10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial

BACKGROUND

If carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA.

METHODS

Between 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3-2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6-11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392.

FINDINGS

1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7% versus 4·8% at 1 year (and 92·1%vs 16·5% at 5 years). Perioperative risk of stroke or death within 30 days was 3·0% (95% CI 2·4-3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1% versus 10·0% at 5 years (gain 5·9%, 95% CI 4·0-7·8) and 10·8% versus 16·9% at 10 years (gain 6·1%, 2·7-9·4); ratio of stroke incidence rates 0·54, 95% CI 0·43-0·68, p<0·0001. 62 versus 104 had a disabling or fatal stroke, and 37 versus 84 others had a non-disabling stroke. Combining perioperative events and strokes, net risks were 6·9% versus 10·9% at 5 years (gain 4·1%, 2·0-6·2) and 13·4% versus 17·9% at 10 years (gain 4·6%, 1·2-7·9). Medication was similar in both groups; throughout the study, most were on antithrombotic and antihypertensive therapy. Net benefits were significant both for those on lipid-lowering therapy and for those not, and both for men and for women up to 75 years of age at entry (although not for older patients).

INTERPRETATION

Successful CEA for asymptomatic patients younger than 75 years of age reduces 10-year stroke risks. Half this reduction is in disabling or fatal strokes. Net benefit in future patients will depend on their risks from unoperated carotid lesions (which will be reduced by medication), on future surgical risks (which might differ from those in trials), and on whether life expectancy exceeds 10 years.

FUNDING

UK Medical Research Council, BUPA Foundation, Stroke Association.

Three controlled trials of interventions to increase recruitment to a randomized controlled trial of mobile phone based smoking cessation support

Background Recruitment is a major challenge for trials but there is little evidence regarding interventions to increase trial recruitment. We report three controlled trials of interventions to increase recruitment to the Txt2stop trial.

Purpose To evaluate: Trial 1. The impact on registrations of a text message regarding an online registration facility; Trial 2. The impact on randomizations of sending £5 with a covering letter to those eligible to join the trial; Trial 3. The impact on randomizations of text messages containing quotes from existing participants.

Methods Single blind controlled trials with allocation concealment. Interventions: Trial 1: A text message regarding our new online registration facility; Trial 2: A letter with £5 enclosed; Trial 3: A series of four text messages containing quotes from participants. The control group in each trial received standard Txt2stop procedures.

Results Trial 1: 3.6% (17/470) of the intervention group and 1.1% (5/467) of the control group registered for the trial, risk difference 2.5% (95% CI 0.6—4.5). 0% (0/ 470) of the intervention group and 0.2% (1/467) of the control group registered successfully online, risk difference —0.2 (95% CI —0.6—0.2); Trial 2: 4.5% (11/246) of the intervention group and 0.4% (1/245) of the control group were randomized into the Txt2stop trial, risk difference 4.0% (95% CI 1.4—6.7); Trial 3: 3.5% (14/405) of the intervention group and 0% (0/406) of the control group were randomized into the Txt2stop trial, risk difference 3.5 (95% CI 1.7—5.2).

Limitations There were no baseline data available for trial 1. Allocation of participant IDs in trials 2 and 3 were systematic.

Conclusion Sending a text message about an online registration facility increased registrations to Txt2stop, but did not increase online registrations. Sending a £5 reimbursement for participants’ time and sending text messages containing quotes from existing participants increased randomizations into the Txt2stop trial. Clinical Trials 2010; 7: 265—273. http://ctj.sagepub.com

Abrogation of glucocorticoid receptor dimerization correlates with dissociated glucocorticoid behavior of compound a

