Identifying former injecting drug users infected with hepatitis C: an evaluation of a general practice-based case-finding intervention

BACKGROUND

In Scotland, a general practice-based case-finding initiative, to diagnose and refer hepatitis C virus (HCV) chronically infected former injecting drug users (IDUs), was evaluated.

METHODS

Testing was offered in eight Glasgow general practices in areas of high deprivation and high HCV and IDU prevalence to attendees aged 30-54 years with a history of IDU. Test uptake and diagnosis rates were compared with those in eight demographically similar control practices.

RESULTS

Of 422 eligible intervention practice attendees, 218 (52%) were offered an HCV test and, of these, 121 (56%) accepted. Poor venous access in 13 individuals prevented testing. Of 105 tested, 70% (74/105) were antibody positive of which 58% (43/74) were RNA positive by PCR. Of 43 chronically infected individuals identified in intervention practices, 22 (51%) had attended specialist care within 30 months of the study, while 9 (21%) had defaulted. In control practices, 8 (22%) of 36 individuals tested were antibody positive. Test uptake and case yield were approximately 3 and 10 times higher in intervention compared with control practices, respectively.

CONCLUSIONS

Targeted case-finding in primary care demonstrated higher test uptake and diagnosis rates; however, to optimize diagnosis and referral of chronically infected individuals, alternative means of testing (e.g. dried blood spots) and retention in specialist care (e.g. outreach services) must be explored.

A cluster of Legionnaires' disease caused by Legionella longbeachae linked to potting compost in Scotland, 2008-2009

Three cases of Legionnaires disease caused by Legionella longbeachae Sg 1 associated with potting compost have been reported in Scotland between 2008 and 2009. The exact method of transmission is still not fully understood as Legionnaires disease is thought to be acquired by droplet inhalation. The linked cases associated with compost exposure call for an introduction of compost labelling, as is already in place in other countries where L. longbeachae outbreaks have been reported.

Genetic diversity and selection of genotypes to enhance Zn and Fe content in common bean

Common bean (Phaseolus vulgaris L.) is an important source of dietary protein and minerals worldwide. Genes conditioning variability for mineral contents are not clearly understood. Our ultimate goal is to identify genes conditioning genetic variation for Zn and Fe content. To establish mapping populations for this objective, we tested mineral content of 29 common bean genotypes. Chemical analyses revealed significant genetic variability for seed Zn and Fe contents among the genotypes. Genetic diversity was evaluated with 49 primer pairs, of which 23 were simple sequence repeats (SSR), 16 were developed from tentative consensus (TC) sequences, and 10 were generated from common bean NBS-LRR gene sequences. The discriminatory ability of molecular markers for identifying allelic variation among genotypes was estimated by polymorphism information content (PIC) and the genetic diversity was measured from genetic similarities between genotypes. Primers developed from NBS-LRR gene sequences were highly polymorphic in both PIC values and number of alleles (0.82 and 5.3), followed by SSRs (0.56 and 3.0), and markers developed from TC (0.39 and 2.0). genetic similarity values between genotypes ranged from 14.0 (JaloEEP558 and DOR364) to 91.4 (MIB152 and MIB465). Cluster analysis clearly discriminated the genotypes into Mesoamerican and Andean gene pools. Common bean genotypes were selected to include in crossing to enhance seed Zn and Fe content based on genetic diversity and seed mineral contents of the genotypes.

Comparison of Methods for Detection of Fulvestrant-Induced Changes in Breast Tumor Estrogen and Progesterone Receptor Expression in a Neoadjuvant Trial (NEWEST)

