The influence of citrate and oxalate on 99TcVII, Cs, NpV and UVI sorption to a Savannah River Site soil

Batch sorption experiments were conducted with 0.5-50 ppb ⁹⁹Tc, ¹³³Cs, ²³⁷Np and U in the presence and absence of citrate and/or oxalate in a 25 g/L Savannah River Site (SRS) soil suspension. Citrate and oxalate were the ligands of choice due to their relevancy to plant exudates, the nuclides were selected for their wide range of biogeochemical behavior, and the soil from SRS was selected as a model Department of Energy (DOE) site soil. Batch samples were continually mixed on a rotary shaker and maintained at a pH of approximately 5. Analysis via ICP-MS indicated that sorption of ²³⁷Np increased with ligand concentration compared to baseline studies, as did sorption of ⁹⁹Tc although to a lesser extent. The increased sorption of ²³⁷Np is proposed to be due to a combination of factors that are dependent on the ligand(s) present in the specific system including, ligand dissolution of the soil by citrate and formation of tertiary soil-oxalate-Np complexes. The increased ⁹⁹Tc sorption is attributed to the dissolution of the soil by the ligands, leading to an increase in the number of available sorption sites for ⁹⁹Tc. Uranium sorption decreased and dissolution of native uranium was also observed with increasing ligand concentration, thought to be a result of the formation of strong U-ligand complexes remaining in the aqueous phase. The majority of these effects were observed at the highest ligand concentrations of 50 mg_C/L. No notable changes were observed for the ¹³³Cs system which is ascribed to the minimal interaction of Cs⁺ with these organic ligands.

Structured Expert Consensus on Actinic Keratosis: Treatment Algorithm Focusing on Daylight PDT

BACKGROUND

A practical and up-to-date consensus among experts is paramount to further improve patient care in actinic keratosis (AK).

OBJECTIVES

To develop a structured consensus statement on the diagnosis, classification, and practical management of AK based on up-to-date information.

METHODS

A systematic review of AK clinical guidelines was conducted. This informed the preparation of a 3-round Delphi procedure followed by a consensus meeting, which combined the opinions of 16 clinical experts from 13 countries, to construct a structured consensus statement and a treatment algorithm positioning daylight photodynamic therapy (dl-PDT) among other AK treatment options.

RESULTS

The systematic review found deficiencies in current guidelines with respect to new AK treatments such as ingenol mebutate and dl-PDT. The Delphi panel established consensus statements across definition, diagnosis, classification, and management of AK. While the diagnosis of AK essentially rests on the nature of lesions, treatment decisions are based on several clinical and nonclinical patient factors and diverse environmental attributes. Participants agreed on ranked treatment preferences for the management of AK and on classifying AK in 3 clinical situations: isolated AK lesions requiring lesion-directed treatment, multiple lesions within a small field, and multiple lesions within a large field, both requiring specific treatment approaches. Different AK treatment options were discussed for each clinical situation.

CONCLUSIONS

The results provide practical recommendations for the treatment of AK, which are readily transferable to clinical practice, and incorporate the physician's clinical judgement. The structured consensus statement positioned dl-PDT as a valuable option for patients with multiple AKs in small or large fields.

Structured Expert Consensus on Actinic Keratosis: Treatment Algorithm Focusing on Daylight PDT

Background:

A practical and up-to-date consensus among experts is paramount to further improve patient care in actinic keratosis (AK).

Objectives:

To develop a structured consensus statement on the diagnosis, classification, and practical management of AK based on up-to-date information.

Methods:

A systematic review of AK clinical guidelines was conducted. This informed the preparation of a 3-round Delphi procedure followed by a consensus meeting, which combined the opinions of 16 clinical experts from 13 countries, to construct a structured consensus statement and a treatment algorithm positioning daylight photodynamic therapy (dl-PDT) among other AK treatment options.

Results:

The systematic review found deficiencies in current guidelines with respect to new AK treatments such as ingenol mebutate and dl-PDT. The Delphi panel established consensus statements across definition, diagnosis, classification, and management of AK. While the diagnosis of AK essentially rests on the nature of lesions, treatment decisions are based on several clinical and nonclinical patient factors and diverse environmental attributes. Participants agreed on ranked treatment preferences for the management of AK and on classifying AK in 3 clinical situations: isolated AK lesions requiring lesion-directed treatment, multiple lesions within a small field, and multiple lesions within a large field, both requiring specific treatment approaches. Different AK treatment options were discussed for each clinical situation.

