The mRNA expression of SETD2 in human breast cancer: correlation with clinico-pathological parameters

Background

SET domain containing protein 2 (SETD2) is a histone methyltransferase that is involved in transcriptional elongation.

There is evidence that SETD2 interacts with p53 and selectively regulates its downstream genes. Therefore, it could be implicated in the process of carcinogenesis. Furthermore, this gene is located on the short arm of chromosome 3p and we previously demonstrated that the 3p21.31 region of chromosome 3 was associated with permanent growth arrest of breast cancer cells. This region includes closely related genes namely: MYL3, CCDC12, KIF9, KLHL18 and SETD2. Based on the biological function of these genes, SETD2 is the most likely gene to play a tumour suppressor role and explain our previous findings.

Our objective was to determine, using quantitative PCR, whether the mRNA expression levels of SETD2 were consistent with a tumour suppressive function in breast cancer. This is the first study in the literature to examine the direct relationship between SETD2 and breast cancer.

Methods

A total of 153 samples were analysed.

The levels of transcription of SETD2 were determined using quantitative PCR and normalized against (CK19).

Transcript levels within breast cancer specimens were compared to normal background tissues and analyzed against conventional pathological parameters and clinical outcome over a 10 year follow-up period.

Results

The levels of SETD2 mRNA were significantly lower in malignant samples (p = 0.0345) and decreased with increasing tumour stage.

SETD2 expression levels were significantly lower in samples from patients who developed metastasis, local recurrence, or died of breast cancer when compared to those who were disease free for > 10 years (p = 0.041).

Conclusion

This study demonstrates a compelling trend for SETD2 transcription levels to be lower in cancerous tissues and in patients who developed progressive disease. These findings are consistent with a possible tumour suppressor function of this gene in breast cancer.

Late treatment mortality and secondary cancers after autologous stem cell transplant for relapsed or refractory Hodgkin lymphoma (HL)

8016

Background: Late treatment-related mortality and second cancers have an important influence on the long-term outcome of patients (pts) with HL. The incidence of treatment failure and causes of death were evaluated in pts with advanced HL receiving high-dose therapy and ASCT, to understand the impact of late events on overall survival (OS). Methods: From Dec 1986 to Nov 2005, 323 pts with relapsed/refractory HL after primary chemotherapy (plus radiation [RT]: 32%) received salvage chemotherapy to best response, followed by etoposide 60 mg/kg day -4 and melphalan 160–180 mg/m2 day -3 supported by autologous bone marrow (46%), mobilized peripheral blood stem cells (49%) or both (5%)on day 0; 24% received involved field RT post-ASCT. Risk of treatment failure and second cancer was estimated using competing risks methods. Results: Patient Characteristics: male: 61%; median age 33 years (range16–67). Number of salvage regimens pre-ASCT: 1: 72%; 2: 25%. Disease status post-salvage chemotherapy: CR 28%, PR 66%. After a median follow-up of 4.7 years post-ASCT (range 1–17), 174 pts (54%) have experienced treatment failure (relapse or treatment related death) and 154 pts (48%) have died, 75% following relapse and 20% from toxicity without relapse. Of the 30 deaths without relapse, 30% occured >5 years post-ASCT. Failure free survival at 3 and 10 years is 50% (95% CI, 44–55%) and 40% (33–46), and overall survival is 68% (63–73) and 39% (33- 46), respectively. There have been 29 second cancers (17 AML/MDS, 12 solid tumors) in pts alive without relapsed HL. The probability of a second cancer is 4.9% (2.8–7.8) at 3 years and 12% (8–17%) at 10 years. The hazard rates for second malignancy, leukemia and solid tumors for each 10-year age increment are 1.9 (p=0.0001), 1.9 (0.001) and 1.8 (0.03), respectively. Only 4 pts have relapsed beyond 5 years post- ASCT but the cumulative incidence of treatment-related death (from toxicity or second cancers) continues to increase from 9% (6–13) at 3 years to 15% (11–20) 10 yrs post-ASCT. Conclusions: In this single-institution series of uniformly treated patients with relapsed/refractory HL, late relapse of disease is uncommon, but late toxicities have a significant and ongoing impact on failure-free survival.

No significant financial relationships to disclose.

Incorporating patients' assessments into objective structured clinical examinations

INTRODUCTION

There is a need to improve the validity of performance assessments and to develop better ways of identifying and assessing what students actually do in practice. Incorporating patients' assessments into OSCEs has the potential to offer both an expert assessment of aspects of the doctor-patient interaction and improve validity. Therefore, we held a trial using simulated patient (SP) assessments in history-taking, explaining and communication skills stations in third year OSCEs.

