The unique molecular signatures of nodular and superficial spreading melanoma

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Background: Primary nodular melanoma (NM) patients have a relatively poor prognosis compared to superficial spreading melanoma (SSM) patients. The disparity is generally attributed solely to NM's advanced thickness at presentation. In this study we attempted to define molecular signatures of NM and SSM that may explain their clinical differences. Methods: We performed an in silico gene expression analysis of 2 public data sets consisting of 36NM and 54 SSM primary melanoma tissues (CCR 2007;13 and JNCI 2006;98). We then utilized DNA microarray to generate gene expression profiles of a panel of 22 melanoma cell lines (2SSM, 4 NM, 12 met, 4 melanocytes). Differentially expressed genes and over-represented pathways in NM and SSM were identified based on a pooled analysis of the 3 data sets. We then used SNP array to define genomic alterations unique to NM and SSM but not altered in normal melanocytes. Finally, we correlated SNP array with gene expression. Results: Genes significantly overexpressed (p<0.05) in NM showed over-representation of pathways related to MAPK signaling (p=0.05) and cytoskeleton organization (p=0.02), while SSM showed over-representation of cell communication (p=0.05) and primary metabolic processes (p=0.002). Notable correlations between gene expression and copy number alteration in NM include increased copy number/overexpression of SOX5 (transcription factor related to embryonic development and cell fate) and the downregulation/deletion of ST14 (suppression of tumorigenicity 14). SSM demonstrated concordance of increased copy number/overexpression of EZR (cell adhesion protein implicated in human cancer) as well as PALLD (a protein related to motility, adhesion, and extracellular matrix interactions). Notable SSM genes showing correlation between downregulation/deletion include BNIP3 (a pro-apoptotic protein) and MTAP (often co- deleted with tumor suppressor p16). Conclusions: Simultaneous integration of gene expression with SNP array revealed molecular signatures characteristic of NM and SSM. These results suggest that NM and SSM are distinct biologic entities and that molecularly targeted adjuvant therapy may be more effective if tailored to the molecular signatures of melanoma subtypes. Validation is necessary to draw further conclusions.

No significant financial relationships to disclose.

Establishing the feasibility of direct observation in the assessment of tics in children with chronic tic disorders

Behavior analysis has been at the forefront in establishing effective treatments for children and adults with chronic tic disorders. As is customary in behavior analysis, the efficacy of these treatments has been established using direct-observation assessment methods. Although behavior-analytic treatments have enjoyed acceptance and integration into mainstream health care practices for tic disorders (e.g., psychiatry and neurology), the use of direct observation as a primary assessment tool has been neglected in favor of less objective methods. Hesitation to use direct observation appears to stem largely from concerns about the generalizability of clinic observations to other settings (e.g., home) and a lack of consensus regarding the most appropriate and feasible techniques for conducting and scoring direct observation. The purpose of the current study was to evaluate and establish a reliable, valid, and feasible direct-observation protocol capable of being transported to research and clinical settings. A total of 43 children with tic disorders, collected from two outpatient specialty clinics, were assessed using direct (videotape samples) and indirect (Yale Global Tic Severity Scale; YGTSS) methods. Videotaped observation samples were collected across 3 consecutive weeks and two different settings (clinic and home), were scored using both exact frequency counts and partial-interval coding, and were compared to data from a common indirect measure of tic severity (the YGTSS). In addition, various lengths of videotaped segments were scored to determine the optimal observation length. Results show that (a) clinic-based observations correspond well to home-based observations, (b) brief direct-observation segments scored with time-sampling methods reliably quantified tics, and (c) indirect methods did not consistently correspond with the direct methods.

Reactivity of Tic Observation Procedures to Situation and Setting

Tic frequency was assessed and compared across home and clinic as well as three experimentally-manipulated situations in order to assess the phenomenon of tic reactivity. Forty-three youngsters with chronic tic disorder recruited from two geographically-distinct sites were videotaped over three weekly laboratory visits under each of the following conditions: (1) alone/camera present, (2) other present/camera present, and (3) alone/camera hidden. Contrary to expectation, more tics were observed during overt as compared to covert observation, while the presence of another person had no overall impact on tic expression. Mean tic counts obtained from clinic observation did not significantly differ from those obtained at home collected either one day before or after. Tic frequency counts were remarkably stable over the three weekly assessments both at home and clinic. Study findings are consistent with past observations that tic expression can be influenced by environmental factors and suggest the stability of tic frequency may exhibit greater temporal and setting stability than previously thought. The clinical and research implications of these results are discussed.

Disseminating information using an anesthesiology consultant report: impact on patient perceptions of quality of care

STUDY OBJECTIVE

To determine if providing an Anesthesiology Consultant Report (ACR) to patients would result in enhanced patients' perceptions of their knowledge about their care and improve their perception of the quality of their care.

