Predicting who applies to study medicine: implication for diversity in UK medical schools

AIMS

Widening access to medical school is a priority in medical selection. If disadvantaged students do not apply, interventions cannot be effective. To date, no studies have examined factors that predict who chooses to apply to medicine and if socio-demographics influence the profile of those who apply to study medicine.

METHODS

A large database provided by the UK University and Colleges Admissions Service on all 1,225,156 applicants to UK universities over a 3-year period (2002-2004) was analysed. The relationship between demographics, preference to study medicine and academic performance prior to entry (A level score) were explored using logistic and linear regression and path modelling.

RESULTS

Those applying to study medicine were more likely to be female, non-white, of higher socio-economic status and from fee-paying schools. Applying to study medicine was associated with increased academic entrance performance over and above socio-demographic factors. Importantly, in those applying to study medicine socio-demographic inequalities in entrance exam performance was either reduced (for ethnicity and SES) or abolished (for sex and schooling).

CONCLUSIONS

It is argued that early interventions are needed to increase applications for certain groups to help to reduce socio-demographic inequalities in entrance exam performance and hence medical school admissions.

Testosterone-mediated sex differences in the face shape during adolescence: subjective impressions and objective features

Sex identification of a face is essential for social cognition. Still, perceptual cues indicating the sex of a face, and mechanisms underlying their development, remain poorly understood. Previously, our group described objective age- and sex-related differences in faces of healthy male and female adolescents (12-18 years of age), as derived from magnetic resonance images (MRIs) of the adolescents' heads. In this study, we presented these adolescent faces to 60 female raters to determine which facial features most reliably predicted subjective sex identification. Identification accuracy correlated highly with specific MRI-derived facial features (e.g. broader forehead, chin, jaw, and nose). Facial features that most reliably cued male identity were associated with plasma levels of testosterone (above and beyond age). Perceptible sex differences in face shape are thus associated with specific facial features whose emergence may be, in part, driven by testosterone.

Hepatitis B Virus Genotype G forms core-like particles with unique structural properties

We have determined the structure of the core capsid of an unusual variant of hepatitis B virus, genotype G (HBV/G) at 14Å resolution, using cryo-electron microscopy. The structure reveals surface features not present in the prototype HBV/A genotype. HBV/G is novel in that it has a unique 36-bp insertion downstream of the core gene start codon. This results in a twelve amino acid insertion at the N-terminal end of the core protein, and two stop codons in the precore region that prevent the expression of HBeAg. HBV/G replication in patients is associated with co-infection with another genotype of HBV, suggesting that HBV/G may have reduced replication efficiency in vivo. We localized the N-terminal insertion in HBV/G and show that it forms two additional masses on the core surface adjacent to each of the dimer-spikes and have modelled the structure of the additional residues within this density. We show that the position of the insertion would not interfere with translocation of nucleic acids through the pores to the core interior compartment. However, the insertion may partially obscure several residues on the core surface that are known to play a role in envelopment and secretion of virions, or that could affect structural rearrangements that may trigger envelopment after DNA second-strand synthesis.

Use and perceived effectiveness of non-analgesic medical therapies for chronic pancreatitis in the United States

BACKGROUND

Effectiveness of medical therapies in chronic pancreatitis has been described in small studies of selected patients.

AIM

To describe frequency and perceived effectiveness of non-analgesic medical therapies in chronic pancreatitis patients evaluated at US referral centres.

METHODS

Using data on 516 chronic pancreatitis patients enrolled prospectively in the NAPS2 Study, we evaluated how often medical therapies [pancreatic enzyme replacement therapy (PERT), vitamins/antioxidants (AO), octreotide, coeliac plexus block (CPB)] were utilized and considered useful by physicians.

RESULTS

Oral PERT was commonly used (70%), more frequently in the presence of exocrine insufficiency (EI) (88% vs. 61%, P < 0.001) and pain (74% vs. 59%, P < 0.002). On multivariable analyses, predictors of PERT usage were EI (OR 5.14, 95% CI 2.87-9.18), constant (OR 3.42, 95% CI 1.93-6.04) or intermittent pain (OR 1.98, 95% CI 1.14-3.45). Efficacy of PERT was predicted only by EI (OR 2.16, 95% CI 1.36-3.42). AO were tried less often (14%) and were more effective in idiopathic and obstructive vs. alcoholic chronic pancreatitis (25% vs. 4%, P = 0.03). Other therapies were infrequently used (CPB - 5%, octreotide - 7%) with efficacy generally <50%.

