Oral Cavity Cancers: Ethnic Differences in Radiotherapy Outcomes in a Majority South Asian Leicester Community

AIMS

Squamous cell carcinoma oral cavity cancers (SCCOCCs) have a higher reported incidence in South Asian countries. We sought to compare presenting stage and outcome by ethnicity in patients with SCCOCC treated with radical radiotherapy in a single centre in the UK.

MATERIALS AND METHODS

All patients with SCCOCC treated with radical radiotherapy at an oncology department in Leicester (UK) between 2011 and 2017 were identified. Baseline demographic, clinical data and 2-year treatment outcomes were reported.

RESULTS

Of the 109 patients included, 40 were South Asian and 59 were non-South Asian. South Asians had significantly poorer 2-year disease-free survival compared with non-South Asians (54.6% versus 73%, P = 0.01).

CONCLUSION

Our analysis suggests that South Asians with SCCOCC have poorer outcomes despite a younger age and similar disease characteristics. Environmental, social factors and differing biology of disease may be responsible and further research is required to inform targeted interventions.

Concurrent Staphylococcus aureus bacteraemia in Plasmodium vivax malaria Infection: A report of two cases from western India

Malaria and concurrent bacteraemia cases have been reported globally, mostly in association with Plasmodium falciparum malaria. In comparison, concurrent bacteraemia with Plasmodium vivax infected patients is reported rarely. However, considering unavailability of blood culture testing and widespread community and empirical antibiotic usage in low- and middle-income countries (LMICs), the frequency of bacteraemia and P. vivax co-infection may be much higher. We reported two cases of Staphylococcus aureus bacteraemia with P. vivax malaria infection. Both patients presented with high grade fever and chills with unremarkable systemic examination. Liver enzymes were raised along with inflammatory markers. Simultaneous diagnosis of methicillin sensitive S. aureus bacteraemia was done using automated blood culture, automated identification and sensitivity testing system. P. vivax malaria was confirmed with microscopy, antigen detection test and molecular test. Patients recovered uneventfully with antimalarial drugs and antibiotics.

Identification and Antifungal Drug Susceptibility Pattern of Candida auris in India

Introduction

Candida auris has turned up as a multidrug-resistant nosocomial agent with outbreaks reported worldwide. The present study was conducted to evaluate the antifungal drug susceptibility pattern of C. auris.

Methods

Isolates of C. auris were obtained from clinically suspected cases of candidemia from January 2019 to June 2021. Identification was done with matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) and panfungal DNA polymerase chain reaction (PCR), followed by sequencing. Antifungal susceptibility testing was performed with broth microdilution method.

Results

Out of 50 isolates C. auris, 49 were identified by MALDI-TOF and one isolate was identified with panfungal DNA PCR followed by sequencing. For fluconazole, 84% (n = 42) isolates were found to be resistant and 16% (n = 8) isolates were susceptible (minimum inhibitory concentrations [MICs] range 0.5-16). Posaconazole exhibited potent activity, followed by itraconazole. For amphotericin B, only 6% (n = 3) isolates were resistant with MICs ≥2 μg/mL. Only 4% (n = 2) isolates exhibited resistance to caspofungin. No resistance was noted for micafungin and anidulafungin. One (2%) isolate was found to be panazole resistant. One (2%) isolate was resistant to fluconazole, amphotericin B, and caspofungin.

Conclusion

Correct identification of C. auris can be obtained with the use of MALDI-TOF and sequencing methods. A small percentage of fluconazole-sensitive isolates are present. Although elevated MICs for amphotericin B and echinocandins are not generally observed, the possibility of resistance with the irrational use of these antifungal drugs cannot be denied. Pan azole-resistant and pan drug-resistant strains of C. auris are on rise.

Cardiovascular adverse events are associated with usage of immune checkpoint inhibitors in real-world clinical data across the United States

Background

Immune checkpoint inhibitors (ICIs) can cause life-threatening cardiovascular adverse events (CVAEs) that may not be attributed to therapy. The outcomes of clinical trials may underestimate treatment-related adverse events due to restrictive eligibility, limited sample size, and failure to anticipate selected toxicities. We evaluated the incidence and clinical determinants of CVAEs in real-world population on ICI therapy.

