Identification of patients undergoing chronic kidney replacement therapy in primary and secondary care data: validation study based on OpenSAFELY and UK Renal Registry

Objective

To validate primary and secondary care codes in electronic health records to identify people receiving chronic kidney replacement therapy based on gold standard registry data.

Design

Validation study using data from OpenSAFELY and the UK Renal Registry, with the approval of NHS England.

Setting

Primary and secondary care electronic health records from people registered at 45% of general practices in England on 1 January 2020, linked to data from the UK Renal Registry (UKRR) within the OpenSAFELY-TPP platform, part of the NHS England OpenSAFELY covid-19 service.

Participants

38 745 prevalent patients (recorded as receiving kidney replacement therapy on 1 January 2020 in UKRR data, or primary or secondary care data) and 10 730 incident patients (starting kidney replacement therapy during 2020), from a population of 19 million people alive and registered with a general practice in England on 1 January 2020.

Main outcome measures

Sensitivity and positive predictive values of primary and secondary care code lists for identifying prevalent and incident kidney replacement therapy cohorts compared with the gold standard UKRR data on chronic kidney replacement therapy. Agreement across the data sources overall, and by treatment modality (transplantation or dialysis) and personal characteristics.

Results

Primary and secondary care code lists were sensitive for identifying the UKRR prevalent cohort (91.2% (95% confidence interval (CI) 90.8% to 91.6%) and 92.0% (91.6% to 92.4%), respectively), but not the incident cohort (52.3% (50.3% to 54.3%) and 67.9% (66.1% to 69.7%)). Positive predictive values were low (77.7% (77.2% to 78.2%) for primary care data and 64.7% (64.1% to 65.3%) for secondary care data), particularly for chronic dialysis (53.7% (52.9% to 54.5%) for primary care data and 49.1% (48.0% to 50.2%) for secondary care data). Sensitivity decreased with age and index of multiple deprivation in primary care data, but the opposite was true in secondary care data. Agreement was lower in children, with 30% (295/980) featuring in all three datasets. Half (1165/2315) of the incident patients receiving dialysis in UKRR data had a kidney replacement therapy code in the primary care data within three months of the start date of the kidney replacement therapy. No codes existed whose exclusion would substantially improve the positive predictive value without a decrease in sensitivity.

Conclusions

Codes used in primary and secondary care data failed to identify a small proportion of prevalent patients receiving kidney replacement therapy. Codes also identified many patients who were not recipients of chronic kidney replacement therapy in UKRR data, particularly dialysis codes. Linkage with UKRR kidney replacement therapy data facilitated more accurate identification of incident and prevalent kidney replacement therapy cohorts for research into this vulnerable population. Poor coding has implications for any patient care (including eligibility for vaccination, resourcing, and health policy responses in future pandemics) that relies on accurate reporting of kidney replacement therapy in primary and secondary care data.

Ethnic differences in depression and anxiety among adults with atopic eczema: Population-based matched cohort studies within UK primary care

BACKGROUND

Evidence demonstrates that individuals with atopic eczema (eczema) have increased depression and anxiety; however, the role of ethnicity in these associations is poorly understood. We aimed to investigate whether associations between eczema and depression or anxiety differed between adults from white and minority ethnic groups in the UK.

METHODS

We used UK Clinical Practice Research Datalink GOLD to conduct matched cohort studies of adults (≥18 years) with ethnicity recorded in primary care electronic health records (April 2006-January 2020). We matched (age, sex, practice) adults with eczema to up to five adults without. We used stratified Cox regression with an interaction between eczema and ethnicity, to estimate hazard ratios (HRs) for associations between eczema and incident depression and anxiety in individuals from white ethnic groups and a pooled minority ethnic group (adults from Black, South Asian, Mixed and Other groups).

RESULTS

We identified separate cohorts for depression (215,073 with eczema matched to 646,539 without) and anxiety (242,598 with eczema matched to 774,113 without). After adjusting for matching variables and potential confounders (age, sex, practice, deprivation, calendar period), we found strong evidence (p < 0.01) of ethnic differences in associations between eczema and depression (minority ethnic groups: HR = 1.33, 95% CI = 1.22,1.45; white ethnic groups: HR = 1.15, 95% CI = 1.12,1.17) and anxiety (minority ethnic groups: HR = 1.41, 95% CI = 1.28,1.55; white ethnic groups: HR = 1.17, 95% CI = 1.14,1.19).

