Dosimetric Impact of Systematic Mediastinal Staging via Endobronchial Ultrasound for Patients with Locally Advanced Lung Cancer: The SEISMIC Trial

PURPOSE/OBJECTIVE(S)

The SEISMIC trial aims to find the best method for mediastinal staging in patients with lung cancer receiving chemoradiotherapy. Currently, CT or PET-CT scans are standard in clinical practice, but histological evaluation of the mediastinum is performed on a case-by-case basis. The study will examine the effect of systematic histological evaluation using Endobronchial Ultrasound (EBUS) on radiotherapy target volumes. The hypothesis of this study is that differences in staging between the diagnostic PET-CT and EBUS would result in reduced tumor coverage and/or increased doses to organs at risk (OAR).

MATERIALS/METHODS

SEISMIC is a prospective multicenter international cohort study. Patients were enrolled from Australia, the Netherlands, USA and Canada after regional IRB approvals. Patients were treated with 4DCT simulation. Two iGTV and PTV target volumes were delineated for each patient with discordant staging according to both PET-CT and EBUS, as were OARs. Two VMAT plans were generated for each patient based on either PET-CT or EBUS target volumes using knowledge-based planning methodology. Plans aimed to achieve institutional guidelines for target coverage and OAR dose constraints, with a prescribed dose of 60 Gy in 30 fractions. Target coverage and OAR doses for the PET- and EBUS-defined volumes were compared.

RESULTS

In 156 patients, EBUS showed a larger extent of disease than PET in 18 (11.5%) and a smaller extent of lymph node (LN) involvement than PET in 49 (31.4%). Out of 67 patients with PET-EBUS discordant results, 25 underwent upfront radiotherapy and were included in the study. EBUS revealed PET-occult LN involvement in 11/25 patients (44%). In these patients, 10/11 patients received <95% of the prescribed dose to PET-occult LN iGTVs; the median [range] minimum dose to the EBUS iGTV was 9.2 Gy [0.1 - 57.9 Gy]. When planning based on EBUS LN involvement, all patients received ≥95% of the prescribed dose to the iGTV (the median [range] minimum dose to the EBUS iGTV was 58.9 Gy [58.1 - 60.5 Gy]). This resulted in increased median [range] doses to OARs; mean lung dose increased by 1.1 Gy [0.3 - 8.4 Gy], esophagus mean dose increased by 3.6 Gy [0.2 - 24.8 Gy], and mean heart dose increased by 0.5 Gy [-0.6 - 8.5 Gy].

CONCLUSION

Systematic endoscopic evaluation of the mediastinum had a significant effect on tumor coverage in a clinically meaningful proportion of cases and consequent plan adaptation impacted on organ-at-risk (OAR) doses. Results suggest systematic mediastinal LN staging should be considered in all patients prior to curative-intent radiotherapy.

CLINICAL TRIAL ID

ACTRN12617000333314.

Comparison of actionable events detected in cancer genomes by whole-genome sequencing, in silico whole-exome and mutation panels

Background

Next-generation sequencing is used in cancer research to identify somatic and germline mutations, which can predict sensitivity or resistance to therapies, and may be a useful tool to reveal drug repurposing opportunities between tumour types. Multigene panels are used in clinical practice for detecting targetable mutations. However, the value of clinical whole-exome sequencing (WES) and whole-genome sequencing (WGS) for cancer care is less defined, specifically as the majority of variants found using these technologies are of uncertain significance.

Patients and methods

We used the Cancer Genome Interpreter and WGS in 726 tumours spanning 10 cancer types to identify drug repurposing opportunities. We compare the ability of WGS to detect actionable variants, tumour mutation burden (TMB) and microsatellite instability (MSI) by using in silico down-sampled data to mimic WES, a comprehensive sequencing panel and a hotspot mutation panel.

Results

We reveal drug repurposing opportunities as numerous biomarkers are shared across many solid tumour types. Comprehensive panels identify the majority of approved actionable mutations, with WGS detecting more candidate actionable mutations for biomarkers currently in clinical trials. Moreover, estimated values for TMB and MSI vary when calculated from WGS, WES and panel data, and are dependent on whether all mutations or only non-synonymous mutations were used. Our results suggest that TMB and MSI thresholds should not only be tumour-dependent, but also be sequencing platform-dependent.

