Chemoradiation for the treatment of epidermoid anal cancer: 13-year follow-up of the first randomised UKCCCR Anal Cancer Trial (ACT I)

Background:

The first UKCCCR Anal Cancer Trial (1996) demonstrated the benefit of chemoradiation over radiotherapy (RT) alone for treating epidermoid anal cancer, and it became the standard treatment. Patients in this trial have now been followed up for a median of 13 years.

Methods:

A total of 577 patients were randomised to receive RT alone or combined modality therapy using 5-fluorouracil and mitomycin C. All patients were scheduled to receive 45 Gy by external beam irradiation. Patients who responded to treatment were recommended to have boost RT, with either an iridium implant or external beam irradiation. Data on relapse and deaths were obtained until October 2007.

Results:

Twelve years after treatment, for every 100 patients treated with chemoradiation, there are an expected 25.3 fewer patients with locoregional relapse (95% confidence interval (CI): 17.5–32.0 fewer) and 12.5 fewer anal cancer deaths (95% CI: 4.3–19.7 fewer), compared with 100 patients given RT alone. There was a 9.1% increase in non-anal cancer deaths in the first 5 years of chemoradiation (95% CI +3.6 to +14.6), which disappeared by 10 years.

Conclusions:

The clear benefit of chemoradiation outweighs an early excess risk of non-anal cancer deaths, and can still be seen 12 years after treatment. Only 11 patients suffered a locoregional relapse as a first event after 5 years, which may influence the choice of end points in future studies.

Finding exact spatial soliton profiles in nematic liquid crystals

Finding exact analytical soliton profile solutions is only possible for certain types of non-linear media. In most cases one must resort to numerical techniques to find the soliton profile. In this work we present numerical calculations of spatial soliton profiles in nematic liquid crystals. The nonlinearity is governed by the optical-field-induced liquid crystal director reorientation, which is described by a system of coupled nonlinear partial differential equations. The soliton profile is found using an iterative scheme whereby the induced waveguide and mode profiles are calculated alternatively until convergence is achieved. In this way it is also possible to find higher order solitons. The results in this work can be used to accurately design all-optical interconnections with soliton beams.

Implementing a public cholesterol screening campaign: the North Coast experience

Several community-based interventions in the United States have indicated that it is possible to economically screen the blood cholesterol levels of large numbers of the population and to assist those with elevated levels to reduce their blood cholesterol. The North Coast Cholesterol Check Campaign was designed to involve existing community health staff and community volunteers in a Health Promotion Campaign to: increase community awareness of the importance of cholesterol levels in relation to coronary heart disease; to offer participants immediate blood cholesterol analysis; and to offer dietary advice to those participants who were above the recommended 5.5 mmol/L level. Fifty-two Cholesterol Check Points were conducted on the North Coast of NSW between 1 September and 15 December, 1987. Each Check Point featured a rapid cholesterol analysis with a finger-prick procedure on the Boehringer-Mannheim Reflotron System and immediate dietary counselling by trained staff for participants with elevated levels. A total of 12,067 persons participated in the Campaign: 43 per cent were found to have cholesterol levels that exceeded the recommended desirable levels set by the Australian National Heart Foundation. A 4-5 month follow up of 61 per cent (3,164) of these individuals indicates that 72 per cent lowered their blood cholesterol levels and 65 per cent reduced their BMI. Mean cholesterol change was 0.65 mmol/L and mean BMI change was 0.51. The results indicate the potential for similar community-based nutrition education programmes to reduce cholesterol levels in Australia. This paper details the rationale for the North Coast Cholesterol Check Campaign and the issues concerned with implementation of the campaign.

The role of community educators in achieving Australian health goals: a public health approach to weight control on the North Coast, NSW

This paper describes the recruitment, training and supervision of Community Educators for weight-control programs, reports the results they have achieved to date, and offers suggestions for improving similar programs. This material is discussed in relation to suggestions about nutrition published by the Better Health Commission.

Practice-based evidence for clinical practice improvement: an alternative study design for evidence-based medicine

This chapter gives an educational overview of * The limitations of evidence-based practice. * Strengths and weaknesses of RCT and observational studies. * The general PBE-CPI study design. * Benefits of PBE-CPI studies and how they can enhance our ability to discover and establish standards for best practice. * The relationship between CIS and PBE-CPI studies.

