Labour induction near term for women aged 35 or over: an economic evaluation

OBJECTIVE

Induction of labour at 39 weeks for nulliparous women aged 35 years and over may prevent stillbirths and does not increase caesarean births, so it may be popular. But the overall costs and benefits of such a policy have not been compared.

DESIGN

A cost-utility analysis alongside a randomised controlled trial (the 35/39 trial).

SETTING

Obstetric departments of 38 UK National Health Service hospitals and one UK primary-care trust.

POPULATION

Nulliparous women aged 35 years or over on their expected due date, with a singleton live fetus in a cephalic presentation.

METHODS

Costs were estimated from the National Health Service and Personal Social Services perspective and quality-adjusted life-years (QALYs) were calculated based on patient responses to the EQ-5D at baseline and 4 weeks.

MAIN OUTCOME MEASURES

Data on antenatal care, mode of delivery, analgesia in labour, method of induction, EQ-5D (baseline and 4 weeks postnatal) and participant-administered postnatal health resource use data were collected.

RESULTS

The intervention was associated with a mean cost saving of £263 and a small additional gain in QALYs (though this was not statistically significant), even without considering any possible QALY gains from stillbirth prevention.

CONCLUSION

A policy of induction of labour at 39 weeks for women of advanced maternal age would save money.

TWEETABLE ABSTRACT

A policy of induction of labour at 39 weeks of gestation for women of advanced maternal age would save money.

Poster - Thur Eve - 21: ROC analysis in patient specific quality assurance

INTRODUCTION

Many institutions rely on a patient specific measurement for IMRT/VMAT patient QA. In diagnostic imaging, radiologists use Receiver Operator Curves (ROC) to help quantify the value of a diagnostic imaging test. The purpose of this work is to investigate the value or ROC methodology for patient specific IMRT QA.

METHODS AND MATERIALS

Beam fluences for 34 prostate IMRT patients were analyzed using gamma analysis. For half of these, measurements were done using the planned beam fluences. For the rest, perturbations to the MLC leaf positions were introduced. Gamma analysis was then used to measure fluence differences. Assuming that the unperturbed fluencies were positive measurements, distributions of true positive and false negatives were calculated.

RESULTS

For poorly performing beam delivery systems the choice of γ-DTA criterion has little effect on test sensitivity and specificity. The AUC is increased by about 10% for high performance beam delivery systems. For a 3%/3mm γ-DTA condition, ideal cut off values are reasonably independent of MLC performance. At a tighter γ-DTA condition of 2%/2mm, then the optimal sensitivity and specificity of the test is more dependent on MLC performance.

DISCUSSION

For a pass-fail test such as the γ-DTA map is, it is important to choose an optimal cut off value to maximize the sensitivity and specificity of the test. ROC methodology allows users to follow a prescriptive method to obtain ideal cut-off values for gamma analysis, and to assess improvements in sensitivity and specificity for higher performing beam delivery system.

Poster - Thur Eve - 54: A software solution for ongoing DVH quality assurance in radiation therapy

PURPOSE

A program has been developed in MATLAB for use in quality assurance of treatment planning of radiation therapy. It analyzes patient DVH files and compiles dose volume data for review, trending, comparison and analysis.

MATERIAL AND METHODS

Patient DVH files are exported from the Eclipse treatment planning system and saved according to treatment sites and date. Currently analysis is available for 4 treatment sites; Prostate, Prostate Bed, Lung, and Upper GI, with two functions for data report and analysis: patient-specific and organ-specific. The patient-specific function loads one patient DVH file and reports the user-specified dose volume data of organs and targets. These data can be compiled to an external file for a third party analysis. The organ-specific function extracts a requested dose volume of an organ from the DVH files of a patient group and reports the statistics over this population. A graphical user interface is utilized to select clinical sites, function and structures, and input user's requests.

RESULTS

We have implemented this program in planning quality assurance at our center. The program has tracked the dosimetric improvement in GU sites after VMAT was implemented clinically. It has generated dose volume statistics for different groups of patients associated with technique or time range.

CONCLUSION

This program allows reporting and statistical analysis of DVH files. It is an efficient tool for the planning quality control in radiation therapy.

The emerging role of IG-IMRT for palliative radiotherapy: a single-institution experience

Many modern radiotherapy centers now have image-guided intensity-modulated radiotherapy (ig-imrt) tools available for clinical use, and the technique offers many options for patients requiring palliative radiotherapy. We describe a single-institution experience with ig-imrt for short-course palliative radiotherapy, highlighting the unique situations in which the technique can be most effectively used.

