have a cardioprotective effect. One possible mechanism is by modifying insulin resistance/secretion. The aims of this study were: (i) to examine the effect of short-term alcohol consumption on the metabolic control of glucose tolerance; (ii) to study the influence of short-term alcohol consumption on cardiac autonomic activity using spectral analysis of heart rate variability.

METHODS

Twenty-one healthy subjects, in a randomized crossover design, either received three units of ethanol daily for 1 week or abstained from ethanol. The control of glucose tolerance was assessed using the intravenous glucose tolerance test with minimal modelling.

RESULTS

There was no difference in fasting glucose, fasting insulin or insulin sensitivity between the two groups. Alcohol showed a lower insulin first phase insulin response (no alcohol 659.0 +/- 394.1 SD, alcohol 535.2 +/- 309.1) pmol L-1 min-1, P = 0.027). There was no difference in heart rate or blood pressure but a significant difference in the ratio of high to low frequency spectral power of heart rate variability; (no alcohol 4.55 +/- 3.78, alcohol 8.16 +/- 6.77, P = 0.033). This suggests decreased sympathetic and/or increased vagal modulation of heart rate in the alcohol group.

CONCLUSION

The finding of no difference in insulin sensitivity between the two groups contrasts with, but does not entirely contradict, the results of previous epidemiological studies--perhaps suggesting that longer term changes such as liver enzyme induction may be important. The difference in insulin secretion questions the validity of previous studies of the influence of alcohol on insulin sensitivity, where insulin levels were used as a surrogate for insulin resistance.

Tumour 'budding' as an index to estimate the potential of aggressiveness in rectal cancer

AIMS

Although the characteristic of invasive pattern which contributes to Jass's classification is a sensitive prognostic marker in rectal cancer, reproducibility of its assessment has been shown to be problematic. As another histological parameter of invasive margin, we examined the prognostic significance of tumour 'budding' and attempted to establish its appropriate criteria.

METHODS AND RESULTS

A total of 638 rectal cancer specimens was examined. We defined tumour 'budding' as an isolated single cancer cell or a cluster composed of fewer than five cancer cells. We divided these into two groups by their intensity, i.e. the number of 'budding' foci within a microscopic field of x 250. Rectal cancer with high-grade 'budding' (>or= 10 foci in a field) was observed in 30.1% of patients, and was associated with lower 5-year survival rates (40.7%) than patients with low-grade 'budding' (84.0%) (P < 0.0001). Based on multivariate analysis, tumour 'budding' was selected as the significant independent variable, together with the number of nodes involved, extramural spread, lymphocytic infiltration, apical nodal involvement and tumour differentiation. Kappa coefficient of two-graded tumour 'budding' in the intraobserver study was 0.84.

CONCLUSIONS

Because of its value as a prognostic indicator and its reproducibility, tumour 'budding' would be a good index to estimate the aggressiveness of rectal cancer.

The role of serial transrectal ultrasonography in a ‘watchful waiting’ protocol for men with localized prostate cancer

OBJECTIVE

To determine the value of serial 6-monthly transrectal ultrasonography (TRUS) in a cohort of men with localized prostate cancer who consented to a programme of watchful waiting with selective delayed intervention.

PATIENTS AND METHODS

Since November 1995, 180 men were accrued into an ongoing prospective study of watchful waiting with selective delayed intervention; 174 patients enrolled before 31 December 1999 comprised the cohort for the present study. The prospectively collected clinical data, including the TRUS reports, were reviewed systematically. Twenty-eight men met the arbitrarily predefined criteria of disease progression and required definitive treatment. The TRUS findings were scored as being consistent with the clinical scenario (i.e. clinical, biochemical or histological progression) if they reported a new or enlarging hypoechoic peripheral zone lesion, or a > or = 30% increase in overall prostate volume at the time of progression. In 136 men who had undergone two or more serial TRUS examinations the relationships between the rate of change of prostate-specific antigen (PSA) and changes in both gland volume and the number of hypoechoic lesions were also examined.

