Cost-effectiveness of expanded latent TB infection testing and treatment: Lynn City, Massachusetts, USA

BACKGROUND: Between October 2016 and March 2019, Lynn Community Health Center in Massachusetts implemented a targeted latent TB infection testing and treatment (TTT) program, increasing testing from a baseline of 1,200 patients tested to an average of 3,531 patients tested, or 9% of the population per year.METHODS: We compared pre-implementation TTT, represented by the first two quarters of implementation data, to TTT, represented by 12 quarters of data. Time, diagnostic, and laboratory resources were estimated using micro-costing. Other cost and testing data were obtained from the electronic health record, pharmaceutical claims, and published reimbursement rates. A Markov cohort model estimated future health outcomes and cost-effectiveness from a societal perspective in 2020 US dollars. Monte Carlo simulation generated 95% uncertainty intervals.RESULTS: The TTT program exhibited extended dominance over baseline pre-intervention testing and had an incremental cost-effectiveness ratio (ICER) of US$52,603 (US$22,008â-"US$95,360). When compared to baseline pre-TTT testing, the TTT program averted an estimated additional 7.12 TB cases, 3.49 hospitalizations, and 0.16 deaths per lifetime cohort each year.CONCLUSIONS: TTT was more cost-effective than baseline pre-implementation testing. Lynn Community Health Centerâ-™s experience can help inform other clinics considering expanding latent TB infection testing.

Results from a Real-World Multicenter Analysis of 482 Patients with Chronic Lymphocytic Leukemia Treated with Ibrutinib: A Look at Racial Differences

BACKGROUND

Despite recent approvals of lifesaving treatments for chronic lymphocytic leukemia (CLL), real-world data on the tolerability of the Bruton tyrosine kinase inhibitor ibrutinib for CLL treatment are lacking, especially in Black patients.

OBJECTIVE

To expand upon a previously reported retrospective chart review of ibrutinib-treated patients with CLL to increase the number of sites and the enrollment period in first-line (1L) and relapsed/refractory (R/R) settings with a subanalysis based on ethnicity.

PATIENTS AND METHODS

Adults with CLL who initiated ibrutinib treatment from five centers were followed for ≥ 6 months.

RESULTS

We identified 482 patients with CLL [405 White (153 1L, 252 R/R), 37 Black (17 1L, 20 R/R), 40 other/unidentified]. At baseline, 58.5% of all patients (68.8% of Black patients) had hypertension. At a median follow-up of 28.2 months, 31.1% of patients overall discontinued ibrutinib, 16.2% due to adverse events (12.2% 1L, 18.8% R/R). Overall, 46.0% of patients experienced ≥ 1 dose hold (40.2% 1L, 49.8% R/R), and 28.8% of patients experienced ≥ 1 dose reduction (24.9% 1L, 31.4% R/R). Among Black patients, ibrutinib was discontinued in 24.3% of patients (17.6% 1L, 30.0% R/R), 8.1% due to disease progression and 5.4% due to adverse events; 40.5% of patients experienced ≥ 1 dose hold (35.3% 1L, 45.0% R/R), and 32.4% of patients experienced ≥ 1 dose reduction (23.5% 1L, 40.0% R/R).

CONCLUSIONS

Toxicity and disease progression were the most common reasons for ibrutinib discontinuations in the overall population and among Black patients, respectively. Encouraging research participation of underrepresented patient groups will help clinicians better understand treatment outcomes.

Prospective Evaluation of Coronavirus Disease 2019 (COVID-19) Vaccine Responses Across a Broad Spectrum of Immunocompromising Conditions: the COVID-19 Vaccination in the Immunocompromised Study (COVICS)

BACKGROUND

We studied humoral responses after coronavirus disease 2019 (COVID-19) vaccination across varying causes of immunodeficiency.

METHODS

Prospective study of fully vaccinated immunocompromised adults (solid organ transplant [SOT], hematologic malignancy, solid cancers, autoimmune conditions, human immunodeficiency virus [HIV]) versus nonimmunocompromised healthcare workers (HCWs). The primary outcome was the proportion with a reactive test (seropositive) for immunoglobulin G to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) receptor-binding domain. Secondary outcomes were comparisons of antibody levels and their correlation with pseudovirus neutralization titers. Stepwise logistic regression was used to identify factors associated with seropositivity.

RESULTS

A total of 1271 participants enrolled: 1099 immunocompromised and 172 HCW. Compared with HCW (92.4% seropositive), seropositivity was lower among participants with SOT (30.7%), hematological malignancies (50.0%), autoimmune conditions (79.1%), solid tumors (78.7%), and HIV (79.8%) (P < .01). Factors associated with poor seropositivity included age, greater immunosuppression, time since vaccination, anti-CD20 monoclonal antibodies, and vaccination with BNT162b2 (Pfizer) or adenovirus vector vaccines versus messenger RNA (mRNA)-1273 (Moderna). mRNA-1273 was associated with higher antibody levels than BNT162b2 or adenovirus vector vaccines after adjusting for time since vaccination, age, and underlying condition. Antibody levels were strongly correlated with pseudovirus neutralization titers (Spearman r = 0.89, P < .0001), but in seropositive participants with intermediate antibody levels, neutralization titers were significantly lower in immunocompromised individuals versus HCW.

CONCLUSIONS

Antibody responses to COVID-19 vaccines were lowest among SOT and anti-CD20 monoclonal recipients, and recipients of vaccines other than mRNA-1273. Among those with intermediate antibody levels, pseudovirus neutralization titers were lower in immunocompromised patients than HCWs. Additional SARS-CoV-2 preventive approaches are needed for immunocompromised persons, which may need to be tailored to the cause of immunodeficiency.

Pembrolizumab plus azacitidine in patients with chemotherapy refractory metastatic colorectal cancer: a single-arm phase 2 trial and correlative biomarker analysis

BACKGROUND

DNA mismatch repair proficient (pMMR) metastatic colorectal cancer (mCRC) is not responsive to pembrolizumab monotherapy. DNA methyltransferase inhibitors can promote antitumor immune responses. This clinical trial investigated whether concurrent treatment with azacitidine enhances the antitumor activity of pembrolizumab in mCRC.