A Phase II Study (FINDER 2) Comparing Three Dosing Regimens of Fulvestrant in Postmenopausal Women with Estrogen Receptor-Positive Advanced Breast Cancer

Background: The Faslodex Investigation of Dose evaluation in Estrogen Receptor-positive (ER+) advanced breast cancer (FINDER) 2 study investigated the efficacy, safety, and pharmacokinetic (PK) profile of 3 fulvestrant dosing regimens in postmenopausal women with ER+ advanced breast cancer, recurring/progressing after prior endocrine therapy.Objectives: Primary: to evaluate the objective response rate (ORR). Secondary included assessment of: time to progression (TTP), clinical benefit rate (CBR), duration of response (DOR), tolerability, and PK parameters.Methods: This randomized, double-blind, parallel-group, multicenter, Phase II study, evaluated patients (pts) randomized 1:1:1 to different doses of fulvestrant: 250 mg (approved dose [AD]; given on Days 0, 28 and every 28 days thereafter), 250 mg plus loading dose (LD; 500 mg on Day 0, then 250 mg on Days 14, 28 and every 28 days thereafter), and 500 mg (high dose [HD]; Days 0, 14 and 28 and every 28 days thereafter). Treatment continued until disease progression, or until any other criterion for discontinuation was met.Results: In total, 144 pts were randomized from 34 centers in 8 countries and 143 received treatment: fulvestrant AD (n=47); LD (n=50); HD (n=46). ORRs were: 8.5% (95% confidence interval [CI] 2.4-20.4%), 5.9% (1.2-16.2%), and 15.2% (6.3-28.9%) in the AD, LD, and HD arms, respectively. CBRs were: 31.9% (95% CI 19.1-47.1%), 47.1% (32.9-61.5%), and 47.8% (32.9-63.1%) for the AD, LD, and HD arms, respectively. Median TTP was numerically longer for the HD (6.0 months) and LD (6.1 months) arms vs the AD arm (3.1 months). The low number of responders in all treatment arms prevented DOR assessment. The incidence of adverse events (AEs) was similar in all groups (76.6% AD, 72.0% LD, 69.6% HD); few pts experienced serious AEs (4 pts AD, 9 LD, 4 HD) with no clustering of event type. AEs with an incidence of ≥10% (in any arm) were back pain, arthralgia, fatigue, injection-site pain, nausea, dyspnea, cough, and hot flash. Concentrations in the AD arm approached steady state in the 3rd month of dosing and within the 1st month for LD and HD. Exposure (AUC, Cmin and Cmax) appeared to be linear across the dose range studied and, for the 250mg arms, similar to that previously reported in Western populations (Studies 9238IL/0020 & 0021).Conclusion: No statistically significant differences in efficacy could be proven between AD, LD and HD given the widely overlapping CIs for median TTP. The tolerability profile was similar across the three dosing regimens. Steady-state concentrations were achieved earlier with LD and HD. A parallel study in Japanese pts will be used for comparisons of fulvestrant efficacy and tolerability in Japanese and non-Japanese pts.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4095.

Simultaneous treatment of multiple basal cell carcinoma lesions

We present a rare case of advanced basal cell carcinoma where multiple large lesions, located on the anterior chest wall and back, were treated simultaneously using tomotherapy (TomoTherapy HiArt; TomoTherapy Inc, Madison, WI). A 74-year-old man presented with seven to eight separate extensive lesions on his body, some with a duration of 7 years or more. The image-guidance component of tomotherapy allowed daily verification of the position of the target and critical structures, enabling accurate targeting in the vicinity of sensitive critical structures. Intensity-modulated radiotherapy on a conventional linear accelerator would have required junctioning of multiple complex plans, owing to the large treatment area, and most likely sequential treatment strategies to target anterior and posterior lesions. Helical tomotherapy allowed the three largest lesions to be treated simultaneously and thus eliminated the need for multiple courses of treatment.

Consultation patterns and provision of contraception in general practice before teenage pregnancy: case-control study

OBJECTIVES

To determine patterns of consultation in general practice and provision of contraception before teenage pregnancy.

DESIGN

Case-control study, with retrospective analysis of case notes.

SETTING

14 general practices in Trent region.

SUBJECTS

240 registered patients (cases) with a recorded conception before the age of 20. Three controls per case were matched by age and practice.

MAIN OUTCOME MEASURES

Consultations in general practice and provision of contraception in the 12 months before conception and recorded provision of contraception at any time before conception.

RESULTS

Overall, 223 cases (93%) had consulted a health professional at least once in the year before conception, 171 (71%) had discussed contraception in this time, and 121 (50%) had been prescribed oral contraception. Cases were more likely to have consulted in the year before conception than controls (odds ratio 2. 70, 95% confidence interval 1.56 to 4.66). Most of the difference was owing to consultation for contraception. Overall, 53 cases (22%) resulted in a termination of pregnancy. Cases whose pregnancy ended in a termination were more likely to have received emergency contraception than either their controls (3.21, 1.32 to 7.79) or cases resulting in other outcomes (3.01, 1.06 to 8.51).

CONCLUSIONS

Most teenagers who became pregnant attended general practice in the year before pregnancy, and many had sought contraceptive advice. The reluctance of teenagers to attend general practice for contraception may be less than previously supposed. The association between provision of emergency contraception and pregnancy ending in termination emphasises the need for continuing follow up of teenagers consulting for this form of contraception.