Genes related to immunity, as expressed in the alfalfa leafcutting bee, Megachile rotundata, during pathogen challenge

Virtually nothing is known about disease resistance in solitary bees, so expressed sequence tag (EST) databases were developed to search for immune response genes in the alfalfa leafcutting bee. We identified 104 putative immunity-related genes from both healthy and pathogen-challenged bee larvae, and 12 more genes using PCR amplification. The genes identified coded for proteins with a wide variety of innate immune response functions, including pathogen recognition, phagocytosis, the prophenoloxidase cascade, melanization, coagulation and several signalling pathways. Some immune response genes were highly conserved with honey bee genes, and more distantly related to other insects. The data presented provides the first analysis of immune function in a solitary bee and provides a foundation for the further analysis of gene expression patterns in bees.

Effect of dietary Spirulina on reduction of copper toxicity and improvement of growth, blood parameters and phosphatases activities in carp, Cirrhinus mrigala (Hamilton, 1822)

The effect of Spirulina supplementation on reduction of copper toxicity based on food utilization, phosphatases activities and selected haematological parameters was studied in a freshwater cultivable fish C. mrigala. Metal concentration in medium, body tissues and fecal matter was also analysed. Sublethal exposure of C. mrigala fed Spirulina-free diet significantly reduced the consumption and growth rates, phosphatases activities and haematological parameters. However, the above parameters enhanced in the copper exposed fish fed with Spirulina supplemented diets. A significant positive correlation was obtained for the relationship between supplementation of dietary Spirulina and copper defecation through feces. Among the doses of Spirulina supplementation, 6% addition has been considered optimum for C. mrigala since this dose produces maximum elimination of copper from the body and feces and better improvement on growth, phosphatases activities and haematological parameters.

Cardiac troponin I as a marker for severity and prognosis of cardiac disease in dogs

The use of cardiac troponin I (cTnI) to assess the severity of disease and prognosis in 120 dogs presented for cardiac evaluation was analysed. cTnI concentrations were measured using a commercially available assay. Dogs were placed into three groups: group 1, cTnI0.15ng/mL; group 2, cTnI 0.151-1.0ng/mL; group 3, cTnI>1.01ng/mL. Dogs in group 1 were significantly younger (P<0.0001) and had no or stable cardiac diseases and longest survival times, whereas those in groups 2 and 3 had severe cardiac diseases and significantly reduced survival times (P<0.0001). Thirty dogs with initially increased cTnI concentrations had a repeat assay less than 2months later with significant reductions in cTnI concentrations (P=0.005). Initial cTnI concentrations could not differentiate dogs that survived in group 3 from those that did not. However, dogs that survived showed significant cTnI reductions (P=0.015) in the repeated assay in contrast to the dogs that died (P=0.22). It was concluded that cTnI is useful in assessing the prognosis and severity of cardiac diseases in dogs, and progression and response to treatment can be assessed by repeat sampling. cTnI concentrations >1.0ng/mL and persistent increases in cTnI concentrations are indicators of a poor prognosis in dogs with cardiac disease.

A randomized trial of chemoradiation using mitomycin or cisplatin, with or without maintenance cisplatin/5FU in squamous cell carcinoma of the anus (ACT II)