Conclusions

There is a large opportunity to repurpose cancer drugs, and these data suggest that comprehensive sequencing is an invaluable source of information to guide clinical decisions by facilitating precision medicine and may provide a wealth of information for future studies. Furthermore, the sequencing and analysis approach used to estimate TMB may have clinical implications if a hard threshold is used to indicate which patients may respond to immunotherapy.

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Genome analysis revealed that treatment biomarkers are shared across solid tumours, highlighting repurposing opportunities.

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Comprehensive panels detect most known biomarkers; however, WGS detects more biomarkers for treatments in clinical trials.

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TMB is well correlated between sequencing methods, but absolute values vary and are dependent on mutation types considered.

Impact of Management on Avian Communities in the Scottish Highlands

The protection of biodiversity is a key national and international policy objective. While protected areas provide one approach, a major challenge lies in understanding how the conservation of biodiversity can be achieved in the context of multiple land management objectives in the wider countryside. Here we analyse metrics of bird diversity in the Scottish uplands in relation to land management types and explore how bird species composition varies in relation to land managed for grazing, hunting and conservation. Birds were surveyed on the heather moorland areas of 26 different landholdings in Scotland. The results indicate that, in relation to dominant management type, the composition of bird species varies but measures of diversity and species richness do not. Intensive management for grouse shooting affects the occurrence, absolute and relative abundance of bird species. While less intensive forms of land management appear to only affect the relative abundance of species, though extensive sheep grazing appears to have little effect on avian community composition. Therefore enhanced biodiversity at the landscape level is likely to be achieved by maintaining heterogeneity in land management among land management units. This result should be taken into account when developing policies that consider how to achieve enhanced biodiversity outside protected areas, in the context of other legitimate land-uses.

Long-term impacts of nitrogen deposition on coastal plant communities

Nitrogen deposition has been shown to have significant impacts on a range of vegetation types resulting in eutrophication and species compositional change. Data from a re-survey of 89 coastal sites in Scotland, UK, c. 34 years after the initial survey were examined to assess the degree of change in species composition that could be accounted for by nitrogen deposition. There was an overall increase in the Ellenberg Indicator Value for nitrogen (EIV-N) of 0.15 between the surveys, with a clear shift to species characteristic of more eutrophic situations. This was most evident for Acid grassland, Fixed dune, Heath, Slack and Tall grass mire communities and despite falls in EIV-N for Improved grass, Strand and Wet grassland. The increase in EIV-N was highly correlated to the cumulative deposition between the surveys, and for sites in south-east Scotland, eutrophication impacts appear severe. Unlike other studies, there appears to have been no decline in species richness associated with nitrogen deposition, though losses of species were observed on sites with the very highest levels of SOx deposition. It appears that dune vegetation (specifically Fixed dune) shows evidence of eutrophication above 4.1 kg N ha(-1) yr(-1), or 5.92 kg N ha(-1) yr(-1) if the lower 95% confidence interval is used. Coastal vegetation appears highly sensitive to nitrogen deposition, and it is suggested that major changes could have occurred prior to the first survey in 1976.

Species composition of coastal dune vegetation in Scotland has proved resistant to climate change over a third of a century

Climate change is expected to have an impact on plant communities as increased temperatures are expected to drive individual species' distributions polewards. The results of a revisitation study after c. 34 years of 89 coastal sites in Scotland, UK, were examined to assess the degree of shifts in species composition that could be accounted for by climate change. There was little evidence for either species retreat northwards or for plots to become more dominated by species with a more southern distribution. At a few sites where significant change occurred, the changes were accounted for by the invasion, or in one instance the removal, of woody species. Also, the vegetation types that showed the most sensitivity to change were all early successional types and changes were primarily the result of succession rather than climate-driven changes. Dune vegetation appears resistant to climate change impacts on the vegetation, either as the vegetation is inherently resistant to change, management prevents increased dominance of more southerly species or because of dispersal limitation to geographically isolated sites.

