Optimal Interval for 18F-FDG-PET After Chemoradiotherapy for Rectal Cancer

INTRODUCTION

Although ¹⁸F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) has been increasingly used to evaluate the response to preoperative chemoradiotherapy (CRT) in patients with rectal cancer, the optimal intervals between completion of CRT, PET, and surgery have not been fully investigated.

PATIENTS AND METHODS

A total of 148 consecutive patients with rectal adenocarcinoma who received CRT followed by FDG-PET and radical surgery were retrospectively analyzed. The association between the FDG-PET maximum standardized uptake value (SUVmax) and pathological response was assessed using a logistic regression model, with a primary focus on the intervals between CRT and PET as well as between PET and surgery.

RESULTS

The baseline SUVmax showed no association with pathological response (P = .201; area under the curve [AUC] = 0.528), whereas the SUVmax after CRT completion showed a strong association (P < .001; AUC = 0.707). Logistic regression analysis revealed that the ability of the SUVmax to accurately predict pathological good responders was significantly associated with a long CRT-PET interval (≥ 7 weeks; P = .027), but was not affected by the length of PET-surgery interval. In patients with a short CRT-PET interval (< 7 weeks), the ability of the SUVmax to predict good responders was poor (P = .201; AUC = 0.669); however, in patients with long intervals (≥ 7 weeks), the predictive ability markedly improved (P < .001; AUC = 0.879).

CONCLUSION

A minimum wait time of 7 weeks is recommended before performing FDG-PET after neoadjuvant CRT for rectal cancer to obtain maximal predictive accuracy for pathological response.

Sprint cycling training improves intermittent run performance

Background/Objective

The aim of this study was to examine the effect of sprint cycling training on the intermittent run performance, sprinting speed, and change of direction (COD) ability of recreational intermittent sports athletes.

Methods

Sixteen participants participated in the study. The experimental group (EG, n = 8) received a total of 12 sessions of sprint cycling training in a 4-week period and the control group (CG, n = 8) received no training. Both EG and CG were instructed to maintain their daily activity during the 4-week period. Each sprint cycling session consisted of 4–7 sets of 30 s all-out sprint cycling.

Results

EG significantly improved in Yo Yo Intermittent Recovery Test (13.4% vs 2.4%,p = 0.006, Effect Size (ES): 0.31 vs 0.04), VO_2max (7.8% vs −0.2%, p = 0.006, ES: 0.42 vs 0.00), and power output at VO_2max (9.8% vs −4.8%, p = 0.002, ES: 0.91 vs 0.32) compared to CG while no significant changes were found in 30 m sprint times and pro-agility times in both EG and CG.

Conclusions

Sprint cycling significantly improved intermittent run performance, VO_2max and peak power output at VO_2max. Sprint cycling training is suitable for intermittent sports athletes but separate speed and COD training should be included.

Time to diagnosis and treatment for cancer patients in the Netherlands: Room for improvement?

BACKGROUND & AIM

Reducing the duration of the diagnostic cancer care pathway is intensively pursued. The aim of this study was to chart the diagnostic pathway for the five most common cancers in the Netherlands.

METHODS

A retrospective cohort study using cancer patients' anonymised primary care data (free text and coded) linked to the Netherlands Cancer Registry. We determined the median duration of the following: 1. Primary care intervals (IPCs): the first cancer-related general practitioner consultation to referral, 2. Referral intervals (IRs): referral to diagnosis, 3. Treatment intervals (ITs): diagnosis to treatment and the overarching intervals, 4. Diagnostic intervals (IDs): IPC and IR combined and 5. Health care intervals (IHCs): IPC, IR and IT combined.

RESULTS

For 465, 309, 197, 237 and 149 patients diagnosed with breast-, colorectal-, lung-, prostate cancer and melanoma, respectively; median IPC, IR and ID durations were shortest for breast cancer and melanoma (ID duration 7 and 21 days, respectively), intermediate for lung- and colon cancer (ID duration 49 and 54 days) and the longest for prostate cancer (ID duration 137 days). For all cancers, the duration of intervals increased steeply for the 10-25% with longest durations. For colorectal cancer, increasing ID durations showed increasing proportions of time attributable to primary care (IPC).

