Cutaneous Lesion of the Nose as Initial Presentation of Esophageal Adenocarcinoma

BACKGROUND/AIM

Cutaneous manifestations of disease are exceedingly rare and commonly overlooked in clinical practice. Allergies or contact dermatitis, autoimmune disease or skin cancer are the most common conditions typically associated with skin lesions. Rarely, cutaneous lesions may be the first sign of internal malignancy, or even resemble recurrent disease in those with history of cancer.

CASE REPORT

Herein, we report a case of an otherwise healthy male who presented to his primary care provider (PCP) with a skin lesion misdiagnosed as a furuncle, which eventually led to diagnosis of metastatic esophageal cancer. The patient was a 64-year-old male, presenting with a fungating lesion on the tip of his nose which was biopsied, confirming adenocarcinoma likely from a gastrointestinal source. Staging imaging showed extensive lung, liver, and boney metastatic disease. He was initially treated with chemotherapy and trastuzumab.

CONCLUSION

Cutaneous lesions are a rare presenting sign of malignancy, but rapidly growing lesions should be evaluated for possible metastatic disease.

Predictors of chemotherapy and its effects in early stage squamous cell carcinoma of the larynx

BACKGROUND

Squamous cell carcinoma (SCC) of larynx is a common head and neck cancer. For cases that are node negative, the role of definitive concurrent chemoradiation is unclear and not supported by guidelines but used at provider discretion. To address this knowledge gap, we examined the oncological outcomes with additional chemotherapy and factors correlated with the chemotherapy administration.

METHODS

We queried the National Cancer Database for patients with early stage (T2N0M0) laryngeal SCC treated nonsurgically. Multivariable logistic regression identified predictors of chemotherapy. Multivariable Cox regression evaluated predictors of survival. Propensity matching accounted for indication biases.

RESULTS

We identified 7181 patients meeting the eligibility criteria, of which 1568 (22%) patients received chemotherapy in addition to radiation. Predictors of chemotherapy use included younger age, Caucasian race, more remote year of treatment, higher grade, sites other than glottis, treatment at a community cancer center, and use of intensity-modulated radiation therapy. Median overall survival was not significantly different in the two arms analyzed-65 months (95% confidence interval [CI] 60, 72months) with chemotherapy compared to 70 months without chemotherapy (95% CI 66, 75 months, P<.37). Predictors for survival on propensity-matched multivariable analysis were increased age, male sex, less education, lower income, higher comorbidity score, receipt of treatment at a community center, and nonglottic sites.

CONCLUSIONS

This study shows no clear survival benefit with chemotherapy in early stage disease. Although this implies that chemotherapy should not be routinely delivered, individualized judgment and prospective studies are recommended as the biology behind this interesting finding is undefined.

LEVEL OF EVIDENCE

2C (Outcomes Research).

Oncology Training in Rwanda: Challenges and Opportunities for Undergraduate Medical Students (The EDUCAN Project)

A critical shortage of trained cancer specialists is one of the major challenges in addressing the increasing cancer burden in low- and middle-income countries. Inadequate undergraduate cancer education in oncology remains a major obstacle for both task shifting to general practitioners and for training of specialists. We provide the first report of cancer education in Rwanda's undergraduate program to survey how new graduates are prepared to provide care for cancer patients. Anonymous online survey was sent January to June 2017 to medical students in their senior clinical years (years 5 and 6). Questions related to the demographics, medical curriculum, and general oncology exposure were included in the survey. Of 192 eligible students, 42% (n = 80) completed the survey and were analyzed. The majority were 25 to 29 years of age and 41% were female. Internal medicine was cited to provide the most exposure to cancer patients (50%) and cancer bedside teaching (55%). Close to a half (46%) have been taught oncology formally in addition to bedside teaching. A tenth (11%) of the participants felt comfortable in attending a cancer patient, and a fifth (21%) of the students felt comfortable while addressing multimodality treatment approach. The majority (99%) of the participants preferred having a formal oncology rotation. Of particular interest, 61% of the students are interested in pursuing an oncology career path. There is a need to modify the current oncology undergraduate curriculum to prepare future physicians for delivering cancer care in Rwanda. Raising the profile of oncology in undergraduate medical education will complement the on-going efforts to increase the country's capacity in task shifting and in training of cancer specialists.

A-71 Comparing College Athletes and Non-Athlete Controls on the ImPACT Validity Indices at Baseline

Objective

In the context of sports-related concussion (SRC) evaluations, athletes have been shown to “sandbag” their baseline testing in order to improve their chances of return-to-play post-concussion. To circumvent this problem, performance validity tests are often administered. The ImPACT, a widely used computerized program in SRC evaluations, has five embedded validity indices (VIs); however, indications of their use as measures of effort have not been well established. With this in mind, we aimed to compare performance on the ImPACT VIs between athletes and non-athlete controls at baseline. Given the incentive to “sandbag” by at least some players, it was hypothesized that athletes would demonstrate poorer performance on all VIs than controls.