Patients and methods

Among 2 687 301 patients diagnosed with cancer from 2011 to 2018, 16 574 received ICIs for any cancer. Patients in the ICI and non-ICI cohorts were matched in a 1 : 1 ratio according to age, sex, National Cancer Institute comorbidity score, and primary cancer. The non-ICI cohort was stratified into patients who received chemotherapy (N = 2875) or targeted agents (N = 4611). All CVAEs, non-cardiac immune-related adverse events occurring after treatment initiation, baseline comorbidities, and treatment details were identified and analyzed using diagnosis and billing codes.

Results

Median age was 61 and 65 years in the ICI and non-ICI cohorts, respectively (P < 0.001). ICI patients were predominantly male (P < 0.001). Lung cancer (43.1%), melanoma (30.4%), and renal cell carcinoma (9.9%) were the most common cancer types. CVAE diagnoses in our dataset by incidence proportion (ICI cohort) were stroke (4.6%), heart failure (3.5%), atrial fibrillation (2.1%), conduction disorders (1.5%), myocardial infarction (0.9%), myocarditis (0.05%), vasculitis (0.05%), and pericarditis (0.2%). Anti-cytotoxic T-lymphocyte-associated protein 4 increased the risk of heart failure [versus anti-programmed cell death protein 1; hazard ratio (HR), 1.9; 95% confidence interval (CI) 1.27-2.84] and stroke (HR, 1.7; 95% CI 1.3-2.22). Pneumonitis was associated with heart failure (HR, 2.61; 95% CI 1.23-5.52) and encephalitis with conduction disorders (HR, 4.35; 95% CI 1.6-11.87) in patients on ICIs. Advanced age, primary cancer, nephritis, and anti-cytotoxic T-lymphocyte-associated protein 4 therapy were commonly associated with CVAEs in the adjusted Cox proportional hazards model.

Conclusions

Our findings underscore the importance of risk stratification and cardiovascular monitoring for patients on ICI therapy.

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Patient claims data across the United States were used to study cardiovascular adverse events (CVAEs) after ICI treatment.

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Patients on ICI treatment for advanced cancer have a higher incidence of CVAEs than previously reported.

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Median time to CVAE onset was significantly shorter with ICIs (~3 months) than with non-ICI systemic therapy (~8 months).

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Anti-CTLA-4 monotherapy or combination had a higher risk of heart failure and stroke than anti-PD-1 therapy (1.5-2 folds).

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Age, male sex, cancer type, nephritis, pneumonitis, and anti-CTLA-4 therapy were associated with a higher risk of CVAEs.

907 Reduction of Nasal Fractures During COVID-19: A Single-Centre Experience

Introduction

The utilization of local or regional anaesthesia for manipulation of nasal fractures (MNF) avoids the need for general anaesthetic (GA), and the risk associated with instrumentation of the airway during the COVID-19 pandemic. Furthermore, MNF under local anaesthetic (LA) provides similar results with regards to cosmesis and patient satisfaction. We present our experience of performing MNF under LA during the COVID-19 pandemic.

Method

A single-centre, prospective study of all patients undergoing MNF under LA was conducted (13th July/20–11thSeptember/20). Following reduction, pain scores and patient satisfaction surveys were administered.

Results

A total of 25 patients (M/F:16/9, median age, 25.6yr (14-52yr)) were enrolled. The majority of patients received either one or two instillations of LA (n = 19, 76%). Pain reported during the MNF procedure was 4.4/10, whilst pain during LA administration was reported as 3.2/10. 80% of patients felt instillation of LA was less painful than expected. 88% of respondents tolerated the LA well, and only 8% would have opted for general anaesthetic. 24 (96%) participants were happy with the cosmetic result.

Discussion

MNF under LA is a safe and effective alternative to MNF under GA. More literature is needed to define the best method of administering LA prior to performing MNF.