CONCLUSION

Approximately 10-25% of cancer patients show substantially long duration of diagnostic intervals. Reducing primary care delay seems particularly relevant for colorectal cancer.

Number of pulses or number of sessions? An open-label study of trajectories of improvement for once-vs. twice-daily dorsomedial prefrontal rTMS in major depression

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) shows efficacy in the treatment of major depressive episodes (MDEs), but can require ≥4-6 weeks for maximal effect. Recent studies suggest that multiple daily sessions of rTMS can accelerate response without reducing therapeutic efficacy. However, it is unresolved whether therapeutic effects track cumulative number of pulses, or cumulative number of sessions.

OBJECTIVE

This open-label study reviewed clinical outcomes over a 20-30 session course of high-frequency bilateral dorsomedial prefrontal cortex (DMPFC)-rTMS among patients receiving 6000 pulses/day delivered either in twice-daily sessions 80 min apart (at 20 Hz) or single, longer, once-daily sessions (at 10 Hz).

METHODS

A retrospective chart review identified 130 MDD patients who underwent 20-30 daily sessions of bilateral DMPFC-rTMS (Once-daily, n = 65; Twice-daily, n = 65) at a single Canadian clinic.

RESULTS

Mixed-effects modeling revealed significantly faster improvement (group-by-time interaction) for twice-daily versus once-daily DMPFC-rTMS. Across both groups, the pace of improvement showed a consistent relationship with number of cumulative sessions, but not with cumulative number of pulses. Although the twice-daily group completed treatment in half as many days, final clinical outcomes did not differ significantly between groups on dichotomous measures (response/remission rates: once-daily, 35.4%/33.8%; twice-daily, 41.5%/35.4%), or continuous measures, or on overall response distribution.

CONCLUSIONS

Twice-daily rTMS appears feasible, tolerable, and capable of achieving comparable results to once-daily rTMS, while also reducing course length approximately twofold. Therapeutic gains tracked the cumulative number of sessions, not pulses. Future randomized studies comparing once-daily to multiple-daily rTMS sessions, while controlling for number of pulses, may be warranted.

Free Interval Duration: Clinical Evidence of the Primary Role of Excitement in Bipolar Disorder

BACKGROUND

Cyclicity is the essential feature of Bipolar disorder, but the effect of different cycle patterns on the clinical features is poorly understood. Moreover, no studies investigated the relationship between mania and depression inside the manic-depressive cycle.

OBJECTIVE

The aim of this study is to verify the presence of a relationship between the manic and the depressive phase during the course of bipolar disorder.

METHOD

160 consecutive patients with BD type I were recruited and followed for a mean period of 10 years. During the follow-up period, four types of euthymic phases were collected: free intervals present between a depressive and a manic/hypomanic episode (D-M); free intervals present between a manic/hypomanic and a depressive episode (M-D); free intervals present between two depressive episodes (D-D); free intervals present between two manic/hypomanic episodes (M-M). One-way ANOVA using the groups as independent variable and the duration of the free intervals as dependent variables was used. Furthermore, ANOVA was followed by Fisher's Protected Least Significant Difference post-hoc test to measure between-group differences.

RESULTS

M-D-free interval phases were shorter than D-M-free intervals. M-D intervals were the shortest ones, the D-D and D-M did not differ, and the M-M were the longest.

CONCLUSION

The strict temporal link between manic and depressive phases supports the idea that the manic-depressive cycle usually begins with a manic episode, and that the subsequent depression is often the consequence of subsiding mania.

University Hospital Waterford: 5-year experience of cutaneous melanoma

INTRODUCTION

The incidence of cutaneous melanoma (CM) continues to rise in Ireland. Despite significant advances in melanoma molecular therapy, surgery remains the mainstay of treatment for CM. The University Hospital Waterford (UHW) prospectively maintained CM registry was established in 2010.

AIM

To summarize 5-year experience (2010-2015) of primary CM presenting to UHW.

METHODS

Data were retrospectively obtained from a central electronic pathology and radiology repository augmented by HIPE data and theatre logs. Data collected included patient demographics and clinico-pathological characteristics, specimen number, size, anatomical location, melanoma subtype, Breslow thickness, Clark's level, ulceration, and mitosis.