Method

Participants included 1,254 college students (70% male; 77.3% Caucasian) divided into two groups: athletes (n = 929) and non-athlete controls (n = 325). All participants completed the ImPACT individually. Primary outcomes of interest included the five ImPACT VIs: Impulse Control Composite, X’s and O’s Total Incorrect, Word Memory Learning Percent Correct, Design Memory Learning Percent Correct, and Three Letters Total Letters Correct.

Results

Independent samples t-tests revealed that athletes performed worse than controls on 4 of the 5 VIs (p = < .001 to .028; d = 0.13 to 0.23). The only VI that was not significantly different between groups was Three Letters (p>.05, d = 0.11).

Conclusion

Consistent with our hypotheses, findings generally showed that athletes demonstrated worse performance on the ImPACT VIs compared to non-athlete controls. Although future research is needed to validate the utility of the VIs, our results suggest that these scores may be useful in detecting suboptimal baseline performance.

Practice patterns and outcomes following radiation dose de-escalation for oropharyngeal cancer

OBJECTIVES/HYPOTHESIS

Numerous trials are evaluating radiotherapy (RT) de-escalation for human papillomavirus (HPV)-mediated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC). Herein, we evaluated the degree to which de-escalated RT is delivered in the United States, as well as comparative outcomes with full-dose RT as stratified for HPV status.

STUDY DESIGN

Retrospective database review.

METHODS

We identified patients diagnosed with OPSCC in the National Cancer Database, excluding those with stage I/II disease, unknown HPV status, receiving surgery or not receiving external beam radiation therapy to the primary site, receipt of radiation doses >75 or <54 Gy, radiation treatment course duration <25 or >75 days, and unknown or inadequate (<2 months) follow-up. Multivariable logistic regression analysis identified variables associated with delivery of de-escalated RT (<66 Gy). Overall survival of HPV+ and non-HPV-mediated (HPV-) disease was compared between full-dose and de-escalated approaches.

RESULTS

Altogether, 617 and 551 patients were HPV+ and HPV-, respectively. De-escalated RT was delivered in 16.9% HPV+ and 15.2% of HPV- disease, respectively. Older patients and omission of systemic therapy were more likely to receive de-escalated RT. In HPV+ patients, 3- and 5-year survival rates were 83% and 80% in the de-escalated cohort versus 83% and 78% in the full-dose group (P = .83). In HPV- patients, corresponding 3- and 5-year survival rates were 29% and 23% versus 61% and 51% (P = .001).

CONCLUSIONS

National utilization of de-escalated RT for OPSCC is low (15%-20%), but does not seem to impact overall survival in HPV+ (but not HPV-) patients. The caveats of this heterogeneous, retrospective analysis require corroboration from a number of ongoing randomized trials.

LEVEL OF EVIDENCE

2c Laryngoscope, 130:E171-E176, 2020.

Practice patterns and outcomes following radiation dose de-escalation for oropharyngeal cancer: A National Cancer Database analysis

e17508

Background: Numerous trials are evaluating radiotherapy (RT) de-escalation for HPV-mediated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC). Herein, we evaluated the degree to which de-escalated RT is delivered in the United States, as well as, comparative outcomes with full-dose RT, as stratified for HPV status. Methods: We identified patients diagnosed with OPSCC in the National Cancer Database, excluding those with stage I/II disease, unknown HPV status, receiving surgery or not receiving EBRT to the primary site, receipt of radiation doses > 75 or < 54 Gy, radiation treatment course duration < 25 or > 75 days, and unknown or inadequate ( < 2 months) follow-up. Multivariable logistic regression analysis identified variables associated with delivery of de-escalated RT ( < 66 Gy). Overall survival of HPV+ and HPV- disease was compared between full-dose and de-escalated approaches. Results: Altogether, 617 and 551 patients were HPV+ and HPV-, respectively. De-escalated RT was delivered in 16.9% HPV+ and 15.2% of HPV- disease, respectively. Older patients and those not receiving systemic therapy were more likely to receive de-escalated RT. In HPV+ patients, 3- and 5-year survival rates were 83% and 80% in the de-escalated cohort versus 83% and 78% in the full-dose group (p = 0.83). In HPV- patients, corresponding 3- and 5-year survival rates were 29% and 23% versus 61% and 51% (p = 0.001). Conclusions: National utilization of de-escalated RT for OPSCC is low (15-20%), but does not seem to impact overall survival in HPV+ (but not HPV-) patients. The caveats of this heterogeneous, retrospective analysis require corroboration from a number of ongoing randomized trials.