CONCLUSIONS

Pancreatic enzyme replacement therapy is commonly utilized, but is considered useful in only subsets of chronic pancreatitis patients. Other medical therapies are used infrequently and have limited efficacy.

Perceiving classroom aggression: The influence of setting, intervention style and group perceptions

BACKGROUND

Violence and aggression in the classroom are often cited as a major concern within the teaching community. Teachers' perceptions of the appropriateness of intervention behaviours during aggressive incidents, however, are less often examined (Meyer, Astor, & Behre, 2002), nor how they compare to the perceptions of training teachers (John, 2002).

AIMS

This paper examines differences in the perceptions of practising and training teachers after exposure to an account of a violent incident where a school teacher is assaulted. The paper also investigates the relative and combined influence of classroom condition and teacher intervention on perceptions of classroom violence.

SAMPLE(S)

Participants included 48 practising teachers, and 48 students undertaking a Postgraduate Certificate in Education (PGCE) also took part in the study.

METHODS

The study utilized a 2 x 2 x 2 between-subjects factorial design, manipulating the impact of classroom condition, teacher intervention, and observer status on evaluations of the teacher, assailant and school following an incident of violence against the teacher.

RESULTS

Classroom environment, teacher intervention, and observer status influenced evaluations of the teacher and school, but not the assailant.

CONCLUSIONS

Implications of these findings and the applied importance of these results are discussed in relation to school policy, teacher training, and classroom maintenance.

Gadolinium as an alternative contrast agent for therapeutic ERCP in the iodine-allergic patient

Performance of endoscopic retrograde cholangiopancreatography (ERCP) requires an intraductal contrast agent. The contrast of choice is an iodine-based agent. The alternatives in patients with a severe allergy to iodinated contrast are limited. We undertook a retrospective review of the success and safety of gadolinium as an alternative radiocontrast agent in patients with allergy to iodine-based contrast in a series of five patients in a tertiary care pancreaticobiliary referral center. The five patients underwent a total of six ERCP procedures using a gadolinium chelate as the radiocontrast agent. ERCP was technically successful in all cases, including pancreatic endotherapy. There were no contrast-related adverse reactions. Gadolinium is concluded to be a reasonable alternative to iodine-based ERCP contrast in selected patients. It provides inferior image quality compared to standard iodine-based contrast but was not technically limiting in our small experience.

Predicting risk of developing invasive breast cancer in the African American female population

11080

Background: African Americans (AA) have a lower incidence of breast cancer with a poorer prognosis than Caucasians. It is unclear whether AA women have fewer known risk factors for breast cancer or that risk factors have a lesser effect in AA. We evaluated the accuracy of the race-based modification Gail Model in predicting the risk of developing invasive breast cancer in the AA population. Methods: With IRB approval, we performed a retrospective analysis of data obtained from women (n=15,973) ages 40–79 presenting to our Breast Center(5/2003 to 7/2005) for a screening mammogram. The five-year probability of breast cancer for AA (n=702) versus Caucasians (n=15,721) was calculated for each individual using 3 methods: 1) the race specific Gail model, 2) the Gail model ignoring race (AA using the Caucasian model), and 3) age and race matched SEER projection using DevCan (v6.1.1) software. Results: There was no significant difference between the 5-year probability of breast cancer for Caucasians as calculated by the Gail model vs. the SEER prediction (p=NS), suggesting our population was representative of the larger study population from which SEER data was derived. As compared to SEER prediction, the modified Gail model underestimated the breast cancer risk for all age groups of AA (p<0.0001). When the Gail Model without the race-based modification was applied to the AA population, the projected risk was not significantly different from the SEER prediction (p=0.1049). Conclusions: This study suggests that the race-based modification of the Gail Model underestimate the risk of breast cancer in AA women. When the model is applied to AA women without incorporating the modification for race, the Gail model accurately reflects SEER 5-year projections of risk of invasive cancer in AA women. Differences in risk factor distribution among race, rather than a differential effect of those factors on risk, may have a substantial role in explaining the lower incidence in AA women as compared to Caucasian women over 40.

[Table: see text]

No significant financial relationships to disclose.

Pilot comparison of adhesion formation following colonic perforation and repair in a pig model using a transgastric, laparoscopic, or open surgical technique

BACKGROUND AND STUDY AIM

Postoperative adhesions create significant morbidity and mortality. Natural orifice transluminal endoscopic surgery (NOTES) procedures may reduce or eliminate adhesions by avoiding disruption of the parietal peritoneum. The primary aim of this pilot study was to compare adhesion formation after performance and subsequent repair of colonic perforation via transgastric, laparoscopic, or open surgical techniques. The secondary aim was to test the feasibility and outcome of transgastric management of bowel perforation in a prepared model.