Background: Fulvestrant downregulates breast tumor estrogen and progesterone receptor (ER and PgR) levels in a dose-dependent manner. Using an Automated Cellular Imaging System (ACIS), NEWEST (NCT00093002) reported that 4-wks' treatment with fulvestrant high-dose (HD, 500mg/month+500mg on Day 14 of Month 1) significantly reduced ER levels in primary breast tumors v approved-dose (AD, 250mg/month). However, no significant difference was detected between the two doses on PgR levels. To allow comparison with previous studies, a non-automated H-score assessment was performed and compared with ACIS.Methods: ER and PgR H-scores were derived by manual assessment of % tumor cells in each of 5 staining categories (negative, very weak, weak, moderate, strong) in the same sections scored by ACIS. This microscopic assessment was performed by 2 experienced observers blind to ACIS and clinical data. Mean % changes in H-scores were then calculated (table).Results: Both scoring methods showed a greater effect for fulvestrant HD v AD on ER expression at Wk 4, but H-score provided better dose discrimination. ACIS showed no difference between fulvestrant HD v AD on PgR expression at Wk 4, however, a significantly greater reduction in PgR expression was detected with fulvestrant HD using H-score.Wk 4Mean % change from baseline ACISH-score HDADHDADER-25.0%-13.5%-50.3%-13.7% n=60(n=63)(n=58)(n=60) p=0.0002 p<0.0001 PgR-22.7%-17.6%-80.5%-46.3% (n=43)(n=45)(n=31)(n=34) NS p=0.0018 Baseline mean H-score for HD and AD: 151.6 and 157.7 for ER; 103.8 and 122.9 for PgR.Conclusion: The choice of scoring method for determining ER and PgR expression in pharmacodynamic studies such as NEWEST is critical. Compared with H-scores, ACIS has a narrower dynamic range and reduced ability to discriminate fulvestrant HD v AD, particularly on PgR expression.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1087.

A Prospective Comparison of Switches in Biomarker Status between Primary and Recurrent Breast Cancer: The Breast Recurrence in Tissues Study (BRITS)

IntroductionDisease recurrence and metastasis results in morbidity and mortality from breast cancer. In deciding the best therapeutic approaches at the time of recurrence, the molecular phenotype of the original (primary) cancer is often used. However, it is unclear whether the phenotype of the recurrent cancer is unchanged or has evolved from the original primary. Following several retrospective studies, the Breast Recurrence In Tissues Study (BRITS) is the first prospective study to address this clinically important question.MethodsTo detect a clinically significant switch in biomarker status 137 matched primary and recurrent breast cancer tissue samples were prospectively collected (to an estimated 95% confidence with a precision of 5% to detect a switch) from consenting patients and successfully constructed into tissue microarrays (TMA). Central laboratory analysis of ER (clone 6F11, 1:200) PR (clone 16, 1:800) and HER2 (CB11, 1:1200) was performed by two specialist breast pathologists. ER and PR were scored using the Allred method and HER2 status confirmed by FISH for HER2 2+ (primary or metastasis).Results137 women, mean age 62.6 years (range 27-87 years), 83/137 (60.6%) of whom were postmenopausal were successfully examined. For the original primaries, 96/137 (70.1%) were invasive ductal cancer, 17 (12.4%) grade 1, 66 (48.2%) grade 2 and 43 (31.4%) grade 3, mean size of original primary 23.96mm (range 2.0-134.0mm) and 27 (19.7%) multicentric. Lymphovascular invasion was identified in 76/137 (55.5%) and a margin not clear in 18 (13.1%).Time from the original primary to the recurrence biopsy was a median 92.2 months (range 5-327 months), and occurred as locoregional recurrence in 101 (73.7%). The recurrent biopsy was excisional tissue in 100 (73%) and core biopsy in 37 (27%).Central laboratory analysis of the original primary was ER positive in 109 (79.6%), PR positive in 85 (62.0%) and HER2 positive in 14 (10.2%); the recurrent disease was ER positive in 101 (73.7%), PR positive in 75 (54.7%) and HER2 positive in 16 (11.7%). A switch in receptor status, in either direction, was identified for ER in 14 patients (10.2%; p=0.983 Wilcoxon sign rank test), PR in 34 (24.8%; p=0.003 Wilcoxon sign rank test) and HER2 in 4 (2.9%; p=0.074 Wilcoxon sign rank test). In the judgement of the investigators the switch led to a change in the subsequent treatment in 24 patients (17.5%).ConclusionThis prospective study has demonstrated that the management of locally recurrent or metastatic breast cancer should include tissue sampling, since switches of ER, PR or HER2 status in the breast cancer recurrence may change the planned treatment for one in six patients.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4053.