Nodular Subcutaneous Phaeohyphomycosis due to Medicopsis romeroi in an Immunocompetent Patient

Fungal infections like subcutaneous phaeohyphomycosis are uncommon but are increasing lately, especially in tropical regions like India. Identification of correct aetiologic agent is essential as different species can have different organ tropism. Here, a rare case of nodular subcutaneous phaeohyphomycosis in an immunocompetent 62-year-old male patient who developed nodule over right dorsum of foot is reported. After various diagnostic tests a rare dematiaceous fungus Medicopsis romeroi was identified as a causative agent in the nodular material by Internal Transcribed Spacer (ITS) sequencing. Surgical excision and antifungal therapy of itraconazole proved beneficial with no recurrence during a six months of follow-up. Medicopsis romeroi has been debated for its role in human infections however, it should be considered as one of the aetiologic agents of subcutaneous phaeohyphomycosis.

Clinical Outcome of Patients on Ceftazidime-Avibactam and Combination Therapy in Carbapenem-resistant Enterobacteriaceae

Introduction

Carbapenem-resistant Enterobacteriaceae (CRE) infections have a major effect on mortality as well as healthcare cost. Intensive care units (ICUs) in India, the epicenters for multidrug-resistant organisms, are facing a “postantibiotic era” because of very limited treatment options. A latest beta-lactam/beta-lactamase inhibitor ceftazidime–avibactam (CZA) new has a broad-spectrum antibacterial activity. CZA inhibits class-A and class-C beta-lactamases (as well Klebsiella pneumoniaecarbapenemase (KPC)), along with some class-D carbapenems such as OXA-48-like enzymes that are seen in Enterobacteriaceae has recently become available. The current study aimed to assess and present the clinical response and patient outcome with infections due to CRE when treated with CZA alone or in combination with other drugs.

Materials and methods

This retrospective study reviews the experience recorded and analyzed at two tertiary care centers including only adult patients with CRE infection who had received CZA alone or in combination with other antibiotics over a period between February 2019 and January 2020.

Results

In the period from February 2019 to January 2020, 119 culture-confirmed CRE isolates were tested for Xpert Carba-R. The predominant genetic mechanism was a combination of NDM+OXA-48 in 45/119 (37.81%). Total 40/57 patients received CZA+aztreonam alone or in combination with other drugs with an overall cure rate of 77.5% while the rest 17 received CZA alone in combination with the cure rate of 82.35%. 41/57 (71.92%) patients were in ICU.

Conclusion

With overall mortality of 21%, these data suggest that CZA is a viable option for patients with CRE infections. To our knowledge, this is the first Indian study reporting CZA data in CRE infections.

How to cite this article

Nagvekar V, Shah A, Unadkat VP, Chavan A, Kohli R, Hodgar S, et al. Clinical Outcome of Patients on Ceftazidime–Avibactam and Combination Therapy in Carbapenem-resistant Enterobacteriaceae. Indian J Crit Care Med 2021;25(7):780–784.

Sensitivity Pattern Of Salmonella typhi And Paratyphi A Isolates To Chloramphenicol And Other Anti-Typhoid Drugs: An In Vitro Study

Purpose

To investigate the antimicrobial sensitivity pattern of commonly prescribed antimicrobials (chloramphenicol, cefixime, ofloxacin, azithromycin, and ceftriaxone) against Salmonella enterica isolates.

Methods

Blood culture positive isolates of S. typhi and S. paratyphi A (N = 251) received at Metropolis Healthcare Limited (Mumbai, India) from four zones of India (North, South, West, and East) between April and August 2018 were tested for antimicrobial susceptibility by E-test method. Based on the minimum inhibitory concentration (MIC), the organism was categorized as sensitive, intermediate, and resistant against the respective antibiotics as per Clinical and Laboratory Standards Institute criteria 2018.

