Erlotinib for the treatment of relapsed non-small cell lung cancer

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of erlotinib for the treatment of relapsed non-small cell lung cancer (NSCLC), according to its licensed indication, based upon the evidence submission from Roche Products to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submitted clinical evidence includes one randomised controlled trial (RCT) (BR21) investigating the effect of erlotinib versus placebo, which demonstrates that erlotinib significantly increases median overall survival, progression-free survival and response rate compared with placebo. The majority of patients in the trial experienced non-haematological drug-related adverse effects. Currently there are no trials that directly compare erlotinib with any other second-line chemotherapy agent. For the purposes of indirect comparison, the manufacturer's submission provides a narrative discussion of data from 11 RCTs investigating the use of docetaxel. From these data the manufacturer concludes that erlotinib has similar clinical efficacy levels to docetaxel but results in fewer serious haematological adverse events; however, it is difficult to compare the results of BR21 with those of the docetaxel trials or with current UK clinical practice because, for example, the BR21 patient population is younger than that expected to present in UK clinical practice and almost half of the BR21 participants received erlotinib as third-line chemotherapy, with third-line chemotherapy being rare in the UK. The manufacturer's submission included a three-state model comparing erlotinib with docetaxel, reporting an incremental cost-effectiveness ratio (ICER) of 1764 pounds per quality-adjusted life-year (QALY) gained for erlotinib compared with docetaxel. Rerunning the manufacturer's economic model with varied parameters and assumptions increases the ICER to in excess of 52,000 pounds per QALY gained. There is still a large amount of unquantifiable uncertainty in the model and it is unlikely that erlotinib could be considered to be cost-effective compared with docetaxel at a willingness to pay of 30,000 pounds and there may even be the potential for docetaxel to dominate erlotinib. Because of the limitations of the indirect analysis undertaken by the manufacturer and the subsequent economic modelling exercise there is a need for a head-to-head trial comparing erlotinib with docetaxel. The guidance issued by NICE in February 2007 as a result of the STA states that erlotinib is not recommended for the treatment of locally advanced or metastatic NSCLC.

Discovery of a potent, metabolically stabilized resorcylic lactone as an anti-inflammatory lead

With bioactivity-guided phenotype screenings, a potent anti-inflammatory compound f152A1 has been isolated, characterized and identified as the known natural product LL-Z1640-2. Metabolic instability precluded its use for the study on animal disease models. Via total synthesis, a potent, metabolically stabilized analog ER-803064 has been created; addition of the (S)-Me group at C4 onto f152A1 has resulted in a dramatic improvement on its metabolic stability, while preserving the anti-inflammatory activities.

Rituximab for the treatment of relapsed or refractory stage III or IV follicular non-Hodgkin’s lymphoma

This paper presents a summary of the evidence review group report into the clinical effectiveness and cost-effectiveness of rituximab for the treatment of relapsed or refractory stage III or IV follicular non-Hodgkin’s lymphoma (NHL), in accordance with the licensed indication, based upon the evidence submission from Roche Products Ltd to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submitted clinical evidence included two randomised controlled trials [European Organisation for Research and Treatment of Cancer (EORTC) and German Low Grade Lymphoma Study Group – Fludarabine, Cyclophosphamide and Mitoxantrone and (GLSG-FCM)] comparing the clinical effects of chemotherapy with or without rituximab in the induction of remission at first or second relapse and the clinical benefits of rituximab maintenance therapy versus the NHS’s current clinical practice of observation for follicular lymphoma (FL) patients. Both trials showed that in patients with relapsed FL the addition of rituximab to chemotherapy induction treatment increased overall response rates. Furthermore, rituximab maintenance therapy increased the median length of remission when compared with observation only. Safety data from the two trials showed that while the majority of patients reported some adverse events, the number of patients withdrawing from treatment in the EORTC trial was low, with rates not being reported for the GLSG-FCM trial. The most commonly reported adverse events were blood/bone marrow toxicity, skin rashes and allergies. The ERG reran the manufacturer’s economic model after altering several of the assumptions and parameter values in order to recalculate the cost–utility ratios, quality-adjusted life-years (QALYs) and estimates of benefits. The manufacturer reported that maintenance therapy with rituximab was cost-effective compared with observation against commonly applied thresholds, with an incremental cost-effectiveness ratio of £7721 per QALY gained. The greatest clinical effectiveness is achieved by R-CHOP followed by rituximab maintenance (R-CHOP > R) and this treatment strategy had the greatest probability of being cost-effective for a QALY of approximately £18,000 or greater. The guidance issued by NICE as a result of the STA states that in people with relapsed stage III or IV follicular NHL, rituximab is now an option in combination with chemotherapy to induce remission or alone as maintenance therapy during remission. Rituximab monotherapy is also an option for people with relapsed or refractory disease when all alternative treatment options have been exhausted.