RESULTS

592 CMs were managed in UHW during the study period. Overall, females comprised the majority of cases with mean age at presentation 60.78 ± 18.29 years. The most commonly affected anatomical location was the lower limb (26.7%) followed by the back (15.1%), upper limb (15.07%), and face (14.40%). Superficial spreading and lentigo maligna were the most common histological subtype accounting for 19.8 and 20%, respectively. Overall, the mean Breslow depth was 2.4 ± 3.7 mm with corresponding Clark's Level III. Sentinel lymph node positivity was 39/103 (37.89%) most commonly located in the axilla (53.8%) and groin (30.7%).

CONCLUSION

There has been a steady increase in the number of cutaneous melanoma presentations over the past 5-years to the South East Cancer Centre. Patients are managed best by prompt surgical excision and multidisciplinary management. Our results are in keeping with international standards and work continues in determining overall 5-year survival and recurrence rates.

Re-Evaluation of Old Findings on Stroke Volume Responses to Exercise and Recovery by Nitrous-Oxide Rebreathin

It is important to verify the old findings of Cumming (1972) and Goldberg and Shephard (1980) who showed that stroke volume (SV) may be higher during recovery rather than during exercise, in order to organize the number of intervals throughout training sessions. The purpose of this study was to re-evaluate individual SV responses to various upright cycling exercises using the nitrous-oxide rebreathing method. Nine moderate to well-trained male athletes volunteered to take part in the study (maximal O₂ uptake (VO_2max): 60.2 ± 7 mL⋅min^-1⋅kg^-1). Workloads ranging from 40-100% of VO_2max were applied to determine individual peak SV (SV_peak) response. Results showed that SV responses were higher during exercise compared to recovery in all exercise loads from 40-100% of VO_2max. Mean SV responses to individual SVpeak loads were also higher during exercise compared to recovery (122.9 ± 2.5 versus 105.3 ± 5.93 mL). The highest SV responses to 10 min exercises of 40-70% of VO_2max were obtained in the 5^th or 7.5^th min of each stage (p≤0.05). Meanwhile, during 5 min exercises between 80-100% of VO_2max, peak SV responses were observed in the 3^rd min of loading (p≤0.05). In conclusion, individual SVpeak levels encountered over wide exercise intensity ranges showed that SVpeak development may also be correlated to exercise intensity corresponding to individual SV_peak loads.

A Taylor-Affine Arithmetic for analyzing the calculation result uncertainty in accident reconstruction

In order to analyze the uncertainty of a reconstructed result, the Interval Algorithm (IA), the Affine Arithmetic (AA) and the Modified Affine Arithmetic (MAA) were introduced firstly, and then a Taylor-Affine Arithmetic (TAA) was proposed based on the MAA and Taylor series. Steps of the TAA, especially in analyzing uncertainty of a simulation result were given. Through the preceding five numerical cases, its application was demonstrated and its feasibility was validated. Results showed that no matter other methods (The IA, AA, the Upper and Lower bound Method, the Finite Difference Method) work well or bad, the TAA work well, even under the condition that the MAA cannot work in some cases because of the division/root operation in these models. Furthermore, in order to make sure that the result obtained from the TAA can be very close to the accurate interval, a simple algorithm was proposed based on the sub-interval technique, its feasibility was validated by two other numerical cases. Finally, a vehicle-pedestrian test was given to demonstrate the application of the TAA in practice. In the vehicle-pedestrian test, the interval [35.5, 39.1]km/h of the impact velocity can be calculated according to steps of the TAA, such interval information will be more useful in accident responsibility identification than a single number. This study will provide a new alternative method for uncertainty analysis in accident reconstruction.

Can robot-assisted laparoscopic radical prostatectomy (RALP) be performed very soon after biopsy?

PURPOSE

To identify the perioperative and oncological impact of different intervals between biopsy and robot-assisted laparoscopic radical prostatectomy (RALP) for localized prostate cancer.

METHODS

All consecutive patients with localized prostate cancer who underwent RALP with primary curative intent in January 2008-July 2014 in a large tertiary hospital were enrolled in this retrospective cohort study. The patients were divided into groups according to whether the biopsy-RALP interval was ≤2, ≤4, ≤6, or >6 weeks. Estimated blood loss and operating room time were surrogates for surgical difficulty. Surgical margin status and continence at the 1 year were surrogates for surgical efficacy. Biochemical recurrence (BCR) was defined as two consecutive postoperative prostate serum antigen values of ≥0.2 ng/ml.

