National consensus on biologic dose reduction in psoriasis: a modified eDelphi procedure.

BACKGROUND: Dose reduction of biologics for psoriasis is applied in daily practice, although guidelines are lacking. Striving for clear criteria is important, as it leads to a consistent application of dose reduction. OBJECTIVE: To achieve consensus on criteria for biologic dose reduction in psoriasis patients with stable and low disease activity. METHODS: An online Delphi procedure (eDelphi) was conducted. Dutch dermatologists were invited to participate in a maximum of 3 voting rounds. Proposed statements were selected based on literature review and included criteria for the application of dose reduction and dosing schedules. Biologic dose reduction was defined as 'application of injection interval prolongation'. Proposed statements were rated using a 9-point Likert scale; consensus was reached when ≥70% of all voters rated 'agree' (7-9) and <15% rated 'disagree' (1-3). RESULTS: A total of 27 dermatologists participated and reached a consensus on 15 recommendations over 2 voting rounds. Agreed statements included criteria for dose reduction eligibility, criteria for dose reduction (dis)continuation, and dosing schedules for adalimumab, etanercept, and ustekinumab. Based on the eDelphi outcomes, an algorithm fit for implementation in current practice was developed. CONCLUSIONS: Recommendations of this national consensus process can guide clinicians, and consequently their patients, toward consistent application of biologic dose reduction.

Influence of age, comorbidity and performance status on the choice of treatment for patients with non-small cell lung cancer; results of a population-based study.

BACKGROUND: In the Netherlands in 1997, 43% of patients with newly diagnosed lung cancer were over 70. Large age-specific differences in treatment exist. We examined whether age, comorbidity, performance status and pulmonary function influenced treatment. PATIENTS AND METHODS: Data on patients with newly diagnosed non-small cell lung cancer (N = 803) were obtained: comorbidity, performance status, pulmonary function (FEV1) and initial treatment. Age-specific differences in treatment according to the guidelines were examined. Odds ratios were calculated by means of logistic regression analyses. RESULTS: 82% with stage I or II disease received treatment according to the guidelines; this applied to 48% with stage IIIA disease and to 54% with stage IIIB disease. For all stages, this proportion decreased with increasing age. In stage IV disease, 36% did not receive any treatment; this applied to 52% of the elderly patients (75+ years). Multivariate analyses showed associations between comorbidity and treatment choice, but none with performance status. Age of 75+ years appeared to be the most important factor for not receiving treatment according to guidelines. CONCLUSION: A substantial proportion of elderly patients with non-small cell lung cancer did not receive standard treatment. Performance status and comorbidity seldom formed the underlying reason. Calendar rather than biological age seemed to play the most important role in choice of treatment for patients with non-small cell lung cancer.

[Sarcoma of the thoracic wall following mastitis radiotherapy 38 years previously]. / Sarcoom van de thoraxwand na radiotherapie voor mastitis 38 jaar eerder.

A 62-year-old woman presented with a feeling of pressure between her shoulder blades. Physical examination and laboratory test showed no abnormalities. Conventional X-ray of the thorax showed, by chance, a condensation of the second rib. CT scan showed a solitary lesion at the same location. Patient's history mentioned post-partum mastitis 38 years earlier, for which she was treated with X-ray therapy of about 4 to 5 Gray in 1 fraction. A partial rib resection was performed prior to diagnosis. The histopathological diagnosis was stage IA chondrosarcoma. It was excised in toto and an uneventful disease course ensued. In the past, X-ray therapy was used for many different benign diseases. Many doctors nowadays are not aware of this. This case illustrates that radiotherapy for benign disease can give rise to post irradiation sarcomas. Long-term follow-up of an irradiated region is essential for early diagnosis and may lead to higher cure rates.

Single-dose radiotherapy (6 Gy): palliation in painful bone metastases.

Approximately 50% of patients with cancer develop bone metastases and these have an important influence on the quality of life. PURPOSE OF THE STUDY. To evaluate a lower dose than the one already proven to be effective (8 Gy) in the palliation of painful bone metastases. METHODS AND MATERIALS. In a prospective study we analyzed the pain relief, after a single dose of 6 Gy, in 170 patients with painful bone metastases. This was assessed by a questionnaire. RESULTS. A degree of pain relief, was achieved in 88% of the treatments and there was complete relief in 39%. When the treatment was given to the vertebrae, infield spinal cord compression developed in 9%, and when given to the pelvis or femur, infield fractures developed in 8%. CONCLUSION. We concluded that a single dose of 6 Gy was very effective in the palliation of painful bone metastases.

A prospective longitudinal study on radiation-induced hearing loss.

Recent clinical reports indicate that patients receiving radiotherapy that includes the auditory system in the treatment volume are likely to develop an irradiation-induced hearing loss. Although the early, presumed reversible, conductive hearing impairment due to secretory otitis media following radiotherapy is a sequela well known by radiation oncologists, permanent hearing loss, both conductive and sensorineural, is believed to be rare. A prospective study was performed enrolling patients receiving postoperative radiotherapy for unilateral parotid tumors. Audiometric results prior to irradiation were compared with those obtained 2 years later. Up to 50% of the patients (9 of 18) developed a clinically relevant hearing loss in the irradiated ear, both conductive and/or sensorineural. The contralateral ear remained unaltered. The hearing loss was permanent in 6 patients (33%) and affected their quality of life. The data suggest that changes occur in the inner ear as well as in the auditory nerve and auditory brain stem with conventional irradiation schemes with daily fractions of 2 to 2.5 Gy with a total dose of 50 Gy.

Does ex vivo labelling of proliferating cells in colonic and vaginal mucosa reflect the S-phase fraction in vivo?

The ex vivo labelling of DNA-synthesizing epithelial cells in colonic and vaginal mucosa was compared with in vivo labelling. For this purpose, in vivo S-phase cells were labelled with [3H]thymidine (Tdr) and ex vivo labelling was continued by culturing tissue specimens in bromodeoxyuridine (BrdU). Various methods of tissue culture were employed in order to improve diffusion of medium (and BrdU) in the tissue. BrdU and 3H-TdR labelling were evaluated by immunohistochemistry and autoradiography respectively. Ex vivo labelling resulted in a patchy distribution of labelled cells, which did not correspond with the 3H-TdR labelling pattern obtained in vivo. Under the described conditions ex vivo labelling does not appear to be a reliable for estimation of the proliferative activities in vivo.