RESULTS

The group of 28 men who progressed to require radical intervention underwent 83 TRUS examinations (median number per patient, three). Two men underwent TRUS only once at baseline because of progression within 6 months. Of these 28 men, only seven had changes on TRUS that were regarded as being consistent with progression; all seven consisted of the growth of an existing nodule or the appearance of a new nodule. In only one case was this accompanied by an increase of > or = 30% in gland volume. In the 136 men who underwent two or more serial TRUS examinations (median three, maximum nine), there was no correlation between the rate of change of PSA and changes in either gland volume or the number of peripheral zone hypoechoic lesions.

CONCLUSION

The use of serial TRUS in men with known but untreated prostate cancer is of limited value as a determinant of disease progression.

Use of CA-125 and ultrasound in high-risk women

Our objective was a retrospective study reporting on ovarian cancer screening in a high-risk female population using both CA-125 and ultrasound over a 7-year period. We used risk estimates of carrying a BRCA mutation that were based on family history. Subjects were screened with CA-125 and ultrasound every 6 months. Each of 311 high-risk subjects had between 1 and 17 screening visits. Overall, 33 of 1209 (2.7%) CA-125 results were abnormal (>35 U/ml); 226 of 1342 (17%) ultrasounds were abnormal, with abnormalities ranging from benign appearing cystic changes to more ominous patterns. Since entry into the program, 29 subjects (9%) have undergone surgery. In 20 of these, the preoperative screening was normal; in six, only the ultrasound was abnormal, and in two, only the CA-125 was abnormal (46-91 U/ml). In only one subject undergoing surgery were both serial CA-125 levels (52-91 U/ml) and ultrasound abnormal. In 7 years of screening, one patient (0.3%) has been diagnosed with ovarian cancer (stage IA, grade 1 endometrioid adenocarcinoma). Overall, 31 (10%) subjects have completed BRCA testing. We conclude that despite screening results comparable to other studies, the detection of only one ovarian cancer over 7 years is lower than expected. Explanations for this observation are discussed. Despite the limitations of CA-125 and ultrasound, we continue to recommend these screening modalities for high-risk women. At the present time, they offer the best opportunity to detect ovarian cancers early. With increasing knowledge of BRCA testing, more women may benefit from this testing in assessing their personal risk.

How important is removal of the parametrium at surgery for carcinoma of the cervix?

OBJECTIVES

The aims of this study were (1) to determine the incidence and factors predictive for pathologic parametrial involvement in clinical stage IA1/2 and IB1 cervical cancer after radical surgery and (2) to identify a population at low risk for pathologic parametrial involvement.

METHODS

All patient information was collected prospectively and extracted from a cervical cancer radical surgery database. Selection criteria for surgery were generally based upon tumor size, with the cutoff for surgery between 3 and 4 cm. Parametrial involvement (PI) was defined as either positive parametrial lymph nodes (PMLN) or malignant cells in the parametrial tissue (PT) (including lymphovascular channels) by either contiguous or discontiguous spread. Statistical analysis included the chi2 test, the Wilcoxon rank test, and the Mantel-Haentzel test.

RESULTS

Between July 1984 and January 2000, 842 patients underwent radical surgery for clinical stage IA1/2 and IB1 cervical cancer at our center. Forty-nine patients (6%) had positive pelvic lymph nodes. Thirty-three patients (4%) had pathologic PI, 8 in the PMLN and 25 in the PT (none had both). PI was associated with older age (42 vs 40 years, P < 0.04), larger tumor size (2.2 vs 1.8 cm, P < 0.04), higher incidence of capillary-lymphatic space invasion (85% vs 45%, P = 0.0004), tumor grades 2 and 3 (95% vs 65%, P = 0.001), greater depth of invasion (18.0 vs 5.0 mm, P < 0.001), and pelvic lymph node metastases (44% vs 5%, P < 0.0001). The incidence of PI in patients with tumor size < or =2 cm, negative pelvic lymph nodes, and depth of invasion < or =10 mm was 0.6%.

