Adjuvant 5-flurouracil, alpha-interferon and interleukin-2 versus observation in patients at high risk of recurrence after nephrectomy for renal cell carcinoma: results of a phase III randomised European Organisation for Research and Treatment of Cancer (Genito-Urinary Cancers Group)/National Cancer Research Institute trial

BACKGROUND

The purpose of this trial was to compare adjuvant 5-flurouracil, alpha-interferon and interleukin-2 to observation in patients at high risk of recurrence after nephrectomy for renal cell carcinoma (RCC) in terms of disease free survival, overall survival and quality of life (QoL).

PATIENTS AND METHODS

Patients 8weeks post nephrectomy for RCC, without macroscopic residual disease, with stage T3b-c,T4 or any pT and pN1 or pN2 or positive microscopic margins or microscopic vascular invasion, and no metastases were randomised to receive adjuvant treatment or observation. QoL was assessed by European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-30 (QLQC-30). Treatment delivery and toxicity were monitored. The trial was designed to detect an increase in 3year disease free survival (DFS) from 50% on observation to 65% on treatment (hazard ratio (HR)=0.63) with 90% power and two-sided alpha=0.05.

RESULTS

From 1998 to 2007, 309 patients were randomised (155 to observation; 154 to treatment). 35% did not complete the treatment, primarily due to toxicity (92% of patients experienced ⩾grade 2, 41% ⩾grade 3). Statistically significant differences between the arms in QoL parameters at 2months disappeared by 6months although there was suggestion of a persistent deficit in fatigue and physical function. Median follow-up was 7years (maximum 12.1years). 182 patients relapsed or died. DFS at 3years was 50% with observation and 61% with treatment (HR 0.84, 95% confidence interval (CI) 0.63-1.12, p=0.233). 124 patients died. Overall survival (OS) at 5years was 63% with observation and 70% with treatment (HR 0.87, 95% CI 0.61-1.23, p=0.428).

CONCLUSIONS

The treatment is associated with significant toxicity. There is no statistically significant benefit for the regimen in terms of disease free or overall survival.

Light sources and cameras for standard in vitro membrane potential and high-speed ion imaging

Membrane potential and fast ion imaging are now standard optical techniques routinely used to record dynamic physiological signals in several preparations in vitro. Although detailed resolution of optical signals can be improved by confocal or two-photon microscopy, high spatial and temporal resolution can be obtained using conventional microscopy and affordable light sources and cameras. Thus, standard wide-field imaging methods are still the most common in research laboratories and can often produce measurements with a signal-to-noise ratio that is superior to other optical approaches. This paper seeks to review the most important instrumentation used in these experiments, with particular reference to recent technological advances. We analyse in detail the optical constraints dictating the type of signals that are obtained with voltage and ion imaging and we discuss how to use this information to choose the optimal apparatus. Then, we discuss the available light sources with specific attention to light emitting diodes and solid state lasers. We then address the current state-of-the-art of available charge coupled device, electron multiplying charge coupled device and complementary metal oxide semiconductor cameras and we analyse the characteristics that need to be taken into account for the choice of optimal detector. Finally, we conclude by discussing prospective future developments that are likely to further improve the quality of the signals expanding the capability of the techniques and opening the gate to novel applications.

Nasty or Nice? Findings from a UK Survey to evaluate the impact of the National Institute for Health and Clinical Excellence (NICE) clinical guidelines on the management of prostate cancer

AIMS

Although the National Institute for Health and Clinical Excellence clinical guideline 58 (CG58) for prostate cancer management was expected to have a positive effect, several recommendations raised concern among UK physicians. We conducted a survey of UK oncologists in 2008 and a second, similar survey in 2010 to assess views on these recommendations and to evaluate the change in opinion over time.

MATERIALS AND METHODS

Two semi-structured questionnaires were issued by the British Uro-oncology Group to society members in September 2008 and October 2010.

