Intermediate-term oncological efficacy of laparoscopic retroperitoneal lymph node dissection for non-seminomatous germ cell testicular cancer

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Other have reported that laparoscopic RPLND is feasible and safe when performed by skilled laparoscopic surgeons. We show that patients undergoing laparoscopic RPLND do not recur at the site of the lymph node dissection, even when chemotherapy is not given for nodal disease. This shows that laparoscopic RPLND is therapeutically effective in removing tumors that may have spread from the testicle to the retroperitoneum.

OBJECTIVE

? To assess the therapeutic efficacy of laparoscopic retroperitoneal lymph node dissection (L‐RPLND) for testicular cancer in patients with nodal disease managed without adjuvant chemotherapy.

PATIENTS AND METHODS

? Consecutive patients undergoing RPLND were treated laparoscopically. ? Medical records for 15 patients with pathological stage I and II were reviewed. ? A modified template dissection was performed laparoscopically. When metastatic disease was noted on intraoperative frozen section, a bilateral template dissection was performed.

RESULTS

? All patients had predominantly embryonal carcinoma and/or lymphovascular invasion in their orchidectomy specimen. All patients had normal tumour markers after orchidectomy. ? Laparoscopic RPLND was performed without intraoperative complications. The mean operative time was 299 min and mean length of hospital stay was 1.5 days. ? After L‐RPLND, two patients were pN1 and five patients were pN2. ? Of the patients with nodal disease, five (two pN1 and three pN2) were followed without chemotherapy for a mean of 30 months with no evidence of recurrence. Isolated pulmonary recurrence occurred in two patients with pathologic stage I disease, and another stage I patient had recurrence in the lung and retroperitoneum outside the dissection template.

CONCLUSIONS

? Laparoscopic RPLND appears to be safe while providing the benefits of minimally invasive surgery. ? Although the therapeutic benefit of L‐RPLND needs to be confirmed in additional patients and with longer follow‐up, our results suggest that L‐RPLND provides both diagnostic and therapeutic benefits.     

Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia

Remifentanil patient-controlled analgesia is well established in many centres and provides satisfactory pain relief for many women in labour. We describe a patient using remifentanil patient-controlled analgesia who suffered a respiratory arrest requiring a brief period of ventilation. In our institution, remifentanil patient-controlled analgesia has been offered to women in labour since 2009. Up to this point, we had not observed any critical incidents in over 130 patients using this mode of analgesia in our labour suite.     

Treatment Patterns,HealthCare Resource Utilization and Costs in Patients with Bipolar Disorder,Newly Treated with Extended Release or Immediate Release Quetiapine Fumarate using US Healthcare Administrative Claims Data

Background

Differences in treatment patterns, health care resource use, and costs are expected among patients newly treated with quetiapine extended release (XR) or quetiapine immediate release (IR).

Objective

To compare treatment patterns, health care resource use, and costs in patients with bipolar disorder newly treated with quetiapine XR or quetiapine IR.

Methods

This was an observational, retrospective cohort study that used HealthCore Integrated Research Database–identified patients (age range, 18-64 years) with an International Classification of Disease, Ninth Revision diagnosis of bipolar disorder and ≥1 pharmacy claim for quetiapine XR or quetiapine IR between October 2, 2008, and July 31, 2010. Outcomes were as follows: patient characteristics at the index date (first claim for quetiapine XR or quetiapine IR); 12-month preindex clinical characteristics, health care resource use, and costs; and 12-month postindex treatment patterns, health care resource use, and costs, assessed using generalized linear models (adjusted for index date and preindex patient demographic characteristics, clinical characteristics, health care resource use, and costs).

Results

In total, 3049 patients with bipolar disorder were analyzed (651 in the quetiapine XR group and 2398 in the quetiapine IR group). Of patients initiating treatment with quetiapine XR, 8.8% had no change in or discontinuation of their index therapy compared with 5.7% of patients treated with quetiapine IR (adjusted odds ratio, 1.44; 95% confidence interval, 1.03-2.00; P = 0.0317). The average daily dose (adjusted mean) of quetiapine XR was higher than quetiapine IR (225 vs 175 mg/d, P < 0.0001). An average daily dose of 300 to 800 mg was reached sooner (15.6 vs 30.8 days, P = 0.0049) and in more patients (44.2% vs 27.2%, P < 0.0001) who were taking quetiapine XR compared with patients taking quetiapine IR. No differences in total health care costs were found between the cohorts; however, patients taking quetiapine XR were less likely to be hospitalized for mental health–related reasons (12.1% vs 18.3%, P = 0.0022) and incurred lower mental health–related costs (US $6686 vs US $7577, P = 0.0063) compared with patients taking quetiapine IR.

Conclusions

Treatment patterns and dosing differ in patients with bipolar disorder treated with quetiapine XR compared with those treated with quetiapine IR. Mental health–related hospitalizations and costs may be reduced in the 12 months after patients initiating treatment with quetiapine XR compared with initiating treatment with quetiapine IR.     