LBA4009

Background: Chemoradiotherapy (CRT) with 5-fluorouracil (5-FU) and mitomycin-C (MMC) is standard treatment for anal cancer. This trial addresses two questions: whether (i) replacing MMC with cisplatin (CDDP) improves the complete response (CR) rate, and (ii) two cycles of maintenance chemotherapy after CRT reduces recurrence. Methods: Between 2001 and 2008, 940 patients (pts) were recruited to a multicenter, randomized factorial trial. Pts received 5-FU (1,000mg/m2/day on d1–4 and 29–32), radiotherapy (RT) (50.4Gy in 28 fractions), and either MMC (12mg/m2, d1; n=471) or CDDP (60mg/m2 on d1 and 29; n=469). Pts were also randomized to receive maintenance therapy (n=448) 4 weeks after CRT (two cycles of CDDP and 5-FU weeks 11 and 14) or no maintenance (n=446). Maintenance randomization was not considered appropriate in 46 pts. Statistical power was ≥80% to detect a difference in the CR rate of 5% (CDDP vs MMC), and 30% reduction in recurrence (maintenance vs no maintenance). Results: Median age 58 yrs; 62% male, 38% female; tumor site - canal (81%), margin (15%); stage T1-T2 (50%), T3-T4 (43%); node negative (62%), positive (30%). Median follow-up was 3 yrs. The CR rate was 94% MMC and 95% CDDP (p=0.53). MMC pts had more acute grade 3/4 haematological toxicities (25 vs 13%, p<0.001) but this did not result in an increase in neutropaenic sepsis (3.1 vs 3.2%, p=0.93). Non-haematologic grade 3/4 toxicities were similar (61 vs 65%, p=0.22). Preliminary analysis shows no statistically significant difference in recurrence free survival (RFS) (HR 0.89, 95% CI 0.68, 1.18; p=0.42) or overall survival (HR 0.79, 95% CI 0.56,1.12; p=0.19) for the maintenance comparison. The number of pre-treatment colostomies not reversed were similar between treatments (18 MMC vs 14 CDDP, p=0.65, Maint/No maint, p=0.23) and only 9 disease-free pts had colostomies performed (5 MMC, 4 CDDP). Conclusions: ACT II is the largest trial conducted in anal cancer. High CR (95%) and RFS (75% at 3 yrs) rates were achieved with this CRT. This excellent outcome may have been influenced by the absence of a gap in the RT schedule. There was no difference in CR rates between MMC and CDDP or in RFS rates with or without maintenance chemotherapy. 5-FU, MMC with RT remains the standard of care.

[Table: see text]

A randomized trial of chemoradiation using mitomycin or cisplatin, with or without maintenance cisplatin/5FU in squamous cell carcinoma of the anus (ACT II)

LBA4009

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

[Table: see text]

Dialysis and the environment: comparing home and unit based haemodialysis

Dialysis, with its high dependence upon technology, disposable products and transport requirements, presents an unusual perspective for environmental management. This study considers and compares the environmental aspects arising from the provision of haemodialysis (HD) in the hospital and home setting. Resource items were measured at two levels of aggregation--unit and individual patient. Unit level items applied to common resources used for HD and require apportioning appropriately with patient level items that could be attributable to individuals. The data was measured in standard units such as hours and number of treatments or apportioned appropriately. With equivalent emissions calculated as CO2 annually per patient for standard HD. The findings indicate that HD in the home offers a net reduction in CO2 emissions per patient annually compared to hospital based HD, and provides an overview of how healthcare provision and the use of resources can be measured, enabling refinement in environmental management plans.

Implantable loop recorders: a viable diagnostic tool in veterinary medicine

OBJECTIVE

The purpose of this study was to investigate whether implantable loop recorders could be used in the diagnosis of unexplained collapse in dogs.

METHODS

The medical records of six dogs presented to the University of Liverpool Small Animal Teaching Hospital between May 2003 and October 2006 for further evaluation of intermittent syncopal episodes, collapse or episodic weakness, were reviewed. All these dogs underwent standard investigations and had implantable loop recorders placed.

RESULTS

A provisional diagnosis of supraventricular tachycardia was made in one dog, and diagnoses of exclusion of arrhythmogenic right ventricular cardiomyopathy and idiopathic epilepsy was made in two dogs. One dog suffered no further syncopal episodes, a diagnosis was not reached in another dog and the final dog was lost to follow-up.

CLINICAL SIGNIFICANCE

The implantable loop recorder can be used successfully for the diagnosis of unexplained collapse in dogs.

