Circumferential resection margin (CRM) in esophageal (OC) and gastroesophageal (GOJ) cancers

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Background: We hypothesized that CRM size affect survival and local recurrence for OC and GOJ cancer. We also assessed the utility of CT in predicting margin status.

Methods: A retrospective analysis of a prospective database was carried out on all patients who had esophagectomy between January 2000 and July 2008. Patients diagnosed with OC and GOJ tumors on final pathologic examination were included. Distance from the CRM was assessed by a specialist upper GI pathologist. Two radiologists, blinded to postoperative margin status, reviewed preoperative CT scans using 16 separate parameters, comparing them to measured CRM status.

Results: 419 patients were assessed. 223 pts had OC or GOJ type 1 tumors, average age 62 years (range 36–80), mean follow-up 5.8 years (2-9.5). There were 125 deaths and median overall survival (OS) 3.33 years (95% CI 2.76-6.24). 76 patients had recurrence at a median of 1.3 years (0.1-4.7). For 144 patients had OC or GOJ type 1 T3 tumors. Selected results are presented in the Table. There was no CRM size above which there was no further reduction in recurrence. Postoperative chemoradiation did not improve OS (p=0.79) or recurrence (p=0.96) in patients with CRM of 0-1 mm. In 50 patients the CT parameters significantly correlated with margin status were largest axial diameter (p=0.003) and contact with adjacent structures (p=0.005). A complete statistical review with multivariate and subgroup analyses will be presented.

Conclusions: CRM size is strongly correlated with survival and recurrence in OC and type 1 GOJ tumors. Prediction of a close CRM could be used to select for more intensive therapy prior to undergoing radical surgery, such as chemoradiation. Preoperative CT can help in this prediction.

[Table: see text]

No significant financial relationships to disclose.

Complexity and accuracy of image registration methods in SPECT-guided radiation therapy

The use of functional imaging in radiotherapy treatment (RT) planning requires accurate co-registration of functional imaging scans to CT scans. We evaluated six methods of image registration for use in SPECT-guided radiotherapy treatment planning. Methods varied in complexity from 3D affine transform based on control points to diffeomorphic demons and level set non-rigid registration. Ten lung cancer patients underwent perfusion SPECT-scans prior to their radiotherapy. CT images from a hybrid SPECT/CT scanner were registered to a planning CT, and then the same transformation was applied to the SPECT images. According to registration evaluation measures computed based on the intensity difference between the registered CT images or based on target registration error, non-rigid registrations provided a higher degree of accuracy than rigid methods. However, due to the irregularities in some of the obtained deformation fields, warping the SPECT using these fields may result in unacceptable changes to the SPECT intensity distribution that would preclude use in RT planning. Moreover, the differences between intensity histograms in the original and registered SPECT image sets were the largest for diffeomorphic demons and level set methods. In conclusion, the use of intensity-based validation measures alone is not sufficient for SPECT/CT registration for RTTP. It was also found that the proper evaluation of image registration requires the use of several accuracy metrics.

Monte Carlo calculation of dose distribution in early stage NSCLC patients planned for accelerated hypofractionated radiation therapy in the NCIC-BR25 protocol

The dosimetric consequences of plans optimized using a commercial treatment planning system (TPS) for hypofractionated radiation therapy are evaluated by re-calculating with Monte Carlo (MC). Planning guidelines were in strict accordance with the Canadian BR25 protocol which is similar to the RTOG 0236 and 0618 protocols in patient eligibility and total dose, but has a different hypofractionation schedule (60 Gy in 15 fractions versus 60 Gy in 3 fractions). A common requirement of the BR25 and RTOG protocols is that the dose must be calculated by the TPS without tissue heterogeneity (TH) corrections. Our results show that optimizing plans using the pencil beam algorithm with no TH corrections does not ensure that the BR25 planning constraint of 99% of the PTV receiving at least 95% of the prescription dose would be achieved as revealed by MC simulations. This is due to poor modelling of backscatter and lateral electronic equilibrium by the TPS. MC simulations showed that as little as 75% of the PTV was actually covered by the 95% isodose line. The under-dosage of the PTV was even more pronounced if plans were optimized with the TH correction applied. In the most extreme case, only 23% of the PTV was covered by the 95% isodose.