American Cancer Society prostate cancer survivorship care guidelines

Answer questions and earn CME/CNE Prostate cancer survivors approach 2.8 million in number and represent 1 in 5 of all cancer survivors in the United States. While guidelines exist for timely treatment and surveillance for recurrent disease, there is limited availability of guidelines that facilitate the provision of posttreatment clinical follow‐up care to address the myriad of long‐term and late effects that survivors may face. Based on recommendations set forth by a National Cancer Survivorship Resource Center expert panel, the American Cancer Society developed clinical follow‐up care guidelines to facilitate the provision of posttreatment care by primary care clinicians. These guidelines were developed using a combined approach of evidence synthesis and expert consensus. Existing guidelines for health promotion, surveillance, and screening for second primary cancers were referenced when available. To promote comprehensive follow‐up care and optimal health and quality of life for the posttreatment survivor, the guidelines address health promotion, surveillance for prostate cancer recurrence, screening for second primary cancers, long‐term and late effects assessment and management, psychosocial issues, and care coordination among the oncology team, primary care clinicians, and nononcology specialists. A key challenge to the development of these guidelines was the limited availability of published evidence for management of prostate cancer survivors after treatment. Much of the evidence relies on studies with small sample sizes and retrospective analyses of facility‐specific and population databases. CA Cancer J Clin 2014;64:225–249. © 2014 American Cancer Society .     

6p22.3 amplification as a biomarker and potential therapeutic target of advanced stage bladder cancer

Genetic and epigenetic alterations have been identified as to contribute directly or indirectly to the generation of transitional cell carcinoma of the urinary bladder (TCC-UB). In a comparative fashion much less is known about copy number alterations in TCC-UB, but it appears that amplification of chromosome 6p22 is one of the most frequent changes. Using fluorescence in situ hybridization (FISH) analyses, we evaluated chromosomal 6p22 amplification in a large cohort of bladder cancer patients with complete surgical staging and outcome data. We have also used shRNA knockdown candidate oncogenes in the cell based study. We found that amplification of chromosome 6p22.3 is significantly associated with the muscle-invasive transitional cell carcinoma of the urinary bladder (TCC-UB) (22%) in contrast to superficial TCC-UB (9%) (p=7.2-04). The rate of 6p22.3 amplification in pN>1 patients (32%) is more than twice that in pN0 (16%) patients (p=0.05). Interestingly, we found that 6p22.3 amplification is as twice as high (p=0.0201) in African American (AA) than European American (EA) TCC-UB patients. Moreover, we showed that the expression of some candidate genes (E2F3, CDKAL1 and Sox4) in the 6p22.3 region is highly correlated with the chromosomal amplification. In particular, knockdown of E2F3 inhibits cell proliferation in a 6p22.3-dependent manner, whereas knockdown of CDKAL1 and Sox4 has no effect on cell proliferation. Using gene expression profiling, we further identified some common as well as distinctive subset targets of the E2F3 family members. In summary, our data indicate that E2F3 is a key regulator of cell proliferation in a subset of bladder cancer and the 6p22.3 amplicon is a biomarker of aggressive phenotype in this tumor type.     

Cortical nociceptive responses and behavioral correlates in the monkey

Experiments were performed to characterize cerebral cortical activity and pain behavior elicited by electrical stimulation of the tooth pulp in unanesthetized monkeys. Four monkeys were trained on two different operant paradigms: two on a simple escape task and two on an appetitive tolerance-escape task. All monkeys were implanted with bipolar stimulating electrodes in the right maxillary canine tooth and subdural recording electrodes over the left primary (SI) and/or secondary (SII) somatosensory cortices. Subdural tooth pulp-evoked potentials (TPEPs) recorded over the SII consisted of components P1 (27.5 ms), N1 (40.3 ms), P2 (84.0 ms), N2 (163.5 ms), P3 (295.3 ms), and N3 (468.0 ms). The long latency component (P3-N3) was found exclusively over the SII and was elicited by high intensity stimulation. The appearance of component P3-N3 required the recruitment of A delta nerve fibers into the maxillary nerve compound action potential and was correlated with high frequencies of escape. Administration of morphine sulfate (4 mg/kg, i.m.) caused a contemporaneous reduction in escape frequency and in the amplitude of P3-N3 recorded over the SII. The relationships between TPEP amplitude, escape behavior and A delta nerve fiber activity strongly suggest that the SII is involved with nociception and pain behavior.     

Epistaxis: a study of the relationship with weather

Epistaxis is the commonest ENT emergency requiring hospital admission. A seasonal variation in the admission rate has been documented. The role of weather in accounting for this variation is uncertain. A retrospective review of 686 adult hospital admissions for idiopathic spontaneous epistaxis over a 2-year period in the Greater Glasgow area was carried out. The most significant weather parameter which correlated with monthly admissions was mean monthly temperature (Pearson's correlation coefficient -0.81, P less than 0.01). Admissions increased by over 100% from the warmest to the coldest months. This is the first report of the high correlation between hospital admissions for epistaxis and mean monthly temperature.