CONCLUSIONS

Adults with eczema from minority ethnic groups appear to be at increased depression and anxiety risk compared with their white counterparts. Culturally adapted mental health promotion and prevention strategies should be considered in individuals with eczema from minority ethnic groups.

Impact of the COVID-19 pandemic on antipsychotic prescribing in individuals with autism, dementia, learning disability, serious mental illness or living in a care home: a federated analysis of 59 million patients' primary care records in situ using OpenSAFELY

BACKGROUND

The COVID-19 pandemic affected how care was delivered to vulnerable patients, such as those with dementia or learning disability.

OBJECTIVE

To explore whether this affected antipsychotic prescribing in at-risk populations.

METHODS

With the approval of NHS England, we completed a retrospective cohort study, using the OpenSAFELY platform to explore primary care data of 59 million patients. We identified patients in five at-risk groups: autism, dementia, learning disability, serious mental illness and care home residents. We calculated the monthly prevalence of antipsychotic prescribing in these groups, as well as the incidence of new prescriptions in each month.

FINDINGS

The average monthly rate of antipsychotic prescribing increased in dementia from 82.75 patients prescribed an antipsychotic per 1000 patients (95% CI 82.30 to 83.19) in January-March 2019 to 90.1 (95% CI 89.68 to 90.60) in October-December 2021 and from 154.61 (95% CI 153.79 to 155.43) to 166.95 (95% CI 166.23 to 167.67) in care homes. There were notable spikes in the rate of new prescriptions issued to patients with dementia and in care homes. In learning disability and autism groups, the rate of prescribing per 1000 decreased from 122.97 (95% CI 122.29 to 123.66) to 119.29 (95% CI 118.68 to 119.91) and from 54.91 (95% CI 54.52 to 55.29) to 51.04 (95% CI 50.74 to 51.35), respectively.

CONCLUSION AND IMPLICATIONS

We observed a spike in antipsychotic prescribing in the dementia and care home groups, which correlated with lockdowns and was likely due to prescribing of antipsychotics for palliative care. We observed gradual increases in antipsychotic use in dementia and care home patients and decreases in their use in patients with learning disability or autism.

People at a persistent pain service can walk it, but some struggle to talk about it: Reliability, detectable difference and clinically important difference of the six-minute walk test

OBJECTIVES

The six-minute walk test (6MWT) is a commonly used measure of functional capacity. This study is the first to investigate the test-retest reliability, minimal detectable difference (MDD) and the minimal clinically important difference (MCID) for people attending a persistent pain service. Relationships between change in 6MWT performance and change in self-reported physical, functional and psychological outcome measures were also explored.

METHODS

A cross-sectional repeated measures design was used with people having >9 months of pain attending an 8-week outpatient persistent pain programme. For reliability and MDD, 27 people were recruited, for MCID calculations, 32 people were recruited. The MCID was examined by dichotomising people into "improvers", or "non-improvers" based upon the Global Rating of Change (GRC) in physical abilities score.

RESULTS

The mean (SD) 6MWT distance was 389.4 (93.6) m at programme start, and 427.8 (83.0) m at week eight completion. The test-retest reliability was good (intraclass correlation coefficient = 0.89) and the MDD = 86.1 m. As there was no relationship between change in 6MWT distance and GRC physical abilities at week eight (r = 0.132, p = 0.472) the MCID could not be calculated. Furthermore, no relationships were found between change in 6MWT distance and other self-reported measures. Changes in GRC physical abilities and 6MWT were frequently discordant, with increased 6MWT for 7/11 "GRC non-improvers" and decreased 6MWT for 7/21 "GRC improvers".

CONCLUSIONS

Amongst this cohort, change in physical ability may or may not be reflected by self-reported change. Objective tests of physical ability are recommended for people attending pain services, and validated tests should align with intervention aims.

Sharing study materials in health and medical research

Making study materials available allows for a more comprehensive understanding of the scientific literature. Sharing can take many forms and include a wide variety of outputs including code and data. Biomedical research can benefit from increased transparency but faces unique challenges for sharing, for instance, confidentiality concerns around participants' medical data. Both general and specialised repositories exist to aid in sharing most study materials. Sharing may also require skills and resources to ensure that it is done safely and effectively. Educating researchers on how to best share their materials, and properly rewarding these practices, requires action from a variety of stakeholders including journals, funders and research institutions.

