The cost-effectiveness of sentinel node biopsy in patients with intermediate thickness primary cutaneous melanoma

BACKGROUND

The aim of this study was to determine the cost-effectiveness of wide excision (WEX) + sentinel node biopsy (SNB) compared with WEX only in patients with primary melanomas >/=1 mm in thickness.

METHODS

A Markov model was populated with probabilities of disease progression and survival from the published literature. Costs were obtained from diagnostic-related group weightings and health outcomes were measured in quality-adjusted life years (QALYs).

RESULTS

Base case analyses suggested that, over a 20-year timeframe, the mean total cost per patient receiving WEX only was AU $23,182 with 10.45 life years (LY) and 9.90 QALYs. The mean cost per patient for WEX + SNB was AU $24,045 with 10.77 LY and 10.34 QALYs. The incremental cost effectiveness ratio for WEX + SNB was AU $2,770 per LY and AU $1,983 per QALY.

CONCLUSION

WEX + SNB appears to offer an improvement in health outcomes (in both LYs and QALYs) with only a slight increase in cost.

Glioblastoma in a boy with fragile X: an unusual case of neuroprotection

Glioblastomas in children usually occur in the brainstem and are often untreatable and associated with an extremely poor prognosis. Such tumours may however occur in supratentorial locations more typically associated with adult gliomas, where the outcome is more variable, but still poor. We report the case of a boy with fragile X who also developed an inoperable midbrain glioblastoma, but who has survived 8 years after diagnosis.

Phase II trial of carboplatin, weekly paclitaxel, and biweekly bevacizumab in patients with unresectable stage IV melanoma

8560

Background: In patients with metastatic melanoma, the combination of chemotherapy with an agent that specifically targets vascular endothelial growth factor (VEGF) might be able to control tumor growth and progression much more effectively than chemotherapy alone. Methods: A two-stage phase II clinical trial was conducted in patients with unresectable stage IV melanoma to assess the anti-tumor activity and toxicity profile of the combination of paclitaxel (80 mg/m2 IV on days 1, 8 and 15 of a 28-day cycle), carboplatin (AUC = 6 IV on day 1) and bevacizumab (10 mg/kg IV on days 1 and 15). The primary end point of the study was the 8-week progression-free survival rate (PFS). Enrollment to the second stage of the study was opened if 8 or more of the first 20 patients enrolled remained progression-free at 8 weeks. Eligible patients had measurable disease by RECIST criteria, a performance status (PS) of 0–2 and acceptable pre-registration organ function. Exclusion criteria included: brain metastases, significant recent bleeding, uncontrolled hypertension and ongoing anticoagulation. The study opened in February 2006 and completed full study accrual in August 2006. Data from the 20 patients enrolled in the first stage are presented here. Results: Patients (60% male) had a median age of 63 and had a good performance status (85% had PS of 0). M1c disease was present in 45% of patients and 35% had undergone previous chemotherapy for stage IV melanoma (50% prior immunotherapy). Only 6 patients did not complete more than 2 cycles of chemotherapy due to refusal (3), desire for alternative treatment (1) or progression (2). Median follow-up among the 15 patients still alive was 5.5 months (range: 6 weeks - 9 months). The 8-week PFS rate was 70% (14/20). The median time to progression was 163 days. One partial response was observed. There were 3 disease-related deaths at 65, 120 and 190 days post-registration. The most common toxicities were neutropenia (95%; 45% = grade 3), anemia (95%; 15% = grade 3), fatigue (90%; 5% = grade 3), leukopenia (85%; 25% = grade 3), and thrombocytopenia (75%; 5% = grade 3). Conclusions: The combination of paclitaxel, carboplatin and bevacizumab appears to be well tolerated and clinically active in patients with stage IV melanoma.

No significant financial relationships to disclose.

