Observer agreement regarding the necessity of retreatment of previously coiled recurrent cerebral aneurysms

BACKGROUND AND PURPOSE

The decision regarding whether or not to retreat a previously treated aneurysm not only directly impacts patient care but also serves as a primary outcome measure in numerous, leading randomized controlled trials of modified coils. Our aim was to determine the degree of interobserver variability regarding the need and type of treatment for recurrent aneurysms following coil embolization.

MATERIALS AND METHODS

Twenty-seven previously treated recurrent aneurysms were identified. Five independent readers rated each aneurysm on a 5-point scale: 1, definitely do not retreat; 2, probably do not retreat; 3, unsure; 4, probably retreat; and 5, definitely retreat. The readers noted, in grades 2-5, the type of retreatment preferred, including simple coiling, balloon- or stent-assist coiling, or surgical clipping. Intraobserver agreement κ was calculated. Retreatment recommendations were evaluated between observers by using a Wilcoxon signed rank comparison. Descriptive statistics were performed for categoric treatment-type comparisons.

RESULTS

At least 2- or 3-point differences between 2 readers were present in 17 (63%) and 11 (41%) of 27 cases, respectively. The median κ was 0.27 (range, 0.04-0.43), which indicates fair agreement. Differences between readers varied, with readers 4 and 5 more often recommending retreatment compared with reviewers 1-3 (P < .05). Wide variation was noted in treatment approach, with recommendations for surgical clipping ranging from 2 (7%) to 18 (67%) of 27 cases between readers 1 and 5.

CONCLUSIONS

The current study demonstrates substantial variability among observers not only in whether to retreat a recurrent aneurysm but also how to treat it. These findings suggest that patient management varies widely across treating physicians and also calls into question the use of "retreatment" as an objective end point in clinical trials.

A comparison of intermediate and long-acting insulins in people with type 2 diabetes starting insulin: an observational database study

AIMS

Insulin is normally added to oral glucose-lowering drugs in people with type 2 diabetes when glycaemic control becomes suboptimal. We evaluated outcomes in people starting insulin therapy with neutral protamine Hagedorn (NPH), detemir, glargine or premixed insulins.

METHODS

Insulin-naïve people with type 2 diabetes (n = 8009), ≥ 35 years old, HbA(1c) ≥ 6.5% and begun on NPH (n = 1463), detemir (n = 357), glargine (n = 2197) or premix (n = 3992), were identified from a UK database of primary care records (The Health Improvement Network). Unadjusted and multivariate-adjusted analyses were conducted, with persistence of insulin therapy assessed by survival analysis.

RESULTS

In the study population (n = 4337), baseline HbA(1c) was 9.5 ± 1.6%, falling to 8.4 ± 1.5% over 12 months (change -1.1 ± 1.8%, p < 0.001). Compared with NPH, people taking detemir, glargine and premix had an adjusted reduction in HbA(1c) from baseline, of 0.00% (p = 0.99), 0.19% (p < 0.001) and 0.03% (p = 0.51). Body weight increased by 2.8 kg overall (p < 0.001), and by 2.3, 1.7, 1.9, and 3.3 kg on NPH, detemir, glargine and premix (p < 0.001 for all groups); insulin dose at 12 months was 0.70 (overall), 0.64, 0.61, 0.56 and 0.76 U/kg/day. After 36 months, 57% of people on NPH, 67% on glargine and 83% on premix remained on their initially prescribed insulin.

DISCUSSION AND CONCLUSION

In routine clinical practice, people with type 2 diabetes commenced on NPH experienced a modest disadvantage in glycaemic control after 12 months compared with other insulins. When comparing the insulins, glargine achieved best HbA(1c) reduction, while premix showed greatest weight gain and the highest dose requirement, but had the best persistence of therapy.

TAK-285, a Novel HER2/EGFR Inhibitor, Penetrates the CNS in Rats with an Intact Blood Brain Barrier (BBB)