MATERIAL AND METHODS

15 Yorkshire pigs were divided into three groups of five: transgastric (needle-knife entry with balloon dilation over a wire), laparoscopic, and open surgical. Aspects of adhesion formation (density/vascularity, width of bands, and number of organ pairs involved) were compared after perforation and repair during the same procedure. Intra- and postoperative complications were documented during the 21-day survival period.

RESULTS

All 15 pigs recovered fully with no immediate procedural complications. After 21 days, there was a trend towards a lower adhesion burden regarding density/vascularity and number of organ pairs involved, and a significant reduction in the width of the adhesive bands, when the transgastric group was compared with the surgical groups. Additionally, there was a trend towards decreased adhesions to the peritoneum in the transgastric group.

CONCLUSIONS

Repair of colonic perforation during transgastric (NOTES) procedures appear feasible and safe in a porcine model. There appears to be a trend towards a lower rate of adhesion formation with the transgastric approach compared with laparoscopic or open surgery.

International Life Sciences Institute (Health and Environmental Sciences Institute, HESI) initiative on moving towards better predictors of drug-induced torsades de pointes

Knowledge of the cardiac safety of emerging new drugs is an important aspect of assuring the expeditious advancement of the best candidates targeted at unmet medical needs while also assuring the safety of clinical trial subjects or patients. Present methodologies for assessing drug-induced torsades de pointes (TdP) are woefully inadequate in terms of their specificity to select pharmaceutical agents, which are human arrhythmia toxicants. Thus, the critical challenge in the pharmaceutical industry today is to identify experimental models, composite strategies, or biomarkers of cardiac risk that can distinguish a drug, which prolongs cardiac ventricular repolarization, but is not proarrhythmic, from one that prolongs the QT interval and leads to TdP. To that end, the HESI Proarrhythmia Models Project Committee recognized that there was little practical understanding of the relationship between drug effects on cardiac ventricular repolarization and the rare clinical event of TdP. It was on that basis that a workshop was convened in Virginia, USA at which four topics were introduced by invited subject matter experts in the following fields: Molecular and Cellular Biology Underlying TdP, Dynamics of Periodicity, Models of TdP Proarrhythmia, and Key Considerations for Demonstrating Utility of Pre-Clinical Models. Contained in this special issue of the British Journal of Pharmacology are reports from each of the presenters that set out the background and key areas of discussion in each of these topic areas. Based on this information, the scientific community is encouraged to consider the ideas advanced in this workshop and to contribute to these important areas of investigations over the next several years.

Small prophylactic pancreatic duct stents: an assessment of spontaneous passage and stent-induced ductal abnormalities

BACKGROUND AND STUDY AIMS

Placing small stents in the pancreatic duct at endoscopic retrograde cholangiopancreatography reduces the risk of pancreatitis. However, this practice means that a second procedure might be required to remove the stent, and stents can also damage the duct. The aims of this study were to determine the frequency of spontaneous dislodgment and to assess the incidence of stent-induced ductal irregularities.

PATIENTS AND METHODS

We performed a retrospective analysis of consecutive patients seen over a 3-year period (2001 - 2004) who had undergone placement of a 3-Fr pancreatic duct stent and in whom the fate of the stent had been documented. Radiographs were reviewed to determine stent passage at 30 days. If applicable, follow-up pancreatograms were reviewed to assess for stent-induced ductal abnormalities. Statistical analysis was performed using chi-squared and Fisher's exact tests for proportions, and 95 % binomial confidence intervals (CI) were calculated.

RESULTS

Records for 125 consecutive patients who had had 3-Fr pancreatic stents placed were reviewed. The stents had passed spontaneously within 30 days in 110/125 patients (88 %). In the remaining 15 patients (12 %, 95 % CI 6.9 % - 19 %), the stents were still present on follow-up radiographs after a median time of 36 days, (range 31 - 116 days). Stent length, pancreatic sphincterotomy, and pancreas divisum had no effect on the likelihood of spontaneous passage. No stent-induced ductal irregularities were observed.

CONCLUSIONS

Nearly 90 % of prophylactic 3-Fr pancreatic duct stents pass spontaneously within 30 days, and these stents were not observed to induce changes in the pancreatic duct.

