Image-Guided Superficial Radiation Therapy Has Superior 2-Year Recurrence Rates to Mohs Micrographic Surgery

PURPOSE/OBJECTIVE(S)

Non-melanoma skin cancers (NMSCs) are the most common malignancy in the USA, and incidence is rising. Mohs micrographic surgery (MMS) is a tissue-sparing surgical technique often used in NMSCs. Superficial radiation therapy (SRT) was widely used prior to the advent of MMS, but MMS has superior recurrence rates and replaced SRT as a first-line therapy. Image-guided SRT (IGSRT) was invented in 2015 and utilizes ultrasound to improve SRT precision and produces minimal side effects (99% grade 1 or 2).[1] The hypothesis is that NMSCs treated with IGSRT will have improved 2-year recurrence rates of compared to those treated with Mohs micrographic surgery.

MATERIALS/METHODS

This retrospective cohort study compared the 2-year recurrence probability of early stage NMSCs (squamous and basal cell carcinomas (SCCs and BCCs)) treated by IGSRT (2,286 lesions) to data on NMSCs treated by MMS (5,391 lesions) via one sample proportion tests. IGSRT-treated NMSC data is from a database published by Yu et al.[1] The 2-year recurrence probability statistical analysis is from McClure et al.[2] Medical Subject Headings were used to search PubMed for reports of 2-year recurrence rates of NMSCs treated by MMS. Seventeen studies were screened; 14 studies were excluded for lack of 2-year time to event analysis, or irrelevant patient population (non-BCC/SCC study, advanced disease), leaving 3 studies for comparison.

RESULTS

IGSRT-treated NMSCs have a statistically significantly improved 2-year recurrence rates compared to MMS-treated (p<0.001 for pooled data). When separated by histology, 2-year recurrence rates of all reported SCCs and BCCs treated by MMS were also inferior to those treated by IGSRT, p<0.001, p = 0.0218, respectively.

CONCLUSION

In this analysis, IGSRT has superior 2-year recurrence rates. Limitations include insufficient follow-up to report on the 5-year recurrence probability and inability to adjust for confounding factors beyond histology. This data implies that IGSRT is a well-tolerated, paradigm-shifting treatment option for patients with early stage NMSCs who cannot tolerate or refuse surgery. IGSRT provides patients the choice of treatment modality that best aligns with their goals of care.

Simple, sensitive, specific self-sampling assay secures SARS-CoV-2 antibody signals in sero-prevalence and post-vaccine studies

At-home sampling is key to large scale seroprevalence studies. Dried blood spot (DBS) self-sampling removes the need for medical personnel for specimen collection but facilitates specimen referral to an appropriately accredited laboratory for accurate sample analysis. To establish a highly sensitive and specific antibody assay that would facilitate self-sampling for prevalence and vaccine-response studies. Paired sera and DBS eluates collected from 439 sero-positive, 382 sero-negative individuals and DBS from 34 vaccine recipients were assayed by capture ELISAs for IgG and IgM antibody to SARS-CoV-2. IgG and IgM combined on DBS eluates achieved a diagnostic sensitivity of 97.9% (95%CI 96.6 to 99.3) and a specificity of 99.2% (95% CI 98.4 to 100) compared to serum, displaying limits of detection equivalent to 23 and 10 WHO IU/ml, respectively. A strong correlation (r = 0.81) was observed between serum and DBS reactivities. Reactivity remained stable with samples deliberately rendered inadequate, (p = 0.234) and when samples were accidentally damaged or 'invalid'. All vaccine recipients were sero-positive. This assay provides a secure method for self-sampling by DBS with a sensitivity comparable to serum. The feasibility of DBS testing in sero-prevalence studies and in monitoring post-vaccine responses was confirmed, offering a robust and reliable tool for serological monitoring at a population level.

