Progress towards automated detection and characterization of the optic disc in glaucoma and diabetic retinopathy

The shape and appearance of the optic nerve head region are sensitive to changes associated with glaucoma and diabetes that may be otherwise asymptomatic. The changes can be diagnostic of the diseases, and tracking of the changes in sequential images can be used to assess treatment and the progress of the illness. At present, change detection and tracking are performed manually, which can be a cause of poor repeatability. We are concerned with developing automated techniques of generating quantitative descriptions of the retinal images that might be used in diagnosis and assessment. In this paper, we investigate the use of images that have been collected and stored remotely, as this will replicate capture and automated processing by outreach clinics. Normal and abnormal images were collected from a range of sources, to simulate the mass screening process. The images were processed using simple signal-processing methods and divided into two groups. Using a chi-squared test, the separation of normal and abnormal images using this test was found to be highly significant (p < 0.05, n = 60).

Clinical testing of ulnar collateral ligament injuries of the thumb

The diagnosis of complete tears of the ulnar collateral ligament of the thumb metacarpophalangeal (MP) joint depends on demonstration of excessive laxity of the ligament, but there is controversy on whether laxity greater than a certain cut-off value or laxity greater than the opposite thumb is the criterion for diagnosis. We examined 200 thumbs of 100 normal individuals in extension and in 30 degrees of flexion. In 34% of subjects there was a difference of 10 degrees or more between right and left thumbs in extension, and 12% had a difference of at least 15 degrees. In flexion, 22% of thumbs differed by 10 degrees or more and 3% by 15 degrees or more. Comparison with the uninjured contralateral thumb is unreliable in many individuals. We recommend the lack of a definite end point on stress examination as indicating complete rupture of the ulnar collateral ligament.

Adjuvant androgen deprivation therapy augments cure and long-term cancer control in men with poor prognosis, nonmetastatic prostate cancer

Historically, adjuvant androgen deprivation therapy has been viewed as a palliative treatment option for patients with poor-prognosis non-metastatic prostate cancer. In addition, guidelines from bodies such as the European Association of Urology and American Society for Clinical Oncology do not specifically categorize adjuvant hormonal therapy as being curative in intent. We propose that adjuvant androgen deprivation therapy should now be classified as a treatment of curative intent in patients with poor-prognosis, non-metastatic prostate cancer. By applying a carefully considered definition of cure (based on long-term (10- to 15-year) disease-free survival curves) to the findings from randomized controlled clinical trials that have studied adjuvant hormonal treatments in non-metastatic prostate cancer, we challenged whether this viewpoint should now be considered redundant. According to our review of relevant studies and our definition of cure, goserelin appears to augment cure in a sizeable proportion of men with poor-prognosis non-metastatic prostate cancer when given adjuvant to radical prostatectomy or radiotherapy. Across several trials, the relevant survival curves for the goserelin-treated population became indefinitely flat after long-term follow-up. This indicates that these patients have a mortality risk comparable to the general population without prostate cancer. On the basis of the evidence presented within this review, we believe that, given it can control disease for a long period of time, adjuvant goserelin should be reclassified as a treatment of curative intent for patients with poor-prognosis non-metastatic prostate cancer.

The influence of nodal status on progression outcomes in patients with prostate cancer: Data from the Early Prostate Cancer program at 7.4 years

