Assessment and Monitoring Challenges Among Patients With Moderate-to-Severe Atopic Dermatitis Across Fitzpatrick Skin Types: A Photographic Review and Case Series.

ABSTRACT: Atopic dermatitis (AD) is a common, chronic, inflammatory skin condition that affects people of all ages, races, and ethnicities. The condition is heterogeneous in both clinical presentation (phenotype) and underlying pathobiology (endotype). Atopic dermatitis diagnosis, assessment, and monitoring rely on clinical evaluation because there are no definitive biomarkers for AD. This review addresses variation in the clinical presentation of AD across the spectrum of Fitzpatrick skin types, with an emphasis on clinical evaluation challenges in patients with skin of color. We present photographs from phase 3 clinical trials that evaluated the safety and efficacy of upadacitinib among patients with moderate-to-severe AD and demonstrate the challenges in evaluating the clinical signs of AD (erythema and excoriation in patients with dark skin types and lichenification in those with light skin types) by illustrating the changes in clinical signs and symptoms that can be achieved with targeted systemic therapies.

Evaluation of the Fluorescence In Situ Hybridization Test to Predict Recurrence and/or Progression of Disease after bacillus Calmette-Guérin for Primary High Grade Nonmuscle Invasive Bladder Cancer: Results from a Prospective Multicenter Trial.

PURPOSE: Single center studies have shown that positive UroVysion® fluorescence in situ hybridization results were associated with recurrence of nonmuscle invasive bladder cancer treated with intravesical bacillus Calmette-Guérin. Our goal was to validate these findings. MATERIALS AND METHODS: We performed a prospective, multicenter diagnostic trial to determine whether the fluorescence in situ hybridization test could predict recurrence or progression in patients with primary high grade nonmuscle invasive bladder cancer who were scheduled to receive bacillus Calmette-Guérin. Fluorescence in situ hybridization testing was performed prior to the first bacillus Calmette-Guérin instillation, prior to the sixth instillation and at 3-month cystoscopy. The performance of fluorescence in situ hybridization was evaluated. RESULTS: A total of 150 patients were enrolled in analysis, including 68 with Ta disease, 41 with T1 disease, 26 with carcinoma in situ alone and 15 with papillary carcinoma plus carcinoma in situ. At 9 months of followup there were 46 events, including 37 recurrences and 9 progressions. For events with positive fluorescence in situ hybridization findings the HR was 2.59 (95% CI 1.42-4.73) for the baseline test, 1.94 (95% CI 1.04-3.59) for the 6-week test and 3.22 (95% CI 1.65-6.27) at 3 months. Patients with positive results at baseline, 6 weeks and 3 months had events 55% of the time and patients with negative results at each time point had no event 76% of the time. CONCLUSIONS: The study validated that a positive UroVysion fluorescence in situ hybridization test was associated with a 3.3-fold increased risk of recurrence. The test may be useful to risk stratify patients entering clinical trials in whom induction therapy fails. However, using the test to change management decisions is limited due to the discordance between results and outcomes as well as the variance of tests results with time.

PIK3CA amplification is associated with poor prognosis among patients with curatively resected esophageal squamous cell carcinoma.

To investigate the clinicopathologic characteristics and the prognostic impact of PIK3CA gene amplification in curatively resected esophageal squamous cell carcinoma (ESCC). Using 534 curatively resected ESCCs, the PIK3CA gene copy number was evaluated with fluorescent in situ hybridization. PIK3CA amplification was defined as PIK3CA/centromere 3 ratio is ≥ 2.0 or average number of PIK3CA signals/tumor cell nucleus ≥ 5.0. PIK3CA mutations in exon 9 and 20, encoding the highly conserved helical and kinase domains were assessed by direct sequencing in 388 cases. PIK3CA amplification was detected in 56 (10.5%) cases. PIK3CA amplification was significantly associated with higher T-stage (P=0.026) and pathologic stage (P=0.053). PIK3CA amplification showed a significantly shorter disease free survival (DFS) compared with that of non-amplified group (33.4 vs 63.1 months, P=0.019). After adjusting for gender, tumor location, pathologic stage, histologic grade and adjuvant treatment, PIK3CA amplification was significantly associated with a shorter DFS (adjusted hazard ratio [AHR] 1.53; 95% CI, 1.10-2.17; P=0.02). Though the statistical insignificance, PIK3CA amplification showed tendency of shorter OS (52.1 vs 96.5 moths, P=0.116). PIK3CA mutations were detected in 6 (1.5%) of 388 cases; 5 cases with exon 9 mutations in E545K while one exon 20 mutation in H1047L. PIK3CA amplification is a frequent oncogenic alteration and associated with shorter survival, suggesting its role as a prognostic biomarker in resected ESCC. PIK3CA amplification may represent a promising therapeutic target for ESCC.

