Delayed therapy with curative intent in a contemporary prostate cancer watchful-waiting cohort

OBJECTIVE

To identify predictors of delayed therapy with curative intent, an increasingly common option in contemporary patients with prostate cancer who initially choose watchful waiting.

PATIENTS AND METHODS

The characteristics of all patients at one institution and diagnosed with T1-4NXM0 prostate cancer between 1993 and 2000 were prospectively recorded. Factors recorded included: age, tumour stage, histological type, Gleason score, serum prostate specific antigen (PSA) level, prostate volume, PSA density (PSAD), percentage of positive biopsy cores, and the initial treatment selection. Outcomes, including all cancer-directed interventions, all serum PSA values, and initial outcomes of all interventions with curative intent, were determined by review of all medical records and cancer registry data.

RESULTS

Of 187 patients on watchful waiting, 175 had stage T1 or T2 cancer and were analysed primarily. Thirty-eight (22%) of these patients received delayed intervention with curative intent (15 radical prostatectomy, 17 external beam radiotherapy, six brachytherapy). Age (P < 0.001) and percentage of positive biopsy cores (P = 0.042) were significant independent predictors of intervention with curative intent. When the PSA doubling time was added to the model it became a significant predictor (P = 0.018), with percentage positive biopsy cores (P = 0.022) and age (P < 0.001).

CONCLUSIONS

Therapy with curative intent is common in contemporary patients with prostate cancer who initially choose watchful waiting. Age and percentage positive biopsy cores are independent predictors of such intervention, with PSA doubling time also an independent predictor.

Five-year survival predictive factors in patients with excessive alcohol intake and cirrhosis. Effect of alcoholic hepatitis, smoking and abstinence

AIM

To evaluate 5-year survival predictive factors in hospitalised patients with excessive alcohol intake and cirrhosis, including in a multivariate analysis the severity of the liver disease, gastrointestinal bleeding, concomitant viral B or C infection, smoking status, presence of alcoholic hepatitis at inclusion and abstinence from alcohol during follow-up.

METHODS

In a non-concurrent cohort study, 122 patients with excessive alcohol intake and cirrhosis were followed up at least five years or till death. Two patients were lost to follow-up.

RESULTS

The 5-year survival rates were 43% in the 122 patients and 66%, 50% and 25% in Child-Pugh class A, B and C patients, respectively. In multivariate analysis, age (P = 0.01), Child-Pugh score (P = 0.0001), gastrointestinal bleeding (P = 0.01), presence of HBs Ag and/or anti-HCV (P = 0.03), smoking (P = 0.01), absence of histologically proven alcoholic hepatitis (P = 0.05) and persistent alcohol intake (P = 0.002) were associated with significantly increased risk ratios of death.

CONCLUSIONS

In hospitalised patients with excessive alcohol intake and cirrhosis: (1) age, liver failure, gastrointestinal bleeding, concomitant viral B or C infection and persistent alcohol intake are independent poor prognostic markers, (2) smoking may contribute to the aggravation of cirrhosis, and (3) alcoholic hepatitis, being a potentially reversible cause of liver failure, has a favourable prognostic significance.

Noncovalent interactions between tetrazole and an N,N'-diethyl-substituted benzamidine

Amidines have long been known to form strong noncovalent complexes with carboxylates and phosphates. However, their interaction with tetrazoles, which are acidic heterocycles and important bioisosteric replacements for carboxylic acids in medicinal chemistry, has remained unexplored so far. The binding of a tetrazole to an N,N'-diethyl-substituted benzamidine has been studied for the first time by X-ray crystallography, solution NMR methods, and electrospray mass spectrometry. The amidinium group of model complex 3 was found to prefer an E,Z configuration in the crystal. Benzamidinium and tetrazolate groups alternate along an infinite chain of hydrogen bonds and salt bridges between the amidine-NH groups and the two tetrazole-N atoms next to the ring carbon. In solution, a 1:1 complex was evident from Job's method of continuous variation, and an association constant of 4.0 x 10(3) +/- 1.6 x 10(3) M(-)(1) (in CDCl(3)/CD(3)CN, 6:1) could be determined by (1)H NMR dilution experiments. Tetrazolate was not only found to be a weaker ligand than carboxylates but, surprisingly, the binding mode also changed with concentration in neat CDCl(3). At low concentrations, the amidine group in complex 3 adapted an E,E configuration as it does in a related carboxylic acid complex 4. With increasing concentration, the E,Z isomer starts to predominate. A free activation enthalpy DeltaG(298)() of 64 +/- 1 kJ mol(-)(1) for the E,E to E,Z isomerization was determined by line shape analysis at different magnetic fields. Binding strength was further probed in a competition experiment between a bisamidine, a carboxylate, and a tetrazolate by electrospray mass spectrometry.

