Factors affecting treatment strategy, completion of planned treatment and survival in older patients with glioblastoma

Introduction

For older patients with glioblastoma (GBM), age, extent of resection, and performance status are prognostic factors. However, an international survey conducted by our Unit found that >40% of neurosurgeons use age alone to discount surgery in older (65+) patients. The aim of this study was to review management in our Unit for 65+ GBM patients, to inform future approaches.

Methods

Patients 65+ with a new GBM diagnosis in our Unit, between 2014 and 2017, were identified. Demographic data, performance status (PS), comorbidity and frailty indices, together with details of surgical/oncological management and outcome were collected.

Results

78 patients were identified. 78% aged 65–74 underwent maximal safe resection, compared with 45% aged 75–84, and 10% aged 85+. Resection was undertaken in 68% PS1, 73% PS2 and 23% PS3 patients. No PS3 patient completed intended radiotherapy, compared with 79% PS1 and 74% PS2 patients. There was a significant difference in frailty scores of patients who completed scheduled oncological therapy compared with those who did not (median score 2 vs 4.5, p=0.0338).

Median survival was 10 months for patients 65–74, 4 months for aged 75 -84, and 40 days for 85+ (p<0.0167). Median survival was significantly lower for PS3 patients (44 days) compared with PS1 or 2 (9.5 months and 7 months respectively; p<0.0167).

Conclusion

There is considerable variability in performance status and frailty of 65+ GBM patients. PS3 patients at diagnosis are very unlikely to complete oncological treatment. These factors, rather than age alone, should be used to guide management decisions.

Implementing Obstetrics Quality Improvement, Driven by Medico-legal Risk, is Associated With Improved Workplace Culture

OBJECTIVE

This study implemented a quality improvement program based on knowledge of medico-legal risk in obstetrics and sought to evaluate the impact of this program on workplace culture.

METHODS

The study conducted needs assessments with front-line providers working in the obstetrical unit of the Queensway Carleton Hospital, an urban community hospital in Ottawa, Ontario, and included the safety, communication, operational reliability, and engagement (SCORE) survey. The study investigators delivered training in quality improvement science and co-developed three projects that were based on their alignment with local needs and aggregate medico-legal risk data: an organized team response to the need for an immediate cesarean section, a protocol for managing patients who present at term with pre-labour rupture of membranes, and regular morning team briefings. Outcome measures were determined for each project from a quality improvement indicator framework, and coaching was provided to project leads. Participants completed the SCORE survey and a program effectiveness tool after the intervention.

RESULTS

The majority of participants (75.2% of 153 pre-intervention and 63.1% of 157 post-intervention participants) completed the SCORE surveys. Post-intervention improvements were found in teamwork, learning environment, and safety climate, whereas levels of provider burnout remained high. Program effectiveness was highly rated, and most projects showed qualitative improvements.

CONCLUSION

This study showed positive workplace culture change associated with the quality improvement intervention. Lessons learned from the implementation of this program can inform future quality improvement initiatives.

Malignant spinal cord compression: NICE guidance, improvements and challenges

BACKGROUND AND AIM

Malignant spinal cord compression (mSCC) is one of the most serious complications of cancer. Recent NICE guidance has aimed to improve patient pathways and outcomes for patients with mSCC. We have examined the current presentations, management and outcomes for patients with mSCC in West London following the implementation of the NICE guidance.

MATERIALS AND METHODS

The electronic records and clinical notes were reviewed for all patients assessed for confirmed or potential mSCC at Charing Cross Hospital in 2012. Details on the number of referrals, the proportion with confirmed mSCC, the cancer diagnosis, treatment and outcome were analysed.

RESULTS

191 patients were reviewed with 127 (66%) cases of confirmed mSCC. The commonest tumour types were prostate cancer (26 cases), lung cancer (26), breast cancer (21) and kidney cancer (15). 21% of the patients had no previous cancer diagnosis; mSCC was their presenting diagnostic event. Radiotherapy was the predominant management, 24% of the patients had first line surgical treatment. At presentation 62% of patients were either chair or bed bound. Treatment brought important mobility benefits to all patients groups with 20% of the initially chair or bed bound patients leaving the hospital with independent mobility.

CONCLUSION

Enhanced patients pathways with ease of access, rapid assessment and prompt treatment can improve outcomes. Despite these pathways many patients still present with gross motor impairment and over 20% have no previous diagnosis of cancer. Ongoing work to maintain awareness for patients and primary care of the diagnosis and emergency pathways is essential to optimize outcomes.