Describing the population experiencing COVID-19 vaccine breakthrough following second vaccination in England: a cohort study from OpenSAFELY

BACKGROUND

While the vaccines against COVID-19 are highly effective, COVID-19 vaccine breakthrough is possible despite being fully vaccinated. With SARS-CoV-2 variants still circulating, describing the characteristics of individuals who have experienced COVID-19 vaccine breakthroughs could be hugely important in helping to determine who may be at greatest risk.

METHODS

With the approval of NHS England, we conducted a retrospective cohort study using routine clinical data from the OpenSAFELY-TPP database of fully vaccinated individuals, linked to secondary care and death registry data and described the characteristics of those experiencing COVID-19 vaccine breakthroughs.

RESULTS

As of 1st November 2021, a total of 15,501,550 individuals were identified as being fully vaccinated against COVID-19, with a median follow-up time of 149 days (IQR: ​107-179). From within this population, a total of 579,780 (<4%) individuals reported a positive SARS-CoV-2 test. For every 1000 years of patient follow-up time, the corresponding incidence rate (IR) was 98.06 (95% CI 97.93-98.19). There were 28,580 COVID-19-related hospital admissions, 1980 COVID-19-related critical care admissions and 6435 COVID-19-related deaths; corresponding IRs 4.77 (95% CI 4.74-4.80), 0.33 (95% CI 0.32-0.34) and 1.07 (95% CI 1.06-1.09), respectively. The highest rates of breakthrough COVID-19 were seen in those in care homes and in patients with chronic kidney disease, dialysis, transplant, haematological malignancy or who were immunocompromised.

CONCLUSIONS

While the majority of COVID-19 vaccine breakthrough cases in England were mild, some differences in rates of breakthrough cases have been identified in several clinical groups. While it is important to note that these findings are simply descriptive and cannot be used to answer why certain groups have higher rates of COVID-19 breakthrough than others, the emergence of the Omicron variant of COVID-19 coupled with the number of positive SARS-CoV-2 tests still occurring is concerning and as numbers of fully vaccinated (and boosted) individuals increases and as follow-up time lengthens, so too will the number of COVID-19 breakthrough cases. Additional analyses, to assess vaccine waning and rates of breakthrough COVID-19 between different variants, aimed at identifying individuals at higher risk, are needed.

OpenSAFELY: impact of national guidance on switching anticoagulant therapy during COVID-19 pandemic

BACKGROUND

Early in the COVID-19 pandemic, the National Health Service (NHS) recommended that appropriate patients anticoagulated with warfarin should be switched to direct-acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately coprescribed two anticoagulants following a medication change and associated monitoring.

OBJECTIVE

To describe which people were switched from warfarin to DOACs; identify potentially unsafe coprescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic.

METHODS

With the approval of NHS England, we conducted a cohort study using routine clinical data from 24 million NHS patients in England.

RESULTS

20 000 of 164 000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in coprescribing of warfarin and DOACs from typically 50-100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. International normalised ratio (INR) testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420).

CONCLUSIONS

Increased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people coprescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.

Embracing artificial intelligence- how can we make it inclusive and relevant for real world dermatological practice?

Artificial intelligence (AI) developments are rapidly advancing with algorithms capable of out-performing dermatologists in specific contrived challenges, but where prospective evaluation in real-world settings remain limited. Professional bodies have a role to encourage AI approaches to address clinical unmet needs, improve quality of care, and enhance patient experience without compromising safety. In 2019, the American Academy of Dermatology advocated principles of human-centred design for augmented intelligence innovations (1) emphasising the importance of synergy between dermatologist and the computer. More recently, the British Association of Dermatologists highlighted the weak current evidence-base supporting effectiveness of AI interventions in routine clinical practice and encouraged clinicians to independently evaluate the evidence prior to adoption (2).

Incidence of acute complications of herpes zoster among immunocompetent adults in England: a matched cohort study using routine health data

BACKGROUND

Herpes zoster can cause rare but serious complications; the frequency of these complications has not been well described.

OBJECTIVES

To quantify the risks of acute non-postherpetic neuralgia (PHN) zoster complications, to inform vaccination policy.

METHODS

We conducted a cohort study among unvaccinated immunocompetent adults with incident zoster, and age-, sex- and practice-matched control adults without zoster, using routinely collected health data from the UK Clinical Practice Research Datalink (years 2001 to 2018). Crude attributable risks of complications were estimated as the difference between Kaplan-Meier-estimated 3-month cumulative incidences in patients with zoster vs. controls. We used Cox models to obtain hazard ratios for our primary outcomes in patients with and without zoster. Primary outcomes were ocular, neurological, cutaneous, visceral and zoster-specific complications. We also assessed whether antivirals during acute zoster protected against the complications.