CONCLUSION

Pathologic parametrial involvement in clinical stage IA1/2 and /IB1 cervical cancer is uncommon. Acknowledging that almost all patients with pelvic lymph node metastases and a high proportion of patients with tumor invasion >10 mm will receive adjuvant radiation regardless of the radicality of surgery, a population at low risk for pathologic parametrial involvement can be identified. These patients are worthy of consideration for studies of less radical surgery performed in conjunction with pelvic lymphadenectomy.

Use of CA-125 and ultrasound in high-risk women

Abstract.

Laframboise S, Nedelcu R, Murphy J, Cole DEC, Rosen B. Use of CA-125 and ultrasound in high-risk women.

Our objective was a retrospective study reporting on ovarian cancer screening in a high-risk female population using both CA-125 and ultrasound over a 7-year period. We used risk estimates of carrying a BRCA mutation that were based on family history. Subjects were screened with CA-125 and ultrasound every 6 months.

Each of 311 high-risk subjects had between 1 and 17 screening visits. Overall, 33 of 1209 (2.7%) CA-125 results were abnormal (>35 U/ml); 226 of 1342 (17%) ultrasounds were abnormal, with abnormalities ranging from benign appearing cystic changes to more ominous patterns. Since entry into the program, 29 subjects (9%) have undergone surgery. In 20 of these, the preoperative screening was normal; in six, only the ultrasound was abnormal, and in two, only the CA-125 was abnormal (46–91 U/ml). In only one subject undergoing surgery were both serial CA-125 levels (52–91 U/ml) and ultrasound abnormal. In 7 years of screening, one patient (0.3%) has been diagnosed with ovarian cancer (stage IA, grade 1 endometrioid adenocarcinoma). Overall, 31 (10%) subjects have completed BRCA testing. We conclude that despite screening results comparable to other studies, the detection of only one ovarian cancer over 7 years is lower than expected. Explanations for this observation are discussed. Despite the limitations of CA-125 and ultrasound, we continue to recommend these screening modalities for high-risk women. At the present time, they offer the best opportunity to detect ovarian cancers early. With increasing knowledge of BRCA testing, more women may benefit from this testing in assessing their personal risk.

Does histology influence prognosis in patients with early-stage cervical carcinoma?

BACKGROUND

The objective of this study was to examine the influence of histology on the outcome of patients with surgically treated, Stage IA-IB carcinoma of the uterine cervix.

METHODS

All patient information was collected prospectively and was extracted subsequently from the University of Toronto cervical carcinoma surgery data base. Selection criteria for surgery were based on tumor size and were independent of histology. Patients with adenocarcinoma were separated into two groups: those with mucinous/endometrioid adenocarcinoma (M/E AC) and those with adenosquamous/clear cell adenocarcinoma (AS/CC AC). Statistical analysis used Wilcoxon rank tests, Mantel-Hanzel tests, chi-square tests, and Cox regression analyses.

RESULTS

Between July 1984 and January 2000, 880 patients with Stage IA-IB cervical carcinoma underwent radical surgery, including pelvic lymphadenectomy, as the primary treatment. Two hundred fifty-five patients had M/E AC (29%), 81 patients had AS/CC AC (9%), and 544 patients had squamous cell carcinoma (SCC; 62%). Compared with patients who had SCC, patients with M/E AC had significantly more favorable prognostic characteristics: age (median, 39 years vs. 41 years; P < 0.03), depth of invasion (3.7 mm vs. 5.5 mm; P < 0.001), vascular space involvement (24% vs. 57%; P < 0.0001), Grade 2-3 tumor (40% vs. 78%; P < 0.0001), and pelvic lymph node metastases (4% vs. 8%; P < 0.04), respectively. Characteristics among patients with AS/CC AC tended have values similar to the median values for patients with SCC (or intermediate between the values for patients with M/E AC and the values for patients with SCC): age (38 years), depth of invasion (6 mm), vascular space involvement (40%), Grades 2-3 (70%), and pelvic lymph node metastases (6%). The 2-year and 5-year recurrence free survival rate was similar between patients with M/E AC and patients with SCC (95% vs. 94% and 90% vs. 90%, respectively); however, both were significantly superior to the rates for patients with AS/CC AC (2-year recurrence free survival rate: 86%, P < 0.03; 5-year recurrence free survival rate: 81%, P % 0.03). There were no differences in the pattern of first recurrence by histology.