RESULTS

In 2008, 61 UK oncologists completed the survey; 60% agreed that CG58 would make a positive contribution towards improving patient care. There was strong opposition towards active surveillance as the first-line treatment for men with low-risk localised prostate cancer (49% disagreement); implementing 5 yearly flexible sigmoidoscopy post-prostate radiotherapy (51% disagreement); offering follow-up outside of the hospital (e.g. by general practitioners in primary care) for men with a stable prostate-specific antigen for ≥2 years (44% disagreement); and recommendations against docetaxel retreatment (47% disagreement) or bisphosphonate use (58% disagreement). In 2010, 77 UK oncologists completed the survey. The results were largely consistent with 2008, although several recommendations, particularly for localised disease, seem to have promoted a change in clinical practice, suggesting that they are facilitating a standardised approach. Compared with 2008, the 2010 results indicate a shift in favour of active surveillance (80% agreement) and primary care follow-up (59% agreement), but increasing opposition for docetaxel retreatment (57% disagreement). Opinions remained divided for flexible sigmoidoscopy and bisphosphonates.

CONCLUSIONS

Despite initial concerns, the CG58 seems to have had a positive impact on prostate cancer management in the UK, with adherence likely facilitating a standardised approach. However, with new data emerging, these findings underscore the need to regularly update guidelines. A revision of the CG58 is anticipated by 2014.

Differential retinal origins of separate anatomical channels for pattern and motion vision in rabbit

The most conspicuous feature of the rabbit retina is the visual streak that extends along the horizontal azimuth from the nasal margin to the temporal limit of the retina. We believe the streak processes movement vision and that the temporal region (area centralis) is responsible for pattern perception. Both anatomical and behavioural experiments were used to test this hypothesis. Behavioural measures of pattern vision in normal and chiasma-sectioned rabbits revealed both to have the same visual acuity. Using OKN as a measure of movement vision, normal rabbits showed both a directional and velocity-tuned response. The chiasma-sectioned rabbits, with only uncrossed fibre projections remaining, showed a total loss of movement detection. The injection of HRP into the vitreal chamber of one eye in normal rabbits revealed extensive uptake throughout the contralateral thalamus. In the ipsilateral thalamus, there was uptake solely from the ipsilateral retinal projection to a restricted wafer of the lateral geniculate nucleus (LGN). The chiasma cut rabbits showed a very different distribution of HRP in the thalamus. The uptake was restricted to a thin wafer of the LGN, with no contralateral uptake. Thus, the thalamic projections from the retinal area centralis were strictly segregated from the thalamic target areas for the visual streak without any overlap. These findings provide strong evidence for separate retinal origins with anatomically separate pathways for pattern and movement vision in the rabbit.

Regional brain blood flow in man during acute changes in arterial blood gases

Despite the importance of blood flow on brainstem control of respiratory and autonomic function, little is known about regional cerebral blood flow (CBF) during changes in arterial blood gases.We quantified: (1) anterior and posterior CBF and reactivity through a wide range of steady-state changes in the partial pressures of CO2 (PaCO2) and O2 (PaO2) in arterial blood, and (2) determined if the internal carotid artery (ICA) and vertebral artery (VA) change diameter through the same range.We used near-concurrent vascular ultrasound measures of flow through the ICA and VA, and blood velocity in their downstream arteries (the middle (MCA) and posterior (PCA) cerebral arteries). Part A (n =16) examined iso-oxic changes in PaCO2, consisting of three hypocapnic stages (PaCO2 =∼15, ∼20 and ∼30 mmHg) and four hypercapnic stages (PaCO2 =∼50, ∼55, ∼60 and ∼65 mmHg). In Part B (n =10), during isocapnia, PaO2 was decreased to ∼60, ∼44, and ∼35 mmHg and increased to ∼320 mmHg and ∼430 mmHg. Stages lasted ∼15 min. Intra-arterial pressure was measured continuously; arterial blood gases were sampled at the end of each stage. There were three principal findings. (1) Regional reactivity: the VA reactivity to hypocapnia was larger than the ICA, MCA and PCA; hypercapnic reactivity was similar.With profound hypoxia (35 mmHg) the relative increase in VA flow was 50% greater than the other vessels. (2) Neck vessel diameters: changes in diameter (∼25%) of the ICA was positively related to changes in PaCO2 (R2, 0.63±0.26; P<0.05); VA diameter was unaltered in response to changed PaCO2 but yielded a diameter increase of +9% with severe hypoxia. (3) Intra- vs. extra-cerebral measures: MCA and PCA blood velocities yielded smaller reactivities and estimates of flow than VA and ICA flow. The findings respectively indicate: (1) disparate blood flow regulation to the brainstem and cortex; (2) cerebrovascular resistance is not solely modulated at the level of the arteriolar pial vessels; and (3) transcranial Doppler ultrasound may underestimate measurements of CBF during extreme hypoxia and/or hypercapnia.