RESULTS

In total 178 964 incident cases of zoster and 1 799 380 controls were included. The absolute risks of zoster-specific complications within 3 months of zoster diagnosis were 0·37% [95% confidence interval (CI) 0·34-0·39] for Ramsay Hunt syndrome, 0·01% (95% CI 0·0-0·01) for disseminated zoster, 0·04% (95% CI 0·03-0·05) for zoster death and 0·97% (95% CI 0·92-1·00) for zoster hospitalization. For other complications, attributable risks were 0·48% (95% CI 0·44-0·51) for neurological complications, 1·33% (95% CI 1·28-1·39) for ocular complications, 0·29% (95% CI 0·26-0·32) for cutaneous complications and 0·78% (95% CI 0·73-0·84) for visceral complications. Attributable risks were higher among patients > 50 years old. Patients with zoster had raised risks of all primary outcomes relative to controls. Antiviral prescription was associated with reduced risk of neurological complications (hazard ratio 0·61, 95% CI 0·53-0·70).

CONCLUSIONS

Non-PHN complications of zoster were relatively common, which may affect cost-effectiveness calculations for zoster vaccination. Clinicians should be aware that zoster can lead to various complications, besides PHN.

Effectiveness of a serious game addressing guideline adherence: cohort study with 1.5-year follow-up

BACKGROUND

Patients presenting with acute shortness of breath and chest pain should be managed according to guideline recommendations. Serious games can be used to train clinical reasoning. However, only few studies have used outcomes beyond student satisfaction, and most of the published evidence is based on short-term follow-up. This study investigated the effectiveness of a digital simulation of an emergency ward regarding appropriate clinical decision-making.

METHODS

In this prospective trial that ran from summer 2017 to winter 2018/19 at Göttingen Medical University Centre, a total of 178 students enrolled in either the fourth or the fifth year of undergraduate medical education took six 90-min sessions of playing a serious game ('training phase') in which they managed virtual patients presenting with various conditions. Learning outcome was assessed by analysing log-files of in-game activity (including choice of diagnostic methods, differential diagnosis and treatment initiation) with regard to history taking and patient management in three virtual patient cases: Non-ST segment elevation myocardial infarction (NSTEMI), pulmonary embolism (PE) and hypertensive crisis. Fourth-year students were followed up for 1.5 years, and their final performance was compared to the performance of students who had never been exposed to the game but had otherwise taken the same five-year undergraduate course.

RESULTS

During the training phase, overall performance scores increased from 57.6 ± 1.1% to 65.5 ± 1.2% (p < 0.001; effect size 0.656). Performance remained stable over 1.5 years, and the final assessment revealed a strong impact of ever-exposure to the game on management scores (72.6 ± 1.2% vs. 63.5 ± 2.1%, p < 0.001; effect size 0.811). Pre-exposed students were more than twice as likely to correctly diagnose NSTEMI and PE and showed significantly greater adherence to guideline recommendations (e.g., troponin measurement and D-dimer testing in suspected PE).

CONCLUSIONS

The considerable difference observed between previously exposed and unexposed students suggests a long-term effect of using the game although retention of specific virtual patient cases rather than general principles might partially account for this effect. Thus, the game may foster the implementation of guideline recommendations.

Partner Bereavement and Detection of Dementia: A UK-Based Cohort Study Using Routine Health Data

BACKGROUND

In the UK, an estimated one third of people with dementia have not received a diagnosis. Good evidence suggests that dementia risk is increased among widowed individuals; however, it is not clear if they are being diagnosed in routine primary care.

OBJECTIVE

This study aimed to investigate if bereavement influenced the probability of having received a dementia diagnosis.

METHODS

A population-based cohort study using UK electronic health records, between 1997 and 2017, among 247,586 opposite-sex partners. Those experiencing partner bereavement were matched (age, sex, and date of bereavement) to a non-bereaved person living in a partnership. Multivariate cox regression was performed.

RESULTS

Partner bereavement was associated with an increased risk of receiving a diagnosis of dementia in the first three months (hazard ratio (HR) 1.43, 95% CI 1.20-1.71) and first six months (HR 1.24, 95% CI 1.09-1.41), while there was a small reduced risk of getting a dementia diagnosis over all follow-up (HR 0.94, 95% CI 0.89-0.98).

