MRI suites and residual design risk from static magnetic field

Since the inception of the UK Construction (Design and Management) Regulations 1994 through to the 2007 Construction (Design and Management) Regulations a duty has been imposed upon the client of premises where a notifiable project has been carried out, to provide a health and safety file which may be needed during future work. This work includes cleaning, maintenance, alterations, extensions, refurbishment and demolition. The Construction (Design and Management) Regulations 2007 also impose further duties on clients to provide information to those who will use their premises as a workplace. This paper reports the results of a study which assessed whether information relevant to the health and safety file for magnetic resonance imaging (MRI) installations in hospitals having had passive magnetic shielding installed was available from National Health Service trusts in Wales, Scotland and England. Information on both the site-specific design and the actual position of the static magnetic field was lacking, as were the existence of as-built drawings showing the magnetic shielding. Information relevant to the risk management of the static magnetic field of MRI suites in the form of a health and safety file is sparse, incomplete and sometimes irrelevant.

How we do it: Secondary tracheoesophageal puncture under local anaesthetic, using a trans-nasal flexible laryngo-oesophagoscope (TNFLO)

We describe our technique for the formation of a secondary tracheoesophageal puncture and insertion of a voice prosthesis under local anaesthetic in the out-patient department. We use a trans-nasal flexible laryngo-oesophagoscope (TNFLO) to provide direct visualization of the procedure allowing early detection and rectification of any problems that might arise.

Clinical trial of NPI-0052 in advanced malignancies including lymphoma and leukemia (advanced malignancies arm)

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Background: The novel structure (non-peptide based) of NPI-0052 (NPI) appears to lead to unique proteasome inhibition (PI), toxicology and signal transduction profiles. Preclinical research suggests improvements in therapeutic ratio and activity in hematologic and solid tumor models, leading to clinical trials in patients with myeloma, lymphomas, leukemias, and solid tumors. Methods: Patients with solid tumor, lymphoma or leukemia diagnoses without standard treatment options were treated with IV NPI on Days 1, 8 and 15 of 28-day cycles in a 3+3 design dose escalation to a Recommended Phase 2 Dose (RP2D). Enrollment then began in 10 patient lymphoma and CLL RP2D cohorts. PI (D1 and D15) and PK (D1 and D15) were assayed. Results: 30 patients were treated at doses ranging from 0.1 mg/m2 to 0.9 mg/m2. 0.7 mg/m2 was selected as the RP2D secondary to DLT of transient “hallucinations” (visual imprints when eyes closed) and dizziness/unsteady gait at 0.9 mg/m2. At the RP2D fatigue, parosmia/dysgeusia, transient peri-infusion site pain and lymphopenia were commonly ascribed to NPI. At the RP2D PK data showed: half-life = 31 ± 28 min; AUCtotal = 270 ± 219 ng/mL*min; Cmax = 33.4 ± 34.2 ng/mL; clearance = 7.17 ± 0.40 L/min; volume of distribution (Vz) = 223.3 ± 229.7 L. PI was assayed in blood, indicating a dose:response relationship with mean inhibition of chymotrypsin-like activity up to of 88% Day 1 and 100% Day 15, and inhibition of caspase-like and trypsin-like activity of up to 51% and 72%. PI remained between doses in whole blood (RBC), but recovered between doses in PBMC. Stable disease was induced in 31% of patients, including one each with mantle cell, Hodgkin's lymphoma, follicular lymphoma, sarcoma, prostate carcinoma, and two with melanoma. Conclusions: NPI-0052 produces dose-dependent pharmacologic effects through the predicted efficacious range to an MTD, while producing a toxicity profile that is tolerable and dissimilar to bortezomib in spite of reaching higher PI levels. These data indicate potential for a greater range of uses than other proteasome inhibitors and lead to additional studies being initiated in hematologic malignancies and solid tumors alone and in combination.

[Table: see text]

International randomized phase III study of capecitabine (Cap), bevacizumab (Bev), and mitomycin C (MMC) in first-line metastatic colorectal cancer (mCRC): Final results of the AGITG MAX trial