Sera selected from national STI surveillance system shows Chlamydia trachomatis PgP3 antibody correlates with time since infection and number of previous infections

BACKGROUND

Seroprevalence surveys of Chlamydia trachomatis (CT) antibodies are promising for estimating age-specific CT cumulative incidence, however accurate estimates require improved understanding of antibody response to CT infection.

METHODS

We used GUMCAD, England's national sexually transmitted infection (STI) surveillance system, to select sera taken from female STI clinic attendees on the day of or after a chlamydia diagnosis. Serum specimens were collected from laboratories and tested anonymously on an indirect and a double-antigen ELISA, both of which are based on the CT-specific Pgp3 antigen. We used cross-sectional and longitudinal descriptive analyses to explore the relationship between seropositivity and a) cumulative number of chlamydia diagnoses and b) time since most recent chlamydia diagnosis.

RESULTS

919 samples were obtained from visits when chlamydia was diagnosed and 812 during subsequent follow-up visits. Pgp3 seropositivity using the indirect ELISA increased from 57.1% (95% confidence interval: 53.2-60.7) on the day of a first-recorded chlamydia diagnosis to 89.6% (95%CI: 79.3-95.0) on the day of a third or higher documented diagnosis. With the double-antigen ELISA, the increase was from 61.1% (95%CI: 53.2-60.7) to 97.0% (95%CI: 88.5-99.3). Seropositivity decreased with time since CT diagnosis on only the indirect assay, to 49.3% (95%CI: 40.9-57.7) two or more years after a first diagnosis and 51.9% (95%CI: 33.2-70.0) after a repeat diagnosis.

CONCLUSION

Seropositivity increased with cumulative number of infections, and decreased over time after diagnosis on the indirect ELISA, but not on the double-antigen ELISA. This is the first study to demonstrate the combined impact of number of chlamydia diagnoses, time since diagnosis, and specific ELISA on Pgp3 seropositivity. Our findings are being used to inform models estimating age-specific chlamydia incidence over time using serial population-representative serum sample collections, to enable accurate public health monitoring of chlamydia.

Birth asphyxia survivors in a developing country

OBJECTIVE

Determine the baseline incidence of birth asphyxia in neonatal intensive care unit (NICU) survivors in a developing country and the early neurodevelopmental outcomes of such infants.

STUDY DESIGN

This cross-sectional, prospective study collected diagnostic and examination findings on all infants seen in the University of Zambia NICU follow-up clinic over a 4-week period.

RESULT

Of the 182 infants, 42 (23%) had a clinical diagnosis of birth asphyxia. Of 42 infants with birth asphyxia, 13 (31%) had an abnormal neurologic examination during the clinic visit; in contrast, 13 of 141 infants without birth asphyxia (9%) had an abnormal examination (odds ratio 4.4, 95% confidence interval: 1.8, 10.4).

CONCLUSION

Birth asphyxia survivors account for almost a quarter of NICU survivors in a developing country and half of those with an abnormal neurologic examination. Studies are necessary to determine the percent of birth asphyxia survivors who have permanent motor and cognitive disabilities.

Characteristics of adolescent girls with depressive symptoms in a so-called "normal' sample

OBJECTIVE

Forty-four percent of adolescent girls who had been screened for absence of psychiatric disorder reported depressive symptoms on a structured interview. Girls reporting symptoms were assigned to a depression group and compared to those who were free of depressive symptoms on behavioral and neuropsychological measures to determine if there were meaningful differences in cognition, behavior and motivation/self-perception between groups.

METHOD

Adolescent girls were randomly selected from local schools to participate in a study of neuropsychological development in adolescence. Those who volunteered and whose parents reported them to be free of psychiatric disorders were enrolled and completed a battery of behavioral, neuropsychological and motivation/self-perception measures.

RESULTS

The depressed group showed more behavioral problems, evaluated themselves as less competent, showed more extrinsic motivational orientation, had lower IQ and differed on a measure of visual spatial perception.