Results

Out of 251 Salmonella isolates, 192 (76.5%) were S. typhi and 59 (23.5%) were S. paratyphi A. All 251 (100%) Salmonella isolates were sensitive to cefixime, ceftriaxone, and azithromycin; 237/251 (94.4%) isolates to chloramphenicol and only 9/251 (3.6%) isolates were sensitive to ofloxacin. Based on average MIC and MIC breakpoints, Salmonella isolates were found to be sensitive to chloramphenicol (MIC: 3.89±6.94 µg/mL), cefixime (MIC: 0.13±0.11 µg/mL), azithromycin (MIC: 3.32±2.19 µg/mL), and ceftriaxone (MIC: 0.11±0.18 µg/mL) and resistant to ofloxacin (MIC: 2.95±6.06 µg/mL). More than 20% of Salmonella isolates had MICs of chloramphenicol as 1.5 µg/mL (27.85% isolates) and 2 µg/mL (29.53% isolates).

Conclusion

Our study confirms the re‑emergence of susceptibility of Salmonella isolates to chloramphenicol. Further, the concern about fluoroquinolone-decreased susceptibility as indicated by the intermediate susceptibility or resistance was reiterated in this study. Though cefixime, azithromycin, and ceftriaxone showed susceptibility, the possibility of antibiotic resistance with the irrational use of these antibiotics cannot be deterred. This study thus emphasizes the need for continuous evaluation and judicious use of antimicrobials, considering the ever-changing landscape.

Eastern Canadian Gastrointestinal Cancer Consensus Conference 2018

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference was held in Halifax, Nova Scotia, 20-22 September 2018. Experts in radiation oncology, medical oncology, surgical oncology, and pathology who are involved in the management of patients with gastrointestinal malignancies participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses multiple topics in the management of pancreatic cancer, pancreatic neuroendocrine tumours, hepatocellular cancer, and rectal and colon cancer, including ■ surgical management of pancreatic adenocarcinoma,■ adjuvant and metastatic systemic therapy options in pancreatic adenocarcinoma,■ the role of radiotherapy in the management of pancreatic adenocarcinoma,■ systemic therapy in pancreatic neuroendocrine tumours,■ updates in systemic therapy for patients with advanced hepatocellular carcinoma,■ optimum duration of adjuvant systemic therapy for colorectal cancer, and■ sequence of therapy in oligometastatic colorectal cancer.

Increasing likelihood of advanced pulmonary tuberculosis at initial diagnosis in a low-incidence US state

SETTING

Arkansas, USA.

OBJECTIVE

To investigate the relationship between an increase in the proportion of cases with advanced disease at first diagnosis and the recently observed slowing of the decline in tuberculosis (TB) incidence in low-incidence US states.

DESIGN

We conducted descriptive statistical analyses of de-identified surveillance data of 1246 culture-confirmed TB patients reported in Arkansas during 1996-2013. We then fitted stepwise, multivariate logistic regression models to identify predictors for advanced disease at diagnosis, defined as having either smear-positive sputum or lung cavitation.

RESULTS

From 1996 to 2013, the proportion of new cases with positive sputum smear and cases with lung cavitation increased from 51.6% to 75% and from 37.7% to 50%, respectively. Patients diagnosed during 2006-2013 were more likely to have positive sputum smears (adjusted odds ratio [aOR] 2.55, 95%CI 1.95-3.35) or lung cavitation (aOR 1.49, 95%CI 1.14-1.95) than those diagnosed during 1996-2005. During 1996-2013, age 15-64 years and excessive alcohol use were predictive of positive sputum smear or lung cavitation.

CONCLUSION

Measures to reduce the proportion of cases with advanced disease at first diagnosis may be helpful to achieve further decline in TB incidence in low-incidence settings.

Urinary tract infections by multidrug resistant Acinetobacter species- A Retrospective Analysis

Background: Acinetobacter species have emerged as important cause of nosocomial infections like pneumonia and urinary tract infections. Acinetobacter species are known to be highly resistant to commonly used antimicrobial agents. SinceAcinetobacter species are ubiquitous and have tremendous colonizing capacity, it is difficult to explain the role of Acinetobacter acquisition in the ICU and medical wards. The objective of this study was to determine the frequency of urinary tract infection (UTI) caused by different Acinetobacter species in hospitalized patients and in the community and to analyze their antimicrobial susceptibility pattern.