METHODS

We conducted a phase 2 single-arm trial evaluating activity and tolerability of pembrolizumab plus azacitidine in patients with chemotherapy-refractory mCRC (NCT02260440). Patients received pembrolizumab 200 mg IV on day 1 and azacitidine 100 mg SQ on days 1-5, every 3 weeks. A low fixed dose of azacitidine was chosen in order to reduce the possibility of a direct cytotoxic effect of the drug, since the main focus of this study was to investigate its potential immunomodulatory effect. The primary endpoint of this study was overall response rate (ORR) using RECIST v1.1., and secondary endpoints were progression-free survival (PFS) and overall survival (OS). Tumor tissue was collected pre- and on-treatment for correlative studies.

RESULTS

Thirty chemotherapy-refractory patients received a median of three cycles of therapy. One patient achieved partial response (PR), and one patient had stable disease (SD) as best confirmed response. The ORR was 3%, median PFS was 1.9 months, and median OS was 6.3 months. The combination regimen was well-tolerated, and 96% of treatment-related adverse events (TRAEs) were grade 1/2. This trial was terminated prior to the accrual target of 40 patients due to lack of clinical efficacy. DNA methylation on-treatment as compared to pre-treatment decreased genome wide in 10 of 15 patients with paired biopsies and was significantly lower in gene promoter regions after treatment. These promoter demethylated genes represented a higher proportion of upregulated genes, including several immune gene sets, endogenous retroviral elements, and cancer-testis antigens. CD8+ TIL density trended higher on-treatment compared to pre-treatment. Higher CD8+ TIL density at baseline was associated with greater likelihood of benefit from treatment. On-treatment tumor demethylation correlated with the increases in tumor CD8+ TIL density.

CONCLUSIONS

The combination of pembrolizumab and azacitidine is safe and tolerable with modest clinical activity in the treatment for chemotherapy-refractory mCRC. Correlative studies suggest that tumor DNA demethylation and immunomodulation occurs. An association between tumor DNA demethylation and tumor-immune modulation suggests immune modulation and may result from treatment with azacitidine. Trial registration ClinicalTrials.gov, NCT02260440. Registered 9 October 2014, https://clinicaltrials.gov/ct2/show/NCT02260440 .

Daratumumab utilization and cost analysis among patients with multiple myeloma in a US community oncology setting

Background: The introduction of daratumumab into the treatment of multiple myeloma has improved outcomes in patients; however, community oncologists often dose more frequently than the US FDA-approved label. Materials and methods: Integra analyzed its database to elucidate daratumumab treatment patterns and the impact of increased utilization on the cost of care for multiple myeloma. Results: Following week 24, 671 (65%) of 1037 patients remained on daratumumab-containing regimens, with 330 patients continuing more frequent treatments than the expected once-every-4-weeks dosing described in the standard dosing schedule. Patients received an average of 14% more daratumumab doses than the FDA-approved label indicates, increasing the 1-year daratumumab costs by an estimated US$31,353. Conclusion: Daratumumab is utilized more frequently than the FDA-recommended dosing, leading to higher multiple myeloma treatment costs.

Tuberculosis Transmission or Mortality Among Persons Living with HIV, USA, 2011-2016

BACKGROUND

Persons living with HIV are more likely to have tuberculosis (TB) disease attributed to recent transmission (RT) and to die during TB treatment than persons without HIV. We examined factors associated with RT or mortality among TB/HIV patients.

METHODS

Using National TB Surveillance System data from 2011 to 2016, we calculated multivariable adjusted odds ratios (aOR) with 99% confidence intervals (CI) to estimate associations between patient characteristics and RT or mortality. Mortality analyses were restricted to 2011-2014 to allow sufficient time for reporting outcomes.

RESULTS

TB disease was attributed to RT in 491 (20%) of 2415 TB/HIV patients. RT was more likely among those reporting homelessness (aOR, 2.6; CI, 2.0, 3.5) or substance use (aOR,1.6; CI, 1.2, 2.1) and among blacks (aOR,1.8; CI, 1.2, 2.8) and Hispanics (aOR, 1.8; CI, 1.1, 2.9); RT was less likely among non-US-born persons (aOR, 0.2; CI, 0.2, 0.3). The proportion who died during TB treatment was higher among persons with HIV than without (8.6% versus 5.2%; p < 0.0001). Among 2273 TB/HIV patients, 195 died during TB treatment. Age ≥ 65 years (aOR, 5.3; CI, 2.4, 11.6), 45-64 years (aOR, 2.2; CI, 1.4, 3.4), and having another medical risk factor for TB (aOR, 3.3; CI, 1.8, 6.2) were associated with death; directly observed treatment (DOT) for TB was protective (aOR, 0.5; CI, 0.2, 1.0).

CONCLUSIONS

Among TB/HIV patients, blacks, Hispanics, and those reporting homelessness or substance use should be prioritized for interventions that decrease TB transmission. Improved adherence to treatment through DOT was associated with decreased mortality, but additional interventions are needed to reduce mortality among older patients and those TB/HIV patients with another medical risk factor for TB.

Overcoming clinical trial accrual barriers at UPMC: A successful experience

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Background: UPMC Hillman Cancer Center Medical Oncology Network is one of the largest integrated community oncology network in the United States. A large gap exists between trial participation rates and the willingness of patients and physicians. There are numerous barriers to clinical trial accrual in the medical oncology community. UPMC identified and created solutions to overcome barriers, and thus dramatically increase clinical trial accrual in 2019. Methods: A physician led advisory board was created to identity problems and find solutions to increase clinical trial accrual in the community. Processes that were implemented in the community to increase physician engagement included identifying more community friendly clinical trials, highlighting high impact clinical trials, and reprioritizing available clinical trials. Also, community physician champions were selected and directly linked with the academic faculty by disease site at UPMC Hillman Cancer Center. Other marketing tools were utilized like a newly developed mobile clinical trial app, community physician dedicated clinical trial retreat, and clinical trial newsletter. High volume community sites were identified as flagship clinical trial accrual centers. Results: With the implementation of physician led initiatives, total (interventional + non interventional) clinical trial accrual increased in the UPMC medical oncology network from 216 in 2018 to 660 in 2019. In 2019 there were 631 interventional trial accruals and 363 therapeutic trial accruals. In 2018 there were only 186 interventional trial accruals and 46 therapeutic trial accruals. Conclusions: The community oncology-directed initiatives created a culture change among the community physicians. UPMC implemented new processes in the medical oncology network that significantly increased clinical trial accrual. [Table: see text]

Biomarker analysis for UPCI 14-118: Phase II study of pembrolizumab in combination with azacitidine in patients with refractory metastatic colorectal cancer