Fibroblast growth factor receptor 1 gene amplification is associated with poor survival in patients with resected esophageal squamous cell carcinoma.

To investigate the frequency and the prognostic impact of fibroblast growth factor receptor 1 (FGFR1) gene amplification in 526 curatively resected esophageal squamous cell carcinoma (ESCC). Using fluorescent in situ hybridization, high amplification was defined by an FGFR1/centromer 8 ratio is ≥ 2.0, or average number of FGFR1 signals/tumor cell nucleus ≥ 6.0, or percentage of tumor cells containing ≥ 15 FGFR1 signals or large cluster in ≥ 10%. Low amplification was defined by ≥ 5 FGFR1 signals in ≥ 50%. FGFR2 and FGFR3 mutations were assessed by direct sequencing in 388 cases and no mutation was detected. High and low amplification were detected in 8.6% and 1.1%, respectively. High FGFR1 amplification had significantly shorter disease-free survival (34.0 vs 158.5 months P=0.019) and overall survival (52.2 vs not reached P=0.022) than low/no amplification group. After adjusting for sex, smoking, stage, histology, and adjuvant treatment, high FGFR1 amplification had a greater risk of recurrence (adjusted hazard ratio [AHR], 1.6; P=0.029) and death (AHR, 1.53; P=0.050). High amplification was significantly higher in current smokers than former and never-smokers (Ptrend<0.001) and increased proportional to smoking dosage. High FGFR1 amplification is a frequent oncogenic alteration and an independent poor prognostic factor in resected ESCC.

A highly specific and discriminatory FISH assay for distinguishing between benign and malignant melanocytic neoplasms.

The diagnosis of certain melanocytic proliferations remains one of the most challenging areas in pathology. In recent times, fluorescence in situ hybridization (FISH) has emerged as a promising diagnostic aid to conventional microscopy. We previously showed that a 4-probe FISH assay targeting 6p25 (RREB1), 6q23 (MYB), Cep6 (centromere 6), and 11q13 (CCND1) could discriminate between histologically unequivocal melanomas and benign nevi with a sensitivity of 86.7% and specificity of 95.4%. However, the sensitivity of the assay is approximately 70% in melanomas with spitzoid morphology. Furthermore, differentiating true gains from tetraploidy may cause difficulties in interpretation by inexperienced examiners. Here we refine the current probe set to better target spitzoid melanomas and more easily distinguish cells with imbalanced copy number aberrations from tetraploid cells. Using FISH data from 3 training sets of 322 tumors, including 152 melanomas and 170 nevi, we identified 9p21, 6p25, 11q13, and 8q24 as a probe set with improved discriminatory power in differentiating melanomas from nevi. In a validation set of 51 melanomas and 51 nevi this probe set had a sensitivity of 94% and specificity of 98%, compared with the original probe set that had a sensitivity of 75% and specificity of 96% in the same validation cohort. We propose that by incorporating 9p21 into the 4-probe FISH assay, with a new diagnostic algorithm, this new probe set would have improved discriminatory power in melanocytic neoplasms and improved sensitivity for detecting spitzoid melanomas, as demonstrated by our previous studies.

Copy number gains in 11q13 and 8q24 [corrected] are highly linked to prognosis in cutaneous malignant melanoma.

Relating specific genetic alterations to prognosis may help improve prognostication in melanoma, may identify key oncogenic drivers in cancer, and may assist in developing targeted therapies. Characteristic genetic alterations in melanoma include chromosomal copy number aberrations. We evaluated 97 melanomas (55 metastasizing and 42 nonmetastasizing) after a minimum 5-year follow-up in a case-control study using fluorescence in situ hybridization, targeting commonly altered chromosomal loci in melanoma. Eight probes arranged in two panels were used, and 11 parameters were evaluated. Parameters showing a statistically significant difference between the metastasizing and nonmetastasizing groups were evaluated with multivariate logistic regression analysis to compare their prognostic potential with other traditional prognostic markers used by the American Joint Committee on Cancer. Four of 11 parameters evaluated, including CCND1 (alias Bcl-1) gain, CCND1 r-gain, MYC (alias c-myc) gain, and MYC r-gain, had a statistically significant difference in the metastasizing versus nonmetastasizing group. All four parameters maintained statistical significance when evaluated in separate multivariate logistic regression analyses that included the seven currently used American Joint Commission on Cancer prognosticators in melanoma. In multivariate analyses, these four parameters were second only to ulceration in their prognostic potential. Copy number changes at 11q13 and 8q24 [corrected] harboring CCND1 and MYC, respectively, are highly associated with prognosis. Fluorescence in situ hybridization targeting these loci may be a useful standardized prognostic marker in melanoma skin cancer.