Predictors of sunburn among Canadian adults

BACKGROUND

Data from the 1996 National Survey on Sun Exposure & Protective Behaviors (4,023 respondents) were analyzed to identify independent predictors of sunburn among adult Canadians.

METHODS

Multivariate models predicting sunburn odds were developed using unconditional logistic regression. Backward elimination model selection was used to identify independent predictors of sunburn.

RESULTS

Nonbehavioral characteristics found to predict sunburn were younger age, male sex, light skin color, nonblack hair color, and birthplace in North America or Europe. Behavioral predictors of sunburn included high awareness of the UV Index, working outdoors in the summer, longer leisure time in the sun, forgetfulness about protecting oneself from the sun, and seeking a tan. Sun avoidance between 11 AM and 4 PM was associated with lower odds of sunburn, while seeking shade when outside and use of protective clothing showed nonsignificant associations with lower sunburn odds. Sunscreen use was found to have a nonsignificant positive association with sunburn.

CONCLUSIONS

These findings highlight risk factors to be considered in the targeting of sunburn reduction strategies to high-risk groups and suggest that sun avoidance, seeking shade, and use of protective clothing may be effective in preventing sunburn.

Novel DNA sequence variants in the hHR21 DNA repair gene in radiosensitive cancer patients

PURPOSE

Radiation therapy is an important treatment modality for oncology patients. DNA sequence variants have so far been identified in only a few genes in radiosensitive cancer patients. Patients known to be clinically radiosensitive were tested for mutation of a gene involved in DNA double-strand break repair and sister chromatid cohesion--hHR21.

METHODS AND MATERIALS

Clinically radiation-sensitive patients were accrued to the study after giving informed consent. Blood samples were obtained and lymphoblastoid cell lines established. Reverse transcriptase-polymerase chain reaction (RT-PCR) was performed to amplify the hHR21 gene, and the DNA product was sequenced to identify any genetic abnormalities. Northern blot analysis, cell survival, and growth assays were performed on control cells and cells with hHR21 variants, and a restriction digest assay was developed to screen for carriers of a detected gene variant.

RESULTS

The DNA sequence of the hHR21 gene was determined in 19 radiation-sensitive cancer patients. In 6 of the 19 patients, a thymidine (T) to cytosine (C) transition was detected at position 1440 of the hHR21 open reading frame (T1440C). This variant did not alter the amino acid sequence and was likely to be a polymorphism. One patient with a particularly severe radiation reaction had a second sequence variant immediately adjacent to the first. This was a guanine (G) to adenine (A) transition (G1441A), resulting in a change of the amino acid sequence (glycine --> arginine) in a portion of the protein conserved in evolution. This suggests that this DNA alteration may be biologically significant. Restriction digest with the HpaII enzyme confirmed the presence of both sequence variants on the same allele.

CONCLUSIONS

We describe the first two DNA sequence variants ever found in the hHR21 gene, in patients with clinical radiation hypersensitivity. Although no direct evidence for the involvement of hHR21 alterations in the radiosensitivity of the cancer patients examined has been demonstrated, the possibility exists that homozygous mutations or other mutations of this gene could contribute to radiosensitivity. A simple test is described that could be applied to screening for these variants in relevant populations.