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Background: DNA mismatch repair (MMR) proficient colorectal cancer (CRC) is resistant to immune checkpoint therapy compared to MMR deficient CRC. DNA hypomethylating agents may promote anti-tumor immune response by re-expression of cancer-testis antigen and reactivating immune genes suppressed by DNA methylation. This trial tested whether epigenetic modulation by concurrent treatment with azacitidine could enhance the anti-tumor activity of pembrolizumab in mCRC. Methods: Phase II trial was conducted to evaluate activity, safety, and tolerability of pembrolizumab in combination with azacitidine in patients with previously treated pMMR metastatic CRC. Patients received pembrolizumab 200 mg IV on day 1 and azacitidine 100 mg daily SQ injection on days 1-5 every 3 weeks. The primary endpoint of the study was ORR. Tumors were biopsied pre-treatment and on-treatment for biomarker studies. Results: 30 patients received at least one dose of therapy. One patient experienced a confirmed partial response, one experienced stable disease. ORR was 3% (1/30; 95% CI, 0.1-17%). Median PFS was 1.9 months, median OS was 6.3 months. Treatment was well tolerated with only one patient (3%) experiencing grade 3 adverse event. The patient with a PR had positive pre-treatment TILs, but no evaluable tumor from on-treatment biopsy. 2 of 6 patients who continued therapy despite PD on first restaging experienced temporary stabilization of disease later. 5 of 16 evaluable biopsy pairs demonstrated increased TILs on treatment compared to baseline; however, all of these patients experienced PD. 10 of 15 paired samples demonstrated decreased methylation of hypermethylated loci on-treatment. Clustering analysis demonstrated a correlation between pre-treatment methylation of immune activation genes with overall survival of the patients. Conclusions: Combining azacitidine and pembrolizumab is safe and tolerable for pMMR mCRC with only limited activity. DNA methylation and TIL changes are detectable after 3 cycles of therapy. DNA methylation of immune activation genes correlate with overall survival. RNA sequencing and peripheral immune cell flow cytometry are ongoing. Clinical trial information: NCT02260440.

Number and cost of hospitalizations with principal and secondary diagnoses of tuberculosis, United States

OBJECTIVE

To estimate the number and cost of hospitalizations with a diagnosis of active tuberculosis (TB) disease in the United States.

METHODS

We analyzed the 2014 National In-Patient Sample using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes to identify hospitalizations with a principal (TB-PD) or any secondary discharge (TB-SD) TB diagnosis. We used a generalized linear model with log link and gamma distribution to estimate the cost per TB-PD and TB-SD episode adjusted for patient demographics, insurer, clinical elements, and hospital characteristics.

RESULTS

We estimated 4985 TB-PD and 6080 TB-SD hospitalizations nationwide. TB-PD adjusted averaged $16 695 per episode (95%CI $16 168-$17 221). The average for miliary/disseminated TB ($22 498, 95%CI $21 067-$23 929) or TB of the central nervous system ($28 338, 95%CI $25 836-$30 840) was significantly greater than for pulmonary TB ($14 819, 95%CI $14 284-$15 354). The most common principal diagnoses for TB-SD were septicemia (n = 965 hospitalizations), human immunodeficiency virus infection (n = 610), pneumonia (n = 565), and chronic obstructive pulmonary disease and bronchiectasis (COPD-B, n = 150). The adjusted average cost per TB-SD episode was $15 909 (95%CI $15 337-$16 481), varying between $8687 (95%CI $8337-$9036) for COPD-B and $23 335 (95%CI $21 979-$24 690) for septicemia. TB-PD cost the US health care system $123.4 million (95%CI $106.3-$140.5) and TB-SD cost $141.9 million ($128.4-$155.5), of which Medicaid/Medicare covered respectively 67.2% and 69.7%.

CONCLUSIONS

TB hospitalizations result in substantial costs within the US health care system.

Real-world effectiveness of palonosetron-based antiemetic regimens: preventing chemotherapy-induced nausea and vomiting

Aim: To evaluate real-world effectiveness of guideline-recommended palonosetron-containing antiemetic regimens in patients receiving highly (HEC) or moderately emetogenic (MEC) chemotherapy. Patients & methods: This retrospective analysis used records of adults receiving first-line chemotherapy and a three-drug palonosetron-containing antiemetic regimen for HEC or palonosetron-containing antiemetic regimen for MEC (carboplatin). Results: A total of 1587 records were evaluated. For HEC and MEC, respectively, chemotherapy-induced nausea and vomiting (CINV) occurred in 40 versus 44% of patient cycles (p = 0.01), and unscheduled iv. antiemetics in 41 versus 35% (p < 0.05). A total of 48% of HEC patients versus 42% of MEC patients had CINV-related clinic visits (p = 0.05). Conclusion: Palonosetron-containing antiemetic regimens may provide insufficient CINV control. Alternative regimens may improve patient quality of life and reduce healthcare resource utilization.

Standardization of inpatient CPR status discussions and documentation within the division of hematology-oncology at UPMC Shadyside: Results from PDSA cycle 1 and 2

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Background: In December 2016, 49% of patients admitted to inpatient oncology services at UPMC Shadyside had CPR status discussion documentation prior to discharge. This project aims to improve quality and rates of CPR status conversations. Methods: During Plan-Do-Study-Act (PDSA) cycle 1, a stakeholder workgroup was formed in January 2017 by oncology faculty, fellows, nurses and advance practice providers (APPs), medicine house staff, and palliative care faculty. All oncology clinicians were reminded weekly to discuss and document CPR status preferences. APPs received communication training with palliative care specialists. Oncology leadership received a monthly update of CPR status documentation rates, and endorsed CPR status best practice guidelines developed by the workgroup. For PDSA cycle 2, patient charts without CPR status documentation in March 2018 were reviewed. Results: PDSA cycle 1 resulted in CPR status assessment rates increasing from 49% to > 80%. 1400+ more CPR status discussions were documented in 2017 than 2016. The percentage of patients discharged “Comfort Measures Only” or “Do Not Resuscitate” increased from 14.2 (S.D. 2.4) to 20.0 (S.D. 2.1). For PDSA cycle 2, 60 patients without CPR assessment were reviewed. Fifty-two percent were admitted overnight by nocturnists, 48% by daytime APPs, and none by housestaff. 55% (33/60) had metastatic disease. Fifty-three percent (31/60) of patients had prior CPR status documentation in the past 12 months. Fifteen percent (11/60) of patients were admitted for scheduled inpatient chemotherapy. Conclusions: PDSA 1 showed that standardization of CPR status assessment with formal training increased CPR status assessments. More patients wanted CMO or DNR when asked, which may indicate the need for earlier goals of care discussions. PDSA 2 indicated that focusing efforts on completing CPR assessment as part of the admission process, especially for scheduled inpatient chemotherapy admissions, is critical in further improving our rates.