CONCLUSIONS

Partner bereavement appears to lead to a short-term increased risk of the surviving partner receiving a diagnosis of dementia, suggesting that bereavement unmasks existing undiagnosed dementia. Over the longer term, however, bereaved individuals are less likely to have a diagnosis of dementia in their health records than non-bereaved individuals.

Comparison of protoporphyrin IX accumulation and destruction during methylaminolevulinate photodynamic therapy of skin tumours located at acral and nonacral sites

BACKGROUND

Topical photodynamic therapy (PDT) is successful in the treatment of nonmelanoma skin cancers and associated precancers, but efficacy is significantly reduced in actinic keratosis lesions not located on the face or scalp.

OBJECTIVES

To compare the changes in protoporphyrin IX (PpIX) fluorescence in lesions undergoing routine methylaminolevulinate (MAL) PDT and the clinical outcome observed 3 months after treatment in lesions located at acral and nonacral sites.

METHODS

This study was a noninterventional, nonrandomized, observational study, which monitored changes in PpIX fluorescence in 200 lesions during standard dermatological MAL-PDT. These data were subsequently analysed in terms of lesions located at acral and nonacral sites.

RESULTS

Clinical clearance was significantly reduced (P < 0·01) in acral skin lesions when compared with lesions located at nonacral sites. The accumulation and destruction of PpIX fluorescence was significantly reduced in these acral lesions (P < 0·05 and P < 0·001, respectively). Specifically, lesion location at acral sites significantly reduced changes in PpIX fluorescence in actinic keratosis lesions during MAL-PDT (P < 0·01 and P < 0·05).

CONCLUSIONS

These data suggest that reduced PpIX accumulation and the subsequent reduction in PpIX photobleaching within acral lesions result in the reduced responsiveness of these lesions to MAL-PDT. Future work should therefore aim to improve photosensitizer accumulation/photobleaching within lesions located at acral sites.

Experience with a wipe guaiac-based faecal occult blood test as an alternative test in a bowel screening programme

The format of the traditional guaiac faecal occult blood test (gFOBT), particularly the collection technique, might cause difficulties for some. A multistage evaluation of alternative tests was performed. Firstly, four tests with different faecal collection approaches were assessed: a focus group recommended further investigation of a wipe gFOBT. Secondly, 100 faecal samples were analysed using two wipe tests and the routine gFOBT: no differences were found. Thirdly, a wipe gFOBT was introduced. Over 21 months, 400 requests were made and 311 wipe kit sets were submitted for analysis: 153 (49.2%) were negative, 21 (6.8%) positive (all 3 kits positive), 96 (30.9%) weak positive (1 or 2 positive) and 41 (13.2%) un-testable. Forty-three participants were referred for colonoscopy. Outcome data were provided on 39 participants: nine declined colonoscopy, two were judged unsuitable, two did not attend, two were already in follow-up, 13 had normal colonoscopy and two normal barium enema, two had diverticular disease, two had a metaplastic polyp, four had a low-risk adenoma and one had a high-risk adenoma. No participant had cancer. Detection of significant neoplasia was small. The use of the wipe gFOBT was ceased: it cannot be recommended as a screening test for bowel cancer.

A rare potentially treatable cause of bilateral optic disc swelling

Rapid onset bilateral optic disc swelling generally indicates an intracranial problem-that is, papilloedema. However, when there is also visual loss, disease affecting the optic nerves themselves must be considered. We present the diagnostic problem of a patient with optic disc swelling and progressive visual loss. Investigations finally revealed hypocalcaemia secondary to primary hypoparathyroidism. With treatment a marked improvement in vision occurred. This reversible rare cause of optic disc swelling should not be forgotten.

Fibrinolysis during anaphylaxis, and its spontaneous resolution, as demonstrated by thromboelastography

A large and ever-growing number of agents used in anaesthesia can precipitate acute anaphylactic reactions after their administration. Anaphylaxis is a sudden onset (or rapidly progressive), severe systemic allergic reaction, affecting multiple organ systems. The number of people who suffer severe systemic allergic reactions is increasing. The incidence is about 1-3 reactions per 10 000 population per annum, although anaphylaxis is not always recognized; therefore, certain UK studies may underestimate the incidence. In this case report, we present an episode of acute fibrinolysis associated with life-threatening anaphylaxis, demonstrated by thromboelastography (TEG) and resolving spontaneously. This is despite an added fibrinolytic insult in the form of cardiopulmonary bypass. There is a paucity of literature detailing fibrinolysis occurring during anaphylaxis, most likely due to the limited availability of TEG in the acute setting and the primary clinical focus of delivering life-saving interventions.