Creutzfeldt-Jakob disease and mad cows: lessons learnt from yeast cells

Transmissible spongiform encephalopathies are fatal neurodegenerative diseases that affect mammals including humans. The proteinaceous nature of the infectious agent, the prion, and its propagation, challenge established dogmas in biology. It is now widely accepted that prion diseases are caused by unconventional agents principally composed of a misfolded host-encoded protein, PrP. Surprisingly, major break-throughs in prion research came from studies on functionally unrelated proteins in yeast and filamentous fungi. Aggregates composed of these proteins act as epigenetic elements of inheritance that can propagate their alternative states by a conformational switch into an ordered ß-sheet rich polymer just like mammalian prions. Since their discovery prions of lower eukaryotes have provided invaluable insights into all aspects of prion biogenesis. Importantly, yeast prions provide proof-of-principle that distinct protein conformers can be infectious and can serve as genetic elements that have the capacity to encipher strain specific information. As a powerful and tractable model system, yeast prions will continue to increase our understanding of prion-host cell interaction and potential mechanisms of protein-based epigenetic inheritance.

Clinical severity and quality of life in children and adolescents with Rett syndrome

OBJECTIVE

The clinical features and genetics of Rett syndrome (RTT) have been well studied, but examination of quality of life (QOL) is limited. This study describes the impact of clinical severity on QOL among female children and adolescents with classic RTT.

METHODS

Cross-sectional and longitudinal analyses were conducted on data collected from an NIH-sponsored RTT natural history study. More than 200 participants from 5 to 18 years of age with classic RTT finished their 2-year follow-up at the time of analysis. Regression models after adjustment for their MECP2 mutation type and age at enrollment were used to examine the association between clinical status and QOL.

RESULTS

Severe clinical impairment was highly associated with poor physical QOL, but worse motor function and earlier age at onset of RTT stereotypies were associated with better psychosocial QOL; conversely, better motor function was associated with poorer psychosocial QOL.

CONCLUSIONS

Standard psychosocial QOL assessment for children and adolescents with RTT differs significantly with regard to their motor function severity. As clinical trials in RTT emerge, the Child Health Questionnaire 50 may represent one of the important outcome measures.

Towards an understanding of the nature of resistance to Phytophthora root rot in red raspberry

A mapping population segregating for root rot resistance was screened under both field and glasshouse conditions over a number of seasons. Few correlations between field and glasshouse scores were significant. Final root rot scores were significantly negatively correlated with measures of root vigour. Two QTL associated with resistance were identified as were overlapping QTL for root vigour assessments. Markers significantly associated with the traits were used to identify BAC clones, which were subsequently sequenced to examine gene content. A number of genes were identified including those associated with stem cell identity, cell proliferation and elongation in the root zone, control of meristematic activity and organisation, cell signalling, stress response, sugar sensing and control of gene expression as well as a range of transcription factors including those known to be associated with defence. For marker-assisted breeding, the SSR marker Rub118b 110 bp allele from Latham was found in resistant germplasm but was not found in any of the susceptible germplasm tested.

Foetal malformations after exposure to antiepileptic drugs in utero assessed at birth and 12 months later: observations from the Australian pregnancy register

BACKGROUND

In studies investigating foetal malformations associated with antiepileptic drug exposure during pregnancy, the common practice has been to assess the incidence and nature of the malformations at, or soon after, birth. The adequacy of this approach to determine the true incidence of the malformations has received little attention.

AIMS OF THE STUDY

To compare the incidence and natures of the foetal malformations recognized by, or soon after, birth with similar data for malformations recognized in the first post-natal year.

METHODS

Analysis of data from the Australian Register of Antiepileptic Drugs in Pregnancy.

RESULTS

Up to 25% of the malformations recognized by the end of the first post-natal year had not been detected by, or soon after, birth. There was a tendency for the late-recognized malformations to differ from the early-recognized ones in relation to the body parts involved.

CONCLUSIONS

Early assessment and delayed assessment of infants for the presence of foetal malformations are complementary, with the latter resulting in finding a higher incidence of malformations. However, omission of an early post-natal assessment may result in biases because of loss of subjects to follow-up.