Conclusions:

The results provide practical recommendations for the treatment of AK, which are readily transferable to clinical practice, and incorporate the physician’s clinical judgement. The structured consensus statement positioned dl-PDT as a valuable option for patients with multiple AKs in small or large fields.

Treating Psoriasis and Psoriatic Arthritis: Position Paper on Applying the Treat-to-target Concept to Canadian Daily Practice

Objective.

To develop preliminary treat-to-target (T2T) recommendations for psoriasis and psoriatic arthritis (PsA) for Canadian daily practice.

Methods.

A task force composed of expert Canadian dermatologists and rheumatologists performed a needs assessment among Canadian clinicians treating these diseases as well as an extensive literature search on the outcome measures used in clinical trials and practice.

Results.

Based on results from the needs assessment and literature search, the task force established 5 overarching principles and developed 8 preliminary T2T recommendations.

Conclusion.

The proposed recommendations should improve management of psoriasis and PsA in Canadian daily practice. However, these recommendations must be further validated in a real-world observational study to ensure that their use leads to better longterm outcomes.

Abstract P4-19-05: Efficacy of screening and treatment of breast cancer patients reporting high level of distress

Background: Cancer patients (pts) are burdened by symptoms related to the disease itself or to the toxicities of treatment. A recent meta-analysis has shown that anxiety is the most common mental health issue among cancer survivors [Mitchell AJ, 2013]. The ASCO clinical oncology guideline adaptation recommends all health care providers routinely screen for the presence of emotional distress and symptoms of anxiety from the point of diagnosis onward [Andersen BL, 2014]. Consensus-based recommendations have been published to help cancer centers meet the American College of Surgeons Commission on Cancer's accreditation requirement to screen for distress [Pirl, 2014] At our comprehensive community cancer center we perform distress screening using the M.D. Anderson Symptom Inventory (MDASI), composed of 27 questions. Pts who report moderate and severe levels of distress (≥5) on the MDASI are identified and referred for therapeutic interventions offered by the facility's integrative oncology services.

Materials and Methods: The MDASI is an assessment tool that captures pts' perceived symptom burden for real-time clinical intervention, taken at the point of no intervention (baseline) and every 21 days or greater. The 27-question MDASI is comprised of the M.D. Anderson Symptom Inventory (MDASI), a validated 19-item assessment instrument, with a Symptom Inventory Tool (SIT) added by our center of 8 questions and a free-text box. Symptoms are rated “at the worst” on an 11-point numeric scale ranging from 0 (“none present”) to 10 (“as bad as you can imagine”), as experienced by the patient in the past 24 hours.

Results: Over a ten-month period (9/1/2014 to 6/30/2015), 247 breast cancer (BC) pts completed the MDASI at intake and again ≥ 21 days after. Analysis of their initial surveys identified 69 pts (27.9%) who rated their distress as ≥ 5 (1st MDASI mean = 6.83), scores which would have initiated a support system response with referrals to integrative medicine services for intervention. Second MDASI results from these 69 BC pts revealed an average 2.29 distress score reduction (2nd MDASI mean = 4.48), with 51 pts (73.9%) reporting a decrease in distress, 7 pts (10.1%) having no change, and 11 pts (15.9%) reporting increased distress. More specifically, the group with decreased distress levels documented a mean distress score of 3 on their 2nd MDASI, averaging a significant 4-point diminution of distress for three-fourths of the BC pts heavily burdened by this symptom. The integrative services most utilized by these pts were Nutrition Therapy (100%), Spiritual Care (96.1%), Mind-Body Counseling (82.4%), Rehabilitation Therapy (41.2%), Acupuncture (35.3%), and Massage Therapy (35.3%).

Conclusions: Distress is a relevant symptom reported by cancer pts. This study demonstrates that early intervention in BC pts using integrative oncology approaches reduced distress in 74% of cases.

Citation Format: Daneker SR, Bendinger GM, Thomas JW, Smith E, Kendrick D, Hartman S, Gordon C, Barber K, Langlois C, Pabbathi H, McKnight JE, Johnson AT, Lammersfeld C, Denny D, Markman M, Alvarez RH. Efficacy of screening and treatment of breast cancer patients reporting high level of distress [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-19-05.

Non-melanoma Skin Cancer in Canada Chapter 3: Management of Actinic Keratoses

Background

Actinic keratosis (AK) and cheilitis (AC) are lesions that develop on photodamaged skin and may progress to form invasive squamous cell carcinomas (SCCs).

Objective

To provide guidance to Canadian health care practitioners regarding management of AKs and ACs.

Methods

Literature searches and development of graded recommendations were carried out as discussed in the accompanying introduction (chapter 1 of the NMSC guidelines).