Effect of anesthesia and sedation on pediatric MR imaging patient flow.

PURPOSE: To determine the effect of sedative and anesthetic administration on the duration and costs of pediatric magnetic resonance (MR) imaging. MATERIALS AND METHODS: This prospective study was approved by the institutional research ethics board; informed consent and/or assent was obtained from all participants or their parents. A patient flow study was conducted in a pediatric MR imaging clinic in which research assistants tracked participants' progress through the clinic. Demographic, visit process, and medication information was collected for 237 participants, categorized as awake, sedated, or anesthetized. The data were analyzed to (a) determine total visit duration differences, (b) investigate variations in visit stage durations according to patient type, and (c) estimate visit costs on the basis of human resource and medication use. Linear regression, the Shapiro-Wilk test, the two-tailed t test, and the nonparametric Mann-Whitney test were used. RESULTS: Complete data sets were obtained for 148 awake, 28 sedated, and 27 anesthetized participants. Data revealed 12 stage sequences among patient visits; dominant sequences differed according to patient category. An awake patient's average visit duration (2 hours 21 minutes) differed significantly from that of sedated (3 hours 38 minutes, P < .001) and anesthetized (4 hours 7 minutes, P < .001) patients; sedated and anesthetized visit durations did not differ significantly (P < .073), although this finding may be attributable to the small sample sizes. Variation in stage durations was also evident within and among patient types. Visit costs for sedated and anesthetized patients were 3.24 and 9.56 times higher, respectively, than those for awake patients. Costs for anesthetized patients were 2.95 times higher than those for sedated patients. CONCLUSION: Visit durations were significantly longer for anesthetized and sedated patients. Anesthetized patients incurred the highest costs, followed by sedated patients.

Fluorescence in situ hybridization (FISH) as an ancillary diagnostic tool in the diagnosis of melanoma.

Although the clinical and pathologic diagnosis of some melanomas is clear-cut, there are many histopathologic simulators of melanoma that pose problems. Over-diagnosis of melanoma can lead to inappropriate therapy and psychologic burdens, whereas under-diagnosis can lead to inadequate treatment of a deadly cancer. We used existing data on DNA copy number alterations in melanoma to assemble panels of fluorescence in situ hybridization (FISH) probes suitable for the analysis of paraffin-embedded tissue. Using FISH data from a training set of 301 tumors, we established a discriminatory algorithm and validated it on an independent set of 169 unequivocal nevi and melanomas as well as 27 cases with ambiguous pathology, for which we had long-term follow-up data. An algorithm-using signal counts from a combination of 4 probes targeting chromosome 6p25, 6 centromere, 6q23, and 11q13 provided the highest diagnostic discrimination. This algorithm correctly classified melanoma with 86.7% sensitivity and 95.4% specificity in the validation cohort. The test also correctly identified as melanoma all 6 of 6 cases with ambiguous pathology that later metastasized. There was a significant difference in the metastasis free survival between test-positive and negative cases with ambiguous pathology (P=0.003). Sufficient chromosomal alterations are present in melanoma that a limited panel of FISH probes can distinguish most melanomas from most nevi, providing useful diagnostic information in cases that cannot be classified reliably by current methods. As a diagnostic aid to traditional histologic evaluation, this assay can have significant clinical impact and improve classification of melanocytic neoplasms with conflicting morphologic criteria.

Implementation and evaluation of a best practice initiative. Venipuncture in the well baby.

Venipuncture is now the standard method of phlebotomy for well newborn infants at Kingston General Hospital (KGH), Canada. Newborn infants require at least one blood sample for mandatory genetic screening. Some will require additional samples for monitoring of hyperbilirubinemia or other laboratory tests. A change from capillary heel sticks to venipuncture was implemented when the lancets in use were discontinued and a suitable replacement could not be found at the time. A review of the literature discovered a Cochrane Neonatal Review that supported newborn venipuncture as a safe, pain-reducing practice when performed by trained phlebotomists. As a result, a quality improvement project was developed to implement the practice of venipuncture for the well newborn. The implementation and evaluation included lectures, demonstrations, return demonstrations, and eventual integration into clinical practice. Process and summative evaluation demonstrated a willingness of staff to learn a new procedure, particularly when they had identified the need for change. In addition, infants were not subjected to multiple, ineffective blood draws.