Dual simulated childbirth injuries result in slowed recovery of pudendal nerve and urethral function

AIMS

Pelvic floor muscle trauma and pudendal nerve injury have been implicated in stress urinary incontinence (SUI) development after childbirth. In this study, we investigated how combinations of these injuries affect recovery.

METHODS

Sixty-seven female Sprague-Dawley rats underwent vaginal distension (VD), pudendal nerve crush (PNC), PNC and VD (PNC + VD), pudendal nerve transection (PNT), or served as unmanipulated controls. Four days, 3 weeks, or 6 weeks after injury, we simultaneously recorded pudendal nerve motor branch potentials (PNMBP), external urethral sphincter electromyography (EUS EMG), and transurethral bladder pressure under urethane anesthesia. The presence of a guarding reflex (increased frequency and amplitude of PNMBP or EUS EMG activity) during leak point pressure (LPP) testing was determined.

RESULTS

Controls consistently demonstrated a guarding reflex. Four days after VD, EUS EMG activity was eliminated, but PNMBP activity reflected the guarding reflex; EUS EMG activity recovered after 3 weeks. Four days after PNC, both EUS EMG and PNMBP activity were eliminated, but demonstrated significant recovery at 3 weeks. Four days after PNC + VD both EUS EMG and nerve activity were eliminated, and little recovery was observed after 3 weeks with significant recovery of the guarding reflex 6 weeks after injury. Little recovery was observed at all time points after PNT. LPP results mirrored the reduction in EUS EMG activity.

CONCLUSION

Functional recovery occurs more slowly after PNC + VD than after either PNC or VD alone. Future work will be aimed at testing methods to facilitate neuroregeneration and recovery after this clinically relevant dual injury.

The National Psychiatric Morbidity Surveys of Great Britain--initial findings from the household survey

This paper describes the Household Survey from the National Survey of Psychiatric Morbidity. This covered a sample drawn at random from the population of Britain, with the exception of the Highlands and Islands of Scotland. The Postcode Address File was used as the sampling frame. Nearly 13,000 adults aged 16-65 were selected for interview, of which 10,108 (79.4%) were successfully interviewed. Eight percent could not be contacted and 13% refused interview. Psychiatric assessment was carried out by lay interviewers using the CIS-R. Subjects were also screened for psychosis, and screen-positive individuals were examined by psychiatrists using SCAN. Sixteen per cent of subjects scored above the standard cut-off of 12 on the CIS-R. The overall one-week prevalence of neurotic disorder was 12.3% in males and 19.5% in females. Unmarried and post-marital groups had high rates of disorder, as did single parents and people living on their own. Respondents in Social Class I had notably lower rates of neurotic disorder than the remainder of the sample. Unemployment was strongly associated with disorder. Subjects living in urban areas had a higher overall prevalence, but there was no significant variation by region. Black respondents had higher rates of disorders that were entirely explained by their age, family type, and social class. Individual neurotic disorders were all significantly commoner in women, with the exception of panic disorder. The one-year prevalence of functional psychoses was four per 1000, with no sex difference. Alcohol and drug dependence was considerably more prevalent in men. For the first time, the survey provides data on the prevalence and correlates of psychiatric disorder on a nationwide sample that can be used to inform equitable and effective national psychiatric services.