Lapatinib and gemcitabine for metastatic pancreatic cancer: A phase II study

e15653

Background: To determine the overall survival for patients with metastatic pancreatic cancer treated with lapatinib and gemcitabine. Methods: Patients with metastatic pancreatic cancer received lapatinib, 1,500 mg/day, and Gemcitabine, 1 gm/m2/week for 3 weeks followed by 1 week off, until disease progression. This multicenter phase II study was planned to enter 125 patients to evaluate if the treatment regimen could achieve a 1-year survival of 30% and a median survival of 7 months. An additional subset of 20 patients were to receive 2 months of single agent lapatinib followed by lapatinib and gemcitabine. Results: At a planned 6 month analysis, the Brown University Oncology Group Data Safety Monitoring Board terminated accrual after 29 patients due to futility analysis. The median survival was 4 months (95% CI, 2.0–5.5 months). The four patients who received single agent lapatinib all progressed at 1 month. Conclusions: Lapatinib is not effective in pancreatic cancer. Evaluation of HER2 inhibitors in pancreatic cancer is not warranted.

[Table: see text]

Comparison of methods for detection of fulvestrant-induced changes in breast tumor estrogen and progesterone receptor expression in a neoadjuvant trial (NEWEST)

e11602^

Background: Fulvestrant downregulates breast tumor estrogen and progesterone receptor (ER and PgR) levels in a dose-dependent manner. Using an Automated Cellular Imaging System (ACIS), NEWEST reported that 4-wks’ treatment with fulvestrant high-dose (HD, 500mg/month+500mg on Day 14 of Month 1) significantly reduced ER levels in primary breast tumors v approved-dose (AD, 250mg/month). However, no significant difference was detected between the two doses on PgR levels. To allow comparison with previous studies, a non-automated H-score assessment was performed and compared with ACIS. Methods: ER and PgR H-scores were derived by manual assessment of % tumor cells in each of 5 staining categories (negative, very weak, weak, moderate, strong) in the same sections scored by ACIS. This microscopic assessment was performed by 2 experienced observers blind to ACIS and clinical data. Mean % changes in H-scores were then calculated (table). Results: Both scoring methods showed a greater effect for fulvestrant HD v AD on ER expression at Wk 4, but H-score provided better dose discrimination. ACIS showed no difference between fulvestrant HD v AD on PgR expression at Wk 4, however, a significantly greater reduction in PgR expression was detected with fulvestrant HD using H-score. Conclusions: The choice of scoring method for determining ER and PgR expression in pharmacodynamic studies such as NEWEST is critical. Compared with H-scores, ACIS has a narrower dynamic range and reduced ability to discriminate fulvestrant HD v AD, particularly on PgR expression.

[Table: see text]

ASCO Conflict of Interest Policy and Exceptions

In compliance with the guidelines established by the ASCO Conflict of Interest Policy (J Clin Oncol. 2006 Jan 20;24[3]:519–521) and the Accreditation Council for Continuing Medical Education (ACCME), ASCO strives to promote balance, independence, objectivity, and scientific rigor through disclosure of financial and other interests, and identification and management of potential conflicts. According to the ASCO Conflict of Interest Policy, the following financial and other relationships must be disclosed: employment or leadership position, consultant or advisory role, stock ownership, honoraria, research funding, expert testimony, and other remuneration (J Clin Oncol. 2006 Jan 20;24[3]:520). The ASCO Conflict of Interest Policy disclosure requirements apply to all authors who submit abstracts to the Annual Meeting.