Real-world efficacy: intravenous palonosetron three-drug regimen for chemotherapy-induced nausea and vomiting with highly emetogenic chemotherapy

AIM

Real-world palonosetron effectiveness was evaluated in an antiemetic regimen with highly emetogenic chemotherapy (HEC).

PATIENTS & METHODS

In this Phase IV, prospective, multicenter observational study, HEC-treated cancer patients received palonosetron, a neurokinin 1 receptor antagonist, and dexamethasone. Primary objective was to assess complete response (CR) for acute (≤24 h), delayed and overall (≤120 h) chemotherapy-induced nausea and vomiting.

RESULTS

Of 159 patients, 65.4% had breast cancer, 64.8% received anthracycline (doxorubicin)-plus-cyclophosphamide-containing chemotherapy; 155 completed one HEC cycle. CR was 60.0% acute, 39.4% delayed and 34.8% overall, and then increased (all phases) in 69 patients completing four HEC cycles. Anthracycline (doxorubicin) plus cyclophosphamide-receiving patients had especially low CR.

CONCLUSION

Even within a recommended three-drug antiemetic regimen, palonosetron may provide suboptimal chemotherapy-induced nausea and vomiting control with HEC in real-world settings.

Tuberculosis hospitalization expenditures per patient from private health insurance claims data, 2010-2014

OBJECTIVE

To determine hospitalization expenditures for tuberculosis (TB) disease among privately insured patients in the United States.

METHODS

We extracted TB hospital admissions data from the 2010-2014 MarketScan® commercial database using International Classification of Diseases version 9 codes for TB (011.0-018.96) as the principal diagnosis. We estimated adjusted average expenditures (in 2014 USD) using regression analyses controlling for patient and claim characteristics. We also estimated the total expenditure paid by enrollee and insurance, and extrapolated it to the entire US employer-based privately insured population.

RESULTS

We found 892 TB hospitalizations representing 825 unique enrollees over the 5-year period. The average hospitalization expenditure per person (including multiple hospitalizations) was US$33 085 (95%CI US$31 606- US$34 565). Expenditures for central nervous system TB (US$73 065, 95%CI US$59 572-US$86 558), bone and joint TB (US$56 842, 95%CI US$39 301-US$74 383), and miliary/disseminated TB (US$55 487, 95%CI US$46 101-US$64 873) were significantly higher than those for pulmonary TB (US$28 058, 95%CI US$26 632-US$29 484). The overall total expenditure for hospitalizations for TB disease over the period (2010-2014) was US$38.4 million; it was US$154 million when extrapolated to the entire employer-based privately insured population in the United States.

CONCLUSIONS

Hospitalization expenditures for some forms of extra-pulmonary TB were substantially higher than for pulmonary TB.

Standardization of inpatient CPR status discussions and documentation within the Division of Hematology and Oncology at UPMC Shadyside Hospital

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Background: Medical professionals are trained to provide life-sustaining and cardiac resuscitation measures for admitted hospital patients. However, not all patients desire such aggressive measures. Lack of discussion and/or documentation about resuscitation preferences has led to care incongruous with patient’s wishes as previously documented or reported to providers or family members. In December 2016, 49% of adult patients admitted to the inpatient oncology service at UPMC Shadyside had a code status discussion documented prior to discharge. The aim of this project is to improve the quality and rates of CPR status conversations. Methods: A workgroup was formed in January 2017 among key stakeholders representing oncology physicians and fellows, palliative care faculty, oncology nursing, advance practice providers (APPs), and internal medicine house staff. A quality improvement (QI) proposal was developed and approved by the UPMC Quality Improvement Committee in February 2017. All oncology faculty, fellows, housestaff, and APPs were reminded weekly to complete CPR status conversations and documentation. APPs were formally trained by palliative care specialists to discuss and document CPR/code status with all admitted patients. Hospital leadership received a monthly update of CPR status documentation rates. Results: Since project implementation, CPR status assessment rates have improved from 49% to 80% as of June 2017, and an additional 714 patients had a CPR status discussed and documented compared to June 2016. Formal system-wide expectations are being developed by the CPR assessment workgroup that all admitted patients should have CPR/Code status discussions and documentation upon admission. Conclusions: Standardization of CPR status assessment with formal training of clinicians and APPs has resulted in a significant increase in the number of CPR status assessments on the inpatient setting. A formal CPR status assessment expectations document is in the process of being developed among the workgroup. Formal trainings by palliative care specialists for APPs are ongoing. Future trainings are planned for physicians, housestaff and fellows.

Phase 2 study of pembrolizumab in combination with azacitidine in subjects with metastatic colorectal cancer

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Background: Microsatellite stable (MSS) metastatic colorectal cancer (mCRC) has relatively poor tumoral infiltration of CD8+ T cells and is resistant to pembrolizumab (Pembro) when compared to MSI-H mCRC. DNA hypomethylating agent induces epigenetic expression of multiple genes including cancer-testis antigens in CRC, which are recognized by cytotoxic CD8+ T cells in vitro and in vivo. This trial tested whether concurrent treatment with azacitidine (Aza) could enhance the anti-tumor activity of Pembro. Methods: This is a phase 2 trial to evaluate anti-tumor activity and safety of Pembro plus Aza in patients (pts) with previously treated mCRC without any further standard chemotherapy option. Pts received Pembro 200 mg IV on day 1 of each cycle Q3W and Aza 100 mg daily SQ injection on days 1-5 of each cycle Q3W. Primary endpoint was response rate (ORR) using RECIST v1.1. Secondary endpoints included progression-free survival (PFS) and overall survival (OS). Tumor tissues were collected for correlative studies. Results: Thirty-one pts were enrolled [median age, 61 years (range, 30-79); 17 M/14 F; ECOG PS 0/1 (58%/42%); 30 pts with MSS mCRC]. Pts received at least 2 lines of prior systemic chemotherapy for mCRC (median, 3; range, 1-5). Thirty pts received at least one dose of study therapy (median, 3 cycles; range, 1-8). Ten pts could not complete the first 3 cycles due to rapid symptomatic tumor progression. One pt with MSS mCRC achieved PR and 3 pts had SD as best response. The ORR was 3% (1/30; 95% CI, 0.1-17%). Seven pts with PD at the end of cycle 3 continued on study therapy, and 2 pts had stabilization of tumor progression. Median PFS was 2.1 months (95% CI, 1.8-2.8), and median OS was 6.2 months (95% CI, 3.5-8.7). While treatment-related adverse events (TRAEs) were reported in 63% of pts, most of the TRAEs were Gr 1/2 (96%). Frequent TRAEs possibly related to Aza were anemia (n = 5), constipation (n = 5), and leukopenia (n = 4); and possibly related to both Aza and Pembro were nausea (n = 5) and fatigue (n = 5). Gr 3 TRAEs included anemia (n = 1), ALT elevation (n = 1), and alkaline phosphatase elevation (n = 1). Conclusions: Pembro plus Aza is feasible with a tolerable safety profile but appears to have minimal anti-tumor effect for MSS mCRC. Clinical trial information: NCT02260440.