Duration of untreated psychosis predicts treatment outcome in an early psychosis program

For patients first presenting with a non-affective psychotic disorder, the duration of untreated psychosis (DUP; the time between the onset of positive psychotic symptoms and the initiation of appropriate treatment) varies widely, from a few weeks to several years. A number of studies report that a longer DUP is associated with poorer clinical outcomes. We studied DUP and its association with clinical outcomes in a group of patients with schizophrenia and related psychotic disorders treated in the naturalistic clinical setting of an early psychosis program. DUP was determined for 19 patients with a non-affective psychotic disorder (schizophrenia, schizoaffective disorder or schizophreniform disorder) and no previous treatment for psychosis, by use of the IRAOS, a retrospective structured interview carried out with patients and their families. Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Function (GAF) ratings were available at baseline and 6month follow-up. For analysis, patients were categorized into a short DUP (n=9) or long DUP (n=10) group. The median DUP (57weeks) was used as the dividing point. At baseline, the two groups did not differ significantly on positive symptoms or total PANSS ratings. However, negative symptoms were more severe in the long DUP group at baseline (P=0.029), and the long DUP group had a significantly higher mean rating for the passive/apathetic social withdrawal item of the PANSS (P=0.024). At 6month follow-up, the long DUP group had significantly higher ratings for positive symptoms (P=0.028) and had lower GAF scores (P=0.044). Significantly more (P=0.033) long DUP patients had enduring positive psychotic symptoms. The results confirm both the wide range of DUP among patients first presenting with schizophrenia and related psychotic disorders and the association of long DUP, defined as greater than approximately 1year, with a poorer clinical outcome. This study highlights the importance of collecting data regarding DUP and supports the view that patients with a long DUP are likely to be less responsive to treatment in general and will require greater resources and more intensive interventions.

Phase I trial of concurrent tirapazamine, cisplatin, and radiotherapy in patients with advanced head and neck cancer

PURPOSE

To determine the maximum-tolerated dose of tirapazamine when combined with cisplatin and radiation in patients with T3/4 and/or N2/3 squamous cell carcinoma of the head and neck.

PATIENTS AND METHODS

The starting schedule was conventionally fractionated radiotherapy (70 Gy in 7 weeks) with concomitant cisplatin 75 mg/m2 and tirapazamine 290 mg/m2 (before cisplatin) in weeks 1, 4, and 7 and tirapazamine alone 160 mg/m2 three times a week in weeks 2, 3, 5, and 6. Positron emission tomography scans for tumor hypoxia (18F misonidazole) were performed before and during radiotherapy.

RESULTS

We treated 16 patients with predominantly oropharyngeal primary tumors, including 10 patients with T4 or N3 disease. Febrile neutropenia occurred toward the end of radiotherapy in three out of six patients treated on the initial dose level. Two of these patients also developed grade 4 acute radiation reactions. Another 10 patients were treated with the same doses, but the week 5 and week 6 tirapazamine doses were omitted. This resulted in less neutropenia and only one dose-limiting toxicity (DLT) (febrile neutropenia), and eight out of 10 patients completed treatment without any dose omissions. In these 10 patients, the acute radiation toxicities were not obviously enhanced compared with chemoradiotherapy regimens using concurrent platinum and fluorouracil. 18F misonidazole scans detected hypoxia in 14 of 15 patients at baseline, with only one patient having detectable hypoxia at the end of treatment. With a median follow-up of 2.7 years, the 3-year failure-free survival rate was 69% (SE, 12%), the 3-year local progression-free rate was 88% (SE, 8%), and the 3-year overall survival rate was 69% (SE, 12%).

CONCLUSION

DLT was due unexpectedly to febrile neutropenia, which could be overcome by omitting tirapazamine in weeks 5 and 6. The combination of tirapazamine, cisplatin, and radiotherapy resulted in remarkably good and durable clinical responses in patients with very advanced head and neck cancers. It warrants further investigation.