LCIS and tamoxifen use: A single institution review

1527

Background: Results of the NSABP-P1 trial were published in 1998 showing a 50% reduction in breast cancer in the high- risk population with the use of tamoxifen. The use of tamoxifen is individualized, and depends on both patient and physician factors. We looked at the recommendations for and the use of tamoxifen in women with LCIS. Methods: A retrospective chart review at a single institution was performed from March 27, 1980 through September 19, 2005 for patients diagnosed with LCIS. Pathology and operative reports, as well as patient notes were reviewed for discussions about tamoxifen. Data was collected on whether a discussion took place, whether tamoxifen was or was not advised, whether the patient declined to take tamoxifen, whether they took it in the past or were currently on tamoxifen. We also examined the rate of DCIS and invasive cancer in this population. Results: There were 321 patients diagnosed with LCIS. Of those patients 193 were diagnosed after the publication of the P1 trial. Of these 193 patients we identified 104(54%) patients whose charts contained notes indicating a discussion about tamoxifen. The results of the discussion about tamoxifen are as follows: 21(20%) patients were currently taking tamoxifen, 16(15%) had taken it in the past, 37(36%) patients declined to take tamoxifen, and 17(16%) had not made a decision about taking tamoxifen. There were 13(13%) patients for whom tamoxifen was advised against. In the entire cohort of 321 patients, 15% went on to develop DCIS or invasive cancer in the first 12 years of follow up. We did not look at cancer rate Vs tamoxifen use due to the small numbers with available information. Conclusions: While the P1 trial recommends tamoxifen for breast cancer prevention in high-risk patients, in our experience, almost half of the patients did not have a documented discussion about the medication, and the majority of those who did decided not to take tamoxifen. This will likely have a large impact on the rate of DCIS and invasive breast cancer in this group.

No significant financial relationships to disclose.

A phase II study of pemetrexed in patients (pts) with advanced neuroendocrine tumors (NETs)

15149

Background: Traditional antifolates such as 5-florouracil have been associated with only modest activity in NETs. Pemetrexed is a multitargeted antifolate active in diseases not known to be responsive to other antifolates. We performed a prospective phase II study of pemetrexed in pts with advanced NETs to assess response, toxicity, and survival. Methods: Pts were treated with Pemetrexed administered intravenously at a dose of 500 mg/m2 every 21 days. To reduce toxicity, folic acid and vitamin B12 supplementation were mandatory. Pts were also treated with oral dexamethasone 4 mg twice daily the day prior to, day of, and day after pemetrexed administration. The study utilized a two-step design, with an initial accrual phase of 17. Pts were required to have metastatic neuroendocrine tumors (excluding small cell carcinoma), and preserved hematologic, renal, and hepatic function. Treatment with prior chemotherapy was allowed; pts receiving octreotide remained on octreotide at a stable dose level during study therapy. Results: 17 pts were enrolled with the following characteristics: M: F=4:13. median age 56 (range 38 to 72); ECOG Performance Status 0/1/2=4/12/1. Tumor types included carcinoid n=12(71%) and islet cell n=5(29%). 17 pts received treatment for a median of three, 21-day cycles; the median time on study was 10 weeks. Grade 3–4 toxicities included: fatigue n=8(47%), leukopenia n=7 (41%), neutropenia n=6 (35%), elevated alkaline phosphatase n=4 (23%), thrombocytopenia n=3 (17%), lymphopenia n=3 (17%), pneumonitis n=2 (11%), hyponatremia n=2 (11%), dyspnea n=1 (5%), hyperbilirubinemia n=1 (5%), weight loss n=1 (5%), diarrhea n=1 (5%), elevated ALT/SGPT n=1 (5%), edema n=1 (5%), weakness n=1 (5%), grade 4 proteinuria n=1 (5%). 15 pts were evaluable for response; the best treatment response was stable disease (n=9;), the remaining 6 pts experienced progressive disease as their best response to therapy. Accrual to the study was halted due to lack of observed antitumor activity. Conclusions: Pemetrexed does not have significant antitumor activity in pts with advanced NET.

No significant financial relationships to disclose.

Phase II study of FOLFOX, bevacizumab and erlotinib as first-line therapy for patients with metastatic colorectal cancer

BACKGROUND

Targeting the epidermal growth factor receptor and angiogenesis have proven useful strategies against metastatic colorectal cancer. The benefit of combining inhibitors of both pathways is unknown.