Carcass provisioning to support scavengers: evaluating a controversial nature conservation practice

A number of scavenger species have suffered population declines across Europe. In attempts to reverse their decline, some land and wildlife managers have adopted the practice of leaving or placing out carcasses of wild or domestic herbivores to provide a source of carrion. However, this can be a controversial practice, with as yet unclear outcomes for many target species and the ecosystems they are part of. Here we bring out the key aspects of this increasingly common conservation practice illustrated using three contrasting cases studies. We show that the provision of carcasses is often motivated by a desire to benefit charismatic species or to facilitate nutrient cycling throughout an ecosystem. Evidence for the effectiveness of this practice in achieving these objectives, however, is mostly lacking, with ecologists studying "easier" species groups such as beetles and therefore not providing relevant insights. Moreover, conflicts between environmental policies that carcass provisioning is aimed at and other social and economic objectives do occur but these projects are often designed without taking into account this broader context. We conclude that expecting carcasses to simply be "good for biodiversity" may be too naïve a view. A greater knowledge of the impact of carcass provisioning and placement on ecosystems and society at large is required before it can become a more effective conservation tool at a wider scale.

The effect of dermatology consultations in secondary care on treatment outcome and quality of life in new adult patients with atopic dermatitis

BACKGROUND

The prevalence of atopic dermatitis (AD) is increasing worldwide, and many patients present to secondary care in adult life. This is a significant contribution to the workload of all dermatology departments. There are no studies investigating the impact of a dermatology consultation within secondary care.

OBJECTIVES

To examine the effect of dermatology consultations in secondary care on treatment outcome and quality of life in new adult patients with AD.

METHODS

This prospective observational study recruited new adult patients with AD referred from primary care. Eczema severity was assessed using the SCORAD (Severity Scoring of AD) index and subjective good or poor clinical outcome. The Dermatology Life Quality Index (DLQI) was used to quantify the impact of AD on adult patients. Patients were assessed at initial consultation (T1), 6 weeks (T2) and 3 months (T3). Statistical analysis was performed using independent t-tests, repeated-measures analysis of variance, correlation coefficients and Bonferroni post hoc comparisons.

RESULTS

Sixty-three patients were recruited (37 women, 26 men) with a mean age of 34 years. Mean SCORAD at T1 was 48.2 and the majority (51%) had severe eczema (objective SCORAD>40). Mean SCORAD reduced by 52% from T1 to T2 (P<0.001) but there was no significant change in SCORAD from T2 to T3. A subjective good clinical outcome was validated by a decrease in SCORAD of >20 (P<0.001). Patients in the good clinical outcome group were significantly older than those in the poor clinical outcome group (38 vs. 27 years, P<0.05). The mean age at presentation of women was significantly younger than men (29 vs. 43 years, P<0.01). Women's mean SCORAD improved over all three visits, while men's mean SCORAD improved from T1 to T2 but worsened from T2 to T3 (P<0.001). The mean DLQI reduced over all three visits, from 9.5 at T1 to 8.8 at T2 and 7.0 at T3, and was significantly correlated with SCORAD at T1 and T2 (P<0.01). Patients accurately self-scored their eczema on a body map as shown by a significant correlation between these scores and SCORAD at T1 and T2 (P<0.001).

CONCLUSIONS

We have shown that within the first 3 months of referral to secondary care, new adult patients with AD have the greatest improvement in AD, measured by SCORAD, after their initial appointment. Quality of life, as measured by DLQI, continued to improve over all three visits.

A multicentre phase II study of cisplatin and gemcitabine for malignant mesothelioma

Our previous phase II study of cisplatin and gemcitabine in malignant mesothelioma showed a 47.6% (95% CI 26.2-69.0%) response rate with symptom improvement in responding patients. Here we confirm these findings in a multicentre setting, and assess the effect of this treatment on quality of life and pulmonary function. Fifty-three patients with pleural malignant mesothelioma received cisplatin 100 mg m(-2) i.v. day 1 and gemcitabine 1000 mg m(-2) i.v. days 1, 8, and 15 of a 28 day cycle for a maximum of six cycles. Quality of life and pulmonary function were assessed at each cycle. The best response achieved in 52 assessable patients was: partial response, 17 (33%, 95% CI 20-46%); stable disease, 31 (60%); and progressive disease, four (8%). The median time to disease progression was 6.4 months, median survival from start of treatment 11.2 months, and median survival from diagnosis 17.3 months. Vital capacity and global quality of life remained stable in all patients and improved significantly in responding patients. Major toxicities were haematological, limiting the mean relative dose intensity of gemcitabine to 75%. This schedule of cisplatin and gemcitabine is active in malignant mesothelioma in a multicentre setting. Investigation of alternative scheduling is needed to decrease haematological toxicity and increase the relative dose intensity of gemcitabine whilst maintaining response rate and quality of life.