Socio-economic status, standard of living, and neurotic disorder

Evidence on the association between socio-economic status and the prevalence of neurotic disorder is contradictory. We studied the association between three elements of socio-economic status and the prevalence of neurotic psychiatric disorder in a representative sample of adults aged 16-64 living in private households in the UK. A cross-sectional survey of 10,108 adults aged 16-65 resident in private households in the UK was selected by a multi-stage, clustered, random-sampling design. Neurotic disorders were defined using a standardised interview, the revised clinical interview schedule (CIS-R). Data for 9570 people were available for this study. We used housing tenure and access to cars as measures of standard of living; both were associated with the prevalence of neurotic disorder even after adjustment for other socio-economic and demographic variables, including the Registrar General's Social Class and educational attainment. Those people with no access to a car had an odds ratio for neurotic disorder of 1.4 (95% CI 1.1-1.7), compared with those who had access to two or more cars. People who rented their homes were also at increased risk (1.3 [1.1-1.5]). We estimated that about 10% of the neurotic disorder in the UK could be attributed to the increased prevalence of those without cars who rented their homes. There was a complex interaction between the Registrar General's Social Class and sex, and there was no independent association with educational attainment. There is an independent association between low standard of living and the prevalence of neurotic psychiatric disorder. The UK has experienced one of the largest increases in income inequality within western market economies over the past 20 years, and this inequality may have had adverse consequences for the mental health of the population.

The prevalence of psychiatric morbidity among adults living in institutions

This paper presents prevalence data from the 1994 OPCS survey of psychiatric morbidity among adults permanently resident in institutions catering for people with mental health problems in Great Britain. It describes briefly the survey methods used, and how diagnoses of psychiatric morbidity were derived. Its main aim is to show the prevalence of psychiatric morbidity in different types of institutional settings. Residents were eligible for the survey if they were aged 16 to 64 at the date of sampling and were permanently resident at the establishment. Residents were defined as permanently resident if they had been living in the sampled establishment for six months or more, or had no other permanent address, or were likely to stay in the establishment for the foreseeable future. In 1994, about 33,200 adults aged 16 to 64 were permanently resident in accommodation for people with mental health problems. About a third of residents were in NHS hospitals, while about two-thirds were in residential care facilities. About two-thirds of adults interviewed suffered from schizophrenia, delusional and schizoaffective disorders. About 8% suffered from neurotic disorders and 8% suffered from affective psychoses (mainly bipolar affective disorder). The prevalence of schizophrenia, delusional, and schizoaffective disorders was higher in hospitals than in residential care, while the prevalence of neurotic and related disorders was higher in residential accommodation. The prevalence of schizophrenia, delusional, and schizoaffective disorders was higher in NHS psychiatric hospitals and general hospital units than in private hospitals, clinics or nursing homes.

The circumstances of adults with a psychotic disorder

This article presents some findings about adults with a psychotic disorder who were identified in the OPCS surveys of psychiatric morbidity. The main aim of the analysis was to identify characteristics associated with differences in the circumstances and health-related behaviour of adults aged 16-64 with psychosis. The analysis covers people who were identified by the various criteria used on the surveys as having a psychotic illness and who were considered to be living in private households. First we describe briefly the survey methods used and how diagnoses of psychosis were derived. We then present results from four topic areas covered in the analysis. These are: use of medication, use of health services, difficulties with activities of daily living, and social support.

The National Psychiatric Morbidity Surveys of Great Britain--strategy and methods

This paper describes the rationale and methodology of the first National Psychiatric Morbidity Surveys to be carried out in Great Britain. The objectives of the surveys were to estimate the prevalence of psychiatric morbidity among adults aged 16-64 living in Great Britain; to identify the nature and extent of social disabilities associated with psychiatric morbidity; to describe the use of health and social services by people with psychiatric morbidity and to investigate the association between mental illness and potential environmental risk factors in a household sample. Four separate surveys were carried out in order to meet the objectives; a private household sample (n = 10,108), a sample of institutions caring for the mentally ill (n = 1191), a sample of homeless people (n = 1166), and a supplementary sample of patients with psychosis living in private households (n = 350). A two-stage assessment procedure was used, in which all subjects were given the Revised Clinical Interview Schedule (CIS-R) administered by lay interviewers to assess neurotic symptoms and disorders and a psychosis screen, including the Psychosis Screening Questionnaire. Those who were positive on the psychosis screen were then interviewed by psychiatrists using the SCAN (incorporating the tenth edition of the Present State Examination). Large scale national surveys such as this augment the inadequate data on psychiatric morbidity that are routinely available and are, therefore, an important source of information upon which to base policy and generate aetiological hypotheses. These surveys provide a possible model for similar surveys in other countries.