The Design and Implementation of Cancer Patient Support Groups in Rural Haiti

Background: In Haiti, cancer is associated with myths that have traumatic effects on patients and families. Cancer diagnoses are drivers of socioeconomic change, with psychological repercussions for an impoverished population. Aware of this reality, the Oncology Service at University Hospital of Mirebalais (HUM) created a dedicated psychosocial team, composed of a social worker, her assistant and a psychologist. Care is provided to patients and families through: individual counseling, support groups, outreach activities, home visits, and mental health consults. This abstract focuses on patient support groups (SG). SGs act as vectors of information and training that are capable of breaking myths, and accompanying patients on their cancer journey. Aim: The primary aim of SGs is to create a space for patients to participate in education and peer counseling. During sessions, the team encourages expressions of emotions and experiences in relation to the disease and its repercussions on patients and caregivers. These discussions encourage participant solidarity and strengthen compliance to treatments. SGs, however, are not static and services are continuously improved by collecting feedback. Methods: To address the psychosocial needs of each cancer patient, SGs were developed with specificity. Patients are categorized in SGs according to the medical treatment they are receiving. Other SGs offered, focus on caregiver experience. SGs have about 12 participants, last 120 minutes and are held in a private space in HUM. In general, discussions relate to patient experience, side effects, relationship implications, and socio-economic impacts. Across all SGs, principles for speaking are negotiated and are always at discretion of participants. Results: The HUM team has provided SG services since 2013. SGs are held often and the majority of oncology patients participate. In 2017, we held 30 SGs with over 380 participants. Therapeutic alliances have improved relationships: patient–patient, family–patient, and patient-clinician - fostering interdisciplinary collaboration. However, all SGs must be performed the same day as the medical appointment due to socio-economic difficulties that can create logistical challenges. Patient needs are also fluid and flexibility is key as SGs evolve. Conclusion: SGs play a critical role in comprehensive cancer care, particularly in Haiti where there are severe social implications for patients. Mental health of cancer patients is critical and SGs are an impactful way to address this need. Arranging SGs by medical treatment, the model used at HUM, is adaptable to other low-income settings. Every SG is different and facilitators approach each session without preconceptions, yet diligent to gather feedback. SGs provide critical information to clinicians about social determinants and implications of cancer diagnoses in Haiti. In the future, we hope to do robust qualitative analysis of SGs, using feedback from cancer patients at HUM.

Establishing a Childhood Cancer Survivorship Program in Rwanda

Background: Over 80% of children diagnosed with cancer survive in high-income countries (HICs). While the survival rate remains poor in low- and middle-income countries (LMICs) such as Rwanda, a growing number of children with cancer are surviving to adulthood. These children and young adults will face an increased risk of secondary cancers and late complications from their curative treatment. Cancer centers in HICs have established Long Term Survivorship (LTS) programs to cater for childhood cancer survivors and to capture these complications and/or recurrences at an early stage. They also address the more complex psychological and social aspects of surviving cancer in childhood. Aims: To develop an LTS program in Rwanda, initial training will take place in Botswana where a pediatric hematology-oncology (PHO) program was established at the national referral hospital, Princess Marina Hospital (PMH), in 2007. This training program will allow successful methods and lessons learned from the development of an LTS program in Botswana to establish a similar program in Rwanda with ongoing bidirectional collaboration. Methods: The Texas Children's Cancer and Hematology Centers (TXCH) Global Hematology-Oncology Pediatric Excellence (HOPE) program in Botswana is the only provider of PHO care in the country, provided at PMH, through a partnership with the Botswana government. The program has over 130 childhood cancer survivors in active follow-up. A one-month bench-marking visit will be conducted. During this period, Dr. Rubagumya will spend time with the medical director of the program learning how the LTS program was established and current operations. He will spend time with clinicians during consultations to understand the scope of tests requested, frequently asked questions across all parties: clinicians, survivors and/or caretakers and use of technology to aid in the management of LTS patients. Focused interviews of clinicians, patients, caregiver and administration will be conducted to further understand the challenges of the pediatric cancer survivors and the development of an LTS program in an LMIC face. Results: After this month visit, critical areas of knowledge transfer will include: how to set up a childhood cancer survivorship programs; methods for sustainable operation of a childhood cancer LTS program, and how to help childhood cancer survivors navigate health care systems. A similar model will be established in Rwanda. Long-term mentorship with Botswana colleagues will help to build Rwanda's first LTS. Conclusion: Survivors involved in dedicated LTS follow-up care have better health outcomes. This indicates the need for life long survivorship care. There is a dearth of data on how to establish and operate a childhood cancer LTS program in LMIC settings. Lessons learned through this program will guide us on how to set up such program in Rwanda.

Patterns of Treatment Noninitiation and Early Loss to Follow-Up in Breast Cancer Care in Haiti