Rituximab for the first-line treatment of stage III/IV follicular non-Hodgkin's lymphoma

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of rituximab for the first-line treatment of stage III/IV follicular non-Hodgkin's lymphoma (FNHL) based upon the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The manufacturer's scope restricts the intervention to rituximab in combination with CVP (cyclophosphamide, vincristine and prednisolone) (R-CVP); the only comparator used was CVP alone. The evidence from the one included randomised controlled trial (RCT) suggests that the addition of rituximab to a CVP chemotherapy regimen has a positive effect on the outcomes of time to treatment failure, disease progression, overall tumour response, duration of response and time to new lymphoma treatment in patients with stage III/IV FNHL compared with CVP alone. Adverse events were comparable between the two arms. This study was confirmed as the only relevant RCT. The economic analyses provided by the manufacturer were modelled using a three-state Markov model with with the health states being defined as progression-free survival (PFS), progressed (in which patients have relapsed) and death (which is an absorbing state). The model generated results for a cohort of patients with an initial age of 53 and makes no distinction between men and women. The model is basic in design, with several serious design flaws and key parameter values that are probably incompatible. Attempting to rectify the identified errors and limitations of the model did not increase the incremental cost-effectiveness ratio (ICER) above 30,000 pounds. Although the cost-effectiveness results obtained appear to be compelling in support of R-CVP compared with CVP for the trial population the results may not be so convincing for a more representative population. The results of the ERG analysis on the impact of age suggest that ICERs increase steadily with age, as the proportion of PFS that can be converted to overall survival (OS) is diminished by rising mortality rates in the general population. For the most extreme scenario (no OS gain) the ICER appears to remain below 30,000 pounds per QALY gained. On balance the evidence indicates that R-CVP is more cost-effective than CVP. The guidance issued by NICE in July 2006 as a result of the STA states that rituximab within its licensed indication (in combination with cyclophosphamide, vincristine and prednisolone) is recommended as an option for the treatment of symptomatic stage III/IV follicular non-Hodgkin's lymphoma in previously untreated patients.

Erlotinib for the treatment of relapsed non-small cell lung cancer

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of erlotinib for the treatment of relapsed non-small cell lung cancer (NSCLC), according to its licensed indication, based upon the evidence submission from Roche Products to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submitted clinical evidence includes one randomised controlled trial (RCT) (BR21) investigating the effect of erlotinib versus placebo, which demonstrates that erlotinib significantly increases median overall survival, progression-free survival and response rate compared with placebo. The majority of patients in the trial experienced non-haematological drug-related adverse effects. Currently there are no trials that directly compare erlotinib with any other second-line chemotherapy agent. For the purposes of indirect comparison, the manufacturer’s submission provides a narrative discussion of data from 11 RCTs investigating the use of docetaxel. From these data the manufacturer concludes that erlotinib has similar clinical efficacy levels to docetaxel but results in fewer serious haematological adverse events; however, it is difficult to compare the results of BR21 with those of the docetaxel trials or with current UK clinical practice because, for example, the BR21 patient population is younger than that expected to present in UK clinical practice and almost half of the BR21 participants received erlotinib as third-line chemotherapy, with third-line chemotherapy being rare in the UK. The manufacturer’s submission included a three-state model comparing erlotinib with docetaxel, reporting an incremental cost-effectiveness ratio (ICER) of –£1764 per quality-adjusted life-year (QALY) gained for erlotinib compared with docetaxel. Rerunning the manufacturer’s economic model with varied parameters and assumptions increases the ICER to in excess of £52,000 per QALY gained. There is still a large amount of unquantifiable uncertainty in the model and it is unlikely that erlotinib could be considered to be cost-effective compared with docetaxel at a willingness to pay of £30,000 and there may even be the potential for docetaxel to dominate erlotinib. Because of the limitations of the indirect analysis undertaken by the manufacturer and the subsequent economic modelling exercise there is a need for a head-to-head trial comparing erlotinib with docetaxel. The guidance issued by NICE in February 2007 as a result of the STA states that erlotinib is not recommended for the treatment of locally advanced or metastatic NSCLC.