Aerosolized sargramostim for the treatment of metastatic melanoma to the lungs

8565

Background: Previous studies using low-dose (250 ug/dose) aerosolized sargramostim (granulocyte macrophage colony stimulating factor: aero-GM-CSF) for the treatment of metastatic melanoma, revealed anecdotal clinical responses that appeared to correlate with an increase in the number of tumor specific cytotoxic T lymphocytes (CTL) in blood. Herein, we address whether or not further dose escalation of aero-GM-CSF is safe, results in greater increase of melanoma specific CTLs, and affects clinical outcomes. Methods: A 5+5 dose escalation clinical trial was conducted to determine the dose of aero-GM-CSF that would increase in the frequency of peripheral blood melanoma specific CTLs in HLA-A2+ patients with metastatic melanoma to the lungs. Aero-GM-CSF was administered twice daily on days 1–7 and 15–21 of a 28 day cycle at doses of: 500, 750, 1,000, 1,250, 1,500, 1,750, and 2,000 ug per cohort. If at most 2 of 5 patients at a dose level reported a 5-fold increase in CTLs, dose escalation occurred. If not, 5 additional patients were treated at that dose. Dose escalation continued until =2 of 5 patients at a dose level developed severe toxicity, at least 7 of the 10 patients at a dose level reported a 5-fold increase in CTLs, or all dose levels were exhausted. Results: The study accrued 40 patients from August 2002 to July 2006. Four patients cancelled participation prior to treatment. One patient was replaced (500 ug) as he died within 13 days of registration. Among the 35 remaining patients, median age was 58 (23–84), 72% were male, and 72% had a PS=0. Dose escalation was not terminated due to toxicity. Toxicities = grade 3 (at least probably treatment related) included: grade 3 fatigue (1) at 1,000 ug; and grade 3 cough (1), and grade 4 dyspnea (1) at 1,750 ug. At the 2,000 ug dose, most patients (4 of 5) exhibited a greater than 2-fold increase in melanoma specific CTLs. Two of these patients remain on treatment: one with partial response at 14.0 months and the other with stable disease at 6.5 months. A 5-fold increase in tumor specific CTLs was not achieved in any patient. Conclusions: Aero-GM-CSF therapy administered at up to 2,000 ug/dose appears safe and seems to correlate with increased frequencies of tumor specific CTLs in a dose-dependent fashion. Further dose escalation followed by clinical efficacy testing is warranted.

No significant financial relationships to disclose.

Therapeutic starvation and autophagy in prostate cancer: A new paradigm

10530

The metabolic fragility of cancer cells is magnified with the preferential utilization of glycolysis that metabolizes glucose inefficiently rather than oxidative phosphorylation (the “Warburg effect”) and from impaired mechanisms of survival. In fact, one pathway by which cells survive metabolic stress is thought to be autophagy, a catabolic process of organelle digestion, which creates ATP during periods on nutrient limitation. Remarkably, autophagy is often impaired in human prostate cancers, due to either activation of the PI-3 kinase/Akt/mTOR pathway, which normally inhibits autophagy, or through allelic loss of the essential autophagy gene beclin1. This suggests that prostate cancers may be susceptible to metabolic stress that can be exploited therapeutically. Using immortalized mouse epithelial prostate cells, as well as PC-3 and LNCaP cell lines, we demonstrated the cytotoxic effect of 2-deoxyglucose (2DG), as an inhibitor of glycolysis. We found that 2DG induced membrane translocation in cells characteristic of autophagy using a transfected pEGFP-LC3 autophagy marker construct. We then demonstrated that induction of autophagy was dependent on Beclin1 expression in these cell models using Beclin1 siRNA. Based on these data, we initiated a phase I/II clinical trial with 2DG in patients with advanced malignancies and prostate cancer, which is now ongoing. In an effort to develop markers of autophagy for assessment in a clinical trial, we stained a human prostate TMA (>35 patient cores) for Beclin1 by IHC. Beclin1 staining was increased in tumor tissue compared to normal tissue. Staining was imaged and digitized using a 40x volume scan on a high- throughput MedMicro whole slide scanner. The imaged specimens were stored in multi-tiled TIFF format on a redundant array of independent devices (RAID); staining will be analyzed using a color decomposition algorithm and compared to tumor characteristics as we have previously done (Foran DJ et al., IEEE Trans Inf Technol Biomed, 8:89–96, 2004). These data further support the rationale to inhibit metabolism in cancer and the potential importance of autophagy with metabolic approaches to therapy. Further imaging assessment and analysis of markers of autophagy such as Beclin1 are ongoing.

No significant financial relationships to disclose.