Background: Loss to follow-up after treatment initiation is a recognized and well-studied problem in cancer care programs in low- and low-middle income countries (LMIC). However, there is less literature on causes of treatment noninitiation in LMIC breast cancer programs. Hôpital Universitaire de Mirebalais (HUM) in Haiti established the main public comprehensive cancer center in the country in 2013. The facility is located in the Centre Department but serves patients from all the other nine departments (regions) of the country. Care provided within the facility is free after an initial nominal deposit, as a result of a multi-institutional collaboration with Zanmi Lasante, a local arm of Partners In Health, an international nonprofit organization, and US academic institutions. Aim: To determine the causes of treatment noninitiation and early loss to follow-up (LTFU) among a retrospective cohort of patients seen in the HUM breast cancer program. Methods: We evaluated 1371 women who had their first visit between July 1, 2013 and December 31, 2016. The list of breast cancer patients was generated from electronic medical record diagnosis codes. We identified individuals who were followed for less than 90 days (Under-90). We reviewed the patient's record to determine reason for care noninitiation and early losses. We used logistic regression analysis to determine if distance from HUM contributed to being Under-90, while controlling for demographic factors. Results: 339 (24.6%) patients in the breast cancer program were seen for less than 90-days. The two most common periods of early LTFU were prior to obtaining diagnostic biopsy (113 patients- 33%), and after referral for staging diagnostic imaging (83 patients- 24%). 49 patients (14%) had confirmed diagnosis and completed staging but never initiated treatment, while only 23 (7%) did not initiate treatment due to confirmed advanced metastatic disease or death. Majority of the patients 1254 (91.5%) came from outside the Centre region; early LTFU was more common among these patients (25.6%) compared with Centre region patients (16.2%). Using logistic regression analysis, controlling for age and rural/urban home classification, we found that the odds of Under-90 was 2.05 (95% CI: 1.22-3.45), P = 0.007, for those living outside the Centre region, compared with living in hospital's region. We repeated the analysis comparing the Centre region to the immediately adjacent regions, and more distant regions; we found the odds of Under-90 was 1.88 (95% CI: 1.12-3.18) for the adjacent regions, and 2.92 (95% CI: 1.61-5.31) for the distant regions. Conclusion: Treatment noninitiation and early losses are a significant problem in the HUM breast cancer program. As anticipated, living farther from HUM increased the odds of early LTFU. Effective interventions are needed to reduce the number of patients failing to initiate therapy, and these interventions must begin at the first contact with the oncology program.

Association Between Living in Urban Areas and Obesity in Haitian Breast Cancer Patients

Background: Obesity and metabolic syndrome (MS) have been linked to increased risk of breast cancer recurrence and mortality in prospective cohorts. These studies have mostly occurred in high-income countries. Little is known about rates of obesity and what factors predict obesity in breast cancer patients from low- and low-middle income countries (LMIC). However, there are increasing rates of obesity in the general population of LMICs. Hôpital Universitaire de Mirebalais (HUM) in Haiti established the main public comprehensive cancer center in the country in 2013. The facility serves patients from all around the country. Aim: To establish the prevalence of obesity in a retrospective cohort of breast cancer patients at HUM, and evaluate the association between living in urban areas and obesity in this population. Methods: We evaluated 1035 women who had their first visit between July 1, 2013 and December 31, 2016, with a coded diagnosis of breast cancer, and who had been followed in the HUM program for ≥ 90 days. We abstracted their first recorded height, weight and blood pressure (BP). We identified individuals who met criteria for obesity (body mass index [BMI] ≥ 30 kg/m2), systolic hypertension (systolic BP [SBP] ≥ 135 mmHg), and diastolic hypertension (diastolic BP [DBP] ≥ 90 mmHg). After exclusion of missing data in the variables of interest, the final analysis cohort was 678. We classified home commune location as rural or urban based on World Bank and UN standards. We used logistic regression analysis to determine the odds of being obese for individuals living in urban areas compared with rural dwellers. Results: 179 breast cancer patients (26.4%) had BMI ≥ 30, of which 58 (8.5%) were morbidly obese (BMI ≥ 35). 309 (45.6%) patients had systolic hypertension (HTN) and 180 (26.6%) had diastolic HTN. 417 (61.5%) lived in urban areas; 125 (30%) of urban dwellers were obese while only 20.7% of rural dwellers were obese. The crude OR for obesity in urban versus rural areas was 1.64 (95% CI: 1.16-2.36). Using logistic regression analysis and controlling for age the OR for obesity in urban areas was 1.67 (95% CI: 1.15-2.40), P = 0.0162. We did a similar analysis for morbid obesity, while controlling for age, the OR in urban compared with rural patients was 2.16 (95% CI: 1.15-4.03), P = 0.0162. There were no statistically significant differences in SBP and DBP comparing rural and urban patients. Conclusion: HUM breast cancer patients from urban areas were more likely to be obese than rural dwellers. Urban patients were twice as likely to be morbidly obese. There were no differences in HTN between the groups. Higher rates of obesity in the HUM breast cancer population is partly driven by the higher proportion of urban patients. Further studies need to be done to evaluate the causes and mediators of obesity as well as its effect on patient cancer outcome in Haiti.

Cancer Education in Rwanda: Challenges and Opportunities for Undergraduate Medical Students (The EDUCAN Project)