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Background: The Early Prostate Cancer (EPC) program is an ongoing study of the effect of adding bicalutamide (CASODEX) 150 mg to standard care (radiotherapy [RT], radical prostatectomy [RP], or watchful waiting [WW]) for men with localized or locally advanced prostate cancer. At a median 7.4 years’ follow-up, bicalutamide significantly improved objective progression-free survival (PFS) in men with locally advanced disease, irrespective of standard care, and improved overall survival in the RT setting. There was no PFS benefit in patients with localized disease. Lymph-node involvement is an established risk factor for progression, so we conducted an exploratory analysis among patients with locally advanced disease to assess the influence of this risk factor on PFS. Methods: The EPC program (n = 8113) comprises 3 randomized trials designed for combined analysis. Patients with localized (T1–2, N0/Nx) or locally advanced (T3–4, any N; or any T, N+) non-metastatic prostate cancer received bicalutamide (n = 4052) or placebo (n = 4061) once daily plus standard care. This subanalysis studied the effect of nodal status (N−, N+, Nx) in locally advanced disease. Results: In patients with locally advanced disease, PFS improvements were irrespective of nodal status. The treatment effect increased as the risk of progression increased from N− to Nx to N+ disease. The greatest reduction in risk was seen in RP patients with N+ disease. Conclusions: The reduction in risk of progression with bicalutamide was seen irrespective of nodal status. The most significant reduction in risk of progression was in RP patients with N+ disease; survival data by nodal status for these patients will be presented.

[Table: see text]

[Table: see text]

Delaying metastatic disease progression in locally advanced disease − Results from the Early Prostate Cancer program at a median follow-up of 7.4 years

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Background: Progression of prostate cancer to bone metastases impacts seriously on patients (pts)’ quality of life and increases treatment costs. The 3rd analysis of the Early Prostate Cancer (EPC) program revealed that bicalutamide (CASODEX) 150 mg plus standard care (radiotherapy [RT], radical prostatectomy [RP] or watchful waiting [WW]) significantly improved progression-free survival (PFS) vs standard care alone in locally advanced disease. Adjuvant bicalutamide 150 mg also improved overall survival for RT pts with locally advanced disease. Here, we report an exploratory analysis of the effect of bicalutamide on delaying bone metastases in pts with locally advanced disease in the EPC program. Methods: The EPC program comprises 3 trials in which pts (n = 8113) were randomized to standard care plus bicalutamide 150 mg or placebo. This exploratory analysis included only pts with locally advanced disease (T3–4, any N; or any T, N+; bicalutamide n = 1367, placebo n = 1315). Distant metastases were assessed by bone scan. Metastatic PFS was defined as time from randomization to either first bone scan-confirmed progression or death in the absence of bone-scan data. A Cox proportional hazards regression model was used for the WW and adjuvant subgroups; each was analyzed separately with covariates for trial, treatment, prior therapy, baseline prostate-specific antigen level, and tumor grade. Results: At 7.4 years’ median follow-up, bicalutamide significantly improved metastatic PFS vs placebo (hazard ratio [HR] 0.64, p < 0.001 for WW; HR 0.77, p = 0.005 for RT/RP; table). The most common adverse events were gynecomastia and breast pain. Conclusion: Addition of bicalutamide 150 mg to standard care significantly reduced the risk of distant metastases in locally advanced prostate cancer, irrespective of standard care. Both the efficacy and tolerability of treatment must be considered, and therefore, bicalutamide is an option for men with locally advanced prostate cancer.

[Table: see text]

[Table: see text]

Translating Management Ideas

Accounts of the spread of management ideas emphasizing the role of ‘supply-side’ actors underplay the active role recipients play in translating them into new and different forms. Comparing firms undergoing a similar process and looking at how a specific event unfolded, this paper aims to extend understanding of the concept of translation. It examines how ideas are rendered appropriate to a new setting through translation from the broad policy level into a set of specific practices. To do this, it looks at how a proposal to introduce lean management into the construction industry was applied within a set of firms and the projects they were undertaking. In the context of large ‘distance’ between the original arenas of the idea and its new one, the paper uncovers how the editing rules that are said to guide the process of translation are operationalized using a set of change interventions.