Myasthenia triggered by immune checkpoint inhibitors: New case and literature review

Immune checkpoint molecules are potent regulators of immunologic homeostasis that prevent the development of autoimmunity while maintaining self-tolerance. Inhibitors of immune checkpoint molecules are used as immunotherapy in the treatment of melanoma and different types of refractory cancer, and can trigger various autoimmune complications including myositis and myasthenia gravis. We describe a case of generalized myasthenia gravis induced by pembrolizumab and review 11 other cases. Five patients also had elevated serum CK levels ranging from 1200 to 8729 IU/L, and biopsy showed myositis in one. Severity was highly variable as symptoms normalized spontaneously in one patient, but three others developed myasthenic crisis (including two with fatal outcomes). Steroids have been recommended as a preferred treatment of autoimmune complications of immune-checkpoint inhibitors. Myasthenia gravis should be considered when weakness, diplopia or bulbar symptoms are seen after treatment with immune checkpoint inhibitors, and additional studies are needed to characterize association with hyperCKemia.

Characteristics and costs of multidrug-resistant tuberculosis in-patient care in the United States, 2005-2007

OBJECTIVE

A population-based study of 135 multidrug-resistant tuberculosis (MDR-TB) patients reported to the Centers for Disease Control and Prevention (CDC) during 2005-2007 found 73% were hospitalized. We analyzed factors associated with hospitalization.

METHODS

We assessed statistically significant multivariable associations with US in-patient TB diagnosis, frequency of hospitalization, length of hospital stay, and in-patient direct costs to the health care system.

RESULTS

Of 98 hospitalized patients, 83 (85%) were foreign-born. Blacks, diabetics, or smokers were more likely, and patients with disseminated disease less likely, to receive their TB diagnosis while hospitalized. Patients aged ⩾65 years, those with the acquired immune-deficiency syndrome (AIDS), or with private insurance, were hospitalized more frequently. Excluding deaths, length of stay was greater for patients aged ⩾65 years, those with extensively drug-resistant TB (XDR-TB), those residing in Texas, those with AIDS, those who were unemployed, or those who had TB resistant to all first-line medications vs. others. Average hospitalization cost per XDR-TB patient (US$285 000) was 3.5 times that per MDR-TB patient (US$81 000), in 2010 dollars. Hospitalization episode costs for MDR-TB rank third highest and those for XDR-TB highest among the principal diagnoses.

CONCLUSIONS

Hospitalization was common and remains a critical care component for patients who were older, had comorbidities, or required complex management due to XDR-TB. MDR-TB in-patient costs are among the highest for any disease.

Risk factors for transmission of tuberculosis among United States-born African Americans and Whites

SETTING

Tuberculosis (TB) patients and their contacts enrolled in nine states and the District of Columbia from 16 December 2009 to 31 March 2011.

OBJECTIVE

To evaluate characteristics of TB patients that are predictive of tuberculous infection in their close contacts.

DESIGN

The study population was enrolled from a list of eligible African-American and White TB patients from the TB registry at each site. Information about close contacts was abstracted from the standard reports of each site.

RESULTS

Close contacts of African-American TB patients had twice the risk of infection of contacts of White patients (adjusted risk ratio [aRR] 2.1, 95%CI 1.3-3.4). Close contacts of patients whose sputum was positive for acid-fast bacilli on sputum smear microscopy had 1.6 times the risk of tuberculous infection compared to contacts of smear-negative patients (95%CI 1.1-2.3). TB patients with longer (>3 months) estimated times to diagnosis did not have higher proportions of infected contacts (aRR 1.2, 95%CI 0.9-1.6).

CONCLUSION

African-American race and sputum smear positivity were predictive of tuberculous infection in close contacts. This study did not support previous findings that longer estimated time to diagnosis predicted tuberculous infection in contacts.

Estimating tuberculosis cases and their economic costs averted in the United States over the past two decades

BACKGROUND

Following a concerted public health response to the resurgence of tuberculosis (TB) in the United States in the late 1980s, annual TB incidence decreased substantially. However, no estimates exist of the number and cost savings of TB cases averted.

METHODS

TB cases averted in the United States during 1995-2014 were estimated: Scenario 1 used a static 1992 case rate; Scenario 2 applied the 1992 rate to foreign-born cases, and a pre-resurgence 5.1% annual decline to US-born cases; and a statistical model assessed human immunodeficiency virus and TB program indices. We applied the cost of illness to estimate the societal benefits (costs averted) in 2014 dollars.

RESULTS

During 1992-2014, 368 184 incident TB cases were reported, and cases decreased by two thirds during that period. In the scenarios and statistical model, TB cases averted during 1995-2014 ranged from approximately 145 000 to 319 000. The societal benefits of averted TB cases ranged from US$3.1 to US$6.7 billion, excluding deaths, and from US$6.7 to US$14.5 billion, including deaths.

CONCLUSIONS

Coordinated efforts in TB control and prevention in the United States yielded a remarkable number of TB cases averted and societal economic benefits. We illustrate the value of concerted action and targeted public health funding.