The relevance of lowered personal control for patients who have stoma surgery to treat cancer

OBJECTIVES

The objective of this study was to explore the experience of patients who had stoma surgery to treat cancer in order to explicate why problems associated with stoma surgery are not decreasing despite technical improvements in stoma care.

DESIGN

A longitudinal design was used in order to capture the process of preparing for surgery and dealing with its aftermath. Participants were interviewed using a semi-structured protocol on three occasions; 1-2 weeks before surgery (eight participants), 1-2 weeks after surgery (seven participants), and 3 months after surgery (four participants).

METHOD

Transcripts were analysed guided by the procedures of grounded theory. This involved developing categories from the data and linking them together to form a conceptual understanding of our participants' experience.

RESULTS

Lowered personal control was the most important concept to emerge from the analysis. We identified perceived causes of lowered control, its mitigating factors, the strategies used to manage this experience and the consequences of these processes.

CONCLUSIONS

We make three recommendations based on the conclusion that improvements could be implemented in the psychological aspects of stoma care and, in particular, the enabling of patient perceived self-efficacy. First, improvements could be made in doctor-patient communication with doctors becoming more aware of their psychological impact on patients. Second, specialist stoma care nurses could be trained to recognize patients with dysfunctional self-efficacy beliefs and/or delayed psychological adaptation. Finally, we identify a need for more prolonged practical and emotional support for at least some stoma out-patients.

Factors related to psychosocial adjustment in children with end-stage renal failure

Psychological functioning and adjustment to dialysis were assessed in the families of 60 children and adolescents undergoing chronic dialysis. Sociodemographic factors, treatment variables, health status and satisfaction with health care provision were also measured. Correlation analyses identified a number of important factors associated with poor adjustment to dialysis and/or anxiety and depression in children and parents. Particularly at risk are parents in lower socioeconomic status households, parents with large families, parents with limited support and parents of young children. Children were more at risk where there was greater functional impairment caused by illness.

Infection control. A long time coming

This article presents the case of a doctor who developed multidrug-resistant tuberculosis in his right lung. Development of the disease was attributed to treatment errors and resulted in surgical intervention to effect a cure. The isolation and management of this patient spanned a total of 12 months. Infection control interventions to minimise the effects of sensory deprivation, given the length of stay of the patient, appear to have been satisfactory, with no treatment for any clinical depression required. The availability of negative pressure ventilation and the then controversial use of masks prevented any nosocomial transmission of MDR TB. Use of masks resulted in a two-tier system of infection control. It was difficult to make such a decision in the absence of any published UK guidelines. Guidelines have subsequently been published.

Motivation, attitudes and experience of donation: a follow-up of women donating eggs in assisted conception treatment

This paper reports a follow-up of 39 women who had donated eggs to an assisted conception unit. Their experience of donation and their motivation and attitudes were assessed. Comparisons were made with a group of semen donors who were attending a second unit. Female and male donors donated for altruistic reasons and neither group wished to have contact with recipients or donor offspring or have their identity revealed. Female donors were more involved in the donation process and more interested in the outcome of donation. They also appeared to be more motivated by 'helping' than male donors. The sample of female donors contained a small group of women who were donating to sisters and friends. In comparison with anonymous donors, these women reported more effects upon the family and issues of secrecy and openness were more apparent. The results are discussed in the light of previous studies and the legal framework for donation in the UK. Attention is drawn to the lack of social psychological analyses in this controversial medical area.

An activity week for children with cancer: who wants to go and why?