METHODS

SPs made two separate ratings of each student they saw in the OSCE. Examiners graded students using checklists and an overall 'borderline' grade. SP and examiners' marks were subject to statistical analysis.

RESULTS

The reliability of the SP ratings was .77. The reliability of the SP borderline grades was .68. The reliability of the ratings and grades combined was .86. SPs reached consensus on the characteristics of high and low performing students.

CONCLUSIONS

SP assessments are reliable. Statistical analysis demonstrated that SPs and clinicians are assessing different aspects of students' performance. We concluded that, due to our approach to working with SPs, their assessments increased validity.

Oral naltrexone as a treatment for relapse prevention in formerly opioid-dependent drug users: a systematic review and economic evaluation

OBJECTIVES

To investigate the clinical effectiveness and cost-effectiveness of naltrexone for relapse prevention in detoxified formerly opioid-dependent individuals compared with any strategy that does not use naltrexone, including treatment with placebo, other pharmacological treatments, psychosocial interventions or no treatment.

DATA SOURCES

Major electronic databases were searched from inception to September 2005.

REVIEW METHODS

Selected studies were screened and quality assessed. Meta-analyses were carried out as appropriate. A decision-analytic model using Monte Carlo simulation was developed that compared naltrexone as an adjunctive therapy to no naltrexone. It assumed compliance rates that were not enhanced by contingent management rewards (because this is current UK practice). Utility values could not be identified from the literature and so were obtained by research specially commissioned from the Value of Health Panel.

RESULTS

The methodological quality of the 26 randomised controlled trials (RCTs) that met the inclusion criteria was poor to moderate. The results suggest that naltrexone as maintenance therapy may be better than placebo in terms of retention in treatment, but this was not statistically significant. A meta-analysis of seven included RCTs gave the relative risk (RR) of loss of retention in treatment in the naltrexone arm as 0.94. The pooled hazard ratio (HR) reported in five of the RCTs for retention in treatment data followed up to 35 weeks was calculated as 0.90 in favour of naltrexone and also did not reach statistical significance. The risk of drug abuse in naltrexone versus placebo, with or without psychological support given in both arms, gave a pooled RR of 0.72, which was a statistically significant difference in favour of naltrexone. The pooled HR from three RCTs for opioid relapse-free rates was significantly different from placebo in favour of naltrexone 0.53; however, this fell off over time and may be of limited clinical significance. The RR of reimprisonment while on naltrexone therapy showed results in favour of naltrexone in the combined two studies of parolees or people on probation, but the number of participants was small. One study of 52 participants found that the difference in improvement score for risky sexual behaviour in the naltrexone group compared with the placebo group was not statistically significant. The adverse events data reported showed no significant difference between the naltrexone and placebo arms. The quality of the nine RCTs of interventions designed to increase retention with naltrexone was poor to moderate; however, all three different modalities of enhanced care showed some evidence of effectiveness. All of the contingency management programmes used incentive vouchers; the mean duration of treatment retention was 7.4 weeks for the contingency management intervention compared with 2.3-5.6 weeks for the naltrexone treatment alone. The mean length of time for which patients stayed on naltrexone was 84-103 days with additional psychosocial therapy compared with 43-64 days for the control group. In trials with added pharmacological agents the RRs of stopping treatment were 1.63 at 6 months and 1.31 at 12 months (in favour of naltrexone plus fluoxetine). It became statistically significant at 6 months, but not at 12 months. A meta-analysis of the RR of stopping treatment at week 12 (the minimum follow-up period) was carried out using six of the nine studies. The pooled RR of stopping treatment was 0.81. The results indicated that overall the intervention groups had 19% fewer patients who stopped treatment compared with the control group, but there was only a small number of studies and their quality was relatively poor. No existing economic evaluations were identified. The point estimate for the cost-effectiveness of naltrexone was pound42,500 per quality-adjusted life-year (QALY). Sensitivity analysis was carried out and the incremental cost-effectiveness ratio varied between pound34,600 and pound42,500 per QALY gained.

CONCLUSIONS

Following successful withdrawal from opioids, naltrexone may be administered on a chronic basis to block any future effects of opioids. Naltrexone appears to have some limited benefit in helping formerly opioid-dependent individuals to remain abstinent, although the quality of the evidence is relatively poor and heterogeneous. The limited quality and extent of the studies precluded an analysis of subgroups likely to benefit from naltrexone prescribing. Oral naltrexone is used infrequently in current UK practice, and this review suggests that this is appropriate as there is little evidence to support its wider implementation. There is an important deficit in information about the quality of life of people who use illicit opioids and this would perhaps be a worthwhile area of research in informing policy questions about the cost-effectiveness of different programmes and interventions.

Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of buprenorphine maintenance therapy (BMT) and methadone maintenance therapy (MMT) for the management of opioid-dependent individuals.

DATA SOURCES

Major electronic databases were searched from inception to August 2005. Industry submissions to the National Institute for Health and Clinical Excellence were accessed.

REVIEW METHODS

The assessment of clinical effectiveness was based on a review of existing reviews plus an updated search for randomised controlled trials (RCTs). A decision tree with Monte Carlo simulation model was developed to assess the cost-effectiveness of BMT and MMT. Retention in treatment and opiate abuse parameters were sourced from the meta-analysis of RCTs directly comparing flexible MMT with flexible dose BMT. Utilities were derived from a panel representing a societal perspective.

RESULTS

Most of the included systematic reviews and RCTs were of moderate to good quality, and focused on short-term (up to 1-year follow-up) outcomes of retention in treatment and the level of opiate use (self-report or urinalysis). Most studies employed a trial design that compared a fixed-dose strategy (i.e. all individuals received a standard dose) of MMT or BMT and were conducted in predominantly young men who fulfilled criteria as opiate-dependent or heroin-dependent users, without significant co-morbidities. RCT meta-analyses have shown that a fixed dose of MMT or BMT has superior levels of retention in treatment and opiate use than placebo or no treatment, with higher fixed doses being more effective than lower fixed doses. There was evidence, primarily from non-randomised observational studies, that fixed-dose MMT reduces mortality, HIV risk behaviour and levels of crime compared with no therapy and one small RCT has shown the level of mortality with fixed-dose BMT to be significantly less than with placebo. Flexible dosing (i.e. individualised doses) of MMT and BMT is more reflective of real-world practice. Retention in treatment was superior for flexible MMT than flexible BMT dosing but there was no significant difference in opiate use. Indirect comparison of data from population cross-sectional studies suggests that mortality with BMT may be lower than that with MMT. A pooled RCT analysis showed no significant difference in serious adverse events with MMT compared with BMT. Although treatment modifier evidence was limited, adjunct psychosocial and contingency interventions (e.g. financial incentives for opiate-free urine samples) appeared to enhance the effects of both MMT and BMT. Also, MMT and BMT appear to be similarly effective whether delivered in a primary care or outpatient clinic setting. Although most of the included economic evaluations were considered to be of high quality, none used all of the appropriate parameters, effectiveness data, perspective and comparators required to make their results generalisable to the NHS context. One company (Schering-Plough) submitted cost-effectiveness evidence based on an economic model that had a 1-year time horizon and sourced data from a single RCT of flexible-dose MMT compared with flexible-dose BMT and utility values obtained from the literature; the results showed that for MMT vs no drug therapy, the incremental cost-effectiveness ratio (ICER) was pound 12,584/quality-adjusted life-year (QALY), for BMT versus no drug therapy, the ICER was pound 30,048/QALY and in a direct comparison, MMT was found to be slightly more effective and less costly than BMT. The assessment group model found for MMT versus no drug therapy that the ICER was pound 13,697/QALY, for BMT versus no drug therapy that the ICER was pound 26,429/QALY and, as with the industry model, in direct comparison, MMT was slightly more effective and less costly than BMT. When considering social costs, both MMT and BMT gave more health gain and were less costly than no drug treatment. These findings were robust to deterministic and probabilistic sensitivity analyses.

CONCLUSIONS

Both flexible-dose MMT and BMT are more clinically effective and more cost-effective than no drug therapy in dependent opiate users. In direct comparison, a flexible dosing strategy with MMT was found be somewhat more effective in maintaining individuals in treatment than flexible-dose BMT and therefore associated with a slightly higher health gain and lower costs. However, this needs to be balanced by the more recent experience of clinicians in the use of buprenorphine, the possible risk of higher mortality of MMT and individual opiate-dependent users' preferences. Future research should be directed towards the safety and effectiveness of MMT and BMT; potential safety concerns regarding methadone and buprenorphine, specifically mortality and key drug interactions; efficacy of substitution medications (in particular patient subgroups, such as within the criminal justice system, or within young people); and uncertainties in cost-effectiveness identified by current economic models.

Hotspots: are some areas of sewer network prone to re-infestation by rats ( Rattus norvegicus ) year after year?