PATIENTS AND METHODS

Patients with previously untreated metastatic colorectal cancer were enrolled in a phase II trial of infusional 5-fluorouracil, leucovorin, oxaliplatin (FOLFOX), bevacizumab and erlotinib. The primary end point was progression-free survival.

RESULTS

Thirty-five patients were enrolled and all came off trial for reasons other than progression; 18 (51%) had protocol-defined adverse events requiring removal, nine (26%) withdrew consent due to toxicity, six pursued surgery or localized therapies and two requested a treatment holiday. Principal toxic effects included rash, neuropathy and diarrhea. Seven patients came off trial before first restaging. By intention-to-treat analysis, one patient had a confirmed complete response, 10 had confirmed partial responses and one had an unconfirmed partial response (response rate = 34%). One patient had progressive disease at time of withdrawal from the trial, thus progression-free survival could not be calculated.

CONCLUSION

The combination of FOLFOX, bevacizumab and erlotinib led to higher than expected early withdrawal due to toxicity, limiting conclusions regarding efficacy. These findings raise concern regarding the tolerability of adding more agents to already complex combination regimens for metastatic colorectal cancer.

A potential generic downstream process using Cibracon Blue resin at very high loading capacity produces a highly purified monoclonal antibody preparation from cell culture harvest

The use of a dye-ligand chromatography for the purification of monoclonal antibody (MAb) from cell culture and other feed streams has been largely overlooked in large scale production. Cibracon Blue dye (CB), a polycyclic anionic ligand, interacts with protein through a specific interaction between the dye, acting as a mimic of NAD+ and NADP+, or through non-specific electrostatic, hydrophobic, and other forces. In this paper, a CB resin was used to effectively and efficiently separate an IgG4 MAb from host and process impurities following the capture of the MAb on a Protein-A (PA) column. The CB unit operation, challenged at </=180 g MAb/L of resin with the PA eluate, reduced BSA (1-2 log), host cell protein (HCP; 2-3 log), MAb oligomer (31-85%), fragment (from approximately 0.8% to <0.1%), and other undesired MAb species. Purity, as measured by non-reducing (NR) SDS-PAGE, was improved 33-85%, to 92-99.5% overall (>99% by reducing SDS-PAGE). A facile three column scalable production scheme, employing CB as the second column in the process was used to generate highly purified MAb from cell culture harvest derived from two media of very different compositions. Free CB dye was </=1 ng/mg in MAb preparations purified through the three column process and then concentrated and buffer exchanged into the appropriate buffer using tangential flow filtration (TFF).

The effect of poly-l-lysine and urine volume upon the attachment to microscope slides of sperm from the urine of Numbats (Myrmecobius fasciatus) and Dibblers (Parantechinus apicalis)

Sperm in numbat and dibbler urine can be seen reliably in wet preparations but adhesion of sperm to the microscope slide during fixation and staining has not been relable. Slide coated with poly-L-lysine show 20% more sperm remaining compared to uncoated slides.

Phase II cisplatin, irinotecan, cetuximab and concurrent radiation therapy followed by surgery for locally advanced esophageal cancer

4064

Background: Weekly irinotecan, cisplatin, and concurrent radiation therapy is a well-tolerated, active regimen in locally advanced esophageal cancer. (Ilson. JCO 2003) Cetuximab, an EGFR inhibitor, is a potent radiation sensitizer in head and neck cancer. (Bonner. Proc ASCO 2004) Methods: In this phase II trial, patients (pts) with T2–4N0–1M0–1A esophageal adenocarcinoma (A) or squamous cell carcinoma (S) receive 5040 cGy/28 fractions of radiation therapy (RT) and concurrent weekly cisplatin 30mg/m2 plus irinotecan 65 mg/m2 on weeks 1, 2, 4, and 5, followed by surgery 4–8 weeks after completion of RT. Additionally, pts receive weekly infusions of cetuximab 250 mg during RT, up to one week before surgery, and for 6 months following surgery. Results: Seventeen pts have been entered: male: female = 14:3, median age 54, ECOG PS 0:1 = 6:11, A:S = 17:0, stage IIA:IIB:III:IVA = 6:1:8:2, tumor location-esophagus-mid:lower:gastroesophageal junction = 1:4:12, >10% weight loss-yes:no = 8:9. Of 17 pts entered, 15 pts have proceeded to surgery, 1 pt died from Aspergillus infection resulting in respiratory failure and sepsis, and 1 pt is pending surgery. Of the 15 pts who underwent surgery, 2 (13%) had a complete pathologic response; pathologic stage for other pts: 0 = 1, I = 3, IIA = 3, IIB = 1, III = 4, IV = 1. Grade III/IV toxicity (17 pts) was: diarrhea 9 pts, neutropenia 9 pts, febrile neutropenia 5 pts, anorexia 5 pts, vomiting 4 pts, fatigue 3 pts, mucositis 1 pt. Chemotherapy dose attenuation was required for diarrhea in 5 pts, for neutropenia in 4 pts, and for folliculitis in 1 pt. One patient was removed from study during week 6 for prolonged diarrhea/ dehydration. Due to the 2-step design of the trial, accrual is on hold pending a 3rd required pathologic CR in the first 17 patients. Conclusions: Compared to other trials of irinotecan, cisplatin, radiation therapy, and surgery in similar groups of esophageal cancer patients, early results for this combination with cetuximab suggest a lower complete response rate and higher overall toxicity. Additional data will be available at ASCO. Supported by Bristol-Myers Squibb.