Results

Treatment of AKs allows for secondary prevention of skin cancer in sun-damaged skin. Because it is impossible to predict whether a given AK will regress, persist, or progress, AKs should ideally be treated. This chapter discusses options for the management of AKs and ACs.

Conclusions

Treatment options include surgical removal, topical treatment, and photodynamic therapy. Combined modalities may be used in case of inadequate response. AKs are particularly common following the longterm immunosuppression in organ transplant patients, who should be monitored frequently to identify emerging lesions that require surgery.

Review of Treatment for Onychomycosis: Consideration for Special Populations

This article provides a brief discussion of onychomycosis treatment in special populations such as children, the elderly, and patients with diabetes, human immunodeficiency virus (HIV), or Down syndrome. These subjects are generally not included in clinical trials, and few data on antifungal therapy are available in the literature. Issues with onychomycosis infection and treatment affecting each group are discussed, and where treatment reports exist, efficacy and safety data are presented. The discussion is restricted to agents approved for use in onychomycosis in Canada: oral terbinafine, oral itraconazole, and ciclopirox 8% nail lacquer. Although sparse, the literature demonstrates that onychomycosis therapies can be used safely and effectively in these special populations, although it is likely that the appropriateness of such treatment would have to be assessed on a case-by-case basis. Typically, oral medications are used reluctantly in these groups as the potential for adverse liver or kidney effects and medication interactions may be significant. Ciclopirox nail lacquer has recently become available for use and may offer an alternative to oral therapy in the future for mild to moderate cases of onychomycosis; however, the efficacy in these patients has not typically been reported. It remains to be seen what impact this medication will have for special populations. More knowledge of treatment in special populations must be accumulated in the literature before more formal treatment guidelines may be formulated.

Pharmacoeconomic Assessment of Ciclopirox Topical Solution, 8%, Oral Terbinafine, and Oral Itraconazole for Onychomycosis

Most pharmacoeconomic data available for antifungal agents are based on US or European cost parameters. Similar data have not been reported in a Canadian health care system. A pharmacoeconomic analysis was performed considering the costs of drug acquisition and medical management, which were representative of the Canadian health care system, for each of the therapies approved for use in toenail onychomycosis in Canada: continuous oral terbinafine, oral pulse itraconazole, and topical ciclopirox 8% nail lacquer. A survey of provincial fee schedules was conducted to determine the representative costs of parameters relating to onychomycosis treatment, such as consultation visit cost, return visit cost, mycology testing, liver function testing, and complete blood count analysis. Manufacturers' costs were used to calculate representative drug acquisition costs. Meta-analysis was used to determine the average mycologic cure rates of each therapy, and the medical literature was consulted to determine the relapse rates for each therapy. Ciclopirox nail lacquer had the lowest drug acquisition costs compared with continuous terbinafine and pulse itraconazole ($197.89 vs $311.39 and $323.40, respectively). Using the pharmacoeconomic model with three 1-year treatment phases, in which failures or relapses were re-treated with the primary drug, the expected cost per patient was $601.52 with ciclopirox nail lacquer, $746.72 with oral terbinafine, and $938.42 with itraconazole. The main analysis assumed that two bottles of ciclopirox nail lacquer were required per treatment. The cost for the ciclopirox lacquer exceeded continuous terbinafine but remained lower than pulse itraconazole when three bottles of ciclopirox nail lacquer were considered in the calculation of cost per mycological cure. A variety of relapse rates were tested, and ciclopirox using two or fewer bottles remained cost-effective compared with continuous terbinafine or pulse itraconazole, regardless of the relapse rate. Where three bottles are required, the cost-effectiveness of ciclopirox nail lacquer is less than that of continuous terbinafine but more cost-effective than that of pulse itraconazole.

The Role of Choledochoscopy

Background. Identifying and surgically removing bile duct calculi is challenging and critical in order to provide good patient outcomes. The history of this surgical pursuit since the introduction of anesthesia is both enlightening and fascinating. Methods. A systematic review of the literature was conducted to identify the techniques and technology used to remove bile duct calculi. Results. All bile duct surgical exploration advances have involved creation of tools to look within the bile duct and extract stones. The Hopkin’s rod lens system was a major breakthrough in light and image transmission. However, flexible endoscope technology added the ability to maneuver better within the bile duct as well as apply the technology via laparoscopy enabling laparoscopic bile duct exploration. Conclusion. Digital, image enhanced, distal tipped chip flexible endoscopes have significantly improved the surgeons’ ability to see within the bile duct, improving the efficiency and ease of stone visualization and removal from both the most proximal and distal ends of the bile duct.