The prognostic value of chromosome 7 polysomy in non-small cell lung cancer patients treated with gefitinib.

INTRODUCTION: Specific subpopulations of non-small cell lung cancer (NSCLC) patients defined by clinical features and molecular profiles seem to derive greater benefit from epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors, but no general consensus on molecular testing to optimize treatment has emerged. The objective of this study was to evaluate chromosome 7 polysomy and other potential indicators of gefitinib efficacy in advanced NSCLC patients. METHODS: Paraffin-embedded tumors from 82 patients treated with gefitinib were analyzed by immunohistochemistry for expression of EGFR and other markers, and by fluorescence in situ hybridization for EGFR gene or chromosome copy number. Mutational status was assessed by single-strand conformational polymorphism, sequence-specific polymerase chain reaction, and direct sequencing. Molecular and clinical characteristics were evaluated in relation to objective response (OR), progression-free survival (PFS), and overall survival (OS). RESULTS: EGFR mutational status (p = 0.002), never smoking (p = 0.052), and chromosome 7 polysomy (p = 0.029) were significant indicators of OR. EGFR mutation, pAKT or PTEN expression, and chromosome 7 polysomy were associated with longer OS. There was a significant difference in OS between the chromosome 7 polysomy groups (p = 0.015) and the groups with both chromosome 7 polysomy and pAkt (p = 0.002) and both chromosome7 polysomy and PTEN (p = 0.04). In a stepwise proportional hazards analysis, chromosome 7 polysomy and PTEN expression were both significantly associated with longer OS (p = 0.004 and 0.017 respectively). CONCLUSION: These results suggest that further study of chromosome 7 polysomy and of pAKT and PTEN expression in patients treated with EGFR tyrosine kinase inhibitors is warranted in developing a clinical test for selecting patients for gefitinib therapy.

Effects of ERBB2 amplicon size and genomic alterations of chromosomes 1, 3, and 10 on patient response to trastuzumab in metastatic breast cancer.

Trastuzumab is widely used for advanced breast cancer patients with ERBB2-amplified tumors. Nevertheless, over half of these patients do not have an objective response. One reason may be altered expression of genes that might compensate for ERBB2 inhibition. We previously mapped the gene-rich region of chromosome 17 telomeric to ERBB2, and reported considerable variability in the telomeric extent of the ERBB2 amplicon. Here we examined whether the variable amplicon size may be associated with patient response to trastuzumab. In addition, we looked at associations between response and several signaling pathway-related genes unrelated to the ERBB2 amplicon, including AKT3, PTEN, PIK3CA, and PTGS2. In 35 patients with ERBB2-amplified metastatic breast cancer, with 40% overall response to trastuzumab, fluorescence in situ hybridization identified the telomeric extent of the ERBB2 amplicon and the status of the several pathway-related genes. Objective response strongly correlated with the telomeric amplicon size, with 62% of patients with shorter amplicons responding, compared with only 7% of patients with longer amplicons (P = 0.0015). Abnormal copy number of PTGS2 was marginally associated with objective response (P = 0.066), while abnormal copy numbers of two reference loci, 1q25 and the chromosome 10 centromere, were significantly associated with response. Pairwise combinations of copy number status of these loci and ERBB2 amplicon size provided stronger associations and identified a group of patients without responders. These results suggest that patient selection for trastuzumab may be improved by considering ERBB2 amplicon size and genomic status of the 1q25, PTGS2, and centromere 10 loci.

Development of an on-line bioterrorism preparedness course.

To reach a large audience of public health workers and others interested in learning more about bioterrorism and emergency preparedness, an on-line, Web-based, certificated course entitled "Terrorism, Preparedness and Public Health: An Introduction" was planned, developed, and implemented. Interactivity and other user-friendly devices helped it gain acceptance. To date (May 2005), more than 6,000 people from all 50 states and some foreign countries have registered for the course, and about 2,400 have passed an exam for a certificate of completion. We believe the success of this course is related to the strength and accuracy of the content and its historical perspective; to the quality of the technical development, including multiple levels of interactivity, ease of use, and a printed completion certificate; and to the use of real case studies and the lack of dramatic overstatement.