Many children now live with cancer rather than die from it, and such children need both to continue their social, emotional and cognitive development and to make long-term psychological adjustments. This paper presents the findings of a research project set up to explore issues pertinent to the current provision of an activity week experience for a group of British paediatric cancer patients. The aims of the study included finding out which factors discriminate between families who apply for a place to attend the week for their child and families who do not, and to develop a knowledge of what factors are considered by parents and children. The findings suggest that the week appeals to children who are confident, active and able to separate from parents and whose parents are keen to encourage independence and new experiences. Children diagnosed and treated at a younger age and further away from treatment were more likely to express concerns about being homesick and safety and to not apply for the week. Issues of protection, independence and disability are discussed with reference to the importance of parental attitude on children's psychological accommodation to disease and treatment and to the experiences of adult survivors of childhood cancer.

Prospects for plant anthelmintics in tropical veterinary medicine

The current use of anthelmintic plants in tropical veterinary medicine is reviewed and attention is drawn to the lack of scientific evidence for the effectiveness of many now in use. The case for anthelmintic plants as a means of overcoming some of the serious limitations of manufactured anthelmintics is outlined. Reasons why anthelmintic plants are not generally used in veterinary medicine, in contrast to their greater acceptance in human medicine, are considered. Strategies for their development and use are discussed, in particular the need for in vivo trials to identify those plants which are effective and suitable for general use: attention is drawn to possible candidates, including pyrethrum and papaya latex. Those helminths of most economic importance should be targeted first. Anthelmintic plants offer a traditional alternative to manufactured anthelmintics that is both sustainable and environmentally acceptable. Such plants could have a more important role in the future control of helminth infections in the tropics.

Role and management of donkeys in Samburu and Turkana pastoralist societies in northern Kenya

A survey was carried out in northern Kenya to obtain data on the role and management of donkeys in Samburu and Turkana pastoralist societies and to identify potential areas, if any, for interventions. Sixty-seven women owning or closely associated with 583 donkeys were surveyed during July/August 1994. The median donkey herd sizes in Samburu and Turkana societies were 4 and 10 respectively. Pack transport of water and domestic materials were the major reasons for keeping donkeys. Donkey milk, meat and blood were consumed widely by the Turkana but not by the Samburu. The major problems in donkey management were donkeys getting lost, being stolen, predation and being affected by diseases, in particular a disease condition involving unthriftiness, emaciation and slow growth. Traditional methods of treating donkey diseases were generally used. It was concluded that donkeys were an important component in the pastoralist societies surveyed although donkey numbers and transport capacity were not limiting factors in pastoralists activities. Potential areas for intervention were identified as disease investigation and stimulation of community based initiatives to tackle general management problems.

Familial Wolf-Hirschhorn syndrome resulting from a cryptic translocation: a clinical and molecular study

We present three cousins who have normal karyotypes, despite having clinical features of Wolf-Hirschhorn syndrome. Fluorescence in situ hybridisation techniques confirmed that all three relatives were monosomic for the distal short arm of chromosome 4 and that a cryptic translocation involving chromosomes 4 and 11 was segregating within the family. Segregation analysis indicated that the risk of an affected child being born to a parent carrying the translocation was 15%. Molecular analysis showed that loci D4S111 and D4S115 were not deleted in the proband, thus excluding these loci from the "Wolf-Hirschhorn critical region". Surprisingly, DNA studies also suggested that the translocation breakpoint on chromosome 4 was within the region of a preexisting paracentric inversion.

Bridging the professions: an integrated and interdisciplinary approach to teaching health care ethics

In 1993, the authors introduced an interdisciplinary course in health care ethics at the University of British Columbia. They were motivated by two convictions: (1) an interdisciplinary approach to health care decision making is best; and (2) every significant health care decision has an ethical component. They wanted to encourage students from the various health care disciplines to participate in interdisciplinary decision making in their future practices by giving them an opportunity to study health care ethics together during their training. The authors give detailed descriptions of the objectives, format, curriculum, and evaluation of this innovative course in the hope that other educators who may want to develop similar courses can learn from their experience.

Eucalyptus: a sustainable self-delivery molluscicide?