No significant financial relationships to disclose.

Phase II study of FOLFOX, bevacizumab and erlotinib as initial therapy for patients with metastatic colorectal cancer (MCRC)

3545

Background: Cytotoxic chemotherapy with targeted therapy against the vascular endothelial growth factor (VEGF) or the epidermal growth factor receptor (EGFR) has become a standard approach in MCRC, though combining VEGF and EGFR inhibition with chemotherapy as initial treatment is not well established. We conducted a phase II study of the combination of infusional 5-fluorouracil (5-FU), leucovorin, oxaliplatin (FOLFOX), bevacizumab, and erlotinib in chemotherapy naïve patients with MCRC. Methods: Eligible patients had measurable MCRC, no prior systemic therapy for MCRC or at least one year since completion of adjuvant therapy (only 5-FU and leucovorin acceptable), performance status 0–1. The regimen consisted of 14-day cycles of FOLFOX started on day 1 (oxaliplatin 85 mg/m2, bolus 5-FU 400 mg/m2, leucovorin 400 mg/m2 and 46-hour infusion 5-FU 2.4 g/m2), day 1 bevacizumab 5 mg/kg and erlotinib 150 mg daily. This isa single stage trial with goal of 35 patients. The primary endpoint was progression-free survival (PFS). Results: Between Jan and Dec 2005, 31 patients have been enrolled with the following characteristics: male/female, 19/12; PS ECOG 0/1, 15/16; median age 58, range 38–81. Of the 28 patients who completed at least 1 cycle, the most common grade 3/4 adverse events include: 8/28 (29%) diarrhea, 8/28 (29%) neutropenia, 5/28 (18%) rash, 4/28 (14%) fatigue, 3/28 (11%) nausea/vomiting, 3/28 (11%) neuropathy. 22/28 (78%) of patients had at least 1 grade 3/4 toxicity. 14/31 patients remain on trial, 13/31 (42%) came off for toxicity or withdrew consent due to treatment-related toxicities, 4 withdrew consent for other reasons. Efficacy data is not available at time of submission but will be more mature by June 2006. Conclusions: The combination of FOLFOX, bevacizumab and erlotinib appears to have moderate toxicity, with ∼40% of patients coming off trial due to side effects. Further characterization of the tolerability profile will be necessary when interpreting the efficacy of the combination. We expect full accrual as well as reasonable point estimates of PFS by June 2006. Supported by: Sanofi-Synthelabo, a member of the Sanofi-Aventis group, Genentech

[Table: see text]

A phase II study of temozolomide and bevacizumab in patients with advanced neuroendocrine tumors