Compound A (CpdA), a dissociated glucocorticoid receptor modulator, decreases corticosteroid-binding globulin (CBG), adrenocorticotropic hormone (ACTH), and luteneinizing hormone levels in rats. Whether this is due to transcriptional regulation by CpdA is not known. Using promoter reporter assays we show that CpdA, like dexamethasone (Dex), directly transrepresses these genes. Results using a rat Cbg proximal-promoter reporter construct in BWTG3 and HepG2 cell lines support a glucocorticoid receptor (GR)-dependent transrepression mechanism for CpdA. However, CpdA, unlike Dex, does not result in transactivation via glucocorticoid-responsive elements within a promoter reporter construct even when GR is co-transfected. The inability of CpdA to result in transactivation via glucocorticoid-responsive elements is confirmed on the endogenous tyrosine aminotransferase gene, whereas transrepression ability is confirmed on the endogenous CBG gene. Consistent with a role for CpdA in modulating GR activity, whole cell binding assays revealed that CpdA binds reversibly to the GR, but with lower affinity than Dex, and influences association of [(3)H]Dex, but has no effect on dissociation. In addition, like Dex, CpdA causes nuclear translocation of the GR, albeit to a lesser degree. Several lines of evidence, including fluorescence resonance energy transfer, co-immunoprecipitation, and nuclear immunofluorescence studies of nuclear localization-deficient GR show that CpdA, unlike Dex, does not elicit ligand-induced GR dimerization. Comparison of the behavior of CpdA in the presence of wild type GR to that of Dex with a dimerization-deficient GR mutant (GR(dim)) strongly supports the conclusion that loss of dimerization is responsible for the dissociated behavior of CpdA.

Updated recommendations from the Canadian National Consensus Meeting on HER2/neu testing in breast cancer

Testing for her2/neu in breast cancer at the time of primary diagnosis is now the standard of care. Accurate and standardized testing methods are of prime importance to ensure the proper classification of the patient’s her2/neu status. A meeting of pathologists from across Canada was convened to update the Canadian her2/neu testing guidelines. This National her2/neu Testing Committee reviewed the recently published American Society of Clinical Oncology/ College of American Pathologists (asco/cap) guidelines for her2/neu testing in breast cancer. The updated Canadian her2/neu testing guidelines are based primarily on the asco/cap guidelines, with some modifications. It is anticipated that widespread adoption of these guidelines will further improve the accuracy of her2/neu testing in Canada.

IFPA Meeting 2009 workshops report

Workshops are an important part of the annual meeting of the International Federation of Placenta Associations (IFPA). At IFPA Meeting 2009 diverse topics were discussed in twelve themed workshops. Topics covered included: immune response to pregnancy; signaling between fetus and placenta; bioactive lipids in placenta; placenta in agricultural species; epigenetics and placentation; trophoblast deportation; glucocorticoids and placental function; endothelium; placental transport; genes and placenta; uteroplacental blood flow and placental stem cells. This report is a full summary of the various topics covered.

A phase I study of XL281, a selective oral RAF kinase inhibitor, in patients (Pts) with advanced solid tumors

3513

Background: XL281 is a potent and selective inhibitor of wild type and mutant RAF kinases showing anti-tumor activity in multiple xenograft models. Mutations in KRAS or BRAF can activate the RAF/MEK/ERK pathway in human tumors and may promote sensitivity to RAF kinase inhibitors. Methods: Pts were enrolled in successive cohorts of XL281 orally once daily on a 28-day cycle. Tumor response was assessed per RECIST every 8 wks. Plasma pharmacokinetic and pharmacodynamic samples were collected. The maximum tolerated dose (MTD) was expanded to 10 pts each with colorectal (CRC), melanoma, papillary thyroid (PTC) and NSCLC. Pre- and post-dose tumor and surrogate tissues were obtained. Biomarker and genotype analyses of pathway genes were performed. Results: The dose escalation phase is complete; 30 pts were treated with XL281. DLTs of fatigue, nausea, vomiting, and diarrhea were observed at the MAD (225 mg). The MTD is 150 mg. The most common related AEs included Grade 1/2, fatigue (48%), diarrhea (35%), nausea (35%), vomiting (35%) and anorexia (30%). Three pts had related AEs ≥G3: hypokalemia, nausea, and vomiting. One pt with an ocular melanoma demonstrated a cPR of 4 mos duration. Twelve pts had SD (3 -17+ mos), including 2 with I131-refractory PTC harboring BRAF V600E mutations (15+ and 17+ mos). Nine of these pts had decreases in target lesions (5–29%), including a pt with KRAS mutant CRC on study for 20 wks with marked symptomatic improvement. At the MTD, paired biopsies from 4 pts (3 melanoma, 1 NSCLC) show an average 72 % decrease in pMEK, 68 % decrease in pERK, 24 % decrease in Ki67 (proliferation) and 64 % increase in TUNEL (apoptosis). Three of 6 evaluable pts in the MTD cohort show SD at first assessment, including 1 melanoma pt with a NRAS Q61R mutation who showed a 20% decrease in target lesions. Conclusions: XL281 was generally well tolerated and the MTD was established at 150 mg. One cPR occurred in an ocular melanoma subject, and clinical benefit (PR or SD) occurred in 43% (13/30) of pts in the dose-escalation phase. XL281 demonstrates biological activity by modulation of the RAF pathway in tumor and surrogate tissue, with decreases in cell proliferation and increases in apoptosis.