Atypical presentation of infiltrative thyroid dermopathy

A 46-year-old woman with Graves' disease developed infiltrative dermopathy of the thenar eminences. We believe this to be the first reported case of infiltrative dermopathy affecting the thenar eminences, and question whether repetitive occupational injury may have been a contributing factor. There is little published evidence to guide the treatment of infiltrative dermopathy.

Results from the first three rounds of the Scottish demonstration pilot of FOBT screening for colorectal cancer

OBJECTIVES

To assess the effects of the first three rounds of a pilot colorectal screening programme based on guaiac faecal occult blood testing (gFOBT) and their implications for a national population-based programme.

METHODS

A demonstration pilot programme was conducted in three Scottish NHS Boards. Residents aged between 50 and 69 years registered on the Community Health Index were included in the study.

RESULTS

In the first round, the uptake was 55.0%, the positivity rate was 2.07% and the cancer detection rate was 2.1/1000 screened. In the second round, these were 53.0%, 1.90% and 1.2/1000, respectively, and in the third round, 55.3%, 1.16% and 0.7/1000, respectively. In the first round, the positive predictive value of the gFOBT was 12.0% for cancer and 36.5% for adenoma; these fell to 7.0% and 30.3% in the second round and were maintained at 7.5% and 29.1% in the third round. The percentage of screen-detected cancers diagnosed at Dukes' stage A was 49.2% in the first round, 40.1% in the second round and 36.3% in the third round.

CONCLUSIONS

These results are compatible with those of previous randomised trials done in research settings, demonstrating that population-based colorectal cancer screening is feasible in Scotland and should lead to a comparable reduction in disease-specific mortality.

Pediatric preclinical testing program (PPTP) efficacy and pharmacodynamic evaluation of the Hsp90 inhibitor 17-DMAG

3575

Background: 17-DMAG is a small-molecule inhibitor of the protein chaperone HSP90 that is being developed as an anticancer agent because of the multiple HSP90 client proteins involved in cancer cell growth and survival. Methods: The PPTP includes an in vitro panel (n=27) as well as panels of xenografts (n=61) representing most of the common types of childhood solid tumors and childhood ALL. 17-DMAG was tested against the in vitro panel at concentrations from 1 nM to 10 microM and was tested against the in vivo tumor panels by IP administration using a 50 mg/kg BID twice weekly x 6 weeks dose and schedule. The PPTP’s 3 measures of antitumor activity were used (Houghton et al. Ped Blood Cancer 2006): 1) an objective response measure; 2) treated to control (T/C) tumor volume at day 21; and 3) a time to event (EFS T/C) measure. HSP70 induction was was used as a pharmacodynamic measure of HSP90 inhibition and was determined in tumor and liver tissue at 8 and 24 hours following the second of two doses of 17-DMAG (50 mg/kg IP) administered at 12 hour intervals. Results: 17-DMAG had an EC50 of 62 nM against the PPTP’s in vitro panel, with a trend for lower EC50 values for the rhabdomyosarcoma panel (median EC50 31 nM) compared to the remaining PPTP in vitro cell lines (p=0.06) and for higher EC50 values for the neuroblastoma lines (median EC50 396 nM, p=0.01). 17-DMAG induced significant differences in EFS distribution in 15 of 30 of the solid tumor xenografts, and in 4 of 6 of the evaluable ALL xenografts. Using the time to event activity measure, 17-DMAG had intermediate or high activity against 4 of 28 evaluable solid tumor xenografts (1 of 2 rhabdoid tumor and 3 of 4 alveolar rhabdomyosarcoma). The only objective response (a PR) observed was for an alveolar rhabdomyosarcoma xenograft. HSP70 induction was observed in both liver and tumor tissue, with robust induction (up to 450% increase versus control) occurring in both responding and non-responding tumors. Conclusions: 17-DMAG produced its greatest antitumor activity against alveolar rhabdomyosarcoma xenografts. Robust HSP70 induction was observed in both responding and non-responding xenografts, suggesting that tumor-specific downstream effects of HSP90 inhibition are primary determinants of response. (Supported by NCI NO1CM42216)

No significant financial relationships to disclose.

