Mediastinal lymph node staging by means of positron emission tomography is less sensitive in elderly patients with non-small-cell lung cancer

PURPOSE: We sought to identify the impact of age on the sensitivity and specificity of integrated positron emission tomography/computed tomography (PET-CT; CT) on mediastinal lymph node staging of patients with non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: We conducted a retrospective review of 206 consecutive patients with histologically proven NSCLC who underwent resection and/or mediastinoscopy in our center between September 2004 and January 2007. All of these patients had preoperative staging with integrated PET-CT as an adjunct to chest CT before resection and/or mediastinoscopy. Diabetic patients and patients who received neoadjuvant chemotherapy were excluded. The pathologic results of all of these cases were reviewed and correlated with those on CT and integrated PET-CT. RESULTS: The sensitivity and positive predictive values (PPV) of PET-CT in mediastinal nodal staging were significantly lower in elderly patients (age>or=65 years; sensitivity, 42%; PPV, 66%) than in younger patients (age<65 years; sensitivity, 52%; PPV, 74%). Specificity and negative predictive values were similar in both groups. CONCLUSION: PET-CT staging of the mediastinum is less sensitive in elderly patients with NSCLC who have a lower PPV. Positive mediastinal uptake on PET-CT should be verified by mediastinoscopy, irrespective of age. Elderly patients with positive mediastinal uptake should not be refuted a curative intent surgical resection on the basis of positive mediastinal uptake alone.     

More than jobs and houses: mental health,quality of life and the perceptions of locality in an area undergoing urban regeneration

BACKGROUND: Urban regeneration initiatives are considered to be one means of making a contribution to improving people's quality of life and mental health. This paper considers the relationship between lay perceptions of locality adversity, mental health and social capital in an area undergoing urban regeneration. METHODS: Using qualitative methods as part of a larger multi-method study, perceptions of material, and non-material aspects of the locality and the way in which people vulnerable to mental health problems coped with living in adversity were identified as being more highly valued than intended or actual changes to structural elements such as the provision of housing or employment. RESULTS: Themes derived from narrative accounts included concerns about the absence of social control in the locality, the reputation of the area, a lack of faith in local agencies to make changes considered important to local residents, a reliance on personal coping strategies to manage adversity and perceived threats to mental health which reinforced a sense of social isolation. We suggest these elements are implicated in restricting opportunities and enhancing feelings of 'entrapment' contributing to low levels of local collective efficacy. The gap between social capital capacity at an individual level and links with collective community resources may in part have accounted for the absence of improvements in mental health during the early life of the urban regeneration initiative. IMPLICATIONS/CONCLUSIONS: In order to enhance quality of life or mental health, agencies involved in urban initiatives need as a basic minimum to promote security, increase leisure opportunities, and improve the image of the locality.     

Recruitment to a trial of self-care skills training in long-term health conditions: analysis of the impact of patient attitudes and preferences

The rise of evidence-based practice has highlighted the importance of effective recruitment to randomised controlled trials if studies are to be adequately powered and valid. However, there are also increasing concerns about patient preferences and choice within trials. The current authors are involved in a trial of a programme to provide self-care skills training for people with long-term health conditions (the 'Expert Patients Programme'), and during the design stage there were significant concerns about the impact of patient preferences on the feasibility and validity of the study, because recruitment required that patients risk randomisation to a waiting list control group. This paper first details the issues raised in this trial, and the methods used to attempt to overcome them. Data on recruitment rates, loss to follow up and patient decision making about participation are presented, which suggested that initial assumptions about the impact of patient preferences were incorrect. Key lessons concerning preferences in this patient population and related issues in trial administration are then discussed.     

Overexpression of the mammalian target of rapamycin (mTOR) and angioinvasion are poor prognostic factors in early stage NSCLC: a verification study

Background

A recent study by Dhillon et al. [12], identified both angioinvasion and mTOR as prognostic biomarkers for poor survival in early stage NSCLC. The aim of this study was to verify the above study by examining the angioinvasion and mTOR expression profile in a cohort of early stage NSCLC patients and correlate the results to patient clinico-pathological data and survival.

Methods

Angioinvasion was routinely recorded by the pathologist at the initial assessment of the tumor following resection. mTOR was evaluated in 141 early stage (IA-IIB) NSCLC patients (67 - squamous; 60 - adenocarcinoma; 14 - others) using immunohistochemistry (IHC) analysis with an immunohistochemical score (IHS) calculated (% positive cells × staining intensity). Intensity was scored as follows: 0 (negative); 1+ (weak); 2+ (moderate); 3+ (strong). The range of scores was 0-300. Based on the previous study a cut-off score of 30 was used to define positive versus negative patients. The impact of angioinvasion and mTOR expression on prognosis was then evaluated.

Results

101 of the 141 tumors studied expressed mTOR. There was no difference in mTOR expression between squamous cell carcinoma and adenocarcinoma. Angioinvasion (p = 0.024) and mTOR staining (p = 0.048) were significant univariate predictors of poor survival. Both remained significant after multivariate analysis (p = 0.037 and p = 0.020, respectively).