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A phase II study of XL184 in patients (pts) with progressive glioblastoma multiforme (GBM) in first or second relapse

2047

Background: XL184 is a potent orally bioavailable inhibitor of MET, RET, KIT, and VEGFR2. Elevated levels of VEGFR2 and its ligand VEGF are found in GBM, and elevated levels of MET and KIT are correlated with poor prognosis in GBM pts. Treatment with XL184 results in potent inhibition of GBM in preclinical models. Methods: This is a phase II study of 46 pts with recurrent GBM who received XL184 175mg PO qd. Co-primary objectives are 6-month progression-free survival (PFS6) and safety. Secondary objectives include response rate (per MacDonald Criteria), duration of response, overall survival, pharmacodynamic and pharmacokinetic parameters, vascular imaging, and changes in steroid usage. Results: As of January 6, 2009, all 46 pts have been enrolled. At least 1 post-baseline tumor assessment at 4 weeks was available for 26 pts. Of these, 17 pts had not received prior therapy with an anti-angiogenic agent, whereas 9 pts had received prior therapy with bevacizumab (n = 6), vandetanib (n = 2), or VEGF-TRAP (n = 1). Safety: 6 pts have experienced a total of 9 possibly related grade 3/4 SAEs including increased troponin I and myocarditis (n = 1); dehydration, nausea, and fatigue (n = 1); elevated ALT (n = 1); pulmonary embolism (n = 2); and CNS hemorrhage (n = 1). 24/46 (52%) pts have required a dose interruption or reduction due to AEs or SAEs. Based on investigator assessment of bidimensional contrast-enhancing tumor measurements, 10 pts (38%) had a best radiologic response of >= 50% reduction from baseline (including 1 pt with a 100% reduction), 9 pts (35%) had tumor measurement changes ranging from +24% and -49%, and 7 pts (27%) had a >= 25% increase in tumor burden. Of the 17 anti-angiogenic-naïve pts, 9 (53%) had a best radiologic response of >= 50% reduction in tumor burden. 1 pt with prior vandetanib therapy has experienced a best radiologic response of >= 50%. Of the 4 pts with > 6 months follow-up, 3 remain on study with a sustained radiologic response. Conclusions: XL184 at a dose of 175 mg PO qd, has demonstrated substantial activity in pts with progressive or recurrent GBM. Updated safety and efficacy results including centrally reviewed PFS6 and response rate will be reported.

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Aicardi syndrome in a male patient

Aicardi syndrome ( OMIM 304050) is defined by the clinical triad of early-onset infantile spasms, agenesis of the corpus callosum and chorioretinal lacunae. Almost all patients are females showing severe cognitive and physical disabilities, and early onset seizures. Astrocytic inclusions containing filamin have been found, but the molecular defect in Aicardi syndrome is not yet known. We report a male patient with Aicardi syndrome characterised by agenesis of the corpus callosum, infantile spasms, chorioretinal lacunae, severe psychomotor retardation, periventricular heterotopias, and patent ductus arteriosus. As the latter two symptoms are suggestive of a mutation in the FLNA gene encoding filamin A, this gene was sequenced, but the sequence did not reveal a disease-causing mutation.

Fatal and non-fatal fire injuries in England 1995-2004: time trends and inequalities by age, sex and area deprivation

AIM

To examine time trends and deprivation gradients in fire-related deaths and injuries.

METHODS

A cross-sectional study and time trend analysis using data on fire casualties in England between 1995 and 2004 obtained from the Department for Communities and Local Government. Injury rates were calculated assuming a Poisson distribution. Incidence rate ratios (IRRs) were calculated to compare changes in deprivation gradients over time.

RESULTS

There were significant reductions in fatal and non-fatal fire injuries in children (fatal injuries IRR chi(2)(1) = 11.18, P < 0.001; non-fatal injuries IRR chi(2)(2) = 61.44, P < 0.001), adults (fatal injuries IRR chi(2)(1) = 15.99, P < 0.001; non-fatal injuries IRR chi(2)(2) = 183.25, P < 0.001) and older people (fatal injuries IRR chi(2)(1) = 56.88, P < 0.001; non-fatal injuries IRR chi(2)(2) = 54.09, P < 0.001) between 1995 and 2004. Adult and child fire deaths were most commonly caused by smokers' materials (e.g. cigarettes, cigars and tobacco), and cigarette lighters and matches, respectively. Cooking appliances caused most non-fatal fire injuries. Injury rates increased with increasing levels of deprivation and deprivation gradients did not change over 10 years.