For clinical trials that began accrual on or after April 29, 2004, ASCO's Policy places some restrictions on the financial relationships of principal investigators (J Clin Oncol. 2006 Jan 20;24[3]:521). If a principal investigator holds any restricted relationships, his or her abstract will be ineligible for placement in the 2009 Annual Meeting unless the ASCO Ethics Committee grants an exception. Among the circumstances that might justify an exception are that the principal investigator (1) is a widely acknowledged expert in a particular therapeutic area; (2) is the inventor of a unique technology or treatment being evaluated in the clinical trial; or (3) is involved in international clinical oncology research and has acted consistently with recognized international standards of ethics in the conduct of clinical research. NIH-sponsored trials are exempt from the Policy restrictions. Abstracts for which authors requested and have been granted an exception in accordance with ASCO's Policy are designated with a caret symbol (^) in the Annual Meeting Proceedings.

For more information about the ASCO Conflict of Interest Policy and the exceptions process, please visit www.asco.org/conflictofinterest .

Randomized Phase III controlled trials of therapy in malignant glioma: where are we after 40 years?

The objective of this study was to review the results of randomized Phase III controlled trials (RCTs) that involve initial treatments of malignant glioma and determine changes in median survival times (MST) over the last 40 years. An electronic database search identified RCTs for patients undergoing initial treatment for supratentorial high-grade malignant glioma. MSTs were analysed with respect to the date that patient accrual to the trial started, to identify the time course of changes in MST. Linear regression was used for statistical analysis. The review included 44 clinical trials that recruited patients between 1966 and 2004. Overall, there was a steady significant improvement in MST for the novel treatment cohorts over this period (r(2) = 0.43, p < 0.001), with MST increasing from around 8 to 15 months. There was also consistent improvement in the MST of the control cohorts, from around 7 months to 14 months, that reached statistical significance (r(2) = 0.41, p < 0.001). However, analysis including a quadratic term revealed a trend towards the rate of improvement in MST decreasing in the last two decades in the control, but not novel treatment, groups. The differences, either positive or negative, in MSTs between the control and novel treatment cohorts, and number of trials performed have all decreased with time. Subgroup analysis of the three most recent clinical trials report statistically significant better outcomes in MST after either >90% or 'complete' tumour resection. Despite tremendous advances in both the understanding of the biology of malignant gliomas and treatments in neuro-oncology, the prognosis for patients with malignant gliomas, although improved, remains very poor. The limitations of this type of analysis, including how trial design can bias outcomes and militate against comparison of trials are discussed.

Inactivated infectious haematopoietic necrosis virus (IHNV) vaccines

The inactivation dynamics of infectious haematopoietic necrosis virus (IHNV) by b-propiolactone (BPL), binary ethylenimine (BEI), formaldehyde or heat and the antigenic and immunogenic properties of the inactivated vaccines were evaluated. Chemical treatment of IHNV with 2.7 mm BPL, 1.5 mm BEI or 50 mm formaldehyde abolished virus infectivity within 48 h whereas heat treatment at 50 or 100 degrees C rendered the virus innocuous within 30 min. The inactivated IHNV vaccines were recognized by rainbow trout, Oncorhynchus mykiss, IHNV-specific antibodies and were differentially recognized by antigenic site I or antigenic site II IHNV glycoprotein-specific neutralizing monoclonal antibodies. The BPL inactivated whole virus vaccine was highly efficacious in vaccinated rainbow trout challenged by waterborne exposure to IHNV 7, 28, 42 or 56 days (15 degrees C) after immunization. The formaldehyde inactivated whole virus vaccine was efficacious 7 or 11 days after vaccination of rainbow trout but performed inconsistently when tested at later time points. The other vaccines tested were not efficacious.