Background: Shortage and lack of trained cancer specialists is one of the major challenges in addressing the increasing cancer burden in low and middle income countries. Inadequate undergraduate cancer education in oncology remains a major obstacle for both task shifting to general practitioners and for training of specialists. We provide the first report of cancer education in Rwanda's undergraduate program to survey how fresh graduates are prepared to provide care for cancer patients. Aim: - Identify the current status of cancer education in one of Rwanda's two medical schools; - Provide a basis for educational reforms that target improvements of cancer knowledge and management. Methods: Anonymous online survey was sent January to June 2017 to medical students in their senior clinical years (year 5 and 6). Questions related to the demographics, medical curriculum and general oncology exposure were included in the survey. Results: Of 192 eligible students, 42% (n=80) completed the survey and were analyzed. The majority were 25 to 29 years of age and 41% were female. Internal medicine was cited to provide the most exposure to cancer patients (50%) and cancer bedside teaching (55%). Close to a half (46%) have been taught oncology formally in addition to bedside teaching. A tenth (11%) of the participants felt comfortable in attending a cancer patient, and a fifth (21%) of the students felt comfortable while addressing multimodality treatment approach. The majority (99%) of the participants preferred having a formal oncology rotation. Of particular interest, 61% of the students are interested in pursuing an oncology career path. Conclusion: There is a need to modify the current oncology undergraduate curriculum to prepare future physicians for delivering cancer care in Rwanda. Raising the profile of oncology in undergraduate medical education will complement the on-going efforts to increase the country's capacity in task shifting an in training of cancer specialists.

Attrition in trials evaluating complex interventions for schizophrenia: Systematic review and meta-analysis

Essential criteria for the methodological quality and validity of randomized controlled trials are the drop-out rates from both the experimental intervention and the study as a whole. This systematic review and meta-analysis assessed these drop-out rates in non-pharmacological schizophrenia trials. A systematic literature search was used to identify relevant trials with ≥100 sample size and to extract the drop-out data. The rates of drop-out from the experimental intervention and study were calculated with meta-analysis of proportions. Meta-regression was applied to explore the association between the study and sample characteristics and the drop-out rates. 43 RCTs were found, with drop-out from intervention ranging from 0% to 63% and study drop-out ranging from 4% to 71%. Meta-analyses of proportions showed an overall drop-out rate of 14% (95% CI: 13-15%) at the experimental intervention level and 20% (95% CI: 17-24%) at the study level. Meta-regression showed that the active intervention drop-out rates were predicted by the number of intervention sessions. In non-pharmacological schizophrenia trials, drop-out rates of less than 20% can be achieved for both the study and the experimental intervention. A high heterogeneity of drop-out rates across studies shows that even lower rates are achievable.

Fine-needle aspiration cytology of disseminated Kaposi sarcoma of the bone in an AIDS patient

BACKGROUND

Kaposi sarcoma (KS) is a vascular neoplasm associated with human herpesvirus 8 (HHV-8). Skin and mucous membranes are the most common sites, but other organs may be involved. Skeletal KS is rare and occurs either by direct spread of mucocutaneous lesions or through dissemination. Patients present with bone pain and lytic lesions for which they may undergo fine-needle aspiration (FNA). While there are about 70 published case reports of skeletal KS, there is limited literature specifically describing its cytomorphology. Our literature search yielded only a single prior reported case of FNA biopsy of skeletal KS in a Nigerian AIDS patient.

CASE

We present a case of disseminated KS of the axial skeleton in a 45-year-old African-American man with AIDS which was diagnosed on FNA cytologic examination. The patient presented with multiple lytic lesions in the axial skeleton. The aspirate, core-needle biopsy and touch imprint cytology of a bone lesion demonstrated clusters of spindle and epithelioid cells in radial and streaming arrangement with indistinct intercytoplasmic borders, elongated nuclei, fine chromatin and inconspicuous nucleoli. Immunohistochemical studies revealed positivity for HHV-8 and vascular markers. The cytomorphologic and ancillary features of the case are presented and discussed.

Protection of non-human primates against rabies with an adenovirus recombinant vaccine

Rabies remains a major neglected global zoonosis. New vaccine strategies are needed for human rabies prophylaxis. A single intramuscular immunization with a moderate dose of an experimental chimpanzee adenovirus (Ad) vector serotype SAd-V24, also termed AdC68, expressing the rabies virus glycoprotein, resulted in sustained titers of rabies virus neutralizing antibodies and protection against a lethal rabies virus challenge infection in a non-human primate model. Taken together, these data demonstrate the safety, immunogenicity, and efficacy of the recombinant Ad-rabies vector for further consideration in human clinical trials.

Temperature-dependent prey capture efficiency and foraging modes of brown trout Salmo trutta

Prey capture success and foraging mode were studied in brown trout Salmo trutta at temperatures ranging from 5.7 to 14.0° C. At low temperatures, there was a positive correlation between prey capture success and the proportion of time that the fish spent holding feeding stations. This correlation was not found at temperatures >10° C.

Genetic component of bee odor in kin recognition

The primitively social sweat bee, Lasioglossum zephyrum, blocks the entry into its nest of most conspecifics from other colonies. Laboratory inbreeding of these bees produced lines which showed a positive linear relationship between the coefficient of relationship of bees tested and how often they permitted non-nestmates to pass them. The most probable mechanism is a genetically determined odor coupled with a learned component by which guard bees discriminate between odors of close kin and other bees.

Efficacy and cardiac safety of adjuvant trastuzumab-based chemotherapy regimens for HER2-positive early breast cancer

BACKGROUND

Trastuzumab-based adjuvant therapy has become the standard of care for human epidermal growth factor receptor-2 (HER2)-positive early breast cancer (EBC). Both anthracycline- and non-anthracycline-containing trastuzumab regimens are approved in the United States, but cardiotoxicity is increased with anthracycline-containing regimens.