Rituximab for the first-line treatment of stage III/IV follicular non-Hodgkin’s lymphoma

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of rituximab for the first-line treatment of stage III/IV follicular non-Hodgkin’s lymphoma (FNHL) based upon the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The manufacturer’s scope restricts the intervention to rituximab in combination with CVP (cyclophosphamide, vincristine and prednisolone) (R-CVP); the only comparator used was CVP alone. The evidence from the one included randomised controlled trial (RCT) suggests that the addition of rituximab to a CVP chemotherapy regimen has a positive effect on the outcomes of time to treatment failure, disease progression, overall tumour response, duration of response and time to new lymphoma treatment in patients with stage III/IV FNHL compared with CVP alone. Adverse events were comparable between the two arms. This study was confirmed as the only relevant RCT. The economic analyses provided by the manufacturer were modelled using a three-state Markov model with with the health states being defined as progression-free survival (PFS), progressed (in which patients have relapsed) and death (which is an absorbing state). The model generated results for a cohort of patients with an initial age of 53 and makes no distinction between men and women. The model is basic in design, with several serious design flaws and key parameter values that are probably incompatible. Attempting to rectify the identified errors and limitations of the model did not increase the incremental cost-effectiveness ratio (ICER) above £30,000. Although the cost-effectiveness results obtained appear to be compelling in support of R-CVP compared with CVP for the trial population the results may not be so convincing for a more representative population. The results of the ERG analysis on the impact of age suggest that ICERs increase steadily with age, as the proportion of PFS that can be converted to overall survival (OS) is diminished by rising mortality rates in the general population. For the most extreme scenario (no OS gain) the ICER appears to remain below £30,000 per QALY gained. On balance the evidence indicates that R-CVP is more cost-effective than CVP. The guidance issued by NICE in July 2006 as a result of the STA states that rituximab within its licensed indication (in combination with cyclophosphamide, vincristine and prednisolone) is recommended as an option for the treatment of symptomatic stage III/IV follicular non-Hodgkin’s lymphoma in previously untreated patients.