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Background: The addition of Bev to oxaliplatin or irinotecan based doublet chemotherapy has shown benefit in mCRC. Cap± MMC are alternate chemotherapy regimens suitable for patients (pts) who are either unfit for or who do not require initial oxaliplatin/irinotecan. This phase III study compared Cap with Cap Bev and Cap Bev MMC. The aim was to develop a low toxicity regimen suitable for a broad population of pts with mCRC. Methods: Previously untreated pts with unresectable mCRC considered suitable for Cap monotherapy were randomised to arm A Cap (Cap 2000mg/m2/d or 2500mg/m2 d1–14 q21d), arm B Cap Bev (Bev 7.5mg/kg q3w) or arm C Cap Bev MMC (MMC 7mg/m2 q6w). Primary endpoint: PFS, secondary endpoints: RR, toxicity, OS, QoL . Randomisation was stratified by age, PS, centre and Cap dose. Response was assessed every 6w. The study was designed to detect an increase in the median PFS from 5.5m (arm A) to 8m (arm B or C) at p<0.025 with 80% power. Results: A total of 471 pts were randomised from July 2005-June 2007. Outcomes were evaluated on an intention to treat basis and included 15 ineligible pts. Baseline demographics were well balanced between arms with median age 67y (range 31–86y). Toxicity was reported: ASCO 2008 abstr 4029. The most common grade 3/4 toxicities were PPE (16%, 26%, 28%) and diarrhoea (11%, 17%, 16%) for arms (A,B,C). However, adjusted rates per cycle were similar as arms B & C received more cycles of Cap (A8.3, B10.8, C10.5). Other toxicity rates were generally <10%. The study achieved its primary endpoint with a highly significant improvement in PFS for arms B & C. RR and OS are summarized ( Table ). Conclusions: All treatment regimens were well tolerated in a relatively elderly patient cohort. The addition of Bev±MMC to Cap significantly improved PFS without significant additional toxicity. OS was similar for all arms. Cap Bev±MMC is an active, low toxicity regimen that may be considered as a treatment option for pts with mCRC.

[Table: see text]

[Table: see text]

A phase I trial of Capecitabine+Gemcitabine with radical radiation for locally advanced pancreatic cancer

Standard chemoradiotherapy with infusional 5FU for locally advanced pancreatic cancer (LAPC) has limited efficacy in this disease. The combination of Capecitabine (Cap) and Gemcitabine (Gem) are synergistic and are potent radiosensitisers. The aim of this phase I trial was thus to determine the highest administered dose of the Cap plus Gem combination with radical radiotherapy (RT) for LAPC. Patients had LAPC, adequate organ function, ECOG PS 0–1. During RT, Gem was escalated from 20–50 mg m⁻² day⁻¹ (twice per week), and Cap 800–2000 mg m⁻² day⁻¹ (b.i.d, days 1–5 of each week). Radiotherapy 50.4 Gy/28 fractions/5.5 weeks, using 3D-conformal techniques. Three patients were entered to each dose level (DL). Dose-limiting toxicity(s) (DLTs) were based on treatment-related toxicities. Twenty patients were accrued. Dose level (DL) 1: Cap/Gem; 800/20 mg m⁻² day⁻¹ (3 patients), DL2: 1000/20 (12 patients), DL3: 1300/30 (5 patients). Dose-limiting toxicities were observed in DL3; grade 3 dehydration (1 patient) and grade 3 diarrhoea and dehydration (1 patient). Dose level 2 was the recommend phase 2 dose. Disease control rate was 75%: PR=15%, SD=60%. Median overall survival was 11.2 months. The addition of Cap and Gem to radical RT was feasible and active and achieved at relatively low doses.

The management of foreign bodies in the pharynx and oesophagus using transnasal flexible laryngo-oesophagoscopy (TNFLO)

INTRODUCTION

We describe our experience of the diagnosis and removal of foreign bodies from the pharynx and oesophagus using transnasal flexible laryngo-oesophagoscopy (TNFLO) under local analgesic. The advantages of this novel instrumentation and technique are discussed.

PATIENTS AND METHODS

Patients were examined with a Pentax 80K Series Digital Video Endoscope after local analgesia. The instrument was passed transnasally examining the oro- and hypopharynx, and then passed into the oesophagus. The presence, type and site of a foreign body could then be established. If a foreign body was detected, such as fish bone, it was extracted using flexible grabbing forceps passed down the instrument channel and delivered through the nasal or oral cavity. The object was then inspected to ensure removal in its entirety.

RESULTS

Five cases have been successfully managed using TNFLO.

CONCLUSIONS

TNFLO represents an improvement in the diagnosis and subsequent treatment of a selected group of foreign bodies as compared with established methodologies.

Is current UK management of oesophageal food bolus obstruction evidence based? An e-mail survey and literature review

There is a great deal of variation in individual management of non-sharp oesophageal food bolus obstruction in the United Kingdom. An e-mail survey of consultants and specialist registrars in ENT was carried out to establish current UK practice. A review of the published literature was under-taken to establish whether current practice is evidence based. The majority of practitioners (95%) do not proceed immediately to rigid oesophagoscopy but use antispasmodic drugs (83%), most commonly hyoscine butylbromide (Buscopan) and diazepam, to try to induce spontaneous passage of the obstruction. There is currently no evidence in the published literature to support the use of these drugs. The use of Buscopan seems to have been encouraged by a misquoted reference in a prominent ENT textbook. Better evidence is needed to establish the best form of treatment for this relatively common problem.