CONCLUSION

The frequency of subclinical depression is high in adolescent girls, even when parents report no psychiatric/emotional problems. The increase in problem behaviors and extrinsic motivation, as well as the decrease in feelings of self-worth suggest that this group may benefit from intervention. Poorer performance on a measure of visual spatial perception needs further investigation to confirm its association with depression and understand its relationship to depressive symptoms.

Influence of depression on cognitive functioning in Fragile X females

We sought to determine the frequency of a history of major depression in women with Fragile X syndrome. In addition, we attempted to disentangle the cognitive effects of major depression from those of Fragile X syndrome. Thirty-seven mothers of developmentally delayed children (Fragile X syndrome: n = 18; comparison group n = 19), matched for age, educational level, and socioeconomic status, were administered psychiatric and neuropsychological measures. Women with Fragile X syndrome had a higher frequency of lifetime diagnosis of major depressive disorder (78%) than the comparison group (37%). Mild impairment was seen on visuospatial construction and memory tasks in women with Fragile X syndrome, while women with depression showed subtle deficits in several aspects of visuospatial perception and learning. There was no interaction of Fragile X syndrome and depression in their influence on cognition. The results underscore the importance of considering the influence of depression on cognitive performance in studies of genetic disorders.

Surveillance for dust storms and respiratory diseases in Washington State, 1991

Southeast Washington State, which has a long history of seasonal dust storms, experienced 2 d of dust storms in October 1991, during which PM10 levels exceeded 1,000 micrograms/m3 (i.e., six times greater than the Environmental Protection Agency's 24-h PM10 standard). Three community hospitals in southeast Washington were visited for the purpose of assessing the possible effects of dust storms on respiratory health. During these visits, the number of emergency room visits for respiratory disorders for each day of 1991 were abstracted. These numbers were compared with daily PM10 levels for 1991. Also determined were the observed/expected ratios for the number of emergency room visits for each respiratory disorder category during October 1991. The maximum observed/expected ratio for the respiratory disorders was 1.2. For 1991, we found a 3.5% increase in the number of daily emergency room visits for bronchitis for each 100 micrograms/m3 increase in PM10. In addition, 2 d subsequent to those days on which the PM10 levels exceeded 150 micrograms/m3, there was a 4.5% increase in the number of emergency room visits for sinusitis for each 100 micrograms/m3 increase in PM10. Our results indicate that the naturally occurring PM10 in this setting has a small effect on the respiratory health of the population in general.

Serum albumin: a marker for morbidity in peritoneal dialysis patients

This study was designed to determine if the serum albumin is a marker for morbidity or mortality in peritoneal dialysis (PD) patients. The impact of a low serum albumin on the risk of hospitalization, peritonitis, or death was examined in 71 patients. Blood urea nitrogen (BUN), cholesterol, age, and the presence or absence of diabetes were also examined. In independent analyses, the serum albumin was lower (32.7 +/- 5.6 v 36.3 +/- 4.3 g/L, P < 0.01), the diagnosis of diabetes was more frequent (41% v 7%, P < 0.01), and the number of episodes of peritonitis were greater (2.0 +/- 1.6 v 0.7 +/- 1.3, P < 0.01) in the group of patients hospitalized compared with those not hospitalized. When diabetics were excluded from analysis, the serum albumin remained significantly lower in hospitalized patients. Stepwise logistic regression analysis, excluding the 10 patients hospitalized only for treatment of peritonitis, confirmed that only a low serum albumin and the diagnosis of diabetes were independent predictors of increased morbidity as evident by the increased frequency of hospitalization. Every 10 g/L decrease in the serum albumin increased the odds ratio for hospitalization by 5.2. The diagnosis of diabetes resulted in a 10-fold increase in the odds ratio. We conclude that a low serum albumin serves as a marker of morbidity in PD patients, primarily as a marker of increased risk for hospitalization. The diagnosis of diabetes also greatly increases the likelihood of hospitalization. Peritonitis is a cause for hospitalization, but not an independent risk factor.