Estimating the incidence of fly myiases in Australian sheep flocks: development of a weather-driven regression model

The blowfly, Lucilia cuprina Wiedemann (Diptera: Calliphoridae), is the primary myiasis (strike) fly of sheep in Australia. Most strike occurs in the anal-perineum area (crutch), but strike to the neck, shoulders, back and withers (body) is also important. Regression analysis was used to determine the extent to which the weekly incidence of flystrike can be explained by variations in fly abundance and/or recent changes in weather, pasture conditions or flock management. Strike and flock management data were collected by questionnaire surveys of 30-60 sheep properties in each of three major sheep-producing areas in southeastern Australia, namely, Gunning (southern New South Wales), Inverell (northern New South Wales) and Flinders Island (Bass Strait). After using simulation modelling to remove effects due to shearing, crutching and/or insecticide treatment, pasture growth index was found to be the most important explanatory variable affecting the incidence of all forms of myiasis. Others were average weekly air temperature, the amount and frequency of rainfall, relative humidity, dung quality index and a factor denoting seasonal effects. Together, these variables accounted for 48.4% of the variation in body strike, 56.8% of that in crutch strike and 51.9% of that in other forms of strike. Prediction was improved by the inclusion of additional lagged variables describing previous strike, fly abundance and fly activity. With these additions, the variation explained increased to 60.4% for body strike, 68.0% for crutch strike and 58.3% for other strikes.

Identifying and comparing risks in emergency medicine

OBJECTIVES

To identify common risk types occurring in emergency departments (EDs). To compare the risks occurring between different emergency departments.

DESIGN

Application of a typology of risks to a database of critical incidents. Comparison of results of applying typology to group of critical incidents collected in a uniform manner in four different EDs.

SETTING

EDs in two teaching hospitals and two district general hospitals in the north west of England.

INTERVENTIONS

Observational study.

MAIN OUTCOME MEASURES

Types of critical incidents identified. Statistical comparisons between EDs.

RESULTS

816 critical incidents were classified. Patient assessment omission failures were the commonest type of failure, accounting for 291 (35.6%) of the critical incidents. Level 1 and level 2 failures accounted for 254 (31.1%) of critical incidents. Significant differences (p = 0.009) were shown between EDs when the categories of critical incidents occurring were compared. No significant differences (p = 0.336) were shown between EDs when the levels of severity of critical incidents occurring were compared.

CONCLUSIONS

Large numbers of critical incidents with potentially fatal consequences occur. The types of risks differ significantly between different EDs.

Co-existent primary cutaneous anaplastic large cell lymphoma and lymphomatoid papulosis

We describe the case of a 37-year-old female with a history of psoriasiform dermatitis who presented with multicentric primary cutaneous CD30-positive anaplastic large T cell lymphoma (ALCL). Despite aggressive systemic therapy, the patient suffered multiple relapses and the lymphoma spread to cervical and inguinal lymph nodes. Later in her clinical course it was appreciated that she was also suffering from lymphomatoid papulosis (LyP). The case illustrates the overlapping clinical, histological and immunophenotypic features of ALCL and LyP, conditions which represent a spectrum of CD30-positive lymphoproliferative disease. A multidisciplinary approach between dermatologist, oncologist and pathologist is essential for the optimal management of these complex conditions.

Quantitative assessment of the radiation hazards and risks in sentinel node procedures

Sentinel node localization using an injected radiopharmaceutical and a gamma probe is performed in many hospitals. Employers have a duty to give appropriate training to staff who may not have been previously formally trained to work with unsealed radioactive sources. A study was performed to assess hazards and risks at all stages of the localization procedure. Whole body doses and finger doses of imaging, surgery and pathology staff were determined. The activity remaining in the tumour specimen, excised nodes and disposable waste from the operating theatre was measured. Any radioactive contamination of the operating theatre and equipment was also ascertained. All results were then assessed in light of current UK radiation protection legislation for the protection of staff and members of the public. Results showed that radiation doses are low and no additional procedures are required for protection of staff, provided the usual procedures for biohazards are in place. However, an information sheet has been prepared for the reassurance of staff, and theatre swabs may need to be stored temporarily before disposal. Injecting and imaging on the day before surgery is preferred, compared with injecting and imaging before surgery on the same day, since this gives lower radiation doses to staff, lower activity in excised specimens and waste, and provides a higher count rate giving better image quality.

