Treatment practices and response in kaposiform hemangioendothelioma: A multicenter cohort study

BACKGROUND AND OBJECTIVES

Kaposiform hemangioendothelioma (KHE) and tufted angioma (TA) are rare vascular tumors in children historically associated with significant morbidity and mortality. This study was conducted to determine first-line therapy in the absence of available prospective clinical trials.

METHODS

Patients from 17 institutions diagnosed with KHE/TA between 2005 and 2020 with more than 6 months of follow-up were included. Response rates to sirolimus and vincristine were compared at 3 and 6 months. Durability of response and response to other treatment modalities were also evaluated.

RESULTS

Of 159 unique KHE/TA subjects, Kasabach-Merritt phenomenon (KMP) was present in 64 (40.3%), and only two patients were deceased (1.3%). Over 60% (n = 96) demonstrated treatment response at 3 months, and more than 70% (n = 114) by 6 months (no significant difference across groups). The vincristine group had higher radiologic response at 3 months compared to sirolimus (72.7% vs. 20%, p = .03), but there were no differences between these groups at 6 months. There were no differences in rates of recurrent or progressive disease between vincristine and sirolimus.

CONCLUSIONS

In this large, multicenter cohort of 159 patients with KHE/TA, rates of KMP were consistent with historical literature, but the mortality rate (1.3%) was much lower. Overall treatment response rates were high (>70%), and there was no significant difference in treatment response or durability of disease comparing sirolimus to vincristine. Our results support individualized treatment decision plans depending on clinical scenario and patient/physician preferences. Response criteria and response rates reported here will be useful for guiding future treatment protocols for vascular tumors.

CARTR Plus: the creation of an ART registry in Canada

STUDY QUESTION

What is the status of fertility treatment and birth outcomes documented over the first 6 years of the Canadian Assisted Reproductive Technologies Register (CARTR) Plus registry?

SUMMARY ANSWER

The CARTR Plus registry is a robust database containing comprehensive Canadian fertility treatment data to assist with providing evidence-based rationale for clinical practice change.

WHAT IS KNOWN ALREADY

The rate of infertility is increasing globally and having data on fertility treatment cycles and outcomes at a population level is important for accurately documenting and effecting changes in clinical practice.

STUDY DESIGN, SIZE, DURATION

This is a descriptive manuscript of 183 739 fertility treatment cycles from 36 Canadian clinics over 6 years from the CARTR Plus registry.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Canadian ART treatment cycles from 2013 through 2018 were included. This manuscript described trends in type of fertility treatment cycles, pregnancy rates, multiple pregnancy rates, primary transfer rates and birth outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

Over the 6 years of the CARTR Plus registry, the number of treatment cycles performed ranged from less than 200 to greater than 1000 per clinic. Patient age and the underlying cause of infertility were two of the most variable characteristics across clinics. Similar clinical pregnancy rates were found among IVF and frozen embryo transfer (FET) cycles with own oocytes (38.9 and 39.7% per embryo transfer cycle, respectively). Fertility treatment cycles that used donor oocytes had a higher clinical pregnancy rate among IVF cycles compared with FET cycles (54.9 and 39.8% per embryo transfer cycle, respectively). The multiple pregnancy rate was 7.4% per ongoing clinical pregnancy in 2018, which reflected a decreasing trend across the study period. Between 2013 and 2017, there were 31 811 pregnancies that had live births from all ART treatment cycles, which corresponded to a live birth rate of 21.4% per cycle start and 89.1% of these pregnancies were singleton live births. The low multiple pregnancy rate and high singleton birth rate are associated with the increase in single embryo transfers.

LIMITATIONS, REASONS FOR CAUTION

There is potential for misclassification of data, which is present in all administrative health databases.

WIDER IMPLICATIONS OF THE FINDINGS

The CARTR Plus registry is a robust resource for ART data in Canada. It provides easily accessible aggregated data for Canadian fertility clinics, and it contains data that are internationally comparable.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding provided for this study. The authors have no competing interests to declare.

The price of performance: a cost and performance analysis of the implementation of cell-free fetal DNA testing for Down syndrome in Ontario, Canada

OBJECTIVE

To examine the cost and performance implications of introducing cell-free fetal DNA (cffDNA) testing within modeled scenarios in a publicly funded Canadian provincial Down syndrome (DS) prenatal screening program.

METHOD

Two clinical algorithms were created: the first to represent the current screening program and the second to represent one that incorporates cffDNA testing. From these algorithms, eight distinct scenarios were modeled to examine: (1) the current program (no cffDNA), (2) the current program with first trimester screening (FTS) as the nuchal translucency-based primary screen (no cffDNA), (3) a program substituting current screening with primary cffDNA, (4) contingent cffDNA with current FTS performance, (5) contingent cffDNA at a fixed price to result in overall cost neutrality,(6) contingent cffDNA with an improved detection rate (DR) of FTS, (7) contingent cffDNA with higher uptake of FTS, and (8) contingent cffDNA with optimized FTS (higher uptake and improved DR).