Inferior outcome after allogeneic transplant in first remission in high-risk AML patients who required more than two cycles of induction therapy

While some patients with high-risk acute myeloid leukemia (AML) require one or two cycles of induction chemotherapy to achieve a complete remission (CR), others require more than two cycles. We examined the outcomes of patients with high-risk AML who received allogeneic HPC transplant in CR1. Forty five consecutive high-risk AML patients in CR1 were included. All 45 patients had adverse cytogenetics, FLT 3 mutations, or secondary AML. Group A patients (n = 33) received one or two cycles, and Group B (n = 12) three or more cycles of induction chemotherapy. The patients were comparable in age, sex, white cell count at presentation, and time from diagnosis and from last chemotherapy to transplant. The 100-day mortality rate was higher in Group B patients (50% vs. 9%, P = 0.006). They had a higher non-relapse mortality (33% vs. 6%, P = 0.035) and a longer length of hospital stay from the day of stem cell infusion (median 21 vs. 20, P = 0.02; third quartile 22 vs. 28, P = 0.02). There was also a trend toward inferior event-free survival and overall survival. High-risk AML patients undergoing allogeneic transplant in CR1 after three or more cycles of induction chemotherapy have an inferior outcome and higher mortality when compared to those who only needed one or two cycles of induction chemotherapy. Novel strategies are needed to reduce the transplant-related mortality in high-risk AML patients needing more than two cycles of induction chemotherapy prior to allogeneic transplant in CR1.

Cost-effectiveness of a 12-dose regimen for treating latent tuberculous infection in the United States

SETTING

A large randomized controlled trial recently showed that for treating latent tuberculous infection (LTBI) in persons at high risk of progression to tuberculosis (TB) disease, a 12-dose regimen of weekly rifapentine plus isoniazid (3HP) administered as directly observed treatment (DOT) can be as effective as 9 months of daily self-administered isoniazid (9H).

OBJECTIVES

To assess the cost-effectiveness of 3HP compared to 9H.

DESIGN

A computational model was designed to simulate individuals with LTBI treated with 9H or 3HP. Costs and health outcomes were estimated to determine the incremental costs per active TB case prevented and per quality-adjusted life year (QALY) gained by 3HP compared to 9H.

RESULTS

Over a 20-year period, treatment of LTBI with 3HP rather than 9H resulted in 5.2 fewer cases of TB and 25 fewer lost QALYs per 1000 individuals treated. From the health system and societal perspectives, 3HP would cost respectively US$21,525 and $4294 more per TB case prevented, and respectively $4565 and $911 more per QALY gained.

CONCLUSIONS

3HP may be a cost-effective alternative to 9H, particularly if the cost of rifapentine decreases, the effectiveness of 3HP can be maintained without DOT, and 3HP treatment is limited to those with a high risk of progression to TB disease.

Diabetes and tuberculosis, US National Health Interview Survey, 2000-2005

Blacks and Hispanics are disproportionately affected by diabetes, which may confound ethnic association with tuberculosis (TB). We analyzed 2000-2005 National Health Interview Survey data. We present adjusted odds ratios (aORs) and 99% confidence intervals (CIs) for the association of diabetes with history of TB disease, controlling for race/ethnicity and age. Diabetics had an aOR of 1.4 (99%CI 1.0-2.0) for history of TB, controlling for being foreign-born non-Hispanic (aOR 2.2, 99%CI 1.6-3.2), US-born Hispanic (aOR 2.1, 99%CI 1.4-3.2), age ≥65 years (aOR 2.0, 99%CI 1.5-2.6), and being Black (aOR 1.6, 99%CI 1.1-2.4). After controlling for race/ethnicity, self-identified diabetics had an increased aOR for history of TB.

Patients diagnosed with tuberculosis at death or who died during therapy: association with the human immunodeficiency virus

OBJECTIVES

To describe trends and risk factors for tuberculosis (TB) mortality.

DESIGN

We calculated trends, identified patient characteristics associated with TB diagnosis at death or death during TB treatment, and described diagnostic procedures using the United States National TB Surveillance System for 1997-2005.

RESULTS

Human immunodeficiency virus (HIV) infected TB patients had an adjusted odds ratio (aOR) of 4-11 for TB diagnosis at death (foreign-born non-Whites, aOR = 11) and of 3-19 for death during TB treatment vs. non-HIV-infected patients. Odds increased by age. Hispanic males had an aOR of 2 for TB diagnosis at death compared with female non-Hispanics. Multidrug-resistant TB (MDR-TB) patients had a three times greater aOR of death during treatment than non-MDR patients. American Indians, Black females, residents in long-term care facilities, US-born patients, and non-HIV-infected homeless persons aged 25-44 years each had an aOR of 2 for mortality during treatment; 86% of pulmonary patients diagnosed at death had a chest radiograph, but 34% had no sputum smear or culture reported.

CONCLUSION

During 1997-2005, controlling for age, HIV remained the characteristic with the greatest aOR for TB diagnosis at death or death during TB therapy. Race/ethnicity, country of birth and homelessness further increased the adjusted odds of death. Results show possible missed opportunities for TB diagnosis prior to death.

Cervical intra-/extramedullary solitary fibrous tumour

A 53-year-old man presented with a 9-month history of symptoms of right-sided weakness, tingling and hypersentivity to clothes on both sides of the body. MRI revealed a large intraspinal intradural tumour at the level of C3-C4 in the cervical cord. The final histology was a solitary fibrous tumour (SFT) of the cervical spinal cord. The radiological diagnosis, surgical management and histology are reviewed.

Knowledge, attitudes and risk perceptions about tuberculosis: US National Health Interview Survey

BACKGROUND

Tuberculosis (TB) disproportionately affects the human immunodeficiency virus (HIV) infected, foreign-born, Black, Hispanic, American Indian/Alaska Native, Asian, homeless, incarcerated, alcoholic, diabetic or cancer patients, male, those aged >44 years, smokers and poor persons.

METHODS

We present TB knowledge, attitudes and risk perceptions overall and for those experiencing TB disparities from the 2000-2005 US National Health Interview Survey (NHIS).

RESULTS

A total of 32% of respondents said TB is curable; 44% correctly recognized that TB is transmitted by air. Persons with less knowledge about TB transmission were aged 18-24 years, alcohol abusers, educated <12 years, Hispanics or males. Persons less likely to say TB is curable were aged 18-44 years, smokers, HIV-tested, uninsured, alcohol abusers or homeless/incarcerated. Only 28% of foreign-born persons from Mexico/Central America/the Caribbean said TB was curable.

CONCLUSIONS

Knowledge about TB transmission and curability was low among a representative US population. Renewed TB educational efforts are needed for all populations, but should be targeted to populations disproportionately affected, especially those who are HIV-infected, homeless/incarcerated, Black, alcohol abusers, uninsured or born in Mexico/Central America/the Caribbean.