RESULTS

Of the 1446 enrolled patients, the biopsy-RALP interval was ≤2, ≤4, ≤6, and >6 weeks in 145 (10 %), 728 (50.3 %), 1124 (77.7 %), and 322 (22.3 %) patients, respectively. The >6 week group had a significantly longer mean operation time than the ≤2, ≤4, and ≤6 week groups. The groups did not differ significantly in terms of estimated blood loss or surgical margin status. Kaplan-Meier analysis showed that interval did not significantly affect postoperative BCR-free survival. Multivariable Cox proportional hazards model analysis showed that interval duration was not an independent predictor of BCR (≤2 vs. >2 weeks, HR = 0.859, p = 0.474; ≤4 vs. >4 weeks, HR = 1.029, p = 0.842; ≤6 vs. >6 weeks, HR = 0.84, p = 0.368).

CONCLUSION

Performing RALP within 2, 4, or 6 weeks of biopsy does not appear to adversely influence surgical difficulty or efficacy or oncological outcomes.

Predictors of pathologic complete response after preoperative concurrent chemoradiotherapy of rectal cancer: a single center experience

Purpose:

To identify possible predictors of pathologic complete response (pCR) of rectal cancer after preoperative concurrent chemoradiotherapy (CCRT).

Materials and Methods:

We conducted a retrospective review of 53 patients with rectal cancer who underwent preoperative CCRT followed by radical surgery at a single center between January 2007 and December 2012. The median radiotherapy dose to the pelvis was 54.0 Gy (range, 45.0 to 63.0 Gy). Five-fluorouracil-based chemotherapy was administered via continuous infusion with leucovorin.

Results:

The pCR rate was 20.8%. The downstaging rate was 66%. In univariate analyses, poor and undifferentiated tumors (p = 0.020) and an interval of ≥7 weeks from finishing CCRT to surgery (p = 0.040) were significantly associated with pCR, while female gender (p = 0.070), initial carcinoembryonic antigen concentration of <5.0 ng/dL (p = 0.100), and clinical stage T2 (p = 0.100) were marginally significant factors. In multivariate analysis, an interval of ≥7 weeks from finishing CCRT to surgery (odds ratio, 0.139; 95% confidence interval, 0.022 to 0.877; p = 0.036) was significantly associated with pCR, while stage T2 (odds ratio, 5.363; 95% confidence interval, 0.963 to 29.877; p = 0.055) was a marginally significant risk factor.

Conclusion:

We suggest that the interval from finishing CCRT to surgery is a predictor of pCR after preoperative CCRT in patients with rectal cancer. Stage T2 cancer may also be an important predictive factor. We hope to perform a robust study by collecting data during treatment to obtain more advanced results.

Multitarget stool DNA for colorectal cancer screening: A review and commentary on the United States Preventive Services Draft Guidelines

Multitarget stool DNA (mt-sDNA) testing was approved for average risk colorectal cancer (CRC) screening by the United States Food and Drug Administration and thereafter reimbursed for use by the Medicare program (2014). The United States Preventive Services Task Force (USPSTF) October 2015 draft recommendation for CRC screening included mt-sDNA as an “alternative” screening test that “may be useful in select clinical circumstances”, despite its very high sensitivity for early stage CRC. The evidence supporting mt-sDNA for routine screening use is robust. The clinical efficacy of mt-sDNA as measured by sensitivity, specificity, life-years gained (LYG), and CRC deaths averted is similar to or exceeds that of the other more specifically recommended screening options included in the draft document, especially those requiring annual testing adherence. In a population with primarily irregular screening participation, tests with the highest point sensitivity and reasonable specificity are more likely to favorably impact CRC related morbidity and mortality than those depending on annual adherence. This paper reviews the evidence supporting mt-sDNA for routine screening and demonstrates, using USPSTF’s modeling data, that mt-sDNA at three-year intervals provides significant clinical net benefits and fewer complications per LYG than annual fecal immunochemical testing, high sensitivity guaiac based fecal occult blood testing and 10-year colonoscopy screening.