Physiological interpretation of electrical impedance epigastrography measurements

Measurement of the electrical impedance of the gastric region is carried out with the epigastrograph. This generates and applies alternating current around the abdominal area and measures the potential difference in order to determine the impedance externally, via electrodes. The change of epigastric impedance for a subject, given a meal after fasting, depends on the conductivity of the meal compared to the stomach and surrounding tissues. Typically a conductive meal has conductivity >7 mS cm(-1), non-conductive <2 mS cm(-1) and neutral about 4.5 mS cm(-1). Half-emptying times (T50s) from gastric emptying studies in volunteers using three test meals of 450 ml volume were obtained and found to be shorter than expected from the literature. The meals were a 10% glucose solution and two milk shakes of energy 1,300 kJ and 2,850 kJ, respectively. These electrical impedance epigastrography (EIE) measurements were carried out with scintigraphy. The T50 values of the latter were significantly longer. The direct comparison of the normalized experimental data obtained by both methods led to the concept that EIE measurements are mainly influenced by gastric secretion. Thus the EIE trace of a 'neutral' meal suggests the hypothesis that the volume of the meal is not the significant factor but is influenced by gastric acid secretions. Physiology of the gastric mucosa during the digestion of a meal and intragastric pH values also suggests this. Gastric function studies using EIE measurements may therefore reflect gastric ionic concentration rather than the volume of the contents of the stomach. In turn this could lead to the development of a non-invasive method for the continuous recording of gastric acid secretions.

Disability in children from different ethnic populations

We report on the prevalence of severe neurodisability in children in the Southern Derbyshire Health Authority from different ethnic groups. Information was obtained from the health records of children at the Child Development Centre (CDC), and analysed according to ethnic group. There were 53 in the Pakistani group, 20 in the Indian group and 764 in a mixed group, of which 95% were of European origin. It was estimated that all children with severe disability in the area of the Health Authority had notes at the CDC, except for 10% of the mixed group living on the periphery. The numbers of children with different disabling conditions were recorded, together with a measure of the level of individual disability; the 'Disability Scores'. We also noted if the condition was genetic or chromosomal in origin. Pakistani children showed a higher prevalence than the other groups of severe learning disorder, severe and profound hearing loss and severe visual problems. They also had a slightly increased prevalence of autism and cerebral palsy. Conversely, they showed a lower prevalence of language disorder. Disability scores for Pakistani children attending the CDC were higher than for other groups. Genetic disease causing disability was 10 times more common in the Pakistani children than other ethnic groups. Disability is more common in Pakistani children probably as a result of the cultural practice of consanguineous marriages. This community needs special help for disabled children, and their families, for general support and appropriate genetic counselling.

Fumigation with carbonyl sulfide: a model for the interaction of concentration, time and temperature

The new fumigant carbonyl sulfide offers an alternative to both methyl bromide and phosphine as a grain fumigant. Separate mathematical models for levels of kill, based on quantitative toxicological studies were developed for adults and eggs of the rice weevil Sitophilus oryzae (L.). These models suggest that fumigation exposure times for carbonyl sulfide will be a compromise between those of methyl bromide (typically 24h) and phosphine (7-10d) to achieve a very high kill of all developmental stages. S. oryzae eggs were more difficult to kill with carbonyl sulfide fumigation than the adults. At 30 degrees C, a 25gm(-3) fumigation killed 99.9% of adults in less than 1d, but took 4d to kill the same percentage of eggs. Models were generated to describe the mortality of adults at 10, 15, 20, 25 and 30 degrees C. From these models it is predicted that fumigation with carbonyl sulfide for 1-2d at 30gm(-3) will kill 99.9% of adults. Furthermore the models illustrate that fumigations with concentrations below 10gm(-3) are unlikely to kill all adult S. oryzae. Significant variation was observed in the response of eggs to the fumigant over the temperature range of 10 to 30 degrees C. Models were generated to describe the mortality of eggs at 10, 15, 20, 25 and 30 degrees C. As the temperature was reduced below 25 degrees C, the time taken to achieve an effective fumigation increased. Extrapolating from the models, a 25gm(-3) fumigation to control 99.9% of S. oryzae eggs will take 95h (4d) at 30 degrees C, 77h (3.2d) at 25 degrees C, 120h (5d) at 20 degrees C, 174h (7.5d) at 15 degrees C and about 290h (11d) at 10 degrees C. The role of temperature in the time taken to kill eggs with carbonyl sulfide cannot be ignored. In order to achieve the desired level of kill of all developmental stages, the fumigation rates need to be set according to the most difficult life stage to kill, in this instance, the egg stage.

Depression accounts for executive function deficits in obsessive-compulsive disorder

OBJECTIVE

To examine the relative impact of depression on executive function deficits in obsessive-compulsive disorder (OCD).