The COPE program: treatment efficacy and medical utilization outcome of a chronic pain management program at a major military hospital

This study presents a treatment efficacy and medical utilization evaluation of a cognitive-behavioral, outpatient, chronic pain management program in a military hospital setting. A total of 61 nonmalignant chronic pain patients with heterogeneous pain syndromes who participated in sequential group programs were included in the study. Comprehensive and multi-dimensional outcome criteria were used, including pain ratings, relaxation skills, quality of life, satisfaction ratings, and medical utilization. The findings demonstrated improvements on all general indices. Military status had no effect on any of the outcome measures. Most significant was an 87% reduction in outpatient clinic visits in the first 3 months after treatment. This reduction amounts to a projected net annual saving of $78,960 in the first year after behavioral medicine intervention. In light of the increasing cost of health care for chronic pain patients, psychological approaches as an adjunct to traditional medical care seem to present a sound solution for cost savings. This study also supports the notion that a strategic biopsychosocial pain program, which targets the multiple dimensions of persistent pain, provides effective treatment and increases patient satisfaction.

Antigen-induced IL-17 response in the peripheral blood mononuclear cells (PBMC) of healthy controls

IL-17 is a T cell cytokine with a complex and important role in the immune system. It has been detected in rheumatoid arthritis (RA) synovial membrane and found to stimulate the production of the proinflammatory cytokines IL-6, IL-8, tumour necrosis factor-alpha (TNF-alpha) and granulocyte-macrophage colony-stimulating factor (GM-CSF) in vitro. To date, there are few data available on the agents that stimulate IL-17 production. We therefore investigated the in vitro IL-17 response to a variety of mitogens and antigens, and compared the IL-17 response to interferon-gamma (IFN-gamma), IL-4, IL-10 and TNF-alpha. In this study we used a type-0 antigen, tetanus toxoid (TT), a type-1 antigen, PPD from Mycobacterium tuberculosis, a potential type-2 rye grass (RG) antigen (Lol I) and an autoantigen SS.B (La), to stimulate PBMC from healthy controls. Cytokine mRNA was measured using semiquantitative reverse transcriptase-polymerase chain reaction and cytokine protein measured using specific ELISA techniques, while the frequency of IL-17-producing T cells was determined by flow cytometry. The mitogens concanavalin A, phytohaemagglutinin and phorbol myristate acetate/ionomycin induced a significant increase in IL-17, with the highest levels being produced by anti-CD3/anti-CD28 stimulation. The antigens TT and PPD significantly increased IL-17 mRNA expression over time, but failed to have such an effect at the protein level. IL-17 protein was also detectable in both antigen-specific (TT, SS. B) and non-specific T cell clones, but at levels lower than IFN-gamma. IL-17 production did not correlate with either the type-1 cytokine IFN-gamma or TNF-alpha or the type-2 cytokine IL-4 or IL-10 at either the mRNA or protein level.

Discriminant validity of the Social Phobia and Anxiety Inventory (SPAI), the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS)

Three measures commonly used in assessment of social phobia, the Social Phobia and Anxiety Inventory (SPAI [Turner, S. M., Beidel, D. C. & Dancu, C. V. (1996). Social phobia and anxiety inventory: manual. Toronto, Ont.: Multi-Health Systems Inc.), the Social Phobia Scale (SPS [Mattick, R. P. & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455-470] and the Social Interaction Anxiety Scale (SIAS [Mattick, R. P. & Clarke, J. C. (1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455-470], were compared for their ability to discriminate between social phobia and other anxiety disorders (panic disorder with or without agoraphobia). Participants were 117 patients attending a specialized anxiety disorders unit for treatment. While all three measures were able to detect differences between social phobic patients and patients with panic disorder with or without agoraphobia, a logistic regression analysis showed that the SPAI, but not the SPS and SIAS, was a significant predictor of membership of the social phobia group. Receiver operating characteristic (ROC) analysis also showed that the SPAI was the better measure for discriminating between social phobia and panic disorder with and without agoraphobia. Analysis of the sensitivity, specificity and positive and negative predictive power of the measures at the optimum cutoff scores produced by the ROC analysis are presented.

Quality of care from the perspective of elderly people: the QUOTE-elderly instrument

BACKGROUND

patient views on the quality of care are usually assessed by means of patient satisfaction questionnaires.

AIM

to develop an instrument that would: (i) produce data related to the expectations and experiences of noninstitutionalized elderly people, (ii) contain items that had been formulated in collaboration with elderly people, (iii) measure quality from the perspective of the users of health care services and (iv) produce data on generic quality aspects and quality aspects specifically related to the needs of elderly people.