CONCLUSIONS

Patients with surgically treated Stage IA-IB cervical carcinoma with M/E AC and SCC histology have a similar prognosis. For patients with disease with AS/CC AC histology, the current results and the literature indicate that patients with uncommon histologies have an inferior recurrence free survival rate. Although the optimal therapy for these patients remains undefined, there is no obvious rationale for altering the treatment strategies from those currently employed for patients with M/E AC and SCC.

Perineural cysts presenting as complex adnexal cystic masses on transvaginal sonography

OBJECTIVE

This study describes the sonographic features of sacral perineural cysts that initially presented as adnexal complex cystic masses on transvaginal sonography.

CONCLUSION

Perineural cysts may have a complex cystic appearance, including septation and internal debris, on transvaginal sonography. The extraovarian, extraperitoneal, and posterior location on real-time sonography are suggestive features.

Amniotic fluid infection, cytokines, and adverse outcome among infants at 34 weeks' gestation or less

OBJECTIVE

We examined the hypothesis that amniotic fluid (AF) infection and elevated cytokine concentrations may cause neonatal injury beyond that expected solely from prematurity.

METHODS

The effects of exposure to AF infection and elevated cytokine concentrations were measured in 151 infants born to afebrile women in preterm labor with intact membranes at less than or equal to 34 weeks' gestation. Amniotic fluid was collected by amniocentesis for culture and determination of tumor necrosis factor-alpha and interleukin-6. Cytokine concentrations, stratified by AF infection, were compared for three gestational age groups. We then examined the associations between a positive AF culture or elevated AF tumor necrosis factor-alpha concentration and adverse neonatal outcomes, adjusted for birth weight.

RESULTS

Amniotic fluid from 45 (30%) of 151 pregnancies had microorganisms, an elevated tumor necrosis factor-alpha concentration, or both. Amniotic fluid cytokine concentrations were significantly higher among women in preterm labor at less than or equal to 30 weeks, compared with 31-34 weeks. Nine of 11 infants who died at less than or equal to 24 hours of age had AF infection or elevated AF tumor necrosis factor-alpha. For the 140 surviving infants, AF infection and/or an elevated AF tumor necrosis factor-alpha was associated with respiratory distress syndrome (adjusted odds ratio [OR] 1.7), grade 3-4 intraventricular hemorrhage (adjusted OR 2.2), necrotizing enterocolitis (adjusted OR 1.8), and multiple organ dysfunction (adjusted OR 3.0).

CONCLUSION

Among infants born at less than or equal to 34 weeks to women who have intact membranes and are initially afebrile, those exposed to AF bacteria or cytokines have more adverse neonatal outcomes than unexposed infants of similar birth weight.

Occult carcinoma in prophylactic oophorectomy specimens: prevalence and association with BRCA germline mutation status

Prophylactic oophorectomy (PO) is an option for women at increased risk for ovarian carcinoma. In this study the value of intensive pathologic examination of PO specimens and accompanying resected tissues in the identification of occult carcinoma and any association of occult carcinoma with BRCA germline mutation status were ascertained. Specimens from 60 consecutive PO patients, who were not suspected of having any ovarian tumor at the time of surgery, were subjected to standardized, complete pathologic examination in a prospective study over an 8-year period. Extra-ovarian tissues were examined as well, but they were not subject to the same standardized protocol. Any occult carcinoma of the ovaries or fallopian tubes was noted. The BRCA status and follow-up of patients were obtained, if available. Fifty-five of the 60 PO specimens did not show any evidence of malignancy. Of the 32 patients in this group followed for >1 year, all are alive and well. The remaining five patients, all BRCA1 mutation positive, showed occult carcinoma of the ovaries and/or in situ or invasive carcinoma of a fallopian tube. One of these five patients has died of abdominal carcinomatosis; four continue to be well, but follow-up is <4 years in all cases. Occult carcinoma is present in a small proportion of BRCA-positive or unknown PO patients and may be of prognostic significance. The entire ovaries and tubes from PO patients should be submitted for histologic examination to identify malignancy.