Targeted prostate cancer screening in men with mutations in BRCA1 and BRCA2 detects aggressive prostate cancer: preliminary analysis of the results of the IMPACT study

OBJECTIVE

To evaluate the role of targeted prostate cancer screening in men with BRCA1 or BRCA2 mutations, an international study, IMPACT (Identification of Men with a genetic predisposition to ProstAte Cancer: Targeted screening in BRCA1/2 mutation carriers and controls), was established. This is the first multicentre screening study targeted at men with a known genetic predisposition to prostate cancer. A preliminary analysis of the data is reported.

PATIENTS AND METHODS

Men aged 40-69 years from families with BRCA1 or BRCA2 mutations were offered annual prostate specific antigen (PSA) testing, and those with PSA > 3 ng/mL, were offered a prostate biopsy. Controls were men age-matched (± 5 years) who were negative for the familial mutation.

RESULTS

In total, 300 men were recruited (205 mutation carriers; 89 BRCA1, 116 BRCA2 and 95 controls) over 33 months. At the baseline screen (year 1), 7.0% (21/300) underwent a prostate biopsy. Prostate cancer was diagnosed in ten individuals, a prevalence of 3.3%. The positive predictive value of PSA screening in this cohort was 47·6% (10/21). One prostate cancer was diagnosed at year 2. Of the 11 prostate cancers diagnosed, nine were in mutation carriers, two in controls, and eight were clinically significant.

CONCLUSIONS

The present study shows that the positive predictive value of PSA screening in BRCA mutation carriers is high and that screening detects clinically significant prostate cancer. These results support the rationale for continued screening in such men.

Prostate cancer in BRCA2 germline mutation carriers is associated with poorer prognosis

Background:

The germline BRCA2 mutation is associated with increased prostate cancer (PrCa) risk. We have assessed survival in young PrCa cases with a germline mutation in BRCA2 and investigated loss of heterozygosity at BRCA2 in their tumours.

Methods:

Two cohorts were compared: one was a group with young-onset PrCa, tested for germline BRCA2 mutations (6 of 263 cases had a germline BRAC2 mutation), and the second was a validation set consisting of a clinical set from Manchester of known BRCA2 mutuation carriers (15 cases) with PrCa. Survival data were compared with a control series of patients in a single clinic as determined by Kaplan–Meier estimates. Loss of heterozygosity was tested for in the DNA of tumour tissue of the young-onset group by typing four microsatellite markers that flanked the BRCA2 gene, followed by sequencing.

Results:

Median survival of all PrCa cases with a germline BRCA2 mutation was shorter at 4.8 years than was survival in controls at 8.5 years (P=0.002). Loss of heterozygosity was found in the majority of tumours of BRCA2 mutation carriers. Multivariate analysis confirmed that the poorer survival of PrCa in BRCA2 mutation carriers is associated with the germline BRCA2 mutation per se.

Conclusion:

BRCA2 germline mutation is an independent prognostic factor for survival in PrCa. Such patients should not be managed with active surveillance as they have more aggressive disease.

Urinary tract infection after stroke

BACKGROUND

Urinary tract infection (UTI) is a recognized complication of stroke. We aimed to determine the incidence of UTI after acute stroke, the risk factors associated with this complication, and its association with outcome.

METHODS

Prospective study of consecutive acute stroke patients admitted to an urban teaching hospital. Routine clinical assessment included the modified National Institutes of Health Stroke Scale (mNIHSS) and modified Rankin scale (mRS). Patients were followed up for 3 months, including recording of clinician diagnosis of UTI.

RESULTS

We studied 412 patients; 65 (15.8%) were diagnosed with UTI, at a median of 14 days (IQR = 4-39) post-stroke. In a binomial multivariate regression analysis, UTI was associated with urinary catheterization (OR = 3.03, 95% CI 1.41-6.52), higher mRS (OR = 1.85, 1.29-2.64) and increasing age (OR = 1.51, 1.13-2.00 for each decade). UTI was associated with death or disability at 3 months, however, this link was attenuated and became non-significant when measures of stroke severity and pre-stroke morbidity were included in a multivariate analysis.

CONCLUSION

UTI is common after acute stroke. It is associated with urinary catheterization, post-stroke disability and increasing age. Avoidance of catheterization might reduce the incidence of this common complication.