13 EFFECTS OF PLASMA PROGESTERONE CONCENTRATIONS ON LH RELEASE AND OVULATION IN BEEF CATTLE GIVEN GnRH

Two experiments were conducted to determine the effects of plasma progesterone (P4) concentrations on LH release and ovulation in beef heifers and lactating beef cows given gonadotropin-releasing hormone (GnRH). Previously autoclaved, once-used CIDR inserts (Colazo et al. 2004 Anim. Reprod. Sci. 81, 25-34) were used for experimental purposes to induce differential plasma progesterone concentrations. In Experiment 1, postpubertal heifers received 25 mg of dinoprost i.m. (prostaglandin F (PGF); Lutalyse; Pfizer Animal Health, Montreal, Quebec, Canada). On Day 4 (estrus = Day 0), heifers were randomly assigned (10/group) to receive no treatment (control) or 1 or 2 autoclaved once-used CIDR (Pfizer Animal Health) inserts (1CIDR and 2CIDR, respectively). On Day 5, heifers in the 1CIDR group were given PGF twice 12 h apart. On Day 6, all heifers received 100 �g of GnRH i.m. (Cystorelin; Merial Canada, Inc., Victoriaville, Quebec, Canada). Once daily on Days 4 to 9, a blood sample was collected and ultrasonography was performed. On Day 6, heifers in the control (3.0 � 0.4 ng/mL; mean � SD) and 1CIDR groups (3.0 � 0.3 ng/mL) had lower (P < 0.01) plasma progesterone concentrations than those in the 2CIDR group (5.7 � 0.4 ng/mL). However, the diameter of the dominant follicle was larger (P < 0.001) in heifers in the control and 1CIDR groups than in the 2CIDR group (12.1 � 1.0, 11.5 � 0.7, and 10.1 � 0.7 mm, respectively). More (P < 0.01) heifers ovulated in response to GnRH in the control and 1CIDR groups than in the 2CIDR group (10/10, 9/10, and 3/10, respectively). In Experiment 2, ultrasound-guided follicular ablation (FA) was performed (to synchronize ovarian follicular wave emergence) 4 to 6 days after estrus in 20 postpubertal heifers and 20 mature lactating cows. Cattle were randomly and equally assigned to receive an autoclaved, once-used CIDR, either with no further treatment (High-P4) or with two PGF treatments 12 h apart (Low-P4) given after FA. All cattle received 100 �g of GnRH either 6 days after FA or the day after the dominant follicle reached 9 mm in diameter. Ultrasonography was performed daily (from 4 days after FA to ovulation or to 3 days after GnRH treatment). In three cows and three heifers per group, blood samples were collected every 30 min for 12 h after GnRH. The dominant follicle at GnRH treatment was larger in cows than heifers (11.0 � 1.1 vs. 10.3 � 0.9 mm, respectively; P = 0.05) and tended to be smaller in the High-P4 group vs. the Low-P4 group (10.3 � 1.0 vs. 11.0 � 1.0 mm; P = 0.06). Ovulatory response was not different (P = 0.9) between heifers (77.7%) and cows (78.9%), but combined for heifers and cows, was lower in High-P4 vs. Low-P4 cattle (61.1 vs. 94.7; P < 0.01). The GnRH-induced LH surge did not differ (P = 0.23) between cows and heifers, but it was lower and of shorter duration (P < 0.001) in the High-P4 group than in the Low-P4 group. In summary, higher plasma P4 concentrations resulted in decreased LH release and the proportion of cattle ovulating in response to GnRH treatment. There was no significant difference between heifers and cows in LH release or ovulatory response.