RESULTS

This modeling study demonstrates that introducing contingent cffDNA testing improves performance by increasing the number of cases of DS detected prenatally, and reducing the number of amniocenteses performed and concomitant iatrogenic pregnancy loss of pregnancies not affected by DS. Costs are modestly increased, although the cost per case of DS detected is decreased with contingent cffDNA testing.

CONCLUSION

Contingent models of cffDNA testing can improve overall screening performance while maintaining the provision of an 11- to 13-week scan. Costs are modestly increased, but cost per prenatally detected case of DS is decreased.

The role of chiropractic in primary care: findings of four community studies

OBJECTIVE

To assess, through qualitative studies of 4 medically underserved communities, the receptivity of chiropractors, other health care providers, and consumers to the idea of chiropractors' assuming a focal role in primary care.

METHOD

Visits by a team of 2 researchers to 4 medically underserved communities: (1) rural towns in eastern Oregon; (2) rural towns in Iowa; (3) underserved areas of Miami, Fla; and (4) underserved areas of Chicago, Ill. Each site visit included interviews with chiropractors, other health care providers, and managers of health facilities as well as with focus groups of consumers.

RESULTS

If chiropractors were to pursue a primary care role based on an allopathic model of primary care, there would not be widespread consumer receptivity. Those consumers who are most likely to use chiropractors as primary care providers are those who prefer health care models that have a close affinity with lay conceptualizations of illness and health care.

CONCLUSIONS

The community studies suggested that chiropractors and consumers might prefer that chiropractors not be primary care providers in a conventional way and that the allopathic community might be indifferent or even hostile to the idea of chiropractors and other non-MDs as major primary care providers. Current practice models of chiropractors do not include a strong allopathic model of primary care, although they are consistent with consumer preferences and satisfying to chiropractors.

The saliva of the medicinal leech Hirudo medicinalis--II. Inhibition of platelet aggregation and of leukocyte activity and examination of reputed anaesthetic effects

1. Leech saliva inhibits platelet aggregation induced by collagen, ADP and epinephrine. 2. Leech saliva inhibits superoxide production by neutrophils stimulated by tetradecanoyl phorbol acetate or polyhistidine. The effect is due in part at least to eglin. 3. Reputed anaesthetic effects of leech saliva were not detected.

The saliva of the medicinal leech Hirudo medicinalis--I. Biochemical characterization of the high molecular weight fraction

1. A method is described for obtaining dilute Hirudo medicinalis saliva by feeding leeches through a membrane on arginine/saline and squeezing them immediately after from the posterior end forwards. The process can be repeated at intervals. Yields are considerably higher than from salivary gland extracts. 2. Hirudo saliva contains hirudin, eglin, hyaluronidase, collagenase and apyrase. Leech collagenase and apyrase are here reported for the first time. 3. On gel filtration of lyophilized saliva, activity peaks were well defined. Approximate molecular weights were determined. Apyrase appears in two forms with optimum activity around pH 7.5. Collagenase was identified as belonging to the mammalian type.

Utilization of psychiatric consultation for elderly patients

Six hundred fifty-one psychiatric consultations performed during a one-year period were reviewed retrospectively. Cognitive impairment was present in 54 per cent and depression in 27 per cent of the elderly patients in the population studied. A second study of the point prevalence of cognitive and emotional disorders in the hospital was carried out using the Mini-Mental State Exam and the General Health Questionnaire. Emotional disorders had similar prevalences in all age groups but cognitive disorders were more common in the elderly. Twenty-one per cent of consultations were done on patients over the age of 60, although elderly patients occupied 28.5 per cent of hospital beds. Thus, elderly patients were less often referred for psychiatric consultation than younger patients, although the incidence of psychiatric disorders increases with age.

Application of differential reinforcement to control disruptive behaviours of mentally retarded students during remedial instruction

This research was concerned with training special education practitioners to utilise DRO procedures (differential reinforcement of other behaviour) to control disruptive behaviours of mentally retarded students during remedial instruction. The procedures consisted of delivering an edible treat to the students if they failed to exhibit specified problem behaviours during selected time frames. In Study I, out-of-seat behaviour of a six-year-old mildly retarded girl was eliminated in two classroom settings following application of DRO. In addition, treatment effects generalised to a second problem behaviour, disruptive vocalising. In Study II, vocal disruption of a sixteen-year-old severely retarded boy was reduced to near-zero levels during speech therapy sessions. Both studies employed single case experimental designs to determine functional control of the reinforcement contingencies and utilised adjusting schedules to gradually increase the interval for reinforcement. The advantages of DRO programmes in special education settings are discussed.