A hand-held OKP chart for the screening of glaucoma: preliminary evaluation

Oculo-kinetic perimetry (OKP) uses controlled movements of the patient's eye to position a static test stimulus in the visual field. The test chart consists of a white tangent screen with 23 numbered fixation points located eccentrically at strategic points in relation to a central black spot, which is the test stimulus. As the patient looks at each number in turn, the spot stimulates the retinal areas that are most likely to show early glaucomatous damage. The result is positive if one or more numbers make the spot disappear. Ninety-eight eyes of 54 patients attending a hospital glaucoma clinic were tested with a prototype OKP glaucoma screener and by conventional perimetry. Visual fields plotted conventionally were independently categorised as normal, equivocal and glaucomatous by the perimetrist and the ophthalmologist and these results were further categorised as normal, equivocal or glaucomatous according to whether they were considered abnormal by none, one or both of the observers respectively. The OKP test was positive in (i) 93% of 27 eyes with glaucomatous defects, (ii) 69% of 32 eyes with equivocal loss, (iii) 41% of 39 eyes without previously recognised field loss but having ocular hypertension, a suspicious disc, or contralateral glaucoma, (iv) 9% of 116 eyes from 60 age matched persons accompanying the patients to hospital. If the results were considered in terms of patients not eyes, the OKP test was positive in 85% individuals with glaucomatous field loss in their worse eye and in 12% of the controls. A hand-held OKP chart testing a small set of points and using a constantly exposed stimulus could be a useful tool for the detection of glaucoma in the community.

The detection of glaucomatous visual field defects by oculo-kinetic perimetry: which points are best for screening?

Oculo-kinetic perimetry (OKP) uses the patient's ocular movements to position a test stimulus in the visual field. By virtue of its simplicity and low cost, this test could be useful in the screening of glaucoma. The general purpose OKP chart, however, which tests 100 points in the central 25 degrees field, is too time-consuming for this purpose, taking approximately 4-7 minutes per eye. Accordingly, this study was performed to identify the points most likely to detect patients with glaucoma. Fifty-one eyes with glaucomatous visual field defects and 51 non-glaucomatous eyes of age matched individuals were tested by conventional and oculo-kinetic perimetry. At least one of only six points were missed by 82.4% of glaucomatous eyes and by 9.8% of nonglaucomatous eyes. These results, although falling short of the ideal efficiency, are comparable with data published by other research groups using computerised equipment and suggest that, with further development, a specialised OKP chart testing only a small number of points might be valuable in screening for glaucoma.

Comparative evaluation of oculokinetic perimetry and conventional perimetry in glaucoma

Oculokinetic perimetry is a new method of visual field assessment in which the patient moves the eye around a central static target to look sequentially at an array of numbers. When fixation on a number is accompanied by disappearance of the central target, that number is deleted from a recording chart. Inversion of the recording chart gives a plot of the central visual field. In this study we have shown that in 64 eyes of 37 patients, with unequivocal field loss attending a glaucoma clinic, the test is efficient and reliable when compared with conventional static (Dicon 3000) and kinetic (Tübingen Oculus) field tests. The results were identical in 88% of eyes tested and approximately comparable in another 6%. Quantitative equivalent targets for the different methods are described. Oculokinetic perimetry was carried out by a previously untrained person, and it is suggested that this new method merits further study as a screening device for glaucoma in the community.

Colour vision of diabetics

The Farnsworth-Munsell 100-hue test has been assessed as a screening test for the detection of diabetic retinopathy likely to benefit from laser photocoagulation therapy. Two hundred and thirty-two diabetic eyes of 126 patients were tested. The results were assessed both for total error score relative to age and for the presence of polarity. Although the incidence of abnormal colour discrimination was found to correlate with the severity of retinopathy, the test was not sufficiently selective to be of value as a screening test in the detection of retinopathy requiring treatment.