Construction of tissue microarrays from prostate needle biopsy specimens

Needle biopsies are taken as standard diagnostic specimens for many cancers, but no technique exists for the high-throughput analysis of multiple individual immunohistochemical (IHC) markers using these samples. Here we present a simple and highly reliable technique for constructing tissue microarrays (TMAs) from prostatic needle biopsies. Serial sectioning of the TMAs, called 'Checkerboard TMAs', facilitated expression analysis of multiple proteins using IHC markers. In total, 100% of the analysed biopsies within the TMA both preserved their antigenicity and maintained their morphology. Checkerboard TMAs will allow the use of needle biopsies (i) alongside other tissue specimens (trans-urethral resection of prostates and prostatectomies in the case of prostate cancer) in clinical correlation studies when searching for new prognostic markers, and (ii) in a diagnostic context for assessing expression of multiple proteins in cancers from patients prior to treatment.

Processing of radical prostatectomy specimens for correlation of data from histopathological, molecular biological, and radiological studies: a new whole organ technique

AIMS

To develop a method of processing non-formalin fixed prostate specimens removed at radical prostatectomy to obtain fresh tissue for research and for correlating diagnostic and molecular results with preoperative imaging.

METHODS/RESULTS

The method involves a prostate slicing apparatus comprising a tissue slicer with a series of juxtaposed planar stainless steel blades linked to a support, and a cradle adapted to grip the tissue sample and receive the blades. The fresh prostate gland is held in the cradle and the blades are moved through the cradle slits to produce multiple 4 mm slices of the gland in a plane perpendicular to its posterior surface. One of the resulting slices is preserved in RNAlater. The areas comprising tumour and normal glands within this preserved slice can be identified by matching it to the haematoxylin and eosin stained sections of the adjacent slices that are formalin fixed and paraffin wax embedded. Intact RNA can be extracted from the identified tumour and normal glands within the RNAlater preserved slice. Preoperative imaging studies are acquired with the angulation of axial images chosen to be similar to the slicing axis, such that stained sections from the formalin fixed, paraffin wax embedded slices match their counterparts on imaging.

CONCLUSIONS

A novel method of sampling fresh prostate removed at radical prostatectomy that allows tissue samples to be used both for diagnosis and molecular analysis is described. This method also allows the integration of preoperative imaging data with histopathological and molecular data obtained from the prostate tissue slices.

ATM polymorphisms as risk factors for prostate cancer development

The risk of prostate cancer is known to be elevated in carriers of germline mutations in BRCA2, and possibly also in carriers of BRCA1 and CHEK2 mutations. These genes are components of the ATM-dependent DNA damage signalling pathways. To evaluate the hypothesis that variants in ATM itself might be associated with prostate cancer risk, we genotyped five ATM variants in DNA from 637 prostate cancer patients and 445 controls with no family history of cancer. No significant differences in the frequency of the variant alleles at 5557G>A (D1853N), 5558A>T (D1853V), ivs38-8t>c and ivs38-15g>c were found between the cases and controls. The 3161G (P1054R) variant allele was, however, significantly associated with an increased risk of developing prostate cancer (any G vs CC OR 2.13, 95% CI 1.17–3.87, P=0.016). A lymphoblastoid cell line carrying both the 3161G and the 2572C (858L) variant in the homozygote state shows a cell cycle progression profile after exposure to ionising radiation that is significantly different to that seen in cell lines carrying a wild-type ATM gene. These results provide evidence that the presence of common variants in the ATM gene, may confer an altered cellular phenotype, and that the ATM 3161C>G variant might be associated with prostate cancer risk.

Gravity Separation: Old Technique/New Methods

A comparative review of various types of the main gravity separation devices, both in the recent past and present is presented. The application of each device is discussed in turn, with details of the variables involved and the respective advantages and disadvantages of the separators, together with explanatory diagrams illustrating the processes.

Expression of the peptide antibiotics human beta defensin-1 and human beta defensin-2 in normal human skin

Normal human skin is remarkably resistant to infection from the large numbers of microorganisms that routinely colonize its surface. In addition to the role of skin as a mechanical barrier, it has long been recognized that skin and other epithelia can produce a range of anti-microbial chemicals that play an important part in eliminating potential cutaneous pathogens. Anti-microbial peptides are an important evolutionarily conserved innate host defense mechanism in many organisms. Human beta defensin-1 and -2 are cysteine-rich, cationic, low molecular weight anti-microbial peptides that have recently been shown to be expressed in epithelial tissues. In this study, we describe the characterization of human beta defensin-1 and -2 mRNA and peptide expression in normal human skin. Using reverse transcription-polymerase chain reaction we demonstrate that human beta defensin-1 is consistently expressed in skin samples from various body sites. Human beta defensin-2 demonstrates expression that is more variable and is more readily detectable in facial skin and foreskin compared with skin from abdomen and breast. In situ hybridization localizes the human beta defensin-1 and -2 transcripts to keratinocytes within interfollicular skin. Using specific antibodies, we have shown that human beta defensin-1 and -2 peptides are localized to the Malpighian layer of the epidermis and/or stratum corneum and that there are interindividual and site-specific differences in intensity of immunostaining and the pattern of peptide localization. The localization of human beta defensins to the outer layer of the skin is consistent with the hypothesis that human beta defensins play an essential part in cutaneous innate immunity.