Intraindividual, right-left comparison of topical methyl aminolaevulinate-photodynamic therapy and cryotherapy in subjects with actinic keratoses: a multicentre, randomized controlled study

BACKGROUND

Actinic keratosis (AK), the most common premalignant skin condition, can represent a management challenge. Treatment should not only be effective, but also well tolerated and allow for good cosmesis on typical sun-exposed highly visible body sites.

OBJECTIVES

The primary objective was to compare the lesion response and subject preference for topical methyl aminolaevulinate (MAL)-photodynamic therapy (PDT) vs. cryotherapy for the treatment of AK.

METHODS

In this 24-week, multicentre, randomized, intraindividual (right-left) study, subjects received both one treatment session of MAL-PDT and a double freeze-thaw cryotherapy; the treatments were randomly allocated to either side of the face/scalp. Lesions with a noncomplete response were retreated after 12 weeks. The primary assessments were the subject's overall preference and lesion response at week 24. Secondary assessments included lesion response at week 12, cosmetic outcome, subject and investigator cosmetic outcome preference at week 24, and investigator overall preference at week 24. Skin discomfort and adverse events were also evaluated.

RESULTS

In total, 119 subjects with 1,501 lesions were included in the study. At week 12, treatment with MAL-PDT resulted in a significantly larger rate of cured lesions relative to cryotherapy (percentage lesion reduction from baseline: 86.9% vs. 76.2%; P < 0.001). At week 24, both treatment groups showed a high rate of cured lesions (89.1% for MAL-PDT vs. 86.1% for cryotherapy; P = 0.20; 95% confidence interval: -1.62 to 7.67). Results for subject and investigator preferences as well as cosmetic outcome favoured MAL-PDT. Both treatment regimens were safe and well tolerated.

CONCLUSIONS

The present study shows that, when treated with both MAL-PDT and cryotherapy, subjects significantly prefer MAL-PDT treatment for AK. MAL-PDT is an attractive treatment option for AK, with comparable efficacy and superior cosmetic outcomes compared with double freeze-thaw cryotherapy.

The national health demonstration projects

The White Paper Towards a Healthier Scotland pledged 15 million Pounds to support four national health demonstration projects to lead the way in achieving sustained improvement in child health, young people's sexual health, coronary heart disease and cancer. The Starting Well project aims to demonstrate that child health in Glasgow can be improved by a programme of activities which both supports families and provides them with access to enhanced community-based resources. The Healthy Respect project aims to help young people in Lothian develop a positive attitude to their own sexuality and that of others, and a healthy respect for their partners, in order to reduce unplanned teenage pregnancies and sexually transmitted infections. The Have a Heart Paisley project is targeting coronary heart disease among the population of Scotland's largest town. The Cancer Challenge project is piloting a screening programme in the North East of Scotland for the detection of colorectal cancer. Though each project has specific objectives, appropriate to its own topic, all share underlying principles. The projects will act as test beds for action and a learning resource for the rest of Scotland.

Cerebral arteriovenous malformation presenting as visual deterioration in a child

A rare case of visual loss as the presenting feature of a central arteriovenous malformation involving the vein of Galen is reported. A 5-year-old girl with a history of deteriorating vision for the past 6 months was examined. Ocular examination showed a left hemianopia, left optic atrophy, and dilated vessels of the right optic disc. MRI revealed a massive deep-seated central arteriovenous malformation involving the vein of Galen. The mechanism of visual loss is likely to be a combination of ischaemic optic atrophy associated with a steal phenomenon and direct compression of the right optic radiation.

Detection of mosaicism in amniotic fluid cultures: a CYTO2000 collaborative study

PURPOSE

To evaluate the assumptions on which the American College of Medical Genetics (ACMG) Standards and Guidelines for detecting mosaicism in amniotic fluid cultures are based.

METHODS

Data from 653 cases of amniotic fluid mosaicism were collected from 26 laboratories. A chi-square goodness-of-fit test was used to compare the observed number of mosaic cases with the expected number based on binomial distribution theory.

RESULTS

Comparison of observed data from the in situ colony cases with the expected distribution of cases detected based on the binomial distribution did not reveal a significant difference (P = 0.525).

CONCLUSIONS

The empirical data fit the binomial distribution. Therefore, binomial theory can be used as an initial discussion point for determining whether ACMG Standards and Guidelines are adequate for detecting mosaicism.