Background: Approximately one third of patients with HER2-overexpressing (HER2+) metastatic breast cancer develop brain metastases. Treatment options for patients whose brain metastases have progressed after radiotherapy are urgently needed. The currently approved HER2-targeted therapies, trastuzumab and lapatinib, have generally shown limited activity against brain metastases, likely due to the limited brain penetration of these drugs. Brain penetration is mediated by multiple factors including drug permeability, tissue binding, and the expression of efflux transporters (P-gp and BCRP) and their interactions with the drug. TAK-285 is a novel, orally active, dual HER2/EGFR inhibitor currently under clinical development. In this nonclinical work, we evaluated the permeability, interactions with efflux transporters, and brain penetration of TAK-285, along with lapatinib and neratinib, using in vitro and animal models.Material and Methods: The first study evaluated the permeability of TAK-285, lapatinib, and neratinib and their interactions with efflux transporters using the Caco-2 cell monolayer system in the absence or presence of efflux pump inhibitors. The second study evaluated brain penetration of TAK-285, lapatinib and neratinib after a single oral administration in rats with an intact BBB.Results: In the Caco-2 cell model, TAK-285 showed high permeability with an efflux ratio of 1.7, indicating it is not a substrate for efflux pumps. The efflux pump inhibitors LY335979 (an inhibitor of P-gp), Ko143 (an inhibitor of BCRP), and GF120918 (an inhibitor of BCRP and P-gp) had no marked effect on the efflux ratio of TAK-285, further confirming that TAK-285 is not a substrate for P-gp and BCRP. Lapatinib and neratinib showed low to medium permeability and appeared to be substrates for P-gp/BCRP in this testing system. In the rat brain penetration study, the brain-to-plasma AUC ratio for total (free and bound) TAK-285, lapatinib, and neratinib was 0.202, 0.0243, and 0.0263, respectively.Discussion: These nonclinical studies showed that, unlike lapatinib and neratinib, TAK-285 is not a substrate for the efflux transporters, P-gp and BCRP. Based on published information, all of the approved receptor tyrosine kinase inhibitors are substrates for efflux transporters. Additionally, in rats with an intact BBB, the brain-to-plasma AUC ratio for TAK-285 was substantially higher than that of lapatinib and neratinib. The AUC ratios observed in this study for lapatinib and neratinib are similar to the proportion of blood volume in the rat brain (ie, outside the CNS) relative to the total rat brain volume. This suggests the actual brain-to-plasma AUC ratio for TAK-285 in rats may be much greater than 8-fold of that of lapatinib and neratinib calculated based on these measured AUC ratios. Consequently, TAK-285 may have a unique role in the treatment of brain lesions in patients with HER2- or EGFR-dependent tumors. Furthermore, TAK-285 may not be subject to drug resistance conferred by efflux transporters.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5098.

Reflection and reflective practice in health professions education: a systematic review

The importance of reflection and reflective practice are frequently noted in the literature; indeed, reflective capacity is regarded by many as an essential characteristic for professional competence. Educators assert that the emergence of reflective practice is part of a change that acknowledges the need for students to act and to think professionally as an integral part of learning throughout their courses of study, integrating theory and practice from the outset. Activities to promote reflection are now being incorporated into undergraduate, postgraduate and continuing medical education, and across a variety of health professions. The evidence to support and inform these curricular interventions and innovations remains largely theoretical. Further, the literature is dispersed across several fields, and it is unclear which approaches may have efficacy or impact. We, therefore, designed a literature review to evaluate the existing evidence about reflection and reflective practice and their utility in health professional education. Our aim was to understand the key variables influencing this educational process, identify gaps in the evidence, and to explore any implications for educational practice and research.

Reflection and reflective practice in health professions education: a systematic review

The importance of reflection and reflective practice are frequently noted in the literature; indeed, reflective capacity is regarded by many as an essential characteristic for professional competence. Educators assert that the emergence of reflective practice is part of a change that acknowledges the need for students to act and to think professionally as an integral part of learning throughout their courses of study, integrating theory and practice from the outset. Activities to promote reflection are now being incorporated into undergraduate, postgraduate and continuing medical education, and across a variety of health professions. The evidence to support and inform these curricular interventions and innovations remains largely theoretical. Further, the literature is dispersed across several fields, and it is unclear which approaches may have efficacy or impact. We, therefore, designed a literature review to evaluate the existing evidence about reflection and reflective practice and their utility in health professional education. Our aim was to understand the key variables influencing this educational process, identify gaps in the evidence, and to explore any implications for educational practice and research.

Model-based sensorimotor integration for multi-joint control: development of a virtual arm model

An integrated, sensorimotor virtual arm (VA) model has been developed and validated for simulation studies of control of human arm movements. Realistic anatomical features of shoulder, elbow and forearm joints were captured with a graphic modeling environment, SIMM. The model included 15 musculotendon elements acting at the shoulder, elbow and forearm. Muscle actions on joints were evaluated by SIMM generated moment arms that were matched to experimentally measured profiles. The Virtual Muscle (VM) model contained appropriate admixture of slow and fast twitch fibers with realistic physiological properties for force production. A realistic spindle model was embedded in each VM with inputs of fascicle length, gamma static (gamma(stat)) and dynamic (gamma(dyn)) controls and outputs of primary (I(a)) and secondary (II) afferents. A piecewise linear model of Golgi Tendon Organ (GTO) represented the ensemble sampling (I(b)) of the total muscle force at the tendon. All model components were integrated into a Simulink block using a special software tool. The complete VA model was validated with open-loop simulation at discrete hand positions within the full range of alpha and gamma drives to extrafusal and intrafusal muscle fibers. The model behaviors were consistent with a wide variety of physiological phenomena. Spindle afferents were effectively modulated by fusimotor drives and hand positions of the arm. These simulations validated the VA model as a computational tool for studying arm movement control. The VA model is available to researchers at website http://pt.usc.edu/cel .