Paired kidney donor exchanges and antibody reduction therapy: novel methods to ameliorate disparate access to living donor kidney transplantation in ethnic minorities

BACKGROUND

Currently ethnic minority patients comprise 60% of patients listed for kidney transplantation in the US; however, they receive only 55% of deceased donor renal transplants and 25% of living donor renal transplants. Ethnic disparities in access to kidney transplantation result in increased morbidity and mortality for minority patients with end-stage renal disease. Because these patients remain dialysis dependent for longer durations, they are more prone to the development of HLA antibodies that further delay the possibility of receiving a successful kidney transplant.

STUDY DESIGN

Two to 4 pretransplant and post-transplant plasma exchanges and i.v. immunoglobulin were used to lower donor-specific antibody levels to less than 1:16 dilution; cell lytic therapy was used additionally in some cases. Match pairing by virtual cross-matching was performed to identify the maximal exchange benefit. Sixty candidates for renal transplantation were placed into 4 paired kidney exchanges and/or underwent antibody reduction therapy.

RESULTS

Sixty living donor renal transplants were performed by paired exchange pools and/or antibody reduction therapy in recipients whose original intended donors had ABO or HLA incompatibilities or both (24 desensitization and 36 paired kidney exchanges). Successful transplants were performed in 38 ethnic minorities, of which 33 were African American. Twenty-two recipients were white. Graft and patient survival was 100% at 6 months; graft function (mean serum creatinine 1.4 g/dL) and acute rejection rates (20%) have been comparable to traditional live donor kidney transplantation.

CONCLUSIONS

Paired kidney donor exchange pools with antibody reduction therapy can allow successful transplant in difficult to match recipients. This approach can address kidney transplant disparities.

Changes in mandibular cortical width measurements with age in men and women

Automated software was used to measure the mandibular cortical width in a large sample of dental radiographs. We determined that cortical thinning normally starts in women at age 42.5 years and accelerates thereafter. We can estimate population referral rates and thus enable cost benefit analyses for osteoporosis detection by dentists.

INTRODUCTION

Previous studies have shown that the mandibular cortical width is significantly correlated with the bone mineral density at sites which may undergo osteoporotic fracture, e.g. hip. Mandibular cortical width can be determined automatically from dental panoramic radiographs that dentists frequently request, using appropriate software. We study the distribution of cortical width given age to predict those patients requiring further investigation for osteoporosis.

METHODS

The mandibular cortical width was measured in 4,949 dental panoramic tomograms, in patients aged 15-94 years. The inferior and superior cortical edges were detected automatically using a global active shape model image search, followed by an active appearance model search. Nonparametric statistical analysis and nonlinear piecewise linear/quadratic regression were used to analyse the data.

RESULTS

For females, the mean cortical width had a linear increase before the age of 17 years, a period of no change (estimate = 3.25 mm, se = 0.01) until the age of 42.5 years, followed by a quadratic decrease with age. For males, it had a linear increase before the age of 19 years, a constant value (estimate = 0.37 mm, se = 0.01) until the age of 36 years and then a slow linear decrease. The rate of decrease in mean cortical width goes from 0.049 to 0.105 standard deviations per year in the 60-80-year-old female age group, in line with published bone mineral density T-score reductions.

CONCLUSIONS

The pattern of decrease in mandibular cortical width with age was similar to the known pattern of bone loss from the hip, accelerating in women after the age of 42.5 years.

Improving physical health of patients with mental health problems

It is well recognised that individuals with severe mental health difficulties have increased risks of significant physical health problems and that some of the treatments for mental health problems can cause physical health difficulties as side effects. It is also known that people with mental health difficulties do not present themselves regularly for physical health monitoring as suggested by national and international guidelines. We show how a secondary care community mental health service cooperated with primary care general medical services to increase the take up of physical health monitoring by patients with severe and enduring mental health problems.

Staff in the community mental health team which served a rural/small urban population identified patients with severe and enduring mental health difficulties or those patients on medications linked to physical problems and contacted the primary care physicians responsible for the patients’ general care with patient details and encouraged patient attendance for physical health monitoring. Physical monitoring included blood pressure, ECG, glucose, thyroid, lipids, height and weight. Post-intervention attendance figures show an increase of 30% in patients attending physical health reviews compared with pre-intervention figures. The intervention has been now rolled out to a larger catchment area of 25000 persons.