Prevention and management of bicalutamide-induced gynecomastia and breast pain: randomized endocrinologic and clinical studies with tamoxifen and anastrozole

A randomized, double-blind, placebo-controlled multicenter trial involving 107 men receiving bicalutamide ('Casodex') 150 mg/day therapy following radical therapy for prostate cancer assessed tamoxifen ('Nolvadex') 20 mg/day and anastrozole ('Arimidex') 1 mg/day for the prophylaxis and treatment of gynecomastia/breast pain. Tamoxifen, but not anastrozole, significantly reduced the incidence of gynecomastia/breast pain when used prophylactically and therapeutically. Serum testosterone levels increased with tamoxifen relative to placebo but prostate-specific antigen levels declined in all treatment groups. Further studies are needed to define the optimum tamoxifen dose and to assess any impact on cancer control. The use of tamoxifen in this setting remains to be investigated.

Bicalutamide (‘Casodex’) 150 mg in addition to standard care in patients with nonmetastatic prostate cancer: updated results from a randomised double-blind phase III study (median follow-up 5.1 y) in the early prostate cancer programme

Trial 24 is one of three placebo-controlled trials within the ongoing bicalutamide ('Casodex') Early Prostate Cancer (EPC) programme evaluating bicalutamide 150 mg/day in addition to radical prostatectomy, radiotherapy or watchful waiting for T1b-4, any N, M0 prostate cancer. In Trial 24, at 5.1 y median follow-up, the addition of bicalutamide significantly (P < 0.0001) improved objective progression-free survival (PFS) and prostate-specific antigen PFS compared with standard care alone. There was no significant difference in overall survival (P = 0.746). In the context of the whole EPC programme, long-term bicalutamide is not appropriate for localised disease, yet provides advantages in delaying disease progression in patients with locally advanced prostate cancer.

Efficacy and Tolerability of Radiotherapy as Treatment for Bicalutamide-induced Gynaecomastia and Breast Pain in Prostate Cancer

OBJECTIVE

To assess the efficacy and tolerability of localised radiotherapy for the treatment of bicalutamide ('Casodex''Casodex' is a trademark of the AstraZeneca group of companies.)-induced gynaecomastia and/or breast pain.

METHODS

This open-label, non-comparative, multicentre study included 51 patients receiving bicalutamide 150 mg for the treatment of non-metastatic prostate cancer (T1b-T4, Nx, M0). Patients who developed symptomatic gynaecomastia and/or breast pain received two 6-Gy fractions of external-beam radiation to the breasts and were then assessed at two 3-monthly follow-up visits.

RESULTS

37/51 (72.5%) patients experienced gynaecomastia and 41/51 (80.4%) experienced breast pain, typically within the first 6 months. Twenty seven and 38 patients, respectively, went on to receive breast irradiation. Following radiotherapy, gynaecomastia improved or resolved in 7/27 (25.9%) and 2/27 (7.4%) cases, respectively, and breast pain improved or resolved in 12/38 (31.6%) and 3/38 (7.9%) cases, respectively. No change was observed in 7 patients (25.9%) with gynaecomastia and 12 patients (31.6%) with breast pain, while 9 patients (33.3%) and 8 patients (21.1%), respectively, worsened. Radiotherapy-related adverse events, reported by 18/41 (43.9%) patients, were generally mild and short lived (median duration approximately 5 weeks).

CONCLUSIONS

Therapeutic radiotherapy, using two fractions of 6 Gy external-beam radiation to the male breast, improves the intensity of bicalutamide-induced gynaecomastia and/or breast pain in approximately one-third of patients. Adverse events were often mild and short lived.

Challenges in presenting high dimensional data to aid in triage in the DARPA virtual soldier project

One of the goals of the DARPA Virtual Soldier Project is to aid the field medic in the triage of a casualty. In Phase I, we are currently collecting 12 baseline experimental physiological variables and a cardiac gated Computed Tomography (CT) imagery for use in an prototyping a futuristic electronic medical record, the "Holomer". We are using physiological models and Kalman filtering to aid in diagnosis and predict outcomes in relation to cardiac injury. The physiological modeling introduces another few hundred variables. Reducing the complexity of the above into easy-to-read text to aid in the triage by the field medic is the challenge with multiple display solutions. A description of the possible techniques follows.