No socioeconomic inequalities in colorectal cancer survival within a randomised clinical trial

There is strong evidence that colorectal cancer survival differs between socioeconomic groups. We analysed data on 2481 patients diagnosed during 1989-1997 and recruited to a randomised controlled clinical trial (AXIS, ISRCTN32414363) of chemotherapy and radiotherapy for colorectal cancer. Crude and relative survival at 1 and 5 years was estimated in five categories of socioeconomic deprivation. Multiple imputation was used to account for missing data on tumour stage. A multivariable fractional polynomial model was fitted to estimate the excess hazard of death in each deprivation category, adjusting for the confounding effects of age, stage, cancer site (colon, rectum) and sex, using generalised linear models. Relative survival in the trial patients was higher than in the general population of England and Wales. The socioeconomic gradient in survival was much smaller than that seen for colorectal cancer patients in the general population, both at 1 year -3.2% (95% CI -7.3 to 1.0%, P=0.14) and at 5 years -1.7% (95% CI -8.3 to 4.9%, P=0.61). Given equal treatment, colorectal cancer survival in England and Wales does not appear to depend on socioeconomic status, suggesting that the socioeconomic gradient in survival in the general population could well be due to health-care system factors.

Canine dynamic left ventricular outflow tract obstruction: assessment of myocardial function and clinical outcome

OBJECTIVE

The aims of this study were (i) to evaluate echocardiographic findings and myocardial function including pulsed wave tissue Doppler imaging in dogs with naturally occurring dynamic left ventricular outflow tract obstruction and (ii) to investigate the clinical outcome and response to therapy in these dogs.

METHODS

Two cases were retrospectively reviewed and three cases were prospectively evaluated including clinical findings, diagnostic test results (including standard Doppler echocardiography and pulsed wave tissue Doppler imaging), response to treatment and outcome. The two retrospective cases received no treatment. Other cases were treated with a beta-blocker.

RESULTS

All dogs had a variable intensity left apical systolic murmur. Concentric left ventricular hypertrophy, systolic anterior motion of the mitral valve and scimitar-shaped left ventricular outflow tract Doppler flow profile were present in all cases. Pulsed wave tissue Doppler imaging interrogation of the interventricular septum revealed E'/A' reversal in all but one patient. Regression of left ventricular hypertrophy and total resolution of the dynamic left ventricular outflow tract obstruction were observed in all cases.

CLINICAL SIGNIFICANCE

Young dogs are affected with a possible terrier breed predisposition. Dynamic left ventricular outflow tract obstruction may be distinguished from canine hypertrophic cardiomyopathy as progressive resolution of echocardiographic abnormalities was documented. Pulsed wave tissue Doppler imaging abnormalities provide further evidence for significant diastolic dysfunction associated with the hypertrophy.

A randomised controlled trial of intramuscular vs. intravenous antivenom for latrodectism--the RAVE study

BACKGROUND

Widow spider-bite causes latrodectism and is associated with significant morbidity worldwide. Antivenom is given by both the intravenous (IV) and intramuscular (IM) routes and it is unclear which is more effective.

AIM

To compare the effectiveness of IV vs. IM redback spider antivenom.

DESIGN

Randomized controlled trial.

METHODS

Patients with latrodectism were given either IV or IM antivenom according to a randomized double-dummy, double-blind protocol. The first antivenom treatment was followed by another identical treatment after two hours if required. The primary outcome was a clinically significant reduction in pain two hours after the last treatment. A fully Bayesian analysis was used to estimate the probability of the desired treatment effect, predetermined as an absolute difference of 20%.

RESULTS

We randomly allocated 126 patients to receive antivenom IV (64) and IM (62). After antivenom treatment pain improved in 40/64(62%) in the IV group vs. 33/62(53%) in the IM group (+9%; 95% Credible Interval [CrI]: -8% to +26%). The probability of a difference greater than zero (IV superior) was 85% but the probability of a difference >20% was only 10%. In 55 patients with systemic effects, these improved in 58% after IV antivenom vs. 65% after IM antivenom (-8%; 95% CrI: -32% to +17%). Twenty-four hours after antivenom pain had improved in 84% in the IV group vs. 71% in the IM group (+13%; 95% CrI: -2% to +27%). A meta-analysis including data from a previous trial found no difference in the primary outcome between IV and IM administration.

DISCUSSION

The difference between IV and IM routes of administration of widow spider antivenom is, at best, small and does not justify routinely choosing one route over the other. Furthermore, antivenom may provide no benefit over placebo.