CONCLUSIONS

Fire prevention interventions should promote the safe use of cooking and heating appliances and the responsible use of smokers' materials, lighters and matches, and should target those at greater risk of fire, including the socially disadvantaged.

The role of ENT surgeons in snoring assessment: some prospective preliminary evidence

OBJECTIVES

To determine (i) the prevalence of unsuspected upper aerodigestive tract disease in snorers, (ii) the diagnostic yield of routine flexible endoscopy and (iii) the relationship between symptoms of upper aerodigestive tract disease and examination findings in snorers.

DESIGN

Prospective analytical cohort study.

SETTING

Snoring clinic in Secondary Care Otolaryngology centre.

PARTICIPANTS

Ninety-three patients referred with disruptive snoring.

MAIN OUTCOME MEASURES

A structured history of upper aerodigestive tract symptoms was obtained by clinic interview. All patients underwent detailed ENT examination. Univariate analysis was undertaken on data collected.

RESULTS

The prevalence of oropharyngeal and laryngeal pathology in the cohort was 3%. No unsuspected upper aerodigestive tract pathology was found on routine flexible endoscopy. A history of Hard Nasal Symptoms was an accurate predictor of underlying nasal pathology.

CONCLUSION

The authors propose that the detailed examination of snorers by ENT specialists is unnecessary in the absence of Hard Nasal Symptoms, hoarseness or pain. We propose that a system of triage based on patient history could help identify the minority of snorers who require specialist assessment.

Use of laboratory data to reduce the time taken to detect new diseases: VIDA to FarmFile

The analysis of laboratory data can provide information about the health of livestock populations; in Great Britain the Veterinary Investigation Diagnosis Analysis (VIDA) system has provided such data since 1975. However VIDA covers only known diagnoses, with limited epidemiological characterisation. The unexpected outbreak of bse showed that it was necessary to improve surveillance to detect new diseases, and a necessary update of the VIDA database for the millennium date change provided the opportunity. The information required to enhance the value of laboratory data was identified, a new form and database, 'FarmFile', were designed to record it, and they began to be used in 1999. The detection of new diseases depends on making comparisons with the expected or 'usual' levels of unexplained disease. The data are analysed quarterly to assess any changes in the levels of unexplained disease in different species, categorised in terms of clinical sign or body system, by comparison with previous years. No new diseases have been detected either through FarmFile or more traditional means since the new analyses started in earnest in 2004, but they have indicated that an unexplained event was not a new disease of concern, and developments continue to improve the system's sensitivity and specificity.

Comparison of combined urea and creatinine clearance and prediction equations as measures of residual renal function when GFR is low

BACKGROUND

UK, US and European guidelines recommend the decision to initiate dialysis should be based on a combination of measurements of kidney function, nutritional status and clinical symptoms. Such recommendations assume an accurate and reproducible measure of glomerular filtration rate (GFR).

METHODS

Prospective study of 97 patients with chronic kidney disease (CKD) and serum creatinine >200 micromol/l (2.26 mg/dl) who between them contributed 388 24 h urine collections. Our main outcome measure was the number of patients with low residual renal function identified by different tests, using widely accepted thresholds. We calculated sensitivity, specificity, positive and negative predictive values and receiver operating characteristic curves for each comparison using a combined urea and creatinine clearance of <15 ml/min to indicate the likely presence of end stage renal disease (CKD stage 5).

RESULTS

Seventy five patients had a combined urea and creatinine clearance <15 ml/min during the study. Using the highest measurement of serum creatinine for each patient, the best of the prediction equations was the 4-variable modification of diet in renal disease (MDRD) equation (area under ROC curve 0.93). This was followed by Kt/V (AUC 0.91) and Cockroft Gault with and without correction for ideal body weight (AUC 0.89). Further analyses showed that the 4-variable MDRD equation had higher NPV (64%) but lower PPV (89%) than the other tests (NPV 40-49%, PPV 92-100%), for identifying patients whose combined clearance was <15 ml/min.

CONCLUSION

The 4-variable MDRD formula is currently the best available prediction equation for GFR, but will nevertheless over estimate residual renal function when this is significantly impaired in up to 36% cases. Collection of 24 h urine samples may still have a role in the assessment of patients with stages 4 and 5 CKD.