DESIGN

This paper reviews published and reported efficacy and cardiac safety data from the adjuvant trastuzumab trials [National Surgical Adjuvant Breast and Bowel Project (NSABP) B-31/North Central Cancer Treatment Group (NCCTG) N9831, Breast Cancer International Research Group (BCIRG) 006, Herceptin Adjuvant (HERA), FinHer, and Programme Adjuvant Cancer Sein (PACS) 04].

RESULTS

The addition of trastuzumab to adjuvant chemotherapy significantly improved disease-free survival (from 24% to 58%) in five of the six trials. Overall survival was significantly improved (23%-35%) in the large trials. In NSABP B-31/ NCCTG N9831, 5.0%-6.6% of patients who received doxorubicin and cyclophosphamide (AC) were unable to receive trastuzumab. Cardiac event rate was highest in the anthracycline-containing trastuzumab arms (1.9%-3.8%) and lowest with the regimen of docetaxel, carboplatin, and trastuzumab (TCH) (0.4%).

CONCLUSIONS

Incorporation of trastuzumab into anthracycline and non-anthracycline adjuvant chemotherapy regimens has substantially improved outcomes in HER2-postive EBC. The TCH regimen has the lowest rates of cardiac dysfunction, but uncertainty exists regarding the relative efficacy of TCH compared with anthracycline-containing trastuzumab regimens. Cardiac risk factor assessment can aid in selection of trastuzumab-based adjuvant therapy regimens.

Reduction in radiation-induced morbidity by use of an intercurrent boost in the management of early-stage breast cancer

PURPOSE

Electron or photon boost immediately following whole-breast irradiation performed after conservation surgery for early-stage breast cancer is the accepted standard of care. This regimen frequently results in Grade III dermatitis, causing discomfort or treatment interruption. Herein, we compare patients treated with whole-breast irradiation followed by boost compared with a cohort with a planned intercurrent radiation boost.

METHODS AND MATERIALS

The records of 650 consecutive breast cancer patients treated at Allegheny General Hospital (AGH) between 2000 and 2008 were reviewed. Selected for this study were 327 patients with T1 or T2 tumors treated with external beam radiotherapy postlumpectomy. One hundred and sixty-nine patients were treated by whole-breast radiotherapy (WBRT) followed by boost at completion. One hundred fifty-eight were treated with a planned intercurrent boost (delivered following 3,600 cGy WBRT). The mean whole breast radiation dose in the conventionally treated group was 5,032 cGy (range, 4500-5400 cGy), and the mean whole breast dose was 5,097 cGy (range, 4860-5040 cGy) in the group treated with a planned intercurrent boost.

RESULTS

The occurrence of Grade III dermatitis was significantly reduced in the WBRT/intercurrent boost group compared with the WBRT/boost group (0.6% vs. 8.9%), as was the incidence of treatment interruption (1.9% vs. 14.2%). With a median follow-up of 32 months and 27 months, respectively, no significant difference in local control was identified.

CONCLUSIONS

Patients treated with intercurrent boost developed less Grade III dermatitis and unplanned treatment interruptions with similar local control.

Aggressive interactions between Solenopsis invicta and Linepithema humile (Hymenoptera: Formicidae) under laboratory conditions

The Argentine ant, Linepithema humile (Mayr), and the red imported fire ant, Solenopsis invicta Buren, are natural agonists in their country of origin. Since the first report of L. humile in California in 1907 its range expanded statewide, displacing native ant species wherever it spread. Since the discovery of established populations of S. invicta in southern California in 1998, it has been restricted to discrete areas of southern California. However, as these discrete populations expand, they are encountering large populations of L. humile, which are effective competitors for available resources and are particularly aggressive in their encounters with other ant species such as S. invicta. Most Dolichoderine ants such as L. humile do not prefer to forage on baits made with defatted corn grit and soybean oil typically used in red imported fire ant control programs. Applications of these baits in areas where distributions of these species overlap might selectively affect populations of S. invicta and give L. humile a competitive advantage. Three laboratory experiments were conducted to determine the competitive outcomes between S. invicta pitted against L. humile: 1) agonistic behavior of workers in small arenas, 2) colony interactions with different population ratios, and 3) the effects of pyriproxyfen on the competitiveness of S. invicta against L. humile. Populations of S. invicta consisting of major workers killed more L. humile than did minors or a mixture of majors and minors. When paired against L. humile colonies consisting of 1,100 workers, colonies consisting of 38 S. invicta workers were easily defeated by L. humile. Colonies consisting of 450 S. invicta workers plugged their nest entrances, but they were ultimately defeated by L. humile after 13 d. The S. invicta colonies consisting of 1,100 workers took control of the bridge connecting the colonies, invaded the L. humile colony, killed the Argentine ant queens, and removed their brood. Pyriproxyfen-treated fire ant workers took significantly longer to chase the Argentine ants from a connecting bridge than did untreated fire ants. Thus, fire ant baits may have long-term effects on intercolonial aggression between S. invicta and L. humile, especially when Argentine ant populations are high in the summer.