A case-control study of melanomas of the soles and palms (Australia and Scotland)

OBJECTIVES

Because the factors that influence risk of acral melanomas on the soles and palms in White populations are unknown, we investigated these in a multi-center case-control study.

METHODS

Cases of melanoma of the feet and hands diagnosed from 1987-93 in persons aged over 18 years were ascertained in eastern Australia and western Scotland. There were 275 cases of melanoma on the soles and palms matched to 496 controls (selected from the electoral roll) in Australia, and 36 cases matched to 72 controls (nominated by general practitioners) in Scotland.

RESULTS

Acral melanoma was strongly associated with high total body nevus counts (adjusted relative risk [RR] = 6.3, 95% confidence interval [CI] = 2.5-15.6), and with nevi on the soles (RR = 7.5, CI = 3.0-18.6). There were also significant positive associations with a penetrative injury of the feet or hands (RR = 5.0, CI = 3.0-8.6) and with heavy exposure to agricultural chemicals (RR = 3.6, CI = 1.5-8.3). Sun-sensitive complexions, cumulative sun exposure and a past history of nonmelanoma skin cancer were also associated with increased risk of acral melanoma. Current cigarette smoking was inversely related to acral melanoma (RR = 0.6, CI = 0.4-0.9).

CONCLUSIONS

Melanomas of the soles and palms resemble other cutaneous melanomas in their association with sun exposure, but are distinguished from them by their strong positive associations with nevi on the soles, previous penetrative injury, and exposure to agricultural chemicals, and by their inverse association with smoking.

Ropivacaine

Ropivacaine is a new aminoamide local anaesthetic drug. Its clinical profile is similar to that of bupivacaine but it causes less motor block and is less cardiotoxic.

Structure and chromosomal assignment of the human cathepsin K gene

Cathepsin K is a recently identified lysosomal cysteine proteinase that is the major protease responsible for bone resorption and remodeling. Mutations in this gene cause the sclerosing osteochondrodysplasia pycnodysostosis. To assess its evolutionary relatedness to other cysteine proteases and to facilitate mutation identification in patients with pycnodysostosis, a genomic clone, 74e16, containing the cathepsin K gene was isolated from a human PAC library, and the cathepsin K genomic structure was determined. The cathepsin K gene contained eight exons and spanned approximately 9 kb. The transcription initiation site, determined by primer extension analysis, was 169 nucleotides upstream from the translation initiation site. The 5'-flanking region lacked a TATA box but contained two AP1 sites. Comparison of genomic and cDNA sequences suggested that this flanking sequence may be the major promoter in osteoclasts and macrophages. Cathepsin K was mapped to chromosome 1q21 by fluorescence in situ hybridization and found to reside within 150 kb of an evolutionarily related cysteine protease, cathepsin S. These findings expand our understanding of the papain family lysosomal cysteine proteases and should facilitate mutation analysis in pycnodysostosis.

Phylogenetic relationships of Lecythidaceae: a cladistic analysis using rbcL sequence and morphological data

This study examined in detail the rbcL sequence and morphological support for subfamilial relationships and monophyly of Lecythidaceae. Initially we needed to establish relationships of Lecythidaceae among other dicot families. To complete this we examined 47 rbcL sequences of 25 families along with molecular observations from several large analyses of rbcL data. All analyses strongly support the monophyly of the asterid III grouping. This analysis revealed Lecythidaceae to be paraphyletic and indicated potential outgroup relationships with Sapotaceae. Once relationships had been evaluated using molecular data we then concentrated on analyzing separate and combined morphological and molecular databases. The topology of the morphological data set was similar to the rbcL sequence and combined data sets except for the positioning of Napoleonaeoideae, Grias, Gustavia, and Oubanguia. According to the combined results, Planchonioideae, Lecythidoideae. and Foetidioideae are monophyletic, whereas the subfamily Napoleonaeoideae are paraphyletic. Nested within Napolconaeoideae, we found Asteronthos forms a strongly supported clade with Oubanguia (Scytopetalaceae). Foetidia, the only genus of Foetidioideae, is sister to Planchonioideae, and this clade is sister to Lecythidoideae. The [(Planchonioideae, Foetidioideae) Lecythidoideae are sister to Asteranthos/Oubanguia. Napoleonaeoideae are sister to the rest of Lecythidaceae.