Derivative (14)t(11;14)(q13;q32)t(11;14)(p11.2;p11.2): a novel unbalanced variant of the t(11;14)(q13;q32) translocation in mantle cell lymphoma

We report the case of a 62-year-old man who presented with splenomegaly, leukocytosis, anemia, and thrombocytopenia. Examination of the peripheral blood, bone marrow, and spleen revealed involvement by mantle cell lymphoma, with some blastoid features and an atypical phenotype. Spleen and bone marrow classical chromosome analysis followed by fluorescence in situ hybridization revealed a novel and unusual unbalanced variant of the t(11;14)(q13;q32) translocation, resulting in a complex derivative chromosome harboring the IGH/CCND1 fusion gene. This chromosome was designated as der(14)t(11;14)(q13;q32)t(11;14)(p11.1;p11.2).

Posterolateral thoracic disc disease: clinical presentation and surgical experience with a modified approach

Posterolateral thoracic disc disease is often misdiagnosed and labelled as demyelination. A high index of suspicion and awareness of this disease entity is the key to diagnosis and treatment. Our experience with a modified posterolateral facetal-sparing pedicle-sparing approach is highlighted.

Costs of patients hospitalized for multidrug-resistant tuberculosis

SETTING

From 1993 through 1998, 1846 cases of multidrug-resistant tuberculosis (MDR-TB) were reported in the United States. Costs associated with MDR-TB are likely to be much higher than for drug-susceptible tuberculosis due to longer hospitalization, longer treatment with more expensive and toxic medications, greater productivity losses, and higher mortality.

OBJECTIVE

To measure the societal costs of patients hospitalized for MDR-TB.

DESIGN

We detailed in-patient costs for 13 multidrug-resistant patients enrolled in a national study. We estimated costs for physician care, out-patient treatment, and productivity losses for survivors and for deceased patients.

RESULTS

In-patient costs averaged US$25,853 per person and $1036 per person-day of hospitalization. Outpatient costs per person ranged from $5744 to $41,821 (average $19028, or $44 a day). Direct medical costs averaged $44,881; indirect costs for those who survived averaged $32,964, and indirect costs for those who died averaged $686,381 per person. Total costs per person ranged from $28,217 to $181492 (average $89,594) for those who survived, and from $509490 to $1278066 (average $717555) for those who died.

CONCLUSION

The societal costs of MDR-TB varied, mostly because of length of therapy (including in-patient), and deaths during treatment.

Neurogenic thoracic outlet syndrome

Current concepts for the diagnosis of neurogenic thoracic outlet syndrome are presented together with the surgical experience and results in series of 51 patients caused by a cervical rib. Surgical treatment is recommended in patients with persistent and disabling symptoms not responding to conservative therapy. In carefully selected patients good to excellent results can be achieved.

Outcomes of contact investigations of infectious tuberculosis patients

The objective of this study was to describe outcomes of tuberculosis (TB) contact investigations, factors correlated with those outcomes, and current successes and ways to improve TB contact investigations. We abstracted clinic records of a representative U.S. urban sample of 1,080 pulmonary, sputum-smear(+) TB patients reported to CDC July 1996 through June 1997 and the cohort of their 6,225 close contacts. We found a median of four close contacts per patient. Fewer contacts were identified for homeless patients. A visit to the patient's residence resulted in two additional (especially child) contacts identified. Eighty-eight percent of eligible contacts received tuberculin skin tests (TSTs). Recording the last exposure date to the infectious patient facilitated follow-up TST provision. Thirty-six percent of contacts were TST(+). Household contacts and contacts to highly smear(+) or cavitary TB patients were most likely to be TST(+). Seventy-four percent of TST(+) contacts started treatment for latent TB infection (LTBI), of whom 56% completed. Sites using public health nurses (PHNs) started more high-risk TST(-) contacts on presumptive treatment for LTBI. Using directly observed treatment (DOT) increased the likelihood of treatment completion. We documented outcomes of contact investigation efforts by urban TB programs. We identified several successful practices, as well as suggestions for improvements, that will help TB programs target policies and procedures to enhance contact investigation effectiveness.

Causes and costs of hospitalization of tuberculosis patients in the United States

OBJECTIVE

To examine the costs, lengths of stay and patient characteristics associated with tuberculosis (TB) hospitalizations.

METHODS

A prospective cohort study of 1493 TB patients followed from diagnosis to completion of therapy at 10 public health programs and area hospitals in the US. The main outcome measures were the following: 1) occurrence, 2) cost, and 3) length of stay of TB-related hospitalizations.

RESULTS

There were 821 TB-related hospitalizations among the study participants; 678 (83%) were initial hospitalizations and 143 (17%) were hospitalizations during the treatment of TB. Patients infected with human immunodeficiency virus (HIV) (OR 1.8, 95% CI 1.2-2.6), and homeless patients (OR, 1.7 95% CI 1.1-2.8) were at increased risk of being hospitalized at diagnosis. Homeless patients (RR 2.5, 95%CI 1.5-4.3), patients who used alcohol excessively (RR 1.9, 95% CI 1.2-3.0), and patients with multidrug-resistant TB (RR 5.7, 95% CI 2.7-11.8) were at increased risk of hospitalization during treatment. The median length of stay varied from 9 to 17 days, and median costs per hospitalization varied from $6441 to $12968 among the sites.

CONCLUSION

Important social factors, HIV infection, and local hospitalization practice patterns contribute significantly to the high cost of TB-related hospitalizations. Efforts to address these specific factors are needed to reduce the cost of preventable hospitalizations.

Disappearance of a basilar tip aneurysm after wrapping

A young woman underwent craniotomy and wrapping of a ruptured basilar tip aneurysm on day 6 following a subarachnoid hemorrhage. An angiogram 3 years later showed that the aneurysm had disappeared. We suggest the possible reasons.

Hospitalization of homeless persons with tuberculosis in the United States

OBJECTIVES

This study assessed whether homeless patients are hospitalized for tuberculosis (TB) more frequently and longer than other patients and possible reasons for this.

METHODS

We prospectively studied hospitalizations of a cohort of TB patients.

RESULTS

HIV-infected homeless patients were hospitalized more frequently than other patients, while homeless patients who had no insurance or whose insurance status was unknown were hospitalized longer. Hospitalization cost $2000 more per homeless patient than for other patients. The public sector paid nearly all costs.

CONCLUSIONS

Homeless people may be hospitalized less if given access to medical care that provides early detection and treatment of TB infection and disease and HIV infection. Providing housing and social services may also reduce hospital utilization and increase therapy completion rates.