11 EFFECTS OF CIDR-BASED PRESYNCHRONIZATION AND eCG ON FERTILITY FOR A GnRH-BASED TIMED-AI PROTOCOL IN BEEF CATTLE

The objectives were to determine the effects of presynchronization and eCG on fertility for a GnRH-based timed-AI (TAI) protocol in beef cattle. Previously autoclaved once-used CIDR inserts (Colazo et al. 2004 Anim. Reprod. Sci. 81, 25-34) were used for experimental purposes so that all cattle had equivalent exogenous progesterone after Day 7 in Experiment 1, and to induce GnRH-responsive follicles in Experiment 2. In Experiment 1, 12-15 month old beef heifers (n = 447) were used (three locations, A, B, and C). On Day 0, half received a new CIDR insert (Pfizer Animal Health, Montreal, Quebec, Canada) and 500 �g of cloprostenol i.m. (PGF: Estrumate; Schering-Plough Animal Health, Pointe-Claire, Quebec, Canada). On Day 7, the remainder received an autoclaved once-used CIDR and all received 100 �g of GnRH i.m. (Cystorelin; Merial Canada, Inc., Victoriaville, Quebec, Canada). On Day 14, CIDR inserts were removed, PGF was given to all heifers, and heifers were given either 300 IU eCG i.m. (Pregnacol; Bioniche Animal Health, Belleville, Ontario, Canada) or no treatment (2 � 2 factorial design). On Day 16 (54-56 h after CIDR removal and PGF administration), heifers were given 100 �g of GnRH i.m., concurrent with TAI. Transrectal ultrasonography was done on Day 0 to assess ovarian structures, and on approximately Day 50 (range, 44-69) to confirm pregnancy. Overall, 72.7% of heifers were puberal on Day 0 (150/150, 5/37, and 170/260 for locations A, B, and C, respectively; P < 0.001). Pregnancy rate was affected (P < 0.001) by location (27.3, 62.2, and 51.1% for the three locations, respectively) but was not affected (P = 0.3) by puberal status at locations B and C. Pregnancy rate was not affected (P = 0.5) by presynchronization, but tended (P = 0.1) to be reduced by eCG treatment (40.4 vs. 47.7%, respectively). In Experiment 2, lactating crossbred beef cows (n = 411), 2-12 years of age were randomly allocated to receive either a previously used, autoclaved CIDR for 7 days and 25 mg of dinoprost i.m. (PGF: Lutalyse; Pfizer Animal Health) or no treatment (control; Day 0). At CIDR removal (Day 7), all cows received 100 �g of GnRH. On Day 14, all cows received PGF and were allocated to receive either 400 IU of eCG i.m. or no treatment (2 � 2 factorial design). On Day 16 (54-56 h after PGF), cows were given 100 �g of GnRH concurrent with TAI. Transrectal ultrasonographic examinations were done on approximately 65 cows in each group on Days 0, 7, and 14 to assess ovarian structures and on all cows on Day 42 to confirm pregnancy. Overall, 88.8% of cows had a corpus luteum (CL) on Day 0. Presynchronization increased both the proportion of cows that ovulated to GnRH treatment on Day 7 (76.7 vs. 55.0%; P < 0.001) and pregnancy rate (58.2 vs. 45.4%; P = 0.03) for cows that had received a CIDR vs. control cows. However, eCG treatment did not affect pregnancy rate (P = 0.3) in either group. In summary, presynchronization with a used CIDR and PGF prior to a Cosynch protocol increased ovulation rate to the first GnRH treatment and pregnancy rate in cows but not in heifers. In a GnRH-based TAI protocol, treatment with eCG had no significant effect on fertility in cows, but tended to decrease fertility in heifers.

Frisby Davis distance stereoacuity values in visually normal children

AIMS

To establish the range of normal distance stereoacuity in young children using the Frisby Davis distance stereo test (FD2).

METHODS

Children passing preschool vision screening assessments underwent measurement of distance stereoacuity with the FD2 using a standard testing protocol.

RESULTS

59 visually normal children aged between 36 months and 68 months were recruited to this study. All 59 were able to understand the test requirements and were examined with the FD2 stereo test. Four (6.8%) had no measurable stereoacuity; 13 (24%) had stereoacuity measurable only at a 3 metre testing distance (mean 92.3 seconds of arc; SD 52.6). These children were significantly younger than the remaining 42 (76%) who demonstrated a stereoacuity response at a 6 metre testing distance (mean 29.6 seconds of arc; SD 13.1, p=0.008).

CONCLUSION

The FD2 stereo test enables the measurement of distance stereoacuity in young children. There appears to be a maturational effect with distance stereoacuity improving between 36 months and 68 months. The data on age related normal values will provide a baseline from which to compare outcomes in clinical populations.

A link between prompt optical and prompt γ-ray emission in γ-ray bursts

The prompt optical emission that arrives with the gamma-rays from a cosmic gamma-ray burst (GRB) is a signature of the engine powering the burst, the properties of the ultra-relativistic ejecta of the explosion, and the ejecta's interactions with the surroundings. Until now, only GRB 990123 had been detected at optical wavelengths during the burst phase. Its prompt optical emission was variable and uncorrelated with the prompt gamma-ray emission, suggesting that the optical emission was generated by a reverse shock arising from the ejecta's collision with surrounding material. Here we report prompt optical emission from GRB 041219a. It is variable and correlated with the prompt gamma-rays, indicating a common origin for the optical light and the gamma-rays. Within the context of the standard fireball model of GRBs, we attribute this new optical component to internal shocks driven into the burst ejecta by variations of the inner engine. The correlated optical emission is a direct probe of the jet isolated from the medium. The timing of the uncorrelated optical emission is strongly dependent on the nature of the medium.