The records of sewer baiting work for three London boroughs were examined to see whether there were locations that exhibited 'rat' (Rattus norvegicus) activity more often than would be expected by chance, a feature we dubbed 'hotspots'. More than 100000 baiting records were checked covering 15 years of the London Borough of Enfield (Enfield) and 5 years each of the London Borough of Barnet (Barnet), and the Royal Borough of Kensington and Chelsea (RBKC). The additional boroughs were included for comparison to see whether any effect observed was confined to Enfield or was a feature that could be found in both inner and outer city locations. Each borough was divided into kilometre squares corresponding with those found both on Ordnance Survey maps and also Thames Water Utilities Asset maps. The number of records per square were logged and then the number of positive records for all the manholes in that square on a year-on-year basis. We examined 350 km2 in Enfield, 377 km2 in Barnet and 66 km2 in RBKC. The data were subjected to a weighted analysis (i.e. allowing for the number of manholes per square and the varying total rat population from year to year). Some areas were shown to exhibit significantly higher amounts of activity than others suggesting that their distribution is not random and that there must be environmental and other factors, which make certain locations attractive to rats. Squares with very high activity, repeating year-on-year, 'hotspots', were found in all three boroughs, suggesting that the phenomena are widespread.

Prediction of hemorrhage in acute ischemic stroke using permeability MR imaging

Increased risk of hemorrhagic transformation (HT) limits the general use of thrombolytic therapy in acute ischemic stroke (AIS). This study shows that early blood-brain barrier defects in AIS can be assessed by using permeability MR imaging. Significantly increased permeability was found in 3 patients who later hemorrhaged. This method indicates the potential for identifying patients at higher risk of HT and offers the use of physiologic imaging rather than time from onset of symptoms to guide treatment decisions.

Freeman-Sheldon syndrome: dental and orthodontic implications

The manifestations of the Freeman-Sheldon syndrome (FSS) in four members of a South African family of Xhosa stock have been documented. Orofacial manifestations are a major syndromic component and warrant early, specialized orthodontic intervention. Our protocol for dental management is outlined and suggestions for holistic oro-dental care are provided.

Determining patient preferences for improved chemotoxicity during treatment for advanced bladder cancer

Determining patient preferences for improved chemotoxicity during treatment for advanced bladder cancer Conventional treatment for advanced bladder cancer is methotrexate, vinblastine, doxorubicin plus cisplatin (MVAC), with a median survival of 1 year but significant toxicity. The newer combination of gemcitabine plus cisplatin (GC) has demonstrated comparable survival and an improved toxicity profile (Von der Maase et al. 2000). At present, the importance to patients of the toxicity of chemotherapy has not been widely studied. An earlier study in bladder cancer indicated that toxicity was an important determinant of treatment preference (Davey et al. 2000). A study of preferences for advanced bladder cancer therapy in the UK was proposed.

Draft risk assessment of the public health impact of Escherichia coli O157:H7 in ground beef

An assessment of the risk of illness associated with Escherichia coli O157:H7 in ground beef was drafted in 2001. The exposure assessment considers farm, slaughter, and preparation factors that influence the likelihood of humans consuming ground beef servings containing E. coli O157:H7 and the number of cells in a contaminated serving. Apparent seasonal differences in prevalence of cattle infected with E. coli O157:H7 corresponded to seasonal differences in human exposure. The model predicts that on average 0.018% of servings consumed during June through September and 0.007% of servings consumed during the remainder of the year are contaminated with one or more E. coli O157:H7 cells. This exposure risk is combined with the probability of illness given exposure (i.e., dose response) to estimate a U.S. population risk of illness of nearly one illness in each 1 million (9.6 x 10(-7)) servings of ground beef consumed. Uncertainty about this risk ranges from about 0.33 illness in every 1 million ground beef servings at the 5th percentile to about two illnesses in every 1 million ground beef servings at the 95th percentile.

Pearl aquaculture-profitable environmental remediation?

Bivalve molluscs are filter feeders, with pearl oysters able to filter water at rates up to 25 lh(-1)g(-1) of dry wt. tissue. Since this process leads to rapid bioaccumulation of recalcitrant pollutants such as heavy metals, organochlorine pesticides and hydrocarbons from impacted sites, it has prompted the widespread use of molluscs as biomonitors to quantify levels of marine pollution. This paper proposes pearl oyster deployment as a novel bioremediation technology for impacted sites to remove toxic contaminants, reduce nutrient loads and lower concentrations of microbial pathogens. Estimates extrapolated from the literature suggest that a modest pearl oyster farm of 100 t oyster material per year could remove 300 kg heavy metals plus 24 kg of organic contaminants via deposition into the tissue and shell. Furthermore, it was estimated that up to 19 kg of nitrogen may be removed from the coastal ecosystem per tonne of pearl oyster harvested. Pearl oysters are also likely to filter substantial amounts of sewage associated microbial pathogens from the water column. Method of cultivation and site selection are the key to minimising negative environmental impacts of bivalve cultivation. Deployment of oysters at sites with high nutrient and contaminant loadings would be advantageous, as these compounds would be removed from the ecosystem whilst generating a value-added product. Future potential may exist for harvesting bio-concentrated elements for commercial production.