Materials and Methods: This is a retrospective analysisfrom January 2016 to December 2017. Urine samples collected in appropriate sterile manner were screened for polymorphonuclear leucocytes and bacteria by routine microscopic examination. This was followed by plating on MacConkey's agar and Blood agar. Isolated Acinetobacter strains which are oxidase negative and non-lactose fermenters from MacConkey's agar were identified with Matrix assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS) to confirm the TM identification. Antibiotic susceptibility was performed by VitekCompact™ 2 (Biomeuriux, France) as per CLSI standards establishing MIC (Minimum Inhibitory Concentration).

Results: Of the 429 isolates of Acinetobacterspecies from urinary tract, Acinetobacterbaumannii complex (78%) found to be the most common species followed by Acinetobacterjunii(10%) and Acinetobacterbaumannii(8%). Of the 334 (78%) isolates of Acinetobacterbaumannii complex from urinary tract, 73 (21.85%) isolates were resistant with doripenem, 62 (18.56%) with imipenem and 59 (17.66%) were resistant with meropenem with MIC values >=8 μg/ml. The rest of the isolates like Acinetobacterjunii, Acinetobacterjohnsonii, andAcinetobacterlwoffiiare found to be more sensitive with carbapenems with lower MIC values.

Discussion: The treatment of multidrug-resistant bacteria in hospitalized patients continues to be a challenge for the clinician's in routine practice. Acinetobacter baumannii complex has proven to be an important pathogen in health care associated infections with significant mortality and morbidity. The drug resistant nature of the pathogen and its unpredictable susceptibility patterns make empirical and therapeutic decisions even more difficult.

Conclusion: A. baumanniiis an important opportunistic agent of nosocomial UTI, especially in patients with longer hospitalization, antibiotic exposure, urinary catheterization and decreased immunity. High antimicrobial resistance and patient co-morbidities limit therapeutic choices. Hence, alternative therapeutic options are urgently needed to treat a patient with A. baumanniiinfection.

Eastern Canadian Colorectal Cancer Consensus Conference 2017

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference 2017 was held in St. John's, Newfoundland and Labrador, 28-30 September. Experts in radiation oncology, medical oncology, surgical oncology, and cancer genetics who are involved in the management of patients with gastrointestinal malignancies participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses multiple topics in the management of gastric, rectal, and colon cancer, including ■ identification and management of hereditary gastric and colorectal cancer (crc);■ palliative systemic therapy for metastatic gastric cancer;■ optimum duration of preoperative radiation in rectal cancer-that is, short- compared with long-course radiation;■ management options for peritoneal carcinomatosis in crc;■ implications of tumour location for treatment and prognosis in crc; and■ new molecular markers in crc.

Oxidative stress serves as a key checkpoint for IL-33 release by airway epithelium

BACKGROUND

Interleukin (IL)-33 is implicated in the pathophysiology of asthma and allergic diseases. However, our knowledge is limited regarding how IL-33 release is controlled. The transcription factor nuclear factor-erythroid-2-related factor 2 (Nrf2) plays a key role in antioxidant response regulation.

OBJECTIVE

The goal of this project was to investigate the role of cellular oxidative stress in controlling IL-33 release in airway epithelium.

METHODS

Complementary approaches were used that included human bronchial epithelial cells and mouse models of airway type-2 immunity that were exposed to fungus Alternaria extract. The clinically available Nrf2 activator 2-cyano-3,12-dioxooleana-1,9-dien-28-oic acid methyl ester (CDDO-Me) was used to evaluate the role of Nrf2-induced antioxidant molecules.

RESULTS

Human bronchial epithelial cells produced reactive oxygen species (ROS) when they were exposed to Alternaria extract. ROS scavengers, such as glutathione (GSH) and N-acetyl cysteine, prevented extracellular secretion of ATP and increases in intracellular calcium concentrations that precede IL-33 release. Administration of CDDO-Me to mice enhanced expression of a number of antioxidant molecules in the lungs and elevated lung levels of endogenous GSH. Importantly, CDDO-Me treatment reduced allergen-induced ATP secretion and IL-33 release by airway epithelial cells in vitro and protected mice from IL-33 release and asthma-like pathological changes in the lungs.