Seasonal abundance and reproductive output of the dung flies Neomyia cornicina and N. viridescens (Diptera: Muscidae)

The seasonal abundance and reproductive output of two common, but little studied, dung-breeding flies, Neomyia cornicina and N. viridescens, were examined in artificial cow pats in pastures in southwest England in 2001 and 2004. In 2001, the numbers of both Neomyia species increased slowly over summer to show a sharp seasonal peak in late August and early September. There was no significant effect of mean temperature, mean relative humidity or dung water content on abundance or seasonally de-trended abundance. High levels of aggregation were seen between pats and, when present, greater numbers of N. cornicina emerged than N. viridescens. Neomyia cornicina was present in 13% of 240 artificial standardized pats put out in 2001, at a median of 19 adults per colonized pat; N. viridescens was present in 8% of artificial pats at a median of three adults per colonized pat. In 2004, N. cornicina emerged from 46% of the 94 artificial pats put out at a median of three adults per colonized pat, while N. viridescens emerged from only 12% of pats at a median of one adult per colonized pat. Flies were also collected in 2004, using sticky-traps and hand nets. Again, free-flying N. cornicina appeared to be more abundant in the field than N. viridescens; 162 N. cornicina were caught compared to 44 N. viridescens over the same sampling period. The size of each adult female was recorded and ovarian dissection was used to determine the numbers of eggs matured. Female N. viridescens were significantly larger than the N. cornicina and matured significantly higher numbers of eggs. Gravid N. viridescens matured a mean of 37.1 (+/-16.9) eggs, whereas gravid N. cornicina matured a mean of 28.8 (+/-13.2) eggs. The reasons why the larger, more fecund, N. viridescens adults are less abundant in the field or emerging from pats than N. cornicina are unknown. Further work is required to identify the nature and cause of the mortality experienced by the larvae of these species and the ecological differences and functional specialisation which allows co-existence to be maintained.

Prospective surveillance of women with a family history of breast cancer: auditing the risk threshold

To evaluate current guidelines criteria for inclusion of women in special ‘breast cancer family history’ surveillance programmes, records were reviewed of women referred to Scottish breast cancer family clinics between January 1994 and December 2003 but discharged as at ‘less than ‘moderate’ familial risk’. The Scottish Cancer Registry was then interrogated to determine subsequent age-specific incidence of breast cancer in this cohort and corresponding Scottish population figures. Among 2074 women, with an average follow-up of 4.0 years, 28 invasive breast cancers were recorded up to December 2003, where 14.4 were expected, a relative risk (RR) of 1.94. Eleven further breast cancers were recorded between January 2004 and February 2006 (ascertainment incomplete for this period). The overall RR for women in the study cohort exceeded the accepted ‘cutoff’ level (RR=1.7) for provision of special counselling and surveillance. The highest RR was found for the age group 45–59 years and this group also generated the majority of breast cancers. The National Institute for Clinical Excellence (‘NICE’) guidelines appear to be more accurate than those of the Scottish Intercollegiate Guidelines Network (‘SIGN’) in defining ‘moderate’ familial risk, and longer follow-up of this cohort could generate an evidence base for further modification of familial breast cancer services.

Inequalities in access to education and healthcare

The burden of disease is borne by those who suffer as patients but also by society at large, including health service providers. That burden is felt most severely in parts of the world where there is no infrastructure, or foreseeable prospects of any, to change the status quo without external support. Poverty, disease and inequality pervade all the activities of daily living in low-income regions and are inextricably linked. External interventions may not be the most appropriate way to impact on this positively in all circumstances, but targeted programmes to build social capital, within and by countries, are more likely to be sustainable. By these means, basic oral healthcare, underpinned by the primary healthcare approach, can be delivered to more equitably address needs and demands. Education is fundamental to building knowledge-based economies but is often lacking in such regions even at primary and secondary level. Provision of private education at tertiary level may also introduce its own inequities. Access to distance learning and community-based practice opens opportunities and is more likely to encourage graduates to work in similar areas. Recruitment of faculty from minority groups provides role models for students from similar backgrounds but all faculty staff must be involved in supporting and mentoring students from marginalized groups to ensure their retention. The developed world has to act responsibly in two crucial areas: first, not to exacerbate the shortage of skilled educators and healthcare workers in emerging economies by recruiting their staff; second, they must offer educational opportunities at an economic rate. Governments need to lead on developing initiatives to attract, support and retain a competent workforce.