Transgenic overexpression of neuromedin U promotes leanness and hypophagia in mice

Recent work has shown that neuromedin U (NmU), a peptide initially identified as a smooth muscle contractor, may play a role in regulating food intake and energy homeostasis. To further evaluate this putative function, we measured food intake, body weight, energy expenditure and glucose homeostasis in transgenic mice that ubiquitously overexpress murine proNmU. NmU transgenic mice were lighter and had less somatic and liver fat, were hypophagic, and had improved insulin sensitivity as judged by an intraperitoneal insulin tolerance test. Transgenic mice had higher levels of hypothalamic NPY, POMC and MCH mRNA. There was no difference in O2 consumption between genotypes; however, NmU transgenic mice displayed a modest increase in respiratory quotient during food deprivation and refeeding. There were no behavioral disturbances in the NmU transgenic mice that could account for the results (e.g. changes in locomotor activity). When placed on a high-fat diet, transgenic mice remained lighter than wild-type mice and ate less, but gained weight at a rate similar to wild-type mice. Despite the increased weight gain with high-fat feeding, glucose tolerance was significantly improved in the transgenic mice. These findings support the hypothesized role of NmU as an endogenous anorexigenic peptide.

Use of computerized health claims data to monitor compliance with antibiotic prophylaxis in sickle cell disease

OBJECTIVE

To demonstrate how computerized claims data can be used to identify children with sickle cell disease probably having low compliance with antibiotic prophylaxis of pneumococcal disease.

METHODS

The study included under-5-year-old children with sickle cell disease who were on antibiotic prophylaxis and covered by Medicaid in Michigan (N=158), Missouri (N=64), and New York (N=297). Medicaid pharmacy claims from 10-month periods were used to estimate the total days' supply of antibiotics dispensed for each child. Low compliance was defined as a ratio less than 0.33 for the child's estimated total days' supply of antibiotics divided by days in the child's study period. Two slightly different methods of estimating antibiotic supplies were used to generate a low and high estimate of the percentage of children having low compliance.

RESULTS

Low and high estimates of the percentage of children having low compliance were 20% and 25% in Michigan, 19% and 31% in Missouri, and 16% and 24% in New York. With each method of estimating antibiotic supplies, low compliance was not associated with age in any state.

CONCLUSIONS

Computerized claims data can be used, potentially by Medicaid programs and managed care organizations, to identify children with sickle cell disease who probably have low compliance with antibiotic prophylaxis.

Developmental neurotoxicity of ketamine: morphometric confirmation, exposure parameters, and multiple fluorescent labeling of apoptotic neurons

Ketamine is a widely used pediatric anesthetic recently reported (C. Ikonomidou et al., 1999, Science 283, 70-74) to enhance neuronal death in neonatal rats. To confirm and extend these results, we treated four groups of PND 7 rats with seven sc doses, one every 90 min, of either saline, 10 mg/kg ketamine, 20 mg/kg ketamine, or a single dose of 20 mg/kg ketamine. The repeated doses of 20 mg/kg ketamine increased the number of silver-positive (degenerating) neurons in the dorsolateral thalamus to a degree comparable to previous results (Ikonomidou et al., 1999, Science 283, 70-74), i.e., 28-fold vs. 31-fold respectively. However, blood levels of ketamine immediately after the repeated 20 mg/kg doses were about 14 micrograms/ml, about seven-fold greater than anesthetic blood levels in humans (J. M. Malinovsky et al., 1996, Br. J. Anaesth. 77, 203-207; R. A. Mueller and R. Hunt, 1998, Pharmacol. Biochem. Behav. 60, 15-22). Levels of ketamine in blood following exposure to the multiple 10 mg/kg doses of ketamine or to a single 20 mg/kg dose ranged around 2-5 micrograms/ml; although these blood levels are close to an anesthetic level in humans, they failed to produce neurodegeneration. To investigate the mode of ketamine-induced neuronal death, coronal sections were stained with both Fluoro-Jade B (a green fluorescent stain selective for neurodegeneration) and DAPI (a blue DNA stain), as well as for caspase-3 (using an antisera labeled red with rhodamine). These histochemical results confirmed the developmental neurotoxicity of ketamine, demonstrated that Fluoro-Jade B (FJ-B), like silver methods, successfully stained degenerating neurons in neonatal rats, and indicated that ketamine acts by increasing the rate of neuronal apoptosis.