Multidisciplinary treatment of synchronous primary rectal and prostate cancers

BACKGROUND

A 58-year-old Caucasian man with a history of irritable bowel syndrome and occasional rectal bleeding presented with a 4-week history of progressive, bright red blood per rectum. A digital rectal examination revealed a 3 cm distal, midrectal mass. Laboratory tests showed an elevated serum prostate-specific antigen of 32 ng/ml but other physical and medical examinations were unremarkable.

INVESTIGATIONS

Digital rectal examination, colonoscopy, rectal mass biopsy, endorectal ultrasound, transrectal ultrasound-guided prostate biopsy, CT scan and MRI.

DIAGNOSIS

Clinical stage III (T3N1M0), moderately differentiated adenocarcinoma of the rectum and clinical stage II (T1cN0M0) adenocarcinoma of the prostate.

MANAGEMENT

Intensity-modulated radiation therapy, chemoradiation, chemotherapy, hormone therapy and surgery.

Assessing an educational intervention to improve physician violence screening skills

OBJECTIVES

Health professionals play an integral role in assessing the risk of violence in their patients. However, there have been few evaluations of violence prevention education programs for health care personnel. The objective of this study was to evaluate the effects of a violence-screening education program on pediatric residents' and medical students' comfort level and skills in the identification and management of violence risks.

SETTING

Adolescent clinic of a tertiary care pediatric hospital.

PARTICIPANTS

Fifty-six second-year residents and third-year medical students assigned to a 4-week adolescent clinic rotation.

DESIGN

Randomized, controlled comparison study conducted over a 1-year period.

INTERVENTION

On alternate months, medical students and residents in the intervention group participated in a 3-hour workshop on violence prevention. The workshop included a didactic session with an overview of firearm, media, and sexual violence; a discussion of risk factors for adolescent violence; and training on the approach to the adolescent interview. Participants also discussed violence risks in the community with a panel of teen health educators, engaged in one-on-one role play with the youth educators, and received feedback on their violence screening skills. The control group received the standard ambulatory clinic manual with articles on violence prevention.

EVALUATION METHODS

All participants completed prerotation and postrotation questionnaires assessing their self-reported screening practices, as well as perceived importance and confidence in violence screening. Participants also interviewed and examined an adolescent standardized patient (SP) in the clinic. SPs completed evaluations on the content of the residents' and students' screening, their interpersonal skills, and their skill in the identification and management of the violence-related problem.

RESULTS

Over 12 months, 30 control and 26 intervention participants were recruited. There were no differences in prerotation questionnaire scores for intervention and control groups in screening practices, perceived importance and confidence in violence screening. Postrotation intervention participants reported more screening compared with controls on violence in school/neighborhood and fighting history. There was also greater perceived importance in asking about access/use of weapons and violence in school/neighborhood. Intervention participants also had improved performance compared with controls on SP evaluations of screening for violence, identification and management of the violence-related scenario, and interpersonal skills.

CONCLUSION

A violence prevention education program with teen health educators improved participants' self-reported violence questioning, as well as increased perceived comfort and importance in violence screening. Participants in the program also improved their identification and management of a standardized violence-related scenario presented in an adolescent clinic setting. adolescent violence, physician education, violence risk screening.

Considerations in choosing a primary endpoint that measures durability of virological suppression in an antiretroviral trial

OBJECTIVES

At present, many clinical trials of anti-HIV-1 therapies compare treatments by a primary endpoint that measures the durability of suppression of HIV-1 replication. Several durability endpoints are compared.

DESIGN

Endpoints are compared by their implicit assumptions regarding surrogacy for clinical outcomes, sample size requirements, and accommodations for inter-patient differences in baseline plasma HIV-1-RNA levels and in initial treatment response.

METHODS

Virological failure is defined by the non-suppression of virus levels at a prespecified follow-up time T(early virological failure), or by relapse. A binary virological failure endpoint is compared with three time-to-virological failure endpoints: time from (i) randomization that assigns early failures a failure time of T weeks; (ii) randomization that extends the early failure time T for slowly responding subjects; and (iii) virological response that assigns non-responders a failure time of 0 weeks. Endpoint differences are illustrated with Agouron's trial 511.

RESULTS

In comparing high with low-dose nelfinavir (NFV) regimens in Agouron 511, the difference in Kaplan-Meier estimates of the proportion not failing by 24 weeks is 16.7% (P = 0.048), 6.5% (P = 0.29) and 22.9% (P = 0.0030) for endpoints (i), (ii) and (iii), respectively. The results differ because NFV suppresses virus more quickly at the higher dose, and the endpoints weigh this treatment difference differently. This illustrates that careful consideration needs to be given to choosing a primary endpoint that will detect treatment differences of interest.

CONCLUSION

A time from randomization endpoint is usually recommended because of its advantages in flexibility and sample size, especially at interim analyses, and for its interpretation for patient management.