METHODS

we developed the instrument for measuring quality of care from the perspective of non-institutionalized elderly people (QUOTE-Elderly) by using a combination of qualitative and quantitative methods. We obtained empirical data on the opinions and experiences of 338 elderly people. We evaluated the taxonomy of the instrument, internal consistency of (sub)scales and the feasibility of the instrument using explorative and confirmative factor analyses and reliability analysis.

RESULTS

using scale optimization, we produced a self-administered questionnaire on quality of health care from the perspective of elderly people. This contains scientific characteristics and provides specific information for practical quality-assurance policies.

Acute toxicity and cost analysis of a phase III randomized trial of accelerated and conventional radiotherapy for squamous carcinoma of the head and neck: a Trans-Tasman Radiation Oncology Group study

The primary purpose of the present analysis was to assess the feasibility and acute toxicity of a pure accelerated fractionation regimen in a cooperative group setting. This analysis included the first 320 patients entered on to the Trans-Tasman Radiation Oncology Group (TROG) randomized controlled trial which compared accelerated radiotherapy (ART) with conventional radiotherapy (CRT) in stage III and IV squamous cell carcinoma (SCC) of the head and neck. Patients were randomized to either 59.4 Gy in 33 fractions over 24 days (ART) or to 70 Gy 35 fractions over 49 days (CRT) after being stratified for site and stage. Accrual began in 1991 and the trial was closed on 3 April 1998 with the targeted 350 patients. The 3-year survival for the whole group was 54%, and the 3-year disease-free survival was 41%. Toxicity data were available on 303 patients (148 ART; 155 CRT). Mucosal toxicity was worse in the accelerated arm, and it peaked approximately 3 weeks earlier than the conventional arm. Skin toxicity was equivalent but occurred approximately 7 days earlier in the accelerated arm. Acute effects in both arms healed completely. Hospitalization was more common in the ART arm (71 vs 52 patients; P = 0.01) but the total bed days in hospital was not greatly different (1707 bed days for ART and 1607 bed days for CRT). Patients were more likely to require nasogastric (NG) feeding in the ART arm (49 vs 33 patients; P = 0.02). There were 1157 NG feeding days for ART and 1154 NG feeding days for CRT. The average cost of radiation treatment per patient including hospitalization, NG feeding and accommodation was $11,750 in the ART arm and $11,587 in the CRT arm. The accelerated arm has been shown to be a tolerable, practical and cost-equivalent regimen. The assessment of the therapeutic ratio of this accelerated protocol (ART) will be determined when the analysis of late effects and loco-regional control is made when the data are more mature.

Trends in HIV-related consultation in Dutch general practice

New medicine against AIDS and a possible changing attitude towards AIDS will affect the role of the general practitioner (GP). We aim to explore and assess the changing role of the GP in preventing and detecting AIDS, which will be done by providing insight into the changing numbers and content of HIV-related consultations in the general practice. Since 1988 a representative sample of 63 Dutch GPs have participated in a network. They recorded all face-to-face consultations with non HIV-infected patients in which the subject of AIDS was brought up. Timetrend analysis is used to investigate variations over time in the number and content of the consultations, GPs' actions and patients' characteristics. The influence of a rural or urban setting and the characteristics of the patients who are involved are also taken into account. Until 1994 a significant increase was found in the number of consultations. In highly urban areas the number of consultations is higher and still growing, whereas physicians in rural areas see fewer patients every year. The most important topic of conversation was the request for an HIV test (74%). This figure grew over the years, as did the number of tests performed. GPs became less passive and restrictive in advising tests. The group of patients has also changed, e.g. patients do not mostly belong to traditional risk groups anymore, and are significantly younger. AIDS seems to have become more familiar to patients and doctors. A lot of general information is available from different sources. Because of this change in attitude and knowledge of patients, the GPs' role as it relates to AIDS is becoming more specific in tracing infected patients and giving customized information to individuals. Patients visit their physicians less often because of concerns about AIDS, but the GP continues to fulfil a very important role in the prevention and detection of AIDS.