Factors influencing the choice of treatment modality for individual patients with varicose veins.

INTRODUCTION There is evidence of effectiveness for a range of different treatment modalities for varicose veins but limited information about factors that influence treatment choice for individual patients. METHODS A postal survey was sent to 438 UK members of the Vascular Society of Great Britain and Ireland. RESULTS Overall, 251 responses were received (response rate 57%). A total of 222 respondents treated varicose veins using conventional surgery (84%), endothermal ablation (82%) and foam sclerotherapy (68%). The clinical pattern of veins appeared to have the greatest influence on treatment choice. This was followed by guidance from the National Institute for Health and Care Excellence, patient expectations, facilities, cost and whether treatment was carried out in the public or private sector. Respondents were asked to indicate whether each of 13 clinical 'scenarios' (eg very extensive varicose veins in both legs) would influence them towards or against using specified treatment modalities. 'Consensus' was defined as ≥80% of responses either towards or against any treatment modality; and disagreement as 41-59% both towards and against any modality (i.e. ∼50:50 split). There was consensus towards using endothermal ablation for truncal reflux, towards UGFS for localised varicose veins and towards conventional surgery for large, extensive, bilateral veins. There was consensus against UGFS for large truncal veins, and against surgery for obese patients and those with a history of venous thromboembolism. There were important disagreements about the influence of large or extensive veins, about whether patients were obese or slim and about a prior history of venous thromboembolism. CONCLUSIONS Conventional surgery is still widely available in the UK. Disagreements about treatment choice in different clinical scenarios suggest substantial variation in the treatments patients are offered. Attention to identifying subgroups in trials would help to guide treatment choice for individual patients.

Does every patient need to be discussed at a multidisciplinary team meeting?

AIM: To evaluate the clinical impact and cost-effectiveness of a multidisciplinary team (MDT) meeting in a large hospital in the UK. MATERIALS AND METHODS: A management plan for colorectal cancer patients was recorded by the supervising surgical consultant prior to the MDT meeting using the available clinical information and the available reports for imaging and histopathology. The recorded outcomes were then compared with the outcomes documented at the subsequent MDT meeting. The cost of the MDT meeting was calculated based on the salaries of individuals involved plus relevant overheads. A range of opportunity costs were considered, the most significant of which was the expenditure required to re-provide direct clinical care displaced by the MDT. RESULTS: Over a 3 month period a sample of 47 random cases were reviewed from the colorectal MDT. In three patients, there were significant differences between the preliminary consultant decision and the MDT recommendation: in one case management was changed based on further information about patient co-morbidity and performance status. In only one case was there a material alteration to a CT report, which altered management. The annual costs of running this colorectal local MDT alone were estimated at £162,734+ per annum with opportunity costs of at least twice that. CONCLUSION: The costs of MDT meetings are very high producing a small clinical impact. At a time of increasing financial and capacity pressure in healthcare systems, the use of scarce resources may be better deployed elsewhere.

From genome to vaccine: in silico predictions, ex vivo verification.

Bioinformatics tools enable researchers to move rapidly from genome sequence to vaccine design. EpiMer and EpiMatrix are computer-driven pattern-matching algorithms that identify T cell epitopes. Conservatrix, BlastiMer, and Patent-Blast permit the analysis of protein sequences for highly conserved regions, for homology with other known proteins, and for homology with previously patented epitopes, respectively. Two applications of these tools to epitope-driven vaccine design are described in this review. Using Conservatrix and EpiMatrix, we analyzed more than 10000 HIV-1 sequences and identified peptides that were potentially immunostimulatory and highly conserved across HIV-1 clades. MHC binding assays and CTL assays have been carried out: 50 (69%) of the 72 candidate epitopes bound in assays with cell lines expressing the corresponding MHC molecule; 15 of the 24 B7 peptides (63%) stimulated gamma-interferon release in ELISpot assays. These results lend support to the bioinformatics approach to selecting novel, conserved, HIV-1 CTL epitopes. EpiMatrix was also applied to the entire 'proteome' derived from two Mycobacterium tuberculosis (Mtb) genomes. Using EpiMatrix, BlastiMer, and Patent-Blast, we narrowed the list of putative Mtb epitopes to be tested in vitro from 1600000 to 3000, a 99.8% reduction. The pace of vaccine design will accelerate when these and other bioinformatics tools are systematically applied to whole genomes and used in combination with in vitro methods for screening and confirming epitopes.