How we do it: The role of trans-nasal flexible laryngo-oesophagoscopy (TNFLO) in ENT: one year's experience in a head and neck orientated practice in the UK

KEYPOINTS: Transnasal flexible laryngo-oesophagoscopy (TNFLO) is a safe and well-tolerated procedure that may be performed in a procedure room in the outpatient or day-case/main theatre setting. It requires a local anaesthetic and no sedation. It may be used to histologically diagnose or exclude pathology from the nose to the gastro-oesophageal junction. It provides a "one stop" diagnosis service, reducing diagnostic delays, the need for endoscopy under general anaesthesia, barium swallows and follow-up outpatient appointments. Therapeutic procedures such as vocal cord medialization, endolaryngeal laser surgery, insertion of speech prostheses and foreign body removal may be performed without general anaesthesia.

Final safety findings from a randomized phase III trial of capecitabine + oxaliplatin (XELOX) vs. bolus 5-FU/LV as adjuvant therapy for patients (pts) with stage III colon cancer

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Background: Adjuvant capecitabine results in at least equivalent disease-free survival (DFS) to i.v. bolus 5-FU/LV in stage III colon cancer [Twelves et al. 2005]. Early phase III data in 1st-line metastatic colorectal cancer suggest that XELOX is as safe as oxaliplatin + infusional 5-FU ± LV [Sastre et al. 2005; Ducreux et al. 2005]. The XELOXA study compared safety and efficacy of XELOX vs. bolus 5-FU/LV (the standard regimen at study start) as adjuvant therapy for stage III colon cancer. Methods: Pts with resected disease were randomized to receive either XELOX (capecitabine 1000 mg/m2 bid d1–14 + oxaliplatin 130 mg/m2 d1, q3w for 8 cycles) or i.v. bolus 5-FU/LV (Mayo Clinic, LV 20 mg/m2 + 5-FU 425 mg/m2 d1–5, q4w for 6 cycles; or Roswell Park [RP], LV 500 mg/m2 + 5-FU 500 mg/m2 d1, w1–6 in 8w cycles x4). Centers’ preferred 5-FU/LV regimen was selected at study start and used in all pts. Results: 1861/1886 pts randomized between Apr 03 and Oct 04 are evaluable for safety. The rate of related grade 3/4 adverse events (AEs) was 54% for XELOX and 45% for 5-FU/LV ( table ). 60-day all cause mortality was 1.0% in both arms. Treatment-related death rate within 28 days from last dose was 0.7% for XELOX and 0.5% for 5-FU/LV. Conclusions: XELOX causes less myelosuppression and stomatitis but more skin toxicity than 5-FU/LV. The inclusion of oxaliplatin adds neurosensory toxicity. Cross-study comparison of grade 3/4 AEs in the current and MOSAIC trials suggests that XELOX safety is similar to FOLFOX4, with the advantage of an oral fluoropyrimidine-based regimen. Final safety data will be presented at the meeting, and efficacy data will be available in 2007.

[Table: see text]

[Table: see text]

Synchronous bilateral tonsillar carcinoma: role of fluoro-deoxyglucose positron emission tomography scanning in detecting occult primary tumours in metastatic nodal disease of the head and neck

We present the second case of primary synchronous bilateral tonsillar squamous cell carcinoma reported in the English literature and evaluate the role of fluoro-deoxyglucose positron emission tomography scanning in the search for the occult primary tumour in a patient presenting with metastatic nodal disease in the head and neck.

Excess non-spine fractures in women over 50 years with celiac disease: a cross-sectional, questionnaire-based study

The association of celiac disease with fracture is controversial. Recent studies may have underestimated the impact by studying patients with low fracture risk. Since postmenopausal women are at greatest risk of fracture, we have investigated non-spine fracture occurrence in women > or =50 years with celiac disease. Patients were recruited from hospital and general practice as well as from volunteers, controls from general practice. All completed a questionnaire detailing fracture occurrence. Three hundred and eighty-three female celiac patients and 445 female controls aged > or =50 years at time of study were compared. Mean age was 61.4+/-7.8 years in celiac patients and 62.7+/-9.9 years in controls. Celiac patients were lighter but not shorter. Celiac patients displayed greater "all fracture" prevalence (odds ratio [OR], 1.51; confidence interval [CI], 1.13:2.02) and fracture after 50 years (OR, 2.20; CI, 1.49:3.25). Wrist fracture was more frequent (OR, 1.65; CI, 1.12:2.41), but significance was lost once height and weight were taken into account. Celiac patients had more multiple fractures (OR, 2.96; CI, 1.81:4.83). To investigate the association of fracture with time from diagnosis, 324 celiac patients were paired with a control by age. No excess fracture risk was found more than 10 years before diagnosis amongst celiac patients diagnosed after age 50 years, but risk increased in the period from 10 years before diagnosis to 5 years after and remained high more than 5 years after diagnosis ( p<0.05). Wrist fracture only increased in the period more than 5 years after diagnosis ( p<0.05). In women diagnosed before 50 years, no excess fracture risk existed. Fracture risk in female celiac patients >50 years is increased overall but is related largely to the peri-diagnostic period. Wrist fracture risk is partly accounted for by height and weight, but is more common more than 5 years after diagnosis. Celiac testing may be indicated in thin women over 50 years with multiple fractures, and after diagnosis adequate calcium and vitamin D intake should be ensured.