Transoral evacuation of a clivus extradural haematoma with good recovery: a case report

We report a case of traumatic atlanto-axial dislocation with a clivus and upper cervical extradural haematoma causing tetraplegia and respiratory paralysis. Surgical evacuation via the transoral route with posterior atlanto-axial fixation resulted in survival with a good outcome.

Identification and assessment of velopharyngeal inadequacy

PURPOSE

To review current literature with respect to the diagnosis and assessment of velopharyngeal inadequacy (VPI), including present knowledge about the most common causes of VPI.

METHODS

Data sources include published reports over the past 20 years derived from computerized databases and bibliographies of pertinent articles and books. Indexing terms used were "velopharyngeal incompetence," "velopharyngeal inadequacy." "velopharyngeal insufficiency."

CONCLUSION

VPI is most commonly associated with cleft palate, submucous cleft palate, and following adenoidectomy. The otolaryngologist can prevent the latter by preoperative identification of physical stigmata associated with VPI. Perceptual assessment is the criterion standard for diagnosis of VPI. Multiview videofluorography and flexible nasal endoscopy provide the best direct assessments to help plan and direct the optimal treatment of VPI.

Dissemination of clinical results. Mastectomy versus lumpectomy and radiation therapy

OBJECTIVES

This study is an assessment of the extent to which clinical findings concerning mastectomy versus lumpectomy with radiation treatment have been disseminated in practice over time.

METHODS

The authors examined the use of breast-conserving surgery followed by radiation therapy as an alternative treatment to mastectomy for early-stage breast cancer by analyzing 5 years (1986-1990) of inpatient and outpatient claims data from four insurers: Medicare, Medicaid, Blue Cross of Western Pennsylvania, and Pennsylvania Blue Shield. The 9,288 women who were eligible for either a lumpectomy or mastectomy during the study period represented approximately 90% of south western Pennsylvania's adult female population. Given the efficacy of both procedures, the authors expected a trend toward more BCS.

RESULTS

By 1990, the use of lumpectomy increased significantly to 42.4% from 35.2%. The choice of lumpectomy was associated with younger women, private health insurance, absence of axillary node metastases, and treatment in urban hospitals. The authors also found, however, that only 45.3% of women with Medicaid coverage who had a lumpectomy during the study period received the requisite follow-up radiation therapy, compared with 77.5% of private insurance subscribers and 88.1% of Medicare beneficiaries. This finding is troubling even though there was substantially more compliance in the later years of the study, with 60.0% of eligible Medicaid beneficiaries receiving follow-up radiation therapy in 1990.

CONCLUSIONS

This research illustrates the usefulness of administrative claims data in describing trends and practice patterns as well as the need for a different type of research to discover the reasons for the lack of compliance with treatment protocols by women or physicians.

Craniosynostosis in babies: complications and management of 40 cases

Forty consecutive craniofacial cases in babies operated on in a district general hospital by a craniofacial team consisting of maxillofacial and neurosurgeons are reviewed with regard to diagnosis, surgical treatment, complications and outcome. Surgery achieved the release of craniosynostosis and the treatment protocol, and perioperative complications are discussed. Dural breaches occurred on four occasions with no postoperative sequelae. Blood transfusion was required in all cases with an average replacement of 36 percent estimated blood volume (EBV). No central nervous system complications occurred but in one case a brachial plexus haematoma resulted in a temporary neuropraxia to the shoulder. No major infections or deaths occurred in this series.

Comparing prenatal and neonatal diagnosis of hemoglobinopathies

OBJECTIVES

To compare the results of prenatal and neonatal hemoglobinopathy screening, a pilot program was developed at the Northern California Kaiser Permanente Health Care Program, a prepaid health maintenance program serving 2.5 million members.

METHODS

In this program, 54,700 pregnant women were screened for hemoglobinopathies.

RESULTS

Of the 54,700 women screened, 1019 (1.9%) had a hemoglobinopathy trait, and 81 women with at-risk fetuses were identified. Half the women with fetuses at risk for thalassemia accepted prenatal diagnosis; of those whose fetuses were at risk for sickle-cell disease or other hemoglobinopathies, 30% accepted prenatal diagnosis. Of the 81 at-risk couples, 53 refused amniocentesis for definitive fetal diagnosis; only 28 (35%) accepted; all 4 women who were carrying a fetus with thalassemia major elected to terminate the pregnancy. Only 7 of the 21 cases of hemoglobinopathies were diagnosed prenatally; 14 were discovered neonatally.

CONCLUSIONS

Prenatal screening was not found to be an ideal method of identifying hemoglobinopathies of the newborn in this large population. With cost-effectiveness a high priority in health care delivery, we believe that testing of newborns for hemoglobinopathies will continue to be the preferred screening method. A combined prenatal and neonatal program would offer the maximum benefit to patients by adding prenatal counseling, parental options, education, and early complete diagnosis to neonatal screening.

Correction of velopharyngeal insufficiency by pharyngeal augmentation using autologous cartilage: a preliminary report

Twenty patients with velopharyngeal insufficiency (VPI) were treated with autologous costal bone or cartilage implants. Videofluoroscopy and videonasopharyngoscopy studies were used to identify candidates for the procedure. The specific size and shape of the gap as well as an appropriate location for the implant were determined in those patients for whom videonasopharyngoscopy was used. A piece of costal bone or cartilage was implanted into a preselected site in the posterior pharynx. Speech and voice evaluation were conducted preoperatively and 8 weeks postoperatively. Hypernasality and audible nasal emissions were completely eliminated in five patients. Four patients had no postoperative change in speech quality. In the remaining patients, improvement occurred without elimination of VPI. The use of costal bone was discontinued after the ninth patient. One infection occurred with complete resorption of the costal bone graft. Resorption has not been a problem with costal cartilage. No extrusion has occurred, and there have been no infections. Overall speech improvement in this group of children (80%) compared favorably with other reports on pharyngeal augmentation. Costal cartilage appears to be a superior choice for implant material.

Schistosoma mansoni in the spinal cord: a correlation between operative and radiological findings

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Recurrence of meningiomas after operation

The authors reviewed 53 consecutive patients who underwent surgical removal of a meningioma within a 10-year period. The removal was graded macroscopically as either a total removal (types I-III) or a subtotal removal (type IV). The patients were observed for an average period of 5.3 years, during which time there was a 9.5% recurrence after type I removals and an 18.4% recurrence after type II. There was regrowth in 20% of the subtotal group. There was no correlation with age or sex, but histology was important. Syncytial tumors tended to recur, and mitosis and area of focal necrosis were associated with a tendency towards recurrence. The significant features associated with recurrence are discussed.