4044

Background: Inhibitors of the VEGF pathway have been shown to have activity in neuroendocrine tumors (NETs). Temozolomide (TMZ), an oral analog of dacarbazine is also active in this setting. We performed a prospective, phase II study to assess the safety and efficacy of TMZ, administered in combination with bevacizuamb, in patients (pts) with advanced NETs. Methods: Pts received TMZ, 150 mg/m2/day po for 7 days every other week, and bevacizumab, 5 mg/kg IV every other week. Due to anticipated lymphopenia, pts received prophylaxis with trimethoprim/sulfamethoxazole (1 DS tablet q MWF) and acyclovir (400 mg po TID). Pts were followed for toxicity, response, and survival. Results: Enrolled patients (n=34) had the following characteristics: M:F = 19:15; median age 61 (range 37–75); ECOG PS 0/1/2 = 12/20/2; carcinoid/pancreatic NET = 16/18. Prior treatments included chemoembolization (n=7) chemotherapy (n=12); and octreotide (n=17); pts on octreotide remained on octreotide at stable doses for the duration of the study. Pts had either well-differentiated tumors (n=27) or moderately/poorly-differentiated NETs (n=7); pts with small cell carcinoma were not eligible for the study. Pts have received treatment for a median of 22 weeks. Grade 3–4 toxicities included: lymphopenia (n=21, 62%), leukopenia (n=2, 6%), thrombocytopenia (n=7, 21%), neutropenia (n=2, 6%), hyponatremia (n=1, 3%), vomiting (n=3, 9%), nausea (n=2, 6%), dehydration (n=1, 3%), fatigue (n=2, 6%), constipation (n=1, 3%), and hypertension (n=1, 3%). 20 pts had elevated CGA levels (>36.4 ng/ml) at baseline; 0/9 (0%) carcinoid and 4/11 (36%) pancreatic NET experienced CGA decreases of >50% from baseline on two consecutive assessments. 29 pts are currently evaluable for radiologic response ( Table ). Conclusions: The combination of TMZ and bevacizumab can be safely administered and shows promising activity in pts with advanced pancreatic NETs. Additional studies with this combination are warranted.

[Table: see text]

[Table: see text]

Control of an ACC-1-producing Klebsiella pneumoniae outbreak in a physical medicine and rehabilitation unit

This article describes an outbreak of ACC-1-producing Klebsiella pneumoniae involving 40 patients. These were mainly men under 40 years old with a spinal cord injury, in a physical medicine and rehabilitation unit. The main risk factors were prolonged hospital stay, multiple-bed rooms, tracheostomy care and assisted defaecation. The outbreak was only controlled after the introduction of rigorous patient placement (i.e. single rooms or cohorting in the same room), while allowing the patients to have free access to the various technical services (e.g. physiotherapy and occupational therapy) and living spaces necessary for re-education.

Bedroom rape: sequences of sexual behavior in stranger assaults

This article examines the sequential, temporal, and interactional aspects of sexual assaults using sequential analysis. Fourteen statements taken from victims of bedroom-based assaults were analyzed to provide a comprehensive account of the behavioral patterns of individuals in sexually charged conflict situations. The cases were found to vary in the sexual severity of assault, distinguishing a variety of motivations and behavioral repertoires of offender and victim. Two quite distinct styles of offense were identified: multiple and single, which may have very different implications for research into rapist taxonomies and rape prevention strategies.

Temporomandibular joint morphology following post-traumatic ankylosis in 26 patients

This study evaluated the joint morphology on coronal computed tomography of ankylosed temporomandibular joints in 26 patients. All patients developed ankylosis following blunt trauma. Post-ankylosis joint morphology was assessed to determine if the precursor condylar fracture could be identified and this was compared to the condylar fracture prevalence to determine if any condylar fractures have an increased risk factor for ankylosis. Mean age at presentation was 20.9+/-14.41 years (range 6-58) and mean age at injury was 13.84+/-13.81 years (range 3-53). Thirty-seven joints were ankylosed in 26 patients (11 bilateral, 15 unilateral) with 27 joints in 19 patients showing vestiges of a medially dislocated condylar fracture (72.9% of joints). The prevalence of MDCF at our unit over a period of 6 months was 16.8% (16 of 95 condylar fractures). This suggests that a medially dislocated condylar fracture is more likely to ankylose than other condylar fractures. A hypothesis is proposed to explain this increased risk.

Terminal ileal stricture in Crohn's disease: treatment using a metallic enteral endoprosthesis

Enteral strictures are a frequent indication for surgery in Crohn's disease. Postoperative complications are increased in patients with poor preoperative nutritional status, which is common in this patient population. We present a 49-year-old female with longstanding Crohn's disease admitted to our Digestive Health Center with four weeks of increasing abdominal symptoms and radiographic evidence of small-bowel obstruction caused by ileal stricture. Given her poor nutritional status, our team elected to pursue metallic enteral stenting as a bridge to surgical resection. Two Wallstents were placed; luminal patency was subsequently confirmed by a fluoroscopic study. The patient tolerated regular diet and was discharged. When seen in follow-up, she remained asymptomatic and wished to defer surgical intervention indefinitely.

Intérêt du dépistage actif des bactéries multirésistantes dans les services de médecine physique et réadaptation

OBJECTIVES

The objective of this study was to evaluate the epidemiology of antibiotic-resistant bacteria among motor impaired patients admitted to an acute rehabilitation unit.