Biodegradable estradiol microspheres do not affect uterine involution or characteristics of postpartum estrus in mares

Quarterhorse mares were used to investigate effects of estradiol-17beta on uterine involution, duration of estrus, interval to ovulation, and fertility achieved by breeding on the first postpartum estrus. On the day of foaling, mares were injected with biodegradable poly (DL-lactide) microspheres containing either 100 mg estradiol-17beta (25 mares) or no drug (27 mares). The treatment period was considered to last for 12 to 15 d. Estrus was determined by teasing mares (n=16) with a stallion. Ovulation was detected by transrectal ultrasonographic examination of ovaries (n=48). On Days 6, 11 and 16 post partum, transrectal ultrasonography was used to measure cross-sectional diameters of the uterine body, uterine horns, and fluid within the uterine lumen (n=28). Uteri were swabbed for bacteriologic culture, and uterine biopsies were obtained from the previously gravid uterine horn on Days 11 and 16 post partum, for assessment of endometritis and morphometric analysis of endometrial histioarchitecture (n=19). Twenty-two mares were bred on foal-heat, and pregnancy was determined by transrectal ultrasonography on 14 to 16 and 30 to 35 d after breeding. With only one exception (diameter of previously gravid uterine horn on Day 11), mean values for all measures of uterine involution did not differ between treatment groups (P > 0.05). No differences were detected between treatment group means for length of estrus or interval to ovulation (P > 0.05). No differences were detected between treatment group liklihoods for recovery of potential bacterial pathogens, presence of endometritis, or presence of intrauterine fluid at 11 or 16 d post partum (P > 0.05). Pregnancy rate of mares treated with estradiol (5 11 ; 45%) was not different from that of control mares (9 11 ; 82%; P > 0.05). Estradiol treatment did not hasten uterine involution, increase duration of estrus, delay ovulation, or increase fertility in these postpartum mares.

Elevated serum alpha fetoprotein and normal liquor alpha fetoprotein values in association with an abdominal pregnancy

A case report is described in which abdominal pregnancy was misdiagnosed by ultrasound scanning as a pregnancy within a horn of a bicornuate uterus. Two serum alpha fetoprotein (SAFP) results were greatly elevated and an amniocentesis was performed, the liquor alpha fetoprotein (LAFP) and karyotype were normal. Elective Caesarean section was performed at 38 weeks for a persistent transverse lie and an abdominal pregnancy was found. The outcome was excellent for both the mother and child. This is the first reported case of amniocentesis and measurement of LAFP in an abdominal pregnancy and confirms abdominal pregnancy as a rare cause of an elevated SAFP.

Epidermoid cyst of the sole

A case is presented of an epidermoid cyst on the sole of the foot. Although few dermatologists have ever encountered this entity, a number of cases have been reported in the podiatric literature. Careful clinical examination should lead to the recognition of more of these lesions, which are easily confused with warts and calluses.

The effect of maternal labetalol on the newborn infant

The possibility that placentally-transferred labetalol might cause sympathetic blockade in the newborn infant was examined by measuring systolic blood pressure, heart and respiratory rates, palmar sweating, blood glucose and the metabolic and vasomotor responses to cold stress. Measurements were made serially over the first 72 h of life in 22 term infants, 11 born to mothers treated with labetalol and 11 carefully matched controls. Infants of mothers treated with labetalol showed a mild transient hypotension which had disappeared within 24 h [mean systolic blood pressure at 2 h, 58.8 (SEM 2.4) mmHg compared with 63.3 (SEM 3.0) mmHg for controls, P less than 0.05]. There were no other significant differences between the two groups. It is concluded that labetalol does not cause clinically important sympathetic blockade in the mature newborn infant.

Ganglion of the ankle

Ganglia rarely occur on the ankle. We report a case of a ganglion on the medial malleolus, originating from the sheaths of the flexor digitorum longus and tibialis posterior tendons, which posed a diagnostic dilemma for the patient's family physician, for her dermatologist, and for the orthopedic surgeon seen in consultation. Ganglia should be considered in the differential diagnosis of all periarticular cystic lesions.

Preoperative dilatation of the first-trimester cervix: a comparison between Lamicel and 16,16-dimethyl-trans delta 2 prostaglandin E1 methyl ester pessaries

Both Lamicel and 16,16-dimethyl-trans delta 2 prostaglandin (PG) E1 methyl ester pessaries have recently been shown to be effective for cervical dilatation prior to first-trimester abortion. In the study described, the force required to dilate the cervix prior to vaginal termination of pregnancy was measured in three groups of patients--a control group, a group which received Lamicel , and a group which received 16,16-dimethyl-trans delta 2 PGE1 methyl ester pessaries. The total force required to dilate the cervix to 10 mm was significantly reduced in the treated groups, but there was no significant difference between the two treatment regimens. The use of Lamicel is associated with fewer side effects.