Attention is drawn to the limitations of conventional methods of controlling important trematode infections such as schistosomosis and fasciolosis. Plant molluscicides could have a role in the future control of these infections. There are, however, major problems with most plant molluscicides in that their use is labour-intensive, in many cases relatively skilled workers are required, they must be applied regularly and arable land may be required for their cultivation. Thus, little progress is to be expected until plant species with sustainable self-delivery systems are identified. Eucalyptus is proposed as a likely candidate. The leaves of many species in this genus have molluscicidal properties and their intermittent fall could effect self-delivery if the trees were planted in appropriate places. Relatively little work has been carried out on this possibility and much more is necessary, especially field trials. Before field trials are started, more laboratory testing is also necessary to determine the LC50 values for different snail species and to study toxicity to non-target organisms.

Adherence to medical regime and related factors in youngsters on dialysis

A pilot study is reported in which 18 children in end-stage renal failure, undergoing either haemodialysis or continuous ambulatory peritoneal dialysis were assessed with regard to adherence to their treatment regime. Measures were used to assess level of depression, locus of control and social desirability. Adherent behaviour was significantly related to high social desirability, and a shorter length of time on dialysis. There was no relationship between adherence and depression or locus of control.

The treatment of scriptophobia by in vivo exposure and cognitive restructuring

A 23-year-old woman with a debilitating fear of signing her name in public was treated in 8 weeks and six treatment sessions using graded exposure in vivo and cognitive restructuring. Progress was maintained in all settings, at home and at work and when the patient was unaccompanied. Treatment gains were maintained at 6-month and 2-year follow-ups.

Children with end-stage renal failure: psychological effects on patients, siblings and parents

Thirty-two children diagnosed as suffering from renal failure, their parents and siblings were the subjects of this study. Anxiety, depression and psychosomatic complaints were examined in the parents and behaviour problems in the child and siblings using standardised tests. The personality characteristics (EPQ) of the child and the child's view of the family (modified family relations test) were also ascertained. Parents showed greater levels of anxiety and depression than a normal sample and more psychosomatic problems than a control group consisting of parents of children with other chronic physical conditions. Siblings and the sick child did not have more behaviour problems at school than a normal control group. Positive correlations were found between age on diagnosis of renal failure and fathers' depression and anxiety scores. Mothers' anxiety and depression scores were also positively correlated with those of father. Negative correlations were found between age on diagnosis of renal failure and lie scores on the EPQ.

An interview with a child to assess psychiatric disturbance: a note on its reliability and validity

Forty-six children with enuresis were given a psychiatirc interview. The two writers made independent ratings of 10 behavioral variables. Seven of these showed satisfactory interrater reliability. No relationship was established between child psychiatric disturbance assessed in this way and estimates of disorder obtained from information given by mothers and teachers.

An evaluation of hospital in-patient treatment in adolescent school phobia

Thirty-two school-phobic youngsters of mean age 13 years were randomly allocated to two treatment groups after stratifying for sex. Length of in-patient management in a psychiatric hospital unit for young adolescents was evaluated. One group was admitted for three months and the other for six. Care was taken to ensure that cases had been fairly distributed between the groups by comparing them on a variety of clinical features. Follow-up assessments were carried out in a reliable fashion at six months, one year and two years after discharge. Outcome, overall, was similar to that found in a previous follow-up study for the same unit, in that symptoms of emotional disturbance and social impairment tended to persist in a considerable proportion of cases over the period of review. Length of stay in hospital did not affect outcome as far as the boys were concerned; the findings in relation to the girls was less certain and it seems likely that longer in-patient treatment improves outcome in school-phobic girls.

Psychiatric disturbance, urgency, and bacteriuria in children with day and night wetting

Forty children with day and night wetting were compared with 46 with night wetting only to see if day wetting was then associated with particular clinical features. Interviews with mothers, questionnaries completed by teachers, physical investigations, and measurement of functional bladder capacities were used. Day wetting combined with bed wetting occurred equally in boys and girls and was associated with daytime urgency and greater frequency of psychiatric disturbance. In boys, soiling was also associated. In girls, bacteriuria, which appeared to be caused by the day wetting, occurred in about 50%. Neither daytime frequency nor small functional bladder capacity were specifically related to day wetting.