Conclusions

Our findings verify angioinvasion and mTOR expression as new biomarkers for poor outcome in patients with early stage NSCLC. mTOR expressing patients may benefit from novel therapies targeting the mTOR survival pathway.     

Influenza and pneumococcal vaccination: do older people know if they have been vaccinated?

Objective: To estimate influenza and pneumococcal immunisation rates by self‐report and validate this with immunisation providers. Method: A random population telephone survey. This was followed by contacting immunisation providers of those reporting having an influenza vaccination (2009 or 2010 only) and/or pneumococcal vaccination to confirm vaccination or not. Results: A total of 680 people aged 65 and older responded to the telephone survey. Seventy‐five per cent of respondents self‐reported influenza vaccination in 2010 and 26% self‐reported having ever had the pneumococcal vaccination. Following up with immunisation providers, we found recall for influenza vaccination was confirmed in 96% of cases. For the pneumococcal vaccination, recall for vaccination was confirmed in 87% of cases. People saying they were not vaccinated for pneumococcal were subsequently confirmed as vaccinated in 77% of cases. Conclusions: In this study, self‐reported influenza vaccination was reliable. The term ‘pneumococcal vaccination or Pneumovax’ was poorly recognised by our telephone survey respondents as evident by the low rate of self‐reported pneumococcal vaccination compared to a much higher rate of pneumococcal vaccinations recorded by GPs. Implications: While pneumococcal vaccination is an accurate term, researchers should be aware of the terminology used in general practice and the community when designing their survey.     

Validity of thoracic gas volume equations in children of varying body mass index classifications.

OBJECTIVE: The aim of the study was to evaluate air-displacement plethysmography (ADP) thoracic gas volume (TGV) prediction equations in children representing a wide range of body mass index (BMI). METHODS: 254 children (5 to 17 years) were recruited from two centres (England and the United States). Subjects were stratified into three BMI categories according to the International Obesity TaskForce (IOTF) criteria: lean (48 male, 42 female), overweight (15 male, 29 female), and obese (52 male, 68 female). As part of the normal ADP procedure, TGV was measured (TGV(Meas)), predicted using child specific equations developed by Fields (TGV(Fields)) and adult derived equations by Crapo (TGV(Crapo)) with percentage body fat (PF) estimates subsequently calculated (PF(Meas), PF(Fields), PF(Crapo)). RESULTS: Compared with the mean TGV(Meas), the TGV(Fields) estimates were within+/-0.2 L in all groups, except obese males (+0.5 L), while the mean TGV(Crapo) estimates were greater than+/-0.3 L in all groups except lean males (+0.1 L). When converted to PF, the mean PF(Fields) estimates were within+/-1% of the measured value in all groups, except obese males (+1.1%), while the mean PF(Crapo) estimates were greater than+/-1% in all groups, except lean males (+0.5%). Using either prediction equation, Bland-Altman analysis revealed that the greatest PF+/-95% limits of agreement were in the lean and overweight groups and lowest in the obese groups. CONCLUSION: The Fields child-specific TGV prediction equations provide accurate mean PF estimates and appear better than using the Crapo equations if a measured TGV cannot be achieved in children of a wide range of BMI. However, individual predictions may result in large PF errors especially in lean children.     

Age alone is not a predictor for survival in glioblastoma

Over half of glioblastoma (GBM) cases are diagnosed in patients older than 65 years. Their median overall survival (OS) is 4–5 months, compared with 12–14 months in patients younger than 70 years. This retrospective audit aims to identify patterns of care and survival of patients diagnosed with GBM at a single institution in Melbourne, Australia. Consecutive histological diagnoses of adult primary GBM from January 2010 to December 2012 were retrospectively identified from medical records. Demographic, treatment and survival characteristics were recorded until death, with follow-up to January 1st 2015. Survival was estimated by Kaplan–Meier method. Planned, sub-group analyses were conducted using multivariate Cox proportional hazards model to identify differences between elderly and younger cohorts, as well as ECOG. 165 patients were identified (36?% aged ≥70 years). Those ≥70 years had a poorer performance status (ECOG 3–4: 27 vs 10?%, p?=?.005); poorer median OS (2.6 vs 11.5 months, p?<?.001); and were less likely to receive adjuvant treatment (no treatment: 40 vs 16?%, p?<?.001) compared with patients <70 years. Age was not a significant predictor of poorer os (HR 1.0; 0.99–1.03; p?>?.05), after adjusting for other clinical factors. Significant predictors of poorer os were poor performance status (p?=?.001), bilateral tumours (p?=?.04), biopsy only (p?=?.001), and no adjuvant treatment (p?<?.001). In patients diagnosed with GBM, those older than 70 years often present with poor performance status, are less likely to receive adjuvant treatment and have inferior os compared with younger patients. Treatment recommendations should be based on performance status/fitness, not age alone.