A controlled release pilocarpine buccal insert in the treatment of Sjögren's syndrome

OBJECTIVES

To assess the efficacy of a novel hydrogel polymer buccal insert containing 5 mg pilocarpine in releasing the pilocarpine in a controlled fashion over a three hour period, and to assess the effects of this on quantitative tear and saliva production and the acceptability of the insert to the patient.

DESIGN

This was an open, uncontrolled pilot study for which Ethics Committee approval was obtained prior to starting. Hydrogel buccal inserts containing 5 mg pilocarpine were used three times a day for seven days.

SETTING

The Department of Oral Medicine, Glasgow Dental Hospital & School.

SUBJECTS

Eight patients with Sjögren's syndrome.

MAIN OUTCOME MEASURES

Changes over baseline in (1) Schirmer test, (2) whole saliva flow rate, (3) oral comfort score (VAS), (4) ocular comfort score (VAS), (5) patient acceptability.

RESULTS

The buccal inserts successfully released in excess of 85% of their 5 mg pilocarpine load over three hours. There was a general improvement in oral and ocular comfort scores assessed by visual linear analogue scale, and saliva and tear production generally increased. The inserts were well tolerated by all patients except one (who wore dentures). Adverse events were few and none was serious.

CONCLUSION

This novel form of buccal pilocarpine delivery demonstrated potential for use in treating patients with Sjögren's syndrome.

Large area mass analyzer instrument for the chemical analysis of interstellar dust particles

A new instrument to analyze the chemical composition of dust particles in situ in space has been developed. The large target area ( approximately 0.2 m(2)) makes this instrument well suited for detecting a statistically significant number of interstellar dust grains or other dust particles with a low flux. The device is a reflectron-type time-of-flight mass spectrometer that uses only flat electrodes for the generation of the parabolic potential. The instrument analyzes the ions from the impact generated plasma due to hypervelocity dust impacts onto a solid target surface. The SIMION ion optics software package is used to investigate different potential field configurations and optimize the mass resolution and focusing of the ions. The cylindrically symmetric instrument operates with six ring electrodes and six annular electrodes biased to different potentials to create the potential distribution of the reflectron. The laboratory model of the instrument has been fabricated and tested. Hypervelocity dust impacts are simulated by laser ablation using a frequency doubled Nd:YAG laser with approximately 8 ns pulse length. The experimental data show typical mass resolution m/Deltam approximately 200.

Varied presentations of pseudoxanthoma elasticum in a family

Pseudoxanthoma elasticum (PXE) is a hereditary disorder of elastic tissue. The characteristic skin changes are asymptomatic yellow papules around the neck and in body folds giving the skin a characteristic cobblestone appearance. The eyes, cardiovascular and gastrointestinal systems are also commonly involved. In this case-series, we present a family of four children, three of whom demonstrated diverse manifestations of PXE. The first child presented with sudden death at age 3 and showed marked coronary and renal arterial intimal fibrosis with prominent fragmentation of the internal elastic lamina, initially attributed to idiopathic arterial calcification. The second child presented with clinical features and histology of the skin typical of PXE at age 11 and the third child, with abnormal, but non-specific cardiological findings at age 8, which raised the possibility of an early stage of PXE. This report emphasizes the importance of considering pseudoxanthoma elasticum in diverse clinical settings, early diagnosis and appropriate screening for asymptomatic family members.

Ear protection as a treatment for disruptive snoring: do ear plugs really work?

BACKGROUND

In the absence of surgical treatments with demonstrable long-term efficacy, conservative treatments for snoring remain appropriate. Only limited evidence evaluating the use of ear protection by partners has been published.

METHODS

Eligible couples were invited to participate in a two-month trial, with each partner using custom-moulded ear plugs. Five questionnaires were completed by patients and their partners, at baseline and after two months: the snoring outcomes survey (SOS) or the spouse/bed partners survey (SBPS), the Epworth sleepiness scale (ESS), the general health questionnaire-12 (GHQ-12), the Nottingham health profile (NHP) and the Golombok-Rust inventory of marital status (GRIMS).

RESULTS

After two months, there was a significant improvement in the SOS score for patients (p = 0.005), the SBPS score for partners (p = 0.001) and the ESS for partners (p = 0.004).

CONCLUSIONS

For selected couples, ear plugs represent an effective short-term treatment for some of the social effects of disruptive snoring, as determined by the SOS, SBPS and ESS questionnaires.