DESIGN

Randomized, unblinded study.

SETTING

Outpatient center associated with tertiary care center.

PATIENTS

371 outpatients without adverse anesthetic events.

INTERVENTIONS

Patients were randomized to receive either routine discharge instructions or routine instructions and an anesthesia discharge summary (ACR).

MEASUREMENTS AND MAIN RESULTS

Short questionnaire with discharge packet regarding knowledge of anesthetic and questions regarding satisfaction and perceptions of quality of care was distributed. The patients in the group that received an ACR were more satisfied with the management of their pain and other symptoms (p < 0.05, by Wilcoxon rank sums) and were more satisfied overall with the quality of the anesthesia care (p < 0.01, by Wilcoxon rank sums). Taken another way, significantly more patients deemed the quality of their anesthetic care as excellent in the ACR group compared to control (83% vs. 67%, p < 0.01).

CONCLUSIONS

Providing patients, with uneventful anesthetic courses, with information regarding their anesthetic care, in the form of the ACR, results in improved perceptions of the quality of care.

Recommendations for training in performance and interpretation of stress echocardiography. Committee on Physician Training and Education of the American Society of Echocardiography

Stress echocardiography has emerged as a clinically useful procedure in the management of patients with ischemic heart disease and other conditions. However, the accuracy of this test relies on the ability of those who carry out the technical aspects of the test and depends critically on proper interpretation of the images. Appreciation of wall motion abnormalities is generally acknowledged as one of the most difficult skills to master in echocardiography. There is consensus that this is also one of the most difficult skills to teach. Appreciating stress-induced changes in wall motion, which sometimes are subtle, requires a significant commitment to initial training in this skill and its maintenance. This document provides recommendations for physician training in stress echocardiography.

Newborn hearing screening

Congenital deafness is a relatively common problem with an incidence of 1/300 to 1/1000. Most states have no mass screening program for hearing loss, but the state of Kentucky compiles a High Risk Registry which is a historical survey of parents relating to risk factors for hearing loss. Unfortunately this survey can miss 50% of those who have a hearing deficit. If not detected prior to discharge, there is often a delay in diagnosis of deafness which prevents early intervention. We report 2 years' experience at Kosair Children's Hospital where 1,987 infants admitted to well baby, intermediate, or intensive care nurseries were screened using the ALGO-1 screener (Natus Medical Inc, Foster City, CA) which is a modified auditory brain stem evoked response (ABR). Our screening of this population led to an 11% incidence of referral for complete audiological evaluation. There were no significant complications. Forty-eight infants were found to have nonspecified, sensorineural, or conductive hearing loss. The positive predictive value of the test was 96%. Therefore, we feel that the use of the modified ABR in the newborn is a timely, cost efficient method of screening for hearing loss and should be used for mass screening of all newborns.

Use of EEG spectral edge as index of equipotency in a comparison of propofol and isoflurane for maintenance of general anaesthesia

Propofol and isoflurane were compared for haemodynamic stability and recovery time as main anaesthetic agents for maintenance in a total of 43 ASA I and II patients in uncomplicated operations lasting at least 30 min. The premedication (oral diazepam), induction (thiopentone-fentanyl-suxamethonium) and maintenance protocol (N2O-O2 2:1 litre min-1, fentanyl and vecuronium in incremental doses) were identical for all patients. In one group of 20 patients, propofol was used in continuous intravenous (i.v.) infusion (starting dose 3 mg kg-1 h-1), while in the second group of 23 patients, isoflurane was administered in a starting concentration of 1%. To improve the equipotency of the two agents in all cases the dose of the main anaesthetic was titrated to keep the EEG 90% spectral edge frequency (SEF-recorded by processed EEG monitor) between 8 and 12 Hz. Mean blood pressure (BP) and heart rate (HR) deviations of +/- 20% from the baseline were recorded. The incidence of mean blood pressure deviations/case in the propofol group was less than half of those occurring in the isoflurane group (0.45 vs. 0.96 P = 0.04). The mean duration of blood pressure deviation from baseline value was 5.5 min in the propofol group vs. 16.8 min in the isoflurane group (P = 0.01). The recovery intervals were significantly shorter in the propofol group (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

The adjuvant effect of lucanthone (miracil D) in clinical radiation therapy

Clinical trials were undertaken to determine whether lucanthone (miracil D) affects radiation-induced regression in measurable pulmonary metastases and advanced squamous-cell oral and pharyngeal tumors. The time required for 50% tumor regression was decreased by approximately 50% in those patients who received lucanthone in addition to irradiation. These results indicate that lucanthone has a definite adjuvant effect when used together with irradiation.