Prevalence and determinants of hepatitis A virus exposure among prison entrants in Queensland, Australia: implications for public health control

In September 1997, a multicentre outbreak of hepatitis A virus (HAV) infection occurred in the Queensland prison system following a prolonged community-based HAV epidemic among illicit drug users. As part of the public health response, a cross-sectional survey was undertaken to estimate the sero-prevalence of, and identify the determinants for, recent and past HAV infection among the incoming male prisoner population. Exposure data were collected through face-to-face interviews with 214 consenting inmates, whose sera were screened for immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies to HAV. Overall, 81 (37.9%) inmates were HAV-IgG seropositive, and four inmates were HAV-IgM seropositive, HAV-IgG seropositivity was strongly associated with year of birth (age) (Ptrend < 0.0001), being born outside Australia (relative risk (RR) 1.9, 95% CI 1.4-2.7) and being of a non-English speaking background (RR 2.5, 95% CI 1.7-3.7). Lifestyle exposures (such as occupation, overseas travel and illict drug use) were not associated with an increased risk of HAV-IgG seropositivity. In contrast, all four HAV-IgM seropositive inmates were English-speaking, Australian-born males who used illicit drugs. These findings suggest that the risk factors for recent and past HAV infections among prisoners differ, with implications for HAV control in correctional settings. Strategies for HAV prevention, including routine screening of inmates and vaccination of susceptibles, are considered in the context of current models of disease transmission.

Poor agreement between reported and recorded nocturnal cough in asthma

Reported presence or absence of night cough was compared with tape recorded cough in 15 children with perennial asthma (median age, 9 years; range, 7-14) who reported troublesome nocturnal symptoms. Measurements were made and diaries kept for 7 consecutive nights. Cough was reported on 66 of 105 (66%) and recorded on 93 (90%) available nights with poor overall agreement (Cohen's coefficient of assessment, kappa +0.30, range -0.17 to +1). The poor agreement between subjective and objective assessment of an important symptom of nocturnal asthma raises questions on the validity of symptom reporting and may in part explain the not infrequent disagreement between medical and patient assessment of disease severity.

Outpatient diagnostic hysteroscopy

Outpatient diagnostic hysteroscopy with endometrial sampling was performed in 160 women. The aim was to assess patient acceptance of the procedure when performed under para-cervical block. The most common indication was abnormal uterine bleeding. In 152 patients the procedure was successful, allowing thorough inspection of the uterine cavity, and in almost half of them no abnormality was detected. Thirty-one required subsequent elective admission, mainly for fibroid polypectomy. In most women the level of discomfort was assessed as 'tolerable', but in two the procedure was abandoned because of severe discomfort. Endometrial carcinoma was detected in six patients. There were no complications attributable to the procedure. Outpatient hysteroscopy considerably reduces the need for hospital admission and can provide early investigation for patients with a spectrum of gynaecological disorders, at low cost and with minimal facilities.

Successful pregnancy following bone marrow transplantation for leukaemia

We report three pregnancies with successful outcomes in two women following allogeneic bone marrow transplantation (BMT) for acute leukaemia using high dose melphalan alone as conditioning therapy. The increasing application and success of BMT together with the instigation of conditioning regimens that do not include total body irradiation should increase such cases. These and previous cases document that a normal outcome of pregnancy is likely in these patients.

Number and size of motoneurons in a forelimb motor nucleus of normal and dystrophic (C57BL/6J dy2j/dy2j) mice

The method of retrograde axonal transport of horseradish peroxidase (HRP) was used to identify the motoneurons that innervate the distal forelimb muscles via the ulnar nerve in normal and dystrophic (C56BL/6J dy2j/dy2j) mice. In both normal and dystrophic mice this motor nucleus was located in spinal segments C6 through T1. No clear division, on the basis of size, into alpha and gamma motoneuron populations was apparent. The motoneurons of dystrophic mice were fewer in number (26.5 vs. 35) but larger in cross-sectional area (780 vs. 674 microns2) than those of age-matched control mice. These results are quantitatively similar to those reported for the hind limb soleus muscle of dystrophic mice and suggest that the motoneuronal changes are a reflection of the dystrophic process rather than the associated spontaneous action potential generation seen in the dystrophic hind limb muscles.