CONCLUSIONS

The balance between oxidative stress and antioxidant responses plays a key role in controlling IL-33 release in airway epithelium. The therapeutic potential of Nrf2 activators needs to be considered for asthma and allergic airway diseases.

Management of Epistaxis - A Single Centre Experience and Economic Considerations

Epistaxis represents the most common ENT emergency and its management has been a focus of audit recently, with consideration given to the associated economic burden. The aim of our study is to evaluate the management of epistaxis in terms of treatments used, duration of stay, recurrence and cost. A retrospective review of hospital inpatient enquiry (HIPE) data from a single secondary referral centre was undertaken during a four year period. Four hundrefd and thirty-four patients were identified. The majority (n= 262, 60.3%) were male and the average age was 64.2 years. The vast majority (n=362, 83.4%) were managed non-operatively. Only 15 patients (3.4%) were managed surgically. The average length of stay was 2.5 days and did not vary greatly between the treatment groups. The recurrence rate was 8.2% (n=36). Approximate costs of packing vs EUA and cautery suggest that packing alone is more economical but more data is needed to fully compare the options.

Outcome of operable oral cavity cancer and impact of maintenance metronomic chemotherapy: A retrospective study from rural India

BACKGROUND

Oral cavity cancer is the most common cancer among rural India. There is a paucity of data for outcomes of operable oral cavity cancer from rural India. Use of maintenance metronomic may delay or avoid relapse.

AIM

To evaluate outcomes of operable oral cavity carcinoma and evaluate impact of maintenance metronomic chemotherapy.

OBJECTIVES

To evaluate disease-free survival (DFS), overall survival (OS), and factors affecting the outcome in operable oral cavity cancer.

MATERIALS AND METHODS

Data of patients diagnosed with oral cavity cancer registered between May 2008 and May 2014 were retrieved. Only those patients with operable oral cavity cancer and upfront definitive surgery were included in the study. Demographic profile, stage, tobacco consumption, adjuvant therapy, and pattern of failure were collected. Kaplan-Meir survival analysis was used to determine DFS and OS. Log-rank test was used to evaluate factors affecting outcome.

RESULTS

Median follow-up is 24 months. Out of 335 patients, 225 (67%) had advanced operable cancer with 42/225 (18%) and 183/225 (82%) as Stages III and IVA, respectively. Buccal mucosa was the most common subsite (178/335, 53%) followed by tongue (63/335, 19%). Ninety-two percent patients were addicted to smokeless tobacco, whereas 27% were smokers. Median DFS is 13 months with 2 years relative DFS 32%. Median OS is 30 months, with 2 years OS of 54%. Metronomic adjuvant oral chemotherapy was given in 130/225 (58%); Stage III and IVA patients with median of 14 months (3-18 months). Use of metronomic chemotherapy improved DFS (8 vs. 14 months, P = 0.22) and OS (14 vs. 26 months, P = 0.04).

CONCLUSION

Oral cavity cancer is a major health care problem in rural India. Presentation at advanced stage leads to suboptimal outcomes. Benefit of metronomic maintenance chemotherapy in locally advanced oral cavity needs to be further evaluated prospectively.

Cesarean scar pregnancy and early placenta accreta share common histology

OBJECTIVE

To determine, by evaluation of histological slides, images and descriptions of early (second-trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

METHODS

The database of a previously published review of CSP and EPA was used to identify articles with histopathological descriptions and electronic images for pathological review. When possible, microscopic slides and/or paraffin blocks were obtained from the original researchers. We also included from our own institutions cases of CSP and EPA for which pathology specimens were available. Two pathologists examined all the material independently and, blinded to each other's findings, provided a pathological diagnosis based on microscopic appearance. Interobserver agreement in diagnosis was determined.