Delaying surgery after neoadjuvant chemoradiotherapy does not significantly influence postoperative morbidity or oncological outcome in patients with oesophageal adenocarcinoma

BACKGROUND

Patients with resectable oesophageal cancer are treated with neoadjuvant chemoradiotherapy (nCRT) followed by surgery within 3-8 weeks. In practice, surgery is often delayed for various reasons. The aim of this study was to evaluate whether delaying surgery beyond 8 weeks has an effect on postoperative morbidity, long-term survival, and pathologic response in patients treated for oesophageal ADC.

METHODS

Patients who underwent nCRT followed by surgery, for cT1-3, N0-3, M0 ADC between 2001 and 2014 were retrospectively included from a prospectively obtained database. Patients with a time from the end of nCRT to surgery (TTS) ≤8 weeks were compared with patients with a TTS >8 weeks.

RESULTS

Of 190 patients, 65 had a TTS ≤8 weeks, and 125 had a TTS >8 weeks. Patient characteristics were comparable for both groups, but patients with TTS >8 weeks exhibited higher ASA scores (p = 0.013) and more comorbidities (p = 0.007). Multivariate analysis revealed that TTS did not significantly influence postoperative morbidity, pathologic complete response rates, and five-year survival rates (42% in patients with TTS ≤8 weeks and 37% in patients with TTS >8 weeks).

CONCLUSIONS

Delaying surgery beyond 8 weeks after nCRT did not significantly influence postoperative morbidity, pathologic response, and survival in patients with non-metastatic ADC. Therefore, it appears reasonable to postpone surgery beyond 8 weeks in patients who have not yet recovered from nCRT. However, if the patient is fit for surgery, postponing surgery does not have any additional advantages.

Hearing outcome does not depend on the interval of intratympanic steroid administration in idiopathic sudden sensorineural hearing loss

We studied the effect of intratympanic steroid administration with different intervals on hearing outcomes in patients with idiopathic sudden sensorineural hearing loss (ISSNHL). The subjects were 197 consecutive patients (197 ears) with ISSNHL (hearing level ≥40 dB, interval between onset and treatment ≤30 days). They received systemic administration of prednisolone (100 mg followed by tapered doses) combined with intratympanic injection of dexamethasone (4 mg/ml). Intratympanic injection was performed once a week for 4 weeks in 105 patients (long-interval group), or 4 times in 1 week in 92 patients (short-interval group). The hearing outcomes were evaluated at two points of time: 1 week from the start of treatment, and 1-2 months after the completion of treatment when the hearing level reached a plateau. There was no significant difference in the cure rate, marked-recovery rate, recovery rate, hearing gain, hearing level, or percent hearing improvement between the long- and short-interval groups at either point of time. Multiple regression analysis also showed that the final hearing level did not depend on the interval of intratympanic steroid injection. These results indicate that the hearing outcome of ISSNHL does not improve even if the interval of intratympanic injection is shortened. This implies that a lower total number of intratympanic steroid injections may be as effective as the present protocol.

Technical note: unsafe rectal temperature measurements due to delayed warming of the thermocouple by using a condom. An issue concerning the estimation of the postmortem interval by using Henßge's nomogram

In some cases, in the Netherlands, an additional layer is being added to the thermocouple, used to measure the rectal temperature in medicolegal death investigations. Because of this deviation from the standard method, questions arose regarding the accuracy and precision of the measured temperature. Therefore, a cooling experiment was carried out on a round body made of agar with an average thermal conductivity of 0.454 W/(m °C) while measuring the temperature with and without an additional layer around the thermocouple for three different starting temperatures: 36, 30, and 27 °C. The results show a significant difference between the measured values for the first 5 min when comparing with and without the additional layer. Further, a decrease in precision is present within the first minutes when using an additional layer. Therefore, it is concluded that it is best to measure the rectal temperature without an additional layer around the thermocouple and caution should be taken when measuring with an additional layer.

Early vs. Late Chemoradiation Therapy and the Postoperative Interval to Adjuvant Therapy Do Not Correspond to Local Recurrence in Resected Pancreatic Cancer

Objective

Standard postoperative therapy for pancreatic cancer consists of both chemotherapy alone and chemoradiation. We sought to investigate whether the sequence of chemotherapy and chemoradiation and overall time to initiation of adjuvant therapy would impact local vs. distant recurrence.