BACKGROUND

Existing data suggest that OCD is associated with basal ganglia and orbital frontal dysfunction, and neurobehavioral abnormalities that are putatively associated with these regions have been demonstrated in OCD. Nonetheless, few studies have accounted for the effects of depression, which is a common concurrent symptom among those with OCD.

METHOD

A broad battery of neuropsychological tests, including measures of executive function and sensory-motor function, was administered to 20 adults with OCD and 31 control subjects. To assess depressive severity, participants were administered the depression scale from the Minnesota Multiphasic Personality Inventory.

RESULTS

Data were analyzed using a regression model in two steps. In step one, patient group was entered, and patients with OCD demonstrated a pattern of executive function and sensory-motor deficits, similar to those shown in previous research. In step two, self-reported depressive symptom severity was entered as a predictor. As a consequence, depression accounted for some executive function deficits, whereas presence of OCD only predicted performance on measures of sensory-motor function.

CONCLUSIONS

These data suggest that abnormalities involving executive function in OCD are related to co-morbid depressive severity. However, sensory-motor deficits seem to be more consistent with basal ganglia/orbital frontal dysfunction in OCD.

Opinion statement on the minimal acceptable standards of healthcare in cerebral palsy

PURPOSE

Recent studies have shown a marked variation in the standards of healthcare for young people with disabilities in different regions of the UK and even within the same health district. Equity in the provision of healthcare is a fundamental principle of the NHS. However, this can only be measured against an agreed minimal standard of healthcare that serves as a benchmark for healthcare purchasers and providers. The aim of the present document is to develop a set of minimum standards of healthcare for children and adults with cerebral palsy (CP).

METHODS

The document was developed in two stages by a multi-professional and multi-disciplinary group of practitioners in the field of CP. Initially, members of the panel jointly formulated a statement of what they believed should be the minimal acceptable standards of healthcare in CP drawing on their own experience and the published scientific evidence. In the second stage the views of some of the relevant professional bodies and voluntary organizations on the draft statement were sought. The responses of these organizations were incorporated into the final document if agreed by the panel.

RESULTS AND CONCLUSIONS

Twenty-two recommendations were made. These were considered the minimum standards of care in a district general hospital. The emphasis was on the organisation and delivery of healthcare for children with CP. The statement is intended to stimulate debate especially in relation to the equity of service provision throughout the country and may be used to inform purchasers of healthcare. Similarly, it may also be useful to providers of healthcare as an audit tool.

A comparison of the development and survival of the dung beetle, Onthophagus taurus (Schreb.) when fed on the faeces of cattle treated with pour-on formulations of eprinomectin or moxidectin

Faeces voided by 1-year old cattle at 3-70 days after treatment with a pour-on formulation of moxidectin had no detectable effects on development or survival of the common dung beetle Onthophagus taurus. In contrast, faeces voided by cattle treated with a pour-on formulation of eprinomectin were associated with high juvenile mortality during the first 1-2 weeks after treatment. Increased mortality also occurred among newly emerged beetles fed on faeces collected 3 days after eprinomectin treatment and there was evidence of suppressed brood production among those that survived. This effect was still apparent even after insects fed for a further 10 days on the faeces of untreated cattle. A model simulating the effects of drug residues on dung beetle populations suggests that in the absence of immigration a single treatment of eprinomectin is capable of reducing beetle activity in the next generation by 25-35%. Effects are likely to be greatest when treatment coincides with emergence of a new generation of beetles.

Statistical analysis of decay of organophosphorus and pyrethroid insecticides and carbaryl on paddy rice, maize, sunflowers and field peas

A model is developed to describe the decay of seven insecticides on stored paddy rice, maize, sunflowers and peas, and is shown to be more precise than each of six literature models on pesticide decay. It relates residues (R), as a ratio of applied concentration (R(0)), to time after insecticide application (t), modifying the usual first-order kinetics equation lnR=lnR(0)-kt by assuming that the rate constant k has a mixture of values according to a gamma distribution with mean K. The resulting equation is lnR=lnR(0)-Kcln(1+t/c), where c is a constant determined empirically. For large c, this model reduces to the first-order model with K=k. The parameter K is further modelled as linear in temperature for maize and rice. The rate of loss of protectants was found not to be seriously affected by co-application with other insecticides, and this is a useful finding for future studies on rates of loss of grain protectants. The apparent rate of loss was also not seriously affected by the method of analysis, whether by gas chromatography or high-performance liquid chromatography, and this finding supports previous validation of the methods.