RESULTS

Forty articles were identified, which included 31 cases of CSP and 13 cases of EPA containing histopathological descriptions and/or images of the pathology. We additionally included six cases of CSP and eight cases of EPA from our own institutions, giving a total of 58 cases available for histological evaluation (37 CSP and 21 EPA) containing clear definitions of morbidly adherent placenta. In the 29 cases for which images/slides were available for histopathological evaluation, both pathologists attested to the various degrees of myometrial and/or scar tissue invasion by placental villi with scant or no intervening decidua, consistent with the classic definition of morbidly adherent placenta. Based on the reviewed material, cases with a diagnosis of EPA and those with a diagnosis of CSP showed identical histopathological features. Interobserver correlation was high (kappa = 0.93).

CONCLUSIONS

EPA and placental implantation in CSP are histopathologically indistinguishable and may represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

Fitness to drive in patients with brain tumours: the influence of mandatory reporting legislation on radiation oncologists in Canada

BACKGROUND

Certain jurisdictions in Canada legally require that physicians report unfit drivers. Physician attitudes and patterns of practice have yet to be evaluated in Canada for patients with brain tumours.

METHODS

We conducted a survey of 97 radiation oncologists, eliciting demographics, knowledge of reporting laws, and attitudes on reporting guidelines for unfit drivers. Eight scenarios with varying disability levels were presented to determine the likelihood of a patient being reported as unfit to drive. Statistical comparisons were made using the Fisher exact test.

RESULTS

Of physicians approached, 99% responded, and 97 physicians participated. Most respondents (87%) felt that laws in their province governing the reporting of medically unfit drivers were unclear. Of the responding physicians, 23 (24%) were unable to correctly identify whether their province had mandatory reporting legislation. Physicians from provinces without mandatory reporting legislation were significantly less likely to consider reporting patients to provincial authorities (p = 0.001), and for all clinical scenarios, the likelihood of reporting significantly depended on the physician's provincial legal obligations.

CONCLUSIONS

The presence of provincial legislation is of primary importance in determining whether physicians will report brain tumour patients to drivers' licensing authorities. In Canada, clear guidelines have to be developed to help in the assessment of whether brain tumour patients should drive.

ERCC1, VEGF along with clinical variants impact the outcome of advanced non-small cell lung cancer (NSCLC) patients

e22129

Background: ERCC1 is a useful marker of resistance to cisplatin and its analogues. Longer survival was noted in patients with ERCC1 negative expression when treated with platinum. VEGF and its receptor-KDR previously indicated poor prognosis with high tumor cell expression. Methods: From 1998–2008, a retrospective study included 32 patients with advanced NSCLC, where clinical variants as well as the levels of expression of VEGF and VEGFR using rabbit monoclonal Ab (VEGF: A-20, 1:100, SCBT; VEGFR: 55B11, 1:250, cell signaling) and immunohistochemistry for ERCC1 (Mouse monoclonal ab-8F1, Thermo Scientific, 1:200) were measured and co-related to the overall survival of those patients using Cox proportional hazards model. Results: Of the 32 patients, six received non-platinum and twenty six received platinum based regimens either first line or later. Eight patients were females (25%), three were African Americans (9%) and the median age was 62.5 (42–84). Females had a significantly higher overall survival; median survival of 30 months compared to 10.6 months for males (p=0.00089). There was no significant correlation between age and survival (p=0.2). Well differentiated NSCLC of any subtype showed better survival (p=0.04). VEGF low expression correlated with better overall survival (p=0.021). Among the 26 patients who received platinum based regimens, 11 (42%) were ERCC1 negative, 10 had strongly positive ERCC1 expression (39%) and 5 patients had weakly positive ERCC1 expression (19%). ERCC1 negativity was strongly associated with longer survival (p=0.0019) in patients treated with platinum based regimens, where patients treated with the first line platinum had better survival (p=0.034). VEGFR low expression was associated with longer survival in the same group of patients (p=0.013). Caucasians had better overall survival in comparison to African Americans (p=0.007). Higher White blood cell counts and platelet counts were associated with lower survival (p=0.0019 and 0.065 respectively). Conclusion: ERCC1 negativitiy with the first line platinum therapy, VEGF low expression, females, Caucasians as well as the absence of elevation of White blood cells and platelet counts correlate with improved overall survival in advanced NSCLC.

No significant financial relationships to disclose.