Toxicity and repellency of borate-sucrose water baits to Argentine ants (Hymenoptera: Formicidae)

The oral toxicity of boron compounds to the Argentine ant, Linepithema humile (Mayr), was evaluated in laboratory tests. The ants were provided 25% sucrose water containing 0.5 and 1% boric acid, disodium octaborate tetrahydrate, and borax. Lethal times of these solutions were a function of the concentration of boron. In field tests, the ants showed no discrimination between disodium octaborate tetrahydrate and boric acid. There was a significant reduction in consumption of sucrose water with > 1% boric acid.

Teaching prevention in pediatrics

Pediatrics has attempted to inculcate the "culture of prevention" into practice, both through anticipatory guidance in well-child care and through behavioral interventions in sick care. The effectivenesses of many components of well-child care have not been conclusively demonstrated, particularly in health education, counseling, and anticipatory guidance, nor has teaching prevention in pediatrics been thoroughly evaluated. This article reviews methods of teaching prevention in pediatrics and highlights innovative programs. Teaching programs use the wide range of approaches now common in medical education, in a variety of inpatient and outpatient sites. Programs across the country are trying new approaches to teaching traditional topics or are introducing new topics into their curricula. Examples of specific programs are given, organized by the themes of the programs. The field needs to develop in three major directions. First, there is a need to develop competencies and curricula in prevention issues of contemporary importance, including the new morbidities, cross-cultural issues, cost-effectiveness, quality of care, and practice in managed care and other community settings. Second, further work is needed to evaluate programs and measure educational outcomes. This feedback must in turn be used to redefine competencies, curricula, and programs, Third, there needs to be an accessible clearinghouse, and educational tools need to be disseminated. To be effective, a curriculum for prevention in pediatrics cannot stand alone, but must be part of a vertically and horizontally integrated curriculum. Further, creating horizontally and vertically integrated curricula in prevention teaching across disciplines should be the standard.

Argentine ant (Hymenoptera: Formicidae) trail pheromone enhances consumption of liquid sucrose solution

We investigated whether the Argentine ant, Linepithema humile (Mayr), trail pheromone, Z9-16:Ald, could enhance recruitment to and consumption of liquid sucrose solutions. All tests were done as paired comparisons with a 10% sucrose solution as food. In the laboratory, mixing 20 microl of a 10-microg/ml solution of the pheromone with 50 microl of the 10% sucrose solution increased the number of ants feeding by >150%. In a field test, we combined the trail pheromone with a 10% sucrose solution in 50-ml vials. These vials were covered with a plastic membrane that has 1.5-mm-diameter holes punched uniformly across its surface. Ants could drink from the holes after the vials were inverted. For half of the vials, 1 microg of the pheromone was put onto the plastic membrane before the vials were filled with a 10% sucrose solution. The remaining vials had no pheromone on the plastic membrane. After 4 h we measured the consumption in each vial. Bait consumption with the pheromone was enhanced by 29%. In a 2nd series of tests, vials were left outside for 24 h. The consumption rate was 33% higher with the pheromone compared with the controls that didn't have pheromone.

Calf augmentation using free TRAM flap

Augmentation of the calf for correction of contour deformities has been most frequently performed utilizing silicone implants. Results of such implants have often been unsatisfactory. We report the case of a 27-year-old woman who chose the use of a transverse rectus abdominis myocutaneous (TRAM) free flap for correction of a left calf contour deformity from childhood polio. This is the first report of calf augmentation with the use of a TRAM free flap and excellent results were obtained.

Effects of estrogen replacement therapy on the lipoprotein profile in postmenopausal women with ESRD

BACKGROUND

Patients with ESRD have excessive cardiovascular morbidity and mortality. In postmenopausal women with normal renal function, estrogen replacement therapy decreases cardiovascular mortality by 50%, in part because of their beneficial effects on the lipoprotein profile. Because of similarities in the lipoprotein profile between healthy, postmenopausal women, and women with ESRD, we examined the effects of estrogen replacement on lipoproteins in 11 postmenopausal women with ESRD.

METHODS

In a randomized, placebo-controlled crossover study (8 week treatment arms) using 2 mg daily of oral, micronized estradiol, 11 postmenopausal women with ESRD were treated. Neither baseline lipid nor lipoprotein abnormalities were used as entry criteria for study participation.

RESULTS

Blood estradiol levels were 19 +/- 4 with placebo and 194 +/- 67 pg/ml (P = 0.024) with estradiol treatment. Total HDL cholesterol concentrations increased from 52 +/- 19 mg/dl to 61 +/- 20 mg/dl (16%), with placebo and estradiol treatments, respectively (P = 0.002). Apolipoprotein A1 increased by 24.6% (P = 0.0002) with estradiol intervention. HDL2 concentrations were 19 +/- 13 with placebo and 24 +/- 16 with estradiol treatment (P = 0.046). There were no differences in total or LDL cholesterol, other lipoprotein fractions including Lp(a), and triglycerides with 2 mg daily estradiol treatment. No significant side effects were observed.

CONCLUSIONS

Therefore, using standard dosage regimens for estrogen replacement therapy in postmenopausal women with ESRD, HDL cholesterol is increased to an extent that would be expected to improve their cardiovascular risk profile. Further studies are needed to assess whether estrogen replacement therapy decreases the incidence or severity of cardiovascular disease in ESRD patients to a similar degree compared with other women.