Inositol lipids and phosphates in the proliferation and differentiation of lymphocytes and myeloid cells

It is established that receptor-stimulated hydrolysis of phosphatidylinositol 4,5-bisphosphate is an essential signalling reaction in the responses of many haemopoietic cells to stimuli: examples include platelet activation, antigen-driven initiation of cell proliferation in mature B and T lymphocytes and histamine release by mast cells, and chemotaxis and oxygen radical generation by neutrophils. However, the roles of inositol lipids and phosphates in the development of haemopoietic and immune cells are less well understood. This paper discusses three such situations: the sequential employment of phosphatidylinositol 4,5-bisphosphate hydrolysis and cyclic AMP accumulation as two signals essential to the action of the B lymphocyte-stimulatory cytokine interleukin 4; the involvement of antigen receptor-triggered inositol lipid hydrolysis in apoptotic elimination of immature anti-self T lymphocytes in the fetal mouse thymus; and the possible role of changes in the levels of abundant inositol polyphosphates in the differentiation of HL-60 promyelocytic cells and of normal human myeloid blast cells.

Entry tests for graduate medical programs: is it time to re-think?

OBJECTIVE

To examine the relationship between medical school applicants' performances in the Graduate Australian Medical School Admissions Test (GAMSAT) and structured interviews and their subsequent performance in medical school.

DESIGN

Students in Years 2-4 of two graduate-entry medical programs were invited to complete two previously validated tests of clinical reasoning. These results and their Year 2 examination results were compared with their previous performance in GAMSAT and at interview.

SETTING

The graduate-entry programs at the Universities of Queensland and Sydney.

PARTICIPANTS

189 student volunteers (13.6% response rate).

MAIN OUTCOME MEASURES

Students' test results on a set of Clinical Reasoning Problems (CRPs) and a Diagnostic Thinking Inventory (DTI) and their Year 2 examination results.

RESULTS

There was no association between performance in GAMSAT and performance in the CRPs; there was a weak negative correlation between performance in GAMSAT and the DTI (- 0.05 > r > - 0.31, P = 0.03). The correlation between GAMSAT and examination results was weak (r < 0.24, P = 0.02). The correlation between GAMSAT and interview scores for each school was weakly negative for University of Queensland (r = - 0.34, P < 0.01) and weakly positive for University of Sydney (r = 0.11), with a combined significance level P < 0.01.

CONCLUSIONS

We did not find evidence that GAMSAT and structured interviews are good predictors of performance in medical school. Our study highlights a need for more rigorous evaluation of Australian medical school admissions tests.

Modeling spinal sensorimotor control for reach task

The spinal sensorimotor control system executes movement instructions from the central controller in the brain that plans the task in terms of global requirements. Spinal circuits serve as a local regulator that tunes the neuromuscular apparatus to an optimal state for task execution. We hypothesize that reach tasks are controlled by a set of feedforward and feedback descending commands for trajectory and final posture, respectively. This paper presents the use of physiologically realistic models of the spinal sensorimotor system to demonstrate the feasibility of such dual control for reaching movements.

Phase I-II trial of daily thalidomide in combination with docetaxel in patients with relapsed non-small cell lung cancer: A final analysis

17060

Background: Recent studies have shown that inhibition of vascular endothelium growth factor (VEGF) in combination with chemotherapy can improve the antitumor efficacy of chemotherapy in NSCLC. This study tested the effectivness and toxicity of thalidomide (an inhibitor of VEGF) combined with docetaxel as second-line therapy for progressive NSCLC. Methods: Patients(pts) with recurrent/progressive NSCLC, prior chemotherapy, measurable/evaluable disease, ECOG performance status (PS) 0–2 and adequate hematologic, renal and hepatic function were enrolled. Pts with uncontrolled CNS disease or hypercoagulable state were excluded. Doxetaxel 75 mg/M2 was administered every 3 weeks (maximum of 8 cycles). Thalidomide was administered orally at a starting dose of 50 mg daily escalated by 50 mg every 3 weeks to a maximum dose of 200mg day and continued until disease progression, dose limiting toxicity, or completion of chemotherapy. Primary end-point was overall survival (OS), secondary end points were time to disease progression(TTP) by Kaplan Meyer method and response rate (RECIST criteria). Results: Of 28 enrolled patients, 26 were eligible for treatment and 25 were evaluable for disease progression and survival. For evaluable pts: mean PS = 1, median age 64.5 years, median number of prior chemotherapy regimens + 1.2. Response rate was 19.1% (1 complete response, 4 partial responses). Stable disease was observed in 9 patients (34.6%). TTP was 2.7 months (95% confidence interval [CI] 2.1–5.0+): median OS was 5.4 months (95% CI 3.1–9.3+). One episode each of febrile neutropenia requiring hospitalization and pulmonary embolism was observed. No grade 3–4 neuropathy was shown. Nonhematologic adverse events included constipation, alopecia, nausea and anorexia. Conclusions: These data suggest thalidomide in doses of 200mg/ day may be combined with docetaxel 75 mg/m2 every 3 weeks in the second line treatment of NSCLC. The response rate, TTP and OS compare favorably with previously reported studies with docetaxel in this population.

No significant financial relationships to disclose.