Methods

After Institutional Review Board approval, resected pancreas cancer patient charts were evaluated for medical background, surgical, pathological, chemoradiation (CRT), and follow-up. Local recurrence (LR) was defined as failures occurring in the postoperative bed and regional lymph nodes. Early vs. late CRT was defined by whether CRT was given early (within 1–2 cycles of adjuvant chemotherapy) or late in the course of adjuvant chemotherapy (after the 3rd cycle of chemotherapy). The postoperative interval variance was compared to LR factors such as progression-free survival (PFS) and overall survival (OS).

Results

Of the 34 eligible patients, 47% (n=16) underwent early CRT and 41% (n=14) underwent late CRT. 12% (n=14) did not undergo any induction chemotherapy. At median follow-up of 22 months, 53% (n=18) had metastases, 24% (n=8) had LR, and 24% (n=8) were disease free. Kaplan-Meier curves revealed that early vs. late CRT did not appear to significantly impact OS (p=0.63), PFS (p=0.085) or LR (p=0.19). Postoperative interval did not affect PFS (p=0.42) or OS (p=0.93).

Conclusions

Early vs. late CRT and the time to initiation of adjuvant therapy were not significantly associated with LR in patients with resected pancreatic cancer. Future prospective studies are required to determine if sequencing of chemotherapy, CRT, or the postoperative interval impact survival and patterns of recurrence.

The influence of prehospital time on trauma patients outcome: a systematic review

OBJECTIVE

Time is considered an essential determinant in the initial care of trauma patients. Salient tenet of trauma care is the 'golden hour', the immediate time after injury when resuscitation and stabilization are perceived to be most beneficial. Several prehospital strategies exist regarding time and transport of trauma patients. Literature shows little empirical knowledge on the exact influence of prehospital times on trauma patient outcome. The objective of this study was to systematically review the correlation between prehospital time intervals and the outcome of trauma patients.

METHODS

A systematic review was performed in MEDLINE, Embase and the Cochrane Library from inception to May 19th, 2014. Studies reporting on prehospital time intervals for emergency medical services (EMS), outcome parameters and potential confounders for trauma patients were included. Two reviewers collected data and assessed the outcomes and risk of bias using the STROBE-tool. The primary outcome was the influence on mortality.

RESULTS

Twenty level III-evidence articles were considered eligible for this systematic review. Results demonstrate a decrease in odds of mortality for the undifferentiated trauma patient when response-time or transfer-time are shorter. On the contrary increased on-scene time and total prehospital time are associated with increased odds of survival for this population. Nevertheless rapid transport does seem beneficial for patients suffering penetrating trauma, in particular hypotensive penetratingly injured patients and patients with a traumatic brain injury.

CONCLUSION

Swift transport is beneficial for patients suffering neurotrauma and the haemodynamically unstable penetratingly injured patient. For haemodynamically stable undifferentiated trauma patients, increased on-scene-time and total prehospital time does not increase odds of mortality. For undifferentiated trauma patients, focus should be on the type of care delivered prehospital and not on rapid transport.

Sertindole: cardiac electrophysiological profile

QT interval prolongation is the ECG correlate of prolongation of the cardiac action potential (AP). Abnormal or excessive QT interval prolongation may be associated with an increased risk of ventricular tachycardia. This association appears increasingly evident in congenital long QT syndrome and with certain classes of cardiovascular and non-cardiovascular therapeutics. Almost all drugs causing QT interval prolongation inhibit the rapid component of the delayed rectifier potassium current (I Kr ), an ion channel involved in the termination of the myocardial AP. Inhibition of I Kr leads to AP and QT interval prolongation. Drugs, which do not encounter a sufficient electrophysiological counterbalance to the inhibitory effect on I Kr , may thus impose a risk of ventricular tachyarrhythmia. Some non-cardiac drugs, including the antipsychotic sertindole, have inhibitory effects on I Kr but, in contrast to the drugs that are known to cause tachyarrhythmia, sertindole possesses an important electrophysiological counterbalancing profile. Sertindole inhibits &#102 1 -adrenoceptors and blocks both sodium and calcium channels. The balanced electrophysiological profile of sertindole may well explain the low proarrhythmic potential observed in animal proarrhythmia models against positive comparators. It also supports the lack of increased cardiac mortality observed in clinical trials with sertindole and in large epidemiological studies.