METHODS

From January 2000 to December 2002, the acute rehabilitation units of R. Poincare Hospital have screened patients for methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase enterobacteria (ESBL-EB) carriage by nasal and rectal swab at admission, every month and exit.

RESULTS

Finally, MRSA was isolated form screening or diagnosis samples of 360 patients and ESBL-EB from screening or diagnosis samples of 170 patients, corresponding respectively to an incidence of 3.6 for 1000 days of hospitalization (DH) and 1.7 for 1000 DH. 66% (236/360) of MRSA carriers and 58% of ESBL-EB carriers were identified only by screening samples. Carriage origin was identified for year 2002: Cases were imported for 40% (26/65) of MRSA carriers and 43% (18/42) of ESBL-EB carriers. The median acquisition delays were of 31 days [3-154] for MRSA and 19 days [3-317] for ESBL-EB.

CONCLUSION

This allowed to set up contact precautions for more than 2 fold patients that would have allowed diagnosis samples alone.

Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma

These guidelines for management of primary cutaneous squamous cell carcinoma present evidence based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. To reflect the collaborative process for the UK, this article is subject to dual publication in the British Journal of Dermatology and the British Journal of Plastic Surgery.

Axillary hyperhidrosis: eccrine or apocrine?

We review the literature regarding axillary hyperhidrosis, discuss normal sweat gland function and postulate on the respective roles of the eccrine, apocrine and apo-eccrine glands in the pathophysiology of excessive axillary sweating.

Improved resuscitation training of senior house officers in oral and maxillofacial surgery

All healthcare professionals are expected to be competent at cardiopulmonary resuscitation. In a previous study [Br J Oral Maxillofac Surg 1999; 37: 1], senior house officers in oral and maxillofacial surgery (OMFS) expressed dissatisfaction about their training in resuscitation, and we now report the results of a follow-up survey. The amount of training in resuscitation has increased in the 5 years since the initial questionnaire, and 77% of the 73 respondents (n=56) been given such training in the 12 months before the present survey, compared to 48% in the previous study. Fifty-one (70%) now think that they would feel confident if required to resuscitate a patient who had a cardiorespiratory arrest, and this has increased from 47%. Despite this, 70 (96%) of senior house officers in OMFS stated that they wanted further training in cardiopulmonary resuscitation.

[Molecular markers in the epidemiologic study of Legionella pneumophila infections]

PURPOSE

Legionnaires' disease is due to the inhalation of contaminated aerosols. The identification of the source of contamination in the aquatic environment is necessary to prevent the occurrence of new cases. A comparative study of clinical and environmental isolates is the basis of epidemiological investigations.

CURRENT KNOWLEDGE AND KEY POINTS

Genotypic methods are now mainly used to compare bacterial strains. Some of these methods are based on the electrophoretic separation of DNA restriction fragments. When electrophoretic profile are complex, some fragments can be visualized after hybridization (ribotyping). Large-sized fragments can be separated by pulsed-field gel electrophoresis. Other techniques are based on gene amplification, such as AP-PCR. This technique is easy to perform but its discriminatory power and reproducibility are lower. Some procedures are combining enzymatic cleavage and gene amplification. Finally methods based on the nucleotide sequence analysis of some genes are being evaluated.

FUTURE PROSPECTS AND PROJECTS

Techniques enabling the rapid comparison of various Legionella isolates will permit a quick detection of outbreaks and contribute to the identification of the source of contamination.

Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma

These guidelines for management of primary cutaneous squamous cell carcinoma present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

From blacklist to beacon, a case study in reducing dermatology out-patient waiting times

At its worst our dermatology department had a waiting list for routine appointments of 57 weeks. As a result we started to lose contract income and consequently were unable to replace a retiring consultant. The service faced fragmentation and loss of the inpatient ward. Using a series of internally planned and driven initiatives it was possible to retrieve the situation. Our efforts were recognized by a national waiting list Beacon award in 1999. This study describes the methods used to increase new patient throughput, reduce demand and hence reduce waiting time for new patient appointments. Change was achieved only when medical, nursing staff, general practitioners, managers and health authorities were involved in the process. The changes needed to be led by a consultant enthusiast and managed effectively. There remains a constantly increasing demand for the service and reducing the waiting list simply invites a further increase in referral. In a resource-limited health care system the provider must be able to limit demand by using agreed referral exclusion criteria in order to balance supply and demand.