Substance misuse and psychiatric comorbidity: an overview of the OPCS National Psychiatric Morbidity Survey

There have been a number of national surveys of psychiatric morbidity, which have included questions on drugs, alcohol, and tobacco. These surveys have helped delineate the overlap between substance use and dependence and other psychological morbidity. There is a strong association reported between high substance consumption and other measures of psychological problems. This article provides an overview of a national household survey, a survey of institutional residents with psychiatric disorders, and a national survey of a homeless population. All three surveys used comprehensive and complex sampling strategies and lay interviewers to conduct structured diagnostic interviews. The household survey included over 10,000 households, the institutional survey interviewed 755 individuals, and the homeless survey of hostels, night shelters, day centres, and private sector leased accommodation interviewed 1,061 individuals. This overview looks at patterns of nicotine, alcohol, and other drug use in the different samples and examines interactions with other psychiatric morbidity. The survey reports that substance-related disorders are some of the commonest disorders in the community, with 5% of the household sample alcohol dependent, 7% alcohol dependent in the institutional sample and over 21% in the homeless sample recorded as alcohol dependent. Tobacco, alcohol and other drug use and dependence were dramatically higher in the homeless sample than in either of the other two samples. Substance use was significantly associated with higher rates of psychological morbidity as measured by the Clinical Interview Schedule Revised. Future service planning needs to take account of the striking disparity of prevalence of psychiatric disorders in different subsections of the population.

Chromosome mapping and phylogenetic analysis of the cytosolic acetyl-CoA carboxylase loci in wheat

The cytosolic isoform of plant acetyl-CoA carboxylase is a multidomain enzyme involved in the synthesis of very-long-chain fatty acids and in secondary metabolism. Chromosome mapping of wheat identified one locus containing cytosolic acetyl-CoA carboxylase genes (Acc-2) and a related partially processed pseudogene (Psi-Acc-2) in the distal region of the long arm of wheat homoeologous group 3 chromosomes. Multiple copies of the Acc-2 genes, whose presence was suggested by sequence analysis, are likely to be arranged in tandem repeats. At least three out of five genes cloned from hexaploid wheat map to this locus. Another locus containing Acc-2--related sequences is present in the distal region of the long arm of chromosome 5D. The identity of the hybridizing DNA present at this locus remains unknown. A system based on PCR-cloning and DNA sequence analysis of acetyl-CoA carboxylase genes was developed to address various phylogenetic and systematics questions in grasses. It was applied to reconstruct the phylogeny of the Acc-2 genes from D- and S-genome Aegilops and A-genome Triticum diploid species, AABB- and AAGG-genome tetraploid wheat, and AABBDD-genome hexaploid wheat, as well as from rye and barley. The combined cytogenetic and molecular evolution approach allowed assignment of gene sequences included in phylogenetic analysis to specific loci on homoeologous chromosomes. Recurring gene duplication followed by chromosome translocation and/or possible loss of some gene copies, as well as loss of introns, occurred in the gene family in different plant lineages. Two major Acc-2 clades appeared before the divergence of barley and rye. Nucleotide substitution rates in different parts of the Acc-2 gene were assessed. This analysis of the Acc-2 loci provides detailed information regarding evolutionary events at a low--copy-number locus containing important functional genes. These events are likely to be common and to play a significant role in shaping grass genomes.