Positive tensilon test and intracranial tumor: a case report

PURPOSE

To report a case of intracranial tumor in a patient with positive tensilon test.

METHODS

Interventional case report. A 19-year-old male presented with left 6th nerve palsy and had a tensilon test, which was highly positive and was diagnosed as having myasthenia gravis.

RESULTS

The neurologist scanned the patient, which showed an intracranial tumor in the floor of the temporal fossa on the left side. The patient had surgery and a schwannoma was removed. The VIth nerve palsy did not improve up to two years after surgery.

CONCLUSIONS

A patient with a positive tensilon test can also have an associated intracranial tumor.

Infant-mother interaction as a predictor of child's chronic health problems

BACKGROUND

Psychological stress is associated with physical illnesses like asthma or infections. For an infant, situations perceived as stressful are highly dependent on the relationship with the caregiver. Constantly poor mother-infant interaction increases the child's vulnerability to stressful conditions and experiences. The aim of the study was to investigate the impact of the quality of early mother-infant interaction on the subsequent physical health of the child. Poor mother-infant interaction was hypothesized to be associated with chronic or recurrent health problems in the child.

PARTICIPANTS

Fifty-seven mother-infant dyads from families at risk of psychosocial problems and 63 from non-risk families, altogether 120 dyads, participated in the study. Families were drawn from normal population, from well-baby clinics in the city of Tampere, Finland. Infants were full-term and healthy, families with severe risks like psychotic illnesses of the parents or a history of child protection concerns were excluded from the study.

METHODS

After the initial interview with the mother, the mother-infant interaction was videotaped when the infants were 8-11 weeks of age and the interaction was assessed using the Global Rating Scale for Mother-Infant Interaction (Murray et al. 1996a). After the 2-year follow-up mothers were interviewed again and the health problems of the child were elicited.

RESULTS

Poor dyadic mother-infant interaction and infant's poor interactive behaviour assessed at two months were separately associated with the physical health of the child during the two-year follow-up. After adjusting for other factors in the logistic regression analysis infant's poor interactive behaviour remained as a significant predictor of chronic or recurrent health problems in the child. Infant's health problems at the time of the initial interview and day care centre attendance were also significant predictors.

CONCLUSIONS

The results suggest that interactional issues between a mother and her infant are related to the child's subsequent physical health. Children with recurrent or chronic health problems may have relationship difficulties with which they need help. Also, early avoidant behaviour of the infant should be regarded as an indicator of the infant's distress with possibly adverse outcomes in the child's physical health, among other consequences.

Can tonic accommodation predict surgical performance?

BACKGROUND

Pilots undergo many visual tests for both selection and assessment, and we know that there are many similarities between pilots and surgeons. Hence, it would not be unreasonable to bring similar visual tests into surgery. Tonic accommodation (TA) is a stable parameter that is adopted by the eye in the absence of any stimulation. Over recent years, surgery has undergone change from traditional open surgery to minimally invasive procedures, bringing many advantages. However, not every surgeon has the ability to perform under conditions where the operative field is represented on a flat monitor.

METHOD

We determined the TA values in medical students and then correlated this with their performance on a virtual reality surgical simulator.

RESULTS

We found that TA values predicted the number of errors made with the dominant hand, accounting for 27% of the variance.

CONCLUSION

The data suggest that TA may play a role in the individual differences that are noted when surgeons perform laparoscopic surgery. Further studies are needed to evaluate the exact role of TA in surgical performance.